bluuebunny/crossref_metadata_2025 huggingface dataset:
PS04 DELAYED DIAGNOSIS OF ANORECTAL MALFORMATION: THE NEED FOR CAREFUL NEONATAL EXAMINATION
Authors: Etheridge C. E. , Holland A. J. A. , Soundappan S. V. S.
Published: April 2007

Purpose  To determine the frequency of delayed diagnosis of anorectal malformation in infants admitted to our institution and determine the resulting morbidity and mortality.

Methodology  A retrospective review was performed of all anorectal malformations treated at the Children’s Hospital at Westmead between November 1995 and November 2006. A detailed review was performed of those infants in whom the diagnoses was made greater than 24 hours after birth.

Results  175 anorectal malformations were seen at this institution over the 11 year review period. Diagnostic delay occurred in 5 (3%): four of which were male. The four males were diagnosed within the first week of life, presenting with abdominal distension, vomiting and intestinal obstruction. The single female was diagnosed at 6 months of age when at onset of solid foods she became acutely obstructed. Delayed diagnosis was found to complicate the surgical repair and may have contributed to functional and psychological issues for patients and their families. One case of delayed diagnosis resulted in the death of the child.

Conclusion  Delayed diagnosis of anorectal malformations should be entirely avoidable but occurred in 3% of all cases presenting to our institution. It was associated with morbidity and even mortality. Careful inspection of the neonatal perineum at birth should allow all anorectal malformations to be consistently detected.
PS07 URACHAL ANOMALIES IN CHILDREN
Authors: Yapo B. R. , Gerges B , Holland A. J. A
Published: April 2007

Purpose  Urachal anomalies present infrequently and may be associated with morbidity. We present the experience of our institution in the diagnosis and management of urachal anomalies.

Methodology  A retrospective review of children presenting to this institution with symptoms secondary to a presumed urachal anomaly between June 1995 and June 2006.

Results  There were 25 children over a period of 11 years with a likely diagnosis of anomaly at presentation. Ages ranged from 3 days to 13 years with 14 males and 11 females presenting with a granulomatous polyp (16 cases), umbilical discharge (5), umbilical infections (2), and abdominal pain (2). One case was diagnosed incidentally during a renal ultrasound. The main investigative tool was ultrasound (10), followed by micturating cystourethrogram (MCUG) (2). Fourteen of the 25 children had a patent urachus confirmed by subsequent further imaging or surgery. There was no adverse outcome from operative intervention.

Conclusions  This review confirmed that whilst clinical examination remain important in the management of a child presenting with a possible urachal pathology, in 36% of the cases the correct diagnosis was only made with further radiological imaging or at operation. Surgical excision was effective with no morbidity or mortality.
PM02 RECURRENT RECTAL CANCER – STRATEGIES FOR PAIN MANAGEMENT
Authors: Heriot A. G.
Published: April 2007

Introduction  Despite improvement in management of primary rectal cancer, local recurrence remains a significant problem. The aim was to address strategies for pain management in patients with recurrent rectal cancer.

Methods  A literature search was performed using Medline, Embase, Ovid, and Cochrane database for studies between 1980 and 2005 assessing pain management of local recurrence of rectal cancer and the evidence was critically evaluated in the light of clinical experience in tertiary colorectal centres.

Results  Nearly 50% of rectal cancer pelvic recurrences are local and are therefore potentially amenable to curative resection. Preoperative imaging with MRI and PET is essential for appropriate selection of patients for surgery and preoperative adjuvant therapy is important. Five year survival following resection ranges from 18%–58% though morbidity ranges from 21% to 82%. Palliative resection is usually inappropriate. Radiotherapy has an important role in the local control of irresectable local disease. Pain management of advanced pelvic disease, particularly with sacral nerve root invasion, remains difficult and often necessitates a multidisciplinary and multimodality approach. Aggressive surgical treatment favourably affects quality of life and is cost effective for irresectable local disease.

Discussion  Surgery for local recurrence can result in significant survival with acceptable morbidity and improved quality of life in appropriately selected patients. Pain management of advanced pelvic recurrence is complex and should be multidisciplinary.
PM04 PERCUTANEOUS BALLOON RHIZOTOMY
Authors: Hunn M. K.
Published: April 2007

Percutaneous balloon rhizotomy is a simple, safe and effective treatment for trigeminal neuralgia. The author will present a description of the technique and a discussion of problems and pitfalls based on personal experience. The relative advantages and disadvantages of the procedure in comparison with the other percutaneous techniques will also be discussed.
PR01 “A PICTURE SPEAKS A THOUSAND WORDS”– THE USE OF DIGITAL PHOTOGRAPHY AND THE INTERNET IN MONITORING FREE TISSUE TRANSFER
Authors: Varkey A. , Tan N. C. , Girotto R. , Tang W. C. , Liu Y. T. , Chen H. C.
Published: April 2007

Purpose  Post operative monitoring is crucial for the success of microsurgical free tissue transfer. Sophisticated and expensive methods are available for monitoring. We propose a novel technique using digital photography and the internet as a reliable and cost effective method to monitor free tissue transfers.

Methods  163 micro‐vascular procedures were monitored using this technique over 8 months. Serial photographs taken to show flap color. Capillary refill time, pin prick‐ bleed time and color and hand held Doppler signal was recorded in the movie mode of a standard 5 mega pixel camera with duration of 15 seconds. Data was sent to the surgeon at regular intervals and or as deemed necessary.

Results  Analysis of the 67 cases is presented. 5 re‐explorations were done. The early diagnosis of venous congestion was possible using this technique. Timely intervention contributed to the success of the re‐explorations and these flaps could be salvaged. The file size of images was in the range of 1 MB–6 MB. The file size of an entire set of images ranged about 7 MB–9 MB. These were sent across the ADSL internet lines.

Conclusion  The use of the digital images and the internet allow reconstructive surgeons to have a reliable picture of the state of their free tissue transfers. This permits decrease in observer error and saves valuable time which otherwise needs to be spent to verify situations of doubt and offers an ideal solution to the logistic problem of having to visit the patient in case of doubt.
PR11 PREOPERATIVE IMAGING FOR DIEA PERFORATOR FLAPS: A COMPARATIVE STUDY OF CT ANGIOGRAPHY AND DOPPLER ULTRASOUND
Authors: Rozen W. M. , Phillips T. J. , Ashton M. W. , Stella D. L. , Gibson R. N. , Taylor G. I.
Published: April 2007

Background  Abdominal donor site flaps, including the Transverse Rectus Abdominis Musculocutaneous (TRAM) and Deep Inferior Epigastric Artery (DIEA) perforator flaps, are the standard in autologous breast reconstruction. With variation in the vascular anatomy of the abdominal wall, preoperative imaging is essential for preoperative planning and reducing intraoperative error. Ultrasound has been used previously with varying results, and the quest continues for optimal preoperative assessment. Computerised Tomography Angiography (CTA) has been recently proposed as a non‐invasive modality for this purpose. This is the first study to formally compare preoperative Doppler ultrasound with CTA for imaging the DIEA.

Methodology  Eight consecutive patients undergoing DIEA perforator flaps for breast reconstruction undertook both CTA and Doppler ultrasound preoperatively. All investigations and procedures were undertaken at the same institution with the same surgeon and radiology team.

Results  CTA was superior at identifying the course of the DIEA, its branching pattern and in visualizing its perforators than Doppler ultrasound. Preoperative CTA was highly specific (100%) and more sensitive in mapping and visualising perforators (p < 0.001). CTA was also proficient at identifying the superficial epigastric arterial system and for effectively displaying the results intraoperatively. CTA was substantially quicker and removed the inter‐observer error associated with Doppler ultrasonography. The study was ceased after eight patients due to the overwhelming benefit of CTA over Doppler.

Conclusions  CTA is a valuable imaging modality for the preoperative assessment of the donor site vascular supply for TRAM and DIEA perforator flaps.
PR16 A TRAUMA CENTRE EXPERIENCE: FLAP RECONSTRUCTION OF TRAUMATIC LOWER LIMB INJURIES
Authors: Lo C. H. , Leung M. , Baillieu C. , Chong E. W. T. , Cleland H.
Published: April 2007

Purpose  Decision making in the management of combined major skeletal and soft tissue trauma to the lower limb is a complex process made more difficult by the uncertainty surrounding outcomes. The aim of this study is to review and present our experience with flap reconstruction of traumatic lower limb defects, with particular reference to in‐hospital complications and outcomes related to timing, choice of flap and pre‐existing complications.

Methodology  Retrospective review of all lower limb flap reconstructions performed by the Plastic and Reconstructive Surgery Unit at the Alfred Hospital (largest trauma centre in Australasia) from 1 July 2001 to 20 October 2005 (51 month period).

Results  Sixty‐four patients had 83 flap reconstructions (35 free, 48 local) of 70 separate lower limb injuries. Twenty‐seven flaps (32.5%) developed soft tissue infections and 16 fixation devices (25.8%) were complicated by deep metal infection. There were 6 (12.5%) local flap partial necrosis and 4 (11.4%) free flap failures. Three patients underwent secondary amputation during their initial admission. Thorough wound debridement and internal skeletal fixation were followed by earlier soft tissue coverage and lower deep metal infection rates. Limbs in which flaps were performed after Day 5 were more likely to develop deep metal infection (p = 0.04) and suffer free flap failure or local flap partial necrosis (p = 0.02).

Conclusion  The current study presented our experience with flap reconstructions of complex lower limb injuries at a major trauma centre. Thorough wound debridement, internal fixation and early soft tissue coverage (within 5 days of injury) is associated with lower infection rates and optimal outcomes.
PR21 ROLE OF BACTERIAL BIOFILMS IN CHRONIC WOUNDS
Authors: Ngo Q. , Vickery K. , Deva A. K.
Published: April 2007

Purpose  Bacterial biofilms are highly organised microbial communities living within a protective extracellular matrix. They are difficult to detect and highly resistant to immune or antibiotic killing. It has been suggested that biofilm presence may contribute to the intractable inflammatory processes seen in chronic wounds.

Method  Twelve chronic wound samples from eight different patients were collected as part of routine debridement. These were examined for biofilm presence using light microscopy, confocal laser scanning microscopy, electron microscopy, and Fluorescent In Situ Hybridisation (FISH) technique. Microbiological profiles were established based on wound swabs.

Results  Histological and microscopic evidence of bacterial biofilms were observed in 7 out of 12 wounds. These were mostly found within the necrotic upper layer of the wound. A range of organisms were identified from swabs including the commonly isolated wound bacteria S.aureus, E.Coli, P.aeruginosa, and mixed anaerobes.

Conclusion  Bacterial biofilms were found in almost two‐third of chronic wounds examined. Given the patchy nature of its occurrence and the small area sampled in each biopsy, the true incidence could be much higher. The necrotic surface layer of wounds appeared to be more conducive to biofilm formation than deeper viable tissues. Such biofilms may then serve as niduses for continual bacterial seeding that perpetuate the inflammatory process seen in these wounds.
PR22 SKULL BASE RECONSTRUCTION WITH FREE FLAPS
Authors: Dunkin C. S. J. , Nabi H. , Carroll T. , McMahon J. , Fitzgerald A. M.
Published: April 2007

Introduction & Aims  Microsurgical reconstruction in skull base surgery is not universally practiced. Current evidence suggests improved outcomes allowing more aggressive management of skull base pathology. We present our experience of free flaps in skull base reconstruction.

Material & Methods  17 patients (10 male, 7 female, aged 30–72 years) required microsurgical reconstruction of skull base defects from 2004–2006. The anterior cranial fossa was involved in 10/17. Indications for surgery included malignancy (12/17) and benign neoplasia (3/17).

Results  18 free flaps included 10 rectus abdominis, 5 radial forearm and 5 latissimus dorsi. Complications included one complete flap loss, one anastomotic revision, one CSF leak, one case of meningitis and one subdural empyema. There were no deaths.

Conclusions  We recommend free flap reconstruction for significant skull base defects involving both skull and dura. Important factors determining outcome include adequate pedicle length, flap thickness, use of fascia and controlled lumbar drainage.
PR24 EFFECTS OF COMBINED TOPICAL NEGATIVE PRESSURE (TNP) AND ANTISEPTIC INSTILLATION ON PSEUDOMONAS BIOFILM
Authors: Ngo Q. , Vickery K. , Deva A. K.
Published: April 2007

Purpose  TNP in the form of V.A.C. dressings have been successfully used to enhance chronic wound healing. An in vitro model of the chronic wound biofilm was created to test the effects of TNP with and without concurrent antimicrobial drug instillation on biofilms.

Method  A P.aeruginosa biofilm model was constructed in vitro. Continuous TNP and TNP combined with varying frequencies of betadine instillation were tested on the biofilm model for 24 hours. Outcome parameters measured included viable bacterial count, fluorescent microscopy, confocal laser scanning microscopy, and electron microscopy. Statistical analysis was performed using ANOVA and MANOVA in SPSS 13.0.

Results  Bacterial biofilms, when exposed to TNP alone, showed a 42% decrease in viable count; while exposure to betadine alone showed a reduction of up to 84%. Combined TNP and antiseptic instillation increased the bacteriocidal effect to 99.7% (p < 0.001).

Exposure to TNP also resulted in a decrease in biofilm thickness, and diffusion distance, with an increase in surface area‐to‐volume ratio (p = 0.005, 0.002, and 0.009 respectively).

Conclusion  TNP alone showed a modest effect on the reduction of bacterial biofilm. More importantly it appeared to compress and fragment the overall biofilm architecture. This physical deformity in turn led to more effective drug penetration into the highly resistant biofilm community. The result was an approximate 100 fold enhancement of bacteriocidal effect when betadine instillation was combined with TNP as compared to betadine alone.
PR25 SOFT TISSUE COVERAGE IN LOWER LIMB TRAUMA – ANNUAL AUDIT FROM A TERTIARY RECONSTRUCTIVE SURGERY UNIT IN INDIA
Authors: Varkey A. , Joseph V. M. , Guido N. , Ashok B. C. , Sriknath V.
Published: April 2007

Purpose  To discuss the entire spectrum of injuries seen in lower limb trauma and choice of reconstructive options.

Methodology  Retrospective review of 72 consecutive cases in one year.

Data collected from individual case records and the department photo data base. Injuries were classified and analyzed based on bone and soft tissue involvement, associated vascular injuries, mechanism of injury as in crush, degloving, and combined. Bony injuries were classified according to Gustilo’s classification. Treatment options and outcome for bone and soft tissue are discussed separately.

Results  Total of 72 cases. 95%of cases were two wheeler traffic accidents. Distribution of cases according to site involved: Leg‐39; Foot‐14; Leg and foot‐16; Thigh, leg, and foot‐3.

8 of them were of Gustilo’s IIIB and 7 of IIIC. 42 flaps done included

Gastrocnemius‐4, Soleus‐7, reverse sural‐7, Cross leg‐2, Fasciocutaneous‐5

Perforator based local flaps‐3Latissimus dorsi‐7, Gracilis‐6 Lateral thigh‐1

Intervention: Immediate: 12%. Early (less than 1 week): 36, Delayed (>1 week): 52%

Complications:Wound infection:Minor: 12; Major: 8 (3 Cases – Clostridia)

Partial flap loss: 6; Loss of SSG over flap/donor site: 5; Acute renal failure: 1

Amputations: Above knee: 4; below knee: 2

Conclusions  This series represents the spectrum of high velocity injuries in an overcrowded urban locality of developing country. Significant tissue loss is most often the rule. A judicious execution of reconstructive options can optimize results. Management protocols were adopted to avoid delayed referrals. This audit served as a benchmark to put together a dedicated trauma team in our hospital.
PR27 FRICTION AND CEMENT: CASE REPORT AND LITERATURE REVIEW OF FULL‐THICKNESS CEMENT BURNS
Authors: Gale K. L. , Milsom P.B.
Published: April 2007

Case Report  A 40 year old policeman was referred to ED at Whangarei Base Hospital with a circumferential full‐thickness burn to the distal third of his right leg. He sustained this whilst helping a friend ‘cut concrete’ despite wearing gumboots. Because the experience was largely non‐irritating, he did not notice water and concrete filling his gumboot as he worked.

The wound became increasingly red and painful, and his GP prescribed augmentin for a cellulitic burn. Ten days later, a green exudate developed over the area, prompting further consultation which resulted in a referral to the Base hospital for ‘debridement of slough’.

On examination there was an almost circumferential full thickness alkali‐friction burn wound, 3cm in width around the distal third of his right leg. A 2 cm bridge of normal skin remained posteriorly.

In theatre, the eschar was debrided to healthy bleeding fat and fascia and grafted with a meshed 1 : 2 SSG and a suction dressing placed. Placed on bedrest with wallsuction, prophylactic oral augmentin and subcutaneous clexane for 5 days. It was reviewed 5 days later with 100% graft take. Discharged home on day 7 with a graduated compression stocking for mobilisation.

Discussion  Wet cement remains a poorly recognised cause of full‐thickness skin burns amongst the general population. The alkalinity of cement causes liquefactive necrosis in tissue, which initially may go unrecognised. Most burns affect the lower limb, and only half of those involved professional users. It is thought that more education and awareness of the potential hazards of cement should be publicised amongst the labouring, and DIY communities of NZ.
PR32 WHAT I’VE LEARNED IN HEAD & NECK SURGERY
Authors: Poole M. D.
Published: April 2007

Over a long career in both ablative and reconstructive surgery in the head and neck, the author has identified certain factors which help in the management of these patients and has learned many lessons.

Such lessons include the importance of multi‐disciplinary management, excellence in anaesthesia, the importance of anatomy, concepts of ablative surgery such as marginal mandibular resection, and many of the concepts of reconstructive surgery which have enabled rapid one stage reconstructions, such that palliative surgery for massive tumours can be sometimes worthwhile.

These and other experiences will be discussed.
PR35 THE INCIDENCE OF NON‐MELANOMA SKIN CANCER IN NEW ZEALAND
Authors: Ch’ng S. , Brougham N. D. L. , Tan S. T.
Published: April 2007

Background  It is estimated that skin cancers cost $33 million per annum to the New Zealand healthcare system. Basal cell carcinoma and squamous cell carcinoma are the commonest types of non melanoma skin cancers (NMSCs). Anecdotal evidence indicates that there has been a doubling in the incidence of NMSCs in New Zealand over the last decade. Because of the high incidence mandatory reporting of NMSCs to the National Cancer Registry is not required. This lack of accurate data has led to poor health care policies and strategies including funding and workforce planning.

Aims  The aims of this study are to (1) present the latest statistics on NMSCs in New Zealand, including the incidence across different regions over the last decade, patient demographics, anatomic distribution of NMSCs, incidence and sites of metastasis, and disease‐specific survival; to (2) the histopathology of NMSCs, including surgical margins, histologic grade, and perineural, lymphatic, and vascular invasion; and (3) the relative role of different faculties treating NMSCs.

Method  This project has been approved by the multi‐centre ethics committee. A retrospective review was conducted from patients’ histology records from public and private pathology laboratories within defined catchment areas. Criterion for analysis is a confirmed diagnosis of NMSC treated surgically. A Microsoft Access database is created that will facilitate subsequent data retrieval and analysis.

Results and Conclusion  It is hoped that this up‐to‐date data will form the framework for the development of sound and sustainable healthcare policies of management of NMSCs including management strategies and workforce planning, and research direction on this common disease.
PR38 PTERYGIUM SYNDROME: A SPECTRUM OF FEATURES
Authors: Mclean N. R. , Parashar S. Y. , Anderson P. J. , Djohansjah M. , David D. J.
Published: April 2007

Pterygium Syndrome is an extremely rare and complex congenital disorder consisting of severe contractures involving multiple flexural surfaces and associated craniofacial abnormalities, including mandibular hypoplasia and epicanthic folds. It is also often associated with other congenital abnormalities of the cardiovascular, respiratory and genitourinary systems. It may present in different forms including multiple Pterygium Syndrome of Escobar, lethal multiple Pterygium Syndrome, Popliteal Pterygium Syndrome and Arthrogryposis Multiplex Congenita. The incidence is unknown, a mutation in the IRF6 gene has been found in the Popliteal varient and it is postulated that the pterygia result from the embryonic onset of foetal akinesia. The clinical presentation, multidisciplinary management and longterm outcome of three patients with this condition, managed in the Australian CranioFacial Unit will be presented.
PR39P TREATMENT OF MITTEN HAND DEFORMITY IN A LONG TERM SURVIVOR OF EPIDERMOLYSIS BULLOSA
Authors: Lo M. , Donahoe S. , Brown T.
Published: April 2007

EB is a recessive condition caused by a defect in collagen 7 production, such that epithelial cells do not adhere adequately to the underlying basement membranes. Minor mechanical trauma and stress forces will cause recurrent blistering of the skin and mucosal surfaces, which heal by scarring.

The hand suffers particularly badly, and a characteristic mitten deformity of scar tissue is a common stigmata of the disease.

We report a 51 year old survivor of EB with a bilateral mitten hand deformity that had been present since the age of 6 years.

Extensive surgical release of the dominant left hand was undertaken, resurfacing the created defects with split skin grafts under regional anaesthesia. Fingers that had been buried for 45 years were straightened and held in place with k wires whilst the grafts were vascularising.

Extensive post operative physiotherapy and splinting were undertaken, with functional improvement to the extent that the patient was able to hold a pen and write. Skin graft donor sites healed uneventfully.

Extensive release of mitten hand deformity in long term survivors of EB is a worthwhile surgical procedure with good functional results. The problems of surgery and anaesthesia in this condition are discussed. Release of the second hand is planned.
PR40P METASTATIC CHONDROID SYRINGOMA
Authors: Carey Smith R. L. , Taylor P. , Zelei D. , Robbins P. , Wood D.
Published: April 2007

A 51 year old man presented in 1975 at the age of 19 with a right hallux mass and underwent wide local excision, pathology revealing a chondroid syringoma. This was complicated by local recurrence within 12 months requiring 1st ray excision and a transposition flap. He was symptom free for 12 years and represented with pain on weight bearing. There was a 1 year delay in management as he refused amputation, and underwent “natural treatment by diet”. Subsequent above knee amputation was performed with radiographic evidence of chest metastasis. He represented in 2004 with an abdominal mass and had a nephrectomy for metastasis, and in 2006 with proximal femoral metastasis requiring allograft reconstruction of the hip.

33 years from initial diagnosis with a documented 13 year history of thoracic metasteses we review the literature on chondroid syringoma.
PR41P EMPTY DRUM . . . THE WELDER’S BOMB?
Authors: Jeeves A. E. , Nabi H. , Greenwood J. E.
Published: April 2007

Welding accidents have resulted in over 50 admissions to the Royal Adelaide Hospital in the last 5 years. Our attention was drawn to the significance of workplace welding accidents when a patient died from 80% burns sustained while welding an empty 44 gallon drum in 2006. Our study performed in conjunction with Workcover and Safework SA revealed that welding empty drums has caused many similar accidents resulting in significant morbidity and mortality throughout Australia each year. To date there is only one report in the literature1 referring to this issue. Welding accidents result in significant time lost to work and financial cost to society. We describe our audit of burns sustained while welding and pay particular attention to oil, petrol and diesel drum explosions. Given their potentially avoidable nature, greater public and workplace awareness must be raised to reduce the tragic consequences of these accidents.
PR44P MONITORING BURIED FREE FLAPS – NEW ZEALAND’S FIRST FOUR CLINICAL CASES OF FREE FLAP MONITORING WITH IMPLANTABLE 20 MHZ ULTRASONIC DOPPLER PROBE
Authors: Mistry Y. , James D. W. , Sinclair S.
Published: April 2007

Purpose  Monitoring buried free flaps is difficult. Currently in NZ only standard methods of clinical examination and surface doppler are used. We review the first four cases of the Cook Swartz Doppler (CSD) blood flow monitoring system in monitoring free flaps.

Method  Retrospective review of the first four clinical applications of the CSD in NZ between October 2006 to January 2007. The doppler was used by 3 different surgeons and interpreted by nursing and medical staff with no prior experience with the device. There were two cases of buried free flaps and two cases where a small skin monitor was utilised to allow clinical correlation with doppler signals.

Discussions were held with respective surgeons and other relevant medical and nursing staff.

Results  In the two buried flaps (vascularised fibula flap for femur reconstruction and an ALT flap for pharyngeal reconstruction) the probe was inserted downstream of the arterial anastomosis. In the two non‐buried flaps (latissimus dorsi to reconstruct a scalp defect and a free TRAM for breast reconstruction) the probe was inserted upstream of the venous anastomosis. There can be difficulty in interpreting the audible signal when the probe is attached to the vein. All surgeons found the technical aspects of inserting and securing the probe to be straightforward. It provided peri‐ and post‐operative assurance of flap viability. All four flaps were viable at one week at the time of probe wire removal.

Conclusion  The CSD system is easily applicable to our clinical practice and requires minimal training for both the clinical and nursing staff. It provided peri‐ and post‐operative assurance of flap viability.
PR05 POST‐OPERATIVE HAEMATOMAS IN MICROVASCULAR FREE FLAP RECONSTRUCTION OF THE HEAD AND NECK: THE INCIDENCE, AETIOLOGY AND OUTCOME MODIFICATIONS
Authors: Kaplan E. D. , Rozen W. M. , Shayan R. , Bernard S. , Taylor G. I. , Ashton M. W.
Published: April 2007

Background  Free tissue transfer using microvascular surgery has become a safe a reliable means to repair soft tissue and/or bony defects of the head and neck. Operative success reaches 98%, however the incidence of significant post‐operative complication is also relatively high (32%). One common and often severe complication is haematoma formation at either donor or recipient sites. The incidence of recipient site haematoma is reported at 6%, however the causes and outcomes of haematomas have not been well investigated. A retrospective historical analysis of both donor and recipient site wound haematoma was performed to identify causative factors and the effect on patient outcome.

Methodology  A five year review was conducted for microvascular free tissue transfer to defects in the head and neck at The Royal Melbourne Hospital, for the period from February 2001 until February 2006. The medical records of these 150 patients were reviewed for donor and recipient site wound haematoma and outcomes.

Results  Significant factors for the development of post‐operative haematomas included lood pressure control during the first post‐operative, correlating with the likelihood of developing either a donor or recipient site haematoma (p value < 0.001), drain‐tube outputs (both high and low), smoking and the use of pre‐operative NSAIDs.

Conclusion  There are significant reversible factors that contribute to the development of post‐operative haematomas in head and neck surgery. Close monitoring of patient blood pressure by theatre and recovery nursing staff, close monitoring of drain outputs, and pre‐operative counselling on the use of NSAIDs and smoking may all be useful in the prevention of haematoma formation.
PR06 NECROTISING FASCIITIS OR PYODERMA GANGRENOSUM – AN INTERESTING CASE
Authors: Luo D. Y. W. , Love R.
Published: April 2007

Purpose  Using a case study, to raise awareness of the diagnosis of Pyoderma gangrenosum in the clinically septic patient with a rapidly deteriorating wound. To support the use of VAC dressings in patients with pyoderma gangrenosum.

Methodology  Case Study – Mr DL is a 30 yo man who presented 7 days after an angle grinder injury to his left thigh. He was clinically septic with a rapidly expanding area of necrosis over the injury site. His other presenting problem was a platelet count of 14 × 10−9/L, which was later diagnosed as myelodysplasia.

Cultures grew coagulase negative staphylococcus, and initial biopsies showed extensive necrotic tissue and suppurative inflammation. Despite multiple wound debridements and appropriate intravenous antibiotics, the patient was still clinically septic with a deteriorating wound. It was only on the second biopsy that pyoderma gangrenosum was diagnosed. He was then treated with steroids and a vacuum assisted dressing.

Results  Mr DL responded well to treatment. The VAC dressing was very successful in promoting healthy granulation tissue. This granulation tissue was later skin grafted with good success.

Conclusion  Pyoderma gangrenosum is an important differential diagnosis in wounds that do not seem to improve after debridement, even if the patient appears clinically septic. It is often not easy to diagnose even on histopathological grounds. The Vac dressing is a useful adjunct in the treatment of pyoderma gangrenosum.
PR07 A SYSTEM FOR QUANTIFYING LYMPHATIC VESSEL ABNORMALITIES IN LYMPHEDEMA MODELS, AND LOCO‐SYSTEMIC EFFECTS OF PRO‐LYMPHATIC TUMOR GROWTH FACTORS
Authors: Shayan R. , Karnesis T. , Paavonen K. , Achen M. G. , Taylor G. I. , Stacker S. A.
Published: April 2007

Purpose  Lymphatic vessels are critical in interstitial fluid balance, and congenital or acquired derangements lead to accumulation of lymph fluid (lymphedema). Further, when induced by pro‐lymphatic growth factors in tumors, they facilitate lymph node metastasis(1). While histological vessel density is counted on tissue sections, there is no method for quantifying lymphatic morphology and patterning in 3‐D; key elements in fluid dynamics and cellular interactions that underlie lymphatic function and diseases resulting from alterations to them. We have developed a method to quantify important biological and functional parameters in lymphatics, to help distinguish subtle phenotypic differences and patterning defects.

Methods  Apical images were taken of whole‐mounted mouse ears that were immunofluorescently stained for the lymphatic marker LYVE‐1. Key lymphatic parameters were quantified using a computer program we developed.

Results  Mice with gross lymphedema were found to have significant derangements of many of the key morphological and patterning characteristics assessed. Subtle yet statistically significant lymphatic abnormalities were also identified in less obviously lymphedematous animals. We were also able to assess loco‐systemic effects of the pro‐lymphatic growth factors.

Conclusions  Increasing emphasis on lymphatics in disease demands quantification methods that assess key biological and functional parameters. Our method allows comparison and identification of abnormal lymphatic phenotypes and allows assessment of the effects induced by pro‐lymphatic growth factors.
RS01 THE VALUE AND EFFECT ON CLINICAL OUTCOMES OF PAEDIATRIC SURGICAL SUPPORT TO SMALLER CENTRES
Authors: Beasley S. W. , Maoate K. , Blakelock R. , Azzie G.
Published: April 2007

Purpose  Until 1996 the South Island of New Zealand had limited access to specialist paediatric surgical services. The establishment of a comprehensive paediatric surgical outreach service has allowed children to receive specialist advice and treatment close to home. This study outlines the structure of the service, its effect on the smaller hospitals and on patient outcomes.

Methodology  Trends in the referral patterns and effects on outcome for indicative conditions (including hernia, undescended testis, pyloric stenosis, Hirschsprung disease) were analysed.

Results  Since 1996 there has been a steady increase in the number of children being treated by the service in all the region’s public hospitals. Regular clinics and day surgical lists are held according to local demand, and organised locally. Audit has demonstrated improvements in clinical outcome.

Conclusion  The advantages of a well‐organised and funded paediatric surgical outreach service include: 1. improved access to quality treatment for children close to their home; 2. fewer complications of surgery and less unnecessary surgery; 3. better identification of cases that require transfer; and 4. better support to the rural surgeon and paediatrician who still have to cope with acute paediatric surgical problems.
RS10P ‘SURGICAL TRAINING FOR THE OVERSEAS TRAINED DOCTORS’, STILL AN UNCHARTED SEA
Authors: Ashrafi M. W.
Published: April 2007

Purpose  To show that a little has been done to optimize the surgically trained work force in Australia.

Methodology  Personal experience, media reports, the very sad & unfortunate Bundaberg incidence and its aftermath and conversation with a few hundred OTDS prepared me for this submission. The number of OTDs is increasing in rural areas of Australia and New Zealand. There are many hospitals which can not run a single day without these doctors. Training these doctors is without a doubt an important part of health authorities’ commitment towards community. Unfortunately general public has little chance to know the facts about the OTDs. Many doctors with their skills are lost in the convoluted pathways of career building in the existing practice.

This is a waste and needs to be addressed immediately.

OTDs are under scrutiny by many areas, but no one care about their concerns and needs.

RACS could identify those who are partially trained and accommodate them in the necessary level.

Results  Increasing need of rural surgeons under the present circumstances dictates that OTD surgical trainees be streamlined. The situation is unique and easiest solution in foreseeable future is very clear.

Conclusions  Surgically trained OTDs should be assessed and trained by RACS only. Training should be decentralised to smaller hospitals.
RS02 BEST PRACTICE MANAGEMENT OF INTUSSUSCEPTION IN RURAL CENTRES: HOW TO MINIMISE MORBIDITY AND MORTALITY
Authors: Beasley S. W.
Published: April 2007

Purpose  In recent years there have been a number of refinements in the management of intussusception (INT) that have led to an increase in the success rate of enema reduction, and reduced morbidity. This study proposes guidelines for the management of children with suspected INT in centres that do not have a specialist paediatric surgeon.

Methodology  Analysis of clinical indicator data for INT and review of the outcomes of treatment in the South Island of New Zealand have been used to develop an algorithm for use in regional centres.

Results  INT reduced non‐operatively has a lower morbidity and costs less to treat than those requiring surgery. In the region reviewed, management guidelines appear to have contributed to an overall success rate of enema reduction using Barium improving from 25% to 75%, and with air enemas from 75% to 86%. Discussion of cases between the rural centre and tertiary centre has become the norm.

Conclusion  In smaller centres, an initial enema (barium or gas) should be performed if the child is in reasonable clinical condition. Sick infants, and those in whom an initial enema has failed, are best transferred to a paediatric surgical institution. Good communication is an essential element in developing and implementing clinical pathways that improve outcomes for children with INT.
RS03 VASCULAR SURGERY IN A RURAL PRACTICE – THE CASE FOR
Authors: Vallance S.
Published: April 2007

Centralisation of principal vascular services to tertiary centres has great merit in enabling adequate specialist numbers to provide an acute service with appropriate support facilities. Demand on this vascular service is expected to increase almost 100% with the aging population over the next 20 years. The demography of the population of New Zealand and Australia is such that providing vascular services only in tertiary centres has great potential to disenfranchise many patients living in rural areas. Unless the overall provision of service is excellent, providing an excellent service for only part of the population is untenable.

A purely centralised, regional service will have difficulty providing satisfactory care for elderly infirm patients, with limited mobility, who live in rural areas. General Surgeons with no vascular training, working in provincial or rural hospitals cannot be expected to spend the significant time required to triage patients with possible peripheral vascular disease simply to refer them on to vascular surgeons in distant tertiary centres. Many aspects of vascular surgery, relating both to patient assessments and operative procedures do not require tertiary facilities and have historically been competently performed by general surgeons. There are also occasions when our colleagues in other specialities require urgent interventional support for vascular complications. There remains a need in smaller centres for general surgeons with some vascular training to provide this local service supported by, and supporting, colleagues in tertiary centres.
RS05 CRAFT GROUP AUDIT FOR RURAL SURGEONS
Authors: Watters D. A. K. , Campbell G. , Pennington B. , Richardson G. , Lowe A. , Graham J.
Published: April 2007

Aims  To establish a prospective audit of surgical outcomes in regional and rural surgical practice and a strategy for recognising and managing outliers identified through audit.

Methods  Support Scheme for Rural Specialist Funding (SSRS – Round 6) was obtained. Five major centres: Geelong, Ballarat, Bendigo, Wagga Wagga and Lismore agreed to participate in a prospective audit from September 06 to March 07. Various individual surgeons and smaller centres also offered to provide audits of their individual practice (Broome, Bathurst, Wangaratta, Kalgoorlie, Alice Springs). Five operations were audited: colorectal cancer surgery, breast cancer surgery, thyroidectomy, inguinal hernia repair and laparoscopic cholecystectomy. Indicators included mortality, unplanned re‐operation, anastomotic leak, recurrent laryngeal nerve damage, bile leak, postoperative pain for >2 months requiring analgesia or referral to a pain clinic after hernia repair, and the same indicators as the breast cancer audit. Anonymity of surgeons and patients was maintained.

Results  At the time of abstract submission all five major sites had appointed project officers. Each centre is contributing about 40+ cases per month. By early December Geelong had collected thyroids (21), laparoscopic cholecystectomy (78 − 2 conversions), breast cancer (17 − 8 mastectomies), adult inguinal hernia repair (38), colorectal surgery (50 − 13 right hemi, 14 anterior resections).

Conclusion  It is hoped that the existence of rural surgery craft group audit will provide indicators to assess the outcomes of any individual surgeon who chooses to contribute and compare their performance.
RS06 INTRODUCTION OF LAPAROSCOPIC RESECTIONAL COLORECTAL SURGERY TO NAIVE HOSPITALS
Authors: Ragg J. , Guest G. D. , Thorne M. , Watters D. , Hurley J. , Crowley S.
Published: April 2007

Purpose  Laparoscopic resectional colorectal surgery (LRCS) was introduced to Australia in the early 90’s but gained widespread acceptance only recently. Most published studies demonstrating safety, benefits and acceptable outcomes are from centres with established colorectal units with extensive experience in LRCS. Hospitals looking to introduce this technique realise a long learning curve exists and hence the introduction of LRCS may initially result in a drop in standard of care. It is prudent to ask how and can LRCS be safely introduced to LCRS naïve hospitals.

Methods  During introduction of LRCS, surgeons and theatre nurses undertook additional training courses and were encouraged to undertake initial cases with support from a colleague. Clinical pathways were introduced for post operative care.

A well established colorectal database was used to prospectively gather data. All LRCS cases during the initial 9 months were included. Comparison is made with non LRCS from the same period, data from the previous year and published studies.

Results  95 LRCS cases were studied representing 57% (95/166) of resectional colorectal cases. Of 14 surgeons performing colorectal procedures, 5 undertook LRCS at 2 hospitals previously naïve to LRCS. Favourable results were demonstrated relative to non LRCS performed in the same period compared over major clinical indicators (death, anastomotic leak, return to theatre, unplanned ICU admission, re‐admission). Improvements were observed in length of hospital stay and ICU days.

Conclusion  We believe this series demonstrates that LRCS can be rapidly, safely and effectively introduced to a LRCS naïve health service.
RS08 THE NEW ZEALAND MOBILE SURGICAL SERVICE: 5 YEARS ON THE ROAD
Authors: Yule A. G. , Gowland S.
Published: April 2007

Purpose  Out of the ashes of a radically pruned Health service the “Surgical Bus” (SB) has risen to redress some of the loss of access to surgery suffered by rural New Zealand (NZ). The mobile surgical service has also contributed towards several of the other stated goals of provision of equitable access healthcare to rural NZ. This study examines the performance of the SB over its first 5 years.

Methodology  Mobile Surgical Services (MSS) has prospectively collected data on the SB. Assessment has been made of number and type of procedure, length of stay and complications. Services for children, services for Maori, social benefits, upskilling for rural staff, training gains through telepresence surgery and cost were also reviewed.

Results  6500 procedures have been performed in the 5 year period 1 March 2002 to 28 February 2007. 6% of patients had complications with 2% having infection.

Children (15 yrs of age or younger) made up 40% of patients treated and 26% were Maori. The SB has traveled 50,000 Km/year, has visited 21 rural centres and has had 9 different specialty services contributing. There have been 145 Telepresence sessions undertaken.

Conclusion  The SB has significantly improved specialist surgical services to many rural areas in NZ over the last 5 years. This is in line with Government health policy of equitable access.
RS09 TO SPRINT OR TO STROLL THAT IS THE QUESTION. EVOLUTION OF SURGICAL SERVICES IN A REGIONAL CENTRE. A THREE YEAR REVIEW
Authors: Desai D. , Almehdi R.
Published: April 2007

Purpose  Mackay Base Hospital is a regional hub for the North of Queensland’s Centre.

There is a definite demographic growth in this region due to the mining industry. The study aimed to identify if this was reflected by a similar growth in the surgical services’ volume and diversity and to recognise the challenges that face this process.

Methodology  Between 2004 and 2006 analysis was done to prospectively collected data banks relevant to both operative and endoscopic procedures. This was compared to other productivity factors like numbers of surgical, anaesthetic and nursing staff respectively. The advent of new technology and utilisation of experience in advanced laparoscopy was also assessed.

Results  In spite of a general trend of lack of permanent surgeons &/or other support services, the number of all surgical procedures were either seen to increase(operative) or maintain a high plateau (scopes). There was an increase in incidence of all major cancers in the region, namely Skin, Colon and Breast respectively. There was a statistical inclination toward Laparoscopy mainly for Appendicectomy, Acute cholecystectomy, Bile duct explorations, Fundoplication and selected Colorectal procedures. Trauma surgery reflected a similar pattern of increase though the referrals to tertiary centres remained selective.

Conclusion  The application of advanced surgical techniques may be restricted by available resources and local experience, nevertheless perseverance (while reasonably recognising these limitations) gives a long term outcome that is quite encouraging and compatible to other established centres.
SE10 SURGICAL TEAMWORK: SYSTEMIC FUNCTIONAL LINGUISTICS AND THE ANALYSIS OF VERBAL AND NON VERBAL MEANING IN SURGERY
Authors: Cartmill J. , Moore A. , Butt D. , Squire L.
Published: April 2007

Purpose  Surgeons rely on teamwork, yet beyond an appreciation that some teams are more enjoyable to work in than others, or more effective, there is little understanding of the myriad complex interactions that make teamwork possible.

Techniques of systemic functional linguistics permit objective analysis of behaviour (often subtle or subliminal) that carries meaning; these techniques can be applied to surgical teamwork.

Methodology  Linguists came into the operating room initially for unobtrusive note taking and sketching. Increasing familiarity over several months allowed detailed audio visual analysis of surgery. Surgical sequences were recorded and analysed using Elan software. Recurring patterns of meaning were identified and catalogued.

Results  The techniques surgeons and their team members use to exchange meaning is made explicit in this study, which brings out the systemic character of the options for meaning available to surgical team members. A grammar, albeit one that encompasses meaning through gesture, touch, body position and gaze, as well as speech, is presented. This grammar captures not only the conventions, rules and consistencies of the surgical ensemble, it also brings out the rhythm, tone, and nuance of the teamwork interactions.

Conclusion  It is possible to analyze the subtle nuances of interaction that constitute teamwork during surgery. We hope that this work will help demystify the operating room and make it easier for junior staff to understand what is being “said” while making it possible for more experienced staff to recognize and optimise the teamwork so essential for the realization of a complex modern operation.