bluuebunny/crossref_metadata_2025 huggingface dataset:
ES04 TOTAL THYROIDECTOMY – DOES UNDERLYING PATHOLOGY EFFECT PARATHYROID AUTOTRANSPLANTATION AND RELATED COMPLICATIONS?
Authors: Ebrahimi H. , Lundgren C. I. , Sidhu S. B. , Sywak M. S. , Edhouse P. , Delbridge L. W.
Published: April 2007

Background  Total thyroidectomy (TT) is increasingly being accepted as the preferred surgical option for the treatment of a majority of benign and malignant thyroid conditions. Parathyroid autotransplantation is an accepted technique for retaining parathyroid function following TT. The present study aims to determine whether the underlying thyroid pathology has any effect on the number of parathyroid glands autotransplanted and subsequent complications.

Methods  A retrospective study of all TT cases performed by this unit in 2004–2005 was performed. The underlying pathology, number of parathyroid glands autotransplanted and incidence of temporary hypocalcaemia and permanent hypoparathyroidism were recorded.

Results  A total of 681 TT were analysed. Of these, 80 (11.7%) were for Graves’ disease and 601 (88.3%) were for other pathologies. For the Graves’ disease cases, 49 (61.3%) required 1 or less parathyroid glands to be autotransplanted and 31 (38.8%) required 2 or more. This is compared to 443 (73.7%) and 156 (26.0%) for non‐Graves’ disease cases (p = 0.023). There was also a significant difference (p = 0.025) in the incidence of temporary hypocalcaemia between Graves’, 10 (12.5%) and non‐Graves’ cases, 33 (5.5%). The incidence of permanent hypoparathyroidism was 1 (1.3%) and 5 (0.8%) for Graves’ and non‐Graves’ cases respectively (p = 0.529).

Conclusion  Total thyroidectomy for Graves’ disease does require the autotransplantation of significantly more parathyroid glands and increases the incidence of temporary hypocalcaemia post TT. It does not however significantly increase the incidence of permanent hypoparathyroidism.
ES07 MICROARRAY GENE EXPRESSION ANALYSIS OF HUMAN ADRENOCORTICAL TUMOURS
Authors: Soon P. S. H. , Sidhu S. B. , Benn D. E. , Gill A. , Robinson B. G. , McDonald K. L.
Published: April 2007

Introduction  Adrenal tumours are common, occurring in 7% of patients over the age of 50. Adrenocortical carcinomas, however, are rare, with an incidence of two per million population per year. The management of adrenocortical tumours is complex, compounded by the difficulty in discriminating benign from malignant tumours using conventional histology. A molecular marker which could reliably distinguish between the two groups would be valuable in patient management.

Objectives  The aim of this study was to identify molecular markers which will discriminate between adrenocortical carcinomas and adenomas using microarray gene expression analysis.

Methods  This study used RNA from 6 normal adrenal cortices, 16 adrenocortical adenomas and 12 carcinomas. Only samples with an RNA integrity number of 7.5 or greater were used. The samples were hybridised to Affymetrix HGU133plus2.0 genechips. Data analysis was performed with Partek and affylmgui softwares.

Results  Using a cutoff of B > 2 and M > 2 or <−2, 217 genes were found to be significantly differentially expressed between adrenocortical adenomas and carcinomas. Of these genes, 120 were unpregulated while 97 were downregulated. Seven of these genes have been selected for validation studies with real time reverse transcription polymerase chain reaction.

Conclusion  In this study, we found 217 genes which were significantly differentially expressed between adrenocortical adenomas and carcinomas. With validation and further studies, these genes will provide further insight into the pathogenesis of adrenocortical tumours as well as possibly proving to be reliable discriminators between adrenocortical adenomas and carcinomas.
ES08 DIAGNOSTIC AND THERAPEUTIC STRATEGIES OF ADRENOCORTICAL CARCINOMA‐A 3‐INSTITUTION EXPERIENCE
Authors: Imisairi A. H. , Hisham A.N. , Lennard T.W.J. , Bliss R.D. , Harrison B.J. , Perini M.
Published: April 2007

Objective  This paper reviews the diagnostic, therapeutic strategies and outcomes of ADCC in 3 Institutions between Newcastle and Sheffield in United Kingdom and Putrajaya, Malaysia.

Patients and Methods  A 10‐year retrospective analysis of proven cases of ADCC was collected from January 1997 to December 2006. The patients’ demographic data, clinical manifestation, site and size of the tumour were analysed. The record of metastasis, and therapeutic modality and outcomes were evaluated.

Results  A total of 22 cases of ADCC were documented in United Kingdom with 11 cases in each respective center. 16 cases were reviewed from Putrajaya. There was no gender preponderance and age significance. Cushing’s Syndrome was the most common clinical manifestation (36.4%) in United Kingdom and (37.5%) in Putrajaya. The mean size of the ADCC was 9.3 cm (5–15 cm) in Newcastle and 9.8 cm (6–15 cm) in Sheffield as compared to 15.7 cm (5–25 cm) in Putrajaya. There were 12(75%) of patients in Putrajaya were diagnosed with Stage IV disease upon presentation whilst only 3(27.3%) and 5(45.4%) patients had metastasis noted in Newcastle and Sheffield respectively. Of note, 7(63.3%) patients in Sheffield were offered radical adrenalectomy. Our data revealed that the 2 years survival of patients who had radical approach in Sheffield has the highest rate of survival of 8(72.7%) as compared to 5(45.4%) in Newcastle and 2(12.5%) in Putrajaya.

Conclusions  Surgical removal remains the only form of curative therapy and hope of prolonged survival. The poorer prognosis of patients in Putrajaya may be attributed to the advanced stage of the disease.
GS01 INGUINAL HERNIORRHAPHY USING KUGEL PATCH
Authors: Ali A. , Childs P. , Sanfilippo F.
Published: April 2007

Purpose  Inguinal hernia repair is one of the most frequently performed operations in general surgical practice. A variety of techniques have been used in the past with different results. The aim of the present study is to report our experience of inguinal hernia repair using the Kugel patch and to measure the frequency of postoperative recurrence and chronic groin pain.

Methodology  Data were recorded prospectively from a series of 333 inguinal hernia repairs performed between January 2004 to December 2006 using the Kugel patch technique. Wound infection, seroma, haematoma urinary retention, 6‐month recurrence and chronic groin pain were the outcome measures.

Results  The Kugel patch hernia repairs were performed in 284 patients during the 3‐year period. There were no recurrences or chronic groin pain within 6 months of the 333 repairs. There was only one reported wound infection. The average operating time for bilateral hernia repair was 40.5 minutes (SD 8.8). Recurrent hernias took an average of 26 minutes (SD6.2) to repair whilst unilateral hernias took an average of 23 minutes (SD 6.8). 5 (1.8%) of the 284 patients had urinary retention. The average operating time for 136 direct procedures was 27 minutes compared with 25 minutes for the 148 indirect procedures (p = 0.096, t‐test).

Conclusion  In this prospective series the Kugel hernia repair is associated with no post hernia repair groin pain and no recurrence within 6 months of the procedure. It is inexpensive compared with laparoscopic repair, and allows the surgeon to cover all potential defects with one piece of mesh.
GS11P LAPAROSCOPIC ANTERIOR RECTOPEXY: CURES RECTAL PROLAPSE AND IMPROVES PREOP CONSTIPATION WITHOUT INDUCING NEW‐ONSET CONSTIPATION
Authors: Collinson R. J. , Boons P. , Cunningham C. , Lindsey I.
Published: April 2007

Purpose  Abdominal posterior rectopexy for rectal prolapse produces the lowest recurrence rates. However, 50% are troubled by severe postoperative constipation. Resection mitigates this dysfunction but involves the risks of an anastomosis. We aimed to evaluate functional results with laparoscopic anterior rectopexy, a novel technique designed to avoid rectal denervation and constipation.

Methodology  Between January 2004 and December 2006 consecutive patients with rectal prolapse were offered undergoing laparoscopic anterior rectopexy. Patients were assessed preoperatively, at 3 and 12 months clinically and functionally (Wexner constipation and Faecal Incontinence Severity Index scores).

Results  63 consecutive patients underwent laparoscopic anterior rectopexy. In this period no patient underwent a perineal procedure. Follow‐up was for a median of 18 months (range 3–36 months). Minor complications occurred in 11%. There was one recurrence (2%), one conversion and no 30‐day mortality. Median operating time (144 mins) and length of stay (3 days) shortened with experience. Constipation improved in 78% and median constipation scores fell from 8 to 3 (p < 0.0001). In no patients was severe new‐onset constipation induced. Continence improved in 90% and median incontinence scores fell from 32 to 0 (p < 0.0001).

Conclusion  Laparoscopic anterior rectopexy cures rectal prolapse and corrects incontinence equivalent to a posterior rectopexy. However uniquely it improves associated constipation without inducing new severe constipation, with the morbidity profile of a minimally invasive procedure. These qualities enable it to become the new gold standard for rectal prolapse.
GS12P MANAGEMENT OF UPPER GASTROINTESTINAL HAEMORRHAGE IN A DISTRICT HOSPITAL
Authors: Dayoub I. , El‐Hasani S. , Kasem A. M. , Kamal T. , Muniyra H. , Chandra N. N.
Published: April 2007

Background  This study was conducted to assess the management of acute upper gastrointestinal bleeding in a district hospital and to compare these results with national guidelines and the published literature.

Materials And Methods  This prospective and retrospective study included 112 patients, mean age 66 years, who presented with acute upper gastrointestinal bleeding between July 2004 and February 2005. All patients were assigned a Rockall risk assessment score.

Results  The surgical on‐call teams managed all the patients according to an agreed protocol. 49 patients had a Rockall score > or = 4. Endoscopy was performed in all patients, with 60% accomplished within the first 24 hours. The most common cause found was peptic ulcer (30%). Therapeutic endoscopy was undertaken in 10 patients (9%) with a success rate of 70%. Open surgery was performed in 3 patients. One patient died after having surgery and the Rockall score was >5. Of the patients admitted with acute upper gastrointestinal bleeding, 90.2% were discharged without complication. 11 patients died (9.8%) and all of them from the high risk group with Rockall scores >5. Their mean hospital stay was 17.8 days (range, 2–43 days).

Conclusion  High‐standard results in acute upper gastrointestinal bleeding can be achieved in a district hospital. The management, including the use of the operating theatre facilities with operative and anaesthetic support, was safe and efficient. A 24‐hour‐a‐day endoscopy service is important to achieve early diagnosis and to plan management. A protocol and early endoscopy improve clinical outcome and reduce mortality, which occurred mostly among elderly patients with high risk scores. It is advisable to introduce the Rockall scoring system in practice.
GS15P IS THERE A BETTER WAY TO DETERMINE PRIVATE SURGICAL FEES IN NEW ZEALAND?
Authors: Windsor J. A. , Brown P. , Law M.
Published: April 2007

Purpose  In New Zealand, surgeons working in the private sector are reimbursed on a fee‐for‐service basis. Due to concerns that a truly competitive market does not exist, other countries have adopted a Relative Value Scale (RVS) to help determine a fair relative rate of reimbursements. No such scale exists in NZ for surgeons, but does so for anaesthetists.

Methodology  This study compares reimbursements to surgeons and anaesthetists from private insurers, other than Southern Cross, using data from 3186 procedures performed between 1996 and 2002. We calculate an implicit hourly rate of reimbursement and then compare the level of reimbursements between procedures and the variance of reimbursements within a procedure for surgeons and anaesthetists.

Results  The results demonstrate significantly greater variations in average reimbursements between procedures for surgeons than for anaesthetists. Furthermore, the variability of reimbursements is greater for reimbursements to surgeons within specific procedures, especially for those more recently introduced.

Conclusions  While the results do not necessarily imply that surgical reimbursements are inconsistent with underlying market rates, the results are consistent with the hypothesis that anaesthetist’s fees show greater stability because of the existence of a RVS. We conclude by suggesting that a RVS for determining private surgical fees should be given serious consideration in New Zealand.
GS20P SINGLE‐CENTRE EXPERIENCE WITH MESH REPAIR OF ABDOMINAL HERNIA IN CAPD PATIENTS
Authors: Johns E. M. , Poole G.
Published: April 2007

Purpose  Patients with end stage renal failure on continuous ambulatory peritoneal dialysis (CAPD) represent a potentially infected environment in which to use mesh for the repair of abdominal hernia. We present a review of our experience with these patients.

Methodology  Retrospective review of all mesh repairs of abdominal hernia in CAPD patients performed by the senior author from 1997–2006.

Results  46 patients had 54 hernias repaired (25 umbilical, 18 inguinal, 9 incisional and 2 epigastric) using polypropylene mesh. 13 patients had simultaneous Tenckhoff catheter insertion. Median age was 63 years (range 22–85) and 22 were diabetic. CAPD was commenced or recommenced a median of 2 weeks after the repair (range 0 days–6 weeks). 6 short‐term complications were recorded. 2 patients were treated for culture negative CAPD peritonitis within the first week after repair. 2 patients had localised wound bleeding and 1 patient was admitted with a wound infection. All were treated conservatively and no patient required mesh removal. 1 patient developed CAPD peritonitis at one month post‐operation and required Tenckhoff removal, subsequent laparotomy and conversion to haemodialysis. At a median follow‐up of 30 months (range 3–87) 29 patients were still alive and 2 patients were lost to follow‐up. There were 4 documented recurrences and 1 patient had been converted to haemodialysis because of hernia recurrence.

Conclusions  Mesh can be safely used to repair most hernias in CAPD patients. The results are comparable to those in healthy patients and mesh removal due to infection is extremely rare.
GS21P THE USE OF ADJUVANT THERAPIES IN COLORECTAL CANCER AT A REGIONAL CENTRE
Authors: Morrissey D. , Yang S. M. , Franz R.
Published: April 2007

Purpose  The use of adjuvant therapies in colorectal carcinoma is becoming more common. However, it can be logistically difficult for patients of regional hospitals to have access to such treatments. Our aim was to document the proportion of regional patients with colorectal cancer who received chemotherapy and/or radiotherapy.

Method  An audit of all patients treated for colorectal cancer at Toowoomba Base Hospital between 1 January 1990 and 1 April 2006 was undertaken. Chemotherapy use, radiotherapy use, anatomical location and histological grade of the cancers were examined.

Findings  Of the 225 patients who had surgery for Dukes B colonic carcinomas, 22.7% were given chemotherapy. This rate increased to 59.6% for Dukes C colon cancers. 141 rectal cancers were curatively excised during the prescribed period. 39 of these patients received radiotherapy (27.7%). Of these, only 2 (5.13%) had pre‐operative radiotherapy. 19 patients had rectal cancers which were considered non resectable and of these, 5 (26.3%) were treated with radiotherapy.

Conclusion  Despite the paucity of high level evidence showing a benefit in using adjuvant therapy in node negative colon cancers, a relatively large proportion of our regional patients with Dukes B adenocarcinomas were given chemotherapy. The rate of such therapy for Dukes C cancers was comparable to other studies. Fewer than expected patients with rectal adenocarcinomas had radiotherapy. Of those who did receive this, only a very small proportion received pre‐operative radiotherapy. It may be that the lower than expected rates of radiotherapy were due to this service being located about 130 km from Toowoomba Hospital.
GS23P PAEDIATRIC SURGERY PERFORMED BY GENERAL SURGEONS IN A PROVINCIAL NEW ZEALAND (NZ) HOSPITAL
Authors: Peng S. L. , Fancourt M. , Gilkison W. , Kyle S. , Mosquera D.
Published: April 2007

Purpose  To perform an audit of paediatric surgical patients in a provincial general surgical unit.

Methodology  Data was prospectively recorded using a standardized proforma on all children aged up to 15 yrs, seen between 11th December 2005 and 11th December 2006.

Results  There were 209 admissions (194 children), median age 8 yrs (6 wks–15 yrs) with 153 (73%) acutes. 37 children (18%) were under 2 yrs. Male : female ratio was 3 : 2. Procedures (n = 119) were appendicectomy (35), inguinal herniotomy (30), skin procedures (29), endoscopy (10), testicular (10) and others (5). The commonest acute and elective operations were appendicectomy and inguinal herniotomy respectively. 51% of operations were acute.

There were 10 tertiary hospital transfers (5%) for burns (4), pyloric stenosis (3), intussusseption (1), neonatal inguinal hernia (1) and pyoderma gangrenosum (1). Median age of transfers was 11 months (6 wks–14 yrs).

Complications were wound infection (1), post‐operative ileus (2) and infarcted ovary (1).

Conclusion  There are increasing moves towards centralization in paediatric surgery.1 With only 4 paediatric tertiary centres in NZ, many general surgeons routinely perform paediatric surgery. A large number of children presented to our surgical department. Around half of these children required surgery and half of operations were acute. There is still a significant need for general paediatric surgery in the provinces and hence close collaboration with specialist paediatric surgeons.
GS24P COMPLIANCE WITH SURGICAL ANTIBIOTIC PROPHYLAXIS GUIDELINES IN VICTORIA, AUSTRALIA
Authors: Russo P. L. , Bennett N. J. , Boardman C. J. , Richards M. J. , Bull A. L.
Published: April 2007

Purpose  To assess compliance with national and international guidelines for surgical antibiotic prophylaxis in Victorian public hospitals and observe trends over time when results were reported back to hospitals.

Methodology  Data on surgical antibiotic prophylaxis (drug choice, time of administration of first dose and duration) were collected as part of a surveillance system for hospital‐acquired infections from April 2003 until September 2006. Results (own hospital and aggregate) were reported to hospitals on a six‐monthly basis during this time.

Results  Compliance with guidelines is best for cardiac and orthopaedic surgery, less so for other types of surgery. Improvements have occurred over the time period following commencement of reporting, mainly in compliance with choice of antibiotics.

Conclusion  Feedback of results appears to have led to a decrease in the proportion of procedures where antibiotic prophylaxis is not considered to comply with guidelines, particularly for drug choice. There is still room for improvement, particularly with timing of administration and documentation of when antibiotics are administered. The VICNISS coordinating centre will continue to feed back results to hospitals on compliance with surgical antibiotic prophylaxis recommendations and to encourage both documentation and compliance.
GS28P LAPAROSCOPIC CHOLECYSTECTOMY FOR OBESE PATIENTS
Authors: Li S. W. , Moss D.
Published: April 2007

Background  Laparoscopic surgery is often perceived to be more difficult for obese patients. Middlemore Hospital has unique patient population with high prevalence of obesity. This is a pilot study to compare the outcome of obese and non‐obese patients who had laparoscopic cholecystectomy in our institution. Our hypothesis is that obese patients do not suffer more adverse postoperative outcome.

Methods  We reviewed all patients undergoing acute and elective cholecystectomy from January 2004 to December 2006, 100 obese patients were identified. The control group consists of 100 non‐obese patients matched for age, sex and type of admission. Outcome assessed includes length of recovery period, complication and conversion rate.

Results  Over the three year period there were 1400 cholecystectomies, of which 96% were commenced laparoscopically. Overall conversion rate was 3.8%. The obese group has increased rate of wound complication (10% vs 2%, p = 0.037) and conversion rate (8% vs 3.5%, p = 0.28). The two study groups have similar median length of postoperative stay of 4 days.

Conclusion  This confirms our hypothesis that it is safe for obese patients to have laparoscopic cholecystectomy. However there is increased risk of conversion and wound complication.
GS29P LAPAROSCOPIC APPENDICECTOMY: TO DO OR NOT TO DO
Authors: Reddy C. , Gunaratnam K.
Published: April 2007

Traditional teaching instructs us to remove a normal appendix during open appendicectomy, to avoid confusion during future presentations with right iliac fossa pain1. This ideology has been associated with a negative appendicectomy rate in the order of 15–20%2. The risk of missing submucosal appendicitis, of which the clinical significance remains unclear, has also propagated the decision to remove the ‘normal’ appendix. The advent of laparoscopy has lead to an improvement in the diagnosis of alternate pathology in the context of suspected appendicitis, particularly in the female population. There however still remains some confusion and concern amongst members of the surgical community as to whether appendicectomy should be performed in the context of normal other laparoscopic findings. We present the results of a retrospective review of 400 patients who underwent laparoscopy (+/− appendicectomy) at Westmead Hospital (Sydney, Australia) from July 2004 to June 2006 for suspected appendicitis, or for the investigation of right iliac fossa pain. Follow‐up ranged from 6 months to 2.5 years. Of the 200 patients reviewed to date, in the 120 patients who underwent laparoscopy, 84% proceeded to have appendicectomies despite normal operative findings in one third of cases. This led to a high negative appendicectomy rate of 34%. In our experience, removal of the appendix is not justified when the appendix appears normal at laparoscopy, even in the absence of alternate pathology.
GS04 CAN EVIDENCE BASED PROFORMA’S AND DEPARTMENTAL AUDIT IMPROVE THE MANAGEMENT OF ACUTE PANCREATITIS?
Authors: Lienert A. R. , Connnor S. J. , Bagshaw P. F.
Published: April 2007

Purpose  To assess whether evidence based proforma’s and departmental audit can improve the management of patients with acute pancreatitis as compared to published international guidelines.

Methodology  From June 2005 all patients admitted with acute pancreatitis were required to have an evidence based proforma prospectively completed. In March 2006 an interim analysis was performed and presented to the department of General Surgery highlighting areas which deviated from published guidelines. Key clinical indicators were analysed pre and post presentation.

Results  Two hundred and eighty one patients were admitted with acute pancreatitis, 168 (60%) of whom were analysed in the interim analysis. The median (range) age was 59 (12–96) years and the aetiology was gallstones in 149/281 (53%) patients. 140/281 (50%) patients had predicted severe pancreatitis, but there was no difference pre and post departmental presentation (85/168 (51%) vs. 56/113 (50%), p = 0.865). On univariate analysis following the departmental presentation there was a significant reduction in the number of CT scans performed (76/168 (45%) vs. 30/113 (27%), p = 0.002), an increase in the number of patients undergoing definitive treatment for mild biliary pancreatitis (36/65 (55%) vs. 35/43 (81%), p = 0.006) and a reduction in mortality (9/168 (5%) vs. 1/113 (1%), p = 0.047). Multivariate analysis confirmed departmental presentation as independent prognostic factor in reducing the number of CT scans (p < 0.001) and increasing definitive treatment of mild biliary pancreatitis (p = 0.02).

Conclusions  For Audit to change practice evidence based protocols alone are not sufficient. Feedback to clinicians would appear to be a powerful motivator of change.
GS06 A PROSPECTIVE NON‐RANDOMIZED STUDY OF 737 CONSECUTIVE CASES OF LAPAROSCOPIC INGUINAL/FEMORAL HERNIA REPAIR: SUPERIORITY OF THE LAPAROSCOPIC EXTRAPERITONEAL APPROACH BY A SPECIALIST HERNIOLOGIST
Authors: Tran H. M.
Published: April 2007

Introduction  Laparoscopic hernia repair remains controversial. This study aims to assess its safety and efficacy by a specialist herniologist.

Materials and Methods  A prospective assessment of all patients referred from 1st January 2002 to 31st December 2006 for laparoscopic extra‐peritoneal inguinal/femoral hernia repair was undertaken. Polypropylene mesh was used prior to June 2004 and light weight mesh after. Patients were followed up for 5 years.

Results  There were 737 hernias performed in 525 patients (including 34 recurrent and 78 Workers Compensation cases) with a median age of 51 years. Mean operation time was 48 minutes for unilateral and 65 minutes for bilateral. Mean follow‐up was 3 years with one recurrence. Conversion to open operation occurred in 4 patients. Day surgery was achieved in 92% of cases with most of those staying overnight for social reasons. There was no mortality. Morbidity was low: 2 cases of urinary retention, 1 case of minor urethral bleeding and 3 cases of pneumomediastinum. Return to work/resumption of full activities occurred at a mean of 14 days. Significant chronic pain occurred in 4 patients (1 with light weight mesh) and all settled with Carbamazepine or Neurontin.

Conclusions  Laparoscopic inguinal/femoral hernia repair can safely be performed as day cases with zero mortality, minimal morbidity, early resumption of physical activities and low recurrence. The use of light weight mesh resulted in fewer cases of chronic pain. Preoperative catheterization seemed to reduce incidence of urinary retention. Careful preoperative counseling achieved identical resumption of physical activities/work with Workers’ Compensation cases.
GS09 AUTOPSY IN GENERAL SURGERY: A COMPARISON OF PRACTICE AND OPINION
Authors: Stiven P. N. , Frampton C. , Lewis D. R.
Published: April 2007

Objective  To examine current practice regarding autopsy requests and assess consultant opinion in a general surgical department.

Methods  100 patient deaths in a general surgical department, over a 2 year period, were randomly selected. A brief summary of each admission was distributed to 13 general surgeons who were asked to comment whether; cases should have been discussed with the coroner, a coroner’s autopsy should have been performed, a hospital post mortem should have been performed and whether it would be appropriate to complete a death certificate without post mortem. Surgeon responses were compared with actual outcomes.

Results  The majority of patients were elderly (median age 79 yrs, 49% > 80 yrs), admitted acutely (92%) and did not undergo an operation (73%). Patients who had undergone recent operation were more likely to be referred to the coroner (p < 0.001) and more likely to undergo coroners autopsy (p = 0.011). Older patients and those admitted from a rest home were less likely to be referred to the coroner (p < 0.001 & 0.02 respectively) or undergo coroners autopsy (p = 0.002). The survey predicted more referrals to the coroner (p = 0.001), more hospital autopsies (p < 0.001), and that the treating doctor would complete the certificate of death less often than actually happened (p = 0.004).

Conclusions  General surgeons consider autopsy to be necessary more often than current practice in our institution. The decline in autopsy rates may compromise the education of surgeons and trainees.
HS10 FLAP COVERAGE IN UPPER LIMB INJURIES
Authors: Teoh L. C.
Published: April 2007

The severely of skin loss and the options of resurfacing is determined by taking into account the following factors. 1) The size & location of the defect, 2) The depth of the defect and the quality of the tissue bed, 3) The extent of exposed vital structures, 4) The associated bone and other tissues injuries, 5) The availability of donor skin flap.

The size of the defect is the most important factor in choosing a resurfacing option. The size can be categorized into small, medium and large. A small defect is one that is less than 5 cm2 in size, a medium defect is between 5 to 15 cm2, and a large defect is greater than 15 cm2.

Local flaps are usually sufficient to cover small defects <5 cm2. These are advancement flaps or rotation and transposition flaps.

Regional flaps are indicated to resurface these medium‐sized defects 5 to 15 cm2. The donor is within the same region of the hand, from one of the digits or from dorsum and palmar surfaces of the hand. It is usually based on vascular or NV pedicles.

Large defects >15 cm2 will need larger flaps for coverage. These large flaps are pedicled distant flaps and free flaps. In these severe injuries, there is usually associated bone and soft tissues injuries. These injuries can be reconstructed as a single stage combined reconstruction or multi‐staged reconstructions. The resurfacing should always be given priority.
HS11 POST‐OPERATIVE HAND PAIN ASSESSMENT
Authors: Teoh L. C.
Published: April 2007

Hand is a very heavily innervated organ. Therefore any traumatic injury or surgical insults will provoke severe pain. Adequate pain management should be given in all the cases. Early motion is always necessary in all operated hands. It is uncertain as to the causes of excessive pain occurring in some patient. It is interesting to note that a hand with complex injury require flap surgery can be less painful in comparison to a lesser crushing injury that require minor repairs.

Excessive pain that is out of proportion should be identified early in the follow up. Patient with pain that is unrelenting, not relieved with NSAID and disturbs sleep (after excluding all causes of complication) is a candidate to developing CRPS. In the first 2 weeks of follow up this is the stage “nascent CRPS”.

Nascent CRPS can be aborted if correctly managed. All pain provoking therapy should be stopped. Only active motion that is not pain provoking is allowed. Contact stimulation is very useful in reducing pain, it works on the basis of “gate‐control”. Self gentle rubbing of the hand on rough fabric cushion is performed hourly for 5–15 minutes. The gentle motion also moves all the normal joints in the upper limb that further suppresses pain.

Excessive pain that continues beyond the duration of 6 weeks is very likely to develop into established CRPS.
HS04 THE USE OF A VISUAL HAND CHART TO AID IN COMMUNICATION OF HAND INJURIES
Authors: Friederich L. J. , Page R. D.
Published: April 2007

The hand is one of the most commonly injured parts of the body, however in a climate of increasingly reduced anatomical teaching, junior doctors are ill equipped to assess and describe hand injuries they encounter in their Emergency Department rotations.

Hand and Plastic surgery registrars are often very busy and can find it time consuming to extract the information they require from junior doctors. Their workload can be managed significantly more effectively with clear, concise and accurate descriptions of hand injuries.

This study was designed to assess the effect of a visual ‘hand chart’ on junior doctor's assessment and description of common hand injuries. The chart illustrates basic underlying anatomical structures and their relevant surface landmarks, together with the appropriate anatomical terms to describe them.

Two groups of 25 junior doctors were tested. Group A were shown a set of 10 digital images of simple hand injuries and asked to transcribe what they would say to the on call hand surgeon. Group B were given the visual ‘hand chart’ and tested in a similar fashion with the same set of images. Group A was later retested with the ‘hand chart’ and a second set of 10 images. Simple demographic information was also collected from participants asking their year since graduation and any prior experience with hand surgery.

A marking key was used to score participants answers and the results were analysed using the students t‐test. Significant differences were found between the groups suggesting that the hand chart was a valuable aid in communication. It may thus prove useful in wider contexts, such as remote and rural medical stations.
HS06 THE CURRENT MEDICAL MANAGEMENT OF NEUROPATHIC PAIN
Authors: Acland R. H.
Published: April 2007

This title is sure to be a turnoff for most surgeons!

Neuropathic pain is a term that has been brought to prominence with the marketing of the drug, neurontin. Neuropathic along with nociceptive are two general terms used to classify pain symptoms. Nociceptive often refers to pain symptoms that are amenable to the surgical knife whereas neuropathic often involves more central mechanisms.

Management of neuropathic pain is generally based around the use of prescription medication. I will briefly detail what is hot and what is not in neuropathic analgesia. Information will be provided on neuromodulation/surgical techniques that modulate central nervous system transmission. My experience of spinal cord stimulation in a case of extreme CRPS will be presented.
HS08 CONGENITAL HAND: THE DEFORMITY‐DEFICIENCY INDEX
Authors: Teoh L. C.
Published: April 2007

Congenital hand is a complex and vast subject therefore classification is very necessary for the purpose of teaching, communication and guide treatment. The first comprehensive and yet user friendly classification was proposed by Swanson et al. in 1976. This classification based on etiopathogenic is popularly known as the ‘IFSSH 7 groups classification’. (I) Failure of formation: transverse or longitudinal (II) Failure of differentiation (III) Polydactyly (IV) Overgrowth (V) Undergrowth (VI) Amniotic band syndrome (VII) Generalized skeletal syndromes. However this classification was found not able to satisfactorily classify 20–30% of cases.

Other classifications based on genetic defects, teratogenic sequence and syndromics were being introduced previously and continue to be used parallel with the IFSSH classification. Furthermore the classification continue to be besieged by multiple morphological types of deformity in a same hand. Ogino introduced the JSSH expanded classification to address some of the deficiencies of the IFSSH classification.

For a beginner in treating congenital hand, it is indeed daunting, as the variations in morphology, the degree of severity and functional deficit even in the same diagnosis can be very different. It is usual to find further sub classifications.

For the purpose of guiding treatment, I propose the concept of deformity/ deficiency index. Group I) The imbalance/ small in size II) Extra digits III) Mal positioned/ Mal‐aligned IV) Poor/ No function V) Total absent. The residual functional decreases from group I to V. And similarly the reconstruction becomes complex and difficult.
HN02 PATIENT RESPONSES TO THEIR MULTIDISCIPLINARY HEAD AND NECK CLINIC VISIT
Authors: Streit J. B. F. , Oates J. , David C. , Sneddon L. , Martin R. , Obrien C.
Published: April 2007

Purpose  To prospectively assess the subjective experience of patients and the degree of benefit they felt they gained from attending the Multidisciplinary Head and Neck Clinic (MDHNC).

Methodology  An internally validated questionnaire of patient responses to their experiences at the MDHNC was implemented prospectively. Data were gathered between May and September 2006. The questionnaire consisted of 36 questions, addressing 3 components of the clinic; before, during and after attendance. Twenty four of 48 questionnaires were completed.

Results  Patients’ experiences of the clinic were mainly positive. All patients reported feeling adequately informed about both illness and their treatment options. No patients left with unanswered questions. All, but one patient, tolerated the examination well, although 4 patients were unprepared for the number of people present at the clinic. Twenty two patients especially valued the post‐clinic discussion with their specialist. Five patients felt that insufficient information about treatment choice was provided to their family. No discrepancy between internal validation questions was recorded.

Conclusion  Patients expressed a high level of appreciation for the care provided in the multidisciplinary clinic. Contrary to our expectations, patients generally did not mind examination in the presence of a large number of clinicians. Most patients reported particularly valuing the discussion with the treating specialist after the clinic visit. Reducing waiting times, providing clearly written plans for treatment resulting from the clinic, and distributing more information to assist individuals accompanying patients, emerged as target areas for future improvement.
HN05 AN ANALYSIS OF COMPLICATIONS FOLLOWING SURGICAL TREATMENT OF BENIGN PAROTID DISEASE
Authors: Mclean N. R. , Nouraei S. A. R. , Ismail Y. , Milner R. H. , Thomson P. J. , Welch A. R.
Published: April 2007

The purpose of this study was to review the incidence of and risk factors for, developing complications following parotidectomy for benign disease. In an 11 year period, 162 parotidectomies were performed for benign disease, the commonest being PSA (43%), Warthin’s (30%) and sialadenitis (22%). There were 71 males/91 females, mean age was 58 years and 79% presented with a painless mass of 26 months. 134 patients underwent a superficial parotidectomy and the mean follow‐up was 23 months. Post‐operatively 40% developed a temporary facial palsy, 11% had Frey’s syndrome and 10% developed a salivary fistula. Sialadenitis was a significant risk factor for the development of facial nerve palsy (p < 0.01) and increased the risk of salivary fistulae. Parotid duct ligation increased the risk of nerve palsy in the distribution of the zygomatic and buccal branches. Operations for Warthin’s tumour were associated with an elevated risk of dysfunction of the cervical branch of the facial nerve. Half of the patients had intra‐operative facial nerve stimulation and this uninfluenced the liklehood of facial paresis. The recovery of facial nerve function showed a biphasic distribution, with 90% of patients having normal function within 12 months, followed by a slower recovery rate for up to two years. In conclusion, the incidence of post‐operative complications was influenced by the pathology, with inflammatory lesions significantly increasing the risk of facial nerve dysfunction and other complications, but also by variations in surgical practice, such as parotid duct ligation. Overall, the incidence of permanent facial palsy was under 2%, but a temporary nerve palsy was common at 40%, with most patients regaining normal function within one year of surgery.
HN08P AUDIT OF 115 CONSECUTIVE PARATHYROIDECTOMIES IN PATIENTS WITH RENAL HYPERPARATHYROIDISM
Authors: Low T. H. , Clark J. , Gao K. , Shannon K. , O’Brien C.
Published: April 2007

Objectives  To review the characteristics and outcomes of patients undergoing parathyroidectomy for renal (secondary and tertiary) hyperparathyroidism.

Methods  Review of prospectively collected data from a dedicated head and neck database at RPAH between 1988 and 2004. A total of 115 patients underwent exploratory parathyroidectomy.

Results  Common indications for parathyroidectomy included hypercalcaemia, renal osteodystrophy, calciphylaxis and calcinosis, bone or joint pain, and pruritus. Sixty‐nine patients had subtotal parathyroidectomy (STP), 47 had total parathyroidectomy (TP) of which 4 had total parathyroidectomy with autotransplant (TPA). Ten patients required re‐exploration for recurrent hyperparathyroidism at a median time to reoperation of 55 months. Of those, 8 had STP, 1 had TP, and 1 had TPA. Predictors of recurrent hyperparathyroidism included higher post operative PTH level (median of 22.5 pmol/L vs 3.4 pmol/L) and higher total parathyroid weight (median of 7.75 gm vs 2.9 gm). 97% of patients reported resolution of symptoms on follow‐up. The average length of hospital admission was 4.4 days. Morbidity of this series included wound infection (0.8%), temporary vocal cord paralysis (0.8%), seizure due to severe hypocalcaemia (0.8%) and neck haematomas requiring evacuation (0.8%).

Conclusions  Parathyroidectomy is effective in the management of renal hyperparathyroidism. Subtotal parathyroidectomy is associated with a higher re‐exploration rate. Predictors for recurrent hyperparathyroidism include total parathyroid weight and post‐operative PTH level.
HN09P ASSESSMENT OF FREE FIBULAR BONE IN THE RECONSTRUCTED MANDIBLE USING THREE‐DIMENSIONAL COMPUTER GENERATED IMAGES
Authors: Nabi H. , Jeeves A. , Caplash Y.
Published: April 2007

We report the preliminary results of the Royal Adelaide Hospital experience with multidimensional simulated views of the fibula‐flap reconstructed mandible. The free fibular flap is a well recognised option for mandibular reconstruction. What is not well understood however is how the fibula behaves in comparison to the dentate mandible. To date, skeletal remodelling and bone atrophy has only been assessed using standard orthopantogram films. For many years three‐dimensional (3D) computer generated models using data from CT scans have been utilised for craniofacial reconstruction. We proposed that these images will enable us to more accurately visualise the integration of the transplanted graft within the mandible. We recalled and CT scanned patients from 2004 to 2006 that underwent free fibular flaps for reconstruction of mandibular malignancy and performed 3D reconstruction of these images. This is the first reported series of multidimensional computer generated images to assess bone in the reconstructed mandible.
HP10 LAPAROSCOPIC RESECTION OF SUBMUCOSAL GASTRIC LESIONS – THE WHANGAREI EXPERIENCE
Authors: Yang J. Y. , Krishna G.
Published: April 2007

Purpose  To evaluate safety of laparoscopic resection of submucosal gastric lesions performed in Whangarei Based Hospital.

Methodology  From November 2002 to December 2006, 8 consecutive patients underwent the above mention surgery. (M : F = 5 : 3; Average age 63 [range, 43–83]). All patients underwent pre‐operative gastroscopy. Wedge resections were performed for anterior wall lesions. (n = 3). Posterior wall lesions were resected via transgastric approach. (n = 4). Retroperitoneal resection was performed for the foregut duplication cyst. (n = 1). All except one lesion were resected using endoscopic GIA stapler. The medical records of the patients were reviewed retrospectively.

Results  All patients were successfully treated laparoscopically. No conversion to open surgery. Pathology included: Gastrointestinal‐stromal tumor (GIST) (n = 5), Malignant leiomyosarcoma (n = 1), Ectopic pancreas (n = 1), and Foregut duplication cysts (n = 1). All achieved adequate negative surgical margin. Average operation time was 106.14 minutes. [Range, 75–150]. Average length of hospital stay was 3.42 days [range, 1–5]. Complication included one wound infection, and one pyloric stenosis. Average length of follow up was 10.96 months [range, 0.46–31.73]. No recurrence detected and all are still alive till date.

Conclusion  Laparoscopic resection of submucosal gastric lesions is a safe and appropriate alternative to open surgery. Its main advantage over open technique includes shorter length of hospital stay, lower recurrence rate and lower mortality rates. Surgical technique depends very much on tumor size and location. Outcome of the patients described from our centre is comparable to the others published till date.
HP11 LYMPH NODE METASTASES AND MICRO‐METASTASES IN SURGERY FOR OESOPHAGEAL CANCER
Authors: Jamieson G. G.
Published: April 2007

The incidence of lymph node metastases in both squamous cell cancer and adenocarcinoma of the oesophagus increases from about 25% for T1 tumours to 100% for T4 tumours.

The absolute number of nodes involved also greatly influences the chance of survival. If no nodes are involved, then cure with oesophagectomy approaches 100%, whilst if more than 10 nodes are involved, cure is close to zero.

The introduction of immunohistochemical staining techniques has shown that malignant cells in lymph nodes occur more frequently than previously thought. For instance, figures from seven studies of oesophagectomy and lymphadenectomy for squamous cancer showed that 349 patients were classified histologically as NO, and yet 30% of the patients were shown to have micro‐metastases by immunohistochemical staining. For adenocarcinoma, the figures are eight studies, 353 classified NO and 25% shown to have micro‐metastases in lymph nodes.

However, there are difficulties. First, there is no consensus on how many sections to cut for each node, and different studies which have looked at 1 section, 3 sections and 5 sections respectively, have produced quite different results. Second, there is no agreement on what constitutes a micro‐metastasis. It appears that some malignant cells in nodes are actually “in transit” at the time of their removal and may not be metastases at all.

Since lymph node status is assuming an ever greater role in the treatment of oesophageal cancer, the necessity for these problems to be resolved is important.
HP12 THE ANATOMICAL BASIS OF THE SURGICAL TREATMENT OF GASTRO‐OESOPHAGEAL REFLUX: LESSONS FROM HISTORY AND SIMULATION
Authors: Windsor J. A. , Yassi R. , Cheng L. , Al‐Ali S. , Le Grice I. , Pullan A.
Published: April 2007

Purpose  To review the anatomical basis for anti‐reflux operations and describe a project designed to develop a 3D micro‐anatomical model of the gastro‐oesophageal junction with integrated physiological events.

Methodology and Results  A realistic 3D anatomically based computer model of the gastro‐oesophageal junction (GOJ) was constructed using cross‐sectional digital images from the Visible Human Project. A finite element mesh was constructed and an iterative fitting process provided smooth surfaces. For accurate simulation of physiologic function it is necessary to augment this geometric model with detailed micro‐structural information. A custom‐built, semi‐automated, extended‐volume imaging system was used to obtain images of the GOJ. The device consists of a three‐axis translation stage where a tissue sample embedded in wax can be sequentially imaged and milled. At each step the top surface was stained for fiber type and connective tissue and the image captured using a high resolution digital camera. Proof of principle was demonstrated with an en‐bloc harvested sheep GOJ and then repeated with a fresh autopsy human GOJ. The 3D microstructural model was constructed using the images with a total volume of 35.1 × 106 voxels. Clinical manometric measurements were used to inform mathematical modeling to simulate physiological events, such as swallowing.

Conclusions  This model may provide opportunities to examine the relationship of anatomy and physiology in health and disease of the GOJ, enhance patient education, enable theoretical drug trials and determine the relative importance of anatomical elements of anti‐reflux surgery.