bluuebunny/crossref_metadata_2025 huggingface dataset:
CT03 RESULTS OF LEFT CORONARY OSTIOPLASTY FOR PROXIMAL SHORT SEGMENT LEFT MAIN STENOSIS
Authors: Peeceeyen C. S. , Paterson H.
Published: April 2007

Background  Surgical angioplasty of left main coronary artery (LMCA) in critical left main stenosis has been described as an alternative to CABG to restore antegrade coronary perfusion. We review our experience with onlay saphenous vein patch augmentation for ostial and short segment proximal left main stenosis in selected patients.

Methods  All data were compiled prospectively and medical records reviewed. Follow up information obtained form cardiologists and local doctors through telephonic questionnaires.

Results  Between May 1997 and August 2005, 14 left coronary ostioplasties (9 posterior and 5 anterior approaches) were performed in 13 patients. One patient had to be taken off the study group because of failed posterior ostioplasty that was identified on table. Another patient who had previous CABG and persistent angina despite patent grafts, had symptomatic relief following left main ostioplasty.

No peri‐operative mortality or myocardial infarction. All patients were followed up for an average period of 5 years. One patient had kinked anterior onlay patch and underwent ostioplasty by posterior approach subsequently. One patient died two years postoperatively due to stroke. All others were leading active symptom free lives. 4 (3 posterior and 1 anterior) follow up coronary angiograms showed widely patent LMCAs.

Conclusion  Left coronary ostioplasty is a safe procedure, which promises excellent results.Eventhough it is considered as an alternative to CABG, in certain situations may be needed as an adjunct to patent grafts to achieve total revascularization. The anterior approach may be technically easier, but there is a definite risk of kinking of onlay patch.
CT04 ULTRA MINIMALLY INVASIVE MITRAL VALVE SURGERY WITHOUT AORTIC CROSS CLAMP
Authors: Kumar S. , Ahmad R. , Greelish J. , Petracek M. , Balaguer J. , Byrne J.
Published: April 2007

Objective  We developed a technique for mitral valve surgery through an ultra small (5 cm) right lateral thoracotomy without aortic cross clamp. This study reports our combined ST. Thomas and Vanderbilt Heart Institutes five years experience with this technique.

Methods  Six hundred and twenty five (316 M /309 F; aged 22–75 mean of 62 years) underwent ultra minimally invasive mitral valve surgery between August 2000 and June 2006. Through a 5 centimeter right lateral thoracotomy along the 4th intercostal space access to the pericardium and the left atrium was gained. Cardiopulmonary bypass was instituted through femoral cannulation. Under cold fibrillatory arrest (28°C) without aortic cross clamp, mitral valve repair (n = 196) or replacement (n = 380), in addition to mitral valve procedure we performed tricuspid valve repair (n = 69), ASD/PFO closure (n = 201) and Maze (n = 156). Mean pre operative New York Heart Association function class was 2.2 ± 0.9. Twenty eight patients had ejection fraction less than 20%.

Results  Thirty‐day mortality was 1.28% (n = 8), Operating time, bypass time operating averaged 189 ± 52, 113 ± 35 minutes, respectively. Three patients had conversion to sternotomy. Fifteen patients (2.4%) underwent reexploration for bleeding. Average length of hospital stay from surgery to discharge was 6.85 ± 3 days. Ten patients (1.6%) had neurological events. Renal failure required hemodialysis in 5 patients (0.81%). Long term follow‐up results are awaited.

Conclusions  This study demonstrate that this simplified technique of ultra minimally invasive mitral valve surgery is reproducible and provides the least invasive operative approach with low mortality and morbidity with good cosmetic results.
CT05 MECHANICAL VALVE OR TISSUE VALVE: DO PATIENTS REGRET THEIR DECISION?
Authors: Macemon J. B. , Smith S. T. , Shaw D. P.
Published: April 2007

Purpose  Patients undergoing heart valve replacement are usually given a choice of valve type, mechanical or tissue. Each of these broad valve types has basic advantages and disadvantages which are discussed with the patient pre‐operatively, allowing them to make their decision. Post‐operatively patients have a variety of experiences, related to the valve itself, complications of the operation, and other co‐morbidities. The aim of this study was to determine patient satisfaction with the type of valve they chose, and whether they would have changed their mind given their experience.

Methodology  A one page postal survey with multiple choice questions was sent to 350 patients identified on the hospital database who had undergone cardiac valve replacement. The data obtained was compared to database information and analysed.

Results  Patients reported a variety of experiences following their discharge from hospital, from thrombo‐embolic events, arrhythmias, bruising and bleeding and ongoing warfarin dosing difficulties. Very few patients (<0.5%) stated that given their experience would have chosen a different type of valve. Also few patients (<5%) who received biological valve replacements ended up requiring warfarin long term.

Conclusions  Despite many patients having significant problems post‐operatively, very few regret their choice of valve type.
CR01 SHORT GUT SYNDROME
Authors: Heriot A. G.
Published: April 2007

Introduction  Short gut syndrome is a rare but devastating condition that can be associated with significant morbidity and mortality.

Methods  A literature search was performed using Medline, Embase, Ovid, and Cochrane database for studies between 1980 and 2005 using key words including intestinal failure and short gut syndrome. This was combined with clinical experience of patient management at tertiary colorectal surgical institutions in Australia (St Vincent’s, Melbourne), United Kingdom (St Mark’s, London), and the USA (Cleveland Clinic, Cleveland, Ohio).

Results  Short gut syndrome may occur secondary to reduction in actual or functional small bowel length, decreased absorptive capacity or functional ability. Three stages of intestinal failure can be recognised, hypersecretory (1–2 mths.), adaptive (3–12 mths.), and stabilisation (12–24 mths.) phases. There are significant pathophysiological changes to small bowel function during these stages affecting management of both fluid and electrolytes and nutrients, which must be proactively managed. Short gut syndrome often develops in the setting of a surgical catastrophe. Management can be summarised in terms of the 4 ‘R’s’, resuscitation, restitution, reconstruction, and rehabilitation. Patients should be managed in the context of a multidisciplinary team including gastroenterological, surgical, and nursing input. Home parenteral nutrition is essential for a proportion of the patients and small bowel transplantation may be a therapeutic option.

Discussion  Short gut syndrome is a complex management conundrum that has acute and chronic impact. A multidisciplinary team management, initially in a tertiary hospital environment, is essential.
CR14 EFFICACY OF PERITONECTOMY FOR PERITONEAL CARCINOMATOSIS FROM COLORECTAL CANCER
Authors: Yan T. D. , Morris D.L.
Published: April 2007

Purpose  The objectives of this report were to critically evaluate the efficacy of cytoreductive surgery combined with perioperative intraperitoneal chemotherapy (peritonectomy) for patients with peritoneal carcinomatosis from colorectal carcinoma.

Methodology  Forty patients with histologically confirmed peritoneal dissemination from colorectal cancer underwent peritonectomy at the St George Hospital, Sydney. All clinical and treatment‐related data were prospectively collected. Perioperative and survival results were analysed by intention‐to‐treat principle.

Results  The mean age at the time of surgery was 54 (S.D. = 14) years. There were 25 male patients. Three, 20 and 17 patients had well‐, moderately‐ and poorly‐differentiated tumours. The mean peritoneal cancer index was 12 (S.D. = 9). The mean operation duration was 7 (S.D. = 4) hours. The mean ICU, HDU and overall hospital stay was 1 (S.D. = 0.5), 5 (S.D. = 8) and 28 (S.D. = 34) days, respectively. Seventeen patients (42%) had moderate morbidity and required interventional procedures for resolution. Six patients (15%) had severe morbidity and required returning to ICU or operating theatre for management. There was no operative death. After a median follow‐up of 12 months since peritonectomy, the overall median survival was 30 months (range 1 to 46), with 1‐ and 2‐year survival of 67% and 61%, respectively.

Conclusions  Peritonectomy is a treatment option for selected patients with peritoneal carcinomatosis from colorectal carcinoma.
CR03 SMOKING IS A MAJOR RISK FACTOR FOR ANASTOMOTIC LEAK AFTER LOW ANTERIOR RESECTION
Authors: Richards C. H. , Hayes J. , Thomson‐Fawcett M. , Elliot T.
Published: April 2007

Purpose  To identify risk factors for anastomotic leak after colonic and rectal anastomosis at our institution.

Methodology  Data was collected prospectively by Otago Clinical Audit between 1/1/2000 and 31/12/2004. All operations involving a colonic or rectal anastomosis were included. For all patients the association between clinical anastomotic leakage and seven demographic and clinical variables was assessed. For the subgroup of 118 patients who underwent low anterior resection, data on a further fifteen variables related to operative technique, lifestyle factors and pathology were obtained from chart review. The association between these and leakage was assessed. Continuous variables were analysed with t‐tests. Categorical variables were analysed with univariate logistic regression, and Odds ratios (OR) with 95% confidence intervals (CI) were calculated.

Results  Over the five‐year period, 878 patients had an operation with a large bowel anastomosis. The overall rate of anastomotic leakage was 4.8% (42 of 878). In this group, longer operating time (p < 0.01) and a low rectal anastomosis (OR 3.12; CI 1.44, 6.41) were significantly associated with anastomotic leak. The leak rate for low anterior resections was 12.7% (15 of 118). Involved lymph nodes (OR 6.7; CI 1.31, 64.7), metastatic disease (OR 4.32; CI 1.12, 16.7) and cigarette smoking (OR 17.6; CI 4.84, 63.8) were significantly associated with anastomotic leak in this subgroup.

Conclusions  Current smokers and patients with advanced malignancy undergoing low anterior resection are at highest risk of anastomotic leak. These findings need to be confirmed prospectively and may have implications for clinical decision making.
CR05 BACTERIA NOT COMMONLY ASSOCIATED WITH HUMAN FAECES IMPLICATED IN ETIOLOGY OF POUCHITIS
Authors: Thompson‐Fawcett M. W. , Tannock G. W. , Lay C. , Baladjay L. , Daynes C. , McLeod R. S.
Published: April 2007

Purpose  Chronic pouchitis is an important long‐term complication following ileal pouch formation. Antibiotics reduce symptoms indicating bacteria play a role in pathogenesis. We analyzed and compared the bacterial content (microbiota) of stool collected from chronic pouchitis and familial adenomatous polyposis patients. Additionally, we compared the microbiota of chronic pouchitis patients on and off antibiotics. We aimed to determine which of the bacterial inhabitants of pouches had a role in the pathogenesis of pouchitis.

Methods  The stool microbiota of 17 patients with chronic pouchitis and of 15 familial adenomatous polyposis patients were analyzed by nucleic acid‐based methods (temporal temperature gradient gel electrophoretic profiles, fluorescence in situ hybridization with flow cytometry).

Results  The composition of the stool of chronic pouchitis and familial adenomatous polyposis patients was markedly different. Electrophoretic profiles of the stool microbiota of familial adenomatous patients clustered at the 80% level of similarity, whereas those of chronic pouchitis patients were disparate. The results of fluorescence in situ hybridization analysis showed that bacteria not commonly present in human faeces, nor in the stool of familial adenomatous polyposis patients, comprised about 50% of the stool microbiota of untreated chronic pouchitis patients. Antibiotic treatment reduced the proportion of these unknown bacteria in the stool of every chronic pouchitis patient.

Conclusion  Chronic pouchitis is associated with a microbiota that contains bacteria not commonly associated with human faeces. These bacteria are reduced with antibiotics and are likely to be the pathogenic agents of chronic pouchitis.
CR09 MANAGING FAECAL INCONTINENCE: THE ROLE OF PTQ INJECTIONS
Authors: Gett R. M. , Gyorki D. , Keck J. , Chen F. , Johnston M.
Published: April 2007

Purpose  An attenuated or disrupted anal sphincter can lead to faecal incontinence. One means of augmenting the sphincter is with the use of the silicone‐based biomaterial PTQ. The aim of this study was to evaluate the effectiveness of PTQ for the symptoms of passive faecal incontinence caused by a weak sphincter mechanism.

Methods  The patient records of 37 patients with passive faecal incontinence treated by 2 surgeons were examined. Their faecal incontinence scores were recorded from pre‐operative consultations and then in a follow‐up phone interview. Any adverse effects of treatment were recorded including significant pain, development of perianal abscesses and loss of injected silicone.

Results  Thirty‐seven patients received PTQ injections and completed follow up interviews. The main cause of faecal incontinence for this group was obstetric trauma. The follow‐up period was from 1–43 months with a median of 9 months. Twenty‐five patients experienced improvements in their faecal incontinence with 7 patients remaining unchanged and 5 worse symptomatically. The median improvement in faecal incontinence scores was 3 with an average of 3.76. It was important to note that the improvement was more marked in follow‐up over 18 months, with an average of 4.5. Four patients developed post injection abscesses, the most common adverse outcome and these were successfully treated with surgical drainage.

Conclusion  PTQ injections are a successful and minimally invasive treatment in the management of passive faecal incontinence. Two thirds of patients were improved with the injection of PTQ. Ten percent of the patients developed injection related abscesses.
ES10 SURGICAL MANAGEMENT OF WELL‐DIFFERENTIATED THYROID CANCERS; RISK GROUP STRATIFICATION AND PREDICTORS OF OUTCOME
Authors: Sarinah B. , Hisham A. N.
Published: April 2007

Objective  The aim of this study was to evaluate the predictive ability of outcomes in the management of well‐differentiated thyroid cancers (WDTC).

Method & Materials  A total of 115 patients operated for primary WDTC from 2002 to 2006 were included in this study. The patient’s demographic data, clinical manifestation, tumour characteristics and outcomes were reviewed. Risk group stratifications were applied using pTNM, AMES and MACIS prognostic systems.

Results  There were 81(70%) women and 34(30%) men with the median age of 44 years (ranged 6 to 78 years). Our results showed that at the median follow up period of 19 months, 93(80.1%) patients are still alive without recurrence disease, 5(4.3%) patients succumbed to the disease and 3(2.6%) are still alive with persisting disease. Local and nodal recurrence occurred in 14(12.2%) patients after primary surgery, of which 12(10.4%) patients already had nodal metastasis at presentation. All 5 patients who succumbed to the disease were proven to be advanced stage with nodal metastasis, coupled with incomplete surgical resection. In addition 3(2.6%) of them also had distant metastasis at presentation. All patients who died were in the high‐risk groups of AMES scoring system, either staged 3 or 4 of pTNM classification and/or scored more than 8 in MACIS prognostic scoring.

Conclusions  Our study emphasized the important of risk group stratification, which may indicate the need for a more aggressive surgical treatment. Poorer survival and outcome is expected if WDTC are locally advanced with nodal and distant metastasis coupled with inability to achieve complete resection.
ES17P IPTH FACILITATES DAY 1 DISCHARGE AFTER TOTAL THYROIDECTOMY: THE FIRST 50 CASES
Authors: Grodski S. , Lundgren C. , Sywak M. , Sidhu S. , Delbridge L.
Published: April 2007

In recent years there has been much published about the use of iPTH to predict hypocalcemia with a view to achieving earlier safe discharge after total thyroidectomy. After recent publication of Australian data on this practice we developed a new protocol for post‐operative calcium management with the aim of achieving a greater number of patients being safely discharged on the first post‐operative day. We present our experience with the first 50 patients being treated under the new protocol.

The first 50 patients admitted for total or completion thyroidectomy since May 2006 were studied and compared to 50 consecutive patients from 2002–2003, before the iPTH assay was used for thyroid surgery. iPTH was measured at 4‐hours post‐operatively and patients with iPTH in the normal range were discharged on the first post‐operative day. Statistical analysis was performed using the Mann‐Whitney U test.

Fifty patients in each group were analyzed. Mean age in the study group was 56 years (51 years in the control group) and sex distribution were similar in both groups (M : F, 1 : 3). Mean lowest post‐operative corrected calcium levels in the study group were 2.19 mmol/L (2.15 mmol/L in the control group). Length of stay was significantly shorter in the study group, mean 1.71 days vs. 2.20 days (P < 0.05).

The use of iPTH accurately predicts hypocalcemia after total thyroidectomy and can be used to facilitate safe early discharge for patients. This study demonstrates a significant reduction in the length of stay for patients undergoing total thyroidectomy when managed with a protocol based on a 4‐hour iPTH level.
ES19P LAPAROSCOPIC ADRENALECTOMY FOR PHAEOCHROMOCYTOMA IS SAFE AND EFFECTIVE
Authors: Meyer‐Rochow G. Y. , Sidhu S. B. , Soon P. S. , Sywak M. S. , Bambach C. P.
Published: April 2007

Purpose  The management of phaeochromocytomas (PC) can present a significant medical and technical operative challenge, however, few studies have assessed whether the outcome of LA of PC differs from other adrenal tumour types. The aim of this study was to determine whether there is any demonstrable difference in outcome for patients undergoing laparoscopic adrenalectomy (LA) for PC compared to other functioning or non‐functioning adrenal tumours.

Methodology  A retrospective review of all patients undergoing transperitoneal LA at our institution from 1995–2006 was performed. Outcome of laparoscopic PC resections was compared to the remaining LA resections.

Results  A total of 176 LA operations (106 left, 68 right, 2 bilateral) were identified of which 36 were performed for PC (18 left, 16 right and one bilateral). Median tumour size was greater in the PC group (35 mm, range 17–80 mm vs 25 mm, range 7–100 mm). 7 PC were considered to be of uncertain malignant potential and 29 to be histologically benign. There were 6 malignant tumours in the remaining cohort. There were 7 conversions to an open procedure of which one was a PC resection. There was one local recurrence of PC after LA in a patient with VHL disease during a median follow up of 6 years. Median operating time (173 vs 145 mins) and length of hospital stay (5 vs 3 days) for the PC patients were significantly longer compared to the remaining patients (p < 0.05). There were no increased complications in the PC group.

Conclusions  Our results demonstrate that LA for PC is safe and effective. There is no increased morbidity when LA is performed for PC compared to other functional and non functional adrenal tumours.
ES20P THE SURGICAL APPROACH TO THE ADRENAL GLAND – THE CHANGING PRACTICE
Authors: Rohana A. , Hisham A. N.
Published: April 2007

Introduction  Adrenal surgery in our institution has evolved from open surgery to laparoscopic approach. The aim of this paper was to evaluate the feasibility and changes in the practice of adrenal surgery.

Methods  A total of 129 consecutive patients who had adrenal surgery from October 1998 to 2006 were included in this study. The patient’s demographic data, clinical manifestation, tumour characteristics and duration of hospitalization were reviewed. The main outcome measures were operation time and perioperative complications.

Results  There were 77(59.7%) women and 52(40.3%) men with the mean age of 41.5 years (ranged 13 to 88 years old). All our patients were closely evaluated and monitored by endocrinologist. CT scan or MRI was routinely used to localize the adrenal lesions. 67(51.9%) patients had open transabdominal adrenalectomy (Group 1), 22(17.1%) patients had open posterior approach (Group 2) and 40(31.0%) patients had laparoscopic adrenalectomy (Group 3). The mean weight of the tumour in Group 1 was 312 grams (ranged10 to 1800 grams), Group 2 was 20 grams (ranged 5 to 200 grams) and Group 3 was 20 grams (ranged 10 to 70 grams). The average hospitalization for Group 1 was 6.5 days (ranged 3 to 14 days), Group 2 was 4.5 days (ranged 4 to 6 days) and Group 3 was 3.3 days (ranged 2 to 8 days).

Conclusions  Laparoscopic adrenalectomy is today the treatment of choice for most small benign adrenal tumour. Nonetheless in larger adrenal lesions and in adrenal malignancy open transabdominal adrenalectomy inevitably may still be the desired approach.
ES05 ROUTINE PARAFIBROMIN IMMUNOHISTOCHEMISTRY OF LARGE PARATHYROID ADENOMAS IS NOT AN EFFECTIVE SCREENING STRATEGY FOR CARCINOMA
Authors: Meyer‐Rochow G. Y. , Gill A. J. , Delbridge L. W. , Sidhu S. B. , Sywak M. S.
Published: April 2007

Purpose  Parathyroid carcinoma (PC) is rare and accounts for less than 1% of all cases of primary hyperparathyroidism (PHPT). The definitive histopathologic diagnosis of PC requires unequivocal invasion or metastasis which may be absent at first presentation. As a result, many cases of PC can only be diagnosed retrospectively. Parafibromin is the protein encoded by HRPT2 which is mutated and not expressed in many parathyroid carcinomas. Given that PCs generally weigh more than parathyroid adenomas (PA)s, we hypothesized that amongst large PAs there may be a high incidence of occult PC which could be identified by negative staining for parafibromin.

Methodology  57 parathyroid glands weighing greater than 2 grams excised from 1998–2006 were identified from the University of Sydney Endocrine Surgical Database. Two specimens with a histopathologic diagnosis of PC were excluded. Immunohistochemical staining for parafibromin was performed on the remaining 55 PAs.

Results  Of the 55 specimens stained for parafibromin only one definite negative stain was detected. This case was originally classified as an “atypical adenoma” because it showed nuclear and architectural atypia without unequivocal evidence of invasive growth. In view of the negative staining for parafibromin it therefore probably represents occult carcinoma. There has been no evidence of recurrence or metastasis after 6.5 years.

Conclusions  Complete loss of staining for parafibromin is very rare in giant parathyroid adenomas suggesting that occult carcinoma is equally rare. As a result routine immunohistochemical staining for parafibromin does not appear to be an effective screening test for carcinoma in large PA without histopathologic features of PC.
ES06 ADRENALECTOMY IN THE LAPAROSCOPIC ERA
Authors: Boldery J. , Gough I.
Published: April 2007

Background  Laparoscopic adrenalectomy is now the accepted standard of care in surgical treatment of most forms of adrenal pathology. This study aims to review our experience with both the laparoscopic and open techniques over a 12 year period.

Methods  A retrospective review of patients who underwent adrenalectomy by the same surgeon between January 1995 and December 2006 was performed. Laparoscopic and open adrenalectomy were compared in terms of operating time, length of stay and peri‐operative morbidity. Patient demographics and tumour characteristics were also studied.

Results  There were 82 adrenalectomies performed over the 12 year period. Sixty‐one were completed laparoscopically, 17 were performed open and four were converted from a laparoscopic to an open procedure. The indications for surgery included 30 phaeochromocytomas, 20 non‐functioning cortical adenomas, 9 aldosteronomas, 6 cortisol‐producing adenomas, 3 adrenocortical carcinomas, 3 pseudocysts, 3 cortical hyperplasias, 2 cortical cysts, and one each of heamangioma, angiolipoma, myelolipoma, haematoma, lymphoma and adrenal metastasis. The average operating time for laparoscopic adrenalectomy was 114 minutes vs 159 minutes for open procedures. Laparosopic adrenalectomy was associated with significantly shorter length of stay (2.6 vs 7.4 days) and decreased post‐operative morbidity (6.4% vs 42%). There was no peri‐operative mortality.

Conclusion  Our results concur with other retrospective reviews comparing laparoscopic and open adrenalectomy, demonstrating unequivocal advantages in terms of reduced operating time, length of stay and post‐operative morbidity.
GS10 AN ACUTE CARE SURGICAL SERVICE – A CHANGE IN PARADIGM
Authors: Parasyn A. , Truskett P. , Bennett M.
Published: April 2007

Background  The provision of acute surgical care in the public sector is becoming increasingly more difficult due to the limitation of resources. The lack of predictability of access to theatres during the working day has the effect of displacing elective cases or forcing some acute cases to be performed after hours. An Acute Care Surgical Service was constructed at the Prince of Wales Hospital so as to provide acute surgery in a more timely and efficient manner.

Methods  A roster of 8 general surgeons was constructed to provide onsite service during the working day and on call service after hours for a 52 week period. An acute care ward of 4 beds and an operating theatre was placed under the control of the Acute Care Surgeon (ACS). At the end of the ACS roster all patients whose treatment was incomplete were handed on to the next rostered ACS. Patient data and theatre utilisation data was prospectively collected and compared to the preceding 52 week period. Data was analysed using unpaired t‐test.

Results  Emergency theatre utilization during the day increased from 55% to 70%. There was a 15% reduction in acute care operating after hours. Fewer cases were done between midnight and 0800. There was more efficient use of the entire theatre block suggesting a significant cultural change. Staff satisfaction was high.

Conclusion  On site consultant driven surgical leadership has provided significant positive change to the provision of Acute Surgical Care in our institution. The paradigm shift in acute surgical care has improved patient and theatre management and stimulated a cultural change of efficiency.
GS17P SIMPLIFIED SURGERY FOR PILONIDAL SINUS
Authors: Claxton R. C.
Published: April 2007

A simplified operation suitable for most cases of straightforward pilonidal sinus is described in detail, and results of a personal series over 10 years are presented.

The operation involves simple excision with closure using deep tension sutures tied over a Telfa or Melolin roll after closing the skin with a separate layer of sutures. it may be carried out in the left or right lateral position or the prone position.

The operation is done as a day surgery procedure. 1–2 weeks off work may be necessary. Results compare favourably with other operations.

This operation has the advantages of simplicity, minimal post‐operative care and short time off work.
GS18P CASE SERIES: OBTURATOR HERNIA
Authors: Fernando M. A. P. , Strang J.
Published: April 2007

Obturator hernia is a very rare cause of small bowel obstruction accounting for only 0.073–1% of all hernias(1). Here we report two such cases.

A 69 year old female presents with 11/2 day history of colicky abdominal pain, vomiting and left medial thigh pain.

Past history includes an admission 2 year ago with small bowel obstruction treated conservatively, diverticular disease and no previous abdominal surgery.

At presentation she was unwell with recurrent faeculent vomiting. The abdomen was soft but generally tender. The left medial thigh was tender. No femoral hernia.

Abdominal films revealed a dilated loop of small bowel. Blood results: raised WCC 18.7 (4.0–10.0), CRP 66 (<5). Obturator hernia was suspected and CT confirmed this.

Laparotomy revealed a Richter’s hernia and viable small bowel. The defect was primarily closed. Patient was discharged 4 days post operatively.

An 89 year old female presented with several days of colicky abdominal pain and no bowel motions. She had multiple co‐morbidities including advanced Vascular Dementia, Asthma and Hypertension.

At presentation she was unwell. Abdominal exam revealed right illiac fossa guarding with a normal WCC and a raised CRP 78. Arterial blood gas analysis revealed a metabolic alklosis with respiratory compensation.

CT abdomen reported a small bowel obstruction due to right Obturator hernia with perforation. Due to her co‐morbidities she was managed conservatively and she passed away a week later.

The management of Obturator hernias is still open to debate with a wide variety of methods being described.
GS19P VERSAJET: A NOVEL APPROACH TO DEBRIDEMENT
Authors: Reddy C. , Goolam S. , Malka V.
Published: April 2007

The addition of hydrosurgery into our surgical armamentarium will aim to revolutionize surgical wound debridement. Hydrosurgery (Versajet1) utilizes a high pressure fine saline jet delivered via a compact hand‐piece to debride, irrigate and remove debri simultaneously. The hydrosurgery system is minimally invasive enabling debridement at the bedside, with minimal haemorrhage and analgesic requirements2. Its applications range from debridement of traumatic and non‐traumatic wounds (acute and chronic), wound lavage, debridement of variable thickness burns, wound bed preparation prior to skin grafting, and flap recontouring. Complex infected wounds (necrotising fasciitis) may also be debrided with potential maximal preservation of adjacent neurovasculature and viable tissues. We present five cases involving the use of the Versajet for the debridement of three diabetic foot wounds, one venous ulcer, and one traumatic chest wound. All hydro‐debridements were performed at the bedside with an average procedure time of 23 minutes (15–40 minutes), an average analgesic requirement of 10 mg morphine (5–15 mg), and with minimal encountered blood losses (including two patients on Coumarin). Only a single ward debridement procedure was required to achieve a healthy wound bed in all five patients. The Versajet enables debridement and wound bed preparation that is efficient, minimally invasive, and cost effective with reductions in hospital stay.
GS02 LATERAL LAPAROSCOPIC SPLENECTOMY: THE AUCKLAND CITY HOSPITAL EXPERIENCE
Authors: Windsor J. A. , Ranasinghe A.
Published: April 2007

Purpose  To review the experience with laparoscopic splenectomy, to determine it’s efficacy for treating immune thrombocytopaenic purpura (ITP) and to highlight key technical issues with the operation.

Methodology  All splenectomies performed between 1992 and 2005 were identified from the Otago Surgical Audit and the clinical notes reviewed, including the laboratory records for follow‐up data related to the haematologic cases.

Results  There were 289 splenectomies performed over the 13 year period. The indications were trauma (111, 38%), haematologic disease (93, 32%), incidental (40, 14%) splenic malignancy (39, 13%), and other (8, 3%). Of the 68 patients with ITP, 49 (72%) had a lateral laparoscopic splenectomy (LLS) with no conversions, a 5% complication rate and one mortality. Based on platelet counts and the requirement for maintenance steroids there was a complete response in 44 (68%) patients at >6 months, a partial response in 16 (24%) and no response in 5 (8%) patients. A short video presentation will highlight the key steps for the safe and efficient performance of the LLS, including patient and port positioning, the use of ultrasonic dissection, splenic pedicle stapling, and morcellation. The indications for hand‐port assisted laparoscopic and open splenectomy will be discussed.

Conclusions  The LLS is the preferred approach to splenectomy for all but massive splenomegaly and can be performed safely with careful attention to key technical issues.
GS25P POSTOPERATIVE NIL BY MOUTH – SIMPLY A SURGICAL DOGMA OR SCIENTIFICALLY SOUND PRACTICE?
Authors: Ashrafi A. N. , Pochin R.
Published: April 2007

Purpose  Traditionally, the postoperative management of patients undergoing gastrointestinal (GI) surgery has been to keep them ‘nil by mouth’ (NBM) until the postoperative ileus resolves. There is an evolving viewpoint that this practice is not based on sound evidence. This review examines the recent literature addressing this issue and aims to evaluate the role of early commencement of postoperative feeding compared to traditional NBM management.

Methodology  Three electronic databases (Ovid Medline, PubMed and Cochrane Reviews) were searched for randomised controlled trials (RCTs), reviews or meta‐analyses. Key words used included ‘nil by mouth’, ‘postoperative feeding’, and ‘early feeding’. Reference lists were crosschecked for additional studies.

Results and Conclusions  The practice of mandatory postoperative starvation and bowel rest is not supported by evidence. There is evidence from several RCTs that early postoperative feeding in patients is safe and tolerable. Some studies have shown that early feeding is beneficial in terms of postoperative complications, ileus and hospital stay. Although most of the literature is on colon surgery, similar evidence also exists for gut perforation and upper GI surgery with a trend towards reduced hospital stay and postoperative complications. In summary, this review identifies an important disparity between common clinical practice in New Zealand and evidence from several small RCTs. There does not appear to be any obvious clinical benefit in keeping patients NBM following GI surgery. The authors suggest that patients and the surgical community alike would benefit from a large scale, high quality, high‐powered RCT to address this issue definitively.
GS27P TECHNIQUES FOR CLOSURE OF MIDLINE ABDOMINAL INCISIONS
Authors: Ali A. , Tait N. , Sanfilippo F.
Published: April 2007

Background  A recent meta‐analysis of randomised controlled trials of abdominal fascial closures concluded that in order to reduce incisional hernia rates without increasing wound pain, or the rate of dehiscence slowly absorbable continuous sutures appear to achieve the best results in abdominal fascial closures. We surveyed the techniques for abdominal fascial closure among general surgeons in Canberra, Australia.

Methodology  49 out of 80 surgeons responded to the survey by form. The information collected included the seniority of the surgeon, the frequency of laparotomy closure, surgical technique and suture material utilised in abdominal fascial closure.

Results  34 (69%) of the surgeons surveyed preferred a non‐absorbable monofilament suture material for abdominal fascial closure with nylon being the most popular. Most (38, 78%) also preferred a non‐absorbable monofilament suture in emergency surgery. 12 (24%) surgeons preferred to use slowly absorbable suture. The majority of surgeons (37, 76%) preferred continuous suture technique, whilst only 2 (4%) used continuous followed by interrupted suture closures. Only 5 (10%) complied with the dual recommendation of continuous suture technique and slowly absorbable suture.

Conclusion  The majority of surgeons preferred non‐absorbable monofilament suture rather than slowly absorbable suture. Only 1 in 10 surgeons complied with both components of evidence base, which supports the use of slowly absorbable suture material and a continuous technique in abdominal fascial closure. A definitive RCT would confirm this observation.
GS03 TIMING OF SURGERY FOR ACUTE SYMPTOMATIC BILIARY DISEASE
Authors: Short H. L. , Zargar Shoshtari K. , Lee D. , Poole G. H. , Hill A. G.
Published: April 2007

Purpose  To evaluate surgical management of patients presenting with symptomatic gallstone disease to Middlemore Hospital in 2005.

Method  Retrospective case review of acute presentations of symptomatic gallstone disease between Jan 1st and Dec 31st 2005.

Results  Four hundred and two patients were included in the final analysis. Forty six of these patients were unfit for surgery, 26 were solely admitted to the emergency department without being referred to a surgical team and 22 declined surgery. Therefore 308 patients (77%) were eligible for surgery at index admission (IA). Sixty six percent (204) of these received surgery during IA with an average time to surgery of 4 days. Of the remaining 104 eligible patients who did not receive surgery during IA, 54% (56) received public surgery at a later date with an average wait of 85 days. Fourteen percent (42) never received surgery despite being eligible during IA. There was no significant difference in duration of total acute hospital stay between those with surgery at IA and those who did not receive surgery at IA. For those who had acute surgery the conversion rate was 2% (4). There were no biliary injuries or perioperative deaths and post‐operative readmission rate was 4% (9). Sixty two percent (64) of the 104 eligible patients who did not receive surgery at IA were subsequently readmitted acutely within 24 months. The average wait time for US, MRCP and ERCP was 0.9, 3.1 and 3.4 days respectively.

Conclusion  Acute surgery remains the treatment of choice for acute biliary disease. This approach requires a committed team approach but is safe and cost effective.
GS31P PROSPECTIVE OCTOGENERIAN GENERAL SURGICAL AUDIT: PREDICTING POST‐OPERATIVE AND NON‐OPERATIVE MORTALITY USING MINIMUM CLINICAL DATA SET
Authors: Nichols K. G. , Mosquera D. A. , Fancourt M. F. , Kyle S. M. , Gilkison W. T. C.
Published: April 2007

Background  A national minimum clinical data set for predicting non‐operative and post‐operative mortality at discharge was developed by Prytherch et al. Our aim to audit the octogenerian surgical admissions in our hospital for complications, discharge outcomes and discharge mortality.

Method  Prospective audit from the 1st January 2006–30th November. Data collected for 243 consecutive admissions: 91 non‐operative, 82 elective and 70 emergency, using standardized pro forma.

Results  In total 223 surgical patients (re‐admission 8.2%) included 70 emergency admissions (28.8%), 82 elective admissions (33.8%) and 91 non‐operative admissions (37.5%). Complications rate of 47.1% Emergency, 18.3% Elective and 23.3% Non‐operative admissions. Discharged home: 52% Emergency, 92% Elective and 57% Non‐operative patients. Mortality: Emergency 7.1% (n = 5), Elective 0% (n = 0) and Non‐operative 5.5% (n = 5) patients. Emergency laparotomy 35% (n = 2) mortality. When minimum clinical data compared predicted to observed mortality emergency ?2 = 10.95 (p < 0.001), elective ?2 = 6.22 (p < 0.0025) non‐operative ?2 = 6.51 (p < 0.025).

Conclusion  The audit overall mortality data was acceptable when compared to published work. Emergency, elective and non‐operative patient groups differed significantly (p < 0.025) from predicted deaths and did not fit this model according to risk stratification.
GS05 SINGLE SURGEON EXPERIENCE WITH RETROMUSCULAR (PREPERITONEAL) MESH REPAIR OF INCISIONAL AND VENTRAL HERNIAS
Authors: Theophilus M. N. , Ooi S. M. , Tan P.
Published: April 2007

Objective  Repair of incisional (and large ventral) abdominal hernias pose a challenge for many surgeons. Numerous techniques have been described. This series reports a single surgeon’s experience using the retromuscular (pre‐peritoneal) mesh repair technique.

Method  Data was collected on 70 consecutive incisional (n = 23) and ventral (n = 47) hernia repairs using retromuscular (pre‐peritoneal) lightweight polypropylene mesh.

Results  The median follow‐up was 26 months (range 10 – 66 months). Overall recurrence rate was 1.4%. There were seven major (10%) and four minor (7%) post‐operative infections. One patient developed post‐operative seroma requiring percutaneous aspiration, and one patient had chronic pain.

Conclusion  Retromuscular mesh repair is a good alternative to traditional onlay mesh repairs. Morbidity and outcomes are acceptable and comparable with literature, with lower rates of seroma formation and hernia recurrence.
GS07 ABDOMINAL WALL COMPONENTS SEPARATION TECHNIQUE FOR CLOSURE OF VENTRAL DEFECTS – INITIAL EXPERIENCE AND LESSONS LEARNT
Authors: Waxman B. P. , Jassal S.
Published: April 2007

Purpose  The Abdominal Wall Components Separation Technique (AWCST), allows closure of ventral defects by transposition of the abdominal wall muscle(1). The aim of this audit of our initial experience was to evaluate the technique for repairing defects after removal of infected mesh or for uncomplicated incisional hernia.

Methodology  A prospective audit was conducted on the initial experience of 9 consecutive patients under the care of one surgeon (BPW) from August to December 2006.

Results  Of the 9 patients, 5 had infected mesh and 4 had large incisional hernias. The median follow up was 62 days range 7–125 days. Significant wound infections occurred in 4 patients requiring re‐operation. In all 4 abdominal wall repair remained in tact. 1 patient has developed a recurrent incisional hernia.

Conclusion  AWCST is an useful procedure for the closure of large defects, particularly for incisional hernia and may avoid the use of mesh. We recommend avoiding primary skin closure after removing infected mesh and follow the principle of delayed primary closure. No specific conclusions can be made from this small series with a short follow up, but the technique has merit and requires further evaluation.
GS08 ANASTAMOTIC LEAK RATES FOR COLORECTAL CANCER RESECTION IN A REGIONAL BASE HOSPITAL
Authors: Yang S. M. , Franz R. , Morrissey D.
Published: April 2007

Purpose  Colorectal cancer (CRC) is the most frequently reported malignancy in Australian cancer registries. A large proportion of these cancers are managed by general surgeons with no specific sub‐specialist training. Our study aims to examine anastamotic leak rates after surgery for CRC in a regional hospital, performed by non sub‐specialty trained general surgeons and to compare this data with those of other specialist colorectal units.

Method  An audit of all patients treated for colorectal cancer at Toowoomba Base Hospital between 1 January 1990 and 1 April 2006 was undertaken. An anastamotic leak was defined as a clinical diagnosis documented in the patients’ medical chart or operative report.

Findings  580 patients were treated for colorectal cancer during the prescribed period. Of these, 444 had surgery which included a gastrointestinal anastamosis. There were 13 anastamotic leaks (2.9%). The following commonest procedures had respective leak rates of: right hemicolectomy 2.2%; anterior resection 2.2%; sigmoid colectomy 3.28%; ultra‐low anterior resection 6.67%. Of the 13 leaks, 1 occurred in Dukes A cancers (1.89%), 9 in Dukes B cancers (4%) and 3 in Dukes C cancers (1.5%).

Conclusion  The anastamotic leak rates over the past 16 years at Toowoomba Hospital appear to be comparable to those of other specialist colorectal surgical units. It may be that leak rates are more dependent on the quality of the individual surgeons performing the procedure and the soundness of their surgical techniques, irrespective of their level of sub‐specialization. However, research needs to be done to prospectively compare the leak rates of different surgical units before further conclusions can be made.
HS01 MANAGEMENT OF OBSTETRIC BRACHIAL PLEXUS PALSY AT MIDDLEMORE HOSPITAL
Authors: Avery G. J. , Bartlett G. , Taylor C.
Published: April 2007

In the year 2000 a surgical service for infants with obstetric brachial plexus palsy commenced at Middlemore Hospital in Auckland. This remains the only service available in New Zealand with the two founding surgeons remaining as its current providers. We present the seven‐year history of this service, the lessons learned from both primary and secondary reconstructive procedures and consider the direction for future treatment.
HS03 BOTULINUM TOXIN A IN THE UPPER LIMB IN CEREBRAL PALSY
Authors: Johnstone B. R. , Coombs C. , McCombe D. , Duncan J.
Published: April 2007

Purpose  To evaluate patients with cerebral palsy treated with botulinum toxin A injections to assist with the management of contracted muscles and joints as well as co‐contraction.

Methods  Since 1998, 40 limbs have been treated. The average age was 14 years (range 4 to 33 years) and the average dose given was 107 units (range 50 to 200 units). Digital flexors were injected in 26 limbs, elbow flexors in 18, wrist flexors in 17, thumb adductors in 13, pronator teres in 9, intrinsics in 3, shoulder abductors in 2 and ECU in one limb. All patients were injected under a general anaesthetic, allowing for an assessment of fixed contractures. Padded plaster casts were applied, putting the injected muscles on full stretch before the reversal of anaesthesia and were maintained for approximately 3 weeks. Thermoplastic splits were then wore 23 hrs per day for a further three weeks. Splints were serially modified to achieve progressively more extension as the flexion contractures were corrected. Simultaneous surgical procedures such as tendon lengthening and transfers were performed in 14 limbs.

Results  The results in the elbow flexors were disappointing. The finger, thumb and wrist flexors have responded extremely well, despite fixed flexion deformities being documented under anaesthesia in the majority of patients.

Conclusion  It is estimated that the muscle bellies have been elongated by 3 to 4 cm either by the lengthening of, or addition to the sarcomeres.

The results in these patients are vastly superior to that which could be obtained surgically.
HS07 TOE TRANSFER – TECHNIQUES & RESULTS
Authors: Teoh L. C.
Published: April 2007

Toe to thumb‐finger transfer requires the understanding of microsurgery and reconstructive technique. The success is measured by the viability of the toe and eventually recreating the function of the original loss.

In harvesting of the toe, the big and second toe follows almost the same technique. Identifying the toe artery over the first web space and then dissecting proximally into the intermetatarsal artery is the best approach. To dissect the artery from proximal to distal is often fraught with many dangers. In my cases about 50% the plantar artery is dominant. Anticipation and planning of the artery length is crucial.

In toe to thumb transfer the choice can be 2nd toe, total big toe, trimmed big toe or wrap around transfer. In our local populations, 2nd toe is always a good choice. First reconstruction with flap resurfacing may be necessary if the thumb amputation is very proximal.

Toe to fingers transfer is usually indicated in 4 finger loss of the hand. In toe to finger transfer I prefer the two 2nd toes transfer into the middle and ring finger position. As the transferred toes can regain less that 50% of motion, the positioning of the toes should be opposable to the thumb.

The concept of total reconstruction should be closely followed. Stable skeletal fixation, tendon weave technique, good nerve repair, adequate skin coverage and primary healing are important to ensure good outcome result.