bluuebunny/crossref_metadata_2025_split huggingface dataset:
ES15 *RECURRENT LARYNGEAL NERVE PARALYSIS AND DELAYED PRESENTATION OF THYROID CANCER
Authors: Suliburk J. W. , Shaw E. , Sidhu S. B. , Sywak M. S. , Delbribridge L. W. 
Published: April 2009

Background:   Recurrent laryngeal nerve paralysis (RLNP) is well recognized as a presenting symptom of thyroid malignancy, however RLNP is more commonly due to other aetiologies such as post‐viral paralysis. The onset of a hoarse voice in a patient with a presumed benign multinodular goiter can thus present diagnostic difficulties and may lead to significant delays in the diagnosis of thyroid cancer.Methods:   Data were obtained from the University of Sydney Endocrine Surgical Unit database. The study group comprised all patients presenting with a pre‐operative diagnosis of RLNP prior to thyroid surgery in the 10 year period 1999 to 2008.Results:   During the study period there were 44 thyroidectomies performed in cases of preoperative RNLP. 16 of these patients (36%) had cancer on final pathology with 14 having well differentiated thyroid cancer. In 3 (18%) of these patients the diagnosis was markedly delayed due to associated multinodular goiter. Mean delay from onset of RLNP to diagnosis of cancer in these 3 patients was 7 years (range 3 to 9 years). Each of these patients had normal neck CT, thyroid nodules of < 8 mm on initial imaging and initial benign FNA. In all 3 patients intra‐operative findings noted tumour posteriorly at the Tubercle of Zuckerkandl and histopathology confirmed invasion of the nerve by papillary carcinoma.Conclusion:   RLNP may be a sign of occult malignancy in the Tubercle of Zuckerkandl. Small tumour size and posterior location on the gland make reliable imaging and FNA difficult. Patients in whom malignancy is initially excluded should have close follow up and reassessment as there is a significant false negative rate in this patient cohort.
ES16 *GENOTYPE PHENOTYPE CORRELATION IN AN AUSTRALASIAN MEDULLARY THYROID CANCER
Authors: Sywak M. , Abraham D. T. , Messina M. , Sidhu S. B. , Robinson B. G. , Delbridge L. 
Published: April 2009

Purpose:   The aim of this study is to review the genotype‐ phenotype correlation in patients with medullary thyroid cancer in an Australian cohort.Methodology:   Patients were identified from a prospectively maintained surgical database. Clinical features of tumour size, pre‐operative calcitonin, rate of lymph node metastases, disease free survival, tumour recurrence, RET mutations, were statistically assessed using the Stata software package.Results:   Eighty patients were identified between 1967 and 2006. Fifty‐three had sporadic MTC (sMTC) and 27 had familial MTC (fMTC). Significant difference p < 0.05 to p < 0.001 between the two groups was found in the following features: tumour size, pre‐operative serum calcitonin, rate of lymph node metastases where sMTC was consistently higher when compared to fMTC. In addition, disease‐free survival were significantly different between the two groups (81% in fMTC vs. 72% in sMTC, p = 0.041). The review of genetic mutations in RET revealed that the 5 year disease free survival for patients with codon 804 mutations was greater than for those with codon 618, 620 and 634 mutations, considered low and intermediate risk groups respectively. Since the introduction of genetic testing, patients with fMTC were detected at an earlier stage with smaller tumour size (13.0 mm vs. 26.0 mm, p = 0.0038), less lymph node metastasis (33% vs. 47%) and better 5 year disease free survival (81% vs. 72%  years).Conclusion:   Patients with familial form of MTC had better outcome compared to the sporadic counterpart. The type of RET gene mutation influenced the outcome of patients with fMTC. Work on an additional genetic marker that may assist in further disease prognosis and better risk stratification is in progress.
ES20P ECTOPIC MEDIASTINAL PARATHYROID ADENOMA: IS 99MTC SESTAMIBI SCINTIGRAPHY REALLY USEFUL?
Authors: Imisairi A. H. , Hasmah W. W. , Zulkarnain H. , Ziyadi G. 
Published: April 2009

Introduction:   Ectopic mediastinal parathyroid tumours that are inaccessible by routine cervical neck exploration account about 1–3% of all parathyroid tumours. 99mTc Sestamibi scintigraphy is said to be one of the good tools for preoperative localization of these glands.Case Report:   We described the case of a 48 year old lady who presented with generalized malaise and backache for one year duration. Investigations confirmed hypercalcaemia and hypophosphataemia with a total calcium and phosphate level of 3.09 mmol/L and 0.6 mmol/L respectively. Her parathyroid hormone (PTH) level was raised at 18.4 pmol/L. A cervical sonography showed a normal thyroid gland with no suspicious parathyroid glands seen. CT scan of the neck and thorax detected a right anterior mediastinal mass in the thymic region. Finally, 99mTc Sestamibi scanning confirmed an abnormal focal uptake and retention of tracer seen at the right side of the mediastinum suggestive of ectopic parathyroid adenoma. Cervical exploration identified three normal‐looking parathyroid glands in their positions except for absence of the right inferior gland. She subsequently had surgical resection of the mediastinal mass by means of a cervical trans‐manubrial approach. A 4 × 3 cm parathyroid adenoma embedded in the right thymus glandular tissue removed which was confirmed histopathologically. Postoperatively was uneventful. The PTH and calcium levels decreased promptly to normal range.Conclusion:   Ectopic mediastinal parathyroid adenoma is very rare and usually difficult to diagnose. The use of 99mTc Sestamibi scintigraphy especially in combination with CT scan of the neck and chest will be very helpful to give an accurate preoperative localization.
ES21P LEFT LAPAROSCOPIC ADRENALECTOMY FOR A RARE CAVERNOUS HAEMANGIOMA
Authors: Richter K. K. , Pfeifer M. , Dempster A. , Losco G. , Elliot T. 
Published: April 2009

Purpose:   The adrenal gland is an extremely rare location for a cavernous haemangioma, and so far only 53 cases have been reported in the literature. Here, we present a rare case of a laparoscopically resected left adrenal haemangioma. Indication for resection of adrenal incidentalomas, laparoscopic technique, and unexpected histologies are discussed with review of the current literature.Methodology:   Incidentally a 5 × 4 cm adrenal tumour was diagnosed in a 30 year old female patient. Preoperative imaging was performed and hormonactive tumours were ruled out. Laparoscopic left adrenalectomy was carried out using a transabdominal lateral flank approach. After mobilization of the spleen and rotation of the tail of the pancreas medially the adrenal vein was endoscopically clipped. Mobilization of all other borders was performed using the harmonic scalpel.Results:   Time of surgery was 100 minutes. Histology revealed a rare case of adrenal cavernous haemangioma. Postoperative follow up after 6 months was normal.Conclusion:   Despite comprehensive preoperative work‐up adrenal lesions may present with rare unexpected histologies, including neurogenic tumours, myelolipoma, metastases, adrenal carcinoma, or hemangioma. Adrenal hemangiomas possess a potential risk of haemorrhage, thrombosis and necrosis. Today, laparoscopic adrenalectomy is the safe and effective treatment of choice for benign tumours and isolated metastases. Operative time and complexity are reduced by using the harmonic scalpel. Incidentalomas larger than 4 cm should be resected laparoscopically if no adrenal carcinoma is suspected.
ES25P TUMOUR HISTOLOGY DOES NOT PREDICT RESPONSE TO LAPAROSCOPIC ADRENALECTOMY IN CONN'S SYNDROME
Authors: Sywak M. S. , Suliburk J. W. , Chou A. S. , Sidhu S. B. , Gill A. J. 
Published: April 2009

Introduction:   Primary aldosteronism (Conn's syndrome) due to an aldosterone producing adenoma is a frequent cause of surgically correctable hypertension. It is unknown exactly which patients will have improved blood pressure (BP) control following resection. This study was undertaken to determine if histology correlated to post operative BP control in Conn's adenoma patients. We hypothesized that degree of zona glomerulosa hyperplasia would predict response to surgery.Methods:   The University of Sydney Endocrine Surgery Database was queried for 20 consecutive patients who did and 20 consecutive patients who did not have improved BP control following surgery for Conn's Syndrome. Histology was reviewed to identify presence and degree of zona glomerulosa hyperplasia as well as dominate adenoma cell type: glomerulosa (G), reticularis (R) or fasciculata (F). Responders were defined as taking no BP medication or reduction of more than 2 medications 3 months after surgery. Student's t and Fischer's Exact tests were used to determine significance (p < 0.05 significant).Results:   20 responders and 13 non‐responders had histology available for review. Age and sex between groups were not significantly different. Glomerulosa hyperplasia was present in 65% and 77% of responders and non‐responders respectively (p = 0.7). Percentage cell type in responder tumours: 0% G, 35% F, 0% R, 65% mixed. Percentage cell type of non‐responders, 0%G, 38% F, 0% R, 62% mixed with no significant difference in cell type between groups.Conclusion:   Tumour histology does not influence clinical outcome following resection of Conn's adenomas. Improvement in BP following resection is unlikely related to local tumour characteristics.
ES03 GOITRE SURGERY IN AFRICA
Authors: Wetzig N. R. 
Published: April 2009

Purpose:   To highlight details and difficulties of management of large goitres in the developing world.Method:   This paper presents a retrospective review of patients undergoing surgery for large goitre at the HEAL Africa Hospital (Health, Education, Action, Leadership) in Goma, Democratic Republic of Congo.Results:   Dr Neil Wetzig has been involved in training African doctors in goitre surgery since 2003. In northern parts of D R Congo a very high incidence of large goitre exists. Published estimates range from 48–85% and it is suggested that four million people in the north of Congo have large goitres. The types of cases encountered will be discussed, along with the likely causes of endemic goitre, including dietary factors in this community, and the social effect of having a large goitre. Patients undergoing surgery at “HEAL Africa” have a mean age of 44 years, a mean duration of goitre of 7 years and they are predominantly euthyroid range. 88% are female. The difficult circumstances in which this surgery is performed, with poor lighting, poor power supply, poor instruments and limited resources, for example limited suture material, will also be outlined. Details will be presented of the teaching that has been conducted for local Congolese doctors, including surgical aspects of these large African goitres, in particular one case of a huge four kilogram recurrent goitre with skin erosion occurring in a 20‐year‐old woman. This experience of very large goitre in Africa is unique for surgeons from developed countries, and the techniques used are of importance to all thyroid surgeons.
ES04 *DIAGNOSTIC LOBECTOMY IS NOT ROUTINELY REQUIRED TO DIAGNOSE THYROID CANCER IN NODULES GREATER THAN OR EQUAL TO 4CM IN SIZE?
Authors: Raj M. D. , Grodski S. , Yeung M. , Serpell J. 
Published: April 2009

Purpose:   The current gold standard for determining malignancy in thyroid nodules >4 cm is diagnostic lobectomy, regardless of the fine needle aspirate cytology (FNAC) result. This is based on the reportedly high false‐negative rates of FNAC (>10%) in large thyroid nodules. The purpose of this study was to determine if routine removal of thyroid nodules >4 cm is best clinical practice. We hypothesize that ultrasound guided FNAC is as effective as diagnostic lobectomy in detecting malignancy in these patients.Method:   We conducted a cross sectional study of 225 consecutive patients with thyroid nodules >4 cm between 1994 and 2008 who all underwent surgical excision. We assessed the efficacy of preoperative FNAC alone in detecting malignancy in this group compared to surgical excision.Results:   225 patients in the study underwent surgery. 162 patients had preoperative FNAC performed. Male to female ratio was 1:3. Overall incidence of thyroid cancer was 9.6% (16/165). The sensitivity of preoperative FNAC alone in identifying thyroid cancer was 81% and specificity was 62%. False negative rate for FNAC was 1/16 (6%). Positive predictive value of FNAC was 22% (13/60), with negative predictive value of 99% (90/91). Likelihood ratio for positive FNAC result was 2.13.Conclusion:   The incidence of carcinoma in thyroid nodules less than 4 cm is low. Preoperative FNAC is highly sensitive and specific in detecting thyroid cancer even in nodules less than 4 cm in size. Effective management of these patients can be confidently carried out based on the preoperative FNAC result alone, without the need for diagnostic lobectomy.
ES07 *EXTRA‐ADRENAL PHEOCHROMOCYTOMA: IS THE “RULE OF 10” STILL APPLICABLE?
Authors: Imisairi A. H. , Hisham A. N. 
Published: April 2009

Background:   The “rule of 10” is often used to described pheochromocytomas, with 10% extra‐adrenal, 10% malignant, 10% extra‐abdomen, 10% bilateral as well as 10% are found in patients who do not have hypertension and 10% are familial.Objective:   To review the extra‐adrenal pheochromocytomas in our center and to establish whether the “rule of 10” is still applicable.Methods:   Retrospective data were collected on all patients diagnosed to have extra‐adrenal pheochromocytomas (EAP) from January 1998 to December 2007 at our institution.Results:   Over the last 10 years a total of 48 patients were diagnosed to have pheochromocytoma in our centre and 10 (20.8%) were documented to have EAP. The clinical presentation of 6(60%) patients was classical of pheochromocytoma with hypertension, headache, and palpitation, 2 (25%) patients had epigastric pain, 1(12.5%) with progressive weight loss and 1 (12.5%) with pregnancy induced hypertension. The EAP in all 10 patients were localized with CT scan or MRI. The anatomic locations of the EAP were as follows: 40% in the organ of Zuckerkandl, 30% adjacent to the adrenals, 20% along the renal vessels and 10% at the pre‐sacral area. All patients were explored via the anterior transperitoneal approach and histopathological report confirmed 9 (90%) were benign and 1(10%) malignant EAP.Conclusion:   Our series demonstrates a higher incidence of 20.8% for EAP and 40% of them do not have hypertension. In addition, none of them had extra‐abdominal lesion. Therefore the study does not correlate with the “rule of 10” except the incidence of malignant EAP.
GS10 LAPAROSCOPIC APPENDICECTOMIES: THE LEARNING CURVE, RBWH EXPERIENCE
Authors: Patel B. M. , O’rourke N. A. 
Published: April 2009

Introduction:   Laparoscopic appendicectomy has become the procedure of choice for acute appendicitis at our hospital. It provides ideal training in a variety of laparoscopic techniques. It is both safe for patients and good for the community by improving the skills of surgical trainees.Methods:   We reviewed the prospective audit of one junior registrar's first 150 consecutive cases of laparoscopic appendicectomy, after supervision for the first five cases.Results:   150 patients underwent laparoscopic appendicectomy over a period of 27 months. Ages ranged from 14 to 72 with a mean of 28. A standard 3 port technique was used, utilizing mostly suture loops, or occasionally linear staplers to tackle the appendix base. Of 124 patients with confirmed appendicitis, 44 (35%) had perforated, possibly reflecting delay in access to operating theatre in a busy public hospital. Despite this, only two post operative abscesses occurred, and both resolved after percutaneous drains. Hospital stay ranged from 2–7 days (Mean 2, Median 3.5 days). Senior surgical assistance was required in only two patients, once for laparoscopic repair of a serosal tear, and once for conversion for an inflammatory mass subsequently shown to be a carcinoma. Analysis of the cohort in three groups of fifty: early, mid, and late in the series demonstrated a statistically significant improvement in both operative time and diagnostic accuracy.Conclusion:   Laparoscopic appendicectomy is the ideal training operation. After some initial supervision the trainees can perform surgery unsupervised and gain experience in a wide variety of surgical techniques. Clinical acumen and operative times improve with experience.
GS11 SEEING IS BELIEVING: A NEW WAY OF LOOKING AT HISTOPATHOLOGY RESULTS
Authors: Guest G. D. , Watters D. A. , Green R. , Bourke J. , Ward R. , Plueckhahn D. 
Published: April 2009

Purpose:   A sentinel case of missed rectal malignancy resulting in a poor outcome for a patient prompted a search for a process that ensures adequate follow up of all significant histopathology results. This paper aims to quantify the problem of inadequate histopathology follow up and develop an electronic tool and review process to ensure the patient's results are acted upon appropriately.Methodology:   A Histopathology audit was undertaken at the Geelong Hospital between 2002 and 2006. Patients where inadequate follow up had occurred were identified. The situation for these patients was rectified and the risk quantified. An integrated electronic tool was then developed including a minimum data set. A review process was then tested to ensure adequacy of future follow up.Results:   6.3% (120/1912) of histopathology results in a 5 year period had been inadequately followed up. No further adverse outcomes were identified but each case was a potential time bomb for the patients who were not scheduled for clinical review (3.8%) or a recommended procedure (2.5%). A process of follow up has now been implemented and a minimum data set, procedure and electronic audit tool developed to assist with this process.Conclusion:   Failure of adequate follow up of histopathology is a potential pitfall in any large health system. One such failure led to a disastrous outcome and a comprehensive audit suggested 6.3% of patients in the last 5 years were also at risk. We have established a review process we believe is reliable and developed an electronic tool to facilitate this process.
GS14 UPPER GI EMERGENCIES FOR GENERAL SURGEONS – BLEEDING PEPTIC ULCER
Authors: Kendall B. J. 
Published: April 2009

Peptic ulcers (PU) are the most common cause of upper gastrointestinal bleeding. They result in significant costs both to the patient and the health care system. Despite a decrease in the prevalence of H. pylori infection, the incidence of bleeding PU has not reduced.Resuscitation of the patient with a bleeding PU remains the foundation of management. Upper gastrointestinal endoscopy has evolved from initially a diagnostic tool to now also being a therapeutic modality. The endoscopic stigmata of a visible vessel or active bleeding have been validated as indicators of a high risk of adverse outcomes. Multiple endoscopic techniques have been developed to treat bleeding PU with these stigmata. The most effective and commonly used are thermal contact therapy (heater probe or bipolar electrocoagulation) and endoscopic clipping. They are each used either as monotherapies or combined with adrenaline injection. These techniques have been shown to reduce the rates of rebleeding, surgery and mortality.Early studies showed no benefit from the use of H2‐receptor antagonists in patients with bleeding PU. In contrast, proton pump inhibitors (PPIs) given after endoscopic haemostatic therapy as a bolus and then a subsequent 72 hr infusion, have been shown to significantly reduce the rates of rebleeding,, surgery and mortality compared to placebo.In summary, endoscopic techniques combined with pharmacological treatment with PPIs significantly improve outcomes in patients with bleeding PU with high risk endoscopic stigmata. These methods are widely available and are essential in the optimal modern management of bleeding PU.
GS16 *MARKERS OF MUCOSAL AND TRANSMURAL INTESTINAL DAMAGE
Authors: Evennett N. J. , Cerigioni E. , Hall N. J. , Pierro A. , Eaton S. 
Published: April 2009

Purpose:   To investigate intestinal fatty acid binding protein (iFABP) and smooth muscle actin (SMA) as markers of mucosal and transmural intestinal damage, respectively, in both rat intestinal ischaemia reperfusion injury, and in human necrotising enterocolitis (NEC).Methodology:   Plasma was collected from anaesthetized rats that underwent intestinal ischaemia reperfusion (IIR) injury and from control rats undergoing sham laparotomy. In a separate study, plasma and urine was collected from infants with NEC, and from control infants with non‐abdominal diagnoses. iFABP was measured in urine and plasma using a commercially available ELISA. SMA was detected in plasma using a western blot technique. Results are median [IQR] and compared by Mann‐Whitney test unless otherwise stated.Results:   Animal model: Plasma iFABP was significantly higher in the IRI group compared with control group (IRI 32.4 [29.2] ng/ml vs. control 3.8 [3.3] ng/ml; p < 0.01). SMA became detectable in IRI plasma during reperfusion (p < 0.01 compared with pre‐ischaemia, Wilcoxon Signed Ranks test), but never in the control group.Human NEC Study:  Urinary iFABP was significantly higher in the NEC group (2.1 [3.9] pg/nmol) compared to controls (1.1 [0.7] pg/nmol, p, < 0.05). Furthermore plasma and urinary iFABP correlated with extent of intestinal damage at laparotomy, and decreased with NEC resolution. SMA was detectable in the plasma of infants with multifocal or panintestinal NEC, but in neither focal nor non‐operative disease.Conclusion:   FABP and SMA are markers of mucosal and transmural intestinal damage, respectively, and may offer clinically relevant information in the diagnosis and management of severe intestinal disease.
GS18 *PROTEOMIC CHANGES IN MESENTERIC LYMPH SECONDARY TO HAEMORRHAGIC SHOCK
Authors: Mittal A. , Phillips A. , Middleditch, K. Ruggiero M. , Loveday B. , Windsor J. A. 
Published: April 2009

Background:   Biologically active factors produced by the intestine and transported by the protein fraction of mesenteric lymph are thought to contribute significantly to the development of distant organ failure in haemorrhagic shock. Despite the likely relevance of the protein composition of mesenteric lymph conditioned by haemorrhagic shock, there is no detailed description of its proteome. The aim of this study was to provide the first comprehensive description of the proteome of haemorrhagic shock conditioned mesenteric lymph.Methods:   20 male Wistar rats were randomized to either control or haemorrhagic shock group. Mean arterial pressure was reduced to 30 mmHg in the shock group for 90 minutes followed by resuscitation and mesenteric lymph collection for another 90 minutes. Proteomic changes in mesenteric lymph due to haemorrhagic shock were identified using LC‐MS/MS.Results:   245 proteins were identified in mesenteric lymph, including 35 hypothetical proteins. 60 of the 245 proteins had a significant increase in their relative abundance in the haemorrhagic shock group vs. sham group. Potentially toxic pancreatic enzymes had increased abundance in post‐shock mesenteric lymph. In addition, a bioinformatics approach allowed for the identification of key pathways relating to defence and metabolic responses. A number of potentially important proteins were also identified as targets for future research in hemorrhagic shock: peroxiredoxins, 14‐3‐3 zeta/epsilon, calmodulin, cofilin, and profilin.Conclusions:   This study not only provides the first comprehensive list of protein changes in the haemorrhagic shock conditioned mesenteric lymph, but also provides rational for future research.