The clinical outcomes from suspected appendicitis depend on balancing the rate of negative appendicectomy (NA) with perforated appendicitis (PA). An Acute Surgical Model (ASM) was introduced at Geelong Hospital (GH) in 2011 involving a dedicated emergency general surgery theatre list every business day giving greater access to theatre for general surgeons. The aim of this study was to evaluate the effect of the ASM at GH on the management of appendicitis, in particular the NA and PA rates.

Data for 357 patients undergoing emergency appendicectomy was collected prospectively over 1 year (2011) and compared with a historical control group of 351 patients (2010). The data was analysed for patient demographics, preoperative diagnostic radiology and outcomes including NA and PA rates and complications. The negative appendicectomy rates were compared with contemporary studies.

There was no difference between the two groups in rates of negative appendicectomy 21% (ASM; 73/357) versus 21% (Control; 73/351) P = 0.98, or perforated appendicitis 17% (ASM; 61/357) versus 13% (Control; 47/351) P = 0.18. The introduction of the ASM corresponded to a significantly lower proportion of emergency appendicectomies overnight (4% [16/357] versus 12% [44/351] P = 0.005). There was no significant difference in the use of preoperative diagnostic radiology or complications. Matched contemporary studies had a NA rate of 26%.

The introduction of the ASM at GH has not significantly altered the rate of NA or PA. The NA rate at GH is comparable to other published UK and Australian series.

Embryology finds itself jostling for precious space in the crowded medical curriculum, yet remains important for helping students understand birth defects. It has been suggested that teaching embryology through clinical scenarios can increase its relevance and interest. The aim of this research was to determine the attitudes of final-year medical students to learning embryology and whether clinical scenarios aid understanding.

Final-year medical students undertaking their paediatric rotation in 2009 and 2010 were invited to attend an optional lecture on clinical embryology and participate in the research. In the lecture, three clinical scenarios were presented, in which the lecturer traced the normal development of a foetus and the abnormal development that resulted in a birth defect. Outcomes were assessed quantitatively using a paper-based survey.

The vast majority of students who valued embryology teaching in their medical programme thought it would assist them with clinical management, and believed learning through case scenarios helped their understanding. Students were divided in their beliefs about when embryology should be taught in the medical programme and whether it would increase their workload.

Embryology teaching appears to be a valuable part of the medical curriculum. Embryology teaching was valued when taught in the clinical environment in later years of the medical programme. Students, clinicians and medical educators should be proactive in finding clinical learning opportunities for embryology teaching.

Muscle hernias are uncommon clinical conditions with no uniform solution of repair. Biocompatible mesh allows for repair of hernias without the donor site morbidity and complications from direct repair under tension.

Over a 6-month period at a Level 1 Trauma centre, four consecutive symptomatic muscle hernias were identified, two in the forearm and two in the lower limb. Three resulted from high-speed motorbike accidents, one from a mining accident. All patients had hernia repair at a minimum of 4 months post accident. A 10 × 15 cm × 1.0 mm sheet of acellular collagen matrix was fashioned to fit as an underlay of the fascia defect. Patients were clinically followed at the 2-, 6-, 12- and 26-week mark. Final phone contact was made 18 months post-operatively.

All patients were pleased with their cosmetic and functional outcomes. All patients returned to work and sport 3 months after reconstruction.

Symptomatic hernias as a result of trauma can be safely reconstructed with a biological mesh implant. This approach can prevent complications from previously described methods and return to active lifestyles with good results.

The role of autologous fat transfer (AFT) for cosmetic breast augmentation is uncertain due to ongoing concerns regarding its safety and efficacy compared with other breast augmentation techniques.

The aim of this systematic review was to assess the safety and efficacy of AFT for cosmetic breast augmentation in comparison with saline and cohesive silicone gel implants.

A systematic search of several electronic databases, including PubMed and EMBASE, was used to identify relevant studies for inclusion. The inclusion of studies was established through the application of a predetermined protocol by two independent reviewers.

There were no comparative studies available, necessitating that all comparisons be indirect. Eighteen studies were included, 11 of which reported outcomes for AFT. Complications associated with AFT occurred in only a small proportion of patients, with fat necrosis, cysts and lumps most commonly reported. No data examining the effect of complications such as microcalcification on long-term mammographic and cancer-related outcomes were identified. Reabsorption of fat occurred to varying degrees, usually during the first 12 months following the procedure. Patient satisfaction following AFT was high. Limitation in breast volume increase was the main complaint associated with this procedure.

Based on the limited evidence available, AFT was considered to be at least as safe as the nominated comparator procedures in regard to complications; however, its safety in regard to cancer detection could not be determined. The efficacy of AFT could not be determined.

The mechanisms and kinetics of hepatic growth have continuously been investigated. This study concerns liver regeneration in animal and patients who underwent partial hepatectomy evaluated by the hepatic extraction fraction (HEF) calculated through radioisotopic methods.

Thirty normal Wistar rats were submitted to an 85% hepatectomy, and 95 patients with primary and secondary liver tumours were included. In animal study, the liver regeneration kinetics was assessed by HEF using 99mTc-mebrofenin, the ratio liver/bodyweight and by using bromodeoxyuridine deoxyribonucleic acid incorporation. In patient study, the liver regeneration was evaluated by calculation of HEF before surgery, 5 and 30 days after hepatectomy.

In animal, we verified a positive correlation between HEF kinetics and liver/bodyweight ratio or hepatocyte proliferation evaluated by bromodeoxyuridine deoxyribonucleic acid staining after 85% hepatectomy. In the clinical arm, no statistical differences of the HEF before hepatectomy, 5 and 30 days after hepatectomy, were observed.

Our results support the view that human liver regeneration commences early, is fast, non-anatomical and functionally complete 5 days after hepatectomy. The fast functional liver regeneration may have a high clinical impact particularly concerning the post-operative oncological therapeutic approaches.

Scoliosis has been shown to affect quality of life of young people. There can be a lengthy wait for surgery. We aim to assess whether the length of time waiting for surgery has an impact on quality of life and surgical outcomes.

Patients who were waiting for or had completed surgery for paediatric spinal deformity in the last 3 years were contacted and asked to complete the Scoliosis Research Society-30 (SRS-30) questionnaire as well as a questionnaire designed to specifically assess the impact of waiting for surgery. Hospital records and X-rays were reviewed to determine surgical outcomes.

Longer waiting time was associated with both lower SRS scores (0.13 points per 6 months, P = 0.01) and lower wait time questionnaire values (0.12 points per 6 months, P < 0.01). Within the SRS-30 questionnaire, pain, satisfaction with management and self-image domains showed a statistically significant decrease with increasing wait time (P = 0.02, 0.05, >0.01 respectively). Cobb angles progressed with increased waiting time, but progression was not statistically significant. No correlation was found between waiting times and the other surgical outcomes measured (surgical duration, hospital stay, blood transfusion, return to theatre or other complications).

Increased waiting time for surgery has a negative impact on quality of life of patients with scoliosis.

Good decision making is essential in surgery. In an emergency, the time for decision making is often short, and the information available is incomplete. The way experienced surgeons make decisions is often not well understood, and therefore is difficult to teach to trainees.

This paper examines how decisions are made, based on recent literature and the experience of the authors and their colleagues.

An accurate assessment precedes decision making, and is directed towards the patient, the personnel and environment. Studies of other high-stakes professions have highlighted the existence of two distinct mental processing symptoms. One is fast and frugal, relying on pattern recognition or following a rule or protocol. This is often performed at a subconscious level. The other is a conscious, reasoned, analytical process. This requires adequate, available mental capacity. In reality, expert and experienced decision makers can adopt either or both approaches, and match their approach to the situation. Decisions made need to be constantly reviewed, particularly where there is mismatch between what was anticipated and what is encountered.

An algorithm of decision making in emergency surgery has been developed that is based on assessment, the decision required and the outcome of the decision. The decision must also consider the urgency of the situation and the likely outcome if the plan made fails.

The Intercollegiate Surgical Curriculum Programme was launched in the United Kingdom in 2007. At its heart was the reliance upon clear, defined curricula, competence-based training and the use of workplace-based assessments to assess the competence. The principle assessments used were Case-based Discussion, Procedure-based Assessments (PBA), Direct Observation of Procedural Skills, and Clinical Evaluation Exercise and a Multisource Feedback tool.

We report the initial experience with that system, and most importantly, the experience with workplace-based assessment.

Themes include issues around faculty development, misuse of assessments, inappropriate timing of assessments, concerns about validity and reliability of the assessments and concerns about the actual process of workplace-based assessments. Of the assessments, the PBA performed best.

As a consequence, there has been an increased focus upon faculty development, while some of the assessments have been redesigned in line with the PBA. A global rating scale has been introduced that uses clinical anchors. The rating scales have also been altered with a reduction in the number of ratings while an enhanced description of the complexity of the case has been introduced within the Case-based Discussion and the Clinical Evaluation Exercise. A re-evaluation will take place in the near future.

Because of the rarity of duodenal adenocarcinoma, little is known regarding its natural history or prognostic factors for survival. We therefore evaluated surgical treatment, and prognostic factors for survival in patients with duodenal adenocarcinoma.

We retrospectively reviewed the medical records of patients who were diagnosed with duodenal adenocarcinoma at Asan Medical Center between December 1999 and December 2009.

Of the 76 patients, 47 (61%) underwent surgery with curative intent and 29 (39%) underwent palliative operation. Of the former, 25 underwent pancreaticoduodenectomy (PD), 19 underwent pylorus-preserving PD, 2 underwent segmental duodenectomy and 1 underwent transduodenal excision. The median survival of the 41 patients who achieved R0 resection was 25.1 months (range 4–134 months), with overall 1-, 3- and 5-year survival rates of 80.4%, 63.4% and 60.9%, respectively. Median survival was significantly longer in patients who underwent curative resection than in those who underwent palliative surgery (28.2 versus 6.6 months, P < 0.001). Univariate analysis showed that transfusion and lymph node metastasis were related to survival, and multivariate analysis revealed that lymph node metastasis was independently associated with survival (P = 0.036). Survival differences were observed between stages of the seventh edition of the American Joint Committee on Cancer staging system.

In the absence of distant metastasis, curative resection enhances the long-term survival of patients with duodenal adenocarcinoma. Lymph node metastasis is prognostic factor of overall survival.

Underlying liver cirrhosis is associated with high morbidity and mortality after surgery. Previous studies have reported conflicting results about the value of Child–Turcotte–Pugh (CTP) and model for end-stage liver disease (MELD) scores as predictors of post-operative mortality. This study was designed to compare the capacities of CTP, MELD and MELD-based indices in predicting mortality for patients with liver cirrhosis who underwent elective extrahepatic surgery.

The medical records of 79 patients with liver cirrhosis who underwent elective extrahepatic surgery under general anaesthesia from December 2000 to December 2009 were reviewed retrospectively.

The median follow-up period was 21 months, and the mortality rate was 24.1% (n = 19). Among the 19 mortalities, nine (11.4%) occurred while the patient was hospitalized after surgery. Intraoperative transfusion amount (≥700 mL; odds ratio 6.294, P = 0.004) and the integrated MELD score (≥34; odds ratio 6.654, P = 0.007) were significantly correlated with post-operative mortality. CTP score (hazard ratio 1.575, P = 0.012) was significantly correlated with overall mortality.

Integrated MELD may be a more accurate predictor of operative mortality in cirrhotic patients undergoing extrahepatic surgery than CTP and other MELD-Na based indices. However, overall mortality may be reflected more accurately by CTP score. Further large-scale study will be needed to validate this result.

Previous studies have suggested that patients with occult peritoneal metastases not seen on preoperative imaging have poor prognosis. In this study, we aim to evaluate the utility and impact of staging laparoscopy and peritoneal cytology in patients with gastric adenocarcinoma.

A retrospective analysis of patients with gastric adenocarcinoma managed at two major metropolitan hospitals in Melbourne, Australia, between January 1999 and July 2010 was undertaken. The main outcome measures were the number of patients in whom laparoscopy and/or peritoneal cytology changed treatment intent, and the overall survival of patients with occult metastases detected by laparoscopy/cytology.

Staging laparoscopy as an independent procedure was performed in 74.3% (148/199) of patients who had neither unequivocal metastases (M1) on preoperative imaging nor early T1 disease on endoscopic ultrasound. Laparoscopy/cytology detected occult metastases in 38 (25.6%) patients (27 macroscopic M1 and 11 microscopic M1 with positive peritoneal cytology only), leading to change in the treatment intent in 37 cases. The median overall survivals of patients with metastatic disease detected at staging laparoscopy (8.3 months, 95% confidence interval (CI) 5.4–16.5) or on peritoneal cytology (4.9 months, 95% CI 4.2–48) were as poor as those with M1 disease seen on preoperative imaging (6.7 months, 95% CI 4.2–8.9), P = 0.97.

Laparoscopy and peritoneal cytology add incremental value to modern imaging in the staging of gastric adenocarcinomas by detecting occult metastatic disease. Their utility needs to be optimized to allow better treatment selection for gastric cancer patients.

After the introduction of tyrosine kinase inhibitors (TKIs), the role of surgical resection in treating liver metastasis from gastrointestinal stromal tumour (GIST) is unclear. In this study, we evaluated the outcome of patients treated with TKIs followed by surgery for metastatic GIST.

Eleven patients underwent liver resection after downsizing TKIs therapy for metastatic GIST from 2006 until 2010 were reviewed.

One and two-year overall survival rates were 80.8 and 70.7%. All patients with an initially resectable tumour were still alive without recurrence. Patients operated on clinical response had a better outcome (1- and 2-year overall survival (OS) rate 100%) than those operated on disease progression (1- and 2-year OS rates 60 and 40%; P = 0.043). No deaths were observed among patients who achieved an R0 resection (R0 versus R1/R2, P = 0.001).

R0 resection and clinical response to TKI are predictor of survival. Surgical resection should be performed as soon as feasible in responding patients. In poor responders, surgery may not add any survival benefit, except in localized progressive disease. In resectable metastatic liver disease, preoperative TKIs or upfront surgery followed by adjuvant therapy could be considered. Larger studies are needed to determine the optimum approach in patients with metastatic GIST.

Determining admission criteria to select candidates most likely to succeed in surgical training in Australia and New Zealand has been an imprecise art with little empirical evidence informing decisions. Selection to the Royal Australasian College of Surgeons' Surgical Education and Training programme is based entirely on applicants' performance in structured curriculum vitae (CV), referees' reports and interviews. This retrospective review compared General Surgery (GS) trainees' performance in selection with subsequent performance in assessments during training.

Data from three cohorts of GS trainees were sourced. Scores for four selection items were compared with scores from six training assessments. Interrelationships within each of the sets of selection and assessment variables were determined.

A single significant relationship was found between scores on the three selection tools. High scores in the CV did not correlate with higher scores in any subsequent assessments. The structured referee report score, multi-station interview score and total selection score all correlated with performance in subsequent work-based assessments and examinations. Direct observation of procedural skills (DOPS) scores appear to reflect increasing acquisition of operative skills. Performance in mini clinical examinations (Mini-CEX) was variable, perhaps reflecting limitations of this assessment. Candidates who perform well in one examination tend to perform well in all three examinations.

No selection tool demonstrated strong relationships with scores in all subsequent assessments; however referee reports, multi-station interviews and total selection scores are indicators for performance in particular assessments. This may engender confidence that candidates admitted into the GS training programme are likely to progress successfully through the programme.

In hepatocellular carcinoma, anatomical resection is important because of portal spread. In right anterior sectionectomy (RAS) and right posterior sectionectomy (RPS), the right hepatic vein (RHV) may not correspond with the intersectional plane if an inferior RHV (IRHV) is present. The aim of this study was to evaluate the influence of the IRHV on the exposure of the RHV retrospectively.

One hundred ninety-one patients underwent RAS or RPS by the Glissonean pedicle transection method. The calibres of the RHV and IRHV were measured and assessed the extent of exposure of RHV.

One hundred seventeen patients underwent RAS and 74 underwent RPS. The calibre of the RHV averaged 8.0 mm and that of the IRHV, 6.2 mm. Exposure of the RHV was divided into three groups: no exposure 31 (16.2%) (with IRHV, 20 patients; without IRHV, 11 patients), upper half exposure 49 (25.7%; with IRHV, 24; without IRHV, 25) and full exposure 111 (58.1%) (with IRHV, 16; without IRHV, 95). The effect of the IRHV on exposure of the RHV was substantial (P < 0.001).

The IRHV can affect the course of the RHV and its exposure. Therefore, in RAS and RPS, it is important to evaluate the existence of the IRHV.

Obesity is a significant risk factor in abdominal hernia occurrence and recurrence. In patients having bariatric surgery, there are no clear guidelines as to whether repair should be done simultaneously, especially if procedures involve division or resection of part of the gastrointestinal tract.

A retrospective case series review over a 6-year period to December 2012 from a prospective database was conducted. As per existing practice for bariatric procedures, patients were followed up indefinitely. Short- and long-term outcomes were analysed.

Forty-five patients underwent combined laparoscopic bariatric surgery and abdominal wall hernia repair. Of these, 36 had resection procedures (gastric bypass or sleeve gastrectomy) and 9 had non-resection procedures (gastric banding). The mean operative time was 151 min and the mean length of stay was 3 days. Two patients developed post-operative mesh seroma infections. To date, there have been no mesh removals or recurrent hernias. There was no mortality in this series.

This study demonstrated a low rate of mesh infection (4.44%) at a median follow-up of 13 months, even when a resectional procedure was performed (5.56%). These results suggest the possible viability and reasonable short-/long-term outcomes of simultaneous laparoscopic abdominal wall hernia repair during bariatric surgical procedures, even if the surgery involved division or resection of part of the gastrointestinal tract. This topic is an area of clinical research that warrants further study.

This paper reviews changes that are underway in postgraduate medical education in various European countries. Training in the workplace is a very effective way of learning, but it has many imperfections. Changes in in-training assessment are proposed to remedy some of these.

The focus is on a set of assessment tools for performance in authentic work-based contexts. These tools include direct performance measures of single clinical events (mini-Clinical Evaluation Exercise, Direct Observation of Practical Skills, Objective Structured Assessment of Technical Skills, Case-based Discussion, Mini-Peer Assessment Tool) and performance measures over a period of time (Multi-Source Feedback), based on judgement by one or more knowledgeable assessors (supervisor, other healthcare professional, patient, trainee himself/herself). Quantitative and qualitative information from single assessments is first and foremost used to promote learning, but also aggregated across a large sample of contexts and assessors in order to obtain an overall picture of a trainee's progress. Aggregating instruments, such as the portfolio, can be used to collect, support and assess outcomes in terms of competencies achieved. We will describe this set of instruments and provide theoretical background as well as our own practical experiences.

A central message is that the utility of assessment methods lies very much in the (understanding of) the users. Therefore, our concern is more with the actual implementation of change than with the assessment technology per se. If we fail in our efforts to implement real change, postgraduate education may be at risk for bureaucratization and trivialization. We nevertheless are excited to see change happening in the right direction, but remain patient, not expecting very quick wins.

Errors are to be expected in health care. Adverse events occur in around 10% of surgical patients and may be even more common in emergency surgery. There is little formal teaching on surgical error in surgical education and training programmes despite their frequency.

This paper reviews surgical error and provides a classification system, to facilitate learning. The approach and language used to enable teaching about surgical error was developed through a review of key literature and consensus by the founding faculty of the Management of Surgical Emergencies course, currently delivered by General Surgeons Australia.

Errors may be classified as being the result of commission, omission or inition. An error of inition is a failure of effort or will and is a failure of professionalism. The risk of error can be minimized by good situational awareness, matching perception to reality, and, during treatment, reassessing the patient, team and plan. It is important to recognize and acknowledge an error when it occurs and then to respond appropriately. The response will involve rectifying the error where possible but also disclosing, reporting and reviewing at a system level all the root causes. This should be done without shaming or blaming. However, the individual surgeon still needs to reflect on their own contribution and performance.

A classification of surgical error has been developed that promotes understanding of how the error was generated, and utilizes a language that encourages reflection, reporting and response by surgeons and their teams.

It is precisely 100 years since the Nobel Prize for Physiology or Medicine was awarded to the French surgeon Alexis Carrel, the second and to date one of only five surgeons to have received this most prestigious award. In spite of his outstanding contributions to the fields of cardiovascular and transplant surgery, the anniversary of his Nobel Prize award is likely to pass unnoticed and unacknowledged because of his outspoken and well-publicized beliefs and philosophies.

A review was carried out of the very many biographical papers of Carrel's work and publications.

Carrel's work did indeed form the basis of modern cardio-vascular and transplant surgery.

In spite of deserving the Nobel prize for his scientific work, Carrel's views on eugenics were so abhorrent that he is unlikely to ever receive the accolades he deserves.

Educational programmes are frequently developed to improve the knowledge of medical trainees. The impact of a programme may be limited if there is no follow-up to reinforce the message. Online Spaced Education (SE) has been developed to address this limitation. This study was performed to assess whether an SE programme would improve the impact of a didactic seminar.

A randomized trial of an online SE programme occurred as part of the 2010 Clinical Oncology Society of Australia Breast Cancer Trainee Workshop. Consenting participants were randomized to undertake SE or not and were then invited to undertake a 22-question knowledge test. A questionnaire was administered relating to the perceived value of the SE programme. Participants consisted largely of surgical and medical oncology trainees.

Two hundred people attended the workshop and 97 consented to randomization. Thirty-eight of 49 randomized to the SE group commenced the SE course. Seventy-one percent of participants answered each question at least once and 55% of participants completed the entire programme. Fifty-nine participants completed the post-test. The SE participants performed significantly better than the control group (P < 0.05). The questionnaire was completed by 26 of the SE group. Ninety-two percent strongly agreed or agreed that SE would improve their practice and 96% agreed that SE effectively reinforced key aspects of workshop.

This study demonstrates the utility of SE to increase knowledge retention following a face-to-face workshop. The programme was very well received by the participants and may be an appropriate reinforcing methodology for other similar seminars.

Soft tissue defects of the digits can be a challenging problem for the hand surgeon. For non-graftable defects, numerous local, regional and free flaps have been described for resurfacing, each with their own limitations – bulk, colour, texture mismatch, donor morbidity. Perforator flaps increasingly provide the optimal option for reconstruction of digital defects as they are thin, pliable and with low donor site morbidity.

A thin, pliable fasciocutaneous flap can be raised from the distal volar forearm based on a perforator of the radial artery. The pedicle is up to 2–3 cm in length with a diameter of at least 0.5 mm in diameter, suitable for anastomosis to the digital artery. Venous drainage is via the venae comitante of the radial artery and superficial volar veins.

A patient presented to our emergency department following circular saw injuries. He suffered multi-digit trauma with subsequent soft tissue defects over the dorsum of the digit. Reconstructive requirements were met utilizing a free fasciocutaneous flap raised on a distal volar forearm perforator from the radial artery. The recovery was uneventful with no donor site morbidity.

Dorsal digital soft tissue reconstruction requires thin, pliable, ideally hairless and sensate skin. Most locoregional options are limited by the need for multi-stage surgery, bulk, limited reach or donor site morbidity. In our patient, the reconstructive requirements were met with preservation of the radial artery. While it requires microsurgical skill and instruments, this flap provides another option for the reconstructive hand surgeon.

Surgical checklists are designed to improve patient outcomes following surgery. While such checklists have been widely implemented worldwide, few studies examine surgical checklists within an Australian context. For this purpose, we have performed a literature review using data from OECD member nations to determine the effectiveness of surgical checklists in improving patient outcomes and factors that contribute to their successful implementation.

The databases, Pubmed, Medline, EMBASE, Cochrane and CINAHL were searched using the keywords (‘surgical’ AND ‘checklist’) and ( (surgical) AND checklist) AND ( (implementation) OR (utilization) OR (usage) ). Studies were limited to those written in the English language, peer-reviewed, published between January 2000 and December 2012, and including an abstract.

Our search yielded 2242 papers, of which 72 papers were identified for their potential relevance and selected for full text review. Of these, nine papers met the inclusion criteria and were reviewed in detail. Evidence that supports the use of surgical checklists in countries with a large number of protocols already in place is limited. Adequate checklist implementation plays a central role in checklist effectiveness, which in turn is dependent on multiple factors.

Although evidence from OECD member countries is non-conclusive, it does suggest that surgical checklists, when effectively implemented, have the potential to be effective at reducing complication and mortality rates following surgery. Within an Australian context, more studies are needed to fully establish the potential effectiveness of surgical checklists and to monitor checklist use compliance in order to ensure greater patient safety.

Sentinel node biopsy is an accurate method for staging the axilla in early (small) breast cancers. However, data for the role of this technique for large breast cancers remain limited.

From the Royal Adelaide Hospital Sentinel Node database and the SNAC trial database, 100 subjects were identified with clinically node negative, large (≥3 cm) primary breast cancer who had undergone sentinel node biopsy and immediate axillary clearance. The pathology results from the sentinel node and axillary specimens were analysed.

Average tumour size was 3.91 cm (range 3–10 cm) and 65 of 100 cases had metastatic disease in the axillary nodes. A sentinel node was successfully identified in 93 out of 100 cases with an average of 1.75 sentinel nodes sampled. Sixty-two per cent (58 out of 93) were sentinel node positive and 43% (43 out of 100) had a positive non-sentinel node. The false negative rate following successful sentinel node identification was 4.9% (3 out of 61).

Sentinel node biopsy was an accurate tool for staging the axilla with a false negative rate comparable to that seen in small tumours. However, given the increased incidence of metastases with larger cancers, further prospective investigation is warranted.

Severe tracheal stenosis is a rare life-threatening condition that often requires early surgical intervention. The management of this anomaly has been associated with significant mortality and morbidity. We describe our experience with repair of this condition.

From 1986 to 2011, 20 patients underwent repair of tracheal stenosis at the Royal Children's Hospital (median age 4.9 months) and were retrospectively reviewed.

Tracheal repair techniques used were as follows: patch tracheoplasty (n = 8; 40%, 8 out of 20), slide tracheoplasty (n = 7; 35%, 7 out of 20), end-to-end anastomosis (n = 5; 25%, 5 out of 20). Six patients (30%, 6 out of 20) had coexisting congenital intracardiac anomalies. There were 12 pulmonary artery sling (60%, 12 out of 20) patients. Overall operative mortality was 15% (n = 3; 3 out of 20). Operative mortality was 20% (n = 2; 2 out of 10) from 1986 to 2001 and decreased to 10% (n = 1; 1 out of 10) from 2002 to 2011. All early deaths occurred in patients who had undergone patch tracheoplasty. Since 2004, there were no operative deaths. Seven patients (35%, 7 out of 20) required tracheal reintervention postoperatively. There were three late deaths (17.6%, 3 out of 17) at 8, 9 and 22 months after surgery. At last follow-up (mean 5.3 ± 6.6 years; range 1 month to 18 years), all 14 survivors remained asymptomatic.

Repair of tracheal stenosis in children has been associated with high morbidity and mortality. Since the introduction of slide tracheoplasty, a multidisciplinary team approach and abandonment of patch tracheoplasty, the mortality has been reduced. Survival beyond 2 years after surgery is associated with an excellent outcome.

Recently, implant manufacturers have made modifications to currently available implants in an attempt to improve postoperative flexion. The Low Contact Stress (LCS) RPS (DePuy Orthopaedics Inc., Warsaw, IN, USA) is one such prosthesis which is a modification of the established LCS RP design. Satisfactory results have been obtained without patella resurfacing in the original LCS RP design.

We report on a single surgeon series showing an alarmingly high incidence of patellofemoral crepitus when this new prosthesis, LCS RPS, is used without patella resurfacing. In addition, the outcomes for this prosthesis from the Australian National Joint Replacement registry will be reported. These results show a high revision rate with most revisions being patella resurfacing for patellofemoral pain.

Affected patients who elected to have a revision procedure underwent either an arthroscopic patellaplasty procedure or revision to resurface the patella. Both of these procedures resulted in satisfactory resolution of symptoms in the majority of patients.

Potential causes for this complication are discussed. It is the recommendation of the authors that when using this prosthesis the patella is resurfaced.

The abdominoperineal resection (APR) is the current accepted surgical technique for low rectal cancers. Negative circumferential surgical margins are an important prognostic indicator and are best obtained by producing a cylindrical specimen. The ‘ideal’ approach to produce such specimen is debated between a standard lithotomy position and turning the patient in the prone position in the later stages of the procedure. We aimed to assess results of perineal morbidity and oncological outcomes following the lithotomy approach at a single institution.

Data were collected retrospectively at a single institution. All patients undergoing the APR for low rectal cancers were included in the current study. Patients underwent this procedure in the standard lithotomy position and a mucocutaneous flap was not routinely used for closure of the perineal wound. The primary outcome measures in this study were local and systemic tumour recurrence and overall patient survival.

Fifty-three patients undergoing APR were included in the current study. Majority of patients (87%) received neoadjuvant therapy. Perineal morbidity was observed in 11% of patients loco-regional recurrence occurred in 4% at 5 years. One-, 3- and 5-year survival was 87, 75 and 66%, respectively. Patients with T3/4 disease and positive circumferential surgical margins had significantly poorer survival outcomes.

APR can be performed in the lithotomy position with acceptable perineal morbidity and oncological safety. Negative circumferential margins can be achieved reliably by producing a cylindrical specimen with this position.

 This study aimed to determine the incidence and outcome of post-traumatic (PT) intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) after the advances in haemostatic resuscitation.

This is a prospective cohort study from January 2009–December 2011 involving patients with PT haemorrhagic shock. Patients' demographics, fluid resuscitation (<24 h) and damage control laparotomy (DCL), morbidity and mortality were assessed. Patients were divided into group 1 (no DCL) and group 2 (DCL needed). Further, group 1 was subdivided into three subgroups (IA pressure (IAP) <12, 12–20 and >20 mmHg).

 One hundred seventeen patients enrolled in the study (102 in group 1 and 15 in group 2) with a mean age of 35 ± 14, injury severity score (ISS) of 23 ± 10, base deficit of −8.7 ± 2.7 mmol/L, serum lactate of 4.6 ± 2.5 mg/dL and haemoglobin level of 8.8 ± 2. Patients received 7 ± 5 red blood cell units, 6 ± 4.7 fresh frozen plasma units and 8.3 ± 3 L of crystalloid per 24 h. There were significant difference between the two groups regarding crystalloid volume, blood transfusion, base deficit and intensive care unit length of stay. However, mortality was higher in group 2 (20% versus 6%). IAP ≥ 20 mmHg was reported in 16.7% patients, while 25.5% had IAP < 12 and 57.8% had IAP of 12–20 mmHg. Patients with IAP > 20 had worse metabolic acidosis and received more blood compared with other groups. One patient died because of ACS (0.9%). Overall multiorgan failure and mortality were 5 and 7.7%, respectively.

With current practice of minimal fluid resuscitation and liberal use of damage control strategies among trauma patients, the IAH was common transient phenomena but the incidence of ACS is remarkably low.

Gastrointestinal (GI) complications after cardiac surgery are uncommon, but are associated with high morbidity and mortality as well as significant hospital resource utilization.

We analysed a prospectively collected database containing all adult cardiac surgery procedures performed from July 2001 to March 2011 at Monash Medical Centre and Jessie McPherson Private Hospital. Patients with post-operative GI complications were compared to patients without GI complications who were operated in the same period.

The incidence of GI complications was 1.1% (61 out of 5382 patients) with an overall 30-day mortality of 33% (versus 3% in the non-GI complication group). The most common complications were GI bleeding, gastroenteritis and bowel ischaemia. Patients who had GI complications were significantly older, had higher incidence of renal impairment, chronic lung disease and anticoagulation therapy and were more likely to be in cardiogenic shock. Emergency procedures, combined coronary artery bypass grafting and valve surgery and aortic dissection cases were more common in the GI complication group. The GI complication group also had higher incidence of return to theatre, renal failure, stroke, septicaemia and multi-organ failure.

GI complications after cardiac surgery remain an uncommon but dreadful complication associated with high mortality. Our findings should prompt a high degree of clinical vigilance in order to make an early diagnosis especially in high risk patients. Further studies aiming to identify independent predictors for GI complications after cardiac surgery are warranted.

To determine the patient, doctor and student perceptions with different styles of student participation in a surgical outpatient clinic.

A randomized controlled trial was conducted in surgical outpatients. Participants included patients scheduled to see one of four specialist general surgeons, the surgeons themselves and third-year medical students undertaking their general surgery rotation at the Geelong Hospital. A total of 151 consultations were randomized to one of three consultation styles between August 2011 and August 2012. (i) ‘No Student’, consultation without a student being present, (ii) ‘Student with Doctor’, consultation where the student accompanied the doctor throughout the consultation and (iii) ‘Student before Doctor’, consultation where the student interviewed the patient before the doctor and examined the patient in the doctor's presence. Participants' perceptions and experience of each of the consultations was assessed in the form of written questionnaires.

There was no difference in overall patient satisfaction with different styles of student participation (P = 0.080). Students showed a clear preference for the ‘Student before Doctor’ consultation style (P = 0.023). There were no differences in consultation outcomes from the doctor's perspective (P = 0.88), except time (P < 0.0001).

This study supports a style of consultation where students are actively involved in patient care as it has no adverse effects on patient satisfaction and it is the preferred participation style from the student's perspective. Doctors do not feel that active student involvement interferes with their ability to deliver healthcare except that it prolongs consultation time.

A number of posterior approaches to the elbow have been described, which vary in the quality of the exposure and morbidity to the triceps mechanism. We describe an adapted technique, the Triceps Split and Snip, which may offer improved surgical exposure during posterior approach to the elbow. We aimed to compare the strength of the triceps repair in this approach to a more traditional approach described by Bryan and Morrey.

Sixteen pairs of cadaveric elbows were randomized by surgical group and operative side. The Triceps Split and Snip and Bryan-Morrey approaches were each performed on eight specimens, followed by repair of the triceps; the contralateral elbow served as the control. The specimens were then mounted on a material testing system and a constant velocity elongation was applied.

The mean load to failure for the Bryan-Morrey group was 421N (range 349–536N). While the Triceps Split and Snip group was 388N (range 267–550N). The percentage ultimate strength loss was 40% for both groups. No significant difference was found in comparing the mean load to failure between the Triceps Split and Snip approach and the Bryan-Morrey approach.

The Triceps Split and Snip approach is a technically simple approach to perform and repair, and provides excellent exposure of the elbow and distal humerus. The tensile strength of the triceps repair following this approach is equivalent to that of the Bryan-Morrey approach.

Oncology literature is increasingly recognizing prevalence of second primary cancers including several longitudinal studies showing an increased risk of colorectal cancer following a prostate cancer diagnosis. A retrospective study was conducted to examine the relationship between prior prostate cancer diagnoses and subsequent colorectal cancer diagnoses.

A multi-centre prospective colorectal cancer registry was queried for patients with a prior history of prostate, breast or lung cancer. Characteristics of these patients were compared to patients with colorectal cancer and no prior cancer history.

Of 4660 cases of colorectal cancer diagnosed between 1998 and 2011, 2665 (57.2%) were male, median age was 68 years. For patients with a history of prostate cancer (n = 111), breast cancer (n = 61) and lung cancer (n = 23), the great majority of subsequent colorectal cancer diagnoses occurred in the initial 2 to 4 years after the first cancer diagnosis. This was accompanied by an increased rate of asymptomatic colorectal cancer at presentation, due to both screen detected and incidental cancer diagnoses. There was no clear relationship between any prostate cancer treatment and subsequent colorectal cancer risk, location or timing.

In the modern era, there is an increased rate of colorectal cancer diagnosis in years shortly following another common cancer history. This is consistently seen across different primary tumour streams including prostate, breast and lung cancers and in part contributed by screen detected and incidental colorectal cancer diagnoses. Future studies should consider this potential confounding factor when asserting an increased rate of colorectal cancer as a second primary cancer.

To better define the prognostic role of nodal disease, evaluation of metastatic lymph node ratio (MLR) has been performed, and this method has recently gained prominence in various gastrointestinal cancers. The present study attempts to identify prognostic factors and evaluate the independent prognostic influence of MLR in patients who have undergone curative pancreaticoduodenectomy.

In our institution within the study period, 111 patients received curative pancreaticoduodenectomy for periampullary cancers. Clinicopathologic data were collected and MLR was calculated for each of the patients. Patients were then divided into four groups based on MLR value: MLR 1 = 0; MLR 2 = 0.01–0.2; MLR 3 0.21–0.4; and MLR 4 >0.4.

Increasing MLR correlates with high recurrence rate and lower overall survival (OS) with significance (P < 0.001, P < 0.001). The recurrent group showed significantly lower OS than the non-recurrent group (P < 0.001). In the multivariate analysis for recurrence, MLR was identified as the only independent prognostic factor (P < 0.001).

The simple and easily obtainable MLR is well qualified as a prognostic factor in patients who undergo curatively radical resection for periampullary cancer. Furthermore, MLR can overcome the limitations of evaluation of lymph nodes status, allowing it to be used as a potential prognostic factor.

Current treatment for locally advanced breast cancer (LABC) includes neoadjuvant chemotherapy and post-mastectomy radiotherapy, which may be deleterious for immediate reconstruction. A few trials have instead combined neoadjuvant chemotherapy followed by preoperative radiotherapy. If safe and oncologically efficacious, mastectomy with immediate free autologous reconstruction (transverse rectus abdominis myocutaneous (TRAM)/deep inferior epigastric perforator (DIEP) flap) could then achieve a shorter, simpler reconstructive journey with better cosmesis. No trials have been performed combining this neoadjuvant regime with free autologous reconstruction as an assessment end point.

We performed a Pubmed/Medline search for oncological efficacy of neoadjuvant chemotherapy followed by preoperative radiotherapy and flap reconstruction of the breast. A new treatment sequencing protocol is proposed in which patients suitable for neoadjuvant chemotherapy followed by preoperative radiotherapy and likely mastectomy are selected. Positive chemotherapeutic response is followed by radiotherapy then surgery within 6 weeks comprising mastectomy/axillary clearance and immediate reconstruction (TRAM/DIEP). Non-responders are offered mastectomy, tissue expander reconstruction, adjuvant radiotherapy then delayed autologous reconstruction. Local/systemic recurrence rates, disease-free survival, complications, patient satisfaction and aesthetics are examined.

Between 1995 and 2012, 10 trials treated LABC patients using combined neoadjuvant chemotherapy followed by preoperative radiotherapy. Compared with chemotherapy alone, increased complete pathological response, complete clinical remission, median survival and tumour-free survival were observed.

Our new treatment sequence protocol offers a simpler, more advantageous approach to LABC. We hypothesize equivalent oncological efficacy, optimized oncological management and surgical planning. The aim was to shorten and simplify the reconstructive journey through a single operation including gold-standard reconstruction, offering better cosmesis, fewer complications and reduced costs.

The objective of this study was to evaluate the evidence for different interventions in the preoperative, perioperative and post-operative care for people undergoing elective total hip (THR) and knee (TKR) replacement surgery.

A multidisciplinary working group comprising consumers, managers and clinicians from the areas of orthopaedics, rheumatology, aged care and rehabilitation evaluated randomized controlled trials (RCTs) and systematic reviews/meta-analyses concerning aspects of preoperative, perioperative and post-operative clinical care periods for THR/TKR through systematic searching of Medline, Embase, CENTRAL and the Cochrane Database of Systematic Reviews from May 2007 to April 2011. Multiple reviewers determined study eligibility and one or more members extracted primary study findings. The body of evidence were assessed and specific recommendations made according to NHMRC guidelines.

Twenty-five aspects were identified for review. Recommendations for 16 of 25 areas of care were made: impact of waiting, multidisciplinary preparation, preoperative exercise, smoking cessation, interventions for comorbid conditions, predictors of outcome, clinical pathways, implementation of a blood management programme, antibiotic prophylaxis, regional anaesthesia and analgesia, use of a tourniquet in knee replacement, venous thromboembolism prophylaxis, early post-operative cryotherapy, early mobilization and continuous passive motion. In the post-operative period, study heterogeneity across all aspects of care precluded specific recommendations.

There was a deficiency in the quality of the evidence supporting key aspects of the continuum of care for primary THR/TKR surgery. Consequently, recommendations were limited. Prioritization and funding for research into areas likely to impact clinical practice and patient outcomes after elective joint replacement surgery are the next important steps.

Traumatic abdominal wall hernia (TAWH) is a rare type of hernia occurring secondary to blunt trauma to the abdomen. Its management remains controversial within the surgical community, mainly due to complexities in diagnosis, appropriate surgical approach and timing of closure.

Cases were identified retrospectively, via interviews with trauma surgeons at a Tertiary Trauma Centre, the Royal Brisbane & Women's Hospital, in Brisbane, Australia. In addition, data were collected via in-house trauma and operative databases.

Five cases of TAWH were identified over a 3-year period. All cases involved injuries sustained from motor vehicle or motor bike accidents. Diagnosis was purely clinical in one case and clinically suspected, then confirmed by computed tomography in the remainder. Herniation was managed by immediate closure in one instance, delayed/staged closure in three cases and conservative management in the remainder. In addition, three of the five patients were obese. At minimal 3-month follow-up, no evidence of recurrence of herniation was present in four of the five cases. One case was lost to follow-up.

TAWH is a complex injury to manage and no one approach is all encompassing. Correct diagnosis is essential as this allows proper planning for the method and timing of repair. This series highlighted that incorrect seatbelt placement, especially in the obese population, may be a risk factor for increased incidence of TAWH.

The superiority of autogenous conduits in infrainguinal bypass surgery is well established. At our institution, arm vein is utilized as the last autogenous option for infrainguinal bypass surgery. The aim of this study was to review the long-term outcomes of last autogenous option arm vein bypass.

All infrainguinal arm vein bypasses performed between 1997 and 2005 by The Queen Elizabeth Hospital vascular surgeons were identified. Patency, reintervention, limb salvage and survival were calculated using the Kaplan–Meier survival estimate method.

Thirty-eight arm vein bypasses were performed in 35 patients. Eighty-nine per cent were performed for critical limb ischaemia. Median follow-up was 58 months (range 2–121). Twelve-month primary, assisted primary and secondary patency rates were 52%, 73% and 76%, respectively. Three-year primary, assisted primary and secondary patency rates were 32%, 61% and 63%, respectively. Five-year primary, assisted primary and secondary patency rates were 21%, 47% and 49%, respectively. Patency was superior in single compared with spliced vein grafts (P < 0.05). Limb salvage rates at 1, 3 and 5 years were 94%, 87% and 76%, respectively. Patient survival at 1, 3 and 5 years was 92%, 68% and 49%, respectively.

Infrainguinal bypass surgery with arm vein can be performed safely with favourable patency and high rates of limb salvage. Secondary interventions to maintain patency are common and we recommend a vigilant surveillance programme to identify the threatened graft.

Surgery for necrotizing pancreatitis is associated with a high rate of morbidity and mortality. We present a series of 26 patients who underwent video-assisted translumbar retroperitoneal necrosectomy and analyse their outcomes.

Records of 26 patients who underwent video-assisted translumbar retroperitoneal necrosectomy and closed drainage for infected pancreatitic necrosis between January 2008 and March 2012 were reviewed, retrospectively.

Twenty-three out of 26 patients were males, with a mean age of 38.6 (±9.9) years. Alcohol was the aetiology in 18 patients, gall stones in 7, and in 1 it was idiopathic. The mean duration of symptoms before patients were taken up for surgery was 47.2 (±34.8) days. The mean computed tomography severity index was 7.7 (±1.2). All patients had undergone video-assisted retroperitoneal necrosectomy through a limited left lumbar incision. Post-operative lavage was given through drains placed in the retroperitoneum. Three patients required re-exploration. Eleven patients developed complications and there were two mortalities. The median intensive care unit (ICU) stay was 4 days (range 2–14 days). The mean post-operative hospital stay was 22.5 (±6.6) days.

Video-assisted translumbar retroperitoneal necrosectomy followed by closed lavage of infected pancreatic necrosis in select cases of infected pancreatic necrosis was associated with a low rate of ICU stay, hospital stay and need for re-entry.

While free flaps can be used in many cases to cover soft tissue defects in the distal leg and ankle in a single stage, factors such as diabetes and advanced age can interfere with success of vascular anastomoses.

Twenty-five patients with deep tissue exposure of the distal leg and ankle underwent reconstruction with a modified reverse sural adipofascial flap. Seventeen cases were due to trauma (13 due to high velocity trauma). All 17 had anterior tibial soft tissue defects without significant rear calf soft tissue injury. Eight patients had iatrogenic soft tissue defects due to orthopaedic surgeries for fractures. The flap is raised through two small incisions (3–5 cm) in the posterior aspect of the leg and the subcutaneous fat is split such that some is preserved with the skin. Once the flap is in place, it is covered by a full-thickness skin graft and the donor site is closed primarily.

Twenty-one flaps survived. Four had partial loss of the skin graft on the flap, which healed spontaneously without secondary resurfacing. Anatomic contour was obtained in the recipient sites of all 25 patients. All donor sites healed primarily with the preservation of protective sensation in the calf and acceptable aesthetic appearance. Numbness in the lateral dorsal foot improved gradually and only minor residual numbness was noted at 1 year postoperatively.

The modified reverse sural adipofascial flap preserved the sensation of the donor site and the anatomic contour of both recipient and donor sites.

Endoscopic thoracic sympathectomy (ETS) provides definitive management for primary focal hyperhidrosis and facial blushing. These conditions are debilitating and not uncommon, but many clinicians avoid ETS due to the risk of complications, particularly compensatory sweating (CS). This retrospective cohort study aimed to evaluate the degree of symptom resolution, patient satisfaction and adverse reactions after ETS and to identify subgroups of patients more likely to achieve a satisfactory outcome.

From 2004 to 2010, 210 patients underwent ETS performed by a single surgeon. These patients responded to a questionnaire regarding levels of satisfaction, symptom resolution and complications encountered, particularly CS.

Palmar hyperhidrosis (97%) and scalp/facial hyperhidrosis (93%) demonstrated greater degrees of symptom resolution than axillary hyperhidrosis (71%) and facial blushing (71%) (P < 0.001). Rates of severe CS were lowest in patients with palmar hyperhidrosis (8%) and highest in patients with axillary (26%) and scalp/facial (44.5%) hyperhidrosis (P = 0.0003). The probability of experiencing no CS was highest at young ages and decreased with age (P = 0.0006). Satisfaction rates also fell as age increased (P = 0.004). Satisfaction rates were highest in patients with palmar (90%) and lowest in patients with scalp/facial (52%) hyperhidrosis (P < 0.02).

Patient satisfaction following ETS is highest among younger patients and those undergoing the procedure for palmar hyperhidrosis. Dissatisfaction arises from failure to achieve the desired aim as well as the development of severe CS, which is more common in older patients and those undergoing ETS for axillary and scalp/facial hyperhidrosis.

Treatment options for patients with portal vein (PV) stenosis or occlusion after surgery are limited. The purpose of this study was to investigate the efficacy and safety of PV stent placement in patients with portal vein occlusion or stenosis after radical operation for hepatobiliary pancreatic malignant tumour.

We retrospectively reviewed the records of 59 patients who underwent portal venous stent placement at the Asan Medical Center, Seoul, Korea, for PV stenosis or occlusion between February 2008 and February 2012.

Stents were placed in the portal venous system across stenotic (n = 47) and occlusive (n = 12) lesions after percutaneous transhepatic portography. Reasons for stent placement were tumour recurrence (n = 30), portal vein resection and anastomosis (n = 18) and post-operative inflammatory changes (n = 11). Pressure gradients (superior mesenteric vein, main PV) decreased immediately after stent placement, from 10.5 mm Hg ± 4.4 (standard deviation) to 2.5 mm Hg ± 2.6 (P < 0.0001). Liver function was improved post-stenting (P < 0.05). The median time between the original surgery and stent placement was 16 (1–137) days in the vascular-orientated group and 306 (13–3703) days in the tumour recurrence group (P < 0.0001). Transient fever developed in 11 patients, but resolved in 2–5 days. Stents were occluded in 15 of the 59 patients (25.4%).

PV stent placement is a safe choice, has an acceptable success rate and provides marked relief from portal hypertension due to portal vein occlusion or stenosis after hepatobiliary pancreatic surgery. Liver function data are also improved after portal venous stent placement.

Early survival and quality of outcome after surgery for hypoplastic left heart syndrome (HLHS) are influenced by patient-specific factors, the quality of surgery and perioperative care. Some skills are common to the care of other complex neonatal presentations but integrating this expertise is a key challenge for new programmes. We began offering surgery for HLHS from 2006 and provided a regional service from January 2009 and report early outcomes.

Prospectively collected data for neonates with HLHS undergoing surgical palliation from January 2006 until June 2011 were analysed. Standard definitions of high-risk and standard-risk presentations were utilized.

Thirty neonates underwent surgical palliation of HLHS with a modified Norwood procedure with an overall survival to stage II palliation of 80%. A total of 46.7% of our patients were categorized as high-risk, mostly on the basis of low birth weight. Survival to stage II palliation was 100% in standard-risk patients and 57.1% in the high-risk group.

Outcomes for this new programme are comparable to reported outcomes demonstrating the feasibility of integrating a new complex procedure within an existing multidisciplinary unit handling large volumes of other complex neonatal work. Excellent outcomes can be achieved in standard-risk patients. Outcomes in the high-risk group may be improved by alternative approaches and rigorous case selection.

Various techniques have been described to try and reduce the rate of anastomotic leak following pancreaticoduodenectomy, which remains a challenge for pancreatic surgeons worldwide. We outline a technique to reinforce the pancreatic anastomosis with a double layer of fibrin glue between suture lines.

Our technique for pancreatic anastomosis is described in detail. A review of consecutive pancreaticoduodenectomies by a single surgeon (NAC) since introduction of fibrin glue anastomosis reinforcement was compared with a historical control cohort performed by the same surgeon.

Thirty-two consecutive pancreaticoduodenectomies were undertaken between March 2008 and March 2012 by a single surgeon, 30 patients had fibrin glue augmentation of the pancreatico-gastrostomy anastomosis. Median length of stay was 12 days. There were no pancreatic leaks or mortality since adopting fibrin glue for the pancreatic anastomosis; however; this single surgeon series is not large enough to provide statistical evidence of a difference since glue was adopted.

Our results since the incorporation of this step in pancreaticoduodenectomy are encouraging. Selective use of glue is worthy of consideration in difficult cases, although confirmation of a reduction in pancreatic leak rate is not yet established, and we advocate a multi-institution randomized controlled trial to explore this.

Smoking cessation before surgery improves perioperative outcomes and some smokers may quit if undergoing surgery. Quitting smoking in community settings is influenced by physician quit advice and knowledge of smoking hazards, but there are few data on whether this applies in perioperative settings.

Survey on day of surgery of elective patients who reported being a smoker at the time of wait-list placement. Duration of smoking abstinence before surgery (if any) and length timing of failed quit attempts was determined. Sources of any quit advice before surgery, including from physicians, and patient knowledge on hazards of smoking and surgery were questioned.

While on the waiting list, 44/177 smokers reported quitting (>24 h) before surgery and 42/177 others made an attempt. Quitting was usually brief. Fewer than 40% of smokers answered yes (correct answer) to questions on whether smoking increased wound infection rates, worsened wound healing, increased anaesthetic complications or increased post-operative pain. Incorrect answers (no) were less likely in quitters than those smoking until surgery (OR 0.41, 95% CI 0.25–0.68). Patients still smoking by admission recalled quit advice from a surgeon in 22.6% of cases, while wait-list quitters recalled surgical quit advice in 43.2% of cases (OR 2.6 95% CI 1.2–5.4 P = 0.01). Effects of general practitioner quit advice were significant (OR 3.2 95% CI 1.5–6.8 P = 0.004) while anaesthetists, nurse and hospital brochure advice were not.

Improving patient knowledge of the perioperative risks of smoking and increased physician advice to quit may improve smoking abstinence at surgery.

During 2008, the Royal Brisbane and Women's Hospital became the first public hospital in Australia to have a da Vinci Surgical Robot purchased by government funding. The cost of performing robotic surgery in the public sector is a contentious issue. This study is a single centre, cost analysis comparing open radical prostatectomy (RRP) and robotic-assisted radical prostatectomy (RALP) based on the newly introduced pure case-mix funding model.

A retrospective chart review was performed for the first 100 RALPs and the previous 100 RRPs. Estimates of tangible costing and funding were generated for each admission and readmission, using the Royal Brisbane Hospital Transition II database, based on pure case-mix funding.

The average cost for admission for RRP was A$13 605, compared to A$17 582 for the RALP. The average funding received for a RRP was A$11 781 compared to A$5496 for a RALP based on the newly introduced case-mix model.

The average length of stay for RRP was 4.4 days (2–14) and for RALP, 1.2 days (1–4). The total cost of readmissions for RRP patients was A$70 487, compared to that of the RALP patients, A$7160. These were funded at A$55 639 and A$7624, respectively.

RALP has shown a significant advantage with respect to length of stay and readmission rate. Based on the case-mix funding model RALP is poorly funded compared to its open equivalent. Queensland Health needs to plan on how robotic surgery is implemented and assess whether this technology is truly affordable in the public sector.

Rural and regional populations suffer higher rates of preventable disease and all-cause mortality than urban areas, with rural areas of the USA experiencing double the rate of ruptured abdominal aortic aneurysms (AAAs). We investigated the incidence and outcomes of ruptured AAAs in an Australian rural and regional setting, and compared these with those of an urban population.

We undertook a retrospective analysis of all patients suffering AAA rupture in New South Wales (NSW) from 2009/2010 to 2010/2011. Variables included rates of rupture, mortality and intensive care admission. Urban and rural–regional areas were stratified according to NSW Health Local Health Districts, and comparisons between the two groups were performed.

Ruptured AAAs had an incidence of 4.1/100 000, with males twice as likely to suffer AAA rupture (P = 0.009), but females 88% more likely to die from rupture (P = 0.001). There was no significant difference between AAA rupture rates (5.0 versus 3.4 per 100 000; P = 0.054) nor case-fatality rates (41.22% versus 40.94%; P = 0.087) in rural–regional and urban populations. Patients in urban areas had a longer hospital stay (5 days versus 1 day, P = 0.001), were more likely to be admitted to intensive care unit (29.4% versus 19.9%, P = 0.001) and were less likely to be transferred to another hospital (19% versus 32%, P = 0.001).

AAA ruptures remain a significant public health burden. Rural and regional areas suffer disproportionately, which may be improved by implementation of AAA screening and funding for rural and regional hospitals to sustain adequate surgical and intensive care facilities.

The aim of this study was to assess the effect of povidone-iodine on the groin wounds of patients undergoing primary varicose vein surgery.

This is a prospective, randomized, blinded, controlled study on patients undergoing primary saphenofemoral ligation. Patients were randomized to a povidone-iodine (Betadine; Pfizer, West Ryde, Australia)-soaked surgical gauze placed in the open wound or a saline-soaked gauze placed in the wound. Patients were then followed up weekly for 6 weeks to observe for signs of wound infection.

Sixty-eight legs in 49 patients were recruited. Thirty-seven groin wounds were randomized to saline and 32 to Betadine. There was a reduced incidence of groin wound infections in those randomized to Betadine (3 versus 1), but this was not statistically significant (P = 0.4).

Although there may be a trend towards a lower wound infection rate when povidone-iodine is use in surgical wounds, this is not significant for varicose vein surgery.

Although useful in evaluation of suspected appendicitis, not all patients require computed tomography (CT) evaluation. Clinical stratification of patients who benefit from CT evaluation is essential. We utilize the Alvarado score (AS) to stratify patients with suspected appendicitis into subgroups who benefit from CT evaluation and propose an objective algorithm with AS guiding CT utilization.

This study is a retrospective review of medical records of all patients admitted for suspected appendicitis over a 6-month duration. Relevant data were recorded. The AS for each patient was determined retrospectively and correlated with histological and CT findings. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were determined for various ASs and for CT.

Three hundred fifty-eight patients were studied, with 167 males (46.6%) and 191 females (53.4%). Prevalence of appendicitis was 50% (179 patients). Two hundred fourteen patients (59.8%) had CT performed. Surgery was performed for 206 patients (57.5%). Overall negative appendicectomy rate was 13.1%. Patients who underwent CT evaluation had a negative appendicectomy rate of 5.7% compared to 17.9% in those without CT evaluation (P = 0.009). CT scan had a sensitivity and specificity of 92.6% and 96.9%, respectively. An AS greater than 3 had a sensitivity superior to CT (95.5%), while an AS of 9 or greater had a specificity superior to CT (100%).

In suspected appendicitis, patients who benefit from CT evaluation are those with the AS ranging from 4 to 8. We propose a management algorithm with the AS guiding the necessity for CT evaluation.

Fatigue has been shown to have a negative impact on surgical performance. However, there is a lack of research investigating its effect on laparoscopy, particularly in Australia. This study investigated whether fatigue associated with a surgeon's usual workday led to a measurable drop off in laparoscopic surgical skills as assessed on a laparoscopic simulator.

A comparative study involving two cohorts was undertaken: a study group whose data were collected prospectively was compared to a historical control group. Participants were required to reach a predetermined level of proficiency in each laparoscopic task on either a FLS or LapSim simulator. The participants in the study cohort were re-tested approximately 1 month after completing 10 h of work. The participants in the historical non-fatigued group were re-tested approximately 1 month after reaching proficiency. Comparisons between cohorts were made using a ‘decrease in score per day elapsed’ value to account for the natural attrition in skills over time and the variability in testing times within and between the two cohorts.

The decrease in overall score per day elapsed for fatigued participants was significantly greater than for historical non-fatigued participants, irrespective of the simulator type. Fatigue had a greater impact on certain laparoscopic skills, including peg transfer and knot tying. Participants who self-reported higher level of fatigue demonstrated significantly better skills than those who self-reported lower levels.

Overall laparoscopic skill proficiency was reduced in the fatigued participants compared to the historical non-fatigued participants, with certain laparoscopic skills more affected than others.

Young patients with colorectal cancer pose diagnostic and management challenges. The study aim was to assess colorectal surgical practice in Australia and New Zealand with respect to management of young patients with colorectal cancer and the impact of family history.

An electronic survey was sent to members of the Colorectal Surgical Society of Australia and New Zealand (CSSANZ). The survey assessed the clinical practice of the respondent and utilized scenario-based questions to investigate their clinical approach to patients under 50 years who develop colorectal cancer with respect to management and surveillance. Colorectal society trainees, members and fellows were also questioned on a scenario of polyposis and no vertical transmission, and which operation they would perform.

Of the 189 surveys sent out, 114 respondents completed the survey (60.3%) with 99 (86.8%) respondents practicing colorectal surgeons and 13.2% (15) CSSANZ trainees. Ninety-five percent of respondents had a practice with greater than 70% colorectal work. Of the surgeons and trainees, 92.1% (105) would perform a limited resection in a young patient with a right-sided cancer. Six percent altered the approach if there was a first-degree relative with colorectal cancer, and 68% altered the approach if the family history fulfilled criteria for hereditary non-polyposis colorectal cancer. Only 22.8% of respondents could recognize potential MutYH-associated polyposis with moderate polyposis and absence of vertical transmission.

Colorectal surgeons in Australia will modify their management of patients under 50 years with colorectal cancer based on a family history and risk of inherited colorectal cancer syndromes. Further education could improve management.

Immunosenescence may contribute to an observed increase in infections and specific cancers in the elderly. Lymph nodes play a key role in the body's immune system. A systematic review was undertaken to investigate the effects of senescence on lymph node number and morphology.

Electronic databases Ovid MEDLINE, Embase and Google Scholar were searched for relevant articles examining normal lymph node number and morphology with senescence. Data on lymph node number, gross anatomy and histo-architecture were collated and analysed.

A total of 20 articles (15 human and 5 animal studies) were eligible for inclusion; many were limited by poorly standardized methods and relatively small sample sizes. However, there is evidence to suggest both a decrease in lymph node number and histological lymph node degeneration with senescence, at least in some lymph node basins. Degenerative changes include loss of lymphoid tissue from both the cortex and the medulla of lymph nodes, a reduction in the number and size of germinal centres, and changes such as hyalinization, fibrosis, fat deposition, a decrease in high endothelial venules and ‘transparency’.

In this first systematic review to examine changes in lymph nodes with senescence, evidence was accrued to suggest a decline in lymph node number and morphological degeneration in older age groups. These changes might adversely affect immune function and the prognosis of infections and selected cancers in the elderly. Further research is required to confirm these morphological changes and to explore their potential immunological and functional effects.

This study aims to compare the effects of two different local resection procedures on the prognosis of ampullary cancer.

We carried out a retrospective study using clinical and pathological data from patients with ampullary cancer who underwent local resection between February 1996 and February 2009 in the PLA General Hospital. In these participants, we carried out a comparative analysis between the transduodenal (the transduodenal group) and the extraduodenal (extraduodenal group) surgical approaches.

No significant differences in gender, age, preoperative bilirubin levels, CA19-9 values, biopsy results, tumour size, differentiation status, degree of invasion, surgical margins, recurrence, metastasis and complication rates, and intraoperative blood loss were found. As compared to the transduodenal group, the extraduodenal group showed a longer duration of surgery and higher survival rates.

Even though the operation time for the extraduodenal resection of ampullary cancer was longer, the survival rate was higher than in patients who underwent transduodenal resection. For certain patients, the extraduodenal approach may be more appropriate when technical conditions allow it.

We sought to investigate the short- and mid-term results of the endovascular repair of infrarenal abdominal penetrating aortic ulcers (aPAUs).

Patients with infrarenal aPAUs treated by endovascular means between March 2004 and June 2012 were recruited. Pre-interventional imaging included computed tomography (CT) or CT angiography. Endoprostheses were chosen and deployed according to standard elective endovascular aneurysm repair anatomical requirements. Endpoints included 30-day survival, in-hospital mortality, 1-year PAU-related mortality, 1-year all-cause mortality, freedom from death and freedom from cumulative complication and interventions. Statistically, the Kaplan–Meier method was applied.

Nineteen patients (18 men, median age 70 years (interquartile range, IQR = 59–75)) suffering aPAUs (n = 29, infrarenal = 25) were detected. The median co-morbid severity scoring was 1.0 (IQR = 0.4–1.4). The median follow-up period was 33 months (IQR = 8–51.5). Furthermore, 94.7% of patients had hypertension. Fourteen patients (73.7%) had symptoms, including four of them admitted with shock from large-contained PAU rupture. Endoluminal stent grafting was successfully delivered in all patients. In-hospital mortality was 10.5%. Two patients required secondary interventions (10.5%). The 30-day survival, 1-year PAU-related mortality and 1-year all-cause mortality were 94.7%, 89.5% and 89.5%, respectively. Freedom from death and freedom from cumulative complications and interventions was 86.4% and 86.4%, 78.9% and 78.9%, and 67.9% and 71.2% at 12, 24 and 36 months, respectively.

Urgent and elective endovascular repair of aPAUs can be achieved with high technical success. The significant co-morbid status of the treated patients is illustrated in the considerable in-hospital mortality and underlines the advantage of such treatment over open surgical repair.

Patients taking warfarin are often given interim anticoagulation in the perioperative period. Institutional guidelines that use low-molecular-weight heparin (LMWH) ‘bridging’ while the international normalized ratio (INR) is sub-therapeutic are often based on the American College of Chest Physicians Anticoagulation Guidelines.

This study aims to identify if patients at a tertiary referral hospital were anticoagulated in line with these guidelines, and the incidence and nature of bleeding and thromboembolic complications.

A retrospective review of the Alfred Hospital General Surgical and ‘Hospital at Home’ databases was conducted, identifying patients who underwent elective general surgical procedures and received bridging anticoagulation with enoxaparin. Demographics, indication for anticoagulation, bleeding and thromboembolism rates were recorded. Thromboembolic risk was estimated.

The study identified 108 patients. Three-quarters of all patients were anticoagulated with LMWH doses in accordance with the guidelines. Thirty of the 108 patients suffered bleeding complications. This group was younger, weighed less, received higher doses of enoxaparin and were at higher predicted risk of thromboembolism than non-bleeding patients. Wound haematoma, rectal bleeding and intra-abdominal bleeding were the most frequent complications. The peak time of bleeding was 3.5 days after surgery. Twelve patients returned to theatre, 13 were readmitted and 3 received blood transfusion. One patient suffered pulmonary emboli on the first post-operative day.

LMWH bridging therapy when prescribed appropriately is associated with low rates of inpatient thromboembolism in elective general surgical patients within our institution, but an unexpectedly high rate of bleeding complications.

This study aims to determine whether tricuspid regurgitation (TR) ≥ 2+ requires attention during mitral valve surgery.

From April 1999 to 2009, 161 patients undergoing primary, isolated mitral valve procedures were assessed. Preoperative moderate TR (≥2+) was present in 56 of 161 patients and tricuspid valve repair (TVR: ring annuloplasty) was carried out on 22 of 56 patients with TR ≥ 2+. Baseline echocardiogram included TR severity (ASE criteria), TR velocity, estimated right atrial pressure, visual assessment of right ventricular failure and strain. Follow-up was 47 ± 33 months (96% complete); 91 of 161 patients overall (57%) and 44 of 45 patients with TR ≥ 2+ had follow-up echocardiogram.

Patients with moderate TR had worse baseline functional class and operative risks, both worst in the non-TVR group. Overall mortality was 15% (n = 23), comprising 2.5% (4/161) 30-day mortality and 12% (9/157) late death. Poorer preoperative TR was associated with worse survival by univariate analysis (P = 0.046), after correction for right ventricular function and pulmonary artery pressure (P = 0.049), age and diabetes (P = 0.041). Despite lower risk of TR ≥ 2+ with TVR, 5-year survival was 42%, which was less than TR < 2+ and that of non-TVR group (90%, P = 0.003). Improvement in overall functional class (NYHA) was better in the non-TVR group (TVR: preoperative 2.1 ± 1.5; post-operative 1.2 ± 1.1 (P = 0.02) versus non-TVR: preoperative 1.8 ± 1.4, post-operative 1.2 ± 0.9 (P < 0.0001)). There was no difference in quality of life (QOL) indices (SF-36 questionnaire) at follow-up between patients with TR < 2+ and TR ≥ 2+ preoperatively, or across all levels of TR before or after surgical repair.

Preoperative TR ≥ 2+, non-TVR group had more favourable functional class and mid-term survival with comparable QOL and echocardiographic parameters to the TVR group.

Liver cysts are common, occurring in up to 5% of the population. For many types of cysts, a variety of different treatment options exist and the preferred management is unclear.

A PubMed and Medline literature review was undertaken and articles pertaining to the diagnosis and management of cystic lesions within the liver were retrieved.

Therapy for symptomatic cysts may incorporate aspiration with sclerotherapy or de-roofing. Polycystic liver disease presents a unique management problem because of the high morbidity and mortality rates from intervention and high rates of recurrence. Careful patient counselling and assessment of symptom index is essential before embarking on any treatment. New medical treatments may ameliorate symptoms. Acquired cystic lesions in the liver require a thorough work-up to fully characterize the abnormality and direct appropriate treatment. Hydatid cysts are best treated by chemotherapy, followed by some form of surgical intervention (either aspiration and sclerotherapy or surgery). Liver abscesses can be effectively treated by aspiration or drainage.

All patients with cystic lesions in the liver require discussion at multidisciplinary meetings to confirm the diagnosis and determine the most appropriate method of treatment.

The prognostic influence of lateral neck nodal metastases present at the time of diagnosis of papillary thyroid cancer (PTC) remains controversial. This study aims to document disease outcomes and nodal recurrence rates in such patients.

Patients with PTC and lateral neck nodal metastases who underwent concurrent total thyroidectomy, central and lateral compartment neck dissection between 2000 and 2010 were identified from the prospectively maintained surgical databases of The University of Sydney and University of Wisconsin Endocrine Surgical Units. Disease outcomes and nodal recurrence rates were compared at 12 months post-operatively and in longer-term follow-up.

During this 11-year period, 121 patients were identified. Mean age was 45 years; 58% were female and 98% underwent post-operative radioactive iodine ablation. At a median follow-up of 31 months (range 12–140), there were no disease-specific deaths and disease-free survival (defined by stimulated serum thyroglobulin (Tg) < 2.0 μg/L, negative clinical and radiological examination) was 66%. Of the 50 patients with persistently elevated Tg measured 12 months post-operatively, 15 developed clinical lateral neck nodal recurrence. All have undergone re-operative surgery. Elevated stimulated Tg at 12 months post-operatively and a nodal ratio of >30% were significantly associated with an increased risk of lateral neck nodal recurrence.

With total thyroidectomy, formal compartmental neck dissection and radioactive iodine treatment, disease-free survival can be achieved in the majority of patients with PTC and synchronous lateral neck nodal metastases. A persistently elevated Tg post-operatively and a high ratio of metastatic nodes identify patients at increased risk of locoregional recurrence.

The two commonly used questionnaires to assess low back pain are the low back outcome score (LBOS) and the Oswestry disability index (ODI). This study aims to identify unique questions and remove redundant questions to develop a composite questionnaire.

Eighty-seven consecutive patients attending the practice of a single spinal surgeon completed both the ODI and the LBOS as part of their initial assessment. Both questionnaires were analysed to eliminate questions that exhibit floor–ceiling bias and questions that are interdependent and correlate strongly. Total scores and the scores obtained for each question were then compared (Spearman's rho). A principal axis factor analysis using a varimax rotation was performed to reduce data and identify questions that were interdependent. Using these data, a composite questionnaire was proposed that would minimize overlap in clinical data.

Eighty-seven patients completed the LBOS and ODI. The mean age is 54, with a range between 18 and 80. The male to female ratio was 50:37. By eliminating questions that contain biases and overlap in clinical data, the composite questionnaire contains 11 questions. From LBOS; housework, dressing, sleeping, sitting, walking and travelling. From the ODI; pain, standing, social life and lifting.

Analysis of the questionnaires identified eight questions that were similar in both questionnaires. Two questions were included that were unique to each questionnaire. The proposed composite questionnaire is of similar size as the original questionnaires and retains questions that are unique to each other while eliminating questions that are redundant and exhibit bias.

Portal vein embolization (PVE) induces compensatory hypertrophy of the future liver remnant volume (FLRV) to improve the safety of major liver surgery by reducing the risk of post-operative liver failure. The aim was to describe our experience of PVE for patients with large or multifocal malignant liver tumours who initially were deemed unresectable.

Perioperative data were retrieved from a prospective database and computed tomographic scans were retrospectively reviewed to calculate volume changes and the degree of liver hypertrophy following PVE.

PVE was successful in 23 out of 25 patients and resulted in a change in the mean estimated FLRV from 585 to 788 mL following PVE. This represented a 35% increase in the remnant liver parenchymal volume post-embolization (P < 0.01). The procedure was well tolerated and did not compromise the surgical resection in any patient. Nineteen patients went on to have a liver resection following PVE with an in-hospital mortality of 16% (3 out of 19) and a 42% morbidity rate. After a mean follow-up of 31 months (1–130 months), 32% (6 out of 19) of patients are alive and 4 of these (21%) are completely disease-free.

PVE results in an increase in the FLRV prior to major hepatectomy. Failure to develop hypertrophy following PVE is a surrogate marker for underlying liver dysfunction. PVE is safe and may increase the pool of patients suitable for liver resection. Long-term survival is similar to those not requiring embolization prior to liver resection.

Obesity is a health problem approaching pandemic proportions. Laparoscopic adjustable gastric banding (LAGB) is the bariatric procedure of choice in Australia for effective surgical treatment of severe obesity. Complications of LAGB lead to a high proportion of patients requiring revision surgery. However, literature regarding outcomes and failure rates of revision bariatric surgery is scarce, such that the choice of procedure at reoperation remains controversial. This paper aims to present outcomes of revision laparoscopic gastric banding.

One hundred eighty-three consecutive revision LAGB procedures were performed in 163 patients between March 1998 and July 2009. Patients were followed up for a median period of 36 months. Weight change in terms of body mass index (BMI) and percentage excess weight loss (%EWL), morbidity and patient tolerance were examined.

The average reduction in BMI from the primary LAGB procedure was 8.45 kg/m², equivalent to a %EWL of 50.55. BMI of patients who underwent revision LAGB appears to remain stable, with mean change of +0.25 kg/m² (%EWL 45.76, P = 0.5) at 3 years and −1.59 (%EWL 51.52, P = 0.12) at 5 years. The overall complication rate of revision LAGB was 13.7%, most commonly recurrent gastric pouch dilatation.

Revision LAGB is reasonably well tolerated by most patients. Preliminary outcome data indicate that revision gastric banding does not result in further weight loss in patients who have lost weight from primary banding, but does maintain the weight loss achieved.

Missed parathyroid adenoma (PTA) is the commonest cause of persistent hyperparathyroidism. Although many are subsequently found in well-described locations, some are found in unusual regions of the neck. This paper presents the combined experience of three large tertiary endocrine surgery centres with maldescended PTA (MD-PTA).

Patients were recruited from the endocrine surgical databases of three tertiary endocrine surgery units. Patients with PTA found >1 cm above the superior thyroid pole or other cervical locations as a result of abnormal or incomplete descent were included for analysis.

MD-PTA was identified in 16 patients out of a total of 5241 patients who had undergone parathyroidectomies in the 7-year study period (incidence 0.3%). Seven (44%) patients had minimally invasive parathyroidectomy, while nine (56%) had bilateral neck exploration. The mean excised gland weight was 750 + 170 mg. Cure was achieved in all patients with a minimum follow-up of 6 months. The locations of MD-PTA in this study included submandibular triangle, retropharyngeal space, carotid sheath (at carotid bifurcation and intravagal), parapharyngeal space (superior to thyroid cartilage or superior thyroid pole) and cricothyroid space.

Despite their rare occurrence, incompletely or abnormally descended PTAs can be encountered by any surgeon who performs parathyroidectomies. It is important to develop a strategy to systematically locate these glands. High cure rates can still be achieved with minimally invasive parathyroidectomy if confident preoperative localization is available. A sound knowledge of embryology and a thorough exploration also facilitate an overall high success rate with open exploration.

The aim of this study was to determine the incidence and tumour characteristics of incidental prostatic cancer in Australian men with primary bladder cancer undergoing radical cystoprostatectomy (RCP).

Cystoprostatectomy specimens were reviewed for a 10-year period from a leading pathology centre in the state of New South Wales, Australia. Stamey classification was used to define significant prostate cancer.

One hundred twenty-nine patients underwent RCP, 50 (39%) had prostatic adenocarcinoma, of which 35 (70%) were clinically significant. Apical involvement was seen in 10 (20%) of which 8 (16%) were clinically significant. High-grade intraepithelial neoplasia was seen in 27 (21%) and urothelial carcinoma or extension of bladder tumour was seen in 15 (12%) and 10 (8%) respectively. Bladder carcinoma in situ (CIS) was strongly associated with presence of urethral disease (P = 0.008).

High rates of prostatic involvement with adenocarcinoma and as well as urothelial malignancy was detected in patients with primary bladder cancer undergoing cystoprostatectomy. Large proportions of prostate adenocarcinoma were clinically significant. Presence of bladder CIS was significantly associated with presence of prostatic urethral disease.

Lower back pain is a common and costly condition in Australia. This paper aims to conduct an economic evaluation of lumbar artificial intervertebral disc replacement (AIDR) compared with lumbar fusion for the treatment of patients suffering from significant axial back pain and/or radicular (nerve root) pain, secondary to disc degeneration or prolapse, who have failed conservative treatment.

A cost-effectiveness approach was used to compare costs and benefits of AIDR to five fusion approaches. Resource use was based on Medicare Benefits Schedule claims data and expert opinion. Effectiveness and re-operation rates were based on published randomized controlled trials. The key clinical outcomes considered were narcotic medication discontinuation, achievement of overall clinical success, achievement of Oswestry Disability Index success and quality-adjusted life-years gained.

AIDR was estimated to be cost-saving compared with fusion overall ($1600/patient); however, anterior lumbar interbody fusion and posterolateral fusion were less costly by $2155 and $807, respectively. The incremental cost-effectiveness depends on the outcome considered and the comparator.

AIDR is potentially a cost-saving treatment for lumbar disc degeneration, although longer-term follow-up data are required to substantiate this claim. The incremental cost-effectiveness depends on the outcome considered and the comparator, and further research is required before any firm conclusions can be drawn.

Operating theatre inefficiency and changeover delays are not only a significant source of wasted resources, but also a familiar source of frustration to patients and health-care providers. This study aimed to prove that the surgical registrar through active involvement in patient changeover can significantly improve operating room efficiency and minimize delays.

A two-phase prospective cohort study was undertaken, conducted over the course of 4 weeks at a single institution. The only inclusion criteria comprised patients to undertake endoscopic urological day surgery cases and require general anaesthesia. There were no exclusions. In the first phase (observational, with no intervention), changeover times between cases were documented. The second phase followed a structured intervention, involving the surgical registrar being actively involved in the patient's operative journey. Outcome measures were qualitative measures of operative efficiency. Statistical analysis was undertaken.

There were 42 patients included in this study, with 21 patients in each of its arms. A 48% (P-value < 0.01) reduction in overall case changeover times was demonstrated with the utilization of a structured intervention from 27.7 min (95% confidence interval (CI) 22.8–32.7%) to 15.7 min (95% CI 13.2–18.2%). The intervention results were statistically significant (P-value < 0.05) for all markers of efficiency except for the waiting time in the anaesthetic holding bay (P-value 0.13).

The surgical registrar can improve operating room efficiency by using a structured intervention, ultimately reducing patient changeover times.

Colorectal cancer is the second most common type of solid organ cancer in New Zealand behind prostate cancer. Even with treatment, distant disease may develop in the liver and lungs. Surgical resection of isolated liver and/or lung metastasis is now commonly considered, but survival outcomes from the latter are not well described. This study aims to review the 5-year survival and prognostic factors of patients who have resection for lung metastasis of colorectal origin.

A retrospective audit of surgical resection for lung metastasis performed by thoracic departments of several tertiary referral centres within New Zealand was performed. The study period was between 1997 and 2011. Patients were identified through operative logs, audit databases, clinical case mix codes and pathology databases. Patient demographics, preoperative and post-operative variables were recorded. All patients were followed up for survival analysis. Mann–Whitney and chi-square tests were performed for data analysis. A P-value of less than 0.05 was significant.

There were 106 (59 male) patients. Median age was 64 (inter-quartile range (IQR) 57–73) years. Median follow-up period was 30 (IQR 16–46) months. The 5-year overall and cancer-specific survival was 40% and 43%, respectively. The only good prognostic factor for survival after lung resection was a long disease-free interval (P = 0.04) between surgery for the colorectal primary and lung metastasis.

Lung resection for isolated colorectal metastases provides a reasonable 5-year survival. Outcomes from lung resection for colorectal metastases in New Zealand are comparable to that from international series.

Several recent studies have suggested that warming up prior to surgery may improve surgical performance. The purpose of this study was to investigate whether warming up prior to laparoscopic surgery improves surgical performance or reduces surgery duration.

Between August 2011 and January 2012, a randomized controlled trial was conducted to compare two warm-up modalities to no warm-up. The study was conducted at a single site, with nine surgeons performing 72 laparoscopic cholecystectomies and 37 laparoscopic appendicectomies. Prior to surgery, surgeons were randomized to either laparoscopic trainer box warm-up, PlayStation 2 warm-up or no warm-up. The activity was performed within 30 min of surgery commencing. Patients provided informed consent for the surgery to be digitally recorded. Digital videodiscs (DVDs) were reviewed by an independent and blinded assessor. Data were collected on duration of surgery, level of training and perceived surgical difficulty. Surgical performance was graded using a validated scoring system.

From the 109 operations performed, there were 75 usable DVDs. Overall, there were no statistical differences in the demographics of patients and surgeons in the three treatment groups, nor in the subset that had useable DVDs. There were no statistical differences in the duration of surgery or surgeon's perceived surgical difficulty. There was no statistical difference in surgical performance.

This study suggests that warm-up prior to laparoscopic cholecystectomy or appendicectomy is not essential, acknowledging that there are several study limitations that preclude definitive conclusion.

Gastrointestinal stromal tumours (GISTs) are the most common gastrointestinal mesenchymal tumour. This study describes clinicopathological and molecular characteristics in association with clinical outcome, in patients undergoing foregut GIST resection.

Clinicopathological data were collated retrospectively for 40 consecutive foregut GISTs. Mutational analysis (quantitative polymerase chain reaction) for KIT exons 9, 11, 13 and 17 and PDGFRa exon 18 was performed on paraffin-embedded tissue (40 primary tumours and three metastases).

The median age was 63 years (range: 40–92), and melaena was the most common presentation (30%). Patients undergoing a totally laparoscopic excision had the shortest mean hospital stay (5.5 days). Over a median of 72-month follow-up, seven patients developed recurrence/metastases. Tumour size and mitotic rate correlated with recurrence (P < 0.01; <0.01) and mortality (P = 0.03; <0.01). KIT (23/40) or PDGFRa (12/40) mutations were found in 87.5% of the primary tumours. Only patients with KIT mutations suffered mortality (n = 4; P = 0.19) and no patient with a PDGFRa developed recurrence (P = 0.13).

Tumour site, size and mitotic rate were confirmed as prognostic markers. While KIT and PDGFRa mutations were associated with negative and positive outcomes, respectively, this did not prove to be significant. The clinical impact of these findings may only become apparent in larger series.

Solitary necrotic nodule of the liver (SNNL) is a rare benign lesion with an uncertain aetiology. There are no typical diagnostic clinical or radiological features, and this lesion is usually detected incidentally during imaging for other purposes.

We describe the clinical and radiological findings in three patients with histologically confirmed SNNL. The pertinent presenting features were documented and subsequent serological testing for parasites was performed.

All three patients underwent resection because it was not possible to exclude a solitary malignancy on preoperative imaging. All three nodules had a serpiginous shape with areas of necrosis that showed marked staining for eosinophil granules. However, no viable parasites were seen in any specimen. There were no specific radiological features that were present in all three patients. Two patients had travelled to areas where parasitic infections are endemic and one patient had an eosinophilia on presentation. The histopathological findings in conjunction with the clinical presentation suggest that SNNL may be parasitic in origin.

The diagnosis of SNNL is usually made after surgical excision. A preoperative diagnosis is difficult to make even with the use of multiple imaging modalities. The clinical and histopathological findings described in our three patients suggest that a transient parasitic infection is likely to be the cause in many cases. A history of potential exposure to parasites and serological testing for an eosinophilia or parasitic antibodies may help make the diagnosis of SNNL without the need for resection.

A set of clinical measures (indicators), developed by an Australian Council on Healthcare Standards (ACHS) and Royal Australasian College of Surgeons (RACS) working party, was introduced into the accreditation programme in 1997. Although early qualitative and quantitative reporting by health-care organizations (HCOs) reflected their value in stimulating change, the number of HCOs reporting data on this set of clinical indicators (CIs) has declined, despite an increase in the number of HCOs reporting data on the CIs programme overall. Possible reasons for this decline were sought.

A retrospective review of prospectively collected surgical CI data was performed, a national survey of stakeholders in the ACHS programme was conducted and a comparison was made with published international data.

From a maximum of 247 HCOs reporting data in 2002, the number fell to 168 by 2011. While favourable trends were evident with some CIs, for example, a decline in the rate of negative histology in childhood appendicectomy and in the rate of in-hospital infection in total hip joint replacement, there was minimal change with many of the CIs, suggesting limited responsiveness as measures of care. In the national survey, stakeholder's response was positive overall, but there was a requirement for regular review of CIs. Although some colleges viewed the CIs as simplistic and not reliable, comparisons with similar measures available in the international literature were favourable.

Possible reasons for the declining number of HCOs reporting surgical CI data are a lack of a recent revision of the CIs and a lack of engagement of clinicians from the RACS. Revision of the surgical CI set is required.

There are well-described benefits to separating emergency and elective surgery. Geelong Hospital lacked the resources to implement a separate acute surgical unit, but instituted daily dedicated emergency general surgery operating sessions, managed by an on-site consultant. This study aims to assess the impact of this on service delivery and surgeons' job satisfaction.

From 1 February 2011, daily half-day operating lists were allocated for general surgical emergencies. Patients treated on these lists were studied prospectively until 31 December 2011. Theatre waiting times and hospital stay were compared with the previous year. A quality-of-life questionnaire was administered to participating surgeons before the project commenced and after 6 months.

A total of 966 patients underwent surgery during an emergency general surgery admission in the control period, and 984 underwent surgery during the study period. The median time from arrival in the emergency department (ED) to surgery was reduced from 19 (18–21) h in the control group to 18 (17–19) h in the study group (P = 0.033). The time from booking surgery to operation was reduced from 4.8 (4.3–5.4) h to 3.9 (3.5–4.3) h (P < 0.0001). For patients undergoing emergency laparotomy, the time from booking to surgery was reduced from 3.1 (2.2–4.1) to 2.4 (1.8–2.9) h, and hospital stay was reduced from 13 (11–15) to 10 (9–12) days (P = 0.0089). The surgeons' responses to the questionnaires showed improvement in job satisfaction (P < 0.0001).

This intervention has improved service delivery for emergency surgery patients, and improved the participating surgeons' job satisfaction.

Transanal minimally invasive surgery (TAMIS) is a novel approach used for the resection of rectal lesions. The purpose of this study was to review our initial experience with TAMIS.

Between March 2012 and May 2012, we collected clinical data on patients who underwent the TAMIS procedure. This included patient demographics, tumour characteristics, operative technique, histological results and post-operative outcomes.

Three patients successfully underwent TAMIS resection of rectal lesions. All tumours were tubulovillous adenomas with high-grade dysplasia, with one also having a small focus of adenocarcinoma. Clear margins were achieved in all cases. One case was complicated by a post-operative bleed, requiring a return to theatre.

TAMIS is a feasible and cost-effective alternative to transanal endoscopic microsurgery for resection of rectal lesions. It may have a shorter learning curve, especially for laparoscopic surgeons already proficient in single-port procedures.

There is a global shortage of medical manpower. One approach to resolve such deficiencies is to effectively promote health careers to high-school students. Summer programmes held by medical faculties provide ideal opportunities for pre-medical students to examine the possible career opportunities in medicine.

The Royal College of Surgeons in Ireland has recently launched a ‘Mini-Medical School’ (MMS) programme for suburban and rural high-school students in the South Eastern Region of Ireland. This paper illustrates the MMS project and describes the participants' reaction and evaluation of the programme and the factors influencing their desire to practise medicine in future.

A total of 90 students completed the online survey (response rate 75%). Eighty-two per cent of the students indicated definitive and strong desire to study medicine after secondary school. There was no difference in interest between male and female students (P-value 0.665). The main factors influencing this interest were personal. Forty-four per cent of participants attributed this to the opportunity to help others while 30% to the intellectual challenge, whereas family, friends and other factors accounted for the rest of influential factors to study medicine. The majority agreed (60%) that the programme was quite accessible and easy to have a place. Opinions about the content of the programme focussed mainly on the interactive sessions. Forty-seven per cent liked the live patient–doctor interaction session the most, and 43% found the live video session very informative.

The MMS is a highly effective platform for both the medical specialties and the high-school students.

Little has been published regarding presenting symptoms, investigations and outcomes for patients with pancreatic cancer in Australia. Data from a series of patients undergoing attempted resection in Queensland, Australia, are presented with the aim of assisting development of consistent strategies in disease management.

We reviewed the medical records of 121 patients who underwent attempted surgical resection and who took part in a case-control study between 2007 and 2009. Information relating to symptoms, investigations, surgical procedures and outcomes was captured.

The mean age was 63 years and 60% were men. The most common presenting symptoms were jaundice (64%) and pain (63%). Over 80% of patients had multiple imaging investigations or laparoscopy prior to surgery. Seventy-eight patients (64%) had a completed resection and 23% of these had involved margins. The presence of metastases and/or involvement of vessels or adjacent structures precluded resection in the remaining patients. The 1-year survival for patients whose resections were completed was 77% compared with 51% for those whose tumours were not resectable (P = 0.004). There was no 30-day mortality and 68% of patients were alive 1 year after diagnosis. Resections were performed in 11 different hospitals but over 90% of patients underwent their surgery in one of five high-volume centres.

The Queensland experience is consistent with that reported internationally. A significant proportion of attempted resections was not completed because preoperative staging underestimated disease extent. Most patients with potentially resectable disease are being treated in high-volume centres.

Computed tomography (CT) has become a widely accepted adjunct imaging tool in the preoperative evaluation of complex intra-articular distal radius fractures. The aim of this study was to evaluate the impact of CT scanning compared with plain X-rays on the choice of intervention in complex distal radius fractures.

Five orthopaedic surgeons were given the de-identified plain films (AP, lateral and oblique) of 20 closed complex intra-articular distal radius fractures (AO23-C), randomly selected from our institution's prospectively maintained fracture database. Each surgeon individually selected a management option for each patient from a series of five interventions, ranked in increasing level of invasiveness. The same patients' CT scans (in randomized order) were blindly reviewed after a 1-week interval by the same clinicians with the same management options again offered. Kappa statistic was used to measure the intra-observer agreement between X-ray and CT decisions, and inter-observer agreement within each modality.

The intra-observer agreement on management between X-rays alone versus CT scan was poor, with an average kappa score of 0.038. Inter-observer agreement based on X-ray alone was higher than that based on CT alone. Regression analysis indicated a trend towards a slightly higher level of invasiveness when the management decision was based on the CT compared with plain X-rays.

There is a very poor intra- and inter-rater agreement between decision-making based on X-ray and on CT. Decision-making based on CT could increase the level of invasiveness in the surgical management of complex distal radius fractures.

Re-operative surgery is stressful for patients and is an additional burden to an already stretched public health system. Intraoperative confirmation of breast cancer metastases in sentinel lymph nodes (SLNs) provides the necessary information for the surgeon to proceed with immediate axillary dissection, avoiding the need for a second operation, its associated cost, morbidity and adjuvant treatment delays. Our challenge was to implement a technique that was rapid, inexpensive and had a negligible false positive rate. The aim of this study was to determine whether touch imprint cytology (TIC) could reduce returns to theatre without compromising patient safety and pathology department and operating theatre efficiency.

Intraoperative TIC was performed on bisected SLNs from 134 patients. Post-operatively, specimens were examined as haematoxylin and eosin-stained, paraffin-embedded 2-mm sections. Further sectioning and immunohistochemisty was performed on negative SLNs.

The sensitivity of TIC for metastases was 23.8%, the specificity was 100% and the accuracy was 76.1%. Ten patients with macrometastases and none with micrometastastes were detected intraoperatively. The sensitivity of TIC for detecting macrometastases was 34.5%, the accuracy was 78.4% and the specificity was 100%.

Ten patients avoided a subsequent surgery. The technique caused no theatre delays and the minimal cost was compensated for by the avoidance of a second procedure for a third of patients who definitively required axillary clearance. No patients had an unnecessary axillary clearance and no patients with micrometastases or isolated tumour cells were subjected to an immediate axillary clearance. It would be justifiable to continue this simple, low-cost and non-disruptive approach.

Mucinous cystic neoplasms (MCNs) of the pancreas are rare, but have recently been increasing in incidence. The aim of this retrospective clinical study was to elucidate the clinicopathological features and prognosis of MCNs with ovarian stroma at a single centre.

Using the presence of ovarian stroma as a requisite criterion for diagnosis of MCNs, the medical records of 47 surgically treated patients with MCNs from January 2004 to April 2011 were reviewed and classified according to the new 2010 World Health Organization classification.

Included were 37 cases of low-grade (78.7%), 4 intermediate-grade (8.5%) and 1 high-grade dysplasia (8.5%), and 5 cases of invasive carcinomas (10.6%). Patients were exclusively women (91.5%) with a mean age of 48.5 years. Most tumours were in the pancreatic body/tail (89.4%) with a mean size of 5.24 cm. More than half were asymptomatic. Findings associated with malignancy were presence of mural nodules (P < 0.001) and cyst wall calcifications (P = 0.017). All invasive MCNs were ≥5.0 cm or had mural nodules. No lymph node metastasis was seen in 20 cases of lymph nodes dissected. None of the 42 patients with non-invasive MCNs recurred after a mean follow-up of 25 months. However, two of five patients with invasive MCNs recurred, and one died within 2 years.

The prognosis of the resected non-invasive MCNs was excellent. Although resection should be considered for all cases, in low-risk MCNs (<5 cm and without nodules), nonradical resections (i.e. enucleations) are appropriate.

Lymph node metastases represent a diagnostic and management challenge in patients with disseminated medullary thyroid carcinoma (MTC). Our understanding of microRNA (miRNA) profiles of metastatic disease also remains limited and may unveil novel therapeutic strategies for these patients.

MTC patients with a history of total thyroidectomy and lymph node dissection were identified from within the prospective Sydney University Endocrine Surgical Unit database. Patients with available formalin-fixed paraffin-embedded tumour tissue were included and clinicopathological data were collated. Total RNA was extracted and quantitave polymerase chain reaction (qPCR) analysis performed on the primary tumour and a corresponding lymph node metastasis for expression of miRNAs of proven significance in MTC (miR-9*, miR-183 and miR-375).

Tissue was available for analysis in seven patients. The median age at diagnosis was 55 years (range: 22–67). Median tumour size was 18 mm (range: 6–55) and over a median follow-up period of 34 months (range: 1–210), five further operations were undertaken for residual disease. One patient died of metastatic disease. Pairwise correlations of qPCR expression levels between primary tumours and corresponding lymph node metastases revealed significant correlations for miR-9* (P < 0.001), miR-183 (P = 0.001) and miR-375 (P = 0.004).

miRNA expression patterns in nodal metastases significantly reflect those of the primary tumour in MTC. This further validates previously reported miRNA profile analyses and reiterates the potential significance of miR-9*, -183 and -375 in the pathophysiology of MTC. The possibility of lymph node biopsy miRNA analysis driven clinical decision making may now also be a possibility where conventional techniques are unhelpful.

Although laparoscopic surgeries are associated with reduced surgical stress response and shortened post-operative recovery, intense pain and high analgesia requirements in the immediate post-operative period are often the chief complaints.

The aim of this study was to evaluate the effect of pre-emptive intraperitoneal local anaesthetic drugs on post-operative pain management and metabolic stress response in laparoscopic appendicectomy.

The method used was a randomized double-blinded placebo-controlled study. Patients with clinical diagnosis of acute appendicitis who fulfil the criteria, were taken into this study. Primary outcomes investigated were consumption of patient-controlled analgesia during the immediate post-operative period (first 6 h) and subsequent 18 h as well as serum cortisol sampling.

Total of 120 patients were recruited into three different treatment groups (placebo, ropivacaine, levobupivacaine). In order to maintain visual analogue score of 0–1 during the immediate post-operative period, patients in the placebo group required significantly (P < 0.001) higher dose of analgesia (morphine/mg) – 11 mg (8.3–15.5) as compared with ropivacaine – 4 mg (3.0–6.0) and levobupivacaine – 3.5 mg (2.0–5.0). The immediate post-operative serum cortisol showed a significant increase in serum cortisol in the placebo group (P = 0.001) as compared with ropivacaine and levobupivacaine groups.

Pre-emptive intraperitoneal local anaesthesia in laparoscopy surgery is a safe, non-invasive procedure that can benefit patients by reducing the immediate post-operative pain intensity and metabolic stress response of the body.

The rates of contralateral prophylactic mastectomy (CPM) are increasing worldwide. This study investigated Australian and New Zealand's breast surgeons' perceptions, knowledge and attitudes towards CPM, and explored if demographic characteristics of surgeons were associated with an increased tendency to recommend or perform CPM.

A cross sectional research design was employed, with breast surgeons completing a self-report questionnaire. The questionnaire collected information including surgeons' perceptions on CPM in their clinical practice, their attitudes and knowledge of CPM and surgeons' demographic information.

 Eighty-one of 220 (37%) breast surgeons contacted via BreastSurgANZ participated in this study. Forty-four per cent of surgeons perceived that the rates of CPMs they performed had increased over the last year. CPM rates were found to be unrelated to surgeons' age (P = 0.773) or gender (P = 0.941). The main reasons a surgeon recommended a CPM to patients included known BRCA+ mutation, family history of breast cancer and patient factors including fear and anxiety and a desire to avoid further breast cancer treatment.

Breast surgeons perceived that rates of CPM were increasing in their own clinical practice. CPM rates were unrelated to surgeon demographics including age and gender. While surgeons are aware of the objective risk factors that make performing a CPM advisable, they also report taking into account subjective factors, including patient fear and anxiety and a desire for breast symmetry when recommending a CPM.

The importance of basic surgical skills is entirely agreed among surgical educators. However, restricted by ethical issues, finance etc, the basic surgical skills training is increasingly challenged. Increasing cost gives an impetus to the development of cost-effective training models to meet the trainees' acquisition of basic surgical skills. In this situation, a cost-effective training framework was formed in our department and introduced here.

Each five students were assigned to a ‘training unit’. The training was implemented weekly for 18 weeks. The framework consisted of an early, a transitional, an integrative stage and a surgical skills competition. Corresponding training modules were selected and assembled scientifically at each stage. The modules comprised campus intranet databases, sponge benchtop, nonliving animal tissue, local dissection specimens and simulating reality operations. The training outcomes used direct observation of procedural skills as an assessment tool. The training data of 50 trainees who were randomly selected in each year from 2006 to 2011 year, were retrospectively analysed.

An excellent and good rate of the surgical skills is from 82 to 88%, but there is no significant difference among 6 years (P > 0.05). The skills scores of the contestants are markedly higher than those of non-contestants (P < 0.05). The average training cost per trainee is about $21.85–34.08.

The present training framework is reliable, feasible, repeatable and cost-effective. The skills competition can promote to improve the surgical skills level of trainees.

A peripheral intravenous device (PIVD) provides venous access for the administration of medications, blood products and fluids. They can be associated with a risk of infection and other complications, which have prompted the development of evidence-based guidelines for their use at the Royal Adelaide Hospital (RAH). A previous audit performed at the RAH found unsatisfactory compliance with these guidelines across a group of wards. The Burns Unit performed poorly compared with other wards, but the reasons for this were not explored.

A repeat audit was performed for all PIVDs in the Burns Unit over a 3-week period and compliance with the PIVD safety guidelines was assessed. Factors influencing compliance were investigated and the evidence behind the guidelines was reviewed.

Overall compliance with the seven safety criteria was 71%. Poorest compliance was for documentation of insertion date, which has implications for scheduling PIVD replacement.

The guidelines are largely evidence-based; however, not all of them are feasible for all patients within a hospital. The Burns Unit had an overall compliance rate of 71%. Auditing of individual wards is not effective in assessing those wards' compliance with the guidelines as many PIVDs are inserted in other locations in the hospital. For compliance to improve, other areas of the hospital where PIVDs are inserted need to be targeted.

Liver resection provides one of the best oncological outcomes for liver metastases in patients with colorectal cancer. However, long-term results concerning laparoscopic resection versus open hepatectomy for stage IV colon cancer are still limited. The aim of this study is to compare the survival outcome of laparoscopic liver resection with open liver resection for colorectal metastases.

Between October 2002 and September 2011, a total of 1697 patients underwent liver resection for liver tumour and 60 patients underwent pure laparoscopic liver resection. Twenty patients had laparoscopic resection for colorectal liver metastases. Case-matched control patients who received open liver resection were included for comparison. The immediate operative outcomes and survival outcomes including operation morbidity were compared.

Twenty patients underwent laparoscopic resection of liver metastases. Forty patients who had open hepatectomy for colorectal metastases were selected as case control. Comparing the laparoscopic group with the open resection group, the median operating time was 180 min versus 210 min P = 0.059, the median blood loss was 200 versus 310 mL (P = 0.043). Hospital stay was 4.5 versus 7 days (P = 0.021), disease-free survival was 9.8 versus 10.9 months (P = 0.299), and the median survival was 69.4 versus 42.1 months (P = 0.235).

Laparoscopic liver resection is a safe and effective treatment for liver metastases in patients with colorectal cancer. It is associated with less blood loss and shorter hospital stay when compared with open surgery. Long-term survival is comparable to the conventional open approach.

The clinical value of preoperative tumour markers remains elusive in gastric cancer. The aim of this study was to investigate the prognostic value of alpha-fetoprotein (AFP), carcinoembryonic antigen (CEA), carbohydrate antigen (CA)19-9, CA50 and CA72-4 in gastric cancer.

About 391 gastric cancer patients who underwent curative D2 gastrectomy between 2001 and 2006 were evaluated. The correlation between tumour markers and clinicopathologic characteristics and prognostic value of preoperative tumour markers was investigated.

Correlation analysis showed that AFP was associated with tumour size (P = 0.040); CEA with lymphatic invasion (P = 0.023) and pathological stage (P = 0.018); CA19-9 with tumour size (P = 0.000), Borrmann type (P = 0.027), lymphatic invasion (P = 0.020) and pathological stage (P = 0.001); CA50 with lymphatic invasion (P = 0.004) and pathological stage (P = 0.004); CA72-4 with tumour size (P = 0.000), tumour size (P = 0.000) and Borrmann type (P = 0.008); lymphatic invasion (P = 0.000), nervous invasion (P = 0.028) and pathological stage (P = 0.000). Multivariate analysis showed that CEA, tumour site, Borrmann type and pathological stage were independent prognostic factors.

Preoperative CEA might be a candidate for the staging system in addition to conventional factors.

There is increasing evidence showing that hepatic resection is probably the best definitive treatment for unilateral hepatolithiasis. However, the role of hepatic resection for bilateral hepatolithiasis is rarely mentioned in the literature.

We retrospectively reviewed 197 patients who underwent hepatic resection for hepatolithiasis in Changhua Christian Hospital from December 1987 to December 2007. A total of 156 patients with unilateral hepatolithiasis were defined as the UNI group (control group), and 41 patients with bilateral hepatolithiasis were defined as the BI group (study group). The short- and long-term outcomes were measured.

The BI group had longer operating time (200 min versus 173 min, P = 0.006), lower immediate stone clearance rate (56.1% versus 91.7%, P < 0.001), lower final stone clearance rate (75.6% versus 94.9%, P = 0.001), higher rate of stone recurrence (22.6% versus 6.1%, P = 0.009) and higher disease-related mortality (19.5% versus 5.1%, P = 0.006). Thirty patients with bilateral peripheral stones were indicated for bilateral hepatectomy, but only 20 (66.7%) of them actually underwent the proposed procedure. Of the patients who did not achieve immediate stone clearance, bilateral peripheral stones represented 88.9% (P = 0.044). Of the patients who had stone recurrence, patients less than 35 years old represented 42.9% (P = 0.007).

Bilateral hepatolithiasis has worse outcomes than unilateral hepatolithiasis after being treated with hepatic resection. Regarding bilateral peripheral stones, there is often a discrepancy between the extent of stone-affected parenchyma and that of final liver resection, resulting in a lower immediate stone clearance rate. A higher stone recurrence rate was observed among younger population.

Patent Blue V dye (PBVD) can cause severe anaphylaxis. For sentinel node biopsy (SNB) in breast cancer patients, controversy exists as to the utility of PBVD in addition to lymphoscintigraphy. This survey assessed Australian and New Zealand breast surgeons' experience of anaphylaxis with PBVD.

The survey was distributed to all 180 members of the BreastSurgANZ society in May 2011. Seventy-six (42%) current members responded. A retrospective analysis was performed on survey responses.

Seventy-five members used PBVD on a median of 50 cases per year (0–250 cases per year) for a median of 10 years (4 months–15 years). Overall, 44 members (58.7%) experienced definite or possible allergic reaction to PBVD, but only 16 members (21%) witnessed severe anaphylaxis associated with a fall in blood pressure. Of the 34 members who experienced what they considered definite anaphylactic reactions with PBVD, only 18 members confirmed with allergy testing. The overall reported incidence of anaphylactic reactions of any severity was 0.15%. The median time to anaphylaxis was 20 min (0–90 min). Forty members (53.3%) reported routine discussion about PBVD risks as part of informed consent. Only seven members performed routine pre-op skin testing. Overall, 91% of the members accepted the rare but real risk of severe anaphylaxis and 76% did not question the additional value associated with its use.

Australian and New Zealand breast surgeons' reported that the anaphylaxis rate from PBVD was 0.15%. The majority of surgeons continued to use PBVD to facilitate SNB.

Infected abdominal defects are a challenge to surgeons. In this study, we describe 10 cases in which the latissimus dorsi myocutaneous flap was used for successful reconstruction of abdominal wall defects severely infected with methicillin-resistant Staphylococcus aureus (MRSA).

Retrospective review of 10 patients with abdominal wall defects that were reconstructed using the latissimus dorsi myocutaneous flap between 2002 and 2010. All patients had abdominal defects with hernias, combined with MRSA infections. The sizes of the flaps ranged from 120 to 364 cm². The deep inferior epigastric artery was the recipient vessel in nine patients and the internal mammary vessels were used for one patient.

There were no complications relating to the flaps, although there were other minor complications including wound dehiscence, haematoma and fluid correction. After reconstruction, there were no signs of infection during follow-up periods, and the patients were satisfied with the final results.

Reconstruction using the latissimus dorsi myocutaneous flap, including muscle fascia structures, is a potential treatment option for severely infected large abdominal wall defects.

Neck of femur fractures (NOFFs) are a common cause of morbidity and mortality in our community. Minimally displaced intracapsular fractures are treated with internal fixation by a two-hole dynamic hip screw (DHS) or three partially threaded cancellous screws. Data to support the superiority of one are limited. This prospective randomized controlled trial compares outcomes with these two fixation methods.

We prospectively recruited patients over 50 years, with an acute fracture subcapital NOFF, who walked and lived independently, and were cognitively intact. They were randomized into DHS or cancellous screw groups and followed up for 2 years (overall 75.9%). Outcomes of mortality, revision, loss of fixation, avascular necrosis, surgical complications, WOMAC, Harris hip score and SF-12 were measured.

We recruited 62 patients (31 DHS, 29 cancellous screws, 2 failed consent). Six deaths (19.3%) were seen in each group. A total of 3.2% of DHS (1 out of 31) and 10.3% (3 out of 29) of cancellous screw patients required re-operation (P = 0.272). There was no statistical significant difference in patient satisfaction, quality of life (QoL), radiological union or osteonecrosis. There are trends towards better functional scores and QoL in cancellous screws, particularly at 1 year (P = 0.0061), but with a higher re-operation rate. There was a combined mortality and transition to institutional care of 40.0% (24 out of 60) at 2 years.

This study found no difference in outcomes between DHS and cancellous screws in the treatment of subcapital NOFFs in a fit, independent population, but we found a high level of physical decline in previously fit, independently ambulating patients. A large, multicentre trial will be required to differentiate between these two fixation methods.

The isolated limb infusion (ILI) technique is a simpler and less invasive alternative to isolated limb perfusion, which allows regional administration of high-dose chemotherapy to patients with advanced melanoma and other malignancies restricted to a limb.

Patients from two institutions, treated by ILI between 1998 and 2009 for extensive disease restricted to a limb, were included. The cohort included 31 patients with melanoma who presented with in-transit metastases or an extensive primary lesion, one patient with squamous cell carcinoma and another with epithelioid sarcoma not suitable for local surgical treatment.

A complete response was achieved in 26.3% of patients and a partial response in 52.6%. Toxicity was assessed according to the Wieberdink limb toxicity scale. Grade II toxicity was noted in 39.5% of patients, grade III in 50% and grade IV in 10.5%. Toxicity was correlated with the results of a number of clinical and laboratory tests. The toxicity of melphalan and actinomycin D was dose-dependent. For melphalan, the relationship between toxicity and mean dose was as follows: grade II – 34.7 mg; grades III and IV – 47.5 mg (P = 0.012). The relationship between toxicity and maximum serum creatine phosphokinase (CPK) was as follows: grade II – 431.5 U/L; grades III and IV – 3228 U/L (P = 0.010).

Toxicity after ILI is dose-dependent and serum CPK correlates with toxicity.

Acute mediastinitis (AM) is the most lethal form of infection within the thorax. The authors of this study, using statistical tools, made an attempt to determine the most important clinical risk factors in retrospective material of patients treated surgically due to AM.

A total of 44 consecutive patients with AM were subjected to surgery. The aetiology was differentiated: iatrogenic (19), traumatic (11), descending mediastinitis (9) and neoplastic (5). A statistical analysis was performed using chi-square test with Yates correction and analysis of variance test to investigate the correlation between mortality and selected risk factors such as age, gender, aetiology, microbiology, delay between the diagnosis and surgery, coexisting diseases and the kind and number of post-operative complications.

The general death rate was 31.82%. Aetiology was associated with mortality: neoplastic (100%), descending (33.3%), iatrogenic (26.3%) and post-traumatic (9.1%). The following types of bacteria were isolated: aerobes (65.9%), anaerobes (25%) and mixed flora (9.1%). The prognosis was not related to age, gender or the kind of the pathogen. The risk of death increased depending on the number of preoperative co-morbidities (P = 0.0446), particularly on the occurrence of a neoplasm (P = 0.0104). Early qualification for surgery (<24 h) resulted in lower death rate (P = 0.085). Manifestation of more than two post-operative complications (P = 0.0007) should be listed as one of the most negative risk factors.

The knowledge of negative prognostic factors can appear to be a crucial tool enabling one to work out a better therapeutic strategy for high-risk patients with AM.

Lymph node metastasis is one of the most important prognostic factors in gastric cancer survival. Sentinel lymph node (SLN) mapping and biopsy may reduce the extension of lymph node dissection by determination of lymph node involvement. The current study prospectively evaluates the feasibility and reliability of SLN biopsy in gastric cancer.

A total of 30 patients with gastric cancer with a preoperative imaging stage of T1-T2 or T3, N0 and M0 were enrolled in the study. Furthermore, 2–16 h prior to each operation, ^99mTc-sulphur colloid solution (0.5 mL, 2 mCi/mL) was endoscopically injected into the submucosal layer around the primary lesion. Lymph nodes were examined using a hand-held gamma probe. Subsequently, a total or subtotal gastrectomy and D2 lymphadenectomy was performed in each patient.

The success rate of SLN biopsy was 100%. Sensitivity, specificity, positive predictive value and negative predictive value were 91.7%, 100%, 100% and 75%, respectively. Both of the two false-negative cases were in the T3 group. In cases of T2 tumours, the sensitivity was 100%.

SLN biopsy using a gamma probe in early stage gastric cancer seems to be a safe, feasible and accurate procedure with high sensitivity in predicting regional lymph node involvement.

Delays in commencing adjuvant chemotherapy for early breast cancer beyond 12 weeks are associated with increased mortality. The aim of this study was to identify factors delaying chemotherapy in an inner metropolitan, outer metropolitan, small rural and large rural cancer centre in New South Wales, Australia.

We retrospectively reviewed 400 consecutive patients that received adjuvant chemotherapy for stages I–III breast cancer. We evaluated factors affecting time from primary and definitive surgery until commencing chemotherapy.

The primary factor associated with chemotherapy delays was the geographic location of the cancer centre. The median time from primary surgery to chemotherapy was longer for the large rural centre (median 58 days), compared with the outer metropolitan (45 days), small rural (39 days) and inner metropolitan centre (33 days). Treatment delays in the large rural centre were associated with higher rates of multiple operations (43% versus 31% elsewhere), mainly because of more staged axillary dissections (34% versus 19%), and longer time from definitive surgery to oncology assessment.

Patients in the large rural centre, who are served by fly-in medical oncology services, are more likely to experience delays in receiving adjuvant chemotherapy for early breast cancer. Strategies to reduce delays include use of intraoperative frozen section analysis, multidisciplinary meetings, improving efficiency in pathology reporting and employment of a breast cancer care coordinator and an on-site medical oncologist.

Peritoneal dialysis via Tenckhoff catheter predisposes to hernia formation due to both local and systemic factors. Another important complication of peritoneal catheter insertion includes infection, which can prompt removal of the catheter.

We performed a retrospective study between January 2005 and July 2011 of 61 patients who underwent laparoscopic placement of a Tenckhoff catheter and peritoneal dialysis at our institution using a single-port technique. We analysed complications of Tenckhoff insertion, specifically infection and the formation of hernias requiring operative management.

Infections noted in our patients included peritonitis (10%) and exit-site infection (5%). Of the five patients who required re-insertion of Tenckhoff catheter, four were for infective complications. A total of seven hernias developed in five (8%) of patients, mostly inguinal or umbilical near the Hassan port entry site.

With infection and hernia formation being the main contributors to failure of the procedure, actively addressing the entry site and areas predisposed to hernia formation, observing aseptic technique and meticulous attention to early signs of complications during follow-up are vital to improve success rates. The outcomes of the laparoscopic single-port insertion technique shows promise compared with conventional Tenckhoff catheter insertion techniques.

An acute care surgery (ACS) model was introduced to manage emergency surgical presentations efficiently. The aim of this study was to evaluate the impact of patient handover in an ACS model on the outcomes of adhesive small bowel obstruction (SBO).

A retrospective study was performed on patients who were admitted with adhesive SBO at Prince of Wales Hospital. The cohort consisted of all patients treated by the ACS team from its introduction in September 2005 to February 2011. Patients in the ACS cohort were divided into two groups: those whose care was handed over to another surgeon and those whose care was not. These groups of patients were compared with a random sample of 50 patients in the pre-ACS period.

In the ACS period, there was no significant difference in complication rates or length of hospital stay in those who were not handed over and those who were. A significantly higher proportion of operations took place during the day for the group who had been handed over (72.7% versus 36.7%; P = 0.005). There were no significant differences in complication rates or length of hospital stay in the pre-ACS and ACS period.

Management under an ACS team does not increase adverse outcomes for adhesive SBO. Patients can be safely handed over within an ACS framework. Other members of the ACS team may help facilitate continuity of care.

Thromboembolism is a common cause of morbidity and mortality in patients with colorectal cancer, but thromboprophylaxis (TP) is underutilized. Current guidelines do not make specific recommendations for colorectal cancer patients and provide minimal guidance for the ambulatory setting, although emerging evidence suggests TP may be warranted during chemoradiotherapy or in the extended post-operative phase. A survey of Australasian colorectal surgeons was therefore performed to assess current TP practice and attitudes.

An online survey was sent to 204 surgeons who were members of the Colorectal Surgical Society of Australia and New Zealand.

One hundred twenty-eight surgeons (63%) completed the survey. Most surgeons consult available guidelines, and where recommendations are made, current practice is in line with them. Lack of data, lack of ownership, logistical issues and an absence of guideline recommendations currently prevent surgeons from instituting TP in the neoadjuvant treatment period. Fifty-four per cent of surgeons currently prescribe TP after hospital discharge; those that do not, cite logistical issues as the main constraint.

More data on thromboembolism risk during various treatment phases are required and should be promulgated in tumour-specific guidelines. Logistical barriers to adopting TP in the ambulatory setting should be addressed.

Hypersplenism with thrombocytopenia is a common complication of cirrhosis with portal hypertension. We evaluated the role of splenectomy in patients with hepatocellular carcinoma (HCC) in terms of the improvement of biochemical indices and liver volume.

Nineteen patients with HCC underwent liver resection and splenectomy from January 2000 to December 2009. Thirty-nine patients who underwent liver resection during the same period were enrolled as case-matched controls. We performed a retrospective review of prospectively collected data. We analysed the results of biochemical tests, disease-free survival and overall survival and measured the liver volume before and at 90 days after operation.

Preoperative white blood cell counts (P = 0.001), platelet counts (P = 0.021), total bilirubin (P ≤ 0.001) and prothrombin time by international normalized ratio (P = 0.043) were significantly different. However, these results had converged to similar levels 90 days after the operation. The degree of increment in liver volume were similar (P = 0.763). In splenectomy group, portal vein thrombosis developed in eight patients and all patients except one recovered using only conservative treatments. There was an operative mortality because of liver failure by thrombosis.

Although splenectomy may induce thrombosis, liver failure and subsequent mortality, splenectomy may improve liver function and expand the indication of liver resection if postoperative management is conducted conservatively.

Metabolic acidosis is frequently observed in perioperative patients, especially those who undergo major surgery. The aim of this study was to evaluate the factors related to post-operative metabolic acidosis and to attempt to identify the clinical effect of metabolic acidosis following major abdominal surgery.

We included 172 patients admitted to a surgical intensive care unit (ICU) following major abdominal surgery. All cases were divided into either the acidosis or the normal group using immediate post-operative standard base excess (SBE). The following clinical data were retrospectively obtained from the chart and ICU database: basic clinical characteristics, operative data, type and volume of fluid infused during the operation, post-operative arterial blood gas analysis, lactate, and central venous oxygen saturation.

The predominant intraoperative fluid was either 0.9% saline or lactated Ringer's solution. The operation length, estimated blood loss, total fluid infused, total saline infused, lactate and corrected chloride were significantly higher in the acidosis group; however, central venous oxygen saturation was lower in the normal group. Among these factors, total infused saline and lactate level were independent factors related to metabolic acidosis. The comparison between the types of fluid revealed that the saline group had a significantly lower SBE, strong ion difference and higher corrected chloride. SBE was significantly correlated with lactate and total infused saline. ICU and hospital length of stay were significantly longer in the acidosis group.

Post-operative metabolic acidosis following major abdominal surgery was closely related to both hyperchloremic acidosis associated with large saline infusion and lactic acidosis caused by lactataemia.

Gallstone disease is a worldwide problem causing morbidity, mortality and a drain on health-care resources. This prospective study aimed to investigate the spectrum of gallstone types in New Zealand and relate these to known risk factors.

Gallstone samples were collected from 107 patients undergoing surgery for gallstone disease at Auckland City Hospital between June 2009 and June 2010. Detailed chemical analyses were performed using Fourier Transform Raman spectroscopy. The relationship between gallstone type and age, gender, ethnicity, obesity and positive family history were analysed.

Median age was 51 years (range 19–88), 75 (70%) were female, one third were obese (body mass index ≥ 30) and 41% had a positive family history. Major ethnic groups were European (51%), Asian (23%) and Māori/Pacific (18%). Gallstone types included pure or mixed cholesterol stones (74%), black pigment stones (20%) and brown pigment stones (5%). Asians had a higher proportion of black pigment stones and NZ Europeans had more cholesterol and mixed cholesterol stones (odds ratio 3.6 (95% CI 1.1 to 11.5)). The frequency of cholesterol/mixed cholesterol stones was not significantly different between NZ Europeans and Māori/Pacific groups (P = 0.7). Black pigment stones were more common in older patients (mean 68.0 years compared with 47.6 for cholesterol/mixed cholesterol stones) (P = 0.0001). There was no significant relationship between stone type and family history (P = 0.16) or gender (P = 0.17).

This novel prospective study highlights risk factors and ethnic differences in gallstone composition in New Zealand. These may be important when considering gallstone prevention strategies.

Graves’ disease is a common cause of thyrotoxicosis. Treatment options include anti-thyroid medications or definitive therapy: thyroidectomy or radioactive iodine (I¹³¹). Traditionally, I¹³¹ has been the preferred definitive treatment for Graves’ disease in New Zealand. Reports of concomitant thyroid cancer occurring in up to 17% of Graves’ patients suggest surgery, if performed with low morbidity, may be the preferred option. The aim of this study was to determine the rate of thyroid cancer and surgical outcomes in a New Zealand cohort of patients undergoing thyroidectomy for Graves’ disease.

This study is a retrospective review of Waikato region patients undergoing thyroid surgery for Graves’ disease during the 10-year period prior to 1 December 2011.

A total of 833 patients underwent thyroid surgery. Of these, 117 were for Graves’ disease. Total thyroidectomy was performed in 82, near-total in 33 and subtotal in 2 patients. Recurrent thyrotoxicosis developed in one subtotal patient requiring I¹³¹ therapy. There were two cases of permanent hypoparathyroidism and one of permanent recurrent laryngeal nerve palsy. Eight patients (6.8%) had thyroid cancer detected, none of whom had overt nodal disease. Five were papillary microcarcinomas (one of which was multifocal), two were papillary carcinomas (11 mm and 15 mm) and one was a minimally invasive follicular carcinoma.

Thyroid cancer was identified in approximately 7% of patients undergoing surgery for Graves’ disease. A low complication rate (<2%) of permanent hypoparathyroidism and nerve injury (<1%) supports surgery being a safe alternative to I¹³¹ especially for patients with young children, ophthalmopathy or compressive symptoms.

The aim of this study was to investigate the hypothesis that prevention of surgical site infection (SSI) is equally effective when patients receive single-dose (SD) or three-dose antibiotic prophylaxis with second-generation cephalosporin and metronidazole in elective colorectal surgery.

Ninety-three patients were enrolled from May 2009 to November 2010. The SD group received only one preoperative prophylactic intravenous dose and the three-dose or multiple-dose (MD) group received one preoperative prophylactic and two additional post-operative doses of second-generation cephalosporin and metronidazole. The incidence of infectious complications (SSI of the incision site and organ/space) was compared in the two groups.

The overall post-operative infection rate did not differ between the two groups (16.7% in the SD versus 13.3% in the MD, P = 0.653). The incidence of SSI of the incision site and organ/space also did not differ between the groups (6.3% (3/48) versus 4.4% (2/45), P = 0.700; 4.2% versus 6.7%, P = 0.593, respectively). The number of antibiotics administered was not an independent risk factor for SSIs in multivariable analysis.

SD antibiotic prophylaxis with second-generation cephalosporin and metronidazole is equivalent to a three-dose prophylaxis for preventing SSI in elective colorectal surgery. But further study would be needed to clarify this because of the small number of participants.

Delayed gastric emptying (DGE) is one of the most troublesome complications of pancreaticoduodenectomy (PD). Diabetes mellitus (DM) is one of the risk factors for pancreatic cancer. Moreover, several studies have shown that diabetic patients tend to have a high incidence of upper gastrointestinal symptoms such as nausea, vomiting and DGE. Here, we compared the influence of DM on the incidence of DGE after PD.

We retrospectively analysed 67 cases of PD with pancreaticogastrostomy. These patients were categorized into the following two groups: the DM group included patients with DM, and the NDM group included patients without DM. The incidence of DGE was determined and compared between the two groups.

In the DM group, 76.5%, 5.9% and 17.6% of the subjects developed classes A, B and C DGE, respectively; the corresponding values in the NDM group were 58%, 22%, and 20%. The incidence of DGE did not differ between the two groups (P < 0.2771).

DM does not accelerate DGE in patients who have undergone PD. Preoperative DM does not appear to play a key role in post-operative DGE after PD.

The establishment of assessment reliability at the level of the individual trainee is an important attribute of assessment methodologies, particularly for doctors who have been failed. This issue is of particular importance for the process of competence assessment in the USA, UK, Australia and New Zealand.

We use data from 19 applicants for higher surgical training in 2008 at the Royal College of Surgeons in Ireland to compare: (i) the objective structured assessment of technical skills (OSATS) method; and (ii) a procedure-specific checklist to assess surgical technical skills in the excision of a sebaceous cyst task by two experienced senior surgeons.

The overall interrater reliability (IRR) of the OSATS assessment as determined by a correlation coefficient was 0.507 (P < 0.03) and 0.67 with coefficient alpha, considerably below the accepted 0.8 level of IRR. The checklist's overall IRR was 0.89. Individually, only five (26%) of the OSATS assessments reached the 0.8 level of IRR in contrast to 18 (95%) of the checklist assessments.

We propose binary procedure-based assessment checklists as more reliable assessment instruments with more robust reproducibility.

Hip fracture is a common clinical problem with historically high morbidity and mortality, and various model of acute and subacute care have been employed. We describe 12-month results from the first dedicated hip fracture unit in Australia, and compare it with other models of care both locally and internationally.

This was performed as a prospective uncontrolled study over a 12-month period. After application of exclusion criteria, a total of 346 patients were yielded. Outcomes measured included performance indicators as well as morbidity and mortality data.

Improvements in performance indicators (adequate preoperative medical assessment, time to surgery, return to premorbid residence, etc.) and morbidity and mortality data (such as pressure sores, infections and in-hospital death) are noted.

Early results suggest more comprehensive preoperative assessment, shorter times to theatre, reduced post-operative complications and diminished mortality rates when the principles undermining this unit are instituted.

While recent studies have shown patients with developmental dysplasia of the hip (DDH) undergoing total hip arthroplasty (THA) to achieve comparable post-operative outcomes to patients with primary osteoarthritis (OA), it is unclear whether DDH patients display better or worse preoperative function than the general THA population. We aimed to compare the preoperative function and functional response to THA of DDH patients with OA patients.

Through a retrospective review of prospectively collected regional joint registry data, we compared the preoperative, 1-year post-operative and post-operative change in disease-specific (Oxford hip score (OHS), Western Ontario and MacMaster Universities Osteoarthritis Index (WOMAC)) and general health (short form 12 physical health (SF-12 PH), mental health (SF-12 MH) scores) functional scores of 33 DDH patients and 968 OA patients undergoing primary THA.

The DDH group displayed substantially worse preoperative function than the OA group (mean OHS 11.2 versus 16.3 (P = 0.001), WOMAC 72.7 versus 60.6 (P < 0.001), SF-12 PH 27.8 versus 28.9 (P = 0.433), SF-12 MH 35.5 versus 44.7 (P < 0.001)). Functional response to THA at 1 year was significantly better in the DDH group than the OA group (mean score improvements: OHS 31.1 versus 24.6 (P < 0.001), WOMAC 61.4 versus 47.2 (P < 0.001), SF-12 PH 22.3 versus 16.5 (P = 0.003), SF-12 MH 18.4 versus 8.4 (P < 0.001)).

Despite experiencing significantly worse preoperative function, DDH patients undergoing THA demonstrated superior early functional response to OA patients, with substantially greater improvements observed in all disease-specific and general health outcome measures.

There is little published data regarding the caseloads of general surgeons working in rural Australia conducting outreach services as part of their practice. It remains difficult to attract and retain surgeons in rural Australia. This study aims to describe the workload of surgeons working in a rural centre with outreach practices in order to determine the required skills mix for prospective surgeons.

A retrospective review of surgical procedures carried out by two surgeons over 5 years working from a base in Wangaratta, Victoria, with outreach services to Benalla, Bright and Mansfield was undertaken. Data were extracted from surgeon records using Medicare Benefits Schedule item numbers.

A total of 18 029 procedures were performed over 5 years, with 15% of these performed in peripheral hospitals as part of an outreach service. A full range of general surgical procedures were undertaken, with endoscopies accounting for 32% of procedures. In addition, vascular procedures and emergency craniotomies were also performed. The majority of procedures undertaken at peripheral centres were minor procedures, with only two laparotomies performed at these centres over 5 years.

General surgeons working in rural centres are required to have broad skills and be able to undertake a large number of procedures. Trainees should be encouraged to consider rural practice, and those who are interested should consider the needs of the community in which they intend to practice. Outreach work to surrounding communities can be rewarding for both the surgeon and the community.

Reported strategies for void filling in bone include autograft, allograft, synthetic bone substitutes or various combinations of these materials, but poor response rates and donor morbidity have created a desire to find a better option. Calcium sulphate as a stand-alone graft material reconstruct bone following curettage has not been previously reported. The purpose of this study was to assess the efficacy and radiological quality of healing, the time to healing, the functional outcomes and the complications following curettage and grafting using an injectable aqueous calcium sulphate (BonePlast; Biomet, Warsaw, IN, USA) as the sole grafting strategy.

The procedure of curettage and grafting with an aqueous solution of calcium sulphate was undertaken. The patients were regularly reviewed clinically and radiologically for a minimum of 12 months (range: 12–85 months). Forty-six procedures in 46 patients were reviewed. Radiological outcomes of healing were established and functional outcomes were obtained from each patient at annual follow-up review.

A complete response was seen in 38 patients (83%) at a median of 6 months following the procedure (range: 1–24 months). Seven patients (15%) displayed only a partial response after a median of 13 months post-surgery (range: 12–53 months). There was one non-response to treatment (2%) after 40 months of follow-up. The mean functional score was 99%.

Aqueous calcium sulphate as a sole grafting agent for void management after curettage simplifies current treatment practices and displays good bone reconstruction in a comparatively short time frame, with excellent functional results and acceptable complication rates in the setting of tumour surgery.

The objective of this study was to review the experience of video-assisted thoracoscopic resection of posterior mediastinal neurogenic tumours and to investigate the technical features and difficulties of this thoracoscopic approach.

From May 2001 to June 2011, 58 consecutive patients underwent thoracoscopic resection of posterior mediastinal tumours sequentially in our institution, including 36 males and 22 females. The median age of the patients was 38.7 years. The median tumour size was 4.9 cm. Twenty-four lesions were located at the left side, 33 lesions at the right side and 1 lesion at the bilateral side. All procedures generally required three ports, and intracapsular enucleation was preferred. For bulky tumours, dense adhesion and massive bleeding, conversion to thoracotomy was performed by extending the anterior incision to 6–10 cm.

All procedures were successfully performed without death or serious complications occurring. The average operating duration was 127.2 min. The average intraoperative blood loss was 206.4 mL. The average chest tube drainage duration was 2.72 days. The average post-operative stay was 5.19 days. Fifty-three procedures were performed entirely under thoracoscopy to achieve gross total resection. There were five cases (8.6%) of conversion to thoracotomy procedure. Seven patients suffered from post-operative complications, including four Horner syndromes. No local recurrence occurred after an average follow-up of 44.9 months.

Video-assisted thoracoscopic resections of the posterior mediastinal tumours were safe and reliable for selected patients with mastered thoracoscopic skills. Intracapsular enucleation was demonstrated to be a safe procedure. For tumours larger than 6 cm and located in the apex, the risk of the operation increased significantly.

There is an assumption that there is a similarity between surgeon-patient and primary care consultations. Yet, surgeon communication has had far less analytic attention than its primary care counterparts. Therefore, this assumption of similarity (and the proposition here of dissimilarity) has yet to be evidenced through detailed interactional analysis.

Conversation analysis (CA) is a methodology used to understand both mundane and institutional interactions. Using CA, we have developed an understanding of surgeon-patient interactions in outpatient clinic settings in New Zealand. Rather than attempting to determine what ‘bad’ communication is, we describe and analyse what occurs routinely in surgeon-patient consultations, particularly how these interactions are built up by both patient and doctor.

This research shows that while surgeon-patient consultations share some similarities to the overall structure of primary care consultations, there are two unique structures that occur in surgical consultations. These structures follow a logical progression of activities and are influenced by the type of visit (referred versus follow-up).

This article summarizes the first comprehensive description of the overall interactional structure of surgeon-patient consultations. It demonstrates that surgeon-patient consultations are structurally distinct from primary care consultations. This key finding has implications for surgeon-specific research and education, highlighting the need to question current assumptions in communication training and in clinical practice.

There is no clear answer regarding the use of laparoscopic techniques versus the Lichtenstein method for the treatment of recurrent inguinal hernia.

The aim of this study was to compare the outcomes of laparoscopy versus the Lichtenstein repair by a meta-analysis of available randomized controlled trials (RCTs).

Databases, including PubMed, EMBASE, the Cochrane Library, and the Science Citation Index updated to May 2012, were searched. The main outcome measures were wound infections and haematoma, urinary retention, post-operative chronic pain and recurrence. A meta-analysis of included RCTs was performed.

Five RCTs, comprising a total of 427 patients, were included. Although most of the analysed outcomes were similar between groups, wound infection rates and post-operative chronic pain occurred less frequently in the laparoscopic group than in the Lichtenstein group (odds ratio: 0.28, 95% CI: 0.08–0.97; P = 0.05; odds ratio: 0.33, 95% CI: 0.17–0.68; P = 0.002, respectively).

The laparoscopic approach to the treatment of recurrent inguinal hernia is superior to the Lichtenstein hernioplasty in some aspects that affect patient satisfaction.

Prolonged post-operative ileus (PPOI) occurs in up to 25% of patients following major elective abdominal surgery. It is associated with a higher risk of developing post-operative complications, prolongs hospital stay and confers a significant financial load on health-care institutions. Literature outlining best-practice management strategies for PPOI is nebulous. The aim of this text was to review the literature and provide concise evidence-based recommendations for its management.

A literature search through the Ovid MEDLINE, EMBASE, Google Scholar and Cochrane databases was performed from inception to July 2012 using a combination of keywords and MeSH terms. Review of the literature was followed by synthesis of concise recommendations for management accompanied by Strength of Recommendation Taxonomy (either A, B or C).

Recommendations for management include regular evaluation and correction of electrolytes (B); review of analgesic prescription with weaning of narcotics and substitution with regular paracetamol, regular non-steroidal anti-inflammatory drugs if not contraindicated, and regular or as-required Tramadol (A); nasogastric decompression for those with nausea or vomiting as prominent features (C); isotonic dextrose-saline crystalloid maintenance fluids administered within a restrictive regimen (B); balanced isotonic crystalloid replacement fluids containing supplemental potassium, in equivalent volume to losses (C); regular ambulation (C); parenteral nutrition if unable to tolerate an adequate oral intake for more than 7 days post-operatively (A) and exclusion of precipitating pathology or alternate diagnoses if clinically suspected (C).

Recommendations have a variable and frequently inconsistent evidence base. Further research is required to validate many of the outlined recommendations and to investigate novel interventions that may be used to shorten duration of PPOI.

Liver resection (LR) and liver transplantation (LT) are two modalities offering potential for cure in patients with hepatocellular carcinoma (HCC). The objective of this study was to evaluate the long-term survival of patients with HCC treated with LT and LR and to analyse variables influencing these outcomes.

Patients referred to the South Australian Liver Transplant Unit and Hepatopancreatobiliary Unit at Flinders Medical Centre from January 1992 to September 2009 with a diagnosis of HCC who underwent LT or LR were included in the study. Histopathological parameters analysed included size, number and grade of tumour, microscopic vascular invasion and presence or absence of cirrhosis in remnant liver.

Eighty-five patients with a median age of 58 years (range 26–85 years) underwent LT or LR. Median follow-up was 40 months in both groups. Overall, 5-year actuarial survival for all patients with HCC in both groups was 55%. LR patients were significantly older (P < 0.001) than LT patients. Their tumours were larger (P < 001) and more often solitary (P < 0.001) compared with the LT group. In multivariate analysis, age >60 (P < 0.02), histopathological evidence of vascular invasion (P < 0.02) and presence of cirrhosis (P < 0.02) were associated with a significantly reduced survival. Patients without vascular invasion and cirrhosis had an actuarial 5-year survival >70%.

Our study indicates that LT (within University of California, San Francisco criteria) and LR can lead to acceptable long-term survival outcomes in patients with HCC. Microscopic vascular invasion and cirrhosis were the most significant prognostic factors impacting on survival.

Preoperative radiotherapy (RT) is an important component of the management of retroperitoneal sarcoma (RPS). We aimed to establish the feasibility of this approach by determining the accuracy of computed tomography (CT)-guided core biopsy, proportion of patients completing treatment, rates of acute toxicity and surgical complications, and treatment outcomes.

This is a retrospective review. Consecutive patients presenting between January 1999 and December 2009 with a diagnosis of either primary or recurrent RPS were identified. Those patients suitable for preoperative RT and surgery were included. Exclusions included presence of metastatic disease, age under 18 years and/or paediatric histology, and treatment with palliative intent.

Twenty-four patients were included, 14 were males. Median age was 61.4 years. Twenty-three patients had Stage T2b, high-grade disease. Twenty patients were treated at initial presentation and four at first local recurrence. Five-year progression-free survival, overall survival and local recurrence rates were 48.9, 53.7 and 22%, respectively. A malignant diagnosis was confirmed in all patients who underwent CT-guided core biopsy; a diagnosis of sarcoma was reached in 90%, histological subtype correctly identified in 66%. All patients in the cohort completed preoperative RT. Grade 3 toxicity occurred in 4% of patients (n = 1). Seventy-five per cent (n = 18) proceeded to radical resection, where complete macroscopic excision was achieved in all cases. There was no perioperative mortality.

Preoperative RT has low levels of Grades 3 or 4 toxicity, and does not adversely impact surgical management. CT-guided core biopsy is an accurate means of confirming a diagnosis of RPS prior to definitive treatment.

The role of ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography (¹⁸F-FDG PET/CT) in evaluating pulmonary artery lesions has not yet been established. The purpose of this study is to evaluate the usefulness of ¹⁸F-FDG PET/CT imaging in differentiating malignant from benign pulmonary artery (PA) lesions.

In this retrospective study, 18 subjects with 26 low-attenuated filling defects suspicious for PA malignancy on contrast-enhanced chest CT were enrolled; all of whom subsequently underwent ¹⁸F-FDG PET/CT. The maximum standardized uptake value (SUVmax) for all PA lesions, defined as the ¹⁸F-FDG uptake, was measured. The final diagnosis was then determined by pathological findings, follow-up chest CT or clinical follow-up, and compared with the PET imaging.

In total, 6 PA sarcomas, 5 tumour embolism, and 15 pulmonary thromboembolism (PTE) occurred in this cohort. Not only was the SUVmax of the malignant PA lesions (10.2 ± 10.8) was significantly higher than that associated with PTE (1.7 ± 0.3; P < 0.001), no overlap occurred between groups. Conversely, no statistically significant difference in SUVmax occurred between PA sarcomas (12.8 ± 14.7) and tumour embolism (7.0 ± 1.32; P = 1.000).

 ¹⁸F-FDG PET/CT is a useful imaging modality for differentiating malignant from benign PA lesions in patients with inconclusive low-attenuation filling defects on contrast-enhanced chest CT.

The principles guiding reconstruction of the lower limb after trauma have become established over 300 years through advances in technology and studies of epidemiology. This paper reviews how these principles came about and why they are important.

This is a structured review of historical and recent literature pertinent to lower limb reconstruction. The outcomes assessed in the pre-modern era were wound mortality, amputation mortality and amputation rate. In the modern era, infection and non-union emerged as measures of outcome, which are morbidity- rather than mortality-based. Indications for amputation published during the eras are taken to reflect the reconstructive practices of the time.

Amputation and wound mortality fell throughout the pre-modern era, from 70% and 20% to 1.8% and 1.8%, respectively. Amputation rates peaked in the American Civil War (53%) but have remained less than 20% since then. Infection and non-union rates in the modern era have fluctuated between 5% and 45%.

Priority areas for research include refinement of soft tissue reconstruction, injury classification, standardization of outcome measures and primary prevention. The impact of débridement and antisepsis on outcomes should not be forgotten as progress is made.

Skin flap survival is a major challenge in reconstructive plastic surgery. Here, we examined the effect of sustained delivery of fibroblast growth factor 2 (FGF2) using heparin-conjugated fibrin (HCF) on skin flap survival in rats.

Rats with a skin flap received either phosphate-buffered saline/FGF2 or HCF/FGF2 in the recipient bed. For the no-treatment group, a random skin flap was sutured on the back without any treatment. Seven days after surgery, angiogenesis in the skin flap was evaluated by using Visitrak system and conventional healing quality scoring method. The efficacy of HCF/FGF2 in skin flap survival was evaluated by comparing the results from different groups.

The necrotic area of the skin flap significantly decreased in the HCF/FGF2 group as compared with the other groups.

The sustained delivery of FGF2 using HCF has a therapeutic potential to improve skin flap survival.

The latissimus dorsi breast reconstruction flap has a number of advantages, but despite the advances in surgical techniques, it has remained vulnerable to skin dehiscence or necrosis at the donor site. We describe a novel surgical technique to prevent this.

Patients treated with extended latissimus dorsi flap reconstruction between January 2005 and January 2010 were studied prospectively.

Eighteen patients were reviewed (12 immediate and 6 delayed). Two patients were smokers. The mean age was 54.4 (range: 42–64) years and the mean body mass index was 31.6 (range: 22.3–38). The mean weight of the mastectomy specimen was 551 g (range: 280–980 g). Six patients developed back seroma which required aspiration, and one patient developed a haematoma of the reconstructed breast. All wounds healed primarily.

The new technique is safe, simple and effective in avoiding wound dehiscence at the donor site after extended latissimus dorsi flap reconstruction.

The aim of this study was to describe the clinical characteristics, causative pathogens, clinical management and outcomes of patients presenting to a tertiary adult Australian intensive care unit (ICU) with a diagnosis of necrotizing fasciitis (NF).

This retrospective observational study was conducted in a 19-bed, level III, adult ICU in a 450-bed tertiary, regional hospital. Clinical databases were accessed for patients diagnosed with NF and admitted to The Geelong Hospital ICU between 1 February 2000 and 1 June 2011. Information on severity of sepsis, surgical procedures and microbiological results were collected.

Twenty patients with NF were identified. The median age was 52.5 years and 38% were female. The overall mortality rate was 8.3%. Common co-morbidities were diabetes (21%) and heart failure (17%), although 50% of patients had no co-morbidities. Group A Streptococcus was the identified pathogen in 11 (46%) patients, and Streptococcus milleri group in 5 (21%) patients. Hyperbaric oxygen therapy was not used in the majority of patients. The initial antibiotics administered were active against subsequently cultured bacteria in 83% of patients. Median time to surgical debridement was 20 h. Diagnosis and management was delayed in the nosocomial group.

This study reports physiological data, aetiology and therapeutic interventions in NF for an adult tertiary hospital. We demonstrate one of the lowest reported mortality rates, with early surgical debridement being achieved in the majority of patients. The main delay was found to be in the diagnosis of NF.

The purpose of the present study was to report on the frequency of reoperation, failure and patient satisfaction after the Mobility total ankle arthroplasty.

Sixty-two consecutive primary total ankle arthroplasties in 60 patients were performed with the use of the DePuy Mobility total ankle system between February 2006 and January 2009. Fifty-eight ankles in 56 patients were followed up between 14 and 49 months (mean: 32 months).

Eighteen ankles (31%) underwent an initial reoperation at a mean time of 14 months after primary total ankle arthroplasty. Only three ankles (17%) had improved symptoms after initial reoperation. Eight of these 18 ankles (44%) underwent a second reoperation. A total of seven ankles (12%) had been revised. Overall, 67% were satisfied, and 79% stated that they would undergo the same operation again.

This study on a third-generation total ankle arthroplasty reported a relatively high rate of reoperation. There was a significant increase in the reported failure when using re-operation rather than component revision as the end point. This may be one of the inherent limitations in Joint Registry data that only include component revision.

We assessed risks of incident in-hospital complications and 1-year and 5-year mortality following elective primary total joint replacement (TJR), focusing on obesity.

Longitudinal data from a population-based cohort of 819 men who had had TJR were integrated with validated hospital morbidity data and mortality records. Complications recorded in the index admission were classified as major or minor by 13 independent orthopaedic surgeons.

Of 819 men (mean age 76.3 (SD 4.5) years), 331 patients (40.4%) had an in-hospital complication from whom 155 (18.9%) had at least one major complication that was classified as potentially life threatening. Obesity and age were independently associated with increased risk of major complications. Compared with patients without complications, those with major complications experienced significantly greater mortality in 1 year (5.8% versus 1.2%, P = 0.001) and 5 years (16.8% versus 8.0%, P = 0.002) following TJR. In Cox regressions, age, Charlson Co-morbidity index and major complications were independently associated with 1-year mortality. Age and Charlson Co-morbidity index were also associated with 5-year mortality. Similarly, risk of dying within 5 years of TJR was higher among patients with class II obesity compared with patients with normal weight. The most frequently reported complications were those in the cardio-respiratory and general systems. Complications in the cardio-respiratory system significantly increased hazard of 1- and 5-year mortality.

The elderly and the obese are more likely to develop adverse outcomes following a primary TJR. Our findings may assist clinicians in better selecting elderly patients for surgery, and informing them about their individual level of risk.

Hip arthroscopy has become an established procedure in adults with well-published results. These techniques have been extended to the teenage population, but the literature remains limited in regard to indications, efficacy, outcomes and complications specific to the paediatric population.

The purpose of this study was to report the short-term outcome of the arthroscopic treatment of cam-type femoroacetabular impingement (FAI) in the skeletally immature adolescent population with open growth plates, with the hypothesis that it is a safe procedure, with good clinical outcomes and low complication rates.

The study design of this article was a multicentre prospective longitudinal case series.

From 2008–2009, 34 consecutive patients who were 18 years or younger at the date of operation (41 hips) with open proximal femoral growth plates had arthroscopic hip surgery for treatment of cam-type FAI and associated lesions by use of the lateral decubitus position by two surgeons. Data were collected prospectively including the modified Harris hip score (MHHS), nonarthritic hip score (NAHS), satisfaction survey and complications. Mean follow-up was 14 months (range 1–2 years).

All hips were available for review. The mean age of patients was 15.7 years with the most common sport activity being Australian Football League, netball and rugby. All patients had cam-type impingement, with the most common associated lesions being acetabular rim lesions (82.9%) and pincer impingement (22%). The labrum underwent debridement in 31.7% of cases, and was repaired in 17.1%. The MHHS and NAHS improved in all patients post-operatively, 77.39–94.15 and 76.34–93.18, respectively. A percentage of 78.1 were able to return to full sporting activity and 88.2% were satisfied with the operation. There were no complications.

Using hip arthroscopy to treat cam-type impingement and associated lesions in the adolescent population, we confirmed our hypothesis with observed high satisfaction levels, return to sports, significant improvement in post-operative hip scores (MHHS and NAHS) and no complications.