25, 50 and 75 years ago

Carnaille B, Oudar C, Pattou F, Combemale F, Rocha J, Proye C. Pancreatitis and primary hyperparathyroidism: forty cases. ANZ J. Surg. 1998; 68:117–9. Pancreatitis is associated with primary hyperparathyroidism (PHPT) in 1.5–7% of cases. The relationship of cause and effect between the two diseases has been debated. To evaluate this relationship, the clinical, biochemical and pathological data on 1435 patients operated on for hyperparathyroidism (HPT) over the past 30 years were retrospectively reviewed. A total of 1224 of these patients had biologically proven and cured PHPT and 211 patients had renal HPT (RHPT). The diagnosis of pancreatitis (PTS) was based on a high serum amylase level and or abnormalities on ultrasound or computed tomography (CT) scan explorations. Only patients without biliary stones were included in the PTS group associated with HPT. A total of 3.2% (n = 40) of patients with PHPT had PTS, which was acute in 18 cases, subacute in 8 cases and chronic in 14 cases. This rate of PTS is higher than in a random hospital population. Surgical cure of HPT was followed by the spontaneous healing of 17/18 acute PTS, whereas six of the 22 patients with subacute or chronic PTS developed complications due to the evolution of their disease (diabetes, pancreatic duct stenosis treated by surgery). A single diseased gland was found in 27 patients with PTS, which is in favour of primary parathyroid disease, being responsible for, and not a consequence of, PTS. Only the serum calcium (13.0 vs. 12.1 g/dL) level was significantly increased in PHPT patients with PTS, when compared with those without PTS. The calcium level is probably of major importance in the development of PTS, which was never encountered in 21I patients with RHPT, who had low calcium and high PTH levels. The data suggest that (i) the PTS-PHPT association is not incidental; (ii) PTS is the consequence and not the cause of PHPT; (iii) hypercalcaemia seems to be a major factor in the development of PTS in PHPT patients; and (iv) cure of PHPT leads to the healing of acute PTS, whereas it does not affect the evolution of subacute and chronic PTS. Young C, Moont M. Routine cholecystocholangiography: a viable alternative during laparoscopic cholecystectomy. ANZ J. Surg. 1998; 68:425–7. The advantages of cholangiography during laparoscopic cholecystectomy (LC), including identification of biliary anatomy and biliary calculi, are well-known. The usefulness of cholecystocholangiography (CCC), by direct injection through the gall bladder, compared to the more popular cystic duct cholangiography (CDC), however, is not so well-known. Two hundred consecutive patients who underwent LC were included in a prospective study of routine CCC. Between 5 and 60 mL of contrast is injected through the gall-bladder fundus, using image intensifier control. Cholecystocholangiography was attempted in 194 cases and was successful in 157 (80.9%). Twenty-one of the 37 cases with a failed CCC proceeded to have a successful CDC, giving an overall cholangiography success rate of 91.8%. The presence of acute inflammation decreased the success rate. Eleven (6%) true positive cases of common bile duct (CBD) calculi were demonstrated (nine on CCC and two on CDC after failed CCC). There was one case of false positive CBD calculus and no false negatives. We have found that the routine use of CCC during LC is safe, successful, quick to perform, and does not prevent conversion to attempted CDC in the cases where it fails. Cholecystocholangiography may have advantages over CDC and be an alternative as the preferred imaging technique.

Pancreatitis is associated with primary hyperparathyroidism (PHPT) in 1.5-7% of cases. The relationship of cause and effect between the two diseases has been debated. To evaluate this relationship, the clinical, biochemical and pathological data on 1435 patients operated on for hyperparathyroidism (HPT) over the past 30 years were retrospectively reviewed. A total of 1224 of these patients had biologically proven and cured PHPT and 211 patients had renal HPT (RHPT). The diagnosis of pancreatitis (PTS) was based on a high serum amylase level and or abnormalities on ultrasound or computed tomography (CT) scan explorations. Only patients without biliary stones were included in the PTS group associated with HPT. A total of 3.2% (n = 40) of patients with PHPT had PTS, which was acute in 18 cases, subacute in 8 cases and chronic in 14 cases. This rate of PTS is higher than in a random hospital population. Surgical cure of HPT was followed by the spontaneous healing of 17/18 acute PTS, whereas six of the 22 patients with subacute or chronic PTS developed complications due to the evolution of their disease (diabetes, pancreatic duct stenosis treated by surgery). A single diseased gland was found in 27 patients with PTS, which is in favour of primary parathyroid disease, being responsible for, and not a consequence of, PTS. Only the serum calcium (13.0 vs. 12.1 g/dL) level was significantly increased in PHPT patients with PTS, when compared with those without PTS. The calcium level is probably of major importance in the development of PTS, which was never encountered in 21I patients with RHPT, who had low calcium and high PTH levels. The data suggest that (i) the PTS-PHPT association is not incidental; (ii) PTS is the consequence and not the cause of PHPT; (iii) hypercalcaemia seems to be a major factor in the development of PTS in PHPT patients; and (iv) cure of PHPT leads to the healing of acute PTS, whereas it does not affect the evolution of subacute and chronic PTS.
The advantages of cholangiography during laparoscopic cholecystectomy (LC), including identification of biliary anatomy and biliary calculi, are well-known. The usefulness of cholecystocholangiography (CCC), by direct injection through the gall bladder, compared to the more popular cystic duct cholangiography (CDC), however, is not so well-known. Two hundred consecutive patients who underwent LC were included in a prospective study of routine CCC. Between 5 and 60 mL of contrast is injected through the gall-bladder fundus, using image intensifier control. Cholecystocholangiography was attempted in 194 cases and was successful in 157 (80.9%). Twenty-one of the 37 cases with a failed CCC proceeded to have a successful CDC, giving an overall cholangiography success rate of 91.8%. The presence of acute inflammation decreased the success rate. Eleven (6%) true positive cases of common bile duct (CBD) calculi were demonstrated (nine on CCC and two on CDC after failed CCC). There was one case of false positive CBD calculus and no false negatives. We have found that the routine use of CCC during LC is safe, successful, quick to perform, and does not prevent conversion to attempted CDC in the cases where it fails. Cholecystocholangiography may have advantages over CDC and be an alternative as the preferred imaging technique.

Fifty years ago
Wright JE. A method of continual assessment of surgical results by computer analysis. ANZ J. Surg. 1973;42:408-11.
A method of continual assessment of surgical results by computer analysis is described. This is a modification of the previous surgical study techniques used at the Royal Newcastle Hospital since 1955. The medical officer who dictates the patient's discharge summary records relevant facts in coded form on a surgical audit blank. This is removed from the chart, stored, and at the end of a given year sent to the Hospitals Commission of NSW for computer analysis. The purpose of this paper is to outline the method of study rather than to give details of statistical results. Only one-years study so far is available from this work. Some features of the results have been commented upon in a previous paper. There has been a distinct fall in the incidence of non-recorded wounds (16.6% to 6.6%). There has been an apparent fall in the overall wound infection rate, but this is difficult to assess. The fall in wound infection rate following hernia operations is not statistically significant. An elective hernia operation is the 'key' clean operation in any wound infection study. Even if this fall were significant, it would be difficult to determine whether it was due to the different method of recording or to other factors. It is clear, however, that in future studies one will have to bear in mind that a change in the method of recording did take place in June 1970, and that comparisons before and after this date may not be valid. An additional benefit has been the diminished workload for the record-room staff and indeed for the registrars and staff specialists. Perhaps it is a disadvantage that the records are no longer perused en masse, and that registrars are not exposed to constant reminders of the importance of good case-history notes.
An analysis of surgical wound infections according to type of operation and bacteria involved, based on a prospective study of 22 822 operations followed at the Princess Alexandra Hospital from 1963 to 1971, is reported. The overall infection rate for clean general surgery (Class 'A' operations) was 4.5%; for potentially infected surgery (Class 'B' operations) 9.5%; and for clean orthopaedic surgery 3%. The infection rates varied from month to month and year to year without any consistent pattern. Staphylococcus aureus was the commonest infecting organism in Class 'A' operations and coliform bacilli in Class 'B'. Cure must be taken before assuming that a drop in the incidence of wound infection is due to the introduction of any particular measure, such as a change in technique or the administration of an antibiotic.

Seventy-five years ago
Orton RH. Controlled respiration and curare in modern surgery. ANZ J. Surg. 1948;18:235-46. In summary: 1. Controlled respiration utilizing closed-system anaesthesia with a carbon dioxide absorption technique (Fig. 1) possesses advantages over voluntary respiration in thoracic surgery and should be employed during abdominal surgery whenever respiratory depression occurs. By its use normal exchange of oxygen and carbon dioxide is possible in all circumstances.
2. By producing muscular relaxation and abolishing reflexes curare allows the use of light anaesthesia and therefore aids in the avoidance of shock.
3. In abdominal surgery, light anaesthesia, combined with the use of curare and controlled respiration, produces the minimum disturbance in the patient compatible with adequate muscular relaxation.
4. In thoracic surgery curare controls bronchial reflexes and with controlled respiration gives the most satisfactory conditions for surgery.
5. The use of controlled respiration and of curare demands a high degree of anaesthetic skill.