25, 50 and 75 years ago

The aim of this study was to evaluate two methods of post-discharge surgical wound surveillance and to compare the incidence and outcomes of wound infections that develop prior to patients ’ discharge with those that develop after hospital discharge. One thousand, three hundred and sixty inpatients who underwent major elective surgery in an 800-bed teaching hospital in western Sydney between February 1996 and July 1997 were followed prospectively. Pre-discharge wound surveillance was performed by clinical assessment by an independent researcher on the ﬁ fth (or later) postoperative day. Post-discharge wound surveillance was performed by a mail out of questionnaires completed independently by patients and surgeons. Overall, 138 wound infections were diagnosed (incidence 10.1%), of which fewer than one-third ( n = 44) were diagnosed before discharge (average 10.4 days postoperatively) and the remainder ( n = 94) after discharge (average 20.6 days postoperatively). Seven hundred and eighty-two (57.5%) post-discharge survey forms were returned by patients and 680 (50.0%) by surgeons. When forms were returned by both surgeons and patients for the same wound (641 cases), there was substantial agreement in diagnosing infection or no infection (kappa = 0.73). The majority of nosocomial surgical wound infections develop after the patients ’ discharge from hospital. A post-discharge surveillance programme including self-reporting of infections by patients and return of questionnaires by patients and surgeons is feasible in an Australian hospital setting. However, such a programme is labour and resource intensive and strategies to increase return of questionnaires are required.

The aim of this study was to evaluate two methods of postdischarge surgical wound surveillance and to compare the incidence and outcomes of wound infections that develop prior to patients' discharge with those that develop after hospital discharge.One thousand, three hundred and sixty inpatients who underwent major elective surgery in an 800-bed teaching hospital in western Sydney between February 1996 and July 1997 were followed prospectively.Pre-discharge wound surveillance was performed by clinical assessment by an independent researcher on the fifth (or later) postoperative day.Post-discharge wound surveillance was performed by a mail out of questionnaires completed independently by patients and surgeons.Overall, 138 wound infections were diagnosed (incidence 10.1%), of which fewer than one-third (n = 44) were diagnosed before discharge (average 10.4 days postoperatively) and the remainder (n = 94) after discharge (average 20.6 days postoperatively).Seven hundred and eighty-two (57.5%) post-discharge survey forms were returned by patients and 680 (50.0%) by surgeons.When forms were returned by both surgeons and patients for the same wound (641 cases), there was substantial agreement in diagnosing infection or no infection (kappa = 0.73).The majority of nosocomial surgical wound infections develop after the patients' discharge from hospital.A post-discharge surveillance programme including self-reporting of infections by patients and return of questionnaires by patients and surgeons is feasible in an Australian hospital setting.However, such a programme is labour and resource intensive and strategies to increase return of questionnaires are required.
Reid RI, Dobbs BR, Frizelle FA.Risk factors for post-appendicectomy intra-abdominal abscess.ANZ J Surg 1999;69:373-374 Appendicectomy is a common emergency operation, after which major complications are uncommon, however when they do occur, they are a major cause of concern to patient and surgeon.This study aims to determine the incidence and risk factors for postappendicectomy intra-abdominal abscess formation.A retrospective review was undertaken of all appendicectomies undertaken in Christchurch Hospital between 1 January and 31 December 1995.
Appendicectomies were identified from a database of histology.The patients' notes were reviewed and the surgical approach, histological diagnosis and postoperative complications identified.A total of 417 appendicectomies was identified of which 331 were open, 66 laparoscopic, and 20 undertaken at laparotomy.Mean day stays for each group were 4.4, 4.2 and 11.5 days, respectively.The percentages of patients with acute appendicitis in each group were 87, 58 and 35%.Histologically the appendix was inflamed in 80% (334) of patients (acute 232, chronic 15, perforated 56 and gangrenous 24).There were six postoperative intra-abdominal abscesses (1.4%), all occurring in the open appendicectomy group when the histology was either perforated or gangrenous appendicitis (P < 0.001).There were no cases of postoperative abscess formation following laparoscopic appendicectomy.All cases of postoperative intra-abdominal abscess were associated with perforated and/or gangrenous appendicitis (P < 0.001).The incidence of intraabdominal abscesses was 7.5% with a perforated and/or gangrenous appendix.There were two cases of iatrogenic perforation following laparoscopic appendicectomy.The incidence of intra-abdominal abscess is 1.4% of all appendicectomies.The only identified risk factor for development of post-appendicectomy intra-abdominal abscess was the underlying pathology of gangrenous or perforated appendicitis.

years ago
Stephens FO.Tumour immunology: a review of the present situation with particular reference to solid tumours and surgical implications.ANZ J Surg 1974;44:321-329 Exciting developments in the immunology of cancer over the past few years have clearly indicated that progress in the fields of diagnosis, prognosis and possibly prophylaxis, as well as therapy, will be forthcoming by the application of immunological principles in the not too distant future.To date, however, in spite of the wealth of accumulating information, there have been no great practical therapeutic advances available for general use.Indeed, the most effective therapeutic weapons remain concerted efforts to effect avoidance of known carcinogenic stimuli such as cigarettes in this country, and betel-nut in other countries, encouragement of early detection, and an intelligent application of standard means of therapy by chemotherapy, radiotherapy and surgery.For the present and the immediate future it appears that immunotherapy will have a place as an adjuvant to standard cancer therapy, but not as an alternative.
To date, the most encouraging practical developments appear to be associated with the use of specific cellular stimulation by injection of irradiated allogenic cells, together with non-specific stimulation by B.C.G. in patients with leukaemia.However, useful as this treatment may be, it is still merely supportive treatment to standard chemotherapeutic methods and has not yet been shown to be able to give comparable results when used as the sole form of treatment.
Another appealing approach which should soon become a practical reality is the use of tumour-specific antibodies to carry anticancer agents directly to the target cells.This should have the effect of increasing the specificity of the agents and reducing toxic sideeffects.Perhaps the most intriguing possibilities may lie in future use of 'transfer factor' and the use of 'unblocking antibodies'.As yet "transfer factor" has not been shown to be effective in the management of cancer patients on its own, and the use of "unblocking antibodies" at this stage has been limited to animal experimentation.
The indications are that there will soon be practical advances in immunotherapy, but at least for the immediate future, eradication of the bulk of malignant tissue by standard techniques will remain an essential part of therapy to allow the immunological defence system a chance of controlling a minimal amount of residual malignant tissue.
Stephens FO.Combined chemotherapy, radiotherapy and surgery in the treatment of advanced but localized solid malignant tumours.ANZ J Surg 1974;44:343-353 The most effective use of chemotherapeutic agents is in a planned combined approach in the treatment of lesions in patients who would not be expected to have a good prognosis with standard therapy.For advanced squamous carcinomata, the combination of Bleomycin and Methotrexate has been effective in reducing the size and extent of the tumours in this series.Chemotherapy alone does not "cure" cancers, but follow-up radiotherapy or surgery should be used to achieve the best long-term results.The use of chemotherapeutic agents for the treatment of carcinomata which are recurrent after previous radiotherapy or surgery is much less likely to be effective.Newer chemotherapeutic approaches are required to attempt to improve the outlook of patients with lesions which cannot be directly infused intraarterially, for patients with massive lymph node involvement, and especially for patients who have recurrent lesions after previous irradiation or surgery.The combination of Bleomycin and Methotrexate with Vincristine was highly effective in some patients, but in two of eight patients given this combination by intravenous administration there was a fatal pancytopenia, and this combination is therefore not recommended.From our small experience of a good result in three patients treated with the combination or Bleomycin, Methotrexate and Hydroxyurea, two of whom had massive metastatic involvement of lymph nodes which responded to chemotherapy, while the other had a fungating carcinoma of lip recurrent after previous irradiation and surgery, it would seem that further use of this combination should be evaluated.
Finally, it is imperative that all patients with advanced lesions or lesions which are not readily eradicated by standard means are better seen in a properly constituted consultative clinic for patients with malignant disease before therapy is commenced, No one clinician alone, be he physician, surgeon, or radiotherapist, can have all the appropriate expertise required for coping with patients with these most formidable problems.The opinions of others must be sought and obtained in order to be certain that each patient is given the most appropriate treatment in a well-planned regimen.It is no longer appropriate for any one clinician to treat his patients with the expertise which he has available to himself and refer his failures for some other form of treatment which at that stage may well be ineffective.

years ago
Wilson E. Instruments for intraabdominal resection and anastomosis for carcinoma of the rectum.ANZ J Surg 1949;18:209-211 If the patient is thin and small the technical difficulties of making an anastomosis in the depths of the pelvis after an intraabdominal resection of the rectum are easily overcome; but in the obese patient these difficulties may appear insurmountable, and indeed they may well be unless, inter alia, suitable instruments are available.In this paper some such instruments are described.It is not intended to suggest that they differ greatly from those usually employed in general surgery; rather it is hoped to emphasize the point that in the obese patient this operation can be facilitated by having at hand some additional, albeit simple, instruments.
There are already many types of angled clamps, but most of the long ones are too large and heavy to be of value to the proctologist.The clamps shown in Figures 1 and 2 are long and robust without being awkward to use.The jaws have rounded ends to lessen the chance of their penetrating the rectum whilst they are being applied, their aides are wide and flat, and the faces of the jaws are grooved longitudinally.
After one of these clamps has been applied to the bowel the second is placed on the opposite side of the bowel below the first and then moved up till the two are in contact.The blades are sufficiently wide to prevent their overriding, and it is easy to tell when they are in contact.They are easily applied and therefore the handling of the bowel before and during their application may be reduced to a minimum.
In order to prevent implantation of fragments of the tumour in the suture line the clamps should be applied above and below the tumour early in the course of the operation.Whenever possible, this should be carried out immediately after the peritoneum on the sides and front of the rectum has been divided and before the remainder of the rectum has been mobilized.After the clamps are in place the distal portion of the rectum should be irrigated with a solution of 1in 2000 perchloride of mercury.
The tissue forceps illustrated in Figure 3 have the handles doubly curved like Magill's intratracheal catheter forceps, but they have been made with the curves to the right and to the left.These forceps may be used for holding the sides of the distal portion of the rectum, and because of the double curve they lie comfortably on each side of the wound and do not obstruct the line of 'vision'.Their straight portions are nine inches long and the jams are grooved longitudinally like Babcock's tissue forceps.
In Figure 1 is shown a pair of dissecting forceps which are thirteen and a half inches long, have four to five fine teeth, and have an old type of adjustable clip, so that, when desired, they may be firmly applied to the tissues without continued pressure of the fingers and thumb.This has been found advantageous during dissections at a depth.
The other special instruments that are useful during this operation in the obese patient are a long needle holder, a wide and deep retractor, scissors at least twelve inches long, an angled knife, a deep ligature carrier, and modified Moynihan gall-bladder forceps eleven and a half inches long and useful for obtaining haemostasis in the depths of the pelvis.