The Australian and New Zealand journal of surgery最新文献

We have reached a phase of diminishing returns in medicine. Increasing costs produce smaller and smaller incremental benefits in health status. Medical scientists continue to work within the ideology of the Enlightenment, whereby advances in knowledge will eventually lead to control of health and welfare. The enormous costs of this ideology have led to two new ideologies: those of economic rationalism and managerialism. At the public level, the Western liberal emphasis on the value of individual life is generally held to justify the amount of public money spent on health. Those who frame health policy are influenced to some extent by this ideal, but we cannot continue to develop costly interventions without constraint. To overcome this impasse, we might accept that economic rationalism provided a proper base for health care; or we might redefine disease so that more people were excluded from treatment programmes; or we might agree to limit medical research in costly areas; we might change our ethical thinking to emphasize classical utilitarianism; or we might undertake systematic studies of community values and opinions to find out what people really want from their health and welfare services. There are serious ethical problems with each of these solutions, except for the last: the idea of modifying services to take note of community values. Testing community values is difficult, but there are ways of doing it, and there have been some exercises in which the process has been undertaken with some success. The recent Constitutional convention suggests that it may even be possible in Australia.

Australia faces general and particular problems in the just distribution of trauma services, such as a proliferation of expensive technologies, economic and geographic limitations on their provision, and inequities in allocation. The ethics of shalom in which people live in harmonious relationships with each other, the world and God provide a moral framework for the discussion of the allocation of health care. Ethics deal with people and their relationships, which entails examining the nature and consequences of an action or policy and the character of the persons and institutions involved. The goal of health care, including trauma services, is not to 'fight disease' or to improve the health of the community, but to return people to proper functioning as people-in-relationships, as far as this is practicable. In applying this to the equitable provision of trauma services in Australia, we should distinguish between sustenance rights and community-provided mercies. The former are basic services that we need in order to function meaningfully in the community, and to which we are entitled (eg., basic health care). The latter are other benefits that we as members of the community choose to provide for each other, but to which we are not entitled per se (eg., ICU, Tertiary Trauma Centres). We should do all we reasonably can to ensure that all people receive their healthcare sustenance rights, that healthcare mercies are equitably distributed, and that the person-orientation of health care is maintained in the face of 'technological imperatives'.

Background: This study was undertaken to assess the outcome of Lichtenstein's tension-free mesh inguinal herniorrhaphy as practised by surgeons in a provincial centre in Taranaki, New Zealand.

Methods: A prospective audit was carried out on all patients who underwent this procedure in Taranaki. They were followed up at 1 month and again at 1 year. Results were entered on a standardized pro forma.

Results: One hundred and twenty-four patients underwent 134 repairs by four different surgeons and their registrars. Eighty-two per cent of them had a general anaesthetic, and 13% had local anaesthestic. Twenty-five per cent of the repairs were performed as day surgery and a further 53% required overnight stays. Complication rates were 6% in hospital, 12.7% at I month and 8% at 1 year. Recurrence occurred in one repair (0.9%) and there were no cases of mesh rejection. The wound infection rate was 3% and all were minor. Only 45% of the patients who had an inguinal hemiorrhaphy were employed and they took an average of 16 days (range 2-30) to return to work. Over half felt that that they could have returned to normal activities within 2 weeks.

Conclusions: The Lichtenstein technique of inguinal herniorrhaphy is a technically simple, reliable procedure with minimal morbidity and patients may expect a reasonably prompt return to work and to normal activities.

Background: This study arose out of a concern about the transmission of infectious diseases through eye splash injuries in surgery. The purpose of this study was to identify the extent of the risk of eye splash injuries.

Methods: A prospective trial was undertaken which examined 160 consecutive eye shields used by surgeons and assistants in operations of 30 min or longer. The shields were inspected for macroscopic splashes and then tested for microscopic splashes using reagent strips.

Results: Of the 160 eye shields used in surgery, 71 tested positive for blood (44%). The surgeon was aware of a spray episode in only 13 cases (8%). The splashes were macroscopically visible in only 26 (16%) cases. The risk of eye splash was higher for the surgeon than for the assistants and increased with the length of the operation.

Conclusions: This study demonstrates that the risk of eye splash injury in surgery is much greater than that perceived by most surgeons and trainees. Eye protection should be mandatory for all personnel in the operating theatre, particularly for those directly involved with the operation.

Background: The Pacific Island countries consist of widely scattered, small, underdeveloped islands which require considerable international assistance, particularly in health care. In 1995, the Pacific Islands Project was established and funded by AusAID to provide tertiary medical assistance to 10 island countries over a 3-year period. The programme was later expanded to include Papua New Guinea.

Methods: The Royal Australasian College of Surgeons was appointed manager of the project, which involved voluntary input from members of several specialist medical colleges and societies. Assistance was provided through short-term visits of multidisciplinary teams according to predetermined priorities. The delivery of medical services was combined with a transfer of skills and educational activities. Feedback was obtained from the recipient countries and each visit evaluated by an independent committee.

Results: One hundred and thirty-one visits in ten disciplines were conducted in 11 countries by 255 participants on a voluntary basis between March 1995 and March 1998: 15 784 patients were seen and 3424 operations performed.

Conclusions: The programme was very successful on all counts. It has now been extended for a further 3 years and will be conducted in parallel with postgraduate educational programmes in the Pacific region and Papua New Guinea.

Background: Male breast cancer is rare and experience of it in any single institution is limited. The aim of this study was to evaluate the presentation, management and outcome of male patients with breast cancer treated at Concord Repatriation General Hospital hospital over a 38-year period and to determine a best-practice protocol based on the results and a review of the literature.

Methods: A total of 42 patients were retrospectively reviewed, pathology slides were re-examined and reclassified where necessary. Outcome was assessed and compared with results obtained from a literature review.

Results: A trend towards less radical surgery has emerged. Overall 5-year survival was 50%, but, due to the late age at presentation, more than half the deaths were non-breast cancer related. One quarter of the patients presented with locally advanced or metastatic disease.

Conclusions: The presentation, diagnosis pathology and outcome of breast cancer are similar in men and women, although the disease occurs at a later age in men. Radical surgery is not required in order to gain local control, but knowledge of axillary node status is important in determining prognosis and the need for adjuvant therapy.

Background: Lymphocoele formation can be a troublesome surgical complication after lymph node dissection and mobilization of large skin flaps. Occasionally, lymphocoeles persist for prolonged periods despite repeated aspiration. Treatment by sclerotherapy has been recommended, but this requires a prolonged treatment time and often causes intense pain.

Methods: The technique used to treat large, persistent lymphocoeles involved 'painting' the lymphocoele wall with an argon beam coagulator after evacuating its contents. Sterile talc was then distributed liberally through the cavity, a closed suction drain placed and the wound closed.

Results: The procedure was completely successful in each of the four patients treated. After a mean follow-up period of 11 months (range 6-15 months) no lymphocoele recurrence has occurred.

Conclusions: Use of an argon beam coagulator and talc reliably achieves rapid, definitive obliteration of large, persistent lymphocoeles.