The Australian and New Zealand journal of surgery最新文献

Background: Axillary dissection may be associated with significant morbidity and, while it is necessary in the treatment of invasive breast cancer, is not indicated for the treatment of pure ductal carcinoma in situ (DCIS), although it is being performed in a significant number of cases. The present study examined the incidence of elective axillary dissection in the treatment of DCIS cases detected in a mammographic screening programme over a 4-year period, and whether surgeons have changed their practice in this respect.

Methods: BreastScreen Victoria records were examined retrospectively for the period from January 1995 to December 1998 to identify patients treated for DCIS. The incidence and indications for axillary surgery were investigated.

Results: There were 579 cases of DCIS and 93 (16%) had some form of axillary surgery, which was thought to be inappropriate in 57 (10%), the latter being performed by 21 city surgeons and 20 rural surgeons. Before surgery, 36 (63%) cases were diagnosed by core biopsy or excision, and 21 (37%) had imaging and cytology alone for diagnosis. The rate of unnecessary axillary dissections dropped steadily from 14% in 1995 to 4% in 1998, a significant reduction (P = 0.01).

Conclusion: The incidence of axillary dissection for DCIS has dropped significantly over the last 4 years in Victoria, possibly due to increased awareness through education and guidelines. Surgeons are now more aware that in situ lesions do not need axillary dissection, and that axillary dissection should not be performed for breast cancer unless invasion has been proved histologically.

Background: Because the postoperative stay after laparoscopic cholecystectomy (LC) has shortened, it seemed that outpatient LC would be feasible. The aim of this study was to prospectively audit initial experience with outpatient LC at the Austin and Repatriation Medical Centre. We aimed to determine appropriate patient selection criteria, to devise anaesthetic and discharge protocols and to assess patient satisfaction at follow up.

Methods: All patients presenting for LC were assessed for suitability, and those elective cases unlikely to have a duct stone and fulfilling the social criteria were studied. After standard anaesthetic and LC technique, patients recovered in the day surgery unit for up to 8 h and were discharged if stable. The hospital in the home nursing service monitored patients for 48 h and arranged readmission if needed. Patient satisfaction was assessed by independent telephone questionnaire 6 weeks postoperatively.

Results: Forty-five patients (median age 43 years) underwent outpatient LC with a discharge rate of 82.3%, resulting in a cost saving of $984 per patient treated. One patient was readmitted, giving an overall success rate of 80%. After stricter implementation of the protocol in the second half of the study, the discharge rate rose to 92%. Patient acceptance of the technique was high at 84.5%.

Conclusions: The results of the first 45 patients show that it is possible to safely perform outpatient LC with a low admission rate in fit, elective patients who live close to medical care. Provided a strict anaesthetic protocol is followed, the technique has good patient acceptance and provides some economic benefit to the hospital.

Background: We reviewed our data of laparoscopic cholecystectomies between 1990 and 1997 with reference to gangrenous cholecystitis.

Methods: In a consecutive series of 1304 patients having laparoscopic cholecystectomies, prospective data collection has permitted analysis of the relationship between gangrenous cholecystitis (GC), acute (non-gangrenous) cholecystitis (AC) and non-acute cholecystectomies (NAC).

Results: Twenty-five patients had gangrenous cholecystitis and 238 had acute cholecystitis. We found that patients with GC were significantly older (65.4 years vs 56.1 years (AC) and 52.7 years (NAC), P < 0.05) and had a higher M: F ratio (1.5:1 vs 1:2.6 (AC) and 1:2.8 (NAC), P < 0.05). Cardiac disease was found to be a significant factor but not diabetes. Preoperative ultrasonography correctly identified only 17 patients with acute inflammatory changes. Seven patients had an absent sonographic Murphy's sign. The gall bladder wall was generally thicker (4.11 mm vs 3.8 mm (AC) and 2.7 mm (NAC), P < 0.05) but there was marked overlap between the three groups. The common bile duct (CBD) was more dilated (6.1 mm vs 4.8 mm (AC) and 4.6 mm (NAC), P < 0.006) and there was increased incidence of CBD stones in the GC group. Our conversion rate was 8.7% with minimal complications and no operative mortality.

Conclusion: Patients with GC were generally older, more likely to be male and had increased incidence of cardiovascular disease. Preoperative ultrasound cannot accurately identify those patients with gangrenous cholecystitis, but with conversion rates of 8.7% and no operative mortality, they can generally be managed safely with laparoscopic surgical techniques.

Background: Duplication of the popliteal and superficial femoral veins (PV, SFV) is a normal variant previously reported in up to 25% of limbs. Little clinical significance, however, has been attributed to this apparently common anomaly. The present study was designed to determine the incidence of duplications in individuals presenting for venous incompetence studies, and whether their presence could, in theory, act as a predisposing factor to deep venous thrombosis (DVT) formation.

Methods: Duplex ultrasound examinations were performed in which venous duplications were actively searched for and recorded. The diameters of both limbs of any duplicated system and the single vessel immediately distal to it were recorded. Using these measurements, the changes in total cross-sectional area (CSA) associated with these anomalies were calculated. In addition, with the knowledge that the volume flow rate must remain constant, the velocity changes associated with such systems were calculated.

Results: A total of 248 limbs from 177 patients was scanned. Duplications were found in 39 (15.7%) of these limbs. Of these, 30 limbs (77%) involved only the SFV, seven (18%) involved both the SFV and PV, and two (5%) involved only the PV. Short-segment SFV duplications were used to calculate the percentage change in total CSA and therefore blood flow velocities. Of the 13 (33%) suitable for such calculations, and calculating for each individual duplicated system, a mean increase in the vessel's total CSA of 42%, which corresponded to a theoretical decrease in blood flow velocity of 36%, was found.

Conclusion: The present study confirms the significantly high incidence of duplications of the PV and SFV and raises the possibility of the potential for DVT formation secondary to changes in flow velocities.

Background: All patients who underwent trans-sphenoidal surgery between January 1984 and December 1998 were reviewed to assess morbidity resulting from this operation.

Methods: There were 185 operations on 165 patients. The operative approach was sublabial in 80 cases and transnasal in 105. One surgeon (VB) performed the vast majority of operations.

Results: Complications included nasal perforation (7.6%), transient diabetes insipidus (4.9%), permanent diabetes insipidus (3.8%), cerebrospinal fluid fistula (4.3%), donor site haematoma (2.2%) and residual tumour haemorrhage (1.6%) causing ophthalmoplegia (1.1%) and loss of vision (1.1%). Other complications included epistaxis (1.1%), meningitis (0.5%) and sinusitis (0.5%). Injury to the anterior superior alveolar nerve also occurred in the sublabial approach in 6.3% of patients. There were no perioperative deaths.

Conclusions: There is a small but significant risk of a number of complications that should be considered for informed consent of this procedure.

Background: A joint-preserving operation was performed on 15 hips with osteoarthrosis, involving 12 patients who had adult cerebral palsy.

Methods: Eleven hips underwent Chiari pelvic osteotomy only; three hips underwent Chiari pelvic osteotomy with femoral osteotomy and the other one hip underwent femoral varus osteotomy only. The mean follow-up period after surgery was 6 years and 2 months (with follow-up range of 2 years and 3 months to 10 years and 6 months).

Results: Good results were achieved in 13 of the 15 hips (86.6%). Two patients with athetotic tetraplegia treated with Chiari pelvic osteotomy had pelvic obliquity. Progressive osteoarthrotic change continued in bilateral hips in one case treated with Chiari pelvic osteotomy.

Conclusion: We confirm that usual treatment for osteoarthrosis of the hip was also applicable for osteoarthrosis of the hip in cases of adult cerebral palsy, provided sufficient attention is given to the complications accompanying spastic paralysis.

Background: Mammographic screening for breast cancer not only reduces the overall mortality from breast cancer but allows greater opportunities for breast-conserving operations. The predicted degree of breast conservation is not being realized, but is increasing in centres that have published their results.

Methods: The operative management of breast cancers diagnosed by BreastScreen Central and Eastern Sydney Screening and Assessment Service were compared between two time periods: January 1988-December 1992 (group 1) and January 1993-December 1995 (group 2). The rate of breast conservation, and other data were compared between the two periods. An attempt was made with multivariate analysis to identify some of the factors that made mastectomy rather than conservation more likely.

Results: There were 723 cancers detected that were suitable for analysis (group 1, n = 273; group 2, n = 450). In group 1 the breast conservation rate was 42.9%; this increased significantly to 60.4% in group 2 (P < 0.001). The data were examined to determine if there was any other factor that had changed over the time periods which might account for the increased rate of breast conservation. The use of pre-operative diagnostic techniques such as fine needle aspirate cytology and core biopsy increased significantly. Multivariate analysis comparing the differences in patient age, diagnostic technique, tumour type, grade, size, location and lymph node status, both independently and compositely did not account for the increase in breast conservation in group 2.

Conclusion: The increase in breast conservation is due to other factors such as the surgeons' approach and patient attitude. The use of pre-operative, minimally invasive tissue sampling techniques is increasing.

Background: Vocal dysfunction in patients with thyroid pathology has been poorly documented, and dysfunction after thyroid surgery is generally reported in terms of recurrent laryngeal nerve or external laryngeal nerve palsy. But voice dysfunction is more complex than simply nerve integrity. The present study reports the incidence of dysphonia in patients presenting for thyroid surgery, and relates postoperative changes in vocal function to recurrent and external laryngeal nerve function, and the surgical handling of the strap muscles.

Methods: Fifty patients were assessed by Visipitch before and after thyroidectomy. Following surgery the patients filled out a questionnaire.

Results: Overall 26 of 44 patients had no subjective postoperative voice change, while 10 reported subjective deterioration and eight reported subjective improvement in voicing. Postoperative objective assessment of these patients found that 17 were the same, eight refused to come for testing because they felt their voice had not changed, 13 were better and six were worse. Following surgery two patients (4.5%) had temporary recurrent laryngeal nerve palsies (2.5% of nerves at risk), and four patients (10%) suffered external laryngeal nerve palsies. Division of strap muscles was not detrimental to voicing. Six patients were lost to follow-up. Fifteen patients (34%) presented with vocal abnormalities, six (40%) of whom improved postoperatively.

Conclusions: Patients may have voicing abnormalities before thyroid surgery is performed. Surgery may improve or worsen the voice irrespective of the pre-operative voice status.