The Australian and New Zealand journal of surgery最新文献

Background: The advent of laparoscopic anti-reflux surgery has generated considerable debate regarding the best technique. The present study was undertaken to determine the trends and current technique in laparoscopic anti-reflux surgery in New Zealand.

Methods: A confidential nationwide postal survey was sent to all general surgeons in New Zealand; it was repeated after a month, and followed up with a telephone prompt, if necessary.

Results: Of the 146 questionnaires sent out, 126 were returned (response rate: 86%), and 104 were excluded (no anti-reflux surgery performed (n = 96); surgeon retired (n = 5); paediatric surgeon (n = 3)). The number of operations performed by the 22 (16%) adult general surgeons who had performed laparoscopic anti-reflux surgery increased 4.6 times from 1991 to 1997 (474 open and 1218 laparoscopic operations). The median number of cases per surgeon was 30 (range: 5-300). In 1997 there were 208 (60%) total fundoplications (TF) and 135 (40%) partial fundoplications (PF) performed. Variations in the technique of TF included the Nissen-DeMeester (10 surgeons), the Nissen-Rosetti (nine surgeons), division of short gastric vessels (10 surgeons), and routine cruroplasty (14 surgeons). A PF had never been performed by six surgeons, was preferred by six surgeons, and four other surgeons were performing it more often. Variations in the technique of PF included posterior (12 surgeons) and anterior (four surgeons) forms.

Conclusion: There is significant variation in the technique of laparoscopic anti-reflux surgery in New Zealand. A TF is preferred by 16 surgeons, but there appears to be a trend towards PF among the more experienced surgeons.

Background: A proportion of the cancers 'missed' at mammography are invisible even with the benefit of hindsight. The aim of the present study was to identify a group of women with proven breast cancer whose mammograms did not show a suspicious lesion even in retrospect (i.e. the truly mammographically occult cancers), and to compare them with mammogram-positive cancers.

Methods: A total of 1757 breast cancers was diagnosed at the Wesley Breast Clinic's Screening or Diagnostic Services between July 1987 and August 1997. One hundred and twenty cases were identified where, after independent review by two of the authors, no mammographic abnormality could be found in the region where the cancer was subsequently found. These 120 cases were compared with 1548 cancers considered to have a lesion visible on mammography, whether benign, indeterminate, suspicious or malignant in appearance.

Results: In 90% of the mammogram-negative cancers, a clinical abnormality led to further investigation, while the remainder were found incidentally on ultrasound. There were a higher proportion of dense breasts, and of women aged 40-49, in the mammogram-negative cancers than in the mammogram-positive cancers. The mammogram-negative cancers were of smaller size overall, but three of them were surprisingly large (7-11 cm). In both the mammogram-positive and -negative cancers approximately 60% were ductal invasive cancers.

Conclusions: Where factors are present that make mammographically occult malignancy more likely (e.g. age 40-49 and dense breasts), women may be targeted for further investigation by other modalities. This is essential in the presence of a clinical abnormality.

Background: Increasing recognition of the need for training in teaching skills for clinical teachers has coincided with data that registrars and residents conduct much 'on the job' teaching as part of their routine work. While attention has been devoted to training consultants, support for the teaching role of the junior staff has been relatively neglected. The aim of the present report is to describe the teaching experiences of surgical registrars and the impact of a registrar teaching workshop.

Method: A half-day programme combining presentation and discussion of surgical teaching with practical skills sessions was designed for surgical registrars at Prince of Wales Hospital. The programme included observation and feedback of brief teaching simulations at the bedside of volunteer patients to newly commenced clinical students, and small group sessions on clinic and operating theatre teaching. A pre-workshop questionnaire sought information about the registrars' own teaching, and a survey 3 months after the workshop determined if any changes to teaching practice had occurred.

Results: The registrars were generally moderately to very confident with their teaching ability but more than 75% felt that they were more confident after the workshop. Only three of 39 registrars had received any instruction aimed at improving their teaching skills, yet 34/39 had taught either on the ward, in the clinics or in the operating room. Follow-up after 3 months revealed that most registrars were enjoying their teaching tasks more, and half had increased their teaching since the workshop and began discussing teaching with their surgical colleagues.

Conclusions: The present project demonstrates that relatively brief interventions focused on skill development may enhance the confidence and enjoyment of junior clinical teachers and increase the frequency of 'teaching on the run'.

Background: Rembrandt's Bathsheba (Louvre, Paris) reveals an abnormality of the left breast and axilla. Previously breast cancer has been suggested as the probable diagnosis.

Methods: The present paper reviews the clinical history as well as the clinical findings.

Results: Inconsistencies, pitfalls in the diagnosis and the consequences of the possibility of a different model for the body of the figure are discussed.

Conclusion: An alternative diagnosis of an infective process such as tuberculous mastitis or, less likely, chronic lactational breast abscess is suggested.

Background: Injuries caused by firearms account for only a small percentage of trauma admissions and deaths in Australia but are frequently the subject of media and public attention. The present study examines the epidemiology and management of firearm injuries presenting to St Vincent's Hospital, which is located at the edge of the central business district of Sydney.

Methods: The medical records of all patients presenting to St Vincent's with a gunshot wound (GSW) from January 1988 to December 1998 were analysed. Additional details were acquired from New South Wales State Coroner's Court reports and media archives, especially major newspapers.

Results: Seventy-four patients presented to St Vincent's Hospital with 103 GSW. The age (mean +/- SD) was 31+/-11 years. Sixty-seven patients (91%) were male. Alcohol was identified as a factor in 24 cases (32%) while other drugs were indicated in four cases (5%). Ten patients (14%) had intentionally self-inflicted wounds, seven (9%) had accidental wounds and 57 (77%) had wounds that were caused by crime-related violence. Sixty patients (81%) underwent operation for their injury. Thirty complications were seen in 18 patients (24%). Eleven patients (15%) died. The length of hospital stay (mean +/- SEM) was 18+/-9 days.

Conclusions: The incidence of trauma due to firearms has not increased at St Vincent's hospital in the period 1988-98. Most GSW were inflicted in the setting of criminal violence, with a high proportion due to handguns. Patients were mostly young men, and alcohol or other drugs were frequently involved. Outcomes are comparable to other centres managing large volumes of penetrating trauma.

Background: Tasmania is an area of endemic iodine deficiency. Amiodarone is a class III anti-arrhythmic drug that is widely used for the management of ventricular and supraventricular tachydysrhythmias. Individuals from areas of endemic iodine deficiency appear more likely to manifest hyperthyroidism following amiodarone therapy, whereas hypothyroidism is a more frequent complication in iodine-replete communities.

Methods: Cases series. The clinical and biochemical response to medical and surgical management of five consecutive Tasmanian patients presenting with severe type-II amiodarone-associated thyrotoxicosis was reviewed.

Results: Five patients were identified. Combinations of antithyroid therapy including propylthiouracil, lithium carbonate, dexamethasone and cholestyramine were used. Thyroidectomy was required in two cases (40%) due to severe unremitting thyrotoxicosis despite combined drug regimens. Anaesthesia and total thyroidectomy were undertaken without complication despite the presence of severe hyperthyroidism at the time of surgery. In both cases thyroid histopathology demonstrated degenerative and destructive follicular lesions with multinuclear cell infiltrate and focal fibrosis.

Conclusion: Amiodarone-associated thyrotoxicosis may be severe and refractory to medical therapy. Despite the potential risks of anaesthesia associated with uncontrolled thyrotoxicosis, thyroidectomy should be considered in the setting of life-threatening thyrotoxicosis.

Background: In order to improve strength in small diameter intramedullary nails, a system was designed in which the implants were manufactured from 30% coldworked ISO 5832-9 stainless steel.

Methods: Nail diameters were 9 and 10 mm for the femur, and 8 and 9 mm for the tibia. The nails were solid rods and the screws were partially threaded. Pre-clinical bending yield tests established that the 8-, 9- and 10-mm diameter rods had strengths comparable, respectively, with 10-, 12- and 14-mm diameter Grosse-Kempf nails. Forty-eight femoral and 98 tibial shaft acute fractures were treated with this system. Postoperatively, patients were allowed to gently bear weight as tolerated.

Results: There was one broken nail, occurring 10 months after femoral nailing. There were six broken screws, occurring between 3 and 6 months postoperatively in two patients and after more than 6 months in four patients. The broken screws had no adverse clinical effect. Five patients required late bone grafting or exchange nailing, and 15 patients required dynamization.

Conclusion: This design of small diameter locked intramedullary nails was strong enough to allow early weightbearing.