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Background: Localizing the source of severe lower gastrointestinal (GI) bleeding is often difficult but is important to plan the extent of colonic resection. The purpose of the present paper was to audit the Auckland Hospital experience of selective angiography, in localizing lower GI bleeding. Methods: Patients admitted to Auckland Hospital with rectal bleeding and who subsequently had angiography were evaluated by reviewing their clinical notes and radiological results during a 7-year period (1997−2003). Data collected included demographic details, haemodynamic parameters, change in haemoglobin level, requirement of blood transfusion within 24 h before the procedure, site of the bleeding and pathology. Results: The notes of 88 patients (male, n = 51; median age 69 years, range 8−99 years) were available for review and analysis. The site of bleeding was localized in 38 (51%); 30 of them had bleeding in the right colon or small bowel and eight in the left colon. Positive localization correlated with: haemodynamic instability P < 0.0001; drop in haemoglobin level of ≥50 from previous admission ( P = 0.02); transfusion requirement of ≥5 units of blood within 24 h ( P < 0.0001). Logistic regression analysis showed transfusion requirement of ≥5 units to achieve haemodynamic stability to be the most powerful predictor of accurate localization (odds ratio, 40). Conclusion: Catheter angiography for acute lower GI bleeding will successfully localize a point of bleeding in approximately 50% of patients. The most useful clinical indicator for positive angiography was haemodynamic instability particularly in those who require transfusion of ≥5 units of blood to achieve haemodynamic stability. [ABSTRACT FROM AUTHOR]

Background: The purpose of this paper is to provide a review, based on collected data, on the topic of ‘fractured zygoma’. The review is presented under the headings of epidemiology, fracture patterns, treatment modalities and complications. Throughout the paper comparison is made with published data from around the world. Methods: A 10-year retrospective audit was undertaken of all hospitalized patients, at the Royal Hobart Hospital, Tasmania, who had sustained a fractured zygoma. All Le Fort fractures involving the zygoma were excluded. Results: A total of 263 fractures was sustained, largely due to assault. Alcohol was a significant contributing factor. Tetrapod fractures were the most frequent type of fractures witnessed. Plating was the most frequently employed fixation. Inferior orbital nerve dysfunction and other complications were seen in 24.6% and 20.7% of follow-up cases, respectively. Open reductions were nearly 4 times more likely to be accompanied by complications if inferior orbital nerve dysfunction was excluded. Conclusions: Both closed and open reductions are good treatment modalities and were used in near equal numbers of patients. There is a higher incidence of postoperative facial deformity in the closed reduction group, but more complications related to the incisions in the open reduction group. Open reduction and internal fixation is advocated for the unstable, markedly displaced or comminuted fractures. Silastic sheeting is a favoured graft for repair of the associated orbital floor defects and is associated with few complications. [ABSTRACT FROM AUTHOR]

Background: Management of the cervical spine following blunt trauma is commonplace. In 2013, the American Association of Neurological Surgeons (AANS) and the Congress of Neurological Surgeons (CNS) published practice guidelines drawn from evidence dating to 2011. Since then, further publications have emerged that are reviewed, and a simple management algorithm produced to assist practitioners in Australian trauma centres. These publications attempt to shed light on two controversial scenarios, those being the management of symptomatic patients with negative computed tomography (CT) and management of the obtunded patient. Methods: The search strategy mirrored that of the AANS/CNS guidelines. A search of the National Library of Medicine (PubMed) database for manuscripts published between January 2011 and October 2014 was conducted. One reviewer extracted data from studies assessing the performance of various imaging modalities in identifying traumatic cervical spine injuries. In clinical scenarios where little evidence has emerged since the AANS/CNS guidelines, key manuscripts published prior to 2011 were identified from bibliographies. Results: Awake, asymptomatic patients may be 'cleared' without further imaging. Awake, symptomatic patients without pathology on CT and without neurological deficit can safely be 'cleared' without magnetic resonance imaging. There is no longer a role for flexion-extension films. In the obtunded patient, findings remain conflicting. Conclusion: Several of these findings represent a departure from previous practices, including clearance of patients with non-neurological symptoms on the basis of CT and the exclusion of flexion-extension film in detecting injury. Management of the obtunded patient remains controversial. [ABSTRACT FROM AUTHOR]

Background: Popliteal artery aneurysms (PAA) are the most common peripheral aneurysm and are recognized as ‘the silent killer of the leg circulation’. The timing and type of interventions used in their treatment is still controversial. This review examines the published data on the natural history, epidemiology, clinical presentation and management options available. The aim of this study is to try and reach a consensus with regards to the best management of PAA. Method: A systematic review of data in the English published works since 1980. Results: The authors include 53 studies containing 2854 patients with 4291 PAA. Most published data involves retrospective studies and personal experience, with one multicentre study. No randomized controlled studies exist regarding the management of PAA. Conclusions: 1. Although most PAA are of atherosclerotic origin in old patients, trauma, infection and family history are the main causes in young patients. 2. Great vigilance is needed for diagnosis as only approximately five patients are seen each year by a major vascular centre. There is no place for screening programmes to detect PAA. 3. Approximately 45% of patients are asymptomatic at the time of initial diagnosis. Aortic aneurysms are found in 40% and bilateral PAA in 50% of patients. More than 95% of patients are men with a mean age of 65 years and 45% have hypertension. 4. Surgical reconstruction is recommended for all symptomatic and asymptomatic aneurysms larger than 2 cm. Five-year graft patency rates after surgical repair range from 30 to 97%, with 5-year limb salvage ranging from 70 to 98%. Patient survival rates at 5 and 10 years are 75 and 46%, respectively. 5. If carried out carefully, intra-arterial thrombolysis can safely prepare patients presenting with acute ischaemia from occluded PAA, for surgical revascularization to restore distal run-off. 6. Endovascular repair of a PAA is a feasible option, although little evidence is yet available. 7. Lifelong, careful patient surveillance is essential to detect and treat new aneurysms at other sites. [ABSTRACT FROM AUTHOR]

Aim: To examine the influence of previous episodes of uncomplicated diverticulitis on the prognosis of patients who subsequently develop complicated diverticulitis. Patients: One hundred and fifty patients with previous episodes of diverticulitis who were admitted to the Mayo Clinic (Rochester, MN, USA) with complicated diverticulitis (perforation, abscess, obstruction, phlegmon, fistula, or bleeding). Design: The retrospective analysis was based on two groups of patients: group A had one or two prior episodes of diverticulitis ( n = 118) and group B had more than two prior episodes of diverticulitis ( n = 32). Measurement of outcome: The following criteria were used: phlegmon was a symptomatic inflammatory mass separate from and not associated with a purulent fluid collection; pericolic abscess was a collection of purulent material localized near the colon or in the pelvis; obstruction was characterized by obstructive symptoms and a stricture or stenosis diagnosed by radiographic studies or pathological evaluation; fistulas included colovaginal and colovesicular connections; perforation was either a collection of contained air outside the bowel wall or a large amount of free intra-abdominal air; and patients who required a transfusion for a lower gastrointestinal haemorrhage associated with symptoms and signs of diverticulitis were placed in the bleeding category. Results: Perforated diverticulitis occurred more often in patients from group A; because of this, patients in group A underwent more surgical diversions. There were no appreciable differences in operative complications, morbidity or mortality rates. Conclusion: Patients with more than two episodes of uncomplicated diverticulitis are not at increased risk for poor outcomes if they develop complicated diverticulitis. [ABSTRACT FROM AUTHOR]

An editorial is presented on the importance of treatment and patient care procedure for abdominal diseases. It expresses the view that the role of informed consent and decision making are important, an overview of the patient with an ileostomy for perforation complicated by faecal peritonitis, and clinical records' help for the doctor in treating their patients.

Introduction Integrity of Transplant Renal Artery is crucial for long term survival of the graft. Literature regarding the evolution of Transplant Renal Artery Stenosis (TRAS) is scant. Method Retrospective analysis of 1042 duplex scans in kidney transplant recipients. Duplex scan (GE VIVID 307, multiphase transducer) was used as routine screening modality. Time period 1999–2006. Total no of patients −148. Mean age 47.4 yrs. M : F: 83 : 65. Average follow up −2.45 yrs. Renal arterial ratio and peak systolic velocities were used as absolute criteria for diagnosis. Relative criteria used were parenchymal perfusion, size of kidney, resistive indices and presence of other vascular conditions. Results Number of patients detected to have TRAS-50. Mean age- 48.36 yrs. M : F: 29 : 21. Average time period for detection of stenosis – 193 days. 20 patients had ostial stenosis, 23 – mid segment, 1 at hilum, 2 – branch and 4 – throughout length of artery. Two groups: Early stenosis i.e. within 3 mo – 36(72%) patients. Late stenosis – 14 (28%) patients. Average time to detect early stenosis 74 (10–100) days and late stenosis 502 (140–1396) days. 21/36 patients in group 1 showed complete resolution of stenosis in an average time of 270 days whereas only 3/14 patients in the late group resolved at an average period of 375 days (p = 0.019). Conclusion Routine duplex scans can detect significant numbers of TRAS. Stenosis occurring early post transplant are more likely to resolve than late occurring stenosis. Prospective controlled studies are needed to resolve the issue. [ABSTRACT FROM AUTHOR]