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The article reports on the study about optimal management of asymptomatic patients with gallstones. According to the study, the progression rate for asymptomatic patients becoming symptomatic is 10-25%. The study reveals that in most patients with asymptomatic gallstone, routine cholecystectomy cannot be justified and expectant treatment is the most suitable option. The study shows that the risk of death from cholecystectomy is greater than the risk of developing gall bladder cancer.

The single vehicle rollover accident is a highly complex crash mode and there is growing concerns about its incidents and consequences in central Australia. The aim of this paper is to assess: 1 The incidence and injury patterns of rollover accidents 2 Pre rollover characteristics on rollover propensity 3 The injury severity and outcome of rollover accidents The absence of speed limit, unfenced roads, vast distances traveled, unsealed roads and high use of alcohol makes the spectrum of MVA’ s in NT unique. In this two year period of study from Jan 2004 – Dec 2005, there were 470 motor vehicle accidents of which 126 were single vehicle rollover accidents. 132 patients were admitted; 73 NT residents of which 45 were of aboriginal origin and 14 were international tourists. There were 37 deaths in Central Australian roads and 20 were due to single vehicle rollover accidents. None of the deaths occurred at the Alice Springs hospital . Most rollover accidents occur at a speed above 100 km/h. 24 patients had an ISS > 15 and 35% of all injuries were to head, neck and shoulder. Rollovers occurred when the vehicle left the road way and encountered a tripping mechanism such as soft dirt or loose gravel. Those who were belted fared better than those unbelted occupants. Completely ejected occupants were all unbelted. Mean time to hospital from time of accident was 8Hrs. Primary prevention strategies need to involve remote communities, tourists traveling in central Australia and address alcohol and restraint use. [ABSTRACT FROM AUTHOR]

The Nuss procedure is a new minimally invasive repair for pectus excavatum that was first published in 1998. Modifications in technique are constantly evolving to minimize complications, especially bar displacement, which are higher in adolescents and adults. The present study reviews our early experience with this procedure in a much older group of children than previously reported and suggests an alternative method of avoiding bar displacement.Retrospective chart review was carried out on 78 consecutive patients who underwent the Nuss procedure between December 1999 and January 2004. All patients underwent a uniform technique using bilateral lateral stabilisers and thoracoscopy was not used. Operative details, subjective cosmetic results and complication rates were assessed.The mean age was 15.4 ± 3.2 years. Single bars were used in 95%, double bars in 5%. The defect was asymmetrical in 26%. The defect was mild in 7%, moderate in 59% and severe in 34%. The median length of stay was 6.0 days (range 4–11). Total operating time was 58 min (range 35–95). Patient controlled analgesia (morphine) for pain relief was used for 105 h (range 61–169) or 4.4 days; the epidural infusion was stopped 1 day earlier. Cosmetic results were excellent in 80.3%. There was residual asymmetry in 75% of the asymmetrical defects although all were improved. Complications included eight (10%) reoperations for bar displacement. This was related to the learning curve as seven of these occurred in the first 2 years of the series. Removal of the bar has been accomplished in 31 (40%) patients. This was elective in all but four patients (three early removals for pain and one for infection).The Nuss procedure gives good results even in teenagers. Modification of technique and increased experience has reduced complications. The use of bilateral lateral stabilisers without additional wire fixation is an alternative method to avoid bar displacement. [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]

Oral iron therapy is often used after orthopaedic surgery to improve haemoglobin levels. The aim of the present trial was to determine if administration of oral iron after orthopaedic surgery results in a better improvement of haemoglobin levels than a control treatment. This was a double blind randomized controlled trial at a tertiary referral orthopaedic centre. The participants were patients undergoing elective hip or knee replacement surgery with normal iron and folic acid stores and no history of iron deficiency, and the primary outcome was the haemoglobin level 10 weeks after surgery. At 10 weeks the mean ± SD haemoglobin in the iron group was 132.8 ± 13.4 g/L and in the control group it was 128.0 ± 10.6 g/L, a difference of 4.8 g/L with a 95% confidence interval for the difference of−1.2 to 10.7 g/l,P = 0.12. Iron taken after elective hip or knee replacement surgery does not result in higher haemoglobin 10 weeks after surgery, or a faster rate of increase in haemoglobin than a control treatment. [ABSTRACT FROM AUTHOR]

The author discusses the importance of learning urgent parathyroidectomy in patients with minimally invasive parathyroidectomy (MIP) and asymptomatic hyperparathyroidism for medical teams. It mentions other cases which requires the said surgery including pregnant patients, patients with brown tumours, and calciphylaxis patients. The author suggests an endocrine surgery training for surgeons.

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]

Purpose To review the experience with laparoscopic splenectomy, to determine it’s efficacy for treating immune thrombocytopaenic purpura (ITP) and to highlight key technical issues with the operation. Methodology All splenectomies performed between 1992 and 2005 were identified from the Otago Surgical Audit and the clinical notes reviewed, including the laboratory records for follow-up data related to the haematologic cases. Results There were 289 splenectomies performed over the 13 year period. The indications were trauma (111, 38%), haematologic disease (93, 32%), incidental (40, 14%) splenic malignancy (39, 13%), and other (8, 3%). Of the 68 patients with ITP, 49 (72%) had a lateral laparoscopic splenectomy (LLS) with no conversions, a 5% complication rate and one mortality. Based on platelet counts and the requirement for maintenance steroids there was a complete response in 44 (68%) patients at >6 months, a partial response in 16 (24%) and no response in 5 (8%) patients. A short video presentation will highlight the key steps for the safe and efficient performance of the LLS, including patient and port positioning, the use of ultrasonic dissection, splenic pedicle stapling, and morcellation. The indications for hand-port assisted laparoscopic and open splenectomy will be discussed. Conclusions The LLS is the preferred approach to splenectomy for all but massive splenomegaly and can be performed safely with careful attention to key technical issues. [ABSTRACT FROM AUTHOR]

Purpose Patients with end stage renal failure on continuous ambulatory peritoneal dialysis (CAPD) represent a potentially infected environment in which to use mesh for the repair of abdominal hernia. We present a review of our experience with these patients. Methodology Retrospective review of all mesh repairs of abdominal hernia in CAPD patients performed by the senior author from 1997–2006. Results 46 patients had 54 hernias repaired (25 umbilical, 18 inguinal, 9 incisional and 2 epigastric) using polypropylene mesh. 13 patients had simultaneous Tenckhoff catheter insertion. Median age was 63 years (range 22–85) and 22 were diabetic. CAPD was commenced or recommenced a median of 2 weeks after the repair (range 0 days–6 weeks). 6 short-term complications were recorded. 2 patients were treated for culture negative CAPD peritonitis within the first week after repair. 2 patients had localised wound bleeding and 1 patient was admitted with a wound infection. All were treated conservatively and no patient required mesh removal. 1 patient developed CAPD peritonitis at one month post-operation and required Tenckhoff removal, subsequent laparotomy and conversion to haemodialysis. At a median follow-up of 30 months (range 3–87) 29 patients were still alive and 2 patients were lost to follow-up. There were 4 documented recurrences and 1 patient had been converted to haemodialysis because of hernia recurrence. Conclusions Mesh can be safely used to repair most hernias in CAPD patients. The results are comparable to those in healthy patients and mesh removal due to infection is extremely rare. [ABSTRACT FROM AUTHOR]

Background Argon plasma coagulation (APC) has been used to ablate Barrett’s oesophagus, although the long-term efficacy is unknown. This study reports the 5 year results of APC ablation vs surveillance of Barrett’s in post-fundoplication patients. Methods 43 post-fundoplication patients with Barrett’s oesophagus were randomised to either APC ablation of Barrett’s or surveillance. 40 have been followed up with endoscopic surveillance for a mean of 68 months to assess treatment efficacy, safety and the durability of the neosquamous re-epithelialisation. Results A median of 2.5 (range 1–6) APC treatment sessions was required to reach >95% ablation of Barrett’s. Both groups had a significant (p < 0.0001) reduction in Barrett’s length over the duration of follow-up, with APC patients having significantly greater length reduction of Barrett’s at last endoscopy compared to the surveillance group (p = 0.0277). At 68 months, 14 of 20 APC patients (70%) continued to have >95% ablation of their Barrett’s, with 8 of 14 (57%) having no macroscopic or histologic evidence of Barrett’s. 4 of 20 surveillance patients (20%) had complete reversal of their Barrett’s, with 3 of 4 (75%) having no macroscopic or histologic evidence for Barrett’s. 2 patients in the APC group developed strictures requiring dilation. 2 patients in the surveillance group developed HGD during follow-up, while none did in the APC group. Conclusions 40% of post-fundoplication patients with APC ablation of Barrett’s retain this reversal beyond 5 years. 20% of Barrett’s patients post-fundoplication regress to normal squamous mucosa. Post-fundoplication Barrett’s surveillance patients continue to develop HGD, this has not been seen in the APC group. [ABSTRACT FROM AUTHOR]

Purpose It is thought that a substantial number of patients who undergo anti-reflux surgery use anti-reflux medication post operatively, despite no objective evidence of reflux. This study aims to determine the prevalence and underlying reasons for anti-reflux medication usage in patients after anti-reflux surgery. Methodology A questionnaire (13 questions) on the usage of anti-reflux medication was sent to 1016 patients from a prospective database of anti-reflux surgery patients. Results 852 patients (84%), (437 males & 415 females with a mean age 58 yrs) returned the questionnaire. Mean follow up was 5.9 yrs after surgery. A single or combination of medications was being taken by 319 patients (37%): 82% proton pump inhibitors, 9% H2-blockers and 34% antacids. 54 patients (18%) had never stopped taking medication, whereas 261 patients (82%) re-started medication at a mean of 2.4 yrs after surgery. Persistent or return of the same or different symptoms was the reason for taking medication by the vast majority (85%), whereas 15% were asymptomatic or had other reasons for medication use. A response of symptoms to the medication occurred for 30% of the patients, whereas 64% noticed some improvement. Postoperative 24-hour pH studies (while off medication) were abnormal in 17/62 patients (27%) on medication and in 5/73 patients (6%) not taking medication. Conclusions Anti-reflux medication is frequently taken by patients for symptoms after surgery, despite normal pH profiles in the majority. Strategies need to be employed to lower the inappropriate use of medications after surgery and to further evaluate the mechanisms underlying postoperative symptoms, which are non-responsive to anti-reflux medication. [ABSTRACT FROM AUTHOR]

Purpose In the presence of static cadaveric donation rates, renal transplantation relies increasingly on living donors. ABO blood group incompatibility has traditionally prevented many potential living donors from donating because risk of hyperacute rejection/antibody-mediated rejection (AbMR) with graft loss, with or without need for concurrent splenectomy and intense immunosuppression. Pre- and post-transplant antibody removal and monitoring anti-blood group antibody levels have allowed this to become a clinical possibility. We report results on the first ten ABO incompatible kidney transplants performed in Australia at The Royal Melbourne and Melbourne Private Hospitals, without splenectomy. Method All patients underwent transplantation after two weeks of Mycophenolate Mofetil, and antibody removal (plasma exchanges or Glycosorb columns). Three patients received Rituximab pre-transplant. Standard immunosuppression was commenced at transplantation. All patients, except one low-titre A2/O patient, received post transplant antibody removal. None underwent splenectomy. Results Thirty day mortality was zero, and at median six-month follow-up, there have been no episodes of rejection or opportunistic infections. All transplants are currently functioning. Two patients developed urosepsis, one post-transplant diabetes. Two patients required reoperation and ureteric reimplantation for ureteric leakage. Conclusion ABO incompatible transplantation can be performed without excessive immunosuppression and with low morbidity. Preservation of the spleen reduces operative risk, post-operative complications and the added vulnerability to infection. [ABSTRACT FROM AUTHOR]

Aim Biliary complications are a common cause of morbidity following liver transplantation (LT). The risk factors for biliary anastomotic stricture (BAS) are poorly understood. We analysed the risk factors for BAS. Methods A respective review of a prospective database of patients who underwent LT between 1988 and 2006 in the Liver Transplant Unit Victoria was undertaken. Forty-five of 502 (9%) LT carried out during this period were complicated by BAS. These cases were compared with 45 controls who underwent LT immediately preceding the cases. Donor, donor operation, recipient, recipient operation and donor/recipient compatibility factors were assessed. Non-parametric data analysis was used. Results Cases were less likely to have had a biliary stent placed at LT than controls (74% vs 91%, respectively, P = 0.037). The BAS rate in patients who had a stent at LT was 7.3% compared with 25.5% for those who did not (P < 0.001). There was no difference in BAS rate with differences in stent type (infant feeding catheter vs T tube) or size. Although there were statistically significant differences between cases and controls for donor potassium (3.9+/−0.8 vs 4.0+/−0.4 mmol/L, respectively, P = 0.032) and HCO3 (25+/−3 vs 23+/−3 mmol/L, respectively, P = 0.021), the clinical significance of these differences is questionable. Conclusions The rate of BAS following LT is higher in patients who did not have a biliary stent placed at the time of LT, though a causative link has not been established. [ABSTRACT FROM AUTHOR]

Introduction Phase Angle (PA), determined using bioelectrical impedance, may be altered in chronic liver disease. We aimed to determine whether 1. PA predicts survival in cirrhotic patients and 2. PA improves after nutritional support and transplantation. Methods Data were extracted from a prospective database of 252 cirrhotic patients referred for nutritional assessment and intervention (HCC excluded). Median age was 49 (16–73), 68% male. Aetiology was viral (55%), ALD (15%), cholestatic (11%), and other (19%), with median MELD 11 (6–36). Measurements included PA and total body protein (TBP). Patients were followed for a median 53 (4–93) months. Survival and logistic regression analysis were performed. Results 138 (55%) died or were transplanted during follow-up. Low PA (<4.4%) was associated with worse survival (median 16 vs. 57 months, P = 0.02) independent of the MELD score (HR for MELD 1.18; 95% CI 1.05–1.32, P < 0.0001 and for PA 0.56; 95%CI 0.32–0.98, P = 0.046). In 93 patients followed for 100 days after nutritional intervention, TBP increased by 200g (P = 0.04) and PA increased from 4.8% to 5.2% (P = 0.0006). PA also increased from low to normal levels one year post-OLT (4.9% to 5.7%, P = 0.0001, n = 69). Conclusion Low PA correlates with reduced TBP and a higher risk progression to transplantation or death. PA improves after nutritional support and transplantation. [ABSTRACT FROM AUTHOR]

• Emergent definitive care of orthopaedic injuries in critical patients may not be the best strategy. • Critically injured patients not in the operating room for life-saving procedures should be physiologically stable prior to major surgical procedures. • Patients with closed head injuries must maintain optimal parameters for best recovery. • Damage control orthopaedic surgery (DCO) is the most controversial and least understood concept in modern trauma surgery. • A damage control approach to fracture care in the multiple trauma patient has merit. • Literature (mostly retrospective and single center) is weak and can be interpreted as desired. – Early major fracture care may be beneficial 1. Need to define early 2. Need to define fracture fixation • Surgery is performed to improve the physiology of the patient. • External fixation and delayed definitive fixation for patients in the operating room. • Bedside application of external fixation or traction until the patient is physiologically stable for definitive care in patients not in need of life-saving surgery. • Develop a “Risk Adjusted” orthopaedic surgery strategy for each patient. [ABSTRACT FROM AUTHOR]