VS15PTHERAPEUTIC EMBOLISATION IN THE TREATMENT OF RECURRENT HAEMARTHROSIS FOLLOWING KNEE ARTHROPLASTY

Recurrent spontaneous haemarthrosis after knee arthroplasty occurs in less than 1% of cases, commonly thought to be result of impingement of hypertrophic vascular synovium or fat pads, exacerbated by anticoagulation or antiplatelet agents. Traditional managements include conservative management with rest and ice initially, followed by open or arthroscopic washout and synovectomy if bleeding recurs or fail to settle. We present 3 cases of recurrent haemarthrosis following knee arthroplasties which were successfully treated with angiography and coil embolisation. Injuries to one of the genicular arteries were identified as the cause in all three cases with one manifesting in formation of a traumatic arteriovenous malformation. All cases were associated with resolution of symptoms with no recurrence (follow‐up period 6 months – 5 years, median of 2 years). We discuss the possibility that direct injury to genicular arteries and the development of subsequent complications including arteriovenous malformation and false aneurysm as more likely aetiology of recurrent bleeding.     

BS15PFACILITATING NATIONAL CONSISTENCY IN BREAST CANCER DATA COLLECTION

In Australia there is currently no consistent approach to collecting breast cancer specific data. The National Health Data Dictionary (NHDD) recommends a core set of generic data items for clinical cancer registration. However this list does not include the more detailed items required by specific tumour streams. The NBCC has developed a supplementary set of Breast Specific Data Items and definitions to serve as a guide for specialist breast cancer data collection in Australia. A multidisciplinary Working Group comprising clinical and consumer representation, including three breast surgeons, identified 16 breast specific data items for collection. The items are designed to align with items collected through the RACS National Breast Cancer Audit and leading cancer centres. A range of items from patient data (menopausal status), diagnostic data (HER2 status, sentinel lymph node), treatment (surgical margin clearance and involvement), and breast reconstruction are included. The data items are recommended as best practice for breast cancer specific data collection and aim to facilitate national consistency in defining, recording, and monitoring information about patients with breast cancer. This national approach will contribute to improved patient outcomes by informing planning, quality improvement and evaluation strategies for cancer services. The items are currently being piloted in two sites in NSW and will be available nationally in late 2007.     

GS14PROUTINE USE OF MEDICAL EMERGENCY TEAMS IN MANAGING SURGICAL EMERGENCIES

Introduction Trauma teams and cardiac arrest teams provide an urgent and expert multi‐disciplinary response to time critical emergencies. The present study documents the contribution of a medical emergency team (MET) to managing non‐trauma surgical emergencies. Materials and Methods Data was prospectively collected over a two year period concerning the contribution of medical emergency teams to the resuscitation of all patients with non‐trauma surgical emergencies and altered vital signs in hospital wards. Results Over the study period, the details of 19 patients with surgical emergencies were recorded. 63% of emergencies occurred outside of normal working hours. In 53% of cases, the surgical registrar was off‐site or physically unavailable to attend the emergency immediately. In 11% of cases, the medical emergency team was activated prior to the arrival of the surgical registrar. In 26% of cases, the patient was left unattended whilst awaiting arrival of the surgical registrar. The medical emergency team provided resuscitation procedures and arranged urgent investigations in all patients, physically transported the patient to the operating theatre in 16% of patients and prepared for general anaesthetic in the operating theatre in 11% of cases. The surgical registrar complemented the medical emergency team response by liaising with consultant surgeons, anaesthetists and operating theatre staff in all cases. All patients received definitive treatment within 30 minutes of MET response. Conclusion Routine use of medical emergency teams in the initial resuscitation of patients with surgical emergencies expedites definitive management.     

HP31PUSE OF BIB INTRA‐GASTRIC BALLOON IN ASIAN PATIENTS

The BIB intra gastric balloon is a popular form of non‐surgical intervention in the management of morbid obesity. This is either used in isolation or as part of a staged bariatric procedure. Large series of BIB intervention has been reported in the literature. Report on use in Asian patients is uncommon. Alexandra Hospital in Singapore has the largest single institution experience in Bariatric intervention. Gastric banding is the most commonly carried out procedure in Singapore. We report a small series of BIB intervention in Singapore patients. Results including efficacy of weight and co‐morbidity reduction, short‐term morbidities, potential for weight regain after removal of the balloon, is reported.     

成纤维细胞生长因子促进小鼠皮肤伤口愈合的研究

为了探索成纤维细胞生长因子（ｆｉｂｒｏｂｌａｓｔｇｒｏｗｔｈｆａｃｔｏｒ，ＦＧＦ）对创伤愈合的作用设计了本实验。于小鼠背部皮肤制成无菌手术切割伤口。实验组用ＦＧＦ溶液（含ＦＧＦ３００μｇ／ｍｌ，肝素１００μｇ／ｍｌ）０．５ｍｌ，对照组用生理盐水０．５ｍｌ，分别滴入伤口处，然后用无菌纱布包扎，每天换药一次。术后１，３，５，７和１０天观察伤口愈合情况。结果显示：实验组毛细血管和成纤维细胞增生较对照组明显，并提前２～３天达最高峰。表明ＦＧＦ能强有力地促进肉芽组织增生和伤口愈合。     

小鼠胫骨中段1/3不同缺损直径单层骨皮质缺损模型比较研究

目的比较研究不同缺损直径对小鼠胫骨中段1/3单层骨皮质缺损模型愈合的影响,为组织工程材料研究、骨缺损修复及其分子机制研究和骨缺损基因治疗研究等提供动物模型。方法取8周龄雄性C57BL/6J小鼠10只,体重(20±2)g,随机分为A、B两组,每组5只。利用牙科磨钻分别制备直径为0.8 mm(A组)和1.0 mm(B组)小鼠胫骨中段1/3单层骨皮质缺损模型。于造模后7、21、28 d摄钼靶X线片观察缺损修复情况;28 d对骨缺损修复行Micro CT扫描及骨组织三维成像;28 d取材行HE染色观察。结果 B组5只小鼠造模7 d内均发生二次骨折,A组无骨折发生。X线片、Micro CT和HE染色均显示A组胫骨单层骨皮质缺损可在28 d达骨性愈合。Micro CT定量分析骨小梁示,A组骨小梁数目、骨小梁密度、骨体积显著高于B组,骨质密度显著低于B组,差异均有统计学意义(P<0.05);两组骨小梁分离度、骨小梁厚度差异无统计学意义(P>0.05)。结论小鼠胫骨中段1/3单层直径0.8 mm骨皮质缺损模型是研究胫骨缺损无外固定缺损修复机制和骨替代植入材料的理想动物模型。     

人Ⅰ型前胶原基因反义寡核苷酸对人增生性瘢痕裸鼠移植模型胶原合成的作用

目的人Ⅰ型前胶原基因(ColⅠA1)反义寡核苷酸(antisense oligodeoxyneucleotide,ASODN)对体外培养的人增生性瘢痕成纤维细胞有抑制胶原合成作用,拟进一步探讨ColⅠA1 ASODN对裸鼠移植模型体内的人增生性瘢痕的胶原合成作用。方法 SPF级BALB/c-nunu品系6～8周龄雌性裸鼠60只,体重约20 g;取行瘢痕切除手术患者自愿捐赠的瘢痕组织块去表皮后,移植至裸鼠背部肩胛内侧皮下,每只裸鼠移植1块,制备人增生性瘢痕裸鼠移植模型。将58只成功制备模型的裸鼠根据处理方法不同,随机分成3组,于瘢痕移植2周根据分组行经皮穿刺瘢痕内注射。A组(n=20):5μL浓度为3 mmol/L ColⅠA1 ASODN、3μL脂质体、92μL Opti-MEMⅠ减血清培养基;B组(n=20):3μL脂质体、97μL Opti-MEMⅠ减血清培养基;C组(n=18):100μL Opti-MEMⅠ减血清培养基。实验最初2周每天注射1次,之后隔天1次,至实验取材。注射后2、4、6周,对存活裸鼠进行瘢痕硬度测量后,处死裸鼠取瘢痕组织行胶原染色组织学观察以及透射电镜观察;提取细胞总RNA后行RT-...     

小鼠脊髓损伤标准化重物打击模型的制备及评价

目的以小鼠作为实验动物，采用改良垂直打击脊髓（weight dropping，WD）建立脊髓损伤（spinal cord iniury，SCI）动物模型，为进一步研究SCI机制奠定基础。方法将健康雌性昆明种小鼠180只随机分为4组，每组45只，采用改良WD法应用Impactor model-Ⅱ脊髓致伤仪分别以2．0&#215;2．5g&#183;cm（A组）、2．5&#215;3．0g&#183;cm（B组）、3．0&#215;5．0g&#183;cm（C组）致伤力致伤脊髓；对照组（D组）仅打开椎板，暴露脊髓，不造成SCI。于打击后即刻，6、12h，1、3d，1、2、4、8周对各组小鼠行运动诱发电位（motor evoked potentials，MEP）检测，并行后肢运动功能（Basso mousescale，BMS）评分，HE染色和甲苯胺蓝染色组织学观察。结果神经电生理检查示B组于伤后6h，C组于伤后12h出现N1潜伏期延长，随着时间延长，A、B、C3组潜伏期开始缩短，A组4周趋于正常为（2．40&#177;0．12）ms，与D组比较差异无统计学意义（P〉0．05）；B组8周逐渐趋于正常为（2．96&#177;0．15）ms，与D组比较差异无统计学意义（P〉0．05），而C组8周仍维持在较高水平（3．76&#177;0．13）ms，与D组比较差异有统计学意义（P〈0．05）。SCI伤后即刻小鼠均呈现双后肢瘫痪，BMS主评分为0分；伤后前3dBMS主评分接近0分；随后各组BMS评分逐渐上升，A组伤后1周BMS主评分（5．45&#177;0．12）分，B组伤后2周BMS主评分为（5．45&#177;0．15）分，与D组比较差异均有统计学意义（P〈0．05）；伤后8周A组主评分（8．004&#177;0．13）分，B组达（7．50&#177;0.31）分；1周后各实验组组间比较差异均有统计学意义（P〈0．05），其中C组低于其余各组（P〈0．01）。伤后2周A组BMS副评分为（10．12&#177;0．76）分，伤后8周B组BMS副评分为（9．85&#177;0．55）分，与同时间点D组比较差异均无统计学意义（P〉0．05）。组织学检查可见C组伤后12h，损伤节段灰质内大片出血灶，炎性细胞浸润，神经元细胞肿胀明显，并出现中央性尼氏小体溶解；随时间推移，神经元细胞数量减少，胶质细胞增生，尼氏小体消失；伤后2周，可见大量胶质细胞增生及空洞形成。B组神经元细胞减少程度及空洞形成均轻于C组，A组最轻，D组除早期可见轻度细胞水肿外，整个观察期内细胞数量无明显改变。结论该模型准确地反映了小鼠脊髓不同程度损伤后的病理生理特点及变化规律，重复性好；可采用重物打击法制作标准小鼠SCI动物模型。     

CR19PTHE VALUE OF BEDSIDE COLONOSCOPY FOR THE CRITICALLY ILL PATIENT IN INTENSIVE CARE UNIT

Purpose Bedside colonoscopy for the critically ill patient in Intensive Care Units (ICU) confronts the endoscopist with a new set of challenges and aims. This study examines the value and benefits that colonoscopy offers to critically ill patients with acute lower gastrointestinal disease. Methodology ICU patients who received bedside colonoscopy were identified from the colonoscopy database and the indications, co morbidities, depth of intubation, progression to surgery and death were recorded. Results 39 patients underwent one or more bedside ICU colonoscopies to investigate ischemic colitis (11, confirmed in 8, 3 operated), colonic distension (10, all decompressed, 2 operated), lower gastrointestinal hemorrhage (13, cause found in 3, 2 operated), and diarrhea (4 patients). 14 patients died. Overall, 18 patients were diagnosed with ischemic colitis; 7 were operated and 6 died. Colonoscopy reached the cecum in 16 patients, the hepatic flexure in 25 and the splenic flexure in 36. Prep was poor in 15 patients and stool prevented completion in 13. In 30% of patients colonoscopy was not pursued to the cecum because decompression was achieved without it, or because ischemic colitis was already diagnosed Colonoscopic techniques specific to ICU included prevention of a loop outside the patient and “slide‐through” with copious irrigation. Conclusion Bedside ICU colonoscopies are able to make an accurate diagnosis. Reaching the cecum is often not the aim of the study, nor is the diagnosis of small adenomas. In many cases a serious colorectal disease can be diagnosed or excluded, helping in the management of these severely ill patients.     

GS19PVERSAJET: A NOVEL APPROACH TO DEBRIDEMENT

The addition of hydrosurgery into our surgical armamentarium will aim to revolutionize surgical wound debridement. Hydrosurgery (Versajet ¹ ) utilizes a high pressure fine saline jet delivered via a compact hand‐piece to debride, irrigate and remove debri simultaneously. The hydrosurgery system is minimally invasive enabling debridement at the bedside, with minimal haemorrhage and analgesic requirements ² . Its applications range from debridement of traumatic and non‐traumatic wounds (acute and chronic), wound lavage, debridement of variable thickness burns, wound bed preparation prior to skin grafting, and flap recontouring. Complex infected wounds (necrotising fasciitis) may also be debrided with potential maximal preservation of adjacent neurovasculature and viable tissues. We present five cases involving the use of the Versajet for the debridement of three diabetic foot wounds, one venous ulcer, and one traumatic chest wound. All hydro‐debridements were performed at the bedside with an average procedure time of 23 minutes (15–40 minutes), an average analgesic requirement of 10 mg morphine (5–15 mg), and with minimal encountered blood losses (including two patients on Coumarin). Only a single ward debridement procedure was required to achieve a healthy wound bed in all five patients. The Versajet enables debridement and wound bed preparation that is efficient, minimally invasive, and cost effective with reductions in hospital stay.     

GS27PTECHNIQUES FOR CLOSURE OF MIDLINE ABDOMINAL INCISIONS

Background A recent meta‐analysis of randomised controlled trials of abdominal fascial closures concluded that in order to reduce incisional hernia rates without increasing wound pain, or the rate of dehiscence slowly absorbable continuous sutures appear to achieve the best results in abdominal fascial closures. We surveyed the techniques for abdominal fascial closure among general surgeons in Canberra, Australia. Methodology 49 out of 80 surgeons responded to the survey by form. The information collected included the seniority of the surgeon, the frequency of laparotomy closure, surgical technique and suture material utilised in abdominal fascial closure. Results 34 (69%) of the surgeons surveyed preferred a non‐absorbable monofilament suture material for abdominal fascial closure with nylon being the most popular. Most (38, 78%) also preferred a non‐absorbable monofilament suture in emergency surgery. 12 (24%) surgeons preferred to use slowly absorbable suture. The majority of surgeons (37, 76%) preferred continuous suture technique, whilst only 2 (4%) used continuous followed by interrupted suture closures. Only 5 (10%) complied with the dual recommendation of continuous suture technique and slowly absorbable suture. Conclusion The majority of surgeons preferred non‐absorbable monofilament suture rather than slowly absorbable suture. Only 1 in 10 surgeons complied with both components of evidence base, which supports the use of slowly absorbable suture material and a continuous technique in abdominal fascial closure. A definitive RCT would confirm this observation.     

PR42PRISK FACTORS AND SAFETY OF IMMEDIATE BREAST RECONSTRUCTION

Welding accidents have resulted in over 50 admissions to the Royal Adelaide Hospital in the last 5 years. Our attention was drawn to the significance of workplace welding accidents when a patient died from 80% burns sustained while welding an empty 44 gallon drum in 2006. Our study performed in conjunction with Workcover and Safework SA revealed that welding empty drums has caused many similar accidents resulting in significant morbidity and mortality throughout Australia each year. To date there is only one report in the literature1 referring to this issue. Welding accidents result in significant time lost to work and financial cost to society. We describe our audit of burns sustained while welding and pay particular attention to oil, petrol and diesel drum explosions. Given their potentially avoidable nature, greater public and workplace awareness must be raised to reduce the tragic consequences of these accidents.     

SO10PA RETROSPECTIVE ANALYSIS OF WOUND INFECTION AFTER PERCUTANEOUS ENDOSCOPIC GASTROSTOMY (PEG) IN CANCER PATIENTS

Purpose To determine infectious complications following PEG insertion with attention to the effect of chemotherapy, radiotherapy and timing of PEG insertion. Methodology A review of medical records of patients who underwent PEG insertion at a single institution between 1st July 2003 and 30th June 2005 was performed. PEG infection rate, antibiotic use, and concurrent chemotherapy and/or radiotherapy were recorded. Overall infection rate was calculated and a Quality Control Chart determined no evidence of an infectious outbreak. Results 96 PEG procedures were performed. 92.8% of patients had head and neck cancers, 90.6% had squamous cell carcinoma, 64.6% had distant disease. 71 of 96 patients were male, mean age 61.2 yrs, mean BMI 22.1 kg/m2. Median length of stay was 8 days for infected patients and 5 days for non‐infected patients; median follow‐up 21 days and 19 days respectively. 56 patients had prior chemo‐radiotherapy, 17 radiotherapy alone, 4 chemotherapy alone and 19 had no prior treatment. 14.6% patients had an infection. 21.4% of infected patients did not receive prophylactic antibiotics. Type of cancer, stage of cancer, and co‐morbidities were not predictive of infection. Chemotherapy and/or radiotherapy treatment before, during or after PEG insertion was not statistically significant for PEG infection. Conclusion An infection rate of 14.6% was found, which falls within the range outlined by other authors. Our study investigated a patient group with tumours, the majority of whom had chemo‐radiotherapy around the time of PEG insertion. There was no statistical difference in infection rate due to timing of PEG insertion and no difference with the use of chemo‐radiotherapy.     

CHROMOSOMAL AND TERATOGENIC EFFECTS OF OXYGEN IN THE MOUSE

The effect of oxygen on chromosomes in bone marrow cells andon the early stages of gestation in the mouse were studied.Three groups of male mice were exposed to hyperbaric oxygenat 2, 3 and 4 atm abs. for 1 h, and four other groups breathedpure oxygen at 1 atm abs. for 6, 12, 24 and 48h respectively.Chromosomes were studied after 24 h. In the pure oxygen groups,no significant increase in chromosome aberration was noted,but in the hyperbaric oxygen groups, significant increases inabnormalities (breakage and gap) were noted at 3 and 4 atm abs.(8.0 and 6.7% respectively, P <0.05). In another study, fourgroups of pregnant mice were exposed once to hyperbaric oxygenat either 2 atm abs. for 1 h on the 7th or 8th day of gestation,or 2.5 atm abs. for 2 h on the 5th or 8th day. Six other groupswere exposed to 2, 3 and 3.5 atm abs. with either oxygen orair for 1 h daily during first 8 days of gestation. Malformations(umbilical hernia and abnormalities of the coccyx) in the newbornwere noted in the groups exposed to hyperbaric oxygen at 2.5atmabs. for 2h on the 5th and 8th days of gestation (1/26, 7/42),and all the groups exposed daily to hyperbaric oxygen (1/58,3/33, 2/24). These findings would seem to indicate a geneticeffect of increased oxygen tension in vivo.     

GS23PPAEDIATRIC SURGERY PERFORMED BY GENERAL SURGEONS IN A PROVINCIAL NEW ZEALAND (NZ) HOSPITAL

Purpose To perform an audit of paediatric surgical patients in a provincial general surgical unit. Methodology Data was prospectively recorded using a standardized proforma on all children aged up to 15 yrs, seen between 11th December 2005 and 11th December 2006. Results There were 209 admissions (194 children), median age 8 yrs (6 wks–15 yrs) with 153 (73%) acutes. 37 children (18%) were under 2 yrs. Male : female ratio was 3 : 2. Procedures (n = 119) were appendicectomy (35), inguinal herniotomy (30), skin procedures (29), endoscopy (10), testicular (10) and others (5). The commonest acute and elective operations were appendicectomy and inguinal herniotomy respectively. 51% of operations were acute. There were 10 tertiary hospital transfers (5%) for burns (4), pyloric stenosis (3), intussusseption (1), neonatal inguinal hernia (1) and pyoderma gangrenosum (1). Median age of transfers was 11 months (6 wks–14 yrs). Complications were wound infection (1), post‐operative ileus (2) and infarcted ovary (1). Conclusion There are increasing moves towards centralization in paediatric surgery. 1 With only 4 paediatric tertiary centres in NZ, many general surgeons routinely perform paediatric surgery. A large number of children presented to our surgical department. Around half of these children required surgery and half of operations were acute. There is still a significant need for general paediatric surgery in the provinces and hence close collaboration with specialist paediatric surgeons.     

LATE FOLLOW UP OF AUTOAUGMENTATION OMENTOCYSTOPLASTY IN A SHEEP MODEL

Four male sheep were studied 12 months after an autoaugmentation omentocystoplasty (AAOC). The omentuni was lined with urothelium, but continued inflammation and/or fibrosis were seen within the subepithelial tissues associated with a failure to achieve enlargement of the bladder when compared with a control group of six animals. The median compliance value was 59 mL/cm H ₂O for the AAOC animals and 9.8 mL/cm H₂O for the control group, indicating that no improvement in bladder dynamic function had been achieved with the AAOC in sheep, and no significant improvement had occurred with time when the results were compared with those seen 6 months earlier.     

EFFECTS OF TOTAL HEPATECTOMY: STUDIES IN A PORCINE MODEL

The effects of total hepatectomy in a porcine model were studied. A portacaval shunt was constructed prior to hepatectomy, and the excised segment of inferior vena cava was replaced with a Dacron graft as soon as the liver had been removed. While the vena cava was clamped, venous return from the lower body to the heart was maintained using an extracorporeal veno-venous bypass system. The results of the study revealed that surprisingly few haemodynamic, biochemical or coagulation disturbances occur within the first 5 h following total hepatectomy in the pig, an animal with remarkably close anatomical and physiological similarities to man. In the anhepatic period which follows total hepatectomy during clinical liver transplantation, the situation is more complex, because pre-existing liver disease and portal hypertension, as well as major blood loss, often provide other reasons for metabolic and haemodynamic instability and coagulation disorders. The possible relevance of the findings in this large animal model to events that occur following total hepatectomy in the clinical situation is discussed.