PR19THE SUPERFICIAL LYMPHATIC DRAINAGE OF THE HEAD AND NECK – AN ANATOMICAL STUDY AND CLINICAL IMPLICATIONS

• 1 To re‐evaluate the basic anatomy of the lymphatic vessel network in the head and neck region for diagnosis and treatment of lymphogenic cancer metastases.
• 2 To compare the anatomy of the lymphatic system with the venous system.
• 3 To investigate the possibility that extensive lymphatic‐venous connections exist.

Materials and Methods The lymphatic vessels in the scalp, face and neck of 5 (ten halves) fresh human cadavers were identified by using 6% hydrogen peroxide with and without India ink, then injecting the vessels with a lead oxide, milk powder and water mixture. The specimens were photographed, radiographed and analyzed. Results Radiographs and photographs show:

• 1 The lymphatic pathway “patterns” found were different in each specimen, even each side of the same head showed considerable variation.
• 2 The lymphatic pathways of the anterior neck lie in the tissue above the platysma and course horizontally and obliquely. This finding confirm those found using lymphoscintigraphy
• 3 The discovery of lymphatic bypass routes confirms the lymphoscintigraphy findings that lymphatic drainage does not always go directly to the first tier lymph nodes.
• 4 We were able to compare the anatomical relationship of the lymphatic and venous systems and demonstrate that a lymphatic‐venous shunt does exist in the occipital region.

Conclusion This study provides an anatomical picture of the superficial lymphatic system of the head and neck and will aid surgical management in the treatment of trauma, infection, lymphoedema and cancer.     

ES13PHEOCHROMOCYTOMA – AN ANALYSIS OF 123 PATIENTS

Background Pheochromocytomas are diagnosed in <1% of patient evaluated for hypertension. Methodology A retrospective analysis of case records of those patients with histopathologically confirmed pheochromocytoma in our hospital from 1976–2006 [30 YEARS] was conducted. Result A total of 123 patients were diagnosed during this period. The median age at presentation was 31 years (range 9–71) with a male to female sex distribution of 75% and 36%. 80% were hypertensive at the time of diagnosis. Headache(84%), palpitations(64%) and sweating(60%) are the most common presenting complaints.Tachycardia [>100 per minute]were seen in 31%. Hypertensive changes in eyes were seen in 87%. In ECG, QTc prolongation in 26%, left ventricular hypertrophy in 30%. Diabetes mellitus/IGT was seen in 35%. Elevated urinary VMA (24 hrs) was seen in 93% when done on 3 consecutive days. MIBG was positive in 85%. Malignant pheochromocytoma was diagnosed by tumour invasion/metastasis seen 10.44%. Extra adrenal pheochromocytoma 18%, followed by bilateral pheochromocytoma in 11%. Hereditary pheochromocytoma in 13% which include 5 with Von Hippel Lindau and 6 with MEN. A median follow‐up was 12 months (range 1–204) in which persistent hypertension was seen in 16%. Cholelithiasis in 7%. Conclusion In our case series the mean age (31 yrs) of presentation seems to be younger compared to other case series. 16% of our patients were asymptomatic at the time of presentation. Urinary VMA was elevated in 93% of patients when done in 3 consecutive samples. Extra adrenal pheo was common in our patients (18%). MIBG was false negative in 15% of those patients with pheochromocytoma.     

PR10DUAL PLANE BREAST AUGMENTATION FOR TUBEROUS BREAST DEFORMITY

The tuberous breast deformity is an uncommon congenital breast anomaly which affects young women unilaterally or bilaterally. It is associated with usually a constriction in the lower pole of the breast as a result of the constricting fibrous ring with hypoplasia of the breast gland and pseudo‐herniation of breast tissue into an enlarged areola. Several methods have been suggested to correct this deformity. A retrospective analysis has been undertaken of six consecutive patients with tuberous breast deformity using a dual plane breast augmentation via an inferior peri‐areolar approach creating a dual plane pocket and using Marionette sutures to control the lower pectoralis major edge. Surgical release of the constricting lower pole glandular tissue was undertaken with excellent aesthetic results. Either immediate or delayed areolar reduction was carried out if required. Results show excellent expansion of the lower pole with good soft tissue coverage of the implant by the pectoralis major in the supero‐medial aspect of the breast. The dual plane pocket combined with lower pole release assists lower pole expansion in a one stage procedure without requiring two stage tissue expansion. The results have been uniformly acceptable and compare favourably with those presented in the literature where other methods were used. The dual plane breast augmentation technique is a simple and reliable way to treat tuberous breast deformity.     

FURTHER DEVELOPMENT OF AN ALTERNATIVE ALGORITHM FOR A CLASS OF H∞ DESIGN PROBLEMS

This article presents a tutorial exposition of an algorithm suggested by Kwakernaak which is an alternative to the standard state space solution for a class of H_∞ optimization problems. In addition, a set of formulae for the computation required is derived. From these formulae one can simply use an ordinary computer language to write a programme for the design purpose and therefore avoid an expensive expenditure on some software packages. A modification of a weighting function is also suggested. © 1997 John Wiley & Sons, Ltd.     

PR35THE INCIDENCE OF NON‐MELANOMA SKIN CANCER IN NEW ZEALAND

Background It is estimated that skin cancers cost $33 million per annum to the New Zealand healthcare system. Basal cell carcinoma and squamous cell carcinoma are the commonest types of non melanoma skin cancers (NMSCs). Anecdotal evidence indicates that there has been a doubling in the incidence of NMSCs in New Zealand over the last decade. Because of the high incidence mandatory reporting of NMSCs to the National Cancer Registry is not required. This lack of accurate data has led to poor health care policies and strategies including funding and workforce planning. Aims The aims of this study are to (1) present the latest statistics on NMSCs in New Zealand, including the incidence across different regions over the last decade, patient demographics, anatomic distribution of NMSCs, incidence and sites of metastasis, and disease‐specific survival; to (2) the histopathology of NMSCs, including surgical margins, histologic grade, and perineural, lymphatic, and vascular invasion; and (3) the relative role of different faculties treating NMSCs. Method This project has been approved by the multi‐centre ethics committee. A retrospective review was conducted from patients’ histology records from public and private pathology laboratories within defined catchment areas. Criterion for analysis is a confirmed diagnosis of NMSC treated surgically. A Microsoft Access database is created that will facilitate subsequent data retrieval and analysis. Results and Conclusion It is hoped that this up‐to‐date data will form the framework for the development of sound and sustainable healthcare policies of management of NMSCs including management strategies and workforce planning, and research direction on this common disease.     

AN ALTERNATIVE TECHNIQUE OF INSERTING THE DISTAL PURSE-STRING SUTURE FOR THE E.E.A. STAPLING DEVICE IN A LOW ANTERIOR RESECTION

A new technique of inserting the distal purse-string suture for the E.E.A. stapling device in a low anterior resection of the rectum is described. The technique is simple and time saving, and does not require any special instruments.     

071TGF‐ß‐Mediated Paracrine Regulation of Keratinocyte Wound Closure

The importance of stromal‐epithelial interactions in wound healing is well established. These interactions likely involve autocrine and paracrine action of multiple growth factors, including members of the TGF‐ß family. TGF‐ß1, ß2 and ß3 isoforms signal by sequentially binding to the TGF‐ß type II and type I receptors, respectively. We address the role of TGF‐ß signaling in dermal fibroblasts using a conditional fibroblastic TGF‐ß type II receptor knockout mouse model (termed FßKO). We found that the loss of TGF‐ß signaling in the dermal fibroblasts results in accelerated excision‐wound closure compared with similar wounds in wild type mice. The mechanism of the altered rate of re‐epitheliaization in the FßKO mice was examined with regard to keratiocyte motility and proliferation. The migration of keratinocytes through collagen I coated 8 μm pore filters in the presence or absence of fibroblast‐conditioned media was tested. These experiments showed increased keratinocyte migration when incubated with FßKO dermal fibroblast conditioned media compared to media conditioned in wild type fibroblasts. Immuno‐histochemical staining of paraffin embedded intact skin indicated both wild type and FßKO mice had similar low levels of keratinocyte proliferation, based on Ki67 staining. In healing wounds, only the distal wound edges of wild type mice were proliferative. In contrast, the FßKO mice exhibited elevated proliferation across the length of the wound, including the leading edge of epithelial closure. Together our results suggest TGF‐ß signaling by the dermal fibroblasts suppresses re‐epithelialization of excision wounds by regulating keratinocyte motility and proliferation through paracrine mechanisms.
Funding: DOD BC99184 and NIH CA85492.     

AL01PACIFIC ISLANDS PROJECT – PAST PRESENT AND FUTURE

The Pacific Islands Project began in 1995 and in its early years had a focus on providing specialist services that were not available in the 10 island nations visited. In 2002 Nauru was added and PIP Phase III will end its 9 month bridging/extension phase in September 2007. During the last 12 years Fiji School of Medicine has commenced a postgraduate medical training program in surgery similar to that has been in existence in PNG since 1975. There are now a growing number of Pacific‐trained surgeons who can select suitable cases, do some of the surgery, and supervise the postoperative care. Increasingly visiting teams have focused on transferring skills and building local capabilities (capacity building). The RACS, the Project Director and the speciality coordinators have managed the first three phases of the project in Australia. Phase III had on‐going evaluation by an internal RACS committee under the chairmanship of Professor Hamish Ewing. AusAid also externally reviewed the project late in 2006. That review was generally complimentary as to what has been achieved but also points to some new goals for the future. At the time of writing this abstract the future direction of PIP is yet to be decided and designed. This will be done mid 2007. However, it is to be hoped there will be a new program, focused on capacity building, that is managed in the Pacific and employs the skills of Pacific Island Specialists wherever possible. RACS is likely to continue to play an important role in sourcing visiting specialists, organising training positions, arranging courses. We have much expertise to offer but there is no longer any need for us to set the agendas.     

Spatio‐temporal analysis of peste des petits ruminants outbreaks in PR China (2013–2018): Updates based on the newest data

Peste des petits ruminants (PPR) is a highly contagious disease of small ruminants. The purpose of this study was to investigate the epidemic characteristics of PPR outbreaks in the People's Republic of China (PR China) from 2013 to 2018. A total of 41,876 PPR outbreaks were recorded in small ruminant populations in PR China during that period. Data from February to June 2018 were used to study new developments in the PPR epidemic in PR China. Spatio‐temporal clusters and temporal distribution patterns were studied based on PPR notifications. We also used multiple logistic regression to examine the contribution of anthropogenic, climatic and topographic factors to PPR outbreaks. Distance to the nearest road (OR = 1.007 [95% CI: 1.001–1.014]), price of mutton (OR = 1.904 [95% CI: 1.358–2.668]) and mean monthly temperature in July (OR 1.156 = [95% CI: 1.110–1.204]) showed positive effects on PPR outbreaks. Negative effects were observed for number of large‐scale farms (OR = 0.962 [95% CI: 0.940–0.985]). We also found that observed patterns of seasonality were characterized by peaks in April of 2014. Spatio‐temporal clusters occurred in Yunnan, Jiangsu, Anhui, Heilongjiang province and Chongqing municipality. Hunan province reported PPR occurrences every year from 2014 to June 2018. Yunnan, Jiangsu and Anhui province have 56, 33 and 30 epidemic locations, respectively. PPR infections were first reported as the cause of death for 19 wild bharals in Qinghai province in 2018. All of this suggests that domestic trading of sheep and goats may be closely related to the spread of PPR. Prophylactic immunization in suspected animal populations or areas is recommended for the control of PPR and wild small ruminants should be monitored. Results presented here provide improved knowledge about PPR dynamics in PR China, which could be helpful in designing more effective prevention strategies.     

The clinical advances of fluorine‐2‐D‐deoxyglucose – positron emission tomography/computed tomography in urological cancers

Fluorine‐18 labeled fluorine‐2‐D‐deoxyglucose (FDG) is the most frequently used positron emission tomography (PET) probe but it has certain limitations when used in urological cancers. The introduction of co‐registered PET and computed tomography (PET/CT) represents a major advance in technology and FDG‐PET/CT has now become the new standard. The diagnostic performance of FDG‐PET and PET/CT depends on the metabolic activity of tumor tissue, which is generally low in primary renal cell and prostate cancers and often in their metastatic deposits. In contrast, both seminomatous and nonseminomatous germ cell tumors are characterized by upregulated glucose metabolism with subsequently increased FDG uptake in tumor sites. Generally, the metabolic activity provides accurate information regarding the presence of a viable tumor, except in patients with residual mature teratoma. Although bladder cancer demonstrates sufficiently increased FDG uptake, primary tumors are difficult to identify due to the renal excretion of FDG. The accuracy of FDG‐PET/CT in metabolically active metastases is generally higher compared to conventional CT except for identifying small lung deposits. With disease progression and subsequent de‐differentiation of prostate cancer, castrate resistant disease is more likely to present with lesions that have increased glucose metabolism.     

PR01“A PICTURE SPEAKS A THOUSAND WORDS”– THE USE OF DIGITAL PHOTOGRAPHY AND THE INTERNET IN MONITORING FREE TISSUE TRANSFER

Purpose Post operative monitoring is crucial for the success of microsurgical free tissue transfer. Sophisticated and expensive methods are available for monitoring. We propose a novel technique using digital photography and the internet as a reliable and cost effective method to monitor free tissue transfers. Methods 163 micro‐vascular procedures were monitored using this technique over 8 months. Serial photographs taken to show flap color. Capillary refill time, pin prick‐ bleed time and color and hand held Doppler signal was recorded in the movie mode of a standard 5 mega pixel camera with duration of 15 seconds. Data was sent to the surgeon at regular intervals and or as deemed necessary. Results Analysis of the 67 cases is presented. 5 re‐explorations were done. The early diagnosis of venous congestion was possible using this technique. Timely intervention contributed to the success of the re‐explorations and these flaps could be salvaged. The file size of images was in the range of 1 MB–6 MB. The file size of an entire set of images ranged about 7 MB–9 MB. These were sent across the ADSL internet lines. Conclusion The use of the digital images and the internet allow reconstructive surgeons to have a reliable picture of the state of their free tissue transfers. This permits decrease in observer error and saves valuable time which otherwise needs to be spent to verify situations of doubt and offers an ideal solution to the logistic problem of having to visit the patient in case of doubt.     

ML06CHRONIC PAIN AND GRADUAL PROCESS INJURY – ACC RESPONSIBILITIES

The Accident Compensation Corporation (ACC) administers New Zealand’s accident compensation scheme, which provides personal injury cover for all New Zealand citizens, residents and temporary visitors to New Zealand. In return people do not have the right to sue for personal injury, other than for exemplary damages. Before a claim can be considered for cover under the current Act (IPRC Act 2001), it must first be established that the claimant has sustained an injury, and that this injury falls within the definition of ‘personal injury’. With respect to chronic pain, a person with chronic pain due to a personal injury may obtain cover for that personal injury through the ACC scheme in a variety of ways. A personal injury caused by a work‐related gradual process, disease, or infection (gradual process injury) is one way in which a person with chronic pain may obtain cover under the ACC scheme. Specifically, ACC has accepted cover for chronic pain syndromes in circumstances such as follows:

• 1 The chronic pain syndrome is a plausible consequence of a person’s work tasks or work environment (i.e. it meets the criteria for personal injury caused by a work‐related gradual process, disease, or infection); or
• 2 The chronic pain syndrome is a plausible consequence of a covered personal injury (ie it meets the criteria for personal injury caused by a gradual process, disease, or infection that is consequential on a covered personal injury)