NEUROSURGERY IN PAPUA NEW GUINEA

Background: An audit of neurosurgery in Papua New Guinea (PNG) based on the experience of a visiting neurosurgeon is presented. The objectives of the study were to determine the type and frequency of neurosurgical conditions in PNG, whether major neurosurgery can be performed successfully in PNG, and to develop a strategy for the development of neurosurgical services in PNG. Methods: The audit was carried out over two periods of 2 weeks duration in 1992 and 1993 in Port Moresby and Goroka. Instrumentation and equipment were limited and no additional equipment was used. Myelography and angiography were available in Port Moresby. Results: There were 82 patients in total, 55 (67.1%) were consultations, 23 (28%) had elective surgery, four (4.8%) had emergency surgery and 16 (19.5%) await surgery. Cases were subdivided into nine major groupings: neurotrauma 18 (seven severe); spine 18; congenital 13; hydrancephaly four; scalp, skull and orbit six; vascular three; peripheral nerve three; and neurology five. Seventy-two (87.8%) patients required CT/MRI which were unavailable. Four ventriculograms were performed in lieu of CT/MRI. Fifteen (18.3%) cases could not be treated in PNG. Conclusions: Neurosurgical problems in PNG can often be adequately managed with limited resources. Complex procedures were performed with gratifying results and acceptable morbidity. There is sufficient pathology in a country of four million people to justify training a small number of neurosurgeons by the end of the decade. CT scanning will be a necessary adjunct.     

SURGICAL THYROID DISEASE IN PAPUA NEW GUINEA

A clinical and histopathological analysis was carried out on 376 thyroid specimens removed under various diagnoses from the surgical clinics of Papua New Guinea over a period of 11 years (1980–90). Solitary nodular goitre (solid and cystic) was the most common clinical diagnosis. Nineteen per cent of the solid and 35% of the cystic solitary nodular goitres were found to be malignant. Malignant goitres were confirmed histologically in 73.3% of the clinically diagnosed cases of malignancy. The presence of amyloid goitre (1.9%) posed a significant diagnostic and therapeutic problem due to its clinical features resembling that of malignant goitre. Hemithyroidectomy (lobectomy) was the most common surgical procedure employed for all unilateral thyroid lesions and partial or subtotal thyroidectomy was performed for benign and most malignant lesions.     

TRAUMA ADMISSIONS IN THE SOUTHERN HIGHLANDS OF PAPUA NEW GUINEA

Background: Trauma is a common cause of surgical admission in Papua New Guinea (PNG) but to date there has been no study of the whole trauma burden in provincial hospitals. Methods: A 1-year retrospective study was made of all surgical admissions to the provincial hospital at Mendi. Results: Trauma was the third commonest reason for hospital admission and accounted for 43% of all surgical cases. The common causes of injury were tribal fights (24%). domestic violence (14.3%). assault (16.7%). road accidents (14%) and domestic accidents (25.1%). which comprised falls, penetrating wounds and bites. Males accounted for two-thirds of cases, and 19% were children below the age of 16. Only eight of 454 patients died (1.8%). because most trauma deaths occur before the patient reaches hospital. There were only 37 multiple injuries and only five patients had an injury severity score of greater than 16. The average inpatient stay for trauma admissions was 10.6 days. Conclusions: The cost of trauma in Mendi is difficult to calculate, but is enormous. In addition to 11% of the recurrent hospital expenditure (over US$I.1 million, excluding pharmaceuticals), the community costs include loss of earnings and productivity, as well as permanent disability. The social disruption caused by tribal fights results in cessation of the local economy, burning of aid posts, schools and homes and destruction of gardens for subsistence farming. Those who reach hospital alive tend to have single injuries and survive.     

EMST IN PAPUA NEW GUINEA: MORE THAN JUST A COURSE

Background : Trauma in Papua New Guinea (PNG) is a major reason for acute hospital admission. The Early Management of Severe Trauma Course (EMST) of the Royal Australasian College of Surgeons was introduced to PNG in 1993 to help in trauma education. Methods : Four EMST courses have been held in Port Moresby since 1993 with the support of the Department of Surgery of the University of PNG. Results : Sixty-two doctors have attended a course and three PNG doctors have been trained as course instructors. Trauma workshops were held in other provincial hospitals extending the course principles to nurses and health professionals in these areas. Conclusion : The introduction of EMST to PNG has proven to be a worthwhile endeavour and the program is now firmly established in PNG.     

THE REPAIR OF FRONTAL ENCEPHALOCELES IN PAPUA NEW GUINEA

Frontal encephaloceles are common in Papua New Guinea (PNG). Seventeen cases collected over 7 years are reported. Eleven frontal (sincipital) encephaloceles were repaired successfully via an extracranial approach. One of these patients with a frontonasal encephalocele developed a recurrence following the extracranial approach, which was subsequently repaired intracranially. Three patients with small naso-ethmoidal encephaloceles were repaired intracranially via an extradural approach. The other three cases have not yet had surgical correction. Complex craniofacial surgery which corrects hypertelorism as well as the encephalocele is unavailable in the developing world. For the general surgeon in the developing world, the extracranial approach is recommended for the frontonasal encephaloceles, and the intracranial approach for the naso-ethmoidal and naso-orbital encephaloceles. Hydrocephalus and epilepsy have not developed in the patients.     

THE FUTURE OF SURGERY IN PAPUA NEW GUINEA AND THE SOUTH PACIFIC

Surgery in the South Pacific is different in many respects from surgery in Australia and New Zealand. It is primarily the surgery of trauma, infection, advanced malignancy, hollow-tube obstruction and congenital abnormalities. Specific tropical infections such as tuberculosis, typhoid, pigbel and amoebiasis occur regularly but constitute only a small proportion of all cases. The patients tend to be young, rural and poor, and often present late because access to surgical services is limited. The treatment patients receive is also compromised by a lack of resources—the result of underfunding and inefficient administration. Standards for appropriate surgical practice should be determined in-country and based at least on surgical audit and clinical studies. Even though Western diseases are emerging in the tropics, the best management may sometimes be different. Training of national surgeons is a priority if a sustainable surgical service is to be established. Such training is more effectively carried out in the home country, or at least in one with similar pathology and problems, rather than overseas. Project aid should support these schemes and encourage regional co-operation through the Fiji and Papua New Guinea medical schools. There remains an important role for visiting surgical specialists, but they need to ensure that they transfer skills and encourage the professional development of promising local doctors rather than simply focusing on treating patients.     

PRIMARY MALIGNANT MELANOMAS OF THE ORAL CAVITY IN PAPUA NEW GUINEA

The aims of this paper are to review the incidence and pathology of primary oral mucosal melanomas in Papua New Guinea and describe the presentation and management of five cases.     

食管插入吻合法在二次开胸处理胸内食管吻合口瘘中的应用

本文报告5例食管癌手术后胸内吻合口瘘采用二次开胸,拆除原吻合口,以食管插入法重新吻合并附加空肠造瘘的方法进行处理的经验。5例均获治愈。作者等认为,该方法具有迅速净化胸腔,防止吻合口再瘘和打开营养通道及时的优点。作者还比较了运用其它方法进行处理的结果,认为本方法是治疗胸内食管吻合口瘘的一种较好方法。     

CRANIOTOMY AND THORACOTOMY FOR NON-SMALL CELL CARCINOMA OF THE LUNG WITH CEREBRAL METASTASIS

Twenty patients with non-small cell carcinoma of the lung who had cerebral metastasis, were treated by craniotomy and thoracotomy. Eighteen of these patients had a solitary metastasis and all were treated as curable. Ten patients presented with synchronous lung and brain disease. Of the remaining 10, nine initially presented with the lung tumour, which was treated first. There was a zero operative mortality rate and median survival was 12 months with reasonable quality of life for this time.     

ADULT HEAD AND NECK LYMPHOMAS IN PAPUA NEW GUINEA: A RETROSPECTIVE STUDY OF 70 CASES

Background : During a 10-year period (1986–95), 70 adult Papua New Guineans with head and neck lymphomas were seen in the 18 years-and-above age group. Methods : The clinical information was obtained from the medical records section of the Port Moresby General Hospital. Relevant treatment modalities and the follow-up data were acquired from the National Cancer Centre, Angau Memorial Hospital, Lae. Results : Of a total of 227 adult lymphomas recorded in a 10-year period, 70 cases were seen in the head and neck region. Non-Hodgkin’s lymphoma constituted 56 cases, which included seven cases of adult Burkitt’s-like lymphoma. Fourteen cases of Hodgkin’s lymphoma were recorded. Conclusions : In Papua New Guinea, malignant lymphomas primarily affecting the head and neck region were seen in 30.8% of all lymphomas. This constitues 2.8% of all malignancies in this region. These lymphomas appear to be more aggressive at this site. Proper tissue diagnosis and combination chemoradiotherapy are the key factors in its management.     

PROSTATE CANCER MORTALITY IN NEW ZEALAND: THE PAST AND PROJECTIONS FOR THE FUTURE

Background : Ageing male populations and improved diagnosis of early stage disease have contributed to the increasing incidence of prostate cancer observed in many Western countries. The clinical significance of these diagnosed cancers is, however, currently unclear. The aim of this study is to examine trends over time in prostate cancer mortality as an indicative measure of clinically significant disease during a 29-year period (1965–93) which preceded the extensive use of early cancer diagnostic techniques or radical therapy protocols. Methods : Age-specific and age-standardized rates were calculated for each year during the study period, using routinely collected mortality and demographic data. A Poisson regression model was used to describe trends in the age-specific rates over time to predict numbers of prostate cancer deaths and the lifetime risk of death over the next 20 years. Results : Significant annual increases ranging from 1 to 2.6% were found for age-specific prostate cancer mortality rates over the 29-year time period, with the largest increases experienced in the younger age groups at risk. Based on projected population ageing and growth alone, annual numbers of prostate cancer deaths are predicted to increase from 487 in 1993 to 664 by the year 2006 and then to 833 by the year 2016. Continuation of the observed increases in age-specific mortality rates would result in a predicted 797 deaths by the year 2006, while an expected 1115 deaths is calculated for the year 2016. This would correspond with an increase in the lifetime risk of death from prostate cancer from a present 3.7 to 4.5% in 10 years and 6.2% in 20 years. Conclusions : The changing pattern of prostate cancer mortality described in this study is likely to represent a significant increase in the incidence of clinically significant disease. This will have a significant impact on the ageing New Zealand male population, and important implications for the provision of effective treatment and preventive strategies.     

儿童良性骨肿瘤手术治疗的新方法

修复儿童因切除四肢骨骼良性肿瘤或肿瘤样病变所产生的骨骼缺损，重建骨支架，是临床上遇到的难题之一。在动物实验的基础上，采用骨膜下彻底切除病变骨段，完整保留骨膜，并以不带骨膜的腓骨段等材料桥接缺损的骨段，成功地重建了骨支架。从１９８４年１月～１９９２年１２月共治疗７例，经１年～９年随访，骨支架均获得牢固的重建，肢体功能恢复正常，未见肿瘤复发。腓骨供区保留的骨膜下长出正常大小的腓骨。     

SEX AND SUBSITE FREQUENCY OF LARGE BOWEL CANCER IN THE KINGDOM OF SAUDI ARABIA: A COMPARISON WITH NEW ZEALAND

New Zealand (NZ) has a high risk population for the development of large bowel cancer (LBC). The Kingdom of Saudi Arabia (KSA) has a low risk population and is estimated to have incidence and mortality rates which are ten times lower than NZ. It has already been shown that in NZ, females have a higher incidence of right-sided colonic cancer and males a higher incidence of rectal cancer. To determine whether the same situation exists in a low risk population the NZ data were compared with similar data from the cancer registry at the King Faisal Specialist Hospital and Research Center (KFSHRC). Between 1975 and 1989. 423 Saudi and Yemeni patients with LBC were registered at KFSH. The subsite distribution of tumours in this group were compared with the subsite distribution in 4678 patients registered in NZ between 1972 and 1975. The male to female (M:F) ratio for right-sided tumours in KSA was 1:0.90 compared with 1:156 in NZ whereas the ratios for rectal tumours were 1:0.61 and 1:0.83 respectively. This study confirms the presence of a lower frequency of right-sided tumours in females in a low risk country and further confirms the importance of gender in LBC. It may be that early and multiple child bearing, physical activity and relatively poor diets have been protective for Saudi females.     

股动脉损伤处理失误分析

报道股动脉损伤处理失误５例。由于对损伤的原因未认真分析，或被其它合并伤掩盖、或手术方法选择不当，致术后发生急性肾功能衰竭死亡２例，股动脉继发血栓形成，修复血管破裂等严重并发症３例，其中经再次手术行血管修复成功２例，截肢１例。提出应重视闭合性股动脉损伤的早期诊断，认真分析血管损伤的不同因素，采用正确的修复方法，是防止股动脉损伤处理失误的关键。     

肝脏外科解剖及肝段体积的测定

本文报告22例肝脏外科解剖学研究及肝段体积测定。结果表明:肝脏平均体积为1289cm~3;肝Ⅰ段平均体积为22.3cm~3;肝Ⅱ至Ⅷ段所占全肝体积百分数分别为9.9％、11.6％、16.6％、17.0％、14.6％、14.7％、15.6％。     

CANCER OF THE TONGUE AND ORAL CAVITY IN AUCKLAND,NEW ZEALAND, 1970–86

This report comprises a retrospective review of the clinical data on 157 patients seen in the auckland area having a diagnosis of cancer of the tongue, floor of the mouth, inferior alveolus, or buccal mucosa (retromolar area, vestibule of the mouth, and cheek mucosa) during 1970–86. One hundred patients were male, 95% were european, 85% were cigarette smokers, and 58% had a history of high alcohol intake. All primary tumours were squamous cell carcinomas, 50% were located in the tongue, 27% in the floor of the mouth, and 11.5% each in the buccal mucosa and inferior alveolus. The majority (60%) of patients with tongue cancer were clinically stage i at presentation while other intra-oral tumours were evenly distributed between stages i and iv. Surgical resection of the primary intra-oral lesion produced local control in 90% of stage i tumours, but this fell to below 70% in stage ii—iv tumours. Most patients (82%) who recurred locally had positive or ‘close’ margins, and this rate of local tumour recurrence as a consequence of narrow margins did not decrease with the addition of adjuvant radiotherapy. Of those patients with stage i disease who received only treatment of the primary lesion, 20% later developed regional nodal disease which was controlled in more than half by neck dissection, but control was achieved only in 11% of patients treated with radiation. The presence of regional disease at presentation was associated with a poor prognosis. It is concluded that local control of inferior oral cavity tumours can be achieved if resection is accomplished with clear margins. Regional control can be obtained in 50% of patients with neck dissection. Considered together, the high rate of regional recurrence with stage i lesions, and the poor results following salvage therapy (12% 2 year survival) indicate that these patients require as aggressive initial therapy (often involving neck dissection) as do those with more advanced disease.     

THE PROVISION OF GENERAL SURGICAL SERVICES IN RURAL SOUTH AUSTRALIA: A NEW MODEL FOR RURAL SURGERY

Background : Rural South Australia (SA), like other rural areas in Australia, faces crisis in the medical workforce. It is also generally assumed that the same applies to rural surgical services but finding evidence to support this is scarce. Methods : All hospitals situated outside the outer metropolitan area of SA were surveyed about surgical services (n= 57). Questions were asked about the frequency of emergency and elective theatre usage and which surgeons provided surgical services. Results: Operating theatre facilities were in active use in 39 of the 57 hospitals studied. At the time of the study there were seven specialist general surgeons resident in rural SA. General practitioners continued to have major input in the provision of surgical services, either by providing the general anaesthetic (34/39) or by performing the surgical procedures (26/39). Conclusions : The Department of Surgery at the University of Adelaide is instituting various measures to counter the rural surgical workforce problem and is developing model that serves either the individual or the two–person surgical practice. Metropolitan teaching hospitals can play an important role in supporting current rural surgeons and can foster an increased commitment to the future of rural general surgery.     

DIFFERENCES IN PATTERNS OF CARE OF PROSTATE CANCER,NEW SOUTH WALES, 1991

Background: In this time of uncertainty about the benefits of earlier diagnosis for prostate cancer and the optimal choice of treatment in various clinical scenarios, we addressed the hypothesis that two groups in the population, namely country dwellers and migrants from non-English-speaking countries, were less likely to be offered new methods of diagnosis and treatment for prostate cancer. Methods: Incident cases of prostate cancer in 1991 were identified through the population-based New South Wales Central Cancer Registry. For 73% of eligible cases information relating to diagnosis, staging and treatment was abstracted onto a checklist from clinical records in urologists' consulting rooms and in public hospitals. Results: Transrectal ultrasound and prostatic biopsy were used for diagnosis significantly more often in urban than in rural cases while the reverse was true for transurethral resection of the prostate. Intravenous pyelography, ultrasound (other than transrectal) and bone scans were performed for staging more frequently in urban than rural cases. Rural cases were more likely to be treated with anti-androgens than urban cases and less likely to be given luteinizing-hormone releasing hormone (LH-RH) agonists. The pattern of use of various diagnostic and staging procedures for 1991 rural cases resembled that for urban men diagnosed with prostate cancer in 1986 rather than that for 1991 urban cases. Conclusions: At least in part, these urban-rural differences could be explained by the fact that some patients in the country would have been treated by general surgeons rather than urologists. The patterns of care for non-English-speaking migrants resembled those for the Australian-born and for English-speaking migrants.