Improving access to specialist care for remote Aboriginal communities: evaluation of a specialist outreach service.

OBJECTIVE: To identify barriers faced by Aboriginal people from remote communities in the Northern Territory (NT) when accessing hospital-based specialist medical services, and to evaluate the impact of the Specialist Outreach Service (SOS) on these barriers. DESIGN: Combined quantitative and qualitative study. SETTING: Remote Aboriginal communities in the "Top End" of the NT, 1993-1999 (spanning the introduction of the SOS in 1997). PARTICIPANTS: 25 remote health practitioners, patients and SOS specialists. MAIN OUTCOME MEASURES: Numbers of consultations with specialists; average cost per consultation; perceived barriers to accessing hospital-based outpatient care; and perceived impact of specialist outreach on these barriers. RESULTS: Perceived barriers included geographic remoteness, poor doctor-patient communication, poverty, cultural differences, and the structure of the health service. Between 1993 and 1999, there were 5,184 SOS and non-SOS outreach consultations in surgical specialties. Intensive outreach practice (as in gynaecology and ophthalmology) increased total consultations by up to 441% and significantly reduced the number of transfers to hospital outpatient clinics (P< 0.001). Average cost per consultation was $277 for SOS consultations, compared with $450 at Royal Darwin Hospital and $357 at the closest regional hospital. Outreach has reduced barriers relating to distance, communication and cultural differences, and potentially bolsters existing primary healthcare services. CONCLUSIONS: When compared with hospital-based outpatient services alone, outreach is a more accessible, appropriate and efficient method of providing specialist medical services to remote Aboriginal communities in the NT.

Intercostal pedicle flap for thoracic oesophageal perforations.

Oesophageal perforations are associated with a high mortality and morbidity. Intrathoracic perforations especially are associated with mediastinitis and sepsis. The repair of these perforations may be difficult, particularly when there has been a delay to diagnosis. We report our use of a method to repair or buttress the suture line after repair with a vascularized intercostal muscle flap, having used it successfully in two patients with intrathoracic oesophageal perforations.

Leaking mycotic abdominal aortic aneurysm.

A case of leaking mycotic abdominal aortic aneurysm is reported, with a brief review of the literature. A 58 year old female presented with shoulder and abdominal pain associated with diarrhoea, vomiting and fever with leucocytosis. Computed tomography of the abdomen showed pooling of contrast in the retroperitoneum anterior to a non-dilated abdominal aorta. There was considerable retroperitoneal blood accumulating in a mass-like lesion in the right lower abdomen and pelvis obstructing the right renal collecting system. Laparotomy revealed a 4 cm diameter saccular aneurysm of the abdominal aorta, with a 1 cm diameter neck. Culture of the thrombus grew Streptococcus pyogenes.

Objective evaluation of the quality of palliation in patients with oesophageal cancer comparing surgery, radiotherapy and intubation.

The objective of this study was to prospectively evaluate the quality of palliation of 103 patients presenting to a joint oesophageal cancer clinic while recording the outcome in terms of treatment, morbidity, mortality and long-term survival. Twenty-five patients underwent surgical resection (S), 22 radical radiotherapy (RR), 30 palliative radiotherapy (PR), 13 intubation (I) and 13 had no treatment (NT). The quality of palliation was quantified by plotting a score out of 100 on a graph at each visit for Karnofsky performance, severity of pain and swallowing ability, then calculating the area under each curve created using an algorithm, Simpson's discrete approximation. Efficiency of palliation was estimated by comparing the area calculated to the maximum that could be achieved during the time frame being studied. The incidence of stricture (benign and malignant) was 16% after surgery and 50% after radical radiotherapy. Treatment mortality was as follows: RR, 0; S, 1 (4%); PR, 3 (7%); and I, 0. The median survival was 26 months after surgery and 16 months after radical radiotherapy. It was 6 months for palliative radiotherapy, 4 months for intubation and 4 months for no treatment. The difference in swallowing was the only statistical difference in the quality of palliation of patients having surgery and radical radiotherapy, there being no differences in patients having palliative measures.

Management of oesophageal cancer at Westmead Hospital from 1979-1985.

The aim of this study was to evaluate the various treatment options, including radiotherapy, surgery and chemotherapy, when all patients with carcinoma of the oesophagus were assessed and managed by the same team. From December 1, 1979 to December 31, 1985, 144 patients with carcinoma of the oesophagus were referred to Westmead Hospital. Eighty-five patients were men, 59 patients were women and the median age was 63 years. Twenty-five patients were at stage I, 75 patients were at stage II, 24 patients were at stage III and 20 patients were at stage IV of oesophageal cancer. Forty-two patients underwent surgical resection. Fifty patients underwent radical radiotherapy, 30 patients underwent palliative radiotherapy and 22 patients underwent palliative intubation. The operative mortality of those patients who underwent surgery was zero. The treatment mortality of those who underwent radical radiotherapy was 6%, and for those who underwent palliative radiotherapy, was 16.7%. The mortality after intubation was 12.5%. The prevalence of benign strictures was 7.5% after surgery, 33% after radical radiotherapy and 8% after palliative radiotherapy. The prevalence of malignant strictures (recurrent disease) was 2.5% after surgery, 21% after radical radiotherapy and 20% after palliative radiotherapy. The median survival after surgery was 12 months; that after radical radiotherapy, 12 months; that after palliative radiotherapy, six months; and that after intubation, 3.5 months. Where all patients with carcinoma of the oesophagus were managed by a team approach the treatment mortality was low but the long-term survival remained poor.

Swallowing performance after radiation therapy for carcinoma of the esophagus.

The purpose of the study reported in this article was to tabulate the incidence and etiologic factors of importance in the development of strictures after radiotherapy for carcinoma of the esophagus and to analyze the outcome of patients who develop such strictures. Eighty patients were treated with radiotherapy, 50 having radical and 30 having palliative treatment. Sixty-nine patients had squamous cell carcinoma, four had adenocarcinoma, one had sarcoma, one had mucoepidermoid carcinoma, and five had undifferentiated tumors. Forty percent developed no stricture, 30% had benign fibrotic stricture, and 28% developed malignant stricture. The etiologic factors analysed included age, pretreatment swallowing score, histology and length (size) of tumor; stage of disease, dose of radiotherapy, and use of chemotherapy. None of these factors were shown to be of etiologic importance. The survival of patients who developed benign strictures was found to be significantly longer (1-year survival 88%) than those who developed no stricture (50%) or malignant stricture (19%). Using a "success score" for palliation of dysphagia, it was found that the majority of patients (71%) who developed a benign stricture had a moderately successful outcome--they were able to tolerate a full or soft diet and required dilatation with a median duration between dilatations of 5 months. Patients who developed a malignant stricture were palliated poorly by dilatation alone, and most required esophageal intubation.

Acute herniation through a posterolateral diaphragmatic (Bochdalek) hernia in an adult.

Acute herniation through a posterolateral diaphragmatic defect is rare. A case is presented in which herniation took place after the sudden inversion of a 16-year old youth. Its aetiology, presentation, diagnosis and treatment are discussed.

Colonic interposition for oesophageal reconstruction with special reference to microvascular reinforcement of graft circulation.

A series of 14 patients who have undergone colonic interposition to cervical oesophagus have been studied. Particular emphasis has been placed on ensuring adequate circulation to the transplanted colon. This included meticulous assessment and care of colic vessels, and the addition of microvascular reinforcement of colonic circulation when the colon was taken to the neck. There were no cases of colonic necrosis or of anastomotic leak postoperatively. There was one postoperative death from a cause unrelated to these complications. Eleven patients could tolerate a full diet postoperatively.

Fundoplication for gastro-oesophageal reflux.

Ninety-two patients with severe gastro-oesophageal reflux submitted to fundoplication from 1979 to 1984 have been studied. Severity of symptoms pre- and postoperatively have been assessed using a symptom score. The mean pre-operative score was 5.39 out of 9. A standard procedure for the fundoplication was used, including a long (5 cm) wrap leaving the wrap in an intrathoracic position when it could not be brought completely into the abdomen. Vagotomy was added in 53 patients. Posterior gastropexy was used in 54 patients. There was a zero incidence of damage to the spleen and a zero mortality. The mean symptom score on follow up was 0.41 out of 9 with 90.5% patients having absent or minimal symptoms. However, only 68% remained satisfied with their overall results. The incidence of sequelae related to the procedure itself including gas bloat (19.6%), dumping (7.6%) diarrhoea (6.5%) and development of gastric ulcer (2.2%) explained this discrepancy. The addition of vagotomy did not improve the results but added its complications especially dumping and diarrhoea. There were no differences in clinical results whether the fundoplication had been left in the chest or in the abdomen but there were two hazardous complications of the intrathoracic fundoplication including a perforated gastric fundus and a gastric ulcer in the thoracic part of the stomach. Posterior gastropexy conferred no benefit to the results. Measures which might improve results include: avoidance of vagotomy, intrathoracic fundoplication and gastropexy; shortening the wrap; and the use of a 50-60 F dilator in the oesophagus during the wrap.

Elective surgery for peptic ulcer: a five-year review.

A prospective study of surgery for peptic ulcer was undertaken to assess the current results of surgery in the so-called "post-cimetidine" era. Over a five-year period, 125 patients had undergone surgery; 82 parietal cell vagotomies, 10 vagotomy and drainage procedures, 10 Billroth I gastrectomies, 7 Billroth II gastrectomies, and 15 vagotomy and antrectomy procedures were performed. There were no postoperative deaths. Overall, the outcome was satisfactory in 92 patients, less than satisfactory in 13, and was considered a failure in 14, either because of recurrent ulceration (8%) or because of postoperative sequelae. The recurrence rate after parietal cell vagotomy was 5%. There was no difference in the recurrence rate after parietal cell vagotomy between women and men, but, overall, the results were less satisfactory in women after this operation. No significant difference in recurrence rate could be demonstrated between patients whose ulcers healed quickly after medical therapy and those whose ulcers did not heal.

Nissen fundoplication for gastro-oesophageal reflux.

Twenty-four patients with gastro-oesophageal reflux were treated by Nissen fundoplication over a three-year period. In 22 patients the symptoms of heartburn, reflux, or dysphagia were abolished or dramatically improved. The operative technique, complications, and reasons for the less successful outcome in the remaining two cases are discussed.

The place and efficacy of operative management of fractured clavicle.

A study of 22 cases of operative fixation of the fractured clavicle has been made. This has shown that with internal fixation and onlay bone grafting, highly successful results can be attained. There were no cases of non-union and there have been no significant complications. The indications for such surgery are presented from the literature. It is clear that the operation is not commonly indicated, but when performed is safe and highly successful.