Vascularised free fibular flap in bone resection and reconstruction.

This paper compares allograft alone and in combination with vascularised free fibular flaps (FFF) to reconstruct long bone defects after tumour excision. We present 33 cases, 21 of these patients had reconstruction with an allograft alone as the initial procedure. Nine patients underwent reconstruction with FFF plus allograft plus iliac crest bone graft (ICG), two patients underwent reconstruction with a FFF and ICG and one patient underwent reconstruction with an allograft, a pedicled fibular flap and a FFF. The allograft was obtained from the Queensland Bone Bank and had been irradiated to 25 000Gy. In our experience (N=21) the complication rates with allograft alone were: delayed union 3, nonunion 7, fractured allograft 6, infection requiring resection of the allograft 3, other infections 2. The revision rate was 48% (10 cases of which five required a free fibular flap) and an average of 1.8 revision procedures were required. In the lower limb cases, the mean time to full weightbearing was 20 months and 40% were full weightbearing at 18 months. We felt that the high complication rate compared with other series may have been related to the irradiation of the graft. FFFs were used in 18 cases, 12 cases were primary reconstructions and six were revision reconstructions. The mean fibular length was 19.4 cm (range 10-29 cm). There were no flap losses and the FFF united at both ends of 11 of 12 primary reconstruction cases. One case had nonunion at one end, giving a union rate of 96% (23 of 24 junctions). When a FFF was used in combination with an allograft as a primary reconstruction, the allograft nonunion rate was 50% (five of 10 cases). The mean time to full weightbearing in the lower limb cases was 7.5 months and 100% were full weightbearing at 18 months. The FFF hastens time to full weightbearing but does not appear to affect the complication rates of allograft. The number of revision procedures required is reduced in the presence of a FFF and is the latter is a useful technique for the salvage of refractory cases.

Inducible nitric oxide synthase (iNOS) activity promotes ischaemic skin flap survival.

We have examined the role of nitric oxide (NO) in a model of functional angiogenesis in which survival of a skin flap depends entirely on angiogenesis to provide an arterial blood supply to maintain tissue viability. The different effects of nitric oxide synthase (NOS) inhibitors on rat skin flap survival appeared to be explained on the basis of their NOS isoform selectivity. Skin flap survival was decreased by iNOS-selective (inducible NOS) inhibitors, S-methyl-isothiourea, aminoguanidine and aminoethylthiorea; unaffected by the non-selective inhibitor nitro-imino-L-ornithine; and enhanced by the cNOS (constitutive NOS, that is endothelial NOS (eNOS) and neuronal NOS (nNOS)) inhibitor, nitro-L-arginine methyl ester. Skin flap survival was reduced in mice with targeted disruption of the iNOS gene (iNOS knockout mice), and the administration of nitro-L-arginine methyl ester significantly increased flap survival in iNOS knockout mice (P<0.05). iNOS immunoreactivity was identified in mast cells in the angiogenic region. Immunoreactive vascular endothelial growth factor (VEGF) and basic fibroblast growth factor were also localized to mast cells. The combination of interferon-gamma and tumour necrosis factor-alpha induced NO production and increased VEGF levels in mast cells cultured from bone marrow of wild-type, but not iNOS KO mice. The increased tissue survival associated with the capacity for iNOS expression may be related to iNOS-dependent enhancement of VEGF levels and an ensuing angiogenic response. Our results provide both pharmacological and genetic evidence that iNOS activity promotes survival of ischaemic tissue.

Young patients with colorectal cancer: how do they fare?

BACKGROUND: Younger patients with colorectal cancer (CRC) have long been thought to have a poorer prognosis than older patients. Recent overseas reports, however, have disputed this. The aim of the present study was to conduct a review of data on patients with colorectal cancer collected over a 29-year period at Princess Alexandra Hospital (PAH) to ascertain the outcome of a younger subset of patients at this hospital. METHODS: The PAH Colorectal Project records on 2495 patients with malignancies of the colon, rectum and anus who were treated and followed since 1971, were analysed to determine clinical presentation, treatment and outcome. A group of 61 patients with colo-rectal adenocarcinoma was identified who were aged less than 40 years at presentation. Their clinical data were then compared with the larger group of older patients. RESULTS: There were 30 male and 31 female patients in the younger group. A positive family history was the most consistent risk factor, present in 34% of patients. Despite this, only one patient out of 61 had been diagnosed as a result of a screening programme. The Australian Clinico-Pathological Stage (ACPS), histology and distribution of tumours corresponded to that of the older patients. The overall 5-year survival among younger patients was 53%. The 5-year survival rates in younger patients were better than that for older patients for ACPS A and B, reaching statistical significance for both of these stages. CONCLUSIONS: Our results indicate that younger patients with colorectal cancer have the potential to do just as well as older ones. With the influence of a family history of colorectal cancer being very apparent in this group, greater emphasis should be placed on an adequate screening programme for them.

Progress of surgical training in Papua New Guinea to the end of the 20th century.

BACKGROUND: Health care in Papua New Guinea (PNG) throughout the 20th century has been characterized by a significant shortage of medical practitioners and surgical expertise. A number of initiatives within the country and from outside have sought to address these deficiencies of numbers and quality. The present paper seeks to review the development of surgery and surgical training in PNG. METHODS: Review of the surgical literature, reports and records in the Division of Surgery at the University of Papua New Guinea (UPNG), and personal observations are used to look critically at the content and productivity of the various training initiatives. RESULTS: For the first half of the century, PNG relied on national medical assistants who were trained, supervised and directed by expatriate doctors. Medical training of PNG doctors began in 1951 and by 1999 more than 600 doctors had graduated. Expatriate specialist surgeons arrived in 1950 and were the only surgeons until the postgraduate Master of Medicine (surgical) programme produced its first graduates in 1978. This programme has now produced 37 surgeons who are reasonably well distributed throughout the country. Higher surgical diplomas were introduced in 1994 for more specialized training of some of the general surgeons. These training developments have been supported by AusAid as well as by Australian surgeons. CONCLUSIONS: Surgical expertise has progressively improved throughout the 20th century with the most major advances being achieved in the last decade. Training programmes have provided an expanding core of expertise of considerable quality, but the numbers of doctors and surgeons remain well below requirements.

Cut or paste? The use of glyceryl trinitrate paste in the treatment of acute and chronic anal fissure.

BACKGROUND: Anal fissure unresponsive to conservative measures such as stool softeners frequently requires surgical intervention. The present study describes the use of glyceryl trinitrate (GTN) in the treatment of acute and chronic anal fissure. METHODS: Eighteen consecutive patients with anal fissure were treated with 0.5% GTN paste in soft white paraffin applied twice daily to the anus. These patients were followed at regular intervals to assess symptom control, rate of healing, adverse effects and recurrence rate. RESULTS: Two patients were lost to follow-up. Twelve of the remaining 16 were cured. Of these, symptomatic relief was obtained for most within 2 days, and for all within 1 week. No patient required cessation of treatment due to adverse effects. Treatment failed in four of 16 patients. Two of these patients subsequently underwent successful surgical procedures, and two patients (while not completely cured) had sufficient symptomatic relief to decide against surgery. CONCLUSIONS: The use of GTN paste in the treatment of acute and chronic anal fissure may be a safe and effective modality that can be considered as first-line treatment for this condition.

The Pacific Islands Project: the first 3 years.

BACKGROUND: The Pacific Island countries consist of widely scattered, small, underdeveloped islands which require considerable international assistance, particularly in health care. In 1995, the Pacific Islands Project was established and funded by AusAID to provide tertiary medical assistance to 10 island countries over a 3-year period. The programme was later expanded to include Papua New Guinea. METHODS: The Royal Australasian College of Surgeons was appointed manager of the project, which involved voluntary input from members of several specialist medical colleges and societies. Assistance was provided through short-term visits of multidisciplinary teams according to predetermined priorities. The delivery of medical services was combined with a transfer of skills and educational activities. Feedback was obtained from the recipient countries and each visit evaluated by an independent committee. RESULTS: One hundred and thirty-one visits in ten disciplines were conducted in 11 countries by 255 participants on a voluntary basis between March 1995 and March 1998: 15 784 patients were seen and 3424 operations performed. CONCLUSIONS: The programme was very successful on all counts. It has now been extended for a further 3 years and will be conducted in parallel with postgraduate educational programmes in the Pacific region and Papua New Guinea.

Methodology for the study and projection of surgical and anaesthetic workforce.

The Australian Medical Workforce Advisory Committee has studied the specialties of anaesthesia, general surgery, orthopaedics, ophthalmology and urology in Australia. A methodology is presented for rationalizing various data sources to establish numbers and characteristics of the existing workforce, for applying a variety of information to establish opinion about current adequacy, to project future needs and to advise the mechanisms to ensure delivery of services. This study emphasizes the importance of the cooperative input of governments, health administrations and professional bodies, careful gathering of fundamental data, the studied application of uneven pieces of evidence, recognition of changes in needs and demands, the overlap of sectors of the medical workforce in service delivery, and the requirement for continued study and monitoring. The current size of the workforce in these surgical specialties is found to be satisfactory overall but with some uneven distribution. The anaesthetic workforce is found to be slightly deficient in number overall. The growth of future demand for these specialties was estimated between 1% and 3% per annum and requirements for increases in trainee numbers to meet these projected future demands are defined.

A model of bridging angiogenesis in the rat.

A model of angiogenesis has been developed in the rat. The epigastric vascular pedicle was exposed in the groin, a 7 mm segment of epigastric artery was excised leaving the vein intact and, after a variable period of time for angiogenesis to occur between the ends of the artery, a skin flap was elevated on the epigastric vascular pedicle so that it depended completely for its blood supply on bridging angiogenesis across the created gap. Skin flap survival and vessel counts were measured as indices of the angiogenic response. In this model we observed a spontaneous increase in vessel counts between the ends of the artery, and a corresponding increase in skin flap tissue survival until day 10 after which time vessel counts plateaued whilst tissue survival continued to increase until day 14. In the angiogenic pedicle, a time-dependent development of granulation tissue containing numerous macrophages and mast cells, and capillary sprouting were documented. When flap elevation was performed 7 days after arterial excision skin flap survival was 42%. Thus, in this model, 7 days is a suitable interval for the future evaluation of the effects of either pro- or anti-angiogenic agents.

Diagnostic failure in colonoscopies for malignant disease.

BACKGROUND: While colonoscopy has become established as more accurate than double contrast barium enema for detecting colonic polyps and cancers, as well as offering the opportunity for therapy, there are occasional instances where colonoscopy is misleading. The present study is to determine what problems occur, with a view to finding a solution. METHODS: The records of the Colorectal Project at the Princess Alexandra Hospital indicate retrospectively that 346 patients have been correctly diagnosed with cancer of the colon and rectum by colonoscopy in the 5 years up to October 1996. During the same time eight patients (2.3%) were recorded at the same hospital as being misdiagnosed by colonoscopy, the lesion being either missed completely or misplaced. RESULTS: In five of these patients there was failure to recognize that the whole colon had not been examined endoscopically, thereby missing a more proximal lesion. In two patients the lesion was missed although the entire colon was examined. In one patient the lesion was discovered but inaccurately sited. Six of these mistakes would have been obviated by the routine use of fluoroscopy to confirm the totality of the colonoscopy and to site any lesions found. The other two cases occurred because of failure to remember that colonic examination during withdrawal should be performed meticulously back as far as the anal canal. Failure to diagnose a colon cancer on the initial colonoscopy led to an average delay of 6 months for definitive care. CONCLUSIONS: It is recommended that fluoroscopy be used routinely during colonoscopy to site accurately any lesions found, and to confirm the completeness of insertion if reliable landmarks, including terminal ileum, are not clearly identified.

Free tensor fasciae latae flap reconstruction of defects of the chest and abdominal wall: selection of recipient vessels.

Reconstruction of a full thickness defect of the abdominal or chest wall requires a combination of a rigid or semi-rigid layer and skin cover. The tensor fasciae latae (TFL) flap is unique in that it provides both of these in substantial quantities, but the most difficult aspect of using this flap in the anterior chest and abdomen is finding suitable recipient vessels. We describe a series of nine cases in which full thickness defects of the chest and abdominal wall were repaired using free vascularised TFL flaps. The recipient vessels included the gastroepiploic vessels (n = 2), the deep inferior epigastric artery (n = 3), the internal mammary artery (n = 2), and the superior thyroid and acromiothoracic arteries (n = 1 each). The gastroepiploic and internal mammary vessels are preferred because of their reliability and because the flap pedicle enters the centre of the deep surface of the flap so that if these vessels are used, circumferential tight closure of the fascial layer can be achieved, with consequent decreased risk of vessel kinking and future herniation.

Malignant sacrococcygeal germ cell tumour in an adult.

In adults, malignant sacrococcygeal germ cell tumour is a rare cause for a presacral tumour, with only 17 cases having been reported in the literature since 1907. We report the case of a 34 year old male who presented with a 6 month history of symptoms relating to a malignant presacral tumour which required en bloc excision including the lower sacrum and rectum. He died with lung and mediastinal metastasis 7 months following surgical excision and adjuvant chemotherapy using Cisplatin, Bleomycin and Etoposide. Prior to his death, he had a severe polyarthritis of his peripheral joints and evidence of hypertrophic osteo-arthropathy. The literature indicates that adults with these tumours have a poor prognosis, with only one reported long-term survivor. Surgical excision offers the only chance of cure, with the role of adjuvant therapy not having been defined because of the small numbers.

A modified surgical technique for temporalis transfer.

A modification of the temporalis muscle transfer for facial animation in facial palsy is described. Seven cases are presented which demonstrate the advantages of the procedure, especially the avoidance of temporal hollowing and the greater power due to less dissection of the muscle belly, a more direct line of pull and the absence of a pulley. In addition, food pooling in the buccal sulcus is reduced, and the procedure is less extensive and thus better tolerated.

Island inner canthal and glabellar flaps for nasal tip reconstruction.

A series of inner canthal and glabellar island flaps for nasal tip reconstruction based on the angular artery and vein is presented. These flaps have the advantages of providing well vascularised tissue of the appropriate colour, texture and thickness for external skin and vestibular lining, with a wide arc of rotation and satisfactory donor site defect, in a single stage procedure.

Free jejunal interposition reconstruction after pharyngolaryngectomy: 201 consecutive cases.

BACKGROUND: Reconstruction of tubular defects following pharyngolaryngectomy has required complicated surgery with high perioperative morbidity and mortality. Free jejunal interposition provides an excellent reconstruction with potential for lower immediate complications and better long-term results than other procedures. METHODS: A total of 201 consecutive free jejunal interpositions were performed following pharyngolaryngectomy between 1977 and 1993. Operative details, complications, and outcome were prospectively documented. RESULTS: Perioperative mortality was low (4.5%) and microvascular success rate high (97%), although a small number of late failures were recorded. Average time until swallowing postoperatively was 11 days, and 92% of patients could maintain full nutrition. Voice rehabilitation was mentioned, and increasingly good results are being obtained. Complication rates for the neck (17%) and the abdomen (2.5%) were also low. There were no problems with excess mucus production or reflux. Radiation effect on the jejunal conduit was not detrimental to long-term patency of the vascular anastomoses or to function as a conduit. CONCLUSIONS: Comparison with other published techniques permits the contention that a free jejunal interposition is the reconstruction of choice after pharyngolaryngectomy.

Afferent arteriovenous anastomosis for thumb replantation: a case report.

Described is a case where an afferent arteriovenous anastomosis was successfully employed in the replantation of a large piece of composite tissue amputated from a patient's thumb. The operative procedure is described and aspects of arterialized venous vascular networks are discussed.

Primary adenocarcinoma in a colonic 'oesophageal' segment.

A case of primary adenocarcinoma of the colon in a segment used to reconstruct after an oesophageal resection is reported. The original lesion was a relatively advanced adenocarcinoma of the gastro-oesophageal junction. An ACPS 'C' colon carcinoma was diagnosed 12 years later. A curative resection was achieved. The literature is reviewed in regard to late complications in colonic interpositions, including primary carcinomas.

Primary adenocarcinoma in a colonic oesophageal segment.

A case of primary adenocarcinoma of the colon in a segment used to reconstruct after an oesophageal resection is described. The original lesion was a relatively advanced adenocarcinoma of the gastro-oesophageal junction. An ACPS 'C' colon carcinoma was diagnosed 12 years later. A curative resection was achieved. The literature is reviewed with respect to late complications in colonic interpositions, including primary carcinomas.

Microvascular salvage for failed colonic interposition.

Free revascularized jejunal grafts have been used in three patients to restore alimentary tract continuity after ischaemic failure of pedicled colonic graft replacements of the oesophagus. In all three patients colon had been placed retrosternally. In one patient immediate replacement of a totally necrotic colon interposition was undertaken. In two patients, late long strictures were replaced by jejunal segments. Access to the retrosternal colon was gained in each case by neck and median sternotomy incisions. Revascularization of the jejunal segments was from the facial artery and external jugular vein in two patients and from the internal mammary vessels in one. Satisfactory swallowing of solids and liquids has been achieved and sustained.