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.

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.

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.

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.

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.

Colorectal cancer: a large unselected Australian series.

An unselected prospective consecutive series of 575 patients with a single adenocarcinoma of the colon and of 331 patients with a single adenocarcinoma of the rectum registered between 1971 and 1984 at the Princess Alexandra Hospital is reported. The tumours were staged according to the Australian Clinicopathological Staging (ACPS) System. Approximately one-quarter of the patients were incurable when they presented. For curative operations for carcinoma of the colon, the operative mortality was 3%. For curative operations for carcinoma of the rectum, the operative mortality was 1% for abdominoperineal resection and 4.5% for anterior resection. The relative 5 year survival for all patients was 54.5%. The findings are compared with other large Australian series as well as with series from the United Kingdom and the United States.

Pharyngolaryngectomy reconstruction by revascularized free jejunal graft.

The results of reconstruction after total pharyngolaryngectomy using a free revascularized jejunal graft in 72 patients are presented. There was a low hospital mortality (2.8%), a short average time until swallowing (13 days) and a short average postoperative hospital stay (20 days). Twelve patients had resections more extensive than the standard total pharyngolaryngectomy. Sixteen patients (22.2%) suffered some graft complication, but only five (two early graft losses, one late graft loss, one fistula and one stricture) required further reconstructive surgery. Abdominal complications were minimal. There were no complications attributable to post-operative radiotherapy. Swallowing of solids and liquids is good and is maintained long-term. These results are compared with those reported for other methods of reconstruction. This comparison supports a contention that jejunal autograft is the reconstruction of choice after pharyngolaryngectomy.

Emergency right hemicolectomy in colon carcinoma: a prospective study.

The morbidity and mortality in right hemicolectomy for carcinoma of the colon is examined, with particular attention to the influence of emergency surgery and advanced disease. Of the 244 patients who had surgery, 57 required emergency surgery and 187 elective surgery. The overall mortality was 5.7% with no difference statistically between the elective and emergency groups. Anastomotic complications were significantly greater in the groups undergoing emergency resection and elective palliative surgery when compared with elective curative surgery. All patients with advanced disease had a higher morbidity and mortality, both in elective and emergency surgery. The factors most important in relation to mortality and morbidity were thus advanced disease, advanced age and cardiorespiratory complications. This being the case, it is felt that the present management of emergency right hemicolectomy with anastomosis should continue to be the treatment of choice for obstructing or perforated carcinomas of the right colon.

Splenorrhaphy in the management of splenic injury.

A retrospective study of 301 adult splenic injuries presenting to the Princess Alexandra Hospital during a 15 year period, from 1970 to 1984, was conducted. Particular attention was paid to the last 5 years during which 25% of the ruptured spleens were preserved. The details of the preserved spleens are discussed. Respiratory infections were the only complications in this same selected group of patients; the complication rate being higher in the splenectomy group (15.8%) than the splenorrhaphy group (6.25%). None of the cases of splenorrhaphy required re-operation for continued haemorrhage. Twenty-five per cent of all cases of splenic injury had associated intra-abdominal injury which, of its own nature, would require laparotomy. A policy of operative management for splenic injury in adults with major trauma is therefore proposed because of the rate of associated intra-abdominal injuries. When laparotomy is performed, splenorrhaphy should be considered because of the now widely acknowledged risks of diminished immunological competence and overwhelming sepsis in asplenic individuals.

Staging of colorectal cancer. The Australian clinico-pathological staging (ACPS) system compared with Dukes' system.

A new system, the Australian Clinico-pathological Staging (ACPS) System, has recently been proposed for the recording and reporting of colorectal carcinoma. This system requires the accurate use of precise definitions, cooperation between surgeons and pathologist, and a complete pathology report. It utilizes all information available--clinical, radiologic, operative, pathologic--before a stage is allotted. This contrasts with Dukes' system, which is based solely on the pathologic examination of the resected carcinoma. It allows classifications of all cases of colorectal cancer seen, whether treated by resection, palliative surgery, local excision or not at all. The stage at presentation and the five-year survival of 490 patients with colorectal cancer are compared using the ACPS and Dukes' systems. Eighty-four cases were not classifiable under Dukes' system, and there was a significant difference in survival in one of the comparable groups of patients.

Colorectal cancer at the Princess Alexandra Hospital: a prospective study of 729 cases.

The results of treatment of 729 patients with cancer of the large bowel treated at the Princess Alexandra Hospital from January 1971 to December 1980 have been analysed. The majority (540 patients or 74.1%) presented with symptoms requiring investigation, and there was an incidence of acute obstruction of 17.6% (128 patients). In just over half the patients (55.3%) there was a significant delay in diagnosis. The operative mortality rate for curative resections for both rectal and colonic cancer was 2.7%. There was no mortality in 24 curative local resections for rectal cancer. The resection rate for the whole group was 87.4% and the age corrected 5-year survival rates were Dukes' A 99.1%; Dukes' B 78.3%; and Dukes' C 32.4%. These results are compared with those reported in a retrospective study from this Hospital in 1975 and with those from other Australian and overseas centres.

Pelvic recurrence after curative resection for carcinoma of the rectum.

Cases of carcinoma of the rectum have been prospectively studied from 1971-80. Two hundred and ten patients had curative resections and 25 of these developed clinical pelvic recurrence in the period of follow-up which ranges from one to eleven years. The rate of recurrence is found to be dependent on the level of the lesion and the degree of its local and lymphatic spread. Results from other papers are discussed. Measures to minimise local recurrence are discussed.