Surgery

Acutaneous dental sinus tract is a channel which leads from a dental focus of infection to drain onto the face or neck.1 These tracts tend to occur more frequently from infected mandibular teeth (80%) than maxillary teeth (20%).2 Hence, they are more common in the submandibular or submental regions of the face.3 Sinus tracts may result from localised infections, such as an infected tooth, periodontal disease, actinomycosis or osteomyelitis.4 There are numerous reports of cutaneous dental sinus tracts in the dental literature,1,4-10 but comparatively few reports in the medical literature.2,3 Patients with these lesions often present first to general practitioners rather than to dentists,1-7 possibly because they do not associate lesions of the face with teeth and often have no associated dental pain. Lessons from practice Dental infection can present with cutaneous lesions of the face and neck. Dental assessment is recommended for non-healing face and neck lesions, particularly in submandibular and submental regions. Biopsies or excisions are not necessary and can cause scarring. Management of the dental focus of infection through endodontic (root canal) treatment or tooth extraction will resolve the sinus tract. Clinically, a cutaneous dental sinus tract may resemble a pimple, ulcer, nodule, or indurated cystic area. Because these tracts have a similar clinical appearance to other facial lesions and are relatively uncommon, they may be misdiagnosed, leading to inappropriate antibiotic therapy, aspiration or surgery. Unless the dental focus of infection is treated, recurrence is likely.1-10 When surgical intervention is attempted, breakdown of the wound can leave scarring and wound contracture.2-8 In our three patients, the dental sinus tracts occurred because of delays in diagnosis or management. The differential diagnosis includes pyogenic granuloma, furuncle, foreign body reaction, and cysts, such as sebaceous, epidermoid and thyroglossal cysts.3 Neoplastic causes, such as basal and squamous cell carcinomas, should also be considered,1 as well as other infective causes, including osteomyelitis, actinomycosis and tertiary syphilis gumma.2 Intraoral radiographic examination is a crucial diagnostic tool. A carious tooth or periapical radiolucency on a dental radiograph suggests a possible dental focus of infection. Dental assessment will confirm diagnosis. Usually, dental sinus tracts drain within the mouth, commonly in the vestibule adjacent to the affected tooth. However, they may drain onto the face, depending on the relationship of the muscle attachments and tissue planes of the face to the focus of infection. In the maxilla, if the focus of infection is superior to the muscle attachment, or in the mandible, inferior to the muscle attachment, a sinus tract may form on the face. Pus travels via the route of least resistance along facial planes until exiting cutaneously. When cutaneous sinus tracts are involved, the infected tooth is often free of pain as the tract provides an outlet for inflammatory exudates, allowing decompression.6 The infected, non-vital (ie, necrotic) tooth may be slightly tender to percussion. Histologically, sinus tracts show inflammatory tissue, granulation tissue or abscess formation. The tract may have an epithelial lining.4 Elimination of the source of infection by endodontic treatment or tooth removal results in resolution of the sinus tract, typically within 2 weeks.4,7,8 In most cases, the result is cosmetically acceptable, as in our Patients 1 and 2, but wound contraction and scar tissue may necessitate surgical revision (as in Patient 3).3 Biopsy should be avoided as it may lead to exacerbation of infection or scarring. Antibiotic therapy is indicated when there are signs of systemic involvement (eg, pyrexia or lymphadenopathy). Clinical records Patient 1 A healthy 40-year-old man presented to his general practitioner complaining of a non-healing pustule, and a swelling on his chin with an associated purulent discharge. The patient was referred by his GP to a hospital for excision of the lesion under the care of a surgeon. The surgeon believed the lesion to be a sebaceous cyst and attempted to remove it. Following the procedure, the patient developed fever, malaise, and marked swelling of the mental region. He was admitted to hospital for 2 days for intravenous antibiotic therapy. A dental origin for the lesion was then considered, and the patient was referred to a dental specialist (an endodontist) for assessment. The patient had a history of a car accident which caused trauma to the teeth 15 years previously. He did not receive dental treatment at the time. Clinical examination revealed an erythematous lesion on the chin measuring 0.5 cm in diameter, from which pus drained freely (Figure 1A). Routine clinical dental tests were conducted, including tooth percussion and CO2 dental pulp testing. Radiographic examination revealed a broad radiolucency associated with three of the lower incisor teeth (Figure 1B). These findings led to a diagnosis of chronic apical periodontitis caused by pulpal necrosis and infection of two lower incisor teeth (teeth 31 and 32). Tooth 41 was vital. The patient underwent endodontic (root canal) therapy to the lower incisor teeth (31 and 32) and reported that the discharge ceased a week later. Photographs taken at 3-month follow-up showed resolution of the tract (Figure 1C and 1D). Patient 2 A healthy 41-year-old woman presented to her GP with a non-healing pimple on her right nasolabial fold (Figure 2A). The GP referred the patient to a surgeon who attempted to excise the lesion. Reportedly, the lesion resolved, only to recur 3 months later. By this time, the surgeon suspected a dental aetiology, and referred the patient to an endodontist. Radiographic examination suggested that the lesion was related to an infected upper canine. A radiolucent area around the root of the tooth was characteristic of a periapical abscess (Figure 2B). The tooth was treated endodontically (Figure 2C), and the skin tract resolved. Patient 3 A 7-year-old girl presented to a dentist with toothache and a developing skin lesion under her chin. She had a history of trauma to her lower lip and teeth at 3 years of age. The lower right lateral incisor tooth was slightly tender to percussion, and radiographic examination revealed a radiolucency associated with the root of the tooth. The dentist referred her to an endodontist, who confirmed the diagnosis of chronic apical periodontitis with facial sinus tract. Endodontic treatment was begun, but, because of a dental phobia, the girl delayed completion of this treatment. She presented again 6 months later because the skin lesion had worsened, becoming raised, firm and erythematous (Figure 3A). Endodontic treatment was completed (Figure 3B), and the skin lesion began to heal. At 6-month follow-up, wound contracture had caused dimpling of the skin in the affected area (Figure 3C). This may require surgical revision.

Roland A Barrowman BDS · Mehdi Rahimi BSc, BDS · Mark D Evans MDSc, GradDipClinDent · Arun Chandu MDSc, MB BS, FRACDS(OMS) · Peter Parashos MDSc, PhD

Radiographs of a woman presenting with abdominal pain revealed a large foreign body within the pelvis. A diagnosis of perforation of the colon was made, and at laparotomy an 8.5 cm long glass fragment was removed from the bowel. A laceration to the lower back, sustained in a fall onto a glass coffee table, had been explored and sutured 20 months earlier. Imaging findings showed the subsequent course of the overlooked glass fragment within the pelvis. Clinical record A Abdominal radiograph A: A large triangular foreign body is visible in the pelvis. Note the deformity of the right transverse processes of L4 and L5 (arrows). B Surgical photograph B: The sigmoid colon is opened to show a large triangular glass fragment in the lumen of the bowel. C Computed tomography scan C: A loop of terminal ileum is in continuity with the anterior surface of the right psoas muscle (arrow), directly in line with the bony tract created by the glass fragment. A 60-year-old woman presented to the emergency department complaining of abdominal pain, nausea and bloating, that had developed over the previous 3 days. On examination, there was generalised guarding and tenderness. A chest radiograph showed a pneumoperitoneum, and an abdominal radiograph showed a large, triangular, radiopaque foreign body within the pelvis (Figure, A). A diagnosis of bowel perforation by a foreign body was made, although the patient denied any history of foreign body insertion or ingestion. Further questioning revealed that 20 months earlier she had fallen onto a glass coffee table, sustaining a large laceration to the lower back, just above the natal cleft. She had presented to the emergency department of a large metropolitan hospital where the wound was explored and sutured, but no radiographs were taken. At laparotomy, the patient had faeculent peritonitis, with a small perforation of the antimesenteric wall of the sigmoid colon. An 8.5 cm long triangular fragment of glass was found within the mid sigmoid colon (Figure, B). A Hartmann’s procedure was performed. DiscussionInitially, this was a baffling case. The source of the glass foreign body was obviously the earlier coffee table accident — but how did the glass fragment get into the bowel and why did it take 20 months to present clinically with intestinal perforation? The radiographs and subsequent computed tomography (CT) scans provided the answers. The abdominal radiograph was reviewed the day after clinical presentation and surgery. It was noticed that there was partial bony fusion of the right transverse processes of the fourth and fifth lumbar vertebral bodies. A CT scan confirmed that new bone formation at this level had produced a solid block of bone with a central defect in the shape of a rectangle. It is thought that the glass fragment snapped off deep to the skin and fractured the right transverse processes of L4 and L5, with the subsequent fracture healing process giving rise to a perfect bony cast of the fragment. It is well documented that a fracture initiates a sequence of inflammation, repair and remodelling, and that the remodelling process continues for years.1 Another CT scan showed the bony tract caused by the glass fragment projecting anteriorly into the right psoas muscle. Directly anterior to this, the terminal ileum could be seen lying on the anterior surface of the right psoas muscle (Figure, C). It is thought that the sharp end of the glass fragment gradually worked its way out the front of the psoas muscle and into the terminal ileum. The radiographs and CT scans provide a vivid account of the course of the glass fragment after it penetrated the skin. All but the most superficial and easily explored penetrating injuries caused by glass should be assessed radiographically at the time of injury.2

Sally A Johnston MB BS · David A Lisle MB BS, FRANZCR · Roderick C Borrowdale MB BS, FRACS

A: Computed tomography (CT) scan showing proximal duodenal dilatation (arrow) tapering towards the point of obstruction (arrow head), resulting in the triangular shape of the duodenum. B: CT scan showing extensive hepatic portal venous gas (arrows) and a massively distended stomach. A 17-year-old man with a slim build presented with recurrent postprandial epigastric fullness and bilious vomiting. He was acutely unwell. An abdominal radiograph showed gastric and duodenal distension. Contrast computed tomography scans showed proximal duodenal dilatation (Box, A, arrow), with a triangular-shaped duodenum, extensive hepatic portal venous gas (Box, B, arrows), and a massively distended stomach. Superior mesenteric artery syndrome with hepatic portal venous gas was diagnosed. This syndrome occurs when the fat pad between the superior mesenteric artery and its origin at the aorta is lost, causing a sharp, narrow angle at the aortomesentery junction. The third portion of the duodenum is compressed and becomes obstructed when passing through this angle.1 Hepatic portal venous gas can develop as a result of bowel ischaemia. Surgical therapy with duodenojejunostomy is the treatment of choice for a severely ill patient, or when more conservative treatment has failed.2

Chi-Lun Tsai MD · Ming-Jenn Chen MD · Che-Kim Tan MD · Khee-Siang Chan MD · Kuo-Chen Cheng MD, FCCP

High patient volume for both hospitals and surgeons is an important determinant of operative mortality and outcome for complex and infrequently performed operations. The 13% of Australia’s population who live in rural and remote areas often choose to have surgery close to home and support networks despite the potentially higher operative mortality and morbidity. Rural patients should be able to make an informed choice about having their surgery locally. Rural and metropolitan surgeons should discuss and reach mutual agreement on where each patient is best treated. A balance must be struck between quality of services that can be provided locally and geographic convenience.

Grant D Stewart BSc(Hons), MB ChB, MRCSEd · Gareth Long MB BS, FRACS · Bruce R Tulloh MS, FRACS, FRCSEd

The Royal Australasian College of Surgeons (RACS) supports the evolution of appropriate task transfer in a team environment led by the most experienced clinician — in our case, the surgeon. A clear requirement needs to be identified for task transfer; it should not be used to avoid redressing the current inefficient use of existing surgeons resulting from ongoing underfunding. Maintenance of standards, defined curricula, professional titles and monitored outcomes are essential.

John P Collins MD, FRACS, FRCS · David J Hillis MHA, FRACGP, FRACMA · Russell W Stitz MB BS, FRACS, FRCS

To the Editor: Boerhaave’s syndrome is a rare condition in which increased intra-oesophageal pressure associated with forceful vomiting leads to spontaneous oesophageal rupture. Although the condition mostly affects middle-aged men,1 we present here a case arising as a complication of appendicitis in a child. A 10-year-old boy presented with a 4-day history of abdominal pain, diarrhoea and bloodstained vomiting. He was febrile and tachycardic, with a mildly distended abdomen but no peritonism. Chest and abdominal x-rays were normal. Over the next 6 hours, despite being given 4 litres of normal saline intravenously, the patient became hypotensive, oliguric and hypoxic, with increased abdominal guarding. A perforated appendix was suspected and an urgent laparotomy was planned. A preoperative chest x-ray revealed a large left-sided hydropneumothorax causing tracheal deviation. Insertion of an intercostal catheter immediately returned 600 mL of haemoserous fluid. At laparotomy, amid gross purulent contamination, a perforated appendix was removed. A subsequent computed tomography (CT) scan of the thorax showed contained mediastinal contrast extravasation with an associated air/fluid level from the lower oesophagus on the left side (Box), suggesting oesophageal rupture and establishing Boerhaave’s syndrome. Intravenous antibiotics and nasogastric and pleural drainage were instituted. A repeat CT scan of the thorax 3 days later showed no further mediastinal contrast extravasation. The child improved clinically until spiking high temperatures on the seventh day postoperatively. A chest x-ray showed a left-sided pleural effusion. Thoracoscopy revealed a loculated empyema. This was managed by a formal decortication via a left lateral thoracotomy. The patient was discharged after 2 weeks. Vomiting is a common presenting symptom in acute appendicitis. Yet there is only one previously reported case of Boerhaave’s syndrome secondary to acute appendicitis.1 Therefore, this unusual complication of acute appendicitis may be missed. Without treatment, 100% mortality is expected.2 In retrospect, it was evident that our patient showed the classical clinical symptoms of Boerhaave’s syndrome: a history of prolonged haematemesis, systemic compromise and a left-sided tension hydropneumothorax.2,3 As an initial chest x-ray may be normal, a repeat x-ray is worthwhile in any patient with prolonged vomiting. If clinical suspicion persists, a CT scan of the thorax, which is a more sensitive and specific test for detecting oesophageal rupture, is advisable.2,3 The management of Boerhaave’s syndrome involves initial resuscitation with broad-spectrum antibiotics, nasogastric intubation and pleural drainage.2-5 In recent literature, urgent operative intervention has been recommended to control communication between the oesophagus and mediastinum.2,3,5 In our case, we pursued non-operative management based on radiological evidence of a small, contained mediastinal collection and clinical improvement after pleural drainage. The present case highlights a rare complication of a common surgical condition and suggests that careful non-operative management may be successful. Computed tomography scan of thorax

Kenneth Wong · Gerard Roy

To the Editor: I found the recent letter to the Editor from Riley1 fascinating, and the comment from Teo2 depressing in the extreme. Of the many factors that drove me from anaesthetic practice and into the houseboat business 4 years ago, the selfish attitude of many surgeons towards our communal working environment was high on the list. If all parties in an operating theatre wish to be “entertained” with music while operating on their fellow man, then I suppose it might be permissible (but one wonders what many patients would say if they knew). However, it seems quite beyond the autocratic mindset of many surgeons to understand that auditory input is important to anaesthetists for monitoring the patient and for communication between the anaesthetist, surgeon and nursing staff. To impose music as background noise is unacceptable to many of us, especially as auditory discrimination decreases with age. Riley’s description of video as well as audio to distract from the primary function of surgery beggars belief. I note that Teo agrees with me here. When are surgeons going to realise that surgery is only one part of the professional work that goes on in an operating theatre?

Douglas N Gow

A recent review shows how much more we need to find out about this important problem Perioperative ischaemic cardiac events include myocardial infarction, cardiac arrest and cardiac death, and are estimated to occur in 2%–5% of patients over 40 years of age.1 Mortality rates associated with perioperative myocardial infarction and cardiac arrest may be as high as 25% and 65%, respectively.2,3 In the Australian context, precise data on the numbers of patients at risk are not available, but with more than 440 000 general anaesthetics performed annually, this is likely to be an issue facing many physicians. A recent narrative review of the problem is therefore of timely importance.1,4 What is the risk of perioperative myocardial infarction? As the review points out, perioperative myocardial infarction may be difficult to diagnose, and often unrecognised. Three studies were identified totalling 1309 patients, with myocardial infarction diagnosed by creatine kinase MB elevations with new Q waves, with or without autopsy or positive pyrophosphate scan evidence. Myocardial infarction was identified in 30 patients (2.3%); notably, more than half of these did not have symptoms or signs. Creatine kinase MB assays may result in false negative and positive results, and troponin assays — the biomarker currently used in the European Society of Cardiology and American Heart Association guidelines for diagnosis of myocardial infarction — are now preferred. However, in the perioperative setting, troponin elevation may also arise from non-cardiac causes such as pulmonary embolism and renal failure, and limitations exist in the specificity of individual assays.5 Further, the pathophysiology of perioperative ischaemic events may differ from the non-perioperative acute coronary syndromes, and these differences may affect risk prediction and treatment. Non-perioperative acute coronary ischaemia results from rupture of an often mild, non-obstructive atherosclerotic plaque and superimposed coronary thrombosis.6,7 Although such plaque rupture and thrombosis is also thought to occur perioperatively, there are other important influences. The perioperative state is associated with activation and release of multiple inflammatory mediators and cytokines, sympathetic nervous system activation and catecholamine release, hypercoagulability, and hypoxia. These contribute to both plaque rupture and thrombosis. Additionally, the perioperative stress state may contribute to increased myocardial oxygen demand, in the setting of reduced oxygen supply from blood loss, hypoxia, and other factors. This adverse environment may be present up to 3 days into the postoperative period.8 How can we assess this risk? Given this propensity for perioperative ischaemic events, individual preoperative risk assessment has been keenly pursued by surgeons and anaesthetists, often resulting in referral to a cardiologist. Two methods are commonly used: clinical assessment, and noninvasive testing. A number of clinical assessment tools have been advised, a commonly used one being the Lee index.9 This defines a number of features of patient history, physical examination, baseline investigations, and proposed surgical procedure. Based on the presence of one to five of these clinical characteristics, patients’ risk can be stratified from 0.4% to 5.4% likelihood of a major perioperative event.9 Noninvasive exercise or pharmacological stress testing, usually with echocardiographic or nuclear imaging, is generally reserved for those at higher risk. In Australia, dobutamine stress echocardiography is a commonly used technique, achieving sensitivity and specificity of 85% and 70%, respectively, for a positive test predicting perioperative events in a meta-analysis,10 with similar results for nuclear imaging techniques.10 However, the relatively modest sensitivity and specificity of these tests mean a number of high-risk patients will be missed, and many with high risk will not have an event. The advice to patients about their risk must also be tempered by whether the planned surgery is elective or should go ahead regardless of the risk. How can we manage this risk? Coronary angiography is often advised for patients assessed to be at higher risk, but there is uncertainty in how to respond to the finding of significant coronary artery disease. Revascularisation — either percutaneous or surgical — has been suggested for patients with high grade coronary stenosis, particularly for widespread disease.11 However, supportive data are scarce; several retrospective studies suggest benefit, but a large recent randomised trial in selected stable patients undergoing vascular surgery showed no improvement in outcomes, and possibly an increased risk of events.11,12 At a practical level, if revascularisation is performed, observational data support delaying non-cardiac operations for at least a month following revascularisation surgery.13 Following coronary stenting, a window of 6 weeks after bare metal stenting is suggested, to allow endothelialisation of the stent struts and reducing stent thrombosis,14 but also reducing the possibility of in-stent restenosis, occurring maximally at 3–6 months.15 There are as yet no comparative data following drug-eluting stents, although these appear less attractive, given that stent-strut endothelialisation takes longer, and combined antiplatelet therapy with aspirin and clopidogrel is likely to be needed for longer, further increasing perioperative bleeding risk if these agents are continued, and increasing the risk of acute stent thrombosis if they are stopped early to allow surgery.16 Perioperative coronary events: risk management strategies for those at increased risk Consider not performing surgery if elective Smoking cessation: can be advised for all patients β-Blockade: some evidence, but disputed Aspirin, nitrates, statins: little evidence Revascularisation: little evidence of benefit, some evidence of harm; a particular problem with drug-eluting stents Similar uncertainty surrounds pharmacological methods of perioperative risk reduction. β-Blockers, by reducing myocardial oxygen demand and blocking sympathetic and catecholamine responses, would seem a logical option. Their use is widely promoted, and included in the joint American College of Cardiology and American Heart Association guidelines for perioperative management.17 However, these recommendations are based largely on two randomised controlled trials: one, a small unblinded study,18 the second, a larger study, which showed no survival benefit for β-blockade assessed on an intention to treat basis.19,20 Further trials are currently underway.20 Use of aspirin or statins also seems appropriate, given their previous efficacy in prevention of non-perioperative events,21 but aspirin may increase the perioperative bleeding risk,22 and statins have not yet shown robust benefit, although this is likely an area for future investigation. How then, should the physician put together what is at times confusing information? Firstly, perioperative ischaemia is relatively common and often unrecognised. Clinical assessment and non-invasive imaging are useful, but far from perfect, in risk stratification. Stopping smoking before surgery is a useful intervention to reduce risk.23 Revascularisation, while often used for patients with angiographically important disease, has little evidence to support it, delays subsequent surgery, and has a number of associated problems. Lastly, while statins, aspirin and β-blockers may appear intuitive and are commonly used, there is likewise little evidence to support these approaches. The review by Devereaux et al1,4 is a timely reminder of how little is known about such an important problem, a call to obtain better data, and a suggestion to discuss the rationale for surgery and its possible attendant risks carefully with patients.

Harry C Lowe FRACP, PhD · Saul B Freedman FRACP, PhD

A 41-year-old man was referred for open biopsy of a 3 cm left lung lesion. The lesion had been discovered incidentally on chest x-ray (Box, A) and investigated with a computed tomography scan of the chest (Box, B) and a fine needle aspiration biopsy under radiological guidance that was inconclusive. The patient had a history of smoking and had also sustained a ruptured left diaphragm and a pulped spleen (with subsequent splenectomy) in a motor vehicle accident 13 years previously. A left thoracotomy was performed and the mass removed. During surgery, the mass was noted to be closely applied to the left phrenic nerve and apparently deriving blood supply from the phrenic pedicle. A smaller mass was discovered posteriorly, adjacent to the descending aorta. Histological examination of the mass revealed encapsulated lymphoid tissue, with lymphoid foci surrounding central hyalinised vessels. The lymphoid foci were separated by a broad region of erythrocyte-filled sinuses. The appearances were of splenic tissue and there was no evidence of malignancy (Box, C). Thoracic splenosis is a rare condition in which ectopic splenic tissue exists in the thoracic cavity, more commonly on the left side.1 It occurs in some patients who have experienced thoraco-abdominal trauma with resulting splenic and diaphragmatic injury. Fragments of splenic tissue implant themselves within the thorax and derive a blood supply.2 Often this occurs at multiple sites within the thorax and abdomen. These ectopic spleens remove aged and abnormal red blood cells from the circulation. So, despite having had a splenectomy, a patient with this condition may have normal red cell morphology on blood smears. Nuclear medicine studies with either 99mTc sulphur colloid, 111I-labelled platelets or 99mTc heat-damaged erythrocytes demonstrate an increased uptake of the radioactive isotope in ectopic splenic tissue. The 99mTc heat-damaged erythrocyte study is more specific because of reduced uptake of 99mTc in otherwise normal liver tissue.3 When a localised area of uptake corresponding to the mass is detected — supporting the diagnosis of thoracic splenosis — no further treatment is required.1-3 Imaging and histopathological findings A: Chest x-ray showing the incidental finding of a left hilar mass (arrow). B: Computed tomography scan showing a well encapsulated mass (arrow) adjacent to the mediastinum. C: Histological section of the left hilar mass demonstrating lymphoid foci (arrows) surrounded by splenic red pulp.

Tinte Itinteang MB BS · James R McGiven MB ChB, FRACS · Catherine B Koleda MB BS · Graham D McCrystal MB ChB

Andrew J A Holland,* Frank I Ross,† Patricia Manglick,‡ Fiona E Fahy,§ Daniel T Cass¶ * Associate Professor of Paediatric Surgery and Urology, † Clinical Nurse Consultant, ‡ Scientific Officer, § Clinical Nurse Consultant, ¶ William Dunlop Professor of Paediatric Surgery and Director of Trauma, Department of Academic Surgery, The Children's Hospital at Westmead, University of Sydney, Locked Bay 4001, Westmead, NSW 2145. andrewh3ATchw.edu.au To the Editor: Several studies from Australasia and North America have identified that in up to 24% of children with pedestrian motor vehicle injuries (MVIs) the event occurred in a driveway.1-4 Earlier work from our centre in Sydney and others in Auckland, New Zealand, highlighted prevention as the most effective method for reducing the morbidity and mortality associated with this unique mechanism of injury.2,3,5 With ethics committee approval, we prospectively reviewed injury circumstances in children under 16 years of age presenting with a driveway MVI to our institution over a 3-year period between June 2002 and May 2005. Of 36 children injured in 35 separate driveway MVIs, 26 caregivers agreed to an interview and scene visit. Fifteen patients (58%) were male, with a mean age of 48 months. The majority of events occurred in western and south-western Sydney — a paediatric population centre — in the afternoon (18; 69%) and on a weekday (19; 73%), with a trend for greater frequency at the beginning and end of the working week. In all but two cases, the injury occurred at the child’s home, which was owned by the parents in 13 cases (50%; with a mean occupation period, 47 months) and rented in 10 (38%; mean occupation period, 22 months). The majority of homes (22; 85%) had no separation between the dwelling, external play areas and the driveway. Even when a separation was present, this had been circumvented. Sedans were the most common vehicle involved (18; 69%), with the remainder four-wheel drives (4WDs) or light commercial vehicles, and 22 (85%) were reversing. The vehicle was driven by an adult known to the child in 21 cases, but in four the vehicle was inadvertently set in motion by another child. Box 1 reports parental perception of contributing factors and Box 2 lists injuries sustained, with 23 (89%) children receiving injuries severe enough to warrant hospital admission. There were no deaths. This review indicates that driveway MVIs persist as a common and potentially fatal problem for children in New South Wales, with at least one child injured every month.2 Following our previous study published in 2000, and findings of the NSW Child Death Review Team, campaigns by the Motor Accidents Authority of NSW and others have focused on driveway safety, particularly for young children. This review suggests that further intervention is needed to reduce the frequency of these injuries, either through enhanced application of present strategies or the development of more effective, novel approaches. 1 Parental perception of factors contributing to their child sustaining pedestrian motor vehicle injuries in the driveway Lack of supervision 15 Child playing in parked car 5 Children’s behaviour around cars 5 Negligent driving 2 Excessive speed 2 Hand brake not applied 1 Front house door left open 1 Hurrying when leaving home 1 2 Injuries identified in children sustaining pedestrian motor vehicle injuries in the driveway Head and neck Skull fracture 1 Intracranial haematoma 1 Concussion 2 Retropharyngeal haematoma 1 Torso Hepatic contusion 1 Adrenal haematoma 1 Haemopneumothorax 1 Multiple rib fractures 1 Pelvic fracture 1 Major soft tissue injury 1 Limb Fractures 2 Burns Full thickness 4 Partial thickness 3 Major soft tissue injury 1 Minor soft tissue injury 17

Andrew J A Holland · Frank I Ross · Patricia Manglick · Fiona E Fahy · Daniel T Cass

To the Editor: Music is often played in operating theatres, for a variety of reasons. It has been shown to decrease the anaesthetic requirements of patients1 and the autonomic reactivity of surgeons,2 and not to interfere with laparoscopic task performance under non-clinical conditions.3 However, I have witnessed several events that have “pushed back the boundaries” of this common practice. In one case, a surgeon requested that a videocassette player and monitor be moved into the operating suite before a major operation. Thinking that this might be for educational purposes before use of a new technique, the nursing staff obliged. After the operation was under way, the surgeon directed that a commercial videocassette of an opera be taken from his briefcase and played during the operation. The anaesthetic team were concerned about this, and the video player was turned off when the operation became more difficult. In another case, a surgeon undertook an operation while listening through ear-bud headphones to low-level music from his digital music player. Before the operation began, the anaesthetist questioned the surgeon about the wisdom of this practice and asked several times if it might interfere with communication or concentration. The operation proceeded without incident with the surgeon listening to his music. These examples may represent extremes of practice, but they do remind us that we should remain vigilant and not allow developments in entertainment technology to interfere with patient care. Further studies are required to determine the effect of these practices on technical performance and decision-making of surgeons and also communication between staff in the operating suite.

Richard H Riley

Comment: Ask most surgeons about their operating theatres, and they will describe them as havens from the stresses and pressures of a busy clinical practice. The theatre protects them from the interruptions of telephone calls, the demands of patients and their relatives, and the politics of medicine. It is a microcosm where a surgeon may rule autocratically. Within reason, most theatre personnel would gladly accommodate any means that might diminish the stress or enhance the smooth running of an operation. Techniques such as dimming the lights, decreasing human traffic, eating lollies and playing music are common practices in operating theatres. As a surgeon, I find background music essential during surgery. It masks the chatter of the scout nurse, the telephone conversation of the anaesthetist, and the beeping of the diathermy machine and the electrocardiograph monitor. Without the pleasant background sound of ABBA or the love songs of Elvis, my stress levels would be compounded by every other audible distraction. The question of whether surgeons should be able to use whatever means necessary to achieve the best outcome, even if the anaesthetic and nursing staff perceive it as inappropriate, could only be answered with a prospective study using patients’ clinical outcomes as the end-point. With so many variables, a study of this nature would be impossible. Personally, I have no objection to the scenario in Riley’s second case if the surgeon can maintain adequate communication with the scrub nurse. However, I cannot accept that a person would not be distracted by watching a video while operating. Even if the surgeon was simply listening to the music, the video playing on the monitor would be a distraction to other theatre personnel. I agree with Riley that we must continually re-evaluate technology in the workplace. Patient care is paramount, and, unless audiovisual technology is helping us achieve this end, we would be wise to return to simpler times.

Charles Teo

Objective: To describe the peer review process of the Western Australian Audit of Surgical Mortality (WAASM), selected outcomes and recommendations.Study design: Prospective audit using peer review of all cases of patients who died while under the care of a Western Australian surgeon between 1 January 2002 and 30 June 2004. Audit reviews were current to 30 September 2004.Participants and setting: 194 of 202 surgeons participated after a patient died under their care.Main outcome measures: Surgeon participation, deficiencies of care, deep vein thrombosis (DVT) prophylaxis, futile surgery, postmortem reviews, proportion of operations performed by consultant surgeons.Results: The audit process was complete for 896 of 1647 reported deaths (54%), while a further 503 (31%) were still under review at 30 September 2004. Twenty deaths associated with terminal care were excluded from analysis. Median patient age was 80 years, and 799 of the 876 patients who died (91%) had significant comorbidities that increased the risk of death. Deficiencies of care were reported in 179/876 (20%). In 45/876 deaths (5%) the deficiency of care was assessed to have caused the death, and 15 deaths were considered preventable. The risk of a deficiency of care was 1.9 times higher in elective admissions than emergency admissions. Autopsy was undertaken in 83/768 (11%) deaths with complete data. Changes in practice were noted in some areas targeted by WAASM, such as improved DVT prophylaxis. A problem with fluid management was recorded.Conclusion: Most patients who died were elderly, had complex comorbidities and were treated appropriately. The WAASM has helped to change surgical practice and emphasises the importance of ongoing systematic audit. The participation of surgeons demonstrates their commitment to accountability and supports the intention of the Royal Australasian College of Surgeons to extend the process throughout Australia and New Zealand.

James B Semmens MSc, PhD · Frank M Sanfilippo BPharm, PGradDipPharm, PhD · S Aqif Mukhtar MSc, GradDipPH, MEMIM · Natasha S Haynes BA(Hons) · Jenny A Mountain BA, MBA · R James Aitken FCS(SA), FRACS

A 30-year-old woman with a history of bipolar disorder presented after ingestion of 4 g of carbamazepine and 40 mg of alprazolam in a suicide attempt. She became increasingly drowsy and eventually required intubation and mechanical ventilation. The patient received a total of 350 g of activated charcoal via a nasogastric tube over 25 hours. She experienced some charcoal-stained vomiting, but made an otherwise unremarkable recovery and was discharged home. The patient was hospitalised again 3 days later complaining of constant sharp abdominal pain, diagnosed on culture as a urinary tract infection. Over the next 4 days, she experienced multiple bouts of nausea, charcoal vomits and colicky central abdominal pain. A Gastrografin meal (Schering Pty Ltd, Sydney) and follow-through showed complete small bowel obstruction (Box 1). Subsequent laparotomy revealed a 2.5 × 5 cm bezoar in the distal small bowel, about 60 cm from the ileocaecal valve (Box 2). The bezoar was manually fragmented and passed through the ileocaecal valve into the caecum. The patient recovered well after the operation, and was discharged with psychiatric follow-up. Charcoal bezoars are a rare complication of activated charcoal administration. They have been associated with treatments for intoxication with carbamazepine,1 amitriptyline,2 theophylline,3 benzodiazepines and barbiturates.4,5 The parasympatholytic effects of the drugs can precipitate or contribute to paralytic ileus, allowing charcoal to accumulate (potentially with remnants of undigested tablets) and form bezoars. Additional factors that influence bowel obstruction secondary to charcoal administration include the dose and timing of activated charcoal therapy, patient age and comorbidities, and previous intra-abdominal surgery. Gastrointestinal complications should be considered whenever activated charcoal is administered. Prompt recognition and treatment at the first sign of ileus or obstruction may prevent bowel necrosis and subsequent perforation/peritonitis. Charcoal-stained vomiting, abdominal distension and ongoing pain should raise the suspicion of mechanical obstruction. We would advocate Gastrografin follow-through as both a diagnostic and potentially therapeutic tool in incomplete obstruction. However, complete obstruction may signal the need for early laparotomy. 1 Abdominal x-ray after Gastrografin meal, showing complete small bowel obstruction 2 Operative photograph of bezoar in distal small bowel

Justin C Y Chan MB BS BMedSci · Chaminda Saranasuriya MBBS · Bruce P Waxman MB BS, FRACS, BMedSci

Stephen Clarke,* Justin G Oakley,† David A Neil,‡ Joseph E Ibrahim§ * Research Fellow, Centre for Applied Philosophy and Public Ethics, Charles Sturt University and the Australian National University, Canberra, ACT 2601; † Director, Centre for Human Bioethics, Monash University; ‡ Lecturer, Faculty of Arts, University of Wollongong; § Professor, Rehabilitation, Aged and Palliative Care Services, Peninsula Health, Mt Eliza, VIC. Stephen. ClarkeATanu.edu.au To the Editor: Last year, three of us made a case for the public reporting of individual surgeon performance information.1 We argued that considerations of safety and accountability strongly justify the collection of individual outcomes data, and that considerations of patient choice make it very hard to argue against the public reporting of collected data. The public trust in health care in Australia has, in the words of a recent MJA editorial, “taken a pounding” as a result of a series of scandals at the King Edward Memorial Hospital, Perth, in 1999, the Canberra Hospital, in 2000, and the Campbelltown and Camden Hospitals in NSW, in 2002.2 We noted that recent developments in public reporting of surgeon performance information in the United Kingdom were driven in large part by the Bristol Royal Infirmary Inquiry, and we warned of the danger of waiting for a scandal like Bristol to occur before acting to improve performance management. Unfortunately, a scandal, perhaps on the scale of that at the Bristol Royal Infirmary, has now occurred in Bundaberg. Although this scandal is ostensibly about the failings of one badly performing surgeon, it is widely seen as symptomatic of a failure of regulation of health care throughout Australia. The Queensland Health Systems Review, headed by Mr Peter Forster, was established in April this year as a result of public disquiet resulting from the Bundaberg scandal.3 The Premier received the report on 30 September and has recommended a wide range of reforms including increased performance monitoring of a range of health care outcomes (Recommendation 13.2), and the insistence that information on health system outcomes be made public (Recommendation 13.3). We welcome the review’s recommendations as both a necessary component of a successful system of management of the health care system and a means to begin to restore public trust in the health care system. Unfortunately, we suspect that this may not be enough to restore trust in the system. A system in which a plainly incompetent surgeon has been allowed to continue operating is one where, in the eyes of the public, the performance of all surgeons working within that system is called into question. A public reporting system that provides reliable and valid information about individual surgeons, as well as hospitals’ clinical performance, would be a significant step towards restoring the public’s confidence and ensuring transparency within that system.

Stephen Clarke · Justin G Oakley · David A Neil · Joseph E Ibrahim

Roxanne L Wu General Surgeon, White Rock Surgery, 2/194 Progress Rd, White Rock, QLD 4868. rockdocsATbigpond.net.au To the Editor: May I suggest some explanations for the findings of Schofield and colleagues on the rate and reasons for surgery cancellations on the intended day of surgery.1 Patients placed on a “never-never” waiting list for relatively minor surgery, such as many ear, nose and throat operations, treat the procedure with the contempt that has been shown to them. If the problem really needed the operation, most will have turned to the private sector, and, if it did not really need an operation, it has got better by itself. Surgeons who have many “no-shows” habitually overbook to fill their lists. In this day and age, surgeons who “underutilise” their lists are punished by losing them. No surgeon who has purposely overbooked their list will put a correct time estimate on the operation. We know how to add up. Surgeons whose lists are often shortened because of lack of beds begin to double book themselves, so that they are not left with an empty day. If the list is full, the surgeon may then be unavailable because of the other commitment. Surgeons who know they have a 30% chance of not getting an elective postoperative intensive-care bed for one patient book a “stand-by” patient, which becomes a cancellation if the intensive-care bed eventuates. I suggest that, before millions of dollars are spent on management consultants, the following simple procedures be considered: Always give the patient a date for the operation, even if it is next year. It keeps everyone a lot more honest, and patients might even ring the hospital to change the date (if they can get through the unnecessarily tedious process of phoning the booking clerks.) Administrators must understand that a hospital’s load fluctuates enormously and, if elective surgery is deemed the least important activity, it will never be done. To have enough beds for elective surgery means having empty beds sometimes. If patients are given a date, the hospital can predict the number of beds required for elective surgery patients, and these should be treated as full beds in advance. Intensive-care beds can also be booked, as intensive-care stays after elective surgery are predictable. If the hospital has excessive emergency admissions, it should be possible to open reserve beds at short notice or to reschedule surgery by negotiating with patients. These simple measures might cost more to the current account, but not the millions required to engineer some high-technology process driven by management consultants.

Roxanne L Wu

John P Royle Vascular Surgeon (retired), Past President, Royal Australasian College of Surgeons, and Associate Professor of Surgery, University of Melbourne, Austin Hospital, Heidelberg, VIC 3084. johnroyleATonthe.net.au Comment: The recent articles in the Journal by Schofield and colleagues1 and Cregan2 on cancellations of surgery on the scheduled day are important, as they focus attention on the management of elective surgery in the public sector. The number of on-the-day cancellations reported by Schofield et al could be reduced by continuing to compile these statistics. The consequent focus on the various problems at their hospital would reduce cancellations, although it might take several years for an effect. The statistics will vary between hospitals, depending on the amount of complex tertiary surgery undertaken and the demographic characteristics of the catchment population. Some of the problems are common to most hospitals, and more dialogue between them would be helpful. Most surgeons working in the public sector experience repeated frustrations with the management of the elective surgery waiting list. The points made by Wu are valid but of course do not cover everything in a multifactorial problem. However, her suggestions for improvement are very worthy of consideration. Giving a patient a date for an operation is sensible: both patient and staff know where they stand. If a patient had to be given a date more than 12 months in advance, then the hospital would be failing in its obligation to provide an adequate service to the community. A major reorganisation might be required. A patient who has been given a definite date can be brought into a pre-admission and pre-anaesthetic clinic (as suggested by Cregan) 3–4 weeks before the date. This would eliminate many of the reasons for cancellation listed by Schofield et al. At the pre-admission clinic, the patient could be instructed to telephone on the day before surgery to confirm arrangements (as is done at some hospitals). This does require staffing the telephone, but puts the onus back on the patient. A late cancellation could then be substituted by a “stand-by” patient, thus avoiding a vacancy on the list. Although cases of sudden illness will still occur (when 4% of staff of large hospitals are on sick leave at any one time, inevitably some patients will be sick too), only a very small number will become acutely ill after 19:00 on the previous day. Wu’s second point, concerning administrators’ views of elective surgery, is even more important. As Cregan points out, elective surgery is the easiest service for health administrators to manipulate to meet budgetary requirements.2 It is essential that, somehow, beds (and intensive care beds) for elective surgery are effectively quarantined to give certainty to patients and staff. The 23-hour model described by Ryan and colleagues3 is a method of achieving this. There is a shortage of surgeons — a fact recognised by the Royal Australasian College of Surgeons and by governments. The training of new surgeons relies heavily on the elective surgery lists of public hospitals. The governments of New South Wales and Victoria have been agitating for the accreditation of more surgical trainees. This becomes a nonsense when an adequate supply of elective surgical patients is denied by financial restrictions and hospital policies that deliberately restrict elective surgical beds. As elective surgery is at the heart of the training of future surgeons and surgical nurses, attention to this problem should be a top priority of all governments.

John P Royle

Obesity is shaping up to be the major health care problem and one of the most frequent causes of preventable death in Western countries in the 21st century. Bariatric surgery is the only current treatment that has been shown to achieve major and durable weight loss. Major weight loss in the severely obese leads to total or partial control of a wide range of common and serious diseases, such as diabetes, heart disease and hypertension. Laparoscopic adjustable gastric banding is the most common type of obesity surgery performed in Australia. It is effective, relatively safe and minimally invasive. The blocks to broader application of bariatric surgery should be identified and resolved.

Paul E O’Brien MD, FRACS · Wendy A Brown MB BS, PhD, FRACS · John B Dixon MB BS, PhD, FRACGP

A 44-year-old woman presented with a 3-day history of worsening right upper quadrant pain associated with nausea, anorexia and fever. She had localised tenderness and guarding in the epigastrium. Initial ultrasound imaging showed a distended gallbladder containing calculi, without wall thickening. A computed tomography scan (performed because of increasing pain) showed a whorled structure in the anterior abdomen (Box 1). At laparotomy this was seen to be torsion of a segment of the greater omentum. Histology of the resected specimen showed congestion of the vessels, haemorrhagic infarction and focal fat necrosis (Box 2). She made an uncomplicated and rapid recovery. Primary omental torsion is a rare cause of acute abdomen. It may affect children and adults, and is commonly misdiagnosed preoperatively as appendicitis. Some cases have presented as acute cholecystitis.1,2 Kimber et al identified 13 cases of omental torsion or infarction in about 8000 cases of suspected appendicitis over a 20-year period.3 Large meals, sudden postural change, and abdominal trauma may be precipitating factors in primary torsion,4 while adhesions, hernia, tumour or focus of inflammation3 occur with secondary torsion. Resection is the preferred treatment,3,4 although some clinicians suggest conservative management2 when the diagnosis is apparent on computed tomography. Laparoscopic resection has also been advocated.5 1 Computed tomography scan of abdomen A whorled structure (arrow) is seen in the anterior abdomen adjacent to the transverse colon. 2 Histological section of omentum There is marked congestion and haemorrhagic infarction, with areas of fat necrosis and an acute inflammatory reaction. (Inset: higher mag-nification shows fat necrosis and a polymorph neutrophil response.)

Wen-Chan Yeow MB BS · Mohan V Jayasundera FRACS, MB ChB · Graham Hool FRACS · Rajalingam Sinniah DSc, FRCPath, FRCPA

The problem of surgical waiting lists requires multifactorial solutions The provision of public hospital services inevitably involves managing the demand for these services. This is usually achieved by rationing. Elective surgery is the easiest service for health administrators to manipulate to meet budget imperatives and to manage demand pressures, through controlling surgical waiting lists. In short, the pestle of demand grinds against the mortar of budget restriction in the management of elective surgical lists. Although health planners are able to accurately predict demand for surgical services, administrators often plan not to meet that demand because of budgetary restrictions. With effective management, the only day-of-surgery cancellations should be occasional patients with an acute change in their medical condition. In this issue of the Journal, Schofield and colleagues report on one aspect of demand management: the cancellation of operations on the day of surgery.1 This is almost unheard of in the private health-care sector, where the supply of surgical services is virtually uncapped. Schofield et al also shed some light on the reasons for these cancellations. In the tertiary-care hospital that was the focus of their investigations, the rate of on-the-day cancellations of surgery (11.9% overall, and 13.2% for weekday elective surgery) is a cause for concern. The Australian Council on Health Care Standards guideline is that the day-of-surgery cancellation rate should be low,2 which, in New South Wales, is interpreted to mean not exceeding 1.5%. In my own hospital, Nepean (also a tertiary-care hospital), it is about 3%. A higher rate of cancellations can be expected in hospitals where patients, such as those undergoing major general and cardiac surgery, depend postoperatively on a dedicated intensive-care bed. For these patients, Schofield et al found cancellation rates of 31.2% and 28.5%, respectively; these are higher than would usually be expected. As intensive-care beds are assigned in NSW as part of a statewide coordination service, the management of this problem requires involvement of agencies at a higher level than hospital administration. However, it is not clear why surgical services in the survey by Schofield et al, such as ear, nose and throat or plastic surgery (which should be largely independent of intensive-care and inpatient beds), had such high cancellation rates. The reasons for elective surgery cancellations revealed by Schofield and colleagues fell into five nearly even groups — lack of theatre time, lack of postoperative beds, cancellation by patient or carer, patient clinical change, and procedural reasons. As elective surgery is one of the most predictable aspects of hospital medicine, the great bulk of these cancellations could be avoided with better management systems. With effective management, the only day-of-surgery cancellations should be occasional patients with an acute change in their medical condition. Managing elective surgery more efficiently requires a well thought out management system with quarantining of resources to ensure patient flow. Such a system has recently been described by Ryan and colleagues — the 23-hour ward model.3 In this model, it is expected that the episode of care can be delivered within an envelope of 23 hours, during which time patients require only pain relief and monitoring in a supervised setting until fit for discharge. This model is quarantined from the rest of the hospital or area bed-base, either in a designated ward or a smaller hospital in the area. Patient care is protocol driven, and patients are not admitted unless they are on a clinical pathway. The protocol includes compulsory pre-admission and pre-anaesthetic assessment, careful construction of lists matching patients to available beds and operating-room slots, and a guarantee that elective procedures will not be cancelled. Patient flows are predetermined, with a staged recovery process. This model does not lead to significant increases in readmission rates, nor does it significantly affect community services.3 It is suitable for about 80% of patients requiring elective surgery. The NSW Surgical Service task force has recently recommended the adoption of this model, and the NSW Department of Health has advised all area health services to institute it. Adopting this model’s approach may also help patients who require stays of over 23 hours. A management process that links the predictable demand for elective surgery to operating sessions and beds can avoid cancellations and enable effective and predictable access for all patients. Waiting times are multifactorial and vary between areas, between hospitals in areas and between individual surgeons within hospitals.4 In addition to better management practices based on operational research,5 other solutions to the problem of waiting lists are needed. In elective orthopaedic surgery, there is a need for more resources for prostheses and a better system of prosthetic purchasing. In ear, nose and throat surgery, there is a need for more creative schemes to better utilise the few available specialists. Other solutions may involve contracting specific groups of patients to the private sector (the subject of a pilot study in NSW6) and developing whole new approaches, especially in the apparently insoluble area of intensive-care bed provision (eg, the surgical acute-care unit7). Currently, 1% of the NSW population is on a surgical waiting list, with similar figures in other states and territories. We have clear evidence of the harm that excessive waiting times cause patients.8 All available means must be used to solve this problem. Above all, there is a need to avoid the distress caused to patients by day-of-surgery cancellations.

Patrick C Cregan FRACS

Objective: To establish the rate of and reasons for cancellations of surgery on the scheduled day in an Australian hospital.Design: Prospective survey.Setting: Major metropolitan tertiary hospital, 13 May to 15 November 2002.Main outcome measures: Proportion of operations cancelled on the day of surgery, obtained each day from the operating theatre list and a separate list of additions and cancellations compiled on the day; reasons for cancellations from the cancellation list, extended or confirmed, as necessary, by questioning of bookings and ward staff, or members of the surgical team; estimated and actual duration of each operation and patient information from hospital clinical records.Results: 7913 theatre sessions were scheduled by 133 surgeons in the study period; 941 of these (11.9%) were cancelled on the day, including 724 of 5472 (13.2%) elective procedures on working weekdays. Main reasons for cancellation were: no theatre time due to over-run of previous surgery (18.7%); no postoperative bed (18.1%); cancelled by patient (17.5%); and change in patient clinical status (17.1%). Procedural reasons (including patient not ready, no surgeon, list error, administrative cause, and communication failure) totalled 21.0%. Ear, nose and throat surgery experienced the most cancellations (19.6%), followed by cardiothoracic surgery (15.8%).Conclusions: There were five major reasons of similar magnitude for on-the-day surgery cancellations. We estimated that 60% of cancellations of elective procedures were potentially avoidable. Change of one factor leading to cancellation (eg, provision of more postoperative beds) is not likely to lead to improvement unless the other major factors are also tackled.

William N Schofield MA, DipEdPsych · George L Rubin FAFPHM, FACR · Michael Piza BA(Hons), MPH · Ying Yin Lai MScApplStat · Doungkamol Sindhusake BA, MPH, PhD · Michael R Fearnside MS, FRACS · Peter L Klineberg FANZCA

Ray Kernutt was born on 2 September 1926 in the small town of Wagin, south of Perth. At the age of 10, he won a scholarship to attend a prestigious school in Perth, but went instead to a public school at Albany, where his sister at boarding school was able to look after him. After matriculation, he studied science at Perth University before winning a scholarship to study medicine at the University of Melbourne. He graduated with honours in 1949. Over the next few years, Ray gained his Master of Surgery and Fellowship of the Royal Australasian College of Surgeons while working as a Hospital Medical Officer at the Royal Melbourne Hospital. He gained his Fellowship of the Royal College of Surgeons in London in 1955, but cut short his postgraduate position as Surgical Registrar to return to Australia. In 1956, he was appointed founding Senior Surgeon at the new surgical unit at Box Hill Hospital, Melbourne, a position he held until retirement. Ray was no stranger to rural surgery. Having attained a commercial pilots licence in 1963, he offered a surgical service to doctors in Apollo Bay and Tocumwal. He was also absorbed in breeding cattle on his 200 acre farming property at Whittlesea. On retirement from public hospital surgery and a busy private practice, Ray became bored with a life of relaxing and playing golf and was drawn to the prospect of rural general practice. He joined a practice in the small town of Cohuna, and, although by then in his 70s, diligently revived his medical skills to become knowledgeable about diabetes, hypertension and respiratory medicine. His undiminished skill, judgement and speed in surgery were also much valued by his colleagues. Ray also came out of retirement on several occasions to provide lengthy locums at other locations where there was an acute shortage of doctors (eg, Christmas Island, Nauru and Castlemaine). It was fitting that he served his last active service in Cohuna before reluctantly retiring due to ill health and failing eyesight. Ray was set apart from his colleagues, not only because of his superb technique and speed — a “surgeon’s surgeon” — but also as a dedicated rural GP. In 2002, he was presented with the first Honorary Fellowship of the Australian College of Rural and Remote Medicine. His last illness was short and unexpected, following complications of vascular investigations. He died on 27 September 2004, and is survived by his second wife, Jillian, and children Graeme, David, Gillian, Paul and Jonathon. Peter W Graham

Peter W Graham

An 81-year-old woman was fitted with a single-chamber pacemaker for atrial fibrillation and symptomatic bradycardia (Microny SR 2425T, Pacesetter, Sylmar, Calif, USA; silicone lead 1402 T, Siemens, Sylmar, Calif, USA). Seven years later, she presented with fatigue and presyncope of 1 week’s duration. She had also noticed contractions of the pectoral muscles on the left side of the chest. An electrocardiogram (Box 1) showed evidence of ventricular undersensing and non-capture, and a chest x-ray (Box 2) revealed complete fracture of the pacemaker lead. The pacemaker was replaced, and a new lead implanted using the cephalic vein cutdown approach. The patient’s medical record indicated that, 8 months previously, when she developed a cough, a chest x-ray had been performed by her physician. At around the same time, a routine check of the function of her pacemaker indicated that it was functioning normally. Re-examination of the x-ray revealed signs of lead erosion (Box 3) which had gone unnoticed. Thus, despite significant damage to the lead, pacemaker function may be unaffected. Friction of the lead, most often against the clavicle and the first rib (known as subclavian crush) can damage the lead. The incidence of fracture of pacemaker leads is about 1.0%–2.5% and increases with the age of the lead.1 A way of avoiding this complication is to introduce the lead into the axillary or cephalic vein rather than via subclavian vein puncture.2,3 Routine chest x-rays should be performed to monitor the condition of pacemaker leads, especially where they cross the clavicle. We recommend an annual chest x-ray for pacemaker-dependent patients. This may identify lead damage that may not be apparent during a standard pacemaker check, and thus, potentially, avoid syncope or sudden death. 1 Electrocardiogram on admission showing pacing spikes with evidence of ventricular undersensing and non-capture 2 Chest x-ray on admission showing complete section of the pacemaker lead at the level of the clavicle 3 Chest x-ray performed 8 months before admission, showing evidence of lead damage that went unnoticed

Stephane L Noble MD · Haran Burri MD · Henri Sunthorn MD

Deborah J Verran Senior Transplant Surgeon, Royal Prince Alfred Hospital, Missenden Road, Camperdown, NSW 2050. deborahATemail.cs.nsw.gov.au To the Editor: A recent editorial by Mathew et al1 and an article by Kennedy et al2 tackle the issue of commercial kidney transplantation. In their editorial, Mathew and colleagues conclude that if the nationwide Australian deceased donor organ donation rate approached South Australian levels, dialysis patients would not travel overseas to purchase renal allografts.1 I believe that this statement oversimplifies the situation with respect to organ trafficking and the motives behind patients’ acceptance of this option. Organ trafficking is illegal under all state and territory laws within Australia and hence cannot occur. In a number of other countries around the world this is not the case. Although laws have been introduced in India, this has not necessarily led to cessation of trafficking in kidneys.3 Compounding this, the option of purchasing an organ is becoming more readily accessible by means of an increasing number of Internet sites.4,5 What motivates patients to go through with purchasing an organ overseas is not explored either in the editorial by Mathew et al1 or the article by Kennedy et al.2 Kennedy et al do not state whether any of the patients who travelled overseas for a kidney had been deemed not fit to be on the renal transplant waiting list in New South Wales. They also do not give the waiting time on dialysis for each patient before he or she decided to travel overseas. What is clear is that only patients who can afford to pay the US$70 000 or more currently quoted for a renal allograft will be the ones who end up travelling overseas. It would be nice to think that, with an increased organ donor rate in Australia, patients will no longer travel overseas to purchase organs. However, the ready availability of the commodity in not-too-distant countries and the increasing ease of access to this organ trade, combined with sufficient cash, will mean that there is no major barrier to some individuals.

Deborah J Verran

Sean E Kennedy,* Yvonne Shen,* John A Charlesworth,† James D Mackie,‡ John D Mahony,§ John J P Kelly,¶ Bruce A Pussell** * Renal Registrar, † Professor of Renal Medicine, Prince of Wales Hospital, Sydney, NSW. ‡ Renal Physician, Prince of Wales Hospital, Sydney, and Illawarra Regional Hospital, Wollongong, NSW. § Renal Physician, Royal North Shore Hospital, Sydney, NSW. ¶ Renal Physician, St George Hospital, Sydney, NSW. ** Professor of Medicine, Department of Nephrology, Prince of Wales Hospital, Sydney NSW 2031. b.pussellATunsw.edu.au In reply: We agree that the motives for organ trafficking are complex. The reasons that people choose to travel overseas to obtain an organ was not addressed in our article on this occasion, but some possible reasons may be self evident given the long waiting time, especially in New South Wales. Our aim was to alert our colleagues to the increased risks associated with overseas commercial transplant procedures so that they could ensure that their patients were fully informed when making a decision. Most of our patients were on the waiting list, and the time on dialysis was detailed in Box 2 in our article.1 However, two were not on the waiting list — one had a pre-emptive transplant and another was not on the list because of age-related medical problems.

Sean E Kennedy · Yvonne Shen · John A Charlesworth · James D Mackie · John D Mahony · John J P Kelly · Bruce A Pussell