Surgery

Anna Peeters,* Reannan L Cashen,† Paul E O’Brien‡ * Senior Research Fellow, † Honours Student, Epidemiology and Preventive Medicine, ‡ Director, Centre for Obesity Research and Education, Monash University, The Alfred Hospital, Commercial Road, Melbourne VIC 3004. anna.peetersATmed.monash.edu.au To the Editor: We support the warning of Talbot and colleagues regarding the inequities of the current system for provision of bariatric surgery to the morbidly obese in Australia.1 We recently analysed data on the number of separations for bariatric surgery for morbid obesity in Australia. The two most common procedures in Australia are gastric reduction surgery (procedure code 30511, which includes gastric stapling, laparoscopic adjustable gastric banding [LAGB] and gastroplasty) and gastric bypass surgery (procedure code 30512). The number of separations for procedure 30512 has remained quite stable and relatively low (around 200 a year) over the past few years. By contrast, the number of separations for procedure 30511 has been continually increasing. While the exact number of LAGB procedures can not be identified from this single code, it is assumed that the majority of the increase is due to LAGB, as it is a less invasive pro-cedure and therefore generally more acceptable to patients.2 However, the number of separations for gastric reduction surgery in public hospitals is low and has remained so. In the financial year 2000–01 there were 1529 separations for gastric reduction for morbid obesity across Australia, only 194 (13%) of which were performed in public hospitals (see Box). In 2001–02 the total number increased to 2351, but the number performed in public hospitals increased only marginally, to 238 (10% of the overall number). In 2002–03, the last year of available data, there were 2612 separations, of which only 287 (11%) were performed in public hospitals (unpublished data, courtesy of the Australian Institute of Health and Welfare). Clearly, if this issue is not addressed systematically, it will only serve to widen the socioeconomic inequalities in health associated with obesity in Australia. Separations for all gastric reduction surgery for morbid obesity, Australia

Anna Peeters · Reannan L Cashen · Paul E O’Brien

Bernard M Bourke Vascular Surgeon, Gosford Hospital, 4/213 Albany Street North, Gosford, NSW 2250. Dr. BourkeATgvs.com.au To the Editor: Up and coming surgical registrar, Ken Wong, presents a revolutionary plan to allow him to look after surgical patients in the operating theatre.1 The use of the telephone for communication has merit, but he won’t feel so smug when he gets to the chapter entitled “The management of surgical patients in NSW public hospitals in winter”. There will be nowhere for Dr Wong to “hide” when he realises our operating theatres are, in fact, solar powered and that, when the sun goes down in winter, the theatres conk out. Surely now, with the statewide mergers of health services, there will be enough excess “committee people” to form a collaboration with the western NSW farmers so that the mice plague can be harnessed and trained to run on the cogs and at least provide lighting during power shortages. I’m sure my daughter could lend a few cats to chase the mice. In the absence of the provision of more hospital beds, the substitution of cat-and-mouse power for solar power is the best “winter strategy” I’ve heard in the last 10 years. This concept will feature in our next chapter, “How to train surgeons without patients or operating time”.

Bernard M Bourke

Advantages to patients of a single anaesthetic for more than one operation are obvious; attracting generalist surgeons, training them and ensuring they have adequate credentials remain hurdles With the inexorable increase in specialised surgery, the concept of “general” surgeons, what they do, and what they represent, is difficult to categorise. Indeed, is there a need for a generalist surgeon when it seems that most areas of our bodies have a designated subspecialist? . . . credentialling, clinical governance and continuing professional development are of critical importance for the practising surgeon. In this issue of the Journal (page 337), Wilson, a general practitioner–surgeon makes a compelling case for the continuing existence of the general surgeon.1 He presents an affirmative argument through the details of his experience in performing multiple elective surgical procedures on individual patients. Most of the procedures were relatively minor, yet traversed a wide range of subspecialties. The complication rates were low, and there can be no doubt that the patients benefited from a single visit to an operating theatre to have multiple problems treated. Where can a trainee gain experience in many of the minor procedures described by Wilson? Emphasis in tertiary hospitals has traditionally been on major caseloads, yet a veritable gold-mine of minor operative cases are present in day-surgical units. With a little imagination and cross-specialty cooperation, a 6-month term exclusively in a day-surgical unit would provide a trainee with a solid grounding in minor operative surgery. Rotations through regional surgical centres, where general surgical operative lists continue to remain varied,2 would provide another significant learning opportunity for trainees. However, the role of the GP–surgeon in major population centres seems limited, especially in view of credentialling requirements imposed by health care authorities. The issues of credentialling, clinical governance and continuing professional development have been highlighted by the Royal Australasian College of Surgeons (RACS) as being of critical importance for the practising surgeon, and much effort has been invested in formulating policies to reflect this and, in turn, maintain a high standard in surgical care. Who is responsible for ensuring that practitioners who are not fellows of the RACS comply with accepted surgical guidelines? While Wilson describes himself as a “GP–surgeon”, he is a fellow of both the Royal Australasian and Edinburgh Colleges of Surgeons, a factor that would certainly ease the path of credentialling in his case. The ongoing need for GP proceduralists in rural regions is unquestionable, and the various support and training mechanisms have been described at length in the Journal.3 The RACS has clearly outlined the general surgical curriculum.4 It states, “trainees should gain sufficient experience in operative surgery to achieve competency in managing common surgical conditions and emergencies as outlined”, and subsequently lists a comprehensive range of surgical conditions. Currently, most advanced trainees seem to attain competency in a core group of the listed procedures and then move into subspecialty regions, rarely to venture outside their chosen field. The lack of young, qualified surgeons to serve the community in a range of generalist procedures will become magnified by the ageing and eventual retirement of a substantial proportion of the Australian surgical community.5 It is precisely this group of surgeons who, by virtue of previous training and experience, remain adept at a wide range of general surgical procedures. There appears to be an opportunity for senior surgeons, perhaps wishing to step back from on-call emergency work, to become “day surgery specialists” and impart invaluable knowledge and skill to junior colleagues. The concept of a general surgeon able to perform a range of procedures on a single patient under a single general anaesthetic is worthy. While there is no rigorous evidence to prove it, anecdotally, at least, there is a definite need for such individuals within the medical community. The importance of performing minor surgical procedures well needs to be re-emphasised, and while the major cases may have more “lustre” for trainees, it soon becomes apparent during surgical practice that much patient satisfaction can be derived from successfully curing ingrown toenails, carpal tunnel syndrome or anal fissure.

Martin H Bruening FRACS, FRCSEd, MS · Guy J Maddern FRACS, PhD, MD

Morbid obesity (defined as having a body mass index [BMI] > 40 kg/m2, or BMI > 35 kg/m2 with obesity-related comorbidities) is a medical disorder associated with increased morbidity and mortality. Management guidelines published by the National Health and Medical Research Council and by similar US and UK bodies have recommended surgery as the most effective treatment available for selected patients with morbid obesity. A recent meta-analysis of obesity surgery has documented its safety and effectiveness in resolving some of the major medical comorbidities that occur in obese patients. To date, no intervention other than surgery has proven either effective or cost-effective in treating severe obesity and its associated medical conditions. Targeting patients with metabolic complications of obesity (eg, type 2 diabetes) could lead to substantial cost savings for the public health system. Currently, Medicare pays for privately insured patients to undergo obesity surgery, while uninsured patients are denied access to surgery in public hospitals. This raises significant equity issues that should be addressed.

Michael L Talbot MB ChB, FRACS · John O Jorgensen MB BS, FRACS · Ken W Loi MB BS, FRACS

Desmond O’Brien Emeritus Honorary Anaesthetist, The Prince of Wales Hospital, Randwick, NSW 2031. hdobrienATbigpond.com.au To the Editor: Tonti-Filippini condemns denial of elective surgery to smokers as discriminatory.1 He disregards the fact that surgery requires anaesthesia, which may require serious consideration before undertaking non-urgent surgery, and in no way involves discrimination. He mistakenly regards denying elective surgery to those who continue to smoke as discrimination, in breach of the Hippocratic Oath, and the Australian Medical Association (AMA) Code of Ethics. In fact, to proceed with elective, especially cosmetic, surgery in a heavy smoker is more in breach of the Oath and the AMA Code than not proceeding, for the following reasons. Smokers are at a significantly greater risk under anaesthesia than non-smokers because, firstly, smoking reduces the capacity of the lungs to take up oxygen, thus increasing the risk of hypoxia and its consequences to heart and brain.2 It also causes coughing and breath-holding during anaesthesia,2,3 creating surgical difficulties, and the risk of error. Postoperative coughing causes additional pain (especially after thoracic and abdominal operations), and increases the risk of postoperative bleeding, infection, delayed healing and even wound breakdown.4,5 Rather than being discriminatory, delaying elective and cosmetic surgery until he or she stops smoking is very much in the patient’s interests.

Desmond O’Brien

Your position never gives you the right to command. It only imposes on you the duty of living your life so that others can receive your orders without being humiliated. Dag Hammarskjöld, UN Secretary-General, 1953–1961 awarded the Nobel Prize for Peace I grew up in Canberra in the 1920s and ’30s, then, as now, a planned and favoured town awash with politics, politicians and public servants. Although interested in these dynamics, our caring, skilled family doctor was the person who most impressed me. John James FRCS was our community’s quiet medical leader, later recognised through the John James Medical Centre, now part of Canberra’s teaching hospital system. My parents were typical of their time. My father had emigrated from Britain in his teens and served in France in World War I. He was a public servant with the Federal Capital Commission (which from January 1925 was responsible for the planning and development of Canberra). He had a vocational flair for amateur theatricals of music hall and comedy genre. My mother was a capable homemaker. We became aware of the Great Depression just about the time my sister was born. My parents combined to have our large yard supplement our pantry. Mother became a genius in food preserving with the Fowler Vacola steam preservation kit, providing a great variety of foods. As children, my sister and I had warm and strong emotional, social and aspirational support, but our choices for our futures were our own. My parents offered two aphorisms: “Hard work is not lethal” and “Loyalty and fairness are necessary for success”. I have not found either to be wanting. In choosing a career, medicine held no competitor for me, although I dallied momentarily with veterinary science. I experienced the grief of three of my school classmates succumbing to diseases that now rarely cause death: poliomyelitis, mastoiditis and diphtheria. Polio returned to the class several times, and, although not lethal, it was damaging beyond reason, both physically and psychologically. Polio, in particular, marginalised those it affected. I felt that more could be done to alleviate this unfairness. “The effect of a teacher may be infinite”My undergraduate days during World War II were spent at the University of Sydney and at St Vincent’s Hospital, Darlinghurst. I commuted daily on the on-time “red rattler” (today we say “if only”) and travelled between campuses on the tram. Hospital life as a student was immensely fulfilling, and I matured among competitive peers. Two of my tutors made these days particularly memorable: Justin Markell, the meticulous, kindly physician in outpatients, and Douglas Miller, later Sir Douglas Miller, who became a leader in neurosurgery and President of the Royal Australasian College of Surgeons. Both encouraged and taught a careful approach to physical examination, diagnosis and patient care. They provided a sound basis for my future clinical endeavours. I became a junior resident at Marrickville District Hospital in 1947. At that time, 18 months to two years after graduation saw most graduates enter general practice. I also aimed to do so. Marrickville Hospital was general practitioner oriented, with specialist honorary staff drawn from Royal Prince Alfred Hospital. These included role models like the late Sir Thomas Greenway, a charismatic, thoughtful and instructive physician, and Frank Mills, a friendly, insightful surgeon who had made his reputation in Changi and Sandakan in World War II. He visited his patients often and always left a dusting of his knowledge on the junior staff. Looking further afieldAfter 18 months and still attracted to general practice, it was time to move forward. Two positions presented themselves: one for a medical officer on Macquarie Island, the most southerly point of Oceania in the Australian Antarctic Basin; and the second, for Medical Superintendent at Collinsville, a small coal mining town in north Queensland. My colleague Bob Allison and I applied for both and were interviewed together by the Antarctic pioneer, Phillip Law, in front of the dying embers of the log fire in the common room of the (old) University Club in Phillip Street, Sydney. Bob went to Macquarie Island and I to Collinsville. As the only doctor in town, I enjoyed 18 months of rich clinical experience. Post-term obstetric deliveries, head injuries, critically ill children, motor vehicle accidents and accidents involving horses all hastened my clinical maturity. I remember a young jackeroo with a perinephric abscess after a nasty horse-related accident. As we were stranded by floods at the time, a surgeon in Mackay took me through the operative steps by phone. All ended well. The community was full of reliable, loyal Aussies with enormous hearts. They were openly friendly and had a great bank of skills, and gave their local doctor the comfort often absent today. An outbreak of croup in some young children was the most formidable of my experiences. They desperately needed steam inhalation, but I was a little nonplussed as to how to supply it. One father spoke with his boss at the mine workshop, who rapidly produced a large galvanised watering can with four arms, each capped with a watering-can rose. Placed on a primus stove, this device effectively dispensed steam to four mosquito-netted cots simultaneously. Problem solved! Surgeon by serendipityI was no longer sure that I wanted to pursue general practice and planned to undertake postgraduate work in the United States. I applied for several positions and was appointed to a rotating internship at Albany Medical College, New York State. At my request, it included a term of psychiatry. I arrived to take up my appointment in 1950, just as the Korean War began. Given my previous surgical experience, I was promptly moved from psychiatry to surgery. The experience was life-changing. As the American surgical residents were drafted to Korea, I was promoted after six months, subsequently accepting the offer of five years’ graduated surgical training in the Halsted tradition at Albany Medical Center. William Halsted had been Foundation Professor of Surgery at Johns Hopkins University in Baltimore, and laid the basis for graduated surgical training. This proved to be five years of restricted finances, but top professional fulfilment and growth. My workday would start with 5.30 am ward rounds (before the chief arrived at 7.30 am), followed by a day in theatre, then admissions and lab work before falling into bed. How much more civilised work practices are today. I was embarrassed when my previous senior resident returned from Korea to be my junior, and his view “c’est la guerre” was most generous and the basis of a long friendship. My training was predominantly in general surgery (with much exposure to thyroid surgery) and included my introduction to clinical investigation, which initially centred on bleeding varices and the monitoring of serum ammonia concentration.1 A three-month exchange with the Women’s Clinic at Johns Hopkins in Baltimore allowed me to work under the dynamic Richard Te Linde, Head of the Gynecology Department. Another privileged memory was witnessing the early development of cardiac surgery, as Alfred Blalock, under the watchful eye of cardiologist Helen Taussig, performed his “blue baby” procedure for tetralogy of Fallot and for alleviating the effects of congenital cardiac defects.2 My final 18 months were spent in Albany in thoracic surgery at the time of its greatest development, as the pump oxygenator was introduced. These five years were shared with a global workforce from 27 nations including Japan and Germany. The chiefs of medicine and surgery offered opportunity and education to all, hoping to heal wounds from World War II. This global experiment was clearly ahead of its time, and resulted in many firm international friendships. Being Australian was a significant plus, as Australia was popular after its Pacific role and genuine friendliness to US troops. In 1953, I married Mary Jo, whom I met in the operating room at Albany Medical Center. She has been my loyal supporter and valued confidante since. Return to Australia — spreading my wingsI returned to Sydney in 1955. Many doors were initially closed, but, with recommendations from mentors, I was eventually employed by Frank Rundle, Director of the Unit of Clinical Investigation at Royal North Shore Hospital (RNSH). After six months I received a full-time research fellowship with clinical responsibilities in my areas of interest, giving me the opportunity to be involved in thyroid surgery and studies; isotopes and cancer chemotherapy; a prospective database for thyroidectomy; and ultrasound of the breast. Thyroid clinic: I worked with Rundle in his multidisciplinary thyroid clinic and helped develop an animal experimental facility. This brought me into contact with Ian Monk, a cardiothoracic surgeon, who, with a pump expert, Viv Ebsary, was exploring open-heart surgery.3 The use of animals for experiments caused significant angst, especially when clandestine activity was required — such as transporting anaesthetised sheep by wheelbarrow to a ground floor angiographic facility for experimental studies. From such humble beginnings, the entire unit later evolved to become the Wellcome Laboratories. Rundle was a perfectionist, demanding that our every activity be of the highest safety and quality. The preoperative checklist was instituted (now indispensable in modern risk management) to ensure nothing was omitted in preparing patients. Every operative step was to be as haemostatic as possible,4 and postoperative care empathic and supportive. These requirements became expected of all who worked or trained in what later became the University of Sydney Academic Surgical Unit at RNSH. Cancer chemotherapy: A grant from the NSW State Cancer Council in 1958 enabled me to spend four months with cancer specialists Joe Burchenal and David Karnofsky (known for the Karnofsky Performance Scale for assessing terminally ill patients) at Memorial Sloan-Kettering Cancer Center in New York. I returned to initiate the provision of cytotoxic therapy at RNSH, which later established a formal medical oncology unit. Even then, the need to embrace randomisation and the careful accrual of evidence was seen as crucial.5-7 Thyroid database: On leaving the United States in 1955, I had been encouraged by my surgical mentors to embrace the computer age and “develop a prospective databank to record progress and results” — “outcome” as a word was still aborning. Our first cases at RNSH were accrued in 1957 and, over time, we honed the database into a useful clinical and research resource. All thyroid and parathyroid surgical procedures by the Endocrine Surgical Unit at RNSH are recorded, and at my retirement in 1988 numbered 10 000 entries. Intrathoracic goitre: During the period of compulsory mass x-ray surveys for pulmonary tuberculosis in Australia between 1948 and 1975, many people were diagnosed with intrathoracic goitre. A prevalence study we conducted in metropolitan Sydney in 1953–1956 showed that intrathoracic goitre occurred in 1/5040 subjects examined (compared with 1/750 with active tuberculosis and 1/3500 with lung cancer) (Box 1). Unexpectedly, the prevalence of intrathoracic goitre was about three times greater among people born in England (then the main source of immigrants) than in those born in Australia.8 Diagnosis of intrathoracic goitre improved with the introduction of computed tomography scanning, as did the safety of operative procedures. We used a surgical approach based on embryology — a transverse incision in the lower neck (a collar incision) — delivering the goitre into the neck, which, with appropriate control of vascularity, resulted in minimal sternal splitting and avoided a transthoracic approach.9 This technique was refined over time with much input from surgical colleagues Alan Poole and Leigh Delbridge (and the surgical registrars) and particularly our anaesthetist Bruce White. Superb scrub and bedside nursing helped to ensure success. This led to a rethink in the treatment of recurrent goitre and provided leadership in optimising total thyroidectomy for nodular goitre, now a widely accepted procedure despite earlier controversy.10-13 Breast ultrasound: A visit to RNSH in 1962 by George Kossoff (who with David Robinson in 1961 built the first ultrasound scanner at the Commonwealth Acoustic Laboratories) led to another fortunate and fruitful long term collaboration — ultrasound of the breast (Box 2). Surgery — academic and vascularIn 1961, Academic Clinical Units were established at RNSH, with the support of Sir John Loewenthal, then the Chair of Surgery at the University of Sydney. I was appointed Senior Lecturer in Surgery and subsequently became the inaugural Professor of Surgery in 1974. I believed, like Osler (quoting John Henry Newman), that: “An academical system without the personal influence of teachers upon pupils, is an Arctic winter.”18 Students were involved as far as possible in all unit activities, and teaching students and residents in the operating theatre became a major thrust of our program, although initially we were limited by a lack of full-time teachers.19,20 Graham Coupland was appointed senior lecturer in surgery in 1967 and was as great a friend and associate as I could have hoped for. With fellow surgeon Harry Cumberland, and encouraged by Douglas Piper, Professor of Medicine, he refined the investigation and surgical treatment of peptic ulcer, for which their preferred procedure was highly selective vagotomy.21 Coupland’s untimely death in 1982 came at a time of unit growth, as we taught exceptional undergraduates, trained bright young people of integrity, and produced quality surgery and research. Vascular surgery was developed by Douglas Tracy with my assistance.22 However, with his departure to the University of New South Wales in 1961, this specialty grew very demanding of those remaining — Ray Hollings, myself, and later Graham Coupland. Ruptured aneurysms, which require immediate surgery, became the bête noire of our social and family life. At that time, pagers, which were the size and weight of a house brick, only emitted an alarm, and a telephone call determined the reason for the call. In 1977, RNSH agreed to the appointment of a full-time academic vascular surgeon, Michael Appleberg, an excellent leader who took the department through to substantial strength in surgery,23 research and training. A stream of overseas and domestic visitors and interactive visits between the RNSH unit and overseas units promoted clinical and research strengths (Box 3). RetirementAll these activities have provided a springboard for continued enjoyment of life after I retired from academia in 1988. Elected President of the Royal Australasian College of Surgeons in 1989, I have travelled extensively in Australia and New Zealand. This experience has reinforced my perception that the exceptional compassion and service given in war are still given in peace. Australasian surgery and surgeons stand high with me. I was asked to report on quality assurance in clinical management to the Australian Government Department of Health,24 and now follow with interest the progress of the Australian Council for Safety and Quality in Health Care. As Chair of the working party developing the Clinical Practice guidelines on the management of early breast cancer25 and as a member of the board of the National Breast Cancer Centre (1995–2003), I have found it very satisfying to see women empowered to handle a life-threatening disease. Working with the Cancer Council Australia and the Clinical Oncological Society of Australia to develop the Australian Cancer Network has, since 1994, also kept me happily in contact with clinicians and consumers in promoting better cancer care. I have also maintained a clinical interest through surgical assisting. I have more time to “smell the roses” and travel with Mary Jo to see friends and enjoy our grandchildren in the United States, with side trips to Europe. I read more, but am unable to keep up with all the good books that are published. I also have time to think over the contrasts between then and now and what is to come. Surgery in 1947 was more uneven than today. There were top-level surgeons who performed to their level. A good deal of surgery, however, was done in small hospitals across the community, and too frequently exploratory laparotomy was performed for an obscure diagnosis. The limitations were primarily in training and diagnostic technology. The idea that doctors “owned” the patients was diminishing, but still prevalent. This limited patients in obtaining a second opinion, when perhaps it should have been embraced. I have observed changes and been pleased to have the opportunity to be involved, and sometimes been supportive in promoting change. Strong academic units centred in training hospitals across Australia have, together with the Royal Australasian College of Surgeons and specialist surgical societies, embraced strong mentoring and graduated and proficient training. The quality of surgery and hospitals has been improved by these educational and vocational developments. Australian patients have access to surgery of the highest quality. The future for surgery should know no limits, with increasing precision of diagnosis, limited wounding associated with surgical access, and developments in pharmacological and genetic interventions. Surgeons will be expected to understand and fully explain the complexities of many new approaches to treatment, some of which will not be operative surgery. The psychosocial aspects of surgery will reinforce the benefits patients should enjoy from the science and art of surgery, in which the level of trust between surgeon and patient must remain inviolable. I am delighted that opportunity for betterment for patients expands apace. Fortune has indeed smiled on me. As I look to the future, remembering colleagues, nurses, students and patients, I remain aware that I have gathered a posy of other men’s flowers and only the ribbon which binds them is mine (Sanskrit). 1 Age distribution of intrathoracic goitre detected by mass x-ray surveys for tuberculosis (1953–1956) Source: Reeve et al8 2 Development of breast ultrasound imaging — from weather maps to quality images Initial attempts to develop breast ultrasound involved many women volunteers and a bistable waterpath machine, which provided linear, sector and compound scans. Sonograms were initially derived through a water bath in contact with but above the patient. Water sometimes spilled (Figure A), or leaked (Figure B), saturating staff and patients, but not dampening their enthusiasm. Technology (Figures B and C) rapidly improved the quality of sonograms, and, in 1974, the patient’s comfort (Figure C). With Kossoff and his associate, Jack Jellins, ultrasonographer Kaye Griffiths and her team, surgical registrar Bruce Barraclough, and sonograms from our volunteers, we were able to determine the “normal” sonographic appearance of the breast. It was hard going until Kossoff introduced “grey-scale” contrast into sonography,14,15 which allowed tissue contrast and better identification of breast disease, a principle later applied to virtually all tissues16 and “leading to the widespread adoption of ultrasound throughout the world.”17 Ultrasound now plays a significant role in breast cancer diagnosis — no more wet shoes and soaked patients! A. CAL Closed water bag breast echoscope (1966). The bag was lowered onto the chest, and the transducer moved through the waterbath. Coupling with the skin was incomplete and the breast compressed. B. CAL Open water bag breast echoscope (1968). This method allowed for improved coupling to the breast and removed the problem of compression of tissue. The breast floated freely in a water bath. C. CAL Open water tank breast echoscope (1974). A new approach, patient prone and breast freely floating, thus eliminating the need for coupling drapes. (Photos courtesy of George Kossoff.) 3 International Surgical Week — International Association of Endocrine Surgeons, Hong Kong 1993. Back row: Joe Tjandra (Melbourne), Tom Reeve, Leigh Delbridge (Sydney). Front row: Raj Nambiar, Abu Rauf (Singapore), Martin Liepins (Riga, Latvia).

Tom Reeve AC, CBE, FRACS, Emeritus Professor of Surgery, The University of Sydney

A 68-year-old woman presented with cholelithiasis and common bile duct obstruction. Laboratory tests showed leukocytosis and raised serum alkaline phosphatase levels, but the eosinophil count was normal. Faecal microscopy was not performed. A roundworm (Ascaris lumbricoides) trapped in a T-tube Removal of the stones by means of endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy was unsuccessful because of difficulty catheterising and visualising the ampulla of Vater. After open cholecystectomy and exploration of the common bile duct, the sphincter of Oddi was dilated with bile duct dilators, and a T-tube was inserted before closure. After an uneventful postoperative period, the T-tube was removed 14 days after operation. A dead Ascaris lumbricoides roundworm was trapped in the T-tube. The patient was discharged 2 days later after receiving anthelmintic treatment. Abdominal ultrasound and stool examinations showed no abnormalities at follow-up after 1 month and 6 months. A. lumbricoides, the most common roundworm infecting humans, is endemic in areas where sanitation standards are poor. Adult worms normally reside in the upper gastrointestinal tract, but can migrate into any organ in the body, including the biliary tree (biliary ascariasis).1

Ilyas Baskonus MD · Gokturk Maralcan MD · Abdullah Serin · Necdet Aybasti MD

Sharps injuries experienced by surgeons are common, but are under-recognised and under-reported. The overall risks of transmission of blood-borne viruses to surgeons are low, with hepatitis C posing the greatest transmission risk. Recent trials show that early treatment of acute hepatitis C results in a cure rate approaching 100%. Surgeons and theatre staff should be encouraged to report and follow up sharps injuries to allow early detection and treatment. Additionally, because exposures to blood-borne viruses may be unrecognised, surgeons should have regular tests for blood-borne viruses. There should be no restriction of practice in the “window period” between potential exposure and obtaining results of testing, because of the overall low risk of transmission.

Katrina J R Watson MB BS, FRACP, MPH

The United Kingdom is currently introducing public reporting of performance information for individual cardiac surgeons. The reports will indicate whether a surgeon has an acceptable level of performance, measured by in-hospital mortality. In the United States, surgeon-specific performance data have been available for over a decade. Arguments from both safety and accountability perspectives provide strong justifications for public reporting of such data. Were Australia to adopt similar public reporting processes, we should learn from overseas experiences. Surgical associations should be actively involved in developing data standards and processes for data collection, validation, analysis and publication. Any Australian policy initiative for public reporting of individual surgeon data should be backed by a political commitment to adequate funding.

David A Neil PhD · Justin G Oakley PhD · Steve Clarke PhD

Darryl J Hodgkinson Director, Cosmetic and Restorative Surgery Clinic, Double Bay Day Surgery, 20 Manning Road, Double Bay, Sydney, NSW 2028. dr_hodgkinsonATbigpond.com To the Editor: I would like to congratulate Peters et al on their strong stance against elective surgery in patients who smoke.1 The plastic surgery community became aware in the last two decades of the problems of healing in smokers. When patients claimed that they gave up cigarette smoking before surgery, we often found that the serum cotinine levels on testing were elevated, indicating that they had not given up smoking. Patients who are smokers and who develop a healing complication, in breast reduction, mastopexy, abdominoplasty or a facelift, often attribute the complication to the surgical technique rather than their own habit. Many of these patients have gone on to litigate successfully. Voracious plaintiff lawyers attribute only a small amount of blame to the patient whose smoking has, in fact, contributed significantly to their complication. In our plastic surgery practice, we have a non-smoking policy, and my malpractice insurer will not cover me for patients on whom I operate and who develop a complication associated with smoking. Hence, all patients who are smokers who wish to have elective surgery are referred to a smoking-cessation program and have to have given up smoking for at least 2 to 4 weeks before surgery. I prefer not to operate on smokers at all, as serum cotinine tests often confirm that their cessation attempt has been incomplete. In the United States, where patients pay for their own health insurance, their premiums are adjusted for lifestyle. In Virginia, in the 1990s, a “Healthy Virginian policy” existed where premiums were reduced for non-smokers. My suggestion would be that the Medicare levy also be either reduced for individuals who do not smoke or increased for those who do.

Darryl J Hodgkinson

Nicholas A Tonti-Filippini Medical Ethicist, 15 Alburnum Crescent, Lower Templestowe, VIC 3107. ntf-dslATkeypoint.com.au To the Editor: Some time ago, I was approached by a general practitioner who had been trying for more than 12 months to arrange surgery for a patient who was suffering from intermittent claudication. The indications for surgery seemed compelling. The man was in great pain and disabled by the condition. The vascular unit at a major metropolitan hospital refused to operate on him while he remained a smoker. The man had been an alcoholic, but had managed to beat that addiction and had been “dry” for the entire 12 months. With the patient’s permission, and at the request of the GP, I contacted the surgeon. The surgeon explained to me that his refusal to provide elective surgery was on the grounds that the patient smoked, which would increase recovery time and the risk of complications. After discussion of the ethical and legal situation, an early appointment for surgery was arranged with the patient. Peters and colleagues, authors of a recent editorial on smoking cessation and elective surgery,1 would do well to attend to the terms of the Commonwealth Disability Discrimination Act 1992. It is unlawful for a person who provides services, or makes facilities available, to discriminate against another person on the grounds of the other person’s disability. It seems legitimate to consider the effects of smoking on success rates as part of deciding whether elective surgery is likely to be safe and effective for an individual patient. However, the editorial suggests that patients be denied surgery, such as joint reconstruction, as a resource-allocation decision, even if the surgery would be in their interests. It is important that smoking is recognised as an addiction. Some groups, such as the mentally ill, are particularly prone to it. A study by the Harvard medical school found that people with mental illness are twice as likely to be smokers, and nearly 45% of all smokers in the United States are people with a “mental disorder”.2 To the extent that it is an addiction, smoking needs to be considered as a medical condition in much the same way as alcoholism is referred to as a medical condition. A doctor who did not provide a needed treatment to a smoker on the grounds that the patient was a smoker would be in violation of that person’s fundamental human right to healthcare and his or her right not to be discriminated against because of a disability. In fact, the doctor would be in breach not only of the Hippocratic oath, but of the Australian Medical Association’s Code of Ethics 2004,3 which states “. . . refrain from denying treatment to your patient because of a judgement based on discrimination”.

Nicholas A Tonti-Filippini

Matthew J Peters,* Lucy C Morgan,† Laurence Gluch‡ *Head, Department of Thoracic Medicine, †Thoracic Physician, ‡ Surgeon, Department of Breast and Endocrine Surgery, Concord Repatriation General Hospital, Hospital Road, Concord, NSW 2137. matthew.petersATcs.nsw.gov.au In reply: The rigid way in which Hodgkinson has addressed risk reduction in plastic surgery seems reasonable, as long as there is open disclosure and access to smoking-cessation services is assured. It is an unfortunate fact that our healthcare system cannot provide everyone with what they want, or need, in a clinically appropriate timeframe. Resources are finite. In his own case example, and without considering the legal or ethical basis of his intervention, once Tonti-Filippini arranged for a patient at high risk of complications to have surgery, someone else was immediately prevented from having hospital care that was necessary for them. If complications developed, extending hospital stay, more than one patient might have been adversely affected. Let me extend Tonti-Filippini’s case a little and imagine that a similar patient with peripheral vascular disease who was moved further down the vascular surgery waiting list as a result of the smoker’s surgery being expedited was an ex-smoker who had taken advice and ceased smoking to reduce risks and improve the surgical outcome. Then, in the period of surgical delay, the affected leg became acutely ischaemic and amputation (rather than vascular reconstruction) was required. Are there not ethical implications that follow? Reading more deeply into the Australian Medical Association’s Code of Ethics, one finds that we should work to increase standards and the quality of and access to medical services in the community, and make available our special knowledge and skills to assist those responsible for allocating healthcare resources. These are important obligations. Most smokers are addicted, and this is a medical problem that needs to be consistently identified and addressed; the issue of smokers with mental illness was highlighted in the editorial. If a clinical decision is made not to perform surgery in the context of continued smoking, it is not made because the person is a smoker, or because they have an addiction, but because the ongoing smoking has major, adverse consequences that we are unwise to ignore. The distinction is subtle but important.

Matthew J Peters · Lucy C Morgan · Laurence Gluch

Sukhi Chand was born on 5 May 1938 in Fiji. He came to Australia in 1957 to study medicine at the University of Sydney, and graduated in 1963. After a 2-year residency at St Vincent’s Hospital, Darlinghurst, Sukhi was a tutor in anatomy for 3 years at the University of Queensland. From 1968 to 1969, he worked at Townsville General Hospital as an orthopaedic registrar and then a general surgical registrar. In 1970, after marrying Jenny, a nursing sister at Townsville General Hospital, Sukhi went to Launceston to continue his surgical training. He gained a Fellowship of the Royal College of Surgeons, Edinburgh, in 1973 and Fellowship of the Royal Australian College of Surgeons in the following year. Sukhi returned to Townsville in 1973 and entered general surgical practice. At that time he was appointed Consultant Surgeon to the Ayr District Hospital. He continued to serve the Burdekin community in Ayr until forced to retire because of ill health. He was a member of the Rotary Club of Mundingburra, in Townsville, for many years. Sukhi was a quietly spoken, patient and thoughtful man who devoted his life to his patients and their problems. Many of them became personal friends. His skill and proficiency, bonhomie and sense of humour were greatly appreciated by his colleagues. Outside his work commitments, Sukhi enjoyed spending time with his wife and four children. He also had a keen interest in the stockmarket — after some spectacular investment successes, his advice on shares was eagerly sought by colleagues and friends. His other great love was his farm. He hand-planted a large mango farm at Crystal Creek, just north of Townsville. He delighted in watching it grow to be a productive and successful venture. A cerebral complication after cardiac stenting left Sukhi markedly restricted, and forced his retirement from practice in 1997. During his prolonged and relentless illness, Jenny cared for Sukhi at home. He died on 7 April 2004. He is survived by Jenny, Anita, Andrew, Sunita and Sonya. A Denis Campbell

A Denis Campbell

Objective: To examine whether hospital patients with cancer who were identified as Indigenous were as likely to receive surgery for the cancer as non-Indigenous patients.Design, setting and patients: Epidemiological survey of all Western Australian (WA) patients who had a cancer registration in the state-based WA Record Linkage Project that mentioned cancer of the breast (1982–2000) or cancer of the lung or prostate (1982–2001).Main outcome measures: The likelihoods of receiving breast-conserving surgery or mastectomy for breast cancer, lung surgery for lung cancer, or radical or non-radical prostatectomy for prostate cancer were compared between the Indigenous and non-Indigenous populations using adjusted logistic regression analyses.Results: Indigenous people were less likely to receive surgery for their lung cancer (odds ratio [OR], 0.64; 95% CI, 0.41–0.98). Indigenous men were as likely as non-Indigenous men to receive non-radical prostatectomy (OR, 0.69; 95% CI, 0.40–1.17); only one Indigenous man out of 64 received radical prostatectomy. Indigenous women were as likely as non-Indigenous women to undergo breast-conserving surgery (OR, 0.86; 95% CI, 0.60–1.21).Conclusions: These results indicate a different pattern of surgical care for Indigenous patients in relation to lung and prostate, but not breast, cancer. Reasons for these disparities, such as treatment choice and barriers to care, require further investigation.

Sonja E Hall BA, MPH, RN · Caroline E Bulsara BA(Hons), GradDipEdStudies · Max K Bulsara BSc(Hons), MSc · Delia Hendrie BSc, MA · C D'Arcy J Holman MPH, PhD, FAFPHM · Timothy G Leahy FRACGP, MFM · Margaret R Culbong

Don Wurth died on 31 March 2004, after a 5-year decline with Lewy body dementia. He was a 50-year member of the Australian Medical Association. Don was born in Sydney on 1 January 1921, the oldest son of Wallace Wurth. He attended Fort Street High School and Sydney High School, and studied medicine at the University of Sydney, doing a compressed course during the war years. Don did his residency at Sydney Hospital, where all-night poker games featured prominently. His father, Director General of Manpower for the Commonwealth, keen to avoid any impression of privilege, made sure Don was one of the first in his year to enlist in the Army. After training at various camps, he was in the first wave landing at Balikpapan in Borneo. He gained valuable surgical experience in field hospitals. After demobilisation, Don worked his passage to England as a ship’s doctor, and gained his Fellowship of the Royal College of Surgeons in London in 1949. He married Ivy Field, a theatre sister at Barnet Hospital, in 1950, and returned to Sydney later that year. He settled in the Cronulla area, and performed the first operation at Sutherland District Hospital in 1958, where he was senior surgeon. He held appointments for many years at Prince Henry and Prince of Wales hospitals and the Royal Hospital for Women. Don was a clinical lecturer at the University of New South Wales, where his father, the University’s first President and Chancellor, had been instrumental in establishing the Wallace Wurth School of Medicine. Don trained many registrars and residents during his long career. His main love, after surgery, was jazz, and he used the opportunities opened up by admission to the American College of Surgeons to attend conferences and listen to jazz in many cities in the United States. However, his favourite city was always London, to which he returned many times. Don performed his last operation in 1986, but continued working in a consultant capacity for the next 5 years. He devoted the first part of his retirement to boating, his grandchildren, and his friend Val Derwin. He is survived by Val, his former wife Ivy, and children Graham, Peter, Jonathan and David. Peter Wurth

Peter Wurth

Barber-surgeons at work! This caricature from the 16th century shows barber-surgeons combining haircuts with various surgical tasks (from Hæger K. The illustrated history of surgery. London: Harold Starke, 1998). The tradition of addressing surgeons as “Mister” or “Miss” rather than “Doctor” is firmly entrenched in English surgical practice. This tradition is generally thought to have had its origins in the days of the “barber-surgeons”, after the Company of Barbers united with the various guilds of surgeons in 1540.1 The blade-wielding skills of barbers had given them opportunities for surgical practice, and “surgeons” at that time seldom had formal qualifications. Whether the two professions united for financial reasons or to bolster their numbers after the Black Plague of the 14th century is unclear.2 By the beginning of the 18th century, physicians and a few surgeon members of the Great Company of Barbers and Surgeons had gained university qualifications.3 All other surgeons were, quite naturally, addressed as “Mister”. With the separation of the surgeons from the Great Company of Barbers and Surgeons1 in 1745 and the establishment of the Royal College of Surgeons of London, the title “Mr” was retained and began to be seen as a label of status, as it marked the completion of formal examinations. The strong influence of the Royal College of Surgeons of England in the formative years of the Royal Australasian College of Surgeons (RACS) led to the persistence of the term in Australia. Anecdotally, the use of the term “Mr” appears to be losing favour, at least in New South Wales, and we sought to determine the prevalence of “Mr’s” among urologists in New South Wales and Victoria. MethodsPractising urologists with workplace addresses listed as NSW or Victoria were identified from the List of Members 2003 booklet of the Urological Society of Australasia.3 Data were collected from the letterheads (or signatures on letters) of practising urologists and, if letters were not available, by contacting urologists’ secretaries by telephone. The level of membership and year of attainment were recorded from the booklet. ResultsOf a total of 134 urologists, data about preferred title were collected from 69 with practice addresses in NSW and 56 with practices in Victoria (response rate, 93%). Year of commencing Society membership ranged from 1963 to 2002. The preferred title across NSW was “Dr”, whereas “Mr” predominated in Victoria (Box). Five Victorian urologists preferred the title “Dr” included among these were all the female urologists contacted who were practising in Victoria. DiscussionThe use of the title “Mr” among NSW urologists appears to have become obsolete. As NSW is the state with the most urologists, the umbrella title of “Mr”, as dictated by English tradition, can no longer be used for male urologists. The first female urologist in Australia completed her training in 1993, and currently about 10 women are practising as urologists in Australia. Greater numbers of women are entering urological surgery training, and, at the time of writing, there are 10 female trainees in advanced urological training posts across Australia. The use of the salutation “Dr” among female urologists, in states where “Mr” is used for male urologists, potentially may cause some confusion — patients may be uncertain of their surgeon’s qualifications. Female surgeons in the United Kingdom are traditionally addressed as “Miss”, regardless of marital status, but convention has expanded to include more recently “Ms” and “Mrs”.4,5 The attitudes and practices of surgeons across Australia, as well as the shift to more women in the profession, should be reflected in surgeons’ titles, and consideration given to phasing out the archaic title of “Mr”. Title preferred by urologists in New South Wales and Victoria Title NSW VIC Doctor 63 (91.3%) 5 (8.9%) Mister 0 48 (85.7%) None 5 (7.2%) 1 (1.8%) Professor 1 (1.4%) 2 (3.6%) Total 69 (100.0%) 56 (100.0%)

Clair Whelan MB BS · Henry H Woo MB BS, FRACS(Urol)

Smokers who undergo surgery have higher risks and are a greater burden on healthcare resources. Is it acceptable to give them lower priority on surgical waiting lists? A wide range of elective surgical procedures should not be offered to smokers who do not try or do not succeed in quitting. There is no denying that this approach is controversial and overtly discriminatory, but it is also evidence-based. New concerns are not based on well-recognised cardiac and respiratory risks, but on increased risks of wound infection and the adverse complications that ensue. The extent of this evidence is such that it is no longer possible for surgeons and others in the healthcare system to ignore it. What, then, is the evidence? Wound infection rates are higher in smokers than in non-smokers who have had joint replacement surgery,1 breast reconstruction,2 “facelifts”, and a variety of other plastic surgery procedures.3 For example, with breast reconstruction, abdominal-wall site necrosis is seen in 7.9% of current smokers compared with 1% of non-smokers, and mastectomy-flap necrosis in 7.7% of smokers compared with 1.5% of non-smokers.2 Furthermore, after abdominoplasty, secondary surgery for dehiscence was necessary in 24% of smokers and 8.2% of non-smokers.4 In a randomised study examining smoking cessation intervention before joint replacement surgery, wound infection rates were reduced from 27% in continuing smokers to zero in those who quit smoking.1 Reduction rather than cessation in smoking is inadequate.1 Infection rates in parasacral incisions made to remove punch biopsy scars were reduced from 12% to 2% in those who abstained from smoking for 4 weeks, while, in the same study, wound ruptures occurred in 12% of smokers but in no non-smokers.5 The optimum period of smoking cessation is uncertain but it is probably at least 6 weeks. Periods of smoking cessation of less than 3 weeks before colorectal surgery are not associated with a benefit.6 The mechanism for the increased wound infection rate is not clear. Tobacco combustion produces more than 3000 products. Nicotine, the best known of these, is a potent vasoconstrictor and impairs revascularisation of bone.3 Reassuringly, nicotine replacement treatment, used to assist smoking cessation, does not increase infection rates in experimental incisions5 or after joint replacement surgery.1 Of the many other combustion products, carbon monoxide decreases tissue oxygenation and a range of other compounds impair the microcirculation. In surgical wounds, there is relative hypoxia in smokers to an extent that is known to impair wound healing in animals.7 Wound infections are never trivial, but in certain clinical situations they can have particular, deleterious sequelae. Immediate breast reconstruction may be desirable for some patients after mastectomy. An infected prosthesis, or necrosis of a flap or tissue donor site, can delay important adjuvant chemotherapy or radiotherapy. Wound infection after joint replacement surgery is associated with increased risk of infection in the prosthesis,8 delays in hospital discharge, increased time to effective rehabilitation and massively increased cost of hospital care. The extent to which doctors seek, and the wider community provides, permission for discrimination is an issue for serious community debate. An essential part of a surgeon’s role is to be selective in choosing who to operate on, and when, in line with current evidence. Policies and practices that flow from this may be regarded by the healthcare community as discriminating, but by smokers and the wider community as discriminatory. Continuing smokers must accept that some risks are simply unacceptable given the intent of the surgery. To put the smoking-related risk in context in orthopaedic surgery, the adverse effect of failing to quit smoking is similar to that of omitting antibiotic prophylaxis.9 The risk of adverse outcomes from wound infections alone is clear enough evidence to suggest that aesthetic plastic surgery should not be offered to current smokers, and that surgery should be delayed for 6 weeks after cessation. Doing otherwise would be simply foolish. Joint replacement surgery presents a different decision-making framework. Patients are likely to have had time to consider and address cessation of smoking. In relation to an individual, pain and limitation of mobility may be deemed sufficient to justify a procedure, despite an increased risk associated with continuing to smoke. However, public health systems are faced with overwhelming demand and must generate the greatest benefit from limited resources. If smokers, as a group, have a reversible factor that causes a longer hospital stay, incurs greater costs and leads to poorer outcomes, might it be reasonable to allocate them a lower priority? Given that the end of a joint replacement waiting list is likely never to be reached, allocating smokers a lower priority could be tantamount to an indefinite deferral of surgery for a smoker unable to quit. A recent Victorian study found that less than 10% of smokers having day-stay surgery recalled being advised by their surgeon or general practitioner to quit smoking.10 Clearly the medical community needs to do better. The message to the wider community is this: continued smoking in the face of elective surgery increases the risk to the individual and stretches the already stretched healthcare resources and expenditure unnecessarily. The community has to decide whether this waste is justified. Critically, if discriminatory policies are implemented, they must be matched by a commitment to fully and effectively support smokers in quitting, which is an altogether different challenge. This applies particularly to smokers who are already socioeconomically disadvantaged and those with mental illness. Failure to help these individuals risks exacerbating existing health and economic inequalities.

Matthew J Peters · Lucy C Morgan · Laurence Gluch

Clinical records Patient 1 A 77-year-old woman was referred to us for an urgent surgical opinion regarding an abdominal mass. Fifteen months previously, she had been referred to a major metropolitan hospital with symptomatic iron deficiency anaemia, and weight loss of 5 kg in 6 months. Gastroscopy, colonoscopy and abdominal CT scan were unremarkable. There were no clinical features to suggest malabsorption, nutritional deficiency or inflammatory bowel disease. A diagnosis of angiodysplasia was considered, although there was no direct evidence of this. The patient received a 5-unit blood transfusion and iron supplements. During the 7 months after initial presentation, she was seen in medical outpatient clinics six times. Over the next 8 months, she was admitted six times, transfused 13 units of red cells, and given two iron infusions. A labelled red cell scan showed no gastrointestinal bleeding. An abdominal ultrasound was unremarkable. Results of investigations for coeliac disease and pernicious anaemia were normal. A bone marrow biopsy was consistent with iron deficiency anaemia. On one occasion, the admitting registrar considered a small bowel follow-through, but this was not performed. Paroxysmal nocturnal haemoglobinuria was excluded. During the last of these admissions, a firm abdominal mass was palpated. A computed tomography (CT) scan revealed an 8 cm heterogeneously enhancing soft tissue mass in the proximal jejunum. Lymphoma was considered the most likely diagnosis, and the patient was referred to our department. Push enteroscopy revealed an ulcerated adenocarcinoma in the proximal jejunum (A). A 10 cm, poorly differentiated jejunal adenocarcinoma was resected. Eleven months after surgery, the patient has shown no further symptoms of anaemia, and no evidence of recurrence. Patient 2 A 68-year-old man was admitted to our department for laparotomy for a small bowel tumour. The patient had a past history of an open cholecystectomy. Twenty-eight months before admission, he had been referred to a gastroenterologist with symptoms of gastro-oesophageal reflux disease; he underwent gastroscopy, which showed reflux oesophagitis, and was treated with proton pump inhibitors. Eleven months later, he was referred to a gastroenterologist again with persistent symptoms. He was seen several times in the next 9 months, and was then admitted to a general surgical service of a metropolitan hospital with abdominal pain. A provisional diagnosis of small bowel obstruction was made, and the patient was discharged the following day once his pain had settled. Twice during the next 5 months, he presented to the emergency department with abdominal pain, nausea and vomiting. His symptoms settled with analgesia and fluids. Persistent retrosternal pain had not been helped by a variety of H2 antagonists, proton pump inhibitors or prokinetic agents. He was admitted to our surgical service after presenting on two successive days with severe epigastric pain. Upper gastrointestinal endoscopy showed severe reflux oesophagitis. The first and second parts of the duodenum were normal. Abdominal CT showed a circumferential mass in the proximal jejunum with dilation of proximal bowel (B). Small bowel follow-through then showed an annular, stenosing lesion in the region of the duodenojejunal flexure. At laparotomy, a localised adenocarcinoma was resected (C). The patient had adjuvant chemotherapy and 12 months after surgery was asymptomatic, taking no medication, and had no evidence of recurrence. A: Small bowel carcinoma detected on push enteroscopy (Patient 1). B: Abdominal CT scan showing a large dilated small bowel loop in the left upper quadrant (Patient 2). C: Operative specimen showing a localised, constricting cancer (Patient 2). Small bowel carcinoma is rare compared with gastric and colorectal cancer. Fifty-eight cases were reported in Victoria in 2001.1 Although the small bowel comprises 75% of the gastrointestinal tract length, less than 2% of gastrointestinal malignancies arise there.2-6 Adenocarcinoma accounts for 40% of small bowel malignancies; others include carcinoids, lymphomas and gastrointestinal stromal tumours, as well as metastases from melanoma, breast, lung and renal cancer.3,5,6 Small bowel tumours are rarely considered as a differential diagnosis, and their discovery is usually greeted with surprise. They are much more common in patients with coeliac disease (risk of lymphoma) and in hereditary bowel cancer syndromes (hereditary non-polyposis colorectal cancer, familial adenomatous polyposis, and Peutz–Jegher syndrome).2,4,6 Thus, small bowel tumours must be considered in patients with a family history of bowel cancer. A low index of suspicion for small bowel tumours is a result of their relative rarity, but delayed diagnosis may reduce the chance of successful treatment. Reasons for diagnostic delay include the non-specific presentation, the lack of awareness of the diagnosis and the inaccessibility of the small bowel to investigation. In one analysis of 77 consecutive patients with primary small bowel malignancy over 22 years, average delays were 2 months before presentation to primary care physicians, 8 months from presentation until appropriate investigation, and 12 months from presentation until definitive diagnosis.7 Our first patient represents a common scenario. A patient with iron deficiency anaemia had investigations to exclude gastroduodenal, colonic, and extra-intestinal sources of blood loss. The inaccessibility of the small bowel to investigation resulted in a 15-month delay to diagnosis of a small bowel adenocarcinoma. An abdominal computed tomography (CT) scan performed early in the investigation of anaemia failed to show any disease, and the patient’s symptoms were attributed to intestinal angiodysplasia, a diagnosis that is difficult to confirm. The failure to perform small bowel follow-through, despite its low sensitivity, may have contributed to the delay in diagnosis. Our second patient highlights the non-specific way in which small bowel adenocarcinoma can present. The patient presented with symptoms of reflux oesophagitis refractory to treatment. The abdominal CT scan was the pivotal investigation that alerted clinicians to a lesion in the jejunum. CT is frequently used to assess the abdominal cavity. The accuracy of abdominal CT in detecting primary small bowel tumours is poor — reported as 57% in one study of 85 patients.5 It is a useful staging procedure, but, given the poor sensitivity for small bowel pathology, abdominal CT should be used in concert with other imaging modalities. Barium contrast studies are the standard test for intraluminal or mucosal abnormalities beyond the duodenojejunal flexure, but have limited sensitivity.3-5 Small bowel enteroclysis is more sensitive than small bowel follow-through,8 and involves delivery of barium to the small bowel via an intestinal tube. Push enteroscopy, using a paediatric colonoscope, is an alternative, but does not visualise the entire small bowel. Video capsule endoscopy has shown promise in the diagnosis of small bowel disorders.9,10 It is not yet widely available, and further trials are required before its role is defined. It is contraindicated when small bowel strictures are suspected, so should be preceded by small bowel follow-through in these cases.9,10 Early studies show that it is more accurate than small bowel follow-through,9,10 so, when there is a strong clinical suspicion of small bowel pathology, patients should be referred to a specialist centre. Occasionally, exploratory surgery is appropriate, particularly when anaemia and abdominal pain coexist and the results of all other investigations have been negative. ConclusionThis report highlights the difficulties in diagnosing small bowel tumours. The diagnosis requires a high index of suspicion and early investigation. Iron deficiency anaemia in an older patient with normal results of endoscopic studies is not an uncommon clinical scenario. Small bowel malignancy should be considered when more common causes have been excluded, especially if there are general features suggestive of malignancy, such as anorexia, abdominal pain or weight loss. Abdominal CT scan coupled with small bowel follow-through is the minimum requirement. If this is negative, further investigation in a specialist centre should be considered. Lessons from practice Small bowel malignancy should be considered in cases of unexplained gastrointestinal bleeding, anaemia or obscure abdominal symptoms. Abdominal computed tomography scan and small bowel barium studies are minimum requirements for investigation, but have limited sensitivity. Capsule enteroscopy appears to be more accurate than barium studies and may have an increasing role in these cases as it becomes available.

Ronil V Chandra MB BS · Julie A Miller MD, FRACS · Ian T Jones MB BS, FRACS · Brett Manley MB BS · G Bruce Mann MB BS, PhD, FRACS

QuestionCan smokers be assisted in giving up smoking before elective surgery and does this reduce complications? Trial detailsDesign: Randomised controlled trial of preoperative smoking intervention in patients undergoing hip and knee replacement surgery. Setting: Three university-affiliated hospitals in Denmark. Patients: 62 women and 46 men aged 30–85 years, scheduled for surgery in 6–8 weeks. A further 12 patients were recruited to the trial, but were not included in the analysis because their operations had been postponed or cancelled. Median (range) of smoking exposure was 15 (3–30) cigarettes per day. Interventions: Weekly counselling with a project nurse and the option of nicotine replacement therapy. The first meeting included a questionnaire to measure nicotine dependence and a personalised nicotine substitution schedule was devised. The patients were strongly encouraged to stop smoking completely, or to at least reduce their tobacco consumption by at least 50%. At all subsequent meetings, tobacco consumption was recorded and patients were advised on how to manage immediate withdrawal symptoms and how to keep weight gain to a minimum. Main outcome measures: Frequency of postoperative complications. Main results: The overall complication rate was 18% in the intervention group and 52% in controls (P = 0.0003). These included wound-related complications (5% v 31%; P = 0.001), cardiovascular complications (0 v 10%; P = 0.08), and secondary surgery (4% v 15%; P = 0.07). The median length of stay was 11 days (range, 7–55 days) in the intervention group and 13 days (range, 8–65 days) in the control group (P = 0.41). Overall relative risk reduction was 65% and the number needed to treat (NNT) to avoid any complication was 3 (95% CI, 2–6). In addition, the NNT to avoid wound infection was 4 and the NNT to avoid secondary surgery was 9. Conclusion: A smoking intervention program before surgery can help smokers quit and is associated with a reduction in postoperative complications. CommentaryRationale for the trialSmoking increases the risk of complications in patients undergoing surgery, and it is usual practice to recommend stopping smoking for at least 6 weeks beforehand. 1-3 About 25% of all patients who undergo surgery are current smokers. Studies of the adverse effects of smoking in surgical patients have mostly focused on cardiopulmonary risk reduction, but recent studies identify an association with wound infection. 4,5 Trial methodsThe trial was very well conducted and interpreted, but some aspects deserve closer scrutiny. The intervention period was 6–8 weeks before and 10 days after the operation. In Australia, many patients undergoing elective surgery have their operations booked within a few weeks, and so may not have an opportunity to participate in such a program. A shorter intervention program may not be effective, which raises the question of whether surgery ought to be delayed to allow such a program to be instituted. The intervention program included many components: counselling with a project nurse, additional information and support for patients, smoking cessation or reduction, and use of nicotine replacement therapy. Each could have contributed to the reduction in complications. Nicotine substitution products were provided without charge. If smokers were asked to pay, they may be less willing to participate. In this study, 46 patients (of 166) refused to participate. Patients who refused may have been heavier smokers, and could have been more at risk of complications, despite a short-term change in smoking behaviour. This could affect the generalisability of the results. The study population was restricted to orthopaedic patients. It is yet to be determined if this intervention can be effective in patients undergoing procedures associated with a higher risk of pulmonary complications, such as abdominal or thoracic surgery. Patients in the control group received standard care, with little or no information about the risk of tobacco smoking or smoking cessation counselling. Some readers may believe that this does not represent contemporary Australian practice, but most smokers do not quit in any case.4 Twelve patients were excluded from the analysis because of cancellation or postponement of surgery. An additional analysis of the entire intention-to-treat population could be expected to reduce the estimated risk reduction and increase the number needed to treat (NNT). New informationSmoking cessation or at least 50% smoking reduction occurred far more frequently in the smoking intervention group — 36 patients, compared with four in the control group, stopped smoking. This study found an impressive reduction in the rate of postoperative wound complications among patients who underwent the smoking intervention program. Implications for clinical practiceThis trial identified a simple and effective intervention that reduces wound complications after orthopaedic surgery. The study was unable to show an impact on postoperative pulmonary morbidity, but this may have been because orthopaedic procedures are associated with a relatively low risk of pulmonary complications. Other information suggests that extrapolating these findings to patients undergoing other types of surgery might be beneficial. 1-6 The extent of the risk reduction attributable to smoking cessation is consistent with Australian data for smokers having other types of surgery on a day-stay basis.4 This effect is substantial, and highlights a need to identify smoking status before elective surgery to enable an effective intervention to be offered. The known risks of smoking and the benefits of stopping smoking should be made clear to patients. Are doctors doing enough to stop their patients smoking? There are reports of successful smoking intervention programs targeting hospital patients.7 There has been considerable success in reducing coronary heart disease risk factor levels and improving general health status, including reduced anxiety and depression, in patients awaiting coronary artery bypass graft surgery.7 Nicotine replacement and bupropion therapy can be useful adjuncts.8 Community smoking intervention programs are cost-effective, especially when absenteeism, premature disability and death are taken into consideration.9 Additional cost savings could be expected if such programs were used for patients requiring elective surgery, in view of the marked additional costs of increased need for intensive care and treating complications.

Paul S Myles MD, FRARCSI, FANZCA

Sandy J Berenger,* John K Ferguson† * Area Infection Control Consultant (and Clinical Nurse Consultant, Hunter Area Pathology Service, University of Newcastle), † Director, Department of Microbiology and Infectious Diseases, John Hunter Hospital, Locked Bag 1, Newcastle, NSW 2310. sberengerAThunter.health.nsw.gov.au To the Editor: Collignon and colleagues decry the reuse of “single-use” medical devices.1 Unfortunately, the focus on reuse of items labelled as single-use detracts attention from some of the more serious issues with cleaning of reusable instruments. All hospitals have cleaning failures that occur because some instruments are virtually impossible to clean. Examples include hollow instruments such as bone reamers, biopsy needles and tissue forceps. The actual sterilisation process (as described under Australian Standard [AS] 41872) is not at issue here. Rather, it is the poor design of instruments, and the lack of any standardised assessment process to determine whether an item is capable of being cleaned against that standard. One study found that most “sterilised” artery forceps had residual tissue, visible by light microscopy, representing an unknown, but real, infection risk.3 Most Australian hospitals do not examine surgical instruments under the microscope for grooves or cracks, and instrument sets remain in circulation for many years. In contrast, the most common “single use” critical items that are reused in many Australian hospitals are electrophysiological stimulation (EPS) and aberrant cardiac pathway ablation catheters; there have been no reports of significant mechanical or patient safety issues from reuse of a wide range of cardiac catheters, including EPS and ablation catheters.4 The sterilisation process itself has been validated for these items.5 At John Hunter Hospital, the process of reuse is controlled by a quality system that is far more stringent than the existing AS 4187 Standard. Devices are used for a set number of times before discard, and each catheter use is tracked to the specific patient and procedure. After cleaning, each catheter is examined under x 10 magnification to detect defects. The catheters are tested electrically at the point of use and patient consent is obtained before the procedure. The John Hunter Hospital program has operated for 6 years with an estimated cumulative cost saving of $6 million (compared with no reuse). Patient outcomes are monitored, and no adverse events have been detected. Clinicians express a high degree of satisfaction with the program. The same standard of equipment design, assessment and cleaning should be applied to all instruments that contact sterile tissue. Whether or not a company chooses to label its product “single-use” should not determine whether the item should or should not be reused. More often than not, such labelling serves to benefit financial return rather than patient safety. Hughes entreats us to cease reuse practices until there is incontrovertible proof of the safety of reuse.6 This statement should also apply to routine surgical items. In this era of zero risk tolerance, perhaps the consent process should make patients aware that reusable instruments processed under AS 4187 cannot be guaranteed to be free from human tissue contamination.

Sandy J Berenger · John K Ferguson

Clifford F Hughes Head, Department of Cardiothoracic Surgery, Royal Prince Alfred Medical Centre, Suite 304, 100 Carillon Avenue, Newtown, NSW 2042 (and former Chairman, Therapeutic Device Evaluation Committee). clifford.hughesATemail.cs.nsw.gov.au In reply: Berenger and Ferguson correctly raise the issue of sterilisation procedures for devices used in surgery. They have also described specific measures taken at their hospital for a specific device and, more importantly, have developed a system to ensure the highest quality of sterilisation process in a medical device. Of course, the use of any surgical device should be subject to the strictest sterilisation procedures. Most reuseable surgical instruments do have documented sterilisation protocols which include verification of the process used. All surgical instruments, whether designed for reuse or not, whether used for the first time or the tenth time, should be subject to the scrutiny, surveillance and meticulous records demonstrated by the John Hunter Hospital system. This hospital is to be congratulated on its attention to detail. Were similar stringent protocols in place across all disciplines and in all hospitals, the debate would cease to rage. More importantly, many devices could be safely and efficiently reused. Others may be considered too difficult to resterilise. Nevertheless, asepsis would, once again, be positioned where it belongs, as one of the key principles of surgery.

Clifford F Hughes

Ethical eye: Transplants. Peter Morris (editor). Strasbourg: Council of Europe, 2003 (258 pp). ISBN 92 871 4779 5. Through its Ethical eye series, the Council of Europe has addressed a number of recent developments in science and technology, including cloning and the human genome. The series aims to outline the ethical issues relating to each topic and to make these topics accessible to as wide an audience as possible. The most recent volume, edited by the eminent transplant surgeon, Sir Peter Morris, addresses the ethics of solid organ transplantation. The organisation of this collection is anachronistic and this provides a clue to its strengths and weaknesses. It begins with a historical review of transplantation and then considers a series of ethical issues raised by transplantation, including threats to identity, xenotransplantation, brain death, rights and duties, the media, conflict between individual benefit and the “common good”, and the appropriate limits of transplantation. The remaining sections cover transplantation practices in Europe, including religious perspectives. While the division of chapters according to national boundaries may seem of little relevance to non-European readers, the format actually provides tangible local exempla of many of the topical issues in transplantation, including presumed consent, cultural determinants of organ donation and organ commerce. The section dealing with religion and transplantation is excellent in its philosophical depth and practical clarity. The book discusses organ donation and transplantation in terms of issues relevant to Christianity, Buddhism, Islam and Judaism. This is invaluable and often lacking in other texts. As with all multiauthored works there is some unevenness in the contributions. A practitioner, not a patient, wrote the chapter called “Patients’ perspective” (a problem common to many medical texts), and several chapters lack references for further reading. Perhaps the weakest of the contributions is the chapter entitled “Agnostic ethics”, which is almost completely lacking in logical and philosophical substance. This book does not provide a comprehensive coverage of the ethics of transplantation, but it does provide a fascinating overview of the ethical, cultural and sociopolitical context of transplantation using examples from contemporary European practice. It is written in an engaging and accessible style that will be of interest both to the professional and the lay reader. Ian H KerridgeAssociate Professor of Bioethics Centre for Values, Ethics and the Law in Medicine University of Sydney, NSW

Ian H Kerridge

Objective: To audit the appropriateness of use of a troponin I assay in three hospitals.Design: Cross-sectional survey of use of a troponin assay.Setting: Three hospitals in Melbourne, Victoria, each with an emergency department and a coronary care unit.Participants: Patients for whom a troponin I assay was requested between 1 and 7 May 2002, 27–42 months after introduction of the assay.Interventions: User-focused dissemination of relevant information, including protocols for use, from opinion leaders when the assay was introduced; continuous reinforcement of information in pathology reports.Main outcome measures: Adherence to protocol for assay use.Results: Troponin assays were requested for 333 patients during 351 symptom episodes. A single assay was used in 194 symptom episodes (55%), and serial assays in 157 (45%); proportions were statistically indistinguishable across all three hospitals (χ2; P = 0.71). Of the 194 single assays, 13 (7%) diagnosed a myocardial infarction. Serial troponin testing in all three hospitals followed the suggested protocol, with mean time between serial assays being more than 6 hours at all hospitals.Conclusions: Adherence to the protocol for serial troponin assay intervals was adequate, but single troponin assays were used extensively and probably inappropriately.

Richard X Davey FRCPA, FACB

Ted Stuckey epitomised "quiet achievement". Born on 15 June 1908, he grew up in Inverell, in northern New South Wales, where he was dux of his school. Later, as a medical student living at St Andrew's College, Sydney University, he excelled academically and in sport. He represented the College in rowing, and played hockey for the College, the University, and a combined Australian universities' team. After doing his residency at the Royal Prince Alfred Hospital and the Royal Alexandra Hospital for Children (RAHC), Ted married Joan Vowell and moved into general practice in Scone, NSW. While working in this practice he obtained his Master of Surgery degree. Ted returned to Sydney in 1939 to become a paediatric surgeon, and was appointed Honorary Relieving Assistant Surgeon at RAHC. When war intervened, he joined the Field Ambulance Service. He served until late 1944 in Queensland, then New Guinea, becoming second-in-charge of the 111th Casualty Clearing Station and attaining the rank of Major. From 1945, as Honorary Assistant Surgeon at RAHC, Ted and his colleagues did pioneering work in cardiothoracic and abdominal surgery. Ted's brother Doug was also part of the Congenital Heart Disease team that was involved in the early development of cardiac catheterisation and angiocardiography. In 1948, Ted gained his Fellowship of the Royal Australasian College of Surgeons. In 1958 he was awarded a Fulbright scholarship to study at Harvard Medical School. From 1958 to 1966 he lectured in paediatric surgery at the University of Sydney. He continued at RAHC as an Honorary Consultant Surgeon until 1973. In later years, Ted adopted a more relaxed lifestyle, doing sessional work with the Commonwealth Health Department until 1988 and Surgical Assistant work until 1994 (then aged 86!). Ted was a founding member of the Medical Benefits Fund in 1945 and served on its Council until 1971. He was also heavily involved with the Australian Medical Association. He was a member (1953–1966) and president (1961–1962) of the NSW Branch Council; a member of the AMA Federal Council (1964–1966); Assistant General Secretary, then Deputy Secretary General (1966–1972); and Secretary General (1972–1973). He was made a Fellow of the AMA in 1964. He was secretary of the AMA/benefit fund working party, which produced a plan for a voluntary health insurance scheme that was largely adopted by the federal government and introduced in 1970. He was also a member of the Medical Benefits Schedule Advisory Committee. Although deeply committed to his profession, Ted remained a devoted husband and father to his five children. Over the years, he built for his family a swimming pool, a terraced garden with a badminton court, and three unique folding caravans in which he loved to take them on camping holidays. Ted died on 7 June 2002 of acute renal failure.

Michael EV Stuckey MB BS FRCS FRACS

Publicly available reports of "surgical waiting times" are, at face value, of interest to patients and referring doctors wishing to access surgical care. Such information might be expected to provide a reasonable indication of the absolute time to surgical intervention for an individual patient, and allow reasonable conclusions to be drawn on the relative performance (in terms of waiting times) of surgical services. Definition Healthcare performance indicators: statistics or other units of information which reflect, directly or indirectly, the performance of the healthcare system in maintaining or increasing the well-being of its target population. Surgical waiting times are a specific example of "healthcare performance indicators" (see Definition). In addition to providing information for users, such indicators are likely to inform the opinions of politicians, journalists, hospital managers and state and federal health departments on the adequacy of our healthcare system and relative hospital or regional performances. They may be used to construct "league tables" of the relative performance of surgical units — individual hospitals, surgical units or surgeons may be deemed to have "good" or even "substandard" performance. Public outcries and political pointscoring are likely to ensue. Good indicators should be easy to understand and use by the intended audience. Depending on how these data are collected, processed and presented, reported waiting time data might or might not provide useful information to people seeking guidance on time to treatment. Reports of surgical waiting times that use different definitions of "waiting time", or simply report on past performance, are of limited value. Waiting time data presented as the frequency with which a certain proportion of patients receive treatment within a stated time (eg, 75% treated within 4 weeks) may also fail to adequately inform patients or general practitioners as to likely delays. Few existing systems are capable of adjusting for delays before initial surgical consultation (ie, waiting time to get onto the surgical waiting list), let alone factors such as primary illness severity, comorbidity or health insurance status — all of which influence actual waiting times. In this issue of the Journal (page 253), Cromwell et al report an assessment of the utility of information regarding surgical waiting times available on the World Wide Web.1 Their findings indicate that current Web-derived information has significant shortcomings in data quality. They conclude that waiting time data currently published on the Web are, by and large, unsuitable for informing either clinician referral or patient decision-making.1 This critique should not be misinterpreted as an example of the well-recognised "dot.com" data reliability phenomenon. It is not just Web-based sources of such data that are open to criticism. Analysis of healthcare performance indicator data derived from any existing sources would generate similar critiques, with similar caveats required on interpretation and use.2,3 The appropriate desire to develop performance indicators in healthcare has often seen a race to deliver indicators overwhelm the need for methodological rigour in development and implementation. All too often, too little emphasis is placed on initial identification of who will use the indicator and how and why they will apply the data. The absence of such ab initio clarity of purpose leads to performance indicators that do not meet the needs and expectations of consumers, providers or purchasers of healthcare services.2-5 Surgical waiting times, and many other indicators, generate a natural curiosity to compare or rank relative performance. For comparisons to be made, common indicator definitions must exist and be systematically applied in data generation, with common data collection methodologies and results that are risk-adjusted. As Cromwell et al found, requirements for clear, consistent definitions are frequently not met, rendering comparisons invalid.2-8 It is crucial that people intending to use indicator data for judging comparative performance, or in any potentially punitive fashion, fully understand the strengths and weaknesses of the primary data. Perhaps the greatest error by those who use indicator data is that of assuming the indicator is an objective measure of relative performance based solely upon its apparent face validity. Reported surgical waiting times would then be assumed to be a direct linear measure of access to care. This ignores evidence that clinician decision-making processes and administrative practices have major impacts on reported waiting times. Without adjustment for relative urgency or disease severity (at a minimum), reports of waiting times are of limited utility. Significant progress has been made in developing and refining healthcare performance measurement locally (by the Australian Council on Healthcare Standards among others) and internationally (by groups such as the Joint Commission on Accreditation of Healthcare Organisations and the Health Care Financing Administration in North America). There is, however, still considerable scope for improving the methodological rigour of both indicator development and application in the field. At present, the reliability and utility of indicator data cannot be assumed. Most current indicators of healthcare performance should be viewed as tools that prompt additional inquiry, rather than allowing definitive judgements on quality and safety of care. Over time, robust, credible indicators will increasingly become available to reliably inform consumers and allow accountability to purchasers of healthcare services. Nevertheless, given the complexity of healthcare, the predominant enduring benefit from attempts to measure performance in healthcare is likely to be the use of data generated by providers of care to provoke reflection on existing practice and to plan efforts at improving care.

Neil W Boyce FRACP, PhD, MRACMA