Surgery

From Kurmond kid to cancer crusader. Pioneering integrated cancer treatment . Fred Stephens. Adelaide: Wakefield Press, 2011 (xiii + 177 pp, $29.95). ISBN 9781862549579. The fascination of an autobiography persists. Can the reader gain insight into the riddle of life by peering into the experience of another? Troubles, tribulations, successes and joys are scattered seemingly randomly across the human journey. So it is with Fred Stephens’ tale, a gentle, interesting story, almost naively presented in first person, extending from early childhood to an international career as a cancer surgeon. Stephens’ life spans a period of extraordinary change in Australian life, and those of the appropriate age will find much to engage with. The younger generation, however, are unlikely to believe that such primitive mid 20th-century life ever existed. The themes which pervade this recital have ongoing relevance to Australian life. Parochialism and nepotism have been a curse on this “lucky” country. The small number of tightly held and isolated medical communities, not excluding Sydney and Melbourne, encouraged dynasties and empire-building. Stephens’ tale accurately documents the impact of these elements on personalities and individual careers. Patients came first with Stephens, but patient-centred health care existed only as a dream. The final acceptance of the concept of surgical oncology by the Royal Australasian College of Surgeons is one of the bright spots. This book tells of a dedicated surgeon of independent mind doing well for his patients and the discipline of surgical oncology, but perhaps never receiving the recognition his achievements deserved. For those of us in the business and still fighting the good fight this is an enjoyable read, and well known characters pop up regularly through the pages. Fred Stephens was a pioneering spirit and his good heartedness and sometimes confronting personal honesty shines through the book.

Robert J S Thomas

To the Editor: The article by Ramsey-Stewart and colleagues1 reports a welcome addition to supplemental anatomy education in graduate-entry medical courses in Australia. Increasing medical student numbers are increasing pressure on teaching resources, further propagating the nationally recognised deficiency in anatomy teaching.2,3 In 2010, the University of Queensland Discipline of Surgery developed an extracurricular applied anatomy course to meet the needs of clinical students (Years 3 and 4) with varying foundations in anatomy.4 The course is based on a clinically oriented anatomy education model, using prosected specimens and computer resources, which has been shown to deliver learning outcomes.5 Student representatives were involved in all facets of curriculum development and evaluation. The course was taught by surgeons and provided an overview of whole-body applied anatomy in an interesting and engaging way. As the course had no seed funding, a modest course fee of $90, which was intended to be easily affordable but enough to encourage committed attendance, was charged. Class size was restricted to 44 students, with selections from the 150 applicants (from about 800 students across both years) made on a first-come, first-served basis. Over seven Saturday mornings, the students received 2-hour tutorials from surgeons with expertise in specific fields of regional anatomy. This scheduling minimised disruption for both surgeons and students. Various educational resources, including three-dimensional virtual modelling and potted pathology specimens, were used. Participants completed a short multiple choice test before each week’s tutorial. The course concluded with a wet laboratory session, staffed by surgeons using prosected cadaveric specimens at multiple stations, with a one-to-five surgeon–student ratio. Students completed a post-course exam of collated pre-tutorial multiple choice questions, as well as five-point Likert-scale evaluation forms. The students evaluated the course well (mean Likert score: 4.6 at 4 weeks, 4.8 at 8 weeks). Post-course exam scores demonstrated a small but significant improvement (mean ± SD: pre-course, 43% ± 16.7% v post-course, 50% ± 10.6%; P = 0.004). Scores were correlated with attendance. The course was highly valued by students and surgeons, effectively improved students’ knowledge and satisfied their desire for further anatomy education. The course structure is time-efficient and cost-effective. However, this course, like that of Ramsey-Stewart et al,1 is extracurricular and does not deliver educational benefit to an entire cohort of students. Further development and evaluation are required to extrapolate the benefits of these extracurricular courses into the wider medical curriculum within the constraints of graduate MB BS programs. Our model has expanded to two courses in 2011.

Matthew J Roberts · Bavahuna Manoharan · Marianne Vonau · Russell W Stitz · Owen A Ung

Hardworking rural doctors make an unrecognised but large difference During my career as a city-based gastroenterologist, I was fortunate to make many trips to Victorian country towns to give educational talks. I often met inspiring people, and one of these was a senior country surgeon on the verge of retirement. This is his story. The older surgeon and I had been chatting with a younger surgeon, new to the town. The new surgeon had proudly told us about the lovely home he had just purchased, some 2 kilometres from the local hospital. The older surgeon sighed and confided to me that he would never have been able to live so far from the hospital, but had always lived within 500 metres because he often had to get to the hospital quickly. He had taken almost no holidays in 35 years of practice because there was rarely anyone to cover his absence. The surgeon gave me an example of his lifestyle over that time. One Easter Thursday he was having his first mouthful of dinner, thinking it was quiet and that he might even get a rest over the Easter break. The phone rang — a multiple-car crash had occurred on the Princes Highway, with a couple of fatalities and several casualties — and that was his Easter gone. He tried to send the patients with head injuries to Melbourne. He rang four hospitals and gave the same details to four admitting officers, to be told four times that there were no beds for them. So he managed the head injuries as best he could, together with all the other injuries, and spent most of his Easter in theatre. The city folk all survived, and were eventually transferred to city hospitals. There were no thanks and no chocolates. In fact, he said he could not remember ever receiving a thankyou letter from any city-based patient. A couple of years later, a trauma helicopter service was introduced and he was informed most decidedly, in a castigatory tone, that he must never manage any neurosurgical patient again. There was no thankyou for past services. I knew this surgeon had an outstanding local reputation for dedicated, expert and compassionate care, but such a reputation would not have carried much weight with city doctors. He had known the limits of his expertise, and had asked for help when appropriate, but often had not received it. His story moved me profoundly. It reminded me of an event from my distant past, when I was a first-year intern in another Victorian country town, on rotation from a city hospital. There were two of us interns, and we thought we were pretty smart. We also thought all the local general practitioners were basically hopeless — they could not read echocardiograms, knew nothing about electrolytes and prescribed old-fashioned drugs. One Sunday morning I was in the shower about to wash my hair, having been in the wards most of the weekend, and my beeper went off. I grudgingly got out of my shower. “It’s the children’s ward; Jason doesn’t look too well; he’s had diarrhoea all weekend.” I wanted to wash my hair and knew I would not get a chance for the rest of the day, so said I’d be there shortly, and continued washing my hair. My beeper went off again: “Jason doesn’t look too well at all,” and I thought “What a nuisance, I’m not even dressed.” Jason was a thin, pale child aged about 5 years who seemed to have been in hospital for weeks, appeared to have no proper family, was always sniffly and was frequently being treated for head lice or scabies; he was none too adorable. Then a third page sounded: “You’d better come right away, Jason has collapsed.” I hurried to the hospital and ran to discover a cold, clammy, blue Jason with a thready pulse and no detectable blood pressure. I panicked: I tried butterfly needles in his hand and in his foot, but it seemed there were no accessible veins. “Should we call Dr Jones?” asked the nurses. “Yes!” I squeaked in desperation. Fortunately, Dr Jones (one of the “hopeless” local GPs) was close by. He did a cut-down in Jason’s cubital fossa, found a vein and ran some fluid in. Jason started to pick up with a bit of saline: his blood pressure became recordable, he opened his eyes, and suddenly seemed quite adorable after all. He lived. I learned many lessons from that episode: that I should always trust the nurses and respond quickly to their call for help; that I, in turn, must ask for help quickly when I need it; that looking after someone engenders love; and that country doctors actually do know quite a lot. So, what of the senior country surgeon? I hope he is happy and relaxed in retirement. Many people owe their lives to him — not only country people, but city people who have been scraped off the roads into his care. I sent a summary of his life to the staff of Australian story (ABC Television), suggesting that he would be a great subject for the program. They never wrote back. Maybe they didn’t think it was much of a story after all.

Katrina J R Watson MB BS, FRACP, MPH

Ken Paver was an outstanding dermatologist with broad vision and a remarkable ability to get things done. To paraphrase one of his maxims, Ken had great ability to which he applied a lot of effort. He was born in Kensington, Sydney, on 24 May 1920 and grew up in Mosman. After gaining his Intermediate Certificate in 1933, he left school to work at an insurance firm to help his family, because his father suffered from debilitating rheumatoid arthritis. During World War II, Ken served as a Private and then Captain in the Coastal Artillery. After the war, Ken studied medicine at the University of Sydney, where he met Elaine Kerr. They married in 1948 and graduated together in 1952. In 1953, after a year of residency at Royal North Shore Hospital, Ken joined a general practice at Merrylands. While working as a general practitioner, he obtained membership of the Royal Australasian College of Physicians (RACP). He received his Diploma of Dermatological Medicine in 1964 and was subsequently awarded the medal of the New South Wales branch of the British Association of Dermatologists. He gained Fellowships of the Australasian College of Dermatologists in 1966 and the RACP in 1971. Ken established a successful private practice in dermatology at Blacktown and was appointed Honorary Dermatologist at St Vincent’s Hospital, Sydney, where he was Chairman of the Department of Dermatology from 1966 to 1975. In 1978, Ken’s drive and momentum led to the establishment of the Skin and Cancer Foundation Australia, of which he was the first Chairman. He was appointed a Member of the Order of Australia in 1988. In 1989, Ken retired to the NSW Central Coast. He became a keen woodworker, an Associate of the Securities Institute of Australia and, in 2005, a Fellow of the Financial Services Institute of Australasia. He also acquired a Bachelor of Arts in sociology and worked on writing the history of the Skin and Cancer Foundation Australia. Ken died on 18 March 2011, and is survived by Elaine and children Graham, Rob, Phil and Cathy.

William Regan

To the Editor: There is international recognition of the substantial threat that global warming presents to human health and of the challenges that it poses to health service delivery. The World Health Organization has estimated that global warming and climate change-related natural disasters account for over 60 000 deaths globally per year.1 Global warming will also have implications for surgery and surgical practice. The Victorian “Black Saturday” bushfires of February 2009 saw 414 people presenting to hospital emergency departments, stretching hospital resources,2 and 173 deaths were attributed to the bushfires. Nineteen patients were admitted to the Alfred Hospital (Melbourne’s burns service) with burns to more than 30% of their bodies. The care of severe burns victims is complex and highly labour-intensive, often with a patient–nurse ratio of 1 : 1. There would have been even more burns victims if the fire had been less ferocious and had not resulted in such a high loss of life.3 In other words, there were fewer injuries because this intense fire killed people outright; a less intense fire may kill fewer people but leave more injured. The extreme weather that led to the fires is an example of the type of event that may become more frequent as global warming increases. The Garnaut climate change review predicts more frequent extreme wind, rain and intense tropical cyclones, and predicts that category 3–5 storms are likely to increase in intensity by 60% by 2030, and by 140% by 2070.4 Increasing population densities along the northern Queensland coast will also expose more people to the risks of floods, storms and cyclones. These natural disasters often produce wounds which are highly contaminated, and primary wound care services may face increased demand. One of the practical implications of research in the field of surgery and climate change will be the need for modelling of future demands for surgical intervention in Australia. The range of trauma impact due to climate change needs to be defined, and the incidence with which this is likely to occur needs to be determined, based on climate change modelling. With this information, models of future demand for surgical interventions can be determined.

Joseph W Smith · Guy J Maddern

To the Editor: Bismark, Spittal and Studdert observed that complaints clustered around certain doctors.1 They state that, in Victoria, extrapolations from their findings indicate that 1% of the medical workforce in private practice accounts for nearly 20% of complaints, and that male surgeons who have practised for more than 30 years are the doctors who are most complained about.1 Bismark and colleagues established that complaint-prone doctors are more likely to be male, surgeons or psychiatrists, to have trained in Australia and to have been in practice for at least 30 years. They agree with previous studies that suggest that the inherent risks of surgical procedures and the relative visibility of poor surgical outcomes are likely to play a role, and also note that the potential for power imbalances between doctor and patient is high in both surgery and psychiatry. That training outside of Australia was found to have a “protective effect” may seem surprising, but this fits my view about what most often motivates a patient to complain about a doctor when something goes a little astray. My belief, based on a long period of surgical practice and of observing other doctors, largely surgeons, is that a common stimulus to make a complaint when there is a degree of dissatisfaction is a perception that the doctor was overconfident, perhaps to the point of arrogance, and had little personal interest in the patient’s welfare. The lower self-confidence of some overseas-trained surgeons could therefore lessen the likelihood of complaints being made about them, whereas the supreme confidence of some highly experienced Australian-trained surgeons may go against them when something goes wrong. Good manners, kindness, demonstrations of personal interest and concern, and a degree of humility all discourage complaints! In an article subtitled “Arrogance: the biggest sin of all”,2 in the United Kingdom Telegraph, in 2009, Dr James LeFanu appropriately commented, “The virtues of generosity, cheerfulness and discretion should be the hallmark not just of medicine, but of all the liberal professions. How many doctors live up to these ideals is, of course, impossible to quantify, but certainly some readers of this column take a rather jaundiced view”.2

John A Buntine

The death of John Buckingham on 29 March 2011, after a courageous battle with pancreatic cancer, robbed the Canberra medical community of its leading breast cancer surgeon, whose knowledge and skill was paired with devotion and kindness to his patients. John was born in Sydney on 19 July 1947. He attended St Ignatius College and graduated in medicine from the University of Sydney in 1971. He completed his advanced surgical training in the United States at Mayo Clinic in Rochester, Minnesota. In 1978, John returned to Australia and attained Fellowship of the Royal Australasian College of Surgeons in 1979. In that year, he commenced as a consultant general surgeon at the newly opened Calvary Hospital in Canberra, where he concentrated his practice for his entire career. In addition to his clinical commitments, he filled roles in the hospital as Head of the Division of Surgery and Chairman of the Medical Staff Council. His inclusive style and collegiate approach allowed all views to be heard and acknowledged. His wise counsel was valued by the Sisters of the Little Company of Mary, board members and clinicians. Throughout his career, John was involved in the broad expanse of general surgical conditions. He was a cautious, methodical and technically proficient operator, who was diligent and attentive in the postoperative care phase. Over time, he came to concentrate exclusively on breast cancer surgery. He developed a comprehensive model of care, involving colleagues from nursing, radiology and oncology, and suffusing it with his virtues of care and compassion. The development of a graduate medical program at the Australian National University Medical School in Canberra allowed John to expand his interest in teaching to both students and registrars. His excellence in this role was recognised with his appointment as Clinical Associate Professor when he retired in 2011. His contribution to the wider ACT community was recognised when he was named ACT Senior Australian of the Year in 2010. John was a remarkable man, who, despite his many achievements, was humble and self-effacing. He was interested in the lives of his coworkers and was unfailingly courteous to everyone he encountered. He was a man of deep religious conviction, and his Catholic faith sustained him in his final illness. Indeed, he lived all his life demonstrating the faith principles he so strongly embraced. John is survived by his wife Sue and children James, Peter, Kate and Michael.

Michael J Gillespie · Stephen A Deane

To the Editor: Since publishing its first national report on mortality data from 2009,1 the Australian and New Zealand Audit of Surgical Mortality (ANZASM) has provided coverage of surgical mortality in participating hospitals across Australia. In their recent article promoting the role of clinical-quality registries in improving the quality of health care in Australia, Evans and colleagues2 describe the importance of national registries, particularly in high-cost areas of medicine. Evans et al present the proposed national quality indicators from a 2009 Australian Institute of Health and Welfare report3 and categorise them as current national indicators, indicators requiring data development and those for which a suitable data source has not been identified or substantial development is required to operationalise the indicator. Indicator 36, “Independent peer review of surgical deaths”, is categorised as the third type. The rationale for this indicator stated that the template of the Scottish Audit of Surgical Mortality had been adapted for use in Australia by some states and territories. The report recommended that data from these sources be reported nationally, ensuring that methods of collecting the data would become standardised across the participating states and territories. We wish to highlight that this is now the case. The ANZASM is an independent, peer review audit process overseen by the Royal Australasian College of Surgeons (RACS) and funded by state and territory health departments. The audit is designed to identify and monitor improvements in the quality of surgical care through the collection and analysis of patient mortality data. It aims to improve the the delivery of safe, efficient and effective surgical care by identifying, improving and preventing system and process errors. The database is standardised across all sites. In January 2010, to ensure complete participation by RACS Fellows in this activity in all states and territories across Australia, participation was deemed a mandatory continuing professional development activity (Category 1, surgical audit and peer review). Feedback is provided to individual surgeons on their cases, and overall results are summarised in a de-identified manner as case-note reviews and annual reports that discuss system issues arising on a state and national basis. These issues are analysed further, and recommendations for quality improvement in surgery are disseminated by the ANZASM to the broader surgical community and the respective regional departments of health through its annual reports, case-note-review booklets and, more recently, through workshops and seminars.

Guy J Maddern · Julian A Smith · Wendy Babidge · Gordon S Guy

Rowan Nicks was born in New Zealand on 24 February 1913. He studied medicine at the University of Otago in Dunedin and, on graduation in 1937, worked as an intern at Auckland City Hospital. After his internship, he moved to the United Kingdom to further his surgical studies, working as a demonstrator in anatomy at Middlesex Hospital, London. Rowan served as a Surgeon Lieutenant in the Royal Navy during the Second World War. In 1945, he was appointed Officer of the Order of the British Empire and became a Fellow of the Royal College of Surgeons. After the war, he turned his attention to cardiothoracic surgery, and worked at Royal Brompton Hospital, London. In 1947, he returned to New Zealand to pioneer cardiothoracic surgery at Greenlane Hospital in Auckland. In 1956, Rowan was appointed Staff Specialist in Cardiothoracic Surgery at Royal Prince Alfred Hospital in Sydney. He was involved in the beginning of open-heart surgery in New South Wales in 1957 and played a leading role in the design and development of the first automatic cardiac pacemaker. After the death of his wife Mary in 1969, Rowan travelled widely, visiting hospitals in Africa and India in particular. This was the beginning of his second career as a significant philanthropist. After his official retirement in 1973, Rowan continued to travel and work in hospitals in East Africa, India and Malaysia, as well as in remote Aboriginal communities in Australia. Rowan established a series of scholarships and fellowships for young surgeons from Africa, India, Asia, the United Kingdom and Ireland, and the Western Pacific region. In 2005, he established the Rowan Nicks Russell Drysdale Fellowship in Australian Indigenous Health and Welfare. Throughout his life, Rowan had a sustaining love of nature and gardening. In his later years, he developed his interest in chamber music, symphony and opera. Rowan died on 26 May 2011, and is survived by his extended family in Australia and New Zealand.

John Masterton · and Brian Morgan

A 27-year-old woman was being treated with gastrojejunostomy feeding for severe anorexia nervosa. The position of the gastrojejunostomy tube was checked by fluoroscopy on the day of insertion (Figure, A, arrow). The next day, the patient presented with abdominal pain and “shortening” of the external portion of the tube. Repeat fluoroscopy showed migration of the tube (Figure, B, arrow). Computed tomography showed two segments of jejunojejunal intussusception (Figure, C, arrow and inset, and D, straight arrow) centred around the tube (Figure, D, curved arrow), with an intervening segment of normal jejunum (Figure, D, label J). The patient’s gastrointestinal tract was intact. The intussusceptions were reduced by applying traction on the tube under fluoroscopic guidance, and the patient resumed tube feeding without recurrence.

Uei Pua

Neil Orr was born on 19 October 1919 on a property called “St Helens” in Toowoomba, Queensland, the only child of Scottish immigrants. Neil attended school at Toowoomba Grammar and studied medicine at the University of Sydney. At university, he stayed at Wesley College, where he was in the rowing team. Neil graduated in 1944 and served his internship at Royal Prince Alfred Hospital, Sydney. He then set sail for England as a ship’s surgeon on the HMS Bellerophon, which stopped on the way at Batavia to collect the Dutch gold that had been sent there for safety at the beginning of the First World War. He arrived in England in 1947, where he worked at several hospitals, including Hillingdon Hospital, Uxbridge, where he undertook most of his surgical training. In 1960, he was awarded Fellowship of the Royal College of Surgeons. In the early 1960s, Mona Vale Hospital opened on Sydney’s northern beaches and Neil was appointed its first Medical Superintendent. He helped set up the hospital and recruit staff. A house in the hospital grounds was built for the Superintendent, with a magnificent view over the ocean and golf course. Neil was a keen surf swimmer and swam regularly. Neil remained in this role until he retired in 1986. As Superintendent, Neil regularly visited all sections of the hospital and knew all who worked there, including nurses, pharmacists, and kitchen and ground staff. Although he no longer practised as a surgeon, he maintained his interest by assisting consultant surgeons at the hospital. In his later years, he helped his close friend Dr Josephine Wiseman in her nuclear medicine practice. She subsequently looked after him in his last few years when he was confined to a wheelchair. After a long illness, Neil died on 9 August 2010. James B Roche

James B Roche

Upcoming large studies may shed light on why this technique was not rapidly widely adopted like certain other laparoscopically assisted procedures Laparoscopic “keyhole” surgery has been the gold standard for gall bladder surgery for a few decades. It has also been widely used for appendicectomies, a multitude of gynaecological procedures and, to various extents, for other procedures such as hernia repair, splenectomy and nephrectomy. However, the uptake of laparoscopically assisted resection in elective surgery for colorectal cancer (CRC) has been slow, both in Australia and overseas. This is the subject of the article by Thompson and colleagues in this issue of the Journal (→ National trends in the uptake of laparoscopic resection for colorectal cancer, 2000–2008).1 The authors searched the National Hospital Morbidity Database (NHMD), which uses codes based on Medicare Benefits Schedule item numbers, for elective laparoscopic resections for CRC. Their search was somewhat restricted and the internal validity was not tested, but Thompson and colleagues reported that, in about a quarter of elective CRC resections performed in Australia in the financial year 2007–08, an item number for a laparoscopy was included. Reliance on databases may overestimate or underestimate outcomes. Three studies from the United States reported percentages of laparoscopic resections for cancers of the colon ranging from 3.3% to 5.2%2-4 in the period July 2003 to June 2004, based on the National Cancer Data Base and Nationwide Inpatient Sample. However, a fourth US study that used the Perspective Rx Comparative Database (Premier Inc, Charlotte, NC), which relies on procedure codes, reported a percentage of 33.7% for the period July 2004 to June 2006.5 Such an increase is far greater than what would be expected to be the result of the publication of the Clinical Outcomes of Surgical Therapy trial.6 The adoption of laparoscopic surgery for CRC has been slow despite the proven short-term benefits of laparoscopic compared with open resection, which include a shorter hospital stay.7,8 In line with other published articles, the Australasian Laparoscopic Colon Cancer Study (ALCCaS) — the largest Australasian study to date of laparoscopic resection for CRC — showed that the laparoscopic method was associated with a smaller number of patients with complications and a shorter length of stay than open resection.9 However, the ALCCaS group also reported that reviews show that the short-term advantages for laparoscopic resection for CRC are arguably relatively minor and often subjective, and that patients who benefit most from improved outcomes are patients who are aged 70 years or older whose procedures were completed laparoscopically.10 The median length of stay for patients younger than 70 years of age undergoing laparoscopic resection in the ALCCaS trial was 7 days (range, 1–30 days) compared with 8 days (range, 4–49 days) for open resections in the same age group — a difference of only 1 day.10 The average hospital stay for conventional open resection has been reported to be about 10 days (range, 7–12 days).7,11-13 It seems likely that authors of large series, trials and reviews report more conservative (and perhaps more realistic) results than earlier series reporting a new surgical procedure or innovation. The first published series of laparoscopic colorectal surgery in 1991 reported achieving the aim of a 5-day hospital stay in 14 out of 20 patients undergoing sigmoid resections (70%).14 Most subsequent larger studies, reviews and meta-analyses report lengths of stay of around 8 days for laparoscopic resection.7-9,11,12 Thompson and colleagues (→ National trends in the uptake of laparoscopic resection for colorectal cancer, 2000–2008) recommend exploring whether the short-term benefits of laparoscopic resection are experienced outside of the clinical trial environment.1 If we accept the limitation of using secondary data, such as those from the NHMD, in exploring the uptake of laparoscopic surgery for CRC, then a quarter of elective resections for CRC performed in Australia in 2007–08 were laparoscopic. That represents an increase from zero to 25% in more than 17 years. There are no comparable studies that used similar methods to assess the uptake of laparoscopic cholecystectomy in the late 1980s. However, many of us experienced first-hand the rapid uptake of laparoscopic gall bladder surgery. The first laparoscopic cholecystectomy was probably performed in France by Phillippe Mouriat of Lyons in 1987.15 There are published data that show that laparoscopic surgery was well and truly the gold standard for gall bladder surgery in 1992.16 That represents an increase from zero to close to 100% in less than 5 years. The contrast is stark. In 1999, Kehlet and Mogensen introduced the concept of fast-track surgery to colorectal resections;17 this concept is now known as Enhanced Recovery After Surgery (ERAS). It involves a multimodal rehabilitation program that commences before surgery to optimise all aspects of care using evidence-based protocols that hasten recovery. Kehlet and Mogensen reported a median hospital stay of 2 days (range, 2–6 days) after 16 consecutive elective open sigmoid colectomies. Fifteen of the 16 patients resumed bowel function before discharge.17 The results of a systematic review of five studies comparing laparoscopic with open colorectal surgery using an ERAS rehabilitation program were inconclusive.18 Further, the authors of a meta-analysis of 11 studies (1021 patients) reported a 2.5-day shorter length of stay for patients on an ERAS rehabilitation program who had resections compared with those not on an ERAS program.19 These authors assumed an added benefit to the laparoscopic approach, but an advantage was not clearly demonstrated. They concluded that ERAS programs should become a mainstay of elective colorectal surgery.19 These later and larger series, trials and reviews have shown that an average length of stay of 5 days seems to be quite achievable within an ERAS protocol, regardless of whether the surgical approach is open or laparoscopic. Many of the aspects of the ERAS program are now included in “standard” care regardless of whether a structured protocol is in place or not. It seems that, on the whole, laparoscopic surgery for CRC has probably not been successful in delivering the outstanding benefits suggested by early reports. This may be partly responsible for its slow uptake. Attention to a multimodal approach such as an ERAS program may, in fact, produce more clinical benefits for patients and cost benefits for hospitals. Whether the laparoscopic approach “adds” to these benefits or not has not been established.20 The Australasian Laparoscopic Cancer of the Rectum Trial (A La CaRT), with a target sample size of 470 patients, is expected to shed more light on the safety and efficacy of laparoscopic compared with conventional open resection for rectal cancer.21 The Dutch Laparoscopy and/or Fast Track Multimodal Management (LAFA) trial, with a target sample size of 400 patients, will examine laparoscopic versus open CRC surgery with or without an ERAS rehabilitation program.22

Ned S Abraham MMed, FRACS, PhD

Trainee surgeons must acquire expert status in the context of reduced hours, reduced operating room time and the need to learn complex skills involving screen-mediated techniques, computers and robotics. Ever more sophisticated surgical simulation strategies have been helpful in providing surgeons with the opportunity to practise, but not all of these strategies are widely available. Similarities in the motor skills required in skilled musical performance and surgery suggest that models of music learning, and particularly skilled motor development, may be applicable in training surgeons. More attention should be paid to factors associated with optimal arousal and optimal performance in surgical training — lessons learned from helping anxious musicians optimise performance and manage anxiety may also be transferable to trainee surgeons. The ways in which the trainee surgeon moves from novice to expert need to be better understood so that this process can be expedited using current knowledge in other disciplines requiring the performance of complex fine motor tasks with high cognitive load under pressure.

Andrew W McCaskie MMus, MD, FRCS · Dianna T Kenny ATCL, MA, PhD · Sandeep Deshmukh MB BChir, MA

A 55-year-old woman, who had undergone a total hysterectomy decades previously, presented with lower abdominal fullness and urinary frequency. An abdominal–pelvic contrast-enhanced computed tomography scan (Box) showed a large cystic lesion measuring 20 × 17 × 15 cm, with a smaller “daughter” cyst, a compressed urinary bladder and bilateral hydronephrosis. The patient subsequently had an ovarian cystic tumour weighing 1822 g removed, and had an uneventful postoperative course. The tumour contained serous fluid, which established the diagnosis of serous borderline ovarian tumour (SBOT). An SBOT manifesting as such a large cyst that mimics neurogenic bladder is rare.1 In general, conservative, fertility-sparing surgery is recommended for its promising outcomes.2 Computed tomography scan showing an ovarian cyst (white arrows) with a daughter cyst (white arrowhead) and a compressed urinary bladder (yellow arrowhead)

Chih-Chung Shiao · Pi-Jen Hong · Shu-Chinh Chao · Jsun-Liang Kao

To the Editor: Laparoscopic adjustable gastric banding (LAGB) is the most common bariatric surgery performed in Australia, and diabetic patients represent an important target population.1 In one of few trials in type 2 diabetes, 73% of 30 LAGB-treated obese patients reverted to normal glucose tolerance by 2 years, compared with 13% of 30 obese patients randomly assigned to treatment with changes to their lifestyle.2 These Australian data precipitated publicity implying that many people with type 2 diabetes were cured by LAGB.3,4 However, only recently diagnosed patients were recruited. The benefits of LAGB in those with diabetes of long duration (and usually with a substantial loss of pancreatic beta-cell function5) may not be as dramatic. We reviewed the records of eight patients with insulin-treated type 2 diabetes (aged 40–65 years, with a diabetes duration of 4–39 years) referred for LAGB by one of us (T D) to two established bariatric surgical units over 4 years. All eight patients had a diabetes-specific review within 2 months of surgery and at 3 and 6 months postoperatively, and six patients had a further review at 12 months. Perioperative diabetes management was coordinated by the anaesthetist and ward staff, but patients were encouraged to contact their doctor or regional diabetes education unit for advice at any time if necessary. Patients attended the bariatric unit for saline insertion into the band once or twice before their diabetes-specific review at 3 months. No patients developed postoperative complications. The median weight loss was 14% at 6 months and 20% at 12 months (Box). By 3 months, insulin doses had been reduced in all patients and two had stopped using insulin. However, most had increased their insulin doses at 6 months (and the two who had discontinued insulin started using it again) because of unsatisfactory glycaemic control. During the 12 months’ follow-up, only one patient stopped using insulin and remained without its use without an unacceptable glycated haemoglobin (HbA1c) increase. Although our eight patients achieved the same median percentage weight loss at 1 year as trial patients with diabetes of relatively short duration achieved over 2 years,2 insulin use was still required in most cases. When asked, the patients suggested that inappropriate initial insulin reductions were not because they experienced hypoglycaemia, but rather because they expected substantial LAGB-associated metabolic improvement. Perhaps this was encouraged by media coverage3,4 and/or concerns of bariatric unit staff that continuing their insulin therapy might retard their LAGB-associated weight loss. In some cases, problems with insulin adjustment and glycaemia overshadowed the psychological benefits of progressive weight loss. These preliminary observations suggest a need for more data on diabetes management after LAGB, to inform acute treatment modification and to provide a realistic idea of the effects of LAGB on longer term disease outcomes. Changes in body weight, insulin dose and HbA1c after LAGB in eight patients with insulin-treated type 2 diabetes HbA1c = glycated haemoglobin. LAGB = laparoscopic adjustable gastric banding. Open-circle line = patients who discontinued insulin during the first 3 months of follow-up.

Timothy M E Davis · Catherine Coleman

To the Editor: We would like to congratulate Gandy and colleagues on their recent article in which they assess outcomes and patient flow in an acute care surgery (ACS) model.1 We have also performed a retrospective historical control study that examined the effect of an ACS model on assessment time and time to operation for acute appendicitis. Our findings were presented in poster format at the Royal Australasian College of Surgeons Annual Scientific Congress in Perth in May 2010.2 We introduced an ACS model in 2007 at Nambour General Hospital, a 350-bed regional hospital on Queensland’s Sunshine Coast. Our model differs in certain details from the model used by Gandy and colleagues at Prince of Wales Hospital, but is similar in principle. The aim of the ACS model was to provide an in-house consultant surgeon to be more available and more directly involved in the care of emergency surgical patients. In our study, the outcome measures included time to assessment of the patient in the emergency department by the surgical registrar, and time to operation after this assessment. We performed a retrospective chart audit of 569 patients who underwent emergency appendicectomy in the calendar years 2006 and 2008. The ACS model resulted in an increase in both time to assessment (198 minutes in 2006 compared with 263 minutes in 2008; P < 0.0001 [t test]) and time to operation (597 minutes in 2006 compared with 793 minutes in 2008; P < 0.0001 [t test]). These results surprised us. Various explanations were postulated, including the trend of an expanding local and regional population on the Sunshine Coast placing a greater demand on the emergency theatre through the study period. Like us, Gandy and colleagues did not see a reduction in time to theatre and in fact “observed no significant change in time from presentation to arrival in theatre”. This was explained on the basis of “an increase in the number of patients treated conservatively overnight”. We have reviewed our data and found a similar trend, with 35% of patients in 2006 and 54% in 2008 managed conservatively overnight. This may, to some extent, explain our surprising results. Our appendicectomies in both historical control patients and those treated in the ACS model were all performed laparoscopically, thus removing one of the confounders experienced in the Prince of Wales Hospital data. A comparison of these two sets of data emphasises the fact that to measure time to assessment and time to operation in isolation misses the important concept of reduction in complication rates, as successfully demonstrated by Gandy and colleagues1 (we did not record complication rates in our study). This process of assessment could be taken a step further with a cost–benefit analysis looking at the presumed reduction in costs associated with the anticipated lower rate of complications resulting from the involvement of the consultant surgeon.

Simone L Geere · Ratna Aseervatham · David Grieve

Terminal decline. A surgeon’s diagnosis of the Australian health-care system. Dr Mohamed Khadra. Sydney: Random House, 2010 (xiii + 263 pp, $34.95). ISBN 9781864711370. THE AUTHOR of this work is a respected surgeon, educator and author, who has done more than most in giving back to the community in which he now lives, as well as to other, more distant, communities. It is therefore disappointing that his latest book is a passionate but superficial tour through the recent history of the Australian health care system. It lacks the rigour required for such analysis. Many of the key political and medical figures involved in the introduction of universal health insurance were interviewed. Not surprisingly, they provide a retrospective justification for their stance of some decades ago. The method of diagnosis is lacking, in that there was no attempt to revisit contemporary texts and media of the time under evaluation. There is much extrapolation from powerful anecdote, leading to gross generalisations and oversimplification of the issues under discussion. There is an almost paranoid obsession with the meddling bureaucracy who obeyed the command to go forth and multiply. The obsession is justified to some extent but does not provide the entire explanation for the system’s woes. Reference to “an anti-doctor nurse turned journalist” bobs up out of nowhere. A glass half empty approach is adopted, from the title through to the denouement. There is repetitive pining for the days, viewed through rose-tinted spectacles, when the medical profession ruled the system and uninsured patients allegedly received wonderful care from charitable consultants. However, once the negativism has passed, which, unfortunately, is not until near the end of the book, the author makes some reasonable recommendations for cure. The publication is more suited to a series of media articles. If one is looking for serious investigative journalism, then the book does not, at least in the opinion of this reviewer, represent value for money.

Allan D Spigelman

The Australian e-Health Research Centre,1 in collaboration with the Queensland University of Technology’s Paediatric Spine Research Group,2 is developing software for visualisation and manipulation of large, three-dimensional (3D) medical image datasets. The software allows the extraction of anatomical data from individual patients for use in preoperative planning. State-of-the-art computer technology makes it possible to slice through the image dataset at any angle, or manipulate 3D representations of the data instantly. Although the software was initially developed to support planning for scoliosis surgery, it can be applied to any dataset whether obtained from computed tomography, magnetic resonance imaging or any other imaging modality. Extraction of anatomical data from three-dimensional image datasets Screenshot of the software visualising a three-dimensional (3D) computed tomography dataset from a patient with scoliosis. The left window shows coronal, sagittal and transverse cross-sections of the dataset, as well as an arbitrary transverse cross-section defined by the green lines on the coronal and sagittal cross-sections. The right window shows a 3D reconstruction of the skeletal information derived from the dataset.

Hans de Visser MSc, PhD · Clayton J Adam PhD · Olivier Salvado PhD · Joshua D Passenger BSc

To the Editor: Readers of the Journal’s editorial on the importance of clinical patient-outcome monitoring asking “Where are the clinical data?”1 will be pleased to know that the state of Victoria collects considerable data on surgical outcomes. Since 2001, the Department of Health’s Victorian Surgical Consultative Council (VSCC; http://www.health.vic.gov.au/vscc/) has monitored surgical outcomes in the state’s public hospitals. Monitoring of both morbidity and mortality outcomes is combined with voluntary and mandatory case reporting and a high level of participation of hospitals and surgeons. It is compulsory for hospitals to report a range of sentinel adverse events and undertake corrective strategies. Data about surgical inpatients are obtained from discharge coding in medical records statewide, and the chief executive officers and directors of surgery of health services with “outlying performance” are invited to analyse the case records and provide their findings to the VSCC. A VSCC subcommittee, the Surgical Outcomes Information Initiative, promulgates the conclusions in a de-identified manner to hospitals, surgeons and trainees, with a view to improving safety, systems and surgical outcomes. Since 2008, deaths of public hospital patients that occur under surgical care are monitored by the Victorian Audit of Surgical Mortality (VASM, derived from the VSCC), which covers most surgical specialties, and is soon to embrace private hospitals and, hopefully, gynaecological surgery as well. De-identified educative information from autopsies and case analyses is offered to surgeons and trainees, whose participation in case reporting and assessing is now a professional requirement of the Royal Australasian College of Surgeons (RACS). Surgical mortality as monitored by the VASM is now bi-nationally compared through the RACS’s overarching Australian and New Zealand Audit of Surgical Mortality. Victoria’s Department of Health has longstanding collections of data for anaesthetic, obstetric and perinatal outcomes, with similar consultative councils. Several surgical specialties have for over a decade collected and promulgated their morbidity and mortality information. The Melbourne Vascular Surgical Association requires its members to participate in clinical outcome audits, as does the Australian and New Zealand Society for Vascular Surgery. Other specialties that audit outcomes are orthopaedic surgery (the bone and joint registry), transplantation surgery and cardiac surgery. Surgeons’ general experience of clinical patient-outcome monitoring is that of enthusiasm for its professional and community benefits, including the benefit of knowing that Australia’s overall surgical standards are comparable with the world’s best. The incentive remains to improve data capture, patient safety and eternal clinical vigilance, and these endeavours deserve support.

Peter L Field

An 82-year-old man presented to the emergency department with abdominal pain and vomiting. An abdominal computed tomography scan showed a whirl sign around the superior mesenteric vessels (Figure, arrow), suggestive of small bowel volvulus. A whirl is formed by the afferent and efferent loops of the volvulus, with the central portion consisting of tightly twisted bowel and mesentery.1 The latter create swirling strands of soft tissue shadow within a background of mesenteric fat attenuation, giving the appearance of a hurricane on a weather map. Caecal and sigmoid volvulus can also give rise to whirl signs. Laparotomy confirmed mid-gut volvulus with 360° rotation. The patient had an uneventful recovery following derotation of the mesentery.

Debasish Debnath · Peter Frecker

Objective: To document presenting symptoms, investigations and management for Australian patients with oesophageal adenocarcinoma (OAC), gastro-oesophageal junction adenocarcinoma (GOJAC) and oesophageal squamous cell carcinoma (OSCC).Design, setting and participants: Cross-sectional study of a population-based sample of 1100 Australian patients aged 18–79 years with histologically confirmed oesophageal cancer diagnosed in 2002–2005, using data from cancer registries and treatment centres, supplemented with clinical information collected through medical record review in 2006–2007 and mortality information collected in 2008.Main outcome measures: Prevalence of primary symptoms, and staging investigations and treatment modalities used.Results: The primary presenting symptom was dysphagia, which was self-reported by 41%, 39% and 48% of patients with OAC, GOJAC and OSCC, respectively. Less common symptoms were reflux, chest pain, bleeding and weight loss. All patients underwent endoscopy, most had a staging computed tomography scan (OAC 93%, GOJAC 95% and OSCC 93%), and about half had positron emission tomography scans (OAC 51%, GOJAC 44% and OSCC 42%). Pretreatment tumour stage was reported in 25% of records, and could be derived from results of investigations in a further 23%, but the remaining half lacked sufficient information to ascribe a pretreatment stage. Curative treatments were attempted for 60% of OAC, 88% of GOJAC and 65% of OSCC patients. Surgery was performed on 52% of OAC, 83% of GOJAC and 41% of OSCC patients. About two-thirds of surgical patients received additional therapies.Conclusions: With anticipated increases in oesophageal cancer incidence, the resources required to diagnose and manage patients with oesphageal cancer are also likely to rise. Our data provide a baseline from which to plan for the future care of patients with cancers of the oesophagus.

Bernard M Smithers MB BS, FRACS, FRCS · Paul P Fahey BSc, MMedStat · Tracie Corish RN · David C Gotley MD, FRACS · Gregory L Falk FRACS, FACS · Garett S Smith MS, FRACS · George K Kiroff MB BS, MS, FRACS · Andrew D Clouston MB BS, PhD, FRCPA · David I Watson MD, FRACS · David C Whiteman MB BS,PhD, FAFPHM

To the Editor: In response to Hall and colleagues,1 the Royal Australasian College of Surgeons supports any measures that have been proven to successfully reduce death and injury in young drivers. Raising the minimum legal drinking age (MLDA) to 21 years has been shown to significantly decrease road crash deaths in the United States.1 The College agrees with these authors that there would be major political obstacles and very little public support in Australia to increasing the MLDA; however, should the politicians and the public see first hand the devastating effects of alcohol on young people that our surgeons see on an all-too-regular basis, the mindset might change significantly. Hall and colleagues state other ways that we can achieve further reductions in road crash deaths — extending the zero-tolerance laws for young drivers until age 22 years, as it is in Victoria, or until 25 years for even further reductions.1 The College certainly supports this, particularly as evidence is building that the physical maturation of the part of the human brain that assesses risk and controls impulsive behaviour is not complete until age 25 years in men.2-4 The Trauma Committee is most concerned about alcohol-related trauma and will explore this issue at the annual Trauma Committee workshop, during the College’s Trauma Week. The workshop, entitled “Alcohol and injury”, will be held at the College in Melbourne on 18 November 2010.

Daryl R Wall

To the Editor: The World Health Organization Surgical Safety Checklist (Checklist) has recently been editorialised by Merry and Barraclough.1 We are all keen to see perioperative mortality and morbidity reduced to a minimum, and one cannot disagree with the intent of the Checklist, which was tested in a pilot study2 involving almost 8000 patients in eight hospitals (in disparate developed and developing countries). The study showed a reduction in the death rate associated with surgery from 1.5% to 0.8% (or 15 per 1000 down to eight per 1000). Impressive indeed! My concerns are firstly with process. One hospital in Brisbane has already introduced the Checklist without the constructive engagement of those at the clinical coalface, contrary to what proponents of the Checklist advocate, and it is being used in a way which distracts personnel during the induction of anaesthesia. To those familiar with accident analysis, this is a good example of poor process implementation by a hospital administration and its managers. Secondly, I am concerned by the use of the study of Haynes and colleagues2 to underwrite the Checklist. Results of the study would be more meaningful if the reduction rates in mortality in the hospitals in the developed countries (Canada, United States, United Kingdom and New Zealand) were separated from those in the developing countries. Or would this have shown the developed countries’ reduction rate to be statistically non-significant? Are we to believe that use of the Checklist could save seven lives per 1000 procedures in Australia, or 15 000 to 21 000 lives across the three million procedures undertaken here annually? Total figures for perioperative mortality across all procedures in all operative categories remain a matter for conjecture. However, in looking at the high-risk group of cardiac surgical operations in Victorian public hospitals,3 we can see a published mortality rate of 10 per 1000 for coronary artery bypass or isolated valve surgery, only a little higher than that seen after the introduction of the Checklist across a broad surgical population. We should be careful to see that spin does not become embedded within medicine, even where it is associated with what is probably a good idea.

James P Bradley

In reply: Thank you for the opportunity to respond to Bradley’s letter. We agree that constructive engagement of clinicians is essential in adoption of the World Health Organization Surgical Safety Checklist (the Checklist) — that point is clearly made in our editorial.1 Bradley’s anecdotal comment about use of the Checklist causing distraction during the induction of anaesthesia is difficult to evaluate in the absence of more detail. Surely any competent anaesthetist committed to patient safety could liaise with other team members to find an acceptable time to fulfil the entirely reasonable expectation of ensuring that relevant safety checks have been done? Furthermore, the study of Haynes and colleagues2 provides considerable reassurance about the possibility of unintended harm from use of the Checklist. Justification for the Checklist does not depend on the above-mentioned study alone: the Checklist was developed by an extensive process of literature review and consultation. It reflects expert consensus, and its endorsement by the Australian and New Zealand College of Anaesthetists, the Royal Australasian College of Surgeons and many other organisations adds to this consensus. There is no suggestion that the Checklist will save any particular number of lives in any given country — rather, its use is likely to reduce the number of patients harmed during surgery, and this is surely worthwhile.

Alan F Merry · Bruce H Barraclough

To the Editor: The long-term functional outcomes in the three cases of swimming pool filter-induced transrectal evisceration described by Price and colleagues1 are excellent and significantly better than many other cases described in the literature. However, it may be possible to improve further on such results, or at least decrease short-term morbidity, by expediting the reduction of the eviscerated bowel. In all three cases described,1 the children presented initially to a local hospital and were subsequently transferred to a tertiary care facility before operative reduction was initiated. It is likely that earlier operative reduction of the eviscerated bowel would decrease secondary venous congestion of the prolapsed segment, thus minimising further ischaemic changes already initiated by the mesenteric arterial and/or venous tear. This in turn may improve the perfusion of the affected segment; lessen the development of hypothermia, hypovolaemia and sepsis; and possibly increase the final length of viable bowel. A “damage control” laparotomy2,3 performed at an appropriate hospital of initial presentation (one with a surgeon and anaesthetist available), with the principal aim of early reduction of the prolapsed bowel into the abdominal cavity, may improve outcomes in such cases.

Phillip J Carson