Surgery

Objective: To assess the outcomes of appendicectomy in an acute care surgery (ACS) model compared with a traditional on-call (Trad) model.Design: Retrospective historical control study comparing appendicectomy outcomes in the Trad period (April 2004 to March 2005) with outcomes in the ACS period (April 2006 to March 2007).Setting: The Prince of Wales Public Hospital, a metropolitan tertiary referral centre in Sydney.Patients: All adult patients undergoing appendicectomy during 1-year periods before and after the introduction of the ACS model.Intervention: The introduction of an ACS model for managing all emergency general surgical presentations.Main outcome measure: Complication rate.Results: A total of 402 appendicectomies were performed, 176 during the Trad period and 226 during the ACS period. There was no perioperative mortality. The complication rate was lower in the ACS period than the Trad period (9.3% v 17.0%; P = 0.02). After the intervention, there was no significant change in the time from presentation to arrival in theatre or in length of stay, but the proportion of operations performed at night (24:00–08:00) was reduced from 26.1% to 15.0% (P = 0.006). The proportion of negative appendicectomies was reduced from 22.7% to 17.3%, but the change was not statistically significant (P = 0.08). There was no difference in perforation rate before and after the intervention (13.6% v 13.3%; P = 0.86).Conclusion: The ACS model provides a safe surgical environment for patients and is associated with a reduced complication rate. Under the ACS model, there was an increase in the number of patients treated conservatively overnight, but this did not lead to an overall increase in perforation rate or length of stay.

Robert C Gandy MB ChB, MRCS · Phillip G Truskett MB BS, FRACS · Shing W Wong MB BS, MS, FRACS · Sanchia Smith MB BS · Michael H Bennett MB BS, MD, FANZCA · Andrew D Parasyn MB BS, FRACS

Blood on my hands: a surgeon at war. Craig Jurisevic. Melbourne: Wild Dingo Press, 2010 (328 pp). ISBN 9780980757002. This Autobiography is set in Kosovo 1999, in the weeks before North Atlantic Treaty Organization bombing finally forced Serbia to make peace and stop its ethnic cleansing of Kosovars. The author, Craig Jurisevic, a cardiothoracic surgeon from Adelaide, served with the International Medical Corps in Albania. There he kept a journal which, a decade later, he revisited, with the help of writer Robert Hillman, to write this book that describes what he saw and how he felt. As the chapters unfold, it is unnerving to see how the author’s sense of responsibility escalates, not only towards the wounded soldiers and civilians on whom he operates but also to those exposed on the front line without medical support. Jurisevic (his mother’s Slovenian surname) becomes disgusted, angered and eventually consumed by the injustice — the evil of ethnic cleansing and the brutality of its perpetrators, the Serbian militia. It is not only the dreadful injuries that move him, but also the way in which they are inflicted and the manner in which people are executed. He is unable to act the part of a detached foreign doctor, nor tolerate the Albanians who exploit and extort the sick and injured Kosovars — local mafia barons who enrich themselves on the suffering. During the final weeks of the war, Jurisevic serves on the front-line, operates in a cave, and is forced to defend himself against Serbian attacks. This is an extremely well written book, but not one that is just to be enjoyed — it is brutal and honest; shocking but authentic. There is no other like it, and small wonder that it is being adapted for the big screen. Its readership will be much wider than the medical market and it is likely to become a bestseller. The worst comment I can make about its content is that it is all true.

David A K Watters

WWyeth Australia has been a valued partner with the Medical Journal of Australia since 1995 in recognising and rewarding the best of original research published each year in the Journal. The 2009 MJA/Wyeth Award was presented at the Australian Medical Association (AMA) National Conference in Sydney on 28 May 2010. The Journal’s Content Review Committee has awarded the prize for 2009 to Tanya Bubner and her colleagues from the University of Adelaide and Flinders University for their research paper, “Effectiveness of point-of-care testing for therapeutic control of chronic conditions: results from the PoCT in General Practice Trial”, published in the 1 June 2009 issue of the Journal. Point-of-care testing (PoCT) provides the treating general practitioner with immediate test results and has the potential to improve monitoring of chronic conditions, therapeutic control and clinical efficiency, and to enhance clinical decision making within the time frame of the consultation. PoCT not only provides an alternative method of pathology testing, but also allows a different style of patient management compared with traditional pathology laboratory testing. Demand for PoCT in general practice is increasing; however, there is little evidence about its benefits, particularly these related to clinical outcomes. Bubner and colleagues assessed the safety, clinical effectiveness and cost-effectiveness of and satisfaction with PoCT in general practice. In a large, multicentre, cluster randomised controlled trial, they found that PoCT was equivalent to pathology laboratory testing for a variety of pathology tests in chronic diseases. The researchers found that for the proportion of patients with results in the target range, PoCT was equivalent to pathology laboratory testing for measuring glycated haemoglobin, urine albumin, albumin–creatinine ratio, total cholesterol and triglyceride levels, but not for high-density lipoprotein cholesterol level and international normalised ratio. The research by Bubner and colleagues provides important evidence for the introduction of PoCT into general practice. The award was presented by Ms Yvonne Bowyer, Deputy Managing Director, Wyeth Australia; I thank her on behalf of the AMA and the Australasian Medical Publishing Company, the publisher of the MJA, for Wyeth’s continuing commitment to promoting excellence in Australian clinical research through the prestigious MJA/Wyeth Award. Martin Van Der Weyden, Jane Harrison, Ruth Armstrong, Justin Beilby, Yvonne Bowyer, Tanya Bubner, Andrew Pesce

When consummate Aboriginal and Torres Strait Islander storyteller Jane Harrison took the stand to receive the 2010 Dr Ross Ingram Memorial Essay Prize in late May, it was an opportunity to reflect on the growing involvement of Aboriginal and Torres Strait Islander people with the MJA — as authors, contributors and reviewers — since the competition’s inception 5 years ago. Jane’s winning essay, Healing our communities, healing ourselves, in which she explores the particular challenges faced by Aboriginal and Torres Strait Islander people who work to improve Indigenous health while facing difficulties in their own lives, was published in the 17 May 2010 issue of the Journal. Jane is a descendant of the Muruwari people of New South Wales, from the area around Bourke and Brewarrina. Currently the Aboriginal Child Rearing Stories Project Officer at the Secretariat of National Aboriginal and Islander Child Care, she spent 6 years researching and writing the award-winning play, Stolen, which has brought the stories of Australia’s stolen generations to thousands of people in Australia and overseas since its release in 1998. Her other work includes the play, Rainbow’s end, and an episode of the popular SBS series, The circuit. In receiving her prize, Jane challenged those present to take their interest in Indigenous health and welfare beyond abstract gestures and endeavours to the personal level, by having real conversations and forging real relationships with Aboriginal people. Entries for next year’s Dr Ross Ingram Memorial Essay Competition are currently open. For full details see http://www.mja.com.au/public/information/RossIngramCompetition.html. Martin Van Der Weyden, Jane Harrison, Ruth Armstrong, Justin Beilby, Yvonne Bowyer, Tanya Bubner, Andrew Pesce

To the Editor: The prophylactic use of inferior vena cava filters (IVCFs) in trauma patients for whom anticoagulation is contraindicated has markedly increased over the past few years. Their need for caval filtration is usually only transient, and once the risk of venous thromboembolism is deemed to be minimal, it would seem appropriate that IVCFs be retrieved. However, a large number of IVCFs remain in situ, due to either failure of retrieval or lack of follow-up. We observed a case that touches on both of these two major problems associated with IVCF retrieval. A 34-year-old man received a prophylactic IVCF after he had sustained severe pelvic fractures, several undisplaced spinal fractures and a splenic laceration in a motorbike accident. He was deemed to be at high risk of venous thromboembolism, and immediate prophylactic anticoagulation was contraindicated because of his pelvic and splenic injuries. The scheduled IVCF retrieval, 8 weeks after insertion, failed due to technical difficulties. A large clot between the struts of the IVCF (Figure) meant further withdrawal attempts were deemed too dangerous. The patient was informed that he had two options: if the filter remained in situ, he would possibly need lifelong oral anticoagulation; or the IVCF could be surgically removed. Soon after this, the patient was discharged with instructions to continue oral anticoagulation. About 5 months later, at a follow-up consultation with the orthopaedic surgeon about his injuries, the patient expressed his concern about the IVCF and especially about the anticoagulation. He was taking it for no other indication than the IVCF. The radiologist who had inserted the IVCF was contacted, and subsequently removed it without any complications. In the case described here, an initial retrieval attempt was thwarted by filter tilt and a large clot burden. After discharge, the patient was lost to follow-up with respect to the IVCF. Fortunately, this was addressed by one of the specialists involved in management of the patient’s other problems. Without this intervention, the patient may have ended up with the filter permanently in situ, with its attendant risks, and an unwarranted lifetime of anticoagulation. When filters have a significant clot burden, anticoagulation can help dissolve this to the point at which retrieval can be effected safely.1 This case highlights the need for appropriate follow-up after IVCF insertion. Various studies have outlined different follow-up strategies, some using a protocol drawn up in a multidisciplinary team setting,2 others designating a key person (usually the clinician who inserted the filter) to undertake this task.3,4 Both strategies have been shown to reduce the number of patients lost to follow-up. The clot, occluding nearly the whole lumen of the inferior vena cava (IVC), is seen as a radiolucent area between the IVC filter struts as the contrast agent passes by.

Dominik Baschera · Jonathan K Sebunya · René Zellweger

To the Editor: In February 2009, a 68-year-old man presented to the Royal Victorian Eye and Ear Hospital within hours of developing an itchy, red left eye. The patient, who was otherwise healthy, lived in suburban Melbourne, usually with his pet dogs, but the last of his dogs had recently died. The patient was unsure if all his dogs had been dewormed regularly because he spends about 6 months a year in Europe. General inspection of the eye suggested subconjunctival haemorrhage. However, slit-lamp examination showed a mobile, tightly coiled structure within the subconjunctival blood. It grew increasingly agitated with higher slit-lamp light intensity (Box, A). Assessment of the patient’s visual acuity and the anterior and posterior chambers of the eyes was unremarkable. Blood tests revealed a positive filarial serology and eosinophilia. The patient was transferred to the operating theatre and, under topical anaesthesia, a 5 mm conjunctival incision was made and the mobile structure removed (Box, B and C). The patient was discharged with a prescription for prednisolone acetate 1% and chloramphenicol 0.5% eye drops (one drop four times a day). He made a full recovery. The extracted specimen was reviewed by one of us (D M S). The 150 mm worm was identified as a young adult female filarioid nematode, Dirofilaria immitis (commonly named dog heartworm) after comparisons with laboratory specimens of D. immitis and Pelecitus roemeri. Infection with either P. roemeri (kangaroo and wallaby knee worm) or Loa loa (loiasis) was excluded. Our specimen did not have lateral alae and the distance from anus to tail was shorter than would be expected for the kangaroo worm. In addition, the patient had never been to Africa where loiasis is endemic to several countries. Subconjunctival dog heartworm is rare, but its incidence is increasing in parts of the world.1,2 Dogs are the natural hosts and transmission to humans occurs through mosquito bites of the skin (into which the third-stage infective larva may escape). For an unknown reason, the worm sometimes takes an abnormal migratory route and ends up in the eye of the host. Ophthalmic cases have been reported in dogs.3,4 Careful measures to exterminate mosquitoes and deworm dogs and cats are important in limiting its transmission. Surgical extraction is the definitive treatment and further treatment with systemic anthelmintics is unnecessary.5 Humans are non-natural hosts for this parasite and, therefore, its life cycle cannot be completed within the human body. When a larva does evade the human immune system, as in the case of our patient, the chances of another larva being present elsewhere in an immunocompetent person seems remote. Furthermore, unless the larva becomes clinically apparent, it would be impossible to find. Subconjunctival Dirofilaria immitis infection in a 68-year-old man A: A whitish mobile structure coiled in the haemorrhagic subconjuctival space B: The female Dirofilaria species measuring about 150 mm C: Day 1 after removal of worm and necrotic temporal conjunctiva, exposing bare sclera

Elaine W Chong · Harsha Sheorey · Cheng Hean Lo · David M Spratt · Enrique Graue-Hernández

A simple-to-use, inexpensive, low-risk tool that is not about ticking boxes but about keeping patients safe — it encourages surgeons, anaesthetists and perioperative nurses to work as a team, communicate and engage fully in safety processes Following pilot implementation of the World Health Organization’s Surgical Safety Checklist (the Checklist), a 30% reduction in surgery-related death and complications was achieved — a great result from a simple and affordable intervention!1 The Checklist2 was launched in Australia by the Hon Nicola Roxon MP, Federal Minister for Health and Ageing, on 19 August 2009, and a week later in New Zealand by the Hon Tony Ryall MP, Minister of Health. Similar launches have occurred around the world. The Checklist, produced by the WHO’s Second Global Challenge of the World Alliance for Patient Safety, was evaluated in a pilot study involving almost 8000 patients in eight centres, including one in our region, in countries with health systems of varying sophistication.1 This study showed that the Checklist was simple to use, and was associated with a worthwhile improvement in outcomes attributable to improved adherence to a number of predefined safety processes. For example, combined results from the sites showed reductions in: deaths, from 1.5% to 0.8% (P = 0.003); complications, from 11% to 7% (P = 0.001); and unplanned re-operations, from 2.4% to 1.8% (P = 0.047). This was a quality improvement study, not a randomised controlled trial, but the Checklist is a well thought-out, inexpensive, low-risk initiative that makes sense and works. The problem of iatrogenic harm has been characterised and quantified in a number of studies internationally,3,4 including widely cited work in our own region.5,6 These studies show that too many patients are harmed by the health care intended to help them,7 and that this harm is often the result of preventable failures in process.8 The Checklist is a cognitive aid to assist in the processes of caring for patients during anaesthesia and surgery but, more importantly, it is also designed to promote teamwork and communication within the operating room. Therefore, it was appropriate that the launches of the Checklist were collaborative affairs, with wide representation from nursing and medical organisations, including the Royal Australasian College of Surgeons, Australian and New Zealand College of Anaesthetists and Australian College of Operating Room Nurses, among others. The value of checklists in process management has been recognised in high-stakes activities other than medicine since at least the 1930s, and it is now time for surgeons, anaesthetists and perioperative nurses to increase their use of checklists for process control. Various methods of checking have been used by nurses, anaesthetists and surgeons for many years, but unacceptable errors continue to occur. For example, of the serious and sentinel adverse events reported in New Zealand in 2008, 19 cases involved the wrong site, wrong patient or wrong procedure, and six involved retained surgical swabs or other paraphernalia.9 This distressing situation is not far out of line with experiences in similarly sized Australian states or other countries. In New South Wales, in the second half of 2007, there were 10 wrong patient, wrong site or wrong procedure incidents in operating rooms; 61 incidents involving imaging and nuclear medicine; two in radiology services; and 13 in wards and other areas.10 The Checklist is applied in three phases: “Sign In”, when key issues are checked before induction of anaesthesia in the operating room; “Time Out”, which includes introducing all staff in the operating room, a briefing of the team and a final check of key issues before incision; and “Sign Out”, which is a clear handover to postoperative staff of important issues for ongoing patient management. It is relevant that the Checklist was developed through a highly evidence-based process, in which an international interprofessional group of experts reviewed the available literature, identified aspects of the perioperative process which typically fail, and consulted widely in designing a solution. Ticking the boxes is not the objective — getting people to engage in the key processes of perioperative care is. Local modification is encouraged, and an Australian and New Zealand version has been developed and launched,11 which includes prophylaxis of venous thromboembolism as one of the key issues checked during “Time Out”. Change management is hard work and worldwide experience indicates the need for active implementation programs led by clinical champions. The Checklist will not eliminate mistakes, but it has good potential to reduce them. All who practise surgery, anaesthesia and perioperative nursing are asked to adopt the Checklist in an engaged and constructive manner and make it work. The importance of instigating the use of the WHO Surgical Safety Checklist as an operating room routine cannot be overstressed. Preventable iatrogenic harm continues to be a major problem internationally, including in surgery and anaesthesia. The Checklist is an inexpensive, low-risk, adaptable initiative based on commonsense that has been shown to be workable and to significantly reduce harm in surgery and anaesthesia. The Checklist has the support of many local and international medical and nursing organisations.

Alan F Merry MB ChB, FANZCA, FFPMANZCA · Bruce H Barraclough FRACS, DDU, FACS

Clinical records Patient 1 A 6-year-old boy briefly sat on an uncovered drain site in a home swimming pool. He extracted himself but his intestines could be seen prolapsing from his anus. On transfer to tertiary care from the local hospital, severe hypovolaemic shock was noted. He received aggressive fluid resuscitation and blood transfusion before undergoing an emergency laparotomy. This found a shearing injury, with complete disruption of the mesenteric vessels and a massive haemoperitoneum, but no active bleeding. A 4 cm anterior rectosigmoid tear was noted, through which 110 cm of small intestine had herniated out via the anus. This length was non-viable. The patient was left with 55 cm of small intestine, with an intact ileocaecal valve. The rest of the colon was normal, and there was no injury to the perineum. Primary closure of the rectal perforation was performed, and both ends of the small bowel were exteriorised. After the operation, the patient was managed with total parenteral nutrition, and loperamide to slow stoma output. Six weeks later, he underwent closure of the stoma. The boy’s long-term growth, diet and continence are normal, although his bowel motions remain loose. Patient 2 A 4-year-old girl sat on a home swimming pool skimmer box and was unable to get up again. Her father broke the seal around her buttocks, and evisceration was immediately apparent. She was taken to the emergency department at a major regional centre, where she was intubated and transferred to tertiary care. A laparotomy found that 75% of the small bowel had prolapsed through a rectal perforation just above the peritoneal reflection. There was a large mesenteric tear, with avulsion of the superior mesenteric vessels. There were 120 cm of jejunum proximally and 90 cm of ileum distally that were viable. The rectal perforation just above the peritoneal reflection was repaired. Over the next 4 days, two laparotomies were performed and non-viable bowel resected on both occasions. The patient was left with 140 cm of small bowel, an intact ileocaecal valve, and a loop sigmoid colostomy. Oral intake commenced on the 11th day, and parenteral nutrition ceased after 16 days. She was discharged after 21 days. The colostomy was closed after 14 weeks, and the girl was well at 6-month follow-up, with normal continence. Patient 3 A 3-year-old boy sat down on an uncovered skimmer box when he baulked while preparing to jump into a pool at a motel. He was initially taken to a small regional hospital then transferred to tertiary care. At laparotomy, the small bowel, from 20 cm distal to the duodenojejunal flexure to the ileocaecal valve, was found to have been eviscerated. There was a 20 cm section of jejunum proximally that had its mesentery stripped off; this was resected and the ends stapled. The rectal perforation just above the peritoneal reflection was repaired. At a second-look laparotomy 2 days later, a further 5 cm of the distal bowel was found to be frankly necrotic, and was resected. The remaining distal bowel had marginal viability, as assessed by intraoperative pulse oximetry, but was left in situ to maximise bowel length (170 cm of small bowel). Postoperative management was complex: epoprostenol (prostacyclin) and dopamine were commenced to promote bowel perfusion. A third laparotomy showed improved perfusion and continuity was restored. The patient had a difficult postoperative course, with prolonged parenteral nutrition, sepsis and an enterocutaneous fistula. The fistula closed spontaneously, enteral feeding was established and he was discharged after a 3-month hospital stay. At 1-year follow-up, the boy was active, tolerating a full diet, continent by day, and above the 90th percentile for weight and height. His wound had healed well except for two slightly keloid areas. The causes of these evisceration injuries are well described in the literature. Vortex-style drains can create a powerful vacuum when occluded.1 In addition to the transanal route, direct evisceration through the perineum has been described.2 Other non-suction-related causes of transanal evisceration have also been described — in adults, it is usually associated with increased abdominal pressure or blunt trauma. This is a rare occurrence in adults, with only 53 reported cases.3 Non-suction-related transanal evisceration in children has only recently been described in relation to accidental and self-inflicted rectal trauma.4,5 The potential for penetrating trauma to cause evisceration should be considered by the astute clinician if the history or physical findings are not consistent. Associated perineal oedema and petechiae are well described with suction injuries. Entrapment in deeper water has also resulted in drowning.6 There can be a spectrum of injury associated with this mechanism, and treatment should be tailored accordingly. At the mild end of the spectrum, prolapse of the rectum can occur, which can be treated with simple reduction.7 True transanal evisceration always requires operative repair and often multiple procedures.1 In the patients described here, the bowel was difficult to reduce and required gentle pressure from below with guidance via laparotomy from above. The injury to the bowel in all cases was due to the traction on the mesentery and subsequent damage to the mesenteric vessels. This is in contrast to reported cases of evisceration from penetrating injury, where the eviscerated bowel was viable and otherwise intact.4,5 Patients 2 and 3 illustrate the importance of second-look laparotomy in the evaluation of bowel of questionable viability, as has been highlighted in the literature.1,6 Bowel that is initially of dubious viability can later be found to have survived, thus preserving length and avoiding complications of short bowel. The use of pulse oximetry to aid in determination of bowel viability has previously been described8 and was helpful in avoiding massive resection in our third patient. Prostacyclin analogues have been shown to have a beneficial effect on splanchnic perfusion in animal models and in human studies.9 There is considerable morbidity associated with this condition. The most minor form of injury can be a transient rectal mucosal prolapse with no perforation, but, even at this end of the spectrum, there is considerable psychological impact.7 At the most serious end of the injury spectrum, short bowel syndrome can occur, with an ongoing requirement for parenteral nutrition, and potentially even death following small bowel transplant.1,2,6 A 2007 review of published cases found that nine of 13 patients were dependent on parenteral nutrition.10 The lengths of bowel lost through these injuries are graphically represented in Box 1. By comparison, our patients had good outcomes, with no ongoing requirement for parenteral nutrition. There is growing literature suggesting that suction drains are not necessary for pool cleaning, and that more effective, safer alternatives are available.11,12 If a suction drain is newly installed or is already in place, protective, or antivortex, covers have been advocated to minimise the suction risk.1 Although these covers will prevent direct suction injuries, hair or digits could still be trapped, and the covers only offer protection when fitted correctly and not removed. Two of our patients’ injuries occurred because the covers had been temporarily removed. In addition to the inherent danger of the pool suction drain, the arrangement of the drain in two of our cases made it even more inviting for a young child to sit on when uncovered (Box 2). Changing the shape, size and configuration of the aperture may therefore also prevent injury. Other potential remedies are adding an automatic cut-off switch so that the filter cannot function if the cover is off, or an override system that cuts off the filter if the intake appears to be occluded, thus limiting the peak negative pressure that can be generated. The role of legislation with regard to education also needs to be considered. There has been a voluntary standard for swimming pool drains in Australia since 1980, and this was updated in 2003. This document mandates that any access hole greater than 150 mm in diameter be separated from the pool edge by a solid permanent beam of at least 100 mm width and be covered by a vented lid.13 The ongoing incidence of these injuries shows that this approach alone has failed to protect children. The “four Es” of injury prevention — education, engineering, enforcement and economics — have previously been described.14 Rather than a voluntary standard, legislation is needed to mandate the safety of swimming pool fittings, as has been the case with pool fencing.15 Enforcement of such legislation is also required to effect change.16 Finally, public education has been shown to be effective in injury prevention in other areas.17 These suction injuries are rare but potentially catastrophic. It is important to publicly highlight the danger of these injuries and effect change before more children are maimed. 1 Length of bowel resected* in our three patients and eight other cases1,2,6 of transrectal evisceration * Length of bowel resected is represented by shaded area. 2 “Potty” style skimmer box This is the location at which Patient 3 was injured. The brown structure to the left is the cover that is intended to sit over the skimmer box. Lessons from practice Evisceration injuries caused by the suction of swimming pool drains are rare but potentially catastrophic events. Delayed resection can minimise the chance of short bowel syndrome in evisceration injuries. Although current engineering standards are adequate to prevent these kinds of injuries, education of pool owners and ultimately enforcement of legislation are required to ensure that standards are enacted.

Neil R Price MB ChB, FRACS(Paed) · S V Soundappan MS(GenSurg), MCh(PaedSurg), FRACS(Paed) · Anthony L Sparnon FRACS · Danny T Cass FRACS

In the Australian public health system, access to elective surgery is rationed through the use of waiting lists in which patients are assigned to broad urgency categories. Surgeons are principally responsible for referring patients to waiting lists, deciding on the appropriate urgency category, and selecting patients from the waiting list to receive surgery. There are few agreed-upon criteria to help surgeons make these decisions, leading to striking differences between institutions in proportions of patients allocated to urgency categories. In other countries with publicly funded health systems, programs have been developed that aim to make prioritisation more consistent and access to surgery more equitable. As demand for health care increases, similar programs should be established in Australia using relevant clinical and psychosocial factors. Prioritisation methodology adapted for elective surgery may have a role in prioritising high-demand procedures in other areas of health care.

Andrea J Curtis BSc(Hons), PhD · Colin O H Russell MB ChB, FRACS · Johannes U Stoelwinder MD, FRACMA, FACHSE · John J McNeil PhD, FRACP, FAFPHM

Hospital funding based on achieving targets for numerical key performance indicators was implicated in Queensland’s Bundaberg Base Hospital scandal and has driven hospital data fraud in Victoria and New South Wales. Nationally uniform legislation is required to make health service reporting standards consistent and to criminalise public sector data fraud. Urgent action is needed to develop realistic outcome measures that base hospital funding more on the quality and safety of patient care and less on patient throughput numbers.

Antony Nocera FACEM, MSc(Emergency Planning and Disaster)

McKittrick–Wheelock syndrome is a rare but recognised complication of hypersecretory rectosigmoid villous adenoma. Fluid and electrolyte imbalances require close monitoring because of large-volume losses of water, sodium and potassium. We report an unusual presentation of the syndrome associated with the development of acute pseudo-obstruction of the colon, presumably due to electrolyte dysfunction and acute renal failure. (MJA 2010; 192: 225-227) Clinical recordA 68-year-old, white, previously fit and healthy man was transferred to our facility with oliguric acute renal failure. The patient reported 72 hours of lethargy, myalgia, generalised weakness and cramps, following 3 weeks of watery diarrhoea, with pink-stained mucous discharge. He reported 10 motions per day, and no abdominal pain or vomiting. Some bloating had been noted in the preceding 24 hours. On examination, the patient had a heart rate of 85 beats/min, blood pressure of 115/65 mmHg, a respiratory rate of 20 breaths/min, and a temperature of 36.2°C. Oxygen saturation was 95% on room air. He was clinically dehydrated, with reduced tissue turgor and dry mucous membranes. Normal breath sounds were audible. His abdomen was noted to be grossly distended and non-tender. No masses or organomegaly were evident. Digital examination demonstrated an enlarged rectum with no palpable mass. Initial laboratory investigations (Box 1) showed hyponatraemia, hypokalaemia and elevated urea and creatinine levels. Haemoconcentration was evident. Results of investigations for intrarenal causes of renal failure were negative. Analysis of arterial blood gases showed a transient respiratory alkalosis and net mild metabolic acidosis. There were multiple causative factors, suggesting the presence of an underlying metabolic alkalosis. Renal tract ultrasound showed no obstructing lesion, with normal kidney size and morphology. Plain imaging (Box 2) and computed tomography (CT) of the abdomen and pelvis with intravenous and oral contrast demonstrated distension of the small bowel up to 4 cm in diameter, with a caecal diameter of 10 cm. Fluid material filled the sigmoid colon and rectum. A non-obstructing, exophytic mass arising from the lateral wall of the rectum, measuring 5 × 9 × 7 cm, was noted. A presumptive diagnosis of colonic pseudo-obstruction due to fluid and electrolyte imbalance was made. The patient was aggressively rehydrated and administered N-acetyl cysteine. He was admitted to the intensive care unit immediately after his CT scans for continuous haemofiltration, vasopressor support and total parenteral nutrition (TPN). A rectal tube was inserted, which drained at a rate of 4 L/day. Haemofiltration and noradrenaline were ceased on Day 2 and TPN on Day 3. Renal function and serum biochemistry normalised by Day 4. Colonoscopy revealed an exophytic, pedunculated tumour about 10 cm long, located 10 cm from the anal sphincters. The large bowel was successfully decompressed. A biopsy of the lesion demonstrated tubulovillous adenoma. The rectal tube was removed on Day 5, and the patient, having opened his bowels, was transferred to the ward. Stool cultures were negative for viral or bacterial pathogens. Loperamide and codeine phosphate were introduced, with effect. Given the patient’s recent renal impairment, indomethacin was not commenced. The patient was discharged home on Day 10. Staging magnetic resonance imaging of the pelvis performed on the day of discharge clearly demonstrated a large, sessile tumour arising from the left rectal wall (Box 3). Appearances were thought to be consistent with a T2 lesion. After 3 weeks of outpatient convalescence, the patient returned for elective low anterior resection, which revealed a large, exophytic lesion within the rectum (Box 4). Histopathological examination of the resected specimen (Box 5) confirmed hypersecretory tubulovillous adenoma with low-grade dysplasia. DiscussionMcKittrick–Wheelock syndrome was described in 1954 and is a rare complication of villous adenoma.1 It is typified by large-volume secretory diarrhoea, prerenal acute renal failure, and severe electrolyte dysfunction (primarily hyponatraemia, hypochloraemia, hypokalaemia and metabolic acidosis). The causative lesion is usually in the rectosigmoid and is normally over 4 cm in diameter.2 One series of 18 patients described tumours ranging between 7 cm and 18 cm.3 Roughly 2% of patients with rectosigmoid villous adenoma will develop hypersecretory complications.4 Cellular composition of non-secretory and secretory villous adenomas differs markedly. Light microscopy of non-secretory villous adenoma reveals relatively few goblet cells within the tumour epithelium, while much of the epithelial architecture of secretory adenomas is composed of these mucin-secreting structures. It has been postulated that the large surface area of the lesion participating in mucin production is a contributing factor to the volume of diarrhoea. The distal location of these lesions means there is a minimal area of normal colonic mucosa remaining to allow fluid absorption.5 The electrolyte composition of mucin secreted by abnormal cells within the causative lesion is of interest. Whereas normal bowel absorbs sodium and water and secretes potassium, segments of intestine affected by villous adenoma have been found to secrete water, sodium and potassium. Absorptive capacity was largely unchanged. In both cases, net movement of water was directly related to net movement of sodium. There was no relationship between net movement of water and potassium loss.6 The cause of this abnormal secretory function has been postulated to be secretagogue-mediated. Rectal effluent from a patient with villous adenoma of the rectum demonstrated prostaglandin E2 (PGE2) levels three to six times higher than normal.7 Tissue from villous adenoma and carcinoma synthesises more PGE2 than normal colonic mucosa. Mucosa adjacent to adenomatous polyps has been found to be unaffected by this, but carcinoma-associated mucosa was demonstrated to synthesise larger amounts of PGE2.8 These secretagogues are active at sites containing the prostaglandin synthetic pathway. Non-reversible cyclooxygenase-inhibiting agents have been used to reduce PGE2 production, and consequently loss of sodium and water through the rectum.9 Cyclic nucleotides have also been implicated.10 It has previously been suggested that elevated PGE2 levels may contribute to the adenoma–carcinoma sequence,11 explaining the beneficial role of non-steroidal anti-inflammatory drugs in preventing colorectal cancer as well as controlling diarrhoea. The presence of colonic pseudo-obstruction added another level of complexity to our case.12 Given the pathophysiology of hypersecretory villous adenoma and the predisposing factors for pseudo-obstruction, this association is not unexpected. Less than 5% of patients will develop colonic pseudo-obstruction idiopathically.13 In an analysis of 378 patients with pseudo-obstruction, 16 cases (4.23%) were precipitated by acute renal failure, and a further 15 (3.97%) by electrolyte dysfunction.14 In another retrospective analysis of 48 cases, 83% of patients were found to have some degree of electrolyte dysfunction.15 The mechanism by which homeostatic derangement causes pseudo-obstruction remains poorly understood. 1 Relevant admission laboratory results* Result Reference range Serum biochemistry Sodium (mmol/L) 120 135–145 Potassium (mmol/L) 3.2 3.5–5.0 Chloride (mmol/L) 86 99–107 Bicarbonate (mmol/L) 18 24–32 Urea (mmol/L) 54.6 4.0–9.0 Creatinine (μmol/L) 580 60–105 Glucose (mmol/L) 7.5 4.0–7.0 Osmolality (mmol/kg) 331 275–300 Corrected calcium (mmol/L) 2.14 2.23–2.50 Magnesium (mmol/L) 1.96 0.7–1.1 Phosphate (mmol/L) 5.15 0.6–1.3 Urine biochemistry Osmolality (mmol/kg) 383 50–1200 Sodium (mmol/L) 8 Variable Protein (g/L) 1.42 0.01–0.14 Full blood examination Haemoglobin (g/L) 191 122–170 White cell count (× 109/L) 15.8 4.6–10.5 Platelets (× 1012/L) 326 150–400 Haematocrit (%) 0.53 0.36–0.49 Mean cell volume (fL) 83 80–97 Neutrophils (× 109/L) 13.4 1.9–8.0 Arterial blood gas pH 7.47 7.35–7.45 PaCO2 (mmHg) 25 35–45 PaO2 (mmHg) 126 75–99 Base excess − 4 − 3 to 3 Other Albumin (g/L) 47 35–52 * Some initial volume resuscitation with normal saline had taken place prior to investigations. 2 Erect (A) and supine (B) abdominal x-rays taken on admission Note the uniform dilation of the large bowel, with multiple air–fluid levels (arrows). 3 Sagittal (A) and coronal (B) magnetic resonance images of the causative lesion Note the large mass occupying the mid to distal rectum, arising from the left rectal wall (arrows). The protruding mass extends almost to the anal verge. These images show no evidence of involvement of perirectal structures. The darkened signal on T2 images is caused by large amounts of mucin within the lesion. H = head. F = feet. A = anterior. P = posterior. R = right. L = left. 4 Macroscopic photograph of rectal villous adenoma found at operation The causative lesion was 12 cm in diameter, with elevation of 5 cm. 5 Low-power (A) and high-power (B) microscopic photographs of the causative lesion These images demonstrate features consistent with villous adenoma with low-grade dysplasia. Of particular interest is the large volume of gelatinous mucin produced by the lesion, as well as the high population of goblet cells evident along the epithelial border of the lesion (arrows).

Lachlan F Miles MB BS(Hons) · Christopher J Wakeman MB ChB, MMedSci, FRACS · K Chip Farmer MB BS(Hons), FRACS, FCSSANZ

To the Editor: In their letter of 5 October 2009, Wong and colleagues highlight the importance of providing training for surgical specialties in the private sector.1 With 64% of surgical activity in Australia now occurring in the private sector,2 and public hospital activity constrained due to ongoing budget imperatives, the Royal Australasian College of Surgeons (RACS) has been actively exploring this idea for some years. The new Surgical Education and Training (SET) program selects trainees into one of nine specialty programs.3 Currently, there are 1254 trainees in the SET program across Australian, New Zealand and overseas positions. Once selected into a specialty program, trainees who succeed in achieving the educational goals will be able to progress through its entirety. Consequently, to enable completion of training in the program, each SET Level 1 post needs to be matched in the public or private sector with more senior training positions to ensure appropriate progression. The RACS has worked with a number of private hospitals and the federal government to identify and fund 50 training positions suitable for surgical education across Australia. The funding has predominantly been provided through the Australian Government’s Expanded Specialist Training Program. This program was established following the release of the Medical Specialist Training Steering Committee report4 to encourage training in settings other than public teaching hospitals. The RACS is keen to have this program substantially enhanced and is attempting to identify models with the federal government that can achieve this. This is where the work by Wong and colleagues1 is so important. The public and private sectors are different. Both can be highly useful for the education of a skilled surgeon. However, all educational environments need enthusiastic supervisors and trainers. The community and our patients also need to be understanding, supportive and enthusiastic for education of surgical trainees to occur. The RACS applauds Wong et al for progressing this discussion and highlighting the benefits that can result from expanding surgical training into the private sector.

Ian R Gough · Ian D Civil · Spencer W Beasley · Bruce H Barraclough · David J Hillis

To the Editor: We describe two liver transplant patients who presented with unexplained dyspnoea and were subsequently found to have unilateral right diaphragmatic palsy, an uncommon complication of orthotopic liver transplantation.1-3 Both transplant recipients were male. One, aged 64 years, had a liver transplant in 2005 for hepatitis C-related chronic liver disease. The other, aged 66 years, had a liver transplant in 2004 for end-stage alcoholic liver cirrhosis. Both patients had presented with exertional dyspnoea several weeks after transplantation. Both were reformed smokers with no prior respiratory symptoms or established respiratory or cardiac condition. Preoperative pulmonary function tests had been essentially normal in both patients (Box 1). Chest x-rays of both patients during the postoperative convalescence period showed unilateral elevation of the right hemidiaphragm compared with the immediate pre-transplant images. (Images for Patient 1 are shown in Box 2.) Fluoroscopic study (the “sniff test”) and a computed tomography scan of the chest confirmed the presence of right hemidiaphragmatic palsy in both patients. Follow-up chest x-rays and pulmonary function tests over 2 years showed no significant improvement. In both patients, the postoperative clinical course over these 2 years was characterised by recurrent hospital admissions with hypoxaemia and intercurrent respiratory tract infections, some requiring supplemental oxygen therapy, non-invasive positive pressure ventilation and invasive ventilation in the intensive care unit. Currently, one of these patients is well, apart from dyspnoea on moderate exertion. The other patient died from a cause unrelated to his diaphragmatic palsy. Unilateral diaphragmatic palsy following liver transplantation is thought to be related to traumatic crush injury to the right phrenic nerve from a clamp placed on the inferior vena cava (IVC) during surgery.1 The proximity of the phrenic nerve to the IVC renders it very vulnerable to this type of injury from side-to-side cross-clamping of the suprahepatic IVC.1,2 In 2008, we modified our technique to avoid cross-clamping of the IVC by performing cavocavostomy, a type of “piggyback” technique that involves “side-biting” (partial clamping) of the retrohepatic IVC away from the diaphragm.4 Unilateral diaphragmatic palsy can reduce exercise tolerance5 and may place additional mechanical stress on ventilation, which could exacerbate hypoxaemia if these patients develop intercurrent pulmonary infections. Reporting on a series of patients with phrenic nerve injury after liver transplantation, McAlister and colleagues1 found right hemidiaphragmatic palsy in 38% of patients after transplantation, but most of the patients recovered their diaphragmatic function within 9 months. In contrast, our patients did not show any signs of recovery for over 2 years, indicating that loss of diaphragmatic function after liver transplantation may be longstanding or permanent. 1 Comparison of pulmonary function tests before and after orthotopic liver transplantation* Patient 1 Patient 2 Pulmonary function test Before transplant After transplant Difference Before transplant After transplant Difference FEV1 (% of predicted) 2.72 L (80%) 1.73 L (51%) – 29% 2.78 L (85%) 1.40 L (47%) – 38% FVC (% of predicted) 3.79 L (87%) 2.41 L (56%) – 31% 3.83 L (92%) 2.17 L (57%) – 35% FEV1/FVC 0.72 0.72 0.73 0.65 TLC (% of predicted) 5.81 L (87%) 4.28 L (62%) – 25% 7.09 L (110%) 5.18 L (86%) – 24% FEV1 = forced expiratory volume in 1 second. FVC = forced vital capacity. TLC = total lung capacity. * Tests were performed while the patients were in a clinically stable condition. 2 Erect chest x-rays before and after orthotopic liver transplantation, Patient 1 A: In 2005, before liver transplant. B: In 2006, 6 months after liver transplant. Note marked elevation of the right hemidiaphragm and presence of bilateral calcified pleural plaques.

H S Subhash · John W C Chen · Libby John · Jeffery J Bowden · Dimitar Sajkov · Peter Frith

Vulnerability to data manipulation is only one of many problems compromising the use of elective surgery waiting times to assess health system performance The recent controversy in Victoria over the manipulation of waiting lists in a number of public hospitals has focused attention again on the problems associated with a performance management system that is not underpinned by the collection and reporting of sound data. An independent audit of Melbourne’s Royal Women’s Hospital found that patients awaiting urgent or semi-urgent elective surgery whose waiting times were approaching the target for their category (30 days and 90 days, respectively [Box]) were reclassified as “not ready for care — patient initiated”. The reclassification ensured that category waiting time targets were not exceeded and that the hospital met elective surgery key performance indicators.1 Although at the time of the audit the hospital did not participate in the bonus scheme designed to reward hospitals for achieving targets, the state Minister for Health has since scrapped the bonus scheme.2 During the ensuing public debate, the Victorian Auditor-General and the Australian Institute of Health and Welfare (AIHW) both released reports highlighting the limitations of waiting times and clinical urgency categories as indicators of patient access to elective surgery and hospital performance.3,4 Taken at face value, waiting times for elective surgery appear to be a simple measure that can provide information about patient access to services, as well as hospital performance. However, the measurement of waiting times and interpretation of waiting times data are inherently complex. Because we currently measure only the period from the date of entry to the waiting list until provision of surgery, improvements in waiting times do not reflect the entire patient journey and may be negated by increases in the time spent waiting for primary care, diagnostic testing or specialist outpatient appointments. And although waiting times may tell us how long it takes for patients to move through one part of the care pathway, they tell us nothing about the quality of care received. Additionally, their use as performance indicators may provide a motive for data manipulation.5 The clinical urgency categories that have been used as part of the waiting-list management process also have important limitations. Patients are classified into three broad urgency categories (Box) by a largely subjective process with poor reproducibility between clinicians and across health services.6 While the intensity of clinical symptoms such as pain has been fundamental to assigning urgency categories, clinicians vary in how they assess these symptoms. In assigning urgency, clinicians may also consider non-clinical factors, but this occurs informally. Further, each urgency category is aligned with recommended waiting times that are not evidence-based.3 In recognition of the problems with jurisdictional variability, the AIHW has excluded urgency categories from its national reporting since 1999. These limitations make the current elective surgery categorisation system unsuited for one of its main purposes — stimulating improvement through benchmarking and the use of performance targets. Lack of reproducibility and vulnerability to manipulation, which are characteristics of some of the system’s access and performance indicators, limit the value of the information collected. This is one of an increasing number of instances where inadequate attention to data quality has compromised the important function of providing accurate information to guide service provision. If waiting times are to be a sound basis for the routine reporting of patient access to elective surgery or other health services, then they should be explicitly defined to provide a valid assessment of the time spent waiting for surgery, and measured in a standardised and unambiguous way. This approach has been advocated in Canada, where there has been a concerted attempt over the past 5 years to establish evidence-based waiting time benchmarks for specific procedures.7 Likewise, the categorisation of urgency needs to be underpinned by an explicit and standardised way of taking into account all factors relevant to a patient’s requirement for elective surgery. This has already occurred to varying extents in New South Wales, New Zealand and Canada. In NSW, recommendations for assigning specific surgical procedures to urgency categories have been developed and set in policy.8 NZ and Canada have both developed explicit, practical tools that help clinicians systematically prioritise patients for a range of specific procedures, such as joint replacement and cataract surgery.9,10 A clinical priority access system, while not without its controversies, has been used throughout NZ since the early 1990s. Some of the prioritisation tools developed by the Western Canada Waiting List Project have been used in elective surgery programs in several Canadian provinces. The challenges in finding reliable measures of health system performance are not unique to waiting lists. In every area of the health care system, problems result when data used to assess access, quality of care and safety are not based on appropriate measurements. The cornerstones of epidemiologically sound data are validity and reproducibility. The identification of measures able to produce valid, reproducible data is essential for credible assessment of health system performance and to drive long-term improvements. Current Victorian urgency categories for elective surgery Urgency category Desirable treatment time Category 1 Urgent: Has the potential to deteriorate quickly to the point where it may become an emergency Admission within 30 days Category 2 Semi-urgent: Causes some pain, dysfunction or disability Unlikely to deteriorate quickly Unlikely to become an emergency Admission within 90 days Category 3 Non-urgent: Causes minimal or no pain, dysfunction or disability Unlikely to deteriorate quickly Unlikely to become an emergency Admission some time in future (within 365 days)

Andrea J Curtis BSc(Hons), PhD · Johannes U Stoelwinder MD, FRACMA, FACHSE · John J McNeil PhD, FRACP, FAFPHM

To the Editor: Training of adequate numbers of surgeons and other medical specialists has, until recently, been a sleeper issue.1‑3 Trainees are intimately involved in public hospital patient care, but it is generally assumed that private patients are off limits for training. To our knowledge, the perceptions of patients in a private hospital setting have not been formally explored before. We present the results of a survey of attitudes of private hospital patients towards trainee involvement in their care. At a major private hospital in Melbourne, 82 consecutive inpatients undergoing elective general surgery over a 6-week period in 2005 were invited by us to respond to a survey (given prior to surgery and collected prior to discharge). Ethics approval was obtained. Sixty-eight survey forms (83%) were returned by the 82 patients. The median age of respondents was 56 years (range, 18–78 years), and 35 (51%) were men. The most important reasons given for having private health insurance were choice of surgeon (68% of respondents), quality of medical facilities (28%) and shorter waiting-list time (4%). Availability of trainees in the hospital to (a) communicate with the surgeon, (b) manage emergencies, and (c) perform minor procedures were all ranked as very to highly important, as was the ongoing education of trainees. When asked how comfortable they felt with trainees being involved in their care, 88% of patients said they supported having a trainee assist the consultant surgeon with surgery. Providing the trainee was under direct supervision of the surgeon, patients supported allowing a trainee to perform part of the surgery (75% of respondents), most of the surgery (50%), or the entire operation (41%). No significant differences in attitudes attributable to patients’ age or sex were found (Mann–Whitney U test). Within the limits of our small survey structure and incomplete response rate, our results show that most patients support the concept of having a trainee involved in ward care. There was polarised opinion on how much of the operation could be performed by the trainee, and this may vary for different subspecialties. Currently, junior medical staff work in many private hospitals, gaining valuable experience in perioperative care and exposure to a range of surgery. These jobs would be ideal for junior Royal Australasian College of Surgeons (RACS) trainees at Surgical Education and Training Level 1 or 2. However, individual surgeons may be concerned about the potential for increased complications4,5 and longer operating times, with a reduced number of cases and earnings per list. Discussion of medicolegal issues, remuneration and accreditation of posts would need to take place between hospitals, government and the RACS. It is clear that increasing demand for surgical training necessitates the consideration of an accredited role for the advanced surgical trainee in the private health care system.

Lih-Ming Wong · Lisa P Wun · Julie Shaw · Dominic Vellar

Objective: To determine the adequacy of consent documentation related to descriptions of intended procedures, associated risks and treatment alternatives, and to analyse trends in the adequacy of consent documentation in a specialty surgical unit.Design, patients and setting: Retrospective reviews of consent forms for all patients on the Urology Unit waiting list of the Repatriation General Hospital, Adelaide on three occasions. Reviews were undertaken during 2005, 2007 and 2008, with a minimum of 12 months between reviews.Results: 1280 consent documents were evaluated. No trend in the studied criteria of adequacy of documentation was observed during the study period. Overall, 18.5% of consent forms described procedures using plain language. In 15.3% of consent forms, a significant component of the procedure was described using only an acronym, without further explanation. In 6.6% of consent forms, procedure descriptions contained only acronyms, abbreviations or technical terminology, with no plain language word. The purpose of the operation was conveyed in 10.1% of consent forms. Relevant risks were provided in 4.1%. Any indication of the magnitude of procedural risks was provided in only four of 1280 forms. No consent form provided information about alternative treatments.Conclusions: We believe these findings are broadly representative of current hospital practice and that the community should consider whether an acronym or technical terminology is appropriate for documenting consent. If not, can minimum practice standards be defined, and should any emerging recommendations be mandated?

Mark T Siddins MB BS(Hons), MS, FRACS(Urol) · Elizabeth M Klinken BM BS, BSc · Lee R Vocale BM BS, BSc

To the Editor: A 70-year-old woman presented to the emergency department with intense pain, erythema, oedema and haemorrhagic bullae of the right lower leg. Twenty-four hours earlier, she had fallen into warm seawater on the south coast of New South Wales, sustaining a penetrating wound by an unknown object. She reported developing excruciating pain and the noted leg changes within hours of the injury. She had a history of systemic lupus erythematosus (SLE), managed long-term with 7.5 mg oral prednisone daily. Soon after presentation, she rapidly developed septic shock, becoming hypotensive, tachycardic, hypoxic and confused. She was experiencing rigors and required inotropic support. On examination, there was marked cellulitis of the right lower leg with purpura and bullae. No crepitus was detectable in the tissues. There was no clinical or laboratory evidence of disseminated intravascular coagulation. Broad-spectrum empirical antibiotic treatment with intravenous gentamicin, cephazolin and metronidazole was commenced, and urgent, extensive surgical debridement of the lower limb was performed (Box). Wound culture swabs and tissue samples were sent for microbiological and histopathological examination. On Day 2, blood cultures taken at initial presentation were positive for Vibrio vulnificus, as were tissue swabs. Based on susceptibility testing, antibiotic therapy was reduced to a single agent, intravenous ciprofloxacin 400 mg twice daily. The patient’s postoperative clinical recovery was slow, but her SLE did not flare up, and on Day 23 she was transferred to a tertiary referral centre for lower-limb skin grafting. Cellulitis is a common presentation to emergency departments, and common organisms are usually implicated. However, in some cases, the presence of more unusual pathogens, such as V. vulnificus, should be considered. V. vulnificus is a virulent halophilic (salt-loving) gram-negative bacterium associated with seawater temperatures (usual range, 18°–24°C). It has two distinct clinical presentations.1,2 The first, well recognised, is septicaemia after ingestion of raw or undercooked seafood, such as oysters, causing acute gastrointestinal disease. The second, not always considered, is necrotising wound infections, as in this case. Open wounds can be directly inoculated with V. vulnificus from seawater containing the organism. “Vulnificus” is a Latin term meaning “inflicting wounds”. Hippocrates described perhaps the first recorded case of a fisherman with pain in the foot, fever, delirium and blistering skin.3 Patients with primary wound infections caused by V. vulnificus develop painful, rapidly progressing cellulitis. More unusually, our patient developed fulminant sepsis from an open wound infection. Patients who are immunocompromised, especially those with alcoholic liver disease, hepatitis B or hepatitis C, have a higher risk of infection with V. vulnificus, as well as patients, like ours, who take long-term steroid therapy.2 Management requires timely recognition, antibiotic therapy and prompt surgical review. Cellulitis of right lower leg caused by infection with Vibrio vulnificus

Tamara C Preda · Veronica A Preda · Allan P Mekisic

To the Editor: A 27-year-old man who had recently emigrated from Sudan was admitted to our department with a 7-hour history of constant peri-umbilical pain. Physical examination revealed inconstant voluntary guarding of the lower abdomen. Full blood and electrolyte examinations were unremarkable. Urinalysis showed protein and traces of blood. A condition requiring surgery was considered unlikely and further investigations were undertaken. Significant bladder calcification was noted from an abdominal x-ray. A computed tomography scan confirmed this finding (Box), and also revealed circumferential distal ureteric calcification, appendiceal thickening with appendicolith, and adjacent fat stranding. Repeat abdominal examination demonstrated right iliac fossa tenderness with a positive Rovsing sign. Acute appendicitis was diagnosed and an inflamed, thickened, retrocaecal appendix was removed laparoscopically. The patient was discharged 2 days later, but did not attend his post-operative review. Histological examination of the appendix demonstrated transmural neutrophil infiltration, without eosinophils. Within the lumen there were numerous oval-shaped helminth ova, some with terminal spines, consistent with acute appendicitis caused by schistosomiasis. The patient did not have a general practitioner, therefore a referral to an infectious diseases clinic was made. He was thereafter lost to follow-up. Infection by schistosomes leads to chronic granulomatous inflammation in many body systems, including the gastrointestinal tract. Adult worms are not usually harmful to the host — eggs provoke a Th2-mediated immune response.1 Three major species of Schistosoma cause schistosomiasis in humans, of which two are endemic in sub-Saharan Africa — Schistosoma mansoni and Schistosoma haematobium. S. haematobium migrates against portal venous flow to the vesical venous plexus, causing urinary tract calcification through chronic inflammation and fibrosis. This species has also been described as a cause of appendicitis.2 Examinations of appendices removed from patients with acute appendicitis in endemic areas have demonstrated schistosomiasis in 2.3%–4.2% of samples, with 2.7% having histological evidence of acute schistosomal appendicitis in one study.3,4 Schistosomiasis can be diagnosed by histological analysis, or urine and stool microscopy. Serological testing cannot be used to differentiate past and present infection, however positive serological results are the basis for treatment of patients in endemic areas. After diagnosis, praziquantel should be prescribed. It is assumed that our patient did not receive praziquantel. He thus risks significant morbidity and mortality from possible gastrointestinal, hepatic, urinary, pulmonary and neurological complications related to chronic schistosomal infection. Surgeons and pathologists should be aware of the atypical pathology of acute schistosomal appendicitis. The number of immigrants arriving in Australia from endemic areas has increased markedly in recent years and further presentations may occur. Non-contrast computed tomography scan of a 27-year-old man with schistosomal appendicitis Calcification of the bladder (black arrow) and distal ureters (white arrows) is evident.

Jordan K Webb · Graeme Thompson

One of the dilemmas in delaying sex-assignment surgery is the increased risk of gonadal malignancy Few areas of medicine are as controversial as the management of disorders of sex development (DSD). The use of the term DSD to describe patients born with ambiguous genitalia has undergone major change from older terms with negative connotations, such as “intersex”, “testicular feminisation” and “hermaphroditism”.1 Meanwhile, international debate continues about the ethics of performing genital surgery on affected infants and children. In fact, the debate has been raging for more than a decade between the medical profession and patient advocacy groups in Western countries, and has been documented by anthropologist Katrina Karkazis in a recent book.2 A long-term outcome study of 50 patients aged 18–32 years who had been treated in Melbourne when they were children showed that mental and physical health outcomes were as good for most of the DSD patients as for those in two control groups; however, there was a small minority of patients whose gender identity as adults was a source of such profound discomfort that they felt compelled to undergo treatment to change it.3 Clearly, this is unsatisfactory, and management practices have been reviewed internationally by clinicians looking for ways of minimising the risk of making such mistakes about gender assignment. The main problem relates to feminising genitoplasty (Box), which involves the removal of phallic erectile tissues and skin that cannot be replaced. This type of operation is considered appropriate for 46,XX girls with congenital adrenal hyperplasia (Box), who rarely identify as male when they are adults if they are treated with appropriate hormones to maintain androgen suppression from soon after birth and throughout childhood.4 However, feminising genitoplasty is much more of a problem in patients with a Y chromosome. For example, in one study of 14 adult patients with genetically confirmed partial androgen insensitivity who were treated at Johns Hopkins University in the United States as children, 25% experienced gender dysphoria (Box) as adults, and a small number wanted to undergo sex change surgery.5 Although policy changes are still being discussed, it seems likely that fewer and fewer XY patients with frankly ambiguous genitalia due to DSD will have feminising genitoplasty and be raised female. The option to assign a gender but postpone surgery until the child is able to give consent has been strongly advocated in some quarters,6 but has not gained much traction because of concerns that children might suffer psychological harm if left with ambiguous genitalia. In 2008, clinicians from Melbourne’s Royal Children’s Hospital, recognised for their expertise in the management of DSD, were required to meet representatives of the Victorian state Justice Department. They were asked to respond to a proposal — advanced by an advisory committee representing the interests of the gay, lesbian, bisexual, transsexual and intersex communities — that doctors wanting to perform surgery to treat ambiguous genitalia in children too young to consent on their own behalf should have to seek approval from the Family Court of Australia on a case-by-case basis. Also in 2008, the Australian Human Rights Commission decided to initiate a public inquiry into the same question, and circulated a draft discussion paper called Genital surgery for babies born intersex to health professionals for comment. Thus, in Australia as elsewhere, the arm wrestle between medical professionals and patient advocacy groups continues. What has largely been missing from the debate is recognition of the fact that surgery forms a necessary part of the risk management strategy for preventing gonadal malignancy. In any DSD associated with a Y chromosome, there is an increased risk of germ cell cancer,7 especially when the testes are intra-abdominal (the risk of seminoma in partial androgen insensitivity is 50% for an intra-abdominal testis) or when there is gonadal dysgenesis. In this issue of the Journal, a salutary case report by Parker and colleagues8 reminds us of the need to be mindful of this risk, and also to take a long-term view of risk. If the intra-abdominal gonad in the patient described had been removed at the initial surgery, he would never have needed to fear this tumour. It had not been removed because, by today’s standards, he had been inadequately investigated in the past, and therefore the intersex condition was not recognised. The trend for surgeons to recommend male-sex rearing for greater numbers of children with DSD could also mean greater reluctance to remove testes that pose a significant risk of cancer on the grounds that physiologically useful hormone secretion might be retained. It is therefore imperative that a risk management strategy be prepared for each patient. This would mandate: educating parents and patients about risk; removing all intra-abdominal gonads that cannot be brought down into the scrotum; regular clinical and ultrasound surveillance of scrotal gonads with removal of any that contain suspicious lumps; biopsy of testes after the onset of puberty, looking for early signs of malignant change; and effective communication between paediatric and adult care-providers at the time of transition. It is also important for all children identified as having DSD to be referred to a centre of excellence where they will be seen by paediatric endocrinologists, surgeons and other health care professionals with expertise in the field and who recognise the importance of a multidisciplinary team approach.9 Case conferences about patients diagnosed as having a DSD in adult life would be enhanced if paediatric specialists in DSD were asked to comment. Of equally great importance is the need for an accurate aetiological diagnosis wherever possible. At the moment, about 40% of patients with 46,XY forms of DSD are left without a precise diagnosis.10 The application of microarray (gene chip) technology,11 which is available in Australia, is an exciting and promising step forward in identifying genetic mutations. In this technique, samples of very large numbers of genes are arranged in a regular pattern on a solid surface or membrane, which is then incubated with DNA from a patient. Alterations in known (and even unknown) genes are rapidly detected by studying patterns of matches and mismatches. The current challenge for researchers is to develop new tools, such as microarray technology, that will lead to gene discovery and to better methods of screening patients for mutations in all the known genes. Glossary of terms relating to disorders of sex development DSD: Disorders of sex development, previously known as intersex. Congenital conditions in which development of the chromosomal, gonadal or anatomical sex is atypical. Feminising genitoplasty: Surgery carried out to give genitalia that were originally ambiguous a more female appearance. Usually involves clitoral reduction (removal of erectile tissue) and surgery to create a vaginal opening separate from the urethra. Congenital adrenal hyperplasia: A genetic disorder caused by a deficiency of the enzyme 21-hydroxylase in the adrenal cortex, and the commonest adrenal disorder of childhood. Cause of virilisation in an affected female fetus. Partial androgen insensitivity: An X-linked genetic disorder causing ambiguous genitalia in 46,XY individuals. Caused by a lack of androgen receptors in androgen target tissues, such as genital skin. Gender dysphoria: Mental distress caused by unhappiness with one’s own sex and the desire to be identified as the opposite sex.

Garry L Warne MB BS, FRACP · Jacqueline K Hewitt MB BS

Phil Douglas will be particularly remembered for his outstanding role in expanding the development of the Post Fellowship Training Programme of the Colorectal Surgical Society of Australia and New Zealand (CSSANZ) and the Royal Australasian College of Surgeons, nurturing it as a legacy to future fellows-in-training. The Society has recently established the annual Philip Douglas Prize in his honour. Phil was born on 30 November 1955 in Sydney. He attended Sydney Church of England Grammar School (“Shore”), where he was a prefect, a cadet under-officer, and member of the First XV rugby and Second XI cricket teams. Sport remained an important part of Phil’s life. After completing a medical degree at the University of New South Wales, Phil spent an additional year working towards a Bachelor of Medical Science degree. The project, for which he was awarded first class honours, involved research into the sensory pathways of the brain and was published in the prestigious Journal of Physiology. Phil was one of the first two fellows admitted under the auspices of the (then) Australian Colorectal Surgical (specialist) Training Programme. In 1990, after 2 years’ training at the Prince of Wales Hospital, Randwick, and the Adventist Hospital, Wahroonga, he became a consultant at the Prince of Wales Hospital. Phil was actively involved in many areas other than colorectal surgery. He was a councillor of the NSW branch of the Australian Medical Association (AMA) (1987–1993) and a director and board member of the AMA Health Fund (later The Doctors’ Health Fund) for 19 years. He also served on committees of the Gastroenterological Society of Australia and the Sydney Colorectal Surgical Society. He was chairman of the Medical Staff Council of the Prince of Wales hospitals (1999–2008) and ultimately chairman of the Medical Staff Executive Council of all hospitals of the South Eastern Sydney Area Health Service. In November 2008, Phil completed a most distinguished 2 years as President of the CSSANZ. A year earlier, metastases from a completely asymptomatic pharyngeal squamous cell carcinoma had been identified, resulting in a program of irradiation and chemotherapy, during which Phil stoically maintained an active clinical and surgical practice until his retirement just 2 weeks before his death, on 3 January 2009. Phil was determined, strong, rational and, above all, fair. He enjoyed many lifelong friendships and possessed a prodigious wine knowledge and tasting ability, which he lost after his radiotherapy — but, to his great joy, later regained. He is survived by his wife Judy and children Katherine and Cameron. His strong Christian faith was a dominant focus throughout his life. Phil is a direct descendent of Richard Rouse of Rouse Hill.

Graham L Newstead

An 81-year-old man presented with a 1-day history of right iliac fossa pain that radiated to the left iliac fossa. Vital signs were normal. Examination revealed abdominal distension with peritonism. An abdominal x-ray showed small bowel obstruction, and a computed tomography scan suggested a small bowel volvulus. Laparotomy revealed a small bowel obstruction due to a pendulous appendix (20 cm in length) that had wrapped around a loop of bowel, causing obstruction and ischaemia (Figure). Histopathological examination confirmed the presence of acute appendicitis with ischaemic small bowel. The patient recovered uneventfully. The average length of the adult appendix is 7.5 cm in men and 6.7 cm in women (SD, 2.1 cm; range, 2–26 cm).1 Small bowel obstruction secondary to “appendiceal tourniquet” is extremely rare, with only 12 cases previously reported.2,3

Richard H Riley · Richard J Martin

Paul Large was born in Beira, Mozambique, on 12 August 1920 and brought up in Durban, South Africa. He was educated at Michaelhouse, in rural Natal, and enrolled at Guy’s Hospital Medical School, London, in 1938. During the war, many Guy’s Hospital patients, staff and students were evacuated to Kent and Sussex because of the German bombing. Paul and other students were strained by decentralisation, by Home Guard and air raid precaution duties, and by a disjointed curriculum. After graduating in 1943, Paul joined the South African Air Force, but returned to Guy’s in 1946. He distinguished himself as a teacher and qualified for Fellowship of the Royal College of Surgeons (London) in 1948 and a Master of Surgery in 1952. Paul returned to Durban in 1953 to work in private surgical practice. He also did honorary work at McCord Hospital and Durban’s fledgling medical school. Both of these institutions catered for people of dark skin. Educating underprivileged South African students of Bantu and Indian origin was in keeping with his compassionate philosophy of life. In 1958, disillusioned with the political situation in South Africa at the time, Paul migrated to Melbourne, Australia, where he built up a solid private and hospital practice. A staff surgeon for many years at the Western General Hospital, he taught many medical students and junior doctors and always showed deep concern for his patients. In 1966, 1969 and 1972, Paul served (as leader) with civilian Australian surgical teams in battle areas in rural South Vietnam. With guerrilla war in progress, much of the surgery dealt with battle trauma. Although dedicated to his profession, Paul’s family and home life were all-important to him. He was erudite, civilised, inquisitive, charming, humorous, kind and selfless. He had a passion for history and a love of the English language. His electoral choices were shaped by the personal qualities of candidates, rather than political parties, and his disgust at exploitation of the weak. He retained a boyhood enthusiasm for dinghy sailing, and was involved in building, racing and administration. He also followed international rugby, retaining a keen interest even as he became more infirm. Paul’s final years were of gentle physical decline until death from an embolic blockage of a coronary artery on 24 October 2008. He is survived by his wife Susan and children Peter, Susanna, Richard, Catherine and Jonathan.

Anthony V Large

There are controversies surrounding the indications, time and place for elective surgery, and role of multistage operations in the treatment of complicated diverticular disease. Most patients with uncomplicated diverticulitis can be managed non-operatively. Previous indications for elective surgery after two attacks of diverticulitis have been questioned. Evidence that patients are less likely to respond to medical therapy in subsequent attacks of diverticulitis is lacking. Decisions should be based on individual circumstances. The Hartmann procedure remains a safe option for patients with free perforation and generalised peritonitis. In experienced hands, a one-stage procedure can be as successful as a two-stage procedure in an emergency setting in selected patients. When possible, an operation should be converted from an emergency to a semi-elective one using techniques such as radiologically or laparoscopically guided drainage of collections.

Kevin Ooi BSc, MB BS · Shing W Wong MB BS, FRACS, MS(Colorectal)

After several years suffering from Parkinson disease, Ian Reid, a paediatric surgeon, died on 20 March 2008. Ian was born on 5 July 1926 at Port Vila, New Hebrides (now Vanuatu). The family returned to Australia in his early childhood. After service in the Royal Australian Air Force, Ian graduated in medicine from the University of Melbourne in 1953. Three years later, he returned to the New Hebrides as Mission Doctor on the island of Tanna. During his years in Tanna, Ian observed at close hand the infamous “cargo cult”. A rather dramatised account of his part in stopping the intrusion of cult members into his hospital was written by David Attenborough in his book The quest for paradise. And his ways are ways of gentleness and all his paths are peace In 1959, Ian went to Papua New Guinea (PNG) to work as a Medical Officer at the Port Moresby General Hospital. He became Foundation Dean of the Papuan Medical College, where he lectured from 1961 to 1969. In 1968, he was awarded a World Health Organization travelling fellowship in paediatric surgery, which took him to Philadelphia Children’s Hospital and other children’s hospitals throughout the United States. During his time in Philadelphia, he worked with “Chick” (C Everett) Koop, one of the first surgeons to successfully separate Siamese twins. On his return from PNG to Australia, Ian worked at the Royal Children’s Hospital, Melbourne, from 1970 to 1971. The following year, he became a James Fairfax Surgical Research Fellow at the Children’s Medical Research Foundation and a Consultant Surgeon at the Royal Alexandra Hospital for Children, Sydney. The award of a Sir Denis Browne Memorial Travelling Fellowship in Paediatric Surgery in 1975 took him to Great Ormond Street Hospital for Children, London, and to other hospitals in the United Kingdom and Ireland. In 1980, Ian was invited to take up a lectureship at the newly established Medical School at the University of Newcastle (New South Wales), where he would help plan the surgical contribution to the paediatric curriculum. In Newcastle he was involved with neonatal work and with children requiring particularly difficult surgical procedures. He also helped to establish neonatal paediatric surgery at the Newcastle Mater Misericordiae Hospital and had the distinction of performing the first neonatal operation at the John Hunter Hospital. Ian’s gentle sense of humour, matched by his courage, invariably won the day. In the somewhat stormy days during the establishment of the Medical School in Newcastle, he quietly retired from the academic arena, citing his reason as “preferring to deal with premature babies than immature professors”. After retirement, he helped in a voluntary capacity with the Hunter Orthopaedic School and the Tingira Centre for blind and deaf children.

The future viability of general surgery may depend on combining subspecialty elective surgery with full-scope acute practice in both public and private settings Subspecialisation in surgery is an irresistible and irreversible force. It improves standards of patient care1 but tends to be accompanied by an erosion of competence in the broad scope of the major specialty. For example, many major hospitals in Australia have had difficulty retaining subspecialty breast surgeons on the on-call roster because these surgeons feel that their competence to manage the full range of general surgical emergencies has been diminished by their day-to-day practice involving primarily the breast and axilla and rarely the abdomen. Nevertheless, the community needs surgeons willing and able to provide acute surgical care in the major specialties, including general surgery. Is it possible to have a model of care that satisfies both of these apparently divergent scopes of practice? A century ago, there was a single broad field of surgery. During the 20th century, specialties within surgery developed, many of these arising from general surgery, which continues to be the largest specialty. The Royal Australasian College of Surgeons (RACS) currently recognises nine specialty disciplines, by training and examination: general surgery; orthopaedic surgery; otolaryngology, head and neck surgery; plastic and reconstructive surgery; cardiothoracic surgery; neurosurgery; paediatric surgery; urology; and vascular surgery.2 Recognition as a surgical specialty has required definition of a discrete area of knowledge and skills, and a group of practitioners dedicated to the practice, teaching and advancement of the specialty. Subspecialisation within each specialty continues this development, driven by surgeons’ motivation to increase their knowledge and improve patient care. However, it may also have professional and personal benefits for the surgeon, including a more regulated lifestyle and enhanced prestige and remuneration. Examples of subspecialisation within the specialty of general surgery are breast, endocrine, upper gastrointestinal, hepato-pancreatico-biliary, and colorectal surgery. Of particular concern is that general surgery — comprising the largest specialty group of surgeons and those most likely to be required to treat emergencies — is now attracting proportionally fewer applicants for training. In 2007, general surgery offered 51% of available training posts but attracted only 30% of applications.2 Until recently, a third of trainees transferred to another specialty during their training. Although it is hoped that the new Surgical Education and Training (SET) program3 will bring improvements for all surgical specialties, attraction to and retention in general surgery training is likely to be a continuing challenge. Despite the best efforts of the RACS and public hospitals, the number of training positions in general surgery of sufficient quality to meet accreditation standards has increased only gradually from 266 in 2004 to 304 in 2008.2 These factors at the supply end, combined with the fact that 40% of active general surgeons are aged over 60,2 are creating serious workforce pressures. Very few surgeons remain on the on-call roster after age 60. The situation seen in Australia is similar in other developed countries and is particularly concerning in the United States, where Fischer has warned of the impending disappearance of the general surgeon.4 General surgical specialists have been trained to a competent level in the full range of the specialty, including trauma and the acute abdomen. However, as subspecialisation develops, surgeons may become de-skilled in the requirements of emergency surgery. Thirty years ago, general surgeons practised the full range of the specialty, taking pride in the breadth and depth of their knowledge and skills. This has changed significantly. In a 2003 survey,5 the practice patterns of members of General Surgeons Australia were: general surgery with subspecialty, 45% general surgery with more than 90% subspecialty, 23% “general” general surgery, 18% subspecialty only, 14% Nevertheless, 83% felt an obligation to stay on emergency rosters out of duty to the community, trainees and professional colleagues. But for how long will this goodwill continue? Emergency work is demanding, and reliance on a diminishing pool of “general” general surgeons will not be sustainable. Indeed, the future viability of the specialty of general surgery may depend on the development of a model of practice that combines subspecialty elective surgery and full-scope acute practice in both public and private settings. What is required to encourage surgeons to continue to work on emergency rosters? First, we need a review of these rosters. The tradition of ongoing responsibility for the care of patients taken in during an on-call period being maintained by visiting surgeons — who make up most of the workforce and who are in private practice outside the public hospital for most of their working week — should be reconsidered. The Australian Medical Association has promulgated safe-hours principles,6 and these depend, in part, on the acceptance of safe-handover principles.7 The RACS supports both these professional workplace ideals.8 Rosters have been successfully trialled where a consultant-led surgical team is on call exclusively for emergencies, with no scheduled elective duties, for a defined time period such as 24 hours, or longer. At the end of this time, the team completely hands over care of patients with unresolved problems to the next team.9 Second, we need a review of the efficient use of operating theatres for emergency and elective surgery. Lack of access to beds and operating theatres for elective surgery is a continuing source of frustration for patients, surgeons and trainees, and may be solved by separating the services.10 This can be achieved by establishing a separate hospital for elective surgery, at least for surgery of minor or moderate complexity, or by effective quarantining of services within a major hospital complex. Third, surgeons need to maintain competence in emergency surgery relevant to their major surgical specialty. It is possible to identify the requirements of emergency surgery as a defined scope of practice within each of the nine major specialties. This set of knowledge and skills could be formalised in a curriculum for continuing professional development and delivered in an adult learning format, including online modules and hands-on technical skills laboratories. Surgeons would then have the confidence to continue to serve on on-call emergency rosters, thereby acting as mentors and role models for trainee surgeons, while also continuing to practise a subspecialty interest in elective surgical practice. Finally, hospitals should value their surgeons and provide appropriate incentives and conditions of service, including adequate remuneration and tangible support for continuing professional development. This will require cultural and organisational reform, but hospitals could then reasonably expect surgeons to provide emergency services as a condition of their employment. My emphasis here has been on general surgery, where the problems are so obvious. However, service issues also apply to other surgical specialties with developed and developing subspecialisation (notably orthopaedics and otolaryngology) and are also relevant to other medical specialties. Problems particularly occur in the public sector; while provision of acute care in the private sector is also problematic, motivations and incentives in private sector settings appear to be more effective in maintaining services. In rural and remote areas, the provision of elective and emergency services is also threatened by workforce pressures beyond the issue of subspecialisation. The RACS has recently responded to concerns about the increasing difficulties in providing adequate emergency and trauma care by publishing a position statement outlining guidelines for the sustainability of emergency surgery services.10 To continue to provide emergency surgical care to the Australian community, it is apparent that models of coexistence must be found, and that solutions will include effective rostering and practice models, the certainty of availability of facilities for care, and the appropriate valuation of surgeons, as well as ongoing support for the maintenance of professional competence.

Ian R Gough MD, FRACS