Surgeons In Australia Research Articles

Anaplastic Large Cell Lymphoma and Breast Implants

There has never been a convincing association between breast implants and breast malignancy. A total of 42 cases of non-Hodgkin's lymphoma of the breast associated with implant capsules have been reported. The majority of the patients have anaplastic large cell lymphoma of T-cell origin. These lymphoma types have less frequently been observed in women without implants. The senior author (H.R.W.) diagnosed and treated two women with anaplastic large cell lymphoma in a short period of time. After this, the authors were contacted by other surgeons in Australia who had treated similar cases. The authors report five new cases of anaplastic large cell lymphoma associated with breast implants. There is an apparent spectrum of disease, with some cases pursuing an aggressive clinical course, although most have experienced a good prognosis. Both saline and silicone implants are implicated. All implant shells were textured. Textured surface implants only became widely used in the 1990s and therefore were not significantly represented in the large cohort studies of breast implant safety undertaken in the early 1990s. The diagnosis of anaplastic large cell lymphoma in the breast needs to be considered in patients, particularly those presenting with a periprosthetic seroma 6 months or more after breast implant insertion. Risk, V.

Examining the orthopaedic examiners: reliability of the Part 2 Orthopaedic Clinical Fellowship Examination in Australia

The Final Examination for Orthopaedic Surgeons in Australia comprises seven components of which two are written responses and five are oral examinations involving separate pairs of examiners. The reliability of the examination process and close marking system was assessed by using a standardized DVD of a sham examination. Fifteen current examiners viewed the DVD and scored the viewed examination independently. The results demonstrated consistency in scoring and reliability. This validation is likely to be further increased by the current system of the pairing of examiners. Additionally, the patient-based examination segments were found to be as reliably scored as the criterion-referenced computer-based examination stations. Candidates for the Fellowship Examination should be reassured that this study has shown that the examination process has inter-examiner reliability and consistency.

The harassment and stalking of plastic surgeons by their patients in Australasia

Abstract Medical professionals come into direct contact with the public. The relationships are often personal. The aim of the survey is to examine the prevalence of harassment of plastic surgeons by their patients. Survey questionnaires were mailed to all plastic surgeons listed in the 1999 Australasian Society of Aesthetic Plastic Surgery List of Members. A very wide definition of harassment was then provided and information in regard to the nature of the harassment was obtained. This was a descriptive survey of plastic surgeons' experiences of harassment by patients in Australia and New Zealand. More than half of the plastic surgeons in Australia and New Zealand who responded to the questionnaire reported having been a victim of harassment at some point of their careers. One quarter had been harassed in the previous year. Over 20% of cases met the legal criteria for stalking. These estimates are in excess of those reported in the other studies of the general community. Harassment persisted in the majority of cases for at least a month and in a third of cases for up to 5 years. The recognition of psychiatric disorder, particularly personality dysfunction, prior to embarking on surgery may limit the likelihood of harassment by difficult patients. Formal teaching may be helpful to surgical registrars and consultants. Expert intervention could assist in reducing clinician anxiety.

Treatment of left-sided colonic emergencies: a comparison of US, UK and Australian surgeons

This study sought to identify and compare the current practice of surgeons in Australia, the UK and the US when presented with a left-sided colonic emergency. Questionnaires were posted to 500 US, 500 UK and 500 Australian surgeons. Demographic data were collected regarding the surgeon's age and surgical interest, as well as their preferred method of managing left-sided colonic emergencies (namely obstruction and perforation in stable and unstable patients). The results were analysed using the chi-squared test. Completed questionnaires were received from 224 UK surgeons (45%), 180 US surgeons (36%) and 259 Australian surgeons (52%). All the US surgeons had an interest in gastrointestinal surgery, while 31% of the UK surgeons and 22% of Australian surgeons had an interest in colorectal surgery. In a haemodynamically stable patient with a good anaesthetic risk presenting with a complete sigmoid obstruction, significantly more UK (84%) and Australian surgeons (70%) would perform a resection and anastomosis than US surgeons (54%, p<0.0001). Of those with a colorectal interest, 97% of UK surgeons and 80% of Australian surgeons would opt for resection and anastomosis. In a haemodynamically stable patient with a good anaesthetic risk with a perforation of the sigmoid colon and purulent peritonitis, 46% of UK surgeons, 32% of Australian surgeons and 33% of US surgeons would opt for resection and anastomosis, and among colorectal surgeons, 68% of UK surgeons and 50% of Australian surgeons would opt for resection and anastomosis. The management of left-sided colonic emergencies varies depending on geographic location and degree of colorectal subspecialization. While the literature suggests that single-stage procedures are accepted and safe, the reasons for this variation are explored.

Invited Commentary

Reoperative coronary artery bypass grafting (CABG) continues to be challenging to the cardiothoracic surgeon. Yap and colleagues [1Yap C.-H. Sposato L. Akowuah E. et al.Contemporary results show repeat coronary artery bypass grafting remains a risk factor for operative mortality.Ann Thorac Surg. 2009; 87: 1386-1391Abstract Full Text Full Text PDF PubMed Scopus (96) Google Scholar] report 458 patients undergoing reoperative CABG who are part of 13,436 patients enrolled in the Australian Society of Cardio and Thoracic Surgery database from June 2001 through May 2008. The database is voluntarily supported by 70% of the cardiothoracic surgeons in Australia. The patients have the privilege of opting out of the registry [2Reid C.M. Rockell M. Skillington P.D. et al.Initial twelve months experience and analysis for 2001–2002 from the Australasian Society of Cardiac and Thoracic Surgeons-Victorian database project.Heart Lung Circ. 2004; 13: 291-297Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar]. Although postoperative outcomes were encouraging and midterm survival was excellent, reoperation remained a significant risk factor for 30-day mortality.The authors point out that the strengths of this study include its large number of patients and the multicenter study reflecting “real world practice.” Knowledge of the incidence of technical problems associated with reoperation causing injury to structures underlying the sternum, damage to functioning bypass grafts, ischemia causing decreased function of the myocardium, and lack of suitable graft material will be of assistance to the surgeon in selecting the best reintervention therapy for each patient. Careful attention to the increased operative risk of reoperation CABG and the appropriate use of angioplasty and stenting as another method of reintervention should assist in reducing the risk of managing patients in need of reoperation. Reoperative coronary artery bypass grafting (CABG) continues to be challenging to the cardiothoracic surgeon. Yap and colleagues [1Yap C.-H. Sposato L. Akowuah E. et al.Contemporary results show repeat coronary artery bypass grafting remains a risk factor for operative mortality.Ann Thorac Surg. 2009; 87: 1386-1391Abstract Full Text Full Text PDF PubMed Scopus (96) Google Scholar] report 458 patients undergoing reoperative CABG who are part of 13,436 patients enrolled in the Australian Society of Cardio and Thoracic Surgery database from June 2001 through May 2008. The database is voluntarily supported by 70% of the cardiothoracic surgeons in Australia. The patients have the privilege of opting out of the registry [2Reid C.M. Rockell M. Skillington P.D. et al.Initial twelve months experience and analysis for 2001–2002 from the Australasian Society of Cardiac and Thoracic Surgeons-Victorian database project.Heart Lung Circ. 2004; 13: 291-297Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar]. Although postoperative outcomes were encouraging and midterm survival was excellent, reoperation remained a significant risk factor for 30-day mortality. The authors point out that the strengths of this study include its large number of patients and the multicenter study reflecting “real world practice.” Knowledge of the incidence of technical problems associated with reoperation causing injury to structures underlying the sternum, damage to functioning bypass grafts, ischemia causing decreased function of the myocardium, and lack of suitable graft material will be of assistance to the surgeon in selecting the best reintervention therapy for each patient. Careful attention to the increased operative risk of reoperation CABG and the appropriate use of angioplasty and stenting as another method of reintervention should assist in reducing the risk of managing patients in need of reoperation. Contemporary Results Show Repeat Coronary Artery Bypass Grafting Remains a Risk Factor for Operative MortalityThe Annals of Thoracic SurgeryVol. 87Issue 5PreviewReoperative coronary artery bypass grafting (redo CABG) shows improving outcomes, but with varying degrees of improvement. We assessed contemporary outcomes after redo CABG to determine if redo status is still a risk factor for early postoperative complications and midterm survival. Full-Text PDF

National Breast Cancer Audit: the use of multidisciplinary care teams by breast surgeons in Australia and New Zealand

To explore the involvement of members of the Royal Australasian College of Surgeons (RACS) Section of Breast Surgery in Australia and New Zealand in multidisciplinary care (MDC) teams. Questionnaire sent to all full members of the RACS Section of Breast Surgery in December 2006. 239 of 262 active full members of the RACS Section of Breast Surgery (response rate, 91.2%). Surgeons' use of, and the composition and functioning of, MDC teams in public and private practice, and in metropolitan, regional and rural settings. 85% of responding surgeons reported participating in at least one fully established MDC team. Public-sector teams were operationally more consistent and functional than private teams, and rural teams were less well developed than those in metropolitan and regional centres. The six core disciplines recommended by the National Breast Cancer Centre appear to be well represented in most teams. Patients and their general practitioners were not considered to be part of the treatment team by surgeons. MDC is supported by most breast surgeons, but there are deficits in rural areas, and in the private sector relative to the public sector.

Long gap esophageal atresia: an Australian experience

Background The diagnosis of long gap esophageal atresia (LGEA) may preclude immediate primary anastomosis. We reviewed our experience with this entity for a period of 10 years. Methods A retrospective review was undertaken of the medical records of all patients managed for esophageal atresia (EA)/tracheoesophageal fistula (TEF) during the period from 1991 to 2001 at the Children's Hospital at Westmead, Sydney, Australia. Esophageal atresia was defined as long gap when primary repair was considered technically impossible by the surgeon. Also, a questionnaire was sent to all the general pediatric surgeons in Australia to explore their attitude toward LGEA management. Results One hundred three patients with EA were managed for that period, 17 (16%) of them were defined as LGEA, with mean gap of 5 cm (SD, 1cm). Eight patients (47%) had TEF. Sixteen patients had gastrostomy tube (GT) insertion at a mean age of 4 days. Six patients had esophagostomy at a mean age of 27 days. Thirteen patients had EA repair at a mean age of 146 days. Four patients died before repair and 2 after repair secondary to associated anomalies. Fifty percent of Australian Pediatric Surgeons (APS) responded to the questionnaire. Forty percent defined LGEA as a gap more than 3 to 4 vertebral bodies, whereas 24% considered the absence of TEF as an indication of LGEA. Fifty-six percent of APS will measure the gap on preoperative chest x-rays, and 80% will assess the gap at thoracotomy for ligation of TEF. Ninety-two will measure the gap by inserting a bougie into the upper pouch and into the lower esophagus via the GT. If LGEA was diagnosed, all APS will perform GT with delayed repair. Seventy-two percent of APS will attempt delayed primary repair within 3 to 6 months of age. Seventy-six percent will perform hiatal dissection, and 48% will use upper pouch myotomies. Forty-eight percent will perform gastric pull up, and 32% will use gastric tube for esophageal replacement. Conclusions Long gap esophageal atresia represents a surgical challenge. Mortality rate is high secondary to associated anomalies. There is no consensus among APS regarding the definition of LGEA. In general, the consensus of APS would be that the preservation of the patient's own esophagus should be attempted before considering the use of an esophageal replacement.

Hallux valgus and hallux rigidus: a comparison of impact on health‐related quality of life in patients presenting to foot surgeons in Australia

BackgroundHallux valgus and hallux rigidus are common foot conditions that lead to a deterioration in health status. Patients with significant pain or deformity from these conditions frequently resort to surgery. In this project, the foot health status of patients with hallux valgus and hallux rigidus presenting to foot surgeons in Australia was compared.MethodsFoot health status was measured in 120 participants using the Foot Health Status Questionnaire (FHSQ), a validated 0 – 100 point health status instrument. All participants had presented for surgical advice regarding hallux valgus/rigidus. The mean age of participants was 48.0 years (SD ± 14.3, range 19 – 79).ResultsIn the sample, 68% of participants were diagnosed with hallux valgus and 32% with hallux rigidus. Participants with hallux rigidus had greater levels of pain and functional limitation compared with hallux valgus. The mean difference for pain was 13.8 points (95% CI 4.6 to 22.9) and the mean difference for function was 15.0 points (95% CI 5.3 to 24.7). Both conditions result in similarly negative levels of impact on shoe fit and overall foot health.ConclusionThis study found measurable differences in foot health status between hallux valgus and hallux rigidus in participants presenting for surgical consultation. While both appear to have a negative impact on health status, hallux rigidus has a more significant impact.

Foot and ankle surgery in Australia: a descriptive analysis of the Medicare Benefits Schedule database, 1997–2006

BackgroundFoot and ankle problems are highly prevalent in the general community and a substantial proportion of people seek surgical treatment to alleviate foot pain and deformity. However, the epidemiology of foot and ankle surgery has not been examined in detail. Therefore, the aim of this study was to examine patterns and costs of private sector foot surgery provision in Australia.MethodsData pertaining to all foot and ankle surgical procedures for the calendar years 1997–2006 were extracted from the Australian Medicare Benefits Schedule (MBS) database and were cross-tabulated by sex and age. Descriptive analyses were undertaken to assess sex and age differences in the number and type of procedures performed and to assess for temporal trends over the ten year assessment period. The total cost to Medicare of subsiding surgeons' fees in 2006 was also determined.ResultsDuring the 1997–2006 period, 996,477 surgical procedures were performed on the foot and ankle by private surgeons in Australia. Approximately equal numbers of procedures were performed on males (52%) and females (48%). However, males were more likely to undergo toenail, ankle, clubfoot, tarsal coalition and congenital vertical talus surgery, whereas females were more likely to undergo lesser toe, first metatarsophalangeal joint (MPJ), neuroma, heel, rearfoot and lesser MPJ surgery. The total number of procedures was stable over the assessment period, however there was a relative increase in the number of procedures performed on people aged over 55 years. The total contribution of Medicare to subsiding surgeons' fees for procedures performed in 2006 was $14 M.ConclusionFoot and ankle surgery accounts for a considerable degree of healthcare expenditure in Australia, and the number of procedures in those aged over 55 years is increasing. Given the ageing demographics of the Australian population, the future public health and economic impact of foot morbidity is likely to be substantial. Strategies need to be implemented to ensure that the surgical labour force is adequate to address this increasing demand.

Cancer specialists' palliative care referral practices and perceptions: results of a national survey

Purpose : Cancer specialists can facilitate timely and appropriate access to specialized palliative care (SPC) services. To better match patients' needs with access to SPC services, we must understand factors associated with referral. This study aimed to investigate cancer specialists' referral practices, perceptions of, barriers to and triggers for referral of people with advanced cancer to SPC services. Method : A self-report questionnaire was mailed to all oncologists, clinical haematologists, respiratory physicians and colorectal surgeons in Australia (N = 1713). Results : Out of 699 specialists who participated, 48% reported referring >60% of patients to SPC services. Most frequent reasons for referral were: the future need for symptom control, the presence of a terminal illness or uncontrolled physical symptoms. Psychosocial issues rarely triggered referral. Main reasons reported for not referring included: ability to manage patients' symptoms; the absence of symptoms or rapid deterioration. Significant predictors of referral (P < 0.05) included: being female; >10 years of practice in the speciality; agreeing all people with advanced cancer need referral, referral for the purpose of multidisciplinary management and having SPC services available. Conclusions : Specialists mainly refer people with advanced cancer for symptom-related reasons. Measures are needed to encourage ongoing needs-based assessments, especially of emotional, cultural and spiritual issues. Palliative Medicine 2008; 22: 51—57

Palatal anaesthesia for the removal of maxillary third molars as practised by oral and maxillofacial surgeons in Australia and New Zealand

Injections of local anaesthetic to the palate are well known to be poorly tolerated. The absolute requirement of a palatal injection for the removal of maxillary third molars has never been investigated. The aim of this study was to document the current practice of palatal anaesthesia for extraction of these teeth with local anaesthesia as practised by oral and maxillofacial surgeons. A postal survey was sent via the ANZAOMS office to all oral and maxillofacial surgeons who were members of the Australian and New Zealand Association, a total of 131. A response rate of 64 per cent (n = 84) was achieved. The frequency of administration and the factors that determined the decision to administer a palatal injection were assessed, as well as the methods employed for reducing the injection discomfort. The majority (77 of the 84) "always" gave a palatal injection for the removal of maxillary third molars, four respondents administered an injection "most of the time", and two respondents "occasionally". Significantly, one respondent "never" gave a palatal injection. The majority (76 per cent) utilized at least one adjunct in order to reduce the discomfort of the injection. The results of this survey suggest that for removal of maxillary third molars the requirement of the poorly tolerated palatal injection may not be absolute as conventionally taught and demonstrates the need for further investigation.

AL05 OF STRINGS AND SPLINTS AND WARS AND WOUNDS

Robert Hamilton Russell (1860–1933), a Melbourne surgeon of international repute, played a pivotal role in the formation of the College. In 1925 a letter signed by G.A.Syme H.B.Devine and Russell was sent to senior surgeons in Australia and NewZealand suggesting the establishment of a body to improve surgical standards, a proposal first put by Louis Barnett in 1920.Born in Kent with medical training at King’s College, Hamilton Russell was House Surgeon to Lister and profoundly influenced by Lister’s mentoring. Russell emigrated to Melbourne in 1890 and with appointments at the (Royal) Children’s Hospital and the Alfred, developed wide surgical interests including fracture management.At the start of World War I, Hamilton Russell was in England and joined the Australian Voluntary Hospital in France. On returning to Melbourne in 1915 he presented a paper on the treatment of war wounds and in 1916 a paper on fractures included his new method of continuous traction for femoral shaft fracture. At this time the proper management of war wounds and fractures was being vigorously debated.It was not until the Spanish Civil War, three years after Hamilton Russell’s death, that significant advances were made in the management of war injuries. In Barcelona, Joseph Trueta successfully combined the principles of triage, blood transfusion, early surgery, wound excision and plaster immobilisation. In 1939 Trueta escaped to Britain and with the aid of influential colleagues his techniques with some modification were adopted during the 1939–45 conflict and form the basis of war wound management today.

Different professionals’ knowledge and perceptions of the management of people with pancreatic cancer

AbstractBackground: Pancreatic cancer is generally associated with a very poor prognosis. The knowledge, beliefs and opinions of clinicians caring for people with pancreatic cancer may affect preferences for particular therapies and may impact upon patient outcomes. The aim of this study was to conduct a postal survey of clinicians who consult patients with pancreatic cancer to assess their knowledge regarding the disease itself and the effectiveness of various treatments, and to gauge their opinions regarding aspects of management.Methods: A 20‐item multiple‐choice questionnaire was mailed to medical and radiation oncologists, gastroenterologists, general surgeons and hepatopancreatobiliary (HPB) surgeons in Australia. Questions assessed knowledge of survival following surgery for resectable disease, and survival and response rate following chemoradiation for locally advanced disease and chemotherapy for advanced disease. Beliefs regarding the need for tissue diagnosis and perceptions of benefit of various treatment strategies were also sought.Results: Overall, knowledge was fair (average knowledge score 4.1 out of 8); 56% of HPB surgeons and 55% of medical oncologists had good knowledge, compared with 39% of gastroenterologists and general surgeons. There were marked differences in opinion regarding requirement for tissue diagnosis before further management. There was considerable variation in opinion regarding the benefit of postoperative adjuvant chemotherapy.Conclusion: These findings argue strongly for the development of evidence‐based guidelines. Multidisciplinary management teams may help educate individual clinicians and professional groups and are likely to result in improved outcomes for patients.

The training of the next generation of surgeons in Australia

The profession of surgery is a calling in which the standards can only be responsibly set by the profession itself. The Royal Australasian College of Surgeons (RACS) has been training surgeons in Australia and New Zealand since 1927. Many challenges to modern surgical training are shared within an increasingly globalised surgical community, while specific local issues add their own challenges to the continued provision of high quality surgical training.

NATIONAL BREAST CANCER AUDIT: OVERVIEW OF INVASIVE BREAST CANCER MANAGEMENT

The National Breast Cancer Audit is an initiative of the Breast Section of the Royal Australasian College of Surgeons collecting surgical information in early breast cancer. It is managed in conjunction with the Australian Safety and Efficacy Register of New Interventional Procedures - Surgical. An overview of results for invasive breast cancer from January 1999 until December 2004 is presented to provide preliminary data for participating surgeons. Invasive breast cancer cases were retrieved from the National Breast Cancer Audit database for the 274 participating breast surgeons in Australia and New Zealand. Data for a variety of clinical parameters were analysed to provide an overview of the diagnostic, histological, surgical and adjuvant therapy management issues. There were 25,026 cases of invasive breast cancer. Annual percentages of mammographically detected cancers from 1999 to 2004 did not differ significantly. Breast-conserving surgery rates also remained stable at 60%. Margins were involved in 5% of patients; an additional 9% had final margins of less than 1 mm. Radiotherapy followed breast-conserving surgery in most cases (86%). Patients undergoing mastectomy with large tumours (>5 cm) underwent radiotherapy in 71% of cases. When at least four lymph nodes were positive, radiotherapy followed mastectomy in the majority (75%) of cases. The most frequently carried out axillary procedure was a level 2 dissection. Chemotherapy was received by 78% of oestrogen receptor negative, axillary node positive, postmenopausal patients. Tamoxifen was used in the majority (83%) of oestrogen receptor positive cases. Surgeons contributing their invasive breast cancer data show a high quality of treatment. Some further improvement may be possibly related to excision margins and tamoxifen prescription for oestrogen receptor negative cancers. Chemotherapy prescription might also warrant further investigation.

Practice activity trends among oral and maxillofacial surgeons in Australia.

BackgroundThe aim of this study was to describe practice activity trends among oral and maxillofacial surgeons in Australia over time.MethodsAll registered oral and maxillofacial surgeons in Australia were surveyed in 1990 and 2000 using mailed self-complete questionnaires.ResultsData were available from 79 surgeons from 1990 (response rate = 73.8%) and 116 surgeons from 2000 (response rate = 65.1%). The rate of provision of services per visit changed over time with increased rates observed overall (from 1.43 ± 0.05 services per visit in 1990 to 1.66 ± 0.06 services per visit in 2000), reflecting increases in pathology and reconstructive surgery. No change over time was observed in the provision of services per year (4,521 ± 286 services per year in 1990 and 4,503 ± 367 services per year in 2000). Time devoted to work showed no significant change over time (1,682 ± 75 hours per year in 1990 and 1,681 ± 94 hours per year in 2000), while the number of visits per week declined (70 ± 4 visits per week in 1990 to 58 ± 4 visits per week in 2000).ConclusionsThe apparent stability in the volume of services provided per year reflected a counterbalancing of increased services provided per visit and a decrease in the number of visits supplied.

Management of tongue-tie in children: a survey of paediatric surgeons in Australia.

To explore the beliefs and practices of Australian surgeons regarding surgical intervention to release tongue-tie and to determine the main referral sources. In addition, we aimed to ascertain if there were differences in beliefs and practices according to surgical specialty. Four hundred surgeons in three different surgical specialties were surveyed via questionnaire. Multiple choice response questions and open ended questions were used to explore beliefs and practices surrounding tongue-tie assessment, management and follow up. The questionnaires were distributed by email (where available), followed by fax and mail. A response rate of 80.8% (n = 323) was obtained. Of these, 236 (73%) reported they practised surgery to release tongue-tie; 46% were oral and maxillofacial surgeons, 37% were plastic surgeons and 17% were paediatric general surgeons. Indications for surgical management and follow up varied according to surgical specialty. There was no clear consensus regarding clinical indicators for surgery or functional outcomes following surgery. It appears that until a prospective study designed to address some of the controversial issues outlined is undertaken, we will remain ignorant about the need for surgery to release tongue-tie in children.

The demand for surgery: an analysis of referrals from Australian general practitioners.

Optimal planning for surgical training and the surgical workforce requires knowledge of the need and demand for surgical care in the community. This has previously relied on indirect indicators, such as hospital throughput. We aimed to describe referrals from general practitioners (GPs) to surgeons in Australia using a classification of surgical disorders developed especially for primary care settings. Terms in the International Classification of Primary Care Version 2-Plus were reclassified into categories delineated by specialist surgeons, resulting in the Surgical Nosology In Primary-care Settings (SNIPS). Referrals to surgeons were analysed using data on 303,000 patient encounters by a random sample of 3030 GPs involved in the Bettering the Evaluation and Care of Health (BEACH) study. Thirty-two per cent (143,013) of all problems were classified as potential surgical problems, of which 9.5% (13,570) were referred to surgeons at an overall rate of 44.8 referrals per 1000 GP encounters. Patients with surgical problems were significantly older than the overall general practice patient population. Women and patients with health care cards were significantly less likely than men and patients without health care cards to be referred when a surgical problem was managed by the GP. Forty-two per cent of all surgical referrals were accounted for by the following categories: skin lesions, skin infection/injury, upper gastrointestinal, breast lumps/cancer, spine, knee arthritis/pain, knee injury/instability, infective and non-infective ear disorders. Many commonly referred problems are usually managed as outpatients. The data from this study may have application for surgical workforce planning and ensuring trainees receive adequate exposure to commonly referred conditions. The classification system (SNIPS) may be useful for future research concerning the interface between primary care and specialist surgical practice.

Endoluminal Repair of Abdominal Aortic Aneurysm—Contemporary Australian Experience

Objective. An audit was established in November 1999 by the Australian Government Department of Health and Ageing to determine the mid- to long-term safety and efficacy of endoluminal graft repair (ELG) of abdominal aortic aneurysm (AAA). The audit has been undertaken by the Australian Safety and Efficacy Register for New Interventional Procedures—Surgical (ASERNIP-S). This study reviews contemporary Australian practice, based on audit data supplied to ASERNIP-S.Design of study. This study is a prospective voluntary register (audit) of Australian data obtained from the private and public sector. Data were collected for ELG repairs performed between 1 November 1999 and 16 May 2001. Follow-up is continuing.Results. Seventy-nine vascular surgeons have contributed data on 950 patients (816 male, 134 female, of median age 75.5 (range 36–94)). The mean aneurysm size was 57.5 mm (±10.2) and 44% of procedures were performed on aneurysms less than 55 mm in diameter. Fifty four percent of patients were considered suitable for open repair.Most ELG procedures were performed in an angiography or endovascular suite, under general anaesthetic using an open technique via the femoral arteries. Perioperative mortality was 1.7%, mostly from cardiac causes. Prior to discharge 7.2% of patients experienced an endoleak and 18.6% had systemic complications. The average length of stay was 7.4 days (median 5 days). Unsuccessful exclusion of the aneurysm occurred in 6.7% of cases.Conclusions. Endovascular repair of AAAs is a well accepted procedure and is performed by the majority of vascular surgeons in Australia. Australian surgeons are taking a rather aggressive approach to the management of aortic aneurysms, particularly in the moderate to higher risk patient groups. Mortality rates are low, given the elderly population in question and morbidity rates acceptable. ASERNIP-S is continuing to collect follow-up data for this patient cohort.

Practice patterns of oral and maxillofacial surgeons in Australia: 1990 and 2000

This study was undertaken to describe practice patterns of oral and maxillofacial surgeons in Australia and compare trends over time. All registered oral and maxillofacial surgeons in Australia were surveyed in 1990 and 2000 using mailed self-complete questionnaires. Data were available from 79 surgeons from 1990 (response rate=73.8%) and 116 surgeons from 2000 (response rate=65.1%). In both 1990 and 2000 the majority of surgeons worked 80+% of the time in the private sector (64.1 and 71.4%), had 80+% referrals from dental versus medical sources (74.0 and 74.7%), and had 80+% of patients from dentoalveolar rather than major maxillofacial surgery (70.7 and 69.7%). The percentage of dual qualified (dental plus medical degree) surgeons increased from 2.5% in 1990 to 17.1% in 2000 ( P<0.05; χ 2). In 2000, surgeons who worked less than 80% in the private sector were more likely to report being overworked (57.9%) and that more surgeons were required in the public sector (65.0%) than those who worked 80% or more private (17.0 and 24.0%, respectively). Multivariate linear regressions of annual non-dentoalveolar surgical procedures per surgeon showed ( P<0.05) higher provision of implant ( β=0.362), TMJ ( β=0.267) and bone graft surgery ( β=0.208) in 2000 compared to 1990, and higher provision of orthognathic ( β=0.199), implant ( β=0.194) and bone graft surgery ( β=0.289) by dual qualified surgeons compared to those with only dental qualifications. Despite the mix of cases remaining predominantly dentoalveolar there was some change over time for selected non-dentoalveolar surgical procedures, with growth in the percentage of medically qualified surgeons and differences in surgery rates by qualification.