Opinions

Professors John Hall and John Harris talk about the future of ANZ J Surg

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Incoming Journal Editor in Chief Professor John HarrisIn this podcast, current Editor in Chief Prof. John Hall talks to incoming Editor in Chief Prof. John Harris about his plans for the Journal in 2012 and beyond.

Click here to listen.

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Discussion: Regarding carotid endarterectomy in asymptomaticpatients

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Re: Mohan IV, Thomas SD. Do patients with asymptomatic carotid stenoses still benefit from surgical intervention? (ANZ J. Surg. 2011; 81: 211-213)

I write in reference to Mohan and Thomas’s article “Do patients with asymptomatic carotid disease still benefit from surgical intervention?”. The word “still” in the title implies that patients once did benefit. They argue that medical treatment has improved and the modest benefit from surgery may no longer hold. The article concludes by warning “surgeons to stop taking comfort from the relative risks of intervention and historic studies of medical management” and urges them to look at results of future studies involving best medical management. The article is, however, somewhat inconsistent in avoiding the possibility that surgery has improved and perhaps commits the same fault that it urges against by quoting historic results of surgical management and comparing these to hypothetical results of future medical studies. (Click here to continue reading.)

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Discussion: Epistaxis as a challenge faced by otolaryngologist

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Re: Ha JF, Hodge JC, Lewis R. Comparison of nasendoscopic‐assisted cautery versus packing for the treatment of epistaxis. (ANZ J. Surg. 2011; 81: 336-339)

We read with great interest the article of Ha et al. published recently in ANZ Journal of Surgery1 and would like to make comments on this study.

First, the authors report successful nasal examination with a rigid nasal endoscope and identification of the initial bleeding site in 100% of cases, even after nasal packing removal. In this study 97% of patients were treated initially with packings! However, these packings could lead to intranasal injuries and cause recurrent bleeding upon removal, especially if placed by an inexperienced physician. Furthermore, in case of septal deviation, such packings may traumatise the nasal (septal and/or turbinate) mucosa and create more sites of bleeding. Traditionally, prior to otolaryngological examination both sides of the nose are already packed.2 That is why, the identification of the site of bleeding after packing removal is frequently a difficult problem. Moreover, septal deformation and hypertrophic turbinates often make it difficult to visualise the bleeding regions.3 Nevertheless, Ha et al. have discussed neither these common issues nor the endoscopical anatomical findings. It is also not clear whether their patients had continuous epistaxis at the moment of cauterization. (Click here to continue reading.)

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Discussion: Unusual metastasis from a rectal adenocarcinoma: penile metastasis

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Re: Lee JI, Kang WK, Kim HJ, Kim SH, Oh, ST. Unusual metastasis from a rectal adenocarcinoma: penile metastasis. (ANZ J. Surg. 2011; 81: 102)

I read this article with great interest. It is really an unusual and interesting case. Metastatic lesion to the penis is uncommon with approximately 372 cases reported in the literature till 20061. I would like to add few interesting points. The most frequent sign is priapism. Priapism is due to metastatic involvement of corpora cavernosa. Penile metastasis indicates advance form of virulent disease and survival is limited. Authors had mentioned various modalities of management. I would like to state here that dorsal nerve section can also be used as a one of the modalities for the treatment of intractable pain2. Radiation therapy has generally been not successful and chemotherapy has not been extensively studied in sufficient number of patients to warrant recommendation3.

Dr Vipul D Yagnik MBBS MS FMAS
Ronak Endo-laparoscopy and General Surgical Hospital, Patan, Gujarat, India

References
1. Cherian J, Rajan S, Thwaini A, Elmasry Y, Shah T, Puri R. Secondary penile tumours revisited. Int Semin Surg Oncol. 2006; 3: 33.
2. Hill JT, Khalid MA: Penile denervation. Br J Urol 1988; 61: 167.
3. Pettaway CA, Lynch DF Jr, Davis JW. Tumors of the Penis. In Wein: Campbell-Walsh Urology, 9th ed. Philadelphia: SAUNDERS, 2007; ch 31.

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Author response: The ASU – Surgeons become more accountable

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Re: Wysocki AP. The ASU – Are surgeons now unaccountable? (ANZ J. Surg. 2010; 80: 944)

The surgeons at Nepean Hospital appreciate the concerns expressed by Dr Wysocki (ANZ J Surg, 2010, 944). There is no need to “ensure compliance”. Compliance occurs because of appropriate and correct professional behaviour. The ASU functions the same way every day of the year. Limited space does not permit me to correct misconceptions and address other minor concerns.

Dr Wysocki’s chief concern is the loss of surgeon accountability. In the traditional system the patient was managed by a registrar-lead service with the surgeon “available”. The ASU is a consultant-lead service. All admissions are seen and assessed by a consultant on the day of admission; all surgery is supervised by the surgeon. Each patient stays in the ASU and is reviewed by the ASU consultant each day. This acts as an audit process on each surgeon’s performance. This is a higher level of consultant responsibility and involvement than in most public hospitals in Australia. We presume from Dr Wysocki’s concern that he sees each of his patients every day, including weekends and public holidays. Unfortunately this outstanding performance is not the norm. (Click here to continue reading.)

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Discussion: Post laryngectomy speech and voice rehabilitation: past, present and future

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Re: Kazi R, Sayed SI, Dwivedi RC. Post laryngectomy speech and voice rehabilitation: past, present and future. (ANZ J. Surg. 2010; 80: 770–1)

The article by Kazi et al.1 states that surgical voice restoration using voice prostheses has made this modality the ‘gold standard’ in post-laryngectomy voice rehabilitation. The prosthesis converts the phonatory source of speech from the vocal cords to the pharyngo-oesophageal (PE) segment. The ability of the PE segment to freely vibrate is therefore paramount to successful voice restoration. Here we outline some operative manoeuvres and post-operative steps at troubleshooting voice problems that we feel deserve additional attention. (Click here to continue reading.)

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Author response: Results of LBDEx via choledochotomy

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Re: Discussion: Laparoscopic bile duct exploration

I would like to thank Dr Ahmed for his complimentary letter and I am also very grateful to you for allowing me the ‘right of reply’.

A failure rate of 25% for endoscopic retrograde cholangiopancreatography (ERCP) would indeed be high but that figure refers to the number of patients in the series who had had ERCP before coming to laparoscopic bile duct exploration (LBDEx). This group is usually reported to have a higher rate of failure of laparoscopic clearance. There was no mention of failure rates of ERCP in the paper as it was simply a descriptive study of exploration via choledochotomy. (Click here to continue reading.)

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Discussion: What makes a competent surgeon? Critical comments on a critical analysis

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Re: Hamdorf JM. Critical evaluation. What makes a competent surgeon? (ANZ J. Surg. 2010; 80: 656)

We read with interest the paper by Hamdorf1 commenting on our study of UK surgeons' perceptions of the CanMEDS-specified competencies.2 We found two distinct ‘families’ of competencies: the first relates to clinical practice (roles of Collaborator, Professional, Manager, Health advocate, Communicator). The second reflects academic expertise (roles of Scholar, Medical expert). Hamdorf finds this of interest, but criticizes some of our analyses. Small sample size is part of the critique, followed by the view that our multivariate analyses (internal consistency, principal components analysis (PCA)) do not add to the findings. (Click here to continue reading.)

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Discussion: Laparoscopic bile duct exploration

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Re: Kelly, MD. Results of laparoscopic bile duct exploration via choledochotomy (ANZ J. Surg. 2010; 80: 694–8)

I wish to congratulate Michael Kelly for an excellent article on the management of common bile duct (CBD) stones. However, I wish to draw the author to some comments.

First, what is the author's practice on patients who are not unwell but jaundiced (due to CBD stones)? A preoperative endoscopic retrograde cholangiopancreatography (ERCP) is not without risks; and at our institution, we would organize cholecystectomy and usually place a transcystic stent (antegrade stent). A post-operative ERCP would then ensue.

Second, a failure rate of 25% for ERCP seems high. Could the author explain this rate?

Third, if there is a suspicion for CBD stones with known gallstones, why bother with a magnetic retrograde cholangiopancreato-graphy; and not plan for surgery?

Fourth, what size of bile duct (diameter) would preclude a choledochotomy?

And finally, why place T-tubes and not consider placing an antegrade stent? T-tubes do carry their own morbidity.

Sulman Ahmed, MB BS (Syd), FRACS
Department of Surgery, Nepean Hospital, Sydney, New South Wales, Australia

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Discussion: Oesophageal bolus impaction

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Oesophageal bolus impaction: role of glucagon, glyceryl trinitrate and carbonated drink

Glucagon, glyceryl trinitrate (GTN) and carbonated drinks are all considered measures, which can be implemented in the emergency department to relieve oesophageal food bolus impaction negating the need for urgent endoscopy. Glucagon and GTN are smooth muscle relaxants. Carbonated drinks increase intra-oesophageal pressure by releasing carbon dioxide and thereby forcing the food bolus into the stomach. The outcome of 45 episodes of oesophageal food bolus impaction presenting to the Bendigo Hospital emergency department between 2007 and 2009 was reviewed. Success was defined as the resolution of symptoms or no bolus seen on endoscopy. Symptoms resolved in three episodes and no bolus was seen on endoscopy in two episodes. Of these five episodes, all three modalities were implemented in one episode while glucagon and GTN was administered in two episodes. No significant difference was found when a comparison is made between the episodes where no intervention was implemented and where glucagon was administered alone or in conjunction with another measure (11.5 versus 10.5%, respectively). This is comparable to Tribbling et al. who found no significant difference between those given glucagon and diazepam and those given placebo.1 Al-Haddad et al. also concluded a lack of advantage of glucagon over placebo.2 There is minimal evidence regarding the efficacy of GTN in the management of oesophageal food bolus impaction. GTN was efficacious in two of 22 episodes, and on both occasions, it was administered in conjunction with glucagon. The efficacy of carbonated drinks is difficult to assess as there was no protocol in regard to the amount of carbonated drink administered. There is no strong evidence to suggest usage of these measures to relieve oesophageal food bolus impaction in this audit and endoscopy will inevitably be required to further ascertain a potential cause.

Rosemarie May Eyre, MB BS
Bendigo Health – Intern, Victoria, Australia

References
1. Tibbling L, Bjorkhoel A, Jansson E et al. Effect of spasmolytic drugs on esophageal foreign bodies. Dysphagia 1995; 10: 126–7.
2. Al-Haddad M, Ward EM, Scolapio JS et al. Glucagon for the relief of esophageal food impaction: does it really work? Dig. Dis. Sci. 2006; 51: 1930–3.

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