ANZ Journal of Surgery

Background:  A surgical technique for closing skin defects following skin cancer (particularly melanoma) removal is described in the present paper. Its use is illustrated in five patients. The technique has been used in 300 cases over the past 7 years and is suitable for all areas of the body from scalp to foot.

We have coined the term Keystone Design Perforator Island Flap (KDPIF) because of its curvilinear shaped trapezoidal design borrowed from architectural terminology. It is essentially elliptical in shape with its long axis adjacent to the long axis of the defect. The flap is based on randomly located vascular perforators. The wound is closed directly, the mid‐line area is the line of maximum tension and by V‐Y advancement of each end of the flap, the ‘islanded’ flap fills the defect. This allows the secondary defect on the opposite side to be closed, exploiting the mobility of the adjacent surrounding tissue. The importance of blunt dissection is emphasized in raising these perforator island flaps as it preserves the vascular integrity of the musculocutaneous and fasciocutaneous perforators together with venous and neural connections. The keystone flap minimizes the need for skin grafting in the majority of cases and produces excellent aesthetic results. Four types of flaps are described: Type I (direct closure), Type II (with or without grafting), Type III (employs a double island flap technique), and Type IV (involves rotation and advancement with or without grafting). The patient is almost pain free in the postoperative phase. Early mobilization is possible, allowing this technique to be used in short stay patients.

Results:  In a series of 300 patients with flaps situated over the extremities, trunk and facial region, primary wound healing was achieved in 99.6% with one out of 300 developing partial necrosis of the flap.

Conclusions:  The technique described in the present article offers a simple and effective method of wound closure in situations that would otherwise have required complex flap closure or skin grafting particularly for melanoma.

Background:  Cat bites are the second most common mammalian bites. Cat bites of the hand in particular represent a potentially devastating problem in terms of wound infection and long‐term disability if not treated appropriately. The purpose of the present study is to give an overview of demographics, management and follow up of the patients with cat bite injuries of the hand treated at the Royal Hobart Hospital.

Methods:  Retrospective and prospective data of all patients with cat bites of the hand seen at the Royal Hobart Hospital for a period of 3 years (January 2000 to April 2003) were collected. Demographics, anatomical site, presentation, assessment, investigations, management and follow up of the patients with this type of injury were analysed. The accuracy of the obtained data was checked by analysing questionnaires returned by our patients.

Results:  Forty‐one patients were treated for cat bites of the hand. Twenty‐six were managed in the department of emergency medicine and 15 were admitted and managed by the department of plastic and reconstructive surgery. Five of 15 admitted patients required surgery. Compliance was not a major problem in our study as very few patients were lost to follow up. Almost all patients had close follow up and extensive hand physiotherapy achieving overall good long‐term results. Out of 39 patients who were sent questionnaires only one indicated long‐term problems with the hand (response rate 46%).

Conclusion:  Appropriate early treatment of cat bites of the hand is the key to success. Treatment with antibiotics, surgical drainage, debridement and copious irrigation, and use of corticosteroids in some cases, proved to be effective. Hand elevation and intensive physiotherapy after a short period of immobilization is critical. We believe that prophylactic antibiotics should be given even in case of a minor infection following cat bites of the hand. Clear guidelines for clinical recognition of infection, hospital admission and management are provided in our study.

Background:  Because of specific methodological difficulties in conducting randomized trials, surgical research remains dependent predominantly on observational or non‐randomized studies. Few validated instruments are available to determine the methodological quality of such studies either from the reader's perspective or for the purpose of meta‐analysis. The aim of the present study was to develop and validate such an instrument.

Methods:  After an initial conceptualization phase of a methodological index for non‐randomized studies (MINORS), a list of 12 potential items was sent to 100 experts from different surgical specialities for evaluation and was also assessed by 10 clinical methodologists. Subsequent testing involved the assessment of inter‐reviewer agreement, test‐retest reliability at 2 months, internal consistency reliability and external validity.

Results:  The final version of MINORS contained 12 items, the first eight being specifically for non‐comparative studies. Reliability was established on the basis of good inter‐reviewer agreement, high test‐retest reliability by the κ‐coefficient and good internal consistency by a high Cronbach's α‐coefficient. External validity was established in terms of the ability of MINORS to identify excellent trials.

Conclusions:  MINORS is a valid instrument designed to assess the methodological quality of non‐randomized surgical studies, whether comparative or non‐comparative. The next step will be to determine its external validity when used in a large number of studies and to compare it with other existing instruments.

Background:  Signet ring cell (SRC) carcinoma of the stomach is characterized by its poor prognosis and potential to infiltrate the wall of stomach, although survival studies comparing carcinomas with and without SRC features have yielded inconsistent results. This study compared the clinicopathological features and prognosis of patients with SRC carcinoma with those with non‐signet ring cell carcinoma of the stomach (NSRC).

Methods:  We reviewed the records of 2358 patients diagnosed with gastric carcinoma who were treated surgically between January 1980 and December 1999 at the Department of Surgery, Chonnam National University Hospital. There were 204 patients (8.7%) with SRC carcinoma as compared to 2154 with NSRC.

Results:  Significant differences were noted in the mean patient age, mean tumour size, depth of invasion, prevalence of hepatic and regional lymph node metastases, tumour stage, and curability between the patients with SRC histology and NSRC. There were no statistically significant differences in patient gender, location, or peritoneal dissemination between patients with SRC carcinoma and NSRC. SRC carcinoma of the stomach had a higher prevalence of early gastric carcinoma (46.1%) than NSRC (21.7%). The overall 5‐year survival of all the patients with SRC carcinoma was 60.2% as compared with 48.9% for the patients with NSRC (P < 0.01). Using Cox proportional hazards model, lymph node metastasis and curability were significant factors affecting the outcome. Signet ring cell histology itself was not an independent prognostic factor.

Conclusions:  Patients with SRC histology do not have a worse prognosis than patients with other types of gastric carcinoma.

Background:  The purpose of this paper is to provide a review, based on collected data, on the topic of ‘fractured zygoma’. The review is presented under the headings of epidemiology, fracture patterns, treatment modalities and complications. Throughout the paper comparison is made with published data from around the world.

Methods:  A 10‐year retrospective audit was undertaken of all hospitalized patients, at the Royal Hobart Hospital, Tasmania, who had sustained a fractured zygoma. All Le Fort fractures involving the zygoma were excluded.

Results:  A total of 263 fractures was sustained, largely due to assault. Alcohol was a significant contributing factor. Tetrapod fractures were the most frequent type of fractures witnessed. Plating was the most frequently employed fixation. Inferior orbital nerve dysfunction and other complications were seen in 24.6% and 20.7% of follow‐up cases, respectively. Open reductions were nearly 4 times more likely to be accompanied by complications if inferior orbital nerve dysfunction was excluded.

Conclusions:  Both closed and open reductions are good treatment modalities and were used in near equal numbers of patients. There is a higher incidence of postoperative facial deformity in the closed reduction group, but more complications related to the incisions in the open reduction group. Open reduction and internal fixation is advocated for the unstable, markedly displaced or comminuted fractures. Silastic sheeting is a favoured graft for repair of the associated orbital floor defects and is associated with few complications.

While the introduction of new surgical techniques can radically improve patient care, they may equally expose patients to unforeseen harms associated with untested procedures. The enthusiastic uptake of laparoscopic cholecystectomy in the early 1990s saw a dramatic increase in the rate of common bile duct injuries, and was described by Alfred Cuschieri as ‘the biggest unaudited free‐for‐all in the history of surgery’ due to ‘a lack of effective centralised control’. Whether a new surgical intervention is considered an acceptable ‘minor’ variation of an established procedure, or is sufficiently ‘novel’ to constitute experimentation on human subjects is often unclear. Furthermore, once a new technique is identified as experimental, there is no agreed protocol for safety evaluation in a first‐in‐human setting. In phase I (first‐in‐human) pharmacological trials only small, single arm cohorts of highly selected patients are enrolled in order to establish the safety profile of a new drug. This exposes only a small number of patients to the unknown or unforeseen risks that may be associated with a new agent, in a highly regulated and scientifically rigorous manner. There is no equivalent study design for the introduction of new and experimental surgical procedures. This article proposes a practical stepwise approach to the safe introduction of new surgical procedures that surgeons and surgical departments can adopt. It includes criteria for new surgical techniques which require formal prospective ethical evaluation, and a novel study design for conducting a safety evaluation at the ‘first in human’ stage.