EVALUATING NOVEL THERAPIES FOR FAECALINCONTINENCE

R. MADOFF

University Of Minnesota, Minneapolis, USA

Current dogma holds that biofeedback is an effective and risk-free therapy forincontinent patients of diverse etiology, and that overlapping sphinctero-plasty is the treatment of choice for patients who are incontinent due tosphincter injury. Unfortunately, emerging data from randomized, controlled trialcall into question the efficacy of biofeedback, and several recent reviewssuggest that the long-term results of sphincteroplasty deteriorate signifi-cantly with time. These findings highlight the ongoing need to develop newtherapies for faecal incontinence, particularly in cases where standardtherapy is not applicable or has failed to alleviate the problem.

The past decade has witnessed the appearance of an impressive array of noveltherapies for faecal incontinence. Dynamic graciloplasty and the artificialanal sphincter both create patient-controlled functional neosphincters. Sacralnerve stimulation alters local physiology in a variety of ways to effectivelyrestore continence. Other new approaches include radiofrequency ablation,topical phenylephrine, and local injection of collagen or microballons torestore normal sphincter contour.

A review of the incontinence literature demonstrates a depressing similarityin reported success rates between various therapies – including those such aspostanal repair that have been abandoned by most clinicians due to poorclinical results. One explanation for this phenomenon is the increased accuracywith which bowel function is now assessed, and the increased stringencywith which results are now reported. Data recorded in 1980 are simply not com-parable to those that are currently being collected.

Success rate is not the only criterion by which novel therapies should beassessed. Faecal incontinence is the first quality of life issue, and the impact onquality of life must be measured for each new therapy.

Treatment morbidity varies tremendously between therapies and must betaken into account when these therapies are evaluated. Cost is an increas-ingly important consideration in today’s world of constrained resources.

Faecal incontinence is receiving ever more attention in both the lay and pro-fessional literature, and novel approaches to its treatment appear with surprisingfrequency. Because the colorectal surgeon has unique expertise in this area, it is his or her responsibility to ensure that conflicting (and increasinglycommercial) claims are properly evaluated. This route is the only one that willlead to optimal patient outcomes.

PR47INTRAVENOUS LINE SEPSIS IN BURN PATIENTS: IS IT WORSETHAN IN OTHER TRAUMA PATIENTS?

W. M. MCMILLAN, T. BROWN, M. MULLER AND T. WILLIAMS

Middlemore Hospital, Auckland, New Zealand

Purpose Many hospitals require that an intravenous cannula be changedevery 72 h, recognizing that the incidence of line related sepsis rises after thistime.1 In burn patients the situation is even more important. The prognosis from line sepsis in burn patients is poor, with a mortality of up to 60%.2This study investigates issues surrounding line sepsis in burn patients comparedwith other trauma patients admitted to ITU.Methodology Interrogation of a database concerning patients treated inthe ITU over a 12-month period. ANOVA and non-parametric statistical tests wereused to examine line sepsis in the trauma and burn groups, ISS scores,length of time lines were in place, and causative organism.Results Eight out of 91 trauma patients and 13 out of 30 burn patients hadpositive growth on lines. The length of time that lines were in situ did not differfor both groups (3.8 ± 1.3 days trauma, 3.8 ± 1.5 days burns). The ISSscores for burn injured patients were significantly less than for other trauma

patients (12.7 ± 10.9, 17.8 ± 9.7, respectively; P = 0.0004). In both groups, the causative organisms were predominantly of skin origin. MRSA was notpresent in trauma patients, but appeared in two burn patients.Conclusion ISS scores are lower for burn patients compared to traumapatients with line sepsis. Sepsis from intravenous lines is common in burnpatients in ITU, and a regular exchange of lines every 72 h is mandatory toprevent line sepsis.

References1 Pearson ML. Guidelines for the prevention of intravascular device

related infections. Infect. Control Hosp. Epidemiol. 1996; 17: 473 2 Pruitt BA, McManus AT, Kim SH, Treat RC. Diagnosis and treatment

of cannula-related intravenous sepsis in burn patients. Ann. Surg.1980: 191; 546–54.

TRAUMA: ‘THE EPIDEMIC FIGHTS BACK’

P. D. DANNE

University of Melbourne, Royal Melbourne Hospital, Melbourne, Australia

The greatest cause of death and disability in the younger age group in ourcommunity (under 40 years) continues to be trauma.

The epidemic of road trauma has been partly addressed by excellentpreventative measures; however, the identified extra pressures of an increasingamount of penetrating trauma, and the threat of terrorism, puts a level ofurgency upon this demand.

The remarkable fact, quite riveting from a clinical point of view, is that thebest evidence we have, from the CCRTF and MTMS studies, and now fromsome follow-up studies in another state, documents that more than one-third of people dying from trauma in Australasia, have potentially preventabledeaths. There is a significant clinical job to be done to bring this level ofmanagement, and hence clinical outcome, up to expected and benchmarkedinternational standards.

It appears uncommonly difficult, to gain a widespread appreciation in thepublic and governmental arenas, of the need to reduce the ongoing endemicdeath rate of more than 3000 people per year in Australia. Death rates of thismagnitude from other diseases, which do seem to attract public attention,such as meningococcal disease and breast cancer would raise public anger, ire and great levels of funding. Trauma does not appear to attract similarresponses very easily.

Currently, in other parts of the world, road trauma is one of the singlelargest epidemic causes of death, but again remains a ‘poor cousin’ to morecommonly publicized diseases. In India, there are more than 100 000 deaths peryear from road trauma, and in China more than 200 000 per year.

To address this problem, the clinical trauma community has well developedstrategies. National and state reports have recommended the establishment of Integrated Trauma Systems (ITS) throughout Australasia. This includesagreed standards for prehospital care, designation of hospitals for traumacare, formal training programmes for all providers, the development oftrauma registries and detailed System Performance Analyses.

A SWAT analysis of where we are at, would reveal that strengths includesome of the QA processes already done, particularly the Systems Perfor-mance Analyses of the CCRTF and MTMS studies, the development of evi-denced-based guidelines for trauma management and the RACS TraumaVerification project. Training programmes have been well developed, butrequire further development. The Victorian Trauma Education Framework is an example of a formulated and planned approach to training. The RACSTrauma Committee functions with many Subcommittees, and is a strength.The preventative Trauma strategies already employed, continue to be a greatstrength. Third party insurers in some states, have provided funding to signifi-cant levels, and informed and interested government agencies, prepared toengage with clinicians, become an essential to the furthering of ITS development.

Weaknesses and threats include apathy at public, clinical and administrativelevels. Bureaucracy, when exemplified by a ignorance, or even denial of,

ANZ J. Surg. 2003; 73: A138–A140

SURGICAL RESEARCH

ROYAL AUSTRALASIAN COLLEGE OF SURGEONS ANNUAL SCIENTIFIC CONGRESS, BRISBANE, 5–9 MAY 2003

results of good QA processes, and manifested in lack of federal organization fortrauma development, present a great threat. Terrorism must be regarded as anunpredictable and ever present threat to our capacity to respond. Last, but notleast, surgeons are leaders in trauma care, yet strategies are not in place, to effec-tively ensure a good cadre of trained trauma surgeons and to retain thosesurgeons in the trauma workforce.

Strategies to be implemented, to address the endemic problem of trauma, andthe threatened epidemic include:

• National burns and trauma plans – Integrated Trauma System implementation• Designation and verification of trauma centres• National Trauma/Burns Committee• National Trauma Registries• QA – through System Performance Analyses and verification projects at a

national level• Trauma training programmes• Clearly defined roles for trauma surgeons• Retention strategies (reimbursement issues)• Implementing lessons learnt from the Bali bombing• Harnessing government and other agency understanding and support for the

urgent needs of ITS development

ReferencesMcDermott FT, Cordner, SM, Tremayne AB, the CCRT (Consultative Com-

mittee on Road Traffic Fatalities). Management deficiencies and deathpreventability in 120 Victorian road fatalities (1993–94) Aust. N. Z. J. Surg.1997; 67: 611–18.

Danne PD, Brazenor G, Cade R et al. Major Trauma Management Study:analysis of the efficacy of current trauma care. Aust. N. Z. J. Surg.1998; 68: 50–57.

THE NATURE OF THE TRAUMA SURGEON: LEVIATHAN,SUPERMAN, FRANKENSTEIN’S MONSTER, SNAG, RURALSURGEON OR ‘EMERGENCY SURGEON’

P. D. DANNE

University of Melbourne, Royal Melbourne Hospital, Melbourne, Australia

The question of ‘who, or what is a trauma surgeon?’ remains poorlyaddressed. Indeed, that role has never been clearly defined in the Aus-tralasian clinical setting.

Even in the USA, the role of the trauma surgeon is changing, and hasbeen significantly questioned recently, due to difficulties in attracting sur-geons to the field, and retaining surgeons, as well as due to the reducedamount of operating on trauma occurring in many trauma centres.

The trauma surgeon role developed in Europe is based on an emergencyorthopaedic model, with broader surgical fields included.

Our surgical forbears (Leviathan’s) were true general surgeons, beforeintensive care management developed, who performed the entire gamut ofsurgery for trauma, including neurosurgery, thoracics, plastic procedures (to theirstage of development) orthopaedics, facio-maxillary and abdominal surgery.Some of these surgeons were giants in surgical folklore and in their lifetimes, but operated before surgical audit existed, and before surgical specialtieshad been developed.

The concept of an all encompassing ‘trauma surgeon’, continuing thetraditions of the Leviathan’s, but adding in intensive care management, and inthe environment of high level surgical audit and quality assurance, meansthat only a ‘superman’ could function at this level. Such a surgeon would runa significant risk of turning into ‘Frankenstein’s Monster’, as he or shewould certainly be unable to maintain the quality level of performance in all ofthose disciplines.

Surgical subspecialties can be very unhelpful in the development of auseful trauma surgeon role, as each speciality is more and more demanding ofretaining all operating within its sphere of influence. A trauma surgeon whorefers every piece of surgery to a subspecialist will represent the ‘sensitive newage guy’ (SNAG) of trauma surgery. This surgeon will be very friendly andwell-liked by all specialities, but would end up operating only rarely him orherself. Such a surgeon is effectively ‘sterilized’ and the species will notreproduce.

The true rural surgeon remains the most common example of a possibletrue trauma surgeon in Australasia. Many, however, have not taken up themantle of responsibility fully by undertaking EMST courses, being involved intrauma system development, trauma team development, and by not yet under-taking inservice training in definitive surgical trauma care (DSTC) courses

As subspecialties develop within general surgery, there is a very realthreat to the provision of emergency general surgical care in tertiary andsecond level hospitals, and even in the regional setting.

There is now an opportunity to foster the concept of the ‘emergency andtrauma general surgeon’.

This would require a co-ordinated effort from both the RACS and healthauthorities, as such surgeons would necessarily need to be part or full timesalaried. The profession as a whole, needs to recognize that trauma surgery isa subspeciality and that a wide spectrum of surgery does need to be undertakenby the trauma surgeon, particularly some minor plastic surgery, some thoracicsurgery, some procedures including tracheostomy, peg-tube insertion etc.

The trauma surgeon may also be sourced from orthopaedic, neurosurgical,cardiothoracic or plastic surgical disciplines, and training pathways havebeen developed through the trauma committee. Links with burns surgery areimportant.

The essential elements to progressing the development of the role of the‘trauma surgeon’ include:

• Prescribed and structured broad training programmes• Long-term career options

– Designated trauma centres with director/deputy director positionsestablished

– Adequate remuneration – Other surgical lines of work encouraged

• Openly audited quality of work• Strong support from speciality and subspeciality groups

If well planned, the trauma surgeon, may serve not only trauma, but emer-gency general surgical voids effectively.

ReferenceRACS Trauma Committee. A Training Pathway for Trauma Surgery, RACS

Trauma Committee: Trauma Office RACS, College of Surgeons Gardens,Spring Street, Melbourne.

SOME TRAUMA SURGICAL TECHNIQUES THAT I HAVE FOUND USEFUL

P. D. DANNE

University of Melbourne, Royal Melbourne Hospital, Melbourne, Australia

To this point in my surgical career, I have had the privilege of working in trauma surgery in the USA, general and trauma surgery in the UnitedKingdom, a large rural Australian regional centre, and in a major traumaservice in Melbourne, Australia.

The range and variety of trauma experience in Australia is wide, but theopportunity of managing penetrating trauma in both Australasia and the UK isrelatively small.

In my practice there are some particularly useful techniques that I willtake the opportunity to delineate in some detail. These are both in the resusci-tative/diagnostic phase of trauma management, and in definitive surgicalmanagement.

The techniques will be described in brief, but succinct detail, with accom-panying video footage.

Resuscitative:• Diagnostic peritoneal lavage – (Seldinger Lazarus percutaneous)• Pericardial window • Cricothyroidotomy • Emergency room resuscitative thoracotomy (ERRT)• Clam shell extension of ERRT

Definitive surgical:• Sequence of trauma laparotomy – ‘follow the clot’• Damage control laparostomy • Packing of liver• Partial splenectomy with mesh wrap • Scissoring technique for control of splenic pedicle• VATs for retained hemothorax

Reference is made throughout to the Definitive Surgical Trauma Care(DSTC) course, which outlines most of these techniques and gives surgeons anopportunity to refresh their skills.

ReferenceSugrue M, Danne PD [co-editors]. The Definitive Surgical Trauma Course

(DSTC) Manual. August 1999. The DSTC Instructor Manual August1999.

ABSTRACTS A139

A140 ABSTRACTS

QUALITY ASSURANCE IN TRAUMA – HOW DO WE RATE,WHERE ARE WE GOING?

P. D. DANNE

University of Melbourne, Royal Melbourne Hospital, Melbourne, Australia

The complexities of management processes for multisystem injury have lead to a high level of sophistication in the development of QA processes. Thetrauma field has, in many respects, led the way in this area.

Some aspects of historical development of QA processes in trauma will be out-lined, and current methods of QA, will be outlined. Prospective, randomized trialsto gain level 1 evidence, are very difficult to conduct in the trauma setting.

The Major Trauma Outcome Study (MTOS) first set benchmarks forexpected outcomes with high quality (level 1) Major Trauma Service Man-agement. These benchmarks are outdated and are currently in the process ofbeing redefined through the National TRACS system in the USA. LocalAustralasian benchmarks are required to be set, but can only be done once anAustralasian trauma registry is established.

At an individual hospital level, sophisticated mortality and morbidityprocesses have existed for many years in most major trauma services. Nowdays, ‘root cause analysis’ has become a coined phrase to describe processeswhich have been used in trauma management for many years.

Risk adjustment of raw mortality data, taking account of variables including age,mechanism of injury, injury severity score, multiplicity of transfer processes(and therefore management) the age of patients, and presence of comorbid diseasescan provide a statistical assessment of outcome with very different results tothe raw mortality figures. A vignette will be presented to detail this.

The selection of patients for discussion in mortality and morbidity audits canbe enhanced and streamlined by the use of audit filters. The best audit filters areselected by the mortality and morbidity audit itself, as key performance indi-cators arising out of detailed peer review analysis. Example lists of auditfilters and KPIs will be given. The accuracy of KPIs depends upon the level ofevidence used for their determination.

The use of the TRISS or ASCOT system of analyses of trauma outcome, arenot only dependent upon the accuracy of current benchmarks, but are inherentlyinaccurate.

The best practice quality assurance process for determining the appropriatenessof outcome, or otherwise, remains with the well structured peer review panelprocess. Carefully structured panel methodologies leads to a high level of objectivityand reliability, with KPI levels concordance levels of 0.7 (very high).

The reporting of potentially preventable death rates remains a less than satis-factory process, and the use of ‘efficacy’ rates is recommended by epidemiologists.

It remains of concern that high quality audit processes, and studies conductedin trauma, have resulted in relatively minimal reaction and activity in govern-mental and departmental levels, compared to the high level of reactivity initi-ated by the quality in Australian health care study, with its significantlylimited methodology. More active engagement between clinicians and gov-ernment/departmental agencies is required in order to enact change.

ReferencesChampion HR, Copes WS, Sacco WJ et al. The major trauma outcome

study: establishing national norms for trauma care. J. Trauma 1990; 30: 11,1356–1365.

McDermott FT, Cordner SM, Tremayne AB. Reproducibility of preventabledeath judgements and problem identification on 60 consecutive roadtrauma fatalities in Victoria, Australia. J. Trauma 1997; 43: 831.

TRAUMA ANGIOGRAPHY: ANGIOGRAPHY SUITE VS THEATRE

A. J. GR A B S

University of New South Wales, St Vincent’s Hospital, Sydney, Australia

Vascular surgeons are performing increasing numbers of diagnostic angiogramsand percutaneous intervention. Endovascular repairs of abdominal aortic

aneurysms in Australia are frequently performed in an operating theatrewithout difficulty.

Given the improvement in mobile digital subtraction angiographymachines, the safest place to undertake trauma angiography is now in theoperating theatre. Features of modern machines include 12-inch field ofview, magnification and road mapping.

The operating theatre is equipped with good lighting, rapid infusiondevices, warming blankets, and a full anaesthestic team should they berequired. If a patient becomes haemodynamically unstable, immediateoperative interventions can be undertaken available. Embolization withcoils or gelform can be undertaken without difficulty with mobile imageintensification.

Trauma surgeons must insist that patients be in the safest environment forassessment and management, this being the operating theatre.

CAROTID DISSECTION AND OTHER VASCULAREMERGENCIES

A. J. GRABS

University of New South Wales, St Vincent’s Hospital, Sydney, Australia

Carotid dissection following a trauma continues to be a difficult diagnosis toestablish especially in head injured patients. The use of duplex ultrasound moreliberally may increase its diagnosis; however, the gold standard continues to be angiography. Abnormalities on duplex should be further investigated.Therapy is traditionally non-operative.

Penetrating injuries of the neck have traditionally been classified into zones 1 (1cm above the clavicle down to and including the base of theneck and thoracic outlet), zone 2 (1cm above the clavicle to the angles of thejaw) and zone 3 (angle of the jaw to the base of the skull). The traditionalapproach is to perform angiography for zone 1 and zone 3 injuries in stablepatients.

We believe all patients who warrant surgical exploration of their woundshould proceed immediately to the theatre and have angiography done by aradiologist or vascular surgeon in theatre. Approaches to unstable patientswill be reviewed.

THE STANDARD WHIPPLE’S PROCEDURE: TECHNIQUE AND RESULTS

J. AVRAMOVIC

Townsville Hospital, Queensland, Australia

Between 1999 and March 2003, 32 conventional, open, pancreaticoduo-denectomies have been performed in Townsville by a single surgeon. Thirty ofthese operations have been performed electively for suspected tumour.

All patients were evaluated with preoperative helical CT scans. Twenty-threeof 30 patients had an ERCP and 19 had preoperative biliary stenting.Twenty-eight from 30 patients underwent staging laparoscopy prior tosurgery.

A pylorus-sparing Whipple’s procedure was performed in 25 out of 30patients. Portal vein resection and reconstruction was necessary in fourpatients. A feeding jejunostomy was inserted at the time of operation inseven patients.

The current operative technique includes the use of staples and an ultrasonicscalpel. These have reduced operating time and intraoperative transfusionrequirements.

Sixty-eight per cent of patients have postoperative complications. Twopatients required reoperation. There were no postoperative pancreatic orbiliary fistulas. There was no in-hospital or 30 day mortality.