use of loupes in urology

Selected letters will be published on ANZJSurg.com before they appear in the print journal

Dear Editor,

ABC approach to history taking in the bariatric patientans_

5980 184..192184..192

Clinical history taking is a fundamental building block in thediagnostic process.1 While structured formats exist for manyof the common clinical specialties, bariatric surgery is arelatively new concept. As such, it can be unclear to both surgeonsand trainees exposed to these patients how such a history shouldbe approached. This is important, as subtleties within the historycan direct the surgeon towards choosing a specific operativeprocedure.

In many bariatric units worldwide, patients are required to com-plete a questionnaire prior to clinic attendance assessing theireating habits, weight loss attempts and exercise routine, in additionto their pre-existing co-morbidity. This often includes an assess-ment of their psychosocial background to identify additional riskfactors such as eating disorders, smoking, and alcohol or drugmisuse. There are currently no clear guidelines regardingwhich surgical procedure patients should receive and thus it islargely guided by individual surgeons’ experience or preferences.Despite this, a clearly structured clinical history, incorporating thepoints previously raised, remains a key component in decision-making.2

We have found the following ‘ABC DEEP’ model to be a usefulmnemonic to not only ensure that key points in the clinical historyare recorded, but also to provide a framework for letter dictation. Aseries of selective questions within each category is required toprovide a complete clinical assessment.

A Age of patientB Body mass indexC Co-morbiditiesD Drug historyE Eating habitsE Exercise habitsP Psychosocial history

References

1. Hampton JR, Harrison MJ, Mitchell JR, Prichard JS, Seymour C. Relativecontributions of history-taking, physical examination, and laboratoryinvestigation to diagnosis and management of medical outpatients. BMJ1975; 2: 486–9.

2. Eldar S, Heneghan HM, Brethauer S, Schauer PR. A focus onsurgical preoperative evaluation of the bariatric patient – TheCleveland Clinic protocol and review of the literature. Surgeon 2011; 9:273–7.

Michael G. Clarke,* MD, FRCS (Gen)Marlene Barr,† MRCGP

Michael Booth,* FRACS*Department of General Surgery, North Shore Hospital, and

†Albany Basin Accident and Medical Centre, Auckland,New Zealand

doi: 10.1111/j.1445-2197.2011.05980.x

Dear Editor,

Hepatic artery aneurysmans_5938 184..192

We present a case of a giant hepatic artery aneurysm in a 48-year-old female, 13 years post-laparoscopic cholecystectomy (intra-operatively, a tortuous right hepatic artery was noted). She presentedjaundiced with pain and nausea for 2 weeks. Computed tomographyand angiogram (Fig. 1) revealed a 10-cm saccular aneurysm of thecommon hepatic artery, extending from just distal to its origin at thecoeliac trunk to approximately 1 cm proximal to its bifurcation. Theaneurysm was readily visible at laparotomy. An 8-mm interpositiongraft was used to bridge the gap between ends within the sac.

Fig. 1. Angiogram of hepatic artery aneurysm.

LETTERS TO THE EDITORANZJSurg.com

© 2012 The AuthorsANZ Journal of Surgery © 2012 Royal Australasian College of SurgeonsANZ J Surg 82 (2012) 184–192

Hepatic artery aneurysms are the second most common of allvisceral artery aneurysms (false aneurysms account for >50%). Theincidence is thought to be increasing with the use of laparoscopicand percutaneous treatments for biliary disease and non-operativemanagement of blunt abdominal trauma; however, convincing dataare absent.1,2

Quincke’s triad, the classic presentation of pain, obstructive jaun-dice and haemobilia, is becoming less common, possibly due tocross-sectional imaging detecting earlier, smaller and asymptomaticaneurysms.1,3 They may present with pain, a pulsatile mass, jaun-dice, haemobilia or with free rupture. Free rupture occurs with ahigher frequency in larger aneurysms and those that are symptomaticand is associated with a high mortality rate. Aneurysms over 2 cmare reported as having a 20–80% risk of rupture and rupture beingassociated with an 8–21% mortality.2,3 Aneurysm diameters thatare reported in the literature range between 1.5 cm and 14 cm, withthose in the upper end of the range, such as our case at 10 cm, beingextremely rare. Treatment options described include surgical, embo-lization and, more recently, endovascular techniques, and need to betailored to the aneurysm size and location.1,4

References

1. Kim J, Rha S, Chun H et al. Giant aneurysm of the common hepaticartery: US and CT imaging findings. Abdom. Imaging 2010; 35: 212–4.

2. Bronstein J, Cohen J, Sehgal S, Kolasinski S. Hepatic artery aneurysm: anunusual case of biliary obstruction. Vasc. Med. 2009; 15: 75–7.

3. Pulli R, Dorigo W, Troisi N, Pratesi G, Innocenti A, Pratesi C. Surgicaltreatment of visceral artery aneurysms: a 25-year experience. J. Vasc.Surg. 2008; 48: 334–42.

4. Jeans P. Hepatic artery aneurysms and biliary surgery: two cases and aliterature review. ANZ J. Surg. 1988; 58: 889–94.

Priscilla Martin, MBBSSteven Foster, MBBS

Christian Kenfield, MBBS, FRACSRoyal Brisbane Hospital, Herston, Queensland, Australia

doi: 10.1111/j.1445-2197.2011.05938.x

Dear Editor,

Use of loupes in urologyans_5973 185..193

We agree that magnification has revolutionized the operating theatreas well as many of the comments supporting the important role ofloupes in the Perspectives article by Ilie and colleagues in the ANZJournal of Surgery.1 However, we disagree with the comment thaturologists are infrequent users of magnification and believe thaturology trainees should consider wearing loupes when training.

A survey in September this year of New South Wales urologytrainees (19 trainees) revealed that 58% owned loupes and 37% usethem regularly. All of the trainees in this group used 2.5¥ magnifi-cation. Loupes are used for mainly radical prostatectomies for whichsome studies indicate that the use of magnification may be associ-ated with a lower positive surgical margin rate.2 They are also regu-larly used for major pelvic surgery, varicocoele ligation and uretericsurgery. Loupes are increasingly being used in all forms of scrotal

surgery to maintain familiarity with their use which translates tooptimal operative speed and comfort when using loupes for majorsurgery.

It is our belief that loupes are the standard of care for nerve-sparing radical prostatectomy or cystoprostatectomy, and urologytrainees should be using them routinely for many open procedures togain the most benefit. We encourage the routine use of loupes for allsurgical trainees and would include urology trainees in the categoryof frequent users.

References

1. Ilie VI, Ilie VG, Lefter M. Loupes in surgical training. ANZ J. Surg. 2011;81: 580–1.

2. JMagera JS Jr, Inman BA, Slezak JM, Bagniewski SM, Sebo TJ, MyersRP. Increased optical magnification from 2.5¥ to 4.3¥ with technicalmodification lowers the positive margin rate in open radical retropubicprostatectomy. J. Urol. 2008; 179: 130–5.

Nicholas Campbell,* MBBSHenry H. Woo,*† MBBS, FRACS (Urol.)

*Department of Urology, Westmead Hospital, and†Sydney Adventist Hospital Clinical School, University of Sydney,

Sydney, New South Wales, Australia

doi: 10.1111/j.1445-2197.2011.05973.x

Dear Editor,

Suction tip: a potential source of infection in clean

orthopaedic proceduresans_5949 185..193

Bacterial contamination of orthopaedic implants may have disas-trous consequences. Despite the multitude of methods employedby surgeons and operating room staff, bacterial contamination mayoccur at the time of surgery. We sought to identify whether dispos-able suction tips could be contaminated with bacteria at the conclu-sion of clean orthopaedic procedures, even if all sterile protocolremained unbreached. This investigation was undertaken at Rotoruapublic hospital, Lakes District Health Board, New Zealand, between23 March 2011 and 8 June 201l. Fifty-one disposable suction tipswere sent to the microbiology laboratory at the conclusion of cleanorthopaedic procedures. Only suction tips which remained withinthe sterile field for the entire duration of the surgery, with no otherbreaches in sterile protocol during the procedures, were sentfor processing. The laboratory staff rolled the suction tip over agarplates and cultured these as per usual laboratory protocols. Four(7.8%) suction tips returned positive cultures. In one case, more thanone main organism was identified. Coagulase negative staphylococ-cus was involved in three cases. Alpha haemolytic streptococcus andmixed skin flora were also cultured in two cases. As coagulasenegative staphylococcus is frequently isolated in orthopaedic pros-thetic joint infections, this is an obvious concern. We feel that thesesuction tips are unlikely to have been contaminated prior to surgery,as they are individually packed and sterilzed and are of singleuse only. There remains a possibility that this may represent a localsterile protocol issue and these processes are being examined thor-

Letters to the editor 185

© 2012 The AuthorsANZ Journal of Surgery © 2012 Royal Australasian College of Surgeons

oughly. Despite this possibility, perhaps the suction tip should betreated cautiously in orthopaedic surgery, even if no breaches insterile protocol have occurred.

Phillip John Insull,* BHB, MBChBJohn Hudson,† Medical Student

*Department of Orthopaedics, Waitemata DHB;†University of Auckland, Auckland, New Zealand

doi: 10.1111/j.1445-2197.2011.05949.x

Dear Editor,

Renal cell carcinoma in tuberous sclerosisans_5983 186..194

A 16-year-old girl presented with facial lesions and generalizedseizures since the age of 4 years. Her younger sister also noticed tohave similar facial lesions. Tuberous sclerosis (TSC) was diagnosed.She is on anti-epileptic medications since then and has lost forfollow-up. Nine months ago, she felt heaviness in the left side ofabdomen and noticed a lump later on. Examination revealed mul-tiple centrofacial angiofibromas (Fig. 1a), ash leaf macules in backand right forearm (Fig. 1b), and periungual fibromas. A hard lump of12 ¥ 10 cm size was palpable in left hypochondrium extending to thelumbar region. Her blood and urine investigations were normal.Ultrasound examination showed a left renal mass suggestive ofmalignancy. Contrast-enhanced computer tomography of theabdomen revealed a 10 ¥ 8 ¥ 7.5 cm heterogeneously enhancingmass lesion with necrosis arising from mid and lower poles of theleft kidney suggestive of renal cell carcinoma (Fig. 1c). Laparo-scopic left radical nephrectomy was done. The final histopathologyreport was conventional renal cell carcinoma (pT2aG2N0M0). Shewas disease free during the last follow-up. Renal lesions occur in50–80% of TSC patients and include angiomyolipomas, cysts, onco-cytomas and renal cell carcinomas.1,2 Angiomyolipomas are the most

common renal lesions, occurring in approximately 75–80% ofaffected children >10 years of age.2,3 RCC has been reported in1–4% of TSC patients.4 Renal cell carcinoma occurs at a youngerage (average age: 28 years).2 Renal manifestations have now becomethe main cause of morbidity and mortality in TSC patients besidesneurological complications.1 Surveillance is essential for earlydetection of renal lesions and effective management.

References

1. Rosser T, Panigrahy A, McClintock W. The diverse clinical manifesta-tions of tuberous sclerosis complex: a review. Semin. Pediatr. Neurol.2006; 13: 27–36.

2. Leung AK, Robson WL. Tuberous sclerosis complex: a review. J. Pediatr.Health Care 2007; 21: 108–14.

3. Crino PB, Nathanson KL, Henske EP. The tuberous sclerosis complex. N.Engl. J. Med. 2006; 355: 1345–56.

4. Coleman JA. Familial and hereditary renal cancer syndromes. Urol. Clin.North Am. 2008; 35: 563–72.

Shanmugasundaram Rajaian, MS, MCh (Urology)Nitin Sudhakar Kekre, MS, DNB (Urology)

Department of Urology, Christian Medical College, Vellore, India

doi: 10.1111/j.1445-2197.2011.05983.x

Dear Editor,

Survival of patient after aorto-oesophageal fistula

following button battery ingestionans_5984 186..194

A 10-month-old boy developed coughing and vomiting. Radio-graphs showed a button battery in the distal oesophagus. The batterywas removed endoscopically with difficulty because of its size andimpaction, 14 h after ingestion. Radiography then showed pneumo-mediastinum, but a contrast study showed no oesophageal leakage.After 5 days of antibiotics, he was discharged. Three weeks later, he

a c

b

Fig. 1. (a) Multiple centrofacial angiofi-bromas; (b) ash leaf macule in rightforearm; (c) enhancing heterogeneousmass lesion in the left kidney withnecrosis (hollow arrow).

186 Letters to the editor


woke with dyspnoea and haematemesis. He was transferred by fixedwing aircraft to the children’s hospital in Perth. Further episodes ofhaematemesis followed, requiring resuscitation and intubation.Endoscopy showed extensive ulceration above the gastro-oesophageal junction and steady slight haemorrhage unaffected byadrenaline injection. The general surgery team approached the ulcerthrough a laparotomy. A distal longitudinal oesophageal incisionrevealed a 5-mm ulcer posteriorly. The trickle became brisk haem-orrhage and aortic involvement was suspected. The ulcer was over-sewn and covered with omentum. Initially stable haemodynamically,the patient went for computed tomography (Fig. 1) which demon-strated an aorto-oesophageal fistula. Shortly afterwards, brisk arte-rial bleeding recommenced.

The cardiothoracic team approached the aorta via a posterolateralthoracotomy. The fistulous section of aorta was excised and end-to-end anastamosis was performed and patched with pericardium. Thefistula tissue was cultured and grew Streptococcus milleri and Strep-tococcus viridans. The wound drained saliva for 2 days, and re-covery was complicated by sepsis. A subcutaneous collection wasdrained percutaneously. Recovery was then uneventful.

Patients with aorto-oesophageal fistulas secondary to ingestedbones sometimes survive but cases secondary to button-batteryinjury have been fatal before this case1–3: the timing of exploratorylaparotomy was fortuitous.

Button battery ingestion incidence is 15 per million per year.Larger batteries (�20 mm diameter) are associated with poorer out-comes and the prevalence of these, including fatalities, is increasing,occurring in 2.7%. Mechanisms include discharge from the negativeterminal, pressure necrosis and acid corrosion. Symptoms includepain, vomiting and fever. Most ingestions are witnessed; 80% areasymptomatic.4

References

1. Kelly SL, Peters P, Ogg MJ, Li A, Smithers BM. Successful managementof an aortoesophageal fistula caused by a fish bone-case report and reviewof literature. J. Cardiothorac. Surg. 2009; 4: 21.

2. Hamilton JM, Schraff SA, Notrica DM. Severe injuries from coin cellbattery ingestions: two case reports. J. Pediatr. Surg. 2009; 44: 644–7.

3. Mortensen A, Hansen NF, Schiødt OM. Fatal aortoesophageal fistulacaused by button battery ingestion in a 1-year-old child. Am. J. Emerg.Med. 2010; 28: 984.

4. Litovitz T, Whitaker N, Clark L, White NC, Marsolek M. Emergingbattery-ingestion hazard: clinical implications. Pediatrics 2010; 125:1168–77.

Alistair Spiers, MBBSShahid Jamil, MBBS

Elizabeth Whan, FRACSDavid Forbes, FRACP

Ian Gollow, FRACSDavid Andrews, FRACS

Princess Margaret Hospital, Subiaco, Western Australia, Australia

doi: 10.1111/j.1445-2197.2011.05984.x

Dear Editor,

Superior non-migration of radioactive seed for

impalpable breast lesion localizationans_5975 187..195

For many years, hook wires have been used to localize impalpablebreast lesions for surgical removal. Wire migration between inser-tion time and surgery is a potential limitation, associated with pos-sible incomplete or total failure to remove the index lesion.

Alternative localization techniques have emerged including theuse of carbon and radioactive isotopes; intralesional Technetium-99 m labelled nanocolloid (ROLL)1 and more recently I-125 radio-active seeds.2 The latter is highlighted here.

A 50-year-old woman with an impalpable right upper inner quad-rant breast cancer was planned for breast-conserving surgery with atherapeutic mammoplasty and sentinel node biopsy. For logisticreasons, localization is needed to be performed 24 h preoperatively.A pilot study of radioactive seed localization (ROLLIS: radio-guided occult lesion localization using I-125 seeds)3 is currentlybeing conducted in our institution. The patient was enrolled in thisstudy, and the lesion was localized with both a hook wire and a lowdose (3.7 MBq) I-125 seed. Both markers were placed under ultra-sound control and excellent position of both was confirmed onmammography (Fig. 1a,b). The external part of the wire was tapedsecurely to the skin.

At operation 21 h later, it became apparent that the hook wire hadmoved substantially further into the breast either overnight, imme-diately preoperatively or even (although not knowingly) intraopera-tively. The I-125 seed, however, remained firmly in optimal positionwithin the lesion centre, and detection with a standard intraoperativegamma probe was used with excellent effect to remove the tumourwith clear pathological margins. Specimen radiograph demonstratesthe disparate marker positions relative to the tumour (Fig. 1c).

The superior position maintenance of the I-125 seed in directcomparison with a traditional hook wire demonstrates one of thepotential advantages of this method – advantages we hope will proveits worth as a preferred impalpable breast lesion localization tech-nique in the near future.

Fig. 1. Contrast-enhanced CT axial image, arrow indicates fistula.



References

1. Paganelli G, Luini A, Veronesi U. Radioguided occult lesion localization(ROLL) in breast cancer: maximizing efficacy, minimizing mutilation.Ann. Oncol. 2002; 13: 1839–40.

2. Gray RJ, Salud C, Nguyen K et al. Randomized prospective evaluation ofa novel technique for biopsy or lumpectomy of nonpalpable breastlesions: radioactive seed versus wire localization. Ann. Surg. Oncol. 2001;8: 711–5.

3. Taylor D, Bourke A. ROLLIS trial. ACTRN 12611000667910. 2011.

Lee R. Jackson,* MBBS, FRACSDonna B. Taylor,†‡ MBBS, FRCP(C), FRANZCR

*Breast Clinic and Department of General Surgery, †Departmentof Diagnostic and Interventional Radiology, Royal Perth Hospital,

Perth, and ‡School of Surgery, University of Western Australia,Crawley, Western Australia, Australia

doi: 10.1111/j.1445-2197.2011.05975.x

Dear Editor,

Post-thyroidectomy hoarseness caused by arytenoid

cartilage subluxationans_5974 188..196

A 40-year-old healthy female patient was admitted for thyroidcancer surgery. She did not have conventional symptoms and spe-cific medical history. She underwent preoperative examination ofvocal cord movements by direct laryngoscopy, and there were noabnormal findings.

Anaesthesia was induced with 1.0% propofol 100 mg andremifentanyl 100 mcg. After rocuronium 50 mg for muscular relax-ation, an insertion of a 39 French (Fr) gauge, left-sided endotrachealtube (BronchoCath®; Mallinckrodt, St Louis, MO, USA), into thetrachea, was attempted using a stylet and a Macintosh 3 laryngo-scope blade (Macintosh No.3; Welch Allyn, Skaneateles Falls, NY,USA).

At the intubation, although the endotracheal tube was insertedwith outside pressing the thyroid cartilage because the glottis could

Fig. 1. (a,b) Localization mammogram(arrow indicates I-125 seed); (c) Speci-men radiograph (arrow indicates I-125seed and tumour).

a

c

b



not be sufficiently viewed, the tube was slightly inserted into thetrachea and fixed at the right oral angle at a depth of 29 cm. Thestylet was removed smoothly immediately after the bronchial cuffpassed between the vocal cords.

The patient was placed in the supine position with hyper-flexionof neck during the operation. A total thyroidectomy with routinecentral compartment node dissection was performed, and both recur-rent laryngeal nerves were well observed and preserved.

Anaesthesia was maintained with oxygen, air and sevoflurane.After the operation, the endotracheal tube cuffs were deflated andthe endotracheal tube was removed without any difficulty. Theduration of the operation was 1 h 30 min and that of anaesthesiawas 2 h.

There were no abnormal symptoms in the recovery room, andthen she was transferred in the general ward. After 8 h, she com-plained of a weak voice, hoarseness and aspiration symptom. Shewas treated with steroid injection, but those symptoms did notimprove even 5 days after surgery. On the fifth day after theoperation, indirect laryngoscopy revealed anterior subluxation ofboth cricoarytenoid cartilages with poor motility and oedemaon the vocal cords. At the sixth day after the operation, a slightimprovement was observed in the hoarseness even withouttreatment. A spontaneous recovery of arytenoid cartilagedislocation was expected. Conservative therapy was selected.Six months later, the voice quality was improved and indirectlaryngoscopy confirmed normal positioning of arytenoidscartilage.

Most of vocal cord palsies after thyroid surgery resulted frominjury to the recurrent or superior laryngeal nerve, so the presenta-tion of hoarseness or aspiration is a critical problem to endocrinesurgeons. Even extremely rare, however, vocal fold immobility orhypomotility can result from an endotracheal intubation, which isreported in 14–50% of the patients who receive general anaesthesia.These problem is usually related to a laryngeal structural problemsuch as arytenoid cartilage dislocation or cricoartenoid joint fixation(Fig. 1).1

The arytenoid cartilage dislocation has been reported to be asso-ciated with direct laryngoscopy, lighted stylet, laryngeal maskairway, McCoy laryngoscope and cases of difficult intubation.2

In conclusion, recognition of the occurrence of arytenoid cartilagedislocation and early diagnosis are important for appropriate treat-ment and preventing long-term consequences.3

References

1. Mencke T, Echternach M, Kleinschmidt S et al. Laryngeal morbidity andquality of tracheal intubation. Anesthesiology 2003; 98: 1049–56.

2. Mikuni I, Suzuki A, Takahata O, Fujita S, Otomo S, Iwasaki H. Arytenoidcartilage dislocation caused by a double-lumen endotracheal tube. Br. J.Anaesth. 2006; 96: 136–8.

3. Sataloff RT, Bough ID Jr, Spiegel JR. Arytenoid dislocation: diagnosisand treatment. Laryngoscope 1994; 104: 1353–61.

Yong Sang Lee, MDBup Woo Kim, MD

Hang-Seok Chang, MDCheong Soo Park, MD

Thyroid Cancer Center, Gangnam Severance Hospital,Yonsei University College of Medicine, Seoul, Korea

doi: 10.1111/j.1445-2197.2011.05974.x

Dear Editor,

Human papilloma virus in oropharyngeal cancers (Re:

ANZ J. Surg. 2011; 81: 581–3)ans_5977 189..197

The answer to the question ‘Should the treatment paradigms for oraland oropharyngeal cancers be changed now: the role of humanpapilloma virus?’1 is ‘with caution’.

Fig. 1. The schematic drawing of thearytenoid cartilage dislocation.

The information in regard to HPV positivity in the Northern Territory waspresented as a free paper at the International Academy of Oral Oncology’sConference in Singapore in July 2011.



The vast majority of publications about oral and oropharyngealmalignancies (OPM) and human papilloma virus (HPV) employ P16immunohistochemistry (P16 IHC) as the only marker.2 This captures85% of all HPV presence in OPM (P18 and P33 account for 15%),and indicates the co-existence of HPV in these sites, but does notprove that HPV actually caused the OPM. To show that the cancerwas caused by HPV, onco-proteins E6/E7 must be over-expressed,and detected by quantitative PCR (qPCR, RNA or DNA) testing.3

Tests with in situ hybridization have also been employed towardsthis purpose. E6 suppresses p53, and E7 suppresses Rb, both ofwhich are tumour suppressor genes.4 As alluded to in Dwivediet al.’s article, between 25% and 30% of all OPM that tested P16positive are E6/E7 positive.

The specificity and sensitivity of these tests have been recentlyreported.5 In isolation, P16 IHC fares poorly (94% and 82%), in situhybridization also is a poor predictor (88% & 88%) and their com-bination is also undependable (88% and 90%); however, when P16IHC is combined with qPCR DNA testing, the reliability is far better(97% and 94%).5

The clear delineation of truly HPV positive cancers exposes a faryounger group, with little or no exposure to tobacco and alcohol.This group, therefore, is far better physiologically compared withthe traditional model of patients with OPM and is well poised tobetter tolerate and respond to treatment.

Our group looked at the incidence and clinical outcomes ofHPV in OPM in the Northern Territory in an ethics-approvedstudy. The preliminary findings indicate that 45% of tumourstested were positive for P16; 63% of those positive were Indig-enous Australians. However, being P16 positive did not conferimproved survival rates.

If the group of patients with OPM that are truly caused by HPV isidentified employing the combination testing approach (combinationP16/qPCR DNA), then it is feasible that the treatment paradigm canbe de-escalated for select patients, with organ preservation produc-ing good QOL and survival. In the interim, caution is indicated in thelight of significant concerns regarding the accuracy and prognosticvalue of assessment employing P16 IHC alone.

References

1. Dwivedi RC, Dwivedi RC, Kazi R, Kanwar N, Nutting CM, HarringtonKJ, Rhys-Evans PH. Should the treatment paradigms for oral and oropha-ryngeal cancers be changed now: the role of human papilloma virus? ANZJ. Surg. 2011; 81: 581–3.

2. Kreimer A, Clifford G, Boyle P, Franceschi S. Human papillomavirustypes in head and neck squamous cell carcinomas worldwide: asystematic review. Cancer Epidemiol. Biomarkers Prev. 2005; 14: 467–75.

3. Moody C, Laimins L. Human papillomavirus oncoproteins: pathways totransformation. Nat. Rev. Cancer 2010; 10: 550–60.

4. Feller L, Wood N, Khanmissa R, Lemmer J. Human papillomavirus-mediated carcinogenesis and HPV-associated oral and oropharyngealsquamous cell carcinoma. Part 2: human papillomavirus associated oraland oropharyngeal squamous cell carcinoma. Head Face Med. 2010; 6:15.

5. Schache A, Liloglou T, Risk J. Oropharyngeal squamous cell carcinoma:sensitivity, specificity, and prognostic discrimination. Clin. Cancer Res.2011; 17: 6262–71.

Methinee Intrapanya,* BSNRama Jayaraj,* MVetSc, PhD

Cameron Scott,† MBBS, FRACDS (OMS)Siddhartha Baxi,§ MBBS, FRANZCR

Justin Curtin,† MBBS, FRACDS (OMS)Isabelle Lys,* BSc (Hons), PhD

Marina Mileva,‡ MBBSMahiban E. Thomas,† FRCS (Glasg), FRACS

*Allied Health, Charles Darwin University, and †Maxillofacial/Head and Neck Surgery and ‡Pathology, Royal Darwin Hospitaland §Radiation Oncology, Alan Walker Cancer Centre, Darwin,

Northern Territory, Australia

doi: 10.1111/j.1445-2197.2011.05977.x

Dear Editor,

Foregut cyst associated with thyroid cancerans_5962 190..198

A 49-year-old female patient presented with an incidental thyroidcancer found on medical examination. Cervical ultrasonographyand computed tomography showed an approximately 1.0-cm-sized,ill-defined, hypoechoic mass with microcalcification on the leftthyroid gland, and an approximately 3.0-cm-sized, low-attenuatedmass in the level VII (anterior-superior mediastinum), just belowthe left thyroid inferior tip (Fig. 1). The mass was suspiciousfor a parathyroid cyst, but aspiration was not performed. Initialserum parathyroid hormone (PTH) concentration was 47.8 pg/mL(normal; 16–88 pg/mL).

A total thyroidectomy along with mass excision was performed.The operative finding showed that the mass had thick capsuleswithout infiltration into adjacent tissues, and was excised com-pletely. The content of the mass was yellow and turbid.

Final pathological examinations demonstrated a cyst lined byciliated columnar epithelium with focal salivary gland tissue, and nocartilaginous or smooth muscle tissue, and confirmed as foregut cyst(Fig. 1).

They are rare clinicopathological entities in adults. Foregut cystsare heterotrophic rests of foregut-derived epithelium, and are usuallyfound in the abdomen and thorax. After the fourth week of devel-opment, the embryonic foregut elongates fairly rapidly. The liningepithelium proliferates, converting the oesophagus into almost asolid tube. At approximately 6 weeks of development, vacuolesform within this solid tube. These vacuoles gradually coalesce toform the oesophageal lumen. Foregut cysts result from an abnormalvacuolization process, in which one vacuole persists.1

Foregut cysts usually involve the thoracic oesophagus, andalthough rarely, they can involve the cervical oesophagus, and thislesion usually presents alone.2

Foregut cysts are usually asymptomatic, but some clinical mani-festations may be due to cyst size or location. Infection, bleeding andmass effects, including dysphagia, epigastric discomfort, retroster-nal pain, dyspnoea, regurgitation, and cough, are the most commoncomplications associated with foregut cyst. Some of the rare com-plications include acute rupture, rapid enlargement and malignanttransformation.3



Diagnosis of a foregut cyst is usually incidental. Endoscopicultrasound may be helpful in the diagnosis of an oesophageal dupli-cation cyst.4 When the imaging findings are equivocal, the diagnosiscan only be made by histopathology.

The only definite treatment for a foregut cyst is surgical excision.Though a patient with a foregut cyst may be asymptomatic, surgeryshould be considered in every case due to the potential forcyst ulceration and perforation. Recently, laparoscopic resection

a

c d e

f g

b

Fig. 1. Cervical ultrasonography (a and b) and computed tomography (c, d and e) showed an approximately 3.0-cm-sized, low-attenuated mass in the levelVI, just below the left thyroid inferior tip, and in microscopic examination, cyst lined by ciliated columnar epithelium with focal salivary gland tissue and nocartilagenous or smooth muscle tissue (f and g).



has been demonstrated a successful treatment for oesophagealduplication cysts.2

Foregut cysts associated with thyroid cancer are extremely rare.A cystic mass around the thyroid gland is usually thought to be ametastatic node or a parathyroid cyst. Fine-needle aspiration cytol-ogy under ultrasonography guidance is the standard method for thediagnosis of cystic lesions, of unknown origin, around the thyroidgland. Thyroglobulin or PTH measurements for aspirate washoutscan be helpful in obtaining an accurate diagnosis of it. In the presentcase, we likewise suspected this cystic mass to be a metastatic nodeor a parathyroid cyst. However, confirmation by fine-needle aspira-tion cytology, and PTH measurement of the contained fluid was notperformed. In the case of a foregut cyst, final diagnosis is best madeby histologic examination. Besides parathyroid cysts, foregut cystsof the neck should be included in the differential diagnosis of per-ithyroidal cystic lesions during thyroid surgery.

References

1. Lee HS, Jeon HJ, Song CW et al. Esophageal duplication cyst compli-cated with intramural hematoma-case report. J. Korean Med. Sci. 1994; 9:188–96.

2. Sharma KK, Ranka P, Meratiya S. Isolated cervical esophageal duplica-tion: a rarity. J. Pediatr. Surg. 2005; 40: 591–2.

3. Neo EL, Watson DI, Bessell JR. Acute ruptured esophageal duplicationcyst. Dis. Esophagus 2004; 17: 109–11.

4. Bhutani MS, Hoffman BJ, Reed C. Endosonographic diagnosis of anesophageal duplication cyst. Endoscopy 1996; 28: 396–7.

Yong Sang Lee,* MDSoon Won Hong,† MD, PhD

Bup Woo Kim,* MDHang-Seok Chang,* MD, PhD, FACSCheong Soo Park,* MD, PhD, FACS

Departments of *Surgery and †Pathology,Gangnam Severance Hospital,

Yonsei University College of Medicine, Seoul, Korea

doi: 10.1111/j.1445-2197.2011.05962.x

Dear Editor,

Operative experience of general surgeons in a rural

hospital (Re: ANZ J. Surg. 2011; 81: 601–3)ans_5978 192..200

In this article, Campbell et al.1 highlights the diverse nature of sur-gical work by two general surgeons at Wimmera Base Hospital(serving a population of 54 000 at Horsham 300 km away fromMelbourne) for over a period of 20 years, reflecting their commit-

ment and dedication for the people they serve and thus setting up anexample for younger surgeons to take up a career in general surgeryin the country Australia.

I note that out of a total of 8336 procedures carried out by twogeneral surgeons over a 5-year period, 44% were classed asgeneral surgical and 27% as endoscopic and 29% as other spe-cialty procedures. This may well be the experience of many othergeneral surgeons working in remote areas in relative isolation.2,3

The most challenging work for a general surgeon working in anisolated small population centre with limited facilities is whendealing with a major trauma case or an acute surgical case, and thepresence of an experienced and competent surgical team at thetime can be the determining factor towards a favourable outcomein such cases.

Providing a broad range of specialty surgical services in remote,relatively isolated areas in a vast country like Australia is no easytask and the need for well trained surgeons and other specialists towork in such areas can only be met by strategic all round develop-ment planning of services for remote Australia, not just hospitalservices, which can be facilitated by amalgamation of services inremote population centres including better linkage amongst networkof peripheral and city hospitals, rotation of trainee specialists inremote hospital as mandatory for specialty training. Australiaalready has this sort of arrangements in place, with highly efficientambulance, air ambulance, retrieval team and of course the RoyalFlying Doctor Service, but these need to be further refined andstrengthened.4 As specialty services develop further in remote areas,general surgeons’ workload in the future is likely to be confined tocore general surgical services and further specialization within thecontext of general surgery as reflected in this paper, with onesurgeon carrying all 13 abdominal aortic aneurysm cases, all thora-cotomies, varicose veins and 145 pacemaker insertions.

References

1. Campbell NA, Kitchen G, Campbell IA. Operative experience of generalsurgeons in a rural hospital. ANZ J. Surg. 2011; 81: 601–3.

2. Green A. Maintaining surgical standards beyond the city in Australia.ANZ J. Surg. 2003; 73: 232–3.

3. Bhattacharyya R. Solcotrans R for emergency auto transfusion. Arch.Emerg. Med. 1987; 3: 200–1.

4. Bhattacharyya R. Maintaining surgical standards beyond the city in Aus-tralia. ANZ J. Surg. 2003; 73: 1061–2.

Ratnakar Bhattacharyya, MBBS, FRCS (Eng), FRACSChatswood 24 Hour Medical & Dental Centre, Sydney,

New South Wales, Australia

doi: 10.1111/j.1445-2197.2011.05978.x



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