San Doctor Autumn 2018

The benefits of robotic San surgery in the management of endometrial cancer Doctor A/PROF FELIX CHAN MBBS MRACOG FRANZCOG CGO Associate Professor Felix Chan is a certified gynaecological oncologist and is currently the Head of the Centre for Robotic Surgery in Gynaecology at Sydney Adventist Hospital. He is also and the Director of Gynaecological Oncology for South Western Sydney Area Health District. A/Prof Chan specialises in advanced laparoscopic, robotic, vaginal and open surgery for the treatment of gynaecologic malignancies and complex gynaecological problems. He was a nominee for Australian of the Year in 2009, 2011 and 2012 and is also AUTUMN 2018 a member of the NSW Doctor’s Orchestra. P: 1300 227 428

In Australia, the incidence of endometrial cancer is resection of recurrent tumours becomes technically rising, due to the ageing population and increased possible. prevalence of obesity. Endometrial cancer can Robotic-assisted reconstructive surgery such as ileal be caused by genetic factors as found in Lynch conduit and continent urinary reservoir, become Syndrome or as a result of increased exogenous and feasible. In addition, complex surgery requiring endogenous oestrogen. a team of surgeons can be carried out efficiently After a confirmed diagnosis based on histology, the without any change of patient position. use of pre-operative imaging such as a CT scans aims Simulation and procedure specific modules allow to assess the extent of the disease. gynaecological surgeons to acquire and maintain Surgery not only removes the origin of the disease, their skills through their surgical career. it also relieves symptoms and defines the extent of Training and teaching can be standardised and the disease. Adjuvant therapy such as chemotherapy allow progression of surgical skill development from and radiotherapy can be recommended to a patient registrars, to specialist consultant. to avoid over, or under-treatment. This article aims to describe the current trends in surgical treatment of Task performance and the learning curve for endometrial cancer. acquisition of skills were found to be superior with the robotics system when compared with Robotic-assisted technology conventional laparoscopy in a laboratory setting. Currently, Intuitive Surgical’s da Vinci robot remains When the viewing condition specifically between the the only surgical system performing robotic surgery two systems was evaluated, the three-dimensional in Australia. It has evolved extensively over the features provided an advantage. last ten years with surgeons now able to control a high definition three-dimensional camera system Endometrial cancer with a wristed instrument that has seven degrees Surgery is the cornerstone in the treatment of of movement. This results in intuitive surgical endometrial cancer, with removal of the uterus and movement, fewer tremors and improved stability, the adnexae along with inspection of the peritoneal precision and reproducibility. Furthermore, the cavity and staging of the disease by removal of surgeon sits at a console to operate, which minimises pelvic and, in some cases, para-aortic lymph nodes surgical fatigue and improves ergonomics. Improved and omentum. Traditionally, the surgical treatment tissue magnification allows the surgeon to visualise of endometrial cancer has been performed by vital structures and avoid unnecessary trauma or laparotomy. injuries. However, a randomised trial of comprehensive staging in more than 2500 women with endometrial cancer comparing laparotomy to laparoscopy, published in 2009 by the Gynaecological Oncology Group, concluded that laparoscopy was safe for endometrial cancer patients1. The study demonstrated a decrease in serious complications, less use of antibiotics and shorter hospital stay and was further supported by a meta-analysis on four randomised controlled trials including 339 patients2. Accordingly, the number of women with endometrial cancer treated by MIS has since increased dramatically from 9% in 2006 to the current 90% years and within this frame, robotic assisted surgery (RAS) Figure 1. Sentinal node removed after injection of ICG using has become the preferred surgical modality by JACARANDA LODGE da Vinci Xi Firefly Cancer Support Centre gynaecological oncologists in the USA3. As the surgeon controls three surgical instruments In 2008, Boggess et al. compared the three in addition to a camera, they can operate with very modalities and found that RAS had lower estimated little assistance, and therefore do not have to rely on blood loss and larger lymph node yield. Transfusions an assistant’s expertise. The latest da Vinci Xi allows were administered less frequently with RAS and multiple quadrants surgery. postoperative complications like ileus and wound This is enabled through the use of cameras in all infections were diminished or similar to total ports, which allow the visualisation of the operative laparoscopic hysterectomy4. Recent data supports field from different vantage points (camera that quality of life after RAS for endometrial hopping), surgeon controlled surgical bed motion, cancer, with regard to fatigue, pain, constipation, and reduction of port distance to 6cm. Complex gastrointestinal symptoms, and appetite, was procedures including pelvic and left infra-renal returned to pre-operative levels five weeks para-aortic node dissection, omentectomy, bowel postoperatively5. resection, anterior and posterior exenteration and continued on page 4 The views and opinions expressed in the articles in this publication are those of the authors and are not necessarily shared by the editors or Adventist HealthCare Limited. The editors and Adventist HealthCare Limited do not accept responsibility for any errors or omissions in any article in this publication. 2 SAN DOCTOR AUTUMN 2018

Table1 provide continual flow to the myocardium. whilstthebypass to isconstructed artery shunt (1.25mm)isplaced insidethecoronary small throughout.providing Avery perfusion isbeatingtechniques and whereby theheart the LIMA grafted ontheLADusingoff-pump chestwall (4cm)and incision ismadeintheleft small opened andtheLADisidentified. A very instruments (Figure 1). The pericardium is usingtheroboticthen harvested cautery of thechestwall andtheLIMA. The LIMA is to increase exposure to theposterior aspect Carbon dioxide isinsufflated under pressure lungisdeflated. anaesthetised andtheleft For arobotic bypass operation, thepatient is stents iffeasible. (PCI)withintracoronary intervention coronary andwould preferundertake, percutaneous is required, whichpatients are hesitant to proven benefit. survival Typically, asternotomy any revascularisation procedure andhasa (LAD) hasthebestlong-term outcome of anterior artery to descending left coronary (LIMA) artery internalThe mammary left minimal pain. sternotomy withvastly improved recovery and withouta canbeperformed bypass surgery magnification in 3D. This meansthat coronary hand movements aswell asprovide 10x mimicthesurgeon’sinstruments perfectly metres away from theoperative field. These controls therobotic from arms aconsole afew bypass surgery.coronary The surgeon robot have facilitated trulyminimallyinvasive The latest iterations oftheda Vinci surgical ROBOTIC CORONARY BYPASS SURGERY Mammary Artery (LIMA). Artery Mammary Figure oftheLeft harvesting 1.Robotic Internal to Circumflex valveMitral repair andvein vein bypass to RCA valveAortic replacement and CABG X 3 CABG P:02 94491559E:[email protected] W: www.levibassin.com includingTAVIsurgery (Transcatheter Valve Aortic Implantation). interesta special inmitral valve repair. inrobotic, Bassinspecialises Dr minimallyinvasive, andhybrid cardiac LeviDr Bassinisaconsultant cardiothoracic surgeon atSydney Adventist Shore andRoyal Hospitalswith North DR DR cardiac surgery and interventional cardiology interventional and surgery cardiac An innovative approach combining the best of surgery cardiac hybrid bypass coronary Robotic and OPEN CARDIAC SURGERY VS HYBRID CARDIAC SURGERY LEVI

BASSIN BSC (COMP) MBBS PHD FRACS Robotic mitralRobotic valve repair andstent to Circumflex AVRMini and stent (Figure to RCA 3) LIMARobotic to LAD, RIMA to LCx, stent to RCA (4cm Thoracotomy). Figure Surgery Bypass 2.Post Coronary Robotic op- to 3months until theyare fit to goaheadwith viaasternotomy surgery willneedto wait up Patients that undergo conventional cardiac procedure, bowel orjoint resection, surgery. suchasa toprior othermajorsurgery Whipple’s patients that require orvalve coronary surgery clinically from are robotic those surgery recovery period, anothergroup that benefits less post-operative painandanabbreviated Aside from theobvious lifestyle benefitsof • • • • Patients that are goodcandidates include: graft to the LADandcircumflex. to arteries two bypasses usingbothmammary somepatients,In itisalsopossibleto perform months following asternotomy (Figure 2). weeks following surgery, compared withthree and are backto theirpreoperative state 2-4 approximatelyafter three days inhospital intensive care. patients Most cangohome in theoperating theatre andtransferred to the first48hours. The patients are extubated a continuous infusion oflocalanaesthesiafor catheter isplaced inthechestwall to provide is closedandthenanultrasound guided closed andthelungisreinflated. The wound the anastomosis. The pericardium isthen This isremoved to justprior completing coronary stents (See Hybrid Cardiac stents Hybrid Surgery) coronary (See remaining stenoses willbetreated with Those vessel withtriple diseasewhere the vessel disease coronary Those that have asignificant singleordouble intramyocardial. Where thecoronaries to bebypasses are not BMI <35

Anterior Thoracotomy-RAT)Anterior stent. andcoronary Figure 3.Post Valve opminiAortic Replacement (Right any case(valve cardiac and/orbypass surgery toor possiblysuperior saphenousvein grafts. In excellent results similar withlongterm patency stents drugeluting coronary have Modern their entire livelihood. substantial financialburden andmay evenrisk threea patients months offof taking adds work and majorbleeding. For many employed such asstroke, risks and morbidity infection longrecovery period, significanta very pain, comes at asignificantIt cost, however, with thelivesand extended ofmillionspatients. has stood thetest oftimewithexcellent results (LCX).circumflex artery coronary This operation vein (RCA) and graftsto therightcoronary and placingaLIMA to theLADandsaphenous a sternotomy, machine useoftheheart-lung bypass grafting(CABG) with artery is coronary vessel disease, coronary thestandard treatment revascularisation (HCR).For patients withtriple The bestexample ofthisishybrid coronary cardiologyinterventional techniques. with theeffectiveness and rapid of recovery combined benefitofcardiac surgery survival of bothworlds’ –that and isthedurability of intracoronarystents to achieve best ‘the (PCI)withtheplacement intervention coronary transcatheter techniques suchaspercutaneous invasive incombination cardiac with surgery strategy that usesrobotic orminimally refers cardiac surgery Hybrid to atreatment surgical trauma, painandrecovery time. options for effective treatments with reduced This isidealfor patients asthere are now more disease. andvalvular heart of bothcoronary with considerable overlap inthetreatment cardiologyand interventional are converging As technology hasimproved, cardiac surgery recovers from asternotomy. or becoming inoperable whilstthepatient minimises thechance ofcancer metastasising facilitates cancer asuperior operation and robotic bypass surgery. This expedited recovery for a Whipple’s procedure two weeks post recently hadpatients undergo alaparotomy another majorsurgery. Conversely, we have HYBRID CARDIAC SURGERY continued onpage 4

Figure 1:Radial Ultrasound image ofalungmass a bronchoscope with a USS that can perform a bronchoscope withaUSSthat canperform method for thediagnosis oflungcancer. is It This isthemostpopularbronchoscopy same procedure. commonly are usedincombination the during These methods canbeusedalone, butmore bronchoscopy andultra slimbronchoscopes. cryobiopsy, electromagnetic navigation, virtual EBUSincombination with Linear EBUS,Radial The commonest bronchoscopic methodsare safety profile. diagnosis oflungcancer dueto themarked adopted as thefirstlineofinvestigation inthe Bronchoscopic methodshave now been for thepatient. toand molecularmarkers provide optimalcare andtest diagnose for the malignancy genetic to lesions isofparamount importance obtaining agoodtissuebiopsyfrom these Once lunglesionisdetected, anabnormal distant sites. at atimewhenthecancer hasspread to Unfortunately, about40%ofpatients present oflungcancer isonly14%inAustralia. survival isaroundresection 70%. The overall five-year localised lungcancer of1cmwithsurgical stage early ofa very survival then thefive-year the bestchance ofcure for lungcancer. Even diagnosisEarly andsurgical gives resection prostate, colon andpancreatic cancer. exceeds to breast, combined deaths secondary worldwide. The death toll oflungcancer alone cancer istheleadingcauseofcancer death diagnosed withlungcancer inAustralia. Lung yearEvery around 11,000patients are LINEAR EBUS DIAGNOSING LUNG CANCER BRONCHOSCOPY METHODSIN MINIMALLY INVASIVE SAFER OPTIMAL TREATMENT A GOOD TISSUE BIOPSY IS REQUIRED FOR CHANCE OF A CURE EARLY DIAGNOSIS GIVES THE BEST THE BURDEN OF LUNG CANCER P: 1300586437E:[email protected] W: www.SydneyRespiratorySpecialist.com.au bronchoscopy/thoracicinterventional fellowship attheprestigious inCanada malignancy McGillUniversity in2013. bronchoscopy andsleepmedicine. Shebecame aFellow oftheRoyal Australasian College ofPhysicians in2011andcompleted acompetitive inlungcancer, training Herath Samantha andexpertise andSleepPhysicianDr isaRespiratory withextensive sub-specialty interventional for lungcancer diagnosis bronchoscopic methods invasiveMinimally &safer DR DR SAMANTHA HERATH

MBBS MPHIL FRACP Bronchoscopy ofalungnodule Figure navigation 2:Lung virtual point without compromising patient safety. biopsy suitablefor amultitude oftesting of thelungtissuethat gives alarger lung whichessentially isa cryobiopsy ‘cold biopsy’ EBUS guidance. Onesuchpromising biopsyis with theradial of biopsiescanbeperformed lesions inthelungparenchyma. Various types biopsy technique for thebiopsyoflung emerging worldwide asasafe andeffective EBUSis lungmasses.abnormal Radial viathebronchoscope to be inserted locate EBUSisathinwire likeUSSthatRadial can affordable. aswellversions asmore whichare portable bronchoscopy systems now come inlaptop when coupled withthissystem. Virtual be reached andbiopsiedwithconfidence which isonly3.7mmindiameter. Lesions can lesions by using anultra-thin bronchoscope scan. This enables accurate location ofthese chest the bronchial tree usingthethinslice CT bronchoscopy creates areal-time 3Dvideoof the bronchoscopy diagnostic methods. Virtual bronchoscopyVirtual is another additionto 1. test for thenewest molecularmarkers. biopsy histology samplesthat canbeusedto now linearEBUScanbeusedto provide core recent introduction oflarger biopsyneedles, procedure withminimalsideeffects. With the Therefore, apatient may onlyrequire asingle mediastinal staging. extent ofthespread inthemediastinumcalled provide thediagnosis aswell asdetermine the gives theaddedadvantage ofbeingableto also ofableedorpneumothorax.100 risk It lymph nodes. This methodis safe with<1in an internal scanofthepatient’s mediastinal RADIAL EBUS THIN BRONCHOSCOPY VIRTUAL BRONCHOSCOPY AND ULTRA- TECHNIQUES? NOVEL BRONCHOSCOPIC BIOPSY WHAT ARE THE ADVANTAGES OF THESE bronchoscopic biopsymethods isthe Increased safety: The keyadvantage in

dealing with this sobering diagnosis. dealing withthis sobering but alsoenablesholisticcare to thepatient in delays andmultiple procedures,unnecessary only fasttracks thediagnostic process, avoids andrespiratory physician practitioner not A closecollaboration withthegeneral equipment. andavailability of by thelocal expertise option. ofbiopsyisalsogoverned The type a bronchoscopic biopsywould bethebetter guided lungbiopsywhilstfor many lesions lunglesionsmaySome bebetter suited for CT biopsy technique for theindividual patient. into account whendecidingonthebest comorbidities ofthepatient shouldbetaken The location ofthe lunglesionaswell asthe 4. 3. 2. WORKING TOGETHER METHOD FOR YOUR PATIENT? HOW DO YOU CHOOSE THE BEST BIOPSY be performed under general anaesthesia. undergeneral anaesthesia. be performed it isarelief that to bronchoscopy know can guided biopsyandfor theanxiouspatients not require positioningasrequired for CT lower sideeffectprofile. Bronchoscopy does lower dueto theanticipated lungfunction bronchoscopy canbedoneinpatients with bronchoscopic procedures: EBUS Radial More patients are eligible to undergo due to side effects, are reduced. patient cost, days andmorbidity off work, procedure for diagnosis andstaging, the As thepatient usually requires asingle Reduces patient cost anddays lostat work: avoid delays. and staging asingleprocedure during and first investigation would enableadiagnosis can becommenced. Referral for EBUSasthe ofpatients beforemajority any treatment bronchoscopy usingEBUSisrequired in spread ofthedisease first. Therefore, patient requires staging or mandatory adequate to commence treatment. The confirm your suspicion butitisNOT guidedlungbiopsymay cancer by aCT multiple procedures: Adiagnosis oflung Reduced timeto treatment andavoid aroundrisk 4%. pneumothorax rate upto 20%andbleeding guidedlungbiopsythat hasa with CT was minimal. This isincomparison rate was 1%andthebleedingrisk patient meta-analysis thepneumothorax EBUSstudiesdoneover Radial a1,000 favourablemarkedly safety profile. On References available onrequest.

3 SAN DOCTOR AUTUMN 2018 4 SAN DOCTOR AUTUMN 2018 open skull defect, areopen skull contraindications for NB. discolouration. Local anaesthesiaallergy, and pain andswelling, thinningor alopecia,skin tolerated; site sideeffectsmay includeinjection cases.in selected NBisusuallysafe andwell ofboth.Steroidsor amixture maybe added anaestheticagents or Ropivacaine)acting (e.g. Lignocaine) orlong(e.g. Bupivacaine anaesthetics whichcould beeithershort involves ofasmallamount oflocal injection zygomaticotemporal nerves. The procedure mental, lacrimal, auriculoptemporal and supratrochlear, infratrochlear, infraorbital, third occipital, auriculotemporal, supraorbital, targets could includelesserand injected. Other could be headorfacialnerves superficial blockfor headache,nerve butany ofthe peripheral the mostcommonly performed Greater (GON) occipital blockisprobably nerve the sensitisation, breaking ‘pain cycle’. butappearsto effect central of thisuncertain, providing relief for weeks to months. The case beyond theduration ofanaesthesia,sometimes therapy. The beneficialeffect couldlast to standardan adjunct acute orpreventive treatment oras modality used astheprimary statement for NB. These procedures canbe decades, withrecently publishedconsensus been employed for by international experts headache conditions. NBandSPGBhave Both and secondary management of various primary tolerated andsafe outpatient techniques inthe sphenopalatine ganglionblock(SPGB)are well Peripheral block(NB)anddevice assisted nerve PERIPHERAL NERVE BLOCK INTRODUCTION subjected to asternotomysubjected inorder to access approach thissamepatient would have been Whereas previously, withoutthishybrid effectively a few days later whilestillinhospital. present, since thiscan betreated withPCI even diseaseis Mitral ifcoronary or Robotic For example, apatient AVR canundergo Mini disease.PCI to thecoronary correct robotically orminimallyinvasively followed by would theprocedure bebetter to perform in order to beableto place thevein grafts, it where asternotomysurgery) isonlyrequired Dr LeviDr Bassin(continued from page2) bleeding and shortened hospitalstay bleeding andshortened healing, bowel complications, reduced of diminishedcomplications inwound advantages inobesewomen ofRAS because There isgeneral agreement onthe A/Prof Felix Chan(continued from page1) technology to identify sentinel nodesafter The da Vinci robotics system hasFirefly consultation inMandarin,Cantonese andHakka. P: 0299871588W: www.northernneuroscience.com.au a neurologist atWellington HospitalandWaikato HospitalinNewZealand priorto moving to Australia in2013.Healsoconducts neurology training inNewZealand, followed by astroke fellowship Hunter atJohn Hospital, Newcastle. Chung was Dr appointed as forheadache. andsphenopalatineganglionblock block Hecompleted nerve general in particular Chung Kong isageneralDr Khi neurologist interests withspecial instroke andheadachemedicine, disorder ganglion blockinheadache block&sphenopalatine Nerve DR DR KONG KHI CHUNG MBBCH FRACP 6 . approach. approach. less invasive, thoughpotentially lessaccurate device orcotton applicator TX360) allows a approach withcommercial (Sphenocath/ with fluoroscopic guidance, thetransnasal by aninterventionist SPGB canbeperformed neuralgia.headache andtrigeminal While recommendation for SPGBinmigraine, cluster recent systematic review provided alevel B of headacheandfacialpaindisorders. A the beneficialeffectofSPGBinanumber research interest internationally showing target for painmanagement withongoing isagood facial andsympathetic system. It to trigeminal, hasmultipleconnections fossa. It ganglion located deepinthepterygopalatine Sphenopalatine ganglionisaparasympathetic headache duration andpainscore. may bebeneficialin reducing headachedays, placebo controlled showed trial GONblock studiesandarecent Observational randomised globally.the leadingcausesofmorbidity isacommonMigraine disorder andoneof randomised class1trials. which isbasedonapositive outcome from two steroid hasanlevel Arecommendation for CH, cranial autonomic features. GONblockwith unilateral headacheassociatedstrictly with headache syndrome.by ischaracterised It CH isprobably the mostpainfulprimary chronic headache syndrome. Aetiology could Cranial neuralgia in canbeacauseorfactor SPHENOPALATINE GANGLION BLOCK MIGRAINE CLUSTER HEADACHE (CH) CRANIAL NEURALGIAS vessel stenting. coronary currently under-way comparing HCRwith triple and thereinfarction isalarge randomised trial in terms ofmortality, stroke andmyocardial results for HCRwhichhave shown equivalence dual antiplatelet agents. There are published hassettledand itissafebleeding risk to start are placed 4-5days post-operatively once the stents firstandthenthe coronary performed Typically for HCR,therobotic bypass is both thevalve andthevein graft. the staging cancer ofendometrial (Figure 1). and cansafely replace lymphadenectomy in cancer endometrial metastases in detecting ICG have ahighdegree ofdiagnostic accuracy showed sentinel lymphnodesidentified with et al. conclusions from amulti-centre trial Green (ICG). ofIndocyanine Rossi injection

co-morbidities. complex pharmaceutical needorsignificant prophylaxis, andeasilyaddedto patients with They canbeusedasbothacute therapy and effects according to publishedliterature. disorders, degrees ofbeneficial withvarying safe procedures for ofheadache avariety NBandSPGBareBoth well tolerated and ablation. potential benefitof radiofrequency ascertain syndrome may alsobenefit from ofNB atrial to headache patch. Apatient withsecondary headache withcontraindication to ablood B1 respectively), andpostdural puncture Bupivacaine andRopivacaine are A,Aand for safety Lignocaine, pregnancy category Administration Goods (TGA) (Therapeutics medication intolerance, mothers expectant and duetoinclude theelderly polypharmacy benefit from NB andorSPGB. This group could may headache control becauseofco-morbidity population withlimited therapeutic optionfor theauthor’sIn experience, patient selected and newdailypersistent headache. headache,puncture neuralgia postherpetic continua, hypnic headache, postdural post traumatic headache, hemicranias headachesyndromes, or secondary including NB andSPGBmay beusefulinotherprimary infraorbital neuralgia. of greater occipital, supraorbital, lacrimal, and blockhasbeenusedinthemanagement Nerve fibrous entrapment, iatrogenic andothers. trauma,include direct vascular compression, SELECTED PATIENTSELECTED GROUP OTHER HEADACHE SYNDROMES • • • Criteria for hybridrevascularisation: coronary complete lymphadenectomy expose fewer patients ofa to themorbidity positive disease, buthasthepotential to metastases in3%ofpatients withnode lymphnodebiopsywillnotidentify Sentinel

12 months. 12 months. Ability toAbility takedualantiplatelet agents for stentingcoronary diseaseissuitableto coronary Residual LIMA to LAD+/-RIMA to circumflex (LCx) candidateGood for witha robotic surgery References available onrequest. References available onrequest. References available onrequest. 7 .

than conventional X-ray imageswithsignificantly quality lower dose This slot-scanning technology produces high spine, pelvicandlower limbsinoneimage. EOSisusedfor imagingCharpak. theentire physicist work Georges ofNobelprize-winning chambersbasedonthe detector proportional bi-planeX-rayco-linked tubesandmultiwire EOS isarelatively newtechnology usingtwo patients compared to only4mGy/year for non-surgical received aradiation doseof1200mGy/yr patients undergoing surgical treatment example, that idiopathic itisreported scoliosis diagnostic imaging tests that are required. For deformities due to ahigh numberoffollow-up patients withbothspinalandlower limb cumulative High radiation doseisseenin (Figure 2). the ovaries for females, 24timeslower dose leg lengthscans with 4.1timeslower doseto The current low doseEOSimaging provides radiation dosesthanconventional X-ray and lateral bendingviews possibleat lower more accuratemaking flexion/extension 1). EOSalsoallows imaging for functional AnteroPosterior (AP) andlateral images(Figure beam magnification and gives true-to-size used intheEOSscannereliminates divergent measurements. The slot-scanning technology imaging resulting in turn ininaccurate spine orlower limbX-ray results inmagnified The divergent beaminconventional and3feet including 3Dmodelsofthespineandpelvis. postural assessment, andpelvicparameters allows for theassessment ofsagittal balance, weightbearingunder normal conditions. This images isthat itoffers true-to-size and CT The advantage ofEOSover conventional X-ray scanspeedandlength. the selected approximately 10-25seconds dependingon and thescanisperformed. The scanitselftakes parameters are by selected theradiographer, oftheimage,and inferior exposure aspects collimators are thenplaced to identify superior ontheirclavicles.placing theirfingertips The stand stillontheimaging platform whilst This form ofimaging requires patients to simply induced breast cancer have ofdeveloping a4%higherrisk radiation treated for Adolescent Idiopathic Scoliosis has however beendocumented that patients the stochastic nature ofradiation exposure. It thetruelongstandingeffects due to certain radiation exposure, know itisdifficult to for adolescent patients to bemore sensitive to EOS LOW DOSE VS MICRO DOSE imaging is spinal interventional radiology.is spinalinterventional P: 0294879850 College ofRadiologists in1981andworks atSydney Adventist Hospital. Kos’ Dr majorarea ofinterest WallyDr Kos radiologist. isaninterventional Hereceived hisFellowship from theRoyal Australian EOS - DR DR 1 . As it is well known for paediatric and . As itiswellfor known paediatric and WALLY KOS KOS the future of lower dose spinal 1 . 1 . MB BS HON FRANZCR

Figure 1.Lumbar SpineX-ray and 88%respectively X-ray withmagnification of-1.3% factors scanograms andconventional EOS thanCT More accurate measurements are possiblewith 3D MEASUREMENTS bothlow andmicro dosescans. perform isableto The EOSscannerat Radiology San withmicroall follow dose. upscansperformed with low doseimaging initiallybeperformed translated into issuggested 3Dmodels. that It measurements canstill bereliably assessedand 2Dand3D allcritical low dosecounterpart, whencompared slightly lessclarity to itis imaging results in Although micro-dose in obvious long-term benefits for the patient background radiation for thepatient resulting dose values contribute to lessthan1day of conventional X-ray counterparts and resulting inatruerto size scanthanCT dependent onfastorslow scanningprotocols magnification ofonly-0.8 to -0.5% factors delivering amere 172.7mGycm2 1283.mGycm2 however imaging micro-dose scans deliver an overall dosearea of product but therelationship withadjacent structures visualisation ofnotonlytheregion ofinterest long bonescanthenbegenerated for better 3D modelsofspine, pelvisandlower limb including lateral pelvictiltandaxialrotation. Jackson measurements andpelvicparameters spinal penetration index, lordosis, kyphosis, Cobb angle, CAM plumbline, vectors, vertebral Parameters for assessment includeleglengths, in a micro-dose EOSscan in amicro-dose 5-7timesresulting radiation doseby afurther of anewcopper vs aluminiumfilter reduces than digital radiography to a CT scan to aCT compared lower andankles doseto theknees to testicles for malepatients and13-30times 2 and skin dose 6-9 times lower dose6-9timeslower andskin 5 . EOS scans show . EOSscansshow

3 . The introduction introduction . The 1 . Low doseEOS 5 1 . . These micro- . These 1 . Figure 2.Full SpineX-ray Radiology) forassistinginwritingthisarticle. (General ManagerandRadiographer, Section San KosDr would like to acknowledgeCaitlin Haimes radiation. dose lessthanoneday’s ofbackground worth benefitthepatient’sdirectly waya oflife at ofthesedeformitiesassists withcorrection to measure anglesofclinicalsignificance. This to precisely these patients buttheopportunity low andmicroonly functional doseimaging for limb deformities. EOSscanningprovides not diagnostic imaging tests for spinalandlower patients receiving ahighnumberoffollow up of radiation especiallyin dose reduction, EOS scanningplays akeyrole inthefuture FUTURE OF EOS References available onrequest.

5 SAN DOCTOR AUTUMN 2018 6 SAN DOCTOR AUTUMN 2018 seal and theoilcontrast ‘flushing’ theendometrial and (arrows).fallopian tubes cavity Figure1. Hysterosalpingogram (HSG) withacatheter forminga the balloon incervix, in2017. ofMedicine Journal was(H2Oil trial) publishedintheNewEngland rates withoilversus water contrast inHSGs to intheNetherlands comparetrial pregnancy The result ofarecent randomised controlled effect. contrast) influences thispotential therapeutic medium used(oil-basedorwater-soluble ofX-rayit isunclearwhetherthetype contrast flushing to increase pregnancy rates. However hysterosalpingography was usefulfor tubal hasbeenpreviously suggestedIt that decline intheuseoffluoroscopic HSGs. to assesstubal patency, there was ageneral hysterosalpingo-contrast-sonography (Hycosy) recentIn years, withtheincreased useof demonstrate tubalpatency. to andto cavity opacify theendometrial andinstillsanX-raycervix contrast agent suite by aradiologist whocatheterises the inafluoroscopic infertility. AHSGisperformed cavity,endometrial ofinvestigations aspart for andthe study to assess tubalpatency historically utilisedasadiagnostic imaging Hysterosalpingograms (HSGs)have been (HSG) isthefocus ofthisarticle. of fallopiantubeswithhysterosalpinography fallopian tubeobstruction. The assessment abnormalities,sperm ovulation disorders and whichare the three maincausesofinfertility and theninvestigations are ordered assessing andexamination are thefirststeps, A history years, thiscanbecommenced 6 months. after investigations. isover thefemale 35 If partner time, itisconsidered appropriate to commence of unprotected sexual intercourse. After this to conceiveinability naturally 12months after couples globally. isgenerally definedasthe It isestimated to affectaround 9%of Infertility HYSTEROSALPINGOGRAMS INTRODUCTION improves infertility Oil contrast hysterosalpingogram P: 0294738728E:[email protected] W: www.sir.net.au radiology,interventional CTguidedprocedures, vascular access andspinalintervention. in Angiography Radiology atWestmead andInterventional Hospital. Hehasinterests ingeneral procedures Radiology. atSan Clinicrooms andperforms patients atSan Tan Dr completed hisfellowship ColinDr Tan radiologist isaninterventional withSydney Radiology. Interventional Heconsults DR DR COLIN TAN TAN BAPPSCI (HONS) MBBS FRANZCR

receptive environment for implantation. a responseinducing beneficial inflammatory to involve dislodging orinducinga debris isunclearbutitthought the endometrium in mechanismofaction underlying agent. Its acids ofpoppy-seed oilandisanoilycontrast isanethyl tumours. ester It ofiodinated fatty routinely usedin chemoembolisation ofliver contrast agent for many decadesandis Lipiodol hasbeenusedinradiology asa groups. two of adverse events were low andsimilarinthe difference was statistically significant. The rates of oilgroup and28.1%inthewater group. The contrast group. were Live seenin38.8% births in theoilcontrast group and29.1%inthewater randomisation. The rate pregnancy was 39.7% within6monthsongoing pregnancy after UltraFluid Guerbet). outcome was The primary standard water contrast oroilcontrast (Lipiodol HSGs. They were randomised into HSGwith undergoing investigation with for infertility There were 1,119women from 27centres benefit of clearing anybenefit ofclearing that debris could have Flushing ofthetubeshas additional shape andany variations canbeidentified. patent. Further information aboutendometrial determining whetherthetubesare blockedor cavity.the endometrial This canbehelpfulin the contrast to assess thetubesand isinjected ofimagesobtainedwhilst andaseries injected inflated to aseal.form Contrast isthenslowly catheter. Aballoonat theendofcatheter is cannulated withasmall position andthecervix an X-ray tablewhere thepatient liesinsupine on performed istypically menstrual cycle. It HSG isusuallybookedat days 5-10ofthe procedure. procedure. canbedoneasanoutpatient day It A HSGwithoilycontrast isaminimallyinvasive WHAT DOES A HSG INVOLVE?

References available onrequest. • • • • • • • ultrasound andaHSG. assays,serum hormonal pelvicand testicular would generally involve semenanalysis, of unsuccessful natural conception, aworkup their workup for infertility. After 12months Patients canbereferred of for aHSGaspart contra-indicated. infections andthosewhoare bleedingare also contrast agent. Patients withcurrent pelvic is pregnant allergy to orhasaknown iodinated The procedure iscontra-indicated ifthepatient to usethe lowest dosenecessary. dose minimisation made withcontinued efforts enhanced equipment, there could befurther diagnostic range. With digitally modern The radiation doseiswell withinthesafe consequences complications. ofthesereported oily contrast agent. There were noadverse the vascular system), orembolisation ofthe included intravasation ofdye into (leakage rare. Previously complications reported have infection. Allergic to reaction theoilcontrast is minimal complications. There of isasmallrisk The procedure isrelatively well tolerated with tubes are distended withcontrast. istraversed the cervix andwhenthefallopian as there as somepainanddiscomfort isoften Women have the optionofconscious sedation tubal recanalisation. guidance. This issometimesreferred to as with guidewires andcatheters underX-ray unblock thetubesusingadvanced techniques proceduralist hastheoptionofattempting to thefallopiantubesareIf blocked, the potentially beenoccluding thetubes. IN ESSENCE: HSG? WHEN SHOULD I REFER A PATIENT FOR A PROCEDURE? WHO IS NOT SUITABLE FOR THE POTENTIAL COMPLICATIONS? WHAT ARE THE ADVERSE AND EFFECTS way to treat infertility. Potentially alessinvasive andlessexpensive digital equipment art doseisminimised withstateRadiation ofthe The procedure islow risk pain anddiscomfort Conscious sedation can be usedto minimise time same Tubal at the recanalisation canbeperformed fertility Use ofoilcontrast hasbeenshown to improve HSG isanimaging investigation for infertility

Executive Dr Jeanette Conley. Clinical Council following therecent appointment of AHCL’s Medical AHCL isnow represented ontheSydney HealthNetwork North culture ofsafety andreliabilityhigh performance to improve patient care. encourages follow-upreporting, andauditingensuring a It action. commitment andprofessionalism ofAHCLstaffproviding training, Patient andProfessional Advocacy. upfor Safety’‘Speaking buildson framework developed by the USA’s Vanderbilt University Centre for program withtheCognitive Instituteusinganevidence based inaprofessionalThe isaninternational San accountability partner [email protected]. refurbishment isplanned. Contact theCentre on94879061oremail thisyear.its 25thanniversary Foundation ASan appealfor its andsubsidisedaccommodation services andcelebratessupport The San’s Centre Cancer Support provides free resources, counselling, www.sah.org.au/prostate-treatmentoptionsSee prostate theenlarged energy usingthermal prostate to kill tissue. procedure whichinvolves delivering steam vapour to directly the urologistSan Prof Henry Woo trained overseas to theRezum learn ProstaticBenign hasbeendoneat Hyperplasia theSan. The first Australian ground-breakingRezum operation for menwith www.sah.org.au/rehabSee hydrotherapy for poolandanactivities dailylivingarea. facility.to anexternal gym,nearby The unithasapurpose-built to wardfrom surgery stay to therehab unitwithoutrequiring discharge complementing theunitopenedlastSeptember. Patients cantransition an additional24-bedinpatient rehabilitation andconditioning ward have Rehabilitation services San expanded withtheopeningof http://sah.org.au/video-face-to-face Richard Harris. See gynaecological oncologist Prof Felix Chanandendovascular surgeon Dr presentations from colorectal surgeon DrStephen Pillinger, New publichealtheducation videosontheSAHwebsite include system, madeitoneofthelargest producers ofsolarpower inthearea. 2016,theinstallation oftheSan’sIn renewable solar energy 100kw biodegradable takeaway food andreusable cups. hotdrink packaging up to 7tonnes andsave closeto 80trees ayear through theuseof end theuseofalmost½milliondisposablecups, reduce landfill by New environmentally friendlyandgreen initiatives by could theSan News Members oftheFoxMembers Valley Medical Centre andDental team www.sah.org.au/fox-valley-medical-and-dental-centre Contact 9487 9700or (resting &exercise) •minoroperationtheatre •pathologycollection assessments for patientsover 75years •electrocardiograms – a2hourcomplete healthassessment•care licence &lifestyle checksby appointment•executive healthchecks children •papsmears&breast examinations •insurance, drivers including yellow fever (by appointment)•immunisationof consults•travel General vaccinationsandimmunisation Fox187 WahroongaRoad Valley Fox Valley andDental Medical Centre

from Adventist HealthCare Adventist from

help otherson1300034357or AC DSC.HelptheFoundation to Governor David General, Hurley Mr luncheon was addressed by NSW Foundation’s endofyear supporters Foundation. ofSan Director The isthenew Managing Karen Gair oftheSan’ssupport ClinicalEducation Centre School. andMedical the former Adventist HealthCare CEO’s outstandingcontribution and University ofSydney. The award hasbeenconferred inrecognition of LeonDr Fellowship Clark hasbeenhonoured withanHonorary of The onthehospitalcampus in2011. started oftheUniversity ofSydney.Hospital ClinicalSchool The medicalschool 2017,23medicalstudents graduatedIn from theSydney Adventist prostate andtesticularsupporting cancer awareness. $7,000 was raised by amoustachegrowing Movember San Team can alsobemadeto Foundation theSan at www.sanfoundation.com.au. the donation offundsto timesofneed. assiststaffduring Contributions The hasestablishedaCaring San for ourColleagues Fund enabling 40 years ofpractice. PaediatricSan Genevieve Surgeon Cummins Doctor hasretired after administration stafforotherheath practitioners. volunteers, andtheremaining females work asnurses, and hospitality staff being females. There are 300 female doctors, more than400 female employer offemales inSydney’s North West withover 75%ofitstotal The recently San celebrated International Women’s Day. isthelargest It IOS andandroid phonesfor doctors. San information abouttheirpatients. to isnow doctors available It onboth providesA new mobileappfor doctors San real timemedical 100 femoral heads. www.tissuedonationnetwork.org.au See Donation Network ‘Femoral HeadProgram’ withthedonation ofover The isoneoftheleadingdonorsto San theAustralian Tissue as thehospitalredevelopment. ofestate developmentare part plannedandapproved at thesametime Parkway, andtheexpansion ofthe Wahroonga Adventist School. Both suites, located onthecorner ofFox Valley andtheComenarra Rd ClinicParkway onboththenewSan Building isunderway medical obstetric patients. frompatients cardiology, andahighranking and general surgery amongst allhospitalgroups. achieved No.1 It from urology ranking reveals Sydney Adventist Hospitalisnow ranked 3rd nationally Patient experience feedback recently released by Private Medibank org.au. 9487 9405oremailfoundation@sah. 2017 graduating medical students

Karen Gair MD San Foundation MDSan Karen Gair

7 SAN DOCTOR AUTUMN 2018 8 SAN DOCTOR AUTUMN 2018 (Gynaecology), Prof JaswinderSamra (UpperGI/HPB)and Yan (Cardiothoracic), DrStephen Pillinger (Colorectal), A/Prof Felix Chan 5 specialties. Centre leadersincludeProfessor for surgery Robotic Tristan The hasmore San than15robotically trained across surgeons working isavailablesurgery at thesamecost ofprocedures. asothertypes them whetherlaparoscopic, traditional orrobotic. meansrobotic It recognising theprocedure patients deserve that isclinicallybestfor having procedures usingtheda Vinci Xiortheda Vinci Xrobotic systems The haswaived San theexpensive cost ofconsumables for patients recovery times.and generally shorter forcomfort outcomes surgeons. includelesspainandscarring Reported play-station likeconsole providing andseated highresolution imagery with greater dexterity, control, andsurgical hasaseparate reach. It through tiny 1-2cmincisions, withrobotic that arms bendandrotate the Xda Vinci robotic systems. These surgeons enableSan to operate The isthefirstprivate San hospitalinNSW to have boththe Xi and established a wider trial willbeinvestigated.established awidertrial Gerontologist DrGreg isalsoinvolved. Bennett therapeutic benefitis If ontreatmenttrial aimedat alleviating symptoms ofParkinson’s. San Patient Association ofParkinson’s Support Australia South andisfor a has beenawarded a$25000grant. This grant was provided by the fromMitrofanis The University ofSydney’s ofMedicine, Department andProfessor inassociationInstitute withDrAnn Liebert John treatment ofParkinsons disease, ledby Australasian San Research A proof ofconcept trial, for photobiomodulation therapy for the programs inNepal. nursing, international healthoutreach, education andcleanwater (posthumous) Order ofAustralia inrecognition to ofherservice Former NurseMsGlenys San Chapman hasbeenawarded a successful 2011 ‘Don’t Rush’ safety campaign. –highlighted driving the during speedingandreckless tackling ‘Australian ofthe Year’ by The Australian newspaper for hiswork on NeurosurgeonSan Professor hasbeennominated BrianOwler Dias(Urology).Dr Max A/Prof Felix ChanwiththedaVinci System XiRobotic Sydney Adventist Hospital 185Sydney Hospital 2076 NSW Adventist Wahroonga Fox Valley Road, |Ph: 02 9111 9487 |Fax: 02 9266 9487 |www.sah.org.au Adventist of HealthCare A division News Tuesday 15May Monday 18June Monday Thursday 26July Wednesday 15August 185 Fox Valley Rd Wahroonga. Enquiries 9480 3660. Lunch sponsored by San Foundation. San by sponsored Lunch 3660. 9480 Enquiries Wahroonga. 185 Rd Valley Fox Campus SAH Building Tulloch Room 2Conference Level 12:30 1:30pm. to Presentation 12 from noon. Refreshments welcome. Practitioners Medical

Dr SusannaPark Lecturer, –Senior Physiology, Centre USYDBrain&Mind Dr Christos ApostolouDr Christos Drs John Keogh, Adam Osomanski &SandraSpremo Adam Osomanski Keogh, Drs John Dr Hilda High – (Medical Oncologist(Medical specialisinginCancer Genetics) – High Dr Hilda from Adventist HealthCare Adventist from Limited ABN 76 096 452 76 925 ABN 096 Limited

GRAND ROUND DATES ROUND 2018GRAND A

au/sustainabilityadvantage. targets across hospitaloperations. www.environment.nsw.gov. See framework to identify andwork towards environmental goalsand The reviewing Hospitalisactively aUnited Nations developed Environment Advantage andHeritageSustainability Program . sah.org.au/orthopaedics-mako execute theprocedure withahigh degree ofaccuracy. www. See patients’ withthecontrolled knee robotic enablessurgeons arm to alignment ofcustomised components andbasedon3Dscansofthe Mako system. The enableshighlyaccurate Mako placement and Total replacements knee arewiththerobotic now performed Dr John Limbers withtherobotic Limbers Mako John Dr system Bookings essential: Bookings Wed 5thSep Wed 25thJul Wed 23rd May Wed 30thMay Wed 2ndMay GP Conferences 2018 FREE Public 2018–All Seminars Welcome 9487 9871 P:9487 Neuropathy research presentation Upper GI/Pancreatic Surgical Management TBC TBC Family Health Family Health Women’s Health CareEmergency The Future ofRobotics E: [email protected] E: NSW Governement’s of Office isabronzeSan memberofthe business development, the a commitment to sustainable Recognised for demonstrating (6.15pm for 7pmstart)