Figure 1: Aneurysm anatomy. Occluded left iliac system and large inferior mesenteric artery supplying pelvis and left leg. Custom aortic graft overlayed over anatomy.

Figure 2: Sealed aneurysm with custom graft and stenting into the inferior mesenteric artery. Flow preserved into pelvis.

AUTUMN 2021

Dr Saissan Rajendran is a minimally invasive vascular surgeon who has undertaken complex endovascular fellowships at St George’s NHS London and Policlino Abano Terme Italy. Dr Rajendran is committed in performing the right operation safely and in the least invasive way possible. P: 8411 3802 F: 8998 6907 E: admin@centralsydneyvascular.com.au

Dr SAiSSAN rajenDran MBBS, MS (Vasc), GDAAD, FRACS (Vasc), DDU

SanDoctor

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.

Complex Endovascular Aortic Stenting for Aneurysm Disease

Treatment of aortic aneurysm disease was, until the advent of modern surgery, impossible, but surgeons never stopped innovating and trying; wrapping, reinforcing, ligating, and even primitive endovascular methods of embolising were all attempted. Real progress did not occur until the modern era when open surgical repair became the standard of care. The well-known high risks of open aneurysm surgery led inquisitive surgical minds to ponder whether or not repair could be performed intraluminal without the need to open the abdomen. The idea of replacing open repair by “endovascular aneurysm repair” (EVAR) had been explored at several centres as early as the mid 1980s with EVAR repair being initially described by Volodos in 1986. in 1991, Juan Parodi published his experience with retrograde deployment through the femoral arteries of a stent-anchored, Dacron-prosthetic graft that would act to depressurize the aneurysm sac and thus reduce the risk of aneurysm rupture. From there, the field of vascular surgery was radically transformed, and the era of EVAR was born. The idea of EVAR spread quickly to Australia’s East Coast, where the late Geoff White and Jim May introduced their own tubular stent graft with metal fixation elements. Perth, Western Australia also became a hotbed of endograft innovation when Michael Lawrence-Brown and David Hartley not only introduced EVAR but also contributed significantly to its development by creating their own stent graft systems. With the constant improvement of stent graft design, from a straight aortic tube graft to the aorto-uni-iliac stent graft and then further to the modular aorto-bi-iliac stent graft, it became obvious that preserving the flow to the aortic branches, especially the renal arteries, was crucial when aiming at a secure and durable seal in the short segment of the normal aorta between the renal arteries and AAAs. This led to the development of the fenestrated graft and the first fenestrated stent graft to a renal artery in a patient was performed by John Anderson in Adelaide, Australia, in 1998. From then the era of complex endovascular stenting for aneurysm disease was born. Development of multibranched devices for thoraco-abdominal aortic aneurysms by adding side branches to a tubular stent graft with a reduced diameter at the level of the visceral arteries further added to our ability to treat extensive aneurysm disease which would have required open repair with cardiopulmonary bypass techniques. Here we present a case of a 70-year-old male who presented with an incidental 6cm infrarenal aneurysm. His left common iliac artery was occluded and his entire left leg circulation was supplied from a large inferior mesenteric artery that arose from the arterial wall of the aneurysm measuring 8mm (Figure 1). His background history included heart failure with an ejection fraction of 40% and COPD, making him a poor candidate for open surgery. Tranditional endovascular treatment would have entailed an aorto-uni iliac graft with a subsequent open right to left femoral bypass graft. Utilising modern endovascular techniques and manufacturing, Cook medical was able to design a custom aorto-uni iliac graft

with an 8mm downward facing inferior mesenteric side branch for us to access and stent into (Figure 2). This was performed through axillary artery access. Our ability to do this enabled this patient to preserve their natural anatomy and seal their aneurysm without the need for any open bypasses. The patient had no lower limb ischaemia at the end of the case.The development and evolution of EVAR to become the worldwide treatment of choice is a classic example of the power of that elegant simplicity and of the human impulse to invent and create. Today with complex endovascular techniques we are able to achieve outcomes that would not have been possible, if it was not for the vision of Volodos 35 years ago and the rapid uphill technological progress made. References available on request.

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OverviewMany patients undergoing a total hip or knee replacement now access their rehabilitation program from their home environment. Patients leave the hospital as early as Day 4 and attend a rehabilitation hospital for their therapies, or therapists may treat patients at their homes – either in person or via telehealth. Medical and nursing care are not always involved in a program, although its safety depends on a successful shared-care arrangement involving GPs. There are no evidence-based standards for what should be included in arthroplasty rehabilitation programs with significant variability between providers. it is up to each provider to ensure that their programs meet the individual care and therapy needs.

Therapy needsThe therapy needs in arthroplasty rehabilitation are predictable and well-defined. Many providers include pre-operative education

and home equipment review. Physical therapy involves gait aid training, increasing active joint range of motion, and strengthening. By discharge from the program, gait aids are weaned with gait retraining for a normal reciprocal gait pattern on all terrains and stairs. Multidisciplinary education and equipment prescription are essential for preventing falls, overuse injuries, wound complications and haemarthrosis in the early recovery period. in knee replacements, patients require active monitoring and motivation to avoid developing a ‘stiff knee’ from kinesiophobia in the setting of post-operative pain and swelling. Patients will require frequent review for medication titration to continue therapy,

especially patients with pre-operative chronic pain, neuropathic pain or trauma. Pain is less problematic in hip replacements, but patients require cognitive skills and adaptability to maintain various hip precautions, which last for six week.

Care needsThe more challenging aspect of arthroplasty rehabilitation from home is the care needs. The care or ‘survival’ needs arise from individual and social factors. in the World Health Organization’s international Classification of Functioning, Disability and Health (iCF), these are the Personal Factors and Environmental Factors that act as barriers or facilitators to functioning and disability. Patients can experience significant post-operative problems because of their pre-existing cognitive, psychological, physical and self-efficacy skills. Patients living in a home environment with stairs, steep terrains, narrow doorways, or small bathrooms may find it difficult to manage at

home. Patients who live alone or provide care for others will likely require external services to address the complex personal, domestic and community care needs while recovering. Medical restrictions for driving for four to six weeks usually exacerbate the problems. GPs play an important part in advocating for patients who may require a period of 24-hour nursing care in the hospital environment in inpatient rehabilitation units or need formal services (e.g. personal care, domestic care, transport and meals) in place before discharge.

wOund CarePost-operative dressings should be left intact for ten to fourteen day as instructed. Fraying edges require reinforcement with waterproof

films. Any significant oozing requires close monitoring. A decision to redress the wound depends on the discharge type and volume. if the dressing is replaced due to oozing, a swab should be taken for microbiology, culture and sensitivities, and redressed with a waterproof dressing using an aseptic technique. A delayed ooze from the incision site is always a concern and requires empirical antibiotic therapy in consultation with the surgeon. A period of protected weight-bearing, rest and review of anticoagulants may be required for significant oozing.

venOus ThrOmbOembOlism (vTe) prOphylaxisPatients will have VTE prophylaxis in place for the first two to five weeks, depending on the surgical protocols and personal risk factors. Patients require clinical monitoring for VTE symptoms. Dependent oedema is common and may be difficult to distinguish from deep vein thrombosis. VTE treatment after arthroplasty is always challenging. Therapeutic anticoagluation risks include haemoarthrosis and requires careful titration of therapies and weight-bearing in consultation with the surgeon.

pain managemenTPatients are discharged to home on a combination of analgesics. Cryotherapy and oedema management makes a significant difference. Analgesic requirements should not increase after discharge from the hospital, although sometimes this reflects the cessation of some medications on discharge. Patients should expect “pain control” and improvement in pain levels over the subsequent two to four weeks. Patients should expect to stop most analgesics by this time. Common causes of increased pain are excessive walking, inadequate use of crutches and oedema. Haemarthrosis, infections and thrombosis should be considered as possible differential diagnoses. Back pain is often aggravated by antalgic gait patterns or unsafe transfer techniques.

OTher issuesPatients often complain of fatigue, nocturia, insomnia, nausea and constipation. Nocturia usually reflects daytime hypotension and redistribution of fluids at night, but urinary tract infections can occur following indwelling catheters. Optimising pain medications should improve sleep without hypnotics. Fatigue without insomnia should prompt review of analgesics and anaemia. Nausea is usually related to constipation and medication side effects, but it could be caused by a urinary tract infection or gastritis with non-steroidal anti-inflammatory drugs (NSAiDs).

References available on request.

Shared-care for Arthroplasty Rehabilitation

Dr Pearl Chung is a rehabilitation physician and clinician-researcher at the Sydney Adventist Hospital. She is the Clinical Director at San Rehabilitation Service, which consists of the inpatient and outpatient (Day Only Rehabilitation) program for orthopaedic rehabilitation. Dr Chung is also a clinician and researcher in traumatic brain injury and concussion. She consults at Suite 118, Parkway San Clinic.P: 9171 2273 E: reception@drpearlchung.com.au

Dr PEARL Chung MBBS, FAFRM, PhD, MPH, BMedSci

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Kawasaki disease is an acute vasculitis of childhood that affects medium-sized arteries, in particular the coronary arteries, leading to the development of coronary artery aneurysms in a quarter of untreated cases. it is the leading cause of childhood acquired heart disease in developed countries. Many children with Kawasaki disease present to GPs and paediatricians with varied symptoms and prompt diagnosis and treatment is needed to reduce the risk of long-term coronary artery damage. it is therefore important to have a high index of suspicion for this condition when children present with prolonged febrile illnesses.

CliniCal and paThOlOgiCal maniFesTaTiOns Kawasaki disease predominantly affects children under five years of age. The aetiology is unknown but it may occur in children with a genetic predisposition who experience a trigger event, possibly a viral illness, which then leads to abnormal inflammatory responses. A recent model of vasculopathy has proposed three linked pathological processes which include necrotizing arteritis (destroying the arterial wall and causing aneurysms), subacute/chronic vasculitis and myofibroblastic proliferation, which can cause progressive arterial stenosis. There is no pathognomonic test and diagnosis is often delayed or missed as it relies on clinical features, many of which are common in children with fever due to other causes. Children may be very irritable and the picture may be complicated by co-occurrence of upper respiratory symptoms, arthralgia and abdominal pain. The criteria for diagnosis include at least five days of fever as well as the presence of at least four out of the following five clinical features: • Bilateral nonpurulent conjunctivitis • Oral mucosal changes including cracked

lips and strawberry tongue • Redness and oedema of the hands or feet

followed by possible desquamation • Polymorphous skin rash • Cervical lymphadenopathy, often unilateral

with nodes measuring >1.5cmSome patients may present with fever but only meet two/three of these criteria and are diagnosed with “incomplete” Kawasaki disease. This is more prevalent in infants, the age group with higher incidence of cardiac sequelae. Therefore, this should be considered even in the absence of all the clinical features. As there is no “gold standard” test, diagnosis can’t be evidence based but is based on informed opinions and consensus statements such as the

recent guidelines from the American Heart Association (Circulation 2017;135:e927-999).

diFFiCulTies in diagnOsisEarly features may mimic other self-limiting febrile illnesses complicating diagnosis. Microbiologically confirmed concurrent viral infections may be present in one-third of cases and rashes may be mistaken for drug reactions following antibiotic treatment for presumed lymphadenitis. important differential diagnoses include toxic shock syndrome, staphylococcal scalded skin syndrome and streptococcal infections, particularly scarlet fever.Certain laboratory findings such as leukocytosis, raised ESR and CRP, hypoalbuminaemia, thrombocytosis and

mildly raised liver enzymes are characteristic but none have high positive predictive values and referral should not be delayed while awaiting results if there is reasonable clinical suspicion.

TreaTmenT OF KawasaKi diseasePrompt treatment with intravenous immunoglobulin(iViG) has reduced the incidence of coronary artery aneurysms from approximately 25% to 4% and should be administered as soon as possible, ideally within 10 days of fever onset. Treatment usually leads to rapid fever resolution and clinical improvement in the majority but if there is no response to initial dosing then further iViG may be administered and consideration given to the use of iV steroids

continued on page 7

Kawasaki Disease: What is it and why is it important to diagnose it?

Dr Irving is a paediatric cardiologist based at Children’s Hospital Westmead and Sydney Children’s Hospital Randwick. Dr Irving looks after children with all forms of congenital and acquired heart disease and has subspecialty interests in the management of paediatric heart failure, cardiomyopathy and in paediatric cardiac transplantation. Dr Irving also has clinics at the San Clinic and the Northern Beaches Hospital. P: 9982 8300 F: 9971 1594 E: admin@cardiologycentre.com.au

Dr CLAiRE IrvIng MBChB, DCH, MRCPCH(UK), FRACP

Figure 1: Normal coronary arteries on echocardiogram.

Figure 2: Left sided coronary aneurysms.

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Barrett’s oesophagus is defined as metaplasia from squamous epithelium to columnar epithelium with goblet cells. it is most commonly associated with Gastro-oesophageal reflux disease (GORD), as the exposure of the oesophageal epithelium to a chronic irritant leads to chronic in-flammation and metaplasia. There is clinical concern for Barrett’s oesophagus due to its association with oesophageal adenocarcinoma where risk of developing is approximately 0.1-0.5% per year in non-dysplastic Barrett’s oesophagus. The risk corresponds with increased levels of dysplasia, rising to 1.1-6%/year for low grade dysplasia and 23-60%/year for high grade dysplasia (HGD)(4). There has been a rising level of detection of Barrett’s oesophagus in Australia recently, which may be due to increased number of upper endoscopies performed1, 6.in addition to GORD main risk factors for Barrett’s oesophagus include central adiposity, smoking, male sex, Caucasian background and increased age1.

diagnOsisDiagnosis of Barrett’s oesophagus is by upper endoscopy and histopathology of intestinal metaplasia with goblet cells of tubular oesophagus. Population screening is not considered to be cost-effective, but can be considered for those with GORD and risk factors such as age over 50, male sex, obesity and Caucasian background5.Frequency of endoscopic surveillance depends on the length of Barrett’s oesophagus and degree of dysplasia. if the maximal length of Barrett’s oesophagus (no dysplasia) is less

than 3cm, endoscopy should be repeated in 3-5 years. if greater than 3cm then repeat endoscopy in 2-3 years. However the presence of dysplasia warrants earlier review and consideration for endoscopic resection or ablation. Low grade dysplasia should be followed with repeat endoscopy in 6 months with consideration for further intervention if low grade dysplasia persists. Patients with Barrett’s and high grade dysplasia should also

be referred to an interventional endoscopist and confirmation of histopathology by a second pathologist 3, 5, 6.

TreaTmenTLifestyle advice has traditionally consisted of avoiding foods that worsen reflux such as alcohol, coffee, carbonated beverages, and acidic juices, and behavioural changes such as avoiding meals before bed. However the evidence for the impact of these on the progression of disease is low or variable2.Those with low grade dysplasia should undergo routine 6 monthly surveillance. For those with high grade dysplasia, the presence of visible nodularity requires resection, whereas flat HGD can be treated with ablation or resection. it is essential to treat the entire Barrett’s segment once high grade dysplasia is identified. Patients are followed up with regular surveillance to monitor for recurrence or complications of treatment such as stricture formation1, 5.Patients with Barrett’s oesophagus should also be started on a proton pump inhibitor even in the case of endoscopic ablation. The attached algorithm is a good guideline, and any concerns should be discussed at an MDT meeting. rOle OF surgeryWhen oesophagitis persists despite medical therapy, surgical therapy in the form of fundoplication can then be considered.

Current Multidisciplinary Approach of Patients with Barrett’s Oesophagus

Dr. Christos Apostolou is a specialist upper gastrointestinal, liver, pancreatic and biliary surgeon with special interests in laparoscopic/robotic surgery, malignancy and anti-reflux surgery. He’s the clinical lead in Upper GI Surgery at the San and a Board Member of the ANZHPBA. P: 9480 4250 W: www.christosapostolou.com.au

Dr. CHRiSTOS apoStolou FRACS

Dr. Saurabh Gupta is an interventional gastroenterologist, specialising in advanced diagnostic and therapeutic endoscopic procedures particularly HPB disease including therapeutic EUS and ERCP, endoscopic resection of neoplasia, obesity endotherapy and small bowel disorders. P: 8921 9188 E: admin@nsgastro.com.au W: www.nsgastro.com.au

Dr. SAURABH gupta MBBS (HONS) FRACP

Figure 1: Barrett’s Mucosa on Endoscopy.

Figure 2: Endoscopic Mucosectomy Resection.

Figure 3: Focal Radio Frequency Ablation.

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Dr. Helen Quach is a general surgery registrar at the Sydney Adventist Hospital, currently undertaking a Masters of Surgery with the University of Sydney.

Dr. HELEN QuaCh B MED/MD

Current Multidisciplinary Approach of Patients with Barrett’s Oesophagus

This will not lead to regression of the metaplasia but can prevent progression of dysplasia or malignancy through reflux control and diminished irritation of the metaplastic epithelium. Younger patients may also prefer surgery to long-term PPi use and associated side effects provided their surgical risk profile is acceptable.in the case of failure of endoscopic techniques, oesophagectomy is the final option3, 5, 6. Oesophagectomy is indicated in inadvertent diagnosis of early cancer in treatment of high grade dysplasia, after discussion in the MDT setting.summaryThe care of patients with Barrett’s oeosphagus is multifaceted and involves appropriate investigation for diagnosis and surveillance where appropriate, modification of risk factors at the primary care level and multidisciplinary management in complicated disease and significant malignant risk.

References available on request.

Dr. SAURABH gupta MBBS (HONS) FRACP

Barrett’s Dysplasia con�rmed on history by 2 independent pathologists

Barrett’s Dysplasia Algorithm

Inde�nite for Dysplasia Low Grade Dysplasia High Grade Dysplasia

Repeat OGD in 6 months with maximal acid suppression

Repeat OGD in 6 months with maximal acid suppression

No Low Grade Dysplasia on 2 consecutive OGDs

Low Grade Dysplasia con�rmed on both OGDs

sMDT review

Management review in clinic prior to any endoscopic intervention

OGD in tertiary referral centre

Flat mucosa Macroscopically visible lesion

Endoscopic Resection +/- CT

Re-review at sMDT for RFA v surgery depending

on EMR histology

Schedule for RFA therapy

No de�nite Dysplasia De�nite Dysplasia

Return to standard Barrett’s surveillance

Follow LGD or HGD Flow chart

Figure 4: Nissen/360 degree Fundoplication.

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inTrOduCTiOnBody contouring surgery has recently developed as a sub-specialty in plastic surgery as a result of the current obesity epidemic. Patients are increasingly presenting with contour abnormalities and loose skin after massive weight loss. Body contouring surgery involves reshaping a patient’s trunk and limbs in conjunction with excision of excess skin and underlying soft tissue. Most often the underlying musculo-aponeurotic system is also reconstructed and strengthened.Typical patients have undergone bariatric surgery such as a gastric sleeve or intestinal bypass; however some have achieved massive weight loss through a regimen of diet and exercise.The ideal candidate for body contouring surgery should have reached and maintained a stable target weight for several months. This is managed by their bariatric surgeon and general practitioner.

preparaTiOn FOr surgeryNutritional programs are important to stabilise and optimise a patient’s metabolism and weight before surgery. This is to ensure that wound healing is optimal and complication free. Deficiencies in vitamins and minerals must be corrected before surgery. Protein, in particular albumin, iron and vitamins A, D, E and K are commonly deficient in patients who have experienced massive weight loss. Major medical conditions are carefully considered before surgery is contemplated. Any history of thrombotic events and smoking is also important to manage to ensure post-operative complications are minimised. Patients are also screened for any potential psychological or psychiatric disorders which may manifest as body dysmorphic syndrome. it is essential to counsel each patient prior to surgery to ensure that they have realistic expectations in regard to what can be achieved through body contouring.

saFeTyPatients are at risk of hypothermia and venous thromboembolism because of the length of some procedures undertaken. Staging of body contouring procedures is extremely important to reduce the length of the procedures and to reduce the risks associated with prolonged surgery. This allows the patient to manage their post-operative recovery and return to normal activities as soon as possible, hopefully free of complications. All patients require a group and hold because of the risk of post-operative haemorrhage.

anaTOmy Body contouring relies on the superficial fascial system supporting the fat, anchoring the skin to the underlying structures. This reduces wound tension and allows the surgeon to achieve aesthetically pleasing results. surgeryPatient needs are individual and surgery is designed to address the specific areas of concern for each patient.The most common procedure is an abdominoplasty. The musculo-aponeurotic system is plicated thereby improving the patient’s ability to optimize their posture and core strength. There are a variety of abdominoplasty techniques depending on the distribution of loose skin. An abdominoplasty may be performed in combination with a belt lipectomy if indicated. This procedure involves excision

of skin and fat circumferentially around the trunk. it is also common to augment the gluteal region (butt lift) at the same time.Another frequently addressed area is the mons pubis region. This area requires rejuvenation because of problematic laxity which causes difficulty with hygiene and can result in social embarrassment.The arms are a common area of concern, particularly for women after massive weight loss. A brachioplasty combines excision of loose skin and liposuction to achieve a satisfactory contour. Brachioplasty can extend into the axilla where a Z -Plasty can be necessary to ensure there is no impairment of shoulder mobility.

Chest wall laxity is also common after massive weight loss in both men and women. This can be addressed in women with a breast lift or breast reduction. Breasts are ptotic and appear deflated after massive

Body Contouring Surgery

Dr Peter Laniewski is a specialist plastic surgeon who specialises in body contouring and facial aesthetic surgery with a special interest in post-mastectomy breast reconstruction, microsurgery, skin cancer and hand surgery. He is the supervisor of advanced training at Westmead Hospital and has held an appointment at the Sydney Adventist Hospital since 2006. He can be contacted at his Bella Vista consulting rooms.P: 8824 8481 E: reception@drpeter.com.au W: www.drpeter.com.au

Dr PETER lanIewSkI MBBS (UNSW) FRACS

Image 1: Before abdominoplasty.

Image 1a: After abdominoplasty.

Image 2: Before brachioplasty.

Image 2a: After brachioplasty.

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weight loss. Male chest surgery is somewhat more challenging and requires excision of a large amount of skin with nipple-areola repositioning.Loose skin in the lower limbs is also

problematic and typically requires a medial thigh lift to rejuvenate this area. This can be achieved usually through an incision through the groin or a vertical incision to allow tightening circumferential of the entire thigh.

COmbining prOCedures There are various favourable combinations of procedures. A breast procedure can be combined with one other procedure depending on patient preference - belt lipectomy, abdominoplasty, brachioplasty or thigh surgery. it is important to discourage patients from having multiple procedures that will compromise their recovery, mobility and return to normal activity. it is usual to wait 3 months between staged procedures.

COnClusiOn Body contouring has a tremendous impact and can be described as ‘life changing’. Strategic planning is important to ensure patient safety throughout their surgical journey and to ensure that individual results are optimised and complication free.it is vitally important that patients have realistic goals, and a thorough understanding of what can be achieved by body contouring procedures.

References available on request.

References available on request.

Image 3: Before breast reduction. Image 3a: After breast reduction.

and other agents such as infliximab. Prompt consultation with paediatric immunologist/infectious disease or rheumatology teams may be needed and these patients should all be managed in in-patient paediatric settings. Following resolution of fever, all patients are started on aspirin as an ‘anti-platelet’ agent for at least 6-8 weeks or longer if there is evidence of coronary involvement.

CardiaC invesTigaTiOns and managemenTThe mainstay of cardiac diagnosis is echocardiography which should be performed either during the acute presentation or within a few weeks. Normal coronary anatomy should be identified

(Figure 1) and an assessment made of ventricular function, valvular regurgitation and pericardial effusion. Occasionally large aneurysms may be seen at presentation (Figure 2) but they are usually not evident until later in the course of the illness. Features looked for include coronary artery ectasia/dilatation (Figure 3), perivascular brightness and lack of normal coronary artery tapering. There may be myocardial dysfunction. Serial echocardiograms are performed to monitor progression and long-term treatment is guided by the presence/extent of coronary artery involvement. Although aspirin may be stopped by 6-12 weeks in the absence of abnormal echocardiographic findings, some children need long-term treatment

with aspirin or, if large aneurysms, other anticoagulants including Warfarin. Duration of therapy and need for other investigations, including CT or catheter-based coronary angiography, exercise stress testing and stress echocardiography is guided by risk-stratified recommendations based usually on the size and z-scores of coronary aneurysms if present.

OTher COnsideraTiOnsiViG administration may interfere with efficacy of live vaccines, which should be delayed for 11 months after treatment and parents and primary care providers need to be aware of this. Parents should be reassured that the illness is not contagious, that most children recover fully without long-term sequelae but occasionally ongoing care by a paediatric cardiologist is needed. The long-term effect of Kawasaki disease on the risk for adult coronary artery disease is unclear and therefore counselling of families about the potential for long-term cardiovascular risk and minimization of modifiable risk factors such as smoking and other lifestyle measures should be undertaken. in summary, it is important to consider the diagnosis of Kawasaki disease in children who present with prolonged fevers and some of the listed clinical features even if the full spectrum of manifestations is not present. Children with suspicion for Kawasaki disease should be referred to a paediatric cardiologist early but prompt treatment with iViG should not be delayed while an echocardiographic assessment is awaited. Ongoing management and treatment is based on the rapidity of fever resolution and the presence or absence of coronary artery dilatation or aneurysms. GPs should therefore have a low threshold for referral to paediatric services and a high index of suspicion for this condition when faced with the irritable, persistently febrile toddler, even if a viral cause is felt to be likely.

Figure 3: Dilated left coronary artery.

Kawasaki disease continued from page 3.

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newS from adventist healthCare

A/Prof Payal Mukherjee with Dr Michelle Atkinson.12

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San Easter Bunny with San Staff.

To wish everyone a happy easter the San had a special visitor. The Easter Bunny surprised both patients and staff, bringing smiles and joy to all. You can see more photos from the San’s Easter Bunny visit here www.sah.org.au/news-easterbunny

san Obstetrician and gynaecologist dr John Keogh has recently launched ‘My Sister’s Baby’. The initiative hopes to raise awareness of the many difficulties women face in pregnancy and childbirth in lower and middle income countries. Their aim is to help raise funds for groups who are already doing the work on the ground but whose capacity is limited by resources. Find out more about ‘My Sister’s Baby’ by visiting the website See: www.mysistersbaby.com.au

sydney adventist hospital is recognised as a Centre of excellence in Left Atrial Appendage (LAA) Closure procedures. in March, San interventional cardiologists Dr Jason Sharp and Dr Dennis Wang facilitated the first of four Centre of Excellence in Left Atrial Appendage (LAA) meetings to be held this year. Cardiologists visit the San for specialist training in LAA from our doctors who are globally recognised leaders in this field. This recent meeting included the observation of a number of cases of left atrial appendage closure in the San’s Cardiac Catheterisation Laboratory. The first attendees of the year were cardiologists Dr David Russel and Dr Heath Adams both visiting from Royal Hobart Hospital, and Dr Chadi Ayoub visiting from Concord Hospital. See: www.sah.org.au/news-LAA

newlY aCCreDIteD DoCtorS a/professor Craig lynch MBChB, MMedSci, FRACS, FCSSANZ, FASCRS(INT)A/Prof Lynch is a colorectal surgeon, with extensive robotic and laparoscopic surgery experience. He has recently moved from the Peter MacCallum in Melbourne. A/Prof Lynch’s interests are managing colorectal cancer, especially advanced and peritoneal disease; hernia repair; colonoscopy and haemorrhoid surgery. P: 0405 435 743 E: craig@craiglynch.com.au W: www.roboticcolorectalsurgery.com.au

a/professor Sumit raniga Sc, MSc (1st Hons), MBChB, FRACS, FAOrthAA/Prof Sumit Raniga is an orthopaedic shoulder and elbow surgeon with three years of dedicated clinical and research fellowships in world renowned centres of excellence, while also being the first and only Fellow of the RACS to be awarded the prestigious Charles S. Neer Award for research in the field of shoulder surgery by the American Shoulder and Elbow Society. A/Prof Raniga is an outstanding communicator who is trained to provide the highest standard of evidence-based management and surgical treatment of shoulder and elbow problems with compassion and empathy. P: 9812 3583 E: enquiries@shoulderandelbowspecialist.com.au W: www.shoulderandelbowspecialist.com.au

Dr Charley Zheng MBBS (UNSW), FRANZCOGDr Charley Zheng has had extensive experience in the field of obstetrics and gynaecology. in addition to specialist training he has furthered his career by advancing his abilities and knowledge in the fields of reproductive/infertility medicine and laparoscopic surgery. Dr Zheng has special interest in poor responders, medical conditions in pregnancy, endometriosis and recurrent miscarriage. P: 8004 5960 E: referral@dr.com W: www.drzheng.com.au

Dr Sudarshan paramsothy BSc(Med), MBBS (Hons Class 1), MRCP (UK), FRACP, PhDDr Sudarshan Paramsothy is a highly accomplished, Australian trained but internationally credentialed and awarded gastroenterologist and hepatologist. He is well versed in, and treats all aspects of general gastrointestinal disorders. Dr Paramsothy’s subspecialty expertise is inflammatory bowel disease (iBD), with other clinical interests including high-quality bowel cancer surveillance and functional gastrointestinal disorders such as irritable bowel syndrome. He was recently awarded a prestigious NHMRC investigator Grant (2021-2025) for his academic endeavours. P: 8921 9188 E: admin@nsgastro.com.au W: www.nsgastro.com.au

Dr Sam Daniels MBBS, FRANZCOG, MMinInvSDr Daniels has undergone three additional years of fellowship training in complex gynaecological surgery and has special interests in advanced endoscopic surgery, endometriosis, pelvic floor prolapse and non-mesh alternatives for Stress incontinence. P: 1300 885 803 E: drsam@thesagecentre.com.au W: www.thesagecentre.com.au

in celebration of international women’s week in march 2021, the Royal Australasian College of Surgeons (RACS) and Women NSW held an event to address the barriers and practices that affect female surgeons. RACS have been proactive in increasing the representation of women on their boards and committees. Currently 35% of RACS committees and boards are women, however only 14% of fellows are female. San surgeons who attended the event included ENT surgeon Associate Professor Payal Mukherjee as RACS Chair, Orthopaedic Surgeon Dr Michelle Atkinson as RACS Deputy Chair, Cardiothoracic Surgeon Dr Emily Granger, Vascular Surgeon Dr Upeksha De Silva, See: www.sah.org.au/news-intlwomensweek

Dr John Keogh launches My Sister’s Baby initiative.

San interventional cardiologists Dr Dennis Wang and Dr Jason Sharp, with visiting doctors Heath Adams, Chadi Ayoub, and David Russel.

Some members of the San Cyclists Team.

Congratulations to our san Cyclists Team that competed in this year’s Bobbin Head Cycle Classic. The team fundraised over $4,287.00 for Lifeline Australia. The team ranked third out of all the registered teams for the most funds raised. See: www.sah.org.au/news-bobbo2021

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Sydney Adventist Hospital

• July 14th – Pain Webinar • September 15th – Orthopaedics Webinar • October 26th – Neurology Webinar • November 24th – Gastroenterology Webinar

Upcoming GP Webinars

Dates, topics, speaker and registration information available at www.sah.org.au/event-calendar