bluuebunny/crossref_metadata_2025 huggingface dataset:
Frequency of early colorectal cancer in patients undergoing colonoscopy
Authors: Smith G A , Oien K A , O'Dwyer P J
Published: March 2003

Background

Early colorectal cancer is defined as carcinoma limited to the mucosa or submucosa. Up to 20 per cent of all colorectal cancers treated in some Japanese institutions are early cancers. These cancers are sometimes flat or depressed, and may be less than 1 cm in diameter. The aim of this study was to identify the frequency and morphology of early colonic cancers detected at colonoscopy by a surgeon aware of and looking for such lesions.

Methods

A review was made of all colonoscopies performed by or under the supervision of a single endoscopist between 1990 and 1998. Follow-up and outcome of all patients with early colorectal cancer was undertaken.

Results

Ninety-five invasive colorectal cancers were identified from 2198 colonoscopies. Eighteen were early colorectal cancers (T1). Macroscopically these were flat (nine tumours), villous (four) and pedunculated (five). Two patients had lymph node metastasis. The median size of flat cancers was 20 (range 9–30) mm. Median follow-up was 3 years. One patient had local recurrence, and another, whose early cancer was metachronous, died from metastatic cancer.

Conclusion

This study identified early colonic cancer with similar frequency and morphology to that reported by the Japanese. Colonoscopy should be considered as the investigation of choice for patients with large bowel symptoms.
Evidence that metastasis is less common in cirrhotic than normal liver: a systematic review of post-mortem case–control studies
Authors: Seymour K , Charnley R M
Published: March 2003

Background

It has been hypothesized that the cirrhotic liver is afforded protection against metastasis. The evidence has been examined and the plausibility of such a phenomenon is reviewed.

Methods

A systematic literature review was conducted with analysis of combined data from post-mortem case–control studies.

Results

Overall, the crude rate of metastasis to normal liver was 37·3 per cent, while the rate to cirrhotic liver was 23·7 per cent. The Mantel–Haenszel (MH) fixed-effects estimate of the odds ratio was 0·47 (95 per cent confidence interval (c.i.) 0·41–0·53; χ2 = 136, 11 d.f., P < 0·001). The DerSimonian–Laird (DL) random-effects estimation of the odds ratio was 0·42 (95 per cent c.i. 0·31–0·58; χ2 = 28, 1 d.f., P < 0·001). For tumours arising within the distribution of the portal vein, the crude rate of metastasis to normal liver was 47·6 per cent, whereas the rate to cirrhotic liver was 29·8 per cent. The MH estimate of the odds ratio was 0·45 (95 per cent c.i. 0·37–0·54; χ2 = 68·2, 5 d.f., P < 0·001). The DL pooled odds ratio was 0·44 (95 per cent c.i. 0·28–0·70; χ2 = 12·3, 1 d.f., P < 0·001). The MH and DL pooled estimates of the odds ratio were similar for groups of patients from the East (Japan) and the West (Europe and the USA).

Conclusion

The post-mortem evidence reviewed suggests that the likelihood of metastasis to the cirrhotic liver is lower than that to normal liver. The degree of protection for tumours arising from within the distribution of the portal vein is neither greater nor less than it is overall. Eastern and Western populations appear to have a similar degree of risk reduction. The differences noted were significant on testing in the meta-analysis, but confounding bias accounting for these differences has not been excluded.
Survival of patients with colorectal cancer diagnosed in a randomized controlled trial of faecal occult blood screening
Authors: Mapp T J , Hardcastle J D , Moss S M , Robinson M H E
Published: March 2003

Background

Analysis of survival of subjects with colorectal cancer diagnosed by different modalities can provide insight into the mechanism by which screening has an effect. It can also give an indication of the feasibility of using prognostic indicators as surrogate outcome measures to predict mortality in future studies.

Methods

This paper examines the survival of individuals with colorectal cancer diagnosed in the Nottingham trial and explores the role of selected prognostic factors as possible surrogate outcome measures.

Results

Survival was significantly better in subjects with screen-detected cancers than in controls, even after adjusting for tumour stage and accounting for lead-time bias. Survival was inversely related to stage of tumour, with patients with stage A tumours having the best survival. Subjects with well or moderately differentiated tumours had a significantly better survival than those with poorly differentiated tumours.

Conclusion

Screening for colorectal cancer by means of faecal occult blood testing improved survival among subjects with screen-detected cancers. Differences in prognostic factors largely explain the differences in survival between both non-responders and subjects with interval cancers and those in the control group, but not the improved prognosis for patients with screen-detected cancers. The use of such factors as surrogate outcome measures may therefore be inappropriate.
Prospective study of primary anastomosis without colonic lavage for patients with an obstructed left colon
Authors: Naraynsingh V , Rampaul R , Maharaj D , Kuruvilla T , Ramcharan K , Pouchet B
Published: March 2003

Background

Traditionally, left-sided colon obstruction is managed by a multistaged defunctioning colostomy and resection. However, there is growing acceptance of one-stage primary resection and anastomosis with on-table antegrade irrigation. This paper presents a series of patients managed prospectively by primary anastomosis without intraoperative colonic lavage.

Methods

Emergency resection of acutely obstructed left-sided colonic carcinomas was performed. This was followed by primary anastomosis without on-table lavage after bowel decompression using a new technique.

Results

Fifty-eight consecutive, unselected patients underwent bowel decompression, resection and primary colocolic anastomosis. Only one patient developed a leak at the anastomotic site, requiring pelvic abscess drainage and transverse loop colostomy. One death occurred 12 h following surgery. Autopsy confirmed that this was due to myocardial infarction. Mean hospital stay was 9·8 days.

Conclusion

Emergency surgery on the obstructed left colon can be carried out safely after decompression alone, without intraoperative colonic lavage.
Early evaluation of renal reperfusion injury after prolonged cold storage using proton nuclear magnetic resonance spectroscopy
Authors: Hauet T , Goujon J M , Tallineau C , Carretier M , Eugene M
Published: March 2003

Background

Proton nuclear magnetic resonance (NMR) spectroscopy can be used as a non-invasive tool to measure renal damage. In the present investigation, proton NMR spectroscopy of urine was assessed in order to detect cellular damage after different periods of cold ischaemia in two standard preservation solutions.

Methods

The isolated perfused pig kidney was used to assess initial renal function after in situ cold flush and cold storage (CS) for 24 or 48 h in two standard preservation solutions: EuroCollins (EC) and University of Wisconsin (UW) solutions. Kidneys flushed with cold heparinized saline and immediately perfused were used as a control group. Kidneys were perfused for 2 h at 37·5°C for functional evaluation. During reperfusion, renal perfusion flow rate was measured. Glomerular filtration rate (GFR), tubular reabsorption of sodium ions, and lactate dehydrogenase (LDH) and N-acetyl-β-d-glucosaminidase (NAG) excretion were determined. Impairment caused by ischaemia and reperfusion was also determined by histological techniques and proton NMR spectroscopy.

Results

The perfusion flow rate, GFR and tubular reabsorption of sodium were significantly decreased in experimental groups compared with the control group. There was no significant difference between experimental groups after 24 h of CS. The perfusion flow rate was significantly decreased in the EC group after 48 h of cold ischaemia compared with that in the UW group. After 48 h of CS, GFR and tubular reabsorption of sodium were significantly reduced in the EC group compared with those in the UW group. The release of LDH into the effluent and the urinary excretion of NAG were not significantly different after 24 h of CS. After more than 45 and 60 min of reperfusion respectively, LDH and NAG excretion was no different in the 48-h CS groups. The most relevant resonances determined by proton NMR spectroscopy were of citrate, trimethylamine-N-oxide, lactate, acetate and amino acids. Excretion of these markers was significantly more accurate and efficient to assess renal ischaemia–reperfusion injury than that of biochemical markers. A resonance (P) detected particularly in the EC group after 48 h of CS was identified and correlated well with renal dysfunction. After CS for 48 h and 2 h of reperfusion, renal injury was histologically more pronounced in EC groups than in UW groups. However, the difference was not significant after CS for 24 h.

Conclusion

NMR spectroscopy, which is a non-invasive and non-destructive technique, is more accurate and efficient when assessing kidney damage after cold ischaemia and reperfusion when compared to conventional histological and biochemical analysis.
Outcome in patients with colorectal cancer managed by surgical trainees
Authors: Singh K K , Aitken R J
Published: March 2003

Background

The surgeon is an important variable that influences outcome following colorectal cancer surgery. Operative training of suitable quality and quantity is essential if intersurgeon variation is to be reduced. The aim of this study was to examine the outcome of colorectal cancer surgery when a high proportion of the operations were performed by trainee surgeons.

Methods

A prospective 7-year (1989–1996) audit of 306 consecutive colorectal cancers referred to a single general surgeon with a colorectal interest was carried out. The outcome (anastomotic leakage, 30-day mortality rate, local recurrence and cancer-related survival) of operations performed by the consultant was compared with that of his trainees.

Results

Some 245 (92·5 per cent) of 265 patients undergoing laparotomy had a resection. Seventy (28·6 per cent) and 67 (27·3 per cent) of operations were performed by supervised and independent trainees respectively. There was no difference between the consultant, supervised and independent trainees for 30-day mortality rate (6·5, 6 and 4 per cent respectively), clinical anastomotic leakage rate (9, 2 and 5 per cent) and local recurrence rate (2, 3 and 7 per cent). There was no difference between the three groups for adjusted 5-year disease-related survival rates.

Conclusion

Properly supervised trainees can resect a high proportion of colorectal cancers without compromising immediate outcome or long-term survival.

Presented in part to the annual meeting of the Association of Surgeons of Great Britain and Ireland, Bournemouth, UK, April 1997, and published in abstract form as Br J Surg 1997; 84(Suppl): 56
Partial ileal resection for hypercholesterolaemia in patients undergoing surgery for obesity
Authors: Dachtler J , Johnston D , Halstead J C , King R F G J
Published: March 2003

The Annual Scientific Meeting of the Association of Surgeons of Great Britain and Ireland was held in Brighton on 5–7 May 1999 under the Presidency of Professor R. C. N. Williamson. The abstracts of the oral and poster presentations of the original work presented at the meeting have been published in a BJS Supplement that accompanied the June 1999 issue of the Journal. The articles that follow in the present issue describe work presented at the Brighton meeting that have been accepted for publication after peer review by the Journal's referees. Other papers from this meeting will appear in subsequent issues.
Clinicopathological study of intrapelvic cancer spread to the iliac area in lower rectal adenocarcinoma by serial sectioning
Authors: Ueno H , Yamauchi C , Hase K , Ichikura T , Mochizuki H
Published: March 2003

Background

The role of iliac lymphadenectomy in surgery for rectal cancer remains unknown. Detailed clinicopathological data on lateral cancer extension may be needed to determine the true role of this procedure.

Methods

Seventy consecutive patients with low rectal cancer who underwent systematic iliac lymphadenectomy between 1991 and 1995 were reviewed. The iliac area was divided into five regions: (1) middle rectal root, (2) internal iliac, (3) obturator, (4) common iliac and (5) external iliac. Iliac lymph nodes that were cancer-free based on conventional pathological examination were serially sectioned at 100-µm intervals and re-examined for occult microscopic involvement.

Results

Occult microscopic foci were detected in five (7 per cent) of the 70 patients, and the overall incidence of lateral cancer spread was 24 per cent (17 of 70). Among patients without other sites of distant metastasis or circumferential involvement of the margin, the 5-year survival rate of those with lateral spread was 35 per cent. Although the prognosis of patients with cancer involving multiple iliac regions was poor, three of six patients with metastasis to only a single region were alive without disease at 3 years.

Conclusion

Surgeons should be aware of the possibility of localized lateral spread, including microscopic metastasis, when determining the optimum procedure for iliac lymphadenectomy in patients with rectal cancer.
24-h pH monitoring is necessary to assess acid reflux suppression in patients with Barrett's oesophagus undergoing treatment with proton pump inhibitors
Authors: Ortiz A , Martínez de Haro L F , Parrilla P , Molina J , Bermejo J , Munitiz V
Published: March 2003

Background

Control of acid reflux is the main objective of treatment for Barrett's oesophagus. However, as these patients have a reduced sensitivity to acid reflux, disappearance of symptoms may not correlate with efficient control of acid reflux. The aim of this study was to determine in a group of patients with Barrett's oesophagus whether treatment with proton pump inhibitors suppressed patho- logical acid reflux once the symptoms of reflux had been controlled and the associated inflammatory lesions cured.

Methods

Eighteen consecutive patients with Barrett's oesophagus were studied, all of whom presented with heartburn. Twenty-four-hour oesophageal pH monitoring before treatment showed pathological acid reflux in all cases: median percentage of total time with pH less than 4, 22 (range 8–52) per cent. All patients received proton pump inhibitors (dose 20–60 mg/day) until symptoms were controlled.

Results

While on therapy, pH was reduced (median percentage of total time with pH less than 4, 3 versus 22 per cent; P < 0·001). However, three patients had persistent pathological rates of acid reflux.

Conclusion

Disappearance of symptoms is not a good indicator of control of pathological acid reflux in patients with Barrett's oesophagus. Twenty-four-hour pH monitoring should be performed for proper adjustment of the dose of medication.
Improving cytological diagnosis and surgical management of parotid adenolymphoma
Authors: Lewis D R , Webb A J , Lott M F , Brookes S T , Farndon J R
Published: March 2003

Background

The role of fine-needle aspiration cytology (FNAC) in the diagnosis and management of discrete parotid swellings remains controversial. Controlled enucleation can be appropriate with accurate preoperative diagnosis. This study (1985–1995) reviewed the role of FNAC in the diagnosis and surgical management of adenolymphoma.

Methods

Review of cytological smears by two observers concentrated on the features of infarction and squamoid metaplasia. Sensitivity, interobserver and intraobserver variation were evaluated statistically in a two-run ‘blinded’ analysis of 80 cytological slides from a variety of lesions.

Results

Of 222 epithelial neoplasms of the parotid, 33 were adenolymphomas. FNAC was performed before operation in 32, producing 34 slides, and a correct cytological diagnosis was made in 21 patients. Retrospective review of the 34 slides, to examine specific features of squamoid metaplasia and infarction, improved diagnostic accuracy. The reliability and reproducibility of cytodiagnosis was confirmed by analysis of interobserver and intraobserver agreement. The sensitivity was high (0·76–0·88). Controlled enucleation was performed in 12 patients and superficial parotidectomy in 11. There were no tumour recurrences.

Conclusion

Attention to the features of squamoid metaplasia and infarction improves cytological diagnosis and directs appropriate surgical management.
Emergency cholecystostomy and subsequent cholecystectomy for acute gallstone cholecystitis in the elderly
Authors: Borzellino G , de Manzoni G , Ricci F , Castaldini G , Guglielmi A , Cordiano C
Published: March 2003

Background

The morbidity and mortality rates associated with acute cholecystitis are higher in the elderly. This study reports the results of treatment of acute cholecystitis in the elderly with emergency ultrasonographically guided percutaneous cholecystostomy followed by elective cholecystectomy after endoscopic treatment of any common bile duct stones diagnosed by percutaneous cholangiography.

Methods

From January 1989 to December 1998, 92 patients aged over 70 years were treated for acute gallstone cholecystitis. A group of 84 patients with ultrasonographic signs of severe cholecystitis or an American Society of Anesthesiologists score of II to IV were submitted to ultrasonographically guided percutaneous cholecystostomy. Transcatheter cholangiography was performed in all patients and endoscopic sphincterotomy was performed before operation in patients with common bile duct stones. After resolution of the acute phase and treatment of any associated diseases, patients were submitted to cholecystectomy.

Results

Cholecystostomy was performed successfully in 83 patients and permitted resolution of the acute attack in all after a mean period of 1·8 days. Cholangiography yielded a diagnosis of non-gallstone obstruction in one patient and common bile duct stones in 19 patients; preoperative endoscopic sphincterotomy and stone extraction was performed in 18 patients. Elective cholecystectomy was then performed in 70 patients with no deaths and a morbidity rate of 24 per cent.

Conclusion

Combining emergency ultrasonographically guided percutaneous cholecystostomy, preoperative endoscopic treatment of common bile duct stones and subsequent elective chole-cystectomy constitutes an optimal treatment regimen for acute gallstone cholecystitis in selected elderly patients with a mortality rate of zero in the authors' experience.
Prospective study of chronic pain after groin hernia repair
Authors: Callesen T , Bech K , Kehlet H
Published: March 2003

Background

The aim was to provide a detailed description of any residual pain 1 year after elective day-case open groin hernia repair under local anaesthesia.

Methods

This was a prospective consecutive case series study by questionnaire of 500 consecutive operations in 466 unselected adult patients 1 year after surgery. Pain was scored (none, mild, moderate or severe) at rest, while coughing and during mobilization, and compared with similar data collected 1 and 4 weeks after operation.

Results

Some 419 questionnaires were returned (response rate 93 per cent); 20 patients had died within the year and 30 data sets from patients who had a subsequent operation during the study were excluded. Eighty patients (19 per cent) reported some degree of pain, and 25 (6 per cent) had moderate or severe pain. Pain restricted daily function in 24 patients (6 per cent). The incidence of moderate or severe pain was higher after repair of recurrent than primary hernias (14 versus 3 per cent; P < 0·001). The risk of developing moderate or severe pain was increased in patients who had a high pain score 1 week after operation (9 versus 3 per cent; P < 0·05) and also in patients who had moderate or severe pain 4 weeks after operation (24 versus 3 per cent; P < 0·001).

Conclusion

Chronic pain is a significant problem after open groin hernia repair. It may be worse after surgery for a recurrent hernia and may be predicted by the intensity of early postoperative pain.
Carotid angiography is used more selectively in the Asymptomatic Carotid Surgery Trial
Authors: Robless P , Halliday A
Published: March 2003

Background

The ongoing Asymptomatic Carotid Surgery Trial (ACST) has randomized more than 1900 patients to determine whether carotid endarterectomy prolongs stroke-free survival compared with best medical treatment alone. Previously the Asymptomatic Carotid Atherosclerosis Study demonstrated that preoperative angiography caused stroke or death in 1 per cent of patients, and many centres have now reduced or abandoned this practice. This study determined the changing practice of carotid angiography in the ACST.

Methods

Collaborating surgeons completed questionnaires annually on their use and method of angiography. Information on patients in the ACST who had angiography at randomization was also obtained.

Results

In 1993, 77 per cent of responding collaborators always performed preoperative angiography and 23 per cent used angiography selectively. This trend has reversed: by 1997, 26 per cent always used preoperative angiography, 70 per cent of respondents used preoperative angiography selectively and 4 per cent had abandoned angiography (P < 0·001, χ2 for trend). Information on carotid angiography at randomization has to date been obtained on 1141 patients in the ACST. Some 44 per cent (497 of 1141) had carotid angiography at randomization. Surgical patients had angiography more commonly than those in the medical group (49 versus 42 per cent; P < 0·03, χ2 test). Changes in carotid angiography were analysed by year of randomization. In 1993, 61 per cent of patients randomized had carotid angiography compared with 42 per cent in 1996 and 1997 (P < 0·001, χ2 for trend). The use of carotid angiography was not related to degree of stenosis estimated by Doppler ultrasonography.

Conclusion

In the ongoing ACST, there is increasingly selective use of carotid angiography. Less than half the patients in this study had carotid angiography and the use of angiography is now decreasing. This has important implications for validation of carotid duplex in this trial and in future studies.
Analysis of cold provocation thermography in the objective diagnosis of the hand–arm vibration syndrome
Authors: Coughlin P , Chetter I C , Kent P J , Kester R C
Published: March 2003

Background

The hand–arm vibration syndrome (HAVS) is the commonest prescribed disease in the UK. Presently the diagnosis is subjective and the need for an objective investigation to support the diagnosis has been highlighted. This study analyses the potential of cold provocation thermography (CPT) to fulfil this role.

Methods

CPT was performed in ten controls (five men, five women; median age 35 (range 24–78) years) and 21 patients with HAVS (20 men, one woman; median age 45 (range 29–81) years). With an infrared camera, a precooling (PC) image was taken and then, following hand cooling in water at a temperature of 5°C for 1 min, further rewarming images were taken every minute for 10 min.

Results

Patient finger tip temperatures were significantly cooler than control temperatures at all time points (P < 0·01, Student's t test). The following Table shows the sensitivity, specificity and PPV of CPT.

Conclusion

CPT provides strong objective evidence to support the clinical diagnosis of HAVS.
Total abdominal approach for repair of type IV thoracoabdominal aortic aneurysm
Authors: Dunning P G , Dudgill S , Brown A S , Wyatt M G
Published: March 2003

Background

The total transabdominal approach for thoracoabdominal aneurysm (TAA) was described in 1995 and it was suggested that outcome might be improved if the chest was not opened. This study reports early results of the technique with respect to operative morbidity and mortality rates for patients with abdominal aortic aneurysm extending to the diaphragm.

Methods

Between 1995 and 1998, 26 patients (median age 71 (range 52–84) years) underwent repair of a type IV TAA using a total abdominal approach and medial visceral rotation.

Results

Three patients presented with a contained leak. All survived but one developed paraplegia. Other complications included chest infection (five patients), myocardial infarction (three), reoperation for bleeding (three) and temporary dialysis in one patient. There were three perioperative deaths, two from myocardial infarction and one from multisystem organ failure.

Conclusion

The total abdominal approach for the repair of type IV TAA is a reasonable alternative to a full thoracoabdominal incision. Thoracic complications are minimized, renal and visceral ischaemia times are low, and the perioperative mortality rate is acceptable.
Changes in proximal aortic neck dimensions following endovascular repair of abdominal aortic aneurysm
Authors: Walker S R , Macierewicz J , Whitaker S C , Gregson R H S , Hopkinson B R
Published: March 2003

Background

Dilatation of the proximal neck following conventional open repair of abdominal aortic aneurysm (AAA) has been reported. Such continued dilatation following endovascular repair (EVR) could potentially be a disaster resulting in graft slippage, endoleak and aneurysm rupture. The aim of this study was to detect any change in proximal neck diameter following EVR of AAAs.

Methods

One hundred patients had undergone EVR of an AAA over a 4-year period in whom contrast-enhanced spiral computed tomography was performed both before and after EVR (1 week, 3, 6 and 12 months and annually thereafter). Change in aortic proximal neck diameter, change in maximum aortic diameter, presence of endoleaks, and change in length from the lowest renal artery to the aortic bifurcation was sought.

Results

The median anteroposterior and transverse diameter decreased from 64 mm before operation to 56 and 54 mm respectively after operation. This trend in reduction in maximum diameter was not seen in patients with endoleaks. There was no significant change in proximal neck diameter when measured at 5-mm intervals following EVR. There was also no significant change in the aortic length following EVR.

Conclusion

There was no evidence of proximal neck dilatation or aneurysm length reduction following EVR of AAAs.
Autologous transfusion reduces blood transfusion requirements in aortic surgery
Authors: Wong J , Haynes S , Dalrymple K , McCollum C N
Published: March 2003

Background

Elective aortic surgery is associated with a blood loss that warrants a routine blood crossmatch of 4–6 units. Autologous transfusion strategies to reduce blood requirements were evaluated in a pilot study involving six hospitals in the North West.

Methods

Eighty patients undergoing elective aortic surgery were randomized to either autologous (a combination of acute normovolaemic haemodilution and intraoperative cell salvage) or homologous transfusion. The transfusion trigger, in the absence of pressing clinical need, was 8 g dl–1 haemoglobin for both groups.

Results

Randomization achieved two groups well matched for age, aneurysm or occlusive surgery, aspirin intake, estimated blood volume, preoperative haemoglobin and aneurysm size. In the ‘best’ hospitals (n = 49) mean(s.d.) blood loss (630(49) ml) was significantly lower (P < 0·01) than that in the ‘worst’ hospitals (1077(110) ml, n = 31) and fewer patients required transfusion (nine of 42 versus 15 of 30; P < 0·05). No significant differences were found between homologous and autologous groups for all variables measured in the ‘best’ hospitals. In the ‘worst’ hospitals blood requirements were significantly higher (P < 0·05) for the homologous group (800(112) ml) compared with the autologous group (489(65) ml), although blood loss was similar (1239(195) versus 915(92) ml respectively).

Conclusion

Autologous transfusion techniques significantly reduced homologous blood requirements in aortic surgery where blood loss exceeded 800 ml.
Mid-term results of arterial allograft below-knee bypasses for limb salvage
Authors: Albertini J N , Barral X , Branchereau A , Favre J P , Magnan P E , Magne J L , Sessa C
Published: March 2003

Background

Arterial allografts (AAs) have been recently reconsidered in the treatment of critical limb ischaemia when vein material is absent, because of the disappointing results with artificial grafts. The aim of this study was to report the results observed in three centres where AAs were used for infrainguinal reconstruction in critical limb ischaemia.

Methods

Between 1991 and 1997, 165 AA bypasses were performed in 148 patients (90 men) with a mean age of 70 (range 20–93) years. Indications for operation were rest pain in 54 patients and tissue loss in 111. Mean resting ankle pressure was 53 mmHg in 96 non-diabetic patients and mean transcutaneous partial pressure of oxygen was 10 mmHg in 52 diabetic patients. AAs were obtained from cadaveric donors. The distal anastomosis was to the below-knee popliteal artery in 34 cases, to a tibial artery in 114 and to a pedal artery in 17.

Results

At 30 days, the mortality rate was 3 per cent, primary patency 83 per cent, secondary patency 90 per cent and limb salvage rate 98 per cent. During follow-up (mean 31 months) 65 grafts failed primarily. Causes of primary failure were thought to be progression of the distal disease in 15 cases, myointimal hyperplasia in 16, graft degradation in ten (four dilatations, three stenoses, two ruptures and one dissection), other causes in eight and not known in 16. Primary and secondary patency rates at 3 years were 35(s.e. 9) per cent and 42(s.e. 10) per cent. The limb salvage rate at 3 years was 76(s.e. 8) per cent.

Conclusion

AAs lead to a good foot salvage rate but poor patency rates. The results are similar to those obtained with polytetrafluoroethylene grafts.
New technique of in situ autogenous venous valve construction using varicose vein and bench hydrostatic testing of its properties in vitro
Authors: Amaragiri S , Lees T
Published: March 2003

Background

Long-term results of valve transposition and autogenous valve grafts (from axillary and brachial vein) for chronic venous insufficiency due to post-thrombotic valve destruction are poor. Attempts at constructing in situ autogenous venous valves using varicose veins have been ongoing since 1953 but have been unsuccessful. A technique has been developed to create new autogenous in situ valve.

Methods

Varicose long saphenous veins were obtained following stripping during routine varicose vein surgery. A longitudinal elliptical segment of vein wall was excised from opposite sides; this effectively reduces the diameter of the vein. Polypropylene sutures were applied on each side, starting at the centre of the elliptical defect, and brought out proximally. After closing the elliptical defects, gentle traction was applied to the initial sutures and they were tied causing invagination of the vein wall. Both ends of the vein were connected to pressure transducers and a standard pressure monitoring device. Normal saline was pumped at various pressures through the valve-bearing segment while pressures were recorded simultaneously.

Results

Fourteen constructed valves were tested for their bench hydrostatic properties. Mean(s.d.) minimum opening pressure of the valves was 5·3(2·4) mmHg. The valves were competent at a minimum pressure of 2·7(0·6) mmHg. They sustained sudden pressures of up to 139·0(13·8) mmHg and remained competent at a maximum pressure of 260 mmHg.

Conclusion

This technique produces a competent one-way valve capable of sustaining high back pressures, while allowing forward flow with minimal resistance.
Duplex ultrasonography overestimates internal carotid artery stenosis in the presence of contralateral disease
Authors: Ray S A , Lockhart S J , Burnand K G
Published: March 2003

Background

Duplex ultrasonography is increasingly used as the only investigation before endarterectomy for internal carotid artery stenosis. Contralateral disease is present in approximately 20 per cent of these patients and may lead to overestimation of the carotid stenosis by duplex imaging before surgery. This problem was investigated in the present study.

Methods

Peak systolic and diastolic duplex velocities were compared with angiographic data before 126 consecutive carotid endarterectomies (106 symptomatic, eight asymptomatic, 12 precoronary revascularization). Some 3 months later velocities were repeated to assess whether endarterectomy of a diseased carotid artery affected contralateral velocity measurements.

Results

Significant contralateral carotid disease was present in 36 (29 per cent) of the 126 preoperative angiograms (14 occlusions, 22 stenoses greater than 60 per cent). Three months after operation 119 of the endarterectomy sites were widely patent. Duplex ultrasonography of the 105 non-operated patent contralateral arteries showed a decrease in mean(s.d.) peak systolic and diastolic velocities from 1·21(0·83) and 0·41(0·29) m s–1 before operation to 1·08(0·69) and 0·35(0·24) m s–1 respectively (P< 0·01, paired t test). Preoperative duplex velocities had indicated contralateral disease of greater than 50 per cent stenosis in 34 cases, but 14 of these were reclassified to less severe disease following surgery. Thirteen of these had been correctly classified by preoperative angiography while use of systolic and diastolic internal/common carotid artery velocity ratios reduced the overestimation of stenosis in eight of the 14 cases.

Conclusion

Bilateral carotid artery disease is common and may lead to overestimation of stenosis by duplex ultrasonography, which should therefore be supplemented with other modes of imaging.
Review of 94 tibial bypasses for intermittent claudication
Authors: Byrne J , Darling R C , Chang B B , Paty P S K , Kreienberg P B , Lloyd W E
Published: March 2003

Background

The management of intermittent claudication is usually non-operative. Most surgeons accept, however, that intervention may be warranted for those with debilitating symptoms. Such interventions are limited to above-knee bypass or balloon angioplasty. However, the authors have performed almost 4500 bypasses for limb salvage, with careful audit of results, and suggest that, in very carefully selected cases, tibial bypass can also be performed for intermittent claudication. The present study aimed to review the results of infrainguinal bypass in this unit; to compare the results for above-knee, below-knee popliteal and tibial bypass in claudicants using either in situ or excised vein as the conduit; and to examine the indications and long-term follow-up for those undergoing tibial bypass for claudication.

Methods

A database has been maintained prospectively in this unit since 1986. Details of all patients undergoing infrainguinal bypass for claudication were retrieved. In-hospital charts were also reviewed and cross-referenced with the computer database. In addition to demographic details, data were extracted on operative indication and procedure, postoperative complications, return to desired level of activity and long-term graft patency.

Results

From 1987 to 1997, 409 infrainguinal reconstructions were performed for intermittent claudication (9 per cent of all infrainguinal reconstructions). Of these 73 per cent were in men and 27 per cent in women with a mean age of 64 (range 24–91) years. The operative procedures comprised 165 above-knee popliteal grafts, 150 bypasses to the below-knee popliteal artery and 94 to tibial arteries. There were no operative deaths. However, one of 165 patients who had an above-knee popliteal graft underwent an amputation. Primary and secondary patency rates at 4 years were 62 and 64 per cent for above-knee popliteal bypass, 77 and 81 per cent for below-knee popliteal bypass, and 86 and 90 per cent for tibial bypass. Cumulative survival was 93 per cent at 4 years.

Conclusion

Tibial bypass for severely disabling claudication can be performed with minimal morbidity and mortality rates, and is at least as durable as more commonly performed bypasses. These data indicate that concern over limb loss, death and limited life span may be exaggerated.
Non-steroidal anti-inflammatory drugs to treat abdominal aortic aneurysm
Authors: Franklin I J , Walton L J , Brown L , Greenhalgh R N , Powell J T
Published: March 2003

Background

Prostaglandin E2 (PGE2) and inflammatory cytokine levels are raised in the wall of abdominal aortic aneurysms (AAAs) and inflammatory processes appear to contribute to aneurysm expansion. The effect of PGE2 on aortic smooth muscle cells (SMCs) and the influence of indomethacin on AAA growth and production of inflammatory mediators were investigated.

Methods

Proliferation and apoptosis of aortic SMCs cultured with PGE2 were assessed by 5-bromo-2′-deoxyuridine uptake and oligonucleosome enzyme-linked immunosorbent assay. Full-thickness AAA explant cultures were used to measure the secretion of PGE2, interleukin (IL) 1β and IL-6 in the presence and absence of indomethacin. In a case–control study, the effect of non-steroidal anti-inflammatory drugs (NSAIDs), including indomethacin, on AAA growth was examined.

Results

PGE2 suppressed proliferation (IC50 6 ng ml–1) and increased apoptosis of aneurysm SMCs. Indomethacin diminished secretion of PGE2, IL-1β and IL-6 by AAA explants (see Table below). The median AAA growth rate of 19 patients taking NSAIDs was 1·8 (range 0–11·2) mm per year compared with 3·2 (0·4–10·9) mm per year in 59 patients (matched for age, sex, smoking and initial AAA diameter) not taking these drugs (P= 0·004).

Conclusion

PGE2 is produced in the AAA wall in concentrations that are detrimental to SMCs. Indomethacin reduces PGE2, IL-1β and IL-6 synthesis in aneurysm tissue and NSAIDs appear to reduce AAA growth. These drugs warrant further consideration for the treatment of AAA.
Platelet function during carotid endarterectomy and the antiplatelet effect of dextran 40
Authors: Robless P , Okonko D , Tegos T , Mansfield A , Stansby G
Published: March 2003

Background

Dextran 40 has been shown to reduce cerebral embolization following carotid endarterectomy (CEA). This study aimed to determine changes in platelet function during CEA and the antiplatelet effect of dextran 40.

Methods

Platelet function was measured by whole-blood flow cytometry in the peripheral arterial blood of patients during CEA and 24 h later. The binding index of P-selectin and PAC-1 expression were measured as markers of activation and aggregation. Patients were kept on aspirin 75–150 mg until the day of surgery and received an intravenous bolus of 5000 units unfractionated heparin before carotid artery clamping. High-intensity transient signals (HITS) in the ipsilateral middle cerebral artery were measured with transcranial Doppler (TCD) ultrasonography before, during and after operation. Results are presented as median (interquartile range) and statistical significance was determined using the Mann–Whitney U test.

Results

Thirty-eight patients undergoing CEA were studied. The P-selectin binding index rose significantly from incision (0·9 (0·2–2·7)) after carotid clamping (1·5 (0·6–3·6); P < 0·01), clamp release (1·7 (0·3–3·0); P < 0·01), 1 h after operation (1·5 (0·3–2·6); P < 0·05) and 24 h after operation (1·3 (0·6–2·5); P < 0·05). PAC-1 binding index increased from incision (0·4 (0·1–0·8)) after carotid clamping (2·0 (0·4–4·2); P < 0·01) and clamp release (1·8 (0·3–2·9); P < 0·05). TCD monitoring showed an increase in preoperative HITS per 30 min (2 (0–3)) during dissection (8 (1–15); P < 0·05), after clamp release (16 (2–27); P < 0·01) and during recovery (10 (2–29); P < 0·01). After operation, patients with more than 50 HITS per 30 min were started on an infusion of dextran 40. Six patients had a dextran 40 infusion. The P-selectin binding index decreased from 1·6 (0·7–1·9) to 0·6 (0·3–1·5) 1 h after dextran (P < 0·05) and 0·1 (0·1–0·2) 24 h after dextran (P < 0·05). PAC-1 expression decreased from 0·4 (0·3–0·5) to 0·1 (0·1–0·1) 24 h after dextran (P < 0·05).

Conclusion

Significant platelet activation and aggregation occurs during CEA despite the use of antiplatelet treatment. A simultaneous increase in HITS was demonstrated with TCD. Dextran 40 was shown to have an antiplatelet effect after CEA; this is further evidence that it may have a role in reducing thromboembolic complications.
Fifteen years of experience using 6 cm as a criterion for abdominal aortic aneurysm surgery
Authors: Scott R A P , Ashton H A , Lamparelli M J
Published: March 2003

Background

One criterion for abdominal aortic aneurysm (AAA) surgery in the authors' unit is aneurysm diameter of 6 cm. The impact of applying this criterion on surgical workload and rupture rate was analysed.

Methods

Some 584 consecutive patients with an AAA of 3 cm or greater presenting to this unit since 1984 have had the following criteria for considering surgery applied prospectively: a diameter of 6 cm, an expansion rate of more than 1 cm per year, or symptoms.

Results

Forty-three patients had an AAA of 6 cm or greater on initial presentation and would have been treated in the same way, if a smaller diameter was used. Sixty-eight patients had an AAA that expanded to 6 cm on observation with ultrasonography over the period of up to 15 years. The total number of patients with a 6-cm AAA was therefore 111. Of the 541 aneurysms that were under 6 cm at the initial scan, 454 were followed with ultrasonography. Some 343 reached 4 cm and 204 reached 5 cm. Operating at 5 cm therefore would have doubled the potential workload, and 4 cm would have tripled it. During the 15 years, 24 (4 per cent) of the 584 AAAs ruptured. Of these 24 patients, 12 were unfit for surgery, five declined operation or follow-up, the aneurysm ruptured beforehand in three who were booked for an operation or outpatient visit, and four failed to reach the operative criteria before rupture occurred. Rupture could therefore possibly have been prevented in seven (1 per cent) of the 584 by operating at a smaller diameter. The reported mortality rate for planned surgery is 2–8 per cent.

Conclusion

By using these criteria for surgery, the workload is cut by half or more and the consequent risk of rupture is lower than the mortality rate associated with planned surgery.
Scottish Audit of Surgical Mortality, 1997
Authors: Black D A , Stonebridge P A , Bradbury A W , Cross K S , Duncan J , McKay A J
Published: March 2003

Background

A national audit of surgical deaths can be seen as the final step in what has been termed the ‘journey of care’ for both the individual patient and for the population as a whole.

Methods

The Scottish Audit of Surgical Mortality (SASM) examines all hospital deaths in Scotland occurring while under the care of a surgical specialist and all deaths within 30 days of an operation.

Results

Compliance for the completion of forms relating to vascular deaths during the first 4 years of the SASM (1994–1997) has remained over 92 per cent. In 1997 the compliance was 97 per cent. These figures compare favourably with the other surgical specialties where the overall compliance for 1997 was 92 per cent. Some 14 per cent of the 4408 deaths reported in 1997 occurred in patients admitted with vascular disease, the majority (83 per cent) being emergency admissions. Of these 507 vascular deaths, 293 were postoperative; the remaining 214 patients did not undergo operation. This represents an improvement over the years 1994–1996 when vascular deaths numbered 554, 573 and 524 respectively. The mean age of the patients who died from vascular disease in 1997 was 73 (range 19–92) years. A consultant surgeon made the decision to operate in 98 per cent of the patients with vascular disease who died at operation and was the principal surgeon in 70 per cent of cases. Vascular consultants carried out a higher percentage of operations than their counterparts in other surgical specialties (general surgery, 63 per cent; mean for other subspecialties, 60 per cent). In the non-operative group of vascular deaths in 1997, a vascular consultant was in charge in 66 per cent of cases; the figure for operated cases was 87 per cent. Adverse factors were believed to contribute to death in 10 per cent of cases, but were considered a direct cause of death in fewer than 1 per cent.

Conclusion

These figures reflect the high quality of vascular services in Scotland, where there is a considerable consultant presence in the management of high-risk patients. This consultant involvement is higher than in other subspecialties and, bearing in mind the high percentage of emergencies, has significant resource implications for the delivery of vascular services.
RETA: the registry of endovascular treatment of abdominal aortic aneurysms
Authors: Thomas S M , Gaines P A , Beard J D
Published: March 2003

Background

RETA is a voluntary registry within the UK established as a joint venture between radiologists and surgeons. The aim is to evaluate carefully the endovascular treatment of abdominal aortic aneurysms during introduction into clinical practice.

Methods

Some 367 patients have been included in the registry from 23 centres since its inception on 1 January 1996. In the majority (82 per cent) an elective repair was performed for an asymptomatic aneurysm. The mean age of the patients was 71·9 years and 28 per cent were deemed unsuitable for conventional repair. One hundred and ninety-nine bifurcated (54 per cent), 18 tube (5 per cent) and 148 aortouni-iliac with crossover (40 per cent) stent graft types were placed.

Results

At the end of the procedure 77 per cent of aneurysms were excluded with no complications. Twenty-one patients (6 per cent) required conversion to open repair. Forty-four (12 per cent) required additional endovascular procedures. At 30 days 87 per cent of the aneurysms were excluded or repaired. The 30-day mortality rate was 7 per cent (n = 24) with a significant improvement between 1996 and 1997, from 11 to 4 per cent. There were 25 persistent leaks (7 per cent). The death rate was related to the fitness of patient, device used and requirement for conversion. One-year follow-up data are available for 140 patients. There have been 13 deaths (9 per cent), three ruptures (2 per cent) and some form of complication in 20 per cent of cases overall.

Conclusion

Improving results have been demonstrated for the primary procedure. At present there is a relatively high complication rate and ruptures have occurred. Rigorous continued follow-up is required.