bluuebunny/crossref_metadata_2025 huggingface dataset:
Incidence, aetiology and mortality rate of acute pancreatitis over 10 years in a defined urban population in Sweden
Authors: Appelros S , Borgström A
Published: March 2003

Background

There is a wide range (5–50 per 100 000) in the reported annual incidence of acute pancreatitis. Furthermore, the predominant aetiology varies in different reports. This study was undertaken to establish the current incidence, aetiology and associated mortality rate in a defined population.

Methods

A retrospective study of all cases of acute pancreatitis admitted over a 10-year period to a single institution was performed. In addition the autopsy and forensic materials were reviewed.

Results

Altogether 883 attacks of acute pancreatitis were recorded, of which 547 were first attacks. The annual incidence of first attacks was 23·4 per 100 000. Including relapses, the incidence was 38·2 per 100 000. Biliary disease was the main aetiological factor in first attacks whereas alcohol was the predominant factor when relapses were included. The mean annual mortality rate for acute pancreatitis in the population was 1·3 per 100 000. Of 31 patients who died from acute pancreatitis only 15 were diagnosed before death. For recurrent disease the mortality rate was 0·3 per cent. In 12 patients the pancreatitis was associated with pancreatic carcinoma.

Conclusion

It is important to differentiate between first attacks and relapses, since both incidence and aetiology figures are influenced by this, and it is important to include autopsy and forensic material in population-based mortality studies.
Leucocyte count and C-reactive protein in the diagnosis of acute appendicitis
Authors: Grönroos J M , Grönroos P
Published: March 2003

Background

The aim of the present work was to study the preoperative leucocyte counts and C-reactive protein (CRP) values in three groups of patients operated on for a clinical suspicion of acute appendicitis with different findings at appendicectomy: an uninflamed appendix, uncomplicated acute appendicitis or complicated acute appendicitis. In particular, patients with acute appendicitis but a normal leucocyte count and CRP level were sought.

Methods

In this retrospective study, the mean preoperative leucocyte count and CRP value in 100 consecutive patients with an uninflamed appendix (group A), in 100 consecutive patients with uncomplicated acute appendicitis (group B) and in 100 consecutive patients with complicated acute appendicitis (group C) were calculated. The numbers of patients with (1) both values normal, (2) only leucocyte count raised, (3) only CRP level raised and (4) both values raised were calculated in each of the three groups.

Results

The increase in leucocyte count was an early marker of appendiceal inflammation, whereas the CRP value increased markedly only after appendiceal perforation or abscess formation. Group A (uninflamed appendix) contained 24 patients in whom both values were normal. Neither group B (uncomplicated acute appendicitis) nor group C (complicated acute appendicitis) contained any patient with both values in the normal range.

Conclusion

Acute appendicitis is very unlikely when both the leucocyte count and CRP value are normal.
Prospective randomized trial of end-to-end versus side-to-side biliary reconstruction after orthotopic liver transplantation
Authors: Davidson B R , Rai R , Kurzawinski T R , Selves L , Farouk M , Dooley J S , Burroughs A K , Rolles K
Published: March 2003

Background

Biliary reconstruction is the Achilles heel of liver transplantation. Side-to-side anastomosis of donor and recipient bile duct has been claimed to be superior to end-to-end anastomosis in uncontrolled studies.

Methods

A total of 100 consecutive patients undergoing orthotopic liver transplantation were randomized after commencement of the transplant procedure to end-to-end or side-to-side anastomosis. No T tube drainage was employed. Endoscopic retrograde cholangiography was performed 2 weeks after transplantation and findings were reported by an experienced endoscopist as normal, leak or stricture. Median follow-up was 53 (range 35–63) months.

Results

Patient age, sex, the graft preservation time and indication for transplantation were similar in both groups. Sixty patients received end-to-end and 40 side-to-side anastomosis. Ten patients randomized to side-to-side anastomosis had an end-to-end procedure. The total number of biliary complications was similar in both groups (end-to-end 32 per cent versus side-to-side 30 per cent) as were the number of leaks (17 versus 18 per cent) and biliary strictures (15 versus 12 per cent). There was no difference in the number of biliary complications that required interventional treatment (22 per cent in both groups).

Conclusion

Side-to-side and end-to-end biliary anastomosis at liver transplantation are equally effective.
Experimental techniques and models in the study of the development and treatment of abdominal aortic aneurysm
Authors: Carrell T W G , Smith A , Burnand K G
Published: March 2003

Background

It is still unclear what initiates aneurysmal dilatation and what determines whether or not an aneurysm will continue to expand and rupture. Early detection and operative repair of an abdominal aortic aneurysm (AAA) still remains the only effective means of reducing the high mortality rate associated with the condition. Endovascular techniques are being developed in an attempt to reduce the mortality rate associated with elective repair. A variety of animal models and experimental techniques have been described in the investigation of the pathophysiology of AAA and in the development of improved endovascular surgical and pharmacological therapies. This article discusses these models and techniques, their advantages and some of the problems encountered in extrapolating experimental findings to the human condition.

Methods

This review is based on a search of the Medline database from 1966 to March 1998 using recognized key words and text words. A further search was then conducted on references quoted within selected relevant publications.

Results and conclusion

Treatment of rodent aortas with intraluminal elastase or periaortic calcium chloride creates reproducible aneurysms that have certain similarities to the human pathology; such aneurysms have been favoured in the investigation of the pathophysiology of aneurysm expansion. However, these models lack several of the prominent features of the human lesion, such as atherosclerosis and intraluminal thrombosis. The development of gene knockout mice may lead to a more analogous aneurysm formation, with associated atherosclerosis. Many large animal models have been used in the development of endovascular techniques but, in general, these do not mimic the human pathophysiology and fail to predict medium- and long-term complications.
Randomized trial to study the effect of fundic mobilization on long-term results of Nissen fundoplication
Authors: Luostarinen M E S , Isolauri J O
Published: March 2003

Background

It has been suggested that fundic mobilization in Nissen fundoplication decreases adverse postoperative symptoms and increases the durability of the fundic wrap. There are no previous randomized, prospection long-term studies assessing this. This study addresses the question.

Methods

Fifty consecutive patients were randomized to undergo open Nissen–Rossetti fundoplication with total fundic mobilization (n = 26) or an identical procedure without mobilization (n = 24). After a median of 36 (range 6–53) months 49 had endoscopy and a personal interview.

Results

Oesophagitis was cured in 20 of 21 patients who had fundic mobilization and 18 of 19 who did not. a defective fundic wrap was observed in five and recurrent reflux symptoms in six of those who had fundic mobilization compared with two and one respectively of those who did not (P not significant). Recurrent sliding hiatal hernia was observed in nine of those with a mobilized fundus and one of those without (P = 0·02). There was no significant difference in incidence of new-onset long-term dysphagia, subjective belching ability, amount of flatus or bloating between the study groups.

Conclusion

Fundic mobilization did not give any apparent advantage regarding postoperative adverse effects. Instead, it was associated with a higher rate of recurrent hiatal hernia.
Estimation of mortality and morbidity risk in vascular surgery using POSSUM and the Portsmouth predictor equation
Authors: Midwinter M J , Tytherleigh M , Ashley S
Published: March 2003

Background

The Physiological and Operative Severity Score for enUmeration of Mortality and morbidity (POSSUM) is a simple scoring system previously validated in general surgical patients which enables estimation of the risk of complications and death after operation. The Portsmouth predictor equation (P-POSSUM) is a modification that may result in more accurate prediction of death than POSSUM. The aim of this study was to test the validity of POSSUM and P-POSSUM in patients undergoing major arterial surgery in a specialist unit.

Methods

Physiological and operative severity scores in 221 patients undergoing elective and emergency arterial surgery in a pure vascular practice under a single consultant were recorded prospectively. Observed morbidity and mortality rates were compared with the rates predicted by POSSUM and P-POSSUM using a linear method of analysis.

Results

The POSSUM equation overestimated deaths with this analysis but the mortality rate estimated by P-POSSUM was not significantly different from the observed death rate. The risk of morbidity predicted by POSSUM was not significantly different from the observed complication rate.

Conclusion

The POSSUM methodology combined with the P-POSSUM adjustment for death allows satisfactory prediction of mortality and morbidity rates in patients undergoing vascular surgery.
Epidemiology of Warthin's tumour of the parotid gland in an Asian population
Authors: Chung Y F A , Khoo M L C , Heng M K D , Hong G S , Soo K C
Published: March 2003

Background

Recent studies have documented a number of changing demographic features in the occurrence of Warthin's tumour (adenolymphoma) of the parotid gland. In order to analyse its epidemiology in an Asian population, a retrospective study was performed on all parotid neoplasms (n = 289) operated on between 1988 and 1998.

Patients and methods

A total of 209 consecutive patients were selected for study, 136 with pleomorphic adenomas (one bilateral) and 73 with Warthin's tumours (seven bilateral). Patients were analysed with regard to tumour incidence, age, sex and race. Smoking as an aetiological factor in the development of Warthin's tumour was also studied.

Results

Warthin's tumour formed 25 per cent of parotid tumours and its ratio to pleomorphic adenomas was 1 : 1·9. Multicentricity was found in 14 patients (19 per cent). The male : female ratio for Warthin's tumours was 4·6 : 1. The proportion of Warthin's tumours did not show any increasing trend relative to pleomorphic adenomas. The racial distribution of Warthin's tumours showed an increased incidence among Chinese and a reduced incidence among Malays and Indians. The adjusted odds ratio for sex and age favouring an association between smoking and Warthin's tumour was 39·5 (95 per cent confidence interval 10·5–149·0; P < 0·0001).

Conclusion

The incidence of Warthin's tumour is considerable among Asians although there is still male predominance. There is no rising incidence of Warthin's tumour; the trend parallels the declining smoking rate in the population. The lower incidence among ethnic groups with dark skin seems to suggest concomitant genetic factors other than environmental factors alone in histogenesis. Smokers have a 40-fold greater risk than non-smokers of developing a Warthin's tumour.
Characterization of the Kupffer cell response to exogenous endotoxin in a rodent model of obstructive jaundice
Authors: Kennedy J A , Clements W D B , Kirk S J , McCaigue M D , Campbell G R , Erwin P J , Halliday M I , Rowlands B J
Published: March 2003

Background

Sepsis and endotoxaemia occur frequently in biliary obstruction. Impaired Kupffer cell endocytosis is implicated in these events. Tumour necrosis factor and interleukin 6, secreted by Kupffer cells, are important mediators of sepsis. Kupffer cell clearance of endotoxin and secretion of cytokines in experimental obstructive jaundice were investigated.

Methods

Wistar rats were randomized to bile duct ligation, sham operation or control. Groups (n = 8) were studied 1 and 3 weeks after operation. Kupffer cell function was assessed using in situ hepatic perfusion.

Results

Clearance of endotoxin was significantly depressed 1 week (median (interquartile range) 20·3 (10·5–27·1) per cent) and 3 weeks (22·1 (20·2–23·2) per cent) after bile duct ligation compared with that in respective sham animals (35·5 (29·9–41·6) and 40·9 (37·7–47·0) per cent) and controls (39·5 (37·3–46·8) per cent). Secretion of tumour necrosis factor was significantly greater 1 week (1113·7 (706·5–1436·8) pg/ml) and 3 weeks (1118·2 (775·7–1484·1) pg/ml) following bile duct ligation compared with that in respective sham animals (114·3 (0–178·5) and 107·6 (63·7–166·4) pg/ml) and controls (0 (0–20·7) pg/ml). Interleukin 6 was not secreted by sham or control animals but was present in the perfusate from jaundiced animals at 1 and 3 weeks (52·5 (9·9–89·5) and 66·2 (60·2–193·1) pg/ml).

Conclusion

These data demonstrate simultaneous impairment of Kupffer cell clearance of endotoxin and increased secretion of proinflammatory cytokines in experimental obstructive jaundice. These diverse responses may contribute to the development of sepsis-related complications in biliary obstruction.
Laparoscopically assisted colorectal surgery in the elderly
Authors: Stewart B T , Stitz R W , Lumley J W
Published: March 2003

Introduction

Open colorectal surgery in elderly patients is associated with increased morbidity and mortality rates compared with those in younger age groups. It also requires more intensive postoperative support, longer hospitalization, and in many cases leads to prolonged rehabilitation or institutionalization. Because of its less invasive nature, laparoscopically assisted colorectal surgery may lead to a reduced period of convalescence. However, the safety of advanced laparoscopic surgical techniques in the elderly has not been established, so this prospective comparative study was undertaken.

Methods

All patients aged 80 years or more who were undergoing an elective laparoscopic or open colorectal procedure between 1 January 1992 and 30 June 1997 were assessed prospectively. Patients having simple stoma formation were excluded. Perioperative care, operative results and subsequent function were analysed.

Results

There were 42 patients in the laparoscopic group and 35 in the open group, with a median age of 84 years in each group. Five patients undergoing laparoscopic surgery required conversion to an open procedure. No complications related to laparoscopy occurred. Three patients died after operation in the laparoscopic group and four in the open group, with morbidity in seven and 15 patients respectively. Median hospital stay was 9 (range 4–21) days for patients having the laparoscopic operation, and 17 (range 7–28) days in the open cases. At 4 weeks after operation 30 of the 35 independent patients surviving the operation in the laparoscopic group and 16 of 28 in the open group were back to preoperative activity levels.

Conclusion

In this series laparoscopically assisted colorectal surgery was safe and was associated with a low incidence of complications, short hospitalization and a rapid return to preoperative activity levels when compared with open colorectal resections in this age group.
Outcome after surgical resection for high-grade anal intraepithelial neoplasia (Bowen's disease)
Authors: Brown S R , Skinner P , Tidy J , Smith J H , Sharp F , Hosie K B
Published: March 2003

Background

High-grade anal intraepithelial neoplasia (Bowen's disease) may predispose to anal carcinoma. Treatment options include surgical resection but effectiveness remains uncertain. This paper reports long-term follow-up of patients with high-grade anal intraepithelial neoplasia treated by surgical resection.

Methods

Between 1989 and 1996, 46 patients were identified with high-grade anal intraepithelial neoplasia. Thirty-four underwent local excision of all macroscopically abnormal disease and the resulting defect was left open, closed primarily or skin grafted. Regular follow-up subsequently included anoscopy and biopsy of any suspicious lesions.

Results

Median follow-up was 41 (range 12–104) months. Total excision was difficult; 19 patients had histological evidence of incomplete excision at the time of initial resection. Some 12 of 19 had histo-logically proven recurrent high-grade intraepithelial neoplasia within 1 year. Even with microscopically complete excision two of 15 patients subsequently developed recurrent high-grade intraepithelial neoplasia at 6 and 32 months after operation. No patient developed carcinoma but five had complica-tions of anal stenosis or faecal incontinence.

Conclusion

Although no definite recommendations can be made for the treatment of high-grade anal intraepithelial neoplasia, these results illustrate some potential drawbacks of surgical excision with a high potential for incomplete excision and persistent disease, even after complete excision in some patients, and a high morbidity rate.
Mesenteric vein thrombosis due to factor V Leiden gene mutation
Authors: Bergenfeldt M , Svensson P J , Borgström A
Published: March 2003

Background

Mesenteric venous thrombosis is a rare cause of acute abdominal pain that may be the result of coagulation abnormalities.

Methods

Four consecutive patients with mesenteric venous thrombosis underwent haematological evaluation.

Results

All four had activated protein C resistance resulting from a single mutation in the gene coding for coagulation factor V. Three had surgery; in one patient the diagnosis was made by ultrasonography. One of the patients who had surgery died but the other three survived and were treated with long-term anticoagulation.

Conclusion

Activated protein C resistance may be an important pathogenetic factor in primary mesen-teric vein thrombosis.
Marimastat inhibits elastin degradation and matrix metalloproteinase 2 activity in a model of aneurysm disease
Authors: Treharne G D , Boyle J R , Goodall S , Loftus I M , Bell P R F , Thompson M M
Published: March 2003

Background

Abdominal aortic aneurysms are characterized by degradation of the extracellular matrix, with a reduction in the elastin concentration of the arterial media. These changes have been linked to increased levels of endogenous metalloproteinases (MMPs) within the aorta, particularly MMP-2 and MMP-9. This provides a potential therapeutic target for pharmacological agents aimed at reducing the growth rate of small aneurysms. In this study, the ability of marimastat (an MMP inhibitor) to reduce matrix degradation was assessed in a previously described model of aneurysm disease.

Methods

Porcine aortic segments (n = 12) were preincubated in exogenous pancreatic elastase for 24 h before culture in standard conditions for 13 days with marimastat 10−5, 10−6 and 10−7 mol/l. Control segments were cultured both without marimastat and without elastase. At the termination of culture, MMPs were extracted from the tissue and quantified by substrate gel enzymography. The volume fractions of elastin and collagen were determined by stereological analysis of sections stained with Miller's elastin and van Gieson's stain.

Results

Stereological analysis demonstrated preservation of elastin in aorta treated with marimastat at 10–6 and 10–5 mol/l; this was significant at the latter concentration (P = 0·007). This was accompanied by a significant reduction in active MMP-2 activity in the samples treated with marimastat 10–5 mol/l (P < 0·01).

Conclusion

Marimastat significantly inhibited elastin degradation and active MMP-2 production within aortic organ cultures.
Local recurrence after curative excision of the rectum for cancer without adjuvant therapy: role of total anatomical dissection
Authors: Bokey E L , Öjerskog B , Chapuis P H , Dent O F , Newland R C , Sinclair G
Published: March 2003

Background

The wide variability of reported local recurrence rates after curative resection of rectal cancer without adjuvant therapy may be a consequence of many different factors. However, few studies have investigated the potential effects of such factors on local recurrence by multivariate analysis. The present study examined clinical and tumour characteristics, operation type and operative technique as potential predictors of local recurrence in patients treated by surgery alone.

Methods

Prospective data were analysed by bivariate and multivariate methods including actuarial survival and proportional hazards regression.

Results

Local recurrence (pelvic or pelvic and systemic) was diagnosed in 59 of 596 patients. The 5-year actuarial local recurrence rate was 11·1 (95 per cent confidence interval 8·7–14·3) per cent. Independent predictive factors for local recurrence were: positive nodes (hazard ratio (HR) 5·5, P < 0·01); distal margin of 1 cm or less (HR 3·8, P < 0·01); venous invasion (HR 2·0, P = 0·02) and total anatomical dissection of the rectum (HR 2·0, P = 0·01). There was no difference in local recurrence between patients who had the mesorectum divided and those in whom it was totally excised.

Conclusion

Nodal involvement is the most potent predictor of local recurrence. In patients in whom total anatomical dissection is performed, total mesorectal excision confers no additional protection against local recurrence.
Experimental study of intraperitoneal suramin on the healing of colonic anastomoses
Authors: Hendriks J M H , Hubens G , Wuyts F L , Vermeulen P , Hubens A , Eyskens E
Published: March 2003

Introduction

The effect of the antiangiogenic agent suramin on the healing of colonic anastomoses was studied in a rat model.

Methods

Rats underwent an end-to-end colonic anastomosis and its healing was tested by measuring bursting pressure, hydroxyproline content and number of newly formed vessels. For the bursting pressure experiment suramin was given intraperitoneally in a dose of 200 mg/kg (maximal tolerable dose) and 100 mg/kg. Hydroxyproline content and vessel density were only tested at 100 mg/kg since the toxicity at this dose was lower whereas bursting pressure was still diminished.

Results

There were no deaths. On the fourth day after operation bursting pressure in the control group was significantly higher than that in rats treated with suramin 200 mg/kg (P = 0·006) and 100 mg/kg (P = 0·002). Rupture occurred at the anastomotic line. On day 7, this difference was not statistically significant. Four days after the operation, the hydroxyproline content and vessel density were significantly below that in control segments (hydroxyproline: 10·3 versus 7·8 μg per mg dry weight; vessel content: 85·7 versus 49·6 vessels per × 100 field for control and suramin-treated rats respectively). On the seventh day no difference in hydroxyproline levels was seen but the vessel density was still diminished significantly (P = 0·04).

Conclusion

Experimentally, suramin significantly inhibits and delays healing of colonic anastomoses.
Comparison of the expression of fibrosis-associated genes in glomeruli after renal transplantation between conventional cadaveric and non-heart-beating donors
Authors: Jain S , Bicknell G R , White S A , Williams S T , Furness P N , Nicholson M L
Published: March 2003

Background

The main difference between cadaveric heart-beating donors and non-heart-beating donors (NHBDs) is the degree of warm ischaemia to which the kidney is subjected. This study was designed to see if this affected the expression of fibrosis-associated genes in the early period after transplantation.

Methods

A series of 29 cadaveric and 19 NHBD renal transplants was studied. Patients underwent protocol needle-core renal transplant biopsies at 1 week, 3 months and 6 months after transplantation. At least two individual glomeruli were isolated from each biopsy. Messenger RNA was extracted and genes of interest were amplified by reverse transcriptase–polymerase chain reaction, then quantified in an enzyme-linked immunosorbent assay system.

Results

Delayed graft function was common in NHBD (17 of 19) compared with cadaveric transplants (six of 29) (P < 0·0001). Acute rejection rates were similar. The level of tissue inhibitor of metalloproteinase 1, an inhibitor of extracellular matrix degradation, was higher in kidneys from NHBDs at 1 week (P = 0·02). There were no other statistically significant differences in the expression of fibrosis-associated genes between the two groups.

Conclusion

Although the increased ischaemic injury in kidneys retrieved from NHBDs leads to a higher rate of delayed graft function, this does not translate into increased expression of fibrosis-associated genes after the first week.
Improved management of infrainguinal bypass graft infection with methicillin-resistant Staphylococcus aureus
Authors: Chalmers R T A , Wolfe J H N , Cheshire N J W , Stansby G , Nicolaides A N , Mansfield A O , Barrett S P
Published: March 2003

Background

There is considerable debate over the management of infected infrainguinal grafts. This report describes recent experience in this field and documents the change in clinical practice needed to deal with methicillin-resistant Staphylococcus aureus (MRSA).

Methods

All infected infrainguinal grafts between January 1991 and July 1997 were reviewed. In the light of the findings, clinical practice was modified considerably. A further 1 year was audited prospectively up to August 1998.

Results

Twenty-six patients were treated for 27 infrainguinal graft infections (25 prosthetic, two vein). Twenty were treated by complete graft excision as the initial therapy; graft preservation was attempted in six patients. Before 1995, the infecting organisms were predominantly Pseudomonas aeruginosa or methicillin-sensitive staphylococci. Subsequently all 14 patients treated up to 1997 had infection with MRSA. The overall amputation rate was 17 of 26; ten amputations were in patients with MRSA. Four patients died, all with MRSA sepsis. As a result of this experience a policy of complete isolation was adopted for all patients infected with MRSA. In the 12 months since this policy was introduced, 77 infrainguinal grafts (61 vein, 16 prosthetic) have been inserted. Two grafts (3 per cent) have become infected, necessitating graft excision and amputation.

Conclusion

MRSA infection of an infrainguinal graft is a serious complication with high associated amputation and mortality rates. Isolation and barrier nursing appeared to contain the problem.
Audit of surgical technique during carotid endarterectomy by intraoperative duplex ultrasonography: trainees compared with consultant
Authors: Padayachee T S , Brooks M D , Self G , Moderesi K B , Taylor P R
Published: March 2003

Background

There has been increasing interest in audit of outcome following surgery. A previous study reported a significant difference in clinical outcome between consultant and trainees but there is no information on technical factors. Duplex ultrasonography before wound closure was used to compare clinical and technical outcome for consultant and trainees.

Methods

Patients underwent endarterectomy (89 by consultant, 60 by six trainees). In the consultant group nine vessels were patched and 36 patients underwent shunting compared with seven and 31 respectively for trainees.

Results

In the consultant group there were two deaths, one stroke, one transient ischaemic attack (TIA) and two cranial nerve injuries. The neurological event rate was 2 per cent, and overall stroke and death rate 3 per cent. There were ten residual flaps (11 per cent) (three re-explored) and eight kinks (9 per cent). The residual stenosis rate was 10 per cent (nine of 89) and following re-exploration this reduced to 7 per cent. In the trainee group there was one death, two strokes, one TIA and one cranial nerve injury. The neurological event rate was 5 per cent, and the overall stroke and death rate 3 per cent. There were nine flaps (15 per cent) (four re-explored) and 13 kinks (22 per cent). The residual stenosis rate was 22 per cent (13 of 60) which reduced to 15 per cent (nine of 60) following re-exploration. There was no significant difference in clinical outcome between consultant and trainees but there was an increased incidence of technical problems among the trainees (t = 2·12, P < 0·05).

Conclusion

Intraoperative duplex ultrasonography is a valuable method for assessing surgical technique; it gives immediate feedback to the surgeon, enables corrective measures to be taken and may facilitate training.
Thrombelastography can differentiate ischaemic from haemorrhagic stroke
Authors: Handa A , Platts A , Tone S , Hamilton G
Published: March 2003

Background

Thrombolysis could be a major step forward in the treatment of acute ischaemic stroke. Early treatment is essential to maximize therapeutic benefit. Imaging by computed tomography (CT) or magnetic resonance imaging is mandatory to exclude haemorrhagic stroke before initiation of therapy. Thrombelastography (TEG), a test of global haemostasis, produces a characteristic tracing over 15–30 min. The potential of TEG to differentiate patients with ischaemic from haemorrhagic stroke was investigated.

Methods

Fifteen patients with a clinical diagnosis of acute stroke were studied. Fibrinogen levels and lipid profiles were measured, and CT of the brain, coagulation screens and TEG were performed. The CT scans were interpreted by a single radiologist. TEG data were classified as normal (index less than 2), hypercoagulable (index 2–3) or profoundly hypercoagulable (index greater than 3).

Results

There was no correlation between any of the parameters studied other than TEG with CT findings. Both patients with a haemorrhagic stroke showed normal findings on TEG. Eleven of the 12 patients with ischaemic stroke were hypercoagulable or profoundly hypercoagulable.

Conclusion

TEG is capable of differentiating haemorrhagic from ischaemic stroke. It has the potential to target thrombolytic therapy for those patients most likely to benefit.
Impact of spontaneous embolization on cognitive function
Authors: Lloyd A J , Smith J L , Loftus I M , Hayes P , Bell P R F , Naylor A R
Published: March 2003

Background

Although microembolization may not be associated with focal neurological events following carotid endarterectomy (CEA), it might contribute towards cognitive impairment.

Methods

Forty-nine patients undergoing CEA underwent 30 min of preoperative ipsilateral transcranial Doppler (TCD) monitoring and a battery of tests of cognitive function, and the results were compared with those of age-matched normal controls.

Results

Seven patients who were spontaneously embolizing had significantly worse preoperative cognitive function scores than 42 patients with no recorded emboli (P = 0·03). Overall, patients undergoing CEA had a significant cognitive deficit compared with age-matched normal controls.

Conclusion

Patients who have evidence of spontaneous preoperative embolization on TCD monitoring have a greater degree of preoperative cognitive impairment. This finding underlines the potential clinical importance of microembolization and suggests that this phenomenon should be investigated further.
Systemic effects of exercise in claudicants are associated with neutrophil activation
Authors: Lewis D R , Day A , Jeremy J Y , Newcombe P V , Brookes S T , Baird R , Smith F C T , Lamont P M
Published: March 2003

Background

Claudication induces potentially harmful systemic effects which may be mediated through free radicals and neutrophil activation. This study examined the impact of these mechanisms on renal tubular function.

Methods

Flow cytometry was used to determine CD11b expression by neutrophils and monocytes, and expression of P selectin (CD62P) by platelets, in 16 patients with intermittent claudication and eight matched controls before and at intervals after exercise. Total antioxidant capacity (TAC) and von Willebrand factor (vWF) were measured at similar intervals. Renal tubular function was assessed before and 60 min after exercise by assay of retinol binding protein: creatinine ratio (RBP: Cr) in urine. All patients and none of the controls had a significant exercise-induced fall in ankle pressure. Fluorescein isothiocyanate-labelled monoclonal antibodies against CD11b and CD62P were added to blood and analysis was performed on the flow cytometer within 72 h.

Results

There were no significant differences in monocytes, platelets or vWF between patients and controls over time. There was a significant change in RBP: Cr following exercise in patients (median 4·2 (95 per cent confidence interval 2·4–85·2); P ≤ 0·01, Wilcoxon test) but not controls (2·7 (–1 to 7·5); P not significant). See Table above.

Conclusion

Renal tubular function was adversely affected by acute exercise in claudicants. TAC was higher in claudicants at rest and was increased after exercise suggesting an increased free radical challenge. Neutrophil activation is significantly different between claudicants and controls before and after exercise, and may provide a link between free radical generation and renal tubular injury.
Role of superficial vein surgery in treatment of venous ulceration
Authors: Bello A M , Scriven M , Naylor A R , Bell P R F , London N J M
Published: March 2003

Background

Recent colour duplex studies of patients presenting with venous ulceration in the community have shown that between 55 and 60 per cent have isolated superficial venous insufficiency. Previous studies of the role of superficial surgery in the treatment of venous ulceration have applied postoperative compression bandaging and therefore it has not been possible to determine the role of superficial surgery in promoting ulcer healing. The purpose of this prospective study was, therefore, to examine the healing rate after superficial surgery in patients with isolated superficial venous incompetence and venous ulceration who did not undergo postoperative compression bandaging.

Methods

Patients with isolated superficial venous incompetence, as demonstrated by colour duplex scanning and an ankle: brachial pressure index greater than 0·8, underwent saphenofemoral or saphenopopliteal disconnection under local anaesthesia, or a high tie and strip under general anaesthesia. Compression bandaging was not applied after operation. Patients were followed regularly after surgery and the endpoint was ulcer healing.

Results

Between May 1994 and July 1997, 122 legs with venous ulceration and isolated superficial venous incompetence underwent superficial surgery. Ninety-three (76 per cent) had long saphenous incompetence alone, 13 (11 per cent) had short saphenous incompetence alone and 16 (13 per cent) had combined long and short saphenous incompetence. The median (range) patient age was 72 (28–94) years and the median duration of ulceration was 32 weeks (range 2 weeks to 32 years). The median (range) ulcer area was 9 (1–500) cm2. Ninety patients (74 per cent) had a local anaesthetic procedure while 32 (26 per cent) had general anaesthesia. Of patients who had long saphenous surgery, 69 had high ligation only and 24 had high ligation and strip. The healing rate by life-table analysis was 58 per cent at 6 months, 73 per cent at 1 year and 82 per cent at 18 months. Clinical review and colour duplex examination of patients with ulcers that had failed to heal (n = 18) showed that two had recurrent superficial to deep connections; the remainder had fixed ankle joints or severe osteoarthritis of the hip and knee.

Conclusion

Superficial venous surgery in patients with isolated superficial venous incompetence and venous ulceration can achieve a very high healing rate in the absence of postoperative compression.
Prevalence and significance of thrombophilia in patients with intermittent claudication
Authors: Evans S M , Brittenden J , Adam D J , Ludlam C , Bradbury A W
Published: March 2003

Background

Thrombophilia may be associated with premature atherosclerosis, an increased susceptibility to primary arterial thrombosis and an increased failure rate for peripheral vascular or endovascular interventions. The aim of this study was to determine the prevalence of thrombophilia in patients with intermittent claudication (IC).

Methods

This was a prospective study of 116 consecutive new patients (70 men; median age 65 (range 43–84) years) referred to this regional vascular surgery unit with IC. Patients on warfarin, or who had previously undergone lower limb reconstruction and/or angioplasty, were excluded.

Results

Thrombophilia was demonstrated in 24 patients (21 per cent). The commonest abnormality (15 patients, 13 per cent) was a raised level of anticardiolipin antibody (ACLA) (11 immunoglobulin (Ig) M, four IgG). Other abnormalities comprised: lupus anticoagulant (one), protein C deficiency (two), protein S deficiency (two), activated protein C resistance (one) and factor V Leiden heterozygosity (three). All abnormalities were confirmed on repeat testing. No patient had a history of venous thrombosis. There was no statistically significant relationship between ACLA status and age, sex, ankle: brachial pressure index, previous myocardial infarction or stroke, previous carotid endarterectomy or coronary artery surgery, serum cholesterol, current use of antiplatelet agents or current smoking status.

Conclusion

Almost one-quarter of new patients referred to this regional vascular unit with IC have thrombophilia; over half of those affected have a raised ACLA level compatible with the antiphospholipid syndrome. At present, the clinical significance and management implications of these abnormalities remain unknown.
Review of out-of-hours vascular procedures in a tertiary vascular unit
Authors: Kelly M , Potter K , Nassef A , Jacob S , Loosemore T , Dormandy J , Taylor R
Published: March 2003

Background

The aim of this study was to review out-of-hours vascular procedures in a tertiary vascular unit.

Methods

The vascular emergencies that presented outside normal working hours (17.00 to 08.00 hours) in a vascular unit between January and June 1998 were reviewed. Only cases considered to be life or limb threatening and requiring urgent surgical or radiological intervention were assessed.

Results

The Table shows that a significant number of vascular emergencies was performed out of hours in one unit. This was, in part, due to an increase in the number of tertiary referrals, which represented 57 per cent of all emergency procedures. Reasons for the tertiary referrals were: no consultant vascular surgeon on call (33 per cent), no consultant interventional radiologist on call (26 per cent), lack of intensive care beds (30 per cent) and complex procedure (11 per cent). The overall mortality rate of patients referred in this period was 15 per cent. The unit has three consultant vascular surgeons, two consultant interventional radio- logists and one vascular specialist registrar.

Conclusion

The significant increase in out-of-hours vascular emergencies, both surgical and radiological, has placed an enormous demand on senior members of the team. In addition, it has had a significant impact on the unit's elective admissions and waiting lists, in particular those for routine general surgery. To support the growth in complex emergency referrals, senior vascular fellows in both vascular surgery and radiology have been appointed and proposals are underway to restructure local vascular services.
VSS abstracts
Authors: Woodcock S A , Hulton N
Published: March 2003

Background

A new emergency vascular cover service came into effect on 1 May 1997 involving three district general hospitals, eight surgeons and covering a patient population of 600 000. Each week one of the three hospitals is on call, accepting the transfer of patients requiring urgent surgical or radiological vascular intervention between 17.00 and 09.00 hours each weekday and throughout the weekend from the other two hospitals. The aim of this project was to evaluate the pattern, appropriateness of referral and increased workload in the first year following the implementation of this model of emergency vascular cover.

Methods

A retrospective study of case notes was conducted identifying all acute vascular emergency admissions from each hospital.

Results

The total number of emergency admissions when on call was 140; 71 per cent were admitted via bed bureau/accident and emergency, 26 per cent were transfers from the other two hospitals and 3 per cent were transfers from elsewhere. Some 66 per cent of admissions occurred between 17.00 and 09.00 hours or at weekends; 36 per cent required emergency operation. Of these patients, 42 per cent required abdominal aortic aneurysm repair, 42 per cent an embolectomy, 11 per cent an amputation and 5 per cent another procedure. Consultants performed 58 per cent of the emergency operations, specialist registrars 37 per cent and senior house officers 5 per cent. Of the total number of emergencies admitted, 12 per cent required intensive care unit facilities. Some 63 per cent of the patients were finally discharged, 11 per cent were transferred and 25 per cent died.

Conclusion

These data demonstrate that one consultant-led vascular team can provide an out-of-hours emergency vascular service for a population served by three hospitals. The workload is manageable without the predicted drain on resources and is preferred by the participating consultants.
Avoiding the complications of thrombolysis
Authors: Thomas S M , Gaines P A
Published: March 2003

Background

NATALI is a voluntary database of patients undergoing peripheral vascular thrombolysis run on behalf of the Thrombolysis Study Group. The size of the data set allows analysis to identify predictors of outcome and complications. These may be patient factors or variables related to the technique used.

Methods

Since its inception on 1 January 1990, 798 thrombolytic events have been recorded. Details are collected on a wide range of factors: perceived risk factors; details of thrombolysis technique; complications; outcome; and adjunctive procedures. Using univariate and multivariate analysis, factors associated with an increased risk of complications were investigated.

Results

Death and complications (perilysis) occurred in 25·9 per cent of episodes (n = 207). Patient factors were the main influence on the risk of complications. Increasing age, use of aspirin and thrombolysis of grafts were significantly associated with an increased risk of complications after adjustment for confounders (P < 0·05). Female sex, the presence of peripheral vascular disease and Fontaine class were of borderline significance. Other patient factors were not associated with an increased risk of complication. Aspects of radiological technique, such as agent used, sheath size, length of lysis, dose of lysis, use of heparin or adjunctive procedures, had no relationship to the rate of complications.

Conclusion

Case selection is the most important factor influencing the occurrence of complications. Radiological technique does not seem to influence the occurrence of complications.
Results of the carotid and vertebral artery transluminal angioplasty study
Authors: Brown M M
Published: March 2003

Background

Trials have demonstrated the benefit of surgery for severe carotid stenosis, but there is still significant morbidity from the operation. Percutaneous transluminal angioplasty (PTA) avoids general anaesthesia and trauma from a neck incision, but has not yet gained acceptance for carotid stenosis because of concern about the risks. The Carotid And Vertebral Artery Transluminal Angioplasty Study was established to investigate the risks and benefits of cerebrovascular PTA.

Methods

Twenty-four centres in Europe, Australia, Canada and the USA collaborated to randomize 504 patients (mean age 67 years; 69 per cent men) with carotid stenosis to surgery (n = 253) or angioplasty (n = 251) between 1992 and 1997.

Results

Some 90 per cent of the patients were recently symptomatic. PTA was carried out using balloon catheters with the adjunctive use of stents in 26 per cent. Mean carotid stenosis by the common carotid method was 87 per cent. Safety analysis by intention to treat showed no difference in the primary outcome measure of disabling stroke or death within 30 days of treatment (surgery, 6 per cent; PTA, 6 per cent). Cranial nerve injury and myocardial ischaemia were only reported at the time of treatment in the surgical group. Long-term survival curves showed no difference in ipsilateral stroke during follow-up.

Conclusion

Carotid surgery and angioplasty are equivalent in safety and efficacy, but angioplasty has advantages with respect to nerve injury and cardiac complications.
Laparoscopic surgery for large hiatus hernia
Authors: Davies N , Toh S , Waston D I , Devitt P G , Jamieson G G
Published: March 2003

Background

The results of laparoscopic surgery for large symptomatic hiatus hernia were revieved prospectively.

Methods

This was a prospective review of large (greater than 10 cm) hiatus hernias treated by laparoscopic surgery at the Royal Adelaide Hospital from January 1994 to July 1997. Demographic data, preoperative investigations, operative findings, operating times, conversion rate, complications and follow-up were recorded prospectively.

Results

Some 48 patients with a large hiatus hernia were treated laparoscopically. All had repair of the hiatal pillars and 47 had a fundoplication. The median age was 58 (range 30–87) years and there were 25 women. There were 11 sliding, eight paraoesophageal and 29 mixed hiatus hernias, and 20 completely intrathoracic stomachs. Median operating time was 75 (range 48–195) min and there were 12 conversions to an open operation; four because of difficulty reducing the hernia, three for obesity, two for bleeding, two because it was not possible to define the anatomy and one for gastric perforation. The majority of conversions occurred earlier in this experience and a change in technique to dissecting the sac out of the thoracic cavity reduced the conversion rate (38 to 15 per cent; P = 0·03, Fisher's exact test). Complications occurred in eight patients and resulted in early reoperation in two (one open and one laparoscopic). There was no death. The median stay was 3 (range 2–10) days. At a median follow-up of 19 (range 3–46) months, eight patients had minor dysphagia and two patients had an incisional hernia (both converted to open operation). One patient had a recurrent paraoesphageal hernia at 6 months and required further surgery. Median satisfaction scores were 10 (range 7–10) of 10 and all patients said they would have the operation again.

Conclusion

Large hiatus hernias can be effectively treated laparoscopically. The initial high rate of conversion to open operation was reduced by a change in operative technique.