bluuebunny/crossref_metadata_2025 huggingface dataset:
Distal venous arterialization for non-reconstructable arterial disease
Authors: Jacob S , Nassef A , Belli A M , Dormandy J A , Taylor R S
Published: March 2003

Background

Despite advances in vascular surgical and interventional radiological techniques, 14–20 per cent of patients with critical lower limb ischaemia will not be suitable for distal arterial reconstruction owing to occlusion of crural and pedal vessels. Following investigation into the venous anatomy of the foot, the disease-free venous bed was used as an alternative conduit for perfusion of peripheral tissues.

Methods

For 22 months, venous arterialization was performed for all patients with non-reconstructable disease but potentially salvageable feet. There were 15 patients; 14 had surgery for chronic ischaemia and one for acute embolization from a popliteal aneurysm after unsuccessful thrombolysis. The inflow vessel was the common femoral artery in 12 and the popliteal artery in three patients. Reversed contralateral long saphenous vein was used in five, a composite graft in three and a polytetrafluoroethylene graft with vein patch in the remaining seven. The distal anastomosis was to the dorsal venous arch (13 cases) and in two to vena comitantes of the posterior tibial vein owing to extensive tissue loss. Various techniques were employed to destroy the valve.

Results

Three procedures failed immediately after operation and major amputation was required. The remaining 12 patent grafts were monitored by duplex scan; two required intervention to correct distal anastomotic stenosis by angioplasty and atherectomy (one patient each). The limb salvage rate at 2–22 months of follow-up was 80 per cent.

Conclusion

Distal venous arterialization is a unique and promising operation which merits further evaluation.
Prospective randomized double-blind placebo-controlled crossover study to assess the effect of sublingual glyceryl trinitrate in patients with intermittent claudication
Authors: Walker S R , Heer R , MacSweeney S T
Published: March 2003

Background

The effect of sublingual glyceryl trinitrate (GTN) on the claudication distance (CD) and maximum walking distance (MWD) of patients with intermittent claudication was assessed.

Methods

Inclusion criteria were: history of intermittent claudication; resting ankle: brachial pressure index (ABPI) of 1·00 or less; fall in ABPI of more than 0·1 following exercise; and patient not taking nitrates. In the first study 22 patients (median age 69 (range 60–73) years, 16 men, five diabetic, median resting ABPI 0·57 (range 0·1–0·64)) had their CD and MWD measured on a treadmill set at 3·2 km h–1 and 10 per cent gradient. They were then randomized to either GTN or placebo spray, and the distances were remeasured. The crossover portion of the study was then completed. In the second study 28 patients (median age 68 (range 45–84) years, 20 men, six diabetic, median resting ABPI 0·57 (range 0·13–0·98)) were randomized to either GTN or placebo and walked at their own pace along a flat corridor for 15 min. Following a rest of 15 min, the crossover portion of the study was completed. Statistical analysis was by the Wilcoxon matched pairs signed rank test.

Conclusion

GTN can increase the MWD by 19 per cent when patients with intermittent claudication are walked on a treadmill and by 9 per cent when walking at their own pace on a flat gradient.
In situ replacement of infected aortic grafts with rifampicin-bonded prostheses
Authors: Nasim A , Hayes P , London N , Barrie W W , Bell P R F , Naylor A R
Published: March 2003

Background

Prosthetic graft infection following abdominal aortic aneurysm (AAA) surgery is life threatening. Treatment options include total graft excision and extra-anatomic bypass or in situ replacement of the graft. The latter option is gaining popularity but the long-term outcome remains uncertain, particularly in light of the increasing prevalence of methicillin-resistant Staphylococcus aureus (MRSA) infection. A retrospective study was undertaken to assess the outcome after graft excision and in situ replacement with a rifampicin-bonded prosthesis for the treatment of major aortic graft infection. The prevalence of MRSA and its influence on outcome was also assessed.

Methods

Over 6 years between January 1992 and December 1997, 11 patients (eight men) with major aortic graft infection underwent total graft excision and in situ replacement with a rifampicin-bonded prosthesis.

Results

The median age was 66 (range 49–78) years. Four patients presented with haemorrhage from an aortoenteric fistula, three had retroperitoneal abscess, two had graft occlusion, one had a perigraft collection on computed tomography and one presented with a ruptured suprarenal false aneurysm. Organisms were cultured from ten patients. Staphylococcus epidermidis and Streptococcus faecalis were predominant. MRSA was isolated from two patients, both of whom had originally undergone ruptured AAA repair. Two patients died and three suffered non-fatal complications. Two patients died during follow-up, one from suspected ongoing MRSA infection and the other from recurrent graft infection. Seven patients remain alive and clinically free from infection, although two were lost to follow-up at 12 and 15 months.

Conclusion

The long-term results following total graft excision and in situ replacement with a rifampicin-bonded prosthesis appear to be favourable. MRSA infection seems to be associated with a poor prognosis.
Inhibition of systemic fibrinolysis is associated with myocardial injury in patients operated on for ruptured abdominal aortic aneurysm
Authors: Adam D J , Evans S M , Ludlam C A , Bradbury A W
Published: March 2003

Background

Previous work has demonstrated that ruptured abdominal aortic aneurysm (AAA) is associated with systemic thrombin generation and inhibition of systemic fibrinolysis. The procoagulant and hypofibrinolytic state associated with ruptured AAA predisposes to microvascular and macrovascular thrombosis and subsequent myocardial injury. The aim of this study was to determine the relationship between haemostatic derangement and biochemical evidence of myocardial injury in patients operated on for ruptured AAA.

Methods

Ten patients undergoing repair of ruptured AAA were studied. Tissue plasminogen activator (tPA) activity, plasminogen activator inhibitor (PAI) activity, prothrombin fragment (PF) 1 + 2, D-dimer and fibrinogen levels were measured before operation, and immediately before and 5 min after aortic clamp release. Plasma levels of cardiac troponin (cTn) I were measured before operation, and 6 and 24 h after aortic clamp release.

Results

There was no relationship between tPA activity, PF 1 + 2, D-dimer or fibrinogen and cTn-I levels at any sampling point. There was, however, a significant positive correlation (Spearman rank test) between PAI activity immediately before (median 38·6 (range 13·0–39·4) units ml–1) and 5 min after (37·2 (10·6–39·4) units ml–1) aortic clamp release, and cTn-I at 6 h (median 3·17 (range less than 0·5 to 71·1) ng ml–1) and 24 h (5·55 (range less than 0·5 to 110) ng ml–1) after aortic clamp release.

Conclusion

These data strongly support the hypothesis that the inhibition of systemic fibrinolysis which occurs in response to ischaemia and reperfusion during ruptured AAA repair contributes to the development of subsequent myocardial injury.
Endovascular aortic aneurysm repair reduces mortality: a physiological analysis
Authors: Treharne G D , Thompson M M , Whiteley M W , Bell P R F
Published: March 2003

Background

Endovascular techniques are gaining acceptance as minimally invasive methods for abdominal aortic aneurysm repair, although there have been few studies that provide direct comparison with conventional techniques. A prospective study that compares morbidity and mortality rates following abdominal aortic aneurysm repair, using a physiological scoring system, is presented.

Methods

Between December 1994 and November 1997, 104 elective open aneurysm repairs and 49 endovascular aneurysm repairs were performed at this institution. These patient cohorts were compared using the Portsmouth predictor equation scoring system, which has been shown to predict outcome in vascular surgery. Prospective data from patient notes were used to obtain physiological and operative severity scores that were analysed to predict expected (E) to observed (O) mortality and morbidity rates.

Results

Although physiological variables were equivalent in both groups, conventional surgery had a higher mortality (P < 0·05) and morbidity (P < 0·001) rate than endovascular surgery, which was related to the operative severity scores.

Conclusion

These data suggest that open aortic aneurysm repair has a higher operative severity than endovascular repair which may be reflected in increased mortality rates.
Influence of contralateral stenosis on long-term mortality rate following carotid surgery
Authors: Black D , Renwick P , Naidu S , McCollum P
Published: March 2003

Background

Recent evidence suggests that high-grade contralateral stenosis has an adverse effect on perioperative morbidity in carotid endarterectomy (CEA). The relationship between contralateral high-grade stenosis and long-term survival after CEA was examined.

Methods

Three hundred and twenty-seven patients undergoing 333 CEA operations were entered prospectively into a database and long-term follow-up was instituted. Cardiac and stroke risk factors were identified before operation and correlated with long-term survival and cause of death.

Results

Mean age at operation was 68 (range 42–86) years. Median follow-up was 2 (range 1–8) years. There were 45 deaths (seven perioperative), 17 myocardial, 16 from stroke (four perioperative), five from neoplasia, three respiratory and four others. The cumulative 5-year survival rate was 75 per cent. Patients with high-grade contralateral stenosis (greater than 80 per cent) had a significantly reduced life expectancy after CEA (P< 0·05).

Conclusion

Severe contralateral carotid disease is not only an adverse perioperative risk factor but also has negative implications for survival of the patient in the longer term. Following CEA, patients in general have a lower life expectancy than a normal age-matched population.
Randomized controlled trial of heparin plus graduated compression stocking for the prophylaxis of deep venous thrombosis in general surgical patients
Authors: Perkins J , Beech A , Hands L
Published: March 2003

Background

A randomized controlled study was undertaken to compare heparin with heparin plus graduated compression stockings (Brevet Tx, Seton Healthcare) in the prophylaxis of deep vein thrombosis (DVT) following abdominal surgery.

Methods

Sixty high-risk patients were recruited if they met at least two of the following criteria identified as predisposing to DVT: age greater than 39 years, malignancy, varicose veins, cardiac disease or hypertension, diabetes mellitus, obesity or previous thromboembolic episode. All patients received subcutaneous heparin and were randomized to receive Brevet Tx to either the right or left leg before surgery. The stocking was worn for 2 weeks after surgery. The patients underwent duplex imaging before surgery, and at 3, 6 and 14 days after operation. All scans were performed by one sonographer. The policy was to perform a venogram where a positive result was indicated by duplex scanning.

Results

Fifty-six patients completed the study. Six patients (11 per cent) suffered a DVT in the non-stockinged leg, but none in the stockinged leg (P = 0·016, McNemar's test). The DVTs occurred on days 3, 6, 7, 8, 9 and 12 following surgery.

Conclusion

Brevet Tx in addition to low-dose subcutaneous heparin significantly reduced the incidence of DVT in high-risk patients undergoing abdominal surgery.
Caval filters are an underexploited therapy for acute pulmonary embolism
Authors: Tai N R M , Atwal A , Handa A , Platts A , Hamilton G
Published: March 2003

Background

Inferior vena caval filters are a recognized intervention for recurrent pulmonary embolism (PE). Filter utilization in the UK is considerably less than in Europe; this may partly be due to omission of referral of appropriate patients.

Methods

A cohort with the prospect of benefit from caval filter insertion was identified by retrospective study of inpatients who died within 30 days of a positive ventilation-perfusion (V/Q) scan over 2 years. The number of actively managed patients in this group who fulfilled the recognized criteria for caval filter insertion was determined.

Results

Fifty-two of 606 patients died within 30 days of scanning. Information was available on 38 (73 per cent) of 52 who had 39 scans (14 positive, 22 negative, three indeterminate). Six of 14 patients (two men and four women, aged 46–84 years) with a positive scan had strong indications for caval filter deployment including contraindication to anticoagulation (three), recurrent PE despite adequate anticoagulation (two) and complications arising from anticoagulation (one). All six died following continuing embolism or complications from anticoagulation.

Conclusion

Six of 14 patients who died following acute PE required caval filtration but were not offered this intervention. Failure to refer patients who would benefit from filtration may partially account for the disparity in utilization of caval filters between the UK and Europe. Furthermore, because of the choice of death as outcome marker, this study underestimated the value of caval filter utilization.
Limb salvage in the octogenarian
Authors: Ramamoorthy P , Johnson B J , Wilkinson A R , Galloway J M , McCollum P T
Published: March 2003

Background

Critical limb ischaemia (CLI) presents a unique set of problems in the elderly patient. Foremost among these is the much greater likelihood of loss of independence and reduced quality of life if major amputation is required. For this reason it has been this unit's policy to attempt reconstructive vascular surgery in almost all cases of CLI. The outcome of this policy was examined.

Methods

All patients had surgery performed under one consultant and data were entered prospectively on to a database.

Results

Risk factors included diabetes (17 per cent), smoking (78 per cent) and ischaemic heart disease (31 per cent). Some 127 patients had either femoropopliteal (59), femorodistal (64) or popliteal–distal grafts (four) performed for limb-threatening ischaemia. Follow-up was performed at 3, 6 and 12 months and then at annual intervals until death. Seventeen of these patients required a subsequent major amputation, 12 at the below-knee and five at the above-knee level. Mean follow-up was 2 years. The perioperative mortality rate was 15 per cent, although eight of these patients were admitted with acute or chronic ischaemia. Cumulative graft secondary patency rate was 68 per cent at 4 years for vein grafts. Some 95 per cent of patients with patent grafts were independently mobile.

Conclusion

Excellent results can be achieved for limb salvage with a relatively low morbidity in this group. Elderly patients with CLI do not live long and avoidance of amputation is particularly desirable in order to maximize the quality of their remaining life.
Patients with a failed infrainguinal bypass graft have abnormal lipid metabolism
Authors: Lewis D R , Taberner P V , Lemon M J C , Day A , Shih M F , Brooks S T , Bird R N , Lamont P M , Smith F C T
Published: March 2003

Background

Dyslipidaemias adversely affect vascular tone, endothelial function and platelet activation. Abnormal lipid metabolism has not been established as a risk factor for infrainguinal bypass graft failure. Lipid metabolism was evaluated prospectively in patients with patent and occluded grafts.

Methods

Twenty-eight patients with failed infrainguinal grafts (group 1) were identified from a prospective computerized database. Twenty matched controls with functioning grafts (group 2) were recruited from a graft surveillance programme. Fasting blood samples were analysed for triglyceride (TG), high-density lipoprotein (HDL) and cholesterol. A newly devised rapid TG tolerance test was conducted with analysis of TG at 1, 2 and 2·5 h. Endothelial lipoprotein lipase (LPL) was measured 30 min after intravenous administration of heparin 50 units kg–1.

Results

The cholesterol: HDL ratio was significantly higher in group 1 than group 2 (median 6·0 (range 3·1–10·0) versus 4·7 (2·3–9·4); P= 0·0008, Mann–Whitney test) as was fasting TG (2·6 (1·0–6·3) versus 1·7 (0·6–4·7) mmol l–1; P= 0·03). The area under the curve of the TG tolerance test was not significantly different (P= 0·08); however, the 2·5-h levels of TG were significantly different between the groups (group 1, 2·0 (0·5–6·6) mmol l–1; group 2, 1·2 (0·3–6·8) mmol l–1; P= 0·01). LPL was significantly lower in group 1 (52·4 (2·2–235·9) versus 86·8 (28·6–281·5) mmol/l; P= 0·04).

Conclusion

These data suggest that abnormal lipid metabolism is a significant risk factor for infrainguinal graft occlusion. This study provides a rationale for randomized trials of lipid-modifying therapies in patients undergoing arterial reconstruction for peripheral vascular disease.
Endovascular aneurysm repair: the need for randomized controlled trials
Authors: Brennan J , Harris P L , Gilling-Smith G L , Bakran A
Published: March 2003

Background

An audit of endovascular aneurysm repair (EVAR) was undertaken in order to assess the efficacy of this new approach in the treatment of abdominal aortic aneurysm.

Methods

An international register of EVAR was started in 1996, with emphasis on close follow-up.

Results

Data have now been accumulated for 895 cases. The 30-day mortality rate is low at 3 per cent; patients who died generally had major co-morbidity. At discharge 14 per cent were identified as having an endoleak (persistent blood flow outside the lumen of the endoluminal graft but within the aneurysm sac) and another 18 per cent developed new endoleaks during the first year of follow-up. Continued expansion of the aneurysm was observed in 22 per cent. This occurred in 53 per cent of patients with an identified endoleak compared with 11 per cent of those in whom no endoleak was demonstrated (P < 0·01). Aneurysm rupture after EVAR occurred in six patients, three of whom died.

Conclusion

That EVAR is technically feasible is beyond doubt. Close follow-up has identified problems specific to the minimally invasive approach. The significance of endoleaks in particular remains unclear, but the strong association with continued aneurysm expansion is of concern. The primary purpose of EVAR, however, is to prolong life and in this study the cumulative 2-year survival rate (including operative deaths) was 85 per cent. In patients without any complications the benefits of the minimally invasive approach are readily apparent. Thus, while there is no place for unrealistic optimism, there certainly appears to be a role for EVAR. To prevent inappropriate widespread application of this new approach, or indeed unwarranted condemnation, randomized controlled trials comparing EVAR with conventional management are essential.
Prospective study examining differences in quality of life between patients surviving 2 years after oesophagectomy and patients dying within 2 years of surgery
Authors: Blazeby J M , Farndon J R , Alderson D
Published: March 2003

Background

Quality of life (QL) measurement is important for patients with oesophageal cancer but longitudinal studies may contain a bias because assessments only include healthy survivors who are able to complete questionnaires. This study examined QL in patients undergoing oesophagectomy by comparing results from those surviving 2 years after operation with results from patients dying within 2 years.

Methods

Between November 1993 and May 1995, 52 patients (36 men; mean age 67 years) underwent oesophagectomy. Prospective QL assessments were performed with the European Organisation for Research on Treatment of Cancer QLQ-C30 and the dysphagia scale from the oesophageal cancer module before treatment, 6 weeks, 3, 6, 9 and 12 months after operation, and at 6-month intervals thereafter, for a minimum of 3 years after operation. Mortality and morbidity rates and survival data were recorded.

Results

Two years after operation, 17 patients (33 per cent) were alive (group 1) and 35 had died (group 2). Groups were comparable for age, sex, tumour histology and length, dysphagia grade and performance scores. Six weeks after surgery patients in group 1 had worse functional, symptom and global health QL scores than before treatment. These subsequently improved such that by 9 months after operation most QL scores had returned to preoperative levels, except for persisting problems with dyspnoea and diarrhoea. Six weeks after operation patients in group 2 also reported worse QL in all domains, but this never recovered. Six months after treatment patients in group 2 had significantly worse physical, role, emotional and social function than those surviving 2 years and significantly more problems with appetite loss (P < 0·001). The notable exception in both groups was dysphagia, which improved after operation. This improvement was maintained until death or for the duration of the study.

Conclusion

Patients dying within 2 years of operation suffer an irreversible loss of QL, except that dysphagia is relieved. Further work is needed to assess whether additional postoperative support or the use of multimodality adjuvant treatment can improve the outcome for this group of patients.
Tonometric measurement of gastric intramucosal pH following oesophagectomy predicts postoperative complications
Authors: Boyle N H , Owen W J , Pearce A C , Hunter D , Beale R J , Mason R C
Published: March 2003

Background

Gastric mucosal hypoperfusion can be assessed tonometrically by measuring the gastric intramucosal pH (pHi); its ability to predict outcome in the critically ill has been demonstrated previously. This study employed the new technique of recirculating gas tonometry to measure gastric pHi following oesophagectomy; its ability to predict anastomotic complications was tested, since ischaemia at the oesophagogastric anastomosis is thought to be an important factor in their aetiology.

Methods

A gastric tonometer was placed in the gastric tube of 28 consecutive patients undergoing oesophageal resection. They were connected to a Tonacap analyser (Datex-Engstrom Division, Instrumentarium Corporation, Helsinki, Finland) which automatically samples gas from the intragastric tonometer balloon and measures the carbon dioxide concentration within it. In conjunction with simultaneously taken arterial blood samples, gastric pHi was calculated at the end of the operation and then at 12-h intervals for up to 48 h after operation. Patients who survived were followed for 3 months and all postoperative complications were recorded. Statistical comparison was made using the independent samples t test.

Results

Eight patients suffered an anastomotic leak or benign stricture after operation; five others had a life-threatening complication not thought to be related to the anastomosis, of whom two survived. Over the first 24 h after operation median gastric pHi was lower at all three measurement points in the complication group than in the no complication group (P > 0·05 in all cases). However, at 36 and 48 h there were significant differences (in both cases P < 0·01); at these times median (range) pHi in the complication group was 7·19 (7·00–7·24) and 7·20 (7·03–7·49) respectively, and in the no complication group 7·28 (7·12–7·39) and 7·32 (7·25–7·44). A mean pHi at 36 and 48 h after operation of 7·25, with both measurements less than this value as a discriminating coefficient, was employed. This had a sensitivity of 92 per cent and a specificity of 92 per cent for predicting all complications. Applied specifically to anastomotic complications the sensitivity was 100 per cent and specificity 92 per cent.

Conclusion

Gastric pHi is easily measured after operation using recirculating gas tonometry. By taking measurements at 36 and 48 h, it appears possible to predict postoperative complications following oesophagectomy and the technique may provide a useful adjunct to the monitoring of these patients.
Lateral resection margin and prognosis following R0 resection for oesophageal carcinoma
Authors: Dexter S P L , Mapstone N , Martin I G
Published: March 2003

Background

For patients with rectal carcinoma, the finding of tumour within 1 mm of the circumferential resection margin is of independent prognostic importance. For patients undergoing oesophageal resection the significance of finding tumour within 1 mm of the lateral margin has not been described prospectively.

Methods

A series of 68 patients undergoing radical R0 oesophagectomy for carcinoma (46 adenocarcinomas) was studied prospectively. The resection specimens were examined prospectively by one pathologist and staged using the 1987 tumour node metastasis (TNM) classification. In addition, specimens in which tumour cells were seen within 1 mm of the lateral margin were regarded as being circumferential margin (CRM) positive. Survival was calculated using the Kaplan–Meier method and the Cox hazard model was used to identify independent effects on survival.

Results

The overall 3-year survival rate was 30 per cent (56 per cent stage I, 42 per cent stage II and 19 per cent stage III; P < 0·04). Although for patients with the CRM involved (n = 38) the survival rate was 20 per cent compared with 40 per cent in those in whom tumour was more than 1 mm from the lateral margin (P = 0·15), using Cox's proportional hazards model the effect of CRM involvement was not independent of the TNM stage.

Conclusion

The impact of CRM involvement in oesophageal cancer may be less marked than for rectal carcinoma. A larger study is needed to quantify the true importance of CRM involvement, particularly with the increasing use of neoadjuvant therapies.
Management of proximal axillary and subclavian artery injuries
Authors: McKinley A G , Carrim A T O Abdool , Robbs J V
Published: March 2003

Background

The aim of this study was to review the management and outcome of proximal axillary and subclavian artery injuries, and to estimate the prehospital mortality rate for subclavian injury through forensic pathology autopsy data.

Methods

Data were collected prospectively for 260 patients who presented between 1977 and 1996 with trauma to the proximal axillary and subclavian arteries.

Results

The majority of victims (214, 82 per cent) were admitted following stab injury. Some 154 patients (59 per cent) presented within 24 h of sustaining an injury and, of these, 59 (38 per cent) required immediate surgery. An additional 67 patients (26 per cent) attended 2 days or more after injury. Comparison of these data with those from forensic autopsy reports suggests that the prehospital mortality rate for penetrating subclavian trauma was approximately 75 per cent.

Conclusion

Approximately 25 per cent of subclavian artery injuries caused minimal initial symptoms but delayed complications prompted attendance for medical attention. The majority of patients who survived subclavian artery injury and attended for medical attention were haemodynamically stable on admission; selective arteriography provided valuable information in these patients. Supraclavicular and infraclavicular incisions avoided clavicular division and reduced the postoperative morbidity associated with distal subclavian artery injuries.
Role of relaparoscopy in the management of minor bile leakage after laparoscopic cholecystectomy
Authors: Wills V L , Jorgensen J O , Hunt D R
Published: March 2003

Background

Bile leakage in the absence of major ductal injury may occur from the liver bed or from the cystic duct remnant after cholecystectomy. The early limitations of minimally invasive surgery led to reliance on endoscopic methods to manage this complication. However, repeat laparoscopy permits drainage of the bile collection and direct control of the site of leakage in selected situations.

Methods

Details of 15 patients with bile leakage after laparoscopic cholecystectomy were recorded prospectively and are reviewed.

Results

Postoperative bile leakage occurred after 15 (0·8 per cent) of 1779 laparoscopic chole-cystectomies. Two patients with bile in drainage fluid had spontaneous resolution. Ten patients with a subvesical duct leak had repeat laparoscopy. The leak was successfully controlled by suturing in eight patients, and by a laparoscopically placed drain in two. One patient required a subsequent laparotomy for a loculated pelvic collection. Three patients had cystic duct stump leakage. This was managed successfully by laparoscopy in one case but required endoscopic management in two.

Conclusion

Laparoscopy is useful in the management of minor bile leaks after laparoscopic chole-cystectomy. Selection of appropriate patients relies on a characteristic clinical presentation after an otherwise uncomplicated cholecystectomy.
Behavioural treatment (biofeedback) for constipation following hysterectomy
Authors: Roy A J , Emmanuel A V , Storrie J B , Bowers J , Kamm M A
Published: March 2003

Background

Constipation after hysterectomy has been postulated to be due to pelvic nerve damage, but there may be emotional or reversible physical factors of pathophysiological relevance. The aim of this study was to determine whether such constipation is responsive to behavioural treatment.

Methods

Three groups of patients who had completed a course of biofeedback treatment were compared: women with no history of abdominal or pelvic surgery (n = 25), women for whom a hysterectomy had led to no change in bowel function (n = 27) and women who stated that their constipation was precipitated (n = 18) or severely worsened (n = 8) by hysterectomy. Pretreatment and post-treatment details about bowel function and symptoms were assessed using structured interview, and pretreatment whole-gut transit time and anorectal physiology testing were assessed for prognostic relevance.

Results

Follow-up after completing treatment was a median of 28 (range 12–44) months. Forty-eight of 78 patients considered that their constipation had improved with treatment; the proportion in each group was similar (P = 0·73). Biofeedback reduced the need to strain, reduced abdominal pain, improved bowel frequency, and reduced laxative use to a similar degree in all three groups. Thirty-three of 53 patients with slow transit considered there was an improvement, compared with 15 of 22 with measured normal transit. Physiological testing did not predict outcome and did not differ between the three groups.

Conclusion

The majority of patients complaining of constipation induced or worsened by hysterectomy respond subjectively to behavioural treatment, in a similar proportion to those with idiopathic constipation. In contrast to the widely held view that nerve damage is responsible for symptoms, reversible factors are likely to be important in many patients.
Genetic predisposition to breast cancer: a surgical perspective
Authors: Sakorafas G H , Tsiotou A G
Published: March 2003

Background

Molecular alterations in proto-oncogenes, tumour suppressor genes, and genes that function in DNA damage recognition and repair are considered to be hallmarks of a carcinogenic process, including breast carcinogenesis.

Methods

A computer-assisted search of the English literature (Medline database, 1990–1999) was performed, followed by a manual search of the reference list of pertinent articles retrieved.

Results

Hereditary breast cancer accounts for 5–10 per cent of all breast cancer cases. About 90 per cent of hereditary breast cancers involve mutation of the BRCA1 and/or BRCA2 genes. Other cancer-related genes (including myc, c-erbB2, Tsg101 and Mdgi) are involved in breast carcinogenesis, but they do not give rise to familial breast cancer syndromes. Risk estimation is the most important clinical implication. Management options for the high-risk mutation carriers include cancer surveillance and preventive strategies (prophylactic surgery or chemoprevention).

Conclusion

Despite inadequate knowledge about the genetic predisposition to breast cancer and its clinical implications, the demand for genetic testing is likely to expand rapidly. In addition to risk estimation, cancer surveillance and preventive strategies, gene therapy offers a new and theoretically attractive approach to breast cancer management.
Beneficial effects of arterialization of the portal vein on extended hepatectomy
Authors: Shimizu Y , Miyazaki M , Shimizu H , Ito H , Nakagawa K , Ambiru S , Yoshidome H , Nakajima N
Published: March 2003

Background

Extended hepatectomy may result in postoperative liver failure. The aim of this study was to evaluate the effects of arterialization of the portal vein on oxygen supply, hepatic energy metabolism and liver regeneration after extended hepatectomy.

Methods

Portal haemodynamics were evaluated 0 or 10 days after arterialization of the portal vein in three experimental groups: 85 per cent partial hepatectomy, 85 per cent partial hepatectomy 10 days after arterialization of the portal vein and 85 per cent partial hepatectomy 10 days after ligation of the hepatic artery. Survival rates, weight of the regenerating liver, levels of adenine nucleotides and hepatic energy charge were assessed.

Results

Arterialization of the portal vein caused a significant increase in partial pressure of oxygen and oxygen saturation. Portal blood flow 10 days after arterialization was significantly increased. Survival rate and weight of the regenerating liver in the group with arterialization of the portal vein were significantly higher than those in the other two groups. The group with arterialization of the portal vein showed the highest levels of adenosine 5′-triphosphate.

Conclusion

The increase in portal blood flow and oxygen supply produced by arterialization of the portal vein has beneficial effects on hepatic energy metabolism and liver regeneration, and leads to improved survival after experimental extended hepatectomy.
Preoperative staging of rectal cancer allows selection of patients for preoperative radiotherapy
Authors: Horgan A F , Finlay I G
Published: March 2003

Background

Variability in rates of local recurrence following resection of rectal cancer has led to the suggestion that all patients should undergo preoperative radiotherapy. This centre employs a selective policy of radiotherapy only in patients with evidence of advanced local disease determined by preoperative staging.

Methods

A retrospective review was carried out of 114 consecutive patients with rectal cancer. Patients were divided before operation into palliative and curative groups based on preoperative staging. Only patients in the palliative group were offered preoperative radiotherapy. Total mesorectal excision (TME) was performed for all tumours of the middle or lower rectum.

Results

The perioperative mortality rate was 0·9 per cent and anastomotic dehiscence occurred in 2·8 per cent. Local recurrence developed in 4 per cent of patients in the ‘curative’ group and in seven of 15 of those assigned to the palliative group before operation (P < 0·01). Positive lateral resection margins were significantly associated with a risk of subsequent recurrence (ten of 13 versus three (3 per cent) of 93; P < 0·001).

Conclusion

Preoperative adjuvant radiotherapy can be omitted reasonably in patients in whom there is no evidence of locally advanced disease, provided that adequate surgery, incorporating TME for low tumours, is performed.
Duplex-guided thrombin injection for iatrogenic femoral artery pseudoaneurysm is effective even in anticoagulated patients
Authors: Lennox A F , Delis K T , Szendro G , Griffin M B , Nicolaides A N , Cheshire N J
Published: March 2003

Background

The aim was to evaluate the efficacy and safety of percutaneous thrombin injection as an alternative non-operative method for treating postcatheterization femoral artery pseudoaneurysm in both anticoagulated and non-anticoagulated patients.

Methods

Thirty consecutive patients with a femoral artery pseudoaneurysm secondary to radiological catheterization confirmed by duplex imaging were included. Thrombin 200–2000 units (1000 units/ml) in a titrating dose was injected into the centre of the cavity under duplex ultrasonographic guidance. Thrombosis was assessed in real time using B mode and colour flow. No sedation or anaesthesia was required during the procedure. The distal pulses and ankle pressures were evaluated before and immediately after the injection, to exclude propagation of thrombus into the femoral artery.

Results

Successful rapid thrombosis of the false cavity was induced in all 30 patients. There were no immediate or mid-term procedure-related complications, or recurrences at 6 weeks. Eighteen patients were anticoagulated therapeutically at the time and following the procedure with either heparin or warfarin.

Conclusion

Percutaneous thrombin injection is a simple, quick, painless, safe and effective technique, particularly in patients taking anticoagulants.
Morbidity and functional outcome after double dynamic graciloplasty for anorectal reconstruction
Authors: Rullier E , Zerbib F , Laurent C , Caudry M , Saric J
Published: March 2003

Background

After abdominoperineal resection (APR), anorectal reconstruction with dynamic graciloplasty has been proposed to avoid abdominal colostomy and improve quality of life. Graciloplasties involving one or two gracilis muscles with various configurations have been described. The aim of this study was to evaluate morbidity and functional results in a homogeneous series of patients undergoing double dynamic graciloplasty following APR for rectal cancer.

Patients and methods

From May 1995 to May 1998, 15 patients (ten men and five women; mean age 54 (range 39–77) years) underwent anorectal reconstruction with double dynamic graciloplasty after APR for low rectal carcinoma. All patients had preoperative radiotherapy (45 Gy), 11 with concomitant chemotherapy, eight had intraoperative radiotherapy (15 Gy) and ten received adjuvant chemotherapy for 6 months. The surgical procedure was performed in three stages: APR with coloperineal anastomosis and double graciloplasty (double muscle wrap); implantation of the stimulator 2 months later; and ileostomy closure after a training period.

Results

There was no operative death. At a mean of 28 (range 3–48) months of follow-up, there was no local recurrence; two patients had lung metastases. Early and late morbidity occurred in 11 patients, mainly related to the neosphincter (12 of 16 complications). The main complication was stenosis of the neosphincter (n = 6), which developed with electrical stimulation. Of 12 patients available for functional outcome, seven were continent, two were incontinent and three had an abdominal colostomy (two for incontinence, one for sepsis). Compared with patients without stenosis, patients with neosphincter stenosis required major reoperations (four versus zero) and had a poor outcome (two of six versus five of six with a good result).

Conclusion

The double dynamic graciloplasty is associated with a high risk of neosphincter stenosis, which may entail morbidity, reintervention and poor functional results. The stenosis is a heterogeneous feature of the neosphincter induced by asymmetrical traction of both gracilis muscles. It is suggested that single dynamic graciloplasty should be used for anorectal reconstruction after APR.
In-hospital delay in the diagnosis of breast cancer
Authors: Jenner D C , Middleton A , Webb W M , Oommen R , Bates T
Published: March 2003

Background

There is evidence that delay in the diagnosis of breast cancer may prejudice survival. The aim of this study was to determine the incidence, time trends and causes of delay in a dedicated breast clinic.

Methods

The interval between first breast clinic visit and a definitive diagnosis was recorded in all patients with invasive breast cancer between 1988 and 1997. In all patients with a delay of 3 months or more, the case notes were reviewed for evidence of a triple assessment (clinical examination, imaging and needle biopsy). The principal cause of delay was identified.

Results

Of 1004 patients with invasive breast cancer, there was a delay in diagnosis of 3 months or more in 42 patients between 1988 and 1997, an incidence of 4·2 per cent. The median delay was 6 months and the median age at diagnosis was 53 (range 27–89) years. Triple assessment was undertaken in 30 patients; ten did not have a needle biopsy performed and three patients had no mammography. The principal cause of delay was: false-negative or inadequate fine-needle aspiration cytology (FNAC) in 19 patients, failure of follow-up in eight, clinical signs did not impress in five, FNAC not carried out in four, false-negative mammogram in three, failure of needle localization in two and one patient did not accept clinical advice. The annual incidence of delay in diagnosis did not change significantly over the 10-year interval.

Conclusion

Triple assessment is not sufficiently sensitive to detect every breast cancer and a small incidence of diagnostic delay is therefore inevitable with current techniques.
Evolution of nutritional support in acute pancreatitis
Authors: Lobo D N , Memon M A , Allison S P , Rowlands B J
Published: March 2003

Background

Acute pancreatitis is a catabolic illness and patients with the severe form have high metabolic and nutrient demands. Artificial nutritional support should therefore be a logical component of treatment. This review examines the evidence in favour of initiating nutritional support in these patients and the effects of such support on the course of the disease.

Methods

Medline and Science Citation Index searches were performed to locate English language publications on nutritional support in acute pancreatitis in the 25 years preceding December 1999. Manual cross-referencing was also carried out. Letters, editorials, older review articles and most case reports were excluded.

Results and conclusion

There is no evidence that nutritional support in acute pancreatitis affects the underlying disease process, but it may prevent the associated undernutrition and starvation, supporting the patient while the disease continues and until normal and sufficient eating can be resumed. The safety and feasibility of enteral nutrition in acute pancreatitis have been established; enteral nutrition may even be superior to parenteral nutrition. Some patients, however, cannot tolerate enteral feeding and this route may not be practical in others. Parenteral nutrition still has a role, either on its own or in combination with the oral and enteral routes, depending on the stage of the illness and the clinical situation.
Bascom's operation in the day-surgical management of symptomatic pilonidal sinus
Authors: Senapati A , Cripps N P J , Thompson M R
Published: March 2003

Background

Many treatments for symptomatic pilonidal sinus disease have been described. Ambulatory treatment with minimal morbidity and a rapid return to normal activity is desirable. Bascom's operation fulfils these requirements. This paper describes the operative technique and results of treatment.

Methods

Some 218 patients of mean age 27 years were treated as day cases. The mean duration of symptoms was 2·4 years. Sixty-eight per cent of patients had complex disease with more than two midline pits and/or a lateral discharging sinus. One hundred and eighty-three patients (84 per cent) were operated on under local anaesthesia.

Results

Ninety-five per cent of patients have been followed up for a mean of 12·1 (range 1–60) months. All except one midline wound healed. Lateral wounds healed after a mean of 4·0 (range 1–15) weeks. Postoperative complications were few, including bleeding in 4 per cent and abscess formation treated by reopening the lateral incision in 6 per cent. Twenty-one patients (10 per cent) have had recurrence and have needed reoperation.

Conclusion

Bascom's operation is simple and results in considerable financial savings with minimal social disruption and an early return to work. Recurrent disease is no more frequent than after other treatments.
Clinical governance and the vascular surgeon
Authors: Irvine C D , Grayson D , Lusby R J
Published: March 2003

Background

Audit of adverse outcome might allow identification of substandard surgical results. To test this hypothesis statistical modelling was applied to two indicator vascular procedures (elective abdominal aortic aneurysm repair and carotid endarterectomy) with accepted adverse event rates.

Methods

Binomial statistical models for varying adverse event rates were constructed. A power calculation was used in an attempt to predict the case numbers required to determine substandard results for individual surgeons and vascular units. Two scenarios were considered: first a base adverse event rate of 6 per cent and surgical practice with 9, 12 and 24 per cent morbidity rates, and second a base adverse event rate of 3 per cent and surgical practice with 6, 9 and 12 per cent morbidity rates.

Results

A mean of 57 elective abdominal aortic aneurysm repairs and 70 carotid endarterectomies were performed per annum. The adverse event rate for both operations was 4 per cent. Power calculations revealed that 130 patients would need to be studied to detect a surgeon with an adverse event rate twice 6 per cent and over 280 patients would be required with an adverse event rate twice 3 per cent. To gather this number of patients 2 years of unit data and between 3 and 22 years of individual data would need to be studied for a base adverse event rate of 6 per cent. A base rate of 3 per cent requires 7–47 years for an individual and 4–65 years for the unit. With a base adverse event rate of 6 per cent, detection of widely variant surgical practice (four times the morbidity rate as base) requires only 21 procedures.

Conclusion

Statistical modelling demands assumptions about accepted adverse event rates, confidence criteria and what constitutes substandard results. Data from large numbers of patients are required even for common operations with accepted adverse event rates. These data raise serious questions as to the feasibility of performing clinical governance on the basis of morbidity and mortality event rates alone.