bluuebunny/crossref_metadata_2025 huggingface dataset:
Peripheral thrombolysis for acute-onset claudication
Authors: Braithwaite B D , Tomlinson M A , Walker S R , Davies B , Buckenham T M , Earnshaw J J
Published: March 2003

Background

The aim of this study was to determine the outcome of patients who presented with sudden onset of incapacitating claudication of less than 2 weeks' duration and who were treated with peripheral arterial thrombolysis.

Methods

The database of the Thrombolysis Study Group was searched retrospectively for patients who received thrombolysis for acute-onset claudication. Some 108 patients (65 men, median age 69 (range 29–94) years) were treated with intra-arterial tissue plasminogen activator at 14 hospitals. The median duration of symptoms was 72 h (range from 2 h to 2 weeks). There were 52 graft and 56 native vessel arterial occlusions.

Results

The immediate outcome of thrombolysis for native vessel arterial occlusion was thrombus clearance in 50 patients (89 per cent) and failed lysis in six (11 per cent). Thirty-six patients (64 per cent) had a secondary radiological or surgical procedure carried out after lysis. After 30 days four patients (7 per cent) had a major amputation, eight (14 per cent) had died, 38 (68 per cent) were symptom free and seven (12 per cent) continued to have claudication. Three patients (5 per cent) suffered a major haemorrhage. The immediate outcome of thrombolysis for graft occlusion was thrombus clearance in 48 patients (92 per cent) and failed lysis in four (8 per cent); 27 patients (52 per cent) had a secondary procedure. After 30 days four patients (8 per cent) had a major amputation, seven (13 per cent) had died, 32 (62 per cent) were symptom free and nine (17 per cent) had persistent claudication. Three patients (6 per cent) suffered a major haemorrhage.

Conclusion

Patients who presented with acute onset of incapacitating claudication had an outcome similar to that after thrombolysis for critical ischaemia. It is recommended that patients who present in this way should be observed and treated with thrombolysis only if they progress to critical ischaemia.
Uptake of tetracycline by aortic aneurysm wall and its effect on inflammation and proteolysis
Authors: Franklin I J , Harley S L , Greenhalgh R M , Powell J T
Published: March 2003

Background

Proteolytic degradation of the aortic wall by matrix metalloproteinases (MMPs) is considered important in the pathogenesis of abdominal aortic aneurysms (AAAs). Many of these MMPs are inhibited by tetracycline derivatives, which may have the potential to retard aneurysm growth.

Methods

Patients undergoing elective repair of an AAA (n = 5) received an intravenous bolus of tetracycline (500 mg) on induction of anaesthesia and levels of tetracycline in serum, aneurysm wall and mural thrombus were assessed by microbiological assay. In a separate series of patients (n = 7) aneurysm biopsies were placed into explant culture (with and without tetracyline) and the accumulation of protein, hydroxyproline, MMP-9, interleukin (IL) 6 and monocyte chemoattractant protein (MCP) 1 in the medium was assessed by colorimetric assay or immunoassay.

Results

At aortic cross-clamping the median concentration of tetracycline was 8·3 µg/ml in serum, 2·9 µg per g tissue in aortic wall and zero in mural thrombus. Tetracycline inhibited, in a concentration-dependent manner, both MMP-9 and MCP-1 secretion (P = 0·022 and P = 0·018 respectively), but did not alter hydroxyproline or IL-6 secretion. At the highest concentration of tetracycline (100 µg/ml) median MMP-9 secretion was reduced from 27 to 5 ng/ml (P = 0·007) and median MCP-1 secretion was reduced from 50 to 10 ng/ml (P = 0·008).

Conclusion

Tetracycline rapidly penetrates the aortic wall, but the concentration achieved may be insufficient to alter collagen turnover through limitation of MMP production or activity.
Expression and clinical significance of apolipoprotein D in male breast cancer and gynaecomastia
Authors: Serra Díaz C , Vizoso F , Lamelas M L , Rodríguez J C , González L O , Baltasar A , Medrano J
Published: March 2003

Background

Apolipoprotein D (Apo D) is a protein component of the human plasma lipid transport system which is present in benign and malignant human breast tissues. This study analysed the expression of Apo D in men with gynaecomastia or breast cancer, and evaluated its use as a prognostic marker in breast cancer.

Methods

Immunohistochemical expression of Apo D was examined in specimens from 15 men with gynaecomastia, two with in situ breast carcinoma and 68 with invasive male breast cancer. Median follow-up in patients with breast cancer was 44 months.

Results

All gynaecomastia specimens, both in situ carcinomas and 57 invasive carcinomas (84 per cent) stained positively for Apo D. Apo D values were significantly correlated with axillary node involvement and histological grade of the tumours. In men with breast cancer univariate analysis showed a statistical association between node status and Apo D content with relapse-free survival (P < 0·001) and overall survival (P < 0·05). Cox multivariate analysis showed that Apo D was a significant indicator of relapse-free survival (P = 0·0089), but node status was the strongest factor able to predict both relapse-free (P = 0·0336) and overall (P = 0·0346) survival.

Conclusion

Apo D was expressed in gynaecomastia and a high percentage of male breast carcinomas. There was a positive association of Apo D content in male breast tumours with favourable outcome. Apo D expression was a significant independent indicator of relapse-free survival in male breast cancer.
Bacterial infection and extent of necrosis are determinants of organ failure in patients with acute necrotizing pancreatitis
Authors: Isenmann R , Rau B , Beger H G
Published: March 2003

Background

The risk factors predisposing to organ failure in patients with necrotizing pancreatitis remain unclear. The relationship between the extent of pancreatic necrosis, the presence of infection and the incidence of organ failure was analysed.

Methods

In a retrospective review, the occurrence of pulmonary insufficiency, renal insufficiency, shock, sepsis/sepsis-like syndrome (SLS) and coagulopathy was evaluated in 273 patients with necrotizing pancreatitis, and a comparison was made between patients with sterile or infected necrosis. Additionally, the relation between the incidence of organ failure and extent of pancreatic parenchymal necrosis was investigated by classifying the patients into three groups according to the amount of necrotic tissue found by contrast-enhanced computed tomography (group 1, extent less than 30 per cent; group 2, 30–50 per cent; group 3, more than 50 per cent).

Results

Organ failure was more frequent in patients with infected necrosis than in those with sterile necrosis. Differences were found in the incidence of pulmonary insufficiency, sepsis/SLS and coagulopathy. Organ failure occurred more frequently in group 3 than in group 2 or 1 (95 versus 79 and 66 per cent; P = 0·0004). The extent of infected necrosis was not related to the incidence of organ failure (group 1, 88 per cent; group 2, 86 per cent; group 3, 96 per cent). However, there was a relation between the incidence of organ failure and the extent of sterile necrosis (group 1, 59 per cent; group 2, 74 per cent; group 3, 94 per cent; P = 0·0001). Multivariate analysis confirmed the presence of infection and the extent of necrosis as independent determinants of organ failure.

Conclusion

The incidence of organ failure is determined by both bacterial infection and extent of necrosis. The incidence of organ failure is determined by the extent of necrotic parenchyma in patients with sterile necrosis. Infected necrosis is associated with a high incidence of organ failure irrespective of the extent of necrosis.
Preoperative alcoholism and postoperative morbidity
Authors: Tønnesen H , Kehlet H
Published: March 2003

Background

Preoperative risk assessment has become part of daily clinical practice, but preoperative alcohol abuse has not received much attention.

Methods

A Medline search was carried out to identify original papers published from 1967 to 1998. Relevant articles on postoperative morbidity in alcohol abusers were used to evaluate the evidence.

Results

Prospective and retrospective studies demonstrate a twofold to threefold increase in postoperative morbidity in alcohol abusers, the most frequent complications being infections, bleeding and cardiopulmonary insufficiency. Wound complications account for about half of the morbidity. The pathogenic mechanisms include preoperative immune incompetence, subclinical cardiac insufficiency and haemostatic imbalance. In addition, surgical trauma and/or postoperative abstinence result in an exaggerated stress response, which may further contribute to postoperative morbidity.

Conclusion

Alcohol consumption should be included in the preoperative assessment of likely postoperative outcome. Reduction of postoperative morbidity in alcohol abusers may include preoperative alcohol abstinence to improve organ function, or perioperative alcohol administration to avoid the abstinence response.
Intrapulmonary shunting in biliary atresia before and after living-related liver transplantation
Authors: Yonemura T , Yoshibayashi M , Uemoto S , Inomata Y , Tanaka K , Furusho K
Published: March 2003

Background

Intrapulmonary shunting (IPS) is frequently observed and causes hypoxaemia in liver cirrhosis. This study investigated the prevalence, predictors of reversibility and the effect of living-related liver transplantation (LRLT) on IPS using contrast echocardiography in patients with end-stage biliary atresia.

Methods

Fifty consecutive patients with biliary atresia were examined for IPS using contrast echocardiography before and after LRLT until IPS disappeared. The severity of IPS was classified into five grades according to the extent of contrast in the left ventricle (0, none; 1, trivial; 2, apparent; 3, complete but less than in right ventricle; 4, as dense as in right ventricle).

Results

Thirty-two patients (grade 1, n = 15; grade 2, n = 7; grade 3, n = 4; grade 4, n = 6) had IPS before LRLT. Forty-four patients have survived for 9–26 months after LRLT. Among patients with grade 3 or 4 IPS (n = 8), there was a significant correlation between age at LRLT and the duration of IPS persistence after LRLT (P = 0·044).

Conclusion

IPS takes longer to disappear in older children than in younger ones, but always disappears eventually. LRLT is an effective treatment for biliary atresia with IPS.

Presented to the 31st annual meeting of the Pacific Association of Pediatric Surgeons, Maui, Hawaii, June 1998
Preoperative radiotherapy for rectal cancer: implications for surgeons, pathologists and radiologists
Authors: Wheeler J M D , Warren B F , Jones A C , Mortensen N J McC
Published: March 2003

Background

Over 10 000 new cases of rectal cancer are reported in the UK each year and adjuvant treatments, such as preoperative radiotherapy, are now being used almost routinely.

Methods

A literature review was performed on the Medline database for English language publications on preoperative radiotherapy and rectal cancer. The radioresponsiveness of rectal cancer, tumour downstaging, radiological staging of irradiated rectal cancer, effects of radiotherapy on anastomotic integrity, anorectal and genitourinary function, the role of preoperative radiotherapy in local excision of rectal cancer, and the histological changes peculiar to radiotherapy were evaluated.

Results and conclusion

Following preoperative radiotherapy, rectal cancer may be downstaged or, occasionally, eradicated histologically. Rectal cancer can now be staged accurately before operation, but this is significantly less reliable following irradiation. The pathological specimen must be examined thoroughly before a tumour can be reported to have been eradicated, especially as unique histological changes are produced by radiotherapy. There is no evidence to suggest that preoperative radiotherapy adversely affects anastomotic integrity. It appears that preoperative radiotherapy has some adverse affects on long-term anorectal dysfunction, but this must not distract from its main objectives in rectal cancer, namely reduced local recurrence rates and improved overall survival.
A 14-year experience with 6 cm as a criterion for surgical treatment of abdominal aortic aneurysm
Authors: Scott R A P , Ashton H A , Lamparelli M J , Harris G J C , Stevens J W
Published: March 2003

Background

It remains unclear when to recommend operation for an asymptomatic abdominal aortic aneurysm (AAA). This study examined a prospective series of patients for whom standard criteria were applied.

Methods

Some 584 consecutive patients with an AAA of diameter 3 cm or greater detected by ultrasonographic screening have been observed for up to 14 years. Repeat ultrasonographic examinations have been performed at intervals. Surgery was not considered unless the aneurysm measured 6 cm in diameter, expanded at a rate equivalent to at least 1 cm per year, caused the patient symptoms, or an iliac aneurysm was present that required treatment.

Results

Operation was performed on 127 patients; the majority (80; 63 per cent) had an aneurysm that reached 6 cm in diameter. Use of the above criteria prevented rupture in all but 24 (4 per cent) of the 584 patients over the 14-year interval. Of these 24 patients, 11 were unfit for planned surgery and eight declined operation or follow-up. Rupture in the five remaining patients (1 per cent) who were available for treatment compared favourably with the reported 30-day mortality rate for elective surgical treatment of 1·4–12 per cent.

Conclusion

Repeated observation is preferable to surgical intervention until an aortic aneurysm measures 6 cm in diameter, expands by 1 cm per annum or causes symptoms.
Treatment of persistent pruritus ani in a combined colorectal and dermatological clinic
Authors: Dasan S , Neill S M , Donaldson D R , Scott H J
Published: March 2003

Background

Pruritus ani is a common and socially embarrassing condition which is often poorly managed. It is often classified as idiopathic where the symptoms are usually transitory or secondary when a more persistent itch is experienced. The aim of this study was to establish the cause of pruritus ani in a group of patients referred to a combined colorectal and dermatological clinic, and to determine the most appropriate treatment.

Methods

Forty consecutive patients with pruritus ani were referred over a 6-month period from either the general practitioner or another hospital consultant to a combined colorectal and dermatological clinic. They were assessed by history, completion of a general health questionnaire, full examination of the skin, digital rectal examination, proctoscopy, sigmoidoscopy and patch testing. Patients were treated according to clinical findings at assessment.

Results

Thirty-four patients had a recognizable dermatosis, three had superficial perianal fissuring and three had a normal perineum; two required surgical intervention. Eighteen patients had a positive reaction when patch tested. All patients have shown an improvement or complete resolution of symptoms with treatment.

Conclusion

This series has shown that the majority of patients presenting with pruritus ani have a dermatosis as the underlying cause of their symptoms and that many of them have developed contact sensitivities to the various topical medications used. These findings suggest that referral to a dermatologist in the first instance may be more appropriate.
Randomized clinical trial of early laparoscopy in the management of acute non-specific abdominal pain
Authors: Decadt B , Sussman L , Lewis M P N , Secker A , Cohen L , Rogers C , Patel A , Rhodes M
Published: March 2003

Background

Abdominal pain of uncertain aetiology (non-specific abdominal pain; NSAP) is the commonest reason for emergency surgical admission. The aim of this study was to examine the role of early laparoscopy in the management of NSAP.

Methods

Some 120 patients, admitted between November 1995 and October 1998 with acute abdominal pain of uncertain aetiology, were randomized into two groups: group 1 had laparoscopy during the first 18 h of admission and group 2 had close observation, conventional investigation and surgical intervention if signs of peritonism developed. Outcome measures were diagnosis, operative procedures, duration of hospital stay, readmission rate, morbidity and death, patient satisfaction and total number of investigations performed.

Results

Median hospital stay was 2 (range 1–13) days in both groups (P = 0·87). A diagnosis was established in 48 (81 per cent) of 59 patients in group 1 compared with 22 (36 per cent) of 61 in group 2 (P < 0·0001). The morbidity rate was 14 (24 per cent) of 59 in group 1 and 19 (31 per cent) of 61 in group 2 (P = 0·3629). The readmission rate at a median follow-up of 21 (range 1–35) months was 17 (29 per cent) of 59 in group 1 compared with 20 (33 per cent) of 61 in group 2 (P = 0·6375). Well-being scores improved from 134 on admission to 149 of 177 6 weeks later in group 1 (P = 0·007) and from 132 to 143 of 177 in group 2 (P = 0·089).

Conclusion

Early laparoscopy provided a higher diagnostic accuracy and improved quality of life in patients with NSAP.
Plasma concentrations of glutathione S-transferase isoenzyme are raised in patients with intestinal ischaemia
Authors: Delaney C P , O'Neill S , Manning F , Fitzpatrick J M , Gorey T F
Published: March 2003

Background

The mortality rate associated with acute mesenteric ischaemia (AMI) remains high. Diagnosis is frequently confounded by the non-specific history and physical signs, in conjunction with the absence of a reliable biological assay. Glutathione S-transferase (GST) is an enzyme with a crucial role in cellular homoeostasis, the α isoenzyme of which is highly specific to small bowel and liver. This study assessed αGST as a marker for AMI.

Methods

Twenty-six patients with acute abdominal pain were enrolled. Each patient manifested a diagnostic dilemma, with a potential diagnosis of AMI. Plasma was reserved for αGST assay during routine blood testing and stored at – 20°C for analysis. A final diagnosis was made by autopsy, laparotomy, a definitive other investigation or a return to full health.

Results

Twelve patients had AMI. Plasma αGST was significantly increased in patients with AMI (P < 0·0001). Although pH differed and other biochemical changes occurred, only αGST accurately predicted AMI.

Conclusion

A threshold of 4 ng/ml for αGST was 100 per cent sensitive and 86 per cent specific for AMI. If these observations can be confirmed, evaluation of αGST may reliably predict the presence or absence of AMI.
Comparison of intra-arterial digital subtraction angiography, magnetic resonance angiography and duplex ultrasonography for measuring carotid artery stenosis
Authors: Modaresi K B , Cox T C S , Summers P E , Jarosz J M , Verma H , Taylor P R , Padayachee T S
Published: March 2003

Background

Duplex ultrasonography and magnetic resonance angiography (MRA) are becoming competitive alternatives to angiography for determining the degree of internal carotid artery (ICA) stenosis. Varying reports have been published regarding the suitability of each technique for grading ICA disease. This retrospective study compared the merits of these three modalities for measuring ICA stenosis.

Methods

One hundred and eleven patients being considered for carotid endarterectomy underwent intra-arterial digital subtraction angiography (DSA) via arch injection. Duplex imaging was performed in all patients and MRA in 50. The degree of carotid stenosis estimated by the three modalities was compared.

Results

There was good correlation between subjectively graded MRA and DSA images (r = 0·87, P < 0·001, n = 82 carotids) but poor correlation for objective estimates. MRA tended to underestimate the degree of stenosis (bias – 4·5 per cent) compared with DSA, but showed good correlation with duplex ultrasonography estimates (r = 0·86, P < 0·001, n = 87 carotids). Both non-invasive modalities produced high values of sensitivity and specificity in estimating stenoses of greater than 70 per cent. MRA was less sensitive for distinguishing between severe stenosis and complete occlusion.

Conclusion

This study did not resolve the debate regarding the method of choice as both MRA and duplex ultrasonography were accurate for imaging carotid stenoses.
Experimental study of neorectal physiology after formation of a transverse coloplasty pouch
Authors: Maurer C A , Z'graggen K , Zimmermann W , Häni H J , Mettler D , Büchler M W
Published: March 2003

Background

A novel transverse coloplasty pouch (TCP) with a larger neorectal volume than a straight coloanal anastomosis (CAA) but a smaller volume than a short colonic J pouch (CJP) may improve short-term function after rectal excision.

Methods

Twelve pigs were investigated 6 weeks after complete rectal excision followed by reconstruction with a CAA, CJP or TCP. The results were compared with findings in the normal pig rectum.

Results

The colonic transit times assessed by radio-opaque marker transit were 24 h for CAA, 60 h for CJP and 32 h for TCP. Non-operated control pigs had a mean transit time of 46 h. Pigs that had a CJP developed colonic dilatation and substantial faecal impaction. Colonic electrostimulation induced an adaptive relaxation in the normal rectum but a pressure increase in all neorecta, particularly after CAA. The neorectal longitudinal smooth muscle layer in pigs with a TCP was significantly thicker than that in pigs with a CAA or CJP; its thickness was closest to that of the normal pig rectum. Colonic smooth muscle layers 10 cm proximal to the coloanal anastomosis, above the neorecta, were significantly thicker after CJP than after CAA or TCP formation. No significant difference in microcirculation was observed between the three restorative procedures.

Conclusion

Accelerated colonic transit and a lack of adequate relaxation upon endoluminal pressure increase was associated with urgency and incontinence after CAA. Delayed colonic transit, faecal impaction and ineffective muscular hypertrophy due to pouch dilatation and constipation indicated evacuation problems after CJP construction. Functional and morphometric data for TCPs suggested almost normal defaecation. Of the three restorative procedures, the data for TCPs were most similar to those obtained in the normal pig rectum at short-term follow-up.
Surgical management of severe secondary peritonitis
Authors: Bosscha K , van Vroonhoven Th J M V , van der Werken Ch
Published: March 2003

Background

Despite advances in diagnosis, surgery, antimicrobial therapy and intensive care support, the mortality rate associated with severe secondary peritonitis remains unacceptably high. This article presents various surgical treatment strategies for severe secondary peritonitis, emphasizing the role of open management of the abdomen and planned relaparotomies.

Methods

Material was identified from previous review articles, references cited in original papers and a Medline search of the literature.

Results and conclusion

Surgical treatment of severe secondary peritonitis is highly demanding and very complex. The combination of improved surgical techniques, antimicrobial therapy and intensive care support has improved the outcome of such peritonitis following perforation or anastomotic disruption of the digestive tract, or infected necrotizing pancreatitis. However, aggressive surgical treatment strategies, such as open management of the abdomen and planned relaparotomies, may have reached their limits.
Value of percutaneous transhepatic portography before hepatectomy for hilar cholangiocarcinoma
Authors: Nishio H , Kamiya J , Nagino M , Kanai M , Uesaka K , Sakamoto E , Fukatsu T , Nimura Y
Published: March 2003

Background

The diagnostic value of percutaneous transhepatic portography (PTP) for assessing cancer invasion of the portal bifurcation in patients with hilar cholangiocarcinoma has not been studied previously.

Methods

From April 1977 to March 1998 combined hepatobiliary and portal vein resection was performed in 45 patients. In 25 patients, PTP was carried out before operation and the resected portal bifurcation was examined histologically. Correlation between portographic and microscopic findings at the portal bifurcation was studied retrospectively.

Results

Portographic and microscopic findings were classified into three groups (type A, B or C, and grade 0, I or II respectively) according to the findings at the portal bifurcation. There was a significant correlation between the portographic type and degree of cancer invasion (P = 0·0001). In seven of the eight patients with type A portograms, there was no microscopic cancer invasion of the portal bifurcation. In 15 of the 17 patients with type B or C portograms, cancer invasion was found microscopically. All patients with microscopic grade II invasion had type C portograms.

Conclusion

PTP can be used to evaluate cancer invasion of the portal bifurcation with sufficient reliability for preoperative staging of hilar cholangiocarcinoma.
Preliminary results of a multicentre trial of the electrically stimulated gracilis neoanal sphincter
Authors: Mander B J , Wexner S D , Williams N S , Bartolo D C , Lubowski D Z , Oresland T , Romano G , Keighley M R B
Published: March 2003

Background

The electrically stimulated gracilis neoanal sphincter was initially developed to treat refractory incontinence. Good early results were reported from the two centres that pioneered the technique. The aim of this study was to assess the operation in a prospective multicentre setting.

Methods

The procedure was performed on 64 patients from seven centres worldwide and was performed in stages. All patients were evaluated clinically and manometrically before and after operation.

Results

There was a high incidence of infective and hardware-related complications. At a median of 10 months following closure of the defunctioning stoma 56 per cent had experienced a good functional result. The major functional problems comprised evacuatory difficulties experienced by 25 per cent.

Conclusion

The technique is effective in treating otherwise refractory incontinence. It is, however, a complex procedure and the morbidity rate may be high, particularly during the learning curve, factors that necessitate careful patient selection.

Presented to the Association of Surgeons of Great Britain and Ireland in Bournemouth, UK, April 1997 and the European Council of Coloproctology in Edinburgh, UK, June 1997; and published in abstract form as Br J Surg 1997; 88(Suppl): 39 and Int J Colorectal Dis 1997; 12: 144
Complexity- and risk-adjusted model for measuring surgical outcome
Authors: Pillai S B , van Rij A M , Williams S , Thomson I A , Putterill M J , Greig S
Published: March 2003

Background

Although currently available surgical scoring systems have good outcome predictive power, their use is often limited by complexity and their non-dynamic nature. The aim of this study was to develop and test a risk adjustment for general surgical audit which is both simple and dynamic, while preserving a high predictive power for surgical morbidity.

Methods

Twelve easily measured, well defined prognostic variables for morbidity were identified from the Otago Surgical Audit data collection form and stratified into suitable categories. Logistic regression was used to adjust for confounding between factors, identifying risk factors with the strongest prognostic value for the outcome of severe and intermediate complications. The resulting model was tested by back-validation and validation.

Results

The derived risk adjustment included all 12 variables. Adjusted odds ratios for all variables were markedly lower than unadjusted values. After logistic regression, the strongest predictors of postoperative morbidity were duration of operation, operation category, inpatient status and organ system in which the procedure was carried out. The area under the receiver operating characteristic curve was 0·86.

Conclusion

A simple dynamic model for surgical morbidity has been developed which is comparable to previously published surgical scoring systems in terms of predictive power. This risk adjustment tool can be incorporated into the existing audit system, enabling comparison of surgical unit performance.
Gallbladder ascariasis: presentation and management
Authors: Javid G , Wani N , Gulzar G M , Javid O , Khan B , Shah A
Published: March 2003

Background

As many as 1·5 billion people around the world harbour Ascaris lumbricoides in the digestive tract. Gallbladder ascariasis, although less common than bile duct ascariasis, is quite often seen in endemic areas.

Methods

Some 1300 patients with hepatobiliary ascariasis, admitted between October 1992 and June 1998, were analysed prospectively. The clinical features and outcome of 56 cases of gallbladder ascariasis are presented.

Results

Forty-seven patients were diagnosed by ultrasonography and nine were diagnosed at laparotomy. Only ten patients diagnosed by ultrasonography expelled the worms spontaneously, with resolution of symptoms and signs. The remaining 37 patients underwent cholecystectomy.

Conclusion

Gallbladder ascariasis is a significant entity in endemic areas which usually requires cholecystectomy.
Training opportunities in liver transplantation surgery
Authors: Praseedom R K , Madhavan K K , Akyol M A , Forsythe J L R , Garden O J
Published: March 2003

Background

Liver transplantation surgery is carried out in only a few selected centres in the UK. This study was performed with a view to identifying potential training opportunities available for the general and specialist higher surgical trainee, and also to assess the outcome following liver transplant surgery according to the grade of the surgeon performing the procedure.

Methods

Data on 111 liver transplants with caval preservation undertaken consecutively in a single unit during a 32-month period were collected and analysed. The transplant procedures were grouped into those performed by consultants and those performed by supervised trainees. Survival was estimated by the Kaplan–Meier method. The Cox regression model was used to examine the influence of grade of the surgeon on survival. χ2 and independent sample t tests were used to identify significant preoperative, intraoperative and postoperative variables.

Results

Trainees carried out 34 recipient hepatectomies (31 per cent), 47 implant procedures (42 per cent) and all 143 retrieval operations. The mean time taken by a supervised trainee to carry out a recipient hepatectomy and implantation was 183 and 44 min compared with 165 and 46 min for a consultant (P = 0·22 and P = 0·44 respectively). The mean intraoperative red cell requirement was 8 units for both consultants and trainees (P = 0·85). The overall patient survival rate was 88 per cent at 3 years and the grade of the surgeon made no difference to survival or the occurrence of complications (P > 0·05).

Conclusion

The outcome following liver transplantation with caval preservation did not differ according to the grade of the surgeon performing the procedure. Extensive training opportunities are available to learn hepatobiliary and vascular surgical techniques in liver transplantation surgery.
Live kidney donor assessment in the UK and Ireland
Authors: Lee J
Published: March 2003

The Editors welcome topical correspondence from readers relating to articles published in the Journal. Letters should be no more than 250 words in length and should be typed on A4-sized paper in double spacing.
Re-evaluation of criteria for reoperation in carotid endarterectomy using intraoperative duplex imaging
Authors: Walker R A , Walker E A , McCabe A , Horrocks E , Budd J S , Horrocks M
Published: March 2003

Background

The aim of this study was to compare data obtained during surgery with data collected at 6 weeks after operation to evaluate appropriate criteria for reoperation.

Methods

One hundred and twenty consecutive patients undergoing carotid endarterectomy had duplex scans at operation and 6 weeks later. Neurological evaluation was also documented.

Results

Of 96 patients who had a normal intraoperative duplex scan by standard criteria, 91 had normal scans at 6 weeks. One occluded an internal carotid artery (ICA) at 6 weeks with no symptoms. Four had kinks or high-grade contralateral lesions leading to velocity enhancement but no filling defect. All were asymptomatic. Twenty-four patients had abnormal intraoperative scans. Thirteen patients had visible kinking of the ICA or reperfusion hyperaemia; 12 of these patients had normal 6-week scans and one had a mild residual kink but no symptoms. Eleven patients had visible colour-filling defects and significant velocity enhancement. Nine of these were reopened and refashioned. Subsequent duplex imaging was satisfactory in all cases and 6-week scans were normal. One patient had an occluded ICA at operation and developed a dense stroke after operation. Another had residual raised velocities distally which remained at 6 weeks. This patient had no symptoms.

Conclusion

Intraoperative velocity measurements alone cannot be relied upon as an indication for reoperation. Significant velocity enhancement combined with a visible filling defect appears to represent a satisfactory criterion for reoperation. There were no complications as a result of reoperation. There was no early restenosis in the whole group and there were no neurological sequelae in any patient with a satisfactory scan using the above criteria.
Transcranial Doppler ultrasonography as a predictor of haemodynamically significant carotid stenosis
Authors: Byrd S , Wolfe J , Nicolaides A , Stansby G , Cheshire N , Thomas D , Mansfield A
Published: March 2003

Background

Transcranial Doppler (TCD) ultrasonography can detect evidence of collateral flow across the anterior communicating artery and/or the posterior communicating artery, which occurs when there is significant alteration of ‘inflow’ to the brain. The aim of the study was to determine the blood flow velocity produced by a carotid stenosis which produces this haemodynamic effect on the cerebral circulation and evokes collateral circulation.

Methods

Forty-eight patients with varying degrees of carotid stenosis (10 per cent to occlusion) who underwent both carotid duplex and TCD examination were reviewed. An ATL HDI 3000 ultrasound system was used for the carotid and TCD studies. The carotid examination recorded peak-systolic velocity (PSV) and end-diastolic velocity (EDV) in the carotid systems bilaterally. TCD recorded Doppler spectra from the bilateral middle cerebral, anterior cerebral, posterior cerebral, intracranial vertebral and basilar arteries. Collateral flow was assessed in two ways: ‘intracranial crossover’ collateral and ‘posterior to anterior’ collateral. Each internal carotid artery (ICA), together with the ipsilateral hemisphere, was analysed for the presence or absence of collateral flow. Data were expressed as mean(s.e.m.).

Results

The PSV of the group with collateral circulation was 472(14) cm s–1 and that of the group without collateral flow was 164(3) cm s–1 (P < 0·0001, Mann–Whitney test). The respective EDVs were 158(13) and 58(7) cm s–1(P < 0·0001).

Conclusion

PSVs and EDVs in the ICA, in conjunction with collateral flow measured by TCD, are indicators of a haemodynamically significant carotid lesion, and provide more information than two-dimensional imaging studies. In the future, parameters set by combining carotid duplex and TCD investigations may represent the ‘gold standard’ for evaluation of cerebral blood flow.
Limb outcome following failed femoropopliteal polytetrafluoroethylene bypass for intermittent claudication
Authors: Renwick P , Johnson B , Wilkinson A , Galloway J , McCollum P
Published: March 2003

Background

Femoropopliteal (FP) bypass using polytetrafluoroethylene (PTFE) is still considered by many surgeons to be a reasonable procedure for severe intermittent claudication (IC) without limb-threatening ischaemia. The consequences of FP graft failure were examined.

Methods

Over 8 years, 54 patients had 55 FP grafts (that subsequently occluded) inserted for severe IC (42 PTFE and 13 vein grafts) above (30) or below (25) the knee. There were no operative deaths. During the same interval a total of 191 FP grafts were placed, 100 of which were vein grafts. Patient demography and risk factor analysis was similar for both groups.

Results

Nineteen patients required amputation subsequent to a failed graft, all of these following PTFE grafts. Mean time to occlusion was 12·2 (range 0–79) months. For PTFE grafts, the mean(s.d.) ankle index rose from 0·51(0·14) to 0·95(0·15) after operation but fell to 0·25(0·15) after occlusion, confirming a highly significant deterioration from preoperative levels, which was not seen in vein graft occlusions.

Conclusion

Long-term FP bypass patency rates with vein are superior to those obtained with PTFE. Failed PTFE grafts show a significant deterioration in pressure indices compared with preoperative values. FP grafts for IC carry an intrinsic risk of limb loss which is much greater when vein is not used (P < 0·001).
First year of a fast-track carotid duplex service
Authors: Bhatti T S , Harradine K L , Davies B , Earnshaw J J , Heather B P
Published: March 2003

Background

The risk of a major stroke after a transient ischaemic attack (TIA) is highest in the first 3 months after the onset of symptoms. Urgent endarterectomy in appropriate cases is recommended through a fast-track one-stop assessment clinic.

Methods

Local general practitioners (GPs) were informed that a duplex scan would be guaranteed within 14 days of referral of any patient who had a recent clearly documented TIA or amaurosis fugax. Referral letters were faxed and the scan was authorized by a consultant surgeon. Those with significant disease were seen in the clinic in preparation for operation. Non-significant results were conveyed by post to the GPs with no further action.

Results

In the first 12 months of the service, 90 scans were performed through the fast track. In the same interval 490 non-fast-track scans were done after request by a physician (38 per cent), geriatrician (24 per cent), neurologist (14 per cent), vascular surgeon (11 per cent), ophthalmologist (8 per cent) or others (4 per cent). Thirteen (14 per cent) of 90 patients in the fast-track group had carotid endarterectomy, with a median period between referral and operation of 30 (range 20–45) days and median time between onset of symptoms and surgery of 7 (range 4–58) weeks. Endarterectomy was carried out in 12 (2 per cent) of 490 patients in the routine group with a median duration between referral and operation of 127 (range 64–184) days.

Conclusion

A fast-track service can significantly reduce the time between referral and operation, and increase the number of endarterectomies. Urgent and appropriate referral from the GPs is vital for the service to work efficiently.
Outcome after ligation of infected false femoral aneurysms in intravenous drug abusers
Authors: Gan J , Leiberman D P , Pollock J G
Published: March 2003

Background

Infected false femoral aneurysm (IFFA) is a life-threatening complication of intravenous drug abuse and presents a difficult management problem for the vascular surgeon. Controversy exists regarding the best management. The choice lies between ligation and excision with immediate revascularization, and ligation and excision with observation; reconstruction is reserved for critical ischaemia.

Methods

After disappointing results with the former method it was decided to perform ligation and excision with observation as the initial treatment of IFFA. A 9-year experience of 28 patients treated at this hospital is reviewed.

Results

In 26 cases of primary ligation and excision of an IFFA there were no amputations and patients described claudication only in follow-up. In two cases of a second IFFA in the same limb, repeat ligation and excision resulted in one viable limb with claudication only and one above-knee amputation for non-viability. At 9-year follow-up (80 per cent complete), over 90 per cent of the patients were still drug abusers and therefore not suitable for revascularization. There were two deaths, both of which were drug related.

Conclusion

Ligation and excision of an IFFA is simple, effective and safe, and is the most appropriate method of dealing with these challenging patients.
Systematic review of intra-arterial thrombolytic therapy for peripheral vascular occlusions
Authors: Palfreyman S J , Michaels J A
Published: March 2003

Background

A systematic review of intra-arterial thrombolytic therapy for peripheral vascular occlusions was undertaken.

Methods

The four major electronic databases (Medline, Cinhal, Embase and The Cochrane Library) were searched to identify randomized controlled trials of thrombolytic therapy in the treatment of limb ischaemia. The search was limited to English language articles, or those that provided a sufficiently detailed English summary, and to articles published after 1980. Trials were considered for inclusion if they were randomized controlled trials, systematic reviews or meta-analyses. Data were extracted independently by two reviewers and aggregate outcomes were obtained using a random effects meta-analysis.

Results

A total of 32 articles were found but only 12 were assessed to be of sufficient quality to be included in the review. There was a distinct lack of large randomized controlled trials comparing thrombolysis with surgical management. The exceptions were the Thrombolysis or Peripheral Arterial Surgery (TOPAS) and Surgery versus Thrombolysis for Ischemia of the Lower Extremity (STILE) trials, but both had some methodological flaws. The STILE trial did not achieve the sample size originally determined and the TOPAS trials had a large number of contributing centres (113) compared with the sample size (548). Meta-analysis showed no significant differences between thrombolysis and surgery in terms of major amputation (relative risk (RR) 0·9 (95 per cent confidence interval 0·6–1·4)) and death (RR 1·2 (0·8–1·9)). However, there was an increased risk of residual ischaemia with thrombolysis (RR 1·8 (1·2–2·5)) and haemorrhage (RR 2·9 (1·1–7·9)). Patients who were shown to benefit from thrombolysis were those with short-duration ischaemia (RR reduction, 72 per cent; numbers needed to treat, three) and occluded grafts (RR reduction, 58 per cent; numbers needed to treat, four).

Conclusion

Despite the theoretical advantages of thrombolysis, there is still insufficient evidence to justify its widespread use except in patients with graft occlusions and short-duration ischaemia.
Outcome of iliac percutaneous transluminal angioplasty with and without the use of stents in patients with intermittent claudication
Authors: Beattie G C , Brittenden J , Gillespie I , McBride K , McInnes G , Bradbury A W
Published: March 2003

Background

Despite the absence of controlled data supporting endovascular treatment of iliac disease in patients with intermittent claudication (IC), there has been a significant increase in iliac percutaneous transluminal angioplasty (PTA), and in particular iliac stenting, in recent years. The clinical and haemodynamic outcome of iliac PTA, with and without stenting, was assessed in patients with IC.

Methods

A prospectively gathered computerized database of iliac PTA (n = 203) and stenting (n = 88), performed between 1 January 1991 and 31 December 1997, was analysed.

Results

Occlusive disease was significantly more likely than stenotic disease to be treated by primary stent deployment (19 of 88, 22 per cent) than PTA alone (11 of 203, 5 per cent) (P < 0·01, χ2 test), as were lesions in the common iliac artery (common 69 of 214 (32 per cent) versus external 14 of 65 (22 per cent); P< 0·05, χ2 test). Primary stent placement was associated with a significant increase in morbidity that delayed hospital stay (13 of 88 (15 per cent) versus seven of 203 (3 per cent); P< 0·05, χ2 test). Emergency revascularization was required in four patients who underwent PTA (2 per cent) and two who had stenting (2 per cent) (P not significant).

Conclusion

Iliac stenting is associated with a significant increase in morbidity but with no improvement in symptomatic or haemodynamic outcome. These results do not justify the increased expense associated with the routine use of iliac stents.
Two-year follow-up after acute thromboembolic lower limb ischaemia: the importance of continuing warfarin treatment
Authors: Campbell W B , Ridler B M F , Szymanska T H
Published: March 2003

Background

The Vascular Surgical Society carried out an audit of follow-up after acute thromboembolic lower limb ischaemia.

Methods

The audit of acute lower limb ischaemia was done between 1 January and 31 March 1996 and included 474 patients. This report describes a 2-year follow-up of patients with a diagnosis of thrombosis or embolism who survived 30 days. Details were obtained for 214 (75 per cent) of 287 patients: half (107) were men, and the age range was 21–96 (mean 74) years.

Results

Amputation of the leg affected initially had been required (after 30 days) in 12 per cent. Further acute leg ischaemia had occurred in 11 per cent, and 9 per cent had undergone arterial reconstruction (11), angioplasty (seven) or thrombolysis (two). Major medical events were reported in 31 per cent and 35 per cent had died during the 2-year period. After the episode of acute ischaemia, warfarin was started in 57 per cent of patients, but was continued in only 43 per cent. Reasons for stopping were seldom known, nor was duration of treatment (range 1–22 (median 6) months in reported cases). Significantly more patients who were not on warfarin suffered recurrent acute limb ischaemia (19 versus 3 per cent; P< 0·01). No significant association was found between recurrent acute ischaemia and initial diagnosis of embolism, thrombosis or atrial fibrillation (but numbers of recurrences in each group were small).

Conclusion

The incidence of recurrent acute thromboembolic limb ischaemia up to 2 years was significantly lower in patients treated with warfarin. Warfarin treatment is often stopped for no clear reason, especially in the elderly. Explicit advice about long-term warfarin therapy should be given when these patients are discharged from hospital.
Angiogenesis and the atherosclerotic carotid plaque: association between symptomatology and plaque morphology
Authors: McCarthy M J , Loftus I M , Thompson M M , Jones L , London N J M , Bell P R F , Naylor A R , Brindle N P J
Published: March 2003

Background

Symptomatic carotid disease due to thromboembolism has been associated with acute plaque instability and intraplaque haemorrhage. These features may be influenced by the fragility and position of plaque neovessels. The purpose of this study was, therefore, to determine whether any association existed between neovessel density, position, morphology and thromboembolic sequelae.

Methods

Carotid endarterectomy (CEA) samples were collected from 15 asymptomatic patients with greater than 80 per cent stenosis and from 13 patients with greater than 80 per cent stenosis and symptoms within 30 days of CEA. Groups were matched for sex, age, risk factors and plaque size. Samples were stained with haematoxylin and eosin, and Van Gieson stains. An endothelial-specific antibody to CD31 was used for immunohistochemistry. Plaques were assessed for histological characteristics while neovessels were counted and characterized by size, site and shape.

Results

There were more neovessels in plaques (P< 0·00001) and fibrous caps (P< 0·0001) from symptomatic than asymptomatic patients. Symptomatic plaque neovessels were larger in size (P< 0·004) and more irregular in shape. There was a significant increase in plaque necrosis and rupture in symptomatic plaques. Plaque haemorrhage and rupture were associated with more neovessels within the plaque (P< 0·02, P< 0·001) and fibrous cap (P< 0·05, P< 0·004). Patients with preoperative or intraoperative embolization had more plaque and fibrous cap neovessels (P< 0·03, P< 0·001).

Conclusion

Symptomatic carotid disease is associated with increased neovascularization within the atherosclerotic plaque and fibrous cap; these vessels appear larger in size, more irregular in shape and may contribute to plaque instability and onset of thromboembolic events.