bluuebunny/crossref_metadata_2025_split huggingface dataset:
Randomized double-blind study of dopexamine versus placebo in aortic surgery
Authors: Baguneid M S , Welch M , Bukkari M , Fulford P E , Howe M , Bigley G , McMahon R F T , Eddleston J , Walker M G 
Published: March 2003

Abstract

Background
Mechanisms involved in the development of colonic ischaemia are not fully understood and there are conflicting reports regarding predisposing factors. The aim of this study was to evaluate the effect of dopexamine hydrochloride on the incidence of colonic ischaemia following aortic surgery and to correlate immunohistochemical markers of inflammatory activation in its pathogenesis.

Methods
Thirty patients, of mean age 65 (range 46–84) years, undergoing elective infrarenal aortic surgery were randomized to receive a perioperative infusion of either dopexamine 2 µg kg–1 min–1 (n = 12) or 0·9 per cent saline placebo (n = 18). All patients underwent colonoscopy and biopsy following induction of anaesthesia and at 1 week after operation. Sections were stained with haematoxylin and eosin, and for mast cell tryptase (MCT), myeloperoxidase (MPO) and both the inducible (iNOS) and endothelial (eNOS) isoforms of nitric oxide synthase. Sections were analysed blindly and independently by two histopathologists. Patient and operative data were collected and stored separately.

Results
Colonic ischaemia was noted in nine patients based on microscopic findings. Endoscopy alone had a sensitivity of 56 per cent. There was a significantly lower incidence of colonic ischaemia in patients receiving dopexamine compared with placebo (P &lt; 0·05). One death resulted from colonic infarction in the placebo group 11 days after operation. There was increased MPO and MCT expression in patients with histological evidence of ischaemia (P &lt; 0·05); iNOS staining within the vascular (P = 0·001) and lamina propria (P &lt; 0·05) components of the mucosa was also significantly greater. No association was found with eNOS.

Conclusion
Perioperative dopexamine infusion confers a degree of protection to colonic mucosa following aortic surgery, possibly through an anti-inflammatory effect.
Management of coexisting intra-abdominal disease in aortic surgery
Authors: Oshodi T O , Abraham J S , Brigg I K , Kelly J F 
Published: March 2003

Abstract

Background
The management of coexisting intra-abdominal disease in aortic surgery is controversial. A staged repair is preferred by many and, in general, the symptomatic lesion is treated first. Twenty-one years ago this vascular unit elected a policy of treating such lesions synchronously. This was on the theoretical premises that the benefits of a single operation in these patients would outweigh the potential risks of graft infection and increased complication rates from a prolonged procedure.

Methods
The case records of 676 patients undergoing aortic grafting for aneurysmal or occlusive disease between 1978 and 1998 were analysed retrospectively.

Results
Fifty-five patients (8 per cent) had coexisting intra-abdominal diseases treated at the time of aortic graft surgery. These included biliary disease (26), and gastric (12), intestinal (13), urological (two), hepatic (one) and splenic (one) pathology. The median age at presentation was 72 (range 46–90) years. There were three hospital deaths and five patients required early reoperation, three for lower limb ischaemia and two for intra-abdominal bleeding. One patient developed a subphrenic abscess and there were three superficial wound infections. There were no graft infections in this group of 55 patients.

Conclusion
This large single-centre experience with synchronous intra-abdominal surgery and aortic grafting demonstrates that it is safe and does not predispose to an increased risk of graft infection or perioperative haemorrhage.
Symptoms of varicose veins
Authors: Bradbury A W , Evans C J , Allan P L , Lee A J , Ruckley C V , Fowkes F G R 
Published: March 2003

Abstract

Background
The relationships between varicose veins (VVs) and leg symptoms have not been studied. The aim of this study was to define the relationships between age, sex, leg symptoms and VVs.

Methods
An age-stratified sample of 699 men and 867 women aged 18–64 years, selected randomly from 12 general practices distributed socioeconomically throughout the city, completed a questionnaire regarding leg symptoms (heaviness/tension, swelling, aching, restless legs, cramps, itching, tingling) and underwent a clinical examination.

Results
In men, swelling and cramps (both P ≤ 0·001), and in women swelling (P= 0·02), restless legs (P= 0·001) and itching (P= 0·045), were significantly more common in older subjects. Data have therefore been age adjusted. Women were significantly (P &lt; 0·01) more likely to respond positively when asked about all leg symptoms, except tingling. The commonest symptoms were aching in women (53·8 per cent) and cramps in men (34·0 per cent). There was no difference between right and left legs. In men, only itching was significantly related to trunk VVs (P= 0·011). In women, there was a relationship between trunk VVs and heaviness/tension, aching and itching (P ≤ 0·005). Hyphen-web varices were not related to symptoms in men but were related to heaviness/tension and swelling in women. There was no association between reticular varices and symptoms in either sex.

Conclusion
Even in the presence of VVs, most lower limb ‘venous’ symptoms are non-venous in aetiology. Surgery is unlikely to ameliorate symptoms in the majority of patients.
Contribution of malnutrition to postoperative morbidity in vascular surgical patients
Authors: Durkin M T , Mercer K G , McNulty M F , Phipps L , Upperton J , Giles M , Scott D J A 
Published: March 2003

Abstract

Background
In an elderly population of surgical patients, poor mobility, poor diet and chronic disease contribute to a significant risk of malnutrition. Malnutrition is associated with muscle weakness, fatigue, poor wound healing and immunological dysfunction. The aim of the study was to establish the prevalence of malnutrition in vascular surgical patients and to compare postoperative infection rates in well nourished and malnourished patients.

Methods
A nutritional assessment was performed on 71 patients (49 men; median age 65 (range 26–85) years) attending preassessment for vascular surgical procedures. Nutritional status was measured using validated indicators of malnutrition: estimated weight changes over 3 months; body mass index; mid-arm muscle circumference (MAMC) calculated using triceps skin fold thickness (TSF) and mid-arm circumference (MAC) (MAMC = MAC – (3·14 × TSF)); and serum albumin concentration. Fifty-nine patients were followed after vascular surgery. The incidence of postoperative infections was related to preoperative nutritional status.

Results
Nineteen patients (27 per cent) had normal values for all nutritional indicators examined. The remaining 52 patients (73 per cent) had one (37), two (12), three (two) or four (one) nutritional indicators within the range for malnutrition. Among the 59 patients who underwent surgery there were five chest infections, seven wound infections, one urinary tract infection and one infected central line in 13 patients following six femorodistal bypasses, four abdominal aortic aneurysm repairs and three miscellaneous arterial procedures. The incidence of septic complications was zero in 14 patients with normal nutritional indicators and 41 per cent (13 of 32) in patients with indicators of malnutrition (P &lt; 0·05, Fisher's exact test).

Conclusion
Malnutrition is prevalent among vascular patients and may contribute to postoperative morbidity. Malnourished patients should be identified and referred to the dietician at the earliest opportunity to minimize the morbid effects of undernutrition.
Integrated care pathways for vascular surgery
Authors: Abu-Own A , Sachs R , Louden C , Linnard D , Buckland J , Murphy S , Barker S G 
Published: March 2003

Abstract

Background
Integrated care pathways (ICPs) represent a multidisciplinary approach to clinical patient care.

Methods
A 1-year prospective trial of the use of ICPs for elective vascular surgical procedures was undertaken. A multidisciplinary group constructed ICPs for patients admitted for open repair of abdominal aortic aneurysm, carotid endarterectomy or femoropopliteal bypass grafting. Patient management followed ICPs on a daily basis with signatures required to confirm that each action had been taken. Variances from the ICPs were carefully recorded. Audit of variance data allowed subsequent revision of the ICPs and hence provision of the best possible nursing and clinical practice.

Methods
A total of 33 patients were entered into the study; 16 had a femoropopliteal bypass graft, eight carotid endarterectomy and nine open repair of an abdominal aortic aneurysm. ICPs were well received by patients and staff. They improved communication, promoted an appreciation of each health group's role in patient care, increased nursing autonomy, reduced calls to junior medical staff, improved patient education and confidence, and caused a marked reduction in length of hospital stay. Overall, patients were discharged 13 per cent earlier after open abdominal aortic aneurysm repair, 22 per cent earlier after carotid endarterectomy and 38 per cent earlier after femoropopliteal bypass grafting.

Conclusion
ICPs have clear benefits. They improve overall clinical efficiency and enhance clinical governance. Successful use of ICPs depends upon ‘clinical champions’ and effective project management. Sufficient resources and training are essential.
Percutaneous transluminal angioplasty for lower limb ischaemia
Authors: Brittenden J , Beattie G C , Gillespie I , McBride K , McInnes G , Bradbury A W 
Published: March 2003

Abstract

Background
Percutaneous transluminal angioplasty (PTA) is increasingly performed for lower limb ischaemia of all severities, despite the absence of controlled data demonstrating its efficacy. The aim of this study was to examine the indications and outcome for lower limb ischaemia over a 16-year period.

Methods
A prospectively gathered database of 1287 consecutive PTAs performed between 1982 and 1997 was analysed. Two time intervals were compared: 1982–1991 and 1992–1997.

Results
Since 1992 there has been a fourfold increase in the number of PTAs performed. There has been a significant increase in the number of PTAs performed for critical ischaemia, occlusive lesions and at infrainguinal sites. Although there has been a significant reduction in morbidity, the number of immediate technical and clinical failures has increased (see Table).

Conclusion
Despite a lack of controlled data supporting a more liberal use of PTA in the treatment of lower limb ischaemia, there has been, in this regional vascular unit, a significant increase in the perceived clinical and anatomical indications for the procedure. Randomized controlled trials are urgently required to define the role of PTA in this condition.
Duplex surveillance does not enhance infrainguinal prosthetic bypass graft patency
Authors: Adam D J , Gillies T E , Kelman J , Allan P L , Chalmers R T A 
Published: March 2003

Abstract

Background
All patients discharged from this unit with a patent infrainguinal polytetrafluoroethylene (PTFE) bypass are entered into a graft surveillance programme. Previous internal audit had suggested that duplex surveillance was not worthwhile in this patient group. The aim of this study was to compare the fate of infrainguinal PTFE grafts before and after stopping duplex surveillance.

Methods
Between January 1986 and December 1994, 220 grafts (141 above-knee popliteal, 69 below-knee popliteal, ten tibial) were entered into the duplex surveillance programme. Between January 1995 and June 1996, 56 further grafts (29 above-knee popliteal, 21 below-knee popliteal, six tibial) were followed prospectively without duplex scans.

Results
During the first study interval, an ‘abnormal’ scan was reported in 66 of 220 grafts. For clinical reasons (no further reconstruction feasible), no intervention was undertaken in 56 patients. Of these, 34 grafts occluded and 17 amputations were performed. An intervention to maintain patency was performed in ten patients. In 154 patients with ‘normal’ scans, 53 grafts occluded and 21 amputations were performed. During the second study interval, 20 grafts occluded and 12 amputations were performed. In six patients, an attempt was made to re-establish patency and this was successful in two. Kaplan–Meier 36-month primary and secondary patency rates were 48 and 51 per cent respectively for the group that underwent duplex surveillance, and 58 and 60 per cent for the group that was followed without duplex imaging.

Conclusion
Prospective duplex surveillance of infrainguinal PTFE bypass grafts does not enhance graft patency and cannot be justified.
Isolated femoral profundoplasty with endarterectomized superficial femoral artery for limb salvage in the elderly
Authors: Witz M , Shnaker A , Lehmann J M 
Published: March 2003

Abstract

Background
This longitudinal observational study was designed to show that isolated profundoplasty to relieve a significant stenosis is a valid procedure for limb salvage in the elderly.

Methods
Twenty-seven patients with critical limb ischaemia underwent isolated profundoplasty using endarterectomized superficial femoral artery as an arterial patch. Nineteen patients were men. The mean age was 72 (range 65–79) years. All patients had rest pain with or without an ischaemic foot ulcer or pedal gangrene.

Results
There was no operative death or immediate operative failure. All 27 limbs were improved, with relief of rest pain, healing of ulcers and healing after minor foot amputations. The 27 patients underwent a mean of 30 (range 12–45) months of periodic observation in an outpatient clinic, either to the present time or until death. Two patients required late amputations and one a femorodistal bypass.

Conclusion
Isolated profundoplasty has a place in leg revascularization in the high-risk elderly patient. Endarterectomized superficial femoral artery as a patch has the advantages of almost universal availability and anatomical convenience.
Laparoscopic ultrasonography is accurate for staging large pancreatic tumours
Authors: Finch M D , Formela L , Jones L , Sutton R , Hartley M N , Slavin J , Neoptolemos J P 
Published: March 2003

Abstract

Background
The accuracy of laparoscopic ultrasonography in staging pancreatic and periampullary tumours in a referral unit was determined and its use for the subgroup of tumours of stage T3 or greater was assessed.

Methods
From a larger series of staging laparoscopies 22 patients with pancreatic lesions and five with periampullary tumours who were being considered for resection were staged with laparoscopy and laparoscopic ultrasonography. Only patients with computed tomography (CT) or magnetic resonance imaging (MRI) scans indicating potentially or equivocally resectable disease were included. The laparoscopist was blinded to the results of CT and MRI. Laparoscopy and laparoscopic ultrasonography were undertaken according to a standard protocol using a B & K Medical Diagnostic Ultrasound System 3535 with a colour flow Doppler module. Ascitic fluid was sent for cytology and metastatic disease was biopsied. Results were recorded on a pro forma which included an assessment of resectability. In the case of large tumours this included an assessment of the potential for a positive resection margin or the need for portal vein resection to obtain tumour clearance. The decision to pursue resection was made by the consultant surgeon, based on all the information available including that from laparoscopic ultrasonography. No patient was denied a surgical exploration on the basis of local irresectability determined only by laparoscopic ultrasonography. The predictions regarding resectability were compared with findings at open surgery and with histology.

Results
Assessment of irresectability by laparoscopic ultrasonography resulted in nine true positives, 16 true negatives, no false positives and one false negative. For pancreatic adenocarcinoma there were eight true positives, 13 true negatives and one false negative. Among the pancreatic group ten of 13 tumours correctly predicted as resectable were stage T3 or greater (Union Internacional Contra la Cancrum, 1997). Of those predicted to be irresectable, all eight were T3 or greater. Among this latter group three were predicted to be irresectable on the basis of local factors alone, two on the basis of metastatic disease alone and three on the basis of both local factors and metastases. Overall, for detection of irresectable disease laparoscopic ultrasonography had a positive predictive value of 100 per cent, a negative predictive value of 94 per cent and an accuracy of 96 per cent. Accuracy was 95 per cent for both the pancreatic tumour subgroup and the T3 pancreatic subgroup.

Conclusion
Laparoscopic ultrasonography was accurate for predicting irresectability in this group of referred patients. The technique was also accurate for the subgroup with T3 or greater pancreatic tumours.
Single-centre audit of endoscopic common bile duct stone retrieval
Authors: Welsh F K S , Mudan S S , Knight M J 
Published: March 2003

Abstract

Background
Endoscopic extraction of stones in the bile duct is not without risk, with complications occurring in up to 10 per cent of patients. The aim of this study was to determine the success and complications of stone retrieval by endoscopic retrograde cholangiopancreatography (ERCP) in this institution.

Methods
This was a retrospective analysis of a prospective database for all ERCPs (single operator, single institution) between 1990 and 1995. Some 271 consecutive patients with a strong suspicion of bile duct stones, from history or investigations, were studied. All patients underwent ERCP and attempted retrieval of bile duct stones if detected. Treatment success was strictly defined as a stone-free postprocedure radiograph. All patients were followed to identify complications occurring within 30 days of the procedure.

Results
The median age of the 271 patients was 73 (range 17–96) years; 62 per cent were women. Some 139 patients had 162 significant other medical conditions (61 per cent cardiopulmonary) that required specialist treatment. The presenting symptoms included painful jaundice (34 per cent), acute pancreatitis (25 per cent), cholangitis (17 per cent), painless jaundice (14 per cent) and abdominal pain alone (9 per cent). Stones were seen at ERCP in 192 patients (71 per cent); the median number of stones was 1 (range 0–20). Successful endoscopic stone retrieval was achieved in 136 patients (71 per cent) at the first attempt, with an overall success rate of 90 per cent. The median number of ERCPs per patient was 1 (range 1–4). There were five false-negative ERCPs (2 per cent) and 19 retrieval failures (10 per cent), which included requirement for percutaneous cholangiography or endoscopic stenting for successful treatment. Complications occurred in eight␣patients (3 per cent), and included cholangitis (1␣per cent), pancreatitis (less than 1 per cent) and haemorrhage (less than 1 per cent). There were two procedure-related deaths (1 per cent), from myocardial infarction and cholangitis.

Conclusion
Endoscopic stone retrieval can be achieved successfully with low morbidity and mortality rates, even in patients with significant co-morbidity. These data provide further support for dedicated units offering a regional ERCP service.
Impact of endoscopic ultrasonography on the management of idiopathic pancreatitis
Authors: Norton S A , Alderson D 
Published: March 2003

Abstract

Background
Conventional ultrasonography may fail to detect small stones responsible for acute pancreatitis, leading to a false diagnosis of idiopathic pancreatitis and exposing 33–66 per cent of these patients to the risk of a recurrent attack from untreated gallstone disease. The aim of this study was to assess whether identification of a potential aetiology in patients with ‘idiopathic’ pancreatitis, using endoscopic ultrasonography (EUS), had any effect on outcome.

Methods
EUS was performed following a diagnosis of idiopathic pancreatitis, using the GF UM-20 echoendoscope (Olympus). The presence of gallstones or other pathology was determined and any appropriate treatment was provided. The frequency of attacks of pancreatitis before and after treatment of the presumed cause was calculated.

Results
Of 20 patients with idiopathic pancreatitis, evidence of gallstone disease (e.g. stones, microlithiasis) was seen in 12 patients leading to endoscopic sphincterotomy and/or cholecystectomy in nine. Pancreatic disease was seen in three patients, of whom one underwent pancreatic duct stenting. One patient underwent cholecystectomy for recurrent pain, despite a normal EUS result, with a diagnosis of acalculous cholecystitis. No pathology was seen in a further four patients. The frequency of attacks of pancreatitis was 1·1 per patient-year before treatment versus 0 per patient-year after treatment (P &lt; 0·0001). The overall morbidity rate from investigation and treatment was 0·05 per cent. This resulted from one episode of post-ERCP pancreatitis following endoscopic sphincterotomy, which resolved rapidly with conservative treatment.

Conclusion
EUS is able to detect pancreatic and biliary abnormalities that are not visible with conventional ultrasonography and can guide appropriate treatment. EUS should be performed before a diagnosis of idiopathic pancreatitis is made, to reduce the risk of recurrent pancreatitis from unrecognized gallstones or other pathology.
Cost implications of endoscopic surveillance of patients with Barrett's oesophagus
Authors: Howell G W , Russel K , Bani-Hani K , Martin I G 
Published: March 2003

Abstract

Background
The cost implications of a 13-year endoscopic surveillance programme for patients with Barrett's oesophagus were assessed and it was considered whether this represents a justifiable use of resources.

Methods
From a population of 597 patients with Barrett's oesophagus, 357 patients (207 men; mean age 61 years) entered a yearly endoscopic surveillance programme. Twelve patients (11 men) developed adenocarcinoma a mean of 72 months after entering the programme. The costs of the surveillance programme were calculated using figures for this institution.

Results
The cost of detecting one cancer at the institution's incidence rate of one cancer per 69 patient-years of follow-up was £24 236. The cost for male patients was £15 801 and for female patients £122 973. For male patients with specialized mucosa the cost was £13 969 per cancer detected. Comparing the stage presentation of surveillance cancers with the stage of adenocarcinomas presenting generally in this institution, the cost per life-year saved was estimated at £6097 for male patients.

Conclusion
Yearly endoscopic surveillance of patients with Barrett's oesophagus is expensive compared with other established screening programmes (e.g. £6006 per breast cancer detected) but for male patients with specialized mucosa it is probably justified. However, its role in female patients must be questioned given the high cost and low yield of cancers.