Use of radiological information system data in Clinical Portal database to screen for missed abdominal aortic aneurysms.

INTRODUCTION: New Zealand lacks a formal abdominal aortic aneurysm screening programme and owing to its rural nature, many patients have limited access to vascular surgery. Patients with vascular emergencies often have limited treatment options locally, especially if they present perimortem. In our small hospital in Whanganui, with the nearest vascular centre more than 150km away, there are cases of aneurysms diagnosed incidentally on radiology reporting but lost to follow-up. METHODS: Clinical Portal (CP) is a widely used patient-centred dashboard for viewing health information that is managed by Orion Health. A search strategy utilising the CP common database was devised that aimed to find aneurysms which were not followed up. This search was performed retrospectively for all imaging within a 5-month period. RESULTS: Some 294 scans were flagged and 53 patients with aneurysms were found. Of these patients, 36 had follow-up by the ordering provider and 17 (32%) were found to have been lost to follow-up. CONCLUSIONS: Our pilot study demonstrated high rates of loss to follow-up and a lack of communication of important health information across multiple health disciplines in the region, and represents a potential method for identifying 'lost' aneurysms. For patients in rural communities, this may be critical to preventing future complications from aneurysmal disease.

Natural history of the ectatic aorta.

OBJECTIVES: To define the natural history of ectatic abdominal aortas and to assess the clinical need for follow-up. DESIGN: Abdominal aortas were considered ectatic if they were diffusely and irregularly dilated with a diameter less than 3 cm. Ectatic aortas were identified either by AAA screening or as incidental findings. Patients who had only one scan were excluded from the study. Clinical data were analysed. SETTING: Two district general hospitals in Wales and England. SUBJECTS: 116 patients (90 men). RESULTS: : The median age of patients was 71 years (range 48-90). Co-existing risk factors included hypertension (75), IHD (22), PVD (8), diabetes (3), COAD (14), stroke (5), popliteal aneurysm (1), malignant disease (3) and 4 had a family history of AAA. The median follow-up was 24 months (range 5-72). The median and maximum growth rate of the ectatic aortas were 0.65 and 14.4 mm/year respectively. In three patients the expansion rate was more than 5 mm/year. In 22 patients the ectatic aorta became aneurysmal, reaching a diameter greater than 3 cm. There were no ruptures and no elective repairs. Two deaths occurred due to IHD. CONCLUSIONS: : This study demonstrates that if ectatic aortas do expand they do so very slowly. However, 22 of the 116 (19%) became aneurysmal in a follow-up of two years. Once identified ectatic aortas should be scanned at intervals of three years.

Controlled trial of the introduction of a robotic camera assistant (EndoAssist) for laparoscopic cholecystectomy.

BACKGROUND: The role of the human camera holder during laparoscopic surgery keeps valuable personnel from other duties. EndoAssist is a robotic camera-holding device controlled by the operator's head movements. This study assesses its introduction into clinical practice. METHOD: Ninety-three patients undergoing laparoscopic cholecystectomy were randomized to have either the robotic (40) or a human (46) assistant. Seven patients converted to open operation were excluded. Six surgeons were evaluated. Operating time and subjective assessments were recorded. Learning curves were constructed. RESULTS: The mean operating time was less using the robotic assistant (66 min) than with human assistance (74 min) (p < 0.05, two-tailed t-test). The learning curves for operating time showed that within three operations surgeons were trained in using the robot. The device was safe in use. CONCLUSION: The EndoAssist operating device is a significant asset in laparoscopic surgery and a suitable substitute for a human assistant. Surgeons became competent in the use of the robot within three operations. The robot offers stability and good control of the television image in laparoscopic surgery.

Is a palpable short saphenous vein a useful clinical sign in varicose vein assessment?

The short saphenous vein (SSV) may be palpable in the popliteal fossa in patients with varicose veins. A prospective study has been carried out to determine the significance of this sign in the presence of primary varicose veins. The SSV was assessed by palpation of the popliteal fossa with the knee slightly flexed. Hand-held Doppler insonation (HHD) was also used in the out-patient clinic. All patients had SSV assessment by duplex scanning. One hundred and sixty legs were examined. In 68 the SSV was palpable; 39 (57%) of these had SSV reflux on duplex examination. When the SSV was not palpable (92 legs), only 1% (1 leg) refluxed on duplex scanning. SSV palpability had a 98% sensitivity, 75% specificity, 57% positive predictive value (PPV), and 99% negative predictive value (NPV). In comparison, HHD had 80% sensitivity, 87% specificity, 67% PPV and 93% NPV. The combined tests had 78% sensitivity, 73% specificity, 76% PPV and 100% NPV. Palpation of the SSV is a valuable part of clinical examination. If the SSV is not palpable, it is unlikely to reflux.

Surgeons have little control over general surgical waiting lists.

AIM: This study describes changes in the general surgical waiting list over a 13-year period. We have also attempted to define the factors affecting the size of the waiting list. METHODS: The number of patients on the waiting list was obtained from Hospital Activity Analysis data. Available surgical beds and theatre sessions were recorded prospectively over 13 years. RESULTS: As the number of beds and theatre sessions decreased, the general surgical waiting list increased. The total number of patients waiting rose from 301 in 1985 to 1,253 by 1990. The number of patients waiting for more than one year rose from 37 to 251. During that time the total number of available beds fell from 143 to 99 and theatre sessions from 21 to 17.5. Despite theatre sessions subsequently increasing to 21.5, the waiting list continued to rise, as these sessions were not matched with an increase in available beds. The introduction of a waiting list initiative that made extra resources available resulted in a fall in the number of patients waiting to 702 by 1993. Only 45 of those patients had been waiting for more than a year. When the waiting list initiative ended, there was a further steady rise in the waiting list, reaching 1,242 by the end of 1997. At this point, further waiting list initiative facilities were made available. We also noticed that during winter months there was a disproportionate number of patients added to the waiting list when surgical beds were 'blocked' by medical patients. CONCLUSIONS: This study shows that external factors, particularly available resources, influence the number of patients on a surgical waiting list. The main factors are lack of beds and theatre sessions. Furthermore, an imbalance between them will result in insufficient beds being available to fill those theatre sessions that do exist. Surgeons have little control over their routine waiting lists.

The effect of intraoperative autotransfusion on antibiotic pharmacokinetics during elective abdominal aortic aneurysm repair.

AIM: Blood loss during aortic surgery has been reduced by the use of cell-salvage techniques (CS). Antibiotics are used routinely to prevent prosthetic graft infection. The influence of CS on antibiotic levels is unknown. This study measured antibiotic levels in serum and cell-salvage fluid during aortic reconstruction. METHODS: Teicoplanin, a glycopeptide with activity against gram positive bacteria was the antibiotic studied. Serial blood levels were measured after a single intravenous dose (400 mg) in five patients undergoing elective aortic aneurysm repair. Patient ages ranged from 67 to 82 yr. Cell-salvage (Dideco compact A75171) fluid was also assayed. SETTING: District General Hospital RESULTS: Serum teicoplanin levels peaked at mean 67.8 mg/l (SD 8.9 mg/l) 5 min after administration, and fell to mean 2.88 mg/l (SD 0.4 mg/l) at 720 min. This is less than levels in healthy volunteers but above the MIC90 for most Gram positive bacterial pathogens encountered in aortic surgery. Teicoplanin levels in discarded CS fluid at the end of the procedure were 0.56 mg/l (SD 0.71 mg/l). CONCLUSIONS: Teicoplanin blood levels are reduced during aortic surgery. Levels remain adequate for antibacterial prophylaxis for 12 h postoperatively other than for methicillin-resistant staphylococcus epidermidis (MRSE). Compared with patients undergoing arterial reconstruction without the use of a cell-salvage device there is no significant loss due to CS use.