The role of cardiopulmonary fitness and its genetic influences on surgical outcomes.

BACKGROUND: Outcome after major surgery remains poor in some patients. There is an increasing need to identify this cohort and develop strategies to reduce postsurgical morbidity and mortality. Central to outcome is the ability to mount cardiovascular output in response to the increased oxygen demand associated with major surgery. METHODS: A medline search was performed using keywords to identify factors that affect, and genetic influences in, disease and outcome from surgery, and all relevant English language articles published between 1980 and 2005 were retrieved. Secondary references were obtained from key articles. RESULTS: Preoperative cardiopulmonary exercise testing assesses patient fitness, highlights those at particular risk and, combined with triage to critical care, facilitates significant improvement in surgical outcome. However, genetic factors also influence responses to increased oxygen demand, and some patients are genetically predisposed to mounting increased inflammatory responses, which raise oxygen demand further. Polymorphisms in genes influencing fitness (angiotensin converting enzyme) and immune and inflammatory responses (such as interleukin 6) may associate with surgical outcome. CONCLUSIONS: Development of preoperative screening methods like cardiopulmonary exercise testing and genotype analysis to identify index factors may permit better patient stratification, provide targets for future tailored treatments and so improve surgical outcome.

Intermittent claudication: exercise-increased walking distance is not related to improved cardiopulmonary fitness.

OBJECTIVES: To assess if exercise training improves the symptoms of intermittent claudication by improvement in cardiopulmonary fitness. METHODS: Claudication distance (CD), maximum walking distance (MWD), calf endurance (repetitive heel raises), cardiovascular fitness (VO2 peak), and ankle-brachial pressure index (ABPI) were measured in 16 subjects with intermittent claudication before, and following an 8-week treadmill training programme. RESULTS: Training resulted in a median increase in CD of 65.5 m (p<0.01), MWD of 339.5 m (p<0.001) and HR of 19 (p<0.03). Notably, improvements in MWD correlated with those in HR (p=0.001; R=0.75). There was no training-associated change in VO2 peak (median increase of only 0.35 ml/kg/min; p=0.60) or ABPI (median increase of only 0.01; p=0.64). CONCLUSION: In this study, overall improvement in claudication was not related to an improvement in cardiopulmonary fitness.

Secondary intervention following endovascular repair of abdominal aortic aneurysm: a single centre experience.

AIMS: We aim from a review of our early and late experience of secondary intervention for technical failures, to examine and describe the impact of endovascular and open interventions. METHODS: 108 Abdominal Aortic Aneurysms (AAAs) repaired endoluminally between 1995-2001 were analysed. In our early experience, during 1995/96 home made pre-expanded polytetrafluoroethylene grafts fixed with Palmaz stents were used (n = 26). In our later experience, 1997/2001 Talent (n = 70) or Zenith endografts (n = 12) were used. All cases underwent spiral CT at 5 days and 6 monthly intervals post-op. Angiography was performed when further intervention was intended. All technical failures requiring intervention or not were studied. RESULTS: There were 28 (26%) technical failures identified of which 14 of 26 (54%) occurred in our early experience, and 14 of 86 (16%) occurred in our later experience (p < 0.05). Eleven in all required open conversion at the time of endovascular repair. Our study cohort were the remaining 17 cases requiring secondary intervention, seven were from our early experience and 10 from our later experience. There were 12 endoleaks, including two as a result of graft migration, two graft occlusions, two graft distortions and one graft infection. Overall 10 (66%) technical failures were treated by endoluminal repair and seven (34%) by open methods. However, in our later experience significantly more endoluminal techniques (80%) were used (p < 0.05). CONCLUSIONS: Technical failure rates were significantly higher in our earlier experience. Open repair, which was a feature of our early experience, has been avoided over the final 3 years. Instead, endoluminal techniques were used without further morbidity or mortality. Aneurysm rupture has not so far been experienced in this experience.

Principles and problems underlying testing the effectiveness of blast protective footwear.

Anti-personnel landmines are a continuing threat to soldiers and civilians working overseas in post conflict situations. Several groups of governmental and commercial scientists are currently designing and/or testing footwear to protect the lower leg from the effects of close proximity blast. The general principles surrounding testing of protective footwear are examined together with an assessment of the known progress to date and the strengths and weaknesses of the designs produced.

Integrated care pathways for vascular surgery: an analysis of the first 18 months.

OBJECTIVES: A review of the use of previously described integrated care pathways (ICPs) established for three elective vascular surgical procedures. DESIGN: A retrospective analysis of information gathered prospectively over an initial 18 month period of use of vascular surgical ICPs. SUBJECT: Patients admitted to a single vascular unit for "open" repair of abdominal aortic aneurysm (AAA), carotid endarterectomy, or femoropopliteal bypass grafting. METHODS: An analysis of variance data, length of stay, and costings after the use of ICPs, compared with previous clinical practice. RESULTS: Variance data were gathered for each of the three procedures. Variances of medication prescribing and delays in discharge were common to all procedures. In particular: (i) gastrointestinal complications were more specific to AAA repair and (ii) wound drains were removed a day later than originally proposed after femoropopliteal bypass. Overall, improved efficiency due to use of ICPs reduced the length of stay for all procedures, which was reflected in a potential cost saving of some 25%. CONCLUSION: There are clear benefits to the use of ICPs, resulting in more structured, efficient, and cost effective patient care. Recommended changes to current practice based on variance analysis will require continued audit to sustain this "evidence based" approach.

Amputations at the London Hospital 1852-1857.

Between 1852 and 1857 at the London Hospital, 142 amputations were performed in 136 patients. The most common indication was an injury sustained at work. Overall mortality was 46% and the death rate was especially high for lower-limb amputations. Most deaths were due to postoperative sepsis. Those who received chloroform anaesthesia did worse than those who received ether.

10-year experience of injuries sustained during clearance of anti-personnel mines.

Clearance of anti-personnel mines and unexploded ordnance in countries recovering from war usually continues long after conflict has ceased. We prospectively recorded 92 traumatic injuries sustained by 73 mineclearers working in seven countries over a period of 10 years. 15% of injuries were fatal, with an incidence of 116 injuries per 100000 workers per year. Limb injury occurred in 59% of cases, with an overall amputation rate of 30%. 44% of injuries were sustained by workers handling a mine, resulting in severe upper limb and facial injuries. The incidence of facial injuries fell after the introduction of visors.

Paediatric rectal prolapse in Rwanda.

During the 1994 crisis in Rwanda, a high incidence of full-thickness rectal prolapse was noted among the refugee children in the south-west of the country. The prolapses arose as a result of acute diarrhoeal illness superimposed on malnutrition and worm infestation. We used a modification of the Thiersch wire technique in 40 of these cases during two months working in a refugee camp. A catgut pursestring was tied around the anal margin under local, regional or general anaesthesia. This was effective in achieving short-term control of full-thickness prolapse until the underlying illness was corrected. Under the circumstances, no formal follow-up could be arranged; however, no complications were reported and only one patient presented with recurrence.