Clinical results of deep venous valvular repair for chronic venous insufficiency.

OBJECTIVE: To evaluate the results of venous valvular repair in the treatment of 16 cases of chronic venous insufficiency (CVI). DESIGN: A retrospective analysis of 16 venous valve repair operations (15 patients) with a minimum follow-up of 2 years. SETTING: A 650-bed university-affiliated teaching hospital. PATIENTS: Fifteen consecutive referred patients who had CVI had deep vein valve surgery. All cases were refractory to prolonged conservative care and removal of incompetent superficial and perforating veins. Investigation included ascending and descending venography, air plethysmography (APG) and colour flow duplex scanning (CFDS). All patients had class 4, 5 or 6 CVI and all demonstrated deep venous reflux from the groin to below the knee on descending venography. INTERVENTIONS: Superficial femoral vein valvuloplasty (12 operations) and venous valve transfer from the axillary vein to the above-knee popliteal vein (4 operations). MAIN OUTCOME MEASURES: Healing of ulcers, relief of edema and improvement in symptoms were clinical criteria of success. An attempt was made to correlate preoperative and postoperative APG, CFDS and descending venography. RESULTS: Ninety-two percent of the valvuloplasty patients and 75% of the valve transfer patients were clinically improved. In this series no statistical association existed between preoperative and postoperative changes noted on APG. CONCLUSION: This series suggests that deep vein valvular reconstruction for CVI refractory to conservative management and superficial surgery offers a good chance of clinical improvement.

Thoracic outlet syndrome: fact or fancy? A review of 409 consecutive patients who underwent operation.

OBJECTIVES: From an analysis of patients operated on by a single surgeon between 1973 and 1994 for thoracic outlet syndrome (TOS), to determine what findings are helpful in substantiating this diagnosis and what are the results of decompressive thoracic outlet surgery in the management of TOS. DESIGN: A chart review with emphasis on signs, symptoms and results. A preoperative questionnaire was presented to all patients operated on since 1989. Postoperative follow-up was by interview or telephone. SETTING: A 560-bed university-affiliated tertiary-care teaching hospital. PATIENTS: There were 409 adults; 83% were women and the average age was 36 years. In 95% of patients physiotherapy had been unsuccessful. Patients presented with neurologic type (368 [(90%]), arterial impingement (29 [7%]) and venous obstructive symptoms (12 [3%]). The series included 44 patients with bilateral symptoms and 26 patients with cervical ribs. Some form of litigation or compensation was associated with 177 patients. INTERVENTIONS: Transaxillary first rib resection in 380 (93%) patients and supraclavicular thoracic outlet decompression in 29 (7%). In 244 patients there was a follow-up of at least 2 years. These patients constituted the follow-up group. RESULTS: Preoperatively, in the 368 patients who had neurologic TOS, 99% displayed supraclavicular brachial plexus tenderness and 98% exacerbation of symptoms with arms in the abduction external rotated position. There were eight complications of surgical intervention (1.9%). In the follow-up group, there were no deaths, no subclavian/axillary artery or vein damage and no brachial plexus injury. Seventy-eight percent of the patients with neurologic TOS in this group improved postoperatively; 21% had complete relief, 32% had good relief and 25% had fair relief. Twenty-two percent showed no improvement. CONCLUSIONS: Signs and symptoms helpful in making the diagnosis of neurologic TOS are supraclavicular tenderness on palpation and exacerbation of symptoms with the arms in the abducted external rotated position. The surgical procedures are safe. Patients with TOS refractory to medical management can benefit from thoracic outlet decompression.

Attitudes toward trauma care of surgeons practising in Ontario.

OBJECTIVE: To assess the attitudes of practising surgeons in the province of Ontario toward issues in trauma care management. DESIGN: A survey by questionnaire. SETTING: The study was carried out in a university-affiliated hospital. The survey respondents generally practised in a nonteaching setting; 48% were over the age of 50 years; 81% worked in an institution with 24-hour in-house physician coverage for the emergency department. SUBJECTS: All 2294 surgeons registered with the Ontario Medical Association were surveyed by completion and return of a questionnaire; 191 surgeons were registered in Ontario but were not practising in the province and were excluded from the survey. Questionnaires were completed by 575 surgeons, but 49 were no longer in active practice, so 526 responses form the basis of this analysis. RESULTS: The response rate to the questionnaire was 27%. One-third of the respondents wished to treat no trauma patients at all; 47% believed that trauma patients had a negative impact on their surgical practice; only 19% considered that trauma patients had a positive impact. Surgeons had negative attitudes toward trauma because of the night and weekend profile of trauma, its effect on elective surgical practice, the poor rate of reimbursement for time spent in trauma management, and the potential medicolegal liability of trauma cases. CONCLUSIONS: These results suggest that there are few surgeons in Ontario who are truly committed to providing care to the injured patient. Strategies to overcome the perceived negative aspects of trauma care must be addressed because a crisis in the availability of surgeons to provide this care seems inevitable.

Preoperative transdermal scopolamine does not reduce the level of nausea and frequency of vomiting after laparoscopic cholecystectomy.

OBJECTIVE: To determine the efficacy of scopolamine administered transdermally before laparoscopic cholecystectomy as a means of reducing postoperative nausea and vomiting. DESIGN: A randomized, double-blind, placebo-controlled study. SETTING: A tertiary-care, university-affiliated hospital. PATIENTS: A volunteer sample of 125 men and women between 20 and 60 years of age scheduled to undergo elective laparoscopic cholecystectomy. Expectant or nursing mothers were excluded, and 35 patients were excluded from the final analysis because of protocol violations. Forty-three patients received scopolamine and 47 patients received a placebo. INTERVENTION: A skin patch (scopolamine or placebo) was applied behind the right ear on the evening before operation and maintained for at least 24 hours postoperatively. MAIN OUTCOME MEASURES: The postoperative level of nausea assessed by the patient on a visual analogue scale, the frequency of vomiting and the frequency of antiemetic use. RESULTS: There was no significant difference in the level of nausea or in the frequency of emesis or use of antiemetics in the first 24 hours postoperatively between the control and study groups. Furthermore, there was no difference in the overall frequency of side effects. However, visual blurring was experienced by six patients in the study group compared with one in the control group (p = 0.082). CONCLUSION: Scopolamine administered transdermally before laparoscopic cholecystectomy does not reduce the frequency or level of nausea and vomiting postoperatively.

Attitudes of surgical residents toward trauma care: a Canadian-based study.

Surgical residents (n = 330) registered in training programs in the province of Ontario, Canada were surveyed about their attitudes toward trauma care related issues. Questionnaires were returned by 48%. Overall, 84% felt that their clinical exposure to trauma was adequate; 78% noted that the emphasis placed on trauma topics in their educational programs was appropriate; 50% spend > 10% of their current clinical time in trauma care. Orthopedic residents (n = 43) were different; 79% devoted > 10% and 29% > or = 30% of their time to trauma. Future clinical activity in trauma as practicing surgeons was expressed by 83% of the trainees: 31% intended < 10%, 46% 10%-30%, and 6% > 30% of their future practices to be related to trauma. The major positive factors of trauma were the scope and excitement of trauma care. The major negative factors were the night/weekend activity and the time away from family. We are encouraged by the results of this survey in that a significant number of residents perceive trauma as a clinical endeavor to be incorporated into their future surgical practices.