Day-case re-do varicose vein surgery.

OBJECTIVE: To assess whether re-do varicose vein surgery as a day case is feasible and safe. METHODS: Data were collected retrospectively on 70 consecutive patients (77 legs) undergoing re-do sapheno-femoral or sapheno-popliteal ligation by consultant surgeons as day cases. Follow-up was by structured telephone interview. RESULTS: The 70 patients comprised 53 females and 17 males. Median age and body mass index were 47.5 years and 27, respectively. All patients were ASA Grade I or II. Median operating time was 75 min (range 25-140). Of the 70 patients intended to be treated as day cases, four (5.7%) were admitted overnight. There were no were re-admissions nor did any patient develop deep vein thrombosis. Eleven per cent developed wound infection and 4% transient lymphatic leakage. Overall, 91% of patients were pleased with the initial surgical result but this decreased to 81% in the longer term. Eighty-nine per cent would have their surgery performed again as a day case. CONCLUSION: Re-do sapheno-femoral or sapheno-popliteal can be performed safely as a day case.

Can cycloidal vibration plus standard treatment reduce lower limb cellulitis treatment times?

OBJECTIVE: This single-centre non-blind randomised controlled trial aimed to compare clinical outcomes in terms of recovery time of standard treatment of lower limb cellulitis versus standard treatment combined with cycloidal vibration (Vibro-Pulse) therapy. METHOD: Thirty-six patients (18 per group) with lower limb cellulitis were randomised to receive either standard treatment (intravenous or oral antibiotic therapy) and bed rest or standard treatment combined with cycloidal vibration treatment three times per day, 30 minutes per treatment. The outcome measure was the daily amount of reduction in erythema/cellulitis and oedema reduction against time for up to seven days of treatment and the resources required. RESULTS: There was a clinically significant difference between the two groups, with 66% of the study group fully recovering within the seven days compared with 11% of the control group. CONCLUSION: Cycloidal vibration combined with standard therapy can significantly reduce cellulitis treatment time. This can reduce both hospital bed days and the resources required.

Non-vascular claudication: a clinical conundrum.

This is a prospective study of patients referred to our department with symptoms of claudication unlikely to be of vascular origin. After clinical assessment these patients were referred to an orthopaedic physician. Of 1070 patients referred, 33 patients were diagnosed with a non-vascular problem. Of these, 21 were cases of spinal stenosis with or without nerve root irritation, seven had a combination of spinal pathology and peripheral vascular disease, and five were diagnosed with intervertebral disc prolapse (n=3), diabetic neuropathy (n=1) and chronic fatigue syndrome (n=1). The prognosis for patients with non-vascular claudication in respect of the development of premature vascular events is likely to be different from vascular claudicants and they should be counselled appropriately. Furthermore, the potentially less favourable outcome following reconstruction must be clearly explained to patients with a non-vascular contribution to their symptoms before any therapeutic vascular intervention. Failure to do this is likely to have significant medicolegal implications.

A prospective audit of hospital-acquired deep vein thrombosis and pulmonary embolism.

The incidence of symptomatic deep vein thrombosis and pulmonary embolism acquired in hospital was studied, and the effectiveness of current thromboprophylaxis was assessed in an open study of 8648 admissions to the Doncaster Royal Infirmary between April and July 1994. On admission, all patients were assessed for their likely risk of thromboembolic problems according to THRIFT criteria. Treatment, prophylaxis, complications and outcome were recorded on discharge. A high risk sub-group was followed up for up to 42 days after discharge. The overall rate of clinically apparent hospital-acquired thromboembolic complications was 0.4% (n = 35). The rate of clinically apparent thromboembolic disease in the high risk group was 2.1% (n = 17). The incidence of thromboembolic problems appeared not to be reduce by prophylaxis apparently even when stratified by risk group. These findings suggest that thromboembolic complications may be less common than would be expected from published literature. Thromboprophylaxis as currently practised within our institution does not seem to affect the incidence of deep vein thrombosis or pulmonary embolism, and these results would appear to argue against a 'blanket' policy for pharmacological thromboprophylaxis.

Emergency abdominal surgery in the elderly.

A retrospective survey of 152 patients undergoing emergency abdominal surgery was carried out to examine factors which may have affected the outcome of surgery. The operative diagnosis and procedure carried out, pre-operative health of the patient, duration of surgery and grade of surgeon were studied to assess whether these factors had any bearing on the eventual outcome. A large variety of surgical emergencies were treated but none of the factors under study were related to the eventual morbidity or mortality recorded. The overall mortality among these patients was 25% which concurs with other studies. The presence of an obstructing cancer of the left colon or upper gastro-intestinal haemorrhage had a particularly poor outcome. Most patients were discharged to their own homes within 3 weeks of admission and they did not comprise an undue burden on the surgical service.

Myofibroblastoma: an unusual breast lump.

A case of myofibroblastoma of the breast is reported. The clinical significance of this entity lies primarily in its recognition as a distinctive benign neoplasm.

Severe reversible arterial spasm with ergotamine.

A patient is described with marked unilateral arterial spasm of the proximal vessels and severe ischaemia of the left foot as a result of excessive use of ergotamine tartrate. Treatment with intravenous heparin infusion followed by chemical sympathectomy was successful.

Outcome after thymectomy for myasthenia gravis: a retrospective review.

This is a retrospective study of 54 patients, who in the period November 1977 to November 1986 underwent thymectomy as treatment for myasthenia gravis. Patients in whom difficulty attempting complete excision of the gland was anticipated were selected for a transthoracic procedure. All others underwent an initial transcervical approach, proceeding to an upper sternal splitting incision if further access was required to remove adequately a large gland. The sample was split almost equally between the two surgical procedures. Patients in the transthoracic group were significantly older and experienced significantly greater peri-operative morbidity or mortality. There was no significant difference in outcome between the two groups, 52% achieving a good result (defined as remission or clinically significant improvement of symptoms) that was sustained over the five year follow-up period. In our opinion, complete removal of the thymus should be the goal of surgical treatment for myasthenia gravis.

Early experience with intra-arterial thrombolytic therapy for peripheral arterial occlusion.

The authors present their early experience with local intra-arterial thrombolytic therapy for peripheral arterial occlusions causing limb threatening ischaemia, using streptokinase or urokinase. Ten patients were treated in a period of one year. Five patients had successful recanalisation, two patients had partial success and three patients required major amputation. The indications, contraindications and results of this treatment are reviewed.

Management of congenital arteriovenous malformations.

Over a 6-year period, 12 patients with 14 congenital arteriovenous malformations were considered for a staged approach to include afferent vessel ligation (AVL) and/or intra-arterial embolization (IAE) and surgical excision where possible. Patients were followed for a period ranging from 3 to 60 months. Two patients had localized lesions which were completely excised. Five patients were treated by IAE followed by excision with a successful outcome in four. One patient had a transmetatarsal amputation for failed IAE. Two patients had both IAE and AVL before excision of the lesion. In one patient AVL alone was followed by a recurrence. Two patients with multiple lesions were kept under observation. It would appear that IAE and excision of an arteriovenous malformation can achieve cure or excellent palliation in most patients.

Vascular complications after total knee replacement.

Arterial complications after total knee replacement are rare. We report 2 patients who presented with ischaemia of the lower limb after ipsilateral total knee replacement. The mechanism of injury and clinical implications are discussed.

Penetrating abdominal stab wounds: a plea for a more conservative policy.

This is a retrospective study of 107 penetrating abdominal stab wounds which have been reviewed on the basis of the clinical indications for surgery. Eighty-four patients underwent laparotomy. The unnecessary laparotomy rate was 35 per cent and the mortality 2.4 per cent. Important complications developed in 44 per cent of those undergoing surgery. Evaluation of clinical variables is presented and it is suggested that in the absence of shock, generalized peritonitis or evisceration, careful initial assessment, monitoring and regular re-examination would be a satisfactory method of treatment for many cases. This would result in a decrease in unnecessary laparotomies and associated excess morbidity.