Modified prone position to dissect the popliteal fossa.

INTRODUCTION: Traditionally, the prone position is used for dissecting the popliteal fossa, which requires endotracheal intubation. Access to the airway in this position is limited, hence the complications. It is not surprising that the prone position is not favoured by the anaesthetists, especially in patients with a high body mass index. We describe a safe and novel alternative to the prone position. METHODS: The modified prone position (MPP) is described as an alternative position that facilitates access to the airway. RESULTS: Between October 2007 and May 2010, 12 patients underwent popliteal fossa dissection using the MPP. All patients had general anaesthesia using a laryngeal mask airway with the exception of one, who had an epidural anaesthesia. There were no airway or haemodynamic complications. The surgical access to the popliteal fossa was as good as with the traditional prone position. CONCLUSIONS: The MPP was satisfactory for both the surgeon and the anaesthetists. The authors now use this position routinely for dissecting the popliteal fossa.

Gastric perforation in an adult male following nasogastric intubation.

INTRODUCTION: Spontaneous gastric perforation is a well known surgical emergency which carries significant mortality and morbidity. Well documented causes in adults include peptic ulcer disease, drugs such as non-steroidal and gastric malignancy. Iatrogenic causes still remain relatively rare. We report an interesting case of an acutely unwell young man who developed gastric perforation secondary to nasogastric intubation. CASE REPORT: A 32 year old man initially treated for gastroenteritis underwent laparotomy for acute intra-abdominal bleeding. This was found to be secondary to a ruptured left hepatic artery aneurysm which was subsequently embolised. Patient had multiple laparotomies, a nasogastric tube inserted at the second laparotomy was later found to be the cause of gastric perforation. On further investigation the patient's multiple aneurysms were histologically confirmed to be secondary to fibromuscular dysplasia (FMD). CONCLUSION: We present here a case of gastric perforation from a nasogastric tube in an adult male and discussed its relevance to the diagnosis of FMD. This case highlights the importance of having a high index of suspicion for this complication when managing patients with severe abdominal sepsis.

Ultrasound guided foam sclerotherapy: factors associated with outcomes and complications.

OBJECTIVES: In recent years ultrasound guided foam sclerotherapy (UGFS) has become an increasingly popular treatment for varicose veins. Although many published series detail the results of UGFS, little is known about the factors which are associated with outcomes and complications. The aim of this study was to identify these factors. DESIGN: A review of a prospectively collected database of UGFS which commenced in July 2007. METHODS: A successful outcome was defined as complete occlusion of the target vein on duplex scanning at follow-up. Eight factors were assessed to determine whether they were associated with outcomes and complications. These factors were age, gender, compliance with post-procedure compression hosiery, previous varicose vein surgery, single or multiple sites of injection, concentration of sclerosant, volume of sclerosant and pre-procedure severity score. RESULTS: Between July 2007 and July 2009, a total of 126 patients (60 men, 66 women) attended follow-up visits and had a post-procedure duplex scan. Targets for UGFS included the great saphenous vein (n = 75), small saphenous vein (n = 13) and anterior accessory great saphenous vein (n = 8). The remainder of procedures involved other veins or more than a single target vein. The median timing of follow-up was 3 months (range 1.5-14 months) with duplex scans revealing complete occlusion of the target vein in 79% of patients. The only factor associated with a successful outcome was compliance with post-procedure compression hosiery (p < 0.05). The most frequently encountered complications following UGFS were skin staining (28%), superficial thrombophlebitis (18%) and pain (14%). The only factor associated with post-UGFS complications was female gender (p < 0.05). When complications were analysed in isolation female gender was also significantly associated with skin staining (p < 0.05), but no other complication. CONCLUSIONS: These data suggest that compliance with post-procedure compression hosiery and gender are important factors associated with a successful outcome and reported complications following UGFS, respectively.

A prospective study of internal carotid artery plication during carotid endarterectomy: early clinical and duplex outcome.

OBJECTIVE: internal carotid artery (ICA) plication prevents kinking and secures the distal intimal step following carotid endarterectomy (CEA). The aims of this prospective study were to quantify the proportion of patients in whom plication might be beneficial and determine whether plication is associated with an increased incidence of early restenosis and a reduction in postoperative thromboembolic complications. METHODS: analysis of a prospectively gathered computerised database. RESULTS: between 1 November 1992 and 31 December 1997, 228 consecutive CEAs were performed in 213 patients, of which 84 (37%) in 79 patients were plicated. Sixty endarterectomy sites have been examined by duplex ultrasonography at a median of 5 (range 1-44) months postoperatively. No abnormality was detected in 52 (87%), six (10%) had restenosis of <50% and two (3%) restenosis of 50-75%. All were asymptomatic. Three patients (3. 6%), one of whom died, had an intraoperative neurological event and one patient (1.2%) had a postoperative cerebral haemorrhage. No patient suffered ICA thromboembolism. During the same time period 144 non-plicated CEAs were performed in 134 patients. Of these, one (0.7%) had an intraoperative and five (3.5%) had a postoperative neurological event. Five of these six complications were due to ICA thromboembolism. There was no mortality in the non-plicated group. CONCLUSION: ICA plication can be used to prevent kinking, secure the distal intimal step, has not, to date, been associated with increased early restenosis rate and has avoided postoperative ICA thromboembolism.

Functional outcome after coloanal anastomosis with J-colonic pouch for rectal cancer.

This study was designed to determine functional outcomes of restorative resections for carcinoma of the rectum. Between 1992 and 1995, 16 patients (8 male) of median age 75 (range 58-88) years underwent resection and coloanal anastomosis with J-colonic pouch reconstruction for rectal cancer. The distance of the lower border of tumor from the anal verge was 5 cm in 7 patients (43.70-0), 6 to 7 cm in 6 patients (37.0%) and 8 to 10 cm in 3 patients (18.7%). The Dukes staging was A in 4 patients (25%), B in 8 patients (50%) and C in 4 patients (25%). Coloanal anastomosis was performed by hand in 4 patients (25%) or with stapler in 12 patients (75%). Seven patients (43.7%) had diverting stoma. No patient died following surgery. Pelvic sepsis and anastomotic dehiscence that required pouch excision occurred in two patients (12.5%). Fourteen patients were evaluated. The mean follow-up was 15 (range 5-23) months. No patient developed recurrent pelvic tumor. Satisfactory fecal continence was achieved by 85.7% of patients. Stool frequency was 1-2 per day in 12 patients (85.7%). Three patients (21.4%) had minor soiling. Five patients (35.7%) occasionally complained urgency. There was no apparent difference between the patients with manual or stapled coloanal anastomosis. Coloanal anastomosis with J-colonic pouch is associated with an excellent long-term outcome.

A 21-year experience of abdominal aortic aneurysm operations in Edinburgh.

BACKGROUND: This study reviews the results of infrarenal abdominal aortic aneurysm (AAA) surgery over 21 years (1 January 1976 to 31 December 1996). METHODS: A prospectively gathered database was analysed. RESULTS: Infrarenal AAA repair was performed in 1515 patients: 492 (32.5 per cent) had elective repair of an asymptomatic AAA; 194 (12.8 per cent) had elective repair of a symptomatic AAA; 156 (10.3 per cent) had emergency repair of a symptomatic non-ruptured AAA; and 673 (44.4 per cent) had surgery for a ruptured AAA. The 30-day and/or same admission mortality rates were 6.1, 5.8, 14.1 and 37 per cent respectively. Operative mortality increased in all four groups over the study interval, although this only attained statistical significance in patients having elective repair of a symptomatic, non-ruptured AAA. There was a significant increase in the age of patients undergoing elective repair of an asymptomatic AAA, but not in the other three groups. There was also a significant increase in the proportion of straight 'tube' grafts inserted in all four groups. CONCLUSIONS: It remains the minority of patients who have elective operation before the onset of symptoms and/or rupture. Despite anaesthetic and surgical specialization, the results of AAA repair have not improved over the past two decades. Operative mortality may be increasing, possibly because of the increasing age and associated comorbidity of the patients presenting to this unit.

Twelve-year experience of the management of ruptured abdominal aortic aneurysm.

BACKGROUND: The operative mortality rate for elective repair of asymptomatic abdominal aortic aneurysm (AAA) is falling but the fate of patients with ruptured AAA may have changed little over the past decade. METHODS: This study was an analysis of a prospectively gathered computerized database. RESULTS: In the 12 years to 31 December 1994, 1144 patients underwent (attempted) repair of AAA. In 514 patients (44.9 per cent) who had an operation for ruptured AAA there was no significant change in the mean age, male:female ratio (418:96), or operative mortality rate (35.0 per cent) over the interval of the study. Forty-seven patients died before reaching the operating theatre, giving an 'intention to operate' mortality rate of 40.5 per cent. A further 68 patients (10.8 per cent of all patients who presented with a ruptured AAA) were not offered operation because of poor medical condition (n = 34) or extreme age (n = 34); three patients refused operation. A greater proportion of patients had surgery between 1989 and 1994 (276 of 323, 85.4 per cent) than between 1983 and 1988 (238 of 309, 77.0 per cent) (P < 0.01, chi2 test). CONCLUSION: The proportion of aneurysms operated on for rupture in this unit remains high (almost 50 per cent). The results of surgery for ruptured AAA have not improved in the past 12 years.

Delayed diagnosis of juvenile primary hyperparathyroidism.

Primary hyperparathyroidism (PHP) is most common in adults in the fifth and sixth decades of life, but is seen infrequently in adolescence and is extremely rare in children under the age of 14 years. We report the case of a young female whom we suspect had PHP from the age of 6 years. This condition remained undiagnosed for the next 11 years in spite of repeated hospital admissions. The hypercalcaemia which was initially labelled as 'idiopathic' was eventually found to be secondary to a parathyroid adenoma, which was treated successfully by surgery. The case illustrates two important advances: (1) in parathyroid hormone measurement with a new sensitive immuno-radiometric assay, and (2) in the development of radionuclide scanning for localization of parathyroid adenoma(s). No case of hypercalcaemia should be labelled as 'idiopathic' or left unexplained without a detailed exploration of the neck to exclude PHP arising from a parathyroid adenoma.

Transverse fracture of the patella in children.

We report two cases of transverse fracture of the patella in children. Contrary to the general belief that this fracture is common in children, we could not find any reported cases since 1973. Both of our cases were sports-related and each illustrates a different mechanism of injury.