Endovenous laser ablation for persistent and recurrent venous ulcers after varicose vein surgery.

A 75-year-old woman presented with painful recurrent venous ulcers (VU) continuously for the past 33 months on a background of frequent intermittent problems for the last 16 years. She had previously been treated with varicose vein surgery and trials of compression bandaging. Subsequently, she underwent endovenous laser ablation (EVLA) targeting the distal incompetent remnant of her great and small saphenous veins. This resulted in complete healing of her ulcers within four weeks. The dramatic response demonstrated in this case suggests that EVLA may represent an effective intervention in the management of postsurgery refractory VU.

Temporal artery biopsy...who needs one?

OBJECTIVE: To review a 10 year period of temporal artery biopsies, using the American College of Rheumatology (ACR) 1990 criteria: a five point scoring system for the diagnosis of giant cell arteritis (GCA). DESIGN: Population based, retrospective cohort analysis. SETTING: One district general hospital in the United Kingdom, over one decade. PARTICIPANTS: All patients who underwent temporal artery biopsy from July 1994 to June 2004. MAIN OUTCOME MEASURES: ACR score and temporal artery biopsy result. RESULTS: During the 10 year period 111 patients were identified. The median (range) age at presentation was 71 (29-85) years. Seventy five patients had an initial ACR score of three or four at presentation. There were 20 positive biopsy specimens. In 19 of these cases at least three of the other criteria were positive so there was already sufficient clinical information for a confident diagnosis. In only one case did the positive result influence the diagnosis by changing the ACR score from two to three. In our series, corticosteroid treatment before biopsy did not significantly reduce the yield of the biopsy. CONCLUSIONS: The ACR score of three or more has a sensitivity of 93.5% and specificity of 91.2% for the diagnosis of GCA. Using these criteria, 68% of patients had sufficient clinical features when referred to make a confident diagnosis of GCA. Temporal artery biopsy was therefore unnecessary in this group. In the remaining group (ACR score < or =2) there was one positive biopsy. The biopsy only changed the diagnosis in this one case-less than 3% of the uncertain cases and less than 1% of the total cases. Using the ACR criteria and restricting biopsy to those cases in which it might change the diagnosis will reduce the number of biopsies by two thirds without jeopardising diagnostic accuracy.

Is there a need for resident general surgical cover in small peripheral hospitals?

AIM: To assess the need for resident general surgical cover in a small peripheral hospital. PATIENTS AND METHODS: The total number of admissions to Caerphilly District Miners' Hospital in the year 2001 was noted along with the admission criterion for elective general and vascular surgical patients. RESULTS: Among the 10,608 in-patients only 120 (1.13%) developed general surgical/vascular problems that merited surgical referral and out of these 30 (0.28%) patients were transferred to neighbouring larger hospitals for specialist care. CONCLUSIONS: A resident staff grade surgeon is not required in a small peripheral hospital and this service could be provided by the resident on-call surgical SpR in a neighbouring larger hospital.

Vascularised muscular flaps and arterial graft infection in the groin.

The groin is the commonest site for graft infections in vascular surgery. This is a potentially catastrophic situation as limb loss or even death occurs in a large percentage of cases. Standard teaching for treatment of infected vascular grafts is removal and extra anatomical bypass grafting whilst commencing appropriate antibiotics. This review article suggests careful scrutiny of the wound, debridement and coverage of the graft with a vascularised muscular flap is appropriate in certain situations.

Left retroperitoneal approach for aortic surgery.

Twenty-eight consecutive patients underwent surgery of the abdominal aorta by the left retroperitoneal approach. There were 11 suprarenal, 12 juxtarenal, three complicated infrarenal aneurysms and two occlusive aortoiliac disease (considered to be at high risk) undergoing surgical repair. Twenty-one underwent a tube graft repair whilst seven had a bifurcation graft. There were five deaths in this series; four of which occurred in the initial 12 patients. In our initial experience using the left retroperitoneal approach the overall mortality rate was 17%, though this reduced to 6% for the latter half of the study. The retroperitoneal approach allows access to the supracoeliac aorta without the need for thoracotomy and this approach should be considered for all aortoiliac reconstructive surgery. The transabdominal route to the abdominal aorta remains the most commonly used approach. However, the left retroperitoneal approach offers advantages in high-risk patients and suprarenal and juxtarenal abdominal aortic aneurysms (AAA). This is our initial experience of 28 patients undergoing surgical repair of the abdominal aorta via the left retroperitoneal approach.

The retroperitoneal approach to unusual abdominal aortic aneurysms.

A retroperitoneal approach was used to repair an infrarenal abdominal aortic aneurysm in three patients. The technique was used because of unusual pathology obscuring the aneurysm neck. We discuss the technique of retroperitoneal exposure and suggest advantages over conventional transperitoneal repair in patients with uncomplicated infrarenal abdominal aortic aneurysm.

Adult hernia surgery in Wales revisited: impact of the guidelines of The Royal College of Surgeons of England.

This study investigated the impact of the guidelines of The Royal College of Surgeons of England on the practice of hernia surgery in Wales. This was assessed by means of a postal survey to all consultant general surgeons in Wales in 1996-1997. The areas covered were: awareness of the guidelines of The Royal College of Surgeons of England and the impact of such guidelines on their practice, attendance at hernia courses, operative technique, materials used for repair and skin suture, proportion of day case hernias, length of inpatient stay, thromboembolic (TE) prophylaxis and postoperative advice to patients with regard to light work, heavy work and sport. In all, 79 replies were received (85%). Almost all the surgeons had read the guidelines; this changed the practice of 20% of respondents but did not in 32%. A further 48% did not answer the question. In contrast with our 1993 survey results, in Wales there is now a uniform surgical management of adult inguinal hernias: the most common operation is the Liechtenstein, with monofilament non-absorbable suture to secure the mesh, followed by the Shouldice repair. The Bassini and inguinal darn operations are becoming much less common and none now uses braided or absorbable sutures for the repair. Skin closure is still rather variable, with only 58% of respondents adhering to the recommended absorbable subcuticular suture. Postoperative advice is now uniform and in accordance with the guidelines. A trend towards more TE prophylaxis and more day case hernia surgery is also seen.

Common bile duct stenting for choledocholithiasis: a district general hospital experience.

The favoured treatment of common bile duct stones is endoscopic sphincterotomy and stone extraction. The management of those cases where duct clearance is not possible is controversial. At our institution it has been policy to insert an endoluminal stent. We report a retrospective review of the outcome of patients stented for common bile duct stones. The study population was 14 men and 22 women, with a median age of 73 years (range 23-89 years). Treatment-related morbidity was seen in nine patients (25%), comprising cholangitis (5), pancreatitis (3), and cholecystitis (1). Three of these patients died; all were over the age of 75 years and had been stented on a long-term basis. These data suggest that endobiliary stents can be employed with an acceptable complication rate. We suggest that patients under the age of 75 years be stented only as a temporising measure, but that patients over 75 years or those unfit on physiological grounds can be stented on a long-term basis as definitive treatment.

What do we do when thrombolysis fails? A United Kingdom survey.

We conducted a postal survey amongst members of the British Cardiac Society to determine current strategies for the detection and management of failed thrombolysis for acute myocardial infarction. The response rate was 290/387 (75%). On-site cardiac catheterisation facilities are available to 162 (60%), 112 (41%) of which are prepared for urgent angiography +/- angioplasty. Streptokinase is the preferred routine thrombolytic agent (n = 242, 90%). After thrombolysis, 121 (45%) respondents rarely search for evidence of reperfusion; a further 55 (20%) confine their search to selected cases. Practice varies amongst those with an active management strategy following proven failed thrombolysis (n = 149, 55%): 50 (19%) perform urgent angiography +/- angioplasty, 49 (18%) administer another thrombolytic agent, 6 (2%) administer another dose of the same agent and 44 (16%) combine these approaches. Transfer to an interventional centre is considered by only 11/106 (10%) without on-site access to cardiac catheterisation. These data indicate considerable variation in the management of failed thrombolysis. Randomised, controlled trials are required to elucidate optimal treatment for this common and important clinical situation.

Experience of a rapid access acute chest pain clinic.

A descriptive follow-up study of a hospital based chest pain clinic set up for the identification of the patients with unstable angina and acute myocardial infarction. The clinic is staffed by a cardiologist-in-training seeing patients on the day of referral by general practitioners because of acute chest pain of unclear origin. Over 6 months, 174 patients were assessed. 34 (19.5%) had a diagnosis of unstable angina or acute myocardial infarction (acute coronary syndrome), 52 (30%) had non-acute cardia pain and 88 (50.5%) had non-cardiac pain. Of those with a clinical diagnosis of acute coronary syndrome, 5 were subsequently shown to have non-cardiac, 8 had acute myocardial infarction and 21 had unstable angina. One month follow-up information was available on 136 of 139 (98%) patients not admitted to hospital via the chest pain clinic. 3 were admitted to hospital within the following 4 weeks because of myocardial infarction in 1 and unstable angina in 2. One year follow-up was available on 118 patients. One patient was admitted with unstable angina 6 months later and one patient sustained sudden cardiac death 3 months later. In the absence of the clinic, general practitioners would have arranged hospital admission for 66 (48%) or assessment in the emergency department for 13 (9%) of those discharged. Almost all general practitioners found the service helpful. The chest pain clinic was well received and provided an efficient method of identifying patients with acute coronary syndrome and minimised unnecessary admissions.

Flush saphenofemoral ligation and multiple stab phlebectomy preserve a useful greater saphenous vein four years after surgery.

PURPOSE: Flush saphenofemoral ligation, with multiple cosmetic stab phlebectomy, successfully treats saphenofemoral reflux and superficial varicosities. The long-term effect on the residual greater saphenous vein (GSV) requires evaluation. METHODS: Noninvasive triplex ultrasound assessment of the residual GSV for potential use as a vein graft was used. We evaluated the independent objective and subjective cosmetic outcomes. We also used analysis to determine the correlation between GSV reflux, symptoms, and cosmetic outcome. RESULTS: Seventy-two limbs were assessed at a median follow-up of 4 years (interquartile range 3 to 5 years). Fifty-nine limbs had patent GSVs above and below the knee. The mean length patent was 51 cm, and the mean internal diameters above and below the knee were 3.6 and 2.8 mm, respectively. In 65% of cases the vein had suitable ultrasonic characteristics, suggesting that it would be suitable for use as a conduit for a vascular bypass graft. Sixty-two limbs were considered a symptomatic success and 61 an objective cosmetic success. There was no correlation between the symptomatic and cosmetic outcome and the presence of superficial GSV reflux (linear regression analysis). CONCLUSIONS: These findings support the effectiveness of the procedure of flush saphenofemoral ligation and multiple stab phlebectomy with regard to cosmetic and symptomatic outcome and may preserve the GSV for use as an autologous bypass graft.

Aspects of hernia surgery in Wales.

The management of elective inguinal herniorrhaphy in Wales was assessed by means of a postal survey of consultant general surgeons. This included technique of repair, length of inpatient stay, follow-up, use of heparin thromboprophylaxis and advice regarding driving, strenuous activities and work. In all, 54 replies (77%) were received. The views of patients on their surgery was assessed by a questionnaire sent to 80 patients treated on a single surgical unit; 60 replies (75%) were received. Waiting times were relatively short among this group, 67.5% of patients being treated within 6 months of seeking medical advice; 16.25% suffered a complication. All wound infections occurred after discharge and 15% of patients had some groin discomfort 6 months after operation. Accuracy of clinical examination of 50 inguinal hernias by different grades of surgeon was assessed. Consultants were significantly more accurate when compared with house officers (P < 0.001). There is a wide range of repair techniques and postoperative advice practised by consultant general surgeons in Wales. Patients' main complaint was that of a sparsity of postoperative advice, although there also appears to be an appreciable postoperative morbidity. Clinical experience plays a significant role in assessment of the suitability of hernias for surgery.

Lupus anticoagulant in patients with peripheral vascular disease: a prospective study.

OBJECTIVE: To assess the incidence of lupus anticoagulant (LAC) in patients with peripheral vascular disease. DESIGN: Prospective clinical study. SETTING: University Hospital. MATERIALS: 20 patients with claudication (group 2), 20 patients with critical ischaemia (group 3) and 20 patients prior to elective abdominal aortic aneurysm surgery (group 4) were compared to 20 general surgical controls (group 1). CHIEF OUTCOME MEASURES: Venous blood samples for coagulation assay. MAIN RESULTS: Positive results for LAC by the Dilute Russell's viper venom time (DRVVT) with the platelet neutralisation procedure were present in 26 out of 60 vascular patients compared with none of the 20 general surgical controls. The three vascular groups showed a similar prevalence of LAC and this differed significantly from that in the control group (chi 2 = 10.94, p = 0.0009). Of the 26 positive results only three were associated with an abnormal activated partial thromboplastin time (APTT), which has previously been used as a marker for the presence of LAC activity. Fibrinogen levels were raised in seven of 20 patients in group 2 but were normal in the remaining vascular groups (p = 0.001). The mean factor VII level (124.1 units dl-1) in group 2 was higher than the mean of the remaining vascular patients (109.3 units dl-1, p < 0.05). CONCLUSIONS: The high prevalence of LAC in patients with peripheral vascular disease and the associated increased risk of early graft thrombosis may justify routine testing by DRVVT prior to reconstructive vascular surgery. Treatment of these patients with antiplatelet agents or formal anticoagulation perioperatively should be considered.