Abdominal aortic aneurysm surgery in a district general hospital: a 15-years experience.

The incidence of patients presenting with both ruptured abdominal aortic aneurysm (RAAA) and elective abdominal aortic aneurysm (EAAA) increases with age. The aim of our study was to find out the incidence of RAAA, age and sex groups of patients at risk, and 30-day all-cause perioperative mortality associated with RAAA as well as EAAA repair in a busy district general hospital over a 15-year time period. All patients operated for AAA during 1989-2003, both elective and ruptured, were included in the study. Patients who died in the community from RAAA were also included. The data were collected from the hospital information system, theater logbooks, intensive therapy unit records, postmortem register, and patients' medical notes. We divided the data for RAAA into two groups of 7.5 years each to see if there was any improvement over time in 30-day postoperative mortality. There were 816 cases of AAA, which included 468 RAAAs (57%) and 348 EAAAs (43%). Out of 468 RAAAs, 243 patients had emergency repair, of whom 213 were males. There were 201 patients who had RAAA postmortem (43%). Median age (range) was 73 (54-94) years in males and 77 (52-99) years in females, with a male-to-female ratio of 7:1. The peak incidence of RAAA was over 60 years of age in males and 70 years in females. Incidence of RAAA was 7.3/100,000/year in males and 5/100,000/year in females. For RAAA, 30-day perioperative mortality was 43% (105/243) while overall mortality was 70% (330/468), which includes deaths in the community. There was no improvement in 30-day mortality over time after comparing data for the first 7.5 years (50/115, 43.5%) with those for the second set of 7.5 years (55/128, 43%). There were 348 patients who had EAAA repair over the same period, comprising 282 males, with a male:female ratio of 4.3:1. The 30-day mortality in the elective group was 7.75%. Incidence and mortality of RAAA remain high. A high proportion of patients with AAA remain undiagnosed and die in the community. More lives may be saved if a screening program is started for AAA.

A survey of patient response to preoperative surgical assessment.

An anonymous questionnaire-based study was devised to examine the role of preoperative assessment of patients by pre-registration surgical house officers. One hundred and eight patients awaiting elective surgery were entered into the study. The main outcome measures were the proportion of patients who felt they had received a satisfactory explanation concerning the risks and benefits of their intended operation at a preoperative assessment clinic (PAC). Of the patients who believed that details of their operations had been explained to them, more than one-quarter cited the PAC as the source. More than 25% of patients who stated that the benefits of their operation had been explained cited the PAC as the source; 45% of patients who believed the risks of their surgery had been provided felt the PAC had been the only source of this explanation. It was concluded that preoperative assessment clinics are an efficient and effective means of providing patients with valuable information about their operation.

Ilioinguinal block dissection for malignant melanoma.

A retrospective analysis of 41 patients treated for metastatic inguinal lymph node malignant melanoma is presented: 16 underwent inguinal node excision and 25 ilioinguinal node excision. The two groups were well matched for age, sex and other characteristics. The mean time in hospital (inguinal 20 days, ilioinguinal 18 days) and the complication rates (inguinal, ten of 16 patients, ilioinguinal, 13 of 25) were similar in each group. The incidence of groin relapse, defined as the development of symptomatic melanoma in the region of the inguinal or iliac node basins following block dissection, was lower after ilioinguinal block dissection (inguinal, three patients; ilioinguinal, none). Histological examination demonstrated a high proportion of iliac node involvement (13 of 25 patients), even in those with a single mobile inguinal lymph node clinically and no clinical or computed tomographic evidence of iliac node involvement. This supports the value of ilioinguinal block dissection and suggests that the associated morbidity need not be greater than that associated with inguinal clearance alone.

Accuracy of duplex versus angiography in patients undergoing carotid surgery.

The operative findings of 23 carotid arteries were compared with pre-operative duplex scans and angiography. Both duplex and angiography had a high degree of accuracy in detecting haemodynamically significant lesions of 50-99% (88 and 92%, respectively). Their accuracy, however, in correctly predicting the grade of stenosis was significantly lower; 30 and 48%, respectively (P < 0.001). They each exhibited an accuracy of 70% and 78%, respectively, in the detection of ulceration. Overall, both duplex and angiography displayed an accuracy of 87% in indicating the proper management course. The combination of both investigations increased this accuracy to 94.6%. In severely stenotic lesions, duplex to rule out occlusion was not reliable. On statistical analysis, there was no difference between duplex and angiography in predicting haemodynamically significant lesions of 50-99%, estimating the grade of stenosis, the detection of ulceration, or indicating the proper management course. In most situations, duplex alone equalled the accuracy of angiography in the pre-operative assessment of patients for carotid surgery. For stenotic lesions of > 90%, however, we recommend supplemental angiography to rule out occlusion.

Benign pigmented nevi in children. Prevalence and associated factors: the West Midlands, United Kingdom Mole Study.

BACKGROUND AND METHODS: Prevalence of benign melanocytic nevi (moles) has been shown to be a major predictor of malignant melanoma. In this study the prevalence of moles in a group of 2140 children, aged 4 to 11 years, was determined. A standard questionnaire was completed by the parents of each child and included information on environmental and life-style factors. Examination data for each child were linked to the data obtained from the questionnaire. RESULTS: Prevalence increases rapidly throughout childhood and studies of children may indicate which factors contribute to mole development. Boys had more moles than girls, as did white children when compared with other ethnic groups. Prevalence of moles increased with age in children of both sexes. Among whites, skin color had little influence on mole prevalence. The following characteristics, however, were associated with an increased prevalence of moles: a propensity to burn rather than tan, a history of sunburn, a tendency to freckle, and a life-style involving increased sun exposure. A striking positive association between prevalence of moles and number of foreign holidays in a hot climate was observed. This association was independent of a history of sunburn. CONCLUSIONS: The study supports the hypothesis that environmental factors influence the prevalence of moles in childhood.

Platelet accumulation after laser angioplasty--a scintigraphic assessment.

Indium 111-labeled platelet scintigraphy was performed to evaluate platelet deposition in response to different levels of Nd:YAG laser/thermal energy. A dose-related increase in platelet deposition was observed. In clinical studies after laser-assisted balloon angioplasty, intense platelet deposition was observed in 2 patients who subsequently developed clinical arterial thrombosis. The pathogenesis of reocclusion appears, however, to be more complicated and ill understood. The authors suggest further extensive studies incorporating several parameters in the evaluation of the pathogenic factors involved in reocclusion after laser angioplasty. Such studies should also consider the role of arterial injury produced by the balloon catheter after laser-assisted balloon angioplasty.

Arterial reconstruction for upper limb ischaemia: an alternative technique.

Reconstructive arterial surgery for upper limb ischaemia has been performed since the early 1950s. The commonest site of occlusion is in the subclavian artery for which the widely preferred surgical reconstruction is the carotid-subclavian bypass graft. We present a series of eight cases of subclavian artery occlusion for which direct subclavian to carotid anastomosis was performed yielding results comparable with carotid-subclavian bypass.

Benign pigmented nevi in children from Kidderminster, England: prevalence and associated factors.

The prevalence of benign pigmented nevi in a group of 187 children, aged 8 or 9 years, was determined for each of 31 anatomic sites. Information on possible associated factors was obtained from the children's parents with a standard interview questionnaire. Pale skin color was found to be associated with a higher prevalence of nevi. A comparison of these data with recent data from Australia supports the hypotheses that (1) the number of nevi is a risk factor for melanoma and (2) groups at high risk of melanoma may be formed in childhood.

Detection of arterial thrombosis after laser angioplasty by platelet scintigraphy.

Indium-111-labelled platelet scintigraphy was performed in two patients after laser-assisted balloon angioplasty. Both patients demonstrated a significant 'hot spot' at the angioplasty site 24 h after successful recanalisation with laser and balloon. Clinically apparent thrombosis of the recanalised arteries occurred 5 and 6 days after angioplasty in both patients. Laser-assisted balloon angioplasty leads to significant platelet deposition over recanalised segments of the artery, which may result in arterial thrombosis, as evident from the reports presented. Indium-111-labelled platelet scintigraphy emphasises the extent of trauma caused by laser and balloon angioplasty to the arterial wall.

Inflammatory abdominal aortic aneurysms.

About 10% of all abdominal aortic aneurysms are characterized by an exuberant inflammatory reaction consisting of a dense white sheath over the aneurysm with peri-aortic fibrosis. The aetiology is unknown. There are characteristic ultrasonic and CT appearances but the condition is usually diagnosed at laparotomy. Surgery is the best treatment, keeping peri-aortic dissection to a minimum. Steroid therapy may occasionally be indicated where the situation is considered inoperable or when the patient declines surgery. If hydronephrosis is present because of ureteric involvement, surgical ureterolysis, as for retroperitoneal fibrosis, should be considered. We report 8 cases treated surgically over a 3-year period, with good results in 6, one postoperative amputation and one late postoperative death.

Common iliac artery aneurysm presenting as acute sciatic nerve compression.

Aneurysms of the iliac arteries usually remain silent, but when they rupture the consequences can be dramatic. They produce few clinical signs suggestive of their presence. However, such aneurysms have been found to be the cause of non-vascular clinical situations. Often they present with features of compression on adjacent viscera. We present a case in which a large common iliac artery aneurysm was found to be causing symptoms of acute sciatic nerve compression.

Fistula-in-ano is usually simple to manage surgically.

Our experience in the surgical management of 115 patients with fistula-in-ano treated over 14 years was reviewed retrospectively. The incidence of previous anorectal infection was 69%. After treatment eight patients (7%) developed a recurrence of the fistula and five (4%) experienced some complication directly resulting from surgical treatment. One patient died of pulmonary embolism following an operation for recurrence. Most of the patients (75%) had a successful outcome of a minor surgical procedure.

The aetiological significance of sunlight and fluorescent lighting in malignant melanoma: a case-control study.

Information on exposure and reaction to sunlight, together with the history of exposure to fluorescent lighting, was elicited by postal questionnaire. Case-control analysis from 58 patients with malignant melanoma, 182 matched controls and 151 unmatched controls showed associations between malignant melanoma and (i) bouts of painful sunburn, (ii) reaction of untanned skin to sunlight, and (iii) number of moles (on right forearm), whereas no association could be found with exposure to fluorescent light at work.

Problems in diagnosis of popliteal aneurysms.

Clinical features and errors in diagnosis have been assessed in a retrospective study of 62 popliteal aneurysms in 40 patients, 22 of whom had bilateral aneurysms. Only 29% of patients complained of pain or swelling behind the knee, while 31% of aneurysms had produced distal ischaemia presenting as intermittent claudication, 9 aneurysms had thrombosed producing ischaemic rest pain in 6 legs, and 4 aneurysms had ruptured. Although 94% of aneurysms were suspected or confidently diagnosed by palpation alone, only 43% of patients had had the correct diagnosis made at the time of initial referral. Treatment was delayed in 12 patients, 8 of whom subsequently required amputation. Popliteal aneurysm should be suspected in patients with a prominent popliteal pulse who present with intermittent claudication, and in patients with acute ischaemia of the leg who may have a thrombosed aneurysm requiring surgical exploration.

Long-term survival in stage I and stage II malignant melanoma of the limbs--a regional review.

A case is reported of survival in excess of 20 years in a patient presenting with Stage II cutaneous malignant melanoma. Long term survival is reviewed of patients with cutaneous malignant melanoma registered during the period 1957-1959. Prognosis is best in women with Stage I disease of the lower limb, but prolonged survival occurs in cases having regional lymph node involvement. Men with stage I disease of the upper limb have a relatively good prognosis.

Imaging of 111In-labelled platelets--a new method for the diagnosis of deep vein thrombosis.

A radionuclide method for detecting established thrombi at all sites in the lower limb would have several advantages. Autologous platelets were labelled with 150 microCi (5.5 MBq) indium-111-oxine and re-injected into patients who were imaged with a gamma camera and data processed by a medical computer. Areas of increased uptake on imaging were correlated with the sites of thrombi identified by bilateral ascending venography. Venography in 27 patients identified 12 unilateral and 5 bilateral thrombi. On the day following the re-injection of labelled platelets, imaging identified thrombi at 13 sites in 24 limbs giving an overall correlation with venography of 84.4 per cent, correlation for the calf and thigh being 79.5 per cent and 89.1 per cent respectively. In the thigh 57.1 per cent of thrombi were identified by imaging and 52.9 per cent in the calf. Activity over thrombi was at least 20 per cent higher than in adjacent areas or at similar sites in the contralateral leg. Herapin therapy is considered to affect the detection of deep vein thrombus adversely by this technique. The technique offers a useful method for the diagnosis of both early and established thrombi at any site in the lower limb.