Duplex scanning is no substitute for surgical expertise in identifying the saphenopopliteal junction: results following short saphenous vein surgery.

OBJECTIVES: Short saphenous vein (SSV) surgery carries a high risk of failure to identify the saphenopopliteal junction (SPJ). We assessed the impact of surgical expertise on anatomical outcome from SSV surgery and the role of preoperative duplex SPJ marking in improving outcome for vascular and non-vascular specialists. METHODS: A retrospective analysis identified patients (30 limbs) who had undergone SSV surgery. These were recalled for duplex scanning of the SPJ. In a prospective study, 187 limbs had preoperative duplex marking of SPJ and postoperative duplex to assess outcome. Grade of operating surgeon was recorded in both retrospective and prospective analysis. RESULTS: In both retrospective and prospective analysis, vascular specialists were significantly more likely than non-vascular specialists to correctly identify the SPJ (P < 0.0001). Preoperative SPJ marking did not improve outcome for the vascular specialist or the non-vascular specialist. CONCLUSION: Preoperative SPJ marking is no substitute for surgical expertise. Competence in SSV surgery should be assessed prior to surgeons proceeding to independent practice.

Medullary thyroid carcinoma: a rare presentation as a hypervascular tumour.

Sporadic medullary thyroid carcinoma (MTC) usually presents with a thyroid mass, cervical lymphadenopathy or other local cervical symptoms. Often the diagnosis is unsuspected pre-operatively. We report a unique case of a mixed follicular medullary thyroid carcinoma presenting as a tumour with extreme vascularity. The management of hypervascular thyroid tumours is discussed together with current controversies regarding persistent hypercalcitoninaemia.

Complications of choledochal cysts in adulthood.

Choledochal cyst is a well-recognised entity, presenting primarily in infants and young children. Where symptoms are delayed until adulthood, associated hepatobiliary pathology may complicate the presentation. These problems may be aggravated by previous treatment with bypass surgery rather than resection. We report seven cases from our recent experience presenting with complications in adulthood. These included cholangitis, hepatic abscess, pancreatitis and malignancy within the cyst. Two patients presented during pregnancy. These complications and their implications for management are discussed.

'Spontaneous' rupture of the diaphragm.

A case of 'spontaneous' rupture of the diaphragm with herniation and strangulation of the stomach is reported. The diagnosis was made by endoscopy and repair achieved via laparotomy. The patient has made a full recovery.

Influence of intravascular activity on the determination of blood flow and oxygen extraction in normal and ulcerated legs using the 15O steady-state technique and positron emission tomography.

An analysis using the 15O steady-state inhalation technique has been carried out into the effects of correction for intravascular activity on the determination of blood flow and oxygen extraction ratio (OER) in the legs of patients affected by ulceration. Transaxial images of the distribution of activity in a plane passing through the ulcer were obtained during steady-state inhalation of C15O2 and 15O2, respectively, using a single slice positron emission tomographic scanner. From these, the basic tracer model equations were solved to obtain blood flow and oxygen extraction with and without additional correction for the presence of intravascular activity. The latter was obtained from a scan following the inhalation of a tracer quantity of 11CO, which labels the red blood cell pool. Mean blood flow and OER in ulcerated regions were 0.087 ml/ml/min and 0.33, respectively. With correction for blood volume, assumed to be all venous, the mean OER decreased to 0.12. In the "mirror" region of normal legs mean blood flow was 0.011 ml/ml/min with uncorrected and corrected OER values of 0.87 and 0.75, respectively. The effect of assuming a nonzero arterial volume increases as flow and OER decrease but is uncertain due to the unknown arterial fraction. Correction for intravascular 15O is essential and generally the assumption that all blood volume is venous is adequate.

Assessment of late patency of profundaplasty by arteriography.

We have reviewed 34 cases of profundaplasty to determine patency rates in arteriographic rather than clinical terms. These patients had required subsequent arteriography for a variety of reasons not always related to their original operation. Clinical improvement following profundaplasty could be due to maturation of the collateral circulation rather than to prolonged patency of the reconstructed segment, but in this series all the profundaplasties were patent except where the external iliac and common femoral arteries supplying the profundaplasty had themselves occluded. These patients with profundaplasty failure showed an adverse pattern of proximal disease. The state of the distal vascular bed did not appear to influence the patency rate of the profundaplasties significantly, although this may affect the outcome for the limb itself.

Antibiotic concentration in the exudate of venous ulcers: the prediction of ulcer healing rate.

We have designed a test to measure the local circulatory insufficiency in the base of chronic venous ulcers by measuring the concentration of Cefuroxime in the ulcer exudate following a single intravenous injection of the antibiotic at a dose of 500 mg/m2. We have studied 28 patients with 42 ulcers and shown that the concentration achieved increased with in-patient conservative treatment (P less than 0.01), decreased again on discharge from hospital if the ulcers had not healed (P less than 0.01) and correlated with observed healing rates (r = 0.72). This test may assist in the clinical management of these cases by predicting healing rates and the likely outcome of conservative treatment.

Iliac aneurysm after total hip arthroplasty. Surgical management.

We report two cases of aneurysm of the external iliac artery after arthroplasty of the hip. In each case the patients suffered from severe, seropositive, rheumatoid arthritis, had been treated with oral corticosteroids and had defects in the acetabular floor which were complicated by sepsis. In these circumstances bleeding from the wound in the hip should be investigated by immediate arteriography with anteroposterior and lateral views. Though vascular injury during operations on the hip is rare, recognition is important as safe and satisfactory treatment can be achieved. In the surgical management of these cases the following points should be noted: an alternative blood supply to the limb must be established using separate surgical incisions; to reduce the risk of sepsis these incisions should be closed and dressed before exploring the aneurysm; the aneurysmal vessel must be isolated and ligated, no attempt being made at primary repair; the aneurysm should be opened longitudinally to avoid damaging the femoral nerve which overlies it; and all foreign material should be removed from the hip.

Positron emission tomography in venous ulceration and liposclerosis: study of regional tissue function.

Oxygen-15 administered by continuous inhalation and emission computed tomography were used to study regional tissue oxygen utilisation and blood flow in the limbs of 11 patients with venous ulceration and five patients with liposclerosis due to venous insufficiency. The results showed increased blood flow and appreciably reduced fractional oxygen extraction in the diseased tissues. These findings indicated a local, functional shunting of blood through the abnormal microcirculation of the skin and subcutaneous tissues. This may be an important factor in the aetiology of the skin changes seen in patients with calf muscle pump failure.