Assessment of generic health-related quality of life in patients with intermittent claudication.

OBJECTIVES: to measure quality of life in patients with intermittent claudication and evaluate the ability of patients and vascular surgeons to make a similar assessment. DESIGN, MATERIALS AND METHODS: in this prospective study patients with intermittent claudication attending two vascular clinics were asked to complete a generic health-related quality of life instrument (MOS SF-36). Patient quality of life and vascular surgeons' assessment of patient quality of life were further evaluated using a single question/adjectival scale response combination. RESULTS: patients' self-assessment of their quality of life correlated better with the SF-36 score than did the surgeons' assessment. There was little correlation between the surgeons' and patients' own assessment of quality of life. The surgeons differed significantly from each other in their assessments. Claudicants had lower SF-36 scores than population norms in pain and physical aspects of quality of life. CONCLUSIONS: claudicants have worse quality of life than the general population, with pain and physical limitations being the most important domains. Surgeons predict the quality of life of claudicating patients less accurately than patients do themselves, and may differ from their colleagues in such assessments. Objective quality of life assessment in claudicants should be undertaken before treatment is decided.

Temporary axillofemoral bypass: its use in high risk cardiac patients requiring urgent abdominal aneurysm repair.

The creation of a temporary axillofemoral bypass in a patient undergoing surgery for an 8.1 cm symptomatic infrarenal aortic aneurysm is described. This adjunctive procedure, rarely used in abdominal aortic surgery, may have contributed to minimizing variations in afterload in a patient with a 20% ejection fraction and severe mitral regurgitation.

Metastatic testicular tumor requiring inferior vena cava resection.

A patient undergoing radical retroperitoneal lymphadenectomy for metastatic embryonal cell testicular carcinoma is presented. Tumor resection required removal of the inferior vena cava due to transmural invasion. The inferior vena cava was replaced using externally stented polytetrafluoroethylene (PTFE) graft. Patency was documented by postoperative Doppler studies, duplex scanning, and computed tomographic scanning. Stented PTFE is currently the graft of choice for inferior vena caval replacement.

Intra-arterial infusion of urokinase for acute, critical ischemia in the lower limb.

OBJECTIVE: To assess the value of intra-arterial urokinase infusion in the management of acute, critical ischemia of the lower limb. DESIGN: A prospective study. SETTING: A vascular surgery department within a university hospital. PATIENTS: Twenty-five consecutive patients with acute, critical ischemia of the lower limb, excluding those requiring immediate surgical intervention. Follow-up ranged from 1 to 18 months. INTERVENTION: Angiography followed by intra-arterial infusion of urokinase. MAIN OUTCOME MEASURES: Angiographic and clinical evidence of clot lysis and limb reperfusion, any surgical procedures required and final clinical outcome. RESULTS: Urokinase was technically successful in lysing clot in 19 patients: 7 required no further treatment; in 8 an underlying lesion was identified and repaired by either percutaneous angioplasty or surgery; in the remaining 4 patients, although the clot was lysed, the limbs remained ischemic and, since reconstruction was considered impossible, amputation was required. Two patients improved clinically with little angiographic evidence of clot lysis. A total of nine patients required amputation, seven of these as a "primary" procedure after urokinase infusion. There were four episodes of significant morbidity but no deaths. CONCLUSION: Urokinase has a place in the management of acute vascular occlusion of the lower limb, not only in treating the occlusion but, equally importantly, in facilitating identification of lesions that require surgical intervention.

Emergency embolization of a ruptured aneurysm of the pancreaticoduodenal arcade.

Inferior pancreaticoduodenal aneurysms are uncommon. A 77-year-old woman was seen with a 1-week history of sharp pain in the right lower abdominal quadrant radiating to the back, associated with malaise, anorexia, vomiting and nonbloody diarrhea. Appendicitis was diagnosed, but at laparotomy a large retroperitoneal hematoma was found; no aneurysm was identified. The abdomen was closed and aortography was done. An aneurysm of the inferior pancreaticoduodenal artery arcade was demonstrated, with occlusion of the celiac artery at its origin. The arc of Buehler was patent and enlarged and supplied the hepatic and splenic arteries. Embolization with Gianturco coils placed proximal to the aneurysm was successful.

Meta-analysis of highly selective vagotomy versus truncal vagotomy and pyloroplasty in the surgical treatment of uncomplicated duodenal ulcer.

OBJECTIVE: To compare critically by meta-analysis the postoperative outcomes after truncal vagotomy and pyloroplasty (TVP) and after highly selective vagotomy (HSV). DATA SOURCES: A search was conducted on MEDLINE with the keywords "peptic ulcer" and "vagotomy". Bibliographics of the articles retrieved and review articles pertaining to the subject were scanned further. STUDY SELECTION: Included were only published prospective, randomized controlled trials comparing TVP and HSV in the English-language literature up to April 1991. Twelve studies were found. DATA EXTRACTION: Two authors, working independently, abstracted raw data on mortality, recurrence, dumping, diarrhea and postoperative Visick grading. DATA SYNTHESIS: A ratio greater than 1.0 indicates a higher proportion occurring with TVP and less than 1.0 a higher proportion with HSV. [Table: See Text] CONCLUSION: The results suggest that the likelihood of adverse long-term sequelae is higher with TVP whereas the likelihood of recurrence is higher with HSV.

Ruptured Baker's cyst causes ecchymosis of the foot. A differential clinical sign.

Three consecutive patients with ruptured Baker's cysts, verified by duplex scan, were found to have ecchymosis on the dorsum of the foot. The appearance of ecchymosis can be helpful in differentiating a ruptured cyst from cellulitis or deep-vein thrombosis.

A technical-skills course for 1st-year residents in general surgery: a descriptive study.

The proper teaching of operative skills to surgical residents is increasingly constrained by operative time, complex procedures and medicolegal concerns. A technical-skills program was developed and introduced over a 3-year period to 28 1st-year residents in general surgery. To introduce the residents to the principles of surgical techniques in a simulated environment outside the operating room, the program consisted of a combination of two didactic sessions and six "wet labs" taking 3 to 4 hours per week for 8 weeks between January and March each year. The didactic sessions included instruction on suture material and the use of stapling devices; the "wet lab" used a "hands-on" approach. Educational objectives in the "wet lab" included instruction on preparation of the patient and draping, aseptic technique, principles of bowel anastomosis, incisions, instrument use and handling, principles of hemostasis, intraoperative surgical emergencies, surgical assisting and overall conduct in the operating room. The residents' surgical technique and skills improved over the course period. The overall value, teaching and understanding of surgical principles were rated highly. Problems cited during resident feedback were the use of live animals and insufficient time to practise. The efficacy of a surgical-skills program has been demonstrated, but its effectiveness requires further evaluation.

The effect of peritoneovenous shunting on catecholamine metabolism in patients with hepatic ascites.

The elevated catecholamine levels in cirrhotic patients with ascites have been proposed to be due to sympathetic overactivity secondary either to reduced intravascular volume or to an underlying cardiovascular abnormality such as reduced pressor responsiveness. Furthermore, these elevated catecholamine levels have been proposed to be involved in the pathogenesis of salt and water retention. Therefore, the effect of peritoneovenous shunting on the circulating levels and renal excretion of catecholamines were studied in six patients with massive refractive ascites preoperative within the first 8 hr postoperative and by 2 weeks postoperative under metabolic conditions. The recirculation of ascites into the intravascular compartment resulted perioperatively in significant rises in cardiac output (p = 0.001), para-amino-hippurate clearance (p = 0.08), creatinine clearance, diuresis (p = 0.05) and natriuresis (p = 0.06). Systemic blood pressure remained unchanged while systemic vascular resistance decreased (p less than 0.05). Preoperative circulating levels of free catecholamine were highly elevated, and renal vein concentrations were about 25% higher than renal arterial levels. Perioperatively, there was little change in circulating catecholamine levels or distribution of renal blood flow although renal artery and vein concentrations tended to equalize. In contrast by 2 weeks postoperatively, free catecholamine levels had fallen to within the normal ranges: mean norepinephrine from 1,477.6 +/- 194.6 to 395 +/- 62.9 pg per ml (p less than 0.05); epinephrine from 276 +/- 74.2 to 65.7 +/- 15.0 pg per ml (p less than 0.02), and dopamine from 325.6 +/- 175.2 to 47.9 +/- 5.3 pg per ml.(ABSTRACT TRUNCATED AT 250 WORDS)

Small bowel transplantation in the dog using cyclosporine.

The effect of the new immunosuppressant cyclosporine on survival after total small intestinal allotransplantation (TSIA) was studied in a canine model. Successful TSIA was performed in 34 dogs. Eleven dogs were treated with cyclosporine, 25 mg/kg/day i.m., starting the day before the operation and continuing for four weeks. Thereafter the same dose was given orally. Thirteen dogs were given oral cyclosporine only, 25 mg/kg/day from the day after transplantation. Ten dogs served as controls. The dogs treated with intramuscular and oral cyclosporine survived a mean of 103.8 +/- 39.4 days (mean +/- S.E.M.). The longest survivor died after 432 days. Survival in this group was significantly longer than that of the control dogs, which survived 12.5 +/- 4.6 days. The orally treated dogs survived 30.4 +/- 7.6 days. All control dogs, and seven of the orally treated dogs, but only two of the intramuscularly treated dogs, died of acute rejection. It is concluded that cyclosporine is effective in prolonging survival after TSIA in the dog and reduces the incidence of acute rejection.