Duplicated inferior vena cava with associated ilio-femoral deep vein thrombosis.

We present the case of a fit and well 20-year-old gentleman who presented to our emergency department with unilateral lower limb pain and swelling. Subsequent imaging revealed a left ilio-femoral deep vein thrombosis, with associated duplication of his inferior vena cava. He was treated conservatively with a heparin infusion, warfarin and compression therapy prior to being discharged following a short inpatient stay.

A comparison of the complication rates following unilateral and bilateral varicose vein surgery.

OBJECTIVE: To compare the complication rates of unilateral and bilateral varicose vein surgery. DESIGN: Observational clinical study with prospective data collection. SETTING: Southport and Ormskirk Hospital NHS Trust. SUBJECTS: 1090 patients undergoing varicose vein surgery during the period January 2002-June 2005. 695 (64%) of these had unilateral surgery and 395 (36%) had bilateral surgery giving a total of 1485 legs operated on (47% as a unilateral operation and 53% as a bilateral operation). RESULTS: 43/695 (6.2%) of patients who underwent unilateral surgery and 34/395 (8.6%) of patients who underwent bilateral surgery developed a wound infection. 77/695 (11%) of patients who underwent unilateral surgery developed paraesthesia compared to 81/395 (21%) for bilateral surgery. 2/695 (0.13%) unilateral surgery patients and no bilateral surgery patients developed neuralgia. Residual varicose veins were present in 30/695 (4.3%) of unilateral group and 32/395 (8.1%) of the bilateral group. 1/695 (0.14%) of unilateral surgery patients and 3/395 (0.75%) of bilateral surgery patients developed DVTs. Comparing limbs, a complication of any type was seen in 153/695 (22%) limbs treated by unilateral surgery and 150/790 (19% N.S., Chi squared) limbs treated by bilateral surgery. CONCLUSION: Complications following varicose vein surgery appear to be more common following bilateral procedures. However, the complication rate per limb is similar for unilateral and bilateral operations.

Post-thoracotomy chylothorax--a cure in the abdomen?

Operative control via a thoracic approach of chylothorax can be difficult to achieve, particularly if the chyle leak is secondary to previous thoracic surgery. This report describes the ligation of the thoracic duct at the level of the diaphragmatic hiatus, via an abdominal approach. This technique was the definitive management in four of the last 5 patients presenting with chylothorax in our unit. Typically the leak ceased within 24 h with early discharge of the patient from hospital.

The management of chronic fissure in-ano with botulinum toxin.

Five patients with a chronic fissure in-ano each received an injection of Clostridium botulinum type A toxin into the lower internal anal sphincter. A mean lowering of maximum resting anal pressure by 23.3 (SEM 5.6) cm H2O was achieved within seven days. Maximum voluntary squeeze pressures were not significantly altered. Anal compliance increased in all cases. Healing of the fissure with an apparent reduction in anal sensation occurred in three of the patients and partial resolution of symptoms in the other two. No adverse effects resulted from injections of the toxin. A controlled trial to compare the relative efficacies of botulinum toxin and lateral sphincterotomy is required.

The assessment of cerebral oxygenation during carotid endarterectomy utilising near infrared spectroscopy.

Near infrared spectroscopy is a non-invasive method for continuous monitoring of tissue oxygenation. In 11 patients undergoing unilateral carotid endarterectomy, changes in cerebral oxygenation following carotid cross-clamping and declamping detected by a near infrared spectrometer were compared with corresponding changes in ipsilateral middle cerebral artery flow velocity measured by transcranial Doppler ultrasonography. Spectroscopic traces were obtained in all patients but adequate Doppler signals in only eight. Changes in cerebral haemoglobin oxygenation correlated closely (r = 0.908, p < 0.001) with changes in middle cerebral artery velocity. The near infrared spectrometer was also sensitive to the changes in cerebral haemodynamics due to intraoperative hypo- and hypertensive episodes. No evidence of cerebral intracellular hypoxia was seen and all patients made an uneventful recovery. Near infrared spectroscopy compares well with transcranial Doppler ultrasound as a monitor of cerebral function during carotid endarterectomy and may have a future role in the elucidation of cerebral perfusion and oxygenation changes following surgery.

Testicular epidermoid cyst--is pre-operative diagnosis possible?

A case of testicular epidermoid cyst which had initially been misdiagnosed as a malignant testicular tumour is presented. The role of clinical and ultrasound examination in the pre-operative assessment is discussed. Although the benign nature of this condition must be demonstrated histologically before conservative surgery is contemplated, it is equally important that the patient should not be told that the tumour is malignant without adequate evidence.

Increasing infantile hypertrophic pyloric stenosis? Experience in an overseas military hospital.

Fifty-four children with proven infantile hypertrophic pyloric stenosis (IHPS) were treated by Ramstedt's pyloromyotomy during a 14-year period. Between the years 1986 and 1989 the mean incidence of the disease was noted to have risen by 2.72 per 1000 live births over the preceding 10 years. Statistical analysis confirmed a significant upward trend between the years 1976 and 1989. Analysis of the majority of the cases revealed comparable perioperative morbidity rates with other UK district general hospitals. There was no operative mortality. The character of IHPS in military personnel overseas has more in common with UK than international trends. The incidence in this subgroup may be rising.