An observational study into the management of arteriomegaly: a call for a revised classification system.

INTRODUCTION: Arteriomegaly is the diffuse ectasia of arteries with or without aneurysmal disease. Patients with arteriomegaly have a higher incidence of morbidity including limb loss compared to patients with other arteriopathies. The aim of this observational study was to review the management of these patients in our institution. METHODS: Radiologists and surgeons prospectively reviewed aortofemoral angiography. Patients with arteriomegaly were identified. Data relating to demographics, mode of presentation, risk factors, type of arteriomegaly, management and progression of disease were analysed. RESULTS: Arteriomegaly was identified in 1.3% of patients (n = 69) undergoing lower limb angiography in the study period. Of these, the majority (n = 67) were men. The mean age was 74 years (range: 60-89 years) and 76% were smokers. Co-morbidities included coronary artery disease (55%), diabetes mellitus (20%), hypertension (45%) and cerebrovascular events (6%). Forty-nine patients presented with critical limb ischaemia and eighteen patients were seen electively in the outpatients department with symptoms of intermittent claudication. Data were incomplete for two male patients and were therefore not included. At presentation, 22 patients were classified as Hollier type I, 5 were type II and 9 were type III. Thirty-one patients had arteriomegalic vessels but no aneurysmal disease. After a median follow-up duration of 76 months (range: 6-146 months), 34 patients progressed to type I, 2 to type II and 18 to type III. Thirteen remained without aneurysmal disease. Twenty-nine patients required angioplasty and twenty-eight required bypass surgery during this time. In total, 102 procedures were required for complicated disease. The limb salvage rate was 92%. Although 8 patients in our series died, the remaining 59 are under regular follow up. CONCLUSIONS: This study illustrates the progressive nature of arteriomegaly. Results of the management of these patients in our institution are similar to those in the literature. We suggest an additional fourth category to Hollier's classification that describes arteriomegalic disease without aneurysmal degeneration as this, too, deserves special management. Regular follow-up visits and early intervention for patients with arteriomegaly is advocated to reduce the high incidence of morbidity.

Parastomal hernia causing gastric emphysema.

We report a case of a parastomal hernia in which the stomach became incarcerated. This is an unusual yet serious complication of parastomal hernias.

Recurrence of inguinal herniae following removal of infected prosthetic meshes: a review of the literature.

PURPOSE: Late-onset mesh infection, occurring months to years following hernia repair, is a rare complication of hernia surgery. Its management usually requires removal of the mesh. The aim of this paper was to assess the rate of recurrence of inguinal herniae following removal of the mesh for late onset deep mesh infection. METHODS: We performed a literature review to assess the rate of recurrence of herniae following the removal of a delayed onset infected mesh. Relevant studies from January 1966 to June 2010 were identified from a Medline, Pub Med, Embase, Scopus and Cochrane database search. Studies that reported recurrence of the hernia following removal of delayed onset infected meshes were included. Results were tabulated and analysed to derive conclusions. RESULTS: Some 153 abstracts were reviewed and 12 potential studies initially identified; of these, only 7 were finally included in this review. The included studies were six case series and one case report and comprised a total of 40 patients in whom delayed-onset infected mesh was removed. The median follow-up period after the removal of the infected mesh was 26 months. Of these 40 patients, only 2 (<5%) developed a recurrent hernia. Removal of the mesh resulted in resolution of symptoms in the majority of the patients. CONCLUSION: Based on this review, removal of a late-onset infected mesh results in resolution of symptoms in the majority of cases, whereas recurrence of hernia is not common. However, further research is required as the number of patients in our review is relatively small.

Laparoscopic cholecystectomy in situs inversus totalis: is it safe?

Situs inversus totalis (SIT) is a rare defect of genetic predisposition. It may cause difficulties in the diagnostic and therapeutic management of abdominal pathology due to the mirror-image anatomy. We report the management of a case of symptomatic cholelithiasis with emphasis on its surgical technique combined with a review of the literature.

Common iliac aneurysm rupture after previous aortic aneurysm resection.

INTRODUCTION: Ruptured common iliac aneurysms present with diagnostic and therapeutic challenges. This case describes the successful outcome in a patient with complex vascular surgical history. CASE PRESENTATION: An elderly patient presented with abdominal pain confirmed by CT as leaking iliac aneurysm. He had previously undergone an aorto-bifemoral bypass graft for ruptured abdominal aortic aneurysm. The iliac aneurysm was treated by simple ligation of the external iliac artery. DISCUSSION: Aorto-bifemoral bypass graft may be required for aortic aneurysm repair in severe iliac calicification. Iliac artery fed by retrograde blood flow from the aorto-bifemoral bypass graft contributed to aneurysm development here.

First case of villous adenoma of the appendix leading to acute appendicitis presenting as strangulated femoral hernia: changes in management owing to concurrent adenoma.

A 78-year-old lady presented with signs and symptoms of a strangulated femoral hernia. Peri-operatively she was found to have appendicitis within the hernia sac. Appendicectomy and non-mesh hernia repair were performed. Histology revealed acute inflammation and a villous adenoma of the appendix. Villous adenomas of the vermiform appendix are extremely rare tumours of the gastrointestinal tract. This is the first case combining two very rare pathologies--acute appendicitis presenting as strangulated femoral hernia and villous adenoma of the appendix. Early diagnosis and surgery are required to avoid high morbidity of perforated appendicitis within a femoral hernia. First, we discuss the diagnosis and surgical treatment of acute appendicitis within a femoral hernia. Second, the presence of an adenoma changes the aetiology of appendicitis. More importantly, changes in surgical management of acute appendicitis presenting as a strangulated femoral hernia owing to a co-existing adenoma are discussed.

Outcomes of emergency and elective femoral hernia surgery in four district general hospitals: a 4-year study.

INTRODUCTION: A large number of femoral herniae present as emergencies accounting for significant morbidity and mortality, which have remained unchanged over the last decade. Reports of outcomes in femoral hernia surgery are scarce, even more so in district general hospitals where a significant proportion of surgeries are performed. This study compares results of emergency and elective femoral hernia surgery in four district general hospitals against published rates up to a decade ago. MATERIALS AND METHODS: A retrospective study of all patients undergoing femoral hernia surgery in four district hospitals between 2000 and 2004. RESULTS: Seventy-three patients had 75 (28 emergency, 47 elective) femoral hernia repairs. Emergency presentations were associated with increased age(P = 0.001) and right-sided hernias (P = 0.024). Emergency surgery led to increased bowel resection (10.7 vs. 0%, P < 0.001) and longer hospital stays (8 vs. 1 day, P < 0.001) compared to elective surgery. There was no difference in complication rates between emergency and elective surgery (21.4 vs. 12.8%, P = 0.322) or opposition and pectineal flap repair (12.9 vs. 36.4%, P = 0.149). Overall recurrence, morbidity, and mortality were 4.2, 16 and 1.3%, respectively. One patient (3.6%) died after emergency surgery, and no deaths occurred with elective surgery. CONCLUSION: The proportion of femoral herniae presenting as emergencies remained unchanged. This accounts for the morbidity and mortality in femoral surgery, which remains high and similar to a decade ago. Early diagnosis by clinicians and general practitioners and elective surgery are required to reduce mortality. Further investigation into the effect of the opposition technique on femoral vein compression and deep venous thrombosis is warranted.

Jaundice as a presentation of phenol induced hepatotoxocity following injection sclerotherapy for haemorrhoids.

A 43-year-old man was admitted with jaundice six days following phenol injection sclerotherapy for haemorrhoids. He was diagnosed with a phenol-induced hepatitis. Although he remained well, liver function tests only returned to normal after six months. Systemic absorption of phenol has been reported with ingestion, upper airway and excessive cutaneous exposure but not as a complication of haemorrhoidal injection sclerotherapy. Hepatic involvement is also rare and usually the result of ongoing sepsis. We report the unique case of a patient presenting with jaundice secondary to chemical hepatitis, following systemic absorption of phenol at injection sclerotherapy. This case highlights the importance of clinical awareness of not only the infective complications of injection sclerotherapy but also the potential for phenol to be absorbed systemically with severe consequences. A brief overview of symptoms of phenol toxicity is included.

Bacterial translocation in patients undergoing abdominal aortic aneurysm repair.

BACKGROUND: Bacterial translocation occurs in humans and is associated with an increased incidence of septic morbidity. The aims of this study were to determine the prevalence of bacterial translocation in patients undergoing open abdominal aortic aneurysm (AAA) repair and to identify any association with postoperative septic complications. METHODS: This was a prospective observational study in which patients undergoing aneurysm repair were assessed for evidence of bacterial translocation by culture of a mesenteric lymph node (MLN), small bowel serosal exudate and thrombus within the aneurysm. All postoperative septic complications were recorded. RESULTS: A total of 51 patients was studied (40 men, 11 women; median age 72 years). Enteric bacteria were isolated from the MLNs of five patients (prevalence of bacterial translocation 10 per cent), one of whom also yielded growth from the serosal exudate. Septic morbidity occurred in four of five patients in whom bacterial translocation was identified, compared with nine of 46 in those without translocation (P = 0.013, Fisher's exact test, mid P). One patient in whom Escherichia coli was grown from the MLN developed an aortoenteric fistula, with a coliform species isolated from the graft. CONCLUSION: This study suggests that bacterial translocation occurs in patients undergoing AAA repair. It is associated with an increased incidence of postoperative septic morbidity and provides a possible mechanism for infection of prosthetic aortic grafts.

Cholesterolosis in patients with chronic acalculous biliary pain.

The outcome of patients with cholesterolosis was compared with that of those with chronic cholecystitis operated on for chronic acalculous biliary pain. A total of 55 patients with acalculous biliary pain with a median symptom duration of 24 (range 6-120) months were investigated by dynamic cholescintigraphy and followed for a median of 24 (range 12-60) months. Thirty-five patients underwent cholecystectomy, of whom 22 had a low gallbladder ejection fraction (under 35 per cent), with symptomatic improvement in 21 of these (P < 0.01). All four patients with a normal ejection fraction (35-50 per cent) improved after cholecystectomy but only four of nine with a high ejection fraction (over 50 per cent) did so. Results of histological examination were available in 32 patients and revealed cholesterolosis in 20. A low ejection fraction was found in 16 patients with cholesterolosis, of whom 15 showed symptomatic improvement after cholecystectomy; the other four patients had a high fraction and all improved after cholecystectomy. Overall, symptoms in 19 of 20 patients with cholesterolosis improved after cholecystectomy compared with only seven of 12 with chronic cholecystitis (P = 0.03).

Direct cephalic vein cannulation for safe subclavian access.

Over a 2-year period we have successfully inserted 70 subclavian catheters in 68 patients from 76 attempts by cephalic vein cutdown. There were no complications of catheter insertion although 40% were inserted by junior surgeons (mean survival of catheters was 16.5 days) and in 30% of patients the catheter was removed before the completion of treatment for both infective and other complications. From our results, we recommend that direct cephalic vein cutdown is the route of choice for elective subclavian access because of its safety.

Postoperative nausea is relieved by acupressure.

One hundred and sixty-two general surgical patients were prospectively randomized to one of three treatments for postoperative nausea and vomiting: (1) acupressure using elasticated bands containing a plastic button to apply sustained pressure at the P6 (Neiguan) point above the wrist, (2) control dummy bands without the pressure button and (3) antiemetic injections of prochlorperazine with each opiate given and as required. All patients received papaveretum injections as required for pain, and additional prochlorperazine injections were prescribed if nausea was not controlled in groups 1 and 2. The severity of nausea was assessed using a linear analogue scale and was significantly (P = 0.002) reduced by acupressure on both days 1 and 2, in comparison to both controls and drug treated patients. The incidence of postoperative vomiting, and the need for unplanned antiemetic injections was also reduced by acupressure but this was not statistically significant. Acupressure can work and should be investigated in other clinical situations.

Changes in emergency surgery between 1973 and 1982: audit of the workload of one surgical team.

The emergency surgical workload of a consultant in general surgery has been studied by comparing two prospectively collected audits of 6-month periods 9 years apart. There have been a number of changes in the pattern and intensity of general surgical admissions (excluding trauma) with a decline in the total number per day from 14.1 to 12.4 and a reduction in the number of days on call for general surgery from 30 to 14 over the 6-month period. There was a similar fall in days on call for trauma from 60 to 23 days and a decline in total emergency surgical operations from 6.6 to 5.2 operations per night on call. These changes have mainly been produced by an increase in the number of consultants in the hospital from five to eight and specialisation with the establishment of an area urology unit. The results of this study suggest that as consultant numbers increase in a particular area there will be diminished exposure of surgical trainees to emergency cases both in quantity and in quality, and this loss of experience will prove deleterious to the trainee surgeon.