Is there a need for resident general surgical cover in small peripheral hospitals?

AIM: To assess the need for resident general surgical cover in a small peripheral hospital. PATIENTS AND METHODS: The total number of admissions to Caerphilly District Miners' Hospital in the year 2001 was noted along with the admission criterion for elective general and vascular surgical patients. RESULTS: Among the 10,608 in-patients only 120 (1.13%) developed general surgical/vascular problems that merited surgical referral and out of these 30 (0.28%) patients were transferred to neighbouring larger hospitals for specialist care. CONCLUSIONS: A resident staff grade surgeon is not required in a small peripheral hospital and this service could be provided by the resident on-call surgical SpR in a neighbouring larger hospital.

Vascularised muscular flaps and arterial graft infection in the groin.

The groin is the commonest site for graft infections in vascular surgery. This is a potentially catastrophic situation as limb loss or even death occurs in a large percentage of cases. Standard teaching for treatment of infected vascular grafts is removal and extra anatomical bypass grafting whilst commencing appropriate antibiotics. This review article suggests careful scrutiny of the wound, debridement and coverage of the graft with a vascularised muscular flap is appropriate in certain situations.

Left retroperitoneal approach for aortic surgery.

Twenty-eight consecutive patients underwent surgery of the abdominal aorta by the left retroperitoneal approach. There were 11 suprarenal, 12 juxtarenal, three complicated infrarenal aneurysms and two occlusive aortoiliac disease (considered to be at high risk) undergoing surgical repair. Twenty-one underwent a tube graft repair whilst seven had a bifurcation graft. There were five deaths in this series; four of which occurred in the initial 12 patients. In our initial experience using the left retroperitoneal approach the overall mortality rate was 17%, though this reduced to 6% for the latter half of the study. The retroperitoneal approach allows access to the supracoeliac aorta without the need for thoracotomy and this approach should be considered for all aortoiliac reconstructive surgery. The transabdominal route to the abdominal aorta remains the most commonly used approach. However, the left retroperitoneal approach offers advantages in high-risk patients and suprarenal and juxtarenal abdominal aortic aneurysms (AAA). This is our initial experience of 28 patients undergoing surgical repair of the abdominal aorta via the left retroperitoneal approach.

Adult hernia surgery in Wales revisited: impact of the guidelines of The Royal College of Surgeons of England.

This study investigated the impact of the guidelines of The Royal College of Surgeons of England on the practice of hernia surgery in Wales. This was assessed by means of a postal survey to all consultant general surgeons in Wales in 1996-1997. The areas covered were: awareness of the guidelines of The Royal College of Surgeons of England and the impact of such guidelines on their practice, attendance at hernia courses, operative technique, materials used for repair and skin suture, proportion of day case hernias, length of inpatient stay, thromboembolic (TE) prophylaxis and postoperative advice to patients with regard to light work, heavy work and sport. In all, 79 replies were received (85%). Almost all the surgeons had read the guidelines; this changed the practice of 20% of respondents but did not in 32%. A further 48% did not answer the question. In contrast with our 1993 survey results, in Wales there is now a uniform surgical management of adult inguinal hernias: the most common operation is the Liechtenstein, with monofilament non-absorbable suture to secure the mesh, followed by the Shouldice repair. The Bassini and inguinal darn operations are becoming much less common and none now uses braided or absorbable sutures for the repair. Skin closure is still rather variable, with only 58% of respondents adhering to the recommended absorbable subcuticular suture. Postoperative advice is now uniform and in accordance with the guidelines. A trend towards more TE prophylaxis and more day case hernia surgery is also seen.

Common bile duct stenting for choledocholithiasis: a district general hospital experience.

The favoured treatment of common bile duct stones is endoscopic sphincterotomy and stone extraction. The management of those cases where duct clearance is not possible is controversial. At our institution it has been policy to insert an endoluminal stent. We report a retrospective review of the outcome of patients stented for common bile duct stones. The study population was 14 men and 22 women, with a median age of 73 years (range 23-89 years). Treatment-related morbidity was seen in nine patients (25%), comprising cholangitis (5), pancreatitis (3), and cholecystitis (1). Three of these patients died; all were over the age of 75 years and had been stented on a long-term basis. These data suggest that endobiliary stents can be employed with an acceptable complication rate. We suggest that patients under the age of 75 years be stented only as a temporising measure, but that patients over 75 years or those unfit on physiological grounds can be stented on a long-term basis as definitive treatment.

Flush saphenofemoral ligation and multiple stab phlebectomy preserve a useful greater saphenous vein four years after surgery.

PURPOSE: Flush saphenofemoral ligation, with multiple cosmetic stab phlebectomy, successfully treats saphenofemoral reflux and superficial varicosities. The long-term effect on the residual greater saphenous vein (GSV) requires evaluation. METHODS: Noninvasive triplex ultrasound assessment of the residual GSV for potential use as a vein graft was used. We evaluated the independent objective and subjective cosmetic outcomes. We also used analysis to determine the correlation between GSV reflux, symptoms, and cosmetic outcome. RESULTS: Seventy-two limbs were assessed at a median follow-up of 4 years (interquartile range 3 to 5 years). Fifty-nine limbs had patent GSVs above and below the knee. The mean length patent was 51 cm, and the mean internal diameters above and below the knee were 3.6 and 2.8 mm, respectively. In 65% of cases the vein had suitable ultrasonic characteristics, suggesting that it would be suitable for use as a conduit for a vascular bypass graft. Sixty-two limbs were considered a symptomatic success and 61 an objective cosmetic success. There was no correlation between the symptomatic and cosmetic outcome and the presence of superficial GSV reflux (linear regression analysis). CONCLUSIONS: These findings support the effectiveness of the procedure of flush saphenofemoral ligation and multiple stab phlebectomy with regard to cosmetic and symptomatic outcome and may preserve the GSV for use as an autologous bypass graft.

Aspects of hernia surgery in Wales.

The management of elective inguinal herniorrhaphy in Wales was assessed by means of a postal survey of consultant general surgeons. This included technique of repair, length of inpatient stay, follow-up, use of heparin thromboprophylaxis and advice regarding driving, strenuous activities and work. In all, 54 replies (77%) were received. The views of patients on their surgery was assessed by a questionnaire sent to 80 patients treated on a single surgical unit; 60 replies (75%) were received. Waiting times were relatively short among this group, 67.5% of patients being treated within 6 months of seeking medical advice; 16.25% suffered a complication. All wound infections occurred after discharge and 15% of patients had some groin discomfort 6 months after operation. Accuracy of clinical examination of 50 inguinal hernias by different grades of surgeon was assessed. Consultants were significantly more accurate when compared with house officers (P < 0.001). There is a wide range of repair techniques and postoperative advice practised by consultant general surgeons in Wales. Patients' main complaint was that of a sparsity of postoperative advice, although there also appears to be an appreciable postoperative morbidity. Clinical experience plays a significant role in assessment of the suitability of hernias for surgery.

Lupus anticoagulant in patients with peripheral vascular disease: a prospective study.

OBJECTIVE: To assess the incidence of lupus anticoagulant (LAC) in patients with peripheral vascular disease. DESIGN: Prospective clinical study. SETTING: University Hospital. MATERIALS: 20 patients with claudication (group 2), 20 patients with critical ischaemia (group 3) and 20 patients prior to elective abdominal aortic aneurysm surgery (group 4) were compared to 20 general surgical controls (group 1). CHIEF OUTCOME MEASURES: Venous blood samples for coagulation assay. MAIN RESULTS: Positive results for LAC by the Dilute Russell's viper venom time (DRVVT) with the platelet neutralisation procedure were present in 26 out of 60 vascular patients compared with none of the 20 general surgical controls. The three vascular groups showed a similar prevalence of LAC and this differed significantly from that in the control group (chi 2 = 10.94, p = 0.0009). Of the 26 positive results only three were associated with an abnormal activated partial thromboplastin time (APTT), which has previously been used as a marker for the presence of LAC activity. Fibrinogen levels were raised in seven of 20 patients in group 2 but were normal in the remaining vascular groups (p = 0.001). The mean factor VII level (124.1 units dl-1) in group 2 was higher than the mean of the remaining vascular patients (109.3 units dl-1, p < 0.05). CONCLUSIONS: The high prevalence of LAC in patients with peripheral vascular disease and the associated increased risk of early graft thrombosis may justify routine testing by DRVVT prior to reconstructive vascular surgery. Treatment of these patients with antiplatelet agents or formal anticoagulation perioperatively should be considered.

Laparoscopic cholecystectomy: laser or electrocautery?

Laparoscopic cholecystectomy is now an accepted part of general surgery. With the recent upsurge of interest in laparoscopic techniques, an optimum method of ensuring secure haemostasis is important particularly during dissection of the gall bladder from its mesenteric attachments. The use of laser to ensure haemostasis has been well practised in the treatment of peptic ulceration. Electrocautery is a time-honoured method of controlling local bleeding points by coagulation of tissue. The aim of this study was to assess whether one procedure showed any advantage over the other in terms of the length of operation time, postoperative drainage volume, time to dissect the gall bladder and length of the hospital stay.

Acute intestinal ischaemia: options in surgical management.

Seven patients (mean age 67 years, range 52-82 years) presented with acute intestinal ischaemia over a 4-year period. Massive bowel resection was performed in all patients. Exteriorisation and secondary restoration of intestinal continuity was employed in four patients. In two patients a primary anastomosis was performed at the time of resection and one patient underwent a 'second-look' procedure. Massive bowel resection and exteriorisation allows direct observation of stoma viability, avoids the risk of anastomotic breakdown and should be considered in all but moribund patients with acute intestinal ischaemia. In elderly patients resection and primary anastomosis may be an alternative option.

'Diabetic tibial disease': the case for revascularisation.

Diabetic patients with critical ischaemia of the lower limb are frequently considered to have unreconstructable vascular disease. In the presence of a palpable popliteal pulse they are often labelled as having 'small vessel disease'. In nine patients (mean age 69 years) with 'diabetic tibial disease' and critical ischaemia we have avoided major amputation using short vein bypasses. All revascularisations remained patent at a mean follow-up of 32 months (range 12-60 months). Diabetic patients with critical ischaemia should at the very least undergo arteriography to ensure that the possibility of successful distal revascularisation is not feasible before amputation is performed. However, if arteriography fails to demonstrate patent distal vessels and limb salvage is considered practical, Doppler insonation of the tibial and pedal vessels should be performed.

Endoscopic transanal resection of large villous tumours of the rectum.

Endoscopic transanal resection (ETAR) is an innovative approach in the management of low lying tumours of the rectum. We report our experience of this technique in six elderly patients (mean age 74 years) with large villous adenomas, situated between 2 and 12 cm from the anal verge. There were no complications. One patient with a circumferential tumour has been spared the more conventional operation of abdominoperineal excision. Follow-up ranged from 6 to 30 months (mean 16 months) during which two recurrences were detected. These were adequately treated by further ETARs. It is concluded that ETAR is a simple and well-tolerated procedure and is a useful addition to the surgeon's armamentarium.

Peak expiratory flow in the detection of retrosternal goitre.

In 24 patients where the lower border of a cervical goitre was poorly defined, the value of simple lung function tests in the prediction of the presence of a retrosternal goitre was assessed. At operation there were nine patients with retrosternal extension (Group I) and 15 without (Group II). The preoperative PEF ratio (observed to predicted) was significantly different between the two groups (P = 0.004) with a positive predictive value of 90% for a retrosternal goitre. This difference was abolished after thyroidectomy. There was a significant improvement in PEF in patients with retrosternal goitres after thyroidectomy (P less than 0.001). It is concluded that the preoperative measurement of PEF is a simple method of detecting the retrosternal extension of a cervical goitre.