Improving risk disclosure during the consent process.

OBJECTIVES: To provide guidance about the risks which should be disclosed to patients and documented during the consent process. METHODS: The Delphi Consensus Technique was used to decide what constitutes mandatory risk disclosure for three index procedures. Documentation of risk on consent forms was audited and compared to these locally agreed standards. A four stage strategy for change was undertaken following which practice was reviewed. RESULTS: Mean mandatory risk documentation rose from 61.2% (95% CI: 58.1-64.4) pre-intervention, to 78.1% (95% CI: 72.6-83.6) post-intervention (ccc2; P < 0.001). CONCLUSIONS: Although we demonstrated some benefit from this simple approach, the need for pragmatic means of achieving and sustaining complete discussion and documentation of risks across all surgical interventions based on universally accepted standards remains.

Surgical experience and supervision may influence the quality of lower limb amputation.

AIM: Only half of those patients undergoing major lower limb amputations for peripheral vascular disease (PVD) are likely to mobilise on a prosthesis. This study aimed to determine whether a surgeon's experience influenced the quality of the residual limb and thus the likelihood of the stump being suitable for a prosthesis. METHODS: All patients undergoing major lower limb amputations for PVD were recruited prospectively, between August 1992 and July 1996. Following surgery, patients were categorised, by a consultant in rehabilitation medicine, as potentially suitable (group 1) or unsuitable (group II) for rehabilitation. Patients in group I were further assessed by prosthetists for limb fitting. RESULTS: A total of 217 patients underwent 260 amputations for PVD between 1992 and 1996: transfemoral (TFA) 131, trans-tibial (TTA) 127, and through-knee (TKA) in 2. The 30-day mortality was 12% (n = 27). Following surgery, 109 patients were assigned to group I (51%), and 81 patients to group II (37%). The proportion of junior surgeons performing surgery was similar for patients in both groups. Twenty-three amputation stumps (9%) required revision or conversion to a higher level within 30 days. Revisions or conversions were significantly more frequent where the original operation had been performed by an unsupervised junior surgeon rather than a senior surgeon (P = 0.009). The rate of defective amputations compromising limb fitting also reached significance when unsupervised junior and senior surgeons were compared (P = 0.04). CONCLUSIONS: Rehabilitation of the relatively few amputees who reach the stage of limb fitting is hindered by poor surgical technique in a large proportion of cases. Patients operated on by a more experienced surgeon had a better chance of mobilising without revision or conversion surgery.

Correlation between psychometric test scores and learning tying of surgical reef knots.

We have investigated the correlation between the scores attained on a computerised psychometric test, measuring psychomotor aptitude and learning tying of a surgical reef knot. Fifteen surgical trainees performed a test of psychomotor aptitude (ADTRACK 2) from the MICROPAT testing system. They then performed a simple test of their ability to tie a surgical reef knot and were assessed by a panel of experts prior to embarking on a standardised course of instruction and practice session. The knot-tying test was repeated at the end of the day and the differences in average scores recorded. There was a significant correlation between the means of the differences in knot tying scores and ADTRACK 2 scores (r = -0.533, P < 0.05). Psychomotor abilities appear to be determinants of trainees' initial proficiency in learning to tie a surgical reef knot.

The assessment of surgical skills and a simple knot-tying exercise.

Basic surgical skills courses are mandatory for all surgical trainees taking the MRCS examination. An important aspect of these courses is the level of practical skill achieved by junior surgeons attending them. We present a simple knot-tying exercise, which may be used to assess the baseline skill level of trainees at the outset of the course and against which their progress can be judged after tuition and practice.

Multicystic peritoneal inclusion cysts: the use of CT guided drainage for symptom control.

Our case study is that of a teenage male presenting with multilocular peritoneal inclusion cystic disease that is now managed symptomatically with a minimally invasive, repeatable technique. Between admissions he leads a relatively normal life. Symptomatic control in MPIC is possible using repeated CT guided aspirations.

Vagus nerve stimulation: quality control in thyroid and parathyroid surgery.

This paper describes the use of the Neurosign 100 Nerve Monitor and vagus nerve stimulation in the identification and assessment of the integrity of the recurrent laryngeal nerve (RLN) during thyroid and parathyroid surgery. Vocal fold function was assessed pre- and post-operatively in all patients undergoing thyroid and parathyroid surgery. The nerve monitor, used in association with endotracheal electrodes, was used to confirm correct RLN identification and demonstrate its integrity at the completion of surgery. There were 21 unilateral and 19 bilateral neck explorations. In these 40 patients, 57 of 59 RLNs were identified. The nerve monitor demonstrated RLN continuity in all but one case (equipment failure: electrode misplacement) after initial identification. Vagus nerve stimulation was performed in 21 patients without adverse sequelae. Damage to the RLN was identified in one of these patients, in whom direct RLN stimulation close to the larynx had failed to indicate discontinuity. Post-operatively this patient had a transient unilateral vocal fold palsy. The use of the Neurosign 100 Nerve Monitor is no substitute for meticulous surgery. Stimulation of the vagus nerve may be a more sensitive means of assessing RLN integrity during thyroid and parathyroid surgery than stimulation of the RLN itself. Confirmation of RLN integrity allows the surgeon to proceed with confidence to the contralateral side of the neck during hazardous bilateral explorations.

Popliteal artery entrapment syndrome.

BACKGROUND: Popliteal artery entrapment syndrome (PAES) is rare and may be underdiagnosed. Improved specialized, non-invasive imaging techniques are producing detailed topographical evidence of the anomaly. METHODS: A historical review of the literature and Medline search was performed with reference to the diagnosis and treatment of the condition. In addition, embryologically based theories for the condition have been postulated. RESULTS AND CONCLUSION: PAES may be the result of abnormal development of the popliteal artery or a consequence of excessive cranial migration of the medial head of the gastrocnemius muscle. Magnetic resonance imaging appears to be the most useful single investigation to demonstrate the anomaly. Popliteal artery release alone or with vein bypass is the treatment of choice when intervention is indicated.

Life-threatening retroperitoneal sepsis after hemorrhoid injection sclerotherapy: report of a case.

We present a case of life-threatening retroperitoneal sepsis after injection sclerotherapy for first-degree hemorrhoids.

Ruptured abdominal aortic aneurysms: selecting patients for surgery.

OBJECTIVES: Mortality from ruptured abdominal aortic aneurysm (RAAA) remains high. Despite this, withholding surgery on poor-prognosis patients with RAAA may create a difficult dilemma for the surgeon. Hardman et al. identified five independent, preoperative risk factors associated with mortality and proposed a model for preoperative patient selection. The aim of this study was to test the validity of the same model in an independent series of RAAA patients. METHODS: A consecutive series of patients undergoing surgery for RAAA was analysed retrospectively by case-note review. Thirty-day operative mortality and the presence of the five risk factors: age (> 76 years), creatinine (Cr) (> 190 mumol/l), haemoglobin (Hb) (< 9 g/dl), loss of consciousness and electrocardiographic (ECG) evidence of ischaemia were recorded for each patient. RESULTS: Complete data sets existed for 69 patients (mean age: 73 years, range: 38-86 years, male to female ratio: 6:1). Operative mortality was 43%. The cumulative effect of 0, 1 and 2 risk factors on mortality was 18%, 28% and 48%, respectively. All patients with three or more risk factors died (eight patients). CONCLUSIONS: These results lend support to the validity of the model. The potential to avoid surgery in patients with little or no chance of survival would spare unnecessary suffering, reduce operative mortality and enhance use of scarce resources.

Popliteal artery entrapment syndrome: collaborative experience of the Joint Vascular Research Group.

BACKGROUND: Popliteal artery entrapment syndrome (PAES) is rare and probably underdiagnosed. This study reviewed a collected experience. METHODS: Patients were identified by the Joint Vascular Research Group (vascular surgeons from ten hospitals serving a population of approximately four million) during 1984-1995. Case notes were reviewed. RESULTS: Twenty-one legs in 17 patients were identified with PAES. There were 15 men and two women. The median age at presentation was 29 (range 14-45) years. One patient was excluded because no further information was available. PAES was bilateral in four patients in whom three legs were asymptomatic. At presentation, the duration of symptoms ranged from a few hours (acute leg ischaemia) to intermittent claudication of 6 years' duration. Primary investigation included angiography (20 patients), duplex imaging (four), plain radiography (one) and magnetic resonance imaging (one). In two cases, attempted thrombolysis failed. Surgery was carried out on 17 legs but failed in two. No amputations were required. Following surgery, 12 legs were asymptomatic and five had residual symptoms. CONCLUSION: PAES should be excluded in young patients with intermittent claudication or acute ischaemia.

Closed rupture of the posterior tibial artery secondary to a soccer injury.

Arterial damage following blunt trauma is uncommon and is usually the result of high-energy injury. We report a case of posterior tibial artery rupture after a closed distal tibial fracture, sustained during a low-energy soccer tackle.

Duplex assessment of run-off before femorocrural reconstruction.

BACKGROUND: This study was a prospective evaluation of colour duplex imaging for the assessment of distal run-off before femorocrural reconstruction. METHODS: Patients with critical ischaemia who required a distal bypass underwent preoperative run-off assessments using dependent Doppler, arteriography and duplex imaging by a vascular surgeon, radiologist and technologist respectively; each was blinded to the findings of the others. Preoperative data were compared with intraoperative clinical findings and completion flow studies/ arteriograms. RESULTS: Forty-three consecutive patients (33 men, ten women; mean age 78 (range 53-95) years; 12 diabetic) undergoing 44 femorocrural reconstructions for critical ischaemia were assessed. The 30-day primary cumulative graft patency for the series was 86 per cent. Dependent Doppler correctly predicted a suitable run-off vessel in 21 limbs but was indeterminate in four and unrecordable in 19. Arteriography correctly predicted a suitable run-off vessel in 32 cases, but was indeterminate in six and failed to demonstrate run-off in three patients. Arteriography suggested an inferior vessel in three cases. Duplex correctly predicted a suitable run-off vessel for all 44 grafts. CONCLUSION: Duplex imaging is superior to arteriography for preoperative assessment of distal run-off for femorocrural reconstruction.

Varicose vein surgery: patient satisfaction.

Surgery for varicose veins is a common surgical procedure performed for various indications including cosmesis. Patient satisfaction with the eventual outcome is therefore important. A total of 311 patients (68%), who underwent varicose vein surgery during a 10-year period, replied to a postal survey of 456 patients [National Health Service (NHS) 327: private patients (PP) 129]. Of those 311, 19% of the NHS patients compared with 34% of the PP were completely satisfied with the surgery, the communication and had had no post-operative complications (P < 0.01). Twenty-six per cent of the NHS patients were very dissatisfied with their treatment compared with 13% of the PP (P < 0.025). The majority of dissatisfied patients were female (P < 0.005). These results suggest that while varicose vein surgery is regarded as a safe and often minor procedure, it is associated with a significant surgical morbidity and patient dissatisfaction. Patients should be made aware of the potential outcome prior to surgery.

Vascular infection: another hazard of listeriosis.

Two case reports are presented of Listeria monocytogenes infection complicating vascular reconstructions. The importance of this problem lies in the resistance of the organism to some of the prophylactic antibiotics recommended for vascular surgery. Patients with prosthetic vascular grafts, particularly if immunocompromised, may be at risk from Listeria infection and may be advised to avoid potentially affected food.