Deep vein thrombosis (DVT) after venous thermoablation techniques: rates of endovenous heat-induced thrombosis (EHIT) and classical DVT after radiofrequency and endovenous laser ablation in a single centre.

INTRODUCTION: Deep vein thrombosis (DVT) after varicose vein surgery is well recognised. Less well documented is endovenous heat-induced thrombosis (EHIT), thrombus extension into a deep vein after superficial venous thermoablation. We examined the rates of DVT in our unit after radiofrequency (RFA) and endovenous laser ablation (EVLA) with specific attention to thrombus type. METHOD: Retrospective analysis of all cases of RFA under general anaesthesia and EVLA under local anaesthesia was performed. Cases of DVT were identified from the unit database and analysed for procedural details. RESULTS: In total, 2470 cases of RFA and 350 of EVLA were performed. Post-RFA, DVT was identified in 17 limbs (0.7%); 4 were EHIT (0.2%). Concomitant small saphenous vein (SSV) ligation and stripping was a risk factor for calf-DVT (OR 3.4, 95%CI 1.2-9.7, P=0.036), possibly due to an older patient group with more severe disease. Post-EVLA, 4 DVTs were identified (1%), of which 3 were EHIT (0.9%). CONCLUSION: The DVT rate including EHIT was similar in patients treated with RFA and EVLA and was low. Routine post-operative duplex ultrasound scanning is recommended until the significance of EHIT is better understood, in accordance with consensus guidelines. DVT rates for both techniques compare favourably with those published for saphenous vein stripping.

Tartrate-resistant acid phosphatase isoform 5a as an inflammation marker in end-stage renal disease.

AIM: End-stage renal disease (ESRD) is often complicated by chronic inflammation and malnutrition. We tested whether serum tartrate-resistant acid phosphatase (TRACP) isoform 5a relates to other markers of inflammation in ESRD. MATERIAL: Predialysis serum was collected from 99 ESRD patients (51 male, 48 female) aged 55 +/- 15 years and a control group of 36 healthy subjects (8 male, 28 female) aged 43.2 +/- 10.5 years. METHODS: Serum TRACP 5a activity and protein, TRACP 5b activity and C-reactive protein (CRP) were estimated by in-house immunoassays. Commercial kits were used for serum bone-specific alkaline phosphatase, Ntelopeptides of Type I collagen, interleukin-6 (IL-6) and fetuin-A. Intact parathyroid hormone was determined by chemiluminescent assay. Albumin, cholesterol, triglycerides, ferritin and hemoglobin were compared to the hospital reference ranges. Bone mineral density (BMD) was measured at the heel in 69 patients and all control subjects and expressed as g/cm2 and age-corrected T-score. RESULTS: Mean (median) levels of all serum markers were significantly elevated in ESRD except fetuin-A, which was significantly reduced. Mean BMD (g/cm2) was not different than control, but mean T-score was significantly reduced. TRACP 5a protein correlated with CRP, triglycerides and ferritin, but not with IL-6 or any other nutritional or bone markers or BMD. TRACP 5b activity correlated with all bone markers and BMD, but not with inflammation or nutritional markers. CONCLUSION: Our findings suggest that TRACP 5a may be a useful marker to estimate the degree of inflammation in ESRD patients on chronic hemodialysis.

It is possible to cause damage to a laser fibre during delivery of tumescent anaesthesia for endovenous laser ablation (EVLA).

AIMS: To establish a possible mechanism of damage to a laser fibre significant enough to cause a retained segment within a patient. METHODS: A 21 G needle was used to pierce a VARILASE 810 nm Laser Fibre inserted within a 4F sheath. A tiny pin source of light from the aiming beam emerged from the needle hole in the sheath. Using laser protection protocol, the generator was fired for one minute at 14 Watts (W) continuous wave. The sheath and fibre were then examined. In a control experiment, we were unable manually to break a fibre where the coating had been damaged prior to the laser being fired. RESULTS: The aiming beam was noted to be concentrated at the side of the catheter at the point of needle damage rather than at the fibre tip. When the fibre was removed from the sheath the distal length, from the point of damage to the tip, was retained within the sheath. Longer firing with the sheath surrounded by a wet towel or a pork loin resulted in complete severance of the sheath and fibre. CONCLUSION: There are no firm manufacturer's guidelines on whether Tumescent Anaesthesia should be delivered before or after the laser fibre has been inserted into the patient. Some units performing EVLA prefer to do this with the laser fibre in situ as it is easier to image on ultrasound than the sheath alone. The results of this in-vitro experiment would suggest it is possible to cause sufficient needle damage to fracture a laser fibre when fired. In the interests of safety we would recommend administration of tumescent anaesthesia should always be carried out before introduction of the laser fibre.

Minimally invasive technique for ligation and stripping of the small saphenous vein guided by intra-operative duplex ultrasound.

BACKGROUND: Small saphenous vein (SSV) disconnection and removal are challenging and considered by some authors to have too high a morbidity and failure rate to justify their routine use. Our audited results are at variance with these views. METHODS: We describe a reliable, ultrasound guided, minimally invasive technique for ligation and stripping of the SSV with an incision usually <1 cm. From our total series, 50 random patients attended for ultrasound review. The sapheno-popliteal junction (SPJ), strip track and signs of recurrence were assessed and recorded. RESULTS: Since 1999, 627 patients (679 limbs) have undergone surgery for ultrasound proven SSV reflux. Fifty-two limbs (50 patients) were ultrasound assessed post-operatively. Fifty-one had flush ligation of the SPJ with one showing a 'stump' <1 cm. All showed successful SSV removal. Three limbs had minor strip track revascularisation but none had obvious clinical recurrence. Of the whole series, 11/627 (1.8%) developed proven deep vein thrombosis (DVT). There were six superficial wound infections and one strip track abscess. Sural nerve neurapraxia occurred in 13/627 (2.1%); one showing no sign of recovery at four weeks post-operatively. CONCLUSIONS: Ultrasound guided SSV is a safe, minimally invasive technique with high success and low recurrence and complication rates

Haemorrhoids are associated with internal iliac vein reflux in up to one-third of women presenting with varicose veins associated with pelvic vein reflux.

OBJECTIVES: To determine the prevalence of haemorrhoids in women with pelvic vein reflux, identify which pelvic veins are associated with haemorrhoids and assess if extent of pelvic vein reflux influences the prevalence of haemorrhoids. METHODS: Females presenting with leg varicose veins undergo duplex ultrasonography to assess all sources of venous reflux. Those with significant reflux arising from the pelvis are offered transvaginal duplex ultrasound (TVS) to evaluate reflux in the ovarian veins and internal Iliac veins and associated pelvic varices in the adnexa, vulvar/labial veins and haemorrhoids. Patterns and severity of reflux were evaluated. RESULTS: Between January 2010 and December 2012, 419 female patients with leg or vulvar varicose vein patterns arising from the pelvis underwent TVS. Haemorrhoids were identified on TVS via direct tributaries from the internal Iliac veins in 152/419 patients (36.3%) and absent in 267/419 (63.7%). The prevalence of the condition increased with the number of pelvic trunks involved. CONCLUSION: There is a strong association between haemorrhoids and internal Iliac vein reflux. Untreated reflux may be a cause of subsequent symptomatic haemorrhoids. Treatment with methods proven to work in conditions caused by pelvic vein incompetence, such as pelvic vein embolisation and foam sclerotherapy, could be considered.

Evidence that orthotopic transposition following rat heterotopic small bowel transplantation corrects overgrowth of potentially pathogenic bacteria.

An overgrowth of pathogenic organisms occurs following rat heterotopic small bowel transplantation. This study assessed whether the bacterial microflora return to normal following subsequent orthotopic transposition of the graft. After 14 days the heterotopic graft was placed into continuity following resection of 15 cm of the host midintestinal loop. Quantitative and qualitative analyses of the intraluminal bacteria were performed studying the resected host intestine, the heterotopic graft at 14 days, and the graft 14 days after transposition. A group of normal rats were used as controls. An overgrowth of Staphylococcus epidermidis evident in the heterotopic graft at 14 days returned to a more normal bacterial profile following orthotopic transposition. These findings suggest that early interposition of a small bowel graft into an orthotopic position may prevent an alteration in the small bowel ecology toward potentially pathogenic organisms capable of translocation.

The effect of rejection and graft-versus-host disease on small intestinal microflora and bacterial translocation after rat small bowel transplantation.

Bacterial translocation and the development of sepsis after small bowel transplantation may be promoted by immunological damage to the intestinal mucosa or by quantitative and qualitative changes in intestinal microflora. This study assessed the effects of rejection, graft-versus-host disease (GVHD) and immunosuppression on intestinal microflora and bacterial translocation after heterotopic rat small bowel transplantation. Isografts, allografts with and without CsA immunosuppression, and the semi-allogeneic parent to the F1 hybrid GVHD model were studied. Intestinal microflora in graft and host loops and bacterial translocation to host organs and the graft mesenteric lymph node were determined. Bacterial colonies were counted and individual colonies identified using API 20E nutrient and fermentation indicator techniques. Colony counts in isografts and allografts were significantly higher than in the native intestine, whereas there was a massive overgrowth in the native intestine in the GVHD group. The species profile for the host and graft loops was similar in animals that had received isografts, allografted animals receiving CsA, and animals undergoing GVHD. However, there was a large increase in Staphylococcus epidermidis in animals with rejection. Bacterial translocation was not detected in isografted animals, but was observed in all other animal groups, with S. epidermidis being the most prevalent organism. These findings demonstrate that rejection and GVHD are associated with shifts in intestinal microflora toward potentially pathogenic organisms and that bacterial translocation into recipient tissues poses a major threat for the development of sepsis.

The effect of somatostatin on central hemodynamics, renal blood flow, and renal function in dogs.

We investigated the effects of infusion of somatostatin (200 and 500 ng/kg/min) on central hemodynamics and renal blood flow measured with radioactive microspheres. At the lower dose infusion rate somatostatin did not alter any hemodynamic parameter, but at 500 ng/kg/min somatostatin caused minor transient bradycardia, lowered cardiac output, and increased peripheral resistance. Both infusions inhibited renal arterial flow, with decreases noted in both cortical and medullary components. The 20% fall in renal perfusion was confirmed by the hippurate clearance technique, and there was a corresponding 17% decrease in the glomerular filtration rate. In contrast, no changes were noted in urine output, urinary concentrations of sodium or potassium, or urine osmolarity. These hemodynamic and renal side effects might limit the therapeutic usefulness of somatostatin infusion.

Significance of pericellular lacunae in cell blocks of effusions.

A retrospective study was conducted to assess the usefulness of pericellular lacunae in cell block sections of serous effusions in diagnosis. From January to December 1988, 286 cell blocks were prepared in our laboratory from pleural, pericardial and peritoneal fluids; 62 of them were excluded from this study because of inadequate cellularity, diagnostic uncertainty or lack of a proteinaceous background. The remaining consisted of 148 benign effusions from 128 patients and 76 malignant effusions from 56 patients. A single specimen from each patient was selected and reviewed to assess the presence and number of pericellular lacunae and to determine the relationship of this feature to cell arrangement (single cells versus cell clusters). Pericellular lacunae were found in 42 (75%) of the malignant effusions as compared to 41 (32%) of benign specimens. In the majority of malignant cases with lacunae, this feature was associated with greater than two-thirds of the cells, whereas in benign cases, when present, it was seen in less than one-third of the cells. Neoplasms characterized by large cell clusters more frequently had lacunae than did those with small groups or single cells. Lacunae were not evident in cases of malignant melanoma and lymphoma. We conclude that although pericellular lacunae are more often associated with malignant cells, their presence in itself cannot be used as a reliable indicator of malignancy in body cavity fluids.

Treatment of metastatic testicular tumours with bleomycin, etoposide, cisplatin and vincristine (BEPV).

Between August 1983 and December 1988, 47 patients with metastatic testicular tumours (44 non-seminomatous, three seminomas) were treated with two to six courses of bleomycin, etoposide, cisplatin and vincristine (BEPV). Five stage I tumours were included, three because of raised tumour markers following orchidectomy, one with vascular invasion of spermatic cord vessels and the other with both these features. Forty-four patients (93.6%) are alive and disease free 12-75 months (median 39 months) after completion of BEPV. Further treatment was necessary in 12 of the survivors. Eight had residual disease excised, one of whom received radiotherapy, one additional chemotherapy and one both radiotherapy and chemotherapy. Of the remaining four, two had radiotherapy and two second line chemotherapy. Thirty-one non-seminomatous and the three seminoma patients had small volume disease and all are in complete remission. Ten of the 13 patients with bulky disease are alive. It is concluded that BEPV is a well-tolerated, effective, first line therapy for patients with metastatic testicular tumour.

Management of chronic fatigue syndrome: case study.

1. Chronic fatigue syndrome (CFS) is a complex disorder marked by incapacitating fatigue of uncertain etiology which has resulted in a least a 50% reduction in activity and is of at least 6 months' duration. 2. Definitive diagnosis can be very challenging. Because no markers objectively identify the presence of CFS, diagnosis depends heavily on the presence of subjective complaints. 3. The current philosophy of CFS management is to use a multidisciplinary approach incorporating these rehabilitation goals: restore a sense of self efficacy and control; gradually increase physical activity; and decrease the restrictions imposed by CFS.

The influence of military surgeons in the development of vascular surgery.

Surgical attention to major blood vessels has been necessary for as long as man has been involved in armed combat. A brief resume of the history of vascular surgery is outlined with special reference to the contribution made by the military surgeon in battle. The role of modern specialist techniques in vascular injuries in present day operations will be briefly discussed.

An anomalous median nerve avoiding injury in a gunshot wound to the antecubital fossa.

We report the case of a 19 year old man who received a gunshot wound to the soft tissues of his left elbow. He presented with an ischaemic hand due to transection of the brachial artery bifurcation anterior to the elbow joint. He was spared an associated median nerve injury by an anomalous course of the nerve through the antecubital fossa.

Simultaneous presentation of both true and false aneurysm in the infrarenal aorta.

Interventional radiology has resulted in a reduced need for bypass procedures for aorto-occlusive disease. However, there are still indications for surgery of this type, which carries with it a small but significant morbidity and mortality. False aneurysms are well described following such procedures but with the development of inert, strong and non-absorbable materials they are becoming less common. This paper describes the acute presentation of a false aneurysm of the aorta following an aorto-iliac bypass where true aneurysmal change had taken place in the area of the anastomosis.

12 year review of testicular tumour treatment by the army medical services.

Between 1977 and 1988 144 patients with tumours of testicular origin were referred to the Queen Elizabeth Military Hospital at Woolwich. 140 of these were malignant and all but two were treated and followed. Three of the malignant lesions appeared to be extragonadal. During the 12 year period staging has become increasingly accurate and treatment protocols have improved. These changes are reflected in this series. Ten deaths from tumour occurred (6.9%) but only one of these in the last three years of the study period despite an increasing case load at the time. The clinical presentation, treatment, and results of treatment are presented and the advances of treatment and improvement of prognosis discussed.

Healing rates following venous surgery for chronic venous leg ulcers in an independent specialist vein unit.

OBJECTIVES: This is a retrospective study over 12 years reporting the healing rates of leg ulcers at a specialist vein unit. All patients presented with active chronic venous leg ulcers (clinical,aetiological, anatomical and pathological elements [CEAP]: C6) and had previously been advised elsewhere that their ulcers were amenable to conservative measures only. METHOD: Seventy-two patients (84 limbs) were treated between March 1999 and June 2011. Patients were contacted in August 2011 by questionnaire and telephone. Of 72 patients,two were deceased and two had moved location at follow-up, so were not contactable. Fifty patients replied and 18 did not (response rate 74%), representing a mean follow-uptime of 3.1 years. RESULTS: Ulcer healing occurred in 85% (44 of 52 limbs) of which 52% (27) limbs were no longer confined to compression. Clinical improvement was achieved in 98% of limbs. CONCLUSIONS: This study shows that a significant proportion of ulcers currently managed conservatively can be healed by surgical intervention.

One-year outcomes of radiofrequency ablation of incompetent perforator veins using the radiofrequency stylet device.

OBJECTIVES: Early success treating incompetent perforator veins (IPVs) with radiofrequency ablation (RFA) and the trend to move varicose vein surgery into a walk-in walk-out service led to the design of a specific device enabling RFA of IPVs using local anaesthesia (ClosureRFS stylet). Our aim was to assess one-year outcomes of a clinical series of patients undergoing treatment with this device. Truncal reflux, where present, was treated initially, and RFA of IPVs was performed as a secondary procedure. METHOD: Duplex ultrasound examinations were performed and the presence of IPVs documented. Results were compared with preoperative scans. IPVs were classified as closed, not closed/reopened or de novo. RESULTS: Of the 75 patients invited for follow-up, 53 attended at a median time of 14 months (range 11-25). Sixty-seven limbs were analysed (M:F 1:2.1, median age 62, range 25-81). Of the 124 treated IPVs, 101 were closed (82%). Clinical, aetiological, anatomical and pathological clinical score was improved in 49.3% limbs. IPV closure was reduced in patients with recurrent varicose veins compared with primary varicose veins (72.3% versus 87%, P = 0.056). CONCLUSION: These results demonstrate the radiofrequency stylet device to be an effective treatment for IPVs.