Skeletal muscle adaptation in response to supervised exercise training for intermittent claudication.

OBJECTIVES: There is evidence that the improvement following supervised exercise for claudication results from skeletal muscle adaptation. The myosin heavy chain (MHC) determines muscle fibre type and therefore efficiency. Immunohistochemical analysis has failed to take account of hybrid MHC expression within myofibres. This study sought evidence of differential MHC protein expression following supervised exercise for claudication. DESIGN: 38 claudicants were recruited. Subjects undertook a three-month supervised exercise programme. Controls were patients awaiting angioplasty for claudication. MATERIALS AND METHODS: Subjects underwent paired gastrocnemius biopsy. Relative expression of MHC proteins was determined by SDS-PAGE electrophoresis. Non-parametric data is presented as median with the inter-quartile range and parametric as the mean ± standard deviation. RESULTS: Upon completion of the exercise programme there was a 94% increase (124 (106-145) to 241 (193-265) metres, p = 0.002) in maximum walking distance, which was not evident in the control group. An 11.1% (p = 0.02) increase in MHC I expression was observed in the exercise but not the control group (34.3% ± 6.8 to 45.4% ± 4.4). There was a positive correlation between the change in MHC I expression and the improvement in claudication distance (r = 0.69, p < 0.05). CONCLUSIONS: Supervised exercise training for claudication results in an increase in the proportion of MHC type I expression within the symptomatic gastrocnemius muscle.

Remodelling of vascular (surgical) services in the UK.

The last few years have seen major changes in the delivery of vascular services in the UK. An increasingly elderly population with greater expectations from their medical services has challenged established methods. It also became apparent that outcomes for low volume, high risk index vascular interventions such as abdominal aortic aneurysm repair were poor in the UK compared to the rest of Europe. Other ongoing challenges were the introduction of a national aortic aneurysm screening programme and the development of vascular surgery as a separate speciality. This article details the approach taken to modernise vascular services in the UK, using a quality framework agreed by vascular specialists, which drove the structural change to move vascular interventions into fewer, higher volume centres. The introduction of modern networks is designed to maintain services in surrounding hospitals without on site vascular inpatient services. The initial effects of this service remodelling are positive, with elective aortic aneurysm mortality rates falling nationally from 7.5 to 2.4 per cent.

Exercise training for claudication.

Exercise advice is a well established component of the conservative management of intermittent claudication. Supervised programmes of exercise remain relatively uncommon and are provided mainly in secondary care. This review outlines the evidence for the effectiveness of different exercise regimens and the relative benefits of exercise therapy, where comparisons have been made with medical therapy, angioplasty and surgery.

The impact of shortened training times on the discipline of vascular surgery in the United Kingdom.

Political initiatives and European health and safety working time regulations have combined to reduce the time available for surgical training in the United Kingdom in the future by a third. For the safety of patient care, surgeons must evolve strategies to cope with these reduced training times so that they preserve the current high level of competence exhibited by UK trainees when they attain the right to independent surgical practice recognized by appointment as a Consultant Surgeon. Such strategies include a focus on dedicated training time, the use of simulators, and a move towards progression based on satisfactory completion of a defined curriculum and competency assessment rather than the amount of time served. With insufficient time to train in every aspect of general surgery, a move towards fragmentation into its sub-specialty components seems unavoidable. Such a move offers an opportunity to re-evaluate conventional surgical training and to consider the evolution of a system-specific vascular specialist with patient-focused expertise in vascular surgery, endovascular radiology, and vascular medicine.

Effects of major and minor surgery on plasma glutamine and cytokine levels.

The plasma levels of glutamine and cytokines have been measured frequently in patients before, during, and after elective abdominal aortic aneurysm surgery ("major surgery") or inguinal hernia repair ("minor surgery"). The plasma glutamine level declined rapidly following major surgery and remained markedly below preoperative levels until at least 7 days after surgery. This response of the plasma glutamine levels was significantly correlated with the production of interleukin 6 but not with that of interleukin 1, tumor necrosis factor, or interferon gamma. In contrast, following minor surgery, the plasma glutamine level was unchanged and the elaboration of interleukin 6 was attenuated. The decrease in the plasma glutamine level following major surgery may contribute to the state of immunosuppression, which follows major surgery, and the relationship between amino acid and cytokine metabolism is worthy of further study.

Portal endotoxin and cytokine responses during abdominal aortic surgery.

Interleukin-6 (IL-6) is a major marker of tissue injury. Surgery induces a systemic IL-6 response related to the magnitude of the operation. An exaggerated IL-6 response is associated with the development of major complications after aortic aneurysm repair. Endotoxemia is a potent stimulus for cytokine release and may occur during aortic surgery. This study attempted to examine whether the observed IL-6 response during abdominal aortic surgery is related to the development of portal endotoxemia. Serial samples of inferior mesenteric and systemic venous blood were obtained before, during, and after aortic cross-clamping in eight patients undergoing elective aortic aneurysm surgery. Portal endotoxemia was detected in only five of the eight patients during the surgery, and there was no correlation with the IL-6 response. Both portal and systemic IL-6 levels rose during the course of surgery, but, by the time of abdominal wound closure, the mean portal IL-6 levels were eight times higher than the systemic IL-6 levels. These results suggest that the portal circulation draining the colon is a major source of the previously observed systemic IL-6 response to aortic surgery. The IL-6 response is not clearly related to portal endotoxemia but may reflect occult cellular injury in the colon occurring during surgery.

Combined topical and systemic antibiotic prophylaxis in experimental wound infection.

The effectiveness of a combined topical and systemic antibiotic regimen was studied in an animal model previously shown to simulate clinical surgical wound infection. At a high level of bacterial contamination, the combination regimen produced a lower infection rate than either a placebo (p less than 0.01), a topical antibiotic administered alone (p less than 0.01), or a systemic antibiotic administered alone. At a lower level of bacterial contamination, no additional reduction in infection rates was produced by the combination regimen when compared with systemic antibiotic administered alone. These experimental results suggest that when wound contamination is great, a combination of topical and systemic antibiotics is the more effective regimen. Where wound contamination is less severe, systemic antibiotic prophylaxis is all that is required; no further benefit is obtained by the additional administration of topical antibiotics. Clinical trials appear justified to confirm or refute this hypothesis.

Characterization of neutrophil iodination for the assessment of phagocytic and opsonic function in septic patients.

To increase our understanding of the nature of surgical infection, further studies on the host defense abilities of infected patients are required. Therefore, a more thorough investigation of the iodination method for the measurement of polymorphonuclear leukocyte function and serum opsonic activity was undertaken to characterize its application in surgical infection. A significant relationship was found between the phagocytic indices derived from different standard neutrophils or sera measured on the same day. When expressed as a value of normal phagocytic indices minus abnormal phagocytic indices, this relationship was constant from day to day despite wide variations in the absolute phagocytic index values. This finding enables direct comparisons to be made between the values obtained both from the same patient and from different patients during the course of their illness by reference to daily control values. We also found that the system was sufficiently sensitive to detect, in a dose-responsive manner, the changes induced in normal neutrophil phagocytosis and serum opsonic activity by a specific bacterial challenge with either K. pneumoniae or E. coli. In addition, zymosan, which is utilized in the iodination reaction but also has immunoadjuvant properties, was found to enhance neutrophil function but depress serum opsonic activity in the face of such bacterial challenges. We conclude that the iodination technique is a credible method for the indirect measurement of polymorphonuclear phagocytosis and serum opsonic function in the face of a bacterial challenge and can be reliably employed in studies of septic patients provided these findings are taken into account.

Isolated tibial vessel disease: treatment options and outcome.

Tibial vessel disease is an important cause of limb ischaemia, particularly in diabetics. Revascularisation by angioplasty and bypass is increasingly feasible. The aim of this study was to review treatment and outcome in patients with this patterns of disease. We have performed 25 procedures in 20 patients since September, 1989. Six patients (5 diabetic) underwent 9 tibial angioplasties for stenotic lesions causing critical ischaemia or short-distance claudication. In 6 procedures there was single vessel run-off. Eight angioplasties were radiologically successful with a median increase in ankle-brachial index (ABI) of 0.15 [range: 0.00-0.44] at a median follow-up of 9 months. A further 4 patients (3 diabetic) with critical ischaemia underwent popliteal-distal, in-situ vein bypass for tibial occlusions. Distal anastomosis was onto the dorsalis pedis artery or distal anterior artery. Three grafts remain patent with successful limb salvage and ABI's greater than 1.0. Angioplasty is also useful for distal disease progression following femoro-popliteal bypass. Six patients with "at-risk" grafts underwent 8 tibial angioplasties for stenotic lesions in distal run-off. Radiologically, 6 procedures were successful with a median increase in ABI of 0.21 [range: 0.00-0.38] at a median follow-up of 7 months. There were less favourable results when a "graft-distal" bypass performed to salvage an occluded femoro-popliteal graft with diseased run-off vessels. Three of 4 grafts reoccluded within 3 months, 2 patients requiring amputation. We advocate an aggressive policy towards localised distal disease causing foot ischaemia.

Lindau's disease and familial hyperparathyroidism.

A case of medullary hemangioblastoma is described occurring in association with familial hyperparathyroidism. The possibility that this combination may represent a previously unreported variant of Lindau's disease is discussed.

Femoral pulse palpation before and after exercise: a guide to occult iliac stenosis?

Iliac artery stenosis may produce significant haemodynamic impairment in the absence of any visible iliac narrowing on uniplanar arteriography. Such stenoses may be unmasked by the use of biplanar angiography or by direct femoral pressure measurements before and after papaverine. The aim of this study is to determine whether simple femoral pulse palpation is a reliable guide to haemodynamic impairment in the radiologically normal aorto-iliac segment, and in particular whether occult iliac stenosis can be unmasked by noting a reduction in the palpable pulse after exercise. Twenty-nine limbs with normal aorto-iliac segments on uniplanar angiography were examined at rest and after exercise and the femoral pulses were graded clinically. Haemodynamic assessment was performed by direct femoral pressure measurements before and after intra-arterial papaverine injection. Significant haemodynamic impairment was noted in 8 out of 29 limbs. Six of these 8 limbs had normal resting femoral pulses and 4 of the 8 limbs had a diminished pulse after exercise. Four out of the 21 limbs with normal haemodynamic studies had diminished pulses after exercise. Resting femoral pulse palpation is a poor guide to radiologically occult but haemodynamically significant iliac stenosis although pulse palpation after exercise may help to unmask a proportion of such stenoses.

Intestinal ischaemia in the unconscious intensive care unit patient.

This paper highlights the difficulties of diagnosing intestinal ischaemia in unconscious patients on an intensive care unit. We have analysed the clinical details and investigations of eight such patients in whom a preoperative diagnosis of intestinal ischaemia was made on clinical grounds. Intestinal ischaemia was confirmed at laparotomy in only four cases (50%). These patients showed no significant differences in any of the commonly accepted parameters of intestinal ischaemia from the four patients who had a negative laparotomy. In particular, all patients exhibited a metabolic acidosis with fever and a leucocytosis. There was a mean delay of 13.6 h between surgical opinion and laparotomy in the four patients with ischaemia, only one of whom was salvaged. There was no morbidity associated with the laparotomy in this small series. It is suggested that, in the intensive care setting, early laparotomy should be performed immediately the clinical suspicion of intestinal ischaemia arises.

Drainage or suture of the cavity after breast biopsy.

An initial series of 105 women who underwent excision biopsy of the breast were entered into a controlled randomised trial to determine the effect on postoperative morbidity of drainage of the cavity with a soft rubber Penrose drain. The use of this drain had no effect on the incidence of postoperative wound complications (drain 11 of 40 (28%), no drain 10 of 58 (17%]. A second series of 202 women were entered into a randomised controlled trial to determine the effect of closed suction drainage and suture of the cavity after breast biopsy. The use of this drain significantly reduced the incidence of postoperative wound complications (drain 9 of 93 (10%), no drain 22 of 105 (21%], but although suture of the cavity halved the number of wound complications (suture 11 of 97 (11%), no suture 20 of 101 (20%], this did not reach statistical significance. Wound complications were more frequent with large wounds (28%) than with smaller ones (15%), and with less experienced operators (registrar 21%, senior registrar/consultant 10%). We conclude that a closed suction drain will reduce the incidence of wound haematomas after breast biopsy but that a Penrose drain is ineffective in the prevention of wound complications.

Lower limb ischaemia in the octogenarian: is limb salvage surgery worthwhile?

Vascular surgeons are being asked to manage vascular disease in an increasingly elderly population, and advanced age may be considered a relative contraindication to limb salvage surgery with an amputation seeming the preferred option. We present a review of 50 patients over the age of 80 years, presenting with ischaemic rest pain, ulceration or gangrene of the lower extremity. Six patients were treated conservatively, four of whom died during the same admission. Only two patients proved suitable for transluminal angioplasty as the sole curative procedure. Twelve patients (24%) underwent primary amputation with a perioperative mortality of 3/12 (25%). Five patients (10%) had an iliac bypass procedure, and 25 patients (50%) were considered suitable for infrainguinal bypass. Of the latter group 14 had femoropopliteal bypasses, and 11 had femorodistal bypasses with an overall perioperative mortality of 3/25 (12%). Mortality at 6 months was high (33%) and was similar in both the grafted and amputation groups. Patients having reconstruction fared well in terms of independent mobility, use of long-term care, and length of hospital stay. Patients over 80 years of age with critical ischaemia should not be denied the opportunity of vascular reconstruction.

Preliminary experience of angioscopy in femorodistal bypass.

During femorodistal bypass angioscopy can be used in vein graft preparation allowing valve lysis and the identification of tributaries under direct vision. A total of 30 patients have undergone angioscopic assisted femorodistal bypass using either an Olympus or Stortz system. Nineteen patients have undergone full vein mobilisation and valve lysis under direct vision. Eleven patients had in situ bypass with ligation of tributaries, identified by the angioscope, through small stab incisions. No evidence of fistula or retained valve cusps was found by subsequent duplex scanning and arteriography. One of these grafts failed at 6 days due to an unrecognised outflow stenosis. The mean hospital stay after operation for this latter group of patients was 5.2 days (range 4.4-6.0 days) compared with 9.5 days (8.6-10.3 days) in a historical group of 30 patients (P < 0.001). Angioscopy is a useful aid in the performance of femorodistal bypass. Early experience suggests that hospital stay may be reduced by angioscope assisted in situ femorodistal bypass because of the minimal dissection involved.

Vascular surgical intervention for complications of cardiovascular radiology: 13 years' experience in a single centre.

This study investigates incidence and outcome of iatrogenic vascular complications needing surgery in a single vascular unit serving interventional vascular radiology and interventional cardiology. Evolution of diagnostic and interventional cardiovascular radiology, along with the introduction of non-surgical therapies for such complications, may have influenced the number of vascular complications requiring emergency surgery. Vascular surgical data were collected from information prospectively entered on computerised database and case note review. Radiology data were collated from prospective entries in logbooks and computerised database. In all 24,033 cardiovascular radiological procedures were performed between 1984 and 1996 (61% cardiac), numbers increasing annually. During this period, 62 patients (40 peripheral; 22 cardiac) required emergency surgical intervention after radiological procedures. Mean age was 61.9 years (range 1-92 years), male to female ratio was 1:1. The absolute number of cases requiring surgical intervention peaked in 1989, subsequently reducing annually. Sites of vascular injury included common femoral artery (40), brachial artery (6), iliac artery (6), popliteal artery (5), other (5). A total of 87 vascular surgical operations was performed (range 1-6 operations per patient). Interventions included thrombectomy/embolectomy (29), bypass grafting (16), direct repair (27). Seven major amputations were performed (two bilateral). Mortality after surgery was 9.7%. Mean inpatient hospital stay was 11.3 days (range 0-75 days). A Poisson regression model indicates a 5% reduction in risk for each successive year of observation; however, this did not reach statistical significance (P = 0.16, 95% CI 12% decreased risk to 2% increased risk). The risk of surgical intervention after diagnostic or interventional cardiovascular radiology is diminishing but still requires vigilance. Necessity for surgical intervention is associated with a high risk of morbidity and mortality.

Computerised audit of carotid endarterectomy: audit loopholes closed?

The number of carotid endarterectomies being performed in the UK is increasing. The role of carotid endarterectomy (CEA) in the prevention of stroke depends on the procedure being associated with as few operative strokes as possible. Good clinical practice, with minimum morbidity, depends upon the integration of recent advances. Continuing audit has been used to examine changes in surgical practice and in case mix. There was a combined death and permanent stroke rate of 3.6% after 333 CEAs in a 6-year period (1990-1995) compared with 4.4% in 203 CEAs in an earlier 5-year audit period (1985-1989). The impact of an increase in the number of operations performed after recovered strokes, those performed by trainees and the use of prosthetic patches on the results of CEA has been assessed. Specific areas to be targeted in future audits are identified.

Is a drain necessary after colonic anastomosis?

To date, there have been no clinical investigations of the usefulness of drains following colonic anastomosis in elective operations. We report a prospective study in which 49 patients were randomized to have a corrugated silastic drain (Portex) placed next to the colonic anastomosis. These patients were compared with a control group of 57 patients who had no drain. The two groups were similar in age, sex, diagnosis and site of anastomosis. There was no difference in outcome between the two groups. Anastomotic leakage occurred in six patients in each group. Wound infections were noted in 10 patients in each group. Two patients with a drain and one patient without a drain died from leakage at the anastomosis. This study provides no evidence to support the use of a corrugated drain after anastomosis of the colon.