Surgical and medical management of extracranial carotid artery aneurysms.

OBJECTIVE: Extracranial carotid artery aneurysms (ECCAs) are extremely rare with limited information about management options. Our purpose was to review our institution's experience with ECCAs during 15 years and to discuss the presentation and treatment of these aneurysms. METHODS: A retrospective review of patients diagnosed with ECCAs from 1998 to 2012 was performed. Symptoms, risk factors, etiology, diagnostic methods, treatments, and outcomes were reviewed. RESULTS: During the study period, 141 aneurysms were diagnosed in 132 patients (mean age, 61 years; 69 men). There were 116 (82%) pseudoaneurysms and 25 (18%) true aneurysms; 69 (49%) aneurysms were asymptomatic, whereas 72 (52%) had symptoms (28 painless masses; 10 transient ischemic attacks; 10 vision symptoms; 9 ruptures; 8 strokes; 4 painful mass; 1 dysphagia; 1 tongue weakness; 1 bruit). Causes of true aneurysms included fibromuscular dysplasia in 15 patients, Ehlers-Danlos syndrome in three, Marfan syndrome in one, and uncharacterized connective tissue diseases in two. Of 25 true aneurysms, 11 (44%) were symptomatic; 15 (60%) true aneurysms underwent open surgical treatment, whereas 10 (40%) were managed nonoperatively. Postoperative complications included one stroke during a mean follow-up of 31 months (range, 0-166 months). No aneurysms managed nonoperatively required intervention during a mean follow-up of 77 months (range, 1-115 months). Of 116 pseudoaneurysms, 60 (52%) were symptomatic; 33 (29%) pseudoaneurysms underwent open surgery, 18 (15%) underwent endovascular intervention, and 65 (56%) were managed medically. Pseudoaneurysm after endarterectomy (28 patients; 24%) presented at a mean of 82 months from the surgical procedure. Mean follow-up for all aneurysms was 33.9 months. One (0.7%) aneurysm-related death occurred (rupture treated palliatively). No patient undergoing nonoperative management suffered death or major morbidity related to the aneurysm. Nonoperative management was more common in asymptomatic patients (71%) than in symptomatic patients (31%). CONCLUSIONS: ECCAs are uncommon and may be manifested with varying symptoms. All segments of the carotid artery are susceptible, although the internal is most commonly affected. Open surgical intervention was more common in patients with symptoms and with true aneurysms. Patients with pseudoaneurysms were more likely to undergo endovascular intervention. Nonoperative treatment is safe in selected patients.

Portomesenteric venous thrombosis following major colon and rectal surgery: incidence and risk factors.

BACKGROUND: Portomesenteric venous thrombosis (PMVT) is an uncommon complication of abdominal surgery. The objective of this study was to assess PMVT risk factor profiles and patient outcomes after colorectal surgery. METHODS: A single center retrospective review of patients undergoing colorectal surgery was performed (2007-2012). PMVT was defined as thrombus within the portal, splenic, or superior mesenteric vein on computed tomography (CT). Inferior mesenteric vein thrombosis was excluded. Independent samples t test was used to compare data variables between PMVT and non-PMVT patients. Univariate and multivariate logistic regression analyses were used to assess PMVT risk factors. RESULTS: There were 1,224 patients included (mean age 62 years, male = 566). Elective bowel resection was performed for colon carcinoma (n = 302), rectal carcinoma (n = 112), ulcerative colitis (n = 125), Crohn's disease (n = 78), polyps (n = 117), and diverticulitis (n = 215). Patients undergoing gynecological resections and emergent laparotomies were included (n = 275). Thirty-six patients (3%) were diagnosed with PMVT by CT: 17/36 on initial presentation and 19/36 by expert radiologist review. Patients with PMVT were younger (53 vs. 62 years, p = 0.001) with higher BMI (30.5 vs. 26.7, p < 0.001) and thrombocytosis (464 vs. 306, p < 0.001) compared to patients without PMVT. Univariate logistic regression identified younger age (p < 0.001), obesity (p < 0.001), ulcerative colitis (p < 0.001), thrombocytosis, (p < 0.001) and proctocolectomy as significant predictors of PMVT. Stepwise multivariate logistic regression identified that obesity (p < 0.001), thrombocytosis, (p < 0.001) and restorative proctocolectomy (p = 0.001) were still significant predictors. No patients in the PMVT group suffered bowel infarction and no related mortalities occurred. Thirty-day readmission rates were higher in the PMVT group (53% vs. 17%, p < 0.01). CONCLUSION: BMI ≥ 30 kg/m(2), thrombocytosis, and restorative proctocolectomy were significant predictors of PMVT. Initial diagnostic studies showed a PMVT rate of 1.4%; however, after expert focused radiologic review, the actual rate was 3%. Thus, the diagnosis of PMVT is difficult and readmission after colorectal surgery should prompt its consideration.

A meta-analysis to compare Dacron versus polytetrafluroethylene grafts for above-knee femoropopliteal artery bypass.

BACKGROUND: Surgical revascularization for lower limb ischemia remains an important component for optimization of quality of life and symptoms in patients with peripheral arterial disease. In the absence of a vein graft, prosthetic alternatives are considered. The objective of this meta-analysis was to establish which prosthetic graft, Dacron or polytetrafluroethylene (PTFE), has the better long-term patency in patients undergoing an above-knee femoropopliteal arterial bypass. METHODS: This meta-analysis was performed by use of Cochrane and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. An electronic search of all relevant databases was performed from 1990 to 2013 with the Medical Subject Headings "Dacron," "polytetrafluroethylene," "PTFE," "above knee," "femoropopliteal," and "bypass" combined with the Boolean operator "AND." The inclusion criteria were randomized controlled trials, use of Dacron vs PTFE prosthetic conduits, and completion of an above-knee femoropopliteal arterial bypass involving adult patients older than 18 years presenting with disabling claudication, rest pain or tissue loss, occlusion of the superficial femoral artery, and reconstitution of the above-knee popliteal artery. Whenever studies included above- and below-knee data, only the above-knee arterial bypass data were extracted and analyzed. Graft patency rates were calculated with RevMan 5.1 software provided by the Cochrane Collaboration. RESULTS: Ninety-one publications were reviewed. After exclusion of duplicate, nonrandomized, and alternative bypass surgery studies, eight randomized controlled trials were identified and included in the meta-analysis. Two of the included trials represented follow-up evaluation of two previous studies, and for the purpose of this analysis, the initial and follow-up studies were subsequently evaluated as one trial. In this meta-analysis, 1192 patients were assessed, including 601 Dacron and 591 PTFE above-knee lower limb arterial bypasses. Primary patency was calculated from all included studies. However, only four studies provided data to evaluate secondary patency. Mean age reported was 66 years. Although all studies described cardiovascular comorbidities and risk factors including myocardial ischemia, diabetes, hypertension, and smoking, exact patient numbers were not consistently provided. Included studies evaluated grafts from 5 to 8 mm. Although primary and secondary patency rates at 12 months were not significantly different (relative risk [RR], 0.78; P = .08, and RR, 0.84; P = .52), 24-, 36-, and 60-month primary patency rates were significantly better with Dacron compared with PTFE grafts (RR, 0.79; P = .003; RR, 0.80; P = .03; RR, 0.85; P = .02). Statistical analysis also supported higher secondary patency rates for Dacron at 24 months (RR, 0.75; P = .02) and 60 months (RR, 0.76-0.77; P = .03-.27). Although primary patency was similar between grafts (28% vs 28%; P = .12), secondary patencies were better with Dacron at 10 years (49% vs 35%; P = .01). Antiplatelet and anticoagulation protocols varied between the trials. There was no difference in amputation, overall morbidity, or mortality rates between the two surgical graft populations. CONCLUSIONS: Current evidence suggests that Dacron prosthetic grafts are superior to PTFE grafts in above-knee femoropopliteal arterial bypass procedures. Further randomized trials targeting standardization of confounding variables, particularly graft size and best medical therapy, are warranted.

Brachiocephalic vein bypass with sternal reconstruction for symptomatic occlusion.

Complications attributed to central venous stenosis and subsequent thrombosis are increasing in frequency and are most commonly associated with neointimal fibroplasia as well as neoplastic, fibrotic, and traumatic pathologies. We present the successful venous bypass and thoracic wall reconstruction of a 58-year-old female with chronic atypical symptoms secondary to brachiocephalic vein occlusion from congenital thoracic dystrophy.

In the time of significant generational diversity - surgical leadership must step up!

The diverse attitudes and motivations of surgeons and surgical trainees within different age groups present an important challenge for surgical leaders and educators. These challenges to surgical leadership are not unique, and other industries have likewise needed to grapple with how best to manage these various age groups. The authors will herein explore management and leadership for surgeons in a time of age diversity, define generational variations within "Baby-Boomer", "Generation X" and "Generation Y" populations, and identify work ethos concepts amongst these three groups. The surgical community must understand and embrace these concepts in order to continue to attract a stellar pool of applicants from medical school. By not accepting the changing attitudes and motivations of young trainees and medical students, we may disenfranchise a high percentage of potential future surgeons. Surgical training programs will fill, but will they contain the highest quality trainees?

Randomized controlled trial assessing the effect of simvastatin in primary biliary cirrhosis.

BACKGROUND: This study evaluated the effect of statins in Primary biliary cirrhosis (PBC) on endothelial function, anti-oxidant status and vascular compliance. METHODS: Primary biliary cirrhosis patients with hypercholesterolaemia were randomized to receive 20 mg simvastatin or placebo in a single blind, randomized controlled trial. Body mass index, blood pressure, glucose, liver function, lipid profile, immunoglobulin levels, serological markers of endothelial function and anti-oxidant status were measured as well as vascular compliance, calculated from pulse wave analysis and velocity, at recruitment and again at 3, 6, 9 and 12 months. RESULTS: Twenty-one PBC patients (F = 20, mean age = 55) were randomized to simvastatin 20 mg (n = 11) or matched placebo (n = 10). At completion of the trial, serum cholesterol levels in the simvastatin group were significantly lower compared with the placebo group (4.91 mmol/L vs. 6.15 mmol/L, P = 0.01). Low-density lipoprotein (LDL) levels after 12 months were also significantly lower in the simvastatin group (2.33 mmol/L vs. 3.53 mmol/L, P = 0.01). After 12 months of treatment, lipid hydroperoxides were lower (0.49 µmol/L vs. 0.59 µmol/L, P = 0.10) while vitamin C levels were higher (80.54 µmol/L vs. 77.40 µmol/L, P = 0.95) in the simvastatin group. Pulse wave velocity remained similar between treatment groups at 12 months (8.45 m/s vs. 8.80 m/s, P = 0.66). Only one patient discontinued medication owing to side effects. No deterioration in liver transaminases was noted in the simvastatin group. CONCLUSIONS: Statin therapy in patients with PBC appears safe and effective towards overall reductions in total cholesterol and LDL levels. Our initial study suggests that simvastatin may also confer advantageous effects on endothelial function and antioxidant status.

Successful endovascular treatment of multiple mesenteric arterial aneurysms associated with alpha-1-antitrypsin deficiency.

We present a rare case of a patient who presented with acute abdominal pain with a previous history of alpha-1-antitrypsin deficiency (alpha1-antitrypsin deficiency). Further clinical deterioration necessitated computed tomography (CT) imaging, which demonstrated a hemoperitoneum. Angiography confirmed the rupture of multiple aneurysms originating from the mesenteric arterial arcade, which were treated successfully with endovascular embolization. The association between mesenteric arterial aneurysm rupture and alpha-1-antitrypsin deficiency is explored.

Common polymorphisms of Fibulin-5 and the risk of abdominal aortic aneurysm development.

Fibulin-5 is a crucial protein in the connective tissue structure of the aortic wall. The purpose of this study was to determine if genetic variation within the Fibulin-5 gene was associated with abdominal aortic aneurysms (AAA). AAA patients, with disease-free controls, were recruited and a past medical history questionnaire completed. Three single nucleotide polymorphisms (SNPs) in the FBLN5 gene (rs2498834, rs2430366 and rs2254320) were genotyped. The two cohorts were compared and haplotype analysis performed. A total of 230 AAA cases and 278 controls were successfully genotyped. The mean age was 71.9 years (+/- 6.8). No difference between cases and controls was found in the distribution of alleles of FBLN5 SNPs rs2498834 (p = 0.47), rs2430366 (p = 0.45) or rs2254320 (p = 0.46). Haplotype analysis did not reveal any significant difference. In conclusion, genetic variation within FBLN5 is unlikely to play any role in the development of AAA.

Single-centre experience of radiation exposure in acute surgical patients: assessment of therapeutic impact and future recommendations.

BACKGROUND: Radiological investigations have become a key adjunct in patient management and consequently radiation exposure to patients is increasing. The study objectives were to examine the use of radiological investigations in the management of acute surgical patients and to assess whether a guideline-based radiation exposure risk/benefit analysis can aid in the choice of radiological investigation used. METHODS: A prospective observational study was completed over a 12-week period from April to July 2008 for all acute surgical admissions. Data recorded included demographics, clinical presentation, differential diagnosis, investigations, surgical interventions, and final clinical outcome. The use of radiological investigative modalities as an adjunct to clinical assessment was then evaluated against The Royal College of Radiologists (RCR) guidelines. RESULTS: A total of 380 acute surgical admissions (M = 174, F = 185, children = 21) were assessed during the study period. Seven hundred thirty-four radiological investigations were performed with a mean of 1.93 investigations per patient. Based on the RCR guidelines, 680 (92.6%) radiological investigations were warranted and included 142 CT scans (19.3%), 129 chest X-rays (17.6%), and 85 abdominal X-rays (11.6%). Clinically, radiological imaging complemented surgical management in 326 patients (85.8%) and the management plan remained unchanged for the remaining 54 patients (14.2%). This accounted for an average radiation dose of 4.18 millisievert (mSv) per patient or 626 days of background radiation exposure. CT imaging was responsible for the majority of the radiation exposure, with a total of 1310 mSv (82.6%) of the total radiation exposure being attributed to CT imaging in 20.8% of acute admissions. Subgroup analysis demonstrated that 92.8% of the CT scans performed were appropriate. CONCLUSION: Radiation exposure was generally low for the majority of acute surgical admissions. However, it is recommended that CT imaging requests be evaluated carefully, particularly for patients with clinically confirmed pathologies and in younger women.

C-reactive protein (CRP) elevation in patients with abdominal aortic aneurysm is independent of the most important CRP genetic polymorphism.

OBJECTIVE: C-reactive protein (CRP) is a marker of cardiovascular disease. The objective was to determine if abdominal aortic aneurysm (AAA) and CRP serum concentration and its CRP gene are associated. METHODS AND RESULTS: AAA patients and AAA negative controls were recruited. CRP concentration was measured and the single nucleotide polymorphism (SNP), rs3091244, assessed. AAA cases were divided into those measuring 30-55 mm and >55 mm in diameter, to assess correlation of CRP with AAA size. A total of 248 (227 male) cases and 400 (388 male) controls were included. CRP concentration was higher in cases (385.0 microl/dL [310.4-442.8] vs 180.3 microl/dL [168.1-196.9]; P < .0001). It was higher in large aneurysms (685.7 microl/dL [511.8-1083.0] vs 291.0 microl/dL [223.6-349.6]; P < .0001), with significant correlation observed to size (r = 0.37, P < .0001). CC was the most common SNP genotype with no difference in distribution (P = .43) between cases and controls. No difference existed in CRP for each genotype in the overall cohort (P = .17), cases (P = .18) and controls (P = .19). CONCLUSION: The results demonstrate that CRP production may be related to the presence of AAA, especially in advanced disease. The serum concentration of CRP does not appear to be influenced by the functional SNP of the CRP gene, which also appears to have no association with AAA formation.

The vascular and biochemical effects of cilostazol in patients with peripheral arterial disease.

OBJECTIVES: Cilostazol improves walking distance and quality of life in patients with peripheral arterial disease (PAD). This study assessed the vascular and biochemical effects of cilostazol therapy in PAD patients. METHODS: PAD patients were prospectively recruited to a randomized, double-blinded, placebo-controlled trial. Baseline clinical data were recorded. Clinical assessment included measurement of arterial compliance, transcutaneous oxygenation, ankle-brachial index (ABI), and treadmill walking distance. Blood analyses included a full blood panel, coagulation screen, urea and electrolytes, liver function tests, estimated glomerular filtration rate, and lipid profiles. Quality of life indices were recorded using validated generic and walking-specific questionnaires. All tests were performed at baseline, 6, and 24 weeks. RESULTS: Eighty patients (53 men) were recruited from December 2004 to January 2006. The cilostazol group had a significant reduction in the augmentation index compared with the placebo group at 6 weeks (19.7% vs 26.7%, P = .001) and at 24 weeks (19.7% vs 27.7%, P = .005). A paradoxic reduction in transcutaneous oxygenation levels was identified in the cilostazol group for the left foot at 6 weeks and for the right foot at both 6 and 24 weeks. The ABIs were not significantly different between treatment groups at baseline, 6 weeks, or 24 weeks for the left and right lower limbs. The mean percentage change in walking distance from baseline improved more markedly in the cilostazol compared with the placebo group for absolute claudication distance at 6 (78.6% vs 26.4%, P = .20) and 24 weeks (173.1% vs 92.1%, P = .27); however, these failed to reach significance. Significant improvements in lipid profiles were demonstrated with cilostazol therapy at 6 weeks (triglycerides, high-density lipoprotein [HDL]) and at 24 weeks (cholesterol, triglycerides, HDL, and low-density lipoprotein). The cilostazol treatment group demonstrated significant improvements in the Short Form-36 (physical functioning, physical component score), Walking Impairment (distance and speed), and Vascular Quality of Life (pain) indices at 6 and 24 weeks. Although cilostazol was associated with side effects in approximately one-third of patients, most settled within 6 weeks, facilitating the continuation of therapy in >89%. CONCLUSION: Cilostazol is a well-tolerated, safe, and efficacious treatment for PAD patients. It not only improves patients' symptomatology and quality of life but also appears to have beneficial effects on arterial compliance, possibly through its lipid-lowering property.

The effects of abdominal compartment hypertension after open and endovascular repair of a ruptured abdominal aortic aneurysm.

OBJECTIVE: This study assessed if emergency endovascular repair (eEVR) reduces the increase in intra-abdominal compartment pressure and host inflammatory response in patients with ruptured abdominal aortic aneurysm (AAA). METHODS: Thirty patients with ruptured AAA were prospectively recruited. Patients were offered eEVR or emergency conventional open repair (eOR) depending on anatomic suitability. Intra-abdominal pressure was measured postoperatively, at 2 and 6 hours, and then daily for 5 days. Organ dysfunction was assessed preoperatively by calculating the Hardman score. Multiple organ dysfunction syndrome, systemic inflammatory response syndrome, and lung injury scores were calculated regularly postoperatively. Hematologic analyses included serum urea and electrolytes, liver function indices, and C-reactive protein. Urine was analyzed for the albumin-creatinine ratio. RESULTS: Fourteen patients (12 men; mean age, 72.2 +/- 6.2 years) underwent eEVR, and 16 (14 men; mean age, 71.4 +/- 7.0 years) had eOR. Intra-abdominal pressure was significantly higher in the eOR cohort compared with the eEVR group. The eEVR patients had significantly less blood loss (P < .001) and transfused (P < .001) and total intraoperative intravenous fluid infusion (P = .001). The eOR group demonstrated a greater risk of organ dysfunction, with a higher systemic inflammatory response syndrome score at day 5 (P = .005) and higher lung injury scores at days 1 and 3 (P = .02 and P = .02) compared with eEVR. A significant correlation was observed between intra-abdominal pressure and the volume of blood lost and transfused, amount of fluid given, systemic inflammatory response syndrome score, multiple organ dysfunction score, lung injury score, and the length of stay in the intensive care unit and hospital. CONCLUSION: These results suggest that eEVR of ruptured AAA is less stressful and is associated with less intra-abdominal hypertension and host inflammatory response compared with eOR.

The vascular and biochemical effects of cilostazol in diabetic patients with peripheral arterial disease.

OBJECTIVES: Cilostazol improves walking in patients with peripheral arterial disease (PAD). We hypothesized that cilostazol reduces diabetic complications in PAD patients. METHODS: Diabetic PAD patients were prospectively recruited to a randomized double-blinded, placebo-controlled trial, using cilostazol 100mg twice a day. Clinical assessment included ankle-brachial index, arterial compliance, peripheral transcutaneous oxygenation, treadmill walking distance and validated quality of life (QoL) questionnaires. Biochemical analyses included glucose and lipid profiles. All tests were at baseline, 6, and 24 weeks. RESULTS: 26 diabetic PAD patients (20 men) were recruited. Cilostazol improved absolute walking distance at 6 and 24 weeks (86.4% vs. 14.1%, P = .049; 143% vs. 23.2%, P = .086). Arterial compliance and lipid profiles improved as did some QoL indices for cilostazol at 6 and 24 weeks. Blood indices were similar at baseline and at follow-up points for both treatment groups. CONCLUSIONS: Cilostazol is a well-tolerated and efficacious treatment, which improves claudication distances in diabetic PAD patients with further benefits in arterial compliance, lipid profiles, and QoL.

Bilateral popliteal artery occlusion in a competitive bike rider: case report and clinical review.

Since its first description in 1879, popliteal artery entrapment syndrome remains a debilitating condition, which frequently affects young active people. Increased awareness of popliteal artery entrapment syndrome combined with improvements in investigative modalities has resulted in a more frequent diagnosis of this eminently treatable condition. In this article, a rare case of bilateral popliteal artery entrapment syndrome in a physically active 33-year-old man precipitated by competitive Bicycle Moto-Cross riding is presented. A higher index of suspicion for popliteal artery entrapment syndrome is recommended as the underlying pathology in a young active person with symptoms of lower limb claudication. Popliteal artery entrapment syndrome should be investigated with thorough radiological assessment prior to any therapeutic intervention, which is often fraught with difficulty due to chronically diseased vasculature and inherent anatomical anomalies.

Effect of preoperative renal dysfunction on mortality and postoperative renal failure following endovascular abdominal aortic aneurysm repair.

This study was aimed to assess the effect of preoperative renal dysfunction on mortality and postoperative renal failure in patients undergoing elective endovascular repair of abdominal aortic aneurysm. A total of 155 patients with a mean age of 74.9 years (+/-6.4) were included. In all, 31 patients (20%) had a preoperative creatinine level of >1.5 mg/dL, whereas 66 patients (42.6%) had an estimated glomerular filtration rate of <60 mL/min. Perioperative mortality was 2.6% with no significant difference between those with and without abnormal renal indices. Long-term survival at 4 years was 30% in patients with creatinine >1.5 mg/dL compared to over 60% in those with normal creatinine (P < .02). The difference in long-term survival was not as significant in patients with normal or reduced glomerular filtration rate (P = .13). However, neither creatinine nor glomerular filtration rate were found to accurately predict survival even though both demonstrated strong predictivity for postoperative renal failure in patients undergoing elective endovascular repair of abdominal aortic aneurysm.

Successful treatment of perineal necrotising fasciitis and associated pubic bone osteomyelitis with the vacuum assisted closure system.

BACKGROUND: Acute necrotising fasciitis is a life-threatening condition, which requires urgent surgical intervention. Surgical debridement is invariably associated with large areas of tissue loss. CASE PRESENTATION: We present a 58-year old woman with a past history of cervical carcinoma who presented with necrotising fasciitis of the perineum and upper thighs with associated pubic bone osteomyelitis. Following extensive debridement, a Vacuum Assisted Closure (VAC) system was applied to the large residual defect to facilitate skin graft application and optimise wound healing. CONCLUSION: This case demonstrates the successful management of a complex and potentially lethal wound of the perineum with debridement, skin grafting and the VAC system.

Small cell carcinoma of the appendix.

BACKGROUND: An extrapulmonary small cell carcinoma is a rare condition. It has similar histological features to pulmonary small cell carcinoma and is equally aggressive. CASE PRESENTATION: We present the case of a 60-year-old woman who presented with right upper quadrant pain. Computerised tomography revealed an appendiceal lesion and multiple liver metastases. Exploratory laparotomy and right hemicolectomy was performed with histopathological analysis confirming a primary small cell carcinoma of her appendix. CONCLUSION: This is the first reported case of a pure extrapulmonary carcinoma arising from the appendix.

Open carpal tunnel release--still a safe and effective operation.

BACKGROUND: Carpal tunnel syndrome is a common cause of neurological symptomatology. Surgical decompression remains the treatment of choice in patients not responding to conservative therapies. The aim of this study was to assess the effectiveness of standard open decompression by analysis of symptomatic and functional improvement and to assess whether a general surgeon can still perform this operation safely. PATIENTS AND METHODS: Patients undergoing standard open carpal tunnel release by a single general surgeon were recruited. A self-administered Boston questionnaire was used to assess symptom severity and functional status pre- and post-surgical intervention. RESULTS: Forty-seven patients (51 hands) underwent carpal tunnel release and 32 patients completed the questionnaire. 88% had a significant reduction in the symptom severity score, while improvement in function status score was achieved in 79% of patients. Mean symptom severity score improved from 3.41 points preoperatively to 1.85 (p < 0.0001) points at the last follow up examination, while the mean function status score improved from 2.73 to 1.99 points (p < 0.0001). Outcome was poor in six patients with slight worsening of either symptom or function status score. Three patients were treated conservatively for minor wound infection without long-term sequelae. DISCUSSION: Standard open carpal tunnel release still provides efficacious symptomatic relief with a low risk of associated complications when performed by a general surgeon.

Foreign body ingestion in prisoners - the Belfast experience.

Deliberate ingestion of foreign bodies is common amongst prison inmates. The motives behind the ingestion are variable. As the only designated hospital in Northern Ireland treating acute surgical pathologies in the prison population, we reviewed our experience of foreign body ingestion between March 1998 and June 2007. Types of foreign objects, symptomatology, haematological analyses, radiological findings, operative intervention and complications were retrieved from case notes. A literature search was performed using Medline to correlate this clinical data with published evidence to produce therapeutic guidelines to assist the surgical multi-disciplinary team. Eleven prisoners presented with foreign body ingestion over the study period (M=8 and F=3, mean age: 28.1 years, range 21-48). Mean follow-up was 597 days (range 335-3325 days). Although the literature states that most foreign bodies usually pass spontaneously without the need for intervention, this study demonstrates a higher intervention rate of 36% within the Northern Irish prison population in comparison with other prisoners.

Benefits of a supervised exercise program after lower limb bypass surgery.

This study evaluated the efficacy of an exercise program after arterial bypass surgery. Patients undergoing bypass surgery were randomized to a control group (group I), with standard preoperative and postoperative care, or the intervention group (group II) with a supervised exercise program of twice-weekly treadmill assessments from 4 to 10 weeks postoperatively. Ankle-brachial pressure indices and hemodynamic measurements were recorded before and after exercise. The mean increase of maximum walking distance was 3.8% in group I and 175.4% in group II (P = .001). There was a significant difference between group I and II in the mean ankle-brachial pressure indices increase at the second assessment (0.08 versus 0.23; P = .02). A supervised exercise program leads to better improvement after lower limb bypass surgery for ischemia, but the feasibility of a formal exercise program would be undermined by the reluctance of patients to participate, both in the short-term and long-term.