Reduction in varicose vein services: impact on operative training.

INTRODUCTION: This study examines the impact of rationing varicose vein operations on operative training on a general surgical unit with a vascular interest. PATIENTS AND METHODS: Log-books of middle-grade surgeons were analysed for 3-month periods before and after a decision by the local Primary Care Trust to ration varicose vein referrals. Number, intermediate equivalents and type of operations were recorded, whether they were general or vascular cases and whether the trainee had carried out or assisted with the operation. RESULTS: There was a slight fall in the total number of operations in which the middle-grade surgeons were involved (208 to 186). There was a significant increase in general surgical cases with the fall in number of varicose vein operations (P < 0.0001). The fall in case-load and work-load operative training in vascular surgery was compensated by an increase in general surgical cases (P = 0.0003). This was largely due to increased number of hernia repairs (P = 0.0035). CONCLUSIONS: From the point of operative training, a vascular unit in a district general hospital would not be sustainable following withdrawal of varicose vein services. However, this can be off-set by increasing general surgical case-load to fill the gap created.

Is a palpable short saphenous vein a useful clinical sign in varicose vein assessment?

The short saphenous vein (SSV) may be palpable in the popliteal fossa in patients with varicose veins. A prospective study has been carried out to determine the significance of this sign in the presence of primary varicose veins. The SSV was assessed by palpation of the popliteal fossa with the knee slightly flexed. Hand-held Doppler insonation (HHD) was also used in the out-patient clinic. All patients had SSV assessment by duplex scanning. One hundred and sixty legs were examined. In 68 the SSV was palpable; 39 (57%) of these had SSV reflux on duplex examination. When the SSV was not palpable (92 legs), only 1% (1 leg) refluxed on duplex scanning. SSV palpability had a 98% sensitivity, 75% specificity, 57% positive predictive value (PPV), and 99% negative predictive value (NPV). In comparison, HHD had 80% sensitivity, 87% specificity, 67% PPV and 93% NPV. The combined tests had 78% sensitivity, 73% specificity, 76% PPV and 100% NPV. Palpation of the SSV is a valuable part of clinical examination. If the SSV is not palpable, it is unlikely to reflux.

Maintenance of patency following remote superficial femoral artery endarterectomy.

BACKGROUND: Remote superficial femoral artery endarterectomy (RSFE) is a minimally invasive means of superficial femoral artery revascularisation. It comprises a single groin incision and securing of the distal cut end of atheroma with an intraluminal stent. AIM: To determine medium-term results of RSFE, with particular reference to costs of maintaining patency. METHODS: Stenosis development, and patency of 25 RSFE were compared with 25 randomly selected in situ vein bypasses with similar follow-up (18-33 months). RESULTS: Following RSFE 17 stenoses were identified by duplex surveillance. Half of those arteries patent at 1 yr had stenoses. Angioplasty (PTA) was carried out for 11 stenoses. Four stenoses developed more than 12 months following RSFE. One patient died and nine arteries occluded during follow-up. Primary and primary- assisted patency at 18 months were 31 and 63% respectively. By contrast six stenoses were identified in 25 in situ grafts, all within one year. Four PTAs were carried out. Three grafts occluded. Excluding cost of three monthly duplex surveillance the cost of maintaining RSFE patency was approximately five times that of maintaining in situ bypass patency. CONCLUSION: The initial cost advantage of RSFE is offset by the increased costs of maintaining patency. Duplex surveillance probably needs to be continued indefinitely.

Iliac occlusions: stenting or crossover grafting? An examination of patency and cost.

OBJECTIVES: Percutaneous transluminal angioplasty with stenting is perceived to be a less invasive and cheaper option for the treatment of iliac artery occlusion than surgical reconstruction. We have carried out a prospective observational study of all patients undergoing an iliac stent or femorofemoral crossover graft for iliac artery occlusion to assess the cost effectiveness of the two approaches in a district general hospital. METHODS: Fifty-one patients underwent primary angioplasty with stenting and 87 patients crossover grafting. Patients were all assessed 2 months after their procedure and then at intervals over the following years. RESULTS: In 13 cases, it was impossible to place the stent successfully. In a further 10 patients, major complications occurred which were mainly thromboembolic. Fifteen patients underwent crossover grafting after failure to insert a stent, or after stent occlusion. No major complications occurred following crossover grafting. The median length of stay following successful stenting was 1 day; the following crossover grafting was 4 days. The mean stay was higher in each group (2.5 and 5.8 days) and is a more accurate parameter for estimation of cost, which for iliac stenting is estimated at pound1912 versus pound3072 for crossover grafting. The mean additional cost of those patients sustaining complications after stenting was pound2481. On an <<<>>> basis, patency following stent insertion at 6 months was 52%; patency after bypass was 100% (p <0.0001). If any complication occurs after stenting, the cost advantage of the procedure is lost. In those patients without complication, the initial cost benefit of iliac stenting is lost within 6 months, as patients require further intervention, usually as a crossover graft, when the stent occludes. Crossover grafting is a durable low-risk procedure. CONCLUSIONS: We suggest that stenting of occluded iliac arteries should be reserved for those patients with limited life expectancy. Patients who are younger and fitter should be offered femorofemoral crossover grafting as a primary procedure until research enables identification of those patients who are most likely to maintain long-term patency after stenting.

A survey of methods used for cardiac risk assessment prior to major vascular surgery.

OBJECTIVES: To assess the frequency with which various methods of cardiac risk assessment are used prior to major vascular surgery and the way in which patients considered to the "high" risk are managed. DESIGN: Questionnaire survey. SETTING: Great Britain and Northern Ireland. MATERIALS: Vascular Surgeons who are current members of the Vascular Surgical Society of Great Britain and Northern Ireland. CHIEF OUTCOME MEASURES: Number of respondents reporting routine or frequent use of particular investigations and methods of management. MAIN RESULTS: Of 246 respondents, 52% had access to a high dependency unit and 77% used intensive therapy units routinely following aortic reconstruction. Some measure of ejection fraction was the most common investigation and was used routinely prior to aortic reconstruction by 35% and often by 33% of respondents, this being more frequent in respondents from teaching hospitals and those carrying out a greater number of reconstructions. Calculated clinical risk indices were rarely used. The identification of high risk patients led to referral to a cardiologist for 90% of respondents and influenced the choice of anaesthetist for 50%. CONCLUSIONS: It is concluded that there is considerable variation in practice, but that those who carry out more vascular surgery are more aggressive in their assessment of cardiac risk prior to reconstruction.

Assessment of peritonism in appendicitis.

The aim of this study was to evaluate the accuracy of different methods of demonstrating right iliac fossa peritonism in appendicitis. The methods used were cat's eye symptom (pain on going over a bump in the road), cough sign, right iliac fossa tenderness, percussion tenderness, rebound tenderness and guarding. A series of 100 consecutive patients with a median age of 25 years (range 4-81 years), presenting with right iliac fossa pain were studied prospectively; the male:female ratio was 39:61. In all, 58 patients underwent operation, 44 had appendicitis confirmed on histology. Fourteen patients had a normal appendix removed; 11 were women aged between 16 and 45 years. Cat's eye symptom and cough sign were sensitive indicators of appendicitis (sensitivity 0.80 and 0.82, respectively), but were not specific (specificity 0.52 and 0.50, respectively) and therefore inaccurate (accuracy 64%). Percussion tenderness was less sensitive (sensitivity 0.57) but more specific (specificity 0.86). Rebound tenderness proved to be sensitive (sensitivity 0.82), specific (specificity 0.89) and accurate (accuracy 86%). Thus, rebound tenderness had a positive predictive value of 86% compared with 56% and 57% for cough sign and cat's eye symptom, respectively. In the difficult diagnostic group of young women, the positive predictive value of rebound tenderness was 88% compared with 58% and 56% for cat's eye symptom and cough sign. Appendicitis remains a difficult diagnosis, particularly in young women. Rebound tenderness still has an important role to play in clinical assessment.

Provision of vascular surgical services in the Oxford Region.

Vascular surgical practice across an entire health region was studied. There was a mean of 115.9 inpatient episodes and 46.9 vascular reconstructions per 100,000 population, with considerable variation between districts. Vein utilization for infrainguinal grafts was greater in the teaching hospital and few femorodistal grafts or carotid endarterectomies were carried out elsewhere; there were few tertiary referrals of elective vascular cases. Only two districts have formal arrangements for emergency vascular 'on-call'. There is marked inequality of provision of vascular surgical services across the region.

Case mix and outcome of patients referred to the vascular service at a district general hospital.

A prospective audit has been carried out to evaluate the trends in case mix and initial management of vascular surgical referrals to a single surgeon at a district general hospital. Over a 3-year period there were 1096 new emergency or routine referrals from a population of approximately 450,000. A total of 613 of these patients underwent vascular procedures, with a further 297 procedures subsequently being undertaken on the same patients during the period of the audit. There was a steady increase in the total number referred with little change in case mix with regard to age or diagnosis. Elderly patients had more severe symptoms and were less likely to be treated by minimally invasive means. The number of patients undergoing angioplasty or thrombolysis increased steadily without any corresponding reduction in the number of surgical procedures. It is concluded that there is a steady trend towards increasing vascular surgical workload which is not easily explained by a change in disease incidence or case mix. Elderly patients appear unlikely to be referred unless symptoms are severe and there are few referrals of elderly patients who might benefit from minimally invasive treatments.

Management of asymptomatic popliteal aneurysms: the use of a Markov decision tree to determine the criteria for a conservative approach.

With recent improvements in the results of treatment of popliteal aneurysms, it has been suggested that it may be preferable to treat asymptomatic aneurysms conservatively and to operate only if symptoms develop. This hypothesis has been tested using decision analysis, with sensitivity and threshold analysis to establish the conditions under which such a policy would be appropriate. A Markov decision tree has been used to model the problem and the relevant probabilities have been obtained from a review of the current literature. A computer spreadsheet was used to calculate the results of policies of immediate operation or operation only if symptoms occur. Sensitivity and threshold analysis have been carried out to assess the effect of inaccuracy or alteration in the key variables and to determine the optimum policy under different conditions. The results suggest that early elective operation produces better results than conservative management at 1-2 years after presentation. Sensitivity analysis reveals that the most crucial data are the rate of development of symptoms in patients with asymptomatic aneurysms and the expected limb loss and mortality of treatment for symptomatic aneurysms. Threshold analysis has been used to define the values of these parameters that would be necessary for conservative management to be preferred. It is concluded that, based upon the currently available data, the optimum policy is elective treatment of asymptomatic aneurysms.(ABSTRACT TRUNCATED AT 250 WORDS)

Prospective audit of vascular surgical emergencies in a district general hospital.

A prospective clinical audit was carried out to assess the volume and distribution of workload generated by vascular surgical emergencies over a 3-month period in a single health district in the UK. Of 53 consecutive patients referred as surgical emergencies with peripheral vascular problems, 45 were referred to a single vascular surgeon, 36 directly from a general practitioner or other specialist and nine from another general surgeon. A total of 39 operations and six radiological procedures were carried out, including 26 vascular reconstructions. To accommodate the 27 non-urgent operations, nine were performed 'out of hours' and 17 planned cases were cancelled. A median of five general surgical beds were required throughout the period studied and 11 patients required intensive therapy unit admission for a total of 39 days. It is concluded that vascular surgical emergencies constitute a substantial workload and are being dealt with mainly by a single vascular surgeon who effectively works a one in one rota. Inadequate facilities for urgent vascular surgery lead to a large number of cases being dealt with out of hours and frequent cancellation of routine operations.