Randomised trial of flush saphenofemoral ligation for primary great saphenous varicose veins.

OBJECTIVES: The aim of this study was to assess different techniques of saphenofemoral ligation in the treatment of primary varicose veins. METHODS: One hundred and eighty-two patients (210 legs) with primary saphenofemoral junction incompetence were randomised to standard saphenofemoral ligation (transfixion with an absorbable suture) (SSL) or flush saphenofemoral ligation (oversewing with 4/0 polypropylene) (FSL). All legs underwent additional great saphenous vein stripping and multiple phlebectomies. Patients underwent assessment preoperatively, and at 6 weeks, 1 year and 2 years postoperatively with clinical examination, duplex imaging and completion of the Aberdeen Varicose Vein Symptom Severity Score (AVVSSS). RESULTS: A total of 148 patients (172 legs) attended follow-up at 2 years postoperatively. Recurrent varicose veins were visible in 30 legs (33 per cent) in the SSL group and 26 legs (32 per cent) in the FSL group (P=0.90). Neovascularisation was present in 20 groins (22 per cent) in the SSL group and 15 groins (19 per cent) in the FSL group (P=0.57). Nine cases of neovascularisation in the SSL group and five in the FSL group directly resulted in clinical recurrence (P=0.37). CONCLUSIONS: Flush ligation of the saphenofemoral junction confers no advantage over standard ligation with respect to clinical recurrence and neovascularisation. REGISTRATION NUMBER: ISRCTN20235689 (http://www.controlled-trials.com).

Open inguinal hernia repair in women: is mesh necessary?

BACKGROUND: There is little information available on recurrence rates following primary open inguinal hernia repair in women. Women are less prone to inguinal hernias than men; for the same reason, recurrences after hernia repair may also be lower so that the well-known advantage of using mesh could be lost on them. METHOD: Women having primary open inguinal hernia repair under the care of one surgical team were identified from the unit database. Recurrences in those who had non-mesh repair were sought by a combination of a written questionnaire and clinical examination. RESULTS: Fifty-two women had a non-mesh inguinal hernia repair over a 12-year interval; 37 responded to a questionnaire. There were no major perioperative complications; one recurrence was diagnosed, giving an overall recurrence rate of 2.8% (95% confidence interval 8.2%). During the study interval 37 women had open mesh repair of an inguinal hernia. There were three major complications. CONCLUSIONS: The routine use of mesh for open indirect inguinal hernia repair in women may not be necessary.

Comparison of different methods of risk stratification in urgent and emergency surgery.

BACKGROUND: The aim was to compare a number of risk scoring systems prospectively in a cohort of patients who underwent non-elective surgery. METHODS: This was a cohort study of 2349 consecutive patients who had urgent or emergency surgery in a district general hospital in the UK. All patients were scored prospectively using the Revised Goldman Cardiac Risk Index (RGCRI), Portsmouth modification of the Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (P-POSSUM), Surgical Risk Score (SRS) and Biochemistry and Haematology Outcome Models (BHOM). Actual 30-day and 1-year survival rates were compared with the predicted outcomes using receiver-operator characteristic (ROC) curves and Hosmer-Lemeshow analysis. RESULTS: Some 141 patients (6.0 per cent) died within 30 days of operation. This increased to 254 (10.8 per cent) by 1 year. The area under the ROC curve for death within 30 days was 0.90 for P-POSSUM, 0.85 for SRS, 0.84 for BHOM and 0.73 for RGCRI. Only the first three risk scores were able to discriminate accurately within the groups (area under ROC curve over 0.8), with no significant variation between expected and observed mortality rates confirmed by Hosmer-Lemeshow analysis. Similar results were found for the ability of each score to predict outcome at 1 year. CONCLUSION: P-POSSUM, SRS and BHOM scoring systems were all able to predict outcome after emergency and urgent surgery, but the SRS had the advantage of ease of calculation. BHOM requires only the most commonly available blood test data and the computer holding these data can easily perform the calculation.

Lessons learned from a randomised controlled study of perioperative beta blockade in high risk patients undergoing emergency surgery.

BACKGROUND: Perioperative beta blockade has been shown to reduce mortality after major elective surgery. The aim of this study was to determine whether it could reduce the rate of death and morbidity from cardiac complications in high risk patients undergoing emergency surgery. METHODS: Over a one-year interval all patients undergoing major non-elective orthopaedic or general surgery were screened to identify those at high risk of cardiac complications. Consenting, high risk patients were randomly allocated atenolol or placebo for seven days, commencing at anaesthetic induction. Deaths and cardiac complications within 30 days were recorded. RESULTS: Some 2351 patients had an emergency operation; 145 were at high risk and eligible for the study. Of 89 patients approached, 57 initially consented. Only 38 patients, however, completed the study protocol, 19 were withdrawn. Of those who completed the study, 5/20 patients in the placebo group and 3/18 in the treatment group died before hospital discharge (p=0.520). Four others in the placebo group and two in the atenolol group had post-operative non-fatal cardiac events (positive troponin T), p=0.311. CONCLUSIONS: This study of emergency surgery proved more difficult than similar trials in elective surgery. The final study groups were small and there were no significant differences in outcomes. A much larger study is required for a definitive answer.

Effect of continuous low-dose intravenous heparin administered during operation on postoperative measurements of antithrombin III and antifactor Xa.

A preliminary subcutaneous dose of heparin given with premedication, followed by a continuous infusion of low-dose heparin up to 2 hours after operation, was given to 20 of 40 patients undergoing major abdominal operation randomly allocated to either act as controls or receive prophylaxis. The anticoagulant effect of heparin was determined by immunologic measurements of antithrombin III (AT III) and by assay of AT III and antifactor Xa activity on postoperative days 1 and 3. Despite lowered plasma AT III levels on postoperative day 3, the patients who had received low-dose heparin had significantly increased plasma antifactor Xa activity when compared with control patients (P less than 0.05). The incidences of thrombosis within 48 hours (early deep venous thrombosis) after operation were 9 of 20 control patients and 1 of 20 patients who received prophylaxis (P less than 0.01 by Fisher's exact test). Preoperative blood samples from another group of patients undergoing major abdominal operation were examined by the thromboelastograph saline dilution test, which has previously been shown to be a predictor of the risk of early deep vein thrombosis. The patients who were considered to be at high risk were treated with low-dose heparin as before, and the low-risk patients received no prophylaxis. The high-risk patients had lower levels of AT III before operation and before heparin administration than the low-risk patients and significantly lower levels on day 3 (P less than 0.02), whereas on day 3 the high-risk patients had significantly raised levels of plasma antifactor Xa. No patient in either group developed deep vein thrombosis within 48 hours of operation.

Prophylaxis of early post-operative deep venous thrombosis by monitored heparin infusion.

Increases in whole blood coagulability in patients undergoing abdominal surgery have been measured with the thrombelastograph. A continuous, low dose intravenous infusion of heparin has been administered in the operative period in an attempt to control these coagulability increases without increasing the risk of haemorrhage. A preliminary sub-cutaneous dose of heparin followed by a continuous infusion throughout the operation and for two hours afterwards effectively prevented the expected coagulability increase and resulted in reduction of early deep venous thrombosis incidence from 9/20 in controls to 1/19 in treated patients (p less than 0.05). The infusion has also been used in conjunction with a pre-operative test to predict the risk of deep venous thrombosis. Of 20 patients examined, 11 were designated as high risk and received an intra-operative heparin infusion and 9 predicted low risk patients received no specific prophylaxis. No venous thrombosis occurred in any patient within 48 hours of surgery.

Coagulation changes during major surgery and relationship to post-operative deep vein thrombosis.

Nineteen patients undergoing aortic surgery during which 5,000 units of heparin were given intravenously were compared with 39 patients undergoing laparotomy or herniorrhaphy. There was an expected significant reduction in coagulability as measured by thrombelastography in those patients undergoing aortic surgery. Moreover, the early post-operative deep vein thrombosis (DVT) rate was significantly less. This implies that a reduction in coagulability by I.V. heparin during surgery is associated with a lower incidence of early post-operative deep vein thrombosis. Among the laparotomy and hernia group who developed a DVT, coagulability was significantly greater both before and during the operation and on the first post-operative day.

The feasibility of screening for abdominal aortic aneurysms in a district general hospital.

The feasibility of a screening programme for abdominal aortic aneurysms within a district general hospital population is explored, based on our current accepted knowledge of the natural history of this disease process. It is shown that ultrasound screening of males aged between 65 and 74 years, with elective repair of the aneurysms discovered, could save up to 20 lives per year in this district at a reasonable and justifiable cost. Moreover, such a programme would not place an unacceptable burden on existing radiological and surgical facilities.

Cutting the cost of emergency surgical admissions.

Over a one-month period, 207 general surgical emergency admissions (excluding urology) to a district general hospital were audited. The potential to improve the delivery of emergency care and reduce inpatient stay was studied. During the year of study, 44 per cent of all surgical admissions were emergency patients who consumed 61 per cent of inpatient bed days. Most emergency admissions were for gastroenterological problems although patients with arterial disorders tended to have relatively prolonged inpatient stays. Operations were performed in 34 per cent of emergency admissions with six post-operative deaths. Delays in operative treatment were mainly due to waiting for space on scheduled operating lists. A number of post-operative patients remained in hospital over the weekend awaiting discharge on Monday. Most emergency admissions were treated conservatively. Delays in discharge of fit patients occurred whilst the results of inpatient investigations were awaited. Twelve patients were admitted for complications of previous procedures. Emergency patients accounted for over half the inpatient bed days. There is considerable scope for improving the process of delivery of emergency surgical care and reducing inpatient stay.

The predictive value of haemodynamic assessment in chronic venous leg ulceration.

OBJECTIVES: The aim of this study was to assess the value of PPG in predicting healing and recurrence in patients with chronic venous ulceration. METHODS: 500 patients with open or recently healed venous ulceration were treated with either multilayer compression or compression plus superficial venous surgery and followed up in specialist clinics as part of a clinical study. At initial assessment, VRT was measured using PPG with and without a below-knee tourniquet inflated to 80 mmHg to occlude superficial veins. Legs were stratified into groups with VRT <11s, 11-20s and >20s and comparison of healing and recurrence rates between these groups was performed. RESULTS: VRT measurements were not achieved in 117 patients, primarily due to ankle stiffness. Of the remaining 383 patients, VRT without tourniquet did not correlate with ulcer healing (p=0.26, 0.40) or recurrence (p=0.20, 0.79, Log rank test) for legs treated with compression or compression plus surgery respectively. However, VRT readings taken with a below-knee tourniquet were predictive of ulcer healing (p<0.01) and recurrence (p=0.05, Log-rank test). The correlation was greatest for healing in legs treated with compression alone, where 24 week healing rates were 62%, 73% and 92% for legs with VRTs with tourniquet <11s, 11-20s and >20s respectively (p<0.01, Log rank test). For legs treated with surgery, 1 year recurrence rates were 24%, 10% and 3% for groups with VRTs with tourniquet <11s, 11-20s and >20s respectively (p=0.03, Log rank test). CONCLUSIONS: Digital PPG assessment may predict ulcer healing and recurrence, but only by using a below-knee tourniquet. This information could aid the selection of patients with venous ulceration most likely to benefit from superficial venous surgery.

Identifying high-risk patients undergoing urgent and emergency surgery.

INTRODUCTION: The aim was to identify high-risk patients undergoing non-elective orthopaedic and general surgery. PATIENTS AND METHODS: This was a retrospective cohort study of all non-elective general and orthopaedic surgical procedures performed in a 1-year interval in a district general hospital. A total of 1869 patients underwent urgent or emergency surgery in the calendar year 2000. Outcomes were identified from various related hospital databases. Case notes of those who died were reviewed. Risk factors for mortality were examined using univariate and multivariate analysis. RESULTS: The mortality rates were 89/1869 (5%) at 30 days and 216 (12%) after 1 year. The high initial death rate continued for about 100 days after surgery. Increasing age (P < 0.0001), size of operation (P = 0.004) and American Society of Anesthesiologists (ASA) fitness grade (P < 0.0001) were associated with significantly higher risk of death at 1 year on multivariate analysis. A high risk group was identified of 273 patients aged over 50 years, of ASA Grade III or above who needed major surgery; they had a 30-day mortality rate of 18%. CONCLUSIONS: A simple scoring system could be used to identify high-risk patients who require non-elective surgery that could be a target for interventions to try and reduce their risk of death.

Risk factors for delayed healing and recurrence of chronic venous leg ulcers--an analysis of 1324 legs.

OBJECTIVE: Despite similar disease patterns and treatment, there is great variation in clinical outcome between venous ulcer patients. The aim of this study was to identify independent risk factors for venous ulcer healing and recurrence. METHODS: Consecutive patients assessed by a specialist nurse-led leg ulcer service between January 1998 and July 2003 with an ABPI>0.85 were included in this study. Independent risk factors for healing and recurrence were identified from routinely assessed variables using a Cox regression proportional hazards model. RESULTS: A total of 1324 legs in 1186 patients were studied. The 24-week healing rate was 76% and 1 year recurrence rate was 17% (Kaplan-Meier life table analysis). Patient age (p <0.001, HR per year 0.989, 95% CI 0.984-0.995) and ulcer chronicity (p =0.019, HR per month 0.996, 95% CI 0.993-0.999) were independent risk factors for delayed ulcer healing. Ulcer healing time (p <0.001, HR per week 1.016, 95% CI 1.007-1.026) and superficial venous reflux not treated with surgery (p =0.015, HR 2.218, 95% CI 1.166-4.218) were independent risk factors for ulcer recurrence. CONCLUSIONS: Elderly patients with longstanding ulcers should be targeted for further research and may benefit from adjunctive treatments to improve clinical outcomes. Patients not treated with superficial venous surgery were at increased risk of leg ulcer recurrence.

The influence of superficial venous surgery and compression on incompetent calf perforators in chronic venous leg ulceration.

OBJECTIVES: Previous studies have suggested that perforating vein incompetence is reduced by surgery to superficial veins. This study analysed the effect in a randomised clinical trial. DESIGN: Retrospective analysis of duplex data. METHODS: Patients in this study were part of the ESCHAR randomised controlled trial. All patients had chronic venous leg ulceration with superficial venous reflux. Patients were treated with compression bandaging alone or compression plus superficial venous surgery. Legs were assessed using colour venous duplex prior to treatment and at 3 and 12 months. RESULTS: Of 500 patients recruited to the ESCHAR trial, 261 were included in this study. One hundred and forty six of 261 legs were treated with compression alone and 115/261 underwent compression and superficial venous surgery. In the compression group, more legs had incompetent perforators at 12 months (77/131) compared to baseline (61/146, p =0.010, Wilcoxon Signed Ranks test for paired data in 131 legs). Following surgery, significantly fewer legs had incompetent calf perforators (59/115 vs 44/104 at 12 months, p =0.001, Wilcoxon Signed Ranks test for paired data in 104 legs). In addition, significantly fewer legs in the compression and surgery group developed new perforator incompetence in comparison to the group treated with compression alone (12/104 vs 36/131, p =0.003, Chi-Squared test). CONCLUSION: Surgical correction of superficial reflux may abolish incompetence in some calf perforators and offer protection against developing new perforator incompetence.

Randomized clinical trial of compression plus surgery versus compression alone in chronic venous ulceration (ESCHAR study)--haemodynamic and anatomical changes.

BACKGROUND: The aim of this study was to evaluate the anatomical and haemodynamic effects of superficial venous surgery and compression on legs with chronic venous ulceration. METHODS: Legs with open or recently healed ulceration and saphenous reflux were treated with multilayer compression bandaging or superficial venous surgery plus compression as part of a clinical trial. Venous duplex imaging was performed before treatment and at 1 year. Legs were stratified before surgery as having no deep reflux, segmental deep reflux or total deep reflux. Venous refill times (VRTs) were calculated before treatment and at 1 year using photoplethysmography, with and without a narrow below-knee cuff inflated to 80 mmHg. RESULTS: Of 214 legs investigated, 112 were treated with compression and 102 with compression plus surgery. Saphenous surgery abolished deep reflux in ten of 22 legs with segmental deep reflux and three of 17 with total deep reflux. Overall median (range) VRT increased from 10 (3-48) to 15 (4-48) s 1 year after surgery (P < 0.001). Preoperative change in VRT on application of a below-knee tourniquet correlated with actual change in VRT following surgery. CONCLUSION: Superficial venous surgery resulted in a significant haemodynamic benefit for legs with venous ulceration despite co-existent deep reflux; residual saphenous reflux was common.

Prophylaxis of early post operative deep venous thrombosis by monitored heparin infusion.

Increases in whole blood coagulability in patient undergoing abdominal surgery have been measured with the thrombelastograph. A continuous, low dose intravenous infusion of heparin has been administered in the operative period in an attempt to control these coagulability increases without increasing the risk of haemorrhage. A preliminary sub-cutaneous dose of heparin followed by a continuous infusion throughout the operation and for two hours afterwards effectively prevented the expected coagulability increase and resulted in reduction of early deep venous thrombosis incidence from 9/20 in controls to 1/19 in treated patients (p less than 0.05).

The relationship between aortic diameter and body habitus.

Nine hundred and six men between the ages of 65 and 74 years were screened to determine whether there was a correlation between abdominal aortic diameter and body size. There was no correlation between aortic diameter and weight or obesity but there was a significant correlation with height and age. Sequential enlargement of the aorta was observed in 57 men with aortic diameters above the normal range, none of these were characterised by one particular body habitus: it is suggested that patients in this group should be rescanned regularly.

The saline dilution test--a preoperative predictor of DVT.

In vitro dilution of blood with normal saline produces an increase in coagulability which can be accurately measured by the thrombelastograph. The degree to which the coagulability of an individual patient's blood is increased by such dilution appears to be directly related to that patient's risk of developing a postoperative deep venous thrombosis. In a small group of patients undergoing major abdominal surgery, a preoperative test based on the coagulability increase after in vitro saline dilution successfully predicted all those who subsequently developed a postoperative deep venous thrombosis on 125I-fibrinogen scanning.

Poor outcome in patients aged over 80 with limb-threatening ischaemia.

The aim of this study was to determine the outcome in a consecutive series of patients over 80 years of age with limb-threatening ischaemia. The authors performed a retrospective case-note review of the treatment and outcome in 108 patients with 131 episodes of leg ischaemia, who presented to a vascular unit between 1992-1996 inclusively. Some 73 (56%) episodes of leg ischaemia occurred in patients suitable for active treatment (limb salvage 75%, amputation 4% and death 21%). Results were inferior in patients not actively treated (limb salvage 19%, amputation 50% and death 31%). Elderly patients not selected for active treatment have a very poor outcome and are seldom mentioned in publications. In future, clinical reports should include actively treated and rejected patients to avoid selection bias. Research should focus on the selection process and alternative therapies.

The Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM).

BACKGROUND AND METHODS: The development of the Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) is described and its methods of analysis and value in a modern surgical practice are reviewed. A computerized search of all published data in Medline, the Cochrane Library and Embase was made for the last 12 years. Relevant articles were then searched manually for further papers on risk analysis, case-mix comparison and POSSUM methodology. RESULTS AND CONCLUSION: POSSUM has been evaluated extensively in both general and specialist surgery. While there are problems with both data collection and analysis, when used correctly POSSUM can usefully compare outcomes between surgeons and between hospitals. In specialist surgery, individual regression equations may be needed for each index procedure.

The value of QTc dispersion in assessment of cardiac risk in elective aortic aneurysm surgery.

OBJECTIVES: To determine the value of QTc dispersion in predicting cardiac risk in aortic aneurysm surgery. DESIGN: Retrospective case-control study. MATERIALS: One hundred and twenty-six patients who had abdominal aortic aneurysm surgery between May 1992 and April 1996. METHODS: Nine patients experienced a postoperative cardiac complication defined as myocardial infarction or cardiac death. Twenty-four age and sex-matched controls who had uncomplicated aortic surgery were selected at random. QTc dispersion was calculated from the preoperative 12 lead electrocardiograms. RESULTS: The mean QTc dispersion in the cardiac complication group was greater than the control group (63.1 ms1/2 vs. 50.4 ms1/2) but the difference did not approach statistical significance. CONCLUSIONS: QTc dispersion cannot be recommended as a predictor of cardiac complication following elective aneurysm repair.