Uncomplicated penetrating colonic injury.

The case of a patient with an air gun pellet injury to the right colon is reported. This was treated conservatively, and the pellet was passed per rectum 12 hours after the injury. Gunshot wounds to the abdomen do not necessarily warrant immediate laparotomy. Sieving of bowel motions may identify if the foreign body has been passed.

Contamination of evacuated pneumoperitoneum air following laparoscopic cholecystectomy: preliminary results from a prospective study.

A prospective microbiological analysis of evacuated pneumoperitoneum air in 20 patients following laparoscopic cholecystectomy for benign gallbladder disease is reported. In six patients (30%) a positive culture was obtained, out of which five had bowel derived organisms. Bile specimens taken at the same time as the air specimens were similarly cultured but failed to yield any organisms. There were no post-operative septic complications. There were no deaths. The initial results suggest that the evacuated peritoneal air is a potential source of contamination to the theatre staff and environment. This must be borne in mind when advocating laparoscopic procedures for treatment of high-risk patients.

Management of co-existing intra-abdominal disease in aortic surgery.

OBJECTIVES: the treatment of abdominal aortic aneurysms more than 5 cm in diameter is well accepted, but controversy surrounds the management of concomitant serious intra-abdominal lesions diagnosed in the perioperative period. This study was undertaken to demonstrate that synchronous surgery is feasible and safe in this group of patients. DESIGN: in 1978 a decision was made to undertake combined operations on all patients with an aortic aneurysm of 5 cm or more in diameter and a significant non-vascular intra-abdominal lesion requiring surgery. METHODS: the case records of 676 patients who had aortic grafting for aneurysmal disease or the urgent management of occlusive disease between 1978 and 1998 were analysed retrospectively. SETTING: district general hospital. RESULTS: fifty-six (8%) patients had co-existing intra-abdominal disease treated at the time of aortic graft surgery. There were three (5%) hospital deaths and seven patients required early reoperation. One patient developed a subphrenic abscess and there were three superficial wound infections. There has been no clinical evidence of aortic graft infection in this series. CONCLUSION: this single centre experience with synchronous surgery demonstrates that it is safe and does not appear to predispose to an increased risk of graft infection.

The influence of total knee arthroplasty on lower limb blood flow.

Ischaemic complications of total knee arthroplasty (TKA) are unusual and tend to occur in patients with peripheral vascular disease (PVD). A prospective study was undertaken to investigate the effect of TKA on blood flow in patients without clinical evidence of PVD. Ankle brachial index (ABI) did not alter post-operatively and no changes in arterial waveforms were found. Unless there is clinical evidence of PVD, TKA under tourniquet control is therefore very unlikely to cause ischaemic complications.

Exploration of the common bile duct for stones: the influence of the flexible choledochoscope and perioperative antibiotic prophylaxis.

A retrospective study of 110 patients, out of a total of 743 open cholecystectomies, who have undergone common bile duct (CBD) exploration for stones between 1985 and 1990. CBD exploration was performed in the presence of abnormal peroperative cholangiogram in 86 (78%) patients. The remaining 24 patients were known to have either an abnormal preoperative ERCP or palpable ductal stones at the time of surgery. Post exploratory choledochoscopy was performed as an additional completion procedure in 58 (53%) patients and it identified further stones in 28 (48.3%) of these patients. There were three patients in whom no stones were identified on exploration of the CBD. Documented evidence of peroperative antibiotic prophylaxis was obtained in 78 (71%) patients. A total of 27 (24.5%) patients developed complications including seven (6.4%) patients with retained stones. In four of these patients with retained stones, flexible choledochoscopy was undertaken as an additional completion procedure to ensure ductal clearance. Cardiorespiratory and septic complications were the next most common problems occurring in 6.5% and 5.4% respectively, of patients reviewed. In conclusion, the retained stone rate has fallen from 14% in 1987 to 6.4% in this study. The choledochoscope has influenced this as it identified further residual stones following conventional exploration. The sepsis rate has also fallen from 19.5% to 4.5% in this study. We believe this is due to the use of antibiotic prophylaxis.

Flush saphenofemoral ligation and multiple stab phlebectomy preserve a useful greater saphenous vein four years after surgery.

PURPOSE: Flush saphenofemoral ligation, with multiple cosmetic stab phlebectomy, successfully treats saphenofemoral reflux and superficial varicosities. The long-term effect on the residual greater saphenous vein (GSV) requires evaluation. METHODS: Noninvasive triplex ultrasound assessment of the residual GSV for potential use as a vein graft was used. We evaluated the independent objective and subjective cosmetic outcomes. We also used analysis to determine the correlation between GSV reflux, symptoms, and cosmetic outcome. RESULTS: Seventy-two limbs were assessed at a median follow-up of 4 years (interquartile range 3 to 5 years). Fifty-nine limbs had patent GSVs above and below the knee. The mean length patent was 51 cm, and the mean internal diameters above and below the knee were 3.6 and 2.8 mm, respectively. In 65% of cases the vein had suitable ultrasonic characteristics, suggesting that it would be suitable for use as a conduit for a vascular bypass graft. Sixty-two limbs were considered a symptomatic success and 61 an objective cosmetic success. There was no correlation between the symptomatic and cosmetic outcome and the presence of superficial GSV reflux (linear regression analysis). CONCLUSIONS: These findings support the effectiveness of the procedure of flush saphenofemoral ligation and multiple stab phlebectomy with regard to cosmetic and symptomatic outcome and may preserve the GSV for use as an autologous bypass graft.