Incisional hernias are more common in aneurysmal arterial disease.

OBJECTIVE: To test the hypothesis that incisional hernia was a more frequent complication following aortic reconstructive surgery in patients with aneurysmal as opposed to occlusive aortic disease. DESIGN: A retrospective review. MATERIALS AND METHODS: All patients having aortic reconstructive surgery at a teaching hospital between 1988 and 1992 were identified and recalled to be examined for evidence of an incisional hernia. RESULTS: Of the 134 patients having aortic reconstructive surgery, 87 were available to be examined by an independent clinician. The overall incisional hernia rate was 28%. Patients with aneurysmal disease were significantly more likely to develop an incisional hernia after elective surgery than patients with occlusive disease (p = 0.04). None of the other variables investigated, including age, chronic obstructive airways disease, diabetes, smoking, wound infection, obesity, length of intensive care unit stay and number of units of blood transfused, were significantly related to the complication of incisional hernia. CONCLUSION: Incisional hernia is a common complication of aortic reconstructive surgery, especially in patients with aneurysmal disease.

Acetylation phenotype and cytochrome P450IA2 phenotype are unlikely to be associated with peripheral arterial disease.

The hypothesis that cytochrome P450IA2 (CYPIA2) and/or N-acetyltransferase 2 (NAT2) may be involved in the pathogenesis of peripheral arterial disease was investigated in 90 Australian patients with significant disease and 81 matched control subjects. CYPIA2 and NAT2 phenotypes were determined from urinary metabolite patterns after an oral dose of caffeine. NAT2 phenotype was similar (chi 2 = 0.01; p = 0.98) in both atherosclerotic patients (43.3% rapid) and control subjects (42.0% rapid). CYPIA2 metabolism as measured by the median ratio of (1,7-dimethylxanthine + 1,7-dimethyluric acid)/caffeine was significantly induced by smoking in both patients with atherosclerosis (ratio of 6.5 in nonsmokers and 12.4 in smokers; p < 0.05) and control subjects (ratio of 8.2 in nonsmokers and 14.8 in smokers; p < 0.05), but values in atherosclerotic and control nonsmokers and smokers were similar. Probit transformation of the data revealed a trimodal distribution of ratios in control subjects who were nonsmokers, with 5% classified as poor metabolizers (homozygous rapid) and 95% as extensive metabolizers. The distribution of ratios in control subjects who were smokers was unimodal, whereas among the patients with arterial disease, both smokers and nonsmokers exhibited a bimodal pattern with 8.2% to 16% poor metabolizer and 84% to 91.8% extensive metabolizer phenotypes. When data from both nonsmokers and smokers were combined, the overall proportion of subjects who were poor metabolizers was not significantly different (chi 2 = 1.82; p = 0.18) between control subjects (3.8%) and patients with atherosclerosis (10.6%). Thus biotransformation of environmental or dietary aromatic or heterocyclic amines by NAT2 or CYPIA2 is unlikely to have a significant role in the cause or pathogenesis of peripheral arterial disease.

General practitioners' attitudes to computer-generated surgical discharge letters. Members of the Department of General Surgery, Fremantle Hospital.

OBJECTIVE: To assess general practitioners' attitudes to a computed-generated general surgical discharge letter. To identify the six most important items of information in an ideal discharge letter. DESIGN: One hundred and thirty general practitioners who had received at least six computer-generated surgical discharge letters in one year were circulated with a questionnaire. RESULTS: Most general practitioners approved of the computer-generated discharge letter which included all six of the most important items of information they requested. Eighty-four per cent wished to see a similar computer-generated discharge system extended into other areas of hospital practice.

How accurate is a computerized surgical audit when resident medical staff collect the data?

Since July 1988 all eight general surgeons at Fremantle Hospital have used a computer-based surgical audit and discharge system. At the time of writing (September 1991) 10,919 computer-generated discharge letters have been produced by the system. This paper describes the system and reports a series of quality control assessments carried out between 1 July 1988 and 30 June 1990 during which 30 pre-registration surgical residents completed 5,716 data collection forms. It was found that: (1) data collection for 23 of 24 monthly surgical audits was at least 95% complete; (2) outstanding surgical discharge summaries were reduced by 89%; (3) the residents recorded 17/19 wound infections and identified 15 (79%) of these as a surgical complication; and (4) the residents tended to under-record complications in patients who had more than one complication during their hospital stay. It was concluded that the system was robust, and that resident staff collected data in such a way that good quality computer-generated discharge letters were produced in a timely manner. Closer attention to aspects of data collection will be required before the optimum surgical audits of the QX system can be generated.

Detection of reversible platelet aggregates in the blood of smokers and ex-smokers with peripheral vascular disease.

OBJECTIVE: To demonstrate that smoking increases platelet aggregation in vivo, that smoking cessation reverses platelet aggregation and that this explains, in part, why smoking perpetuates the development of peripheral vascular disease. DESIGN: Prospective case-control study involving three groups of patients: smokers with peripheral vascular disease, ex-smokers with peripheral vascular disease and smokers with peripheral vascular disease who quit smoking during the study. SETTING/PARTICIPANTS: Fourteen smokers and seven ex-smokers, new patients with confirmed peripheral vascular disease, attending the vascular clinic at Fremantle Hospital between February and November, 1988. INTERVENTIONS: Blood samples taken weekly from all subjects for five weeks. Week 1 was taken as the baseline before smoking cessation in the six smokers who were assigned to stop smoking during the study. MAIN OUTCOME CRITERIA: Platelet aggregate ratio, an indicator of in-vivo platelet aggregability where an increase in platelet aggregate ratio suggests a decrease in platelet function. RESULTS: Only three of six smokers stopped smoking for the duration of the study. Median platelet aggregate ratios were: smokers = 0.85 (range, 0.79-0.92) v. non-smokers = 0.93 (range, 0.91-1.00). The difference was statistically significant P less than 0.0002. The difference in platelet aggregate ratios between smokers and quitters was not statistically significant. CONCLUSIONS: This study demonstrated an increase in platelet aggregability in smokers compared to ex-smokers but there was no clear evidence that platelet function was fully reversed after only four weeks cessation of smoking. The data suggested that platelet function of the ex-smokers had fully reversed to normal over a longer period. This could explain the decreased incidence of complications of peripheral vascular disease in ex-smokers. The small number of patients able to quit smoking impeded this study.

Synchronous combined oesophagectomy: a review of 20 cases.

Twenty patients with carcinoma of the oesophagus treated by a modification of the Ivor Lewis oesophagectomy using two surgeons working synchronously were reviewed. All the patients had carcinomas of the middle or lower thirds of the oesophagus. The median age was 68 years. There were 17 males and 3 females. Average total operating time was 3 h 40 min. There was one peri-operative death. The median length of stay was 15 days. The synchronous combined approach to oesophagectomy has advantages, which are discussed, similar to synchronous combined abdomino-perineal resection of the rectum.

Prevalence of abdominal aortic aneurysm in Western Australia.

The prevalence of abdominal aortic aneurysm (AAA) in Western Australia was studied using health department mortality data. Age-standardized and age-specific mortality rates related to the disease were calculated for the period 1980-88. The mortality rate has risen by 36 per cent for men and 24 per cent for women. Most of this rise was due to an increase in non-hospital and emergency admission hospital deaths. The number of elective and emergency operations has also risen. Despite two decades of elective surgery, the mortality rate for AAA continues to rise. This rise is highly suggestive of an increasing prevalence. This contrasts with the decline in deaths from other manifestations of arteriosclerosis and provides support for a policy of screening for aneurysm.

Acetylation phenotype is not associated with breast cancer.

In the present study, we have measured acetylation phenotype in 45 patients who had undergone surgical resection of a primary adenocarcinoma of the breast and in 48 patients or volunteer subjects with no breast disease. Phenotype was determined by measuring the ratio of N-acetylsulfamethazine to N-acetylsulfamethazine plus sulfamethazine in plasma 6 h after a p.o. dose of sulfamethazine. In the control group, there were 31 slow and 17 rapid acetylators, while in the breast patients, there were 25 slow and 20 rapid acetylators. The proportions of slow/rapid acetylators were not significantly different between the 2 groups (Pearson's chi 2 with Yates' correction = 0.45; P = 0.51). The data suggest that acetylation phenotype is not a useful risk prediction measurement in breast cancer.

Biliary bile acids in cholelithiasis and colon cancer.

The role of biliary deoxycholate as an endogenous colon carcinogen and the possible association between cholelithiasis and/or cholecystectomy and the subsequent development of large bowel cancer is unclear. This paper describes biliary bile acids analysis performed on 13 patients undergoing cholecystectomy for gall stones, 10 patients undergoing colonic resection for colon cancer, and eight control patients. For all 31 patients the total bile acids concentration was highly variable (8.3 mg/ml-106.5 mg/ml). The median ratio of primary to secondary bile acids was 2.7:1. The biliary bile acid ratios were similar in both control patients (3.7:1) and those with colon cancer (3.1:1), whereas patients with gall stones had significantly higher secondary bile acid levels in their biliary bile (ratio 1.9:1, p = less than 0.05). This result indicates that raised biliary deoxycholate concentrations are not present in patients with colon cancer and are therefore unlikely to be a major predisposing factor in the aetiology of this disease. It is unlikely that cholelithiasis and/or cholecystectomy predispose to the subsequent development of colon tumours.

An audit of clinical teaching: an approach to one performance indicator of educational competence.

This paper describes a simple, self-administered audit of the year-by-year clinical examination results of 149 students taught by the writer (Dr X) over a 9-year tenure (1977-1985) as a Senior Lecturer in Surgery at the University of Western Australia. The clinical examination results of these 149 students are compared with the clinical examination results of a total peer group cohort of 1567 students taught by the writer's colleagues in the same academic department over the same years. The limitations and applicability of this method of audit are discussed, and it is argued that this type of self-assessment might be of use, in conjunction with other evidence, in the documentation of teaching expertise. Such documentation might be of use in applications for clinical teaching appointments or promotions.

The Hollywood surgical-audit programme: a computer-based discharge and data-collection system for surgical audit.

This article describes the development of a computer-based system for the prospective collection of data for surgical audit and peer review with the generation of a surgical discharge letter. The software has been developed for an IBM personal computer and is suitable for any compatible computer. The system has potential advantages for teaching hospitals as it enables patients to obtain a definitive discharge letter on their discharge from hospital. It is also of potential benefit to surgeons who wish to collect clinical data and to audit the quality of their surgical practice.

Acetylation phenotype in colorectal carcinoma.

Sulfamethazine acetylation phenotype was determined in 49 patients with cancer of the colon or rectum, 41 old, and 45 young control subjects. Metabolic clearance of sulfamethazine, plasma ratio of N-acetylsulfamethazine:N-acetylsulfamethazine plus sulfamethazine and urinary ratio of N-acetylsulfamethazine:N-acetylsulfamethazine plus sulfamethazine were used to classify subjects into slow and fast acetylation phenotypes. All three measures gave similar results. The proportions of slow and fast acetylators were similar in both control groups and there were significantly more fast acetylators in the cancer group than in the control groups (chi 2 = 5.0-8.5; P less than 0.05). The data suggest that there may be an association between acetylation phenotype and colorectal carcinoma.

Changes in tobacco advertising in Western Australian newspapers in response to proposed government legislation.

The number of cigarette and tobacco advertisements in the major Western Australian newspapers was counted for the six-month period June to November in the years 1981 and 1983. The latter period covered the introduction of the Western Australian Government's Tobacco (Promotion and Sales) Bill 1983 and the debate surrounding it. The change in the volume of cigarette advertising in Western Australia in those two years was compared with that which occurred in comparable Queensland papers in the same period. Three major factors emerged: (i) the volume of cigarette advertising was much higher in Western Australia in 1983 compared with 1981; (ii) the volume of advertising increased markedly in Western Australia when legislative action was threatened, and remained at very high levels until the Bill failed; and (iii) the number of cigarette advertisements placed in the Queensland papers surveyed fell between 1981 and 1983. The findings are presented in support of the view that the tobacco industry made a powerful and organized attack to defeat the proposed legislation; the means it adopted to do this are discussed.

Abdominal aortic aneurysms in Western Australia: descriptive epidemiology and patterns of rupture.

All abdominal aortic aneurysms presenting to hospitals and coroners in Western Australia over an 11-year period (January 1971 to December 1981) have been reviewed. A total of 1237 abdominal aortic aneurysms were found. After age and sex standardization it was apparent that the prevalence of diagnosis of abdominal aortic aneurysms had increased from 74.8 per 100 000 to 117.2 per 100 000 for men over 55 years of age (increase of 56.7 per cent) and from 17.5 per 100 000 to 33.9 per 100 000 for women over 55 years of age (increase of 93.7 per cent) during this period. One hundred and twenty-three patients were identified by coroner's autopsy after sudden death from ruptured abdominal aortic aneurysms in whom there had been no previous diagnosis of abdominal aortic aneurysm. Between 1971 to 1981, 478 patients underwent surgery; 225 had elective resection of their aneurysm with a 4.0 per cent fatality rate, and 253 had emergency operations with a 31.2 per cent fatality rate. Seasonal variations contributing to the date of emergency presentation or death from rupture of abdominal aortic aneurysms indicated a possible influence of colder weather upon rupture. It is hoped that the information provided in this paper will be of use to surgeons and physicians involved in health care planning for similar populations.