Angioplasty via retrograde popliteal approach in a stenosed persistent sciatic artery.

Persistent sciatic arteries are a rare developmental anomaly prone to aneurysm formation and atherosclerotic disease. We present a case of a patient with bilateral persistent sciatic arteries presenting with unilateral claudication due to a symptomatic stenosis. The stenosis (just above knee) was treated with angioplasty via popliteal puncture. The puncture was complicated by pseudoaneurysm formation. Persistent sciatic arteries can cause diagnostic difficulties as Duplex ultrasound can give the impression of an occluded superficial femoral artery. Angiographic techniques are the mainstay of diagnosis and we demonstrate both conventional and CT angiographic appearances.

Postoperative arrhythmias in colorectal surgical patients: incidence and clinical correlates.

OBJECTIVE: To determine the incidence and clinical correlates of postoperative cardiac arrhythmias in patients undergoing elective large bowel resection. METHODS: Fifty-one consecutive patients undergoing elective open colorectal resection were recruited for this prospective observational study. Participating patients underwent daily three-lead electrocardiograms postoperatively. Data regarding potential risk factors for arrhythmias were recorded. Post-operative complications were recorded. RESULTS: Thirteen (26%) patients developed a postoperative arrhythmia, most commonly atrial fibrillation. Significant univariate correlates with postoperative arrhythmias were: age (P<0.01), hypertension (P<0.01), pre-operative serum potassium levels (P<0.01), postoperative pulmonary oedema (P=0.03), postoperative serum potassium (P=0.03) and sodium (P<0.01). Arrhythmia patients were more likely to have other complications (P=0.02). Thirty-one percent of arrhythmia patients had underlying sepsis compared with 18% of controls (P=0.38). CONCLUSION: Arrhythmias are common following elective large bowel resection. They occur in older patients and are associated with the development of other complications.

Pelvic kidney and aorto-iliac aneurysm--a rare association--case report and literature review.

Association of a congenital pelvic kidney with abdominal aortic aneurysm is rare and to date only a handful cases have been reported in literature. We report one such case, which was successfully treated using the technique of temporary extra-anatomical perfusion of the kidney.

Thromboprophylaxis can be omitted in selected patients undergoing varicose vein surgery and hernia repair.

BACKGROUND: There is no current agreement on the routine use of thromboprophylaxis in patients undergoing varicose vein surgery and hernia repair. In the authors' hospital, prophylaxis is given only to those considered to be at an increased risk. A retrospective review was conducted to determine whether it was safe to omit prophylaxis in low-risk patients. METHODS: Data were extracted from the hospital database about all patients who underwent the above procedures between January 1997 and December 2001. The case notes of patients who developed venous thromboembolism (VTE) within 3 months of surgery were reviewed. The pharmacy database was then analysed to determine the effect of prophylaxis. RESULTS: A total of 4670 patients were identified. Some 2186 patients had varicose vein surgery; 1283 patients received prophylaxis, of whom four developed VTE. None of the 903 patients who did not receive prophylaxis developed VTE. A total of 2484 patients had hernia repair, of whom 1854 patients received prophylaxis and 630 did not; one patient from each group developed VTE. CONCLUSION: Low-risk patients having hernia and vein surgery do not need thromboprophylaxis.

Predilection for frailty remedial strategies among black and white seniors.

BACKGROUND: Frailty prevention and remedial programs based on exercise, hormone replacement, and vitamin supplementation are becoming available for use with older patients, but success of these programs depends largely on seniors' willingness to participate. METHODS: We evaluated preferences for specific aspects of these programs using a sample of 359 older persons recruited from potential delivery sites. Main effects and subgroup analyses were done. RESULTS: Subjects preferred stretching, chair-based, walking, and dynamic balance exercises over lifting weights, dancing, hormone and vitamin therapy; exercising alone in their own homes over exercising in groups; and vitamins over hormones. Preferences were affected to some extent by sex, race, recruitment site, and functional status. However, subjects' willingness even to consider exercise was rarely as high as the desired levels of participation set forth in Healthy People 2000. CONCLUSIONS: Physicians and public health authorities need to educate older persons about effective methods to prevent or treat frailty.

Letters.

A NEW CLASSIFICATION OF LEG ULCERS CYTOCOMPATIBILITY OF HYDROCOLLOID DRESSINGS CORRECTION.

Letters.

MEDIEVAL ULCER MANAGEMENT SCIENTIFIC PAPERS SPECIAL EQUIPMENT IN NURSING HOMES TWO BANDAGING SYSTEMS SELECTION OF DRESSINGS FOR DIABETIC FOOT ULCERS.

Prospective randomized trial comparing sequential avulsion with stripping of the long saphenous vein.

Eighty patients with primary varicose veins of the long saphenous system were randomized to have the long saphenous vein removed either by stripping to below the knee or by sequential avulsion. There was no difference between the two methods in the time taken to remove the vein. There was significantly more pain after stripping during the week following operation (P < 0.001). Median pain score after stripping was 5, reducing to 3 at 1 week, compared with 2, reducing to 1, for sequential avulsion. Median area of bruising measured at 1 week was 160 (range 0-1800) cm2 for stripping and 56 (range 0-544) cm2 for sequential avulsion (P < 0.01). Sequential avulsion is less painful, reduces bruising and avoids a significant scar below the knee.

Emergency oesophageal transection for uncontrolled variceal haemorrhage.

Continued haemorrhage from oesophageal varices despite adequate injection sclerotherapy and tamponade has a high mortality rate. Such patients are usually referred for surgery. Over a 10-year period, 30 patients (21 men and nine women of median age 52 (range 21-70) years) with acute variceal haemorrhage uncontrolled by initial treatment underwent early emergency oesophageal transection. Portal hypertension was caused by alcoholic cirrhosis in 22 patients; other forms of cirrhosis were present in seven and portal vein thrombosis in one. Hepatic function immediately before operation was Pugh grade A in two patients, B in six and C in 22. Deterioration between admission and transection from grade A to B occurred in one patient and from B to C in five. Oesophageal transection stopped variceal haemorrhage in 29 of the 30 patients. Rebleeding from gastric varices within 35 days of surgery occurred in five patients. Postoperative haemorrhage also occurred from perioesophageal vessels (two patients), a gastrotomy (one) and oesophageal ulceration (two). Hepatic failure developed in seven patients, renal failure in five and both hepatic and renal failure in four. Mortality at 30 days occurred in neither of the two patients with liver function of grade A, in one of six of grade B and in 18 of 22 of grade C. The overall 30-day mortality rate was thus 63 per cent. Mortality was related to the preoperative Pugh grade (hazard ratio 3.95 per grade; P = 0.013) and preoperative blood transfusion (hazard ratio 1.37 per unit; P = 0.035). Four of six patients with grade B liver function died within 3 months and 21 of 22 with grade C disease within 1 year. Oesophageal transection is effective at stopping variceal bleeding but does not modify the underlying disease. Caution is urged for patients with grade C hepatocellular impairment proceeding to acute oesophageal transection after initial sclerotherapy. Such patients may benefit more from treatment with somatostatin or an intrahepatic porta-systemic stent shunt while awaiting definitive therapy.

The use of duplex scanning to diagnose perioperative carotid occlusions.

Perioperative stroke following carotid endarterectomy is reported to occur in 3-20% of patients and may be associated with spontaneous development of thrombus at the operation site or technical imperfections. In 118 consecutive patients, duplex scanning performed immediately before anaesthesia was used to confirm that all high grade carotid stenoses had not progressed to occlusion since the arteriogram. A new technique at completion, using subcuticular prolene sutures for the skin and a plastic dressing for the wound, permitted immediate postoperative assessment by duplex scanning if necessary. Of the 118 patients, symptoms of neurological instability developed in 4 (3.4%) in the first 6 hours after surgery. At duplex scanning, developing thrombus was demonstrated in three of these patients. Arterial thrombus was removed at reoperation and all three patients recovered with no neurological deficit. The fourth patient had occluded the contralateral carotid artery, developed a major stroke and was not considered for re-exploration. Duplex scanning provides accurate diagnostic information in selecting patients for urgent re-exploration, reducing the 24 h stroke rate to 0.8% in this series.

Colour-coded duplex ultrasonography in the selection of patients for endovascular surgery.

Endovascular surgery using angioplasty or atherectomy may potentially relieve the symptoms of claudicants with minimal morbidity, but results are best when short stenoses are treated. In this study, colour-coded duplex ultrasonography has been compared with angiography. In aortoiliac segments duplex examination had a sensitivity of 88 per cent and a specificity of 100 per cent; in femoropopliteal disease the sensitivity was 100 per cent and duplex scanning identified more disease than angiography. Subsequently, 73 symptomatic limbs with femoropopliteal disease were scanned to assess their suitability for endovascular surgery. Of these limbs, 27 (37 per cent) had suitable lesions and the remaining 46 (63 per cent) were spared angiography. Colour-coded duplex ultrasonography can reliably be used to select patients for endovascular surgery.

Bilateral progressive essential iris atrophy and keratoconus with coincident features of posterior polymorphous dystrophy: a case report and proposed pathogenesis.

We report the first case known to us of an apparent bilateral association of essential iris atrophy (EIA) and keratoconus (KC), with coincident features of posterior polymorphous dystrophy (PPD). Based on this case and the published natural history and findings of both the irido corneal endothelial (ICE) syndrome and PPD, we propose a new hypothesis for the pathogenesis of the ICE syndrome with associated KC and/or PPD. We suggest that, similar to the genetics of retinoblastoma, the predisposition for either the ICE syndrome or for PPD is inherited as an inactive allele, the so-called "first hit." Inactivation of the second allele, or "second hit," which could occur at any time, might be the product of the background mutation rate or of an environmental trigger. Dedifferentiation or an abnormality in normal development could occur after the first or second hit, resulting in varying clinical patterns. We also concur with other investigators that PPD could be part of the spectrum of the ICE syndrome, owing to similarities in their clinical presentations, histopathology, specular and electron microscopy, and natural history.

Oxerutins in the prevention of recurrence in chronic venous ulceration: randomized controlled trial.

The value of oxerutins [O-(beta-hydroxyethyl)-rutosides] in the prevention of venous ulcer recurrence was investigated in a double-blind randomized controlled trial of 138 patients with recently healed chronic venous ulcers. Oxerutins in the form of Paroven 500 mg twice daily or identical placebo were given, and all patients were provided with elastic compression stockings. At follow-up 3 months later, patients were assessed for re-ulceration and for tablet and stocking compliance. Oxerutins (n = 69) and placebo (n = 69) groups were well matched for age, sex, duration of previous ulceration and deep vein thrombosis. Cumulative re-ulceration by life-table analysis at 12 and 18 months was 22 and 32 per cent respectively for placebo, and 23 and 34 per cent respectively for oxerutins (P = 0.93). Recurrence was more frequent in patients who complied with both tablets and stockings, suggesting that compliance was influenced by continued symptoms (P = 0.006). This trial failed to demonstrate that oxerutins influenced ulcer recurrence.

The value of radioimmunoguided surgery in first and second look laparotomy for colorectal cancer.

Radioimmunoguided surgery (RIGS) using an anti-CEA (A5B7) monoclonal antibody has been assessed in 52 patients (43 primary excisions and nine second look procedures) undergoing surgery for colorectal carcinoma. The antibody localized in 97.8 percent of primary tumours and in 88.8 percent of the principal tumor in second look procedures. Additional information concerning the extent of primary tumor was obtained in 11 of 43 patients (25.5 percent) undergoing excision of primary carcinoma and five of nine patients (55 percent) in the second look series. Incorrect information was obtained about the extent of the primary tumour in six patients (11.3 percent), whereas no incorrect information was obtained during second look procedures. RIGS correctly predicted the subsequent Dukes' staging in 77 percent of first look cases (sensitivity 65 percent, specificity 90 percent), although accurate identification of individual nodes was impossible. The technique influenced the surgical procedure performed in 2 of 43 cases (4.6 percent) in primary surgery and in three of nine patients undergoing second look laparotomy (33 percent). RIGS in primary colorectal carcinoma may provide additional information concerning extent of locally advanced tumors in particular and the principle that the subsequent surgery may be influenced has been established. The technique appears to have a greater role in second look procedures where it may help determine the extent of recurrent tumour. Larger follow-up series are required to define how the additional information provided by this technique may best be exploited.

Comparison of anti-fetal colonic microvillus and anti-CEA antibodies in peroperative radioimmunolocalisation of colorectal cancer.

Local recurrence of colorectal cancer may result from failure to assess accurately the extent of tumour at operation. It has been suggested that peroperative radioimmunolocalisation may improve this assessment. The degree to which this is possible has been studied using a hand-held gamma detecting probe and comparing two 125I-labelled monoclonal antibodies to colorectal tumours. The antibodies were to fetal colonic microvillus membrane (FM1D10) and to carcinoembryonic antigen (A5B7). Sixty-nine per cent (9/13) of the FM1D10 and 98% (43/44) of A5B7 labelled tumours took up significant amounts of antibody with a tumour to normal colon ratio of more than 1.5:1. The uptake was significantly better for A5B7 with a median tumour to normal colon ratio of 3.3 (1.1-13.8) compared to 1.85 (0.75-7.7) for FM1D10 (P less than 0.001). The tumour: colon ratio of both antibodies was independent of the serum CEA, Dukes' stage or the degree of histological differentiation. There was a linear correlation for tumour to normal colon ratios between the gamma detecting probe and the same tissue examined in a conventional well counter (correlation coefficient r = 0.78, P less than 0.001). Colorectal tumours demonstrate a rapid and reliable uptake of anti-CEA monoclonal antibody A5B7. This antibody can be detected with a peroperative gamma detecting probe and has the potential to improve the surgeon's appreciation of the extent of tumour and therefore may influence the surgery performed. Detailed clinical studies are now being carried out.