Isoenzyme analysis of hyperamylasaemia associated with ruptured abdominal aortic aneurysms.

Hyperamylasaemia may occur following abdominal aortic aneurysm rupture and its use as a prognostic indicator has been suggested. However, the isoenzyme responsible for the rise in serum amylase has not been investigated. In this study, isoenzyme analysis was performed on the serum of patients noted to have a raised amylase from their routine biochemistry samples. Individual cases were then reviewed regarding clinical course and outcome. The pancreas has been thought to be the predominant source of the observed hyperamylasaemia. However, in this study a mixed picture of pancreatic and salivary isoenzymes was found. Of the four highest recorded amylase levels two were salivary in origin, one pancreatic and one mixed. The highest recorded amylase level was of salivary origin in a patient that survived without any major complication. The four patients that died all showed evidence of gut infarction/ischaemia. Two had hyperamylasaemia of a mixed pattern, one pancreatic and one of salivary origin.

Infrageniculate vein bypass graft for critical limb ischaemia: one surgeon's experience.

The results of 63 patients under the care of one surgeon who underwent a bypass, using vein, for critical limb ischaemia are presented. Thirty-two operations were to the crural vessels and the results are compared with those for 31 infrageniculate femoropopliteal bypasses. All patients were entered into a graft surveillance programme. There were no graft failures after 1 year in the femoropopliteal group with primary, primary assisted and secondary patency rates of 86, 90 and 93% respectively at 3 years. In the femorocrural group the rates were 55, 60 and 64% respectively. The difference in secondary patency was considered statistically significant (P < 0.01). Mortality rate of the femoropopliteal group was 31% at 3 years compared with 53% for the femorocrural group (n.s.). Five patients underwent major amputation, all of whom were in the femorocrural group. Failures, interventions and the effect of graft surveillance are discussed and the high mortality rate is highlighted.

Prospective audit of discharge summary errors.

During an 8-month interval of prospective audit, 63 of 637 (10 per cent) vascular discharge summaries were found to contain 94 errors. These comprised 11 (12 per cent) general errors, 21 (22 per cent) diagnostic errors, 19 (20 per cent) operative data errors, 19 (20 per cent) cases of incorrect clinical text information, 14 (15 per cent) missed complications and 10 (11 per cent) concerning follow-up arrangements. Overall, 2 per cent of consultant discharge summaries contained errors compared with 7 per cent for the senior registrar, 10 per cent for registrars and 17 per cent for senior house officers. Given that the majority of discharge summaries are currently prepared by junior staff, this study suggests that verification of the accuracy of clinical and management data should be an essential component of departmental audit meetings.

Major lower limb amputation for vascular disease in the Grampian area: the outcome of rehabilitation.

The outcome of lower limb amputation in the Grampian Region has been studied. In the years 1990-1991, 93 patients had 104 amputations for vascular disease. Rehabilitation was supervised by a multidisciplinary team. The amputation level was: unilateral and below-knee (BKA), 55 patients; unilateral and above-knee (AKA), 27 patients; and bilateral (BA) in 11 patients. At a median follow-up of 27 months, survivors who had had a limb fitted were sent a questionnaire to assess their physical mobility. The response rate was 95%. There were 33 (60%) survivors in the BKA group. Fourteen patients (25%) indicated good mobility and seven (13%) indicated fair mobility. There were five (19%) survivors in the AKA group, only one of whom described fair mobility with a prosthetic limb. There were 5 (46%) survivors of BA. Two described good and one fair mobility. Although vascular amputees have a high mortality rate, physical mobility tends to be good in those fitted with a prosthesis after BKA.

Aggressive limb salvage using tibio-pedal bypass grafting with free tissue transfer in a diabetic patient.

A 63-year-old man presented with intermittent claudication, diabetes, and an ischaemic heel ulcer. After control of infection, the os calcis was left exposed. An aggressive combined infra-inguinal revascularization and reconstruction procedure involving free-tissue transfer resulted in rapid wound healing with independent walking by day 26. Recent improvements in surgical techniques mean that this approach should be considered in selected patients.

Upper-limb arterial disease in women treated for breast cancer.

A 5-year cohort of patients treated 15-19 years previously for breast cancer was studied to establish the prevalence of symptoms and objective evidence of circulatory insufficiency in the upper limbs. There were 187 survivors of the original cohort of 665. In all, 102 patients were evaluated; 50 had received radiotherapy in addition to surgery. Irradiated and non-irradiated groups were comparable for age, extent of axillary dissection and vascular risk factors. Both arms were assessed for symptoms and examined by Doppler ultrasonographically derived segmental pressures and hyperaemia testing, Doppler ultrasonographic waveform analysis, pulse volume recording and venous outflow air plethysmography. Seven ipsilateral arms (14 per cent) in patients given radiotherapy were symptomatic, compared with four (8 per cent) in those receiving surgery alone, and two contralateral control arms (2 per cent). Evidence of arterial disease was found in 11 ipsilateral arms of patients given radiotherapy (22 per cent) and two ipsilateral arms of those receiving surgery alone (4 per cent) (P < 0.03). There was no association between symptoms and evidence of arterial disease, and no evidence of abnormal venous function.

Hyperamylasaemia in ruptured aortic aneurysm: incidence and prognostic implications.

A study was carried out to determine the incidence of increased serum amylase activity in patients with ruptured aortic aneurysm during the 48 h after presentation and to assess its clinical significance. In a prospective series of 25 patients, hyperamylasaemia occurred in ten and was significantly associated with poor outcome (P = 0.005). In patients who died or had a major complication, serum amylase activity was significantly higher than in those who had an uncomplicated postoperative recovery (P < 0.05). There was a correlation between preoperative serum amylase activity and length of stay in the intensive care unit after operation (rs = 0.78 (95 per cent confidence interval 0.54-0.90), P < 0.002). Serum amylase activity may be useful as a prognostic indicator in patients with ruptured aortic aneurysm.

Pneumoperitoneum due to PCI in a patient with a strangulated femoral hernia.

Although pneumatosis cystoides intestinalis (PCI) is a well-recognised condition, an individual surgeon is unlikely to encounter it often. The collected experience of two surgical units in Glasgow teaching hospitals over a 15-year period consisted of five patients. Surgical and radiological trainees may therefore have little or no exposure to the diagnostic difficulties this condition can cause. We report an illustrative case.

A method of single-incision, four compartment fasciotomy of the leg.

A method of achieving four compartment fasciotomy of the leg using a single skin incision is described. This procedure may be used to decompress the leg in acute compartment syndromes.

Delayed presentation of bilateral popliteal artery injury.

We describe a patient who developed serious vascular complications following gunshot wounds to both popliteal fossae. There was minimal evidence of vascular injury on presentation to hospital, in particular ankle systolic pressures were normal. Five days following the initial injuries he was found to have a false aneurysm of the popliteal artery in his right leg and an arteriovenous fistula affecting the popliteal vessels of his left leg. The roles of arteriography and Doppler pressure studies in assessment of possible peripheral vascular injury following penetrating trauma are discussed. It is emphasised that a high index of suspicion and careful clinical review is essential if vascular injuries and their complications are not to be missed.

Ileal haemangiopericytoma and von Recklinghausen's disease.

Haemangiopericytoma is an uncommon tumour of vascular pericytes which usually arises in deep subcutaneous tissues or the retroperitoneum. There are few reports in the English literature of haemangiopericytoma arising in the ileum. Von Recklinghausen's disease, a condition of autosomal dominant inheritance with a prevalence of 1 in 3000, is often associated with tumours of neural origin. Tumours of non-neural origin also occur in Von Recklinghausen's disease but haemangiopericytoma has not been described. We report on a patient with Von Recklinghausen's disease presenting with massive haemorrhage from an ileal haemangiopericytoma.

The prognostic significance of marrow micrometastases in women with early breast cancer.

Twenty-five patients with early breast cancer (T0-T2, N0-N1, M0) have been studied prospectively to determine the relationship between marrow micrometastases, disease-free interval and survival. Marrow specimens were aspirated from three sites immediately prior to breast surgery. An immunocytochemical technique using monoclonal antibody LICR.LON.M8.4 was employed to detect micrometastases. The minimum follow-up was 38 months. Twelve of the 25 patients (48%) had micrometastatic lesions in their marrow at presentation. Four of these patients developed distal recurrence during follow-up, causing death in two of them. Five of the 13 patients with no evidence of micrometastases developed distant recurrence and four of them have died. There was no correlation between the state of the marrow and the development of metastatic disease, although axillary lymph node status, disease stage and tumour volume correlated significantly with outcome (all P less than 0.025). Micrometastatic lesions appear to be common in the marrow of patients with early breast cancer. We have been unable to demonstrate that they have prognostic significance.

The "isolated" popliteal segment: a comparative evaluation of its vascular resistance.

During femoro-popliteal and femoro-distal bypass, measurement of vascular resistance (VR) at the site of graft outflow may be used to quantify "run off". Intra-operative measurements were made in 51 lower limbs to compare VR in different categories of outflow; the "isolated" popliteal segment (IPS group, n = 11), the popliteal artery in continuity with patent vessels to the pedal arch (PIC group, n = 26) and the single calf vessel (SCV group, n = 14). VR was measured both before and after intra-arterial papaverine. The values in the 37 popliteal arteries were correlated with two different methods of arteriographic scoring. Vascular resistance in the IPS group (median 1149 mPRU, P = 0.003) but not significantly different from VR in the SCV group (median 1014 mPRU, range 743-1541 mPRU). VR in the SCV group was significantly greater than that in the PIC group (P = 0.006). After papaverine administration, the same relationships were observed between the IPS, PIC and SCV groups. Both before and after papaverine, VR in the popliteal artery correlated significantly with both arteriographic scores. In terms of VR, the isolated popliteal segment provides an outflow comparable to that of a single calf artery but less favourable than a popliteal artery wtih patent run off.

Outflow resistance and early occlusion of infrainguinal bypass grafts.

Distal outflow vascular resistance (VR) has been measured intra-operatively during 67 infrainguinal bypass procedures to establish whether it might have a role as a predictive test for early graft thrombosis. The graft outflow was popliteal artery above the knee (48), popliteal artery distal to the knee (6) or a single calf vessel (13). VR was measured before anastomosis of the graft, calculated from the relationship between pressure and flow in the outflow artery during infusion of the patient's own blood at a constant rate. VR was measured before and after vasodilation with papaverine. Primary graft patency at 30 days was documented. In the 10 limbs in which graft thrombosis occurred, VR was 1167 +/- 367 mPRU, significantly higher than VR in 57 limbs with a patent graft, 850 +/- 310 mPRU (P = 0.02, Mann-Whitney U test). After papaverine, VR was 823 +/- 368 mPRU in the limbs with a thrombosed graft, significantly higher than that of limbs with a patent graft, 463 +/- 211 mPRU (P = 0.001). VR appeared to show most promise as a predictor of early thrombosis in the group of femoro-tibial and femoro-peroneal grafts. In this group, the value of 800 mPRU after papaverine was 92% efficient and was 80% sensitive, 100% specific and had a predictive value of 100% for early thrombosis. Distal outflow VR is an important factor in early graft thrombosis and might have a practical application as a predictor of early thrombosis of femoro-distal bypass grafts.

Simultaneous aortic and renal artery reconstruction.

Nine patients presenting with combined aortic and renal artery disease underwent simultaneous infrarenal aortic reconstruction and renal revascularization. Seven patients had aneurysmal and two had occlusive aortic disease in association with unilateral (four cases) or bilateral (five cases) atheromatous renal artery stenosis. The indications for renal revascularization were hypertension (n = 8) refractory to medical treatment or associated with renal functional impairment and chronic renal failure alone (n = 1). Five patients developed postoperative complications with one fatality. Eight patients were followed up for between 7 months and 4 years. Control of blood pressure had improved in six of seven hypertensive patients. Serum creatinine levels were stabilized or had fallen in five patients. Simultaneous aortic and renal artery reconstruction is widely recognized as having a high postoperative morbidity rate but can improve control of hypertension and stabilize renal function in carefully selected patients.