Neovascularisation after surgery for recurrent saphenofemoral incompetence: does surgical dissection technique matter?

BACKGROUND: The effect of the type of surgery on neovascularisation in the groin is unknown. The aim of the present study was to compare three different surgical techniques used for recurrent saphenofemoral incompetence in view of their effect on neovascularisation in the groin at short- and long-term follow-up after surgery. PATIENTS AND METHODS: 36 consecutive patients undergoing surgery for recurrent saphenofemoral incompetence were randomised. 12 patients underwent sharp dissection with knife or scissors and excision and ligation of scar tissue using absorbable suture material; 12 had dissection with electrocoagulation and 12 dissection with ultrasound (Ultracision Harmonic Scalpel). Clinical outcome was assessed using the venous clinical severity score and venous disability score, and the saphenofemoral junction was evaluated by means of duplex sonography three months and seven years after the operation respectively. If neovascularisation was present, the maximal diameter of new refluxing veins in the groin was measured. RESULTS: There was no statistically significant difference between the three surgical techniques. Duplex ultrasound showed neovascularisation with an average maximal diameter (± standard error) of the newly formed refluxing vessel of respectively 2.00 (± 0.63) mm, 1.00 (± 0.45) mm and 0.50 (± 0.50) mm after three months and 4.29 (± 1.41) mm, 3.32 (± 0.90) mm and 3.00 (0.83) mm after seven years (no significant difference between groups). After seven years no reflux was detected in 8/36 patients, no varicose veins were found in 14/36 patients. The patients were less symptomatic than before our redo operation and no one needed reoperation within the seven years. CONCLUSIONS: Dissection techniques in the groin did not influence the clinical and sonographic result at 3 months and at 7 years after redo surgery for recurrent varicose veins.

Truncular vascular malformations in a varicose vein surgery patient cohort.

BACKGROUND: To determine the incidence and significance of vascular malformations in a varicose vein surgery patient cohort in a prospective cohort study. PATIENTS AND METHODS: During a ten year time span we prospectively searched for patients with vascular malformations within a varicose vein surgery cohort. All patients underwent colour duplex sonography and surgery for symptomatic chronic venous disease or chronic venous insufficiency corresponding to clinical classes C2 to C6 according to CEAP. RESULTS: Five out of 1488 patients had truncular vascular malformations. One patient had an arterio-venous malformation in the groin. Venous malformations were found in three marginal veins and one bone perforating vein. Two of these five patients had a mitral valve prolapse syndrome, one a persistent foramen ovale, one had a bone cyst in a finger and one ectromelia of the hands and feet, respectively. No complications occurred following surgical treatment of these five malformations. CONCLUSIONS: Truncular arterio-venous and venous malformations in a varicose vein surgery patient cohort are rare. In our cohort the hemodynamic impact of the vascular malformations was low, the surgical treatment combined with varicose vein surgery resulted in technical and clinical success.

Primary surgery for sapheno-femoral incompetence: A randomised controlled trial to compare two techniques to reduce lymphatic complications.

BACKGROUND: We prospectively compared lymphatic complications after two types of surgery for primary sapheno-femoral incompetence: sharp dissection with meticulous ligation of lymphatic tissue and electrocoagulation technique respectively. PATIENTS AND METHODS: 154 consecutive patients undergoing surgery for bilateral primary sapheno-femoral incompetence were randomised. Each side was the control for the other side. 154 groins underwent sharp dissection with ligation of lymphatic tissue using absorbable suture material and 154 controls had a dissection performed with electrocoagulation. RESULTS: There was no lymphocoele, no relevant lymphorrhea and no extremity oedema in either group. Three patients had a minor lymphatic discharge in both groins, self-limiting within 24 hours (1.9%). There were no significant differences between the two groups. CONCLUSIONS: Lymphatic complications in primary surgery for sapheno-femoral incompetence are very rare. There is no detectable advantage of sharp dissection with ligation of lymphatic tissue over dissection with electrocoagulation without ligatures.

Tumors associated with superficial thrombophlebitis.

BACKGROUND: To assess the incidence of malignant tumors in patients with thrombophlebitis of the leg with regard to potential early tumor detection. PATIENTS AND METHODS: 140 consecutive patients were enrolled over a period of over 9 years in a retrospective follow-up study based on the electronic patient record. RESULTS: There were 18 patients (12.9%) suffering from thrombophlebitis in association with a malignant tumor: breast cancer in seven patients, colon carcinoma and haematologic cancer in four, skin cancer in three patients and one case each of oesophageal, prostatic, kidney and neck cancer . In two patients thrombophlebitis preceded the diagnosis of the malignancy. Superficial thrombophlebitis may have been associated in four cases (2.9%) with a benign tumor. CONCLUSIONS: Breast, colonic, haematological and skin cancer were mainly associated with superficial thrombophlebitis in our patients. In case of a thrombophlebitis without a known malignancy a thorough clinical examination with special regard to skin, breast and abdomen is mandatory.

Recurrence after surgery for varices in the groin is not dependent on body mass index.

OBJECTIVE: To investigate if the body mass index (BMI) differs between different groups of patients (incomplete ligation also defined as technical error, neo-revascularisation, uncertain and mixed) in recurrent same site inguinal varices after surgery (REVAS). METHODS: During a six and half year time span, we retrospectively analysed 203 consecutive procedures in 153 patients undergoing recurrent same site vein surgery in the groin. Individual BMI was calculated and compared within the different REVAS nature of the source groups. RESULTS: The median BMI was 28 for patients undergoing recurrent vein surgery in the groin with no relevant difference in BMI between the different source groups (confidence interval for the difference of adjusted group means equals [-1.5, 2.6]). CONCLUSIONS: There is no relevant difference in BMI between the two commonest REVAS groups. This may be due to small sample size, but confidence limits for difference of.

Follow-up after deep venous thrombosis in azygos continuation.

BACKGROUND: To determine the sequelae of patients after deep venous thrombosis inpatients with azygos continuation defined as agenesis of the inferior vena cava with collateral flow. PATIENTS AND METHODS: Five patients post deep venous thrombosis in the context of azygos continuation were followed up clinically and with colour duplex ultrasonography. RESULTS: All five patients had to our knowledge after the initial deep venous thrombosis no further thromboembolic events. Three patients after isolated iliac thromboses are symptom free or nearly symptom free, two after more extended thromboses still sufferfrom venous claudication. Four patients are without anticoagulation, one patient is permanently orally anticoagulated. CONCLUSIONS: Azygos continuation may not influence the risk of recurrent venous thrombo-embolism nor the outcome of a deep venous thrombosis. Careful deep venous thrombosis prophylaxis in patients with azygos continuation may be sufficient when a risk factor is present but conclusions lack due to the small numbers of patients of enough supportive data.

A randomised trial of ultrasonic dissection versus electrocoagulation to reduce lymphatic complications after surgery for recurrent sapheno-femoral incompetence.

OBJECTIVE: Prospectively to compare lymphatic drainage after ultrasonic dissection, an electrocoagulation technique and sharp dissection in the groin during surgery for recurrent sapheno-femoral incompetence. DESIGN: Prospective, randomised study comparing three surgical techniques. METHODS: Thirty-six consecutive patients undergoing surgery for recurrent sapheno-femoral incompetence were randomised. Twelve patients underwent dissection with ultrasound, 12 with electrocoagulation and 12 controls had sharp dissection with ligation of scar and lymphatic tissue using absorbable suture material. RESULTS: The mean drain output per patient was 13.5 ml in the ultrasonic group, 15.4 ml in the electrocoagulation group and 8.3 ml in the suture ligation group. Six minor cases of lymphatic leakage occurred in the ultrasonic group. This resulted in no clinical problem. There were no other significant differences between the three groups. CONCLUSIONS: There is no detectable advantage for the use of ultrasound or electrocoagulation in recurrent saphenous high ligation compared to sharp dissection.

Morbidity in superficial thrombophlebitis and its potential surgical prevention.

Thrombophlebitis is a common condition which can lead to deep venous thrombosis (DVT) and subsequent pulmonary embolism (PE). Thrombophlebitis can reach the deep venous system via the long or short saphenous vein or via perforating veins. Between the 1st of January 1999 and the 31st of December 2000 a total of 17 cases of superficial (or ascending) thrombophlebitis closer than 5 cm to the deep venous system were surgically treated in our clinic. 14 times the long saphenous vein was affected and 3 times the short-saphenous vein. The age of the nine females and seven males ranged from 31 to 77 (mean of 54.6) years. Duplex ultrasound was performed in all patients. In the case of a deep venous thrombosis (four cases) a computer tomography scan (CT) of the pelvis and abdomen was performed to define the extension of DVT. In all 17 (100%) cases a high ligation (crossectomy) and in four (23.5%) cases a venous thrombectomy was performed. In all of these four cases the DVT was limited to the common femoral vein. In all seventeen procedures including venous thrombectomy there was no mortality and no relevant morbidity. Mean hospitalization time was 3.1 days for crossectomy with thrombectomy, and 1.8 days for crossectomy alone. Follow-up has been so far uneventful (mean follow-up time being 12 months in the case of a DVT). In the literature there is no clear concept of how to treat, conservatively or operatively, ascending thrombophlebitis. The surgical procedure can be performed under local anesthesia, and it is safe and efficient.

A randomized controlled trial to determine the effect of humidified carbon dioxide (CO2) insufflation on postoperative pain following thoracoscopic procedures.

BACKGROUND: It has previously been shown that the insufflation of humidified gas during laparoscopy results in less postoperative pain than is observed following the use of dry gas. Experimental evidence also suggests that dry gas insufflation during thoracoscopy results in greater structural injury to the pleura than occurs with the use of humidified gas. The present study was designed to determine the effect of humidified gas insufflation on postoperative pain following thoracoscopic procedures. METHODS: Forty consecutive patients were prospectively randomized. Twenty patients were insufflated with humidified carbon dioxide (CO(2)), and 20 control patients received standard dry CO(2). RESULTS: The patients' analogue pain score was significantly lower following humidified gas insufflation compared to dry gas insufflation when assessed at 6 h postoperatively, as well as on the 1st, 2nd, 3rd, and 14th postoperative days. The postoperative morphine consumption was lower in the humidified group than it was in the control group. The incidence of respiratory complications was identical for both groups. CONCLUSION: The use of humidified gas appears to reduce postoperative pain but not the rate of respiratory complications.

Proximalized lateral tunnel for the bypass to the dorsalis pedis artery -- a safe way to go.

BACKGROUND: Wound complications associated with bypass grafting to the dorsalis pedis artery are frequent, and threaten the viability of the bypass and the limb. METHODS: The long saphenous vein can be tunneled from its bed down the lateral side of the anterior margin of the tibia for subsequent anastomosis with the dorsalis pedis artery. CONCLUSION: The proximalized lateral tunnel for the bypass to the dorsalis pedis artery has the advantage of protecting the bypass graft from exposure if the patient develops wound breakdown.

Bronchial anatomy and single-lung ventilation in the pig.

PURPOSE: To explore why two pigs died in the course of a study in which a double-lumen tube (DLT) was used to achieve single-lung ventilation, the bronchial anatomy of all six pigs involved in the study was examined at autopsy. METHODS: Autopsy involved examination of the lungs in situ and subsequent dissection of the lung tissue from the lobular bronchi. RESULTS: All six pigs were found to have an apical lobe (or lobular) bronchus arising from the trachea. In three it was on the right, as is usual in pigs, and in three, including the two that died, it was on the left. The mainstem bronchi to both lungs were short in all pigs, with major segmental bronchi arising just distal to the carina. CONCLUSION: The bronchial anatomy of the pig is such that the inflated cuffs of commercially available DLTs may cause partial or complete obstruction of the apical bronchi of one or both lungs, regardless of the side of the tracheal bronchus. The transmission of the resulting breath sounds across the narrow pig thorax can make auscultation unhelpful in assisting with optimal tube placement.

Pain after laparoscopy.

BACKGROUND: In the context of the much-heralded advantages of laparoscopic surgery, it can be easy to overlook postlaparoscopy pain as a serious problem, yet as many as 80% of patients will require opioid analgesia. It generally is accepted that pain after laparoscopy is multifactorial, and the surgeon is in a unique position to influence many of the putative causes by relatively minor changes in technique. METHODS: This article reviews the relevant literature concerning the topic of pain after laparoscopy. RESULTS: The following factors, in varying degrees, have been implicated in postlaparoscopy pain: distension-induced neuropraxia of the phrenic nerves, acid intraperitoneal milieu during the operation, residual intra-abdominal gas after laparoscopy, humidity of the insufflated gas, volume of the insufflated gas, wound size, presence of drains, anesthetic drugs and their postoperation effects, and sociocultural and individual factors. CONCLUSIONS: On the basis of the factors implicated in postlaparoscopy pain, the following recommendations can be made in an attempt to reduce such pain: emphathically consider each patients' unique sociocultural and individual pain experience; inject port sites with local anesthesia at the start of the operation; keep intra-abdominal pressure during pneumoperitoneum below 15 mmHg, avoiding pressure peaks and prolonged insufflation; use humidified gas at body temperature if available; use nonsteroidal anti-inflammatory drugs at the time of induction; attempt to evacuate all intraperitoneal gas at the end of the operation; and use drains only when required, rather than as a routine.

A randomized controlled trial to determine the effects of humidified carbon dioxide insufflation during thoracoscopy.

BACKGROUND: The humidification of gas insufflated during laparoscopy can reduce the degree of postoperative hypothermia and may result in less peritoneal reaction and less postoperative pain. The present study was designed to determine whether the beneficial effects of humidified gas insufflation also applied to thoracoscopy. METHODS: Six pigs were each studied on three separate occasions with insufflation into the right thoracic cavity of either humidified gas, standard dry gas, or with no insufflation (control procedure). Core body temperature was recorded every 15 min, and biopsies of the parietal pleura were taken at the end of each study for electron microscopy. RESULTS: Humidification of insufflated gas significantly minimized the fall in core temperature during the procedure. Electron microscopy showed that dry gas insufflation resulted in greater structural injury to the pleura than humidified gas insufflation. CONCLUSIONS: The potential benefits of humidifying insufflation gas during thoracoscopy warrant its evaluation in the clinical setting.

A randomized controlled trial assessing the benefit of humidified insufflation gas during laparoscopic surgery.

BACKGROUND: We conducted a randomized controlled trial during laparoscopic cholecystectomy to determine the extent of heat preservation and postoperative pain reduction using humidified carbon dioxide (CO2) gas insufflation instead of standard dry insufflation gas. METHODS: Forty consecutive patients were randomized. Twenty patients received humidified CO2, and 20 control patients received standard CO2 insufflation. A sample of 16 patients from each group was evaluated for postoperative pain levels. RESULTS: No adverse effects from the humidification of insufflated gas were observed. There was no significant difference in core body temperature between the two groups for this brief operation. Pain, as assessed by the Analogue Pain Score (APS) was significantly less for the group with humidified gas insufflation than for the control group at 6 h postoperatively as well as on the 1st, 2nd, and 3rd postoperative day and at follow-up 10 days after the operation. In the humidified group, the mean time to return to normal activities was significantly less-5.9 days, as compared to 10.9 days in the control group. CONCLUSIONS: The use of humidified insufflation gas reduces postoperative pain following laparoscopic cholecystectomy, but except for these relatively brief procedures, the heat-preserving effect of humidified gas insufflation is not significant.

Rationale and intended use for the Veress needle: a translation of the original descriptive article.

The technical development of equipment in the last decade has resulted in a rapid expansion in the range of procedures capable of being performed safely by a laparoscopic technique. For many procedures, the first step is induction of a pneumoperitoneum. This has inherent danger, and there is disagreement on the preferred technique. The Veress needle is an instrument developed in the 1930s that has continued to be used into the 1990s. In view of the controversy about its present role, the authors reviewed the article that provided the original description of the needle. This review demonstrates that the designer had a clear intention for its use and an understanding of the hazards involved. In his hands, the complications were few. A translation of the article from German into English is provided.

A large duplication cyst of the stomach in an adult presenting as pancreatic pseudocyst.

Intestinal duplication is a rare congenital disease. It appears throughout the gastrointestinal tract, especially in the ileum. Here we describe the rare case of a gastric duplication cyst in a 59-year-old patient. Diagnostic findings and surgical therapy are discussed. Gastric duplications in adults are extremely rare, and diagnosis is often missed. Symptoms are unspecified pain in the upper abdomen, vomiting and fever, with some patients having weight loss. Complications are rare. Chronic infections and ruptures are described. For diagnosis, CT scan with oral contrast is preferred. Endoscopy is negative in most cases. Therapy is surgery. Local excision of a small wall of gastric mucosa is sufficient in most cases, but sometimes a subtotal gastrectomy is necessary.

Looking back to the advent of modern endoscopy: 150th birthday of Maximilian Nitze.

This year, 1998, marks the 150th anniversary of the birthday of Maximilian Nitze (1848-1906), a German scientist responsible for the initiation of modern endoscopy: He integrated two of his ideas in the construction of the first functional cystoscope. Nitze realized that the field of view during endoscopy could be enlarged by the use of an optical system, and that the light source should be placed on the tip of the instrument. He presented this cystoscope on October 2, 1877 for the first time, at age 28 years.