Effect of diabetes on the cutaneous microcirculation of the feet in patients with intermittent claudication.

AIMS: To evaluate endothelial-dependent and - independent cutaneous vasodilator responses in the feet of patients with peripheral arterial disease (PAD) with or without Type 2 diabetes. METHODS: Cutaneous microvascular responses in the dorsum of both lower limbs were measured in the supine position using Laser Doppler Fluximetry combined with iontophoretic administration of endothelial-dependent (acetylcholine, Ach) and -independent (sodium nitroprusside, SNP) vasodilators in diabetic (n = 19) and non diabetic (n = 17) patients with PAD (presenting as unilateral calf intermittent claudication (IC). RESULTS: In patients with diabetes and IC, endothelial-dependent vasodilation was significantly impaired in the symptomatic limb [74 (57,105) vs 68 (24,81) PU, Z =-2.79, p = 0.005] compared to the asymptomatic limb. Patients without diabetes showed no impairment of vasodilation. Resting ankle-brachial pressure index did not identify the presence of abnormalities in microvascular function. CONCLUSIONS: The combination of diabetes and PAD is associated with a reduction in endothelial-dependent cutaneous vasodilation in the feet without an associated reduction in endothelial independent vasodilation.

Metabolic response of rectal cancer assessed by 18-FDG PET following chemoradiotherapy is prognostic for patient outcome.

BACKGROUND: Complete pathological response has proven prognostic benefits in patients with locally advanced rectal cancer treated with neoadjuvant chemoradiotherapy. Sequential 18-FDG PET may be an early surrogate for pathological response to chemoradiotherapy. OBJECTIVES: The aim of this study was to identify whether metabolic response measured by FDG PET following chemoradiotherapy is prognostic for tumor recurrence and survival following neoadjuvant therapy and surgical treatment for primary rectal cancer. METHODS: Patients with primary rectal cancer treated by long-course neoadjuvant chemoradiotherapy followed by surgery had FDG PET performed before and 4 weeks after treatment, before surgical resection was performed. Retrospective chart review was undertaken for patient demographics, tumor staging, recurrence rates, and survival. RESULTS: : Between 2000 and 2007, 78 patients were identified (53 male, 25 female; median age, 64 y). After chemoradiotherapy, 37 patients (47%) had a complete metabolic response, 26 (33%) had a partial metabolic response, and 14 (18%) had no metabolic response as assessed by FDG PET (1 patient had missing data). However, only 4 patients (5%) had a complete pathological response. The median postoperative follow-up period was 3.1 years during which 14 patients (19%) had a recurrence: 2 local, 9 distant, and 3 with both local and distant. The estimated percentage without recurrence was 77% at 5 years (95% CI 66%-89%). There was an inverse relationship between FDG PET metabolic response and the incidence of recurrence within 3 years (P = .04). Kaplan-Meier analysis of FDG PET metabolic response and overall survival demonstrated a significant difference in survival among patients in the 3 arms: complete, partial, and no metabolic response (P = .04); the patients with complete metabolic response had the best prognosis. CONCLUSION: Complete or partial metabolic response on PET following neoadjuvant chemoradiotherapy and surgery predicts a lower local recurrence rate and improved survival compared with patients with no metabolic response. Metabolic response may be used to stratify prognosis in patients with rectal cancer.

How good are newly qualified doctors at digital rectal examination?

AIM: Digital rectal examination (DRE) is an essential skill which all newly qualified doctors should have. There is evidence in the literature that junior doctors lack this important examination technique. The aim of our study was to determine, with the help of a questionnaire, the abilities of foundation year 1 (FY1) doctors to perform DRE. METHOD: A questionnaire was developed and sent to newly qualified FY1 doctors qualified in two universities (Nottingham and Sheffield) within the first 4 weeks of starting as a FY1 doctor. RESULTS: Ninety (75%) out of 120 questionnaires were completed. Most FY1 doctors had very little experience in performing DRE on a patient, and 68 (76%) had performed less than 10 procedures prior to qualification. Very few of these doctors had their clinical findings on DRE checked by a senior doctor (n = 7, 8%). Comparing DRE with other forms of examination, newly qualified doctors were most confident at groin hernia examination followed by testicular examination. They were least confident with vaginal examination and DRE (ANOVA P = 0.0082). CONCLUSION: Digital rectal examination is frequently performed by the most inexperienced doctor and may not be verified by a more senior colleague. More training and supervision of junior doctors are required both prior to qualification and during the early stages of their medical career.

Intraoperative radiotherapy and colorectal cancer.

Intraoperative radiotherapy (IORT) is a highly specialized component of multidisciplinary management of advanced and recurrent colorectal cancer. The aim of this review was to assess its role and effectiveness in the management of colorectal cancer. A literature search was performed using Medline, Embase, Ovid and Cochrane to identify English language studies which have used IORT in the multidisciplinary management of primary and recurrent colon and rectal cancers. Improved survival and local control in patients with involved surgical margins treated with IORT have been shown in many studies, but these results have been mainly from retrospective studies. There is associated morbidity from IORT. IORT does have a role in the management of colorectal cancer. Further research needs to be performed to optimize the application of this therapy.

Fibrin glue for the treatment of fistulae in ano--a method worth sticking to?

OBJECTIVE: The current evidence for fibrin glue as a treatment for anal fistulae is mixed. This study reviews the experience of fibrin glue as a treatment for anal fistulae in a single tertiary referral centre and attempts to identify factors related to failure of therapy and the length of follow-up required. METHOD: Patients with fistulae in ano that were treated with fibrin glue between February 2004 and August 2008 were analysed. All procedures were performed by two colorectal consultants based at the Queens Medical Centre, Nottingham. All patients were followed-up to assess the outcome of this treatment. RESULTS: Forty patients (21 male, 19 female) with a mean age of 46.5 years were studied. The mean duration of symptoms prior to presentation was 39 months (range 4-240 months). Presenting symptoms included perianal discharge (72.5%), perianal abscess (57.5%), pain (12.5%), PR bleeding (7.5%), itching (5%) and urgency (2.5%). Patients had a minimum of two follow-up appointments and the median follow-up period was 5.2 months (range 1-16 months). Following MRI and operative assessment, 28 (70%) of the 40 fistulae were considered complex (high trans-sphincteric, extra-sphincteric, pouch-vaginal). Patients who had inflammatory bowel disease were classified as simple tracts but all failed to heal (three patients). Twenty of the complex fistulae failed to heal. Three patients who had repeat application of glue for their complex fistulae failed to heal on follow-up. Of the remaining 12 patients who had simple fistulae in ano, five (41.7%) healed completely. There were no complications such as abscess, related to treatment. All patients who were asymptomatic at 3 months did not develop any further recurrence. CONCLUSION: Fibrin glue is a simple treatment strategy, preserves sphincter function with minimal adverse side effects. It should therefore be considered as possible first line treatment in simple fistulae but it is less likely to be successful in complex or those fistulae associated with inflammatory bowel disease. Repeat gluing is unlikely to be successful. Fistulae that have failed to heal by 3 months will need further treatment.

Colonic tattooing in laparoscopic surgery - making the mark?

OBJECTIVE: Laparoscopic surgery for colorectal cancer is now widespread. Small lesions in the colon can be difficult to palpate and with lack of tactile sensation, it is essential to accurately localize them preoperatively. This is a review article on current methods of tattooing including the use of different agents and associated complications. Aim To review current techniques in preoperative tumour localization and methods used for colonic tattooing including agents used, dosage and potential complications. METHOD: A literature search (Medline and Pubmed) was performed with manual cross referencing of all articles related to colonic tattooing. RESULTS: Methods for localizing colonic tumours for laparoscopic resection include preoperative barium enema examination, CT colonography and intraoperative colonoscopy. The most effective method is, however, by tattooing with India ink performed endoscopically before surgery. CONCLUSION: India ink is a reliable method of marking tumour location within the colon as prelude to laparoscopic resection. Surgeons must, however, be aware of potential complications associated with this technique.

Community nurses' practices in managing perianal abscesses.

A survey of community nurses identified that a wide range of dressings, and in some cases unethical practices, are being used for this simple postoperative condition. Communication between hospital, community staff and patients was poor.

Contrasting effects of varicose vein surgery on endothelial-dependent and -independent cutaneous vasodilation in the perimalleolar region.

OBJECTIVES: To evaluate the effects of varicose vein surgery on cutaneous microvascular perfusion and vasodilator responses to acetylcholine (Ach) and sodium nitroprusside (SNP) in the gaiter area of patients with great saphenous vein insufficiency. METHODS: Twenty-nine patients with isolated great saphenous vein incompetence attended three study mornings (before surgery, and 6-8 weeks and 6 months after sapheno-femoral ligation+partial stripping) during which cutaneous microvascular responses were measured in the supine and standing positions using laser Doppler fluximetry (LDF) combined with incremental-dose iontophoretic administration of endothelial-dependent (Ach) and -independent (SNP) vasodilators. RESULTS: Varicose vein surgery had no significant effect on baseline cutaneous perfusion or the microvascular response to Ach: e.g. peak vasodilator responses to the 1000 microC stimulus were mean 58 SEM 7, 64 SEM 6 and 65 SEM 7PU on the pre-operative, 6-8 weeks and 6 months assessments. In contrast, the corresponding responses to SNP were significantly increased following surgery: e.g. at 2000 microC, mean 63 SEM 9, 142 SEM 4 and 157 SEM 9PU (p<0.0001) in the upright position. CONCLUSIONS: Sapheno-femoral ligation and partial stripping in patients with great saphenous vein insufficiency improves endothelial-independent cutaneous vasodilator function at the gaiter area, which may at least partly explain the benefits of surgery in reducing the risk of venous ulceration.

Surgical treatment of in-growing toenails performed by senior house officers: are they good enough?

BACKGROUND: Although the surgical treatment of in-growing toenails is a common procedure, the success of ingrown toenail surgery is extremely variable and recurrences frequently impair the quality of lift of those who have this condition. In most hospitals this procedure is commonly performed by junior surgical trainees who may have little experience. AIM: We proposed to find out if the success of this procedure is operator-dependent by comparing the results of standard of toenail surgery performed by basic surgical trainees (BSTs) in our hospitals with already published data. METHODS: A retrospective analysis of nail bed ablation surgery performed by BSTs under local anaesthesia over a 15-month period in a district general hospital was conducted. RESULTS: 106 phenol ablations and 46 germinal matrix excisions were prformed. Symptomatic recurrence rates 12 months following the procedure were 5.7% for phenol ablation and 4.3% for germinal matrix excisions. CONCLUSION: Our results are comparable to published data, and we conclude that toenail ablation surgery can be just as successfully performed by junior surgeons after relatively little training in the procedure.

Effects of posture and venous insufficiency on endothelial-dependent and -independent cutaneous vasodilation in the perimalleolar region.

OBJECTIVES: To assess the effects of posture, endothelial function and venous insufficiency on cutaneous microvascular vasodilator function in the gaiter area, in particular defining factors which may affect microangiopathy and ulcer formation. METHODS: Endothelial-dependent and -independent vasodilator responses to incremental-doses of acetylcholine (Ach) and sodium nitroprusside (SNP) were evaluated in the perimalleolar region in the supine and standing positions in middle-aged patients with isolated superficial venous insufficiency (ISVI) (n = 25) and healthy controls (n = 28) using laser Doppler fluximetry (LDF) and iontophoresis of vasodilators. RESULTS: The venoarteriolar reflex (vasoconstriction on standing) was equally present in both groups, and reduced the vasodilator responses to SNP in the upright position (e.g., for patients with ISVI, peak SNP response was 82 +/- 11 PU [standing] vs 123 +/- 15 PU [supine]). The presence of ISVI had no effect on endothelial vasodilator function in the supine position, but on standing cutaneous reactivity to Ach was significantly reduced (e.g., peak Ach response 69 +/- 8 PU [ISVI] vs 109 +/- 11 PU [controls], p < 0.003). CONCLUSIONS: Upright posture impairs cutaneous endothelial-dependent vasodilation in the gaiter area of patients with ISVI. This may be of clinical and prognostic utility in identifying which patients with uncomplicated ISVI are at highest risk of tissue breakdown and ulcer formation in the gaiter area.

Does the angiotensin-converting enzyme (ACE) gene polymorphism affect rate of abdominal aortic aneurysm expansion?

OBJECTIVES: the tissue renin-angiotensin system (RAS), which plays an important role in vascular structure and function, is regulated in part by an insertion-deletion polymorphism of the angiotensin converting enzyme (ACE) gene. We hypothesised that ACE genotype might affect rate of AAA expansion via modulating long-term structural changes associated with RAS activation. METHODS: fifty-eight patients (50 M, mean age 70 years, mean initial aneurysm size 4.3 cm) with current or previous AAA and serial (>3) annual ultrasound measurements of antero-posterior AAA size provided a sample of leucocyte DNA for ACE genotyping. AAA expansion rate (cm per year) for individual subjects was calculated by linear regression. RESULTS: median AAA expansion rate was 0.28 cm/year (range 0-1.8 cm/year), and the genotype distribution included DD (n=14), DI (n=29) and II (n=15). Corresponding median AAA expansion rates for each of the three genetic subgroups were 0.22, 0.32 and 0.30 cm/year, respectively (p=0.6, nonparametric). CONCLUSIONS: the wide inter-individual variability in AAA expansion rate is likely to reflect complex genetic and environmental interactions, but the lack of any relationship with ACE genotype suggests that differences in vascular ACE activity in aortic tissue are not major determinants of the variability in rate of AAA dilatation.