Predicted shortage of vascular surgeons in the United Kingdom: A matter for debate?

BACKGROUND

Vascular surgery became a new independent surgical specialty in the United Kingdom (UK) in 2013. In this matter for debate we discuss the question, is there a "shortage of vascular surgeons in the United Kingdom?"

MATERIALS AND METHODS

We used data derived from the "Vascular Surgery United Kingdom Workforce Survey 2014", NHS Employers Electronic Staff Records (ESR), and the National Vascular Registry (NVR) surgeon-level public report to estimate current and predict future workforce requirements.

RESULTS

We estimate there are approximately 458 Consultant Vascular Surgeons for the current UK population of 63 million, or 1 per 137,000 population. In several UK Regions there are a large number of relatively small teams (3 or less) of vascular surgeons working in separate NHS Trusts in close geographical proximity. In developed countries, both the number and complexity of vascular surgery procedures (open and endovascular) per capita population is increasing, and concerns have been raised that demand cannot be met without a significant expansion in numbers of vascular surgeons. Additional workforce demand arises from the impact of population growth and changes in surgical work-patterns with respect to gender, working-life-balance and 7-day services.

CONCLUSIONS

We predict a future shortage of Consultant Vascular Surgeons in the UK and recommend an increase in training numbers and an expansion in the UK Consultant Vascular Surgeon workforce to accommodate population growth, facilitate changes in work-patterns and to create safe sustainable services.

Descending thoracic endovascular aneurysm repair: antegrade approach via ascending aortic conduit

Challenging access situations continue to arise in endovascular aneurysm repair, despite evolving arterial access techniques. We report a modified access approach, where an ascending aortic conduit was successfully used for antegrade delivery of a thoracic endograft to repair a descending thoracic aortic aneurysm, in a patient with previous surgical ligation of the infra-renal aorta.

Secondary Interventions and Mortality Following Endovascular Aortic Aneurysm Repair: Device-specific Results from the UK EVAR Trials

OBJECTIVES

To compare secondary intervention rate, aneurysm-related mortality and all-cause mortality for patients receiving elective endovascular aneurysm repair (EVAR) for large abdominal aortic aneurysms with different commercially available endografts.

DESIGN, MATERIALS & METHODS

In the EVAR 1 and 2 multi-centre trials, the principal endografts used were Zenith and Talent and these are compared in 505 patients from EVAR 1 and 143 patients from EVAR 2 followed-up for an average of 3.8 years until 31st December 2005. Outcomes were analysed by Cox proportional hazards regression, with adjustments for potential confounding risk factors and centre. Gore/Excluder graft outcomes also are reported.

RESULTS

Across the two trials the secondary intervention rates were 7.0 and 9.4 per 100 patient years for Zenith and Talent grafts respectively, adjusted hazard ratio 0.77 [95%CI 0.52-1.12]. Aneurysm-related mortality was 1.2 and 1.4 per 100 patient years for Zenith and Talent grafts respectively, adjusted hazard ratio 0.90 [95%CI 0.37-2.19]. All-cause mortality was 8.5 and 10.3 per 100 patient years for Zenith and Talent grafts respectively, adjusted hazard ratio 0.81 [95%CI 0.58-1.14]. The direction of all results was similar when the two trials were analysed separately.

CONCLUSION

There was no significant difference in the performance of the two endografts but the direction of results was slightly in favour of patients with Zenith (versus Talent) endografts.

Peripheral Seeding of Mycotic Aneurysms from an Infected Aortic Stent Graft

Aortic stent graft infection is rare and there are no reported cases of seeded peripheral mycotic aneurysms complicating this condition. We describe the case of a 54 year old man who developed a late stent graft infection at three years, resulting in the peripheral seeding of three mycotic aneurysms with two incidents of rupture. He was successfully treated with extra-anatomic bypass of the aorta and both surgical and endovascular repair of his peripherally seeded mycotic aneurysms.

The Mid-term Effect of Bare Metal Suprarenal Fixation on Renal Function Following Endovascular Abdominal Aortic Aneurysm Repair

OBJECTIVE

The aim of this study was to assess the mid term effect of proximal bare metal fixation design on renal function in patients undergoing endovascular repair (EVR) of abdominal aortic aneurysm (AAA).

METHODS

Consecutive EVR patients for AAA from December 1995-2001 were included and grouped to either infrarenal (Group 1) or uncovered suprarenal (Group 2) fixation. Peri-operative renal function and at 6, 12 and 24 months was determined by serum creatinine (sCr mmol l(-1)) and Cockroft-Gault creatinine clearance (CrC ml min(-1)). Changes in renal function were compared using non-parametric analysis.

RESULTS

Of the 179 EVR procedures during this six-year period, paired renal data was available for 135 patients at a minimal follow-up of 6 months (Gp1, n = 63; Gp2, n = 72). Median pre-EVR sCr and CrC were 113, 57 in Group 1 and 108, 58 in Group 2, p = NS. There was no significant deterioration in renal function within or between either group at 2 years post-EVR: median sCr, CrC values were 118, 56 (Group 1) and 111, 56 (Group 2), all p = NS.

CONCLUSION

This study suggests mid-term renal function remains unaffected following EVR of AAA, irrespective of proximal fixation type. Designs to improve stent durability and EVR applicability do not appear to compromise renal function.

The Vanguard Endovascular Stent-graft: Mid-term Results from a Single Centre

PURPOSE

Despite initial enthusiasm for endovascular aortic repair, few descriptions of longer-term follow-up of any endovascular device have been published. This paper represents the experience of a single centre with the Vanguard device over a 5-year period.

METHODS

Fifty-five patients with a median age of 71 years (range 45-87 years) and aneurysm diameter of 59 mm (45-84 mm) received a bifurcated Vanguard stent-graft between December 1995 and July 1999. Follow-up was according to the Eurostar criteria (clinical assessment, plain film radiography and computed tomography) at 1, 3, 6, 12, 18 and 24 months and then annually thereafter.

RESULTS

All primary stent deployments were successful. Median duration of surgery was 120 min (70-360 min). Median post-operative stay was 3 days (1-19 days) with a peri-operative mortality of 5.5%. In the follow-up period (median 40 months, range 6-64 months) there was one aneurysm associated death, and 14 deaths due to other causes. There have been three device migrations, 12 occluded graft limbs, four type II endoleaks and nine type III endoleaks. At 48 months, this has resulted in a survival rate of 67%, an endoleak free survival of 81% and intervention free survival of 59% (Kaplan-Meier).

CONCLUSION

Medium term results with the Vanguard device appear to be at least equivalent to open repair with regard to morbidity and mortality. Nevertheless, several delayed complications appear to be related to endograft limb distortion. Important lessons have been learnt in relation to the deployment of bifurcated endografts to reduce the incidence of secondary limb related problems.

Outcome following surgery for thoracic outlet syndrome

INTRODUCTION

the diagnosis of thoracic outlet syndrome (TOS) relies heavily on subjective rather than objective assessment criteria. Subsequently, published results after surgical decompression vary considerably. This study aimed to use a symptom-based patient-directed questionnaire to assess the outcome after decompression for TOS.

METHODS

sixty patients who underwent decompression procedures were identified from a prospectively maintained vascular database. Patient records were analysed for details regarding initial presentation, investigation, type of procedure used for decompression and management. Outcome questionnaires were sent to all identified patients to give a patient-based outcome measure.

RESULTS

eighty-four per cent of patients responded. In 90% of these patients there was an improvement in symptoms post-surgery with a median follow up of 43 months. The results were not influenced by the procedure or approach used.

CONCLUSION

surgery remains an effective tool in the management of TOS. A simple patient-directed questionnaire as used in this study could assist in the standardisation of outcome assessment.

Combined surgical and radiological procedures

Background

The aim was to audit the effect of provision of an interventional theatre on the management of vascular disease in a tertiary centre.

Methods

All patients undergoing joint vascular surgical and radiological procedures during 20 months were reviewed. Data are presented with respect to type of procedure, initial success and length of hospital stay.

Results

Between October 1997 and July 1999, 100 combined procedures were performed in an endovascular operating theatre. Sixty of these were for stent-graft repair of abdominal aortic aneurysm and are excluded from further analysis. Forty patients (23 men and 17 women, of median age 65 (range 37–80) years) underwent combined procedures for claudication (nine), rest pain (13), tissue necrosis (five), acute ischaemia (seven), iliac aneurysm (three), amaurosis fugax (one), arteriovenous malformation (one) and subclavian vein occlusion (one).

Combined intervention was successful initially in 35 patients. Of the five failures, three were technical (not possible to cross an occluded vessel) and two were due to absence of run-off vessels. There was no perioperative death. Median hospital stay was 9 (range 1–116) days.

Conclusion

These data confirm that patients requiring both radiological and surgical intervention can be treated successfully within the confines of an interventional operating suite. Cooperation and coordination between surgeon and radiologist allows the tailoring of procedures to the individual patient's needs.

Midterm results of a single endovascular device for repair of an abdominal aortic aneurysm: one centre's experience of the Vanguard device

Background

The aim of the study was to evaluate the midterm results of the Vanguard device.

Methods

All deployments performed in a single centre with follow-up according to EUROSTAR criteria were reviewed.

Results

Fifty-five patients underwent deployment of a Vanguard device between December 1995 and July 1999. All stents were implanted successfully, with a perioperative mortality rate of 5 per cent (three of 55 patients). Twelve systemic complications (23 per cent) and three access site complications (6 per cent) were observed. Predischarge computed tomograms revealed one type I and five type II endoleaks. Eleven patients died during follow-up (median 23·4 (range 6–48) months) (ten unrelated, one ruptured abdominal aortic aneurysm). The 2-year survival rate was 70 per cent. Eleven occluded graft limbs (22 per cent; median onset 18 months (range from 24 h to 36 months)), one graft migration and eight late endoleaks (16 per cent; median onset 24 (range 3–42) months) were observed. The 2-year intervention-free survival rate was 68 per cent, with an endoleak-free survival rate of 84 per cent. Median (range) neck diameter increased from 20 (15–23) to 23 (17–27) mm at 24 months (P < 0·01).

Conclusion

The onset of late endoleak and limb occlusion suggests that follow-up is essential, even after 36 months. The increasing neck diameter may prove significant with regard to long-term fixation of the proximal device.

A dual strategic approach to mega-aortic aneurysms

Staged resection of mega-aortas with Borst's two-stage elephant trunk (ETK) is the gold standard but has a higher mortality and morbidity compared to single-segment repair. We report the first case of combined surgical and covered-stent approach in Europe. Location and dilatation of the proximal landing zone accounts for the majority of failures in covered-stenting but an ETK is stable, easy to localise and gives an excellent seal. In high-risk cases where surgical resection is not offered, stenting is an option. The lack of a thoracotomy is an advantage in often-frail patients recovering from stage-I and shortens ITU-stay. Therefore, a combined approach is an acceptable alternative in selected individuals.

Fatal subdural haemorrhage following lumbar spinal drainage during repair of thoraco-abdominal aneurysm

A 63-year-old male patient collapsed and died from a major subdural haemorrhage 5 days after elective repair of a Type III thoraco-abdominal aortic aneurysm. The anaesthetic technique had included the use of a lumbar cerebrospinal fluid drain. The management of the patient is described, and the association between subdural haemorrhage and cerebrospinal fluid drainage is discussed.

Vascular surgical society of great britain and ireland: total abdominal approach for repair of type IV thoracoabdominal aortic aneurysm

BACKGROUND: The total transabdominal approach for thoracoabdominal aneurysm (TAA) was described in 1995 and it was suggested that outcome might be improved if the chest was not opened. This study reports early results of the technique with respect to operative morbidity and mortality rates for patients with abdominal aortic aneurysm extending to the diaphragm. METHODS: Between 1995 and 1998, 26 patients (median age 71 (range 52-84) years) underwent repair of a type IV TAA using a total abdominal approach and medial visceral rotation. RESULTS: Three patients presented with a contained leak. All survived but one developed paraplegia. Other complications included chest infection (five patients), myocardial infarction (three), reoperation for bleeding (three) and temporary dialysis in one patient. There were three perioperative deaths, two from myocardial infarction and one from multisystem organ failure. CONCLUSION: The total abdominal approach for the repair of type IV TAA is a reasonable alternative to a full thoracoabdominal incision. Thoracic complications are minimized, renal and visceral ischaemia times are low, and the perioperative mortality rate is acceptable.

Aortoiliac aneurysm with arteriocaval fistula treated by a bifurcated endovascular stent-graft

A 71-year-old patient with high-output cardiac failure was found to have an aneurysmal distal aorta with evidence of an arteriocaval fistula on ultrasound scanning. CT demonstrated an aneurysm of the distal aorta and right common iliac artery and an intraarterial digital subtraction angiogram confirmed an arteriocaval fistula. In view of the patient's cardiac failure and general condition an endovascular stent was considered. The right internal iliac artery was occluded with Tungsten coils prior to the insertion of a bifurcated stent-graft. This resulted in total occlusion of the aneurysm and obliteration of the arteriocaval fistula. To our knowledge such a case has not been previously reported.

Critical and subcritical ischaemia

OBJECTIVES

To stratify leg ischaemia into high and low risk groups with respect to outcome.

METHODS

An evaluation of 20 recent publications, reporting the results of 6118 patients with critical ischaemia. Low and high risk patient groups are identified by the definition of critical ischaemia. These groups are analysed with respect to outcome of the patient and limb.

MAIN OUTCOME MEASURES

Major amputation and mortality.

RESULTS

From these data subcritical (rest pain and/or ankle pressure > 40 mmHg, n = 4089) and critical (tissue loss and/or ankle pressure < 40 mmHg, n = 2029) risk group of patients was identified. The 1, 3 and 5-year mortality is 26%, 44% and 56% with or without reconstruction. For patients in the low risk group, 27% did not lose their leg within the year if treated conservatively. For patients in the high risk group, amputation was required by 95% if treated conservatively, compared to 25% if treated with arterial reconstruction.

CONCLUSION

Reconstructive surgery should be viewed from the following, more realistic, perspective. For patients with rest pain (and/or ankle pressure > 40 mmHg), 100% cumulative patency is equivalent to 64% resolution of symptoms at 1 year, as the rest may have improved without treatment. For high risk patients (tissue loss and/or ankle pressure < 40 mmHg), 100% cumulative patency is equivalent to 93% limb salvage at 1 year. Future reports should identify these two groups separately, as the dominant difference between outcome studies is the proportion of subcritical patients in the study rather than better surgical or radiological techniques. This stratification also has an important bearing on pharmacotherapy trials.

Isolated tibial vessel disease: treatment options and outcome

Tibial vessel disease is an important cause of limb ischaemia, particularly in diabetics. Revascularisation by angioplasty and bypass is increasingly feasible. The aim of this study was to review treatment and outcome in patients with this patterns of disease. We have performed 25 procedures in 20 patients since September, 1989. Six patients (5 diabetic) underwent 9 tibial angioplasties for stenotic lesions causing critical ischaemia or short-distance claudication. In 6 procedures there was single vessel run-off. Eight angioplasties were radiologically successful with a median increase in ankle-brachial index (ABI) of 0.15 [range: 0.00-0.44] at a median follow-up of 9 months. A further 4 patients (3 diabetic) with critical ischaemia underwent popliteal-distal, in-situ vein bypass for tibial occlusions. Distal anastomosis was onto the dorsalis pedis artery or distal anterior artery. Three grafts remain patent with successful limb salvage and ABI's greater than 1.0. Angioplasty is also useful for distal disease progression following femoro-popliteal bypass. Six patients with "at-risk" grafts underwent 8 tibial angioplasties for stenotic lesions in distal run-off. Radiologically, 6 procedures were successful with a median increase in ABI of 0.21 [range: 0.00-0.38] at a median follow-up of 7 months. There were less favourable results when a "graft-distal" bypass performed to salvage an occluded femoro-popliteal graft with diseased run-off vessels. Three of 4 grafts reoccluded within 3 months, 2 patients requiring amputation. We advocate an aggressive policy towards localised distal disease causing foot ischaemia.

Femorotibial bypass: the learning curve

Femorotibial bypass is still infrequently performed in many district hospitals, because it is time consuming and the risk of failure is high, especially during the learning curve. This article reviews the results of a single consultant surgeon and his team after starting femorotibial bypass de novo in a district general hospital. During the period 1987 to 1992, 85 femorotibial grafts were performed in 76 patients for ulceration and gangrene (57), rest pain (19) and severe claudication (9). Sixty-six were autogenous vein, 15 were PTFE with distal vein cuff, two were composites and two were umbilical vein. Overall, 22 grafts (26%) failed within the first 30 days (two were salvaged) and 21 amputations were required (five despite patent grafts). There were three early deaths (mortality 3.9%). At the end of 1993, 39 limbs had been amputated and 24 patients had died (eight with amputations). Twenty-three (44% of survivors) were alive with patent grafts. These disappointing early results were due to an initial technical learning curve, after which increased confidence may have led to reconstructing some patients with inadequate distal arteries. A more selective approach is now used. Limb salvage can be achieved in a worthwhile proportion of these patients and 3-year primary patency rates are similar to those of teaching hospitals in this country.

Preferential use of vein for above-knee femoropopliteal grafts

OBJECTIVES

Many centres preferentially use polytetrafluoroethylene (PTFE) for above-knee femoropopliteal bypass as surgery is simplified and patency rates are comparable to vein, which is preserved for subsequent revisions or for distal disease progression. In this Unit, vein remains first choice graft material. The aim of this study was to audit our results with respect to above-knee bypass to establish the demand for vein for secondary reconstruction and to document the ultimate fate of the limb.

PATIENTS

Between 1983 and 1992, 112 above-knee reconstructions were performed on 109 patients (89 vein and 23 PTFE grafts). PTFE was used where vein was absent or inadequate. Life table analysis of primary graft patency, limb salvage and patient survival up to 36 months follow-up concurs with previously reported series.

RESULTS

Twenty-eight vein grafts (31%) and 11 PTFE grafts (48%) occluded during a median follow-up of 64 months (8-116 months). In only four cases was vein required for secondary procedures. The remainder were salvaged by thrombectomy and local procedures for technical problems. Amputation rates following graft occlusion were 12% in the vein group (20% of these being above-knee) as against 26% in the PTFE group (80% above knee).

CONCLUSIONS

The demand for vein for secondary procedures is low. Amputation rates when vein grafts do occlude are half those of PTFE and amputation level is significantly influenced by graft type. We advocate preferential use of vein in above-knee femoropopliteal bypass.

Femoropopliteal angioplasty for severe limb ischaemia

Fifty patients undergoing 51 percutaneous transluminal angioplasties of the femoropopliteal segment for severe limb ischaemia were reviewed regularly. They comprised 30 men and 20 women of median age 70 (range 56-85) years. There were two deaths within 30 days. At 2 years the cumulative patient survival rate was 60 per cent. Eleven angioplasties were technical failures, 25 failed in the first 6 months and 14 were successful at 6 months' follow-up; in addition one patient died from myocardial infarction within 30 days of technically successful angioplasty. Subsequent vascular procedures were successful in 11 limbs following failed angioplasty. The primary limb survival rate was 42 per cent at 2 years. There were eight major complications after angioplasty, requiring amputation in five instances. Of the 23 long occlusions (greater than 5 cm) that were recanalized and dilated, 22 procedures failed within 6 months. The run-off score and diabetic status did not predict outcome. In this group of patients angioplasty had a low durability. Dilatation of long occlusions is associated with high rates of reocclusion and, on the basis of these results, should not be performed.

Effect of weight on claudication distance

Conservative measures to improve claudication distance include advice on smoking, exercise, diet and weight reduction. Although the effects of smoking, exercise and diet are established, the effect of weight is less clear. The aim of this study was to investigate the effect of carrying extra weight on the maximum walking distance in stable claudicants. Twenty stable claudicants were exercised on a treadmill (3.5 km/h, 0 degrees slope) carrying 0, 2.5, 5, 7.5 and 10 kg weights in randomized sequence. Maximum claudication distance and ankle: brachial pressure indices were recorded. Patients were categorized into mild or severe claudicants depending on their ability to walk 200 m. A response index (RI) was calculated as the reduction in claudication distance per kilogram load; RI = [CD0-CD10]/10 m/kg, where CD0 and CD10 represent claudication distance with 0 and 10 kg weights, respectively. Claudication distance was significantly reduced in subjects carrying 5 kg or more (P less than 0.01). A linear relationship was demonstrated between the mean claudication distance and the load carried (r = 0.98, P less than 0.01) with a mean response index of 10.2 m/kg. The mean(s.e.m.) RI in mild claudicants (25.9(9.5) m/kg) was greater than the value observed in the severe claudicants (3.3(0.8) m/kg; P less than 0.01, Mann-Whitney U test). This study demonstrates that weight adversely affects claudication distance and suggests that weight reduction may deserve greater emphasis in the management of some patients with intermittent claudication.

Primary squamous cell carcinoma of the caecum

A case of primary squamous cell carcinoma of the caecum arising in a tubulo-villous adenoma is described. This rare lesion develops following genomic derangement of the multipotential colonic stem cells. The literature is reviewed and factors contributing towards squamous cell differentiation discussed.

Intra-arterial streptokinase infusion in acute lower limb ischaemia

Between 1986 and 1988, 38 patients (29 men and nine women), median age 65 years (range 38-85 years), underwent local intra-arterial streptokinase therapy for acute lower limb ischaemia. Three patient groups were identified: 15 with acute on chronic ischaemia (group 1), 12 postangioplasty (group 2) and 11 postfemorodistal bypass (group 3). Distal arteriographic run-off was a significant discriminant between success and failure in group 1 (n = 15, chi 2 = 11.5, P = 0.001) and in the overall group (n = 38, chi 2 = 17.2, P less than 0.001). In group 2, four patients with good run-off had an unsuccessful outcome; this was due in all cases to technical problems (haemorrhage in two and intimal dissection in two). In group 3, two patients with good run-off had unsuccessful streptokinase infusions. In both cases the graft failed in the early postoperative period (less than 30 days). By contrast, the four patients whose grafts occluded after 30 days had successful streptokinase infusions and long-term graft patency was achieved by further surgery and balloon dilatation. In all groups, no patient with a poor run-off had a successful outcome following streptokinase administration. The role of local intra-arterial streptokinase therapy in the critically ischaemic limb remains controversial, but these results suggest that an adequate run-off is an important factor in the selection of patients for treatment.

Impedance analysis to identify the at risk femorodistal graft

Computer-assisted impedance analysis is a newly developed technique to identify femoropopliteal and distal vein graft stenoses before failure. Pulsatile flow is measured from the proximal and distal graft by use of an 8Mhz Doppler velocimeter. A pulse volume recorder measures pulsatile pressure within the thigh and calf. Fourier transfer analysis is performed on paired Doppler pulse volume recorder waveforms and an impedance score derived for the thigh and calf, respectively. In a retrospective review of 50 nonreversed femoropopliteal/distal grafts performed for limb salvage, postoperative biplanar intraarterial digital subtraction arteriography was compared with impedance analysis. Arteriography showed graft or runoff stenoses in 22 grafts (at risk) and 28 normal grafts (controls). Impedance scores were significantly higher in the at risk group (0.58 + [0.43 to 0.72]*), when compared with the controls (0.34 + [0.30 to 0.38], p less than 0.001*). A thigh or calf impedance score of greater than 0.45 was able to detect 20 of 22 stenoses, including 6 lesions in grafts with normal resting and postexercise ankle pressures. This score was then applied prospectively and compared with serial biplanar digital subtraction arteriography in a further 56 femoropopliteal/distal bypasses for limb salvage. Thirty-three of 34 lesions were successfully predicted and impedance scores were significantly higher in the at risk limbs (0.56 + [0.44 to 0.68]*) when compared with the controls (0.38 + [0.35 to 0.41], p less than 0.001*). In this series impedance analysis proved more sensitive than resting or stressed ankle pressures and, unlike Duplex scanning, was able to detect runoff as well as graft stenoses.(ABSTRACT TRUNCATED AT 250 WORDS)

Theatre delay for emergency general surgical patients: a cause for concern?

The delay involved in operating on emergency general surgical patients is often excessive. This problem has been examined prospectively in a district general hospital with a catchment population of 450,000. Over a 16-week period, the details of 204 consecutive general surgical emergency operations were recorded and analysed. Following essential resuscitation, the median delay in operating on emergency general surgical patients was 3 h. Eighty-eight patients had to wait in excess of 1 h, with 15% experiencing a delay of over 6 h. In only 10% of cases was a theatre required after midnight, yet 26% of all emergency general surgical operating was performed between midnight and 8 am. The majority of delays were due to a combination of factors; theatre delay was mentioned in 47% of cases, anesthetic delay in 30% and the overrunning of routine lists in 14% of cases. Our results suggest that unnecessary theatre delay results in an unacceptable number of emergency general surgical operations occurring after midnight. It is important that routine afternoon lists do not overrun, as this contributes directly to evening theatre delay. If both theatre and anaesthetic availability could be ensured in the afternoon and early evening, the after midnight workload could be cut from 26% to 10%, and staff sleep deprivation reduced.

An objective comparison of four stress tests in the assessment of "at risk" femoro-distal grafts

Femoro-distal vein grafts for limb salvage have a 30% failure rate at 6 months. Graft surveillance may enable the "at risk" grafts to be recognised and corrected, but there remains the need for a simple test to identify these patients. The ankle pressure response to exercise and reactive hyperaemia has been investigated prospectively in 40 "at risk" femoro-distal non-reversed grafts (median age 73 years, range 51-87 years, M/F = 33:7), defined as those with a resting ankle brachial index less than 0.9 or a drop of greater than 0.2 following a stress test. Four different stress tests have been assessed; active ankle plantar-dorsiflexion for 2 minutes (I), occlusive calf cuff 50 mmHg above systolic pressure for 2 minutes (II), treadmill exercise test for 1 minute, slope = 10%, at 3 km/hr (III) and 4 km/hr (IV). Ankle brachial indices (ABI's) were recorded before and immediately following each test and expressed as mean % drop +/- standard error of mean. Test I was only tolerated by 45% of patients whereas 55% and 50% could complete tests III and IV respectively. By contrast, 85% of patients could tolerate occlusive cuff hyperaemia (test II). Test I produced a significantly lower mean percentage drop in ABI when compared with each of the others (p less than 0.02, Mann U Whitney). There was an excellent correlation between test II and both the 3 km/hr (r = 0.77, p less than 0.001) and 4 km/hr (r = 0.84, p less than 0.001) exercise tests.(ABSTRACT TRUNCATED AT 250 WORDS)

Management of high grade parotid carcinomas

Thirty-four patients admitted to the Bristol Royal Infirmary during the 20-year period 1966-85 and diagnosed as suffering from high grade parotid carcinoma were studied. The male:female ratio was 2.4:1, with a mean age at presentation of 68 years. Facial swelling was present in all patients with a mean duration of 9.9 months before treatment. Pain, deep fixation, facial nerve involvement, ulceration and distal metastases were all associated with a poor prognosis. Diagnosis was made either at operation or by fine needle biopsy. All 34 patients received radiotherapy. Fourteen patients (41 per cent) underwent a definitive surgical procedure. The local recurrence rates for the non-surgical and surgically treated groups were 30 per cent (six patients) and 36 per cent (five patients) respectively; twelve patients (60 per cent) in the non-surgical group developed distant metastases as opposed to six patients (43 per cent) in the surgical group. Both local and distant recurrent disease are indicators of poor prognosis, with only one patient alive at 104 months. Seven patients (21 per cent) remain recurrence free. Definitive surgery, combined with radiotherapy, improved survival in those with amenable localized disease.

Prostatectomy in the over 80-year-old

With an ageing population the demand for prostatectomy in the over 80-year-olds is increasing. This study assesses the place of prostatectomy in this age group. All patients over the age of 80 who underwent prostatectomy in a 2-year period were studied retrospectively; 90 such patients underwent 94 operations, 90 of which were TURPs. Serious concomitant disease was found in 64 patients (71%) and 11 (12%) had had a previous prostatectomy at least 1 year before. The mean weight of tissue removed was 24.8 g. In 18 men histology showed malignant change. Two men died from cardiovascular disease immediately after surgery (2.1%); a further 5 patients (7.8%) died within 6 months. Post-operative morbidity was high, with 64 patients (71%) developing complications. These were related to pre-operative urinary tract infections and uraemia. Nevertheless, at 6 weeks 72 patients (80%) were considered to have had a satisfactory result. Prostatectomy in the over 80-year-old has a good long-term outcome. Although the morbidity rate is high, these patients should be considered for operation provided they undergo careful pre-operative assessment.

The malignant potential of colorectal Crohn's disease

Six patients developed colorectal carcinoma in association with Crohn's disease. The cancer was diagnosed at a mean age of 46 years and a mean 19 years after the onset of Crohn's disease. Five carcinomas arose in the chronically inflamed segment of bowel, while a sixth arose in caecum previously bypassed for Crohn's ileitis. Four carcinomas were mucinous, four presented with fistula and four were treated by complete removal of the large intestine. Three patients have died of residual or recurrent cancer. The data support an aetiological link between Crohn's proctocolitis and carcinoma.

A preliminary study of the role of gastrointestinal endocrine cells in the maintenance of villous structure following X-irradiation

The mechanism of gastrointestinal villous damage following ionizing irradiation is complex. Various compartments within the gastrointestinal tract have in turn been considered important for the maintenance of normal villous structure. To date, however, evidence for a single overriding regulator of epithelial well-being is lacking. In this study, the role of the gastro-intestinal (enteroendocrine) cells is explored and comparison made between endocrine cell number and villous structure. Experiments were organised using both control and irradiated groups of mice. Two time points (1 and 3 days) and three radiation doses (6, 10 and 18Gy) were employed. A simple method for endocrine cell identification and subsequent quantification is described. Endocrine cell number was then compared with villous surface detail, as seen with a scanning electron microscope (SEM). Results indicated a decrease in the endocrine cell number at all three radiation doses. Whereas at low doses endocrine cell recovery occurred between 1 and 3 days, at medium and high doses further decline was noticed. A similar pattern was seen when considering villous surface structure. It is suggested that both scanning electron microscopy and endocrine cell number provide a more sensitive indicator of gastrointestinal radiation damage than do current crypt counting techniques. In addition, a link between endocrine cell number and villous structure is proposed.