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Abstract
This article outlines the current best practice in the management of varicose veins. “Varicose veins” traditionally means bulging veins, usually seen on the legs, when standing. It is now a general term used to describe these bulging veins, and also underlying incompetent veins that reflux and cause the surface varicose veins. Importantly, “varicose veins” is often used for superficial venous reflux even in the absence of visible bulging veins. These can be simply called “hidden varicose veins”. Varicose veins usually deteriorate, progressing to discomfort, swollen ankles, skin damage, leg ulcers, superficial venous thrombosis and venous bleeds. Patients with varicose veins and symptoms or signs have a significant advantage in having treatment over conservative treatment with compression stockings or venotropic drugs. Small varicose veins or telangiectasia without symptoms or signs can be treated for cosmetic reasons. However, most have underlying venous reflux from saphenous, perforator or local “feeding veins” and so investigation with venous duplex should be mandatory before treatment. Best practice for investigating leg varicose veins is venous duplex ultrasound in the erect position, performed by a specialist trained in ultrasonography optimally not the doctor who performs the treatment. Pelvic vein reflux is best investigated with transvaginal duplex ultrasound (TVS), performed using the Holdstock-Harrison protocol. In men or women unable to have TVS, venography or cross-sectional imaging is needed. Best practice for treating truncal vein incompetence is endovenous thermal ablation. Increasing evidence suggests that significant incompetent perforating veins should be found and treated by thermal ablation using the transluminal occlusion of perforator (TRLOP) approach, and that incompetent pelvic veins refluxing into symptomatic varicose veins in the genital region or leg should be treated by coil embolisation. Bulging varicosities should be treated by phlebectomy at the time of truncal vein ablation. Monitoring and reporting outcomes is essential for doctors and patients; hence, participation in a venous registry should probably be mandatory.
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Dos Santos SJ, Holdstock JM, Harrison CC, Lopez AJ, Whiteley MS. Ovarian Vein Diameter Cannot Be Used as an Indicator of Ovarian Venous Reflux. Eur J Vasc Endovasc Surg 2015; 49:90-4. [PMID: 25457295 DOI: 10.1016/j.ejvs.2014.10.013] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Accepted: 10/17/2014] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Previous research into pelvic venous reflux has suggested that the size of the ovarian veins indicates the presence or absence of reflux. It is already known that vessel diameter is not an indicator of reflux in the great saphenous vein. However, to this day, physicians still use vein size to plan treatment of refluxing ovarian veins. The authors aimed to investigate whether or not vessel diameter can be used as an indicator of reflux in the ovarian veins. METHODS Nineteen female patients (mean 40.2 years, range 29-60) presenting to a specialist vein unit with leg varicose veins underwent duplex ultrasonography (DUS). All were found to have a significant pelvic contribution to their leg reflux on transvaginal duplex ultrasonography (TVS) and were referred to an interventional radiologist for treatment by transjugular coil embolization. During the procedure, the diameter of the ovarian veins was measured using digital subtraction venography. RESULTS Thirty-four ovarian veins were measured (17 right, 17 left) and of these 18 were found to be non-refluxing while 16 displayed reflux. The mean diameter of the non-refluxing veins was 7.2 mm (range 3-13 mm)and that of the refluxing veins was 8.5 mm (range 4-13 mm). This difference was found to be insignificant at a 95% confidence level (Student t test, p = .204). CONCLUSIONS There is no significant difference between the diameters of competent and refluxing ovarian veins and, as such, techniques that measure vein diameter may not be suitable for the diagnosis of venous reflux in the ovarian veins.
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Whiteley MS, Dos Santos SJ, Harrison CC, Holdstock JM, Lopez AJ. Transvaginal duplex ultrasonography appears to be the gold standard investigation for the haemodynamic evaluation of pelvic venous reflux in the ovarian and internal iliac veins in women. Phlebology 2014; 30:706-13. [PMID: 25324278 DOI: 10.1177/0268355514554638] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES To assess the suitability of transvaginal duplex ultrasonography to identify pathological reflux in the ovarian and internal iliac veins in women. METHODS A retrospective study of patients treated in 2011 and 2012 was performed in a specialised vein clinic. Diagnostic transvaginal duplex ultrasonography in women presenting with symptoms or signs of pelvic vein reflux were compared with the outcomes of treatment from pelvic vein embolisation. A repeat transvaginal duplex ultrasonography was performed 6 weeks later by a blinded observer and any residual reflux was identified. RESULTS Results from 100 sequential patients were analysed. Mean age 44.2 years (32-69) with mode average parity of 3 (0-5 deliveries). Pre-treatment, 289/400 veins were refluxing (ovarian - 29 right, 81 left; internal iliac - 93 right, 86 left). Coil embolisation was successful in 86/100 patients and failed partially in 14/100 - 5 due to failure to cannulate the target vein. One false-positive diagnosis was made. CONCLUSION Currently there is no accepted gold standard for pelvic vein incompetence. Comparing transvaginal duplex ultrasonography with the outcome from selectively treating the veins identified as having pathological reflux with coil embolisation, there were no false-negative diagnoses and only one false-positive. This study suggests that transvaginal duplex ultrasonography could be the gold standard in assessing pelvic vein reflux.
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Affiliation(s)
- M S Whiteley
- The Whiteley Clinic, Stirling House, Guildford, Surrey, UK Faculty of Health and Medical Sciences, University of Surrey, UK
| | - S J Dos Santos
- The Whiteley Clinic, Stirling House, Guildford, Surrey, UK Faculty of Health and Medical Sciences, University of Surrey, UK
| | - C C Harrison
- The Whiteley Clinic, Stirling House, Guildford, Surrey, UK
| | - J M Holdstock
- The Whiteley Clinic, Stirling House, Guildford, Surrey, UK
| | - A J Lopez
- The Imaging Clinic, Mount Alvernia Hospital, London, UK
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Smith EA, Patel SB, Whiteley MS. Evaluating the success of Nd: YAG laser ablation in the treatment of recalcitrant verruca plantaris and a cautionary note about local anaesthesia on the plantar aspect of the foot. J Eur Acad Dermatol Venereol 2014; 29:463-7. [PMID: 24910163 DOI: 10.1111/jdv.12579] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Accepted: 05/05/2014] [Indexed: 12/01/2022]
Abstract
BACKGROUND There are various methods advocated for the treatment of verruca plantaris. However, many verrucas do not respond to simple treatment. OBJECTIVE This study presents our results using Nd: YAG laser ablation therapy for such recalcitrant cases. METHODS We performed a retrospective audit by sending a questionnaire to all patients with recalcitrant verrucas who had been treated with Nd:YAG laser ablation over the previous 12 months. The questionnaire asked whether treatment had been successful, successful but new lesions had emerged, partially successful with improvement or unsuccessful. A Fontana Nd:YAG laser was used at the following specifications; long pulsed mode with pulse width 25 ms, frequency 1.0 Hz; fluence 240 J/cm(2) and spot size 2 mm. Some patients requested local anaesthesia and had direct infiltration with 0.5% plain lidocaine. RESULTS Fifty-three of the original 87 patients responded (60.9% response rate) with a male to female ratio of 24:29, mean age of 47 years and an age range between 22-72. Thirty-seven patients reported complete success post treatment (69.8%) and a further five reported improvement. The remaining 11 felt their treatment was unsuccessful. The cure rate was 81.8% in unilateral single cases, 68.1% in unilateral multiple cases and 65% in bilateral cases. Ten patients requested sublesional lidocaine injections of which 4 had skin breakdown after Nd: YAG ablation. CONCLUSION Nd:YAG laser ablation is effective in the treatment of recalcitrant verruca plantaris. However, we caution against the use of direct local anaesthesia infiltration before laser treatment.
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Affiliation(s)
- E A Smith
- Chiropodist and Podiatrist at the Whiteley Clinic, Guildford, UK
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Holdstock JM, Dos Santos SJ, Harrison CC, Price BA, Whiteley MS. Haemorrhoids are associated with internal iliac vein reflux in up to one-third of women presenting with varicose veins associated with pelvic vein reflux. Phlebology 2014; 30:133-9. [PMID: 24755923 DOI: 10.1177/0268355514531952] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To determine the prevalence of haemorrhoids in women with pelvic vein reflux, identify which pelvic veins are associated with haemorrhoids and assess if extent of pelvic vein reflux influences the prevalence of haemorrhoids. METHODS Females presenting with leg varicose veins undergo duplex ultrasonography to assess all sources of venous reflux. Those with significant reflux arising from the pelvis are offered transvaginal duplex ultrasound (TVS) to evaluate reflux in the ovarian veins and internal Iliac veins and associated pelvic varices in the adnexa, vulvar/labial veins and haemorrhoids. Patterns and severity of reflux were evaluated. RESULTS Between January 2010 and December 2012, 419 female patients with leg or vulvar varicose vein patterns arising from the pelvis underwent TVS. Haemorrhoids were identified on TVS via direct tributaries from the internal Iliac veins in 152/419 patients (36.3%) and absent in 267/419 (63.7%). The prevalence of the condition increased with the number of pelvic trunks involved. CONCLUSION There is a strong association between haemorrhoids and internal Iliac vein reflux. Untreated reflux may be a cause of subsequent symptomatic haemorrhoids. Treatment with methods proven to work in conditions caused by pelvic vein incompetence, such as pelvic vein embolisation and foam sclerotherapy, could be considered.
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Affiliation(s)
- J M Holdstock
- The Whiteley Clinic, Stirling House, Stirling Road, Guildford, Surrey, UK
| | - S J Dos Santos
- The Whiteley Clinic, Stirling House, Stirling Road, Guildford, Surrey, UK Faculty of Health and Medical Sciences, University of Surrey, Guildford, Surrey, UK
| | - C C Harrison
- The Whiteley Clinic, Stirling House, Stirling Road, Guildford, Surrey, UK
| | - B A Price
- The Whiteley Clinic, Stirling House, Stirling Road, Guildford, Surrey, UK
| | - M S Whiteley
- The Whiteley Clinic, Stirling House, Stirling Road, Guildford, Surrey, UK Faculty of Health and Medical Sciences, University of Surrey, Guildford, Surrey, UK
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Thomas CA, Holdstock JM, Harrison CC, Price BA, Whiteley MS. Healing rates following venous surgery for chronic venous leg ulcers in an independent specialist vein unit. Phlebology 2013; 28:132-9. [DOI: 10.1258/phleb.2012.011097] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Objectives This is a retrospective study over 12 years reporting the healing rates of leg ulcers at a specialist vein unit. All patients presented with active chronic venous leg ulcers (clinical, aetiological, anatomical and pathological elements [CEAP]: C6) and had previously been advised elsewhere that their ulcers were amenable to conservative measures only. Method Seventy-two patients (84 limbs) were treated between March 1999 and June 2011. Patients were contacted in August 2011 by questionnaire and telephone. Of 72 patients, two were deceased and two had moved location at follow-up, so were not contactable. Fifty patients replied and 18 did not (response rate 74%), representing a mean follow-up time of 3.1 years. Results Ulcer healing occurred in 85% (44 of 52 limbs) of which 52% (27) limbs were no longer confined to compression. Clinical improvement was achieved in 98% of limbs. Conclusions This study shows that a significant proportion of ulcers currently managed conservatively can be healed by surgical intervention.
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Affiliation(s)
- C A Thomas
- Southampton University Medical School, Southampton
| | - J M Holdstock
- The Whiteley Clinic, Stirling House, Guildford, Surrey, UK
| | - C C Harrison
- The Whiteley Clinic, Stirling House, Guildford, Surrey, UK
| | - B A Price
- The Whiteley Clinic, Stirling House, Guildford, Surrey, UK
| | - M S Whiteley
- The Whiteley Clinic, Stirling House, Guildford, Surrey, UK
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Whiteley AM, Taylor DC, Whiteley MS. Pelvic Venous Reflux is a Major Contributory Cause of Recurrent Varicose Veins in more than a Quarter of Women. J Vasc Surg Venous Lymphat Disord 2012; 1:100-1. [PMID: 26993904 DOI: 10.1016/j.jvsv.2012.10.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
| | - D C Taylor
- The Whiteley Clinic, Guildford, United Kingdom
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Whiteley MS. Letter regarding: 'The role of perforators in chronic venous insufficiency' by TF O'Donnell. Phlebology 2010;25:3-10. Phlebology 2010; 25:314; author reply 315-6. [PMID: 21107003 DOI: 10.1258/phleb.2010.010013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Marsh P, Price BA, Holdstock JM, Whiteley MS. One-year outcomes of radiofrequency ablation of incompetent perforator veins using the radiofrequency stylet device. Phlebology 2010; 25:79-84. [DOI: 10.1258/phleb.2009.008084] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Objectives Early success treating incompetent perforator veins (IPVs) with radiofrequency ablation (RFA) and the trend to move varicose vein surgery into a walk-in walk-out service led to the design of a specific device enabling RFA of IPVs using local anaesthesia (ClosureRFS™ stylet). Our aim was to assess one-year outcomes of a clinical series of patients undergoing treatment with this device. Truncal reflux, where present, was treated initially, and RFA of IPVs was performed as a secondary procedure. Method Duplex ultrasound examinations were performed and the presence of IPVs documented. Results were compared with preoperative scans. IPVs were classified as closed, not closed/reopened or de novo. Results Of the 75 patients invited for follow-up, 53 attended at a median time of 14 months (range 11–25). Sixty-seven limbs were analysed (M:F 1:2.1, median age 62, range 25–81). Of the 124 treated IPVs, 101 were closed (82%). Clinical, aetiological, anatomical and pathological clinical score was improved in 49.3% limbs. IPV closure was reduced in patients with recurrent varicose veins compared with primary varicose veins (72.3% versus 87%, P = 0.056). Conclusion These results demonstrate the radiofrequency stylet device to be an effective treatment for IPVs.
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Affiliation(s)
- P Marsh
- The Whiteley Clinic, 1 Stirling House, Stirling Road, Guildford, GU2 7RF, UK
| | - B A Price
- The Whiteley Clinic, 1 Stirling House, Stirling Road, Guildford, GU2 7RF, UK
| | - J M Holdstock
- The Whiteley Clinic, 1 Stirling House, Stirling Road, Guildford, GU2 7RF, UK
| | - M S Whiteley
- The Whiteley Clinic, 1 Stirling House, Stirling Road, Guildford, GU2 7RF, UK
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Marsh P, Holdstock J, Harrison C, Smith C, Price BA, Whiteley MS. Pelvic vein reflux in female patients with varicose veins: comparison of incidence between a specialist private vein clinic and the vascular department of a National Health Service district general hospital. Phlebology 2009; 24:108-13. [DOI: 10.1258/phleb.2008.008041] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Objectives Mounting evidence suggests that pelvic vein reflux is an important contributing factor to recurrent varicose veins. We compared the incidence in our specialist private unit (Unit A) with that of a District General Hospital (Unit B). Methods Results of all female patient lower limb duplex ultrasound (LLDUS) and transvaginal pelvic ultrasound (TVUS) scans performed over a one-year period were retrospectively reviewed. Patients with refluxing veins emanating from the abdomen or pelvis on LLDUS (non-saphenous reflux) routinely proceeded to TVUS in Unit A. Results In Unit A, non-saphenous reflux on LLDUS was present in 90–462 female patients (19.5%). In 81.1% of these, TVUS confirmed reflux in truncal pelvic veins (incidence 15.8%). In Unit B, non-saphenous reflux was present in 60–279 female patients (21.5%). Conclusion One in five women presenting with varicose veins have reflux of non-saphenous origin. This is the case in specialist and non-specialist units. One in six has associated pelvic vein reflux.
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Affiliation(s)
- P Marsh
- The Whiteley Clinic, 1, Stirling House, Stirling Road, Guildford GU2 7RF
- The Royal Surrey County Hospital, Egerton Road, Guildford, Surrey GU2 7XX, UK
| | - J Holdstock
- The Whiteley Clinic, 1, Stirling House, Stirling Road, Guildford GU2 7RF
| | - C Harrison
- The Whiteley Clinic, 1, Stirling House, Stirling Road, Guildford GU2 7RF
| | - C Smith
- The Whiteley Clinic, 1, Stirling House, Stirling Road, Guildford GU2 7RF
- The Royal Surrey County Hospital, Egerton Road, Guildford, Surrey GU2 7XX, UK
| | - B A Price
- The Whiteley Clinic, 1, Stirling House, Stirling Road, Guildford GU2 7RF
| | - M S Whiteley
- The Whiteley Clinic, 1, Stirling House, Stirling Road, Guildford GU2 7RF
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Bacon JL, Dinneen AJ, Marsh P, Holdstock JM, Price BA, Whiteley MS. Five-year results of incompetent perforator vein closure using TRans-Luminal Occlusion of Perforator. Phlebology 2009; 24:74-8. [DOI: 10.1258/phleb.2008.008016] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
In 2000, we developed a percutaneous method of treating incompetent perforator veins (IPV) using ultrasound-guided radiofrequency ablation (RFA), which we termed TRansluminal Occlusion of Perforator (TRLOP). Objective To audit the five-year outcome of the TRLOP technique as indicated by the rate of IPV closure on duplex ultrasound (DUS). Methods Patients underwent DUS five years post-TRLOP. Experienced vascular technologists documented the presence of IPVs using a two co-ordinate system, blinded to previous results. Results were then compared with preoperative scans. IPVs were classified as: closed; not closed/reopened; or de novo. Closed IPVs were defined as the absence of any IPV at or within 5 cm of a previous IPV in the vertical and horizontal plane. Any IPVs found outside the delineated area were defined as de novo IPVs. Results Of 67 patients invited, 37 attended DUS (55% participation rate; men to women ratio of 14:23, age 40–84; mean 64). Preoperative clinical, aetiological, anatomical and pathological classification: C2, 36.2%; C3, 27.6%; C4, 34.5%; C6, 1.7%. From 125 IPVs analysed, 101 were closed (81%), 24 were not closed/reopened (19%) and 14 de novo IPVs were found. Discussion Despite these results representing our learning curve for the procedure, we found TRLOP to be an effective treatment for IPVs. The closure rates described are comparable with the published clinical series data for subfascial endoscopic perforator surgery.
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Affiliation(s)
- J L Bacon
- The Whiteley Clinic, Stirling Road, Guildford, UK
| | - A J Dinneen
- The Whiteley Clinic, Stirling Road, Guildford, UK
| | - P Marsh
- The Whiteley Clinic, Stirling Road, Guildford, UK
| | | | - B A Price
- The Whiteley Clinic, Stirling Road, Guildford, UK
| | - M S Whiteley
- The Whiteley Clinic, Stirling Road, Guildford, UK
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Kianifard B, Holdstock J, Allen C, Smith C, Price B, Whiteley MS. Randomized clinical trial of the effect of adding subfascial endoscopic perforator surgery to standard great saphenous vein stripping. Br J Surg 2007; 94:1075-80. [PMID: 17701962 DOI: 10.1002/bjs.5945] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND This randomized trial was undertaken to investigate the fate of incompetent perforating veins (IPVs) following saphenofemoral ligation and stripping of the great saphenous vein (GSV), with or without subfascial endoscopic perforator surgery (SEPS). METHODS Patients with venous reflux (greater than 0.5 s) of the GSV and additional IPVs were allocated randomly to standard surgery (saphenofemoral ligation, stripping and phlebectomies alone) or with the addition of SEPS. Patients with ulceration, recurrent veins, deep venous reflux/thrombosis or saphenopopliteal reflux were excluded. Duplex ultrasonography was carried out before operation, and at 1 week, 6 weeks, 6 months and 1 year after surgery. Quality of life questionnaires were completed and visual analogue scale scores collected at the same time points. RESULTS Thirty-eight patients were allocated to SEPS and 34 to the no SEPS group. Two patients in the no SEPS group were excluded (one withdrew and the other had the wrong treatment). There were no differences between the two groups with respect to pain, mobility or quality of life scores during follow-up. A significantly higher proportion of patients in the no SEPS group had IPVs on duplex imaging at 1 year (25 of 32 versus 12 of 38; P < 0.001). CONCLUSION IPVs do not remain closed following standard varicose vein surgery. The addition of SEPS was not associated with significant morbidity but did reduce the number of IPVs. Up to 1 year this had no effect on recurrence rates or quality of life, but late results remain to be seen. REGISTRATION NUMBER ISRCTN18288048 (http://www.controlled-trials.com).
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Affiliation(s)
- B Kianifard
- Department of Vascular Surgery, Royal Surrey County Hospital, Guildford, UK
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Affiliation(s)
- P Marsh
- The Whiteley Clinic, 1 Stirling House, Stirling Road, Guildford GU2 7RF, UK
| | - B A Price
- The Whiteley Clinic, 1 Stirling House, Stirling Road, Guildford GU2 7RF, UK
| | - M S Whiteley
- The Whiteley Clinic, 1 Stirling House, Stirling Road, Guildford GU2 7RF, UK
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Munasinghe A, Smith C, Kianifard B, Price BA, Holdstock JM, Whiteley MS. Strip-track revascularization after stripping of the great saphenous vein. Br J Surg 2007; 94:840-3. [PMID: 17410557 DOI: 10.1002/bjs.5598] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Abstract
Background
Varicose veins that recur after standard high tie and strip are often associated with venous reflux in the thigh, as shown by duplex ultrasonography. The aim of this study was to look for evidence of revascularization in the strip track after great saphenous vein (GSV) stripping.
Methods
A consecutive series of patients with duplex-proven great saphenous varicose veins underwent saphenofemoral ligation with intraoperative confirmation of successful stripping. Duplex ultrasonography was performed 1 week and 1 year after surgery. The presence and extent of haematoma was noted, as was any venous reflux within the strip track.
Results
At 1 year, four (6 per cent) of 70 patients had complete revascularization of the strip track and 12 (17 per cent) had partial revascularization, all with duplex-proven reflux. Partial revascularization was in the distal third of the track in six legs (9 per cent of the 70 patients), in the distal half in five (7 per cent) and was almost complete in one leg (1 per cent). All patients with revascularization had a significant strip-track haematoma at 1 week after surgery.
Conclusion
Revascularization of the GSV strip track after stripping was found in 23 per cent of patients after 1 year; all of these had a postoperative haematoma in the track.
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Affiliation(s)
- A Munasinghe
- Department of Vascular Surgery, Royal Surrey County Hospital, Guildford, UK
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Whiteley MS, Lewis G, Holdstock JM, Smith C, Harrisone CS, McGuinness CL, Price BA. Minimally invasive technique for ligation and stripping of the small saphenous vein guided by intra-operative duplex ultrasound. Surgeon 2006; 4:372-3, 375-7. [PMID: 17152202 DOI: 10.1016/s1479-666x(06)80113-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Small saphenous vein (SSV) disconnection and removal are challenging and considered by some authors to have too high a morbidity and failure rate to justify their routine use. Our audited results are at variance with these views. METHODS We describe a reliable, ultrasound guided, minimally invasive technique for ligation and stripping of the SSV with an incision usually <1 cm. From our total series, 50 random patients attended for ultrasound review. The sapheno-popliteal junction (SPJ), strip track and signs of recurrence were assessed and recorded. RESULTS Since 1999, 627 patients (679 limbs) have undergone surgery for ultrasound proven SSV reflux. Fifty-two limbs (50 patients) were ultrasound assessed post-operatively. Fifty-one had flush ligation of the SPJ with one showing a 'stump' <1 cm. All showed successful SSV removal. Three limbs had minor strip track revascularisation but none had obvious clinical recurrence. Of the whole series, 11/627 (1.8%) developed proven deep vein thrombosis (DVT). There were six superficial wound infections and one strip track abscess. Sural nerve neurapraxia occurred in 13/627 (2.1%); one showing no sign of recovery at four weeks post-operatively. CONCLUSIONS Ultrasound guided SSV is a safe, minimally invasive technique with high success and low recurrence and complication rates
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Affiliation(s)
- M S Whiteley
- The Whiteley Clinic, Stirling House, Stirling Road, Guildford, Surrey, GU2 7RF, UK.
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Kianifard B, Holdstock JM, Whiteley MS. Radiofrequency ablation (VNUS closure®) does not cause neo-vascularisation at the groin at one year: Results of a case controlled study. Surgeon 2006; 4:71-4. [PMID: 16623160 DOI: 10.1016/s1479-666x(06)80032-6] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Despite adequate training in the surgical treatment of varicose veins, recurrence continues to be a problem and a burden to the vascular services. A major cause of recurrence is reported to be neo-vascularisation at the sapheno-femoral junction (SFJ). The aim of this study was to compare the incidence of neo-vascularisation at the SFJ following radiofrequency ablation (RFA) and open high saphenous tie and stripping (HSTS). MATERIALS AND METHODS Fifty-one patients (55 legs) underwent standardised HSTS as part of a prospective study. These were compared with an age (range 28-83, mean 54.4) and sex (male:female 31:20) matched group of patients treated during the same time period, by the same consultant vascular surgeon, using RFA (VNUS closure). Each patient had a pre-operative duplex scan to confirm SFJ reflux, a one-week scan to confirm successful surgery and a one-year post-operative scan to assess neo-vascularisation. The same vascular technologist performed all scans. Neo-vascularisation was identified by the presence of refluxing tortuous vessels arising from the area of the SFJ. RESULTS AND CONCLUSION Six of 55 (11%) legs in the open surgery group showed clear evidence of tortuous refluxing veins related to the SFJ. None of the 55 in the RFA group showed any neo-vascularisation at the SFJ (Fischer exact test P = 0.028). Further randomised controlled trials are necessary to confirm these observations.
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Affiliation(s)
- B Kianifard
- The Royal Surrey County Hospital, Guildford, UK
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Whiteley MS, Georgen M, Azagra JS, Braithwaite BD, Gear MWL, Kumar S, Bremner DN. Herniation at the site of cannula insertion after laparoscopic cholecystectomy. Br J Surg 2005. [DOI: 10.1002/bjs.1800801138] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- M S Whiteley
- Department of Surgery, Royal United Hospital, Bath BA1 3NG, UK
| | - M Georgen
- Department of Abdominal Surgery, CHU A Vesale, B-6110 Montigny-Le-Tilleul, Belgium
| | - J S Azagra
- Department of Abdominal Surgery, CHU A Vesale, B-6110 Montigny-Le-Tilleul, Belgium
| | - B D Braithwaite
- Department of Surgery, Gloucestershire Royal Hospital, Gloucester GL1 3NN, UK
| | - M W L Gear
- Department of Surgery, Gloucestershire Royal Hospital, Gloucester GL1 3NN, UK
| | - S Kumar
- Department of Surgery, Borders General Hospital, Roxburghshire TD6 9BS, UK
| | - D N Bremner
- Department of Surgery, Borders General Hospital, Roxburghshire TD6 9BS, UK
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Fassiadis N, Kianifard B, Holdstock JM, Whiteley MS. Ultrasound changes at the saphenofemoral junction and in the long saphenous vein during the first year after VNUS closure. INT ANGIOL 2002; 21:272-4. [PMID: 12384650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
Abstract
BACKGROUND The VNUS Closure is an endoluminal, percutaneous catheter-based device using a radiofrequency current to cause permanent closure of the long saphenous vein (LSV) as an alternative to high tie and stripping. This study describes our postoperative ultrasound scan surveillance results of VNUS Closure cases over a one year period. METHODS Between March and August 2000, 79 patients had 127 legs treated. Postoperative ultrasound scans were performed in order to evaluate persistence of a patent superficial inferior epigastric vein at the saphenofemoral junction (SFJ), stump length of the remaining SFJ and changes in morphology and diameter of the ablated LSV. Ten legs were chosen randomly for this evaluation at each follow-up appointment. RESULTS Fifty-seven per cent of the patients' legs had a patent SFJ-stump with a remaining patent superficial epigastric vein but none of the patients showed neovascularisation at the SFJ or recanalisation of the LSV. The stump length at the SFJ appeared to be getting smaller as our experience grew greater. CONCLUSIONS This new technique of radiofrequency ablation provides a minimal access alternative to the classical high tie and stripping. Our results to date show that this procedure leaves a small patent stump at the SFJ with no evidence of neovascularisation and a completely atrophied closed LSV.
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Affiliation(s)
- N Fassiadis
- Department of Vascular Surgery, Royal Surrey County Hospital, Guildford, UK.
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Fassiadis N, Kianifard B, Holdstock JM, Whiteley MS. A novel approach to the treatment of recurrent varicose veins. INT ANGIOL 2002; 21:275-6. [PMID: 12384651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
Abstract
BACKGROUND A variety of approaches has been described for the treatment of recurrence at the saphenofemoral junction (SFJ) after primary varicose vein surgery most, of them based on dissection through virgin tissue. This observational study describes our clinical experience with the VNUS Closure, a percutaneous catheter-based procedure in which the long saphenous vein (LSV) is ablated from within by resistive heating. METHODS Twelve patients who had undergone previous high tie and stripping procedures had 18 legs treated with the VNUS Closure between March 1999 and April 2000. In one patient VNUS Closure was performed also in an anterior thigh branch. Postoperative ultrasound scans were performed at regular intervals in order to assess successful closure of the LSV. RESULTS None of the patients showed recanalisation of the LSV during the duplex ultrasound scan surveillance and the only complication related to the VNUS Closure noted were sensory disturbances at the inner thigh in 6 legs. CONCLUSION This new endovascular technique is the authors' preferred method of treating recurrent varicose veins where an incompetent LSV persists either due to neovascularisation at the saphenofemoral junction or to a persisting midthigh perforator.
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Affiliation(s)
- N Fassiadis
- Department of Vascular Surgery, Royal Surrey County Hospital, Guildford, UK.
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20
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Kianifard B, Price S, Whiteley MS. Clipping perforators without dividing them could reduce postoperative pain and swelling following subfascial endoscopic perforator surgery. Ann R Coll Surg Engl 2002; 84:210-1. [PMID: 12092881 PMCID: PMC2503824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023] Open
Affiliation(s)
- B Kianifard
- Department of Vascular Surgery, Royal Surrey County Hospital, Guildford, UK
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21
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Rutherford EE, Kianifard B, Cook SJ, Holdstock JM, Whiteley MS. Incompetent Perforating Veins are Associated with Recurrent Varicose Veins. Eur J Vasc Endovasc Surg 2001; 21:458-60. [PMID: 11352523 DOI: 10.1053/ejvs.2001.1347] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
AIMS we suspected incompetent perforating veins of having a role in the development of recurrent varicose veins in some patients. The aim was to look for an association between perforators and recurrent varicose veins. METHODS a consecutive group of patients presenting with varicose veins were examined using colour duplex ultrasonography by an experienced vascular technologist. Pathological perforating veins were defined as those exhibiting bi-directional flow and a diameter of 4 mm or greater at the fascia. RESULTS between September 1998 and July 1999, 204 patients were examined. Primary varicose veins were found in 198 legs (135 patients) and recurrent varicose veins in 91 legs (69 patients). In patients with primary varicose veins, 88 (44%) had incompetent perforators compared to 57 (63%) of those with recurrent varicose veins (Chi-squared, p <0.005). Also, for recurrent varicose veins, the percentage of patients with any given number of incompetent perforators was higher than for primary varicose veins. Overall, there was a higher number of incompetent perforators in those with recurrent veins compared to primary veins and this difference was significant at 95% confidence interval. CONCLUSION patients with recurrent varicose veins have both a higher prevalence and a greater number of incompetent perforating veins than patients with primary varicose veins.
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Affiliation(s)
- E E Rutherford
- Department of Vascular Surgery, Royal Surrey County Hospital, Egerton Road, Guildford, Surrey, UK
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22
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Affiliation(s)
- E E Rutherford
- Department of Vascular Surgery, The Royal Surrey County Hospital, Guildford, Surrey, UK
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23
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Galland RB, Whiteley MS, Gibson M, Simmons MJ, Torrie EP, Magee TR. Maintenance of patency following remote superficial femoral artery endarterectomy. Cardiovasc Surg 2000; 8:533-7. [PMID: 11068213 DOI: 10.1016/s0967-2109(00)00072-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Remote superficial femoral artery endarterectomy (RSFE) is a minimally invasive means of superficial femoral artery revascularisation. It comprises a single groin incision and securing of the distal cut end of atheroma with an intraluminal stent. AIM To determine medium-term results of RSFE, with particular reference to costs of maintaining patency. METHODS Stenosis development, and patency of 25 RSFE were compared with 25 randomly selected in situ vein bypasses with similar follow-up (18-33 months). RESULTS Following RSFE 17 stenoses were identified by duplex surveillance. Half of those arteries patent at 1 yr had stenoses. Angioplasty (PTA) was carried out for 11 stenoses. Four stenoses developed more than 12 months following RSFE. One patient died and nine arteries occluded during follow-up. Primary and primary- assisted patency at 18 months were 31 and 63% respectively. By contrast six stenoses were identified in 25 in situ grafts, all within one year. Four PTAs were carried out. Three grafts occluded. Excluding cost of three monthly duplex surveillance the cost of maintaining RSFE patency was approximately five times that of maintaining in situ bypass patency. CONCLUSION The initial cost advantage of RSFE is offset by the increased costs of maintaining patency. Duplex surveillance probably needs to be continued indefinitely.
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Affiliation(s)
- R B Galland
- Department of Surgery and Radiology, Royal Berkshire Hospital, London Road, Berks, Reading, UK
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24
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Cook SJ, Rocker MD, Jarvis MR, Whiteley MS. Patient outcome alone does not justify the centralisation of vascular services. Ann R Coll Surg Engl 2000; 82:268-71. [PMID: 10932662 PMCID: PMC2503500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023] Open
Abstract
BACKGROUND The Provision of Vascular Services document from the Vascular Surgical Society of Great Britain and Ireland argues for the centralisation of vascular services into units served by a minimum of four vascular consultants. The rationale for this is the presumed advantages of improved patient care, better utilisation of resources and a more comprehensive arrangement of consultant vascular cover. Since April 1998, the Royal Surrey County Hospital (RSCH) has had a single-handed vascular consultant with out-of-hours cross-district consultant vascular cover. OBJECTIVES To use P-POSSUM analysis to determine patient outcome from the RSCH vascular unit, and to compare these with previously published P-POSSUM analysis from a major vascular unit in Leeds. PATIENTS AND METHODS All patients undergoing major vascular surgery or amputation between April and November 1998 were analysed. RESULTS 86 patients underwent 102 surgical procedures in 92 separate admissions. Data retrieval was 100%. Predicted (E) mortality 16 cases; observed (O) mortality 13 cases; O:E ratio 0.80. Predicted morbidity 26 cases; observed morbidity 19; O:E ratio 0.73. O:E ratio for mortality from Leeds = 0.83. CONCLUSIONS Patient outcome in a single-handed vascular unit, with cross-district consultant cover, is equivalent to that found in a major vascular unit. Centralisation of vascular services cannot be justified on the basis of differences in patient outcome.
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Affiliation(s)
- S J Cook
- Department of Vascular Surgery, Royal Surrey County Hospital, Guildford, UK
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25
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Whiteley MS, Cook SJ. The 'morbidity and mortality' meeting--no longer defensible as surgical audit. Ann R Coll Surg Engl 2000; 82:168. [PMID: 10889783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023] Open
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26
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Galland RB, Whiteley MS, Gibson M, Simmons MJ, Torrie EP, Magee TR. Remote superficial femoral artery endarterectomy: medium-term results. Eur J Vasc Endovasc Surg 2000; 19:278-82. [PMID: 10753691 DOI: 10.1053/ejvs.1999.1021] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND the aim of this study is to determine the medium-term results following successful remote superficial-femoral endarterectomy (RSFE). SETTING district general hospital in United Kingdom. METHODS RSFE comprises a single incision over the origin of the superficial femoral artery. The endarterectomy is carried out in a closed fashion from above. The cut end of distal atheroma is secured with a stent. Twenty-five limbs were followed up with three monthly duplex scans and angiography if any abnormality was suggested. All patients presented with intermittent claudication; in addition three had rest pain and three ulceration or gangrene. The length of atheromatous core removed was 10-30 cm. RESULTS all patients had a follow-up of at least one year (range 12-27 months). Eleven arteries developed 14 stenoses. Nine became apparent within nine months of RSFE. The cumulative risk of stenoses developing in patent arteries was 24% at 6 and 63% at 12 months. Eleven angioplasties (PTA) of these stenoses were undertaken. Nine of these remain patent at a median of 12 months after PTA. At one year primary patency was 10 of 25 (40%), primary-assisted patency 18 of 25 (72%) and secondary patency 19 of 25 (76%) and at two years 29%, 57% and 57% respectively. CONCLUSIONS RSFE is worth considering for superficial femoral artery occlusive disease, particularly in high-risk patients without suitable vein and with limited life expectancy. Careful duplex surveillance is important. Until stenoses can be prevented, the widespread use of RSFE cannot be recommended.
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Affiliation(s)
- R B Galland
- Department of Surgery, Royal Berkshire Hospital, Reading, UK
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Riepe G, Whiteley MS, Wente A, Rogge A, Schröder A, Galland RB, Imig H. The effect of autoclave resterilisation on polyester vascular grafts. Eur J Vasc Endovasc Surg 1999; 18:386-90. [PMID: 10610826 DOI: 10.1053/ejvs.1999.0891] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES polyester grafts are expensive, single-use items. Some manufacturers of uncoated, woven grafts include instructions for autoclave resterilisation to be performed at the surgeon's own request. Others warn against such manipulation. Theoretically, the glass transition point of polyester at 70-80 degrees C and the possible acceleration of hydrolysis suggest that autoclave resterilisation at 135 degrees C might be a problem. MATERIALS AND METHODS a DeBakey Soft Woven Dacron Vascular Prosthesis (Bard) and a Woven Double Velour Dacron Graft (Meadox) were autoclave-resterilised 0 to 20 times, having been weighed before and after sterilisation. Tactile testing was performed. Mechanical properties were examined by probe puncture and single-filament testing, the surface was examined by scanning electron microscopy and the degree of hydrolysis by infra-red spectroscopy. RESULTS tactile testing revealed a change of feeling with increasing cycles of resterilisation. Investigation of weight, textile strength, single-filament strength, electron microscopy of the surface and infra-red spectroscopy showed no change of the material. CONCLUSIONS changes felt are presumably a surface phenomenon, not measurably affecting strength or chemistry of material after autoclave resterilisation. We therefore feel that it is safe to use once-autoclave-resterilised surplus uncoated polyester grafts, provided that sterility is guaranteed.
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Affiliation(s)
- G Riepe
- Department of General, Vascular and Thoracic Surgery, General Hospital of Hamburg-Harburg, Germany
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Abstract
BACKGROUND This prospective study compared morbidity and mortality rates following conventional and endovascular abdominal aortic aneurysm (AAA) repair using a physiological scoring system. METHODS Between December 1994 and November 1997, 104 elective open aneurysm repairs and 49 endovascular aneurysm repairs were performed. These patient cohorts were compared using the Portsmouth predictor equation (P-POSSUM) scoring system. Data collected prospectively from patient notes were used to obtain physiological and operative severity scores which were analysed to compare expected and observed mortality and morbidity rates. RESULTS There were three deaths (6 per cent) in the endovascular AAA repair group and 17 (16 per cent) in the conventional aneurysm repair group, whereas the P-POSSUM formulae predicted mortality rates of 8 and 19 per cent respectively. Although the mean physiological scores were similar for both groups (endovascular 20.8 versus conventional 20.1), the operative severity score was significantly greater in the conventional group (26.3 versus 19.7; P < 0.001). CONCLUSION In this study open aortic aneurysm repair had a higher operative severity than endovascular repair, which was reflected in the increased mortality rate.
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Affiliation(s)
- G D Treharne
- Department of Vascular Surgery, Leicester Royal Infirmary, UK
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Menon KV, Whiteley MS, Burden P, Galland RB. Surgical patients with methicillin resistant staphylococcus aureus infection: an analysis of outcome using P-POSSUM. J R Coll Surg Edinb 1999; 44:161-3. [PMID: 10372484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
The significance of MRSA infection in surgical patients was studied using the P-POSSUM scoring system. All surgical patients undergoing operation between 1/10/96 and 30/09/97 were prospectively scored using P-POSSUM. A subset of these patients with MRSA infection was analysed using P-POSSUM predicted mortality. Physiological and operative severity scores were compared with non-MRSA surgical patients and length of hospital stay with P-POSSUM matched non-MRSA controls. Thirty of the 1,132 patients were MRSA positive and of these five died, giving a P-POSSUM observed/expected deaths ratio of 1.7 (not significant; 95% CI -0.24 to 0.10). The P-POSSUM physiology score of 30 MRSA positive patients, compared with the non-MRSA group (n = 1102), was significantly more severe (20.9 v/s 17.4; 95% CI 1.09 to 5.95) as was the operative severity score (15.6 v/s 9.2; 95% CI 4.40 to 8.42). The length of stay for surviving MRSA positive patients was significantly longer than P-POSSUM matched controls. MRSA infection in surgical patients does not increase mortality. However, patients who contract MRSA infection are more debilitated and have undergone a greater surgical insult.
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Affiliation(s)
- K V Menon
- Department of Surgery, Royal Berkshire Hospital, Reading, U.K
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Turton EP, Whiteley MS, Berridge DC, Scott DJ. Calman, venous surgery and the vascular trainee. J R Coll Surg Edinb 1999; 44:172-6. [PMID: 10372487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
BACKGROUND Surgical training in Great Britain is undergoing inevitable changes to accommodate the processes of Higher Surgical Training. Junior surgeons have long argued that their training experiences have been haphazard or without satisfactory supervision. With the advent of changes following the Calman Report and the implementation of the Vascular Surgical Society recommendations, we have audited the venous surgical experience of vascular trainees in Great Britain. METHODS AND RESULTS Questionnaires were sent to 90 vascular surgical trainees achieving an overall 76.7% response rate (n = 69). Just under half of the trainees had spent more than 12 months on a pure vascular firm. The majority of trainees had received formal training in sapheno-femoral junction ligation and sapheno-popliteal junction ligation. However, several areas of training were deemed insufficient at both the junior and senior trainee levels. Very few trainees gain instruction on deep venous surgery and the techniques of microsclerotherapy. CONCLUSIONS Despite the participation of trainees in specialised vascular units, current training schedules fail to cover the field of venous surgery adequately. Training by vascular specialists needs greater focus and should be tailored to the trainee's experience on entry to their firm.
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Affiliation(s)
- E P Turton
- Department of Vascular and Endovascular Surgery, St James's University Teaching Hospital, Leeds, U.K.
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Abstract
We present the case of a patient with acute upper limb ischemia after radial artery harvest for coronary artery bypass grafting. This occurred despite adequate preoperative and intraoperative assessment with the Allen test, hand-held Doppler and radial artery backbleeding. A successful outcome was achieved by performing brachioradial bypass grafting using reversed cephalic vein.
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Affiliation(s)
- A D Fox
- Nuffield Department of Surgery, John Radcliffe Hospital, Headington, Oxford, England
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Whiteley MS, Galland RB. Assessing arterial inflow before infra-inguinal bypass grafting: a survey of the members of the Vascular Surgical Society of Great Britain and Ireland. Cardiovasc Surg 1999; 7:70-3. [PMID: 10073764 DOI: 10.1016/s0967-2109(98)00048-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
The optimal assessment of arterial inflow is controversial. We investigated current preferences of inflow assessment prior to infra-inguinal bypass grafting. A questionnaire was sent to 364 members of the Vascular Surgical Society of Great Britain and Ireland asking about inflow assessment in different clinical situations, access to resources, size of hospital and number of grafts performed each year. Questionnaires analysed = 169. Angiography was used by 89.5%, most single view. Two views angiography was used more often by surgeons performing more than 20 femoro-distal grafts each year (79.3 versus 37.6%). Routine use of iliac duplex was < 20%; poor femoral pulse increased this to near 30%. About 90% of respondents had access to colour flow duplex. Most respondents use single-plane angiography to assess inflow before infra-inguinal grafting. Two views and functional tests are used more commonly by surgeons working in larger or teaching hospitals and those performing more grafts.
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Affiliation(s)
- M S Whiteley
- Department of Surgery, Royal Berkshire Hospital, Reading, UK.
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Whiteley MS, Magee TR, Torrie EP, Galland RB. Minimally invasive superficial femoral artery endarterectomy: early experience with a modified technique. Eur J Vasc Endovasc Surg 1998; 16:254-8. [PMID: 9787308 DOI: 10.1016/s1078-5884(98)80228-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVES To describe our experience of a modified technique for carrying out remote endarterectomy for superficial femoral artery occlusive disease. METHODS A 4-French arterial dilator is inserted using a Smart needle into the popliteal artery below the occlusion. A remote endarterectomy is carried out through an arteriotomy in the proximal superficial femoral artery. The atheroma is cut distal to the lower extent of disease using a Moll ring cutter. The lower flap of atheroma is secured with an intraluminal stent inserted from the arteriotomy in the superficial femoral artery. The arteriotomy is extended into the common femoral artery and closed with a vein patch. RESULTS The procedure was completed in 21 of 26 limbs. In 18 cases the superficial femoral artery remained patent at 30 days. Of the 21 cases all but four stayed in hospital for one night. A successful femoropopliteal bypass was carried out in the five patients in whom the procedure was not completed. CONCLUSION Insertion of the dilator into the popliteal artery distal to the occlusion before carrying out the remote endarterectomy has two advantages. Firstly, the stent insertion is carried out in the correct plane and prevents dissection of the distal cut atheroma when attempting to pass the guidewire from above. Secondly, the procedure can be carried out under simple image intensification without sophisticated radiological equipment. The early results are encouraging and further evaluation of the technique is justifiable.
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Affiliation(s)
- M S Whiteley
- Department of Surgery, Royal Berkshire Hospital, Reading, U.K
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Prytherch DR, Whiteley MS, Higgins B, Weaver PC, Prout WG, Powell SJ. POSSUM and Portsmouth POSSUM for predicting mortality. Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity. Br J Surg 1998; 85:1217-20. [PMID: 9752863 DOI: 10.1046/j.1365-2168.1998.00840.x] [Citation(s) in RCA: 485] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND There is a need for an accurate measure of surgical outcomes so that hospitals and surgeons can be compared properly regardless of case mix. POSSUM (Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity) uses a physiological score and an operative severity score to calculate risks of mortality and morbidity. In a previous small study it was found that Portsmouth POSSUM (P-POSSUM; a modification of the POSSUM system) provided a more accurate prediction of mortality. METHODS Some 10000 general surgical interventions (excluding paediatric and day cases) were studied prospectively between August 1993 and November 1995. The POSSUM mortality equation was applied to the full 10000 surgical episodes. The 10000 patients were arranged in chronological order and the first 2500 were used as a training set to produce the modified P-POSSUM predictor equation. This was then applied prospectively to the remaining 7500 patients arranged chronologically in five groups of 1500. RESULTS The original POSSUM logistic regression equation for mortality overpredicts the overall risk of death by more than twofold and the risk of death for patients at lowest risk (5 per cent or less) by more than sevenfold. The P-POSSUM equation produced a very close fit with the observed in-hospital mortality. CONCLUSION P-POSSUM provides an accurate method for comparative surgical audit.
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Affiliation(s)
- D R Prytherch
- Department of Medical Physics, Portsmouth Hospitals NHS Trust, UK
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Abstract
OBJECTIVES Increasing numbers of patients with small abdominal aortic aneurysms (AAA) are being diagnosed. The aim of this paper is to define the fate of those patients undergoing surveillance of small AAAs. SETTING U.K. district general hospital. METHODS A prospective study has been carried out of all patients undergoing surveillance. At the time of the first consultation the patient was assessed, a Detsky score calculated and the referral source noted. End points of the study were elective repair of the aneurysm, aneurysm rupture or death of the patient. RESULTS Details of 267 patients were analysed. The referral source was general practitioner in 39%, patients with peripheral vascular disease in 32% and department of urology in 21%. None were referred from population screening. The cumulative 5-year risks of rupture, elective repair or non-AAA related deaths were 15%, 26% and 46% for all patients, 4%, 13% and 38% for patients initially presenting with AAA less than 4 cm diameter and 21%, 42% and 54% for patients presenting with an AAA 4-5.5 cm diameter. All but one of 11 patients whose aneurysm ruptured were unfit or had declined elective repair. There were 56 non-AAA related deaths, the majority due to cardiovascular causes. Those patients with low Detsky scores had a 5-year survival of 62%, those with high scores 44%. The age/sex matched survival or a normal population at 5 years in 80%. CONCLUSION Overall the non-AAA related mortality was greater than the risks of rupture or elective repair. It is important to bear in mind the poor prognosis of this group of patients compared with a normal population when considering elective repair of small AAAs.
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Affiliation(s)
- R B Galland
- Department of Surgery, Royal Berkshire Hospital, Reading, U.K
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Whiteley MS. Doppler forceps: an instrument to identify vessels during surgical dissection. Ann R Coll Surg Engl 1998; 80:269-70. [PMID: 9771228 PMCID: PMC2503079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023] Open
Affiliation(s)
- M S Whiteley
- Department of Surgery, Royal Berkshire Hospital, Reading
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Whiteley MS. Scoring systems. Eur J Vasc Endovasc Surg 1998; 16:87. [PMID: 9715725 DOI: 10.1016/s1078-5884(98)80100-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Whiteley MS, Fox AD, Horrocks M. Photoplethysmography can replace hand-held Doppler in the measurement of ankle/brachial indices. Ann R Coll Surg Engl 1998; 80:96-8. [PMID: 9623371 PMCID: PMC2502998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Ankle/brachial pressure index (ABPI) using hand-held Doppler and sphygmomanometer is a standard assessment for patients with peripheral arterial occlusive disease (PAOD). Good Doppler technique is difficult to master and so we investigated replacing Doppler with photoplethysmography (PPG). Two investigators examined 52 legs in 32 vascular patients. Both used standard sphygmomanometer cuff occlusion. Restoration of flow was detected by either an 8 MHz Doppler ultrasound probe or a PPG transmitter/receiver on index finger or great toe. Doppler-derived ABPIs were compared with PPG-derived ABPIs. Excellent correlation was found between both indices (correlation coefficient 0.875). Four lower limbs had unrecordable PPG traces, one also having an unrecordable Doppler signal. Excluding these four patients, the correlation coefficient rose to 0.975. PPG placed on the pulp of a digit can replace the hand-held Doppler in measuring ABPIs.
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Affiliation(s)
- M S Whiteley
- Department of Surgery, Royal United Hospital, Bath
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39
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Whiteley MS, Smith JJ, Galland RB. Subfascial endoscopic perforator vein surgery (SEPS): current practice among British surgeons. Ann R Coll Surg Engl 1998; 80:104-7. [PMID: 9623373 PMCID: PMC2502990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Subfascial endoscopic perforator vein surgery (SEPS) has recently caused considerable interest among British surgeons. There are no data indicating which, if any, patients benefit from SEPS. A series of 47 British surgeons, identified as having taken up SEPS, were sent a questionnaire asking about their current practice; 26 were returned completed (55% response rate). Of those surgeons replying, 22 (85%) had performed their first SEPS procedure within the previous 21 months, 18 (69%) within the previous 9 months. Most surgeons had performed five procedures (range 1-52). The most common indication for SEPS was venous ulceration with proven incompetent perforators (eight surgeons), but there was a wide diversity of other indications used to select patients for SEPS. Only nine surgeons had changed their indications for surgery with the advent of SEPS, yet their predicted number of SEPS procedures was far greater than the number of open procedures they currently performed. Out of 26 surgeons, 25 intend to continue performing SEPS. Prospective studies are needed to identify which patients might benefit from this new procedure.
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Affiliation(s)
- M S Whiteley
- Department of Surgery, Royal Berkshire Hospital, Reading
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40
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Whiteley MS, Fox AD, Harris RA, Horrocks M. Full-dose and half-dose Klean Prep produce clearer images with iliac duplex examination than picolax. Eur J Vasc Endovasc Surg 1998; 15:261-6. [PMID: 9587343 DOI: 10.1016/s1078-5884(98)80188-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Iso-osmotic bowel preparation (Klean Prep) improves the accuracy of iliac duplex examination and reduces the time of each examination. Full-dose Klean Prep entails 4 l of fluid. We studied the effect of 2 l of Klean Prep (half-dose) and Picolax on image quality. DESIGN Prospective study comparing clarity of duplex examination after three different bowel preparation regimes with that after 12 h starvation. MATERIALS AND METHODS Thirty patients underwent iliac duplex examination after 12 h starvation. Scans were scored subjectively for grey scale and colour image quality, and Doppler signal-to-noise ratio. Patients were allocated blindly to: (a) full-dose Klean Prep, (b) half-dose Klean Prep, or (c) Picolax. After out-patient preparation, the scan was repeated and scored by the same observer, blinded to the preparation. RESULTS Both full- and half-dose Klean Prep produced significant improvements in image quality for all three modalities; Picolax produced minimal change. There was minimal advantage of full-dose over half-dose Klean Prep. Patients preferred half-dose Klean Prep to full-dose. CONCLUSION Klean Prep significantly improves the image obtained by iliac duplex examination; Picolax does not. Half-dose Klean Prep is an acceptable preparation to patients.
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Affiliation(s)
- M S Whiteley
- Department of Surgery, Royal United Hospital, Combe Park, Bath, U.K
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41
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Whiteley MS, Ray-Chaudhuri SB, Galland RB. Combined fascia and mesh closure of large incisional hernias. J R Coll Surg Edinb 1998; 43:29-30. [PMID: 9560503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Large incisional hernias of the abdominal wall represent substantial defects of supportive tissues. The repair of these requires the mobilization of fascia or the use of a prosthetic mesh. A method for closing large midline incisional hernias using both the fascia and a mesh was described in 1979. This repair was used for six midline hernias and four large incisional hernias in the right subcostal region. No wound complications and no recurrences (median follow-up 1 year 5 months) were seen. The combined fascia and mesh repair can be successfully used for large incisional hernias of the anterior abdominal wall in areas other than the midline.
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Affiliation(s)
- M S Whiteley
- Department of Surgery, Royal Berkshire Hospital, Reading, UK
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42
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Andrews S, O'Riordan DC, Whiteley MS. The reduction in hours of work for surgical trainees--an enlightened move or a great mistake? Ann R Coll Surg Engl 1998; 80:177-80. [PMID: 9849325 PMCID: PMC2502743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023] Open
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43
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Whiteley MS, Wilmott K, offland RB. A specialist nurse can replace pre-registration house officers in the surgical pre-admission clinic. Ann R Coll Surg Engl 1997; 79:257-60. [PMID: 9496173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Pre-admission clinics reduce non-attendance rates for elective surgery and help in management of surgical waiting lists. Nurse-led pre-admission clinics have been reported to be successful by simple audits of their efficiency. However data are lacking comparing such nurses with PRHOs that they are replacing leaving open questions of their safety in this role. We performed a prospective study involving 100 consecutive patients attending the surgical pre-admission clinic. We compared clerking by a specialist nurse using a standard proforma and ordering pre-operative investigations with that of PRHOs who ordered investigations as is their normal practice. The specialist nurse was as accurate or more accurate than PRHOs in taking a surgical history with the exception of noting drug doses and frequencies, and taking a full social, alcohol and smoking history. She also performed well with regard to limited physical examination, ordering investigations and assessing ASA grades. With minor modifications to our proforma we believe the specialist nurse is safe to replace the PRHOs in the pre-admission clinic.
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Affiliation(s)
- M S Whiteley
- Department of Surgery, Royal Berkshire Hospital, Reading
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44
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Whiteley MS, Fox AD, Thompson MM. Career aspirations and expectations of vascular trainees in 1996. The Rouleaux Club. Ann R Coll Surg Engl 1997; 79:195-9. [PMID: 9496159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Sub-specialisation within general surgery has now become accepted as part of surgical training and consultant posts are being increasingly advertised for surgeons with a special interest. Transplantation surgery is currently losing trainees and proposals have been made to combine vascular and transplant surgery to a greater or lesser degree. The Rouleaux Club is a society for junior vascular surgeons in Great Britain and Ireland. Questionnaires were sent to 78 non-consultant members in July 1996 and 67 were returned and analysed. A reasonable cross-section of all training grades was obtained. Of this number 44 (65.7 per cent) did not want to spend any period of their higher surgical training in full-time transplantation training, although 32 (47.8 per cent) would accept some time in transplantation training if it were combined with another surgical specialty. Training in vascular access work was welcomed by 51 (76.1 per cent) but this contrasts with 40 (59.7 per cent) who would not want to offer this as a service once appointed to consultancy. Almost all of the trainees (60/64 = 93.8 per cent) ideally wanted to be appointed to consultant posts with > 50 per cent commitment to vascular surgery and most thought that they would realistically get such positions. Most trainees ideally wanted consultancies in academic/ university departments or teaching hospitals but many thought that in reality they would be appointed to posts in district general hospitals.
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Affiliation(s)
- M S Whiteley
- Nuffield Department of Surgery, John Radcliffe Hospital, Oxford
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45
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Whiteley MS, Smith JJ, Galland RB. Tibial nerve damage during subfascial endoscopic perforator vein surgery. Br J Surg 1997; 84:512. [PMID: 9112904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- M S Whiteley
- Department of Surgery, Royal Berkshire Hospital, Reading, UK
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46
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Whiteley MS, Williams DJ, Hocken D. Attitudes of patients to elective surgical admissions over Christmas and Easter. Ann R Coll Surg Engl 1997; 79:68-71. [PMID: 9166010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
It is often accepted by hospital staff that patients would prefer to be at home for the Christmas and Easter holiday periods. This is one of the reasons that elective surgery is reduced at these times. However there is very little evidence to prove whether this is true. To investigate this question 310 patients attending surgical or urological outpatients were given a self completion questionnaire asking them whether they would accept admission over these holidays if offered it. Overall 77 per cent of males and 76 per cent of females would accept admission over the Christmas period for elective surgery. This rises to 87 per cent and 88 per cent over the Easter period. Older patients, widows or widowers, retired patients and patients with subjectively severe symptoms and conditions were groups that independently accepted such admissions more readily than others. Contrary to the perceived opinion in hospital staff, in this sample of surgical and urological patients most patients appear willing to accept admission for elective surgery over the Christmas or Easter holiday periods.
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Affiliation(s)
- M S Whiteley
- Department of Surgery, Princess Margaret Hospital, Swindon
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47
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Abstract
Abstract
Transthoracic endoscopic sympathectomy (TES) has become the method of choice for treating patients with palmar hypcrhidrosis. There are few complications reported with this procedure. A complication not described previously is reported here.
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Affiliation(s)
- M S Whiteley
- Department of Surgery, Royal Berkshire Hospital, Reading, UK
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48
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Whiteley MS. Tumor necrosis factor receptor: Fc fusion protein in septic shock. N Engl J Med 1996; 335:1607-8; author reply 1608-9. [PMID: 8927111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Fox AD, Whiteley MS, Murphy P, Budd JS, Horrocks M. Comparison of magnetic resonance imaging measurements of abdominal aortic aneurysms with measurements obtained by other imaging techniques and intraoperative measurements: possible implications for endovascular grafting. J Vasc Surg 1996; 24:632-8. [PMID: 8911412 DOI: 10.1016/s0741-5214(96)70079-4] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
PURPOSE Abdominal aortic aneurysm morphologic evaluation with conventional imaging techniques is inadequate when endovascular repair is being contemplated. This study has addressed the problem with magnetic resonance imaging (MRI). METHODS Twenty patients (14 men, 6 women) with a median age of 73 years were recruited and assessed according to current endovascular graft selection criteria. Thirteen patients subsequently underwent open aneurysmorrhaphy, and the intraoperative parameters have been compared with those of duplex ultrasonography and MRI. RESULTS No significant difference was demonstrated in the diameter of the infrarenal neck among ultrasonography, MRI, and intraoperative findings (p > 0.05, Mann Whitney U Test) and also during assessment of infrarenal neck length; however, duplex sonography accurately defined the renal ostia in only five cases. MRI visualized 38 of 40 renal arteries. Distal aortic involvement (cuff diameter and length) and the length and diameter of the common iliac arteries were accurately determined by MRI in all cases, and no significant difference was demonstrated with the intraoperative findings. Comparison of the intraoperative and MRI aneurysm lengths suggested a slight trend of overestimation by MRI resulting from angulation of the aneurysm, but this figure did not reach statistical significance. Only two patients met the current criteria for endoluminal straight grafting. CONCLUSIONS Both MRI and duplex sonography accurately predicted aortic morphologic characteristics; however, MRI provided the most comprehensive anatomic picture for patient selection and should be considered the nonionizing imaging modality of choice when an endovascular repair is being contemplated.
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Affiliation(s)
- A D Fox
- Department of Surgery, Royal United Hospital, Bath, United Kingdom
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50
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Whiteley MS, Ray-Chaudhuri SB, Cornes J, Michaels JA, Galland RB. General surgery with a special interest in vascular surgery: changing patterns of workload. Br J Surg 1996; 83:1364-6. [PMID: 8944452 DOI: 10.1002/bjs.1800831011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Prospective surveys of workload were carried out during 1989, 1990 and 1995. Analysis of outpatient referrals, inpatients and operations performed over periods of 3 months was undertaken and the changing patterns of general surgical and vascular surgical workload noted. The number of outpatient referrals rose throughout the study period because of a significant increase in the number of patients with both varicose veins and other vascular problems. There was an increase in the number of emergency admissions for vascular disease. The number of patients having general surgical operations fell; there was a corresponding increase in the number for arterial and venous disease. The general surgical component of a general surgical unit with a vascular interest is gradually declining, as increased numbers of patients with vascular problems are being referred and managed.
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Affiliation(s)
- M S Whiteley
- Department of Surgery, Royal Berkshire Hospital, Reading, UK
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