Evaluating the safety profile of anti-platelet therapy in patients undergoing elective inguinal hernia repair: a systematic review and meta-analysis

INTRODUCTION

There remains no consensus surrounding the safety of prescribing anti-platelet therapies (APT) prior to elective inguinal hernia repair (IHR).

AIMS

To perform a systematic review and meta-analysis evaluating the safety profile of APT use in patients indicated to undergo elective IHR.

METHODS

A systematic review was performed in accordance with PRISMA guidelines. Meta-analyses were performed using the Mantel-Haenszel method using the Review Manager version 5.4 software.

RESULTS

Five studies including outcomes in 344 patients were included. Of these, 65.4% had APT discontinued (225/344), and 34.6% had APT continued (119/344). The majority of included patients were male (94.1%, 288/344). When continuing or discontinuing APT, there was no significant difference in overall haemorrhage rates (odds ratio (OR): 1.86, 95% confidence interval (CI): 0.29-11.78, P = 0.130) and in sensitivity analysis using only RCT data (OR: 0.63, 95% CI: 0.03-12.41, P = 0.760). Furthermore, there was no significant difference in reoperation rates (OR: 6.27, 95% CI: 0.72-54.60, P = 0.590); however, a significant difference was observed for readmission rates (OR: 5.67, 95% CI: 1.33-24.12, P = 0.020) when APT was continued or stopped pre-operatively. There was no significant difference in the estimated blood loss, intra-operative time, transfusion of blood products, rates of complications, cerebrovascular accidents, myocardial infarctions, or mortality observed.

CONCLUSION

This study illustrates the safety of continuing APT pre-operatively in patients undergoing elective IHR, with similar rates of haemorrhage, reoperation, and readmission observed. Clinical trials with larger patient recruitment will be required to fully establish the safety profile of prescribing APT in the pre-operative setting prior to elective IHR.

Readmission rates following major colorectal surgery

BACKGROUND

Readmissions following colorectal surgery (CRS) have negative clinical, psychological and financial implications. Identifying patients at risk of readmission remains challenging.

AIMS

To determine factors predictive of those likely to require readmission at 40-days following major CRS and to identify novel strategies capable of reducing readmissions.

METHODS

Consecutive patients were studied from a prospectively maintained database. All patients were operated on by a single surgeon in a high-volume centre. Where applicable, photography was recorded by patients and emailed directly to the institutional email of the consultant surgeon. Data was recorded and analysed using descriptive statistics.

RESULTS

515 patients were included over a 15-year period (2007-2022). The mean age at surgery was 64 years (18-93). The majority of patients were male (56.9%, n=293) and underwent cancer surgery (58.2%, n=299). Overall, 55 patients were readmitted within 40 days of major CRS (10.7%). Patients with pre-treatment diagnoses of heart failure (P=0.012), ischemic heart disease (P=0.002), renal impairment (P<0.001), atrial fibrillation (P=0.006), hypercholesterolemia (P=0.001), asthma (P=0.013) and hypertension (P=0.001) were more likely to require readmission. The majority of patients were readmitted for definitive management of surgical site issues (SSIs) (43.7% n=24). Other reasons included bowel obstruction (9.1%, n=5), pelvic sepsis (7.3%, n=4) and gastrointestinal upset (7.3%, n=4).

CONCLUSION

This series demonstrated that patients with cardiopulmonary comorbidities were more likely to be readmitted following major CRS and most readmissions are SSI related. Readmissions for SSIs can be reduced by patients sending photography to the treating surgeon which could reduce readmissions and A&E attendances.

Evaluating opioid prescribing patterns following discharge from elective surgical procedures: a worrying trend during the 'opioid crisis' - an audit of elective surgical procedures

BACKGROUND

The 'opioid crisis' has reached epidemic proportions globally. Importantly, 30% of opioid dependency stem from opioids obtained on hospital discharge prescriptions.

AIM

The aim of this study is to evaluate opioid prescription patterns on discharge of post-operative patients in an Irish Hospital.

METHODS

A retrospective cohort study was undertaken in a single institution during the 5 year eligibility period (January 2017-October 2021). Comparisons in opioid prescription patterns following minor (inguinal hernia repair (IHR), intermediate (laparoscopic cholecystectomy (LC)) and major (colonic resection (CR)) were made. Descriptive statistics were performed using SPSS version 26.0 RESULTS: In total, 300 patients were included in this study with mean age 59.6 years (range: 20-92). Of these, 112 patients underwent IHR (37.3%), 116 patients underwent LC (38.7%), and 72 patients underwent CR (24.0%). The mean age at diagnosis was 61 years, 53 years and 58 years for IHR, LC and CR, respectively (P < 0.001). Patients undergoing CR were more likely to have greater comorbidity burden (3.1 vs. 1.2 (IHR) vs. 1.8 (LC) respectively (P = 0.030). On discharge, 27.8% of CR patients received opioids (20/72) compared to 24.1% of IHR (28/116) and 15.9% of LC (18/113) patients, respectively (P = 0.126).

CONCLUSION

We observed considerable variability in opioid prescribing patterns following minor, intermediate and major operations in our centre. Care is required when prescribing opioids in the post-operative setting, and opioid prescription guidelines are required to both tackle and prevent an escalation of this 'opioid crisis'.

Rectal cancer surgery: does low volume imply worse outcome-a single surgeon experience

BACKGROUND

The centralisation of rectal cancer management to high-volume oncology centres has translated to improved oncological and survival outcomes. We hypothesise that individual surgeon caseload, specialisation, and experience may be as significant in determining oncologic and postoperative outcomes in rectal cancer surgery.

METHODS

A prospectively maintained colorectal surgery database was reviewed for patients undergoing rectal cancer surgery between January 2004 and June 2020. Data studied included demographics, Dukes' and TNM staging, neoadjuvant treatment, preoperative risk assessment scores, postoperative complications, 30-day readmission rates, length of stay (LOS), and long-term survival. Primary outcome measures were 30-day mortality and long-term survival compared to national and international standards and best practice guidelines.

RESULTS

In total, 87 patients were included (mean age: 66 years [range: 36-88]). The mean length of stay (LOS) was 16.5 days (SD 6.0). The median ICU LOS was 3 days (range 2-17). Overall, 30-day readmission rate was 16.4%. Twenty-four patients (26.4%) experienced ≥ 1 postoperative complication. The 30-day operative mortality rate was 3.45%. Overall 5-year survival rate was 66.6%. A significant correlation was observed between P-POSSUM scores and postoperative complications (p = 0.041), and all four variants of POSSUM, CR-POSSUM, and P-POSSUM scores and 30-day mortality.

CONCLUSION

Despite improved outcomes seen with centralisation of rectal cancer services at an institutional level, surgeon caseload, experience, and specialisation is of similar importance in obtaining optimal outcomes within institutions.

Patient reported satisfaction levels with the use of telemedicine for general surgery-A systematic review of randomized control trials

Background

As healthcare continues to evolve in the wake of COVID-19 pandemic, surgeons are presented with the opportunity to integrate telemedicine into healthcare in tandem with in-person consultations. We aimed to perform a systematic review of randomized controlled trials to assess patient satisfaction with telemedicine interventions in general surgery.

Methods

A systematic review was performed in accordance to the PRISMA guidelines. Randomized control trials (RCTs) were included. The risk of bias 2.0 assessment was used to determine potential bias.

Results

In total, 11 prospective, randomized trials involving 1,598 patients (mean age: 49.1 years) were included. Overall 45.5% (5/11) of the trials compared videoconferencing or telephone follow up to traditional in person follow up. Three studies used smart technologies which include activity tracking devices in combination with a website and mobile application (27.3%). The other 3 interventions involved accelerated discharge on post operative day (POD) 1 with tele videoconferencing on POD 2, Post-operative daily text messages with education videos and video calling capability, and supportive text messages post-operatively. Telemedicine was shown to provide similar levels of patient satisfaction compared to controls in all 11 included RCTs.

Conclusion

Patient reported satisfaction with the use of telemedicine is similar to standard of care models in general surgery. With several shortcomings confounding the results in support of telemedicine, further experimentation with telemedicine interventions will likely improve patient reported satisfaction with using telemedicine for peroperative surgical care.

Impact of frailty on oncological outcomes in patients undergoing surgery for colorectal cancer - A systematic review and meta-analysis

INTRODUCTION

Frailty describes patients who are at an extreme risk of vulnerability to stressors that may lead to adverse clinical outcomes. The impact of frailty on clinical, oncological and survival outcomes in colorectal cancer (CRC) remains unclear.

AIM

To determine the anticipated oncological and survival outcomes for patients who are frail when diagnosed and undergo treatment with curative intent for CRC.

METHODS

A systematic review and meta-analysis was performed as per PRISMA guidelines. Descriptive statistics were used to determine associations between frailty and survival outcomes. The impact of frailty on disease-free and overall survival were expressed as hazard Ratios (HRs) and 95% confidence intervals (CIs) were estimated using the time-to-effect generic inverse variance and Mantel-Haenszel method.

RESULTS

Nine studies including 15,555 patients were included, of whom 8.1% were frail (1206/14,831). The mean age was 77.1 years (range: 42-94 years), 61.1% were female (9510/15,555) and mean follow-up was 48.0 months. Overall, frailty was associated with an increased risk of mortality (HR: 2.95, 95% CI: 1.64-5.29, P < 0.001) and worse disease-free survival (HR: 1.80, 95% CI: 1.34-2.41, P < 0.001). Frailty was also associated with an increased risk of mortality at 1-year (HR: 3.70, 95% CI: 1.00-13.66, P = 0.050) and 5-years (HR: 2.79, 95% CI: 1.65-4.71, P < 0.001) follow-up respectively.

CONCLUSION

Frailty is associated with poorer oncological and survival outcomes in patients diagnosed and treated with curative intent for CRC. CRC multidisciplinary team meetings should incorporate these findings into the management paradigm for these patients and patient counselling should be tailored to include these findings.

Diverticular disease is associated with benign intra-abdominal cystic disease

BACKGROUND

Diverticular disease (DD) and hepatic and renal cysts have been linked with defects in collagen and dysfunctional matrix metalloproteinases.

METHODS

Consecutive abdominal computed tomography scans between January-July 2015 were prospectively studied to determine a correlation between visceral cysts and DD. Patients with a sigmoid colectomy for pathology other than DD and scans in which DD and/or solid organs were not fully visualized were excluded. A subgroup analysis was performed on youthful DD patients (<55 years of age, n = 32) vs. older controls (>55, n = 213).

RESULTS

238 DD patients (50.8% male) and 369 controls (40.5% male, p = .02) were included. Incidence of visceral cystic disease in DD patients vs. controls was 71.4% vs. 22.5% (p < 0.00001). Renal cysts, present in 53.4% of the DD patients and 18.7% of the controls (p < .00001), were more common than hepatic cysts in both groups. Hepatic cyst prevalence was 8.8 vs. 2.4% (p = .0008). In the subgroup analysis, cystic disease was present in 56.2% of youthful DD patients vs. 29.1% of older controls (p = .004).

CONCLUSIONS

A significant association between cystic disease and DD was demonstrated overall and in subgroup analysis inclusive of youthful DD patients and older controls. These findings suggest a global defect in connective tissue integrity in DD patients.

Pseudomyxoma peritonei diagnosed 19 years after appendicectomy

Pseudomyxoma peritonei (PMP) is an uncommon clinical finding describing the intraperitoneal accumulation of abundant mucinous, jelly-like material. This entity may represent a spectrum of diseases ranging from mucinous ascites, commonly associated with ruptured epithelial tumours of the appendix, to frank mucinous carcinomatosis. In cases of appendiceal origin, the patient may present with signs and symptoms of acute appendicitis, and thus careful diagnosis must be made in order to correctly and appropriately guide management. This may include a combination of surgical debulking with or without intraperitoneal or systemic chemotherapy. We present a 52-year-old woman with a 4-month history of abdominal pain and distension with a previous appendicectomy 19 years earlier. Radiological and pathological investigations diagnosed a probable PMP secondary to ruptured appendicitis many years ago. We describe her unique case, with emphasis on length of time to diagnosis and clinical management by surgical cytoreduction alone.

A reduction in serum cytokine levels parallels healing of venous ulcers in patients undergoing compression therapy

INTRODUCTION

vascular endothelial growth factor (VEGF) and tumour necrosis factor alpha (TNF(alpha)) have been specifically implicated in the tissue damage associated with chronic venous disease (CVD). Furthermore, production of both factors is known to be upregulated in vessel wall cells subject to hypertension. The aim of this study was to determine the local venous levels of VEGF and TNF(alpha) in limbs with venous ulcers before and after treatment with graduated compression.

PATIENTS AND METHODS

eight patients with venous ulcers and 8 patients with varicose veins only were included in the study. For ulcer patients, serum samples were taken from the superficial veins in lower limbs and repeated after 4 weeks of treatment with 4-layered graduated compression. Serum from the arms of the same patients served as controls. Determination of the concentrations of VEGF and TNF(alpha) proteins were performed with sandwich enzyme-linked immunosorbent assays.

RESULTS

both groups of patients had elevated levels of VEGF and TNF(alpha). In patients with venous ulcers there was a reduction in the levels of both cytokines to below control values with treatment. These changes correlated with healing of the ulcers as determined by reduction in ulcer size.

CONCLUSION

these data, for the first time, suggest a central role for both TNF(alpha) and VEGF in the pathogenesis of venous ulceration which may constitute a causative link between venous hypertension and tissue pathology.

Information for surgical patients: implications of the World Wide Web

OBJECTIVE

To sample the amount and scope of information available on the internet about three common surgical conditions, identify the sources, and to examine the relevance of the web to the surgical community.

DESIGN

Internet search.

SETTING

General hospital, Republic of Ireland.

MATERIAL

Three arbitrarily chosen conditions were sought--varicose veins, inguinal hernia, and gallstones. Four commonly used search engines--Yahoo, Altavista, Excite and Lycos, were used to search worldwide, and then sites restricted to the UK and Republic of Ireland.

MAIN OUTCOME MEASURES

Quality and quantity of information available.

RESULTS

All four search engines retrieved patient-orientated information on the three conditions. The sites accessed from the web page matches generally presented a comprehensive summary of the condition including aetiology, risk factors and clinical features, but gave variable amounts of information on treatment options, surgical complications, comparisons between treatments, and expected outcomes. Online health magazines provided most of the information sites.

CONCLUSION

The internet offers easily-accessible patient-orientated information. Surgeons should make more use of it to satisfy patients' increasing need for information.

Feasibility of day case varicose vein surgery in a district general hospital

BACKGROUND

Day case surgery may reduce inpatient bed requirements, and varicose surgery may be an ideal operation to test the functioning of a day surgery service.

AIMS

To evaluate retrospectively the feasibility of day case varicose vein surgery in all-comers, and to identify the risk factors for admission.

METHODS

Over a three-year period from July 1995 to July 1998, all patients requiring varicose vein surgery had their procedure performed as a day case. A standard technique of sapheno-femoral ligation with below-knee stripping of the long saphenous vein and multiple stab avulsions of varicosities was performed. All limbs were dressed with wool in crepe bandage and were reviewed post-operatively at six weeks.

RESULTS

Five hundred and forty two patients underwent varicose vein surgery, of whom 26% had bilateral varicose veins, 88% had primary varicose veins and 22% had recurrent disease. The procedure was performed under general anaesthesia in 86% of cases and under spinal anaesthesia in the rest. There was no peri-operative mortality. Ten patients (1.9%) developed post-operative complications. Seventy two per cent of patients were discharged on the day of surgery, a further 25% required admission for one night due to minor anaesthetic complications and patient preference. Four per cent required admission for more than 24 hours. The need for overnight admission was associated with the age of the patients (p < 0.0001), bilateral varicose vein surgery (p < 0.005) and the use of spinal anaesthesia (p < 0.01).

CONCLUSION

Although varicose vein surgery is safe, acceptable and cost-effective as a day case procedure, if attempted in all-comers, overnight admission will be required in a significant proportion. Pre-operative selection is advised.

Advanced trauma and life support principles: an audit of their application in a rural trauma centre

In December of 1995 a system of trauma care based on Advanced Trauma Life Support (ATLS) principles was instituted to assess the impact of such principles on trauma care in a rural general hospital setting. This audit reviews the results over a 2 yr period to December 1997. All patients admitted with major trauma (i.e. with life threatening or potentially life threatening injuries) to Cavan General Hospital (CGH) were eligible for inclusion. This numbered 70 patients admitted (for at least 3 days), or who were transferred after resuscitation and stabilization as well as inpatient deaths. Twenty-seven patients who died prior to admission are also reviewed. The endpoints assessed were death, disability and survival 3 months post-accident. Based on injury severity scores 7 per cent of cases suffered fatal non-survivable injury, 20-30 per cent had very serious injury with an overall mortality rate of 17 per cent. The predicted mortality rate was 30 per cent. One-third had their full treatment at CGH with a 76 per cent survival rate. The other two-thirds were transferred for specialist intervention with an overall survival of 80 per cent, a disability rate of 16 per cent and a mortality rate of 4 per cent. No patient died during transportation.

Pathological evidence in support of total mesorectal excision in the management of rectal cancer

Some 50 total mesorectal excision specimens were examined following rectal excision for cancer. Circumferential margin involvement was rare, but mesorectal tumour deposits were present in 17 of 44 patients with pT3 tumours, and 23 of 44 had mesorectal nodal involvement. No patient with a pT2 tumour had mesorectal involvement. Failure to excise the mesorectum completely has the potential to leave gross or microscopic residual disease that may in theory predispose to local failure. Total mesorectal excision is necessary to avoid incomplete pathological evaluation of the mesorectum and understaging of rectal cancer.

Gastrointestinal haemorrhage from a jejunal gangliocytic paraganglioma

A case of jejunal gangliocytic paraganglioma is reported in a 54 year old woman who presented with brisk melaena. The tumour was not encapsulated, involved the mucosa and submucosa, and was composed of epithelial nests, spindle cells, and ganglion cells. These cells were mixed, giving carcinoid-like, paraganglioma-like, and ganglioneuroma-like patterns in different areas of the tumour. The lesion was excised locally and recovery was uneventful. Only four previous cases have been reported at this site.

Pulse Oximetry in the Diagnosis of Non-Critical Peripheral Vascular Insufficiency

Pulse oximetry was used to detect return of pulsatile flow in 27 subjects during reactive hyperaemia following 3 min of total limb ischaemia induced by above knee tourniquet occlusion. Fourteen patients with exercise induced leg pain had 18 symptomatic limbs tested. Thirteen controls had 25 limbs tested. Return of pulsatile flow during reactive hyperaemia occurred within 20 s of tourniquet release in the 25 control limbs which was then regarded as normal. The mean time for return of pulsatile flow in 18 symptomatic limbs was 53±37 s ( P > 0.05 versus controls). Three limbs had a normal value, two of which did not have peripheral vascular disease. Pulse oximetry correctly identified all 25 asymptomatic limbs and 15 of 16 patients with claudication secondary to peripheral vascular disease (PVD). This modification of the reactive hyperaemia test using the pulse oximeter is simple and quick to perform. It has potential as a non-invasive screening test for PVD, suitable for outpatient assessment.

Magnetic resonance imaging of rectal carcinoma: a prospective study

Accurate preoperative staging of rectal cancer is necessary to identify patients who might benefit from adjuvant therapy. Magnetic resonance imaging (MRI) was evaluated in 20 consecutive patients with rectal cancer undergoing 'curative' surgery. Detailed histopathological examination of the resected lesion was correlated with findings of MRI. MRI staging concurred with histological staging in 18 of 20 patients using the Dukes or tumour node metastasis classification but in only 14 using the modified Astler-Coller system. MRI diagnosed transmural invasion in all but one patient with microscopic mural invasion (positive predictive value, 100 per cent; negative predictive value, 80 per cent; overall accuracy, 95 per cent). MRI correctly diagnosed tumour deposits or involved lymph nodes in 12 patients. MRI overstaged one patient, in whom nodes that were enlarged on imaging studies were negative at histological examination (positive predictive value, 92 per cent; negative predictive value, 100 per cent; overall accuracy, 95 per cent). MRI has a role in selected cases for the preoperative assessment of rectal carcinoma.

The value of water-soluble contrast radiology in the management of acute small bowel obstruction

A series of 127 consecutive patients with symptoms and signs and radiological features suggestive of acute small bowel obstruction underwent water-soluble contrast small bowel follow-through examination. A dose of 100 ml of Gastrograffin in adults, or 20-50 ml in children, was injected via a nasogastric tube and supine plain abdominal radiographs were taken at 30 min and 4 h after administration. If contrast passed to the colon a non-operative course was followed. If there was a clear cut-off in contrast level in the small bowel or if contrast failed to pass into the large bowel by 4 h, patients underwent laparotomy. Based on these radiological findings 15 patients (11.8%) underwent surgery and all had established small bowel obstruction at laparotomy. The remaining 112 patients were successfully managed conservatively. Water-soluble contrast radiology is safe, easy to use and to interpret, and is a major benefit in differentiating mechanical from other causes of small bowel obstruction. Our experience indicates that this underused technique is of significant value in identifying those patients who require urgent surgery.

The prognostic value of nucleolar organiser regions in colorectal cancer: a 5-year follow-up study

Nucleolar organiser regions (AgNORs) are loops of ribosomal DNA which reflect the cellular activity or malignant potential of the cell and are identified by a specific staining technique. The purpose of this study was to assess the prognostic value of AgNORs in colorectal cancer and to compare it with other accepted prognostic methods. We studied 164 patients who were surgically staged for colorectal cancer and who had complete follow-up data available for 5 years. Using a highly specific silver staining and counting technique each patient was given an AgNOR score. There were 5 Dukes' C tumours, 108 were Dukes' B and 5 were Dukes' A. No cancer deaths occurred in patients with Dukes' A tumours. The incidence of well-differentiated, moderately-differentiated and poorly-differentiated tumours was 37.2%, 53.7% and 9.1%, respectively. Non-survivors had significantly higher AgNOR scores compared with survivors (mean value +/- SD, 14.2 +/- 0.9 vs 8.2 +/- 0.6, P less than 0.0001). In a regression analysis model AgNOR score was the most significant individual variable for predicting survival (chi 2 = 15, P less than 0.01) when compared with Dukes' classification, histological grade, tumour depth or vascular invasion.

Identification of bile duct stones in patients undergoing laparoscopic cholecystectomy

To identify patients with common bile duct stones, all patients considered for laparoscopic cholecystectomy in this unit undergo intravenous cholangiography (IVC) with tomography and, more recently, operative cholangiography. To date 100 consecutive patients with symptomatic gallstones have undergone laparoscopic cholecystectomy with no specific exclusion criteria. Eight patients of 100 were found to have duct stones on IVC with one false-positive. These IVC data were compared with data from 52 patients who also had operative cholangiograms performed. One stone was detected on operative cholangiography that was not identified on IVC. No additional information was gained from operative cholangiography. These data suggest that preoperative IVC is adequate for the detection of duct stones in patients considered for laparoscopic cholecystectomy.

Gastrointestinal complications in 4473 patients who underwent cardiopulmonary bypass surgery

Thirty-nine gastrointestinal complications occurred in 35 of 4473 patients (0.78 per cent) who underwent surgery involving cardiopulmonary bypass during an 8-year period. The mortality rate when one of these complications occurred was 22 (63 per cent) representing 11.5 per cent of the 191 deaths from all causes in the series. The relative risk of developing a gastrointestinal complication was 1:249 when the heart was not opened, 1:66 when it was and 1:5 after cardiac transplantation. Gastrointestinal bleeding (n = 20) was the most common complication of whom nine (45 per cent) died, followed by intestinal infarction (n = 12) with eight (67 per cent) deaths and acute pancreatitis (n = 6) all of whom died. There was one death after surgery for gastrointestinal bleeding (n = 7). No patient survived bowel infarction without operation but resection was possible in five of the eight who underwent surgery, four of whom survived. The results demonstrate that surgical intervention is not associated with undue mortality but inappropriate conservative therapy is poorly tolerated in this high-risk group.

The role of central haemodynamic monitoring in abdominal aortic surgery. A prospective randomised study

To test the hypothesis that central haemodynamic monitoring is not necessary in all patients undergoing abdominal aortic surgery, a prospective randomised study in 40 consecutive patients undergoing elective abdominal aortic surgery was carried out. Patients with unstable angina, recent myocardial infarction (less than or equal to 6 months), and left ventricular ejection fraction (LVEF) less than 0.50 were excluded. Twenty-one patients had perioperative central haemodynamic monitoring while 19 patients had central venous pressure monitoring alone. Parameters studied included, perioperative haemodynamics and fluid balance, perioperative cardiac drug administration, operation time and clamp time, postoperative renal function, incidence of postoperative ventilation and line complications, duration of hospital and ICU stay, and 30 day postoperative outcome. Results obtained were compared with a high risk group of patients (LVEF less than 0.50) undergoing similar surgery. Statistical analysis failed to show any difference in outcome for any variable measured in either low risk group. All serious postoperative cardiac complications occurred in patients with LVEF less than 0.50 (P less than 0.0001). These data suggest that patients with LVEF greater than or equal to 0.50 are at low risk of developing postoperative cardiac complications and can be successfully managed perioperatively without the added potential risks and costs of central haemodynamic monitoring.

Free radical inhibition and serial chemiluminescence in evolving experimental pancreatitis

Oxygen free radical activity and inhibition were examined in experimental pancreatitis. Twenty-five rats were randomized to five groups: controls received intravenous saline, to simulate pancreatitis one group received intravenous caerulein (5 micrograms kg-1 h-1), and three groups received sodium taurocholate via the pancreatic duct (0.2 ml, 5 per cent), either alone, following allopurinol or immediately before superoxide dismutase. Chemiluminescence (a phenomenon based on the emission of light during chemical reactions and which is dependent on oxygen free radical activity) was used as an index of oxygen free radical activity and was measured in tissue samples at 5-min intervals following induction of pancreatitis. The control mean(s.e.m.) serum amylase level 1 h after induction of pancreatitis was 635(13) units. It was significantly elevated in caerulein-induced pancreatitis, 1833(118) units (P less than 0.05) and exceeded 3000 units in all taurocholate-infused animals. Mean(s.e.m.) chemiluminescence ranged from 44 (8) mV 100 mg-1 at time zero to 404(113) mV 100 mg-1 at 1 h in controls. In caerulein-induced pancreatitis mean(s.e.m.) chemiluminescence peaked at 20 min (1399(239) mV 100 mg-1, P less than 0.02) and in taurocholate-induced pancreatitis at 15 min (2316(95) mV 100 mg-1, P less than 0.004). Superoxide dismutase significantly reduced chemiluminescence and hyperamylasaemia in taurocholate groups. Increasing oxygen free radical activity paralleled evolving pancreatitis. Superoxide dismutase may have a therapeutic role in pancreatitis.

Pulse oximetry: a new non-invasive assessment of peripheral arterial occlusive disease

Peripheral skin perfusion reflects the level of vascularity and viability of a limb and may help in planning the site of amputation or bypass surgery in patients with vascular disease. This study used peripheral pulse oximetry in 20 healthy volunteers and in 20 patients with limb ischaemia. Pulse oximetry saturation levels (Psa,O2) were compared with ankle artery Doppler pressures and transcutaneous oxygen measurements (Ptc,O2). Recordings were taken at two standard sites distally and referenced to finger and forearm to calculate an index. A significant correlation was found between Ptc,O2 and Psa,O2 in patients with ischaemia (r = 0.68, P less than 0.01). A further group of 12 patients with acute limb ischaemia was similarly assessed before and after revascularization. After revascularization mean(s.d.) Ptc,O2 increased from 38(13) to 44(1) mmHg (P greater than 0.05) and mean(s.d.) Psa,O2 increased from 86(3) to 90(4) per cent (P less than 0.01). These data suggest that pulse oximetry is a more sensitive index of peripheral perfusion than Ptc,O2 or ankle artery Doppler pressure and that, because of its accuracy and simplicity, it merits further use.

Acute visceral ischemia secondary to aortic graft occlusion

This report describes a case of acute visceral ischemia precipitated by aortic graft occlusion. The importance of recognizing and treating visceral artery lesions at the time of aortic reconstruction is emphasized.

The influence of central haemodynamics on transcutaneous oxygen (TcpO2) measurements

Transcutaneous oxygen measurements (TcpO2) have been shown to be an index of tissue perfusion and it has been suggested that the main haemodynamic variable influencing tissue perfusion is cardiac output, assuming that inspired oxygen remains constant. To investigate this hypothesis we studied 23 consecutive patients in order to identify if changes in cardiac output correlated with similar changes in TcpO2 measurements. No correlation was found to suggest that cardiac output was the main haemodynamic determinant of TcpO2 measurements.

Supraceliac clamping: an underused alternative in aortic surgery

In the majority of patients undergoing abdominal aortic surgery, proximal clamping can be readily achieved below the renal vessels. In some situations however, this may be difficult, impossible or ill advised, and an alternative method of control must be sought. We describe the technique and report our personal experience with supraceliac clamping, a maneuver which merits more widespread use in emergency and difficult infrarenal aortic surgery.

Failure of bicycle exercise electrocardiograms to predict major post-operative cardiac complications in patients undergoing abdominal aortic surgery

To determine if exercise electrocardiograms (EECGs) are justified in routine pre-operative screening for cardiac disease, we performed a prospective study on 77 consecutive patients scheduled for infrarenal aortic reconstructive surgery. All patients had EECGs performed 1-12 days prior to elective surgery. In addition to routine clinical assessment of cardiac disease, all patients were allocated a Goldman risk score. Four patients developed major post-operative cardiac complications of whom one patient died. EECG was not a significant predictor of outcome, as 48.6% of all EECGs were inadequate due to non-completion of the exercise protocol. Significant pre-operative predictors of outcome were a history of angina (p less than 0.01), myocardial infarction (p less than 0.001), congestive cardiac failure (p less than 0.0001), or a Goldman score of greater than 14 (p less than 0.05). By multivariate analysis of the pre-operative risk factors a history of congestive cardiac failure was found to be the most significant independent predictor of post-operative cardiac complications.

Small bowel complications of metastatic lung carcinoma

A case of small bowel perforation and a case of small bowel obstruction as a result of metastatic lung carcinoma are presented. The surgical management of each is discussed. The patient who presented with small bowel perforation died in the immediate post-operative period, while the patient who presented with small bowel obstruction is alive and well six months later. Patients with primary lung carcinoma who present with an acute abdomen should be treated by standard surgical principles irrespective of their primary pathology.

Leaking thoraco-abdominal aortic aneurysm presenting with a massive left haemothorax: a clinical trap

A case is described in which a patient, who had had an aortic aneurysm repair 10 years previously, presented with a thoraco-abdominal aortic aneurysm which ruptured immediately above the previous graft. The implications for the management of patients with an abdominal aortic aneurysm repair are discussed.