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Biomedical subjects

R B Galland

Publications and source records attributed to R B Galland.

At least 19 recordsLinked to original sources
PubMed2007

Outcome following bypass, and proximal and distal ligation of popliteal aneurysms.

BACKGROUND: The aim of this study was to describe early and late results of proximal and distal ligation for popliteal aneurysm (PA), combined with bypass, with particular reference to the fate of the excluded aneurysm. METHODS: Of a cohort of 116 patients with PAs, 66 were treated with bypass and ligation. Graft patency was determined by duplex surveillance. In addition, 17 patients with bypassed PAs underwent a total of 33 duplex scans to determine flow within the aneurysm and change in size. RESULTS: For initially patent PAs, 3-, 5- and 8-year primary bypass graft patency was 78, 78 and 51 per cent respectively. These rates were not statistically significantly different from those following bypass for thrombosed PA, 3- and 5-year primary patency being 72 and 65 per cent respectively. No PA produced further symptoms after bypass and ligation. No flow was seen in any aneurysm at follow-up. Only one showed an increase in size. CONCLUSION: Proximal and distal ligation with bypass produced satisfactory long-term patency with good exclusion of the PA.

Aneurysm↗
PubMed2006

Combined fascia and mesh repair of incisional hernias.

Incisional hernia is a relatively common complication following abdominal operations. Due to high recurrence rates following primary suture, a prosthetic mesh is now usually used to repair the hernia. Several different types of repair are described. A combined fascia and mesh technique avoids opening the peritoneal cavity and potential damage to bowel. This study describes results of this technique. Consecutive patients undergoing the operation were contacted to assess freedom from recurrence and satisfaction with results. Some 34 patients underwent 36 incisional repairs. Of the 34 patients 21 were men and 13 were women with a median age of 69 years (range 31-86 years). The causative incisions were midline (30), Kochers (2), Pfannesteil (2) and transverse (2). The median time spent in hospital was three nights (range 1-14 days). Two patients developed seromas, another complained of pain soon after operation, one patient developed a superficial wound infection another developed a tender drain site which required exploration. One patient with significant co-morbidity died 13 days postoperatively from multiorgan failure. Freedom from recurrence of the hernia was 91% at 5 years. However patient survival was only 70% at 5 years. This technique is associated with low postoperative morbidity and a low recurrence rate. Patients presenting with incisional hernias have a poor long-term prognosis which needs to be borne in mind when planning intervention.

Adult↗
PubMed2006

A waiting list to go home: an analysis of delayed discharges from surgical beds.

INTRODUCTION: The aim of this paper was to analyse patients who were unable to be discharged from a surgical ward despite being surgically fit to leave. PATIENTS AND METHODS: Data were collected on all surgical in-patients on a single day. Patients who were surgically fit for discharge but whose discharge was delayed were identified. Demographic data and reasons for delay were noted. RESULTS: Nine of 75 patients (12%) were surgical bed blockers. These patients were more likely to have been admitted as emergencies (P = 0.035) and were older (P < 0.01) than the remaining patients. They occupied 35% of the total 'bed-days' of the group as a whole with a median in-patient stay of 41 days compared with 2 days for the other patients. Trust-collected data, based on UK Government guidelines, showed only one surgical delayed discharge patient on the day studied. CONCLUSIONS: Due to problems in defining delayed discharge Government figures probably underestimate the true numbers. Lack of intermediate care and social service provision are a major cause of bed blocking.

Adult↗
PubMed2006

Vascular surgical emergencies: how will future surgeons be trained?

INTRODUCTION: We wished to assess whether pattern and impact of emergency vascular surgical referrals has altered since a previous study in 1990. Following introduction of shift working patterns, we wished to assess how these changes may affect vascular training and vascular on-call cover. PATIENTS AND METHODS: Prospective survey of emergency vascular referrals at two district general hospitals (DGH-R and DGH-L) in 2003. DGH-R received only regional referrals whereas DGH-L also received 'next day' referrals from a smaller hospital. Results were compared between centres and with a previous study undertaken at DGH-R in 1990. RESULTS: From 1990 to 2003 emergency vascular referrals at DGH-R increased by 51% (53 to 80). The number seen at DGH-R and DGH-L were similar in 2003. There were significantly more out-of-hours referrals in DGH-R than DGH-L (59% versus 35%; P = 0.0123). Referrals were more likely to be seen initially by the vascular team at DGH-L than DGH-R (80% versus 47%, P < 0.0001). CONCLUSIONS: Vascular emergency referrals have increased. A trainee was likely to see more emergency referrals at DGH-L than DGH-R. This may impact on future training.

After-Hours Care↗
PubMed2005

Remote superficial femoral endarterectomy: Long-term results.

PURPOSE: The aim of this study was to determine long-term results following successful remote superficial femoral endarterectomy (RSFE). METHODS: RSFE is a minimally invasive technique of revascularising the superficial femoral artery. A single incision was made over the origin of the superficial femoral artery. The endarterectomy was carried out in a closed fashion from above. The cut end of distal atheroma was secured with a stent. Following RSFE patients were followed up with intravenous digital subtraction angiography (IVDSA) and 3-monthly duplex scans. IVDSA was repeated if any abnormality was found. RESULTS: RSFE was attempted on 30 patients with 33 symptomatic legs to treat tissue loss (n = 3), rest pain (n = 3) or intermittent claudication (n = 27). In 26 limbs it was possible to complete the RSFE satisfactorily (technical success 79%), but during follow-up 18 later developed stenoses. Of 31 stenoses detected, 27 were treated by angioplasty. Primary patency at 1, 2 and 5 years was 38, 31 and 16%, respectively. Primary-assisted patency at 1, 2 and 5 years was 77, 65 and 60%. CONCLUSIONS: Primary-assisted patency following RSFE is reasonable, however, it is only achieved with life-long surveillance and intervention. Until results can be improved the widespread use of RSFE cannot be recommended.

Aged↗
PubMed2005

Popliteal aneurysms: distortion and size related to symptoms.

OBJECTIVES: To examine size and distortion of popliteal aneurysms (PA) in relation to symptoms produced at presentation. METHODS: A prospective study of all PA presenting to a single unit 1988-1994. Wherever possible patients underwent angiography, duplex scanning and measurement of both PA diameter and the most proximal angle of distortion. Symptoms and measurements were noted at the time of first presentation. RESULTS: Seventy-three patients presented with 116 PA. At initial diagnosis 44 PA (38%) were asymptomatic and 39 (34%) produced acute ischaemia. As the PA increased in diameter so did the degree of distortion (p < 0.0001). Size and distortion were greater in PA producing acute ischaemia or acute thrombosis than in asymptomatic PA (p < 0.01). Degree of distortion differentiated symptomatic from asymptomatic PA (p = 0.0066). Size was not significantly different between these two groups. For PA 3 cm or larger in diameter with greater than 45 degrees distortion sensitivity, specificity and positive and negative predictive values for thrombosis were 90, 89, 83 and 94%, respectively. CONCLUSION: Distortion and size can differentiate between PA producing different symptoms. Combining the two provides a reliable method of differentiating PA which should be managed by early elective repair.

Aged↗
PubMed2005

Critical appraisal of femorofemoral crossover grafts.

BACKGROUND: The aim of this study was to determine how often femorofemoral crossover grafting for critical ischaemia or intermittent claudication gives an ideal result. An ideal result is an uncomplicated operation with primary wound healing, relief of ischaemic symptoms without recurrence and no need for further intervention. METHODS: All patients undergoing primary femorofemoral crossover grafting between January 1988 and December 2003 were studied. RESULTS: Some 144 operations were analysed; 51 patients had critical ischaemia and 93 claudication. There was one postoperative death (0.7 per cent). Complications occurred within 30 days in 32 patients (22.2 per cent), including graft occlusion in three (2.1 per cent); six patients (4.2 per cent) required early reoperation. Primary patency for patients with critical ischaemia was 88, 82 and 74 per cent at 1, 3 and 5 years respectively. Respective figures for those who presented with claudication were 93, 92 and 90 per cent (P = 0.034). Late symptoms included graft occlusion (20 patients), disease progression (25), ongoing ulceration (six), graft infection (nine), false aneurysm formation (two) and late donor-site stenosis (two). CONCLUSION: When obtaining informed consent, simply describing patency and limb salvage rates does not provide an accurate picture of the outcome of femorofemoral grafting.

Aged↗
PubMed2005

Popliteal aneurysms: controversies in their management.

Popliteal artery aneurysms (PAs) occur in older men with significant comorbidity and limited life expectancy. This needs to be remembered when planning elective operation for asymptomatic aneurysms. In the absence of significant distortion PAs <3 cm in diameter can be managed by sequential ultrasound scanning. Their rate of thrombosis is no worse than that of grafts after elective bypass. Intra-arterial thrombolysis for acute thrombosis should be restricted to intra-operative usage to clear run off.

Aged↗
PubMed2005

Changes in the provision of vascular surgery in a single health region over 10 years.

INTRODUCTION: This study examines changes in vascular service provision and activity in a single UK health region over 10 years. PATIENTS AND METHODS: A questionnaire on involvement in vascular surgery was sent to all general surgeons in the Oxford region in 1992, 1997 and 2001. Data on involvement in vascular surgery were obtained from the Department of Health. RESULTS: Over 10 years the number of general surgeons not performing any emergency vascular (arterial) surgery rose from 33% to 65% (P = 0.002). There was also a fall in the number of general surgeons performing only emergency vascular surgery (P = 0.009). Trends were observed towards more vascular emergencies being transferred to another hospital (P = 0.068) and proportionally fewer general surgeons undertaking recurrent varicose vein surgery (P = 0.09). The number of vascular reconstructions was 20.8 per 100,000 population in 1990-1991, rising to 32.3 per 100,000 in 1997-1998 but falling to 27.2 per 100,000 by 1999-2000, the greatest increase in activity was seen in the regional centre. Endovascular procedures increased from 8.2 per 100,000 in 1990-1991 to 21.27 in 1995-1996 falling to 17.4 by 1999-2000. In the regional centre there was a fall of 57% in such procedures from 1996-1997 to 1999-2000. Over 10 years, the overall major amputation rate remained between 10-12 per 100,000. CONCLUSIONS: The changes reflect the gradual separation of vascular surgery from general surgery occurring nationally. They also suggest a more conservative approach in the management of certain vascular conditions.

Health Care Surveys↗
PubMed2005

Subintimal angioplasty for superficial femoral artery occlusion: poor patency in critical ischaemia.

INTRODUCTION: Subintimal angioplasty has been proposed for the treatment of long segment occlusive disease and for patients with critical limb ischaemia (CLI) with significant co-morbidity. There is no consensus as to short- and long-term patency. We present our experience with this technique. METHODS: Between 1995 and 2000, 43 consecutive patients (48 limbs) underwent subintimal angioplasty for superficial femoral artery occlusions. Outcome measures were haemodynamic and/or symptomatic patency. RESULTS: Technical success was achieved in 14/17 limbs with CLI (82%) and 30/31 (97%) with intermittent claudication (IC). There were 7 complications (15%), 6 occurring in the claudicant group. The median occlusion length was 10 cm for CLI and 6 cm for IC. Patency at 12 and 36 months, on an intention-to-treat basis, was 69% and 58% for claudicants and 25% and 25% for patients with CLI (P = 0.0005 and P = 0.0044, respectively). Following only technically successful procedures, 12-month patency was 72% (IC) and 31% (CLI) (P = 0.009). Patients with occlusions > or = 10 cm were more likely to re-occlude than those < 10 cm (12-month patency 60% versus 25%;P = 0.037). CONCLUSIONS: In this series, short- and long-term patency in patients with CLI is poor. Subintimal angioplasty in the treatment of CLI should be reserved for those patients not fit for surgical bypass.

Adult↗
PubMed2005

Intra-operative peritoneal lavage--who does it and why?

INTRODUCTION: Intra-operative peritoneal lavage (IOPL) is widely practised but its benefits are unclear. The frequency and pattern of its use amongst general surgeons is investigated. METHODS: A postal questionnaire was sent to 153 general surgical consultants and registrars enquiring about their use of IOPL. The surgeon was asked the volume and type of lavage fluid used, under various circumstances. RESULTS: 118 (77%) questionnaires were returned. 115 (97%) surgeons used IOPL. The majority of surgeons (61%) lavaged until the fluid was clear, 20% used more than 1 l and 17% used between 500-1000 ml. In the case of the dirty abdomen (i.e. gross pus or faecal peritonitis), 47% used saline as the lavage fluid, 38% aqueous betadine, 9% water and 3% antibiotic lavage. Similar results were found in the case of a contaminated abdomen (i.e. a breached hollow viscus). 34% of surgeons used IOPL during clean cases. 36% used water lavage during intra-abdominal cancer surgery; 21% lavaged with saline and 17% with betadine. More registrars (47%) than consultants (29%) lavaged with water during cancer surgery. Consultants, however, used more aqueous betadine. CONCLUSIONS: The frequency of use and choice of lavage fluid varies widely. The successful management of the septic abdomen rests on at least 3 tenants - systemic antibiotics, control of the source of infection and aspiration of gross contaminants. There is little good evidence in the literature to support IOPL in the management of the septic abdomen. The use of IOPL during cancer surgery is supported by in vitro evidence. The current use of IOPL, as shown by this study, appears not to be evidence based.

Anti-Infective Agents, Local↗
PubMed2005

MRSA in lower limb amputation and the role of antibiotic prophylaxis.

AIM: Methicillin Resistant Staphylococcus Aureus (MRSA) colonisation is reported in 3-20% of vascular patients. Many develop infective complications. MRSA is associated with poor prognosis. Aim of the study is to assess MRSA in lower limb amputation and efficacy of antibiotic prophylaxis. METHODS: Prospective study of lower limb amputation. MRSA screen and wound swabs were taken at operation. Antibiotic prophylaxis included teicoplanin (400 mg) 1 dose at operation. RESULTS: Twenty-five patients underwent 33 primary amputations. At operation 15 legs (45%) were colonised with MRSA and 18 legs (58%) had active wound infection; MRSA (4) and other (14). Following surgery 3 patients died. Twenty-two legs (76%) had primary healing. Infection developed in 7 stumps (24%), MRSA (5) and Pseudomonas (2). Stump infection increased time to wound healing (p<0.0001). MRSA stump infection increased revision amputation (p=0.009) and duration of hospital stay (p<0.0074). MRSA wound infection at operation increased the risk of MRSA stump infection (p=0.007). Non-MRSA wound infection at operation was not associated with a worse outcome. No patient colonised with MRSA at operation developed postoperative MRSA stump infection. CONCLUSIONS: MRSA is more prevalent that previously reported. MRSA infection has a poor prognosis. Prophylaxis may be effective for patients colonised with MRSA.

Aged↗
PubMed2004

Results of thoracoscopic sympathectomy for the treatment of axillary and palmar hyperhidrosis with respect to compensatory hyperhidrosis and dry hands.

BACKGROUND: We examined the results of thoracoscopic sympathectomy (TS) for palmar and axillary hyperhidrosis with respect to operative method, symptom control, patient satisfaction and complications. METHODS: We performed a retrospective review of patient records with mail and telephone questionnaire follow-up of 55 patients (15 men) with a median age of 26 years (range, 15-52) who underwent TS between February 1994 and December 2001. RESULTS: There were no differences in complication rates between those having bilateral TS (n = 23) and those having unilateral procedures (n = 20) with a median follow-up of 21 months (range, 2-94). Forty-three patients returned questionnaires (response rate, 78%). Forty patients (93%) were satisfied with the results. Thirty-four patients (79%) noted compensatory hyperhidrosis and 22 (51%) excessively dry hands. CONCLUSION: Despite high rates of compensatory sweating, the majority of patients are very satisfied with the results. The high rate of excessively dry hands is a previously unreported finding and important to discuss when obtaining consent.

Adolescent↗
PubMed2004

Expansion rates of asymptomatic popliteal artery aneurysms.

OBJECTIVES: In the absence of symptoms the decision to operate on popliteal artery aneurysms (PA) is often made on PA diameter. Little information exists on growth rate and therefore optimum scanning intervals. The aim of this paper is to define growth rate of PA managed conservatively. METHODS: A prospective study of patients with asymptomatic PA was carried out. Patients were invited for ultrasound scanning at 6-12 months intervals. Diameter changes between consecutive pairs of scans were measured. A decision to operate was made in fit patients if PA became symptomatic and/or had a diameter above 3 cm. RESULTS: Twenty-one men (24 aneurysms) with a median age of 69 years (46-86) underwent 78 scans. Sixteen PA were on the right and eight on the left. Eighteen patients had bilateral aneurysms, 15 of which were complicated on one side at presentation and were dealt with surgically on that side. The median size at first scan was 19 mm (14-36). The median time interval to the first follow-up scan was 9 months and subsequent scans were 12 months. The mean rate of expansion at aneurysm sizes below 20 mm diameter was 1.5 mm/year. PA grew by 3.0 mm/year at sizes 20-30 mm and by 3.7 mm/year at sizes >30 mm. Among the risk factors analysed, hypertension appeared to increase the risk of aneurysm growth. CONCLUSION: The expansion rate of PA increases with increasing size of the PA. This rate of growth in relation to size at previous scan and threshold diameter for intervention should be borne in mind when planning surveillance intervals.

Aged↗
PubMed2004

Significance of routine digital rectal examination in adults presenting with abdominal pain.

AIM: Routine digital rectal examination (DRE) in children with abdominal pain has slowly gone out of practice but is still performed routinely in adults. This study was undertaken to assess the significance of routine DRE in adults with acute abdominal pain. PATIENTS AND METHODS: A total of 100 consecutive adults admitted to the emergency surgical unit with acute abdominal pain were studied prospectively. Following DRE, patients who were willing to participate in the study were requested to complete an anonymous questionnaire. The house officer conducted the rectal examination at admission and also completed an evaluation sheet. RESULTS: A working diagnosis of acute appendicitis in 38 patients and gastroduodenal, pancreatobiliary pathology in 24 patients was made. DRE did not alter clinical diagnosis or initial management in any of the 100 patients. Routine DRE did not detect any unrelated pathology. Of the patients, 93 wanted to know why rectal examination was required. Overall, 78 patients rated the DRE as uncomfortable. Although 43 were willing for DRE as a routine, 54 patients preferred to have the DRE at the time of other bowel tests rather than at the time of the emergency admission. CONCLUSIONS: Various routine medical procedures have given way to evidence-based practice. This study has demonstrated the limited role of routine DRE in adults with no anorectal or GI symptoms during their initial evaluation for acute abdominal pain.

Abdominal Pain↗
PubMed2003

Natural history of the ectatic aorta.

OBJECTIVES: To define the natural history of ectatic abdominal aortas and to assess the clinical need for follow-up. DESIGN: Abdominal aortas were considered ectatic if they were diffusely and irregularly dilated with a diameter less than 3 cm. Ectatic aortas were identified either by AAA screening or as incidental findings. Patients who had only one scan were excluded from the study. Clinical data were analysed. SETTING: Two district general hospitals in Wales and England. SUBJECTS: 116 patients (90 men). RESULTS: : The median age of patients was 71 years (range 48-90). Co-existing risk factors included hypertension (75), IHD (22), PVD (8), diabetes (3), COAD (14), stroke (5), popliteal aneurysm (1), malignant disease (3) and 4 had a family history of AAA. The median follow-up was 24 months (range 5-72). The median and maximum growth rate of the ectatic aortas were 0.65 and 14.4 mm/year respectively. In three patients the expansion rate was more than 5 mm/year. In 22 patients the ectatic aorta became aneurysmal, reaching a diameter greater than 3 cm. There were no ruptures and no elective repairs. Two deaths occurred due to IHD. CONCLUSIONS: : This study demonstrates that if ectatic aortas do expand they do so very slowly. However, 22 of the 116 (19%) became aneurysmal in a follow-up of two years. Once identified ectatic aortas should be scanned at intervals of three years.

Aged↗