Transperitoneal ureter following ureteric reimplantation: a rare cause of small bowel obstruction and infarction.
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Adult↗
Biomedical subjects
T R Magee
Publications and source records attributed to T R Magee.
Phlegmasia caerulea dolens and venous gangrene.
Phlegmasia caerulea dolens and venous gangrene are rare conditions that tend to occur in association with malignancy. They are characterized by total or near-total occlusion of the venous drainage of the limb, including the microvascular collaterals. Associated mortality and morbidity rates are high, especially when progression to venous gangrene has occurred. Treatment options are limited; elevation and anticoagulation are recommended as first-line management. Experience with thrombolysis has been disappointing although intra-arterial administration of thrombolytic agents may improve results. Thrombectomy cannot be advocated routinely. Little advance in management, or in life and limb salvage, has been made in the past 30 years.
Female↗
Evaluation of distal run-off before femorodistal bypass.
The quality of distal run-off is one of the most important factors in determining outcome of femorodistal bypass. Accurate evaluation is important. Preoperative intra-arterial digital subtraction angiography and Doppler evaluation with pulse-generated augmentation of 90 patients who underwent femorodistal reconstruction were compared with postoperative angiography. Underestimation of distal run-off of the calf vessels occurred in 33% of cases by preoperative intra-arterial digital subtraction angiography. A below-knee pulse-generated run-off score of 3 or less was associated with a 12-month cumulative patency of 73% compared with 85% with a below-knee pulse-generated run-off score of 4 or more (P=0.079, log rank test; P =0.060, Wilcoxon signed rank test). The 12-month cumulative patency for grafts with a complete, incomplete and occluded arch as defined by pulse-generated run-off was 78, 90 and 38% respectively (P<0.0001 log rank and Wilcoxon signed rank tests). Preoperative evaluation of distal run-off before femorodistal bypass should not be based exclusively on intra-arterial digital subtraction angiography.
Aged↗
A ten year audit of surgery for vascular trauma in a British teaching hospital.
Vascular trauma is uncommon in the U.K. with the exception of Northern Ireland. In marked contrast to North America, gunshot wounds are rare and stabbings are infrequent. A 10 year audit was carried out in a regional vascular referral unit to determine the mechanisms, treatment and outcome of vascular injuries. Forty-seven patients were operated on during the period. The median age was 26 years (range 7-85 years); two-thirds were men. Road traffic accidents accounted for 21 (45%) of injuries, other accidents 15 (32%) and stabbings 11 (23%). There were no gunshot wounds. Most injuries were penetrating with no associated fracture. Commonly injured vessels were the brachial (30%) and superficial femoral (15%) arteries. Fifty-three primary operations were performed, 10 were vein interpositions and 21 were bypass grafts. There were three primary amputations (6%). Eleven patients suffered a complication including one death. One graft occluded requiring a further bypass. Two patients required fasciotomy as a secondary procedure. Median follow-up was 6 months. Eighty-one percent of patients were symptom free at last follow-up. There were no late vascular complications. Our experience is likely to represent that of other vascular units in countries with strict gun control legislation, little civil violence and modest levels of road traffic accidents.
Accidents, Traffic↗
Carotid patches.
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Endarterectomy, Carotid↗
Intraoperative duplex scanning as a means of quality control during carotid endarterectomy.
OBJECTIVES: To identify correctable technical errors following carotid endarterectomy using intraoperative colour duplex sonography (ATL, UM9, HDI). Results were compared with intraoperative flow measurements using an operative flow meter and with middle cerebral artery velocity measured by trans-cranial Doppler (TCD). DESIGN: Prospective study. MATERIALS AND METHODS: 50 consecutive patients undergoing carotid endarterectomy were investigated. Follow-up was performed at 6 weeks using duplex scanning and clinical evaluation. RESULTS: Significant intraoperative technical errors were detected in three patients and were re-explored. Two scans demonstrated kinking or pinching at the distal endarterectomy site requiring patch-plasty and the third revealed a large mass of intramural thrombus. A further 18 endarterectomies yielded 21 additional minor abnormalities. CONCLUSIONS: Duplex sonography provides a sensitive intraoperative technique for detecting thrombus and technical errors. It yields both anatomic and hemodynamic details and is superior to intraoperative flow measurements and transcranial doppler.
Aged↗
Duplex-guided compression of femoral artery false aneurysms reduces the need for surgery.
In a 1-year period, 13 patients underwent duplex-guided compression (DGC) of femoral artery false aneurysms. Of the 13 false aneurysms, 11 arose after cardiac catheterisation, and DGC was successful in 10 (77%) cases. The number of percutaneous cardiological procedures has risen over the past 5 years, and with time a greater proportion of these procedures have become more complex, involving coronary angioplasty or coronary stenting. The rate of vascular complications has risen from 0.2% in 1991-1992 to 0.61% in 1994-1995. Duplex-guided compression has reduced the number of operations performed for the vascular complications of percutaneous cardiological procedures by 50%. No complications have arisen from DGC, and it is recommended as the first line of management for femoral artery false aneurysms after percutaneous cardiological procedures.
Aged↗
A prospective audit of cholecystectomy in a single health district.
Laparoscopic cholecystectomy is becoming the treatment of choice for patients presenting with gallstones. A prospective audit of all patients undergoing cholecystectomy in a single health district over a six-month period was carried out. The aim was to define those patients not having laparoscopic cholecystectomy and determine the morbidity and mortality associated with open and laparoscopic procedures. Cholecystectomy was performed on 173 patients; 149 operations were attempted laparoscopically, of which 134 were successful, giving a conversion rate of 10%. Elective open cholecystectomy was performed on 24 patients. Twenty of these patients were under the care of a consultant who only performs open cholecystectomy and the others were not offered a laparoscopic procedure because of previous abdominal operations. The median time taken for open cholecystectomy was significantly shorter (P < 0.05) than for laparoscopic cholecystectomy or for converted procedures. Laparoscopic cholecystectomy resulted in bile duct injury in one patient (0.7%). This study shows that the majority of patients with gallstones are being offered laparoscopic cholecystectomy, although some patients will undergo open cholecystectomy. The latter include patients under the care of surgeons not performing laparoscopic cholecystectomy, those presenting as an emergency where laparotomy is performed and those where laparoscopy is contra-indicated. The findings of this study are probably representative of other health districts where a similar mix of surgical practice exists.
Adult↗
Colour duplex in assessing the infrainguinal arteries in patients with claudication.
Non-invasive assessment of the lower-limb vasculature may avoid unnecessary arteriography. Colour duplex scanning of the femoral and popliteal arteries was performed in claudicants who were potential candidates for endoluminal therapy. This was compared with the findings of biplanar conventional arteriography and intra-arterial digital subtraction angiography. In 112 lower limbs duplex gave the following results compared with angiography: the sensitivity, specificity, positive predictive value, negative predictive value and accuracy for occlusions (n = 48), stenoses (n = 31), atheromatous vessel (n = 21) and disease-free (n = 12) were all greater or equal to 94%. The lengths of the occlusions were accurately identified by duplex. Clinical examination and spectral analysis at the common femoral artery failed to identify two patients who had an iliac lesion. Colour duplex examination is the investigation of choice in assessing the major infrainguinal arteries in patients with claudication.
Adult↗
Regarding "Is transcranial Doppler a worthwhile addition to screening tests for cerebrovascular disease?".
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Adult↗
Thigh embolisation in association with bilateral profunda femoris aneurysms.
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Aged↗
Theatre delay for general surgical emergencies: a prospective audit.
A prospective audit of emergency theatre use for general surgery has been undertaken. Two month periods were studied before and after the introduction of a fully staffed 24-hour emergency theatre. Data were collected using a proforma documenting the time of the decision to operate, the actual time of the operation and the reason for and duration of any delay. After the introduction of the facility the proportion of procedures performed after midnight fell from 29 cases (21.3 per cent) to 7 (6.3 per cent) (p < 0.05). Emergency operating between 0900-1700 hrs increased from 40 cases (29.4 per cent) to 71 (61.3 per cent) (p < 0.05). There was no significant difference in the causes of delay between the two groups, the commonest being queuing for theatre. However, the length of the delay was significantly reduced. That for an appendicectomy was reduced from a median of 4 hrs 40 mins (range 30 mins-18 hrs 45 mins) to 1 hr 29 mins (0-6 hrs 30 mins) (p < 0.01) and for drainage of abscess from 5 hrs 56 mins (15 mins-20 hrs 30 mins) to 1 hr 51 mins (0-4 hrs 30 mins) (p < 0.01). There was no significant difference in the seniority of the surgeon making the decision to operate. In the first part of the audit we identified problems with regard to delay which were addressed by the introduction of the emergency theatre. The audit cycle has been successfully closed improving the care of general surgical emergencies requiring urgent or emergency operations.
Emergencies↗
Early reoperation rates after arterial surgery.
Between 1 January 1985 and 31 December 1991, 2426 patients underwent arterial surgery. Three hundred and seventy one reoperations were performed on 258 patients within 30 days of the initial procedure. One hundred and ninety three (52%) of the operations were attempted revascularisations, 95 (26%) were amputations and 58 (16%) were to control bleeding. One hundred and sixty nine (66%) of first operations were successful, but 76 patients required a further 113 reoperations. The mortality of reoperation was 16%, while the mortality of patients not requiring reoperation was 9% (p < 0.01). The mean hospital stay in days was higher in patients requiring reoperation (p < 0.05). Where appropriate, patients should be informed of the significant incidence of reoperation and reoperative mortality after vascular surgery. The increased hospital stay in reoperated patients has financial implications.
Adolescent↗
Transcranial Doppler evaluation of cerebral hyperperfusion syndrome after carotid endarterectomy.
Cerebral hyperperfusion syndrome after carotid endarterectomy is rare. Unilateral headache, confusion, seizures or focal neurological signs may occur and intracranial haemorrhage may be a terminal event. We report a case of hyperperfusion accompanied by transient hemiparesis. The changes in cerebral perfusion were documented using transcranial Doppler sonography which helped to make the diagnosis.
Arterial Occlusive Diseases↗
Vein graft factors in the outcome of femorodistal bypass.
Various vein factors affect the outcome of femorodistal bypass using vein in the treatment of lower limb ischaemia. In this review, the effect of factors such as vein size, compliance and morphology are discussed.
Femoral Artery↗
Criteria for identification of the "at-risk" infrainguinal bypass graft.
The criteria for identifying the "at-risk" femorodistal bypass are controversial. Eighty-eight patients were entered into a surveillance programme using ankle-brachial pressure indices (ABPI), colour Duplex and intraarterial digital subtraction angiography (IADSA). Changes in ABPI of more than 0.1 identified 12/22 (51%) grafts thought to be "at-risk". In the 88 grafts, a PMV (peak mean velocity) < 45 cm per second had a sensitivity and specificity of 55 and 85% compared to 91 and 95% if a PMV < 45 cm per second and a V2/V1 ratio of greater than 2 was used to identify the 22 grafts "at-risk". In total 341 examinations were performed, the sensitivity, specificity, positive predictive value, negative predictive value and accuracy for impedance analysis was 70, 90, 48, 97 and 91% respectively, compared to 93, 97, 77, 99 and 97% for colour Duplex in identifying the "at-risk" grafts. Between 6 weeks and 12 months the mean PMV was seen to drop by 29% and the mean impedance score by 19%. The most sensitive mode of non-invasive graft surveillance is colour Duplex providing the assessment involves both a measurement of the velocity ratio and the absolute velocity. However, impedance analysis is a better screening test than ABPI and PMV.
Angiography, Digital Subtraction↗
The aetiology of vein graft stenoses.
The aetiology of vein graft stenosis is poorly understood. In a cohort of 88 patients, the mean internal diameter of the vein grafts that developed a stenosis was 3.7 (3.1-4.2) mm compared to 4.7 (4.4-5.0) mm in those that did not (p = 0.006). The mean lowest compliance value in the 11 patients who developed a stenosis was 0.1 (0.07-0.13) % per mmHg compared to 0.21 (0.19-0.23) % per mmHg in the rest (p < 0.001). The presence of vein incompetence, site of tributaries or valves and the degree of endothelial cell loss were not related to the development of vein graft stenoses. The presence of a macrophage infiltrate (p < 0.001), lymphocyte infiltrate (p < 0.025) and subendothelial smooth muscle cells (p < 0.05) were all significantly more common in those grafts that developed a stenosis. Vein quality is an important factor in the development of graft stenoses.
Aged↗
Prediction of long saphenous vein graft adaptation.
The ability of vein to dilate may allow smaller veins to be used for bypass if this change could be predicted. Sixty patients undergoing femorodistal popliteal or infrapopliteal bypass have had their long saphenous vein studied. Diameter measurements of the long saphenous vein have been performed using an ATL Duplex scanner at the groin, mid-thigh and knee. Measurements were performed preoperatively both at rest and with a venous occlusion cuff to dilate the vein and subsequently at 7 days and 3, 6, 9, 12 months after implantation. The mean diameter of the vein at the mid thigh was 4.2 mm non dilated, 5.1 mm with occlusion, 5.4 mm 7 days postoperatively and 5.5 mm at 12 months (p < 0.01 ANOVA). The mean diameter of the vein at the knee was 3.8 mm non-dilated, 4.8 mm with occlusion, 4.8 mm at 7 days and 5.0 mm at 12 months after operation (p < 0.01 ANOVA). If the minimum resting internal diameter of vein regarded as being suitable for bypass was 3 mm, this technique would have increased the vein utilisation rate by 22%. These results show that by using a technique of venous occlusion at the time of preoperative vein mapping the adaptive response of the vein can be predicted and this can result in an increased rate of vein utilisation.
Aged↗