R. B. Galland

Prospective evaluation of quality of life after conventional abdominal aortic aneurysm surgery

OBJECTIVES To evaluate the changes in quality of life following conventional abdominal aortic aneurysm repair. DESIGN Prospective study. MATERIALS AND METHODS Fifty-nine consecutive patients (50 men; nine women) in two surgical centres were investigated preoperatively, and at 6 weeks, 3 months and 6 months postoperatively. Quality of life was measured using the Short Form 36 (SF 36) questionnaire and the York Quality of Life questionnaire, from which the Rosser index was calculated. RESULTS Rosser index assessment showed restoration of quality of life to preoperative levels by 3 months, and significant improvement at 6 months. Changes in the SF 36 revealed significant improvement in mental health, and physical role limitation at all times postoperatively. Social function worsened at 6 weeks but improved to preoperative levels by 3 and 6 months after surgery. CONCLUSIONS Quality of life was improved after open aortic aneurysm repair. The time course of recovery shows a predominant improvement between 6 weeks and 3 months postoperatively.

The fate of patients undergoing surveillance of small abdominal aortic aneurysms

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.

Doctors’ knowledge of radiation — a two-centre study and historical comparison

AIM To investigate knowledge of the use of ionizing radiation in 2010 and whether there has been any change in this knowledge since the study was first undertaken over 7 years ago. MATERIALS AND METHODS In both studies a single chest x-ray was classed as one unit of radiation. Doctors from all grades were asked to evaluate the average radiation dose incurred with 13 commonly undertaken radiological procedures, including magnetic resonance imaging (MRI), computed tomography (CT), etc. Answers within 20% of the actual dose were marked as correct. RESULTS Two hundred and forty-two questionnaires were completed (130 in 2003; 112 in 2010). Equal numbers of juniors, middle grades, and consultants were questioned, and scores were comparable (23.3% in 2003; 29.4% in 2010). The majority of doctors (92% in 2003; 86% in 2010) correctly noted that ultrasound and MRI involve no radiation. Doctors underestimated the radiation doses of all investigations by a smaller margin in 2010 compared to 2003 (i.e., more accurately), with only one exception: CT of the abdomen. CONCLUSION Despite evidence of some improvement, doctors of all grades still have a very poor knowledge of radiation exposure even with the most common investigations. The worsening appreciation of the radiation involved in CT scanning is especially worrying considering its increasing use in practice today.

A simple way to improve DVT protocol compliance

Objective: To assess the impact on deep vein thrombosis (DVT) protocol violations of the introduction of a label attached to the patients drug chart, which specifically allows low-dose subcutaneous heparin or thromboembolic deterrent stockings (TEDS) to be prescribed as appropriate. Design: An audit study. Setting: Department of General Surgery of a District General Hospital in the United Kingdom. Method: All adult general surgical inpatients on a Weekday were studied. Staff were not forewarned of the studies. Patient details and risk factors for DVT were noted. Details of administered DVT prophylaxis were recorded. In total four separate studies were undertaken, namely: with original protocols (I), with refined protocol 1 and 3 years later (II, III) and finally after introduction of the label (IV). Results: Protocol violations were defined as being ‘acceptable’ or ‘unacceptable’. Raising awareness between studies I and II reduced acceptable violations to zero. There was no statistically significant reduction in unacceptable violations (24 in 80 patients, 1; 17 in 75, II; 13 in 60, III). In study IV, following introduction of the label, there were only 6 violations in 51 patients (p<0.02). Conclusion: Combining increased awareness with the attachment of a label to the drug chart reduced unacceptable violations by 63%.

The Treatment of Upper Limb Vascular Occlusions Using Intraarterial Thrombolysis

Acute ischaemia of the lower limb is increasingly treated by intraarterial thrombolysis. Four cases are reported in which this technique has been used successfully for treatment of upper limb emboli. The possible indications and potential drawbacks of such treatment are discussed.

Double blind comparison of iomeprol 350 and iopamidol 340 in intravenous digital subtraction angiography for peripheral vascular disease

A randomized double blind study was undertaken to compare the diagnostic efficacy and side effects of a new non-ionic contrast medium Iomeprol with a commonly used one--Iopamidol. Visual and densitometric comparison was made of intravenous digital subtraction angiograms performed for peripheral vascular disease. The results show the two media to be similar both in imaging quality and in the incidence of associated side effects. Ninety-eight per cent of the intravenous digital subtraction angiograms were assessed as adequate for clinical management by the vascular surgeon.

Maintenance of patency following remote superficial femoral artery endarterectomy

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.

The effect of intraoperative autotransfusion on antibiotic pharmacokinetics during elective abdominal aortic aneurysm repair.

AIM Blood loss during aortic surgery has been reduced by the use of cell-salvage techniques (CS). Antibiotics are used routinely to prevent prosthetic graft infection. The influence of CS on antibiotic levels is unknown. This study measured antibiotic levels in serum and cell-salvage fluid during aortic reconstruction. METHODS Teicoplanin, a glycopeptide with activity against gram positive bacteria was the antibiotic studied. Serial blood levels were measured after a single intravenous dose (400 mg) in five patients undergoing elective aortic aneurysm repair. Patient ages ranged from 67 to 82 yr. Cell-salvage (Dideco compact A75171) fluid was also assayed. SETTING District General Hospital RESULTS Serum teicoplanin levels peaked at mean 67.8 mg/l (SD 8.9 mg/l) 5 min after administration, and fell to mean 2.88 mg/l (SD 0.4 mg/l) at 720 min. This is less than levels in healthy volunteers but above the MIC90 for most Gram positive bacterial pathogens encountered in aortic surgery. Teicoplanin levels in discarded CS fluid at the end of the procedure were 0.56 mg/l (SD 0.71 mg/l). CONCLUSIONS Teicoplanin blood levels are reduced during aortic surgery. Levels remain adequate for antibacterial prophylaxis for 12 h postoperatively other than for methicillin-resistant staphylococcus epidermidis (MRSE). Compared with patients undergoing arterial reconstruction without the use of a cell-salvage device there is no significant loss due to CS use.

Reconstruction for lower limb occlusive disease in the elderly.

OBJECTIVES To determine the acceptability of performing distal limb bypass for occlusive vascular disease in the over 75s. METHOD Patients undergoing surgery between January 1988 and December 1996 were included. Data were obtained from a card system, operating ledgers, admission diaries and hospital notes. RESULTS A total of 166 patients were identified. There were 69 women and 97 men, 79 were aged 75-79 years, 81 were 80-89 years and six older than 90 years. A total of 171 procedures were performed: infrainguinal bypass in 131 (77%), aorto-femoral bifurcation grafts in 10 (6%) and extra-anatomic bypass in 30 (17%). This represents 28.1% of all reconstructions for occlusive disease during this time. Nine patients (5.4%) died within 30 days and one (0.6%) required a major amputation. During the follow-up period (median 12 months), 14 major and 10 minor amputations were required. Ten patients underwent a second successful reconstructive procedure. CONCLUSION Reconstruction in this group of older patients can be carried out with acceptable 30-day mortality and limb salvage rates.

Day Case Varicose Vein Operations: Patient Suitability and Satisfaction:

Objectives: To define how many patients with varicose veins are suitable to have the operation carried out as a day case. To define how well the procedure is tolerated. Design: A prospective 6-month study. Setting: District General Hospital. Patients: One hundred and sixty-eight new patients and a separate group of 100 patients having a day case varicose vein operation. Interventions: New patients were assessed according to RCS guidelines. Postoperatively, patients completed a one-page questionnaire. Results: Of the 168 patients, 141 (84%) were suitable for a day case operation. The main indications for an overnight stay were associated medical conditions and social problems. Of the 100 patients having an operation, 90 stated they would have a similar procedure carried out as a day case again. In the first 2 postoperative weeks, 12 patients saw their GP and three a district nurse. No patients contacted their GP before the fifth postoperative day. Twenty-eight patients took no analgesia following discharge from hospital; 81 felt that their postoperative pain was less than or as they expected. Conclusion: Most patients with varicose veins are suitable to have a day case procedure, which is well tolerated and provides no additional workload for the GP.