Stuart R. Walker

AN AUDIT OF OPERATIVE NOTES: FACTS AND WAYS TO IMPROVE*

Background:  Accurate operation record keeping is an important element of risk management. Handwritten surgical notes are often produced as evidence in medico‐legal malpractice cases and incomplete and illegible notes may be a source of weakness in a surgeon’s defence. Therefore, we audited the surgical notes in a teaching hospital surgical department.

ENDOVASCULAR REPAIR OF POPLITEAL ARTERY ANEURYSMS: TECHNIQUES, CURRENT EVIDENCE AND RECENT EXPERIENCE

Endovascular repair of popliteal artery aneurysms is a new technique, which has emerged as an alternative to open surgical bypass. However, evidence to support its use is limited. We present a review of current literature relevant to this technique. The MEDLINE search terms were popliteal artery, aneurysm, endovascular, endoluminal and stent. Fifty‐eight articles were yielded, of which 21 were studies of endovascular repair by implantation of stent or stent graft of true aneurysms of the popliteal artery. There was only one randomized study. Small numbers of endovascular interventions are reported, with variations in study design and endovascular techniques. Long‐term follow‐up data is lacking; however, early results have been promising with high rates of initial treatment success. Early thrombosis of stent grafts occurs in approximately 10%, but this does not herald limb loss. Endovascular treatment offers potential benefits over traditional surgery, but needs to be studied further with a large‐scale multicentre randomized trial.

Endovascular Repair of Ruptured Abdominal Aortic Aneurysms in a Rural Center Is Both Feasible and Associated with Reduced Blood Product Requirements

Endovascular aneurysm repair (EVAR) of ruptured abdominal aortic aneurysm (rAAA) has been shown to be both feasible and associated with a reduced operative mortality when compared with conventional open repair (OR). The aim of this study was to show the feasibility of EVAR of rAAA in a rural vascular unit and to investigate the blood product requirements when compared to OR. The method used in this study was a retrospective case note review of patients presenting with rAAA to a small, rural vascular unit between February 2004 and November 2008. Admission demographics and hematological variables were recorded. Volumes of crystalloid, colloid and blood products were recorded prior to intensive care unit (ICU) admission and for the first 48 hours following ICU admission. Results are expressed as medians and Mann-Whitney U test was used to compare variables. Of 81 patients presenting with rAAA, 36 were treated palliatively. Of 45 patients who underwent intervention, 7 had EVAR and all survived to discharge (0% operative mortality). Of 38 who had OR, 16 died before discharge for an operative mortality of 42%, 36% if the EVAR patients are included. Admission demographics and hematological variables of patients who had EVAR, patients who had OR and survived (ORS) and patients who had OR and died (ORD) showed no significant difference. When compared with ORS patients, those undergoing EVAR had significantly less pre-ICU crystalloid (3 L vs 7.5 L, p = .001), less red blood cell transfusion (1 unit vs 6.5 units, p = .0006), and less colloid (0 L vs 0.5 L, p = .008). When compared with ORD, those undergoing EVAR had less red blood cell transfusion (1 unit vs 7 units, p = .0001) and less fresh frozen plasma (0 units vs 4 units, p = .03). Within the first 48 hours of admission to ICU, the blood product requirements were no different in those undergoing EVAR when compared with OR. EVAR of rAAA is feasible in a small rural vascular unit and appears to be associated with reduced requirements for blood products.

VASCULAR SURGERY CONSULTS: A SIGNIFICANT WORKLOAD

Background:  Patients with vascular disease typically suffer from widespread atherosclerosis and complex multisystem pathologies. As a result, it may be expected that significant portion of a vascular surgeon’s inpatient workload is derived from consultations from other inpatient specialist units. This aspect of the workload of vascular surgeons is poorly documented.

A Retrospective Study on the Use of Heparin for Peripheral Vascular Intervention

PURPOSE To compare immediate outcomes for patients who receive and those who do not receive heparin during lower limb endovascular intervention. METHODS A retrospective case series of 330 procedures for lower limb peripheral arterial occlusive disease. Patient records were interrogated for bleeding or thrombotic/embolic complications during or immediately after endovascular intervention for peripheral arterial occlusive disease. RESULTS Of the 220 patients who received heparin, 21 (9.6%) suffered an access site bleed compared with 2 of the 110 patients (2%) who did not receive heparin (odds ratio [OR] = 5.7; 95% confidence interval [CI] = 1.3-25; P = .01). There were 6 embolic/thrombotic complications in the patients who received heparin (2.7%) compared with 4 in those that did not receive heparin (3.6%; P = .74). In 187 cases, a closure or compression device was used (StarClose, n = 109; Angio-Seal, n = 42; FemoStop, n = 35; ProGlide, n = 1), of which there were 3 access bleeding complications (2%). One hundred and forty-three cases did not have a closure or compression device associated with 17 (12%) access bleeding complications (OR = 0.25; 95% CI = 0.09-0.64; P = .004). CONCLUSIONS In this study, heparin use and nonuse of a closure or compression device was associated with an increased risk of access site bleeding. Embolic/thrombotic complications were uncommon.

Epithelioid hemangioma of the ulnar artery.

This case report describes a rare vascular tumor (epithelioid hemangioma) in the ulnar artery of a young male patient, treated by excision and bypass grafting.

Thrombin injection to treat a scalp pseudoaneurysm.

We describe the successful treatment of a large scalp pseudoaneurysm using direct thrombin injection.

Randomized, blinded study to assess the effect of povidone‐iodine on the groin wound of patients undergoing primary varicose vein surgery

The aim of this study was to assess the effect of povidone‐iodine on the groin wounds of patients undergoing primary varicose vein surgery.

U Clips for arteriovenous anastomosis: a pilot, randomized study.

The objective of this study was to assess a novel, new, nitinol clip for performing arteriovenous anastomoses.

Is routine surgical patient follow-up required?

To most surgeons, their patients and other health-care professionals, review by the surgeon following a routine surgical procedure is standard practice. It is also thought that it may reduce the risk of medico-legal claims for negligence. But, what is the clinical purpose of this follow-up? Particularly in public hospitals, without setting limits on outpatient clinic numbers, clinics can quickly become overburdened. Consequently, for most public hospitals, there is a waiting period between the time of referral and the time of being seen in a specialist clinic. As health economics and streamlining of health systems expand, there is ever increasing pressure towards more effective utilization of resources with attached demands for improved performance. One easy performance measure is the waiting time to be seen in a clinic. This does not measure quality of care, it is simply a measure of speed of care. In a retrospective review of outpatient attendances to general surgery clinics in a district general hospital in the UK, Gurjar et al. reported that 22% of clinic attendances were for benign post operative follow-ups and they felt that more than half of these were unnecessary. If we could reduce the number of patients seen unnecessarily then there could be more time to see new patients. In a postal questionnaire sent to clinical directors of surgical departments in Australian public hospitals (response rate 47.5%) it was noted that only one hospital had a formal policy on the follow-up of surgical patients. Table 1 shows a trend toward clinicians recommending fewer patients requiring follow up. So why do surgical patients have follow-up following routine surgery?