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This study is supported by the J P Moulton Charitable Foundation (grant number: N/A). The DCD allograft is provided free of charge by NHSBT., The authors wish to thank the principal investigators, research nurses and their teams at the recruiting sites. The authors also wish to thank the NHS Blood and Transplant (NHSBT) for providing the DCD allograft free of charge and for their support in training clinical staff, and the NIHR Clinical Research Networks (CRNs) for their support in identifying sites. Finally, the authors wish to thank all individuals who participated in the PPI focus groups and extend a special thank you to PPI representative Emanuel Ezeife, whose useful feedback helped to inform the design of the study., Introduction Venous leg ulceration (VLU), the most common type of chronic ulcer, can be difficult to heal and is a major cause of morbidity and reduced quality of life. Although compression bandaging is the principal treatment, it is time-consuming and bandage application requires specific training. There is evidence that intervention on superficial venous incompetence can help ulcer healing and recurrence, but this is not accessible to all patients. Hence, new treatments are required to address these chronic wounds. One possible adjuvant treatment for VLU is human decellularised dermis (DCD), a type of skin graft derived from skin from deceased tissue donors. Although DCD has the potential to promote ulcer healing, there is a paucity of data for its use in patients with VLU. Methods and analysis This is a multicentre, parallel group, pragmatic randomised controlled trial. One hundred and ninety-six patients with VLU will be randomly assigned to receive either the DCD allograft in addition to standard care or standard care alone. The primary outcome is the proportion of participants with a healed index ulcer at 12 weeks post-randomisation in each treatment arm. Secondary outcomes include the time to index ulcer healing and the proportion of participants with a healed index ulcer at 12 months. Changes in quality of life scores and cost-effectiveness will also be assessed. All analyses will be carried out on an intention-to-treat (ITT) basis. A mixed-effects, logistic regression on the outcome of the proportion of those with the index ulcer healed at 12 weeks will be performed. Secondary outcomes will be assessed using various statistical models appropriate to the distribution and nature of these outcomes. Ethics and dissemination Ethical approval was granted by the Bloomsbury Research Ethics Committee (19/LO/1271). Findings will be published in a peer-reviewed journal and presented at national and international conferences., J P Moulton Charitable Foundation

Background Treatment of superficial venous reflux in addition to compression therapy accelerates venous leg ulcer healing and reduces ulcer recurrence. The aim of this study was to evaluate the costs and cost-effectiveness of early versus delayed endovenous treatment of patients with venous leg ulcers. Methods This was a within-trial cost-utility analysis with a 1-year time horizon using data from the EVRA (Early Venous Reflux Ablation) trial. The study compared early versus deferred endovenous ablation for superficial venous truncal reflux in patients with a venous leg ulcer. The outcome measure was the cost per quality-adjusted life-year (QALY) over 1 year. Sensitivity analyses were conducted with alternative methods of handling missing data, alternative preference weights for health-related quality of life, and per protocol. Results After early intervention, the mean(s.e.m.) cost was higher (difference in cost per patient £163(318) (€184(358))) and early intervention was associated with more QALYs at 1 year (mean(s.e.m.) difference 0·041(0·017)). The incremental cost-effectiveness ratio (ICER) was £3976 (€4482) per QALY. There was an 89 per cent probability that early venous intervention is cost-effective at a threshold of £20 000 (€22 546)/QALY. Sensitivity analyses produced similar results, confirming that early treatment of superficial reflux is highly likely to be cost-effective. Conclusion Early treatment of superficial reflux is highly likely to be cost-effective in patients with venous leg ulcers over 1 year. Registration number: ISRCTN02335796 (http://www.isrctn.com).

This randomized clinical trial uses data from the Early Venous Reflux Ablation trial to evaluate the long-term clinical and cost benefits of combined early endovenous ablation and compression compared with compression therapy alone and deferred ablation for treating superficial venous reflux of the leg., Key Points Question In patients with venous leg ulceration and superficial reflux, what is the clinical and cost-effectiveness of early endovenous ablation of reflux? Findings In this 450-patient, multicenter, randomized clinical trial, early endovenous ablation with compression accelerated venous ulcer healing, reduced the overall incidence of ulcer recurrence, and was highly cost-effective compared with compression with deferred intervention. Meaning To deliver clinical and cost benefits, leg ulcer care pathways should be revised to include early assessment and treatment of superficial venous reflux., Importance One-year outcomes from the Early Venous Reflux Ablation (EVRA) randomized trial showed accelerated venous leg ulcer healing and greater ulcer-free time for participants who are treated with early endovenous ablation of lower extremity superficial reflux. Objective To evaluate the clinical and cost-effectiveness of early endovenous ablation of superficial venous reflux in patients with venous leg ulceration. Design, Setting, and Participants Between October 24, 2013, and September 27, 2016, the EVRA randomized clinical trial enrolled 450 participants (450 legs) with venous leg ulceration of less than 6 months’ duration and superficial venous reflux. Initially, 6555 patients were assessed for eligibility, and 6105 were excluded for reasons including ulcer duration greater than 6 months, healed ulcer by the time of randomization, deep venous occlusive disease, and insufficient superficial venous reflux to warrant ablation therapy, among others. A total of 426 of 450 participants (94.7%) from the vascular surgery departments of 20 hospitals in the United Kingdom were included in the analysis for ulcer recurrence. Surgeons, participants, and follow-up assessors were not blinded to the treatment group. Data were analyzed from August 11 to November 4, 2019. Interventions Patients were randomly assigned to receive compression therapy with early endovenous ablation within 2 weeks of randomization (early intervention, n = 224) or compression with deferred endovenous treatment of superficial venous reflux (deferred intervention, n = 226). Endovenous modality and strategy were left to the preference of the treating clinical team. Main Outcomes and Measures The primary outcome for the extended phase was time to first ulcer recurrence. Secondary outcomes included ulcer recurrence rate and cost-effectiveness. Results The early-intervention group consisted of 224 participants (mean [SD] age, 67.0 [15.5] years; 127 men [56.7%]; 206 White participants [92%]). The deferred-intervention group consisted of 226 participants (mean [SD] age, 68.9 [14.0] years; 120 men [53.1%]; 208 White participants [92%]). Of the 426 participants whose leg ulcer had healed, 121 (28.4%) experienced at least 1 recurrence during follow-up. There was no clear difference in time to first ulcer recurrence between the 2 groups (hazard ratio, 0.82; 95% CI, 0.57-1.17; P = .28). Ulcers recurred at a lower rate of 0.11 per person-year in the early-intervention group compared with 0.16 per person-year in the deferred-intervention group (incidence rate ratio, 0.658; 95% CI, 0.480-0.898; P = .003). Time to ulcer healing was shorter in the early-intervention group for primary ulcers (hazard ratio, 1.36; 95% CI, 1.12-1.64; P = .002). At 3 years, early intervention was 91.6% likely to be cost-effective at a willingness to pay of £20 000 ($26 283) per quality-adjusted life year and 90.8% likely at a threshold of £35 000 ($45 995) per quality-adjusted life year. Conclusions and Relevance Early endovenous ablation of superficial venous reflux was highly likely to be cost-effective over a 3-year horizon compared with deferred intervention. Early intervention accelerated the healing of venous leg ulcers and reduced the overall incidence of ulcer recurrence. Trial Registration ClinicalTrials.gov identifier: ISRCTN02335796

Background Venous ulceration is a common and costly health-care issue worldwide, with poor healing rates greatly affecting patient quality of life. Compression bandaging has been shown to improve healing rates and reduce recurrence, but does not address the underlying cause, which is often superficial venous reflux. Surgical correction of the reflux reduces ulcer recurrence; however, the effect of early endovenous ablation of superficial venous reflux on ulcer healing is unclear. Objectives To determine the clinical effectiveness and cost-effectiveness of compression therapy with early endovenous ablation of superficial venous reflux compared with compression therapy with deferred endovenous ablation in patients with venous ulceration. Design A pragmatic, two-arm, multicentre, parallel-group, open randomised controlled trial with a health economic evaluation. Setting Secondary care vascular centres in England. Participants Patients aged ≥ 18 years with a venous leg ulcer of between 6 weeks’ and 6 months’ duration and an ankle–brachial pressure index of ≥ 0.8 who could tolerate compression and were deemed suitable for endovenous ablation of superficial venous reflux. Interventions Participants were randomised 1 : 1 to either early ablation (compression therapy and superficial endovenous ablation within 2 weeks of randomisation) or deferred ablation (compression therapy followed by endovenous ablation once the ulcer had healed). Main outcome measures The primary outcome measure was time from randomisation to ulcer healing, confirmed by blinded assessment. Secondary outcomes included 24-week ulcer healing rates, ulcer-free time, clinical success (in addition to quality of life), costs and quality-adjusted life-years (QALYs). All analyses were performed on an intention-to-treat basis. Results A total of 450 participants were recruited (224 to early and 226 to deferred superficial endovenous ablation). Baseline characteristics were similar between the two groups. Time to ulcer healing was shorter in participants randomised to early superficial endovenous ablation than in those randomised to deferred ablation [hazard ratio 1.38, 95% confidence interval (CI) 1.13 to 1.68; p = 0.001]. Median time to ulcer healing was 56 (95% CI 49 to 66) days in the early ablation group and 82 (95% CI 69 to 92) days in the deferred ablation group. The ulcer healing rate at 24 weeks was 85.6% in the early ablation group, compared with 76.3% in the deferred ablation group. Median ulcer-free time was 306 [interquartile range (IQR) 240–328] days in the early ablation group and 278 (IQR 175–324) days in the deferred endovenous ablation group (p = 0.002). The most common complications of superficial endovenous ablation were pain and deep-vein thrombosis. Differences in repeated measures of Aberdeen Varicose Vein Questionnaire scores (p p = 0.03) and Short Form questionnaire-36 items body pain (p = 0.05) over the follow-up period were observed, in favour of early ablation. The mean difference in total costs between the early ablation and deferred ablation groups was £163 [standard error (SE) £318; p = 0.607]; however, there was a substantial and statistically significant gain in QALY over 1 year [mean difference between groups 0.041 (SE 0.017) QALYs; p = 0.017]. The incremental cost-effectiveness ratio of early ablation at 1 year was £3976 per QALY, with a high probability (89%) of being more cost-effective than deferred ablation at conventional UK decision-making thresholds (currently £20,000 per QALY). Sensitivity analyses using alternative statistical models give qualitatively similar results. Limitations Only 7% of screened patients were recruited, treatment regimens varied significantly and technical success was assessed only in the early ablation group. Conclusions Early endovenous ablation of superficial venous reflux, in addition to compression therapy and wound dressings, reduces the time to healing of venous leg ulcers, increases ulcer-free time and is highly likely to be cost-effective. Future work Longer-term follow-up is ongoing and will determine if early ablation will affect recurrence rates in the medium and long term. Trial registration Current Controlled Trials ISRCTN02335796. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 24. See the NIHR Journals Library website for further project information.

Objective: To assess the outcome after transthoracic endoscopic sympathectomy (TES) for upper limb hyperhidrosis. Design: Prospective cohort study. Setting: District general hospital. Subjects: Consecutive patients undergoing TES for upper limb hyperhidrosis over a fifteen month period. Interventions: One-stage bilateral TES. Main outcome measures: Change in quality of life as shown by the Short Form-36 health assessment questionnaire. Results: Sixteen patients (11 women and 5 men, median age 26 years) underwent operation without complications. At median follow-up of 6.2 months, symptomatic improvement was found in 26 of 32 limbs treated (82%). Truncal compensatory hyperhidrosis was reported by 13 patients but was severe in only three. There were significant improvements in social function (p = 0.01) and mental health (p = 0.025) as assessed by the SF-36. Conclusion: Despite a high incidence of compensatory hyperhidrosis, TES improved both the symptoms and overall quality of life in patients with upper limb hyperhidrosis. Copyright © 1998 Taylor and Francis Ltd.

Role of superficial venous surgery in the treatment of venous ulceration Letter 1: J. Barwell, K. Poskitt, M. Whyman, Department of Vascular Surgery, Cheltenham General Hospital, Cheltenham GL53 7AN, UK Letter 2: S. S. Shoab, P. D. Coleridge Smith, Department of Surgery, University College London Medical School, First Floor Jules Thorne Building, Middlesex Hospital, London W1N 8AA, UK Author's reply: N. J. M. London, A. M. Bello, Department of Surgery, Leicester Royal Infirmary, Leicester LE2 7LX, UK Anomalous pancreaticobiliary junction without choledochal cyst W. T. Ng, K. W. Lui, Department of Surgery, Yan Chai Hospital, Hong Kong Trauma centres in the USA – past and present Trauma centres: a British perspective Letter 1: D. A. Lloyd, Department of Child Health, Institute of Child Health, Alder Hey Children's Hospital, Liverpool L12 2AP, UK Letter 2: R. K. Gendy, Department of Surgery, Dorset County Hospital, Dorchester DT1 2JY, UK The sportman's groin E. A. Benson, Department of Surgery, General Infirmary at Leeds, Great George Street, Leeds LS1 3EX, UK Author's reply: D. A. D. Macleod, Department of Surgery, St John's Hospital at Howden, Livingston EH54 6PP, UK Randomized trial to study the effect of fundic mobilization on long-term results of Nissen fundoplication G. S. Smith, M. A. Richardson, G. L. Falk, Department of Endosurgery/Upper Gastrointestinal Surgery, Concord Repatriation General Hospital, Hospital Road, Concord, New South Wales 2139, Australia Author's reply: M. E. S. Luostarinen, Department of Surgery, Tampere University Hospital FIN-33521 Tampere and J. O. Isolauri, Turku University Central Hospital Turku Finland Thyroid surgery and the recurrent laryngeal nerve Letter 1: R. O. Wise, Suite 12, Level 5, North Wing Entabeni Hospital, 148 South Ridge Road, Durban 4001, South Africa Letter 2: A. Agarwal, G. Agarwal, S. K. Mishra, Department of Endocrine Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow 226014, India Author's reply: M. H. Wheeler, Department of Surgery, University Hospital of Wales, Heath Park, Cardiff CF14 4XW, UK Epidemiology of Warthin's tumour of the parotid gland in an Asian population A. Renehan, Department of Surgery, Christie Hospital NHS Trust, Wilmslow, Manchester M20 4BX, UK and O. Gallo, Institute of Otolaryngology, Head and Neck Surgery, University of Florence, Florence, Italy and M. McGurk, Department of Oral and Maxillofacial Surgery, Guy's, King's and St Thomas' Schools of Medicine, Dentistry and Biomedical Sciences, London, UK Author's reply: K. C. Soo, Department of Surgery, Singapore General Hospital, Outram Road, Singapore Adrenal-sparing surgery for phaeochromocytoma P. Iacconi, P. Miccoli, Department of Surgery, Pisa University Via Roma 67, 56100, Italy and C. O. Barlascini, G. Bernini, Department of Internal Medicine, Pisa University, Via Roma 67, 56100, Italy Author's reply: H. P. H. Neumann, Medizinische Universitätsklinik, Hugstetter Strasse 55, D-79106 Freiburg, Germany Laparoscopic management of complicated gallstone disease M. N. Siddiqui, Department of Surgery, Faculty of Medicine and Health Sciences, United Arab Emirates University, PO Box 17666, Al Ain, United Arab Emirates Peripheral thrombolysis for acute-onset claudication J. G. Mosley, C. Poon, Department of General Surgery, Leigh Infirmary, The Avenue, Leigh WN7 1HS, UK Chronic groin sepsis following tension-free inguinal hernioplasty S. Kumar, Department of General Surgery, Alexander Donald Building, Western General Hospital, Edinburgh EH4 2XU, UK During liver regeneration following right portal vein embolization the growth rate of liver metastases is more rapid than that of the liver parenchyma K. Seymour, D. Manas, R. M. Charnley, HPB Surgery Unit, Ward 5 Office, Freeman Hospital, High Heaton, Newcastle upon Tyne NE7 7DN, UK Author's reply: D. Elias, Service de Chirurgie Générale Oncologique, Institut Gustave Roussy, Rue Camille Desmoulins, 94805 Villejuif Cedex, France Physiological comparison of open and endovascular aneurysm repair A. Mahon, N. E. Bourantas, R. J. Whiston, Department of Surgery, Llandough Hospital, Penarth CF64 2XX, UK Author's reply: G. D. Treharne, M. M. Thompson, M. S. Whiteley, P. R. F. Bell, Department of Surgery, Robert Kilpatrick Clinical Sciences Building, Leicester Royal Infirmary, PO Box 65, Leicester LE2 7LX, UK Identification of patients likely to benefit from biofeedback for outlet obstruction constipation S. D. Wexner, Department of Colorectal Surgery, Cleveland Clinic Florida, 3000 West Cypress Creek Road, Fort Lauderdale, Florida 33309-1743, USA

Publisher Summary This chapter discusses the results comparing compression alone versus compression and surgery in treating venous ulceration. Chronic venous ulceration is widely accepted as a common, debilitating, and expensive health problem. Although most patients have superficial venous incompetence potentially amenable to surgical correction, evidence to support operative intervention has been scarce. Other researches strongly suggest that superficial venous surgery reduces venous ulcer recurrence and should be considered for all patients with chronic venous ulceration. Patients deemed suitable for surgical treatment should undergo color duplex venous mapping in order to identify superficial venous incompetence potentially suitable for surgical correction. Although the advantage appears greatest for legs with isolated superficial reflux, surgery may also reduce ulcer recurrence for some patients with deep venous incompetence, and hemodynamic assessment may be a useful selection tool. Despite any proven clinical benefit, it must be acknowledged that elderly patients with leg ulcers may be unfit for surgical intervention or unwilling to accept it. Local anesthetic surgery was performed in a quarter of patients, but long-term effectiveness is unlikely to match general anesthetic procedures. Residual venous reflux after venous surgery was common, although this was not associated with reduced hemodynamic function or clinical outcomes.

Much has been written on the subject of graft surveillance following infra-inguinal bypass graft surgery, but surprisingly little information exists on actual attendance rates for such programmes. The aim of this study was to calculate the attendance rate for graft surveillance at the vascular unit in Cheltenham. All patients who entered the graft surveillance programme following an infra-inguinal graft procedure over a 5-year period were included in the study. Partial and complete surveillance attendance rates were calculated for each year in the study period. Both rates were seen to rise over the 5-year period, from 31% to 78% and 0 to 38%, respectively. These attendance rates were much lower than were expected. Vascular units relying on such graft surveillance programmes should evaluate their own 'surveillance rates'.

To report the results of a protocol for the preoperative diagnosis of stones in the common bile duct in patients with symptomatic cholelithiasis.Prospective open study.District general hospital, United Kingdom.Ultrasonography and liver function tests, and in selected patients preoperative cholangiography.The ability of the investigations to diagnose stones in the common bile duct preoperatively.Ultrasonography or liver function tests, or both indicated that 53 patients were at low risk of having stones in the common duct, and they underwent laparoscopic cholecystectomy without further investigation. A further 38 patients had minor abnormalities on the first two investigations and underwent intravenous cholangiography; ductal stones were identified in 6. Nine patients were thought to be at high risk and so underwent endoscopic retrograde cholangiopancreatography (ERCP) or open exploration of the common bile duct, and stones were found in 5. No further stones have been identified after a minimum follow up of 12 months.Selective preoperative cholangiography is a reliable way of detecting stones in the common bile duct before laparoscopic cholecystectomy.

Transthoracic endoscopic sympathectomy is now considered the treatment of choice for patients with upper limb hyperhidrosis requiring sympathetic ablation. This procedure requires the use of an endobronchial double lumen tube and subsequent one-lung anaesthesia, a technique that is associated with a number of potential problems. Full patient monitoring is thus required and includes pulse, ECG, non-invasive blood pressure measurement, pulse oximetry, end-tidal carbon dioxide concentration and peak inspiratory airway pressure. We reviewed our anaesthetic technique and peri-operative complications in 26 patients, to assess patient safety. In our study hypoxaemia occurred commonly but was transient in all bar one case where re-expansion of the lung was required. Hypotension occurred at two stages of the procedure, but active intervention was not required, and two patients required underwater drainage of the pleural cavity for treatment of pneumothorax. With skilled anaesthetic personnel and adequate monitoring this procedure may be carried out safely.

The pathophysiological response to peripheral percutaneous transluminal balloon angioplasty in 20 patients was investigated using 111-Indium labelled platelets. Platelet deposition was quantified by measuring the degree of radioactivity uptake at angioplasty and control sites using a computer linked system and expressing the uptake as a ratio of angioplasty/control. Following platelet labelling, scans were performed before angioplasty and at 1, 24 and 48 h after angioplasty. To assess patency of the angioplasty, ankle brachial Doppler pressure indices were performed and supported by repeat angiograms if doubt of patency existed. All patients were followed-up at 1 week, 1 month and 6 months to correlate the degree of early platelet uptake with failure. The mean +/- sem platelet radioactivity ratio at the angioplasty site increased from 1.1 +/- 0.1 prior to the procedure to a peak of 2.1 +/- 0.3 at 1 h (p less than 0.01), 1.6 +/- 0.2 at 24 h (p less than 0.05), and 1.7 +/- 0.3 at 48 h (p less than 0.05). Angioplasties that failed within 6 months tended to have a higher maximum early platelet uptake (3.1 +/- 0.6) compared to successful angioplasties (1.9 +/- 0.3) but the difference was not significant in the numbers studied. This study provides a suitable model to assess the role of platelet accumulation in angioplasty failure and the influence of various antiplatelet regimes.

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Thrombus formation within arterial aneurysms may lead to embolisation and distal ischaemia. We have investigated the use of 111-indium labelled plate lets in the diagnosis of atherosclerotic and false aneurysms. Autologous platelets labelled with 111-indium oxine were injected into patients with eleven proven aneurysms (8 atherosclerotic, 3 false) . Gamma camera imaging performed be tween 24 and 72 hours later was positive for 10 of the aneurysms. In every case there was increased uptake of label over the aneurysm when compared to undis eased blood vessels (p < 0.05). Most aneurysms could be demonstrated within 24 hours of labelling platelets. 111-indium labelled platelets may prove useful in identifying the source of peripheral arterial emboli.

The aetiology and treatment of 35 femoral false anastomotic aneurysms in 29 patients presenting over the 4-year period 1984–88 were reviewed retrospectively. The mean interval between primary anastomosis and false aneurysm repair was 6 years (range from 2 weeks to 16 years). Twenty-two (63 per cent) false aneurysms had occurred after previous aortobifemoral bypass grafting for occlusive aortoiliac disease. Seven (20 per cent) presented as acute surgical emergencies. Review of the records of the initial operations revealed that superficial wound infections with positive bacteriological cultures had been present in eight cases (23 per cent) and a further two (6 per cent) had lymph fistulae. Thirty-two false aneurysms were repaired, by simple reanastomosis in 14 cases, interposition grafting in 17 cases and in one case by complete revision to an aortobifemoral bypass graft. The risk of a further operative repair was less (P < 0.05) following interposition grafting, than after simple revision. False aneurysm repairs, when compared with primary reconstructions done during the same period, were associated with more superficial wound infections (37 versus 10 per cent) and more explorations for haemorrhage within 30 days (19 versus 7 per cent).

Chronic venous ulcers are common, and even with effective compression or elevation large ulcers may take months to heal. Pinch skin grafting may allow healing from epithelial islands throughout the surface area of the ulcer, and a prospective randomised trial was therefore conducted comparing this treatment with porcine dermis dressings. Most patients were treated as outpatients, 25 ulcers being randomised to treatment with pinch skin grafts and 28 to treatment with porcine dermis. Though the groups were well matched, the mean healing rate in the first week was 15 cm2 for pinch skin grafts compared with 3.5 cm2 with porcine dermis (p less than 0.02). By life table analysis 64% of ulcers treated by pinch grafts were healed at six weeks and 74% by 12 weeks compared with 29% and 46% of ulcers, respectively, treated with porcine dermis dressings (chi2 = 4.1; p less than 0.05). All ulcers that failed to heal within 12 weeks included an area posterior to the medial malleolus, where local compression may have been inadequate. Pinch skin grafting improves the rate of healing in large venous ulcers and is a simple technique that may be performed as an outpatient procedure under local anaesthesia.

Between January 1980 and September 1988, 34 octogenarians underwent aortic aneurysm repair. There were 26 men and eight women with a median age of 83 years (range 80–88 years). Twenty underwent ‘emergency’ repair after presenting with pain and/or collapse: 11 with a retroperitoneal rupture, three with an intraperitoneal rupture and six with an expanding aneurysm. The mortality rate for this group was 35 per cent. During the same period 14 patients had an elective repair and there were no deaths within 30 days. The mean hospital stay for the elective group was 14.2 days compared with 17.0 days for survivors in the emergency group. There was no significant difference in terms of risk factors between those who developed postoperative complications and those who did not. These mortality rates compare favourably with our overall mortality results for elective (4.6 per cent) and emergency (31 per cent) surgery. Those patients over 80 years of age with infrarenal abdominal aortic aneurysms should not be refused surgery on the basis of age alone; each patient should be judged individually.

Multiple pulmonary emboli are recognized to be the cause of progressive pulmonary failure. In these patients, the source of emboli may be difficult to detect, even by venography. The authors describe the use of autologous Indium 111-labeled platelets to locate the origin in a patient with progressing right heart failure.

Embolisation of microaggregates following major surgery may be a cause of pulmonary arterio-venous shunt and postoperative respiratory failure (1). Prostaglandin E1 may prevent intravascular aggregation and we studied this possibility in a pig model of surgical shock.Following autologous platelet labelling with Indium, 16 pigs (20-30kg) were randomised to receive a perioperative infusion of PGE1 (100ng/kg/min) or placebo. Arterial and Swann Ganz catheters were inserted under anaesthesia prior to surgery consisting of midline laparotomy, exteriorisation of small bowel 1.5 hours of aortic clamping and 1 hour of hypotension. On induction, during shock and at 3 days in survivors platelet and leucocyte count, blood radioactivity, venous aggregates (SFP), lung platelet uptake (LPU), pulmonary vascular resistance (PVR) and alveolar-arterial p02 difference (A-ad02) were measured.All results mean ± sem *p During surgical shock, the formation of venous aggregates, the fall in circulating radiolabelled platelets and their accumulation in lungs were reduced by PGE1 (p< 0.05). BP, CVP and PWP were all lower on PGE1 and at 3 days the improvement in A-ad02 in PGE1 pigs failed to reach significance.PGE1 reduced platelet aggregate formation and their subsequent pulmonary microembolisation despite worsening shock due to vasodilation.1. McCollum CN, Campbell IT. The value of measuring intravascular platelet aggregation in the prediction of postoperative pulmonary dysfunction. Br J Surg 1979: 66; 703-707

Adult respiratory distress syndrome (ARDS) is a frequent cause of death in intensive care units and probably represents a collection of different conditions. In the complex issue of its aetiology the failure to define terms has led in our opinion to considerable confusion. It is doubtful whether the pulmonary failure that follows viral pneumonia or specific lung infections has the same pathophysiology as that following 3 days after massive blood transfusion, although both may share similar X-ray features and be called “ARDS”. In this chapter “shock” refers to that condition in which there is a failure of the circulation of blood to meet the metabolic needs of the tissues. “Shock lung” is defined here as pulmonary failure without left ventricular failure typified by increased pulmonary arteriovenous admixture and widespread opacification of the lung fields on X-ray, developing as a consequence of and at an interval of hours or days following an episode of shock or severe sepsis. In this way we may concentrate entirely on that variety of ARDS that almost certainly has a common, although possibly multiple, cause that was almost certainly active during the episode of shock. The delay before pulmonary failure develops is a consistent feature of great importance in understanding the pathophysiology.

Platelet aggregation response to collagen has been studied in 20 rabbits, randomly allocated to receive a normal (control) or high cholesterol diet. The sensitivity of platelets to collagen was significantly higher in the hypercholesterolaemic group (p less than 0.01) compared to controls. All hypercholesterolaemic rabbits developed generalised atherosclerosis and this may be due to increased circulating platelet activity.

Skin grafting is commonly used in the treatment of burns, venous and ischaemic ulceration and post-operative wound defects. Most skin grafting can adequately be performed with the use of free skin grafts which can be broadly categorised into whole and split skin grafts. The use of pinch skin grafts (Fig 1) which are in effect whole skin grafts centrally and split skin grafts peripherally are more1,2 frequently being used for the treatment of venous ulceration . It is well described that the donor sites from which skin grafts are obtained are the source of more discomfort than the recipient site. This discomfort is caused by exposure of the dermal nerve endings and is diminished more rapidly it epithelialisation occurs readily. The presence of infection delays healing and can in addition cause increased discomfort. Donor site discomfort may also vary depending on the site from which the skin graft is obtained. In pinch skin grafting the donor sites more commonly used are the anterolateral and anteromedial aspect of the thigh.

Thromboxane release from platelet microemboli during major arterial surgery may mediate depression of cardio-pulmonary function. The effect of cyclo-oxygenase inhibition by aspirin has been studied in a porcine model of aortic surgery.Following autologous platelet labelling with 111-lndium, 24 pigs (20-25kg) were randomised to low dose (LD) aspirin (0.5mg/kg), high dose (HD) aspirin (10mg/kg) or placebo.Arterial and Swann Ganz catheters were inserted prior to surgery consisting of midline laparotomy, small bowel extériorisation, 1.5 hours of aortic clamping and 1 hour shock before resuscitation. On induction, during shock and at 3 days, platelet and leucocyte counts, lung platelet uptake (LPU), venous aggregates by screen filtration (SFP), mean arterial pressure (BP), cardiac output (CO), pulmonary shunt (PS) and alveolar-arterial pO2 difference (A-adO2) were measured.During shock following aortic declamping aspirin preserved blood pressure by increasing vascular resistance rather than CO. Venous aggregates by SFP tended to be lower on aspirin with significantly reduced LPU, subsequent pulmonary shunting and A-adO2. The improvement in PS but not A-adO2 remained significant at 3 days (pCyclo-oxygenase inhibition improved pulmonary function during surgical shock either by inhibiting platelet microemboli or by a direct effect on pulmonary arteriovenous shunts.

Platelet inhibitory therapy has applications in vascular surgery and in patients who have coronary and cerebral vascular disease1. Screening of new products to assess their ethicacy involves measurement of platelet aggregation responses to standard aggregants2 the use of artificial circuits3 and clinical trials, which are time consuming and expensive. The frequent side-effects found with the standard platelet inhibitory therapy of aspirin combined with dipyridamole4 has led for a search for new compounds. We have developed an in vivo canine model which is used to identify effective compounds on the basis of the rate of platelet accumulation and subsequent thrombosis on artificial arterial prostheses. We describe this model and its use to evaluate a new reversible cyclo-oxygenase inhibitor, indobufen (Farmitalia Carlo Erba).

Pulmonary dysfunction frequently follows major surgery and has many features identical to ‘shock lung’. A porcine model of aortic surgery is described in which 111In-labelled platelet kinetics were related to subsequent pulmonary function. In 14 pigs, standardized aortic surgery resulted in reproducible shock and a 50 per cent mortality at 3 days. Cardiac output fell from 22.3±0.2 to 1.0±0.1 litres min−1 following removal of the aortic clamp and mean platelet and leucocyte counts fell from 437±48 to 252±39×109 litres−1 and 21.7±1.5 to 12.9±1.2×109 litres−1 respectively (P

Fibronectin is an adhesive glycoprotein present in high concentration in plasma, >300 mg/1. Fibronectin has binding sites for collagen, heparin, cells, Factor XIII and other macromolecules.1 Plasma fibronectin is thought to function as a non-specific opsonin to promote reticuloendothelial cell clearance of microaggregates. The depletion of this opsonin has been related to poor prognosis in critically ill surgical and burn patients.2 Plasma fibronectin depletion has also been reported in the early postoperative period in patients undergoing uncomplicated gastro-intestinal surgery.3 We have developed a model of surgical shock in pigs involving aortic-cross clamping and followed the plasma fibronectin and platelet counts.

An in vivo method of measuring thrombus deposition and pseudo-intimal thickening in prosthetic arterial grafts in an animal model is described. The effect of indobufen, a new cyclo-oxygenase inhibitor, was evaluated and compared to aspirin plus dipyridamole and placebo in 24 greyhounds. Luminal platelet accumulation expressed as thrombogenicity index was 0.33 ± 0.07 in the placebo group. This was significantly reduced to 0.14 ± 0.01 by indobufen (P

Human prosthetic vascular grafts do not sustain a growth of endothelium on the luminal surface and remain thrombogenic indefinitely1. Whilst large diameter aortic grafts develop a thin layer of platelet thrombus as pseudointima, smaller prostheses such as those in the femoro-popliteal position have a thrombosis and occlusion rate approaching 60% at 1 year after implantation2. Platelet inhibitory therapy is established in the prevention of thrombosis but the combination of aspirin plus dipyridamole produces frequent gastro-intestinal side effects. This has been shown in the recent Persantin Aspirin Re-infarction Study3 where 25% of patients had to discontinue aspirin therapy. Thromboxane A2 (TXA2) which is a product of aracidonic acid metabolism, is a powerful stimulator of platelet aggregation4. It is produced by enzymes including cyclo-oxygenase and thromboxane synthetase in platelets and the natural biological opponent of TXA2 is prostocyclin (PGI2).

Two cases of claudication of the cauda equina due to ischaemia secondary to distal aortic disease in the Small Aorta syndrome are reported. The association has not been previously reported and the appropriate management is discussed.

Summary A case of pneumatosis cystoides intestinalis discovered at laparotomy for a perforated duodenal ulcer is described. Nitrous oxide administration is contra-indicated in this condition, and the rapid effectiveness of 100% oxygen administration is observed during the surgical procedure.

Infection of surgical wounds leads to delaying healing, incisional herniation and occasionally to fatal septic complications. Contamination by micro-organisms at the time of surgery is prevented by an aseptic operating environment. Postoperatively, wounds are dressed to reduce entry of bacteria such as Staphyloccoci aureus and Eschericia coli which occur naturally as skin commensals.

Conservative measures to improve claudication distance include advice on smoking, exercise, diet and weight reduction. Although the effects of smoking, exercise and diet are established, the effect of weight is less clear. The aim of this study was to investigate the effect of carrying extra weight on the maximum walking distance in stable claudicants. Twenty stable claudicants were exercised on a treadmill (3.5 km/h, 0º slope) carrying 0, 2.5, 5, 7.5 and 10 kg weights in randomized sequence. Maximum claudication distance and ankle: brachial pressure indices were recorded. Patients were categorized into mild or severe claudicants depending on their ability to walk 200 m. A response index (RI) was calculated as the reduction in claudication distance per kilogram load; RI = [CD0 − CD10]/10 m/kg, where CD0 and CD10 represent claudication distance with 0 and 10 kg weights, respectively. Claudication distance was significantly reduced in subjects carrying 5 kg or more (P < 0.01). A linear relationship was demonstrated between the mean claudication distance and the load carried (r = 0.98, P < 0.01) with a mean response index of 10.2 m/kg. The mean(s.e.m.) RI in mild claudicants (25.9(9.5) m/kg) was greater than the value observed in the severe claudicants (3.3(0.8) m/kg; P < 0.01, Mann-Whitney U test). This study demonstrates that weight adversely affects claudication distance and suggests that weight reduction may deserve greater emphasis in the management of some patients with intermittent claudication.