Subfascial Endoscopic Perforator Surgery is More Cost-Effective Than Compression Bandaging for Healing Venous Ulcers

Objective:

To determine whether subfascial endoscopic perforator surgery (SEPS) is more cost-effective than compression bandaging for healing venous ulcers.

Design:

Cost analyses based on theoretical patients supposing the two methods are equally effective in healing venous ulcers.

Setting:

District hospital.

Patients:

A theoretical population of 200 patients with unilateral leg ulceration due to incompetent perforating veins.

Intervention:

The cost of SEPS was calculated based on outpatient visits, investigations and surgery including complications, with varying failure and re-ulceration rates. The cost of compression bandaging was estimated from published data and compared with that of SEPS.

Results:

The average cost per patient undergoing SEPS was £723. In 100 patients with an operative failure rate of 2% and a 10% re-ulceration rate, the cost increased to £818/patient in the first year (£16/ulcer-free week). A re-ulceration rate of 35% increased the cost to £23/ulcer-free week. However, the cost of compression bandage was £33/ulcer-free week using the same model, with healing rates of 50–70% at 20–40 weeks and a recurrence rate of 18–30% at 30–40 weeks.

Conclusion:

In a theoretical model SEPS was more cost-effective in healing venous ulcers due to incompetent perforators compared with compression bandaging.

Prospective 5-year audit for day-case laparoscopic cholecystectomy

AIMS: Laparoscopic cholecystectomy can be performed as a day-case procedure but success depends on adequate recovery time, patient motivation and physical condition. To determine the proportion of patients suitable for a day-case procedure, 23-h stay and inpatient treatment, a prospective audit was introduced in 1994. METHODS: A 5-year (1994-1999) prospective annual audit was performed for all patients undergoing laparoscopic cholecystectomy (537 patients). In the first 3 years patients were either classified as day-case or inpatient stay; the establishment of a 23-h stay ward allowed a third option for these patients. RESULTS: Day-case laparoscopic cholecystectomy, including 23-h stay in the final 2 years of the audit, increased in each of the 5 years from 16 to 80 per cent. The audit loop was closed when the successful allocation rate for day-case patients was reaudited; this increased from 56 per cent in the first year to 88 per cent in the final year. CONCLUSIONS: This audit has identified the need for extended recovery for patients undergoing more major procedures on an ambulatory basis such as laparoscopic cholecystectomy. Further refinements in selection criteria and improved analgesia control are needed to reduce the unexpected extended stay for day-case and ambulatory patients.

Iatrogenic Leg Ulcer after Subfascial Endoscopic Perforator Surger (SEPS)

Objective:

To report a case of iatrogenic leg ulcer after subfascial endoscopic perforator surgery (SEPS).

Design:

Case report.

Setting:

Department of Vascular Surgery, Milton Keynes Hospital, a district general hospital.

Patient, intervention and results:

A 57-year-old woman underwent SEPS for a venous ulcer secondary to an incompetent perforating vein. Post-operatively she developed a new ulcer directly over the site of the divided perforator. The ulcer healed completely with conservative bandaging treatment after 4 months.

Conclusion:

We describe a complication of SEPS not previously reported. The perforating artery might have been divided inadvertently instead of the perforating vein. It is important to positively identify the perforating vein during SEPS before its division, especially in the presence of mixed arteriovenous disease.

A prospective survey of patients presenting with abdominal aortic aneurysm

OBJECTIVES

To define the presentation and management of patients presenting with abdominal aortic aneurysm (AAA) DESIGN AND SETTING: A prospective survey was carried out of all patients presenting to hospitals within the Oxford region.

MATERIALS AND METHODS

Data were collected by one surgeon in each hospital. Full details were collected onto data sheets.

RESULTS

One hundred and ninety patients presented, 141 electively, 46 with ruptured AAA and three with acute AAAs. In 53 patients presenting electively the aneurysm was small and surveillance started. Fifty-six patients underwent an operation, three patients died. Of 46 patients with a ruptured aneurysm 24 (52%) died. In 11 no operation was carried out and all of these patients died within 24 h. Operative mortality was 13 of 35 patients (37%). More patients with a ruptured AAA were transferred to the teaching hospital compared with a district general hospital (p < 0.05). This was reflected in a lower operative mortality in the teaching hospital.

CONCLUSIONS

The presentation of AAA in this study was approximately 15 per 100,000 population. Approximately one-third of patients presenting electively had small AAAs which required surveillance. A further third underwent an operation, the remaining patients being unfit. Approximately one-quarter of patients with a ruptured aneurysm did not undergo an operation. The operative mortality was 37%.

Rehabilitation outcome 5 years after 100 lower-limb amputations

Received wisdom commends a policy of maximizing the ratio of below-knee to above-knee amputations in patients with end-stage arterial disease. After adoption of this policy, the long-term outcome of 100 consecutive lower-limb amputations in 96 patients was monitored by annual review for 5 years. The ratio of primary below-knee to above-knee amputations was 2:1, with 9 per cent of below-knee amputations undergoing revision to a higher level. At 2 years after amputation only 26 per cent of patients were successfully walking out of doors, while 40 per cent had died. By 5 years 67 per cent were dead and only 9 per cent continued to walk out of doors with an artificial limb, although a further 8 per cent continued to use the limb within the confines of their own homes. In a previous audit of 193 amputations performed during the 3.5 years to December 1984, stump healing was a problem in 45 per cent of primary below-knee amputations, compared with 25 per cent in the present study. Although the below- to above-knee ratio in 1984 was only 1:2, the overall rehabilitation rate, as determined by the proportion of patients able to walk at 2 years, was 34 per cent. It is concluded that increasing the proportion of below-knee amputations from one-third to two-thirds of lower-limb amputations for occlusive arterial disease does not improve effective rehabilitation rates. Received wisdom on the desirability of a high below- to above-knee ratio may be wrong.

Provision of vascular surgical services in the Oxford Region

Vascular surgical practice across an entire health region was studied. There was a mean of 115.9 inpatient episodes and 46.9 vascular reconstructions per 100,000 population, with considerable variation between districts. Vein utilization for infrainguinal grafts was greater in the teaching hospital and few femorodistal grafts or carotid endarterectomies were carried out elsewhere; there were few tertiary referrals of elective vascular cases. Only two districts have formal arrangements for emergency vascular 'on-call'. There is marked inequality of provision of vascular surgical services across the region.

Combination drug therapies for immunosuppression in transplantation

Current combination immunosuppression protocols used worldwide include azathioprine/prednisolone, cyclosporine protocols, cyclophosphamide/steroids and FK506/steroids. The fact that many different immunosuppression protocols are currently in use, demonstrates that none is ideal. Major determinants in the choice of any protocol include graft and patient survival, side effects and cost. While most protocols may offer one year graft survival rates of 80% to 90% in renal transplantation, it is the long term results which are becoming increasingly important, but as many protocols have only been recently introduced, it may be sometime before these answers are known. While the most effective regimens include cyclosporine, long term nephrotoxicity remains a problem. Furthermore, the cost of the drug may be prohibitive in many countries worldwide. Azathioprine and low dose steroids still provide acceptable results with lesser expense and where cost and drug availability are critical, cyclophosphamide may even be introduced in place of azathioprine in living-related renal transplant recipients. The role of the newer immunosuppressive agents such as FK506 remains unclear, as the results of prospective randomised studies are not yet available. With excellent results now obtained with many different protocols, it is apparent that the choice of the most suitable immunosuppressive regimen is no longer dictated by graft survival alone.

Immunohistological analysis of renal allograft biopsies from cyclosporin-treated patients. Induced HLA-class II antigen expression does not exclude a diagnosis of cyclosporin nephrotoxicity

Differentiation of cyclosporin nephrotoxicity from renal allograft rejection is often difficult. Induction of tubular HLA-class II antigens and elevated levels of leucocyte infiltration are associated with allograft rejection but their association with cyclosporin nephrotoxicity is unclear. In order to determine these relationships, transplant biopsies (n = 32) from patients considered to have cyclosporin nephrotoxicity, allograft rejection or stable graft function were stained with monoclonal antibodies specific for HLA-class II antigens and infiltrating leucocytes. Leucocyte infiltration was elevated during rejection but not in cyclosporin nephrotoxicity or stable graft function. While HLA-class II antigen expression was induced in 71% of the biopsies obtained during clinical rejection, no increased expression was found in the other 29%. Induced antigens were detected in five of the nine biopsies obtained in the presence of cyclosporin nephrotoxicity 90 days after transplantation. In four of these, induction was attributed to prolongation of increased class II expression following previous rejection episodes. Thus, the presence of induced class II antigens in the renal allograft does not exclude a diagnosis of cyclosporin nephrotoxicity.

The diagnosis of renal allograft rejection: an improved assessment of graft infiltration using image analysis

These results show that image analysis is an accurate alternative to point counting in the assessment of infiltration in renal allograft biopsies and can provide an efficient and rapid diagnosis of cellular rejection in the transplanted patient.

Precise specificity of induced tubular HLA-class II antigens in renal allografts

HLA-class II antigen expression is induced in the tubules of renal allografts, but it is unclear whether all three class II products--HLA-DR, DQ, and DP--are induced, and whether the induced product is of donor origin. A pretransplant (n = 14) and serial transplant biopsies (n = 45) were obtained from 14 transplant recipients in whom induced HLA-class II antigen was detected after transplantation with a monoclonal antibody reactive with HLA-DR, DP, and possibly DQ antigens. Cryostat sections were stained with locus-specific or polymorphic monoclonal antibodies in an indirect immunoperoxidase assay. In pretransplant biopsies intracellular HLA-DR antigen was expressed on proximal tubules, whereas all tubules were negative for HLA-DQ and DP products. After transplantation grafts with induced tubular HLA-class II antigen had induced HLA-DR, DQ and DP antigens expressed both within the cytoplasm and on the cell membranes. The donor or recipient origin of induced HLA-class II expression was determined using polymorphic antibodies specific for either donor or recipient antigens. This approach demonstrated that the induced class II antigen is of donor origin--and, furthermore, that the renal parenchyma remains of donor HLA-type, even one year after transplantation, and thus remains a source of antigenic stimulus to the recipient.

The influence of HLA-A,B and -DR matching on leucocyte infiltration in renal allografts

The influence of donor and recipient HLA-A,B and -DR matching on the cellular infiltration in renal allografts was examined in 78 transplant recipients who received either cyclosporin (Cy) or azathioprine and low-dose prednisolone (AP) immunosuppression. Transplant biopsies (n = 161) were routinely obtained up to 40 days after transplantation, and biopsy material was therefore available from both rejecting grafts and grafts with stable function. Tissue sections were labelled with a panel of monoclonal antibodies and stained using an indirect immunoperoxidase technique. Cellular infiltration was assessed using a morphometric point counting technique. In AP-treated patients with well-functioning grafts, poor HLA-AB and HLA-DR matching was associated with increased leucocyte infiltration, while in patients receiving Cy therapy the effect of matching on cellular infiltration was seen only during rejection in grafts poorly matched for HLA-AB antigens. In addition, where an effect of HLA-AB matching on cellular infiltration was found, CD8+, but not CD4+ cells, were significantly increased in number, while when an HLA-DR matching effect was seen, a significant increase was observed in the CD4+ and not the CD8+ infiltration. Thus, HLA matching may influence the magnitude of the cellular response in renal allografts and the phenotype of the infiltrating cells.

The influence of cyclosporine on cellular infiltration in rat renal allografts

In this study donor specific blood transfusion of PVG recipients prevented rejection of DA strain kidneys but, paradoxically, failed to prevent the rapid and progressive accumulation of large numbers of mononuclear cells within enhanced grafts. Morphometric analysis showed that the percentage cellular infiltrate at day 3 was significantly greater in enhanced than in rejecting grafts but a notable feature in the phenotypic analysis of day 5 infiltrates was a markedly reduced number of MRC OX8 positive cells (Tc/s and NK cells) in enhanced grafts. Both rejecting and enhanced allografts showed a marked induction not only of class I but also of class II MHC antigens, and quantitative absorption analysis of donor class I MHC antigens indicated that induction occurred more rapidly in enhanced grafts. Taken together, these findings suggest that blood transfusion sensitizes the recipient, resulting in a more rapid allograft response, but that even in the presence of massive MHC/antigen induction and large numbers of infiltrating cells, immunoregulatory mechanisms are able to suppress the rejection response.

Morphometric analysis of cellular infiltration assessed by monoclonal antibody labeling in sequential human renal allograft biopsies

The mononuclear cell infiltrate in a total of 279 human renal allograft biopsies was determined by a panel of monoclonal antibodies using an indirect immunoperoxidase technique. Two hundred and seventy-two biopsies were obtained from 83 patients randomly allocated to receive short-term cyclosporine (CsA) or conventional azathioprine and low-dose prednisolone (AP). Biopsies were obtained routinely at days 0 (control biopsies), 7, 21, 90, and 365, as well as at other times when clinically indicated. A further 7 patients on AP therapy were biopsied several years after transplantation (median: 6 years 1 month). Morphometric analysis of cryostat tissue sections using a point-counting technique has shown that the infiltration in rejecting grafts is significantly greater than in grafts with stable function. However, significant infiltration also occurs within the first week after transplantation in grafts with stable function. While this infiltrate diminishes with time, it remains significant even in grafts biopsied several years after transplantation. The infiltration with CsA treatment is significantly less than with AP therapy. The magnitude of the infiltrate therefore varies with time, graft status, and immunosuppression. In contrast the phenotypic composition of the infiltrate remains relatively constant in all biopsies after transplantation with T lymphocytes (CD3+), accounting for approximately 35% of infiltrating cells and CD8+ cells more common than CD4+. Monocytes and macrophages account for most of the remainder of the infiltrate.

Sequential analysis of HLA-class II antigen expression in human renal allografts. Induction of tubular class II antigens and correlation with clinical parameters

The expression of HLA-class II antigens was assessed in 142 biopsies from 29 recipients of cadaveric renal allografts who received either short-term cyclosporine (n = 12) or azathioprine and low-dose prednisolone (n = 17). Biopsies were obtained before transplantation, routinely at days 7, 21, 90, and 365 after transplantation, and at other times as clinically indicated. Cryostat sections were labeled with monoclonal antibodies using an indirect immunoperoxidase technique. In all biopsies HLA-class II antigens were expressed on glomeruli and intertubular structures. In pretransplant biopsies proximal tubules expressed class II antigens, whereas distal tubules were always negative. After transplantation three patterns of class II expression were recognized based on renal tubular class II staining: normal, focal increased, and generalized increased expression. Sequential biopsy analysis showed fluctuating levels of expression in individual patients, which correlated with cellular infiltration and was associated with allograft rejection. 71% of biopsies obtained at day 90 from patients on conventional therapy showed increased class II expression compared with only 9% of biopsies from patients on cyclosporine immunosuppression. All patients with normal class II antigen expression in day 90 biopsies had well-functioning grafts two years after transplantation, whereas 3 of 9 with increased class II antigen expression had failed. Furthermore, all grafts failing from irreversible rejection before 90 days showed marked increase of class II antigen expression. The increased class II antigen expression in renal allografts may be merely a marker of rejection or may have a role in the augmentation of the response, either in its induction or as a target for the effector arm of the reaction.

Dinitrochlorobenzene skin testing predicts response to hepatitis B vaccine in dialysis patients

The pattern of seroconversion and anti-HBs titres after 3 doses of hepatitis B vaccine was studied in 40 haemodialysis patients who had been grouped on the basis of their cell-mediated immune (CMI) response into strong or weak reactors. CMI response was determined by means of a dinitrochlorobenzene (DNCB) skin test. Titres of anti-HBs were comparable to those in healthy controls in 13 of 14 (93%) strong reactors but in only 9 of 26 (35%) weak reactors. Strong reactors had an equally satisfactory seroconversion rate with either 20 micrograms or 40 micrograms of vaccine whereas weak reactors had a negligible seroconversion rate with the 20 micrograms dose. In terms of hepatitis B prophylaxis, haemodialysis patients with a well preserved CMI response require only 20 micrograms of vaccine, with a consequent saving in cost. In contrast, it will be necessary to devise more effective immunisation schedules for most patients with a poor CMI response.

The rise and fall of surgery for the "floating" kidney

The latter half of the nineteenth century produced a remarkable expansion of surgical practice. Although most of these new techniques and concepts were soundly based, others, such as the movable or floating kidney, were later ridiculed and discredited.In Glasgow Royal Infirmary during the 48 years from 1880, when movable kidney was first mentioned in the annual reports of the hospital, to 1928 472 patients (89% female) were diagnosed as suffering from the condition. Nearly half of them (216) underwent operation and the operative mortality was low. In the first decade of this century an average of 18 cases a year were admitted to the wards of the infirmary. From 1915 to 1920 the number of cases dropped, as did the proportion undergoing operation, but in the 1920s the numbers increased again.In common with other ineffective treatments for imaginary diseases, operations for the movable kidney simply faded away in Britain in the 1930s.

The pre-operative electrocardiogram: an assessment

Electrocardiography is of limited value in pre-operative screening for cardiac disease. A short questionnaire has been shown to be helpful in assessing cardiac status and could permit a 30% reduction in the number of pre-operative ECGs performed.