Surgical Palliation for Pancreatic Cancer: Will Biliary Bypass Alone Suffice?

Because a number of options are available to relieve the obstructed bile duct, stomach or both in patients with irresectable carcinoma of the pancreatic head, palliative surgery for this condition was reviewed retrospectively between 1971 and 1981 at the Royal United Hospital, Bath. One hundred and sixty-five patients underwent a biliary bypass procedure with (n = 37), or without (n = 128) gastric drainage. Thirty patients had a prophylactic gastroenterostomy to avoid gastric outlet obstruction: tumour encroachment made gastroenterostomy essential in seven others. After biliary bypass alone, operative mortality was 14%. After a concomitant gastroenterostomy, mortality was 27% (P less than 0.04). Within a year of biliary bypass alone, there was a 9% incidence of gastric outlet obstruction requiring gastric drainage, with an associated mortality rate of 18%. Survival after biliary bypass or biliary bypass with gastroenterostomy was equal (7-8 months). Except where gastric outlet obstruction is imminent, palliation for irresectable pancreatic head carcinomas should be by biliary bypass alone, because the addition of a gastroenterostomy almost doubles the mortality without any advantage in survival time.

Improving the accuracy of self-assessment of practical clinical skills using video feedback--the importance of including benchmarks

INTRODUCTION

Isolated video recording has not been demonstrated to improve self-assessment accuracy. This study examines if the inclusion of a defined standard benchmark performance in association with video feedback of a student's own performance improves the accuracy of student self-assessment of clinical skills.

METHODS

Final year medical students were video recorded performing a standardised suturing task in a simulated environment. After the exercise, the students self-assessed their performance using global rating scales (GRSs). An identical self-assessment process was repeated following video review of their performance. Students were then shown a video-recorded 'benchmark performance', which was specifically developed for the study. This demonstrated the competency levels required to score full marks (30 points). A further self-assessment task was then completed. Students' scores were correlated against expert assessor scores.

RESULTS

A total of 31 final year medical students participated. Student self-assessment scores before video feedback demonstrated moderate positive correlation with expert assessor scores (r = 0.48, p < 0.01) with no change after video feedback (r = 0.49, p < 0.01). After video feedback with benchmark performance demonstration, self-assessment scores demonstrated a very strong positive correlation with expert scores (r = 0.83, p < 0.0001).

CONCLUSIONS

The demonstration of a video-recorded benchmark performance in combination with video feedback may significantly improve the accuracy of students' self-assessments.

Ruptured aneurysm of the common iliac artery as a cause of unilateral hip pain

Rupture of an aneurysm of the common iliac artery is a rare cause of pain in the hip. We describe an elderly hypertensive patient with an aneurysmal rupture of the left common iliac artery who presented with unilateral hip pain masquerading as septic arthritis.

MRSA-infected external iliac artery pseudoaneurysm treated with endovascular stenting

A 48-year-old woman with severe juvenile-onset rheumatoid arthritis presented with a bleeding cutaneous sinus distal to her right total hip replacement scar. Methicillin resistant Staphylococcus aureus (MRSA) was isolated on culture. She had previously undergone bilateral total hip and knee replacements at aged 23 and six years later had the right knee prosthesis removed for infection, with subsequent osteomyelitis of the femoral shaft and right total hip prosthesis disruption. Peripheral arteriography was performed in view of persistent bleeding from the sinus, which revealed a 6 cm false aneurysm filling from and compressing the right external iliac artery (EIA). A PTFE-covered, balloon expandable JOSTENT was deployed in the right EIA, successfully excluding the false aneurysm and preventing further bleeding from the sinus. No graft infection was reported at 12 months. This case illustrates the potential use of endovascular stent-grafting in the treatment of an infected pseudoaneurysm.

A technique for atraumatic clamping of calcified arteries

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Management of varicose veins according to reason for presentation

Of 229 newly referred patients with varicose veins, untoward symptoms were the most frequent reason for presentation (38%). Cosmetic concerns were significantly more common in women than in men (33% vs 8%, P < 0.001). Sclerotherapy was offered to 20 patients (8.7%). Surgical operation was offered in 113 (49.3%), mostly for symptoms. No invasive treatment was indicated in 96 patients (42%), more than half of whom had presented because of inappropriate fears of deterioration or with symptoms unrelated to their veins. We advocate that careful evaluation of the reasons for presentation should be used as a guide to the efficient management of varicose veins.

Aneurysm of the profunda femoris artery

A case of profunda femoris artery aneurysm is presented. It is particularly unusual in that it is associated with anomalous vascularity, which may be of interest in the repair of ruptured lesions.

PTFE bypass grafting to isolated popliteal segments in critical limb ischaemia

Although the quality of the distal run-off has been considered as an important factor affecting the success of bypass grafting, reasonable results have nevertheless been reported for bypass grafts to a popliteal artery with no direct communication with the tibial or peroneal vessels (isolated popliteal segment, IPS). The use of autogenous vein has produced the best results in this situation with most authors finding polytetrafluoroethylene (PTFE) less satisfactory. Improved results have nevertheless been shown for femoropopliteal and femorotibial PTFE grafts by the incorporation of vein patches into the anastomoses. In this paper, the influence of this technique on the patency of PTFE grafts to IPS is evaluated. Thirty-three PTFE grafts to an IPS and 67 to the below knee (BK) popliteal artery with one or more run-off vessels were studied. All IPS grafts were carried out for limb salvage and in the BK popliteal group, 46 (69%) were for limb salvage and 21 (31%) were for severe claudication. Groups were matched in terms of age, smoking history and prevalence of diabetes mellitus. Cumulative patency rates of 84% at 1 year and 76% at 3 years were achieved in the IPS group compared to 90 and 81% for the BK popliteal group with one or more run-off vessels. Using the Taylor patch technique, comparable 3 year patency rates can be expected for PTFE grafts to IPSs and to BK popliteal arteries with patient tibial or peroneal run-off.

Accelerated thrombolysis using pulsed intra-thrombus recombinant human tissue type plasminogen activator (rt-PA)

The efficacy of regional thrombolysis for treating leg ischaemia is well established, but the duration of infusion and the frequent complications remain major disadvantages. By delivering recombinant human tissue type plasminogen activator (rt-PA) as pulsed intra-thrombus 5-mg aliquots combined with catheter manipulation to maintain an intra-thrombus location, the average time taken to achieve thrombolysis in 20 consecutive patients with infra-aortic occlusions was 109 min. Immediate thrombolysis was achieved in every case. Pulsed delivery of high dose rt-PA significantly accelerates thrombolysis, decreases dose and reduces costs.

Improved technique for polytetrafluoroethylene bypass grafting: long-term results using anastomotic vein patches

Results of peripheral arterial bypass using polytetrafluoroethylene grafts have remained poor in comparison with those using saphenous vein grafts, particularly for anastomoses to tibial and peroneal vessels. A simple modification to the conventional operative technique, involving the incorporation of a vein patch into the distal anastomosis, has enabled considerable improvement. Five-year patency rates of 71 per cent for popliteal and 54 per cent for infrapopliteal grafts have been achieved in a series of 256 patients operated on between 1982 and 1989.

Vascular reconstruction at the groin: oblique or vertical incisions?

Incisions for vascular access at the groin are usually vertical. Because such incisions cross the moist skin-crease area and disrupt lymphatics, they may be more prone to infection than oblique incisions placed above and parallel to the groin crease. To determine whether this was the case, 149 patients undergoing vascular reconstruction through a groin incision over a period of 30 months were studied. Those with previous groin incisions were excluded, and where an incision was necessary in both groins, each wound was studied separately. Over a 10-day postoperative period 5 of 85 vertical wounds developed infection with purulent discharge, whereas no oblique wounds (n = 82) became infected (P = 0.032). Oblique incisions for vascular access at the groin are associated with a decreased incidence of wound infection compared with conventional vertical incisions.

PTFE, collars, and patches

The results of PTFE grafts to crural vessels have been sufficiently poor for some surgeons to consider primary amputation for critical ischemia in the absence of suitable lengths of autologous vein from arm or leg. However, the results of two anastomotic techniques using a short segment of interposed vein, are encouraging. We have attained 1-year patency rates of 74% (n = 72) using PTFE with the Taylor patch technique (personal communication) and 47% (n = 27) using PTFE with Miller collar anastomoses to distal crural vessels. To investigate the hemodynamic benefit of these techniques, they have been tested (using a pulsatile flow model incorporating standard pressure, viscosity, graft and vessel length, and anastomotic angle) against a standard end-to-side PTFE anastomosis to cadaver internal mammary artery. There was no significant difference in flow between the anastomotic methods. Downstream resistance was dictated by the diameter of the recipient vessel providing a vein interposition technique was used (r greater than .80), but this relationship was lost if a direct PTFE-arterial anastomosis was performed (r = .06), suggesting additional anastomotic resistance in the latter. This constitutes experimental evidence to suggest that direct PTFE-arterial anastomosis risks hemodynamically important technical errors, which are avoidable by the use of either the Miller collar or Taylor patch.

Analgesic benefit of locally injected bupivacaine after hemorrhoidectomy

The analgesic efficacy of locally injected bupivacaine was studied in 40 patients undergoing hemorrhoidectomy. After a standard Milligan-Morgan hemorrhoidectomy, 40 age- and sex-matched patients were randomized to receive either 0.5 percent bupivacaine (1.5 mg/kg) in adrenaline solution (1:200,000) injected into the perianal area, or equivalent volumes of adrenaline solution. Intramuscular opiate was available on demand during the postoperative period, and the amount and timing of analgesia given was recorded. All patients noted their pain on a daily basis using a linear analogue scale, and all patients answered a questionnaire assessing analgesic efficacy. Although the median time interval between surgery and first analgesic demand was nearly four times greater for patients receiving bupivacaine compared with adrenaline solution, there was no difference in the levels of pain recorded or in the overall opiate requirements. Local injection of bupivacaine after hemorrhoidectomy provides initial pain relief, but patients do not obtain an overall analgesic benefit.

Meatal strictures after transurethral prostatectomy using latex or polyvinyl chloride three-way catheters

Because latex rubber catheters have been implicated in urethral stricture formation, the incidence of urethral strictures following transurethral prostatectomy (TUP) and subsequent catheterisation with latex rubber or polyvinyl chloride catheters was compared. A total of 84 patients with benign prostatic hyperplasia (n = 71) or prostatic carcinoma (n = 13) underwent assessment of urethral diameter and subsequent internal urethrotomy prior to TUP. Following resection, 42 patients received three-way self-retaining latex rubber catheters and 42 received similar catheters made of PVC. Catheters were removed when the urine was clear (mean time = 3 days), and no patient required recatheterisation. Urinary flow was assessed in all patients at 6, 12 and 24 weeks after surgery, and diminution of flow with submeatal stricture formation was noted in one patient who had received a latex rubber catheter, and in one who had received a PVC catheter. In this study, the composition of the catheter had no bearing on subsequent stricture formation following TUP.

Experimental evidence to support the use of interposition vein collars/patches in distal PTFE anastomoses

We have conducted three in vitro experiments (using cadaver internal mammary artery as a model for crural artery), which establish the advantage of the Miller collar and Taylor patch over direct PTFE-artery anastomoses: (1) A new method of simultaneously measuring longitudinal and circumferential elasticity in human saphenous vein (n = 16) has demonstrated the latter to be anisotropic (i.e.: greater longitudinal than transverse compliance, P less than 0.002). This suggests that benefit may be gained by aligning the saphenous vein's longitudinal axis with that of the arteriotomy--a feature of both vein interposition anastomoses. (2) We have compared maximal pulsatile and constant flow across each type of anastomosis (n = 10 of each) using a flow model incorporating standard pressure, viscosity, graft and outflow vessel length, and anastomotic angle. This experiment has demonstrated loss of anastomotic reliability only in direct PTFE-artery anastomoses (i.e. no correlation between flow and vessel diameter, r = 0.04). (3) Casts of the internal anatomy of the anastomoses (n = 10 of each) have demonstrated a greater degree of oval distortion of the toe of the outflow vessel of direct PTFE-artery anastomoses than either of the other techniques (P less than 0.01). This experimental evidence suggests that both of these vein interposition techniques optimise the mechanical properties of saphenous vein and protect small arteries from anastomotic distortion. These benefits do not occur with direct PTFE-artery anastomoses.

Wound perfusion with bupivacaine: objective evidence for efficacy in postoperative pain relief

Conflicting reports exist for the efficacy of intermittent wound perfusion with bupivacaine in the relief of postoperative pain. A study was devised to assess postoperative pain relief objectively using a Patient Controlled Analgesic Device (PCAD) during continuous wound perfusion with bupivacaine or saline. Thirty consecutive patients undergoing cholecystectomy were randomised to receive continuous postoperative wound perfusion with 0.5% bupivacaine for 24 h followed by normal saline for a further 24 h or vice versa. During the study period, conventional analgesia was provided using a PCAD set to deliver (and record the number of) on-demand bolus doses of intravenous pethidine 0.2 mg/kg at half-hourly intervals as required. Pethidine requirements were higher on the first postoperative day, regardless of which solution was given, but bupivacaine perfusion almost halved mean linear analogue pain scores compared to those recorded with saline. Likewise, the number of bolus doses of pethidine demanded was reduced by an average of 68% compared to those recorded during saline perfusion on day 1 (P = 0.01) and by 82% on day 2 (P = 0.01). When assessed by objective criteria, perfusion of surgical wounds with bupivacaine after cholecystectomy produces better pain relief than wound perfusion with saline.

Experimental pancreatic cancer in the Syrian hamster: effect of cholecystectomy

Because cholecystectomy stimulates hypertrophy and hyperplasia in the hamster pancreas, its effect on experimental pancreatic carcinogenesis was studied in this animal model. Forty female Syrian hamsters underwent cholecystectomy, while 40 others underwent sham operations. Two weeks later, 30 hamsters undergoing cholecystectomy and 30 hamsters undergoing sham operations received 4 weekly subcutaneous injections of N-nitroso-bis (2-oxopropyl) amine (BOP) (10 mg/kg). Remaining hamsters (n = 20) received equal volumes of 0.9% saline solution. A further 10 hamsters (controls) underwent no surgery and received no injections. Thirty weeks after the first BOP or saline injection the pancreas of hamsters that had undergone cholecystectomy was only 3% heavier than that of sham-operated animals, and there was no difference in the incidence of pancreatic cancer between BOP-treated hamsters that had undergone cholecystectomy and those that had undergone sham operations. In this study, cholecystectomy had no influence on BOP-induced pancreatic carcinogenesis in the Syrian hamster.

Binding of deferoxamine to asbestos fibers in vitro and in vivo

We studied the binding of tritium-labeled deferoxamine, a strong iron chelator, to crocidolite asbestos fibers in vitro and in vivo. In aqueous suspension of asbestos, deferoxamine binding was rapid and strong, suggesting specific binding to iron. For the in vivo experiments, diffusion chambers containing native asbestos fibers or deferoxamine-washed asbestos were implanted in the peritoneal cavities of mice. Five days after parenteral injection of tritiated deferoxamine chambers were removed and the asbestos counted. More than twice as much label (2206 +/- 348 c.p.m./100 mg asbestos) was bound to the native asbestos as compared to the deferoxamine-washed asbestos (1080 +/- 201 c.p.m./100 mg asbestos), suggesting specific binding in vivo. Since deferoxamine can inhibit asbestos toxicity in vitro, these experiments suggest the feasibility of testing whether deferoxamine can prevent asbestos-related disease in vivo.

Partial amputations of the foot for diabetic gangrene

Over a 5-year period 68 diabetic patients underwent 102 primary partial amputations of the foot for infected diabetic gangrene. Seventy (69%) of these operations healed without further local surgery, but five patients needed seven femoropopliteal bypass grafts (two bilateral) to achieve healing. In total, 32 primary operations needed revision by further surgery to the foot or by leg amputation. Of the original operations 31% were carried out by a consultant surgeon; the rest (69%) were performed by a junior surgeon. By contrast, only four of the 32 operations needing revision (12%) had originally been done by a consultant, whereas 28/32 (88%) had been carried out by a junior surgeon. Of limbs at risk 65/80 (81%) were salvaged. Five patients died during their hospital admission, giving an overall mortality of 7%.

Intestinal obstruction by overdistension of a jejunostomy catheter balloon: a salutary lesson

Jejunostomy is an alternative method for feeding patients who cannot be fed orally. However, there may be an associated morbidity and potential mortality. In the case presented, overdistension of a jejunostomy catheter balloon led to intestinal obstruction and pressure necrosis (of the small bowel), with subsequent abscess formation leading to death from septicemia.

A support brace for the endoscope

The availability of an endoscopic support brace for use during gastrointestinal endoscopy is described.

Fibrin deposition in autochthonous Syrian hamster pancreatic adenocarcinomas induced by the chemical carcinogen N-nitroso-bis(2-oxopropyl)amine

Immunofluorescence studies have demonstrated the presence of fib (a group of fibrinogen- and fibrin-related proteins that react with antibodies raised against fibrinogen) in the stroma of several transplantable animal and autochthonous human tumors. Acceptance of these reports was tempered by the possibility of artifactual clotting and fibrinolysis associated with tumor removal or tumor transplantation and by the relatively poor histology inevitable when immunofluorescence is performed on frozen tissue sections. An immunoperoxidase study therefore was undertaken of the ductal pancreatic carcinomas induced in female LGV Syrian hamsters by N-nitroso-bis(2-oxopropyl)amine [(BOP) CAS: 60599-38-4]. Artifactual clotting and fibrinolysis associated with tumor removal were avoided by systemic anticoagulation and antifibrinolysis. Fibronectin and residual fib were prominent components of tumor stroma. Prominent fib deposits also were found in a new location: the basement membrane zones of atypical pancreatic ducts and invasive carcinomas. In contrast, fib deposits were never found in the basement membranes of blood vessels, nerves, or pancreatic acini of BOP-treated or normal animals, or in the ductal basement membranes in the normal pancreas. Ducts with marked atypicality and invasive pancreatic carcinomas frequently exhibited discontinuous basement membrane staining for fib, which often paralleled loss of staining for the integral basement membrane proteins--type IV collagen and laminin. Loss of acquired fib basement membrane staining with malignant disease progression may serve as a new marker for local tumor invasion.

N-[4-(5-nitro-2-furyl)-2-thiazolyl] formamide-induced bladder cancer in mice: augmentation by sutures through the bladder wall

The augmenting effect of chronic inflammation on bladder cancer was studied in female Swiss mice treated with N-[4-(5-nitro-2-furyl)-2-thiazolyl] formamide (FANFT), 0.15% by weight of diet for 20 weeks. To produce chronic inflammation one silk suture and one catgut suture were placed through the bladder wall of 63 mice to receive FANFT and 18 to receive normal diet. In remaining mice (no. = 62) the bladder was simply touched without suture insertion. Thirty-two animals treated with FANFT and 33 treated with FANFT + sutures also received supplements to their drinking water throughout the experiment of the sulfhydryl-reducing agent N-acetylcysteine (500 mg./kg. body weight/day). Seven weeks following FANFT treatment, bladder cancers developed in 12% of mice with sutures and FANFT and in 19% of those with sutures, FANFT, and N-acetylcysteine. No cancers developed in mice receiving FANFT alone or FANFT with N-acetylcysteine and none in mice treated with sutures only. Placement of silk sutures through the bladder wall of mice augments FANFT-induced bladder cancer. N-acetylcysteine at these doses does not influence the incidence.

Augmentation of chemically induced pancreatic and bronchial cancers by epidermal growth factor

The incidence of Syrian golden hamsters with pancreatic cancer induced by subcutaneous injections of N-nitroso-bis(2-oxopropyl)amine for 19 weeks (each 10 mg/kg) increased from 44% to 75% (p=0.016) when epidermal growth factor was also administered from week 5 through week 8 (5 mug energy three days for injections). Epidermal growth factor increased pancreatic weight and body weight. The incidence of animals with bronchial cancer doubled. Epidermal growth factor could be a cocarcinogen as a result of its mitogenic activity.

Juvenile pancreatic pseudocyst

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Method of one-way surgical drainage for the inexpensive accurate measurement of abdominal secretions

A simple, inexpensive method for one-way collection and measurement of secretions is described. This method has been used successfully in surgical practice in Bath for more than 20 years (1).

Pancreatic cancer in the Syrian hamster induced by N-nitrosobis(2-oxopropyl)-amine: cocarcinogenic effect of epidermal growth factor

Because epidermal growth factor (EGF) is rapidly bound and internalized into rat pancreas, stimulates uptake of tritiated thymidine, and increases pancreatic weight, a cocarcinogenic effect on pancreatic cancer seemed likely. Pancreatic adenocarcinomas were induced in 70 female Syrian hamsters by 19 weekly s.c. injections of N-nitrosobis(2-oxopropyl)amine (BOP) (10 mg/kg). From Wk 5 through Wk 8 of BOP injections, additional s.c. injections of EGF (5 micrograms every 3 days for 10 injections) were given to 45 animals, while 25 received saline solution. An additional group of 10 received EGF alone, and another 10 animals received saline solution alone (controls). Eleven wk later, the mean body weight of EGF-treated animals increased by 29% as compared with that of controls, and their mean pancreatic weight relative to body weight increased by 44% as compared with controls. The mean body weight of EGF + BOP-treated animals increased by 10%, and their pancreatic weight relative to body weight increased by 22% as compared with that of animals treated with BOP alone. The incidence of pancreatic cancer in the EGF + BOP-treated animals was 75% versus 44% in those treated with BOP alone (P = 0.016). No tumors developed in either animals treated with EGF alone or control animals. EGF augments pancreatic carcinogenesis induced by BOP. The incidence of bronchial carcinomas doubles.

Augmentation of 1,2-dimethylhydrazine-induced colon cancer by experimental colitis in mice: role of dietary vitamin E

Because ulcerative colitis predisposes to colonic cancer, for determination of the effect of colitis on experimental colon carcinogenesis, rectal instillations of peptides that attract and activate neutrophils were used to induce colitis in CD-1 (ICR) BR mice receiving 20 weekly injections of the carcinogen 1,2-dimethylhydrazine [(DMH) CAS: 540-73-8]. From week 4 through week 15 of DMH injections, twice-weekly enemas of formyl-norleucyl-leucyl-phenylalanine were given to DMH-treated mice. The effect of the antioxidant vitamin E in the diet (1,750 IU/kg diet) was studied in another group of mice treated with DMH and having colitis. Four weeks after DMH was discontinued, cancer occurred in 9 of 28 (32%) animals with DMH plus control enemas, in 22 of 29 (76%) animals with DMH plus colitis (P = .001), and in 16 of 28 (57%) animals with DMH plus colitis plus supplemental vitamin E (P = .11 compared with the group with DMH and colitis). Colitis enhances DMH-induced colonic carcinogenesis.

Acute urinary retention secondary to benign prostatic hyperplasia. Effect of alpha-adrenergic blockade

The alpha-adrenergic blocker phenoxybenzamine has been shown to be useful in the treatment of prostatism. To assess the place of phenoxybenzamine in the management of acute retention, 43 patients presenting with acute urinary retention secondary to benign prostatic hyperplasia were catheterized suprapubically. They were then randomized to receive either oral phenoxybenzamine (10 mg b.i.d.; n = 21), or placebo tablets (n = 22). Forty-eight hours later, the bladder of each patient was filled through the catheter with 300 ml sterile saline, the catheter was clamped, and the patient encouraged to void. Only 2 of 21 (10%) patients receiving phenoxybenzamine and 3 of 22 (14%) receiving placebo were able to void satisfactorily (p = NS). In this study phenoxybenzamine had no place in the management of acute retention of urine secondary to benign prostatic hyperplasia.

Acute colitis produced by chemotactic peptides in rats and mice

Colonic inflammation was produced in rats and mice by peptides chemotactic for polymorphonuclear leukocytes. Instillation of formylmethionyl-leucyl-phenylalanine (FMLP) and formylnorleucyl-leucyl-phenylalanine (FNLP) into isolated segments of rat colon caused marked mucosal edema and polymorphonuclear leukocyte infiltration within 2 hours. Higher concentrations of FNLP caused ulceration and necrosis as well. Formylmethionine (FMet), a compound with less chemotactic activity, caused much less inflammation. In mice, rectal instillation of FNLP caused dose-dependent acute mucosal inflammation which persisted for longer than 12 hours. Twice-weekly rectal instillation of FNLP provided a model of colitis based on neutrophil chemotaxis.

Implantable device for drug delivery and blood sampling in the rat

An implantable drug-delivery and venous sampling device is described that is constructed from a polyvinyl chloride catheter and a rubber intravenous catheter plug coated with Silastic. The implant was used for repeated venous sampling and for both administration of parenteral solutions and injections into the right colon of the rat for periods to 1 mo.

Some cerebrovascular complications of exercise

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The effect of cephradine prophylaxis on wound infection after arterial surgery through a groin incision

Cephradine administered prophylactically to a group of 35 patients undergoing reversed saphenous vein femoro-popliteal bypass, iliofemoral endarterectomy or profundaplasty through a groin incision, resulted in a significant reduction in the incidence of wound infection (P = 0.025; exact probability test). One gram of cephradine was given at induction of anaesthesia, followed by three postoperative doses of one gram at 6 hourly intervals. The overall wound infection rate at 7 days, as assessed by frank purulent discharge, was 15%. After cephradine prophylaxis, no infections were noted as judged on this basis, but erythema of the suture line was seen in equal numbers (40% of each group). Where the indication for operative intervention was rest pain or gangrene, the incidence of wound infection was very much increased, 80% of the infected cases being from this group.