Quality assurance of lower limb venous duplex scans performed by vascular surgeons

AIM

Duplex scanning is the gold standard for investigating venous reflux; increasingly surgeons perform these scans themselves. There has been no data published analysing the accuracy of Duplex scans performed by vascular surgeons. We aimed to evaluate an objective method of comparing the results of lower limb Duplex scans performed by one consultant vascular surgeon with those performed by a vascular technologist.

METHODS

We assessed 100 legs with symptomatic varicose veins. Each patient underwent two lower limb venous Duplex scans; one performed by a consultant vascular surgeon and one by a vascular technologist. Scan results were randomised and sent to two consultant vascular surgeons blinded to the identity and experience of the sonographer. They were asked to recommend treatment. A k score was calculated in each case to assess the level of agreement between the scans performed by the consultant and the technologist.

RESULTS

Eighty-one patients were studied (53 females). The kappa score for assessor 1 was 0.60 (95%CI:0.44-0.75) and for assessor 2 was 0.62 (95%CI:0.48-0.75). k scores >0.60 represent a substantial strength of agreement.

CONCLUSION

Duplex scans performed by this surgeon were comparable to those performed by a vascular technologist. It is possible to quality-assure duplex performed by vascular surgeons without directly observing the scanning process or reviewing digitally recorded images. We propose standardisation of training, assessment and quality assurance for vascular surgeons wishing to perform ultrasound scans.

Diaphragm disease of the small bowel--a case report and literature review

A 75-year-old man who had an emergency laparotomy for small bowel obstruction was found at operation to have multiple mid-ileal strictures. Histology of the resected specimen confirmed diaphragm disease of the bowel. The pathogenesis of this disease remains unclear but it is associated with long-term use of NSAID. Diagnosis is often difficult as many clinicians are unaware of this condition. The relevant literature has been reviewed.

Endoluminal repair of abdominal aortic aneurysm causes more perioperative renal dysfunction than open repair

Background

In this prospective case–control study the aim was to compare perioperative renal function in well matched patients undergoing open repair (OR) (group 1) or endoluminal repair (ER) (group 2) of an abdominal aortic aneurysm (AAA) and preoperative renal function in other patients undergoing ER (group 3) with function 1–3 years after surgery.

Methods

Of 73 patients undergoing AAA repair, 45 were recruited to the study as follows: 14 patients (median age 77 years, 12 men) to group 1, 14 patients (median age 76 years, 11 men) to group 2 and 17 patients (median age 76 years, 14 men) to group 3. Serum creatinine, creatinine clearance and/or glomerular filtration rate (GFR) were measured coupled with 99mTc-radiolabelled mercaptoacetyltriglycine (MAG3) renal studies. From the MAG3 renal scans, perfusion, split renal function, mean parenchymal transit time (MPTTI) and outflow pattern were assessed. Groups 1 and 2 underwent scintigraphic evaluation before, and 8 days after operation. Group 3 was assessed before operation and 1–3 years later.

Results

Fifteen of 31 patients undergoing ER had preoperative renal dysfunction (GFR less than 50 ml min−1) compared with two of 14 who had OR. Ten patients from groups 2 and 3 developed severe renal dysfunction. Of these, two died, one required haemodialysis (graft deployed over the renals), two were dialysis-free but developed worsening renal function and five regained their previous renal function. In four patients who had ER, differential function improved, in one with retroperitoneal fibrosis it deteriorated and in nine it was unchanged. See Table below.

Conclusion

ER is associated with a greater degree of perioperative renal dysfunction than OR. In the absence of technical problems with endograft deployment, renal function in ER in the long term is not adversely affected.

Teaching hospital perspective of the quality of trauma care in Lagos, Nigeria

Information including respiratory rate, blood pressure, Glasgow Coma Scale, and anatomic injuries were obtained for all injured patients consecutively admitted to the Lagos University Teaching Hospital (LUTH) during the 9-month period from September 1995 to May 1996. The data were analyzed using the UK Major Trauma Outcome Study (MTOS) methodology. The Revised Trauma Score (RTS), the Injury Severity Score (ISS), and the Probability of Survival (Ps) were calculated for each patient. In addition, the "M," "z," and "w" scores were calculated for blunt injuries. Of the 253 patients (median age 28 years; male/female ratio 4:1) studied, 85% suffered blunt trauma, 75% of which were due to RTA. About 60% of RTA victims were pedestrians. Only 8% of nonpedestrian victims wore protective devices. The mean ISS was 10, the mean RTS 6.98, and the mean Ps 0.96. The "m" statistic for blunt trauma was 0.91, and there were 122 survivors compared to the 163 predicted. The "z" and "w" scores were -18.49 and -24.55, respectively. Altogether, 42.7% of patients with ISS > 15 and 40.7% with RTS < 7.5 died. According to these results, the severity of injuries encountered in Lagos is comparable to those reported from the United Kingdom and the United States, but the death rate is higher.

For debate: concomitant critical coronary arterial disease and abdominal aortic aneurysm--timing of corrective procedures

BACKGROUND

The high prevalence of coronary artery disease (CAD) in patients with abdominal aortic aneurysm (AAA) is responsible for most , 30-day mortality and morbidity in elective repair of AAA. The continuing debate regarding staged or combined surgery for AAA and CAD (coronary artery bypass grafting -CABG) in the small number of patients with critical degrees of both co-morbidities has not had a significant impact on the greater mortality and morbidity when the AAA repair is undertaken using the standard open operation.

PATIENTS

We report four cases with these combined pathologies which we have managed over the last 30 months during which time we have developed techniques of endolumenal repair of AAA.

CONCLUSIONS

Whilst it is not possible to make firm recommendations regarding management strategy owing mainly to a lack of large series reporting this unusual combination of co-morbidities, the options are debated on the basis of published anecdotal evidence as well as our own case reports. We suggest that if the AAA is non-tender and/or 5.5-8.0 cm, the staged approach is appropriate. If the AAA is tender and/or > 8.0 cm, a combined approach may be a better option in order to avoid the risk of AAA rupture during the interval between the operations. Endolumenal repair of AAA offers a further option for the staged and combined approach, and may be less invasive than the standard open surgery for AAA repair.

Ecstasy induced retropharyngeal emphysema

This is the first reported case of isolated retropharyngeal emphysema caused by ingestion of the amphetamine derivatives "Ecstasy" and "Speed". The same complication has been reported with marihuana, cocaine, and heroin abuse. The condition resolved spontaneously and this seems to be the experience of others who have reported cases of cervical emphysema and pneumomediastinum associated with substance abuse. Because of the self limiting nature of this condition, extensive investigations may not be necessary but hospital admission and close observation are still mandatory.