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Purpose: This study aimed to determine patients' experiences following inguinal hernia repair at a tertiary hospital and associated cottage hospital in terms of postherniorraphy pain and follow-up., Methods: After exclusions, 373 adult patients undergoing inguinal hernia repair at Derriford and Tavistock hospitals during a 1-year period from October 2017 were sent a questionnaire regarding preoperative pain experience, current symptoms, and pain severity at 28 days and other intervals postoperatively. Statistical analysis of responses included unpaired t test to compare means and χ 2 test for discrete variables with a p value < 0.05 regarded as statistically significant., Results: The survey response rate was 68% (253/373). The mean pain score on visual analogue scale was 1.5 at 28 days postoperatively in those without preoperative pain compared to 3.2 in those with preoperative pain (p = 0.0001). Although 64 (25%) patients complained of pain at a mean follow-up of 47.9 ± 15.6 weeks, pain severity was insignificant after 28 days. Gender, employment status and mesh type did not affect pain scores. Return to normal activity after laparoscopic repair was longer than after open repair (5.4 ± 3.4 versus 4.2 ± 2.2 weeks, respectively; p = 0.0322). Overall, 34.6% thought follow-up was necessary and patients were more likely to agree with a decision not to follow them up., Conclusion: This study puts postherniorrhaphy pain in perspective of preoperative pain. Active discussion with patients prior to discharge or telephone follow-up by an appropriate individual may reduce the need for hospital follow-up.

Purpose: The use of prophylactic antibiotics in the mesh repair of inguinal hernias remains controversial. The aim of this study was to determine the perception of surgeons about surgical site infection and how this affects their clinical practice., Methods: A SurveyMonkey of general surgeons and senior surgical trainees was conducted via the local trust network and the questionnaire was displayed on the website of the Association of Surgeons of Great Britain and Ireland and Association of Surgeons in Training., Results: Eighty-one responses were received from surgeons who perform an average of 75 hernia repairs per year - the majority by open technique. Thirty-six (44.4%) used routine antibiotic prophylaxis, 40 (49.4%) selectively, and five (6.2%) not at all as the five surgeons who did not use antibiotics perceived their surgical site infection rate to be <1% and have never removed an infected mesh from a hernia wound. There was no clear difference between those who use prophylactic antibiotics routinely or selectively as the experience of mesh explantation is similar (56% versus 55% had 2-10 meshes removed respectively). Seventy-seven (95%) of surgeons felt a new specific set of guidelines was required., Conclusion: This study highlights the fact that in the absence of clear guidelines, most surgeons base their use of prophylactic antibiotics on their perceived risk or experience of surgical site infection. There is a strong need for a new set of guidelines to address the use of prophylactic antibiotics in groin hernia surgery.

One third of deceased donor kidneys for transplantation in the UK are donated following cardiac death (DCD). Such kidneys have a high rate of delayed graft function (DGF) following transplantation. We conducted a multicenter, randomized controlled trial to determine whether kidney preservation using cold, pulsatile machine perfusion (MP) was superior to simple cold storage (CS) for DCD kidneys. One kidney from each DCD donor was randomly allocated to CS, the other to MP. A sequential trial design was used with the primary endpoint being DGF, defined as the necessity for dialysis within the first 7 days following transplant. The trial was stopped when data were available for 45 pairs of kidneys. There was no difference in the incidence of DGF between kidneys assigned to MP or CS (58% vs. 56%, respectively), in the context of an asystolic period of 15 min and median cold ischemic times of 13.9 h for MP and 14.3 h for CS kidneys. Renal function at 3 and 12 months was similar between groups, as was graft and patient survival. For kidneys from controlled DCD donors (with mean cold ischemic times around 14 h), MP offers no advantage over CS, which is cheaper and more straightforward., (© 2010 The Authors Journal compilation © 2010 The American Society of Transplantation and the American Society of Transplant Surgeons.)

Purpose: To increase the proportion of dialysis patients using native arteriovenous fistulae (AVF), improved selection of the most appropriate procedure must be coupled with early access surveillance to determine which access would likely mature and when intervention might lead to access salvage. This study was aimed at auditing pre-operative vessel mapping and post-operative access surveillance against the primary outcome measure of AVF maturation., Methods: Between January 2006 and August 2007, 113 AVF created in 101 patients were studied. Data on pre-operative vessel mapping, type of AVF, post-operative surveillance scans were analyzed against the outcome AVF., Results: Pre-operative mapping and post-operative scanning were carried out in 86% and 91%, respectively. A maturing fistula on post-operative scan highly correlated with a satisfactory outcome (p<0.001). The sensitivity and specificity of the post-operative scan were 100% and 85%, respectively. There were 79 brachiocephalic and 34 radiocephalic fistulae with a primary failure rate of 23% and 47%, respectively, giving an overall failure rate of 30%. Nine fistulae had further intervention (angioplasty or thrombolysis) and five (56%) were salvaged. Seventy-two AVF matured satisfactorily giving a primary cumulative patency of 71% (72/102)., Conclusion: This study shows that preoperative vessel mapping provides useful information regarding the choice of AVF. Access surveillance duplex scanning at 6-8 weeks post-operatively is viable and has a high sensitivity and specificity for final outcome of fistula. Identifying AVF with potential problems early means that further intervention or surgery can be planned earlier, which will have a positive impact on patients.

This is a review of our experience with vascular access procedures over a 5-year period at Derriford Hospital, Plymouth, UK. The aims of the study were to examine the outcome of vascular access procedures and factors influencing access survival. Between April 1995 and March 2000, 151 patients who underwent 221 vascular access procedures were studied. Of these, 136 had autogenous arteriovenous fistulae, whereas 85 had prosthetic AV grafts (41% in the thigh). The overall primary failure rate was 21% whereas the 1- and 5-year cumulative access survival rates were 60 and 41%, respectively. Thigh grafts have a mean survival of 36 months compared with 32 months for prosthetic upper limb and 43 months for autogenous fistulae. Age, diabetes and predialysis status did not significantly influence access survival. Thrombosis was responsible for access failure in 62 cases (28%). Avoiding subclavian vein canulation and performing vessel mapping prior to access placement should reduce the risk of access failure due to outflow obstruction.

The last 40 years has witnessed revolutionary changes in vascular access provision for haemodialysis. Autogenous arteriovenous (AV) fistula is the best access modality and should be considered first when planning vascular access. Education is required to ensure preservation of the cephalic veins in patients at potential risk for the development of end stage renal disease (ESRD). The best access procedure should be performed first and the AV fistula allowed to mature before use. Autogenous AV fistula have a cumulative patency of 85-90% and 60-85% at 1 and 3 years respectively. Increased use of preoperative imaging and the use of autogenous vein are essential to improved long-term results.

Indications for using central venous catheters (CVC) for haemodialysis include patients with: exhausted vascular access sites, no suitable vessels, failed peritoneal dialysis or short life expectancy. Catheter design and technology have changed in recent years to address the perennial problems of poor flow and infection. Permanent CVC offer a real alternative to arteriovenous access as 11-22% of long-term haemodialysis patients use CVC as their permanent vascular access. Recent advances in catheter use including measures to avoid insertion complications are highlighted. CVC provide mean flow rates of 274-525 ml/min with a one year cumulative catheter survival of 47-93%. Tunnelled CVC provide a safe and effective long-term access for haemodialysis and are particularly suitable for use in developing countries. They are cheaper to maintain and remove the temptation to re-use disposable dialysis needles.

Of the 283, 932 patients with end stage renal disease (ESRD) receiving replacement therapy in the US in 1996, 62% were being treated with haemodialysis. Improved survival of haemodialysis patients coupled with the inability to provide enough renal transplants for the growing ESRD population has resulted in an increase in the average length of time patients spend on dialysis. Vascular accesses are, therefore, required to function for longer periods of time. Maintenance of a reliable access to the circulation has been described as the Achilles' heel of modern haemodialysis. Preserving access function and long-term patency are essential for efficient dialysis delivery.

Patients with end stage renal failure (ESRF) and lower urinary tract abnormality (LUTA) are often considered high risk for renal transplantation. To examine the degree of risk, we have reviewed our experience of 44 patients who received a total of 58 renal allografts at the Western Infirmary, Glasgow, between 1978 and 1996. All patients had a detailed urological assessment and 19 of them underwent a urinary diversion procedure prior to transplantation. One-year patient and graft survival rates were 97% and 84%, respectively, while the five-year figures were 87% and 59%, respectively. The presence of an ileal conduit did not adversely affect graft survival (P = 0.52). The commonest complication was persistent urinary tract infection, which occurred in 15 (34%) patients. Of the 29 graft losses that occurred during the follow up period of 7-217 months, only one was due to infection of the transplant. We conclude that renal transplantation is a satisfactory option for patients with ESRF due to LUTA but that it is important to carry out detailed urological assessment prior to the transplant procedure.

Permanent dual lumen catheters (PDLC) provide alternative vascular access in patients considered unsuitable for arteriovenous fistula, arteriovenous graft or peritoneal dialysis. Experience with their use for long-term haemodialysis is presented. Between January 1990 and April 1994, 101 catheters were inserted into 63 patients (median age 62 years). A PDLC was the primary vascular access type in 5 patients. Of the first catheters, 70% were inserted percutaneously into the subclavian vein. The median duration of catheter use was 168 days (range 5-1582 days). The overall cumulative observed catheter survival rate was 94% at 6 months, 89% at 1 year and 75% at 4 years following insertion. The major complications were blockage and catheter related infection occurring in 28% and 15% of catheters, respectively. Death and blockage were the commonest reasons for catheter removal. PDLC play a vital role in the provision of access for long-term dialysis and should be considered the access type of choice in patients with limited life expectancy.

Background: One of the most frequent reasons for failure of haemodialysis lines is catheter blockage caused by fibrin sheath formation. We report our experience of percutaneous fibrin sheath stripping in treating this problem., Methods: A consecutive series of failing haemodialysis catheters underwent percutaneous fibrin sheath stripping in an attempt to retrieve and prolong the life of the catheter. Immediate technical success, clinical success, and primary and secondary patency were measured based on clinical follow-up., Results: Sixteen non-functional permanent haemodialysis lines in 15 patients underwent percutaneous fibrin sheath stripping on 21 occasions. Technical success rate was 100%. Catheter flow rates sufficient for initial dialysis were achieved in 12 (75%) lines. Successful percutaneous fibrin sheath stripping produced a mean catheter patency of 126 days (range 6-299 days)., Conclusions: Percutaneous fibrin sheath stripping is a simple, repeatable procedure that can usefully extend the life of a failing dialysis line. However, a randomized trial will be needed to evaluate its role compared with catheter replacement.

The value of preoperative assessment in relation to outcome and long-term survival was studied in 171 octogenarians undergoing major gastrointestinal surgery at Dumfries and Galloway Royal Infirmary between 1985 and 1990. The 30-day mortality rates for elective and emergency operations were 11% and 25% respectively. The American Society of Anesthesiologists (ASA) physical status scale was found to be a useful predictor of morbidity and mortality. ASA class 2 patients had a postoperative complication rate of 36% and a mortality rate of 13% while the figures for ASA class 4 patients were 85% and 54% respectively. Cox proportional hazards survival analysis using the variables age group, sex, ASA class, and type of surgery showed that the only statistically significant differences were between ASA classes. The relative 5-year survival of 63% indicates that these patients compare favourably with a population of the same age and sex not undergoing an operation. These data suggest that in the absence of severe concomitant medical disease, gastrointestinal surgery can be carried out reasonably safely in the elderly.

Two cases of congenital absence (agenesis) of the gallbladder seen at one hospital over a 5-year period are presented. One patient presented with ascending cholangitis due to choledocholithiasis, while the other presented with right upper quadrant abdominal pain and equivocal findings on ultrasound and oral cholecystography. Although diagnosis was made at laparotomy in both cases, it is likely that the arrival of laparoscopic cholecystectomy will avoid laparotomy in the future. The place of laparoscopy in establishing the presence of this anomaly is discussed.

A review of 60 patients undergoing surgery of typhoid perforation at the Ahmadu Bello University Teaching Hospital in Northern Nigeria between January 1981 and April 1987 was performed. Solitary perforation of the terminal ileum was found in 45 of 58 (78%) patients. 52 (87%) patients had debridement of the edge of perforation and simple closure. The overall hospital mortality was 57%. Important prognostic factors identified were blood urea level and duration of perforation before admission. In order to improve prognosis in typhoid perforation, patients must present early to hospital where early diagnosis, aggressive resuscitation and prompt surgery should be carried out.

A rare occurrence of salmonella abscess in a congenital cyst of the spleen is presented. Although splenectomy was curative, the role of splenic salvage is discussed. Percutaneous drainage is curative in about 70% of cases and may be the treatment of choice in solitary thick-walled abscesses. It should be remembered, however, that residual or regenerated splenic tissue is no absolute guarantee against sepsis. The treatment of splenic abscess should be individualised.

In this review of English language publications from 1970, 5-year survival rates after surgery for gastric cancer have been analysed. While the proportion of patients coming to operation has fallen from 92 per cent before 1970 to 71 per cent by 1990, the proportion of operated patients undergoing resection has increased from 37 per cent before 1970 to 48 per cent before 1990. This change suggests improved preoperative staging leading to better patient selection for operation. The 5-year survival rate following all resections has increased significantly from 20.7 per cent before 1970 to 28.4 per cent before 1990, an increase of 7.7 per cent (95 per cent confidence interval 7.1-8.3 per cent). The 5-year survival rate following curative or radical resection has risen from 37.6 to 55.4 per cent over the same period, an increase of 17.8 per cent (95 per cent confidence interval 17.1-18.5 per cent). It is likely that this improvement has contributed to the decrease in the mortality rate from gastric cancer. Comparison of Japanese series with others suggests that diagnosis and treatment of the disease at an earlier stage will result in an even greater increase in 5-year survival rates outside Japan. Of the papers studied, 56 per cent were excluded from analysis, the majority because the data provided about 5-year survival rates were insufficient or the survival calculations inappropriate. Results of survival after operations for gastric cancer should be calculated and presented in a standardized manner.

In a prospective study of typhoid fever in Ahmadu Bello University Hospital, Zaria, the relative diagnostic sensitivities of blood culture and bone marrow culture were studied. The results in 64 patients with proved diagnosis of typhoid fever (either by recovery of S. typhi from stool, blood and/or bone marrow or by a positive Widal agglutination test) are presented. Forty-four per cent and 59% of the patients yielded S. typhi on blood and bone marrow cultures, respectively. In 31 patients who were investigated by both blood and bone marrow cultures, the yields of S. typhi were 35% and 61% respectively. This difference is statistically significant (P less than 0.05). In this study bone marrow culture proved to be the most sensitive diagnostic test for typhoid fever. A simple technique of bone marrow aspiration is described and its use is recommended for large general teaching hospitals.

In this review of English language publications from 1970, operative mortality following surgery for gastric cancer has been analysed. Operative mortality has declined in series reporting operations in successive decades to 1970, 1980 and 1990. Series reporting patients having surgery for gastric cancer in the decade to 1990 show a mean operative mortality rate of 7.8 per cent (median 4.6 per cent). This improvement may have contributed to the declining mortality rates for gastric cancer in the face of unchanging surgical workload. Results of operations for gastric cancer should be reported in a standard manner.

Objective: To determine the changes in incidence of and mortality from gastric cancer in Scotland between 1978 and 1987 and in the operative workload in Lothian between 1979 and 1988., Design: Analysis of national incidence statistics for gastric cancer derived from the Scottish national cancer registry, deaths from gastric cancer recorded by the registrar general for Scotland, and Lothian surgical audit data., Setting: Scotland and Lothian Health Board area., Patients: Patients in Scotland with gastric cancer during 1978 to 1987 inclusive; patients in Scotland with gastric cancer recorded on their death certificate as cause of death during 1978 to 1987; patients who had an operation in Lothian for gastric cancer during 1979 to 1988., Main Outcome Measures: Changes in incidence of and mortality from gastric cancer in Scotland from 1978 to 1987 and in the number of operations performed for gastric cancer in Lothian from 1979 to 1988., Results: Mortality from gastric cancer in Scotland fell by about 25% over the 10 years. The incidence and standardised incidence of gastric cancer showed a marginal decline of about 9%. The differences in trends between incidence and mortality were significant (p less than 0.05)., Conclusions: This study shows that the surgical workload associated with gastric cancer is not declining. This is because the incidence has remained almost static, which may be due to the relative increase in the numbers of older people in the population, who are at greater risk of developing gastric cancer. Gastric cancer should not be regarded as a disease in decline. Incidence and workload should determine resources allocated to this disease rather than mortality statistics.

Of 280 patients presenting to one hospital with gastric cancer between 1975 and 1985, 97 (35 per cent) did not undergo surgery and 29 per cent (54 out of 183) of those who did had no resection performed. The 30-day operative mortality rate in the study period was 15 per cent (28 out of 183) but in the subsequent 4-year period this fell to 7 per cent (5 out of 69). The survival rate correlated significantly with depth of invasion but not with tumour site or degree of differentiation. The incidence of early gastric cancer in this series was 5 per cent but the 5-year survival rate in this group was 52 per cent suggesting that the true incidence might be even lower. The overall 5-year survival rate in our area 20 years ago was only 5.2 per cent but in this series it was 11 per cent overall and 24 per cent after resection, and with actuarial correction 15 per cent overall and 28 per cent after resection. The continuing improvement in operative mortality rates and in 5-year survival rates gives grounds for optimism, but the disease must be diagnosed earlier if this improvement in outlook is to continue.