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In 2001, Collin and Murie[1] challenged the concept of endovascular repair (EVAR) for abdominal aortic aneurysm (AAA) in an editorial that remains controversial even now. EVAR offers minimally invasive treatment which can be done under local or regional anaesthesia, reducing postoperative pain, hospital stay and 30-day mortality compared with conventional open aortic aneurysm repair (OAR)[4]. In patients unfit for OAR (the EVAR 2 cohort), EVAR is pretty well tolerated and can minimize the risk of death from subsequent AAA rupture. Endovascular versus open repair of abdominal aortic aneurysm in 15-years' follow-up of the UK endovascular aneurysm repair trial 1 (EVAR trial 1): a randomised controlled trial. [Extracted from the article]

Background This study aimed to assess how the prevalence and growth rates of small and medium abdominal aortic aneurysms (AAAs) (3·0-5·4 cm) have changed over time in men aged 65 years, and to evaluate long-term outcomes in men whose aortic diameter is 2·6-2·9 cm (subaneurysmal), and below the standard threshold for most surveillance programmes. Methods The Gloucestershire Aneurysm Screening Programme (GASP) started in 1990. Men aged 65 years with an aortic diameter of 2·6-5·4 cm, measured by ultrasonography using the inner to inner wall method, were included in surveillance. Aortic diameter growth rates were estimated separately for men who initially had a subaneurysmal aorta, and those who had a small or medium AAA, using mixed-effects models. Results Since 1990, 81 150 men had ultrasound screening for AAA (uptake 80·7 per cent), of whom 2795 had an aortic diameter of 2·6-5·4 cm. The prevalence of screen-detected AAA of 3·0 cm or larger decreased from 5·0 per cent in 1991 to 1·3 per cent in 2015. There was no evidence of a change in AAA growth rates during this time. Of men who initially had a subaneurysmal aorta, 57·6 (95 per cent c.i. 54·4 to 60·7) per cent were estimated to develop an AAA of 3·0 cm or larger within 5 years of the initial scan, and 28·0 (24·2 to 31·8) per cent to develop a large AAA (at least 5·5 cm) within 15 years. Conclusion The prevalence of screen-detected small and medium AAAs has decreased over the past 25 years, but growth rates have remained similar. Men with a subaneurysmal aorta at age 65 years have a substantial risk of developing a large AAA by the age of 80 years. [ABSTRACT FROM AUTHOR]

Real and present danger [ABSTRACT FROM AUTHOR]

Background The Abdominal Aortic Aneurysm ( AAA) Screening Programme was introduced by the National Health Service ( NHS) in England to reduce the rate of death from ruptured AAA in men. The programme commenced in 2009 and was implemented completely across the country in April 2013. The aim was to review the first 5 years of the programme, looking specifically at compliance and early outcome. Methods Men aged 65 years were invited for a single abdominal ultrasound scan. Data were entered into a bespoke database ( AAA SMaRT). This was a planned analysis after the first 5 years of the programme. Results The summation analysis involved the first 700 000 men screened, and the first 1000 men with a large AAA referred for possible treatment. The prevalence of AAA (aortic diameter larger than 2·9 cm) in 65-year-old men was 1·34 per cent. Mean uptake was 78·1 per cent, but varied from 61·7 to 85·8 per cent across the country. Based on the Index of Multiple Deprivation, uptake was 65·1 per cent in the most deprived versus 84·1 per cent in the least deprived areas. Of the first 1000 men referred for possible treatment of a large AAA (greater than 5·4 cm), the false-positive rate was 3·2 per cent. Some 870 men underwent a planned AAA intervention (non-intervention rate 9·2 per cent), with seven deaths (perioperative mortality rate 0·8 per cent). Conclusion The processes in the NHS AAA Screening Programme are effective in detecting and treating men with AAA. [ABSTRACT FROM AUTHOR]

The article presents a study which examines the application of mesh and sutured wound closure following open abdominal aortic aneurysm (AAA) surgery. An overview of the methodology used for the study is provided, along with information on AAA and incisional hernia. Researchers found that prophylactic preperitoneal polypropylene mesh closure lessened cases of incisional hernia after being subjected to elective open AAA repair.

The article presents a study on the outcome of foam sclerotherapy in patients who wear compression bandages for 24 hours or 5 days. The study performed a randomized clinical trial among patients with primary uncomplicated varicose veins with a primary end point of 6-week Aberdeen Varicose Vein Severity Score (AVVSS) and Burford pain score. Results indicated that compression bandaging for 24 hours is ineffective when thromboembolus deterrent stockings are worn for the remaining 14 days.

Overused? [ABSTRACT FROM AUTHOR]

Background: The aim was to compare a number of risk scoring systems prospectively in a cohort of patients who underwent non-elective surgery. Methods: This was a cohort study of 2349 consecutive patients who had urgent or emergency surgery in a district general hospital in the UK. All patients were scored prospectively using the Revised Goldman Cardiac Risk Index (RGCRI), Portsmouth modification of the Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (P-POSSUM), Surgical Risk Score (SRS) and Biochemistry and Haematology Outcome Models (BHOM). Actual 30-day and 1-year survival rates were compared with the predicted outcomes using receiver-operator characteristic (ROC) curves and Hosmer-Lemeshow analysis. Results: Some 141 patients (6.0 per cent) died within 30 days of operation. This increased to 254 (10.8 per cent) by 1 year. The area under the ROC curve for death within 30 days was 0.90 for PPOSSUM, 0.85 for SRS, 0.84 for BHOM and 0.73 for RGCRI. Only the first three risk scores were able to discriminate accurately within the groups (area under ROC curve over 0.8), with no significant variation between expected and observed mortality rates confirmed by Hosmer-Lemeshow analysis. Similar results were found for the ability of each score to predict outcome at 1 year. Conclusion: P-POSSUM, SRS and BHOM scoring systems were all able to predict outcome after emergency and urgent surgery, but the SRS had the advantage of ease of calculation. BHOM requires only the most commonly available blood test data and the computer holding these data can easily perform the calculation. [ABSTRACT FROM AUTHOR]

Long overdue [ABSTRACT FROM AUTHOR]

Evaluates the anatomical and hemodynamic effects of superficial venous surgery and compression on legs with chronic venous ulceration. Treatment of legs with open or recently healed ulceration and saphenous reflex with multilayer compression bandaging or superficial venous surgery plus compression; Finding that superficial venous surgery resulted in a significant hemodynamic benefit for legs with venous ulceration despite co-existent deep reflux.

Background and methods: The development of the Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) is described and its methods of analysis and value in a modem surgical practice are reviewed. A computerized search of all published data in Medline, the Cochrane Library and Embase was made for the last 12 years. Relevant articles were then searched manually for further papers on risk analysis, case-mix comparison and POSSUM methodology. Results and conclusion: POSSUM has been evaluated extensively in both general and specialist surgery. While there are problems with both data collection and analysis, when used correctly POSSUM can usefully compare outcomes between surgeons and between hospitals. In specialist surgery, individual regression equations may be needed for each index procedure. [ABSTRACT FROM AUTHOR]

Background: Screening for abdominal aortic aneurysm (AAA) has been carried out in Gloucestershire since 1990. All men in the county are offered aortic ultrasonography in their 65th year. Men with an aortic diameter of less than 26 mm are considered ‘normal’ and no follow-up is arranged. The aim of this study was to ascertain if men with ‘normal’ aortic diameters at age 65 years ever develop a clinically significant aneurysm. Methods: A cohort study was performed on 223 65-year-old men who had an aorta of less than 26 mm in diameter in 1988. These men had repeat ultrasonography in 1993 and 2000. The causes of death in men who died during this interval were investigated. Results: Eight men were lost to follow-up. As far as it was possible to ascertain, none of the 86 men who died over the 12-year interval did so from ruptured AAA. There was no clinically significant increase in mean aortic diameter in the remaining 129 men who had three serial ultrasonographic scans over the 12-year interval. Conclusion: A single, ‘normal’ ultrasound scan at age 65 years effectively rules out the risk of clinically significant aneurysm disease for life in men. [ABSTRACT FROM AUTHOR]

Discusses results of an aneurysm screening pilot study program for individuals aged 65 or 66 years. Patient characteristics; Aortic diameter; Mortality of study group not related to aortic aneurysm.

Presents reply to a correspondence focusing on the safety parameters of using polytetrafluoroethylene patch saphenoplasty in preventing the recurrence of varicose veins. Issue of deep vein thrombosis; Sites of possible failure; Patient satisfaction.

Summary Background The aim of this study was to determine whether a polytetrafluoroethylene (PTFE) patch sutured over the religated saphenofemoral junction could reduce the rate of recurrence after operation for recurrent varicose veins. Methods Fifty patients who had surgery for recurrent long saphenous incompetence (81 legs had a small PTFE patch sutured over the religated saphenofemoral junction. There were no major complications following surgery. Three patients had a wound infection or delayed healing. All patients were invited for clinical examination and duplex imaging at a median of 19 (range 6–39) months after operation. Results Some 38 of 43 patients (70 legs) remained satisfied with the results of surgery; 16 (23 per cent) of 70 legs had visible veins on inspection and eight of these (11 per cent) involved symptomatic recurrence. Duplex imaging showed that recurrence was due to saphenofemoral junction incompetence in ten legs; two appeared to have a major groin connection but the other eight appeared to have neovascularization. Other causes were thigh perforator reflux (three legs) and cross-groin collaterals (three). Eleven of the 16 legs with recurrence had varicography but in two the procedure was a technical failure. Two legs had evidence of a significant connection (more than 3 mm) and two a minor connection (less than 3 mm) to the femoral vein at the level of the PTFE patch, but in the remainder recurrence was due to upper thigh perforating veins. There was good concordance between duplex imaging and varicography. Conclusion PTFE patch saphenoplasty appears to be safe. Although these are early results, the technique seems potentially as effective as other barrier methods that have been investigated; in ten legs (12 per cent) recurrence was attributed to failure at the level of the PTFE patch. [ABSTRACT FROM AUTHOR]

Summary Background The organization of leg ulcer care is poorly defined in the community. This study assessed the overall influence of a specialized community service on management and outcome of chronic leg ulcers, irrespective of aetiology. Methods Assessment and outcome of ulcers were compared in patient samples (n = 200) from East and West Gloucestershire, before and after the introduction of specialized clinics into East Gloucestershire. In clinics, vascular disease was routinely assessed by duplex scanning and determination of the ankle : brachial pressure index. Results There was no coordinated community structure for the care of patients with leg ulcers before the service was introduced, and 74 and 67 per cent of limbs in East and West Gloucestershire respectively had aetiology undiagnosed. After introduction of the clinics, the 12-week healing rate increased from 12 to 22 per cent in East Gloucestershire (P = 0·05) and to 47 per cent in the specialized East Gloucestershire clinics (P < 0·001). The 12-month recurrence rate decreased from 50 to 41 per cent in East Gloucestershire and to 17 per cent in the East clinics (P < 0·001). The West Gloucestershire control showed no significant changes. Conclusion A specialized leg ulcer service with defined protocols provides an improved management structure for treating patients with leg ulcers in the community. Accurate diagnosis of chronic leg ulcers and improved outcome may be achieved within this specialized service. [ABSTRACT FROM AUTHOR]

Presents an abstract of the article 'Randomized Trial of Rifampicin-bonded dacron Grafts for Extra-anatomic Vascular Reconstruction: 2-year Results,' by J.J. Earnshaw, B. Whitman and B.P. Heather.

Presents an abstract of the article 'Mortality Rate of Elective Abdominal Aortic Aneurysm Repair is Lower in Screened Men,' by C.D. Irvine, M.R. Whynman, K.R. Poskitt, B.P. Heather and J.J. Earnshaw.

Presents an abstract of the article 'Population Screening Reduces the Total Community Mortality Rate From Aortic Aneurysms,' by E. Shaw, K. Poskitt, J. Earnshaw, M. Whyman and B. Heather.

Presents an abstract of the article 'Vascular Surgical Society Operative Outcome Study: Preoperative Physiology Predicts Outcome,' by D. Prytherch, J.D. Beard, B.F. Ridler and J.J. Earnshaw.

SummaryBackground: The aim of this study was to determine the outcome of patients who presented with sudden onset of incapacitating claudication of less than 2 weeks’ duration and who were treated with peripheral arterial thrombolysis. Methods: The database of the Thrombolysis Study Group was searched retrospectively for patients who received thrombolysis for acute-onset claudication. Some 108 patients (65 men, median age 69 (range 29–94) years) were treated with intra-arterial tissue plasminogen activator at 14 hospitals. The median duration of symptoms was 72 h (range from 2 h to 2 weeks). There were 52 graft and 56 native vessel arterial occlusions. Results: The immediate outcome of thrombolysis for native vessel arterial occlusion was thrombus clearance in 50 patients (89 per cent) and failed lysis in six (11 per cent). Thirty-six patients (64 per cent) had a secondary radiological or surgical procedure carried out after lysis. After 30 days four patients (7 per cent) had a major amputation, eight (14 per cent) had died, 38 (68 per cent) were symptom free and seven (12 per cent) continued to have claudication. Three patients (5 per cent) suffered a major haemorrhage. The immediate outcome of thrombolysis for graft occlusion was thrombus clearance in 48 patients (92 per cent) and failed lysis in four (8 per cent); 27 patients (52 per cent) had a secondary procedure. After 30 days four patients (8 per cent) had a major amputation, seven (13 per cent) had died, 32 (62 per cent) were symptom free and nine (17 per cent) had persistent claudication. Three patients (6 per cent) suffered a major haemorrhage. Conclusion: Patients who presented with acute onset of incapacitating claudication had an outcome similar to that after thrombolysis for critical ischaemia. It is recommended that patients who present in this way should be observed and treated with thrombolysis only if they progress to critical ischaemia. Presented to the Association of Surgeons of... [ABSTRACT FROM AUTHOR]

Background Much attention has been paid to the management of acute leg ischaemia. Acute arm ischaemia is perceived as less of a problem because the risk of limb loss is lower. After conservative treatment up to half the patients have late symptoms, such as forearm claudication. Methods This study was a review of all published English language data on acute arm ischaemia. The entire Medline database was searched and other references were derived from the material perused. There were no randomized or controlled studies. Results The incidence of acute arm ischaemia is one-fifth that of acute leg ischaemia. Patients with arm ischaemia tended to be older with a mean age of 74 years compared with 70 years for acute leg ischaemia. Since the development of the embolectomy catheter, embolectomy can be performed in most patients under local anaesthetic. Collected outcome included successful restoration of the circulation in 65–94 per cent of patients and amputation in 0–18 per cent. The mortality rate ranged from 0 to 19 per cent, despite the use of local anaesthesia, mostly from associated cardiac disease. Management by a vascular specialist may be beneficial, particularly in complex cases. Conclusion An active approach to the management of acute arm ischaemia is safe and effective and reduces the risk of late disabling symptoms. [ABSTRACT FROM AUTHOR]

Background The aim of this study was to determine whether the routine use of an antibiotic-bonded gelatin-coated Dacron graft could reduce the incidence of prosthetic graft infection. Extra-anatomic grafts were chosen for study as they have the highest risk of graft infection. This paper reports early results up to 1 month after surgery. Methods This multicentre study involved 14 vascular units in the UK. A total of 257 patients underwent extra-anatomic bypass. Patients were randomized to rifampicin bonding (1 mg/ml rifampicin soak for 15 min before graft insertion) or a control group. Routine three-dose antibiotic prophylaxis was administered to patients in both groups. Results There were 178 men and 79 women of median age 69 (range 43–92) years. Rifampicin-bonded (n=123) and control (n=134) groups were well matched for clinical details, risk factors and operative techniques. No side-effects were noted from rifampicin bonding. Only one patient (in the control group) developed a graft infection and this proved fatal. There were no significant differences between bonded and unbonded grafts in terms of perioperative mortality rate (9 and 5 per cent respectively), median hospital stay (10 days for both groups), total infective complications (15 and 21 per cent respectively) or need for postoperative antibiotics (13 and 18 per cent respectively). Conclusion Early results from this study have not identified any significant advantage in the routine use of rifampicin bonding, but the rate of graft infection was very low (0·4 per cent). Gelatin coating alone may provide protection against infection. Definitive recommendations about the role of antibiotic bonding cannot be made until longer follow-up becomes available. [ABSTRACT FROM AUTHOR]

Background Peripheral thrombolysis is advocated by some as the best initial treatment for acute leg ischaemia, but this may not be true for elderly patients. This study reviewed the management of acute leg ischaemia in patients aged over 75 years. Methods Over a 5-year interval, 91 events of acute leg ischaemia in 84 patients were managed in a single district general hospital according to a local protocol. There were 60 women and 24 men of median age 81 (range 75–100) years. Fifteen patients were too elderly and infirm for active treatment and received anticoagulation alone. Some 76 events (84 per cent) occurred in patients suitable for active therapy: 33 were managed by initial surgery and 43 by peripheral thrombolysis with tissue plasminogen activator. Results Overall outcome after 30 days was limb salvage in 48 (53 per cent), amputation in five (5 per cent) and death in 38 (42 per cent). In actively treated patients the corresponding values were 43 (57 per cent), four (5 per cent) and 29 (38 per cent). Initial successful revascularization was more likely following surgery (29 of 33 versus 25 of 43 events with thrombolysis, P<0·01), but the 30-day outcome was similar in the actively treated groups owing to subsequent morbidity and mortality. Conclusion A group of patients (mostly women) with emboli could be identified, using clinical criteria, who had a high chance of successful revascularization following embolectomy. Late outcome remained poor due to associated co-morbid conditions. Thrombolysis is associated with substantial risk in the elderly, and with high complication rates. [ABSTRACT FROM AUTHOR]

Maximizing potential [ABSTRACT FROM AUTHOR]

Stop smoking. Exercise under supervision [ABSTRACT FROM AUTHOR]

Focuses on the endovascular repair of abdominal aortic aneurysm (AAA). Incidence of AAA; Replacement of aorta with a prosthetic graft; Reduction in the risk of subsequent rupture; Alternative to open repair.

Background: Inguinal hernia surgery has undergone numerous advances in the last few years. This study analysed the changes in the practice of one surgeon in a district general hospital over a seven year interval. The effect of changing from Bassini to Lichtenstein repair in 1994 was evaluated.Methods: The study involved two parts: first a search of a computerised database of inguinal hernia procedures, and second, postal audits of men who had an inguinal hernia repair in 1993 and 1994 with outpatient follow up for those with a possible recurrence.Results: A total of 1037 hernias were repaired over the seven years. There was an increase in the proportion of day cases from 18% to 70% and the number of operations performed under local anaesthetic rose from 1% to 45%. The postal audits had response rates of 79% (1993) and 66% (1994). Some 5/98 (5%) recurrent hernias were identified from the 1993 (Bassini) patients compared with 1/67 (1.5%) from the 1994 (Lichtenstein) cohort.Conclusion: Lichtenstein hernia repair can be performed safely as a day case using local anaesthetic in the majority of patients and appears to have a lower recurrence rate than Bassini repair. [ABSTRACT FROM AUTHOR]

Welcome to BJS Open [ABSTRACT FROM AUTHOR]

More necessary than ever [ABSTRACT FROM AUTHOR]

A challenge to surgeons [ABSTRACT FROM AUTHOR]

The article focuses on abdominal aortic aneurysm (AAA), a degenerative disease that most commonly victimizes men over 65 years old. The author states that while there is much data on how and why AAAs develop, little information is available regarding aneurysm growth rates. Ways of improving the effectiveness of screening programmes are discussed, as well as how results from these can be useful for the development of future preventive programs.

Better than the alternative [ABSTRACT FROM AUTHOR]