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1.  Gastric explosion: a cautionary tale. 
BMJ : British Medical Journal  1989;298(6666):93-94.
PMCID: PMC1835403  PMID: 2493306
2.  Screening for abdominal aortic aneurysms in men 
BMJ : British Medical Journal  2004;328(7448):1122-1124.
Gloucestershire's screening project shows the potential benefits of a national programme and how it could be run
PMCID: PMC406329  PMID: 15130983
6.  Management of primary and recurrent inguinal hernia by surgeons from the South West of England. 
BACKGROUND: The National Institute of Clinical Excellence (NICE) has advocated open mesh repair for primary hernia but suggested laparoscopic repair may be considered for recurrent hernias. AIM: To establish current surgical practice by surgeons from the South West of England. METHODS: A postal survey was distributed to 121 consultant surgeons and a response rate of 75% was achieved. RESULTS: The majority (86%) of the surgeons surveyed performed hernia repairs, and most (95%) of these used open mesh repair as standard for primary inguinal hernia. Only 8% used laparoscopic repair routinely for primary hernias. Few consultants (only 28%) were able to quote formally audited hernia recurrence rates. A total of 90% of respondents still employed open mesh repair routinely for recurrent hernias; however, if mesh had been used for the primary repair, this figure fell to 55%. Some 7% of respondents recommended laparoscopic repair for recurrent hernia, but this increased to 17% if the primary repair was done with mesh. All laparoscopic surgeons in the South West employed the totally extraperitoneal approach (TEP). There was a range of opinion on the technical demands of repair of a recurrent hernia previously mended with mesh; the commonest cause of mesh failure was thought to be a medial direct recurrence (insufficient mesh medially). CONCLUSIONS: Current surgical practice for primary hernias in the South West England reflects NICE guidelines although many surgeons continue to manage recurrent hernias by further open repair. In this survey, there was anecdotal evidence to suggest that hernia recurrence can be managed effectively by open repair.
doi:10.1308/003588403322520780
PMCID: PMC1964431  PMID: 14629882
7.  First two years of a follow-up breast clinic led by a nurse practitioner. 
After special training a nurse practitioner ran an independent clinic for follow-up patients with breast disease. All patients referred to a single surgical firm with breast cancer and most patients with benign disease who required follow-up were included. In the first 2 years of the service 382 clinic visits were recorded (median 5/clinic, range 1-12). The nurse practitioner reviewed 236 (62%) patients alone but involved the consultant surgeon in the remainder. No significant lesion was missed in these patients. The nurse-led clinic is popular with patients and, subject to careful supervision, offers an attractive option for follow-up of patients with breast disease.
PMCID: PMC1296259  PMID: 9204020
8.  Clinical outcomes audit in vascular surgery: a shield for our profession. 
Surgeons are under pressure from both patients and politicians to supply outcome data. The reporting of crude mortality rates by third parties is both unfair and divisive. Validated methods exist to describe risk-adjusted outcomes in arterial surgery, but surgeons will need to become more involved in data collection and analysis. The Vascular Surgical Society of Great Britain and Ireland has started a process of data collection - the National Vascular Database - that could be used by individuals to collate and compare their surgical outcomes. Monitoring outcomes and managing the results could become one of the principal roles of a specialist society.
doi:10.1308/003588403766274971
PMCID: PMC1964404  PMID: 12855029
9.  NATALI--a model for National Computer Databases in the investigation of new therapeutic techniques. 
New medical treatments are often introduced without the benefit of randomized trials. We describe how a national computerized database was produced, by the Thrombolysis Study Group, for monitoring one such new treatment: peripheral arterial thrombolysis. A novel method for transferring angiograms to computer generated arterial maps that can help in the classification and analysis of the outcome of thrombolysis is also described. Data provided by prospective collection from 14 hospitals within the UK was entered onto the database (Auditbase for Windows), to give contributing members a continual audit of their own results and complications that can be compared with that of the group as a whole. This system may be an appropriate model for other forms of multi-centre audit and the monitoring of new treatments.
Images
PMCID: PMC1295329  PMID: 7562848
12.  Should endoscopic stenting be the initial treatment of malignant biliary obstruction? 
Forty-two patients with biliary obstruction caused by a stricture had a diagnostic ERCP with subsequent insertion of a straight 10G endoprosthesis. These patients represented 70% of a cohort in which stent insertion had been attempted. The majority (63%) had pancreatic carcinoma, but 22% had malignant hilar obstruction. Five patients (12%) died within a few days of stent insertion; ERCP may have contributed to two deaths. Jaundice was relieved in all survivors. Median hospital stay was 6 days (range 2-32 days). After further investigation, nine patients were thought to be potentially curable and underwent laparotomy. Late complications after stent insertion alone included cholangitis (26%) and recurrent jaundice (28%). Only one patient developed gastric outlet obstruction and needed a gastroenterostomy. Median survival in the endoprosthesis group was 11 weeks (range 2-84 weeks). Survival was longer for patients with bile duct (14 weeks) rather than hilar strictures (6 weeks). Median survival after subsequent surgery was 40 weeks (range 4-80 weeks) with two long-term survivors. This study confirms that ERCP and stent insertion is a useful initial treatment for obstructive jaundice due to a biliary stricture, being both diagnostic and therapeutic. Subsequent evaluation for curative surgery is not precluded and in the majority of cases worthwhile palliation may be achieved by stenting alone.
PMCID: PMC2497636  PMID: 1384416
15.  Robin Hood's legacy. 
Images
PMCID: PMC1419185  PMID: 3936577
17.  Risk factors in vascular surgical sepsis. 
The risk factors for sepsis after vascular surgery were studied in 100 consecutive patients with lower limb arterial ischaemia. Patients were randomised either to a short or long course of antibiotic prophylaxis with amoxycillin/clavulanic acid combination (Augmentin). Pathogenic organisms were isolated from the skin preoperatively in 39 (36%) cases, significantly more frequently in patients with ischaemic rest pain and skin necrosis (66%) than rest pain alone (21%) (P = 0.0004) or claudication/aneurysm (11%) (P = 0.0001). All but three organisms isolated (5%) were sensitive to amoxycillin/clavulanic acid. A wound infection occurred after 21 (19%) reconstructions, significantly more frequently both in patients suffering rest pain with skin necrosis (P = 0.001) and rest pain without skin necrosis (P = 0.04) compared with claudication/aneurysm. Sixteen of the 21 patients with a wound infection had at least one organism isolated from their skin preoperatively (P = 0.0001). Twelve patients (57%) had a similar organism isolated from the skin preoperatively and from the postoperative wound infection. Reducing the course of antibiotic prophylaxis from 5 days to 3 doses did not significantly increase the infection rate. The only other significant risk factor for sepsis was increasing age of the patient. Although prophylaxis is undisputed in patients having synthetic grafts, antibiotics may not be as important in the prevention of wound sepsis as had been thought. The role of antiseptic agents requires further evaluation.
PMCID: PMC2498719  PMID: 3408172
18.  Intraoperative use of thrombolytic agents. 
BMJ : British Medical Journal  1993;307(6905):638-639.
PMCID: PMC1678988  PMID: 8401044
19.  A 5-year review of carotid endarterectomy in a vascular unit using a computerised audit system. 
BIPAS, a computerised vascular audit has been used to analyse the results of 203 carotid endarterectomies performed over a 5-year period in a vascular unit. In addition, all but two patients have been followed up with regular duplex scans. The indications and surgical techniques have remained similar over the study period though preoperative carotid arteriography is no longer considered essential and intraoperative monitoring with transcranial Doppler insonation is becoming routine. There were six perioperative deaths and 20 postoperative neurological defects. However, only three survivors had any long-term disability. It was not possible to identify any particular patients at high risk of perioperative stroke, although simultaneous major surgery and significant bilateral carotid endarterectomy seemed to be more hazardous. Routine follow-up using duplex scanning identified patients with late occlusion (5%) and restenosis (8%), but only three patients (1.5%) suffered a late stroke. Once the perioperative hazards of death and permanent stroke (4.4% in this series) have been overcome, carotid endarterectomy provides good protection against subsequent stroke.
PMCID: PMC2497715  PMID: 1471842
20.  A 10-year review of false aneurysms in Nottingham. 
Over a 10-year period, twenty-nine patients who developed false aneurysms were reviewed retrospectively. The diagnosis was delayed for as long as 7 months in the eight patients who developed aneurysms following trauma. However, all these patients had an excellent outcome after surgery. The results were also good in patients with non-infected false aneurysms after vascular reconstruction, with 17 of the 19 patients having the affected limb saved by remedial surgery. The main principle of remedial surgery was to perform the simplest surgical procedure possible. The results in infected false aneurysms were poor and management should be considered along the lines laid down for graft infection. The incidence of false aneurysms may be reduced by the use of suitable non-absorbable sutures, prevention of tension at an anastomosis and prevention of infection. However, degeneration of the arterial wall is thought to be a major cause of false aneurysms and is, of course, beyond control. Recent technical advances such as digital subtraction angiography, labelled leucocyte scanning and computed tomography have all contributed to improvements in the management of false aneurysms.
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PMCID: PMC2498794  PMID: 3415176

Results 1-20 (20)