Biomedical subjects

J Golledge

Publications and source records attributed to J Golledge.

49 records · Page 3Linked to original sources

PubMed1996

Comparison of clinical follow-up and duplex surveillance of infrainguinal vein bypasses.

The evidence in support of surveillance has been principally based on the favourable primary-assisted patency of stenosed grafts following revision (60-80% at 5 years) compared with the poor secondary patency of revised occluded grafts (20-40% at 5 years). Both the capital cost and workload generated by surveillance are considerable. More information is needed on the benefits of surveillance compared with clinical follow-up. A retrospective comparison of 50 vein grafts (44 reversed, six in situ) undergoing colour-coded duplex surveillance and 50 vein grafts (46 reversed, four in situ) under clinical follow-up, with duplex scans obtained only when clinically indicated, has been performed. Four (8%) stenoses of > or = 50% were identified in the surveillance group. One 50% proximal anastomotic stenosis failed to progress on sequential scans. Three stenoses were treated (one mid graft, two popliteal) by vein patch angioplasty (two cases) and transluminal angioplasty (one case). Both groups were followed-up for 12 months. Secondary patency at 12 months (88% surveillance; 80% clinical follow-up) was not significantly different (P = 0.3). Similarly, limb salvage at 12 months (94% surveillance; 88% controls) was not significantly different (P = 0.4). A large randomized prospective study comparing duplex surveillance and clinical follow-up is warranted.

Adult↗

PubMed1996

Have the results of infrainguinal bypass improved with the widespread utilisation of postoperative surveillance?

OBJECTIVES: The objectives of this study were to assess the impact of Duplex surveillance on the results of infrainguinal vein grafts. A review has been performed comparing the outcome of vein grafts undergoing Duplex surveillance plus prophylactic treatment of stenoses to that of vein grafts followed clinically. DESIGN, PATIENTS, AND METHODS: Only studies providing information on occlusion rates were included. Mortality and limb salvage rates were also analysed but were not available from all studies. RESULTS: 2680 surveillance and 3969 non-surveillance vein grafts were analysed. There was no significant difference between the two groups with respect to presence of critical ischaemia (p=0.3) and level of distal anastomosis (p>0.5). Surveillance identified 493 stenoses in 469 (19%) grafts, 397 (16%) grafts were treated by surgery (248; 62%) and angioplasty (149; 38%). Ninety-eight (26%) grafts developed recurrent stenoses. Total number of deaths, total number of occluded grafts and number of occlusions after 30 days were significantly greater for the non-surveillance group (p<0.001; p<0.001; p<0.01). Perioperative occlusion rates were not significantly different (p=0.1). Few surveillance studies reported limb salvage rates (6 of 17). The numbers of amputations were not significantly different between the two groups (p>0.5). CONCLUSIONS: The patency of infrainguinal vein grafts would appear to be improved as a result of surveillance. However, no improvement in limb salvage has been demonstrated.

Arteriovenous Shunt, Surgical↗

PubMed1996

Outcome of selective patching following carotid endarterectomy.

OBJECTIVES: Routine patch angioplasty has been advocated following carotid endarterectomy but patching can be associated with complications. This study assesses the effect of a selective patching policy based on distal internal carotid diameter on the rate of restenosis and outcome following carotid endarterectomy. DESIGN, MATERIAL AND METHODS: A consecutive series of 213 patients underwent carotid endarterectomy performed by one surgeon. Preoperative carotid dimensions were measured intraoperatively using calipers. Following endarterectomy a 5mm Dacron patch was selectively employed if the distal internal carotid was 5mm or less (group 1, 95 patients) or 6mm or less (group 2, 118 patients). Patients underwent colour-coded Duplex scanning at 24 h, 1 week, 3, 6, 9, and 12 months, and yearly following this. RESULTS: Overall 27 restenoses (5 residual) of 50% or greater and two occlusions developed. Patching was performed in 47% of group 1 and 61% of group 2 arteries. In group 1 14% of patched compared with 24% of non-patched arteries developed restenosis at 24 months (p=0.4). In group 2 13% of patched compared to 11% of non-patched arteries developed restenosis at 12 months (p>0.5). Stroke rate at 24 months were similar for patched and non-patched patients in groups 1 (p>0.5) and 2 (p=0.4). CONCLUSIONS: This study suggests that patch angioplasty of larger carotid arteries may be unnecessary. Randomisation of larger arteries between patch and primary closure would be required to confirm this.

Aged↗

PubMed1996

Assessment of peritonism in appendicitis.

The aim of this study was to evaluate the accuracy of different methods of demonstrating right iliac fossa peritonism in appendicitis. The methods used were cat's eye symptom (pain on going over a bump in the road), cough sign, right iliac fossa tenderness, percussion tenderness, rebound tenderness and guarding. A series of 100 consecutive patients with a median age of 25 years (range 4-81 years), presenting with right iliac fossa pain were studied prospectively; the male:female ratio was 39:61. In all, 58 patients underwent operation, 44 had appendicitis confirmed on histology. Fourteen patients had a normal appendix removed; 11 were women aged between 16 and 45 years. Cat's eye symptom and cough sign were sensitive indicators of appendicitis (sensitivity 0.80 and 0.82, respectively), but were not specific (specificity 0.52 and 0.50, respectively) and therefore inaccurate (accuracy 64%). Percussion tenderness was less sensitive (sensitivity 0.57) but more specific (specificity 0.86). Rebound tenderness proved to be sensitive (sensitivity 0.82), specific (specificity 0.89) and accurate (accuracy 86%). Thus, rebound tenderness had a positive predictive value of 86% compared with 56% and 57% for cough sign and cat's eye symptom, respectively. In the difficult diagnostic group of young women, the positive predictive value of rebound tenderness was 88% compared with 58% and 56% for cat's eye symptom and cough sign. Appendicitis remains a difficult diagnosis, particularly in young women. Rebound tenderness still has an important role to play in clinical assessment.

Abdominal Pain↗

PubMed1996

Colour-coded duplex assessment alone before carotid endarterectomy.

This study assessed whether carotid colour-coded duplex imaging can provide sufficient information to investigate patients before carotid endarterectomy. One hundred patients with symptomatic carotid artery disease (amaurosis fugax 24, transient ischaemic attack 38 and established stroke 38) were assessed by both colour-coded duplex imaging and arch angiography. Stenoses were graded at angiography using the linear method from the European Carotid Surgery Trial and on duplex using peak systolic velocity criteria. Angiograms were also analysed for any arch or intracerebral pathology which would alter surgical management. In defining 70-99 per cent stenoses, duplex had a sensitivity of 98 per cent, specificity 96 per cent, positive predictive value of 96 per cent, negative predictive value 98 per cent and accuracy 97 per cent compared with angiography for both symptomatic and asymptomatic carotids (chi 2 = 1.22, 1 d.f., P = 0.25). With respect to the symptomatic carotid arteries angiography gave different information from duplex in six patients (6 per cent): definition of 70-99 per cent carotid stenosis was different (four), visualization was poor on duplex (one) and an intracerebral aneurysm was identified by angiography. One patient died following arch angiography as a result of mesenteric thrombosis. Carotid duplex imaging alone would appear to be sufficient to assess most patients before carotid endarterectomy as an accurate, safe and relatively cheap investigation compared with angiography. In cases where duplex assessment does not allow full visualization of the carotid bifurcation angiography is required.

Adult↗

PubMed1996

Hip ganglion: case report and review of the literature.

We present an unusual case of a ganglion of the hip. The patient presented with a groin mass initially thought to be inguinal lymphadenopathy, related to a scrotal malignant melanoma excised 2 years earlier. Five similar cases have been previously reported. In all cases the pre-operative diagnosis was wrong (femoral hernia, inguinal lymphadenopathy, inguinal abscess). Only at operative exploration was the correct diagnosis made. The diagnosis of hip ganglion should be borne in mind when a patient presents with an inguinal swelling.

Aged↗

PubMed1995

Head and neck liposarcoma.

BACKGROUND: Liposarcoma of the head and neck region represents approximately 1% of head and neck sarcomas. Therefore, there are few data on the natural history, presentation, treatment, and prognosis of this neoplasm. METHODS: This study is a report of data from 76 patients with head and neck liposarcoma of whom 4 were treated at The Royal Marsden Hospital during the past 50 years. RESULTS: The median age of patient presentation was the seventh decade (range, 6 months-86 years), and 65% of the patients were male. The commonest site of presentation was the neck (28%), followed by the larynx (20%) and pharynx (18%). Sixty-two percent of tumors were low grade (well differentiated and myxoid), and 38% were high grade (pleomorphic and round cell). The principal determinant of outcome was histologic grade. Five-year survival by life-table analysis was 67% overall and varied with tumor type as follows: well differentiated 100%, myxoid 73%, pleomorphic 42%, and round cell 0%. Site appears to have had some influence on prognosis. Oral liposarcoma had a poor prognosis with a 5-year survival of 50%, despite the low grade of all tumors; however, the 5-year survival for laryngeal (89%) and head (83%) liposarcoma was considerably better. Tumor size did not affect prognosis. The mainstay of treatment was surgical excision, used alone in 70% of the cases. Radiotherapy was used with other treatments in 25% of the cases. Prognosis was best for patients treated with surgery only (5-year survival, 83%), compared with those receiving surgery plus radiotherapy (5-year survival, 63%), chemotherapy (5-year survival, 33%), and radiotherapy alone (5-year survival, 0%). CONCLUSIONS: Liposarcoma rarely involves the head and neck region. The prognosis for patients with this disease appears to be better than for those with liposarcoma arising elsewhere, particularly in the retroperitoneum. Prognosis is principally dependent on histologic grade. Complete surgical excision provides the most effective treatment.

Adolescent↗

PubMed1995

Lysis-assisted angioplasty in the treatment of lower-limb arterial thrombosis.

This study examined the results in 30 patients treated with lysis-assisted angioplasty and compared them with the results of 30 patients with simple stenotic disease treated by angioplasty alone. One patient died on the day of treatment with lysis-assisted angioplasty from arterial perforation and haemorrhage. Of the remaining 29 patients 16 (55 per cent) were symptomatically improved and 13 had early reocclusion. Six patients developed major complications (two deaths, two major haemorrhage, two cerebrovascular accident). The late results were comparable to those for patients undergoing angioplasty alone. The best outcome was obtained in patients with proximal disease (P < 0.01); poor run-off or critical ischaemia did not preclude a good outcome.

Adult↗

PubMed1995

Lower limb intra-arterial thrombolysis.

In the UK, approximately 5000 patients present annually with acute lower limb ischaemia. The aetiology is usually thromboembolic disease, other causes include aortic dissection and arterial trauma. Over the past two decades thrombosis has replaced embolism as the principal cause of acute ischaemia, and now accounts for approximately 59% of cases. As a consequence, intra-arterial thrombolysis is being increasingly used as first-line treatment for this condition.

Humans↗

PubMed1995

Vascular trauma in civilian practice.

Vascular trauma is associated with major morbidity and mortality, but little is known about its incidence or nature in Britain. A retrospective study of 36 patients requiring operative intervention for vascular trauma under one vascular surgeon over a 6-year period was undertaken. Twenty-four patients suffered iatrogenic trauma (median age 61 years); including cardiological intervention (19), radiological intervention (2), varicose vein surgery (1), umbilical vein catherisation (1) and isolated hyperthermic limb perfusion (1). There were 23 arterial and three venous injuries. Twelve patients had accidental trauma (median age 23 years). Three of the ten patients with blunt trauma were referred for vascular assessment before orthopaedic intervention, two after an on-table angiogram and five only after an initial orthopaedic procedure (range of delay 6 h to 10 days). Injuries were arterial in nine, venous in two and combined in one. Angiography was obtained in six patients, and in two patients with multiple upper limb fractures identified the site of injury when clinical localisation was difficult. A variety of vascular techniques were used to treat the injuries. Two patients died postoperatively and one underwent major limb amputation. Thirty-two (89%) remain free of vascular sequelae after a median follow-up of 48 months (range 3-72 months). Vascular trauma is uncommon in the United Kingdom. To repair the injuries a limited repertoire of vascular surgery techniques is needed. Therefore, vascular surgical assessment should be sought at an early stage to prevent major limb loss.

Accidents↗

PubMed1994

Renal impairment after thoracotomy: incidence, risk factors, and significance.

One hundred thirty patients undergoing major thoracotomy between June 1991 and June 1992 at The Royal Brompton Hospital, London, were analyzed; renal impairment developed in 31 patients (24%). The mortality and morbidity was significantly greater for the renal impairment group. Six patients (19%) with renal impairment died after operation, in contrast to 0 of the 99 patients in whom renal impairment did not develop. The average length of hospital stay for the patients with renal impairment was 12 days compared with 8 days for the normal renal function group (p << 0.001). Five factors were highly significantly associated with renal impairment: a past history of renal impairment or diuretic intake, undergoing pneumonectomy, postoperative infection, and blood loss (p < 0.001). The most important of these appears to be postoperative infection or blood loss, as they also were associated with death (p = 0.01). Other factors less significantly associated with renal impairment included a past history of hypertension, ischemic heart disease, intraoperative gentamicin, and epidural analgesia (p < 0.01). This study emphasizes that thoracotomy must be considered carefully in patients with these predisposing factors, particularly if pneumonectomy is likely. Care must be taken in the use of aminoglycosides and epidural analgesia. Maintenance of renal blood flow by careful control of hemodynamic indices appears to be the most important intervention.

Female↗

PubMed1994

The aetiology of lateral cervical (branchial) cysts: past and present theories.

Four theories have been suggested to explain the aetiology of lateral cervical cysts. Ascherson (1832) suggested that the cysts arose due to incomplete obliteration of branchial cleft mucosa, which remained dormant until stimulated to grow later in life. His (1886) suggested these cysts were vestiges of the precervical sinus. Wenglowski (1912) believed lateral cervical cysts developed from the third pharyngeal pouch (thymopharyngeal duct). A number of investigators during the 19th century noted the close relationship between lateral cervical cysts and lymphoid tissue (Lucke, 1861). Luschka (1848) suggested that cystic degeneration of cervical lymph nodes was the mechanism by which lateral cervical cysts were formed. This theory received little support until King (1949) studied the histology of a large number of lateral cervical cysts and concluded that these cysts resulted from cystic transformation of cervical lymph nodes. The evidence for and against these theories of aetiology is discussed. The debate is centred on a study of 20 patients with lateral cervical cysts operated on in the Department of Otolaryngology, Bedford Hospital, between January 1986 and December 1991. In all twenty cases the wall of the cyst was found to be composed of lymphoid tissue, histologically identical to the present in lymph nodes. The mean age of presentation was 31 years, and in no case was a tract or cord found which connected the cyst to the skin or pharynx. The evidence strongly suggests that lateral cervical cysts develop from the cystic transformation of cervical lymph nodes. Mechanisms by which this may occur are discussed.

Adolescent↗

PubMed1993

Clinical correlates of acoustic neuroma morphology.

Thirty-eight patients with vestibular schwannomas were reviewed. A correlation was found between tumour morphology and clinical presentation. Based on our knowledge of the variability in the neurilemmal-neurologlial junction and therefore the site of origin of these tumours in relation to the internal auditory canal, a classification into three different appearances on magnetic resonance imaging was possible. Dumbbell shaped tumours (21 per cent) represented laterally arising schwannomas, lollipop shaped tumours (18 per cent) were medially arising and cone shaped tumours (61 per cent) were the more common intermediate form. Patients with laterally arising dumb-bell shaped tumours were more likely to present early with hearing loss and had smaller tumours than patients with medially arising lollipop shaped ones. The relatively well preserved hearing in patients with medially arising tumours made them more likely to present at a later stage with signs of trigeminal compression, cerebellar dysfunction and raised intracranial pressure.

Cranial Nerve Neoplasms↗