No death following ETS has ever been reported in the literature, but nine anecdotal fatalities are known, five resulting from major intrathoracic bleeding and three from anaesthetic mishap. Significant intrathoracic bleeding may occur in up to 5 per cent of patients but only a minority require thoracotomy; pneumothorax occurs in 2 per cent of patients and two instances of brain damage are known. In the longer term compensatory hyperhidrosis is extremely common and 1-2 per cent of patients regret having had surgery because of its severity. Horner's syndrome, on the other hand, is rare. Improvements in instrumentation, adequate training and careful patient selection may help reduce the drawbacks of ETS.

We present a case series and literature review of injury to the popliteal vessels during total knee replacement (TKR). This is rare but may be limb-threatening with devastating consequences for the patient. An individual surgeon will see few cases. Over a 28-month period 3913 elective TKRs were performed at three hospitals in East Anglia, United Kingdom. We present nine cases (0.23%) of popliteal artery injury following TKR. All required further investigation and intervention. The range of pathology included intra-operative haemorrhage (3 cases), thrombosis (2 cases), pseudo-aneurysm (3 cases) and arteriovenous fistula (1 case). Definitive treatment of the arterial injury was by primary repair (4 cases), interposition graft (2 cases), bypass graft (2 cases), endovascular stenting (1 case) and primary above-knee amputation (AKA; 1 case). There was morbidity in four patients: two AKAs, one case of foot-drop, and one unsightly fasciotomy scar. There was no mortality. Compared to other published studies (totalling 141 cases) complications resulting from direct arterial injury were significantly more common in our series. Incidence remains steady. More careful surgical technique may be the most effective preventative measure. Ongoing awareness is therefore essential for early diagnosis and management of this rare but serious complication.

Pulmonary microembolization in experimental aortic surgery: K. R. Poskitt et al. 15.16. 17.18. 19.prostacyclin and thromboxane play a role in endotoxic shock? Br J Surg 1981; 68: 720-4.Worthen GS, Goins AJ, Mitchell BC, Larsen GC, Reeves JR, Henson PM. Platelet-activating factor causes neutrophil accumulation and oedema in rabbit lungs. Chest 1983; 33: Bone RC, Francis PB, Pierce AK. Intravascular coagulation associated with the adult respiratory distress syndrome. Am J Med 1976; 61: 584-9. Spagnuolo PJ, Ellner JJ, Hassid A, Dunn MJ. Thromboxane A, mediates augmented polymorphonuclear leucocyte adhesiveness. J CIin Invest 1980; 66: 40G14. Hyman AL, Spannhake EW, Kadowitz PJ. Prostaglandins and the lung. Am Rev Resp Dis 1978; 117: 111-36. Bowald S, Eriksson I, Wiklund L. The influence of heparin on 13-15s. Short note haemodynamics and blood gases during abdominal aortic surgery. Acta Chir Scand 1980; 146: 333-41. Thorne LJ, Kuenzig M , McDonald M , Schwartz S1. Effect of denervation of a lung on pulmonary platelet trapping associated with traumatic shock. Surgery 1980; 88: 208-14. Ljungqvist U, Bergentz SE, Lewis DH. The distribution of platelets, fibrin and erythrocytes in various organs following experimental trauma. Eur Surg Res 1971; 3: 293-300. Ford-Hutchinson AW. Leukotrienes: Their formation and role as inflammatory mediators. Fed Proc 1985; 44: 25-9. Hammerschmidt DE. Leucocytes in lung injury. Chest 1983; 83: 16s-20s. Modig J. Adult respiratory distress syndrome: Pathogenesis and treatment. Acta Chir Scand 1986; 152: 241-9. 20. . 21. 22. 23. 24.

We studied pain and mobility in 101 men undergoing elective unilateral inguinal herniorrhaphy. Subcutaneous infusion of 0.5 per cent bupivacaine via a fine catheter was used as an adjunct to conventional analgesia in half of the patients. This had no effect on the perception of pain measured at 8 and 24 h by visual linear analogue, nor on the analgesics requested by the patients. The walking ability of all patients was significantly impaired 24 h postoperatively, but again bupivacaine conferred no benefit. Organisms were cultured from 12.5 per cent of the catheters.

Currently, thoracic sympathetic ablation is indicated mainly for primary hyperhidrosis, especially affecting the palm, and to a lesser degree, axilla and face, and for facial blushing. Despite modern pharmaceutical, endovascular and surgical treatments, sympathetic ablation has still a place in the treatment of very selected cases of angina, arrhythmias and cardiomyopathy. Thoracic sympathetic ablation is indicated in several painful conditions: the early stages of complex regional pain syndrome, erythromelalgia, and some pancreatic and other painful abdominal pathologies. Although ischaemia was historically the major indication for sympathetic ablation, its use has declined to a few selected cases of thromboangiitis obliterans (Buerger's disease), microemboli, primary Raynaud's phenomenon and Raynaud's phenomenon secondary to collagen diseases, paraneoplastic syndrome, frostbite and vibration syndrome. Thoracic sympathetic ablation for hypertension is obsolete, and direct endovascular renal sympathectomy still requires adequate clinical trials. There are rare publications of sympathetic ablation for primary phobias, but there is no scientific basis to support sympathetic surgery for any psychiatric indication.

Deceit and fraud in medical research is a serious problem for the credibility of published literature. Although estimating its prevalence is difficult, reported incidences are alarming. The spectrum of the problem ranges from what may seem as rather innocuous gift authorship to wholesale fabrication of data. Potential factors which may have promoted fraud and deceit include financial gain, personal fame, the competitive scientific environment and scientific hubris. Fraud and deceit are difficult to detect and are generally brought to the fore by whistleblowers. Although most cases may be dealt with at an institutional level, regulatory organisations such as the Committee on Publication Ethics (COPE) and Medical Research Ethics Committee (MREC) have been established to monitor and try to remedy the problem.

Endoscopic Thoracic Sympathectomy (ETS) has gained an increasing popularity due to its minimal invasive character. Despite the simplicity of the procedure, non-surgical options should always be considered as the first line of treatment. The complication risk of ETS is low but side effects, primarily compensatory sweating (CS) of mainly the trunk may be severe enough to cause regret of the procedure. The risk/benefit ratio should always be discussed with the patient. Severe palmar hyperhidrosis and facial blushing respond very well to ETS with a high patient satisfaction rate. Facial hyperhidrosis is effectively treated with ETS but is associated with a high risk for severe CS. Axillary hyperhidrosis is best treated by other means than ETS. The use of ETS for pain syndromes, vascular insufficiency and angina pectoris is not well supported by scientific evidence, making mandatory careful patient selection.

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