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Randomized clinical trial comparing multiple stab incision phlebectomy and transilluminated powered phlebectomy for varicose veinsChetter IC, Mylankal KJ, Hughes H, et al. Br J Surg 2006;93:169-74. Conclusion:Transilluminated power phlebectomy (TIPP) compared with multiple stab incision phlebectomy (MSIP) results in fewer surgical incisions but has reduced early postoperative quality of life, with more extensive bruising and more prolongation of postoperative pain.Summary: This was a randomized clinical trial at a university teaching hospital in Australia. Patients who were to undergo surgery for varicose veins were randomized to receive either TIPP or MSIP for treatment of the varicosities. For both groups, analysis consisted of operative times, number of incisions, and postoperative outcome. A quality-of-life analysis was conducted at 1 and 6 weeks after surgery using disease-specific (Aberdeen varicose vein questionnaire) and generic (Short Form 36 and EuroQual 5D) measures as well as the domain-specific Burford Pain Scale. The MSIP arm of the trial had 33 patients, and the TIPP arm had 29 patients. All patients had complicated or symptomatic varicose veins. In the MSIP group, 29 of the 33 patients were CEAP class II, and 27 of 29 patients in the TIPP group were CEAP class II.Mean duration of surgery was 48 minutes (range, 41 to 63 minutes) in the MSIP patients and 50 minutes (range, 40 to 60 minutes) in the TIPP group (P ϭ .717). A significantly lower number of phlebectomy incisions were used in the TIPP group (mean, 5; range, 3 to 7), than the MISP group (mean, 20; range, 11 to 25) (P Ͻ .001). At 1 and 6 weeks, skin bruising was significantly higher in the TIPP group (P Ͻ .01), and the Burford Pain Scale at 6 weeks was also significantly higher in the TIPP group (P ϭ .019). At 1 week after surgery, both groups had significant deterioration on the qualityof-life outcomes domains of physical function, role play, and social function of the SF36. The magnitude of deterioration was greater after TIPP. At 6 weeks, patients who had TIPP had no significant change in any SF36 quality-of-life domain compared with pretreatment values. Patients treated with MSIP at 6 weeks showed significant improvements in role play and in physical and bodily pain.Comment: In this randomized trial of transilluminated power phlebectomy vs standard multiple stab incisions for varicose vein treatment, the only advantage of the transilluminated power phlebectomy was a decreased number of incisions. Surprisingly, there was no difference in operative time. If patient recovery is the issue, it therefore appears that standard multiple incisions provide a better outcome. If the patient is interested in fewer incisions for cosmetic concerns, transilluminated power phlebectomy will provide this but at the expense of a more prolonged recovery from the initial procedure.

A total of 145 consecutive patients receiving a colorectal anastomosis were randomized to 'test' or 'no test' once the anastomosis had been completed. Anastomotic testing was performed with the pelvis filled with saline and the rectum distended by sigmoidoscopic insufflation of air. Any leaks demonstrated were oversewn. A water-soluble contrast enema was performed on the tenth postoperative day. Seventy-four patients were randomized to 'test' and 71 to 'no test' but one patient was withdrawn from each group leaving a total of 143 for analysis. The two groups were well matched for age, sex, diagnosis and operative details. Eighteen (25 per cent) air leaks were detected and repaired in the 'test' group. After operation there were three (4 per cent) clinical leaks in the 'test' group and ten (14 per cent) in the 'no test' group (Fisher's exact test, P = 0.043). There were eight (11 per cent) radiological leaks in the 'test' group and 20 (29 per cent) in the 'no test' group (P = 0.006). Intraoperative air testing and repair of colorectal anastomoses significantly reduces the risk of postoperative clinical and radiological leaks.

Background: A policy of intra-operative transcranial Doppler (TCD) and completion angioscopy was previously associated with virtual abolition of intra-operative stroke (apparent upon recovery from anaesthesia) following carotid endarterectomy (CEA). The aims of this study were to determine whether the prevalence of technical error has diminished with experience and whether our monitoring/quality control policy was still associated with low rates of intra-operative stroke 20 years after its introduction. Methods: Retrospective review of four consecutive cohorts of 400 patients undergoing CEA between October 1995 and March 2010 (1600 CEAS in total). Results: One hundred four patients (7%) had thrombus removed following angioscopy and prior to flow restoration, while 31 (2.1%) underwent repair of a distal intimal flap. The prevalence of intimal flaps diminished from 4.9% in the first 400 patients to 0.8% in the last 400 patients (p ϭ 0.006). By contrast, the prevalence of retained thrombus did not decline with experience (8.5%, 3.7%, 10.3% and 5.4% for the four consecutive periods). Intra-operative TCD and completion angioscopy was, however, associated with extremely low rates of intra-operative stroke (0.25%, 0.25%, 0.5% and 0.25% during the four study periods). Conclusion: Most intra-operative strokes probably follow embolisation of thrombus following restoration of flow. This can be prevented by angioscopy which has the advantage of being performed prior to flow restoration. Increasing experience was associated with a decline in the detection of intimal flaps, but not in the prevalence of retained thrombus. Even the most experienced of surgeons can still be responsible for inadvertent technical error.

The long saphenous vein is frequently used as a graft in both coronary artery and femoro-distal bypass surgery. The histological changes which are seen after implantation into the arterial system have been well documented in the past, but little attention has been focused on the histological appearances of the donor long saphenous vein prior to grafting. In this study, samples of the long saphenous vein in excess of that required for bypass have been examined. In none of the veins did the histological appearances conform to the described normal. All showed evidence of intimal fibrosis which contained elastic tissue and enmeshed smooth muscle cells. The longitudinal and circular muscle layers showed evidence of muscle cell hypertrophy with increase in intervening connective tissue. Elsewhere, similar histological changes have been attributed to 'arterialization'. This study shows that many of the changes are present prior to grafting and may be important in graft failure.