The changing world of vascular surgery

Blog Post by Mr Vish Bhattacharya MB BS, FRCS (Glas & Edin), FRCS (Gen Surg) Consultant General and Vascular Surgeon, Queen Elizabeth Hospital, Gateshead, UK.

Vascular surgery has changed dramatically over the last 10 years. The major emphasis has been on prevention of vascular disease and on minimally invasive surgery. There has been much better awareness among the general body of doctors especially GPs about arterial disease and their management. Early detection of peripheral arterial disease and its management is gaining increased importance in order to reduce the number of amputations.

Venous disease management has also changed and less invasive forms of treatment for example foam sclerotherapy, radiofrequency ablation and laser treatment of veins have emerged.

The future of heart and lung transplantation

Blog Post by Clive Lewis, Andrew Klein, Nick Lees and Stephen Webb, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge, CB23 3RE

The field of transplantation has spawned more new specialties and Nobel prize winners than any other in medicine. Christiaan Barnard’s performed the first heart transplant in 1969 in Cape Town, South Africa. The first lung transplant was performed even earlier, in 1963, by Hardy and colleagues at the University of Mississippi in the USA, although two decades passed before this procedure become a viable option for end stage lung disease. Heart transplant is now the treatment of choice for selected patients with advanced heart failure, with over 85,000 procedures having been performed worldwide during the last 40 years. On average, more than 5000 heart transplants are undertaken every year, in more than 225 centres.

Two important challenges transplantation are the increasing numbers of referrals, and the falling number of suitable donor organs available. This has lead to a major imbalance between supply and demand.

Non-invasive ventilation for acute cardiogenic pulmonary oedema

Blog Post by Mr Tim Case MPhil MA (Cantab) Medical Student, Hughes Hall, University of Cambridge, Cambridge, CB1 2EW, UK, and Dr Stephen T Webb MB BCh BAO FRCA EDIC, Consultant in Anaesthesia & Intensive Care Medicine, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge, CB23 3RE, UK

Acute cardiogenic pulmonary oedema (ACPO) is a life-threatening consequence of acute heart failure that affects more than 17000 patients in the UK per year[i].  As the left ventricle fails, increased hydrostatic pressure causes fluid to leave the pulmonary capillaries and fill the alveoli.  Clinical features of ACPO include dyspnoea, tachypnoea, wheeze, pulmonary crepitations and hypoxaemia. 

The Ongoing Challenges with the Peri-operative Care of the Morbidly Obese Patient

Blog Post by Jay B. Brodsky, MD and Harry J.M. Lemmens, MD, PhD, and Stanford University School of Medicine, Stanford, CA, 94305

We are all aware that the world is experiencing an obesity epidemic. Given the great numbers of morbidly obese patients currently undergoing surgery and the predicted increases in those numbers for the future, every health care professional must be familiar with the unique management concerns of these potentially complex patients.          

The morbidly obese patient can be especially challenging for their anesthesiologist and surgeon.  There are physiologic changes to almost every organ system, numerous associated medical co-morbidities, altered uptake and distribution of anesthetic agents and other drugs, potentially difficult airways, as well as technical difficulties related to the large size of these patients.

Post-thoracotomy regional analgesia

Blog Post by Dr Darcy M Pearson FRCA, Specialty Trainee in Anaesthesia & Intensive Care, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge, UK and Dr Stephen T Webb MB BCh BAO FRCA EDIC, Consultant in Anaesthesia & Intensive Care Medicine, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge, UK

Inadequate postoperative pain relief after thoracotomy increases the risk of respiratory complications and chronic post-surgical pain. A number of regional analgesic techniques may be used for post-thoracotomy analgesia including intercostal,intrapleural, extrapleural, paravertebral, intrathecal and epidural analgesia. Extrapleural and paravertebral techniques may be performed by percutaneously or under direct vision and may involve single injections or continuous infusions.

“So you want to become a COLORECTAL consultant surgeon” Career Pathways 5

Blog Post by Mr Nigel Hall, Colorectal Consultant Surgeon

·         What does the speciality offer?                 

Coloproctology encompasses a wide variety of  conditions (benign and malignant, acute and chronic, functional and organic, sporadic and hereditary, trivial and life threatening), in both sexes and all age groups, treatable through a range of techniques – open surgery, laparoscopic, transanal and endoscopic.  Our patients require holistic care and challenge us to improve their lives.  It is a stimulating and rewarding environment, and friendly too with a lot of multidisciplinary and team working. There is plenty of scope for research, teaching and training.  Coloproctology is the backbone of general surgery – and a major specialty in every hospital – you need look no further for a great job!

“So you want to become a vascular consultant surgeon?” Career Pathways 4

Blog Post by Mr. Kevin Varty, Vascular Consultant Surgeon 

·         What does speciality offer?  

Rewarding surgery. Interesting patients who are both a surgical and medical challenge.  New technology, stents to treat aneurysms, combined endovascular and open surgical skills.

Anesthesia awareness

Blog Post by George Mashour, University of Michigan School of Medicine

“Anesthesia awareness” refers to consciousness and explicit memory of surgical events.  This complication is thought to occur in approximately 1-2 cases/1000 and can range from a transient auditory perception to the experience of being fully awake, in pain, and chemically paralyzed. Risk factors for this event traditionally include certain cardiac procedures, emergency cases with blood loss, emergency cesarean section, difficult airway management, and cases with total intravenous anesthetic.  Many of these cases (cardiac, trauma, cesarean section) represent situations in which giving adequate anesthesia could be potentially life-threatening.  Other causes include resistance to anesthetics, machine or equipment malfunction, and human error.  The experience of anesthesia awareness can be psychologically devastating.  In a new study by Dr. Kate Leslie and colleagues (Anesthesia & Analgesia, March issue), 5 of 7 awareness patients identified in a larger study met criteria for post-traumatic stress disorder.  The role of brain monitoring for the prevention of awareness is still unclear; several large studies are ongoing to determine the value of one such monitor.  Part of the difficulty of detecting awareness in the surgical setting relates to our limited understanding of the neural correlates of consciousness.  As we develop more sophisticated knowledge of the mechanisms of both consciousness and anesthesia, improved monitoring capabilities may become available.  In the meantime, recognizing high risk cases and vigilance on the part of the anesthesia provider is the first line of defense.    

Now published in the US, and available from the UK and Europe in March 2010, Consciousness, Awareness, and Anesthesia, edited by George Mashour, is a fascinating insight into both the scientific problem of consciousness and the clinical problem of awareness during general anesthesia.

“So you want to become a cardiothoracic consultant surgeon” Career Pathways 3

Blog Post by Mr Large, Cardiothoracic Consultant Surgeon

·         What does your speciality offer?             

Cardio-thoracic surgery offers an exceptional combination of medicine, physiology and delicate technical skills. It is one of the few surgical specialities which is truly reconstructive rather than ablative. It offers patients substantial improvements in quality of life and prognosis. It is probably one of the most evidence-based practices in medicine. CT surgery is a small surgical speciality with some 250 consultant in about 35 centres. It’s very well organised and it is closely monitored. Cardio-thoracic disease is changing with heart failure is on the rise along with patient age. With age comes atrial fibrillation and degenerative valve disorders.

Cardiac surgery in the very elderly

Blog Post by Dr Alan D Ashworth MB BCh FRCA, Clinical Fellow in Cardiothoracic Anaesthesia, Papworth Hospital NHS Foundation Trust and Dr Stephen T Webb MB BCh BAO FRCA EDIC Consultant in Anaesthesia & Intensive Care Medicine, Papworth Hospital NHS Foundation Trust

As the average life expectancy of the general population increases, the age of patients requiring cardiac surgery is also increasing.  In the 1970s patients over the age of 65 were regarded as too high risk and were denied cardiac surgery.  In 1985 a series of 25 octogenarians undergoing cardiac surgery was reported with an operative mortality of 4% and a 92% postoperative complication rate. 

Surgical techniques, perioperative management and postoperative critical care continue to improve, with ever reducing morbidity and mortality following cardiac surgery.  There is however the undeniable risk of cardiac surgery in patients of advanced age.  Observational studies of nonagenarians undergoing cardiac surgery have demonstrated an increased frequency of perioperative complications and mortality.  Mortality rates for nonagenarians vary from 7 – 18%.