INTRODUCTIONThe treatment options for varicose veins have increased over the last few years. Despite al ack of randomised trials comparing the various modalities, many surgeons are changing their practice. The aim of this study was to assess the current practice of surgeons in Great Britain and Ireland.MATERIALS AND METHODS Ap ostal questionnaire survey was sent to surgical members of the Vascular Society of Great Britain and Ireland and the Venous Forum of The Royal Society of Medicine. Of 561 questionnaires sent, 349 were returned completed (62%). RESULTS The types of varicose vein treatments offered by each surgeon varied widely in both NHS and private practice. The vast majority (96%) offered conventional surgery (CS) on the NHS. Foam sclerotherapy (FS) endovenous laser (EVL) and radiofrequency ablation (RF) were more likely to be offered in private practice than in NHS practice. Overall, 38% of respondents for NHS practice and 45% of respondents for private practice offered two or more modalities. Of the respondents who were not yet performing FS, EVL, or RF,1 9% were considering or had undertaken training in FS, 26% in EVL and 9% in RF. When asked to consider future practice, 70% surgeons felt that surgery would remain the most commonly used treatment. This was followed by FS (17%), EVL (11%) and RF (2%).CONCLUSIONS Over one-third of respondents are now offering more than one treatment modality for the treatment of varicose veins. Whilst there is movement towards endovascular treatments, the problem of cost has yet to be solved. At present, surgery remains the most popular modality in both the NHS and private practice; however,i mproved outcomes and patient preference may lead to ac hange in practice. WINTERBORNC ORBETT TREATMENT OF VARICOSE VEINS: THE PRESENT AND THE FUTURE -AQ UESTIONNAIRE SURVEYAnn RC oll Surg Engl 2008; 90:5 61-564

Bile peritonitis can occur when a T-tube is electively removed from the common bile duct, but this is regarded as a rare complication. Plastic T-tubes are known to increase the risk and should not be used. Latex rubber T-tubes are preferred but the complication can still occur. We present three patients with this complication despite the use of a latex T-tube. A questionnaire was sent to 107 surgeons in the South East Thames Region. The replies showed that the complication is far more common than generally realized. Based on these replies the risk of bile peritonitis each time a latex T-tube is electively removed from the common bile duct is calculated to be 0.84 per cent or 1 in every 119 explorations.

Patients with primary varicose veins were examined by a combination of the standard tourniquet test with detection of reflux by Doppler ultrasound. Results were compared with standard clinical tests: impulse or thrill at the saphenous opening on coughing, tap impulse at the groin, and the 'Trendelenburg' tourniquet test. The state of competence of the saphenofemoral junction was noted at operation. One hundred and sixty-one limbs of 105 patients were studied. The saphenofemoral junction was incompetent in 132/161 limbs (82 per cent) and was judged competent in 29/161 limbs (18 per cent). The combined Doppler and tourniquet test assessed the saphenofemoral junction correctly in 82 per cent of limbs and was more accurate than all the other tests. The test had good sensitivity (0.9) but poor specificity (0.45). Poor specificity was a feature of all the tests except for thrill which was a highly insensitive test. The combined Doppler and tourniquet test appears to be the most simple, rapid and accurate means of detecting saphenofemoral incompetence.

The retained stone in the common bile duct remains a problem for the surgeon. Although more effective methods are available, mechanical flushing of the bile duct is, when successful, a simple solution. Pharmacological dilatation of the sphincter of Oddi is a logical adjunct to flushing. Pressure changes in the bile duct during flushing were studied in 20 postoperative patients with T‐tube drains and the effectiveness of two drugs in reducing Omnopon induced spasm of the sphincter was compared. Hymecromone intravenously and lignocaine via the T‐tube were equally effective, reducing sphincter activity in the majority of patients, but there was considerable individual variation.

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