All lower limb amputations performed during 1986 and 1988 in eight hospitals in the south-east region were assessed. Of 440 amputations for vascular disease, 193 were above-knee, 193 below-knee, 15 Gritti-Stokes, 15 through-knee and 24 bilateral. Of the 440 patients, 75 died in hospital, 113 were considered unsuitable for a prosthesis and 252 (57 per cent) were referred for prostheses. Rehabilitation questionnaires were sent to 179 patients (41 per cent), as a further 54 had died and 19 had become known non-wearers before the study commenced. The response rate was 81 per cent; 102 patients completed the questionnaire, 21 were reported dead, and 22 were non-wearers. Of a maximum rehabilitation score of 12, 52 patients scored 6 or more (consistent with mobility on their artificial limb around the home), and 21 scored 9 or more (a standard accepted as successful rehabilitation). It is concluded that 10-15 per cent of amputees achieve mobility around the home on their prosthesis. Only 5 per cent, however, rehabilitate well and become independent of their wheelchair. When amputation is inevitable, more consideration should be given to surgery that optimizes wheelchair rehabilitation.

No level I evidence for the endoluminal treatment of mycotic aneurysms exists. Ideally a randomised controlled trial of open surgery versus endoluminal treatment should be performed but this may be difficult to perform because of the low incidence of infected aneurysms.

Surg 2009;xx:xx-xx.Objectives: To update our previous systematic review of outcomes following synchronous carotid endarterectomy (CEA) and off-pump coronary artery bypass grafting (OFF-CABG).Design: A systematic review of operative risks reported in published studies of synchronous CEA plus OFF-CABG procedures.Results: We identified 12 eligible studies, including data on 324 synchronous CEA plus OFF-CABG procedures. Operative mortality was 1.5% (95% confidence interval (CI): 0.3-2.8), the risk of death or ipsilateral stroke was 1.6% (0.4 -2.8%), risk of death or any stroke was 2.2% (95% CI: 0.7-3.7) and the risk of death, stroke or myocardial infarction was 3.6% (95% CI: 1.6 -5.5).Conclusions: Limited published data on 324 patients suggest that early outcomes after synchronous CEA plus OFFCABG are better than those following staged or synchronous CEA plus CABG where the cardiac procedure was performed on-pump. This may, however, be attributed to publication bias, case selection or the fact that the aorta was not manipulated or cannulated, rather than CEA being primarily responsible for the lower stroke risk. Colleagues with unpublished experience of CEA plus OFF-CABG are encouraged to submit their data to further inform the debate.

Objective: We report the uptake, length of stay and vascular readmission rates of carotid endarterectomy (CEA) and CAS among patients with symptomatic or asymptomatic carotid artery disease in the English National Health Service (NHS).Methods: Retrospective cohort study based on routinely collected Hospital Episode Statistics (HES) inpatient data. We identified individual admissions for CEA (n = 15996) or CAS (n = 632) between 2006 and 2009. Summary data were used to describe procedure volumes between 2009 and 2012. We analysed trends in procedure use over time and used ordinary least squares regression to evaluate patient, clinical and organisational characteristics associated with longer length of stay for revascularisation.Results: CAS made up less than 5% of carotid revascularisation procedures; there was no trend for increasing use between 2006 and 2012. Patients treated with CAS were on average younger, lived in areas of higher deprivation and were more likely to have amaurosis fugax or a comorbidity of heart disease. CAS patients had a 19% (95% CI 14-24) shorter stay in hospital than CEA patients.Conclusion: Despite the early promise of CAS and numerous randomised controlled trials evaluating efficacy, it has not been rapidly adopted in England. Cautious adoption may be appropriate given the higher periprocedural risk of stroke or death after CAS, particularly in recently symptomatic patients.

Mr R C Mason.Accepted for publication 28 January 1991 The incidence of gastric stump cancer remains controversial." A large recent series, however, has shown that gastric surgery for benign disease is associated with a pronounced increase in gastric adenocarcinoma when compared with a control population from the same locality.7Studies in experimental animals have shown that gastric surgery can induce adenocarcinoma of the stomach without the use of carcinogens.8 Furthermore, the incidence of malignant change in the gastric mucosa was proportional to the degree of duodenogastric reflux. In this rat model of duodenogastric reflux the pancreaticoduodenal secretions, rather than the bile, seemed to be responsible for the tumour.9 In tissues which have a high proliferative rate the activity of the rate-limiting enzyme in polyamine biosynthesis, ornithine decarboxylase, and the concentrations of the polyamines are relatively high. Many human cancers also show high levels of ornithine decarboxylase activity in the malignancy.Since duodenogastric reflux is a reliable model for inducing gastric cancer, and since polyamine metabolism has never been studied in the gastric mucosa in this model, we examined the sequential longterm effects of duodenogastric reflux on gastric mucosal morphology, mucin histochemistry, ornithine decarboxylase activity, and polyamine concentration and correlated the results with the labelling index assessed autoradiographically, an established method of measuring tissue proliferation. Methods STUDY DESIGNAltogether, 186 male Wistar rats weighing 200-250 g were randomised to undergo either simple gastrojejunostomy or gastrotomy. Laparotomy was performed through an upper midline abdominal incision and a 7 mm gastrotomy was made 2 mm distal to the squamocolumnar junction along the anterior surface of the greater curvature. In gastrotomy rats this was closed with an all layer 6/0 Ethibond suture. In gastrojejunostomy animals a loop of jejunum 4 cm distal to the ligament of Treitz was anastomosed to the stomach using an all layer 6/0 Ethibond suture in an isoperistaltic, antecolic manner. Animals from the two groups which survived the operation (operative mortality 10-8%) were allocated to cohorts to be sacrificed at 8,16, 24, 32, 40, 48, and 56 weeks after surgery. An intraperitoneal injection of tritiated thymidine (specific activity 5 Ci/mmol, Amersham International) was given one hour before sacrifice at a dose of 1 RCi/g body weight.The rats were killed by exsanguination under general anaesthetic. The stomach was removed en bloc and opened along the greater curvature. After washing briefly in tap water, the stomach was pinned out on a cork board and the macroscopic findings noted. Some 20-70 mg samples of gastric mucosa were removed by sharp dissection from the underlying serosa and muscle immediately adjacent to the gastrotomy or to the anastomosis. The samples were stored at -70°C until analysed for polyamines and related enzymes within three months of sacrifice.The stomach was fixed in 10% f...