Dissections of regional lymph nodes for treatment of skin cancer: predicting annual caseloads that will optimise outcomes

IntroductionDissection of regional lymph nodes (RLNs) can lead to significant morbidity and a high prevalence of complications. Published guidance states that these procedures should be carried out by surgeons who are members of a specialist skin multidisciplinary team who carry out a combined minimum of 15 axillary/groin dissections per year. However, there is little evidence to guide this minimum figure of procedures. We report on the burden of service provision and prevalence of complications across the South West of England and Wales.MethodsA 12-month review of dissections of RLNs for skin cancer was undertaken covering five Plastic Surgery Units with a collective catchment of 8.4 million people. Detailed data were collected on patient demographics, pathology, timing of surgery, and prevalence of complications.ResultsA total of 163 dissections were carried out. Forty-three per cent of patients experienced one or more complication. In that 12-month period, an average of 8 axillary/groin dissections was carried out per surgeon. A funnel plot demonstrated that the prevalence of complications for individual surgeons was within the limit of the plot but, in many cases, this was based only on a relatively small number of procedures per consultant. If surgeons carried out 10 procedures per year, the upper and lower limits on the plot were 73% and 11%, respectively.ConclusionsFunnel plots can provide a useful guide as to whether the prevalence of complications for procedures for individual surgeons lies within acceptable limits. Based on these results, 10 procedures per consultant per year should be sufficient to enable meaningful assessment of the prevalence of complications.     

Intracardiac surgery in infants under age 3 months: Incremental risk factors for hospital mortality

During the 13 year period from January 1967 to July 1980, the hospital mortality rate for open intracardiac operations in infants in the first 3 months of life was 43 percent (75 deaths among 194 patients), higher than the 22 percent mortality rate (35 deaths in 161 patients) for closed operations in the same age group. The mortality rate was lower late in the experience (p = 0.0001). Poor preoperative condition of the patient increased the mortality rate 87 percent in patients preoperatively acidotic or in shock [preoperative class V]and 22 percent in patients with moderate or severe symptoms but without recent hemodynamic deterioration (preoperative class II or III). The presence of major associated cardiac lesions increased hospital mortality (p < 0.0001). The hospital mortality rate was highest (59 per cent) in infants less than age 1 month, possibly in part because of their sensitivity to the damaging effects of cardiopulmonary bypass. This hypothesis is supported by the association of a long period of cardiopulmonary bypass with increased hospital mortality (p = 0.05) and of total circulatory arrest during profound hypothermia with decreased mortality (p = 0.05). Most deaths (72 percent) occurred in association with acute postoperative cardiac failure. The length of cardiac ischemia (aortic cross-clamping time) was directly related to the probability of cardiac death, unless cold cardioplegia was used. Thirteen percent of the hospital deaths were associated with acute postoperative respiratory failure. Current mortality rates in typical cases without acute hemodynamic deterioration is estimated from these data to be 7 percent (70 percent confidence limits 4 to 12 percent), as a result of the scientific advances made over this period of time. Research into mechanisms of the damaging effects of cardiopulmonary bypass should further improve results in these very young patients.     

Fixation of the annulus of the mitral valve with a rigid ring Hemodynamic studies

Currently available prostheses used for replacement of the mitral valve feature a rigid ring for fixation to the annulus of the mitral valve. The effect on the hemodynamics of the left heart of fixation of the annulus of the mitral valve bysuturing a ring from a 1M or a 2M Starr-Edwards valve under cardiopulmonary bypass, leaving the valve leaflets and chordae tendineae intact, was studied in 6 dogs.

Intracardiac and intravascular pressures, cardiac output, and the size of the left ventricle were measured in these animals and a control group of 5 normal dogs in the “resting state” and during induced changes in peripheral vascular resistance (intra-aortic administration of angiotensin II and acetylcholine). Small diastolic pressure differences were detected between the left atrium and the left ventricle in the dogs operated on during the control resting state. These atrial-to-ventricular pressure gradients were greatly increased with the high flow and tachycardia associated with vasodilatation. This increased resistance to flow across the mitral valve constituted the major hemodynamic difference between the two animal groups under the conditions of the study.     

Donor insemination: Dutch parents' opinions about confidentiality and donor anonymity and the emotional adjustment of their children

Results from a comparative study investigating 38 donor insemination (DI) Dutch families with 4-8 year old children are presented. The aims of this study were to investigate parents' opinions on the issues of confidentiality and donor anonymity, to assess the emotional development of the children, and to examine in DI families the association between secrecy with regard to the use of a donor and the emotional adjustment of the children. The DI families were compared to families with a child conceived by in-vitro fertilization (IVF) and to families with a naturally conceived child. Secrecy appeared to be associated with DI and not with IVF: 74% of the DI parents intended not to inform the child about the way in which she/he was conceived, whereas none of the IVF parents intended to keep the secret. Only one set of DI parents and two sets of IVF parents had actually told the child. As to donor anonymity, a spread of opinions appeared among DI parents; 57% preferred an anonymous donor, 31% would have liked non- identifying information about the donor, 9% preferred the donor's identity to be registered and 3% remained unsure. Parents' major concern was to know more about the medical/genetic background of the donor. Mothers and fathers in the DI families differed in their opinions concerning the issues of confidentiality and donor anonymity: fathers, more often than mothers, were secretive with regard to the use of a donor and husbands, more often than their wives, were in favour of donor anonymity. With regard to the emotional development of the children, more emotional/behavioural problems were revealed among DI children than among children who were naturally conceived. No association was found between secrecy and the emotional/behavioural adjustment of the children.      

Continuous murmurs in tetralogy of fallot and pulmonary atresia with ventricular septal defect

The associated lesions found in 22 cases of tetralogy of Fallot or pulmonary atresia with ventricular septal defect in which a continuous murmur was present were (1) some form of aortopulmonary connection and (2) stenosis of a pulmonary artery. Corrective surgical treatment is possible in some of these patients, provided pulmonary arteries are present and proper technics are used.