{"title":"Varicose veins","authors":"Manj Gohel","doi":"10.1016/j.mpsur.2025.03.010","DOIUrl":"10.1016/j.mpsur.2025.03.010","url":null,"abstract":"<div><div>Varicose veins are dilated, tortuous bulging veins in the legs caused by superficial venous reflux, most commonly in the great and short saphenous veins. This is part of a spectrum of chronic venous disease which is a significant cause of patient distress and health service burden. The assessment of patients with venous disease involves a detailed history and careful examination of the legs for the distribution of veins and skin changes. The gold-standard investigation is duplex ultrasound scanning to identify reflux and obstruction in superficial and deep veins. Superficial venous reflux is the most common abnormality seen and there have been significant advances in recent years away from traditional surgical stripping operations, to minimally invasive endovenous ablation modalities. Modern varicose vein procedures are performed under local anaesthesia with small incisions, low risks of complications and a rapid return to normal activities. Careful patient consent is imperative as is a shared decision-making process with the patient to identify their priorities and adopt the optimal treatment strategy to achieve the best outcomes.</div></div>","PeriodicalId":74889,"journal":{"name":"Surgery (Oxford, Oxfordshire)","volume":"43 5","pages":"Pages 277-285"},"PeriodicalIF":0.0,"publicationDate":"2025-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143931409","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Test yourself: MCQ and single best answer","authors":"Adrian Ben Cresswell","doi":"10.1016/j.mpsur.2025.04.001","DOIUrl":"10.1016/j.mpsur.2025.04.001","url":null,"abstract":"","PeriodicalId":74889,"journal":{"name":"Surgery (Oxford, Oxfordshire)","volume":"43 5","pages":"Pages 347-348"},"PeriodicalIF":0.0,"publicationDate":"2025-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143931427","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Venous thrombosis","authors":"Stephen Black, Ehsanul Choudhury","doi":"10.1016/j.mpsur.2025.03.003","DOIUrl":"10.1016/j.mpsur.2025.03.003","url":null,"abstract":"<div><div>Venous thrombosis occurs commonly in the deep veins of the lower limb (DVT) and can result in pulmonary embolus (PE). Venous thromboembolism is the most common cause of death in hospitalized patients. It also represents a significant cost burden. The most common chronic complication of DVT is the post thrombotic syndrome (PTS). Manifestations of PTS can range from mild to severely debilitating. Patients report pain, swelling, and fatigue that is aggravated by walking or standing and improves with rest and elevation. It is a clinical diagnosis and while there is no gold standard diagnostic test, it is generally diagnosed using validated scoring systems; however, these all have shortcomings. PTS develops due to venous hypertension. The mechanism behind this is persistent obstruction and valvular reflux. Risk factors for PTS include a proximal DVT, previous ipsilateral DVT, pre-existing venous insufficiency, elevated Body Mass Index (BMI), increasing age and subtherapeutic anticoagulation. The principles of preventing PTS are DVT prophylaxis, thrombolysis of acute thrombus, and therapeutic anticoagulation. Early thrombus removal is indicated in emergent scenarios or where symptoms are not responding to treatment and may have benefit in the prevention of the development of moderate/severe PTS. Open deep venous surgery has largely been superseded by endovascular approaches. Adjunctive deep venous stenting is an exciting and developing area for the management of these patients.</div></div>","PeriodicalId":74889,"journal":{"name":"Surgery (Oxford, Oxfordshire)","volume":"43 5","pages":"Pages 267-276"},"PeriodicalIF":0.0,"publicationDate":"2025-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143931428","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Foot complications in people with diabetes","authors":"Ian Diebels, Robert J. Hinchliffe","doi":"10.1016/j.mpsur.2025.03.007","DOIUrl":"10.1016/j.mpsur.2025.03.007","url":null,"abstract":"<div><div>Foot complications are the most common cause of hospital admission of people with diabetes and a frequent cause of amputation. Neuropathy and peripheral arterial disease make the foot particularly vulnerable to ulceration, but infection is often the pathology precipitating presentation. Recognition of the patient at risk of ulceration may allow interventions to prevent the development of foot complications. When complications do occur, urgent treatment is required to prevent limb loss; <em>the infected foot in a patient with diabetes is a surgical emergency</em>. In addition to antibiotics, debridement and surgical drainage of infection should be considered within the first 24 hours after presentation. Once the foot is made safe, revascularization should be undertaken in those with significant arterial disease. Adoption of a multidisciplinary team approach to managing diabetic foot complications has resulted in reduction in major amputations in some European countries.</div></div>","PeriodicalId":74889,"journal":{"name":"Surgery (Oxford, Oxfordshire)","volume":"43 5","pages":"Pages 306-312"},"PeriodicalIF":0.0,"publicationDate":"2025-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143931422","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Swelling of the legs and feet","authors":"Divarshan Govender, Adam Q Howard","doi":"10.1016/j.mpsur.2025.03.008","DOIUrl":"10.1016/j.mpsur.2025.03.008","url":null,"abstract":"<div><div>There are many different causes of leg and foot swelling, some are benign and transient, others can be debilitating and progressive. Correct diagnosis and early treatment are crucial as conservative measures are most effective before the condition is allowed to progress. Current waiting times in the UK National Health Service (NHS) for General Practitioners and Specialists are leading to delays in care for people with chronic leg swelling. Delayed or inadequate treatment for these patients can lead to irreversible tissue damage, episodes of cellulitis and ulceration. There is a significant impact on quality of life associated with living with the pain, anxiety, and reduced mobility resulting in social isolation. The causes of acute and chronic leg and foot swelling are outlined. Diagnosis and treatment of the common causes of leg and foot swelling in the Western adult population are discussed. The mainstay of treatment for most of these conditions relies on physical therapy and graduated elastic compression garments or inelastic Velcro compression wraps as many do not have a cure.</div></div>","PeriodicalId":74889,"journal":{"name":"Surgery (Oxford, Oxfordshire)","volume":"43 5","pages":"Pages 286-298"},"PeriodicalIF":0.0,"publicationDate":"2025-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143931410","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Acute limb ischaemia","authors":"Paris L Cai, James M Forsyth","doi":"10.1016/j.mpsur.2025.03.005","DOIUrl":"10.1016/j.mpsur.2025.03.005","url":null,"abstract":"<div><div>Acute limb and/or digital ischaemia (ALI, acute limb ischaemia) is a global healthcare problem that is associated with high morbidity and mortality. It is caused by occlusion of a native artery, vascular bypass graft, or angioplasty site/stent due to embolization or thrombosis, or occlusion of digital micro-vessels due to vasospasm or thrombosis. The culprit risk factor for embolic ALI is most often cardiogenic associated with atrial fibrillation. Other risk factors for ALI include smoking, hypertension, raised cholesterol and diabetes. ALI is diagnosed clinically by identifying the classical ‘6 Ps’: <em>Pain, Pallor, Pulselessness, Perishing cold, Paraesthesia, and Powerlessness</em>. Rutherford's classification is used to grade the severity of ALI, and helps the clinician ascertain whether the limb is viable (I), marginally threatened (IIa), immediately threatened (IIb), or non-salvageable (III). Immediate management of ALI involves analgesia, supplemental oxygen, intravenous fluids, intravenous heparin, and arranging for an urgent CT angiogram. Definitive revascularization options include open surgery, endovascular procedures, or a combined ‘hybrid’ surgical and radiological approach. If a limb, or digit, is non-salvageable primary amputation may be indicated. Dependent upon the severity of ischaemia and on patient fitness, the most appropriate management strategy may instead be conservative, including palliation. Whatever the management approach decided upon, the patient (and ideally their family and/or carers) should be appropriately counselled and given a realistic picture of their options, including doing nothing, with their associated risks and benefits.</div></div>","PeriodicalId":74889,"journal":{"name":"Surgery (Oxford, Oxfordshire)","volume":"43 5","pages":"Pages 319-328"},"PeriodicalIF":0.0,"publicationDate":"2025-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143931424","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Peripheral arterial disease","authors":"Than Dar, Patrick Coughlin","doi":"10.1016/j.mpsur.2025.03.006","DOIUrl":"10.1016/j.mpsur.2025.03.006","url":null,"abstract":"<div><div>This article provides an overview of peripheral arterial disease (PAD) of the lower limb including its epidemiology, risk factors, diagnosis, and current management approaches. PAD is most commonly the result of atherosclerosis. It can be thought of as a continuum of disease from asymptomatic through to chronic limb-threatening ischaemia (CLTI). Most patients are asymptomatic. Intermittent claudication is the most common symptom. Key risk factors for PAD are smoking, age, male sex, hypertension, chronic kidney disease (CKD), and diabetes mellitus. The diagnosis of PAD tends to be a marker of atherosclerosis in other arterial beds, putting these patients at high risk of adverse cardiovascular outcomes. Diagnosis of PAD is primarily achieved through history and examination with the aid of non-invasive bedside tests. Imaging is essential when planning revascularization to establish the anatomical patterns and severity of disease. Management of PAD is centred around (1) reduction of cardiovascular morbidity and mortality and (2) management of lower limb symptoms to improve quality of life and protect the limb. Treatment tends to be conservative in the early stages. Patients with CLTI require lower limb revascularization using an endovascular, open surgical, or hybrid approach. In some patients, primary amputation is the best option.</div></div>","PeriodicalId":74889,"journal":{"name":"Surgery (Oxford, Oxfordshire)","volume":"43 5","pages":"Pages 299-305"},"PeriodicalIF":0.0,"publicationDate":"2025-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143931421","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Lower limb amputation","authors":"Rhiannon Nielsen, David C Bosanquet","doi":"10.1016/j.mpsur.2025.03.004","DOIUrl":"10.1016/j.mpsur.2025.03.004","url":null,"abstract":"<div><div>Peripheral arterial disease (PAD) and diabetes are the leading cause of lower limb amputation worldwide (other significant causes are neuropathy and trauma). With our ageing population, many patients with these conditions are frail, comorbid individuals with limited or no arterial reconstructive options. Therefore, a thorough grounding in the indications for lower limb amputation and all perioperative considerations that accompany it remain a high priority for surgeons. Minor lower limb amputations are characterized by removal of the toe(s), forefoot, midfoot or hindfoot. Major lower limb amputations (MLLAs) involve a significant part of the limb being removed, and include below-, through- and above-knee amputations. Hip disarticulations and hindquarter amputations are discussed here but infrequently used in practice. Shared decision making should be utilized to ensure a well-informed and prepared patient. A cohesive MDT approach is vital to provide ideal perioperative care and follow-up to patients undergoing amputation. Focus should be paid to optimization of comorbidities such as diabetes, respiratory compromise and coagulopathies, and to postoperative rehabilitation including prosthesis. The overall aim for amputation surgery is to remove non-viable/non-salvageable tissue whilst maintaining sufficient tissue for good wound healing and maximizing the potential for ambulation.</div></div>","PeriodicalId":74889,"journal":{"name":"Surgery (Oxford, Oxfordshire)","volume":"43 5","pages":"Pages 313-318"},"PeriodicalIF":0.0,"publicationDate":"2025-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143931423","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Thoracic outlet syndrome","authors":"Tim Beckitt","doi":"10.1016/j.mpsur.2025.03.002","DOIUrl":"10.1016/j.mpsur.2025.03.002","url":null,"abstract":"<div><div>Thoracic outlet syndrome (TOS) consists of a group of three syndromes resulting from compression of the subclavian artery (arterial – ATOS), brachial plexus (neurogenic – NTOS) or subclavian vein (venous – VTOS) as they pass through the thoracic outlet. The thoracic outlet is not one, but three distinct anatomical spaces and compression at differing sites results in differing combinations of symptoms. NTOS is the most common, usually caused by compression of the brachial plexus in the scalene triangle or pectoralis minor space. In making the diagnosis of NTOS, neurogenic compression in the cervical spine, carpal and cubital tunnels should be excluded. Management of NTOS is usually conservative, with physiotherapy and postural exercise, but pain or muscle wasting may be indications for surgery. VTOS is caused by compression of the subclavian vein at the costoclavicular junction. It may present as acute venous thrombosis (Paget–Schroetter syndrome) or positional swelling of the upper limb without thrombosis (McCleery's syndrome). In acute thrombosis, clot lysis, rib excision and venoplasty may be indicated. ATOS occurs due to compression of the subclavian artery, often in association with an anomalous structure, such as a cervical rib. Post-stenotic aneurysmal dilatation of the artery can result in thrombosis and distal embolization. Acute upper limb ischaemia necessitates urgent rib excision and arterial reconstruction.</div></div>","PeriodicalId":74889,"journal":{"name":"Surgery (Oxford, Oxfordshire)","volume":"43 5","pages":"Pages 329-335"},"PeriodicalIF":0.0,"publicationDate":"2025-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143931425","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Mesenteric ischaemia","authors":"YousifAbdallah Adam, Jonathan Nicholls","doi":"10.1016/j.mpsur.2025.03.009","DOIUrl":"10.1016/j.mpsur.2025.03.009","url":null,"abstract":"<div><div>Acute mesenteric ischaemia (AMI) is a life-threatening vascular condition from which outcomes are poor. It results from acute thrombosis or embolization of one or more mesenteric arteries. Chronic mesenteric ischaemia (CMI) is a clinical syndrome of abdominal pain after eating related to stenosis or occlusion of one or more mesenteric vessels associated with other cardiovascular disease. Mesenteric ischaemia can also result from hypoperfusion, non-occlusive mesenteric ischaemia (NOMI), or mesenteric venous thrombosis (MVT). This article looks at the epidemiology, diagnosis, and management of mesenteric ischaemia. It recognizes the need for resuscitation and time-critical resection of non-viable bowel and revascularization in the acute setting. Improving outcomes necessitates a multidisciplinary approach involving emergency medicine, diagnostic radiology, general surgery, vascular surgery, interventional radiology, anaesthetic, and critical care specialists.</div></div>","PeriodicalId":74889,"journal":{"name":"Surgery (Oxford, Oxfordshire)","volume":"43 5","pages":"Pages 336-346"},"PeriodicalIF":0.0,"publicationDate":"2025-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143931426","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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