Evaluation of outcomes and utility of abdominal aortic aneurysm surveillance in octogenarians and nonagenarians

INTRODUCTION

The aim of this study was to evaluate the utility of our regional abdominal aortic aneurysm (AAA) screening programme in octogenarians and nonagenarians. This was to help decide whether discontinuation might be appropriate in certain instances. Primary outcomes were the number of patients who reached threshold (5.5cm) and the number where intervention was offered. Secondary outcome was cost effectiveness.

METHODS

A retrospective review of a regional AAA surveillance database was carried out to evaluate outcomes. Data collected included patient age, sex, date of first and last scan, initial and latest size of aneurysm, outcome, time under surveillance and total number of scans. Patients were divided into three groups (80-84 years, 85-89 years and 90+ years).

RESULTS

The number of patients in this age group was 354. Only 2.0% (n=7) of patients underwent intervention. Threshold size was achieved in 8.3% (n=18), 14.8% (n=18) and 26.7% (n=4), in the age groups 80-84 years, 85-89 years and 90+ years, respectively. Of these patients, operative intervention was possible in 2.8% (n=6), 0.8% (n=1) and 0% (n=0), respectively.

CONCLUSION

A relatively small number of octogenarians and nonagenarians reach the threshold size during surveillance. An even smaller proportion require repair of their aneurysm. While there may be a role for AAA surveillance in octogenarians in highly selected groups, these data should inform the discussions made with individual patients. It should also inform future evaluation of such surveillance.

High jejunal perforation complicating tuberculous abdominal cocoon: a rare presentation in immune-competent male patient

BACKGROUND

Tuberculosis (TB) peritonitis is a rare presentation of TB that is typically insidious, presenting with systemic symptoms and nonspecific abdominal pain. In the majority of the cases, this leads to bowel obstruction and rarely causes abdominal cocoon. The disease process predominantly affects the small bowel with a tendency to involve the terminal ileum, leading to perforation on rare occasions.

METHODS

We are presenting a case report of multiple small-bowel perforations in immune-competent male patient complicating a TB cocoon and discuss clinical course and therapeutic options.

DISCUSSION

TB cocoon is a rare form of TB peritonitis presenting usually in the form of bowel obstruction. However, TB can cause multiple bowel perforations, particularly in children and immune-compromised patients. Such presentation carries a high rate of mortality. With the global increase in TB infections and the emergence of aggressive, multidrug-resistant strains, more severe manifestations are expected to increase. We presented a case of such severe acute manifestation on a background of insidious TB cocoon in a fit immune-competent male. Although primary repair of TB perforation is considered hazardous, it could not be avoided on this occasion. Nevertheless, proximal defunctioning jejunostomy and the early use of anti-TB drugs seemed to facilitate healing in such scenario.

CONCLUSIONS

TB should be considered in all cases of atypical bowel perforations. Proximal jejunostomy and early use of anti-TB drugs can facilitate primary repair in aggressive TB infection with multiple bowel perforations.

Interventions for preventing venous thromboembolism following abdominal aortic surgery

BACKGROUND

Deep vein thrombosis (DVT) is one of the most common, preventable complications of surgery. Although the relationship between surgery and DVT is well established in general surgical operations and most other subspecialties, the same cannot be said about arterial surgery. Deep vein thrombosis is believed to be less common in aortic surgery where its management is rather controversial with a reported incidence of DVT from 2% to 18%.Intra-operative heparin is believed to provide protection during the period when DVT is most likely to develop. However, the practice of using intra-operative heparin could increase the risk of haemorrhagic complications if further heparin is used during the recovery period. This can significantly limit the use of such prophylactic measures especially with the low perceived risk of venous thromboembolism (DVT or pulmonary embolism (PE)) following abdominal aortic surgery. However, vascular patients are usually older, with more co-morbidity and are subject to prolonged immobility, all of which increase the likelihood of developing venous thromboembolism.

OBJECTIVES

To determine the efficacy of anticoagulant prophylaxis (with or without mechanical devices) in patients undergoing surgery for abdominal aortic aneurysm.

SEARCH STRATEGY

The Cochrane Peripheral Vascular Diseases Group searched their trials register (last searched 8 August 2007) and the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, (last searched Issue 3, 2007). The authors searched for additional trials through reference lists of retrieved studies and conference proceedings.

SELECTION CRITERIA

Randomised controlled trials comparing the use of anticoagulants (with or without mechanical devices) with control or no intervention in preventing DVT or PE after abdominal aortic operations.

DATA COLLECTION AND ANALYSIS

Three authors independently selected potential trials and assessed trial quality.

MAIN RESULTS

Two studies (n=147) were included. Both studies had methodological limitations. There were no data to indicate that post operative anticoagulation, with or without the use of mechanical devices, can safely reduce the incidence of DVT after aortic surgery. Neither study reported a significant effect of anticoagulants on the incidence of PE or related mortality. One study was terminated before recruiting sufficient participants due to a higher incidence of bleeding with the use of anticoagulants. The incidence of minor bleeding events was also slightly higher with anticoagulants.

AUTHORS' CONCLUSIONS

There is not enough evidence to make a definitive conclusion about the use of anticoagulant drugs (with or without mechanical devices) for DVT prophylaxis in patients undergoing abdominal aortic surgery.