AbcApp: incidence of intra-abdominal ABsCesses following laparoscopic vs. open APPendectomy in complicated appendicitis

BACKGROUND

Patients with complicated appendicitis are more at risk for the occurrence of postoperative intra-abdominal abscesses than patients with uncomplicated appendicitis. Studies comparing laparoscopic and open appendectomy showed limitations and contradictory findings on the incidence of intra-abdominal abscesses after appendicitis, as most of these studies analysed both uncomplicated and complicated appendicitis as one group. The aim of the present study is to investigate the incidence of intra-abdominal abscesses after laparoscopic versus open appendectomy for complicated appendicitis.

METHODS

A retrospective cohort study was performed over the period January 2009 till May 2020. All patients who had an intra-operative diagnosis of complicated appendicitis (e.g. perforation, necrosis) were included. The outcome measure was the occurrence of intra-abdominal abscesses with a postoperative follow-up of 30 days. Multivariate logistic regression analysis was performed including adjustments for significant confounders.

RESULTS

A total of 900 patients had undergone appendectomy for complicated appendicitis. The majority was operated laparoscopically (78%, n = 705). The incidence of postoperative intra-abdominal abscess was 12.3% in both laparoscopic and open appendectomy groups. On univariable analysis, the postoperative rates of intra-abdominal abscesses between laparoscopic and open appendectomy were not significantly different (odds ratio 1.11, 95% CI [0.67-1.84], p = 0.681).

CONCLUSION

The present study provides evidence that, in current daily practice, intra-abdominal abscess formation remains a common postoperative complication for complicated appendicitis. Nonetheless, no significant difference was found with regard to intra-abdominal abscess formation when comparing laparoscopy with open surgery.

Editor's Choice - Nationwide Analysis of Patients Undergoing Iliac Artery Aneurysm Repair in the Netherlands

OBJECTIVE

The new 2019 guideline of the European Society for Vascular Surgery (ESVS) recommends consideration for elective iliac artery aneurysm (eIAA) repair when the iliac diameter exceeds 3.5 cm, as opposed to 3.0 cm previously. The current study assessed diameters at time of eIAA repair and ruptured IAA (rIAA) repair and compared clinical outcomes after open surgical repair (OSR) and endovascular aneurysm repair (EVAR).

METHODS

This retrospective observational study used the nationwide Dutch Surgical Aneurysm Audit (DSAA) registry that includes all patients who undergo aorto-iliac aneurysm repair in the Netherlands. All patients who underwent primary IAA repair between 1 January 2014 and 1 January 2018 were included. Diameters at time of eIAA and rIAA repair were compared in a descriptive fashion. The anatomical location of the IAA was not registered in the registry. Patient characteristics and outcomes of OSR and EVAR were compared with appropriate statistical tests.

RESULTS

The DSAA registry comprised 974 patients who underwent IAA repair. A total of 851 patients were included after exclusion of patients undergoing revision surgery and patients with missing essential variables. eIAA repair was carried out in 713 patients, rIAA repair in 102, and symptomatic IAA repair in 36. OSR was performed in 205, EVAR in 618, and hybrid repairs and conversions in 28. The median maximum IAA diameter at the time of eIAA and rIAA repair was 43 (IQR 38-50) mm and 68 (IQR 58-85) mm, respectively. Mortality was 1.3% (95% CI 0.7-2.4) after eIAA repair and 25.5% (95% CI 18.0-34.7) after rIAA repair. Mortality was not significantly different between the OSR and EVAR subgroups. Elective OSR was associated with significantly more complications than EVAR (intra-operative: 9.8% vs. 3.6%, post-operative: 34.0% vs. 13.8%, respectively).

CONCLUSION

In the Netherlands, most eIAA repairs are performed at diameters larger than recommended by the ESVS guideline. These findings appear to support the recent increase in the threshold diameter for eIAA repair.

A Rare Case of Thromboembolism in a 21-year Old Female with Elevated Factor VIII

In this article we present the history of a previously healthy female adolescent, who was seen at our hospital with abdominal pain. This was the result of a large floating thrombus in the aorta. Widespread embolism occurred, which lead to the loss of a limb and a left hemicolectomy. Although our patient is a smoker, used oral contraceptives and was found to have a heterozygote mutation at the factor V Leiden gene, the most important factor contributing to her thrombophilia is thought to be her significantly elevated factor VIII. We stress an aggressive diagnostic and therapeutic approach in young patients with unknown embolism in order to avoid the grave consequences of delay.

Asymptomatic Carotid Artery Stenosis: Past, Present and Future

BACKGROUND

The role of carotid endarterectomy (CEA) for asymptomatic carotid artery stenosis (aCAS) remains a matter of debate. It seems that not only the degree of stenosis, but also other factors have to be taken in account to improve patient selection and increase the benefit of CEA for aCAS.

METHODS AND RESULTS

The literature pertaining aCAS was reviewed in order to describe the natural history, risk of stroke and benefit of CEA for patients with aCAS in regard to several factors.

CONCLUSION

The benefit of CEA for aCAS is low. Current factors influencing the indication for CEA are severity of stenosis, age, contralateral disease, stenosis progression to >80%, gender, concomitant operations and life expectancy. To improve patient selection investigations will concentrate on plaque characteristics and instability and cerebral hemodynamics and metabolism.

The impact of training in unselected patients on mortality and morbidity in carotid endarterectomy in a vascular training center and the recommendations of the European Board of Surgery Qualification in Vascular Surgery

PURPOSE

To investigate the impact of training of vascular fellows on the results of carotid endarterectomy (CEA) in unselected patients and to evaluate the recommendations of the European Board of Surgery Qualification in Vascular Surgery (EBSQ-VASC) concerning CEA.

METHODS

Complication rates and selection criteria of all CEAs, performed between 1995 and 2000 (n = 200) were retrospectively analysed and correlated to operating surgeon; supervised, nonsupervised vascular trainees, and consultant vascular surgeons. The number of CEAs were compared with the required minimal procedures according to the EBSQ-VASC.

RESULTS

Selection criteria for CEA did not differ significantly between operating surgeon groups, except that combined procedures were more performed by nonsupervised trainees and asymptomatic stenosis by consultant surgeons. The overall persistent disabling stroke rate and stroke-related mortality was 3%, with 4.3% in the supervised group, 0% in the unsupervised, and 2.8% in the consultant surgeon group, respectively. The amount of CEAs corresponded to the demands of the EBSQ-VASC.

CONCLUSIONS

In our institution, no significant differences in neurological morbidity and mortality following CEA could be demonstrated in relation to surgeon training level. The number of CEAs performed by residents fulfill the criteria of the EBSQ-VASC. We conclude that CEA can be safely taught to vascular trainees in unselected patients in a vascular training centre.

Continuing expansion of internal iliac artery aneurysms after surgical exclusion of the inflow. A report of two cases

Two patients with continuing expansion of an internal iliac artery aneurysm following earlier repair of an aortoiliac aneurysm are described. At the primary operation, inflow to small internal iliac aneurysms had been interrupted by simple proximal ligation only. During follow-up, however, increasing diameter of the by CT-angiography completely thrombosed internal iliac aneurysms required re-operation. The observation of continuing growth of thrombosed internal iliac artery aneurysms following proximal ligation emphasises the danger of persistent collateral circulation and supports the concept of endotension in the absence of endoleak following endovascular AAA repair.

Is semi-closed endarterectomy of the superficial femoral artery combined with a short venous bypass in case of insufficient venous material an acceptable alternative for limb-threatening ischemia?

BACKGROUND

The aim of this study was to analyse the results of infragenual arterial revascularisation using semiclosed endarterectomy of the superficial femoral artery combined with a short venous bypass in patients with critical leg ischemia and insufficient venous material for a straightforward femorocrural reconstruction.

METHODS

From December 1990 through December 1998 thirty patients were studied (22 males and 8 females; mean age 65 years, range 31-92 years). The mean follow-up was 26 months (range 1-96 months). Cumulative primary patency and limb salvage rates were calculated according to life-table analysis.

RESULTS

The cumulative primary patency was 60.3% at 1 year and 48.4% at 3 years. The limb salvage rate was 68.6% at 1 and at 3 years.

CONCLUSIONS

In patients with limb-threatening ischemia and lack of venous material for a straightforward venous femorocrural bypass, semi-closed endarterectomy of the superficial femoral artery combined with a short popliteo-crural bypass provides a good alternative.

Percutaneous duplex-guided thrombin injection for treatment of iatrogenic femoral artery pseudoaneurysms

OBJECTIVES

to evaluate the feasibility of treatment of post-catheterisation pseudoaneurysms with duplex-guided thrombin injection.

TECHNIQUE

the technique of duplex-guided injection of thrombin in post-catheterisation pseudoaneurysms of the femoral artery is described and illustrated.

RESULTS

between December 1998 and October 1999, eight post-catheterisation pseudoaneurysms of the femoral artery were successfully thrombosed with thrombin injection. One patient developed a new pseudoaneurysm within 6 hours and this was also successfully treated with thrombin. Follow-up duplex-scanning at 3 months revealed no recurrences. No other adverse events occurred.

CONCLUSIONS

this initial experience suggests that duplex-guided thrombin injection in the treatment of post-catheterisation pseudo-aneurysms is feasible and safe.

[Radiation-induced arterial disease]

Arterial occlusive disease developed after radiation therapy in three patients: a woman aged 56 had a sensation of heaviness in her right arm and bluish-black discolorations of fingers 3 years after radiation therapy for breast carcinoma, and two men aged 46 and 45 years had intermittent claudication 23 and 14 years, respectively, after radiation therapy for testicle malignancy. After creation of a bypass, the symptoms subsided. Radiation-induced arterial disease is a rare complication after radiotherapy and usually presents after a latent period of several years. Arterial lesions induced by radiotherapy may be distinguished from atherosclerotic lesions by their atypical localization, limited to the irradiated sites, and occurrence at an earlier age. Symptoms may be masked by pain, limitation of motion, nerve root damage and lymphoedema and may therefore not always be recognized. Indications for treatment are identical to those for atherosclerotic occlusive disease, but due to increased risk of restenosis, rethrombosis and graft infection, percutaneous transluminal angioplasty (with or without stent), endarterectomy or venous bypass surgery should be preferred to prosthetic bypass material.

Rupture of renal artery aneurysm during pregnancy

A case of rupture of a renal artery aneurysm during pregnancy is described. Both patient and child survived despite a delayed diagnosis and treatment. Renal artery aneurysm is a rare disease but rupture is increased in pregnancy with a high mortality for mother and child.

Inflammation of the abdominal aortic aneurysm wall

Inflammation and fibrosis do not only appear in an "inflammatory" aneurysm, but also in "ordinary" abdominal aortic aneurysms. In this study inflammatory changes in 130 abdominal aortic aneurysms were studied and related to patients' clinical records. According to histopathological criteria five different degrees of inflammation (Histological Inflammation Scale of Aneurysms) were found and patients were classified according to these criteria: grade A or mixed acute/chronic inflammation (4.5%); grade 0 or no inflammation (16.2%); grade 1 or mild chronic (57.7%); grade 2 or moderate chronic (16.2%); and grade 3 or severe chronic inflammation (5.4%) corresponding to an "inflammatory" aneurysm. Patients with grade 3 or an "inflammatory" aneurysm were younger (p = 0.013), were all symptomatic (p = 0.02), showed no associated iliac or femoral aneurysms (p = 0.03), were only recognised peroperatively and had elevated erythrocyte sedimentation rates (p = 0.0002). No other differences could be demonstrated between sex, risk factors, cardiovascular diseases, previous abdominal operations, bacterial culture, aneurysm diameter, white blood count, cholesterol level in-hospital mortality when compared to the degree of inflammation.