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.

Beta-cell function of the pancreas after necrotizing pancreatitis

AIM

To investigate the late sequellae of necrotizing pancreatitis on the endocrine function of the pancreas.

PATIENTS AND METHODS

Twenty patients, 15 men (mean +/- SEM age 52.2+/-2.6 years and BMI 26.8+/-0.8 kg/m2) and 5 women (age 51.0+/-7.6 years and BMI 26.7+/-0.8 kg/m2) were submitted to a glucagon stimulation test 63 (range 8-136) months after an attack of pancreatitis. All nondiabetic patients (n = 15) were also submitted to an oral glucose tolerance test. For comparison, 16 healthy volunteers, 8 men (age 56.0+/-0.9 years and BMI 26.3+/-0.4 kg/m2) and 8 women (age 50.5+/-1.0 years and BMI 28.2+/-0.6 kg/m2), were also studied.

RESULTS

Five patients (25%) had diabetes mellitus and needed insulin treatment, 6 patients (30%) had an impaired glucose tolerance (IGT). Nondiabetic patients (IGT included) had a significantly higher basal insulin level (15.8+/-1.9 vs. 10.9 +/-2.2 mU/l, p < 0.05) and a lower glucose/insulin ratio (p < 0.05) compared with controls. The serum concentrations of insulin and C peptide, after stimulation with glucagon, calculated as peak value, maximal increment and as area under the curve were not significantly different in the nondiabetic patients compared to controls. The subgroup of IGT patients had a significantly higher basal C peptide (p < 0.05) and a reduced maximal increment (p < 0.05).

CONCLUSIONS

After nonresectional therapy for necrotizing pancreatitis, there is a high prevalence of disturbances in glucose metabolism. Patients with IGT have signs of both loss of beta-cell function and insulin resistance.

Hyperhomocysteinemia as a cause of superior vena cava syndrome

A case is presented in which superior vena cava (SVC) syndrome was caused by a stenosis of the SVC due to thrombosis. Hyperhomocysteinemia was diagnosed as a possible underlying mechanism. The role of hyperhomocysteinemia as a risk factor for the development of recurrent venous thrombosis, its diagnosis, and treatment are discussed.

Bilateral thoracoscopic splanchnicectomy in patients with chronic pancreatitis

BACKGROUND

Intractable pain, the most prominent feature of chronic pancreatitis, causes the patient great disability, and its treatment poses a difficult problem for gastroenterologist and surgeon alike. The main goal of treatment is to provide sufficient and lasting pain relief without the use of opiates. Conservative management, including stopping alcohol consumption, dietary measures, pancreatic enzyme suppletion and analgesics, is discussed. When these measures fail, surgery is often unavoidable. Indications, effect on pain relief, morbidity and mortality of drainage and resection procedures are described. Bilateral thoracoscopic splanchnicectomy, a newly developed operation to alleviate pain irrespective of the type of anatomic abnormality, is outlined in more detail. Early encouraging results of pain relief in patients with chronic pancreatitis after thoracoscopic splanchnicectomy are presented.

Heterotopic ossification induced by hypoxia in a retrosternal gastric tube following transhiatal oesophagectomy

A 71 year old man underwent retrosternal gastric tube reconstruction following transhiatal oesophagectomy for squamous cell carcinoma. On the second post-operative day, the patient developed a cardiac arythmia with secondary hypotension followed by hypoxaemia necessitating artificial ventilation. Two weeks after surgery, endoscopy revealed massive necrosis of the proximal segment of the gastric tube extending from the anastomosis in the neck to the watershed area. Three weeks later, the patient died and a necropsy was performed. Macroscopic evaluation of the gastric tube revealed a sharply demarcated and fully ossificated proximal segment. Heterotopic ossification was present on histological examination. This condition has only been described in conjunction with primary or metastatic gastric adenocarcinoma. The location of the ossification and the presence of temporary systemic hypoxia suggest that the latter was the main factor responsible for the ossificative response.