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.

Long-term clinical effectiveness of supervised exercise therapy versus endovascular revascularization for intermittent claudication from a randomized clinical trial

BACKGROUND

Long-term comparisons of supervised exercise therapy (SET) and endovascular revascularization (ER) for patients with intermittent claudication are scarce. The long-term clinical effectiveness of SET and ER was assessed in patients from a randomized trial.

METHODS

Consenting patients with intermittent claudication were assigned randomly to either SET or ER. Outcome measures on functional performance (pain-free and maximum walking distance, ankle : brachial pressure index), quality of life (QoL) and number of secondary interventions were measured at baseline and after approximately 7 years of follow-up. Repeated-measurement and Kaplan-Meier methods were used to analyse the data on an intention-to treat-basis.

RESULTS

A total of 151 patients were randomized initially to either SET or ER. After 7 years, functional performance (P < 0.001) and QoL (P ≤ 0.005) had improved after both SET and ER. Long-term comparison showed no differences between the two treatments, except in the secondary intervention rate, which was significantly higher after SET (P = 0.001). Nevertheless, the total number of endovascular and surgical interventions (primary and secondary) remained higher after ER (P < 0.001).

CONCLUSION

In the longer term, SET-first or ER-first treatment strategies were equally effective in improving functional performance and QoL in patients with intermittent claudication. The substantially higher number of invasive interventions in the ER-first group supports a SET-first treatment strategy for intermittent claudication.

REGISTRATION NUMBER

NTR199 (http://www.trialregister.nl).

[Guideline 'Chronic Achilles tendinopathy, in particular tendinosis, in sportsmen/sportswomen']

--Chronic Achilles tendinopathy in sports often leads to various therapeutic strategies, medical shopping and frequently to inability to perform at the desired level. --Although it is clear that this chronic tendinopathy is not an inflammatory disease of the tendon, the cause of the degeneration of the tendon fibres is not understood. --The main therapeutic measure--based on scientific evidence--is eccentric calf-muscle training for at least 3 months. --Recent therapies such as sclerotherapy ofneovascularizations in and around the Achilles tendon appear to be promising, but more studies are required. --About 20% of the patients tend to be refractive to conservative measures. --In selected cases surgery can be undertaken, with percutaneous longitudinal tenotomy proving effective in 75-80% of the cases.

Totally extraperitoneal repair for bilateral inguinal hernia: does mesh configuration matter?

BACKGROUND

The endoscopic preperitoneal approach has numerous advantages for the reconstruction of bilateral inguinal hernias. Repair may be achieved using either one large or two small meshes. The aim of this study was to investigate whether one of the techniques was superior in terms of recurrence and complication rate.

METHODS

Data obtained from 113 patients who underwent surgery between January 1998 and December 2001 was reviewed. For the sake of this study, 86% of all patients were examined for hernia recurrence at an additional outpatient visit.

RESULTS

The findings showed recurrence rates, of 3.5% for single mesh and 3.7% for double mesh. This difference was not significant. Complication rates did not differ significantly between the groups.

CONCLUSIONS

Endoscopic preperitoneal bilateral hernia repair is a safe and reliable technique in the hands of experienced surgeons. The rate of hernia recurrence and complications is low and independent of the mesh configuration (single or double). Mesh configuration based on personal preference is permissible.

The place of the posterior surgical approach for lesions of the rectum

BACKGROUND

Although there are many advantages of a posterior approach to rectal disease, these procedures are not widely accepted because many surgeons fear the postoperative complications.

METHODS

The medical records were reviewed of 57 patients who underwent a posterior approach to the rectum between January 1980 and December 2002.

RESULTS

Twenty-eight men and 29 women with a mean age of 70.5 (range 47-83) years underwent either a posterior transsacral (n = 52) or a transsphincteric (n = 5) procedure. Indications for surgery were benign lesions (n = 33), e.g. villous adenoma, rectal prolapse and endometriosis as well as invasive adenocarcinoma (n = 24). All patients with an invasive adenocarcinoma were classified as ASA grade III or IV. Postoperative morbidity occurred in 12 patients (21%), consisting of temporary incontinence, anastomotic leakage, wound infection, and hemorrhage. There was no mortality. During a mean follow-up of 29 (range 2-86) months, 3 patients with a villous adenoma and 2 patients who were treated for a malignant lesion had a locally recurrent lesion.

CONCLUSION

We believe that a posterior approach to the rectum should be considered for various benign and selected malignant diseases, especially in case of elderly patients or patients with a compromised general condition, and has to be a part of the surgeon's armamentarium.

Long-term results after modified Gallie technique for incisional hernia repair: results in 19 patients

BACKGROUND

A modified forgotten technique for repairing large incisional hernias is described together with its long-term results in 19 patients. A synthetic mesh with 1-cm wide spokes radiating from the mesh is placed preperitioneally, overlapping the fascial defect. The spokes are pulled through rectus sheaths and muscle and sutured ventrally, thereby creating a solid reconstruction withstanding shrinking of the mesh.

METHOD

Nineteen patients were operated on (13 primary incisional hernia, minimal fascial defect 10 cm). Notes on patients were reviewed, and the patients were contacted for follow-up examination.

RESULTS

No major complications occurred. After a median of 49 months, 17 patients were reviewed at the outpatient clinic. Two possible recurrences were detected, of which one was operated on. This proved to be bulging of the mesh, resulting in a recurrence of 1 out of 17 (6%).

CONCLUSION

From these results, it is concluded that Gallie's technique using synthetic mesh is a safe and effective repair for incisional hernia and deserves more attention, especially for large fascial defects.

[Diagnostic image (172). A man with blisters after the use of a cold pack. Cryotrauma caused by frozen cold pack]

A 19-year-old soccer player developed cryotrauma after the prolonged application of a cold pack to a sprained ankle.

Treatment of unstable trochanteric fractures

The proximal femoral nail (PFN) is a recently introduced intramedullary system, designed to improve treatment of unstable trochanteric fractures of the hip. In a multicentre prospective clinical study, the intra-operative use, complications and outcome of treatment using the PFN (n = 211) were compared with those using the gamma nail (GN) (n = 213).

The intra-operative blood loss was lower with the PFN (220 ml v 287 ml, p = 0.001). Post-operatively, more lateral protrusion of the hip screws of the PFN (7.6%) was documented, compared with the gamma nail (1.6%, p = 0.02). Most local complications were related to suboptimal reduction of the fracture and/or positioning of the implant. Functional outcome and consolidation were equal for both implants.

Generally, the results of treatment of unstable trochanteric fractures were comparable for the PFN and GN. The pitfalls and complications were similar, and mainly surgeon- or fracture-related, rather than implant-related.

Treatment of unstable trochanteric fractures. Randomised comparison of the gamma nail and the proximal femoral nail

The proximal femoral nail (PFN) is a recently introduced intramedullary system, designed to improve treatment of unstable trochanteric fractures of the hip. In a multicentre prospective clinical study, the intra-operative use, complications and outcome of treatment using the PFN (n = 211) were compared with those using the gamma nail (GN) (n = 213). The intra-operative blood loss was lower with the PFN (220 ml v 287 ml, p = 0.001). Post-operatively, more lateral protrusion of the hip screws of the PFN (7.6%) was documented, compared with the gamma nail (1.6%, p = 0.02). Most local complications were related to suboptimal reduction of the fracture and/or positioning of the implant. Functional outcome and consolidation were equal for both implants. Generally, the results of treatment of unstable trochanteric fractures were comparable for the PFN and GN. The pitfalls and complications were similar, and mainly surgeon- or fracture-related, rather than implant-related.

[The necrology meeting as an instrument for quality of care improvement; experiences at the Ikazia Hospital, 1990-2000]

The death of a patient highlights the demand for quality of care. Publication of hospital mortality figures risks incorrect interpretation and does not lead to an improvement in care. However, an above-average hospital mortality rate can be a sign of poor quality in a particular aspect of care. In the necrology meeting, the evaluation of this quality must take place with critical self-reflection, to detect opportunities by which to improve the quality of care. Quantitative data to support the necrology meeting are necessary to improve the quality. This requires systematic registration and a valid code system. In the Department of Surgery at the Ikazia Hospital Rotterdam, the Netherlands, an ABC coding system is used which indicates whether the patient died of the disease or complications, whether the death was influenced by identifiable shortcomings in the diagnostic work-up, surgical treatment or non-surgical treatment, or whether no shortcoming could be identified, and whether autopsy was carried out or refused. A more detailed registration model is developed which may be more useful in future necrology meetings and in the evaluation of these meetings.

The vascular laboratory in practice: a national survey in the Netherlands

OBJECTIVES

to overview Dutch vascular laboratory practice and specifically the variation in duplex criteria.

METHODS

a questionnaire was sent to all vascular laboratories in The Netherlands (n=140).

RESULTS

the response rate of the inquiry was 64% (n=89). There is no consensus on interpretation of outcome. In 22% of the clinics (n=20) a diagnostic angiography will be omitted when a percutaneous angioplasty is advised on account of duplex ultrasound. Only 5% (n=4) relies upon duplex ultrasound for operation without diagnostic angiography. In 44% (n=39) a PSV (peak systolic velocity) of 125 cm/s is used to identify a>70% or internal carotid artery stenosis. In 44% (n=39) a PSV of 210 cm/s and 10% (n=9) a PSV > or =150 cm/s is used. For grading a relevant stenosis in the femoro-politeal arteries a PSV ratio > or =2.5 is chosen in 75% (n=67). Criteria used for graft surveillance shows also a wide variation.

CONCLUSIONS

a commission for the accreditation of vascular laboratories should be established with the goal of creating standards and performing quality control.

Technical considerations and pitfalls in laparoscopic live donornephrectomy

BACKGROUND

Recent developments in laparoscopic solid organ surgery suggest a possible reduction in postoperative discomfort and disability for kidney donors. Technical aspects and the influence of surgical experience in laparoscopic donor nephrectomy were evaluated.

METHODS

The clinical outcome of 57 laparoscopic donor nephrectomies (LapNx) was compared with that for a historic control group of 27 open donor nephrectomies (OpenNx).

RESULTS

Three conversions to open nephrectomy (5.2%) were necessary. Postoperative complications were minor and comparable in both groups. Patients who underwent laparoscopic surgery demonstrated significantly less postoperative pain and a shorter hospital stay, but operative time and warm ischemia time were significantly longer. Graft survival after LapNx was 100% during a median follow-up period of 13 months. Operative time for LapNx decreased considerably with experience gained and seemed to be less for right nephrectomy. Stenotic ureter-bladder anastomoses occurred after LapNx in four patients during the first half year (7.0%), but this problem seemed to be resolved after modification of the technique.

CONCLUSION

LapNx is associated with less postoperative discomfort and improved convalescence.

Splenic abscess after lithotripsy of pancreatic duct stones

We describe a case of splenic abscess following lithotripsy of pancreatic stones, for which emergency splenectomy eventually had to be performed. It is important to be aware of this complication, because splenic abscess is still a life-threatening entity.

Comparison of one-lung ventilation and high-frequency ventilation in thoracoscopic surgery

OBJECTIVE

To report our experience of the use of high frequency ventilation (HFV) in thoracoscopic surgery.

DESIGN

Retrospective study.

SETTING

University Hospital Rotterdam, The Netherlands.

SUBJECTS

31 patients (18 men and 13 women, mean age 42 years, range 26-67 years) who underwent 46 thoracoscopic procedures between January 1992 and December 1997.

INTERVENTIONS

Until October 1994 patients had conventional mechanical ventilation with a double-lumen tube. Since then HFV has been used.

MAIN OUTCOME MEASURES

Duration of induction, oxygen saturation, and end-tidal carbon dioxide tension.

RESULTS

25 procedures were done with a double-lumen endotracheal tube for one-lung ventilation and in 21 HFV was used. Induction of anaesthesia took significantly less time in the HFV group (median 14 minutes) compared with one-lung ventilation group (median 31 minutes) (p < 0.05). There were no significant differences between the groups in either SaO2 or end-tidal CO2.

CONCLUSION

HFV is both safe and simple for use in thoracoscopic surgery.

[Laparoscopic splenectomy for hematological diseases; results in 28 patients]

OBJECTIVE

To evaluate the first results of laparoscopic splenectomy for haematological diseases and the learning curve.

DESIGN

Retrospective.

PATIENTS AND METHODS

Data of all patients who underwent a laparoscopic splenectomy in October 1994-July 1998 in the University Hospital Rotterdam, Department of surgery, the Netherlands, were collected from electronic databases. Data on postoperative complications were collected from medical records. Patients with splenomegaly (> 15 cm) were not eligible for the procedure.

RESULTS

28 patients were eligible for a laparoscopic splenectomy. The male:female ratio was 1:4. The mean age was 35 years. The indications for surgery were idiopathic thrombocytopenic purpura (ITP; n = 24), Gilbert syndrome (n = 1), spherocytosis (n = 1), thalassaemia (n = 1) and haemolytic anaemia with ITP (n = 1). Conversion to an open procedure was necessary in 5 of 28 laparoscopic splenectomies (18%). The median operating time was 172 minutes. Complications occurred in four patients: pneumonia (n = 2), bleeding (n = 1) and urosepsis (n = 1). The median hospital stay was 5 days (range: 1-18). The first 14 laparoscopic splenectomies differed from the following 14 by a higher conversion rate (p = 0.01), a longer operation time (p = 0.002) and a longer hospital stay (p = 0.004). In 23 out of 25 patients with ITP the thrombocyte count became normal.

CONCLUSION

Laparoscopic splenectomy is associated with a learning curve, with a high incidence of conversion in the early procedures. It appears to be a safe and effective operation.

Infections and bacteriological data after laparoscopic and open gallbladder surgery

In two hospitals 637 patients undergoing cholecystectomy between June 1989 and June 1993 were entered into a prospective audit. The aim of this study was to determine the incidence of postoperative infections, especially wound infections, after open and laparoscopic biliary surgery and to assess the bacteriological data on these patients. The incidence of minor wound infection was 10.4% (66/637), of major wound infection 3.6% (23/637) and the overall incidence was 14% (89/637). The incidence of wound infection after laparoscopic cholecystectomy was 5.3% (10/189) and all were minor. Significant specific risk factors for developing a wound infection after laparoscopic cholecystectomy were emergency of the operation (P = 0.046) and acute cholecystitis (P = 0.014). Overall, bile cultures were positive in 22%. There were 85 patients (13.3%) with positive bile from the gallbladder. From the laparoscopically operated patients 2.8% had a positive bile culture. The predominant micro-organisms from gallbladder bile were Escherichia coli (56 isolates), Klebsiella spp. (20 isolates) and Streptococcus spp. (16 isolates). There was no relationship between positive gallbladder cultures and wound infection. The consequences of wound infections can be serious and this study showed a morbidity rate comparable with the literature. The incisions used in laparoscopic gallbladder surgery are less susceptible to major problems. This combined with the significantly lower incidence of wound infections after laparoscopic cholecystectomy suggests that routine antibiotic prophylaxis as recommended for biliary surgery in general is now questionable.

Direct and indirect methods for the quantification of leg volume: comparison between water displacement volumetry, the disk model method and the frustum sign model method, using the correlation coefficient and the limits of agreement

Volume changes can be measured either directly by water-displacement volumetry or by various indirect methods in which calculation of the volume is based on circumference measurements. The aim of the present study was to determine the most appropriate indirect method for lower leg volume calculation using water displacement volumetry as a 'golden standard'. For 20 male volunteers, age range: 20-35 years, the volume of both lower legs was determined directly by water-displacement volumetry, and indirectly by the frustum sign model method and the disc model method. Calculation of the correlation coefficient and the limits of agreement showed that water-displacement volumetry and the disc model method are interchangeable (r = +0.99, mean +/- 2s = -45 +/- 78 ml), whereas this does not hold for the frustum sign model (r = +0.93, mean +/- 2s = 521 +/- 238 ml). In the clinical situation volume measurement can be valuable for monitoring of the severity of oedema or haematoma occurrence after surgery or severe trauma. This non-invasive diagnostic aid may be a valuable adjuvant means of diagnosis for several volume dependent disorders of the extremities.

The late complications of aorto-ilio-femoral Dacron prostheses: dilatation and anastomotic aneurysm formation

Dilated prosthetic grafts and anastomotic aneurysms are recognised as a long-term complication of aorto-ilio-femoral reconstruction. In the literature an incidence of 1-24% for anastomotic aneurysms and a mean dilatation of 85.7% for Dacron aortic prostheses is reported. In our own clinic the frequency of these complications was not known, and we started a follow-up study in order to establish: the mean dilatation of the prosthetic grafts, the actual incidence of anastomotic aneurysms and the relationship between these two. All patients (n = 61) who underwent aorto-ilio-femoral reconstruction between 1980 and 1985 were retrospectively studied. During the mean 8 years follow-up period 16 patients died (26%). Complete data were available from 36 patients, who underwent physical examination and ultrasonography. In the whole series the degree of dilatation varied from 0 to 44% with an average of 5.9% at the aortic level and 8.9% at the distal level. The diameters of 25 grafts remained unchanged, and the maximum dilatation observed was 44%. The incidence of anastomotic aneurysms in these patients was 13.8%. The anastomotic aneurysms were located at the following anatomical sites: aortic anastomoses 5.9%, iliac anastomoses 0 and 30.4% for the femoral anastomoses. There was no relationship between the dilated grafts and anastomotic aneurysms. In our clinic the degree of dilatation and the incidence of anastomotic aneurysms seems to be low, especially if we compare these results with the results reported by other investigators. None of the patients who underwent aorto-ilio-femoral reconstruction between 1980 and 1985 died or had to undergo emergency surgery because of graft failure or a ruptured anastomotic aneurysm.