Long-term outcome and cancer incidence after abdominal aortic aneurysm repair

Purpose

The influence of cancer development on long-term outcome after elective endovascular (EVAR) vs. open repair (OAR) of non-ruptured abdominal aortic aneurysms (AAA) was investigated.

Methods

Patient survival and cancer incidence were recorded for 18,802 patients registered with the AOK health insurance company in Germany who underwent EVAR (n = 14,218) and OAR (n = 4584) in the years 2010 to 2016 (men n = 16,086, women n = 2716). All patients were preoperatively and in their history cancer-free.

Results

30.1% of EVAR and 27.6% of OAR patients (p ≤ .001) developed cancer after a follow-up period of up to 9 years (Kaplan–Meier estimated). Patients with cancer had a significantly less favorable outcome compared to patients with no cancer (HR 1.68; 95% CI 1.59–1.78, p < .001). After 9 years, the estimated survival of patients with and without cancer was 27.0% and 55.4%, respectively (p < .001). Survival of men and women did not differ significantly (HR 0.94; 95% CI 0.88–1.00, p = .061). In the Cox regression analysis (adjusted outcomes by operative approach, gender, age, and comorbidities), the postoperative cancer incidence was not significantly different between EVAR and OAR (HR 1.09; 95% CI 1.00–1.18, p = .051). However, EVAR showed an increased risk of postoperative development of abdominal cancer (HR 1.20; 95% CI 1.07–1.35, p = .002). 48.0% of all EVAR patients and 53.4% of all OAR patients survived in the follow-up period of up to 9 years. This difference was not significant (HR 0.96; 95% CI 0.91–1.02, p = .219).

Conclusion

Cancer significantly worsened the long-term outcome after EVAR and OAR, without significant differences between the two repair methods in the overall cancer incidence. However, the higher abdominal cancer incidence with EVAR can affect quality of life including oncological therapy and therefore should be considered when determining the indication for surgery, and the patient should be informed about it.

[Publication performance of university orthopedic trauma surgery in Germany]

Hintergrund

Zu den Leistungskriterien einer Universitätsklinik gehören ihre Publikationsaktivitäten. Ziel der vorliegenden bibliometrischen Untersuchung war es, die Publikationsaktivitäten deutscher unfallchirurgischer Universitätskliniken in einem Benchmarking vergleichend darzustellen.

Material und Methodik

Die Publikationsleistung der Führungsmannschaften, bestehend aus Chef- und Oberärzten, Sektions- und Bereichsleitern von 39 deutschen unfallchirurgischen Universitätskliniken wurde über 10 Jahre (01.01.2010 bis 31.12.2019) erfasst. Berücksichtigt wurden alle Publikationen, die in PubMed gelistet waren und bei denen die entsprechenden Personen Erst- oder Letztautor waren. Zusätzlich wurde der Impact-Faktor (IF) bestimmt.

Ergebnisse

Insgesamt wurden 4438 Veröffentlichungen erfasst, publiziert von 381 Chirurgen. Der Anteil der publizierenden Mitarbeiter betrug 72,8 %. Publiziert wurde in 545 Journalen. Der durchschnittliche IF aller Publikationen war 1,81. Die Publikationsaktivitäten der Kliniken zeigten eine hohe Streubreite, dies galt sowohl für die Publikationsanzahl als auch für die generierten IF des einzelnen Mitarbeiters. Die Publikationsaktivität reichte von durchschnittlich 16,4 Publikationen pro Mitarbeiter in der bestplatzierten Klinik bis 1,5 Publikationen bei der letztplatzierten. Gleiches ergab die Summe der IF. In der nach diesem Maßstab bestplatzierten Klinik erzielte der einzelne Mitarbeiter durchschnittlich kumuliert 42,1 IF verglichen mit 1,7 IF bei der letztplatzierten.

Schlussfolgerung

Die Publikationsleistung deutscher unfallchirurgischer Universitätskliniken zeigt eine hohe Varianz, wie dies auch bei anderen Disziplinen gefunden wurde. Die Ursachen müssen offen bleiben, eine unterschiedliche Forschungsmotivation ist aber nicht auszuschließen.

[Case load and quality indicators in the treatment of abdominal aortic aneurysms]

BACKGROUND

The MTL30 (mortality, transfer, length of stay) was proposed as a surrogate parameter for evaluating the quality of large and potentially complication-prone visceral surgical interventions.

OBJECTIVE

The aim of this study was to find out to what extent the MTL30 can be correlated with the results of the abdominal aortic aneurysm (AAA) registry of the German Institute for Vascular Health Research (DIGG) of the German Society for Vascular Surgery and Vascular Medicine (DGG) and with the case volume of the participating hospitals.

MATERIAL AND METHODS

Elective endovascular abdominal aortic aneurysm repair (EVAR) was performed in 14,282 patients and open repair (OAR) in 3923 patients. Case volume of the treating hospitals, hospital mortality, length of stay and transfer to another acute care hospital were determined 30 days after the index intervention.

RESULTS

The hospital mortality was 1.3% for EVAR and 4.9% for OAR (p = 0.000), the MTL30 was 5.0% and 14.4%, respectively (p = 0.000). For EVAR, no relationship between case volume and hospital mortality (quintile 1: 1.0%; quintile 5: 1.3%) as well as case volume and MTL30 (quintile 1: 5.3%; quintile 5: 5.3%) could be demonstrated. Also in OAR there was no significant relationship between case volume and hospital mortality (quintile 1: 5.8%, quintile 5: 3.5%; p = 0.505) and case volume and MTL30 (quintile 1: 16.4%, quintile 5: 12.2%, p = 0.110). With a hospital mortality rate of 7.2% (5-10%) the MTL30 for OAR was 17.6%. In both EVAR and OAR, the length of stay correlated significantly with hospital mortality and MTL30.

DISCUSSION

A clear relationship between hospital case volume and hospital mortality could not be shown in the AAA registry of the DIGG. The same was true for the MTL30. It remains to be seen whether the MTL30 offers an additional benefit compared to the recording of hospital mortality and inpatient length of stay as a quality parameter.

Publication activity of chief and consultant general/visceral surgeons in German university hospitals-a ten-year analysis

PURPOSE

The publication activity of 38 German general/visceral surgery university departments, documented by first or last authorship from staff surgeons (chief and consultants), was evaluated.

METHODS

The observation period extended from 2007 to 2017 and all PubMed-listed publications were considered. Impact factor (IF) was evaluated through the publishing journal's 5-year IF in 2016, as was the IF for each individual publication. Ranking was expressed in quartiles.

RESULTS

The staff surgeons of the 38 departments comprised 442 surgeons, of which only 351 (79.4%) were active as first or last authors. Four thousand six hundred and ninety-nine publications published in 702 journals were recorded. The four leading departments in publication number published as much as the last 20 departments (1330 vs. 1336 publications, respectively). The mean of the first (most active) department quartile was 19.6 publications, the second 15.4, the third 11.0, and the last quartile 7.6 per publishing surgeon. The total cumulative impact factor was 14,130. When examining the mean number of publications per publishing surgeons per the 10 year period, the mean of the first quartile was 57.9 cumulative IF, the second 45.0, the third 29.5, and the fourth quartile 17.1. With 352 (7.5%) publications, the most frequently used journal was Chirurg, followed by Langenbeck's Archives of Surgery with 274 (5.8%) publications. Pancreas-related topics led in terms of publication number and IF generated per individual publication.

CONCLUSION

A significant difference in publication performance of individual departments was apparent that cannot be explained by staff number. This indicates that there are as yet unknown factors responsible for minor publication activity in many university departments.

[The DIGG risk score : A risk predictive model of perioperative mortality after elective treatment of intact abdominal aortic aneurysms in the DIGG register]

OBJECTIVE

The aim of the study was to develop a specific risk score for the aortic register of the German Institute for Vascular Health Care Research (DIGG) of the German Society for Vascular Surgery and Vascular Medicine (DGG) for the prediction of postoperative mortality in elective treatment of intact abdominal aortic aneurysms (iAAA). The score should also enable a risk-adjusted presentation of the register results in the near future.

METHODS

The method of binary logistic regression analysis was used to calculate the model. The data from 10,404 patients were included in the analysis, of whom 7870 (75.6%) were treated by endovascular (EVAR) and 2534 (24.4%) by open (OR) aortic repair. It was examined which factors have an independent influence on hospital mortality and the effect size was determined as a score.

RESULTS

For EVAR, the influencing factors with their effect sizes (score in brackets) were: age >85 years (2), female gender (2), juxtarenal AAA (5), maximum diameter >65 mm (2), diabetes mellitus (2), American Society of Anesthesiologists (ASA) score >3 (2), cardiac comorbidities (3) and renal insufficiency stage >3 (5). For OR the factors were: age >80 years (2), female gender (2), juxtarenal AAA (2), ASA score >3 (3), previous myocardial infarction (2), renal comorbidities (3) and previous stroke (2). The estimated hospital mortality was calculated for the individual case from the sum of the risk factors (scores). The accuracy of the model (correlation between observed and expected results) was determined using the receiver operating characteristic (ROC) curve. An area under the curve (AUC) of 0.817 (confidence interval 0.789-0.844) demonstrated an excellent discrimination. In a validation group of 3831 patients, the good agreement between observed and calculated results was confirmed.

CONCLUSION

The DIGG risk score can predict risk-adjusted hospital mortality after EVAR and OR of iAAA in the DIGG register. Improvements with respect to the prediction are desirable for OR and should be strived for by extending the model in the future.

[The publication performance of German academic vascular surgery-journals, focal topics and impact factors]

AIM

The aim of the present study was to describe the publication performance of the academic surgical management teams in Germany based on the preferred journals, their impact factors (IF) and the focal topics.

METHODS

The publications of the vascular surgical management teams, consisting of chief and senior physicians, of 37 German university hospitals were analyzed. Reference date for all considerations (staffing and publications) was 1 July 2017. The publication period covered the last 10 years. The literature search was based on an evaluation of the PubMed database.

RESULTS

A total of 1047 publications published in 197 journals were recorded. Among them were 3 German language journals with 136 (13.0%) publications but only 3.3% of all cumulative IFs. In 126 journals (64.0%) only one article was published and in 30 (15.2%) two articles. The three PubMed listed journals in which German university vascular surgeons published most frequently were the J Vasc Surg with 126 publications, Eur J Vasc Endovasc Surg with 94 and J Endovasc Ther with 88 publications. Of all 1047 publications 46.5% were published in an IF range under 2 and a total of 907/1047 publications (86.6%) in an IF range under 4. In 8.6% of the journals 44.1% of the IFs were generated. In terms of publication topics, thoracic and abdominal aorta were at the top of the list, accounting for almost half of all publications with 501 publications and with 52% of all 1252.08 accumulated IFs.

CONCLUSION

A total of 78.6% of the publications in the 17 journals, in which more than 10 publications were made, came from independent institutions, 19.3% from the sections. None of the 91 publications in journals with an IF > 4 came from a subordinate organizational structure, indicating a gap between independent departments, sections and subordinate structures. The number of publications was based on the achievable IF of the individual topic and thus its attractiveness. Peripheral arterial disease was underrepresented in the publication topics in relation to the number of patients, with a share of 8.5.

Surgical publication activity in the English literature over a 10-year interval

Background

Surgical publication activity in the English literature over a 10-year interval may have changed. This study sought to identify which countries make the most contributions and whether significant shifts have occurred in this time.

Methods

Screening of 17 international journals in PubMed was performed for the time periods 2006-2007 and 2016-2017, for papers published by a first author belonging to a general surgical department. Data were collected by country regarding the total number of publications, cumulative impact factors (IFs), publications per inhabitant, IFs per inhabitant, and number of RCTs, meta-analyses and systematic reviews per country in both periods.

Results

A total of 2247 and 3029 papers were found for 2006-2007 and 2016-2017 respectively. In 2006-2007, most papers (605, 26·9 per cent; 2697·3 IFs) came from the USA, followed by Japan (284, 12·6 per cent; 1042·1 IFs) and the UK (197, 8·8 per cent; 923·1 IFs). In 2016-2017, the USA led again with 898 papers (29·6 per cent; 4575·3 IFs), followed by Japan with 414 papers (13·7 per cent; 1556·6 IFs) and the Netherlands with 167 (5·5 per cent; 885·2 IFs). From the top 15 countries, Sweden, the Netherlands and Switzerland contributed the most articles per inhabitant during both time periods. During both periods, the UK published the most RCTs, meta-analyses and systematic reviews.

Conclusion

Surgeons from the USA were the most productive in total number of publications during both time periods. However, smaller European countries were more active than the USA in relation to their population size.

[Multimorbid vascular patients-do endovascular techniques expand the limits?]

The answer to the question of whether endovascular techniques extend the barriers to treatment in multimorbid vascular patients depends on the localization of the vascular disease and its stage. In multimorbid vascular patients with limited life expectancy and asymptomatic carotid stenosis, neither an endovascular nor an open procedure is indicated but a conservative best medicinal treatment is to be preferred. In symptomatic carotid stenosis the endovascular procedure is indicated for special anatomical conditions, such as contralateral carotid artery occlusion, contralateral recurrent nerve palsy, recurrent stenosis following endarterectomy, radical neck dissection and radiotherapy in the cervical region. In the treatment of intact abdominal aortic aneurysms (AAA), endovascular procedures reduce the perioperative risk especially in older patients, allowing the indications for intervention in this group of patients to be expanded, provided that the life expectancy of such treated patients is still several years. There is no clear evidence as to whether endovascular repair should be preferred in ruptured AAAs but there are indications that with the establishment of EVAR the proportion of patients receiving treatment has increased in those patients who were previously denied surgery after arrival in hospital. In critical limb ischemia the propagation of endovascular techniques has not so much extended the indications for invasive therapy but instead the endovascular approach has superseded open bypass surgery, which is positively reflected in a lower perioperative morbidity, especially in older frail patients.

Percutaneous endovascular treatment of infrainguinal PAOD: Results of the PSI register study in 74 German vascular centers

Background

The percutaneous infrainguinal stent (PSI) register study aimed to collate all percutaneous endovascular procedures for infrainguinal peripheral arterial occlusive disease (PAOD) conducted in 74 German vascular centers between September and November 2015 (3 months). In order to obtain representative results all consecutive treatment procedures had to be submitted by the participating trial centers.

Material and methods

This was a prospective, nonrandomized multicenter study design. All patients suffering from intermittent claudication (IC, Fontaine stage II) or critical limb ischemia (CLI, Fontaine stages III and IV) were included. Trial centers with less than 5 cases reported within the 3‑month trial period or centers that could not ensure the submission of all treated patients were excluded.

Results

In the final assessment 2798 treated cases from 74 trial centers were reported of which 65 (87.8 %) centers were under the leadership of a vascular surgeon. Approximately 33 % of the interventions in centers under the leadership of vascular surgeons were conducted by radiologists. Risk factors, especially chronic renal disease, diabetes and cardiac risk factors were significantly different between patients with IC and CLI. Of the patients with Fontaine stage II PAOD 41.3 % had 3 patent crural vessels compared to only 10.8 % of patients with Fontaine stage IV. With respect to peri-interventional complications, percutaneous endovascular treatment of IC was a safe procedure with severe complications in less than 1 % and no fatalities. Only 4.5 % of the procedures were conducted under ambulatory conditions. In the supragenual region self-expanding bare metal stents, standard percutaneous transluminal angioplasty (PTA) and drug-coated balloons were the most frequently used procedures. For interventions below the knee, standard PTA was the most commonly employed treatment.

Conclusion

The main aim of the PSI study was to obtain a realistic picture of percutaneous endovascular techniques used to treat suprapopliteal and infrapopliteal PAOD lesions and to describe the treatment procedures used by vascular specialists in Germany. To investigate the change in trends for treatment over time, this study has to be repeated in the future in order to test how quickly the results of randomized studies can be implemented in practice.

Electronic supplementary material

A complete list of the PSI study collaborators is available under doi: 10.1007/s00772-016-0202-2.

The endovascular performance spectrum of vascular surgery departments in Germany: Results of an online survey among senior department physicians

Aim

To survey the scope of vascular surgery services in Germany.

Method

A total of 308 senior German vascular surgeons received a 19-point questionnaire pertaining to department structure and scope of services. Of these surgeons 223 replied between 16 August 2015 and 23 October 2015 (response rate 72 %), with 62.2 % reporting an additional qualification as an endovascular surgeon according to the guidelines of the German Society for Vascular Surgery and Vascular Medicine (Deutsche Gesellschaft für Gefäßchirurgie und Gefäßmedizin, DGG) and 43.5 % as a DGG® endovascular specialist.

Results

The number of respondents fully authorized to train in vascular surgery was 71.3 %, while 28.3 % were authorized for limited training. Authorization as a DGG® endovascular surgeon was reported by 24.2 % and authorization as a DGG® endovascular specialist by 17 % of respondents. All respondents performed endovascular interventions on pelvic vessels and 99.1 % also reported carrying out femoral and popliteal endovascular interventions. Endovascular procedures in crural vessels were carried out by 90.1 % and 93.7 % of vascular surgeons performed endovascular procedures in the region of the abdominal aorta (segment V), arteriovenous (AV) fistulas and shunts (85.2 %), upper extremity vessels (80.3 %), the thoracic aorta (segment III, 68.2 %), renal arteries (62.8 %) and visceral aorta (segment IV, 60.5 %). In all 43.5 % of respondents reported experience with endovascular procedures on the carotid bifurcation. Percutaneous arterial procedures formed the focus of endovascular activity, totalling on average 259 interventions per year and department, followed by diagnostic angiography (without intervention) at 166 procedures per year and hybrid arterial interventions at 141 interventions per year.

Conclusion

This survey revealed a high level of endovascular expertise among vascular surgeons in Germany. This applies not only to the scope of endovascular activities in diagnosis and treatment but also to the number of estimated annual procedures.

[Endovascular versus conventional vascular surgery--old-fashioned thinking? Part 2: carotid artery stenosis and peripheral arterial occlusive disease]

Endovascular therapy has widely replaced conventional open vascular surgical reconstruction. For this reason, both techniques were widely considered to be competing approaches. Evidence-based data from randomized prospective trials, meta-analyses and clinical registries, however, demonstrated that both techniques should be used to complement each other. It became increasingly more evident that the use of either procedure depends on the underlying disease and the anatomical conditions, whereby a combination of both (hybrid approach) may be the preferred option in certain situations. This review focuses on the treatment of patients with carotid artery stenosis, intermittent claudication, critical limb ischemia and acute limb ischemia.

[Endovascular versus conventional vascular surgery - old-fashioned thinking? Part 1: interventions on the aorta]

Endovascular therapy has widely replaced conventional open vascular surgical reconstruction. For this reason both techniques were widely considered to be competing approaches. Evidence-based data from randomized prospective trials, meta-analyses and clinical registries, however, demonstrated that both techniques should be used to complement each other. It became increasingly more evident that the use of either procedure depends on the underlying disease and the anatomical conditions, whereby a combination of both (hybrid approach) may be the preferred option in certain situations. This review focuses on the treatment of complicated acute type B aortic dissection, descending thoracic aortic aneurysms, thoracoabdominal aortic aneurysms as well as asymptomatic and ruptured abdominal aortic aneurysms.

[Vascular medicine needs more evidence: recent results and meta-analyses for the treatment of diabetic feet]

BACKGROUND

This overview comments on clinical trials and meta-analyses from the literature on the treatment of diabetic feet.

METHODS

For the literature review, the MEDLINE database (PUBMED) was searched under the key words "diabetic foot". Publications of the last three years (2012 to 2014) were extracted.

RESULTS

For patients with diabetic feet, both endovascular (ER) and open (OR) revascularisation techniques are possible. There are not sufficient data to demonstrate whether open bypass surgery or endovascular interventions are more effective in these patients. However, registries show that ER has now in terms of quantity become the preferred method. Angiosome-targeted revascularisation has to be considered in these situations. For the local treatment of a diabetic foot ulcer a variety of dressings are available, the evidence for their recommendation is low. Dressing cost and the wound management properties, e.g. exudate management therefore can influence the choice of dressing. There is no evidence that more expensive dressings as compared to basic dressings offer advantages in terms of healing. In plantar diabetic foot ulcers, non-removable off-loading devices regardless of type are more likely to result in ulcer healing than removable off-loading devices, presumably, because patient compliance with off-loading is facilitated. Meaningful pressure-relieving interventions for treating diabetic foot ulcers also include Achilles tendon lengthening, a plantar fascia release and percutaneous flexor tenotomy. The value of a standardised treatment protocol carried out by a specialist team could be proven in large registries based on decreasing amputation rates.

CONCLUSION

This survey reveals a significant disparity between the large number of treatment recommendations and their evidence. For the future, therefore it is imperative to implement nationwide register surveys with respect to treatment and outcome of these patients.

[Cost and cost-effectiveness in the treatment of peripheral arterial occlusion disease - what is proven?]

BACKGROUND

This overview comments on the health-care relevance of peripheral arterial occlusive disease (PAOD) in patients with intermittent claudication (IC) and critical limb ischaemia (CLI). We evaluated different treatment modalities in terms of cost-effectiveness.

METHOD

For the literature review, the Medline database (PubMed) was searched under the key words "critical limb ischemia AND cost", "critical limb ischemia AND economy", "peripheral arterial disease AND cost", "peripheral arterial disease AND economy".

RESULTS

In the years 2005 to 2009, the hospitalisations of patients with PAOD rose disproportionately in Germany by 20 %, to 483,961 hospital admissions. By comparison, hospital admissions altogether increased by only 8 %. The average in-patient costs were estimated to be approximately € 5000 per PAOD-patient - a rather conservative estimate. For the patient with IC the economic data position is clear, supervised exercise training is by far the most cost-effective treatment option, followed by percutaneous transluminal angioplasty (PTA) and finally the peripheral bypass. In accordance with the guidelines of the UK, the latter is therefore indicated only if PTA fails or is technically not possible. In patients with CLI, the situation is not obvious. Indeed, a short-term economic advantage can be calculated for the PTA, the long-term comparison of both methods, however, is impossible due to insufficient data. In addition, the risk factors for the patient have to be included in the calculation. This was indeed demonstrated in the short-term, but could not be analysed in the long-term follow-up.

CONCLUSION

The issue of greater cost-effectiveness of open or endovascular treatment in patients with CLI is uncertain, the studies and patient populations are too heterogeneous. Further studies are urgently needed to structure the sequence of the various treatment options in guidelines and clinical pathways.

[Gender-specific influencing factors on incidence, risk factors and outcome of carcinoma of the liver, gallbladder, extrahepatic bile duct and pancreas]

BACKGROUND

This overview comments on gender-specific differences in incidence, risk factors and prognosis in patients with carcinoma of the liver, gallbladder, extrahepatic bile duct and pancreas.

METHOD

For the literature review, the MEDLINE database (PubMed) was searched under the key words "liver cancer", "gallbladder cancer", "extrahepatic bile duct carcinoma", "pancreatic cancer" AND "gender".

RESULTS

There were significant gender differences in the epidemiology of the analysed carcinomas. The incidence of hepatocellular carcinoma (HCC) is much higher in men than in women, one of 86 men, but only 1 out of 200 women develop a malignant primary liver tumour in Germany in the course of their life. The lifetime risk for carcinomas of the gallbladder and extrahepatic bile ducts in Germany amounts to about 0.6 % for women and 0.5 % for men, specifically gallbladder carcinomas are observed more frequently in women than in men. For pancreatic cancer, no clear gender preference exists in Germany, although the mortality risk for men is higher than that for women (age-adjusted standardised death rate in men 12.8/100, 000 persons, in women 9.5). Remarkable is furthermore the shift of the tumour incidence in the last decades. Liver cancer has increased among men in Germany by about 50 % in the last 30 years, the incidence of gallbladder carcinoma has inversely dropped. The prognosis of these cancers across all tumour stages is uniformly bad in an unselected patient population. This is probably the main reason why only little - if any - gender differences in survival are described.

CONCLUSION

In addition to avoiding the known risk factors such as hepatitis B and C virus infection, alcohol abuse, and smoking, the avoidance of overweight and obesity plays an increasingly important role in the prevention of these cancers.

[Gender-specific influences on the results of vascular surgery]

BACKGROUND

This overview comments on gender-specific differences in prevalence, treatment and outcome in patients with peripheral arterial disease (PAD), carotid stenosis, and abdominal aortic aneurysm (AAA).

METHOD

For the literature review, the Medline database (PubMed) was searched under the key words "peripheral arterial disease AND gender", "carotid stenosis AND gender" and "abdominal aortic aneurysm AND gender".

RESULTS

1.) Women (preferably black women) with PAD experience rather than men bypass failure or amputation. Nevertheless, gender should not constitute a selection criterion for revascularisation therapy. Despite an older age and more advanced stages of disease in women, infrainguinal arterial reconstructions could achieve, in published series, patency and limb salvage rates which did not differ from those of men. 2.) The benefit of carotid endarterectomy (CEA) for asymptomatic carotid artery stenosis is less for women compared with men. However, registries exhibited at best for symptomatic women an increased perioperative risk of CEA compared with men, with CEA especially in women better than carotid artery stenting. The treatment of AAA shows significant gender differences. The risk of rupture for small aneurysms is significantly greater in women compared with men, and they have higher in-hospital mortality rates for both open and endovascular repair of ruptured and intact AAA. Yet women also benefit from endovascular repair of AAA compared to open repair, although their eligibility for endovascular repair is less than that of men due to anatomic conditions.

CONCLUSION

As a rule, for the mentioned diseases less favourable results were reported in women. This may reflect biological disparities, or the differences are based on the fact that women develop arteriosclerotic changes later in life, requiring treatment in older age, with more advanced disease, and with higher comorbidity than men. In addition gender-related differences in the use of secondary medical prevention of PAD have been described. Future studies on the potential impact of gender on the results of vascular surgery are needed.

[Second primary malignancy among cancer survivors - epidemiology, prognosis and clinical relevance]

BACKGROUND

Rising population age and advances in treatment with improved survival from cancer have led to more frequent survivors of cancer treatment and subsequently to more patients with a second primary tumour. The consequences are presented in this overview.

METHOD

For the literature review, the Medline database (PubMed) was searched under the key words "multiple primary malignant tumors" and "(Neoplasms, second primary) AND "Neoplasms, Second Primary"[Mesh]". Primarily, publications in the last 7 years (2005 - 2011) were sought.

RESULTS

The prevalence of patients with second primary cancer is reported in various cancer registries with 6.6 % to 9 %. Here, the risk of developing new primary cancer in cancer survivors, depending on age, compared to the general population is increased at least by 20 %. Among childhood cancer survivors, the risk was even 3 - to 6-times higher than would have been expected in the general population. The incidence of second malignant neoplasms is crucially dependent on the prognosis of the first tumour. Fifteen years after initial diagnosis, in patients with prognostically unfavourable tumours such as pancreatic or gastric carcinoma, second primary malignancies are detected in less than 5 %. However, the cumulative incidence of all second cancers combined is approximately 15 % at 25 years in patients with colorectal or thyroid cancer.

CONCLUSION

Implications from these data arise for primary diagnostics which must look at cancers with frequent synchronous second malignancies for respective tumours before treatment. Examples are synchronous colorectal lesions in patients with colorectal carcinoma or synchronous cancers of the oral cavity and pharynx in patients with oesophageal carcinoma. Another consequence is a targeted follow-up of corresponding risk populations. This includes the screening for metachronous colorectal cancer, the exclusion of gastrointestinal second malignancies in patients with GIST, or the breast cancer screening in young female thyroid cancer survivors. Since radiotherapy increases the rate of second primary neoplasms, adjuvant radiotherapy should be well justified. Nevertheless, this is true only for young patients, mainly in childhood. The risk of a second cancer after irradiation in adults is small.

[Hartmann's procedure for perforated diverticulitis and malignant left-sided colorectal obstruction and perforation]

BACKGROUND

This review comments on the question whether laparoscopic techniques and interventional strategies have in the last ten years changed the emergency management of perforated diverticulitis and malignant colorectal obstruction or perforation with regard to the broad spectrum of indications for Hartmann's procedure (HP).

PERFORATED DIVERTICULITIS

Colon resection with primary anastomosis and defunctioning stoma is the optimal strategy for patients with perforated diverticulitis. HP should be considered for older patients with multiple comorbidities, realising that restoration of bowel continuity is no longer an issue. Laparoscopic peritoneal lavage is an alter-native to HP in Hinchey-III diverticulitis with promising results in experienced centers which should be further evaluated. OBSTRUCTIVE / PERFORATED LEFT-SIDED COLORECTAL CANCER: In perforated left-sided colorectal cancer HP may be generously indicated. In malignant obstruction, however, a temporary colostomy or -colonic stenting in case of appropriate expertise has been suggested as preoperative treatment -before elective surgery, allowing higher rates of RPA.

CONCLUSION

HP remains relevant, especially in high-risk patients and after hours and during the weekend, when the most experienced surgeon is not always available. However, subspecialised colorectal surgeons obtain with single-stage resection in this situation at least comparable results with respect to morbidity and mortality, but better patient quality of life.

[Palliative medicine and inpatient palliative care unit--functions, organisation forms and significance of surgery]

About 160  palliative care units with 1228 beds or 15  beds / 1  million inhabitants were available in German hospitals in the year 2008. Demand analyses consider 35  beds / 1  million inhabitants as necessary. Whether the additional demand could be reduced by a greater use of home- and hospice-based end-of-life care is discussed. For general hospitals the establishment of an acute palliative care unit within a medical (oncology) ward is recommended due to costs, organisation facilities and attitudes of physicians toward referral. The establishment of an acute palliative care unit may be costly for the hospital, nevertheless, outpatient palliative medicine and hospices are a cost-effective health service from a socioeconomic point of view, avoiding unnecessary hospital admissions and freeing up hospital beds by early discharge. An analysis of consultants demonstrates a minor interest of surgeons in specialisation in palliative medicine. However, data suggest that prior experience in palliative care alters the selection of treatment recommendations by surgeons with respect to more supportive or aggressive interventions in patients with advanced cancer. Ethical decision-making regarding therapy and counselling of patients at the end of life and discussing the prognosis with patients and their families require education in palliative medicine. A core curriculum to teach palliative care for surgical residents therefore has been presented.

[The acute (surgical) abdomen - epidemiology, diagnosis and general principles of management]

AIM

This review comments on epidemiology, diagnosis and general principles of surgical management in patients with acute abdomen. DEFINITION AND EPIDEMIOLOGY: The most common cause of acute abdominal pain is non-specific abdominal pain (24 - 44.3 % of the study populations), followed by acute appendicitis (15.9 - 28.1 %), acute biliary disease (2.9 - 9.7 %) and bowel obstruction or diverticulitits in elderly patients. Acute appendicitis represents the cause of surgical intervention in two-thirds of the children with acute abdomen.

DIAGNOSIS

A standardised physical examination combined with ultrasonography (US) represents the initial investigation in patients with acute abdominal pain. Due to the risk associated with radiation and due to the costs, a selective use of CT imaging is recommended. The work-flow given in this paper restricts the use of CT imaging to less than 50 % of patients with acute abdominal pain. Diagnostic laparoscopy should be considered in patients without a specific diagnosis after appropriate imaging and as an alternative to active clinical observation which is the current practice in patients with non-specific abdominal pain.

MANAGEMENT

Acute small bowel obstruction has previously been considered as a relative contraindication for laparoscopic management, but it has been shown in the meantime that laparoscopic treatment is an elegant tool for the management of simple band small bowel obstruction. Bedside diagnostic laparoscopy is recommended in intensive care unit (ICU) patients with acute abdomen or sepsis of unknown origin, in suspicion of acute cholecystitis, diffuse gut hypoperfusion and mesenteric ischaemia or in refractory lactic acidosis, especially after cardiac surgery. Early administration of analgesia to patients with acute abdominal pain in the emergency department will reduce the patient's discomfort without impairing clinically important diagnostic accuracy and is recommended on the basis of some prospective randomised trials. However, the impact on diagnostic accuracy depends on dosage, kind of application and cause of acute abdominal pain. A practice of judicious provision of analgesia therefore appears safe. There are significant differences between the knowledge of the current literature and the routine practice of providing analgesia as a survey has shown demonstrating that less than 50 % of paediatric emergency physicians and paediatric surgeons are usually willing to provide analgesia before definitive diagnosis.

[Diagnosis of and therapy for gastric cancer--work-flow]

AIM

This review comments on the diagnosis and treatment of gastric cancer in the classical meaning--excluding adenocarcinoma of the -oesophagogastric junction. Algorithms of diagnosis and care with respect to tumour stage are presented. PREOPERATIVE DIAGNOSIS: Besides oesophagogastroduodenoscopy, endoscopic ultrasonography is necessary for the accurate diagnosis of T categories and as a selection criterion for neoadjuvant chemotherapy. Computed tomography is recommended for preoperative evaluation of tumours > T1, laparoscopy has become an effective stag-ing tool in T3 and T4 tumours avoiding unnecessary laparotomies and improving the detection of small -liver and peritoneal metastases.

TREATMENT

Endoscopic mucosal resection and submucosal dissection are indicated in superficial cancer confined to the mucosa with special characteristics (T1 a / no ulcer / G1, 2 / Laurén intestinal / L0 / V0 / tumour size < 2 cm). In all other cases total gastrectomy or distal subtotal gastric resection are indicated, the latter in cases of tumours located in the distal two-thirds of the stomach. Standard lymphadenectomy (LAD) is the D2 LAD without distal pancreatectomy and splenectomy. The Roux-en-Y oesophagojejunostomy is still the preferred type of reconstruction. An additional pouch reconstruction should be considered in -patients with favourable prognosis, this also -applies for the preservation of the duodenal passage by jejunum interposition. Extended organ resections are only indicated in cases where a R0-resection is possible. Hepatic resection for metachronous or synchronous liver metastases is rarely advised since 50 % of patients with liver metastases show concomitant peritoneal dissemination of the disease.

DISCUSSION AND CONCLUSIONS

Undergoing gastrectomy at a high-volume centre is associated with lower in-hospital mortality and a better prognosis, however, clear thresholds for case load cannot be given. Perioperative chemotherapy and postoperative chemoradiotherapy are based on the MAGIC and MacDonald trials. Perioperative chemotherapy should be performed in patients with T3 and T4 tumours with the aim to increase the likelihood of curative R0-resection by downsizing the tumour. Adjuvant postoperative chemotherapy cannot be recommended since its benefit has so far not been proven in randomised trials. In selected patients with incomplete lymph-node dissection and questionable R0-resection postoperative chemoradiotherapy may be debated.

[Diagnosis and treatment of colorectal liver metastases - workflow]

In this review, standards of diagnosis and treatment of colorectal liver metastases are described on the basis of a workshop discussion. Algorithms of care for patients with synchronous / metachronous colorectal liver metastases or locoregional recurrent tumour are presented. Surgical resection is the procedure of choice in the curative treatment of liver metastases. The decision about the resection of liver metastases should consider the following parameters: 1. General operability of the patient (comorbidity); 2. Achievability of an R 0 situation: i. if necessary, in combination with ablative methods, ii. if necessary, neoadjuvant chemotherapy, iii. the ability to eradicate extrahepatic tumour manifestations; 3. Sufficient volume of the liver remaining after resection ("future liver remnant = FLR): i. if necessary, in combination with portal vein embolisation or two-stage hepatectomy; 4. The feasibility to preserve two contiguous hepatic segments with adequate vascular inflow and outflow as well as biliary drainage; 5. Tumour biological aspects ("prognostic variables"); 6. Experience of the surgeon and centre! Extrahepatic disease does not contraindicate hepatectomy for colorectal liver metastases provided a complete resection of both intra- and extrahepatic disease is feasible. Even in bilobar colorectal metastases and 5 or more tumours in the liver, a complete tumour resection has been described. The type of resection (hepatic wedge resection or anatomic resection) does not influence the recurrence rate. Preoperative volumetry is indicated when major hepatic resection is planned. The FLR should be 25 % in patients with normal liver, 40 % in patients who have received intensive chemotherapy or in cases of fatty liver, liver fibrosis or diabetes, and 50-60 % in patients with cirrhosis. In patients with initially unresectable colorectal liver metastases, preoperative chemotherapy enables complete resection in 15-30 % of the cases, whereas the value of neoadjuvant chemotherapy in patients with resectable liver metastases has not been sufficiently supported. In situ ablative procedures (radiofrequency ablation = RFA and laser-induced interstitial thermotherapy = LITT) are local therapy options in selected patients who are not candidates for resection (central recurrent liver metastases, bilobar multiple metastases and high-risk resection or restricted patient operability). Patients with tumours larger than 3 cm have a high local recurrence rate after percutaneous RFA and are not optimal candidates for this procedure. The physician's experience influences the results significantly, both after hepatectomy and after in situ ablation. Therefore, patients with colorectal liver metastases should be treated in centres with experience in liver surgery.

Lebermetastasen kolorektaler Karzinome - darf das DRG-System das operative Vorgehen beeinflussen?

The economic analysis of surgery in colorectal liver metastases reveals the different effectiveness of various follow-up programmes after curative surgery for colorectal cancer. Interval hepatic resection for synchronous liver metastases is recommended in the majority of cases with rectal cancer. This procedure provides benefits for the patient and the hospital under the economic point of view. The interval between primary tumor resection and surgery of liver metastases does not deteriorate the prognosis, on the contrary, unnecessary resections will be avoided if additional metastases will grow in the time between, excluding curative treatment (selection mechanism). The identical statement cannot be applied to patients with colon cancer, since the operative risk is only slightly increased in case of easily accessible liver metastases which may be removed simultaneously. However, also in these patients interval hepatic resection after neoadjuvant chemotherapy should be considered as a therapeutic option! In patients with multiple liver metastases liver surgery as well as radiofrequency ablation or a combination of both may be economically justified. Radiofrequency ablation is the preferred palliative procedure under aspects of cost-effectiveness, however, wether this procedure is superior to chemotherapy alone has not be evaluated so far in prospectively randomized trials.

Bericht über den Workshop „Workflow Rektumkarzinom II” am 10. / 11.11.2006 in Burghausen

The task force "workflow rectal cancer II" defined operative techniques in lower rectal cancer, especially the total mesorectal excision and an improved technique of abdominalperineal resection. New aspects for treatment of rectal cancer with primary distant metastases are described. Due to newer publications a concept of bidirectional procedure with surgery and radiochemotherapy is recommended, where the operation must not be inevitably the first step. In anastomoses below 6 cm of the anocutaneous verge a reservoir should be performed on principle due to better functional results. The colon-j-pouch with a maximal loop length of 6 cm is best investigated under these conditions, the other procedures should be further evaluated.

Qualitätsindikatoren bei Diagnostik und Therapie des Rektumkarzinoms

Diagnostic and treatment of rectal cancer need a continuous quality assessment. Indicators of quality were compiled as indicator profile for a summarizing evaluation. The indicators selected should potentially show an appreciable variation of the quality target and in addition should be decisive for the outcome. For the evaluation of the clinical diagnostic the frequency of the determination of the pretherapeutic T, N and M categories and the proportion of pT 1-tumors were chosen, for the pathological diagnostic the number of histologically examined lymph nodes and the proportion of lymphnode positive patients. Process quality of treatment was defined by the following indicators: proportion of tumor excision, of definite therapy by local tumor removal, of neo-adjuvant long-term radiochemotherapy, of adjuvant treatment in patients not selected for neoadjuvant therapy, of total / partial mesorectal excision, of abdomino-perineal resection, postoperative mortality, frequency of clinically apparent anastomotic leakage, and of neurogenic bladder dysfunction at hospital discharge. The indicators for the quality of the performance of treatment were differentiated between surrogate indicators that can be determined immediately after accomplishment of primary surgical therapy giving strong clues for the further course of disease at an early date, and definite indicators. Important surrogate indicators comprise the occurrence of intraoperative local tumor cell dissemination, R 1 / 2-resection, pathohistologically CRM-positive tumor resection, and the quality of mesorectal excision (proportion of incomplete mesorectal excision). The definite indicators include the 5-year local recurrence rate and the 5-year overall survival rate. The corresponding quantifying parameters for the individual indicators are specified in this paper with precise figures.

Systemic and local antibiotic prophylaxis in the prevention of prosthetic vascular graft infection: an experimental study

AIM

to determine if local, in addition to systemic antibiotic prophylaxis (compared to that provided by systemic prophylaxis alone) provides additional benefit in terms of reducing graft infection.

METHODS

gelatin-sealed Dacron grafts were interposed in the infrarenal aorta of 36 mongrels and inoculated with 1 ml of a S. aureus suspension. Group 1 (control group) received no prophylaxis and were inoculated with 1 ml containing 10(9)cfu/ml. Group 2 (n=6) received systemic prophylaxis (1 g cephamandole) and were inoculated with 10(5) cfu/ml (n=3) or 10(7) cfu/ml (n=3). Group 3 received systemic prophylaxis (1 g cephamandole) and were inoculated with 109 cfu/ml. Group 4 received systemic prophylaxis (2 g cephamandole) and were inoculated with 10(9)cfu/ml. In group 5 and 6 grafts were soaked in a rifampicin solution before use and inoculated with 10(9) cfu/ml. Group 5 received no systemic prophylaxis and group 6 received systemic prophylaxis (1 g cephamandole). Grafts were harvested at 2 weeks, and peritonitis, perigraft abscess, anastomotic disruption and graft occlusion recorded. Swabs were taken of the graft, the perigraft tissues and the peritoneal fluid. Graft segments were incubated in broth medium.

RESULTS

inoculation with 10(9) cfu/ml ensured graft infection. Systemic or local prophylaxis alone failed to prevent graft infection. Only systemic and local antibiotic prophylaxis provided significant better results than no prophylaxis at all (p<0.01) and local prophylaxis alone (p<0.05). However, total "graft sterility" was not achieved as bacteriologic analysis of the graft segments showed low bacterial counts (<10 bacteria/graft) in 5 of 6 grafts.

CONCLUSION

local and systemic prophylaxis provided more protection as demonstrated by the significant decrease in the incidence of "overt" graft infection. Total "graft sterility" cannot be expected in the case of an overwhelming bacterial challenge.

[Quality assurance by introduction of internal medicine guidelines. What Can we learn by comparing various clinics?]

It is the objective of guideline controlled quality assurance to transfer the best knowledge (evidence based medicine) into clinical practice. The best approach to make these guidelines effective is to involve the potential users (doctors/nurses) in local guideline development. An own study of benchmarking "laparoscopic gallbladder surgery" in 9 hospitals could demonstrate the enormous potential of increasing effectiveness and efficiency by guideline application, since the hospital costs differed double the price with the same result. Internal guidelines help to improve the results and reduce costs.