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Aortic replacement in aorto-occlusive disease: an observational study
Gareth Morris-Stiff, Samuel Ogunbiyi, Richard K Winter, Russell Brown and Michael H Lewis Fri, 31 Oct 2008 00:00:00 -0000
Background: For many patients with aorto-occlusive disease, where stent deployment is not possible, surgery remains the only treatment option available. The aim of this study was to assess the results of aortic reconstruction surgery performed in patients with critical ischaemia. Methods: All patients with critical ischaemia undergoing surgery during 1991-2004 were identified from a prospectively maintained database. Mortality data was verified against death certificate data. Demographic and clinical data were obtained from the clinical notes and the radiology database. Disease was classified as: type I - limited to aorta and common iliac arteries; type II - external iliac disease and type III combined aortic, iliac and infra-inguinal disease. Results: 86 patients underwent aortic replacement surgery all of whom had critical ischaemia consisting of: type I (n=16); type II (n=37) and type III (n=33). The 30-day mortality rate was 10.4%, the one-year patient survival was 80%, and the 1-year graft survival was 80%. At 2 years the actual patient survival was 73% and no additional graft losses were identified. All patients surviving 30 days reported excellent symptomatic relief. Early, complications occurred in 6 (7%) patients: thrombosis within diseased superficial femoral arteries (n=4); haemorrhage and subsequent death (n=2). Ten (14%) late complications (> 12 months) occurred in the 69 surviving patients and included: anastomotic stenosis (n = 3); graft thrombosis (n = 4), graft infection (n = 3). Four patients developed claudication as a result of more distal disease in the presence of a patent graft, and 1 patient who continued smoking required an amputation for progressive distal disease. Conclusions: Aortic reconstruction for patients with extensive aorto-occlussive disease provides long-standing symptomatic relief for the majority of patients. After the first year, there is continued patient attrition due to co-existent cardiovascular disease but no further graft losses.
Clinical evaluation of an air-capsule technique for the direct measurement of intra-abdominal pressure after elective abdominal surgery
Jens Otto, Daniel Kaemmer, Andreas Biermann, Marc Jansen, Rolf Dembinski, Volker Schumpelick and Alexander Schachtrupp Fri, 17 Oct 2008 00:00:00 -0000
Background: The gold standard for assessment of intraabdominal pressure (IAP) is via intravesicular pressure measurement (IVP). This accepted technique has some inherent problems, e.g. indirectness. Aim of this clinical study was to assess direct IAP measurement using an air-capsule method (ACM) regarding complications risks and agreement with IVP in patients undergoing abdominal surgery. Methods: A prospective cohort study was performed in 30 patients undergoing elective colonic, hepatic, pancreatic and esophageal resection. For ACM a Probe 3 (Spiegelberg®, Germany) was placed on the greater omentum. It was passed through the abdominal wall paralleling routine drainages. To compare ACM with IVP t-testing was performed and mean difference as well as limits of agreement were calculated. Results: ACM did not lead to complications particularly with regard to organ lesion or surgical site infection. Mean insertion time of ACM was 4.4 days (min-max: 1–5 days). 168 pairwise measurements were made. Mean ACM value was 7.9 ± 2.7 mmHg while mean IVP was 8.4 ± 3.0 mmHg (n.s). Mean difference was 0.4 mmHg ± 2.2 mmHg. Limits of agreement were -4.1 mmHg to 5.1 mmHg. Conclusion: Using ACM, direct IAP measurement is feasible and uncomplicated. Associated with relatively low pressure ranges (<17 mmHg), results are comparable to bladder pressure measurement.
Could lymphatic mapping and sentinel node biopsy provide oncological providence for local resectional techniques for colon cancer? A review of the literature
Ronan A Cahill, Joel Leroy and Jacques Marescaux Wed, 24 Sep 2008 00:00:00 -0000
Background: Endoscopic resectional techniques for colon cancer are undermined by their inability to determine lymph node status. This limits their application to only those lesions at the most minimal risk of lymphatic dissemination whereas their technical capacity could allow intraluminal or even transluminal address of larger lesions. Sentinel node biopsy may theoretically address this breach although the variability of its reported results for this disease is worrisome. Methods: Medline, EMBASE and Cochrane databases were interrogated back to 1999 to identify all publications concerning lymphatic mapping for colon cancer with reference cross-checking for completeness. All reports were examined from the perspective of in vivo technique accuracy selectively in early stage disease (i.e. lesions potentially within the technical capacity of endoscopic resection). Results: Fifty-two studies detailing the experiences of 3390 patients were identified. Considerable variation in patient characteristics as well as in surgical and histological quality assurances were however evident among the studies identified. In addition, considerable contamination of the studies by inclusion of rectal cancer without subgroup separation was frequent. Indeed such is the heterogeneity of the publications to date, formal meta-analysis to pool patient cohorts in order to definitively ascertain technique accuracy in those with T1 and/or T2 cancer is not possible. Although lymphatic mapping in early stage neoplasia alone has rarely been specifically studied, those studies that included examination of false negative rates identified high T3/4 patient proportions and larger tumor size as being important confounders. Under selected circumstances however the technique seems to perform sufficiently reliably to allow it prompt consideration of its use to tailor operative extent. Conclusion: The specific question of whether sentinel node biopsy can augment the oncological propriety for endoscopic resective techniques (including Natural Orifice Transluminal Endoscopic Surgery [NOTES]) cannot be definitively answered at present. Study heterogeneity may account for the variability evident in the results from different centers. Enhanced capacity (perhaps to the level necessary to consider selective avoidance of en bloc mesenteric resection) by its confinement to only early stage disease is plausible although not proven. Specific study of the technique in early stage tumors is clearly essential before proffering this approach.
Robotic assisted Laparoscopic partial Nephrectomy for suspected Renal Cell Carcinoma: Retrospective review of surgical outcomes of 35 Cases
Sam B Bhayani and Nitin Das Wed, 24 Sep 2008 00:00:00 -0000
Background: A standard of care for the treatment of small renal masses is partial nephrectomy. The open and laparoscopic approaches have been well described in the literature. Robotic assistance may augment partial nephrectomy by aiding in dissection and renal reconstruction. In this communication we describe the surgical outcomes of 35 patients undergoing robotic partial nephrectomy. Methods: Patient records and databases were reviewed for 35 consecutive patients undergoing RPN. Clinical, pathological, and radiographic data were obtained. The data was deidentified. Results: Thirty five patients successfully underwent RPN. An additional 2 patients were converted to other nephron sparing procedures. Mean tumor size was 2.8 cm, and mean OR time was 142 minutes. Mean warm ischemia time was 20 minutes. All margins were negative. There were 4 complications, and no patients required reoperation. Conclusion: Robotic partial nephrectomy can produce excellent initial results. Further studies should be performed to compare the outcomes to laparoscopic and open operations.
Laparoscopic ileocolic resection versus infliximab treatment of distal ileitis in Crohn's disease: a randomized multicenter trial (LIR!C-trial)
Emma J Eshuis, Willem A Bemelman, Ad A van Bodegraven, Mirjam AG Sprangers, Patrick MM Bossuyt, AW Marc van Milligen de Wit, Rogier MPH Crolla, Djuna L Cahen, Liekele E Oostenbrug, Meindert N Sosef, Annet MCJ Voorburg, Paul HP Davids, C Janneke van der Woude, Johan Lange, Rosalie C Mallant, Maarten J Boom, Rob J Lieverse, Edwin S van der Zaag, Martin HMG Houben, Juda Vecht, Robert EGJM Pierik, Theo JM van Ditzhuijsen, Hubert A Prins, Willem A Marsman, Henricus B Stockmann, Menno A Brink, Esther CJ Consten, Sjoerd DJ van der Werf, Andreas WKS Marinelli and Jeroen M Jansen Fri, 22 Aug 2008 00:00:00 -0000
Background: With the availability of infliximab, nowadays recurrent Crohn's disease, defined as disease refractory to immunomodulatory agents that has been treated with steroids, is generally treated with infliximab. Infliximab is an effective but expensive treatment and once started it is unclear when therapy can be discontinued. Surgical resection has been the golden standard in recurrent Crohn's disease. Laparoscopic ileocolic resection proved to be safe and is characterized by a quick symptom reduction.The objective of this study is to compare infliximab treatment with laparoscopic ileocolic resection in patients with recurrent Crohn's disease of the distal ileum with respect to quality of life and costs.Methods/designThe study is designed as a multicenter randomized clinical trial including patients with Crohn's disease located in the terminal ileum that require infliximab treatment following recent consensus statements on inflammatory bowel disease treatment: moderate to severe disease activity in patients that fail to respond to steroid therapy or immunomodulatory therapy. Patients will be randomized to receive either infliximab or undergo a laparoscopic ileocolic resection. Primary outcomes are quality of life and costs. Secondary outcomes are hospital stay, early and late morbidity, sick leave and surgical recurrence. In order to detect an effect size of 0.5 on the Inflammatory Bowel Disease Questionnaire at a 5% two sided significance level with a power of 80%, a sample size of 65 patients per treatment group can be calculated. An economic evaluation will be performed by assessing the marginal direct medical, non-medical and time costs and the costs per Quality Adjusted Life Year (QALY) will be calculated. For both treatment strategies a cost-utility ratio will be calculated. Patients will be included from December 2007.DiscussionThe LIR!C-trial is a randomized multicenter trial that will provide evidence whether infliximab treatment or surgery is the best treatment for recurrent distal ileitis in Crohn's disease.Trial registrationNederlands Trial Register NTR1150
The One-stop trial: Does electronic referral and booking by the general practitioner (GPs) to outpatient day case surgery reduce waiting time and costs? A randomized controlled trial protocol
Knut Magne Augestad, Arthur Revhaug, Barthold Vonen, Roar Johnsen and Rolv-Ole Lindsetmo Mon, 11 Aug 2008 00:00:00 -0000
Background: Waiting time and costs from referral to day case outpatient surgery are at an unacceptably high level. The waiting time in Norway averages 240 days for common surgical conditions. Furthermore, in North Norway the population is scattered throughout a large geographic area, making the cost of travel to a specialist examination before surgery considerable. Electronic standardised referrals and booking of day case outpatient surgery by GPs are possible through the National Health Network, which links all health care providers in an electronic network. New ways of using this network might reduce the waiting time and cost of outpatient day case surgery.Materials and MethodsIn a randomised controlled trial, selected patients (inguinal hernia, gallstone disease and pilonidal sinus) referred to the university hospital are either randomised to direct electronic referral and booking for outpatient surgery (one stop), or to the traditional patient pathway where all patients are seen at the outpatient clinic several weeks ahead of surgery.Consultants in gastrointestinal surgery designed standardised referral forms and guidelines. New software has been designed making it possible to implement referral forms, guidelines and patient information in the GP's electronic health record. For "one-stop" referral, GPs must provide mandatory information about the specific condition. Referrals were linked to a booking system, enabling the GPs to book the hospital, day and time for outpatient surgery. The primary endpoints are waiting time and costs. The sample size calculation was based on waiting time. A reduction in waiting time of 60 days (effect size), 25%, is significant, resulting in a sample size of 120 patients in total.DiscussionPoor communication between primary and secondary care often results in inefficiencies and unsatisfactory outcomes. We hypothesised that standardised referrals would improve the quality of information, making it feasible to use a one-stop approach for all patients undergoing surgery on an outpatient basis for inguinal hernia, pilonidal sinus and gallstones.In this study we wanted to investigate the waiting time and cost-effectiveness of direct electronic referral and booking of outpatient surgery compared to the traditional patient pathway, where the patient is seen at the outpatient clinic prior to surgery.Trial registrationThis trial has been registered at ClinicalTrials.gov. The trial registration number is: NCT00692497

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