Takao Ohki, MD, and Frank J. Veith, MD [From the Division of Vascular Surgery, Department of Surgery, Montefiore Medical Center and the Albert Einstein College of Medicine, New York]
Endovascular Grafts and Other Image-Guided Catheter-Based Adjuncts to Improve the Treatment of Ruptured Aortoiliac Aneurysms0
Annals of Surgery, Volume 232, October 2000, No.4, Pg Nos. 466-479
This is a report of a new approach for the treatment of ruptured aortoiliac aneurysms.
Hypotensive hemostasis minimizing fluid intake allowing [ systolic Blood Pressure 50 mmHg] was used. Under local anesthesia, a transbrachial guidewire was placed in the supraceliac aorta under fluoroscopic control. A 40-mm balloon catheter was inserted over this guidewire and inflated only if BP was less than 50 mmHg, before or after induction of anesthesia. Angiography was performed to determine suitability for endovascular graft repair. A prepared one-size-fits-most endovascular aortounifemoral stented PTFE graft was used. The contralateral common iliac artery was occluded and femorofemoral bypass performed.
If the anatomy was unsuitable for endovascular graft repair, a standard open repair was performed using proximal balloon control.
25 ruptured aorto-iliac aneurysms [ 18 aortic, 7 iliac] were managed by this approach. Balloon inflation was required in 9 cases. 20 were treated with endovascular prosthesis. 5 patients required open surgery. The ruptured aneurysms were excluded in all 25 cases, 23 survived. The two deaths occurred where endovascular prosthesis was used with serious comorbidities. The surviving patients had a median hospital stay of 6 days with complete relief of all symptoms.
Christopher K. Zarins, MD, Yehuda G. Wolf, MD, W. Anthony Lee, MD, Bradly B. Hill, MD,m Cornelius Olcott IV, MD E, John Harris, MD, Ronald L. Dalman, MD, and Thomas J. Fogarty, MD
Will Endovascular repair Replace Open Surgery for Abdominal Aortic Aneurysm Repair?
Annals of Surgery, Volume 232, October 2000, No.4, Pg Nos. 501-507
This study evaluates the impact of endovascular aneurysm repair on the rate of open surgical repair and the overall treatment of abdominal aortic aneurysms [AAAs].
All patients with AAA who were treated during two consecutive 40 month period were reviewed. During the first period only open surgical repair was performed and in the second period endovascular repair and open surgery were treatment options.
A total of 727 patients with aneurysm were treated in the initial period [ 40 months] 268 patients were treated by open surgery. [216 infrarenal 43 complex and 9 ruptured. In the second period 459 patients were treated. There was no significant change in the number of patients undergoing open surgery , and no difference in the rate of ifrarenal and complex AAA.
353 patients were referred for endovascular repair of these 190 were considered suitable on CT scan or anteriography. The most common reason for ineligibility were related to morphology of the neck in 65% and of the iliac arteries in 28%, a total of 149 cases underwent endovascular repair. It was successful in 147 patients and 2 patients had to be opened surgically. The hospital death rate was 0% and the 30 day mortality was 1%. During a follow up period of 1 to 39 months [mean 12 + 9 ]. 21 secondary procedures to treat endo leak or to maintain graft patency were performed in 17 patients [ 11%].
Endovascular repair has augmented treatment option rather than replaced open surgery in AAA.
Jennifer C. Hirsch, MD, Ralph S. Mosca, MD, and Edward L. Bove, MD [ From the Section of Cardiac Surgery, Department of Surgery, The University of Michigan School of Medicine, Ann Arbor, Michigan]
Complete Repair of Tetralogy of Fallot in the Neonates – Results in Modern Era
Annals of Surgery, Volume 232, October 2000, No.4, Pg Nos. 508-514
This is a review of more than a decade of experience with complete repair of Tetralogy of Fallot [TOF] in neonates, to assess early and late survival, perioperative complications and the incidence of reoperation and to analyze the risk factors.
Palliation of TOF with a systemic to pulmonary artery shunt has been accepted standard for symptomatic neonates and infants. Complete repair is traditionally done after the age of 6 months because of the high risk in infants.
This retrospective study [Aug. 1988 to Nov. 1999] includes 61 consecutive symptomatic neonates with TOF who underwent complete repair. 31 cases had TOF with pulmonary stenosis [ 24 had atresia and 6 had nonconfluent pulmonary arteries. The mean age at repair was [16+ 13 days and the mean weight was 3.2 + 0.7 kg. Before surgery, 36 patients were receiving an infusion of prostaglandin, 26 were mechanically ventilated, and 11 required inoropic support. Right ventricular outflow tract obstruction was managed with a transannular patch in 49 patients and a right ventricle to pulmonary artery conduit in 12, The cardiopulmonary bypass time averaged 71 + 26 minutes. Hypothermic circulatory arrest was used in 52 patients [mean 38 + 12 minutes]. After cardiopulmonary bypass the average intraoperative right/left ventricular pressure ratio was 55% + 13%.
There were no new clinically apparent neurologic sequelae after surgery. The postoperative intensive care stay was 9.1 + 8 days with 6.8 + 7 days of mechanical ventilation. There was one hospital death from nacrotizing enterocolstis on postoperative day 71 and four late deaths. Only one of which was cardiac related. Actuarial survival was 93% at 5 years. Follow up was available on all 60 survivals and overlapped 62 months [1-141 months].
22 patients required a total of 24 reoperations at an average interval of 26 months after repair [right ventricular outflow tract obstruction in 19, branch pulmonary artery stenosis 11, severe pulmonary insufficiency 4, and residual ventricular septal defect 1.
The 1 month, 1 year and 5 year freedom from reoperation rates were 100%, 89% amd 58% respectively.
Complete repair of TOF in the neonate has excellent intermediate term survival. The reoperation rate is significant.
R.J.F. Laheij, J. Buth, P.L. Harris, F.L. Moll, W.J. Stelter and E.L.G. Verhoeven on behalf of the EUROSTAR collaborators [ EUROSTAR Data Registry Center, Department of Surgery, Catharina Hospital, Eindhoven, Departments of Surgery, St. Antonius Hospital, Nieuwegein and University Hospital, Liverpool, UK and Department of Surgery, Stadtische Kliniken Frankfurt-Hoecht, Frankfurt, Germary]
Need for Secondary Interventions After Endovascular Repair of Abdominal Aortic Aneurysms. Intermediate-term Follow-up Results of a European Collaborative Registry [ EUROSTAR]
Br. Jour. of Sur. Volume 87, No.12, December 2000, Pgs-1666-4673
This study assesses the frequency of secondary interventions after endovascular repair of abdominal aorta aneurysms [AAA] and correlates with the clinical and radiological features during follow up.
Data was studied on 1023 patients with minimum follow up of one year.
Overall, 186 patients [18%] had a secondary intervention at a mean of 14 months after primary surgery. 12% of the interventions were transabdominal, 11% consisted of an extra-anatomic bypass, 76% had a transfemoral procedures. The rates of freedom from intervention at 1,3 and 4 years were 89, 67 and 62 per cent respectively. Migration and rupture were the most frequent causes of transabdominal intervention Graft limb thrombosis was the principal indication for extra anatomic bypass. Endoleak, graft kinking, stenosis or thrombosis and device migration were the other causes for transfemoral intervention.
The high incidence of secondary interventions is a cause for concern and emphasizes the need for life long surveillance
S.A. Norton and D. Alderson [ University of Surgery, Bristol Royal Infirmary, Bristol Uk]
Endoscopic Ultrasonography in the Evaluation of Idiopathic Acute Pancreatitis
Br. Jr. of Sur. Volume 87, No.12, December 2000, Pgs-1650-1655
The aim of this study was to determine if endoscopic ultrasonography [EUS] is able to detect small gallstones missed at transabdominal ultrasonography in case of ‘idiopathic’ pancreatitis.
Forty-four patients with ‘idiopathic’ pancreatitis were assessed using EUS for the presence of gall stones or other potential causes of the attack. A control group was also imaged. Ten patients had earlier attacks of pancreatitis. EUS revealed proven pathology in 18 patients. Unconfirmed pathology was evident in 14. No abnormality was seen in only 9 patients. EUS failed in one patient and there were two possible false positive results.
EUS is able to identify significant pathology in patients with ‘idiopathic ‘ pancreatitis.
T.M. Kennedy and R.H. Jones [ Department of General Practice and Primary Care, Guy’s King’s and St. Thomas’ School of Medicine, 5 Lambeth Walk, London SE11 6SP, UK]
Epidemiology of Cholecystectomy and Irritable Bowel Syndrome in a UK Population
Br. Jour. of Sur. Volume 87, No.12, December 2000, Pgs-1658-1663
This paper describes the prevalence of cholecystectomy and IBS in a sample of British adults. The association between the two conditions and their relation to consultation behavior and socioeconomic status are analyzed.
A postal questionnaire was sent to 4432 adults between 20-69 years with six general practices. The standard occupational classification was used as a proxy for socioeconomic status.
Cholecystectomy was reported by 4.1% of women and 1.3% of men. 22.9% of women had IBS [ odds ratio 1.9 (95% confidence interval 1.2-3.2); P<0.01]. The prevalence of cholecystectomy of IBS and of consultation for symptoms of IBS was not influenced by socioeconomic status.
They conclude that symptoms of IBS may cause diagnostic confusion and unproductive surgery. Cholecystectomy may cause IBS like symptoms, a single underlying disorder may produce symptoms in both gastrointestinal and biliary tracts or the associations might be a due to a combination of these factors.
M. R. Kell, D. C.Winter, G.C. O’Sullivan, F. Shanahan and H.P. Redmond
[Departments of Academic Surgery and Medicine, National University of Ireland, Cork University Hospital and ‘Mercy Hospital, Cork, Ireland]
Biological Behaviour and Clinical Implications of Micrometastases
Br. Jour. of Sur. Volume 87, No.12, December 2000, Pgs-1629-1639
The most important prognostic determinant in cancer is the identification of designated tumor burden [metastases]. Micrometastases are microscopic [<2mm] deposits of malignant cells that are segregated spatially from the primary tumour and depend on neovascular formation [angiogenesis] to propogate.
The literature on micrometastases and their implications in malignant melanoma and epithelial cancers is reviewed.
Immunohistochemical and serial sectioning methods were used. Molecular techniques were reserved for blood samples and bone marrow aspirates.
Detection of micrometastases in regional lymph nodes and/or bone marrow confers a poor prognosis in epithelial cancers. The concept of sentinel node biopsy combined with serial sectioning and dedicated screening for micrometastases may improve staging procedures. Strategies against angiogenesis may provide novel therapies to induce and maintain micrometastatic dormancy.
A Llaneza, F. Vizoso, J.C. Rodriguez, P. Raigoso, J.L. Garcia-Muniz, M.T. Allende and M. Garcia-Moran [ Department of Surgery and Nuclear Medicine, Hospital Central de Asturias, Oviedo and Department of Surgery, Hospital de Jove, Gijon, Spain]
Hyaluronic Acid as Prognostic Marker in Resectable Colorectal Cancer
Br. Jour. of Sur. Volume 87, No.12, December 2000, Pgs 1690-1696
Hyaluronic Acid [HA] an extracellular high molecular mass polysaccharide, is thought to be involved in the growth and progression of malignant tumours. This study evaluates the cytosolic HA content in resectable colonic cancer, and its possible relationship with clinicopathological parameters of tumours and its prognostic significance.
Cytosolic HA levels were examined by radiometric assay in 120 patients with resectable colorectal cancer. The mean follow up period was 33.4 months. The levels of cytosolic HA levels of tumours ranged widely from 3o to 29412 ng/mg protein. Intratumour HA levels were significantly correlated with Dukes Stage [P<0.005] and were higher in patients with advanced tumours [ mean [s.e.m.] 2695, 2858 and 5274 ng/mg protein for stages A-B and C respectively]. In addition, Cox multivariate analysis demonstrated that tumour HA levels >2000 ng/mg protein predicted shorter relapse free survival and overall survival period [both P<0.05].
They conclude that there is a wide variability in cytosolic HA levels in colorectal cancers, which seems to be related to the biological heterogeneity of the tumours. High tumour cytosolic HA levels were associated with an unfavourable prognosis.
O.Bernell, A. Lapidus and G. Hellers [ Departments of Surgery and Gastroenterology, Karolinska Institute, U niversity Hospitals, S-141 86 Huddinge, Sweden]
Risk Factors for Surgery and Recurrence in 907 Patients with Primary Ileocaecal Crohn’s Disease
Br. Jour. of Sur. Volume 87, No.12, December 2000, Pgs-1697-1701
This study aims to assess the risk for resection and postoperative recurrence, in the treatment of ileocaecal Crohn’s disease and to define factors affecting the course of the disease.
907 patients with primary ileocaecal Crohn’s disease were reviewed retrospectively.
Resection rates were 61, 77 and 83% at 1,5 and 10 years respectively after the diagnosis.
Relapse rates were 28 and 36 per cent 5 and 10 years after the first resection. A younger age at diagnosis resulted in a low resection rate. Presence of perianal Crohn’s disease and long resection segments increased the risk of recurrence, and resection for a palpable mass and /or abscess decreased the recurrence rate. A decrease in the recurrence rate during the study period was observed.
For ileocaecal Crohn’s disease the probability of resection is high and the risk of recurrence moderate. Perianal disease and extensive ileal resection increases the risk of recurrence. Diagnosis in childhood carries a lower risk of primary resection.
J.B.Y. So, A. Yam, W.K. Cheah, C.K. Kum and P.M.Y. Goh [ Department of Surgery, National University Hospital, Lower Kent Ridge Road, Singapore 119072, Republic of Singapore]
Risk Factors Related to Operative Mortality and Morbidity in Patients Undergoing Emergency Gastrectomy
Br. Jour. of Sur. Volume 87, No.12, December 2000, Pgs-1702-1707
This study aimed to evaluate the results of emergency gastrectomy and to examine the factors that predict the operative outcome.
82 patients who underwent emergency gastrectomy were studied. The following variables were assessed – pathology, mortality rate, morbidity, reasons for reoperation and factors related to the outcome.
There were 64 men and 18 women with a median age of 62 years [30-90]. The indications were bleeding or perforated ulcers in 45 and 20 cases respectively, and bleeding and perforated gastric tumours in 7 and 10 patients respectively.
The overall mortality was 17% [n=14]. The complication rate was 63%. 13% required reoperation.
By multivariate analysis, age greater than 65 years and a hemoglobin level less than 10 g/dl on admission were predictive of complications after emergency gastrectomy. Post-operative pulmonary and cardiac complications and hypotension on admission were independent risk factors associated with operative death. The mortality was not affected by the underlying pathology.
E. Trondsen, O. Mjaland, J. Raeder and T. Buanes [ Department of Gastroenterological Surgery and Anaesthesiology, Ullevel Hospital and University of Oslo, Oslo, Norway]
Day-case Iaparoscopic Fundoplication for Gastro-oesophageal Reflux Disease
Br. Jour. of Sur. Volume 87, No.12, December 2000, Pgs1708-1711
The initial results of outpatient laparoscopic fundoplication for gastro-oesophageal reflux disease are presented.
The inclusion criteria were American Society of Anaesthesiologists grade I-II, living within 30 minutes travel from the hospital and adult company at home.
The operation [Nissen-Rosetti fundoplication ] was done under general intravenous anaesthesia .
45 patients were operated. 4 needed admission and 41 were discharged as planned 3-8 hours after the operation but 5 of these were readmitted. One had to be re-explored for necrosis of the gastric fundus. A further 5 patients visited the OPD but did not need admission.
31 patients were satisfied with the procedure, 5 were indifferent, and 5 were dis-satisfied with the result because of pain.
The authors conclude that day case laparoscopic fundoplication is safe and well tolerated.
A.Kanamoto, H. Yamaguchi, Y. Nakanishi, Y. Tachimori, H. Kato and H. Watanabe [ Department of Internal Medicine and Surgery, National Cancer Center Hospital and Pathology Division, National Cancer Center Research Institute, Tokyo, Japan]
Clinicopathological Study of Multiple Superficial Oesophageal Carcinoma
Br. Jour. of Sur. Volume 87, No.12, December 2000, Pgs-1712-1715
The incidence of superficial oesophageal carcinoma has increased markedly in Japan in recent years as a result of advances in endoscopy.
359 patients with superficial oesophageal carcinoma [squamous cell] who underwent oesophagectomy [n=276] or endoscopic mucosal resection [ EMR n=83] were reviewed. The clinico-pathological features were compared with those of a single superficial oesophageal carcinoma.
Of 359 patients 99 [28%] had multiple superficial oesophageal carcinoma [M:F = 98:1 compared with 5:3:1 for those with a single carcinoma [n=260]. The incidence of tobacco and alcohol use was significantly higher in patients with multiple carcinomas. The incidence of pharyngeal malignancy was also higher in patients with multiple carcinomas.
They conclude that the high incidence of multiple superficial oesophageal carcinomas indicates a need for careful evaluation of the oesophagus at the time of initial diagnosis, treatment and follow up. Male sex, smoking, alcohol and the presence of pharyngeal malignancy are high risk factors.