Using glue & self-gripping mesh reduce operation duration in open hernia repair

Type: Randomized multicenter trial – FinnMesh Study.

 

Three groups were randomised: glue fixation vs. self-gripping mesh vs. suture fixation of mesh in Lichtenstein hernia repair

The duration of surgery was different: 34 min with glue, 32 min with self-gripping,  and 38 min with sutured mesh (P<0⋅001). The postoperative pain, pain killer requirement, complication rate or quality of life were not different.

 

Ann Surg 2015; 262: 714–720.

 

Preventing delirium in elderly patients after non-cardiac surgery

Level of evidence:  Randomised, double-blind, placebo-controlled trial

 Intravenous dexmedetomidine given to patients over 65 in the first 24 hours who are admitted to ITU following a major surgery can significantly reduce the risk of delirium (9% vs 23%, P<0⋅0001)

Lancet 2016; 388: 1893–1902.

Is it reasonable to use a stent inside the vein graft?

Ref. Circumstances Cardiovascular Interv Nov 2016

This study allows us, as vascular surgeons, to conclude .. as it is not exactly applicable in a direct manner.

Sealing Intermediate Nonobstructive Coronary Saphenous Vein Graft Lesions With Drug-Eluting Stentsas a New Approach to Reducing Cardiac Events: A Randomized Controlled Trial.

Abstract

BACKGROUND:

The objective of this study was to assess the efficacy of sealing intermediate nonobstructive coronary saphenous veingraft (SVG) lesions with drug-eluting stents (DES; paclitaxel- or everolimus-eluting stents) for reducing major adverse cardiac events (MACE).

METHODS AND RESULTS:

This was a randomized controlled multicenter clinical trial that enrolled patients with a previous coronary artery bypass graft who had developed at least 1 intermediate nonobstructive SVG lesion (30%-60% diameter stenosis by visual estimation). Patients were randomized (1:1) to DES implantation (SVG-DES) or medical treatment (SVG-MT) of the target SVG lesion. The primary efficacy outcome was the first occurrence of MACE defined as the composite of cardiac death, myocardial infarction, or coronary revascularization related to the target SVG during the duration of follow-up (minimum of 2 years). Secondary efficacy outcomes included MACE related to the target SVG lesion and overall MACE. A total of 125 patients (mean age 70±9 years, 87% men) were included, with a mean time from coronary artery bypass graft of 12±5 years. Sixty and 65 patients were allocated to the SVG-DES and SVG-MT groups, respectively. There were no events related to the target SVG at 30 days. After a median follow-up of 3.4 (interquartile range: 2.8-3.9) years, the MACE rate related to the target SVG was not significantly different in the 2 groups (SVG-DES: 15.0%, SVG-MT: 20.0%; hazard ratio, 0.65; 95% confidence interval, 0.23-1.53; P=0.33). There were no significant differences between groups in MACE related to the target SVG lesion (SVG-DES: 10.0%, SVG-MT: 16.9%; hazard ratio, 0.53; 95% confidence interval, 0.20-1.43; P=0.21) or global MACE (SVG-DES: 36.7%, SVG-MT: 44.6%; hazard ratio, 0.73; 95% confidence interval, 0.42-1.27; P=0.26).

CONCLUSIONS:

Sealing intermediate nonobstructive SVG lesions with DES was safe but was not associated with a significant reduction of cardiac events at 3-year follow-up.

What makes vascular surgery so distinctive?

Reflections from ‘know yourself’ – consultant interview preparation course

Vascular surgery is distinct in four main aspects when compared to almost all other branches of surgery:

  1. The level of complexity of cases is generally significantly higher than average.
  2. The age and comorbidities for vascular patients is huge
  3. There is a high level of potential complications, almost 30-50% of arterial cases will have a complication or more in the first 2 years.
  4. There is a continuous need for high attention to details ALL the time; one lost opportunity is a guarantee for a complication.

It is not therefore surprising that this branch of surgery:

  1. Result in a very high level of preoperative stress to the surgeon
  2. requires a high demand on creative thinking
  3. requires a huge demand on time, urgent, and duration of procedures.
  4. s very dynamic and changing
  5. is full of basic science
  6. is two specialties in one: surgery and targeted radiology; each requires to apply the 10,000 hour rule to master
  7. nd is the only surgical specialty that can intimately integrates both physics and physiology

 

Well .. not everyone is convinced though. This is what Br J Cardiol 2009;16:299–302 has to say:

We undertook a seven-year in-depth review of all reported obituaries of medical practitioners in the BMJ to assess the age and disease distribution of mortality of medical practitioners in order to identify relationships between mortality and discipline, ethnicity and other demographic factors. In total, 3,342 obituaries reported in the BMJ from January 1997 to December 2004 were reviewed.

The majority of obituaries were of male doctors. Doctors who qualified in the developed world appeared to live longer (mean age at death of 78 years) than those who qualified in Asia (mean age at death of 70 years). White-European doctors lived significantly longer than doctors from other ethnic groups. There was no significant difference in longevity between doctors working in the primary care sector and those in the secondary care sector. An eighth (12.5%) of doctors died between the ages of 60 and 70 years and, of these, nearly half died between the ages of 61 and 65 years. There were significantly more suicides and accidental deaths in Accident and Emergency (A&E) doctors compared with other specialties.

 

Does AAA rupture after EVAR, and how ‘dramatic’ the presentation is?

ref. JVS Jan 2017

Comparison of the outcomes between those occurring after endovascular repair (group 1) and those occurring without previous endovascular treatment (group 2) was made using the data collected and combining the results obtained by a previous study that analyzed the same findings between 1992 and 2003 from the same center to provide a total 22-year experience (1992-2014) at a single quaternary referral center.

Results

From May 1992 to September 2014, there were 1921 elective repairs of intact infrarenal AAAs, with 1288 endovascular and 633 open repairs. During 22 years, 40 of the 1288 patients (3.1%) who underwent endovascular repair for AAA had rupture. The proportion of patients with hypotension at presentation in group 1 (13/40) was significantly less than in group 2 (108/138P < .01). The difference in perioperative 30-day mortality rate in group 1 (8/40 [20%]) compared with group 2 (68/138 [49%]) was significant (P < .01).

Conclusions

This study confirmed that endovascular AAA repair does not prevent rupture in all patients. The data suggest that rupture, when it does occur, may not be accompanied by such major hemodynamic changes and higher mortality rate as with rupture of an untreated AAA. Strict surveillance and follow-up are required, especially in patients with relatively large initial AAA diameter or presence of endoleak and graft migration, to reduce the rate of ruptures after endovascular repair. Complete prevention will remain challenging because rupture may occur without any predisposing abnormalities. With the advent of new-generation devices, continuous larger long-term studies are required to document reduction in rupture rates after endovascular aneurysm repair.

predicting the behaviour of dissection from level of CT enhancement!

ref: JVS Jan 2017:

This relatively easy method of comparing the degree of enhancement of thrombus in the false lumen is easily obtainable and useful to a) understand the dynamics and b) predict outcome.

A total of 65 patients (42 men; mean age, 75 years) with type B IMH were evaluated retrospectively. On initial CT scans, attenuation of the false lumen (AFL) was determined before enhancement and in the early and delayed phases of contrast enhancement. Then enhancement of the false lumen (EFL) was calculated (AFL in the delayed image − AFL in the precontrast image). The Cox proportional hazards model was employed to estimate the risk of IMH-related events, including death or surgical repair.

Results

The mean AFL for precontrast CT, arterial phase enhanced CT, and delayed phase enhanced CT was 56.3 ± 10.5, 59.9 ± 10.8, and 63.7 ± 11.1 Hounsfield units, respectively, whereas the mean EFL was 7.4 ± 9.0 Hounsfield units. EFL was the only independent predictor of IMH-related events (n = 23; hazard ratio, 1.008; 95% confidence interval, 1.03-1.15; P = .0044) and IMH-related death/surgical repair (n = 10; hazard ratio, 1.111; 95% confidence interval, 1.017-1.213; P = .0197).

Conclusions

In patients with IMH, EFL is the most powerful predictor of IMH-related events, as well as IMH-related death or surgical repair.

Restenosis following Carotid endarterctomy: open redo or stenting??

Source: JVS Jan 2017:

This is a challenging question for real life cases … here is the results from this very large cohort of patients:

We studied all patients in the Vascular Quality Initiative (VQI) database who underwent CEA or CAS after prior ipsilateral CEA between January 2003 and April 2015. Univariate methods (χ2 and t-test) were used to compare patients’ characteristics and outcomes ≤30 days and up to 1 year. Multivariate logistic and Cox regression analyses, adjusting for patients’ demographic and clinical characteristics, were used to compare the procedures with respect to ipsilateral stroke, death, myocardial infarction (MI), stroke/death, and stroke/death/MI.

Results

This cohort of patients with prior ipsilateral CEA underwent 2863 carotid interventions, 1047 (37%) CEA, and 1816 (63%) CAS. Characteristics were similar in both groups. The 30-day ipsilateral stroke rate comparing CEA vs CAS was 2.2% vs 1.3% (P = .09) for asymptomatic patients and 1.2% vs 1.6% (P = .604) for symptomatic patients. The 30-day mortality was 1.3% vs 0.6% (P = .04), and MI occurred in 1.4% of CEA vs 1.1% of CAS patients (P = .443). Cranial nerve injury occurred in 4.1% of the redo-CEA cases, and access site complications occurred in 5.3% of the CAS cases. CEA was associated with higher mortality at 30 days (adjusted odds ratio [aOR], 2.83; 95% confidence interval [CI], 1.13-7.14; P = .027) and at 1 year (adjusted hazard ratio, 2.17; 95% CI, 1.03-4.58; P = .042). However, there were no differences in postoperative stroke (aOR, 0.54; 95% CI, 0.20-1.45, P = .22), MI (aOR, 0.98; 95% CI, 0.31-3.10; P = .97), stroke/death (aOR, 1.38; 95% CI, 0.72-2.67; P = .22), and stroke/death/MI (aOR, 1.38; 95% CI, 0.80-2.37; P = .25) between CEA and CAS after adjusting for patient characteristics, and freedom from stroke at 1 year was also similar (CEA: 96.7% vs CAS: 96.4%; P = .78).

Conclusions

In this population-based study, we have shown higher mortality but similar stroke and MI associated with redo CEA compared with CAS after prior ipsilateral CEA. We recommend avoidance of redo CEA in very sick patients. Smoking cessation remains a potent target for improvement of outcomes of carotid revascularization in these patients.