RESUMO
The aim of this study was to compare the filling of the pilonidal sinus tract with fibrin sealant (FS) against tract excision and primary closure (PC) as the primary procedure. Details of all patients who underwent treatment for a symptomatic first episode of pilonidal sinus disease between January 2011 and December 2015 were prospectively recorded in a custom database. Patients underwent PC (n=17) or FS (n=17) according to patient preference. Prior surgical treatment and ongoing infection precluded entry. Patients were treated with antibiotics if presenting with infection. Outcomes measured were recurrence, further procedures, outpatient attendances and length of follow-up to resolution. 34 consecutive patients [FS vs. PC: male n=15 vs. 12 p=0.398; mean age 29 (SEM 12) vs. 30 (SEM 15) p=0.849] were included. Treated preoperative infections were similar FS (n=5) vs. PC (n=12) (p=0.038, chi-squared test). FS cohort had more sinuses FS median (range) 2 (1-4) vs. PC 1 (1-3) (p=0.046). Postoperative outcomes: recurrence rate FS (n=5) vs. PC (n=4) (p=0.629); infection rate FS (n=1) vs. PC (n=8) (p=0.045); total number of operations required FS 1 (1-2) vs. PC 1 (1-4) (p=0.19); total number of outpatient attendance FS 2 (1-7) vs. PC 3 (1-16) (p=0.629); follow-up FS 129 days ± 33 vs. PC 136 ± 51 (p=0.914). Fibrin sealant is not inferior to excision followed by primary closure.
Assuntos
Adesivo Tecidual de Fibrina , Seio Pilonidal , Adulto , Feminino , Adesivo Tecidual de Fibrina/uso terapêutico , Humanos , Masculino , Recidiva Local de Neoplasia , Seio Pilonidal/cirurgia , Recidiva , Resultado do TratamentoRESUMO
PURPOSE: Pancreatic and periampullary adenocarcinoma have not generally been included in the tumour types considered for metastasectomy. However, there is an increasing interest that metastasectomy in well-selected patients can prolong survival. This review aims to establish the recent evidence on the surgical management of oligometastatic disease and survival outcome in patients who underwent metastasectomy focusing on isolated hepatic and pulmonary metastases. METHODS: A systematic search was performed in the PubMed database to identify all original articles on the role of metastasectomy for oligometastasis of pancreatic and periampullary adenocarcinoma. Data on methodologies used, 1,3,5 - year survival and median overall survival were summarized, and used to address relevant clinical questions related to the survival outcome in patients who underwent metastasectomy. RESULTS: Sixteen studies were included in this review. All the studies included were retrospective and heterogenous in nature and did not have a uniform reporting on survival outcomes. CONCLUSION: There is insufficient evidence to support a change of current practice in managing metastatic pancreatic and periampullary cancer. However, patients with ampullary cancer as the primary and any patients with first recurrence as isolated pulmonary metastases had better prognosis than patients with synchronous metastasis or metastases to the liver. This need to be explored in future studies.
Assuntos
Adenocarcinoma/cirurgia , Ampola Hepatopancreática/cirurgia , Neoplasias do Ducto Colédoco/cirurgia , Metastasectomia/mortalidade , Neoplasias/cirurgia , Neoplasias Pancreáticas/cirurgia , Adenocarcinoma/secundário , Ampola Hepatopancreática/patologia , Neoplasias do Ducto Colédoco/secundário , Humanos , Neoplasias/patologia , Neoplasias Pancreáticas/secundário , Prognóstico , Taxa de SobrevidaRESUMO
George Theofanis, Mahmud Saedon, Soo Hua Kho, Francesk Mulita, Stylianos Germanos and Edmund Leung discuss the use of sugar as an aid to reducing a stomal prolapse.
Assuntos
Colostomia/efeitos adversos , Açúcares da Dieta/administração & dosagem , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Administração Tópica , Idoso , Edema/prevenção & controle , Tratamento de Emergência , Humanos , Masculino , Prolapso , AçúcaresRESUMO
BACKGROUND: Obesity is increasingly common in patients referred for the management of an abdominal aortic aneurysm (AAA). Evidence of the effect of obesity on outcomes after endovascular repair (EVAR) is not well established. We sought to compare the immediate and midterm outcomes of elective EVAR between obese and nonobese patients in a case control study. METHODS: Patients undergoing elective EVAR were divided in 2 groups: obese (defined as a body mass index [BMI] ≥30 kg/m(2)) and nonobese (mean BMI [kg/m(2)] ± SD: 33 ± 1 vs 25 ± 3). Both groups were case-matched for age, sex, smoking, and AAA diameter. One hundred fifty-nine patients were included (mean age: 69 ± 9 years; 10 women [9%]; mean BMI: 28 ± 5 kg/m(2); 53 were obese and 106 were nonobese). All aneurysms were successfully excluded. Mean follow-up was 34 ± 13 months. RESULTS: All patients who developed a complication within the perioperative period (≤30 days) were obese (P = 0.01). Thirteen patients (8.2%) died during follow-up (8 obese versus 5 nonobese; P = 0.76). Survival and non-procedure-related morbidity did not differ significantly between the obese and nonobese groups (P = 0.64 and 0.16; log-rank test). BMI was not associated with mortality or non-procedure-related morbidity on multivariate analysis (mortality-hazard ratio: 1.0 [95% confidence interval: 0.9-1.2]; P = 0.37; non-procedure-related morbidity-hazard ratio: 1.0 [95% confidence interval: 0.9-1.1], P = 0.2). CONCLUSIONS: This is the first case control study to assess the independent impact of obesity in the outcome after EVAR. No difference was documented with regards to mortality or non-aneurysm-related morbidity.
Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular , Procedimentos Endovasculares , Obesidade/complicações , Idoso , Aneurisma da Aorta Abdominal/complicações , Aneurisma da Aorta Abdominal/mortalidade , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/mortalidade , Índice de Massa Corporal , Estudos de Casos e Controles , Procedimentos Cirúrgicos Eletivos , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Obesidade/diagnóstico , Obesidade/mortalidade , Complicações Pós-Operatórias/mortalidade , Modelos de Riscos Proporcionais , Estudos Prospectivos , Fatores de Risco , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND AND PURPOSE: Cerebral microemboli signals (MES) are associated with increased risk of acute stroke syndromes. We compared the effects on cerebral microemboli after carotid endarterectomy of tirofiban with dextran-40. METHODS: We used transcranial Doppler ultrasound to study transient MES acutely after carotid endarterectomy between August 2000 and December 2010 in 128 subjects refractory to preoperative antiplatelet treatment. Antithrombotic treatment was given for MES ≥50 hour(-1) (tirofiban: 40 patients [age 74 ± 1 {SEM}, males 27, and white 38]; dextran-40: 34 patients [age 69 ± 2, males 22, white 30]). In 54 patients with MES <50 hour(-1) (age 71 ± 1, male 36, white 52), MES were monitored during their spontaneous resolution (controls). Data are median (interquartile range). RESULTS: The time to 50% reduction in MES (tirofiban 23 minutes [15-28]; dextran-56 [43-83]; controls 30 [22-38]; P<0.001, Kruskal-Wallis analysis) and for complete MES resolution (tirofiban 68 minutes [53-94]; dextran-113 [79-146]; controls 53 [49-68]; P<0.001, Kruskal-Wallis analysis) were shorter with tirofiban. The early cardiovascular event rate was similar with tirofiban compared with controls but increased in patients who received dextran. CONCLUSIONS: These findings suggest that transcranial Doppler-directed tirofiban therapy is more effective than dextran-40 in suppression of cerebral microemboli after carotid endarterectomy.
Assuntos
Endarterectomia das Carótidas/efeitos adversos , Embolia Intracraniana/prevenção & controle , Inibidores da Agregação Plaquetária/farmacocinética , Inibidores da Agregação Plaquetária/uso terapêutico , Complicações Pós-Operatórias/prevenção & controle , Sistema de Registros , Idoso , Feminino , Humanos , Embolia Intracraniana/diagnóstico por imagem , Embolia Intracraniana/metabolismo , Cinética , Masculino , Microcirculação/efeitos dos fármacos , Microcirculação/fisiologia , Complicações Pós-Operatórias/diagnóstico por imagem , Complicações Pós-Operatórias/metabolismo , Estudos Retrospectivos , Resultado do Tratamento , Ultrassonografia Doppler Transcraniana/métodosRESUMO
Acute kidney injury (AKI) after any type of intervention negatively impacts mortality, length of hospitalization, and perhaps long-term survival. In the case of endovascular aneurysm repair (EVAR), the incidence of AKI ranges from 1% to 23% for elective and emergency procedures and is lower compared to open repair. The pathophysiology of AKI in EVAR is complex: contrast-induced nephropathy, renal microembolization, and acute tubular necrosis are all implicated. Prevention strategies include hydration, ischemic preconditioning, regional anesthesia, and pharmacological agents. There is no level I evidence regarding the prevention of AKI in EVAR, so this review sought to examine the mechanisms and prevention strategies for this potentially fatal complication.
Assuntos
Injúria Renal Aguda/etiologia , Aneurisma da Aorta Abdominal/cirurgia , Procedimentos Endovasculares/efeitos adversos , Injúria Renal Aguda/prevenção & controle , HumanosRESUMO
Aims: To demonstrate feasibility and efficacy of simultaneous intraoperative cholangiogram (IOC) and antegrade biliary stenting (ABS) with laparoscopic cholecystectomy (LC) compared with preoperative biliary investigation and delayed LC in acute gallstone pancreatitis (AGP). Methods: A retrospective case-control study was performed comparing patients who had a simultaneous IOC ± ABS with LC at index admission with those who had delayed LC in the treatment of AGP. 74 patients were included in this study from January 2016 to October 2018. All patients who underwent LC for AGP were included in a prospective database with 1 year follow-up. Results: 30 (40.5%) patients underwent simultaneous IOC ± ABS with LC, 11 of these required ABS insertion. 2 (6.7%) patients also underwent magnetic resonance cholangiopancreatography (MRCP). No patients underwent endoscopic retrograde cholangiopancreatography (ERCP). No patients were readmitted with AGP or symptomatic gallbladder. Mean length of total hospital admission was 10.1 days. 44 (59.5%) patients underwent delayed LC. Of this cohort, 7 (15.9%) patients underwent ERCP and 19 (43.2%) underwent MRCP. In total, there were 19 (43.2%) readmissions in this group with pancreatitis or symptomatic gallbladder. Mean length of total hospital admission was 13 days. Conclusions: In our pilot study we demonstrated that performing simultaneous IOC ± ABS with LC is a feasible option in the secondary care setting. Using this surgical technique, we have demonstrated a reduction in readmissions with AGP and symptomatic gallbladder while also reducing the number of CBD investigations required. Using simultaneous IOC ± ABS with LC reduced the mean total length of stay in hospital.
Assuntos
Colecistectomia Laparoscópica , Coledocolitíase , Cálculos Biliares , Pancreatite , Humanos , Cálculos Biliares/complicações , Cálculos Biliares/cirurgia , Colecistectomia Laparoscópica/métodos , Projetos Piloto , Estudos Retrospectivos , Estudos de Casos e Controles , Colangiografia , Colangiopancreatografia Retrógrada Endoscópica/métodos , Pancreatite/cirurgia , Pancreatite/complicações , Coledocolitíase/cirurgia , Cuidados IntraoperatóriosRESUMO
BACKGROUND: With recent emphasis placed on workplace based assessment (WBA) as a method of formative performance assessment, there is limited evidence in the current literature regarding the role of feedback in improving the effectiveness of WBA. The aim of this systematic review was to elucidate the impact of feedback on the effectiveness of WBA in postgraduate medical training. METHODS: Searches were conducted using the following bibliographic databases to identify original published studies related to WBA and the role of feedback: Medline (1950-December 2010), Embase (1980-December 2010) and Journals@Ovid (English language only, 1996-December 2010). Studies which attempted to evaluate the role of feedback in WBA involving postgraduate doctors were included. RESULTS: 15 identified studies met the inclusion criteria and minimum quality threshold. They were heterogeneous in methodological design. 7 studies focused on multi source feedback, 3 studies were based on mini-clinical evaluation exercise, 2 looked at procedural based assessment, one study looked at workplace based assessments in general and 2 studies looked at a combination of 3 to 6 workplace based assessments. 7 studies originated from the United Kingdom. Others were from Canada, the United States and New Zealand. Study populations were doctors in various grades of training from a wide range of specialties including general practice, general medicine, general surgery, dermatology, paediatrics and anaesthetics. All studies were prospective in design, and non-comparative descriptive or observational studies using a variety of methods including questionnaires, one to one interviews and focus groups. CONCLUSIONS: The evidence base contains few high quality conclusive studies and more studies are required to provide further evidence for the effect of feedback from workplace based assessment on subsequent performance. There is, however, good evidence that if well implemented, feedback from workplace based assessments, particularly multisource feedback, leads to a perceived positive effect on practice.
Assuntos
Competência Clínica/normas , Educação Médica Continuada/normas , Avaliação Educacional/métodos , Local de Trabalho , Retroalimentação , HumanosRESUMO
There is no consensus regarding timing of peritoneal dialysis (PD) catheter removal following kidney transplant. We hypothesize that early removal of PD catheter reduces the risk of peritonitis. We conducted a prospective closed-loop audit to review existing practice in our department and determine whether a better strategy could be implemented. Simple descriptive and inferential statistics were used to generate results. Categorical data were described using frequency and percentage. Continuous values were reported as mean ± standard deviation. Between November 2016 and April 2017, forty patients had renal transplant with PD in situ. On average time to removal of PD catheter, posttransplant was 84 days. Four patients (10%) developed exit-site infection. Following departmental consultation, practice was changed to remove all PD catheters at the time of transplant. Between May 2017 and January 2018, twenty patients had renal transplant and 19 had PD catheter removed at the time of transplant. Of these, one required re-insertion. In the patient where PD catheter was left in situ, peritonitis was a complication. We continue to recommend PD catheter removal at the time of transplant.
Assuntos
Cateteres de Demora , Remoção de Dispositivo , Transplante de Rim , Diálise Peritoneal/instrumentação , Peritonite/microbiologia , Cateteres de Demora/efeitos adversos , Humanos , Transplante de Rim/efeitos adversos , Diálise Peritoneal/efeitos adversos , Diálise Peritoneal Ambulatorial Contínua , Peritonite/diagnóstico , Peritonite/etiologia , Estudos ProspectivosRESUMO
We describe a case where a patient received a successful dual kidney transplantation in a staggered fashion. Two kidneys from a deceased donor were accepted for 2 separate primary intended recipients, however, due to unforeseen circumstances, both kidneys were eventually transplanted in a staggered fashion into an alternate single recipient. The intention behind this method was to enhance the patient's renal function and to prevent the wastage of a kidney. Despite the significantly prolonged cold ischemia times, the recipient has excellent dual graft function after 3 years. The positive outcome underpins the effectiveness of donor kidneys even with prolonged cold ischemia times outside established best practice guidelines. It also reinforces the effectiveness of dual kidney transplantation. Transplant professionals encounter complex situations occasionally where an established evidence-base or aids to decision-making are limited. This case reflects challenges in decision-making, patient counselling and consent, especially when the opportunity for the staggered dual kidney transplantation, with potential increased morbidity, came about as another recipient declined a usable kidney. It also highlights the widely differing risk appetites of different patients. Crucially, it optimised the donation process and procurement of 2 kidneys while preventing wastage. To our knowledge, this is the first report of a staggered dual kidney transplantation in a single recipient.
Assuntos
Transplante de Rim , Obtenção de Tecidos e Órgãos , Sobrevivência de Enxerto , Humanos , Rim , Fatores de Risco , Doadores de TecidosRESUMO
Gallstone ileus is a rare but potentially serious complication of cholelithiasis. It is usually preceded by history of biliary symptoms. It usually occurs as a result of a large gallstone creating and passing through a cholecysto-enteric fistula. Most of the time, the stone will pass the GI tract without any problems, but large enough stones can cause obstruction. The two most common locations of impaction are the terminal ileum and the ileocaecal valve because of the anatomical small diameter and less active peristalsis. We present an unusual case of small bowel obstruction secondary to gallstone ileus 24 years after an open cholecystectomy.
Assuntos
Colecistectomia , Colelitíase/complicações , Cálculos Biliares/complicações , Íleus/etiologia , Idoso , Colelitíase/diagnóstico por imagem , Colelitíase/etiologia , Colelitíase/cirurgia , Cálculos Biliares/diagnóstico por imagem , Cálculos Biliares/cirurgia , Humanos , Íleus/diagnóstico por imagem , Íleus/cirurgia , Masculino , Fatores de Tempo , Tomografia Computadorizada por Raios XRESUMO
BACKGROUND: Cerebral microemboli may lead to ischaemic neurological complications after carotid endarterectomy (CEA). The association between classical cardiovascular risk factors and acute cerebral microemboli following carotid surgery has not been studied. The aim of this study was to explore whether an established cardiovascular risk score (Pocock score) predicts the presence of cerebral microemboli acutely after CEA. SUBJECTS AND METHODS: Pocock scores were assessed for the 670 patients from the Carotid Surgery Registry (age 71±1 (SEM) years, 474 (71%) male, 652 (97%) Caucasian) managed from January 2002 to December 2012 in the Regional Vascular Centre at University Hospitals Coventry and Warwickshire NHS Trust, which serves a population of 950 000. CEA was undertaken in 474 (71%) patients for symptomatic carotid stenosis and in 196 (25%) asymptomatic patients during the same period. 74% of patients were hypertensive, 71% were smokers and 49% had hypercholesterolaemia. RESULTS: A high Pocock score (≥2.3%) was significantly associated with evidence of cerebral microemboli acutely following CEA (P=0.039, Mann-Whitney (MW) test). A Pocock score (≥2.3%) did not predict patients who required additional antiplatelet therapy (microemboli signal (MES) rate >50 hour-1: P=0.164, MW test). Receiver operating characteristic analysis also showed that the Pocock score predicts acute postoperative microemboli (area under the curve (AUC) 0.546, 95% CI 0.502 to 0.590, P=0.039) but not a high rate of postoperative microemboli (MES >50 hour-1: AUC 0.546, 95% CI 0.482 to 0.610, P=0.164). A Pocock score ≥2.3% showed a sensitivity of 74% for the presence of acute postoperative cerebral microemboli. A Pocock score ≥2.3% also showed a sensitivity of 77% and a negative predictive value of 90% for patients who developed a high microembolic rate >50 hour-1 after carotid surgery. CONCLUSION: These findings demonstrate that the Pocock score could be used as a clinical tool to identify patients at high risk of developing acute postoperative microemboli.
Assuntos
Estenose das Carótidas/cirurgia , Técnicas de Apoio para a Decisão , Endarterectomia das Carótidas/efeitos adversos , Embolia Intracraniana/etiologia , Idoso , Estenose das Carótidas/complicações , Estenose das Carótidas/diagnóstico por imagem , Tomada de Decisão Clínica , Feminino , Humanos , Embolia Intracraniana/diagnóstico por imagem , Masculino , Valor Preditivo dos Testes , Sistema de Registros , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Ultrassonografia Doppler TranscranianaRESUMO
Gastroesophageal reflux disease (GORD) is a pathological process in infants manifesting as poor weight gain, signs of esophagitis, persistent respiratory symptoms and changes in neurobehaviour. It is currently estimated that approximately one in every 350 children will experience severe symptomatic gastroesophageal reflux necessitating surgical treatment. Surgery for GORD is currently one of the common major operations performed in infants and children. Most of the studies found favour laparoscopic approach which has surpassed open antireflux surgery as the gold standard of surgical management for GORD. However, it must be interpreted with caution due to the limitation of the studies, especially the small number of subject included in these studies. This review reports the changing trends in the surgical treatment of GORD in children.
Assuntos
Refluxo Gastroesofágico/cirurgia , Criança , Fundoplicatura , Refluxo Gastroesofágico/diagnóstico , Refluxo Gastroesofágico/fisiopatologia , Humanos , Lactente , Laparoscopia , Fatores de RiscoRESUMO
INTRODUCTION: ABCD2 risk score and cerebral microemboli detected by transcranial Doppler (TCD) have been separately shown to the predict risk of recurrent acute stroke. We studied whether ABCD2 risk score predicts cerebral microemboli in patients with hyper-acute symptomatic carotid artery stenosis. PARTICIPANTS AND METHODS: We studied 206 patients presenting within 2â weeks of transient ischaemic attack or minor stroke and found to have critical carotid artery stenosis (≥50%). 86 patients (age 70±1 (SEM: years), 58 men, 83 Caucasian) had evidence of microemboli; 72 (84%) of these underwent carotid endarterectomy (CEA). 120 patients (age 72±1â years, 91 men, 113 Caucasian) did not have microemboli detected; 102 (85%) of these underwent CEA. Data were analysed using X2 and Mann-Whitney U tests and receiver operating characteristic (ROC) curves. RESULTS: 140/206 (68%: 95% CI 61.63 to 74.37) patients with hyper-acute symptomatic critical carotid stenosis had an ABCD2 risk score ≥4. There was no significant difference in the NICE red flag criterion for early assessment (ABCD2 risk score ≥4) for patients with cerebral microemboli versus those without microemboli (59/86 vs 81/120 patients: OR 1.05 ABCD2 risk score ≥4 (95% CI 0.58 to 1.90, p=0.867)). The ABCD2 risk score was <4 in 27 of 86 (31%: 95% CI 21 to 41) embolising patients and in 39 of 120 (31%: 95% CI 23 to 39) without cerebral microemboli. After adjusting for pre-neurological event antiplatelet treatment (APT), area under the curve (AUC) of ROC for ABCD2 risk score showed no prediction of cerebral microemboli (no pre-event APT, n=57: AUC 0.45 (95% CI 0.29 to 0.60, p=0.531); pre-event APT, n=147: AUC 0.51 (95% CI 0.42 to 0.60, p=0.804)). CONCLUSIONS: The ABCD2 score did not predict the presence of cerebral microemboli or carotid disease in over one-quarter of patients with symptomatic critical carotid artery stenosis. On the basis of NICE guidelines (refer early if ABCD2 ≥4), assessment of high stroke risk based on ABCD2 scoring may lead to inappropriate delay in urgent treatment in many patients.
Assuntos
Estenose das Carótidas/diagnóstico , Regras de Decisão Clínica , Embolia Intracraniana/diagnóstico , Ataque Isquêmico Transitório/diagnóstico , AVC Isquêmico/diagnóstico , Idoso , Estenose das Carótidas/complicações , Estenose das Carótidas/terapia , Tomada de Decisão Clínica , Feminino , Humanos , Embolia Intracraniana/etiologia , Embolia Intracraniana/terapia , Ataque Isquêmico Transitório/etiologia , Ataque Isquêmico Transitório/terapia , AVC Isquêmico/etiologia , AVC Isquêmico/terapia , Masculino , Valor Preditivo dos Testes , Prognóstico , Estudos Prospectivos , Sistema de Registros , Medição de Risco , Fatores de Risco , Fatores de Tempo , Triagem , Ultrassonografia Doppler TranscranianaRESUMO
We presented a staged approach to treating oropharyngeal venous malformation in Jehovah Witness patient.
Assuntos
Imageamento por Ressonância Magnética , Faringe , Traqueia , Malformações Vasculares , Feminino , Humanos , Testemunhas de Jeová , Pessoa de Meia-Idade , Faringe/irrigação sanguínea , Faringe/diagnóstico por imagem , Faringe/cirurgia , Traqueia/irrigação sanguínea , Traqueia/diagnóstico por imagem , Traqueia/cirurgia , Malformações Vasculares/diagnóstico por imagem , Malformações Vasculares/cirurgiaAssuntos
Colostomia , Glucanos/efeitos adversos , Glucose/efeitos adversos , Soluções para Hemodiálise/efeitos adversos , Cuidados Intraoperatórios/efeitos adversos , Aderências Teciduais/induzido quimicamente , Idoso , Feminino , Reação a Corpo Estranho/induzido quimicamente , Reação a Corpo Estranho/patologia , Humanos , Icodextrina , Masculino , Pessoa de Meia-Idade , Aderências Teciduais/patologiaRESUMO
BACKGROUND: Chronic mesenteric ischemia (CMI) can be treated with surgical revascularization (SR) or endovascular revascularization (ER). MATERIALS AND METHODS: Systematic review of 12 studies comparing ER and SR in CMI. Primary end point was perioperative (30 days) survival. A secondary composite end point consisted of perioperative mortality, nonfatal cardiac events, nonfatal stroke, and nonfatal bowel ischemia. Further end points included late survival, primary patency, and symptom improvement. RESULTS: The cumulative odds ratio (OR) for perioperative mortality was 0.78 (95% confidence interval [CI]: 0.40-1.50, P = .45) and 0.56 (95% CI: 0.28-1.11, P = .10) for the composite end point. The cumulative OR for survival after the 30th day was 0.83 (95% CI: 0.47-1.46), P = .51. Late primary patency was reported in 8 studies, with a cumulative OR of 3.57 (95% CI: 1.83-6.97, P = .0002)-favoring SR. CONCLUSION: In the first meta-analysis to compare ER and SR in CMI, there were no differences in mortality and morbidity. Patency rates were better following SR.
Assuntos
Implante de Prótese Vascular , Procedimentos Endovasculares , Isquemia Mesentérica/cirurgia , Oclusão Vascular Mesentérica/cirurgia , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/mortalidade , Doença Crônica , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Humanos , Isquemia Mesentérica/diagnóstico , Isquemia Mesentérica/mortalidade , Isquemia Mesentérica/fisiopatologia , Oclusão Vascular Mesentérica/diagnóstico , Oclusão Vascular Mesentérica/mortalidade , Oclusão Vascular Mesentérica/fisiopatologia , Razão de Chances , Complicações Pós-Operatórias/etiologia , Fatores de Risco , Análise de Sobrevida , Fatores de Tempo , Resultado do Tratamento , Grau de Desobstrução VascularRESUMO
BACKGROUND: In 2009, the NHS evidence adoption center and National Institute for Health and Care Excellence (NICE) published a review of the use of endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAAs). They recommended the development of a risk-assessment tool to help identify AAA patients with greater or lesser risk of operative mortality and to contribute to mortality prediction.A low anaerobic threshold (AT), which is a reliable, objective measure of pre-operative cardiorespiratory fitness, as determined by pre-operative cardiopulmonary exercise testing (CPET) is associated with poor surgical outcomes for major abdominal surgery. We aimed to assess the impact of a CPET-based risk-stratification strategy upon perioperative mortality, length of stay and non-operative costs for elective (open and endovascular) infra-renal AAA patients. METHODS: A retrospective cohort study was undertaken. Pre-operative CPET-based selection for elective surgical intervention was introduced in 2007. An anonymized cohort of 230 consecutive infra-renal AAA patients (2007 to 2011) was studied. A historical control group of 128 consecutive infra-renal AAA patients (2003 to 2007) was identified for comparison.Comparative analysis of demographic and outcome data for CPET-pass (AT ≥ 11 ml/kg/min), CPET-fail (AT < 11 ml/kg/min) and CPET-submaximal (no AT generated) subgroups with control subjects was performed. Primary outcomes included 30-day mortality, survival and length of stay (LOS); secondary outcomes were non-operative inpatient costs. RESULTS: Of 230 subjects, 188 underwent CPET: CPET-pass n = 131, CPET-fail n = 35 and CPET-submaximal n = 22. When compared to the controls, CPET-pass patients exhibited reduced median total LOS (10 vs 13 days for open surgery, n = 74, P < 0.01 and 4 vs 6 days for EVAR, n = 29, P < 0.05), intensive therapy unit requirement (3 vs 4 days for open repair only, P < 0.001), non-operative costs (£5,387 vs £9,634 for open repair, P < 0.001) and perioperative mortality (2.7% vs 12.6% (odds ratio: 0.19) for open repair only, P < 0.05). CPET-stratified (open/endovascular) patients exhibited a mid-term survival benefit (P < 0.05). CONCLUSION: In this retrospective cohort study, a pre-operative AT > 11 ml/kg/min was associated with reduced perioperative mortality (open cases only), LOS, survival and inpatient costs (open and endovascular repair) for elective infra-renal AAA surgery.
RESUMO
OBJECTIVES: Temporal artery biopsy (TAB) is performed in suspected cases of sight-threatening giant cell arteritis (GCA). We aimed to determine the feasibility of TAB in patients who are suspected of having GCA. DESIGN, SETTING AND PARTICIPANTS: A retrospective audit of all patients undergoing TAB at a single teaching hospital between 2005 and 2011, identified from the histopathology database. MAIN OUTCOME MEASURES: (1) Clinical profile and biochemical criteria associated with positive histology. (2) Proportion of negative histology patients who were commenced on steroid therapy. RESULTS: One hundred and fifty-three TAB were performed (mean age 70.8 years, men:women = 3:2, 110 Caucasian: 43 Asian). Thirty-two biopsies were positive for GCA and 121 were negative. In total, 68 (61%) of 112 negative TAB patients were clinically diagnosed with GCA despite histological findings (P < 0.001). Nine out of 153 biopsies were non-arterial. Histologically positive TAB patients were of higher mean age (77.1 [95% CI 74.5-79.7] versus 69.1 [95% CI 66.7-71.6]; P < 0.001) and had a higher erythrocyte sedimentation rate (ESR) (60 [95% CI 46.1-73.9] versus 39.8 [95% CI 34.2-45.3]; P < 0.01)] than those with negative histology. CONCLUSIONS: Raised ESR and higher age may be the most useful indicators of GCA. Many histologically negative individuals were nevertheless clinically diagnosed and managed as GCA.