Locoregional anesthesia for endovascular aneurysm repair.

OBJECTIVE: This was a systematic review and meta-analysis of the mode of anesthesia and outcome after endovascular aneurysm repair (EVAR). METHODS: Review methods were according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Published and unpublished literature was searched. The primary outcome was 30-day mortality. Secondary outcomes were categorized for patient selection, perioperative outcomes, and postoperative outcomes. Weighted mean differences (WMD) were calculated for continuous variables, such as length of stay, and pooled odds ratios (OR) were calculated for discrete variables such as major morbidity. RESULTS: Ten studies of 13,459 patients given local anesthesia (LA) or general anesthesia (GA) were eligible for analysis. There was no difference in 30-day mortality. The LA patients were older than the GA patients (WMD, 0.17; P = .006), with an increased burden of cardiac (LA vs GA: OR, 1.28; P = .011) and respiratory (LA vs GA: OR, 1.28; P = .006) comorbidity. LA EVAR was reported with shorter operative time (WMD, -0.54; P = .001) and hospital stay (WMD, -0.27; P = .001) vs GA. LA patients developed fewer postoperative complications than GA patients (OR, 0.54; P < .001). CONCLUSIONS: The absence of randomized data is a major hurdle to understanding the effect of anesthetic technique on morbidity after EVAR. The data presented are encouraging in selected patients. The use of locoregional anesthesia for EVAR should be further investigated with better reporting of aneurysm morphology to clarify its potential benefits and identify the subgroups that will derive greatest benefit.

Preoperative cardiopulmonary exercise testing in England - a national survey.

BACKGROUND: Cardiopulmonary exercise testing (CPET) has become well established in the preoperative assessment of patients presenting for major surgery in the United Kingdom. There is evidence supporting its use in risk-stratifying patients prior to major high-risk surgical procedures.We set out to establish how CPET services in England have developed since the only survey on this subject was undertaken in 2008 (J Intensive Care Soc 2009, 10:275-278). METHODS: Availability of preoperative CPET and contact details were collected via a telephone survey and email invites to complete the online survey were sent to all contacts. The survey was live during March and April 2011. RESULTS: We received 123 (74%) responses from the 166 emails that were sent out. In total, 32% (53/166) of all adult anesthetic departments in England have access to preoperative CPET services and a further 4% (6) were in the process of setting up services. The number of departments offering preoperative CPET, including those in the process of setting up services, has risen from 42 in 2008 to 59 in 2011, a rise of over 40%. Only 61% of the clinics are run by anesthetists and 39% of clinics have trained cardiorespiratory technicians assisting in the performance of the test. Most of the clinics (55%) rely solely on a bicycle ergometer. Vascular surgical patients are the largest group of patients tested, and the majority of tests are run to a symptom-limited maximum. We estimate that 15,000 tests are performed annually for preoperative assessment in England. Only 37% of respondents were confident that the tests performed were being billed for. CONCLUSIONS: CPET is increasing in popularity as a preoperative risk assessment tool. There remains a lack of consistency in the way tests are reported and utilized. The results highlight the extent and diversity of the use of preoperative CPET and the potential for further research into its use in unstudied patient groups.

Meta-analysis and systematic review of the relationship between surgeon annual caseload and mortality for elective open abdominal aortic aneurysm repairs.

OBJECTIVE: To assess the relationship between the annual caseload of elective open abdominal aortic aneurysm (AAA) repairs performed by individual surgeons and mortality. METHODS: PubMed, EMBASE, and the Cochrane library were searched for articles on the volume-outcome relationship in AAA surgery. The review conformed to the QUOROM statement. The data were meta-analyzed to compare the mortality rates of higher- and lower-volume surgeons. A critical volume threshold was calculated for better practice. RESULTS: Fourteen relevant articles were retrieved from the searches. A systematic review was performed, and six were meta-analyzed. A total of 115,273 elective open AAA repairs were considered, with a mean mortality rate of 5.56%. Significant relationships between higher surgeon caseload and lower mortality were demonstrated in 12 of 14 studies. From the meta-analysis, the pooled effect estimate was an odds ratio of 0.56 (95% confidence interval, 0.54-0.57) in favor of higher-volume surgeons. A critical volume threshold was identified as 13 cases per annum for individual surgeons. CONCLUSIONS: As surgeons performed higher annual volumes of elective open AAA repairs, significantly lower mortality rates were demonstrated. Surgeons wishing to perform elective AAA repairs should achieve a minimum case volume of 13 repairs per annum.