Editor's Choice - Nationwide Analysis of Patients Undergoing Iliac Artery Aneurysm Repair in the Netherlands.

OBJECTIVE: The new 2019 guideline of the European Society for Vascular Surgery (ESVS) recommends consideration for elective iliac artery aneurysm (eIAA) repair when the iliac diameter exceeds 3.5 cm, as opposed to 3.0 cm previously. The current study assessed diameters at time of eIAA repair and ruptured IAA (rIAA) repair and compared clinical outcomes after open surgical repair (OSR) and endovascular aneurysm repair (EVAR). METHODS: This retrospective observational study used the nationwide Dutch Surgical Aneurysm Audit (DSAA) registry that includes all patients who undergo aorto-iliac aneurysm repair in the Netherlands. All patients who underwent primary IAA repair between 1 January 2014 and 1 January 2018 were included. Diameters at time of eIAA and rIAA repair were compared in a descriptive fashion. The anatomical location of the IAA was not registered in the registry. Patient characteristics and outcomes of OSR and EVAR were compared with appropriate statistical tests. RESULTS: The DSAA registry comprised 974 patients who underwent IAA repair. A total of 851 patients were included after exclusion of patients undergoing revision surgery and patients with missing essential variables. eIAA repair was carried out in 713 patients, rIAA repair in 102, and symptomatic IAA repair in 36. OSR was performed in 205, EVAR in 618, and hybrid repairs and conversions in 28. The median maximum IAA diameter at the time of eIAA and rIAA repair was 43 (IQR 38-50) mm and 68 (IQR 58-85) mm, respectively. Mortality was 1.3% (95% CI 0.7-2.4) after eIAA repair and 25.5% (95% CI 18.0-34.7) after rIAA repair. Mortality was not significantly different between the OSR and EVAR subgroups. Elective OSR was associated with significantly more complications than EVAR (intra-operative: 9.8% vs. 3.6%, post-operative: 34.0% vs. 13.8%, respectively). CONCLUSION: In the Netherlands, most eIAA repairs are performed at diameters larger than recommended by the ESVS guideline. These findings appear to support the recent increase in the threshold diameter for eIAA repair.

Performance insights of endobronchial ultrasonography (EBUS) and mediastinoscopy for mediastinal lymph node staging in lung cancer.

INTRODUCTION: Endobronchial Ultrasonography (EBUS) and mediastinoscopy are used for mediastinal lymph node staging in patients with suspected non-small cell lung carcinoma (NSCLC). In our hospital, confirmatory mediastinoscopy has been largely abandoned, which may reduce the number of surgical interventions and health care costs. This study provides insight into EBUS and mediastinoscopy performance in patients with proven NSCLC from January 2007 until January 2019. METHODS: This is a single-centre, retrospective study, evaluating unforeseen N2 rates, negative predictive value and survival, providing insight into the diagnostic yield of EBUS and mediastinoscopy. Surgical lung resection with lymph node dissection was used as reference. RESULTS: A total of 418 patients with proven NSCLC after lung resection (mean age: 66 years; 61 % male) and 118 patients who underwent mediastinoscopy, have been included in the study. The overall prevalence of N2 metastases after lung resection was 10.5 %. The percentage of unforeseen N2 cases after negative EBUS was 14.5 %, and 14.3 % after negative mediastinoscopy. Over the past nine years, none of the confirmatory mediastinoscopies were tumor positive after negative EBUS results. The median survival in patients with surgically confirmed N2 metastases was 33 months, compared to 23 months in patients with EBUS/mediastinoscopy-proven N2 metastases. CONCLUSION: Despite optimisation of mediastinal staging procedures, it remains difficult to identify all patients with N2 metastases in the workup of NSCLC. In our institute, confirmatory mediastinoscopy has no added value after tumor-negative EBUS procedures, and has been abandoned as standard procedure.

Human umbilical vein versus heparin-bonded polyester for femoro-popliteal bypass: 5-year results of a prospective randomized multicentre trial.

PURPOSE: To compare long-term patency of Heparin-Bonded Dacron (HBD) and Human Umbilical Vein (HUV) vascular prostheses in above-knee femoro-popliteal bypass surgery. DESIGN: A prospective randomized multi-centre clinical trial. PATIENTS AND METHODS: Femoro-popliteal bypasses were performed in 129 patients between 1996 and 2001. After randomization 70 patients received an HUV and 59 an HBD prosthesis. Patients were followed up every three months during the first postoperative year and yearly thereafter. The median follow-up was 60 months (range 3-96 months). Graft occlusions were detected by duplex scanning, angiography or surgical exploration. RESULTS: The cumulative primary patency rates were 79%, 66% and 58% at 1, 3 and 5 years postoperatively. Primary patency rates for HUV were 74%, 64% and 58% at 1, 3 and 5 years and 84%, 68% and 58% for HBD, respectively (log-rank test, p=0.745). Overall secondary patency rates were 82%, 72% and 61% at 1, 3 and 5 years postoperatively. The overall cumulative limb salvage at 5 years follow-up was 89% (CI 80%-91%) and was not dependent on graft type. Smoking (p=0.019), number of patent crural arteries (p=0.030) and previous cerebro-vascular events (p=0.030) were significant predictors of graft occlusion. CONCLUSION: There was no difference in long-term graft performance between HUV and HBD for above knee infrainguinal bypass.

[Diagnostic image (359). A 13-year-old girl with intermittent claudication]. / Diagnose in beeld (359). Een 13-jarig meisje met claudicatio intermittens.

A 13-year-old girl suffered from intermittent claudication in the right calf caused by a type III popliteal artery entrapment syndrome due to an accessory muscle bundle of the medial gastrocnemius head.

Colonoscopic perforations: a review of 30,366 patients.

BACKGROUND: Although the incidence of perforation after endoscopic procedures of the colon is low, the rising number of procedures could pose relevant health problems. Recognizing risk factors and optimizing treatment may reduce perforation incidence and the probability of (severe) complications. This study aimed to determine perforation frequency and the management of endoscopic colonoscopic perforation. METHODS: A retrospective review of patient records was performed for all patients with iatrogenic colonic perforations after sigmoido/colonoscopy between 1990 and 2005. The patients' demographic data, endoscopic procedural information, perforation location, therapy, and outcome were recorded. RESULTS: In the 16-year period, 30,366 endoscopic colonic procedures were performed. In total, 35 colonic perforations occured (0.12%). All the patients underwent a laparotomy: for primary repair in 18 cases (56%), for resection with anastomosis in 8 cases (25%), and for resection without anastomosis in 6 cases (19%). In three patients (8.6%), no perforation was found. The postoperative course was uncomplicated in 21 cases (60%) and complicated in 14 cases (40%), including mortality for 3 patients (8.6% resulting from perforations and 0.01% resulting from total endoscopic colon procedures). The relative risk ratio of colonoscopic and sigmoidoscopic procedures for perforations was 4. Therapeutic procedures show a delay in presentation and diagnosis compared with diagnostic procedures. Of the 35 perforations, 26 (74%) occurred in the sigmoid colon. CONCLUSION: Iatrogenic colonic perforation is a serious but rare complication of colonoscopy. A perforation risk of 0.12% was found. The perforation risk was higher for colonoscopic procedures than for sigmoidoscopic procedures. The sigmoid colon is the area at greatest risk for perforation. Immediate operative management, preferably primary repair and sometimes resection, appears to be a good strategy for most patients.

[Thoracic endometriosis with aspecific manifestation]. / Thoracale endometriose met een aspecifieke uiting.

BACKGROUND: Endometriosis is a common disease, especially in subfertile women. The most common location is in the pelvis, but extragenital locations are also possible. This far less common condition has been described in almost all tissues in the body. Symptoms occurring cyclically are characteristic of endometriosis. CASE DESCRIPTION: A 37-year-old woman was discovered by chance to have ascites and pleural effusion. She had no symptoms of this. Thoracoscopy showed an image consistent with thoracic endometriosis. After initial drug therapy was unsuccessful, surgical intervention was performed. CONCLUSION: Thoracic endometriosis is a rare disease, in which the cyclical nature of the symptoms often leads to correct diagnosis. Drug therapy is the preferred treatment for patients.

Autopsy analysis in patients with vascular diseases.

An analysis of autopsy findings in 68 patients who died with vascular surgical disorders was performed. Incorrect diagnoses and therapy were evaluated. It was found that complications of the primary disease or its treatment were frequently missed clinically (41%). Septic complications and severe hemorrhage were common in examinations of morbidity and mortality. In 13% of cases a treatment error with adverse impact on survival was detected. It is concluded that postmortem examination is a valuable tool in the final evaluation of patient care in a vascular surgical unit. A repeated plea for the autopsy is supported by this study.

Relevance of bacterial cultures of abdominal aortic aneurysm contents.

BACKGROUND: To establish further insight into the relevance of intraoperative bacterial cultures of abdominal aortic aneurysm contents a study was performed of the rate of occurrence of prosthetic graft infection after aneurysm repair. METHODS: Bacterial cultures were obtained from 216 patients, who were followed up for more than 3.5 years after operation and studied retrospectively in a single center analysis. RESULTS: Thrombus cultures yielded bacteria in 55 of 216 (25.5%) cases, including 11 of 44 (25%) cases with ruptured aneurysms. Prosthetic infections (4 of 216; 1.9%) occurred more frequently (p < 0.02) in patients with positive thrombus cultures (3 of 55; 5.5%) than in patients with negative cultures (1 of 161; 0.6%). In two patients the species isolated from the thrombus was also cultured from the vascular prosthesis, although in one graft infection other organisms were also isolated. CONCLUSIONS: The presence of bacteria in the intraluminal thrombus does not appear to be an important factor in the development of graft infection after primary elective and urgent abdominal aortic aneurysm repair. Therefore routine intraoperative cultures are unnecessary unless clinical signs of infective aortitis are present.

Migration of the guide-wire into the pleural cavity after needle localization of breast lesions.

The hook-wire is frequently used for pre-operative localization of non-palpable breast lesions. We describe a case where this hook-wire migrated into the pleural cavity, causing paralysis of the ipsilateral phrenic nerve. A thoracoscopic procedure resulted in successful removal of the wire from the chest. Migration of the hook-wire after localization of mammographic lesions is a serious complication for which potential occurrence should be noted.

The value of parasternal mediastinoscopy in staging bronchial carcinoma.

Computed tomography (CT) is the non-invasive staging procedure of choice for assessment of metastasis to mediastinal lymph nodes in patients with bronchial carcinoma. Cervical mediastinoscopy can provide histologic evidence of mediastinal spread to the peritracheal, tracheobronchial and subcarinal lymph nodes. Sub-aortic and para-aortic nodes cannot be sampled via this route. The present study was performed to assess the staging value of the parasternal mediastinoscopy as a separate entity. Cervical and parasternal mediastinoscopy was performed in 37 patients with a proven diagnosis of non-small cell carcinoma of the left upper lobe. In 16 patients lymph node or tumor tissue could be biopsied via the parasternal route, in 21 patients no parasternal biopsy was taken. Of the 16 cases with biopsies, only one was positive (6%). Histologic examination of lymph node biopsy tissue was false negative in one other patient (6%). Of the 21 patients without biopsies taken during parasternal mediastinoscopy, three (14%) had proven lymphogenic spread to the subaortic and para-aortic nodes, detected at thoracotomy. The parasternal procedure changed treatment in only one patient (3%). Diagnostic sensitivity was 20%. It is concluded that parasternal mediastinoscopy should not be used as a routine staging procedure in patients with left upper lobe lung cancer.

Mortality figures in a rural hospital.

The causes of death in a rural hospital in Bophuthatswana were recorded in 1983, 1984 and 1985. Several preventable conditions were found to be the most common causes of death in adults and in children.

The results of autopsy of patients with surgical diseases of the digestive tract.

The results of autopsy of 77 patients who died because of surgical disease of the digestive tract were compared with antemortem findings. An analysis was performed to identify missed diagnoses and incorrect therapy. Primary diagnoses had not been frequently missed, but many complications of the primary disorder or treatment had been overlooked. Many patients died because of septic conditions. Error in treatment, with an adverse impact on the course of the disease as assessed by the postmortem examination, occurred in 9 percent of the patients. The most common error had been failure to reoperate upon patients with an intra-abdominal complication. Unexpected death was significantly associated with incorrect diagnosis; failed or inadequate diagnostic methods were significantly associated with treatment failure (chi-square tests). The autopsy remains a valuable procedure in clinical operation. Selection of patients for autopsy, as indicated by decreasing autopsy rates, is not justified.

Autopsy analysis in surgical patients: a basis for clinical audit.

An autopsy study was performed to quantify diagnostic fallibility in clinical surgery. Autopsy results in 312 surgical patients were compared with clinical findings. The primary clinical diagnosis was correct in 93 per cent of patients; complications had been correctly diagnosed in 60 per cent and error in treatment was found in 16 per cent. Error in treatment had an adverse impact on the course of disease in 11 per cent of patients. Infective complications such as abdominal sepsis and bronchopneumonia were encountered most often. Sensitivity was low for the clinical diagnosis of pulmonary embolism, bronchopneumonia, myocardial infarction and terminal haemorrhage. Statistical analysis showed that sudden unexpected death is the most obvious condition in which a high yield is expected from a post-mortem examination. Autopsy remains a valuable means of quality control in clinical surgery and could be a basis for surgical audit.

Quality control in fatally injured patients: the value of the necropsy.

OBJECTIVE: To identify the contribution of necropsy results to the audit care of severely injured patients. DESIGN: Retrospective study. SETTING: University Hospital in The Netherlands. SUBJECTS: 56 patients who died of severe trauma or its complications during the 10 year period, 1977 to 1987. MAIN OUTCOME MEASURES: Correlation between clinical and necropsy findings. RESULTS: The clinical and necropsy findings corresponded in 31 patients (55%). The necropsy brought to light errors in diagnosis or treatment that might have affected survival in eight cases (14%). The most common missed diagnoses were bronchopneumonia and severe haemorrhage, and the most common cause of death was sepsis. Age, length of stay in hospital, and time between admission and operation were not correlated with accuracy of diagnosis or adequacy of treatment. CONCLUSION: Necropsies in patients who die after severe injuries make a useful contribution to the audit of the care of patients admitted with such injuries.

Video assisted thoracoscopic treatment of pleuropericardial cysts.

Question of the Study In this study, safety and feasibility of thoracoscopic fenestration of pleuropericardial cysts under local and general anaesthesia is evaluated. Besides, a rare case of a pleural cyst, causing a superior vena cava syndrome, is described.Materials, Patients and Methods In a retrospective study, the results of thoracoscopic treatment of pleuropericardial cysts in three patients are presented. We performed videothoracoscopic fenestration of pleuropericardial cysts. One of these was performed under local anaesthesia. The two other cases were performed under general anaesthesia. After fenestration, talc poudrage of the inner lining of the cysts was performed in one case.Results Thoracoscopic fenestration appeared to be safe and effective. No recurrence was observed. One patient was lost to follow-up.Answer to the Question Thoracoscopic fenestration of pleuropericardial cysts is safe and effective. This procedure can be performed under local anaesthesia in selected cases. The role of talc poudrage of the cysts is unclear and needs further investigation.

Hyperhomocysteinemia as a cause of superior vena cava syndrome.

A case is presented in which superior vena cava (SVC) syndrome was caused by a stenosis of the SVC due to thrombosis. Hyperhomocysteinemia was diagnosed as a possible underlying mechanism. The role of hyperhomocysteinemia as a risk factor for the development of recurrent venous thrombosis, its diagnosis, and treatment are discussed.

Increased incidence of renal allograft thrombosis after continuous ambulatory peritoneal dialysis.

Allograft thrombosis occurred in 44 cases (4.8%) among 915 consecutive cadaveric renal transplantations performed in a single center over a 13-year period. Multiple logistic regression analysis of risk factors revealed that continuous ambulatory peritoneal dialysis (CAPD) was the only independent variable associated with renal allograft thrombosis. When CAPD was used for prior renal replacement therapy graft thrombosis occurred in 7.3% (22/303), whereas hemodialysis was associated with 3.6% (22/612) of graft thromboses (p < 0.02). No differences in transplant characteristics, including hemodynamics, hematological parameters, immunosuppressive therapy, graft anatomy and preservation, were observed between the cases with graft thrombosis and a matched control group (n = 88). CAPD treatment appears to be a risk factor in the development of renal allograft thrombosis that requires further perioperative coagulation studies in order to design an effective prophylaxis.

Changes in venous hemodynamics after renal transplantation.

To explain an occasionally observed transient swelling of the ipsilateral leg in renal transplant recipients in the absence of deep vein thrombosis, we took serial measurements of venous outflow resistance and duplex examinations of both legs. Fourteen recipients of a living related donor kidney graft were submitted to strain gauge plethysmography and duplex examination before transplantation and 1 and 6 weeks thereafter. Venous outflow resistance and venous flow were measured and the veins were assessed for thrombosis. Strain gauge plethysmography showed a significant increase in venous outflow resistance in the leg on the side of the renal transplant 1 week after transplantation [0.28 +/- 0.13 vs 0.40 +/- 0.15 mmHg.s (ml/100 ml)-1; P < 0.05]. Six weeks later, the venous outflow resistance had returned to preoperative values [0.30 +/- 0.11 mmHg.s (ml/100 ml)-1; P = NS]. On the contralateral side, no significant differences were found. Duplex examinations showed no signs of thrombosis. Venous flow measurements in the common femoral vein showed no significant differences. We conclude that the additional blood supply to the iliac veins results in an increase in venous outflow resistance in the ipsilateral leg, which can explain the observed swelling of this leg and may have implications for the preferred method of diagnosis of venous thrombosis after renal transplantation.

Fate of renal allografts connected to vascular prostheses.

OBJECTIVE: The outcome of renal transplantation with an arterial anastomosis to a vascular prosthesis in the aortofemoral tract is evaluated. PATIENTS AND METHODS: All 7 Dutch transplant centers were invited to review their experience. Among a total of 5791 cadaveric renal transplantations performed between 1978 and 1994, 13 cases (0.2%) in 3 different centres were identified. In 6 cases the vascular reconstruction and transplant operation were performed simultaneously, and in 7 cases separately, with a mean interval of 3.5 yr. The indications for vascular reconstruction were aneurysmal disease in 4 and obstructive disease in 9 cases. RESULTS: The early vascular complications of these procedures were hemorrhage in 4 and renal vein thrombosis in 1 and led to graft loss in 3 cases. The perioperative mortality was 2/13 (15%). The graft and patient survival were 68 and 83% respectively after 1 yr and 17 and 37% after 5 yr. Late mortality was mainly due to cardiovascular disease. CONCLUSIONS: Renal transplantation with an arterial anastomosis to a vascular prosthesis in the aortofemoral tract is a hazardous procedure with relatively poor short- and long-term results. These observations should be considered in the choice of renal replacement therapy in this special patient population.