Long-term Results of Totally Laparoscopic Aortobifemoral Bypass.

OBJECTIVES: The aim was to estimate the long-term results and patency rates of totally laparoscopic aortobifemoral bypass in aorto-iliac occlusive disease (AIOD). METHODS: All 87 patients who received a laparoscopic aortobifemoral bypass for AIOD on an intention to treat basis between October 2003 and October 2013 were identified. All operations were performed by the same surgical team using a totally laparoscopic technique. Demographic, pre-operative, peri-operative, and follow up variables were collected and analyzed. Patients were followed up at 1 month post-operatively and annually thereafter. Patency rates were calculated in accordance with published patency reporting standards. RESULTS: The median age was 57 years (range 40-78 years). The conversion rate was 20.6% overall. The thirty-day post-operative mortality was 1.1%. Six patients required early re-intervention. There were no graft infections. The median length hospital stay was 6 days (range 4-39 days). The mean follow up was 58.0 months (range 1-133 months). Graft limb based primary, primary assisted, and secondary patency rates were respectively 96.1%, 98.1% and 99.4% at 1 year, and 83.0%, 92.0% and 97.0% at 5 years. CONCLUSION: Totally laparoscopic aortobifemoral bypass is a safe alternative to open surgery in selected patients, with excellent long-term patency rates, albeit at the cost of a steep learning curve.

Relationship between prolactin, breast cancer risk, and antipsychotics in patients with schizophrenia: a critical review.

OBJECTIVE: A recent meta-analysis showed that breast cancer probably is more common in female patients with schizophrenia than in the general population (effect size = 1.25, P < 0.05). Increasing experimental and epidemiological data have alerted researchers to the influence of prolactin (PRL) in mammary carcinogenesis. We therefore investigated the possible relationship between antipsychotic-induced hyperprolactinemia (HPRL) and breast cancer risk in female patients with schizophrenia. METHOD: A literature search (1950 until January 2015), using the MEDLINE database, was conducted for English-language published clinical trials to identify and synthesize data of the current state of knowledge concerning breast cancer risk (factors) in women with schizophrenia and its (their) relationship between HPRL and antipsychotic medication. RESULTS: Although an increasing body of evidence supports the involvement of PRL in breast carcinogenesis, results of human prospective studies are limited, equivocal, and correlative (with risk ratios ranging from 0.70 to 1.9 for premenopausal women and from 0.76 to 2.03 for postmenopausal women). Moreover, these studies equally do not take into account the local production of PRL in breast epithelium, although amplification or overexpression of the local autocrine/paracrine PRL loop may be a more important mechanism in tumorigenesis. Until now, there is also no conclusive evidence that antipsychotic medication can increase the risk of breast malignancy and mortality. CONCLUSION: Other breast risk factors than PRL, such as nulliparity, obesity, diabetes mellitus, and unhealthy lifestyle behaviours (alcohol dependence, smoking, low physical activity), probably are of greater relevance in individual breast cancer cases within the population of female patients with schizophrenia.

[Prolactin, antipsychotics and breast cancer: is there a connection?]. / Prolactine, antipsychotica en borstkanker: is er een verband?

BACKGROUND: The use of antipsychotics can result in elevated prolactin levels or hyperprolactinemia. An increasing number of studies suggests that prolactin plays a role in mammary carcinogenesis, leading to concerns about a possible relationship between antipsychotics and breast cancer.
AIM: To provide an overview of recent literature regarding the relationship between prolactin, antipsychotics and breast cancer and an association between schizophrenia and breast cancer.
METHOD: We used PubMed to search for English- or Dutch-language articles concerning breast cancer risk (factors), prolactin, antipsychotics and schizophrenia.
RESULTS: Studies have not shown any causal link between antipsychotics and the development of breastcancer. Moreover, antipsychotic medication seems to have no influence on locally produced prolactin - which some experts believe plays a role in the tumor genesis - and certain antipsychotics actually provide protection against breast cancer. There are conflicting reports on the prevalence of breast cancer among patients with schizophrenia. Nevertheless, research has revealed that several well-known risk factors for breast cancer (such as an unhealthy lifestyle) are more prevalent in patients with schizophrenia.
CONCLUSION: There is no conclusive evidence that antipsychotic medication that raises prolactin levels increases the risk of breast cancer. Nevertheless, clinicians should always be cautious about prescribing antipsychotics for breast cancer patients. In our view, clinicians should always treat breast cancer risk factors as efficiently as possible, particularly when attending to patients who have schizophrenia.

[Obsessive-compulsive behaviour in two patients with right temporal variant frontotemporal dementia]. / Obsessief-compulsief gedrag bij de rechter temporale variant van frontotemporale dementie.

There is often a long delay before right temporal variant of frontotemporal dementia (rtlv) is correctly diagnosed. The late diagnosis is usually due to the occurrence of psychiatric symptoms as the first signs of disease and to the relatively young age of the patient. We report two patients who were initially treated for obsessive-compulsive disorder but were later diagnosed as having rtlv.

Laparoscopic versus open approach for aortobifemoral bypass for severe aorto-iliac occlusive disease--a multicentre randomised controlled trial.

OBJECTIVES: To investigate differences between open and laparoscopic aortobifemoral bypass surgery for aorto-iliac occlusive disease on postoperative morbidity and mortality. DESIGN: A multicentre randomised controlled trial. METHODS: Between January 2007 and November 2009, 28 patients with severe aorto-iliac occlusive disease (TASC II C or D) were randomised between laparoscopic and open approach at one community hospital and one university hospital (TASC = Trans-Atlantic Inter-Society Consensus on the Management of Peripheral Arterial Disease). RESULTS: The operation time was longer for the laparoscopic approach (mean 4 h 19 min (2 h 00 min to 6 h 20 min) vs. 3 h 30 min (1 h 42 min to 5 h 11 min); p = 0.101)). Nevertheless, postoperative recovery and in-hospital stay were significantly shorter after laparoscopic surgery. Also oral intake could be restarted earlier (mean 20 h 34 min (6 h 00 min to 26 h 55 min) vs. 43 h 43 min (19 h 40 min to 77 h 30 min); p = 0.00014)) as well as postoperative mobilisation (walking) (mean 46 h 15 min (16 h 07 min to 112 h 40 min) vs. mean 94 h 14 min (66 h 10 min to 127 h 23 min); p = 0.00016)). Length of hospitalisation was shorter (mean 5.5 days (2.5-15) vs. mean 13.0 days (7-45); p = 0.0095)). Visual pain scores and visual discomfort scores were both lower after laparoscopic surgery. Also return to normal daily activities was achieved earlier. There were no major complications in both groups. CONCLUSION: Laparoscopic aortobifemoral bypass surgery for aorto-iliac occlusive disease is a safe procedure with a significant decrease in postoperative morbidity and in-hospital stay and earlier recovery.

Conversion during laparoscopic aortobifemoral bypass: a failure?

OBJECTIVES: To study the impact of conversion on postoperative recovery, morbidity and mortality in laparoscopic aortobifemoral bypass surgery for aorto-iliac occlusive disease (AIOD). DESIGN: Retrospective analysis of a prospectively maintained database. METHODS: Between November 2002 and December 2006, 139 patients were treated for severe AIOD with a laparoscopic aortobifemoral bypass at one community and one university hospital. Demographic data, operative data, postoperative recovery data, morbidity and mortality were recorded and analysed according to a conversion and a non-conversion group. RESULTS: Conversion was needed in 13.7% of the patients. Morbidity was 16.5%-14.2% in the non-conversion group and 31.8% in the conversion group. Systemic morbidity was significantly higher in the conversion group (31.6% vs.10%; p=0.002), but only one patient had incomplete recovery; local morbidity was comparable in both groups (10.5% vs. 5.8%; p=0.337). Mortality rate was 2.2%. CONCLUSION: Laparoscopic aortobifemoral bypass surgery is a safe procedure for the treatment of AIOD. The outcome of patients after conversion is not affected in the way that it could be an impediment to start a laparoscopic procedure. Conversion in time is a safe way to overcome the learning curve.

The learning curve of totally laparoscopic aortobifemoral bypass for occlusive disease. How many cases and how safe?

OBJECTIVES: Totally laparoscopic aortic surgery is appealing. However, the adoption of this technique in the broad vascular world is hampered by the steep learning curve and the fear of exposing patients to excessive morbidity and mortality. We assessed how many patients should be treated to overcome this learning curve. MATERIALS AND METHODS: The first 50 patients treated with totally laparoscopic aortobifemoral bypass for severe aorto-iliac occlusive disease were followed prospectively. Operative variables such as operative time, aortic clamping time, amount of blood loss, conversion to laparotomy etc were recorded (as well as 30-day mortality and morbidity). To discover a turning point we used the technique of sliding averages. These data were compared with the mortality and morbidity as predicted by POSSUM and P-POSSUM. RESULTS: A clear turning point, with improved operative variables, was seen after 20-30 patients. Mortality and morbidity were not higher than predicted by POSSUM and P-POSSUM. CONCLUSIONS: These data confirm the intuition of most people involved in laparoscopic aortic surgery that the learning curve could be set at 25-30 cases. However, patients are not exposed to excessive morbidity and mortality during this learning curve.

Hand-assisted laparoscopy versus conventional median laparotomy for aortobifemoral bypass for severe aorto-iliac occlusive disease: a prospective randomised study.

OBJECTIVES: To demonstrate that hand-assisted laparoscopy for aortofemoral bypass for severe aorto-iliac occlusive disease reduces morbidity with earlier recovery of bowel function and shorter in-hospital stay. DESIGN: Randomised controlled trial. MATERIALS AND METHODS: Thirty-six consecutive patients with severe aorto-iliac occlusive disease (TASK C/D) without history of major abdominal surgery necessitating an aortobifemoral bypass were randomised between a hand-assisted laparoscopic (HALS) approach and a conventional medial laparotomy. Operative data, early recovery data, quality of life and vascular outcome were analysed. RESULTS: No significant differences in operative data were found. Fluid and solid diet were resumed earlier (28.8 hrs vs. 76.9 hrs; p = 0.016) (45.6 hrs vs. 105.6 hrs; p = 0.02) and in-hospital stay was shorter (7.5 vs. 8.9 days; p = 0.005) in the HALS group. Six weeks post-operatively social functioning measured by the SF-36 survey score was better in patients randomised to HALS (p=0.023). CONCLUSIONS: HALS is a less invasive approach for aortofemoral bypass.