Protocol for an independent patient data meta-analysis of prophylactic mesh placement for incisional hernia prevention after abdominal aortic aneurysm surgery: a collaborative European Hernia Society project (I-PREVENT-AAA).

INTRODUCTION: Incisional hernia (IH) is a prevalent and potentially dangerous complication of abdominal surgery, especially in high-risk groups. Mesh reinforcement of the abdominal wall has been studied as a potential intervention to prevent IHs. Randomised controlled trials (RCTs) have demonstrated that prophylactic mesh reinforcement after abdominal surgery, in general, is effective and safe. In patients with abdominal aortic aneurysm (AAA), prophylactic mesh reinforcement after open repair has not yet been recommended in official guidelines, because of relatively small sample sizes in individual trials. Furthermore, the identification of subgroups that benefit most from prophylactic mesh placement requires larger patient numbers. Our primary aim is to evaluate the efficacy and effectiveness of the use of a prophylactic mesh after open AAA surgery to prevent IH by performing an individual patient data meta-analysis (IPDMA). Secondary aims include the evaluation of postoperative complications, pain and quality of life, and the identification of potential subgroups that benefit most from prophylactic mesh reinforcement. METHODS AND ANALYSIS: We will conduct a systematic review to identify RCTs that study prophylactic mesh placement after open AAA surgery. Cochrane Central Register of Controlled Trials, MEDLINE Ovid, Embase, Web of Science Core Collection and Google Scholar will be searched from the date of inception onwards. RCTs must directly compare primary sutured closure with mesh closure in adult patients who undergo open AAA surgery. Lead authors of eligible studies will be asked to share individual participant data (IPD). The risk of bias (ROB) for each included study will be assessed using the Cochrane ROB tool. An IPDMA will be performed to evaluate the efficacy, with the IH rate as the primary outcome. Any signs of heterogeneity will be evaluated by Forest plots. Time-to-event analyses are performed using Cox regression analysis to evaluate risk factors. ETHICS AND DISSEMINATION: No new data will be collected in this study. We will adhere to institutional, national and international regulations regarding the secure and confidential sharing of IPD, addressing ethics as indicated. We will disseminate findings via international conferences, open-source publications in peer-reviewed journals and summaries posted online. PROSPERO REGISTRATION NUMBER: CRD42022347881.

A risk-adjusted and anatomically stratified cohort comparison study of open surgery, endovascular techniques and medical management for juxtarenal aortic aneurysms-the UK COMPlex AneurySm Study (UK-COMPASS): a study protocol.

INTRODUCTION: In one-third of all abdominal aortic aneurysms (AAAs), the aneurysm neck is short (juxtarenal) or shows other adverse anatomical features rendering operations more complex, hazardous and expensive. Surgical options include open surgical repair and endovascular aneurysm repair (EVAR) techniques including fenestrated EVAR, EVAR with adjuncts (chimneys/endoanchors) and off-label standard EVAR. The aim of the UK COMPlex AneurySm Study (UK-COMPASS) is to answer the research question identified by the National Institute for Health Research Health Technology Assessment (NIHR HTA) Programme: 'What is the clinical and cost-effectiveness of strategies for the management of juxtarenal AAA, including fenestrated endovascular repair?' METHODS AND ANALYSIS: UK-COMPASS is a cohort study comparing clinical and cost-effectiveness of different strategies used to manage complex AAAs with stratification of physiological fitness and anatomical complexity, with statistical correction for baseline risk and indication biases. There are two data streams. First, a stream of routinely collected data from Hospital Episode Statistics and National Vascular Registry (NVR). Preoperative CT scans of all patients who underwent elective AAA repair in England between 1 November 2017 and 31 October 2019 are subjected to Corelab analysis to accurately identify and include every complex aneurysm treated. Second, a site-reported data stream regarding quality of life and treatment costs from prospectively recruited patients across England. Site recruitment also includes patients with complex aneurysms larger than 55 mm diameter in whom an operation is deferred (medical management). The primary outcome measure is perioperative all-cause mortality. Follow-up will be to a median of 5 years. ETHICS AND DISSEMINATION: The study has received full regulatory approvals from a Research Ethics Committee, the Confidentiality Advisory Group and the Health Research Authority. Data sharing agreements are in place with National Health Service Digital and the NVR. Dissemination will be via NIHR HTA reporting, peer-reviewed journals and conferences. TRIAL REGISTRATION NUMBER: ISRCTN85731188.

An Implanted Blood Vessel Support Device for Arteriovenous Fistulas: A Randomized Controlled Trial.

RATIONALE & OBJECTIVE: Reducing turbulent blood flow through dialysis arteriovenous fistulas (AVFs) and radial stretching of their venous wall may attenuate hyperplasia and stenosis and improve AVF outcomes in hemodialysis patients. The goal of this study was to evaluate the safety and efficacy of the VasQ implant, which intervenes on these mechanisms by physically supporting the surgical arteriovenous anastomosis. STUDY DESIGN: Prospective, randomized, controlled, multicenter study. SETTINGS & PARTICIPANTS: 40 consecutive patients with kidney failure referred for creation of a brachiocephalic fistula in 4 vascular access centers in the United Kingdom and Israel. INTERVENTIONS: AVF surgical creation with placement of the VasQ implant (treatment) versus AVF placement without the implant (control). OUTCOMES: Safety assessed as percentage of severe device-related adverse events was the primary outcome. Secondary outcomes were efficacy assessments including: (1) AVF maturation at 3 months, defined as cephalic vein diameter≥5mm and flow≥500mL/min; (2) functional cumulative patency, defined as successful 2-needle cannulation for two-thirds or more of all dialysis runs for 1 month in study participants receiving dialysis; (3) cephalic vein diameter and blood flow; and (4) primary and cumulative patency at 6 months. RESULTS: No severe device-related adverse events were observed. There was no significant difference in maturation at 3 months or primary patency at 6 months between treatment and control (85% vs 80% and 80% vs 66%). Significantly larger vein luminal diameters were observed in the treatment group versus controls at 3 and 6 months (8.27±2.2 vs 6.69±1.8mm [P=0.03] and 9.6±2.5 vs 7.56±2.7mm [P=0.03]). Functional patency at 6 months was significantly greater in the treatment group (100% vs 56% [P = 0.01]). LIMITATIONS: Small sample size, limited power for secondary end points. CONCLUSIONS: No safety signals were detected for the VasQ external support of brachiocephalic AVFs. Higher functional patency and vein luminal diameters were achieved with the device at 3 and 6 months. VasQ may safely intervene on mechanisms associated with the disturbed hemodynamic profile in the juxta-anastomotic region. FUNDING: Funded by Laminate Medical Technologies Ltd. TRIAL REGISTRATION: Registered at ClinicalTrials.gov with study number NCT02112669.

Acute aortic dissection: a missed diagnosis.

A 60-year-old man with a history of indigestion and untreated hypertension presented with sudden-onset central chest pain which radiated to his back. Acute coronary syndrome was initially suspected but excluded in the emergency department before the patient was discharged. The pain subsequently abated to mild intermittent episodes and was misdiagnosed as indigestion. A week later the patient developed new shortness of breath and 'flu-like' symptoms with a positive d-dimer test. CT angiography revealed a Stanford type B aortic dissection which was causing hypoperfusion of the right kidney, resulting in an acute kidney injury. Due to uncontrolled hypertension despite rigorous antihypertensive medication and his failing renal function, the patient underwent endovascular repair and made a good recovery postoperatively.

The association between referral source and outcome in patients with colorectal cancer.

AIM: The colorectal two-week wait fast track (FT) referral system was nationally implemented in the UK in 2000 to ensure patients with colorectal cancer (CRC) received prompt access to specialized services. The aim of this study was to determine the association between the mechanism of referral to colorectal services and the 5-year outcomes for patients with CRC. METHODS: Consecutive patients with newly diagnosed CRC presenting between October 2002 and September 2004 were identified retrospectively. Analysis for survival and recurrence of disease at 5 years from presentation was undertaken. Outcomes for patients were compared between fast track (FT), non-fast track (NFT) and emergency referral (ER) routes, using Kaplan-Meier survival estimates. RESULTS: Out of 189 patients, 96 (51%) presented via the FT, 41 (22.5%) via the NFT and 52 (27.5%) via the ER referral route. The 5-year overall survival was 52.6% ± 5.1, 41.5% ± 7.7 and 38.5% ± 6.7 for the FT-, NFT- and ER groups respectively (p = 0.075). The 5-year cancer specific survival was 60.3% ± 5.2, 58.8% ± 5.3 and 43.5% ± 7.2 for the FT-, NFT- and ER groups respectively (p = 0.056). Patients referred as emergencies had worse 5-year overall survival; 49.3% ± 4.3 (FT&NFT) vs. 38.5% ± 6.7 (ER) (p = 0.042) and 5-year cancer specific survival 59.8% ± 4.4 (FT&NFT) vs. 43.5% ± 7.2 (ER) (p = 0.016). A total of 136 patients (FT n = 71, NFT n = 34, ER n = 31) underwent potentially curative surgery. Differences in 5-year survival did not reach statistical significance in these patients. CONCLUSION: Referral route to specialist services for patients with CRC via the fast track pathway compared to non-fast track pathway was not associated with improved survival.

Venous ulcer review.

CLINICAL QUESTION: What is the best treatment for venous ulcers? RESULTS: Compression aids ulcer healing. Pentoxifylline can aid ulcer healing. Artificial skin grafts are more effective than other skin grafts in helping ulcer healing. Correction of underlying venous incompetence reduces ulcer recurrence. IMPLEMENTATION: POTENTIAL PITFALLS TO AVOID ARE: Failure to exclude underlying arterial disease before application of compression.Unusual-looking ulcers or those slow to heal should be biopsied to exclude malignant transformation.

Radiocephalic and brachiocephalic arteriovenous fistula outcomes in the elderly.

BACKGROUND: A recent meta-analysis has suggested that patients aged >65 have worse outcomes with radiocephalic arteriovenous fistulas (RCAVFs) compared with brachiocephalic arteriovenous fistulas (BCAVFs). We hypothesized that outcomes in patients aged > or = 80--a rapidly expanding cohort within this elderly group--might be skewing the results, and that age >65 may not be a contraindication to RCAVF formation. This study examined the effect of age group (<65, 65 to 79, >or =80) on functional outcomes (use; primary and secondary functional patency) in RCVAFs and BCAVFs. METHODS: We identified the outcomes of all patients undergoing a first surgical access procedure for a RCAVF or BCVAF between January 1, 2000, and December 31, 2005. We examined the effect of age and other factors including sex, diabetes mellitus, hypertension, late referral (<3 months before dialysis), dialysis before surgical access, preoperative duplex ultrasound imaging, and ethnicity on non-AVF use and primary and secondary functional AVF patency. Logistic regression and Cox proportional hazards regression models were used. RESULTS: From a total of 658 patients, 361 had a RCAVF, and 297 had a BCAVF. Their median age was 68.5 years (interquartile range [IQR], 54.4 to 76.5 years), and 288 (43.8%) were aged <65 years, 274 (41.6%) were 65 to 79, and 96 (14.6%) were > or =80. Age did not influence the site of the first surgical access (P = .874). Only 85.7% of patients actually progressed to hemodialysis, and the RCAVF or BCAVF in 45.7% of those was never used for dialysis. Female sex (hazard ratio [HR], 2.24; 95% confidence interval [CI] 1.387 to 3.643; P = .001) was the only factor associated with an increase risk of RCAVF nonuse, whereas diabetes (HR, 2.095; 95% CI, 1.261 to 3.482; P = .004) was the only factor associated with an increase risk of BCAVF nonuse. The respective primary patency rates at 1 and 2 years for RCAVFs were 46.0% and 27.1% for patients <65, 47.0% and 36.0% for those 65 to 79, and 45.7% and 38.1% for those >or =80. Only female sex (HR, 1.679; 95% CI, 1.261 to 2.236; P = .001) and prior hemodialysis (HR, 1.363; 95% CI, 1.0.29 to 1.804; P = .031) were associated with loss of patency of RCAVFs. The primary functional patency rates for BCAVFs at 1 and 2 years were 39.3% and 31.0% for those <65 years; 53.30% and 37.5% for those 65 to 79, and 46.3% and 42.6% for those >or =80. No factors analyzed were associated with loss of primary functional patency of BCAVFs. CONCLUSIONS: Age did not affect usability, primary or secondary patency of either RCAVFs or BCAVFs. Although patient selection is important, even patients > or =80 years who are considered suitable for surgical placement of access should not be denied a RCAVF solely because of age.

A comparison between transposed brachiobasilic arteriovenous fistulas and prosthetic brachioaxillary access grafts for vascular access for hemodialysis.

OBJECTIVE: Patients requiring access for hemodialysis in whom radiocephalic or brachiocephalic arteriovenous fistulas cannot be formed or have failed present a significant clinical challenge. We compare outcomes in patients undergoing transposed brachiobasilic arteriovenous fistulas (BBAVF) with expanded polytetrafluoroethylene brachioaxillary access grafts in a single European center. METHODS: We identified all patients undergoing a first upper limb tertiary-access procedure-that is, either BBAVF or brachioaxillary access graft for hemodialysis-between January 1, 2000, and December 31, 2005. The median follow-up was 18.1 months (interquartile range, 8.7-34.9 months). Successful use for dialysis, primary patency, secondary patency, and patient survival was assessed. RESULTS: A total of 185 patients were identified; 71 had a BBAVF, and 114 had an access graft. The median age was 64.3 years (interquartile range, 50.7-74.4 years). The groups were well matched for age, sex, ethnicity, diabetes, and number of prior access procedures. Significantly fewer BBAVFs were successfully used for dialysis: 69.0% BBAVFs compared with 89.4% access grafts (P = .001; chi(2)). One- and two-year primary patency rates were 45.3% and 40.0%, respectively, for BBAVF and were 56.4% and 43.2% for access grafts (P = .579; log rank). Furthermore, there was no significant difference in secondary patency between the two procedures (P = .868; log rank). We found that surgeons in training had no influence on the primary patency of either BBAVF or access grafts. However, infective complications necessitating an operation were significantly higher in the access graft group (6.2% vs 0%; P = .031; Fisher exact test). CONCLUSIONS: Although more difficult to establish, BBAVFs provide patency at least equivalent to that of brachioaxillary access grafts. However, infective complications are fewer in the BBAVF group. As such, we believe that BBAVF should be the first choice of the vascular access surgeon when fistulas using the cephalic vein are not possible or have failed.

Wound oozing after total hip arthroplasty.

INTRODUCTION: Total hip arthroplasty is a commonly performed operation and yet little information exists about the duration of wound oozing, the factors associated with this and the implications. The aim of this work was to identify factors influencing wound oozing by establishing their effect on the time taken for wounds to cease oozing after total hip arthroplasty. PATIENTS AND METHODS: Sixty-two consecutive patients undergoing total hip arthroplasty were included. Wounds were examined for wound oozing on a daily basis by the same observer and were then re-dressed. The time taken for each wound to become dry was recorded. Data were analysed to determine if the time-to-dryness was influenced by wound length, body mass index, estimated volume of blood in the dissected tissues, duration of surgery and ASA grade. RESULTS: Time to dryness was associated with wound length (P = 0.01), body mass index (BMI, P = 0.05), estimated volume of blood in dissected tissues (P = 0.05) and length of hospital stay (P = 0.02). No association was found with duration of surgery or ASA grade. CONCLUSIONS: A small-incision, meticulous haemostasis at surgery and a reduction in pre-operative obesity reduce the time taken for hip arthroplasty wounds to become dry. Prolonged wound oozing delays hospital discharge.