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.

Bilateral thoracoscopic splanchnicectomy for pain in patients with chronic pancreatitis impairs adrenomedullary but not noradrenergic sympathetic function.

BACKGROUND: Bilateral thoracoscopic splanchnicectomy (BTS) is a well-known technique to alleviate intractable pain in patients with chronic pancreatitis. BTS not only disrupts afferent fibers from the pancreas that mediate pain but also postganglionic sympathetic fibers, which originate in segments T5-T12 and which innervate the vasculature of the liver, pancreas, and the adrenal gland. The purpose of this study was to assess whether and how BTS affects sympathetic noradrenergic and adrenomedullary function in patients with chronic pancreatitis. METHODS: Sixteen patients with chronic pancreatitis for at least 1 year underwent autonomic function testing before and 6 weeks after BTS for intractable pain. Testing was performed during supine rest and during sympathetic stimulation when standing. RESULTS: Supine and standing systolic and diastolic blood pressure were significantly lower post-BTS compared with pre-BTS (P = 0.001). One patient showed orthostatic hypotension after BTS. Baseline plasma norepinephrine levels and plasma norepinephrine responses to sympathetic activation during standing were not reduced by BTS. In contrast, supine plasma epinephrine levels and responses during standing were significantly reduced (P < 0.001). Parasympathetic activity was unaffected by BTS as shown by unaltered Valsalva ratio, I-E difference, and ΔHRmax. CONCLUSIONS: BTS for pain relief in patients with chronic pancreatitis reduced adrenomedullary function, due to disruption of the efferent sympathetic fibers to the adrenal gland. BTS did not affect noradrenergic sympathetic activity, although blood pressure was lower after the sympathectomy.

Increased sympathetic activity in chronic pancreatitis patients is associated with hyperalgesia.

Pain treatment in chronic pancreatitis patients is difficult, with pain frequently relapsing or persisting. Recent studies suggest that altered central nervous system pain processing underlies the chronic pain state in these patients. There is evidence that increased sympathetic activity may also play a role in some chronic pain syndromes. This study assessed sympathetic nervous system activity and its relation to pain processing in patients with severe painful chronic pancreatitis. The authors postulated that chronic pancreatitis patients with more sympathetic activity exhibit more generalized hyperalgesia. In 16 chronic pancreatitis patients, sympathetic activity was measured via venous plasma norepinephrine (NE) levels (supine, standing). Pain processing was quantified via pressure pain tolerance thresholds (PPTs) in dermatomes T10 (pancreatic area), C5, T4, L1. Five patients showed increased supine plasma NE levels (NE ≥ 3.0 nmol/L). PPTs were lower in patients with increased NE levels (INE) compared with patients with normal NE (NNE) (means [95% confidence interval]: INE 402 kPa [286-517] versus NNE 522 kPa [444-600]; P = .042). In severe chronic pancreatitis patients, increased sympathetic activity and hyperalgesia appear associated, suggesting that sympathetic activity may also play a role in these patients' pain.

Effect of thoracoscopic splanchnic denervation on pain processing in chronic pancreatitis patients.

BACKGROUND: Central sensitisation due to visceral pancreatic nociceptive input may play an important role in chronic pancreatitis pain. Using quantitative sensory testing (QST), this first study investigates whether thoracoscopic splanchnic denervation (TSD), performed to reduce nociceptive visceral input, affects central sensitisation in chronic pancreatitis patients. PATIENTS AND METHODS: We studied 19 chronic pancreatitis patients (11 men, 8 women on stable opioid medication) and 18 healthy volunteers as preoperative controls. Preoperatively and 6 weeks after TSD, pain numeric rating scores, opioid medication, and thresholds to electric skin stimulation and pressure pain (measured in dermatomes T10 (pancreas), C5, T4, L1, L4) were documented. Treatment success was defined as cessation of opioids 6 weeks after TSD. RESULTS: Six weeks after TSD, there was a trend towards lower pain scores, only 10 patients were still on opioids (P<0.05 vs. preoperatively) and thresholds overall were significantly higher than preoperatively (pressure pain: +25%, P<0.001; electric: sensation +55%, pain detection +34%, pain tolerance +21%, P<0.05). Gender-specific differences in hypoalgesia patterns were seen. Preoperatively, TSD treatment successes consumed significantly less opioids than failures, without significant differences in preoperative patterns of neuroplasticity. CONCLUSIONS: TSD for chronic pancreatitis pain resulted in fewer patients on opioids and overall increases in pain thresholds. Our results suggest that TSD for reducing visceral nociceptive input may be effective in reducing resulting central sensitisation. Although patients benefiting from TSD consume less opioids preoperatively, we were unable to clearly link treatment success with specific perioperative patterns of neuroplasticity such as the presence or absence of hyperalgesia.

Long-term results of bilateral thoracoscopic splanchnicectomy in patients with chronic pancreatitis.

BACKGROUND: The management of pain in patients with chronic pancreatitis is difficult. The aim of this prospective study was to evaluate the early and long-term pain relief provided by bilateral thoracoscopic splanchnicectomy. METHODS: From August 1995 to August 1999, 44 patients with chronic pancreatitis underwent bilateral thoracoscopic splanchnicectomy. Data were collected prospectively. Thirty-six patients required opioids. Pain intensity was registered before operation and at regular intervals after surgery by means of a visual analogue scale (VAS). Use of analgesics (opioids; non-steroidal anti-inflammatory drugs and acetaminophen; no analgesics or aminocetophen) was noted before and after splanchnicectomy. Median follow-up was 36 (range 12-60) months. RESULTS: The procedure was technically successful in 40 patients. Thirty-six patients had no complications. Eleven of 24 patients who have been followed up for 24 months or more had a significantly reduced VAS score at 2 years (median (range) 8.5 (7-10) versus 2.5 (0-5); P < 0.01). The cumulative rate of pain relief was 46 per cent 48 months after splanchnicectomy. CONCLUSION: Bilateral thoracoscopic splanchnicectomy alleviated pain in patients with chronic pancreatitis. It was associated with a low morbidity rate and no deaths. Pain eventually recurred in approximately 50 per cent.

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.

Bilateral thoracoscopic splanchnicectomy in patients with chronic pancreatitis.

BACKGROUND: Intractable pain, the most prominent feature of chronic pancreatitis, causes the patient great disability, and its treatment poses a difficult problem for gastroenterologist and surgeon alike. The main goal of treatment is to provide sufficient and lasting pain relief without the use of opiates. Conservative management, including stopping alcohol consumption, dietary measures, pancreatic enzyme suppletion and analgesics, is discussed. When these measures fail, surgery is often unavoidable. Indications, effect on pain relief, morbidity and mortality of drainage and resection procedures are described. Bilateral thoracoscopic splanchnicectomy, a newly developed operation to alleviate pain irrespective of the type of anatomic abnormality, is outlined in more detail. Early encouraging results of pain relief in patients with chronic pancreatitis after thoracoscopic splanchnicectomy are presented.

Beta-cell function of the pancreas after necrotizing pancreatitis.

AIM: To investigate the late sequellae of necrotizing pancreatitis on the endocrine function of the pancreas. PATIENTS AND METHODS: Twenty patients, 15 men (mean +/- SEM age 52.2+/-2.6 years and BMI 26.8+/-0.8 kg/m2) and 5 women (age 51.0+/-7.6 years and BMI 26.7+/-0.8 kg/m2) were submitted to a glucagon stimulation test 63 (range 8-136) months after an attack of pancreatitis. All nondiabetic patients (n = 15) were also submitted to an oral glucose tolerance test. For comparison, 16 healthy volunteers, 8 men (age 56.0+/-0.9 years and BMI 26.3+/-0.4 kg/m2) and 8 women (age 50.5+/-1.0 years and BMI 28.2+/-0.6 kg/m2), were also studied. RESULTS: Five patients (25%) had diabetes mellitus and needed insulin treatment, 6 patients (30%) had an impaired glucose tolerance (IGT). Nondiabetic patients (IGT included) had a significantly higher basal insulin level (15.8+/-1.9 vs. 10.9 +/-2.2 mU/l, p < 0.05) and a lower glucose/insulin ratio (p < 0.05) compared with controls. The serum concentrations of insulin and C peptide, after stimulation with glucagon, calculated as peak value, maximal increment and as area under the curve were not significantly different in the nondiabetic patients compared to controls. The subgroup of IGT patients had a significantly higher basal C peptide (p < 0.05) and a reduced maximal increment (p < 0.05). CONCLUSIONS: After nonresectional therapy for necrotizing pancreatitis, there is a high prevalence of disturbances in glucose metabolism. Patients with IGT have signs of both loss of beta-cell function and insulin resistance.

Heterotopic ossification induced by hypoxia in a retrosternal gastric tube following transhiatal oesophagectomy.

A 71 year old man underwent retrosternal gastric tube reconstruction following transhiatal oesophagectomy for squamous cell carcinoma. On the second post-operative day, the patient developed a cardiac arythmia with secondary hypotension followed by hypoxaemia necessitating artificial ventilation. Two weeks after surgery, endoscopy revealed massive necrosis of the proximal segment of the gastric tube extending from the anastomosis in the neck to the watershed area. Three weeks later, the patient died and a necropsy was performed. Macroscopic evaluation of the gastric tube revealed a sharply demarcated and fully ossificated proximal segment. Heterotopic ossification was present on histological examination. This condition has only been described in conjunction with primary or metastatic gastric adenocarcinoma. The location of the ossification and the presence of temporary systemic hypoxia suggest that the latter was the main factor responsible for the ossificative response.