Surgery for ruptured abdominal aortic aneurysm and early mortality in women. Risk factors and complication profile.

AIM: Repair of ruptured abdominal aortic aneurysm (rAAA) is reported to have a higher mortality in women than in men. The aim was to study whether this difference could be verified in our institution and secondary if difference in risk- and complication profiles could explain the higher 30 day mortality after surgery for rAAA in women. METHODS: During the period 1983-2009 1649 patients, 1348 men and 301 women, were operated consecutively for infrarenal abdominal aortic aneurysm (AAA); 430 patients had rAAA, 98 women and 332 men. Co-morbidities were identified from the patients' medical records. Outcome measures within 30 days were mortality, cardiac disease (heart attack, heart failure), cerebrovascular disease (stroke, TIA), renal insufficiency (serum creatinine >140 µmol/L), major amputation, bowel infarction, pancreatitis and graft related complications. RESULTS: Compared to men, women had higher 30 d mortality after surgery for rAAA (54.1% vs. 36.3%, P=0.002). Women were significantly older than men (76 years vs. 73 years, P=0.001). In the period 1995-2009 women had more autoimmune diseases than men (P=0.045). There was no significant difference between men and women for the other measured outcomes. CONCLUSION: During the period 1995-2009, autoimmune disease were more common among women than men. For all other parameters recorded, there were no differences in risk - or complication profile that could explain the higher 30 d mortality in female patients after surgery for rAAA.

Elective open operation for abdominal aortic aneurysm in octogenarians--survival analysis of 105 patients.

OBJECTIVES: To study early mortality and long-term survival of patients more than 80 years of age having elective open repair for abdominal aortic aneurysm (AAA). DESIGN: Retrospective multicenter cohort study. MATERIAL: One hundred and five patients, 23 women and 82 men, with a median age of 82 years, operated at three Norwegian hospitals during the period 1983-2002. METHOD: Survival analyses were based on data from medical records and the Norwegian Registrar's Office of Births and Deaths. Expected survival was based on mortality rates of the general population, matched by age, sex, and calendar period. Relative survival was calculated as the ratio between the observed and the expected survival. RESULTS: During the study period there has been a 10 fold increase in octogenarians treated with open operation for AAA. Early mortality (30-day) for the whole group of patients was 10.5% (95% confidence interval (95% CI) 5.3-18.0), and similar for both genders. The 5-year survival rate was 47% (95% CI 35.9-57.4), and not significantly different from that of a matched group in the general population. Patients aged 84 years or more had a median survival time of 35 months (95% CI 18.5-51.6). CONCLUSION: The number of AAA operations in octogenarians has increased considerably during 20 years. Octogenarians operated electively for AAA has higher 30-day mortality as compared to younger patients. Their long-term survival appears similar to a matched control group. The benefit of surgery must be carefully considered against the perioperative risk, especially for the oldest octogenarians.

Quality of data reported on abdominal aortic aneurysm repair--a comparison between a national vascular and a national administrative registry.

OBJECTIVE: To study consistency of data and completeness of reporting in a national vascular registry, NorKar, and a national administrative registry, The Norwegian patient register (NPR). DESIGN: Comparative registry-based national study supplemented with a comprehensive control of patients registered in one major hospital. MATERIAL: All patients registered with a procedure-code for treatment of AAA in NorKar or NPR during 2001 or 2002, were included. METHOD: We compared the reporting of procedure-codes, diagnosis-codes and in-hospital deaths after treatment for abdominal aortic aneurysm (AAA) in the two registries to evaluate completeness. Consistency between procedure-codes and diagnoses were evaluated within both registries. Completeness of reporting to one NorKar Local Registry was investigated in more detail in one of the hospitals. RESULTS: Compared with the NPR numbers, NorKar contained 69% of the patients treated for AAA in Norway, while completeness for NorKar member hospitals was 84%. The detailed investigation in one of the hospitals showed a completeness of 91% and a false inclusion of 5.3% of all cases treated for AAA. The consistency between procedure-codes and diagnosis-codes was 93% in both registries. We found evidence of substantial underreporting of in-hospital deaths to NorKar in several hospitals. Overall reporting of early deaths to NorKar relative to completeness of reported cases was estimated to 72%. CONCLUSION: There is an underreporting of patients with AAA to NorKar according to the NPR numbers and a need for better control of procedure-diagnosis consistency in both registries. There seems to be a substantial underreporting of early deaths to NorKar. Introduction of unique patient-identifiable data could improve the quality of both registries by making matching of data possible.

Emergency non-ruptured abdominal aortic aneurysm.

OBJECTIVES: To investigate symptoms and early mortality (<30 days) following open surgery for emergency, symptomatic non-ruptured abdominal aortic aneurysm (AAA). DESIGN: Retrospective cohort study. PATIENTS AND METHODS: During the period 1983-1994, 129 patients had an emergency admission, followed by surgery, for symptomatic non-ruptured AAA. Sixty-one received surgery within 24 h of admission and 68 received surgery more than 24 h after admission (median 135 h, inter-quartile range: 51-239 h). During the same period 239 patients had elective surgery for non-ruptured AAA. Early mortality (<30 days), symptoms and co-morbidities were recorded. Data were retrieved from the patient records. RESULTS: Mortality (30 days) was 18% in the 61 patients having surgery within 24 h of emergency admission for non-ruptured AAA. Mortality following either delayed surgery (semi-elective) after emergency admission or elective surgery was 4.2% (p=0.0002). Four out of 11 patients who died within 30 days following an acute operation had previously been declared unfit for elective surgery. One additional emergency patient had been found unfit for open surgery, but survived a delayed operation. CONCLUSION: The high mortality rate of patients with non-ruptured, symptomatic AAA undergoing surgery within 24 h of admission appears to be influenced by several factors, including co-morbidities and the acute operation. We propose that the 30-day mortality for non-ruptured AAA should be reported in two categories: mortality rate for elective surgery and mortality for surgery performed within 24 h of emergency admission. The term 'emergency non-ruptured' is a suitable term for the latter group.

Inflammatory aortic aneurysm is associated with increased incidence of autoimmune disease.

OBJECTIVE: It has been suggested that certain genetic risk factors indicative of an autoimmune mechanism can be identified in patients with inflammatory aortic aneurysm (IAA). We therefore investigated whether there was a higher incidence of autoimmune diseases in patients with IAA. Further, we explored risk factors, need for in-hospital resources, and early results of treatment, in a case-control study in a university hospital setting. Material and methods From 1983 to 1994, 520 patients were operated because of abdominal aortic aneurysm (AAA). Thirty-one patients had IAA. Control subjects were matched for aneurysm rupture, emergency or elective hospital admission, and date of operation. Two noninflammatory AAA were included for every IAA. RESULTS: Of the 31 patients with IAA, 6 patients (19%) had autoimmune disease, compared with none of the control subjects (P =.0017). Two patients had rheumatoid arthritis, 2 patients had systemic lupus erythematosus, 1 had giant cell arteritis, and 1 patient had an undifferentiated seronegative polyarthritis diagnosed as rheumatoid arthritis. Nineteen patients (61%) with IAA had involvement of the duodenum, and 8 patients (26%) had hydronephrosis with ureteral involvement. Operating time was longer in the IAA group, which also had a higher need for blood transfusion. Hospital stay, intensive care unit stay, and 30-day mortality were similar in the two groups. CONCLUSION: Except for longer operating time and more need for blood transfusions in the IAA group, use of hospital resources was similar after operations to treat IAA or noninflammatory AAA. The study findings indicate an association between IAA and autoimmune disease. This is in accordance with other reports that showed a genetic risk determinant mapped to the human leukocyte antigen (HLA) molecule in these patients. Further research is necessary to explore whether IAA might be a separate entity with a role of antigen binding in the origin of the disease.

[Collaborated admission to a surgical department]. / Samordnet pasientmottak i en kirurgisk avdeling.

BACKGROUND: The medical case record is an important tool for securing high quality in treatment and care of patients. Efficient and accurate documentation of diagnostic and therapeutic procedures, patient information etc. is crucial. MATERIAL AND METHODS: We have prospectively studied how time and patient satisfaction are influenced when nurse and doctor together ("combined model") take the patient's medical history, perform a clinical examination, and inform the patient, compared to separate history-taking by nurse and doctor ("separate model"). RESULTS: The mean nurse time per patient increased from 17 min in the separate model to 21 min in the combined model (p = 0.01). Corresponding time use by the doctor was 26 min and 21 min (p = 0.04), and for the patient 43 min and 23 min (p < 0.001). Patients reported the two models to be comparable in quality. INTERPRETATION: The "combined registration model" secures high quality of the medical case record, respects the patient's time, and signals professional collaboration to the patient.

Chylous complications after abdominal aortic surgery.

Two patients developed chylous complications following abdominal aortic aneurysm repair. One patient had chylous ascitis and was successfully treated by a peritoneo-caval shunt. The other patient developed a lymph cyst, which gradually resorbed after puncture. Chylous complications following aortic surgery are rare. Patients in bad a general condition should be treated by initial paracentesis and total parenteral nutrition, supplemented by medium-chain triglyceride and low-fat diet. If no improvement is observed on this regimen, the next step should be implementation of a peritoneo-venous shunt, whereas direct ligation of the leak should be reserved for those who are not responding to this treatment.

[Results after surgical treatment of abdominal aortic aneurysm]. / Resultater etter kirurgisk behandling av abdominale aortaaneurismer.

During the period 1983-1993 altogether 403 patients were operated on for abdominal aortic aneurysm. The median age was 69.5 years. 246 were operated on electively whereas 58 had symptoms without rupture and 99 had ruptured aneurysm. The 30 day mortality in the three groups was 4.1, 12.0 and 28.3% respectively. The mortality in hospital was 4.5, 12.0 and 31.3% in the three groups respectively. Coronary artery disease dominated as cause of death in the group as a whole, whereas irreversible shock and complications secondary to haemorrhage were common in the group with ruptured aneurysm. There were no graft infections in this series, and only one superficial infection which healed without complications. Investigation and treatment of coronary artery disease might perhaps decrease the mortality rate in the elective group. These results form a basis against which the results of endovascular treatment should be compared.

[The new medical curriculum in Trondheim. Organization and planning of a new curriculum]. / Det nye medisinstudiet i Trondheim. Organisering og planlegging av et nytt studium.

In autumn 1993, the Faculty of Medicine in Trondheim will be able to offer complete undergraduate medical education to 60 students per year, after 18 years of 3 1/2 years' education, based only on the clinical part of undergraduate medical school. The entire new curriculum is based on problem-based learning with the preclinical and the clinical part of the study totally integrated for 5 1/2 years. Throughout the curriculum any health care problem will be analyzed in terms of three perspectives: the biological, the environmental and the behavioural. The new medical curriculum was planned as a project during which both teachers and students took part in planning groups organized on several levels. Through clinical demonstrations and a course on the doctor-patient-relationship, the 60 students will meet patients as a natural part of their study from day one. In the Family Practice and in the Skills Lab they will acquire clinical skills during the first two years. In the fourth and fifth years the students spend two 8-week clerkship periods in community hospitals and community health practices.