[A woman with a large tumor in the thorax]. / Een vrouw met een grote tumor in de thorax.

Myoepithelial tumors are described very rarely in the thorax. We report a case of such a tumor. A 64 year old female presented with shortness of breath. A CT-scan was performed which showed a giant tumor occupying the left hemithorax. Thoracotomy with excision of the myoepithelial tumor was performed.

Neonatal Rupture of the Spleen: Successful Treatment with Splenic Artery Embolization.

Neonatal intra-abdominal hemorrhage has been rarely reported in the literature. We report a case of splenic injury in a neonate, highlighting the importance of a high-index suspicion in early recognition of this rare and potentially fatal injury. We report the first case of a neonate who had a splenic rupture and underwent successful endovascular treatment.

Prevalence and Risk Factors for Delirium in Elderly Patients With Severe Burns: A Retrospective Cohort Study.

Little is known about delirium in elderly burn center patients. The aim of this study is to provide information on the prevalence of delirium and risk factors contributing to the onset of delirium. All patients aged 70 years or older admitted with burn injuries to the Burn Center, Maasstad Hospital, in 2011 to 2017 were eligible for inclusion. We retrospectively collected data regarding the presence of delirium, potential risk factors contributing to the onset of delirium and outcome after delirium. We included elderly 90 patients in this study. The prevalence of delirium in our population was 13% (N = 12). Risk factors for delirium were advanced age, increased American Society for Anesthesiologists score, physical impairment and the use of anticholinergic drugs during admission. Patients with delirium had a poorer outcome, with prolonged hospital stay and increased mortality 6 and 12 months after discharge. Delirium is diagnosed in 13% of the elderly patients admitted to our burn center. Risk factors for delirium found in this study are advanced age, poor physical health status, physical impairment, and the use of anticholinergic drugs. Delirium is related to poor outcomes, including prolonged hospital stay and mortality after discharge.

Quality of Life and Traditional Outcome Results at 1 Year in Elderly Patients Having Critical Limb Ischemia and the Role of Conservative Treatment.

INTRODUCTION: Revascularization is the cornerstone of the treatment of critical limb ischemia (CLI), but the number of elderly frail patients increase. Revascularization is not always possible in these patients and conservative therapy seems to be an option. The goals of this study are to analyze the 1-year quality of life (QoL) results and mortality rates of elderly patients with CLI and to investigate if conservative treatment could be an acceptable treatment option. METHODS: Patients with CLI ≥70 years old were included in a prospective observational cohort study in 2 hospitals in the Netherlands between 2012 and 2016 and were divided over 3 treatment modalities: endovascular therapy, surgical revascularization, and conservative treatment. The World Health Organization Quality of Life (WHOQoL-Bref) instrument, a generic QoL assessment tool that includes components of physical, psychological, social relationships and environment, was used to evaluate QoL at baseline, 6 months, and 1 year. RESULTS: In total, 195 patients (56% male, 33% Rutherford 4, mean age of 80) were included. Physical QoL significantly increased after surgical (10.4 vs 14.9, P < .001), endovascular (10.9 vs 13.7, P < .001), and conservative therapy (11.6 vs 13.2, P = .01) at 1 year. One-year mortality was relatively low after surgery (10%) compared to endovascular (40%) and conservative therapy (37%). CONCLUSION: The results of this study could not be used to designate the superior treatment used in elderly patients with CLI. Conservative treatment could be an acceptable treatment option in selected patients with CLI unfit for revascularization. Treatment of choice in elderly patients with CLI is based on multiple factors and should be individualized in a shared decision-making process.

Important differences between quality of life and health status in elderly patients suffering from critical limb ischemia.

INTRODUCTION: Critical limb ischemia (CLI) patients are often of advanced age with reduced health status (HS) and quality of life (QoL) at baseline. Physical health is considered as the most affected domain due to reduced mobility and ischemic pain. QoL and HS are often used interchangeably in the current literature. HS refers to objectively perceived physical, psychological, and social functioning and in assessing QoL, change is measured subjectively and can only be determined by the individual since it concerns patients' evaluation of their functioning. It is important to distinguish between QoL and HS, especially in the concept of shared decision-making when the opinion of the patient is key. Goal of this study was to examine and compare QoL and HS in elderly CLI patients in relation to the used therapy, with a special interest in conservatively treated patients. METHODS: Patients suffering from CLI and ≥70 years old were included in a prospective study with a follow-up period of 1 year. Patients were divided into three groups; endovascular revascularization, surgical revascularization, and conservative therapy. The WHOQoL-Bref was used to determine QoL, and the 12-Item Short Form Health Survey was used to evaluate HS at baseline, 5-7 days, 6 weeks, 6 months, and 1 year. RESULTS: Physical QoL of endovascularly and surgically treated patients showed immediate significant improvement during follow-up in contrast to delayed increased physical HS at 6 weeks and 6 months (P<0.001). Conservatively treated patients showed significantly improved physical QoL at 6 and 12 months (P=0.02) in contrast to no significant improvement in physical HS. CONCLUSION: This study demonstrates that QoL and HS are indeed not identical concepts and that differentiating between these two concepts could influence the choice of treatment in elderly CLI patients. Discriminating between QoL and HS is, therefore, of major importance for clinical practice, especially to achieve shared decision-making.

Delirium after hip hemiarthroplasty for proximal femoral fractures in elderly patients: risk factors and clinical outcomes.

BACKGROUND: The primary aim of the present study was to verify the potential risk factors for developing a delirium after hip fracture surgery. The secondary aim of this study was to examine the related clinical outcomes after a delirium developed post-hip fracture surgery. PATIENTS AND METHODS: Data were extracted from a prospective hip fracture database and completed by retrospective review of the hospital records. A total of 463 patients undergoing hip fracture (hip hemiarthroplasty) surgery in a level II trauma teaching hospital between January 2011 and May 2016 were included. Delirium was measured using the Delirium Observation Screening Scale, the confusion assessment method, and an observatory judgment by geriatric medicine specialists. RESULTS: The results showed that 26% of the patients (n=121) developed a delirium during hospital stay with a median duration during admission of 5 days (IQR 3-7). The multivariable model showed that the development of delirium was significantly explained by dementia (OR 2.75, P=0.001), age (OR 1.06, P=0.005), and an infection during admission (pneumonia, deep surgical site infection, or urinary tract infection) (OR 1.23, P=0.046). After 1 year of follow-up, patients who developed delirium after hip fracture surgery were significantly more discharged to (semi-independent) nursing homes (P<0.001) and had a significantly higher mortality rate (P<0.001) compared to patients without delirium after hip fracture surgery. CONCLUSIONS: The results showed that 26% of the patients undergoing hip fracture surgery developed a delirium. The risk factors including age, dementia, and infection during admission significantly predicted the development of the delirium. No association was confirmed between delirium and time of admission or time to surgery. The development of delirium after hip fracture surgery was subsequently found to be a significant predictor of admission to a nursing home and mortality after 1 year.

Quality of Life and Mortality after Endovascular, Surgical, or Conservative Treatment of Elderly Patients Suffering from Critical Limb Ischemia.

BACKGROUND: Revascularization to relieve ischemic pain and prevent limb loss is the cornerstone of critical limb ischemia (CLI) treatment; however, not all elderly patients are deemed fit for revascularization. Patient-related outcome measurements are important in these patients. Quality of life (QoL) results regarding the effect of endovascular, surgical, and conservative treatment on the QoL in the elderly are scarce in the current literature. The goal of this study was to explore the outcomes of the different treatment modalities in elderly patients suffering from CLI, with a specific focus on QoL. METHODS: A total of 195 CLI patients ≥70 years were prospectively included between January 2012 and February 2016 and divided into 6 groups (endovascular revascularization, surgical revascularization, and conservative treatment). Two age groups (70-79 and >80 years) were analyzed. Follow-up was performed at 5-7 days, 6 weeks, and 6 months. World Health Organization Quality of Life-BREF questionnaire was used to determine QoL. The Vascular-Physiological and Operative Severity Score for Enumeration of Mortality and Morbidity score was noted. QoL was used as the primary end point, with mortality and limb salvage as the secondary end points. RESULTS: Six-month mortality was significantly lower in surgically treated patients aged 70-79 years (4%) as compared with endovascular (24%, P = 0.001) or conservative treatment (25%, P = 0.02). There was no significant difference in 6-month mortality in patients >80 years among endovascularly (38%), surgically (15%), and conservatively treated patients (27%). QoL significantly increased at all follow-up moments in surgically treated patients between 70 and 79 years and at 6 months in endovascularly treated patients. Conservatively treated patients did not improve their QoL in this age group. All patients aged >80 years, including conservatively treated patients, showed significantly improved QoL results at 6 months. CONCLUSIONS: Elderly patients judged fit for surgery may benefit the most from surgical revascularization, reporting low mortality rates, low adverse events and significantly gained QoL in multiple domains. However, all 3 treatment modalities have significantly increased physical health at 6 months. Conservative therapy seems to be an acceptable treatment option in patients unfit for revascularization with gained physical health at 6 months.

Quality of Life in Patients Suffering from Critical Limb Ischemia.

BACKGROUND: Various treatment options exist for patients suffering from critical limb ischemia (CLI). These options consist of endovascular procedures, surgical revascularization, primary amputation, or conservative therapy. The effect of the treatment is traditionally focused on outcomes, such as primary patency and limb salvage, though quality of life (QoL) is considered an important additional primary end point in a more patient-oriented healthcare system. The aim of this systematic review is to explore the best clinical decision making possible, to increase QoL in CLI patients. METHODS: This review is based on a systematic electronic literature search using the PubMed and EMBASE databases. Articles evaluating QoL in patients with CLI were selected for further analysis. Only prospective studies, written in English, describing QoL and health status (HS) after endovascular or surgical revascularization, amputation or conservative therapy were considered for inclusion. Treatment results were divided into short-term (≤3-month follow-up) and long-term results (≥1-year follow-up) to achieve a clear view of the QoL in patients suffering for CLI patients. RESULTS: Twenty-five articles describing HS in patients suffering from CLI were included. It was found that while most of these articles reported HS of patients, rarely did they report on QoL. As a result, it is difficult to determine the best treatment to increase HS as studies that focus on the comparison of treatment modalities are lacking. All 4 treatment modalities can raise HS in the short and the long terms; however, endovascular and surgical revascularization seem to positively effect HS the most. QoL results are lacking in both the short and long terms. CONCLUSIONS: All treatment methods included in the study resulted in an increase in patients' HS in both short and long terms. More comparative studies with inclusion of all different treatments of CLI are needed to assist in clinical decision making and perform tailored interventions for the individual patient. QoL and HS are confusingly used in current international literature with abundant HS research. To take patients individual opinions more into account, focus on QoL research is needed to designate the superior treatment in patients suffering from CLI.

Life Expectancy in Nonagenarians Suffering from Critical Limb Ischemia.

BACKGROUND: Peripheral arterial disease has become an increasing problem in the aging population of the western world with a prevalence of 10-14%. This will result in a growing group of nonagenarians being referred to vascular surgeons, with an estimated growth of 2.5 times the number of nonagenarians between 2015 and 2040. Outcome results of nonagenarians suffering from critical limb ischemia (CLI) are scarce, which can cause difficulties in choosing superior therapy options. We propose that the life expectancy of nonagenarians suffering CLI compared to the overall population of nonagenarians is valuable information required in clinical decision-making. METHODS: Between January 2012 and October 2015, all patients suffering from CLI were retrospectively reviewed in the Amphia Hospital, Breda, The Netherlands. Patients aged ≥90 years at admission were exclusively included. The main outcome result of this study is the life expectancy of nonagenarians suffering from CLI. Closely related to life expectancy is the primary end point of mortality. Secondary end points were adverse events, reoperations, and limb salvage. RESULTS: A total of 36 patients were included in this study of which 27 were women. The median age was 92 years. Conservative therapy was performed in 61% of the patients. Based on 24 deaths (of which 19 were women), the mortality rate ratio of the study group relative to the Dutch population was 3.13 (95% confidence interval [CI], 2.00-4.66; P < 0.000001), adjusted for age and gender. Life expectancy in years of the total Dutch population at age 90 years in 2013 was 3.83 for men and 4.54 for women in contrast to, respectively, 1.23 (95% CI, 0.50-5.69) and 2.70 (95% CI, 1.76-3.74) years in our patient group. CONCLUSIONS: CLI is a severe disease in nonagenarians with a dreadful life expectancy of 1.23 and 2.7 years for men and women, respectively, corresponding with an age- and gender-adjusted mortality rate ratio of 3.13 relative to the Dutch population. Individual factors such as preoperative status, arterial occlusive lesion, and especially predicted postoperative quality of life are important parameters in clinical decision-making. Results of conservative therapy might be acceptable in selected patients, but more focus on quality of life is needed to be conclusive.

New aspects of delirium in elderly patients with critical limb ischemia.

OBJECTIVE: The primary objective was to identify possible risk factors for delirium in patients with critical limb ischemia undergoing surgery. The secondary objective was to study the effect of delirium on complications, the length of hospital stay, health care costs, and mortality. METHODS: All patients 65 years or older with critical limb ischemia undergoing surgery from February 2013 to July 2014 at Amphia Hospital, were included and followed up until December 31, 2014. Delirium was scored using the Delirium Observation Screening Scale (DOSS). Perioperative risk factors (age, comorbidity, factors of frailty, operation type, hemoglobulin, and transfusion) were collected and analyzed using logistic regression. Secondary outcomes were the number of complications, total hospital stay, extra health care costs per delirium, and mortality within 3 months and 6 months of surgery. RESULTS: We included 92 patients with critical limb ischemia undergoing surgery. Twenty-nine (32%) patients developed a delirium during admission, of whom 17 (59%) developed delirium preoperatively. After multivariable analysis, only diabetes mellitus (odds ratio [OR] =6.23; 95% confidence interval [CI]: 1.11-52.2; P=0.035) and Short Nutritional Assessment Questionnaire for Residential Care (SNAQ-RC) ≥3 (OR =5.55; 95% CI: 1.07-42.0; P=0.039) was significantly associated with the onset of delirium. Delirium was associated with longer hospital stay (P=0.001), increased health care costs, and higher mortality after 6 months (P<0.001). CONCLUSION: Delirium is a common adverse event in patients with critical limb ischemia undergoing surgery with devastating outcome in the long term. Most patients developed delirium preoperatively, which indicates the need for early recognition and preventive strategies in the preoperative period. This study identified undernourishment and diabetes mellitus as independent risk factors for delirium.

Risk Factors and Outcomes for Postoperative Delirium after Major Surgery in Elderly Patients.

BACKGROUND: Early identification of patients at risk for delirium is important, since adequate well timed interventions could prevent occurrence of delirium and related detrimental outcomes. The aim of this study is to evaluate prognostic factors for delirium, including factors describing frailty, in elderly patients undergoing major surgery. METHODS: We included patients of 65 years and older, who underwent elective surgery from March 2013 to November 2014. Patients had surgery for Abdominal Aortic Aneurysm (AAA) or colorectal cancer. Delirium was scored prospectively using the Delirium Observation Screening Scale. Pre- and peri-operative predictors of delirium were analyzed using regression analysis. Outcomes after delirium included adverse events, length of hospital stay, discharge destination and mortality. RESULTS: We included 232 patients. 51 (22%) underwent surgery for AAA and 181 (78%) for colorectal cancer. Postoperative delirium occurred in 35 patients (15%). Predictors of postoperative delirium included: delirium in medical history (Odds Ratio 12 [95% Confidence Interval 2.7-50]), advancing age (Odds Ratio 2.0 [95% Confidence Interval 1.1-3.8]) per 10 years, and ASA-score ≥3 (Odds Ratio 2.6 [95% Confidence Interval 1.1-5.9]). Occurrence of delirium was related to an increase in adverse events, length of hospital stay and mortality. CONCLUSION: Postoperative delirium is a frequent complication after major surgery in elderly patients and is related to an increase in adverse events, length of hospital stay, and mortality. A delirium in the medical history, advanced age, and ASA-score may assist in defining patients at increased risk for delirium. Further attention to prevention of delirium is essential in elderly patients undergoing major surgery.

The utility of peritoneal drains in patients with perforated appendicitis.

BACKGROUND: Intra-abdominal abscesses are the most common complication after perforated appendicitis and remain a significant problem ranging in incidence from 14 to 18%. Drainage following appendectomy is usually determined by whether the underlying appendicitis is simple or complicated and largely determined by the surgeons' belief, based on expertise or personal opinion. In this report we discuss the results of patients diagnosed with peritoneal drainage, treated with or without a peritoneal drain. PATIENTS AND METHODS: A retrospective study of patients diagnosed with perforated appendicitis having surgery was performed. Patients diagnosed with perforated appendicitis treated with a peritoneal drain and patients treated without a peritoneal drain. Both groups were evaluated in terms of complications: intra-abdominal abscess, re-intervention, readmission and duration of hospital stay. RESULTS: 199 patients diagnosed with perforated appendicitis underwent appendectomy. 120 patients were treated without a peritoneal drain and 79 patients with a peritoneal drain. Thirty-one (26%) patients from the group without a peritoneal drain had a re-intervention compared to 9 (11%) in the group with a peritoneal drain (p = 0.013). Overall complications and readmission were also significantly lower in patients treated with a peritoneal drain. CONCLUSION: A peritoneal drain seems to reduce overall complication rate, re-intervention rate and readmission rate in patients treated with perforated appendicitis.

Conservative Treatment in Selected Patients with Severe Critical Limb Ischemia.

OBJECTIVE: To assess the outcome of conservative treatment of severe critical limb ischemia (CLI) classified as Rutherford 5/6. BACKGROUND: The preferred therapy for CLI is either endovascular revascularization or bypass surgery. With a growing aged population with more serious comorbidities, these therapies are not always a viable option. Primary amputation leads to decreased mobility and a reduced quality of life. There is a lack of literature regarding the outcome of conservative therapy. METHODS: Hospital charts were reviewed of all patients who were diagnosed with Rutherford classification 5-6 and received conservative treatment and lacked interventional options. Outcome measures were mortality, complete wound closure, and limb salvage rate. RESULTS: 38 patients were included with a median age of 80 years (range 57-97). The amputation rate during follow-up was 16%. In 58% of patients, complete wound closure was achieved. All-cause mortality was 58% with a 2-year survivability rate of 55%. CONCLUSIONS: Conservative management in our selected patients with CLI results in a moderate rate of wound closure and acceptable amputation rates albeit with a high mortality rate. For patients not eligible for endovascular revascularization or bypass surgery, conservative treatment could be a viable option besides primary limb amputation.

Current factors of fragility and delirium in vascular surgery.

BACKGROUND: Vascular surgery patients are frequently deemed to be in a frail clinical condition and at risk for delirium. Therefore, we evaluated the incidence and independent perioperative risk factors for delirium. In addition, we describe factors on frailty in the various vascular disease groups in current practice. METHODS: This observational longitudinal study included 206 selected patients who were referred to a vascular surgery ward of a large-sized teaching hospital (Amphia Hospital, Breda, The Netherlands) for critical limb ischemia (n = 80), diabetic foot ulcers (n = 27), abdominal aortic aneurysm (AAA) (n = 62), and carotid surgery (n = 37) between April 2013 and December 2013. Data on factors that characterize frailty were collected. Delirium was scored using the Delirium Observation Screening Scale. Multivariable logistic regression analysis was performed to find independent risk factors for delirium. RESULTS: Delirium was present in 24% of the critical limb ischemia patients, in 19% of the patients with a diabetic foot ulcer, in 7% of the patients with an AAA, and in 8% of the patients undergoing carotid surgery (P > 0.05). Of the patients with critical limb ischemia and a delirium, 53% were octogenarians. Multivariable stepwise logistic regression analysis revealed that history of delirium and nurse help at patient's home were independently associated with delirium. Patients with critical limb ischemia scored worse on factors related to frailty compared with the other disease groups in our current clinical practice on vascular surgery. CONCLUSIONS: Delirium is a frequent complication in vascular surgery clinical practice, especially in the elderly. Nurse visits at patients' homes and the Amphia Risk Score for delirium were independent risk factors for delirium in our study population. In this study, we identified patients with critical limb ischemia as the most frail and vulnerable.

Long-term outcome of ruptured abdominal aortic aneurysm: impact of treatment and age.

BACKGROUND: Despite advances in operative repair, ruptured abdominal aortic aneurysm (rAAA) remains associated with high mortality and morbidity rates, especially in elderly patients. The purpose of this study was to evaluate the outcomes of emergency endovascular aneurysm repair (eEVAR), conventional open repair (OPEN), and conservative treatment in elderly patients with rAAA. METHODS: We conducted a retrospective study of all rAAA patients treated with OPEN or eEVAR between January 2005 and December 2011 in the vascular surgery department at Amphia Hospital, the Netherlands. The outcome in patients treated for rAAA by eEVAR or OPEN repair was investigated. Special attention was paid to patients who were admitted and did not receive operative intervention due to serious comorbidity, extremely advanced age, or poor physical condition. We calculated the 30-day rAAA-related mortality for all rAAA patients admitted to our hospital. RESULTS: Twelve patients did not receive operative emergency repair due to extreme fragility (mean age 87 years, median time to mortality 27 hours). Twenty-three patients had eEVAR and 82 had OPEN surgery. The 30-day mortality rate in operated patients was 30% (7/23) in the eEVAR group versus 26% (21/82) in the OPEN group (P=0.64). No difference in mortality was noted between eEVAR and OPEN over 5 years of follow-up. There were more cardiac adverse events in the OPEN group (n=25, 31%) than in the eEVAR group (n=2, 9%; P=0.035). Reintervention after discharge was more frequent in patients who received eEVAR (35%) than in patients who had OPEN (6%, P<0.001). Advancing age was associated with increasing mortality (hazard ratio 1.05 [95% confidence interval 1.01-1.09]) per year for patients who received operative repair, with a 67%, 76%, and 100% 5-year mortality rate in the 34 patients aged <70 years, 59 patients aged 70-79 years, and 12 octogenarians, respectively; 30-day rAAA-related mortality was also associated with increasing age (21%, 30%, and 61%, respectively; P=0.008). CONCLUSION: The 30-day and 5-year mortality in patients who survived rAAA was equal between the treatment options of eEVAR and OPEN. Particularly fragile and very elderly patients did not receive operative repair. The decision to intervene in rAAA should not be made on the basis of patient age alone, but also in relation to comorbidity and patient preference.

[A 15-year old boy with abdominal pain]. / Een jongen met pijn links onder in de buik.

A 15-year-old boy came to the emergency department with abdominal pain in the left lower quadrant. The medical history included surgery for malrotation of bowel in two of his brothers. A CT-abdomen showed malrotation of the colon with a left-sided appendicitis and polysplenia. An emergency laparoscopic appendectomy was performed. Recovery was uneventful.