Laparoscopic versus hybrid approach for treatment of incisional ventral hernia: a prospective randomised multicentre study, 1-year results.

PURPOSE: Laparoscopic incisional ventral hernia repair (LIVHR) is often followed by seroma formation, bulging and failure to restore abdominal wall function. These outcomes are risk factors for hernia recurrence, chronic pain and poor quality of life (QoL). We aimed to evaluate whether LIVHR combined with defect closure (hybrid) follows as a diminished seroma formation and thereby has a lower rate of hernia recurrence and chronic pain compared to standard LIVHR. METHODS: This study is a multicentre randomised controlled clinical trial. From November 2012 to May 2015, 193 patients undergoing LIVHR for primary incisional hernia with fascial defect size from 2 to 7 cm were recruited in 11 Finnish hospitals. Patients were randomised to either a laparoscopic (LG) or a hybrid (HG) repair group. The main outcome measure was hernia recurrence, evaluated clinically and radiologically at a 1-year follow-up visit. At the same time, chronic pain scores and QoL were also measured. RESULTS: At the 1-year-control visit, we found no difference in hernia recurrence between the study groups. Altogether, 11 recurrent hernias were found in ultrasound examination, producing a recurrence rate of 6.4%. Of these recurrences, 6 (6.7%) were in the LG group and 5 (6.1%) were in the HG group (p > 0.90). The visual analogue scores for pain were low in both groups; the mean visual analogue scale (VAS) was 1.5 in LG and 1.4 in HG (p = 0.50). QoL improved significantly comparing preoperative status to 1 year after operation in both groups since the bodily pain score increased by 7.8 points (p < 0.001) and physical functioning by 4.3 points (p = 0.014). CONCLUSION: Long-term follow-up is needed to demonstrate the potential advantage of a hybrid operation with fascial defect closure. Both techniques had low hernia recurrence rates 1 year after operation. LIVHR reduces chronic pain and physical impairment and improves QoL. TRIAL REGISTRY: Clinical trial number NCT02542085.

Air gap technique is recommended in axiolateral hip radiographs.

PURPOSE: To investigate the replacement of conventional grid by air gap in axiolateral hip radiographs. The optimal air gap distance was studied with respect to radiation dose and image quality using phantom images, as well as 26 patient axiolateral hip radiographs. METHODS: The CDRAD phantom, along with polymethylmethacrylate slabs with thicknesses of 10.0, 14.6, and 20.0 cm was employed. The inverse image quality index and dose area product (DAP), as well as their combination, so called figure-of-merit (FOM) parameter, were evaluated for these images, with air gaps from 20 to 50 cm in increments of 10 cm. Images were compared to those acquired using a conventional grid utilized in hip radiography. Radiation dose was measured and kept constant at the surface of the detector by using a reference dosimeter. Verbal consent was asked from 26 patients to participate to the study. Air gap distances from 20 to 50 cm and tube current-time products from 8 to 50 mAs were employed. Exposure index, DAP, as well as patient height and weight were recorded. Two radiologists evaluated the image quality of 26 hip axiolateral projection images on a 3-point nondiagnostic - good/sufficiently good - too good scale. Source-to-image distance of 200 cm and peak tube voltage of 90 kVp were used in both studies. RESULTS AND CONCLUSION: Based on the phantom study, it is possible to reduce radiation dose by replacing conventional grid with air gap without compromising image quality. The optimal air gap distance appears to be 30 cm, based on the FOM analysis. Patient study corroborates this observation, as sufficiently good image quality was found in 24 of 26 patient radiographs, with 7 of 26 images obtained with 30 cm air gap. Thus, air gap method, with an air gap distance of 30 cm, is recommended in axiolateral hip radiography.

Effect of display type and room illuminance in chest radiographs.

OBJECTIVES: To compare diagnostic accuracy in the detection of subtle chest lesions on digital chest radiographs using medical-grade displays, consumer-grade displays, and tablet devices under bright and dim ambient light. METHODS: Five experienced radiologists independently assessed 50 chest radiographs (32 with subtle pulmonary findings and 18 without apparent findings) under bright (510 lx) and dim (16 lx) ambient lighting. Computed tomography was used as the reference standard for interstitial and nodular lesions and follow-up chest radiograph for pneumothorax. Diagnostic accuracy and sensitivity were calculated for assessments carried out in all displays and compared using the McNemar test. The level of significance was set to p < 0.05. RESULTS: Significant differences in sensitivity between the assessments under bright and dim lighting were found among consumer-grade displays in interstitial opacities with, and in pneumothorax without, Digital Imaging and Communication in Medicine-Grayscale Standard Display Function (DICOM-GSDF) calibration. Compared to 6 megapixel (MP) display under bright lighting, sensitivity in pneumothorax was lower in the tablet device and the consumer-grade display. Sensitivity in interstitial opacities was lower in the DICOM-GSDF calibrated consumer-grade display. CONCLUSIONS: A consumer-grade display with or without DICOM-GSDF calibration or a tablet device is not suitable for reading digital chest radiographs in bright lighting. No significant differences were observed between five displays in dim light. KEY POINTS: • Ambient lighting affects performance of consumer-grade displays (with or without DICOM-GSDF calibration). • Bright light decreases detection of pneumothorax on non-medical displays. • Bright light decreases detection of interstitial opacities on DICOM-GSDF-calibrated, consumer-grade displays. • Dim light is sufficient to detect subtle chest lesions from all displays.

Early and midterm outcomes after endovascular treatment of degenerative aneurysms of the descending thoracic aorta: a Finnish multicenter study.

PURPOSE: To evaluate results of endovascular stent-graft placement for aneurysms of the descending aorta in 3 Finnish university hospitals during 1998-2010. METHODS: Among 158 consecutive patients treated with stent-graft placement for disease of the descending thoracic aorta, all 69 patients (58 men; mean age 71.7 years, range 54-90) with an aneurysm were included in the analysis. Medical records, radiological images, and national death records were collected and analyzed on an intention-to-treat basis. RESULTS: The 30-day mortality rate was 3.7% in 54 elective patients and 46.7% in 15 urgently treated acute patients. The paraparesis rate was 4.3%, and the major stroke rate was 4.3% after the operation. There were 4 aneurysm ruptures, all in the urgent group, two of whom had access failure. The other two died despite seemingly good initial results. The mean follow-up was 34.8±29 months. Two late ruptures occurred in patients who were lost to follow-up. In all, 12 type I (10 early, 2 late) and 1 late type III endoleaks were encountered in the observation period. CONCLUSION: Based on our findings, endovascular treatment of aneurysms of the descending aorta is relatively safe. To reduce the risk of postoperative complications, optimal preoperative imaging is mandatory. Postoperative regular imaging controls are indicated for early detection and prompt treatment of late type I or III endoleaks and to reduce the risk of late ruptures.

Inferior mesenteric artery embolization before endovascular repair of an abdominal aortic aneurysm: effect on type II endoleak and aneurysm shrinkage.

PURPOSE: To evaluate the value of preoperative embolization of the inferior mesenteric artery (IMA) before endovascular repair of an abdominal aortic aneurysm. MATERIALS AND METHODS: From January 2000 to October 2006, 79 patients (mean age, 72.3 years; 69 men) scheduled for endovascular aneurysm repair (EVAR) were found to have a patent IMA at computed tomography. Coil embolization of the patent IMA was performed in 40 patients at Kuopio University Hospital, and their outcome was compared with that of 39 patients with a patent IMA who underwent EVAR at Oulu University Hospital without preoperative IMA embolization (control group). All patients were treated with a Zenith stent-graft. The mean follow-up time was 3.4 years +/- 1.7 (median, 3.1 years; range, 0-7.6 years). RESULTS: There were significantly fewer type II endoleaks in the IMA embolization group than in the control group (25% vs 59%, respectively; P = .002). Preoperative IMA embolization did not correlate with aneurysm size change. The overall linearized aneurysm shrinkage rate per year was 1.4 mm per year +/- 3.8 in the IMA embolization group and 1.7 mm per year +/- 2.4 in the control group (P = .72). CONCLUSIONS: Preoperative coil embolization of the IMA reduced the frequency of type II endoleaks after EVAR, but the authors failed to show any influence on late postoperative aneurysm shrinkage.

Risk prediction in patients undergoing elective endovascular repair of an abdominal aortic aneurysm.

OBJECTIVES: The aim of this study was to retrospectively evaluate three risk scoring methods in predicting outcome after elective endovascular repair of an abdominal aortic aneurysm. DESIGN: A Zenith stent graft was employed in 205 patients during years 2001-2005. RESULTS: The 30-day postoperative mortality rate was 2.9%. Receiver operating characteristics (ROC) curve analysis showed that the Glasgow aneurysm score (GAS) (AUC: 0.843, p=0.004) and the Giles' score (AUC 0.815, p=0.009) had a rather large area under the curve in predicting 30-day mortality rate. The modified Leiden score was much less accurate (AUC: 0.594). The best cut-off value for the GAS in predicting 30-day mortality was 90 (0.6% vs. 17.9%, p<0.0001). Patients with a GAS > or = 90 had a 4-year survival rate of 56.8%, whereas it was 78.5% among those with a lower GAS (p = 0.001). The best cut-off value for the Giles' score was 11 (1.3% vs. 8.3%, p<0.0001). Patients with a Giles' score > or = 11 had a 4-year survival rate of 63.9%, whereas it was 79.0% among those with a lower score (p = 0.016). CONCLUSIONS: The GAS and Giles' risk scoring methods are good predictors of poor immediate and late outcome after EVAR.

Finnish multicenter study on the midterm results of use of the Zenith stent-graft in the treatment of an abdominal aortic aneurysm.

PURPOSE: To assess the midterm results of endovascular repair of abdominal aneurysm (AAA) with a Zenith stent-graft. MATERIALS AND METHODS: Between January 2001 and December 2005, a Zenith stent-graft was employed for endovascular repair of an infrarenal AAA in 206 patients. The mean patient age (+/-standard deviation) was 73.2 years +/- 7.3. Bifurcated grafts were used in 196 patients (96.1%), aortouni-iliac grafts were used in seven patients (3.4%), and a tubular graft was used in one patient (0.5%). The mean follow-up period was 2.4 years +/- 1.7. RESULTS: The 30-day mortality rate was 2.9%. The overall survival rates at 1-, 3-, and 5-year follow-up were 93.3%, 78.7%, and 64.5%, respectively. None of the patients died of AAA rupture. The primary and assisted technical success rates 1 week after endovascular aneurysm repair were 82.0% and 90.3%. The primary clinical success rates at the 1-, 3-, and 5-year follow-up were 90.6%, 85.6%, and 83.5%. Twenty-seven patients (13.1%) underwent a secondary intervention during the study period. CONCLUSIONS: An 83% rate of freedom from repeat vascular intervention over a period of 5 years as well as an absence of structural failures or aneurysm ruptures demonstrates that a Zenith stent-graft is associated with good midterm results.

Type II endoleak after endovascular repair of abdominal aortic aneurysm: effectiveness of embolization.

The purpose of this study was to report our experience in treating type II endoleaks after endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms. Two hundred eighteen patients underwent EVAR with a Zenith stent-graft from January 2000 to December 2005. During a follow-up period of 4.5 + or - 2.3 years, solely type II endoleak was detected in 47 patients (22%), and 14 of them underwent secondary interventions to correct this condition. Ten patients had transarterial embolization, and four patients had translumbar/transabdominal embolization. The embolization materials used were coils, thrombin, gelatin, Onyx (ethylene-vinyl alcohol copolymer), and glue. Disappearance of the endoleak without enlargement of the aneurysm sac after the first secondary intervention was achieved in only five of these patients (5/13). One patient without surveillance imaging was excluded from analyses of clinical success. After additional interventions in four patients and the spontaneous disappearance of type II endoleak in two patients, overall clinical success was achieved in eight patients (8/12). One patient did not have surveillance imaging after the second secondary intervention. Clinical success after the first secondary intervention was achieved in two patients (2/9) in the transarterial embolization group and three patients (3/4) in the translumbar embolization group. The results of secondary interventions for type II endoleak are unsatisfactory. Although the small number of patients included in this study prevents reliable comparisons between groups, the results seem to favor direct translumbar embolization in comparison to transarterial embolization.

Outcome of symptomatic, unruptured abdominal aortic aneurysms after endovascular repair with the Zenith stent-graft system.

OBJECTIVE: Symptomatic abdominal aortic aneurysms (AAA) account for up to 20% of patients with unruptured AAA undergoing open repair. This condition is associated with an average postoperative mortality rate after open repair of about 16%. The aim of this study was to evaluate the outcome of a consecutive series of patients who underwent endovascular repair for symptomatic, unruptured AAA. MATERIAL AND METHODS: From January 2000 to October 2006, 14 patients underwent endovascular repair of intact AAA within 15 days since admission for AAA-related symptoms. In these patients, a Zenith stent-graft (Cook Incorporated, Bloomington, IN, USA) was deployed at the Oulu University Hospital, Kuopio University Hospital and Helsinki University Hospital, Finland. RESULTS: Stent-grafting was not successful in one patient because of access failure. The procedure was immediately converted to open repair and an aortobifemoral bypass with a Dacron prosthesis was performed. In the remaining 13 patients, bifurcated Zenith stent-grafts were deployed. After the procedure, type II endoleak was observed in three patients. The mean follow-up time was 1.9+/-1.4 years. The 2-year survival rate was 69%. The survival freedom from secondary procedure was 71% as one patient underwent stent-grafting for a distal type I endoleak 5 months after the procedure. Another patient underwent femoro-femoral cross-over bypass surgery because of right limb graft thrombosis which occurred 9 months after the procedure. CONCLUSIONS: These preliminary results suggest that endovascular repair of symptomatic, unruptured AAA is feasible and can be associated with a favourable outcome despite a very high operative risk.