The influence of age on valve disease in patients with varicose veins analysed by transmission electron microscopy and stereology.

BACKGROUND: The aim of this study was to investigate the influence of age on the ultrastructure of venous valve morphology in patients with C2 classified chronic venous disorders according to the CEAP classification. PATIENTS AND METHODS: The study population consisted of 16 consecutive patients with varicose veins (C2). The mean age was 49.8 years (30-66). The (pre-) terminal valve including the vessel wall was harvested within the proximal 2 centimetres of the great saphenous vein. The mean thickness (volume-to-surface ratio = V/S ratio) of elastin, collagen, endothelium and of the entire valve was determined. A blinded morphologist performed the examination by transmission electron microscopy and stereology. Analyses by Pearson's product moment correlation, Kendall's tau and Spearman's rank correlation were performed to investigate whether there is a correlation between age and the ultrastructural morphology. RESULTS: Stereological analysis of the valves demonstrated a mean V/S ratio (signifying a thickness estimation) for elastin of 0.87 µm3/µm2, for collagen of 18.0 µm3/µm2, for endothelium of 0.65 µm3/µm2, and for the entire valve of 25.2 µm³/µm². Statistical analyses showed no statistically significant correlation between age and the ultrastructural morphology in this patient group. CONCLUSIONS: The ultrastructural morphology of the venous valves in chronic venous disorders may not depend on age in patients presenting with C2 disease. This conclusion may or may not apply to all C classes as we investigated a homogenous group of patients with C2 limbs.

More great saphenous vein valves - less varicose veins?

BACKGROUND: In patients with chronic venous disease (CVD) the number of venous valves and the degree of valve deterioration have not been extensively investigated and are poorly understood. The aim of this prospective study was to quantitatively and qualitatively investigate the venous valves in CVD patients in view of their clinical classification. PATIENTS AND METHODS: Within two years a consecutive series of 152 patients (223 limbs) undergoing primary surgery for great saphenous vein varicose veins was investigated. In all patients the 'C' class according to the basic CEAP-classification was registered preoperatively (C2 to C6) for each limb. Both the quantity and quality of venous valves were assessed in the GSV's after removal. Qualitative evaluation of the valves was based on macroscopic appearance using a classification from 0 to 5 and described as 'valve disease class'. RESULTS: A negative correlation between age and the number of valves was detected (p = 0.0035). There was an increase of C-class with increasing age. No significant correlation between the average number of valves per meter and the C-class was detected. For all C-classes an average of between four and five valves per meter was counted. Valve disease class was positively correlated with the C-class although the valve disease class was never higher than the C-class (p < 0.05). CONCLUSIONS: The valve disease class of the great saphenous vein correlates with the C-class of the CEAP-classification. The number of valves did not correlate with the 'C'-class. With each increase in the CEAP class the age increased as well.

Esophageal dysmotility disorders after laparoscopic gastric banding--an underestimated complication.

OBJECTIVE: To evaluate the effects of laparoscopic adjustable gastric banding (LAGB) on esophageal dysfunction over the long term in a prospective study, based on a 12-year experience. BACKGROUND: Esophageal motility disorders and dilatation after LAGB have been reported. However, only a few studies present long-term follow-up data. METHODS: Between June 1998 and June 2009, all patients with implantation of a LAGB were enrolled in a prospective clinical trial including a yearly barium swallow. Esophageal motility disorders were recorded and classified over the period. An esophageal diameter of 35 mm or greater was considered dilated. RESULTS: Laparoscopic adjustable gastric banding was performed in 167 patients (120 females and 47 males) with a mean age of 40.1±5.2 years. Overall patient follow-up was 94%. Esophageal dysmotility disorders were found in 108 patients (68.8% of patients followed). Esophageal dilatation occurred in 40 patients (25.5%)with a mean esophageal diameter of 47.3±6.9 mm(35.0­94.6) after a follow-up of 73.8 ± 6.8 months (36­120) compared with 26.2± 2.8 mm (18.3­34.2) in patients without dilatation (diameter of <35 mm)(P < 0.01). Thirty-four patients suffered from stage III dilatation (band deflation necessary) and 6 from stage IV (major achalasia-like dilatation, band removal mandatory). In 29 patients, upper endoscopy was carried out because of heartburn/dysphagia. In 18 patients, the endoscopy was normal; 9 patients suffered from gastroesophageal reflux disease, 1 from a stenosis, and 1 from a hiatus hernia. CONCLUSIONS: This study demonstrates that esophageal motility disorders after LAGB are frequent, poorly appreciated complications. Despite adequate excess weight loss, LAGB should probably not be considered the procedure of first choice and should be performed only in selected cases until reliable criteria for patients with a low risk for the procedure's long-term complications are developed.

Histopathology of Neovascularisation Observed During Saphenofemoral Re-Do High Ligation.

OBJECTIVE: The primary aim of this study was to assess the histopathological criteria of neovascularisation following saphenofemoral high ligation with regard to the delineation of the pathophysiology of the process. The secondary aims were to describe the perivenous morphological changes and to present cost effective agents to histopathologically diagnose neovascularisation. METHODS: In a prospective study design, vein samples of consecutive patients with recurrent varicose veins in the groin undergoing surgery were collected. The samples were analysed by a vascular histopathologist with a light microscope using standard staining techniques. RESULTS: The study population comprised 35 patients, 24 of whom were female (69%). Histopathologically, 28 samples (80%) showed typical aspects of neovascularisation. The remaining seven specimens (20%) showed thickened residual veins. An irregular vascular network, increasing perivenous collagen and elastic fibres and perivenous lymph nodes were observed. Present venous valves were the main criterion for residual veins. A surprising finding was the presence of scar tissue in the views of reparative incomplete new valves. Standard staining agents were sufficient to make the diagnosis of neovascularisation in 73% of the samples and reduced the cost by 30% compared with the regular use of specific markers. CONCLUSION: The histopathological analysis of operative specimens may clarify whether a varicose vein recurrence is the result of neovascularisation or some other cause. Although interesting for research, academic interest, and classification, this may be of very limited clinical relevance for the patient.

Outcome of colorectal cancer surgery in the early fast-track era with special regard to elderly patients.

Colorectal cancer (CRC) is one of the most frequently diagnosed cancers in the Western world. Differentiated surgical therapy in the last years have made a curative resection possible in more than 80% of the cases. Two hundred ninety consecutive patients with colorectal cancer over 6 years were enrolled in a retrospective follow-up study based on the electronic patient record, with special regard to patients more than 70 years old. The outcome was evaluated using the following endpoints: resectability, 30-days morbidity (local and general complications), mortality, re-operation rate, and survival. The mean age of the 290 patients was 71.5 years; 176 patients were more than 70 years old and the male to female ratio was 148:142. Three hundred eight tumors had been diagnosed in the 290 patients. Tumor staging was as follows: stage I, 18.5%; stage II, 30%; stage III, 32%; and stage IV, 19.5%. A local R0 resection was made possible in 97% of the tumors. The 30-days morbidity incidence for patients younger/older than 70 years was 33%/57% (P < 0.05), the mortality incidence was 2.6%/3.4% (P value not significant), and the reoperation rate was 7.0%/9.1% (P value not significant). Anastomotic leaks occurred in 3.5% of the patients. The 1-, 2-, and 5-year survival rates were 81.4%, 66.3%, and 61.5%, respectively. Our findings show that colorectal carcinomas may be operated with mostly curative intent with a low mortality rate, a high R0 resection rate, and similar complications, mortality, and re-operation rates, even in patients more than 70 years old.

Factors Determining Seasonal Variations in Varicose Vein Surgery.

OBJECTIVES: Varicose vein operations are traditionally performed during the winter season because of supposed advantages during post-operative care. This prospective study aimed to investigate how, and on what grounds, patients and physicians time varicose vein surgery. METHODS: Unselected patients attending a consultation for varicose vein surgery at a Regional Hospital in Thun, Switzerland were asked to fill out an anonymous and standardised questionnaire to register the C of CEAP, age, and gender and to understand the drivers behind the timing of the actual intervention. The five main criteria were: job, workplace; symptoms, prevention; family, leisure, sports; season; and other. RESULTS: Between May 2015 and April 2017 (a 24 month period spanning two full seasonal cycles) 153 consecutive patients were included and returned 153 questionnaires for analysis. The actual timing of varicose vein surgery correlated inversely with the average temperatures measured in Thun. Among men (n = 65, 43% of the study population), job requirements were the most frequent determinant (41% of cases) of the operating day. Among women, by contrast, symptoms and prevention were named most often (32% of cases) as the leading motivation for surgical timing. Although for both men and women job and workplace was a leading factor over all CEAP classes (28.6%), the importance of symptoms and prevention increased with the CEAP class: from 26.3% in classes 2-4 to 51.8% in classes 5-6. CONCLUSIONS: Although inversely correlated with outside temperature, the concentration of varicose vein surgery to the winter months seems to be coincidental. The patient's job situation represents overall the most important determinant of surgical planning. Symptoms and prevention are more important in certain subgroups than in others, that is among women and among patients with high CEAP classes.

Outcome and complications after laparoscopic Swedish adjustable gastric banding: 5-year results of a prospective clinical trial.

BACKGROUND: Bariatric surgery is currently the only effective treatment for morbid obesity in terms of inducing and maintaining satisfactory weight loss and decreasing weight-related co-morbidities. A study was conducted to assess the effects, complications and outcome after laparoscopic Swedish adjustable gastric banding (SAGB) to 5 years. METHODS: Between June 1998 and December 2005, all patients with implantation of a SAGB were enrolled in a prospective clinical trial. Results were recorded and classified, with special regard to long-term complications and re-operation rate. RESULTS: SAGB was performed in 128 patients (87 female, 41 male). Mean age was 40.2 +/- 5.3 years, with mean preoperative BMI 44.5 +/- 3.9 kg/m2. Overall mortality was 0%. Patient follow-up was 94.5%. BMI after 1, 2 and 5 years was 35.7 +/- 3.7 kg/m2 (P < 0.005), 33.7 +/- 3.8 kg/m2 (P < 0.001) and 31.8 +/- 3.8 kg/m2 (P < 0.001), respectively. Mean EWL after 1, 2 and 5 years was 33.3 +/- 6.8% (P < 0.005), 45.5 +/- 6.4% (P < 0.001) and 57.4 +/- 6.5% (P < 0.001), respectively. The nonresponder rate (EWL < 30%) after 2 and 5 years was 17.0% and 6.8%, respectively. The early complication rate (< 30 d) was 6.25% (8/128), with 5 minor and 3 major complications. Late complications (> 30 d) occurred in 10.9% (14/128), of whom 2 were minor and 12 were major complications. The overall re-operation rate was 11.7% (15/128). CONCLUSIONS: At 5-year follow-up, laparoscopic SAGB is a safe and effective surgical treatment for morbid obesity. Our results appear to confirm that SAGB is a safer surgical treatment regarding rate and severity of complications compared with gastric bypass and malabsorptive procedures.

Prescribing practice in a Swiss primary and secondary acute care hospital.

QUESTIONS UNDER STUDY: Little is known about the prescribing behaviour of physicians in hospitals. This analysis, using data based on Computerised Physician Order Entry (CPOE), was performed to evaluate prescription patterns, to analyse possible over-prescribing of drugs and to assess the compliance with therapy-guidelines. METHODS: Within a 12 month period, 68,133 prescriptions in three departments were analysed with respect to drug class, duration of therapy, dosage, administration route, patient's age, patient's length of stay and number of prescriptions per patient. RESULTS: On average, each patient received 12 drugs. A steady increase in the number of prescribed drugs can be seen between the age of 20 and 85. The median duration of intravenously administered antibiotics was 4.0 days, the median duration of antibiotic therapy was 9.5 days. DISCUSSION: On average, patients were taking 5 drugs on a regular basis on admission to hospital. This number was doubled during the hospital stay where patients were prescribed 12 drugs on average. On discharge 6 drugs were prescribed and thus a reasonable reduction was made. Surgical and Internal Medicine wards were using very similar drug classes. Concerning the use of low molecular-weight heparin, guidelines were widely adhered to whereas proton-pump-inhibitors were prescribed too often and the duration of intravenous antibiotic therapy tended to be too long.

Venous injury in lumbar anterior spine surgery.

UNLABELLED: To assess the clinical and angiological outcome of venous injury in lumbar anterior spine surgery. DESIGN: Follow-up study. METHODS: During a seven-year time span 77 consecutive patients underwent lumbar anterior spine surgery. Of these patients three patients suffered two minor and two major vein injuries. In two cases this was a common iliac vein injury. The other two injuries were at the level of the junction of the iliac veins with the inferior vena cava. The injuries were repaired by direct suture and the patients were followed-up by an independent angiologist. RESULTS: The follow-up, done clinically and with duplex sonography, plethysmography and ankle pressures showed no sequelae from the venous injuries. CONCLUSIONS: Venous injuries following anterior spine surgery are rare and may have a good recovery. Preoperative informed consent is recommended.

Preperitoneal mesh repair in Spigelian hernia.

The first Spigelian hernia was described in 1764. From April 1995 to April 2004, 29 patients underwent 35 Spigelian hernia repair operations in our department. The choice of primary closure or additional mesh was based on the condition of the local tissue. If the tissue appeared of good quality, primary closure was performed; if the tissue was of weak quality, an additional nonresorbable mesh was implanted to induce a stronger scar tissue. Twenty-one Spigelian hernias were repaired using the primary closure method. There were three radiological recurrences, one of which was symptomatic after 10 months and required reoperation. In 14 cases, an additional preperitoneal mesh was implanted. There was no radiological or clinical recurrence in this group. Spigelian hernia repair may therefore have a lower recurrence rate if a preperitoneal mesh is initially implanted.

Valve disease in chronic venous disorders: a quantitative ultrastructural analysis by transmission electron microscopy and stereology.

INTRODUCTION: The ultrastructure of venous valves and walls in chronic venous disease was investigated. METHODS: Consecutive patients were categorised into one of three groups (group A: patients with C1 venous disease in accordance with CEAP (Clinical severity, Etiology, Anatomy, Pathophysiology); group B: C2 and C3; group C: C4, C5 and C6). The terminal or preterminal valve and adjacent vessel wall was harvested from the great saphenous vein. Sections were examined with a transmission electron microscope. The volumes of elastin and of collagen per unit surface area of valve were assessed, as well as the surface endothelium of valve and vessel wall. RESULTS: The study population consisted of 17 patients. The elastin ratio was analysed by means of stereology. Mean values were: in group A, 0.45 µm3/m2; in group B, 0.67 µm3/m2; in group C, 0.97 µm3/m2. The ratio was similar for collagen (A, 15.7 µm3/m2; B, 26.8 µm3/m2; C, 30.1 µm3/m2). Surface analysis of the valve endothelium and the adjacent vessel wall endothelium showed a trend towards increasing damage with more severe disease. CONCLUSIONS: With progression of venous disease, the valve elastin content, assessed morphologically, seems to increase, and the endothelium of the venous valve and the vein wall tend to show more damage.

Small-bowel volvulus in late pregnancy due to internal hernia after laparoscopic Roux-en-Y gastric bypass.

Internal hernias are a specific cause of acute abdominal pain and are a well-known complication after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Although internal hernias are a rare cause of intestinal obstruction, they may evolve towards serious complications, such as extensive bowel ischemia and gangrene, with the need for bowel resection and sometimes for a challenging reconstruction of intestinal continuity. The antecolic position of the Roux limb is associated with a decrease in the incidence of small-bowel obstruction and internal hernias. The best prevention of the formation of these hernias is probably by closure of potential mesenteric defects at the initial operation with a non-absorbable running suture. We present a patient in late pregnancy with a small-bowel volvulus following laparoscopic Roux-en-Y gastric bypass for morbid obesity and discuss the available literature. For a favorable obstetric and neonatal outcome, it is crucial not to delay surgical exploration and an emergency operation usually is mandatory.

Graft survival and complications after laparoscopic gastric banding for morbid obesity--lessons learned from a 12-year experience.

Laparoscopic adjustable gastric banding (LAGB) has been considered by many as the treatment of choice for morbid obesity because of its simplicity and encouraging early results. The aim of this prospective study was to critically assess the effects, complications, and outcome after LAGB in the long-term, based on a 12-year experience. Between June 1998 and June 2009, all patients with implantation of a LAGB have been enrolled in a prospective clinical trial. Results were recorded and classified, with special regard to long-term complications, re-operation rate, and graft survival. LAGB was performed in 167 patients (120 female, 47 male) with a mean age of 40.1 +/- 5.2 years. Operative mortality was 0%, overall 1.2% (not band-related). Overall patient follow-up was 94.0%. Mean excess weight loss (EWL) after 1, 2, 5, 8, and 10 years was 31.1 +/- 7.5% (p < 0.005), 44.2 +/- 6.5% (p < 0.001), 50.3 +/- 6.9% (p < 0.001), 51.7 +/- 6.3% (p < 0.001), and 48.8 +/- 6.0% (p < 0.001), respectively. The non-responder rate (EWL < 30%) after 2, 5, 8, and 10 years was 24.5%, 18.3%, 12.5%, and 16.6%, respectively. The early complication rate (<30 days) was 7.8% (13/167), with 10 minor and three major complications. Late complications (>30 days) occurred in 40.1% (67/167), of whom seven were minor and 60 were major complications (three band infections, two band migrations, 11 band leakages, two slippings/pouch dilatations, two band intolerances, and 40 esophageal dilatations). The overall re-operation rate was 20.4% (34/167). The graft survival of the implanted band after 2, 5, 8, 10, and 12 years was 98.8%, 94.0%, 86.8%, 85.0%, and 85.0%, respectively. The failure rate of the procedure after 2, 5, 8, and 10 years was 25.7%, 24.3%, 25.7%, and 31.6%, respectively. In the present long-term high-participation follow-up study, LAGB is a safe and effective surgical treatment for morbid obesity. However, the high complication, re-operation, and long-term failure rates lead to the conclusion that LAGB should be performed in selected cases only, until reliable criteria for patients at low risk for long-term complications are developed.