Laparoscopic appendectomy for complicated appendicitis.

BACKGROUND: Acute gangrenous and perforating appendicitis are associated with an increased risk for postoperative complications and have been considered a relative contraindication of laparoscopic appendectomy. OBJECTIVE: To determine the complication rate following laparoscopic appendectomy for gangrenous of perforating appendicitis. DESIGN: A retrospective analysis of patients who underwent laparoscopic appendectomy for gangrenous or perforating appendicitis. SETTING: A multispecialty clinic. RESULTS: Fifteen patients underwent laparoscopic appendectomy for gangrenous appendicitis and 19 patients for perforating appendicitis. In the gangrenous appendicitis group, average operating time was 85 minutes; average length of hospitalization, 2 days; and morbidity rate, 7% (one patient with abdominal abscess). The perforating appendicitis group had an average operating time of 84 minutes, hospitalization of 7 days, and a morbidity rate of 42%. This morbidity included five patients (26%) who developed intra-abdominal abscesses, two patients (10%) in whom wound infections developed, and one patient (5%) who died of Candida sepsis and multisystem organ failure.

Economic considerations for aortic surgery: retroperitoneal approach--is it worth it?

BACKGROUND: Planned reductions in reimbursement for all forms of vascular surgery dictate a need for the development of more cost efficient, yet quality oriented, treatment programs. We are faced with an increasingly older patient population with multiple comorbidities. In this environment it will become extremely difficult to accomplish aortic surgery in a way which will be profitable for our hospitals. More than 100,000 aortic surgeries are performed annually in the United States. Previous reports suggest that earlier hospital discharges and reduced postoperative complications occur when a retroperitoneal approach is used for aortic surgery. Other publications refute this concept. In an effort to determine the most cost efficient method for aortic surgery in our institution, while maintaining high standards of care and outcome, we compared the retroperitoneal approach to the conventional transperitoneal aortic operation. PATIENTS AND METHODS: Between December 1995 and April 1998, 120 patients underwent aortic surgery by either the transperitoneal (n = 60) or retroperitoneal approach (n = 60). All patients were enrolled prospectively in a vascular registry and retrospectively reviewed. Patients were randomly assigned to one of three vascular surgeons. A clinical pathway for elective aortic surgery was developed and applied to both groups. Patients were evaluated with respect to demographics, comorbidities, preoperative risk stratification, conduct of the operative procedure, length of stay, complications, cost, clinical outcomes and patient satisfaction. The indications for aortic surgery were similar in both groups--64% for aneurysm disease and 36% for occlusive disease. Both symptomatic and asymptomatic aneurysms were included and size ranged from 4.4 cm to 14 cm. All aortic reconstructions were done in the standard manner using knitted Dacron velour prostheses in either the aortic tube, bi-iliac or bi-femoral configuration. Statistical analysis of means and medians was accomplished using the Wilcoxin Rank-sum test and percentages were compared using Fisher's Exact test. P values less than 0.05 indicate statistical significance. RESULTS: There were no statistically significant differences in patient demographics. The incidence of atherosclerotic coronary artery disease, obstructive pulmonary disease, diabetes, hyperlipidemia, tobacco abuse, distal lower extremity occlusive disease and the results of chemical myocardial stress evaluations were similar in both groups. Comorbidities of preexisting renal insufficiency/failure and morbid obesity were increased in the retroperitoneal group. Five patients in the retroperitoneal group represented redo aortic surgery and there were no redo procedures in the transperitoneal group. Length of operative procedures and blood replacement requirements for both groups were similar. The transperitoneal group required 2-3 liters more intraoperative intravenous (i.v.) crystalloid than the retroperitoneal group (p < 0.0001). Statistically significant reductions in ICU days, postoperative ileus and total lengths of stay were observed in the retroperitoneal group (p < 0.0001). This resulted in substantial reductions in hospital costs for the retroperitoneal group (p < 0.01). Postoperative complications were similar for both groups except for statistically significant increases in pulmonary edema (p < 0.01) and pneumonia (p < 0.001) in the transperitoneal group. Cardiac arrhythmias, primarily atrial dysrhythmias, were more frequent in the transperitoneal group but this failed to reach statistical significance (p < 0.16). Combined thirty day mortality was 0.9%. Time of recovery to full activity and patient satisfaction substantially favored the retroperitoneal group. CONCLUSION: Our clinical pathway and algorithm for aortic surgery was easily followed by those patients in the retroperitoneal approach group and resulted in decreases in ICU time, postoperative ileus, volume of intraoperative crystalloid and total length of stay. The patients in the transperitoneal group often failed to progress appropriately on the pathway. Reduced hospital costs associated with aortic surgery using the retroperitoneal approach has increased the profitability for this surgery in our institution by an average of $4000 per case and has increased the value (quality/cost) of this surgery to our patients and our institution. This was accomplished in an academic environment with surgical residency training where cost containment has historically been difficult.

Portal vein aneurysm: a rare occurrence.

Portal vein aneurysms (PVA) are a rare vascular anomaly of the portal system, representing fewer than 3% of all venous aneurysms, with only 150 known cases since first reported in l956 by Barzilai and Kleckner. PVA can be divided into 2 categories: extrahepatic and intrahepatic with acquired and congenital etiologies. Bimodal treatment includes medical and surgical approaches. With increased use of noninvasive radiological imaging, PVA will be increasingly recognized in the practice of vascular surgery.

Adverse consequences of internal iliac artery occlusion during endovascular repair of abdominal aortic aneurysms.

OBJECTIVE: Embolization of the internal iliac artery (IIA) may be performed during endovascular abdominal aortic aneurysm (AAA) repair if aneurysmal disease of the common iliac artery precludes graft placement proximal to the IIA orifice. The IIA may also be unintentionally occluded because of iliac trauma or coverage by the endograft. The purpose of this study was to determine the incidence, etiology, and consequences of IIA occlusion during endoluminal AAA repair. METHODS: Over 2 years, 96 patients have undergone endoluminal AAA repair. The details of the operative procedure, reasons for IIA occlusion, perioperative complications, and clinical follow-up were recorded. RESULTS: The IIA was intentionally occluded in 15 patients (16%) to treat 13 common iliac artery aneurysms, one IIA aneurysm, and one external iliac artery aneurysm. The IIA was unintentionally occluded in 9 patients (9%), resulting from traumatic iliac dissection in 5 patients and coverage of the IIA by the endograft in the remaining 4 patients. Three patients had colon ischemia. One patient with a unilateral IIA occlusion had sigmoid infarction necessitating resection. The other two patients underwent intentional occlusion of one IIA followed by unintentional occlusion of the contralateral IIA because of a traumatic iliac dissection. Both had postoperative abdominal pain and distention; rectosigmoid ischemia was revealed through colonoscopy. Conservative treatment with bowel rest and broad-spectrum antibiotics was successful in both cases. Nondisabling hip and buttock claudication occurred in seven patients (32%) at 1 month but resolved by 6 months in three of these patients. CONCLUSION: Embolization of the IIA for iliac aneurysmal disease and unintentional IIA occlusion due to trauma or graft coverage occurs in a considerable number of patients undergoing endoluminal AAA repair. Most patients with unilateral occlusion do not experience colon ischemia or disabling claudication. Therefore, unilateral embolization of the IIA is well tolerated and allows for the endoluminal treatment of patients with both an AAA and an iliac artery aneurysm, thereby expanding the number of patients who can be managed with an endovascular approach. Although acute, bilateral IIA occlusions should be avoided, significant consequences were not observed in our small series of patients.

Management of ectatic, nonaneurysmal iliac arteries during endoluminal aortic aneurysm repair.

PURPOSE: Most endografts for an endoluminal AAA repair cannot achieve an adequate hemostatic seal in ectatic common iliac arteries larger than 14 mm. The extension of the endograft into the external iliac artery can alleviate this problem but requires sacrifice of the internal iliac artery. We have used the larger diameter aortic extension cuff to obtain adequate endograft to arterial wall apposition in patients with ectatic, nonaneurysmal common iliac arteries. Because of the resultant flared configuration of the iliac limb, the technique is termed bell-bottom. However, it is unknown whether subsequent enlargement of these ectatic common iliac arteries that will lead to endoleaks or endograft migration will occur. METHODS: The records of all 96 patients who have undergone endoluminal abdominal aortic aneurysm repair at our institution were reviewed. Fourteen patients were identified in whom aortic extension cuffs were placed into 18 ectatic (>14 mm, but <20 mm) common iliac arteries. The mean follow-up time was 14 months (range, 6-24 months). The maximal diameter of the common iliac artery on computed tomography scan before endograft placement was compared with the maximal diameter at the most recent follow-up. The incidence of endoleaks, ruptures, and endograft migration related to the "bell-bottom" technique were recorded. RESULTS: The mean preoperative common iliac artery diameter was 18 mm (range, 15-20 mm). Aortic extension cuffs of 20-mm diameter and 24-mm diameter were used in 14 and 4 common iliac arteries, respectively. The diameter did not change in 11 common iliac arteries (61%), increased by 1 mm in 4 common iliac arteries (22%), and decreased by 1 mm in 3 common iliac arteries (17%). No endoleaks, ruptures, or endograft migration related to this technique was identified. CONCLUSION: The use of aortic extension cuffs for ectatic common iliac arteries expands the number of patients who can be treated endoluminally without sacrifice of the internal iliac artery. Most common iliac arteries do not increase in diameter. When enlargement occurs, the degree of dilation is minimal. Therefore, the "bell-bottom" technique appears to be an acceptable option in the management of large, nonaneurysmal iliac vessels during endoluminal abdominal aortic aneurysm repair.

Outcome of venous stasis ulceration when complicated by arterial occlusive disease.

OBJECTIVE: to report the outcome of patients with venous stasis ulceration (VSU) and severe arterial occlusive disease (AOD). DESIGN: retrospective study. METHODS: using the International Classification of Diseases (ICD-9), codes for VSU and AOD were cross-matched to identify patients from 1989 to 1999 at two tertiary hospitals. Entry into the study required the presence of a VSU and an ipsilateral procedure to improve AOD or major amputation during the same hospitalisation. RESULTS: fourteen patients (15 extremities) with a mean age of 80 years (range: 47-93) were identified as having VSU and AOD. Mean duration of VSU up to the time of revascularisation or amputation was 6.4 years (range: 4 months-21 years). The mean number of VSUs per extremity was 2.1 and mean wound area was 71 cm(2). Mean ankle-brachial index was 0.46 (range: 0.10-0.78). Nine extremities (60%) had a bypass procedure, 3 (20%) had an interventional procedure, 1 (0.6%) had a lumbar sympathectomy, and 2 (13%) had an amputation. Over a mean follow-up of 2.8 years, 3 extremities (23%) healed of which 2 recurred. On last review, 11 patients with 12 afflicted extremities had expired. Nine of the remaining 10 extremities were not healed at the time of death. Eight of nine bypass grafts remained patent in follow-up or at death and subsequent limb salvage was 100%. CONCLUSIONS: combined VSU and AOD represents a rare condition predominantly found in elderly patients with multiple comorbidities. Few patients had complete healing despite an arterial inflow procedure and mortality was high over the short term.

Retroperitoneal approach for aortic surgery: is it worth it?

BACKGROUND: Previous reports suggest that earlier hospital discharges and reduced postoperative complications occur when a retroperitoneal approach is used for aortic surgery. Other publications refute this concept. In an effort to determine the most cost efficient method for aortic surgery in our institution, while maintaining high standards of care and outcome, we compared the retroperitoneal approach to the conventional transperitoneal aortic operation. PATIENTS AND METHODS: Between December 1995 and April 1998, 120 patients underwent aortic surgery by either the transperitoneal (n=60) or retroperitoneal approach (n=60). All patients were enrolled prospectively in a vascular registry and retrospectively reviewed. Patients were randomly assigned to one of three vascular surgeons. A clinical pathway for elective aortic surgery was developed and applied to both groups. Patients were evaluated with respect to demographics, comorbidities, preoperative risk stratification, conduct of the operative procedure, length of stay, complications, cost, clinical outcomes and patient satisfaction. The indications for aortic surgery were similar in both groups - 64% for aneurysm disease and 36% for occlusive disease. Both symptomatic and asymptomatic aneurysms were included and size ranged from 4.4 to 14cm. All aortic reconstructions were done in the standard manner using knitted Dacron velour prostheses in either the aortic tube, bi-iliac or bi-femoral configuration. Statistical analysis of means and medians was accomplished using the Wilcoxin Rank-sum test and percentages were compared using Fisher's Exact test. P values less than 0.05 indicate statistical significance. RESULTS: There were no statistically significant differences in patient demographics. The incidence of atherosclerotic coronary artery disease, obstructive pulmonary disease, diabetes, hyperlipidemia, tobacco abuse, distal lower extremity occlusive disease and the results of chemical myocardial stress evaluations were similar in both groups. Comorbidities of pre-existing renal insufficiency/failure and morbid obesity were increased in the retroperitoneal group. Five patients in the retroperitoneal group represented redo aortic surgery and there were no redo procedures in the transperitoneal group. Length of operative procedures and blood replacement requirements for both groups were similar. The transperitoneal group required 2-3l more intraoperative intravenous (IV) crystalloid than the retroperitoneal group (P<0.0001). Statistically significant reductions in ICU days, postoperative ileus and total lengths of stay were observed in the retroperitoneal group (P<0.0001). This resulted in substantial reductions in hospital costs for the retroperitoneal group (P<0.01). Postoperative complications were similar for both groups except for statistically significant increases in pulmonary edema (P<0.01) and pneumonia (P<0.001) in the transperitoneal group. Cardiac arrhythmias, primarily atrial dysrhythmias, were more frequent in the transperitoneal group but this failed to reach statistical significance (P<0.16). Combined thirty day mortality was 0.9%. Time of recovery to full activity and patient satisfaction substantially favored the retroperitoneal group. CONCLUSION: Our clinical pathway and algorithm for aortic surgery was easily followed by those patients in the retroperitoneal approach group and resulted in decreases in ICU time, postoperative ileus, volume of intraoperative crystalloid and total length of stay. The patients in the transperitoneal group often failed to progress appropriately on the pathway. Reduced hospital costs associated with aortic surgery using the retroperitoneal approach has increased the profitability for this surgery in our institution by an average of $4000 per case and has increased the value (quality/cost) of this surgery to our patients and our institution.

Carotid endarterectomy in women: challenging the results from ACAS and NASCET.

OBJECTIVE: To evaluate and compare the short- and long-term outcomes in female and male patients after carotid endarterectomy (CEA). SUMMARY BACKGROUND DATA: Randomized carotid trials have clearly shown the benefits of CEA in specific symptomatic and asymptomatic patients. However, the short- and long-term benefits in women appear to be less clear, and the role of CEA among women with carotid disease remains uncertain. METHODS: During a 21-year period, 1,204 CEAs were performed, 464 (39%) in women and 739 (61%) in men. Complete follow-up was available in 70% of patients. RESULTS: Women were less likely to have evidence of coronary artery disease, were more likely to be hypertensive, and had a significantly greater incidence of diabetes. The mean age at CEA was 68.5 +/- 9.5 years for women and 68.0 +/- 8.5 years for men. There were no significant differences in the use of shunts, patching, tacking sutures, or severity of carotid stenoses between men and women. Surgical death rates were nearly identical for asymptomatic and symptomatic patients. Perioperative stroke rates were similar for asymptomatic and symptomatic patients. Life-table stroke-free rates at 1, 5, and 8 years were similar for asymptomatic women and men and symptomatic women and men. Long-term survival rates at 1, 5, and 8 years were higher for asymptomatic women compared with men and for symptomatic women compared with men. As a result, stroke-free survival rates at these follow-up intervals were greater for asymptomatic women compared with men, and for symptomatic women compared to men. CONCLUSIONS: The results from this study challenge the conclusions from the Asymptomatic Carotid Endarterectomy Study and the North American Symptomatic Carotid Endarterectomy Trial regarding the benefits of CEA in women. Female gender did not adversely affect early or late survival, stroke-free, or stroke-free death rates after CEA. The authors conclude that CEA can be performed safely in women with asymptomatic and symptomatic carotid artery disease, and physicians should expect comparable benefits and outcomes in women and men undergoing CEA.