The EAG tool: a decision support system for selection of abdominal aorta aneurysm endografts

This article describes a decision support system (the EAG tool = Effective AAA Graftmanship) that assists the vascular surgeon in deciding whether a patient is fit for an endograft procedure and that assists the vascular surgeon in selecting the proper graft and in planning the endograft procedure. The EAG tool is the first step in the development of a learning environment for AAA procedures. As such the EAG tool is part of the VREST development project aiming to create a complete set of Virtual Reality Educational Surgical Tools. The EAG tool has been validated by using the expert knowledge of five experienced AAA physicians: three vascular surgeons and two interventional radiologists. In over 3,000 assessments, the EAG tool showed a false-positive rate of 0.2%, or in other words: in only 1 out of 500 cases the EAG tool indicated the possible use of an endograft, whereas the combined group of experts believed that it was not possibe. The EAG tool proved to be more prudent than the group of experts in having a false-negative rate of 3.7%. The EAG tool thus proved to be useful in daily clinical practice. Further developments are ongoing to use the EAG tool in a learning environment, specifically for unexperienced physicians.

Ruptured Abdominal Aortic Aneurysm: Endovascular Repair is Feasible in 40% of Patients

INTRODUCTION

Open repair of ruptured abdominal aortic aneurysm (rAAA) still has a high mortality. Endovascular aortic repair (EVAR) may be the way to improve survival rates. However, it is not clear how many patients with rAAA will be suitable for acute EVAR.

METHODS

Between October 2000 and April 2002 all patients with acute symptomatic or ruptured AAA were assessed for EVAR on an intention-to-treat basis with emergency computed tomographic angiography (CTA). Patient and logistic characteristics were analysed. We used two commercially available aorto uni-iliac devices with a maximum proximal diameter of 28 and 34 mm.

RESULTS

Five out of 26 patients were excluded for CTA and EVAR because of severe and persistent hypotension (3 pts) or logistic reasons (2 pts, both eligible). Twelve patients were found not eligible for EVAR due to unsuitable infrarenal aortic neck length (3 pts), neck diameter (1 pt) or a combination of both (8 pts). The remaining six patients were treated with EVAR. After 6 months no graft failure or aneurysm related deaths were recorded in the EVAR group.

CONCLUSION

A total of 28% of patients with symptomatic or ruptured AAA was treated with EVAR. A potential 42% of patients could have been suitable for EVAR, if the correct devices had been in stock and all patients had been properly assessed.

Endovascular treatment of traumatic thoracic aortic rupture combined with diaphragmatic rupture--a case report

The purposes of this report are to describe the immediate repair of a diaphragmatic rupture and subsequent endovascular treatment of a thoracic aortic rupture secondary to blunt chest and abdominal trauma and to discuss the outcome in the light of the trauma scores. A 29-year-old man was injured in a car collision. There were signs of a left diaphragmatic rupture and spleen injury. After urgent laparotomy, the diaphragm was repaired. The spleen appeared uninjured; however, there was a dissection with a transmural tear of the thoracic aorta, which was subsequently treated intraluminally by using a Talent endovascular graft and two AneuRx aortic extension cuffs. The patient fully recovered, and the thoracic endograft showed no evidence of endoleak both 1 month and 1 year after treatment. Fourteen months after the operation, the patient is doing well. Endoluminal techniques can be used successfully in the immediate repair of thoracic aortic injuries, even in the presence of a diaphragmatic rupture. With the introduction of advanced repair modalities, such as endovascular techniques, mortality rates will decrease and may eventually alter injury-scoring systems such as the Injury Severity Score.

Partial matrix excision or segmental phenolization for ingrowing toenails

OBJECTIVE

To decide whether partial nail extraction with phenolisation or with partial excision of the matrix should be the standard treatment in patients with ingrowing toenails of the hallux.

DESIGN

Randomized clinical trial with 12-month follow-up evaluations performed by observers who did not know which procedure was applied.

SETTING

Outpatient department of a surgical teaching hospital.

PATIENTS

Fifty-eight consecutive patients with a total of 63 ingrowing toenails were randomized.

INTERVENTION

Thirty-four partial matrix excisions ("matrix" group) and 29 phenolizations ("phenol" group) were performed.

MAIN OUTCOME MEASURES

Recurrence rate, postoperative morbidity (pain, wound exudates, and scar discomfort), and time to complete recovery (wearing shoes, performing normal activities/work).

RESULTS

Recurrences were seen after 7 procedures in the matrix group and also after 7 procedures in the phenol group, of which patients were symptomatic and required a second operation in 4 and 3 instances, respectively. None of the observed differences in wound healing, postoperative pain, and recovery were statistically significant.

CONCLUSIONS

Partial matrix excision and phenolization are equally effective in treating ingrowing toenails. Because the use of the toxic agent phenol should be avoided, partial matrix excision is the preferable procedure. But in view of the high recurrence rate, there is a need for further improvement of the treatment of ingrowing toenails.

[Injury to the right A. pulmonalis due to blunt thoracic trauma]

Immediately after a moped accident a 16-year old patient was haemodynamically unstable. Following adequate drainage of a haematopneumothorax in the hospital the patient collapsed into a shock. Thoractomy revealed a tear of the right A. pulmonalis. The hilus was clamped and a lobectomy was performed. After this the patient was haemodynamically stable; due to bone and nerve damage he was transferred to a rehabilitation centre. Laceration of the A. pulmonalis as a consequence of blunt thoracic trauma is rare and mostly fatal. In the case of a patient with a massive haematothorax rapid transport to the nearest hospital is preferable to thorax drainage at the site of the accident.

Exercise induces gastric ischemia in healthy volunteers: a tonometry study

Heavy physical exercise may cause gastrointestinal signs and symptoms, and, although splanchnic blood flow may decrease through redistribution by more than 50%, it is unclear whether these signs and symptoms relate to gastrointestinal ischemia. In 10 healthy volunteers, we studied the effect of exercise on gastric mucosal perfusion adequacy using air tonometry. Two relatively short (10 min) exercise stages were conducted on a cycle ergometer, aiming for 80 and 100% of maximum heart rate, respectively. The intragastric-arterial PCO(2) gradient (Delta PCO(2)) was elevated by 1.1 +/- 1.0 kPa over baseline values (-0.1 +/- 0.3 kPa) only after maximal exercise (P < 0.001). Delta PCO(2) positively correlated with the arterial lactate level taken as an index of exercise intensity (Spearman's rank test: r = 0.76, P < 0.0001). By bilinear regression analysis, a lactate level of 12 mmol/l, above which a sharp rise in the Delta PCO(2) occurred, was calculated. We conclude that, in healthy volunteers with normal splanchnic vasculature, gastric ischemia may develop during maximal exercise as judged from intragastric PCO(2) tonometry.

Prospective study of primary anastomosis following sigmoid resection for suspected acute complicated diverticular disease

BACKGROUND

A primary anastomosis after resection of the sigmoid colon for suspected acute complicated diverticular disease has the advantage of saving the patient a secondary operation for restoring bowel continuity. Fear of anastomotic leakage often deters surgeons from making a primary anastomosis.

METHODS

A series of 45 patients who underwent primary anastomosis was studied prospectively to evaluate the feasibility of a primary anastomosis following acute sigmoid resection. Acute Physiology and Chronic Health Evaluation (APACHE) II score, Mannheim Peritonitis Index (MPI) and Hughes' peritonitis classification were used to classify patients and to detect factors predictive of postoperative outcome. Death, anastomotic leakage and septic complications were main outcome measures.

RESULTS

Neither anastomotic leakage (four of 45 patients) nor death (three of 45) was related to a higher MPI, APACHE II or Hughes' score. More postoperative septic complications were seen in patients with a MPI over 16. Death, anastomotic leakage, reintervention and wound infection were observed more frequently in patients who presented with colonic obstruction than in those with abscess or perforation.

CONCLUSION

Primary anastomosis is safe and effective in non-obstructed cases of complicated diverticular disease. Colonic obstruction seems to be a risk factor for the development of postoperative complications.

Chronic splanchnic ischaemia

Chronic splanchnic ischaemia is a relatively unusual clinical entity consisting of pain and/or weight loss and caused by chronic splanchnic disease (i.e. stenosis and/or occlusion of the coeliac and superior mesenteric artery). The occlusive disease is usually caused by atherosclerosis and is in itself not rare in older individuals. Extensive collateral circulation can develop between the three splanchnic arteries and may compensate for the decreased splanchnic perfusion over time. The pathophysiology of chronic splanchnic ischaemia has still not been completely elucidated.A reliable diagnosis of chronic splanchnic ischaemia, based on a proven causal relationship between the occlusive disease and the symptoms, can be very difficult. Traditionally, tests for evaluating the haemodynamic consequences of the vascular stenoses were not available. Important improvements in establishing a more reliable diagnosis have been achieved with duplex ultrasound and magnetic resonance evaluation of the splanchnic circulation. Tonometry is another promising functional test that may prove useful not only for gaining greater insight into the pathophysiology of chronic splanchnic ischaemia but also for the clinical evaluation of this syndrome. The natural history of chronic splanchnic disease suggests that progressive disease may result in acute mesenteric ischaemia. Surgical reconstruction of the coeliac and/or the superior mesenteric artery is the therapeutic standard with excellent short and long-term results. Satisfactory early results using angioplasty with or without stent suggest that this type of intervention may relieve symptoms in selected patients with a higher surgical risk.

Quality of life with a temporary stoma: ileostomy vs. colostomy

PURPOSE

The hypothesis is that the impact of a temporary stoma on a patient's daily life is determined by complications and related stoma care problems.

METHOD

A prospective clinical trial was performed, studying complications and social well-being of 37 patients with loop ileostomy and 39 patients with a loop colostomy (randomly assigned comparison). Patients were categorized according to degree of social restriction. The association between the degree of social restriction and the presence of stoma care problems and complications was assessed. Follow-up was scheduled every three months until the stoma was closed (94 percent).

RESULTS

There is no relation between stoma type (ileostomy or colostomy) and degree of social restriction (chi-squared test, P = 0.42). The more stoma care problems or complications seen, the higher the degree of social restriction: significantly more stoma care problems were seen in the completely isolated group of patients when compared with the patients who were less socially restricted (Spearman correlation coefficient 1 = 0.35, P = 0.003). Especially stoma leakage, peristomal skin irritation, dietary prescriptions, retraction, and prolapse of the stoma have significant impact on the patient's daily life.

CONCLUSION

Stoma surgery has a great influence on a patient's daily life. There is a clear relation between the number of stoma care problems and the degree of social restriction. Follow-up of stoma patients under close surveillance of stoma care nurse to minimize stoma care problems and a careful surgical technique are advocated for good stoma care.

[Gastrointestinal surgery and gastroenterology. VIII. Gastroenterologic aspects of chronic gastrointestinal ischemia]

The main cause of chronic gastrointestinal ischaemia is atherosclerosis. Stenotic lesions of the mesenteric circulation are relatively common, but lead to chronic ischaemic complaints due to collateral circulation in probably only 2-3 per 100,000 inhabitants per year. The classical presentation (post-prandial abdominal pain, weight loss, upper abdominal souffle) is present in a minority of patients only. Symptoms also occur after exercise. Gastric ulcers and diarrhoea are less frequent. Although patients with 2 and 3 vessel involvement (coeliac artery, superior mesenteric artery and inferior mesenteric artery) usually experience the most severe ischemic complaints, patients with single vessel involvement can also develop symptoms. In the diagnosis of cases with abdominal complaints, factors that aggravate or reduce the complaints anamnestically are the guideline for supplementary diagnostics. The more frequent causes of the symptoms are to be excluded first. Doppler-ultrasonography of the mesenteric vessels can detect most stenotic lesions accurately. To establish the diagnosis visceral angiography is needed. A new method of examination is magnetic resonance angiography (MRA). Another new method is tonometry during exercise: a PCO2 value in the lumen that is higher than that in the blood indicates ischaemia. Non-invasive treatment of chronic gastrointestinal ischaemia is aimed at reduction of the gastrointestinal metabolic workload by smaller meals, at suppression of acid secretion, at inhibition of the secretion of gastric acid and on risk factors for atherosclerosis.

Operations that require supracoeliac aortic cross-clamping: perioperative monitoring with gastric tonometry

OBJECTIVE

To assess the predictive value of a gastric intramucosal pH of less than 7.35 for mortality in surgical patients after supracoeliac aortic cross-clamping.

DESIGN

Open prospective clinical study.

SETTING

University hospital, The Netherlands.

SUBJECTS

Six patients who required temporary supracoeliac, and four patients who required temporary infrarenal, cross-clamping of the aorta.

MAIN OUTCOME MEASURES

Mortality and conventional measures of organ dysfunction correlated with gastric tonometry.

RESULTS

All 6 patients who required supracoeliac cross-clamping underwent a steep, and 5 patients a prolonged, decrease in the gastric intramucosal pH. The mean lowest gastric intramucosal pH in the supracoeliac group was 7.05 and in the infrarenal group 7.28. All patients recovered completely.

CONCLUSION

A pHig value below 7.35 does not seem to be a marker of mortality in patients who have undergone supracoeliac cross-clamping of the aorta.

[Acute disorders of intestinal perfusion; a nonrigid abdomen may still be acute]

Three patients, a man aged 50 years and two women aged 46 and 45 years, with abdominal pains and an undistended abdomen, were found to have acute mesenteric ischaemia. The causes were: unknown, a thrombus in the descending aorta and severe atherosclerosis, respectively. In the male patient, only 30 cm of vital small intestine ultimately remained; in one woman embolectomy sufficed, in the other, resection of a limited portion of the jejunal tract. All three patients fully recovered. Acute mesenteric ischaemia is a potentially lethal disease. Diagnosis in the first reversible phase makes full recovery of the intestine possible. This may be difficult since the clinical signs and symptoms are not specific in this phase and invasive diagnostic procedures (angiography) are required for accurate diagnosis. By making an angiogram of the mesenteric vessels in each patient with severe abdominal pain, no signs of peritonitis and leukocytosis, without another diagnosis, reversible mesenteric ischaemia can be diagnosed and a vascular surgical reconstruction can be planned.

Duodenal meal stimulation leads to coeliac artery vasoconstriction and superior mesenteric artery vasodilatation: an intra-abdominal ultrasound study

To evaluate the influence of duodenal feeding on splanchnic blood flow, 14 patients with normal coeliac and superior mesenteric arteries underwent intra-abdominal duplex scanning of the systemic and splanchnic circulation under standardised basal and meal-stimulated conditions. Doppler samples and diameter measurements were taken of the aorta, coeliac artery, common hepatic artery, splenic artery, superior mesenteric artery, and inferior mesenteric artery. Duodenal meal stimulation has no systemic effects (p > 0.4). However, duodenal meal stimulation results in coeliac artery vasoconstriction (p < 0.06) and superior mesenteric artery vasodilatation (p < 0.05). This study supports other reported results that gastrointestinal blood flow is dependent on the site of food stimulation.

[The number of carotid artery operations in the Twente Medical Spectrum before and after the publication of relevant international research on the benefits of the relief of carotid stenosis]

OBJECTIVE

To determine the effect of adequate scientific research on the treatment of extracranial stenosis of the internal carotid artery.

DESIGN

Retrospective and comparative.

SETTING

Twenty Medical Spectrum, Enschede, the Netherlands.

METHOD

A comparison was made of the relevant data from 2 years of carotid artery surgery before (1989-1990; period I) and after the publication of two randomized multicentre studies (1994-1995; period II).

RESULTS

The number of patients treated surgically and the number of carotid artery desobstructions had increased during period II by 339% and 319%, respectively. In period I, 25% of the patients had an asymptomatic ipsilateral stenosis of the internal carotid artery; in period II, this had decreased to 11%. In period I, 65% of the patients had a stenosis in excess of 70% of the diameter of the vessel; in period II this was 85%. The combined mortality and permanent disabling morbidity after 30 days was 6% in period I and 3% in period II.

CONCLUSION

After the publication of two high-quality studies in 1991, the number of carotid artery operations increased by over 300%. The indications for the surgical treatment of stenosis were stricter rather than less strict in period II. The increase of the number of carotid desobstructions can be explained by the fact that GPs' and neurologists' referral to the vascular surgeon has changed. This change in the referring pattern may be the consequences of use of 'evidence-based' medicine.

Temporary decompression after colorectal surgery: randomized comparison of loop ileostomy and loop colostomy

BACKGROUND

Loop ileostomy or loop transverse colostomy for temporary decompression of a left colonic anastomosis represents an important issue in abdominal surgery.

METHODS

A randomized study, comparing loop ileostomy (n = 37; group 1) or loop transverse colostomy (n = 39; group 2), was conducted. Patients were followed from construction to closure of the stoma.

RESULTS

Age, weight, sex and indication for surgery were similar in both groups. After stoma construction complications were reported in nine of 37 patients in group 1 and in one of 39 in group 2 (P < 0.01), leading to postoperative death in five of 37 in group 1 and one of 39 in group 2. In the period between stoma construction and closure significant differences were observed only in prolapse rate (one of 32 group 1, 16 of 38 group 2; P < 0.01), need for temporary adaptation of clothing (eight of 32 group 1, 22 of 38 group 2; P < 0.01) and dietary guidelines (23 of 32 group 1, four of 38 group 2; P < 0.01). One patient died in group 1 and four in group 2; the deaths were not stoma related. After stoma closure eight of 29 patients in group 1 had complications and there were two deaths compared with three of 32 and no deaths in group 2.

CONCLUSION

Both types of stoma carry a high complication rate with a considerable associated mortality rate. The interval between stoma construction and closure has substantial impact on social and economic status. Based on all three phases studied, routine use of transverse colostomy is advised if decompression of the left colon is indicated.

Analysis of the variety in surgeons' decision strategies for the management of left colonic emergencies

OBJECTIVES

The aim of this study is to analyze surgeons' decision strategies about the optimal treatment for acute sigmoid resection for different patients. In particular, the authors wished to determine the predominant accepted treatment choice among surgeons, to determine the importance of patient characteristics for surgeons' evaluations of the appropriateness of treatments, and to identify the variety in decision strategies.

METHODS

A survey was carried out among all surgical members of the Netherlands Society of Gastro Intestinal Surgery, who evaluated 16 patient cases. Approximately 70% of the members completed the survey.

RESULTS

Overall, the predominant accepted strategy is resection, delayed anastomosis, and colostomy (Hartmann procedure). Consensus in terms of preferred treatment, however, was low. The most important factors influencing surgeons' evaluations of the appropriateness of treatments were the age of a patient, the degree of peritonitis, and the degree of fecal contamination. Further analysis showed that the variety in surgeons' decision strategies could not be explained by differences in experience, but was shown to be related to the evaluation of the appropriateness of treatment for 60-year-old patients and patients with a local peritonitis. Except for these factors, surgeons did not differ fundamentally in the evaluation of the factors that make a treatment more appropriate. Surgeons agreed about the optimal treatment for older patients in poor condition, although there is no epidemiologic literature to support this consensus position.

CONCLUSIONS

This study showed that lack of consensus in surgeons' choice of treatment could be explained partly by disagreement of the appropriateness of treatments for some, rather than all, patients.

The splanchnic syndrome. Diagnosis and indications for treatment

The typical chronic splanchnic syndrome is characterized by upper abdominal pain usually provoked by a meal, the finding of an epigastric bruit and weight loss in conjunction with haemodynamically significant stenosis of two or more of the splanchnic arteries. Diagnosis of chronic splanchnic syndrome depends mainly on a strong clinical suspicion. Usually the classical triad is incomplete or absent. Therefore chronic splanchnic syndrome should be considered, in every patient with chronic abdominal discomfort, after exclusion of other more common causes of upper abdominal discomfort. Findings from nonvasive and invasive diagnostic tests support the presence of chronic splanchnic syndrome. However, until now, the diagnosis of chronic splanchnic syndrome has usually only been made retrospectively if all the symptoms disappeared after technically successful reconstructive surgery. A variety of surgical techniques has been advocated to repair the splanchnic arteries. The choice of the technique is usually based on the preference and experience of the surgeon.

Chronic splanchnic ischaemia: is tonometry a useful test?

OBJECTIVE

To find out if gastric tonometry is of sufficient accuracy to diagnose chronic splanchnic syndrome.

DESIGN

Prospective open study.

SETTING

University hospital, The Netherlands.

SUBJECTS

10 patients in whom chronic splanchnic syndrome had been suspected, and in 5 of whom it was subsequently confirmed.

INTERVENTION

Standardised measurement of intramucosal gastric pH (tonometry) and multiplane angiography of the abdominal aorta and splanchnic arteries.

MAIN OUTCOME MEASURE

Correlation between intramucosal gastric pH and angiographic and clinical findings.

RESULTS

The mean basal pH preoperatively was 7.48 among 5 patients subsequently found to have splanchnic syndrome (group 1) and 7.41 among the 5 who did not (group 2). Those in group 1 all had extensive three vessel disease with stenoses of 70% or more in at least two of the three splanchnic arteries. The 5 patients in group 2 had no clinically important stenoses in either the coeliac or the superior mesenteric artery; 4 had occlusions of the inferior mesenteric artery.

CONCLUSION

Gastric tonometry is of no use in the diagnosis of chronic splanchnic syndrome.

Comparison of sufentanil/propofol versus isoflurane/nitrous oxide anaesthesia on mesenteric artery blood flow

Duplex sonography was used to determine the changes in mesenteric arterial blood flow occurring in patients undergoing aortic surgery, anaesthetised either by total intravenous anaesthesia with propofol and sufentanil (group A) or inhalational anaesthesia with isoflurane and nitrous oxide (group B). Sixteen patients were studied. Measurements were performed immediately before and 15 min after induction of anaesthesia, before surgery. There was a 38% decrease (p = 0.015) in the superior mesenteric artery end diastolic velocity in group A and a 23% decrease (p = 0.033) in the superior mesenteric artery peak systolic velocity in group B. There were no changes in any of the other sonography parameters in either group. We conclude that neither total intravenous anaesthesia with propofol and sufentanil nor inhalational anaesthesia with isoflurane and nitrous oxide have any clinically significant influence on mesenteric blood flow in the absence of surgical stimulation.

Systolically gated 3D phase contrast MRA of mesenteric arteries in suspected mesenteric ischemia

OBJECTIVE

Our goal was to assess the value of MRA for detecting stenoses in the celiac (CA) and superior mesenteric (SMA) arteries in patients suspected of having chronic mesenteric ischemia, using an optimized systolically gated 3D phase contrast technique.

MATERIALS AND METHODS

In an initial study in 24 patients who underwent conventional angiography of the abdominal vessels for different clinical indications, a 3D phase contrast MRA technique (3D-PCA) was evaluated and optimized to image the CAs and SMAs. Subsequently, a prospective study was performed to assess the value of systolically gated 3D-PCA in evaluation of the mesenteric arteries in 10 patients with signs and symptoms of chronic mesenteric ischemia. Intraarterial digital subtraction angiography and surgical findings were used as the reference standard.

RESULTS

In the initial study, systolic gating appeared to be essential in imaging the SMA on 3D-PCA. In 10 patients suspected of mesenteric ischemia, systolically gated 3D-PCA identified significant proximal disease in the two mesenteric vessels in 4 patients. These patients underwent sucessful reconstruction of their stenotic vessels.

CONCLUSION

Cardiac-gated MRA may become a useful tool in selection of patients suspected of having mesenteric ischemia who may benefit from surgery.

Pitfalls in the diagnosis of origin stenosis of the coeliac and superior mesenteric arteries with transabdominal color duplex examination

The purpose of this study is to evaluate the effects of respiration, localization of the Doppler sample, and the presence of origin stenosis on the Doppler parameters of coeliac and superior mesenteric arteries in 22 patients undergoing elective abdominal vascular reconstructive surgery under standardized stable anesthesia. Deep inspiration decreased peak systolic and end diastolic velocities of the coeliac artery origin. Proximal to distal Doppler velocities of normal coeliac and superior mesenteric artery origins were comparable. However, in the presence of an origin stenosis, the increase of Doppler velocities at the origin of the coeliac and superior mesenteric arteries is likely to be missed by transabdominal scanning.

Comparison of trans- and intra-abdominal duplex examinations of the splanchnic circulation

To evaluate the influence of the technical problems experienced when scanning transabdominally, a comparison was made between transabdominal and intra-abdominal Doppler parameters of the aorta and the splanchnic arteries. Peroperative color duplex sonography of the abdominal aorta and the splanchnic arteries was performed on 25 patients who were undergoing abdominal vascular reconstructive surgery under stabilized standardised anaesthesia. Doppler samples and diameter measurements were taken of the aorta, celiac, common hepatic, splenic, superior and inferior mesenteric arteries, both trans- and intra-abdominally. Significantly higher velocities were recorded in the celiac artery during intra-abdominal examinations. There was a trend toward higher recorded velocities in the other vessels. There was also a significant difference in the diameter measurements of most of the vessels. The trans- and intra-abdominal results were not always equivalent. The differences were not due to technical aspects. Transabdominal duplex sonography is difficult and may not be completely accurate in detecting quantitative flow parameters in the splanchnic arteries.

Mesenteric vascular disease: a review of diagnostic methods and therapies

Mesenteric vascular disease is a relatively rare disease; however the morbidity and mortality are significant. Improved diagnosis and treatment of mesenteric obstructive arterial disease and its complications have occurred. Biplanar angiography of the mesenteric arteries remains the best method of diagnosing mesenteric vascular diseases, though duplex sonography of the mesenteric arteries appears to be a valuable screening tool. Magnetic resonance angiography has the potential to improve on the diagnostic accuracy. Mesenteric artery reconstructive surgery remains the treatment of choice. Newer surveillance techniques such as tonometry may enhance perioperative monitoring and consequently improve the results of mesenteric artery reconstructive surgery. Aggressive support medical therapy plays a significant role in the treatment and reduces patient morbidity and mortality in carefully selected cases. There remains a dearth of prospective controlled trials in patients with this condition.

[Surgical strategy in acute or elective sigmoid resection in The Netherlands; survey based on a marketing model]

OBJECTIVE

To gain insight into the operative strategies used by Dutch surgeons for complicated diverticulitis and sigmoid carcinoma, and into the influence of patient risk factors and surgeon's experience on the preferred operative strategy.

DESIGN

Descriptive.

METHOD

A questionnaire was sent to all 148 members of the Dutch Society of Gastrointestinal Surgery, concerning 32 fictitious patients with sigmoid pathology. It was based on conjoint-analysis, a model used in marketing research. This model analyses qualities that make a product preferable to another product of the same product group. The operative choices were: resection with Hartmann's procedure, resection with primary anastomosis after on-table lavage, or with primary anastomosis only, or no primary resection but diverting stoma only, or some personal technique. The survey focused on experience of the surgeons with the operative procedures, and on treatment choices in four fictitious cases frequently encountered in general surgery.

RESULTS

There was little agreement concerning the preferred surgical option for treatment of complicated diverticular disease or sigmoid carcinoma. With the exception of one fictitious young, electively operated 'ideal' patient (resection with primary anastomosis) there is hardly any consensus among the surgeons with respect to preferred treatment.

CONCLUSIONS

Reasons to depart from the conceptually optimal treatment (resection and anastomosis) in complicated cases (from the point of view of the surgeon or the patient), and absence of agreement on responsible other treatment could be differences in appraisal of the importance of several risk factors, or differences in acquired decision making strategies. The literature offers no answer to the question which techniques should be preferred under various circumstances.

Sweet syndrome associated with liposarcoma: a case report

A 36-year-old woman with a dedifferentiated liposarcoma is described who had suffered from Sweet syndrome in the past. From the literature a relationship between this syndrome and malignancy is known to exist. However, the combination of Sweet syndrome with a sarcoma has not previously been reported.

Pressure sores and pressure-decreasing mattresses: controlled clinical trial

Pressure sores are a problem, especially in elderly patients. Our study was designed to determine the effectiveness in pressure-sore prevention of a new interface-pressure decreasing mattress. In a prospective randomised controlled clinical trial we tested the Comfortex DeCube mattress (Comfortex, Winona, USA) against our standard hospital mattress in 44 patients with femoral-neck fracture and concomitant high pressure-sore risk score. In addition both groups were treated according to the Dutch consensus protocol for the prevention of pressure sores. On admission and 1 and 2 weeks after admission, pressure sores were graded. The two groups were similar in patient characteristics and pressure-sore risk factors. At 1 week, 25% of the patients nursed on the DeCube mattress and 64% of the patients nursed on the standard mattress had clinically relevant pressure sores (grade 2 or more). At 2 weeks the figures were 24% and 68%, respectively. The maximum score over the several body regions of the pressure-sore grading, measured on a 5-point sale, was significantly different in favour of the DeCube mattress at 1 week (p = 0.0043) and 2 weeks (p = 0.0067) postoperatively. We show that the occurrence of pressure sores and their severity can be significantly reduced when patients at risk are nursed on an interface-pressure decreasing mattress.

Chronic mesenteric vascular syndrome. Results of reconstructive surgery

Since 1961, 14 patients at the University Hospital of Leiden, the Netherlands, have undergone reconstructive surgery for treatment of chronic mesenteric vascular syndrome. Of the 42 mesenteric arteries, 31 were severely obstructed (mean, 2.2 stenotic arteries per patient). A total of 23 mesenteric arteries were repaired. Long-term follow-up data were available for all 13 surviving patients (mean follow-up, 11.8 years). Symptoms were relieved immediately after surgery, and relief was maintained during follow-up. Digital subtraction angiography at long-term follow-up evaluation was performed in eight patients (13 reconstructions) with these results: 11 (85%) of the 13 reconstructions were patent and severe stenoses were found in eight (33%) of the 24 mesenteric arteries (mean, 1.0 stenotic artery per patient). We conclude that reconstructive surgery for patients with chronic mesenteric vascular syndrome promptly relieves symptoms, provides excellent patency, and has long-lasting beneficial results.

Surgical treatment of intestinal artery aneurysms

Intestinal artery aneurysms are usually asymptomatic. However, occasionally they occur as a vascular emergency and when rupture occurs, mortality rates of up to 75% have been reported. Therefore, elective surgery of asymptomatic intestinal artery aneurysms seems indicated provided that the procedure is safe with a low morbidity and mortality. We have reviewed the results of surgical treatment of eight patients with intestinal artery aneurysm who were operated on electively and seven who had emergency procedures over a 20 year period. Mortality was high when rupture had occurred, despite acute surgical intervention. After elective procedures however mortality and morbidity were substantially lower. Elective surgical intervention should therefore be performed as soon as an intestinal artery aneurysm is diagnosed.

Coeliac artery compression syndrome: the effect of decompression

The effects of operation to decompress the coeliac artery were evaluated in 11 consecutive patients with coeliac artery compression syndrome. Immediately after the operation all patients were free of symptoms. Three months later three of the 11 had recurrent abdominal pain. Long-term follow-up between 15 and 23 years, obtained by questionnaire, was available for eight patients. All eight had return of symptoms similar to those before surgery. These unsatisfactory results suggest that operation should not be undertaken in patients with vague upper abdominal complaints and compression of the coeliac artery by the median arcuate ligament, who do not otherwise have pathological conditions which might explain their symptoms.