Minimal incision aortic surgery

PURPOSE

In this study we evaluated the clinical and economic impact of minimal incision aortic surgery (MIAS) for treatment of patients with abdominal aortic aneurysms (AAAs) and aortoiliac occlusive disease (AIOD).

METHOD

Fifty patients with either AAA (34) or AIOD (16), prospectively treated with the MIAS technique, were compared with 50 patients (40 AAA and 10 AIOD) treated in the same time period with long midline incision and extracavitary small bowel retraction. MIAS was also compared with a cohort of 32 patients with AAA treated by means of endoaortic stent-grafts. Outcomes and cost (based on metric mean length of stay) were compared for the open and endoaortic techniques.

RESULTS

Patients who experienced no perioperative complications after the MIAS or endovascular repair technique had shorter hospital stays than patients with uncomplicated aortic repairs performed with a traditional long midline abdominal incision (3 days vs 3 days vs. 7.2 days). Hospital stay was also significantly shorter for the less invasive procedures when perioperative complications were included (4.8 days vs. 4.3 days vs 9.3 days). The MIAS and endovascular aortic repair groups had a shorter intensive care unit stay (< or = 1.0 day) and a quicker return to general dietary feeding (2.5 days) than patients treated with standard open repair (1.8 days, 4.7 days). The overall morbidity for the MIAS technique (14%) and endovascular technique (21%) was not significantly different from standard open repair (24%). The mortality rate for the different treatment groups was equivalent (MIAS, 2%; endovascular repair, 3%; standard repair, 2%). The MIAS was more cost-efficient than standard open repair ($12,585 vs $18,445) because of shorter intensive care unit and hospital stay and was more cost-efficient than endoaortic repair ($12,585 vs $32,040) because of reduced, direct intraoperative costs.

CONCLUSIONS

MIAS is as safe as standard open or endovascular repair in the treatment of AAA and AIOD. MIAS is more cost-efficient than standard open or endoaortic repair.

Visceral artery aneurysm rupture

PURPOSE

Aneurysms of the visceral arteries are infrequently encountered. Many are found incidentally and are thought to have a benign outcome. To better characterize these lesions and their clinical course, we reviewed our experience with visceral artery aneurysms (VAAs) at a single institution.

METHODS

A retrospective analysis of all VAAs diagnosed at our institution over the past 10 years was performed. The presentation, management, and outcome of therapy was examined for each patient.

RESULTS

Thirty-four VAAs in 26 patients were diagnosed over the past 10 years. Four patients had multiple VAAs: splenic (17), hepatic (7), celiac (3), superior mesenteric (2), gastroduodenal (2), pancreaticoduodenal (1), right gastric (1), ileal (1) artery aneurysms. Associated aneurysms were found in 31% of patients and involved the thoracic aorta (3 patients), abdominal aorta (4 patients), renal arteries (2 patients), iliac artery (3 patients), lower extremity (1 patient), and intracranium (1 patient). In 15 patients (58%), VAAs were detected before rupture by chance or because abdominal symptoms resulted in diagnostic evaluation. Eight of these underwent elective surgery, and there were no deaths. Of those 15 patients with known VAAs, one patient died of rupture and hemorrhage from an untreated splenic artery aneurysm. Eleven patients (42%) presented unexpectedly with rupture, and two died despite prompt surgical treatment. The mortality rate in patients who had ruptured VAAs was 25%, including those who presented with ruptured aneurysms and those observed whose aneurysms eventually ruptured.

CONCLUSIONS

Aneurysms of the visceral arteries are rare but important vascular lesions. Associated aneurysms are common. Because of the risk of rupture, often with a fatal outcome, an aggressive approach to the treatment of VAA is essential.

Less invasive aortic surgery: the minilaparotomy technique

BACKGROUND

This study evaluated a less invasive technique for exposure of the infrarenal aorta and its impact on the treatment of patients with abdominal aortic aneurysms (AAA) or aortoiliac occlusive disease (AIOD), or both.

METHODS

Forty patients with AAA (26), aneurysmal extension into the iliac arteries (6), or AIOD (8) were prospectively selected for minilaparotomy aortic exposure and repair using a small periumbilical midline incision (< or =10 cm); intra-abdominal, nondisplaced retraction of the small bowel; and conventional hand-sewn vascular anastomoses. Perioperative comparisons with a contemporary group of AAA patients treated with long, open midline incision and extracavitary small bowel retraction were made.

RESULTS

There was no significant difference between the minilaparotomy and open surgical control groups for operating room time; intraoperative, perioperative morbidity; or mortality. Significant differences were documented between the minilaparotomy and the control group with regard to stay in the intensive care unit (days; 1.0+/-1.2 versus 1.8+/-1.5); return to general diet (days; 3+/-1.3 versus 4.7+/-2.8); and length of stay (days; 4.9+/-1.8 versus 7.3+/- 3.4).

CONCLUSIONS

Minilaparotomy exposure is safe and effective for treatment of infrarenal AAA and AIOD. This technique maintains quality outcome while reducing postoperative ileus, hospital stay, and resource utilization.

Morphology of liver repair following cholestatic liver injury: resolution of ductal hyperplasia, matrix deposition and regression of myofibroblasts

BACKGROUND/AIMS

Myofibroblasts are the primary cells responsible for increased matrix deposition in hepatic fibrosis. Activation of hepatic stellate cells and portal fibroblasts to myofibroblasts during cholestatic liver injury is accompanied by increased expression of the activation marker, alpha-smooth muscle actin (SMA), and collagen genes. In contrast to our understanding of injury, the cellular mechanisms of liver repair are not well defined. This study was designed to examine the morphological relationship between bile duct hyperplasia, matrix deposition and myofibroblast phenotype in a model of chronic cholestatic liver injury and repair.

METHODS

Reversible extrahepatic obstruction was accomplished in rats using a soft vessel loop suspended from the anterior abdominal wall: duct manipulation alone was performed in sham-operated controls. After 7 days, rats were either sacrificed or decompressed by release of the loop and subsequently sacrificed 2-10 days after reversal. Liver sections were obtained for in situ hybridization for procollagen alpha1(I) mRNA, immunohistochemical staining for SMA and cytokeratin 19, and histochemical staining for reticulin.

RESULTS

Cholestatic livers demonstrated bile duct hyperplasia, which reversed to normal within 10 days after decompression. Fibrosis was also substantially reduced during this period. SMA-positive myofibroblasts were abundant and localized to regions adjacent to proliferating ducts and excess matrix in the obstructed animals. Decompressed livers showed a dramatic time-dependent reduction in the number of SMA-positive cells and in the expression of procollagen I mRNA.

CONCLUSIONS

Our results show that the disappearance of bile duct hyperplasia after biliary decompression is accompanied by a similarly rapid loss of SMA-positive myofibroblasts. Both cellular events may abrogate enhanced matrix synthesis and allow repair to occur.

Preliminary experience with minilaparotomy aortic surgery

This prospective nonrandomized study assessed clinical outcomes of a minilaparotomy technique (MLT) used for elective graft repair of infrarenal aortic aneurysm (AAA) and/or aortoiliac occlusive disease (AIOD). Twenty-three patients requiring infrarenal AAA or aortofemoral bypass underwent a small periumbilical midline incision, nondisplacement of the small bowel, and a traditional vascular anastomosis. Results from these procedures were compared with those from contemporaneous procedures performed in the standard transabdominal (STA) fashion (n = 21). Age, weight, and comorbid conditions were comparable between groups. Patients requiring concomitant renal, mesenteric, or infrainguinal revascularization were excluded. Operating time, length of stay in the intensive care unit (ICU), number of oral feeding times, and length of hospital stay were recorded. There were no significant differences in age, operative time, or aneurysm size between the MLT and STA groups. With the MLT then were significant decreases in ICU stay (1 vs. 1.8 days), length of time to return to a general diet (3 vs. 4.7 days), and length of stay (4.9 vs. 7.3 days.) Morbidity and mortality were not statistically different between groups. Patients undergoing the MLT have reduced ICU and hospital stay, and decreased post operative ileus. The MLT does not increase operating room costs or require expensive laparoscopic equipment or the extended postoperative radiographic surveillance needed after endovascular repair.

Activated inflammatory cells are associated with plaque rupture in carotid artery stenosis

BACKGROUND

Histologic studies of carotid plaques have demonstrated an association between symptomatic disease and plaque rupture. The purpose of this study was to characterize the cellular changes associated with plaque rupture.

METHODS

Carotid plaques were obtained from 61 patients undergoing carotid endarterectomy for established indications. Plaques were fixed in formalin, embedded in paraffin, and stained with hematoxylineosin and Movat pentachrome stain to demonstrate plaque structure. Each plaque was examined with light microscopy and classified as containing evidence of plaque rupture (n = 29) or no plaque rupture (n = 32). By using immunohistochemical staining, the fibrous cap was examined for the presence of smooth muscle cells (alpha-actin), macrophages (KP-1), T lymphocytes (UCHL-1), and cell activation (HLA-DR). Data were analyzed with chi-squared analysis.

RESULTS

With plaque rupture, macrophages and T lymphocytes were significantly more common than in specimens without evidence of rupture. Similarly, macrophages and T lymphocytes expressing HLA-DR were more often found in sections containing plaque rupture. Furthermore, vascular smooth muscle cells were more common with intact fibrous caps and were diminished with cap thinning.

CONCLUSIONS

Rupture of the fibrous cap in carotid artery lesions is associated with increased numbers of macrophages and T lymphocytes, which are in an activated state. The activated inflammatory cells may release cytokines or metalloproteinases, which may be responsible for loss of the fibrous cap. Thus inflammation appears to play a role in the pathogenesis of the neurologic symptoms associated with carotid artery stenosis.

Transactional Analysis of Communication Styles in HIV/AIDS Advertisements

Television advertising has been an important medium for health promotion campaigns addressing HIV/AIDS. This study sought to evaluate the 'Grim Reaper' and 'Multiple Beds' advertisements frequently broadcasted throughout Australia. Our model for evaluation was based on a theoretical synthesis of television advertising, transactional analysis (TA) and recall congruence. Eighty-three participants viewed each advertisement and rated which ego state the source of the message was attempting to 'hook' in the audience. They also predicted their own ego state during sexual intercourse and rated the effectiveness of the advertisements. As predicted by TA theory, a crossed transaction was associated with significantly less psychological impact than a parallel transaction for the 'Grim Reaper' advertisement. A similar trend was apparent for the 'Multiple Beds' advertisement. Important issues which warrant further research in order to evaluate whether transactional analysis could be a useful tool in promoting health are discussed.

Effects of unreasonable pay discrepancies for under- and overpayment on double demotivation

The "double demotivation" hypothesis that pay discrepancies decrease work motivation among both lower and higher paid groups was tested in two experiments. In experiment 1, 70 Australian undergraduates received either $1 or $2 to work on an intrinsically rewarding puzzle, with or without knowledge of what amount other participants were receiving. A comparison of participants with a no-payment control showed that participants exhibited significantly reduced intrinsic motivation (seconds spent interacting with the puzzle during a free-choice period) when they knew that they were being under- or overpaid. In experiment 2, 126 occupationally matched Australian workers receiving wages equal to, lower than, or higher than those of counterparts reported their level of job satisfaction and whether they would stay on the job, change jobs, or retire, if given the financial opportunity. Compared with equitably paid workers, employees who felt they were being under- or overpaid reported lower job satisfaction and greater readiness to change jobs. The results provide experimental support for double demotivation, which is relevant not only to international development cooperation but also to Western enterprise bargaining, merit pay, and minority groups in the multicultural workplace.

Current management of visceral artery aneurysms

BACKGROUND

Visceral artery aneurysms are an uncommon but important form of abdominal vascular disease. This study reviews a contemporary experience with special emphasis on newer methods of diagnosis and treatment.

METHODS

From 1980 to 1994, 37 patients were diagnosed with 46 visceral artery aneurysms. These consisted of 22 splenic, 10 hepatic, 4 superior mesenteric, 2 gastroduodenal, 3 celiac, 2 left gastric, 1 pancreatoduodenal, 1 jejunal-ileal, and 1 inferior mesenteric artery aneurysms. Follow-up was complete for 28 patients, average of 37.7 months. There were 17 asymptomatic and 29 symptomatic aneurysms, including 11 presenting with rupture.

RESULTS

Seventeen patients were treated surgically, with no surgical deaths. Surgical complications included splenic abscess (two) and failure to thrombose (one). Transcatheter embolization was used in 12 patients. Complications included splenic infarction (one) and recurrence (two), successfully treated with repeat embolization. Nine patients were treated with observation. Eight experienced no complications during follow-up; one died of a ruptured splenic artery aneurysm before treatment was initiated.

CONCLUSIONS

The widespread use of computed tomography has led to increased detection of asymptomatic visceral artery aneurysms. Although surgery remains necessary in many patients, transcatheter embolization is effective in the treatment of selected visceral artery aneurysms with few complications and low recurrence.

The expression of regenerative growth factors in chronic liver injury and repair

Acute hepatic injury initiates known cellular and molecular events for regeneration. In contrast, the molecular mechanisms of repair following chronic liver injuries have not been defined. Transforming growth factor alpha (TGF alpha) and hepatocyte growth factor (HGF) are hepatocyte mitogens whose in vivo expression in liver is central to the regulation of regeneration. To study the role of TGF alpha and HGF in liver injury and repair, we used a model of reversible biliary obstruction without a bilioenteric anastomosis. In rats, the common bile duct was obstructed either by a vessel loop suspended from the abdominal wall (LOOP) or by ligation and division (DLD). After 7 days of obstruction, animals were autopsied or were decompressed by subcutaneous release of the loop and then autopsied at 1, 2, 4, 7, or 10 days of postdecompression. Serum bilirubin (mg/dl) increased to 14.8 +/- 2.9 (DLD) and 10.3 +/- 3.0 (LOOP) (+/- SEM, NS, ANOVA) at 7 days of obstruction. Liver sections demonstrated equal ductal hyperplasia and collagen deposition after LOOP and DLD. Biliary decompression reversed bile duct proliferation and normalized bilirubin. Analysis of injured and repairing liver mRNA by ribonuclease protection assay showed that TGF alpha mRNA levels were not significantly altered by injury or during repair. HGF mRNA was elevated following obstruction and showed increased expression 1 day after decompression, peaking at 2 days of repair. This evidence of modulation of HGF during liver repair following chronic cholestatic injury suggests that HGF may have a role in cellular proliferation during repair or act as a compensatory growth factor during injury.

Managing the AIDS crisis in Africa: in support of pluralism

Although substantial evidence is now accumulating that some African peoples readily accept advice and help about health from both modern medical and traditional sources, this has not yet happened with--what is arguably the major health problem in many part of Africa--AIDS. We asked 175 of Malawi's undergraduates what sources they judged to be credible with regard to information on preventing and clinically managing AIDS. While traditional healers were seen on average to be less credible than modern health professionals (doctors and nurses), there was no correspondence between credibility of traditional healers and modern health professionals. Thus a strong belief in the credibility of modern health professionals was not associated with low credibility ratings for traditional healers. Our findings provide further support for "tropical tolerance", especially as regards a pluralistic (modern and traditional together) approach to the prevention of AIDS. Given the over-stretched health services in Malawi and many other African countries, a pluralistic approach to AIDS prevention could be a credible and economic use of indigenous human resources.

Palliative versus curative beliefs regarding tropical epilepsy as a function of traditional and medical attributions

Although epilepsy may be successfully managed with appropriate medication, in Africa epileptics are often vilified, sometimes because of traditional beliefs about the illness. We investigated the strength of beliefs which 112 rural Malawians held regarding traditional and medical explanations for the cause, treatment and cure of epilepsy. Those who believed in traditional causes of epilepsy also endorsed traditional treatment for it, though they did not see such treatment as curative. Those who believed in a medical treatment, did however see such treatment as curative. Knowledge of a local medical facility for the treatment of epilepsy was also positively related to the belief that epilepsy is curable. The ability of people to simultaneously hold medical and traditional beliefs about epilepsy was noted.