What is the significance of endoleaks and endotension

Endovascular repair has been used over a decade as a treatment of abdominal aortic aneurysm, and has become a widely accepted treatment method with a low rate of perioperative complications. Endoleak, perigraft blood flow outside endograft but within aneurysmsac, has been intensively studied during the last 10 years of endovascular aneurysm repair (EVR). The natural history of aneurysms with endoleak and the true clinical significance of various types of endoleaks remains unclear. Type I/III endoleak has been found to be associated with aneurysm rupture, while the risk of rupture of aneurysms with type II endoleak and endotension appears very small. In endotension, the aneurysm sac remains pressurized, even if there is no evidence of an endoleak. Currently,it is accepted that type I/III endoleaks should be corrected, preferably by endovascular means, due to the risk of rupture. If endovascular repair is not possible, then open conversion should be considered. The risk of conversion should be weighed against the risk of aneurysm rupture. Treatment of type II endoleaks and endotension is more controversial. In those with aneurysm enlargement,secondary interventions are often performed.     

2O10国际腹部创伤暨第十届全国脾脏外科学术研讨会纪要

由中华医学会外科学分会脾功能与脾外科学组及<中华创伤杂志>、<肝胆外科杂志>编辑部联合主办,哈尔滨医科大学附属第一医院和安徽医科大学附属第一医院承办的"2010国际腹部创伤暨第十届全国脾脏外科学术研讨会"于2010年6月4～6日在合肥市召开.来自国际、国内的30余位著名专家应邀出席会议.美国Roger A.Orsini教授、俄罗斯Dubinkin Vladimir教授、日本Takashi Tajiri教授、韩国Chang Moo Kang博士及黎介寿院士、巴德年院士、夏穗生教授、姜洪池教授等知名专家到会并作精彩的专题报告.参会代表300余人.大会由全国脾功能与脾外科学组副组长乔海泉教授主持.     

The significance and management of different types of endoleaks

Development of endovascular abdominal aortic aneurysm repair (EVAR) has been accompanied by previously unencountered complications. The most challenging but least understood of these complications is the incomplete seal of the endovascular graft (endoleak), a phenomenon that has a variety of causes. An important consequence of endoleakage may be persistent pressurization of the aneurysm sac, which may ultimately lead to post-EVAR rupture. Data of 110 European centers were recorded in a central database (EUROSTAR). Patient, anatomic characteristics, and operative and device details were correlated with the occurrence of different types of endoleaks. Outcome events during follow-up, particularly expansion of the aneurysm, incidence of conversion to open repair, and post-EVAR rupture were assessed in the different categories of endoleaks and in a group of patients without any endoleak. Type I and III endoleak were associated with an increased frequency of open conversions or risk of rupture of the aneurysm. Device-related endoleaks also correlated with an increased need for secondary interventions. These types of endoleaks need to be treated without delay, and when no other possibilities are present, an open conversion to avert the risk of rupture should be considered. Type II endoleaks do not pose an indication for urgent treatment. However, they may not be harmless, because there was a frequent association with enlargement of aneurysm and reinterventions. Our findings suggest that more frequent surveillance examinations are indicated than in patients without collateral endoleak. The indication for intervention is primarily dictated by documented expansion of the aneurysm.     

Faculty and resident opinions regarding the role of morbidity and mortality conference

BACKGROUND: The role of the surgical morbidity and mortality (M&M) conference as a forum for examination of surgical failure may remain unclear. This paper reports the results of a national survey of surgical faculty and trainees regarding the role and effectiveness of the M&M conference. METHODS: Based on focus groups and pilot studies from multiple institutions in one geographic area, a questionnaire addressing critical issues in attitudes toward the M&M conference was sent to 1,100 randomly chosen subjects nationwide: 500 residents and 600 staff. The survey includes individual and institutional demographic information, 15 statements answered using a Likert scale, and 2 open-ended questions. RESULTS: Faculty response rate was 501 of 600 (83%) and resident response rate was 166 of 500 (33%). Responses were generally positive in both groups, with staff showing small but significantly more positive attitudes than residents. A higher proportion of residents characterize the M&M conference as too defensive. CONCLUSION: The M&M conference is fulfilling its potential as a teaching tool but there may be room for improvement as residents view the experience slightly less positively than faculty. This questionnaire provides a perspective of expectations for the M&M conference, allowing educators to optimize its effectiveness.     

A canine model to study the significance and hemodynamics of type II endoleaks

OBJECTIVE: The clinical significance of Type 2 endoleak after endovascular repair of abdominal aortic aneurysms (AAA) remains incompletely delineated. This study describes the development of a novel canine model that allows for continuous monitoring of intraaneurysmal pressure in the setting of Type 2 endoleak. METHODS: Infrarenal AAA were created in 10 mongrel dogs by implanting a prosthetic aneurysm containing an intraluminal, solid-state, strain gauge pressure transducer which is able to measure pressures in both solid and liquid media. A segment of native aorta with two or more patent side branch vessels was reimplanted into the prosthetic aneurysm using a Carrel patch. Four animals had two lumbar vessels implanted; two had two lumbar vessels and the caudal mesenteric artery implanted, and four control animals had no vessels reimplanted. Retrograde flow in the aneurysmal side branches caused a Type 2 endoleak after the aneurysm was excluded from antegrade flow by deploying a stent graft. Both systemic and intra-sac pressures were measured daily for up to 90 days after endovascular exclusion and indexed to systemic pressure. Endoleak patency and flow were assessed with digital subtraction angiography, duplex ultrasound, and cine-magnetic resonance angiography (MRA). Histological characterization of the intraaneurysmal contents was performed. RESULTS: Before endovascular exclusion, the systolic, mean arterial, and pulse pressure within the aneurysmal sac closely matched that of the systemic circulation (systolic, 0.96 +/- 0.22; mean, 0.94 +/- 0.21; pulse pressure, 0.97 +/- 0.22) (R value, 0.97). Endovascular exclusion in animals with no collateral side branch vessels resulted in no endoleak and significantly reduced intraaneurysmal pressure when compared to systemic pressure, with systolic, mean arterial, and pulse pressure 0.172 +/- 0.05, 0.137 +/- 0.05, and 0.098 +/- 0.02, respectively (P < 0.001). In animals with Type 2 endoleaks, the pressures were lower than systemic pressure, but statistically significant in their difference from the control group. The systolic pressure of those with Type 2 endoleaks was 0.702 +/- 0.048; mean arterial pressure was 0.784 +/- 0.028, and pulse pressure was 0.406 +/- 0.031 when indexed to systemic pressure (P < 0.001). Cine-MRA and Duplex ultrasound documented persistent patency of the Type 2 endoleaks throughout the study period in animals with multiple side branches. CONCLUSION: Intraaneurysmal pressure in the setting of Type 2 endoleaks may be accurately determined using this canine model. Intraaneurysmal pressure is maintained at a significant level in the context of this retrograde collateral perfusion, suggesting that persistent Type 2 endoleaks are of clinical significance. This model may serve to allow further evaluation and characterization of Type 2 endoleaks.     

Living kidney donor follow-up: state-of-the-art and future directions, conference summary and recommendations

In light of continued uncertainty regarding postkidney donation medical, psychosocial and socioeconomic outcomes for traditional living donors and especially for donors meeting more relaxed acceptance criteria, a meeting was held in September 2010 to (1) review limitations of existing data on outcomes of living kidney donors; (2) assess and define the need for long-term follow-up of living kidney donors; (3) identify the potential system requirements, infrastructure and costs of long-term follow-up for living kidney donor outcomes in the United States and (4) explore practical options for future development and funding of United States living kidney donor data collection, metrics and endpoints. Conference participants included prior kidney donors, physicians, surgeons, medical ethicists, social scientists, donor coordinators, social workers, independent donor advocates and representatives of payer organizations and the federal government. The findings and recommendations generated at this meeting are presented.     

Focused Assessment with Sonography for Trauma (FAST): results from an international consensus conference

OBJECTIVE: To assemble an international panel of experts to develop consensus recommendations on selected important issues on the use of ultrasonography (US) in trauma care. SETTING: R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Md. The conference was held on December 4, 1997. PARTICIPANTS: A committee of two co-directors and eight faculty members, in the disciplines of surgery and emergency medicine, representing four nations. Each faculty member had made significant contributions to the current understanding of US in trauma. RESULTS: Six broad topics felt to be controversial or to have wide variation in practice were discussed using the ad hoc process: (1) US nomenclature and technique; (2) US for organ-specific injury; (3) US scoring systems; (4) the meaning of positive and negative US studies; (5) US credentialing issues; and (6) future applications of US. Consensus recommendations were made when unanimous agreement was reached. Majority viewpoints and minority opinions are presented for unresolved issues. CONCLUSION: The consensus conference process fostered an international sharing of ideas. Continued communication is needed to advance the science and technology of US in trauma care.     

Outcome of popliteal artery aneurysms after exclusion and bypass: significance of residual patent branches mimicking type II endoleaks

PURPOSE: Popliteal aneurysms (PAs) often are treated with exclusion and bypass. However, excluded aneurysms can transmit systemic pressure from persistent flow through collateral arteries (endoleak), resulting in aneurysm growth and rupture. We used duplex ultrasound scanning for postoperative surveillance more than 2 years after PA repair with exclusion and bypass, to determine the presence of flow and aneurysm growth. METHODS: From 1995 to 2001, 23 patients with 26 PAs (mean diameter, 3.2 cm; range, 1.6-5.6 cm) underwent surgical repair and were available for more than 2 years of follow-up. The popliteal artery was ligated proximal and distal to the aneurysm, and autogenous revascularization was performed. All patients who underwent PA endoaneurysmorrhaphy through a posterior approach were excluded from the study. During long-term follow-up, aneurysm sac flow and size were evaluated with duplex ultrasound scanning, computed tomography, or magnetic resonance angiography, and standard angiography. Patients with increased PA size and persistent flow were offered repair through a posterior approach. RESULTS: Over 7 years, 26 PAs (symptomatic, 11; asymptomatic, 15) treated with aneurysm exclusion and bypass were available for more than 2 years of follow-up (mean, 38 months; range, 24-78 months). In the postoperative period 16 PAs (62%) became thrombosed, 10 (38%) had persistent collateral flow through geniculate vessels, 6 (23%) increased in size, and 3 (12%) ruptured; 1 (4%) resulted in limb loss. Operative findings for all ruptured PAs and 3 of 6 PAs with increased sac size that underwent aneurysm sac exploration and endoaneurysmorrhaphy revealed retrograde flow through geniculate vessels, mimicking type II endoleak. CONCLUSIONS: These findings question the effectiveness of PA exclusion through proximal or distal ligation and bypass. In addition, retrograde flow into the aneurysm sac (ie, type II endoleak after endovascular abdominal aortic aneurysm repair) may transmit systemic pressure that can result in aneurysm rupture. We recommend PA treatment with aneurysm sac decompression and ligation of geniculate vessels whenever possible and routine postoperative surveillance of the excluded aneurysm sac.     

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目的探讨胸主动脉夹层腔内隔绝术后内漏的分型及其意义.方法 97例主动脉夹层行腔内隔绝术.移植物释放定位成功后进行主动脉DSA,术后7～10天行螺旋CT,分别评估内漏的来源及量的多少,决定内漏的处理.近端多量内漏时,在近端附加延伸移植物置入,少量内漏暂不处理;移植物针孔内漏暂不处理;远端内漏根据量的多少决定处理方式.结果 12例近端内漏中,10例多量内漏经附加延伸移植物将内漏封闭,2例少量近端内漏未处理.5例远端反流及针孔内漏均在观察中.结论根据内漏的来源,可将内漏分成4型.正确分型将有利于判断、处理以及规范化统计比较.     

胸主动脉夹层腔内隔绝术后内漏的分型及意义

目的 探讨胸主动脉夹层腔内隔绝术后内漏的分型及其意义。方法 97例主动脉夹层行腔内隔绝术。移植物释放定位成功后进行主动脉DSA，术后7－10天行螺旋CT，分别评估内漏的来源及量的多少，决定内漏的处理。近端多量内漏时，在近端附加延伸移植物置入，少量内漏暂不处理；移植物针孔内漏暂不处理；远端内漏根据量的多少决定处理方式。结果 12例近端内漏中，10例多量内漏经附加延伸移植物将内漏封闭，2例少量近端内漏未处理。5例远端反流及针孔内漏均在观察中。结论 根据内漏的来源，可将内漏分成4型，正确分型将有利于判断、处理以及规范化统计比较。     

Publication rate of Trauma abstracts presented at an International Orthopaedic conference

INTRODUCTION: Oral presentations at major conferences are often used to present new material and generate discussion. However, conference abstracts that ultimately fail to be published are of little use to the wider medical community. The aim of this study was to evaluate the publication rate of trauma papers presented at an international orthopaedic conference, and to assess the factors which predict publication. METHODS: All abstracts presented orally at the trauma sessions of the European Federation of National Associations of Orthopaedics and Traumatology (EFORT) Congresses in 1999 (Belgium) and 2001 (Greece) were assessed. A MEDLINE and EMBASE search was performed to identify articles written by the first, second and last authors of each abstract to identify a matching journal article. Subspecialty, country of origin of abstract, study type, journal of publication and publication year were tabulated. RESULTS: Two hundred and seventy eight trauma abstracts were presented orally, and 112 (40.3%) achieved subsequent publication. Abstracts on fractures of the proximal femur were the most common (18.7%) and had one of the highest rates of publication (44.2%). Greece and the UK provided the largest number of abstracts, and randomised trials were the study type with the highest rate of publication (80.0%). Thirty two percent of journal articles appeared within 1 year of the conference and 63% within 2 years. Injury was the journal most likely to publish the articles. CONCLUSION: About 60% of Trauma abstracts presented did not result in a subsequent full-text publication. The citation of conference proceedings should be discouraged, and clinicians should be wary of implementing information gleaned from conference presentations into their clinical practice.     

Laparoscopic inferior mesenteric artery ligation: an alternative for the treatment of type II endoleaks

One of the complications of endovascular repair of abdominal aortic aneurysm is endoleak from a patent inferior mesenteric artery (IMA). Between 1995 and 2002, of 213 patients who had endografts placed for abdominal aortic aneurysm, 4 (1.8%) had enlarging aneurysms from type II endoleaks involving a patent IMA and underwent a secondary procedure. Two patients had endovascular embolizations through the superior mesenteric artery, and two patients underwent laparoscopic inferior mesenteric artery ligation. In the laparoscopic group, operative time was 85 minutes (range, 35-136 minutes). One laparoscopic procedure had to be redone due to a missed IMA branch. Length of stay was 0 and 3 days. At mean followup at 16 months (range, 2-42 months), all patients had had successful resolution of endoleaks. Laparoscopic ligation is a minimally invasive treatment for IMA-mediated type II endoleaks.     

Report of the international consensus development conference on female sexual dysfunction: definitions and classifications

PURPOSE: Female sexual dysfunction is highly prevalent but not well defined or understood. We evaluated and revised existing definitions and classifications of female sexual dysfunction. MATERIALS AND METHODS: An interdisciplinary consensus conference panel consisting of 19 experts in female sexual dysfunction selected from 5 countries was convened by the Sexual Function Health Council of the American Foundation for Urologic Disease. A modified Delphi method was used to develop consensus definitions and classifications, and build on the existing framework of the International Classification of Diseases-10 and DSM-IV: Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association, which were limited to consideration of psychiatric disorders. RESULTS: Classifications were expanded to include psychogenic and organic causes of desire, arousal, orgasm and sexual pain disorders. An essential element of the new diagnostic system is the "personal distress" criterion. In particular, new definitions of sexual arousal and hypoactive sexual desire disorders were developed, and a new category of noncoital sexual pain disorder was added. In addition, a new subtyping system for clinical diagnosis was devised. Guidelines for clinical end points and outcomes were proposed, and important research goals and priorities were identified. CONCLUSIONS: We recommend use of the new female sexual dysfunction diagnostic and classification system based on physiological as well as psychological pathophysiologies, and a personal distress criterion for most diagnostic categories.