Is infrainguinal bypass grafting successful following failed angioplasty?

OBJECTIVES: Angioplasty is often used in the management of lower limb ischaemia and can reduce the need for infrainguinal bypass in some patients. There is an associated failure rate with this technique and bypass surgery is often used in this situation as a secondary limb salvage procedure. We aimed to evaluate the outcome of infrainguinal bypass grafting following failed attempt at angioplasty. METHODS: All cases of infrainguinal bypass at a single centre over a seven year period were identified and notes reviewed. Cases were divided into four groups according to their indication for surgery; acute ischaemia, chronic critical ischaemia, failed angioplasty and an 'other' group including aneurysmal disease and claudicants. The failed angioplasty group was compared with the other three groups. Survival analysis was performed using Kaplan Meier curves and groups compared in terms of long term patency and survival. RESULTS: Primary patency was 61.2% in the failed angioplasty group at 12 months compared with 60.6% in the other groups (P=1.11). There was also no significant difference in primary patency at 60 months (50% vs 40.6%, P=0.26). Survival at 12 months was also comparable between the groups (failed angioplasty group 74.2% compared with 77.3% in the other groups, P=0.662) as was 60 months survival (33.3% and 35.4% respectively, P=0.166). DISCUSSION: In this study, outcome of infrainguinal bypass following failed angioplasty was comparable to outcome of surgery performed for another indication. This paper supports the use of distal bypass surgery for limb salvage in cases where minimal access techniques have failed.     

What is the value of minimizing access trauma for patients?]

Minimizing the access trauma of surgical interventions is becoming an essential task in modern surgery in order to make the treatment more comfortable for the patient. Minimally invasive surgery has had a major impact on the improvement of surgical results over the last decade. This is why such surgery is often named as the third patient friendly revolution in surgery after the introduction of asepsis and anesthesia. Operations that caused a huge strain on the patients in the past and led to immense costs for society because of the patient's lost working time and extensive rehabilitation, have lost their fear thanks to this technique. The physical strain is lower, the cosmetic effect is considerable and the costs for society might be reduced due to the significantly shorter duration of convalescence.Despite its known advantages, which have been reported in numerous studies, minimally invasive surgery has recently gained increased interest because of the installation of new accounting systems as well as strict budgeting and restricted resources.Realistic cost-benefit analysis and objectified quality controls are needed in order to guarantee innovative and patient friendly basic approaches in medicine in the future.     

Dreaming during Anesthesia and Anesthetic Depth in Elective Surgery Patients: A Prospective Cohort Study

Background: Dreaming reported after anesthesia remains a poorly understood phenomenon. Dreaming may be related to light anesthesia and represent near-miss awareness. However, few studies have assessed the relation between dreaming and depth of anesthesia, and their results were inconclusive. Therefore, the authors tested the hypothesis that dreaming during anesthesia is associated with light anesthesia, as evidenced by higher Bispectral Index values during maintenance of anesthesia.

Methods: With approval, 300 consenting healthy patients, aged 18-50 yr, presenting for elective surgery requiring relaxant general anesthesia with a broad range of agents were studied. Patients were interviewed on emergence and 2-4 h postoperatively. The Bispectral Index was recorded from induction until the first interview. Dream content and form were also assessed.

Results: Dreaming was reported by 22% of patients on emergence. There was no difference between dreamers and nondreamers in median Bispectral Index values during maintenance (37 [23-55] vs. 38 [20-59]; P = 0.68) or the time at Bispectral Index values greater than 60 (0 [0-7] vs. 0 [0-31] min; P = 0.38). Dreamers tended to be younger and male, to have high home dream recall, to receive propofol maintenance or regional anesthesia, and to open their eyes sooner after surgery. Most dreams were similar to dreams of sleep and were pleasant, and the content was unrelated to surgery.