Julie A. Freischlag

Outcomes Following Endovascular vs Open Repair of Abdominal Aortic Aneurysm: A Randomized Trial

CONTEXT Limited data are available to assess whether endovascular repair of abdominal aortic aneurysm (AAA) improves short-term outcomes compared with traditional open repair. OBJECTIVE To compare postoperative outcomes up to 2 years after endovascular or open repair of AAA in a planned interim report of a 9-year trial. DESIGN, SETTING, AND PATIENTS A randomized, multicenter clinical trial of 881 veterans (aged > or = 49 years) from 42 Veterans Affairs Medical Centers with eligible AAA who were candidates for both elective endovascular repair and open repair of AAA. The trial is ongoing and this report describes the period between October 15, 2002, and October 15, 2008. INTERVENTION Elective endovascular (n = 444) or open (n = 437) repair of AAA. MAIN OUTCOME MEASURES Procedure failure, secondary therapeutic procedures, length of stay, quality of life, erectile dysfunction, major morbidity, and mortality. RESULTS Mean follow-up was 1.8 years. Perioperative mortality (30 days or inpatient) was lower for endovascular repair (0.5% vs 3.0%; P = .004), but there was no significant difference in mortality at 2 years (7.0% vs 9.8%, P = .13). Patients in the endovascular repair group had reduced median procedure time (2.9 vs 3.7 hours), blood loss (200 vs 1000 mL), transfusion requirement (0 vs 1.0 units), duration of mechanical ventilation (3.6 vs 5.0 hours), hospital stay (3 vs 7 days), and intensive care unit stay (1 vs 4 days), but required substantial exposure to fluoroscopy and contrast. There were no differences between the 2 groups in major morbidity, procedure failure, secondary therapeutic procedures, aneurysm-related hospitalizations, health-related quality of life, or erectile function. CONCLUSIONS In this report of short-term outcomes after elective AAA repair, perioperative mortality was low for both procedures and lower for endovascular than open repair. The early advantage of endovascular repair was not offset by increased morbidity or mortality in the first 2 years after repair. Longer-term outcome data are needed to fully assess the relative merits of the 2 procedures. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00094575.

Burnout and medical errors among American surgeons.

Objective:To evaluate the relationship between burnout and perceived major medical errors among American surgeons. Background:Despite efforts to improve patient safety, medical errors by physicians remain a common cause of morbidity and mortality. Methods:Members of the American College of Surgeons were sent an anonymous, cross-sectional survey in June 2008. The survey included self-assessment of major medical errors, a validated depression screening tool, and standardized assessments of burnout and quality of life (QOL). Results:Of 7905 participating surgeons, 700 (8.9%) reported concern they had made a major medical error in the last 3 months. Over 70% of surgeons attributed the error to individual rather than system level factors. Reporting an error during the last 3 months had a large, statistically significant adverse relationship with mental QOL, all 3 domains of burnout (emotional exhaustion, depersonalization, and personal accomplishment) and symptoms of depression. Each one point increase in depersonalization (scale range, 0–33) was associated with an 11% increase in the likelihood of reporting an error while each one point increase in emotional exhaustion (scale range, 0–54) was associated with a 5% increase. Burnout and depression remained independent predictors of reporting a recent major medical error on multivariate analysis that controlled for other personal and professional factors. The frequency of overnight call, practice setting, method of compensation, and number of hours worked were not associated with errors on multivariate analysis. Conclusions:Major medical errors reported by surgeons are strongly related to a surgeons degree of burnout and their mental QOL. Studies are needed to determine how to reduce surgeon distress and how to support surgeons when medical errors occur.

Burnout and career satisfaction among American surgeons.

Objective:To determine the incidence of burnout among American surgeons and evaluate personal and professional characteristics associated with surgeon burnout. Background:Burnout is a syndrome of emotional exhaustion and depersonalization that leads to decreased effectiveness at work. A limited amount of information exists about the relationship between specific demographic and practice characteristics with burnout among American surgeons. Methods:Members of the American College of Surgeons (ACS) were sent an anonymous, cross-sectional survey in June 2008. The survey evaluated demographic variables, practice characteristics, career satisfaction, burnout, and quality of life (QOL). Burnout and QOL were measured using validated instruments. Results:Of the approximately 24,922 surgeons sampled, 7905 (32%) returned surveys. Responders had been in practice 18 years, worked 60 hours per week, and were on call 2 nights/wk (median values). Overall, 40% of responding surgeons were burned out, 30% screened positive for symptoms of depression, and 28% had a mental QOL score >1/2 standard deviation below the population norm. Factors independently associated with burnout included younger age, having children, area of specialization, number of nights on call per week, hours worked per week, and having compensation determined entirely based on billing. Only 36% of surgeons felt their work schedule left enough time for personal/family life and only 51% would recommend their children pursue a career as a physician/surgeon. Conclusion:Burnout is common among American surgeons and is the single greatest predictor of surgeons’ satisfaction with career and specialty choice. Additional research is needed to identify individual, organizational, and societal interventions that preserve and promote the mental health of American surgeons.

Long-Term Comparison of Endovascular and Open Repair of Abdominal Aortic Aneurysm

BACKGROUND Whether elective endovascular repair of abdominal aortic aneurysm reduces long-term morbidity and mortality, as compared with traditional open repair, remains uncertain. METHODS We randomly assigned 881 patients with asymptomatic abdominal aortic aneurysms who were candidates for both procedures to either endovascular repair (444) or open repair (437) and followed them for up to 9 years (mean, 5.2). Patients were selected from 42 Veterans Affairs medical centers and were 49 years of age or older at the time of registration. RESULTS More than 95% of the patients underwent the assigned repair. For the primary outcome of all-cause mortality, 146 deaths occurred in each group (hazard ratio with endovascular repair versus open repair, 0.97; 95% confidence interval [CI], 0.77 to 1.22; P=0.81). The previously reported reduction in perioperative mortality with endovascular repair was sustained at 2 years (hazard ratio, 0.63; 95% CI, 0.40 to 0.98; P=0.04) and at 3 years (hazard ratio, 0.72; 95% CI, 0.51 to 1.00; P=0.05) but not thereafter. There were 10 aneurysm-related deaths in the endovascular-repair group (2.3%) versus 16 in the open-repair group (3.7%) (P=0.22). Six aneurysm ruptures were confirmed in the endovascular-repair group versus none in the open-repair group (P=0.03). A significant interaction was observed between age and type of treatment (P=0.006); survival was increased among patients under 70 years of age in the endovascular-repair group but tended to be better among those 70 years of age or older in the open-repair group. CONCLUSIONS Endovascular repair and open repair resulted in similar long-term survival. The perioperative survival advantage with endovascular repair was sustained for several years, but rupture after repair remained a concern. Endovascular repair led to increased long-term survival among younger patients but not among older patients, for whom a greater benefit from the endovascular approach had been expected. (Funded by the Department of Veterans Affairs Office of Research and Development; OVER ClinicalTrials.gov number, NCT00094575.).

Rupture rate of large abdominal aortic aneurysms in patients refusing or unfit for elective repair

CONTEXT Among patients with abdominal aortic aneurysm (AAA) who have high operative risk, repair is usually deferred until the AAA reaches a diameter at which rupture risk is thought to outweigh operative risk, but few data exist on rupture risk of large AAA. OBJECTIVE To determine the incidence of rupture in patients with large AAA. DESIGN AND SETTING Prospective cohort study in 47 Veterans Affairs medical centers. PATIENTS Veterans (n = 198) with AAA of at least 5.5 cm for whom elective AAA repair was not planned because of medical contraindication or patient refusal. Patients were enrolled between April 1995 and April 2000 and followed up through July 2000 (mean, 1.52 years). MAIN OUTCOME MEASURE Incidence of AAA rupture by strata of initial and attained diameter. RESULTS Outcome ascertainment was complete for all patients. There were 112 deaths (57%) and the autopsy rate was 46%. Forty-five patients had probable AAA rupture. The 1-year incidence of probable rupture by initial AAA diameter was 9.4% for AAA of 5.5 to 5.9 cm, 10.2% for AAA of 6.0 to 6.9 cm (19.1% for the subgroup of 6.5-6.9 cm), and 32.5% for AAA of 7.0 cm or more. Much of the increased risk of rupture associated with initial AAA diameters of 6.5-7.9 cm was related to the likelihood that the AAA diameter would reach 8.0 cm during follow-up, after which 25.7% ruptured within 6 months. CONCLUSION The rupture rate is substantial in high-operative-risk patients with AAA of at least 5.5 cm in diameter and increases with larger diameter.

Relationship of age, gender, race, and body size to infrarenal aortic diameter

PURPOSE To assess the effects of age, gender, race, and body size on infrarenal aortic diameter (IAD) and to determine expected values for IAD on the basis of these factors. METHODS Veterans aged 50 to 79 years at 15 Department of Veterans Affairs medical centers were invited to undergo ultrasound measurement of IAD and complete a pre-screening questionnaire. We report here on 69,905 subjects who had no previous history of abdominal aortic aneurysm (AAA) and no ultrasound evidence of AAA (defined as IAD > or = 3.0 cm). RESULTS Although age, gender, black race, height, weight, body mass index, and body surface area were associated with IAD by multivariate linear regression (all p < 0.001), the effects were small. Female sex was associated with a 0.14 cm reduction in IAD and black race with a 0.01 cm increase in IAD. A 0.1 cm change in IAD was associated with large changes in the independent variables: 29 years in age, 19 cm or 40 cm in height, 35 kg in weight, 11 kg/m2 in body mass index, and 0.35 m2 in body surface area. Nearly all height-weight groups were within 0.1 cm of the gender means, and the unadjusted gender means differed by only 0.23 cm. The variation among medical centers had more influence on IAD than did the combination of age, gender, race, and body size. CONCLUSIONS Age, gender, race, and body size have statistically significant but small effects on IAD. Use of these parameters to define AAA may not offer sufficient advantage over simpler definitions (such as an IAD > or = 3.0 cm) to be warranted.

Stress and burnout among surgeons: understanding and managing the syndrome and avoiding the adverse consequences.

Training for and practicing surgery are stressful endeavors. 1-4 Studies 5-11 involving national samples of surgeons from surgical subspecialty societies and graduates of surgical training programs suggest that burnout rates among surgeons range from 30% to 38%. These statistics indicate that a substantial number of our colleagues are struggling with personal and professional distress at a level that should be of concern to all surgeons.

Healing of venous ulcers in an ambulatory care program: The roles of chronic venous insufficiency and patient compliance

PURPOSE A nurse-managed/physician-supervised treatment program for venous ulceration was evaluated to determine the influence of venous hemodynamics, comorbidities, patient behavior, and ulcer characteristics on time to healing and time to recurrence. METHODS The clinical course and long-term follow-up of 71 patients with 99 venous ulcers diagnosed between November 1981 and August 1994 were analyzed by a retrospective review of clinic records. Demographic data, severity of venous insufficiency, ulcer characteristics, and patient compliance were studied. Outcome variables were time to complete ulcer healing and time to first recurrence. RESULTS Ninety-one percent of the ulcers healed completely at a median 3.4 months. There were 52 (57%) recurrences at a median 10.4 months. Ulcers on limbs with a venous refill time of 10 seconds or less demonstrated a significantly longer time to complete healing (p < or = 0.03); however, no effect on time to recurrence was observed. Patients who were in strict compliance with the treatment regimen (n = 32) had significantly faster healing (p < or = 0.02) and fewer recurrences (p < or = 0.004) compared with patients who were less compliant (n = 67). CONCLUSIONS Most venous ulcers can be expected to heal when patients are enrolled in a nurse-managed/physician-supervised ambulatory ulcer clinic. Photoplethysmography-derived venous refill time of 10 seconds or less predicted delayed healing. Strict compliance with the treatment protocol significantly decreased the time to healing and prolonged the time to recurrence.

Long-term results of infrainguinal revascularization with polytetrafluoroethylene: A ten-year experience☆

Two hundred fifty-eight patients underwent 322 infrainguinal revascularizations with use of polytetrafluoroethylene (PTFE) between 1978 and 1988. The indication was limb salvage in 190 (59%) reconstructions. Two hundred nineteen (68%) were above-knee, and 75 (23%) were below-knee femoropopliteal bypasses. Twenty-eight (8.6%) were femoral-infrapopliteal bypasses, all done for limb salvage. Follow-up ranged from 24 to 144 months (mean, 66 months). The perioperative mortality rate (1 to 30 days) was 3.4% (9 patients), with no significant difference according to indication (2.9% vs 3.7%). Actuarial primary patency at 8 years for the entire series of femoropopliteal bypasses was 53% (above knee 53%; below knee 39%; p less than 0.05), and improved with additional procedures for a secondary patency of 72%. Femoropopliteal bypasses done for severe claudication had an 8-year actuarial primary patency of 63%, compared with 38% for limb salvage (p less than 0.02). Actuarial limb salvage in the latter group at 8 years was 66%. Femoral-infrapopliteal reconstructions with PTFE had a significantly lower primary patency at 3 years (22%, with a 37% limb salvage). Sixty-four percent of the failures for all reconstructions (N = 111) occurred within 12 months, with remarkable stabilization of patency curves beyond that interval. This experience represents the largest reported series of PTFE reconstruction with longest follow-up to date and may serve as a basis for comparison of other conduits. These results suggest an important role for PTFE in femoropopliteal revascularization and a limited role of this prosthetic conduit in femoral-infrapopliteal arterial reconstructions.

Complications of diverticular disease of the colon in young people.

Diverticular disease of the colon in patients under the age of 40 years is uncommon. Between 1975 and 1985, 58 patients (31 men and 27 women) were admitted for pathologically or radiographically proven acute diverticulitis. Seventeen (29.3 percent) were younger than 40 years. Fifteen of the 17 (88.2 percent) required urgent or emergent surgery for complications of diverticular disease. This represents a significantly (P<0.02) larger proportion of that age group than those patients older than the age of 40 (17/41 or 41.5 percent). Twelve of the patients younger than age 40 (70.6 percent) had had their symptoms for 72 hours or less, and in 13, surgery was required during the first attack. Indications for surgery included abscess, perforation, and persistence of symptoms. Six patients required surgery in less than 24 hours. In young people, the initial attack of colonic diverticulitis is frequently severe, often requiring an urgent operation for complications. Excellent results with few complications can be obtained when the index of suspicion is high, an early diagnosis is made, and timely surgical intervention is employed.