Sohail Choksy

Upper- versus lower-limb aerobic exercise training on health-related quality of life in patients with symptomatic peripheral arterial disease

OBJECTIVE This randomized controlled trial investigated the effects of upper- and lower-limb aerobic exercise training on disease-specific functional status and generic health-related quality of life (QOL) in patients with intermittent claudication. METHODS The study recruited 104 patients (mean age, 68 years; range, 50-85) from the Sheffield Vascular Institute. Patients were randomly allocated to groups that received upper-limb (ULG) or lower-limb (LLG) aerobic exercise training, or to a nonexercise control group. Exercise was performed twice weekly for 24 weeks at equivalent limb-specific relative exercise intensities. Main outcome measures were scores on the Walking Impairment Questionnaire (WIQ) for disease-specific functional status, the Medical Outcomes Study Short Form version 2 (SF-36v2), and European Quality of Life Visual Analog Scale (EQ-VAS) for health-related QOL. Outcomes were assessed at baseline, and at 6, 24, 48, and 72 weeks. RESULTS After 6 weeks, improvements in the perceived severity of claudication (P = .023) and stair climbing ability (P = .011) vs controls were observed in the ULG, and an improvement in the general health domain of the SF-36v2 vs controls was observed in the LLG (P = .010). After 24 weeks, all four WIQ domains were improved in the ULG vs controls (P ≤ .05), and three of the four WIQ domains were improved in the LLG (P < .05). After 24 to 72 weeks of follow-up, more consistent changes in generic health-related QOL domains were apparent in the ULG. CONCLUSIONS These findings support the use of alternative, relatively pain-free forms of exercise in the clinical management of patients with intermittent claudication.

Effect of Upper- and Lower-limb Exercise Training on Circulating Soluble Adhesion Molecules, hs-CRP and Stress Proteins in Patients with Intermittent Claudication

OBJECTIVES To investigate the effects of exercise training on levels of circulating biomarkers associated with the progression of atherosclerosis and risk of cardiovascular events in patients with intermittent claudication. METHODS Circulating levels of soluble adhesion molecules (sVCAM-1, sICAM-1, sE-selectin), high sensitivity C-reactive protein (hs-CRP) and stress proteins (Hsp60 and Hsp70) in patients randomised to a 24-week programme of arm- or leg-cranking exercise were compared with those in usual care controls. RESULTS Arm and leg exercise similarly improved lower-limb aerobic exercise capacity (20% vs 19%, respectively; P<0.001) and maximum walking distance (30% vs 35%, respectively; P<0.001). Improvements in training limb-specific peak oxygen consumption were attenuated for patients in the highest vs lowest quartile for circulating sVCAM-1 levels at baseline (3% vs 25% respectively, P<0.001). Although circulating hs-CRP levels tended to be lower in the arm-cranking group (-1.55 [95% CI: -1.06 to -2.26]mgl(-1)), exercise training had no effect on circulating levels of soluble adhesion molecules or stress proteins. CONCLUSIONS These findings suggest that high levels of circulating sVCAM-1 are associated with an attenuated exercise training response and that arm-cranking exercise may provide an effective stimulus for evoking systemic anti-inflammatory adaptations in patients with intermittent claudication.

Introduction of laparoscopic abdominal aortic aneurysm repair.

The aim was to review a consecutive series of patients treated with laparoscopic abdominal aortic aneurysm (AAA) repair. These patients were compared with patients having elective open AAA repair.

Laparoscopic aortic surgery (Br J Surg 2010; 97: 1153-1154).

Sir We read with interest the well conducted randomized study by Braga and colleagues comparing laparoscopic versus open left colonic resection. There is now a consistent body of literature showing that laparoscopic colonic surgery, although associated with longer operating times, contributes towards shorter length of hospital stay, equivalent or improved morbidity, and improved early quality of life compared with open colonic resection. In a previous study by the same group, the increased hospital costs in the laparoscopic surgery group were attributed to the higher cost of laparoscopic instrumentation and longer operating times1. In the present study, the authors suggest that performing the anastomosis and splenic flexure takedown laparoscopically resulted in reducing the invasiveness of the approach. This is in contrast to their previous study on right colectomy where the bowel division and ileocolonic anastomosis was done extracorporeally and the benefits of the laparoscopic approach were not as profound. We are not convinced that bowel division and anastomosis carried out extracorporeally necessarily decreases the benefit of the laparoscopic approach. Not discussed in this article is the use of hand-assisted laparoscopic surgery (HALS) for colonic resection, where the division and anastomosis is often done extracorporeally2. HALS has been shown to produce similar shortand long-term clinical outcomes, as well as potentially decreasing the rate of conversion compared with the standard laparoscopic technique3 – 5. The most important benefit of HALS seems to be a decreased duration of operation, while maintaining the benefits of a minimally invasive approach5. Marcello and colleagues2 noted a time saving of 28 min for left colectomy and 51 min for total colectomy. There is possibly also a reduction in the need for instruments in HALS, although this has not been investigated in any of the studies. We therefore suggest that in selected patients it may be beneficial to employ HALS to decrease the operating time as well as the rate of conversion. This will be associated with a decreased hospital cost of laparoscopy overall, and allow the cost–benefit analysis to shift further in favour of the laparoscopic compared with the open technique. A. Sarin, J. W. Milsom and P. J. Shukla Surgery, Division of Colorectal Surgery, New York Presbyterian Hospital/Weill Cornell Medical College, New York, New York, USA (e-mail: jwm2001@med.cornell.edu) DOI: 10.1002/bjs.7321