Stephen Black

Early Results of Fenestrated Endovascular Repair of Juxtarenal Aortic Aneurysms in the United Kingdom

Background— Fenestrated endovascular repair of abdominal aortic aneurysms has been proposed as an alternative to open surgery for juxtarenal and pararenal abdominal aortic aneurysms. At present, the evidence base for this procedure is predominantly limited to single-center or single-operator series. The aim of this study was to present nationwide early results of fenestrated endovascular repair in the United Kingdom. Methods and Results— All patients who underwent fenestrated endovascular repair between January 2007 and December 2010 at experienced institutions in the United Kingdom(>10 procedures) were retrospectively studied by use of the GLOBALSTAR database. Site-reported data relating to patient demographics, aneurysm morphology, procedural details, and outcome were recorded. Data from 318 patients were obtained from 14 centers. Primary procedural success was achieved in 99% (316/318); perioperative mortality was 4.1%, and intraoperative target vessel loss was observed in 5 of 889 target vessels (0.6%). The early reintervention (<30 days) rate was 7% (22/318). There were 11 deaths during follow-up; none were aneurysm-related. Survival by Kaplan–Meier analysis was 94% (SE 0.01), 91% (0.02), and 89% (0.02) at 1, 2, and 3 years, respectively. Freedom from target vessel loss was 93% (0.02), 91% (0.02), and 85% (0.06), and freedom from late secondary intervention (>30 days) was 90% (0.02), 86% (0.03), and 70% (0.08) at 1, 2, and 3 years. Conclusions— In this national sample, fenestrated endovascular repair has been performed with a high degree of technical and clinical success. Late survival and target vessel patency are satisfactory. These results support continued use and evaluation of this technique for juxtarenal aneurysms, but illustrate the need for a more robust evidence base.

Is endovascular repair of mycotic aortic aneurysms a durable treatment option

OBJECTIVE Endovascular repair for degenerative aortic aneurysms is well established, but its role in those with infective pathology remains controversial. This study aims to assess the durability of endovascular repair with a review of our midterm results. METHOD A retrospective analysis of a prospectively maintained endovascular database (1998-2008) was conducted, which identified 673 consecutive patients with aortic aneurysms. RESULTS Nineteen patients (2.8%) were identified with infected aortic aneurysms, in which there were a total of 23 separate aneurysms (16 thoracic and seven abdominal). Six patients (32%) presented with rupture. Eleven patients (58%) had received antibiotics preoperatively for a median duration of 11 days (1-54 days). Fifteen of the 19 (79%) had positive blood cultures, with Staphylococcus aureus being the most common organism. All 19 patients underwent endovascular repair. There were three Type I endoleaks (one requiring conversion to open repair) and two Type II endoleaks. One patient developed transient paraplegia, resolved by cerebrovascular fluid (CSF) drainage, and one patient had a stroke. The 30-day mortality was 11%, and survival at median follow-up of 20 months (0-83 months) was 73%. All eight deaths in the series were related to aneurysm. CONCLUSION Endovascular treatment of infective aortic pathology provides an early survival benefit; however, concerns over on-going graft infection remain.

Assessment of surgical competence at carotid endarterectomy under local anaesthesia in a simulated operating theatre

Methods of surgical training that do not put patients at risk are desirable. A high‐fidelity simulation of carotid endarterectomy under local anaesthesia was tested as a tool for assessment of vascular surgical competence, as an adjunct to training.

Long-term surveillance with computed tomography after endovascular aneurysm repair may not be justified

There is a common perception that a large number of secondary interventions are needed following endovascular aortic aneurysm repair.

Competence assessment of senior vascular trainees using a carotid endarterectomy bench model

Competency‐based assessment is being introduced to surgical training. The value of bench‐top technical skills assessment using a synthetic carotid endarterectomy (CEA) model was evaluated in vascular trainees and consultants.

Laparoscopic vs Open Appendectomy in Older Patients

HYPOTHESIS The results of a meta-analysis of individual studies comparing laparoscopic vs open appendectomy in older patients may guide the choice of surgical approach. DESIGN Meta-analysis. SETTING Academic research. PATIENTS MEDLINE, EMBASE, Web of Science, and Cochrane databases were searched for comparative studies of older patients with a diagnosis of acute appendicitis. MAIN OUTCOME MEASURES Primary outcomes were postoperative mortality and overall morbidity. Secondary outcomes were operative time, length of hospital stay, postoperative wound infection, and intra-abdominal collection. Using the lowest threshold from the articles included, older patients were defined as those older than 60 years. RESULTS Analyzed were 6 studies comprising 15 852 appendectomies (4398 laparoscopic and 11 454 open procedures). Laparoscopic appendectomy was associated with significant reductions in postoperative mortality (pooled odds ratio, 0.24; 95% CI, 0.15-0.37), postoperative complications (pooled odds ratio, 0.61; 95% CI, 0.50-0.73), and length of hospital stay (weighted mean difference, -0.51 days; 95% CI, -0.64 to -0.37 days) (P < .05 for all). No significant group differences were observed in operative time, postoperative wound infection, or intra-abdominal collection. CONCLUSIONS In older patients, laparoscopic appendectomy is associated with reduced postoperative mortality and morbidity, although randomized data are required to infer causality. A health economic analysis with quality-of-life metrics is needed to investigate potential benefits of the reduced length of hospital stay observed following laparoscopic appendectomy in this cohort.

Simulated anaesthetists in high fidelity simulations for surgical training: feasibility of a training programme for actors

Background: High fidelity simulations within the operating theatre (OT) require physical infrastructure and a full OT team. Such teams place heavy demands on clinical service. Research and training programmes in our surgical department were often compromised by the late cancellation of anaesthetists. Aims: This paper describes and evaluates a training programme in which actors were trained as simulated anaesthetists. Methods: The training programme was developed, piloted and implemented in a surgical education programme. Evaluation consisted of interviews with actors after the series of simulations. Surgical participants were not informed that the anaesthetist was an actor until after the simulation when they completed an interview and a 10-point authenticity scale (1 = not at all to 10 = highly authentic). Results: Three actors played the role of anaesthetists in 34 scenarios with 17 surgeons in simulations of carotid endarterectomy. Although initially anxious about their role, actors found the training programme valuable and came to feel confident. Mean ratings of anaesthetist authenticity was 8.1 (Range 2–10). Surgeons? comments showed that in most scenarios they found the anaesthetist?s performance highly authentic. Conclusions: Although this study demonstrates the feasibility of using actors as anaesthetists in high fidelity surgical simulations, there are also limitations. Factors contributing to success included: selective actor recruitment; written training materials; formal OT orientation, audio link between the control room and the actor; the opportunity to rehearse; and, structured observations.

Gaining Consent for Carotid Surgery: A Simulation-Based Study of Vascular Surgeons

AIM Despite no formal training in consenting patients, surgeons are assumed to be competent if they are able to perform an operation. We tested this assumption for carotid endarterectomy (CEA). METHODS Thirty-two surgeons [Group 1: junior surgical trainees--performed 0 CEAs (n=11); 2: senior vascular trainees--1-50 CEAs (n=11); 3: consultant vascular surgeons - > 50 CEAs (n=10)] consented two patients (trained actors) for a local anaesthetic CEA. The performance was assessed at post hoc video review by two independent assessors using a validated rating scale and checklist of risk factors. RESULTS There was no difference in performance between the junior and senior trainees (1: median 91 range 64-121; 2: median 100.5 range 66-125; p=0.118 1 vs. 2 Mann-Whitney). There was a significant improvement between senior trainees and consultant surgeons (3: median 120 range 89-1 142; p=0.001 2 vs. 3). Few junior (1/11) and senior (2/11) trainees, and most (8/11) consultants, were competent. Inter-rater reliability was high (alpha=0.832). Consultant surgeons were significantly more likely to discuss cranial nerve injuries (p<0.0001 Chi-square test) as well as personal or hospital specific stroke risk (p<0.0001) than their junior counterparts. They were less likely to discuss infection (p<0.0001). CONCLUSION Senior trainees, despite being able to perform a CEA, were not competent in consent. The majority of consultant surgeons had developed competence in consenting even though they had no formal training.

Simulated patients and the development of procedural and operative skills.

The Interprofessional HIV/AIDS Prevention and Care course, offered by the College of Health Disciplines, University of British Columbia, Vancouver, Canada, has been available to nursing, dietetics, medicine, pharmaceutical sciences and social work students since 1997. In 2003 and 2004, a problem-based learning (PBL) approach was integrated using Corbin & Strauss’s (1992) chronic illness trajectory model. PBL patient scenarios were designed using five stages from the model: pre-trajectory, trajectory-onset, stable, unstable, and downward and dying. Incremental patient scenario ‘snapshots’ were discussed and analysed during five facilitated sessions, in small groups of two to five students from the different healthcare professions. Tutorials and lectures were also used to encourage large-group discussions and provide content relevant to the PBL scenarios. In 2003, 22 students (six nursing, one dietetics, six medicine, five pharmaceutical sciences, and four social work) and in 2004, 25 students (six nursing, five dietetic, four medicine, six pharmaceutical sciences and four social work) completed a course evaluation. Specific PBL components were evaluated and students also rated their overall interprofessional learning experiences using a four-point Likert scale of 1 (strongly disagree), 2 (disagree), 3 (agree) and 4 (strongly agree). The course evaluation return rate was 100% (n1⁄4 22) in 2003 and 2004 (n1⁄4 25). Student evaluations of specific PBL components in 2003 were: scenario reality 3.6 (SD 0.6), appropriateness of PBL group size 3.59 (SD 0.50), PBL group identification of learning needs and sharing of information 3.64 (SD 0.49), and facilitator effectiveness 3.59 (SD 0.50). Comparatively, in 2004 student approval ratings increased slightly for scenario reality 3.68 (SD 0.48) and appropriateness of the group size 3.72 (SD 0.54). However, there were decreases in the ratings of identified group learning needs and sharing of information 3.36 (SD 0.81) and facilitator effectiveness 3.28 (SD 0.68). The same faculty members facilitated the PBL sessions in both 2003 and 2004; however, the student evaluations did not support our hypothesis that facilitator effectiveness would increase with experience, and in turn that would increase group efficacy. Students showed strong agreement in both 2003 and 2004 that interprofessional learning would help them become better healthcare professionals 3.91 (SD 0.29) and 3.96 (SD 0.20); had increased their understanding of clinical problems 3.91 (SD 0.29) and 3.80 (SD 0.41); and enhanced their ability to manage clinical problems 3.86 (SD 0.35) and 3.76 (SD 0.44). The inclusion of PBL was premised on the expectation that it would contribute significantly to these aspects of interprofessional learning. However, all components of PBL were rated lower than students’ evaluation of their interprofessional learning. Overall student evaluations of the PBL component of the course were positive. The use of Corbin and Strauss’s illness trajectory model provided an effective framework to guide both students and faculty in the PBL scenarios. However, many pedagogical challenges accompanied the integration of PBL. We strongly recommend PBL group rules and roles be established from the outset, and that formal student and faculty support is available to assist with the unique challenges inherent to PBL and IPE. Furthermore, the increased financial cost associated with the large number of faculty required to facilitate PBL small-group sessions should be considered when deciding to adapt this approach.

Emergency endovascular aneurysm repair for ruptured abdominal aortic aneurysm: the way forward?

We present the early results of a policy of treating all anatomically suitable ruptured abdominal aortic aneurysms (rAAAs) by emergency endovascular aneurysm repair (eEVAR), regardless of hemodynamic instability. Data were retrospectively collected from prospectively maintained databases identifying patients with rAAA from 2006 to 2007. Forty-seven patients with true rAAA were identified (87% men; median age 76 years [range 63–97 years]), of whom 18 (38%) were treated with eEVAR, 19 (40%) received open aneurysm repair (OAR), and 10 (21%) were managed nonoperatively. Fifteen of 18 (83%) eEVAR patients received an aortouni-iliac device + femorofemoral crossover, 2 patients (11%) had bifurcated devices, and 1 patient (6%) had a new iliac limb. Thirty-day mortality was 11% (2 of 18) for eEVAR and 32% (6 of 19) for OAR (p = not significant). At the 6-month follow-up, mortality was 22% (4 of 18) for eEVAR and 37% (7 of 19) for OAR (p = not significant). A clinically significant early survival advantage is suggested for eEVAR in patients presenting with rAAA.