Carotid artery surgery--critical analysis of indications in a regional Finnish vascular center.

BACKGROUND: The purpose of this study was to analyze retrospectively the treatment of patients referred for carotid artery stenosis to a vascular surgical unit in the 1990's. Main attention was paid to the appropriateness of the indications for CEA. MATERIAL AND METHODS: In the Pirkanmaa region (population of 440 000), all carotid surgery is performed in the regional University Hospital. All new referrals for vascular surgery because of carotid stenosis or bruit in 1990, 1992, 1994, 1996 and 1998 were included and case records reviewed. RESULTS: Four hundred patients were referred. Indication for referral was a neurologic event in 46.2%, indefinite symptom in 27.9% and asymptomatic stenosis or carotid bruit in 25.9%. Most patients underwent carotid ultrasound as first imaging (93.7%). Almost half of the patients were operated (n=176). The 30-day combined stroke and death rate was 6.5%. Appropriate indication for CEA was found in 31.6%. Over half (57.0%) of the indications were considered uncertain and 11.4% inappropriate, most of these patients having asymptomatic stenosis. CONCLUSION: Patients with asymptomatic stenosis underwent CEA relatively often and the proportion of inappropriate indications was too high. Evaluation of indications and perioperative complications is highly important in carotid surgery.

Ruptured abdominal aortic aneurysm in a well-defined geographic area.

OBJECTIVE: Despite an increasing number of elective operations on abdominal aortic aneurysms (AAAs), the age- and sex-standardized mortality rate of ruptured AAA (RAAA) continues to increase. In the Pirkanmaa region, population 440,000, all aortic surgery is performed at Tampere University Hospital (TAUH). Procedures have been collected into the vascular registry. The purpose of this study was (1) to establish the incidence, modes of treatment, and mortality of RAAA in a defined geographic area; (2) to evaluate the prerupture history to determine if there are any ways to prevent rupture; and to make a forecast about the increase of RAAAs in the next decades. METHODS: Population and outcome data in the Pirkanmaa region and information on all patients who died of RAAA during 1990-1997 were provided by Statistics Finland. All operated RAAAs that underwent procedures during 1990 to 1999 were identified from the local vascular registry. To make a forecast for the next decades, an incidence of RAAA was calculated separately for each age group in 5-year intervals. RESULTS: From 1990 to 1997, 221 patients presented with RAAA. The mean incidence was 6.3/100,000 inhabitants. The incidence in the population over 65 years was 35.5/100,000. The total RAAA mortality was 76.9%. A total of 139 patients reached TAUH and 111 underwent emergency surgery. The overall hospital mortality in TAUH was 63.3%. The calculated annual number of RAAA will increase 49.6% in the next 2 decades, and the overall incidence will increase from 6.3 to 8.9/100,000 inhabitants. According to the vascular registry, 166 patients were operated on for RAAA during 1990 to 1999 in TAUH. The 30-day mortality was 50.6%. A minority of the patients (n = 18, 10.8%) had a previously documented AAA. The median diameter at the time of rupture was 7 cm. Seven (5.0%) men and six (24.0%) women had a diameter of less than 5.5 cm. CONCLUSION: The incidence of RAAA in the Pirkanmaa region in 1990s was the Finnish average. In the next two decades, the number of individuals with RAAA will increase significantly. One quarter of women had a diameter of AAA at the time of rupture that was under the current threshold indicator for elective operation.

The fate of AAA patients referred electively to vascular surgical unit.

BACKGROUND: The ideal treatment of abdominal aortic aneurysms (AAA) is to operate aneurysms likely to rupture, without exposing other cases to major surgery. The purpose here was to analyse retrospectively the management of AAA in a well-defined geographical region in the 1990's. METHODS: 194 new vascular surgical outpatient consultations due to AAA were done to the regional vascular centre during the years 1990, 1992, 1994, 1996 and 1998. Data were collected from case records. Statistics Finland provided causes and dates of death. RESULTS: The mean observed annual AAA incidence was 9.0 per 100 000 inhabitants and it rose significantly (33.3%) during the study period. The duration of follow-up varied between 0 and 129 months. The 5/8-year cumulative mortality was 37.3/50.7%. The most common causes of death were AAA-related (31.7%), cardiac (29.1%) or malignancy (19.0%). Twenty-five patients with small AAA were referred to primary health care sector for further follow-up. There were no RAAA (ruptured AAA) deaths in this group. The cumulative 5/8-year mortality was 43.2/49.9%. One hundred patients underwent an elective aneurysm repair with in-hospital mortality of 7.0%. The cumulative 5/8-year mortality was 23.7/35.4%. Twelve patients refused elective treatment. The cumulative 5/8-year mortality was 45.1/ 63.4% and 5/7 deaths were due to RAAA. Twenty-three patients were unfit for elective repair. The cumulative 5/8-year mortality was 87.0%/100% and 5/20 deaths were caused by RAAA. The cumulative 5/8-year RAAA-rate in the patients with AAA more than 5.0 cm in diameter and outside elective aneurysm-repair (n = 23) was 51.9%/100.0%. CONCLUSION: The observed incidence of AAA increased during the 1990's. Half of the patients underwent an elective procedure. Patients unfit for surgery died mainly for other reasons than RAAA. Most patients with AAA over 5.5 cm not subjected to elective procedure, died of rupture.

Cast treatment and intramedullary locking nailing for simple and spiral wedge tibial shaft fractures--a cost benefit analysis.

BACKGROUND AND AIMS: The aim of this retrospective study was to compare the relative costs of treating simple and spiral wedge (requiring closed reduction under anaesthesia) tibial shaft fractures in a plaster cast or with intramedullary locking nail. MATERIAL AND METHODS: The material consisted of 26 fractures treated in a plaster cast and 51 fractures treated with an intramedullary locking nail. The costs caused by the direct costs (treatment, hospitalisation, and outpatient appointments) as well as indirect costs (lost productivity) were taken into account. Costs caused by complications were also included in the analysis. RESULTS: Mean direct costs per patient were FIM 22920 and FIM 26952 and mean overall costs per patient were FIM 120486 and FIM 82224 in plaster cast and intramedullary locking nailing groups, respectively (FIM 1 = USD 0.19). The higher mean overall costs of the plaster cast group were attributable to the longer sick leave periods in this group (218 days in plaster cast group and 124 in intramedullary nailing group). CONCLUSION: Plaster cast treatment of simple and spiral wedge tibial shaft fractures requiring closed reduction under anaesthesia is more expensive to society than operative treatment with intramedullary locking nail.

Projected workload for a vascular service in 2020.

OBJECTIVE: to estimate the workload of a vascular service during the next two decades as the proportion of people aged over 65 years increases. METHODS: the study used the vascular registry data of Tampere University Hospital and the population data of Pirkanmaa region provided by the Central Statistical Office in Finland. The current workload is 1420 vascular procedures per million inhabitants yearly (951 surgical and 207 endovascular). Sixty-five per cent of all procedures are done on people over 65 years old. Pirkanmaa has a population of 440 000 persons of whom 15.6% are over 65 years. According to the population data the population will increase to 460 000 persons by the year 2020 and 22.9% of them will be over 65 years old. RESULTS: The total amount of procedures will rise by 40.5% (1906) and the increase in endovascular and surgical group will be 39.2% (640) and 43.5% (1265) respectively. The proportion of treated patients over 65 years will rise from 65.0% to 70.5%. In the next two decades the amount of patients with claudication will increase by 35.4%, critical limb ischaemia by 44.2%, carotid surgery by 34.0%, abdominal aortic aneurysms by 40.7%, acute limb ischaemia by 45.0% and access surgery by 27.4%. CONCLUSION: In the next two decades the number of elderly people will increase so rapidly that, whatever happens to the incidence and prevalence of peripheral vascular disease, the workload for a vascular service will increase significantly.

Trends of vascular service in a well defined geographical area in 1990's.

BACKGROUND AND AIMS: The treatment policy of vascular surgical patients has undergone changes in the last decade. The aim of this study was to evaluate development of vascular service in a well defined geographical area, the district of Tampere University Hospital. MATERIAL AND METHODS: This population based study is established on the vascular registry. During the eight year period (1990-1997) totally 5019 procedures had been registered, 3363 vascular surgical operations and 1656 endovascular interventions. This data was analysed retrospectively. RESULTS: The annual amount of vascular surgical procedures was in average 959 per million inhabitants and the amount of endovascular procedures 474 per million inhabitants during the period and the trend was slightly increasing. The mean age of surgical patients increased significantly during the eight year period, from 63.6 to 66.6 years, while the mean age of endovascular patients remained fairly stable over the whole period. The proportion of critical limb ischaemia as an indication for surgical procedure increased during the period from 7.3% to 16.6% (p < 0.001). In the same time also the amount of femoropopliteal and femorodistal bypasses as a treatment of CLI increased significantly (p < 0.001). Further, the proportion of surgical procedures compared to the endovascular procedures in the treatment of CLI increased constantly over the 8-year period from 25% to 61% (p < 0.001). The absolute amount of access surgery increased over the period and the mean age of these patients increased significantly. The median of hospital stay decreased during the eight year period in the surgical group from 9 days to 6 days and in the endovascular group from 2 days to 1 day. CONCLUSIONS: The main changes have been the increased mean age of patients, their shortened hospital stay and the increasing surgical activity on patients with CLI and the larger number of patients with need for vascular access.

Histological improvement of oesophagitis after Nissen fundoplication.

Nissen fundoplication gives lasting relief from symptoms of gastro-oesophageal reflux and cures endoscopic oesophagitis effectively. The histological effect on the oesophageal mucosa is less clear. We studied the long-term histological effect of Nissen fundoplication on refractory gastro-oesophageal disease with erosive oesophagitis or Barrett's metaplasia in 33 patients with biopsy both before and after antireflux surgery. The median postoperative interval to re-examination was 80 (range 37-110) months. Symptoms of reflux were greatly relieved; 31 (94%) of the 33 patients had none or, at the most, mild symptoms. Endoscopic oesophagitis was healed in 26 (79%) of the cases. The histological appearance of the oesophageal mucosa had been abnormal in all the patients preoperatively, but at follow-up it was normal in 22 cases (67%): in 89% of the patients without objectively observed recurrent reflux and in 45% of those with recurrence. Both the pre- and postoperative severity of the histological changes correlated significantly with the endoscopic grade of oesophagitis (r=0.42, P=0.017 and r=0.837, P=0.0001, respectively), but not with the clinical reflux score. In conclusion, Nissen fundoplication resulted in histological healing in the great majority of patients with oesophagitis.

Preoperative treatment and survival of patients with pheochromocytomas.

BACKGROUND: Operative treatment is the method of choice for pheochromocytomas. The best success of the operation requires both good operative technique and effective preoperative medication. Phenoxybenzamine hydrochloride, an alpha-receptor blocker, has been our traditional premedication. Since 1988 we have used it in a combination with alpha-methylthyrosine, a catecholamine-synthesis blocker. AIM: To evaluate different preoperative medications. MATERIAL AND METHODS: Between 1984 and 1994 22 patients were operated on for pheochromocytomas in Tampere University Hospital. Five patients received alpha-receptor blocker, three patients received catecholamine-synthesis blocker, and 14 patients received their combination for a median of 33 days prior to the operation. RESULTS: Three of the five patients receiving alpha-receptor blocker, two of the three patients receiving catecholamine-synthesis blocker, and four of the 14 patients receiving combination therapy demonstrated high systolic blood pressure during the operation. Three patients, one in the alpha-receptor blocker group and two in the combination therapy group, demonstrated a short hypotensive period during the operation. None of the patients experienced severe perioperative cardiac arrhythmias. Mild sedation occurred similarly in either premedications, but the treatment did not need to be discontinued due to adverse reactions. There was no hospital mortality. Two patients had postoperative complications. CONCLUSION: Our initial experience with the combination therapy with alpha-receptor blocker and catecholamine-synthesis blocker is encouraging.

Posterior approach for adrenal surgery: experiences with 59 patients.

BACKGROUND: The laparoscopic approach has become popular for adrenal surgery. AIM: When starting with laparoscopic adrenalectomies we studied our experiences of posterior open approach for different adrenal disorders to obtain reference data. MATERIAL AND METHODS: Between 1983 and 1993 95 adrenalectomies were performed, of which 59 were via the posterior route. There were 51 unilateral (7 phaeochromocytomas, 6 Cushing's syndromes, 33 Conn's syndromes, 1 sex steroid secreting tumour and 4 incidentalomas) and 8 (Cushing's disease) bilateral adrenalectomies. RESULTS: Of the 4 incidentalomas one was a benign adenoma, one was cyst, one was cortical carcinoma, and one was a metastasis from breast cancer. Operative blood loss was median 300 ml, being higher in the bilateral than in the unilateral adrenalectomies (median 500 (range 300-1,250) ml vs. 300 (30-4,500 ml) (P = 0.01). Complications occurred in overall 11 patients (19%) (8 wound infections, 3 postoperative bleeding, 2 pneumonias, 1 urinary infection). Complications were more frequent in Cushing's patients than in the others (6/14 (43%) vs. 5/45 (11%); P = 0.015). Postoperative hospital stay was median 8 (range 5-21) days. The patients started liquids orally and were mobilised on the first post operative day, except for the 3 re-operated patients. Thromboembolic complications did not occur. Narcotics were used postoperatively for median 2 (range 0-7) days. CONCLUSIONS: With the posterior approach mortality and complications related to the pancreas, spleen, colon and duodenum were avoided. Other complications were rare except for the patients with Cushing's disease or syndrome.

Misclassification in a questionnaire survey of varicose veins.

The objective of this study was to assess the determinants and the effect of misclassification in a questionnaire survey of varicose veins. A random sample of 166 individuals aged 50 years in a larger prevalence study (n = 6874) was examined by a surgeon to validate the self-reporting of varicose veins. Varicose veins were assessed by a mailed questionnaire completed by the study subjects themselves and validated in a clinical examination by a surgeon. The sensitivity, specificity, positive and negative predictive values, kappa coefficient, and Chamberlain indices of the self-assessed diagnosis in reference to the diagnosis by surgeon were estimated overall and in categories of determinants. The overall sensitivity and specificity estimates were 0.92 and 0.93, respectively. The specificity appeared to be poorer among subjects who reported positive family history of varicose veins (0.83) than among those with negative family history (0.98). With respect to some other determinants of varicose veins such as gender, height and weight, occupational status and position at work, there was at best weak but nevertheless inconclusive evidence on possible differential misclassification. Sensitivity appeared to be relatively good for epidemiologic purposes but one could have hoped for better specificity. The correction for misclassification resulted in estimated prevalence of 19% (uncorrected 24%) in men and 43% (uncorrected 45%) in women. A questionnaire survey of varicose veins showed a relatively good validity. The effect of misclassification in the total 5-year-old study population was small in women but moderately large in men. Familial predisposition to varicosis was associated with a lower accuracy of self-assessed diagnosis.

Varicose veins in a Finnish population aged 40-60.

STUDY OBJECTIVE: To assess the prevalence and the extent of treatment of varicose veins in a Finnish population. DESIGN: A prevalence study in a defined cohort was performed by using a mailed questionnaire. The method's validity was tested in a random sample of 166 individuals who were studied clinically. SUBJECTS: In 1989 a questionnaire was mailed to every resident born in 1929, 1939, and 1949 who was living in Tampere, the second largest town in Finland. The eligible population comprised 3284 men and 3590 women. MEASUREMENTS AND MAIN RESULTS: The response rate was 75% in men and 86% in women. Both the sensitivity and specificity of the self assessed diagnosis were 0.92. The life time prevalence of varicose veins was 18% for men and 32% for women, with an increasing prevalence in relation to age. Twenty five per cent of the men and 41% of the women who reported varicose veins had received treatment. CONCLUSIONS: Self reporting of varicose veins by mailed questionnaire was a relatively valid method. The prevalence of varicose veins was high in the population studied, and the disease is more common in women than men. Moreover, the prevalence increased with age. The results are comparable with other western populations. Preventive methods are needed because treatment alone seems to be inadequate in the control of varicose veins.

Aetiology, diagnosis and treatment of patients with renal trauma. A survey on patients in the Tampere area during two decades.

A material of 185 renal traumas treated during 1972-1991 was analyzed. A typical patient was a young man; the mean age was 30 years. The most common aetiology was traffic accident (45%). Penetrating traumas were rare (2%). The most common and significant finding was macroscopic haematuria, but the absence of haematuria did not exclude renal trauma. Unexpected findings were seen in 7% of cases. The most common renal injuries were contusion (69%) and laceration (20%) which were mostly treated conservatively (85%) with good results. Only 15% of patients were operated. Renal complications were few both in the conservatively and in the surgically treated patients. No mortality was seen.

Improved detection of cancer of the body or tail of the pancreas.

Ultrasonography (US), computed axial tomography (CT) and endoscopic retrograde cholangiopancreatography (ERCP) have not improved detection or prognosis of carcinoma of the pancreatic head. We investigated the influence of these imaging techniques on detection, and consequently prognosis of carcinoma of the pancreatic body or tail, where the symptoms are less specific (seldom jaundice or vomiting) and imaging techniques may be more important. Of 139 patients, 29 were treated in 1972-1977, when US, CT and ERCP were not used, 27 in 1978-1980, when US was occasionally performed, and 83 in 1981-1989, when all three methods were common. In 1978-1980 and 1980-1981 correct ante-mortem diagnosis was more common than in 1972-1977, and the diameter and stage of tumour were significantly reduced at laparotomy. The resectability rate was not increased, however, and the incidence of exploratory laparotomy was not reduced. The survival time in the last study period was significantly longer only in the non-operatively treated patients. The reason was not earlier diagnosis, but possibly better general management.

Phospholipids and fatty acids in breast cancer tissue.

The fatty acid composition of fractionated phospholipids and neutral lipids was analyzed in human breast cancer tissues and the surrounding, apparently healthy tissue. In the cancer tissues the relative amounts of unsaturated fatty acids were increased in all the phospholipid subclasses analyzed. The differences were more marked in phosphatidylethanolamine than in the other phospholipid fractions and, furthermore, the relative amount of phosphatidyl-ethanolamine was increased in cancerous tissue. In blood-erythrocyte phospholipids, no differences in fatty acid composition could be found between breast cancer and control patients. The present study suggests that the lipid composition of cancerous breast tissues differs from that of the surrounding tissue and may be involved in carcinogenesis.

Human pancreatic phospholipase A2 in acute necrotizing pancreatitis.

The activity and the content of phospholipase A2 (PLA2), a potential 'toxin' in pancreatitis, were determined separately by respective methods in pancreatic tissue resected from 22 patients treated for acute necrotizing pancreatitis. Correspondent enzyme assays were analyzed in the serum of 6 last patients. In cases with total necrosis in the tissue resected, the pancreatic PLA2 activity, but not the content, was almost totally lost. Serum PLA2 activity slightly decreased within the extension of pancreatic necrosis. The timing of sampling, number of positive Ranson signs or the course of the disease had no influence on the tissue PLA2 results. Serum PLA2 activity showed a correlation with tissue PLA2 activity.

DNA flow cytometric analysis indicates that many breast cancers detected in the first round of mammographic screening have a low malignant potential.

An organized mammographic screening program covered 8,690 women from selected birth cohorts (aged 50-59) in the Tampere University Central Hospital district. Forty-four breast cancer cases were detected in the first round of mammographic screening, which is 3.7 times the expected annual number of new cases in this population. To evaluate the proliferative kinetics and biological properties of these cancers, DNA flow cytometric analysis was carried out in 37 of the screen detected cancers (SDCs) using 60 clinically detected stage I-II cancers and 30 screen-detected benign lesions as reference. DNA aneuploidy was observed in 17/37 (46%) of the SDCs as compared to 41/60 (68%) in the clinical controls (p less than 0.05), while all the benign lesions were DNA-diploid. The median S-phase fraction (SPF) in the SDCs was significantly (p less than 0.001) lower (3.5%) than in the clinical controls (9.6%). Differences in SPF persisted in subgroups defined by DNA ploidy and histological type. In stage-I SDCs the median SPF value (2.5%) approached that of benign tumors (1.9%). Our epidemiological and biological data indicate that the first round of mammography predominantly detects prevalent preclinical lesions, some of which are of very low malignant potential. At present such patients may often receive too extensive treatment. DNA flow cytometry could help in the identification of cases which could be treated, for example, by breast-conserving methods.

ERCP in evaluating the mode of therapy in pancreatic pseudocyst.

Twenty patients with ultrasonographic or computed tomographic diagnosis of pancreatic pseudocyst were referred for endoscopic retrograde cholangiopancreatography (ERCP). Two of these were found at laparotomy not to have pseudocysts and were excluded. Pancreatography was successful in 15 out of 18 cases (83%) and cholangiography in 12 out of 18 cases (67%). Three types of pseudocysts were noticed according to the communication of the pseudocyst to the main pancreatic duct and the presence of pancreatic duct stenosis. Successful treatment included two spontaneous resolutions, two internal drainages and three left pancreatic resections. In the eight percutaneous external drainages four recurrences (50%) occurred, one after closure of temporary pancreatocutaneous fistula. All the recurrences occurred in Type III pseudocysts with communication of the pseudocysts to stenotic main pancreatic duct. In these cases internal drainage would have been the preferable treatment method. We believe that by ERCP one can identify pseudocysts not suitable for external drainage.