Venous thromboembolism during air travel: does the existing evidence raise legal implications?

Venous thromboembolism associated with prolonged sitting during air travel has been reported in the medical literature. The aim of this article was to review whether the existing evidence can raise ethical concerns and grounds for legal implications. Review of the pertinent literature. Long duration air travel is linked with venous thromboembolism in susceptible individuals. However, the jurisdictions in countries that have adopted the Warsaw Convention 1929 and its amendment at Hague in 1955 have invariably based their approach on whether venous thromboembolism developed after air travel is an ''accident'' under the provision of article 17. Not only this has failed to be proven under various jurisdictions but also inaction, including not warning of the risk and not giving advice on the precautions that would minimise that risk have not been considered sufficient to rank venous thromboembolism as an ''accident''. While there is scientific evidence to support that long-haul flights may predispose to the development of venous thromboembolism in susceptible individuals, there is a clear trend in various jurisdictions that the airline carrier does not incur liability under the Warsaw convention. Nevertheless, the existing scientific evidence raises ethical concerns on the need for information and advice on prevention to those passengers at risk from the airline companies.

Hybrid endovascular and open treatment of severe multilevel lower extremity arterial disease.

OBJECTIVE: To evaluate the feasibility and efficacy of simultaneous combined endovascular and open lower extremity arterial reconstruction. DESIGN: Case series study with retrospective analysis of prospectively collected non-randomised data. METHODS: Patients were divided into three groups: group 1 and group 2 included patients who underwent endovascular reconstruction proximal and distal to the site of open reconstruction, respectively, whereas group 3 included patients who underwent open surgery with both proximal and distal endoluminal procedures. Patency analyses were performed using Kaplan-Meier life tables. Univariate and multivariate analyses were used to assess the influence of various risk factors on primary patency. RESULTS: Complete data were obtained from 60 patients who underwent 61 single-step hybrid procedures. Technical and haemodynamic success rates were 100% and 95%, respectively. The perioperative mortality rate was 3%. The primary and assisted-primary patency rates at 12 months were 71% and 98%, respectively. Primary patency rates were lower in group 3 when compared with groups 1 and 2 (log-rank test, p=0.006). The presence of diabetes and dyslipidaemia were independent predictors of decreased primary patency (p=0.003 and p=0.014, respectively). CONCLUSIONS: Hybrid procedures provide an effective treatment management of selected patients with multilevel lower extremity arterial disease. The extent of the disease, diabetes and dyslipidaemia are associated with worse outcome.

Blind on table internal iliac artery embolization in severe post partum hemorrhage: a case report.

A case of a woman that had been transferred to our hospital in hemorrhagic shock secondary to post partum hemorrhage due to uterine atony, automatic abortion and extended vaginal lacerations has been described. Subtotal hysterectomy had already been performed but failed to control bleeding. The authors performed on table blind embolisation of internal iliac arteries in order to control hemorrhage as a life-saving procedure that was successful.

Remote endarterectomy for long segment superficial femoral artery occlusive disease. A systematic review.

BACKGROUND: Remote endarterectomy is a minimally invasive procedure which combines open and endovascular surgery for the treatment of long segment superficial femoral artery (SFA) occlusive disease. We conducted a systematic review of the medical literature to analyze the indications, technical limitations and the outcome of remote SFA endarterectomy (RSFAE). METHODS: The English literature was searched using the MEDLINE electronic database up to February 2008. We considered studies comprising at least 10 patients treated with RSFAE and reporting on the primary and/or secondary patency rates. Average primary and secondary patency rates were obtained by weighting the data of each study by the number of limbs treated. RESULTS: Our search identified 19 retrospective or prospective case series; no randomized controlled trials comparing RSFAE with another treatment modality were identified. The average technical success rate was 94% and the procedure-related complication rate was 14.7%. The weighted mean cumulative primary patency rates were 60%, 57% and 35% at 1, 2 and 5 years, respectively. The weighted mean assisted primary patency rates were 75%, 77% and 50% at 1, 2 and 5 years, respectively. The weighted mean secondary patency rates were 88% and 62% at 1 and 2 years, respectively. CONCLUSIONS: RSFAE has acceptable short-, medium- and long-term results but patients should undergo intensive surveillance postoperatively. Randomized controlled trials are needed to assess the durability of this procedure as compared to conventional open bypass surgery.

The evolution of lower limb amputation through the ages. Historical note.

The aim of this study was to highlight the important stages of the evolution of limb amputation through the ages through the search of the relevant international literature. Limb amputation is one of the most serious surgical operations, which is associated with high mortality and morbidity. Evidence regarding the execution of limb amputation can be found back in Neolithic times. The most important steps in the evolution of the technique of limb amputation were made in the 16th, 17th, and 18th centuries when A. Pare' introduced the vessel ligation and the French barber surgeon Morell introduced the use of a tourniquet to reduce the bleeding. During the same period, from the ''one-stage circular cut'' the technique evolved to either ''three-stage circular cut'' or to ''flap amputation'', single or double. Limb amputation represents one of the oldest and most serious surgical operations. Its evolution parallels the maturation process of surgery, with the major developments in the technique to have been made from the 16th to the 18th century. In the beginning of the 21st century, limb amputation appears to be a safe operation ending up with a functional stump.

Malpractice issues in modern anaesthesiology.

Medical malpractice has been raised as an important problem in daily practice, while the media and public remain unforgiving to those perceived to have harmed the patients' life. This article highlights important legal issues related to medical malpractice and summarizes the sources and the nature of potential errors in anaesthesiology practice.

Mycotic aneurysm of the infrarenal aorta.

The mycotic aneurysms of the infrarenal aorta (MAIA) are extremely rare and the associated morbidity and mortality is very high. The classification of infected aneurysms considers four types: a) true mycotic aneurysms, b) secondary mycotic aneurysms due to bacterial arteritis, c) infected preexisting abdominal aortic aneurysms and d) post-traumatic infected false aneurysms. The prognosis of true MAIA's is better than the other forms of infected aneurysms. The standard treatment includes the resection of the aneurysm and infectious surrounding tissues and the restoration of the flow using ex situ (axillobifemoral) bypass or in situ replacement with autologous vein or a rifampicinebonded graft. We present a case of mycotic aneurysm of the infrarenal aorta and a brief discussion of the alternative treatments from the relevant literature.

'On-line' alterations of contralateral jugular blood gas profile during carotid clamping.

The aim of this work was to record the metabolic status of the brain (pH, PCO(2) and PO(2)) during carotid endarterectomy (CEA), with the use of an intravascular multiparameter sensor (Paratrend 7) via retrograde catheterization of the contralateral jugular vein. Twenty-four patients with ASA grades II and III scheduled for CEA were included in the study. After induction of anesthesia, the contralateral internal jugular vein was punctured retrogradely and the sensor was introduced. During clamping, pH became persistently more acidotic (7.34-7.31; p < 0.05), PCO(2) was elevated (43.2-46.8 mm Hg; p < 0.05) while most of the patients showed a non-significant decrease in PjvO(2)/SjvO(2) (jv = jugular venous). Correlation with clamping time or stump pressure was not significant. Unclamping was followed by a short period (5- 9 min) of decrease in pH and elevation of PCO(2) (7.30-7.22; p < 0.05, and 48.0-52.5 mm Hg; p < 0.05, respectively). PjvO(2) was significantly elevated (51.8-58.0 mm Hg; p < 0.001) after the restoration of flow. The study suggests that local CO(2) creates conditions for compensation of flow after the application of a carotid clamp. We consider that this monitoring technique, after further validation, may provide useful information.

Incidence of abdominal wall hernias in patients undergoing aortic surgery for aneurysm or occlusive disease.

BACKGROUND: The aim of this study was to compare the incidence of abdominal and incisional hernias in patients with abdominal aortic aneurysm (AAA) versus patients with aortoiliac occlusive disease (AOD). PATIENTS AND METHODS: The study included retrospectively 121 patients, who underwent elective aortic surgery due to AAA (n = 63) or AOD (n = 58) in the period between January 1998 and January 2000. The patients were examined for the presence of abdominal hernias upon admission, as well as for the development of incisional hernias on follow-up. RESULTS: The incidence of inguinal hernias was significantly higher in the group AAA (21/6-33.3%) compared to the group with AOD (6/58-10.3%) (p < 0.01). The incidence of other abdominal wall hernias (umbilical, epigastric or miscellaneous hernias) was also significant higher in AAA group. Furthermore, the incidence of inguinal hernias was significantly higher in the subgroup of patients with an aneurysm diameter more than 6 cm (41.5% vs 18.2%, p < 0.05). The mean follow-up of the patients was 1.7 +/- 0.3 years. 7 cases of incisional hernia were noted in the AAA group (11.1%) and only 2 cases in the AOD group (3.4%) (p < 0.05). The size of the aneurysm had no influence on the incidence of incisional hernias in the AAA group. CONCLUSION: We conclude that there seems to be an increased incidence of abdominal wall hernias as well as postoperative incisional hernias in patients undergoing aortic surgery for aneurysm disease compared with aortoiliac occlusive disease.

Alterations in carbon dioxide release during abdominal aortic clamping for aneurysmal or occlusive repair.

BACKGROUND: Application and removal of an infrarenal aortic clamp is associated with changes in oxygen consumption, especially when collateral perfusion is limited. Carbon dioxide production during abdominal aortic clamping is expected also to change. The aim of this study was to evaluate the alterations of CO2 release during abdominal aortic surgery. DESIGN: prospective study. SETTING: University Hospital, Greece. PATIENTS: 17 patients undergoing abdominal aortic aneurismal (AAA) repair and 8 patients undergoing repair of aortoiliac occlusive disease. INTERVENTION: intraoperative record or calculation of PaCO2, PetCO2, PECO2, VD, VDalv, and VCO2. Patients with aneurysms were randomly divided to have constant ventilation (group AA) or modified ventilation to preserve normocapnia (group AB) during clamping. Ventilation was kept constant in the occlusive patients group (group OD). RESULTS: Patients with AAA showed a significant decrease of VCO2 during clamping and an elevation after unclamping in both groups (AA and AB), with no difference of statistical importance between them. During clamping, PetCO2/ PaCO2 ratio was decreased and VDalv was increased especially in group AA, while unclamping produced the opposite effect. Occlusive patients showed insignificant alterations. CONCLUSIONS: Our results suggest that, the calculated alveolar dead space is only an indicator of the true V/Q in patients with AAA, because it is strongly dependent on the CO2 load to the lungs, which is markedly altered in the same period. The modification of ventilation during clamping based only on PetCO2 and not on arterial sampling, could possibly lead to hypercarbia in these patients.

Continuous contralateral jugular acid-base and blood gas monitoring during carotid endarterectomy.

BACKGROUND: The aim of this study is to evaluate the intravascular multiparameter sensor Paratrend 7 (P7) for continuous acid-base and blood gas monitoring after retrograde jugular catheterization during carotid endarterectomy. PATIENTS AND METHODS: We studied 11 patients with history of smoking (72.7%), coronary artery disease (72.7%), hypertension (100%), diabetes mellitus (55.5%) and TIA's and/or nondisabling stroke (90.9%). The contralateral internal jugular vein was punctured retrogradely and the calibrated P7 sensor was introduced. The sensor was removed after surgery. The P7 provides continuous graphical display of pH, pCO2, and pO2, while temperature, oxygen saturation, HCO3 concentration and base excess are displayed numerically. RESULTS: Mean duration of carotid cross-clamping was 17.0 +/- 6.2 min. Mean stump pressure was 50.2 +/- 12.9 mmHg. Intraluminal shunting was not used in any operation. All sensors were easily inserted. During clamping, pH became persistently more acidic (7.31 to 7.28; p < 0.05), pCO2 was elevated (44.7 to 49.8 mmHg; p < 0.05) while, in the majority of the patients, there was a non significant decrease in pjvO2/SjvO2. Declamping was followed by a short period of decrease of pH and elevation of pCO2 reminiscent of wash out phenomena. PjvO2 was significantly elevated (53.8 +/- 5.2 to 59.0 +/- 5.8 mmHg; p < 0.001) after the restoration of flow. In one case, P7 was diagnostic for unsuccessful endarterectomy. CONCLUSIONS: P7 is useful during carotid endarterectomy providing continuous and "on-line" information on brain metabolism. It is a simple and powerful technique, which should be further investigated.

Surgical management of short bowel syndrome by construction of an isoperistaltic intestinal valve: an experimental study in dogs.

OBJECTIVE: To develop of an isoperistaltic invaginated valve for the treatment of short bowel syndrome. DESIGN: Randomised experimental study SETTING: University Hospital, Greece MATERIAL: 8 mongrel dogs INTERVENTION: 90% resection of the small bowel, followed by construction of an invaginated valve one month later. MAIN OUTCOME MEASURES: weight loss, fat excretion in the faeces, radiographic and histological examination of the valve, pressure curve along the valve. RESULTS: Weight loss and steatorrhoea were reversed over a period of 2-3 months without evidence of intestinal obstruction in any of the animals. CONCLUSIONS: The construction of an isoperistaltic invaginated valve could be a solution to the management of the short gut syndrome.