International trends in patient selection for elective endovascular aneurysm repair: sicker patients with safer anatomy leading to improved 1-year survival.

BACKGROUND: To review the trends in patient selection and early death rate for patients undergoing elective endovascular repair of infrarenal abdominal aortic aneurysms (EVAR) in 3 countries. For this study, audit data from 4,163 patients who had undergone elective infrarenal EVAR were amalgamated. The data originated from Australia, Canada (Ontario), and England (London, Cambridge, and Leicester). METHODS: Statistical analyses were undertaken to determine whether patient characteristics and early death rate varied between and within study groups and over time. The study design was retrospective analysis of data collected prospectively between 1999 and 2012. RESULTS: One-year survival improved over time (P = 0.0013). Canadian patients were sicker than those in Australia or England (P < 0.001). American Society of Anesthesiologists classification (ASA) increased over time across all countries although more significantly in Canada. Age at operation remained constant, although older patients were treated more recently in London (P < 0.001). English centers treated larger aneurysms compared with Australia and Canada (P < 0.001). Australian centers treated a much larger proportion of aneurysms that were <55 mm than other countries. Preoperative creatinine levels decreased over time for all countries and centers (P < 0.001). Infrarenal neck angles have significantly decreased over time (P < 0.001). Recent data from London (UK) showed that operations were performed on longer (P < 0.001) and wider (P < 0.001) infrarenal necks than elsewhere. CONCLUSIONS: In this international comparison, several trends were noted including improved 1-year survival despite declining patient health (as measured by increasing ASA status). This may reflect greater knowledge regarding EVAR that centers from different countries have gained over the last decade and improved medical management of patients with aneurysmal disease.

Acute perforated appendicitis: an analysis of risk factors to guide surgical decision making.

INTRODUCTION: Acute perforated appendicitis is associated with increased post-operative morbidity and mortality. Avoiding delays in surgery in these patients may play a role in reducing observed morbidity. OBJECTIVE: To analyze the clinico-pathological profile and outcomes in a cohort of patients undergoing emergency appendicectomies for suspected acute appendicitis and to determine factors influencing the risk of perforated appendicitis in order to aid better identification of such patients and develop protocols for improved management of this subset of patients. MATERIALS AND METHODS: A retrospective analysis of patients undergoing emergency appendicectomies following presentation with acute appendicitis to the Modbury hospital, South Australia from March 2007 to April 2011 was conducted. Statistical analyses were performed in SAS 9.2. RESULTS AND DISCUSSION: 506 patients underwent emergency appendectomy for acute appendicitis which included equal number of male and female patients with a median age of 25 years. Perforated appendicitis was found in 102 (20%) patients. Post-operative morbidity was significantly higher in patients with perforated appendicitis (28.4% vs 4.7%; P<0.0001). Male sex, patients older than 60 years, along with raised neutrophil counts and C-reactive protein levels were found to be significantly associated with the risk of perforation (P<0.05). CONCLUSIONS: Acute perforated appendicitis is associated with high morbidity. The increased risk of perforation in males and elderly patients appears unrelated to delays in presentation, diagnosis, or surgery. Patients with clinically diagnosed acute appendicitis and an elevation in neutrophil count and CRP level must be considered candidates for early surgery as they are likely to have an appendicular perforation.