Parathyroidectomy in a district general hospital: outcomes and evolution in the era of minimally invasive surgery.

AIM: To determine the outcomes of bilateral neck exploration (BNE) and uptake as well as outcomes of minimally invasive parathyroidectomy (MIP) for primary hyperparathyroidism in a district general hospital (DGH). METHODS: Patients who underwent first-time parathyroidectomy for primary hyperparathyroidism between August 1999 and December 2010 were identified from a prospectively maintained database of a single surgeon and were analysed for outcomes of MIP and BNE. MIP was adopted in 2006 and prior to that all patients underwent BNE. Results were analysed on an intention-to-treat basis. RESULTS: A total of 368 patients underwent parathyroid surgery; BNE (n = 314) and MIP (n = 54). Overall cure rate was 97%. Intention-to-treat analysis, based on surgical approach, showed cure rates of 96.5% with BNE and 96.3% with MIP (p = 1.0). Of the 92 patients assessed for MIP, localisation by ultrasound and sestamibi were noted in 60 (65%) and 65 (71%) patients respectively; however, concordance between the scans was noted in only 54 (59%) patients. Of the 54 patients who underwent MIP, 5 (9.2%) were converted to BNE. Intention-to-treat analysis, based on preoperative imaging, showed cure rates of 96% with BNE and 98% with MIP (p = 0.53). CONCLUSIONS: Satisfactory cure rates for parathyroidectomy are achievable in a 'medium-volume' endocrine unit within a DGH. Preoperative localisation studies with USS and MIBI have a positive concordance rate in only 60% of those considered for MIP, thereby limiting the use of MIP and reinforcing the role of BNE in this era of minimally invasive surgery.

Bifurcated abdominal aortic endograft deployment via the carotid artery.

BACKGROUND: We report the use of the common carotid artery as an alternate access in endovascular therapy. METHODS/RESULTS: A 77-year-old man with an enlarging abdominal aortic aneurysm in whom previous attempts at standard endovascular repair had failed because of difficult iliac access underwent endovascular repair via the left common carotid artery. A custom-made Zenith infrarenal bifurcated stent graft was reverse-loaded on a thoracic distal delivery device and deployed in a caudal-to-cranial fashion. The patient made an uneventful recovery without any complications. Computed tomography confirmed exclusion of the aneurysm. CONCLUSION: This case report highlights the role of the common carotid artery as an access vessel for stent-graft deployment when standard access via the femoral and iliac routes is unachievable.

A systematic review of open versus endovascular repair of inflammatory abdominal aortic aneurysms.

INTRODUCTION: Inflammatory abdominal aortic aneurysms (IAAAs) have traditionally been treated by open surgical repair (OSR). Over the last decade, endovascular aneurysm repair (EVAR) has been increasingly employed. The optimal treatment option for IAAA remains unclear. This article aims to evaluate and compare outcomes of OSR and EVAR in IAAA repair. METHODS: All publications in the English language relating to IAAA were sought electronically using OVID and MEDLINE (1972-2008). Studies identifying 30-day mortality were considered. Periaortic inflammation (PAI), hydronephrosis and 1-year mortality were obtained from studies with at least 1-year computed tomography (CT) follow-up. Outcomes of OSR and EVAR were compared and analysed for statistical significance using Fisher's exact test. RESULTS: The results were obtained from 35 studies comprising 999 patients and 21 studies with 121 patients who underwent OSR and EVAR, respectively. One-year CT follow-up was available for 124 and 52 patients from the two groups, respectively. Thirty-day mortality after OSR was 6% (95% confidence interval (CI); 6-13) and 2% (95% CI; 0-7) after EVAR (p=0.1). At 1 year, PAI regressed in 73% (95% CI; 64-80) in the OSR group compared to 65% (95% CI; 49-77) of the EVAR group (p=0.7). Conversely, inflammation progressed in 1% and 4%, respectively (p=0.1). Forty-five patients undergoing OSR and 29 EVAR were found to have preoperative hydronephrosis. This regressed postoperatively in 69% (95% CI; 53.3-81.8) and 38% (95% CI; 20.6-57.7), respectively (p=0.01). Hydronephrosis progressed in 9% of patients after OSR and in 21% after EVAR (p=0.1). New-onset hydronephrosis developed in 6% undergoing OSR compared to 2% with EVAR (p=0.2). One-year all-cause mortality after OSR was 14% (95% CI; 6-18) compared to 2% (95% CI; 0-13) after EVAR (p=0.02). CONCLUSION: Either OSR or EVAR may be considered based on patient suitability. EVAR is associated with lower 1-year mortality compared to OSR. However, OSR may be preferred in those patients who have hydronephrosis and are deemed low risk.

Beta blockers for peripheral arterial disease.

OBJECTIVES: To quantify the potential harm of beta blockers in patients with peripheral arterial disease. MATERIALS AND METHODS: All randomised controlled trials (RCTs) comparing beta blockers with placebo for the outcomes of claudication and maximal walking distance and time, calf blood flow, vascular resistance and skin temperature were searched using the Cochrane Controlled Trials Register, PubMed and CINAHL. Trials comparing different types of beta blockers were excluded. RESULTS: Six RCTs fulfilling the above criteria, with a total of 119 patients, were included. The beta blockers studied were atenolol, propranolol, pindolol and metoprolol. None of the trials showed a statistically significant worsening effect of beta blockers on the outcomes measured. There were no reports of any adverse events with the beta blockers studied. CONCLUSIONS: Currently, there is no evidence to suggest that beta blockers adversely affect walking distance in people with intermittent claudication. Beta blockers should be used with caution if clinically indicated, especially in patients with critical ischaemia where acute lowering of blood pressure is contraindicated.

Contemporary management of aorto-iliac aneurysms in the endovascular era.

Up to 40% of abdominal aortic aneurysms have co-existing unilateral or bilateral iliac artery ectasia or aneurysm. These are associated with an increased risk of endoleak, morbidity and mortality following endoluminal repair. To reduce the adverse sequelae of internal iliac artery (IIA) occlusion, various open, endovascular and hybrid measures have been described to maintain perfusion to the pelvis. This review discusses the contemporary management of aorto-iliac aneurysm in the endovascular era with reference to the sequelae of IIA occlusion and the strategies to preserve IIA perfusion. Particular consideration is given to iliac bifurcation devices.

Optimising the timing of carotid surgery using a carotid risk scoring system.

OBJECTIVES: Transient ischaemic attacks (TIA's) have 4-20% risk of evolving into a major stroke within 90 days, with half of them occurring in the first 2 days. The Department of Health, UK, guidelines (2007) suggests all higher-risk patients with TIA and minor stroke need to be assessed by a specialist and treated within 24 hours. However, the reality in the health system is that the delay between the last cerebrovascular event (CVE) and surgery is often in excess of 90 days. Recently validated ABCD(2) scoring stratifies the risk of stroke after CVE and can help in prioritizing patients for investigations and urgent carotid endarterectomy (CEA). The aim of this pilot study was to stratify patients who underwent CEA, post cerebrovascular event, using the ABCD(2) scoring method. This would help us assess our current CEA practice and, in future, prioritise surgery according to estimated stroke risk. DESIGN & METHODS: Retrospective analysis of ABCD(2) scoring of patients who underwent CEA. RESULTS: The average delay between first presentation and carotid endarterectomy was 172.8 days (range 3 to 837 days). This average delay for the low, moderate and high risk groups was 200.8, 154.1 and 156.5 days, respectively. CONCLUSION: The ABCD(2) scoring is an easily applicable method to stratify patients post CVE at risk of further stroke. Our results suggest that to maximize the benefit of CEA within a limited resource health system, patients with a high ABCD(2) score should be given the highest priority for investigations followed by CEA.