Patient satisfaction after carotid endarterectomy using a selective policy of local anesthesia.

BACKGROUND: Patient satisfaction after carotid endarterectomy has not been specifically studied or reported. Results of carotid endarterectomy using either local or general anesthesia have been widely reported, and outcomes are not significantly different for either technique. Patient satisfaction data were obtained in order to determine whether patients preferred one method of anesthesia over another. Data regarding outcome may be added to the surgical literature as benchmark data when comparing operative carotid endarterectomy to newer techniques. METHODS: During a 30-month period, 186 consecutive carotid endarterectomies were performed on 169 patients by a single surgeon with assistance from senior surgical residents. All patients were offered local anesthesia using a cervical block technique with intraoperative supplementation. Patients for whom local anesthesia was inappropriate or who declined were operated on using general endotracheal anesthesia. Results of operation were tabulated including indication for operation, method of anesthesia, intraoperative and postoperative complications, and mortality, and completion of a patient satisfaction survey form either on postoperative visit or by telephone questionnaire. RESULTS: Of 169 patients who underwent carotid endarterectomy, 151 (89%) completed the satisfaction survey form. One hundred fourteen (62%) had local anesthesia and 71 patients (38%) had general anesthesia. There was 1 stroke (0.5%) and 1 death (0.5%) in the series. Perioperative complications including temporary cranial nerve injury, neck hematoma, myocardial infarction, and restenosis were noted and not significantly different in either the general anesthesia or local anesthesia group. Patient satisfaction data including intraoperative discomfort, postoperative pain, attentiveness of the operating room staff, and length of stay were all tabulated. There was no statistically significant difference in satisfaction between the general anesthesia group and the local anesthesia group (chi-square and Fisher's exact test). Additionally, satisfaction with the procedure was extremely high. CONCLUSIONS: Patient outcome and perception of pain and recovery were not statistically significantly different in patients undergoing carotid endarterectomy using local anesthesia compared with general anesthesia. Overall patient satisfaction was extremely high. Patients should be offered carotid endarterectomy using an anesthesia technique with which the surgeon and patients are both comfortable, having confidence that the outcome is not related to anesthesia technique and that patients will be highly satisfied.

Isolated hypogastric artery aneurysms.

Iliac artery aneurysms are rare in the absence of concomitant abdominal aortic aneurysm (AAA), and isolated internal iliac (hypogastric) aneurysms in particular are extremely rare. From 1986 to 1997 we repaired 572 aortic and/or iliac artery aneurysms in 440 patients. Among these there were only seven hypogastric aneurysms and three of these occurred in the absence of, or remote to, AAA. Hypogastric aneurysms are difficult to diagnose, and large aneurysms are associated with significant morbidity and mortality due to compression of adjacent structures and a high rate of rupture. They pose technical challenges in repair because of their location deep in the pelvis and because it is difficult to gain distal control of the hypogastric artery and its branches. However, the technique of obliterative endoaneurysmorrhaphy has made repair of these aneurysms safe and straightforward. Moreover, this method, unlike percutaneous endovascular techniques, eliminates the compressive mass that is often associated with significant symptomatology. We report three isolated hypogastric aneurysms repaired over an 11-year period, illustrating the technique of proximal ligation and obliterative endoaneurysmorrhaphy, and review the literature on the topic.

The shift toward a managed care environment in a multispecialty group practice model. Looking for reciprocal benefits.

Managed care is notably affecting the practice of surgery in the United States. Four principal elements are subject to change: (1) patient care patterns, (2) ethics, (3) education and research, and (4) surgeon compensation. The Virginia Mason Clinic, a multispecialty group practice, is adapting to the demands of managed and capitated care. With the patient as the primary focus of effort, the goal is to create optimum value in health care. The principles of Continuous Quality Improvement are used to increase value in health care by ensuring appropriate treatment with optimum outcome at reasonable cost. Practice patterns are shifting to provide value to patients and payers. Ethical conflicts threaten but have been avoided. Surgical education remains unaffected, but future funding is problematic. The emphasis in surgical research has shifted toward outcome-based studies. The conflict between work effort and resource conservation as determinants of physician compensation is less for surgical than for medical practitioners. Although the principal benefactors of the shift toward managed care have been the payers, patients have gained modestly through efficiencies in the health care process and more stable insurance premiums. The satisfaction level of the surgeons in our multispecialty group practice remains high. Surgical research is thriving, volumes and case mix remain excellent, and changes in practice pattern have enabled us to increase efficiency without compromising patient care.

Revascularization for chronic mesenteric ischemia: comparison of operative arterial bypass grafting and percutaneous transluminal angioplasty.

PURPOSE: To compare the relative safety and efficacy of the two primary techniques for treatment of chronic mesenteric ischemia (CMI): operative bypass grafting (OBG) and percutaneous transluminal angioplasty (PTA). PATIENTS AND METHODS: Retrospective analysis of hospital charts and angiograms, and supplemental telephone follow-up were performed for 17 patients treated for CMI between January 1985 and September 1993. Nine patients underwent OBG; eight patients underwent PTA (one patient underwent two PTA procedures). RESULTS: Technical success was 100% for OBG versus 30% according to angiographic criteria for PTA (although 80% had improved luminal diameter). Procedure-related mortality was 11% (one of nine patients) for OBG and 13% (one of eight) for PTA. The nonfatal major complication rate was 33% (three of nine) for OBG and 25% (two of eight) for PTA. Initial pain relief occurred in seven of nine (78%) successful OBGs and all of seven (100%) PTA procedures with lumen improvement. Long-term pain relief among OBG survivors was complete in seven of eight (88%) and four of six (67%) of PTA survivors with CMI (mean follow up, 34.5 and 9.2 months, respectively). CONCLUSIONS: Due to the greater durability of results, OBG is indicated in patients with low operative risk and classic symptoms and angiographic findings of CMI ischemia. PTA is best reserved for patients with prohibitive operative risks, classic symptoms, and atherosclerotic stenoses.

Lethal nature of ischemic gastropathy.

Gastropathy on the basis of mesenteric arterial ischemia can be masked in presentation as the typically more benign entities of gastritis, gastric ulceration, or gastric atony. Gastritis and ulceration are commonly associated with stress, hyperacidity, Helicobacter pylori infection, or medication injury. Gastric atony is less commonly seen and usually attributable to diabetes mellitus, vagotomy, or mechanical gastric outlet obstruction. Gastric ischemia as a cause of gastropathy is an underappreciated phenomenon with a particularly poor prognosis in which early diagnosis is essential to potentially successful intervention. Seven patients with ischemic gastropathy are described; all are women, aged 41 to 71 years, smokers, with hypertension. Nausea, vomiting, weight loss, and gastrointestinal bleeding were the common presenting symptoms. All patients had endoscopic or autopsy-proven gastric ulcerations or necrosis, and two patients had proven gastroparesis. Four of five patients with ischemic gastritis died within 3 months of diagnosis despite vascular reconstruction. The two patients with gastroparesis underwent aorto-celiac bypass and are well 9 and 20 months, respectively, after operation. Treatment results were distressingly unsatisfactory, especially in those patients in whom gastritis rather than gastroparesis was the presenting problem. Although the high mortality of mesenteric ischemia is well described, little documentation of gastric ischemia exists in the literature. This entity is generally not considered in the differential diagnosis of gastritis, ulceration, or gastroparesis. Empirically, an early diagnosis and treatment may improve the survival in this select patient group.

Extra-anatomic bypass: a new look (opposing view).

The criteria by which revascularizations are measured ultimately is patency, since cessation of blood flow equates with a failed graft and usually signals a return to the preoperative limb perfusion or less. An uncommonly analyzed criterion for graft function is blood flow capacity through the reconstruction which is critically important when increased blood flow demands are required with exercise. This is particularly true in the aortoiliac segment when the bypass must meet large blood flow requirements. When the extra-anatomic bypass is evaluated in this manner, it is often inadequate to meet the blood flow demands required with activity. The source of blood flow is the subclavian artery and not the aorta. The graft diameter is almost one half that used to bypass or substitute for the aorta and four times as long. It is not surprising, therefore, that increases in blood flow are limited in this remote subcutaneous bypass circuit. The axillofemoral and, to some extent, the femorfemoral bypass grafts produce hemodynamic gradients to blood flow increases above basal rates. Thus, graft patency alone does not realistically measure the functional capacity of an aortoiliac reconstruction. The conceptual design of an extra-anatomic bypass results in hemodynamic liabilities that produce an inferior performance to that observed with in-line direct aortofemoral bypass. This observation further supports our contention that extra-anatomic bypass of the aortoiliac segment should be restricted to circumvent a prosthetic graft infection in the aortoiliac segment to maintain limb perfusion following graft removal. Whether it has a role in selected patients with a short life span and critical ischemia who appear to be a prohibited risk for in-line aortofemoral reconstruction will always be debatable. Current experience does not justify expanded indications for extra-anatomic bypass in symptomatic patients with aortoiliac disease. The proven effective and durable intervention is aortofemoral revascularization.

Current management and clinical outcome of hemangiopericytomas.

Hemangiopericytoma is a rare vascular tumor with variable malignant potential. We report perioperative embolization of a hemangiopericytoma and review the Virginia Mason Clinic experience with six patients during the period 1975 to 1990 with respect to demographics, diagnosis, treatment, and outcome. Our experience suggests that hemangiopericytomas have a variable but predictable malignant potential based on histology and clinical behavior. Three of six patients died of their disease. The remainder were alive and well at 1, 3.5, and 12 postoperative years. These tumors can be specifically and completely delineated preoperatively using magnetic resonance imaging and angiography, the diagnostic procedures of choice. Hemangiopericytomas are highly vascular and amenable to preoperative transarterial embolization. Our most recent case was performed without blood transfusion. This differs from literature reports of massive transfusion requirements and two cases of exsanguination following resection. Finally, recent literature has reported these tumors to respond to greater than 4,500 cGy of local postoperative radiotherapy. We conclude that this interval review of hemangiopericytomas is both timely and relevant with respect to recent developments in imaging and catheter technology. We recommend routine angiography and perioperative embolization prior to wide excision and postoperative radiotherapy.

Arteriovenous fistulas following lumbar laminectomy: the anatomy defined.

Iatrogenic arteriovenous fistulas between the aorta or its major branches and the vena cava or its tributaries resulting from lumbar disc operations are uncommon but serious problems for the vascular surgeon. Using three cases from our experience and adding illustrations, x-ray films, and descriptive text we have precisely defined the anatomy of the major vessels at the L3-4, L4-5, and L5-S1 disc interspaces. This information will not only aid the surgeon in the repair of the chronic fistula but will help the surgeon who is called urgently to the operating room for bleeding and shock when preoperative angiography is not possible.

In-continuity gastrointestinal stapling.

Several surgical procedures have been proposed to interrupt continuity of the gut, without transection, by means of a row of staples. Using the dog, we investigated the functional and histologic results of incontinuity stapling of the gastric antrum, the small intestine, and the colon. After creation of an end antrostomy, ileostomy, or colostomy, a staple line was placed proximal to the stoma (TA 55-4.8 mm staples). Decompression of the bowel proximal to the staple line was accomplished by an enteric anastomosis. Separation of the staple closure was detected by intestinal contents exiting from the stoma. Animals were sacrificed at the time of disruption, and specimens were obtained for histologic examination. Three of five antral closures broke down at a mean of 19.6 days after operation. All five small-bowel staple lines opened at a mean of 12.4 days. Five of five colonic staple lines disrupted 13.0 days postoperatively. The staples pulled through the bowel wall without losing their "B" shaped configuration. Microscopic examination showed intact mucosa across the staple line, with no submucosa to submucosa healing. Staple lines in the undivided small bowel or colon disrupt after approximately two weeks, due to lack of fibrotic healing. Staple interruptions of the gastric antrum also disrupt, but with less regularity.