Evaluation of outcomes and utility of abdominal aortic aneurysm surveillance in octogenarians and nonagenarians.

INTRODUCTION: The aim of this study was to evaluate the utility of our regional abdominal aortic aneurysm (AAA) screening programme in octogenarians and nonagenarians. This was to help decide whether discontinuation might be appropriate in certain instances. Primary outcomes were the number of patients who reached threshold (5.5cm) and the number where intervention was offered. Secondary outcome was cost effectiveness. METHODS: A retrospective review of a regional AAA surveillance database was carried out to evaluate outcomes. Data collected included patient age, sex, date of first and last scan, initial and latest size of aneurysm, outcome, time under surveillance and total number of scans. Patients were divided into three groups (80-84 years, 85-89 years and 90+ years). RESULTS: The number of patients in this age group was 354. Only 2.0% (n=7) of patients underwent intervention. Threshold size was achieved in 8.3% (n=18), 14.8% (n=18) and 26.7% (n=4), in the age groups 80-84 years, 85-89 years and 90+ years, respectively. Of these patients, operative intervention was possible in 2.8% (n=6), 0.8% (n=1) and 0% (n=0), respectively. CONCLUSION: A relatively small number of octogenarians and nonagenarians reach the threshold size during surveillance. An even smaller proportion require repair of their aneurysm. While there may be a role for AAA surveillance in octogenarians in highly selected groups, these data should inform the discussions made with individual patients. It should also inform future evaluation of such surveillance.

Phytobezoar: a rare cause of late upper gastrointestinal perforation following gastric bypass surgery.

Marginal ulcers are a well described complication following Roux-en-Y gastric bypass. These may be a cause for perforation. We describe a case of upper gastrointestinal perforation 18 months following a laparoscopic Roux-en-Y gastric bypass that appeared to be caused by a food bezoar. The perforation occurred at the site of the jejunojejunal anastomosis and was repaired after an exploratory laparotomy. After extracting the food debris (phytobezoar) through the perforation, direct closure resulted in an uneventful post-operative recovery. To our knowledge, this is the first description of a food bezoar causing an intestinal perforation in such a manor after bariatric surgery. Patients should be educated carefully on what and how to eat after having undergone surgery for superobesity.

Thiersch repair of a spontaneous rupture of rectal prolapse with evisceration of small bowel through anus - a case report.

Spontaneous rupture of colon or rectum is a rare event. Protrusion of several loops of small bowel through the anal orifice is a bizarre condition which has only rarely been reported in the literature. We report the first case where Thiersch repair was used to manage spontaneous perforation of rectal prolapse and provided a successful outcome.

Effect of oral micronized purified flavonoid fraction treatment on leukocyte adhesion molecule expression in patients with chronic venous disease: a pilot study.

PURPOSE: The purpose of this study was to determine the effects of a micronized purified flavonoid fraction treatment on surface expression of leukocyte adhesion molecules in chronic venous disease (CVD). METHODS: Twenty patients with chronic venous disease were assessed with the use of clinical and Duplex scanning criteria. Consenting patients were treated for 60 days with a micronized purified flavonoid fraction treatment (500 mg twice daily). Blood was collected from a foot vein immediately before the start of treatment and within 1 week after the treatment was stopped. Neutrophil and monocyte surface adhesion molecule expression was determined by flow cytometry using the monoclonal antibodies to CD11b and CD62L. RESULTS: Neutrophil CD11b (248:212), monocyte CD11B (204:190), neutrophil CD62L (130:97 [P =.002]), and monocyte CD62L (170:121 [P =.03]) were determined, respectively, before and after treatment. All values are arbitrary units and represent median values. CONCLUSION: Micronized purified flavonoid fraction treatment for 60 days seems to decrease the surface expression of CD62L by neutrophils and by monocytes. The clinical significance of this finding needs to be explored further. It is feasible to use changes in the levels of these molecules as a marker for response to therapy in chronic venous disease.

Plasma VEGF as a marker of therapy in patients with chronic venous disease treated with oral micronised flavonoid fraction - a pilot study.

AIM: to study the effect on plasma vascular endothelial growth factor (VEGF) levels of oral purified flavonoid fraction treatment for sixty days in patients with chronic venous disease (CVD). MATERIAL AND METHODS: twenty patients <> (clinical stage 2-4) with chronic venous disease were included. Duplex ultrasonography was used to assess the venous disease. Patients were treated for 60 days with Daflon(R) 500 mg twice daily. Blood was collected from a foot vein immediately before starting treatment and within one week of stopping treatment. Plasma VEGF levels were determined using a sandwich ELISA method. RESULTS: VEGF levels decreased in patients with stage C4 CVD after treatment with purified micronised flavonoid fraction treatment (98 pg/ml to 57 pg/ml). The levels of VEGF in patients with skin changes were significantly higher (98 pg/ml) than those with normal skin (9 pg/ml p=<0.001 Wilcoxon). CONCLUSIONS: plasma VEGF levels were much higher in patients who have skin changes of CVD. Plasma VEGF protein decreases in patients with CVD-induced dermatologic changes following treatment with purified micronised flavonoid fraction.

Endothelial activation response to oral micronised flavonoid therapy in patients with chronic venous disease--a prospective study.

BACKGROUND: Endothelial activation is important in the pathogenesis of skin changes due to chronic venous disease (CVD). Purified micronised flavonoid fraction has been used for symptomatic treatment of CVD for a considerable period of time. The exact mode of action of these compounds remains unknown. AIM: To study the effects of micronised purified flavonoidic fraction (Daflon 500 mg, Servier, France) treatment on plasma markers of endothelial activation. MATERIALS AND METHODS: Twenty patients with chronic venous disease were treated for 60 days with DAFLON 500 mg twice daily. Duplex ultrasonography and PPG was used to assess the venous disease. Blood was collected from a foot vein immediately before starting treatment and within 1 week of stopping treatment. Plasma markers of endothelial activation were measured using commercial ELISA kits. RESULTS: Reduction in the level of ICAM-1, 32% (141 ng/ml: 73 ng/ml) and VCAM 29% (1292 ng/ml: 717 ng/ml) was seen. Reduction in plasma lactoferrin (36% decrease, 760 ng/ml: 560 ng/ml) and VW factor occurred in the C4 group only. CONCLUSIONS: Micronised purified flavonoidic fraction treatment for 60 days seems to decrease the levels of some plasma markers of endothelial activation. This could ameliorate the dermatological effects of (CVD). This could also explain some of the pharmacological actions of these compounds. Our study demonstrates the feasibility of using soluble endothelial adhesion molecules as markers for treatment.

Inter-observer variation. An alternative method of assessing the role of ultrasonic imaging in clinical decision-making in lower limb arterial disease.

BACKGROUND: The aim of the study is to determine the role of duplex scanning in deciding on the final treatment for patients with lower limb arterial disease compared to intra-arterial digital subtraction arteriography (IA DSA). METHODS: Eighty-two patients (55 males, 27 females, mean age 68 years) with lower limb arterial disease had both duplex and arteriography performed. The findings of both modalities were reported by sonographer and radiologist in 164 anonymous reports. Five vascular surgeons (consultant grade) were asked to plan their treatment on the data provided in these reports. For the purposes of statistical analysis, the actual treatment the patient received was used as the reference standard. Both reports and treatment decisions were coded (double blinded). RESULTS: The overall accuracy of duplex scanning to assess arterial disease of the lower limbs showed a sensitivity of 92%, and specificity of 99%. The accuracy of the decisions based on duplex was 84% and kappa with k of 0.62 (95% CI+0.14) compared to the reference standard, while the accuracy of the decision based on arteriography was 85% and kappa 0.63 (95% CI+0.14). The accuracy of decisions based on duplex compared to those based on arteriography (arteriography used as reference standard) was 91% and a kappa of 0.77 (95% CI+0.14). CONCLUSIONS: Duplex scanning is an accurate diagnostic modality, and clinical decisions can be safely based on its findings.

Increased plasma vascular endothelial growth factor among patients with chronic venous disease.

Skin damage in the presence of chronic venous disease is partially mediated through leukocytes. The endothelium is activated and exhibits proliferation in the skin. Up-regulation of vascular endothelial growth factor (VEGF) expression in the skin of patients with chronic venous disease has been demonstrated with immunohistologic techniques. Abnormal VEGF expression can have local deleterious effects. The aim of this study was to determine whether patients with chronic venous disease have elevated plasma levels of VEGF. We conducted a prospective study with 30 patients with varicose veins of clinical, etiologic, anatomic, and pathologic class C3 (normal skin, n = 15) and C4 (trophic skin changes, n = 15) and 25 control subjects with no clinical evidence of venous or arterial disease of the lower limb. Blood samples were collected from a foot vein of each subject before and after a period of experimental venous hypertension produced by means of standing. Assay of VEGF protein was performed with a sandwich enzyme-linked immunosorbent assay. Plasma VEGF level was elevated in both groups of patients with venous disease compared with the control group. The median VEGF levels among patients were 81 pg/mL (interquartile range [IQR] 56 to 122) supine and 98 pg/mL (IQR 63 to 153) after standing for 30 minutes. Median VEGF levels among control subjects were 52 pg/mL (IQR 35 to 71) lying supine and 60 pg/mL (IQR 39 to 105) after standing for 30 minutes. Experimental venous hypertension caused a small rise in VEGF levels among the patients but not the control subjects. Further studies are required to determine whether increased VEGF expression contributes to tissue injury in chronic venous disease.