Debus, E. Sebastian; Grundmann, Reinhart T.

Springer-Verlag Berlin Heidelberg, 1. Aufl. 2015, ISBN 978-3-662-47166-1

Aus dem Vorwort: Thema dieses Buches ist die evidenzbasierte operative und endovaskuläre Gefäßchirurgie / Gefäßmedizin. Dabei werden alle häufigen arteriellen Gefäßerkrankungen abgehandelt, von der Karotisstenose über thorakale und abdominelle Aortenaneurysmen bis zur peripheren arteriellen Verschlusskrankheit und dem diabetischen Fuß. Hinzu kommt die speziell für den ambulanten Bereich so wichtige Behandlung der Varikosis. Das Buch will kein weiteres Lehrbuch sein und wie so viele andere operative Techniken beschreiben, sondern es will den Leser zu der Frage beraten, welches operative oder endovaskuläre Vorgehen zurzeit das am besten begründete ist. Dies beginnt bei den Empfehlungen der Leitlinien, die nicht unbedingt in allen Ländern identisch sind und in vielen Fällen auch nicht eine S3-Qualität besitzen. Aufgabe war es folglich, die nach Ansicht der Autoren von ihrem Umfang und ihrer Aktualität her wichtigsten Leitlinien herauszusuchen und deren Kernaussagen übersichtlich zusammenzustellen. Es wurde überprüft, inwieweit die Aussagen internationaler Leitlinien identisch sind und wo sie eventuell voneinander abweichen.

Damit kommen wir zu dem zweiten Schwerpunkt dieses Buches, den Behandlungsergebnissen, die ja die Basis für einen evidenzbasierten Therapieentscheid darstellen. Diese werden nach ihrer Wertigkeit klar gegliedert besprochen: Alle wichtigen Metaanalysen und Cochrane Reviews werden dargestellt und die aktuellen Ergebnisse randomisierter Studien erläutert. Nicht in allen Fällen lassen sich die Ergebnisse randomisierter Studien mit ihren zahlreichen Ein- und Ausschlusskriterien im klinischen Alltag reproduzieren. Große Registererhebungen, wie z. B die Nationwide Inpatient Sample (NIS) der USA, die Medicare-Datenbank, das National Surgical Quality Improvement Program (NSQIP) oder Swedvasc und Vascunet, sind deshalb für eine Darstellung der Ergebnisrealität unverzichtbar. Auch hier wurden alle aktuellen Berichte systematisch berücksichtigt.

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Debus ES, Torsello G, Behrendt CA, Petersen J, Grundmann RT

Chirurg. 2015 Sep 22.

Abstract

Objective: This study determined whether the routine data of a single health insurance company (DAK health) can allow equivalent statements on hospital mortality of endovascular (EVAR) and open (OR) repair of intact (iAAA) and ruptured (rAAA) aortic aneurysms (AAA) in Germany in comparison to clinical registry surveys of the German Vascular Society (GVS).

Methods: The study compared two cohorts that were comparable in group sizes but not identical in terms of the duration of treatment and the selection of the centers. The GVS registry included 5080 patients with iAAA and 485 with rAAA and the DAK data consisted of 5182 patients with iAAA and 576 with rAAA. In GVS (in brackets DAK) 72.6 % (71.0 %) of patients with iAAA received EVAR and 27.4 % (29 %) OR, with rAAA 34.6 % (26.9 %) of patients received EVAR and 65.4 % (73.1 %) OR. Both cohorts were comparable with respect to patient age and gender distribution.

Results: Intact AAA: the hospital mortality rate in GVS (DAK in brackets) was 0.95 % (1.4 %) with EVAR and 4.7 % (5.5 %) with OR. For patients less than 80 years old the statements were almost identical when the hospital mortality in the GVS and DAK registers constituted 0.85 % and 0.9 % after EVAR and 3.8 % and 4.0 % after OR, respectively. Patients over 80 years old in particular had a benefit by EVAR as the hospital mortality in GVS (DAK in brackets) was 1.3 % (2.6 %) with EVAR vs. 13.9 % (17.4 %) with OR. A benefit by EVAR was also seen in women. Ruptured AAA: the hospital mortality rate in GVS (DAK in brackets) was 19.6 % (27.1 %) with EVAR and 38.5 % (42.0 %) with OR. Again, particularly patients over 80 years old showed an advantage with EVAR where the hospital mortality was 31.0 % (34.3 %) with EVAR vs. 56.7 % (61.3 %) with OR in this group.

Conclusion: Hospital mortality is an important quality parameter of endovascular and open repair of iAAA and rAAA. Administrative data of a health insurance company can be used to provide representative and comprehensive statements on inhospital mortality.

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Torsello G, Debus S, Meyer F, Grundmann RT

Zentralbl Chir. 2015 Apr;140(2):219-27. doi: 10.1055/s-0035-1545683. Epub 2015 Apr 14.

Abstract

Background: This overview comments on clinical trials and meta-analyses from the literature on the treatment of diabetic feet.

Methods: For the literature review, the MEDLINE database (PUBMED) was searched under the key words "diabetic foot". Publications of the last three years (2012 to 2014) were extracted.

Results: For patients with diabetic feet, both endovascular (ER) and open (OR) revascularisation techniques are possible. There are not sufficient data to demonstrate whether open bypass surgery or endovascular interventions are more effective in these patients. However, registries show that ER has now in terms of quantity become the preferred method. Angiosome-targeted revascularisation has to be considered in these situations. For the local treatment of a diabetic foot ulcer a variety of dressings are available, the evidence for their recommendation is low. Dressing cost and the wound management properties, e.g. exudate management therefore can influence the choice of dressing. There is no evidence that more expensive dressings as compared to basic dressings offer advantages in terms of healing. In plantar diabetic foot ulcers, non-removable off-loading devices regardless of type are more likely to result in ulcer healing than removable off-loading devices, presumably, because patient compliance with off-loading is facilitated. Meaningful pressure-relieving interventions for treating diabetic foot ulcers also include Achilles tendon lengthening, a plantar fascia release and percutaneous flexor tenotomy. The value of a standardised treatment protocol carried out by a specialist team could be proven in large registries based on decreasing amputation rates.

Conclusion: This survey reveals a significant disparity between the large number of treatment recommendations and their evidence. For the future, therefore it is imperative to implement nationwide register surveys with respect to treatment and outcome of these patients.

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