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Debus ES, Torsello G, Behrendt CA, Petersen J, Grundmann RT
Chirurg. 2015 Sep 22.
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.
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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Torsello G, Bisdas T, Debus S, Grundmann RT
Zentralbl Chir. 2015 Feb;140(1):18-26. doi: 10.1055/s-0034-1383241. Epub 2014 Dec 19.
Background: This overview comments on the health-care relevance of peripheral arterial occlusive disease (PAOD) in patients with intermittent claudication (IC) and critical limb ischaemia (CLI). We evaluated different treatment modalities in terms of cost-effectiveness.
Method: For the literature review, the Medline database (PubMed) was searched under the key words "critical limb ischemia AND cost", "critical limb ischemia AND economy", "peripheral arterial disease AND cost", "peripheral arterial disease AND economy".
Results: In the years 2005 to 2009, the hospitalisations of patients with PAOD rose disproportionately in Germany by 20 %, to 483,961 hospital admissions. By comparison, hospital admissions altogether increased by only 8 %. The average in-patient costs were estimated to be approximately € 5000 per PAOD-patient - a rather conservative estimate. For the patient with IC the economic data position is clear, supervised exercise training is by far the most cost-effective treatment option, followed by percutaneous transluminal angioplasty (PTA) and finally the peripheral bypass. In accordance with the guidelines of the UK, the latter is therefore indicated only if PTA fails or is technically not possible. In patients with CLI, the situation is not obvious. Indeed, a short-term economic advantage can be calculated for the PTA, the long-term comparison of both methods, however, is impossible due to insufficient data. In addition, the risk factors for the patient have to be included in the calculation. This was indeed demonstrated in the short-term, but could not be analysed in the long-term follow-up.
Conclusion: The issue of greater cost-effectiveness of open or endovascular treatment in patients with CLI is uncertain, the studies and patient populations are too heterogeneous. Further studies are urgently needed to structure the sequence of the various treatment options in guidelines and clinical pathways.
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Grundmann RT, Meyer F
Zentralbl Chir. 2014 Apr;139(2):184-92. doi: 10.1055/s-0034-1368231. Epub 2014 Apr 28.
Background: This overview comments on gender-specific differences in incidence, risk factors and prognosis in patients with carcinoma of the liver, gallbladder, extrahepatic bile duct and pancreas.
Method: For the literature review, the MEDLINE database (PubMed) was searched under the key words "liver cancer", "gallbladder cancer", "extrahepatic bile duct carcinoma", "pancreatic cancer" AND "gender".
Results: There were significant gender differences in the epidemiology of the analysed carcinomas. The incidence of hepatocellular carcinoma (HCC) is much higher in men than in women, one of 86 men, but only 1 out of 200 women develop a malignant primary liver tumour in Germany in the course of their life. The lifetime risk for carcinomas of the gallbladder and extrahepatic bile ducts in Germany amounts to about 0.6 % for women and 0.5 % for men, specifically gallbladder carcinomas are observed more frequently in women than in men. For pancreatic cancer, no clear gender preference exists in Germany, although the mortality risk for men is higher than that for women (age-adjusted standardised death rate in men 12.8/100, 000 persons, in women 9.5). Remarkable is furthermore the shift of the tumour incidence in the last decades. Liver cancer has increased among men in Germany by about 50 % in the last 30 years, the incidence of gallbladder carcinoma has inversely dropped. The prognosis of these cancers across all tumour stages is uniformly bad in an unselected patient population. This is probably the main reason why only little - if any - gender differences in survival are described.
Conclusion: In addition to avoiding the known risk factors such as hepatitis B and C virus infection, alcohol abuse, and smoking, the avoidance of overweight and obesity plays an increasingly important role in the prevention of these cancers.
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