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Background: Thoracoscopic sympathicotomy is highly effective in treating disabling palmar hyperhidrosis. The ideal level to maximize efficacy and minimize the side effect of compensatory hyperhidrosis (CH) is controversial. This study compared sympathicotomy over the second (R2) vs third (R3) costal head relative to these variables in patients with massive palmar hyperhidrosis. Methods: This prospective, randomized study enrolled 121 patients with disabling palmoplantar hyperhidrosis assigned to bilateral sympathicotomy (sympathetic transection), which was done over R2 in 61 (n = 122 extremities) or R3 in 60 (n = 120 extremities). Patients were questioned at 6 months and at 1 year or more to assess efficacy, side effects, and satisfaction with the procedure. Results: Sympathicotomy at R2 failed to cure palmar hyperhidrosis in 5 of 122 (4.1%) extremities, but only 2 (1.6%) were to a truly profound dripping level of recurrence. Sympathicotomy at R3 failed to cure palmar hyperhidrosis in 5 of 120 extremities (4.2%), and all were dramatic failures with dripping recurrent sweating. The patients whose palmar hyperhidrosis was not completely cured were aged 19.7 ± 2.5 vs 26.4 ± 8.0 years ( p = 0.04). Two R3 patients with failure underwent three redo R2 sympathicotomies, with curative results. R2 patients showed a trend toward a higher level of CH vs R3 patients at 6 months and after 1 year. The CH severity scale was 4.7 ± 2.7 (n = 38) for R2 vs 3.8 ± 2.8 (n = 36) for R3 ( p = NS) at 6 months and 4.7 ± 2.5 (n = 43) for R2 vs 3.7 ± 2.8 (n = 37) for R3 ( p = NS) after 1 year. Younger age, male sex, and higher levels of preoperative and postoperative plantar sweating were predictors of failed sympathicotomy. Increased age was associated with increased CH. Conclusions: R2 and R3 sympathicotomy for massive palmoplantar hyperhidrosis are highly effective, with low recurrence and incidences of severe CH. R2 tends to have a higher level of CH vs R3, and a higher incidence of dramatic failures is suggested in R3 patients, for which reoperation at the R2 level will likely be curative. [Copyright &y& Elsevier]

We have empirically observed that patients with abdominal aortic aneurysms (AAAs) seem to have an increased incidence of renal cysts on computed tomography (CT). In order to evaluate this possible association, a retrospective cohort study was conducted comparing the incidence of renal cysts on CT scan in 100 patients with AAA to 100 patients without AAA (matched by age and gender). Univariate analysis and multiple logistic regression were performed to evaluate the association of AAAs and other risk factors with the presence of renal cysts. Of patients with AAAs, 54% had renal cysts compared to only 30% in the control group ( p = 0.0006, relative risk = 2.73). The AAA group had a higher incidence of chronic obstructive pulmonary disease (COPD, 14% vs. 1%), hypertension (76.6% vs. 46.5%), coronary artery disease (38.3% vs. 12%), and hypercholesterolemia (41.5% vs. 9.1%) compared to the non-AAA group. There was a significant linear correlation between renal cysts and COPD ( p = 0.011), the presence of AAA ( p = 0.0005), and age ( p = 0.019), whereas hypercholesterolemia ( p = 0.059) and diabetes ( p = 0.063) approached significance. On multivariate analysis, there were three independent predictors of renal cysts: COPD ( p = 0.051), age ( p = 0.01), and AAA ( p = 0.028). In conclusion, there is a significantly higher incidence of renal cysts in patients with AAA compared to patients without AAA. To our knowledge, this association has not previously been reported. Future studies are needed to determine whether this correlation is the result of a commonality in the pathogenesis of AAA and renal cysts. [ABSTRACT FROM AUTHOR]

Objectives: To analyze the results of endograft exclusion of acute and chronic descending thoracic aortic dissections (Stanford type B) with the AneuRx (n = 5) and Talent (n = 37) thoracic devices and to compare postoperative outcomes of endograft placement acutely (<2 weeks) and for chronic interventions. Methods: Patients treated for acute or chronic thoracic aortic dissections (Stanford type B) with endografts were included in this study. All patients (n = 42) were enrolled in investigational device exemption protocols from August 1999 to March 2005. Three-dimensional computed tomography reconstructions were analyzed for quantitative volume regression of the false lumen and changes in the true lumen over time (complete >95%, partial >30%). Results: Forty-two patients, all of whom had American Society of Anesthesiologists (ASA) risk stratification ≥III and 71% with ASA ≥ IV, were treated for Stanford type B dissections (acute = 25, chronic = 17), with 42 primary and 18 secondary procedures. All proximal entry sites were identified intraoperatively by intravascular ultrasound (IVUS). The procedural stroke rate was 6.7% (4/60), with three posterior circulation strokes. Procedural mortality was 6.7% (4/60). The left subclavian artery was occluded in 11 patients (26%) with no complaints of arm ischemia, but there was an association with posterior circulation strokes (2/11) (18%). No postoperative paraplegia was observed after primary or secondary intervention. Complete thrombosis of the false lumen at the level of endograft coverage occurred in 25 (61%) of 41 patients ≤1 month and 15 (88%) of 17 patients at 12 months. Volume regression of the false lumen was 66.4% (acute) and 91.9% (chronic) at 6 months. Lack of true lumen volume (contrast) increase and increasing false lumen volume (contrast) suggests continued false lumen pressurization and the need for secondary reintervention. Thirteen patients (31%) required 18 secondary interventions for proximal endoleaks in 6, junctional leaks in 3, continued perfusion of the false lumen from distal re-entry sites in 3, and surgical conversion in 4 for retrograde dissection. Conclusions: Preliminary experience with endografts to treat acute and chronic dissections is associated with a reduced risk of paraplegia and lower mortality compared with open surgical treatment, the results of medical treatment alone, or a combination. [Copyright &y& Elsevier]

Evidence-based medicine suggests that in the management of chronic anal fissure (CAF), lateral internal sphincterotomy (LIS) is far more effective than medical treatment in lowering the anal sphincter tone and curing the fissure. In the current study, we developed a treatment algorithm from topical nitroglycerin (NTG) to botulinum toxin type A (Botox [BTX]) to LIS and analyzed its cost benefit by calculating the effective and potential costs based on the treatment success and the rate of avoided surgeries. Patients presenting between November 2003 and December 2004 with CAF and symptoms for greater than 3 months were prospectively treated according to a treatment algorithm which started with (1) topical NTG, in case of failure (2) injection of BTX, thus limiting (3) surgery to those who failed both nonsurgical options or at any point chose the surgical approach. Based on the primary end points of fissure healing or surgery, we calculated the true cost (algorithm) and the potential incremental cost (BTX plus surgery or surgery in all patients, respectively). Sixty-seven patients with CAF (25 men and 42 women; median duration of symptoms, 16 weeks) were treated according to the algorithm. NTG alone was successful in fissure healing in 31 of 67 patients (46.2%). Two developed a recurrent fissure and then received BTX as part of the protocol. Of the 36 patients who failed NTG trial, 3 requested surgery; the others were treated with BTX, which was successful in 84.8%. Five patients (15.2%) failed BTX and subsequently required surgery. The overall surgery rate in the whole study group was 11.9%, whereas CAF healed in 88.1% of our patients with medical treatment alone. Cost for NTG is $10; for 100 units BTX, $528; and for outpatient surgery, $1119. The total cost for these 67 patients therefore was $33,252 ($290 for NTG, $20,580 for NTG plus BTX, $3,357 for NTG plus LIS, and $9,025 for NTG plus BTX plus LIS). If all patients had received BTX with a 15% failure rate, the total cost would have been $56,688 (70.3% cost increase). If all patients had undergone surgery as initial/only treatment, the total cost would have been $74,973 (125% cost increase). Our treatment algorithm for CAF with stepwise escalation can avoid surgery in 88% of the patients. It is highly cost-efficient and resulted in savings of 41% (compared with BTX plus LIS) and up to 70% (compared with surgery in all patients), respectively. [ABSTRACT FROM AUTHOR]

Background: Recent studies suggest that preoperative cardiac stress testing is unnecessary in low to intermediate cardiac risk patients undergoing operations, and that targeted beta blockade is cardiac protective. Study Design: A cohort study of patients undergoing vascular surgery or major amputation, with low to intermediate cardiac risk, but without cardiac stress testing, was performed. Targeted beta blockade was initiated preoperatively. The primary end point was a composite of adverse cardiac outcomes. A comparison was made with historical controls who received selective stress testing and selective nontargeted beta blockade. Results: One hundred consecutive patients were prospectively enrolled, and 80 retrospective controls were identified. There were no differences between groups with respect to median revised cardiac index (RCI; 0 versus 1). In the retrospective group, 14% underwent preoperative cardiac stress testing versus none in the prospective group (p=0.0002). Nontargeted beta blockade was given in 61% of the retrospective group. The median heart rate for the prospective group was significantly lower (66 versus 77 beats/minute; p=0.0007). The composite cardiac complication rate was 2% in the prospective group versus 10% in the retrospective group (p=0.02). There were no deaths. On multivariate analysis, after adjusting for revised cardiac index score, there was a lower cardiac complication rate in the prospective group (odds ratio, 2.46; 95% CI, 1.3 to 4.5; p=0.003). Conclusions: In patients undergoing vascular surgery or major amputation, with low to intermediate cardiac risk, preoperative targeted beta blockade alone is more effective than selective cardiac stress testing and nontargeted beta blockade in preventing cardiac morbidity. [Copyright &y& Elsevier]