Robot-assisted laparoscopic surgery of the infrarenal aorta: The early learning curve

Background Recently introduced robot-assisted laparoscopic surgery (RALS) facilitates endoscopic surgical manipulation and thereby reduces the learning curve for (advanced) laparoscopic surgery. We present our learning curve with RALS for aortobifemoral bypass grafting as a treatment for aortoiliac occlusive disease. Methods Between February 2002 and May 2005, 17 patients were treated in our institution with robot-assisted laparoscopic aorto-bifemoral bypasses. Dissection was performed laparoscopically and the robot was used to make the aortic anastomosis. Operative time, clamping time, and anastomosis time, as well as blood loss and hospital stay, were used as parameters to evaluate the results and to compare the first eight (group 1) and the last nine patients (group2). Results Total median operative, clamping, and anastomosis times were 365 min (range: 225–589 min), 86 min (range: 25–205 min), and 41 min (range: 22–110 min), respectively. Total median blood loss was 1,000 ml (range: 100–5,800 ml). Median hospital stay was 4 days (range: 3–57 days). In this series 16/18 anastomoses were completed with the use of the robotic system. Three patients were converted (two in group 1, one in group 2), and one patient died postoperatively (group 1). Median clamping and anastomosis times were significantly different between groups 1 and 2 (111 min [range: 85–205 min] versus 57.5 min [range: 25–130 min], p < 0.01 and 74 min [range: 40–110 min] versus 36 min [range: 22–69 min], p < 0.01, respectively) Total operative time, blood loss, and hospital stay showed no significant difference between groups 1 and 2. Conclusions Robot-assisted aortic anastomosis was shown to have a steep learning curve with considerable reduction of clamping and anastomosis times. However, due to a longer learning curve for laparoscopic dissection of the abdominal aorta, operation times were not significantly shortened. Even with robotic assistance, laparoscopic aortoiliac surgery remains a complex procedure

Endovascular Stent Treatment for Symptomatic Benign Iliofemoral Venous Occlusive Disease: Long-Term Results 1987–2009

Venous stenting has been shown to effectively treat iliofemoral venous obstruction with good short- and mid-term results. The aim of this study was to investigate long-term clinical outcome and stent patency. Twenty patients were treated with venous stenting for benign disease at our institution between 1987 and 2005. Fifteen of 20 patients (15 female, mean age at time of stent implantation 38 years [range 18–66]) returned for a clinical visit, a plain X-ray of the stent, and a Duplex ultrasound. Four patients were lost to follow-up, and one patient died 277 months after stent placement although a good clinical result was documented 267 months after stent placement. Mean follow-up after stent placement was 167.8 months (13.9 years) (range 71 (6 years) to 267 months [22 years]). No patient needed an additional venous intervention after stent implantation. No significant difference between the circumference of the thigh on the stented side (mean 55.1 cm [range 47.0–70.0]) compared with the contralateral thigh (mean 54.9 cm [range 47.0–70.0]) (p = 0.684) was seen. There was a nonsignificant trend toward higher flow velocities within the stent (mean 30.8 cm/s [range 10.0–48.0]) and the corresponding vein segment on the contralateral side (mean 25.2 cm/s [range 12.0–47.0]) (p = 0.065). Stent integrity was confirmed in 14 of 15 cases. Only one stent showed a fracture, as documented on x-ray, without any impairment of flow. Venous stenting using Wallstents showed excellent long-term clinical outcome and primary patency rate

Squatting test: a dynamic postural manoeuvre to study baroreflex sensitivity.

INTRODUCTION: Squatting is an active posture test that can be used to assess baroreflex sensitivity. Indeed, the shift from squatting to standing imposes a major orthostatic stress leading to rapid and large changes in arterial blood pressure (BP) and heart rate (HR) allowing precise baroreflex assessment. MATERIAL AND METHODS: BP and HR can be continuously and non-invasively monitored with a Finapres device. RESULTS: The standing to squatting transition is accompanied by rises in BP, pulse pressure and cardiac output, mainly due to increased venous return, and by a secondary reduction in HR. Conversely, the squatting to standing transition is associated with an immediate drop in BP and both reflex tachycardia and vasoconstriction. This mirror changes in BP and HR, mimicking those observed with the classical pharmacological approach using vasopressor/vasodilating agents, allows the calculation of the so-called baroreflex gain. DISCUSSION: The present review describes the haemodynamic changes occurring in normal subjects during the shifts from standing to squatting and from squatting to standing and discusses the underlying cardiovascular and autonomic mechanisms. CONCLUSION: This careful analysis in healthy individuals should help in the understanding of disturbances that may be observed in patients with autonomic dysfunction, such as in diabetic patients with cardiovascular autonomic neuropathy