Splanchnic Artery Stenosis and Abdominal Complaints: Clinical History Is of Limited Value in Detection of Gastrointestinal Ischemia

BACKGROUND: Splanchnic artery stenosis is common and mostly asymptomatic and may lead to gastrointestinal ischemia (chronic splanchnic syndrome, CSS). This study was designed to assess risk factors for CSS in the medical history of patients with splanchnic artery stenosis and whether these risk factors can be used to identify patients with high and low risk of CSS. METHODS: All patients referred for suspected CSS underwent a standardized workup, including a medical history with questionnaire, duplex ultrasound, gastrointestinal tonometry, and angiography. Definitive diagnosis and treatment advice was made in a multidisciplinary team. Patients with confirmed CSS were compared with no-CSS patients. RESULTS: A total of 270 patients (102 M, 168 F; mean age, 53 years) with splanchnic artery stenosis were analyzed, of whom 109 (40%) had CSS and 161 no CSS. CSS-patients more often reported postprandial pain (87% vs. 72%, p = 0.007), weight loss (85% vs. 70%, p = 0.006), adapted eating pattern (90% vs. 79%, p = 0.005) and diarrhea (35% vs. 22%, p = 0.023). If none of these risk factors were present, the probability of CSS was 13%; if all were present, the probability was 60%. Adapted eating pattern (odds ratio (OR) 3.1; 95% confidence interval (CI) 1.08-8.88) and diarrhea (OR 2.6; 95% CI 1.31-5.3) were statistically significant in multivariate analysis. CONCLUSIONS: In patients with splanchnic artery stenosis, the clinical history is of limited value for detection of CSS. A diagnostic test to detect ischemia is indispensable for proper selection of patients with splanchnic artery stenosis who might benefit from treatment

Abdominal angina due to recurrence of cancer of the papilla of Vater: a case report

Abdominal angina is usually caused by atherosclerotic disease, and other causes are considered uncommon. This is the first report of a case of abdominal angina secondary to neoplastic vascular stenosis caused by local recurrence of an adenocarcinoma of the papilla of Vater. CASE PRESENTATION: An 80-year-old woman of Caucasian origin presented with abdominal pain and diarrhea. She had undergone a pancreaticoduodenectomy for adenocarcinoma of the papilla of Vater four years earlier. Computed tomography revealed a mass surrounding her celiac trunk and superior mesenteric artery. Her abdominal pain responded poorly to analgesic drugs, but disappeared when oral feedings were withheld. A duplex ultrasonography of the patient's splanchnic vessels was consistent with vascular stenosis. Parenteral nutrition was started and the patient remained pain free until her death. CONCLUSION: Pain relief is an important therapeutic target in patients with cancer. In this case, abdominal pain was successfully managed only after the ischemic cause had been identified. The conventional analgesic therapy algorithm based on nonsteroidal anti-inflammatory drugs and opioids had been costly and pointless, whereas the simple withdrawal of oral feeding spared the patient of the discomfort of additional invasive procedures and allowed her to spend her remaining days in a completely pain-free state

Guidelines for CME activities accredited by the EBVS

Continuing Medical Education (CME) can be defined \u2018educational activities that serve to maintain, develop, or increase the knowledge, skills and professional performance (and) relationships used by a physician to provide services for patients, the public, or the profession\u2019.1 It is a professional responsibility for all practicing physicians and it has become increasingly important in a fast moving medical world. Many CME activities are organized on a national level. For CME organized on a European level, the European Board of Vascular Surgery of the UEMS (Union Europ\ue9enne des M\ue9dicins Sp\ue9cialistes) has accepted a responsibility concerning the quality of these CME activities. It is important to realize that the EBVS is not a provider of Continuing Medical Education (CME) but must be seen as an independent authority that by its activities may assist as a clearinghouse for CME credits from a European to a national level. The EBVS has proposed accreditation for European Vascular CME activities since 1999.2 The CME Committee has been very active and accredits many European vascular meetings each year according to simple published criteria. Criteria for CME initially focused on major meetings in order to ensure that our criteria were reliable. CME activities have now been extended to technical skills workshops, again with specific and transparent criteria. Why are guidelines necessary? Traditionally, the pharmaceutical and medical device manufacturers have generously supported CME for physicians. Without industrial support, the quality of many activities would have been reduced and some activities would have been cancelled. During the last decade physicians, editorial boards of scientific journals and authorities have increasingly scrutinised the role of industry supporting these activities. [3] , [4] and [5] The basis for the concern is that scientific activities may be used for promotional activities without clearly identifying these activities. In 1993, Mannick reported on the \u2018scientific symposium\u2019 grafted onto the national meetings. For many of these both the programme and the speakers were picked and sponsored by a company. Under these circumstances an unbiased presentation is difficult to attain.6 It is clear that a conflict of interest may easily occur if organizers of CME activities need the support of the industry. In fact, travel funds, honoraria for nominal consultancies, free lunches, elegant dinners accompanied by product demonstrations and guest lectures with favourable views of the sponsors' products all threaten our integrity.7 Fortunately, both CME providers and the industry have recognized this issue and both are keen to resolve the problem. The CME Committee of the European Board of Vascular Surgery has discussed this issue at length and believes that for both CME providers and industry, as well as for the participants of CME activities, it would be helpful to provide clear and objective guidelines describing the relationship between the various parties. These guidelines are meant to stimulate a healthy and clear relationship between organizers of CME activities and the industry. The EBVS of the UEMS approved these Guidelines on 2nd September 2003 in Dublin. The Guidelines are published on the website of the EBVS and will be handed to both CME providers and the industry. For practical purposes the Guidelines have been subdivided into those for providers of CME activities, speakers and faculty and industrial sponsors. The Guidelines will be evaluated regularly and comments are encouraged

European continuing medical education in vascular surgery: 5-year results of congresses approved by the Union Europ\ue9enne des M\ue9decins Sp\ue9cialistes Section of Vascular Surgery

AIM: Continuing medical education (CME) can be defined as ''educational activities that serve to maintain, develop, or increase the knowledge, skills and professional performance of a physician to provide services for patients, the public, or the profession''. CME is a major professional responsibility. The European Board of Vascular Surgery of the Union Europ\ue9enne des M\ue9decins Sp\ue9cialistes (UEMS) Section of Vascular Surgery has, through its European Vascular CME (EVCME) Committee, accredited 74 congresses during the 5-year period from 2000-2004. METHODS: Official evaluation forms were completed by the congress participants for a personal appraisal of the quality of the activities. The data in this manuscript focused on questions that were the most relevant and of the greatest interest to the participants. A statistical analysis of the results was performed utilizing ANOVA and Robust tests of equality of means as well as a posthoc analysis for further investigation, and non parametric Wilcoxon signed ranks test. RESULTS: The educational needs of participants regarding new diagnostic and therapeutic modes were stated as ''important'' and ''extremely important'' in the responses at over 80% in total. Over 75% of the participants answered ''extremely important'' and ''important'' to the question ''how important is evidence-based practice to your practice''. CONCLUSION: This survey indicates that the EVCME approved congresses had a positive impact for the vascular surgeon by updating overall knowledge on vascular surgery; the majority of comments by the participants also indicates that EVCME is fulfilling its aim to bring as much evidence-based practice as possible into the daily work schedule of the surgeon by turning knowledge acquired by CME into performance of the participants

Increased local cytostatic drug exposure by isolated hepatic perfusion: a phase I clinical and pharmacologic evaluation of treatment with high dose melphalan in patients with colorectal cancer confined to the liver

A phase I dose-escalation study was performed to determine whether isolated hepatic perfusion (IHP) with melphalan (L-PAM) allows exposure of the liver to much higher drug concentrations than clinically achievable after systemic administration and leads to higher tumour concentrations of L-PAM. Twenty-four patients with colorectal cancer confined to the liver were treated with L-PAM dosages escalating from 0.5 to 4.0 mg kg(−1). During all IHP procedures, leakage of perfusate was monitored. Duration of IHP was aimed at 60 min, but was shortened in eight cases as a result of leakage from the isolated circuit. From these, three patients developed WHO grade 3–4 leukopenia and two patients died due to sepsis. A reversible elevation of liver enzymes and bilirubin was seen in the majority of patients. Only one patient was treated with 4.0 mg kg(−1)L-PAM, who died 8 days after IHP as a result of multiple-organ failure. A statistically significant correlation was found between the dose of L-PAM, peak L-PAM concentrations in perfusate (R = 0.86, P≤ 0.001), perfusate area under the concentration-time curve (AUC; R = 0.82, P< 0.001), tumour tissue concentrations of L-PAM (R = 0.83, P = 0.011) and patient survival (R = 0.52, P = 0.02). The peak L-PAM concentration and AUC of L-PAM in perfusate at dose level 3.0 mg kg(−1)(n = 5) were respectively 35- and 13-fold higher than in the systemic circulation, and respectively 30- and 5-fold higher than reported for high dose oral L-PAM (80–157 mg m(−2)) and autologous bone marrow transplantation. Median survival after IHP (n = 21) was 19 months and the overall response rate was 29% (17 assessable patients; one complete and four partial remissions). Thus, the maximally tolerated dose of L-PAM delivered via IHP is approximately 3.0 mg kg(−1), leading to high L-PAM concentrations at the target side. Because of the complexity of this treatment modality, IHP has at present no place in routine clinical practice. © 2000 Cancer Research Campaig