Major amputation for intractable extremity melanoma after failure of isolated limb perfusion

AIM: The aim of this study was to analyse indications and results of amputation for intractable extremity melanoma after failure of isolated limb perfusion (ILP). METHODS: Between 1978 and 2001, 451 patients with loco-regional advanced extremity melanoma underwent 505 ILPs. Amputation of the affected extremity had to be carried out for intractable recurrent disease in 11 of these patients. RESULTS: The indications for amputation were uncontrollable pain (n=2), extensive loco-regional tumour progression (n=4), loss of ankle function due to local tumour growth (n=1), and ulcerating and fungating lesions, not responding to other treatments (n=4). Four patients developed stump recurrence after amputation. Ten patients died of melanoma metastases after a median of 11 months (range 2-110 months). Two patients survived more than 5 years after amputation. CONCLUSIONS: Major amputation is rarely indicated for intractable extremity melanoma but long-term survival can be achieved in selected patient

Cost-effectiveness and cost-utility of endovascular versus open repair of ruptured abdominal aortic aneurysm in the Amsterdam Acute Aneurysm Trial

Background: Minimally invasive endovascular aneurysm repair (EVAR) could be a surgical technique that improves outcome of patients with ruptured abdominal aortic aneurysm (rAAA). The aim of this study was to analyse the cost-effectiveness and cost-utility of EVAR compared with standard open repair (OR) in the treatment of rAAA, with costs per 30-day and 6-month survivor as outcome parameters. Methods: Resource use was determined from the Amsterdam Acute Aneurysm (AJAX) trial, a multicentre randomized trial comparing EVAR with OR in patients with rAAA. The analysis was performed from a provider perspective. All costs were calculated as if all patients had been treated in the same hospital (Onze Lieve Vrouwe Gasthuis, teaching hospital). Results: A total of 116 patients were randomized. The 30-day mortality rate was 21 per cent after EVAR and 25 per cent for OR: absolute risk reduction (ARR) 4.4 (95 per cent confidence interval (c.i.) -11.0 to 19.7) per cent. At 6 months, the total mortality rate for EVAR was 28 per cent, compared with 31 per cent among those assigned to OR: ARR 2.4 (-14.2 to 19.0) per cent. The mean cost difference between EVAR and OR was (sic)5306 (95 per cent c.i. -1854 to 12 659) at 30 days and (sic)10 189 (-2477 to 24 506) at 6 months. The incremental cost-effectiveness ratio per prevented death was (sic)120 591 at 30 days and (sic)424 542 at 6 months. There was no significant difference in quality of life between EVAR and OR. Nor was EVAR superior regarding cost-utility. Conclusion: EVAR may be more effective for rAAA, but its increased costs mean that it is unaffordable based on current standards of societal willingness-to-pay for health gains

Mortality of ruptured abdominal aortic aneurysm with selective use of endovascular repair

The aim of this review was to examine the results over a seven-year period of treatment for ruptured abdominal aortic aneurysm (RAAA). From 2002 on, our tertiary referral centre offered both open and endovascular (EVAR) treatment modalities for RAAA. All patients with a proven RAAA who were admitted into our hospital were included. Primary outcome measure was surgical mortality. In total 261 patients were admitted with suspicion of acute AAA. Of these, 175 (67%) had a RAAA, confirmed by computed tomography-scanning or at laparotomy. One hundred and fifty-nine patients (90.9%) were treated, 114 by open repair and 45 by EVAR. Overall mortality of patients treated was 25.2%, with an open repair mortality of 27.2%, and EVAR mortality of 20%. EVAR was used more often in patients who were hemodynamically more stable. Evaluation for EVAR and treatment by EVAR increased during the study period. Overall mortality rate for treatment of RAAA in our centre was 25% over the seven-year study period