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EDITORIALS: Roger M Greenhalgh and Janet T Powell Screening men for aortic aneurysm BMJ 2002; 325: 1123-1124 [Full text]

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Can we do better in managing aortic aneurysms?

Richard G Fiddian-Green   (19 November 2002)

What About The Human Cost?

Simon P Curtis   (26 November 2002)

Can we do better in managing aortic aneurysms? 19 November 2002
Richard G Fiddian-Green, None None Send response to journal: Re: Can we do better in managing aortic aneurysms?	We might be able to do much better not only in screening patients at risk of ruturing abdominal aortic aneurysms but also in treating patients with aneurysmal disease. Might aneurysms be the product of an inadequacy of mitochondrial oxidative phosphorylation not only in the endothelium, as proposed for thromboembolism and atherosclerosis, but also in the media (1)? Laminal flow, turbulance and even a Venturi effect might render the intima and even the media in the intrarenal location at particularly risk of developing an impairment of oxidative phosphorylation. This might induce apoptosis in media cells and fibrosis in addition to the atherosclerosis. In which case aneurysms might be just one of many different manifestations of a systemic impairment of oxidative phosphorylation with many causes, including iatrogenic ones, and patients might be best screened by looking for systemic evidence of an impairment of oxidative phosphorylation from an early age (2). This might be best accomplished with a stress test, be it exercise or a meal, and measurements of gastric intramucosal pH. Once evidence of an impairment had been found then the appropriate preventative measures could be taken as considered for heart failure, remembering that the release of cytokines such as TNF alpha might be an important cause of impaired oxidative phosphorylation (3,4). In preparing patients for elective surgery for abdominal aortic aneurysms cleansing the gut with a Golytely gavage the afternoon before surgery would seem desirable prophylactic measure, given that ischaemic colitis and its accompanying translocation of endotoxin appears to be the “Achilles heel” of this operation (5). The prevention of a gastric intramucosal acidosis during surgery would appear to be especially desirable (6). Using supplementary goals should help in achieving this objective by simpler means than those used by Mythen and Webb and in keeping patients adequately resuscitated after surgery (7,8). The management of severe haemorrhagic shock, such as that enountered in patients with ruptured aneurysms, remains an unsolved problem with a high mortality (9). Innovative strategies need be tried if a serious attempt is to be made to reduce postoperative mortality from its horrendous 41% to a more acceptable 5%. These strategies might include replacing blood loss with Celsior or Perflubron rather than red cells and colonic lavage through a diverting ileostomy in selected patients largely amongst those who have had ruptured aneurysms successfully repaired (10). Experience with fulminant amoebic colitis suggests that enormous benefits might be obtained by diversion and lavage without resecting the colon even if it were to become overtly ischaemic, the ischaemic colon being likely to heal by fibrosis. The question is whether the risk of graft infection and mortality would be lower in adopting a conservative approach or in performing a second operation to resect the ischaemic colon. 1. Unreversed ATP hydrolysis: the initiating endothelial event? Richard G Fiddian-Green bmj.com/cgi/eletters/325/7369/887#26445, 22 Oct 2002 2. Iatrogenic diseases with a common cause? Richard G Fiddian-Green bmj.com/cgi/eletters/325/7370/913#26512, 25 Oct 2002 3. The need to manage heart failure from an early age Richard G Fiddian-Green bmj.com/cgi/eletters/325/7361/422#26766, 6 Nov 2002 4. Heart failure: a need to redefine it? Richard G Fiddian-Green bmj.com/cgi/eletters/325/7373/1156#27040, 16 Nov 2002 5. Gastric lavage for major operations? Richard G Fiddian-Green bmj.com/cgi/eletters/325/7366/674/b#25849, 27 Sep 2002 6. 2. Mythen MG, Webb AR. Perioperative plasma volume expansion reduces the incidence of gut mucosal hypoperfusion during cardiac surgery. Arch Surg. 1995 Apr;130(4):423-9. 7. Fiddian-Green RG, Haglund U, Gutierrez G, Shoemaker WC. Goals for the resuscitation of shock. Crit Care Med. 1993 Feb;21(2 Suppl):S25-31. Review 8. Fiddian-Green RG. In pursuit of the Holy Grail: complete resuscitation in one hour. Trauma and Emergency Medicine. Cannon Medical Media (South Africa). April 2000. 9. Severe haemorrhagic shock: an unsolved problem Richard G Fiddian-Green bmj.com/cgi/eletters/325/7365/616/e#25684, 20 Sep 2002 10. Colonic lavage for severe haemorrhagic shock? Richard G Fiddian-Green bmj.com/cgi/eletters/325/7366/674/b#25839, 27 Sep 2002 Competing interests:   None declared
What About The Human Cost? 26 November 2002
Simon P Curtis, GP Principal Summertown Health Centre,160 Banbury Road, Oxford, OX2 7BS Send response to journal: Re: What About The Human Cost?	Greenhalgh and Powell's editorial cooly assesses the economic evaluation of the MASS trial, but it masks with numbers a human tragedy at the core of the story: this is a screening study that killed people. En passant they mention the 6% mortality of the 322 men who had elective surgery as a result of the screening invitation. This figure represents 19 men, relatively young and fit at retirement age, who prior to receiveing the invitation letter would have been living their lives unfettered by the knowledge they even had an anuerysm. Now they are dead. Some of these men may have died anyway, but there is a clear moral distinction between dying naturally rather than at the instigation of doctors. One could perhaps accept this from an ethical perspective if the study showed a convincing overall survival benefit in the screened population, but it does not. Although not considered a primary end point of the trial, the all cause mortality at the end of the study was the same in both groups at 11%. The authors of the editorial confidently announce that the data 'support a national screening programme for aortic aneurysm'. They do not. The National Screening Committee's criteria (adapted from Wilson and Junger) are not fulfilled as there is no RCT evidence of overall survival benefit, and no evidence that benefit outweighs the physical and psychological harm of screening. The results of the MASS study are surprisingly similar to the recent study looking at 'watch and wait' or radical surgery for early prostate cancer(1). The radical treatment group had a halving of prostate cancer related deaths, but overall there was no survival advantage versus the watch and wait group. Supporters of screening put a positive spin on these results(2) but the result justifies the UK decision not to roll out a national screening programme for PSA testing; likewise the results of the MASS study do not justify aortic aneurysm screening. It is unfortunate that the BMJ (in the pages of which in the last year there has been much discussion on medicalisation, iatrogenesis and the institutionalisation of risk) give the study such a positive spin on its front cover. Yours sincerely, Simon Curtis 1)Homberg et al. A Randomised trial comparing radical prostatectomy with watchful waiting in eraly prostate cancer NEJM 2002:347;781 2)The operation was a success (but the patients died). BMJ 2002:325;664 Competing interests:   None declared