Using distal revascularization with interval ligation as the primary treatment of hand ischemia after dialysis access creation.

BACKGROUND: Arterial steal syndrome after angioaccess surgery can lead to potentially devastating complications. Past treatments either ensured loss of the newly created access through ligation or attempted salvage by increasing resistance within the fistula. None of these proved to be entirely satisfactory. In 1994, we began to employ distal revascularization with interval ligation (DRIL) as our primary method of relieving hand ischemia after dialysis access creation. Described here is our experience with this procedure. METHODS: After institutional review board approval, the charts of patients undergoing the DRIL procedure for relief of hand ischemia after dialysis access surgery were reviewed. Patient demographics, risk factors, types of fistulas, and indications for operation were recorded. The clinical results of DRIL surgery, as well as fistula and bypass graft patency, were noted. RESULTS: Between May 1994 and August 2011, 81 DRIL procedures were performed on 77 patients ranging from 37 to 94 (mean, 65) years of age. Forty-four were female and 33 were male, with diabetes present in 83.3%. DRIL procedures were performed for ischemic symptoms after 37 autogenous brachiocephalic, 30 prosthetic bridge, and 14 autogenous brachiobasilic fistulas. Thirty-eight DRIL procedures were performed for ischemic rest pain (46.9%), 21 for digital ulceration (25.9%), 16 for neurological deficits (19.7%), and six for digital gangrene (7.4%). Complete symptom resolution was seen in 31 patients with ischemic rest pain (81.6%), 19 patients with digital ulcerations (90.5%), nine patients with neurological deficits (56.3%), and five patients with digital gangrene (83.3%). Fistula and brachial-brachial bypass survival 60 months after the DRIL procedure was 56% and 96.9%, respectively. The overall complication rate was 17.2%, and no patients died within 30 days of operation. CONCLUSIONS: The DRIL procedure is a very effective treatment for symptomatic steal syndrome and is associated with low morbidity and mortality. It is extremely effective in the treatment of ischemic hand pain and tissue loss, but less so for neurological sequelae. It can allow for prolonged fistula utilization.

Surgical site infection rates in laparoscopic versus open colorectal surgery.

The purpose of this study was to use the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to evaluate the incidence of postoperative surgical site infections (SSIs) between laparoscopic (LAP) and open colorectal surgery. The 2008 ACS-NSQIP Participant Use File was queried by Current Procedural Terminology codes for colorectal surgery cases. SSI rates were compared between groups using Pearson chi-square and Fisher exact tests. Univariate and multivariate analyses were performed to identify factors associated with the LAP approach and/or SSIs. A total of 7,755 LAP and 16,184 open cases were identified. The laparoscopic group had an SSI rate of 9.4 versus 15.7 per cent for the open group (P < 0.0001). There was no statistical difference in the type of SSI (superficial, deep, and/or organ space) between the two groups. Although multivariate analysis identified several factors associated with SSIs of different types, LAP was the only factor found to decrease risk, whereas wound class and operative time were found to increase risk among all categories of SSIs. Despite a significantly lower incidence of postoperative SSI, only 32 per cent of colorectal surgery was performed laparoscopically in NSQIP hospitals in 2008. Wider adoption of LAP approaches for colorectal surgery should continue to reduce SSIs.

Long-term persistence of male copulatory behavior in castrated and photo-inhibited Siberian hamsters.

Gonadal steroids are essential for the long-term maintenance of the full repertoire of sexual behavior in male rodents. Typically, all individuals of several species cease to display the ejaculatory reflex within a few weeks of castration. The present study documents the persistence of the ejaculatory reflex 19 weeks after orchidectomy in 40% of male Siberian hamsters maintained in long or short day lengths; testosterone was undetectable in the circulation of these animals. Intact hamsters transferred from a long to a short photoperiod underwent gonadal regression: 50% of these animals continued to display mating behavior culminating in ejaculation throughout 25 weeks of testing. The remaining animals failed to ejaculate after approximately 11 weeks of short day treatment but resumed mating coincident with spontaneous gonadal recrudescence. Activation of sex behavior in the latter cohort appears to depend on gonadal steroids and is in contrast to the copulatory behavior of the substantial proportion of the study population that sustains the full sexual repertoire in the long-term absence of gonadal steroids. Sex behavior of the latter animals may be dependent on nongonadal steroids or mediation by steroid-independent mechanisms.