Inferior vena cava occlusion in retroperitoneal fibrosis and exogenous testosterone administration.

Retroperitoneal fibrosis (RPF) causing large vessel stenosis and thrombosis is rare but well-described. We describe a 50-year-old man with rapid progression of central venous thrombosis in the presence of RPF and exogenous testosterone use. Therapeutic anticoagulation was initiated and catheter directed thrombolysis was performed after placement of an inferior vena cava (IVC) filter. Repeat venogram revealed severe focal retrohepatic IVC stenosis, which was treated with serial venoplasty and stenting. Clinical improvement was significant 48 hours after intervention. This case represents a rare presentation of IVC occlusion in the setting of RPF and exogenous testosterone administration successfully treated with endovascular interventions.

Shared Blood: Expeditionary Resuscitative Surgical Team (ERST-5) Use of Local Whole Blood to Improve Resuscitation of Host Nation Partner Forces.

US Special Operations Forces work by, with, and through partner forces (PFs) to accomplish mutual objectives. Surgical teams support these forces directly and may assist in treating injuries sustained by PF, based on established medical rules of engagement. These surgical operations are often conducted in austere conditions, with limited access to blood products. Limited blood product availability decreases US medical capacity to resuscitate injured PFs and augment the local trauma system. We present an innovative solution used by an expeditionary resuscitative surgical team (ERST) and Special Operations civil affairs team to partner with host nation (HN) medical personnel to improve PF access to damage control resuscitation and surgery. Whole blood obtained through a local HN hospital was provided to the ERST to allow for increased capacity to resuscitate PF casualties and augment the local trauma system. The ERST subsequently used this blood to resuscitate two PF surgical casualties.

Determination of Proper Timing for the Placement of Intra-Abdominal Mesh after Incidental Enterotomy in a Rodent Model (Rattus norvegicus).

Controversy exists regarding the appropriate timing for placement of permanent intra-abdominal mesh after inadvertent enterotomy during elective hernia repair. The aim of this study was to examine mesh placement at variable postoperative periods and the subsequent risk of infection. Fifty rodents were divided into five groups. Groups one to four underwent laparotomy, enterotomy, and repair. Physiomesh® was placed at the index operation one, three, or seven days postoperatively in Groups 1, 2, 3, and 4. Group 5 underwent mesh placement only. Necropsy with mesh harvest was performed seven days after placement. Cultures of mesh were obtained and Fisher's exact test was used to compare groups. Bacterial growth postsonication was identified in 30, 30, 50, and 90 per cent versus 20 per cent in controls. Compared with controls, there was significantly increased risk of mesh infection when it was placed seven days after enterotomy (P = 0.006). There was no significant difference in bacterial growth when mesh was placed at the time of enterotomy, one or three days later. The risk of bacterial contamination of permanent mesh placed immediately after inadvertent enterotomy during elective hernia repair is as safe as placing mesh at one or three days. Placing mesh at seven days significantly increased the risk of mesh contamination.

Tibioperoneal Occlusive Disease: A Review of below the Knee Endovascular Therapy in Patients with Critical Limb Ischemia.

BACKGROUND: Tibioperoneal occlusive disease is one of the most difficult disease processes to successfully treat. Previous studies have attempted to address the outcomes of tibial interventions in this patient population; however, the majority of these study cohorts are composed of patients who have undergone concomitant aortoiliac or femoral procedures. Our objective was to present the outcomes of patients treated with endovascular intervention for isolated below-the-knee atherosclerotic disease causing critical limb ischemia (CLI). METHODS: We performed a retrospective review of all patients who underwent isolated endovascular treatment of the below-knee popliteal, tibial, and/or peroneal arteries for CLI (Rutherford class 4-6). Primary outcomes include wound healing, reintervention rates, and amputation-free survival out to 5 years, as well as 1-year primary patency rates. RESULTS: 116 patients were identified as having undergone a tibial endovascular intervention. Ninety-two had concomitant aortoiliac or femoropopliteal interventions; after excluding those patients, we identified 24 limbs that were treated for isolated below-knee popliteal, tibial, and/or peroneal occlusive disease using an endovascular modality. 62.5% of limbs had successful wound healing, whereas 37.5% eventually required a major amputation. Mean time to amputation was 514.6 days (standard error: 57.3). Of those patients with successful limb salvage (n = 15), 66.7% required only the index procedure to heal; the remaining 33.3% required a repeat endovascular intervention, an arterial bypass, or a combination to successfully heal. The mean time to reintervention was 780.1 days (standard error: 179.5). The 1-year primary patency rate was 52.6% (n = 19). CONCLUSIONS: Patients with CLI secondary to isolated below-the-knee atherosclerotic occlusive disease are a difficult population to successfully treat; despite this, these patients benefit from an initial attempt at endovascular limb salvage. In our experience, this approach resulted in a respectable limb salvage rate of 62.5% and did not compromise open surgical solutions in the event of nonhealing.

Weight-loss outcomes of SPIDER(®) sleeve gastrectomy at 6 months compared to traditional laparoscopic technique.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) has become a primary stand-alone procedure for weight-loss surgery. The standard technique for LSG involves several small abdominal incisions. The single port instrument delivery extended reach (SPIDER(®)) surgical system has been introduced as a single site modality. This technique has been described previously; however, weight-loss outcomes of SPIDER(®) sleeve gastrectomy have not been compared to multi-port LSG. METHODS: We performed a retrospective review of a prospectively collected database. All cases were performed by a single surgeon between August 2011 and September 2013. Thirty-two patients underwent SPIDER(®) sleeve gastrectomy, while 30 underwent LSG. Primary outcomes were change in BMI and percent excess weight loss (%EWL) at 6 months post-operatively. Secondary outcomes included: operative time, estimated blood loss (EBL), and complications. RESULTS: There were no demographic differences between cohorts except initial BMI (SPIDER(®) = 42.1, LSG = 46.5, p < 0.001). Mean %EWL at 6 months post-operatively was higher in the SPIDER(®) cohort (59.1 vs. 48.3 %, p < 0.005). Similarly there was a lower mean BMI at 6 months post-operatively in the SPIDER(®) cohort (31.1 vs. 35.5, p < 0.0001). The net change in BMI for each cohort was equivalent (SPIDER(®) = 11.1, LSG = 11.0, p = 0.95). Mean operative time was longer in SPIDER(®) cases (104.6 vs. 90.7 min, p < 0.02), while EBL was equivalent (32.1 vs. 34.3 mL, p = 0.56). There was one post-operative hemorrhage requiring laparoscopic clot evacuation in the SPIDER(®) cohort, and one wound infection in the LSG cohort. CONCLUSIONS: SPIDER(®) sleeve gastrectomy is not inferior to LSG with regard to decrease in BMI and %EWL at 6-months post-operatively. The higher %EWL observed in the SPIDER(®) cohort is likely due to patient selection bias. This study demonstrates that the SPIDER(®) technique is a viable alternative to LSG with similar weight-loss outcomes.

Thrombocytopenia in the setting of hemodialysis using biocompatible membranes.

Thrombocytopenia is a known potential side effect of hemodialysis, however, it is rarely seen in patients who undergo hemodialysis using biocompatible membranes. This case demonstrates hemodialysis-associated thrombocytopenia with use of biocompatible dialysis membranes that expose blood directly to polysulfone. The thrombocytopenia resolved in this patient when the dialysis membrane was changed to a biocompatible model with a polyethylene glycol barrier layer preventing direct interaction between patient blood and polysulfone. The calculated Naranjo ADR score of 9 indicates a highly probable adverse reaction.