Postintervention Patency: A Comparison of Stenting versus Patch Angioplasty for Dysfunctional Hemodialysis Access Sites.

BACKGROUND: Arteriovenous access dysfunction is commonly caused by venous outflow stenosis, leading to thrombosis of the conduit. Given that there are limited lifetime hemodialysis access sites, the preservation of existing sites through novel means is of high priority. This study compares the efficacy of balloon angioplasty and stent placement to surgical patch angioplasty for upper arm (brachium) thrombosed or dysfunctional hemodialysis access sites in a group of patients at a single institution. METHODS: Using the operating room log and electronic medical record system, we retrospectively examined the outcomes of 52 consecutive patients (3 were lost to follow-up), who had either stent placement (34 patients) or patch angioplasty (15 patients) for hemodialysis access salvage to calculate postintervention patency. RESULTS: Initial postinterventional patency (PIP1) for patch angioplasty compared with stent placement was not statistically significant at any time during a mean 6-month follow-up (60% vs. 67.65% at 1 month, 33.33% vs. 41.18% at 3 months, and 13.33% vs. 17.65% at 6 months, respectively; P = 0.75). Patency after secondary reintervention (PIP2) was longer for patients who had stent placement as the initial intervention (n = 15) than patients who had patch angioplasty (n = 5; 100% vs. 80% at 1 month, 66.68% vs. 80% at 3 months, and 46.67% vs. 40% at 6 months, respectively), but again there was no statistically significant difference between the 2 groups (P = 0.84). At last, the initial PIP1 of arteriovenous fistula (AVF) and arteriovenous graft (AVG) salvaged before occlusion was significantly different from that of occluded access sites (40% vs. 10% at 6 months, P = 0.024). CONCLUSIONS: Our data suggest that AVF had a longer postinterventional primary patency than AVG though the difference did not reach statistical significance. Stents extended PIP1 for the thrombosed or failing arteriovenous access longer than patch angioplasty, but the difference was not statistically significant. Patency is longer if intervention is made before graft thrombosis. Our data also indicate better prolongation of patency with a second reintervention (PIP2) if the first intervention was a stent placement. Patch angioplasty appears to be a less attractive alternative for correction of venous outflow stenosis given the more invasive and occasionally technically difficult procedure.

Less Than Total Excision of Infected Prosthetic PTFE Graft Does Not Increase the Risk of Reinfection.

BACKGROUND: Traditional treatment of infected polytetrafluoroethylene (PTFE) grafts consist of removal of the entire prosthesis. Closure of the native vessels may compromise vascular patency. We examined the outcomes for patients in whom a PTFE remnant of an infected graft was retained on the vessel. METHODS: We reviewed the operating room log from 2000 to 2011 and identified all patients who had partial removal of an infected PTFE graft used for hemodialysis or peripheral bypass. These patients were examined for subsequent complications. RESULTS: Twenty-seven patients underwent 30 partial graft excisions with mean follow-up of 27 months. A total of 17% (5 of 30) of the partial graft resection procedures resulted in complications. Of 48 total remnants left behind at the arterial or venous anastomoses, reinfection occurred in 15%. CONCLUSIONS: Leaving a well-incorporated small 1-to 5-mm PTFE remnant at the arterial or venous anastomoses can be performed safely with a low risk of complications.

Stent salvage of arteriovenous fistulas and grafts.

OBJECTIVES: This study analyzes our experience using stents to salvage dysfunctional hemodialysis access sites at a single institution. METHODS: We examined the outcomes of 42 consecutive patients who had covered (36 patients) or bare-metal (9 patients) stent intervention for hemodialysis access salvage. RESULTS: Of our 42 male patients, 11 had stent salvage of an arteriovenous fistula, which yielded postintervention primary and secondary 6-month patencies of 27% and 55%, respectively. For 31 patients with arteriovenous grafts, the postintervention primary and secondary 6-month patencies were 26% and 29%, respectively. Patency rates were superior for stents placed in patent access sites, in fistulas compared to grafts, and when stents were placed in forearm sites although only the latter achieved statistical significance. CONCLUSIONS: Stents can extend patency for the thrombosed or failing arteriovenous access, but results are poor once thrombosis has occurred. Stent placement appears to be more effective in fistulas compared to grafts.

Surveillance computed tomographic arteriogram does not change management before 3 years in patients who have a normal post-EVAR study.

BACKGROUND: Standard surveillance after endovascular abdominal aortic aneurysm repair (EVAR) consists of periodic computed tomographic arteriographies (CTAs) usually performed at postoperative months 1, 6, and 12, and then annually. This imaging regimen is expensive and exposes patients to the hazards of radiation and intravenous contrast. We hypothesized that a normal 1-month CTA after EVAR with no endoleak or other significant abnormality predicts a low rate of future complications, which would justify a reduction in frequency of subsequent CTAs. METHODS: We identified 106 consecutive patients who underwent EVAR at a single hospital from 2003 to 2010 and reviewed all their CTAs. Fifteen patients for whom we could not review a postoperative CTA were excluded. Of the remaining 91 patients, 70 (76.9%) had no abnormality on their CTA at 1 month after EVAR. The medical records of these 70 patients were analyzed for subsequent complications and interventions related to EVAR. RESULTS: The mean patient follow-up was 3.4 ± 2.1 years. Five of the 70 (7.1%) patients with a normal post-EVAR CTA developed late complications consisting of 1 type I endoleak, 3 type II endoleaks, and 1 case of endotension. Only the type I endoleak and one of the type II endoleaks met criteria for intervention, and in both cases, the endoleaks were discovered >3 years after EVAR. Log-rank test showed a statistically significant increased freedom from aneurysm sac expansion in patients with a normal compared with an abnormal 1-month CTA (P < 0.001). CONCLUSIONS: For patients who have a normal CTA with no endoleak 1 month after EVAR, it is reasonable to consider less-frequent CTA surveillance because no significant complications requiring intervention occurred before 3 years. This would decrease unnecessary CTAs and health care expenditures as well as minimize patient exposure to radiation and intravenous contrast.

Noncompressible arteries correlate with increased cardiovascular mortality at 2 years.

BACKGROUND: The ankle-brachial index (ABI) is a useful screening tool for the detection of peripheral vascular disease (PVD). Using ABI measurements, patients can be stratified into different severities of arterial occlusive disease. METHODS: Four hundred forty-four Veterans Health Administration Medical Center patients were referred for PVD between 2004 and 2005. Of those, 231 patients had an ABI ≤0.90 or >1.2 with known treatment and follow-up obtained from electronic medical records. These individuals had bilateral ABI measurements and were observed for a median of 23 months (range, 4.0-60.0 months). Patients were divided into 4 ABI categories: severe (ABI ≤0.30; n = 62), moderate (ABI 0.30-≤0.60; n = 138), mild (ABI 0.60-≤0.90; n = 89), normal (ABI 0.90-≤1.2; n = 86), and noncompressible (ABI >1.2; n = 69). RESULTS: Mortality from cardiovascular disease in the severe, moderate, mild, normal, and noncompressible groups was 4.8%, 8.0%, 10.1%, 0%, and 21.7%, respectively, at the mean follow-up of 2 years. For all-cause mortality, the overall percent for each group respectively was 32.3%, 31.9%, 31.5%, 14%, and 42% (P = 0.003). To our surprise, ABIs <0.9 did not show a linear correlation with 2-year survival. However, an ABI >1.2, indicating noncompressible arteries, correlated significantly with higher rates of mortality at a mean follow-up of 2 years (33.3%). Cardiovascular disease and amputation were also significantly higher in those with noncompressible arteries than in the other groups. CONCLUSIONS: ABI is a noninvasive, inexpensive test that provides valuable information on a patient's risk of death. We recommend that patients with noncompressible vessels undergo systemic cardiovascular work-up, including coronary and carotid artery evaluation.

The surgeon and AIDS: twenty years later.

BACKGROUND: Since the first reports on indications and outcome for abdominal procedures in the HIV/AIDS patient were published 20 years ago, the epidemiology and presentation of surgical illness have changed remarkably with the advent of new antiviral regimens. A review of the now occasional, but still important, role of the surgeon in contemporary treatment of HIV/AIDS is presented. DATA SOURCES: Information was obtained by PubMed searches of medical journals, examination of reference lists, and Web resources. STUDY SELECTION: Articles on operative indications, outcomes, precautions, source of transmission, and pathophysiology of HIV/AIDS were selected. DATA EXTRACTION: Data was obtained from peer-reviewed articles and references. DATA SYNTHESIS: The last 2 decades have seen a decrease in operative mortality from as high as 85% to approximately 15% with a corresponding improvement in morbidity. Surgical emergencies such as appendicitis occur in HIV patients with the same frequency as non-HIV patients and are treated with equivalent results. Concern about transmission of HIV in the operating room has lessened somewhat. Although still a hazard, the probability of HIV transmission with accidental exposure is low, with risks below 0.5% for percutaneous hollow-bore needles and less than 0.1% risk for mucus membrane exposure. CONCLUSIONS: Improved surgical outcomes together with of accurate data on the modes and likelihood of accidental transmission of HIV to members of the surgery team have resulted in the treatment of HIV/AIDS patients becoming an accepted part of routine surgical practice.

Effect of the 80-hour workweek on resident burnout.

HYPOTHESIS: With the introduction of the newly mandated restrictions on resident work hours, we expected improvement in subjective feelings of personal accomplishment and lessened emotional exhaustion and depersonalization. DESIGN: Residents and faculty members completed an anonymous online Maslach Burnout Inventory Human Services Survey (3rd ed; Consulting Psychologist Press Inc, Palo Alto, Calif) and work-hour registry before and after implementation of new restrictions. SETTING: Urban, university-based department of surgery. PARTICIPANTS: All house staff (n = 37) and faculty (n = 27). INTERVENTION: Introduction of new Institutional Standards for Resident Duty Hours 2003. Main Outcome Measure Resident work hours and levels of emotional exhaustion, perceived degree of depersonalization, and personal accomplishment. RESULTS: Resident work hours per week decreased from 100.7 to 82.6 (P < .05) with introduction of the new schedule. Home call and formal educational activity time within working hours (eg, clinical conferences) significantly (P < .05) decreased from 11.5 and 4.8 hours to 4.6 and 2.5 hours per week, respectively. Operating room hours, clinic time, and duration of rounds did not show a significant change. Changes in parameters of resident and faculty emotional exhaustion, depersonalization, and personal accomplishment did not show statistical significance (P > .05). CONCLUSIONS: Despite successful reductions in resident work hours, measures of burnout were not significantly affected. However, important clinical activities such as time spent in the operating room, clinic, and making rounds were maintained. Formal in-hospital education time was reduced.

Stapled hemorrhoidectomy: a review of our early experience.

Treatment of hemorrhoids may safely be accomplished by using a circular stapler instead of the conventional open procedure for large symptomatic hemorrhoids. Our purpose was to assess the safety and early post-op results of this new surgical technique as it was introduced into clinical practice. Medical records from 62 patients treated by circumferential mucosectomy/stapled hemorrhoidectomy were obtained from 6 surgeons. Preoperative factors assessed included demographics, comorbidities, prior anorectal surgery, hemorrhoid grade, and the indications for surgery. Operative factors examined included operating time, use of perioperative antibiotics, and oversewing of the suture line. Postoperative factors included complications and date of last follow-up. Sixty-two patients underwent this operation, and complications were reported in six patients (10%). There was one death unrelated to the hemorrhoid surgery. Postoperative pain, defined as requiring pain control with intravenous medication, hospital admission, or an emergency department visit, occurred in two patients. Two patients reported postoperative bleeding. One patient experienced bleeding the first evening, and the second patient had bleeding 1 week postoperatively. The first patient was admitted overnight and required no blood transfusion or further intervention. The second patient was subsequently found to have a bleeding diverticulum. One patient experienced urinary retention that resolved with conservative management. Postoperative follow-up was available for over 90 per cent of the patients at a median of 4 weeks postoperatively. No additional complications were discovered at follow-up. This data suggests that stapled hemorrhoidectomy is a safe and effective approach to hemorrhoidal disease. Our findings indicate an acceptable complication rate among a group of surgeons beginning to integrate this modality into clinical practice.

Postoperative complications of carotid patching: pseudoaneurysm and infection.

Patch angioplasty after carotid endarterectomy has been advocated to improve results by decreasing the incidence of recurrent stenosis and postoperative carotid thrombosis. Aneurysmal and infectious complications may be secondary to use of prosthetic materials in arterial reconstruction. We report four patients who developed late operative site complications related to carotid patching. All four of our patients had delayed pseudoaneurysms and three had infection related to the Dacron patch. In a typical case, a 57-year-old who had a right carotid endarterectomy in 1994 presented with a 1-month history of an enlarging right neck mass 7 years later. Imaging revealed a 6 x 4 cm pseudoaneurysm originating from an opening between the patch graft and the old endarterectomized carotid wall. Analysis of the literature disclosed an additional 45 patients who had pseudoaneurysms and/or infection related to carotid patching, most frequently with Dacron. We postulate that a low-grade Staphylococcus epidermidis infection of the foreign body patch may be the etiology. Autogenous saphenous vein interposition graft and antimicrobials effective against gram-positive organisms corrected the pseudoaneurysm. Although the benefits of routine carotid patching may include a decrease in restenosis, this advantage must be weighed against the risk of late pseudoaneurysm and/or infection when a prosthetic patch is used to closed the endarterectomy site.

Serial abdominal closure technique (the "SAC" procedure): a novel method for delayed closure of the abdominal wall.

Abdominal compartment syndrome may occur after any elective or emergent abdominal operations that are complicated by postoperative hemorrhage or in the trauma patient who has massive fluid replacement for intra-abdominal bleeding. Once the abdomen is decompressed the type of closure varies as much as the surgeon performing the procedure. We have devised a simple, reproducible, inexpensive, and safe method to close the abdomen at the bedside. Serial abdominal closure (SAC) was performed on three patients 45, 54, and 14 years of age who had developed abdominal compartment syndrome secondary to an upper gastrointestinal bleed requiring massive transfusion, a tear of the superior mesenteric vein, and a grade 4 liver laceration respectively, all necessitating abdominal decompression. All three patients had their abdominal wounds closed at the bedside over the course of several days with our SAC technique. Subsequent postoperative course was uneventful and the abdominal wall was free of defects at one-year follow-up. SAC is an efficient, inexpensive, and easily reproducible method of managing the open abdomen. The use of SAC prevented abdominal closure-related complications such as enteric fistula and hernia formation in our three patients.

Reducing the noneducational and nonclinical workload of the surgical resident; defining the role of the health technician.

PURPOSE: Recent controversy over excessive resident work hours has prompted surgical educators and program directors to search for more efficient methods to limit the nonclinical and noneducational workload of surgical residents. Health technicians were employed at a large Veteran's Administration Medical Center to allow residents more time for direct patient care in the clinics and wards and in educational activities. METHODS: In a two-week period, daily data cards were collected from each intern and health technician identifying total hours spent in work, operations, clinics, and conferences. Each intern recorded the number and type of tasks performed and those tasks assigned to the health technician. The number and type of task performed were tabulated and averaged for each health technician and physician. RESULTS: Each intern (n = 3) and health technician (n = 8) completed 100% of the required data forms. In a control survey, each intern worked a mean of 16.9 hours per weekday and 5.0 hours per weekend day. With the addition of the health technicians, interns worked 12.9 hours per weekday and 6.8 hours per weekend day (when the health technicians were not present). Following the addition of the health technicians, resident time in the operating room increased from 3.3 hours per week to 9.8 hours per week. Each health technician aided the intern by performing an average of 20.25 tasks per day. CONCLUSIONS: This study shows that health technicians can be effective in reducing the overall hours and workload of surgical residents and increasing time spent in the operating room. Consideration should be given to including the health technician as integral members of the health care team in the teaching hospital.

Choosing general surgery: insights into career choices of current medical students.

HYPOTHESIS: The number of unfilled general surgery programs in the United States increased from 4 in 1999 to 41 in 2001. This study seeks to determine if changes in student attitudes occurring during their medical school careers and during the third-year general surgery clerkship contribute to a decline in interest in a surgical career. DESIGN: Prospective survey of medical students at a public medical school in California. PARTICIPANTS AND METHODS: Each medical student received a survey via the Internet. Responses were anonymous. Once quantified, chi(2) analysis was used for comparison and analysis of survey results. Comparisons were made between individual class years and on the basis of whether the respondent completed the third-year general surgery clerkship. RESULTS: Of 368 surveys sent, 232 (63%) were successfully completed and included in the study. Comparison of students' attitudes before and after completion of their general surgery clerkship showed that following surgical course exposure more students believed surgery lacked breadth of expertise, limitations over stress, control over one's time, regularity of schedule, adequacy of leisure time, and income commensurate to workload (P<.05). These results are also consistent in comparisons between individual class years. CONCLUSIONS: Data suggest that medical students seem to be more concerned with issues of "controllable lifestyle" such as adequacy of family and/or leisure time, high level of stress, and amount of work and commitment. The erosion of income differential between demanding and less taxing specialties was also an important cause cited for the flagging interest in surgical disciplines.