Measuring Peri-Anastomotic Pressure to Identify Patients at High-Risk for Dialysis Associated Steal Syndrome.

OBJECTIVE: Dialysis Access-associated Steal Syndrome (DASS) is one of the most serious complications of hemoaccess surgery. Treatment algorithms involve significant morbidity; a tool to reliably identify patients at risk who could benefit from interventions at time of operation would be useful. We present a strategy of using peri-anastomotic pressure (PAP) measurement to identify patients who may be at high risk of developing DASS. METHODS: Patients who underwent dialysis access creation between January 1, 2018 and September 30, 2022 at our institution were reviewed. Beginning October 2019, we developed a strategy of measuring systolic pressure at the arterial anastomosis intra-operatively. A ratio of this value compared to the systemic systolic pressure was calculated. In patients believed to be high-risk for developing DASS based on clinical findings, selective banding of the access was performed intra-operatively to augment distal perfusion. RESULTS: Of 857 total patients, 36 (4.2%) developed clinically significant DASS, defined as requiring operative treatment, either intraoperatively or during follow-up (mean, 76 days; range, 0-602 days). DASS was more common for femoral-based accesses (6/12, 46.2%) compared to upper extremity accesses (30/840, 3.6%, p < 0.001). No patients who underwent radiocephalic arteriovenous fistula (AVF) or infraclavicular axillary arteriovenous graft construction developed DASS. There was no difference in DASS for upper extremity AVFs (20/576, 3.47%) vs. AV grafts (10/264, 3.79%, p = 0.82). 216 patients had PAP measured intra-operatively. Fourteen (6.5%) of these 216 patients developed DASS requiring intervention in follow-up. The mean PAP ratio of these 14 patients was 0.395 vs. 0.557 for the 202 patients who did not [CI 0.07-0.25, p = 0.001]. Seventeen patients who had low PAP ratio with poor distal perfusion underwent intra-operative banding, which improved mean PAP ratios from a mean of 0.33 to 0.58. Despite banding, 3 of these 17 (17.6%) patients in this high-risk subgroup went on to develop DASS postoperatively. The calculated mean PAP ratio in patients who either developed DASS post-operatively or underwent prophylactic banding intra-operatively was 0.37, which was significantly lower than the mean ratio of 0.57 in the control group (p = 0.001). CONCLUSIONS: Low PAP ratios (less than 0.50) identified patients at elevated risk for DASS, but prophylactic banding did not always prevent the occurrence of DASS in select patients. Because steal is a dynamic phenomenon, intraoperative conditions are not always going to reflect later adaptation. Nonetheless, PAP measurement may identify a subgroup warranting procedural modification or closer postoperative physiologic monitoring.

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy: Effects of postoperative fluids beyond the first 24 h.

BACKGROUND AND OBJECTIVES: There are no guidelines for intravenous fluid (IVF) administration after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC). This study assessed rates of post-CRS/HIPEC morbidity according to perioperative IVF administration. METHODS: All patients undergoing CRS/HIPEC March 2007 to June 2018 were reviewed, recording clinicopathologic, operative, and postoperative variables. Patients were divided by peritoneal cancer index (PCI), comparing IVF volumes and types administered intraoperatively and during the first 72 h postoperatively. Optimal IVF rate cutoffs calculated using area under the receiver operating characteristic curves and Youden's index determined associations with complications. RESULTS: Overall, 185 patients underwent CRS/HIPEC, and 81 (51%) had low PCI (<10) and 77 (49%) had high PCI (≥10). In low-PCI patients, high IVF rates on postoperative days (POD) #0-2 were associated with higher overall complications: POD#0 (46% vs. 89%, p = 0.001), POD#1 (40% vs. 86%, p < 0.05), and POD#2 (42% vs. 72%, p < 0.05). High IVF rates were associated with respiratory distress (7% vs. 26%, p = 0.02) on POD#0, ileus (14% vs. 47%, p = 0.007) and intensive care unit stay (11% vs. 33%, p = 0.022) on POD#1, and ICU stay (8% vs. 33%, p = 0.003) on POD#2. CONCLUSIONS: For low PCI patients undergoing CRS/HIPEC, higher IVF rates were associated with postoperative complications. Post-CRS/HIPEC, IVF rates should be limited to prevent morbidity.

Diaphragmatic Peritoneal Stripping Versus Full-Thickness Resection in CRS/HIPEC: Is There a Difference?

BACKGROUND: Pleural recurrence after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is rare and poorly delineated. Specifically, data are limited on the effect that diaphragmatic peritoneal stripping versus full-thickness resection has on the nature of ipsilateral pleural recurrence and postoperative morbidity. METHODS: Patients with peritoneal carcinomatosis who underwent CRS/HIPEC were included from a prospectively maintained database. The patients were divided into three cohorts based on surgical management of the diaphragm as follows: diaphragm-stripping (DS) cohort, full-thickness resection (FTR) cohort, and no diaphragm manipulation (ND) cohort. Postoperative morbidity and incidence of ipsilateral pleural recurrence were evaluated. All diaphragmatic defects were closed before abdominal chemoperfusion. RESULTS: The inclusion criteria were met by 409 CRS/HIPEC procedures: 66 in DS, 122 in FTR, and 238 in ND. Ipsilateral pleural recurrence rates did not differ significantly between the three cohorts (DS 6%, FTR 3%, ND 3%; p = 0.470). Postoperative respiratory complications and overall morbidity were significantly greater for the patients who underwent diaphragmatic disruption (stripping and/or resection) than for the patients who did not (p ≤ 0.0001), but the two groups did not differ in terms of 30-day mortality. However, comparison of FTR with DS showed no impact on major morbidity or pleural recurrence. CONCLUSION: Although patients undergoing surgical manipulation of the diaphragm during CRS/HIPEC experienced significantly greater morbidity, diaphragmatic stripping did not differ from full-thickness resection in terms of grades 3 and 4 complications or incidence of ipsilateral pleural recurrences. When deemed necessary to achieve complete cytoreduction, full-thickness diaphragmatic resection should be undertaken. In addition, the data support the observation that definitive repair of the diaphragmatic defect before abdominal chemoperfusion does not adversely influence ipsilateral pleural recurrence.

Stem cells: a new paradigm for disease modeling and developing therapies for age-related macular degeneration.

Age-related macular degeneration (AMD) is the leading cause of blindness in people over age 55 in the U.S. and the developed world. This condition leads to the progressive impairment of central visual acuity. There are significant limitations in the understanding of disease progression in AMD as well as a lack of effective methods of treatment. Lately, there has been considerable enthusiasm for application of stem cell biology for both disease modeling and therapeutic application. Human embryonic stem cells and induced pluripotent stem cells (iPSCs) have been used in cell culture assays and in vivo animal models. Recently a clinical trial was approved by FDA to investigate the safety and efficacy of the human embryonic stem cell-derived retinal pigment epithelium (RPE) transplantation in sub-retinal space of patients with dry AMD These studies suggest that stem cell research may provide both insight regarding disease development and progression, as well as direction for therapeutic innovation for the millions of patients afflicted with AMD.

A minimally invasive approach to the infected aorta with novel endovascular use of biocomposite antibiotic material.

We have presented the case of a symptomatic, primarily infected aortic pseudoaneurysm treated with endovascular stent graft exclusion and adjunctive use of a long-acting biocomposite antibiotic material injected directly into the pseudoaneurysm sac. We have described preparation of the biocomposite antibiotic material and the catheter-directed delivery technique in detail. Although the use of long-acting antibiotic materials such as antibiotic beads has been well described when performing open surgery in an infected field, the application of these materials in endovascular procedures has been less certain. The techniques we have described have the potential to promote field sterilization in a minimally invasive manner for patients with aortic infections who could be poor candidates for open surgery.

Distal pancreatectomy in cytoreductive surgery with hyperthermic intraperitoneal chemotherapy: Identifying risk and improving patient selection.

BACKGROUND: Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) has become a principal tool in the management of peritoneal carcinomatosis (PC), but inclusion of pancreatic resection to obtain optimal debulking remains controversial. METHODS: We performed a retrospective review of 419 patients with PC who underwent CRS/HIPEC. The patients were divided into two cohorts, those with distal pancreatectomy (DP) and those without (NP), and morbidity and survival outcomes were compared. RESULTS: The DP cohort (n = 37) and the NP cohort (n = 371) had similar clinicopathologic characteristics (age, p = 0.596; gender, p = 0.328; ASA, p = 0.072). Operative time, number of organs resected, and EBL were greater in the DP cohort (<0.0001). A complete cytoreduction was achieved in 90% of the NP cohort versus 69% of the DP cohort (p = 0.0004). Major perioperative morbidity was more common in those with pancreatic resection (41% vs 19%, p = 0.002). However, there was no significant difference in 90-day mortality or overall survival. CONCLUSION: Achieving complete cytoreduction is critical to improving long term outcomes for patients with PC. Although pancreatic resections are associated with higher morbidity, short-term survival is not impacted adversely. Pancreatic involvement should not be a strict exclusion criterion for CRS/HIPEC, but patients need to be selected carefully, with close attention to disease burden prior to proceeding.

Inconsistencies Between Physician-Reported Disclosures at the AAOS Annual Meeting and Industry-Reported Financial Disclosures in the Open Payments Database.

BACKGROUND: The purpose of this study was to determine the rate and type of inconsistencies between disclosures self-reported by physicians at a major academic meeting in the United States and industry-reported disclosures in the Open Payments database for a concordant time period. METHODS: Disclosures for every first and last author from the United States with a medical degree of a podium or poster presentation at the 2014 American Academy of Orthopaedic Surgeons (AAOS) Annual Meeting were collected and were compared with the disclosures reported in the Open Payments database to determine if any inconsistencies were present and, if so, within which category. RESULTS: In total, 1,925 total AAOS presenters were identified, and 1,113 met the inclusion criteria. Based on AAOS disclosures, 432 (39%) should have been listed within the Open Payments database. There were 125 presenters (11%) who reported an AAOS disclosure and thus should have been included in the Open Payments database, but were not included. An additional 259 presenters (23%) had ≥1 AAOS disclosures that were not reported or were improperly categorized in the Open Payments database. Inconsistencies were more common for authors who had significantly more poster presentations (p < 0.001), podium presentations (p = 0.01), total presentations (p < 0.001), and AAOS disclosures (p < 0.001) and a significantly higher value of payments in the Open Payments database (p < 0.001). CONCLUSIONS: In this sample, there was a 35% rate of inconsistency between physician-reported financial relationships for presenters at the AAOS Annual Meeting and industry-reported relationships published in the Open Payments database.