Small Caliber Distal Cephalic Veins Undergo Significant Dilation under Anesthesia and Can Successfully Be Used for Arteriovenous Fistula Creation.

BACKGROUND: Successful arteriovenous fistula (AVF) maturation and use for dialysis is highly dependent on preoperative diameter. Small veins (<2 mm) exhibit high failure rates and are typically avoided. This study investigates the effects of anesthesia on the distal cephalic vein diameter as compared to preoperative outpatient vein mapping for the purpose of hemodialysis access creation. METHODS: One hundred eight consecutive procedures for dialysis access placement met inclusion criteria and were reviewed. All patients received preoperative venous mapping and postanesthesia ultrasound mapping (PAUS). All patients received either regional and/or general anesthesia. A multiple regression was conducted to determine predictors of venous dilatation. The independent variables included both demographical and operative-specific variables such as the type of anesthesia. Outcomes of fistula maturation (successful cannulation and dialysis) were analyzed. RESULTS: In this cohort, the mean preoperative vein diameter was 1.85 mm and the mean PAUS diameter was 3.45 mm, a 2.21× increase, with only 2 patient veins failing to increase in diameter. Smaller veins (<2 mm) exhibited significantly more dilation than larger veins after anesthesia (2.73 vs. 1.47×, P < 0.001). In the multiple regression analysis, smaller vein diameter was correlated with a significantly greater degree of dilation (P < 0.001). The degree of venous dilation was not affected by patient demographic-specific factors or by the type of anesthesia (regional block versus general) in the multiple regression analysis. 6 month follow-up data for fistula maturation was available for 75 of 108 patients. Small veins (<2 mm) on preoperative ultrasound matured at a similar rate as larger veins (90% vs. 91.4%, P = 0.833). CONCLUSIONS: Small caliber distal cephalic veins experience a significant degree of dilation under regional and general anesthesia and can successfully be used for AVF creation. Consideration should be made to perform a postanesthesia vein mapping for all patients undergoing access placement despite preoperative venous mapping results.

A Reevaluation of the Gritti-Stokes (Above-Knee) Amputation for the Nonambulatory Patient.

OBJECTIVE: To reevaluate the benefits of a Gritti-Stokes amputation (GSA), as an alternative to the traditional above-knee amputation (AKA), in patients who are nonambulatory or not a candidate for a below-knee amputation (BKA). TECHNIQUE: A fish-mouth incision is fashioned below the tibial tuberosity into the popliteal crease, resulting in an anterior soft tissue flap and smaller posterior soft tissue flap. Thus the incision line will be on the posterior thigh, instead of the end of the stump. The patellar tendon is detached from the anterior tibial tuberosity, then the dissection is carried proximally behind the patellar tendon and the adjoining tendons of the vastus medialis and vastus lateralis, until the patella can be flipped over to expose the posterior patellar surface and joint capsule. The patellar's posterior surface is shaved down flat to medulla bone, with an electric small-toothed bone saw and large bur. The femur is then cleared circumferentially at its base. The foot is then placed at 90°, creating a 45-degree angle between the femur and the tibia, and the femur is then transected with a Gigli saw near the base or just above the base, depending on the size of the patellar surface area. This creates a 45-degree angle to the femur posteriorly, which allows the shaved patella to be secured to the end of the femur, with less chance of shifting. The fascia is then circumferentially closed around the patella and femur. Then, the remnant patellar tendon is sutured to the tendons of the posterior compartment. The dermis and skin are then closed in the standard tension-free manner using 2-0 interrupted vicryl sutures, followed by interrupted 2-0 nylon vertical mattress sutures. The dressing consisted of a single layer of ADAPTIC Non-Adhering Dressing to allow drainage, gauze fluffs, 6-inch kerlix, and finally a 6-inch ACE wrap was applied. The dressings are left intact for 2-3 days and then replaced daily thereafter. METHODS: A retrospective chart review was performed to identify patients who had undergone a GSA from January 2016 to September 2017 by a single surgeon. Estimated blood loss (EBL), operative time, and perioperative and postoperative complications were assessed. RESULTS: A total of 16 GSAs were performed on 15 patients by a single surgeon between January 7, 2016 and September 19, 2017. In our series, intraoperative outcomes were notable for an average EBL of 114 mL, lower than the traditional AKA (average EBL: 300-500 mL) with comparable operative times as short as 90 min (skin incision to dressing). No transfusions were required in the GSA group (postop days: 1-4) compared with traditional AKA group which required an average of 2.1 units. Postoperative outcomes showed low complication rates. Postoperative complications were limited to 2 cases of a stump infection, which were treated with local wound care and subsequently healed completely. One patient died from septic shock secondary to pneumonia unrelated to the GSA surgery. CONCLUSIONS: A reevaluation of the GSA in the nonambulatory patient population is warranted in the United States as an alternative to the traditional AKA whenever possible. Our experience with a small series of GSA's has yielded promising advantages including potential for decreased blood loss and fewer complications in the postoperative period when compared with the standard AKA. Retained muscle attachments facilitate increased limb function and allow use of slide joint prosthetics, which are gaining popularity for ambulatory patients. The thickened skin and subcutaneous tissues overlying the patella, and the posterior incision have the potential benefit of protection against trauma and osteomyelitis seen with traditional AKA, in which case the open ended medullary bone is deep to the incision. We believe that for these same reasons the GSA should be considered in the nonambulatory patient as well.

The Benefits of a Muscle-Sparing Below Knee Amputation in the Elderly Population.

BACKGROUND: It is well accepted that good muscle coverage of the bones at the end of a below knee amputation (BKA) stump is preferable, for both weight bearing and protection against prosthesis failure. Elderly patients often have atrophy of the leg musculature secondary to age-related physiological changes and decreased use. These patients often have poor coverage and bulk in their stumps after the standard BKA. We propose a selective muscle-sparing approach to these patients, utilizing selective removal of muscle bundles with regard to their blood supply and fascial planes. The surgical method technique along with outcomes of patients undergoing the procedure is presented here. METHODS: A retrospective chart review was performed to identify patients who had undergone a muscle-sparing BKA from March 2008 to October 2017 by a single surgeon. Estimated blood loss, operative time, and perioperative and postoperative complications were assessed. RESULTS: Forty-six patients greater than 60 years of age underwent muscle-sparing BKA procedures. Complete healing was seen in 30 (65%) patients, while 7 (15%) were lost to follow-up and 9 (20%) required conversion to an above knee amputation (AKA). Intraoperative outcomes in our series were notable for an average estimated blood loss (EBL) of 84.3 ml, lower than the traditional BKA (average EBL 150-500 ml), with comparable operative times averaging 131 minutes and as short as 85 minutes (skin incision to dressing). No patients in the cohort required postoperative blood transfusions (day 0-4), significantly less than the reported 3-7 ml/kg body weight blood requirements in similar patient populations. CONCLUSIONS: The muscle-sparing BKA technique should be considered in elderly patients, where the normally bulky posterior calf muscle mass is lacking. The selective removal of muscle bundles with regard to their blood supply leaves maximum coverage of the bone with decreased potential hematoma formation and blood loss.

Incidental Appendiceal Tumors During Appendectomy: A Nineteen-Year Retrospective Review at a Municipal Hospital.

Non-operative management of appendicitis (NOMA) has recently gained popularity, but a concern is that NOMA might miss appendiceal neoplasms. We conducted a retrospective review of 1694 appendectomies done for acute appendicitis at our institution between January 2001 and December 2019 to study the incidence and distribution of appendiceal tumors. We identified 24 appendiceal neoplasms (1.43%), including 9 Low Grade Appendiceal Mucinous Neoplasms (LAMNs), 6 neuroendocrine tumors (NETs), 6 mucoceles, and one each of adenocarcinoma, endometrioma, and neurofibroma. Tumor occurrence had two age peaks, with LAMNs prominent in the 5th and 6th decades of life and NETs in the 2nd and 3rd decades. All patients under age 40 had benign disease. Presence of appendicoliths was independent of the presence of neoplasms. All cases were managed per National Comprehensive Cancer Network (NCCN) guidelines, with twenty cases cured by appendectomy alone. Given these, we conclude that NOMA is safe for patients under 40.