Surgical portosystemic shunts in the era of TIPS and liver transplantation are still relevant.

BACKGROUND: The surgical portosystemic shunts (PSS) are a time-proven modality for treating portal hypertension. Recently, in the era of liver transplantation and the transjugular intrahepatic portosystemic shunts (TIPS), use of the PSS has declined. OBJECTIVES: This study was conducted to evaluate changes in practice, referral patterns, and short- and longterm outcomes of the use of the surgical PSS before and after the introduction of the Model for End-stage Liver Disease (MELD). METHODS: A retrospective analysis of 47 patients undergoing PSS between 1996 and 2011 in a single university hospital was conducted. RESULTS: Subgroups of patients with cirrhosis (53%), Budd-Chiari syndrome (13%), portal vein thrombosis (PVT) (26%), and other pathologies (9%) differed significantly with respect to shunt type, Child-Pugh class, MELD score and perioperative mortality. Perioperative mortality at 60 days was 15%. Five-year survival was 68% (median: 70 months); 5-year shunt patency was 97%. Survival was best in patients with PVT and worst in those with Budd-Chiari syndrome compared to other subgroups. Patency was better in the subgroups of patients with cirrhosis and other pathologies compared with the PVT subgroup. Substantial changes in referral patterns coincided with the adoption of the MELD in 2002, with decreases in the incidence of cirrhosis and variceal bleeding, and increases in non-cirrhotics and hypercoagulopathy. CONCLUSIONS: Although the spectrum of diseases benefiting from surgical PSS has changed, surgical shunts continue to constitute an important addition to the surgical armamentarium. Selected subgroups with variceal bleeding in well-compensated cirrhosis and PVT benefit from the excellent longterm patency offered by the surgical PSS.

Clinical outcomes and implications of failed infrainguinal endovascular stents.

OBJECTIVE: While the influence of initial TransAtlantic InterSociety Consensus (TASC) II classification has been clearly shown to influence the primary patency of infrainguinal stenting procedures, its effect on outcomes once stent failure has occurred is less well documented. It is the objective of this paper to determine whether clinical outcomes and implications of anatomic stent failure vary according to initial TASC II classification. METHODS: Results were analyzed by TASC II classification. Kaplan-Meier survival curves were plotted and differences between groups tested by log-rank method. A Cox proportional hazards regression model was used to perform the multivariate analysis. RESULTS: During a 5-year period, 239 angioplasties and stents were performed in 192 patients. Primary patency was lost in 69 stented arteries. Failure was due to one or more hemodynamically significant stenoses in 43 patients, and occlusion in 26 patients. After primary stenting, limbs initially classified as TASC C and D were more likely to fail with occlusion (P < .0001), require open operation (P = .032), or lose run-off vessels (P = .0034) than those classified as TASC A or B. In two patients initially classified as TASC C, stent failure changed the level of open operation to a more distal site. Percutaneous reintervention was performed on 35 limbs. Successful reintervention improved the patency of TASC A and B lesions to 92%, 85%, and 64% and TASC C and D lesions to 78%, 72%, and 50% at 12, 24, and 36 months, respectively. Initial TASC classification was highly predictive of first anatomic failure (P < .0001), but it did not predict the durability of subsequent catheter based reintervention (P = .32). Ten patients with stent failure required operation, and five underwent amputation; all had failed with occlusion. Overall limb salvage was 89% and peri-procedural mortality was 0.4%. CONCLUSIONS: Following primary stenting of the superficial femoral artery (SFA) and popliteal artery, lesions classified as TASC C or D are more likely to fail with occlusion, lose run-off vessels, and alter the site of subsequent open operation than their TASC A and B counterparts. Although these complications are infrequent, they may negatively impact later attempts at revascularization, and this must be considered when deciding upon the proper treatment strategy for patients with infrainguinal occlusive disease.

Baroreceptor failure syndrome after bilateral carotid body tumor surgery.

A 41-year-old healthy man was diagnosed with bilateral carotid body tumors. The patient had a staged surgical removal of the tumors approximately 8 months apart. Postoperative recovery was uneventful after removal of the first and largest tumor; however, after removal of the second tumor, the patient developed tachycardia and hypertension. He was diagnosed with baroreceptor failure syndrome after ruling out other possible causes. Baroreceptor failure syndrome is a rare and important complication known to be associated with many conditions, one of them being inadvertent baroreceptor denervation during bilateral carotid body tumor resection. Medical management of this condition is necessary to prevent cerebrovascular events; thus, it is important for the surgeon and the internist to recognize and treat it aggressively.

Safety and outcomes following resection of colorectal liver metastases in the era of current perioperative chemotherapy.

BACKGROUND: Preoperative chemotherapy is increasingly utilized in the treatment of colorectal liver metastases (CRLM). Although this strategy may improve resectability, long-term advantages of preoperative chemotherapy for resectable CRLM are less clear. The objective of this study is to report safety and outcomes when perioperative chemotherapy is routinely added to surgery for CRLM. METHODS: A retrospective review of patients undergoing liver resections for CRLM during 2003-2011 in single academic oncology center. Demographic data, tumor characteristics, chemotherapy, surgical details, complications and survival were analyzed. RESULTS: The study included 157 patients that underwent 168 liver operations. One hundred eighteen patients (70 %) underwent preoperative chemotherapy (75 % oxaliplatin-based). Preoperative portal vein embolization was utilized in 16 (10.1 %) patients. Overall survival (OS) was 89, 57, and 27 % at 1, 3, and 5 years, respectively (median survival-42.8 months). Eleven (7 %) patients had repeat resections for liver recurrence. Thirty-day mortality was 1.26 %, morbidity-24 % (6 %-liver related). Complications were not significantly different in patients that had preoperative chemotherapy. On a multivariate analysis advanced age and >3 lesions predicted poor OS, while advanced age, lesions >5 cm, synchronous lesions, margin-positivity and resection less than hepatectomy were associated with decreased DFS. CONCLUSIONS: Our results suggest that even with chemotherapy and resection only a subset of patients remain disease-free after 5 years. However, even in a high-risk patient with multiple lesions, preoperative chemotherapy can be administered safely without apparent increase in postoperative complications. Perioperative chemotherapy should be considered particularly in patients with multifocal or large lesions, synchronous disease and short disease-free interval.

The computerized synoptic operative report: a novel tool in surgical residency education.

HYPOTHESIS: As opposed to the traditional dictated report, the use of a computer-based synoptic operative report will mandate that the surgical resident have a better understanding of all facets of the procedure. DESIGN: A prospective study over a 10-month period. SETTING: A 636-bed community teaching hospital. PATIENTS: A total of 57 consecutive patients and 60 operative procedures for breast cancer. MAIN OUTCOME MEASURES: A total of 60 consecutive breast cancer narrative operative reports, dictated by the attending surgeon, were compared with synoptic computerized operative reports filled by an operating resident. It included a total of 36 items containing data on demographics, preoperative history, diagnostic evaluation, and precise intraoperative findings. The 2 types of reports were compared for overall completeness and for the completeness of individual items. RESULTS: Comparison of the narrative and synoptic reports showed that there was significant improvement in data completeness with the use of the synoptic report. The overall analysis showed that the synoptic operating report contained 94.7% of the preoperative and operative data, whereas the dictated operative report was able to capture only 66% of the data (P < .001). Eleven of 15 items in the general and preoperative sections of the dictated report and 6 of 21 items in the intraoperative section of the dictated report were underreported compared with those same items in the synoptic report (P = .004-.001). CONCLUSION: The computerized synoptic operative report is superior to the dictated report in the documentation of important preoperative and intraoperative data. Although checklists and templates are not new in medicine, the use of a synoptic operative report as a surgical educational tool is a novel concept. Each resident who participated in our study had to develop a better understanding of the operative procedure in order to complete a more accurate synoptic report.

Carotid stenting: a surgeon's perspective.

BACKGROUND: Recent multicenter studies have determined that the results of carotid stenting (CAS) are comparable to those of endarterectomy. Because most of these trials were performed in academic centers, it will be necessary to determine whether similar results can be obtained in community settings. This study reviewed the results of a single surgeon's experience with CAS performed in a university-affiliated community hospital. STUDY DESIGN: All patients were treated with CAS during a 5-year period. Major and minor perioperative stroke and death, transient ischemic attack, myocardial infarction, restenosis, and late stroke were documented. A 2-tailed t-test was used to compare variables between groups. RESULTS: A total of 162 carotid artery stents were placed in 149 patients. Ninety-three stents (57.41%) were placed for asymptomatic stenosis, and 69 (42.59%) were placed for symptomatic carotid disease. There were 8 neurologic complications, including 3 transient ischemic attacks (1.85%), 3 minor strokes (1.85%), and 2 major strokes (1.23%). Seven of 8 neurologic events including both major strokes occurred in patients older than 80 years. Octogenarians were significantly more likely to suffer a neurologic event or stroke than those younger than 80 years (p = 0.0004 and p = 0.0179, respectively). There was 1 death within 30 days of the procedure, and there were no symptomatic myocardial infarctions. CONCLUSIONS: When CAS was performed by a vascular surgeon in patients younger than 80 years, the rate of neurologic events was acceptable and similar to the results of carotid endarterectomy in previously published studies. However, the risk of stroke is disproportionately high in octogenarians undergoing CAS. These patients may best be treated surgically.