Endovascular management of central thoracic veno-occlusive diseases in hemodialysis patients: a single institutional experience in 69 consecutive patients.

PURPOSE: To assess the functional status and long-term outcomes of endovascular management for the treatment of central veno-occlusive disease in patients undergoing hemodialysis. MATERIALS AND METHODS: Retrospective chart evaluation of 600 patients with threatened upper extremity dialysis access showed central veno-occlusive disease in 69 patients (11%; 30 women and 39 men; mean age, 63.9 years; age range, 26-92 years). A total of 92 venous segments were involved with disease. Initial endovascular procedures consisted of transvenous angioplasty (n = 88) and stent placement (n = 6); there were 134 repeat interventions (14 stents). The mean follow-up was 14.5 months (range, 1-44 months). Angiographic data were reviewed prospectively by two independent observers for the extent of veno-occlusive disease. Technical failures were defined as residual stenosis of at least 30% or lesions that were unable to be dilated or crossed. Statistical analysis, including interobserver agreement and Kaplan-Meier analysis, was performed. RESULTS: Technical success rates for initial and follow-up interventional procedures were 90% (81 of 92 segments) and 96% (129 of 134 interventions), respectively. Two complications required treatment with interventional procedures. There was excellent interobserver agreement (kappa = 0.84; 95% confidence interval: 0.67, 0.93) for grading the degree of venous stenoses. Primary patency rates of hemodialysis access at 1, 6, and 12 months were 81%, 46%, and 22%, respectively, which significantly (P = .001) improved to assisted patency rates of 91%, 77%, and 63% at 1, 6, and 12 months, respectively. CONCLUSIONS: Endovascular management including a combination of angioplasty and selective stent placement can be effectively used to treat central veno-occlusive disease and preserve functional access in patients with threatened upper extremity dialysis access.

Change in practice patterns of an academic division of vascular surgery.

HYPOTHESIS: Technological advances have required that faculty of academic divisions of vascular surgery acquire new technical skills and significantly alter their past clinical practice patterns. DESIGN: Retrospective medical record review. SETTING: An academic tertiary referral center and a community teaching hospital. PATIENTS: All patients undergoing 10 specific vascular procedures during a 5-year period. MAIN OUTCOME MEASURES: We analyzed volumes for 10 specific open and endovascular index procedures performed by 5 vascular surgeons during a 60-month period. Procedures reviewed included open abdominal aortic aneurysm repair, endovascular abdominal aortic aneurysm repair, carotid endarterectomy, carotid artery stent, suprainguinal arterial reconstruction, suprainguinal percutaneous transluminal angioplasty/stent (PTA/S), infrainguinal arterial reconstruction, infrainguinal PTA/S, renal and visceral arterial reconstruction, and renal and visceral PTA/S. In-hospital length of stay was compared between open procedures and their endovascular counterparts. RESULTS: In 2000, 453 open and 44 endovascular index procedures were performed. In contrast, by 2005, open index cases had decreased by 47.0% (239) and endovascular index cases had increased by 679.5% (299). Open abdominal aortic aneurysm repairs had decreased by 54.5% (68 vs 31), carotid endarterectomies by 28.8% (139 vs 99), suprainguinal arterial reconstructions by 47.5% (40 vs 21), infrainguinal arterial reconstructions by 56.5% (186 vs 81), and renal/visceral arterial reconstructions by 65.0% (20 vs 7). In 2005, 62 endovascular abdominal aortic aneurysm repairs and 45 carotid stents were performed, whereas none were performed in 2000. In addition, infrainguinal PTA/S had increased by 675.0% (12 vs 81) and suprainguinal PTA/S by 20.0% (20 vs 24). CONCLUSIONS: Although the total number of procedures performed has remained relatively constant, there has been a dramatic increase in the number of endovascular procedures as well as an associated decline in the number of open procedures. This change in practice pattern has allowed the members of our division to maintain a significant role in the care of patients undergoing vascular surgery, as evidenced by stable overall procedural volume. This will provide a platform for future outcome-related analyses of open vs endovascular procedures performed within a single specialty group.

Intraoperative fluid replacement and postoperative creatine phosphokinase levels in laparoscopic bariatric patients.

BACKGROUND: Morbid obesity and bariatric surgery are both risk factors for the development of postoperative rhabdomyolysis (RML). RML results from injury to skeletal muscle, and a serum creatine phosphokinase (CK) level >1,000 IU/L is considered diagnostic of RML. The aim of this study was to determine if intraoperative intravenous fluid (IVF) volume affects postoperative CK levels following laparoscopic bariatric operations. STUDY DESIGN: Prospective, single blinded, and randomized trial was conducted. METHODS: Patients scheduled to undergo laparoscopic sleeve gastrectomy, adjustable gastric band, or Roux-en-Y gastric bypass operations were randomized into two groups. Subjects in Group A received 15 ml/kg total body weight (TBW) of IV crystalloid solution during surgery, while subjects in Group B received 40 ml/kg TBW. Preoperative and postoperative CK and creatinine levels and intra- and postoperative urine output were monitored and recorded. RESULTS: Forty-seven patients were assigned to Group A and 53 patients to Group B. Group B patients had significantly higher urine output in the operating room, in the post-anesthesia care unit (PACU), and on postoperative days 0 and 1. Group B patients also had significantly lower serum creatinine level in the PACU and a trend towards lower creatinine levels on postoperative days 0, 1, and 2. There were no statistical differences in CK levels at any time between the two groups. Four patients in Group A and three patients in Group B developed postoperative RML. CONCLUSIONS: Conservative (15 ml/kg) versus liberal (40 ml/kg) intraoperative IVF administration did not change the incidence of RML in patients undergoing laparoscopic bariatric operations. Since the occurrence of RML in this patient population is relatively high, postoperative CK levels should be routinely obtained in patients at special risk.

Benefits to patients choosing preoperative weight loss in gastric bypass surgery: new results of a randomized trial.

BACKGROUND: Historically, preoperative weight loss has been encouraged for patients undergoing gastric bypass surgery to decrease liver mass, technically facilitating the procedure. In an earlier prospective randomized trial investigating effects of preoperative weight loss on patients' clinical outcomes, we reported no differences in postoperative complications or weight-loss profiles at 6-month followup. This article demonstrates results of the same study, with 1-year followup. STUDY DESIGN: One hundred consecutive patients in an 18-month period preparing to undergo gastric bypass surgery at Stanford University Medical Center were selected. Fifty patients were randomly assigned to lose 10% or more of their excess body weight preoperatively, and 50 patients were assigned to no preoperative weight-loss requirements. After 1 year, patient demographics and data on postoperative complications, cure or improvement of comorbidities, and differences in weight-loss profiles were collected. RESULTS: At 1 year, the 2 groups had similar preoperative demographics and body mass indexes (BMIs). Patients in the weight-loss group, on average, lost 8.2% of their excess body weight preoperatively compared with the nonweight-loss group, which gained 1.1% (p = 0.007). After a year, the patients in both arms of the study showed no difference in weight, BMI, excess weight-loss, and number of remaining comorbidites. But when patients were divided according to those who had lost at least 5% of their excess body weight preoperatively, the 1-year results for excess weight-loss, weight, and BMI were much lower for the weight-loss group. CONCLUSIONS: Preoperative weight loss in patients undergoing gastric bypass surgery is safe and feasible. It should be encouraged, because it will markedly improve longterm weight loss.

Comparison of hospital charges between robotic, laparoscopic stapled, and laparoscopic handsewn Roux-en-Y gastric bypass.

The feasibility and safety of laparoscopic and robotic Roux-en-Y gastric bypass (RRYGB) have been established. To evaluate the cost-effectiveness of robotic surgery we compared the hospital charges for robotic, laparoscopic stapled (SRYGB), and laparoscopic handsewn Roux-en-Y gastric bypass (HRYGB) at our institution. One hundred thirty-five consecutive patients undergoing Roux-en-Y gastric bypass at Stanford University Medical Center by handsewn, stapled or robotic techniques from 1 July 2005 to 31 December 2005 were evaluated. Medical records of these patients were retrospectively reviewed and the following variables were collected and analyzed: age, gender, body mass index (BMI), number of preoperative comorbidities, length of stay (LOS), operating and anesthesia times, postoperative complications, mortality, professional fees, and hospital and total charges. Twenty-one RRYGB, 78 SRYGB, and 36 HRYGB were performed during the study period. Comparison of the above three groups demonstrated no statistically significant differences in age, gender, BMI, number of preoperative comorbidities, LOS, operating and anesthesia times, postoperative complications, mortality or professional fees. Total charges were higher for RRYGB (US $77,820) when compared with SRYGB (US $66,153) but not when compared with HRYGB (US $68,814). RRYGB higher hospital charges resulted in higher total charges when compared with SRYGB and HRYGB. These differences do not reflect actual cost to the hospital.