Technical approach and outcomes of failed infrarenal endovascular aneurysm repairs rescued with fenestrated and branched endografts.

BACKGROUND: Endovascular rescue of failed infrarenal repair (EVAR) has emerged as an attractive option to stent graft explantation. The procedure, however, is underutilized due to limited devices accessibility and the challenges associated with their implantation in this patient population. The purpose of this study was to report our outcomes and discuss our approach to rescuing previously failed infrarenal endovascular aneurysm repairs (EVAR) with fenestrated/branched endografts (f/b-EVAR). METHODS: A retrospective analysis of prospectively collected data of consecutive patients with failed EVAR rescued with f/b-EVAR at our institution from November 2013 to March 2019 was conducted. The study primary end point was technical success; defined as the implantation of the device with no type I a/b or type III endoleak or conversion to open repair. Secondary endpoints included major adverse events (MAEs), graft patency and reintervention rates. RESULTS: During this time, 202 patients with complex aortic aneurysms were treated with f/b-EVAR. Of these, 19 patients (Male: 17, mean age 79 ± 7 years) underwent repair for failed EVAR. The median time from failed repair to f/b-EVAR was 48 (30, 60) months. Treatment failure was attributed to stent graft migration in 9 (47.4%) patients, disease progression in 5 (26.3%), short initial neck in 3 (15.8%) and unable to be determined in 2 (10.5%). Three patients were treated urgently with surgeon modified stent graft. Technical success was achieved in 18 patients (95%), including two who had undergone emergent repair for rupture. Seventy-two targeted vessels (97.3%) were successfully incorporated. Sixteen (84.2%) patients required a thoracoabdominal repair to achieve a durable seal. Major adverse events (MAEs) occurred in 3 patients (15.7%) including paralysis and death in one (5.3%), compartment syndrome and temporary dialysis in another and laparotomy with snorkeling of one renal and bypass of the other in the third patient. Median (IQR) hospital length of stay was 3 (2, 4) days. Late reintervention, primary target vessel patency and primary assisted patency rates were 5.3%, 98.6% and 100%, respectively. CONCLUSION: Implantation of f/b-EVAR in patients with failed previous EVAR is a challenging undertaking that can be performed safely with a high technical success and low reintervention rates.

Single-center experience with complex abdominal aortic aneurysms treated by open or endovascular repair using fenestrated/branched endografts.

OBJECTIVE: The objective of this study was to evaluate outcomes of patients with complex abdominal aortic aneurysms (cAAAs) treated with open repair (OR) or fenestrated/branched endovascular aneurysm repair (F/B-EVAR) from a single center. METHODS: A retrospective analysis of consecutive patients with cAAAs treated electively by OR or F/B-EVAR between January 2010 and February 2017 was conducted. Demographics of the patients, cardiovascular risk factors, procedure time, number of vessels incorporated, radiation dose, estimated blood loss, intensive care unit (ICU) length of stay (LOS), and hospital LOS were recorded. End points included target vessel patency, aneurysm rupture, freedom from reintervention, and major adverse events (MAEs). RESULTS: During this period, 153 patients (OR, 69; F/B-EVAR, 84) underwent repair of cAAA. The majority were male (OR, 55; F/B-EVAR, 64), with a mean age of 75.8 ± 7.6 years (F/B-EVAR) and 71.2 ± 7.9 years (OR). Patients in the F/B-EVAR group were more likely to be American Society of Anesthesiologists class 3 and 4 (60% vs 0%; P < .001) and had a higher median Society for Vascular Surgery/American Association for Vascular Surgery comorbidity severity score (15 vs 7; P < .001). A total of 235 vessels were targeted in the F/B-EVAR group, with a technical success of 97.6%. Thirty-one patients in the OR group required concomitant renal artery revascularization. Transfusion requirements (100% vs 1.2%), MAEs (40.6% vs 13.1%), procedure length (304 minutes vs 140 minutes), estimated blood loss (2246 mL vs 165 mL), ICU LOS (3 days vs 1 day), and hospital LOS (7 days vs 2 days) were higher (P < .001) in the OR group compared with the F/B-EVAR group. The 30-day mortality was 2.9% and 2.4% (P = .84) in the OR group and F/B-EVAR group, respectively. Supraceliac clamp site was associated with increased incidence of postoperative renal insufficiency. A decrease in procedure time, contrast volume, fluoroscopy time, and fluoroscopy dose was noted in the F/B-EVAR group with increasing experience even as case complexity increased. More patients were discharged home after F/B-EVAR (97.6% vs 59.4%; P < .001). With a mean follow-up of 31 months (F/B-EVAR, 17 months; OR, 48 months), the rate of secondary intervention was 3.7% and 5.8% (P = NS) for F/B-EVAR and OR, respectively. Freedom from branch instability and reintervention was 99% (95% confidence interval, 96.2%-99.8%) and 96% (95% confidence interval, 87.1%-98.6%), respectively. CONCLUSIONS: Results of this "real-world" experience suggest that the use of F/B-EVAR for the treatment of cAAAs in high-risk surgical patients is safe and effective and has comparable short-term results to those of low-risk patients undergoing OR. Patients treated by F/B-EVAR had shorter ICU and hospital LOS, lower MAEs, and faster convalescence. A decrease in procedure time and radiation dose was noted as experience was gained, even as complexity increased.

Diagnosis, Management, and Outcome of Aortitis at a Single Center.

BACKGROUND: Aortitis is a rare condition with inflammatory or infectious etiology that can be difficult to diagnose due to the highly variable clinical presentation and nonspecific symptoms. However, current literature on the diagnosis, management, and prognosis of aortitis is extremely scarce. METHODS: We retrospectively reviewed all patients' charts who were diagnosed with giant cell arteritis, Takayasu arteritis, or noninfectious aortitis presenting at a single center between January 1, 2009, and April 17, 2015. Data collected included demographics, medical history, comorbidities, laboratory and imaging data, management, and outcome. RESULTS: Among the included 15 patients presenting with aortitis at our center, 53% were diagnosed with Takayasu arteritis, 33% with idiopathic inflammatory aortitis, and 13% with giant cell arteritis. All patients received steroid treatment, 67% received adjunctive immunosuppressants or immunomodulators, and 33% underwent interventional procedures. Based on clinical presentation and laboratory and imaging findings at the last follow-up visit for each patient, 67% showed improvement, 27% had no change in disease activity, and 7% had a progression of the disease. CONCLUSIONS: Takayasu arteritis was found to be more common than idiopathic inflammatory aortitis and giant cell arteritis among our 15 cases diagnosed with aortitis. All patients received medical therapy and 33% received interventional procedures, leading to 67% improvement of disease activity or related complications. This article also offers a comprehensive review of the diagnosis, management, and outcome of aortitis, supplementing the very limited literature on this disease.

A Dedicated Surveillance Program Improves Compliance with Endovascular Aortic Aneurysm Repair Follow-up.

BACKGROUND: Current recommendations suggest lifetime follow-up for endovascular aortic aneurysm repair (EVAR) patients to avoid consequences associated with endoleak and aneurysm enlargement. Follow-up compliance has been reported between 43% and 92%, with most single-center studies citing successful follow-up surveillance at less than 60%. We investigated follow-up completeness with a defined surveillance program and subsequent secondary intervention prevalence from a single center. METHODS: Our surveillance program notified patients of the need for follow-up imaging and surgeon review. Data were obtained from retrospective review of a prospective database, including operative and follow-up details, follow-up imaging completeness, endoleak incidence, and secondary intervention prevalence. RESULTS: Five hundred seventeen patients received elective EVAR from 2005 to 2015. Surveillance was achieved in 425 (82.3%). Mean number of follow-up studies was 4.2 ± 2.9 and median time to first follow-up was 36 days. Four hundred forty-eight patients (86.7%) had freedom from intervention. Sixty-nine unique patients (13.3%) had 107 secondary interventions. Median time to first secondary intervention in 69 patients was 476 days. Mean number of imaging studies for secondary intervention patients was 6.1 ± 3.9, compared with mean 3.4 ± 2.3 for patients without (P < 0.001). Overall mortality was 24.6% (n = 127), including 32 deaths of unknown cause (6.2% overall) and 95 of non-EVAR-related causes (18.3%). No aneurysm-related deaths were reported. CONCLUSIONS: Regular post-EVAR surveillance through a dedicated program resulted in a high rate of follow-up compliance, 13.3% rate of secondary intervention, and low aneurysm-related mortality. Careful lifetime surveillance remains important in long-term care following elective EVAR.

A prospective randomized comparison of contralateral snare versus retrograde gate cannulation in endovascular aneurysm repair.

OBJECTIVE: The objective of this study was to compare snare vs the standard retrograde gate cannulation method during endovascular aneurysm repair to determine the most efficient technique and to evaluate whether time was affected by graft design or the surgeon's experience. METHODS: This was a prospective randomized study involving single-center elective endovascular aneurysm repairs. Patients were randomized to the snare or retrograde group in a 1:1 ratio. The initial method was attempted for 15 minutes; if it was unsuccessful, the team switched to the alternative technique for an additional 15 minutes. The protocol continued until success was achieved. Data collected on demographic, anatomic, and procedural factors were analyzed for statistically significant differences. RESULTS: A total of 101 patients were included. Average age was 75.3 years, and 82% were male; 49 patients were randomized to snare and 52 to retrograde cannulation. The groups were overall similar. Median cannulation times were 3.9 minutes for the snare and 2.7 minutes for the retrograde technique (P = .13). The snare group attempts were successful within the initial 15-minute period in all but one patient (98% success). In the retrograde group, 5 of the 52 (10%) crossed over to snare. This difference did not reach statistical significance (P = .11). A difference was seen in the extremes of cannulation times. The surgeon's experience and graft design were not found to have significant effects on cannulation times. Further analysis of the retrograde group patients with long cannulation time found a relative breakpoint at the 5-minute mark. In those exceeding this time mark, the chance of eventual cannulation within 15 minutes dropped to 67%. In this group, median time to cannulation was 12.2 minutes for retrograde compared with 7.1 minutes for snare after crossover. CONCLUSIONS: Gate cannulation was successful using both methods with no statistical difference between the two in median time. Retrograde cannulation was found to be more likely to have short times. If cannulation by retrograde technique had not been achieved in the first 5 minutes, the chances of eventual success dropped significantly, and crossover to snare was more efficient. This finding suggests that one should consider an alternative method of gate cannulation if it has not been accomplished within this time.

Preoperative Inferior Mesenteric Artery Embolization: A Valid Method to Reduce the Rate of Type II Endoleak after EVAR?

BACKGROUND: Type II endoleak is the most commonly encountered endoleak after endovascular abdominal aortic aneurysm repair (EVAR). Some have advocated preoperative inferior mesenteric artery (IMA) embolization as a valid method for reducing the incidence of this endoleak, but controversies exist. We sought to demonstrate the impact of IMA embolization using a meta-analysis of currently available studies combined with our own experience. METHODS: We conducted an institutional review board-approved, retrospective analysis of all patients undergoing IMA embolization before EVAR between the years 2010 and 2015 and used as a control a similar group of patients with patent IMA. We divided patients from our own experience and 5 other studies into 2 groups: those who did not undergo IMA embolization (control) before EVAR and those who did. Rates of type II endoleaks, aneurysm sac regression, and secondary interventions were analyzed. RESULTS: A total of 620 patients from 6 studies were analyzed, including 258 patients who underwent an attempted IMA embolization before EVAR with a cumulative success rate of 99.2% (range, 93.8% to 100%). There was 1 fatality associated with IMA embolization. A meta-analysis showed that preoperative IMA embolization protected against type II endoleaks compared to the control group (odds ratio [OR], 0.31 [0.17-0.57]; P < 0.001, I2 = 43%). Furthermore, the rate of secondary intervention was significantly lower in the treatment group (OR, 0.12 [0.004-0.36]; P < 0.001, I2 = 0%). After IMA embolization, type II endoleak resulted from patent lumbar arteries in all 62 patients with persistent endoleak. CONCLUSIONS: Preoperative embolization of the IMA protects against the development of type II endoleaks and secondary interventions and may potentially lead to a rapid aneurysm sac regression. The procedure can be performed with a high technical success rate and minimal complications and should be considered in patients with IMA >3 mm before EVAR. A randomized trial, however, is required to clearly delineate the clinical significance of this technique.

Arterial Embolisms and Thrombosis in Upper Extremity Ischemia.

OBJECTIVE: Upper extremity ischemia (UEI) is an uncommon condition that can lead to permanent disability. There is a limited understanding of the etiology, management, and outcomes of the disease. METHODS: We retrospectively reviewed the charts of all patients who were diagnosed with "embolism and/or thrombosis of arteries of upper extremity" at our institution from January 2005 to December 2013. RESULTS: Patients diagnosed with embolisms were older (P < .001), more likely to undergo thromboembolectomy (P < .001), had higher rates of hypertension (P = .001), and had longer lengths of hospital stay (P = .002). There were no significant differences in complications or mortality at 30 days and up to 1 year. CONCLUSION: At our center, embolism was found to be the most common etiology for UEI followed by thrombosis and stenosis. Patients presented with embolism were older, were more likely to undergo thromboembolectomy, and had higher rates of hypertension and longer hospital stays.

Endovascular Repair of Descending Thoracic Aorta in Loeys-Dietz II Syndrome.

Loeys-Dietz syndrome (LDS) is an autosomal dominant disorder that is predominantly characterized by involvement of the aorta, manifesting as aneurysmal dilatation or aortic dissection. Patients with LDS manifest with spontaneous aneurysms and dissections of central and peripheral arterial beds. We present 2 cases of young male patients with Loeys-Dietz II aortopathy, who manifested with spontaneous intimal tear of descending thoracic aorta and contained aortic rupture. Both patients were managed by endovascular repair, with collaborative efforts of teams comprising interventional cardiologists and radiologists, and a vascular surgeon.

Hyperbaric oxygen treatment outcome for different indications from a single center.

BACKGROUND: Hyperbaric oxygen (HBO) is used as an adjunctive therapy for a variety of indications. However, there is a lack of high-quality research evaluating HBO treatment outcomes for different indications available in the current literature. METHODS: We retrospectively reviewed all patients who underwent HBO therapy at a single hyperbaric center from January 2010 to December 2013 using predetermined criteria to analyze successful, improved, or failed treatment outcomes for the following indications: chronic refractory osteomyelitis, diabetic foot ulcer, failed flap or skin graft, osteoradionecrosis, soft tissue radiation necrosis, and multiple coexisting indications. RESULTS: Among the included 181 patients treated with adjunctive HBO at our center, 81.8% had either successful or improved treatment outcomes. A successful or improved outcome was observed in 82.6% of patients treated for chronic refractory osteomyelitis (n = 23), 74.1% for diabetic foot ulcer (n = 27), 75.7% for failed flap or skin graft (n = 33), 95.7% for osteoradionecrosis (n = 23), 88.1% for soft tissue radiation necrosis (n = 42), and 72.4% for multiple coexisting indications (n = 29). Among 4 patients treated for other indications, 100% of the cases were either successful or improved. CONCLUSIONS: This study has provided a comprehensive outcome survey of using HBO for the previously mentioned indications at our center. It supplements the literature with more evidence to support the consideration of HBO in different indications.

The success and safety of endovenous ablation in patients with previous superficial venous thrombosis: a retrospective case-control study.

OBJECTIVES: Retrospective case-control study to determine the failure and endovenous heat-induced thrombosis (EHIT) rates of endovenous ablation (EVA) in patients with a history of superficial venous thrombosis (SVT). METHODS: Study and control groups each consisted of 73 patients with or without the history of SVT, who underwent EVA between June 2010 and July 2012. All patients were followed with venous duplex ultrasound. Procedural failure and EHIT rates were considered primary outcomes. RESULTS: There was no difference in EHIT or failure rates between study and control groups (P = 1.00). There was no difference in EHIT or failure rates between patients with and without the history of venous thromboembolism (VTE), with and without the history of VTE and/or SVT, with and without the history of thrombophilia, and on and off anticoagulation for either group or the combined study population. For the combined study population, failure rate was higher in patients with a history of VTE. CONCLUSIONS: Although EVA seems to be safe and effective in patients with a history of SVT, vein access in this patient group might require multiple attempts.

Chronic venous ulcer: minimally invasive treatment of superficial axial and perforator vein reflux speeds healing and reduces recurrence.

BACKGROUND: Chronic venous ulcer (CVU) is common and is responsible for significant health care expenditures worldwide. Compression is the mainstay of treatment, but long-term compliance with this therapy is often inconsistent, particularly in the elderly and infirm. Surgical ablation of axial and perforator reflux has been used as an adjunct to compression to reduce recurrence rates and assist healing. These surgical techniques are being replaced by minimally invasive procedures, such as thermal ablation and foam sclerotherapy, in the treatment of uncomplicated venous disease. The role for these techniques in the treatment of CVU is just beginning to be defined. METHODS: Eighty-six patients with CVU with 95 active ulcers (Clinical, Etiology, Anatomy, Physiology-CEAP clinical class 6) presenting to a multispecialty wound clinic were retrospectively reviewed and analyzed by leg. All patients underwent duplex scanning for venous insufficiency. Ulcer dimensions at each visit were recorded and used to calculate healing rates. Presence or absence of ulcer recurrence at 1-year follow-up was recorded. Ulcers treated with compression alone ("compression group") were compared with those treated with compression and minimally invasive interventions, such as thermal ablation of superficial axial reflux and ultrasound-guided foam sclerotherapy (UGFS) of incompetent perforating veins and varicosities ("intervention group"). RESULTS: The average age in the intervention and compression groups was 67 and 71 years, respectively (P = not significant [NS]). Body mass index was 32.4 ± 9.5 and 33.6 ± 11.8 kg/m(2), in the compression and intervention groups, respectively (P = not significant [NS]). Ulcers were recurrent in 42% of the intervention group and 26% of the compression group (P = NS). In the intervention group, 33% had radiofrequency ablation of axial reflux, 31% had UGFS of perforators, and 29% had both treatments. The only complication of intervention was a single case of cellulitis requiring hospitalization. Compared with the compression group, the ulcers in the intervention group healed faster (9.7% vs. 4.2% per week; P = 0.001) and showed fewer recurrences at 1-year follow-up (27.1% vs. 48.9 %; P < 0.015). Multivariate analysis showed use of intervention was the strongest determinant of healing with a coefficient of variation of 7.432, SE 2.406, P = 0.003. Analysis of just the intervention group before and after intervention using matched pairs showed acceleration of healing after intervention from ranging from a median of 1.2% (interquartile range [IQR], 14.3) to 9.7% (IQR, 11.3) per week (P ≤ 0.001). CONCLUSIONS: Minimally invasive ablation of superficial axial and perforator vein reflux in patients with active CVU is safe and leads to faster healing and decreased ulcer recurrence when combined with compression alone in the treatment of CVU.

Outcomes related to antiplatelet or anticoagulation use in patients undergoing carotid endarterectomy.

BACKGROUND: The number of cases involving patients undergoing vascular procedures who are prescribed clopidogrel or warfarin as treatment options continues to rise. Our aim was to examine outcomes related to antiplatelet or anticoagulation therapy in patients undergoing carotid endarterectomy (CEA). METHODS: A retrospective review of 260 consecutive patients undergoing CEA. Data including patient demographics, operative details, perioperative use of aspirin (ASA), clopidogrel, or warfarin, and early and/or late outcome(s) were collected. Endpoints included postoperative morbidity and/or mortality rate(s) and bleeding complications. RESULTS: The study included 152 men and 108 women (mean age = 69.3 years), with a mean follow-up of 406 days. In all, 46% of endarterectomies were for a symptomatic disease. The technique of eversion endarterectomy was applied in 126 (48.5%), Dacron-patch in 112 (43.1%), and bovine pericardial-patch in 14 (5.4%) of the cases. Among the patients, 171 were taking ASA, 50 were taking clopidogrel ± ASA, and 10 were taking warfarin (mean INR = 1.62; range, 1.2-2.1); the remaining 29 were not on any antiplatelet therapy. All patients who were on warfarin therapy underwent an eversion endarterectomy. Overall, there were 19 (7.3%) complications (12 major and seven minor). The 30-day stroke rate and stroke death rate was 0.7% and 1.1%, respectively. Patients taking clopidogrel developed more number of neck hematomas (16% vs. 1.7%, p = 0.0004) compared with patients who were on ASA alone. For patients taking clopidogrel, Dacron-patch repair resulted in more hematomas than eversion endarterectomy (35% vs. 4.2%, p = 0.012). There was no difference in the incidence of neck hematoma on the basis of endarterectomy technique in patients who were on ASA alone. The patients taking warfarin neither had a perioperative complication nor developed a neck hematoma. CONCLUSIONS: In this study, clopidogrel use during CEA resulted in a significant risk for developing a neck hematoma, particularly when using a Dacron-patch. The risk of a neck hematoma in patients who were on clopidogrel was much less when an eversion endarterectomy was performed.

A rapid ultra-performance liquid chromatography/tandem mass spectrometric methodology for the in vitro analysis of Pooled and Cocktail cytochrome P450 assays.

Drug-drug interaction evaluations of new pharmaceutical candidates are critical to preventing drug withdrawal and are routinely determined through the use of cytochrome P450 assays. The measurement of the effect of test compounds on the metabolism of known substrates allows for the determination of specific CYP450 isoenzyme inhibition and calculation of IC50 values. A sensitive, high-throughput ultra-performance liquid chromatography/tandem mass spectrometric (UPLC/MS/MS) method is presented for the evaluation of CYP450 inhibition. The assay was performed using a cocktail of probe substrates and the results were compared to those obtained with the more time-consuming methodology utilizing individual substrates. The use of a high-resolution, sub-2 microm particle, LC system allowed for a high-throughput assay of just 1 min. The extra resolution of the UPLC/MS/MS system allowed for the complete resolution of the analytes, with a fast switching MS for comprehensive data collection. The CYP450 inhibition results obtained using the substrate cocktail approach were found to be essentially identical to those obtained using individual substrates.

Addressing the analytical throughput challenges in ADME screening using rapid ultra-performance liquid chromatography/tandem mass spectrometry methodologies.

High-throughput ADME screening for compound drug development properties has become an essential part of the modern drug discovery process, allowing more informed decisions to be made on the best compounds to take forward in the discovery/development process. This however is a time-consuming process requiring multiple tests to be performed, demanding a significant amount of liquid chromatography/mass spectrometry (LC/MS) instrument time. This article focuses on the use of sub-2 microm porous particle LC coupled to tandem quadrupole MS/MS mass spectrometry for the rapid screening of ADME properties. Using this approach analysis times from 30 s to 1 min were achievable allowing analysis times to be cut by 80%. The use of the small particles coupled to high flow rates allowed for sufficient resolution, even with very short analysis time, to resolve the analytes of interest from similar compounds that would interfere with the assay. The use of dedicated, intelligent, software packages allowed for the user-free generation of MS/MS conditions and the processing of the data.

Sub one minute inhibition assays for the major cytochrome P450 enzymes utilizing ultra-performance liquid chromatography/tandem mass spectrometry.

The measurement of cytochrome P450 (CYP450) isoenzyme inhibition is often done during evaluation of new chemical entities in drug discovery. Typical assay protocol consists of multiple CYP450 probe substrates incubated with selected drug candidates and CYP450. Results of the assay, the amount of probe substrate metabolite formed with respect to control, are used to determine the level of interaction. Liquid chromatography utilizing columns packed with sub-2-micron particles have been shown to provide up to 8X faster analysis time and 3X increases in sensitivity over traditional high-performance liquid chromatography (HPLC). The work presented here shows the development of a high-throughput, sub-2-micron particle LC method coupled with tandem quadrupole mass spectrometry for the rapid analysis of six CYP450 probe substrate metabolites in 30s.

Ultra-performance liquid chromatography/tandem mass spectrometric quantification of structurally diverse drug mixtures using an ESI-APCI multimode ionization source.

We report in this paper an ultra-performance liquid chromatography/tandem mass spectrometric (UPLC(R)/MS/MS) method utilizing an ESI-APCI multimode ionization source to quantify structurally diverse analytes. Eight commercial drugs were used as test compounds. Each LC injection was completed in 1 min using a UPLC system coupled with MS/MS multiple reaction monitoring (MRM) detection. Results from three separate sets of experiments are reported. In the first set of experiments, the eight test compounds were analyzed as a single mixture. The mass spectrometer was switching rapidly among four ionization modes (ESI+, ESI-, APCI-, and APCI+) during an LC run. Approximately 8-10 data points were collected across each LC peak. This was insufficient for a quantitative analysis. In the second set of experiments, four compounds were analyzed as a single mixture. The mass spectrometer was switching rapidly among four ionization modes during an LC run. Approximately 15 data points were obtained for each LC peak. Quantification results were obtained with a limit of detection (LOD) as low as 0.01 ng/mL. For the third set of experiments, the eight test compounds were analyzed as a batch. During each LC injection, a single compound was analyzed. The mass spectrometer was detecting at a particular ionization mode during each LC injection. More than 20 data points were obtained for each LC peak. Quantification results were also obtained. This single-compound analytical method was applied to a microsomal stability test. Compared with a typical HPLC method currently used for the microsomal stability test, the injection-to-injection cycle time was reduced to 1.5 min (UPLC method) from 3.5 min (HPLC method). The microsome stability results were comparable with those obtained by traditional HPLC/MS/MS.

Laparoscopic gastric fundoplication for treatment of gastroesophageal reflux disease (GERD). Results from 150 consecutive cases.

Gastroesophageal reflux disease (GERD) is common and often not adequately managed with lifestyle changes and medication. Laparoscopic gastric fundoplication has widely been accepted as the mainstay in surgical treatment for patients who fail medical management. We present a review of 150 consecutive patients with symptoms of failed medical management of GERD who were operated on at a community hospital. Patients received either a 360 degrees wrap (Nissen Fundoplication) or a 270 degrees wrap (Toupet) and, if warranted, a repair of a hiatal hernia. Thirty-nine percent of the patients were discharged on the first postop day, and another 47% were discharged on the second postop day. Heartburn and coughing were completely eliminated in 90% of patients and reduced to a level that was well tolerated in all but three patients. Some dysphagia, early satiety, and bloating were typical in the immediate postop period but were generally minor and improved substantially in the first 4 to 8 weeks. Six percent of patients had some complication, some severe and requiring reoperation, but all resolved. Eighty-five percent of the patients stated that the outcomes was either "perfect" or "much better." Laparoscopic gastric fundoplication for treatment of chronic GERD is an excellent option for patients who have medically uncontrolled reflux symptoms.