A propensity score-matched analysis of laparoscopic versus open pancreaticoduodenectomy: Is there value to a laparoscopic approach?

BACKGROUND: Laparoscopic pancreaticoduodenectomy has been found safe and associated with advantages over open pancreaticoduodenectomy in prior studies. We compared outcomes of laparoscopic pancreaticoduodenectomy versus open pancreaticoduodenectomy at a single institution after applying technical aspects and perioperative care learned from laparoscopic pancreaticoduodenectomy to the open pancreaticoduodenectomy practice. METHODS: From January 2010 to December 2020, all patients undergoing pancreaticoduodenectomy were identified, and information was collected in a prospective fashion. Open pancreaticoduodenectomy (n = 347) and laparoscopic pancreaticoduodenectomy (n = 242) were performed using the same selection criteria, operative technique, and recovery protocols at a single institution. Propensity score matching was performed, and then perioperative data and 90-day outcomes were compared, and statistical analysis was performed. RESULTS: A total of 589 patients underwent pancreaticoduodenectomy, including open pancreaticoduodenectomy (n = 347) and laparoscopic pancreaticoduodenectomy (n = 242). After excluding those undergoing total pancreatectomy or major vascular or concomitant organ resection, there were 497 patients (open pancreaticoduodenectomy = 301 and laparoscopic pancreaticoduodenectomy = 196). Propensity score matching was performed, and 187 open pancreaticoduodenectomy patients were matched to 187 laparoscopic pancreaticoduodenectomy patients. Operative time (475 vs 280 minutes) was longer, and estimated blood loss (150 vs 212 mL) was less for laparoscopic pancreaticoduodenectomy than open pancreaticoduodenectomy, respectively. Pancreatic fistula (18.8% vs 5.4%) and delayed gastric emptying (18.8% vs 9.7%) were higher for laparoscopic pancreaticoduodenectomy than open pancreaticoduodenectomy, respectively. Postpancreatectomy hemorrhage, major morbidity, mortality, hospital stay, and readmissions were nonsignificantly higher for laparoscopic pancreaticoduodenectomy than open pancreaticoduodenectomy. Intensive care use and overall costs were significantly higher for laparoscopic pancreaticoduodenectomy than open pancreaticoduodenectomy. CONCLUSION: In our experience, open pancreaticoduodenectomy offers similar to improved outcomes over laparoscopic pancreaticoduodenectomy, with less use of perioperative resources, thereby offering better value to patients requiring pancreaticoduodenectomy.

Preoperative CA19.9 level predicts lymph node metastasis in resectable adenocarcinoma of the head of the pancreas: A further plea for biological resectability criteria.

INTRODUCTION: Lymph-nodal involvement (N+) represents an adverse prognostic factor after pancreatoduodenectomy (PD) for pancreatic adenocarcinoma (PDAC). Preoperative diagnostic and staging modalities lack sensitivity for identifying N+. This study aimed to investigate preoperative CA19.9 in predicting the N+ stage in resectable-PDAC (R-PDAC). METHODS: Patients included in a multi-institutional retrospective database of PDs performed for R-PDAC from January 2000 to June 2021 were analyzed. A preoperative laboratory value of CA19.9 >37 U/L was used in univariate and multivariate logistic regression analysis to determine a possible association with N+. Additionally, different cut-offs of CA19.9 related to the preoperative clinical T (cT) stage was assessed to evaluate the risk of N+. RESULTS: A total of 2034 PDs from thirteen centers were included in the study. CA19.9>37 U/L was significantly associated with higher N+ at univariate and multivariate analysis (P<0.001). CA19.9 levels >37 U/L were associated with N+ in 75.9%, 81.3%, and 85.7% of patients, respectively, in cT1, cT2, and cT3 tumors and with higher cut-off values for all cT stages. CONCLUSION: Lymph nodal involvement is strongly related to preoperative CA19.9 levels. Specially in patients staged as cT3 the CA 19.9 could represent a valid and easy tool to suspect nodal involvement. Due to these findings, R-PDAC patients with elevated CA19.9 values should be considered in a more biologically advanced stage.

Comparison of complications for cirrhotic versus non-cirrhotic patients undergoing pancreaticoduodenectomy.

PURPOSE: To compare the outcomes between patients with cirrhosis and those without who have undergone pancreatoduodenectomy (PD) in our institution. METHODS: A review of patients undergoing PD from the time period of January 2010 to December 2020 was performed. Patients that have undergone open or laparoscopic PD and had liver cirrhosis diagnosed prior to surgery were included and matched on a 1:2 basis with non-cirrhotic patients based on age, gender, Eastern Cooperative Oncology Group (ECOG), and date of surgery. Data was obtained from our medical records and ten major postoperative complications variables were compared to the matched group. RESULTS: Overall, 16 patients with cirrhosis were compared to 32 matched controls. No significant differences were found in pancreatic fistula (18.8% vs. 21.8%; P= 1.000), hemorrhage (6.3% vs. 6.2%; P= 1.000), delayed gastric emptying (6.3% vs. 15.6%; P= 0.648), wound infection (0% vs. 9.3%; P= 0.541), and intraabdominal abscess (31.2% vs 6.2%; 0.4998) for cirrhotic vs. non-cirrhotic respectively. There were no postop ileus, gastric fistula, mesenteric portal thrombosis, biliary fistula, and abdominal ischemic event in either group. The average length of stay for both groups was similar (6.9 vs. 9.3 days; P= 0.4019). There were no mortalities and major morbidity was similar (37.5% vs 34.3%; P=0.3549). One patient required readmission for liver-related decompensation with full recovery. CONCLUSION: PD in patients with cirrhosis can be safe and feasible in well-selected patients. In a high-volume institution, postoperative complications are similar to those patients without cirrhosis of the liver.

A narrative review of prognostic indices in the evaluation of gastrointestinal cancers.

Background and Objective: Accurate cancer prognostication allows for conscious decision-making. There is a need for precise indices, along with predictive biomarkers, which aid cancer prognostication. We sought to conduct an overview of the current state of prognostic indices and biomarkers in the evaluation of gastrointestinal (GI) cancers, specifically esophageal, colon and rectal. Methods: We conducted a comprehensive review of articles in the PubMed database between September 2001 and February 2022. Only articles written in English were included. We reviewed retrospective analyses and prospective observational studies. Key Content and Findings: Nomograms are well-described tools that provide estimates of specific cancer-related events, such as overall survival (OS). They are also useful in unroofing specific patient-related variables, which may be associated with cancer survival. Certain prognostic indices have been tested against each other with the goal of discerning superiority. Finally, specific biomarkers have emerged as promising prognostic indicators. Conclusions: Nomograms play a significant role in the prognostication of GI cancer. The identification of specific biomarkers in cancer prognostication is evolving. As we embark on the era of precision medicine, further investigation of reliable prognostic indices and biomarkers is needed.

Pancreaticoduodenectomy After Liver Transplantation: A Single-Center Experience.

BACKGROUND: The aim of this study is to report the feasibility and short-term outcomes of pancreaticoduodenectomy (PD) in patients who have undergone orthotopic liver transplantation (OLT). METHODS: We performed a retrospective review of a prospectively maintained pancreatic surgical database for all patients undergoing pancreaticoduodenectomy (PD) after liver transplant from January 1995 until June 2022. Demographics, indications for pancreatic resection, liver transplant and time from liver transplant to PD were reported. Operative mortality and morbidity were recorded within 90 days of surgery. Continuous variables were recorded as mean and range, while categorical variables were summarized using frequency and percentage. Postoperative complications within 90 days from PD were graded based on Clavien-Dindo classification with major complication recorded as grade IIIa or higher. Additionally, a comprehensive literature review was performed. RESULTS: A total of 916 patients who underwent PD at our institution between January 1995 and June 2022 were identified, and 9 patients had previous OLT. Five patients were females and 4 males with a mean age of 65 years (range 51-78). Average body mass index (BMI) was 30.8. Two patients had major complications, and three patients had minor complications. No clinically relevant POPF, PPH or DGE were observed. One patient died within 90 days from PD due to ischemic biliary pancreatic limb causing intrabdominal sepsis. CONCLUSION: Although uncommon, PD after OLT is feasible with acceptable outcomes at high volume institutions and if performed by experienced surgeons.

Surgical Treatment for Intrahepatic, Peri-Hilar, and Distal Cholangiocarcinoma: 20-Single Institutional Year Experience.

BACKGROUND: Surgical resection is the curative treatment for all subtypes of cholangiocarcinoma (CCA), including intrahepatic, hilar/peri-hilar, and distal. This study evaluates patients with CCA who underwent surgery and determines factors that impact their survival. METHODS: A retrospective cohort study was performed for patients who underwent surgical resection for CCA at our institution from 1995 to 2016. Demographics, operative variables between CCA tumors, and postoperative complications were analyzed. Predictors of overall and recurrence-free survival were determined via statistical analysis. RESULTS: A total of 170 patients with a mean age of 61 years old underwent surgical resection of intrahepatic (n = 64, 37.6%), hilar/peri-hilar (n = 75, 44.1%), and distal (n = 31, 18.2%) CCA. Operations performed included liver resections (n = 83, 48.8%), liver transplants (n = 56, 32.9%), and pancreaticoduodenectomies (n = 31, 18.2%). The overall survival rate at 1, 5, and 10 years was 81.1%, 32.4%, and 17.2%, respectively. Low pathological stage and negative resection margins were associated with lower recurrence and higher survival rates. Tumor location and the type of operation performed were not predictive of recurrence or OS in this cohort. DISCUSSION: This study shows that definitive surgical resection with negative margins can result in long-term survival even at 10 years. Small tumor size and low pathological stage are predictive of higher survival rates post-surgery, emphasizing the importance of early diagnosis and appropriate surgical treatment in achieving positive outcomes.

Comparing Post-Operative Outcomes of Pancreaticoduodenectomy for Pancreatic Ductal Adenocarcinoma: Neoadjuvant Therapy Versus Surgery First Approach.

OBJECTIVES: Optimal use of surgery first (SF) vs neoadjuvant therapy (NAT) for localized pancreatic ductal adenocarcinoma (PDAC) is still unclear. There is concern that NAT may result in worsened post-operative outcomes. Our study objectives were to show the impact of NAT on post-operative morbidity and mortality. METHODS: All patients undergoing resection for PDAC between 1/1/2010 and 12/31/2020 were reviewed and those who underwent pancreaticoduodenectomy (PD) were included. Demographics, perioperative details, and pathology details were gathered. Data pertaining to 90-day complications were obtained and graded according to international consensus guidelines. Those undergoing SF were compared to those who had NAT. Categorical variables were compared by Fisher's exact test and continuous variables by Student's t-test. RESULTS: Two hundred and forty-one subjects who underwent PD for PDAC were included in this review. There was no significant difference in the rate of major morbidity between subjects who received NAT vs SF (19.4 vs 20.3%, P = 1.0). Similarly, there were no significant differences in the rates of mortality (3.1 vs 4.2%, P = .742), post-operative pancreatic fistula (8.2 vs 10.5%, P = .658), or post-pancreatectomy hemorrhage (7.1 vs 7.7%, P = 1.0), respectively. CONCLUSION: Post-operative outcomes are not worsened by the use of the NAT approach prior to PD for PDAC. Further investigation is needed to reveal which patient subgroups may benefit from the use of NAT, especially regarding survival.

Hybrid Open-Endovascular Repair in a Patient With Giant Contained Aortic Aneurysm Rupture.

Contained rupture of an aortic aneurysm is a high-mortality condition that requires immediate repair. Open repair has been the gold standard; however, endovascular and hybrid open-endovascular repair techniques have also emerged as less invasive solutions to this vascular emergency. Here. we present a patient with a giant 14.0 cm contained rupture of a Thoracic aortic aneurysm and 7.4 cm juxtarenal abdominal aortic aneurysm who was successfully treated with hybrid open-endovascular repair.

Racial Disparities in Outcomes Among Asians With Gastric Cancer in the USA.

BACKGROUND/AIM: We aimed to evaluate disparities in presentation and treatment of gastric cancer (GC), including time between diagnosis and treatment, based on race, focusing on Japanese patients within the USA. PATIENTS AND METHODS: The National Cancer Database was queried for patients diagnosed with GC between 2004-2013. Clinical and treatment variables were summarized by race (White, non-Japanese Asian, Japanese). The association between race and overall survival (OS) was evaluated using the log-rank test. RESULTS: A total of 79,481 patients were included. Japanese patients received surgery the earliest after diagnosis in all stages. Regarding radiotherapy, white patients had the shortest waiting time followed by Asian and Japanese patients. Asian patients had better OS at both 3 and 5 years of follow-up. White patients were associated with the lowest OS. CONCLUSION: Japanese and Asian GC patients have better OS compared to White patients. Moreover, there were disparities in time to both GC diagnosis and treatment, with Japanese patients being sooner diagnosed and surgically treated, which may ultimately impact patient experience.

Trends in utilization of sentinel node biopsy and adjuvant radiation in women ≥ 70.

BACKGROUND AND OBJECTIVES: Omission of routine axillary staging and adjuvant radiation (XRT) in women ≥ 70 years old with early stage, hormone receptor-positive, clinically node-negative breast cancer has been endorsed based on several landmark studies. We sought to determine how much omission of axillary staging/XRT has been adopted. METHODS: Using the National Cancer Data Base, we selected malignant breast cancer cases in women ≥ 70 with ER + tumors, ≤2 cm with clinically negative lymph nodes who underwent breast conservation and had known XRT status in 2005-2015. The use of sentinel lymph node biopsy (SNB) and XRT status was summarized by year to determine trends over time. RESULTS: In total, 57 230/69 982 patients underwent SNB. Of the 12 752 patients in whom SNB was omitted, 6296 were treated at comprehensive community cancer programs. Regarding XRT, 33 891/70 114 received adjuvant XRT. There were no significant trends with regards to patients receiving SNB or those receiving XRT. CONCLUSION: Since 2005, there has been no change in SNB or XRT for early stage ER + breast tumors. However, there was a difference in omission of SNB based on facility type and setting. Future monitoring is needed to determine if these trends persist following the recently released Choosing Wisely® recommendations.

Upper extremity reconstruction following open surgical repair of giant arteriovenous fistula aneurysm: clinical case and systematic review of the literature.

BACKGROUND: Nearly 30% of arteriovenous fistulas (AVFs) located in the upper extremity for hemodialysis access result in short- and long-term adverse effects, such as rupture, necessitating emergent surgical management and extensive soft-tissue reconstruction. With this systematic review, we aimed to compile all reported open surgical techniques used for complicated AVF repair in the upper extremity, the respective soft-tissue reconstructive outcomes, and vascular patency rates at final follow-up. METHODS: Using Ovid Medline/PubMed databases, we conducted a review of the English-language literature on AVF aneurysm surgical management in the upper extremity, filtered for relevance to open surgical technique and outcomes in vascular patency after aneurysmal repair at long-term follow-up (≥6 months postoperatively). We include a detailed case of surgical removal of a giant AVF aneurysm and subsequent flap elevation and reconstruction of the upper extremity. RESULTS: Of 150 articles found in the initial search, 19 (from 2010-2017) met inclusion criteria. From the reviewed studies, 675 patients underwent open surgical repair of AVF aneurysm in the upper extremity. Surgical approaches included partial-to-full aneurysm excision, interposition graft, tubularized extracellular matrix, sutured and stapled aneurysmorrhaphy, and stent graft. Rates of vascular patency at repair site ranged from 47% to 100%, with a pooled average of 78% at 6 months or longer postoperatively. CONCLUSIONS: For plastic and hand surgeons, aneurysmal ligation and excision is feasible even in severe cases and is associated with overall good vascular and soft-tissue reconstructive outcomes in the upper extremity. LEVEL OF EVIDENCE: III.

The Role of Regional versus General Anesthesia on Arteriovenous Fistula and Graft Outcomes: A Single-Institution Experience and Literature Review.

BACKGROUND: Multiple studies have demonstrated the benefits of creating arteriovenous fistulas (AVFs) under regional anesthesia. This is most likely because of the avoidance of hemodynamic instability and stress response of general anesthesia, as well as the sympathectomy associated with brachial plexus blockade. As vein diameter is the major limiting factor for primary AVF creation and maturation, our aim is to investigate if the vasodilation that accompanies regional anesthesia leads to improved patency and maturation rate of autologous AVF and improved patency of arteriovenous graft (AVG) compared with those placed under general anesthesia. METHODS: This retrospective study was approved by the institutional review board. A total of 238 patients who had either an AVF or an AVG placed at the Mayo Clinic, Florida, between 2012 and 2017 were analyzed. Demographics, access type, preoperative vein diameter, anesthesia type, change of plan after regional versus general anesthesia, and outcomes were assessed. All statistical tests were 2 sided, with the alpha level set at 0.05 for statistical significance. RESULTS: Among 238 patients, 120 (50.4%) had regional anesthesia. Differences between the 2 groups in risk factors and 30-day or long-term outcomes (failure, abandonment, or reoperation) were not statistically significant. Of the accesses placed under general anesthesia, 58.5% were abandoned compared with 45.2% of those placed under regional anesthesia. Owing to loss of patency, 25.8% of accesses placed under general anesthesia were abandoned compared with 19.2% of those placed under regional anesthesia. Two-month failure was higher in the general anesthesia group than that in the regional anesthesia group (P = 0.076). After preoperative vein mapping, 22 patients were originally intended to have an AVG placed under regional anesthesia. After brachial plexus blockade, 9 of these patients (41%) were successfully switched to AVF, while the other 13 followed the original surgical plan and received an AVG. Of these, 0 failed and 0 were abandoned because of loss of patency. CONCLUSIONS: This study showed possible improvements in failure rates for vascular accesses placed under regional anesthesia compared with those placed under general anesthesia. In addition, we showed an impact of regional anesthesia on the surgical plan by transitioning from a planned AVG to an AVF, intraoperatively. Giving patients with originally inadequate vein diameter the chance to have the preferred hemodialysis access method by simply switching anesthesia type could reduce the number of grafts placed in favor of fistulas.

Complex management of acute superior mesenteric venous thrombosis in the setting of metastatic ovarian cancer.

•Superior mesenteric vein thrombosis (SMVT) is rare but seen in patients with hypercoagulable states.•Prevention of mortality in patients with SMVT requires immediate diagnosis and complex management.•A hierarchical approach to treatment progresses to more aggressive treatment as needed.•Supportive care, medication, and endovascular and/or surgical interventions are available management options.•In patients with underlying conditions, long-term treatment such as anticoagulation must also be initiated.

Value of Axillary Ultrasound after Negative Axillary MRI for Evaluating Nodal Status in High-Risk Breast Cancer.

BACKGROUND: It is assumed that axillary ultrasound (AxUS) is the best method for axillary nodal evaluation in newly diagnosed breast cancer patients. However, few have evaluated the efficacy of preoperative axillary MRI. We compared the statistical accuracy of AxUS and MRI in detecting nodal metastases among breast cancer patients who were selected for neoadjuvant chemotherapy. STUDY DESIGN: We retrospectively analyzed 219 breast cancer patients undergoing neoadjuvant chemotherapy from 2007 to 2015, all of whom had AxUS and breast MRI before chemotherapy. Two breast radiologists, blinded to clinical, pathologic, and AxUS findings, re-reviewed all breast MRIs, specifically focusing on axillary nodal characteristics. We correlated clinico-pathologic characteristics, AxUS, and MRI findings, and quantified predictive values of both imaging modalities. RESULTS: Overall, 101 of 219 (47%) patients had T2 tumors. The most common abnormal nodal finding was size >10 mm. Axillary ultrasound and MRI agreed on nodal status in 192 of 219 patients (87.6%). When correlated with pre-chemotherapy needle biopsy in 129 patients, AxUS and axillary MRI performed similarly (sensitivity of 99.1% vs 97.4% and specificity 15.4% vs 15.4%, respectively). Only 4 of 129 (3.1%) patients had a negative MRI and positive AxUS; 3 of 4 of these patients (75%) had a positive biopsy and 2 of 3 had positive lymph nodes on final pathology, therefore suggesting MRI missed clinically significant disease in only 2 of 129 (1.5%) patients. CONCLUSIONS: In a high-risk patient population, AxUS and MRI have similar statistical profiles in evaluating axillary nodal status. Routine use of AxUS after a normal axillary MRI is not warranted.

Complex Repair of Juxtarenal Abdominal Aortic Aneurysm with an Anatomical Variant of the Renal Arteries.

Hybrid repair involves both open and endovascular interventions. This technique has been increasingly used in treating complex aortic aneurysms as an alternative to conventional open repairs, mainly because of the avoidance of aortic cross-clamping and the associated increased ischemia time to the viscera. We report a hybrid repair of a juxtarenal abdominal aortic aneurysm complicated by a nonstandard right renal artery originating just proximal to the aortic bifurcation in the setting of a nonfunctional left kidney.

What to expect with major vascular reconstruction during Whipple procedures: a single institution experience and literature review.

BACKGROUND: Major vascular reconstruction during a pancreaticoduodenectomy (PD), also known as a Whipple procedure, leads to controversial postoperative outcomes compared to conventional Whipple. Discussion with the patient regarding postoperative expectations is a crucial component of holistic surgical healthcare. The aim of this study was to report our 8-year experience of Whipple procedures involving vascular reconstruction and to review relevant literature to further evaluate expectant outcomes, therefore leading to more accurate discussion. METHODS: A retrospective review of patients undergoing Whipple procedures from January 2010, through December 2017 was performed. Patch, graft, and primary anastomosis during Whipple procedures were considered major vascular reconstruction. Literature on the current understanding of the outcomes associated with vascular reconstruction during Whipple procedures was reviewed. RESULTS: Twenty-nine from a total of 405 patients that met inclusion criteria had a Whipple procedure that involved major vascular reconstruction. Twelve patients were male and 17 were female (mean age, 65.2 years). Median hospital and intensive care unit (ICU) stay [range] of patients with vascular reconstruction was 12 [5-92] days and 3 [0-59] days, respectively. Thirty-day survival and 1-year survival of patients with vascular reconstruction was 93.1% and 55.2%, respectively, compared to non-vascular reconstruction patients 96.0% and 83.5%, respectively (P=0.35, P<0.001). Ninety-day readmission for vascular reconstruction patients was 31.0% compared to 14.6% in non-vascular reconstruction patients (P=0.03). The 1-year survival of those who had patch reconstruction, graft reconstruction, and primary anastomosis was 50.0%, 62.5%, 53.8%, respectively. CONCLUSIONS: Compared to conventional Whipple procedures, those requiring major vascular reconstruction are associated with decreased survival. When vascular reconstruction is a valid option patients should be well aware of the associated outcomes.

Is metastasectomy a worthy option?-the role of surgery in metastatic colon cancer to liver and lungs.

BACKGROUND: The role of surgery and metastasectomy is controversial in the treatment of stage IV colon cancer (CC). The aim of this study was to investigate the relationship between primary tumor resection (PTR) with metastasectomy and survival in patients diagnosed with metastatic CC. METHODS: The National Cancer Data Base (NCDB) was retrospectively queried for patients diagnosed with colon adenocarcinoma from 2004 to 2013. Patient demographics, clinical characteristics, and short-term outcomes were collected. Groups were generated based on if surgery was performed and, if so, was metastasectomy involved. Associations between groups were evaluated using Kruskal-Wallis and Pearson Chi-square tests. Overall survival (OS) was summarized using standard Kaplan-Meier methods. The association between surgical group and OS was evaluated using the log-rank test. RESULTS: Of 31,172 patients, 13,214 (42.4%) had surgery while 17,958 (57.6%) did not. Among these, 81.3% of patients had liver metastases only, while 18.7% of patients had both liver and lung metastases. Median OS was 15.1 months (95% CI: 14.8 to 15.5 months) for the entire cohort. However, median OS was significantly better for those who had surgery (either PTR alone or PTR with metastasectomy) compared to those who did not (21.8 vs. 7.5 months, P<0.001). Patients who received PTR with metastasectomy had worse median OS (20.5 vs. 21.8 months, P=0.035) compared to those who only received PTR (P=0.211). CONCLUSIONS: PTR in select patients diagnosed with metastatic CC provides a remarkable improvement to survival rate. The role of metastasectomy remains controversial as no difference in survival outcomes exists between patients who received it and who did not.

Intraoperative fluid restriction in hyperthermic intraperitoneal chemotherapy.

BACKGROUND: Multiple studies highlight the importance of liberal fluid administration in cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC). Over-resuscitation can delay recovery and wound healing. We report an intraoperative protocol that restricts fluid administration and minimizes morbidity. MATERIALS AND METHODS: Retrospective analysis of 35 patients that underwent CRS-HIPEC for curative intent under fluid restriction protocol from June 2015 to July 2017 was performed. Protocol consists of continuous infusion of vasopressin 0.02 units/h and maintaining urine output at 0.5 mL/kg/h via crystalloid and colloid. Endpoint was Clavien-Dindo ≥3 events within 30 d of CRS-HIPEC. RESULTS: Median age was 56 y; 71% were female. Malignancies treated: appendix (49%), colon (31%), and other (20%). Median peritoneal cancer index was 15, complete cytoreduction was achieved in 91% of patients. Median time for return of bowel function was 5 d, median length of hospital stay was 7 d. There were 28 bowel anastomoses. Median intraoperative crystalloid, colloid, and packed red blood cells were (1900, 1500, and 700 mL), respectively. Clavien-Dindo grade 3-4 events occurred in five patients. There were no deaths 30 d after surgery. CONCLUSIONS: A fluid restriction protocol appears to be safe and feasible in the setting of CRS-HIPEC for curative intent.

Durability of Carotid Endarterectomy with Bovine Pericardial Patch.

BACKGROUND: Multiple studies have shown that patch angioplasty after carotid endarterectomy (CEA) reduces the risk of stroke and restenosis when compared with primary closure. Biological, synthetic, or vein patches have been traditionally used in CEA. This article reports the early and long-term outcomes of bovine pericardium (BP) for patch angioplasty in CEA. METHODS: A retrospective, consecutive analysis of 874 patients who underwent CEA during the past 17 years at Mayo Clinic, Florida, was performed. BP patch (BPP) was used in 680 patients. Other CEA techniques were used in 194 patients (standard without patch, 78; standard with Dacron, 74; standard with vein patch, 16; and other techniques: bypasses, 26). We defined group 1 as those who underwent BPP angioplasty and group 2 as those who underwent all other techniques. Early and late clinical outcomes and patch-related complications (restenosis, infection, and hematoma) were recorded and analyzed. RESULTS: Median follow-up for the entire series was 39.6 months. There were no statistically significant differences in 30-day mortality and morbidity between the 2 groups, except that BP group has less 30-day stroke (0.1%, 1 of 680) versus other techniques (1.5%, 3 of 194, P = 0.03). Thirty-day postoperative mortality rate was 0.1% (1 of 680) in BPP group and 1.0% (2 of 194) in other technique group (P = 0.13). No statistically significant difference was noted in 30-day postoperative major complications (transient ischemic attack [TIA], wound infection, hematoma requiring surgical evacuation, and nerve injury) between the 2 groups. Ten-year freedom from stroke/TIA were 97.8% in the BP group compared with 98.5% in the other group (P = 0.86). Ten-year freedom from restenosis was also similar between groups (89.0% BP vs. 90.4% others, P = 0.69). Ten-year survival rate was 38.4% in BP group and 45.0% in other technique group, and this was statistically significant on univariate analysis only. CONCLUSIONS: CEA with BP angioplasty has excellent early and late outcomes with minor morbidity and mortality.