Atherosclerotic Carotid Artery Disease: Where to from the emergency room? University hospital experience.

Objectives: Stroke is the second leading cause of death worldwide, resulting in 5.5 million deaths in 2016. Vascular interventions, including carotid endarterectomy (CEA) and carotid artery stenting, play a major role in stroke prevention, especially when performed early after onset of symptoms. This study aimed to define the role of vascular surgeons in ischaemic stroke management and hence improve referral patterns by creating an algorithm for the referral process. This could reduce time to intervention and optimise patient benefit from intervention. Methods: This retrospective study reviewed symptomatic and asymptomatic patients with atherosclerotic disease of the carotid artery who were referred to the Vascular Surgery Unit of Sultan Qaboos University Hospital, Muscat, Oman, from April 2018 to March 2020 to examine factors influencing recognition of suitable candidates for intervention. Following analysis of the data, algorithms/protocols were created to simplify the referral process of symptomatic and asymptomatic carotid artery disease for surgical intervention. Results: A total of 38 patients with ischaemic stroke were recognised as having carotid artery stenosis and were referred to the vascular surgery service during the study period. Only six met the criteria for CEA, four of which underwent the procedure. Conclusion: Choice of patients for CEA involves multiple steps, with potential for missed opportunities. By involving a multidisciplinary team approach, the recommended protocol aims to lead to early and appropriate referral to a vascular surgeon or an interventional radiologist, resulting in increased and optimised intervention in stroke prevention.

Spontaneous Near Fatal Hemorrhage into Neurofibromatosis Type 1 Lesion in the Scalp.

Neurofibromatosis type 1 (NF1) (von Recklinghausen's disease) is an autosomal dominant disorder characterized by café-au-lait spots, pigmented hamartomas of the iris, and multiple neurofibromas. Patients can present with hemorrhage secondary to trauma or rarely with spontaneous hemorrhage, both of which can be lethal and life-threatening. We report a 14-year-old girl with a rapidly expanding hematoma in a rare presentation of spontaneous bleed into the NF1 lesion in her scalp. Soon after presentation, she went into hemorrhagic shock. Emergency coiling of the left maxillary artery and branches successfully arrested the bleeding, while resuscitation reversed the hemorrhagic shock.

Managing Vascular Surgery Emergencies and Referrals During the COVID-19 Pandemic at a Tertiary Centre in Oman.

OBJECTIVES: This study aimed to discuss the different challenges faced while managing emergency vascular surgery cases during the COVID-19 pandemic and how these challenges were overcome. METHODS: This study details 14 emergency cases that were managed during a period of one month from mid-March to mid-April at Sultan Qaboos University Hospital, Muscat, Oman. The cases included acute limb ischaemia, critical limb ischaemia, type B dissection of the thoracic aorta, thoraco-abdominal aneurysm, critical internal carotid artery stenosis, trauma, infected arteriovenous forearm loop graft and thrombosed arteriovenous fistulas. RESULTS: Only one patient was confirmed to have COVID-19. Five were negative for COVID-19 while the remaining eight were not tested. Various strategies on how the vascular surgical team accommodated changes in hospital protocols and nationwide lockdown are discussed in detail. CONCLUSIONS: With the judicious use of personal protective equipment and consumable surgical and endovascular devices, communication with support services and other hospitals and implementation of triage protocols, it was possible to manage vascular surgery emergencies effectively.

Our early experience with mesenteric ischemia in COVID-19 positive patients.

Literature has been published stating that thrombosis is occurring at higher rates in patients who are positive for COVID-19. This experience is more with limb ischemia. Reports of mesenteric ischemia are coming in from different parts of the globe. We share our early experience of managing two patients with acute mesenteric ischemia.

Dissecting Aneurysm of the Internal Carotid Artery as a Complication of Facial Bone Trauma.

The involvement of the internal carotid artery in dissecting aneurysm is rarely reported in the literature and may occur as a complication of trauma, surgery, and other medical conditions. We report a case of a 22-year-old male who was involved in a motor vehicle accident with associated multiple orthopedic and maxillofacial fractures. During surgical management, the patient was incidentally diagnosed with a dissecting aneurysm involving the right internal carotid artery.

Laparoscopic Adrenalectomy for Large Adrenocortical Carcinoma.

BACKGROUND: Adrenocortical cancer (ACC) is a rare disease that is difficult to treat. Laparoscopic adrenalectomy (LA) is performed, even for large adrenocortical carcinomas. However, the oncological effectiveness of LA remains unclear. This review presents the current knowledge of the feasibility and oncological effectiveness of laparoscopic surgery for ACC, with an analysis of data for outcomes and other parameters. DATABASE: A systematic review of the literature was performed by searching the PubMed and Medline databases for all relevant articles in English, published between January 1992 and August 2014 on LA for adrenocortical carcinoma. DISCUSSION: The search resulted in retrieval of 29 studies, of which 10 addressed the outcome of LA versus open adrenalectomy (OA) and included 844 patients eligible for this review. Among these, 206 patients had undergone LA approaches, and 638 patients had undergone OA. Among the 10 studies that compared the outcomes obtained with LA and OA for ACC, 5 noted no statistically significant difference between the 2 groups in the oncological outcomes of recurrence and disease-free survival, whereas the remaining 5 reported inferior outcomes in the LA group. Using a paired t test for statistical analysis, except for tumor size, we found no significant difference in local recurrence, peritoneal carcinomatosis, positive resection margin, and time to recurrence between the LA and OA groups. The overall mean tumor size in patients undergoing LA and OA was 7.1 and 11.2 cm, respectively (P = .0003), and the mean overall recurrence was 61.5 and 57.9%, respectively. The outcome of LA is believed to depend to a large extent on the size and stage of the lesion (I and II being favorable) and the surgical expertise in the center where the patient undergoes the operation. However, the present review shows no difference in the outcome between the 2 approaches across all stages. A poor outcome is likely to result from inadequate surgery, irrespective of whether the approach is open or laparoscopic.

Successful Direct Adsorption of Lipoproteins (DALI) Apheresis During Pregnancy in an Omani Woman with Homozygous Familial Hypercholesterolemia.

We report our experience with Direct Adsorption of Lipoproteins (DALI) apheresis in an Omani pregnant woman affected by homozygous familial hypercholesterolemia. To the best of our knowledge this is the first successful pregnancy treated with DALI apheresis. The patient had a history of coronary artery disease, supra-aortic valvular stenosis and severe carotid artery disease with right carotid artery stenting. She was on a regular biweekly DALI apheresis since 2008. In May 2013, she became pregnant and rosuvastatin and ezetimibe were stopped while she continued on DALI apheresis biweekly. This treatment during pregnancy was successful with no major complications. The average low-density lipoprotein cholesterol reduction during therapy was 50%. She spontaneously delivered a healthy male infant (2,400 g) at 37 weeks. We showed that DALI apheresis therapy was safe during pregnancy with a good outcome for both mother and neonate.

Solid pseudopapillary neoplasm of the pancreas: a case report with review of the diagnostic dilemmas and tumor behavior.

Solid pseudopapillary neoplasm of the pancreas is a rare tumor of the pancreas often detected initially on imaging. Of uncertain histogenesis, it has a low-grade malignant potential with excellent post-surgical curative rates and rare metastasis. Despite advances in imaging, pseudocysts and other cystic neoplasms feature in the differential diagnosis. Pathological and/or cytological evaluation remains the gold standard in reaching a definitive diagnosis. On morphology alone, other primary pancreatic tumors and metastatic tumors pose a diagnostic challenge. Recent advances in immunohistochemical characterization have made the histopathologic diagnosis more specific and, in turn, shed light on the likely histogenesis of this rare tumor. We report a case of solid pseudopapillary neoplasm of the pancreas that was suspected on radiology and diagnosed intraoperatively on imprint cytology guiding definitive surgery. The diagnostic dilemmas are reviewed.

Port Site Herniation of the Small Bowel following Laparoscopic-Myomectomy: A case report.

Bowel herniation, through fascial defects secondary to laparoscopic surgery at the site of trocar entry, is a rare, but potentially serious, complication. Closure of the fascia at port sites measuring 10mm or more has been highly recommended to avoid such complications. We report a case of a small bowel which herniated and strangulated through the port site immediately after laparoscopic myomectomy. Resection of the strangulated bowel with primary anastomosis was required to manage this complication. We present this case report with literature review to discuss the risk factors and the methods to prevent such a complication post laparoscopic surgery.

Patient-reported quality of life after abdominal aortic aneurysm surgery: a prospective comparison of endovascular and open repair.

PURPOSE: This study evaluated and compared changes over time in health-related quality of life reported by patients with infrarenal abdominal aortic aneurysm (AAA) undergoing elective endovascular (EVAR) and open aneurysm (OR) repair. METHODS: A prospective, nonrandomized cohort of 76 patients (62 men, 14 women; age range, 42 to 89 years) undergoing elective, infrarenal AAA repair (EVAR, n = 43; OR, n = 33) at two university teaching hospitals during a 15-month period were administered the Medical Outcomes Study Short-Form 36-item (SF-36) health survey preoperatively and then 1 week, 1 month, and 6 months postoperatively. Patient demographics, procedural details, postoperative follow-up data, and SF-36 scores were compared between groups. RESULTS: Both groups had total SF-36 scores that were significantly lower than preoperative scores at 1 week and 1 month after surgery but were not significantly different from the preoperative scores at 6 months (OR 66.2 +/- 21.1 to 72.3 +/- 19.8, P > .1; and EVAR 61.0 +/- 17.7 to 58.7 +/- 19.4, P > .1). Six-month total SF-36 scores were significantly higher in the OR group compared with the EVAR group (mean 72.3 +/- 19.8 OR vs 58.7 +/- 19.4 EVAR; P = .009). In the postoperative period, a significant drop occurred in mean scores in six of the eight domains of the SF-36 in the OR patients (physical function, PF; role physical, RP; bodily pain, BP; vitality, VT; social function, SF; role emotional, RE) and five domains for EVAR patients (PF, RP, BP, SF, RE). In two domains, RE and PF, scores returned to baseline values significantly sooner in EVAR patients than in OR patients (RE, EVAR 1 month vs OR 6 months; and PF, EVAR 1 month vs OR 6 months). In the VT domain, no significant postoperative drop occurred in the EVAR group, but in the OR group, mean scores were significantly lower at 1 week and 1 month compared with preoperative values. In the domains of general health and mental health, no significant drop occurred in SF-36 score postoperatively in either group. CONCLUSIONS: Patient reported health-related quality of life after infrarenal AAA repair is significantly impaired in the early postoperative period but returns to baseline by 6 months in patients treated with EVAR and OR. Patients having EVAR had significantly more rapid return to preoperative scores in selected domains of the SF-36. Even though EVAR is associated with shorter and less invasive perioperative hospital course and fewer postoperative complications, EVAR patients had lower quality of life scores 6 months after surgery than OR patients.