Perioperative Glycemic Control in Plastic Surgery: Review and Discussion of an Institutional Protocol.

Perioperative hyperglycemia is a well-known risk factor for surgical morbidity such as wound healing, infection, and prolonged hospitalization. This association has been reported for a number of surgical subspecialties, including plastic surgery. Specialty-specific guidelines have become increasingly available in the literature. Currently, glucose management guidelines for plastic surgery are lacking. Recognizing that multiple approaches exist for perioperative glucose, protocol-based models provide the necessary structure and guidance for approaching glycemic control. In this article, we review the influence of diabetes on outcomes in plastic surgery patients and propose a practical approach to perioperative blood glucose management based on current Endocrine Society and Mayo Clinic institutional guidelines.

Pancreatic Resection for Side-Branch Intraductal Papillary Mucinous Neoplasm (SB-IPMN): a Contemporary Single-Institution Experience.

BACKGROUND: Given the malignant potential of main duct intraductal papillary mucinous neoplasm (M-IPMN), surgical resection is generally indicated. With regard to side-branch intraductal papillary mucinous neoplasm (SB-IPMN), resection vs. observation is a topic of debate. Further review of SB-IPMN is necessary to clarify appropriate management. The primary focus of this project is to determine the incidence of malignant final pathology for patients undergoing surgery for isolated SB-IPMN with non-malignant fine-needle aspiration (FNA) cytology. We also sought to describe the relationship between factors considered in the international consensus guidelines and final pathologic outcome. METHODS: The study is a retrospective review of all patients who underwent surgical resection for intraductal papillary mucinous neoplasm (IPMN) from 2002 to 2013 at our institution. Patients with a preoperative diagnosis of isolated SB-IPMN and FNA results for non-malignant cytology were selected among this surgical cohort for further analysis of preoperative clinical characteristics and outcomes. RESULTS: A total of 137 patients undergoing resection for IPMN were identified. Of these, 81 patients (59%) had a component of M-IPMN or invasive disease on FNA, leaving 66 (46%) patients with SB-IPMN and non-malignant cytology. Invasive adenocarcinoma was found in 8/66 (12%) patients and high-grade dysplasia (HGD) in 4/66 (8%) patients. The mean [SD] diameter of benign SB-IPMN was 2.0 cm [1.1] (range 0.3-5.7) vs. that of HGD/invasive disease which was 3.1 cm [1.3] (range 1.5-6.0; P = 0.014). Of the 12 patients found to have HGD or invasive disease, symptoms, mural nodules, and septations were found in 7 (58%), 5 (42%), and 6 (50%), respectively. Tumor staging were as follows: IA (2), IB (2), 2A (4), and 2B (1). CONCLUSION: With proper selection criteria, SB-IPMN is associated with a low rate of invasive pancreatic ductal adenocarcinoma at the time of resection. Nevertheless, given the demonstrated incidence of malignancy, appropriate operative candidates should undergo resection.

Management of cervical thoracic duct cyst with cyst-venous anastomosis.

INTRODUCTION: Cervical thoracic duct cyst (CTDC) is a rare cause of lateral neck mass. Surgical excision with ligation of the cervical thoracic duct is the current standard for definitive management with symptomatic patients. We report the first case of an alternative method of management performing a cyst venous anastomosis for decompression. PRESENTATION OF CASE: A 77 year old female presented with a six month history of left arm pain, swelling and a left-sided cystic neck mass. She was treated with cyst-venous anastomosis between the cyst wall and the left internal jugular vein. At two year follow-up, she has had resolution of pain and no recurrence of the mass. DISCUSSION: Many potential etiologies have been proposed for CTDC, though surgical management of this rare problem has consistently required cyst excision and thoracic duct ligation. Few innovative modes of therapy have been developed to address this problem in a less invasive manor. Maintaining a more natural thoracic duct anatomy decreases the likely of complications associated with duct ligation. CONCLUSION: Cyst-venous anastomosis for the management of CTDC provides an effective, novel form of treatment which maintains the integrity of the thoracic duct and avoids potential complications associated with duct ligation.

Long-term results of aortouniiliac stent grafts for the endovascular repair of abdominal aortic aneurysms.

BACKGROUND: Long-term follow-up of patients with aortouniiliac (AUI) grafts is lacking in the current literature. The purpose of this study was to review the outcomes of endovascular aneurysm repair (EVAR) using commercially available AUI devices with femorofemoral bypass in patients whose aortoiliac anatomy was unfavorable for bifurcated repair. METHODS: A retrospective review of 35 patients from September 2000 to February 2012, who underwent EVAR with commercially manufactured AUI devices, was performed. These comprised 35 of 372 (9.4%) patients who underwent EVAR during that period. Patient records were reviewed to determine morbidity, mortality, and survival after AUI repair. Patients were followed at 1-, 3-, 6-, and 12-month intervals with computed tomography (CT) scans during each visit. Median follow-up was 40 months (range: 2-135 months). RESULTS: Median age at surgery was 76 years (range: 60-93). The median preoperative aneurysm diameter was 57 mm (range: 45-71) and the median postoperative diameter was 53 mm (range: 29-80). Two type II endoleaks occurred on 1-month CT, whereas 10 endoleaks (type I [3], II [6], and III [1]) occurred during follow-up after 1 month. Migration of the stent graft occurred in 9% (n=3). Secondary procedures were required in 26% (n=9), whereas tertiary procedures were required in 3% (n=1). One patient required treatment for thrombosis of the iliac extension and 2 required treatment for thrombosis of the femorofemoral component. Mortality over the follow-up period was 34% (n=12) with no deaths occurring within 30 days. CONCLUSIONS: High-risk patients who present with aortoiliac anatomy unsuitable for bifurcated stent graft placement should be offered AUI graft placement as a potential alternative to open repair.