Critical Airway Compromise due to a Massive Vagal Schwannoma.

We describe the case of a 37-year-old man with a slowly enlarging neck lump and compressive symptoms. He presented to a separate institution 10 years prior where an observational approach was advocated. Following preoperative investigations and embolization, an 11cm vagal schwannoma was excised and vagus nerve was sacrificed. Although conservative management is appropriate for a select patient population, surgical excision is treatment of choice for cervical neurogenic tumours and paraganglionomas and must be considered in young patients or rapidly expanding tumours to avoid compressive symptoms, as in this case.

Three-dimensional computed tomographic reconstruction of the carotid artery: identifying high bifurcation.

OBJECTIVE: To investigate variability in the level of bifurcation relative to other anatomical landmarks on computed tomography (CT) and to develop an objective and reproducible technique for identifying patients with a high carotid bifurcation who might therefore be at greater risk of operative complications. METHODS: This was a retrospective cross-sectional, imaging study. A series of 86 nonselected consecutive CT carotid angiograms (172 arteries) were analysed. Using three-dimensional reconstructive software, the curved length (CL) of the internal carotid artery (ICA) and the straight-line distance (SLD) from the bifurcation to the base of skull was measured for 140 carotid arteries. The tortuosity index (TI) of each ICA was calculated by dividing CL by SLD. The relationship of the bifurcation to eight anatomical landmarks in the neck was assessed in order to identify a landmark that could act as a surrogate marker of high carotid bifurcation. The landmarks examined were the angle of mandible, greater horn of hyoid, body of hyoid, upper margin of thyroid cartilage, cervical vertebrae, mastoid process, sternoclavicular joint, and sternal notch. RESULTS: The median curved length of the ICA was 80.4 mm (range 58.0-129.0 mm). The median distance of bifurcation from the base of the skull was 72.7 mm (range 58.1-98.1 mm). There was excellent interobserver agreement in measuring SLD, with an intraclass correlation coefficient of 0.993 (p = .00). The median tortuosity index was 1.12 (range 1.01-1.64). Distance from the mastoid process had the greatest correlation with high bifurcation; Pearson's correlation coefficient of 0.894 (two-tailed p = .00). Bifurcations within 5 cm of the mastoid process are likely to be in the highest quartile (82.9% sensitive, 80.1% specific). CONCLUSIONS: Measuring the distance of carotid bifurcation from the base of the skull (SLD), a measure previously not well defined, may be useful in predicting difficult neck dissection and endarterectomy. A distance from mastoid of ≤ 5 cm may also alert the surgeon to potential difficulties.

Sizing fenestrated aortic stent-grafts.

INTRODUCTION: Fenestrated aortic stent-grafts are increasingly being used to treat patients with juxtarenal abdominal aortic aneurysms (AAA). Sizing of these stent-grafts is critical to ensure success and requires detailed expert assessment of aortic morphology. At present little is known about how sizing of these stent-grafts varies between observers and the necessary tolerances involved to ensure a successful procedure. METHODS: CT scans of 19 consecutive patients with juxtarenal aortic aneurysms that underwent successful endovascular repair with fenestrated stent-grafts were selected. Sizing of fenestrated aortic stent-grafts was performed independently by four experienced endovascular surgeons and results were compared. Data from the stent-graft manufacturer was available for comparison in 12 cases. RESULTS: All observers agreed on the number of fenestrations; 16 devices had 3 fenestrations and 3 had 4. The overall inter-observer measurement error for all target vessel orientation was ± 12.6° (10.8-14.4 95% CI), and for distance between target vessels ± 5.3 mm (4.4-6.2 95% CI). The median difference in internal stent-graft diameter was 1 stent size. Agreement on fenestration type ranged from (84-95%). Comparison was performed with the manufactured stent-graft in 12 cases. The overall mean difference of target vessel orientation between the manufactured devices and the four observers was -1.3° (SD ± 6.9,-3.8-1.2 95% CI). There was less agreement between observers and device manufacturers on body and limb lengths and distal limb diameters. CONCLUSIONS: There was generally a high level of agreement between experienced endovascular surgeons in sizing the fenestrated stent component. There were differences in component lengths but these could have been accommodated by varying the degree of overlap between components.

Ready-to-fenestrate stent grafts in the treatment of juxtarenal aortic aneurysms: proposal for an off-the-shelf device.

OBJECTIVE: A prototype ready-to-fenestrate stent graft (RFSG) was designed with a fixed scallop, and eight potential fenestrations allowing for variation in the position of each renal artery (RA) relative to the superior mesenteric artery (SMA). We aimed to determine the proportion of juxtarenal aneurysms treatable using this potentially 'off-the-shelf' device. METHODS: A total of 439 consecutive orders for custom-made devices were analysed, and positions for potential fenestrations in the RFSG were determined, based on the most frequent anatomical target vessel variations: a fixed SMA scallop 12 mm deep at 12:00, RA fenestrations at 9:15, 10:15 (target within the range 8:45-10:45), 2:15 and 3:15 (target within the range 1:45-3:45), each either 19 or 28 mm from the graft edge (GE); (within the range 15-32 mm), and 6 x 8 mm in diameter. Proximal diameters of 24, 26, 28, 30, 32 and 36 mm were chosen. RESULTS: Of the 439 plans, 372 standard juxtarenal (SJR) cases, defined by the inclusion of a scallop and 0, 1 or 2 small fenestrations (12%, 13% and 75% of the cases, respectively) were identified and used to test the applicability of the model. Mean CP (clock position) for right RA was 9:30, for the left RA 3:00, being a mean of 21 +/- 5 and 22 +/- 5 mm, respectively from the GE. RA CP was within the RFSG range in 86% (right) and 88% (left) of the cases, with 96% and 98%, respectively, within the allowable distance from the GE. A total of 81% of all SJR cases were potentially treatable using the RFSG model. CONCLUSIONS: An RFSG device would allow for the treatment of the majority of juxtarenal aortic aneurysms, which currently require custom-made devices.

A prospective feasibility study of duplex ultrasound arterial mapping, digital-subtraction angiography, and magnetic resonance angiography in management of critical lower limb ischemia by endovascular revascularization.

Duplex ultrasound arterial mapping (DUAM) allows precise evaluation of peripheral vascular disease (PVD). However, magnetic resonance angiography (MRA) and digital-subtraction angiography (DSA) are the diagnostic tools used most frequently prior to intervention. Our aim was to compare clinical pragmatism, hemodynamic outcomes, and cost-effectiveness when using DUAM alone compared to DSA or MRA as preoperative assessment tools for endovascular revascularization (EvR) in critical lower limb ischemia (CLI). From 2002 through 2005, 465 patients were referred with PVD. Of these, 199 had CLI and 137 required EvR. Preoperative diagnostic evaluation included DUAM (n = 41), DSA (n = 50), or MRA (n = 46). EvR was aortoiliac in 27% of cases and infrainguinal in 73%. Patients were assessed at day 1, 6 weeks, 3 months, and 6 months. Composite end points were relief of rest pain, ulcer/gangrene healing, and increase in perfusion pressure, as measured by ankle-brachial index (ABI) and digital pressures. Patency by DUAM, limb salvage, morbidity, mortality, length of stay, and cost-effectiveness were compared between groups using nonparametric t-test, analysis of variance, and Kaplan-Meier analysis. The three groups were comparable in terms of age, sex, comorbidity, and Society for Vascular Surgery/International Society of Cardiovascular Surgery clinical classification. Six-month mean improvement in ABI in the DUAM group was comparable to that in the DSA group (P = 0.25) and significantly better than that in the MRA group (P < 0.05). Six-month patency rates for the DUAM group were comparable to those in the DSA group (P = 0.68, relative risk [RR] = 0.74, 95% confidence interval [CI] 0.18-2.99) and superior to that in the MRA group (P = 0.022, RR = 0.255, 95% CI 0.09-0.71). Length of hospital stay was lower in the DUAM group compared with the DSA group (P < 0.0001) and the MRA group (P = 0.0003). The cost of DUAM is lower than that of both DSA and MRA. DUAM accurately identified the total number of target lesions for revascularization; however, MRA overestimated it. Our results indicate that DUAM is outstanding when compared with other available modalities as a preoperative imaging tool in a successful EvR program. DUAM is a minimally invasive preoperative evaluation for EvR and offers precise consecutive data with patency and limb salvage rates comparable to EvR based on DSA and superior to MRA. We believe that our feasibility study has established DUAM as an economically proficient primary modality for investigating patients with CLI that significantly shortens length of hospital stay.

Laparoscopic Nissen fundoplication: predicting outcome from peri-operative evaluation.

BACKGROUND: Although laparoscopic Nissen fundoplicaton is a safe, effective treatment for gastrooesophageal reflux (GOR), questions remain about the durability of the procedure and patient selection criteria. AIMS: To review a single surgeon's experience of laparoscopic Nissen fundoplicaton and to determine which factors, if any are likely to influence long term outcome. METHODS: Data were collected on all 124 patients who underwent laparoscopic Nissen fundoplication over a five-year period, and a detailed questionnaire was used to evaluate outcome. RESULTS: Eighty-nine per cent of patients were satisfied with the results of surgery whilst 8.8% of patients had significant recurrence of symptoms. Time since surgery was longer in those patients with symptom recurrence who were also more likely to be female. Pre-operative age, body mass index (BMI),Visick Score, endoscopic findings or pH analysis scores were not predictive of outcome, nor were intra-operative findings or post-operative complications. CONCLUSION: Although laparoscopic Nissen fundoplication is a safe and effective treatment for GOR, it is difficult to predict the small but significant group of patients with poor longterm outcome based on pre-operative assessment and peri-operative parameters alone.

Recombinant factor VIIa in the treatment of intractable bleeding in vascular surgery.

Intractable bleeding unresponsive to conventional haemostatic measures is an uncommon but potentially life threatening surgical complication. Several studies have suggested that recombinant factor VIIa (rVIIa), a genetically engineered substitute for endogenous factor VIIa may have therapeutic application in patients with uncontrollable haemorrhage not previously diagnosed with coagulopathy. We report our experience of rVIIa use in eight such vascular surgery patients who developed life-threatening non-surgical haemorrhage either intra-operative or post-operatively. In all but one patient a marked clinical improvement was noted following treatment with rVIIa with significantly less transfusion, and obvious haemostasis associated with haemodynamic stability without adverse thrombotic complications.

Nasogastric intubation causes gastroesophageal reflux in patients undergoing elective laparotomy.

BACKGROUND: The routine use of nasogastric tubes in patients undergoing elective abdominal operation is associated with an increased incidence of postoperative fever, atelectasis, and pneumonia. Previous studies have shown that nasogastric tubes have no significant effect on the incidence of gastroesophageal reflux or on lower esophageal sphincter pressure in healthy volunteers. We hypothesized that nasogastric intubation in patients undergoing laparotomy reduces lower esophageal sphincter pressure and promotes gastroesophageal reflux in the perioperative period. METHODS: A prospective randomized case-control study was undertaken in which 15 consenting patients, admitted electively for bowel surgery, were randomized into 2 groups. Group 1 underwent nasogastric intubation after induction of anesthesia, and Group 2 did not. All patients had manometry and pH probes placed with the aid of endoscopic vision at the lower esophageal sphincter and distal esophagus, respectively. Nasogastric tubes, where present, were left on free drainage, and sphincter pressures and pH were recorded continuously during a 24-hour period. Data were analyzed with 1-way analysis of variance. RESULTS: The mean number of reflux episodes (defined as pH < 4) in the nasogastric tube group was 137 compared with a median of 8 episodes in the group managed without nasogastric tubes (P =.006). The median duration of the longest episode of reflux was 132 minutes in Group 1 and 1 minute in Group 2 (P =.001). A mean of 13.3 episodes of reflux lasted longer than 5 minutes in Group 1, with pH less than 4 for 37.4% of the 24 hours. This was in contrast to Group 2 where a mean of 0.13 episodes lasted longer than 5 minutes (P =.001) and pH less than 4 for 0.2% of total time (P =.001). The mean lower esophageal sphincter pressures were lower in Group 1. CONCLUSIONS. These findings demonstrate that patients undergoing elective laparotomy with routine nasogastric tube placement have significant gastroesophageal reflux in the perioperative period and a reduced ability to clear refluxed acid from the distal esophagus. Due to the associated risk of postoperative pulmonary complications, we recommend that nasogastric intubation be performed on a selective rather than routine basis.