Mobile Smartphone Thermal Imaging Characterization and Identification of Microvascular Flow Insufficiencies in Deep Inferior Epigastric Artery Perforator Free Flaps.

BACKGROUND: Mobile smartphone thermal imaging (MTI) devices correlate with blood flow, which makes them appealing adjuncts during reconstructive surgery. MTI was assessed in the setting of deep inferior epigastric artery perforator (DIEAP) free flaps. We hypothesized that MTI can be a surrogate for blood flow to identify microvascular flow insufficiencies. METHODS: Nineteen patients underwent 30 DIEAP flaps for breast reconstruction. Images were obtained preoperatively, intraoperatively, and at instances of concern for flap viability. Three groups were evaluated: normal DIEAP flaps (NDFs), flaps with arterial insufficiency (AI), and flaps with venous congestion (VC). RESULTS: All flaps were successful. There were significant temperature increases from max ischemia (24.5 ± 2.1°C) to 1 min after anastomosis (27.2 ± 1.6°C, P < 0.001). NDFs continued to warm until the final MTI was taken when leaving the operating room. There were no differences between MTI flap temperatures before transfer to the chest and after completion of microanastomosis. With questionable flap viability, VC and AI temperatures were found to be significantly colder than the NDF group (28.3 ± 1.9°C versus 32.2 ± 1.8°C, P = 0.003) in the VC group and (27.2 ± 0.7°C versus 32.2 ± 1.8°C, P = 0.001) in the AI group. After correction of the identified flow insufficiency, VC and AI rewarmed and temperatures were no different compared with NDF. CONCLUSIONS: MTI recognizes microanastomotic failure and is a practical adjunct in the evaluation of free flap perfusion.

Cost-effectiveness of simultaneous resection and RFA versus 2-stage hepatectomy for bilobar colorectal liver metastases.

BACKGROUND AND OBJECTIVES: The current healthcare climate demands evaluation of treatment modalities in terms of costs and benefits. We compared the cost-effectiveness of two different strategies for bilobar colorectal liver metastases (bCRLM). METHODS: Patients with bCRLM treated with either resection/RFA or planned 2-stage hepatectomy at our institution between 1999 and 2011 were reviewed. A decision analysis model was populated with treatment probabilities, outcomes, survival, and costs (Medicare payment, 2011 US$). RESULTS: Two hundred fourteen patients underwent resection/RFA. Eighty-two patients were treated with planned 2-stage hepatectomy; 26 (32%) patients never completed a 2nd resection. In the 2-stage cohort, 50 patients underwent portal vein embolization (PVE). Overall complication rate and 90-day mortality for resection/RFA was 36% and 3.7%, and for 2-stage hepatectomy (both procedures combined) was 44% and 7.3%, respectively. Cost-effectiveness analysis revealed that resection/RFA cost $37,120 for 46.2-month survival, while planned 2-stage resection cost $62,198 for 35.9-month survival. If, hypothetically, all 2-stage patients completed both stages of resection, the per-patient cost was $72,644 for 40.3-month survival. CONCLUSIONS: Resection/RFA is associated with lower costs and longer survival when compared to 2-stage resection. This 1-stage approach for bCRLM should be viewed as an efficient use of resources for this challenging clinical scenario.

Surgical Training for a Disaster: Preparation of Surgical Trainees for Victims of Conflict.

INTRODUCTION: With increasing global unrest and military physician shortages potentially leading to a surgeon draft, we sought to evaluate the readiness of graduating general surgery residents to care for casualties of war. MATERIALS AND METHODS: We evaluated the National Data Reports of Surgery Case Logs for general surgery residents from 2009 to 2018 to quantify experience with key procedures that provide critical skills required for wartime surgery. Reported cases from the Accreditation Council for Graduate Medical Education for graduating residents from civilian and military residency programs were analyzed for 28 individual procedures determined to be critical for the care of combat casualties. These included central and peripheral vascular procedures, as well as neck, thoracic, abdominal, and peripheral interventions. RESULTS: From 2009 to 2018, there has been a significant decrease in wartime-relevant cases by graduating residents. Notably, these include aorto-iliac/femoral bypasses (50% reduction; 7.1%/year; P < .001), femoral-popliteal bypasses (60% reduction; 6.9%/year; P < .001), femoral-femoral bypasses (30% reduction; 2.6%/year; P < .001), upper extremity amputations (50% reduction; 6.4%/year; P = .016), fasciotomies for trauma (50% reduction; 4.5%/year; P = .013), open repair of ruptured infrarenal aorto-iliac aneurysms (70% reduction; 5.8%/year; P < .001), repair of traumatic aorta or vena cava injuries (70% reduction; 7%/year; P = .007), carotid endarterectomies (40% reduction; 4%/year; P < .001), lung resections (40% reduction; 3.7%/year; P = .001), trauma splenectomies/splenorrhaphy (30% reduction; 2.9%/year; P < .001), and repair of traumatic liver lacerations (30% reduction; 2.5%/year; P = .036). CONCLUSIONS: Graduating general surgery residents has limited exposure to wartime critical skills due to a significant reduction in open vascular, head and neck, thoracic, and operative trauma cases. As the threat of global war persists and new graduates continue to deploy worldwide, residency training must be augmented to ensure adequate preparation in case a surgeon draft is required to fulfill demand for military surgeons.

Phase I Trial of Encapsulated Rapamycin in Patients with Prostate Cancer Under Active Surveillance to Prevent Progression.

No approved medical therapies prevent progression of low-grade prostate cancer. Rapamycin inhibits cell proliferation and augments immune responses, producing an antitumor effect. Encapsulated rapamycin (eRapa) incorporates rapamycin into a pH-sensitive polymer, ensuring consistent dosing. Here, we present results from a phase I trial evaluating the safety and tolerability of eRapa in patients with prostate cancer. Patients with Gleason ≤7 (3+4) disease (low and intermediate risk) under active surveillance were enrolled in a 3+3 study with three eRapa dosing cohorts (cohort 1, 0.5 mg/week; cohort 2, 1 mg/week; and cohort 3, 0.5 mg/day). Patients were treated for 3 months and followed for an additional 3 months to assess safety, pharmacokinetics, quality of life (QoL), immune response, and disease progression. Fourteen patients (cohort 1, n = 3; cohort 2, n = 3; and cohort 3, n = 8) were enrolled. In cohort 3, one dose-limiting toxicity (DLT; neutropenia) and two non-DLT grade 1-2 adverse events (AE) occurred that resulted in patient withdrawal. All AEs in cohorts 1 and 2 were grade 1. Peak serum rapamycin concentration was 7.1 ng/mL after a 1 mg dose. Stable trough levels (∼2 ng/mL) developed after 48-72 hours. Daily dosing mildly worsened QoL, although QoL recovered after treatment cessation in all categories, except fatigue. Weekly dosing increased naïve T-cell populations. Daily dosing increased central memory cell populations and exhaustion markers. No disease progression was observed. In conclusion, treatment with eRapa was safe and well-tolerated. Daily dosing produced higher frequencies of lower grade toxicities and transient worsening of QoL, while weekly dosing impacted immune response. Future studies will verify clinical benefit and long-term tolerability.Prevention Relevance: There is an unmet medical need for a well-tolerated treatment capable of delaying progression of newly diagnosed low-grade prostate cancer. This treatment would potentially obviate the need for future surgical intervention and improve the perception of active surveillance as a more acceptable option among this patient population.

The treatment of radial scars in the modern era--surgical excision is not required.

The clinical significance of isolated radial scars (RS) diagnosed on core needle biopsy (CNB) remains unclear. By determining the pathologic concordance rate, we sought to define the indications for surgical excision for RS diagnosed on CNB. Between January 1994 and December 2007, 38 RS were diagnosed by CNB. Twenty-eight underwent surgical excision with 27 (96%) patients having further benign diagnoses. One patient, who was found to have invasive cancer on CNB, was also found to have malignancy on open biopsy. Fourteen lesions were diagnosed by 8-gauge, 13 lesions by 11-gauge, and one lesion by 14-gauge biopsy needles. Seven studies met inclusion criteria for analysis; 341 lesions with follow-on surgical biopsy were identified. Sixteen (5%) radial'scars were found to harbor malignancy and all were percutaneously biopsied with 14-gauge needles. With the inclusion of the current study, none of the isolated radial scars diagnosed by the larger 11- or 8-gauge biopsy needles resulted in upgraded lesions on follow-on surgical biopsy. Based on the current review, histologic radial scars are infrequently associated with occult malignancy and do not mandate surgical excision. Indications for excision include the mammographic diagnosis of RS and specimens associated with atypia that would otherwise require open biopsy.

Focused Changes in Opioid Prescribing Yield Far-reaching Benefits Through Culture Change and Attention to Opioid Minimization.

OBJECTIVE: Standardization of prescriptions after specific procedures (laparoscopic appendectomy, cholecystectomy, inguinal/umbilical hernia repair) significantly reduces opioid prescriptions for these targeted procedures. We sought to determine the impact of increased attention to responsible opioid prescribing in the absence of protocolization. DESIGN: Prescription practices of Laparoscopic Sleeve Gastrectomies and Roux-en-y Gastric Bypasses at a tertiary medical center (October 1, 2016-September 30, 2018) were retrospectively reviewed. Patients were grouped into whether surgical intervention took place before or after institution of an unrelated opioid protocol in November 2017. Patients with chronic opioid use or extended hospital stay (>4 days) were excluded. Discharge prescriptions, oral morphine equivalents (OME), and need for repeat prescriptions were compared. SETTING: This study was set at Madigan Army Medical Center in Tacoma, Washington. PARTICIPANTS: All general surgery residents engaged in clinical duties at our institution during the dates of the study were included. RESULTS: Study population included 187 patients, with 91 patients undergoing surgery prior to the protocol and 88 post-protocol. Preprotocol patients were provided an average of 413 OME (SD 103) and 5.5% required repeat opioid prescriptions within 3 months of surgery. The most common opioid prescription was 300 mL of oxycodone elixir (450 OME, 88%). Postprotocol, opioid prescriptions fell 61% to an average of 161 OME (SD 71, p < 0.001). Repeat opioid requirements remained statistically unchanged (8.0%, p = 0.562). The most common opioid prescription postprotocol included 20 oxycodone tablets (150 OME, 76%). CONCLUSIONS: Opioid reduction efforts reap benefits beyond those procedures specifically targeted. Focus on responsible opioid prescribing through standardization, even when limited to certain procedures, may result in a hospital culture change with global opioid prescription reduction.

Senior surgical resident autonomy and teaching assistant cases: A prospective observational study.

INTRODUCTION: Teaching assistant (TA) cases allow senior residents (SR) to gain autonomy. We compared the safety profiles of TA cases performed under direct vs. indirect staff supervision. METHODS: Prospective observational study of operative cases where a SR served as the TA between 7/2014-6/2017 (n = 161). Patient/operative characteristics, 30-day outcomes, and SR survey data were compared by level of supervision. RESULTS: Case mix included 68 laparoscopic appendectomies (42%), 49 laparoscopic cholecystectomies (30%), 10 I&Ds (6%), 10 umbilical hernia repairs (6%), 4 port placements (3%), and 11 others. Indirectly supervised cases were shorter (61 vs. 76 min, p < 0.01), with less blood loss (11 vs. 24 ml, p < 0.05), and lower conversion rates (0% vs. 5.7%, p < 0.05). Perceived difficulty was high in 20% of cases with indirect vs. 49% with direct supervision (p < 0.01). Mean SR comfort was high (4.4 vs. 4.6 out of 5) regardless of level of staff supervision. 30-day complications did not differ for indirect vs. direct supervision (all p = NS). DISCUSSION: Carefully selected TA cases offer SRs opportunities to practice autonomy without sacrificing operative time or patient safety.

Validation of a low-cost simulation strategy for burn escharotomy training.

BACKGROUND: Escharotomy is the primary effective intervention to relieve constriction and impending vascular compromise in deep, circumferential or near-circumferential burns of the extremities and trunk. Training on escharotomy indications, technique and pitfalls is essential, as escharotomy is both an infrequent and high-risk procedure in civilian and military medical environments, including low-resource settings. Therefore, we aimed to validate an educational strategy that combines video-based instruction with a low-cost, low-fidelity simulation model for teaching burn escharotomy. METHODS: Pre-hospital and hospital-based medical personnel, with varying degrees of burn care-related experience, participated in a one-hour training session. The first part of the training consisted of video-based instruction that described the indications, preparation, steps, pitfalls and complications associated with escharotomy. The second part of the training consisted of a supervised, hands-on simulation with a previously described low-cost, low-fidelity escharotomy model. Participants were then offered two psychometrically validated instruments to assess their learning experience. RESULTS: 40 participants were grouped according to prior burn care and surgical experience: attending surgeons (6), surgery and emergency medicine residents and fellows (26), medical students (5), and pre-hospital personnel (3). On two psychometrically validated questionnaires, participants at both the attending and trainee levels overwhelmingly confirmed that our educational strategy met best educational practices on the criteria of active learning, collaboration, diverse ways of learning, and high expectations; they also highly rated their satisfaction with and self-confidence under this learning strategy. DISCUSSION: An educational strategy that combines video-based instruction and a low-cost, low-fidelity escharotomy simulation model was successfully demonstrated with participants across a broad range of prior burn care experience levels. This strategy is easily reproducible and broadly applicable to increase the knowledge and confidence of medical personnel before they are called to perform escharotomy. Important applications include resource-limited environments and deployed military settings.

Stemming the Tide of Opioid Addiction-Dramatic Reductions in Postoperative Opioid Requirements Through Preoperative Education and a Standardized Analgesic Regimen.

INTRODUCTION: Surgery is a known gateway to opioid use that may result in long-term morbidity. Given the paucity of evidence regarding the appropriate amount of postoperative opioid analgesia and variable prescribing education, we investigated prescribing habits before and after institution of a multimodal postoperative pain management protocol. MATERIALS AND METHODS: Laparoscopic appendectomies, laparoscopic cholecystectomies, inguinal hernia repairs, and umbilical hernia repairs performed at a tertiary military medical center from 01 October 2016 until 30 September 2017 were examined. Prescriptions provided at discharge, oral morphine equivalents (OME), repeat prescriptions, and demographic data were obtained. A pain management regimen emphasizing nonopioid analgesics was then formulated and implemented with patient education about expected postoperative outcomes. After implementation, procedures performed from 01 November 2017 until 28 February 2018 were then examined and analyzed. Additionally, a patient satisfaction survey was provided focusing on efficacy of postoperative pain control. RESULTS: Preprotocol, 559 patients met inclusion criteria. About 97.5% were provided an opioid prescription, but prescriptions varied widely (256 OME, standard deviation [SD] 109). Acetaminophen was prescribed often (89.5%), but nonsteroidal anti-inflammatory drug (NSAID) prescriptions were rare (14.7%). About 6.1% of patients required repeat opioid prescriptions. After implementation, 181 patients met inclusion criteria. Initial opioid prescriptions decreased 69.8% (77 OME, SD 35; P < 0.001), while repeat opioid prescriptions remained statistically unchanged (2.79%; P = 0.122). Acetaminophen prescribing rose to 96.7% (P = 0.002), and NSAID utilization increased to 71.0% (P < 0.001). Postoperative survey data were obtained in 75 patients (41.9%). About 68% stated that they did not use all of the opioids prescribed and 81% endorsed excellent or good pain control throughout their postoperative course. CONCLUSIONS: Appropriate preoperative counseling and utilization of nonopioid analgesics can dramatically reduce opioid use while maintaining high patient satisfaction. Patient-reported data suggest that even greater reductions may be possible.

Functional and survival outcomes in traumatic blunt thoracic aortic injuries: An analysis of the National Trauma Databank.

OBJECTIVE: Blunt thoracic aortic injury (BAI) remains a leading cause of trauma deaths, and off-label use of endovascular devices has been increasingly utilized in an effort to reduce the morbidity and mortality in this population. Utilizing a nationwide database, we determined the incidence of BAI, and analyzed both functional and survival outcomes at discharge compared with matched controls. METHODS: Patients with BAI were identified by International Classification of Disease-9 codes from the National Trauma Data Bank (Version 6.2), 2000-2005. Patients were analyzed based on aortic repair, associated physiologic burden, and coexisting injuries. Control groups were matched by age, mechanism, major thoracic Abbreviated Injury Scale score (AIS >/= 3), major head AIS, and major abdominal AIS. Outcomes were assessed using the functional independence measure (FIM) score and overall mortality. FIM scores were scored from 1 (full assistance required) to 4 (fully independent) for three categories: feeding, locomotion, and expression. RESULTS: During the study period, 3,114 patients with BAI were identified among 1.1 million trauma admissions for an overall incidence of 0.3%. One hundred thirteen (4%) were dead on arrival, and 599 (19%) died during triage. Of the patients surviving transport and triage (n = 2402), 29% had a concomitant major abdominal injury and 31% had a major head injury. Sixty-eight percent (1,642) underwent no repair, 28% (665) open aortic repair, and 4% (95) endovascular repair with associated mortality rates of 65%, 19%, and 18%, respectively (P < .05). Aortic repair independently improved survival when controlling for associated injuries and physiologic burden (odds ratio (OR) = 0.36; 95% confidence interval (CI), 0.24-0.54, P < .05). Compared with matched controls, BAI resulted in a higher mortality (55% vs. 15%, P < .05), and independently contributed to mortality (OR = 4.04; 95% CI, 3.53-4.63, P < .05). In addition, BAI patients were less likely to be fully independent for feeding (72% vs. 82%, P < .05), locomotion (33% vs. 55%, P < .05), and expression (80% vs 88%, P < .05). CONCLUSION: This manuscript is the first to define the incidence of BAI utilizing the NTDB. Remarkably, two-thirds of patients are unable to undergo attempts at aortic repair, which portends a poor prognosis. When controlling for associated injuries, blunt aortic injury independently impacts survival and results in poor function in those surviving to discharge.

Efficacy of three topical hemostatic agents applied by medics in a lethal groin injury model.

BACKGROUND: Advanced topical hemostatic agents are increasingly utilized to control traumatic hemorrhage. We sought to determine the efficacy of three chitosan based hemostatic agents in a lethal groin injury model when applied by combat medic first responders. METHODS: After creation of a standardized femoral artery injury in a goat model, medics attempted hemorrhage control with standard gauze dressing followed by randomization to one of three hemostatic agents in this two tiered study. In the first tier, medics were randomized to either a chitosan based one-sided wafer (OS) or a dual-sided, flexible, roll (DS). In the second tier, medics were randomized to the flexible DS dressing or a chitosan powder (CP). Efficacy of gauze, each chitosan agent, proper application, and participant surveys were obtained and included for analysis using univariate techniques. RESULTS: From January 2007 to June 2007, 55 (45%) DS, 36 (29%) OS, and 32 (26%) CP agents were used to treat 123 actively bleeding arterial injuries in 62 animals. Standard gauze failed to stop hemorrhage in 122 (99%) groins. Although all three chitosan agents were marginally effective at 2 min, the recommended time for application, hemostasis improved after 4 min. The DS dressing was the most effective, controlling hemorrhage 76% at 4 min. Of the failures, 3 (23%) DS and 9 (53%) OS were due to improper application. End-user survey results demonstrated that medics preferred the DS dressing 77% and 60% over the OS and CP, respectively. CONCLUSIONS: Chitosan based bandages are significantly more effective at hemorrhage control compared to standard gauze field dressings. The dual-sided chitosan dressing demonstrated better hemorrhage control than the one-sided dressing and the chitosan powder, and was less likely to fail despite application errors.

Bioprosthetic repair of complex duodenal injury in a porcine model.

BACKGROUND: Complex duodenal injury remains a challenging problem for the trauma surgeon. Although primary repair of small injuries is often possible, extensive damage requires complex enteric reconstruction and drainage procedures. We sought to determine the efficacy of a bioprosthetic repair for large duodenal wounds in a porcine model. METHODS: A 60% circumferential wall defect in the second portion of the duodenum was created in eight female Yorkshire swine (38 kg +/- 5 kg). After 30 minutes of peritoneal soilage, a bioprosthetic repair using 1.5 mm porcine acellular dermal matrix was performed. Animals were recovered and resumed a normal diet on day 3. Repeat abdominal exploration and anastomotic bursting pressure strength was performed at 1-, 2-, 3-, and 6-week intervals. Pathologic analysis of all specimens was performed. RESULTS: All animals tolerated a normal diet postoperatively, with progressive weight gain and normal bowel function. On re-exploration, no animal had evidence of duodenal stenosis, proximal dilation, or abscess formation. Pathologic analysis demonstrated progressive in-growth of native bowel tissue, with almost complete incorporation at 6 weeks. Mean bursting pressure (202 mm Hg +/- 60 mm Hg) occurred at native bowel, not patch repair site, in three of eight animals. CONCLUSION: Bioprosthetic repair of enteric wall defects, even in proximity to upper intestinal secretions, allows successful recovery of bowel function and injury repair without extensive anatomic reconstruction. This technique may provide a more conservative approach to the treatment of complex duodenal injuries after trauma.

Is bigger better? Twenty-year institutional experience of atypical ductal hyperplasia discovered by core needle biopsy.

OBJECTIVES: The increasing accuracy of large-bore (11- or 8-gauge) vacuum-assisted core needle biopsies (VACNB) has challenged the commonly-accepted practice that surgery is needed for definitive diagnosis when atypical ductal hyperplasia (ADH) is found on VACNB. This study seeks to demonstrate the impact of increased VACNB caliber on the pathologic upgrade rate of ADH. METHODS: Patients diagnosed with isolated ADH by VACNB who subsequently underwent surgical excision at our tertiary medical center were retrospectively studied. Demographics, needle gauge, number of needle passes, and pathology results were analyzed. RESULTS: From June 1996 to June 2016, approximately 3740 VACNBs were performed. 139 patients were diagnosed with isolated ADH on VACNB and underwent surgical excision. 30 patients (22%) were upgraded to ductal carcinoma in-situ or invasive cancer; 17 upgrades (21%) from 11-gauge CNB vs. 13 upgrades (23%) from 8-gauge CNB (p = 0.67). CONCLUSION: Increasing core needle biopsy size from 11 g to 8 g does not decrease the rate of pathologic upstaging at the time of surgical excision. Surgical excision of ADH is still required for complete diagnosis.

Sage wisdom or anecdotal dictum? Equivalent opioid use after open, laparoscopic, and robotic inguinal hernia repair.

BACKGROUND: Purported benefits of minimally-invasive inguinal hernia repair techniques include less postoperative pain, but objective data is lacking. We analyzed prescribing habits and opiate requirements to provide an objective comparison. METHODOLOGY: Inguinal hernia repairs performed on patients aged 18-65 from October 2016 through February 2018 were examined. Patients with prior opiate use or complicated operative courses were excluded. Discharge prescriptions, morphine milligram equivalents(MME), and additional prescriptions within three months were evaluated. RESULTS: 173 patients met criteria including 90 open(OMR), 34 laparoscopic(TEP), and 49 robotic(RTAPP) repairs. There was no difference in age or gender. There was no difference in average opiate prescriptions(OMR 230 MME, TEP 229 MME, RTAP 208 MME; p = 0.581), percentage prescribed acetaminophen(OMR 96.7%, TEP 97.1%, RTAPP 98.0%; p = 0.910), or percentage prescribed NSAIDs(OMR 43.3%, TEP 44.1%, RTAP 46.9%; p = 0.919). On follow up, there was no difference in repeat opiate prescriptions(OMR 10.0%, TEP 8.8%, RTAPP 8.2%; p = 0.934). CONCLUSIONS: Patients undergoing open, laparoscopic, and robotic inguinal hernia repairs showed no evidence of differing pain medication requirements. The implication that minimally-invasive techniques cause less pain may be inaccurate.

Poor compliance despite equal access: Military experience with screening breast MRI in high risk women.

BACKGROUND: Using the military as a model for an equal-access, no-cost healthcare system, we sought to (1) describe screening breast MRI compliance rates and (2) identify patient-perceived barriers to screening. METHODS: In this retrospective cohort study of a prospectively maintained database at a tertiary level center, we compared compliance among women at ≥20% risk of developing breast cancer (Tyrer-Cuzick) and conducted structured phone interviews with women at ≥30% risk. RESULTS: From 2015 to 2016, 1,052 women met criteria for screening MRI. Of these, only 251 (24%) underwent MRI screening. Compliance among women with a 20-24%, 25-29%, 30-39%, and ≥40% risk was 16%, 24%, 37%, and 51%, respectively (p < 0.02). 37 of 128 unique patients (29%) with ≥30% risk agreed to interview. 43% cited time/inconvenience as the key barrier to screening; 22% cited questions regarding screening recommendations; and only 3% cited fear/concerns as the key barrier. CONCLUSIONS: Even in an equal-access system, there is poor compliance in patients who are at high risk for developing breast cancer. Patients cited time/inconvenience and questions regarding screening as key barriers to screening.

Colonic ischemia complicating open vs endovascular abdominal aortic aneurysm repair.

OBJECTIVE: Colonic ischemia (CI) is a known complication of both open abdominal aortic aneurysm (AAA) repair and endovascular aneurysm repair (EVAR). Despite a relatively low incidence of 1% to 6%, the associated morbidity and mortality are high. We sought to analyze factors that affect the development of CI on the basis of type of repair as well as associated outcomes from a large nationwide database. METHODS: All admissions undergoing AAA repair were selected from the 2003 and 2004 Nationwide Inpatient Sample. Univariate and logistic regression analyses were used to compare outcome measures and identify independent predictors of development of colonic ischemic complications. RESULTS: We identified 89,967 admissions for AAA repair (mean age, 69.9 years). Open elective repair was performed in 49% of cases, elective EVAR in 41%, and ruptured aneurysm repair in 9%. The overall incidence of CI was 2.2% (1941 cases); however, the incidence for specific procedures was significantly higher after repair of ruptured aneurysm (8.9%) and open elective repair (1.9%) than after EVAR (0.5%; both P < .001). Patients who developed CI were at increased risk for mortality (37.8% vs 6.7%), had longer hospital stays (21.5 vs 8.1 days), incurred higher hospital charges ($182,000 vs $77,000), and were less likely to be discharged home from hospital (36% vs 71%; all P < .001). Independent predictors of development of CI included ruptured aneurysm (odds ratio [OR] = 6.4), female gender (OR = 1.6) and, in the setting of elective repair, open operation (OR = 3.1). CI was found to be a strong independent predictor of mortality in evaluations of both the entire cohort (OR = 4.5) and the elective open repair and EVAR (OR = 2.4) subgroups. CONCLUSIONS: CI is significantly more common after open AAA repair and is associated with increased morbidity and a two- to fourfold increase in mortality.

Lobular neoplasia: is surgical excision warranted?

The treatment of breast cancer associated with lobular neoplasia detected on core needle biopsy (CNB) remains controversial. The purpose of this study was to review the prevalence of lobular neoplasia in CNB specimens and to correlate CNB pathology to final surgical pathology. Patients with lobular neoplasia were included for analysis in this retrospective review. Patients with concomitant malignant or atypical lesions were excluded. Method of initial diagnosis, clinical history, pathology results, and follow-up data were then analyzed. From January 1994 to December 2005, 5257 CNBs were performed at our tertiary level medical facility. Of patients with lobular neoplasia, 42 of 50 (84%) patients had atypical lobular hyperplasia, whereas 8 (16%) patients were diagnosed with lobular carcinoma in situ on CNB specimens. There were no associated malignancies in 21 patients who underwent immediate surgical excision. Of those patients who were serially followed, four developed malignancies at an average of 73 months after the sentinel diagnosis. Three of the four (75%) malignancies occurred in the ipsilateral breast. Patients with a diagnosis of lobular neoplasia by CNB should not routinely undergo an open surgical biopsy. Lobular neoplasia should only be considered a risk marker for future invasive breast cancer.

Ultrasound-guided access improves rate of access-related complications for totally percutaneous aortic aneurysm repair.

Previous experience with totally percutaneous aortic aneurysm repair has identified morbid obesity and larger sheath sizes (> or =20F) as complicating factors for percutaneous access closure. We sought to evaluate the impact of ultrasound-guided femoral access on rates of technical success, conversion to open femoral repair, and access-related complications. A retrospective review of a prospectively maintained database was performed. All consecutive patients undergoing totally percutaneous closure of large-bore-sheath (>12F) access sites with a suture-mediated closure device were included. The cohort was stratified into two groups by access technique, standard percutaneous femoral access, and ultrasound-guided femoral access. Patient variables were evaluated, and outcome measures included technical success, requirement for conversion to open repair, and access-related complications. Recorded conversions only included those related to access closure technique. During the study period, 88 consecutive patients underwent percutaneous closure of 152 large-bore access sites after endovascular aneurysm repair. There was no difference in the proportion of morbidly obese patients (body mass index >35 kg/m(2)) between the two cohorts. Access-related complications were significantly reduced in the group undergoing ultrasound-guided access. Despite the lower complication profile with ultrasound guidance, 24 sites (41%) had sheath sizes > or =20F compared to only 21 sites (24%) in the standard access group (p<0.05). Evaluating conversions and technical success of percutaneous closure, a significant benefit was identified for sheath sizes > or =20F (p<0.05). Upon comparing the two cohorts, operative time continued to decrease from 154 (+/-64) to 101 (+/-56) min after the addition of ultrasound guidance for access (p<0.05). The addition of ultrasound-guided femoral access to totally percutaneous aortic aneurysm repair continues to increase the technical success rate for vessel closure and has a clinically profound impact on access-related complications. This technical adjunct appears to have the largest impact on patients requiring larger sheath sizes.

A comparison of open versus closed techniques using the Harmonic Scalpel in outpatient hemorrhoid surgery.

BACKGROUND: Surgical excision using the Harmonic Scalpel is a modern technique for symptomatic third- and fourth-degree hemorrhoids. The resulting mucosal defect is then left open or sutured closed depending on surgeon preference. PURPOSE: The purpose of this study was to compare the open vs. closed techniques of hemorrhoid excision using the Harmonic Scalpel in an outpatient setting. METHODS: From July 2000 through October 2001, 42 patients underwent surgical excision of complex grade III or grade IV hemorrhoids via the Harmonic Scalpel with closure of the overlying mucosa (closed), and without closure of the overlying mucosa (open). Quality of life was assessed using the Short Form-36 survey. RESULTS: Both groups were comparable in terms of patient demographics and type of anesthesia. There were no late complications. Mean follow-up was 16.9 (range, 12-27) months. CONCLUSION: Leaving the mucosal defect open following Harmonic Scalpel hemorrhoidectomy significantly reduces operative time, and thus operative costs, without diminishing quality of life. Although morbidity was equivalent, this requires further evaluation with a prospective study to ensure patient safety.

Incidental pathologic findings in open resectional gastric bypass specimens with routine cholecystectomy and appendectomy.

BACKGROUND: Morbid obesity has become a public health epidemic in the United States. With this epidemic, the demand for surgical intervention has led to rapid growth in the field of bariatric surgery. Although various procedures exist, one of the procedures offered at our institution is resectional Roux-en-Y gastric bypass with incidental cholecystectomy and appendectomy. This procedure allows for pathologic assessment of otherwise normal viscera routinely removed as a part of the gastric bypass. The purpose of this study was to determine the incidence of abnormal findings of the extirpated, gallbladder, appendix, and distal stomach after gastric bypass surgery. METHODS: We performed a retrospective review of 427 patients undergoing Roux-en-Y at a tertiary level medical center. RESULTS: Abnormal findings were divided according to the organ. In the gastric remnant, the reported pathologic findings included chronic or active gastritis in 66, fundic gland polyps in 7, intestinal metaplasia in 3, gastric ulcers in 2, gastropathy in 2, lymphoid aggregate in 1, diverticulum in 1, a developmental cyst in 1, and leiomyoma in 1. We analyzed 311 appendixes and found the following abnormalities: fibrous obliteration of the appendiceal lumen in 76, carcinoids in 2, infarcted appendicial epiploica in 2, follicular hyperplasia in 2, and subserosal endometriosis in 1. In the gallbladder the sole abnormality, other than cholelithiasis, was an adenomyoma. Other resected findings included five Meckel's diverticula, one bile duct adenoma, and one sigmoid diverticulum. CONCLUSION: The results of our study have shown that the resection of grossly normal and asymptomatic organs results in a very low prevalence of clinically significant incidental pathologic findings.