Open aortic surgery volume experience at a regionalized referral center and impact on Accreditation Council for Graduate Medical Education trainees.

OBJECTIVE: The objective of this study was to review our institute's open aortic surgery volume experience and its impact on Accreditation Council for Graduate Medical Education trainees. METHODS: A review was conducted of the vascular surgery department's operative database for all cases that underwent aortic aneurysm repair, whether open aortic repair (OAR), endovascular aneurysm repair (EVAR), or fenestrated EVAR (FEVAR). We also reviewed our graduating trainees' case logs. In the setting of our regionalized referral center, all patients who underwent open or endovascular aortic intervention between 2010 and 2014 at our main campus were included. The total number of aortic procedures performed by our graduation trainees was determined. All aortic aneurysm interventions, both open and endovascular (both EVAR and FEVAR), were included. The main outcome measures were the total number of aortic interventions, any change in trends of intervention, and the total number of open aortic cases that our graduation trainees had. RESULTS: During the 5-year period analyzed, a total of 1389 abdominal aortic aneurysm repair procedures were performed by OAR, EVAR, and FEVAR. Of those, 462 were OARs, representing 33.2% of the total; 440 were EVARs, representing 31.6%; and 487 were FEVARs, representing 35.2%. For all OAR procedures, there was a significant increase in the proportion of these cases over time (P = .014). The total number of EVAR and FEVAR cases performed annually during this time did not change, whereas the number of OAR cases has increased. Of the OARs, 59.3% were performed for juxtarenal aneurysms, whereas 22.9% involved type IV thoracoabdominal aortic aneurysms. On average, graduating vascular surgery trainees performed 23.1 OARs before graduation (range, 19-26). CONCLUSIONS: In contrast to the documented national trend of decreased OAR, our institute continues to see increased OAR relative to EVAR and FEVAR. Moreover, we theorized that the preservation of OAR volume in our program and other similar institutions might offer a practical solution to the challenge of addressing vascular surgery training in aortic surgery by OAR, EVAR, and FEVAR. Inclusive discussions at the national and international levels are needed to reach consensus regarding the future of vascular surgery training and key issues, such as additional, mandatory, subspecialized training in OAR and FEVAR for both residents and fellows who wish to receive certification in OAR; creation of centers of excellence for open aortic surgery that would centralize OAR and direct trainees to those centers for their needed training; and possibly development of new training strategies whereby single cases can be shared among trainees with alternating roles as exposure and closure vs repair.

Open versus Endovascular Treatment of Visceral Artery Aneurysms and Pseudoaneurysms.

BACKGROUND: Visceral artery aneurysms and pseudoaneurysms (VAAP) represent a rare and potential life-threatening disease with a documented incidence of 0.1-2.0%. Treatment options for VAAP vary from open approach with aneurysm excision, exclusion and revascularization to endovascular techniques. Aneurysm anatomy and pathogenesis dictate treatment choice. The purpose of this study was to compare the perioperative, short- and mid-term outcomes of open and endovascular approaches. METHODS: Between January 2007 to April 2015, patients with VAAP who underwent surgical treatment, either by endovascular technique (endovascular surgery [EV] group) or by open surgery (OS group), were selected for analysis. Aneurysm's anatomy and pathogenesis dictated treatment choice. Demographic variables, surgical data, and postoperative follow-up were retrospectively analyzed. Preoperative computed tomography scans were evaluated for aneurysm characteristics. RESULTS: A total of 296 consecutive patients were identified with VAAP. Surveillance without intervention occurred in 183 patients, and 113 underwent surgical treatment: 57 by EV technique and 56 by OS. The VAAP sites were: splenic (50.9/5.4%), renal (7.0/50%), superior mesenteric (7.0/7.1%), celiac (12.3/17.9%), hepatic (14.0/5.4%), gastroduodenal (7.0/7.1%), and pancreaticoduodenal (1.8/7.1%). Eight urgent surgeries occurred in EV and 5 in OS group (P = 0.39). Operative time and estimated blood loss were 122 ± 54 vs. 312 ± 157 min (P < 0.001) and 5 (interquartile range [IR], 0-50) vs. 550 (IR, 200-980) mL (P < 0.001) in groups EV and OS, respectively. The intraoperative and postoperative major complications, including end-organ infarction, and reinterventions were comparable between the groups. Transfusion of blood products was necessary in 12.3% (EV) and 42.9% (OS; P < 0.001). Median hospital length of stay was 1 (IR, 1-3) and 6 (IR, 4-9) days in groups EV and OS, respectively (P < 0.001). Short-term technical success was achieved in 98.2% (EV) and 96.4% (OS). During the median follow-up period of 16 (IR, 7.1-43.9) months, the clinical success was 91.2% and 92.9% (P = 0.74), and the overall survival was 94.7% and 96.4% (P = 1.0) in groups EV and OS, respectively. CONCLUSIONS: Open and endovascular approaches have similar rates of technical and clinical success, as well as mortality during follow-up. However, periprocedural morbidity was significantly higher in cases treated by OS. Although longer-term follow-up is needed to access the durability of the endovascular treatment, initial successful outcomes and low reintervention rates make it a safe and feasible approach.

Preoperative weight loss before bariatric surgery.

HYPOTHESIS: Preoperative weight loss reduces the frequency of surgical complications in patients undergoing bariatric surgery. DESIGN: Review of records of patients undergoing open or laparoscopic gastric bypass. SETTING: A comprehensive, multidisciplinary obesity treatment center at a tertiary referral center that serves central Pennsylvania. PATIENTS: A total of 881 patients undergoing open or laparoscopic gastric bypass from May 31, 2002, through February 24, 2006. INTERVENTION: All preoperative patients completed a 6-month multidisciplinary program that encouraged a 10% preoperative weight loss. MAIN OUTCOME MEASURES: Loss of excess body weight (EBW) and total and major complication rates. RESULTS: Of the 881 patients, 592 (67.2%) lost 5% or more EBW and 423 (48.0%) lost more than 10% EBW. Patients referred for open gastric bypass (n = 466) were generally older (P < .001), had a higher body mass index (P < .001), and were more often men (P < .001) than those undergoing laparoscopic gastric bypass (n = 415). Total and major complication rates were higher in patients undergoing open gastric bypass (P < .001 and P = .03, respectively). Univariate analysis revealed that increasing preoperative weight loss is associated with reduced complication frequencies for the entire group for total complications (P =.004) and most likely for major complications (P = .06). Controlling for age, sex, baseline body mass index, and type of surgery in a multiple logistic regression model, increased preoperative weight loss was a predictor of reduced complications for any (P =.004) and major (P = .03) complications. CONCLUSION: Preoperative weight loss is associated with fewer complications after gastric bypass surgery.

The azygos system as a rare alternative for chronic indwelling catheters placement.

Chronic indwelling catheters are plagued with a high rate of complications, including infection, central venous occlusion, or thrombosis. When direct access to the superior or inferior vena cava is not possible, venography may identify alternatives that might be viable with current endovascular techniques. This case report describes the successful placement of a tunneled catheter for total parenteral nutrition in the azygos arch through a small collateral vein from the left jugular vein in a patient with no other alternatives because of superior vena cava occlusion and inferior vena cava thrombophlebitis.