The Importance of Team Alignment and Retention in Vascular Center Development: A Clinician's Perspective.

The healthcare landscape is in a state of constant evolution, presenting both challenges and opportunities. Recent trends, including the departure or retirement of medical professionals, the rise in travel and per diem positions, and the expansive growth of healthcare networks, have resulted in a palpable divide within the field. This divide often manifests as a shift from prioritizing patient care and staff well-being toward financial security and operational efficiency and productivity. Amid these ongoing changes, vascular centers possess the potential for a positive distinction that extends beyond their specialization to encompass their approaches to patient care and team dynamics. This article presents a 3-phase strategy for vascular clinicians and centers to consider as they seek to attract and retain top-tier staff, provide exceptional patient care, and attain sustainable growth and financial success.

Association Between a Physical Activity Vital Sign and Cardiometabolic Disease in High-Risk Patients.

OBJECTIVE: To determine the association between the physical activity vital sign (PAVS) and markers of cardiometabolic disease. DESIGN: Patients were assessed through the PAVS, a validated tool self-reporting the frequency and duration of physical activity. Patients were categorized into 3 groups: inactive (0 minutes per week), underactive (1-149 minutes per week), and active (>150 minutes per week). Associations were tested between the PAVS and the cardiometabolic disease biomarkers of body mass index, hemoglobin A1c (A1c), blood pressure, and low-density lipoprotein (LDL) using one-way analyses of variance. SETTING: High-risk family medicine residency clinic. PARTICIPANTS: Two thousand three hundred twenty-one adult patients (age ≥ 18 years). RESULTS: Participants reported a mean of 97.87 (SD = 149.35) minutes per week of exercise. Overall, 50.1% reported physical inactivity, 25.7% were underactive, and 24.3% were active. Younger individuals (P < 0.001) and men (P < 0.05) reported more physical activity than older individuals and women. Patients who reported being active were significantly less likely to be overweight (P < 0.05), obese (P < 0.05), or hypertensive (P < 0.05), but there was no association with A1c or LDL levels. CONCLUSIONS: This is the first investigation to examine the PAVS in a high-risk population. In these patients, reported levels of physical inactivity are 150% higher than other clinical settings, and the PAVS is only associated with improvements in 2 of 4 major cardiometabolic risk factors. For this group, self-reported levels of physical activity may need to be higher for cardiovascular benefits to be realized in all 4 cardiometabolic domains. The PAVS offers health professionals an opportunity to encourage lifestyle-based interventions to reduce cardiovascular risk, but refinements may be necessary to address this population.

Use of Spermatic Cord Block Systematically Identifies a Paraspinal Tumor as Source of Orchialgia.

Orchialgia is a common urologic complaint with a myriad of etiologies. Workup for orchialgia requires a broad differential diagnosis and a thorough understanding of relevant anatomy. We report the case of a 43-year-old man who presented to a urologist with right testicular pain. Following a negative workup, the patient received a spermatic cord block for therapeutic and diagnostic purposes. Two months after the block, the patient returned with new complaints of ipsilateral inner thigh paresthesias, suggesting a pathologic process proximal to the genital branch of the genitofemoral nerve. A subsequent MRI of the lumbosacral spine revealed a paraspinal mass involving nerve roots at L1-2. We highlight the utility of the spermatic cord block and its role in the diagnosis of a paraspinal tumor as an uncommon cause of orchialgia.

Traumatic Aorto-Cisterna Chlyi Fistula with Treatment of Aortic Pseudoaneurysm with CT-Guided Thrombin Injection.

BACKGROUND: Only 3 cases of aorto-cisterna chyli fistula have been described in the literature but none with a resulting pseudoaneurysm (PSA). METHODS: A 68-year-old man presented following a motor vehicle collision. Imaging revealed a retroperitoneal hematoma with enhancement of the cisterna chyli, representing an aortic to cisterna chyli fistula. Three days later, computed tomography angiography showed resolution of the fistula, but revealed a PSA. The patient underwent arteriography that confirmed the PSA, and then a computed tomography-guided thrombin injection was performed. Follow-up imaging showed resolution of the PSA. RESULTS: Only 3 cases of aorto-cisterna chyli fistula have been described. We hypothesize that this fistula was caused from his L2 vertebral body fracture, which avulsed the lumbar artery and injured the cisterna chyli. The cisterna chyli provided an outflow tract for the aortic injury. We believe this type of fistula follows a benign clinical course. Aorto-cisterna chyli fistula is rare, and reports point to spontaneous resolution. Our case is unique in that the patient progressed from a fistula to a PSA. Options for treatment of this PSA include covered stent graft, open repair, coil embolization, or thrombin injection. CONCLUSIONS: This case report describes an extremely rare diagnosis and the natural history of this aorto-cisterna chyli fistula. Furthermore, the resulting aortic PSA was successfully treated with computed tomography-guided thrombin injection, which in the appropriate setting, should be considered an acceptable option.

Postoperative outcomes in bariatric surgical patients participating in an insurance-mandated preoperative weight management program.

BACKGROUND: Many insurance companies require patient participation in a medically supervised weight management program (WMP) before offering approval for bariatric surgery. Clinical data surrounding benefits of participation are limited. OBJECTIVE: To evaluate the relationship between preoperative insurance-mandated WMP participation and postoperative outcomes in bariatric surgery patients. SETTING: Regional referral center and teaching hospital. METHODS: A retrospective review of patients who underwent vertical sleeve gastrectomy or Roux-en-Y gastric bypass between January 2014 and January 2016 was performed. Patients (N = 354) were divided into 2 cohorts and analyzed according to presence (n = 266) or absence (n = 88) of an insurance-mandated WMP requirement. Primary endpoints included rate of follow-up and percent of excess weight loss (%EWL) at postoperative months 1, 3, 6, and 12. All patients, regardless of the insurance-mandated WMP requirement, followed a program-directed preoperative diet. RESULTS: The majority of patients with an insurance-mandated WMP requirement had private insurance (63.9%). Both patient groups experienced a similar proportion of readmissions and reoperations, rate of follow-up, and %EWL at 1, 3, 6, and 12 months (P = NS). Median operative duration and hospital length of stay were also similar between groups. Linear regression analysis revealed no significant improvement in %EWL at 12 months in the yes-WMP group. CONCLUSION: These data show that patients who participate in an insurance-mandated WMP in addition to completing a program-directed preoperative diet experience no significant benefit to rate of readmission, reoperation, follow-up, or %EWL up to 12 months postoperation. Our findings suggest that undergoing bariatric surgery without completing an insurance-mandated WMP is safe and effective.

Short-Term Preoperative Weight Loss and Postoperative Outcomes in Bariatric Surgery.

BACKGROUND: Preoperative weight loss is often encouraged before undergoing weight loss surgery. Controversy remains as to its effect on postoperative outcomes. The aim of this study was to determine what impact short-term preoperative excess weight loss (EWL) has on postoperative outcomes in patients undergoing primary vertical sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB). STUDY DESIGN: All patients who underwent SG (n = 167) or RYGB (n = 188) between 2014 and 2016 and who completed our program-recommended low calorie diet (LCD) for 4 weeks immediately preceding surgery were included. These patients (N = 355) were then divided into 2 cohorts and analyzed according to those who achieved ≥8% EWL (n = 224) during the 4-week LCD period and those who did not (n = 131). Primary endpoints included percent excess weight loss (% EWL) at 1, 3, 6, and 12 months postoperatively. RESULTS: Patients achieving ≥8% EWL preoperatively experienced a greater % EWL at postoperative month 3 (42.3 ± 13.2% vs 36.1 ± 10.9%, p < 0.001), month 6 (56.0 ± 18.1% vs 47.5 ± 14.1%, p < 0.001), and month 12 (65.1 ± 23.3% vs 55.7 ± 22.2%, p = 0.003). Median operative duration (117 minutes vs 125 minutes; p = 0.061) and mean hospital length of stay (1.8 days vs 2.1 days; p = 0.006) were also less in patients achieving ≥8% EWL. No significant differences in follow-up, readmission, or reoperation rates were seen. Linear regression analysis revealed that patients who achieved ≥8% EWL during the 4-week LCD lost 7.5% more excess weight at postoperative month 12. CONCLUSIONS: Based on these data, preoperative weight loss of ≥8% excess weight, while following a 4-week LCD, is associated with a significantly greater rate of postoperative EWL over 1 year, as well as shorter operative duration and hospital length of stay.

Use of Bioabsorbable Tissue Reinforcement Reduces Incidence of Internal Hernia in Roux-en-Y Gastric Bypass Patients.

Internal hernias are one of the most devastating late, postsurgical complications associated with laparoscopic Roux-en-Y gastric bypass (LRYGB). The objective of this study was to determine whether placement of a bioabsorbable tissue matrix in soft tissue defects after gastric bypass resulted in a lower incidence of internal hernia development. Prospective database was used to identify all patients who underwent LRYGB between January 2002 and January 2016. These patients were then retrospectively reviewed to determine the development of internal hernia. Before 2009, the retro-Roux defect was left open during the primary operation and the defect at the jejunojejunostomy was closed with sutures or staples. Beginning in 2009, all soft tissue internal defects were reinforced with an 8 cm × 8-cm piece of bioabsorbable matrix. The incidence of subsequent internal hernia development was compared between these two groups: no bioabsorbable matrix versus use of a bioabsorbable matrix. A total of 2771 patients underwent LRYGB during our study period. From these, 1215 procedures were performed without tissue reinforcement and 1556 were performed using a bioabsorbable matrix. During the study period, 274 patients developed an internal hernia. Patients who did not have tissue reinforcement at closure had a significantly higher internal hernia rate [225/1215 (18.5%) vs 49/1556 (3.1%), P < 0.005]. This study demonstrates a statistically significant reduction in internal hernia formation after LRYGB with the addition of a bioabsorbable tissue matrix. Although prospective studies are needed, early evidence suggests that reinforcement with a bioabsorbable tissue scaffold is an effective method for minimizing internal hernias after LRYGB.

Instituting Ultrasound-Guided FNA for Thyroid Nodules into a General Surgery Residency Program: What We Learned.

BACKGROUND: Evaluation of a thyroid nodule is a common referral seen by surgeons and frequently requires ultrasound-guided fine needle aspiration (US-guided FNA). While surgical residents may have sufficient exposure to thyroid surgery, many lack exposure to office-based procedures, such as US-guided FNA. General surgery residents should be provided with knowledge and practical skills in the application of diagnostic and interventional neck ultrasound to manage the common workup of a thyroid nodule. METHODS: This study sought to instruct and measure surgical residents' performance in thyroid US-guided FNA and evaluate their views regarding instituting such a formal curriculum. Twelve (n = 12) senior residents completed a written pretest and questionnaire, then watched an instructional video and practiced a simulated thyroid US-guided FNA on our created model. Then residents were evaluated while performing actual thyroid US-guided FNAs on patients in our clinic. Residents then completed the same written exam and questionnaire for objective measure. RESULTS: Eight of the chief residents (62%) felt "not comfortable" with the procedure on the pre-course survey; this was reduced to 0% on the post-course survey. Moderate comfort level increased from 15% to 50% and extreme comfort increased from 0% to 8%. From the 11 residents who completed the pre- and post-test exam, 82% (n = 9) significantly improved their score through the curriculum (pre-test: 40.9 vs. post-test: 61.8; p = 0.05). CONCLUSION: With focused instruction, residents are able to learn ultrasound-guided thyroid biopsy with improvement in subjective confidence level and objective measures. Resident feedback was positive and emphasized the importance of such training in surgical residency curriculum.

Improving Patient Outcomes and Health Care Provider Communication with a Small, Yellow Plastic Band: the Patient URinary Catheter Extraction (PURCE) Protocol©.

INTRODUCTION: Great efforts are being made to reduce catheter associated urinary tract infections as they increase patient morbidity and are costly to health care centers. Although various catheter associated urinary tract infection prevention initiatives exist, efficient communication between physicians and nurses continues to be a significant barrier. In an effort to enhance communication and reduce catheter associated urinary tract infections, we implemented a novel Patient URinary Catheter Extraction (PURCE) Protocol© and in this study we evaluate the utility of the PURCE Protocol. METHODS: The PURCE Protocol was implemented for all urology and vascular surgical patients admitted to 1 surgical specialty unit between January and December 2014 (treatment group, 901 patients). The control group consisted of urology and vascular surgical patients admitted to the same surgical specialty unit during the 12-month period (January to December 2013) before protocol implementation (926). End points included annual catheter associated urinary tract infection rates, device utilization ratio and protocol deviations. RESULTS: The majority of urology/vascular surgery patients in both groups underwent catheter placement (control 55.4% vs treatment 58.9%). The annual catheter associated urinary tract infection rate for urology/vascular surgery patients in the control group was 2.5 compared to 0.0 in the treatment group. The annual device utilization ratio increased slightly from 0.15 in the control to 0.17 in the treatment group. Within the first 6 months of implementation there were 405 patient audits and 28 protocol deviations (6.9%), and no additional deviations occurred in the last 6 months of the study. CONCLUSIONS: According to our findings implementation of the PURCE Protocol led to a reduction in catheter associated urinary tract infections in a highly susceptible surgical patient population.

Patterns of Recurrence and Mechanisms of Failure after Open Ventral Hernia Repair with Mesh.

Recurrence after ventral hernia repair (VHR) remains a significant complication. We sought to identify the technical aspects of VHR associated with recurrence. Patients who underwent open midline VHR between 2006 and 2013 (n = 261) were retrospectively evaluated. Patients with recurrence (Group 1, n = 48) were compared with those without recurrence (Group 2, n = 213). Smoking, diabetes, and body mass index were not different between groups. More patients in Group 1 underwent clean-contaminated, contaminated, or dirty procedures (43.8 vs 27.7%; P = 0.021). Group 1 had a higher incidence of surgical site occurrence (52.1 vs 32.9%; P = 0.020) and surgical site infection (43.8 vs 15.5%; P < 0.001). Recurrences were due to central mesh failure (CMF) (39.6%), midline recurrence after biologic or bioabsorbable mesh repair (18.8%), superior midline (16.7%), lateral (16.7%), and after mesh explantation (12.5%). Most CMF (78.9%) occurred with light-weight polypropylene (LWPP). Recurrence was higher if the midline fascia was unable to be closed. Recurrence with midweight polypropylene (MWPP) was lower than biologic (P < 0.001), bioabsorbable (P = 0.006), and light-weight polypropylene (P = 0.046) mesh. Fixation, component separation technique, and mesh position were not different between groups. Wound complications are associated with subsequent recurrence, whereas midweight polypropylene is associated with a lower overall risk of recurrence and, specifically, CMF.

Electromagnetic Navigational Bronchoscopy Reduces the Time Required for Localization and Resection of Lung Nodules.

OBJECTIVE: The aims of the study were to evaluate electromagnetic navigational bronchoscopy (ENB) and computed tomography-guided placement as localization techniques for minimally invasive resection of small pulmonary nodules and determine whether electromagnetic navigational bronchoscopy is a safer and more effective method than computed tomography-guided localization. METHODS: We performed a retrospective review of our thoracic surgery database to identify patients who underwent minimally invasive resection for a pulmonary mass and used either electromagnetic navigational bronchoscopy or computed tomography-guided localization techniques between July 2011 and May 2015. RESULTS: Three hundred eighty-three patients had a minimally invasive resection during our study period, 117 of whom underwent electromagnetic navigational bronchoscopy or computed tomography localization (electromagnetic navigational bronchoscopy = 81; computed tomography = 36). There was no significant difference between computed tomography and electromagnetic navigational bronchoscopy patient groups with regard to age, sex, race, pathology, nodule size, or location. Both computed tomography and electromagnetic navigational bronchoscopy were 100% successful at localizing the mass, and there was no difference in the type of definitive surgical resection (wedge, segmentectomy, or lobectomy) (P = 0.320). Postoperative complications occurred in 36% of all patients, but there were no complications related to the localization procedures. In terms of localization time and surgical time, there was no difference between groups. However, the down/wait time between localization and resection was significant (computed tomography = 189 minutes; electromagnetic navigational bronchoscopy = 27 minutes); this explains why the difference in total time (sum of localization, down, and surgery) was significant (P < 0.001). CONCLUSIONS: We found electromagnetic navigational bronchoscopy to be as safe and effective as computed tomography-guided wire placement and to provide a significantly decreased down time between localization and surgical resection.

Atrial Esophageal Fistula Secondary to Ablation for Atrial Fibrillation: A Case Series and Review of the Literature.

This article describes 2 patients who presented to our institution with left atrial esophageal fistula after atrial fibrillation ablation; it also compares our experience with other atrial esophageal fistula cases reported in the literature. We performed a retrospective review of 2 patients who presented to our hospital between July 2015 and September 2015 with atrial esophageal fistula. Patient A, a 57-year-old man, presented 31 days postablation with a fever and right-sided weakness. A chest computed tomography showed gas in the left atrium and esophagus; an echocardiogram confirmed the diagnosis of atrial esophageal fistula. The patient subsequently underwent a left thoracotomy. Postoperative recovery was poor and included significant coagulopathy, sepsis, cardiogenic shock, and multisystem organ failure. The patient died on postoperative day 28. Patient B, a 77-year-old man, presented 21 days post-atrial fibrillation ablation with left-arm weakness and altered mental status. An esophagram was performed and showed no evidence of an esophageal perforation. Because of positive cultures and worsening altered mental status, the patient underwent a head computed tomography, which showed pneumocephalus, leading to our suspicion of the atrial esophageal fistula. A follow-up chest computed tomography confirmed the atrial esophageal fistula. Treatment included an esophagectomy and repair of the atrium. Unfortunately, the atrial esophageal fistula closure dehisced, and the patient developed acute respiratory failure and cardiac tamponade, which led to cardiopulmonary arrest, and the patient died on postoperative day 10. Based on our experience, and the literature, we recommend that a chest computed tomography be immediately performed on patients presenting with the described symptoms after a recent atrial fibrillation ablation.

Reconstruction of a Long-Segment Tracheal Defect Using an AlloDerm Conduit.

This case describes successful reconstruction of a long-segment tracheal defect using AlloDerm as the conduit for reconstruction. A 38-year-old woman who had undergone a thyroid lobectomy in 2011 presented several months later unable to swallow. Chest computed tomography results revealed a tracheal/esophageal mass and a subsequent bronchoscopy, and esophagogastroduodenoscopy results revealed an upper esophageal/tracheal mass with two areas concerning for fistula. She underwent a bronchoscopy with a tracheal stent and percutaneous endoscopic gastrostomy placement. All biopsies were nondiagnostic for malignancy and the patient recovered well. After a repeat bronchoscopy and esophagogastroduodenoscopy a few months later, she underwent a diagnostic right video-assisted thoracoscopic surgery and thoracotomy. To obtain adequate tissue for diagnosis, the fistula was opened, resulting in a large defect in the esophagus and trachea, as portions of the trachea, esophagus, and right recurrent laryngeal nerve liquefied. A 7-cm portion of her esophagus, 8 cm of the posterior trachea, and 5 cm of the right trachea wall were removed. The pathology came back as Hodgkin lymphoma. Because of the size of the esophageal defect, reconstruction was not an option. Therefore, the remainder of the esophagus was resected, the stomach stapled off, and esophageal hiatus closed. The tracheal defect was also too large for patch repair and was reconstructed with a tube of AlloDerm (6 × 10 cm). Four years after reconstruction, the patient is disease free and living a normal life. This case demonstrates successful tracheal reconstruction with AlloDerm.

Impact of sarcopenia on long-term mortality following endovascular aneurysm repair.

Sarcopenia, also known as a reduction of skeletal muscle mass, is a patient-specific risk factor for vascular and cancer patients. However, there are no data on abdominal aortic aneurysm (AAA) patients treated with endovascular aneurysm repair (EVAR) who have sarcopenia. To determine the impact of sarcopenia on mortality following EVAR, we retrospectively reviewed 200 patients treated with EVAR by estimating muscle mass on abdominal computed tomography (CT) scans. Mortality was analyzed according to its presence (n=25) or absence (n=175). Sarcopenia was more common in women than men (32.0% vs 9.7%; p=0.005). Patients with sarcopenia had an increased risk of mortality compared to those without (76% vs 48%; p=0.016). Of note, the overall mortality rate was 51% with a median follow up of 8.4 years (interquartile range, 5.3-11.7). In conclusion, the presence of sarcopenia on a CT scan is an important predictor of long-term mortality in patients treated for AAA with EVAR. Pending further study, these data suggest that sarcopenia may aid in pre-procedural long-term survival assessment of patients undergoing EVAR.

Electromagnetic Navigational Bronchoscopy: A Safe and Effective Method for Fiducial Marker Placement in Lung Cancer Patients.

The emergence of Electromagnetic Navigational Bronchoscopy (ENB) as a diagnostic tool for small peripheral lung nodules has introduced a new method for delivery of fiducial markers. This technique has not been well studied in the literature. The purpose of our study was to evaluate the safety and effectiveness of ENB when used in fiducial marker placement. We reviewed all patients undergoing ENB fiducial placement between June 2010 and February 2014 (n = 64). These 64 patients had 68 lung lesions, in which we placed a total of 190 markers. Primary end points were marker retention and postoperative complications. The retention rate for the study was 82 per cent (n = 156). Upper lobe lesions had a 78 per cent retention rate and the middle/lower lobe lesions had an 89 per cent retention rate; the difference was not significant (P = 0.126). Complications included hospital admissions, respiratory failure, and pneumothorax. The difference in complication rates between upper and middle/lower lobe markers was not significant. We found ENB to be a safe method for the placement of fiducial markers. We also found that placement of an average of three markers/lesion led to an adequate retention rate to allow for successful treatment of lung cancer in nonsurgical patients using lung-sparing stereotactic radiation.