Distally based V-flap on the artery in an end-to-side anastomosis for arteriovenous fistula creation - A randomized controlled pilot study.

BACKGROUND: With an increasing number of chronic kidney disease (CKD) patients presenting at a young age, it is necessary to create a vascular access (VA) that is reliable, long-lasting, and has minimal complications. Despite improvements in anastomotic techniques, distal arteriovenous fistula (AVF) has a high failure rate. The successful use of a geometric design for the end-to-side anastomosis in free tissue transfer led us to consider whether V-flap technique can be employed to achieve consistent and earlier maturation in distal AVF and reduce the failure rates. METHODS: This was a prospective randomized controlled trial conducted between January and April 2022. Twenty CKD patients were randomized into two groups and underwent AVF creation using the slit-arteriotomy and the V-flap technique. Postoperative follow-up was performed on the 1st, 2nd, 4th, 6th, and 8th weeks. Cross-sectional area (CSA) and circumference of vein, linear and volumetric flow across the anastomosis, and the time taken to achieve AVF maturation were analyzed. RESULTS: There was a significant increase in the CSA and circumference in the V-flap group as compared to that in the slit-arteriotomy group. The volumetric flow across the anastomosis in the V-flap group was significantly higher than that of the slit-arteriotomy group. The median time to achieve AVF maturation in the slit-arteriotomy group was 8 weeks, whereas it was 4 weeks in the V-flap group. CONCLUSION: The V-flap technique creates an anastomosis with a greater CSA facilitating larger volumetric flow rate. This helps to achieve a consistent, reliable, and earlier maturation with successful initiation of hemodialysis.

Use of Minced Residual Skin Grafts to Improve Donor Site Healing in Split-Thickness Skin Grafting.

Background The morbidity of the donor site in split-thickness skin graft (STSG) may include abnormal pigmentation, delayed healing, and unfavorable scarring. Studies are usually focused on improving the healing of the recipient site, so donor site management becomes a secondary consideration. An optimal solution should be sought for donor site management to improve healing and minimize morbidity. Methods In this study, we used minced residual skin grafts over half of the donor site (cases) and compared the healing duration and scar quality with the other half (control). Healing duration was measured in days and the scar quality was assessed by the Patient and Observer Scar Assessment Scale (POSAS) at 90 days, 180 days, and 360 days. Results The healing time was reduced with the application of minced residual skin grafts on the donor site. The scar quality was significantly better in the case group as compared to the control group at 90 days, 180 days, and 360 days (p<0.05). Conclusion Mincing residual skin grafts and replacing them back to the donor site reduces the healing time and improves the quality of the scar.

Outcomes of Arteriovenous Fistula Creation in Patients Undergoing Hemodialysis: An Indian Experience.

Introduction Creating an arteriovenous fistula (AVF) to provide a patent and long-term vascular access (VA) for hemodialysis (HD) still remains a challenge. A methodical approach to choosing the appropriate HD access in accordance with patients' end-stage kidney disease (ESKD) life plan will help them achieve their goals safely. This study summarizes the impact of various factors on the AVF outcomes in an Indian population as well as the necessary considerations before choosing the site of AVF creation. Materials and methods This study involved a single-center, retrospective evaluation of all patients who had undergone arteriovenous (AV) access creation for maintenance HD from October 2018 to August 2019 at a center in India. Results In our study of 216 cases, the average age at presentation was 43.9 years and the difference in age between the successful and unsuccessful group was not significant. The successful outcomes in males were significantly higher than those in females (p=0.005). The mean venous diameter in the successful group was significantly larger than that in the unsuccessful group. The distal arterial and vein diameter was higher in both males and females of the laborer group compared to the clerical group; however, the outcomes were comparable. The overall complication rate was 22.22%. We had primary patency rates of 83% at the end of one year with a primary failure rate of 8.80%. Conclusion Vein diameter was the most important predictive factor for a successful outcome in our study. Factors like age and life expectancy, gender, comorbidities, occupation, and type of anastomosis may not be individually predictive of outcomes but need to be considered before choosing the appropriate site of access creation according to the life plan of the patient. This will reduce morbidity associated with an additional procedure and facilitate the initiation of HD as early as possible. Occupation can be considered as a surrogate for preoperative forearm exercises with the increased caliber of vessels found in people performing heavy/manual labor favoring a more distal AVF creation.

Management of recurrent post-traumatic seroma of thigh (Morel-Lavallée lesion) by percutaneous aspiration and sclerotherapy using tetracyclines (PAST).

Morel-Lavallée lesion is a chronic, recurrent collection of serous fluid in the soft tissues and usually occurs following injury. The most common sites are thigh, hip and pelvic region. This presents as a local or diffuse swelling and may cause discomfort to the patient besides being a potential site for bacterial contamination. So, early diagnosis and timely management is crucial for an early and successful outcome. The investigation modality of choice for diagnosis of these lesions is MRI. Definitive management ranges from percutaneous aspiration with or without sclerotherapy to open debridement and irrigation. Although recurrences are common with conservative management, it can be minimised with judicious use of sclerotherapy.

A Masquerading and Unconventional Cause of Dynamic Intestinal Obstruction: Strangulated Obturator Hernia.

Obturator hernia is an extremely rare type of abdominal wall hernia occurring mostly in elderly, thin females. It is characterized by the herniation of intra-abdominal contents through the obturator foramen. Symptoms are often nonspecific, and the patient usually presents with an acute or subacute intestinal obstruction. A high index of suspicion is needed in such females presenting with abdominal distention and positive Howship-Romberg signs. Computed tomography of the abdomen and pelvis are often necessary to arrive at a diagnosis, and immediate surgical intervention is recommended. The high postoperative morbidity and mortality are often attributed to a delay in the diagnosis and in initiating treatment. We present a case of a 65-year-old lady with strangulated obturator hernia who underwent emergent, lower midline laparotomy with resection and anastomosis of the small bowel and purse-string repair of the hernial defect.