A simple tissue-handling technique performed in the endoscopy suite improves histologic section quality and diagnostic accuracy for serrated polyps.

BACKGROUND AND STUDY AIMS: Surveillance intervals after colonoscopic resection of serrated polyps are partially predicated on the histology of the polyp(s) removed during the index exam. Histologic discrimination between sessile serrated adenomas/polyps (SSA/P) and hyperplastic polyps is challenging. We devised and tested a simple tool--an envelope--that gastroenterologists can integrate into routine colonoscopy practice to address this problem. METHODS: In the "modified protocol," immediately after polypectomy each serrated polyp was flattened and enclosed in a paper envelope before being placed in formalin. In the pathology laboratory, each polyp was sectioned after processing. A two-site, prospective, randomized, single-blinded trial was performed to compare this modified protocol with the conventional protocol. Serrated polyps located proximal to the splenic flexure and 5-20 mm in diameter were included. A novel orientation score that measured the number of well-oriented crypts per unit area of polyp (higher orientation score = better orientation) was validated. Orientation score, SSA/P diagnosis rate, and inter-pathologist agreement were measured. RESULTS: A total of 375 polyps were enrolled, of which 264 were identified for analysis. The mean orientation scores in the modified and conventional protocol groups were 3.11 and 1.13, respectively (P < 0.0001). SSA/Ps were diagnosed in 103/135 cases (76.3%) in the modified protocol group vs. 54/129 (41.9%) in the conventional protocol group (P < 0.0001). Inter-pathologist agreement was higher with the modified than the conventional protocol (77.0% vs. 62.8%; P = 0.015). CONCLUSION: Standard polyp handling techniques may be sub-optimal for interpretation of serrated polyps resected at colonoscopy, and may lead to inadvertent histologic "under-grading" of many lesions. Our intervention improved histopathologic interpretation and increased the SSA/P diagnosis rate.

Vocal cord paralysis after aortic surgery.

OBJECTIVE: The purpose of this study was to investigate variables associated with vocal cord paralysis during complex aortic procedures. DESIGN: A retrospective review. SETTING: A tertiary care center. PARTICIPANTS: Four hundred ninety-eight patients who underwent aortic surgery between 2002 and 2007. METHODS: Two groups were studied. Group A patients had procedures only involving their aortic root and/or ascending aorta. Group B patients had procedures only involving their aortic arch and/or descending aorta. RESULTS: The incidence of vocal cord paralysis was higher (7.26% v 0.8%) in group B patients (p < 0.0001). Increasing the duration of cardiopulmonary bypass time was associated with an increased risk of vocal cord paralysis and death in both groups A and B (p = 0.0002 and 0.002, respectively). Additionally, within group B, descending aneurysms emerged as an independent risk factor associated with vocal cord paralysis (p = 0.03). Length of stay was statistically significantly longer among group A patients who suffered vocal cord paralysis (p = 0.017) and trended toward significance in group B patients who suffered vocal cord paralysis (p = 0.059). The association between tracheostomy and vocal cord paralysis among group A patients reached statistical significance (p = 0.007) and trended toward significance in group B patients (p = 0.057). CONCLUSIONS: Increasing duration of cardiopulmonary bypass time was associated with a higher risk of vocal cord paralysis in patients undergoing aortic surgery. Additionally, within group B patients, descending aortic aneurysm was an independent risk factor associated with vocal cord paralysis. Most importantly, vocal cord paralysis appeared to have an association between an increased length of stay and tracheostomy among a select group of patients undergoing aortic surgery.

Methohexital and succinylcholine dosing for electroconvulsive therapy (ECT): actual versus ideal.

This report compares the actual doses of methohexital and succinylcholine used for optimal anesthesia and muscle relaxation in electroconvulsive therapy with written guidelines for dosing. The initial doses of methohexital and succinylcholine in milligrams per kilogram were reviewed and compared with subsequent doses of each agent after adjustments were made for individual patient responses during treatment. The dose of methohexital required to induce general anesthesia for most patients is 1.0 mg/kg. The dose of succinylcholine required to provide adequate muscle relaxation during electroconvulsive therapy is 0.9 mg/kg, although there is considerable variability in patient response to this drug.

Is production pressure jeopardizing the quality of colonoscopy? A survey of U.S. endoscopists' practices and perceptions.

BACKGROUND: Fatigue is an underestimated cause of underperformance among physicians. There is evidence that fatigue or other byproducts of production pressure may negatively influence the quality of colonoscopy. OBJECTIVE: To investigate the practices and perceptions of U.S. endoscopists regarding the effect of production pressure on the performance of colonoscopy. DESIGN: We conducted a 40-question online survey to assess endoscopists' practices and perceptions concerning production pressure. SETTING: A total of 5030 U.S. American Society for Gastrointestinal Endoscopy members. MAIN OUTCOME MEASUREMENTS: The proportion of endoscopists responding positively to questions pertaining to the impact of production pressure on colonoscopy practice. RESULTS: Ninety-two percent of respondents indicated that production pressure influenced one or more aspects of their endoscopic practices. Examples of production pressure included (1) postponing polypectomy for a subsequent session (2.8%), (2) reducing the length of time spent inspecting the colon (7.2%), and (3) proceeding with colonoscopy in a patient with an unfavorable risk/benefit ratio (69.2%). Forty-eight percent of respondents reported witnessing the effects of production pressure on a colleague. Respondents working fee-for-service and those with >10 years since completion of fellowship were more likely to describe their weekly workloads as excessive compared with those who were salaried (81.3% vs 71.3%; P = .01) and <10 years out of training (81% vs 72.7%; P = .01). LIMITATIONS: Nonresponse bias due to low response rate (22.3%). CONCLUSION: Production pressure influences the conduct of colonoscopy for many endoscopists and could have an adverse effect on the outcome of colorectal cancer screening. ( CLINICAL TRIAL REGISTRATION NUMBER: RE:GIE D 11-01288R1.) The study was an Internet study and did not involve human subjects.

A morphologic analysis of sessile serrated polyps observed during routine colonoscopy (with video).

BACKGROUND: Proximal colorectal cancer may arise from sessile serrated polyps (SSPs), which are often inconspicuous during colonoscopy. The gross morphologic characteristics of SSPs have not been systematically described, and this omission may contribute to colonoscopists overlooking them. OBJECTIVES: To analyze the gross morphologic characteristics of SSPs detected during routine colonoscopy. DESIGN: Retrospective analysis of high-resolution endoscopic video clips depicting SSPs in situ. SETTING: Outpatient gastroenterology practice. PATIENTS: A total of 124 subjects undergoing surveillance or screening colonoscopy after split-dose bowel preparation. INTERVENTIONS: Analysis of 158 SSPs performed by using validated descriptors. MAIN OUTCOME MEASUREMENTS: The prevalence of morphologic characteristics related to polyp shape, color, and texture. RESULTS: A total of 158 SSPs were studied. For 7 visual descriptors, a κ coefficient of ≥ 0.7 was achieved, indicating good to excellent intraobserver agreement. The most prevalent visual descriptors were the presence of a mucous cap (63.9%), rim of debris or bubbles (51.9%), alteration of the contour of a fold (37.3%), and interruption of the underlying mucosal vascular pattern (32.3%). The most common "sentinel signs" were the presence of a mucous cap and alteration of the contour of a mucosal fold (each 24.6%), rim of debris or bubbles (21.7%), and a dome-shaped protuberance (20.3%). When comparing SSPs with adenomatous polyps, the frequencies of 5 of 7 morphologic characteristics and the distribution of sentinel signs differed (P < .01). LIMITATIONS: Single-site, retrospective analysis. CONCLUSIONS: SSPs exhibit distinct, variable morphologic characteristics. Many do not display classic features such as a mucous cap. Enhanced appreciation of these morphologic characteristics may improve SSP detection and thereby colorectal cancer prevention.

Staged approach prevents spinal cord injury in hybrid surgical-endovascular thoracoabdominal aortic aneurysm repair: an experimental model.

BACKGROUND: In a porcine model, we investigated the impact of sudden stent graft occlusion of thoracic intercostal arteries after open lumbar segmental artery (SA) ligation. METHODS: After randomization into two groups, 20 juvenile Yorkshire pigs (27.1±0.6 kg) underwent open lumbar SA sacrifice (T13-L5) followed by endovascular coverage of all thoracic SAs (T4-T12) at 32°C, either in a single operation (group 1) or in two stages separated by seven days (group 2). Collateral network pressure (CNP) was monitored by catheterization of the SA L1, and postoperative hind limb function was assessed using a modified Tarlov score. RESULTS: The CNP in group 1 decreased to 34% of baseline, whereas CNP after lumbar SA ligation in group 2 fell to 55% of baseline (74±2.4 to 25±3.6 mm Hg vs 74±4.5 to 41±5.5 mm Hg; p<0.0001). Subsequent thoracic stenting (group 2) led to another significant but milder drop (p=0.002 versus stage 1) from the restored CNP (71±4.2 to 54±4.9 mm Hg). Five of ten pigs in group 1 suffered paraplegia, in contrast to none in group 2 (median Tarlov score 6, vs 9; p=0.0031). Histopathologic analysis showed more severe ischemic damage to the lower thoracic (p=0.05) and lumbar spinal cord (p=0.002) in group 1. CONCLUSIONS: These results underline the potential of the staged approach in hybrid procedures. Furthermore they highlight the need for established adjuncts for preventing paraplegia in hybrid and pure stent-graft protocols in which sudden occlusion of multiple SAs occurs.

The detection of premalignant colon polyps during colonoscopy is stable throughout the workday.

BACKGROUND: Recent studies have shown that colonoscopic polyp detection decreases as the workday progresses. This may reflect time-dependent factors such as colonoscopist fatigue and decreased colon cleanliness, which can be addressed through adaptations in colonoscopy practice. OBJECTIVE: To test for time-of-day differences in adenomatous polyp (AP) and sessile serrated polyp (SSP) detection in a practice that uses split-dose bowel preparation and moderated daily colonoscopist procedure loads. DESIGN: Retrospective chart review. SETTING: Community-based, group gastroenterology practice. PATIENTS: This study involved 2439 patients undergoing surveillance or screening colonoscopy. INTERVENTION: Colonoscopy. MAIN OUTCOME MEASUREMENTS: Detection rate of all premalignant polyps (PMPs), and of APs and SSPs, individually. RESULTS: A total of 1183 PMPs were identified in 1486 eligible patients (mean PMP/colonoscopy = 0.80; PMP detection rate = 47%). In univariate and multivariate analyses, PMP detection as well as detection of APs or SSPs individually did not vary significantly in relation to the hour of the day. In a binary comparison of morning (am) versus afternoon (pm) procedures, the total polyp detection rate was 67% and 66%, respectively. For PMPs, APs, SSPs, and hyperplastic polyps (HPs), the am and pm detection rates were 46% and 47%, 41% and 44%, 8% and 8%, and 27% and 24%, respectively. Bowel preparation quality was independent of time of day and was rated excellent or good in 86% to 87% of cases. LIMITATIONS: Retrospective, nonrandomized study. CONCLUSION: Stable PMP, AP, SSP, and HP detection rates throughout the workday occur under certain practice conditions, including the use of split-dose bowel preparation and/or moderated daily colonoscopist procedure loads.

Is gastroduodenal biopsy safe in patients receiving aspirin and clopidogrel?: a prospective, randomized study involving 630 biopsies.

GOALS: To assess prospectively the bleeding risk attributable to gastroduodenal biopsy in subjects taking antiplatelet medications. BACKGROUND: No prospective data exist regarding the bleeding risk attributable to endoscopic biopsy in patients taking antiplatelet agents. A majority of Western endoscopists withdraw antiplatelet agents before upper endoscopy, despite expert guidelines to the contrary. STUDY: We performed a prospective, single-blind, randomized study in healthy volunteers participating in a larger study regarding the effect of antiplatelet agents on gastroduodenal mucosal healing. Multiple gastroduodenal biopsies were performed during 2 esophagogastroduodenoscopy in subjects dosed with aspirin enteric-coated 81 mg once daily or clopidogrel 75 mg once daily. Data for endoscopic bleeding, clinical bleeding, blood vessel size, and depth of biopsy in histology specimens were collected. RESULTS: Four hundred and five antral biopsies and 225 duodenal biopsies were performed during 90 esophagogastroduodenoscopy in 45 subjects receiving aspirin or clopidogrel. Median maximum blood vessel diameter per biopsy was 31.9 µ (range: 9.2 to 133.8). About 50.8% of biopsy specimens breached the muscularis mucosa. In the clopidogrel group, no bleeding events were noted after 350 biopsies [upper confidence limit (UCL) for probability of bleeding=0.0085]. In the aspirin group, there were no clinical events (UCL=0.0106) and one minor endoscopic bleeding event (UCL=0.0169). CONCLUSIONS: Consistent with expert guidelines, the absolute risk attributable to gastroduodenal biopsy in adults taking antiplatelet agents seems to be low. Half of routine biopsies enter submucosa. The largest blood vessels avulsed during biopsy correspond to midsized and large arterioles and venules.

When to operate on the bicuspid valve patient with a modestly dilated ascending aorta.

BACKGROUND: Bicuspid aortic valves (BAV) are frequently associated with root/ascending aorta dilatation, but there is controversy regarding when to operate to prevent dissection of a dilated aorta associated with a well-functioning BAV. METHODS: From 1988 through 2008, 158 patients (mean age: 56 ± 13.5 years) with a dilated ascending aorta (AA) and a well-functioning BAV were referred to our institution. All patients underwent computed tomographic (CT) scanning and digitization to calculate mean AA diameter. Forty-two patients underwent operation a median of 52 days after initial CT scan with a mean AA diameter of 5.6 ± 0.5 cm. One hundred sixteen patients (mean diameter 4.6 ± 0.5 cm) were enrolled in annual or semiannual surveillance. Seventy-one patients, 45 with 2 or more CT scans, are still under surveillance. RESULTS: Average follow-up was 6.5 ± 4.1 years. Overall survival after the first encounter was 93% at 5 years and 85% at 10 years. A total of 87 of 158 patients had a Bentall or Yacoub procedure, with two hospital deaths (2.3%). Mean duration of surveillance in the 116 patients without immediate operation was 4.2 ± 2.9 years (481 patient-years). Average growth rate of the AA in patients with 2 scans or greater was 0.77 mm/year (p < 0.0001 versus normal population) with no significant impact of hypertension, sex, smoking or age. Forty-five of the 116 surveillance patients underwent operation after a mean of 3.4 ± 2.9 years (mean age 55 ± 14.7 years; mean AA diameter 4.9 ± 0.6 cm). Six patients died without surgery, median age 82 (range, 44 to 87) years, but none within one year of the last CT scan. CONCLUSIONS: A consistent approach to patients with a well-functioning BAV and AA dilatation, recommending operation to those with an AA diameter greater than 5 cm and deferring operation in patients under surveillance in the absence of significant enlargement (>0.5 cm/year), resulted in overall survival equivalent to a normal age-matched and sex-matched population. Operation was necessary in approximately 10% of patients under surveillance each year.

Long-term outcome after aortic arch replacement with a trifurcated graft.

OBJECTIVE: We describe the long-term results of aortic arch replacement using a trifurcated graft, including an assessment of survival, neurologic complications, and graft patency. METHODS: A retrospective review was conducted on data from 206 consecutive patients (125 male; median age, 67 years; range, 20-87 years) who had a trifurcated graft used for aortic arch replacement between September 1999 and September 2009. Seventy-four patients (35.9%) had chronic dissection, 68 patients (33.0%) had atherosclerotic aneurysms, and 39 patients (18.9%) had degenerative disease. Ninety-one patients (44.2%) had undergone previous cardiac surgery. RESULTS: An elephant trunk was placed in 190 patients (92.2%) and completed in 101 patients (53.1%), with an interval of less than 365 days between stages in 94 of 101 patients. Hospital mortality was 6.8% (14/206). Adverse outcome (death/stroke within the first year postoperatively) occurred in 27.7% of patients (57/206; 50 deaths/7 strokes). Among 152 1-year survivors, the annual rates of transient ischemic attack and stroke were 0.85% and 1.1%, respectively. At 6 years, 75% of patients were still alive, compared with 92% in a matched New York State control population (P < .001). Follow-up computed tomography scans (189 studies in 176/206 patients [85.4%]) revealed 100% patency of the trifurcated graft limbs at a mean of 2.3 years. CONCLUSIONS: Aortic arch replacement using a trifurcated graft is highly durable, with excellent patency in the branch grafts, and is associated with a low incidence of cerebral embolization. However, the long-term outcome in these patients is compromised by extensive comorbidities.

Predicting the risk of paraplegia after thoracic and thoracoabdominal aneurysm repair.

BACKGROUND: Endovascular repair of descending thoracic and thoracoabdominal aortic aneurysms is an appealing alternative to the standard surgical approach, but precludes revascularization of segmental arteries (SAs). For safer surgical and endovascular repairs, an accurate prediction of the risk of paraplegia in relation to the extent of SA sacrifice is needed. METHODS: From January 1994 to October 2008, 609 patients (mean age, 63 ± 14 years) underwent surgical descending thoracic or thoracoabdominal aortic aneurysm repair without SA reimplantation. Three hundred seventy-six patients (62%) were male; 159 (26%) had urgent or emergent operation; 199 (33%) had previous aortic surgery. Somatosensory- or motor-evoked potential monitoring and cerebrospinal fluid drainage were routinely performed. RESULTS: Hospital mortality was 10.7% (65 patients). Spinal cord injury (SCI) occurred in 3.4% (21 patients). The extent of resection-expressed as the number of SAs sacrificed (p = 0.007)-and the need for visceral artery reimplantation (p = 0.03) were independent risk factors for paraplegia. Further analysis identified four risk groups (p < 0.0001): fewer than 8 SAs sacrificed (group A, SCI = 1.2%); sacrifice of 8 to 12 SAs with proximal origin in the upper thorax (group B, SCI = 3.7%); 8 to 12 SAs sacrificed beginning in the lower thorax (group C, SCI = 15.4%); and 13 or more SAs sacrificed (group D, SCI = 12.5%). This four-group model more accurately predicts SCI risk than the Crawford classification (goodness of fit c statistic: 0.748 versus 0.640). CONCLUSIONS: The extent of SA sacrifice is the most powerful predictor of paraplegia risk. For aneurysms of moderate extent, a more distal location involving the abdominal aorta increases the risk of spinal cord injury. Sacrifice of fewer than 8 SAs is associated with a very low paraplegia risk regardless of location.

Experimental two-stage simulated repair of extensive thoracoabdominal aneurysms reduces paraplegia risk.

BACKGROUND: In a pig model, we compared spinal cord injury after extensive segmental artery (SA) sacrifice in a single stage with recovery after a two-stage procedure: lumbar artery followed by thoracic SA sacrifice. METHODS: Twenty juvenile Yorkshire pigs were randomly assigned to undergo extensive SA sacrifice at 32 degrees C in a single operation (group 1, n = 10), or thoracic SA ligation 7 days after lumbar artery sacrifice (group 2, n = 10). Spinal cord perfusion pressure (SCPP) was monitored using a catheter placed in the distal stump of L1. Hind limb function was evaluated intraoperatively using motor-evoked potentials and for 5 days postoperatively using a modified Tarlov score. RESULTS: Motor-evoked potentials were intact in all pigs until 1 hour after surgery. All pigs in group 2 fully recovered hind limb function, whereas 40% in group 1 experienced paraplegia (median Tarlov scores 9 versus 7; p = 0.004). Group 1 SCPP fell to 28 +/- 6 mm Hg after SA sacrifice, compared with 44 +/- 8 mm Hg in group 2 (p < 0.0001). After sacrifice of all residual SAs, SCPP in group 2 remained consistently greater than 85% of baseline, significantly higher than group 1 SCPP from end clamping until 72 hours (p = 0.0002). Histopathologic analysis showed more severe ischemic damage to the lower thoracic (p < 0.001) and lumbar spinal cord (p = 0.01) in group 1. CONCLUSIONS: In contrast with the single-stage approach, a two-stage procedure, starting with ligation of six or fewer lumbar SAs, leads to only a mild drop in SCPP and stimulates vascular remodeling, minimizing the impact of subsequent SA sacrifice on spinal cord function. The greater safety of extensive SA sacrifice when undertaken in two stages has important implications for endovascular and hybrid aneurysm repair.

The impact of blood conservation on outcomes in cardiac surgery: is it safe and effective?

BACKGROUND: Increasing evidence shows that perioperative blood transfusion in cardiac surgery is associated with increased postoperative morbidity and mortality and decreased long-term survival. Tolerance of "permissive anemia" is an important element of perioperative blood conservation strategy. The safety of tolerating perioperative anemia has been a significant deterrent for widespread application of blood conservation. This study examines whether blood conservation is equally safe or superior to the common practice of transfusion in cardiac surgery. METHODS: The total study population consisted of 32,449 patients who underwent isolated coronary artery bypass surgery from June 2000 until December 2004 with complete data from 17 institutions in the State of New Jersey. Englewood Hospital and Medical Center (EH) has a well-established blood conservation program. Five hundred eighty-six EH patients (blood conservation cohort) were compared with a propensity score-matched cohort of 586 patients from the other New Jersey institutions (OH-M) representing the common practice of transfusion. Outcomes were classified as very serious complications, serious complications, or neither (no very serious complication or serious complication). Analysis consisted of McNemar tests and multiple logistic regression. RESULTS: Fewer patients were transfused at EH compared with OH-M (10.6% versus 42.5%; p < 0.0001). Englewood Hospital had 5 (0.8%) deaths versus 15 (2.5%) in the OH-M group (p = 0.02). Of the EH patients, 11.1% experienced a very serious complication or serious complication versus 18.7% in the OH-M cohort (p = 0.0002). Transfusion was associated with an increased risk of an adverse outcome in both cohorts (EH: odds ratio, 7.3; 95% confidence interval, 3.7 to 14.4 versus OH-M: odds ratio, 4.6; 95% confidence interval, 2.8 to 7.7). CONCLUSIONS: Blood conservation is safe and effective in reducing transfusions. Tolerance of perioperative anemia, which is one of the main components of blood conservation, does not increase the risk of complications or death in cardiac surgery. Avoidance of transfusion reduces the risk of complications. This study further solidifies the relationship between transfusion and adverse outcome in cardiac surgery.

Staged repair significantly reduces paraplegia rate after extensive thoracoabdominal aortic aneurysm repair.

OBJECTIVE: Paraplegia remains a devastating, and still too frequent, complication after repair of extensive thoracoabdominal aortic aneurysms. Strategies to prevent ischemic spinal cord damage after extensive segmental artery sacrifice-or occlusion, essential for endovascular repair-are still evolving. METHODS: Ninety patients who underwent extensive segmental artery sacrifice (median, 13; range, 9-15) during open surgical repair from June 1994 to December 2007 were reviewed retrospectively. Fifty-five patients (mean age, 65 +/- 12 years; 49% were male), most with extensive Crawford type II thoracoabdominal aortic aneurysms, had a single procedure (single-stage group). Thirty-five patients (mean age, 62 +/- 14 years; 57% were male) had 2 procedures (2-stage group), usually Crawford type III or IV repair after operation for Crawford type I descending thoracic aneurysm. The median interval between the 2-stage procedures was 5 years (3 months to 17 years). There were no significant differences between the groups with regard to age, gender, cause of the aneurysm, hypertension, chronic obstructive pulmonary disease, urgency, previous cerebrovascular accidents, year of procedure, or cerebrospinal fluid drainage. In single-stage procedures, hypothermic circulatory arrest was used in 29% of patients, left-sided heart bypass was used in 40% of patients, and partial cardiopulmonary bypass was used in 27% of patients. Somatosensory-evoked potentials were monitored in all patients, and motor-evoked potentials were monitored in 39% of patients. Cerebrospinal fluid was drained in 84% of patients. RESULTS: Overall hospital mortality was 11.1%. There were no significant differences in mortality, stroke, postoperative bleeding, infection, renal failure, or pulmonary insufficiency between the groups. However, 15% of patients in the single-stage group had permanent spinal cord injury versus none in the 2-stage group (P = .02). The significantly lower rate of paraplegia and paraparesis in the 2-stage group occurred despite a significantly higher number of segmental arteries sacrificed in this group: a median of 14 (11-15) versus 12 (9-15) (P < .0001). CONCLUSION: A staged approach to extensive thoracoabdominal aortic aneurysm repair may reduce the incidence of spinal cord injury. This is of particular importance in designing strategies involving hybrid or entirely endovascular procedures.

Long-term survival after open repair of chronic distal aortic dissection.

BACKGROUND: The optimal treatment of chronic distal aortic dissection remains controversial, with endovascular stent-graft techniques challenging traditional surgery. METHODS: From January 1994 to April 2007, 104 patients (82 male, median age 60.5 years) with chronic distal aortic dissection underwent surgical repair, 0 to 21 years after initial diagnosis of acute type A or B dissection (median 2.1 years). Twenty-three (22%) patients underwent urgent-emergent surgery. Mean aortic diameter was 6.9 +/- 1.4 cm. Indications for surgery, other than aortic expansion, were pain in 6 (6%) patients, malperfusion in 6 (6%), and rupture in 11 (11%). Forty-nine (47%) had previous cardioaortic surgery (29% dissection-related), 21 (20%) had coronary artery disease, 12 (12%) had Marfan syndrome, and 4 (4%) were on chronic dialysis. Twenty-six (25%) had a thrombosed false lumen. Thirty (29%) patients required reimplantation of visceral arteries; 8.3 +/- 2.7 segmental artery pairs were sacrificed. RESULTS: Hospital mortality was 9.6% (10 patients). Paraplegia occurred in 5 (4.8%). Twenty-seven patients (26%) experienced adverse outcome (death within one year, paraplegia, stroke, or dialysis). Adverse outcome was associated with atheroma (p = 0.04, odds ratio = 4.3). Survival was 78% at 1, 68% at 5, and 59% at 10 years (average follow-up, 7.7 +/- 4.1 years). Freedom from distal aortic reoperation was 99% at 1, 93% at 5, and 83% at 10 years. After one year, patients enjoyed longevity equivalent to a normal age-sex matched population (standardized mortality ratio = 1.38, p = 0.23). By multivariate analysis, atheroma (p = 0.0005, relative risk = 9.32) and age (p = 0.0003, relative risk = 1.15/year) were risk factors for long-term survival. CONCLUSIONS: The efficacy of open repair for distal chronic dissection is highlighted by normal survival after the first year, and a low reoperation-reintervention rate.

Labor pain at the time of epidural analgesia and mode of delivery in nulliparous women presenting for an induction of labor.

OBJECTIVE: To assess whether the degree of labor pain at the initiation of neuraxial analgesia is associated with mode of delivery. METHODS: Nulliparous women who presented to the labor department for an induction of labor, who were between 37 and 41 weeks of gestation, and who requested labor epidural analgesia with a pain score of 0-3 (low pain) and a cervical dilatation less than 4 cm were assessed retrospectively. Maternal and neonatal outcome including mode of delivery and duration of labor were compared with a similar group of women with pain scores of 4-6 (moderate pain), and 7-10 (severe pain). Assessing whether there was an association between pain level at the time of epidural and operative delivery rates was analyzed using a chi test for trend and by logistic regression to include potentially relevant covariates. RESULTS: We found 185 nulliparous women with low pain and compared them with a randomly selected equal number of women in each of the other pain groups. There was no significant association between pain groups in terms of duration of the first or second stage of labor or mode of delivery. Women with low pain had an operative delivery rate (instrumental assisted vaginal delivery plus cesarean delivery) of 49%, compared with 45% and 45% in those with moderate and severe pain, respectively (P=.40). CONCLUSION: We did not find an association between the degree of labor pain at initiation of epidural analgesia and mode of delivery or duration of labor. LEVEL OF EVIDENCE: II.

Redo lateral thoracotomy for reoperative descending and thoracoabdominal aortic repair: a consecutive series of 60 patients.

BACKGROUND: Reoperative descending thoracic aorta (DTA) or thoracoabdominal aortic aneurysm (TAAA) surgery is a challenge because of increased risk of lung injury and diffuse bleeding. METHODS: Sixty patients (34 male, mean age 54.4 years) underwent redo thoracotomy for DTA (22 patients) or extended thoracoabdominal incision for reoperative TAAA (38 patients) from March 1988 to June 2007, after 1.7 +/- 0.9 previous cardioaortic procedures. Forty-one patients were hypertensive (68%), 18 were smokers (30%), 9 had Marfan syndrome (15%), 9 had coronary artery disease (15%), 5 had chronic obstructive pulmonary disease (8%), and 3 had diabetes mellitus (5%). In all, 45% (27 patients) had previous dissection, 30% (18) had atherosclerotic aneurysms, 15% had coarctation surgery (9), and 6 patients had other etiologies. Mean follow-up, 100% complete, was 6.5 years. RESULTS: Hospital mortality for reoperative DTA/TAAA was 13.3% (8 patients). Although 6.3 +/- 2.9 (0 to 14) segmental artery pairs were sacrificed at reoperation-and 6.2 +/- 2.3 (1 to 12) initially-for a total of 10.6 +/- 3.9 (2 to 15) segmental artery pairs sacrificed, only 1 patient had paraplegia (1.6%). Four patients had a 2-day procedure, with 12 to 24 hours of intensive care unit recovery after lysis of extensive adhesions: all survived. Respiratory complications occurred in 13 patients (21.6%), and permanent dialysis was required in 2 (3.3%), but there were no strokes. Adverse outcome-1-year mortality, stroke, permanent dialysis, or paraplegia-occurred in 13 patients (21.6%). Adverse outcome was marginally associated (p < 0.2) with increased age, atherosclerotic aneurysms (33% versus 17% other), TAA incision (30% versus 9%), and greater aneurysm extent, and was significantly associated with perfusion technique (p = 0.02). Adverse outcome occurred in 3 of 4 patients who had clamp-and-sew technique, 6 of 21 using partial cardiopulmonary bypass (28.6%), and 3 of 17 with partial left heart bypass (17.7%), but only 1 of 18 with hypothermic circulatory arrest (5.6%). CONCLUSIONS: Reoperative DTA/TAAA repair was significantly safer with hypothermic circulatory arrest rather than partial cardiopulmonary bypass, partial left heart bypass, or clamp-and-sew strategy. A 2-day procedure may be advisable for patients with extensive adhesions.

Direct spinal cord perfusion pressure monitoring in extensive distal aortic aneurysm repair.

BACKGROUND: Although maintenance of adequate spinal cord perfusion pressure (SCPP) by the paraspinal collateral network is critical to the success of surgical and endovascular repair of descending thoracic and thoracoabdominal aortic aneurysms, direct monitoring of SCPP has not previously been described. METHODS: A catheter was inserted into the distal end of a ligated thoracic segmental artery (SA) (T6 to L1) in 13 patients, 7 of whom underwent descending thoracic and thoracoabdominal aortic aneurysm repair using deep hypothermic circulatory arrest. Spinal cord perfusion pressure was recorded from this catheter before, during, and after serial SA sacrifice, in pairs, from T3 through L4, at 32 degrees C. Somatosensory and motor evoked potentials were also monitored during SA sacrifice and until 1 hour after cardiopulmonary bypass. Target mean arterial pressure was 90 mm Hg during SA sacrifice and after nonpulsatile cardiopulmonary bypass, and 60 mm Hg during cardiopulmonary bypass. RESULTS: A mean of 9.8 +/- 2.6 SAs were sacrificed without somatosensory and motor evoked potential loss. Spinal cord perfusion pressure fell from 62 +/- 12 mm Hg (76% +/- 11% of mean arterial pressure) before SA sacrifice to 53 +/- 13 mm Hg (58% +/- 15% of mean arterial pressure) after SA clamping. The most significant drop occurred with initiation of nonpulsatile cardiopulmonary bypass, reaching 29 +/- 11 mm Hg (46% +/- 18% of mean arterial pressure) before deep hypothermic circulatory arrest. Spinal cord perfusion pressure recovered during rewarming to 40 +/- 14 mm Hg (51% +/- 20% of mean arterial pressure), and further within the first hour of reestablished pulsatile flow. Somatosensory and motor evoked potentials returned in all patients intraoperatively. Recovery of SCPP began intraoperatively, and in 5 patients with prolonged monitoring, continued during the first 24 hours postoperatively. All but 1 patient, who had remarkably low postoperative SCPPs and experienced paraparesis, regained normal spinal cord function. CONCLUSIONS: This study supports experimental data showing that SCPP drops markedly but then recovers gradually during the first several hours after extensive SA sacrifice. Direct monitoring may help prevent a fall of SCPP below levels critical for spinal cord recovery after surgery and endovascular repair of descending thoracic and thoracoabdominal aortic aneurysms.

A mission-based productivity compensation model for an academic anesthesiology department.

INTRODUCTION: We replaced a nearly fixed-salary academic physician compensation model with a mission-based productivity model with the goal of improving attending anesthesiologist productivity. METHODS: The base salary system was stratified according to rank and clinical experience. The supplemental pay structure was linked to electronic patient records and a scheduling database to award points for clinical activity; educational, research, and administrative points systems were constructed in parallel. We analyzed monthly American Society of Anesthesiologist (ASA) unit data for operating room activity and physician compensation from 2000 through mid-2007, excluding the 1-yr implementation period (July 2004-June 2005) for the new model. RESULTS: Comparing 2005-2006 with 2000-2004, quarterly ASA units increased by 14% (P = 0.0001) and quarterly ASA units per full-time equivalent increased by 31% (P < 0.0001), while quarterly ASA units per anesthetizing location decreased by 10% (P = 0.046). Compared with a baseline year (2001), Instructor and Assistant Professor faculty compensation increased more than Associate Professor and Professor faculty (P < 0.001) in both pre- and postimplementation periods. There were larger compensation increases for the postimplementation period compared with preimplementation across faculty rank groupings (P < 0.0001). Academic and educational output was stable. DISCUSSION: Implementing a productivity-based faculty compensation model in an academic department was associated with increased mean supplemental pay with relatively fewer faculty. ASA units per month and ASA units per operating room full-time equivalent increased, and these metrics are the most likely drivers of the increased compensation. This occurred despite a slight decrease in clinical productivity as measured by ASA units per anesthetizing location. Academic and educational output was stable.

Reoperative aortic root and transverse arch procedures: a comparison with contemporaneous primary operations.

OBJECTIVES: Long-term survival and risk factors affecting outcome after reoperative root/ascending aorta and transverse arch procedures have not been clearly described. METHODS: Two hundred patients (138 male patients; age, 60 +/- 15 years) underwent reoperative root/ascending aorta (n = 100) or transverse arch (n = 100) procedures at our institution from January 1998 to December 2004 and were compared with 480 consecutive contemporaneous patients with primary procedures (323 male patients; age, 62 +/- 16 years; 335 proximal aorta and 145 transverse arch procedures). RESULTS: Reoperative proximal aorta procedures had a higher hospital mortality (7%) than primary root/ascending aorta procedures (3%), but there was a less dramatic difference in operative mortality after primary and reoperative arch procedures (9% vs 10%). Separate multivariable analyses of root/ascending aorta procedures and arch procedures revealed chronic obstructive pulmonary disease and age to be significant risk factors for death after either procedure. In addition, an ejection fraction of less than 30% posed a significant risk for proximal aortic surgery, and diabetes and nonelective operations predicted poorer outcome after arch operations. For survivors of root/ascending aorta operations, there was no significant difference in long-term outcome between reoperations and primary procedures, with both restoring longevity to expected levels for an age- and sex-matched normal population. Patients undergoing arch operations, however, continued to have a poorer long-term outlook than their normal peers. CONCLUSIONS: In this series, reoperations in the transverse arch carry the same risk as primary arch procedures, but a higher operative mortality is seen with reoperative than with primary root/ascending aorta procedures. The long-term outlook is better for patients undergoing root/ascending operations than for patients undergoing aortic arch operations, with no difference in the longevity of patients undergoing primary procedures versus reoperations.