Simultaneous hybrid repair of symptomatic femoral, iliac, and abdominal aortic aneurysms.

BACKGROUND: Focal peripheral arterial aneurysms, though rare, have a relatively high association with coexisting synchronous or metachronous aneurysms. While most are asymptomatic at presentation, there is concern for aneurysm thrombosis, embolization, or rupture, which can lead to acute limb ischemia or even limb loss. These complications require early intervention with either open or endovascular surgery, oftentimes staged due to complexity. METHOD: We describe a case of a 65-year-old male presenting with a symptomatic common femoral artery aneurysm with a simultaneous infrarenal abdominal aortic aneurysm, requiring a hybrid endovascular and open approach for operative repair due to the size and characteristics of his aneurysms. DISCUSSION: As the consensus for the management of synchronous/metachronous aneurysms is to stage the procedures, it is important to report scenarios where a single hybrid operation was technically feasible and resulted in good patient outcomes. CONCLUSION: This report supports the role of utilizing multiple hybrid operative techniques to best repair the respective aneurysm in a single operation, with favorable patient outcomes.

Recurrent upper extremity arterial thrombosis preceding a diagnosis of COVID-19.

Arterial thrombosis occurs when there is endothelial damage in the setting of hypercoagulability and arterial blood stasis. COVID-19 has been theorized to cause both endothelial damage and promote hypercoagulability by causing an imbalance of clotting factors. In many studies, there have been a large proportion of COVID-19 patients that suffered a thromboembolic event, in both the venous and arterial systems. Our patient, who did not have a significant past medical history, presented with a recurrent brachial artery occlusion despite medical and surgical management, and subsequently tested positive for COVID-19 late in his admission. In conclusion, there is high suspicion that there is a relationship between COVID-19 infection and recurrent arterial thrombosis.

Migrating Foreign Body in the Heart.

Foreign bodies in the heart are a rare condition and an exact mechanism for this occurrence has not been well described. These objects can reach the heart by direct penetration due to local trauma or through intravenous migration or may remain in the heart after medical procedures. The most common foreign bodies that reach the heart are bullets and shrapnel. The purpose of this study is to review a case where a patient injected himself with recreational drugs. The needle subsequently dislodged from the syringe and migrated into the heart.

Prolonged recovery of acute kidney injury following AngioJet rheolytic thrombectomy.

AngioJet rheolytic thrombectomy, although a successful treatment modality for arterial thrombus removal and recanalization, has been shown to have increased rates of postoperative acute kidney injury (AKI) compared with other methods of treatment for acute limb ischemia. The postinterventional course of AKI can differ markedly from patient to patient, but typically resolves relatively quickly. Herein, we present a case of AKI secondary to AngioJet intervention that demonstrates an exceedingly prolonged but ultimately recoverable course with conservative management and without the need for renal replacement therapy.

Does the modified Glasgow Prognostic Score (mGPS) have a prognostic role in esophageal cancer?

BACKGROUND: The modified Glasgow Prognostic Score (mGPS), which combines indices of decreased plasma albumin and elevated CRP, has reported independent prognostic significance in colorectal cancer, but its value in upper gastrointestinal cancer is unclear. The aim of this study was to assess the prognostic significance of mGPS in patients with operable esophageal malignancy. METHODS: Patients undergoing resection with curative intent between January 2008 and June 2013 were included. The mGPS was scored as 0, 1, or 2 based on CRP(>10 mg/L) and albumin(<35g/L). The mGPS score (0 vs. 1/2 combined) was correlated with patient and tumor characteristics, and operative and oncologic outcomes. RESULTS: Two hundred and twenty-three patients were included. Median (range) follow-up was 21(12-70) months. The mGPS was 0 in 174 patients(78%). mGPS was significantly associated with positive nodal status(P = 0.008) and stage ≥III (P = 0.017). There was a significant improvement in overall survival in patients with mGPS = 0 (47.8 vs. 37.5 months, P = 0.014) but in multivariate analysis, only TNM-stage and nodal status were found to be independent prognostic indicators. CONCLUSIONS: mGPS is associated with advanced stage but has no independent prognostic significance and does not impact on operative outcomes. Consequently, this data does not support its routine application in patient selection or prognostication. J. Surg. Oncol. 2016;113:732-737. © 2016 Wiley Periodicals, Inc.

Long-term results of percutaneous transhepatic cholangiographic drainage for palliation of malignant biliary obstruction.

INTRODUCTION: Percutaneous stenting is established in the palliation of malignant biliary obstruction. We examined the indications, success rate, complications, and long-term postoperative course of patients undergoing this procedure. METHODS: All patients undergoing percutaneous transhepatic cholangiography (PTC) and metal stenting over a 12-month period in a tertiary referral center were studied. Data regarding diagnosis, number and type of procedures, complications, and survival were collected from multidisciplinary case notes and general practitioner records. RESULTS: There were 21 patients of median age 70 (mean, 71; range, 54-93), 56.5% (11) had pancreatic cancer and 33% (7) cholangiocarcinoma. The mean number of PTC procedures was 2.43 and mean length of stay in hospital 20.66 days (range, 3-99). Serum bilirubin fell post drainage from 397 to 226 (µmol/L; p < 0.001) on discharge, however, in 19% (4) there was no significant reduction. Complications included cholangitis (19%) and acute pancreatitis (10%). Mortality was high and 9 patients (43%) died within 30 days, of whom 2 died in the hospital (1 from ascending cholangitis and another from pneumonia). The median time between discharge and death was 25 days (mean, 59.1 days) and no patient was alive after 193 days. CONCLUSIONS: The prognosis following PTC stenting of malignant biliary obstruction is extremely poor despite adequate drainage. The procedure can lead to significant morbidity and a lengthy hospital stay. Patient selection is therefore of paramount importance and an expedient treatment protocol and early return home recommended.

A prospective randomised study comparing two treatment modalities for chronic pilonidal sinus with a 5-year follow-up.

BACKGROUND: The optimal treatment of chronic pilonidal sinus is a matter of debate. Although excision and suture offers faster healing, it is associated with an increased incidence of wound infection. This study compared excision and primary closure of pilonidal sinus using incorporated gentamicin impregnated collagen with conventional laying open. METHODS: Consecutive patients with pilonidal sinus were randomly assigned to one of two treatment groups: (1) open method-wound left open post-excision and (2) closed method-wound closed in two layers over gentamicin impregnated collagen. The main outcome measures were operating time, hospital stay, linear analogue pain scores (days 1, 2, 4, 7 and 14), healing rates, analgesic use and cost. Rate of recurrence at 5 years was further assessed by means of a telephone survey. RESULTS: Sixty patients were recruited from June 1999 to December 2000. Operating time was significantly longer in the closed method. Pain scores were significantly lower for the closed group. A significantly higher proportion of closed wounds healed at 4 weeks. The overall cost per patient was significantly lower for the closed group. Recurrence rate was similar at 5 years. CONCLUSION: Excision and primary closure over a gentamicin impregnated collagen is a cost-effective method of treating pilonidal sinuses, as it ensures faster healing, causes less pain and its long-term recurrence rates are similar to other techniques.