Hybrid Repair of an Iatrogenic Left Subclavian Artery Injury: A Case Report.

We present the case of an iatrogenic injury to the left subclavian artery during placement of a port for chemotherapy. The artery was inadvertently accessed at its infraclavicular position, and then was perforated centrally, entering the mediastinum at the origin of the left vertebral artery. Given that the patient's posterior circulation was largely dependent on the left vertebral artery, it could not be sacrificed. To preserve her left vertebral artery and to avoid the need for a sternotomy, which would more substantially delay initiation of chemotherapy, we elected to perform a hybrid repair: an open left carotid to vertebral artery bypass with reversed great saphenous vein followed by repair of the proximal left subclavian injury with a covered stent graft, which was delivered via the left axillary artery. The patient recovered uneventfully. This case demonstrates a hybrid open and endovascular repair for a complex iatrogenic arterial injury. We were able to obtain a desirable outcome by careful assessment of the anatomic particulars of her injury and the technical constraints in proposed methods of repair, all in the context of the patient's overall goals of care.

Longer Operative Time and Intraoperative Blood Transfusion Are Associated with Postoperative Anastomotic Leak after Lower Gastrointestinal Surgery.

Anastomotic leak after lower gastrointestinal surgery is a complication with potential for high morbidity, mortality, and increased costs. A single-institution retrospective chart review was performed on all patients who underwent lower gastrointestinal surgery between June 2009 and June 2013. Fifty-seven variables were included in our analysis and their association with postoperative anastomotic leak was examined. Nine hundred fifty-two patients underwent 983 lower gastrointestinal anastomoses with an overall leak rate in this series of 6 per cent. Type of intestinal anastomosis created (P < 0.00005), operative indication (P < 0.015), operation performed (P < 0.014), intraoperative blood transfusion (P < 0.017), and intraoperative surgical drain placement (P < 0.022) were all predictive of anastomotic leak. Anastomotic leak rate increased by 1.3 times for every additional hour in the operating room after three hours. Both increasing operation time and intraoperative blood transfusions were associated with an increased rate of anastomotic leak. When operative time extends beyond three hours or in those cases were blood transfusions are given, surgeons should consider taking steps to minimize the risks of a potential anastomotic leak.

Outcomes in complex ventral hernia repair with anterior component separation in class III obesity patients.

BACKGROUND: Consensus guidelines recommend against elective ventral hernia repair (VHR) in patients with BMI >30 kg/m2 without preoperative weight loss intervention. We aim to compare hernia recurrence and perioperative complications in VHR utilizing anterior component separation (CS) in patients with class III obesity (BMI >40 kg/m2). METHODS: A retrospective review of patients undergoing VHR with CS was performed. The primary endpoint was hernia recurrence; secondary endpoints were wound complications, postoperative medical complications, mortality and length of stay. RESULTS: 185 consecutive patients were identified from 2008 to 2016. There were no significant differences between groups: hernia recurrence (6.9% BMI >40 kg/m2, 2.4% BMI <39.9 kg/m2, p = 0.21), wound complications (58.6% BMI >40 kg/m2, 47.2% BMI <39.9 kg/m2, p = 0.16), postoperative complications (39.7% BMI >40 kg/m2, 26% BMI <39.9 kg/m2, p = 0.08), mortality (1.6% BMI >40 kg/m2, 3.4% BMI <39.9 kg/m2, p = 0.59), and length of stay (10.6 days BMI >40 kg/m2, 11.2 days BMI <39.9 kg/m2, p = 0.5). CONCLUSION: This study demonstrates similar outcomes in class III obesity patients undergoing elective VHR compared to patients with BMI <39.9 kg/m2.