Reversible cerebral vasoconstriction syndrome is a rare cause of stroke after carotid endarterectomy.

Neurologic events after carotid endarterectomy (CEA) require prompt diagnosis and management to avoid potentially catastrophic sequelae. This report describes a 69-year-old gentleman who underwent a left CEA for a high-grade asymptomatic carotid stenosis with concomitant contralateral carotid occlusion. He had transient and crescendo neurologic events in the first 3 postoperative weeks that culminated in right hand weakness and paresthesia, despite dual antiplatelet therapy, maximal anticoagulation, and undergoing stenting of the endarterectomy site. Neurologic events recurred despite these measures and subsequent angiography showed reversible cerebral vasoconstriction syndrome that was successfully managed without further events. Reversible cerebral vasoconstriction syndrome is an unusual but important cause of neurologic events after CEA that requires aggressive and directed medical therapy.

Pharmacologic attenuation of the hyperdynamic response to supraceliac aortic clamping.

BACKGROUND: Aortic occlusion is accompanied by a hyperdynamic cardiovascular response secondary to increased systemic vascular resistance and increased cardiac output. This study was designed primarily to determine the safety and cardiovascular response to hydrogen sulfide (H2S; HS) administration with supraceliac aortic cross-clamp and, secondarily, on short-duration resuscitation. METHODS: A validated porcine model (five sham swine compared with five controls) demonstrated a significant hyperdynamic cardiovascular response to 35% blood volume hemorrhage, 50-minute suprarenal aortic cross-clamping, and 6-hour resuscitation. Eight additional experimental swine were administered HS at 4 mg/min during aortic cross-clamping. RESULTS: During the cross-clamp period, hemodynamic curves of mean arterial pressure and heart rate demonstrated a blunting effect with HS administration, with a significant decrease being seen with mean arterial pressure at the end of the cross-clamp period (120 vs 149 mm Hg; P = .04). Resuscitation requirements were significantly reduced at 6 hours because the HS cohort received 8 L less crystalloid (P = .001) and 10.4 mg less epinephrine (P < .001). There was not a significant change in cardiac output, systemic vascular resistance, pulmonary vascular resistance, or pathologic liver analysis. CONCLUSIONS: The administration of HS during the 50 minutes of supraceliac aortic cross-clamp significantly reduced stress of the left heart. On clamp release, HS significantly reduced the need for volume and pressors. HS has positive benefits during cross-clamp and subsequent resuscitation, demonstrating that targeted pharmacologic therapy is possible to minimize adverse physiologic changes with aortic occlusion.

Traumatic Transradial Forearm Amputation Temporized With Extracorporeal Membrane Oxygenation: A Brief Report.

INTRODUCTION: Extracorporeal membrane oxygenation (ECMO) is typically used to provide mechanical perfusion and gas exchange to critically ill patients with cardiopulmonary failure. We present a case of a traumatic high transradial amputation in which the amputated limb was placed on ECMO to allow for limb perfusion during bony fixation and preparations and coordination of orthopedic and vascular soft tissue reconstructions. MATERIALS AND METHODS: This is a descriptive single case report which underwent managment at a level 1 trauma center. Instutional review board (IRB) approval was obtained. RESULTS: This case highlights many important factors of limb salvage. First, complex limb salvage requires a well-organized, pre-planned multi-disciplinary approach to optimize patient outcomes. Second, advancements in trauma resuscitation and reconstructive techniques over the past 20 years have drastically expanded the ability of treating surgeons to preserve limbs that would have otherwise been indicated for amputation. Lastly, which will be the focus of further discussion, ECMO and EP have a role in the limb salvage algorithm to extend current timing limitations for ischemia, allow for multidisciplinary planning, and prevent reperfusion injury with increasing literature to support its use. CONCLUSIONS: ECMO is an emerging technology that may have clinical utility for traumatic amputations, limb salvage, and free flap cases. In particular, it may extend current limitations of ischemia time and reduce the incidence of ischemia reperfusion injury in proximal amputation, thus expanding the current indications for proximal limb replantation. It is clear that developing a multi-disciplinary limb salvage team with standardized treatment protocols is paramount to optimize patient outcomes and allows limb salvage to be pursued in increasingly complex cases.

Ultrasound is a critical adjunct in the diagnosis and treatment of popliteal entrapment syndrome.

This article describes our approach and evidence-based evaluation of popliteal entrapment syndrome. Included is a technical description of our use of preoperative intravascular ultrasound for diagnosis and operative planning in combination with our utilization of intraoperative duplex ultrasound. This evidence-based, methodical approach enables not only the correct diagnosis of the type of popliteal entrapment, but more importantly, identifies irreparable injury to the popliteal artery that would necessitate operative arterial reconstruction prior to surgery.

Beneficial effects of histone deacetylase inhibition with severe hemorrhage and ischemia-reperfusion injury.

BACKGROUND: Valproic acid (VPA) is a histone deacetylase inhibitor that may decrease cellular metabolic needs following traumatic injury. We hypothesized that VPA may have beneficial effects in preventing or reducing the cellular and metabolic sequelae of ischemia-reperfusion injury. METHODS: Twenty-eight Yorkshire swine underwent 35% blood volume hemorrhage, followed by a lethal truncal ischemia-reperfusion injury and 6 h of resuscitation. Physiologic and laboratory parameters were closely measured and the pigs divided into four groups: sham, control (injury protocol), VPA dosing before cross-clamp (VPA-B), and VPA dosing after cross-clamp (VPA-A). RESULTS: All animals developed significant coagulopathy, acidosis, and anemia. Animals receiving VPA-A had decreased acidosis and coagulopathy as measured by pH (P = 0.016) and international normalized ratio (P = 0.013) over the resuscitation. VPA-A pigs had a decreased requirement for crystalloid (P = 0.007) and epinephrine (P < 0.0001) during resuscitation. Pathologic analysis demonstrated decreased liver injury with VPA administration. VPA administration increased levels of acetylated proteins in liver and lung tissues, and was associated with increased expression of heat shock protein 70 versus controls. CONCLUSIONS: Valproic acid conferred a significant cardiovascular, metabolic, and pathologic protective effect in a model of severe injury. Earlier administration (VPA-B) was significantly less effective compared with dosing after initial hemorrhage control.

Single-incision laparoscopic colectomy: training the next generation.

BACKGROUND: Single-incision laparoscopic colectomy (SILC) is touted to be an improved approach for minimally invasive surgery although no data currently exists regarding the acquisition of skills for the safe performance of this technique. The authors report their early experience with proctoring of surgical residents in SILC by experienced colorectal surgeons. METHODS: Data regarding patient demographics, operative data, and short-term outcomes were prospectively collected at two surgical training hospitals. Residents and staff independently rated individual components of this technique to compare them with learning standard multiport colectomy (MP). RESULTS: A total of 31 SILC cases (15 men; mean age 53 years) were managed. The average BMI was 26.5 kg/m(2) (range 16-39 kg/m(2)). The surgical indications included cancer (n = 13), polyps (n = 8), diverticular disease (n = 4), Crohn's disease (n = 2), familial adenomatous polyposis (n = 2), volvulus (n = 1), and rectal prolapse (n = 1). The average operative time was 164 ± 86 min, and the mean blood loss was 80 ± 83 mL. The mean incision length was 4.1 ± 1.1 cm. One case required additional trocar placement (stoma creation), and three cases required conversion to open procedure because of failure to progress, difficult colorectal anastomosis, or poor visualization. The median hospital stay was 5.7 ± 1.3 days. The 30-day morbidity included minor wound infections (9.7 %), ileus (6.5 %), blood transfusion (3.2 %), and intraabdominal abscess (3.2 %). No deaths occurred. Residents rated vascular pedicle isolation, mobilization, critical structure exposure, instrument conflict/handling, and ergonomics as significantly more difficult with SILC. CONCLUSIONS: Senior-level residents can safely perform SILC under appropriate experienced supervision. The required advanced skills reflect complex laparoscopic training occurring during residency. Opportunities exist for better preparation and training of surgical residents to perform this complex surgery independently and safely at completion of residency.

Three-dimensional ultrasonography measurements after endovascular aneurysm repair.

BACKGROUND: Ultrasonographic (US) assessment of abdominal aortic aneurysms is typically performed by measuring maximal aneurysm diameter from two-dimensional images. These measurements are prone to inaccuracies owing to image planes and interobserver variability. The purpose of this study was to compare the variability in diameter, cross-sectional area (CSA), and volume measurements of abdominal aortic aneurysms obtained using a three-dimensional (3D) US imaging system with those obtained using computed tomographic (CT) angiography, and to determine the reliability of these measures. METHODS: Seven patients in whom endovascular aneurysm repairs were performed underwent CT angiography in addition to a 3D US scan. Measurements computed using 3D surface reconstructions of CT and 3D US scans included maximum diameter, CSA, and aneurysm volume. The seven matched CT and 3D US scans were compared at baseline and 6 to 8 weeks later. RESULTS: The average aneurysm measured 57.2 mm on CT and 56.2 mm on US (P = 0.14). Correlation coefficients for diameter, CSA, and volume were 0.88, 0.90, and 0.93, respectively (all P values < 0.001). A Bland-Altman analysis demonstrated a strong agreement between 92% of the diameter, 96.4% of the CSA, and 100% of the volume measurements. The interrater reliability was remarkably high comparing the modalities (CT vs. US), and ranged from 0.934 to 0.997 for single measurements and 0.965 to 0.998 for all measurements together; moreover, there was a strong reliability when the tests were reviewed 6 to 8 weeks later, with a reliability of 0.962 to 0.998 for single measurements and 0.992 to 0.999 for all tests (all P values < 0.001). CONCLUSIONS: The 3D US is an accurate and noninvasive method of determining aneurysm size and geometry that is reproducible. Volumetric measurements may represent a significant advancement in long-term follow-up after endovascular aneurysm repair.

Application of preoperative brain natriuretic peptide levels in clinical practice.

The purpose of the study was to determine the clinical utility and practical application of preoperative brain natriuretic peptide (BNP) levels. This is a retrospective review of operating room procedures from November 2006 to March 2009. Preoperative history and physical were reviewed and BNP laboratory levels obtained prior to all procedures and the postoperative course reviewed for incidence of 30-day cardiac complications. A receiver operator curve analysis demonstrated that a preoperative BNP threshold ≥95.5 pg/mL correctly identified 75% of patients with cardiac complications and values ≤18.5 pg/mL identified 100% of patients without adverse postoperative cardiac complications. Multivariable analysis also revealed a history of peripheral arterial disease as the most significant preoperative predictor of cardiac complications followed by BNP above the threshold (odds ratio = 3.7), hypothyroidism, coronary artery disease and prior myocardial infarction. In conclusion, preoperative BNP levels are a useful adjunct in clinical practice to help identify those patients with a high postoperative risk and those with a minimal postoperative risk.

Valproic acid reversed pathologic endothelial cell gene expression profile associated with ischemia-reperfusion injury in a swine hemorrhagic shock model.

BACKGROUND: Vascular endothelial cells serve as the first line of defense for end organs after ischemia and reperfusion injuries. The full etiology of this dysfunction is poorly understood, and valproic acid (VPA) has proven to be beneficial after traumatic injury. The purpose of this study was to determine the mechanism of action through which VPA exerts its beneficial effects. METHODS: Sixteen Yorkshire swine underwent a standardized protocol for an ischemia-reperfusion injury through hemorrhage and a supraceliac cross-clamp with ensuing 6-hour resuscitation. The experimental swine (n = 6), received VPA at cross-clamp application and were compared with a sham (n = 5) and injury-control models (n = 5). Aortic endothelium was harvested, and microarray analysis was performed along with a functional clustering analysis with gene transcript validation using relative quantitative polymerase chain reaction. RESULTS: Clinical comparison of experimental swine matched for sex, weight, and length demonstrated that VPA significantly decreased resuscitative requirements, with improved hemodynamics and physiologic laboratory measurements. Six transcript profiles from the VPA treatment were compared with the 1536 gene transcripts (529 up and 1007 down) from sham and injury-control swine. Microarray analysis and a Database for Annotation, Visualization and Integrated Discovery functional pathway analysis approach identified biologic processes associated with pathologic vascular endothelial function, specifically through functional cluster pathways involving apoptosis/cell death and angiogenesis/vascular development, with five specific genes (THBS1, TNFRSF12A, ANGPTL4, RHOB, and RTN4) identified as members of both functional clusters. This study also examined gene expression of transforming growth factor (TGF)-ß (TGF-ß1, TGF-ß2, and TGF-ß-releasing thrombospondin 1 [THBS1]) and genes expressing vascular endothelial growth factor (VEGF) C, VEGFD, and VEGFR1 and found that these genes were involved in the endothelial functional preservation associated with VPA administration. CONCLUSIONS: VPA minimized pathologic endothelial cell function through the TGF-ß and VEGF functional pathways. This study also implicates that integrated functional modeling and analysis will enable advancements in endothelial dysfunction using a systems biology approach.

That's why it's a 5-year program: resident acquisition of anorectal disease management competence.

BACKGROUND: Although surgical residents are expected to be proficient in the diagnosis and management of anorectal pathology upon graduation, there is little data related to the timing and degree of proficiency acquired during training. METHODS: Prospective study of new patients presenting to a colorectal surgical clinic for evaluation of anorectal complaints over a 3-y period. Trainees performed an initial evaluation and recorded their exam findings, diagnosis, and treatment plan. A separate evaluation by a staff colorectal surgeon was performed, with results compared by an independent reviewer. RESULTS: A total of 236 patient evaluations were included. The accuracy of referral diagnosis was significantly better when originated from a surgeon than from all other referral sources (91.7% versus 59.1%, P = 0.031). The most common conditions were internal hemorrhoids (25%), anal fissures (22%), and external hemorrhoids (19.5%). Internal hemorrhoids were most commonly misdiagnosed as external hemorrhoids (58%). Anal fissures were missed 38% of the time, and were most often given the diagnosis of internal hemorrhoids (45%). Residents also demonstrated difficulty in identifying thrombosis in external hemorrhoids, with a 45% error rate. Medical students and residents had an overall correct primary diagnosis of 69.5%; however, there was a significant improvement in the accuracy of diagnosis from medical students and interns to upper level residents (62.9% versus 81.2%, P = 0.003). Medical treatment plans agreed between resident and staff in 74%, the surgical management agreed in 62%, and overall the residents had the correct diagnosis and corresponding treatment plan in 44%. Additional adjunctive procedures were proposed in 66 patients with residents stating the correct adjunct in 79%. The most frequently missed adjuncts were endorectal ultrasound (34%) and colonoscopy (28%). CONCLUSION: Surgical trainees demonstrated significant deficiencies in the ability to evaluate and manage anorectal pathology; however, marked improvement occurred with time in training. Common areas of misdiagnosis and therapeutic errors were identified which could aid in curriculum development.

The efficacy of Combat Gauze in extreme physiologic conditions.

INTRODUCTION: Combat Gauze (CG) is currently the most widely used hemostatic dressing in combat. The testing of CG was initially performed in healthy and physiologically normal animals. The goal this study was to assess the efficacy in a model of severe acidosis and coagulopathy. METHODS: To obtain an acidotic and coagulopathic model, Yorkshire swine sustained 35% blood volume hemorrhage followed by a 50-min supraceliac aortic ischemia-reperfusion injury with 6-h resuscitation (epinephrine to keep mean arterial pressure >40 and intravenous fluids to keep central venous pressure >4). We created a femoral artery injury and randomized the animals to CG versus a standard gauze (SG) dressing. We performed rotational thromboelastography with both CG and SG. RESULTS: Using our model, 17 anesthetized Yorkshire swine developed appropriately significant coagulopathy, acidosis, and anemia. The SG failure rate was 100% on the first application and worked once on the second application. Combat Gauze was successful in achieving hemostasis 93% of the time on the first application and had 100% success with the second application. Rotational thromboelastography demonstrated that the only difference was a decreased clotting time with CG compared with SG (P = 0.012). CONCLUSIONS: Combat Gauze significantly outperforms standard gauze dressings in a model of major vascular hemorrhage in acidotic and coagulopathic conditions. This effect appears to result from a decreased time lag between activation and first detectable clotting. Combat Gauze appears to maintain its efficacy even in the setting of severe acidosis and coagulopathy for the control of hemorrhage from vascular injury.

Initial operative time and metastatic disease recurrence.

Colon cancer metastases are a major source of morbidity and mortality for patients following oncologic resection. The purpose of this study was to identify whether operative time as a surrogate for resident involvement increased the risk of future liver metastases. We performed a retrospective review of patients undergoing curative colon resection from 2001 to 2010 at two military residency training hospitals. Intraoperative time as well as preoperative comorbidities and perioperative factors were gathered from electronic medical records. Liver metastases were identified from the tumor registry and inpatient records. A total of 106 patients underwent resection for colon cancer (Stage I-III) from 2001 to 2005 with 5-year follow-up through 2010. Operative times in patients who had recurrence was 205 +/- 60 minutes and those without recurrence was 187 +/- 73 minutes (p = 0.398). There was no correlation between operative time and time to recurrence (p = 0.452), and Cox regression demonstrated that case duration had no impact on time to metastatic recurrence (p = 0.461). Within our cohort, operative time had no impact on metastatic cancer recurrence. Surgeons should continue to focus on proper oncologic principles and tumor biology rather than the concern that increased operative time or resident training leads to increased metastatic recurrence.

Historical and current trends in colon trauma.

The authors discuss the evolution of the evaluation and management of colonic trauma, as well as the debate regarding primary repair versus fecal diversion. Their evidence-based review covers diagnosis, management, surgical approaches, and perioperative care of patients with colon-related trauma. The management of traumatic colon injuries has evolved significantly over the past 50 years; here the authors describe a practical approach to the treatment and management of traumatic injuries to the colon based on the most current research. However, management of traumatic colon injuries remains a challenge and continues to be associated with significant morbidity. Familiarity with the different methods to the approach and management of colonic injuries will allow surgeons to minimize unnecessary complications and mortality.

Identifying risk factors for renal failure and myocardial infarction following colorectal surgery.

BACKGROUND: The development of acute renal failure and myocardial infarction (MI) following colectomy prolongs recovery and is associated with worse outcomes. The purpose of this study is to identify perioperative factors that predispose patients to an adverse cardiac or renal complication. MATERIALS AND METHODS: We conducted a retrospective review of colectomies from 2001 to 2009. Patients were evaluated based upon the electronic inpatient record and followed to determine the incidence of acute renal failure (creatinine elevation over 50% of baseline) and myocardial injury. RESULTS: A total of 339 inpatient records were reviewed, of which 134 were female (40%) and 205 male (60%). The mean age was 61.96 ± 16.2 years with 39.5% right hemicolectomies, 22.7% sigmoidectomy, 13.9% Left hemicolectomy, 11.5% total abdominal colectomy, and 6.2% for ileocectomy and transverse colectomy. Within the cohort, 13.9% had baseline renal insufficiency (Cr > 1.4), 7.1% sustained anastomotic leak, 23.9% required postoperative intubation, 15% sustained postoperative sepsis, 11.2% postoperative MI, and 5% clinically significant acidosis. Excluding patients with an anastomotic leak, postoperative intubation, and sepsis, we found that the need for blood product transfusion was associated with postoperative acute renal failure (OR= 7.15 [2.4-20.7]). Preoperative creatinine > 1.5, limited functional capacity, and preoperative systolic blood pressure < 90 mm Hg were all associated with increased MI rates (OR= 15.7 [3.6-66.8], 9.5 [2.1-42.2], 12.0 [5.523-26.072], and 40.6 [1.7-968], respectively). CONCLUSION: This study demonstrates that several potentially modifiable preoperative and intraoperative factors exist that predispose patients to postoperative cardiac and renal dysfunction in the absence of major surgical complications.

Microarray and functional cluster analysis implicates transforming growth factor beta1 in endothelial cell dysfunction in a swine hemorrhagic shock model.

BACKGROUND: Trauma leading to massive hemorrhage results in widespread tissue hypoxia, anaerobic metabolism, and production of inflammatory cytokines and oxidative molecules injurious to the vascular endothelium. Although trauma-related endothelial cell pathophysiology has been extensively studied, very little is known regarding gene transcriptional changes that occur during the event, particularly in endothelia. Thus, we employed fluorescent microarray analysis of gene transcription to elucidate critical pathways and gene products involved in endothelial dysfunction. MATERIALS AND METHODS: A trauma-hemorrhage/shock (T-H/S) model mimicking the physiologic changes seen in human trauma was performed on 10 Yorkshire swine, consisting of 35% blood volume hemorrhage followed by 6 h of full resuscitation. Aortic endothelium was analyzed by microarray and functional clusters were identified through the use of Database for Annotation, Visualization, and Integrated Discovery (DAVID) software. RESULTS: Injured swine developed profound acidosis, coagulopathy, massive resuscitative fluid requirements, and microscopic changes of ischemia/reperfusion injury. While 1007 transcripts were down-regulated, 529 transcripts were up-regulated. DAVID functional clustering analysis revealed 21 significantly altered biological processes that were grouped into 12 distinct functional categories. The transforming growth factor beta (TGFß) family of genes was the most interrelated. In addition, vascular endothelial growth factor (VEGF) signaling members and leukocyte chemoattractants were also altered. CONCLUSIONS: Our model identified two major signaling pathways, TGFß and VEGF, which undergo early transcriptional changes in injured endothelial cells. Our results suggest that TGFß and VEGF may play a crucial role in the development of endothelial cell injury leading to increased vascular permeability during shock-trauma.

Transcriptional analysis of novel hormone receptors PGRMC1 and PGRMC2 as potential biomarkers of breast adenocarcinoma staging.

BACKGROUND: The expression of progesterone receptor membrane component 1 (PGRMC1) in breast cancer has generated interest in this recently discovered protein because of its role in tumorigenesis. However, correlations between patient age, PGRMC1 gene expression, breast cancer morphology, and breast cancer stage have not been adequately studied. Furthermore, very little is known about possible roles for other PGRMC isoforms in breast cancer, like PGRMC2. Thus, we examined the expression of PGRMC1 and PGRMC2 mRNA by relative quantitative PCR (RelqPCR) and determined whether transcript levels correlate with age, breast cancer staging, estrogen receptor alpha (ERα) status, and other morphometric features routinely used during the pathological examination of breast ductal adenocarcinomas. METHODS: Twenty-eight frozen or paraffin embedded breast cancer samples (ductal carcinoma in situ and stages I thru IV invasive ductal adenocarcinoma) and 10 control benign breast tissue samples were randomly selected and interrogated by RelqPCR to determine PGRMC1, 2, and ERα mRNA transcript levels. To control for slight variations in sample preparation, receptor transcript was normalized to the housekeeping gene phosphoglycerate kinase 1 (PGK1). Descriptive statistics and ANOVA of multiparametric datasets were used to correlate transcript levels with pathological staging parameters. RESULTS: PGRMC1 mRNA levels decreased significantly with patient age (Pearson's correlation -0.369; P=0.035), whereas PGRMC2 levels did not. Although the mean relative expression of PGRMC1 significantly decreased in stage II breast cancer compared with controls (P=0.050), it was no longer significant when age was considered a covariance (P=0.371). On the other hand, PGRMC2 mRNA transcript was significantly decreased in stage II breast cancer when compared to stage III cancer (P=0.028) in a manner independent of age (corrected model Bonferroni pair wise comparison, P=0.036). Furthermore, PGRMC2 levels positively correlated with ERα mRNA transcripts in patients with ER positive tumors (Pearson's correlation 0.503, P=0.096). CONCLUSIONS: Decreases in PGRMC1 mRNA are partially explained by increasing patient age. On the other hand, compared to stage III, PCRMC2 mRNA was significantly decreased in stage II adenocarcinoma of the breast in an age-independent manner. Additionally, PGRMC2 mRNA levels displayed a positive correlation with ERα transcripts. Thus, in addition to morphometric pathologic staging criteria, measurements of PGRMC2 mRNA may be useful for distinguishing low stage tumors from higher stages that require more aggressive clinical management, and may be a useful test when tumor ER IHC results are equivocal.

Superficialization of arteriovenous fistulae employing minimally invasive liposuction.

Superficialization of arteriovenous fistulae allows for improved dialysis access allowing for prolonged utilization and more efficient dialysis treatment. Multiple methods are described for superficializing arteriovenous fistulae, and minimizing the surgical intervention is advantageous for patient recovery and potentially improved outcomes. We describe a novel technique of superficialization of an upper extremity arteriovenous fistula employing ultrasound-guided liposuction. This article describes the suction lipectomy technique and the tools necessary for superficialization of an upper extremity arteriovenous fistula.

Limb salvage after delayed diagnosis for blunt traumatic infrapopliteal occlusion.

Infrapopliteal occlusion is uncommon after blunt trauma, and limb salvage after delayed diagnosis is even rarer. We present the case of a 56-year-old man who had complex lower leg orthopedic fractures along with a reportedly normal pulse examination with an 11-day diagnostic delay of limb-threatening ischemia requiring distal revascularization. This case illustrates an incidence of delayed infrapopliteal three-vessel occlusion with successful revascularization and subsequent endovascular management to maintain patency. We describe the workup and treatment of delayed infrapopliteal occlusion and a review of the current literature on this topic.

Intraoperative duplex and functional popliteal entrapment syndrome: strategy for effective treatment.

Functional popliteal entrapment syndrome (FPES) was first described by Rignault and colleagues in 1985 (Int. Angiol. 1985;4:341-343). This syndrome results from compression of the popliteal artery by a hypertrophied medial head of the gastrocnemius muscle with no other identifiable anatomical abnormality. The incidence, significance, natural history, and appropriate treatment of this syndrome remain controversial. We present three cases of FPES where intraoperative positional duplex scans guided gastrocnemius muscle resection and confirmed appropriate resection. Additionally, B-mode duplex obtained during one of the cases demonstrated intimal changes consistent with repetitive vessel trauma. All patients had resolution of their claudication and normal physiological testing postoperatively.

The impact of Model for End-Stage Liver Disease-Na in predicting morbidity and mortality following elective colon cancer surgery irrespective of underlying liver disease.

BACKGROUND: The Model for End-Stage Liver Disease Sodium Model (MELD-Na) is a validated scoring system that uses bilirubin, international normalized ratio, serum creatinine, and sodium to predict mortality in cirrhotic patients awaiting liver transplantation. The aim of this study was to identify the utility of MELD-Na to predict patient outcomes, with and without liver disease, after elective colon cancer surgery. METHODS: A review of the American College of Surgeons National Surgical Quality Improvement Program database (2005 to 2010) was conducted to calculate risk-adjusted 30-day outcomes using regression modeling. RESULTS: A total of 10,842 patients (mean age, 68 years; 51% women) were included. MELD-Na scores were higher in men (10.2 vs 9.1, P < .001) and in open procedures (9.9 vs 9.1, P < .001). The overall complication and mortality rates were 26.3% and 3.3%, respectively. Incremental increases in MELD-Na score correlated with a 1.2% increase in mortality and a 1.1% increase in complications. On multivariate analysis, complications increased with MELD-Na score (odds ratio [OR], 1.05 per 1 point increase; 95% confidence interval [CI], 1.038 to 1.066). MELD-Na score was also associated with increased mortality (OR, 1.13; 95% CI, 1.1 to 1.16), along with ascites (OR, 5.7; 95% CI, 3.7 to 8.8) and corticosteroids (OR, 2.1; 95% CI, 1.3 to 3.3). CONCLUSIONS: Elevated preoperative MELD-Na score is significantly associated with worse outcomes after elective resection for colon cancer.