Surgical management of mycotic aortic aneurysms

Huang YK, et al. Clinical, microbiologic, and outcome analysis of mycotic aortic aneurysm: the role of endovascular repair. Surg Infect (Larchmt). 2014 Jun;15(3): 290-8.

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Results: All of the patients had positive blood cultures, radiologic findings typical of MAA, and clinical signs of infection (leukocytosis, fever, and elevated C-reactive protein). The mean age of the patients was 63.8±10.6 y and the mean period of their follow up was 35.7±39.3 mo. Twenty-nine patients with MAAs underwent traditional open surgery, 11 others received endovascular stent grafts, and four MAAs were managed conservatively. The most frequent causative pathogens were Salmonella (36/44 patients [81.8%]), in whom organisms of Salmonella serogroup C (consisting mainly of S. choleraesuis) were identified in 14 patients, organisms of Salmonella serogroup D were identified in 13 patients, and species without serogroup information were identified in nine patients. The overall mortality in the study population was 43.2% (with an aneurysm-related mortality of 18.2%, surgically related mortality of 13.6%, and in-hospital mortality of 22.7%).

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Article of interest: A randomized trial comparing antibiotics with appendectomy for appendicitis.

CODA Collaborative, Flum DR, et al. A randomized trial comparing antibiotics with appendectomy for appendicitis. N Engl J Med. 2020 Oct 5. [Epub ahead of print.]

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Results: In total, 1552 adults (414 with an appendicolith) underwent randomization; 776 were assigned to receive antibiotics (47% of whom were not hospitalized for the index treatment) and 776 to undergo appendectomy (96% of whom underwent a laparoscopic procedure). Antibiotics were noninferior to appendectomy on the basis of 30-day EQ-5D scores (mean difference, 0.01 points; 95% confidence interval [CI], -0.001 to 0.03). In the antibiotics group, 29% had undergone appendectomy by 90 days, including 41% of those with an appendicolith and 25% of those without an appendicolith. Complications were more common in the antibiotics group than in the appendectomy group (8.1 vs. 3.5 per 100 participants; rate ratio, 2.28; 95% CI, 1.30 to 3.98); the higher rate in the antibiotics group could be attributed to those with an appendicolith (20.2 vs. 3.6 per 100 participants; rate ratio, 5.69; 95% CI, 2.11 to 15.38) and not to those without an appendicolith (3.7 vs. 3.5 per 100 participants; rate ratio, 1.05; 95% CI, 0.45 to 2.43). The rate of serious adverse events was 4.0 per 100 participants in the antibiotics group and 3.0 per 100 participants in the appendectomy group (rate ratio, 1.29; 95% CI, 0.67 to 2.50).

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Treatment methodologies of carotid stenosis

Bae C, et al. Comparative Review of the Treatment Methodologies of Carotid Stenosis. Int J Angiol. 2015 Sep;24(3):215-22. .

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The treatment of carotid stenosis entails three methodologies, namely, medical management, carotid angioplasty and stenting (CAS), as well as carotid endarterectomy (CEA). The North American Symptomatic Carotid Endarterectomy Trial (NASCET) and European Carotid Surgery Trial (ECST) have shown that symptomatic carotid stenosis greater than 70% is best treated with CEA. In asymptomatic patients with carotid stenosis greater than 60%, CEA was more beneficial than treatment with aspirin alone according to the Asymptomatic Carotid Atherosclerosis (ACAS) and Asymptomatic Carotid Stenosis Trial (ACST) trials. When CAS is compared with CEA, the CREST resulted in similar rates of ipsilateral stroke and death rates regardless of symptoms. However, CAS not only increased adverse effects in women, it also amplified stroke rates and death in elderly patients compared with CEA. CAS can maximize its utility in treating focal restenosis after CEA and patients with overwhelming cardiac risk or prior neck irradiation. When performing CEA, using a patch was equated to a more durable result than primary closure, whereas eversion technique is a new methodology deserving a spotlight. Comparing the three major treatment strategies of carotid stenosis has intrinsic drawbacks, as most trials are outdated and they vary in their premises, definitions, and study designs. With the newly codified best medical management including antiplatelet therapies with aspirin and clopidogrel, statin, antihypertensive agents, strict diabetes control, smoking cessation, and life style change, the current trials may demonstrate that asymptomatic carotid stenosis is best treated with best medical therapy. The ongoing trials will illuminate and reshape the treatment paradigm for symptomatic and asymptomatic carotid stenosis.


More PubMed results on management of carotid artery stenosis.

See also: The Carotid Revascularization Endarterectomy vs Stenting Trial (CREST)

The surgical management and outcomes of dialysis access-associated steal syndrome (DASS)

Al Shakarchi J, et al. Surgical techniques for haemodialysis access-induced distal ischaemia. J Vasc Access. 2016 Jan-Feb;17(1):40-6.

Results: Following strict inclusion/exclusion criteria by two reviewers, twenty-seven studies of surgical interventions were included and divided into subgroups for banding, DRIL, PAI and RUDI procedures. Both DRIL and banding procedures were found to have high rates of symptomatic relief. In addition, the DRIL has a significantly lower rate of early thrombosis than banding although the more recent papers seem to suggest that early thrombosis is less of a problem in banding. PAI and RUDI showed some promise but there were too few studies to be able to make any clear conclusions.

Conclusions: All four procedures have high success rate in relieving ischaemic symptoms with the DRIL procedure having a significantly better vascular access patency rate than other techniques, although further well designed studies are required to compare all four surgical techniques.

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Visceral Hypersensitivity

Zhou Q, Verne GN. New insights into visceral hypersensitivity–clinical implications in IBS. Nat Rev Gastroenterol Hepatol. 2011 Jun;8(6):349-55.

Key points

  • Visceral and somatic hypersensitivity are present in some patients with functional gastrointestinal disorders
  • Injury to visceral afferents is the most common underlying cause of visceral hypersensitivity that is maintained by either peripheral and/or central nervous system mechanisms
  • Animal models of hypersensitivity have been used to examine the neural mechanisms of hypersensitivity following inflammatory injury, such as alterations in the N-methyl, D-aspartate receptor, dorsal horn neurons or c-Fos
  • Increased intestinal permeability might lead to hypersensitivity and abdominal pain in patients with functional gastrointestinal disorders
  • Functional gastrointestinal disorders are similar to other chronic pain disorders in which persistent nociceptive mechanisms are activated

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Pancreaticoduodenectomy in patients with previous Roux-en-Y gastric bypass

Shah MM, Martin BM, Stetler JL, Patel AD, Davis SS, Sarmiento JM, Lin E. Reconstruction Options for Pancreaticoduodenectomy in Patients with Prior Roux-en-Y Gastric Bypass. J Laparoendosc Adv Surg Tech A. 2017 Nov;27(11):1185-1191.

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“In summary, of the 13 patients that have been described in the literature who underwent PD after RYGB, 7 (54%) of these patients underwent reconstruction, similar to our preferred approach (Fig. 2), which involved remnant gastrectomy with the BP limb forming the BP anastomoses. Overall, 8 (61.5%) of the 13 patients had remnant gastrectomy. Five patients did not have a remnant gastrectomy. There are 10 patients in the literature where the surgeon attempted resecting the gastric remnant, and 8 (80%) of these patients had successful remnant gastrectomy. However, based on the published literature, this is clearly a small sampling of what might have actually been performed. We have had three such patients where we performed PD in patients with prior RYGB (similar to Fig. 2a). In all patients, we had adequate BP limb length for the anastomoses. The patients had early recovery of bowel function and were discharged from the hospital on or before postoperative day 5 without any significant complications. Continue reading

Iatrogenic ureteral injury in colorectal cancer surgery

Andersen P, et al. Iatrogenic ureteral injury in colorectal cancer surgery: a nationwide study comparing laparoscopic and open approaches. Surg Endosc. 2015 Jun;29(6): 1406-12.

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Results: A total of 18,474 patients had a resection for colorectal cancer. Eighty-two ureteral injuries were related to colorectal surgery. The rate of ureteral injuries in the entire cohort was 0.44 %, with 37 (0.59 %) injuries in the laparoscopic group (n = 6,291) and 45 (0.37 %) injuries in the open group (n = 12,183), (P = 0.03). No difference in ureteral injury was found in relation to surgical approach in colon cancer patients. In rectum cancer patients (n = 5,959), the laparoscopic approach was used in 1,899 patients, and 19 (1.00 %) had ureteral injuries, whereas 17 (0.42 %) of 4,060 patients who underwent an open resection had a ureteral injury. In multivariate analysis adjusted for age, gender, ASA score, BMI, tumor stage, preoperative chemo-radiation, calendar year, and specialty of the surgeon, the laparoscopic approach was associated with an increased risk of ureteral injury, OR = 2.67; 95 % CI 1.26-5.65.

Conclusion: In this nationwide study laparoscopic surgery for rectal cancer with curative intent was associated with a significantly increased risk of iatrogenic ureteral injury compared to open surgery.

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Mortality and treatment outcome following surgical interventions for acute mesenteric ischemia.

Beaulieu RJ, et al. Comparison of open and endovascular treatment of acute mesenteric ischemia. J Vasc Surg. 2014 Jan;59(1):159-64. Erratum in: J Vasc Surg. 2014 Jul;60(1):273.

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Results: Of 23,744 patients presenting with AMI, 4665 underwent interventional treatment from 2005 through 2009. Of these patients, 57.1% were female, and the mean age was 70.5 years. A total of 679 patients underwent vascular intervention; 514 (75.7%) underwent open surgery and 165 (24.3%) underwent endovascular treatment overall during the study period. The proportion of patients undergoing endovascular repair increased from 11.9% of patients in 2005 to 30.0% in 2009. Severity of comorbidities, as measured by the Charlson index, did not differ significantly between the treatment groups. Mortality was significantly more commonly associated with open revascularization compared with endovascular intervention (39.3% vs 24.9%; P = .01). Length of stay was also significantly longer in the patient group undergoing open revascularization (12.9 vs 17.1 days; P = .006). During the study time period, 14.4% of patients undergoing endovascular procedures required bowel resection compared with 33.4% for open revascularization (P < .001). Endovascular repair was also less commonly associated with requirement for TPN support (13.7% vs 24.4%; P = .025).

Conclusions: Endovascular intervention for AMI had increased significantly in the modern era. Among AMI patients undergoing revascularization, endovascular treatment was associated with decreased mortality and shorter length of stay. Furthermore, endovascular intervention was associated with lower rates of bowel resection and need for TPN. Further research is warranted to determine if increased use of endovascular repair could improve overall and gastrointestinal outcomes among patients requiring vascular repair for AMI.

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Extramammary Paget’s Disease

Herrel LA, Weiss AD, Goodman M, Johnson TV, Osunkoya AO, Delman KA, Master VA. Extramammary Paget’s disease in males: survival outcomes in 495 patients. Ann Surg Oncol. 2015 May;22(5):1625-30.

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Results: Incidence rates of EMPD in men have been increasing with an annual percent change of +3.2 % (p < .0002) since 1978. Incidence of EMPD in blacks was nearly four times lower (p = .0003) and in Asians/Pacific islanders four times higher (p < .0001), relative to whites. Overall survival among 495 patients was 60.2 % at 120 months post-diagnosis. On multivariate analysis, significant factors negatively impacting survival were primary site in the perianal region compared to penoscrotal and truncal lesions (both p < .001), age older than 75 years (p < .001), and presence of distant versus localized disease (p = .018). Survival did not differ by race or presence of additional cancer.

Conclusions: Survival in men with EMPD is lower among those with distant disease and primary tumors located in the perianal region. The reasons for increasing EMPD incidence over time and for the racial disparities in disease occurrence require further study.

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