Is elevated creatinine level a contraindication to endovascular aneurysm repair?

PURPOSE: It is widely believed that chronic renal insufficiency (CRI) greatly increases the risk associated with endovascular abdominal aortic aneurysm repair (EVAR) and is a relative contraindication to the procedure and to the use of intra-arterial contrast agents (IACA). We reviewed a 5-year EVAR experience to determine whether the procedure and use of IACA have an important deleterious effect on renal function in patients with and without pre-existing CRI. METHODS: Endovascular aneurysm repair (EVAR) was performed in 200 patients with a variety of endografts, with intra-arterial contrast agents. The patients were retrospectively assigned to three groups on the basis of preoperative serum creatinine concentration (Cr): group 1 (n = 108), Cr less than 1.5 mg/dL (normal range); group 2 (n = 65), Cr 1.5 to 2.0 mg/dL; group 3 (n = 27), Cr 2.1 to 3.5 mg/dL. No patients had undergone hemodialysis. In groups 2 and 3, patients received hydration perioperatively, and received mannitol intraoperatively; no nephrotoxic drugs were administered during the procedure, other than nonionic contrast agent (Omnipaque 350). RESULTS: The incidence of postoperative complications between the three study groups was not statistically different. In group 1 a transient increase in serum Cr (>30% over baseline and >1.4 mg/dL) was noted in three patients (2.7%), two of whom (1.9%) required temporary hemodialysis and one (0.9%) who died of renal failure. In group 2 a transient increase in serum Cr was noted in two patients (3.1%); both patients (3.1%) required temporary hemodialysis, and one patient (1.5%) died of renal failure. In group 3 a transient increase in serum Cr was noted in two patients (7.4%); one patient (3.7%) required temporary hemodialysis, and one patient (3.7%) died of renal failure. Perioperative hypotension significantly increased the risk for elevated serum Cr and death (P <.05), and larger contrast volume was associated with an increase in serum Cr (P <.05) during the postoperative period. CONCLUSIONS: EVAR with intra-arterial contrast agents can be accomplished in patients with chronic renal insufficiency who do not require dialysis, with limited and acceptable morbidity and mortality, similar to that observed with open aneurysm repair. Contrary to other reports in which perioperative precautions were not used, our study shows that with EVAR the risk for worsening renal failure, dialysis, and death is only slightly, and not significantly, greater in patients with preoperative chronic renal insufficiency compared with patients with normal renal function. Perioperative hypotension and increased contrast volume are significant risk factors for postoperative increase in serum Cr and death. With appropriate precautions such as averting perioperative hypotension and limiting the volume of nonionic contrast agents, elevated Cr need not be a contraindication to EVAR with intra-arterial contrast agents.     

Is larger tumor size a contraindication to retroperitoneal laparoscopic adrenalectomy?

Purpose

To evaluate the surgical feasibility of retroperitoneal laparoscopic adrenalectomy for tumors exceeding 5 cm.

Methods

A retrospective review was carried out on all adrenalectomies performed between 2002 and 2011. All surgical procedures were performed or supervised by one of two experienced laparoscopic surgeons. A total of 133 patients who underwent retroperitoneal laparoscopic adrenalectomy were divided according to tumor size: group I (n = 57) had tumors <5 cm and group II (n = 76) had tumors ≥5 cm. The operative outcomes included surgical time, change in hemoglobin level, estimated blood loss, necessity for blood transfusion, time to ambulation, hospitalization duration, postoperative complications according to the Clavien-Dindo classification, and the rate of conversion to open surgery.

Results

The estimated blood loss (271.75 ± 232.98 mL vs. 367.24 ± 275.11 mL; p = 0.037), time to ambulation (1.60 ± 0.49 days vs. 1.89 ± 0.31 days; p = 0.001), and postoperative hospitalization (7.88 ± 3.08 days vs. 9.264 ± 3.10 days; p = 0.012) were significantly higher in group II. The operation time and hemoglobin level change were not statistically different between groups. Blood transfusions were performed in 3 patients from group I and 6 patients from group II (5.3 vs. 7.9 %; p = 0.449). No patients experienced conversion to open surgery.

Conclusions

Retroperitoneal laparoscopic adrenalectomy can be used in patients with tumors larger than 5 cm.     

Is old age a contraindication to elective ventral hernia repair?

Background

Ventral hernia repair (VHR) is a frequent problem in the expanding aging population. However, advanced age is often viewed as a contraindication to elective hernia surgery. We aimed to analyze outcomes of VHR in a large cohort of elderly patients. We hypothesized that elective VHR is safe and effective even in patients over 70 years old.

Methods

We conducted a retrospective review of consecutive patients over the age of 70 who underwent VHR at a at a tertiary care hospital. Main outcome measures included postoperative complications and recurrence rate.

Results

Between 2006 and 2015, 263 elderly patients who underwent elective VHR were included. Major comorbidities included diabetes, COPD, and smoking history. The majority of the patients underwent open repairs. Surgical site events occurred in 54 patients (21%). Postoperative complications included 17 venous thromboembolism occurrences, 2 myocardial infarctions, 41 patients who required postoperative critical care, and 1 mortality. Readmission within 90 days postoperatively occurred in 34 patients (13%). At a mean follow-up of 25.6 months, 17 patients in the open group and 6 patients in the laparoscopic group had a recurrence.

Conclusion

We demonstrated that VHR can be performed reasonably safely and effectively even in this potentially risky cohort. The use of laparoscopy might be associated with further reduction in morbidity. Overall, age should not be a contraindication to elective VHR, even in patients over 70 years old.

     

Are bronchoscopic approaches to post-pneumonectomy bronchopleural fistula an effective alternative to repeat thoracotomy?

A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was whether bronchoscopic or other minimal access approaches to the closure of bronchopleural fistulae (BPFs) were effective compared to a conventional re-thoracotomy. Our search identified 1052 abstracts, from which we identified six case series of greater than two post-pneumonectomy bronchopleural fistula patients. These series included reports of bronchial stenting, glue occlusion and scar obliteration of fistulae. No thoracoscopic techniques were reported except in case report form. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We identified 85 post-pneumonectomy bronchopleural fistulae reported in the literature who underwent bronchoscopic procedures to attempt repair. There was a 30% cure rate using a range of bronchoscopic techniques in these series. Bronchoscopic techniques included cyanoacrylate or fibrin glue application, YAG laser therapy, injection of the vein sclerosant polidocanol and tracheo-bronchial stenting. The mortality was 40% in these patients reflecting the very high mortality with this complication. Many patients required multiple bronchoscopic procedures and also further drainage procedures of their empyemas. Bronchoscopic treatment has so far only been reported in small case series but may offer further treatment options in patients too unwell to undergo re-thoracotomy.     

Is obesity a contraindication to bilateral total knee arthroplasties under one anesthetic?

Three-hundred sixteen patients who underwent 405 primary knee replacements between January 1994 and June 1999 were reviewed for the incidence of local wound and systemic complications after unilateral and simultaneous bilateral total knee arthroplasties. A body mass index of 30 or greater was used to define obesity, and patients were divided into four groups based on obesity and whether they were undergoing unilateral or bilateral total knee arthroplasties. Preoperative and postoperative knee scores were not significantly different for any patient group. Local wound complication rates did not differ between any of the study groups. Patients who were not obese who underwent unilateral total knee arthroplasty had lower systemic complication rates (3%) than the other groups; however, there was no significant difference in complication rates between patients with obesity who underwent unilateral or simultaneous bilateral total knee arthroplasties. Based on these findings, obesity does not seem to be a contraindication to bilateral total knee arthroplasties under one anesthetic.     

Is the presence of surgically treatable coronary artery disease a contraindication to liver transplantation?

Advanced coronary artery disease has been traditionally considered an absolute contraindication to orthotopic liver transplantation where chronic liver failure significantly increases the surgical risk for coronary artery bypass grafting. Performing a simultaneous coronary artery bypass grafting and liver transplant is a theoretically attractive strategy in liver transplant candidates with coronary artery disease in need of revascularization. In the present article, we report a successful simultaneous coronary artery bypass grafting and orthotopic liver transplant with 1-yr post-operative follow-up and we discuss the rationale for this approach. In selected cases, the presence of advanced coronary artery disease should not be considered an absolute contraindication to liver transplantation.     

Is prolonged cold ischemia a contraindication to using kidneys from acute kidney injury donors?

To determine the impact of prolonged cold ischemia time (CIT) on the outcome of acute kidney injury (AKI) renal grafts, we therefore performed a single‐center retrospective analysis in adult patients receiving kidney transplantation (KT) from AKI donors. Outcomes were stratified according to duration of CIT. A total of 118 patients receiving AKI grafts were enrolled. Based on CIT, patients were stratified as follows: (i) <20 hours, 27 patients; (ii) 20‐30 hours, 52 patients; (iii) 30‐40 hours, 30 patients; (iv) ≥40 hours, nine patients. The overall incidence of delayed graft function DGF was 41.5%. According to increasing CIT category, DGF rates were 30%, 42%, 40%, and 78%, respectively (P = .03). With a mean follow‐up of 48 months, overall patient and graft survival rates were 91% and 81%. Death‐censored graft survival (DCGS) rates were 84% and 88% for patients with and without DGF (P = NS). DCGS rates were 92% in patients with CIT <20 hours compared to 85% with CIT >20 hours (P = NS). In the nine patients with CIT >40 hours, the 4‐year DCGS rate was 100%. We conclude that prolonged CIT in AKI grafts may not adversely influence outcomes and so discard of AKI kidneys because of projected long CIT is not warranted when donors are wisely triaged.     

Is the clinically positive axilla in breast cancer really a contraindication to sentinel lymph node biopsy?

BACKGROUND: Clinically positive axillary nodes are widely considered a contraindication to sentinel lymph node (SLN) biopsy in breast cancer, yet no data support this mandate. In fact, data from the era of axillary lymph node dissection (ALND) suggest that clinical examination of the axilla is falsely positive in as many as 30% of cases. Here we report the results of SLN biopsy in a selected group of breast cancer patients with palpable axillary nodes classified as either moderately or highly suspicious for metastasis. STUDY DESIGN: Among 2,027 consecutive SLN biopsy procedures performed by two experienced surgeons, clinically suspicious axillary nodes were identified in 106, and categorized as group 1 (asymmetric enlargement of the ipsilateral axillary nodes moderately suspicious for metastasis, n = 62) and group 2 (clinically positive axillary nodes highly suspicious for metastasis, n = 44). RESULTS: Clinical examination of the axilla was inaccurate in 41% of patients (43 of 106) overall, and was falsely positive in 53% of patients (33 of 62) with moderately suspicious nodes and 23% of patients (10 of 44) with highly suspicious nodes. False-positive results were less frequent with larger tumor size (p = 0.002) and higher histologic grade (p = 0.002), but were not associated with age, body mass index, or a previous surgical biopsy. CONCLUSIONS: Clinical axillary examination in breast cancer is subject to false-positive results, and is by itself insufficient justification for axillary lymph node dissection. If other means of preoperative assessment such as palpation- or image-guided fine needle aspiration are negative or indeterminate, then SLN biopsy deserves wider consideration as an alternative to routine axillary lymph node dissection in the clinically node-positive setting.     

Is severe atherosclerosis in the aortoiliac region a contraindication for kidney transplantation?

Background

Atherosclerosis is common in end-stage renal disease patients on dialysis. However, it has previously been considered to be a relative contraindication to kidney transplantation. Currently, patients with extended indications are accepted onto the waiting list, including those with severe atherosclerosis. These patients require vascular procedures before or during kidney transplantation. The aim of this study was to present our experience with vascular reconstruction before kidney transplantation.

Material and Methods

Twelve atherosclerotic, uremic patients referred to be candidates for kidney transplantation were refused because of occlusive lesions of the iliac arteries or the distal aorta. The 10 males and 2 females had an age range of 45 to 68 years. Preoperative assessments consisted of a Doppler ultrasound and an angio computed tomography scan. The reconstructions were performed with aorto-biliac, aorto-bifemoral, or ilio-femoral dacron grafts in 7, 4, and 1 patient, respectively, under general anesthesia.

Results

There were no major postoperative complications; the patients were discharged and placed on a special waiting list. Eight patients received kidney allografts, including one living-related transplantation. All procedures were performed with arterial anastomosis of the transplanted kidney to the side of the prosthesis. No patient developed signs of arterial graft infection. In the postoperative period, there were no arterial or transplanted kidney-related complications, except for delayed graft function in four cases. The remaining four patients are still on the waiting list.

Conclusion

In end-stage renal disease patients with severe atherosclerosis in the aortoiliac region, vascular reconstruction allows kidney transplantation.