Fenestrated endovascular aneurysm repair is associated with lower perioperative morbidity and mortality compared with open repair for complex abdominal aortic aneurysms

ObjectiveThe Zenith Fenestrated Endovascular Graft (ZFEN; Cook Medical, Bloomington, Ind) has expanded the anatomic eligibility of endovascular aneurysm repair (EVAR) for complex abdominal aortic aneurysms (AAAs). Current data on ZFEN mainly consist of single-institution experiences and show conflicting results. Therefore, we compared perioperative outcomes after repair using ZFEN with open complex AAA repair and infrarenal EVAR in a nationwide multicenter registry.MethodsWe identified all patients undergoing elective AAA repair using ZFEN, open complex AAA repair, and standard infrarenal EVAR between 2012 and 2016 within the American College of Surgeons National Surgical Quality Improvement Program targeted vascular module. Open complex AAA repairs were defined as those with a juxtarenal or suprarenal proximal AAA extent in combination with an aortic cross-clamping position that was above at least one renal artery. The primary outcome was perioperative mortality, defined as death within 30 days or within the index hospitalization. Secondary outcomes included postoperative renal dysfunction (creatinine concentration increase of >2 mg/dL from preoperative value or new dialysis), occurrence of any complication, procedure times, blood transfusion rates, and length of stay. To account for baseline differences, we calculated propensity scores and employed inverse probability-weighted logistic regression.ResultsWe identified 6825 AAA repairs—220 ZFENs, 181 open complex AAA repairs, and 6424 infrarenal EVARs. Univariate analysis of ZFEN compared with open complex AAA repair demonstrated lower rates of perioperative mortality (1.8% vs 8.8%; P = .001), postoperative renal dysfunction (1.4% vs 7.7%; P = .002), and overall complications (11% vs 33%; P < .001). In addition, fewer patients undergoing ZFEN received blood transfusions (22% vs 73%; P < .001), and median length of stay was shorter (2 vs 7 days; P < .001). After adjustment, open complex AAA repair was associated with higher odds of perioperative mortality (odds ratio [OR], 4.9; 95% confidence interval [CI], 1.4-18), postoperative renal dysfunction (OR, 13; 95% CI, 3.6-49), and overall complication rates (OR, 4.2; 95% CI, 2.3-7.5) compared with ZFEN. Compared with infrarenal EVAR, ZFEN presented comparable rates of perioperative mortality (1.8% vs 0.8%; P = .084), renal dysfunction (1.4% vs 0.7%; P = .19), and any complication (11% vs 7.7%; P = .09). Furthermore, after adjustment, there was no significant difference between the odds of perioperative mortality, postoperative renal dysfunction, or any complication between infrarenal EVAR and ZFEN.ConclusionsZFEN is associated with lower perioperative morbidity and mortality compared with open complex AAA repair, and outcomes are comparable to those of infrarenal EVAR. Long-term durability of ZFEN compared with open complex AAA repair warrants future research.     

Laparoscopic surgery is associated with a lower incidence of venous thromboembolism compared with open surgery

BACKGROUND: Although laparoscopy now plays a major role in most general surgical procedures, little is known about the relative risk of venous thromboembolism (VTE) after laparoscopic compared with open procedures. OBJECTIVE: To compare the incidence of VTE after laparoscopic and open surgery over a 5-year period. PATIENTS AND INTERVENTIONS: Clinical data of patients who underwent open or laparoscopic appendectomy, cholecystectomy, antireflux surgery, and gastric bypass between 2002 and 2006 were obtained from the University HealthSystem Consortium Clinical Database. The principal outcome measure was the incidence of venous thrombosis or pulmonary embolism occurring during the initial hospitalization after laparoscopic and open surgery. RESULTS: During the 60-month period, a total of 138,595 patients underwent 1 of the 4 selected procedures. Overall, the incidence of VTE was significantly higher in open cases (271 of 46,105, 0.59%) compared with laparoscopic cases (259 of 92,490, 0.28%, P < 0.01). Our finding persists even when the groups were stratified according to level of severity of illness. The odds ratio (OR) for VTE in open procedures compared with laparoscopic procedures was 1.8 [95% confidence interval (CI) 1.3-2.5]. On subset analysis of individual procedures, patients with minor/moderate severity of illness level who underwent open cholecystectomy, antireflux surgery, and gastric bypass had a greater risk for developing perioperative VTE than patients who underwent laparoscopic cholecystectomy (OR: 2.0; 95% CI: 1.2-3.3; P < 0.01), antireflux surgery (OR: 24.7; 95% CI: 2.6-580.9; P < 0.01), and gastric bypass (OR: 3.4; 95% CI: 1.8-6.5; P < 0.01). CONCLUSIONS: Within the context of this large administrative clinical data set, the frequency of perioperative VTE is lower after laparoscopic compared with open surgery. The findings of this study can provide a basis to help surgeons estimate the risk of VTE and implement appropriate prophylaxis for patients undergoing laparoscopic surgical procedures.     

Laparoscopic surgery for inflammatory bowel disease

Laparoscopic surgery has recently been gaining acceptance as an alternative approach for patients with inflammatory bowel disease. There is increasing evidence demonstrating the multiple potential benefits of laparoscopy including faster recovery, reduced costs, and lower morbidity. For patients with acute colitis, a laparoscopic subtotal colectomy and end ileostomy have been shown to be feasible and safe in experienced hands. When indicated, many of these patients may be able to safely undergo a subsequent laparoscopic approach for construction of an ileo-anal pouch. Although still controversial, an elective laparoscopic restorative proctocolectomy with ileo-anal pouch anastomosis has also been shown to be feasible with functional outcomes at least similar to those obtained with an open approach. However, larger randomized series of patients are needed with longer follow-up in order to draw definite conclusions. For Crohn's disease, a laparoscopic approach is ideal for stoma creation. In addition, laparoscopic ileo-colectomy is arguably the preferred approach for patients with terminal ileal disease. Some experienced laparoscopic groups have also applied laparoscopic techniques for more complicated cases with recurrent disease or disease-related complications, such as fistulous disease. Other short-term benefits of a laparoscopic approach may include a decreased incidence of ventral hernias, decreased incidence of small bowel obstruction, and faster recovery. These benefits may also have significant economic impact. In contrast to earlier reports, there is reliable evidence that conversion is not associated with a poorer outcome. A policy of starting most suitable cases laparoscopically may offer patients the potential benefits of a laparoscopic approach without increasing morbidity.     

Laparoscopically assisted bowel surgery for inflammatory bowel disease

Background: Laparoscopic bowel surgery was evaluated in 44 consecutive patients who underwent surgery for inflammatory bowel disease (IBD). We studied feasibility, results, and final outcome. Methods: At two academic institutes, 44 laparoscopically assisted colectomies and laparoscopic ileostomies or colostomies were attempted. All patients had histologically proven IBD and no prior surgery for IBD. Loop ileostomy (n= 4), end colostomy (n= 1), ileocecal resection (n= 26) and (procto)colectomy (n= 13) were performed. All resections were laparoscopically assisted with extracorporal resection and anastomosis. Results: Only in two patients (ileocecal resection in both) was conversion to open surgery necessary. Two patients with laparoscopic ileocolic resection had intra-abdominal abscesses, which were drained percutaneously in both. One patient in the laparoscopically assisted colectomy group had a subphrenic abscess that was drained percutaneously, and one patient had a generalized candidiasis. Conclusions: Laparoscopically assisted colectomies can be performed safely in treating IBD. The laparoscopic method with use of a small vertical umbilical or Pfannenstiel's incision seems acceptable with regard to operating time and overall costs, also allowing superior cosmesis to be maintained. Received: 12 August 1998/Accepted: 13 January 1999     

Laparoscopic surgery for inflammatory bowel disease

BACKGROUND: Common laparoscopic colorectal procedures in patients with Crohn's disease include ileocolic resection and subtotal colectomy. The aim of this study was to compare and contrast the results of these two procedures. METHODS: Patients who underwent one of these procedures between June 1992 and January 1999 were identified and included in the study. Statistical analysis was performed using the Mann-Whitney test, Student's t-test, or Fisher's exact test. RESULTS: In all 109 patients (63 women and 46 men) with an average age of 36.7 years (range, 15-74) underwent ileocolic resection (ICR), while 21 patients (16 women and five men) with an average age of 36.5 years (range, 18-77) underwent subtotal colectomy (STC) (p = NS). There were 14 intraoperative complications, eight (7%) in the ICR group and six (29%) in the STC group (p = 0.01). Total operative time was 167 min (range, 90-285) in the ICR group and 231 min (range, 140-340) in the STC group (p < 0.01). Despite this difference in operating time, the hospital stays were very similar at 8.8 days (range, 3-27) and 8.8 days (range, 3-14) (p = NS). In 19 (17%) of the ICR patients and five (24%) of the STC patients, their procedure was converted to a laparotomy (p = NS). In the ICR group, 20 of the patients (18%) had surgery-related postoperative complications, including five anastomotic leaks. In the STC group, six of the patients (29%) had surgery-related complications, including two anastomotic leaks (p = NS). CONCLUSION: Although STC is a far more extensive procedure than ICR, the overall postoperative complication rate is not significantly different between the two groups; however, we found that there were more intraoperative complications associated with STC.     

Aortic neck dilation is not associated with adverse outcomes after fenestrated endovascular aneurysm repair

Objective

Long-term outcomes after endovascular aneurysm repair (EVAR) are threatened by aortic neck dilation (AND), graft migration, and subsequent endoleak development. The aim of this study was to determine the rate of AND and the occurrence of endoleaks after fenestrated EVAR of juxtarenal aneurysms with physician-modified endovascular grafts (PMEGs).

Xanthogranulomatous cystitis associated with inflammatory bowel disease

Xanthogranulomatous inflammation is a benign condition characterized by the presence of multinucleated giant cells, chronic inflammatory cells and lipid-laden macrophages, known as xanthoma cells. Only 22 cases of xanthogranulomatous cystitis (XGC) have been reported in the Japanese and English literature. In this report, we describe the twenty-third case of XGC and the third case associated with inflammatory bowel disease (IBD). A 50-year-old woman with quiescent Crohn’s disease was incidentally found to have a bladder mass on ultrasound. The lesion was resected through a transurethral approach. Pathology demonstrated XGC. At 3 months post-resection, there was no evidence of recurrence adjacent to the previous resection scar.     

Complex endovascular aneurysm repair is associated with higher perioperative mortality but not late mortality compared with infrarenal endovascular aneurysm repair among octogenarians

Objective

As our collective experience with complex endovascular aneurysm repair (EVAR) has grown, an increasing number of older patients are being offered endovascular repair of juxtarenal aneurysms. Outcomes after complex EVAR in this older subpopulation are not well-described. We sought to specifically evaluate clinical outcomes after complex EVAR compared with infrarenal EVAR in a cohort of octogenarians.

Pelvic pouch cancers associated with inflammatory bowel disease

Patients with inflammatory bowel disease who undergo ileal pouch-anal anastomosis are at finite risk of developing neoplasia of various parts of the pouch. In this review article, we will describe different forms of pelvic pouch-related cancers, with a focus on diagnosis and management of small bowel adenocarcinomas of the pouch body, rectal neoplasia of the rectal cuff and anal transition zone, small intestinal lymphoma of the pouch, and anal dysplasia and squamous cell cancer of the anal canal.     

Aneurysm sac failure to regress after endovascular aneurysm repair is associated with lower long-term survival

Background

The early survival advantage of endovascular aneurysm repair (EVAR) compared with open repair reverses over time, possibly because of higher rates of reintervention related to endoleaks and aneurysm sac expansion. Therefore, we sought to examine the association between sac behavior, endoleaks, reintervention, and long-term survival.

Endovascular aneurysm repair is associated with less malnutrition than open abdominal aortic aneurysm repair

Background

Patients undergoing abdominal aortic aneurysm (AAA) repair have high rates of postoperative malnutrition. We examined whether endovascular aneurysm repair (EVAR) is associated with reduced postoperative malnutrition compared with open AAA repair.

Methods

The records of patients undergoing AAA repair in the Veterans Affairs (VA) Connecticut Healthcare System were reviewed. Primary outcomes were 30-day morbidity, lengths of hospitalization and intensive care unit stay, duration of intubation, and nutritional risk index scores.

Results

Sixty-two patients were included (open repair, 37; EVAR, 25). Nutritional parameters were comparable between groups before surgery. Patients treated with EVAR had improved postoperative nutritional profiles as determined by albumin level (3.7 ± .08 vs 3.2 ± .12; P = .003), and nutritional risk index (97.9 ± 1.3 vs 88.9 ± 1.8; P = .0006), compared with patients treated with open repair.

Conclusions

Patients undergoing EVAR developed significantly less postoperative malnutrition compared with those having open repair. EVAR may be a strategy to avoid malnutrition and improve outcomes in patients at risk for malnutrition after undergoing AAA repair.     

Oncoplastic breast conserving surgery is associated with a lower rate of surgical site complications compared to standard breast conserving surgery

Background

Oncoplastic breast conserving surgery (OBCS) integrates plastic surgery techniques in the resection of breast cancer and lowers the rate of re-excision while improving breast cosmesis. The goal of this study is to compare the surgical site complication rate of OBCS with that of standard BCS.

Catheter-associated bloodstream infection after bowel surgery in patients with inflammatory bowel disease

Purpose

Catheter-associated bloodstream infections (CABSIs) are a leading cause of nosocomial infections. The objectives of this study were to establish the incidence of CABSIs after bowel surgery and to identify the risk factors.

Methods

We reviewed the prospectively collected data of patients who underwent abdominal surgery with central venous catheter (CVC) insertion between March, 2006 and September, 2009. We analyzed all possible variables, including age, sex, disease, CVC duration, insertion frequency, CVC site, infliximab, corticosteroid, and immunosuppressant administration, preoperative serum albumin level, surgical wound class, and emergency surgery.

Results

A total of 1261 patients were prospectively surveyed. The underlying diseases comprised ulcerative colitis (UC; n = 428), Crohn’s disease (CD; n = 334), colorectal cancer (CA; n = 344), esophageal cancer (ESO; n = 28), gastric cancer (GAST; n = 44), and others (n = 83). The incidences of CABSI were 6.9/1000 catheter days for UC, 7.4 for CD, 4.3 for CA, 3.7 for ESO, 3.7 for GAST, and 5.1 for others. CD patients had the highest rate of CABSI. The risk factors for CABSI were CD with an odds ratio (OR) of 1.63, dirty/infected wound class (OR 3.34), and CVC insertion via the internal jugular vein (OR 9.89).

Conclusion

A high CABSI incidence was found in association with CD, especially in dirty/infected surgery. Thus, the use of CVCs should be restricted in the presence of these risk factors.