Allyson L. Hale

Impact of sarcopenia on long-term mortality following endovascular aneurysm repair

Sarcopenia, also known as a reduction of skeletal muscle mass, is a patient-specific risk factor for vascular and cancer patients. However, there are no data on abdominal aortic aneurysm (AAA) patients treated with endovascular aneurysm repair (EVAR) who have sarcopenia. To determine the impact of sarcopenia on mortality following EVAR, we retrospectively reviewed 200 patients treated with EVAR by estimating muscle mass on abdominal computed tomography (CT) scans. Mortality was analyzed according to its presence (n=25) or absence (n=175). Sarcopenia was more common in women than men (32.0% vs 9.7%; p=0.005). Patients with sarcopenia had an increased risk of mortality compared to those without (76% vs 48%; p=0.016). Of note, the overall mortality rate was 51% with a median follow up of 8.4 years (interquartile range, 5.3–11.7). In conclusion, the presence of sarcopenia on a CT scan is an important predictor of long-term mortality in patients treated for AAA with EVAR. Pending further study, these data suggest that sarcopenia may aid in pre-procedural long-term survival assessment of patients undergoing EVAR.

Videoscopic inguinal lymphadenectomy in malignant melanoma: safe in pregnancy?

Lymphadenectomy is the standard of care for metastatic melanoma in the inguinal lymph node basin. Historically, open surgery was the only treatment option. However, in recent years, videoscopic inguinal lymphadenectomy (VIL) has become a popular approach as it offers a minimally invasive alternative, provides similar oncologic control and reduces wound complications. Even though the VIL approach is being used more frequently, the patient populations that stand to benefit the most from this approach are still under investigation. Despite continued advances in safety for laparoscopic surgery, many surgeons are hesitant to perform these procedures on pregnant women. In this report, we present a successful VIL in a pregnant patient, describe our technique and demonstrate the safety of performing VIL in expectant mothers. To our knowledge, this case represents the first VIL performed in an expectant mother.

Postoperative outcomes in bariatric surgical patients participating in an insurance-mandated preoperative weight management program

BACKGROUND Many insurance companies require patient participation in a medically supervised weight management program (WMP) before offering approval for bariatric surgery. Clinical data surrounding benefits of participation are limited. OBJECTIVE To evaluate the relationship between preoperative insurance-mandated WMP participation and postoperative outcomes in bariatric surgery patients. SETTING Regional referral center and teaching hospital. METHODS A retrospective review of patients who underwent vertical sleeve gastrectomy or Roux-en-Y gastric bypass between January 2014 and January 2016 was performed. Patients (N = 354) were divided into 2 cohorts and analyzed according to presence (n = 266) or absence (n = 88) of an insurance-mandated WMP requirement. Primary endpoints included rate of follow-up and percent of excess weight loss (%EWL) at postoperative months 1, 3, 6, and 12. All patients, regardless of the insurance-mandated WMP requirement, followed a program-directed preoperative diet. RESULTS The majority of patients with an insurance-mandated WMP requirement had private insurance (63.9%). Both patient groups experienced a similar proportion of readmissions and reoperations, rate of follow-up, and %EWL at 1, 3, 6, and 12 months (P = NS). Median operative duration and hospital length of stay were also similar between groups. Linear regression analysis revealed no significant improvement in %EWL at 12 months in the yes-WMP group. CONCLUSION These data show that patients who participate in an insurance-mandated WMP in addition to completing a program-directed preoperative diet experience no significant benefit to rate of readmission, reoperation, follow-up, or %EWL up to 12 months postoperation. Our findings suggest that undergoing bariatric surgery without completing an insurance-mandated WMP is safe and effective.

Improving Patient Outcomes and Health Care Provider Communication with a Small, Yellow Plastic Band: the Patient URinary Catheter Extraction (PURCE) Protocol©

Introduction: Great efforts are being made to reduce catheter associated urinary tract infections as they increase patient morbidity and are costly to health care centers. Although various catheter associated urinary tract infection prevention initiatives exist, efficient communication between physicians and nurses continues to be a significant barrier. In an effort to enhance communication and reduce catheter associated urinary tract infections, we implemented a novel Patient URinary Catheter Extraction (PURCE) Protocol© and in this study we evaluate the utility of the PURCE Protocol. Methods: The PURCE Protocol was implemented for all urology and vascular surgical patients admitted to 1 surgical specialty unit between January and December 2014 (treatment group, 901 patients). The control group consisted of urology and vascular surgical patients admitted to the same surgical specialty unit during the 12‐month period (January to December 2013) before protocol implementation (926). End points included annual catheter associated urinary tract infection rates, device utilization ratio and protocol deviations. Results: The majority of urology/vascular surgery patients in both groups underwent catheter placement (control 55.4% vs treatment 58.9%). The annual catheter associated urinary tract infection rate for urology/vascular surgery patients in the control group was 2.5 compared to 0.0 in the treatment group. The annual device utilization ratio increased slightly from 0.15 in the control to 0.17 in the treatment group. Within the first 6 months of implementation there were 405 patient audits and 28 protocol deviations (6.9%), and no additional deviations occurred in the last 6 months of the study. Conclusions: According to our findings implementation of the PURCE Protocol led to a reduction in catheter associated urinary tract infections in a highly susceptible surgical patient population.

A Renal Arteriovenous Malformation Case Study: The Importance of Utilizing Color Doppler During Point-of-Care Sonography:

We report the successful diagnostic and observational treatment of a renal arteriovenous malformation (RAVM) diagnosed with point-of-care color Doppler imaging. The patient presented with clinical symptoms suggestive of hydronephrosis. A physician-performed point-of-care sonography demonstrated gray-scale imaging that initially appeared to confirm renal pelvis dilatation. However, the addition of color Doppler revealed color blooming resembling a vascular turbulence within the kidney and the renal pelvis. A computed tomography angiogram was used to confirm the diagnosis of RAVM as the etiology of renal pelvic dilation. This case highlights the potential value of using color Doppler as a standard component for physicians who evaluate patients believed to have hydronephrosis.

Traumatic Aorto-Cisterna Chlyi Fistula with Treatment of Aortic Pseudoaneurysm with CT-Guided Thrombin Injection

BACKGROUND Only 3 cases of aorto-cisterna chyli fistula have been described in the literature but none with a resulting pseudoaneurysm (PSA). METHODS A 68-year-old man presented following a motor vehicle collision. Imaging revealed a retroperitoneal hematoma with enhancement of the cisterna chyli, representing an aortic to cisterna chyli fistula. Three days later, computed tomography angiography showed resolution of the fistula, but revealed a PSA. The patient underwent arteriography that confirmed the PSA, and then a computed tomography-guided thrombin injection was performed. Follow-up imaging showed resolution of the PSA. RESULTS Only 3 cases of aorto-cisterna chyli fistula have been described. We hypothesize that this fistula was caused from his L2 vertebral body fracture, which avulsed the lumbar artery and injured the cisterna chyli. The cisterna chyli provided an outflow tract for the aortic injury. We believe this type of fistula follows a benign clinical course. Aorto-cisterna chyli fistula is rare, and reports point to spontaneous resolution. Our case is unique in that the patient progressed from a fistula to a PSA. Options for treatment of this PSA include covered stent graft, open repair, coil embolization, or thrombin injection. CONCLUSIONS This case report describes an extremely rare diagnosis and the natural history of this aorto-cisterna chyli fistula. Furthermore, the resulting aortic PSA was successfully treated with computed tomography-guided thrombin injection, which in the appropriate setting, should be considered an acceptable option.