Carlos A. Hinojosa

Acute bile duct injury. The need for a high repair.

Background: An immediate repair is considered optimal in acute biliary duct injuries; however, it may prove to be a challenge, because such repairs are usually performed on small ducts whose viability cannot always be determined. Methods: We performed a retrospective review of the charts of patients with acute bile duct injury who underwent repair at a tertiary care academic university hospital. A total of 204 patients with acute bile duct injury were seen between 1989 and 2002. Of these, 30 were repaired within minutes to hours after the injury. These patients were divided into two groups. Group I patients had a Roux-en-Y hepatojejunostomy below the hepatic junction; Group II patients had a Roux-en-Y hepatojejunostomy at the junction level. We then performed a long-term evaluation of anastomosis function in these patients, using clinical, radiological, and laboratory. Results: Twenty-eight injuries were secondary to a laparoscopy; the other two resulted from open cholecystectomies. All of the patients suffered complex injuries with complete section of the duct and substance loss (Strasberg E). There were 12 patients in group I and 18 in group II. Three cases in group I (25%) and one in group II (5%) developed anastomosis dysfunction. Mean follow-up was 56 months (range, 12–80) in group I and 52 months (range, 10–76) in group II. Two cases in group I (16%) and none in group II (0) required reoperation (p < 0.05). Conclusions: In the acute setting, complex lesions should be treated with a high bilioenteric anastomosis (at the junction level) in the first attempt at repair. Lower-level anastomoses are associated with a higher dysfunction rate and the need for radiological manipulation and reoperation. Also, stenosis of the anastomosis secondary to undetected duct ischemia in the acute repair is more frequent in low bilioenteric anastomoses.

Fenestrated endovascular grafts for juxtarenal aortic aneurysms: a step by step technical approach.

Fenestrated endovascular aortic aneurysm repair is a valuable alternative for patients who are at high risk for open surgery, but have unsuitable anatomy for infrarenal endovascular repair due to a short aneurysmal neck. Recognizing that this is an evolving and complex technology, we present a step by step approach to the surgical technique that may be useful for endovascular therapist interested in the management of these complex patients.

Small-diameter mesocaval shunts: A 10-year evaluation

The use of small-diameter portosystemic shunts for the treatment of bleeding esophageal varices caused by portal hypertension has emerged as an outgrowth of the development of polytetrafluoroethylene vascular grafts, which allow the use of a narrow lumen. We report our experience with this type of graft over a 10-year period. Thirty-three patients with good liver function (Child-Pugh class A) were electively operated. The average age of these patients was 45 years (range 17 to 71 years). Twenty-nine patients had liver cirrhosis, one had portal fibrosis, and three had idiopathic portal hypertension. Operative mortality was 3%, and the rebleeding rate was 15%. Postoperative encephalopathy was observed in 14 patients (11%), three of whom had grade III to IV encephalopathy. The remaining 11 patients, had mild encephalopathy that was easily controlled. Postoperative angiography showed shunt patency in 81% of the patients, reduction in portal vein diameter in 33% of the patients, and portal vein thrombosis in 6%. Good postoperative quality of life was observed in 63% of the patients. Survival according to the Kaplan-Meier actuarial method was 81% at 12 months, 56% at 60 months, and 36% at 10 years. These shunts are a good alternative for patients being considered for surgery in whom other portal blood flow preserving procedures (i.e., selective shunts, devascularization with esophageal transection) are not feasible.

Diminished morbidity and mortality in portal hypertension surgery: Relocation in the therapeutic armamentarium

Although several effective therapeutic options are available for bleeding from portal hypertension, surgery has a well-defined role in the management of patients with good liver function who are electively operated. The aim of this investigation was to evaluate the operative mortality and morbidity of portal blood flow-preserving procedures in a highly select patient population. The records of 148 patients operated on between 1996 and 2000 using one of two techniques (selective shunts or a Sugiura-Futagawa operation [complete portoazygos disconnection]) were analyzed with particular attention to operative mortality, postoperative rebleeding, and encephalopathy. Survival was calculated according to the Kaplan-Meier method. Sixty-one patients had distal splenorenal shunts placed, and 87 patients had a devascularization procedure. Operative mortality for the group as a whole was 1.2%. In the group with selective shunts, the rebleeding rate was 4.9%, the encephalopathy rate was 9.8%, and the shunt obstruction rate was 1.6%. Survival at 24 months was 94% and at 48 months was 92%. In those undergoing devascularization, the encephalopathy rate was 5% and the rebleeding rate was 14%. Survival at 24 months was 90% and at 48 months was 86%. Portal blood flow-preserving procedures have very low morbidity and mortality rates at specialized centers. In addition, a low rebleeding rate is associated with a good quality of life. Low-risk patients with bleeding portal hypertension should be considered for surgical treatment.

Compression therapy and liposuction of lower legs for bilateral hereditary primary lymphedema praecox.

In this report, we describe a case of bilateral non-syndromic hereditary lymphedema praecox of lower legs. The patient was diagnosed at age 16. Ten years later, he was unable to ambulate due to increased bilateral lower leg volume, continuous pain, and recurrent episodes of cellulitis. He was treated at our tertiary-care center with compression therapy and circumferential liposuction of lower legs, ankles, and dorsum of feet in order to remove hypertrophic fat deposits, facilitate conservative therapy, and decrease further risk of cellulitis. No complications were seen and compression therapy was continued. Fourteen month follow-up reveals no increase in leg volume over time, absence of pain, and no further episodes of cellulitis with complete ability to ambulate and return to normal activities. Even when it does not eliminate the underlying cause of primary lymphedema, combined therapy consisting of compression and liposuction is safe and is able to achieve control, at least on a short term, of clinically disabling conditions associated with advanced stages.

Early cannulation graft Flixene™ for conventional and complex hemodialysis access creation

Purpose The Flixene™ (Atrium™, Hudson, NH) is a trilaminate composite polytetrafluoroethylene (PTFE) graft that allows access within 72 hours. We evaluate our initial experience with this device for conventional and complex hemodialysis access creation. Methods Retrospective review in end-stage renal disease (ESRD) patients who underwent access creation with Flixene from January 2013 to July 2014. For our analysis, the patients were divided in two groups: those with complex access configurations tunneled in the chest and/or abdominal wall (thoraco-abdominal wall access [TAWA]), and those tunneled in conventional sites (extremity access [EA]). Patients demographics, indications, complications, reinterventions, patency rates and factors influencing outcomes were evaluated. Results In 19 patients (54% men; mean age 44 years ± 18), 24 grafts were implanted, (13 EA [54%] vs. 11 TAWA), all patent after surgery. Central venous occlusive disease (CVOD) was present in all patients with TAWA and in 7/13 (54%) EA patients (p = 0.016). Early cannulation (within 72 hours) was successful in 12 EA and 5 TAWA grafts (p = 0.044). Complication rates including infection, thrombosis, bleeding and steal syndrome were 8/11 (73%) in TAWA and 5/13 (38%) in EA (p = 0.02). At 12 months, primary patency rates for EA and TAWA were 25% and 41%; secondary patency rates were 55% and 41%, respectively. Conclusions Early cannulation (EC) grafts are viable alternatives for conventional and complex access creation that allowed early cannulation (<72 hours) in 17 (70%) of our cases. Primary and secondary patency rates at 12 months were equivalent to data reported on ePTFE grafts.

Impact of the bacteriology of diabetic foot ulcers in limb loss

Infections in feet of patients with diabetes mellitus is common, complex and costly. The aim of this study to investigate the isolated microorganisms in infected diabetic foot ulcers, and the impact of these infectious agents in limb loss in a tertiary medical center in Mexico City. We conducted a retrospective review in diabetic patients with infected foot ulcers from 1997 to 2014. Diabetic foot was defined according to the World Health Organization (WHO), the bacteriology of wound cultures and the impact of microorganisms in limb loss (major amputation) was studied. Patients demographics, comorbidities, wound characteristics, and other factors associated in clinical outcomes were determined. A total of 165 subjects with soft tissue infections and/or osteomyelitis and positive cultures were included. One hundred and five (64%) were male, with a mean age of 60 year old +/− 15. One hundred fifty‐nine (96%) had Type 2 diabetes mellitus, 68 (41%) history of peripheral arterial disease (PAD) and 97 (59%) patients had osteomyelitis. In 89 patients (54%), cultures were polymicrobial and one single organism was isolated in 76 cultures (46%). During the follow up, 96 (58%) patients preserved their limbs and 69 (42%) required major amputation (above or below knee). Sixty percent of patients that suffered from limb loss had polymicrobial culture (p = 0.13). Growth of Escherichia coli and Enterococcus faecium (p = 0.03) and E. coli and Morganella morgagnii (p = 0.03) was associated to limb loss. Among monomicrobial cultures, infections associated with Proteous mirabilis had higher rate of progression to limb loss (p = 0.03). PAD was associated to limb loss (p = 0.001). Management of diabetic foot requires a multimodality approach. In this study, in patients that received appropriate antibiotic therapy and optimal surgical management, we observed that history of PAD, polymicrobial and isolated P. mirabilis infections were variables associated with higher rate of limb loss.

IBS patients differ according to age: self-reported symptom severity is related

with functional constipation, ranging in age from six to eighteen years (M 9.9, SD 3.2), and their parents. Children completed self-report measures of defecation anxiety scale (Defecation Anxiety Scale–Self-Report) and general anxiety (Revised Children’s Manifest Anxiety Scale), and their parents rated their children’s defecation anxiety (Defecation Anxiety Scale—Parent Rating Scales). The information was collected prospectively. Results: By self-report and parent report, children with functional constipation were found to have more defecation anxiety than a normative group of well children. By parent report, children with constipation were also found to have more defecation anxiety than a normative group of children with asthma. As a whole, children with constipation did not manifest clinically significant general anxiety. Defecation anxiety and general anxiety were found to be positively correlated. Discussion: The results suggest that children with functional constipation have significantly more anxiety specific to toileting behavior than well children and, at least by parent report, children with asthma, without displaying significant general anxiety. Though causality cannot be inferred, the positive correlation between defecation anxiety and general anxiety underscores the importance of addressing anxiety when treating children with constipation.

Concomitant Surgical Treatment of Symptomatic Carotid Artery Disease With a Coexisting Shamblin I Carotid Body Tumor

Symptomatic carotid artery atherosclerotic disease is an indication for carotid artery endarterectomy. The coexistence of carotid body tumors (CBTs) with symptomatic carotid disease is rarely encountered and adds significant challenges to vascular surgeons, with a reported overall mortality for patients who undergo endarterectomy and tumor excision of 8.8%, as opposed to the 2% for those who had CBT excision only. We describe the case of a 79-year-old female who experienced an acute cerebrovascular accident in the left hemisphere; duplex ultrasound revealed high-grade carotid stenosis in the left side and the presence of a Shamblin I CBT. The risks and benefits of the planned operation were reviewed, and the decision was made to proceed with early carotid endarterectomy and concomitant surgical resection of the tumor using the retrocarotid dissection technique. The patient recovered well, and at 11 months from the combined procedure, her neurological deficits improved significantly.

Endovascular recanalisation of a chronic occlusion of the retrohepatic IVC associated to a filter in a patient with antiphospholipid syndrome

Inferior vena cava (IVC) filters are useful adjuncts to prevent venous thromboembolism to the pulmonary circulation in the setting of contraindication for anticoagulation. Despite their proven decreased rate of pulmonary embolism, IVC filters are not without complications. We herein present the case of a 22-year-old man with a history of antiphospholipid antibody syndrome who was sent to our institution for evaluation with Budd-Chiari and post-thrombotic syndromes associated to a chronic retrohepatic complete IVC occlusion secondary to an IVC filter placed 5 years earlier. Via common femoral, transjugular and transhepatic accesses, we performed a successful endovascular recanalisation and reconstruction of the IVC with a 16 mm×60 mm covered stent; the hepatic outflow was restored with an 8×20 mm Palmaz stent. At 12-month follow-up, his symptoms have resolved, and his liver tests are within normal limits. He remains on systemic anticoagulation.