Jamal J. Hoballah

Smoking and the Risk of Mortality and Vascular and Respiratory Events in Patients Undergoing Major Surgery

IMPORTANCE The effects of smoking on postoperative outcomes in patients undergoing major surgery are not fully established. The association between smoking and adverse postoperative outcomes has been confirmed. Whether the associations are dose dependent or restricted to patients with smoking-related disease remains to be determined. OBJECTIVE To evaluate the association between current and past smoking on the risk of postoperative mortality and vascular and respiratory events in patients undergoing major surgery. DESIGN Cohort study using the American College of Surgeons National Surgical Quality Improvement Program database. We obtained data on smoking history, perioperative risk factors, and 30-day postoperative outcomes. We assessed the effects of current and past smoking (>1 year prior) on postoperative outcomes after adjustment for potential confounders and effect mediators (eg, cardiovascular disease, chronic obstructive pulmonary disease, and cancer). We also determined whether the effects are dose dependent through analysis of pack-year quintiles. SETTING AND PARTICIPANTS A total of 607,558 adult patients undergoing major surgery in non-Veterans Affairs hospitals across the United States, Canada, Lebanon, and the United Arab Emirates during 2008 and 2009. MAIN OUTCOMES AND MEASURES The primary outcome measure was 30-day postoperative mortality; secondary outcome measures included arterial events (myocardial infarction or cerebrovascular accident), venous events (deep vein thrombosis or pulmonary embolism), and respiratory events (pneumonia, unplanned intubation, or ventilator requirement >48 hours). RESULTS The sample included 125,192 current (20.6%) and 78,763 past (13.0%) smokers. Increased odds of postoperative mortality were noted in current smokers only (odds ratio, 1.17 [95% CI, 1.10-1.24]). When we compared current and past smokers, the adjusted odds ratios were higher in the former for arterial events (1.65 [95% CI, 1.51-1.81] vs 1.20 [1.09-1.31], respectively) and respiratory events (1.45 [1.40-1.51] vs 1.13 [1.08-1.18], respectively). No effects on venous events were observed. The effects of smoking mediated through smoking-related disease were minimal. The increased adjusted odds of mortality in current smokers were evident from a smoking history of less than 10 pack-years, whereas the effects of smoking on arterial and respiratory events were incremental with increased pack-years. CONCLUSIONS AND RELEVANCE Smoking cessation at least 1 year before major surgery abolishes the increased risk of postoperative mortality and decreases the risk of arterial and respiratory events evident in current smokers. These findings should be carried forward to evaluate the value and cost-effectiveness of intervention in this setting. Our study should increase awareness of the detrimental effects of smoking-and the benefits of its cessation-on morbidity and mortality in the surgical setting.

Update on totally implantable venous access devices

The use of totally implantable venous devices (TIVAD) has changed the care and quality of life for cancer patients, these devices allow chemotherapy administration, and blood sampling without the need for repeated venipuncture. These ports are used mainly when IV access is needed only intermittently over a long period of time. We are presenting a brief overview on TIVADs, with focus on the mid and long-term complications associated with these devices with their management.

Could international medical graduates offer a solution to the surgical workforce crisis? Balancing national interest and global responsibility.

From the Department of Surgery, VA Boston Health Care System, Boston University and Harvard Medical School, Boston, MA; the Department of Surgery, American University of Beirut, Lebanon; the Department of Surgery, Tufts Medical Center and Tufts University School of Medicine, Boston, MA; the Department of Surgery, University of the Philippines College of Medicine and Philippine General Hospital, Manila, Philippines; and the Department of Surgery, Weill Cornell Medical College, New York, NY

Preoperative Pneumonia and Postoperative Venous Thrombosis: A Cohort Study of 427,656 Patients Undergoing Major General Surgery

BackgroundThe literature is sparse regarding the association between pneumonia and venous thrombosis in surgical patients. The aim of this study was to investigate the risk of postoperative venous thrombosis in patients who fit the criteria for preoperative pneumonia using data from the ongoing American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database while adjusting for potential confounders.MethodsThis is a cohort study using data from the ACS NSQIP database participating sites from 2008 (211 sites) and 2009 (237 sites). 427,656 patients undergoing major general surgery were included. The 30-day risk of postoperative venous thrombosis including deep vein thrombosis (DVT) and pulmonary embolism (PE) was evaluated in patients with preoperative pneumonia diagnosed before undergoing major general surgery.ResultsPatients with preoperative pneumonia had a higher incidence of both 30-day DVT and PE than patients without preoperative pneumonia. After adjusting for all potential confounders, the effect estimates for the association between preoperative pneumonia and venous thrombosis were DVT, OR: 1.67 (95% CI 1.32–2.11) and PE, OR: 2.18 (95% CI 1.48–3.22).ConclusionsA large, multicenter database of surgical patients showed that preoperative pneumonia may increase risk for developing venous thrombosis. This adds to our understanding of risk factors for venous thrombosis and suggests a potential benefit of diagnosing preoperative pneumonia in patients undergoing major general surgery.

Mesh-wrapping for the treatment of fractured liver-A case report.

Highlights • Liver injuries can be managed conservatively but operative management is needed once patients are hemodynamically unstable.• Peri-hepatic packing is considered a life-saving procedure in complex liver injuries; however, it is not very efficient in case of significant liver injury.• Intra-operative liver bed bleeding was initially controlled by high beam cauterization, surgicel and some Argon beam.• The liver was later wrapped with a polyester mesh with collagen barrier; the mesh was wrapped completely over the right lobe of the liver and was sutured to itself and to the diaphragm surface as well as to the falciform ligament.• Using an absorbable mesh on a traumatized and fragmented liver appears to be a safe and effective approach to high grade liver injury.

Femoropopliteal Endovascular Interventions

The treatment of peripheral arterial disease (PAD) has witnessed a remarkable evolution in the past two decades. While endovascular therapy has become well established as a primary treatment modality in aortoiliac occlusive disease, transcatheter treatment of infrainguinal occlusive disease remains controversial. The availability of a wide range of therapeutic options and devices applicable to infrainguinal interventions has resulted in a dramatic increase in the number of peripheral endovascular procedures over the past decade, with a staggering reported 979 % growth in peripheral vascular interventions reported since 1995. Despite this remarkable growth and increasing acceptance, many questions remain unanswered regarding the indications, choice of device/technique, clinical efficacy, long-term outcome, and cost-effectiveness of the available competing modalities. These decisions are also compounded by intense and often conflicting marketing efforts by the industry in the current competitive market. With the scarcity of randomized controlled trials, much of the published reports for newer endovascular technologies rely primarily on immediate angiographic outcomes and target limb revascularization (TLR) data. The following text is meant to provide an overview over current treatment options, technologies, and devices based on available evidence and the experience and opinions of the authors. The endovascular surgeon must be familiar with all the available treatments for PAD in order to continue to manage these patients amidst the increasingly complex health-care environment.

Internal Iliac Artery Embolisation

Internal iliac artery embolization is performed for patients with common iliac aneurysm extending to the iliac bifurcation who are going to be treated with endovascular repair. The embolization allows for extension of the graft into the external iliac and eliminates the potential for type II endoleak through the internal iliac artery. Iliac branch devices are now available to preserve the internal iliac artery. Nevertheless, internal iliac artery embolization may still be performed. This chapter describes indications, essential steps, variations, and complications of this procedure. It provides a detailed template operative note for the procedure.

Superior Vena Cava Syndrome

Superior vena cava (SVC) syndrome is a debilitating condition related to a variety of benign and malignant processes causing intrisinc or extrinsic compression of the SVC. Patients typically present with facial swelling, shortness of breath, and headache related to venous hypertension in the upper body. Endovascular therapy is effective and considered first line therapy. Open reconstruction is needed in conjuction with oncological resection or when endovascular therapy fails. This chapter summarizes the evaluation and treatment of patients with SVC syndrome.

Comparing the 30-Day Risk of Venous Thromboembolism and Bleeding in Simultaneous Bilateral vs Unilateral Total Knee Arthroplasty

BACKGROUND Simultaneous bilateral total knee arthroplasty (SBTKA) may offer certain benefits; however, its overall safety is still disputed. This study aimed at comparing the risk of thromboembolism and bleeding in patients who underwent SBTKA vs unilateral total knee arthroplasty (TKA). METHODS The American College of Surgeons National Surgical Quality Improvement Program database from 2008 to 2015 was used to investigate the short-term postoperative complications and their risk factors following SBTKA as compared to unilateral TKA. Demographics, comorbidities, and 30-day outcomes were analyzed. Complications with an increased incidence following SBTKA were stratified to identify subgroups of patients at high risk. RESULTS A total of 155,022 patients were identified, of which 150,581 underwent unilateral TKA and 4441 underwent SBTKA. The SBTKA group was found to be at a higher risk of venous thromboembolism (VTE), bleeding, and composite morbidity. Stratification analysis revealed that SBTKA subgroups at higher risk of VTE include patients of black or Asian origin, obese patients, and those who underwent anesthesia other than general or spinal/epidural. SBTKA subgroups at higher risk of bleeding include patients older than 85 years, those with race other than white, underweight and obese patients, and patients who underwent anesthesia other than spinal/epidural. Although none of the subgroups were protected from bleeding, patients who underwent spinal/epidural anesthesia had a lower risk of bleeding compared to other types of anesthesia. CONCLUSION SBTKA confers an increased risk of postoperative VTE, bleeding, and composite morbidity at 30 days, with no increase in mortality.

Ultrasound-Guided Placement of an Internal Jugular Tunneled Cuffed Dialysis Catheter

Tunneled cuffed catheters are inserted in patients with chronic renal failure expected to need dialysis for more than 2–3 weeks. This chapter describes indications, essential steps, variations, and complications of this procedure. It provides a detailed template operative note for the procedure.