Jason Faulds

Planned ilioinguinal nerve excision for prevention of chronic pain after inguinal hernia repair: a meta-analysis.

BACKGROUND Inguinal hernia repair is a common operative procedure, but the development of chronic postoperative pain is a dreaded potential complication. The role of neurectomy in decreasing the incidence of chronic pain after inguinal hernia repair is currently unknown. Our objective was to determine whether a planned ilioinguinal nerve excision results in a decrease in the development of chronic pain experienced after inguinal hernia repair. METHODS A systematic literature review was carried out to identify studies investigating the influence of ilioinguinal nerve excision on the development of chronic pain after inguinal hernia repair. A quantitative analysis of the pooled data was carried out. RESULTS Of 6,023 abstracts reviewed, 4 high-quality, randomized-controlled trials were identified. The pooled mean difference in degree of pain at 6 months postoperatively on a 10-point scale was -0.29 (95% confidence interval: -0.48 to -0.11), favoring neurectomy to decrease the chance of developing chronic pain. Not surprisingly, those individuals undergoing neurectomy were also more likely to develop altered sensation at the same time point (odds ratio: 3.70, 95% confidence interval: 2.61-5.25). CONCLUSION A planned resection of the ilioinguinal nerve at the time of inguinal hernia repair is associated with a decrease in the incidence of chronic postoperative pain. Thus, carrying out this simple maneuver at the time of operation might decrease a major source of postoperative patient morbidity.

Hepatic Artery Transection Reconstructed With Splenic Artery Transposition Graft

INTRODUCTION Hepatic artery transection presents a technical challenge in vascular reconstruction. Formal arterial repair is indicated in patients with underlying liver disease and those undergoing bile duct reconstructions because of a higher risk of complication following hepatic artery injury. This report highlights a novel approach to hepatic artery transection with splenic artery transposition. METHODS A case of hepatic artery transection repaired with splenic artery transposition is presented with an accompanying literature review. RESULTS During elective pancreaticoduodenectomy, the common hepatic artery was injured at its origin. The splenic artery was divided and transposed to the hepatic artery, thus restoring arterial flow to the liver and bile duct. CONCLUSION Various strategies to manage a hepatic artery injury have been described, ranging from ligation to complex vascular reconstruction. In hemodynamically stable patients, arterial transposition using the splenic artery is a feasible method to ensure adequate arterial supply to the liver and biliary tract.

Technical Report of a Novel Surgical Technique: Laparoscopic Cyst Fenestration and Falciform Ligament Pedicle Graft for Treatment of Symptomatic Simple Hepatic Cysts

BACKGROUND Simple hepatic cysts are common and infrequently develop into large symptomatic cysts that require surgical therapy. These benign cysts have been shown to be amenable to minimally invasive surgery; however, recurrences of symptoms have been reported. Our experience with over 200 simple hepatic cysts has lead to the development of a novel therapy to resolve symptoms associated with large simple hepatic cysts and reduce the rate of recurrent symptoms. METHODS An observational study demonstrating our experience with a novel minimally invasive technique for the management of symptomatic simple hepatic cyst. RESULTS A total of 6 cases were identified where laparoscopic mini-fenestration and placement of a falciform pedicle graft was used. There were no operative complications and 4 of 6 patients were discharged home the day of surgery. With mean follow-up of 9.6 months, there has not been any recurrence to date. One patient required an open hepatic resection for the treatment of a cystadenoma. CONCLUSION Laparoscopic mini-fenestration and placement of a falciform ligament pedicle graft shows promising early results as a treatment for the simple hepatic cyst. Long term follow-up data is required.

An age-based comparison of fistula location, patency, and maturation for elderly renal failure patients

Objective: Current Kidney Disease Outcomes Quality Initiative guidelines do not incorporate age in determining autogenous arteriovenous hemodialysis access placement, and the optimal initial configuration in elderly patients remains controversial. We compared patency, maturation, survival, and complications between several age cohorts (<65 years, 65‐79 years, >80 years) to determine whether protocols should be modified to account for advanced age. Methods: All patients at two teaching hospitals undergoing a first autogenous arteriovenous access creation in either arm between 2007 and 2013 were retrospectively analyzed from a prospectively maintained database. Kaplan‐Meier survival and Cox hazards models were used to compare access patency and risk factors for failure. Results: There were 941 autogenous arteriovenous accesses (median follow‐up, 23 months; range, 0‐89 months) eligible for inclusion; 152 (15.3%) accesses were created in those >80 years, 397 (42.2%) in those 65 to 79 years, and 392 (41.8%) in those <65 years. Primary patencies in patients >80 years, 65 to 79 years, and <65 years were 40% ± 4%, 38% ± 3%, and 51% ± 3% at 12 months and 12% ± 5%, 13% ± 3%, and 27% ± 3% at 36 months (P < .001). Primary assisted patencies were 72% ± 4%, 70% ± 2%, and 78% ± 2% at 12 months and 52% ± 5%, 52% ± 3%, and 67% ± 3% at 36 months (P < .001). Secondary patencies were 72% ± 4%, 71% ± 2%, and 79% ± 2% at 12 months and 54% ± 5%, 55% ± 3%, and 72% ± 3% at 36 months (P < .001). Radiocephalic patencies were lowest among older cohorts; in those >80 years, 65 to 79 years, and <65 years, they were 65% ± 7%, 67% ± 4%, and 77% ± 3% at 12 months and 41% ± 8%, 51% ± 5%, and 68% ± 4% at 36 months (P = .019). Secondary brachiocephalic access patencies in these cohorts were 78% ± 5%, 80% ± 3%, and 82% ± 3% at 12 months and 68% ± 7%, 66% ± 5%, and 77% ± 4% at 36 months (P = .206). Both the age groups 65 to 79 years and >80 years demonstrated superior brachiocephalic vs radiocephalic secondary patencies (P = .048 and P = .015, respectively); however, no differences between configuration and secondary patency were observed within the cohort <65 years. Radiocephalic access maturation failure at 12 and 24 months was 25% ± 3% and 29% ± 4% in those <65 years, 32% ± 3% and 39% ± 4% in those 65 to 79 years, and 40% ± 7% and 48% ± 8% in those >80 years (P = .006). Brachiocephalic access maturation failures were 17% ± 3% and 20% ± 3% at 12 and 24 months in those <65 years, 21% ± 3% and 25% ± 4% in those 65 to 79 years, and 18% ± 5% and 21% ± 5% in those >80 years (P = .740). On multivariate analysis, coronary disease, female sex, previous ipsilateral or bilateral catheters, radiocephalic configuration, and age >65 years were associated with secondary patency loss. Conclusions: Patients aged 65 to 79 years and >80 years had inferior primary, primary assisted, and secondary patency and maturation compared with those <65 years. When stratified by configuration, radiocephalic accesses demonstrated lower patency and maturation compared with brachiocephalic accesses for patients aged 65 to 79 years and >80 years and were an independent predictor of secondary patency loss.

Fifty-Liter Blood Loss Without a Single Blood Transfusion: Report of Rapid Recirculation of Unprocessed Blood in Emergency Thoracic Aortic Surgery

amputation, limb ischemia, and compartment syndrome. Factors that influenced diagnosis and incidence of these complications were also evaluated. Methods: We reviewed all patients undergoing peripheral VA ECMO since the inception of routine placement of an antegrade distal perfusion catheter. Data collected included patient demographics, indication for VA ECMO, ECMO cannula size, ECMO flow rates, pH and regional perfusion oxygen saturation, and serum creatine kinase values. Patients were evaluated for vascular complications including compartment syndrome, minor and major amputation, bleeding or arterial injury requiring intervention before decannulation, and wound complications. Results: Between January 2012 and December 2014, 68 adult patients were placed on VA ECMO with a downstream antegrade perfusion catheter. Twenty-nine patients (42%) developed vascular complications, most of which were bleeding at access site (nine) or wound complications (nine). Five patients (7.4%) developed compartment syndrome requiring emergent dermatofasciotomy. Six patients (8.8%) required major amputation, with one additional patient requiring multiple toe amputations. Indication for ECMO, ECMO cannula size, ECMO flow rates, pH, and initial serum creatine kinase levels were not predictive of either compartment syndrome or amputation. Average regional perfusion oxygen saturation was significantly reduced in patients with compartment syndrome or ultimately requiring amputation (42 vs 70; P 1⁄4 .013). Conclusions: The percentage of patients who develop compartment syndrome or require amputation after initiation of peripheral VA ECMO remains high despite routine placement of downstream antegrade arterial perfusion catheters. Regional oxygen saturation markers are an excellent indicator of arterial insufficiency and may guide early management to prevent these complications.

Endovascular Repair of Extent II-IV Thoracoabdominal Aortic Aneurysms

Two type II endoleaks were present but did not require reintervention. The composite outcome was achieved in 83% of cases (5 of 6). Conclusions: Off-the-shelf bifurcated-bifurcated aneurysm repairs for aortoiliac aneurysm disease can be safely and efficiently performed in a majority of cases to maintain IIA perfusion and to avoid pelvic ischemic complications. Attention should be directed at purpose-built bridging stents for the general purpose of branch vessel preservation. Comparison to historical controls with IIA embolization is warranted.

Standard Thoracic Endovascular Aortic Repair Compared With Provisional Extension to Induce Complete Attachment in Aortic Dissection

Objective: We compared the management of patients with symptomatic, unruptured aortic aneurysms (sxAAAs) treated at a tertiary care center between two decades. This 20-year period encapsulated a shift in surgical approach to aortic aneurysms from primarily open to primarily endovascular, and we sought to determine the impact, if any, of this shift. Methods: A consecutive 2380 patients treated at a tertiary care hospital by six staff surgeons were reviewed between 1995 and 2005 (period 1) and 2005 and 2015 (period 2). Of those patients, 156 (6.5%) were treated for sxAAAs and were included in our study. Patient demographics, operative approach, and outcomes were analyzed and compared for each period. Results: Period 1 included 72 patients treated for sxAAA (80.6% infrarenal, 15.3% juxtarenal, 2.8% thoracic aortic aneurysm type IV, and 1.8% endoleak after endovascular aneurysm repair); 70.8% of patients were treated with open repair, and 29.2% were treated with an endovascular repair. Period 1 patients had an average age of 74.9 6 9.4 years and were made up of 63.9% men. In-hospital mortality during this period was 4.2% (5.9% for open cohort and 0% for endovascular). Period 2 included 84 patients treated for sxAAA (72.6% infrarenal, 15.5% juxtarenal, 7.1% thoracic aortic aneurysm type IV, and 4.8% endoleak after endovascular aneurysm repair); 32.1% were treated with open repair, and 67.9% underwent endovascular repair. The average age in this cohort was 73.0 6 9.8 years, and 76.2% were men. In-hospital mortality was 1.2% (3.7% for open cohort and 0% for endovascular). Period 2 had a significantly higher rate of endovascular repair compared with period 1 (P < .0001) and a trend toward decreased mortality and increased aneurysm complexity. The length of hospital stay was significantly longer in the open cohort compared with endovascular for both periods (P < .02). Conclusions: To our knowledge, this is the largest singleinstitution cohort of symptomatic unruptured aortic aneurysms. As to be expected, we found a significant change in the approach to these patients from a primarily open to a primarily endovascular technique between decades, associated with decreased mortality and increased operative complexity. Overall, however, the incidence and mortality for both periods appear to be lower than previously published. Standard Thoracic Endovascular Aortic Repair Compared With Provisional Extension to Induce Complete Attachment in Aortic Dissection Kyle Arsenault, MD, Darren Klass, MD, Joel Price, Michael Janusz, Joel Gagnon, Jerry Chen, Jason Faulds. Vascular Surgery, University of British Columbia, Vancouver, British Columbia, Canada; University of British Columbia, Vancouver, British Columbia, Canada