Mark E. O’Donnell

Malignant neoplasms of the appendix

BackgroundAppendiceal neoplasms, first described in 1882, are still rare, with pre-operative diagnosis invariably difficult. We present our 10-year experience of these lesions with a review of current epidemiology, pathology and treatment modalities.Materials and methodsA retrospective histopathological review of all appendicectomy specimens was completed between April 1994 and December 2003 to identify patients diagnosed with malignant neoplasms. Patient demographics, operative details, histopathology and clinical outcomes were obtained from case notes. A literature search of the PubMed database was then performed using the medical search headings; appendix, tumour, neoplasm and malignancy.ResultsTwenty-two patients (eight men) were identified during the study period, with no age difference between gender (mean age in women 58, range 14–83 vs mean age in men 55, range 16–78). Eleven patients were found to have carcinoid-type tumours, eight patients with adenocarcinomas and three patients with lymphomas. Other appendiceal pathologies were identified after appendicectomies, hemicolectomy and oophorectomy. Mean follow-up was 41xa0months (range 1–125xa0months). Fourteen patients were alive at the end of follow-up. Patients with classical carcinoid tumours (CCT) had better outcomes than patients with the goblet cell carcinoid, adenocarcinoma and lymphoma.ConclusionsFrom our own experience and a subsequent review of the literature, we recommend right hemicolectomy as the treatment of choice for all malignant appendiceal neoplasms, except for small CCT less than 2xa0cm in diameter at the tip of the appendix, with a low proliferative index, without angiolymphatic or mesoappendiceal extension. Further adjuvant therapy should be considered after oncological assessment.

Benefits of a Supervised Exercise Program After Lower Limb Bypass Surgery

This study evaluated the efficacy of an exercise program after arterial bypass surgery. Patients undergoing bypass surgery were randomized to a control group (group I), with standard preoperative and postoperative care, or the intervention group (group II) with a supervised exercise program of twice-weekly treadmill assessments from 4 to 10 weeks postoperatively. Ankle-brachial pressure indices and hemodynamic measurements were recorded before and after exercise. The mean increase of maximum walking distance was 3.8% in group I and 175.4% in group II (P = .001). There was a significant difference between group I and II in the mean ankle-brachial pressure indices increase at the second assessment (0.08 versus 0.23; P = .02). A supervised exercise program leads to better improvement after lower limb bypass surgery for ischemia, but the feasibility of a formal exercise program would be undermined by the reluctance of patients to participate, both in the short-term and long-term.

Portomesenteric venous thrombosis following major colon and rectal surgery: incidence and risk factors

BackgroundPortomesenteric venous thrombosis (PMVT) is an uncommon complication of abdominal surgery. The objective of this study was to assess PMVT risk factor profiles and patient outcomes after colorectal surgery.MethodsA single center retrospective review of patients undergoing colorectal surgery was performed (2007–2012). PMVT was defined as thrombus within the portal, splenic, or superior mesenteric vein on computed tomography (CT). Inferior mesenteric vein thrombosis was excluded. Independent samples t test was used to compare data variables between PMVT and non-PMVT patients. Univariate and multivariate logistic regression analyses were used to assess PMVT risk factors.ResultsThere were 1,224 patients included (mean age 62xa0years, malexa0=xa0566). Elective bowel resection was performed for colon carcinoma (nxa0=xa0302), rectal carcinoma (nxa0=xa0112), ulcerative colitis (nxa0=xa0125), Crohn’s disease (nxa0=xa078), polyps (nxa0=xa0117), and diverticulitis (nxa0=xa0215). Patients undergoing gynecological resections and emergent laparotomies were included (nxa0=xa0275). Thirty-six patients (3xa0%) were diagnosed with PMVT by CT: 17/36 on initial presentation and 19/36 by expert radiologist review. Patients with PMVT were younger (53 vs. 62xa0years, pxa0=xa00.001) with higher BMI (30.5 vs. 26.7, pxa0<xa00.001) and thrombocytosis (464 vs. 306, pxa0<xa00.001) compared to patients without PMVT. Univariate logistic regression identified younger age (pxa0<xa00.001), obesity (pxa0<xa00.001), ulcerative colitis (pxa0<xa00.001), thrombocytosis, (pxa0<xa00.001) and proctocolectomy as significant predictors of PMVT. Stepwise multivariate logistic regression identified that obesity (pxa0<xa00.001), thrombocytosis, (pxa0<xa00.001) and restorative proctocolectomy (pxa0=xa00.001) were still significant predictors. No patients in the PMVT group suffered bowel infarction and no related mortalities occurred. Thirty-day readmission rates were higher in the PMVT group (53xa0% vs. 17xa0%, pxa0<xa00.01).ConclusionBMIxa0≥xa030xa0kg/m2, thrombocytosis, and restorative proctocolectomy were significant predictors of PMVT. Initial diagnostic studies showed a PMVT rate of 1.4xa0%; however, after expert focused radiologic review, the actual rate was 3xa0%. Thus, the diagnosis of PMVT is difficult and readmission after colorectal surgery should prompt its consideration.

Bilateral Pulmonary Emboli Secondary to Indwelling Hemodialysis Reliable Outflow Catheter

We present a 33-year-old dialysis-dependent female who presented with new onset split second heart sound. Following a failed left upper extremity dialysis fistula, a right upper extremity hemodialysis reliable outflow (HeRO) graft was performed in 2011. Her subsequent cadaveric renal transplant had delayed function necessitating concurrent use of hemodialysis. However, as renal function improved, hemodialysis was discontinued. Two weeks following transplantation, the HeRO graft occluded. Subsequent clinical and radiological assessment confirmed widespread pulmonary emboli. Following cessation of hemodialysis and subsequent HeRO graft occlusion, removal was deemed appropriate to reduce further thromboembolic phenomenon. Right atrial thrombi are complications associated with central venous catheters. However, their actual incidence varies significantly. Right heart thromboemboli are associated with a 4% to 6% pulmonary embolism rate. Katzman et al assessed 38 patients who underwent HeRO graft and reported 1 (2.6%) patient with right atrial emboli and likely pulmonary embolism. Although thrombotic complications remain rare, consideration of graft removal should always be evaluated particularly in the absence of an alternative thrombotic source.

Thymic Flap for Bronchial Stump Reinforcement After Lobectomy

Buttressing of the bronchial stump after pulmonary resection has been reported to decrease the prevalence of bronchopleural fistula. This adjuvant maneuver is most commonly performed in patients undergoing resection for infection or in those who have received preoperative radiation. The anatomic location of the upper lobe bronchus often makes it difficult to create a tension-free flap using muscle or pericardial fat. Parietal pleura is often mobilized for such cases. We present a case in which the parietal pleura was not available, and the right inferior pole of the thymus was used for bronchial coverage following upper lobectomy.

Minimally invasive treatment for breast cancer metastasis to the esophagus

Results A sixty-two year-old female presented in May 2009 with an eighteen-month history of dysphagia due to a chronic benign esophageal structure, presumed secondary to previous radiotherapy treatment for breast cancer. She complained of occasional heartburn, indigestion and cough and described a 60lbs weight loss due to tolerance of a liquid only diet. She had a fifteen-year smoking history. She had been undergoing monthly esophageal dilatations over the previous six-months. Multiple previous esophageal biopsies were benign. Clinical assessment was unremarkable. Endoscopic ultrasound demonstrated a tight fibrotic stricture at 26cm.Additional biopsies were again negative for malignancy. She was referred for MIE surgical resection. After creation of the pneumoperitoneum and insertion of four trocars, the short gastric vessels were divided followed by mobilisation of the gastric fundus with preservation of the gastroepiploic artery. High mediastinal dissection was performed to mobilize the esophagus followed by a chemical pyloromyotomy. A mini-right posterior-lateral thoracotomy identified a small caliber esophagus which was dissected free of right bronchial adhesions. The esophagus was subsequently divided proximally and distally followed by a stapled anastomosis. Histopathological analysis confirmed an invasive adenocarcinoma consistent with a breast primary. She remains well four-years post-surgery. Unfortunately, in advanced cases, therapeutic interventional strategies tend to target symptomatic palliation rather than curative resection. Conventional open esophagectomy involves a myriad of incisions depending on the tumour site. These incisions create significant patient morbidity.MIE surgery has evolved to minimise patient morbidity compared to conventional open techniques. Shorter operative times without the need to reposition the patient is cost-effective, whilst preservation of the latisimus dorsi muscle may reduce post-operative pain and improve overall quality of life (QOL) post operatively. The four laparoscopic port sites provide adequate abdominal exposure whilst the mini-thoracotomy facilitates esophageal mobilisation and division. Higher physical function index scores have been reported twenty-four weeks following MIE surgery compared to conventional open surgeries.

The thymic flap for bronchial stump reinforcement following lobectomy

Results A sixty-one year old male presented with a one-day history of severe left chest pain and a five-week history of a nonproductive cough. He had a history of multiple bilateral rib fractures following a motor vehicle accident. He was an exsmoker with no previous asbestos exposure. His respiratory rate was 22/minute with room air oxygen saturation of 95%. He had absent left basal breath sounds. Blood tests were normal. An erect chest x-ray revealed a left sided pleural effusion and a 2.6cm right upper lobe mass, confirmed with CT imaging..Although bronchoscopy and thoracocentesis were negative for malignancy, transbronchial endoscopic ultrasound needle aspiration of station 4R lymph nodes reported non-small cell lung carcinoma (T1B,M0,N2). He responded to neoadjunctive chemoradiotherapy. Follow-up PET/CT imaging showed a reduction in the apical mass to 2.2cm. Right upper lobectomy was performed via a 5th ribspace posterolateral thoracotomy where a solitary malignant intrapulmonary peribronchial lymph was identified. Due to extensive pleural adhesions from previous rib fractures, the right inferior tip of the thymus was mobilized from the pericardium and retrosternal attachments and used to secure the bronchial stump. The patient remains well following an uneventful recovery. Post-lobectomy bronchopleural fistula remains a rare and serious complication with an incidence rate between 0.5%-0.99% [2]. Persistent empyemas necessitating open drainage and prolonged hospitalization contribute to a high mortality rate ranging from 25%67% [2]. A reduction in complications had been reported with the incorporation of pleural,diaphragmatic, intercostal and azygous vein bronchial stump reinforcements [1]. In our case, the thymic flap was mobilized due to inability to successfully dissect the parietal pleura. Infante et al (2004) evaluated the protection of right pneumonectomy bronchial sutures with a pedicled thymus flap where 82% (27/33) of cases had a satisfactory thymic inferior pole length [3].

Percutaneous Thrombolysis of Acute-On-Chronic Inferior Vena Cava Thrombosis After Previous Insertion of an Adams-DeWeese Clip

We describe the successful percutaneous treatment of acute-on-chronic IVC thrombosis 30 years following previous placement of Adams-DeWeese clip.

Successful Coil Embolization of Circumflex Iliac Artery Pseudoaneurysms Following Paracentesis

Abdominal paracentesis complicated by perforation of a penetrating arterial branch is an extremely rare complication. We report 2 patients who presented with abdominal wall pseudoaneurysms following abdominal paracentesis for the evaluation and treatment of their hepatic dysfunction. We subsequently review the treatment modalities and interventions performed in each case.

Successful Percutaneous Management of Ruptured Middle Colic Aneurysm Following Endovascular Aneurysm Repair

A 56-year-old male with end-stage renal failure secondary to hypertension was admitted for endovascular repair of an asymptomatic right common iliac aneurysm that had been identified intraoperatively during his renal transplant via a right retroperitoneal incision. Computed tomography (CT) angiography confirmed a 6.2-cm right common iliac aneurysm. Following bilateral vertical groin incisions to access the common femoral arteries, the patient proceeded to embolization of the right internal iliac artery using a 22-mm Amplatzer II plug. A bifurcated Zenith Flex abdominal aortic aneurysm endovascular stent was successfully deployed followed by the contralateral limb and then bilateral iliac extensions. Completion angiogram demonstrated successful exclusion of the right internal iliac artery and a late type II endoleak from the inferior mesenteric artery (IMA). The patient was discharged home the following day but represented later that day to our emergency department following a syncopal episode with increased abdominal pain. The CT angiography revealed a left upper quadrant intraperitoneal hematoma with evidence of active contrast extravasation (Figure 1). The endograft was stable. Mesenteric angiography identified a 3-mm pseudoaneurysm arising from a branch of the splenic artery that was embolized. However, subsequent superior mesenteric angiography identified a larger pseudoaneurysm with active contrast extravasation at the junction of the middle colic artery and ascending branch of the IMA (Figure 2). Microcatheter access, because of tortuosity, facilitated coil embolization (Figure 3). Completion angiography confirmed arterial occlusion. He was discharged home on day 4. Six weeks later, he was treated for Klebsiella urinary sepsis where CT angiogram demonstrated a hematoma in the left upper quadrant, with no evidence of contrast extravasation. A percutaneous drain was inserted and bacteriological cultures identified Klebsiella. He completed a 2-week course of intravenous cetriaxone followed by oral ciprofloxacin. He showed continued improvement clinically. Endovascular aneurysm repair (EVAR) is an established treatment modality with a lower perioperative blood loss Division of Vascular and Endovascular Surgery, Mayo Clinic, Phoenix, AZ, USA DivisionofVascular and Interventional Radiology,MayoClinic, Phoenix,AZ, USA