Matthias Biebl

Wound complications in 1145 consecutive transumbilical single-incision laparoscopic procedures.

Objective:To evaluate the wound complication rate in patients undergoing transumbilical single-incision laparoscopic (SIL) surgery. Background:SIL surgery claims to be less invasive than conventional laparoscopy. Small SIL series have raised concerns toward a higher wound complication rate related to the transumbilical incision. Methods:In a 44-month period, 1145 consecutive SIL procedures were included. The outcomes were assessed according to the intention-to-treat analysis principle. All procedures were followed for a minimum of 6 months postoperatively, and wound complications were recorded as bleeding, infection (superficial/deep), or hernia. Patients were classified as having a wound complication or not. For all comparisons, significance level was set at P < 0.05. Results:Pure transumbilical SIL surgery was completed in 92.84%, and additional trocars were used in 7.16%. After a median follow-up of 22.1 (range, 7.67–41.11) months, 29 wound complications (2.53%) had occurred [bleeding 0%/infection 1.05% (superficial 0.9%/deep 0.17%)/early-onset hernia 0.09%/late-onset hernia 1.40%, respectively]. Factors associated with complications were higher patient body mass index (28.16 ± 4.73 vs 26.40 ± 4.68 kg/m2; P = 0.029), longer skin incisions (3.77 ± 1.62 vs 2.96 ± 1.06 cm; P = 0.012), and multiport SIL versus single-port SIL (8.47% vs 2.38%; P = 0.019) in complicated versus uncomplicated procedures. Furthermore, a learning curve effect was noted after 500 procedures (P = 0.015). Conclusions:With transumbilical SIL surgery, the incidence of wound complications is acceptable low and is further reduced once the learning curve has been passed.

Recipient and donor body mass index as important risk factors for delayed kidney graft function.

Background. Obesity is increasingly impacting the overall health status and the global costs for health care. The increase in body mass index (BMI) is also observed in kidney allograft recipients and deceased organ donors. Methods. In a retrospective single-center study, we analyzed 1132 deceased donor kidney grafts, transplanted at our institution between 2000 and 2009 for recipient and donor BMI and its correlation with delayed graft function (DGF). Recipients/donors were classified according to their BMI (<18.5, 18.5–24.9, 25–29.9, and >30 kg/m2). DGF was defined as requirement for one dialysis within the first week after transplantation. Results. Overall DGF rate was 32.4%, mean recipient BMI was 23.64±3.75 kg/m2, and mean donor BMI was 24.69±3.44 kg/m2. DGF rate was 25.2%, 29.8%, 40.9%, and 52.6% in recipients with BMI less than 18.5, 18.5 to 24.9, 25 to 29.9, and more than 30 kg/m2, respectively (P<0.0001). Donor BMI less than 18.5, 18.5 to 24.9, 25 to 29.9, more than 30 kg/m2 resulted in a DGF rate of 22.5%, 31.0%, 37.3%, and 51.2% (P<0.0001). Multivariate analysis revealed recipient BMI and dialysis duration as independent risk factors for DGF. DGF results in inferior 1- and 5-year graft and patient survival. Conclusion. Recipient and donor BMI correlate with the incidence of DGF. Awareness thereof should have an impact on peri- and posttransplant measures in renal transplant recipients.

Natural History of the Iliac Arteries after Endovascular Abdominal Aortic Aneurysm Repair and Suitability of Ectatic Iliac Arteries as a Distal Sealing Zone

PURPOSE To investigate the natural history of dilated common iliac arteries (CIA) exposed to pulsatile blood flow after endovascular abdominal aortic aneurysm repair (EVAR) and the suitability of ectatic iliac arteries as sealing zones using flared iliac limbs. METHODS Follow-up computed tomograms of 102 CIAs in 60 EVAR patients were investigated. Diameter changes in CIAs < or =16 mm (group 1) were compared with changes in vessels where a dilated segment >16 mm in diameter continued to be exposed to pulsatile blood flow (group 2). Within group 2, cases in which the stent terminated proximal to the dilated artery segment (2a) were compared with those that had been treated with a flared limb (2b). RESULTS The mean CIA diameter increased by 1.0+/-1.0 mm in group 1 (p<0.001 versus immediately after EVAR) and by 1.5+/-1.7 mm in group 2 (p<0.001 versus immediately after EVAR) within an average follow-up of 43.6+/-18.0 months. Diameter increase was more pronounced in dilated CIAs (p=0.048), and it was not significantly different between groups 2a and 2b (p=0.188). No late distal type I endoleak or stent-graft migration associated with CIA ectasia was observed. CONCLUSION Dilatation of the CIA is significant after EVAR, and it is more pronounced in ectatic iliac arteries. Although ectatic iliac arteries appear to be suitable sealing zones in the short term, continued follow-up is mandatory.

Long-term outcome in kidney transplant recipients over 70 years in the Eurotransplant Senior Kidney Transplant Program: a single center experience.

Background. Kidney transplantation in the elderly is complicated by comorbidities and a higher incidence of death. The Eurotransplant Senior Program (ESP) has been established to allocate kidneys from older donors to the increasing number of older recipients. In this retrospective, single center data analysis, we compare the outcome of recipients older than 70 years with younger recipients transplanted under the ESP protocol. Methods. Between 1999 and 2009, a total of 83 kidneys were transplanted under the ESP protocol in Innsbruck and 19 of the recipients were older than 70 years (mean, 72.7 years). Cold ischemia time was kept short in both groups by giving preference to regional donor organs. Results. Patient survival at 1 and 5 years were 95% and 67% in the 70+ group and 94.4% and 82.6% in the 70− group. Graft survival was 95% and 52% at 1 and 5 years in the 70+ group and 94.4% and 79.0% in the 70− group. When censored for death, graft survival at year 1 and 5 were 100% and 82% in the 70+ group and 98.1% and 92.7% in the 70− group. The delayed graft function rate was high in both groups (36.8% and 41.1%, respectively). Morbidities were largely related to hemodynamic, oncologic, and infectious events. Cardiac failure was the major cause of death. Conclusion. Relatively good results can be achieved with renal transplantation in patients older than 70 years under careful pretransplant evaluation and postoperative management of comorbidities.

Impact of gender on the outcome of endovascular aortic aneurysm repair using the Zenith stent-graft: midterm results.

PURPOSE To analyze the 2-year outcomes of female patients after endovascular aortic aneurysm repair (EVAR) with the Zenith AAA Endovascular Graft. METHODS A retrospective analysis was conducted of data from the US Zenith multicenter trial and the Zenith female registry on 40 women (10.9%, study group) and 326 men (89.1%, control group) enrolled. All patients had completed their 2-year follow-up. Primary study endpoints were survival, aneurysm rupture, and conversion rate. Significance was assumed if p<0.05. RESULTS Overall rates of mortality (12.5% for women versus 13.2% for men, p = 0.94) and aneurysm rupture (2.5% for women versus 0% for men, p = 0.11) were comparable between groups. Conversion to open repair within 2 years was significantly more frequent in women compared to men (7.5% versus 0.6%, p = 0.01). The incidence of endoleaks of any type was equivalent between groups at 2 years (13.3% for women versus 6.9% for men, p = 0.30). No difference was observed in the need for secondary interventions (15% for women versus 13.5% for men, p = 0.81) or aneurysm dilatation >5 mm (10.5% for women versus 2.3% for men, p = 0.10). None of the patients developed device migration >10 mm or required intervention for migration. CONCLUSION While women underwent conversion to open repair more frequently compared to men at 2 years post EVAR, there was no difference in survival, freedom from aneurysm rupture, or need for secondary interventions between groups. As in men, the Zenith AAA Endovascular Graft provides reliable protection from aneurysm rupture and aneurysm-related death in women in a midterm follow-up.

Evaluation of Subclinical Cerebral Injury and Neuropsychologic Function in Patients Undergoing Carotid Endarterectomy

We examined subclinical alterations of cerebral function during carotid endarterectomy (CEA) and predictability of minor cerebral damage by perioperative levels of biochemical markers of brain damage (S100B and neuron-specific enolase [NSE]). Twenty consecutive patients with > or =70% asymptomatic carotid stenosis undergoing elective CEA were enrolled. Pre- and postoperative testing included magnetic resonance imaging (MRI) of the head, a standardized neurological exam, a battery of neuropsychological tests, and measurement of serum levels of S100B and NSE. There were no major ischemic strokes. In one patient, a mild weakness of the contralateral lower extremity was discovered on neurological examination; in another individual, postoperative MRI revealed two new small subcortical lesions without clinical correlate. While S100B increased significantly early after opening of the carotid clamp (p = 0.015), the NSE increase did not reach statistical significance. As a group, participants obtained a significantly higher mean overall neuropsychological score at follow-up testing (p < 0.05). In one patient, a significant decline of cognitive function was observed. This was the only individual to obtain a consistently high S100B and NSE increase. Neuropsychological testing combined with measurements of S100B and NSE may improve sensitivity when assessing subtle cerebral damage following CEA.

Management of a Large Intraoperative Type IIIb Endoleak in a Bifurcated Endograft A Case Report

The purpose of this paper is to describe the intraoperative management of a type IIIb endoleak after deployment of a bifurcated endograft in a patient with narrow iliac access vessels. A 62-year-old man underwent elective endovascular repair (EVAR) of a 53 mm abdominal aortic aneurysm. After device deployment, a large IIIb endoleak, arising from the main body of the device, was visualized. Narrow iliac vessels precluded deployment of a second bifurcated graft, and the endoleak was successfully excluded with an aortomonoiliac device, followed by contralateral iliac occlusion and subsequent creation of a femorofemoral bypass. At 1-year follow-up, the aneurysm remains excluded and is decreasing in size. Type III endoleaks are a known complication of EVAR, requiring immediate treatment through their association with aneurysm enlargement and rupture. If an additional bifurcated graft cannot be used, aortomonoiliac conversion represents a feasible endovascular alternative treatment for type III endoleaks, other than conversion to open surgical repair. Therefore, aortomonoiliac converters with appropriate occluder devices should be readily available during deployment of bifurcated devices.

Does chronic oral anticoagulation with warfarin affect durability of endovascular aortic aneurysm exclusion in a midterm follow-up?

Purpose: To evaluate the effect of oral anticoagulation on durability of endovascular aortic aneurysm repair (EVAR). Methods: Retrospective review was conducted of 182 consecutive EVAR patients (169 men; mean age 75.3 years, range 53–89) between 1999 and 2003. Patients on warfarin anticoagulation (WA, n=21; International Normalized Ratio of 2 to 3) were compared against a control group (CG) with no postoperative anticoagulation (n=161). Death, aneurysm rupture, and reintervention were considered primary endpoints; endoleaks, endograft migration, and aneurysm remodeling were secondary endpoints. Results: Mean follow-up was 16.3±12.6 months. One-year mortality was 6.6% (9.5% WA versus 6.2% CG); overall mortality was 14.3% (p=0.414). No aneurysm rupture occurred. At 1, 2, and 3 years, respectively, cumulative reinterventions (20%/20%/20% WA versus 12%/15%/20% CG; p=0.633) and endoleak rates (25%/25%/25% WA versus 17%/22%/34% CG; p=0.649) were comparable. In both groups, most completion endoleaks resolved (42.9% WA versus 74.4% CG; p=0.474), but few de novo endoleaks did (0% WA versus 12.8% CG; p=0.538). Anticoagulation did not affect mean time to aneurysm sac shrinkage (1.3±0.3 WA versus 1.4±0.1 years CG; p=0.769). Conclusions: After EVAR, anticoagulation appears safe and does not significantly alter mortality, risk for rupture, or the incidence of reintervention. Early endoleaks appear more common in anticoagulated patients, but anticoagulation does not preclude spontaneous endoleak resolution nor does it increase late endoleak rates. Irrespective of the anticoagulation status, early but not late endoleaks usually sealed spontaneously. Observing type II endoleaks appears safe in the absence of aneurysm enlargement.

Paravertebral blockade with propofol sedation versus general anesthesia for elective endovascular abdominal aortic aneurysm repair.

The objective of this study was to evaluate the applicability of paravertebral blockade (PVB) for endovascular abdominal aortic aneurysm repair compared with general anesthesia (GA). Data from patients who underwent elective infrarenal endovascular abdominal aortic aneurysm repair between August 2001 and July 2002 using PVB or GA were retrospectively reviewed and compared with respect to risk factors, intraoperative hemodynamic characteristics, operative outcome, and complications. Ten patients underwent elective infrarenal endovascular abdominal aortic aneurysm repair under PVB, whereas 15 patients were operated on under GA. One conversion from PVB to GA was necessary for block failure. The perioperative (< 30 days) cardiovascular morbidity and overall mortality were zero in both groups. The PVB group benefited significantly with respect to the incidence of intraoperative hypotension (p < .05) and blood pressure lability (p < .01), as well as postoperative nausea (p < .01). Our preliminary results indicate that PVB is feasible and can be performed safely in a patient population with significant comorbidities.

Optimizing clinical utilization and allocation of older kidneys.

Purpose of reviewWith a persisting organ shortage and constant high discard rates, there is an urgent need to optimize the outcome and allocation of marginal grafts. Recent findingsThe Eurotransplant Senior Program was established as an ‘old-for-old’ allocation system emphasizing on the importance of keeping ischemic times short when utilizing marginal grafts. In addition to refined allocation systems, brief cold ischemic times, novel preservation techniques, a careful assessment of organ quality the utilization of dual kidney transplantation and donation after cardiac death kidneys from elderly donors may all help to increase the supply for renal transplantation. Moreover, age-adapted immunosuppression, improved patient selection and preparation for transplantation may help in improving outcomes when using marginal kidneys. SummaryThere is a significant potential to increase the utilization of marginal grafts with reduced discard rates, an increased utilization of dual kidney transplantation and the application of novel preservation methods.