Nicolas J. Mouawad

Risk factors for anastomotic leakage after colectomy.

BACKGROUND: Anastomotic leakage is a morbid and potentially fatal complication of colorectal surgery. Determination of pre- and intraoperative risk factors may identify patients requiring increased postoperative surveillance for this major complication. OBJECTIVE: The purpose of this study was to identify risk factors associated with anastomotic leakage after colectomy with primary intra-abdominal anastomosis. DESIGN: The prospective, statewide multicenter Michigan Surgical Quality Collaborative database was analyzed. SETTING: This study was performed at academic and community medical centers in the state of Michigan. PATIENTS: Included were all cases of open and laparoscopic colectomy with primary intra-abdominal anastomosis from 2007 through 2010. MAIN OUTCOME MEASURES: Univariate analysis followed by a multivariate logistic regression model was used to determine the influence of patient factors and operative events with respect to the incidence of postoperative anastomotic leakage. RESULTS: Inclusion criteria were met by 4340 cases. Anastomotic leakage occurred in 85 (3.2%) of the 2626 (60.5%) open colectomies, and in 51 (3.0%) of the 1714 (39.5%) laparoscopic procedures, which was not significantly different (p = 0.63). Significant risk factors associated with anastomotic leakage based on the multivariate logistic regression model were fecal contamination with OR 2.51, 95% CI, 1.16 to 5.45, p = 0.02; and intraoperative blood loss of more than 100 mL and 300 mL, with OR 1.62, 95% CI, 1.10 to 2.40, p = 0.02; and OR 2.22, 95% CI, 1.32 to 3.76, p = 0.003. LIMITATIONS: The Michigan Surgical Quality Collaborative colectomy project excluded high-risk rectal resections and low pelvic anastomoses. Information about operative technique and intraoperative events is limited, and anastomotic leakage was determined through chart review. CONCLUSION: Fecal contamination and increased blood loss during colectomy should raise suspicion for potential postoperative anastomotic leakage.

Construct domain analysis of patient health- related quality of life: physical and mental trajectory profiles following open versus endovascular repair of abdominal aortic aneurysm

Purpose Many clinical trials comparing the outcomes of open surgical repair (OSR) versus endovascular aneurysm repair (EVAR) for abdominal aortic aneurysms (AAAs) have been conducted, with varying results. Surprisingly, few outcomes studies have closely examined perceived physical and mental health-related quality of life (HRQOL) factors through a validated survey tool. The purpose of this prospective observational study was to describe the trajectory of HRQOL measures, from baseline to 1 year after surgery, in patients undergoing OSR or EVAR for AAA, and to explore for differences in physical and mental composite scores and their construct domains (subscales) using the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36®) tool. Patients and methods Over an 18-month period, a small sample of patients undergoing elective AAA repair in a community hospital setting were prospectively enrolled. Fifteen patients undergoing OSR and twenty patients undergoing EVAR were studied. Physical and mental HRQOL parameters were assessed using the SF-36. Results No significant differences in demographic and clinical variables were found between the OSR and EVAR groups. In the multivariable linear models with repeated measures, both groups showed a significant decline in physical health composite scores 30 days after the surgical procedure (P < 0.01). However, although the OSR group showed a statistically significant decline in three of the four physical health domains, the EVAR group declined in only one physical health domain. Only the OSR group showed a significant decline in three of the four mental health domains at 30 days; however, the decline of these domains was not reflected in the group’s mental health composite scores. By 90 days after surgery, both groups were not significantly different from their baseline in physical or mental health composite scores, or in any of their respective physical health domains. Conclusion In this small sample of patients undergoing AAA repair, EVAR resulted in less physical and emotional decline than OSR in the early postoperative period. However, patients in both groups may return to near baseline status at 90 days.

Anemia and Transfusions in Surgical Patients: Current Concepts and Future Directions

Anemia is a frequent finding during routine assessment of patients prior to elective surgery. In this setting, anemia has been demonstrated to be a risk factor for negative post-operative outcomes as well as increased intra- and postoperative transfusion requirements. nHistorically, blood products were given in abundance to surgical patients, based on liberal “transfusion triggers”, i.e. mildly decreased hemoglobin or hematocrit levels prompted the transfusion of blood. Current guidelines propose a more restrictive approach for surgical patients, reflecting the increased recognition of complications of blood products beyond hemolytic transfusion reactions and disease transmission. Transfusionrelated acute lung injury, immunosuppression, alloimmunization, and even increased recurrence of malignancies have been associated with the administration of blood transfusions, and are of particular concern in the surgical population. Restoration of homeostasis and augmentation of oxygen delivery to tissues are the most common indications to administer blood products in surgical patients; their capability to achieve these goals, however, is rather limited. nA stronger focus on preoperative optimization of elective surgical patients, including earlier detection and treatment of anemia, along with increased efforts to minimize intraoperative blood loss may be the most promising strategies to avoid the complications associated with both anemia and blood products.

Venous Anatomy, Development, and Variations

Venous developmental anatomy and embryology are fundamental to understanding venous disorders. Embryologic signaling has now been defined to establish differentiation of the circuit into arterial and venous components. The venous system is the most varied system in the human body. Clinical impact of developmental anomalies is reviewed. The currently accepted terms of venous dysfunction, anatomy, and clinical syndromes associated with congenital vascular malformations are presented.

eComment. The TEVAR App

The TEVAR App contains the TEVAR Calculator, which assists one in planning the stent graft size according to the indicated device, individual aortic dimensions and desired oversizing factors. The TEVAR Calculator user must first select a device and then choose diameters of the proximal and distal landing zones as well as oversizing factors, respectively. The TEVAR Calculator provides suggestions for one to four most appropriate stent graft sets and also the information on the minimal and true length of the overlapping zone between stent grafts and the factual proximal and distal oversizing factors.