Spyros Papadoulas

Prospective evaluation of biliopancreatic diversion with Roux-en-Y gastric bypass in the super obese

The aim of this study was to determine prospectively the efficacy and safety of the biliopancreatic diversion with Roux-en-Y gastric bypass (BPD with RYGBP) procedure used as the primary bariatric procedure in super obese patients. The main characteristics of the BPD with RYGBP procedure were a gastric pouch of 15 ± 5 ml, biliopancreatic limb of 200 cm, common limb of 100 cm, and alimentary limb of the remainder of the small intestine. From June 1994 through July 2003, 132 super obese patients (body mass index [BMI]: 57 ± 7), with an incidence of comorbidities 6 ± 2 per patient, underwent BPD with RYGBP and subsequent follow-up. Mean follow-up time was 29 ± 14 months. Maximum weight loss was achieved at 18 months postoperative with average excess weight loss (EWL) 65%, average initial weight loss (IWL) 39%, and average BMI 35 kg/m2. Thereafter, a decline was observed with EWL stabilizing at around 50%, IWL at around 30%, and BMI at around 40 kg/m2, respectively, by the end of the study period. The majority of preexisting comorbidities were permanently resolved by the 6-month follow-up visit. Early mortality was 1% and early morbidity was 11%. Late morbidity was 27%, half of which was due to incisional hernia. Deficiencies of microelements were mild and successfully treated with additional oral supplementation. The incidence of hypoalbuminemia was 3% and there were no hepatic complications. We conclude that BPD with RYGBP is a safe and effective procedure for the super obese with few metabolic complications.

Endovascular Management of Arterioenteric Fistulas: A Systemic Review and Meta-Analysis of the Literature

Purpose: To present a systemic review and meta-analysis investigating the outcomes of endovascular management of arterioenteric fistula (AEF). Methods: Literature review on AEF management with endovascular surgery using MEDLINE search, including two cases managed by the authors. Results: Fifty-nine patients (50 men; mean age 68 years, range 23–90) were identified. AEF was successfully managed in 55 (93%) patients and 30-day mortality was 8.5% (5/59). During follow-up, 10 (19%) patients developed recurrent bleeding, which occurred more often in AEFs due to cancer. The freedom from recurrence rate at 12 and 24 months was 71.5%. Seventeen (32%) patients developed sepsis, which was managed conservatively in 8 (7 successful). Freedom from sepsis at 12 and 24 months was 64%, while the freedom from combined recurrence and sepsis at 12 and 24 months was 59%. Patients who did not have intestinal repair had a higher rate of combined recurrence and sepsis compared to patients who did; the freedom from combined recurrence and sepsis at 12 months was 52% for patients not having intestinal repair versus 100% in patients who did (p=0.022). Total AEF-related mortality rates at 12 and 24 months were 15% and 19%, respectively, significantly worse when AEF recurred (p=0.001). Overall survival rates at 12 and 24 months were 68% and 52%; prognosis was worse in patients with perioperative sepsis, large bowel fistulization, tube graft placement, no intestinal repair, and recurrent AEF. Conclusion: Endovascular management of AEF can achieve satisfactory short and midterm results, better than those historically reported for open surgery, despite the high rate of recurrent bleeding and sepsis. Further investigation of the role played by intestinal repair is warranted.

Seasonal variation in the incidence of superficial venous thrombophlebitis

INTRODUCTION Previous studies have demonstrated an increased frequency and severity of symptoms due to varicose veins during summer. However there is no data on their complications, including superficial venous thrombophlebitis (SVT). The aim of this study was to test the hypothesis that SVT follows a seasonal pattern. MATERIALS AND METHODS During the two-year period between January 2007 and December 2008, inclusive, 123 patients with SVT were evaluated, including 60 females and 63 males. In 8 patients (6.5%) an additional and/or other predisposing factor was present. On presentation, SVT was complicated by thrombus extension to the proximal deep system in 5 cases (4.1%); above-knee SVT was present in 4 of these 5 cases. RESULTS SVT occurred more often during the months of May through October (monthly incidence of 7.3 cases) compared to remaining of the year (monthly incidence of 2.9 cases). SVT showed a peak in June and July with 33.3% of all SVTs occurring during these two months (monthly incidence of 10.25 cases). Using time-series statistics SVT occurrence showed a periodical seasonal pattern (p=0.003). Although a seasonal pattern was evident in all patient subgroups, this was significant only in males and patients with below-knee SVT. CONCLUSIONS SVT showed a clear seasonal pattern of occurrence, with a significant rise during summer time. Although a possible explanation of this observation could be poor patient compliance and suboptimal usage of elastic stockings during the hot Mediterranean summer, further studies to investigate the cause, clinical significance and preventive methods of this complication are justified.

Mycotic aneurysm of the internal carotid artery presenting with multiple cerebral septic emboli.

Mycotic aneurysms of the extracranial carotid artery are uncommon and always warrant surgical treatment to prevent eventual rupture and death. Septic embolization to the brain is an even rarer complication of these aneurysms. We present a case of a 79-year-old male with an extracranial internal carotid artery mycotic aneurysm during Staphylococcus aureus bacteremia. He presented with hemiparesis owing to brain embolism from multiple septic emboli originating from the aneurysm. Multidetector computed tomographic angiography contributed to the diagnosis. Resection of the aneurysm and restoration of arterial supply to the brain by vein graft interpositioning was the therapeutic procedure along with long-term antibiotic treatment. A high index of suspicion is required for the diagnosis of a mycotic carotid aneurysm and aggressive treatment is always needed to prevent lethal complications.

Randomized controlled trial comparing primary and staged basilic vein transposition

Objective It is unclear if brachio-basilic vein fistula should be performed as a primary or staged procedure, particularly for smaller basilic veins. Our aim was to report on a randomized controlled trial comparing these two techniques. Methods Sixteen patients with a basilic vein ≥2.5 mm were randomized into primary transposed brachio-basilic vein (TBBV) fistula (n = 9) and staged TBBV fistula (n = 7). Patients with basilic veins enlarged by previous arteriovenous fistulas were excluded. Baseline characteristics of the two study groups, including vein size, were comparable (median basilic vein diameter 3.5 mm, range 2.8–4.1 mm). The staged group had a brachio-basilic vein fistula performed first followed by the transposition procedure performed at least 6 weeks later to allow the basilic vein to enlarge. TBBV fistula maturation at 10 weeks, primary, assisted-primary, and secondary patency were the primary outcome measures. Early failures were included in the calculation of patency rates. Results Transposed brachio-basilic vein fistula maturation rate after primary procedures (3/9, 33%) was lower compared to maturation rate after staged procedures (7/7, 100%, P = 0.011, Fisher’s exact test), which led to premature termination of the trial. Time to hemodialysis [median (interquartile range)] of primary and staged procedures was 54 (51.5–113.5) days and 97 (93–126) days, respectively (P = 0.16). One-year primary and assisted-primary patency rates of primary and staged procedures were equivalent (44 vs 57%, P = 0.76 and 44 vs 71%, P = 0.29, respectively); however, there was a trend toward a better 1-year secondary patency after staged procedures (86 vs 44% for primary procedures, P = 0.09). Conclusions Among candidates for TBBV fistula with a small basilic vein, staged transposition achieves higher maturation rates compared to primary procedures, a difference reflected in long-term secondary patency. Trial registration www.ClinicalTrials.gov, identifier NCT01274117.

Open Versus Endovascular Repair of Inflammatory Abdominal Aortic Aneurysms A Comparative Study and Meta-Analysis of the Literature

Objectives: Open surgical repair (OSR) of inflammatory abdominal aortic aneurysms (IAAAs) can have significant morbidity. The aim of the present investigation was to compare IAAA outcome after OSR and endovascular aneurysm repair (EVAR) and perform a meta-analysis of the literature. Methods: Twenty-seven patients with an intact IAAA operated on during a 21-year period were included. Results: Nine patients were managed with EVAR and 18 with OSR. In the EVAR group, the number of transfused red blood cell units (P = .001), procedure duration (P < .001), and postoperative hospitalization (P = .004) were significantly reduced compared to OSR. A trend for decreased morbidity with EVAR (11% vs 33% for OSR, P = .36) was observed. On literature review and meta-analysis, morbidity after EVAR was 8.3%, significantly lower compared to OSR (27.4%, P = .047). Mortality for nonruptured IAAAs was 0% after EVAR and 3.6% after OSR (P = 1.00). Conclusions: Endovascular aneurysm repair of IAAAs is associated with decreased procedure duration, transfusion needs, hospitalization, and morbidity compared to OSR.

Preoperative evaluation for vascular access creation.

In an effort to increase the prevalence of arteriovenous fistulae (AVF), ultrasound vessel mapping (USVM) and upper extremity venography (UEV) have been suggested; however, the effectiveness of their combined use remains unknown. We studied the effect of such a combined protocol on arteriovenous (AV) access type change compared with physical examination alone. Consecutive patients with chronic kidney disease (n = 137) after an initial estimation of the AV access type, based on physical examination, had USVM and UEV to detect vascular pathology that could potentially alter the original plan. USVM changed the preoperative plan in 31 (22.6%) patients; this was 36.7% (n = 18) in diabetics compared with 14.8% (n = 13) in nondiabetics (p < .001). Patients for whom USVM changed the type of planned AV access had been on hemodialysis significantly longer (2.7 years vs 0.9 years; p < .001). Venography identified 18 patients with central vein stenosis that led to a site change in 12 of them. Significant venous stenosis in patients with a history of two or more central catheters placed and patients without such a history was 93% and 1%, respectively. In eight patients, intraoperative findings dictated AV graft placement or creation of a central AVF. The original plan was revised in 31%, and this rate was similar for distal AVF, central AVF, and AV grafts (38%, 26%, and 43%, respectively; all p > .05). The 30-day patency rate was 92.2%. A significant proportion of patients have vascular pathology severe enough to alter the access type as suggested by physical examination alone. USVM should be routinely performed, whereas UEV should be selectively performed in patients with a history of surgery or instrumentation of their central veins.

Sympathetic skin response in patients with peripheral arterial occlusive disease

OBJECTIVE The current study aimed to assess the viability of sympathetic sudomotor fibers in patients suffering from mild peripheral arterial occlusive disease (PAD). METHODS Sympathetic skin response (SSR) from the hand (electrical stimulation) and sole (electrical and magnetic stimulation) of 25 patients with PAD (19 males and 6 females with mean age 62.7 +/- 10.2 years) was recorded unilaterally depending on the side of the affected limb (18 right side, 7 left side). Electrophysiological data were also collected and correlated with the SSR results. Twenty-five, age- and gender-matched healthy volunteers served as controls. RESULTS No evidence of nerve conduction abnormalities was recorded from the group of patients. Intact SSR recordings were obtained from the upper limb of patients. Nine patients (36%) had absent SSR in the lower limb following electrical stimulation, whilst the same 9 patients had absent SSR following magnetic stimulation. Significant differences occurred between groups in the SSR latency scores recorded from the lower limb. Following electrical stimulation the mean SSR latency in patients was significantly prolonged, compared to that of controls (P = 0.000), whilst the same applied following magnetic stimulation (P = 0.000). There was no correlation between SSR abnormalities and nerve conduction measurements. The manifestation of intermittent claudication at a walking distance of 250 m was strongly correlated with absent lower limb SSR (r = 0.71, P = 0.035). CONCLUSIONS SSR abnormalities appeared to be an early and independent finding of neural impairment in our patients. SIGNIFICANCE SSR study, performed at an early stage of PAD may prove useful in differentiating PAD-induced neuropathy from other neuropathic processes.

Dynamic F wave study in patients suffering from peripheral arterial occlusive disease

Objective –  To prospectively detect significant transient F wave abnormalities obtained after exercise in patients with peripheral arterial disease (PAD) and to assess the potential diagnostic sensitivity of dynamic F wave study in such a context.

Listeriosis infection of an abdominal aortic aneurysm in a diabetic patient

A rare case of an abdominal aortic aneurysm (AAA) infected by Listeria monocytogenes in a 72-year-old male diabetic farmer, is reported. Our patient had a history of a recent pneumonia that could have been caused by Listeria too. Aneurysm infection was manifested by fever and abdominal and back pain, which prompted investigation with CT scanning that revealed a 4.9 cm AAA with typical signs of infection. He underwent urgent AAA repair with aortobifemoral bypass grafting and had an uneventful course. Aneurysm content microbiology revealed Listeria monocytogenes and following a 9-week course of antibiotics our patient remains asymptomatic 11 months later.