Tazo Inui

Vascular surgical site infection: risk factors and preventive measures

Surgical site infection (SSI) after arterial intervention is a common nosocomial vascular complication and an important cause of postoperative morbidity. Its prevention requires the vascular surgeon and the health care team to be cognizant of its epidemiology and patient-specific risk factors to apply effective measures to reduce the incidence. The majority of vascular SSIs are caused by Gram-positive bacteria with methicillin-resistant Staphylococcus aureus (MRSA) now a prevalent pathogen that is involved in more than one-third of cases. Nasal carriage of methicillin-sensitive S. aureus or MRSA strains, recent hospitalization, a failed arterial reconstruction, and the presence of a groin incision are major risk factors for developing a vascular SSI. Overall, the SSI rate after arterial intervention is higher than predicted by the Centers for Disease Control and Preventions National Nosocomial Infections Surveillance Risk Category System, and ranges from 1% to 2% after open or endovascular aortic interventions, to as high as 10% to 20% after lower-limb bypass grafting procedures. Application of perioperative measures to reduce S. aureus nasal and skin colonization in conjunction with appropriate, bactericidal antibiotic prophylaxis, meticulous wound closure, and postoperative care to optimize patient host defense regulation mechanisms (eg, temperature, oxygenation, and blood sugar) can minimize SSI occurrence.

Mortality after ground-level fall in the elderly patient taking oral anticoagulation for atrial fibrillation/flutter: A long-term analysis of risk versus benefit

BACKGROUND Elderly patients with atrial fibrillation or flutter who experience ground-level falls are at risk for lethal head injuries. Patients on oral anticoagulation (OAC) for thromboprophylaxis may be at higher risk for these head injuries. Trauma surgeons treating these patients face a difficult choice: (1) continue OAC to minimize stroke risk while increasing the risk of a lethal head injury or (2) discontinue OAC to avoid intracranial hemorrhage while increasing the risk of stroke. To inform this choice, we conducted a retrospective cohort study to assess long-term outcomes and risk factors for mortality after presentation with a ground-level fall among patients with and without OAC. METHODS Retrospective analysis of the longitudinal version of the California Office of Statewide Planning and Development database was performed for years 1995 to 2009. Elderly anticoagulated patients (age > 65 years) with known atrial fibrillation or flutter who fell were stratified by CHA2DS2-VASc score and compared with a nonanticoagulated control cohort. Multivariable logistic regression including patient demographics, stroke risk, injury severity, and hospital type identified risk factors for mortality. RESULTS A total of 377,873 patient records met the inclusion criteria, 42,913 on OAC and 334,960 controls. The mean age was 82.4 and 80.6 years, respectively. Most were female, with CHA2DS2-VASc scores between 3 and 5. Mortality among OAC patients after a first fall was 6%, compared with 3.1% among non-OAC patients. Patients dying with a head injury constituted 31.6% of deaths within OAC patients compared with 23.8% among controls. Risk of eventual death with head injury exceeded annualized stroke risk for patients with CHA2DS2-VASc scores of 0 to 2. Predictors for mortality with head injury on the first admission included male sex, Asian ethnicity, a history of stroke, and trauma center admission. CONCLUSION Elderly patients on OAC for atrial fibrillation and/or flutter who fall have a greater risk for mortality compared with controls. Patients with low CHA2DS2-VASc scores (0–3) at high risk for falls with identified risk factors should speak to their prescribing physicians regarding the risk/benefits of continued use of OAC. LEVEL OF EVIDENCE Epidemiologic/prognostic study, level III.

Long-Term Outcomes of Patients with Nonsurgically Managed Uncomplicated Appendicitis

BACKGROUND Emerging literature has supported the safety of nonoperative management of uncomplicated appendicitis. STUDY DESIGN Patients with emergent, uncomplicated appendicitis were identified by appropriate ICD-9 diagnosis codes in the California Office of Statewide Health Planning and Development database from 1997 to 2008. Rates of treatment failure, recurrence, and perforation after nonsurgical management were calculated. Factors associated with treatment failure, recurrence, and perforation were identified using multivariable logistic regression. Mortality, length of stay, and total charges were compared between treatment cohorts using matched propensity score analysis. RESULTS Of 231,678 patients with uncomplicated appendicitis, the majority (98.5%) were managed operatively. Of the 3,236 nonsurgically managed patients who survived to discharge without an interval appendectomy, 5.9% and 4.4% experienced treatment failure or recurrence, respectively, during a median follow-up of more than 7 years. There were no mortalities associated with treatment failure or recurrence. The risk of perforation after discharge was approximately 3%. Using multivariable analysis, race and age were significantly associated with the odds of treatment failure. Sex, age, and hospital teaching status were significantly associated with the odds of recurrence. Age and hospital teaching status were significantly associated with the odds of perforation. Matched propensity score analysis indicated that after risk adjustment, mortality rates (0.1% vs 0.3%; p = 0.65) and total charges (

The contemporary management of renal artery aneurysms

23,243 vs

A multiregional registry experience using an electronic medical record to optimize data capture for longitudinal outcomes in endovascular abdominal aortic aneurysm repair.

24,793; p = 0.70) were not statistically different between operative and nonoperative patients; however, length of stay was significantly longer in the nonoperative treatment group (2.1 days vs 3.2 days; p < 0.001). CONCLUSIONS This study suggests that nonoperative management of uncomplicated appendicitis can be safe and prompts additional investigations. Comparative effectiveness research using prospective randomized studies can be particularly useful.

Intervention after endovascular aneurysm repair: Endosalvage techniques including perigraft arterial sac embolization and endograft relining

BACKGROUND Renal artery aneurysms (RAAs) are rare, with little known about their natural history and growth rate or their optimal management. The specific objectives of this study were to (1) define the clinical features of RAAs, including the precise growth rate and risk of rupture, (2) examine the current management and outcomes of RAA treatment using existing guidelines, and (3) examine the appropriateness of current criteria for repair of asymptomatic RAAs. METHODS A standardized, multi-institutional approach was used to evaluate patients with RAAs at institutions from all regions of the United States. Patient demographics, aneurysm characteristics, aneurysm imaging, conservative and operative management, postoperative complications, and follow-up data were collected. RESULTS A total of 865 RAAs in 760 patients were identified at 16 institutions. Of these, 75% were asymptomatic; symptomatic patients had difficult-to-control hypertension (10%), flank pain (6%), hematuria (4%), and abdominal pain (2%). The RAAs had a mean maximum diameter of 1.5 ± 0.1 cm. Most were unilateral (96%), on the right side (61%), saccular (87%), and calcified (56%). Elective repair was performed in 213 patients with 241 RAAs, usually for symptoms or size >2 cm; the remaining 547 patients with 624 RAAs were observed. Major operative complications occurred in 10%, including multisystem organ failure, myocardial infarction, and renal failure requiring dialysis. RAA repair for difficult-to-control hypertension cured 32% of patients and improved it in 26%. Three patients had ruptured RAA; all were transferred from other hospitals and underwent emergency repair, with no deaths. Conservatively treated patients were monitored for a mean of 49 months, with no acute complications. Aneurysm growth rate was 0.086 cm/y, with no difference between calcified and noncalcified aneurysms. CONCLUSIONS This large, contemporary, multi-institutional study demonstrated that asymptomatic RAAs rarely rupture (even when >2 cm), growth rate is 0.086 ± 0.08 cm/y, and calcification does not protect against enlargement. RAA open repair is associated with significant minor morbidity, but rarely a major morbidity or mortality. Aneurysm repair cured or improved hypertension in >50% of patients whose RAA was identified during the workup for difficult-to-control hypertension.

An Intergenerational Reflection on the First Night on Call-plus ça change, plus c'est la même chose? (The More Things Change, the More They Stay the Same?).

OBJECTIVE Registries have been proven useful to assess clinical outcomes, but data entry and personnel expenses are challenging. We developed a registry to track patients undergoing endovascular aortic aneurysm repair (EVAR) in an integrated health care system, leveraging an electronic medical record (EMR) to evaluate clinical practices, device performance, surgical complications, and medium-term outcomes. This study describes the registry design, data collection, outcomes validation, and ongoing surveillance, highlighting the unique integration with the EMR. METHODS EVARs in six geographic regions of Kaiser Permanente were entered in the registry. Cases were imported using a screening algorithm of inpatient codes applied to the EMR. Standard note templates containing data fields were used for surgeons to enter preoperative, postoperative, and operative data as part of normal workflows in the operating room and clinics. Clinical content experts reviewed cases and entered any missing data of operative details. Patient comorbidities, aneurysm characteristics, implant details, and surgical outcomes were captured. Patients entered in the registry are followed up for life, and all relevant events are captured. RESULTS Between January 2010 and June 2013, 2112 procedures were entered in the registry. Surgeon compliance with data entry ranges from 60% to 90% by region but has steadily increased over time. Mean aneurysm size was 5.9 cm (standard deviation, 1.3). Most patients were male (84%), were hypertensive (69%), or had a smoking history (79%). The overall reintervention rate was 10.8%: conversion to open repair (0.9%), EVAR revision (2.6%), other surgical intervention (7.3%). Of the reinterventions, 27% were for endoleaks (I, 34.3%; II, 56.9%; III, 8.8%; IV and V, 0.0%), 10.5% were due to graft malfunction, 3.4% were due to infection, and 2.3% were due to rupture. CONCLUSIONS Leveraging an EMR provides a robust platform for monitoring short-term and midterm outcomes after abdominal aortic aneurysm repair. Use of standardized templates in the EMR allows data entry as part of normal workflow, improving compliance, accuracy, and data capture using limited but expert personnel. Assessment of patient demographics, device performance, practice variation, and postoperative outcomes benefits clinical decision-making by providing complete and adjudicated event reporting. The findings from this large, community-based EVAR registry augment other studies limited to perioperative and short-term outcomes or small patient cohorts.

Endovascular Management of a Large Persistent Sciatic Artery Aneurysm

Endovascular aneurysm repair (EVAR) has revolutionized the treatment of abdominal aortic aneurysm (AAA). However, persistent AAA sac endoleak following EVAR can result in sac diameter increase requiring re-intervention in up to one-third of cases and even result in aneurysm rupture. In this case review, we summarize and detail endovascular re-interventions for each type of endoleak. We also detail specific options including stent-graft relining for indeterminate, Type III, and Type IV endoleaks and perigraft arterial sac embolization to induce thrombosis and resolve acute Type I, II, or III endoleaks. Endograft relining involves placement of a new stent-graft-elevating the bifurcation and extending the repair from renal artery to hypogastric arteries; perigraft arterial sac embolization involves placement of a catheter into the excluded sac from common femoral artery access, characterization of the inflow and outflow of the endoleak, and inducing cessation of the blood flow into the sac by the administration of thrombogenic material. Endoleaks range from low-pressure endoleaks, which can be safely monitored in a surveillance program to high-pressure endoleaks, which mandate intervention when associated with AAA sac diameter increase to protect from rupture. The evaluation of new devices and techniques to treat endoleak after EVAR remains an important issue in patient care after EVAR.

Managing Conflict of Interest

On the afternoon of Tuesday, June 30, 1969, I picked up my ‘‘whites’’ and presented myself to Osler 3, one of the internal medicine house staff services at the Johns Hopkins Hospital. My internship formally began later that day (12 midnight, July 1). That afternoon I read through some of the ‘‘off-service notes’’ written by the interns who were themselves about to become ‘‘JARs (junior assistant resident).’’ As I recall, one of them may even have served as a source of continuity for the Osler 3 service team, which included 2 JARs, 3 interns, and 3 students. By tradition our attending physician would go on rounds with the team 3 times a week, hearing about our patients as we ‘‘flipped the cards’’ in the doctor’s office or did walking rounds. I stored my black bag (a gift from Eli Lilly) and the Barnes Manual (the Washington University handbook of inpatient medicine) on the shelf above the desk in Osler 3 (next to several vials of Ritalin someone had left behind), introduced myself to Amy (the Osler 3 charge nurse), and went home to my row house apartment 1 block behind Hopkins Hospital in the neighborhood where my new wife and I would live for the next several years while I completed training. I returned to Osler 3 at midnight, and made rounds on my patients. Some time in the middle of the night I was urgently called to the emergency department to pick up my first admission. He was a man in his mid-50s who was described to me over the telephone as febrile, hypotensive, stuporous, with possible ‘‘polymicrobial sepsis,’’ and Di Guglielmo syndrome, type 2. On the way down to the emergency department I looked at the Barnes Manual to see if I could find any mention of this syndrome but found none. In the emergency department I was told by the admitting resident that it was ‘‘some kind of myelodysplastic condition.’’ Having no real clue what this meant, I met my patient, who was semistuporous with a low blood pressure, on the gurney. He had various purpuric lesions, no nuchal rigidity, and came with a thick chart that told me he had been taking prednisone. The admitting resident said they had ‘‘Gram stained’’ his blood smear and thought there might be both gram-positive and gram-negative organisms on the slide. His Wright stain blood smear showed immature-looking white cells. I do not recall his complete blood count. I remember that we did our own laboratory work in the rudimentary facility that each Osler floor hosted at the end of the entrance hallway. Honestly frightened by how sick this patient was, I admitted him to a bed just across the hall from the nursing station (the priority arrangement that served as an intensive care unit [ICU] in those days). Calling my resident, who was at home, we developed a plan for a lumbar puncture (atraumatic and clear), chest x-ray, urinalysis, blood cultures, stress-level steroids, pushing normal saline, and broad antibiotic coverage for sepsis. In those days we used a regimen short-handed as ‘‘KKK’’ (an acronym I never fully understood because it referred to kanamycin, Keflex, and colistin: KKC?). The patient somehow survived the night. The patient was seen by the attending physician the next morning, who elaborated on the differential diagnosis of polymicrobial sepsis (a phenomenon I recall as one associated with visceral abscesses that erode into an intravascular space). I remember being interested in the differential diagnosis, although I was confused by how it might apply to this particular case. There was also a discussion of how exogenous steroids were metabolized, in what form they were active, and the advantages/disadvantages of methylprednisolone. The attending physician asked about the blood cultures, which I knew were ‘‘cooking but negative.’’ I wondered whether I had somehow mismanaged the patient. Not much was said about Di Guglielmo syndrome, type 2. The patient died several weeks later, partially of renal failure. Years later I believe it was suggested that the KKK Tazo S. Inui, MD, is a first-year surgery resident at the University of California, San Diego; Thomas S. Inui, ScM, MD, is President and Chief Executive Officer of the Regenstrief Institute for Health Care, the Sam Regenstrief Professor of Health Services Research, and Associate Dean for Health Care Research at Indiana University School of Medicine.

510 Transanal Minimally Invasive Surgery Assisted Single Incision Low Anterior Resection With Total Mesorectal Excision (Tamis Assisted LAR Tme) in a Cadaver Model

The persistent sciatic artery (PSA) is a remnant of the fetal circulatory system that is preserved in less than 0.1% of the population. Up to 60% of patients with this vascular anomaly will go on to development of a PSA aneurysm (PSAA), which can produce a variety of symptoms including neuropathy, claudication, and acute limb-threatening ischemia. Historical management is by open operation and interposition grafting, which can be highly morbid. We describe successful management of a large, symptomatic PSAA by endovascular stent grafting with intermediate term follow-up.