Special Issue:
Challenges and Opportunities in Vascular Surgery
Amna Ali, MD
Division of General Surgery, UCSF Fresno, Fresno, California
Shamsuddin Khwaja, MD
Division of General Surgery, UCSF Fresno, Fresno, California; Central California Heart and Lung Surgery, Clovis, California
Jeffrey Saavedra, MD
CMI Radiology, Fresno, California
Kamell Eckroth-Bernard, MD
Division of General Surgery, UCSF Fresno, Fresno, California; Valley Vascular Surgery Associate, Fresno, California
Usman Javed, MD
The Heart Group, Fresno, California
Chandrasekar Venugopal, MD
CMI Radiology, Fresno, California
Heidi Reich, MD
Division of General Surgery, UCSF Fresno, Fresno, California; Central California Heart and Lung Surgery, Clovis, California
Habiba Hashimi, MD
Division of General Surgery, UCSF Fresno, Fresno, California
Leheb Araim, MD
Division of General Surgery, UCSF Fresno, Fresno, California; Central California Heart and Lung Surgery, Clovis, California
Robert Stewart, MD
Division of General Surgery, UCSF Fresno, Fresno, California; Central California Heart and Lung Surgery, Clovis, California
Lisa Wilkins, NP
Central California Heart and Lung Surgery, Clovis, California
Navjot Janday, NP
Central California Heart and Lung Surgery, Clovis, California
Alex Calkins, NP
Central California Heart and Lung Surgery, Clovis, California
John C Lin, MD
Division of General Surgery, UCSF Fresno, Fresno, California; Central California Heart and Lung Surgery, Clovis, California
Abstract
There have been significant advances in the technique and application of endovascular repair of thoracic aortic pathology over the past 20 years. The Stanford type A and the complicated type B dissection patients require urgent/emergent intervention. In the last decade, earlier intervention has been pursued for uncomplicated type B dissections. The INvestigation of STent-grafts in Aortic Dissection (INSTEAD) Long term (XL) study showed that there was significant crossover from medical management to Thoracic EndoVascular Aortic Repair (TEVAR) at year 3, suggesting TEVAR might benefit this population long term.
Today, the application of TEVAR, which was initially designed to address aneurysmal disease, has become a standard and Food and Drug Administrative (FDA) approved management option in dissections.
Currently there are four FDA approved TEVAR devices in the United States for the treatment of the thoracic dissections, namely Gore, Medtronic, Cook, and Terumo. With each iteration, there are increased opportunities for customization and widespread use in individualized patient’s pathology. As the technology improves and the feasibility of the grafts expands, the complication rates continue to decline cementing the safety and efficacy of these thoracic aortic grafts. Two rare but catastrophic complications in spinal ischemia and retrograde Stanford type A aortic dissection are further discussed. With the success of the TEVAR, a new frontier of hybrid aortic surgery has developed. The debranching of the aortic arch vessels in order to advance the TEVAR proximal landing zones has been aggressively pursued. With the widespread growth of TEVAR technology it is apparent that complex aortic pathology can be safely repaired endovascularly.
Laura De Donder
Vicky Maerens
Heidi Maertens
Department of Thoracic and Vascular Surgery, Sint-Lucas Hospital, 9000 Ghent, Belgium.
Kjell Fierens
Department of General Surgery, Sint-Lucas Hospital, 9000 Ghent, Belgium.
Anneleen Stockman
Department of Thoracic and Vascular Surgery, Sint-Lucas Hospital, 9000 Ghent, Belgium.
Stefanie De Buyser
Biostatistics Unit, Ghent University, Corneel Heymanslaan 10, 9000 Ghent, Belgium
Cedric Coucke
Department of Thoracic and Vascular Surgery, Sint-Lucas Hospital, 9000 Ghent, Belgium.
Yves Blomme
Department of Thoracic and Vascular Surgery, Sint-Lucas Hospital, 9000 Ghent, Belgium.
Abstract
Objective: In patients with symptomatic or asymptomatic severe internal carotid artery stenosis, carotid endarterectomy (CEA) has been shown to reduce risk for stroke. The optimal surgical technique remains subject of debate. In the latest European Society of Vascular Surgery (ESVS) guidelines on the management of atherosclerotic carotid disease, routine patching is preferred to routine primary closure. However, there are no RCT’s evaluating selective patching strategies. This follow-up study aimed to assess long term complication rate and restenosis after carotid endarterectomy with selective patching.
Methods: Two hundred thirteen consecutive carotid endarterectomies over a 3-year period from January 5th 2011 to December 19th 2013 were prospectively analyzed in a follow-up study over 5 years (mean 4.6, range 3.17-6.17). Patient population consisted of 141 procedures on males and 72 on females with mean age 73 years at the time of surgery (standard deviation (SD) 8.57, range 53-95). There was a follow-up of 89%. Postoperative risk factors were assessed such as hypertension, diabetes mellitus, coronary artery disease and smoking. Postoperative symptoms of cranial nerve injury, transient ischemic events, cerebrovascular events and mortality were evaluated. Duplex ultrasound was performed by a radiologist blinded to the operative technique to evaluate patency of the carotid artery after carotid endarterectomy.
Results: Primary closure was used in 110 operations, and patch angioplasty in 103 procedures (Dacron patch). Primary closure was performed when the carotid artery had a diameter above 5 mm, when there was a high carotid bifurcation or when the contralateral carotid artery was occluded. There were no significant differences among groups’ baseline characteristics at the time of surgery. Primary closure was performed significantly more in male patients (P= .02). Overall complication rate was 3.76% postoperatively (1.8% after primary closure, 5.8% after patch angioplasty) and after 5 years 5.29% (2.0% after primary closure, 9.1% after patch angioplasty). There are no significant differences in results between the two groups (P= .09 and P= .05).
In four cases patients experienced symptoms of cranial nerve damage postoperatively, two in each group. In one of the two cases in each group, the patient fully recovered and the other had persistent complaints (P-value= 1). None of the patients experienced amaurosis fugax during the 5-year follow up period. In five cases a patient had an ipsilateral cerebrovascular thrombosis in the group after patch angioplasty compared to zero in the primary closure group (P-value= .02). In the group of primary closure there was a mortality of 26 patients (23.6%) compared to 26 (25.2%) patients after patch angioplasty (P-value = .70). One was caused by cerebral hyperperfusion syndrome within one month postoperative after patch angioplasty and none were caused by an ipsilateral ischemic stroke. Objective duplex ultrasound showed no significant difference comparing restenosis in both groups (P-value= .43). In twelve cases patients showed a restenosis between 50-70% (6 primary closure and 6 patch angioplasty), none of the patients had high grade restenosis of more than 70%. Patient characteristics did not show a significant effect on long term outcomes. There was a correlation between postoperative use of antihypertensive medication and long-term stroke (P-value= .006), restenosis (P-value= .01) and mortality (P-value= .003).
Conclusion: After long-term follow-up we found primary closure and patch angioplasty to be equivalent with respect to complication rate and restenosis when used in selected cases. Best medical treatment and especially the use of antihypertensive medication should be emphasized.
Julien Guihaire
Marie Lannelongue Hospital, University of Paris Saclay
Simon Dang Van
1) Department of Cardiac and Vascular Surgery, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, University of Paris Saclay, France ; 2) Laboratory of Preclinical Research, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, University of Paris Saclay, France
Dorothee Brunet
1) Department of Cardiac and Vascular Surgery, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, University of Paris Saclay, France; 2) Laboratory of Preclinical Research, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, University of Paris Saclay, France
Ali Akamkam
1) Department of Cardiac and Vascular Surgery, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, University of Paris Saclay, France; 2) Laboratory of Preclinical Research, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, University of Paris Saclay, France
Maïra Gaillard
1) Department of Cardiac and Vascular Surgery, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, University of Paris Saclay, France; 2) Laboratory of Preclinical Research, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, University of Paris Saclay, France
Aurelien Vallee
1) Department of Cardiac and Vascular Surgery, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, University of Paris Saclay, France; 2) Laboratory of Preclinical Research, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, University of Paris Saclay, France
Jacques Thes
1) Department of Cardiac and Vascular Surgery, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, University of Paris Saclay, France; 2) Laboratory of Preclinical Research, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, University of Paris Saclay, France
Stephan Haulon
1) Department of Cardiac and Vascular Surgery, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, University of Paris Saclay, France; 2) Laboratory of Preclinical Research, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, University of Paris Saclay, France
Abstract
Heart transplantation is the gold standard treatment for advanced heart failure in selected patients. Organ shortage is however a major concern, leading transplant teams to expand the criteria for donor selection. Organ retrieval is routinely performed nowadays in donors older than 55 years, with impaired left ventricular function and/or hypertrophy, or after prolonged cardiac arrest such as after circulatory-determined death. All these conditions are associated with an increased high of primary graft failure, the main cause of early death after heart transplantation. Machine preservation technology has been recently applied to allow for extended preservation of the donor heart. Compared to conventional static cold storage, this approach can also provide viability assessment of the donor heart before transplant, especially in case of ex situ normothermic blood perfusion. After a brief review of currently available preservation machines, we sought to describe different approaches for assessment of the donor heart using ex situ organ perfusion, from metabolic monitoring to cardiac imaging and hemodynamic investigations.
Rod J. Nault
Anesthesia residency, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio; Department of OUTCOMES RESEARCH, Cleveland Clinic, Cleveland, Ohio
Quinton Riter
Anesthesia residency, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio; Department of OUTCOMES RESEARCH, Cleveland Clinic, Cleveland, Ohio
Daniel I. Sessler
Anesthesia residency, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio; Department of OUTCOMES RESEARCH, Cleveland Clinic, Cleveland, Ohio
Abstract
Cancer is the second-leading cause of death worldwide. The initial treatment for nearly all solid cancers is surgical resection of a primary tumor. While tumors can usually be grossly removed, surgical interventions release tumor cells into the lymphatics and vascular beds1. Whether circulating tumor cells develop into clinical metastases depends largely on host defense, mostly natural killer cell function2,3.
Surgery and opioids have the potential to shift the disease-patient relationship towards cancers via at least three major avenues. One is the surgical intervention itself that depresses cell-mediated immunity, reduces concentrations of anti-angiogenic factors, and increases pro-angiogenic factors and release of growth factors that stimulate cancer cells1,3-8. Another factor is general anesthesia, which impairs the function of several immune cells important for anti-metastatic immune activity9. A third factor is the use of opioids for pain management which inhibit cellular and humoral immunity, and might even promote angiogenesis and tumor growth10-12.
Regional anesthesia and analgesia techniques attenuate perioperative tumor-promoting effects by blocking afferent signaling to the central nervous system. Thus, regional techniques might reduce the neuroendocrine response to surgery more effectively than general anesthesia. Furthermore, regional analgesia decreases the need for volatile anesthetics and opioids. Regional analgesia might thus help maintain perioperative anti-cancer immune function, notably natural killer cell activity, and thus reduce the risk of circulating tumor cells developing into clinical metastases13-16.
Potential benefit of regional analgesia for cancer recurrence is supported by animal investigations. For example, a study in rats compared halothane alone combined with either systemic morphine or with spinal block using bupivacaine with morphine. General anesthesia alone increased tumor retention in the lungs by up to 17-fold. Additionally, natural killer cell activity was depressed by general anesthesia7. Another study compared general anesthesia with sevoflurane alone versus spinal blocks combining bupivacaine and morphine. Addition of the spinal block to general anesthesia attenuated suppression of tumoricidal liver mononuclear cells and consequently reduced promotion of tumor metastasis17. Animal evidence is thus largely consistent in suggesting benefit from regional analgesia and from reducing volatile anesthesia and opioid use.
Subsequent retrospective analyses in humans were encouraging. One compared combined general anesthesia with paravertebral analgesia versus general with morphine analgesia for breast cancer and reported that paravertebral analgesia reduced cancer recurrence18. Another retrospective analysis reported that epidural analgesia reduced biochemical recurrence of prostate cancer by 57%19. However, many other retrospective analyses found no association between regional anesthesia and cancer outcomes20-23, leaving the overall record mixed.
Because purpose-designed trials of cancer recurrence naturally take a long time, investigators initially re-purposed previous randomized trials that were conducted for other purposes. For example, a team re-evaluated patients who participated in the MASTER trial.24 They identified 503 patients who had surgery for cancer and were able to obtain long-term follow-up information in 446 of them. Two other re-analyses evaluated 99 patients who had prostatectomies for prostate cancer comparing general to general plus epidural analgesia and 132 patients who had intra-abdominal surgery via midline or bilateral subcostal incisions for non-benign cancer resection comparing general anesthesia with epidural blocks versus with fentanyl analgesia followed by continuous subcutaneous morphine. None of these trials demonstrated notable differences in cancer-associated outcomes25,26. The only exception was a re-analysis that compared survival in patients randomized to general anesthesia with and without epidural supplementation for colon cancer surgery. A post hoc subgroup analysis implausibly found enhanced survival in the epidural group only in patients without metastasis before 1.5 years27. Analyses of trials conducted for other purposes thus provide little support for a benefit of regional analgesia for reducing cancer recurrence.
There have been three major trials of regional analgesia on cancer recurrence. The first randomized 2,132 patients having potentially curative primary breast cancer surgery to paravertebral analgesia or conventional opioid analgesia. Cancer recurrence was similar in each group after a median follow-up time of 36 months (hazard ratio 0.97, 95% CI 0.74–1.28; p=0.84). The authors noted that breast surgery causes less operative stress and pain than major abdominal and thoracic surgery, and postulated that regional analgesia might yet be beneficial for such cases.28
The next trial therefore compared overall survival and cancer-free survival in patients randomized to combined general-epidural anesthesia versus general anesthesia alone for major abdominal cancer resections. In a total of 1,712 patients with a median follow-up duration of 66 months, there were no differences in terms of mortality (adjusted hazard ratio, 1.07; 95% CI, 0.92 to 1.24; P = 0.408) or recurrence-free survival (adjusted hazard ratio, 0.97; 95% CI, 0.84 to 1.12; P = 0.692)29.
The third major trial randomized 400 patients having video-assisted thoracoscopic lung cancer resection to general anesthesia alone or general anesthesia combined with thoracic epidural analgesia. At a median follow-up duration of 32 months, epidural analgesia did not reduce recurrence-free (adjusted hazard ratio, 0.90; 95% CI, 0.60 to 1.35; P = 0.608), overall (adjusted hazard ratio, 1.12; 95% CI, 0.64 to 1.96; P = 0.697), or cancer-specific survival (adjusted hazard ratio, 1.08; 95% CI, 0.61 to 1.91; P = 0.802).30 Thus, even when restricting analysis to patients experiencing high surgical stress and considerable postoperative pain, regional techniques failed to reduce cancer recurrence.
While regional anesthetic techniques have many benefits, three robust trials which randomized a total of 4,244 patients conclusively demonstrate that regional analgesia does not reduce recurrence of breast, abdominal, and lung cancer (Figure). Given the quality and diversity of evidence, further investigations into regional analgesia are unlikely to prove fertile. Case closed. Instead, perioperative investigators might better focus on comparisons between volatile and intravenous anesthesia31-33, and on adjuncts such as COX-2 inhibitors34,35 and lidocaine36.
Figure legend: Forest plot of hazard ratios for cancer recurrence and recurrence-free survival from three major trials of regional analgesia in patients having cancer surgery. There was no evidence of benefit in any of the trials.
Kyle M. Hocking, PhD
Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Biomedical Engineering, Vanderbilt University, Nashville, TN, USA
Jessica Huston, MD
Department of Medicine, Division of Cardiovascular Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
Jeffery Schmeckpeper, MD, PhD
Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
Monica Polcz, MD
Department of Surgery, Atrium Health, Carolinas Medical Center, Charlotte, NC, USA
Marisa Case, RN
Department of Anesthesiology, Division of Critical Care, Vanderbilt University Medical Center, Nashville, TN, USA
Meghan Breed, MD
Department of Emergency Medicine, TriStar Skyline Medical Center, Nashville, TN, USA
Lexie Vaughn, MD
Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
Dawson Wervey, BS
Department of Anesthesiology, Division of Critical Care, Vanderbilt University Medical Center, Nashville, TN, USA
Colleen Brophy, MD
Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
JoAnn Lindenfeld, MD
Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
Bret D Alvis, MD
Department of Surgery, Atrium Health, Carolinas Medical Center, Charlotte, NC, USA; Department of Biomedical Engineering, Vanderbilt University, Nashville, TN, USA
Abstract
Introduction: A cornerstone of heart failure assessment is the right heart catheterization and the pulmonary capillary wedge pressure measurement it can provide. Clinical and hemodynamic parameters such as weight and jugular venous distention are less invasive measures often used to diagnose, manage, and treat these patients. To date, there is little data looking at the association of these key parameters to measured pulmonary capillary wedge pressure (PCWP). This is a large, retrospective, secondary analysis of a right heart catheterization database comparing clinical and hemodynamic parameters against measured PCWP in heart failure patients.
Methods: A total of 538 subjects were included in this secondary analysis. Spearman’s Rho analysis of each clinical and hemodynamic variable was used to compare their association to the documented PCWP. Variables analyzed included weight, body mass index (BMI), jugular venous distention (JVD), creatinine, edema grade, right atrial pressure (RAP), pulmonary artery systolic pressure (PASP), systemic vascular resistance, pulmonary vascular resistance, cardiac output (thermal and Fick), systolic blood pressure, diastolic blood pressure, heart rate, respiratory rate, oxygen saturation (SpO2), and pulmonary artery diastolic pressure (PADP).
Results: Ten out of 17 selected parameters had a statistically significant association with measured PCWP values. PADP had the strongest association (0.73, p<0.0001), followed by RAP and PASP (0.69, p<0.0001 and 0.67, p<0.0001, respectively). Other significant parameters included weight (0.2, p<0.001), BMI (0.2, p<0.001), SpO2 (-0.17, p<0.0091), JVD (0.24, p<0.005) and edema grade (0.2, p<0.0001).
Conclusion: This retrospective analysis clarifies the associations of commonly used clinical and hemodynamic parameters to the clinically used gold standard for volume assessment in heart failure patients, PCWP.
Dr. Sanjiv C Nair
Professor and Head of the Department, Maxillofacial Surgery Department, Bangalore Institute of Dental Sciences, Bangalore, India
Dr. Niveditha N
Assistant Professor, Maxillofacial Surgery Department, Vokkaligara Sangha Dental College and Hospital, Bangalore, India
Dr. Advaith Nair
Former Trainee, Vydehi Institute of Medical Sciences And Research Centre, Bangalore, India
Dr. Prashanth R
Associate Professor, Maxillofacial Department, Vokkaligara Sangha Dental College and Hospital, Bangalore, India
Abstract
Head and neck vascular lesions management has been a great challenge to the surgeons due to catastrophic bleeding that obscures the visibility during the surgery. A proposed surgical technique called CORSET SUTURING for the treatment of non cutaneous low-flow vascular malformations in the head and neck region minimizes the blood loss and facial disfigurement. Corset sutures are placed to strangulate the lesion and restore the facial symmetry with the least amount of comorbidities. The aim of the present study is to describe the clinical characteristics of patients treated by corset suturing technique, material used and surgical morbidity, in order to contribute to a better understanding of this technique. Medical records and images of 15 patients treated by the same corset suturing protocol were retrieved and analysed. The indications, advantages and disadvantages, technique and complications observed are discussed. There was a significant reduction in the bulkiness of tumour mass noted and also a return of the regional facial outline was evident. In conclusion, corset suturing has an important role in management of diffuse low-flow vascular malformations of the head and neck as it is found to be a simple, cost-effective, less scarring and acceptable method, hence can be considered as an alternative to the other expensive methods such as embolization, with least surgical comorbidities.
Giuseppe Mangiameli
Division of Thoracic Surgery, IRCCS Humanitas Research Hospital, via Manzoni 56, Rozzano, 20089 Milan, Italy; Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20090 Milan, Italy
Ugo Cioffi
Department of Surgery, University of Milan, Milan, Italy
Marco Alloisio
Division of Thoracic Surgery, IRCCS Humanitas Research Hospital, via Manzoni 56, Rozzano, 20089 Milan, Italy; Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20090 Milan, Italy
Federica Carlea
Division of Thoracic Surgery, IRCCS Humanitas Research Hospital, via Manzoni 56, 20089 Rozzano, Milan, Italy
Alberto Testori
Division of Thoracic Surgery, IRCCS Humanitas Research Hospital, via Manzoni 56, Rozzano, 20089 Milan, Italy
Abstract
Castleman’s disease is a benign lymphoproliferative disorder affecting both lymph nodes and extranodal loci. Castleman’s disease can occur in practically any part of the body, but it occurs mainly in the thorax (~70%) followed by the abdomen and pelvis, neck and axilla. Clinically, Castleman’s disease can be classified into a unicentric or multicentric form, depending on the number of lymph nodes involved, and histologically into a hyaline vascular variant, plasma cell, mixed cellular or plasmablastic variant. In this mini-review we briefly report and focus on all clinical thoracic manifestations of Castleman’s disease resuming for each of them the possible strategy of treatment.
Nutan Jain
MS. (Obs & Gynae)
Sakshi Srivastava, Dr.
MS. (Obs & Gynae)
Suksham Sharma, Dr.
MS. (Obs & Gynae)
Vandana Jain, Dr.
MS. (Obs & Gynae)
Abstract
Background: Laparoscopic entry in previous surgery cases has several challenges but complexity rises further in patients with history of multiple previous surgeries leading to intra-abdominal adhesions, visceral, vascular, nerve injuries, dilemma in port placement, difficulty in establishing pnemoperitoneum, reduced visibility and all these leading to longer operative time. To address the above issues, we conducted this study to assess the safety and efficacy of Jain point in avoiding trocar injuries in patients with multiple previous surgeries.
Methods: We present a retrospective analysis of 720 cases with two or more previous surgeries conducted at a tertiary care referral centre for advanced gynecological laparoscopic surgery from January 2011 to July 2023. We perform a detailed preoperative work up of the patient and delve into all details of the previous surgeries including indications and nature of surgery, open or laparoscopic. We then inspect all scar sites to assess possible intra-abdominal adhesions and feasibility of Jain point entry. Veress entry is made at Jain point, which lies at L4 level on left side of abdomen, 10-13 cm lateral to the umbilicus. This is followed by primary blind trocar entry at the Jain point, which becomes the main working port in due course of the surgery. We make a note of intraoperative adhesions and postoperative complications.
Results: In total 720 cases with history of multiple previous surgeries, laparoscopic entry was safely made through Jain point port by consultants, senior residents and fellows, almost in equal number of cases. In this study group, no major bowel or vascular complications were noted.
Conclusion: Jain point laparoscopic entry is safe for all types of previous scars, in all quadrants of abdomen, in all ranges of BMI, age, with varied indications and by surgeons of various subspecialties. It is feasible in low resource settings as in this study we utilized our routine reusable trocars. Jain point has the potential to minimize trocar injuries in hands of novice as well as experts, as its precise location avoids injury to vessels, viscera and bowel; thus posing as a safe and feasible laparoscopic entry port in multiple previous surgeries.
Dr. M. Sravya Keerthi
Department of General Surgery, JN Medical College, KLE Academy of Higher Education & Research, Nehru Nagar, Belagavi, Karnataka 590010, India
Dr. S. S. Shimi Kore
Department of General Surgery, JN Medical College, KLE Academy of Higher Education & Research, Nehru Nagar, Belagavi, Karnataka 590010, India
Dr. Manoj D. Togale
Department of General Surgery, JN Medical College, KLE Academy of Higher Education & Research, Nehru Nagar, Belagavi, Karnataka 590010, India
Abstract
Laparoscopic surgeries are advantageous over open surgeries in terms of minimal tissue handling, earlier return of bowel function, less postoperative pain, better cosmesis, lesser duration of hospital stay, earlier return to full activity and decreased overall cost. The incidence of bowel injuries is 0.13%, vascular injuries is 0.05-2% and abdominal wall vascular injuries 0.2-2%. Therefore, safe abdominal entry in laparoscopy is a major concern. Considering the fact that initial entry to abdominal cavity is a blind procedure, there is no ideal entry site. Various entry points used are Umbilicus, Palmar’s point, Jain point, Lee-Huang point, etc. The current study aimed to compare the better cosmetic outcome between trans umbilical and periumbilical incision for primary port insertion in cases of Laparoscopic Appendicectomy and Laparoscopic Cholecystectomy. This is a one year RCT done in Department of General Surgery, KLEs Dr.Prabhakar Kore Hospital and Medical Research Centre, Belagavi, from January 2022-December 2022. A total of 100 patients operated for laparoscopic appendectomy and laparoscopic cholecystectomy were studied. The patients were divided into Group A and Group B based on type of incision taken either periumbilical or transumbilical. Postoperative cosmetic outcome was analyzed using POSAS score on post op day 3,7 and 1-month follow up. The results are statistically significant (P<0.05). Between the two incisions during POD# 3 and 7 there is significant difference between variables such as induration, erythema, SSI. In our study 3 cases had SSI in both the groups. Transumbilical incision has better cosmetic satisfaction compared to Periumbilical incision.
Lamboni Damessane
Chirurgien Thoracique, Clinique Médico-Chirurgicale du CHU Sylvanus Olympio de Lomé (Togo).
Kondoh Bignandi
Chirurgien Cardiovasculaire et Thoracique, CHU Fann de Dakar, (Sénégal).
Barnabo Nampoukine Kan-paatib, MD
Division of Cardiothoracic and Vascular Surgery, Tongji Hospital, Huazhong; Wuhan (China).
Alassani Tarek
Chirurgien Généraliste, CHU Sylvanus Olympio de Lomé (Togo).
Issa-Toure A
Chirurgien Généraliste, CHU Sylvanus Olympio de Lomé (Togo).
Adjoh Komi
Pneumologue, Chef de Service de Pneumologie au CHU Sylvanus Olympio de Lomé (Togo).
Adabra Komlan
Chirurgien Générale et Vasculaire, Clinique Médico-Chirurgicale du CHU Sylvanus Olympio de Lomé (Togo).
Tchangaï Katanga Boyodi
Chirurgien Viscéraliste, Chef du Département de Chirurgie et Spécialités Chirurgicales, Faculté des Sciences de la Santé de l’Université de Lomé (Togo).
Abstract
Objectives: Video-assisted thoracoscopic surgery is experiencing significant growth nowadays. However, in Africa, it is slow to develop. The objectives of this study were to describe the indications and results of thoracoscopy in low and incomes country as Togo.
Materials and Methods: A retrospective descriptive cross-sectional study was conducted on patients who underwent exploration and therapeutic procedures by video-assisted surgery from June 2019 to November 2020 and from January 2022 to September 2023 (39 months) in Lomé.
Results: Sixteen patients underwent thoracoscopy during the study period. The mean age was 46.06 +/- 23 years. Patients over 45 years old represented 56.2%. The male-to-female ratio was 2.2. Six patients underwent preoperative pleural biopsies. Videothoracoscopy was diagnostic in 10 patients and therapeutic in 6 patients. It was performed under general anesthesia with or without selective intubation in the majority of cases (14/16). Two ports were used in the majority of cases (8/16). Biopsies were performed in 11 patients and intraoperative pleural talc pleurodesis in 4 patients. Pleural debridement was performed in 2 patients. Conversion to thoracotomy was done in 5 patients. The average drainage duration was 4 days. The average length of hospital stay was 5 days. Morbidity and mortality were marked by one case of bronchopleural fistula.
Conclusion: Video-assisted thoracoscopic surgery is in its early stages in Togo. Preliminary results are encouraging for its development in Togo.
Jared M Hall
Department of Physiology, University of Louisville, Louisville, KY 40202, USA
Nicholas E Yates
Department of Physiology, University of Louisville, Louisville, KY 40202, USA
Philip Bauer
Department of Physiology, University of Louisville, Louisville, KY 40202, USA
Gustavo Perez-Abadia
Department of Orthopedic Surgery, University of Louisville, Louisville, KY 40202, USA
Claudio Maldonado
Abstract
The Primo Vascular System was discovered by Bong Han Kim in the 1960s when searching for an anatomical correlate of the acupuncture meridians used in eastern medicine. The Primo Vascular System is a systemic network of thread-like Primo-vessels with intermittent enlargements known as Primo-nodes. Primo-vessels are difficult to view under a microscope due to their small diameters (20-50 µm) and translucent appearance. Primo-vessels have a porous outer membrane that encapsulates small channels named Primo sub-vessels filled with flowing fluid. Primo-vessels are classified into six sub-types based on their anatomical location. The physiological mechanisms of Primo-vessel function are not clear. There are multiple hypotheses based on Primo-vessel and Primo-node structure and cell content, however, supportive functional experimental data is lacking. This review focuses on the “interior” lymphatic vessel Primo-vessel (ILVPV) sub-type, the techniques that are used to visualize them, and experimental studies that attempt to unravel their physiological role after inflammatory stimulation. Speculative hypotheses are presented regarding the handling of signals by ILVPVs for intercellular communication between injured cells and cells stored within “interior” lymphatic vessel Primo-nodes (ILVPNs). One of the stored cell types that are of interest for tissue repair are very small embryonic-like cells. Very small embryonic-like cell activation may be induced by biophoton signals emitted by injured cells and transmitted to ILVPNs via Primo-vessel and/or ILVPV networks. An alternative or additional method for intercellular communication may involve the release of signaling proteins and/or extravesicular bodies carrying genetic messages (i.e., exosomes) by cells in injured tissues. As these signaling factors enter the lymphatic circulation, porous ILVPVs filter them out and transport them to ILVPNs where they initiate very small embryonic-like cell activation to start the tissue regenerative process. Primo Vascular System research will require more physiological functional studies to elucidate the role of ILVPVs and ILVPNs in tissue regeneration. To achieve this goal, future mechanistic studies will need novel biomarkers and animal models.
Kanokwan Demeekul
Interdisciplinary Health and Data Sciences Research Unit, Faculty of Allied Health Sciences, Naresuan University, Phitsanulok, Thailand; Department of Cardio-Thoracic Technology, Faculty of Allied Health Sciences, Naresuan University, Phitsanulok, Thailand
Prarinya Boonchai
Department of Electrical and Computer Engineering, Faculty of Engineering, Naresuan University, Phitsanulok, Thailand
Anuchit Manin
Heart Center, Naresuan University Hospital, Faculty of Medicine, Naresuan University, Phitsanulok, Thailand
Arthit Juncome
Heart Center, Naresuan University Hospital, Faculty of Medicine, Naresuan University, Phitsanulok, Thailand
Nanthaphoom Niangkanta
Heart Center, Naresuan University Hospital, Faculty of Medicine, Naresuan University, Phitsanulok, Thailand
Kreangkrai Bunkhampha
Heart Center, Naresuan University Hospital, Faculty of Medicine, Naresuan University, Phitsanulok, Thailand
Montatip Poomvanicha
Interdisciplinary Health and Data Sciences Research Unit, Faculty of Allied Health Sciences, Naresuan University, Phitsanulok, Thailand; Department of Cardio-Thoracic Technology, Faculty of Allied Health Sciences, Naresuan University, Phitsanulok, Thailand
Yonthida Wongvichit
Department of Cardio-Thoracic Technology, Faculty of Allied Health Sciences, Naresuan University, Phitsanulok, Thailand
Saranya Singkhwa
Department of Cardio-Thoracic Technology, Faculty of Allied Health Sciences, Naresuan University, Phitsanulok, Thailand
Sanruethai Rodmay
Department of Cardio-Thoracic Technology, Faculty of Allied Health Sciences, Naresuan University, Phitsanulok, Thailand
Phatiwat Chotimol
Interdisciplinary Health and Data Sciences Research Unit, Faculty of Allied Health Sciences, Naresuan University, Phitsanulok, Thailand; Department of Cardio-Thoracic Technology, Faculty of Allied Health Sciences, Naresuan University, Phitsanulok, Thailand
Abstract
The goal of this work is to construct a mobile application device that has a wide variety of functions which has clinical planning and decision making for heart-lung machine controlling and to assess the users’ level of satisfaction. The app was constructed according to the steps of design, algorithm, and validation, which is based on the ionic framework. The levels of satisfaction with the developed mobile app among 20 perfusionists were assessed by a questionnaire. The project researchers have officially assigned this medical mobile application with the name is Perfusion Assistant app. that can be accessed and used effectively cross platform on iOS and Android. The application is comprised of 5 main categories which includes: a perfusion calculator, myocardial protection chart, drugs details, priming solution, and parameters values. This finding shown that all cardiovascular parameters did not significant differ from Perfusion Assistant app. when compared to manual calculation. User’s satisfaction was at 3.64 ± 0.76 in the first evaluation. After modification with feedback from experts, the satisfaction of this application was evaluated with a 4.13 ± 0.56. Thereby, Perfusion Assistant app. is an application designed in clinical planning and decision of heart-lung machine controlling for perfusionists and medical staff that work in an opened heart surgery arena. Perfusion Assistant app. offers a variety of calculations related to cardiopulmonary bypass including blood flow rate, systemic vascular resistant, priming volume, and predicted hematocrit. Furthermore, Perfusion Assistant app. provides a quick, easy access, and real-time application for cardiopulmonary bypass that user’s satisfaction was a good level.
Marina M. Tabbara
Department of Surgery, University of Miami Miller School of Medicine; Miami, Florida; Miami Transplant Institute, University of Miami Miller School of Medicine, Jackson Memorial Hospital; Miami, Florida
Javier González
Servicio de Urología, Unidad de Trasplante Renal, Hospital General Universitario Gregorio Marañón; Madrid, Spain
Gaetano Ciancio
Department of Surgery, University of Miami Miller School of Medicine; Miami, Florida: Miami Transplant Institute, University of Miami Miller School of Medicine, Jackson Memorial: Department of Urology, University of Miami Miller School of Medicine; Miami, Florida
Abstract
Renal cell carcinoma (RCC) accounts for 2-3% of all malignant disease in adults and has a propensity to infiltrate the surrounding adjacent structures with a biologic predisposition for vascular invasion. This tropism for the venous system facilitates propagation into the renal vein and inferior vena cava (IVC) in up to 25% of patients with RCC. Surgical resection remains the mainstay treatment for RCC with venous tumor thrombus (TT) extension and the only hope for a potential cure. Higher thrombus levels correlate with more advanced stages of disease and thus poorer survival rates. Although CPB with circulatory arrest has been successfully performed during resection of these tumors, its use remains controversial due to the risk of coagulopathy, platelet dysfunction, and central nervous system complications. Complete intraabdominal surgical excision of level III thrombi can be achieved without sternotomy and CPB by utilizing hepatic mobilization maneuvers. The purpose of this review is to provide an update on the surgical management of these difficult cases of RCC with supradiaphragmatic tumor thrombi, including a description of transplant-based techniques that avoid sternotomy and cardiopulmonary bypass (CPB), minimizing intra- and post-operative complications.
Yahia M Lodi
Neurology, Neurosurgery & Radiology, Upstate Medical University and UHS-Hospitals1, Johnson City, NY
Abstract
Background: Cerebral Aneurysms (CA) including dissecting pseudoaneurysms are treated endovascularly through a trans-radial or trans-femoral approach. When these options are not available, a trans-carotid approach via Direct Carotid Artery Cutdown (DCAC) may be used as the last option. However, the safety and feasibility of DCAC is not well studied or defined in these contexts. Our objective is to present our four unique patients who were treated by the DCAC approach for their cerebral aneurysm and/or internal carotid artery dissecting pseudoaneurysm using flow diversion.
Method: This is a report of a case series and retrospective review.
Results: Patient 1; A 75-year-old woman with known left internal carotid artery (ICA) petrocavernous aneurysm that enlarged from 6 mm to 10 mm resulting in double vision and headaches. Trans-femoral approach failed due to the tortuosity in the common carotid artery (CCA). A multidisciplinary team was formed; A vascular surgeon began the surgery followed by FD by a neuroendovascular surgeon. A 6 French sheath was placed on the right common carotid artery via DCAC then brought to right ICA by vascular surgeon, and a neuroendovascular surgeon confirmed the placement with digital subtraction angiography (DSA). The DSA confirmed a large 10 x 8 x 5mm broad-based aneurysm. Flow diversion was performed with pipeline flex measuring 5 x 30mm. Patient was discharged home and achieved baseline modified Rankin Scale (mRS )1 which sustained in 5 years with aneurysm obliteration. Patient 2; A 65- year-old woman with multiple symptomatic left ICA-Para-ophthalmic artery aneurysm measuring 9 mm. Both femoral and radial arteries were occluded and underwent DCAC and flow diversion with pipeline flex of 4×30 mm using the similar technique described above. Patient discharged home in 48 hours with National Institute of Health Stroke Scale (NIHSS) of 0 and achieved her baseline mRS. However, this patient refused to have any further follow-up studies done. Patient 3; A 67-year-old man with aortic arch endograph with stent graft after previous aortic dissection and diagnosed with bilateral internal carotid artery dissecting pseudoaneurysm (ICADP) by computed topographic angiography (CTA). The right ICADP measured 19 x 15 x 20 mm, was multilevel, extending from skull base to the internal carotid artery (ICA) origin. The left ICADP was 16 x 9 x 22 mm with inflow-zone stenosis. The DSA was attempted but failed due to the aortic stent. The right ICADPA was repaired first using Surpass streamline (Stryker Neurovascular, Irving, CA) device measuring 4 x 50 mm x2 and 5 x 40 mm covering the entire dissecting artery. Patient was discharged home in 48 hours. Three months after the first procedure, using similar technique the left ICADPA was treated with a 5 x 50 mm Surpass evolve flow diverter. Patient achieved mRS 0. In 24-months follow up CTA demonstrated complete resolution of left ICDAP, but occlusion of the right ICA without impairing his mRS 0. Patient 4; a 76-year-old-woman with tinnitus, headaches and dizziness; DSA demonstrated RICA dissecting large 16 x 8 mm pseudoaneurysm. Trans-femoral approach failed and underwent DCAC, and flow diversion with a single surpass evolve flow diverter 4.5 x3 0 mm. Patient was discharged with NIHSS 0 and achieved her baseline mRs 0.
Yahia M Lodi
CAST Certified in Neuroendovascular Surgery Professor and Neurosciences Academic Chair Upstate Medical University, Binghamton, NY
Adam Bowen
Upstate Medical University, Binghamton & NYUHS-Hospitals, Binghamton, NY
Aria Soltani
Upstate Medical University, Binghamton & NYUHS-Hospitals, Binghamton, NY
Irfan Khan
Upstate Medical University, Binghamton & NYUHS-Hospitals, Binghamton, NY
H Polavarapu
Upstate Medical University, Binghamton & NYUHS-Hospitals, Binghamton, NY
Anas Hourani
Fort Hays State University, Haya, KS.
Abstract
Background: Despite the advancement in acute ischemic stroke with large vessel occlusion (LVO), golden time is lost in assessment lengthy neurological examination and redundantly in the Emergency department, often after emergency medical service prehospital stroke scale evaluation indicating possible LVO. A simple acute ischemic stroke scale (AISS) of the cortical representations of the anterior circulation can rapidly predict LVO, saving precious time to initiate early intravenous tissue plasminogen activator and endovascular mechanical thrombectomy. We proposed an ASIS in the emergency department called Gaze Weakness Neglect Speech (GWNS) to evaluate its feasibility and predictability for the detection of LVO in anterior circulation in the emergency department. Additionally, to evaluate if time can be gained that has been lost in obtaining National Institute of Health stroke Scale (NIHSS) and computed tomographic angiography (CTA), avoiding unnecessary radiation.
Methods: This is a prospective observational study. An institutional review board permission was obtained, and patient enrollment started in January 2020 and ended in January 2021. Consecutive patients from January 2020 to September 2021 were selected from the database. The GWNS stroke scale was used by stroke and vascular neurologist during the emergency triage. The GWNS stroke scale scores range from 0 to 4 (1 for positive 0 for negative). The GWNS stroke scale assesses gaze deviation or gaze preference (G), presence of any weakness (W), neglect/disregard (N), and any speech impairment (S). Demographic data, CTA/cerebral angiographic data, and scores from NIHSS were also collected. The collected data was analyzed by a biostatistician to determine the association between the GWNS scale score and LVO.
Results: In our study,109 qualifying patients were selected. Fifty-eight patients had GWNS stroke scale score of 3 or 4, with 57 having confirmed LVO and 1 presenting after a seizure. The GWNS stroke score ≥3 (0.86) correlated with LVO better than NIHSS (0.67), regardless of hemisphere side involvement. The GWNS stroke scale score of ≥3 also was effective in detection of proximal and distal blood vessels occlusion in the anterior circulation (Internal carotid artery, middle cerebral artery and its branches). A GWNS stroke scale score of ≥3 with presence of gaze was the most predictive for LVO (0.9) followed by neglect/disregards (0.8). The time to obtain GWNS stroke scale was 1.5 minutes (range 1-3) and time to obtain/interpretation CTA was 41.3 +/- 7.4 minutes after emergency department arrival (range: 29-51 minutes).
Conclusions: Our Gaze Weakness Neglect Speech stroke scale can be performed rapidly in the emergency department and is highly predictive of LVO in the internal carotid artery, middle cerebral artery and middle cerebral branches. A GWNS stroke scale score of ≥3 is highly predictive of LVO, especially when gaze or neglect is present. Patients can potentially bypass CTA or advanced imaging in future studies, saving precious time and millions of brain cells for better outcome.
Ryan Dashek
Comparative Medicine Program, Veterinary Pathobiology, University of Missouri-Columbia, MO, USA; Research Service, Harry S. Truman Memorial Veterans Hospital, Columbia, MO, USA
Yusuke Higashi
Medicine, Tulane University School of Medicine, New Orleans, LA, USA
Nitin A. Das
Cardiothoracic Surgery, UT Health, San Antonio, TX, USA
Jacob J. Russell
Comparative Medicine Program, Veterinary Pathobiology, University of Missouri-Columbia, MO, USA; Research Service, Harry S. Truman Memorial Veterans Hospital, Columbia, MO, USA
Luis A. Martinez-Lemus
Department of Biomedical, Biological and Chemical Engineering, University of Missouri-Columbia, MO, USA; Dalton Cardiovascular Center, University of Missouri, Columbia, MO, USA; Medical Pharmacology and Physiology, University of Missouri, Columbia, MO, USA; Department of Medicine, University of Missouri School of Medicine, Columbia, MO, USA
R. Scott Rector
Research Service, Harry S. Truman Memorial Veterans Hospital, Columbia, MO, USA; Department of Nutrition and Exercise Physiology, University of Missouri, Columbia, MO, USA; Division of Gastroenterology and Hepatology, Department of Medicine, University of Missouri, Columbia, MO, USA
Bysani Chandrasekar
Research Service, Harry S. Truman Memorial Veterans Hospital, Columbia, MO, USA; Dalton Cardiovascular Center, University of Missouri, Columbia, MO, USA; Medical Pharmacology and Physiology, University of Missouri, Columbia, MO, USA; Department of Medicine, University of Missouri School of Medicine, Columbia, MO, USA
Abstract
Aims: Chronic intermittent hypoxia (IH), a characteristic feature of obstructive sleep apnea (OSA), contributes to cardiovascular diseases, including atherosclerosis, potentially through persistent oxidative stress and inflammation. TRAF3IP2 (TRAF3 Interacting Protein 2) is an oxidative stress-responsive proinflammatory adapter molecule and plays a causal role in a preclinical model of atherosclerosis. Since SGLT2 (Sodium/Glucose Cotransporter 2) inhibitors have shown protective effects in CVD by inhibiting oxidative stress and inflammation, we hypothesized that IH promotes the crosstalk between oxidative stress and TRAF3IP2, resulting in IL-6-dependent human aortic smooth muscle cell (SMC) proliferation, and that these effects are inhibited by the SGLT2 inhibitor empagliflozin.
Materials and methods: Primary human aortic SMC were exposed to various cycles of IH. Normoxia served as a control. To understand the molecular mechanisms underlying IH-induced nitroxidative stress, TRAF3IP2 and IL-6 induction, and SMC proliferation and those targeted by empagliflozin were determined by treating SMC with various pharmacological inhibitors and viral vectors.
Results: IH upregulated TRAF3IP2 expression, TRAF3IP2-dependent superoxide, hydrogen peroxide and nitric oxide generation, NF-kB and HIF-1a activation, IL-6 induction, and SMC proliferation. Exposure to IL-6 by itself induced SMC proliferation in part via TRAF3IP2, IL-6R, gp130, JAK, and STAT3. Further, SMC express SGLT2 at basal conditions, and is upregulated by both IH and IL-6. Importantly, empagliflozin inhibited IH-induced TRAF3IP2 upregulation, reactive oxygen and nitrogen species generation, TRAF3IP2-dependent HIF-1a and NF-kB activation, IL-6 induction, and IL-6-dependent JAK-STAT3-mediated SMC proliferation. Moreover, empagliflozin inhibited IL-6-induced STAT3-dependent SMC proliferation.
Conclusions: These results suggest the therapeutic potential of empagliflozin in IH and inflammatory vascular proliferative diseases associated with OSA.
