bluuebunny/crossref_metadata_2025 huggingface dataset:
Ruptured Popliteal Aneurysm Resulting from Neurofibromatosis
Authors: Bueno Alicia , Acín Francisco , Rodríguez Jose M. , March Jose R. , de Benito Luis , Fernández-Casado Jose L.
Published: March 2006

Rupture of an aneurysm in a patient suffering from neurofibromatosis is a rare though documented complication. Presented here is the case of a 33-year-old woman with known neurofibromatosis who underwent repair of a symptomatic popliteal aneurysm. The presentation, diagnostic evaluation, and treatment are discussed, and the literature is reviewed on this rare entity.
The Effect of Secondary Operations on Mortality Following Abdominal Aortic Aneurysm Repair in the United States: 1988–2001
Authors: Eliason Jonathan L. , Wainess Reid M. , Dimick Justin B. , Cowan John A. , Henke Peter K. , Stanley James C. , Upchurch Gilbert R.
Published: March 2006

Certain complications following open repair of abdominal aortic aneurysms (AAAs) require additional operations or invasive procedures. The purpose of this study was to determine the effect of secondary interventions on mortality rate following open repair of intact and ruptured AAAs in the United States. Clinical data on 98,193 patients treated from 1988 to 2001 with an International Classification of Diseases, Ninth Revision, Clinical Modification(ICD-9-CM) primary procedure code 38.44 (resection of the abdominal aorta with replacement) were analyzed. Demographic factors, types of secondary interventions, and in-hospital mortality rates were assessed by univariate and multivariate logistic regression analysis (SPSS Version 11.0, Chicago, IL). The database utilized in this study was The Nationwide Inpatient Sample (NIS). The mortality rate was 4.5% in the intact AAA group and 45.5% in the ruptured AAA group. The rate of secondary operations and procedures was much higher in the ruptured AAA group, especially related to renal failure (5.52% vs 1.49%, p <0.001); respiratory failure (3.67% vs 0.71%, p <0.001); postoperative bleeding (2.41% vs 0.81%, p <0.001); or colonic ischemia (2.38% vs 0.36%, p <0.001). Increased mortality following open repair of intact AAAs accompanied: peripheral artery angioplasty/stenting (OR, 1.25; 95% CI, 1.04–1.51; p = 0.018); coronary artery angioplasty/stenting (OR, 1.68; 95% CI, 1.05–2.70; p = 0.031); inferior vena cava (IVC) filter placement (OR, 2.02; 95% CI, 01.31–3.1; p = 0.001); vascular reconstruction or thromboembolectomy (OR, 2.05; 95% CI, 1.9–2.22; p <0.001); lower extremity amputation (OR, 4.09; 95% CI, 2.78–6.0; p <0.001); coronary artery bypass (OR, 6.71; 95% CI, 3.74–12.03; p <0.001); operations for postoperative bleeding (OR, 6.92; 95% CI, 5.71–8.4; p <0.001); initiation of hemodialysis (OR, 10.52; 95% CI, 9.22–12.01; p <0.001); tracheostomy (OR, 11.9; 95% CI, 9.86–14.37; p <0.001); and colectomy (OR, 16.22; 95% CI, 12.55–20.95; p <0.001). Increased risk of mortality following open repair of ruptured AAAs accompanied the following: operations for postoperative bleeding (OR, 1.5; 95% CI, 1.22–1.85; p <0.001); colectomy (OR, 1.63; 95% CI, 1.32–2.01; p <0.001); and initiation of hemodialysis (OR, 2.66; 95% CI, 2.30–3.08; p <0.001). The only independent variable in this group associated with decreased risk of inhospital mortality was IVC filter placement (OR, 0.41; 95% CI, 0.27–0.64; p <0.001). This study confirms the perception that additional operations or invasive procedures following open repair of AAA entail significantly worse in-hospital mortality rates, especially when related to colonic ischemia, respiratory failure, and renal failure.
Deciphering Mesenteric Venous Thrombosis: Imaging and Treatment
Authors: Grisham Andre , Lohr Joann , Guenther J. Michael , Engel Amy M.
Published: March 2006

The principal cause of a high mortality rate in mesenteric vein thrombosis (MVT) is a delay in diagnosis. Recent data indicate that the mortality rate is decreasing owing to earlier diagnosis and anticoagulation. The authors examined the treatment profile of MVT to see how the increased use of imaging and early anticoagulation has impacted this process. They retrospectively analyzed the treatment paradigm with acute MVT at one institution over a 10-year period. Twenty-three patients were identified. Data were analyzed using chi-squares and Student's t tests. Twenty-three patients (11 men and 12 women with an average age of 51.74 ±14.8 years) were identified with acute MVT between the years of 1993 and 2003. Five patients had splenic vein thrombosis, 17 had superior mesenteric vein thrombosis, 1 had inferior mesenteric vein thrombosis, and 12 had portal vein thrombosis. Nine patients had combination mesenteric vein segment thrombosis. Thrombolytics were utilized in a total of 6 patients. Four of the 6 patients in whom lytics were utilized had combined mesenteric vein thrombosis; however, these 4 patients did not require surgical intervention. There was no significant difference in length of hospital stay between patients taking lytics versus patients treated with traditional anticoagulation with heparin (p = 0.291). A hypercoagulable state was identified in 66.7% of the patients. Four patients required surgical intervention. The overall mortality rate was 8.7% (2 of 23). The use of thrombolytics was associated with a significant mortality (p = 0.04). The use of antibiotics made no difference in mortality (p = 0.235), nor did antibiotic use influence length of hospitalization (p = 0.192). MVT is relatively rare, and often the delay in diagnosis increases the mortality rate. In the majority of cases prompt anticoagulation will preserve bowel viability and decrease mortality and morbidity rates. The majority of patients do not need surgery. There is a marked increase in mortality rate when these patients progress to surgical intervention. An increased awareness and early diagnosis has led to decreased morbidity and mortality rates.
A Changing Pattern of Infection After Major Vascular Reconstructions
Authors: Pounds Lori L. , Montes-Walters Miguel , Mayhall C. Glenn , Falk Pamela S. , Sanderson Ellen , Hunter Glenn C. , Killewich Lois A.
Published: March 2006

Wound and graft infection can occur in more than 40% of patients undergoing vascular reconstructions for peripheral arterial disease (PAD). A recent increase in the frequency and severity of infections, as well as a change in the microorganisms recovered, led us to undertake a retrospective case-controlled study of wound/graft infections at this institution. The medical records of all patients undergoing vascular reconstruction for PAD during the previous 36 months were reviewed. Patient demographics, graft location and conduit, infection location, causative microorganisms, and factors potentially associated with development of infection were recorded. Infections were classified according to a modification of the CDC criteria into superficial incisional, deep incisional, or involving the graft (body only, anastomosis without disruption, or anastomosis with disruption). Univariate and multivariate regression analyses were used to identify factors associated with the development of infection. Four hundred ten (84 aortic, 41 extraanatomic, and 285 infrainguinal) revascularization procedures were performed in 217 men and 193 women with a mean age of 62 years (range 43–88). The infection rate for the entire group was 11.0% (45/410). Eighty percent (36/45) occurred after infrainguinal reconstructions and 64% (29/45) of the infections involved the groin incision. Direct involvement of the graft occurred in 67% (30/45), and 27% (12/45) presented with anastomotic disruption. Of the infrainguinal infections, in situ and prosthetic reconstructions were associated with a significantly higher rate of infection than reversed vein grafts tunneled anatomically (p <0.001, chi-square analysis). Patients with nonautogenous grafts (24 expanded polytetrafluoroethylene and 2 bovine) presented with more advanced infections involving the graft (20/26 procedures) and were more likely to present with anastomotic disruption (11/26). Staphylococcus aureus was isolated in the majority of infections (64%) and in all cases involving graft disruption. Multivariate regression analysis identified the following factors associated with development of infection: previous hospitalization (p = 0.03), a younger age (p = 0.047), and the presence of a groin incision (p = 0.04). Twenty-five percent of graft infections resulted in major amputation, and 11% of patients with graft infection died as a result. The incidence, morbidity, and mortality of infections in vascular reconstructions for PAD are increasing dramatically, particularly in infrainguinal reconstructions involving groin incisions. Perioperative antibiotic selection should be modified to include coverage for all Staphylococcal subspecies and hospitalization before surgical procedures should be avoided.
Risk Factors for Poor Collateral Development in Claudication
Authors: De Vivo Salvatore , Palmer-Kazen Ulrika , Kalin Bo , Wahlberg Eric
Published: March 2006

The objective of this retrospective, cross-sectional study was to determine risk factors for poor collateral development in patients with claudication. The authors listed all patients with calf claudication who had undergone angiography in this hospital between 1999 and 2001 and extracted those with superficial femoral artery (SFA) occlusion, a popliteal artery without major lesions, and at least 1 patent calf artery. Forty-five patients met the criteria, and concomitant disease and claudication characteristics, ankle/brachial index (ABI) and number of outflow vessels were recorded. Three blinded observers calculated the number of collaterals on the angiograms, and the collateral count was related to the other factors by use of regression analysis. The mean patient age was 69 years (SD 11), and 62% were women. Their walking distance was 90 m (77) and ABI 0.47 (0.15). Thirty-three percent had diabetes and 50% had duration of symptoms longer than 5 years. The mean number of collaterals bypassing the occlusion was 15.1 (SD 4.8). Univariate regression analysis indicated an association (p <0.08) between few collateral vessels and diabetes, short duration of symptoms, current smoking habits, and old age. In the multivariate analysis only diabetes and short duration of symptoms were related to having few collaterals. In patients with claudication and SFA occlusion, few collaterals from the deep femoral artery appear to be associated with having diabetes and a short duration of symptoms.
Salvage of Critical Limb Ischemia with the “Trellis Reserve” of Subintimal Superficial Femoral-Popliteal Artery Occlusion: A New Modality in Managing Critical Limb Ischemia
Authors: Sultan Sherif , Heskin Leonie , Hynes Niamh , Akhtar Yousaf , Cough Val , Manning Brian , Aremu M. , Courtney D.
Published: March 2006

Subintimal angioplasty is a safe, effective, but nondurable procedure in treating long superficial femoral artery occlusions in patients with severe lower limb ischemia. The authors report a case of acute thrombosis that presented 16 weeks after subintimal angioplasty. The “Trellis” percutaneous thrombolytic infusion system permitted a controlled site-specific infusion of recombinant tissue-type plasminogen activator (rtPA). The unique design of the “Trellis” allowed complete aspiration of thrombus and avoiding regional and systemic thrombolytic side effects. The “Trellis” system is effective in percutaneous management of thrombotic lesions; however, intimal dissection may need to be addressed.
Outcome of Surgical and Endoluminal Intervention for Infrainguinal Bypass Anastomotic Strictures
Authors: Eagleton Matthew J. , Erez Orry , Srivastava Sunita D. , Henke Peter K. , Upchurch Gilbert R. , Stanley James C. , Wakefield Thomas W.
Published: March 2006

The objective of this study was to compare the outcomes of percutaneous transluminal angioplasty (PTA) versus open surgical repair of anastomotic strictures affecting infrainguinal bypasses. Anastomotic strictures affecting 39 bypasses in 36 patients were identified among 593 consecutive infrainguinal arterial reconstructions performed between 1994 and 2004. The mean age of affected patients was 65 ±2 years (range: 61 to 101 years). The original bypasses, with vein grafts outnumbering prosthetic grafts 2 to 1, were performed for acute (5%) and chronic (54%) limb-threatening ischemia, disabling claudication (28%), or popliteal aneurysms (13%). Anastomotic strictures were first recognized an average of 16 ±3 months (range 2 to 92 months) postoperatively. Strictures affected the distal anastomosis in 62% of cases and the proximal anastomosis in 38%. Primary patency, assisted primary patency, secondary patency, and limb salvage were assessed following PTA or open surgical repair of the strictures. Anastomotic strictures were detected following acute (41%) and chronic (18%) limbthreatening ischemia, claudication (13%), or during routine graft surveillance (28%) in asymptomatic patients. Graft thrombosis, occurring in 51% of patients at the time of presentation, was not affected by the site of anastomotic stricture, although prosthetic grafts were affected more than vein grafts (92% vs 31%). Interventions included PTA (67%) and conventional open procedures (33%). The latter included vein patch angioplasty, short interposition grafts, and redo bypasses. The stricture site and bypass material used in the original revascularization did not affect reintervention patency rates. Sixteen (62%) of the endovascular procedures were performed on a graft presenting with thrombosis, while only 4 (31%) were initially treated with operative therapy. Treatment of thrombosed grafts resulted in an 18-month patency of 32% compared to an 80% patency in treating grafts that were not occluded at the time of presentation (p <0.05). No anastomotic stricture repaired operatively required reintervention, whereas 42% of those treated by PTA required a mean of 1.3 additional reinterventions (p <0.03). Anastomotic strictures affecting infrainguinal bypass grafts contribute to low patency rates. Outcomes can be significantly improved if these strictures are identified before graft thrombosis. Open surgical repair, compared to PTA, provides improved graft function as evident by fewer subsequent interventions required to maintain graft patency.
Impact of Duplex Arteriography in the Evaluation of Acute Lower Limb Ischemia from Thrombosed Popliteal Aneurysms
Authors: Kallakuri Sreedhar , Ascher Enrico , Hingorani Anil , Markevich Natalia , Schutzer Richard , Hou Alexander , Nahata Suresh , Jacob Theresa , Yorkovich William
Published: March 2006

Acute limb-threatening ischemia from thrombosis may be the initial presentation of popliteal artery aneurysms (PAA) and is associated with amputation rates of 20–30%. Since contrast angiography may miss the diagnosis, the authors suspect that thrombosis of PAA may be an underappreciated cause of acute ischemia. Routine use of duplex arteriography (DA) may aid in the diagnosis and may help identify the outflow vessels with improved results. One hundred and nine patients (group 1) from 1994 to 1997 and 201 patients from 1998 to 2001 (group 2) presenting with acute limb-threatening ischemia were studied. None of the group 1 patients underwent preoperative DA and no diagnosis of acute popliteal artery aneurysm thrombosis was made. Ten patients with acute ischemia due to thrombosed popliteal artery aneurysms were identified in group 2 when preoperative DA was routinely performed. Urgent revascularization based on the results from DA was performed with use of autogenous saphenous vein in all patients. Six patients had functioning bypasses with a mean follow-up of 15.6 months. There were 3 deaths, 2 within 30 days and 1 after 2/ years with functioning grafts. One patient was lost to follow-up. No major amputations were performed. Incidence of thrombosed popliteal artery aneurysms as the cause of acute limb-threatening ischemia is probably underestimated. Routine use of DA may provide the diagnosis and identifies the available outflow vessels. Contrary to previously published reports, urgent revascularization of an acutely ischemic extremity from thrombosed popliteal aneurysm can provide excellent rates of limb salvage.
Outcomes of Endovascular AAA Repair in Patients with Hostile Neck Anatomy Using Adjunctive Balloon-Expandable Stents
Authors: Cox Daniel E. , Jacobs Donald L. , Motaganahalli Raghunandan L. , Wittgen Catherine M. , Peterson Gary J.
Published: March 2006

Hostile neck anatomy remains the predominant reason that patients are denied endovascular aneurysm repair (EVAR). We reviewed our experience of EVAR with use of prophylactic adjunctive proximal balloon-expandable stents in patients with hostile neck anatomy and adjunctive proximal balloon-expandable stents in patients with type I endoleaks. Of 140 patients who underwent EVAR between 2000 and 2004, we reviewed data for 19 patients in whom we used proximal balloon-expandable stents. By high-resolution computed tomography scan or angiography, hostile neck anatomy was classified as length <15 mm, neck diameters = 26 mm, circumferential thrombus at the proximal neck, angulated neck =60 degrees, and neck bulge or reverse taper necks. Patients were considered to have hostile anatomy if they met 1 or more of the above-cited criteria. All patients underwent AAA repair with commercially available endograft systems, Zenith (Cook, Bloomington, IN) and AneuRx (Medtronic/AVE, Minneapolis, MN). Balloon-expandable stents utilized included Cordis-Palmaz stents (17/19) and eV3 Max stents (2/19). Stents were deployed in the proximal graft with transrenal extension. AneuRx (18/19) and Zenith (1/19) endografts were used in all of the patients. Of the 19 patients, 15 had prophylactic stent placement for known hostile neck anatomy and 4 patients had stent placement for type I endoleak. Assisted primary technical success was achieved in all patients. Three patients had maldeployment of the endograft or proximal stent requiring additional endovascular interventions at the time of surgery. No endografts were deployed too low requiring stent placement. Procedure-related complications occurred in 2 of 19 patients. These included 1 operative death secondary to pneumonia and 1 patient who developed progressive renal failure. Short-term clinical success was achieved in 17 of 19 patients. Two patients required secondary interventions, 1 due to device migration with secondary conversion to open repair, and an endoleak, which, on angiogram, was a large type II endoleak successfully treated with coiling of the inferior mesenteric artery. One patient was observed to have a type II endoleak with no associated aneurysm enlargement. Short-term results suggest the use of prophylactic adjunctive balloon-expandable stents may decrease the incidence of secondary interventions related to hostile neck anatomy when used as an adjunctive measure with EVAR. Based on our experience, we feel EVAR may be offered to an expanded patient population with hostile neck anatomy with use of prophylactic balloon-expandable stents.
Can Computed Tomography Scan Findings Predict “Impending” Aneurysm Rupture?
Authors: Boules Tamer N. , Compton Christopher N. , Stanziale Stephen F. , Sheehan Maureen K. , Dillavou Ellen D. , Gupta Navyash , Tzeng Edith , Makaroun Michel S.
Published: March 2006

Several findings on computed tomography (CT) scans of intact aneurysms have been taken to suggest “imminent” or “impending” aneurysm rupture. Often these are identified incidentally in asymptomatic patients when an urgent operation was not planned and may even be ill advised. The authors evaluated whether these signs can truly predict short-term aneurysm rupture. A computerized medical archival system was reviewed from August 1994 to August 2004. Patients with aortic aneurysms and official CT scan reports of “impending rupture” were reviewed. CT films and reports were reviewed for aneurysm characteristics, while computerized medical records were reviewed for patient demographics, comorbidities, symptoms, documented subsequent rupture, and operative findings. Signs of “impending rupture” included the crescent sign, discontinuous circumaortic calcification, aortic bulges or blebs, aortic draping, and aortic wall irregularity. Rupture occurring within 2 weeks of the index CT was defined as supporting the “imminent” label. Forty-five patients with aortic aneurysms and CT stigmata of “impending rupture” were identified. Five patients with additional signs of suspicious leak and 1 with an infected previously repaired aneurysm were excluded. Of 39 intact aneurysms, 26 (67%) were infrarenal, 2 (5%) were suprarenal, and the remaining 11 (28%) were thoracoabdominal. The patient group had more women than expected (19/39, 49%) and larger aneurysms (mean diameter, 6.8 ±1.4 cm). Mean age was 74 years. Ten patients underwent elective repair within the first 2 weeks after the index CT scan (mean, 4 days), precluding adequate observation for early rupture. None had intraoperative signs of rupture. Early rupture: 2 of the 29 remaining patients ruptured within 72 hours of the CT scan, for a positive predictive value of 6.9%. One additional patient ruptured 7 months later after declining an early intervention. No Rupture: 26 patients were observed an average of 246 days (range, 14 days to 3 years) without evidence of rupture. Fourteen were repaired electively 2 weeks to 3 years after the index CT scan, and 12 never underwent repair, mostly because of severe associated comorbidities, and were observed a mean of 394 days without rupture. Although they should be taken seriously, CT signs of “impending rupture” alone are poor predictors of short-term aortic aneurysm rupture, and alternative terminology is needed until better predictors can be identified.
Mitogen-Activated Protein Kinase Pathway Regulates Cell Proliferation in Venous Ulcer Fibroblasts
Authors: Raffetto Joseph D. , Vasquez Ricardo , Goodwin David G. , Menzoian James O.
Published: March 2006

Venous ulcer fibroblasts have been demonstrated to have low growth rates in response to platelet-derived growth factor (PDGF). Mitogen-activated protein kinase (MAPK) is an important signal transduction mechanism that regulates growth, differentiation, and apoptosis in eukaryotic cells. PDGF binds PDGF receptors that activate a multitiered signaling cascade involving MAPK. We hypothesize that the growth regulation in venous ulcer fibroblasts is dependent on the MAPK extracellular signal-regulated kinase (ERK) pathway in the presence of PDGF. Fibroblasts (fb) were isolated from 8 patients with venous ulcers (w-fb) and the normal skin (n-fb) of the ipsilateral thigh via punch biopsies. Fb were plated at 1,500 cells/dish and treated with PDGF-AB (10 ng/mL) for 15 days. Growth rates were determined. Immunoblot analysis of MAPK ERK for n-fb and w-fb were analyzed. To determine if PDGF-stimulated w-fb and n-fb utilized the MAPK ERK pathway in a dependent manner, the upstream kinase MAPK kinase 1 (MEK 1) was inhibited by PD 98059. In addition, fb were treated with chronic venous ulcer wound fluid (WF) to study its effect on MAPK ERK. In the presence of PDGF, growth rates were substantially lower in w-fb than in n-fb, and MAPK was activated in 6/8 w-fb and in only 2/8 n-fb. Fibroblasts expressing MAPK had significantly reduced cell proliferation compared to fibroblasts not expressing MAPK (p = 0.023). PD 98059 significantly inhibited wfb and n-fb cell proliferation from basal level, which was reversible with addition of PDGF. In neonatal fibroblasts WF demonstrated inhibition of MAPK ERK over time and addition of PD98059 was not additive. This study suggests that the MAPK ERK pathway is important for cell proliferation in venous ulcer fibroblasts. In the presence of PDGF, fibroblasts with decreased growth rate express MAPK, and proliferation is further abrogated with addition of MEK 1 inhibitor, suggesting the importance of the MAPK ERK pathway regulating w-fb and nfb proliferation. Although the majority of w-fb activated the MAPK ERK pathway in the presence of PDGF, proliferation was significantly attenuated, indicating that other MAPK inhibitory pathways are competing. Venous ulcer wound fluid directly inhibits the MAPK ERK pathway, suggesting that the venous ulcer wound environment has negative trophic factors that effect fibroblasts proliferation and ulcer healing.
Delayed-Onset Heparin-Induced Thrombocytopenia and Thrombosis After Intraoperative Heparin Anticoagulation
Authors: Jackson Mark R. , Neilson William J. , Lary Michael , Baay Peter , Web Kent , Clagett G. Patrick
Published: March 2006

Delayed-onset heparin-induced thrombocytopenia (HIT) is a rare and only recently described condition. The authors report 4 cases of delayed-onset HIT, each of which presented with thrombotic complications 8–18 days after receiving heparin for coronary artery bypass grafting. Delayed-onset HIT should be suspected in any patient presenting with arterial or venous thromboembolism after heparin therapy, even 1 to 3 weeks after heparin exposure.
Ruptured Popliteal Artery Aneurysm
Authors: Parmer Shane S. , Skelly Christopher L. , Carpenter Jeffrey P.
Published: March 2006

A high index of suspicion for popliteal aneurysms must be present when evaluating a popliteal mass. Though typically pulsatile, in the presence of chronic thrombosis, the absence of a pulse may make the diagnosis even more difficult. A case is presented that illustrates this point, where an 83-year-old man presents following the biopsy of what turned out to be a very large popliteal aneurysm. In the presence of chronic thrombosis and adequate collateral flow, decompression and ligation of any feeding vessels is typically sufficient. These patients must be followed lifelong for the development of other associated aneurysms.
Catheter Embolization of an Hepatic Artery Aneurysm
Authors: Dwivedi Amit J. , Greben C. , Krishnasastry K. V.
Published: March 2006

Hepatic artery aneurysms (HAAs) are considered rare. The great improvement in the diagnosis of vascular diseases and the increasing incidence of atherosclerosis have resulted in a wider recognition of these pathologies. Differently from other splanchnic locations, HAAs have a high risk of rupture so that an aggressive treatment is required. Different therapeutic options are currently available: simple ligation of the artery, aneurysm excision with vascular reconstruction, and transcatheter embolization. We describe the usefulness of transcatheter arterial embolization of an 8 cm hepatic artery aneurysm incidentally found on an abdominal computed tomography (CT) scan in an asymptomatic patient.
A Current Assessment of Endoluminal Approaches to the Treatment of Gastroesophageal Reflux Disease
Authors: Portale Giuseppe , Filipi Charles J. , Peters Jeffrey H.
Published: March 2006

Over the past decade, a number of endoscopic techniques have been developed as alternatives to medical and surgical treatment of gastroesophageal reflux disease (GERD). The driving force was to provide an outpatient transoral, endoscopic procedure effective in controlling reflux in a portion of patients with GERD. Three major technologies emerged, although each use different approaches to augment the barrier function of the lower esophageal sphincter, mechanisms may be similar. These include Endocinch which tightens the gastroesophageal junction via a set of suture plications around the lower esophageal sphincter, Stretta, which delivers radiofrequency energy at the cardia, and Enteryx, which is an inert polymer injected into the muscle layer of the gastroesophageal junction. To date, the underlying mechanism of action of these procedures has not been completely elucidated, although each alters the compliance of the GEJ and thus its ability to respond to a “refluxogenic stress”. The target population currently consists of proton pump inhibitor-dependent GERD patients, with little or no hiatal hernia and without severe esophagitis or Barrett's. The Stretta procedure is the only procedure to date to be subjected to a sham-controlled trial. Registries of complications suggest that these techniques are relatively safe, but serious morbidity including rare mortality have been reported. All can be performed on an outpatient basis. Future comparative studies with predetermined end points, validated outcome measures, prolonged follow-up, and complete complication registries are needed to determine the role of endoscopic procedures in the clinical practice of patients with GERD. Evolution of the current technologies will almost certainly occur, and a commonly performed, efficacious endoscopic antireflux procedure is likely to emerge.
Initiation and Progression of Physical Activity After Laparoscopic and Open Gastric Bypass Surgery
Authors: Evans Ronald K. , Bond Dale S. , DeMaria Eric J. , Wolfe Luke G. , Meador Jill G. , Kellum John M.
Published: March 2006

This study compared postoperative physical activity participation among patients who underwent laparoscopic (LGBS) or open gastric bypass surgery (OGBS). Postoperative physical activity participation is considered important for achieving optimal weight loss and maintenance after gastric bypass surgery. However, no study has examined the relationship between surgery type and postoperative physical activity. Minimal invasiveness and reduced recovery time associated with LGBS compared with OGBS may permit earlier initiation and faster progression of postsurgical physical activity and potentially contribute to greater long-term adherence rates. Self-reported physical activity participation and aerobic physical activity hours per week at 2-weeks, 3-months, and 6-months postsurgery were assessed among LGBS and OGBS patients (presurgical body mass index of 35 to 70 kg/m2) at a university hospital from 1988-2002. Of the 2,235 patients, 531 (24%) and 1704 (76%) underwent LGBS and OGBS, respectively. A greater proportion of LGBS patients reported physical activity participation at each time point compared with OGBS patients (2 week, 76% vs 62%; 3 months, 84% vs 74%; 6 months, 85% vs 76%). Furthermore, LGBS patients reported a significantly greater physical activity duration at 2-weeks postsurgery compared with OGBS patients. A nonsignificant trend toward greater physical activity duration was observed in the LGBS patients at 3 months, whereas 6-month physical activity duration was similar between groups. LGBS, compared with OGBS, may promote earlier onset, progression, and maintenance of physical activity until 6 months postsurgery. Future studies need to prospectively determine whether LGBS, via facilitation of greater engagement in postsurgical physical activity, contributes to more successful weight loss and weight maintenance compared with OGBS.
Novel Technology and Innovations in Colorectal Surgery: The Circular Stapler for Treatment of Hemorrhoids and Fibrin Glue for Treatment of Perianal Fistulae
Authors: Person Benjamin , Wexner Steven D.
Published: March 2006

The introduction of new techniques and technologies in medical science is both stimulating and controversial. This article is a review of the current status of two such advances. Since its first description, the so-called “stapled hemorrhoidectomy” has been gaining increasing popularity, at first in Asia and Europe, and more recently in the United States. It is obviously a misnomer, since no excision of hemorrhoidal tissue is undertaken in this procedure. It is probably the most significant change in the surgical treatment of hemorrhoids since the introduction of conventional hemorrhoidectomy. Patients routinely experience less postoperative pain and have excellent control of symptoms, with few serious complications in most series. Despite a relatively simple operative technique, the procedure still has specific steps and features that must be followed and mastered to help insure success. The use of fibrin glue for treatment of perianal fistulae has also been a controversial issue, thus it is seldom included in any algorithm as a therapeutic step for fistula-in-ano. The reported success rates of the treatment range from 0% to 100% owing to the heterogeneity of the clinical trials, treatment protocols, patients, etiologies, and types of fistulae. However, the benign nature, simplicity, negligible morbidity, and repeatability of the treatment, potentially makes fibrin glue an attractive first line treatment for perianal fistulae.
Ampullary Tumors: Endoscopic Versus Operative Management
Authors: Tran Tin C. , Vitale Gary C.
Published: March 2006

Most ampullary adenomas (80%) are common benign ampullary tumors; however, they can range from mild dysplasia to high-grade dysplasia to invasive carcinoma. They are considered premalignant lesions found in the setting of familial polyposis syndromes or found sporadically, usually manifested by vague abdominal pain, liver enzyme elevation, jaundice, recurrent pancreatitis, or with uncommon symptoms such as gastrointestinal bleeding or duodenal obstruction. Endoscopic retrograde cholangiopancreatography with biopsy is a minimally invasive technique used to visualize these tumors directly and to evaluate their histologic characteristics. Definitive treatment primarily depends on these histologic results. Local resection has a high rate of recurrence (5% to 30%) and requires postoperative endoscopic surveillance, which is the reason it is not considered as a first choice in the management of ampullary tumors. The operative mortality is 10% or less for pancreaticoduodenectomy, a procedure of choice at most experienced centers for frank carcinoma, foci papillary adenocarcinoma in pre-excisional biopsies, or high-grade dysplasia ampullary adenomas. Endoscopic interventions for presumed benign ampullary adenomas have resolved symptoms of obstruction, but long-term follow up is necessary to detect early malignant transformation. In summary, the choice of treatment depends on level of surgical skill available, patient tolerance of long-term endoscopic surveillance versus radical surgery, and the presence or absence of coexisting familial adenomatous polyposis.
Minimally Invasive Surgeons of Texas: A New Concept in Fellowship Training
Authors: Wilson Erik B. , Scarborough Terry K. , Reardon Patrick R. , Leggett Philip L. , Franklin Morris E.
Published: March 2006

Minimally invasive fellowship training has seen phenomenal growth, with 94 organized fellowship programs in North America. Training experience is varied across programs owing to the differences in surgical practices. Many programs are often weighted to a specific field of advanced laparoscopic surgery, which can limit a fellow's clinical experience. Minimally Invasive Surgeons of Texas (MIST) is a combined organization of four independent private practice and academic MIS fellowships brought together for the common goal of improved fellowship training.
A Broader View of Marketing: Implications for Surgeons
Authors: Kelley Scott W. , Schwartz Richard W.
Published: March 2006

The health care sector of the economy is changing. There is unprecedented growth in the health care sector, and competitive forces have a more prominent role. In addition, consumers have become more informed and as a result, more empowered. Patients in the health care sector are no exception to this trend. As patients become more informed, it is imperative that health care providers become more effective at marketing their services. In general, physicians typically have received little training in the field of marketing, which results in potentially limited understanding of the key marketing issues being faced in today’s health care environment. We identify and examine several key marketing issues critical to the success of health care providers in today’s environment. Further, we offer some managerial recommendations designed to address each of these issues.
Laparoscopic Splenectomy: What Barriers Remain?
Authors: Weiss Carl A. , Kavic Stephen M. , Adrales Gina L. , Park Adrian E.
Published: March 2006

Conditions that once were considered either relative or absolute contraindications for laparoscopic splenectomy have become fewer and less significant in the overall assessment of candidates for this procedure. Advances in surgical technique, operative conduct, and instrumentation have made it feasible to perform splenectomy laparoscopically with good outcomes and minimal morbidity in a variety of different pathologic conditions. Obesity, malignancy, pregnancy, and splenomegaly are assessed here in detail.
Does Hyaluronic Acid-Carboxymethylcellulose (HA-CMC) Membrane Interfere With the Healing of Intestinal Suture Lines and Abdominal Incisions?
Authors: Yamaner Sümer , Kalayci Murat , Barbaros Umut , Balik Emre , Bulut Türker
Published: March 2006

Although hyaluronic acid-carboxymethylcellulose (HA-CMC) membrane has the advantage of preventing intraabdominal adhesions, it has theoretical risk of negative effects on the healing of intestinal suture lines by forming a barrier between the suture lines and neighboring serosal surfaces. This study evaluated the effect of HA-CMC on bowel anastomoses, scar healing, and intraabdominal adhesion formation. Two groups of 10 male Sprague-Dawley rats were examined. In the first group, laparotomy was performed with a median incision. Colotomy on the cecum and a single-layer repair of the bowel wall was performed. HA-CMC membrane was placed on the cecal suture line and under the laparotomy incision before abdominal closure. The second group had the same procedure but no HACMC membrane was placed. The animals were killed on postoperative day 14. Intraabdominal adhesions, laparotomy suture line endurance, bursting pressure of the repaired cecal wall, and tissue hydroxyproline levels were determined. The repaired cecal wall was also examined histopathologically. The statistical analyses revealed that HA-CMC prevented intraabdominal adhesions significantly. No negative effects of this material on the healing of the bowel and laparotomy suture lines were observed. HA-CMC appears to be a safe material to prevent intraabdominal adhesions, without negative effects on the healing of abdominal incisions and bowel suture lines.
A Basis for Electronic Cognitive Simulation: The Heuristic Patient
Authors: Mallott David , Raczek John , Skinner Craig , Jarrell Kevin , Shimko Mark , Jarrell Bruce
Published: March 2006

Although medical trainees are expected to become expert quickly and safely, limited electronic methods are available to rehearse medical cognition for common outpatient and nonemergent inpatient problems. We conducted a series of formal observational sessions designed to determine what interaction requirements are desirable for student rehearsal of medical management by using an electronic patient. The studies utilized both manual and electronic methods for a student to evaluate and manage patients with medical and surgical problems. We observed the following major requirements for an effective simulation experience: the user must have a trial-anderror experience with the patient; the user must have unconstrained access to query and treat the patient; anatomic and physiologic values in the patient must change appropriately in response to user actions; and the user must be able to control certain time-related aspects of the simulation. When these requirements are implemented within a simulation, userdirected management of an electronic patient, by itself, becomes a strong aid to learning by trial-and-error techniques. We conclude that the heuristic patient is a practical and useful concept. Once fully developed, it would allow rehearsal of patient care decision making, intrinsically demonstrating trainee knowledge deficits, and resulting in self-directed learning.
The Argument for Lightweight Polypropylene Mesh in Hernia Repair
Authors: Cobb William S. , Kercher Kent W. , Heniford B. Todd
Published: March 2006

The development of polypropylene prosthetics revolutionized surgery for the repair of abdominal wall hernias. A tensionfree mesh technique has drastically reduced recurrence rates for all hernias compared to tissue repairs and has made it possible to reconstruct large ventral defects that were previously irreparable. The repair of abdominal wall defects is one of the most commonly performed general surgical procedures, with over 1 million polypropylene implants inserted each year. Surprisingly, little research has been performed to investigate the interaction of abdominal wall forces on a ventral hernia repair or the required amount or strength of the foreign-body material necessary for an adequate hernia repair. The longterm consequences of implantable polypropylene prosthetics are not without concern. The body generates an intense inflammatory response to the prosthetic that results in scar plate formation, increased stiffness of the abdominal wall, and shrinkage of the biomaterial. Reducing the density of polypropylene and creating a "light weight" mesh theoretically induces less foreign-body response, results in improved abdominal wall compliance, causes less contraction or shrinkage of the mesh, and allows for better tissue incorporation. A review of the laboratory data and short-term clinical follow-up is reviewed to provide a strong basis or argument for the use of "light weight" prosthetics in hernia surgery.
Effective Training and Assessment of Surgical Skills, and the Correlates of Performance
Authors: Hamstra Stanley J. , Dubrowski Adam
Published: March 2006

This report briefly describes the University of Toronto Surgical Skills Centre and summarizes research in technical skills conducted at that site. This includes work on curriculum evaluation, the development and validation of assessment instruments, the retention of technical skills after training, and the prediction of success in surgery. These studies benefited from the large number of participants made available by the Surgical Skills Centre, allowing for randomized controlled studies or correlation studies where larger numbers are necessary for adequate statistical power. Recent emphasis has been on the further development of objective means of assessment and the exploration of correlates of surgical performance. Ongoing research is also aimed at simulator validation.
Assessing Mental Workload During Laparoscopic Surgery
Authors: Carswell C. Melody , Clarke Duncan , Seales W. Brent
Published: March 2006

Although the use of performance efficiency measures (speed, movement economy, errors) and ergonomic assessments are relatively well established, the evaluation of cognitive outcomes is rare. This report makes the case for assessment strategies that include mental workload measures as a way to improve training scenarios and training/operating environments. These mental workload measures can be crucially important in determining the difference between well-intentioned but subtly distracting technologies and true breakthroughs that will enhance performance and reduce stress.
Cholecystectomy After Endoscopic Sphincterotomy for Common Bile Duct Stones: Is Surgery Necessary?
Authors: Harris Hobart W. , Davis Brian R. , Vitale Gary C.
Published: March 2006

It has been more than 30 years since the introduction of endoscopic sphincterotomy for the management of choledocholithiasis. Once introduced, this endoscopic intervention subsequently enabled clinicians to witness the natural history of leaving the gallbladder in situ once the common duct calculi were removed. Because many people were free of symptoms once the common bile duct was cleared of stones, patients and physicians alike soon questioned whether it was necessary to remove the gallbladder at all. Despite more than two decades of clinical research and numerous published reports, the answer to this question remains elusive. Similarly, the management algorithm for choledocholithiasis in patients with an intact gallbladder remains controversial. We review the available key data regarding this question. Importantly, there are only three prospective, randomized trials that have examined the need for cholecystectomy after endoscopic sphincterotomy, with case studies constituting most of the published reports. Consequently, the literature on this topic remains inconclusive, weakened by its retrospective approach, considerable variability between the patients studied, inconsistent inclusion and exclusion criteria, and frequently poor patient follow-up. Nonetheless, the preponderance of data favor removing the gallbladder after endoscopically clearing the common bile duct of gallstones because an estimated 25% of patients will experience recurrent symptoms within a 2-year follow up period. Recognizing the existence of various mitigating clinical factors, we advocate adopting a selective wait-and-see approach for high-risk patients, especially those with a life expectancy of less than 2 years or severely debilitating comorbidities.
Optional Vena Cava Filters for Patients with High Thromboembolic Risk: Questions to be Answered
Authors: Sing Ronald F. , Rogers Frederick B. , Novitsky Yuri W. , Heniford B. Todd
Published: March 2006

The use of vena cava filters has increased rapidly over the past few years to more than 140,000 filters inserted worldwide in 2003. Continued improvements in filter design have increased the safety of intravascular caval filtration. Although there are many factors attributed to this increase, the most significant contributing factor has been the development of optional vena cava filters. That is, filters that can be left as a permanent device or can be removed endovascularly at a later date. Three filters are approved for removal in the United States, the Günther Tulip, the OptEase, and the Recovery. Recent reports have demonstrated the safety and feasibility of these devices in appropriate patients, but a number of questions have arisen regarding their use.
Real-Time Objective Assessment of Knot Quality With a Portable Tensiometer Is Superior to Execution Time for Assessment of Laparoscopic Knot-Tying Performance
Authors: Ritter E. Matt , McClusky David A. , Gallagher A. G. , Smith C. Daniel
Published: March 2006

Objective: Laparoscopic intracorporeal knot tying is a difficult skill to acquire. Currently, time to complete a knot is the most commonly used metric to assess the acquisition of this skill; however, without a measure of knot quality, time is a poor indicator of skills mastery. Others have shown that knot quality can be accurately assessed with a tensiometer, but obtaining this type of assessment has typically been cumbersome. We investigated a new method of real-time assessment of knot quality that allows for more practical use of knot quality as a performance metric. Methods: Eleven experienced endoscopic surgeons tied 100 intracorporeal knots in a standard box trainer. Each of the knots was immediately tested using the InSpec 2200 benchtop tensiometer (INSTRON, Canton MA) where a knot quality score (KQS) is generated based on the load handling properties of the knotted suture. The execution time was also recorded for each knot. Results: The assessment of all knots ended with one of two end points: knots that slipped (n = 48)or knots that held until the suture broke (n = 52). Knots that slip are generally of poorer quality than those that held. Execution time did not correlate with knot-quality score (r= 0.009, P= .9), and the mean execution time did not differ significantly between slipped and held knots (65 vs 68 seconds, P= .8). No completion time criteria were able to accurately predict slipped versus held knots. The mean KQS difference between held and slipped knots was highly significant (24 vs 12, P< .0001). A knot with a KQS exceeding 20 was nearly 10 times more likely to hold than slip. Conclusion: Time to complete a knot is a poor metric for the objective assessment of intracorporeal knot-tying performance in the absence of a measure of knot quality. Real-time evaluation of the knot quality can accurately distinguish welltied knots from poorly tied knots. This mode of assessment should be incorporated into training curriculum for surgical knot tying.