Pancreaticoduodenal Artery Aneurysm Complicated by Median Arcuate Ligament Syndrome

PURPOSE

To highlight median arcuate ligament syndrome as a potential cause for celiac artery stenosis and pancreaticoduodenal artery aneurysm, and describe treatment options in this setting.

CASE REPORT

A 63-year-old male presented with a pancreaticoduodenal artery aneurysm and concomitant celiac artery stenosis that was treated with celiac artery stenting and aneurysm coiling. He subsequently developed stent fracture and celiac artery occlusion secondary to previously unrecognized median arcuate ligament syndrome causing reperfusion of the aneurysm. This was treated with open median arcuate ligament release and aorta to common hepatic artery bypass with good clinical result and stable 20-month surveillance imaging.

CONCLUSION

It is critical to recognize median arcuate ligament syndrome as a cause of celiac artery stenosis in the setting of pancreaticoduodenal artery aneurysm given the high risk of failure of endovascular stenting. Open aorto-hepatic artery bypass and endovascular aneurysm coiling should be the preferred approach in these patients.

Impact of a High Observation Trauma Protocol on Patients with Isolated Traumatic Brain Injury

BACKGROUND

Nationally, the volume of geriatric falls with intracranial hemorrhage (ICH) is increasing. Our institution began observing patients with ICH, a GCS ≥ 14, and no midline shift or intraventricular hemorrhage with hourly neurologic examination outside the ICU in a high observation trauma (HOT) protocol. We first excluded patients on anticoagulants/antiplatelets (HOT I), then included antiplatelets and warfarin (HOT II) and finally included direct oral anticoagulants (HOT III). Our hypothesis is that HOT protocol safely reduces ICU utilization and creates cost savings in this patient population.

STUDY DESIGN

Our institutional trauma registry was retrospectively queried for all patients on HOT protocol. Patients were stratified based on date of admission: HOT I (2008-2014), HOT II (2015-2018) and HOT III (2019-2021). Demographics, anticoagulant use, injury characteristics, lengths of stay (LOS), incidence of neuro-intervention, and mortality.

RESULTS

Over the study period, 2343 patients were admitted, including HOT I (n=939), HOT II (n=794), and HOT III (n=610). Of these patients, 331 (35%), 554 (70%), and 495 (81%) were admitted to the floor under HOT protocol. HOT patients required neurointervention in 3.0%, 0.5% and 0.4% of cases over HOT I, II, and III, respectively. Mortality among HOT protocol patients was found to be 0.6% in HOT I, 0.9% in HOT II and 0.2% in the HOT III cohort (p=0.33).

CONCLUSION

Across the study period, ICU utilization decreased without an increase in neurosurgical intervention or mortality indicating the efficacy of the HOT selection criteria in identifying appropriate candidates for stepdown admission and high observation trauma protocol.

Endovascular therapy for Stanford B aortic dissection for patients with Marfan Syndrome: systematic review and meta-analysis

INTRODUCTION

The role of thoracic endovascular aortic repair (TEVAR) in patients with Marfan Syndrome with Stanford type B aortic dissection (TBAD) remains under debate.

EVIDENCE ACQUISITION

MEDLINE and EMBASE were searched through December 2021 to identify studies that investigated outcomes in MFS patients with TBAD who underwent TEVAR. Data regarding patient characteristics, perioperative and late outcomes were extracted.

EVIDENCE SYNTHESIS

Twelve studies were identified including 120 patients. The mean age was 40.2 years (95% confidence interval [CI], 36.8-43.6). 40.4% (95% CI: 10.8-70.0) of cases were performed emergently. 76.2% (95% CI: 64.6-87.8) of patients had a history of previous aortic surgery. In-hospital mortality was 3.7% (95% CI: 0.6-6.8). Primary endoleak occurred in 15.2% (95% CI: 8.6-21.8), which was comprised of type 1 (9.3% [95% CI: 3.9-14.6]) and type 2 (7.1% [95% CI: 2.3-12.0]) endoleaks. During mean follow-up period of 37.4 months (95% CI: 24.1-50.7), secondary endoleak was reported in 14.1% (95% CI: 7.1-21.1), which was comprised of type 1 (7.4% [95% CI: 2.4-12.5]) and type 2 (4.0% [95% CI: 0.3-7.7]) endoleak. Repeat TEVAR was performed in 15.5% (95% CI: 9.3-21.8) and open aortic surgery in 18.6% (95% CI: 9.6-27.5). Long-term mortality was 11.9% (95% CI: 6.5-17.3).

CONCLUSIONS

Our analysis showed that TEVAR for TBAD in patients with MFS has low perioperative morbidity and mortality but was associated with a high rate of late reintervention. This treatment option should be limited to emergent cases and to patients deemed unsuitable for open repair. Lifelong follow-up with imaging is mandatory in this population.

[The practice of episiotomy in France 10 years after the recommendations of CNGOF: What inventory?]

Since its creation, the practice of episiotomy has evolved, being influenced by several factors. Various stances on its use were stated, until the eventual reduction of this practice, as suggested by numerous practical guides. In 2005, the National College of Obstetricians and Gynecologists in France published its French Guidelines for Clinical practice in this area. Today, it seems appropriate to focus on the evolution of the use of episiotomy, ten years after the publication of these recommendations. The authors propose a literature review, browsing through all the available epidemiological data in France related to episiotomy, recording all national statistics and some local trends, as there are regional specificities. This review allows to follow the overall evolution of the practice of episiotomy in France between 1981 and 2014, and to identify territorial disparities. Finally, in the specific context of the practice of episiotomy in French gynecological and obstetrics field, the authors conclude it by considering the possible evolution of this surgical practice, as well as, the Clinical Practice Recommendations related to it.

Modulation of biliary lipid secretion by forskolin and cyclic AMP analogues

Exposure of isolated perfused rat livers to either 100 microM-forskolin, a potent activator of adenylate cyclase, or to 0.5 mM-concentrations of the cAMP analogues chlorophenylthio cAMP (CPTcAMP), dibutyryl cAMP (dbcAMP) and 8-bromo cAMP (8BrcAMP), to provoke increases in intracellular concentrations of cAMP, resulted in marked changes in bile volume and composition. Bile flow reached a peak after 10 min, before declining towards control levels, and an increase in several secretory parameters was also observed at this time. At 20 min, a substantial decrease in the output of both phospholipid and cholesterol was evident, and this suppression of secretion was maintained throughout the remainder of the experiment. The order of effectiveness of the cAMP-elevating agents at decreasing biliary lipid output was CPTcAMP greater than forskolin greater than dbcAMP greater than 8BrcAMP. Biliary output of bile acids was essentially unaltered compared with controls; similarly, no decrease in the secretion of protein and triacylglycerols into the perfusion medium was observed. This suggests that the elevation of intracellular levels of cAMP may cause a selective inhibition of biliary lipid output rather than a more general inhibition of hepatic secretion.