Predicting Symptom Relief After Reoperation for Suspected Internal Herniation After Laparoscopic Roux-en-Y Gastric Bypass

Background

Internal herniation (IH) is one of the most common long-term complications after laparoscopic Roux-en-Y gastric bypass (LRYGB). Diagnosis of IH may be difficult, and not all patients with suspected IH will have full relief of symptoms after closure of both mesenteric defects.

Objectives

To investigate possible predictive factors for relief of symptoms in patients with suspected IH.

Methods

All patients that underwent reoperation for (suspected) IH after LRYGB from June 2009 to December 2016 were retrospectively evaluated in this multicentre cohort study. Logistic regression analysis was used to identify predictive factors for pain relief after closure of the mesenteric defects.

Results

A total of 193 patients underwent laparoscopy for (suspected) IH during the study period. The median interval between LRYGB and reoperation was 18.3 ± 19.0 months. In 40.2% of cases, IH was identified on computed tomography (CT), and IH was objectified during surgery in 61.1%. Postoperative symptom relief was observed in 146 patients (77.2%). For patients in which IH was present during surgery, 82.8% had relief of pain postoperatively, as compared to 68.5% for those procedures in which no IH was found. The only significant predictor for postoperative pain relief was a swirl sign on CT (OR 4.24, 95%CI 1.63–11.05).

Conclusions

Pain relief after closure of the mesenteric defects for IH remains unpredictable. A positive CT for IH was a predictive factor for symptom relief after reoperation for (suspected) IH after LRYGB. However, many patients benefit from closure of the mesenteric defects, irrespective of perioperative presence of IH.

The influence of hospital volume on long-term oncological outcome after rectal cancer surgery

PURPOSE

The association between hospital volume and outcome in rectal cancer surgery is still subject of debate. The purpose of this study was to assess the impact of hospital volume on outcomes of rectal cancer surgery in the Netherlands in 2011.

METHODS

In this collaborative research with a cross-sectional study design, patients who underwent rectal cancer resection in 71 Dutch hospitals in 2011 were included. Annual hospital volume was stratified as low (< 20), medium (20-50), and high (≥ 50).

RESULTS

Of 2095 patients, 258 patients (12.3%) were treated in 23 low-volume hospitals, 1329 (63.4%) in 40 medium-volume hospitals, and 508 (24.2%) in 8 high-volume hospitals. Median length of follow-up was 41 months. Clinical tumor stage, neoadjuvant therapy, extended resections, circumferential resection margin (CRM) positivity, and 30-day or in-hospital mortality did not differ significantly between volume groups. Significantly, more laparoscopic procedures were performed in low-volume hospitals, and more diverting stomas in high-volume hospitals. Three-year disease-free survival for low-, medium-, and high-volume hospitals was 75.0, 74.8, and 76.8% (p = 0.682). Corresponding 3-year overall survival rates were 75.9, 79.1, and 80.3% (p = 0.344). In multivariate analysis, hospital volume was not associated with long-term risk of mortality.

CONCLUSIONS

No significant impact of hospital volume on rectal cancer surgery outcome could be observed among 71 Dutch hospitals after implementation of a national audit, with the majority of patients being treated at medium-volume hospitals.

Correction to: Age-Related Effects of Bariatric Surgery on Early Atherosclerosis and Cardiovascular Risk Reduction

Frederik H. W. Jonker and Vera A. A. van Houten contributed equally to this work.

Comparison of a low Hartmann's procedure with low colorectal anastomosis with and without defunctioning ileostomy after radiotherapy for rectal cancer: results from a national registry

AIM

This study used a national registry to compare the outcome after a low Hartmann's procedure (LHP), defined as removal of most of the rectum to leave a short anorectal stump and an end colostomy, and low anterior resection (LA) with or without a diverting ileostomy (DI) in rectal cancer patients all of whom had received preoperative neoadjuvant radiotherapy (RT).

METHOD

Patients who underwent LHP or LA with or without DI for rectal cancer after RT between 2009 and 2013 were identified from the Dutch Surgical Colorectal Audit. The postoperative outcome was compared between the three groups and risk of complications, reoperation and mortality were analysed in a multivariable model.

RESULTS

The study included 4288 patients were included, of whom 27.8% underwent LHP, 20.2% LA and 52.0% LA with DI. Thirty-day mortality was higher after LHP (3.2% vs 1.3% and 1.3% for LA with or without DI, P < 0.001), but LHP was not an independent predictor of mortality in multivariable analysis. LHP and LA with DI were associated with a lower rate of abdominal infective complications (6.5% and 10.1% vs 16.2%, P < 0.001) and reoperation (7.3% and 8.1% vs 16.5%, P < 0.001). In multivariable analysis, LHP (OR 0.35, 95% CI 0.26-0.47) and LA with DI (OR 0.43, 95% CI 0.33-0.54) were associated with a lower risk of reoperation than LA alone. LHP was associated with a lower risk of any postoperative complication than LA with or without DI (OR 0.81, 95% CI 0.66-0.98).

CONCLUSION

LHP and LA with DI were associated with fewer infective complications and reoperations than LA alone. The rate of any complication was less after LHR than LA with or without DI.

Aneurysm Sac Enlargement after Endovascular Abdominal Aortic Aneurysm Repair

The aim of this study is to give an overview of current knowledge regarding abdominal aortic aneurysm (AAA) growth after endovascular aortic aneurysm repair (EVAR) that could potentially lead to aortic rupture. A search on Pubmed was performed. A total of 705 articles were found after initial search, of which 49 were included in the final selection. Reports on the incidence of aneurysm enlargement after EVAR vary between 0.2% and 41%. Continuous growth could lead to rupture of the aneurysm sac. There are several supposed risk factors for growth after EVAR. Endoleaks remain a hot topic as these could lead to persistent pressurization of the aneurysm sac causing growth. Various types of endoleak exist, of which each kind requires an individual treatment approach, other risk factors for aneurysm growth include endotension and the use of EVAR outside instructions for use (IFU). Reinterventions after EVAR are common; however, it is unclear how frequently these are required because of aneurysm enlargement. Aneurysm enlargement after EVAR remains a subject of debate, as this could lead to aortic rupture. This emphasizes the need for life-long radiologic surveillance during follow-up. Aortic growth after EVAR is often a result of endoleak; however, in some cases, no endoleak is detectable. Endoleak in combination with aortic growth >5 mm generally requires reintervention. A cause of concern is the liberal use of endovascular devices outside the IFU that may result in increased risk of AAA growth after EVAR.

Predictors of false lumen thrombosis in type B aortic dissection treated with TEVAR

BACKGROUND

Thoracic endovascular aortic repair (TEVAR) offers a less invasive treatment option in type B aortic dissection (TBAD) patients and its value has been demonstrated in acute and chronic dissection patients. Total false lumen thrombosis (FLT) is associated with better long-term outcome in these patients, however, this is not obtained in all patients. The purpose of this study was to investigate predictors of FLT.

METHODS

We retrospectively investigated patients who underwent TEVAR for a type B dissection in a large referral center between 2005 and 2012. All patients with a CT angiogram (CTA) obtained preoperatively, postoperatively and after one year of follow-up were selected for analysis. Volume measurements and several morphologic characteristics were analyzed for all scans using Aquarius iNtuition software (TeraRecon, San Mateo, Calif, USA). Multivariate logistic regression analyses were used to study the influence of these characteristics on FLT.

RESULTS

Of 132 patients that received TEVAR for an aortic dissection, 43 patients (mean age, 60.3±14.2; 30 male) met our inclusion criteria, of whom 16 (37%) developed full FLT after 1 yr of follow-up. Multivariate logistic regression showed that side branch involvement [odds ratio (OR), 0.03; 95% confidence interval (CI), 0.00-0.92; P=0.045] and a total patent false lumen (FL) at presentation (OR, 0.01; 95% CI, 0.00-0.58; P=0.027) were associated with decreased complete FLT. Volumetric data showed significantly more reduction of the thoracic false lumen in FLT patients compared with non-FLT (-52.3% vs. -32.4%; P=0.043) and also a tendency of less volume increase in the abdominal segment (-5.0±37.5 vs. 21.8±44.3; P=0.052).

CONCLUSIONS

Patients admitted with type B dissection and branch vessel involvement or a patent entry tear after TEVAR are less likely to develop FLT and aortic remodeling during follow-up. These findings suggest that these patients may require a more extensive procedure and more intensive follow-up to prevent long-term complications.

Predicting aortic enlargement in type B aortic dissection

Patients with uncomplicated acute type B aortic dissection (ABAD) can generally be treated with conservative medical management. However, these patients may develop aortic enlargement during follow-up, with the risk of rupture. Several predictors have been studied in recent years to identify ABAD patients at high risk of aortic enlargement, who may benefit from early surgical or endovascular intervention. This study reviewed and summarized the current available literature on prognostic variables related to aortic enlargement during follow-up in uncomplicated ABAD patients. It revealed multiple factors affecting aortic expansion including demographic, clinical, pharmacologic and radiologic variables. Such predictors may be used to identify those ABAD patients at higher risk for aortic enlargement who may benefit from closer radiologic surveillance or early endovascular intervention. This approach deserves even more consideration because a significant number of patients develop aneurysmal degeneration along the dissected segments during follow-up, and may lose the opportunity for endovascular treatment if not identified at an early stage.

Thoracic aortic pulsatility decreases during hypovolemic shock: implications for stent-graft sizing

PURPOSE

To investigate the thoracic aortic pulsatility during hypovolemic shock in an experimental porcine model.

METHODS

The circulating blood volume of 7 healthy Yorkshire pigs was gradually lowered until the subjects had lost 40% of their normal blood volume. Intravascular ultrasound was used to assess the aortic pulsatility in normovolemic and hypovolemic state at the level of the ascending and descending thoracic aorta.

RESULTS

The mean aortic pulsatility at the level of the ascending aorta decreased from 15.9% ± 7.2% (range 6.3%-25.7%) in normovolemia to 6.2% ± 2.8% (range 2.9%-10.7%, p = 0.018) in hypovolemia. At the level of the descending thoracic aorta, the mean aortic pulsatility decreased from 8.7% ± 2.8% (range 4.4%-12.2%) at baseline to 5.6% ± 2.5% (range 1.5%-9.5%, p = 0.028) in hypovolemia. The maximum mean aortic diameter, obtained in cardiac systole, was significantly smaller as well at both evaluated levels during hypovolemic shock compared with the mean diameter in normovolemia.

CONCLUSION

The thoracic aortic diameter and pulsatility decreased significantly during hypovolemic shock in this porcine model, most impressively at the level of the ascending aorta. Electrocardiographically-gated imaging may not be necessary for hypovolemic patients with acute aortic disease requiring endovascular repair because of the minimal aortic pulsatility.

Endograft collapse after thoracic endovascular aortic repair

PURPOSE

To provide insight into the causes, timing, and optimal management of endograft collapse after thoracic endovascular aortic repair (TEVAR).

METHODS

A comprehensive review was conducted of all published cases of endograft collapse after TEVAR identified using Medline, Cochrane Library Central, and EMBASE. In total, 32 articles describing 60 patients (45 men; mean age 40.6 ± 17.2 years, range 17-78) with endograft collapse were included. All data were extracted from the articles and systematically entered into a database for meta-analysis.

RESULTS

In the 60 cases of endograft collapse, TEVAR had most commonly been applied to repair traumatic thoracic aortic injuries (39, 65%), followed by acute and chronic type B aortic dissections (9, 15%). The median time interval between TEVAR and diagnosis of endograft collapse was 15 days (range 1 day to 79 months). On average, the collapsed endografts were oversized by 26.7% ± 12.0% (range 8.3%-60.0%). Excessive oversizing was reported as the primary cause of endograft collapse in 20%, and a small radius of curvature of the aortic arch was responsible for 48% of the cases. The 30-day mortality was 8.3%, and the freedom from procedure-related death at 3 years after diagnosis of stent-graft collapse was 83.1% for asymptomatic patients compared with 72.7% for patients who had symptoms at diagnosis (p=0.029).

CONCLUSION

Endograft collapse typically occurs shortly after TEVAR, most frequently after endovascular repair of traumatic aortic injury. A high level of suspicion for endograft collapse in the first month after TEVAR, as well as further improvement of current endovascular devices, may be required to improve the long-term outcomes of patients after TEVAR.

The impact of hypovolaemic shock on the aortic diameter in a porcine model

OBJECTIVES

To investigate the impact of hypovolaemic shock on the aortic diameter in a porcine model, and to determine the implications for the endovascular management of hypovolaemic patients with traumatic thoracic aortic injury (TTAI).

MATERIALS AND METHODS

The circulating blood volume of seven Yorkshire pigs was gradually lowered in 10% increments. At 40% volume loss, an endograft was deployed in the descending thoracic aorta, followed by gradual fluid resuscitation. Potential changes in aortic diameter during the experiment were recorded using intravascular ultrasound (IVUS).

RESULTS

The aortic diameter decreased significantly at all evaluated levels during blood loss. The ascending aortic diameter decreased on average with 38% after 40% blood loss (range 24-62%, p = 0.018), the descending thoracic aorta with 32% (range 18-52%, p = 0.018) and the abdominal aorta with 28% (range 15-39%, p = 0.018). The aortic diameters regained their initial size during fluid resuscitation.

CONCLUSION

The aortic diameter significantly decreases during blood loss in this porcine model. If these changes take place in hypovolaemic TTAI patients as well, it may have implications for thoracic endovascular aortic repair (TEVAR). Increased oversizing of the endograft, or additional computed tomography (CT) or IVUS imaging after fluid resuscitation for more adequate aortic measurements, may be needed in TTAI patients with considerable blood loss.

Subintimal angioplasty is superior to SilverHawk atherectomy for the treatment of occlusive lesions of the lower extremities

PURPOSE

To evaluate the outcomes of atherectomy versus subintimal angioplasty (SIA) in patients with lower extremity arterial occlusive disease.

METHODS

From September 2005 through July 2006, 27 patients (17 women; mean age 65 years, range 37-85) underwent atherectomy of 46 lesions (11 TASC C/D occlusions) with the SilverHawk device. Results were compared to 67 patients (34 men; mean age 69 years, range 46-92) undergoing SIA for 67 lower extremity arterial occlusions from July 1999 through June 2004.

RESULTS

Technical success in the atherectomy cohort was 100%. In the 11 patients with occlusions, symptoms improved in 10 and worsened in 1, but 9 (82.0%) of the 11 patients required reintervention, and 8 (72.7%) patients with occlusive lesions re-occluded. Endovascular reintervention was required to maintain primary patency in only 2 (12.5%) of 16 patients treated for stenotic lesions. At 1 year, the assisted primary patency was 37.7% in the atherectomy group. In the 11 patients with occlusive lesions, the patency rates were 36.8% and 12.3% at 6 and 9 months, respectively, versus 100% and 83.3% at the same time intervals in patients with stenotic lesions. SIA was technically successful in 56 (83.6%) of 67 occlusions. The assisted primary patency and limb salvage rates of the entire group (intention-to-treat) at 12 and 24 months were 59.2% and 45.0%, respectively, while the assisted primary patency of the 56 technically successful SIAs at 12 and 24 months were 70.7% and 53.8%, respectively. Limb salvage for the entire group (intention-to-treat) was 90.6% and 87.9% at 12 and 24 months, respectively.

CONCLUSION

Atherectomy may yield acceptable primary patency and limb salvage in patients with stenotic lesions. Many of the patients treated for occlusive lesions require reintervention. Based on patency and limb salvage, SIA appears superior to atherectomy for the treatment of lower extremity occlusive disease.

Aortic endograft sizing in trauma patients with hemodynamic instability

OBJECTIVES

To investigate changes in aortic diameter in hemodynamically unstable trauma patients and the implications for sizing of thoracic endovascular aortic repair (TEVAR) in patients with traumatic thoracic aortic injury (TTAI).

METHODS

We retrospectively evaluated all trauma patients that were admitted with hemodynamic instability (mean arterial pressure <95 mm Hg and a pulse >or=100 beats/min) and underwent computed tomography (CT) of the thorax and abdomen both at admission and at another moment (control CT scan), at the Yale New Haven Hospital between 2002 and 2009. The CT examinations were reviewed in a blinded fashion and the aortic diameter was measured at six different levels by a cardiovascular radiologist. Differences in aortic diameter between the initial CTs obtained in the trauma bay and the control CTs were compared using the paired Student t test.

RESULTS

Forty-three patients were identified, including 32 males. Mean age was 37 +/- 16 years, mean injury severity score was 26 +/- 15, the mean pulse and blood pressure were 122 beats/min and 103/63 mm Hg, respectively. Overall, the mean aortic diameter was significantly larger at the control CT examinations compared with the initial CT examinations while hemodynamically unstable, at all evaluated levels. Among patients with a pulse >or=130/min, the mean increase in aortic diameter was most consistent at the level of the mid descending thoracic aorta (DTA, +12.6%, P = .003) and at the level of the infrarenal aorta (+12.6%, P = .004).

CONCLUSIONS

The aortic diameter decreases dramatically in trauma patients with hemodynamic instability. This decrease in aortic diameter could theoretically lead to inaccurate aortic measurements and undersizing of the endograft in hemodynamically unstable TTAI patients requiring TEVAR. Further research is needed to better predict the actual aortic diameters in individual hemodynamically unstable patients requiring endovascular aortic repair.

Abdominal aortic aneurysm repair in obese patients: improved outcome after endovascular treatment compared with open surgery

PURPOSE

To investigate outcomes in obese patients with abdominal aortic aneurysm (AAA) treated with elective open or endovascular repair (EVAR).

STUDY DESIGN

We compared the outcomes of obese patients with AAA treated with elective open repair and EVAR. Obesity was defined as a body mass index (BMI) > or =30 kg/m( 2).

RESULTS

A total of 56 patients with a BMI > or =30 kg/m(2) were identified for analysis (mean age 70 +/- 8 years; mean BMI 34 +/- 4 kg/m(2), and 95% [n = 53] were male). Open surgery was performed in 55% (n = 31). The in-hospital complication rate (including nonsurvivors) was significantly increased after open repair compared with EVAR (26% vs 4%, P = .033). Mortality did not differ significantly during 3 years of follow-up (P = .816). Length of stay, intensive care unit (ICU) stay, and need for ventilation were significantly increased after open surgery compared with EVAR.

CONCLUSIONS

We observed improved short-term outcomes among obese AAA patients after EVAR compared to open repair. Endovascular repair may be preferable in obese patients with AAA.

Outcomes of thoracic endovascular aortic repair for aortobronchial and aortoesophageal fistulas

PURPOSE

To identify in-hospital and follow-up outcomes of thoracic endovascular aortic repair (TEVAR) for aortobronchial fistula (ABF) and aortoesophageal fistula (AEF).

METHODS

The authors reviewed all published cases of ABF and AEF undergoing TEVAR indexed in the MEDLINE, Cochrane Library CENTRAL, and EMBASE databases. After removal of duplicates, 850 articles were scrutinized for relevance and validity. Exclusion criteria included: (1) no clear description of the organs involved with the fistula, (2) no description of outcomes after TEVAR for ABF or AEF, or (3) no original data presented in the article. In this manner, 66 relevant articles were identified that included original data on 114 patients (76 men; mean age 63+/-1.5 years) with ABF (n = 71) or AEF (n = 43). Meta-analyses were performed to investigate outcomes of TEVAR for ABF and AEF.

RESULTS

Patients with AEF presented more frequently with hypovolemic shock (33% versus 13%, p = 0.012) and systemic infection (36% versus 9%, p<0.001) compared to patients with ABF. In-hospital mortality was 3% (n = 2) after TEVAR for ABF and 19% (n = 8) after TEVAR for AEF (p = 0.004). Additional thoracic surgery in the first 30 days after TEVAR was performed in 3% (n = 2) of ABF patients and in 37% (n = 16) of AEF patients (p<0.001); 12 AEF patients who had received esophageal surgery in the first month after TEVAR showed lower fistula-related mortality during 6 months of follow-up compared to patients who did not receive additional esophageal surgery (p = 0.018).

CONCLUSION

TEVAR is associated with superior outcomes in patients with ABF. Endovascular management of AEF is associated with poor results and should not be considered definitive treatment. TEVAR could serve as a bridge to surgery for emergency cases of AEF only, with definitive open surgical correction of the fistula undertaken as soon as possible.