A Structured Approach for Safely Reintroducing Bariatric Surgery in a COVID-19 Environment.

Due to the profound effect of novel coronavirus disease 2019 (COVID-19) on healthcare systems, surgical programs across the country have paused surgical operations and have been utilizing virtual visits to help maintain public safety. For those who treat obesity, the importance of bariatric surgery has never been more clear. Emerging studies continue to identify obesity and several other obesity-related comorbid conditions as major risk factors for a more severe COVID-19 disease course. However, this also suggests that patients seeking bariatric surgery are inherently at risk of suffering severe complications if they were to contract COVID-19 in the perioperative period. The aim of this protocol is to utilize careful analysis of existing risk stratification for bariatric patients, novel COVID-19-related data, and consensus opinion from multiple academic bariatric centers within our organization to help guide the reanimation of our programs when appropriate and to use this template to prospectively study this risk-stratified population in real time. The core principles of this protocol can be applied to any surgical specialty.

Gender and Letters of Recommendation: A Linguistic Comparison of the Impact of Gender on General Surgery Residency Applicants✰.

OBJECTIVE: We investigated letters of recommendation for general surgery residency applicants to determine if any gender-based disparities exist. DESIGN: A dictionary of over 400 terms describing applicants and 24 unique categories into which these terms were classified was created. Word count and language comparisons were performed using linguistic analysis software to assess for differences in applicant characterization, letter length, and writing style between male and female applicants and letter writers. SETTING: A large, Midwest, academic general surgery residency program. PARTICIPANTS: Five hundred and fifty-nine letters of recommendation received during the 2015 and 2016 interview cycles were selected for analysis. RESULTS: Average word count was approximately equal for male and female applicants (503 vs 508, respectively). Female writers wrote longer letters (mean word count 545.5 vs 497.1, p = 0.028). "Standout" terms were more likely to be used to describe female applicants. Otherwise no statistically significant differences in applicant characterization were discovered. CONCLUSIONS: Letters of recommendation for general surgery are written using similar descriptive terms and lengths for male and female applicants. This suggests that there is no specific gender disadvantage with regard to letters of recommendation when applying for general surgery residency.

Magnetic surgery: first U.S. experience with a novel device.

INTRODUCTION: Magnet-assisted surgery is a new platform within minimally invasive surgery. The Levita™ Magnetic Surgical System, the first magnetic surgical system to receive Food and Drug Administration (FDA) approval, includes a deployable, magnetic grasper and an external magnet that is used to manipulate the grasper within the peritoneal cavity. This system is currently approved for patients undergoing laparoscopic cholecystectomy with a body mass index (BMI) between 21 and 34 kg/m2. Herein, we detail the first United States experience with the Levita™ Magnetic Surgical System during laparoscopic cholecystectomy. METHODS: The Levita™ Magnetic Surgical System was used on consecutive patients undergoing laparoscopic cholecystectomy at our institution from June 2016 through November 2016. Only patients undergoing elective surgery and those with a body mass index (BMI) between 21 and 34 kg/m2 were included. Baseline patient characteristics, operative time, and perioperative details were collected. RESULTS: A total of ten patients underwent laparoscopic cholecystectomy with the Levita™ Magnetic Surgical System during the defined study period. The mean age at the time of surgery was 49.0 years and the average BMI of the cohort was 27.6 kg/m2. The average operative time was 64.4 min. There were no perioperative complications. Seven (70.0%) patients were discharged to home on the day of surgery, while the remaining three (30.0%) patients were discharged to home on postoperative day number one. Surgeons reported that the magnetic grasper was easy to use and provided adequate tissue retraction and exposure. CONCLUSIONS: The Levita™ Magnetic Surgical System is safe and feasible to use in patients undergoing laparoscopic cholecystectomy. Routine use of this system may facilitate a reduction in the total number of laparoscopic trocars used, leading to less tissue trauma and improved cosmesis. Additional studies are needed to determine the applicability and utility of this system for other general surgery cases.

Fulminant Clostridium difficile enteritis causing abdominal compartment syndrome.

INTRODUCTION: Clostridium difficile infection of the small bowel, or C. difficile enteritis (CDE), is an uncommon condition. Cases reported previously have been described in patients with inflammatory bowel disease (IBD), compromised immune systems, or a history of colectomy or small bowel surgery. CASE DESCRIPTION: We present a case of fulminant CDE causing abdominal compartment syndrome following a routine outpatient inguinal hernia repair. This patient developed multiple organ failure dysfunction syndrome requiring surgical abdominal decompression and a small bowel resection. This case highlights the challenges in the diagnosis of CDE, particularly in patients with intact colons and unusual presentations. DISCUSSION: A high index of suspicion is required, as early recognition of CDE is essential in reducing morbidity and mortality. This case report is followed by a review of the current literature on CDE, with a focus on the complexities inherent in the identification of this problem and the decision-making process for surgical intervention.

Single-incision laparoscopic cholecystectomy: do patients care?

INTRODUCTION: Single-incision approaches to laparoscopic cholecystectomy typically involve increasing the size of the umbilical incision and eliminating three smaller incisions, but it is not intuitive that patients would view this as a benefit. We hypothesize that when patient satisfaction with standard laparoscopic cholecystectomy is assessed, most dissatisfaction will be linked to the umbilical incision and, given the option, patients would actually wish to eliminate this incision. METHODS: Two hundred eighty-one female patients aged 18 to 40 years who underwent laparoscopic cholecystectomy over a 2-year period were identified, and data were collected on 125 patients. RESULTS: Fewer than half of patients correctly remembered the number of incisions they had, with 57 patients (45.6%) recalling fewer incisions than were present. Of 58 patients reporting one site to be more painful, 38 (65.5%) cited the umbilical site as the most painful. Eighty-one patients (68.6%) would have preferred to eliminate an incision, with 51 of these (63.0%) choosing to eliminate the umbilical incision. CONCLUSION: As single-incision cholecystectomy enlarges what is already a painful and undesirable incision, and since patients often do not recall the smaller incisions, we should ask ourselves whether surgeons and industry care more about this technique than do the patients to whom we offer it.

Neovascularization after great saphenous vein ablation.

OBJECTIVE: To determine the prevalence, distribution, and flow characteristics of intraluminal neovascularization in patients undergoing great saphenous vein (GSV) endovenous laser (EVLT) or radiofrequency ablation (RFA). METHODS: Duplex ultrasound (DU) was performed in patients undergoing EVLT or RFA before, during, and after their procedures. Follow-up included assessment for deep venous thrombosis and obliteration. When new vessels were identified, the source, extent, direction, and location of flow were noted. Flow channel diameters were measured and the resistivity index (RI) was used to characterize the flow patterns. RESULTS: A total of 102 venous ablations were performed of which 46 were RFA, and 56 EVLT. Arterio-venous fistulae (AVF) were found in five patients that were not identified by DU prior to intervention. Involved segments had variable length and multiple channels (mean diameter 2.2mm). No patient had local or systemic symptoms related to the AVF. The mean RI was 0.42, consistent with an AVF. The perivenous arteries feeding the AVF had enhanced flow but a significantly higher RI (0.63, p<0.001). CONCLUSION: Multiple small vessels were found directly adjacent to the involved vein segments forming small AVF within the obliterated vein. The prevalence of AVF in the ablated GSV was 5%. This process may be responsible for recanalization or recurrence after endovenous ablation procedures.

Are your arteries older than your age?

PURPOSE: To determine the effect of age and atherosclerotic risk factors on the carotid intima-media layer thickness and morphology characteristics. PATIENTS AND METHODS: Three groups of subjects were included in the study: Individuals with atherosclerotic risk factors including a family history of CHD, hypertension, hyperlipidemia, diabetes, and/or smoking (group A, n=180), age- and sex-matched healthy subjects without risk factors (group B, n=60) and a group of significantly younger volunteers (group C, n=25). The carotid artery was imaged longitudinally with B-mode ultrasound. Intima media thickness (IMT) was measured in the common (CCA) and internal carotid (ICA) arteries. Surface irregularity and continuity of the intima-media layer (IML) were assessed by high definition imaging. Echogenicity of the wall was quantified using Adobe Photoshop. The presence of calcium deposits was recorded. The double line wall pattern seen in young healthy people was used as a control to assess patterns and texture of the carotid IML. Fifteen subjects had their measurements repeated for intraobserver variability. RESULTS: IMT measurements were reproducible in both the CCA and ICA (coefficient of variation 6% and 9%). IMT increased linearly with age (adjusted R(2)=0.72, p<0.0001), which was also an independent risk factor for increased IMT. All the risk factors had a significant association with increased IMT. In the lowest (third) decade the wall/blood interface was smooth and the double line was visualized with an echolucent center. With increased age and number of risk factors present, the wall/blood interface became more irregular (p<0.01), the double line was distorted (p<0.01) and the IML was more echogenic (p<0.01). The increase in IMT and the changes in the echogenicity of the IML were more pronounced in the ICA. CONCLUSIONS: Age is an independent risk factor for increased IMT. Atherosclerotic risk factors are associated with the age-related changes seen in the IML. Such changes are also seen in younger asymptomatic volunteers with risk factors indicating that their arteries are older than their age.

What are the long-term results of conventional open surgical repair of abdominal aortic aneurysms?

PURPOSE: To determine the long-term results of conventional open surgical repair of abdominal aortic aneurysms (AAAs) and the prevalence of late arterial abnormalities. METHODS: CT scan follow-up was obtained between 8 and 9 years after elective AAA repair on a cohort of patients enrolled in the Canadian Aneurysm Study, a registry that originally consisted of 680 patients. A request for CT follow-up was sent to the responsible surgeon in 1994 when 251 patients were alive and available. Ninety-four of the 251 patients agreed to undergo an abdominal and thoracic CT scan, and each scan was interpreted independently by two vascular radiologists. RESULTS: The aorta was analysed in five defined segments, and an aneurysm was defined as > 50% enlargement from the expected normal value as defined in the Reporting Standards for Aneurysms. Using this strict definition, 64.9% of patients had an aneurysm, but the abnormality was considered a possible indication for surgical repair in 13.8%. Of the 39 patients who had an initial repair with a tube graft, 12 (30.8%) were found to have an iliac aneurysm and 6 (15.4%) were considered to be of possible surgical significance. The median graft size at the time of operation was 18 mm, which increased to a median size of 22 mm at follow-up. Fluid or thrombus around the graft was observed in 28%, and bowel was intimately associated with the graft in 7%. CONCLUSIONS: The longterm results of conventional open surgical repair is durable. CT scan follow-up between 8 and 9 years postoperatively often demonstrates aortic and iliac abnormalities, but the majority are not clinically significant. On the basis of these findings, a routine CT scan of the abdomen and chest is recommended after 5 years. This study provides a population based study for comparison with the longterm results of endovascular repair.

Aortic and iliac reconstruction after kidney transplantation: experience with an algorithm for renal protection.

Advances in renal transplantation have allowed for improved survival and an increased age of recipients. This has resulted in more aortoiliac lesions requiring intervention. The optimal approach for renal protection during aortoiliac surgery remains unknown. A retrospective review of transplant patients admitted to Toronto General Hospital for aortoiliac reconstruction between 1990 and 2000 was performed. A total of 20 aortic reconstructions were carried out in 18 patients: 5 patients with ascending aortic repairs and 15 patients with aortoiliac reconstructions. Of the five ascending repairs, all had cardiopulmonary bypass and four were performed under hypothermic arrest. There was one allograft loss in the postoperative period and one mortality. Of the 15 aortoiliac reconstructions 12 had protection: 10 temporary axillofemoral artery bypasses and 2 renal cold perfusion. In the 10 patients with temporary bypass protection, there were no graft losses. There was no graft loss in the hypothermic perfusion group. Of the three patients without protection, there was one graft loss. The postoperative rise in serum creatinine was significantly higher (p <0.05) in the no-protection group than in those receiving temporary bypass protection. Our algorithm of (1). temporary axillofemoral bypass, (2). cold perfusion if temporary bypass cannot be performed, and (3). clamp and sew if the patient is too unstable allows for surgery with excellent graft survival.

Identification of a multifunctional binding site on Ubc9p required for Smt3p conjugation.

Ubiquitin-like proteins (ub-lps) are conjugated by a conserved enzymatic pathway, involving ATP-dependent activation at the C terminus by an activating enzyme (E1) and formation of a thiolester intermediate with a conjugating enzyme (E2) prior to ligation to the target. Ubc9, the E2 for SUMO, synthesizes polymeric chains in the presence of its E1 and MgATP. To better understand conjugation of ub-lps, we have performed mutational analysis of Saccharomyces cerevisiae Ubc9p, which conjugates the SUMO family member Smt3p. We have identified Ubc9p surfaces involved in thiolester bond and Smt3p-Smt3p chain formation. The residues involved in thiolester bond formation map to a surface we show is the E1 binding site, and E2s for other ub-lps are likely to bind to their E1s at a homologous site. We also find that this same surface binds Smt3p. A mutation that impairs binding to E1 but not Smt3p impairs thiolester bond formation, suggesting that it is the E1 interaction at this site that is crucial. Interestingly, other E2s and their relatives also use this same surface for binding to ubiquitin, E3s, and other proteins, revealing this to be a multipurpose binding site and suggesting that the entire E1-E2-E3 pathway has coevolved for a given ub-lp.

How do vascular surgeons perceive atherosclerotic risk factor management?

The specific objectives of this report were to determine (1) the usual practice of vascular surgeons with respect to risk factor inquiry and intervention, (2) which risk factors are endorsed by vascular surgeons as being very important in the management of patients with PAD, and, finally, (3) which risk factors vascular surgeons are confident in managing.

Long-term follow-up of management of failing in situ saphenous vein bypass grafts using endovascular intervention techniques.

PURPOSE: To report the long-term follow-up of previously reported cases of salvaging failing or failed in situ bypass grafts using endovascular techniques, to include previously unreported cases, and to include the results of thrombolysis for the salvage of occluded in situ venous bypass grafts. MATERIALS AND METHODS: Between 1985 and 1995, 352 patients underwent distal bypass via the in situ saphenous vein. Seventy-three of these patients underwent endovascular interventions for (i) graft stenoses (65 lesions in 40 patients) treated by balloon angioplasty (PTA), (ii) AV residual fistulas to veins (AVF) (23 patients) occluded by coil embolotherapy, (iii) graft occlusion (21 occluded grafts in 19 patients) treated by catheter-directed high-dose thrombolytic infusion and PTA or surgical revision of uncovered stenoses, and (iv) retained valve leaflets causing stenoses (five patients) treated by valvectomy and/or PTA. Cumulative patency rates were determined by the Kaplan-Meier method. Twenty-nine of 73 patients had been previously reported by the authors. RESULTS: PTA was successful in 39 of 40 patients, cumulative patency after bypass PTA was 0.79 (SE +/- 0.07) for 12 months and 0.63 (SE +/- 0.12) for 5 years. The only complication of PTA was a graft anastomotic disruption that was successfully treated by surgery. Longer lesions and lesions requiring repeated PTA were more likely to restenose. For thrombolysis, there were 13 of 19 successful infusions and five delayed occlusions. The cumulative patency for both 12 months and 5 years was 0.43 (SE +/- 0.12). AVF embolization was successful in 21 of 23 patients. Cumulative patency for 12 months and 5 years was 0.87 (SE +/- 0.07) and 0.81 (SE +/- 0.09), respectively. Five successful valvectomy procedures were performed by stripping residual valves with endocardial forceps. CONCLUSION: In experienced hands, PTA and AVF embolization can be performed on failing in situ saphenous vein bypass grafts with good long-term patency. Thrombolysis results were less favorable but can prolong patency of grafts.

Thoracofemoral bypass: proximal exposure and tunneling.

Although axillobifemoral bypass is the usual alternative to the standard aortobifemoral bypass (ABF) when the latter is contraindicated because of comorbid operative risk or when the transabdominal approach is considered hazardous, a more proximal aortic inflow source is desirable in selected low-risk patients. The results with these more proximal aortic procedures are more durable than with axillobifemoral bypass and approach those that can be achieved with an ABF. This article reviews some of the specific technical details of descending thoracofemoral bypass, specifically, the techniques for proximal exposure and tunneling.

Saccular aortic aneurysms.

Most vascular surgeons believe that saccular aortic aneurysms have a more ominous natural history than the typical fusiform aneurysm, although this is not documented in the literature. Expeditious repair is indicated for symptomatic saccular aneurysms, and intervention is usually advocated even when they are asymptomatic because of the general belief that their unique shape predisposes them to rupture. The objective of this report is to review the presentation and surgical management of this uncommon pathology. The records of 10 patients who underwent surgical intervention for an aortic saccular aneurysm between 1985 and 1998 were reviewed. To summarize their presentation and management, we grouped patients according to anatomic location: group A (distal arch), group B (descending thoracic aorta), group C (visceral aorta), and group D (infrarenal aorta). From analysis of these data we conclude that although saccular aortic aneurysms are rare, when present, they are most commonly found in the thoracic and suprarenal aorta. Most cases treated with surgery are symptomatic. Most thoracic and suprarenal saccular aneurysms can be repaired with a patch graft, which spares thoracic intercostals. Repair of saccular aneurysms of the distal arch are only feasible when performed with the use of hypothermic circulatory arrest. Infrarenal saccular aneurysms generally require tube graft replacement because the coexistent atherosclerosis makes patch repair difficult. Endovascular techniques may be the procedure of choice in the future.

A practical approach to vascular access for hemodialysis and predictors of success.

PURPOSE: The long-term results and predictors of success for vascular access at The Toronto Hospital were studied. This report describes the access program and emphasizes the role of the vascular access coordinator. METHODS: A total of 384 consecutive patients underwent 466 vascular access procedures. The access program is centered around a dedicated, full-time vascular access coordinator, who is a registered nurse and is responsible for all aspects of access care, including follow-up. Outcome variables were collected prospectively. Primary, primary-assisted, and secondary success was determined by means of Kaplan-Meier analysis, and the stepwise Cox proportional hazards model was used for multivariate analysis of the factors that were independently predictive of primary success. RESULTS: There were 235 autogenous arteriovenous fistulae (AVFs) and 231 arteriovenous grafts (AVGs). The cumulative primary, assisted-primary, and secondary success (patent and functional for effective dialysis) at 24 months for all 466 cases combined was 36% +/- 3%, 54% +/- 3%, and 66% +/- 3%, respectively. The primary success for AVFs and AVGs at 2 years was 54% +/- 4% and 18% +/- 4%, respectively (P <.001; log-rank test); the primary-assisted success for AVFs and AVGs at 2 years was 62% +/- 4% and 44% +/- 6%, respectively (P <.001; log-rank test); and the secondary success for AVFs and AVGs at 2 years was 70% +/- 4% and 60% +/- 5%, respectively (P =.331; log-rank test). Stratification of variables revealed significant benefit for AVFs (P =.001), the female sex (P =.014), and the absence of diabetes mellitus (P =.001). Multivariate analysis with Cox regression determined that access type (AVF vs AVG; P =.001) and diabetes mellitus (P =.024) were independently predictive of primary success. The improved clinical coordination of access patients with the initiation of the vascular access program resulted in a significant reduction in length of hospital stay before and after the program was organized (2.5 +/- 0.06 vs 1.1 +/- 0.03 days; P =.001). CONCLUSION: The organization of a vascular access program in a practical and cost-effective way for reduced length of hospital stay is streamlined through a dedicated access coordinator, who ensures an integrated, multidisciplinary approach. The results for the Cox model is useful when discussing the anticipated results of access procedures with individual patients.

The value of late computed tomographic scanning in identification of vascular abnormalities after abdominal aortic aneurysm repair.

PURPOSE: The purpose of this study was to determine the prevalence of late arterial abnormalities after aortic aneurysm repair and thus to suggest a routine for postoperative radiologic follow-up examination and to establish reference criteria for endovascular repair. METHODS: Computed tomographic (CT) scan follow-up examination was obtained at 8 to 9 years after abdominal aortic aneurysm (AAA) repair on a cohort of patients enrolled in the Canadian Aneurysm Study. The original registry consisted of 680 patients who underwent repair of nonruptured AAA. When the request for CT scan follow-up examination was sent in 1994, 251 patients were alive and potentially available for CT scan follow-up examination and 94 patients agreed to undergo abdominal and thoracic CT scanning procedures. Each scan was interpreted independently by two vascular radiologists. RESULTS: For analysis, the aorta was divided into five defined segments and an aneurysm was defined as a more than 50% enlargement from the expected normal value as defined in the reporting standards for aneurysms. With this strict definition, 64.9% of patients had aneurysmal dilatation and the abnormality was considered as a possible indication for surgical repair in 13.8%. Of the 39 patients who underwent initial repair with a tube graft, 12 (30.8%) were found to have an iliac aneurysm and six of these aneurysms (15.4%) were of possible surgical significance. Graft dilatation was observed from the time of operation (median graft size of 18 mm) to a median size of 22 mm as measured by means of CT scanning at follow-up examination. Fluid or thrombus was seen around the graft in 28% of the cases, and bowel was believed to be intimately associated with the graft in 7%. CONCLUSION: Late follow-up CT scans after AAA repair often show vascular abnormalities. Most of these abnormalities are not clinically significant, but, in 13.8% of patients, the thoracic or abdominal aortic segment was aneurysmal and, in 15.4% of patients who underwent tube graft placement, one of the iliac arteries was significantly abnormal to warrant consideration for surgical repair. On the basis of these findings, a routine CT follow-up examination after 5 years is recommended. This study provides a population-based study for comparison with the results of endovascular repair.

Clinical and pathophysiological effects of active and passive smoking on the cardiovascular system.

Both passive and active cigarette smoking increase the risk of cardiovascular disease, the leading cause of death in Western industrialized nations. The prevalence of smoking as a major cardiovascular risk factor has been well characterized over the past 30 years. The two demographic groups of particular concern are women and the young. The relationship between active tobacco smoking and increased risk of coronary artery disease (stable and unstable angina, acute myocardial infarction or sudden death), cerebrovascular disease (cerebral infarction, and cerebral and subarachnoid hemorrhage), peripheral arterial disease (large and small vessel) and aortic aneurysm has been well established in numerous longitudinal and cross-sectional epidemiological and basic science studies. More recently, passive smoking has been shown to represent an important risk factor for coronary artery disease. Smoking can elicit both acute and chronic cardiac and vascular events due to the multiplicity of mechanisms involved: hematological, neurohormonal, metabolic, hemodynamic, molecular genetic and biochemical pathways. Smoking cessation can result in both the inhibition of progression and the regression of pathophysiological changes, improving morbidity and mortality among chronic smokers. The incidence of coronary artery and cerebrovascular diseases in former smokers decreases by 50% two to three years following cessation, but a small long term excess risk persists. Smoking as a cardiovascular risk factor and the clinical cardiovascular features associated with active and passive smoking are discussed, and a pathophysiological framework to explain the association between cigarette smoking and cardiovascular disease is provided.