Changes in the practice of angioaccess surgery: impact of dialysis outcome and quality initiative recommendations.

PURPOSE: Recommendations recently published by the National Kidney Foundation-Dialysis Outcome and Quality Initiative (DOQI) included an appeal for increased use of native arteriovenous fistulas (NAVFs) to improve overall patency and contain angioaccess costs. We evaluated the impact of the DOQI recommendations on angioaccess surgery and its outcome at our institution. METHODS: From June 1996 to April 1999, 483 angioaccess procedures were performed on 247 patients. There were 133 men and 114 women, with an average age ranging from 28 to 95 years (mean age, 69 +/- 0.59 years). Risk factors included smoking in 143 patients (58%), diabetes mellitus in 135 patients (55%), hypertension in 150 patients (61%), and coronary artery disease in 98 patients (40%). The patients were divided in two groups. Group I (pre-DOQI) included patients who had angioaccess procedures between June 1996 and November 1997, and group II (post-DOQI) included patients who had angioaccess procedures between December 1997 and April 1999. The types of procedures performed included placement of arteriovenous grafts (AVGs) in 122 patients (25%), creation of NAVFs in 99 patients (20%), revision of AVGs in 123 patients (25%), and temporary access procedures in 135 patients (28%). Forty-seven of the NAVF procedures were radial-cephalic fistulas (47%), 22 were brachial-cephalic fistulas (23%), and 30 were brachial-basilic fistulas (30%). Patients underwent serial ultrasonography scanning and physical examinations; the mean follow-up period was 9 months. Choice of angioaccess procedures and patency rates before and after implementation of the DOQI recommendations were compared. RESULTS: There was a significant increase in the use of NAVFs after implementing DOQI recommendations (5% vs 68%, P <.001). The 1-year primary patency rate of AVGs was less than that of arteriovenous fistulas (54% vs 85%, P <.001). During the study period, the percentage of AVGs placed at our institution that required revision (59%; 72 of 123) was higher than that of NAVFs that required revision (4%; 4 of 99; P <.001). There was no significant difference in the maturation rates of radial-cephalic fistulas (75%), brachial-cephalic fistulas (91%), and brachial-basilic fistulas (87%). CONCLUSION: By adopting the DOQI recommendations, we used NAVFs more often. This resulted in superior patency rates, compared with synthetic grafts. The liberal use of preoperative duplex venous mapping further increased NAVF use, surpassing the DOQI expectations for primary arteriovenous fistulas. Additionally, fewer revisions were required.

Trocar site tumor recurrence after laparoscopic-assisted colectomy.

As a variety of procedures become technically feasible with laparoscopic techniques, it becomes increasingly important to appropriately select the patients who will benefit from the laparoscopic approach. We report the case of a patient with Dukes C2 colon cancer treated by laparoscopic-assisted sigmoid colectomy who subsequently developed an abdominal wall recurrence at a trocar site scar. The case raises some concerns about the use of the laparoscopic technique in the surgical management of colon cancer.