Treatment-refractory vulvodynia from nutcracker syndrome: A case report.

BACKGROUND: Pelvic venous disorders are often undiagnosed due to the symptom variability and similarity to other disease presentations. 'Pelvic congestion syndrome' is a term often used as a diagnosis of exclusion, since there is currently no standardized diagnostic approach for pelvic venous disorders, which further delays treatment. CASE: A 25-year-old woman with treatment-refractory vulvodynia presented with symptoms that included left-sided vaginal wall pain, pruritis, dysmenorrhea, dyspareunia, muscle tension, and a chronic vaginal ulceration. Abnormal pelvic varices were discovered, and she was referred to vascular surgery for treatment of nutcracker syndrome causing ovarian vein reflux and abnormal engorgement of pelvic varices. CONCLUSION: Patients presenting with signs of pelvic venous insufficiency such as vaginal pruritis, irritation, pain, recurrent vaginitis, or chronic ulcerations should be examined for pelvic venous disorders.

Preoperative risk score for the prediction of mortality after repair of ruptured abdominal aortic aneurysms.

OBJECTIVE: Even in the ruptured endovascular aneurysm repair first era, there are still patients who will not survive their ruptured abdominal aortic aneurysm (rAAA). All previously published mortality risk scores include intraoperative variables and are not helpful with the decision to operate or in providing preoperative patient and family counseling. The purpose of this study was to develop a practical preoperative risk score to predict mortality after repair of rAAA. METHODS: Data of all patients with rAAA presenting between January 1, 2002, and October 31, 2013, were collected. Logistic regression was used to evaluate predictive variables both univariately and jointly, and the results of multivariate models guided the definition of the final simplified scoring algorithm. RESULTS: There were 303 patients who presented during the study period. Sixteen patients died in the emergency department, en route to surgery, or after choosing comfort care. Preoperative variables most predictive of mortality were age >76 years (odds ratio [OR], 2.11; confidence interval [CI], 1.47-4.97; P = .011), creatinine concentration >2.0 mg/dL (OR, 3.66; CI, 1.85-7.24; P < .001), pH <7.2 (OR, 2.58; CI, 1.27-5.24; P = .009), and systolic blood pressure ever <70 mm Hg (OR, 2.70; CI, 1.46-4.97; P = .002). Assigning 1 point for each variable, patients were stratified according to the preoperative rAAA mortality risk score (range, 0-4). For all repairs, at 30 days, patients with 1 point suffered 22% mortality; 2 points, 69% mortality; and 3 points, 80% mortality. All patients with 4 points died. There was a mortality benefit for ruptured endovascular aneurysm repair across all categories. CONCLUSIONS: Our rAAA mortality risk score is based on four variables readily assessed in the emergency department and allows accurate prediction of 30-day mortality after repair of rAAAs. It also has a direct impact on clinical decision-making by adding prognostic information to the decision to transfer patients to tertiary care centers and aiding in preoperative discussions with patients and their families.

The Incidence of Ischemic Colitis after Repair of Ruptured Abdominal Aortic Aneurysms Is Decreasing in the Endovascular Era.

BACKGROUND: Ischemic colitis (IC) is a well-described complication of ruptured abdominal aortic aneurysms (rAAAs). The purpose of this study was to compare the incidence of IC in patients with rAAA undergoing open repair (OR) versus endovascular aneurysm repair (EVAR) at a single institution. In addition, we analyzed the incidence of IC before and after the implementation of a formal rupture AAA protocol (rEVAR protocol). METHODS: A retrospective analysis of prospectively collected data on all patients presenting with rAAA to our institution between January 2002 and October 2013 was performed. Variables were analyzed for association with IC. Comparisons were made using Pearson's chi-squared test or Fisher's exact test for categorical variables, Student's t-test for continuous variables, and logistic regression for multivariate analysis. Significance was set at P < 0.05. RESULTS: Three hundred three patients with rAAA presented over the 10-year study period. One hundred ninety-one patients underwent OR and 89 patients underwent endovascular repair. Twenty-three patients died either in the emergency department, en route to the operating room, or after choosing comfort care. Predictive factors of IC included estimated blood loss, corresponding need for resuscitation, and duration of procedure. Of patients who underwent OR, the rate of IC was 21% (40/191). This was significantly higher than patients who underwent EVAR, 7% (6/89), P < 0.05. The type of intervention did not influence 30-day mortality in patients with IC. However, only 17% (1/6) of patients who had IC following EVAR required colectomy versus 48% (19/40) of patients with IC following OR (P = 0.21). Implementation of our formal rEVAR protocol decreased the incidence of IC significantly from 37.1% (36/97) to 6.4% (10/157), P < 0.001. CONCLUSIONS: The incidence of IC has decreased significantly in the endovascular era but continues to portend a poor prognosis. Implementation of a formal, multidisciplinary rEVAR protocol in our institution decreased the incidence of IC.

Accreditation Council for Graduate Medical Education (ACGME) Surgery Resident Operative Logs: The Last Quarter Century.

STUDY OBJECTIVE: To describe secular trends in operative experience for surgical trainees across an extended period using the most comprehensive data available, the Accreditation Council for Graduate Medical Education (ACGME) case logs. BACKGROUND: Some experts have expressed concern that current trainees are inadequately prepared for independent practice. One frequently mentioned factor is whether duty hours' restrictions (DHR) implemented in 2003 and 2004 contributed by reducing time spent in the operating room. METHODS: A dataset was generated from annual ACGME reports. Operative volume for total major cases (TMC), defined categories, and four index laparoscopic procedures was evaluated. RESULTS: TMC dropped after implementation of DHR but rebounded after a transition period (949 vs 946 cases, P = nonsignificance). Abdominal cases increased from 22% of overall cases to 31%. Alimentary cases increased from 21% to 26%. Trauma and vascular surgery substantially decreased. For trauma, this drop took place well before DHR. The decrease in vascular surgery also began before DHR but continued afterward as well: 148 cases/resident in the late 1990s to 107 currently. CONCLUSIONS: Although total operative volume rebounded after implementation of DHR, diversity of operative experienced narrowed. The combined increase in alimentary and abdominal cases is nearly 13%, over a half-year's worth of operating in 5-year training programs. Bedrock general surgery cases-trauma, vascular, pediatrics, and breast-decreased. Laparoscopic operations have steadily increased. If the competence of current graduates has, in fact, diminished. Our analysis suggests that operative volume is not the problem. Rather, changing disease processes, subspecialization, reductions in resident autonomy, and technical innovation challenge how today's general surgeons are trained.

Abnormal molecular response to Takayasu arteritis causing extensive large-vessel calcification.

Takayasu arteritis is a large-vessel vasculitis that often results in pulselessness due to fibrotic stenoses. Whereas minor calcification is sometimes seen with Takayasu arteritis, it rarely causes stenosis. Extensive calcification resulting in malperfusion is exceedingly rare and has been attributed to disorders in calcium trafficking in a chronic inflammatory state. We report an unusual case of rapidly progressive and extensive aortic calcification in the setting of Takayasu arteritis.

Endovascular repositioning of a migrated stent graft using "endoanchor capture".

Endovascular aneurysm repair is increasingly used to treat patients harboring abdominal aortic aneurysms with severe comorbidities that make them unfavorable candidates for open repair. Graft-related complications in these patients also require unique solutions. We report the novel technique of "endoanchor capture" for successful repositioning of a migrated stent graft.