Patency and limb salvage after femoral endarterectomy and iliac stenting are not affected by severity of iliac disease.

OBJECTIVE: The hybrid procedure of femoral endarterectomy and iliac artery stenting (FEIS) has been used as an alternative to traditional open surgical repair of iliofemoral arterial occlusive disease, but whether the severity of the iliac disease component affects long-term results is not well understood. METHODS: This was a retrospective cohort study of patients undergoing FEIS at Geisinger Health System from January 1, 2004, through December 31, 2013, for the treatment of symptomatic iliofemoral atherosclerotic occlusive disease. The cohort was stratified according to the severity of the iliac occlusive disease component into patients with mild iliac disease (group 1) and patients with severe iliac disease (group 2). RESULTS: Between January 1, 2004, and December 31, 2013, 99 patients underwent 111 total FEIS procedures. The mean age of the cohort was 67.4 years. Men composed 61% of patients. Indications for surgery were claudication (41%), ischemic rest pain (36%), and tissue loss (23%). At 5 years of follow-up, there was no difference in primary patency (73% in group 1 vs 68% in group 2 [P = .67]) and limb salvage (90% in group 1 vs 92% in group 2 [P = .51]). There was a trend toward higher overall mortality in group 2 patients vs group 1 patients (53% vs 81%; P = .08), but this did not reach statistical significance. Univariate analysis did not identify any device-related or anatomic factors predictive of patency. CONCLUSIONS: When combined iliofemoral arterial occlusive disease is treated with FEIS, the severity of the iliac disease component does not affect long-term patency or limb salvage.

Indirect inguinal hernia with uterine tissue in a male: A case of persistent Mullerian duct syndrome and literature review.

A 32-year-old male presenting with a direct inguinal hernia was found to have uterine tissue extending through the inguinal canal, warranting a diagnosis of persistent Mullerian duct syndrome (PMDS). PMDS is an extremely rare form of internal male pseudo-hermaphroditism in which female internal sex organs, including the uterus, cervix and proximal vagina, persist in a 46XY male with normal external genitalia. The condition results from a congenital insensitivity to anti-Mullerian hormone, or lack of anti-Mullerian hormone, leading to persistence of the female internal sex organs in a male. Clinically, this condition is associated with cryptochoridism. Controversy persists regarding the appropriate treatment of PMDS, since resection of the remnant structures is associated with potential morbidity, but retention risks development of occasional malignancies. We review the literature and discuss various aspects of pathophysiology, diagnosis, and management of PMDS.

ACS-NSQIP criteria are associated with APACHE severity and outcomes in critically ill surgical patients.

BACKGROUND: Similarity between the ICU patient data acquired by the APACHE system and the patient outcomes data acquired by the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) suggests that variables in NSQIP data could be effective mortality predictors. We theorized that identifying ACS-NSQIP preoperative data points predictive of patient outcomes would assist in identifying potential complications earlier. STUDY DESIGN: Between 2006 and 2008 at the University of Maryland Medical Center, we identified 340 surgical ICU patients included in both databases as our study cohort. Median APACHE score calculation permitted division of study subjects into quartiles from which to examine length of stay, mortality variables, and ACS-NSQIP-recorded postoperative occurrences and preoperative risk factors. Outcomes were compared using each database's percentage of patients who had died. RESULTS: Mortality was positively correlated with APACHE score increases. Initially, the average ICU length of stay increased, then declined. Most common postoperative occurrences were ventilator dependence >48 hours, pneumonia, unplanned intubation, sepsis, and septic shock. It was also noted that preoperative variables, such as American Society of Anesthesiologists classification and serum albumin levels, had an association with a poorer prognosis. CONCLUSIONS: APACHE score predictions are consistent with ACS-NSQIP-recorded postoperative outcomes. Higher APACHE scores correlated with increased incidence of postoperative outcomes and were associated with earlier mortality in the most extremely ill. Poorer states of health before surgery also correlated with poor outcomes postoperatively.