The role of endoscopic stents in the management of chronic anastomotic and staple line leaks and chronic strictures after bariatric surgery.

BACKGROUND: The use of endoluminal stents has been proposed for the management of fistulas and anastomotic strictures after bariatric surgery. The objective of our study was to determine the success of endoscopically placed, self-expandable metal stents (SEMS) in bariatric patients specifically with either chronic persistent anastomotic or staple line leaks/fistulas or chronic, persistent anastomotic strictures. METHODS: We treated 21 patients including 5 with chronic staple line leaks/fistulas (4 from the gastric sleeve after biliopancreatic diversion with duodenal switch [BPD/DS] and 1 after removal of an eroding laparoscopic adjustable gastric band) and 16 with chronic anastomotic strictures (15 at the gastrojejunostomy after Roux-en-Y gastric bypass and 1 at the duodenoileal anastomosis after BPD/DS). Patients with early leaks or anastomotic strictures were excluded. RESULTS: All but one of these patients had been referred to our institution after chronic treatment elsewhere was unsuccessful with prior stent placement for fistulas or multiple endoscopic dilations for strictures. Their bariatric operations had been performed a mean of 386 days beforehand. Stent placement was performed successfully in all patients without complications but was successful in only 4 of 21 patients (19%)-2 with chronic fistulas and 2 with chronic anastomotic strictures. Stent migration occurred in 10 patients (47%); the migrated stents were removed/replaced endoscopically in 7 patients but required elective operative removal in 3 with concomitant correction of the leak, fistula, or anastomotic stricture; none were operated emergently. CONCLUSION: Only 4 of 21 patients with a chronic persistent leak or anastomotic stricture were treated definitively using a SEMS. Although endoluminal stents may not lead to resolution of a chronic leak or stricture, SEMS may suppress ongoing sepsis and allow patients to undergo nutritional resuscitation orally before operative correction.

Improved results in the management of ruptured abdominal aortic aneurysm may not be on the basis of endovascular aneurysm repair alone.

Recent improvement in the survival of patients presenting with a ruptured abdominal aortic aneurysm (rAAA) has been credited to endovascular aneurysm repair (EVAR). We present our clinical series in the management of rAAA from 2007 to 2011. A total of 55 consecutive patient charts were reviewed. Thirty-eight patients underwent EVAR, 17 of the 55 patients did not have favorable anatomy for EVAR. Nine of the 17 patients underwent standard open repair. Eight patients underwent a 'hybrid repair' defined as suprarenal aortic endovascular balloon control followed by open repair. Overall 30-day mortality for all 55 patients was 22%. Mortality for the patients managed by endovascular aortic aneurysm repair was 26% compared with 22% with open repair. There were no deaths in the eight patients undergoing the hybrid repair. Endovascular balloon control of the aorta followed by open rAAA repair in patients who are not candidates for rEVAR has produced good results in our experience. Improved results being reported in the management of rAAA may not be on the basis of endovascular repair alone.

The utility of procalcitonin in critically ill trauma patients.

BACKGROUND: Procalcitonin (PCT), the prohormone of calcitonin, has an early and highly specific increase in response to systemic bacterial infection. The objectives of this study were to determine the natural history of PCT for patients with critical illness and trauma, the utility of PCT as a marker of sepsis versus systemic inflammatory response syndrome (SIRS), and the association of PCT level with mortality. METHODS: PCT assays were done on eligible patients with trauma admitted to the trauma intensive care unit (ICU) of a Level I trauma center from June 2009 to June 2010, at hours 0, 6, 12, 24, and daily until discharge from ICU or death. Patients were retrospectively diagnosed with SIRS or sepsis by researchers blinded to PCT results. RESULTS: A total of 856 PCT levels from 102 patients were analyzed, with mean age of 49 years, 63% male, 89% blunt trauma, mean Injury Severity Score of 21, and hospital mortality of 13%. PCT concentration for patients with sepsis, SIRS, and neither were evaluated. Mean PCT levels were higher for patients with sepsis versus SIRS (p < 0.0001). Patients with a PCT concentration of 5 ng/mL or higher had an increased mortality when compared with those with a PCT of less than 5 ng/mL in a univariate analysis (odds ratio, 3.65; 95% confidence interval, 1.03-12.9; p = 0.04). In a multivariate logistic analysis, PCT was found to be the only significant predictor for sepsis (odds ratio, 2.37; 95% confidence interval,1.23-4.61, p = 0.01). CONCLUSION: PCT levels are significantly higher in ICU patients with trauma and sepsis and may help differentiate sepsis from SIRS in critical illness. An elevated PCT level was associated with increased mortality.

A case of hybrid repair of ruptured abdominal aortic aneurysm with use of thrombin for acute treatment of type II endoleak.

Endovascular repair for ruptured abdominal aortic aneurysm has demonstrated superior results when compared with open repair and will likely become the standard of care when the anatomy of the aneurysm is appropriate for endovascular repair.