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Background Popliteal artery aneurysms (PAAs) are relatively rare but are one of the most common peripheral arterial aneurysms. Open popliteal artery aneurysm repair (OPAR) has been the standard, but technological advancements have made endovascular popliteal artery aneurysm repair (EPAR) a promising alternative. The aim of this study is to compare EPAR and OPAR efficacy and outcomes over a 10-year period.Methods This study retrospectively reviewed 72 patient charts who were diagnosed with PAA or popliteal artery pseudoaneurysm and underwent EPAR or OPAR from 1 January 2010 to 31 December 2019. Endovascular popliteal artery aneurysm repair was used in 37 cases and OPAR in 35 cases.Results Graft patency <30 days postoperative was 100% in both EPAR and OPAR groups. Graft patency >90 days postoperative was 72.73% in the EPAR group and 82.35% in the OPAR group (p= 0.477). Graft patency >2 years postoperative was 81.25% in the EPAR group and 86.67% in the OPAR group (p= 0.682). Freedom from reoperation 30-day postoperative was 78.38% in the EPAR group and 80% in the OPAR group (p= 0.865). Freedom from amputation 30-day postoperative was 91.43% in the EPAR group and 94.29% in the OPAR group (p= 0.263). The 30-day survival rate was 94.59% in the EPAR group and 100% in the OPAR group.Conclusions Endovascular repair represents a promising alternative for PAA repair. Our results demonstrate that EPAR has similar outcomes for asymptomatic, acutely symptomatic, and chronic symptomatic patients. Technological advancements of stent properties and refinement of surgical techniques may further improve endovascular techniques.

Background Management of residual pleural space remains a challenge in the practice of thoracic surgery. Options include thoracotomy with muscle flap/wound vac, Eloesser procedure, or thoracoplasty. We examine current practice and short-term outcomes of thoracoplasty in the American College of Surgeons National Surgery Quality Improvement Program (ACS NSQIP).Methods A retrospective review of thoracoplasty procedures (by CPT® code 32900, 32905, or 32906) in the ACS NSQIP database from the years 2012 to 2017 was performed. The ACS NSQIP prospectively collects perioperative and rigorous 30-day outcome data for patients undergoing major thoracic surgical nationally.Results The dataset contained 131 thoracoplasties in patients with an average age of 48 years (SD 19), average BMI of 26 kg/m2(SD 5), 48% female, and 21% of minority race. Forty percent of patients were ASA class III and 10% class IV–V. Five percent of the patients had muscle flap in addition to thoracoplasty. Median operative duration was 101 min (interquartile range 61–167) and 8% of patients required blood transfusion. The average length of hospital stay was 6 days (SD 9), and 93% of patients were discharged home. There was one death, and 23% experienced other major morbidity. Thirty-day readmission occurred in 8% of patients and 6% returned to the operating room within 30 days. Four percent of patients experienced respiratory failure, 4% sepsis, and 5% developed pneumonia.Conclusions Short-term outcomes of current thoracoplasty demonstrate low mortality and morbidity. Thoracoplasty should remain in our armamentarium for managing residual pleural space.

In this era of potent medications and interventional cardiovascular (CV) procedures, the importance of beginning with and including Therapeutic Lifestyle Changes (TLC) is frequently forgotten. A major goal of this review article is to show and emphasize that modification of CV risk with nonmedication approaches makes an essential contribution to CV risk reduction. Available information on TLC and modifiable CV risk factors was reviewed and assessed. Modifiable major CV risk factors include diabetes mellitus, hypertension, hyperlipidemia, tobacco abuse, obesity, stress, and a sedentary lifestyle. Age as a major CV risk factor is, of course, not susceptible to modification. A contribution to the control of CV risk factors can occur without the start of medications and there is proof of benefit for beginning with a non-pharmacological approach. TLC can benefit all of the major modifiable CV risk factors and there is good evidence for the additional benefit of supervised and group TLC. TLC includes physical activity, diet, and smoking cessation. Evidence for the benefits of TLC in reducing CV disease events is well established. However, medications must be added in those patients with higher CV risk to obtain maximum cholesterol reduction (lower is better for the low-density lipoprotein cholesterol) and good blood pressure control. • The benefit of TLC is frequently forgotten in this era of potent medications and invasive procedures. The benefits of diet and physical activity are emphasized with supporting data. Many motivated patients can prolong their lives significantly by dedication to TLC. • Therapeutic Lifestyle Change (TLC) especially encompasses increased physical activity, a healthy diet, and smoking cessation. • There is extensive proof for the benefit of TLC in contributing to cardiovascular (CV) disease prevention. • CV diseases have strong metabolic and inflammatory components, both of which can be improved by TLC.

Background Lung cancer is the number one cause of cancer death in America. Timely and appropriate care is critical in the management of lung cancer. We retrospectively reviewed our experience at the University of Kentucky to determine whether there were delays from initial presentation to diagnosis and from diagnosis to treatment. Furthermore, if delays existed, whether they affected overall survival and what factors contributed to these holdups in patient care.Methods This was a retrospective review of all patients who were diagnosed with lung cancer at the University of Kentucky between 2014 and 2017, including only those newly diagnosed at our institution and excluding patients who were diagnosed at other hospitals as well as patients with cancer recurrence. Out of a cohort of 3588 patients, only 517 were included.Results The average time between presentation and diagnosis was 43 days, and 86.7% of patients were diagnosed within 60 days. The average time to treatment from diagnosis was 27.5 days with 77.7% of patients being treated with either surgery, chemotherapy, and/or radiation within 42 days.Conclusion The majority of our patients were diagnosed and treated within the recommended time. The 13.3% and 22.3% of patients who did not fall within this timeframe were delayed due to personal reasons, comorbidities, and/or “watchful waiting”. Mortality seemed to be unaffected by any delays in diagnosis or treatment. This analysis is the first step in understanding the challenges in patient care, and can be a tool to institute programs to help patients obtain necessary care.

Purpose Historically, mediastinoscopy has been the gold standard for lung cancer diagnosis and staging, but mediastinoscopy has many limitations including sensitivity, the limited number of lymph node levels that can be sampled, and safety. Endobronchial ultrasound-guided transbronchial needle aspiration is a relatively new and less-invasive technique being used for lung cancer screening. Many studies have reported that it has similar sensitivity and specificity compared to mediastinoscopy, with a significantly lower complication rate. We performed this review to determine our institution’s experience with endobronchial ultrasound-guided transbronchial needle aspiration in lung cancer diagnosis and staging.Methods We reviewed the last 150 patients with suspected lung cancer who underwent endobronchial ultrasound-guided transbronchial needle aspiration procedures in our institution from May 26, 2016 to August 31, 2017.Results Ninety-seven of the 150 patients had a confirmed diagnosis of malignancy. Forty patients had a diagnosis other than cancer, and 13 had incomplete information or were lost to follow-up. Endobronchial ultrasound-guided transbronchial needle aspiration was correct in diagnosing malignancy or excluding malignant lymph nodes in 92 of the 97 patients with malignancy. Overall, the sensitivity, specificity, positive-predictive value, and negative-predictive value was 94.0%, 100.0%, 100.0%, and 91.5%, respectively. Only 3 complications were reported: 2 patients suffered minor bleeding, and one suffered major bleeding that resulted in cardiac arrest.Conclusions Real-time endobronchial ultrasound-guided transbronchial needle aspiration has a similar sensitivity and specificity to mediastinoscopy in diagnosing malignancy, with fewer complications and more financial benefit.

Background Extracorporeal membrane oxygenation is used for many different conditions including respiratory distress, cardiogenic shock, and trauma. In these patient groups, extracorporeal membrane oxygenation has been extensively studied. Recently, it has been used as a rescue measure in patients experiencing acute respiratory distress after thoracic surgery. The goal of our study was to examine the efficacy and cost-effectiveness of extracorporeal membrane oxygenation as a rescue measure after thoracic surgery at a single center.Methods We conducted a retrospective review of all patients who received extracorporeal membrane oxygenation after thoracic surgery at the University of Kentucky from January 9, 2012 to January 9, 2017. Eight patients were identified.Results The average time on extracorporeal membrane oxygenation was 9.125 days, and the average hospital stay was 65.125 days. Of the 8 patients placed on extracorporeal membrane oxygenation, 3 survived to discharge. Of the 3 patients who survived to discharge, 1 died within 6 months and 2 have been followed up for less than 4 months. The average total charge per patient was calculated to be $1,053,551, and the average charge per day was $16,177. The contribution margin was $109,200 per case.Conclusions Extracorporeal membrane oxygenation is a tool that saves lives in many different patient populations but it does not appear to be as effective in patients experiencing acute respiratory distress syndrome after thoracic surgery. Extracorporeal membrane oxygenation in this group also uses a tremendous amount of hospital resources.

Background: Polypharmacy is now a frequent aspect and reality of current medicine practice, driven by managing multiple comorbidities, especially in older adults. However and unfortunately, polypharmacy can expose patients to adverse drug reactions, and drug-drug or drug-disease interactions. On the other hand, clinicians are often hesitant to add new drugs to complex regimens even when recommended by evidence-based medicine and guidelines. In addition, there is frequently a failure to assess which medications might not be beneficial and may therefore be stopped. Method: Cardiovascular disease prevalence is increasing despite the efforts to prevent this with pandemics of obesity and diabetes as leading causes. The healthcare system is facing an increasing number of cardiovascular diseases in older patients with multiple comorbidities. New cardiovascular guidelines encourage multiple drug use to control these conditions and improve mortality and morbidity. However, use of multiple drugs can lead to inappropriate drug interactions and increased adverse outcomes. On the other hand, the so-called polypill has been proposed as a means to decrease the burden of multiple medications as well as increase cardiovascular disease prevention. Conclusion: This review discusses multiple issues of polypharmacy and its challenges, with a focus on cardiovascular diseases.

Empyema is a morbid complication of pneumonia in children, whose gold standard of surgical treatment technique remains undefined. Historically, treatment consisted of open thoracotomy with decortication. We evaluate the effectiveness and safety of video-assisted thoracoscopic surgery (VATS) as a surgical treatment in for empyema thoracis in a pediatric population at a single institution from 2005 to 2013. After receiving Institutional Review Board approval, we performed a retrospective chart review of children surgically treated for empyema as a complication of pneumonia from 2005 to 2013. Charts were reviewed for the type of procedure performed (VATS or open thoracotomy), comorbid conditions, preoperative status, operative outcomes, and postoperative status. A total of 112 pediatric patients were treated surgically for empyema. Surgical treatment consisted of VATS in all cases; no open thoracotomy procedures were performed. The success rate of VATS in our study was 96.4 per cent. Mean total length of stay was found to be 8.8 days, whereas postoperative length of stay was 6.3 days. Mean postoperative chest tube duration was 3.4 days. Perioperative complication rate was 11.6 per cent, with respiratory failure being the most common complication. The data from our study demonstrate that the exclusive use of VATS in children for the surgical management of all stages of empyema was safe and produced results with high efficacy. We consider VATS to be the new gold standard for surgical drainage of empyema.

IMPORTANCE: A minority of patients who experience postoperative complications die (failure to rescue). Understanding the preoperative factors that lead to failure to rescue helps surgeons predict and avoid operative mortality. OBJECTIVE: To provide a mechanism for identifying a high-risk group of patients with postoperative complications who are at a substantially increased risk for failure to rescue. DESIGN, SETTING, AND PATIENTS: Observational study evaluating failure to rescue in patients entered into the American College of Surgeons National Surgical Quality Improvement Program database. The large sample of surgical patients included in this study underwent a wide range of operations during a 5-year period in more than 200 acute care hospitals. We examined and identified patients at high risk for failure to rescue using propensity stratification. We also developed a risk-scoring system that allowed preoperative identification of patients at the highest risk for failure to rescue. MAIN OUTCOMES AND MEASURES: Risk-scoring system that predicts failure to rescue. RESULTS: Of the 1 956 002 database patients, there were 207 236 patients who developed serious postoperative complications. Deaths occurred in 21 731 patients with serious complications (10.5% failure to rescue). Stratification of patients into quintiles, according to their propensity for developing serious complications, found that 90% of operative deaths occurred in the highest-risk quintile, usually within a week of developing the initial complication. A risk-scoring system for failure to rescue, based on regression-derived variable odds ratios, predicted patients in the highest-risk quintile with good predictive accuracy. Only 31.8% of failure-to-rescue patients had a single postoperative complication. Perioperative deaths increased exponentially as the number of complications per patient increased. Patients with complications who had surgical residents involved in their care had reduced rates of failure to rescue compared with patients without resident involvement. CONCLUSIONS AND RELEVANCE: Twenty percent of high-risk patients account for 90% of failure to rescue (Pareto principle). More than two-thirds of patients with failure to rescue have multiple complications. On average, a few days elapse before death following a complication. A risk-scoring system based on preoperative variables predicts patients in the highest-risk category of failure to rescue with good accuracy. In high-risk patients who develop complications, our results suggest that early intervention, preferably in a high-level intensive care facility with a surgical training program, offers the best chance to reduce failure-to-rescue rates.

Background Pneumonectomy for nonmalignant disease is unusual. We wondered about the incidence, predisposing risks, and outcomes of this entity.Methods We interrogated the Society of Thoracic Surgeons General Thoracic Surgery Database to compare patients undergoing pneumonectomy for benign or malignant indications between 2006 and 2010.Results 309 of 3081 (10%) patients underwent pneumonectomy for nonmalignant conditions. The benign group were younger (56 vs. 62 years), more likely to be on steroid therapy (11.3% vs. 2.7%), and less likely to be current smokers (14.4% vs. 20.1%). Both groups had an equal incidence of comorbidities. Preoperative pulmonary function was decreased in the nonmalignant group: forced expiratory volume in 1 s 61% vs. 74% of predicted; carbon monoxide diffusion in the lung 61% vs. 71% of predicted. The most common nonmalignant etiologies requiring pneumonectomy were lung and pleural infections. The benign group had increased postoperative bleeding, infections, and lung-related complications.Conclusions Approximately 10% of patients undergoing pneumonectomy have nonmalignant disease. In these cases, careful patient selection with detailed preoperative preparation including improvement in nutrition and functional status are indicated. Technical aspects of pneumonectomy, which minimize perioperative bleeding and infectious complications, are particularly important when this surgery is performed for nonmalignant conditions.

Background This study explored the modern treatment of thoracic empyema. We evaluated outcomes of various operative approaches in both academic and nonacademic institutions.Methods We queried the Society of Thoracic Surgeons National Database for patients undergoing thoracic procedures with a primary diagnosis of empyema between 2009 and 2011. We compared treatment outcomes of patients having procedures at academic (n?=?1101, 28.3%) and nonacademic (n?=?2790, 71.7%) medical centers.Results Empyema treatments recorded in the database included tube thoracostomy (n?=?325, 8.4%), video-assisted thoracic surgery (n?=?1992, 51.2%), and thoracotomy (n?=?1574, 40.5%). Academic centers had higher rates of treatment by thoracostomy (13.8% vs. 6.2%), similar treatment rates of video-assisted thoracic surgery (49.9% vs. 51.7%), and lower rates of thoracotomy (36.3% vs. 42.1%) compared to nonacademic centers (p?48?h was more frequent in the nonacademic centers (7.6% vs. 4.4%, p?=?0.013).Conclusion Surgeons in both academic and nonacademic centers use selective surgical approaches for treatment of thoracic empyema, depending on the clinical condition of the patient, with fairly equivalent results across all procedure types.

Introduction:Over the past 15 years, a wide range of agents have been developed for use in surgical procedures to achieve hemostasis. These agents can be divided into three broad categories: hemostats, sealants and adhesives. They vary widely related to their mechanism of action, composition, ease of application, adherence to wet or dry tissue, immunogenicity and cost.Areas covered:This article focuses on the agents used in vascular surgery to achieve hemostasis; agents involved in clinical trials are also covered.Expert opinion:When surgeons achieve rapid hemostasis, potential benefits include better visualization of the surgical area, shorter operative times, decreased requirement for transfusions, better management of an anticoagulated patient, decreased wound healing time and overall improvement in patient recovery time. The need for safe and efficacious hemostatic agents that can provide a range of benefits is clearly a significant surgical issue.

Objective to investigate long-term survival in patients who underwent pneumonectomy for non-small-cell lung cancer at the University of Kentucky Medical Center.Methods we retrospectively reviewed 100 consecutive pneumonectomy cases from 1998 to 2009 at the University of Kentucky. We were able to obtain follow-up data on 99 of 100 patients.Results overall 1-, 2-, and 5-year survival was 66%, 48%, and 32%, respectively. The 1-, 2-, and 5- survival for left pneumonectomy was 76%, 55%, and 40%, respectively, compared to 56%, 44%, and 22%, respectively, for right pneumonectomy. The median survival for left pneumonectomy was 2.4 years compared to 1.2 years for right pneumonectomy (p?=?0.056). The 5-year survival for patients diagnosed with stage I disease was 34%, compared to 19% for stage II disease, and 38% for stage III disease. The 5-year survival for patients who underwent neoadjuvant therapy was 31% compared to 39% for patients who received adjuvant therapy and 29% for patients who received surgery alone. These results were also not statistically significant.Conclusion neoadjuvant therapy did not adversely affect long-term survival in our study. When compared to left pneumonectomy, right pneumonectomy for non-small-cell lung cancer is associated with adverse postoperative outcomes as well as poorer long-term survival.

There is occurring a progressive increase in peripheral arterial disease (PAD) in the United States and around the World. This is undoubtedly associated with deterioration in health status and an increase in cardiovascular risk factors. There are multiple old and new antithrombotic and anticoagulation medications that have been used for the treatment of PAD. Several are considered in this review. The purpose of antithrombotics in surgery is the prevention of thrombosis of surgical bypass grafts in order to help maintain their patency. Multiple different medication approaches can be made in association with surgery. Just as in the case of peripheral vascular surgery, thrombosis also plagues the long-term maintenance of patency following peripheral vascular interventions (PVIs). Platelets play a key role in the initiation and propagation of thrombus formation following these PVIs and the use of antithrombotic medication helps reduce the likelihood of intravascular thrombus formation and adverse ischemic events during and after the procedure. Currently used antithrombotic agents after percutaneous peripheral revascularization include aspirin, clopidogrel, cilostazol and warfarin. Available medications remain in a state of flux and new oral direct thrombin and Factor Xa inhibitors may also find a place as clinical evidence-based medicine accumulates.

OBJECTIVE To examine outcomes in patients who receive small amounts of intraoperative blood transfusion. DESIGN Longitudinal, uncontrolled observational study evaluating results of intraoperative transfusion in patients entered into the American College of Surgeons National Surgical Quality Improvement Program database. We made propensity-matched comparisons between patients who received and did not receive intraoperative transfusion to minimize confounding when estimating the effect of intraoperative transfusion on postoperative outcomes. SETTING We queried the American College of Surgeons National Surgical Quality Improvement Program database for patients undergoing operations between January 1, 2005, and December 31, 2009. PATIENTS A large sample of surgical patients from 173 hospitals throughout the United States. MAIN OUTCOME MEASURES Operative mortality and serious perioperative morbidity (≥1 of 20 complications). RESULTS After exclusions, 941 496 operations were analyzed in patients from 173 hospitals. Most patients (893 205 patients [94.9%]) did not receive intraoperative transfusions. Patients who received intraoperative infusion of 1 unit of packed red blood cells (15 186 patients [1.6%]) had higher unadjusted rates of mortality and more serious morbidity. These rates further increased with intraoperative transfusion of more than 1 unit of packed red blood cells in a dose-dependent manner. After propensity matching to adjust for multiple preoperative risks, transfusion of a single unit of packed red blood cells increased the multivariate risk of mortality, wound problems, pulmonary complications, postoperative renal dysfunction, systemic sepsis, composite morbidity, and postoperative length of stay compared with propensity-matched patients who did not receive intraoperative transfusion. CONCLUSIONS There is a dose-dependent adverse effect of intraoperative blood transfusion. It is likely that a small, possibly discretionary amount of intraoperative transfusion leads to increased mortality, morbidity, and resource use, suggesting that caution should be used with intraoperative transfusions for mildly hypovolemic or anemic patients.

Medical, percutaneous interventional, and surgical treatments for the management of coronary heart disease have progressed markedly during the past decade. There is evidence to suggest that for patients with stable coronary heart disease optimal medical therapy is equal in effectiveness for lowering the risk of major cardiovascular events, such as cardiovascular death, myocardial infarction, and stroke, as are revascularization procedures, such as coronary artery bypass grafting or percutaneous coronary intervention. The landmark Surgical Treatment for Ischemic Heart Failure (STICH) trial found no significant difference between medical therapy alone and medical therapy plus coronary artery bypass grafting with respect to the primary end point of death from any cause (all-cause mortality). However, secondary outcomes showed fewer deaths from cardiovascular causes in the surgical group versus the medical group. Medical therapy has improved over time, as have surgical techniques including myocardial preservation, and both approaches have their place, especially since chest pain relief and quality of life may benefit more in some cases by revascularization. Certainly, coronary artery bypass grafting has general acceptance for three-vessel coronary heart disease, and percutaneous coronary artery intervention is the standard of care for the involved artery in acute ST-segment elevation myocardial infarction when the intervention can be accomplished rapidly. Medical management includes lifestyle changes that benefit coronary heart disease, drug therapy to improve prognosis, and drug therapy to improve symptoms. The key to clinical management is the selection of the procedure and/or medical management strategy that is in the best interest of the individual cardiovascular patient. In addition, discussing with patients their options and considering what best fits their wishes is especially critical when there is no clear-cut best strategy. Continued collaboration between cardiologists concentrating on medical approaches with interventionists and cardiac surgeons (heart team approach) is essential for optimal management for each individual patient.

The low thrombogenicity, porosity, and limited elasticity of expanded polytetrafluoroethylene (ePTFE) vascular grafts, although beneficial, may exacerbate the problem of suture-line bleeding at vascular anastomoses and consequently lead to increased operating times. The overall objective of this prospective, randomized, controlled, subject-blinded, multicenter phase 2 study was to evaluate the efficacy and safety of a fibrin sealant containing 500 IU/mL thrombin and synthetic aprotinin (FS; marketed in the United States under the name TISSEEL) for hemostasis in subjects undergoing vascular surgery and receiving prosthetic ePTFE vascular grafts.

The presence of peripheral vascular disease along with coronary heart disease are the two components of generalized atherosclerosis. The risk of having one when the other is present is extremely high. There are four parts to consider in peripheral vascular disease management and these are prevention, plaque stabilization, percutaneous intervention and surgery. Each part has its place but no one would argue that prevention is best when risk is recognized and treated. Classic risk factors and the available diagnostic methods are discussed. Treatment of risk factors is presented with reduction of the low density lipoproteins as the established gold standard during the current era. Procedures of percutaneous vascular intervention with their procedural indications are presented and their advantages and disadvantages discussed. Surgical indications are presented with special indication due to major claudication, rest pain, or tissue loss. Prognosis is also considered and this prognosis is worse in more proximal peripheral vascular disease. Association with other diseases is an important part of prognosis, with the latter especially made worse by the presence of diabetes mellitus. Surprisingly, the long-term prognosis of peripheral vascular disease is worse than that of coronary heart disease. These patients have a significant increase of cardiovascular risk factors and of comorbidities. It has been shown that these patients are undertreated in spite of their high cardiovascular risk. It is mandatory that they receive the same intensive treatment of risk factors as that given to coronary heart disease patients.

We observed significant morbidity and mortality in patients with preexisting cardiac disease who suffer severe traumatic injuries. We wondered about the types of injury seen and about the cardiac risks factors that predispose to worse outcomes in these patients. Our hypothesis is that significant cardiac comorbidity is associated with adverse trauma outcomes.

Abstract: Carotid endarterectomy in very elderly patients remains controversial. We report our experience with this operation on 101 very elderly patients at the Baptist Heart Institute, a community hospital in Lexington, Kentucky. Ages ranged from 80 to 93 years with an average age of 86.5 years. There are 7 nonagenarians in this study. The indications included asymptomatic severe carotid artery stenosis in 29 (29.7%) patients and symptomatic disease in 72 patients (71.3%). Sixty eight percent of the patients had significant co-morbidity that included hypertension, diabetes mellitus, lipid disorders, previous stroke, previous carotid endarterectomy, coronary artery disease and previous myocardial infarctions. Thirty two percent of the patients had no significant past medical history. Two deaths occurred during hospitalizations (1.98%). One of these patients had carotid endarterectomy in conjunction with coronary artery bypass grafting. This patient suffered a stroke. The second death occurred as the result of respiratory failure. There was 1 perioperative infarct. From this study, we conclude that carotid endarterectomy can be performed safely in very elderly patients in a community hospital.

Abstract. The management of concomitant coronary and carotid disease is controversial. We report our experience of simultaneous coronary artery bypass surgery and carotid artery endarterectomy on 70 consecutive patients (34 males and 36 females) with a mean age of 68 years. The oldest patient was 91 years old. The average percent of carotid artery stenosis was 86% (range 60%-99%). The average number of grafts per patient was 3.35 (range 1-6). Two patients experienced postoperative strokes (2.86%), 1 had a perioperative infarct (1.42%), and 4 died in the hospital (5.7%). The simultaneous approach offers the advantage of shorter hospital stays, decreased anesthesia exposure, and significant cost savings. The causes of death include stroke, renal failure, and bowel infarction. This review indicates the simultaneous approach has a higher incidence of adverse outcomes compared with elective carotid endarterectomy or elective coronary artery bypass surgery. These patients, however, are at significantly higher risk due to their poor medical conditions, extensive atheromatous disease, and often emergent medical condition.

Giant pulmonary cysts, often developing as a major complication of emphysema, seriously interfere with breathing mechanics. This report describes the results in 35 patients with giant pulmonary cysts who underwent surgical excision. A case report involving a 26-year-old coal miner with bilateral bullous emphysema is also presented.

Summary: The case of a patient with a giant diverticulum is reported, with a brief review of the literature. The patient was 71 years old when he developed abdominal pain on straining. The diverticulum was diagnosed by x-ray and treated by segmental resection of the involved area of the colon. The patient is now leading a normal life.

Neoplasms of the thymus gland (thymomas) represent up to 20% of primary mediastinal tumors and are the most common tumors in the anterior mediastinum. In this report we present our experience with thymoma in 28 patients. Surgical resection was the primary method of treatment and excellent results were obtained in the majority of our patients. There was one surgical death within this series. Although surgical resection has been identified as the treatment of choice, prognosis is dependent on tumor staging. Radiotherapy is recognized as beneficial in the treatment of stages II to IV. The role of chemotherapy, however, has not been determined conclusively in the treatment of thymoma.

Summary: A review of 200 colostomies showed that the incidence of complications was 11 per cent. Prolapse was the most common complication. Indications for colostomy and factors resulting in complications are mentioned. Technics that may prevent or reduce the incidence of complications are briefly discussed.