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Intimomedial mucoid degeneration (IMMD) is an extremely rare vascular condition characterized by mucin accumulation in the intima and media, resulting in arterial wall elastic tissue degradation and aneurysm formation. We report the case of a 34-yearold woman who presented to the emergency department with a 1-month history of left lower limb pain. On local physical examination, both lower limbs were warm with palpable regular pulses in the entire lower limbs and normally capillary refill. No palpable masses were felt. Computed tomography angiography (CTA) of the lower limbs revealed an aneurysm with a thrombosed sac in the left popliteal artery behind the knee joint. Thoracic and abdominal CTA revealed normal findings. The patient underwent posterior exploration of the left popliteal artery, which revealed a large aneurysm requiring excision, and an interposition vein graft end-to-end anastomosis was performed. Histopathological examination of the aneurysm disclosed the presence of fibrosis, scattered chronic inflammatory cells, and a hyalinized fibrin thrombus associated with marked fragmentation and distortion of the elastic tissue. Extensive mucoid deposition in the intima and media of the artery was also detected. The postoperative recovery was uneventful, and the patient was discharged home with regular follow-up during the last year in our outpatient clinic. IMMD can affect smaller vessels such the brachial, coronary, temporal arteries, and dorsalis pedis. The main histological hallmarks of IMMD include intimal and medial thickening caused by the formation of mucin pools, which leads to elastin fibers fragmentation and aggregation. The prognosis of IMMD-related aneurysms is determined by the extent of the disease and the time it is discovered. IMMD-related aneurysms should be included in the differential diagnosis of isolated popliteal artery aneurysms. Open surgical repair is the gold standard of treatment for IMMD-related aneurysms. [ABSTRACT FROM AUTHOR]

Despite the development of fenestrated and branched endovascular aortic repair (f/bEVAR), the surgical management of thoraco-abdominal aortic aneurysms (TAAAs) remains a major challenge. The aim of this study was to analyse the hospital incidence and hospital mortality of patients treated for TAAAs in Switzerland. Secondary data analysis was performed using nationwide administrative discharge data from 2009–2018. Standardised incidence rates and adjusted mortality rates were calculated. A total of 885 cases were identified (83.2% nonruptured (nrTAAA), 16.8% ruptured (rTAAA)), where 69.3% were male. The hospital incidence rate for nrTAAA was 0.4 per 100,000 women and 0.9 per 100,000 men in 2009, which had doubled for both sexes by 2018. For rTAAA, there was no trend over the years. The most common procedure was f/bEVAR (44.2%), followed by OAR (39.5%), and 9.8% received a hybrid procedure. There was a significant increase in endovascular procedures over time. The all-cause mortality was 7.1% with nrTAAA and 55% with rTAAA. The mortality was lower for rTAAA when f/bEVAR or hybrid procedures were used. A ruptured aneurysm and higher comorbidity were associated with higher hospital mortality. This study demonstrates that the treatment approach has changed significantly over the observed period. The use of f/bEVAR nearly tripled in nrTAAA and doubled in rTAAA during this decade. [ABSTRACT FROM AUTHOR]

Purpose: Perioperative risk assessments for complex aneurysms are based on the anatomical extent of the aneurysm and do not take the length of the aortic exclusion into account, as it was developed for open repair. Nevertheless, in the endovascular repair (ER) of complex aortic aneurysms, additional segments of healthy aorta are excluded compared with open repair (OR). The aim of this study was to assess differences in aortic exclusion between the ER and OR of complex aortic aneurysms, to subsequently assess the current classification for complex aneurysm repair. Methods: This retrospective observational study included patients that underwent complex endovascular aortic aneurysm repair by means of fenestrated endovascular aneurysm repair (FEVAR), fenestrated and branched EVAR (FBEVAR), or branched EVAR (BEVAR). The length of aortic exclusion and the number of patent segmental arteries were determined and compared per case in ER and hypothetical OR, using a Wilcoxon signed-rank test. Results: A total of 71 patients were included, who were treated with FEVAR (n = 44), FBEVAR (n = 8), or BEVAR (n = 19) for Crawford types I (n = 5), II (n = 7), III (n = 6), IV (n = 7), and V (n = 2) thoracoabdominal or juxtarenal (n = 44) aneurysms. There was a significant increase in the median exclusion of types I, II, III, IV, and juxtarenal aneurysms (p < 0.05) in ER, compared with hypothetical OR. The number of patent segmental arteries in the ER of type I–IV and juxtarenal aneurysms was significantly lower than in hypothetical OR (p < 0.05). Conclusion: There are significant differences in the length of aortic exclusion between ER and hypothetical OR, with the increased exclusion in ER resulting in a lower number of patent segmental arteries. The ER and OR of complex aortic aneurysms should be regarded as distinct modalities, and as each approach deserves a particular risk assessment, future efforts should focus on reporting on the extent of exclusion per treatment modality, to allow for appropriate comparison. [ABSTRACT FROM AUTHOR]

Thoracoabdominal aortic aneurysms (TAAA) represent a unique pathology that is associated with considerable mortality if untreated. While the advent of endovascular technologies has introduced new modalities for consideration, the mainstay of TAAA treatment remains open surgical repair. However, the optimal conduct of open TAAA repair requires careful consideration of patient risk factors and a collaborative team effort to mitigate the risk of perioperative complications. In this chapter, we briefly outline the history of treating TAAA, preoperative preparation and postoperative care, and our operative techniques for treatment. [ABSTRACT FROM AUTHOR]

Background: Open repair is the most promising curative treatment option for patients with chronic type B aortic dissection. However, based on our experience, following the accidental detection of intra-pleural adhesions during open surgery for chronic type B aortic dissection, complete replacement of the diseased aorta cannot be accomplished. To overcome this problem, we switched the procedure to create a distal landing zone for subsequent endovascular repair by replacing the distal aorta with a vascular graft.Case Presentation: We report two cases in which open repair was attempted; however, the proximal descending thoracic aorta could not be exposed due to the presence of severe adhesion in the pleural cavity. In these patients, we accessed the lower descending thoracic aorta or thoracoabdominal aorta and created a distal landing zone for subsequent endovascular repair by replacing the aorta with a vascular graft. Thereafter, endovascular repair was performed with good outcomes.Conclusions: Replacement of the distal aorta, which is typically easy to access despite the presence of intra-pleural adhesions, with a vascular graft serves as a reliable distal landing zone for subsequent endovascular repair. This method may be a viable option for the management of severe adhesions accidentally detected in the pleural cavity during open repair for chronic type B aortic dissection. [ABSTRACT FROM AUTHOR]

Background: Parastomal hernia is a common complication of an enterostomy and can have a significant impact on health-related quality of life. Currently used methods of repair have high recurrence rates and considerable risk for complications. We have developed a new technique for parastomal hernia repair that uses full-thickness skin graft as reinforcement.Methods: This study protocol describes a multicentre randomised controlled trial on parastomal hernia repair comparing a new full-thickness skin graft technique with conventional synthetic composite mesh as reinforcement of the abdominal wall. Patients with a symptomatic parastomal hernia will be included and followed up at 3, 12 and 36 months, with surgical complication as the primary outcome. Secondary outcomes will be recurrence rate and health-related quality of life assessed with VHPQ, EORTC C30 and CR29. Tissue biology and collagen metabolism will be investigated pre- and postoperatively using biopsies of the abdominal wall fascia and blood samples.Discussion: Parastomal hernia constitutes a major clinical problem where the prospects of a good result after hernia repair are presently poor. This new method of repair with full-thickness skin grafting could be a new alternative in our surgical toolbox, but before then, it must be evaluated properly.Trial Registration: ClinicalTrials.gov NCT03667287. Registered on September 12, 2018. [ABSTRACT FROM AUTHOR]

Abdominal aortic aneurysm (AAA) is a fatal disease with high perioperative morbidity and mortality. Endovascular AAA repair (EVAR) is associated with remarkable improvement in the morbidity, mortality and length of hospital stay relative to open operative repair. We report a 79-year-old man with epigastric pain, which was diagnosed to be due to AAA on a computerised tomography angiogram (CTA). His only risk factor was hypertension. He had endovascular repair in 2018, the first-ever in Ghana and West Africa. 2021 is the 3rd year of surveillance post-EVAR with no disease progression or complication. This seminal case is a beacon of hope in Ghana's resource-constrained healthcare system. [ABSTRACT FROM AUTHOR]

Background: Heparin is used worldwide for 70 years during all non-cardiac arterial procedures (NCAP) to reduce thrombo-embolic complications (TEC). But heparin also increases blood loss causing possible harm for the patient. Heparin has an unpredictable effect in the individual patient. The activated clotting time (ACT) can measure the effect of heparin. Currently, this ACT is not measured during NCAP as the standard of care, contrary to during cardiac interventions, open and endovascular. A RCT will evaluate if ACT-guided heparinization results in less TEC than the current standard: a single bolus of 5000 IU of heparin and no measurements at all. A goal ACT of 200-220 s should be reached during ACT-guided heparinization and this should decrease (mortality caused by) TEC, while not increasing major bleeding complications. This RCT will be executed during open abdominal aortic aneurysm (AAA) surgery, as this is a standardized procedure throughout Europe.Methods: Seven hundred fifty patients, who will undergo open AAA repair of an aneurysm originating below the superior mesenteric artery, will be randomised in 2 treatment arms: 5000 IU of heparin and no ACT measurements and no additional doses of heparin, or a protocol of 100 IU/kg bolus of heparin and ACT measurements after 5 min, and then every 30 min. The goal ACT is 200-220 s. If the ACT after 5 min is < 180 s, 60 IU/kg will be administered; if the ACT is between 180 and 200 s, 30 IU/kg. If the ACT is > 220 s, no extra heparin is given, and the ACT is measured after 30 min and then the same protocol is applied. The expected incidence for the combined endpoint of TEC and mortality is 19% for the 5000 IU group and 11% for the ACT-guided group.Discussion: The ACTION-1 trial is an international RCT during open AAA surgery, designed to show superiority of ACT-guided heparinization compared to the current standard of a single bolus of 5000 IU of heparin. A significant reduction in TEC and mortality, without more major bleeding complications, must be proven with a relevant economic benefit. TRIAL REGISTRATION {2A}: NTR NL8421 ClinicalTrials.gov NCT04061798 . Registered on 20 August 2019 EudraCT 2018-003393-27 TRIAL REGISTRATION: DATA SET {2B}: Data category Information Primary registry and trial identifying number ClinicalTrials.gov : NCT04061798 Date of registration in primary registry 20-08-2019 Secondary identifying numbers NTR: NL8421 EudraCT: 2018-003393-27 Source(s) of monetary or material support ZonMw: The Netherlands Organisation for Health Research and Development Dijklander Ziekenhuis Amsterdam UMC Primary sponsor Dijklander Ziekenhuis Secondary sponsor(s) N/A Contact for public queries A.M. Wiersema, MD, PhD Arno@wiersema.nu 0031-229 208 206 Contact for scientific queries A.M. Wiersema, MD, PhD Arno@wiersema.nu 0031-229 208 206 Public title ACT Guided Heparinization During Open Abdominal Aortic Aneurysm Repair (ACTION-1) Scientific title ACTION-1: ACT Guided Heparinization During Open Abdominal Aortic Aneurysm Repair, a Randomised Trial Countries of recruitment The Netherlands. Soon the recruitment will start in Germany Health condition(s) or problem(s) studied Abdominal aortic aneurysm, arterial disease, surgery Intervention(s) ACT-guided heparinization 5000 IU of heparin Key inclusion and exclusion criteria Ages eligible for the study: ≥18 years Sexes eligible for the study: both Accepts healthy volunteers: no Inclusion criteria: Study type Interventional Allocation: randomized Intervention model: parallel assignment Masking: single blind (patient) Primary purpose: treatment Phase IV Date of first enrolment March 2020 Target sample size 750 Recruitment status Recruiting Primary outcome(s) The primary efficacy endpoint is 30-day mortality and in-hospital mortality during the same admission. The primary safety endpoint is the incidence of bleeding complications according to E-CABG classification, grade 1 and higher. Key secondary outcomes Serious complications as depicted in the Suggested Standards for Reports on Aneurysmal disease: all complications requiring re-operation, longer hospital stay, all complications. [ABSTRACT FROM AUTHOR]

Mesenteric ischemia is rare, yet a fatal etiology of abdominal pain. It is common in the elderly population, specifically women more than men. Mesenteric ischemia manifests itself in a variety of presentations and has a range of causes, and always poses a diagnostic challenge. A high index of suspicion is needed, and early identification and intervention raise the survival rate of the patients. Because of its high accuracy performance, computed tomographic angiography (CTA) has become the gold standard diagnostic modality. Options for intervention include endovascular procedures and open repair. We aimed to review the literature to promote the understanding and awareness of mesenteric ischemia. We reviewed the literature for mesenteric ischemic syndromes, pathophysiology, diagnosis, evaluation, and treatment options. Articles were chosen from the PubMed database, and selected studies were subjected to a thorough review. Mesenteric ischemia is a rare cause of abdominal pain, yet it is a potentially life-threatening condition. To diagnose and treat the condition early, a high index of suspicion is essential. Delay in diagnosis and treatment might result in a high rate of morbidity and mortality for the patient. Early bowel revascularization with an open or endovascular repair is critical for survival. [ABSTRACT FROM AUTHOR]

Background: This study aims to review contemporary lines of management of popliteal artery aneurysm (PAAs) illustrating the pros and cons of each treatment modality. Methods: This is a prospective cohort study of all consecutive PAAs treated between 2015-2017. All patients Patients' data were entered into a prospectively designed registry including all clinical, radiologic, operative and postoperative data. Results: The study included thirty-seven PAAs in 35 patients. Management was by open repair in 48.6%, while endovascular repair in 24.3%, primary major amputation in 5.4%, and surveillance in 21.6%. PAAs were asymptomatic in 32.4% and symptomatic in 67.6% (acute ischemia in 35.1%, claudication in 32.4%, rupture in 8.1% and leg swelling and pain in 8.1%). An emergency procedure done in 29.7%, elective procedure in 51.4% and no intervention in 18.9%. Length of hospital stay in open repair was 15.1 days and in endovascular repair was 2 days. One year patency, limb salvage and mortality rates were 53.3%, 60% and 26.7%, respectively in open repair and were 75%. 100%, and .0%, respectively in endovascular repair (p=0.526). Conclusions: Results of repair of asymptomatic PAAs are significantly better than those in symptomatic PAAs. In the emergency setting with severe limb ischemia and complete thrombosis of PAAs, there is significantly increased mortality, limb loss, and decreased primary patency rate. Endovascular treatment is feasible in selected patients with having adequate landing zones. A prospective randomized trial is necessary to compare the immediate and long-term outcome of endovascular repair with open repair in a large population of patients with PAAs. [ABSTRACT FROM AUTHOR]

Background: There are no standard criteria to select patients for thoracoscopic repair of congenital diaphragmatic hernia (CDH). The objective of this study was to compare open laparotomy versus thoracoscopic repair of CDH in neonates.Patients and Methods: This retrospective study included 41 patients who had repair of CDH from 2011 to 2019. Patients were divided into two groups according to the surgical approach; open laparotomy (n = 30) and thoracoscopic repair (n = 11). Study endpoints were duration of post-operative mechanical ventilation, hospital stay and the return to full enteral feeding.Results: Patients who had thoracoscopic repair were significantly younger (3 [25th- 75th percentiles: 3-3] vs. 4 [3-5] days; P = 0.004). Other pre-operative variables were comparable between both groups. The duration of surgery was significantly longer in the thoracoscopic repair (174 [153-186] vs. 91 (84-99) min; P < 0.001). The use of pre-operative nitrous oxide inhalation was associated with prolonged ventilation (P = 0.004), while the thoracoscopic repair was associated with shorter mechanical ventilation (P = 0.006). Hospital stay is lower in the thoracoscopic approach but did not reach a significant value (P = 0.059). The use of pre-operative nitrous oxide was associated with a prolonged hospital stay (P = 0.002). Younger age (HR: 1.33, P = 0.014) and open approach (HR: 3.56, P = 0.004) were significantly associated with delayed feeding.Conclusions: The thoracoscopic approach is safe and effective for repairing the CDH. It is associated with shorter mechanical ventilation and rapid return to enteral feeding. Proper patient selection is essential to achieve good outcomes. [ABSTRACT FROM AUTHOR]

The triangular fibrocartilage complex (TFCC) is an intrinsic stabiliser of the distal radioulnar joint (DRUJ), which serves an important role in wrist movement, forearm rotation and grip strength. A stable DRUJ is a key requirement for pain-free movement of the wrist. TFCC tears are a common ulnar-sided wrist pain associated with decreased grip strength and impaired function. TFCC tears are classified according to the location and cause. The Palmer classification delineates tears into traumatic type 1 and degenerative type 2. The present study investigated the clinical outcomes of using micro suture anchors in open repair in comparison with trans-osseous TFCC repair. From July 2017 to July 2020, 51 patients underwent open repair of TFCC tear by hand and upper limb surgeons in Royal Rehabilitation Center at King Hussein Medical Center (Amman, Jordan). Stability of DRUJ and tenderness at the ulnar aspect of the wrist were evaluated by Disability of the Arm, Shoulder and Hand (DASH) and Modified Mayo Wrist Score (MMWS) pre- and post-operatively. A total of 38 patients (27 male and 11 females) underwent open repair using micro suture anchors and 13 (7 male and 6 female) by trans-osseous repair. A total of 51 patients in the follow-up 6-48 months had significant improvement in pain and range of motion. A total of 45 patients showed improved grip strength and were pain-free; six patients showed improvement of grip strength and decreased pain. For the patients who underwent TFCC repair by micro suture anchors, there was an improvement of MMWS from 70 to 90%, and for those who underwent TFCC repair by trans-osseous technique, MMWS improved from 65 to 85%. There was also significant improvement in DASH score post-operatively with both techniques, from 60 to 15% in the trans-osseous technique and from 70 to 15% in the suture anchors. Open repair of TFCC tears using either micro anchor or trans-osseous repair led to pain-free range of motion, improved grip strength, stable DRUJ and improvement in DASH and MMWS scores, with no significant differences in clinical outcome between techniques. [ABSTRACT FROM AUTHOR]

Background: Repair of rotator cuff tears has yielded excellent functional outcomes in recent decades; however, poor outcomes and dissatisfaction have been noted in specific groups. Spontaneous tendon rupture has been reported in patients receiving long-term hemodialysis owing to alteration of tendon structure, which might impede functional recovery after rotator cuff repair. The purpose of the present study was to compare the clinical outcomes between hemodialysis and non-hemodialysis patients after rotator cuff repair.Methods: We retrospectively reviewed patients who underwent mini-open rotator cuff repair from Jan 2013 to Jan 2017. A total of 14 patients under chronic hemodialysis (HD) were matched to non-hemodialysis (NHD) patients at a 1:2 ratio according to age, gender, tear size, severity of fatty infiltration and history of diabetes. Pre- and post-operative functional outcome was assessed using the simple shoulder test (SST), American Shoulder and Elbow Surgeons (ASES), Shoulder Rating Scale of the University of California at Los Angeles (UCLA) and visual analog scale (VAS) scores. Clinical functional outcome at the last follow-up was adopted for comparison of the HD and NHD groups.Results: A total of 42 patients were enrolled in this comparative study, with a mean age of 66.64 ± 1.68 years in the HD group and 65.71 ± 5.40 years in the NHD group. At the final clinical assessment, the post-operative functional outcome was significantly improved in both groups (p < 0.001). However, the functional outcome of the HD group was significantly inferior to that of the NHD group in terms of the SST score (6.50 ± 2.24 vs 9.39 ± 1.87, p < 0.001), ASES score (63.17 ± 15.93 vs 86.96 ± 11.43, p < 0.001), UCLA score (20.14 ± 7.71 vs 29.82 ± 5.08, p < 0.001) and VAS score (3.00 ± 0.96 vs 1.21 ± 1.03, p < 0.001).Conclusion: The improvement of pain and functional improvement of long-term hemodialysis patients were inferior to those of patients without hemodialysis after mini-open rotator cuff repair. [ABSTRACT FROM AUTHOR]

OBJECTIVES To compare short-term outcomes, long-term survival and reinterventions in patients requiring surgery after chronic Type I and chronic primary Type III aortic dissections. METHODS Over an 11-year period, 466 patients underwent thoraco-abdominal aortic aneurysm repair for chronic Type III (n  = 239) and Type I (n  = 227) aortic dissections. Short-term outcomes and reinterventions were evaluated by multivariable regression analysis for the entire group; propensity matching produced 169 pairs. RESULTS Mortality was 6% (n  = 28) in the overall cohort and 6.2% (n  = 14) and 5.9% (n  = 14) in those with chronic Type I and Type III aortic dissections, respectively. Overall stroke and persistent spinal cord deficit rates were 4.0% and 2.6%, respectively, in the Type I group and 1.3% and 3.8% in the Type III group. In the propensity-matched patients, analysis showed no neurological differences between the 2 groups, but respiratory failure was significantly more frequent in the chronic Type I group (30.2% vs 15.4%; P  =   0.001). Multivariable analysis identified chronic Type I dissection as an independent risk factor for postoperative pulmonary complications (odds ratio 1.612; 95% confidence interval 1.060–2.452; P  =   0.026) and an association between chronic Type I dissection and stroke (odds ratio 4.013; 95% confidence interval 1.026–15.698; P  =   0.046). Six-year survival was 74.4%   ±   4.1% and 74.4%   ±   4.6% in the chronic Type I and Type III groups, respectively (P  =   0.87). CONCLUSIONS Short- and long-term mortality and reintervention rates were comparable after open repair for chronic Type I and primary chronic Type III aortic dissections. Respiratory failure was more frequent in the chronic Type I aortic dissection group. [ABSTRACT FROM AUTHOR]

In the conventional way of thoraco-abdominal aortic replacement, the intercostal arteries are reimplanted directly to the main aortic graft or by the interposition of branch grafts. To overcome the disadvantages of these techniques, we adopted a different technique using a parallel side graft. The good patency rate of reimplanted intercostal arteries achieved by this technique and its potential technical advantages can contribute to the improvement of the surgical outcome. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To evaluate surgical outcomes in open repair of thoracoabdominal aortic (TAAA) and descending thoracic aortic aneurysms (DTA) in patients with preoperative renal failure (PRF). METHODS: Our database was examined for all patients undergoing open TAAA/DTA repair. Patients with a creatinine greater than or equal to 1.5 gm/dl or on haemodialysis were defined as having PRF and were compared to those having normal preoperative renal function. Logistic and Cox regression analysis were used to identify independent determinants of in-hospital outcomes and long-term survival. RESULTS: From 1997 to 2015, 711 patients underwent open TAAA/DTA repair. Two hundred and two were categorized as having PRF, of which, 22 where on preoperative haemodialysis. PRF patients had significantly worse comorbidities; smoking (95.5% vs 69.0%; P < 0.001), chronic pulmonary disease (65.8% vs 29.7%; P < 0.001), peripheral vascular disease (44.1% vs 19.4%; P < 0.001) and diabetes (16.3% vs 6.7%; vs P < 0.001). Operative mortality (OM) was seven-times higher in patients with PRF (14.2 vs 2.2%; P < 0.001). Logistic regression analysis showed that PRF was a predictor of OM [odds ratio (OR): 4.91; confidence interval (CI): 2.01–11.97; P < 0.001] and major adverse events (OR: 2.05; CI: 1.21–3.46; P = 0.007). Kaplan–Meier 5-years survival was significantly lower in PRF patients (45.0% vs 69.8%; P < 0.001). CONCLUSIONS: PRF predicts higher OM and major adverse events incidence following open TAAA/DTA repair. Long-term survival is negatively impacted. Strategies for improving preoperative and intraoperative renal function may lead to better outcomes. [ABSTRACT FROM AUTHOR]

Background: No reliable comparative data exist between open repair (OR) and endovascular aneurysm repair (EVAR) for mycotic abdominal aortic aneurysms (MAAAs). This nationwide study assessed outcomes after OR and EVAR for MAAA in a population-based cohort.Methods: All patients treated for MAAAs in Sweden between 1994 and 2014 were identified in the Swedish vascular registry. The primary aim was to assess survival after MAAA with OR and EVAR. Secondary aims were analyses of the rate of recurrent infections and reoperations, and time trends in surgical treatment. Survival was analyzed using Kaplan-Meier and log-rank tests. A propensity score-weighted correction for risk factor differences in the 2 groups was performed, including the operation year to account for differences in treatment and outcomes over time.Results: We identified 132 patients (0.6% of all operated abdominal aortic aneurysms in Sweden). Mean age was 70 years (standard deviation, 9.2), and 50 presented with rupture. Survival at 3 months was 86% (95% confidence interval, 80%-92%), at 1 year 79% (72%-86%), and at 5 years 59% (50%-68%). The preferred operative technique shifted from OR to EVAR after 2001 (proportion EVAR 1994-2000 0%, 2001-2007 58%, 2008-2014 60%). Open repair was performed in 62 patients (47%): aortic resection and extra-anatomic bypass (n=7), in situ reconstruction (n=50), and patch plasty (n=3); 2 patients died intraoperatively. EVAR was performed in 70 patients (53%): standard EVAR (n=55), fenestrated/branched EVAR (n=8), and visceral deviation with stent grafting (n=7); no deaths occurred intraoperatively. Survival at 3 months was lower for OR than for EVAR (74% versus 96%, P<0.001), with a similar trend present at 1 year (73% versus 84%, P=0.054). A propensity score-weighted risk-adjusted analysis confirmed the early better survival associated with EVAR. During median follow-up of 36 and 41 months for OR and EVAR, respectively, there was no difference in long-term survival (5 years 60% versus 58%, P=0.771), infection-related complications (18% versus 24%, P=0.439), or reoperation (21% versus 24%, P=0.650).Conclusion: This study demonstrates a paradigm shift in treatment of MAAA in Sweden, with EVAR being the preferred treatment modality. EVAR was associated with improved short-term survival in comparison with OR, without higher associated incidence of serious infection-related complications or reoperations. [ABSTRACT FROM AUTHOR]

Background: Inguinal hernia repair using mesh is one of the most frequently performed operations in general surgery. We evaluated pain, recurrence, complications such as wound infection, mesh infection, return to work and length of hospital stay after hernia repair using standard mesh. Materials and methods: A prospective clinical study was conducted with standard polypropylene mesh repair of a hernia. Data were collected from admission till discharge from the hospital, one month, two months and three months after surgery. At each visit clinical examination and ultrasound was done to evaluate chronic persisting inguinal pain and recurrences. Results: A total of 80 patients underwent tension free hernia repair with standard mesh. There were 36 males and 44 females. The mean age of the patients was 54±8.2 years. The average duration of stay in the hospital was 5.2±1.4 days. 4/80 (5%) had wound infection, 2/80 (2.5%) had mesh infection and only 7/80 (10%) had recurrent pain after one year. Conclusion: In our study, low recurrence rates, early return to work and a low percentage of persistent pain suggest that open repair with standardised mesh for hernia repair remains a good option for the low-income group patients. Additionally, it is easy to perform, inexpensive and can be done under local anesthesia. [ABSTRACT FROM AUTHOR]

Many years following transplantation, heart transplant recipients may require noncardiac major surgeries. Anesthesia in such patients may be challenging due to physiological and pharmacological problems regarding allograft denervation and difficult immunosuppressive management. Massive hemorrhage, hypoperfusion, renal, respiratory failure, and infections are some of the most frequent complications related to thoracic aorta aneurysm repair. Understanding how to optimize hemodynamic and infectious risks may have a substantial impact on the outcome. This case report aims at discussing risk stratification and anesthetic management of a 54-year-old heart transplant female recipient, affected by Marfan syndrome, undergoing thoracic aorta aneurysm repair. [ABSTRACT FROM AUTHOR]

Background/aim: To investigate the differences in perioperative oxidative stress (OS) in abdominal aortic aneurysm (AAA) patients treated with either endovascular repair (EVAR) or open repair (OR). Materials and methods: Twenty patients (11 OR, 9 EVAR) treated for AAA with no known malignant or inflammatory disease and an aneurysm diameter of over 5 cm and no rupture were included in the study. Blood samples were obtained preoperatively, during aortic occlusion, and 1 h and 24 h after reperfusion. Total antioxidant status (TAS), total oxidative stress (TOS), and malondialdehyde (MDA) levels were measured and oxidative stress index (OSI) was calculated. Results: OSI at 1 h and 24 h after reperfusion was higher in the EVAR group (P = 0.004 and P = 0.002, respectively). TAS levels were higher (P = 0.001, P = 0,029). MDA levels showed no difference (P = 0.291, P = 0.076). TOS levels were lower 24 h after reperfusion in the EVAR group (P = 0.018). Conclusion: Markers of oxidative stress were lower in the EVAR group. This may be associated with advantages of EVAR. More studies are required for a clear-cut conclusion. [ABSTRACT FROM AUTHOR]

Background: Anterior open treatment of the inguinal hernia with a tension-free mesh has reduced the incidence of hernia recurrence. The Lichtenstein procedure is the current reference technique for inguinal hernia treatment. Chronic pain has become the main postoperative complication after surgical inguinal hernia repair, especially following Lichtenstein. Preliminary experiences with a soft mesh positioned in the preperitoneal space (PPS) by transinguinal preperitoneal (TIPP) or total extraperitoneal (TEP) technique, showed promising results considering the reduction of postoperative chronic pain. Evolution of surgical innovations for inguinal hernia repair led to an open, direct approach with preperitoneal mesh position, such as TIPP. Based on the TIPP procedure, another preperitoneal repair has been recently developed, the transrectus sheath preperitoneal (TREPP) mesh repair. Methods: The ENTREPPMENT trial is a multicentre randomized clinical trial. Patients will be randomly allocated to anterior inguinal hernia repair according to the TREPP mesh repair or TIPP procedure. All patients with a primary unilateral inguinal hernia, eligible for operation, will be invited to participate in the trial. The primary outcome measure will be the number of patients with postoperative chronic pain. Secondary outcome measures will be serious adverse events (SAEs), including recurrence, hemorrhage, return to daily activities (for example work), operative time and hospital stay. Alongside the trial health status, an economic evaluation will be performed. To demonstrate that inguinal hernia repair according to the TREPP technique reduces the percentage of patients with postoperative chronic pain from 12% to <6%, a sample size of 800 patients is required (two-sided test, a = 0.05, 80% power).The ENTREPPMENT trial aims to evaluate the TREPP and TIPP procedures from patients' perspective. It is hypothesized that the TREPP technique may reduce the number of patients with any form of postoperative chronic pain by 50% compared to the TIPP procedure. [ABSTRACT FROM AUTHOR]

Thoracic aortic injury (TAI) is associated with very high mortality rates. Although it occurs in less than 0.5% of all road traffic accidents, TAI is the second most common cause of death in this patient group. Until recently, the standard procedure in such cases was an open repair requiring left thoracotomy approach and the implantation of an aortic prosthesis. The mortality rate in such cases reached up to 15% to 30%. Due to the high mortality and morbidity rates following the surgical repair, endovascular stent-grafting (thoracic endovascular aortic repair, TEVAR) has recently become primary treatment modality in TAI patients. Numerous reports in the literature indicate a significant reduction both regarding the rates of mortality rate and severe complications occurring in patients undergoing endovascular treatment. The aim of this paper was to analyse important issues associated with TEVAR basing on a series of four patients undergoing TEVAR for TAI in the Department of Vascular, General, and Oncologic Surgery, Copernicus Memorial Hospital, Lodz, Poland. The analysis of available literature and our own experience reveals that TEVAR seems to be the optimal treatment modality for TAI patients with concomitant severe injuries of other organs and systems. [ABSTRACT FROM AUTHOR]

OBJECTIVE Throughout the history of surgery for pectus excavatum (PE), the Nuss procedure and open repair have been performed with many modifications, with most of these procedures using a metal bar. However, the use of a metal bar has several drawbacks. Thus, we aimed to develop a procedure that did not require a metal bar. METHODS Through our experience of 426 pediatric cases that underwent various procedures for open repair of PE at Nagoya City University, we arrived at the current procedure that we describe herein. We have evaluated this procedure by review of clinical results and deformity indices (Haller's, steepness, excavation volume, and asymmetry index). RESULTS The latest and current procedure that supports the sternum with a bridge constructed by the 4th or 5th costal cartilages is associated with fewer complications, a lower re-operation rate, and striking improvement in the indices examined. CONCLUSIONS Our current open-repair procedure that does not require a metal bar is recommended for correction of deformities of PE in children. [ABSTRACT FROM AUTHOR]

Chylous ascites is a rare complication after abdominal aortic aneurysm repair. Accumulation of chyle within the close space of the peritoneal cavity may cause severe discomfort to the patient, complicating the postoperative course. Prompt diagnosis is needed to adopt measures for reducing lymph leakage and contributing to lymphatic fistula closure. Fortunately, conservative treatment is successful in the majority of cases. In the rare cases that do not respond to conservative treatment, surgery becomes mandatory. Accurate preoperative localization of lymph leakage is a prerequisite for a successful outcome. Postoperative chyloperitoneum has a benign course and an excellent prognosis. [ABSTRACT FROM AUTHOR]

Background/Aim: The author has published results from two series based on his new technique of inguinal hernia repair. Interrupted sutures with a nonabsorbable material were used for repairs in both theses series. The author now describes the results of repairs done with continuous absorbable sutures. Materials and Methods: This is a prospective study of 229 patients having 256 hernias operated from December 2003 to December 2006. An undetached strip of the external oblique aponeurosis was sutured between the inguinal ligament and the muscle arch to form the new posterior wall. Continuous sutures were taken with absorbable suture material (Monofi lament Polydioxanone Violet). Data of hospital stay, complications, ambulation, recurrences, and pain were recorded. Follow-up was done until June 2007. Results: A total of 224 (97.8%) patients were ambulatory within 6-8 h (mean: 6.42 h) and they attained free ambulation within 18-24 h (mean: 19.26 h). A total of 222 (96.4%) patients returned to work within 6-14 days (mean: 8.62 days) and 209 (91.26%) patients had one-night stays in the hospital. A total of 216 (94.3%) patients had mild pain for 2 days. There were four minor complications, but no recurrence or incidence of chronic groin pain. Patients were followed up for a mean period of 24.28 months (range: 6-42 months). Conclusions: The results of this study correlate well with the author's previous publications. Continuous suturing saves operative time and one packet of suture material. The dream of every surgeon to give recurrence-free inguinal hernia repair without leaving any foreign body inside the patient may well become a reality in future. [ABSTRACT FROM AUTHOR]

Repair of inguinal hernia is one of the commonest operations performed by surgeons around the world. The treatment of this common problem has seen an evolution from the pure tissue repairs to the prosthetic repairs and in the recent past to laparoscopic repair. The fact that so many hernia repairs are practiced is a testimony to the fact that probably none is distinctly superior to the other. This review assesses the current status of surgery for repair of inguinal hernia and examines the various controversial issues surrounding the subject. [ABSTRACT FROM AUTHOR]

Background: There is still no definite consensus on whether arthroscopic repair shows superiority over open repair for chronic lateral ankle instability. We conducted a systematic review and meta-analysis of the current comparative studies to make a generalized analysis. Methods: PubMed, Embase, and Web of Science databases were searched from inception to April 2020. Included studies were assessed by the level of evidence and quality of evidence (Cochrane Handbook or MINORS). The process of data extraction was conducted by two independent authors. The comparative results of clinical outcomes, stress radiographic outcomes, and complication rates between two groups were pooled. Statistical analysis was performed using STATA. Results: Nine comparative studies for a total of 473 patients (250 arthroscopic repair, 223 open repair) were included. For the clinical outcomes, a significant difference was found in favor of arthroscopic repair with regard to AOFAS scores (MD 0.32, 95% CI 0.12 to 0.53, I2 = 7.7%, P =.370) and VAS scores (MD − 0.30, 95% CI − 0.54 to − 0.05, I2 = 48.3%, P =.102). No significant difference was found regarding to stress radiographic outcomes. Importantly, the total complication rate (RR 0.88, 95% CI 0.51 to 1.49, I2 = 0%, P =.957) as well as nerve complication rate (RR 1.21, 95% CI 0.53 to 2.75, I2 = 0%, P =.975) of arthroscopic repair group is not significantly different to that of open repair group. Conclusions: Arthroscopic repair for lateral ankle instability shows excellent clinical results comparable to open repair. Especially, arthroscopic repair might alleviate more pain due to the minimally invasive procedure. Patients receiving arthroscopic repair do not result in a higher total complication rate and nerve injury rate. [ABSTRACT FROM AUTHOR]

The author comments on the state of total aortic arch replacement surgery in 2013. According to the author, despite technological progress and development and exploration of hybrid procedures to manage the disorder, high stroke and operative mortality rates have been reported in centers worldwide. He believes that only sufficient data can provide the answer whether hybrid procedures are as good or better than open ones for total repair of the aortic arch.

Reconstruction of the visceral and intercostal arteries is the most challenging part in the open repair of thoraco-abdominal aortic aneurysm. For efficient and expeditious reconstruction of these branching vessels, a technique of using a pre-handsewn 8-branch aortic graft (octopod technique) has been adopted. The octopod graft was manually constructed using commercially available two 4-branch aortic grafts that were spatially oriented based on the preoperative computed tomographic images and connected each other prior to surgery. This approach was adopted in 12 open repairs of extent II thoraco-abdominal aortic aneurysms from 2015 to 2017, including 8 Marfan patients. Median pump and procedural times were 173 (102-207) min and 437 (343-489) min, respectively. There was no operative mortality or spinal cord injury. The octopod technique for open thoraco-abdominal aortic aneurysm repair showed excellent early results with high procedural efficiency. [ABSTRACT FROM AUTHOR]