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Objective: Endovenous therapies are currently the standard of care for the treatment of patients with symptomatic great saphenous vein (GSV) reflux. The effectiveness and long-term outcomes of these therapies for anterior accessory great saphenous veins (AAGSVs) are poorly defined. The objective of this investigation is to determine treatment outcomes in patients with symptomatic AAGSV reflux compared with patients with symptomatic GSV reflux., Methods: Data were prospectively collected in the Center for Vein Restoration's electronic medical record system (NexGen Healthcare Information System, Irvine, Calif) and retrospectively analyzed. Treatment outcomes after a standalone ablation and ablation + phlebectomy were compared in patients with isolated AAGSV and GSV reflux. Treatment outcomes were assessed at 1 month and 6 months postprocedure using the revised Venous Clinical Severity Score (rVCSS) and the 20-item Chronic Venous Insufficiency Quality-of-Life Questionnaire (CIVIQ20) survey for quality of life. Medical and surgical comorbidities, Clinical-Etiological-Anatomical-Pathophysiological classification, body mass index, gender, race, and the average number of procedures performed were all analyzed., Results: From January 2015 to December 2018, 31,186 patients and 49,193 limbs were assessed. Of these, 91 patients/103 limbs had isolated AAGSV reflux, and 7704 patients/10,371 limbs had isolated GSV reflux. There were 95% and 75% women in the isolated AAGSV and GSV groups, respectively (P ≤ .001). For the ablation-only patients, AAGSV (n = 57 patients/61 limbs) and GSV (n = 5349 patients/7191 limbs), there were no differences in preintervention (7.0 ± 2.0 vs 6.8 ± 2.8, P = .99), 1-month (4.0 ± 2.4 vs 3.9 ± 2.8, P = .99), and 6-month (3.9 ± 2.6 vs 3.9 ± 2.9, P = .55) rVCSS scores. Similar results were observed when ablations and phlebectomies were performed (AAGSV [n = 34 patients/42 limbs] and GSV [n = 1848 patients/2491 limbs]). CIVIQ20 scores for patients with isolated AAGSV and GSV were 53.3 ± 19.6 vs 50.6 ± 18.8 (P = .43) preintervention, 37.2 ± 17.6 vs 35.7 ± 15.9 (P = .91) at 1 month, and 41.3 ± 21.7 vs 35.1 ± 15.7 (P = .36) at 6 months, respectively. Postprocedure scores within groups improved at 1 and 6 months (P ≤ .02); however, 6-month AAGSV CIVIQ20 scores after an ablation increased slightly compared with 1-month scores and were not different to preintervention GSV scores (P = .07). When phlebectomies were performed with ablations, 6-month CIVIQ20 scores were similar between groups (P = .72). There was no difference in the average number of ablations in patients with phlebectomies in the AAGSV or GSV group (1.24 ± 0.44 vs 1.35 ± 0.49, P = .15)., Conclusions: Endovenous therapies for the treatment of symptomatic AAGSVs demonstrate similar outcomes to patients with symptomatic GSV reflux. For standalone ablations, the rVCSS scores are similar between the groups; however, CIVIQ20 scores increase to preintervention levels in standalone ablation AAGSV patients at 6 months. This increase disappears when phlebectomies are performed with ablations. Based on these data, patients with symptomatic AAGSV treated with ablation also require treatment of the associated tributaries (varicosities) to achieve similar outcomes to patients with GSV, and this calls into question the effectiveness of ablation for isolated AAGSV reflux., (Copyright © 2021 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Obesity is a known risk factor for the development and progression of chronic venous disorders (CVDs). It is currently unknown whether the treatment outcomes, after an intervention for CVDs, are affected by obesity. The purpose of the present investigation was to assess the effectiveness of various CVD treatments in obese patients and determine what level of obesity is associated with poor outcomes., Methods: Data were prospectively collected in the Center for Vein Restoration electronic medical record system (NexGen Healthcare Information System, Irvine, Calif) and retrospectively analyzed. The patients and limbs were categorized by the following body mass index (BMI) categories: <25, 26 to 30, 31 to 35, 36 to 40, 41 to 45, and >46 kg/m 2 . The changes in the revised venous clinical severity score and Chronic Venous Insufficiency Quality of Life Questionnaire 20-item (CIVIQ-20) quality of life survey were used to determine the CVD treatment effectiveness for patients who had undergone endovenous thermal ablation (TA), phlebectomy, or ultrasound-guided foam sclerotherapy (USGFS)., Results: From January 2015 to December 2017, 65,329 patients (77% female; 23% male) had undergone a venous procedure. Of these patients, 25,592 (39,919 limbs) had undergone ablation alone, ablation with phlebectomy, or ablation with phlebectomy and USGFS. The number of procedures performed was as follows: TA, n = 37,781; USGFS, n = 22,964; and phlebectomy, n = 17,467. The degree of improvement at 6 months after the procedure was progressively less with an increasing BMI for the patients who had undergone TA, and the decrease was more significant for those patients with a BMI >35 kg/m 2 (P ≤ .001). The outcomes improved ∼12% with the addition of phlebectomy to TA. The patients who had undergone a combination of TA, phlebectomy, and USGFS demonstrated no additional improvement. Significantly inferior outcomes were noted in patients with a BMI ≥35 kg/m 2 , with the poorest outcomes observed in patients with a BMI ≥46 kg/m 2 (P ≤ .001). The average number of TAs per patient increased with an increasing BMI and was significantly different compared with the number for those with a BMI <30 kg/m 2 (P ≤ .001). All pre- and post-CIVIQ-20 quality of life scores, within a BMI category, at 6 months were significantly different (P ≤ .01). No differences in the degree of improvement were observed in patients with a BMI ≥31 kg/m 2 . Finally, multivariate logistic regression analysis indicated that when controlling for BMI, diabetes, a history of cancer, female gender, and black and Hispanic race were independently associated with poorer outcomes., Conclusions: Progressive increases in BMI negatively affected CVD-related treatment outcomes as measured using the revised venous clinical severity score and CIVIQ-20. The outcomes progressively worsened with a BMI >35 kg/m 2 for patients undergoing CVD treatment. The treatment outcomes for patients with a BMI ≥46 kg/m 2 were so poor that weight loss management should be considered before offering CVD treatment., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: This is a case of a solitary hepatic gastrinoma in a 65-year-old male. The patient was diagnosed with Zollinger-Ellison syndrome in 1991. He had negative radiologic and surgical explorations at that time. He was maintained on proton-pump inhibitors for the next 10 years without symptoms., Methods: A computed tomographic (CT) scan done in April 2001 demonstrated a 5-cm right hepatic lesion. Radionucleotide scanning with octreotide demonstrated intense activity in the same area in the right hepatic lobe. His serum gastrin was 317 pg/mL. He underwent laparoscopic radiofrequency ablation of the lesion., Results: Treatment resulted in a 6-cm ablative area giving a 1-cm margin on the tumor. One- and 3-month follow-up CT scans demonstrated adequate ablation of the tumor. An octreotide scan done 3 months postoperatively did not reveal any areas of abnormal uptake., Conclusion: We report success with laparoscopic radiofrequency ablation as an alternative to major hepatic resection in patients with a solitary hepatic gastrinoma.

Historically, parastomal hernias have represented a challenge to surgeons. Unsatisfying results from surgical repair have led to many modifications over time. Surgical repair of parastomal hernias has evolved from the traditional open technique to the current laparoscopic approach. We outline a technique that combines mesh reinforcement with a minimally invasive approach.

Background: Endotoxin (ETX) is thought to be the primary inducer of proinflammatory mediator release associated with bacterial sepsis. Furthermore, a number of studies indicate that preexposure of animals to high doses of ETX produces macrophages (M luminal diameters) that are refractory to ex vivo stimulation with ETX. However, it is unknown if levels of ETX comparable to those typically encountered in sepsis induce a similar refractory state in M luminal diameters., Design: To assess this, peritoneal M luminal diameters (PM luminal diameters) were harvested from C3H/HeN mice (ETX sensitive) at 1 hour (early) or 24 hours (late) following cecal ligation and puncture (CLP) to induce polymicrobial sepsis, sham CLP, or laparotomy followed by peritoneal implantation of a minipump delivering either saline or ETX (0.025 microgram/g of body weight, every 24 hours). Peritoneal M luminal diameter cultures were incubated with ETX, either 0 or 10 micrograms/mL, for 24 hours, and their ability to release interleukin-1, interleukin-6, and tumor necrosis factor was assessed by bioassay., Results: Chronic low-dose ETX with 0 microgram of ETX media added produced early (at 1 hour) in vivo activation of PM luminal diameter interleukin-1 release, which was comparable to that seen in mice subjected to CLP. However, unlike PM luminal diameter taken from CLP mice, PM luminal diameters from mice implanted with the ETX minipump at 1 or 24 hours showed no marked decline in their ability to respond to ETX (10 micrograms). Comparable changes were seen for interleukin-6 and tumor necrosis factor release., Conclusions: Bacterial component(s) other than ETX per se induces the sustained dysfunction in PM luminal diameter capacity to produce proinflammatory cytokines during sepsis and/or peritonitis. Thus, agents directed against ETX alone may not be adequate in the treatment of polymicrobial sepsis.

Although studies indicate that polymicrobial sepsis produces marked depression in lymphocyte functions, it remains unclear whether this dysfunction is due to the chronic exposure of immune cells to endotoxin (ETX; a product of the gram-negative bacterial cell wall) at levels typically encountered in the septic state. The aim of this study, therefore, was to determine whether the changes in lymphokine release seen during polymicrobial sepsis are comparable to those observed with chronic ETX infusion. To assess this, splenocytes were harvested from C3H/HeN mice (ETX-sensitive) at 1 or 24 hr following cecal ligation and puncture (CLP; to induce polymicrobial sepsis), Sham CLP (Sham), or laparotomy followed by peritoneal implantation of a mini-osmotic pump which delivered either saline vehicle (Sal-pump) or ETX (ETX-pump; 0.025 micrograms lipopolysaccharide/25 g body wt/24 hr). Splenocytes were then stimulated with concanavalin A (2.5 micrograms/ml/48 hr) and their capacity to release interleukin (IL)-2, interferon (IFN)-gamma, IL-4, and IL-10 was determined by bioassay or ELISA. The results indicated that there were no changes in lymphokine release capacity at 1 hr after CLP or ETX-pump implantation. However, prolonged sepsis (i.e., at 24 hr) caused a marked suppression of IL-2 and IFN-gamma release (immune-enhancing lymphokines characteristic of Th1-cells), while enhancing the release of immunosuppressive Th2-cell products IL-4 and IL-10. Chronic exposure to ETX at a level comparable to that seen in CLP caused no depression in lymphokine (IL-2/IFN-gamma) release. This implies that a bacterial component other than ETX mediates the differential alterations observed in lymphokine release during prolonged polymicrobial sepsis.