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Background Arterial restenosis after vascular surgery is a common cause of midterm restenosis and treatment failure. Herein, we aim to investigate the role of microbe‐derived butyrate, FFAR2 (free fatty acid receptor 2), and FFAR3 (free fatty acid receptor 3) in mitigating neointimal hyperplasia development in remodeling murine arteries after injury. Methods and Results C57 BL /6 mice treated with oral vancomycin before unilateral femoral wire injury to deplete gut microbiota had significantly diminished serum and stool butyrate and more neointimal hyperplasia development after arterial injury, which was reversed by concomitant butyrate supplementation. Deficiency of FFAR 3 but not FFAR2, both receptors for butyrate, exacerbated neointimal hyperplasia development after injury. FFAR 3 deficiency was also associated with delayed recovery of the endothelial layer in vivo. FFAR 3 gene expression was observed in multiple peripheral arteries, and expression was increased after arterial injury. Treatment of endothelial but not vascular smooth muscle cells with the pharmacologic FFAR 3 agonist 1‐methylcyclopropane carboxylate stimulated cellular migration and proliferation in scratch assays. Conclusions Our results support a protective role for butyrate and FFAR 3 in the development of neointimal hyperplasia after arterial injury and delineate activation of the butyrate‐ FFAR 3 pathway as a valuable strategy for the prevention and treatment of neointimal hyperplasia.

Background The potential role of the gut microbiome in cardiovascular diseases is increasingly evident. Arterial restenosis attributable to neointimal hyperplasia after cardiovascular procedures such as balloon angioplasty, stenting, and bypass surgery is a common cause of treatment failure, yet whether gut microbiota participate in the development of neointimal hyperplasia remains largely unknown. Methods and Results We performed fecal microbial transplantation from conventionally raised male C57BL/6 mice to age‐, sex‐, and strain‐matched germ‐free mice. Five weeks after inoculation, all mice underwent unilateral carotid ligation. Neointimal hyperplasia development was quantified after 4 weeks. Conventionally raised and germ‐free cohorts served as comparison groups. Conclusions Germ‐free mice have significantly attenuated neointimal hyperplasia development compared with conventionally raised mice. The arterial remodeling response is restored by fecal transplantation. Our results describe a causative role of gut microbiota in contributing to the pathogenesis of neointimal hyperplasia.

BACKGROUND: Surgeons play a pivotal role in the opioid epidemic but it is unknown how different members of a surgical team vary in the way they prescribe opioids after surgical episodes. STUDY DESIGN: We conducted a retrospective cohort study of all inpatient discharges for 5 common surgeries. Total number of tablets and total milligram equivalents (MME) prescribed were calculated and differences in prescription patterns were determined for attending surgeons, surgical residents and advanced practice providers. Using a generalized ordered logistic regression, we examined factors associated with ordering a higher number of tablets or MME. RESULTS: The median number of tablets (range) prescribed by rank were attending surgeon 30 (6–72), surgical resident 20 (6–189) and advanced care practitioner 40 (5–1000); p

Exposure to pain management curriculum in medical school is currently variable. This paper reports on formal prescribing education, self-perceived prescribing readiness, and prescribing practices among incoming surgical residents before and after a pain management training session.Pre-residency survey of thirty surgical interns at a single urban medical center, followed by a repeat survey after an educational session on prescription writing and opioid abuse.Thirty-three percent of respondents had formal education on prescription writing in medical school. Median subjective preparedness to write an opioid prescription was 1.5 (range 1-10) on a 1-10 Likert scale. Ranges of morphine milligram equivalents (MME) prescribed varied from 420-2700 MME for 8 mock surgical scenarios. Post-training, median subjective preparedness increased to 3.5 (range 1-6) and prescription accuracy (the inclusion of a medication, dose, frequency, and duration) improved from 75% to 97% (p 0.001). Overall, 90% of interns found the training session useful.Most surgical interns were not trained in prescribing narcotics in medical school. Improved pain management curriculum is necessary to assure safe and consistent opioid prescriptions.

BackgroundThoracic aortic aneurysm rupture is often a fatal condition. Emergent thoracic endovascular aortic repair (TEVAR) has emerged as a suitable treatment option. Unfortunately, respiratory complications from hemothorax continue to be an important cause of morbidity and mortality even after successful management of the aortic rupture. We hypothesize that early hemothorax decompression after TEVAR for ruptured aneurysms decreases the rate of postoperative respiratory complications.MethodsSingle-center, retrospective eight-year review of ruptured thoracic aneurysms treated with TEVAR.ResultsSeventeen patients presented with ruptured degenerative thoracic aortic aneurysms, all of which were successfully treated emergently with TEVAR. The mean age was 74 years among the 12 (70.6%) men and 5 (29.4%) women treated. Inpatient and 30-day mortality rates for the entire cohort were both 17.6% (three patients). The 90-day mortality rate was 47.1% (eight patients). Thirty-day morbidities of the entire cohort included stroke ( n = 1, 5.9%), spinal cord ischemia ( n = 3, 17.6%; only one was temporary), cardiac arrest ( n = 4, 23.5%; 3 were fatal), respiratory failure ( n = 5, 29.4%), and renal failure ( n = 5, 29.4%). A large hemothorax was identified in the majority of patients ( n = 14, 82.4%). While six (42.9% of 14) patients had immediate chest tube decompression on the day of index procedure, three (21.4% of 14) patients had decompression on postoperative day 1, 4, and 7, respectively. Although not statistically significant, there were trends toward higher rates of respiratory failure (50.0% vs. 16.7%, P = 0.198) and 90-day mortality (62.5% vs. 33.3%, P = 0.280) for patients with delayed or no hemothorax decompression when compared to patients with immediate hemothorax decompression.ConclusionsThe morbidity and mortality of ruptured degenerative thoracic aortic aneurysms remains high despite the introduction of TEVAR. In this single-center experience, there was a trend toward decreased respiratory complications and increased survival with early chest decompression of hemothorax after TEVAR.

INTRODUCTION: The relationship between preoperative hyperglycemia and complications after surgery is not well defined. We compared the relationship of preoperative versus postoperative hyperglycemia on clinical outcomes and assessed if preoperative hyperglycemia was a predictor for postoperative hyperglycemia in patients undergoing elective colorectal surgery. METHODS: We performed a retrospective review of an institutional database for patients undergoing elective colorectal resection between July 2015 and June 2017. Data regarding patient characteristics, history of diabetes, preoperative and postoperative hyperglycemic events, and postoperative complications were collected. Bivariate and multivariate logistic analyses were used to assess relationships. RESULTS: With 755 surgical operations, preoperative hyperglycemia >180 mg/dL was not significantly associated with adverse outcomes in an adjusted model. Only postoperative hyperglycemia >180 mg/dL was significantly associated with complications, including acute kidney injury (OR 2.58, p

Background For patients with renal cell carcinoma with venous tumor thrombus (VTT), the importance of the extent of the VTT on survival has inconsistent published results. The aim of the study was to evaluate the prognostic value of the VTT on morbidity and mortality of our patients with renal cell carcinoma. Methods This was a single institution review of all patients who underwent resection of renal cell carcinoma with VTT over a 15-year period. Results Thirty-seven patients (26 men, 11 women) with a mean age of 61 years were analyzed. The majority of the cohort were of Neves level II (n = 19), while 8 were of Neves 0 (only renal vein) or I, and 10 were of Neves III (extending into retrohepatic cava) or IV (extending supradiaphragmatically). When compared with Neves 0–II patients, there were more Neves III–IV patients with operative time >3 hours (70% vs 30%), blood loss >2,000 mL (70% vs 33%), and intensive care unit stay longer than one day (60% vs 30%) (P ≤ .05 each). Mean follow-up was 58 months. The overall 5-year survival was 71%, and all 10 patients with Neves III–IV had survived since the operation. Conclusion We found advanced tumor thrombus involvement did not impact long-term survival; however, cases with suprahepatic VTT had increased operative time, blood loss, and duration of hospital stay.

Leiomyosarcomas are an uncommon malignant subset of tumors accounting for approximately 20% of soft tissue sarcomas. Primary vascular leiomyosarcomas (PVLs) are a rare subset of leiomyosarcomas that may originate in the arterial or venous circulation but most commonly affect the inferior vena cava (IVC). PVLs more commonly affect women to men in a 2:1 ratio and most frequently occur in the fourth to sixth decades of life. Few reports have described this infrequent pathologic state in the setting of advanced pregnancy. Presented is a case of a 44-year-old 30-week pregnant woman who presented with a PVL of the retrohepatic IVC, which was complicated by occlusion of the IVC and tumor thrombus extension into the hepatic veins and right atrium. Herein, we describe our multidisciplinary management of this rare problem with successful surgical resection of her tumor and IVC reconstruction.

Background Neointimal hyperplasia is a major contributor to restenosis after arterial interventions, but the genetic and environmental mechanisms underlying the variable propensity for neointimal hyperplasia between individuals, including the role of commensal microbiota, are not well understood. We sought to characterize how shifting the microbiome using cage sharing and bedding mixing between rats with differing restenosis phenotypes after carotid artery balloon angioplasty could alter arterial remodeling. Methods We co-housed and mixed bedding between genetically distinct rats (Lewis [LE] and Sprague-Dawley [SD]) that harbor different commensal microbes and that are known to have different neointimal hyperplasia responses to carotid artery balloon angioplasty. Sequencing of the 16S ribosomal RNA gene was used to monitor changes in the gut microbiome. Results There were significant differences in neointimal hyperplasia between non-co-housed LE and SD rats 14 days after carotid artery angioplasty (mean intima + media [I + M] area, 0.117 ± 0.014 mm2 LE vs 0.275 ± 0.021 mm2 SD; P Conclusions We describe a novel mechanism for how microbiome manipulations affect arterial remodeling and the inflammatory response after arterial injury. A greater understanding of the host inflammatory-microbe axis could uncover novel therapeutic targets for the prevention and treatment of restenosis.

Background Recurrent ischemic events have been associated with delayed carotid endarterectomy (CEA) for patients who present with acute strokes. As such, earlier intervention has been advocated to preserve cerebral function and expedient rehabilitation. We sought to determine the differences in 30-day postoperative major adverse clinical events (MACEs) for patients who undergo early (≤7 days) and delayed (>7 days) CEA after acute stroke. Methods Our sample consisted of patients captured in the CEA-targeted American College of Surgeons National Surgical Quality Improvement Program data set between 2011 and 2015. The primary outcome was 30-day postoperative MACEs (death, stroke, or myocardial infarction [MI]). Differences in postoperative MACEs were determined between early and delayed CEA treatment. In addition, multivariable analyses were done to determine the association between various patient factors and postoperative complications after CEA for patients who presented with acute strokes. Results A total of 3,427 patients were identified who underwent CEA for acute stroke in the CEA-targeted files between 2011 and 2015. Overall, perioperative rates of 30-day death, stroke, or MI were 1.30% (n = 43), 2.74% (n = 94), and 0.96% (n = 33), respectively. There were no differences in 30-day postoperative death, stroke, or MI for early or delayed CEA after acute strokes. On multivariable analysis, independent predictors for postoperative MACEs in patients with acute stroke were age ≥80 years (OR 2.41; 95% CI [1.15–5.06]), preoperative beta-blocker use (OR 2.11; 95% CI [1.13–3.93]), and operative time > 150 min (OR 2.39; 95% CI [0.82–4.98]). Conclusions There are no differences in postoperative 30-day death, stroke, or MI in early and delayed CEA after an acute stroke. These results substantiate the recommendation for early (

This review outlines the preoperative evaluation, clinical decision making, and surgical treatment options for patients with aortoiliac occlusive disease. It also details the open surgical techniques for the treatment of aortoiliac occlusive disease and reviews endovascular treatment options. The discussion of treatment options includes the potential complications and expected outcomes, as well as steps that can be taken to optimize surgical results. Key words: aortobifemoral bypass, aortoiliac reconstruction, atherosclerotic occlusive disease, endovascular reconstruction, femoral endarterectomy, iliac angioplasty, iliac stenting, peripheral vascular disease

The number and strength of opioids prescribed after surgery can vary widely at a single institution. Further research is needed to elucidate variations in prescribing., Introduction: Recent literature has shown a wide variation in the prescribing patterns of opioids after elective surgery. We conducted an evaluation of discharge opioid prescribing after elective surgical procedures to determine whether opioid-prescribing patterns varied at our institution. Method: A single academic medical center retrospective review of patients undergoing laparoscopic cholecystectomy, laparoscopic appendectomy, open umbilical hernia repair, simple mastectomy, or thyroidectomy between July 2015 and July 2016. Results: Among a total of 615 unique surgical cases, we found a wide variation in the number of pills and morphine milligram equivalents prescribed for each procedure evaluated. In addition, 94.8% of all patients discharged received a prescription for opioids, whereas only 15.6% of patients received a prescription for a nonopioid analgesic. Conclusion: The number and strength of opioids prescribed after surgery can vary widely at a single institution. Further research is needed to elucidate variations in prescribing.