High secondary failure rate of rebanding after failed gastric banding

Background: Over the last decade, more than 130,000 laparoscopic adjustable gastric bandings (LAGB) have been performed for the treatment of morbid obesity. Nowadays, longer follow-up data are available in the literature and increasing numbers of late complications and treatment failures of gastric banding have been reported. The aim of the present study was the long-term evaluation of two different rescue operations after failed LAGB: conversion to laparoscopic Roux-en-Y bypass (LRYGB) versus laparoscopic gastric rebanding. Methods: Between January 1997 and November 2002, 74 consecutive patients underwent either laparoscopic gastric rebanding (n = 44) or LRYGB (n = 30) after failed LAGB. There were 14 men and 60 women, with a median age of 42 (23-60) years. The indication for reoperation was an increasing body mass index (BMI) and band-related complications such as pouch dilatation, band slippage, and penetration after LAGB. Rebandings were done by preference during the initial period of the study and LRYGB was the treatment of choice during the latter period. The success of the rescue operation was assessed by postoperative changes in the BMI, improvements of co-morbidities, and the need for further reoperations (secondary failure). The median follow-up was 36 months (range, 24-60 months). Results: Patients who underwent LRYGB had a significantly better weight loss than patients with a rebanding operation (mean −6.1 versus +1.5 BMI points). In addition, the LRYGB patients showed a significantly better control of serum cholesterol during the long term follow-up (−0.6 versus +0.1 mmol/l). Almost half of the patients (45%) in the rebanding group needed a further operative revision, whereas only 20% underwent reoperation after rescue LRYGB. Thus, the secondary failure rate in the rebanding group was significantly higher compared to the bypass group (p = 0.028). Conclusions: The present long-term study confirms our previous finding that LRYGB is a better treatment than rebanding after failed laparoscopic gastric banding regarding weight loss and treatment of co-morbidities. During the long-term follow-up the reoperation rate due to secondary failure became significantly higher in the rebanding group. We therefore recommend that LRYGB should be preferred as rescue procedure after failed laparoscopic adjustable gastric bandin

Total vs hemi-aortic arch transposition for hybrid aortic arch repair

ObjectiveTo compare the outcomes of total aortic arch transposition (TAAT) vs hemi-aortic arch transposition (HAAT) for hybrid aortic arch repair.MethodsA systematic search was performed using PubMed between November 1998 and May 2010 by two independent observers. Studies included reporting on patients treated by TAAT or HAAT and stent grafting in a proximal landing zone 0 or 1 by Ishimaru, respectively. Further articles were identified by following MEDLINE links, by cross-referencing from the reference lists, and by following citations for these studies. Case reports and case series of less than five patients were excluded. Primary technical and initial clinical success, perioperative, and late morbidity and mortality were extracted per study and were meta-analyzed.ResultsFourteen studies were included in the statistical analysis. The number of reported patients totaled 130 for TAAT/zone 0 and 131 for HAAT/zone 1. The primary technical success rate was significantly higher in zone 0 than 1 (95% vs 83%; odds ratio [OR], 4.0; 95% confidence interval [CI], 1.47-10.88; P = .0069), due to significantly higher primary type I or III endoleak rates in zone 1 (15.48% vs 3.97%; P = .0050). Reintervention rates were significantly higher in zone 1 (25.81% vs 12.00%; P = .0321). Initial clinical success rates were comparable between zone 0 and 1 (88% vs 85%; OR, 1.35; 95% CI, 0.61-3.02; P = .5354). In-hospital mortality was higher in zone 0 than 1 (8.46% vs 4.58%; P = .2212).ConclusionThe more invasive TAAT allows a better landing zone at the cost of higher perioperative mortality, therefore, patient selection is crucial

Quantitative high-field diffusion tensor imaging of cerebral white matter in asymptomatic high-grade internal carotid artery stenosis

Background: Recently, several studies using diffusion-sensitized MRI reported changes in patients with high-grade internal carotid artery stenosis (ICAS) suggestive of subtle brain tissue damage. We used diffusion tensor imaging (DTI) to investigate the microstructural cerebral white matter integrity in asymptomatic patients with high-grade ICAS. Methods: In 15 asymptomatic patients with unilateral high grade (>70%) ICAS, we used 3T MRI including DTI. We used a region-of-interest approach comparing quantitative DTI metrics between both hemispheres including the so-called border zones. MR images were also assessed for periventricular white matter lesions (PWML) as well as collaterals via the circle of Willis. Results: There was no significant intraindividual difference of fractional anisotropy or mean diffusivity values between the hemispheres for any region. PWML was graded 0 degrees in 6 patients, I degrees in 9 and II degrees in 2. Conclusions: In clinically asymptomatic patients with high-grade unilateral ICAS, there was no difference between the DTI parameters of the affected and the unaffected hemisphere. These findings contrast with other studies in asymptomatic high-grade ICAS, which is likely due to patient selection. These findings argue against concomitant chronic tissue integrity changes and implicate the benignity of asymptomatic carotid artery disease in individual patients. Copyright (C) 2012 S. Karger AG, Base

Altered in-stent hemodynamics may cause erroneous upgrading of moderate carotid artery restenosis when evaluated by duplex ultrasound

ObjectiveTo assess the influence of stent application on in-stent hemodynamics under standardized conditions.MethodsOvine common carotid arteries before and after stent (6 × 40 mm, sinus-Carotid-RXt, combined open-closed cell design; Optimed, Ettlingen, Germany) application were used. Plastic tubes, 10 mm in length, simulating stenosis were placed in the middle of the applied stent to induce different degrees of stenosis (moderate 57.8% and severe 76.4%). Flow velocity and dynamic compliance were, respectively, measured with ultrasound and laser scan; proximal, in-stent, and distal to the stented arterial segment (1 cm proximal and distal) in a pulsatile ex vivo circulation system.ResultsStent insertion caused the in-stent peak systolic velocity to increase 22% without stenosis, 31% with moderate stenosis, and 23% with severe stenosis. Stent insertion without stenosis caused no significant increase in in-stent end-diastolic velocity (EDV) but a 17% increase with moderate stenosis. In severe stenosis, EDV was increased 56% proximal to the stenosis. Compliance was reduced threefold in the middle of the stented arterial segment where flow velocity was significantly increased.ConclusionsWith or without stenosis, stent introduction caused the in-stent peak systolic velocity to become significantly elevated compared with a nonstented area. EDV was also increased by stent insertion in the case of moderate stenosis. The stent-induced compliance reduction may be causal for the increase in flow velocity since the stent-induced flow velocity elevation appeared in the stented area with low compliance. Because of altered hemodynamics caused by stent introduction when measured by duplex ultrasound, caution is prudent in concluding that carotid artery stenting is associated with a higher restenosis rate than carotid endarterectomy. Mistakenly upgrading moderate to severe restenosis could result in unnecessary reintervention.Clinical RelevanceClinical experience and prior studies support the supposition that restenosis after carotid artery stenting in carotid lesions displays erroneously elevated velocity when evaluated by duplex ultrasound (DUS), thus contributing to misleading interpretation of the degree of stenosis. This study, in contrast to studies of other groups, employs exactly the same conditions to measure flow with DUS in an unstented and then stented section of the carotid artery. Since DUS is the first-choice tool for carotid artery evaluation, knowledge about inexactness of the method is essential to avoid errors in treatment or follow-up decisions

Sonographic Evaluation of Complications of Extracranial Carotid Artery Interventions

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/142556/1/jum14376_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/142556/2/jum14376.pd

Patient-reported outcome measures in carotid artery revascularization: systematic review and psychometric analysis

Objective: Patient-reported outcome measures (PROMs) provide a way to measure the impact of a disease and its associated treatments on the quality of life from the patients’ perspective. The aim of this review was to identify PROMs that have been developed and/or validated in patients with carotid artery stenosis (CAS) undergoing revascularisation and to assess their psychometric properties and examine suitability for research and clinical use. Methods: Eight electronic databases including MEDLINE and CINAHL were searched using a two-stage search approach to identify studies reporting the development and/or validation of relevant PROMs in patients with CAS undergoing revascularisation. Supplementary citation searching and hand-searching reference lists of included studies were also undertaken. The COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) and Oxford criteria were used to assess the methodological quality of the included studies and the psychometric properties of the PROMs were evaluated using established assessment criteria. Results: Five studies reporting on six PROMs were included: 36-Item Short Form Health Survey (SF-36), Euro-QoL-5-Dimension Scale (EQ-5D), Hospital Anxiety and Depression Scale (HADS), Dizziness Handicap Inventory (DHI), Quality of life for carotid artery disease scale and a disease-specific PROM for CAS. The rigour of the psychometric assessment of the PROMs was variable with most only attempting to assess a single psychometric criterion. No study reported evidence on construct validity and test-retest reliability. Evidence for acceptability for the use of SF-36, EQ-5D and the disease-specific PROM were rated good in most studies. Only one study reported a Cronbach alpha score >0.70 as evidence of internal consistency. Overall, the psychometric evaluation of all included PROMs was rated as poor within the CAS population undergoing revascularisation. Conclusions: This review highlighted a lack of evidence in validated PROMs used for patients undergoing carotid artery revascularisation. As a result, the development and validation of a new PROM for this patient population is warranted in order to provide data which can supplement traditional clinical outcomes (stroke<30 days post-procedural, myocardial infarction and death) and capture changes in health status and quality of life to help inform treatment decisions

High secondary failure rate of rebanding after failed gastric banding

BACKGROUND: Over the last decade, more than 130,000 laparoscopic adjustable gastric bandings (LAGB) have been performed for the treatment of morbid obesity. Nowadays, longer follow-up data are available in the literature and increasing numbers of late complications and treatment failures of gastric banding have been reported. The aim of the present study was the long-term evaluation of two different rescue operations after failed LAGB: conversion to laparoscopic Roux-en-Y bypass (LRYGB) versus laparoscopic gastric rebanding. METHODS: Between January 1997 and November 2002, 74 consecutive patients underwent either laparoscopic gastric rebanding (n = 44) or LRYGB (n = 30) after failed LAGB. There were 14 men and 60 women, with a median age of 42 (23-60) years. The indication for reoperation was an increasing body mass index (BMI) and band-related complications such as pouch dilatation, band slippage, and penetration after LAGB. Rebandings were done by preference during the initial period of the study and LRYGB was the treatment of choice during the latter period. The success of the rescue operation was assessed by postoperative changes in the BMI, improvements of co-morbidities, and the need for further reoperations (secondary failure). The median follow-up was 36 months (range, 24-60 months). RESULTS: Patients who underwent LRYGB had a significantly better weight loss than patients with a rebanding operation (mean -6.1 versus +1.5 BMI points). In addition, the LRYGB patients showed a significantly better control of serum cholesterol during the long term follow-up (-0.6 versus +0.1 mmol/l). Almost half of the patients (45%) in the rebanding group needed a further operative revision, whereas only 20% underwent reoperation after rescue LRYGB. Thus, the secondary failure rate in the rebanding group was significantly higher compared to the bypass group (p = 0.028). CONCLUSIONS: The present long-term study confirms our previous finding that LRYGB is a better treatment than rebanding after failed laparoscopic gastric banding regarding weight loss and treatment of co-morbidities. During the long-term follow-up the reoperation rate due to secondary failure became significantly higher in the rebanding group. We therefore recommend that LRYGB should be preferred as rescue procedure after failed laparoscopic adjustable gastric banding

Anomaly of Haughton type D left cervical aortic arch in combination with type B dissection: case report and literature review

BACKGROUND: The anomaly of cervical aortic arch is a rare phenomenon first described by Reid in 1914 and categorized by Haughton in 1975. The left cervical aortic arch Type D consisting of an ipsilateral descending aorta and coarctation or aneurysmatic formation of the arch demonstrates a complicated form requiring surgical management. Because of its rarity and unspecific symptoms only few cases are documented with the focus on surgical management. CASE PRESENTATION: A 43-year old, asymptomatic woman presented with a mediastinal mass overlapping the aortic arch region in a routine x-ray. For verification, a computed tomography was performed and revealed incidentally a type B dissection originating from an aneurysm of a left cervical arch with a maximum diameter of 6 cm. Because of the huge diameter and the potential risk of rupture, an urgent surgical repair was planned. Surgical access was performed through median sternotomy and an additional left lateral thoracic incision through the fourth intercostal space. Simultaneously to the preparation, partial cardiopulmonary bypass was installed in the left groin. After preparation of the recurrent and phrenic nerve and the supraaortic branches, the descending aorta was clamped. Before the distal anastomosis to a straight graft, we performed a fenestration of the dissection membrane about a length of 5 cm to preserve the perfusion of both lumina. Then, the straight graft was sutured to the proximal part of descending aorta. The left axillary artery originated directly from the aneurysm and was dissected and reimplanted with a separate 8 mm sidegraft to the straight graft between the distal arch and proximal descending aorta. The patient was extubated on first postoperative day and recovered well. CONCLUSION: The left cervical aortic arch type D is a rare disease, which is prone to aneurysm formation due to abnormal flow patterns and tortuosity of the aorta. The difficulty lays in the identification of the pathology, especially in the physical examination, since a pulsating mass or cervical murmur seem to be the most specific symptoms in the majority of young, female patients. If diagnosed, surgical therapy with resection of the aneurysm and reimplantation of the axillary artery under cardiopulmonary bypass demonstrates the treatment of choice

Longterm results after surgical thrombectomy and simultaneous stenting for symptomatic iliofemoral venous thrombosis

AbstractObjectivesTo evaluate the longterm outcome of venous thrombectomy and simultaneous stenting in patients with acute, symptomatic iliofemoral deep venous thrombosis (DVT).MethodsBetween January 1996 and December 2007, a total of 45 patients underwent venous thrombectomy at our institution. Thrombectomy results were classified by intraoperative phlebography as: TYPE I=complete, TYPE II=partial, TYPE III=complete with stenosis other than thrombus, TYPE IV=permanent occlusion. TYPEs I and IV were excluded from this analysis because no endovascular repair was performed.25 patients underwent a venous hybrid operation comprising balloon-catheter thrombectomy, thrombolysis and stenting of residual stensosis. Three TYPE 2 and 22 TYPE 3 lesions were diagnosed. Three patients died during follow-up from causes unrelated to their treatment. Three were lost to follow-up. Hence, 19 patients were examined. A retrospective, non comparative single-centre study was performed.ResultsMedian follow-up was 68 months (range 3–129). Primary and secondary patency rates were 74% (14/19) and 84% (16/19), respectively. Re-thrombosis occurred within seven days of operation in 26% (5/19). Procedure related mortality was zero. There was no case of late re-thrombosis. Four patients showed post-thrombotic sequelae (CEAP: C1, 2 or 3s). No leg ulcer developed in any patient.ConclusionVenous thrombectomy with simultaneous stenting results in excellent longterm results in selected patients with symptomatic iliofemoral venous thrombosis