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Background Panniculus morbidus is a large abdominal apron found in morbidly obese patients. This condition creates a vicious cycle of weight gain and functional incapacity. Our study assessed the functional improvement in patients undergoing massive panniculectomy. Methods A retrospective review of panniculectomies performed from 1994 to 2012 was conducted. Twenty-seven patients with resections >20 lbs were selected. Data on demographics, operative details, complications, and pre- and postoperative functional capacity (using the Steinbrocker Functional Classification) were collected. Results The preoperative mean body mass index was 58 kg/m 2 , with a mean resection weight of 33 lbs. The overall complication rate was 74%. A statistically significant improvement in functional capacity (preop mean 3.7 vs postop mean 2.0; P Conclusions Panniculus morbidus is a functionally debilitating condition and massive panniculectomy is often the only treatment available. Our data suggest that massive panniculectomy is a viable option for patients functionally incapacitated by panniculus morbidus.

Body weight, body mass index (BMI), and percent excess weight loss are used to assess patient outcomes after bariatric surgery; however, they provide little insight into the true nature of the patient's weight loss. Body composition measurements monitor fat versus lean mass losses to permit interventions to reduce or avoid lean body mass loss after bariatric surgery. A retrospective review of patients who underwent bariatric surgery between 2002 and 2008 was performed. Patients underwent body composition testing via air displacement plethysmography before and after surgery (6 and 12 months). Body composition changes were assessed and compared with the BMI. Results include 330 patients (54 male, 276 female). Average preoperative weight was 139 kg, BMI was 50 kg/m2, fat percentage was 55 per cent, and lean mass percent was 45 per cent. Twelve months after surgery average weight was 90 kg, mean BMI was 32 kg/m2, fat percentage was 38 per cent, and lean mass percent was 62 per cent. Body composition measurements help monitor fat losses versus lean mass gains after bariatric surgery. This may give a better assessment of the patient's health and metabolic state than either BMI or excess weight loss and permits intervention if weight loss results in lean mass losses.

Background Abdominal aortic aneurysm (AAA) accounts for >15,000 reported deaths annually. Early screening in high-risk populations is important to decrease morbidity and mortality from rupture. Methods A prospective, population-based study of free ultrasound-based AAA screening was conducted from July 2004 to December 2006. Before examination, subjects completed surveys asking their medical history, including known AAA risk factors. Incidence rates and comparison analyses were performed. Results The final analysis included 979 patients, of whom AAA was discovered in 27 (2.8%). AAA was found in only male patients >60 years old (4% of the male population). AAA size ranged from 3 to 10 cm. Of patients diagnosed with AAA, 85% were current or past smokers, and 70% had hypercholesterolemia. There was a 6% incidence of AAA in male smokers ≥60 years old who had hypercholesterolemia. Conclusions Four factors were predominant in our population of patients with AAA: patient age, male sex, smoking history, and hypercholesterolemia.

Pneumonectomy for lung cancer is associated with significant morbidity and mortality. Risk factors for the morbidity and mortality have been reported, but consistent conclusive data are undetermined. Current accepted 30-day mortality rates for pneumonectomy range from 7 to 11 per cent. The objective of this study is to determine whether various perioperative factors can serve as predictors of morbidity and mortality in pneumonectomy patients and to review outcome data on patients undergoing pneumonectomy for lung cancer. A total of 105 patients undergoing pneumonectomy for lung cancer from 1988 through 1998 are studied in a retrospective chart review. The main outcome measure is the 30-day operative mortality and morbidity. Complications occurring in 10 per cent or more of the patients included atrial fibrillation (33.3%), respiratory failure (23.8%), pneumonia (21.9%), and bronchopleural fistula (12.4%). The 30-day mortality rate was 10.5 per cent (11 deaths). By Fisher's exact test for Chi-square only three statistically significant mortality factors were identified: respiratory failure ( P < 0.021), sepsis ( P < 0.008), and male sex ( P < 0.031); respiratory failure, sepsis, and sex were predictors of death. Significant correlation could not be made to predict postoperative morbidity. Overall long-term clinical outcome for pneumonectomy as lung cancer treatment was poor. Clinical judgment remains an essential factor when considering pneumonectomy as an option for lung cancer treatment.

Lower extremity claudication most commonly results from atherosclerotic disease. Cystic adventitial disease of the popliteal artery is a rare entity that also manifests with symptoms of claudication. The disease usually occurs in otherwise healthy men without cardiovascular risk factors for atherosclerosis. Extrinsic compression of the arterial lumen leads to arterial insufficiency in these patients. A fairly typical case of cystic adventitial disease of the popliteal artery is reported and a review of the literature is presented.

Between 1993 and 1998, we performed a linear study of laparoscopic ventral hernia repair performed in a standard fashion using expanded polytetrafluoroethylene on 49 patients. Eighteen patients had recurrent hernias and 30 patients were morbidly obese with a body mass index >30. Conversion to open procedure was required in two patients. Patients were observed a mean of 27 months. Three patients died of unrelated causes during the observation period. Three patients developed recurrent hernias. By a follow-up survey, we found that 90 per cent of patients were “satisfied” with their operation and results. Because of decreased complications, postoperative pain, hospital stay, and hernia recurrence, the “four-before” laparoscopic repair is our preference for ventral hernias. It has been particularly useful for obese patients and patients with recurrent ventral hernias.

Blunt carotid injuries are rare, and present late with devastating strokes. A sizeable single-institution descriptive report could help characterize the injury and its diagnosis and treatment.We performed a retrospective review of blunt carotid artery injuries from May 1988 to December 1997 at a level I trauma center. Chart review consisted of demographics, mechanism of injury, associated injuries, diagnostic modalities, initial neurologic status, treatment, and outcome. Discharge outcome was classified as "good" (normal-mild deficit), "fair" (needing daily assistance), "poor" (institutionalized), or "dead."During the study period 16 patients sustained a carotid artery injury. Mean age was 35 years and 63% were female. Vehicular trauma was the most common mechanism of injury (81%), followed by assaults (13%). Dissection was the most common injury (75%), with one quarter having an associated pseudoaneurysm. Initial neurologic presentation was normal in 31% and Glasgow Coma Score was13 in 31% (including 13% in coma). Eventual hemispheric symptoms developed in 81%. Associated injuries were present in 94%, commonly head (44%) and chest (50%). Duplex ultrasound accurately identified the injury in all patients (5 of 5) when used. Anticoagulation (88%) had no complications. Observation and therapeutic embolization each resulted in 1 fatal stroke. A third patient, with worsening deficits on heparin, died after carotid ligation, for an overall mortality of 19%. There were no deaths in the 13 patients treated by anticoagulation alone. Six patients (38%) had a "good" neurologic outcome, five (31%) "fair," and two (13%) "poor." Initial neurologic presentation, associated injuries, and mechanism of injury did not appear to correlate with these outcome categories.These uncommon injuries should be suspected in the presence of head and/or chest injuries, basilar skull fracture, or coma (particularly if the computed tomography scan is unremarkable). Presentation may be varied, but most patients eventually develop hemispheric symptoms. Duplex ultrasound detects many of these injuries, but this does not demonstrate its utility as a screening tool. Anticoagulant therapy appears to be associated with a better outcome than expectant or occlusive therapy.

Body weight, body mass index (BMI), and percent excess weight loss are used to assess patient outcomes after bariatric surgery; however, they provide little insight into the true nature of the patient's weight loss. Body composition measurements monitor fat versus lean mass losses to permit interventions to reduce or avoid lean body mass loss after bariatric surgery. A retrospective review of patients who underwent bariatric surgery between 2002 and 2008 was performed. Patients underwent body composition testing via air displacement plethysmography before and after surgery (6 and 12 months). Body composition changes were assessed and compared with the BMI. Results include 330 patients (54 male, 276 female). Average preoperative weight was 139 kg, BMI was 50 kg/m(2), fat percentage was 55 per cent, and lean mass percent was 45 per cent. Twelve months after surgery average weight was 90 kg, mean BMI was 32 kg/m(2), fat percentage was 38 per cent, and lean mass percent was 62 per cent. Body composition measurements help monitor fat losses versus lean mass gains after bariatric surgery. This may give a better assessment of the patient's health and metabolic state than either BMI or excess weight loss and permits intervention if weight loss results in lean mass losses.

Over a 30-month period (May 1988 to November 1990) 143 acutely ischemic lower extremities (126 patients) were treated with an aggressive surgical approach that included ankle level tibial-peroneal artery thromboembolectomy. Twelve lower extremities in 10 patients that remained ischemic were further treated with adjuvant ankle level urokinase infusion. Sixteen ankle level arteries in 12 extremities were infused with an intraoperative bolus (1 to 2) of urokinase (50,000 to 100,000 units). Continuous postoperative urokinase (25,000 to 50,000 units per catheter per hour × 1 to 5 days) was infused through ankle level arteriotomies in 10 extremities (14 arteries) that did not improve with the initial intraoperative bolus. Concomitant bypass grafting was necessary in four extremities. With adequate inflow established, adjuvant ankle level urokinase salvaged all 12 extremities. The mean increase in ankle/brachial pressure index was 0.84. During continuous postoperative urokinase infusion, lower extremity bleeding requiring blood transfusion occurred in four patients (50%). No deaths occurred in the operative period. Although rhabdomyolysis occurred in 90% of patients, no patients had renal insufficiency. The addition of ankle level urokinase delivery increased the potential limb salvage from 90% of the entire 143 extremities treated during this period to an actual limb salvage of 98%. A mean follow up of 13 months (6 to 36 months) identified one late amputation. Despite the demanding postoperative management required in these patients and the frequent need for early reoperation, the limb salvage obtained justifies this aggressive adjuvant technique in the management of the acutely ischemic lower extremity. (J Vasc Surg 1992;15:771–9.)

An aberrant right subclavian artery (ARSA) is an anomaly with a reported incidence of 0.5% to 2%. Usually the aberrant artery follows a retroesophageal course; rarely it takes a course anterior to the esophagus or the trachea. Most patients with an ARSA remain asymptomatic; however, progressive dysphagia develops occasionally. The choice of approach depends on the presence or absence of aneurysmal disease, the urgency of the operation, and the surgeon's experience. A case is reported of a 33-year-old white male patient who had a 3-year history of progressive dysphagia to the point that he was only able to swallow liquids. A barium swallow demonstrated a posterior extrinsic compression of the esophagus. Angiography was performed, which demonstrated an ARSA with a common origin of the right and left common carotid arteries. Surgical correction was performed via a right supraclavicular neck incision. The proximal aberrant artery was mobilized behind the esophagus. The distal, right subclavian artery was exposed, transected, and transposed with reimplantation into the right common carotid artery. An aberrant right thoracic duct was encountered and ligated. The English language literature from 1960 to present was reviewed via a Medline search. Reported anomalies associated with ARSAs include a nonrecurrent right inferior laryngeal nerve, a common origin of the common carotid arteries, a replaced right or left vertebral artery, coarctation of the aorta, a right-sided thoracic duct, and a right-sided aortic arch. It is important to be aware of these associated anomalies and how they impact the operative approach involved in the correction of dysphagia lusoria.

Hypothesis Percutaneous angioplasty would provide a durable alternative to surgical revision in the treatment of infrainguinal vein graft stenosis. Design Outcome analysis of the results of percutaneous angioplasty of infrainguinal vein graft stenosis. Setting Academic vascular surgical practice in a university-affiliated community hospital. Participants All patients undergoing percutaneous intervention for infrainguinal vein graft stenosis from January 1, 1995, to May 31, 2002, were enrolled in the study. Interventions Lower extremity arterial reconstruction was performed by one of us. Proximal and distal sites of graft placement were identified, as well as the conduit used. Percutaneous angioplasty was performed on grafts by 1 of 4 interventional radiologists. Criteria for intervention and the anatomic location of intervention were noted. Morbidity from percutaneous intervention was also determined. Main Outcome Measures Success and durability of percutaneous angioplasty were determined by clinical follow-up, duplex surveillance, and arteriography. Failure was defined as duplex ultrasonographic or arteriographic documentation of stenosis of 75% or greater. Kaplan-Meier life table analysis was applied to all grafts in the study. Results Ninety-four patients with 101 grafts were included in the study. Nearly 35% of angioplasties had failed at 6 months, 53.6% had failed at 12 months, 60.6% had failed at 24 months, and 75.1% had failed at 36 months. Comorbid disease, use of anticoagulant medications, criteria for intervention, or anatomic location of percutaneous intervention did not affect patency. Eight angioplasties (7.9%) were associated with significant complications. Conclusions Percutaneous angioplasty does not provide a durable solution to the problem of infrainguinal vein graft stenosis. Because of the high rate of complications, its routine use cannot be advocated.

To assess and compare intimal and medial vascular damage caused by three mechanical wall-contact thrombectomy devices: Fogarty embolectomy catheter, Arrow-Trerotola peripheral thrombectomy device, and MTI-Castañeda over-the-wire brush.Bilateral external iliac arteries of 15 canines were thrombosed before mechanical thrombolysis. Ten thrombosed arteries were randomly assigned to receive each device. Animals were sacrificed immediately, and histologic assessment of endothelial and medial damage in the vessels was performed.The vascular damage found with all devices extended into the tunica media. The Fogarty embolectomy catheter and the Arrow-Trerotola device caused significantly more damage than the Castañeda brush.All devices caused lesions extending into the media. Previous research has shown that the extent and depth of the vascular lesion may be contributing factors in promoting early atherosclerotic and accelerated hyperplastic intimal and medial changes. These findings warrant further study of these devices in an atherosclerotic model with longer follow-up.

As a first-year surgical resident in 1974, during one of my first hernia operations, I was personally instructed by Dr. Lloyd Nyhus on the anatomy of the iliopubic tract and its relationship to the femoral vessels. After he cautioned me about injury to the vessels and what to do if I should inadvertently penetrate the artery or vein with the needle, I promptly and confidently placed a suture to approximate the transversus abdominis aponeurotic arch to the iliopubic tract and shelving portion of inguinal ligament and was rewarded with considerable oozing of blood from the injured femoral vein. Looks (but not words) were exchanged, and I registered one of the first lessons of my clinical surgical education. Given over 500,000 hernia operations performed in the United States annually and the close proximity of the femoral and iliac vessels to the site of repair, it is surprising that, apparently, so few major vascular complications occur. It may well be that these injuries do occur with greater frequency than surgeons wish to admit but that most are recognized and properly handled at the time of injury with little fanfare and without significant morbidity for the patient. Delayed symptomatic presentation usually implies a more significant, unrecognized or initially poorly treated injury to an artery or vein. These more serious injuries may then be properly treated, but not reported. Avoidance of these accidents is a matter of constant awareness of the circumstances in which an iatrogenic vascular injury can occur and thorough understanding of the anatomical environment of the surgical field and its neighboring vascular structures.

“A serious consideration of prophylactic and remedial measures in large hernia, of whatever nature, is surely justified by the knowledge that the individual thus afflicted can be nothing but a miserable invalid. Not even the best fitting supporter can render life more than bearable, nor is it possible for such a person to make any severe exertion, whether it be in the pursuance of an occupation or in the enjoyment of an athletic sport.” (Willard Bartlett, M.D., Washington University, St. Louis, Mo., 19031)

Since the time of Bassini, surgeons have looked for techniques and applicable prostheses to improve the results of hernia surgery. This article records the historical parade of biomaterials used in this endeavor from the earliest use of sliver wire coils to the current popular prostheses in use today, each prosthesis is reviewed with respect to its introduction, popularization, clinical use, and ultimate failure. Current prosthetic biomaterials are compared in detail. The quest for the ideal material to reinforce or bridge abdominal wall defects is discussed.

Background The incidence of adenocarcinoma in the distal esophagus and at the gastroesophageal junction (GEJ) has been increasing in the last decades. It has been suggested that patients in whom Barrett mucosa can be identified in the surgical specimen have a better prognosis compared with those without. This has led to the belief that patients with and without Barrett mucosa may represent 2 distinct cancer types. Hypothesis Distal esophageal–GEJ adenocarcinoma with and without Barrett mucosa share the same origin, but differ only in clinical presentation and outcome. Design and Setting Retrospective cohort study in a university tertiary referral center. Patients and Methods Between 1992 and 2002, 215 patients (173 men and 42 women; median age, 66 years; age range, 26-91 years) had esophagogastrectomy for adenocarcinoma of the distal esophagus-GEJ. Patients receiving neoadjuvant chemotherapy or radiation therapy were excluded. Main Outcome Measures Clinical presentation, tumor characteristics, and survival were compared in patients with Barrett mucosa (n = 140) and those without (n = 75). Results Patients with Barrett mucosa in the specimen had tumors that were diagnosed earlier; were smaller in size; earlier in stage, with fewer node metastases; and had a better 5-year survival. Conclusions Observed differences in survival between patients with distal esophageal–GEJ adenocarcinoma with and without Barrett mucosa can be explained by earlier diagnosis. Patients without Barrett mucosa have their tumors detected later, when the disease is more advanced. This suggests the possibility that tumors without Barrett mucosa are not of a different origin, but rather are larger tumors that may have overgrown areas of Barrett mucosa.

Hypothesis Surgical faculty and residents have significantly different attitudes regarding work hour restrictions. Setting All general surgery residencies approved by the Accreditation Council for Graduate Medical Education (ACGME). Participants All voluntarily participating surgical faculty and residents. Main Outcome Measures Current hours worked, days off per month, and attitudes and opinions regarding the current surgical-training environment. Methods A 17-question survey instrument was mailed to the program directors of all ACGME-approved surgical-training programs in the United States. They were requested to distribute the survey to all faculty and residents for completion and to return the forms for analysis. Results Responses (N = 1653) were received from 46% of surgical-training programs. A significant difference was noted between faculty and resident responses in most categories. Most residents (87%) reported more than 80 duty hours per week, whereas 45% reported working more than 100 hours per week. Only 30% of residents reported an average of 1 day per week free of clinical activities. Although a minority of residents (43%) felt that their workload was excessive, 57% felt that their cognitive abilities had been impaired by fatigue. A significant number of residents (64%) and faculty (39%) believe that duty hour restrictions should be adopted. A minority of residents (20%) and faculty (47%) believe that the duration of residency training should be increased to compensate for duty hour restrictions. One quarter of residents regret choosing a career in surgery. Conclusions Current duty hours for most surgical residents exceed the proposed ACGME limits. Although most residents support duty hour limits; surgical faculty are less supportive. Significant alterations in the current design and structure of surgical-training programs will be required to meet the ACGME guidelines.

Hypothesis Enteric leakage is a significant complication of the Roux-en-Y gastric bypass (RYGB) procedure that can be treated successfully. Design Retrospective study of 400 consecutive RYGB patients from 1999-2002. Setting Community hospital with a university surgical residency. Patients Hospital records of 400 morbidly obese patients who underwent gastric bypass surgery were reviewed. Main Outcome Measures Time of discovery of leak, location of leak, treatment, hospital stay, and mortality. Results Twenty-one patients (5.25%) developed leaks. The mean body mass index (calculated as weight in kilograms divided by the square of height in meters) was 54.2. Thirteen patients were noted to develop a leak at the gastrojejunal anastomosis, with an average time to diagnosis of 7.0 days. Five of these patients underwent reexploration, and 8 were successfully treated with percutaneous drainage alone. Four patients developed leaks at the jejunojejunal anastomosis (mean time to diagnosis, 2.0 days). All of these patients required exploration, and 2 patients died. Four patients were noted to have leaks in other areas (average time to diagnosis, 3.5 days). Two patients were treated with drainage, and 2 underwent exploration. The average hospital stay of all patients was 33 days. Conclusions Enteric leakage is a significant complication of the RYGB. Patients who are suspected of having an enteric leak because of signs of sepsis or hemodynamic instability require emergent exploration. Leaks that are more insidious may be treated successfully with percutaneous drainage. Aggressive exploration of patients who appear to be septic, and percutaneous drainage of insidiously developing leaks may decrease patients' morbidity and mortality.

In the classic subclavian steal syndrome, vertebrobasilar insufficiency is caused by reverse flow in the vertebral artery ipsilateral to a subclavian stenosis or occlusion. We present two patients with vertebrobasilar insufficiency and ipsilateral vertebral and subclavian occlusive disease. The postulated mechanism of vertebrobasilar insufficiency is reverse flow in collateral neck vessels. In both patients, symptoms were relieved by carotid subclavian bypass. Thus, vertebral occlusion ipsilateral to a subclavian stenosis does not preclude subclavian steal syndrome. (J VASC SURG 1985;2:913-6.)

A 56 year old man had an unusual case of heterotopic pancreas of the stomach. The patient had two lesions. One was at the gastroesophageal junction, representing the highest location in the stomach reported for this lesion. The second lesion was in the prepyloric antrum and consisted of heterotopic pancreatic tissue as well as tissue consistent with heterotopic ampulla of Vater. A general review of heterotopic pancreas is presented.

In peripheral blood of patients with rheumatoid arthritis the percentages of lymphocytes carrying surface-bound IgG, IgA or IgM did not differ significantly from those in normal controls. However, both the sum of these percentages and the percentage of cells carrying receptors for human C3 were significantly lower than in normal controls. Immunoglobulin and C3 receptor were almost always present on the same cells, indicating that the latter also is a marker for B lymphocytes. In rheumatoid synovial fluids the percentage of lymphocytes carrying immunoglobulin appeared to be significantly higher than in peripheral blood from the same patients. No similar difference was observed for the percentage of cells carrying C3 receptors, probably due to impaired detection of this receptor in some of the fluids.

Thirteen patients with internal carotid artery occlusion and symptomatic external carotid artery stenosis underwent external carotid artery revascularization by means of endarterectomy (n = 10) or subclavian artery--external carotid artery bypass (n = 3). All patients but one were followed up, for five to 46 months (mean, 20 months). There were no operative deaths or complications and no late strokes. One patient (7.7%) required early extracranial-intracranial (EC-IC) bypass for failure of the external carotid artery endarterectomy to relieve the initial symptoms. All remaining patients were completely (n = 9) or partially (n = 2) relieved of symptoms, and EC-IC bypass was not required. There were no criteria identified by either oculopneumoplethysmography or angiography that could reliably predict the need for subsequent EC-IC bypass. Ninety-two percent of the patients were adequately treated with external carotid artery revascularization alone, suggesting that subsequent EC-IC bypass is seldom required in patients with ipsilateral internal carotid artery occlusion and external carotid artery stenosis.