Office-based surgery and patient outcomes

Purpose of review The purpose of this review is to provide an update on the current knowledge about patient safety and outcomes in the office-based setting. Ambulatory procedures performed outside the hospital are steadily increasing, resulting in an increasing number and complexity of office-based procedures and patient comorbidities over the past two decades. In this review we focus on most recent outcomes studies encompassing different surgical specialties and patient populations. Recent findings Rates of complications in the office-based surgical (OBS) setting from the latest publications are similar to, or better than previously reported studies. Many of the studies published were in the field of plastic surgery, with a few publications on office vascular and dental procedures. The most common complications were haematomas, infections and venous thromboembolisms (VTE)s and pulmonary emboli. Death was a rare finding, though when it occurred, it was often associated with VTE/pulmonary emboli and abdominoplasties. Summary Overall, these studies contribute positively to the safety of office-based anaesthesia. As an increasing number of procedures migrate from the hospital setting to ambulatory and office-based environments, it will be critically important to continue ensuring patients are well tolerated. Correspondence to Richard D. Urman, MD, MBA, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA. Tel: +1 617 732 8222; e-mail: Rurman@bwh.harvard.edu Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Thoracic endovascular aortic repair with perioperative antibiotic therapy for infected ductus arteriosus aneurysm in an adult

Abstract

Ductus arteriosus aneurysm (DAA) is rare in adults, but often involves life-threatening complications. Open repair is common, but is invasive and relatively dangerous. With the continued development of endovascular devices, we can now choose endovascular repair for DAA. However, endovascular repair for infected lesion is controversial. We report a successful case of thoracic endovascular aortic repair with perioperative antibiotic therapy for infected DAA in a 59-year-old man.

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Retrograde embolization of anterior tibial artery for an iatrogenic arterio-venous fistula causing left lower extremity claudication

Abstract

Lower extremity angiogram is generally a safe and effective procedure with a low rate of vascular complications. We report here a unique case of a 33-year-old female with anterior tibial artery (ATA) to anterior tibial vein fistula formation after lower extremity endovascular intervention. This was initially treated with open repair of the fistula and ligation of ATA. However, patient continued to complain of claudication like symptoms. Patient subsequently had an endovascular embolization of ATA in a retrograde fashion. Recovery was unremarkable; patient was discharged home same day. Three months postoperatively patient denies leg pain, a follow-up arterial duplex failed to show presence of arterio-venous fistula. This case illustrates the effectiveness of an endovascular approach as a minimally invasive treatment for this uncommon complication that occurs after lower extremity endovascular intervention.

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Urgent Repositioning After Venous Air Embolism During Intracranial Surgery in the Seated Position: A Case Series

Background: Venous air embolism (VAE) is a well-described complication of neurosurgical procedures performed in the seated position. Although most often clinically insignificant, VAE may result in hemodynamic or neurological compromise resulting in urgent change to a level position. The incidence, intraoperative course, and outcome in such patients are provided in this large retrospective study. Methods: Patients undergoing a neurosurgical procedure in the seated position at a single institution between January 2000 and October 2013 were identified. Corresponding medical records, neurosurgical operative reports, and computerized anesthetic records were searched for intraoperative VAE diagnosis. Extreme VAE was defined as a case in which urgent seated to level position change was performed for patient safety. Detailed examples of extreme VAE cases are described, including their intraoperative course, VAE management, and postoperative outcomes. Results: There were 8 extreme VAE (0.47% incidence), 6 during suboccipital craniotomy (1.5%) and 2 during deep brain stimulator implantation (0.6%). VAE-associated end-expired CO2 and mean arterial pressure reductions rapidly normalized following position change. No new neurological deficits or cardiac events associated with extreme VAE were observed. In 5 of 8, surgery was completed. Central venous catheter placement and aspiration during VAE played no demonstrable role in patient outcome. Conclusions: Extreme VAE during seated intracranial neurosurgical procedures is infrequent. Extreme VAE-associated CO2 exchange and hemodynamic consequences from VAE were transient, recovering quickly back to baseline without significant neurological or cardiopulmonary morbidity. The authors have no funding or conflicts of interest to disclose. Address correspondence to: Arnoley S. Abcejo, MD, Department of Anesthesiology, Mayo Clinic, Rochester, MN 200 1st St SW, Rochester, MN 55905 (e-mail: Abcejo.Arnoley@mayo.edu). Received April 11, 2018 Accepted July 19, 2018 Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved

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Chordoma: a case series and review of the literature

Chordoma is a rare malignant tumor of the skull base and axial skeleton, with an incidence of less than 0.1/100,000 per year. Patients with advanced chordoma have a poor prognosis due to locoregional recurrenc...

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Tocilizumab for the Treatment of Mevalonate Kinase Deficiency

Mevalonate kinase deficiency (MKD) is a severe autoinflammatory disease caused by recessive mutations in MVK resulting in reduced function of the enzyme mevalonate kinase, involved in the cholesterol/isoprenoid pathway. MKD presents with periodic episodes of severe systemic inflammation, poor quality of life, and life-threatening sequelae if inadequately treated. We report the case of a 12-year-old girl with MKD and severe autoinflammation that was resistant to IL-1 and TNF-α blockade. In view of this, she commenced intravenous tocilizumab (8 mg/kg every 2 weeks), a humanised monoclonal antibody targeting the IL-6 receptor (IL-6R) that binds to membrane and soluble IL-6R, inhibiting IL-6-mediated signaling. She reported immediate cessation of fever and marked improvement in her energy levels following the first infusion; after the fifth dose, she was in complete clinical and serological remission, now sustained for 24 months. This is one of the first reported cases of a child with MKD treated successfully with tocilizumab and adds to the very limited experience of this treatment for MKD. IL-6 blockade could therefore be an important addition to the armamentarium for the treatment of this rare monogenic autoinflammatory disease.

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Testimony of an Ethiopian girl sexually assaulted by her stepfather: a case report

The sensitiveness and stigma associated with sexual assault deter many victims from speaking about their experiences. This silence of victims worsens the problem, especially in patriarchal communities like Eth...

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