Access Surgeon Research Articles

Dialysis Access Steal Syndrome: The Severity Criteria Diagnosis with Arterial Doppler Examinations

Patients with dialysis access steal phenomenon can present with pain, paresthesia, ulceration, and tissue loss of the digits. Some degree of steal is common, up to 80% of patients with a radiocephalic arteriovenous fistula have mild, asymptomatic arterial steal documented by a decreased digital blood pressure. Critical ischemia of the upper extremity is a rare condition compared with ischemia of the lower extremities. High-flow arteriovenous fistulas have a greater risk of steal than normal flow arteriovenous fistulas; however, combined with arteriosclerotic disease they may also lead to ischemia. There are several strategies to prevent arterial steal following hemodialysis access that should be used; preoperative testing to identify proximal arterial lesions, upper extremity vein mapping and sizing, Allen's test (radial artery patency), end-to-side arteriovenous anastomosis to decrease steal and distal venous hypertension, selective venous arterialization at the elbow with ligation of deep perforation branch to improve maturation and restrict flow, and stepped or tapered grafts to limit flow. A noninvasive upper extremity arterial Doppler diagnosis is of importance to determine treatment options for patients. The goal of the vascular access surgeon is to promptly recognize and treat the disorder to maximize both limb and access salvage.

Access Ligation in Transplant Patients

Access surgeons will encounter patients with functioning transplants who want to lose their fistula, and every dialysis unit sees patients returning after a failed kidney transplant for whom an old fistula is a readily available lifeline. The decision is straightforward in patients with perfectly functioning transplants and disabling complications of their fistula, or in patients with failing transplants and a good fistula. The challenge is to make this decision in patients with good transplant function and an asymptomatic fistula. Despite improvements in one-year survival of renal grafts, the long-term graft survival has improved modestly. This means about half of the patients with a successful kidney transplant will return to dialysis within 10 years. Use of recently developed risk calculators, based on clinical parameters, may help in the decision process. A high flow fistula can lead to heart failure but most fistulae are well tolerated in asymptomatic patients and the effects of closure of the AVF on the heart are modest. Recent evidence suggests that there may be benefits of a functioning AVF that may need to be considered in this decision process. This article reviews the literature and comes to pragmatic recommendations of what to do with this conundrum.

Treatment of symptomatic thoracic disc herniations with lateral interbody fusion.

Symptomatic thoracic herniated discs have historically been treated using open exposures (i.e., thoracotomy), posing a clinical challenge given the approach related morbidity. Lateral interbody fusion (LIF) is one modern minimally disruptive alternative to thoracotomy. The direct lateral technique for lumbar pathologies has seen a sharp increase in procedural numbers; however application of this technique in thoracic pathologies has not been widely reported. This study presents the results of three cases where LIF was used to treat symptomatic thoracic disc herniations. Indications for surgery included thoracic myelopathy, radiculopathy and discogenic pain. Patients were treated with LIF, without supplemental internal fixation, and followed for 24 months postoperatively. Average length of hospital stay was 5 days. One patient experienced mild persistent neuropathic thoracic pain, which was managed medically. At 3 months postoperative all patients had returned to work and by 12 months all patients were fused. From preoperative to 24-month follow-up there were mean improvements of 83.3% in visual analogue scale (VAS), 75.3% in Oswestry Disability Index (ODI), and 79.2% and 17.4% in SF-36 physical (PCS) and mental component scores (MCS), respectively. LIF is a viable minimally invasive alternative to conventional approaches in treating symptomatic thoracic pathology without an access surgeon, rib resection, or lung deflation.

Current outcomes and indications for cryopreserved vein allografts in hemodialysis access surgery.

Cryopreserved vein allografts (cadaveric vein) have emerged as an option for arteriovenous graft reconstruction; however, indications for their use in hemodialysis access remains to be clearly defined. Observations from our own experience have suggested that cadaveric vein grafts (CVGs) provide good outcomes, particularly in patients with a history of infection, recurrent access failure and advanced age. This is a 10-year retrospective study. Primary outcomes were (1) to identify characteristics specific to this patient population and (2) to better define indications for use of cadaveric vein in hemodialysis access creation. Indications for creation of CVGs included patient history of either active or recent infection (41.5%), recurrent access failure (43.4%) or surgeon preference secondary to patients' advanced age (9.4%). Observed primary patency rates were 84.9% (30 days), 22.6% (1 year) and 16.0% (2 years). Secondary patency was 93.4% (30 days), 66.0% (1 year) and 52.8% (2 years). Patient death was the highest cause of graft abandonment (52.9%) followed by thrombosis (19.1%), infection (11.7%) and rupture (11.7%). CVG patency at the time of patient death was 83.7%. The rates of both primary and secondary patency in CVGs are highly comparable to the reported patency rates of polytetrafluoroethylene (PTFE) grafts and allow for lifelong maintenance of dialysis access. Our observed outcome suggests that CVGs should be considered for patients needing vascular access in the presence of infection. CVGs may likewise be viable alternatives to PTFE grafts in the elderly and patients with limited access options.

Superficialization of Segmentally Matured Brachial Vein Complex as the Last Possible Native, Upper arm Vascular Access for Hemodialysis

We present a case report on superficialization of the segmentally matured brachial vein complex as the last possible native vascular access for hemodialysis in the upper arm. A 57-year-old, female patient was hemodialysed for 14 years. Due to multiple failures of her previous forearm and upper arm vascular access for hemodialysis, the last attempt at the creation of upper arm native vascular access was planned in terms of the formation of a two-stage autogenous brachial-brachial arterio-venous fistula (ABBA). The second stage exposure of the brachial vein - 4 weeks after anastomosis with the brachial artery showed an unusual intraoperative situation. Segmental maturation of both brachial veins, connected by a bridging vein was encountered. Both the mature segments of the brachial veins, connected by the bridging vein were elevated/superficialized into a subcutaneous bed. Immature parts of brachial veins were left near their anatomical position. Superficialized venous conduit was easily accessible and provided adequate parameters of uncomplicated hemodialysis for 6 months. In month 7, thrombosis of the fistula caused by an embolus due to an atrial fibrillation episode required thrombo-embolectomy. The fistula is still in use 13 months after its creation. Our technique is feasible in cases of unusual, segmental maturation of both brachial veins during two-stage ABBA formation. Selective superficialization of matured segments only may provide suitable access for hemodialysis. Vascular access surgeons should be aware of possible anatomical variations and be prepared to perform unusual access configurations as dictated by the local anatomy.

A call to action for pre-end-stage renal disease care.

Malas and colleagues1haveused theUSRenal Data System to analyze the impact of the incident hemodialysis access type on long-term survival as a follow-up to the original Dialysis Outcome Quality Initiative (DOQI) that set a 50% incident goal for autogenous arteriovenoushemodialysis access (arteriovenous fistula [AVF]).2 Unfortunately, there has been little improvement in the incident AVF rate (14%) since the publication of these guidelines in 1997, despite the consistent observation that initiatingdialysiswith anAVFwas associated with improved long-term survival. In the current study,1 the use of an AVF at the initiation of dialysis was associated with a 35% lower mortality when compared with hemodialysis catheters (HCs), with similar benefits for patients dialyzing with a catheter while waiting for their AVF to mature (23%mortality decrease) and those with a prosthetic arteriovenous access (arteriovenous graft [AVG], 18%mortality decrease).Not surprisingly, theuseof anAVForAVGat theonset of dialysis was associated with a lower hazard of cardiovascularand sepsis-related mortality. Indeed, these known survival benefits provided some of the impetus for the originalDOQIguidelinesalongwith their successor, theKidneyDisease Outcome Quality Initiative3 and the Fistula First Breakthrough Initiative.4 These findings are very sobering and suggest that our health care system has woefully underperformed, particularly given the fact that mortality is only one of several important outcome measures (ie, morbidity, quality of life, and cost) for patients with end-stage renal disease (ESRD). The potential impact on health care costs of the incident access choicewas addressed byMalas and colleagues1 in their Discussion section and, predictably, their estimates on the additional cost (or potential savings) were staggering. The authors’ findingsmust be interpretedwith some cautionbecause it isworth emphasizing that startingdialysiswith functional AVF truly represents the best case scenario that reflects a tremendous amount of selection bias at each stage of thecareprocess includinganinvolvedpatient,earlyreferral from theprimarycarephysician toanephrologist, early referral from a nephrologist to a committed access surgeon, arterial/venous anatomy suitable for an AVF, access construction well in advance of the anticipated dialysis date, and an AVF that matures suitable for cannulation. Indeed, it is not surprising that patients with this level of pre-ESRD care (and favorable outcome in termsof a functionalAVF)haveabetter long-termoutcome. Iwould contend it is notpossible to construct anAVFon everypatientgiventheiranatomyandcomorbiditiesandwould echo the findings of the current study that AVGs are far better thanHCs and the sentiment that “fistula first” should really be “catheter last.” Interestingly, the authors’ sophisticated statistical analyses did not support the hypotheses that the low incidence of AVF was owing to poor pre-ESRD care or the patients being poor surgical candidates for an AVF. The outstanding question remains as to how these powerful data can be used to improve the incident AVF rates and, more importantly, patient outcomes. The authors have proposed changes inhealth care policy and reimbursement,with the hope of extending coverage to uninsured patients preESRD and rewarding quality care (eg, early referral to a nephrologist).Althoughsoundrecommendations, I remainskeptical that these proposed changes are practical in our rapidly shifting health care landscape. The authors have also proposed developing multidisciplinary teams that include all of the stakeholders detailed in the best-case scenario outlined here and the various hospital systems. This seems like amore realistic approach, although the challenge remains to developeffectivestrategies that leadto thedesiredoutcomewithout reproducing the failed efforts from the past decade. It is worth emphasizing that the DOQI, Kidney Disease Outcome Quality Initiative, andFistulaFirstBreakthrough Initiativehad a collective dramatic impact on the prevalence ofAVF (23% in 2003 vs 60% in 2011)5 and it has always struck me that most of these efforts were largely directed at access surgeons. Perhapsweneed to redefine the expectations andprovide gentle pressure to the nonsurgeonmembers of the pre-ESRD health care team.

Complications of the Anterior Approach to the Lumbar Spine

Introduction Lumbar spine pathology, such as tumors and fractures, commonly affect vertebral bodies, making anterior access to the spine an important tool in the armamentarium of spinal surgeons. Furthermore, accessing the front of the spine via a posterior approach is associated with the potential for neural injury. Reports in the literature of high rates of complications, particularly vascular injury, has led to questions about the safety of the anterior lumbar approach. As a result, various recommendations have been made such as the used of “access” surgeons and ring retractor systems to reduce the complication rate. We present the complication rates from over 550 anterior approaches performed in Exeter, United Kingdom, by multiple surgeons over an 18-year period, without the use of an access surgeon or ring retractor system. Materials and Methods We retrospectively reviewed the notes of 567 consecutive patients having undergone an anterior approach to the lumbar spine for any procedure from 1996 to 2014. Information was collected from operation notes, anesthetic records, postoperative ward rounds, and clinic letters. Details were recorded on intraoperative blood loss and complications such as vascular injury and peritoneal opening as well as postoperative complications such as infection, DVT/PE, ileus, and hernias. Results There was an overall complication rate of 13.4%. The rate of vascular injury requiring suture repair was 3.2% and the rate requiring input from a vascular surgeon 0.8%. Conclusion We report a comprehensive and critical review of our practice over 18-years with a large series of consecutive patients undergoing anterior lumbar surgery for a wide range of pathology. This has been performed in a single center by multiple orthopedic spinal surgeons without the use of access surgeons or dedicated ring retractor systems. Our complication rates have been shown to be comparable to the existing literature demonstrating that in high volume centers the anterior approach to the lumbar spine is safe and effective for a multitude of applications.

Long-Term Results of PTFE Grafts

Vascular surgeons are essential in "lifeline" creation for hemodialysis patients and should be the central player in any multidisciplinary access service together with nephrologists, dialysis staff and interventional radiology. In this position, access surgeons are involved in complicated clinical decision making regarding primary and secondary access selection, which throughout the last decade has been largely aided, and influenced, by national and international guidelines as well as other initiatives. These recommendations, unanimously and appropriately, advocate the placement of native fistulas over synthetic grafts (the majority grafts from expanded polytetrafluoroethylene, ePTFE, herein referred to as PTFE) based on the superiority of fistulas with respect to complications such as infections and thrombosis. Nevertheless, the use of PTFE grafts for hemodialysis access is an accepted and firmly established alternative to native fistulas where data today reveal unwanted consequences to overinterpretation of established guidelines such as increased catheter use. This information highlights a need for an adjustment of access selection strategies based on patient-centered algorithms. Here, available results on PTFE graft performance in hemodialysis access is recapitulated, with respect to both conventional grafts and technical modifications, and conclude with a modified approach to primary access selection.

Videoscopic basilic vein harvest for creation of transposed brachiobasilic arteriovenous fistulae.

Due to the extensive dissection required during the standard transposed brachiobasilic arterial venous fistula (BB-AVF) procedure and the potential for postoperative complications, many surgeons are reluctant to construct BB-AVFs. Less invasive vein harvest has been performed for this procedure with good results, but this procedure remains rarely used. We began to perform videoscopic-assisted BB-AVF creation in selected patients at our institution in 2006. Vein harvesting from the antecubital fossa to the level of the axilla is performed by an experienced surgical technician under the guidance of the dialysis access surgeon. Perioperative data and postoperative outcomes were retrospectively reviewed with institutional review board approval. From 2006 to 2010, we performed videoscopic-assisted BB-AVF in 21 patients. Median age was 59 years and median body mass index was 30; women comprised 52% of the cohort. Previous vascular access procedures had been performed on 81% of patients. Of the 21 attempts with the video-assisted approach, only 1 required conversion to a standard open procedure. Of the remaining cases, there were no significant intraoperative or postoperative surgical complications with a median operative time of 159 minutes and maximum length of stay of 1 night. Maturation of the fistula sufficient for cannulation and use occurred in 80% of patients, with the median time to first access in patients who matured being 60 days. At 3 years follow-up, 47% of fistulas that matured were still functional, with 33% lost to death or successful renal transplantation. Videoscopic-assisted transposition of the basilic vein is a reasonable option for BB-AVF placement. The procedure can be performed in an acceptable expeditious fashion with near elimination of infection, wound breakdown, lymph drainage, nerve injury, and satisfactory maturation (80%) and patency rates. Technicians experienced in lower extremity vein harvest can perform this procedure successfully under the supervision of an experienced access surgeon.

Barriers, biases, and beliefs about arteriovenous fistula placement in children: A survey of the International Pediatric Fistula First Initiative (IPFFI) within the Midwest Pediatric Nephrology Consortium (MWPNC)

There has been recent emphasis on increased arteriovenous fistula (AVF) use and decreased central venous catheter use in hemodialysis (HD) patients. The International Pediatric Fistula First Initiative was founded via collaborative effort with the Midwest Pediatric Nephrology Consortium to alert nephrologists, surgeons, and dialysis staff to consider fistulae as the best access in pediatric HD patients. A multidisciplinary educational DVD outlining expectations and strategies to increase AVF placement and usage in children was created. Participants were administered a survey previewing and postviewing to identify barriers to placement and usage of AVF in children. A total of 52 surveys were subdivided as either "dialysis staff" or "proceduralist" at five centers. Thirty-three percent of respondents were unaware if their practice was following published guidelines. Sixty-five percent of respondents stated they referred to a dedicated vascular access surgeon at their respective institutions. Methods used to monitor AVF function included physical exam, venous pressure monitoring, and ultrasound dilution. Vascular access was placed within 3 months in only 35% of patients. Interdisciplinary communication problems between surgeons, interventional radiologists, and nephrologists were identified as a major barrier. Lack of AVF usage was often due to maturation failure. Routine access rounds did not occur in any centers. Regarding monitoring, 74% of the respondents use physical exam, 26% use venous pressure monitoring, and 9% use ultrasound dilution. Ninety-three percent of dialysis staff stated they would change practice patterns following the intervention; however, 12% of surgeons stated they would alter practice patterns. To our knowledge, this is the first report to identify barriers to placement of AVF in children from the perspectives of multidisciplinary team members including pediatric nephrologists, surgeons, interventional radiologists, and multidisciplinary dialysis staff.

Incidence of Vascular Complications Arising from Anterior Spinal Surgery in the Thoraco-Lumbar Spine

Study DesignModern biomaterials and instrumentation have popularised surgery of the thoraco-lumbar spine through an anterior route. The advantage of anterior surgery is that it allows for a direct decompression of the compromised spinal canal. However, the potential for devastating long-term sequelae as a result of complications is high.PurposeThe aim of this study was to give a general overview and identify the incidence of vascular complications.Overview of LiteratureThere is limited literature describing the overall incidence and complications of anterior spinal surgery.MethodsA retrospective review of a prospective database of 1,262 consecutive patients with anterior surgery over a twelve-year period.ResultsIn our study, 1.58% (n=20) of patients suffered complications. Injury to a major vessel was encountered in 14 (1.11%) cases, of which nine involved an injury to the common iliac vein. In six cases, the original procedure was abandoned due to a life-threatening vascular injury (n=3) and unfavourable anatomy (n=3).ConclusionsThe incidence of vascular and other complications in our study was relatively low. Nevertheless, the potential for devastating long-term sequelae as a result of complications remains high. A thorough knowledge and awareness of normal and abnormal anatomy should be gained before attempting such a procedure, and a vascular surgical assistance especially should be readily accessible. We believe use of access surgeons is mandatory in cases with difficult or aberrant anatomy.

The role of routine chest radiography for detecting complications after central venous catheter insertion.

Chest radiographs are obtained routinely after central venous catheter (CVC) insertion in many institutions, although it consumes time and money. The purpose of this study was to evaluate the role of post-procedural chest X-ray in detecting complications of CVC insertion; we performed CVC insertion without using ultrasonography guidance. A total of 454 patients who required an emergency vascular access for hemodialysis between February 2008 and March 2010 were included in this study. In cases where three to five unsuccessful attempts were encountered to place the CVC or pierce the artery, we used another site for CVC placement or we placed the CVC under ultrasonographic guidance. Both the internal jugular and the subclavian veins were used as routes for catheter insertion. All the catheters were dual lumen and were inserted by the same vascular access surgeon. All the catheters were inserted using the same protocol. This protocol consists of five stages including position, percutaneous anesthesia, puncture, pull out and placement. Chest radiography was obtained after the procedure and patients were interviewed for the presence of any unusual symptoms. The X-rays were reviewed by a radiologist who was unaware of the patients' symptoms. Complications occurred in two patients who had unusual symptoms after the placement of the catheter. Although immediate postprocedural chest radiography is recommended for tip position confirmation, it should not be considered a reliable procedure for detecting complications in the absence of clinical symptoms. It is recommended to monitor patients after catheter insertion and perform delayed chest X-ray in the presence of any unusual symptoms.

Projecting requirements for end stage renal disease services in Libya 2014-2024

Chronic kidney disease is a public health issue with significant humanitarian and economic implications. Between 2007 and 2009, the number of patients on dialysis in Libya increased from 2116 to 2417. It is projected that the number of patients on dialysis will increase from 2417 in 2009 to 7667 in 2024. The proportion of patients on peritoneal dialysis is projected to rise from 1.2% in 2014 to 16% in 2024. To maintain a patient to dialysis machine ratio of 1: 3.4, the number of dialysis machines will need to grow from 1045 in 2014 to 2255 in 2024. Hemodialysis units are better organized into main and satellite units, with a potential use of mobile hemodialysis units to deliver a local service to much smaller number of hemodialysis patients. The required number of general nephrology beds in 2014 is estimated around 468, with 59 additional regional transplant beds. These numbers are expected to be around 547 and 69 respectively by 2024. Required staff to deliver service to these rising numbers of patients is estimated to be 78 nephrologists, 9 vascular access surgeons, 4 transplant surgeons and 4 hepatologists in 2014. The corresponding numbers in 2024 are 123, 51, 18, and 7, respectively. The number of required renal nurses in 2014 is 1767, rising to 3400 by 2024. A steady increase in the number of required transplant coordinators, histocompatibility and immunogenetics laboratory consultants and scientists, dialysis technicians, renal dietitians, social workers, clinical psychologists and clinical renal pharmacists is to be expected. Recently published data showing great variability in patient mortality, hepatitis sero-conversion rates and the lack of consistent practice to check dialysis dose and adequacy are strong indicators for the nephrology community in Libya, the regulatory authorities and decision makers to urgently agree national nephrology clinical practice guidelines, and to adequately plan to train and develop the skills of the personnel required to cope with the rising number of end stage renal disease patients.

Anterior approach for surgery of thoracolumbar spine: surgical outcomes of series of one self-trained neurosurgeon

Summary Purpose Most neurosurgeons in Taiwan are not trained formally to perform anterior approaches for thoracolumbar corpectomies in the treatment of thoracolumbar lesions during their residencies. Often, such procedures are conducted with the assistance of “access surgeons”. Materials and methods Prior to performing anterior thoracolumbar corpectomies in clinical cases, one senior neurosurgeon, who was not trained in the anterior approaches, acquired the relevant skills from cooperating access surgeons, by attending a workshop, and by practicing on cadavers. Between December 2006 and March 2011, 18 consecutive patients underwent surgeries involving the anterior approach to thoracolumbar lesions. Patients operated on by the self-trained neurosurgeon were included in Group 1, and those operated on by neurosurgeons assisted by access surgeons were included in Group 2. Operative time, blood loss, complications, and neurologic outcomes were compared between the two groups. Results Group 1 consisted of 10 patients (4 men), with a mean age of 62.5 years, and Group 2 of eight patients (5 men), with a mean age of 58.3 years. The median follow-up periods for both groups were 15.5 and 17 months, respectively. Operative time, blood loss, rate of complications, and neurologic outcomes were comparable between the two groups. Conclusion Through observation, by attending workshops, and by practicing the anterior approach on cadavers, the self-trained neurosurgeon became competent in the anterior thoracolumbar corpectomy and achieved comparable results to surgeons who were assisted by access surgeons in terms of operative time, blood loss, complications, and neurologic outcomes.

Transforaminal Retrieval of Intradiscal Retained Broken Surgical Knife Blade

Case report. To report a middle-aged female in whom a knife blade was broken and lodged in the disc space during lumbar discectomy. Transforaminal route as an alternative corridor for its removal is proposed. Lumbar discectomy is being done in increasing frequency worldwide. One risk associated with this procedure is breaking of the surgical knife during discectomy. Most of the broken blades can be removed during the initial surgery. However, in a few cases, surgeon's attempts might be unsuccessful, resulting in retained foreign body in the disc space. Literature regarding this issue is scarce, and there are no unique guidelines to address this complication. A 69-year-old female in whom a surgical knife blade was inadvertently broken and retained in the disc space during lumbar discectomy. The broken blade could not be removed during the first surgery. In the second surgery, it was retrieved through the initial midline incision but via transforaminal route. The patient was discharged a day after blade removal and is doing well now. Retrieval of a broken knife blade unintentionally buried in the intervertebral disc space can be a challenge and even impossible to achieve, despite hours of attempts. In the second surgery, the retained blade in the disc space is traditionally removed via the anterior approach. The transforaminal corridor might be a simple alternative route that does not carry inherent difficulties and risks associated with the anterior corridor. Eventually, removal of a broken blade via this route does not require the collaboration of an access surgeon.

Early postoperative dislocation of the anterior Maverick lumbar disc prosthesis

The authors report on 2 cases of anterior dislocation of the Maverick lumbar disc prosthesis, both occurring in the early postoperative period. These cases developed after experience with more than 50 uneventful cases and were therefore thought to be unrelated to the surgeon's learning curve. No similar complications have been previously reported. The anterior Maverick device has a ball-and-socket design made of cobalt-chromium-molybdenum metal plates covered with hydroxyapatite. The superior and inferior endplates have keels to resist translation forces. The patient in Case 1 was a 52-year-old man with severe L4-5 discogenic pain; and in Case 2, a 42-year-old woman with disabling L4-5 and L5-S1 discogenic back pain. Both patients were without medical comorbidities and were nonsmokers with no risk factors for osteoporosis. Both had undergone uneventful retroperitoneal approaches performed by a vascular access surgeon. Computed tomography studies on postoperative Day 2 confirmed excellent prosthesis placement. Initial recoveries were uneventful. Two weeks postoperatively, after stretching (extension or hyperextension) in bed at home, each patient suffered the sudden onset of severe abdominal pain with anterior dislocation of the Maverick prosthesis. The patients were returned to the operating room and underwent surgery performed by the same spinal and vascular surgeons. Removal of the Maverick prosthesis and anterior interbody fusion with a separate cage and plate were performed. Both patients had recovered well with good clinical and radiological recovery at the 6- and 12-month follow-ups. Possible causes of the anterior dislocation of the Maverick prosthesis include the following: 1) surgeon error: In both cases the keel cuts were neat, and early postoperative CT confirmed good placement of the prosthesis; 2) equipment problem: The keel cuts may have been too large because the cutters were worn, which led to an inadequate press fit of the implants; 3) prosthesis fault: Both plates of the dislocated implants looked normal and manufacturer analysis reported no fault; 4) patient factors: Both dislocations happened early in the postoperative period, after hyperextension of the spine while the patient was supine in bed. Bracing would not have reduced hyperextension. Dislocation of a lumbar spinal implant represents a life-threatening complication and should therefore be considered and recognized early. Radiographic and CT studies of both the lumbar spine (for prosthesis) and the abdomen (for hematoma) should be performed, as should CT angiography (for vessel damage or occlusion). Any anterior lumbar revision surgery is hazardous, and it is strongly advisable to have a vascular surgeon scrubbed. In cases of dislocation or extrusion of a lumbar interbody prosthesis, the salvage revision strategy is fusing the segment via the same anterior approach. Surgeons should be aware of the risk of anterior dislocation of the Maverick prosthesis. Keel cutters should be regularly checked for sharpness, as they may be implicated in the loosening of implants. Patients and their physical therapists should also avoid lumbar hyperextension in the early postoperative period.

Variations in the Iliolumbar Vein During the Anterior Approach for Spinal Procedures

Retrospective study from data from a single access surgeon at 2 hospitals. To increase the surgeon's awareness of iliolumbar vein (ILV) variants during the anterior approach to the lumbar spine. Although there are many advantages to using the anterior approach, serious risks are involved, namely, vascular injury. The ILV is especially vulnerable when exposing the L4 and L5 vertebrae, and its ligature is recommended to avoid massive hemorrhage from its disruption. Cadaver studies on ILV variants have mainly analyzed drainage patterns. To our knowledge, however, no studies on ILV variants have been conducted on live humans during anterior spinal surgical procedures. A total of 159 patients who underwent anterior spinal surgery of at least the L4-L5 levels were included. Cases not involving the L4-L5 level were excluded. Frequency of anomalous ILVs and their possible association with diagnosis (spondylolisthesis, herniated nucleus pulposus, degenerative disc disease, and stenosis), sex, comorbidities, and pelvic history was evaluated. ILV was classified into 5 types: type 0 (missing ILV), type 1 (single ILV), type 2 (2 ILVs), type 3 (3 ILVs), and type 4 (>3 ILVs). Most patients had a single ILV (73%, N = 116). Multiple ILVs were found in 25.8% of cases: 27 cases (17%) for type 2, 11 cases (6.9%) for type 3, and 3 cases (1.9%) for type 4. A higher frequency of multiple ILVs was found in males (32%) than in females (19.2%) (P = 0.034). Diagnosis, comorbidity, and pelvic surgical history were not associated with the number of ILVs. The high frequency of multiple ILVs found during the anterior approach is crucial knowledge for access surgeons, as it will help them anticipate such anomalies and thus avoid the potentially catastrophic complications of an avulsion of an unexpected extra vein.

Peritoneal Dialysis Access: Open versus Laparoscopic Surgical Techniques

To outline pros and cons with the open and laparoscopic techniques when placing peritoneal dialysis (PD) catheters. Controversy exists regarding which technique, the open and laparoscopic, if any, is superior to the other. In addition, there is the question of which approach is best in rescuing malfunctioning PD catheters. Rather than promoting one doctrine fits all, philosophically, doing the right thing for the patient by specific criteria is ethically the better model. These specific selection criteria include patient characteristics, the team's skills and knowledge and institutional resources and commitment. Also, the sophistication of a PD unit for training and monitoring of patients is crucial for successful outcomes. Open paramedian and two laparoscopic approaches are described in detail, outlining advantages and disadvantages of each, with suggestions when one method is preferred. In general, the laparoscopic technique is associated with longer operative times, higher costs and the need to utilize general anesthesia. It is, however, the preferred method when rescuing malfunctioning catheters and may increase the PD patient population in patients with previous abdominal surgeries. The dialysis access surgeon should be familiar with both open and laparoscopic techniques and appropriately choose the ideal method based upon the individual patient and institutional resources.

Extreme Lateral Interbody Fusion (XLIF) in the Thoracic and Thoracolumbar Spine: Technical Report and Early Outcomes

Previous studies have demonstrated the distinct advantages of thoracoscopically assisted spinal fusion compared to traditional open thoracotomy. However, these techniques are limited by a steep learning curve, prolonged operative time, and lack of three-dimensional visualization of the surgical field. The objective of this study was to describe our initial experience with an adaptation of the extreme lateral interbody fusion (XLIF) technique allowing access to the anterior aspect of the thoracic and thoracolumbar spine with specific reference to (1) early pulmonary complications, (2) non-pulmonary complications, and (3) ability of this technique to successfully achieve spinal decompression and fusion at the operative level. Clinical and radiographic data were reviewed for the entire perioperative period. A total of 18 patients (72% females; mean age, 56.8years) underwent a thoracic XLIF procedure for spinal pathologies including disc herniation, fracture, tumor, pseudoarthrosis, and proximal junctional kyphosis. A total of 32 levels were treated, with the majority located at the thoracolumbar junction. Twelve of the procedures were done as part of a combined anterior/posterior surgery. The mean estimated blood loss was 577ml and the mean length of stay was 12days. At a mean follow-up of 14months, all patients except for one (who died of widely metastatic disease) had achieved radiographic evidence of fusion. Two patients developed pulmonary effusions requiring medical intervention. Six patients had seven non-pulmonary complications: incidental durotomy (two), infection (one), instrumentation pullout (one), cardiac arrhythmia (two), and death from metastatic disease (one). The XLIF technique can be utilized for access to the anterior column of the thoracic and thoracolumbar spine. The advantages of this minimally invasive technique include avoidance of the need for an access surgeon and for lung deflation during surgery as well as excellent visualization of the spinal pathology.

The Extreme Lateral Interbody Fusion (XLIF): Its Today and Tomorrow

Copyright: © 2014 He Q. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. The extreme lateral interbody fusion (XLIF) was first introduced by Pimenta in 2001 [1] and developed in 2003. It is a minimally invasive, lateral, transpsoas approach for lumbar interbody fusion and is an alternative approach to anterior lumbar interbody fusion (ALIF) [2]. The XLIF approach minimizes anterior approach related complications such as vascular and visceral injury, without the need for an access surgeon [3], furthermore, it bears the several advantages to this approach, including less tissue dissection, smaller incisions, decreased operative time, blood loss, shorter hospital stay, reduced postoperative pain, enhanced fusion rates, and the ability to place instrumentation through the same incision [4].