Bypass Group Research Articles

A regional strategy to decrease the time to thrombectomy in patients with low probability of treatment by thrombolysis

Background and purposeThe best transportation strategy for patients with suspected large vessel occlusion (LVO) is unknown. Here, we evaluated a new regional strategy of direct transportation to a Comprehensive Stroke Center (CSC) for patients with suspected LVO and low probability of receiving intravenous thrombolysis (IVT) at the nearest Primary Stroke Center (PSC). MethodsPatients could be directly transported to the CSC (bypass group) if they met our pre-hospital bypass criteria: high LVO probability (i.e., severe hemiplegia) with low IVT probability (contraindications) and/or travel time difference between CSC and PSC<15 minutes. The other patients were transported to the PSC according to a “drip-and-ship” strategy. Treatment time metrics were compared in patients with pre-hospital bypass criteria and confirmed LVO in the bypass and drip-and-ship groups. ResultsIn the bypass group (n=79), 54/79 (68.3%) patients met the bypass criteria and 29 (36.7%) had confirmed LVO. The positive predictive value of the hemiplegia criterion for LVO detection was 0.49. In the drip-and-ship group (n=457), 92/457 (20.1%) patients with confirmed LVO met our bypass criteria. Among the 121 patients with bypass criteria and confirmed LVO, direct routing decreased the time between symptom discovery and groin puncture by 55 minutes compared with the drip-and-ship strategy (325 vs. 229 minutes, P<0.001), without significantly increasing the time to IVT (P=0.19). ConclusionsOur regional strategy led to the correct identification of LVO and a significant decrease of the time to mechanical thrombectomy, without increasing the time to IVT, and could be easily implemented in other territories.

Protective effect of dexmedetomidine on intestinal mucosal barrier function in rats after cardiopulmonary bypass.

Cardiopulmonary bypass can result in damage to the intestines, leading to the occurrence of systemic inflammatory response syndrome. Dexmedetomidine is reported to confer anti-inflammatory properties. Here, the purpose of this study is to investigate the effect of dexmedetomidine on the intestinal mucosa barrier damage in a rat model of cardiopulmonary bypass. It was observed that cardiopulmonary bypass greatly decreased the levels of hemodynamic parameters than SHAM group, whereas dexmedetomidine pretreatment in a cardiopulmonary bypass model rat prevented this reduction. Also, it showed that compared with control animals, cardiopulmonary bypass caused obvious mucosal damage, which was attenuated in dexmedetomidine + cardiopulmonary bypass group. The above findings were in line with that of dexmedetomidine pretreatment, which increased the expression of tight junction proteins, but it decreased the levels of DAO, D-LA, FABP2, and endotoxin. Moreover, the results demonstrated that due to pre-administration of dexmedetomidine, the level of pro-inflammatory factors was decreased, while the level of anti-inflammatory cytokine was increased. Also, it showed that dexmedetomidine suppressed TLR4/JAK2/STAT3 pathway that was activated by cardiopulmonary bypass. Together, these results revealed that dexmedetomidine pretreatment relieves intestinal microcirculation, attenuates intestinal damage, and inhibits the inflammatory response of cardiopulmonary bypass model rats, demonstrating that in CPB-induced damage of intestinal mucosal barrier function, dexmedetomidine pretreatment plays a protective role by inactivating TLR4/JAK2/STAT3-mediated inflammatory pathway.

Revisional Roux-en-Y gastric bypass after failed gastric banding: a case-matched study.

Revisional surgery is technically demanding and is usually associated with higher intraoperative and perioperative risks than primary procedures. The objective of this study is to compare outcomes of patients who had gastric bypass procedures performed as a rescue procedure for failed gastric banding, with those who had a primary gastric bypass. The group of patients undergoing revisional gastric bypass for failed gastric band was matched in a 1:2 ratio with control patients who underwent a primary RYGB, based on gender, score, preoperative body mass index, and comorbidities. Data were retrospectively retrieved. Thirty one (33.3%) patients underwent band removal and gastric bypass (group A) and 62 (66.6%) only primary gastric bypass (group B). Nonsignificant differences were seen in operative time, operative bleeding, or length of stay. Complications were more frequent in group A. Postoperative weight at 12-month follow-up was greater in group A, however, not statistically significant. Changes in weight, both absolute, and percentage were not different between groups. This observation was also true for BMI, in which no significant differences were seen. Overall, mean follow-up was 16 ± 3.2months. Gastric bypass can be performed as revisional bariatric surgery, with low complication rates and acceptable outcomes, though not with the same safety as a primary procedure. Gastric bypass is a satisfactory option for patients with a failed gastric band.

COMPARATIVE STUDY BETWEEN BALLOON ANGIOPLASTY AND BYPASS SURGERY IN LONG SUPERFICIAL FEMORAL ARTERY LESIONS

Background: Critical limb ischemia is the most advanced stage of peripheral arterial occlusive disease. The prognosis is poor, with amputation rates up to 30 % and mortality up to 25% after 1 year. Objective: To compare using of balloon angioplasty versus bypass surgery in management of long superficial femoral artery (SFA) lesions. Patients and methods: A prospective comparative study conducted at the Vascular Surgery Department at Al-Azhar University Hospitals starting from November 2019 to November 2020. The study included (30) patients (15 patients were treated by angioplasty and 15 patients were treated by autogenous femoro popliteal bypass) suffering from long SFA lesions. Results: No statistical difference was found regarding age and sex distribution and associated comorbidities. Technical success rate after endovascular intervention (group A) reached 93.3% compared to 86.7% in femoropopliteal bypass (group B). Procedure duration was 1.1±0.85 compared to 2.8±1.7 in Group B. This was statistically lower in endovascular group (P=0.032). Mean hospital stay was 0.6±0.35 compared to 3.1±2.6 in Group B. This was statistically lower in endovascular group (P=0.013). We achieved a limb salvage rate of 14 (93.3%) in group A and 13 patients (86.7%) for group B and a major amputation rate of 6.7% (1 patients) in group A and 13.3% (2 patients) in group B over 1-year follow-up period. No difference was found between both interventions. Patency rate at 12 months was higher in group B than in group A (66.7% vs. 46.7%). P=0.27. Postoperative improvement of ankle brachial pressure index (ABPI) was statistically non-different (P=0.07, 0.89). Superficial infection, Deep infection and Seroma were all confined to bypass group. Other complications were not statistically different in both groups. There was no significant difference in the mortality rate which was 6.7% and 13.3% in group A and B respectively. Conclusion: Both balloon angioplasty and bypass surgery were safe and effective method for treatment of long SFA lesions. Bypass group showed better patency rates at final follow up.

Level of von Willebrand factor to assess the occurrence and prognosis of acute myocardial infarction.

To observe and compare the differences in von Willebrand factor antigen (vWF:Ag) levels between patients with acute myocardial infarction (AMI) and healthy residents, and to determine whether this measure can be used to evaluate the incidence of AMI and whether or not to undertake cardiac bypass surgery. A retrospective analysis was conducted using the clinical data of 110 patients with acute cardiovascular disease without bypass (no bypass group), 351 patients with AMI and bypass (bypass group), and 60 healthy volunteers (healthy group) who underwent physical examination between July 2018 and May 2019 in Tianjin Chest Hospital. The plasma vWF:Ag was measured and the receiver operating characteristic (ROC) curve was utilized to critically assess its efficacy in determining the occurrence and prognosis of AMI, and the Chi-square test was used to evaluate the correlation between vWF:Ag and clinicopathological factors. The plasma vWF:Ag was 201% (139%, 250%) in the bypass group, 118% (107%, 134%) in the non-bypass group, and 95.5% (85.25%, 102.75%) in the control group, and the differences were statistically significant (P<0.05). The component status of the plasma vWF:Ag used in the bypass group was greater as compared to that of the normal group (P<0.05) and the non-bypass group (P<0.05). The area under the ROC curve of plasma vWF:Ag level was 0.797 (95% CI: 0.749-0.845). When the medical decision level of plasma vWF:Ag was set at 155.5%, the sensitivity and specificity of predicting AMI were 68.9% and 86.7%, respectively. The levels of plasma vWF:Ag in patients with AMI were correlated with hypertension, diabetes, age, and history of cerebral infarction (P<0.05). The plasma vWF level can predict the occurrence of AMI and provides guidance for cardiac bypass surgery.

GASTRO-ESOPHAGEAL REFLUX DISEASE BEFORE AND AFTER BARIATRIC SURGERIES

Background: The relationship between obesity and gastro esophageal reflux disease (GERD) risk has been well established. Many authors suggest performing esophagogastroduodenoscopy (OGD) in all patients before bariatric procedures. On the other hand, many other investigators advocate a selective approach for asymptomatic patients. Laparoscopic Roux-en-Y gastric bypass (LRYGB) is considered by most experts the procedure of choice for the management of GERD in obese patients; however, the effect of LSG on GERD is still unclear. Objective: To identify presences or absences of GERD in patients undergoing different types of bariatric surgery and the effect of this surgery on GERD status post operatively. Patients and Methods: This study included forty successive morbidly obese patients who present to Surgery Department of Al-Azhar University Hospitals seeking for bariatric surgery, during the period from January 2018 to April 2020. Seventeen (42.5%) of the patients were males, while twenty-three (57.5%) were females. Upper endoscopy was performed preoperatively in all cases. Full history, physical examination and special investigations were taking, Patients was classified into laparoscopic sleeve gastrostomy (LSG) group (14 cases), laparoscopic greater curvature gastric plication (LGCGP) group, (3 cases), LRYGB group, (19 cases), and laparoscopic mini gastric bypass (LMGB) group, (4 case). OGD was done preoperatively in all patient and yearly postoperatively for two successive year. Result: In LSG group (14 cases), post-operatively with follow up by OGD, there was five cases (35.7%) have GERD sings and the rest of cases, nine cases (64.3%) have normal esophageal mucosa. In LRYGB group, all patients have normal esophageal mucosa after operation. In LGCGP group, three cases, post-operatively with follow up by OGD, there was one case (33.3%) have GERD signs, and the rest of cases, two cases (66.7%) have normal esophageal mucosa. In LMGB group, two case 50% improved in the 2nd year, one (25%) improved from the 1st year, and one case (25%) has increased GERD symptoms, signs, and biliary reflux. Conclusion: OGD should be done before bariatric procedures routinely or selectively, Laparoscopic Roux-en-Y gastric bypass (LRYGB) was considered the procedure of choice for the management of GERD in obese patients, However LSG still unclear on obese patient with GERD.

Laparoscopic Gastric Plication; Comparative Study between Modified Enteric Bypass and Loop Bipartition

Background: Laparoscopic gastric plication (LGP) is emerging as a safe and effective bariatric procedure. A comparative study between the efficacy and complications of LGP with modified enteric bypass and LGP with loop bipartition, which are still an investigational bariatric procedure. The objective of this study to compare safety and efficacy of LGP with enteric bypass and LGP with loop bipartition in the treatment of morbid obesity in a one-year follow-up study. Methods: A prospective study between February 2016 to December 2017, conducted on 80 morbid obese patients who were candidates for laparoscopic gastric plication, with either loop bipartition or modified enteric bypass surgery were randomly assigned to receive either LGP modified enteric bypass (n = 40) or LGP with loop bipartition (n = 40). Early and late complications, body mass index (BMI), excess weight loss, and obesityrelated co-morbidities were determined at the 1-year follow-up. Results: Operative time and mean length of hospitalization were shorter in the LGP with modified enteric bypass group than LGP with loop bipartition; (110 minutes versus 120 minutes, P<.001, and 2 days versus 3 days; P<.001, respectively). The mean percentage of excess weight loss (%EWL) at 12 months follow-up was (79.5%) in the LGB with modified enteric bypass group and (74.1%) in the LGP group (P = 0.03). Improvement was observed in all co-morbidities in both groups. Conclusion: Both LGP and LGB are effective weight loss procedures. LGP enteric bypass proved to be a simpler and less costly procedure compared with LGP with loop bipartition with a lower risk of stomal ulcer during one year follow up.

Metabolic Effects of Gastrectomy and Duodenal Bypass in Early Gastric Cancer Patients with T2DM: A Prospective Single-Center Cohort Study.

We evaluated the metabolic effects of gastrectomies and endoscopic submucosal dissections (ESDs) in early gastric cancer (EGC) patients with type 2 diabetes mellitus (T2DM). Forty-one EGC patients with T2DM undergoing gastrectomy or ESD were prospectively evaluated. Metabolic parameters in the patients who underwent gastrectomy with and without a duodenal bypass (groups 1 and 2, n = 24 and n = 5, respectively) were compared with those in patients who underwent ESD (control, n = 12). After 1 year, the proportions of improved/equivocal/worsened glycemic control were 62.5%/29.2%/8.3% in group 1, 40.0%/60.0%/0.0% in group 2, and 16.7%/50.0%/33.3% in the controls, respectively (p = 0.046). The multivariable ordered logistic regression analysis results showed that both groups had better 1-year glycemic control. Groups 1 and 2 showed a significant reduction in postprandial glucose (−97.9 and −67.8 mg/dL), body mass index (−2.1 and −2.3 kg/m2), and glycosylated hemoglobin (group 1 only, −0.5% point) (all p < 0.05). Furthermore, improvements in group 1 were more prominent when preoperative leptin levels were high (p for interaction < 0.05). Metabolic improvements in both groups were also observed for insulin resistance, leptin, plasminogen activator inhibitor-1, and resistin. Gastrectomy improved glycemic control and various metabolic parameters in EGC patients with T2DM. Patients with high leptin levels may experience greater metabolic benefits from gastrectomy with duodenal bypass.

Results of Early Proximal Femoral Osteotomy at Skeletal Maturity in Legg-Calvé-Perthes Disease: Implication for the Bypass of Fragmentation Stage.

The aim was to assess the long-term radiographic outcomes of patients with Legg-Calvé-Perthes disease following an early proximal femoral osteotomy (PFO) performed in avascular necrosis stage or early fragmentation stage. In this retrospective study, we analyzed data of 65 patients aged above 6 years at the time of diagnosis with unilateral Legg-Calvé-Perthes disease, following early PFO performed at our institution between 1979 and 2013. We observed the presence of bypassing fragmentation stage, which was classified into complete and incomplete. We compared radiographic outcomes between patients with bypass of fragmentation stage (26 hips) and those without (31 hips). Regarding skeletal maturity, the hips were graded according to the femoral head shapes: spherical, ovoid, or flat. The mean age at diagnosis was 7.9 years (range: 6.0 to 11.9 y). The average follow-up period was 11.8 years (range: 5.9 to 22.9 y). Fragmentation bypass occurred in 40.5% (26/65) of patients, with 8 (12.3%) "undetermined" cases. Patients who completely or partially bypassed fragmentation experienced significantly less severe lateral pillar collapse (P=0.016). The femoral head was also significantly more spherical in patients with bypass (P=0.024). Our results show that 40.5% of patients who underwent early PFO bypassed the fragmentation stage. The degree of lateral pillar collapse was lower in patients with bypass. In addition, there were significantly more patients with more spherical femoral head in the bypass group. Level IV-case series.

The role of bilio-pancreatic limb in nonalcoholic steatohepatitis improvement after duodenal–jejunal bypass in rats

BackgroundNonalcoholic fatty liver disease, which is highly associated with obesity, includes nonalcoholic steatohepatitis. Lipopolysaccharides from the intestine would induce inflammation in the liver in nonalcoholic fatty liver disease. This study aimed to examine the role of the bilio-pancreatic limb in the effect of duodenal–jejunal bypass on nonalcoholic steatohepatitis, with respect to the gut–liver axis, using a rat model. MethodsNonalcoholic steatohepatitis model rats were randomly assigned into 3 groups as follows: 1 sham group and 2 duodenal–jejunal bypass groups. The 2 duodenal–jejunal bypass groups were defined according to the bilio-pancreatic limb length: 30 cm (30-DJB group) and 0 cm (0-DJB group). Pathology findings and blood biochemistry, inflammatory cytokine and lipopolysaccharides receptor mRNA in the liver and common channel, and lipopolysaccharide-binding protein level in the portal vein were assessed. ResultsThe reduction in plasma alanine aminotransferase and nonalcoholic fatty liver disease activity score in the 30-DJB group was not observed in the 0-DJB group, similar to the sham group. In the liver tissue, mRNA of inflammatory cytokines and lipopolysaccharide receptors, the area occupied by CD68-positive macrophages, and the number of CD3-positive T-lymphocytes on immunostaining were lower in the 30-DJB group; however, these findings were not observed in the 0-DJB group, and lipopolysaccharide-binding protein levels in the portal vein and mRNA expressions of inflammation-related genes in the common channel showed similar tendencies. ConclusionThe bilio-pancreatic limb plays an important role in the beneficial effect of duodenal–jejunal bypass for nonalcoholic steatohepatitis. The bilio-pancreatic limb may suppress lipopolysaccharides-related cascades in the liver by reducing intestinal inflammation.

Postoperative neovascularization, cerebral hemodynamics, and clinical prognosis between combined and indirect bypass revascularization procedures in hemorrhagic moyamoya disease

ObjectiveWe evaluated what few studies emphasized the postoperative collateral formation and cerebral hemodynamics of hemorrhagic moyamoya disease (MMD). MethodsHemorrhagic MMD patients treated surgically were retrospectively collected and dichotomized into combined bypass (CB) and indirect bypass (IB) groups. CB used superficial temporal artery-to-middle cerebral artery anastomosis combined with encephaloduroarteriomyosynangiosis (STA-MCA+EDAMS), and IB used encephaloduroarteriomyosynangiosis (EDAMS) for revascularization. Postoperative complications and clinical prognosis, as well as pre- and post-operative Modified Rankin Scale (mRS), collateral circulation status, and cerebral hemodynamics were observed and compared between the CB and IB groups. ResultsA total of 37 patients with hemorrhagic MMD were identified. Of the 68 cerebral hemispheres, 47(69.1%) were combined revascularization, and the rest were indirect. During an average follow-up of 16.5 ± 8.7 months, the recurrent stroke events were significantly lower, as well as having a postoperative mRS scores≤ 2. A satisfactory postoperative collateral formation, and an improved dilation or extension of the anterior choroidal/posterior communication artery (AchA/PcoA) were significantly higher in the CB group than in the IB group (all P < .05). Compared with preoperative cerebral hemodynamics, relative cerebral blood flow (rCBF), relative cerebral blood volume (rCBV), mean transit time (MTT), and relative time to peak (rTTP) in the CB group; rCBF, rCBV, and MTT in the IB group were significantly improved (all P < .001). The CB group’s postoperative rCBF was significantly improved compared with the IB group (P < .001). ConclusionsSTA-MCA bypass combined with EDAMS can obtain better postoperative collateral formation, cerebral hemodynamics, and clinical prognosis than EDAMS alone.

Direct vs Indirect Revascularization in a North American Cohort of Moyamoya Disease.

In adults with ischemic moyamoya disease (MMD), the efficacy of direct vs indirect revascularization procedures remains a matter of debate. To investigate the outcomes of ischemic MMD in a North American cohort treated by direct and indirect revascularizations. We retrospectively reviewed medical records of adult patients with MMD with ischemic presentation from 1984 to 2018 at the Brigham and Women's Hospital and Massachusetts General Hospital who underwent either direct or indirect bypasses. Early postoperative events and outcome at more than 6 mo postoperatively were evaluated using multivariable logistic regression analyses. Multivariable Cox proportional hazards regression analyses were used to evaluate delayed ischemic and hemorrhagic events. Analyses were performed per hemisphere. A total of 95 patients with MMD and 127 hemispheres were included in this study. A total of 3.5% and 8.6% of patients had early surgical complications in the direct and indirect bypass cohorts, respectively (P=.24). Hemispheres with direct bypasses had fewer long-term ischemic and hemorrhagic events at latest follow-up (adjusted hazard ratio [HR] 0.19, 95% confidence interval [CI] 0.058-0.63, P=.007; median follow-up 4.5 [interquartile range, IQR 1-8] yr). There was no difference between the direct and indirect bypass groups when the endpoint was limited to infarction and hemorrhage only (P=.12). There was no difference in outcome (modified Rankin Scale [mRS]≥3) between the 2 cohorts (P=.92). There was no difference in early postoperative events, long-term infarction or hemorrhage, or clinical outcome between direct and indirect revascularization. However, there was a significant decrease in all ischemic and hemorrhagic events combined in direct revascularizations compared to indirect revascularizations.

Biliopancreatic Limb Length of Small Intestinal Bypass in Non-obese Goto-Kakizaki (GK) Rats Correlates with Gastrointestinal Hormones, Adipokines, and Improvement in Type 2 Diabetes.

The purpose of this study was to explore the effects on type 2 diabetes, gastrointestinal hormones, and adipokines after the small intestinal bypass of different biliopancreatic limb (BPL) lengths in non-obese type 2 diabetic rats. Small intestinal bypass with the BPL length at 10cm, 20cm, 30cm, and 40cm, respectively, and sham surgery were performed in non-obese GK rats. Fasting serum was collected at 2 days preoperatively and 1, 3, 6, and 9 weeks postoperatively. Body weight and fasting blood glucose (FBG) were measured during the experiment. Glycated hemoglobin (GHb), fasting insulin (FINS), C-peptide, ghrelin, leptin, adiponectin, and somatostatin were measured postoperatively. Rats with a bypassed length of 40cm died within 5-9 weeks. No statistically significant was observed in body weight between the sham group and the bypass groups at the 9th week postoperatively. FBG, GHb, FINS, C-peptide, and HOMA-IR in the bypass groups were lower than those in the sham group postoperatively and were negatively correlated with BPL length. Ghrelin and leptin declined compared with preoperative but were not associated with BPL length. Adiponectin of the bypass groups increased after operation and was positively correlated with BPL length. Somatostatin remained stable among groups during the experiment. Ghrelin and leptin of non-obese GK rats decreased postoperatively without a linear relationship with the BPL length, while adiponectin increased with positively correlation with the BPL length. In addition, somatostatin remained steady after small intestinal bypass. Further studies are expected to confirm the effect of the BPL length of small intestinal bypass on gastrointestinal hormones and adipokines.

Non–open-heart surgery for intravascular leiomyomatosis extending from the inferior vena cava to the right heart chamber

ObjectiveIn the present study, we analyzed the advantages and feasibility of non–open-heart surgery without cardiopulmonary bypass for intracardiac intravenous leiomyomatosis. MethodsWe retrospectively reviewed 23 cases of intracardiac intravenous leiomyomatosis and divided them into a noncardiopulmonary bypass (NCPB) group (9 cases) and a cardiopulmonary bypass (CPB) group (14 cases) according to the surgical treatment received. The clinical characteristics and anatomic features, including the diameter of the tumor, right atrium, and inferior vena cava, were recorded, and the perioperative data, including the operation time, blood loss, postoperative hemoglobin change, and follow-up results, were analyzed and compared between the two groups. ResultsThe NCPB group had required a shorter operation time (321.9 ± 104.2 minutes vs 526.3 ± 95.6 minutes; P < .001) and had experienced less blood loss (456.3 ± 249.9 mL vs 815.4 ± 435.6 mL; P = .048) compared with the CPB group. The NCPB group had a small maximum cross-sectional area of the tumor inside the right atrium (475.5 ± 509.6 mm2), a low proportion of the maximum cross-sectional area of the entrance of the right atrium (average, 26.1%), no tricuspid valve or atrial wall involvement, and high mobility inside the inferior vena cava and heart chamber. All 23 patients had recovered well postoperatively, and no recurrence had developed during 24 months of follow-up. ConclusionsFor intravenous leiomyomatosis with a smaller cross-sectional area in the right atrium that can be mobilized, surgery without CBP is feasible and should be considered.

Efficacy and Safety of Emergency Extracranial–Intracranial Bypass for Revascularization within 24 Hours in Resolving Large Artery Occlusion with Intracranial Stenosis

Endovascular treatment (EVT) is less effective for intracranial atherosclerosis-induced emergent large vessel occlusion. Extracranial-intracranial (EC-IC) bypass surgery is a possible treatment option to augment cerebral blood flow in the perfusion defect area. We compared the efficacy and safety of EC-IC bypass surgery with those of EVT and maximal medical treatment for acute ischemic stroke. The data from 39 patients, for whom vessel revascularization had failed despite mechanical thrombectomy, were retrospectively analyzed. Of the 39 patients, 22 had undergone percutaneous transluminal angioplasty or intracranial stenting (PTA/S), 10 had undergone emergency EC-IC bypass surgery within 24 hours of symptom onset, and 7 had received maximal medical treatment (MMT) only. The patency, perfusion status, and postoperative infarct volume were evaluated. The clinical outcomes were assessed at 6 months postoperatively using the modified Rankin scale. The mean reperfusion time was significantly longer for the EC-IC bypass group (14.9 hours) compared with that in the PTA/S group (4.1 hours) and MMT group (7.5 hours; P < 0.05). The postoperative infarct volume on diffusion-weighted magnetic resonance imaging was significantly lower in the emergency EC-IC bypass group (11.3 cm3) than in the MMT group (68.0 cm3) but was not significantly different from that of the PTA/S group (14.0 cm3; P < 0.05). The proportion of patients with a modified Rankin scale score of 0-2 at 6 months after surgery was significantly higher in the EC-IC bypass group (80%) than in the PTA/S (59%) and MMT (14%) groups (P < 0.05). Emergency EC-IC bypass surgery is an effective and safe treatment option for intracranial atherosclerosis-induced acute ischemic stroke for which EVT is inadequate.

Spinal Cord Protection of Aorto-Iliac Bypass in Open Repair of Extent II and III Thoracoabdominal Aortic Aneurysm

Spinal cord injury (SCI) is one of the serious complications of thoracoabdominal aortic aneurysm (TAAA) repair. Cardiopulmonary bypass (CPB) and left heart bypass (LHB) are well-established extracorporeal circulatory assistance methods to increase distal aortic perfusion and prevent spinal cord ischaemia in TAAA repair. Aorto-iliac bypass, a new surgical adjunct offering distal aortic perfusion without the need of complex perfusion skills, was developed as a substitute for CPB and LHB. However, its spinal cord protective effect is unknown. The perioperative data of 183 patients who had elective open Crawford extent II and III TAAA repair at our aortic centre from July 2011 to May 2019 were retrospectively analysed. Spinal cord protection was compared between the aorto-iliac bypass group (n=106) and the extracorporeal circulatory assistance group (n=77 [65 CPB, 12 LHB]), and the risk factors for SCI in these patients were explored. Eleven (11) patients had postoperative SCI: five (6.5%) in the extracorporeal circulatory assistance group (four with CPB and one with LHB), and six (5.7%) in the aorto-iliac bypass group. The incidence of SCI was 6.0% (11/183 cases). There was no difference between the aorto-iliac bypass group and the extracorporeal circulatory assistance group (p=1.0), while operation time, proximal aortic clamp time, intercostal artery clamp time, and length of intensive care unit stay were all increased in the latter group. Multivariate logistic regression analysis showed that cerebrospinal fluid pressure (odds ratio [OR] 1.270; 95% confidence interval [CI] 1.092-1.478 [p=0.002]) and lowest haemoglobin on the first postoperative day (OR 0.610; 95% CI 0.416-0.895 [p=0.011]) were the independent predictors of SCI in TAAA repair. Spinal cord protection of aorto-iliac bypass is comparable to that of CPB and LHB in open TAAA repair.

Long-term risk of anaemia after bariatric surgery: results from the Swedish Obese Subjects study

Nutritional deficiencies, such as iron and vitamin B12 deficiencies, are potential adverse consequences of bariatric surgery. Long-term data on anaemia after bariatric surgery are largely lacking. We aimed to investigate the risk of anaemia, iron and vitamin B12 deficiency anaemia, and vitamin B12 deficiency over 20 years in individuals who had bariatric surgery or received usual obesity care. The prospective, controlled Swedish Obese Subjects study recruited people with obesity via recruitment campaigns in the mass media and at primary health-care centres, and was done at 480 primary health-care centres and in 25 surgical departments in Sweden. Eligible participants were aged 37-60 years and had a BMI of either 34 kg/m2 or more (for men) or 38 kg/m2 or more (for women). Participants were excluded if they had undergone previous bariatric surgery or had contraindicating conditions. Two main groups were formed: those who chose bariatric surgery, the type of which was determined by the operating surgeon, and a contemporaneously matched control group, created by use of 18 matching variables, who received usual non-surgical obesity care that ranged from lifestyle advice to no treatment. Haemoglobin concentration was measured during examination visits at baseline and at 1 year, 2 years, 3 years, 4 years, 6 years, 8 years, 10 years, 15 years, and 20 years of follow-up. Anaemia was defined as a haemoglobin concentration of less than 120 g/L for women and 130 g/L for men. The primary, non-specified outcome was the incidence of anaemia, and was assessed in the as-treated population, which comprised only patients who received the actual treatment. The associations between treatment type and anaemia are expressed as unadjusted hazard ratios (HRs) and HRs adjusted for age, sex, BMI, menopausal status, education, diabetes, and hypertension, with 95% CIs. This study is registered in ClinicalTrials.gov, NCT01479452, and is closed to new participants, with follow-up ongoing. Between Sept 1, 1987, and Jan 31, 2001, 6905 individuals were assessed for eligibility, of whom 5335 were eligible. Of these, we included 2007 patients who chose bariatric surgery (266 in the gastric bypass group, 1365 in the vertical-banded gastroplasty group, and 376 in the gastric banding group) and 2040 matched controls who received usual obesity care. During a maximum of 20 years and a median of 10 years (IQR 3-20) of follow-up, there were 133 anaemia events in the gastric bypass group, 359 in the vertical-banded gastroplasty group, 101 in the gastric banding group, and 261 in the control group. Compared with the control group (13 cases per 1000 person-years, 95% CI 11-14), the incidence of anaemia was higher in the gastric bypass group (64 cases per 1000 person-years, 53-74; HR 5·05, 95% CI 3·94-6·48; p<0·0001), the vertical-banded gastroplasty group (23 cases per 1000 person-years, 21-26; 2·67, 2·25-3·18; p<0·0001), and the gastric banding group (26 per 1000 person-years, 21-31; 2·76, 2·15-3·52; p<0·0001). These associations remained after adjustment. Our findings highlight the increased risk of anaemia after bariatric surgery and the importance of long-term compliance to nutritional supplementation and monitoring to enable prevention and early detection of serious nutritional deficiencies after bariatric surgery. Swedish Research Council, the Swedish state under the agreement between the Swedish Government and the county councils, the Swedish Diabetes Foundation, the Swedish Heart-Lung Foundation, and the Novo Nordisk Foundation.

Comparison of Treatment Modalities in Postirradiation Carotid Blowout Syndrome: A Multicenter Retrospective Review

Carotid blowout syndrome (CBS) is not uncommon in our locality, where head and neck cancers, especially nasopharyngeal carcinoma, are prevalent. Traditionally, CBS has resulted in high morbidity and mortality. The treatment paradigm has evolved from open surgery to endovascular interventions, and each treatment modality has its merits and drawbacks. In the present study, we investigated the outcomes of different treatment modalities for postirradiation CBS. We performed a 10-year multicenter retrospective review of the outcomes after endovascular trapping, flow diverters, and bypass surgery from 2009 to2019. A total of 53 patients with 60 blowouts were included in the present study. Of the 60 blowout cases, 25 were in the flow diverter group, 27 in the endovascular trapping group, and 8 in the bypass group. The mean survival was 32.2 months, with patient age affecting overall survival (P= 0.002). The stroke rate affected the 3- and 6-month functional outcomes (odds ratio, 7.388 and 6.353; P= 0.008 and P= 0.014, respectively). Of the 24 cases in the flow diverter group, 96% had achieved immediate hemostasis, with a rebleeding rate of 20% (P= 0.009). No rebleeding had occurred with endovascular trapping or bypass. The stroke rate in the endovascular trapping, flow diverter, and bypass groups was 25.9%, 20%, and 12.5%, respectively (P= 0.696). Our results have shown that endovascular trapping is the first-line treatment of CBS. For patients with contraindications to endovascular trapping, the flow diverter is an alternative. For patients who have undergone flow diversion alone, definitive treatment such as bypass surgery might be indicated for selected patients to minimize the risk of rebleeding. After endovascular trapping, surgical bypass might be considered for selected patients with a higher risk of stroke.

The effect of using the minimized cardio-pulmonary bypass Systems for Coronary Artery Bypass Grafting in diabetic patients

IntroductionMultiple studies have shown a decrease in the inflammatory response with minimized bypass circuits leading to less complications and mortality rate. On the other hand, some other studies showed that there is no difference in post-operative outcomes. So, the aim of this study is to investigate the clinical benefits of using the Minimized cardiopulmonary Bypass system in Coronary Artery Bypass Grafting and its effect on postoperative morbidity and mortality in diabetic patients as one of the high-risk groups that may benefit from these systems.MethodsThis is a retrospective study that included 114 diabetic patients who underwent Coronary artery bypass grafting (67 patients with conventional cardiopulmonary bypass system and 47 with Minimized cardiopulmonary bypass system). The patients’ demographics, intra-operative characteristics and postoperative complications were compared between the two groups.ResultsCoronary artery bypass grafting was done on a beating heart less commonly in the conventional cardiopulmonary bypass group (44.78% vs. 63.83%, p = 0.045). There was no difference between the two groups in blood loss or transfusion requirements. Four patients in the conventional cardiopulmonary bypass group suffered perioperative myocardial infarction while no one had perioperative myocardial infarction in the Minimized cardiopulmonary bypass group. On the other hand, less patients in the conventional group had postoperative Atrial Fibrillation (4.55% vs. 27.5%, p = 0.001). The requirements for Adrenaline and Nor-Adrenaline infusions were more common the conventional group than the Minimized group.ConclusionThe use of conventional cardiopulmonary bypass for Coronary Artery Bypass Grafting in diabetic patients was associated with higher use of postoperative vasogenic and inotropic support. However, that did not translate into higher complications rate or mortality.

Outcomes of bypass and endovascular interventions for advanced femoropopliteal disease in patients with premature peripheral artery disease

ObjectivePatients with premature peripheral artery disease (PAD), defined as age ≤50 years at presentation, have had poor outcomes with open and endovascular lower extremity revascularization. It is unclear whether either strategy is associated with better outcomes because comparative studies have been limited to case series in this patient population. The aim of the present study was to compare the outcomes of patients with premature PAD who had undergone bypass or endovascular revascularization for advanced femoropopliteal disease. Our hypothesis was that open bypass would provide superior long-term outcomes compared with endovascular intervention for patients with premature advanced femoropopliteal PAD. MethodsAll the patients with premature PAD who had undergone isolated femoropopliteal lower extremity revascularization and included in the Vascular Quality Initiative infrainguinal bypass and peripheral vascular intervention files were reviewed from 2003 through 2019. Propensity score matching (1:1) was performed between patients who had undergone femoropopliteal bypass and endovascular interventions for isolated femoropopliteal Trans-Atlantic Classification System C or D lesions. The 1-year outcomes, including reintervention, patency, major amputation, and mortality, were analyzed. ResultsOf the 2538 included patients, 902 had undergone isolated femoropopliteal endovascular intervention and 1636 had undergone femoropopliteal bypass. The endovascular intervention group were more likely to have diabetes (68.9% vs 54.0%; P < .001), coronary artery disease (31.0% vs 23.0%; P < .001), renal failure requiring dialysis (14.2% vs 7.2%; P < .001), and claudication (45.1% vs 36.6%; P < .001) compared with the bypass group. After propensity score matching, 466 patients were in each group with no significant differences in the baseline characteristics. Perioperative morbidity was higher with femoropopliteal bypass compared with endovascular intervention (12.0% vs 7.9%; P = .038); however, the rates of major amputation and mortality were not different. At 1 year, patients who had undergone femoropopliteal bypass were less likely to require reintervention (17.0% vs 25.2%; P = .012). However, no differences were found in major amputation (7.7% vs 7.9%; P = .928) or mortality (5.2% vs 5.2%; P = 1.00). Propensity score matching was also performed between femoropopliteal bypass with the great saphenous vein and isolated femoropopliteal endovascular interventions, and the outcomes were similar. ConclusionsFor patients with premature PAD and advanced femoropopliteal disease, bypass surgery decreased the reintervention rate at 1 year but was associated with increased perioperative morbidity and hospital length of stay compared with endovascular therapy. No differences were found in major amputation or mortality between the two strategies.