Portal vein thrombosis:Prevalence,patient characteristics and lifetime risk:A population study based on 23796 consecutive autopsies

AIM： TO assess the lifetime cumulative incidence of portal venous thrombosis （PVT） in the general population. METHODS： Between 1970 and 1982, 23 796 autopsies, representing 84% of all in-hospital deaths in the Malmo city population, were performed, using a standardised protocol including examination of the portal vein. PVT patients were characterised and the PVT prevalence at autopsy, an expression of life-time cumulative incidence, assessed in high-risk disease categories and expressed in terms of odds ratios and 95% CI. RESULTS： The population prevalence of PVT was 1.0%. Of the 254 patients with PVT 28% had cirrhosis, 23% primary and 44% secondary hepatobiliary malignancy, 10% major abdominal infectious or inflammatory disease and 3% had a myeloproliferative disorder. Patients with both cirrhosis and hepatic carcinoma had the highest PVT risk, OR 17.1 （95% CI 11.1-26.4）. In 14% no cause was found; only a minority of them had developed portal-hypertension-related complications. CONCLUSION： In this population-based study, PVT was found to be more common than indicated by previous clinical series. The markedly excess risk in cirrhosis and hepatic carcinoma should warrant an increased awareness in these patients for whom prospective studies of directed intervention might be considered.

Surgical management of peritonitis secondary to acute superior mesenteric artery occlusion

Diagnosis of acute arterial mesenteric ischemia in the early stages is now possible using modern computed tomography with intravenous contrast enhancement and imaging in the arterial and/or portal phase.Most patients have acute superior mesenteric artery(SMA)occlusion,and a large proportion of these patients will develop peritonitis prior to mesenteric revascularization,and explorative laparotomy will therefore be necessary to evaluate the extent and severity of intestinal ischemia,and to perform bowel resections.The establishment of a hybrid operating room in vascular units in hospitals is most important to be able to perform successful intestinal revascularization.This review outlines current frontline surgical strategies to improve survival and minimize bowel morbidity in patients with peritonitis secondary to acute SMA occlusion.Explorative laparotomy needs to be performed first.Curative treatment is based upon intestinal revascularization followed by bowel resection.If no vascular imaging has been carried out,SMA angiography is performed.In case of embolic occlusion of the SMA,open embolectomy is performed followed by angiography.In case of thrombotic occlusion,the occlusive lesion can be recanalized retrograde from an exposed SMA,the guidewire snared from either the femoral or brachial artery,and stented with standard devices from these access sites.Bowel resections and sometimes gall bladder removal due to transmural infarctions are performed at initial laparotomy,leaving definitive bowel reconstructions to a planned second look laparotomy,according to the principles of damage control surgery.Patients with peritonitis secondary to acute SMA occlusion should be managed by both the general and vascular surgeon,and a hybrid revascularization approach is of utmost importance to improve outcomes.

Incisional Negative Pressure Wound Therapy in the Prevention of Surgical Site Infection after Vascular Surgery with Inguinal Incisions: Rationale and Design of a Randomized Controlled Trial (INVIPS-Trial)

Background/Aims: Inguinal incisions are a common route of access in vascular surgery. Due to anatomical challenges and a diverse bacterial flora in this area, surgical site infections (SSI) represent a common, debilitating and sometimes life-threatening complication. The INVIPS-Trial evaluates the role of Negative Pressure Wound Therapy (NPWT) on closed inguinal incisions in elective vascular surgery to prevent SSI and other wound complications. Methods: This randomized controlled trial (RCT) registered at ClinicalTrials.gov (Identifier: NCT01913132) compares the effects of a NPWT dressing (PICO, Smith & Nephew, UK) and the center’s standard wound dressing (Vitri Pad, ViTri Medical, Sweden) on postoperative wound complications, especially SSI. The study includes two distinct vascular procedures with different SSI risk profiles: endovascular aortic repair (EVAR) and open surgical approaches involving the common femoral artery (OPEN). Results: Four hundred ninety-five groin incisions in both treatment arms are anticipated to be included in the EVAR group and 147 inguinal incisions in both treatment arms in the OPEN group. Since a large percentage of inguinal vascular procedures in both groups but especially in the EVAR group are performed bilaterally, many patients can serve as their own control by randomly receiving NPWT on one and the standard dressing on the contralateral inguinal incision. Conclusions: This ongoing RCT attempts to elucidate the potential benefit of NPWT on closed inguinal incisions after different vascular procedures. Outcome and conclusions of this trial could have implications on postoperative wound care of patients in both vascular surgery and other surgical specialties.

Preoperative echocardiographic predictors for 1-year mortality in patients treated with standard endovascular aneurysm repair for abdominal aortic aneurysm

Background: Abdominal aortic aneurysm (AAA) and cardiovascular disease are intimately associated, the latter representing the most common cause of death in Sweden. Cardiac complications are held responsible for the majority of perioperative morbidity and mortality in patients undergoing repair of AAA. The importance of preoperative thorough cardiac assessment is therefore obvious. The aim of this study was to evaluate the prognostic significance of preoperative echocardiographic findings for 1-year mortality after elective endovascular aneurysm repair (EVAR) of infrarenal AAA. Design: Retrospective analysis. Methods: The 505 patients were identified in a prospective database for endovascular interventions between 1998 and 2011, and data were retrieved from patient records. Preoperative echocardiography reports in 380 patients were reviewed and findings were notified according to a predefined protocol. Results: The 1-year mortality rate was 6.7%. Severe valve disease was present in 8.7% of the patients, aortic valve stenosis being the leading cause of valve pathology. Severe valve disease (OR 3.5, 95% CI [1.2 - 10.7];p = 0.025) and chronic kidney disease grade ≥ 3 (OR 7.5, 95% CI [2.1 - 26.1];p = 0.002) were the only independent risk factors for increased mortality rate at 1-year. Conclusion: Echocardiography should be a part of the preoperative workup in AAA patients. Finding of severe valve disease should be further evaluated by a cardiologist prior to EVAR.