Background Anastomotic leak (AL) is a major source of morbidity in colorectal surgery and has become an area of interest in performance metrics. It is unclear whether AL is associated primarily with surgeons’ technical performance or explained better by patient characteristics and institutional factors. We sought to establish if AL could serve as a valid quality metric in colorectal surgery by evaluating provider variation after adjusting for patient factors. Methods We performed a retrospective cohort study of colorectal resection patients in the Michigan Surgical Quality Collaborative. Clinically relevant patient and operative factors were tested for association with AL. Hierarchical logistic regression was used to derive risk-adjusted rates of AL. Results Of 9,192 colorectal resections, 244 (2.7%) had a documented AL. The incidence of AL was 3.0% for patients with pelvic anastomoses and 2.5% for those with intra-abdominal anastomoses. Multivariable analysis showed that a greater operative duration, male sex, body mass index > 30 kg/m2, tobacco use, chronic immunosuppressive medications, thrombocytosis (platelet count > 400×109/L), and urgent/emergent surgery were independently associated with AL (C-statistic = 0.75). After accounting for patient and procedural risk factors, there were five hospitals with a significantly greater incidence of postoperative AL. Conclusions This population-based study shows that risk factors for AL include male sex, obesity, tobacco use, immunosuppression, thrombocytosis, greater operative duration, and urgent/emergent surgery; models including these factors predict most of the variation in AL rates. This study suggests that AL can serve as a valid metric that can identify opportunities for quality improvement.

Surgeons valued palliative and end-of-life care but reported multilevel barriers to its provision. These data will inform strategies to reduce these perceived barriers.

Introduction Despite significant advances in vascular biology, bioengineering and pharmacology, restenosis remains a limitation to the overall efficacy of vascular reconstructions, both percutaneous and open. Although the pathophysiology of intimal hyperplasia is complex, a number of drugs and/or molecular tools have been identified that can prevent restenosis. Moreover, the focal nature of this process lends itself to treatment with local drug administration. In this article we provide a broad overview of current and future techniques for local drug delivery that have been developed to prevent restenosis following vascular intervention. Methods A systematic electronic literature search using PubMed was performed for all accessible published articles through September 2012. In an effort to remain current, additional searches were performed for abstracts presented at relevant societal meetings, filed patents, clinical trials and funded NIH awards. Results The efficacy of local drug delivery has been demonstrated in the coronary circulation with the current clinical use of drug-eluting stents (DES). Until recently, however, DES were not found to be efficacious in the peripheral circulation. Further pursuit of intraluminal devices has led to the development of balloon-based technologies with a recent surge in trials involving drug-eluting balloons. Early data appears encouraging, particularly for treatment of lesions in the superficial femoral artery, with several devices having recently received the CE mark in Europe. Investigators have also explored periadventitial application of biomaterials containing anti-restenotic drugs, an approach that could be particularly useful for surgical bypass or endarterectomy. In the past systemic drug delivery has been unsuccessful, however, there has been recent exploration of intravenous delivery of drugs designed specifically to target injured or reconstructed arteries. Our review revealed a multitude of additional interesting strategies including more than 65 new patents issued over the past two years for approaches to local drug delivery focused on preventing restenosis. Conclusion Restenosis following intraluminal or open vascular reconstruction remains an important clinical problem. Success in the coronary circulation has not translated into solutions for the peripheral arteries. However, our review of the literature reveals a number of promising approaches including drug-eluting balloons, periadventitial drug delivery as well as targeted systemic therapies. These innovations as well as others suggest that the future is bright and a solution for preventing restenosis in peripheral vessels will soon be at hand.

Although phlegmasia cerulea dolens, May-Thurner syndrome, and nutcracker syndrome are rare entities, knowledge of these syndromes associated with the deep veins is essential. This study presents current management of these disorders, including diagnostic and interventional strategies. Endovascular techniques have evolved and now play a significant role in the treatment of both phlegmasia cerulea dolens and May-Thurner syndrome. However, endovascular therapy for nutcracker syndrome remains untested.

Despite novel surgical therapies for the treatment of atherosclerosis, restenosis continues to be a significant impediment to the long-term success of vascular interventions. Transforming growth factor-beta (TGF-β), a family of cytokines found to be up-regulated at sites of arterial injury, has long been implicated in restenosis; a role that has largely been attributed to TGF-β-mediated vascular fibrosis. However, emerging data indicate that the role of TGF-β in intimal thickening and arterial remodeling, the critical components of restenosis, is complex and multidirectional. Recent advancements have clarified the basic signaling pathway of TGF-β, making evident the need to redefine the precise role of this family of cytokines and its primary signaling pathway, Smad, in restenosis. Unraveling TGF-β signaling in intimal thickening and arterial remodeling will pave the way for a clearer understanding of restenosis and the development of innovative pharmacological therapies.