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Study Design. Case–control. Objectives. The aim of this study was to evaluate fusion rates and compare a stand-alone cage construct with an anterior-plate construct in the setting revision anterior cervical discectomy and fusion (ACDF) for adjacent segment disease. Summary of Background Data. Anterior cervical discectomy and fusion are considered the criterion standard of surgical treatment for cervical myelopathy and radiculopathy. One common consequence is adjacent segment disease. Treatment of adjacent segment disease is complicated by the previous surgical implants, which may make application of an additional anterior cervical plate difficult. Stand-alone cage constructs obviate the need for removal or revision of prior implants in the setting of adjacent segment disease. Methods. All patients undergoing surgery for adjacent segment disease in a 2-year period were identified and separated into groups based on implant construct. A control group of patients undergoing primary, single-level ACDF were selected from during the same 2-year period. Demographic variables, fusion rate, and reoperation rate were compared between groups. Continuous variables were compared using Student t test, fusion, and revision rates were compared using Pearson χ 2 test. Results. Patients undergoing primary ACDF had lower age and American Society of Anesthesia score as well as shorter operative time. Fusion rate was higher for primary ACDF compared to all patients who underwent ACDF for adjacent segment disease (95% vs. 74%). When compared to primary ACDF, patients with a stand-alone cage construct had significantly lower fusion rate (69% vs. 95%) and higher reoperation rate (14% vs. 0%). There were no significant differences in anterior plate construct versus stand-alone cage construct in terms of fusion and reoperation. Conclusion. Symptomatic adjacent segment disease can be managed surgically with either revision anterior plating or a stand-alone cage constructs, although our results raise questions regarding a difference in fusion rates that requires further investigation. Level of Evidence: 3

The incidence of venous thromboembolism (VTE) in peritoneal malignancies can approach 30 to 50 per cent without prophylaxis. Prophylaxis in cytoreductive surgeries (CRS) presents a challenge to preoperative heparin-based therapy because of an increased risk of coagulopathy and potential for bleeding. Herein, we report the large series of CRS and hyperthermic intraperitoneal chemotherapy receiving dextran-40 prophylaxis. Retrospective chart review of peritoneal malignancies patients undergoing CRS at University of Nebraska Medical Center identified 69 individuals who received dextran-40 between 2010 and 2013. The incidences of VTEs, perioperative bleeding, complications, morbidity, and mortality were determined in-hospital and at 90 days. Of the 69 patients treated, the 30-day VTE rate was 8.7 per cent, and no pulmonary embolisms, bleeding, anaphylactoid reaction, or mortality were observed with dextran usage. The specific VTE events included three upper extremity and three lower extremity VTEs. No additional VTE events were identified between 30 and 90 days. In conclusion, dextran-40 prophylaxis was not associated with any perioperative bleeding events, and the observed incidence of VTE was comparable to reported heparin-based prophylaxis in CRS/hyperthermic intraperitoneal chemotherapy patients. This data supports further exploration of dextran-40 as a VTE prophylactic agent in complex surgical oncology cases.

BackgroundVisceral venous aneurysms are exceedingly rare, and until now, there have been no reports of this phenomenon in the adrenal vasculature. This report details the first adrenal venous aneurysm reported in the literature. The aneurysm presented as an 18-cm mass that was initially suspected to be a hematoma or tumor on the basis of the complex medical history of the patient, which included hemophilia A and testicular cancer. After surgical excision, pathologic examination confirmed this mass to be a 15.9-cm adrenal vein aneurysm, the largest aneurysm of any type or location recorded in the medical literature.Case presentationA 58-year-old caucasian male with hemophilia A presented to the emergency room of another institution with abdominal pain, blood in the stool, and a history of diverticulosis and symptomatic hemorrhoids. A large, left-sided adrenal mass was detected by computed tomography, and because of the patient’s hemophilia A and imaging consistent with a hemorrhagic mass, a hematoma was initially suspected. The patient was transferred to our institution, monitored for further bleeding with a stable hospital course, and discharged from the hospital under close monitoring. After 7–8 weeks with no change in the size of the mass, concerns grew regarding increasing symptoms of both satiety and mass effects from the large anomaly, as well as about the patient’s complicated medical history, which also included cancer. Surgical excision was recommended because of the concerns about increasing symptoms and the possibility of a malignancy. Correction and maintenance of factor VIII levels were incorporated pre-, intra-, and postoperatively, and en bloc surgical resection was performed to minimize bleeding and provide oncologic extirpation of the mass. A bowling ball-sized mass was removed, and careful pathologic examination revealed the mass to be a venous adrenal aneurysm. After a brief hospital stay, the patient made a full recovery. Extensive review of the literature revealed 11 reports of adrenal artery aneurysms but no reported case of an adrenal aneurysm arising from the venous system.ConclusionsSeveral case reports suggest a correlation between hemophilia and aneurysms. In patients with inherited clotting disorders such as hemophilia A, aneurysms may present in atypical fashions and should be carefully ruled out.

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