Month: July 2015

Categories
imaging Lymphatic training

Mind the Lymphatics: managing a persistent postoperative seroma

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The patient was referred from an outside institution for the development of a large tender mass in her below knee incision after a femoropopliteal bypass done with PTFE for ischemia after a aorto-bifemoral bypass. The patient reported swelling that grew in the months after the operation to the point that she was unable to walk without pain. On examination, she had a Nerf football sized swelling in her previous below knee incision without erythema. It was quite tender. CTA showed a patent aorto-bifemoral bypass and a femoropopliteal bypass to the below knee popliteal artery. Incidentally noted was the absence or occlusion of the profunda femoral artery. There was bland lymphedema below the knee.

Differential diagnosis included:

  1. Graft Infection
  2. Seroma from PTFE ultrafiltration leak
  3. Seroma from lymph leak.

Graft infections can present like this, but also drive local and systemic inflammation and in the absence of fevers and white counts, was highly unlikely. Occasionally, indolent infections with S. epidermidis will present with fluid collections but typically this is a late presentation. Ultrafiltration leaks from PTFE are fairly rare in my practice but can occur randomly. Most PTFE grafts nowadays come with an external wrap that acts as a seal against microporosity, but on occasion, I have seen protein rich fluid accumulated around PTFE grafts. This typically is not high pressure and accumulates along significant or whole length of graft. I used to treat that with graft excision and replacement, but I have had success with relining the graft with PTFE based stent grafts and externally draining the seroma.

I suspected this to be a seroma from lymphatic leak. The lymphatics are an unusual system of vessels in that they are remnants of an earlier circulatory system that was designed to move and mix nutrients and primitive phagocytic immune cells throughout the external compartment of an organism. They are diaphanous vessels that have smooth muscles that periodically contract like cardiac muscle, propelling fluid and cellular components past valves. Typically, cautery, suturing, and the inflammation of wound healing are sufficient to close lymphatics, but when there is potential space and a large lymphatic trunk that has been divided within it, that space will be filled with fluid, particularly with edema fluid that accumulates post surgically with dependency.

This patient was treated with I&D, but the lymphatic was identified by injection with Isosulfan blue in the subcutaneous space of the foot (between the toes). The dye is avidly taken up by the lymphatics and it can be used to identify the leak, allowing for extirpation and closure.

Isosulfan blue is injected into the subcutaneous spaces between the toes.
Isosulfan blue is injected into the subcutaneous spaces between the toes.

The vital dye will be cleared by the kidney -the pee will be greenish blue for a day or two. This is contraindicated in patients with known sulfa allergies.

The dye is seen in the wound within minutes without any added measures -no pumping or massaging was required. The patient had begun spontaneously draining the night before her operation.
The dye is seen in the wound within minutes without any added measures -no pumping or massaging was required. The patient had begun spontaneously draining the night before her operation.

The dye concentrates in the lymphatics which are easily identified.

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The lymphatics were ablated and a VAC dressing was applied. Two weeks later, there has been significant healing with complete resolution of the seroma.

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Loss of lymphatics at this level does not cause permanent injury but clearance of edema is slowed. Clearly, the avoidance of lymph leaks is the first step in preventing seromata, but when they occur, it is simple enough to identify and treat them using this technique.

They are one way self circulating pipes and therefore treating the afferent termini is all that is necessary.
They are one way self circulating pipes and therefore treating the afferent termini is all that is necessary.
Categories
AAA EVAR techniques

The Last Vein

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The deep femoral vein offers an important source of autologous conduit, particularly for aortic reconstruction or for limb salvage. It may be mobilized on one day and harvested another in a staged fashion to avoid a prolonged operation. While there is a period of leg edema postoperatively, most tolerate harvest of this vein which may be life saving.

Categories
peripheral aneurysm techniques

Open repair is preferred for younger patients

  
The patient had an isolated 3.0cm common iliac artery aneurysm. Patient is in his fifties and wants to avoid the need for annual CT scans, buttock claudication. He had also read about neurological complications with open aortic surgery like retrograde ejaculation. 

  
An older patient may be well served with hypogastric artery embolization and iliac stent grafting. In the absence of an aortic or contralateral common iliac artery aneurysm, it would be hard to justify placing a bifurcated aortic stent graft to then accessorize with snorkels. He was not a candidate for the branched iliac stent graft trial (disclosure: I am a site PI for the Gore iliac branched trial and the Cook iliac branched device is also available on trial) and he was not enthusiastic about the follow up -neither was I, when we discussed other endovascular options. 

When I broached open surgery, there was a pause because he had read about all the endovascular procedures that were possible, but truthfully, he had never had an honest discussion about open repair. 

In the current set up of care and training, there would be opinions favoring a purely endovascular approach. Ironically, in another time, the approach we chose would have been considered minimally invasive. The operation was planned with a left lower quadrant retroperitoneal pelvic exposure. The plan was to replace only the aneurysm and revascularize both the internal and external iliac arteries. The internal was revascularized with an end to side anastomosis to a 12mm graft and the common iliac to external iliac revascularization was end to end. 

  

  
The patient recovered and was discharged in two days. The good thing is that he won’t face buttock claudication and has a low risk of neurologic complications (primarily retrograde ejaculation). Future endovascular options were maintained in the way the graft was tailored -particularly in the creation of a generous landing zone for any future aortic endograft. The patient won’t need to come back for surveillance on the same rigorous schedule as an endograft. 

Categories
humor training

A Dozen Snippets of Advice to Graduating Trainees

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  1. Pass your boards and get your licenses. Board eligibility has the shelf life of a sack of dog food. After about two or three years, you better throw it out. While your apprenticeship with me and my partners has given you insight into the various styles and techniques of repairing arteries and veins, no hospital or insurance company will let you touch a patient without eligibility or certification. And while you are at it, maintain your certification  with CME’s. Apply for licenses early and diligently. You are like newly hatched baby sea turtles and the ocean is your board certification.
  2. Look the part. Stand up, look people in the eye, smile. Stay well groomed and wear clean clothes. Scrubs are acceptable only on days you are operating in the hospital, but no one should see you at the grocery store in them. Dress professionally, but don’t spend more money than your peers or partners. Clean fingernails a given.
  3. Remember, your first job is not like a first spouse and may not be forever. Exit strategies at a basic that can be negotiated from the start is coverage of a tail policy upon mutual separation. Triggers for retention salary (never bonus which is taxed differently) can be negotiated. For example, you take a rural job away from people you might want to marry –you may put in your contract that every year after a certain number you aren’t married, you get a raise. Same with partners who are said to be near retirement –people live longer and want to work longer, and you might find that promised increase in volume and salary does not come to fruition. Contracts can be structured for retention salary increases in those instances. Hard to recruit areas need to recognize that and be willing to increase your salary based on volume that would otherwise go to another partner if they could recruit them.
  4. While it can be viewed as a business transaction, you are setting out to take care of people in a community. Cultural competence is a huge advantage if you are not a native. Understanding the reluctance of an 80 year old Iowa farmer to get surgery in the fall because of the harvest may give you insights to head off argument –their fine sons or daughters may come home and help organize the harvest. Part of the process of getting to know the community is establishing some roots –I don’t mean marrying the mayor’s daughter or having three kids out of wedlock. It means joining clubs, churches, community organizations. It means attending the local fairs and buying from local stores even when Amazon would be a lot more convenient.
  5. Towns can be measured by metrics. How hard is it to get to New York from where you are. Is it in fact New York? How hard is it to get to your town from where your loved ones are? What is the swankiest brand of car sold in that town. Is sushi made by Japanese, is dim sum by Chinese, the pho by Vietnamese? Is there Korean food? Is there a Whole Foods? Is there a functioning public transportation system? Can you get fresh fish? How many pro sports teams are there? Is there a college nearby that you have heard of? How fast is the internet? Is there cell coverage? Do they drink the tap water? Is there a meth/heroin/oxycontin problem? Is the highest paid person in the state the football coach?
  6. Learn the limits of your hospital, your ICU, your floors, your consultants, your office staff, and yourself in equal measure of importance. Be patient and stick to simple straightforward low risk cases if possible and have partners co-scrub more challenging cases. Find and know the regional referral center if you are in a community hospital and don’t feel shy about referring patients beyond the capabilities of everything in the first sentence. Your results will be under a microscope, but the most important watcher is you.
  7. Take care of yourself. Exercise, eat right, and take up a leisure time activity that won’t result in lawsuits or court ordered DNA tests. Golf is great. Vacationing is okay, but spending every moment of time out of town sends the wrong message. Budget and start saving for retirement because you won’t be doing this forever. Pay down debts and don’t take on unnecessary debts. You don’t need a Porsche or a McMansion. If you have kids, stick to public schools and live modestly unless your spouse has a lot of money, then you’re a trophy spouse!
  8. Low hanging fruit of publicity –eating meals in the doctor’s lounge, chatting with staff in the OR lounge, attending staff functions, joining the local medical society. The ten minutes of conversation over a stale sandwich or rubbery, overcooked chicken works. Make sure to have business cards handy or your contact set up to share easily by text or email. Pro tip: having pens printed with your name and practice and number –the equipment and drug reps can’t give you swag but you can give them swag to give out. Give grand rounds or CME talks. Bring in your former faculty as guest speakers. Get an article in the local paper –it will end up on the web site, but mostly older people, ie your patients, will read actual papers. Social media and the internet –unless you are deeply committed to keeping a live presence there with frequent posts and comments, don’t bother. There are too many practice websites and doctors blogs that get refreshed every 3-5 years that they are a liability. You need to blog weekly or FB, Tweet, and Instagram post daily to get a following. That said, done right, you can control your image far better than the hive mind will. The people reading the internet won’t be your vascular patients, but it will be their kids who will search you out on the internet. The other tactic is to never, ever be on the internet.
  9. Humans, from the time of the Australopithecines and maybe before, are organized through direct personal relations in groups numbering up to ten or twenty. You will be in control of an OR or an office, and you have to learn how to do this well to be effective, and it will depend on forming good working relationships. This is not easy and mistakes will be made, but ultimately your success will depend on how well you orchestrate your team. Buying pizza for the team is a good way to get pizza for yourself, but will also earn the gratitude of your people.
  10. No amount of preparation on your part will make up for problems outside of your control. When managing these by “taking ownership,” usually by starting committees and study groups, takes up increasing part of your day and happen without compensation or acknowledgement, it is time to move.
  11. Surround yourself with smart competent people. No referral stream is worth the trouble of associating with stupid, incompetent people, because ultimately, you will become one of them. That said, graduating at PGY 5-7, maybe more, means that you are likely the most trained, most up to date individual in the medical community and to the degree you have to live and work there, you have to give something of yourself to take care of patients. If that means admitting a complex patient with an unrecognized exacerbation of a connective tissue disorder because they were referred to your clinic with foot pain, it may be simpler to simply admit the patient to your service and start the care and workup rather than trying to do an outpatient turf. Sending this patient to the emergency room or dismissing the patient with instructions to set up a specialist appointment washes your hands, but you are not taking care of this person are you?
  12. You are being paid to be smart and competent at vascular surgery like LeBron James was brought back to Cleveland to revive it economically and redeem its souls from perdition. Act accordingly.