Alessio Bridda

The hostile neck does not increase the risk of carotid endarterectomy

INTRODUCTION Hostile neck anatomy is assumed to be associated with increased surgical risk for patients undergoing carotid endarterectomy (CEA) and is often considered a reason to choose carotid stenting or medical management. This retrospective case-control study evaluated whether, and how much, anatomically hostile necks represent a condition of higher surgical risk of early and late mortality and major or minor morbidity. METHODS The data for 966 homogeneous CEA patients was prospectively entered in a computer database. Seventy-seven had a hostile neck anatomy due to previous oncologic surgery or neck irradiation, restenoses after CEA, high carotid bifurcation, or bull-like and inextensible neck. A case-control matched-pair cohort study considered sex, age (5-year intervals), and year of operation. Regional anesthesia was used for all operations for atherosclerotic stenosis >or=70%, conforming to the European Carotid Surgery Trial (ECST) in symptomatic and asymptomatic patients, at a single center and by one surgeon or under his direct supervision. RESULTS The hostile neck patients and the control group were matched for age, sex, carotid-related symptoms, degree of stenoses, and main risk factors for cardiovascular diseases. Intraoperative variables were substantially equivalent in the two groups; however, procedure length and clamping time were, respectively, about 22 minutes (P = .0001) and 7 minutes longer (P = .01) in the hostile neck group. Rates of postoperative mortality and neurologic events were equivalent. Peripheral nerve lesions were multiple and significantly more frequent in the hostile neck patients (21% with >or=1 cranial nerve lesion vs 7% of controls, P = .03), yet all were transient and limited to a few months. The subgroups of patients with hostile neck, restenoses, and bull-like inextensible necks required the longest operative and clamping time, and those with bull-like and high bifurcation had the most frequent cranial nerve dysfunctions. At the respective follow-up of 47 and 45 months, survival curves (P = .48) and the incidence of restenoses and fatal and nonfatal strokes were similar (5 and 4, respectively). CONCLUSIONS Hostile necks led to more complex CEA procedures but without substantial consequences in early and late morbidity and mortality. Most patients with hostile neck can undergo CEA at low risk, with the benefit of effective long-lasting stroke prevention similar to standard patients. In our opinion, the more frequent but temporary cranial nerve dysfunctions that occur are not sufficient to consider hostile neck patients noneligible for CEA.

Is laparoscopic cholecystectomy safe for lymphangioma of the gallbladder? A complicated case mimicking subhepatic abscess

Lymphangiomas are rare benign neoplasms of the lymphatic tissue generally occurring in the childhood. Cystic lymphangioma of the gallbladder is an extremely rare tumor with only eight cases having been reported in the literature. The aspecific and potentially misleading clinical presentation of these tumors requires complex preoperative imaging in the setting of clinical suspicion to make the correct diagnosis. The treatment of choice is complete excision with negative margins to avoid local recurrence. Their tendency to locally invade the surrounding tissues requires sometimes extended resections. Laparoscopic cholecystectomy can be a questionable choice in this setting; however, the procedures can be performed safely in most cases, although complicated. We report the case of a hemorrhagic cystic lymphangioma of the gallbladder mimicking a subhepatic abscess and operated in emergency with laparoscopic approach.