Daniele Pontello

Duplex ultrasound changes in the great saphenous vein after endosaphenous laser occlusion with 808-nm wavelength

BACKGROUND Endosaphenous laser ablation is used in the treatment of great saphenous vein insufficiency with various methods, with and without surgical interruption. However, its mode of action and indications are not yet clear. METHODS To verify the mode of action of endosaphenous laser ablation by duplex ultrasound (DUS) follow-up, with the support of histologic observations of eight cases, 44 of 182 affected limbs (CEAP C2 to C6) were selected for intravenous laser ablation of the great saphenous vein. Saphenofemoral junction incompetence was treated by surgical interruption. An 808-nm diode laser (Eufoton, Trieste, Italy) was used (variable pull-back velocity, 1 to 3 mm/s; power, 12 to 15 W; energy, 30 to 40 J/cm). In eight limbs the venous fragments were studied under light microscopy at 5 minutes and after 1 and 2 months. In 44 limbs DUS and clinical examinations were performed from 7 days to 1, 2, 6, and 12 months. RESULTS Variously organized thrombi containing necrotic inclusions and patent areas were observed in the vein lumen. Neither neovascularization nor thrombus extension were detected at the groin by DUS examination. Progressive venous diameter decrease and thrombus fibrotic transformation up to the hypotrophic venous disappearance at 12 months were followed up (P < .00001). Not occluded (18.8%), recanalized short segments (22.7%), two entirely recanalized saphenous veins with varicose recurrence (4.5%), and postoperative phlebitis (13.6%) were observed. Nonocclusions and phlebitis prevailed in the larger veins (P < .05). CONCLUSION The healing process is based on vein thrombosis, fibrosis, and venous atrophy. Saphenofemoral interruption makes venous occlusion easier and prevents potential thrombotic complications and recurrence by recanalization. DUS monitoring makes possible to follow-up the thrombus involution and perform early retreatment. The 808-nm endosaphenous laser should be mainly applied to veins of <10 mm in diameter.

Endovenous 808-nm Diode Laser Occlusion of Perforating Veins and Varicose Collaterals: A Prospective Study of 482 Limbs

BACKGROUND Endovenous laser ablation (EVLA) was performed in the treatment of great and small saphenous veins (GSVs, SSVs), perforating veins (PVs), and varicose collaterals (VCs). OBJECTIVE To verify the outcome in PVs and VCs. MATERIALS AND METHODS Four hundred eighty‐two limbs of 306 patients were studied. EVLA was performed on 167 GSVs, 52 SSVs, and 534 PVs of 303 limbs and on VCs of 467 limbs; 133 GSVs were stripped, 300 of saphenofemoral junctions (SFJs) and 45 saphenopopliteal junctions (SPJs) were interrupted. Limbs were selected using duplex ultrasound examination and photographs; PVs‐VCs diameter (<4 mm) and VC length were measured. EVLA was performed using a 808‐nm diode laser, 0.6‐mm fibers, continuous emission, 4 to 10 W, and 10 to 20 J/cm. Follow‐up on 467 limbs occurred over a mean 27.5 months (range 3 months to 6 years); 98 limbs were followed up for longer than 4 years. RESULTS Operating time range from 10 to 30 minutes per limb. Blood vaporization, thrombosis, fibrosis, and atrophy prevailed in PVs and in the large VCs (>4 mm) and massive coagulation in the smaller (<4 mm). High rate of occlusion was seen, with different rates of patent PV‐VC mainly in diameter >6 mm. Thirty‐nine out of 511 patent PVs (7.6%) and 96 out of 778 VCs (12‐13%) were re‐treated using EVLA or foam sclerotherapy. Minor complications occurred in 88 of the 778 (11%). CONCLUSIONS EVLA of PVs and VCs is effective and faster than surgery in 2‐ to 6‐mm PVs and VCs using an 808‐nm diode laser. This study was supported by Eufoton, Trieste, Italy.

The predictive value of clinical evaluation of response to neoadjuvant chemoradiation therapy for rectal cancer.

Introduction Multimodality therapy has become the standard treatment for patients with locally advanced (T3 and T4) rectal carcinoma. Accurate preoperative staging of the patients with rectal cancer has increased in importance because the selection of patients with transmural rectal cancer (T3 or T4) or node-positive disease leads to a previous nonsurgical neoadjuvant treatment. The purpose of this study was to evaluate the predictive value of the clinical response to neoadjuvant therapy on the basis of pathological results obtained on rectal cancer patients treated by chemoradiotherapy and surgery. Methods From 1994 to 2003, 58 patients with a primary diagnosis of rectal cancer were studied at our department and enrolled in a neoadjuvant protocol of chemoradiotherapy followed by surgery. All patients were treated by 30 days of chemoradiotherapy. At the end of the chemoradiotherapy, each patient underwent clinical examination, including digital rectal examination, proctoscopy and abdominal-pelvic computerized tomography to define the clinical response to the chemoradiotherapy. Surgical resection was performed in all patients three weeks after the end of chemoradiotherapy, and histological analysis was performed on all resected specimens. Results The clinical complete response rate corresponded to the pathological complete response rate, whereas the clinical evaluation overestimated partial response and stable disease. The pathologic examination revealed that 3.5% of clinical partial responses and 3.4% of clinical stable disease were really pathological progressive disease. Clinical partial response and clinical stable disease positive predictive values were 92.8% and 90.9%, respectively, whereas the clinical progressive disease negative predictive value was 20%. Then, 6.9% of patients believed to have responded to the therapy, or not to have responded or worsened, actually had worsened by the end of the chemoradiotherapy. Conclusions Positive and negative predictive values, in particular for partial response and stable disease, of clinical evaluation of the response to chemoradiotherapy were not high enough to consider clinical evaluation accurate enough to make treatment decisions.

The biotechnologies in the treatment of neuro-vascular ulcers in the elder. Cultivated autografts of skin: fibroblasts and/or cheratinocytes

These, after having been separated, centrifugated and implanted on an adapted medium which consists of modified three-dimensional jaluronic acid, develop in vitro an extended layer of tissue (dimensions 100–200 cmq), which then will be grafted separately (after 4 weeks from the biopsy) on the surface of the ulcer. For the correct execution of such procedure are necessary four surgical steps, in sequence:

Role of surgery in the treatment of liver metastases from colo-rectal cancer in the elderly

Aim of the study Liver metastases from carcinoma of the colon-rectum (CCR) develop in about 50% of patients undergoing resection of primary tumor and about 15–25% of patients had synchronous metastases at presentation. In the absence of surgical treatment, survival 1 year after diagnosis is 30% and is less than 5% at 5 years. The 5-year survival after resection varies from 20 to 54%, while the value of post-operative mortality is currently less than 5%. Resection should be considered for all patients with disease confined to the liver where there is a real possibility of radical resection and maintaining a proper liver function. Currently, the average age of patients undergoing resection is over 60 years. At the same time we are witnessing an expansion of that surgery in patients older than 70 years. This retrospective work is to evaluate whether age may be a limit to liver surgery, and which clinical-pathological factors are predictive of outcome in the medium to long term.