Francesco Vietri

Outpatient repair for inguinal hernia in elderly patients: Still a challenge?

BACKGROUND Elective inguinal hernia repair as a day case is a safe and suitable procedure, with well-recognized feasibility. The increasing number of elderly patients requiring inguinal hernia repair leads clinicians to admit a growing number of outpatients. The aim of the current study was to analyze the outcomes (feasibility and safety) of day case treatment in elderly patients. METHODS Eighty patients >80 years of age and 80 patients ≤55 years of age underwent elective inguinal hernia repairs under local anesthesia. RESULTS There were no mortalities or major complications in the elderly undergoing inguinal herniorraphies as outpatients, and only one unanticipated admission occurred in the younger age group. CONCLUSIONS Elective inguinal hernia repair in the elderly has a good outcome, and age alone should not be a drawback to day case treatment.

Is Minimally Invasive Surgery Appropriate for Small Differentiated Thyroid Carcinomas

PurposeTo retrospectively evaluate the surgical completeness of minimally invasive total thyroidectomy for small (<20 mm) differentiated thyroid carcinoma (DTC).MethodsThe subjects of this study were 30 patients who underwent minimally invasive total thyroidectomy as a single procedure. We registered the following postoperative measurements in the LT4 withdrawal period: serum thyroglobulin level, 6-h radioiodine uptake diagnostic test results, and neck ultrasound (US) findings.ResultsThe mean serum thyroglobulin level was 4.99 ± 4.67 ng/ml, the mean radioiodine uptake diagnostic test after 6 h was 3.11% ± 2.90%, and US showed no thyroid remnant.ConclusionsThe short-term outcome measures showed adequate resection of thyroid tissue, comparable with that reported after conventional surgery. Our findings suggest that small nodules with suspicious or malignant cytology are one of the best indications for minimally invasive surgery.

Results of axillofemoral by-passes for aorto-iliac occlusive disease

The purpose of this study was to review our results with axillofemoral by-passes performed for aortoiliac occlusive disease. Fifty patients receiving 51 axillofemoral by-passes from January 1989 to December 1994 were retrospectively reviewed. The 30-day post-operative mortality was 4%. Seven patients (14%) presented graft-related local complications and all but one required reoperation. Five patients were lost to follow-up, the mean length of which was 36 months (16–74 months). Forty-nine per cent of the patients died during the follow-up period. At 36 months, the primary patency rate was 51%, the secondary patency rate was 69%, and limb valvage rate was 87%. A statistical difference was seen in the secondary patency rate between axillobifemoral by-pass (87%) and axillo-unifemoral by-pass (56%) at 36 months (P<0.01), but no difference was seen in the limb salvage rate at 36 months between the two configurations of the by-pass (94% vs 81 %) (P=NS). Twenty patients (40%) operated upon for acute ischemia had a significantly higher post-operative mortality rate (10% vs 0), a significantly higher amputation rate (20% vs 6.6%) and a significantly lower patency rate of by-pass (26% vs 63%) (P<0.01), than the 30 patients (60%) operated on for claudication, rest pain or trophic ulcers. Our findings indicate that the results of axillofemoral by-pass are significantly influenced by the selection of patients for operation, namely the clinical status of ischaemic symptoms, and that since the overall results of axillofemoral by-pass are inferior to those of aortofemoral by-pass, this treatment should be restricted to patients at high risk of aortic clamping.ZusammenfassungEs wurden 51 axillofemorale By-passoperationen aus dem Zeitraum Januar 1989 bis Dezember 1994 retrospektiv analysiert. Die postoperative Mortalitätsrate (nach 30 Tagen) betrug 4%. Bei 7 Patienten (14%) traten am Graft Komplikationen ein, so daß 6 von ihnen reoperiert werden mußten. In die Nachuntersuchung (mittleres Follow-up: 36 Monate, Spanne: 16–74 Monate) konnten 5 Patienten nicht einbezogen werden. Während der Follow-up-Periode verstarben 49% der Patienten. Nach 36 Monaten betrug die primäre Durchflußwiederherstellungsrate 51%, die sekundäre 69%, die Sanierungsrate im betroffenen Glied 87%. Statistisch gab es nach 36 Monaten bei der sekundären Durchflußwiederherstellungsrate einen Unterschied zwischen axillo-bifemoralen (87%) und axillo-uni-femoralem Bypass (56%) (p<0,01), aber hinsichtlich der Heilungsrate gab es zu diesem Zeitpunkt zwischen den beiden Bypass-Arten keinen signifikanten Unterschied (94% vs. 81%). Die postoperative Mortalitätsrate war bei 20 Patienten (40%), die wegen akuter Ischämie operiert worden waren, signifikant höher (10% vs. 0%); ebenso die Amputationsrate (20% vs. 6,6%); signifikant niedriger hingegen war die Durchflußwiederherstellungsrate nach Bypass (26% vs. 63%) (p<0,01) —im Vergleich zu 30 Patienten (60%), die wegen Claudicatio, Ruheschmerz oder trophischen Ulzera operiert worden waren. Nach unseren Untersuchungen sind die Ergebnisse bei axillofemoralen Bypassoperationen entscheidend abhängig von der Auswahl der Patienten gemäß klinischem Zustand und ischämischen Symptomen. Die Gesamtergebnisse nach axillofemoralem Bypass sind schlechter als nach aortofemoralem Bypass, und darum sollte die erstgenannte Operation nur bei Patienten angewendet werden, bei denen die Abklemmung der Aorta ein hohes Risiko darstellen würde.

Hemangiopericytoma of the spleen

INTRODUCTION Hemangiopericytoma of the spleen is a very rare tumor, with 14 isolated reports. It was our aim to review our experience and compare it with all the reported cases in an attempt to standardize surgical treatment, adjuvant treatment and follow-up protocol of this infrequent condition. METHODS A consecutive case series study, with a mean follow-up of 44 months. Five patients (mean age, 49 years) underwent simple splenectomy for hemangiopericytoma limited to the spleen followed by adriamycin-based chemotherapy in one patient. RESULTS All the patients are alive and free from disease. CONCLUSIONS For tumors confined to the spleen, simple splenectomy can be considered curative, without any need for further adjuvant treatment. On review of the medical literature, cure can still be achieved with complete resection of recurrences, when feasible, with adjuvant chemotherapy being also indicated. The slow-growing pattern of the tumor suggests a 10-year follow-up.

Infrarenal aorta as the donor site for bypasses to the superior mesenteric artery for chronic mesenteric ischemia: A prospective clinical series of 24 patients

Background. Treatment of symptomatic, chronic mesenteric ischemia is indicated to relieve symptoms and prevent acute ischemia and death. Current therapeutic options include endovascular and open surgery. The purpose of this prospective study was to evaluate the results of bypasses to the superior mesenteric artery arising from the infrarenal aorta or infrarenal aortic grafts. Methods. From January 1999 to December 2016, 24 consecutive patients with a mean age of 61 years underwent a prosthetic bypass to the superior mesenteric artery. Nine patients (37%) presented with an associated clinically important stenosis of the celiac artery and 10 (42%) of the inferior mesenteric artery. Five patients (21%) received preoperative parenteral nutrition. Four patients (17%) underwent dual antiplatelet treatment. The donor site was the infrarenal aorta in 19 patients (79%) and an infrarenal, Dacron graft was used in 5 (21%). The origin of the bypass was from the distal infrarenal aorta or Dacron graft in 19 patients (79%) and from the proximal infrarenal aorta in 5 patients (21%). The graft material consisted of 7 mm polytetrafluoroethylene in 19 cases (79%) and 7 mm Dacron in 5 cases (21%). A concomitant bypass to the inferior mesenteric artery was performed in 4 patients (17%). The primary end points were postoperative mortality, morbidity, graft infection, late survival, primary patency, and symptom‐free rate. The secondary end point was postoperative hemorrhagic complications. Results. No postoperative mortality occurred. Postoperative morbidity included a prolonged postoperative ileus in 4 patients (17%), transitory postoperative increases in serum creatinine concentrations in 3 patients (12%), and myocardial ischemia in 2 patients (8%). No postoperative hemorrhagic complications or graft infection were observed. Overall, the cumulative survival rate was 77% at 60 months. The overall late‐patency rate and freedom from recurrence of symptoms were both 87% at 60 months. Conclusion. Infrarenal aorta and infrarenal aortic grafts are an excellent source for the revascularization of the superior mesenteric artery. Bypasses to the superior mesenteric artery from the infrarenal aorta, either isolated or associated with adjunctive bypass to the inferior mesenteric artery, yield results that are comparable with those obtained with complete digestive artery revascularization using other donor sources.

Schwannoma of the descending loop of the hypoglossal nerve: Case report

Highlights • Schwannomas of the descending loop of the hypoglossal nerve are extremely rare.• They may masquerade a carotid body tumor at preoperative imaging.• En bloc resection together with the descending branch ensures durable cure.

Endovascular Strategy for the Elective Treatment of Concomitant Aortoiliac Aneurysm and Symptomatic Large Bowel Diverticular Disease

BACKGROUND The purpose of this study was to evaluate the strategy for treatment of patients presenting with asymptomatic diverticular disease of the large bowel associated with an asymptomatic aortoiliac aneurysmal (AAA) disease. METHODS Sixty-nine patients were included in this retrospective study. The patients were divided into 5 groups according to the type and sequence of the surgical treatment: 32 patients (47%) underwent colectomy followed by a staged open AAA repair (group A); 10 patients (14%) were treated with open AAA repair followed by a staged colectomy (group B); 13 patients (18%) received endovascular aneurysm repair (EVAR) followed by a staged bowel resection (group C); 8 patients (12%) had a bowel resection followed by staged EVAR (group D); and 6 patients (9%) underwent simultaneous open AAA repair and bowel resection (group E). Primary end points were mortality and complications after any of the procedures. Secondary end point was the time interval between the staged procedures. RESULTS The cumulative death rate for delayed treatment of AAA was 6.5% and 0% for delayed treatment of diverticular disease [P=0.22]. The mean time interval between the staged procedures was 11 days for EVAR/colon resection (group C and group D) and 73 days for open AAA repair/colon resection (group A and group B; P<0.01). CONCLUSIONS EVAR allows a significant reduction in the time required between AAA repair and colon resection, but no definite rule can be established regarding the sequence of staged procedures. Combined procedures should be reserved for selected cases.

Internal carotid artery rupture caused by carotid shunt insertion.

Highlights • Few reports deal with shunt-related complications during carotid endarterectomy.• We present a complication of shunting, consisting of internal carotid artery rupture at the distal tip of the shunt.• The management consisted of successful arterial repair via a saphenous vein patch.

Long-term Evaluation of a Modified Double Staple Technique for Low Anterior Resection.

Abstract Background: When performing low anterior resection for rectal cancer with the double staple technique, closing the rectum with a linear stapler in the abdomen can be challenging, especially when dealing with a narrow pelvis. For such instances we proposed to modify this technique by pulling the rectal stump through the anus, doing an extra-anal resection of the tumor and linear suture of the rectal stump, before performing a standard, stapled colorectal anastomosis. The purpose of this study was to assess the adequacy of this modification of the double staple technique. Methods: Retrospective review of 108 patients undergoing a stapled, low colorectal or coloanal anastomosis, after eversion, extra-anal resection of the tumor and linear closure of the rectal stump for colorectal cancer, from January 1990 to December 2012. Results: Operative mortality was 0.9%. Fourteen patients (13%) presented early, surgery-related complications consisting of 7 anastomotic leaks, 5 wound infections, 1 ureteral lesion, and 1 peristomal abscess. Late complications related to surgery included 5 incisional hernias (4.6%), 4 anastomotic strictures (3.7%), 4 neurogenic bladders (3.7%) and 2 fecal incontinences (1.8%). The incidence of local disease recurrence was 10%. Conclusions: Surgical and oncological results validate the proposed modification of the double staple technique, when facing difficulties in suturing the rectum from the abdomen.