Luigi F. Presenti

Extended and Total Aortic Resection in the Surgical Treatment of Acute Type A Aortic Dissection: Experience with 54 Patients

Fifty-four patients with acute type A aortic dissection were surgically treated with extended aortic resection. The age of the patients ranged from 22 to 75 years, and all of them were in very critical condition. In 50 patients, the resection extended from the aortic valve (included in 33) to the beginning of the descending thoracic aorta and in 4, from the valve (included in 3) to the aortic bifurcation. Deep hypothermia and circulatory arrest were employed during the aortic arch resection; inclusion of the graft at the end of procedure was done in 44 patients; in the others, the diseased aortic wall was excised. Early mortality was 20 +/- 6% (11/54). Nine deaths were due to persistence of the distal dissection. Acute type A aortic dissection with aortic valve insufficiency should be treated as an emergency with extended aortic resection. As far as control of bleeding and closure of distal dissection are concerned, the best results have been achieved when the diseased aortic wall has been completely excised.

Adrenal masses in neoplastic patients: The role of laparoscopic procedure

BackgroundThe incidence of complications resulting from fine-needle biopsy of adrenal masses in patients already treated by radical procedures for primitive neoplasms of the lungs and kidneys substantiates our opinion concerning laparoscopy as both a diagnostic and therapeutic procedure.MethodsWe performed 70 laparoscopic adrenalectomies from April 1995 to December 1999. In five patients, the adrenal mass appeared at follow-up evaluation in patients submitted to surgery for a spinocellular lung cancer. One patient underwent surgery for renal adenocarcinoma. In two patients, the adrenal mass was present already at the time primitive lung tumor was diagnosed, so adrenalectomy was performed at the first lung surgery in one patients were placed in a lateral position for a transperitoneal approach. Right adrenal masses were present in seven patients, whereas one patient had an adrenal mass in a left location.ResultsNo laparotomy was required. The average surgical time was 160 min. (range, 115–120 min). No morbility or mortality occurred, and the average hospital stay was 4 days (range, 3–11 days). All the patients had a complete removal of their masses, which averaged 4.5 cm (range, 2.5–6 cm) in size. Histology confirmed the metastatic origin of the mass in five of seven patients with primary lung cancer, and in one patient with previous kidney cancer. At this writing, three patients were disease free and still alive respectively at 3, 5, and 18 months. Three patients died of brain metastases respectively at 16, 36, and 36 months. An adenoma was proved in the other two cases.ConclusionsLaparoscopic adrenalectomy allows us to propose a much more aggressive approach to adrenal masses demonstrated at follow-up evaluation or in patients with primary lung or kidney cancer and no masses at other locations. Nevertheless a much larger study is required for definitive conclusions on a survival rate. We believe that a mini-invasive procedure such as laparoscopy may allow us to replace a rational surgical approach with a more certain pathologic diagnosis.

The influence of new technologies on laparoscopic adrenalectomy

BackgroundLaparoscopic adrenalectomy has proved to be the technique of choice for managing benign pathologies of the adrenals and isolated adrenal metastases, especially those arising from lung tumor, but the procedure should not be performed for primitive adrenal carcinoma. The Authors wanted to test the advantages of the Harmonic Scalpel in laparoscopic adrenalectomy.MethodsFrom April 1995 to April 2001, the authors investigated their series of laparoscopic adrenalectomies performed at the Careggi General Hospital, Division of General and Vascular Surgery, Florence, Italy. This study enrolled 91 patients with various adrenal pathologies. The transperitoneal approach was used, with the patient in a lateral position, as suggested by Gagner. Special care was taken to improve the surgical approach to the adrenals by the use of new technological devices such as the Harmonic Scalpel. The operative time required by the surgical procedure was computed by dividing the study into thee periods: 1995–1997, 1998–1999, 2000–2001. The first period was necessary to complete the learning curve. In the second period, a steady state in surgical time was reached. During the third period, the Harmonic Scalpel was introduced. The differences between the three periods were tested using a nonparametric analysis (Mann-Whitney U test or Kruskal-Wallis test) as appropriate. A two-tailed p value of 0.05 or less was considered statistically significant. The authors investigated the cost of the operation performed in each of the two groups using, respectively, the conventional laparoscopic device (1998–1999) and the Harmonic Scalpel (2000–2001). The following expenses were considered: Harmonic Scalpel impulse generator and disposable shears, operating room cost per hour, and endoclip applier.ResultsThe 91 laparoscopic adrenalectomies were performed with these indications: 31 incidentalomas (26 adenomas and 5 cysts), 25 cases of Conn’s disease, 18 cases of Cushing’s disease, 9 pheochromocytomas, 2 myelolipomas, 5 metastases (from lung, kidney, and breast) and 1 primitive carcinoma diagnosed preoperatively. Considering the whole series (1995–2001), there was a significant trend of reduction in operative time (p =0.0001). Moreover looking at the first period (1995–1997), in which the learning curve was completed, the mean surgical time was 148 min, as compared with 125 mm. For the second period (1998–1999) (p=0.0002). This represents a significant reduction in operative time. The authors notes a further reduction in the operative time when surgery was performed with the Harmonic Scalpel (2000–2001) (92 min; p=0.001). The reduction in operative time attributable to the Harmonic Scalpel was confirmed also by a multivariate analysis of covariance general linear models procedure (GLM), which accounts for several confounders: age, gender, site and size of tumors, and histology (p=0.0001). The rate was 3.3% for morbidity, 1.1% for mortality, and 2.2% for conversion. There was no difference in complications between patients treated with conventional devices and those treated with the Harmonic Scalpel.ConclusionsThe laparoscopic approach has proved to be an extremely reliable procedure for benign pathologies and isolated metastases. There may yet be doubts about its use for the treatment of adrenal carcinomas preoperatively diagnosed. When surgery is performed using Harmonic Scalpel, operative time is significantly reduced and surgery is easier and less expensive. Infact use of the Harmonic Scalpel allowed the cost per operation to be reduced

Portal thrombosis. A rare complication of laparoscopic splenectomy.

70. Moreover, if surgery is performed using the nondisposable clip applier, the expences are reduced

Expectations and outcomes when moving from open to laparoscopic adrenalectomy: Multivariate analysis

105.

Simultaneous total aortic replacement from valve to bifurcation: Experience with 21 cases

Abstract. Portal thrombosis is a rare complication of splenectomy. We performed 12 laparoscopic splenectomies and observed this complication only in one patient with idiopathic thrombocytopenia (ITP). The right branch of the portal vein presented a partial thrombosis, while the left branch was completely obstructed by thrombi. Abdominal ultrasonography and an ultrasound doppler exam allowed us to diagnose this event and a retrograde angiography performed afterward confirmed our diagnosis. A 48-h intravenous heparin treatment was promptly begun, followed by anticoagulant drugs (dicumarol). The patient was dismissed 5 days afterward, presenting a steady-state ultrasound doppler pattern and a complete normalization of liver parameters. An ultrasound doppler exam performed 1 month after anticoagulant therapy showed a complete resolution of portal thrombosis. We believe that early diagnosis of this rare complication, prompt beginning of anticoagulant therapy, and care in surgical procedures may reduce patient life-threatening risks and assure complete remission.

Combined Myocardial and Peripheral Revascularization of the Lower Limbs

Various authors have suggested that laparoscopic adrenalectomy (LA) leads to better surgical outcomes than open surgery. The debate is still open, however, and indications and limitations of minimally invasive surgery have not been completely established. The objective of our study was to compare surgical outcomes of LA and open adrenalectomy (OA), using multivariate analysis to adjust for potential confounding factors (e.g., size of the lesion, histology). Between 1995 and June 2000 at “Careggi” Hospital in Florence, Italy patients with an indication for adrenalectomy were treated laparoscopically if the lesion was < 10 cm and there was no clinical evidence of malignancy. All 79 patients who underwent LA have been included in this study. Among 152 patients who underwent OA at “La Sapienza” University in Rome, 93 had an adrenal lesion < 10 cm and no clinical evidence of malignancy; they were selected for comparison. Multivariate analysis has been used to analyze the effect of the surgical approach (OA vs. LA) on the surgical outcome, controlling for potential confounders. Multiple logistic regression showed that there is no significant difference in intraoperative outcomes (i.e., surgical time > 2 hours, blood loss ≥ 500 ml) between patients operated on through a traditional approach and those who underwent LA. On the other hand, patients operated on laparoscopically have a significantly higher probability than the OA group of experiencing a better recovery from surgery (i.e., require less postoperative analgesics and return to normal activities earlier). The results of the present study show that, although LA does not add much benefit in terms of expected intraoperative outcomes, it dramatically speeds patients’ recovery from surgery. The two approaches are complementary and should both be integrated into the technical background of all endocrine surgeons.

Excision of the aortic wall in the surgical treatment of acute type-A aortic dissection

From June 1985 to December 1991, 21 patients (12 men and 9 women; mean age, 60 years) underwent total simultaneous aortic replacement that extended from the valve to the bifurcation. The causes of the diseased aorta were: medial degeneration with total aortic dilatation or multiple aneurysms (n = 7) and either acute (n = 4) or chronic (n = 10) dissection. Clinical evaluation and investigation in all patients consisted of computed tomography and magnetic resonance imaging as well as angiography. Only patients with combined thoracic and abdominal emergencies were selected, and these comprised worsening of cardiac conditions resulting from aortic regurgitation, and rapid dilatation of the ascending aorta and arch with impending rupture in conjunction with ischemia of the abdominal viscera, kidney, or either leg. The surgical technique consisted of inducing deep hypothermia by means of femoral vein-femoral artery cardiopulmonary bypass. During the cooling time, the aortic root was replaced under cardioplegia. Once lowering of the body temperature attained electroencephalographic silence, circulation was stopped and the aorta was replaced from the arch to the bifurcation. Circulation and rewarming were resumed only after the operation was completed. In our most recent patient, the operating time was reduced by opening the thoracic and the abdominal incisions during cooling; the cardioplegic solution as not injected but, instead, the myocardium was cooled down along with the whole body. In these patients, the hypothermy at electroencephalographic silence ranged from 14 degrees to 19 degrees C.(ABSTRACT TRUNCATED AT 250 WORDS)

Laparoscopic adrenalectomy. Personal experience in 78 patients.

In a series of 2,786 patients submitted to operation for peripheral arterial disease of the lower limbs from 1964 to 1986, the overall mortality rate was 6.9%, and 69% of these died of acute myocardial infarction (AMI). In order to reduce the incidence of AMI, from 1979 to 1990, 258 patients with lower limb ischemia were investigated for coronary artery disease (CAD). All of them had clinical signs of myocardial ischemia and were submitted to coronary arteriog raphy after previous evaluation with dipyridamole thallium scanning and echo cardiography. Severe CAD was shown in 137 patients, and combined myocardial and peripheral revascularization was planned: coronary artery by pass grafting (CABG) was performed first on 61 patients followed by peripheral operation after an average of three weeks; simultaneous procedure was per formed on 76 patients upon intraoperative decision. The overall mortality rate was 3.6%: 3.3% for staged and 3.9% for simultaneous procedure. No myocar dial infarction was registered in the early postoperative period, but peripheral graft occlusion in 5.8% (8/137) was the main complication. The actuarial five- year survival rate was 87%; the actuarial five-year patency of the peripheral grafts was 61.9%. The authors conclude that combined myocardial and peripheral revascular ization prevents early death from myocardial infarction and improves late sur vival without increasing surgical risks; with proper judgment simultaneous operations can be performed.