Maria Antonietta Pacilè

Short-term results of a randomized trial examining timing of carotid endarterectomy in patients with severe asymptomatic unilateral carotid stenosis undergoing coronary artery bypass grafting

OBJECTIVE This study evaluated the timing of carotid endarterectomy (CEA) in the prevention of stroke in patients with asymptomatic carotid stenosis >70% receiving a coronary artery bypass graft (CABG). METHODS From January 2004 to December 2009, 185 patients with unilateral asymptomatic carotid artery stenosis >70%, candidates for CABG, were randomized into two groups. In group A, 94 patients received a CABG with previous or simultaneous CEA. In group B, 91 patients underwent CABG, followed by CEA. All patients underwent preoperative helical computed tomography scans, excluding significant atheroma of the ascending aorta or aortic arch. Baseline characteristics of the patients, type of coronary artery lesion, and preoperative myocardial function were comparable in the two groups. In group A, all patients underwent CEA under general anesthesia with the systematic use of a carotid shunt, and 79 patients had a combined procedure and 15 underwent CEA a few days before CABG. In group B, all patients underwent CEA, 1 to 3 months after CABG, also under general anesthesia and with systematic carotid shunting. RESULTS Two patients (one in each group) died of cardiac failure in the postoperative period. Operative mortality was 1.0% in group A and 1.1% in group B (P = .98). No strokes occurred in group A vs seven ipsilateral ischemic strokes in group B, including three immediate postoperative strokes and four late strokes, at 39, 50, 58, and 66 days, after CABG. These late strokes occurred in patients for whom CEA was further delayed due to an incomplete sternal wound healing or because of completion of a cardiac rehabilitation program. The 90-day stroke and death rate was 1.0% (one of 94) in group A and 8.8% (eight of 91) in group B (odds ratio [OR], 0.11; 95% confidence interval [CI], 0.01-0.91; P = .02). Logistic regression analysis showed that only delayed CEA (OR, 14.2; 95% CI, 1.32-152.0; P = .03) and duration of cardiopulmonary bypass (OR, 1.06; 95% CI, 1.02-1.11; P = .004) reliably predicted stroke or death at 90 days. CONCLUSIONS This study suggests that previous or simultaneous CEA in patients with unilateral severe asymptomatic carotid stenosis undergoing CABG could prevent stroke better than delayed CEA, without increasing the overall surgical risk.

Results of a pancreatectomy with a limited venous resection for pancreatic cancer

PurposeThe indications for a pancreatectomy with a partial resection of the portal or superior mesenteric vein for pancreatic cancer, when the vein is involved by the tumor, remain controversial. It can be assumed that when such involvement is not extensive, resection of the tumor and the involved venous segment, followed by venous reconstruction will extend the potential benefits of this resection to a larger number of patients. The further hypothesis of this study is that whenever involvement of the vein by the tumor does not exceed 2 cm in length, this involvement is more likely due to the location of the tumor being close to the vein rather than because of its aggressive biological behavior. Consequently, in these instances a pancreatectomy with a resection of the involved segment of portal or superior mesenteric vein for pancreatic cancer is indicated, as it will yield results that are superposable to those of a pancreatectomy for cancer without vascular involvement.MethodsTwenty-nine patients with carcinoma of the pancreas involving the portal or superior mesenteric vein over a length of 2 cm or less underwent a macroscopically curative resection of the pancreas en bloc with the involved segment of the vein. The venous reconstruction procedures included a tangential resection/lateral suture in 15 cases, a resection/end-to-end anastomosis in 11, and a resection/patch closure in 3.ResultsPostoperative mortality was 3.4%; morbidity was 21%. Local recurrence was 14%. Cumulative (standard error) survival rate was 17% (9%) at 3 years.ConclusionA pancreatectomy combined with a resection of the portal or superior mesenteric vein for cancer with venous involvement not exceeding 2 cm is indicated in order to extend the potential benefits of a curative resection.

Management of Carotid Dacron Patch Infection: A Case Report Using Median Sternotomy for Proximal Common Carotid Artery Control and In Situ Polytetrafluoroethylene Grafting

We report on a 58-year-old male who presented with an enlarging cervical hematoma 3 months following carotid endarterectomy with Dacron patch repair, due to septic disruption of the Dacron patch secondary to presumed infection. The essential features of this case are the control of the proximal common carotid artery gained through a median sternotomy, because the patient was markedly obese with minimal thyromental distance, and the treatment consisting of in situ polytetrafluoroethylene bypass grafting, due to the absence of a suitable autogenous saphenous vein. Median sternotomy is rarely required in case of reintervention for septic false aneurysms and hematomas following carotid endarterectomy but should be considered whenever difficult control of the common carotid artery, when entering the previous cervicotomy, is anticipated. In situ polytetrafluoroethylene grafting can be considered if autogenous vein material is lacking.

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.

Surgical outcomes for liposarcoma of the lower limbs with synchronous pulmonary metastases.

Surgical resection of pulmonary metastases from soft tissues sarcomas has typically yielded disparate results, owing to the histologic heterogeneity of various series and the presentation times relative to primary tumor discovery. It was our hypothesis that with expeditious, curative surgical resection of both, primary and metastatic disease, patients with liposarcoma of the lower limb and synchronous, resectable, pulmonary metastases might achieve satisfactory outcomes.

Iliac side branch device for bilateral endovascular exclusion of isolated common iliac artery aneurysms without brachial access.

A 74-year-old man with an asymptomatic pulsatile abdominal mass was found on computed tomography scan to have nonruptured, bilateral, isolated common iliac artery aneurysms measuring 4.7 cm on the right and 3.0 cm on the left. Arteriography demonstrated a favorable angle of origin of 50° for both hypogastric arteries (A), so endovascular exclusion of both the aneurysms with iliac bifurcation devices was performed. An iliac bifurcation device (Cook Inc, Bloomington, Ind) was advanced from the right femoral artery until the side branch was over the ostium of the right hypogastric artery. The delivery sheath was partly withdrawn, the distal end of the side branch was deployed, and the indwelling guidewire was advanced above the aortic bifurcation. A snare catheter was advanced through an 18F introducer sheath through the left femoral artery to retrieve and extract the guidewire. An 8F crossover sheath was advanced from the left to the opening of the side branch, in the right iliac bifurcation device. The introducer sheath of the iliac bifurcation device was further withdrawn, and the device was fully deployed. The crossover guidewire was removed, and a 0.035-inch guidewire was advanced from the left side into the distal right hypogastric artery, within the crossover sheath. This sheath was then further advanced into the left hypogastric artery. An 859-mm Advanta V12 stent graft extension (Atrium Medical, Hudson, NH) was advanced into the right hypogastric artery. The crossover sheath was withdrawn. The stent graft was deployed and balloon-expanded between the side branch of the iliac bifurcation device and the hypogastric artery. The same procedure was then performed on the left side by introducing crossover guidewires, sheath, and stent graft through the right femoral artery, without a brachial access (B). Finally, a Zenith aortobiiliac device (Cook) was deployed. Completion angiography was satisfactory (C). At 1 month, the patient is in good condition. A well-patent reconstruction, with no endoleak, is evident on the computed tomography scan (Cover).

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.

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.