Piergaspare Palumbo

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.

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.

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.

Fondaparinux for intra and perioperative anticoagulation in patients with heparin-induced thrombocytopenia candidates for peripheral vascular surgery: Report of 4 cases.

Highlights • Antigoagulant treatment of vascular surgery patients with heparin induced thrombocytopenia is a challenge.• Fondaparinux was tested for intra/perioperative anticoagulation in vascular surgery.• Fondaparinux can be proposed for standard intra/perioperative anticoagulation in vascular surgery patients with heparin induced thrombocytopenia.

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.

Hybrid treatment of tandem, common carotid/innominate artery and ipsilateral carotid bifurcation stenoses by simultaneous, retrograde proximal stenting and eversion carotid endarterectomy: Preliminary results of a case series

BACKGROUND Tandem stenoses of the internal carotid artery (ICA) and proximal, ipsilateral common carotid artery (CCA) or innominate artery can be treated with a hybrid approach, combining conventional carotid endarterectomy (CEA) and retrograde stenting of the proximal stenosis, through surgical exposure of the carotid bifurcation. The purpose of this study was to evaluate the results of combining eversion CEA with retrograde CCA/innominate artery stenting. MATERIAL AND METHODS From January 2015 to July 2017, 7 patients, 6 men of a mean age of 72 years (range 59-83 years) underwent simultaneous, retrograde stenting of the proximal CCA/innominate artery and an eversion CEA of the ipsilateral ICA, through surgical exposure of the carotid bifurcation, for severe tandem stenoses. The proximal stenosis involved the left proximal CCA in 4 patients, the proximal innominate artery in 2 patients and the right CCA in one patient. The procedure was performed under general anesthesia in a conventional operating room equipped with a mobile C-arm. A covered, balloon expandable stent was deployed over the proximal stenosis via a 6-F sheath directly introduced into the proximal CCA through the obliquely transected carotid bulb. After removing the sheath, debris were flushed through the carotid bulb and eversion CEA completed the procedure. Study endpoints were: postoperative stroke/mortality rate, cardiac mortality and morbidity, peripheral nerve injury, cervical hematoma, overall late survival, freedom from ipsilateral stroke and patency of arterial reconstruction. RESULTS No postoperative mortality or neurologic morbidity was observed in any patient. Cervical hematomas and peripheral nerve injuries were likewise absent. At a mean follow-up of 18 months, all the patients were alive, free from neurologic events of new onset and free from restenosis. CONCLUSION Combined proximal stenting and eversion CEA for tandem lesions seems a valid treatment, with the advantages of eversion CEA over other techniques of carotid bifurcation revascularization.

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.