Renata Lorenzetti

Midline abdominal wall incisional hernia after aortic reconstructive surgery: A prospective study

BACKGROUND AND PURPOSE To evaluate rate of formation of midline abdominal wall incisional hernia (MAIH) after elective open repair of abdominal aortic aneurysm (AAA) and revascularization for aortoiliac occlusive disease (AOD). METHODS AAA and AOD patients operated electively via a primary midline abdominal incision at our institution over a decade were entered in this prospective study. Patients who had already undergone midline laparotomy or had an MAIH after previous celiotomy were excluded. Patients were examined for MAIH 6-monthly for 2 years, then yearly. RESULTS We included 1,065 patients who underwent aortic reconstructive surgery (412 with AAA and 653 with AOD). The follow-up (mean ± standard deviation) was 6.4 ± 3.8 years (range, 0.5-12.7). Wounds were closed with a suture length-to-wound length (SL:WL) ratio of at least 4:1 in 58% (239 of 653) of AAA patients and 66% (431 of 653) of AOD patients (P = .01). There were 124 (11.6%) MAIHs, with an incidence of 12.4% (51 of 412) in the AAA group and 11.2% (73 of 653) in the AOD group (P = .62), and 3 (0.4%) wound infections (all among the AOD patients), none of which resulted in MAIH. At multivariate analysis, a SL:WL ratio of <4:1 was the only independent predictor of MAIH in AAA (P = .004) and AOD patients (P < .001). CONCLUSION AAA and AOD patients had a similar incidence of MAIH, which seems related to the wound closure technique. A SL:WL ratio of at least 4:1 is recommended. Further clinical studies are required to determine possible technical and perioperative variables that may be modified to decrease the incidence of MAIH development after aortic reconstructive surgery.

The impact of gender on outcome after infrainguinal arterial reconstructions for peripheral occlusive disease

OBJECTIVE The role of gender on the outcome of infrainguinal arterial revascularization (IAR) for peripheral arterial occlusive disease remains uncertain. This study analyzed the outcome of IARs performed over 15 years, stratifying the results by sex. METHODS Details of consecutive patients undergoing primary IAR for peripheral arterial occlusive disease from 1995 to 2009 at our institution were prospectively stored in a vascular registry. Demographics, risk factors, indications for surgery, inflow sources, outflow target vessels, types of conduit, and adverse outcomes were analyzed. Postoperative surveillance included clinical examination supplemented with duplex scans and ankle-brachial index measurements in all patients at discharge, 30 days, 6 months, and every 6 months thereafter. End points of the study, ie, patency, limb salvage, and survival rates, were assessed using Kaplan-Meier life-table analysis. The χ(2) or Fisher exact, Student t, and log-rank tests were used to establish statistical significance. RESULTS Our sample consisted of 1459 IARs performed in 1333 patients, comprising 496 women (37.2%; 531 IARs), who were a mean 3 years older than the men (74 vs 71 years; P < .001) and had a higher incidence of diabetes mellitus (52% vs 46%; P = .03) and surgery for limb salvage (91% vs 87%; P = .02). An autogenous vein conduit (great or small saphenous, or both, spliced, arm, or composite veins) was used in 87% of the IARs. No deaths occurred perioperatively (30 days). The major and minor complication rates were comparable between men and women. At 10 years, the primary patency rate was 47% in women vs 49% in men (P = .67), the assisted primary patency rate was, respectively, 53% vs 50% (P = .69), the secondary patency rate was 61% vs 61% (P = .66), limb salvage rate was 93% vs 91% (P = .54), and survival rate was 43% vs 49% (P = .65). Stratifying by type of conduit revealed no differences in patency or limb salvage rates. CONCLUSIONS Despite an older age and more advanced stages of disease on presentation in women, IAR performed in women can achieve patency and limb salvage rates statistically no different from those recorded in their male counterparts, supporting the conviction that sex per se does not influence the outcome of lower extremity revascularization.

Gender-based outcomes after eversion carotid endarterectomy from 1998 to 2009

BACKGROUND AND PURPOSE Although the benefit of carotid endarterectomy (CEA) in reducing the risk of stroke in selected symptomatic and asymptomatic patients has been well documented, the higher incidence of adverse events after CEA for women than for men remains controversial. The purpose of this study was to analyze the effect of female gender on perioperative (30-day) and long-term outcomes after eversion CEA (eCEA). METHODS Patients entered into a prospectively compiled computerized database of all primary consecutive eCEAs performed at our institution from September 1998 to December 2009 were analyzed. Endpoints were perioperative death and stroke, late carotid restenosis or occlusion, and long-term freedom from stroke and survival rates. Long-term follow-up was obtained in 96.8% of patients (97.5% of the women). RESULTS Among 1294 patients who underwent 1458 eCEAs under general anesthesia with continuous electroencephalographic monitoring and selective shunting, 409 (31.6%) were women (466 eCEAs). More women than men were over 80 years old (P = .001), and female patients were more likely to have arterial hypertension (P = .02) or hyperlipidemia (P = .006) than male patients. Preoperative statin medication (P = .01), contralateral carotid occlusion (P = .02), and shunting use (P = .03) were more frequent among female patients. No perioperative deaths occurred in the series as a whole, while the perioperative stroke risk (0.6% vs 0.5%), and the combined late carotid restenosis and occlusion rate (1.1% vs 0.4%) were comparable between female and male patients. The 7-year stroke-free survival and overall survival rates did not differ significantly between female and male patients (98.3% vs 98.8% and 87.2% vs 93.8%, respectively). CONCLUSIONS This single-center university hospital study shows that although women have a different cardiovascular risk profile from men when they undergo eCEA, there is no evidence of a different gender effect on perioperative and long-term outcomes.

Predictors of neck bleeding after eversion carotid endarterectomy

OBJECTIVE The aim of this study was to identify predictors for neck bleeding after eversion carotid endarterectomy (eCEA). METHODS A prospectively compiled computerized database of all primary eCEAs performed at a tertiary referral center between September 1998 and December 2009 was analyzed. The end point was any neck bleeding after eCEA. End point predictors were identified by univariate analysis. RESULTS Of 1458 eCEAs performed by the same surgeon on 1294 patients under general anesthesia with continuous electroencephalographic monitoring and selective shunting, there were five major and three minor perioperative strokes (0.5%), and no deaths. Neck bleeding after eCEA occurred in 120 cases (8.2%), of which 69 (4.7%) needed re-exploration. Univariate analysis (odds ratio [95% confidence interval]) identified preoperative antiplatelet treatment with clopidogrel (1.77 [1.20-2.62], P = .004), particularly when continued to the day before CEA (3.84 [2.01-7.33], P < .001), and postoperative hypertension (9.44 [6.34-14.06], P < .001) as risk factors for neck bleeding in general and for neck bleeding requiring re-exploration (4.50 [1.85-10.89], P = .001; 15.27 [2.08-104.43], P = .006, and 2.44 [1.12-5.30], P = .02, respectively). An increased risk of neck bleeding in general was associated with clopidogrel plus acetylsalicylic acid (12.00 [2.59-56.78], P = .005), acetylsalicylic acid alone (4.37 [1.99-9.57], P < .001), and ticlopidine (2.49 [1.10-5.63], P = .02) only when they were continued to the day before CEA. No neck bleeding was associated with preoperative treatment with dipyridamole or warfarin, or no medication. No further complications occurred in the patients who underwent re-exploration. CONCLUSIONS The results of this single-center university hospital study show that neck bleeding after CEA is relatively common but is not associated with an increased risk of stroke or death. Preoperative treatment with clopidogrel, particularly when it is continued to the day before surgery, and postoperative arterial hypertension seem to be associated with a higher risk of neck bleeding after CEA, requiring re-exploration in most cases. Other antiplatelet agents appear to be associated with an increased risk of postoperative neck bleeding only if they are continued to the day before CEA. Larger studies are warranted to confirm our findings and prevent this feared surgical complication.

Durability of eversion carotid endarterectomy

OBJECTIVE Carotid endarterectomy (CEA) remains the gold standard for treating carotid disease in selected symptomatic and asymptomatic patients, though carotid angioplasty and stenting has emerged as a safe alternative. The aim of this study was to assess the durability of CEA in a large series of patients followed up according to a strict clinical and ultrasonographic protocol. METHODS Over a 23-year period (1990-2012) a total of 1773 patients (1251 men and 522 women) with a mean age of 75.2 years (range, 31 to 96 years) who underwent 2007 consecutive primary eversion CEAs performed by the same surgeon under general anesthesia with electroencephalographic monitoring and selective shunting were prospectively followed up with ultrasonography at 1, 6, and 12 months, then yearly. A long-term follow-up (median, 11.2 years; mean, 12.9 years) was obtained for 1680 patients (94.8%). End points were perioperative (30-day) stroke and death and late carotid restenosis/occlusion rates. RESULTS More than two in three of the lesions (1446 of 2007, 72.1%) were symptomatic at the time of surgery, with a 25% rate of preoperative stroke. Preoperative antiplatelet or anticoagulant therapy was used by 1675 patients (94.4%), whereas 918 (51.8%) were receiving statin treatment. Overall, there were eight (0.4%) perioperative strokes and no deaths. During the follow-up, there were nine (0.47%) asymptomatic late carotid restenoses (six moderate [50%-69%] and three severe [≥ 70%]) and one (0.05%) carotid occlusion. Nine patients (0.47%) had late ipsilateral strokes, none of them related to restenosis/occlusion. Overall, there were 159 late deaths (9.4%). CONCLUSIONS The results of this study show that eversion CEA can be performed in symptomatic and asymptomatic patients with an extremely low perioperative stroke/death risk and a negligible incidence of late restenosis/occlusion, thus assuring a persistently good protection against the risk of cerebral ischemia.

Carotid endarterectomy for asymptomatic carotid stenosis in the very elderly

BACKGROUND The indication for carotid endarterectomy (CEA) is uncertain in patients with asymptomatic severe (≥60% luminal narrowing according to the North American Symptomatic Carotid Endarterectomy Trial criteria) carotid stenosis (ASCS), especially in the very elderly, because current evidence suggests that the risk of future stroke has been dropping in the past two decades owing to the recent advances in medical therapy. The aim of this observational study was to compare early and late outcomes in patients ≥80 years old with ASCS treated with CEA plus best medical treatment (BMT) or with BMT alone. METHODS From 2005 to 2012, 69 octogenarians with ASCS underwent CEA plus BMT (group 1), and another 54 received BMT alone (group 2). All operations were eversion CEAs. BMT included lipid-lowering drugs, new antiplatelet and antihypertensive agents, avoidance of smoking, careful blood pressure and glycemic control, and lifestyle changes. Follow-up with serial ultrasonographic examination was obtained in 118 patients for a median 4.4-year period. RESULTS There were no perioperative (30-day) strokes or deaths and one transient ischemic attack (1.4%). One late minor stroke developed in a CEA patient (1.5%). No late restenoses or occlusions were detected. Five patients in group 2 (9.6%) became symptomatic (one transient ischemic attack and four minor strokes) and subsequently underwent successful CEA; all their carotid plaques were complicated by ulceration and intraplaque hemorrhage (with plaque progression in four cases), confirmed by computed tomography images. The rate of freedom from cerebral ischemic events at 5 years showed a significant benefit for elderly patients who had CEA vis-à-vis those who did not (98% vs 84%; P = .04), and so did the 5-year rate of freedom from ipsilateral carotid disease progression (100% vs 91%; P = .01). At 5 years, the mortality rate was comparable for elderly patients whether they had CEA or not (66% vs 68%; P = .65). CONCLUSIONS CEA is a safe, effective, and durable treatment for ASCS in patients aged 80 years or more, carrying an insignificant perioperative stroke/death risk. CEA associated with BMT seems preferable to BMT alone in preventing the risk of ipsilateral ischemic events, without translating into a longer survival.

Pluriannual experience in stapled haemorrhoidopexy in the elderly

Background Compare two groups of patients, ≥ 70 years old and < 70 years old, diagnosed with III-IV grade haemorrhoids that underwent a stapled haemorrhoidopexy. [1]

Reconstructive surgery for complex aortoiliac occlusive disease in young adults

BACKGROUND Although aortoiliofemoral bypass grafting is the optimal revascularization method for patients with severe aortoiliac occlusive disease (AIOD), previous studies have documented poor patency rates in young adults. This study investigated whether young patients with AIOD have worse outcomes in patency, limb salvage, and long-term survival rates after reconstructive surgery than their older counterparts. METHODS Patients aged≤50 years undergoing reconstructive surgery at our institution for AIOD between 1995 and 2010 were compared with a cohort of randomly selected patients aged≥60 years (two for each of the young patients, matched for year of operation), analyzing demographics, risk factors, indications for surgery, operative details, and outcomes. RESULTS Among 927 consecutive patients undergoing primary surgery for AIOD, 78 (8.4%) aged≤50 years (mean age, 48.4 years) and 156 older control patients (mean age, 71.2 years) were identified. The younger patients were mainly men (81%) and 59% had surgery for limb salvage and 41% for disabling claudication (P=.02). Compared with older patients, they were significantly more likely to be smokers (90% vs 72%; P=.002) and had previously needed significantly more inflow procedures (28% vs 16%; P=.03). Only one death occurred perioperatively (30-day) among the control patients, and no major amputations or graft infections occurred in either group. The need for subsequent infrainguinal reconstructions was greater in the younger patients (18% vs 7%; P=.01). The primary patency rates were inferior in the younger patients at 5 years (82% and 75%) and 10 years (95% and 90%; P=.01), whereas assisted secondary patency (89% and 82% vs 96% and 91%; P=.08), secondary patency (93% and 86% vs 98% and 92%; P=.19), limb salvage (88% and 83% vs 95% and 91%; P=.13), and survival rates (87% and 76% vs 91% and 84%; P=.32) were comparable in the two groups. CONCLUSIONS This study shows that despite a higher primary graft failure rate than that in older patients, aortoiliofemoral revascularization for complex AIOD is a safe procedure for younger patients with disabling claudication or limb-threatening ischemia, providing they are willing to follow a regular protocol to complete their postoperative surveillance and to undergo graft revision as necessary.

Surgery of diabetic foot in the elderly: early Vs deferred treatment

Background In 1996, the overall prevalence of diabetic patients was 120 million and it will more than double by the year 2025. The most important complication in these patients is the diabetic foot (sepsis, abscess etc.). The aim of this study was to assess the role and results of surgery, performed in emergency or deferred emergency, in older population affected by acute septic foot.

Local recurrence of gastric cancer after total gastrectomy: an unusual presentation.

A 71 years old Italian man had type 3 gastric cancer of the greater curvature. Total gastrectomy with splenectomy and D2 lymph node dissection were performed. After discharge chemotherapy ELF regimen was administred for 6 months. After 16 months from the operation a local recurrence was discovered by CT scan. Surgical en-bloc resection was performed removing pancreatic tail, splenic colic flexure and a portion of left diaphragm. Histological examination confirmed local recurrence of gastric adenocarcinoma infiltrating pancreas, colon and diaphragm with lymph node metastasis.