Tasselli S

Laparoscopic approach to postoperative adhesive obstruction

BackgroundSome authors have assessed the feasibility of laparoscopy in the treatment of postoperative adhesive obstruction, but conclusions about its effectiveness are related to different selection criteria used for surgery. This paper reports on our experience in laparoscopic adhesiolysis and analyses the results on the basis of the selection criteria used.MethodsFrom January 1993 to December 2001, 65 patients were submitted to laparoscopic adhesiolysis for small bowel obstruction according to specific selection criteria. Of the 65 patients, 40 were admitted for acute obstruction and 25 for chronic or recurrent transit disturbances. Correlation between historical and clinical data and the results of surgical treatment were statistically analyzed.ResultsThe procedure was completed by laparoscopy in 52 patients (conversion rate: 20%). Mean postoperative stay was 4.4 days with a 12.3% morbidity and no mortality. Recurrence rate was 15.4%; a single correlation was found between recurrence and age.ConclusionsLaparoscopic adhesiolysis in the treatment of small bowel obstructions seems to be effective; further studies are required to define selection criteria for surgery and confirm real advantages in terms of recurrences.

Radio Frequency Ablation for Hepatocellular Carcinoma in Cirrhotic Patients: Prognostic Factors for Survival

BackgroundRadio frequency ablation (RFA) of hepatocellular carcinoma has proved to be useful in local control of tumor. A few data on survival after treatment are available in literature. The aim of the study was to evaluate factors related to survival and to identify different classes of risk after radio frequency ablation.MethodsNinety-eight cirrhotic patients with 145 hepatocellular carcinomas were treated with radio frequency ablation from January 1998 to May 2004. In 55 patients, cirrhosis was in Child-Pugh class A, and in 43, in class B. Tumor was single in 60 and multiple in 38; mean tumor number was 1.5 (range 1–3). Tumor size ranged from 1.5 to 6.0xa0cm, mean 3.8xa0cm. Mean follow up period was 24.9xa0months. Radio frequency ablation was performed with expandable type needle with percutaneous approach under real-time ultrasound guidance. For statistical analysis, univariate and multivariate analysis were performed.ResultsComplete ablation of the tumor was achieved in 85.5% of lesions. Survival, 1 and 3xa0years, was 76.7 and 36.6%, respectively. Univariate analysis showed that Cancer of the Liver Italian Program (CLIP) score, tumor growth pattern, α-fetoprotein level, and complete tumor necrosis, were factors significantly related to poor survival. Multivariate analysis identified that factors related to poor survival were α-fetoprotein level >100xa0ng/ml, Child-Pugh class B, and incomplete tumor necrosis with a hazard ratio of 4.0, 2.7, and 3.8, respectively. After complete ablation, median survival was 38xa0months in patients with Child-Pugh class A cirrhosis and α-fetoprotein level ≤100xa0ng/ml, 22xa0months for patient with Child-Pugh class B cirrhosis and α-fetoprotein ≤100xa0ng/ml, and 9xa0months for patient with Child-Pugh class A cirrhosis and α-fetoprotein >100xa0ng/ml (Pu2009<u20090.01).ConclusionsComplete necrosis and absence of residual tumor positively affect survival after RFA. In patients with Child-Pugh A cirrhosis and α-fetoprotein level ≤100 radio frequency, ablation have results, 55% after 3xa0years, that are comparable to those of surgical resection. Patients with Child-Pugh B cirrhosis and/or α-fetoprotein >100xa0ng/ml showed less satisfactory results, and in these patients, multimodality treatment or other treatments should be considered.

Treatment of ruptured abdominal aortic aneurysm after endovascular abdominal aortic repair: A comparison with patients without prior treatment.

OBJECTIVEnA retrospective analysis of immediate outcomes following aneurysm rupture (rAAA) in two groups: patients previously treated at our center with primary endovascular repair (EVAR) and patients without previous EVAR for abdominal aortic aneurysms (AAA) in an 8-year period.nnnMETHODSnFourteen patients with a confirmed rAAA identified throughout the follow-up period following primary EVAR repair at our center (from a population of 820 AAA treated at our center in election) were retrospectively compared with 155 patients without previous EVAR in the same time period, from the introduction of an intention-to-treat protocol with EVAR for rAAA in January 1999. Primary study outcomes included 30-day mortality and severe systemic complications following rAAA correction with both open and EVAR treatments.nnnRESULTSnIn the 14 patients secondary interventions were necessary throughout follow-up prior to rupture in 43% (6/14). The mean time to rupture was 50.23 months (9-113). The mean increase in maximum aneurysmal diameter at rupture was 18.39 mm. Type of endoleaks observed at rupture: 35.7% I proximal, 35.7% III contralateral stump disconnection, 14.3% I distal, 14.3% III midgraft tear: treatment at rupture included five EVAR corrections with aortouniiliac endografts, four EVAR corrections with extensions, and five surgical conversions. Thirty-day mortality between the two groups, 28.5% (patients with prior EVAR) 38.7% (patients without prior EVAR), and severe systemic complications, 50% vs 37.6%, were not found to be statistically significant. Hemodynamic instability, 36% (patients with prior EVAR) 63% (patients without prior EVAR), was found to be an independent predictor of 30-day mortality (P < .0001), whereas severe systemic complications, 50% vs 33.5%, did not influence the same outcome (P = .852).nnnCONCLUSIONSnIn terms of mortality, it would be logical to expect a protection from the endograft in patients with previous EVAR. A trend seems to confirm this assumption, but no statistical significance was found, which may be due to the small population size.

Endovascular treatment of abdominal aortic aneurysms with the Powerlink Endograft System: influence of placement on the bifurcation and use of a proximal extension on early and late outcomes.

OBJECTIVEnWe evaluated the influence of placement of the bifurcated Powerlink endograft (Endologix Inc, Irvine, Calif) on the aortic bifurcation, with the addition of a proximal extension, in the endovascular treatment (EVAR) of selected patients with atherosclerotic abdominal aortic aneurysms (AAAs).nnnMETHODSnFrom September 1999 to June 2007, 205 patients were treated with the bifurcated Powerlink endograft for atherosclerotic AAA at two Italian centers with shared protocols. Patients were retrospectively divided in two groups according to treatment with the bifurcated graft only (n = 126), or its placement on the bifurcation with the addition of a proximal extension (n = 79) at the initial procedure. Study end points included postoperative complications, secondary procedures, immediate and late conversion, migration, endoleak, death, and aneurysmal sac behavior.nnnRESULTSnOverall technical success was 98.5%. Additional procedures were performed in 18%, and postoperative complications occurred in 11.2% (systemic, 8.3%; local, 2.9%). Median follow-up was 42.4 months (range, 6-94 months). Secondary procedures were recorded in 11.2%, migration in 3.9%, type I proximal endoleak in 7.8%, and late conversions in 2.4%. Placement on the bifurcation and the addition of an extension were associated with a higher incidence of postoperative complications (7.1% vs 17.7%, P = .020). A reduced incidence of endoleak (19% vs 8.9%, P = .048), secondary procedures (14.3% vs 6.3%, P = .04), and migration (6.3% vs 0%, P = .024) were observed in the group with a proximal extension. Analysis of single variables reveals that migration was significantly influenced by placement of the graft on the bifurcation (47% vs 0%, P < .001). Both placement on the bifurcation and the addition of an extension positively influenced the type I proximal endoleak rate (3.8% vs 35.3% P < .001) and the need for a secondary intervention (6.3% vs 35.3% P < .001) Two aneurysm ruptures and five cases of late conversion occurred in the group treated with a bifurcated graft only (4%, P = .52, P = .159). Analysis of aneurysm sac behavior was not statistically significant: enlargement, 4.1% vs 1.3% (P = .158); reduction, 34.1% vs 40.5% (P = .542).nnnCONCLUSIONnThe placement of the bifurcated Powerlink endograft on the aortic bifurcation with a proximal extension for complete sealing seems to improve late outcomes, particularly secondary procedures, migration, and endoleak development. Larger prospective studies with longer follow-up are necessary to confirm these promising results.

Metastases to the para‐aortic lymph nodes in adenocarcinoma of the cardia

OBJECTIVEnTo find out the extent of involvement of the para-aortic nodes in patients with adenocarcinoma of the gastric cardia.nnnDESIGNnOpen prospective study.nnnSETTINGnTeaching hospital, Italy.nnnSUBJECTSn23 patients with advanced adenocarcinoma of the cardia (type II, n = 10, and type III, n = 13) who were treated by total gastrectomy with resection of the distal oesophagus and extended lymphadenectomy (D4) between January 1997 and June 1999. These were compared with 21 patients with advanced carcinoma of the proximal third of the stomach who had total gastrectomy with D4 lymphadenectomy during the same period. Lymph nodes were retrieved immediately postoperatively and assigned to the appropriate station according to the classification of the Japanese Research Society for Gastric Cancer.nnnMAIN OUTCOME MEASURESnNumber of para-aortic and other nodes involved.nnnRESULTSn22 of the 23 patients had lymph node metastases, and in 5 the para-aortic nodes were involved (N4). N3 lymph nodes were involved in only 1 patient, despite involvement of para-aortic nodes. Among the 5 patients with N4 metastases, 1 had only N1 metastases in addition, with no involvement of N2 or N3 nodes. Patients with involved N4 nodes had more nodes involved overall than those who did not (mean (SD) 17 (5) compared with 8 (12)).nnnCONCLUSIONSn5/23 patients with advanced carcinoma of the cardia had involved para-aortic nodes. This may have some prognostic value, but larger studies of D4 lymphadenectomy specimens is required.

Thoracic Endograft for Abdominal Aortic Aneurysms, an Unusual Application for Severe Neck Angulation: Case Report and Literature Review

Our goal was to achieve complete proximal sealing in severe aortic neck angulation (SNA) during endovascular aneurysm repair (EVAR) of a patient with an abdominal aortic aneurysm (AAA) unfit for surgery. An 82-year-old patient with an infrarenal AAA of 9.8 cm with an SNA of 90° was admitted for acute coronary syndrome. Following coronary treatment, the patient was considered unfit for surgery and therefore was evaluated for EVAR. Aneurysm sac exclusion was obtained with the deployment of a Powerlink bifurcated graft (Endologix Inc, Irvine, CA) inside a Relay thoracic endograft (Bolton Medical, Florida) placed just below the most distal renal artery. At 6 months, computed tomographic angiography confirmed correct graft placement, complete aneurysm exclusion, and a reduction in the aneurysmal sac. In AAA patients with an SNA at high risk of EVAR failure, the adaptability of a thoracic endograft could be considered for proximal sealing.

Bifurcated coronary stents for infrapopliteal angioplasty in critical limb ischemia

OBJECTIVEnThe goal of this article is to report the preliminary results of infrapopliteal percutaneous transluminal angioplasty stenting with the Nile Croco coronary bifurcated stent (Minvasys, Gennevilliers, France) for selected patients with critical limb ischemia (CLI).nnnMETHODSnFrom October 2006 to December 2010, 31 patients with CLI with below-the-knee TransAtlantic Inter-Society Consensus C and D lesions at the popliteal (n = 17, 54.8%) and distal tibioperoneal trunk (n = 14, 45.2%) bifurcations, with suboptimal primary percutaneous transluminal angioplasty results (residual stenosis >30%, elastic recoiling, or dissection), with at least two-vessel runoff to the foot (present or after percutaneous transluminal angioplasty), free of aortoiliac arterial disease, and at high surgical risk (more than three risk factors) were treated with the Nile Croco coronary bifurcated stent. Study end points included technical success, immediate and midterm primary and secondary patency rates, clinical improvement, and limb salvage.nnnRESULTSnTechnical success was achieved in all patients (100%) without any intraoperative complications. Early complications included an acute stent occlusion and an acute compartment syndrome for a collateral arterial branch perforation. Median follow-up was 12.1 months (range, 1-32). Primary and secondary patency rates were 96.7% and 86.2% (95% confidence interval [CI], 67.2%-94.6%) at 30 days and and 100% and 96.6% (95% CI, 78.0%-99.5%) at 1 year, respectively. Clinical improvement (an upward shift of at least two Rutherford categories) was achieved in 28 patients (90.3%). A major amputation was required in one patient (3.2%). The overall limb salvage rate at 1 year was 96.7% (95% CI, 78.6%-99.5%).nnnCONCLUSIONSnPreliminary data suggest that the Nile Croco bifurcated stent for below-the-knee angioplasty in selected patients with CLI is associated with high rates of technical success, early and midterm patency, and clinical improvement. Limb salvage rates are acceptable for this technically highly challenging anatomy, yet further studies with larger patient populations are necessary to validate these results.

[Endoscopic, percutaneous and laparoscopic treatment for acute biliary pancreatitis].

Resume But de l’etudexa0: Le but de ce travail a ete d’evaluer les resultats du traitement endoscopique d’une serie de pancreatites aigues d’origine biliaire et d’en discuter les indications. Materiel et methodexa0: De janvier 1992 a juin 2001, 137 patients ont ete pris en charge pour une pancreatite aigue biliaire. Les criteres du diagnostic et de gravite reposaient sur des donnees cliniques, biochimiques et radiologiques. Les patients avec instabilite hemodynamique etant exclus, un groupe de 129 patients a ete traite par cholangiopancreatographie retrograde endoscopique (CPRE) comportant une eventuelle sphincterotomie ou, en cas d’echec, une cholecystostomie percutanee echo-guidee (CPC), puis, a distance, une cholecystectomie par voie cœlioscopique. Resultatsxa0: Une CPRE a ete realisee avec succes chez 121 des 129 patients (93xa0%). Une CPC a ete realisee en cas d’echec de l’endoscopie (nxa0=xa05) et en cas de cholecystite aigue (nxa0=xa014). Les cholangiographies par voie retrograde ou percutanee ont permis de retrouver des calculs de la voie biliaire chez 89 malades, une dilatation des voies biliaires sans lithiase chez 26 et aucune anomalie dans six cas. Une sphincterotomie endoscopique a ete realisee chez 117 malades. Une cholecystectomie a ete realisee 118 fois. Mortalite et morbidite ont ete respectivement de 1,6 et 10,3xa0%. Conclusionxa0: La CPRE avec sphincterotomie nous semblent indiquees dans tous les cas de PAB observees pendant les premieres 72 heures. Le traitement endoscopique associe aux procedures percutanees permet de reduire a un taux tres faible les cas qui evoluent defavorablement. Un traitement definitif peut enfin etre realise par cholecystectomie cœlioscopique elective.

Envahissement des ganglions para-aortiques dans les adénocarcinomes de l'estomac.

But de letude : Analyse de lincidence des metastases ganglionnaires au niveau des relais para-aortiques (N4) en fonction du siege de la tumeur afin de mieux preciser la place du curage super elargi (D4) dans le traitement du cancer de lestomac. Patients et methode : Letude a porte sur la frequence des metastases des ganglions para-aortiques. De juin 1988 a octobre 1999, 110 malades ayant un cancer gastrique ont eu une gastrectomie avec curage D4, cinq cas de linite plastique et trois cas de carcinome du moignon gastrique ont ete exclus. Resultats: La mortalite postoperatoire a ete de 2,7 % (n = 3) et la morbidite de 29,1 % (n = 32). Les complications postoperatoires les plus frequentes ont ete les fistules pancreatiques (7,3 %) et les complications respiratoires (6,4 %). Au total, 5 245 ganglions ont ete reseques chez 110 patients (moyenne : 47,7 ganglions par patient). Il y avait 639 ganglions para-aortiques (moyenne: 5,8 ganglions par patient). Un envahissement ganglionnaire a ce niveau a ete constate chez 20 patients (18,2 %). La tumeur etait localisee au tiers superieur de lestomac chez 12 patients (33 %), au tiers moyen chez deux (6 %) et au tiers inferieur chez six (15 %). Conclusion : La presence de ganglions metastatiques au relais para-aortique dans 18,2 % des cas souligne limportance du curage D4 dans le traitement a visee curative du cancer avance de lestomac surtout lorsquil est localise au tiers superieur (N4 + dans 33 % des cas).

Use of combined thoracic and abdominal endografts for proximal severe neck angulation in abdominal aortic aneurysms.

Purpose To evaluate endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAA) with severe neck angulation (SNA) utilizing a thoracic endograft placed proximal to a bifurcated endograft. Methods A retrospective review was conducted of 28 consecutive EVAR patients (25 men; mean age 71 years, range 62–86) with proximal SNA ≥60° treated electively between December 2006 and May 2011. The average AAA neck diameter was 23 mm (range 22–28), with a mean length of 25 mm (range 10–51) and a mean maximum sac diameter of 63 mm (range 55–98). The mean neck angulation was 73° (range 60–92). All patients received an endograft designed for the thoracic aorta (Relay) placed as a proximal extension above a bifurcated abdominal aortic endograft (IntuiTrak Powerlink). Results Technical success was achieved in 100% of cases. An intraoperative type I proximal endoleak was successfully treated with stent deployment, and 2 type II endoleaks spontaneously resolved within 30 days. In all 28 patients, endograft integrity and correct positioning were confirmed at the latest imaging follow-up (mean 23.7 months, range 6–43). Fifteen (56%) aneurysm sacs were stable and 13 (46%) were reduced in size. Two patients died of unrelated causes during follow-up. Conclusion The unique morphology of SNA requires the development of a precise proximal fixation technology for successful endovascular repair. This hybrid solution exploits the technological advances of the thoracic aortic endograft and the stability of an anatomically fixed bifurcated endograft. This device combination may be an alternative solution for patients with SNA who are unsuitable for traditional surgery.