Guidelines on the diagnosis, treatment and management of visceral and renal arteries aneurysms: a joint assessment by the Italian Societies of Vascular and Endovascular Surgery (SICVE) and Medical and Interventional Radiology (SIRM).

The objective of these Guidelines is to provide recommendations for the classification, indication, treatment and management of patients suffering from aneurysmal pathology of the visceral and renal arteries. The methodology applied was the GRADE-SIGN version, and followed the instructions of the AGREE quality of reporting checklist. Clinical questions, structured according to the PICO (Population, Intervention, Comparator, Outcome) model, were formulated, and systematic literature reviews were carried out according to them. Selected articles were evaluated through specific methodological checklists. Considered Judgments were compiled for each clinical question in which the characteristics of the body of available evidence were evaluated in order to establish recommendations. Overall, 79 clinical practice recommendations were proposed. Indications for treatment and therapeutic options were discussed for each arterial district, as well as follow-up and medical management, in both candidate patients for conservative therapy and patients who underwent treatment. The recommendations provided by these guidelines simplify and improve decision-making processes and diagnostic-therapeutic pathways of patients with visceral and renal arteries aneurysms. Their widespread use is recommended.

Twenty-Five Year Multicentre Experience of Explantation of Infected Abdominal Aortic Endografts.

We report a multicenter experience of open conversions (OC) for aortic endograft infections (AEI). We retrospectively analyzed all patients who underwent OC for AEI after endovascular aneurysm repair (EVAR), from 1997 to 2021 in 12 Italian centers. The endpoints were as follows: mortality (30-days, in-hospital), major postoperative complications. Follow-up data included: survival, aortic-related complications, infection persistence or reoccurrence. Fifty-eight patients (mean age: 73.8 ± 6.6 years) were included. Median time from EVAR to OC was 14 months (interquartile range 7-45). Thirty-five patients (60.3%) were symptomatic at presentation. Aortic reconstruction was anatomic in 32 patients (55.2%), extra-anatomic in 26 (44.8%). Thirty-day mortality was 31% (18/58). Six additional patients died after 30 days during the same hospitalization (in-hospital mortality: 41.4%). Most common post-operative complications included respiratory failure (38.6%) and renal insufficiency (35.1%). During 28.1 ± 4 months follow-up, 4 aneurysm-related deaths were recorded. Infection re-occurred in 29.4% of the patients. Estimated survival was 50% at 1 year, and 30% at 5 years, and was significantly lower for patients who underwent extra-anatomic reconstructions (37 vs 61% at 1 year, 16 vs 45% at 5 years; log-rank P = .021). OC for AEI is associated with high early mortality. The poor mid-term survival is influenced by aortic complications and infection re-occurrence.

Long-term outcomes of endovascular aortic repair with flared iliac limb endografts in patients with abdominal aortic aneurysm and aneurysmal common iliac arteries.

BACKGROUND: The aim of this study was to evaluate the long-term outcomes of endovascular aneurysm repair with flared iliac limb grafts in patients with abdominal aortic aneurysm (AAA) and aneurysmal common iliac arteries (CIAs). METHODS: This is a multicenter, retrospective, observational cohort study that involves four tertiary referral hospitals between May 1, 2005, and April 30, 2019. Primary outcomes were freedom from aneurysm-related mortality (ARM), and freedom from iliac-related reintervention. RESULTS: We studied 995 aneurysmal iliac limbs in 795 (85.2%) patients who met the inclusion criteria. Median AAA diameter was 55mm (IQR: 51-60). Early mortality occurred in 3 (0.4%) patients. The median of follow-up time was 52 months (IQR: 26-88). Estimated freedom from ARM was 99±0.002% (95% CI: 99-99.9) at 1 year, and 99±0.004% (95% CI: 97.9-99.6) at 5-years. Chronic obstructive pulmonary disease (HR=6.4, 95% CI: 1.7-24.0, P=0.006), chronic kidney disease (HR=5.5, 95% CI: 1.4-21.9, P=0.016), and the presence of an aneurysmal left CIA (HR=5.3, 95% CI: 1.0.5-27.4, P=0.044) was associated with ARM. There were 42 (7.3%) late iliac-related events (limb occlusion, N.=5; iliac-related endoleaks, N.=37). Estimated freedom from iliac-related reintervention was 98±0.003% (95% CI: 97-99) at 1 year, and 95±0.01% (95% CI: 92.7-96.7) at 5-years, which was associated with an aneurysmal right CIA (HR=2.2, 95% CI: 1.3-3.9; P=0.005), and age ≥78 years (HR=1.9, 95% CI: 1.01-1.3; P=0.039). CONCLUSIONS: EVAR flared iliac limb grafts showed a high rate of freedom from ARM and a low reintervention rate. Owing to these results, it can be a durable and stable alternative for patients aged >78 years.

Pain control in laparoscopic surgery: a case-control study between transversus abdominis plane-block and trocar-site anesthesia.

Local anesthesia in laparoscopic operations is gaining increasing consensus. To standardize analgesia, a prospective case-control study was created over a 1-year period, in collaboration with the anesthesiology service in our community hospital. Starting from February 2016, we prospectively enrolled adult patients (more than 16 years old) undergoing laparoscopic appendectomy or cholecystectomy, either in emergency or elective setting. Patients were preoperatively assigned (based on the chart-admission number) either to transversus abdominis plane (TAP) block treatment (Group 1-experimental arm) or trocar-site anesthesia (TSA) (Group 2-experimental arm), and then compared with group of patients not submitted to treatment (Group 3-control arm). Demographic and clinical characteristics of each patient were recorded. Post-operative pain level (primary outcome) was assessed with visual analog scale (VAS) score; analgesic use and length of stay in hospital were defined as secondary outcomes. Forty-two patients were assigned to TAP block treatment (Group 1), fifty-two to TSA (Group 2), and thirty-nine underwent no pre-incisional treatment (Group 3). In the comparison between patients undergoing TAP block or TSA with the control arm, a significance difference in reported pain was recorded in every scheduled time (p < 0.05 at 0, 6, 12, 18, 24, and 48 h from awakening). Both local anesthesia groups share a benefit in terms of primary outcome. The use of pre-incisional TSA for all the patients undergoing laparoscopic cholecystectomy and appendectomy could become a routine practice to reduce post-operative pain both in the elective and emergency setting.

Overall and disease-free survival in patients treated with CRS + HIPEC with cisplatin and paclitaxel for gastric cancer with peritoneal carcinomatosis.

BACKGROUND: Our experience regarding cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) was reviewed in terms of overall survival (OS) and disease-free survival (DFS) in patients with synchronous peritoneal carcinomatosis (SPC) and metachronous peritoneal carcinomatosis (MPC) from gastric cancer (GC). METHODS: An analysis of prospectively collected data about patients who underwent CRS and HIPEC from July 2011 to July 2016 was carried out. Patients and tumor characteristics were taken into consideration together with pre and post-operative data. The outcomes concerned OS and DFS in both groups. RESULTS: A total of 17 cases were reported. All patients of SPC group underwent neoadjuvant chemotherapy, while all patients of MPC group underwent adjuvant chemotherapy subsequently to surgery of the primary tumor. The mean follow up period was 9 months (SD±9.5). Thirteen patients (76.5%) had SPC and four (23.5%) had MPC. The mean total Peritoneal Cancer Index (PCI) was 8.5 (SD±8.4). The mean PCI was 3.75 (SD±4.9) for SPC group and 16 (SD±9.5) for MPC (P=0.003). HIPEC regimen was cisplatin plus paclitaxel for fourteen patients (82.4%) and cisplatin plus mitomycin-C (MMC) for three patients (17.6%). OS was 16 months and 6 months respectively in patients with SPC and MPC (P=0.189). DFS was 11 months and 2 months respectively in the two groups (P=0.156). Patients with SPC patients and PCI ≥12 were significantly different in terms of DFS from SPC with PCI <12 (P=0.001). Overall, twelve patients had postoperative major complications (CTCAE>2), in particular eight (61%) in SPC group while four (100%) in MPC group. Our study showed significantly better DFS for patients aged >60 years (P=0.016). CONCLUSIONS: HIPEC and CRS with cisplatin and paclitaxel in patients with PC from GC showed promising results in improving the DFS and the OS, particularly for patients with PCI <12 and for those aged >60. Although a high incidence of complications was revealed, especially in MPC group.

Distant nodal metastasis: is it always an unresectable disease?

This article aims at analyzing the published literature concerning the treatment of patients with gastric cancer and distant nodal metastases, actually considered metastatic disease. A systematic search was undertaken using Medline, Embase, Cochrane and Web-of-Science libraries. No specific restriction on year of publication was used; preference was given to English papers. Both clinical series and literature reviews were selected. Only 11 papers address the issue of surgery for nodal basins outside the D2 dissection area. From these papers, in selected cases extended surgery may prove useful in prolonging survival, when a comprehensive therapeutic pathway including chemotherapy is scheduled. In conclusion, in presence of nodal metastases outside the loco-regional nodes, surgery may be considered for metastatic nodes in stations 13 and 16, in selected cases.

Hepatoblastoma of the adult: A systematic review of the literature.

Hepatoblastoma is the most common malignant liver tumor in children. On the other hand in the adult HB is very rare and characterized by unfavorable prognosis. A review of the entire literature was performed: 58 articles and 63 cases of HB were found. The patient's data were collected and analyzed. No correlation with hepatitis virus was found and AFP was elevated in most cases. Usually HB forms a large single mass in the liver and presents aggressive behavior, with local invasiveness and metastatic spread. The current median survival time is 5 months, with a 1-year survival rate near 30%. Surgical resection is the only curative treatment. However major liver resections or extensive demolitions of the adjacent organs are necessary. There are no standardized protocols in the multimodal approach to this tumor.