Endoconduits with "Pave and Crack" Technique Avoid Open Ilio-femoral Conduits with Sustainable Mid-term Results.

OBJECTIVE/BACKGROUND: The objective was to evaluate the feasibility and mid-term outcomes of endoconduits (EC) with the "pave and crack" technique during endovascular aneurysm repair (EVAR) of varying complexity. METHODS: This was a retrospective study. All patients undergoing EC between July 2009 and October 2015 were included. The primary endpoint was technical success of the EC defined as the ability to successfully deliver the aortic stent graft through the EC without rupture, dissection, or thrombosis of the iliac or femoral arteries, and with the absence of haemodynamically significant blood loss related to the EC. Secondary outcomes included EC patency and mortality. RESULTS: Nineteen patients underwent EVAR with EC (16 juxtarenal or thoraco-abdominal, two infrarenal and one thoracic; four were ruptured). Fourteen patients (73.7%) had TASC D lesions. In 10 cases (52.6%) adjunctive open/endovascular procedures to improve the femoral outflow were required. EC was technically successful in all cases and all EC were patent at EVAR completion. Thirty day mortality occurred in two cases (10.5%) One of these patients had been treated for rupture. One patient required two endovascular re-interventions at 1 and 5 years post-operatively to restore patency of the EC. No open re-interventions related to the EC were necessary. After a median follow-up period of 17 (interquartile range 5-37) months, the primary assisted patency of the EC was 88.9% (SE 10.5). No new onset of claudication or lower limb amputations occurred during the follow-up. CONCLUSION: EC allows EVAR of varying complexity without the need for open surgical ilio-femoral conduits in patients with concomitant advanced iliac occlusive disease. Intra-operative haemodynamic instability was always avoided and mid-term patency was high.

Ultrastructural analysis of different-made staplers' staples.

AIM: Recently, Chinese-made mechanical staplers with lower price respect to American-made ones have been introduced in clinical practice. In literature, small case series compare the clinical outcomes of different staplers concluding that the new stapler devices perform as well as the American ones. The aim of this study is to compare with an ultrastructural analysis the staples of different staplers in order to verify the existence of differences that might explain significant price disparity and condition clinical outcomes. METHODS: Each stapler was subjected to morphological analysis, energy dispersive X-Ray spectroscopy, metal release assessment followed by inductively coupled plasma mass spectroscopy. P-values were considered statistically significant when <0.05. RESULTS: Autosuture staples have square section whereas the other American one and Chinese made staples have round sections. Roughness index and chips presence before and after ageing tests were comparable for all samples except for Ethicon Endo-Surgery stapler. Energy dispersive X-Ray spectroscopy showed that all staplers are made of pure Titanium but Ethicon Endo-Surgery staples are made with an alloy. Metal release analysis release statistically significant differences between samples in simulated body fluid 20 days solution (P=0.002) and in Aquaregia at 14 days solution. Discussion. Stapling devices have became routinely used in gastrointestinal surgery mainly because of operative time reduction. Recently, new Chinese-made mechanical staplers, with significantly lower prices, have been introduced in clinical practice. In literature, there are some studies that compare clinical outcomes of American-made and Chinese-made staplers on small groups of patients but doesn't exist any work which consider structural differences between traditional and new devices. In our study, for the first time, we propose a comparison between two American-made staplers and three Chinese-made staplers which evaluate morphology, metal composition and chemical staples release. CONCLUSION: Our study suggest that there are some ultrastructural differences between commercially available staplers with no correlation to price disparity. More studies are needed to confirm our results and to verify if our findings could condition clinical outcomes.

Idiopathic ileo-colonic varices in a young patient.

Colonic varices are an infrequent cause of rectal bleeding and haematochezia and they are often related to portal hypertension due to either haepatopathy or any other cause of obstruction of the portal circulation. A 20-year-old patient was studied after she suffered a serious episode of rectal bleeding, followed by syncope. In view of her clinical picture of serious rectal bleeding, which could not be kept under control by means of medical therapy or endoscopy, the patient underwent total video laparoscopic colectomy surgery with ileum-rectum anastomosis. The histological examination revealed prominent ectasia presence of venous vessels under the mucosa. Colonic varices are one of the most common causes of low gastroenteric bleeding and in most cases they are caused by portal hypertension or intestinal occlusion. In less common cases, they are caused by thrombosis of the splenic vein, cardiac insufficiency, venous mesenteric thrombosis, extrinsic compression on tumoral invasion. Idiopathic colonic varices are described in the literature as the cause of low gastroenteric bleeding in not more than 20 patients. Therapeutic options are conservative follow-up or surgery. As it happened in our case, surgery is generally the chosen treatment, in view of the risk of recurring bleeding, the young age of patients and the low degree of co-morbidity of patients. The prognosis for surgery of idiopathic colonic varices is very good at any age when compared with the one for the treatment of varices caused by cirrhosis of the liver, thus confirming the importance of diagnosing idiopathic varices, only after having ruled out the presence of other basic pathologies.