Locally recurrent rectal cancer: Oncological outcomes for patients with a pathological complete response after neoadjuvant therapy.

BACKGROUND: For patients with locally recurrent rectal cancer, it is an ongoing pursuit to establish factors predicting or improving oncological outcomes. In locally advanced rectal cancer, a pCR appears to be associated with improved outcomes. The aim of this retrospective cohort study was to compare the oncological outcomes of patients with locally recurrent rectal cancer with and without a pCR. METHODS: Patients who underwent neoadjuvant treatment and surgery for locally recurrent rectal cancer with curative intent between January 2004 and June 2020 at a tertiary referral hospital were analysed. Primary outcomes included overall survival, disease-free survival, metastasis-free survival, and local re-recurrence-free survival, stratified according to whether the patient had a pCR. RESULTS: Of a total of 345 patients, 51 (14.8 per cent) had a pCR. Median follow-up was 36 (i.q.r. 16-60) months. The 3-year overall survival rate was 77 per cent for patients with a pCR and 51.1 per cent for those without (P < 0.001). The 3-year disease-free survival rate was 56 per cent for patients with a pCR and 26.1 per cent for those without (P < 0.001). The 3-year local re-recurrence-free survival rate was 82 and 44 per cent respectively (P < 0.001). Surgical procedures (for example soft tissue, sacrum, and urogenital organ resections) and postoperative complications were comparable between patients with and without a pCR. CONCLUSION: This study showed that patients with a pCR have superior oncological outcomes to those without a pCR. It may therefore be safe to consider a watch-and-wait approach in highly selected patients, potentially improving quality of life by omitting extensive surgical procedures without compromising oncological outcomes.

Predicting in-hospital mortality in acute type B aortic dissection: evidence from International Registry of Acute Aortic Dissection.

BACKGROUND: The outcome of patients with acute type B aortic dissection (ABAD) is strongly related to their clinical presentation. The purpose of this study was to investigate predictors for mortality among patients presenting with ABAD and to create a predictive model to estimate individual risk of in-hospital mortality using the International Registry of Acute Aortic Dissection (IRAD). METHODS AND RESULTS: All patients with ABAD enrolled in IRAD between 1996 and 2013 were included for analysis. Multivariable logistic regression analysis was used to investigate predictors of in-hospital mortality. Significant risk factors for in-hospital death were used to develop a prediction model. A total of 1034 patients with ABAD were included for analysis (673 men; mean age, 63.5±14.0 years), with an overall in-hospital mortality of 10.6%. In multivariable analysis, the following variables at admission were independently associated with increased in-hospital mortality: increasing age (odds ratio [OR], 1.03; 95% confidence interval [CI], 1.00-1.06; P=0.044), hypotension/shock (OR, 6.43; 95% CI, 2.88-18.98; P=0.001), periaortic hematoma (OR, 3.06; 95% CI, 1.38-6.78; P=0.006), descending diameter ≥5.5 cm (OR, 6.04; 95% CI, 2.87-12.73; P<0.001), mesenteric ischemia (OR, 9.03; 95% CI, 3.49-23.38; P<0.001), acute renal failure (OR, 3.61; 95% CI, 1.68-7.75; P=0.001), and limb ischemia (OR, 3.02; 95% CI, 1.05-8.68; P=0.040). Based on these multivariable results, a reliable and simple bedside risk prediction tool was developed. CONCLUSIONS: We present a simple prediction model using variables that are independently associated with in-hospital mortality in patients with ABAD. Although it needs to be validated in an independent population, this model could be used to assist physicians in their choice of management and for informing patients and their families.

Late Conversion After Sac Anchoring Endoprosthesis for Secondary Aortic Aneurysm Infection.

PURPOSE: To demonstrate explantation of the Nellix Endovascular Aneurysm Sealing (EVAS) System in the setting of infection. CASE REPORTS: Two male patients, 71 and 83 years old, underwent Nellix implantation for asymptomatic infrarenal aortic aneurysms measuring 5.1 and 6.3 cm, respectively. Each developed late infections at 8 and 4 months post EVAS, respectively. The first patient experienced aneurysm rupture after medical therapy failed; the Nellix endosystem was explanted in an uneventful procedure. The second patient developed an aortoduodenal fistula, which was sutured before the Nellix device was removed without complications. The patient died 3 months later, presumably due to ongoing infection. CONCLUSION: The need to explant a Nellix EVAS System due to graft infection is a straightforward procedure compared to the removal of a conventional endograft with suprarenal fixation. It requires only temporary suprarenal clamping. The devices can be easily removed due to the lack of penetrating components and without damage to the aortic segment needed to create an anastomosis.

Biomechanical Changes After Thoracic Endovascular Aortic Repair in Type B Dissection: A Systematic Review.

Thoracic endovascular aortic repair (TEVAR) has evolved into an established treatment option for type B aortic dissection (TBAD) since it was first introduced 2 decades ago. Morbidity and mortality have decreased due to the minimally invasive character of TEVAR, with adequate stabilization of the dissection, restoration of true lumen perfusion, and subsequent positive aortic remodeling. However, several studies have reported severe setbacks of this technique. Indeed, little is known about the biomechanical behavior of implanted thoracic stent-grafts and the impact on the vascular system. This study sought to systematically review the performance and behavior of implanted thoracic stent-grafts and related biomechanical aortic changes in TBAD patients in order to update current knowledge and future perspectives.

Complex Iatrogenic Dissection Complicating Thoracic Endovascular Aneurysm Repair.

BACKGROUND: To report one the most feared complication of thoracic endovascular aneurysm repair (TEVAR); a retrograde aortic dissection who can involve the aortic arch or ascending aorta, which require commonly coextensive open surgical repair. CASE REPORTS: We report 2 cases of combined retrograde and antegrade dissection after endovascular treatment of an aneurysm of the descending aorta. In both cases, a dissection was identified at short-term follow-up; which required open surgical repair in one case and an additional endovascular treatment for the second case. CONCLUSIONS: The incidence of extensive iatrogenic dissection after TEVAR is relatively low, open repair should be considered as a primary option in some cases with limited aortic dilatation to avoid such life-threatening complications.

Predictors of aortic growth in uncomplicated type B aortic dissection.

BACKGROUND: Patients with uncomplicated acute type B aortic dissection (ABAD) generally can be treated with conservative medical management. However, these patients may develop aortic enlargement during follow-up, with the risk for rupture, which necessitates intervention. Several predictors have been studied in recent years to identify ABAD patients at high risk for aortic enlargement who may benefit from early surgical or endovascular intervention. This study systematically reviewed and summarized the current available literature on prognostic variables related to aortic enlargement during follow-up in uncomplicated ABAD patients. METHODS: Studies were included if they reported predictors of aortic growth in uncomplicated ABAD patients. Studies about type A aortic dissection, aortic aneurysm, intramural hematoma, or ABAD that required acute intervention were excluded. RESULTS: A total of 18 full-text articles were selected. The following predictors of aortic growth in ABAD patients were identified: age <60 years, white race, Marfan syndrome, high fibrinogen-fibrin degradation product level (≥20 µg/mL) at admission, aortic diameter ≥40 mm on initial imaging, proximal descending thoracic aorta false lumen (FL) diameter ≥22 mm, elliptic formation of the true lumen, patent FL, partially thrombosed FL, saccular formation of the FL, presence of one entry tear, large entry tear (≥10 mm) located in the proximal part of the dissection, FL located at the inner aortic curvature, fusiform dilated proximal descending aorta, and areas with ulcer-like projections. Tight heart rate control (<60 beats/min), use of calcium-channel blockers, thrombosed FL, two or more entry tears, FL located at the outer aortic curvature, and circular configuration of the true lumen were associated with negative or limited aortic growth. CONCLUSIONS: Several predictors might be used to identify those ABAD patients at high risk for aortic growth. Although conservative management remains indicated in uncomplicated ABAD, these patients might benefit from closer follow-up or early endovascular intervention.

Aortic hemodynamics after thoracic endovascular aortic repair, with particular attention to the bird-beak configuration.

PURPOSE: To quantitatively evaluate the impact of thoracic endovascular aortic repair (TEVAR) on aortic hemodynamics, focusing on the implications of a bird-beak configuration. METHODS: Pre- and postoperative CTA images from a patient treated with TEVAR for post-dissecting thoracic aortic aneurysm were used to evaluate the anatomical changes induced by the stent-graft and to generate the computational network essential for computational fluid dynamics (CFD) analysis. These analyses focused on the bird-beak configuration, flow distribution into the supra-aortic branches, and narrowing of the distal descending thoracic aorta. Three different CFD analyses (A: preoperative lumen, B: postoperative lumen, and C: postoperative lumen computed without stenosis) were compared at 3 time points during the cardiac cycle (maximum acceleration of blood flow, systolic peak, and maximum deceleration of blood flow). RESULTS: Postoperatively, disturbance of flow was reduced at the bird-beak location due to boundary conditions and change of geometry after TEVAR. Stent-graft protrusion with partial coverage of the origin of the left subclavian artery produced a disturbance of flow in this vessel. Strong velocity increase and flow disturbance were found at the aortic narrowing in the descending thoracic aorta when comparing B and C, while no effect was seen on aortic arch hemodynamics. CONCLUSION: CFD may help physicians to understand aortic hemodynamic changes after TEVAR, including the change in aortic arch geometry, the effects of a bird-beak configuration, the supra-aortic flow distribution, and the aortic true lumen dynamics. This study is the first step in establishing a computational framework that, when completed with patient-specific data, will allow us to study thoracic aortic pathologies and their endovascular management.

Use of Chimney graft after accidental coverage of the left common carotid artery in TEVAR procedure.

BACKGROUND: Thoracic endovascular aneurysm repair (TEVAR) is currently the therapy of first choice for most thoracic aortic disease. Because aortic stent grafts are placed in the vicinity of aortic side branches, unintentional coverage of these arteries may occur. CASE REPORT: We report a case of a 69-year-old male with an asymptomatic penetrating ulcer of the aortic arch, based at the origin of the left subclavian artery. Due to his medical story, we decided to perform an endovascular procedure with placement of a stent graft in the left hemi-ach wit previous left common carotid subclavian bypass. During the deployment of the aortic stent graft, the proximal margin of the stent graft displaced, inadvertly covering the origin of the left common carotid artery. As a bail out procedure, we successfully revascularized the left common carotid artery with the use of the chimney technique. CONCLUSION: Endovascular treatment of aortic disease has gained popularity over the last decade. Despite increasing experience, these procedures remain technically challenging. Unintentional coverage of main aortic side branches during TEVAR is a serious complication, which requires immediate intervention. The chimney technique offers a minimal invasive procedure in such case, with promising results.

Factors associated with one-year mortality after curative surgery for primary clinical T4 and locally recurrent rectal cancer in elderly patients.

INTRODUCTION: Despite advancements in colorectal cancer care, one-year post-operative mortality rates remain high for elderly patients who have undergone curative surgery for primary clinical T4 rectal cancer (cT4RC) or locally recurrent rectal cancer (LRRC). This study aimed to identify factors associated with one-year mortality and to evaluate the causes of death. MATERIALS & METHODS: This retrospective cohort study included patients aged ≥70 years who underwent surgery with curative intent for cT4RC or LRRC between January 2013 and December 2020. Clinical and follow-up data were collected and analyzed to determine survival rates and investigate factors associated with mortality within one year after surgery. RESULTS: A total of 183 patients (94 cT4RC, 89 LRRC) were included. One-year mortality rates were 16.0% for cT4RC and 28.1% for LRRC (P = 0.064). In cT4RC patients, factors associated with one-year mortality were preoperative anemia (OR 3.83, P = 0.032), total pelvic exenteration (TPE) (OR 7.18, P = 0.018), multivisceral resections (OR 5.73, P = 0.028), pulmonary complications (OR 13.31, P < 0.001) and Clavien-Dindo grade ≥ III complications (OR 5.19, P = 0.025). In LRRC patients, factors associated with one-year mortality were TPE (OR 27.00, P = 0.008), the need for supported care after discharge (OR 3.93, P = 0.041) and Clavien-Dindo grade ≥ III complications (OR 3.95, P = 0.006). The main causes of death in cT4RC and LRRC patients were failure to recover (cT4RC 26.6%, LRRC 28.0%) and disease recurrence (cT4RC 26.6%, LRRC 60.0%). CONCLUSION: In order to tailor treatment in elderly with cT4RC and LRRC, factors associated with increased one-year mortality (e.g. pre-operative anemia, TPE) should be incorporated in the decision-making process. CLINICAL TRIAL REGISTRATION: Not applicable.

Technical considerations and results of chimney grafts for the treatment of juxtarenal aneursyms.

OBJECTIVE: To present our initial experience and technical considerations for the use of chimney grafts in the treatment of patients that require endovascular aneurysm repair with aortic branch preservation. METHODS: All patients treated with a chimney procedure between October 2009 and June 2011 were included in our analyses. Chimney procedures were only performed in patients that were unsuitable for open repair and without opportunity to use fenestrated grafts (because of unsuitable anatomy or emergency operation). Open brachial or axillary access was used to deploy covered chimney grafts in the target vessels, and subsequently, a stent graft was deployed via femoral cut-down access. RESULTS: Thirteen patients (12 males; mean age, 77.2 ± 6.2 years; mean maximal diameter, 71.4 ± 10.2 mm) underwent a chimney procedure with the preservation of 22 aortic side branches. Primary technical success was 92.3% due to occlusion of one renal artery within 24 hours. Thirty-day mortality was 0%. Infrarenal mean neck length was 2.6 mm ± 3.2 mm (range, 0-8 mm) and could be extended to 27.3 mm ± 9.9 mm (range, 18-53 mm) by the use of chimney grafts. During follow-up (median, 10.8 months; interquartile range, 7.4-19.4), one patient died from complications from mesenteric ischemia based on a stenosis of the celiac trunk attributable to the bare stent of the stent graft, and one patient died from aneurysm rupture. Other complications included late occlusion of one renal artery and a type II endoleak, which was unsuccessfully treated with coil embolization and required laparotomy. If we disregard the ruptured patient who had an enormous increase of aneurysm diameter, mean aortic aneurysm diameter reduced from 70.7 ± 10.3 mm (range, 54-89 mm) to 66.7 ± 13.9 mm (range, 48-96 mm) during follow-up (P = .13). In three patients, the aneurysm diameter decreased by more than 5 mm and in two patients, the diameter increased by more than 5 mm. The aneurysm diameter remained stable in the other eight patients. CONCLUSIONS: Until off-the-shelf fenestrated or branched stent grafts become available, the chimney procedure offers a minimally invasive treatment option in patients requiring aneurysm exclusion with side branch revascularization. Although long-term follow-up has to be awaited, the initial results show that chimney grafts can help to decrease or stabilize the aneurysm diameter in most patients, but aneurysm rupture was not prevented in all patients.

The double two-chimney technique for complete renovisceral revascularization in a suprarenal aneurysm.

Suprarenal pathologies can be treated with immediately available devices with the chimney technique, which offers a bail-out in patients not eligible for a branched or fenestrated stent graft. We present an adjusted chimney technique for total renal and visceral revascularization in a patient with a suprarenal aneurysm. Although short-term results look promising, longer follow-up is anticipated.

The differences and similarities between intramural hematoma of the descending aorta and acute type B dissection.

INTRODUCTION: Aortic intramural hematoma type B (IMHB) is a variant of acute aortic syndrome, which presents with symptoms similar to classic type B aortic dissection (ABAD). However, the natural history of IMHB is not well understood. The purpose of this study was to better characterize IMHB, comparing its clinical characteristics, treatment, and in-hospital and long-term outcomes to those with classic ABAD. METHODS: A total of 107 IMHB and 790 ABAD patients enrolled in the International Registry of Acute Aortic Dissection (IRAD) between January 1996 and June 2012 were analyzed. Accordingly, differences in presentation, diagnostics, therapeutic management, and outcomes were assessed. RESULTS: As compared with the ABAD, IMHB presented predominantly in males (62% vs 33%; P < .001) at older age (69 ± 12 vs 63 ± 14; P < .001). IMHB patients more often had chest pain (80% vs 69%; P = .020) and periaortic hematoma (22% vs 13%; P = .020) and were more often treated medically (88% vs 62%; P < .001), with surgical/endovascular interventions being reserved for more complicated patients. Overall in-hospital mortality was 10% (IMHB, 7% vs ABAD, 11%; P = NS). Six out of seven IMHB deaths occurred during medical treatment, two due to aortic rupture. During follow-up in IMHB, patient mortality was 7%, and no adverse events, including progression to an aortic dissection or aortic rupture, were observed. Imaging showed significantly more aortic enlargement at the level of the descending aorta in ABAD patients (39% vs 61%; P = .034). CONCLUSIONS: Most IMHB patients can be treated medically, and aortic enlargement is less common during follow-up, which may suggest that IMHB may have a slightly more benign course compared with classic ABAD in the acute setting.

Morphologic predictors of aortic dilatation in type B aortic dissection.

BACKGROUND: Conservative management of acute type B aortic dissection (ABAD) is often associated with aortic dilatation during follow-up increasing the risk of aortic rupture. The goal of this study was to investigate whether morphologic characteristics of the dissection can predict aortic growth. METHODS: All conservatively managed ABAD patients from four referral centers were included (2000 to 2010). Aortic diameters were measured at five levels at baseline and at the last follow-up computed tomography angiography, and annual aortic growth rates were calculated for all segments. Linear regression was used to study the influence of aortic morphologic characteristics for aortic dilatation. RESULTS: Included were 62 patients (41 men) with a mean age of 60.3 ± 10.7 years. Among the 310 analyzed aortic segments, 248 (80.0%) were dissected, of which 211 (85.1%) showed aortic growth. Overall, the mean diameter increased from 36.1 ± 9.4 to 40.2 ± 11.1 mm (P < .01), which corresponds with a mean aortic growth rate of 3.1 ± 6.3 mm/y. Multivariate linear regression analysis showed that male sex (95% confidence interval [CI], 0.60-4.04; P = .005) and a saccular false lumen (95% CI, 2.07-7.81: P = .001) were associated with a significantly increased aortic growth rate. Increasing age (95% CI, -0.23 to -0.04; P = .005), increased number of entry tears (95% CI, -2.40 to -0.43; P = .005), false lumen located on the aortic outer curvature (95% CI, -4.30 to -0.38; P = .019), and a circular configuration of the true lumen (95% CI, -5.35 to -0.32; P = .027) were associated with a decreased aortic growth rate. CONCLUSIONS: Multiple morphologic characteristics appear to predict aortic dilatation in ABAD patients treated medically. Early assessment of these morphologic signs may be useful in the selection of ABAD patients who might benefit from closer radiologic surveillance or prophylactic intervention.

Influence of oversizing on outcome in thoracic endovascular aortic repair.

PURPOSE: To investigate the influence of stent-graft oversizing on device-related complications after thoracic endovascular aortic repair (TEVAR) for thoracic aortic aneurysm (TAA). METHODS: The study cohort was composed of patients enrolled in 4 clinical trials of the TAG thoracic stent-graft. A total of 337 TAA patients (222 men; mean age 72 years) treated in these trials had sufficient data for analysis of oversizing and post-procedure mortality and complications, such as endoleak, migration, rupture, and reinterventions. Mean oversizing at the proximal landing zone was 14.6% (range -3.4% to 39.7%). Patients were stratified based on the percentage of oversizing: <10% (n=85, group 1), 10%-20% (n=188, group 2), and >20% (n=64, group 3). RESULTS: Patients in group 1 had significantly larger preoperative proximal aortic diameters (32.6 vs. 31.3 vs. 28.2 mm, respectively; p<0.001) and neck lengths (6.9 vs. 5.8 vs. 5.2 cm (p=0.035). Overall, type I endoleak was the most frequent complication during the first 30 days of follow-up (35, 10.4%), but the incidences did not differ among the 3 groups (10.6% vs. 11.2% vs. 7.8%, respectively; p=0.809). Over a mean follow-up of 41.8±20.7 months, there were no significant differences in the occurrence of device-related complications among the groups, though the incidence of type I endoleaks was lower in group 2 (9.4% vs. 3.2% vs. 7.8%, respectively; p=0.073). Cox proportional hazards modeling showed no difference in the time to type I endoleak among oversizing groups [group 1 vs. 2: HR 1.24, 95% CI 0.65 to 2.36 (p=0.509) and group 3 vs. 2: HR 1.24, 95% CI 0.60 to 2.60 (p=0.562)]. CONCLUSION: The percentage of oversizing did not significantly affect the incidence of device-related complications after TEVAR for TAA. Although oversizing may enhance the radial force and help maintain a good proximal seal, additional oversizing seemed not to improve the overall outcome in this analysis. The current guidelines regarding stent-graft oversizing for TAA seem appropriate, though the correct percentage remains to be determined.

An evaluation of postoperative outcomes and treatment changes after frailty screening and geriatric assessment and management in a cohort of older patients with colorectal cancer.

INTRODUCTION: Adequate patient selection is crucial within the treatment of older patients with colorectal cancer (CRC). While previous studies report increased morbidity and mortality in older patients screened positive for frailty, improvements in the perioperative care and postoperative outcomes have raised the question of whether older patients screened positive for frailty still face worse outcomes. This study aimed to investigate the postoperative outcomes of older patients with CRC screened positive for frailty, and to evaluate changes in treatment after frailty screening and geriatric assessment. MATERIALS AND METHODS: Patients ≥70 years with primary CRC who underwent frailty screening between 1 January 2019 and 31 October 2021 were included. Frailty screening was performed by the Geriatric-8 (G8) screening tool. If the G8 indicated frailty (G8 ≤ 14), patients were referred for a comprehensive geriatric assessment (CGA). Postoperative outcomes and changes in treatment based on frailty screening and CGA were evaluated. RESULTS: A total of 170 patients were included, of whom 74 (43.5%) screened positive for frailty (G8 ≤ 14). Based on the CGA, the initially proposed treatment plan was altered to a less intensive regimen in five (8.9%) patients, and to a more intensive regimen in one (1.8%) patient. Surgery was performed in 87.8% of patients with G8 ≤ 14 and 96.9% of patients with G8 > 14 (p = 0.03). Overall postoperative complications were similar between patients with G8 ≤ 14 and G8 > 14 (46.2% vs. 47.3%, p = 0.89). Postoperative delirium was observed in 7.7% of patients with G8 ≤ 14 and 1.1% of patients with G8 > 14 (p = 0.08). No differences in 30-day mortality (1.1% vs. 1.5%, p > 0.99) or one-year and two-year survival rates were observed (log rank, p = 0.26). DISCUSSION: Although patients screened positive for frailty underwent CRC surgery less often, those considered eligible for surgery can safely undergo CRC resection within current clinical care pathways, without increased morbidity and mortality. Efforts to optimise perioperative care and minimise the risk of postoperative complications, in particular delirium, seem warranted. A multidisciplinary onco-geriatric pathway may support tailored decision-making in patients at risk of frailty.

Implementation of an Enhanced Recovery after Surgery Protocol in Advanced and Recurrent Rectal Cancer Patients after beyond Total Mesorectal Excision Surgery: A Feasibility Study.

INTRODUCTION: The implementation of an Enhanced Recovery After Surgery (ERAS) protocol in patients with locally advanced rectal cancer (LARC) and locally recurrent rectal cancer (LRRC) has been deemed unfeasible until now because of the heterogeneity of this disease and low caseloads. Since evidence and experience with ERAS principles in colorectal cancer care are increasing, a modified ERAS protocol for this specific group has been developed. The aim of this study is to evaluate the implementation of a tailored ERAS protocol for patients with LARC or LRRC, requiring beyond total mesorectal excision (bTME) surgery. METHODS: Patients who underwent a bTME for LARC or LRRC between October 2021 and December 2022 were prospectively studied. All patients were treated in accordance with the ERAS LARRC protocol, which consisted of 39 ERAS care elements specifically developed for patients with LARC and LRRC. One of the most important adaptations of this protocol was the anaesthesia procedure, which involved the use of total intravenous anaesthesia with intravenous (iv) lidocaine, iv methadone, and iv ketamine instead of epidural anaesthesia. The outcomes showed compliance with ERAS care elements, complications, length of stay, and functional recovery. A follow-up was performed at 30 and 90 days post-surgery. RESULTS: Seventy-two patients were selected, all of whom underwent bTME for either LARC (54.2%) or LRRC (45.8%). Total compliance with the adjusted ERAS protocol was 73.6%. Major complications were present in 12 patients (16.7%), and the median length of hospital stay was 9 days (IQR 6.0-14.0). Patients who received multimodal anaesthesia (75.0%) stayed in the hospital for a median of 7.0 days (IQR 6.8-15.5). These patients received fewer opioids on the first three postoperative days than patients who received epidural analgesia (p < 0.001). CONCLUSIONS: The implementation of the ERAS LARRC protocol seemed successful according to its compliance rate of >70%. Its complication rate was substantially reduced in comparison with the literature. Multimodal anaesthesia is feasible in beyond TME surgery with promising effects on recovery after surgery.

The chimney graft, a systematic review.

BACKGROUND: Approximately 20% to 30% of the patients are considered not eligible for standard endovascular aneurysm repair because of aortic neck morphology. Most of these patients have an aortic neck situated in the vicinity of the aortic side branches, requiring extensive open surgery. The introduction of fenestrated and branched stent grafts has made endovascular branch preservation possible, but these procedures are time-consuming and expensive. The chimney procedure offers a readily available endovascular alternative for the treatment in patients with acute aneurysms and challenging anatomy. We conducted a systematic review to evaluate the short- and long-term results of the chimney procedure. METHODS: A comprehensive literature search for studies describing the chimney procedure was performed using MEDLINE and Excerpta Medica Database. All articles were critically appraised and included, based on relevance, validity, and outcome measures. Patient characteristics, details of the surgical intervention, and short- and long-term outcomes were studied. RESULTS: A total of 75 patients were included who underwent a chimney procedure for the preservation of a total of 96 branches. Used operating techniques differed considerably between all studies, with an overall technical success rate of 98.9%. Three perioperative deaths were reported, of which one patient died from intervention-related complication. The follow-up duration ranged from 2 days to 54 months. Late complications included three deaths, none of which was device or aneurysm related. Three chimney grafts occluded during follow-up, of which two required reintervention. CONCLUSION: The chimney procedure appears as an acceptable alternative for patients in an emergency setting, although data regarding long-term follow-up are not yet available.

A Multidisciplinary Approach for the Personalised Non-Operative Management of Elderly and Frail Rectal Cancer Patients Unable to Undergo TME Surgery.

Despite it being the optimal curative approach, elderly and frail rectal cancer patients may not be able to undergo a total mesorectal excision. Frequently, no treatment is offered at all and the natural course of the disease is allowed to unfold. These patients are at risk for developing debilitating symptoms that impair quality of life and require palliative treatment. Recent advancements in non-operative treatment modalities have enhanced the toolbox of alternative treatment strategies in patients unable to undergo surgery. Therefore, a proposed strategy is to aim for the maximal non-operative treatment, in an effort to avoid the onset of debilitating symptoms, improve quality of life, and prolong survival. The complexity of treating elderly and frail patients requires a patient-centred approach to personalise treatment. The main challenge is to optimise the balance between local control of disease, patient preferences, and the burden of treatment. A comprehensive geriatric assessment is a crucial element within the multidisciplinary dialogue. Since limited knowledge is available on the optimal non-operative treatment strategy, these patients should be treated by dedicated multidisciplinary rectal cancer experts with special interest in the elderly and frail. The aim of this narrative review was to discuss a multidisciplinary patient-centred treatment approach and provide a practical suggestion of a successfully implemented clinical care pathway.

Pulsatility in the iliac artery is significant at several levels: implications for EVAR.

PURPOSE: To evaluate the pulsatility of the iliac arteries and compare their distension at several levels that might influence preoperative stent-graft sizing and the long-term durability of stent-graft sealing and fixation. METHODS: Preoperative dynamic computed tomographic angiography (CTA) scans of 30 patients (24 men; median age 75 years, range 60-85) with an abdominal aortic aneurysm and patent iliac arteries were included. The CTAs consisted of 8 images per heartbeat. Bilateral diameter and area changes per heartbeat were measured semi-automatically in the common iliac artery (CIA) at 3 levels: (A) 0.5 cm after the aortic bifurcation, (B) in the middle of the CIA, and (C) 0.5 cm proximal to the iliac bifurcation. Pulsatility was defined as the largest difference in area and average diameter change over 180 axes per heartbeat. Pulsatility at the 3 levels was compared, and the intraobserver variability of the method was calculated according to Bland and Altman. RESULTS: The mean area increases in the CIAs at levels A, B, and C were 12.5% (16.3 mm²), 11.2% (13.6 mm²), and 9.6% (12.6 mm²), respectively, and the mean iliac diameter increases were 9.2% (1.1 mm), 8.5% (1.0 mm), and 8.1% (1.0 mm). The iliac distension was statistically significant at all levels. The iliac distension at level A was statistically significantly larger than the distension at level C. The intraobserver variability was 13.3 mm² for area and 0.6 mm for diameter measurements. CONCLUSION: The pulsatility in the iliac arteries is statistically significant at several levels relevant to endovascular aneurysm repair. The distension of the iliac artery possibly decreases more distally, which might encourage the extension of stent-grafts to the internal iliac artery.