Endovenous 808-nm diode laser occlusion of perforating veins and varicose collaterals: a prospective study of 482 limbs.

BACKGROUND: Endovenous laser ablation (EVLA) was performed in the treatment of great and small saphenous veins (GSVs, SSVs), perforating veins (PVs), and varicose collaterals (VCs). OBJECTIVE To verify the outcome in PVs and VCs. MATERIALS AND METHODS: Four hundred eighty-two limbs of 306 patients were studied. EVLA was performed on 167 GSVs, 52 SSVs, and 534 PVs of 303 limbs and on VCs of 467 limbs; 133 GSVs were stripped, 300 of saphenofemoral junctions (SFJs) and 45 saphenopopliteal junctions (SPJs) were interrupted. Limbs were selected using duplex ultrasound examination and photographs; PVs-VCs diameter (<4 mm) and VC length were measured. EVLA was performed using a 808-nm diode laser, 0.6-mm fibers, continuous emission, 4 to 10 W, and 10 to 20 J/cm. Follow-up on 467 limbs occurred over a mean 27.5 months (range 3 months to 6 years); 98 limbs were followed up for longer than 4 years. RESULTS: Operating time range from 10 to 30 minutes per limb. Blood vaporization, thrombosis, fibrosis, and atrophy prevailed in PVs and in the large VCs (>4 mm) and massive coagulation in the smaller (<4 mm). High rate of occlusion was seen, with different rates of patent PV-VC mainly in diameter >6 mm. Thirty-nine out of 511 patent PVs (7.6%) and 96 out of 778 VCs (12-13%) were re-treated using EVLA or foam sclerotherapy. Minor complications occurred in 88 of the 778 (11%). CONCLUSIONS: EVLA of PVs and VCs is effective and faster than surgery in 2- to 6-mm PVs and VCs using an 808-nm diode laser.

[Lack of prognostic predictive value of hepatic agobiopsy in a group of patients operated of hepatic resection for hepatocellular carcinoma]. / Mancanza di valore prognostico predittivo dell'agobiopsia epatica sull'outcome di una serie consecutiva di pazienti resecati per epatocarcinoma.

AIM: To determine prior to surgery whether a fine needle biopsy is able to define a hepatocellular carcinoma grading, or not. MATERIAL OF STUDY: Thirty patients, who all underwent liver resection for HCC. In every case a fine needle biopsy of the neoplasm was taken prior to surgery, and after the operation a complete microscopic assessment of tumor grade according to Edmondson and Steiner classification was taken. RESULTS: We found no correlation between fine needle biopsy grading and post surgical one. We also found no correlation between fine needle grading and other relevant elements, alpha-fetoprotein levels and number of neoplastic nodules. DISCUSSION: Considering the small number of patients in the study, fine needle biopsy seems to be unfit to determine HCC grading before surgery, this is probably due to the different levels of neoplastic differentiation present into every single nodule and to the characteristics of Edmondson and Steiner classification. In Literature there is at least one study, similar to ours, showing problems in the correct attribution of grading level using this classification. Other authors consider the possibility to modify the scale from a 4-levels one to a 3-levels one. CONCLUSIONS: In spite of these discouraging results, and with a strict follow up monitoring any tumor seeding, we think fine needle biopsy is still fundamental for controversial cases, and for new studies on hepatocellular carcinoma, like those over vascular invasion or the molecular profile of the neoplasm.

Duplex ultrasound changes in the great saphenous vein after endosaphenous laser occlusion with 808-nm wavelength.

BACKGROUND: Endosaphenous laser ablation is used in the treatment of great saphenous vein insufficiency with various methods, with and without surgical interruption. However, its mode of action and indications are not yet clear. METHODS: To verify the mode of action of endosaphenous laser ablation by duplex ultrasound (DUS) follow-up, with the support of histologic observations of eight cases, 44 of 182 affected limbs (CEAP C2 to C6) were selected for intravenous laser ablation of the great saphenous vein. Saphenofemoral junction incompetence was treated by surgical interruption. An 808-nm diode laser (Eufoton, Trieste, Italy) was used (variable pull-back velocity, 1 to 3 mm/s; power, 12 to 15 W; energy, 30 to 40 J/cm). In eight limbs the venous fragments were studied under light microscopy at 5 minutes and after 1 and 2 months. In 44 limbs DUS and clinical examinations were performed from 7 days to 1, 2, 6, and 12 months. RESULTS: Variously organized thrombi containing necrotic inclusions and patent areas were observed in the vein lumen. Neither neovascularization nor thrombus extension were detected at the groin by DUS examination. Progressive venous diameter decrease and thrombus fibrotic transformation up to the hypotrophic venous disappearance at 12 months were followed up (P < .00001). Not occluded (18.8%), recanalized short segments (22.7%), two entirely recanalized saphenous veins with varicose recurrence (4.5%), and postoperative phlebitis (13.6%) were observed. Nonocclusions and phlebitis prevailed in the larger veins (P < .05). CONCLUSION: The healing process is based on vein thrombosis, fibrosis, and venous atrophy. Saphenofemoral interruption makes venous occlusion easier and prevents potential thrombotic complications and recurrence by recanalization. DUS monitoring makes possible to follow-up the thrombus involution and perform early retreatment. The 808-nm endosaphenous laser should be mainly applied to veins of <10 mm in diameter.

The predictive value of clinical evaluation of response to neoadjuvant chemoradiation therapy for rectal cancer.

INTRODUCTION: Multimodality therapy has become the standard treatment for patients with locally advanced (T3 and T4) rectal carcinoma. Accurate preoperative staging of the patients with rectal cancer has increased in importance because the selection of patients with transmural rectal cancer (T3 or T4) or node-positive disease leads to a previous nonsurgical neoadjuvant treatment. The purpose of this study was to evaluate the predictive value of the clinical response to neoadjuvant therapy on the basis of pathological results obtained on rectal cancer patients treated by chemoradiotherapy and surgery. METHODS: From 1994 to 2003, 58 patients with a primary diagnosis of rectal cancer were studied at our department and enrolled in a neoadjuvant protocol of chemoradiotherapy followed by surgery. All patients were treated by 30 days of chemoradiotherapy. At the end of the chemoradiotherapy, each patient underwent clinical examination, including digital rectal examination, proctoscopy and abdominal-pelvic computerized tomography to define the clinical response to the chemoradiotherapy. Surgical resection was performed in all patients three weeks after the end of chemoradiotherapy, and histological analysis was performed on all resected specimens. RESULTS: The clinical complete response rate corresponded to the pathological complete response rate, whereas the clinical evaluation overestimated partial response and stable disease. The pathologic examination revealed that 3.5% of clinical partial responses and 3.4% of clinical stable disease were really pathological progressive disease. Clinical partial response and clinical stable disease positive predictive values were 92.8% and 90.9%, respectively, whereas the clinical progressive disease negative predictive value was 20%. Then, 6.9% of patients believed to have responded to the therapy, or not to have responded or worsened, actually had worsened by the end of the chemoradiotherapy. CONCLUSIONS: Positive and negative predictive values, in particular for partial response and stable disease, of clinical evaluation of the response to chemoradiotherapy were not high enough to consider clinical evaluation accurate enough to make treatment decisions.