Factors affecting long-term outcomes after thromboembolectomy for acute lower limb ischemia.

AIM: The aim of this study was to analyze factors influencing outcomes of surgical management for lower limb acute ischemia. METHODS: A retrospective analysis of 490 thromboembolectomies performed in 468 patients was conducted. Perioperative and follow-up results were analyzed. Univariate and multivariate analysis of clinical variables and patients' characteristics for the risk of reocclusion, amputation and mortality at 2 years were performed. Statistical significance was defined as a P value <0.05. RESULTS: Cumulative reocclusion, amputation and mortality rates at 24 months were 22.6%, 14.3% and 42.8%, respectively. At univariate analysis, the factors associated with increased 2-year reocclusion rate were severity of clinical presentation, current smoking habit, arterial thrombosis rather than embolism, atrial fibrillation and the avoidance of completion angiography. All these factors except clinical presentation maintained significance at multivariate analysis. Factors associated with increased 2-year amputation rate at univariate analysis included severity of clinical presentation, smoke, arterial thrombosis, atrial fibrillation and valvulopathy. All these factors except clinical presentation and valvular defects maintained significance at multivariate analysis. Factors associated with increased 2-year mortality rate at univariate analysis included age >80 years, arterial thrombosis, history of peripheral arterial disease and antiplatelet drugs. The same factors, except antiplatelet treatment, were found to be significant at multivariate analysis. CONCLUSION: Surgical intervention for lower limb ischemia is associated with high 2-year mortality but offers good 2-year limb salvage. The pattern of risk factors for reocclusion and amputation rates is quite different from those affecting mortality. Only thrombotic aetiology is a significant risk factor for all the three outcomes.

Contrast media-induced nephropathy in patients undergoing angiography prior to or during vascular surgery: a systematic review.

Nephropathy induced after administration of contrast medium is an acute and severe complication that is of particular concern in vascular surgery. While patients undergoing coronary procedures have been extensively studied, there is a paucity of data on pre- and intraoperative prevention of contrast-induced nephropathy in vascular surgery patients. There is lack of a robust analysis exploring the additive effect of pre- or intraoperative administration of drugs such as N-acetylcysteine, dopamine and sodium bicarbonate in addition to adequate hydration in patients undergoing angiography prior to or after completion of vascular surgery. A systematic review of contrast-induced nephropathy after angiography in patients undergoing vascular surgery was carried out. Eligible trials were sought by multiple methods, and the pooled odds ratios for contrast-induced nephropathy were computed under a random effects model. Twenty-one publications were identified for screening and 6 studies were included for systematic review. All 6 studies investigated preoperative angiography-related contrast-induced nephropathy; one study also investigated completion angiography. The overall frequency of contrast-induced nephropathy in patients undergoing vascular surgery was 9.2% (79/862). Risk factors for contrast-induced nephropathy identified were age >70 years, high contrast volume, pre-existing renal disease and antihypertensive medication. Two studies found that administration of N-acetylcysteine prior to angiography does not provide added benefit in preventing contrast-induced nephropathy. Advanced age and pre-existing renal and vascular risk factors such as arterial hypertension expose vascular surgery patients to increased risk of contrast-induced nephropathy. Those undergoing completion angiography appear to be at even higher risk, particularly if severely azotemic. Further randomized clinical trials analyzing strategies for preventing contrast-induced nephropathy are needed.

Lower extremity traumatic vascular injury at a level II trauma center: an analysis of limb loss risk factors and outcomes.

AIM: The objectives were to review in our series the risk factors, management and outcomes of patients who sustained vascular injuries in the lower limbs and to determine the effect of risk factors and treatment on the outcome of the injured extremity. METHODS: Fifty-six patients submitted to surgical treatment were retrospectively reviewed. Results were analysed in terms of type of operation and reconstruction, intraoperative and 30 day complications, reconstruction occlusion, major amputation and mortality. RESULTS: The mechanism of trauma was blunt in 30.4% and penetrating in 69.6%. The overall primary amputation rate was 5.4%, the overall secondary amputation rate was 1.8%. The overall intraoperative and postoperative mortality were 1.8% and 5.4% respectively. At univariate analysis, the presence of compartment syndrome and ischemia time >6 hours were associated with a significantly higher risk of early reconstruction thrombosis (both P=0.03). It showed also that the number of patent vessels (P=0.0000) and the presence of a MESS score >7 (P=0.0000) significantly affected primary amputation, and that the occurrence of postoperative deep wound infection or sepsis (P=0.0000), of tibio-peroneal trunk injury (P=0.003) and of a MESS score >7 (P=0.004) significantly affected secondary amputation. CONCLUSION: The number of patent arteries (0-1), the presence of a MESS score >7, the incidence of tibio-peroneal trunk injury and the occurrence of postoperative deep wound infection are significant independent factors for limb loss. The presence of compartment syndrome and of ischemia time >6 hours are associated with a significantly higher risk of early reconstruction thrombosis.

Prospective evaluation of total parathyroidectomy and autotransplantation for the treatment of secondary hyperparathyroidism.

OBJECTIVE: To evaluate the clinical effectiveness of total parathyroidectomy with autotransplantation for the treatment of hyperparathyroidism and the recurrence rate of hyperparathyroidism after this procedure. DESIGN: A prospective study of total parathyroidectomy and autotransplantation in 19 consecutive patients with severe secondary (renal) hyperparathyroidism. SETTING: University hospital department of surgery. PATIENTS: Nineteen patients operated on for the treatment of secondary hyperparathyroidism between March 1993 and March 1996. Eighteen had been receiving longterm hemodialysis, and 1 had a functioning renal graft. INTERVENTION: Total parathyroidectomy and autotransplantation of excised parathyroid tissue into the brachioradialis muscle of the arm opposite that in which the arteriovenous fistula had been placed for dialysis. MAIN OUTCOME MEASURES: Clinical and biochemical improvement, morbidity, mortality, and recurrence rates of hyperparathyroidism after the procedure. RESULTS: The conditions of 13 (72%) of 18 patients followed up improved, and the clinical and laboratory variables indicating secondary hyperparathyroidism returned to normal. One patient died 50 days after surgery. In 2 patients (10%), mild hypoparathyroidism developed, and in 1 patient (5%), persistent hyperparathyroidism developed and required reoperation. In 2 patients (10%), recurrent hyperparathyroidism developed, and 1 (5%) required reoperation. CONCLUSIONS: Total parathyroidectomy with autotransplantation effectively relieves the symptoms of hyperparathyroidism, and the recurrence rate of hyperparathyroidism is low. Because all procedures used resulted in good control of clinical and biochemical variables, the method used for the surgical treatment of secondary hyperparathyroidism depends on the surgeon's preference.

The value of somatostatin-receptor scintigraphy in newly diagnosed endocrine gastroenteropancreatic tumors.

BACKGROUND: Conventional imaging techniques do not routinely detect endocrine gastroenteropancreatic tumors preoperatively. The purpose of this study was to determine whether the new technique of somatostatin-receptor scintigraphy would improve the detection rate of these tumors before initial treatment. STUDY DESIGN: In a prospective study, 55 patients with a recent diagnosis of endocrine gastroenteropancreatic tumors (22 intestinal carcinoids, 17 gastrinomas, 10 nonfunctioning pancreatic tumors, and 6 insulinomas), were examined with somatostatin-receptor scintigraphy, computed tomography, and ultrasonography. Results of the three imaging modalities were compared with findings at surgical exploration. RESULTS: None of the insulinomas were localized by somatostatin-receptor scintigraphy, but 4 of 6 insulinomas were detected by computed tomography and ultrasonography. Of 17 gastrinomas, 9 were detected by somatostatin-receptor scintigraphy; computed tomography and ultrasonography localized only 7. Metastases from the gastrinoma were localized by somatostatin-receptor scintigraphy in all cases; computed tomography and ultrasonography detected metastases in only 6 of 9 patients. Nonfunctioning tumors could be localized by somatostatin-receptor scintigraphy, computed tomography, and ultrasonography in 4, 7, and 8 of 10 cases, respectively. Detection rate for corresponding metastases was the same for all three imaging techniques. Primary carcinoids were identified by somatostatin-receptor scintigraphy, ultrasonography, and computed tomography in 7, 8, and 11 of 22 cases, respectively. Extra-abdominal metastases were detected by somatostatin-receptor scintigraphy in only 7 of 19 patients. CONCLUSIONS: In patients with insulinomas, somatostatin-receptor scintigraphy is not indicated because none of the six tumors was imaged. This holds true for nonfunctional pancreatic endocrine tumors and their metastases because no advantage for somatostatin-receptor scintigraphy was found over computed tomography and ultrasonography. In contrast, somatostatin-receptor scintigraphy is superior to computed tomography and ultrasonography for determining the extent of the disease in patients with gastrinomas or carcinoids. The problem of detecting primary tumors in these patients is not solved by somatostatin-receptor scintigraphy.

Laparoscopic gastric banding for morbid obesity with expanded PTFE: technique and early results in the first 100 consecutive cases.

BACKGROUND/AIMS: Surgery is the only effective treatment for the truly morbidly obese patient. Gastric banding was demonstrated to be a safe, effective, and easily reversible technique in the open surgical approach. METHODOLOGY: A five-puncture technique, developed by the authors, for laparoscopic gastric banding utilizing an expanded polytetrafluoroethylene (ePTFE) band is fully described and discussed. This technique was utilized in 100 consecutive patients operated on between October 1995 and November 1996. RESULTS: We recorded no mortality, no cases of conversion, a 1% rate of major complications, a low minor morbidity rate (10%), and an acceptable length of operative time (106+/-8 minutes). This was significantly related to body weight, B.M.I. and % of I.B.W. being longer in more obese patients, but not to the experience of the surgical team. Weight loss (35.0+/-5.1 kg), percentage of excess weight lost (55.3+/-5.3%), percentage of ideal body weight achieved (149.1+/-8.4%), and body mass index (33.8+/-2.0) were all significantly improved at 3, 6, 9 and 12-months follow-up. CONCLUSIONS: Early results of this series are promising, showing low morbidity and a rate of weight loss comparable to that achievable by means of open gastric banding or vertical banded gastroplasty. Any statement about long-term results deserves a longer follow-up.

Routine use of open laparoscopy: 1,006 consecutive cases.

Blind insertion of the Veress needle and of the first trocar is a significant cause of laparoscopic surgery complications. Despite this risk, the closed technique is still more popular than the open one. The authors retrospectively evaluated 1006 consecutive laparoscopic operations in which Hasson's technique was routinely performed. The overall complication rate was 2.2%, but the vast majority of complications occurred during the first 50 cases (6% vs. 1.9%). They conclude that after a learning phase of about 50 cases, Hasson's technique is a quick and safe procedure.

[Somatostatin receptor scintigraphy in preoperative diagnosis of the site of endocrine gastrointestinal tumors]. / Die Somatostatinreceptor-Szintigraphie in der präoperativen Lokalisationsdiagnostik endokriner gastrointestinaler Tumoren.

To determine the value of somatostatin-receptor scintigraphy in the localization of various endocrine gastrointestinal tumors, we compared the results obtained with this new technique with the results obtained with computed tomography and sonography. We could not find an overall advantage of somatostatin-receptor scintigraphy as compared to computed tomography or sonography in the localization of intestinal carcinoids (n = 13), gastrinomas (n = 12), functionally non-active endocrine pancreatic tumors (n = 8) and various other endocrine pancreatic tumors (n = 4). In 2 patients with endocrine pancreatic tumors however, the tumors were localized preoperatively only by somatostatin-receptor scintigraphy. Somatostatin-receptor scintigraphy may occasionally be helpful in the localization of gastrointestinal endocrine tumors if these tumors are not localized by conventional imaging studies. Somatostatin-receptor scintigraphy does not solve the problem to localize small endocrine tumors.

[Routine use of open laparoscopy: technique and results in 1006 consecutive cases]. / Uso routinario della laparoscopia aperta: tecnica e risultati in 1.006 casi consecutivi.

Blind insertion of the Veress needle and/or the first trocar is one of the most frequent causes of laparoscopic surgery complications. Nevertheless, the closed technique is still more preferred than the open one. The Authors retrospectively analyzed 1006 consecutive laparoscopic procedures in which Hasson's technique was routinely utilized. The overall complication rate was 2.2%, but the vast majority of complications occurred during the learning curve (6% vs. 1.9%). The Authors conclude that after the first 50 cases the open technique is a quick and safe procedure.

[A case of intestinal occlusion caused by endometriosis of the cecum]. / Un caso di occlusione intestinale da endometriosi del cieco.

The purpose of this study is to heighten awareness of intestinal endometriosis, a disease that may mimic other abdominal pathologies (bowel carcinoma, intestinal inflammatory disease, diverticulitis), sometimes found in the emergency setting. The Authors report a case of acute bowel obstruction due to coecal endometriosis with appendix mucocele, peritoneal pseudomyxoma and ovarian endometrioma. The patient was operated on in the emergency setting, a right colectomy was performed and she then received pharmacological suppressive treatment with Gn-RH analogues and danatrol. We remark that preoperative diagnosis is very difficult in those cases that do not have a past history of pelvic endometriosis. An accurate anamnesis regarding the chronology of pain onset (typically only during the menstruation at first), but especially intraoperative histopathologic examination are useful for diagnosis. An increased awareness of intestinal endometriosis in reproductive age women with acute bowel obstruction, associated with an accurate anamnesis of menstrual history may allow pre- or intraoperative diagnosis, which is the clue to a less aggressive operation. Postoperative follow up and hormonal therapy are mandatory.

[Benign thyroid disease: 20-year experience in surgical therapy]. / Malattia tiroidea benigna: esperienza ventennale di terapia chirurgica.

This retrospective study compares recurrence and postoperative complication rates after isthmo-lobectomy and subtotal thyroidectomy (group I) vs near-total and total thyroidectomy (group II) for benign thyroid disease. Seven hundred and forty-three patients were operated on for thyroid diseases over the period from 1977 to 1998. We considered 202 patients operated on for benign thyroid disease from 1988 to 1998. The follow-up ranged from 1 to 10 years (mean: 3.4 yrs). One hundred and thirty-two patients (65.3%) were operated on for bilateral nodular goitre, 35 (17.3%) for unilateral nodular goitre, 14 (6.9%) for toxic goitre and 21 (10.4%) for thyroiditis. Over the period 1988-1992, 19 patients underwent isthmo-lobectomy and 71 subtotal thyroidectomy (group I). From 1993 to 1998, 39 patients underwent near-total thyroidectomy and 61 total thyroidectomy (group II). The relapse rate was 14.4% in group I, while there were no recurrences in group II (p = 0.000064). Temporary hypocalcaemia was significantly higher (p = 0.000001) in group II (29%) than in group I (2.2%). Within group II, the rate was significantly higher (p = 0.0013) after total thyroidectomy (37.7%) than after near-total thyroidectomy (15.4%). In our experience, near-total and total thyroidectomy are an appropriate approach for preventing recurrence in patients with benign thyroid disease despite the fact that the risk of temporary hypocalcaemia is higher than after less radical surgery. Near-total thyroidectomy and the exercise of all due care in the surgical technique may help to reduce its incidence.

[History of reconstruction following total gastrectomy]. / Storia della ricostruzione dopo gastrectomia totale.

Near a century after the first successful total gastrectomy for gastric cancer, the authors review the various technical proposals for digestive tract reconstruction following total gastrectomy. Following a classification based on duodenal circuit, on the viscerum employed and on the creation of pouches and/or anti-reflux mechanisms, pros and cons of the various classes of reconstructions are clearly depicted, suggesting the reasons that made Roux-en-Y esophago-jejunostomy and jejunal interposition the most used reconstructive procedure in worldwide clinical practice.

[Acute biliary pancreatitis. Role of laparoscopy after 30 years of traditional surgery experience]. / Pancreatite acuta biliare. Ruolo della laparoscopia dopo un'esperienza di chirurgia tradizionale di oltre trenta anni.

The authors herein show their own experience in the treatment of acute biliary pancreatitis. Aim of this study is to evaluate the effectiveness and the safety of the "early" laparoscopic approach to the mild to moderate acute biliary pancreatitis. The authors studied sixty cases of laparoscopic cholecystectomy with intraoperative colangiography for acute biliary pancreatitis (M/F 1:1.2; mean age 59.6 yrs, range 29.79). The patients were divided in two groups on the basis of the severity of the pancreatitis, defined through Ranson's score and Balthazar classification. The mortality rate was nil. Intraoperative morbidity rate was 6.6% in the group I (3/45), and 13.3% in the group II (2/15). Postoperative morbidity rate was 6.7% (3/45) in the group I and 40% in the group II (6/15). The authors show an original diagnostic and therapeutic algorithm for the treatment of acute biliary pancreatitis. Early laparoscopic cholecystectomy with I.O.C. is proposed as the gold standard treatment for mild to moderate acute biliary pancreatitis. This approach appears to be effective and safe in their experience. In case of severe acute biliary pancreatitis, further investigations are mandatory to evaluate the role of laparoscopic approach.

[Laparoscopic diverticulectomy for ileal volvulus on Meckel's diverticulum]. / Diverticulectomia laparoscopica per volvolo ileale su diverticolo di Meckel.

Laparoscopy in the emergency setting is a logical extension of this technique. Open laparoscopy is particularly useful in the management of acute abdomen. In fact, after a sequential work-out that includes physical examination, laboratory data, plain abdominal x-rays and ultrasonography, diagnostic laparoscopy is advocated. The Authors herein report a case of intestinal obstruction (volvulus due to Meckel's diverticulum) treated with laparoscopy. The efficacy and safety of the diagnostic and/or therapeutic laparoscopic procedure in the emergency setting are discussed.

[Surgical treatment of 4th-stage hemorrhoids: the role of anatomical techniques]. / Trattamento chirurgico delle emorroidi al IV stadio: il ruolo delle tecniche anatomiche.

Surgical options for fourth-degree hemorrhoids are still matter of debate. The high incidence of the disease encouraged research and brought to technical improvements able to achieve a painless, reliable, harmless and well tolerated surgical treatment. The Authors report a retrospective study of 193 patients who underwent surgery for fourth-degree hemorrhoids. In these cases the Authors advise anatomic techniques using local anaesthesia with i.v. administration of sedatives, thus allowing a 24-hour hospitalization.

[Technique and immediate results of the Moreno Gonzalez-Carboni reconstruction after total gastrectomy]. / La tecnica ed i risultati immediati della ricostruzione secondo Moreno Gonzalez-Carboni dopo gastrectomia totale.

Reconstruction following total gastrectomy for gastric cancer is still matter of debate. The Roux-en-Y esophagojejunostomy and the interposed loop esophago-jejunoduodenostomy are the techniques commonly employed. The Authors describe their modification of Henley's jejunal interposition and report early results achieved in a series of 60 consecutive patients.

Senior versus proctored young and resident surgeons' experience in laparoscopic cholecystectomy: is there any need of previous exposure to open biliary surgery?

Since its introduction in 1987 laparoscopic cholecystectomy (LC) has gained rapid acceptance as the preferred management of symptomatic cholelithiasis. In our department, during the past 3 years, the number of open cholecystectomies (OCs) has dramatically decreased. The impact of the introduction of LC as a part of the overall surgical procedures performed by residents is analyzed. To date junior-level residents have already more experience in LC than in OC. Indeed in our teaching unit junior-level residents performed only 5% of biliary surgical procedures in open surgery. Residents participated in the "surgeon's" position in 47.9% of the LCs and as either surgeon or first assistant in 100%. We analyzed both the cases where residents acted as surgeons and where they did not. It appeared that there was no difference in the complication and conversion rates. More intraoperative cholangiographies (IOCs) were performed by residents. This was probably due to the anxiety of making a mistake because of their lack of experience. This report suggests that the decrease in the number of OCs is not a drawback and that it is possible to acquire an adequate knowledge of biliary anatomy and surgery from LC training, if strict proctoring criteria are respected.

Lost intraperitoneal stones after laparoscopic cholecystectomy: harmless sequela or reason for reoperation?

Laparoscopic cholecystectomy has become the "gold standard" in the therapy of noncomplicated cholelythiasis. Gallbladder perforation with bile and calculi spreading in the abdominal cavity is one of the most frequent intraoperative complications of laparoscopic cholecystectomy. When not recognized during surgery or unproperly treated, it may lead to intraperitoneal abscess formation and may require a reoperation. We report a case of an intraperitoneal abscess with a cutaneous fistula, a site of a mucopurulent exudate, and stone spillage after an unrecognized gallbladder perforation and residual lithiasis in the peritoneal cavity found 3 months after laparoscopic cholecystectomy.