Needle tract seeding following core biopsies in retroperitoneal sarcoma.

BACKGROUND: Retroperitoneal tumours often require a preoperative core needle biopsy to establish a histological diagnosis. Literature is scarce regarding the risk of biopsies in retroperitoneal sarcomas, so the aim of this study is to identify the potential risks of core needle biopsies causing needle tract recurrences or local recurrences. METHOD: Patients who underwent resection of a primary retroperitoneal sarcoma between 1990 and 2014 were identified from a prospectively maintained database from two tertiary referral centres. Patient demographics, tumour characteristics and biopsy techniques were examined. The primary endpoint was needle tract recurrence and local intra-abdominal recurrence. RESULTS: 498 patients were included in the analysis. The most common histological subtypes were liposarcoma (66%) and leiomyosarcoma (18%). Of the 498 patients that underwent resection, 255 patients were diagnosed with a preoperative biopsy. Five patients (2%) developed a biopsy site recurrence: 3 patients with leiomyosarcomas and 2 patients with dedifferentiated liposarcomas. All biopsy site recurrences occurred after trans-abdominal biopsies and were not performed with a co-axial technique. There was no significant difference in local recurrence rate between the patients with or without a biopsy (=0.30) or for the biopsy route (trans-abdominal or trans-retroperitoneal (p = 0.72)). CONCLUSION: The risk of a needle tract metastasis after core needle biopsy for retroperitoneal sarcoma is very low but not zero. The safest method seems a trans-retroperitoneal approach with a co-axial technique. Local recurrence rate is not altered after doing a core needle biopsy.

Catheter-directed thrombolysis for acute upper extremity ischemia.

AIM: Acute nontraumatic upper extremity ischemia has significant chronic disability when not treated adequately and timely. As surgical treatment can be challenging, this study evaluates catheter-directed thrombolysis as first-line treatment for acute upper extremity ischemia. METHODS: Between January 2006 and December 2010, 28 patients (22 women; mean age, 63±16 years) underwent catheter-directed thrombolysis for acute upper extremity ischemia, Rutherford class I or IIa. Proximal extent of the occlusion was in the subclavian (32%), axillary (7%), brachial (25%) and forearm arteries (36%). Median occlusion length was 18 cm (range, 12-43). Causes were embolus (14%), thrombus (39%), thoracic outlet syndrome (14%), paraneoplastic (4%), or unknown (29%). RESULTS: Technical success was 96%, radiologic success (>95% clot lysis) 61%, and clinical success 68%. Median duration of thrombolysis was 24 hours (range, 18-96). Of the 11 radiologically unsuccessful patients (39%), five were treated conservatively and six underwent surgical intervention. In-hospital amputation-rate was 7%. Four complications occurred: embolization to the lower extremity, a transient ischemic attack, a subcapsular splenic hematoma and a pseudoaneurysm. Cumulative amputation-free survival at six months was 93%, standard error (SE) 4.87 and at one year 88%, SE 6.50. CONCLUSION: These results show that catheter-directed thrombolysis is effective in over 60% of patients as first-line treatment of extensive acute upper extremity ischemia and can prevent surgical intervention in these patients.

Endoclips for fixation of nasoenteral feeding tubes: a review.

BACKGROUND: Maintaining the position of an endoscopically placed nasoenteral feeding tube beyond the pylorus is often problematic because of retrograde migration. Fixation of a feeding tube to the small intestinal wall with an endoclip may prevent this. This article reviews available literature on the feasibility, efficacy and safety of endoclips for fixation of nasoenteral feeding tubes. METHODS: A systematic search of the English literature was performed using MEDLINE, EMBASE and Cochrane databases to identify articles assessing the use of endoclips for fixation of feeding tubes, as well as articles assessing duration of attachment of endoclips. RESULTS: Five cohort series were identified that evaluated the applicability of endoclips for fixation of feeding tubes to the small intestinal wall. In all patients, except one, a nasoenteral feeding tube could be successfully fixated to the small intestinal wall. During follow-up, no spontaneous migrations of feeding tubes were observed. No complications related to placement or removal of endoclips were observed. Three comparative studies evaluated duration of attachment of different types of endoclips to the gastrointestinal wall. Duration of attachment ranged from less than 1 week to more than 18 weeks, depending on the type of endoclip. CONCLUSIONS: Based on available literature the use of endoclips for fixation of nasoenteral feeding tubes is feasible, effective and safe. Data from randomized controlled trials are needed.

Hybrid procedures for peripheral obstructive disease.

The incidence and prevalence of high-risk patients suffering from critical limb ischemia due to multilevel arterial obstructive disease is growing rapidly. Invasive surgical procedures to restore inflow to the crural and pedal circulation in case of TransAtlantic InterSociety Consensus C and D (TASC) lesions of the iliacofemoral arteries are related with substantial morbidity and mortality. The mid-term and long-term outcomes of sole percutaneous revascularization procedures are disappointing for TASC C and D lesions. Hybrid endovascular and open surgical revascularization procedures might be of benefit because of its less invasive character, no need for extensive venous graft material, and the ability to overcome long-segment arterial obstructions. The common femoral artery (CFA) plays a central role in most of the hybrid procedures. CFA desobstruction, in combination with open iliac angioplasty or open superficial femoral artery (SFA) angioplasty, and CFA desobstruction with remote endarterectomy of the superficial femoral artery, are commonplace. Another valuable hybrid technique is open angioplasty of the SFA and one-staged distal origin bypass grafting. Hybrid techniques can safely be performed in the vascular operating room providing that the inventory is equipped for endovascular interventions. Vascular surgeons with thorough experience in open transluminal angioplasty, whether or not in cooperation with interventional radiologists or angiologists, will have the lead in the preoperative and perioperative planning. No randomized controlled trials have been published comparing hybrid techniques and open surgical reconstructions, or sole endvascular methods for multilevel peripheral arterial disease. During the last decade, multiple prospective and retrospective series have been reported concerning hybrid techniques, all with good initial technical success (up to 95%) and acceptable 30-day morbidity and mortality rates. Mid-term and long-term patency rates are comparable with the more invasive sole surgical revascularization procedures. The results of the endovascular part of the hybrid procedures are still influenced by the extent of the obstructions (best results in TASC A and B lesions), and patency rates of bypasses are inversely associated with increasing length of the conduit. A review of the literature concludes that hybrid techniques for the treatment of severe lower extremity arterial disease provide less invasive, long lasting, and reliable therapeutic options tailored to the needs of high-risk patients and should be in the armamentarium of today's vascular surgeon.

Clinical outcome of acute leg ischaemia due to thrombosed popliteal artery aneurysm: systematic review of 895 cases.

OBJECTIVES: A systematic review was performed to summarise outcomes of acute thrombosed popliteal artery aneurysms (PAAs) treated with thrombolysis or thrombectomy followed by bypass. METHODS: A systematic review was conducted of data on acute thrombosed PAAs dated 1 January 1990 through 30 June 2008 using the Cochrane Library, MEDLINE and EMBASE databases. Primary endpoint was limb salvage; secondary endpoints were mortality and patency of the bypasses. RESULTS: Eight prospective studies and 25 retrospective studies with 895 patients presenting with acute ischaemia were included. No randomised trials were included. The mortality rate after surgical repair was 3.2% (95% confidence interval (C.I.) 1.8-4.6). The amputation rate was 14.1% (95% C.I. 11.8-16.4). Thrombolysis before surgery did not result in a significant reduction of the number of amputations, compared with surgery (thrombectomy and bypass) alone. The mean primary patency rates of the bypasses at 1, 3 and 5 years were 79%, 77% and 74%, respectively, in the 'thrombolysis' group and 71% (P=0.026), 54% (P=0.164) and 45% (P=0.249) in the 'thrombectomy' group. No distinction could be made regarding secondary patency and limb-salvage rates between the groups owing to insufficient data. CONCLUSIONS: Preoperative and intra-operative thrombolyses result in a significant improvement in 1-year primary graft patency rates, but do not result in a significant reduction for amputations compared with surgery alone.