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Background and Objectives: Paragangliomas (PGLs) are rare neuroendocrine extra-adrenal tumors that could be secreting mass. The symptoms are the typical triad of paroxysmal headache, hypertension and sweating, but could also be accompanied by symptoms involving multiple organs. Surgery is the gold standard treatment for both PGLs and pheochromocytomas (PHEOs). Material and Methods: We used a computerized endocrine surgery registry to record the demographic and clinical data of 153 patients who underwent surgery for PPGL between 2010 and 2023 at our hospital. Results: Thirteen patients (8.43%) with paragangliomas underwent surgery at our institute. Five patients presented symptomatic syndrome. Preoperative investigations included enhanced abdominal CT (nine patients) and enhanced MRI (seven patients). In cases of suspicious mass, we performed 131I-MIBG scans (two patients) or 68GA-DOTATOC PET-CT scans (11 patients). Laparoscopic approach was used in four cases (30.7%) and abdominal laparotomy in the other nine (69.3%). Biochemical tests were performed on all patients. Conclusions: In this retrospective study, we discuss the multidisciplinary management in our institute of this rare disease, from its challenging diagnosis to the surgical strategy for PGLs. Laparoscopic surgery is the gold standard, but a tailored approach should be adopted for each patient.
Subject(s)
Paraganglioma , Humans , Female , Male , Middle Aged , Adult , Retrospective Studies , Paraganglioma/surgery , Paraganglioma/diagnosis , Paraganglioma/diagnostic imaging , Aged , Positron Emission Tomography Computed Tomography/methods , Abdominal Neoplasms/surgery , Abdominal Neoplasms/diagnostic imaging , Abdominal Neoplasms/therapy , Tomography, X-Ray ComputedABSTRACT
Every year in Italy, about 60,000 new cases of nodular thyroid pathology are diagnosed, of which almost 30% are cytologically indeterminate (TIR3A/3B). The risk of malignancy reported in the literature on thyroid nodules ranges from 5% to 15% for TIR3A and from 15% to 30% for TIR3B. It is suspected that these percentages are higher in practice. We performed univariate and multivariate analyses of clinical risk factors. The medical records of 291 patients who underwent surgery for cytologically indeterminate nodular thyroid disease were retrospectively reviewed. Clinical parameters and preoperative serum markers were then compared between the benign nodular thyroid disease and thyroid cancer groups. For each patient, clinical characteristics, comorbidities, neck ultrasonographic features, and histological reports were statistically analyzed using Chi-squared and Fisher's exact tests. A total of 134 malignant neoplasms were found (46%), divided into 55 cases (35%) in the TIR3A group and 79 cases (59%) in the TIR3B group. Statistical analysis was not significant in both populations for both sex and age (TIR3A p-value = 0.5097 and p-value = 0.1430, TIR3B p-value = 0.5191 p-value = 0.3384), while it was statistically significant in patients with TIR3A nodules associated with thyroiditis (p-value = 0.0009). In addition, the patients with TIR3A and 3B nodules were stratified by ultrasound risk for the prediction of malignancy and it was significant (p = 0.0004 and p < 0.0001). In light of these results, it emerges that surgical treatment of nodular thyroid pathology with indeterminate cytology TIR3A should always be considered, and surgery for TIR3B is mandatory.
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BACKGROUND: Papillary thyroid carcinoma (PTC) is a common neoplasia with multiple variants. One of these extremely rare and poorly described variants is PTC with fibromatosis-like stroma (PTC-FMS), a peculiar entity distinguished by its predominant mesenchymal component. This paper reviews the literature, discusses the diagnostic challenges, and the clinical and surgical implications of this type of tumor which has fewer than 30 cases reported in the literature. CASE PRESENTATION: We reported a case of PTC-FMS found in a 41-year-old Italian woman, who came to our Institute with a recent growth in the form of a mass on the neck. Further immunohistochemical examination showed ß-catenin aberrant staining both in the nuclei and cytoplasm of the mesenchymal cells. The patient underwent total thyroidectomy and received radioactive iodine (RAI) 2 months after surgery. CONCLUSION: Given the possibility of recurrence of PTC-FMS and the ineffectiveness of RAI therapy, complete surgical resection represents the main treatment for this type of tumor. Despite the fact that the specific nature of these lesions has yet to be determined, guidelines for classical PTC should be followed.
Subject(s)
Carcinoma, Papillary , Fibroma , Thyroid Neoplasms , Female , Humans , Adult , Thyroid Cancer, Papillary/diagnosis , Thyroid Cancer, Papillary/surgery , Thyroid Neoplasms/diagnosis , Thyroid Neoplasms/surgery , Thyroid Neoplasms/pathology , Iodine Radioisotopes/therapeutic use , Carcinoma, Papillary/diagnosis , Carcinoma, Papillary/surgery , Carcinoma, Papillary/pathology , Thyroidectomy , Fibroma/drug therapy , Fibroma/surgeryABSTRACT
This study aims to present the evolution of our center's approach to treating primary hyperparathyroidism (PHPT) from diagnosis to intraoperative interventions. We have also evaluated the intraoperative localization benefits of indocyanine green fluorescence angiography. This retrospective single-center study involved 296 patients who underwent parathyroidectomy for PHPT between January 2010 and December 2022. The preoperative diagnostic procedure included neck ultrasonography in all patients, [99mTc]Tc-MIBI scintigraphy in 278 patients, and, in 20 doubtful cases, [18F] fluorocholine positron emission tomography (PET) computed tomography (CT) was performed. Intraoperative PTH was measured in all cases. Indocyanine green has been administered intravenously since 2020 to guide surgical navigation using a fluorescence imaging system. The development of high precision diagnostic tools that can localize an abnormal parathyroid gland in combination with intra-operative PTH assay (ioPTH) enables the surgical treatment of PHPT patients with focused approaches and excellent results that are stackable with bilateral neck exploration (98% of surgical success). Indocyanine green angiography has the potential to assist surgeons in identifying parathyroid glands rapidly and with minimal risk, especially when pre-operative localization has failed. When everything else fails, it is only an experienced surgeon who can resolve the situation.
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PEComa has become a widely accepted entity, and increased recognition has led to descriptions of this tumor in a wide variety of anatomic sites, including the adrenal gland. PEComa (perivascular epithelioid cell tumor) is a mesenchymal tumor composed of perivascular cells, and the most frequent sites of PEComas are the uterus and retroperitoneum. The incidence is <1 per 1,000,000 people. We report a case of adrenal metastatic PEComa in a 63-year-old man discovered by a spontaneous hematoma of the rectus abdominis. In our case, PEComa of the adrenal gland was a significant diagnostic dilemma as the morphologic and immunophenotypic features of this neoplasm may easily be confused with those of other more commonly encountered lesions.
Subject(s)
Perivascular Epithelioid Cell Neoplasms , Male , Female , Humans , Middle Aged , Perivascular Epithelioid Cell Neoplasms/diagnosisABSTRACT
Papillary thyroid carcinoma (PTC) is the most common malignant tumour of the thyroid and it is often found in association with Hashimoto's thyroiditis (HT). This concomitance is still under debate. The aim of this study is to investigate the influence of Hashimoto's thyroiditis in patients with papillary thyroid carcinoma. Two thousand two hundred eighteen patients underwent thyroidectomy in our department between January 2015 and January 2020. Of these, 435 patients had surgery for papillary thyroid carcinoma and form the basis of our studies. The association between PTC and HT was found in 180 patients (41.4%), mostly represented in the female group (78.9%), with a lower median age than patients with PTC without HT. In comparison to patients with PTC alone, the PTC-HT group had less invasive and smaller tumours, as well as less lymph node involvement. Moreover, tumours of patients with PTC-HT were diagnosed earlier. Our data showed that Hashimoto's thyroiditis may be considered a protective factor when PTC develops. Furthermore, we concluded that patients with PTC and HT had a better prognosis and a lower risk of recurrence than those that did not have HT.
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Background and Objectives: surgery for substernal goitre is still debated in the literature, due to the wide range of surgical options. This article outlines the findings of our extensive experiences, which include 264 cases of patients with "goitre plongeant", and compares postoperative complications, despite surgical approaches. Material and Methods: preoperative planning and anatomical landmarks are described to determine the potential need of a combined approach. The surgical procedure is described, along with some stratagems, to ensure that the operation is completed safely. A statistical analysis of complications and the length of stay, with a comparison of cervicotomy and combined access, was performed using the Pearson chi-square significance test. Results: 264 patients underwent thyroid surgery for substernal goitre. The Kocher incision was the surgical approach chosen in 256 patients (96.6%), while an accessory incision was performed in 8 patients (3.4%). The necessity to use a two-fold surgical access was linked to a higher rate of postoperative complications (p-value < 0.01). The average length of stay (LOS) for cervicotomy was 2 days (1−3 days), while the average LOS was 5 days (4−7 days) (p-value = n.s.) for combined access. Conclusions: cervicotomy should be the gold standard technique for exploring intrathoracic goitre with a digital dissection, which, in almost all cases, enables the externalization of the mediastinal portion associated. Sternotomy is related to a higher rate of complications, so it should be performed only in selected cases. Management in large-volume centres may be more appropriate.
Subject(s)
Goiter, Substernal , Goiter, Substernal/surgery , Humans , Mediastinum , Postoperative Complications/surgery , Sternotomy , Thyroidectomy/methodsABSTRACT
INTRODUCTION: The rate of adrenal disease diagnosed is progressively increasing due to the diagnostic tools improvement. We analysed patients that underwent to adrenalectomy in our centre for different adrenal pathologies and we tried to established guidelines for the surgical therapy. METHODS: Demographic and clinical data were prospectively entered in a computerized endocrine surgery registry for all patients who underwent surgery for adrenal lesions at our institution over a 35-year period and statistical analyses was performed. RESULTS: Between 1986 and 2020, 502 patients underwent adrenalectomy: open adrenalectomy (OA) was performed in 104 patients (28,6%), laparoscopic adrenalectomy (LA) in 398 patients (71,4%). The rate of conversion to OA was 5,9% (21 patients). The mean operating time in laparoscopic approach was 84.3 min (range 40-180) while in open approach was 121.9 min (40-210). The average length of stay (LOS) for LA was 3.6 days, while for OA was 7.4 days. The time to return to normal activity for LA was 21 days while for OA was 37 days. CONCLUSIONS: The progressive increase in the number of adrenalectomies performed is due more to a better understanding of adrenal disease than to the availability of minimally invasive techniques. The choice of a laparoscopic approach should depend on the surgeon's experience, regardless the dimension of the lesion. Considering our long experience, we suggest OA for lesion of more of 6 cm, for malignant lesion with a diameter higher than 3 cm or with a pre-operatory evidence of invasion of the surrounding tissue.
Subject(s)
Adrenal Gland Neoplasms/surgery , Adrenalectomy/statistics & numerical data , Adolescent , Adrenal Gland Neoplasms/pathology , Adult , Aged , Female , Humans , Laparoscopy , Length of Stay , Male , Middle Aged , Operative Time , Patient Selection , Practice Patterns, Physicians' , Retrospective Studies , Young AdultABSTRACT
PURPOSE: Complete mesocolic excision (CME) has introduced a promising surgical approach for treatment of right colon cancer. However, benefits of CME are still a matter of debate. We conducted a systematic review and meta-analysis to assess safety and long-term outcomes of CME versus conventional right hemicolectomy (CRH). METHODS: We systematically searched MEDLINE, the Cochrane Database of Systematic Reviews, Scopus, Web of Science, and Embase for retrieving studies comparing CME with CRH in right colon cancer. After data extraction from the included studies, meta-analysis was performed to compare postoperative complications, anastomotic leakage, 30-day mortality, number of lymph node yield, disease-free survival (DFS), and overall survival (OS). RESULTS: Eight studies met the inclusion criteria with a total of 1871 patients enrolled. No difference was observed in postoperative complications (OR 1.13, 95% CI 0.88-1.47, p = 0.34). CME was associated with significantly higher number of lymph nodes retrieved (MD 9.17, CI 4.67-13.68, p < 0.001). CME also improved 3-year OS (OR 1.57, 95% CI 1.17-2.11, p = 0.003), 5-year OS (OR 1.41, 95% CI 1.06-1.89, p = 0.02), and 5-year DFS (OR 1.99, 95% CI 1.29-3.07, p = 0.002). A sub-group analysis for patients with stage III colon cancer showed no significant impact of CME on 3-year and 5-year OS (OR 2.47, 95% CI 0.86-7.06, p = 0.09; OR 1.23, 95% CI 0.78-1.94, p = 0.38). CONCLUSION: Although with limited evidence, CME shows similar postoperative complication rates and an improved survival outcome compared with CRH.
Subject(s)
Colonic Neoplasms , Laparoscopy , Mesocolon , Colectomy , Colonic Neoplasms/surgery , Humans , Lymph Node Excision , Mesocolon/surgery , Treatment OutcomeABSTRACT
INTRODUCTION: We report the resolution of tooth discoloration following parathyroidectomy in an otherwise asymptomatic woman with primary hyperparathyroidism-associated hypercalcemia. Case Report. A 59-year-old Caucasian woman, diagnosed with primary hyperparathyroidism in 2011, nonsmoker with excellent overall oral health. She complained of tooth discoloration starting in 2013. Pigmentation was particularly evident in the necks of the lower central and lateral incisors (Vita Classical score C2). No bleaching was undertaken. Parathyroidectomy was performed five years after primary hyperparathyroidism diagnosis. Six months later, a reduction in pigmentation was strikingly evident, with incisors scoring A1 and A2. The improvement persisted over time. Tooth value also increased compared to baseline. CONCLUSIONS: This is, to our knowledge, the first report that parathyroidectomy might resolve dental discoloration. This outcome deserves investigation in a meaningful sample size and may eventually prompt the inclusion of dental issues among the consequences of primary hyperparathyroidism.
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OBJECTIVES: Several studies have shown the beneficial role of statins in reducing the risk of major perioperative complications and death associated with noncardiac vascular surgery, but few have focused on their effects in the event of carotid endarterectomy (CEA). This study analyzes the effects of preoperative statin use on perioperative outcomes in patients undergoing CEA. MATERIALS AND METHODS: Data from all consecutive patients who underwent primary CEA for symptomatic and asymptomatic carotid disease between 2002 and 2014 at a single institution were prospectively stored in a vascular surgery registry, recording risk factors, medication, and indication for surgery. Endpoints of the study were perioperative (30-day) stroke and death. RESULTS: Overall, 784 patients were on statins (825 CEAs, Group I), while 494 were not (545 CEAs, Group II). There were two perioperative strokes in Group I (0.24%) and four in Group II (0.73%; p = .22), and no deaths. The only nonfatal cardiac complication occurred in Group II (0.18%, p = .39). A neurologist assessed patients at 1, 6, and 12 months after CEA, and every 2 years thereafter. Follow-up (range: 0.1-13 years; mean, 6.3 ± 3.7 years) was obtained for 1,239 patients (1,326 CEAs). Because 165 patients (166 CEAs) crossed over from Group II to Group I during the follow-up time, long-term data were stratified by postoperative statin treatment rather than by preoperative statin use. The 5- and 10-year restenosis/occlusion and survival rates did not differ significantly between the two groups. CONCLUSIONS: Taking statins prior to CEA did not seem to affect the risk of major perioperative ischemic events and death, most likely due to the extremely low overall incidence of perioperative complications.
Subject(s)
Endarterectomy, Carotid/statistics & numerical data , Hydroxymethylglutaryl-CoA Reductase Inhibitors/pharmacology , Intraoperative Complications/prevention & control , Outcome Assessment, Health Care/statistics & numerical data , Postoperative Complications/prevention & control , Registries , Stroke/prevention & control , Aged , Aged, 80 and over , Endarterectomy, Carotid/mortality , Female , Follow-Up Studies , Humans , Hydroxymethylglutaryl-CoA Reductase Inhibitors/administration & dosage , Intraoperative Complications/mortality , Male , Postoperative Complications/mortality , Preoperative Period , Stroke/mortalityABSTRACT
Gender influences Papillary Thyroid Cancer (PTC) with an incidence of 3:1 when comparing women to men with different aggressiveness. This gender discrepancy suggests some role of sex hormones in favoring the malignant progression of thyroid tissue to cancer. Estrogens are known to promote Stem Cell self-renewal and, therefore, may be involved in tumor initiation. The goals of these studies are to investigate the underlying causes of gender differences in PTC by studying the specific role of estrogens on tumor cells and their involvement within the Cancer Stem Cell (CSC) compartment. Exposure to 1nmoll-1 Estradiol for 24h promotes growth and maintenance of PTC Stem Cells, while inducing dose-dependent cellular proliferation and differentiation following Estradiol administration. Whereas mimicking a condition of hormonal imbalance led to an opposite phenotype compared to a continuous treatment. In vivo we find that Estradiol promotes motility and tumorigenicity of CSCs. Estradiol-treated mice inoculated with Thyroid Cancer Stem Cell-enriched cells developed larger tumor masses than control mice. Furthermore, Estradiol-pretreated Cancer Stem cells migrated to distant organs, while untreated cells remained circumscribed. We also find that the biological response elicited by estrogens on Papillary Thyroid Cancer in women differed from men in pathways mediated. This could explain the gender imbalance in tumor incidence and development and could be useful to develop gender specific treatment of (PTC).
Subject(s)
Estrogens/pharmacology , Stem Cells/physiology , Thyroid Neoplasms/metabolism , Adult , Animals , Biomarkers , Cell Line, Tumor , Dose-Response Relationship, Drug , Drug Administration Schedule , Estrogens/administration & dosage , Estrogens/metabolism , Female , Humans , Male , Mice , Middle Aged , Neoplasms, Experimental , Sex Characteristics , Stem Cells/drug effectsABSTRACT
BACKGROUND: Uncertainty exists about the influence of advanced age and diabetes mellitus on the clinical effect of carotid endarterectomy (CEA). This study analyzed the perioperative (30-day) outcomes of CEA in diabetic patients aged ≥80 years. METHODS: Data of 1872 consecutive patients who underwent 2125 primary eversion CEAs from 1990 to 2014 at our institution were prospectively stored in a vascular surgery registry. Risk factors, medication, and indication for surgery were recorded. The 354 patients (387 CEAs) aged ≥80 years formed the study base; of whom, 207 (219 CEAs) were diabetic and 147 (168 CEAs) were not. A neurologist assessed all patients preoperatively, on waking from the anesthesia, and before discharge from the hospital. All procedures were eversion CEA performed by the same surgeon under general anesthesia with routine electroencephalographic monitoring for selective shunting. RESULTS: Diabetic patients were more likely to have arterial hypertension (P = .033), cardiac disease (P = .038), peripheral aneurysmal/atherosclerotic disease (P = .046), and contralateral carotid occlusion (P = .042) than their nondiabetic counterparts. Overall, there were no deaths, two (0.51%) perioperative strokes (both in diabetic patients), and 13 nonfatal cardiac complications (3.3%), of which 10 occurred in diabetic patients, but the difference failed to reach statistical significance. CONCLUSIONS: Findings from this study show that CEA is safe and effective for stroke prevention in diabetic patients aged ≥80 years, with a negligible incidence of perioperative adverse events and no deaths.
Subject(s)
Carotid Stenosis/surgery , Diabetes Complications/prevention & control , Diabetes Mellitus , Endarterectomy, Carotid , Stroke/prevention & control , Age Factors , Aged, 80 and over , Anesthesia, General , Carotid Stenosis/complications , Carotid Stenosis/diagnostic imaging , Comorbidity , Diabetes Complications/etiology , Diabetes Mellitus/diagnosis , Diabetes Mellitus/therapy , Electroencephalography , Endarterectomy, Carotid/adverse effects , Female , Heart Diseases/complications , Humans , Intraoperative Neurophysiological Monitoring/methods , Male , Registries , Risk Factors , Severity of Illness Index , Stroke/etiology , Time Factors , Treatment OutcomeABSTRACT
BACKGROUND AND PURPOSE: The risk of perioperative stroke and the benefits of carotid endarterectomy (CEA) remain uncertain in the case of an ipsilateral intracranial stenosis. The aim of this observational study was to analyze the early and late outcomes of CEA in patients with a carotid tandem lesion (CTL), defined as a severe stenosis at the bifurcation with any concomitant lesion ≥50 % involving the intracranial portion of the ipsilateral internal carotid artery or the main trunk of the anterior or middle cerebral artery. METHODS: From 2000 to 2009, 1143 patients underwent CEA for symptomatic or asymptomatic extracranial carotid stenosis according to the NASCET and ACAS recommendations, respectively. CTLs were diagnosed in 219 patients (19.2 %) by extracranial and transcranial color-coded Doppler sonography combined with noninvasive brain imaging studies. The primary endpoints of the study were perioperative (30-day) stroke and death, and any ipsilateral ischemic adverse events during the follow-up, which ranged from 0.1 to 10 years (mean 4.9 ± 3.3 years). The rates of the primary endpoints were compared between patients with (group I) and without CTL (group II). RESULTS: Overall, 219 CEAs were performed in group I and 924 in group II. Nearly two in three of the carotid lesions (777 of 1143, 68 %) were symptomatic at presentation (62.1 % in group I vs 69.4 % in group II; p = 0.03), with a 23.8 % rate of stroke (21.9 % in group I vs 24.2 % in group II; p = 0.85). There were 2 (0.9 %) perioperative ipsilateral strokes in group I and 5 (0.5 %) in group II (p = 0.62), and no deaths. The 5-year ipsilateral stroke-free, any stroke-free, and overall survival rates did not differ significantly between patients with and without CTL. CONCLUSIONS: This study has shown that patients with and without CTL who underwent CEA had a similar occurrence of perioperative adverse events (probably due to the extremely low incidence of perioperative complications) and comparable late outcomes, suggesting that the presence of CTL does not justify refusing CEA for patients who could benefit from it.
Subject(s)
Anterior Cerebral Artery/pathology , Carotid Stenosis/diagnosis , Carotid Stenosis/surgery , Endarterectomy, Carotid , Middle Cerebral Artery/pathology , Stroke/epidemiology , Aged , Aged, 80 and over , Anterior Cerebral Artery/diagnostic imaging , Asymptomatic Diseases/therapy , Constriction, Pathologic/diagnosis , Constriction, Pathologic/surgery , Disease-Free Survival , Endarterectomy, Carotid/adverse effects , Female , Follow-Up Studies , Humans , Incidence , Male , Middle Cerebral Artery/diagnostic imaging , Neuroimaging , Retrospective Studies , Survival Rate , Ultrasonography, Doppler, ColorABSTRACT
BACKGROUND: The indication for carotid endarterectomy (CEA) is uncertain in patients with asymptomatic severe (≥60% luminal narrowing according to the North American Symptomatic Carotid Endarterectomy Trial criteria) carotid stenosis (ASCS), especially in the very elderly, because current evidence suggests that the risk of future stroke has been dropping in the past two decades owing to the recent advances in medical therapy. The aim of this observational study was to compare early and late outcomes in patients ≥80 years old with ASCS treated with CEA plus best medical treatment (BMT) or with BMT alone. METHODS: From 2005 to 2012, 69 octogenarians with ASCS underwent CEA plus BMT (group 1), and another 54 received BMT alone (group 2). All operations were eversion CEAs. BMT included lipid-lowering drugs, new antiplatelet and antihypertensive agents, avoidance of smoking, careful blood pressure and glycemic control, and lifestyle changes. Follow-up with serial ultrasonographic examination was obtained in 118 patients for a median 4.4-year period. RESULTS: There were no perioperative (30-day) strokes or deaths and one transient ischemic attack (1.4%). One late minor stroke developed in a CEA patient (1.5%). No late restenoses or occlusions were detected. Five patients in group 2 (9.6%) became symptomatic (one transient ischemic attack and four minor strokes) and subsequently underwent successful CEA; all their carotid plaques were complicated by ulceration and intraplaque hemorrhage (with plaque progression in four cases), confirmed by computed tomography images. The rate of freedom from cerebral ischemic events at 5 years showed a significant benefit for elderly patients who had CEA vis-à-vis those who did not (98% vs 84%; P = .04), and so did the 5-year rate of freedom from ipsilateral carotid disease progression (100% vs 91%; P = .01). At 5 years, the mortality rate was comparable for elderly patients whether they had CEA or not (66% vs 68%; P = .65). CONCLUSIONS: CEA is a safe, effective, and durable treatment for ASCS in patients aged 80 years or more, carrying an insignificant perioperative stroke/death risk. CEA associated with BMT seems preferable to BMT alone in preventing the risk of ipsilateral ischemic events, without translating into a longer survival.
Subject(s)
Carotid Stenosis/surgery , Endarterectomy, Carotid , Age Factors , Aged, 80 and over , Asymptomatic Diseases , Cardiovascular Agents/therapeutic use , Carotid Stenosis/complications , Carotid Stenosis/diagnosis , Carotid Stenosis/mortality , Diagnostic Imaging/methods , Disease Progression , Disease-Free Survival , Endarterectomy, Carotid/adverse effects , Endarterectomy, Carotid/mortality , Female , Humans , Ischemic Attack, Transient/etiology , Ischemic Attack, Transient/mortality , Kaplan-Meier Estimate , Male , Patient Selection , Recurrence , Registries , Retrospective Studies , Risk Assessment , Risk Factors , Risk Reduction Behavior , Severity of Illness Index , Stroke/etiology , Stroke/mortality , Time Factors , Treatment OutcomeABSTRACT
BACKGROUND: The impact of diabetes mellitus on the technical and clinical outcomes of infrainguinal arterial reconstruction (IAR) for critical limb ischemia (CLI) remains controversial. This study analyzed the outcome of IAR in diabetic patients with CLI over a 17-year period. METHODS: Details on all consecutive patients undergoing primary IAR at our institution were stored prospectively in a vascular registry from 1995 to 2011. Demographics, risk factors, indications for surgery, inflow sources and outflow target vessels, types of conduit, and adverse outcomes were analyzed. Postoperative surveillance included clinical examination, duplex scans, and ankle-brachial index measurements in all patients at discharge, 1 and 6 months after surgery, and every 6 months thereafter. End points were patency, limb salvage, survival, and amputation-free survival rates, and were assessed using Kaplan-Meier life-table analysis. The χ(2) or Fisher exact, Student t, and log-rank tests were used to establish statistical significance. RESULTS: Overall, 1407 IARs were performed in 1310 patients with CLI by the same surgeon, 705 (50.2%) in 643 diabetic patients and 702 in 667 nondiabetic patients. Autogenous vein conduits were used in 87% of the IARs. There were no perioperative deaths. Diabetic patients had significantly more major (16.7% vs 11.8%; P = .02) and minor complications (9.7% vs 6.5%; P = .02) than nondiabetic patients. At 5 and 10 years, there were no significant differences between diabetic and nondiabetic patients in the rates of primary patency (65% and 46% vs 69.5% and 57%; log-rank test, P = .09), secondary patency (76% and 60% vs 80% and 68%; log-rank test, P = .20), limb salvage (88% and 76% vs 91% and 83%; log-rank test, P = .12) survival (51% and 34% vs 57% and 38%; log-rank test, P = .41), or amputation-free survival (45.5% and 27% vs 51% and 29%; log-rank test, P = .19). The type of conduit did not affect patency or limb salvage rates in either group. CONCLUSIONS: Diabetic patients receiving IAR for CLI can have the same survival and amputation-free survival rates as nondiabetic patients. Their comparable technical and clinical outcomes strongly demonstrate that diabetics with CLI can expect the same quantity and quality of life as nondiabetics with CLI, and aggressive attempts at limb salvage in patients with diabetes mellitus, including distal and foot level bypass grafting, should not be discouraged.
Subject(s)
Diabetic Angiopathies/surgery , Ischemia/surgery , Lower Extremity/blood supply , Plastic Surgery Procedures , Vascular Grafting , Veins/transplantation , Aged , Aged, 80 and over , Amputation, Surgical , Autografts , Chi-Square Distribution , Critical Illness , Diabetic Angiopathies/diagnosis , Diabetic Angiopathies/mortality , Diabetic Angiopathies/physiopathology , Disease-Free Survival , Female , Graft Occlusion, Vascular/etiology , Graft Occlusion, Vascular/physiopathology , Graft Occlusion, Vascular/surgery , Humans , Ischemia/diagnosis , Ischemia/mortality , Ischemia/physiopathology , Kaplan-Meier Estimate , Limb Salvage , Male , Middle Aged , Odds Ratio , Patient Selection , Proportional Hazards Models , Quality of Life , Plastic Surgery Procedures/adverse effects , Plastic Surgery Procedures/mortality , Registries , Reoperation , Retrospective Studies , Risk Factors , Time Factors , Treatment Outcome , Vascular Grafting/adverse effects , Vascular Grafting/mortality , Vascular PatencyABSTRACT
OBJECTIVE: Carotid endarterectomy (CEA) remains the gold standard for treating carotid disease in selected symptomatic and asymptomatic patients, though carotid angioplasty and stenting has emerged as a safe alternative. The aim of this study was to assess the durability of CEA in a large series of patients followed up according to a strict clinical and ultrasonographic protocol. METHODS: Over a 23-year period (1990-2012) a total of 1773 patients (1251 men and 522 women) with a mean age of 75.2 years (range, 31 to 96 years) who underwent 2007 consecutive primary eversion CEAs performed by the same surgeon under general anesthesia with electroencephalographic monitoring and selective shunting were prospectively followed up with ultrasonography at 1, 6, and 12 months, then yearly. A long-term follow-up (median, 11.2 years; mean, 12.9 years) was obtained for 1680 patients (94.8%). End points were perioperative (30-day) stroke and death and late carotid restenosis/occlusion rates. RESULTS: More than two in three of the lesions (1446 of 2007, 72.1%) were symptomatic at the time of surgery, with a 25% rate of preoperative stroke. Preoperative antiplatelet or anticoagulant therapy was used by 1675 patients (94.4%), whereas 918 (51.8%) were receiving statin treatment. Overall, there were eight (0.4%) perioperative strokes and no deaths. During the follow-up, there were nine (0.47%) asymptomatic late carotid restenoses (six moderate [50%-69%] and three severe [≥ 70%]) and one (0.05%) carotid occlusion. Nine patients (0.47%) had late ipsilateral strokes, none of them related to restenosis/occlusion. Overall, there were 159 late deaths (9.4%). CONCLUSIONS: The results of this study show that eversion CEA can be performed in symptomatic and asymptomatic patients with an extremely low perioperative stroke/death risk and a negligible incidence of late restenosis/occlusion, thus assuring a persistently good protection against the risk of cerebral ischemia.
Subject(s)
Carotid Stenosis/surgery , Endarterectomy, Carotid/methods , Adult , Aged , Aged, 80 and over , Anesthesia, General , Anticoagulants/therapeutic use , Asymptomatic Diseases , Brain Ischemia/etiology , Brain Ischemia/mortality , Carotid Stenosis/complications , Carotid Stenosis/diagnostic imaging , Carotid Stenosis/mortality , Electroencephalography , Endarterectomy, Carotid/adverse effects , Endarterectomy, Carotid/mortality , Female , Humans , Hydroxymethylglutaryl-CoA Reductase Inhibitors/therapeutic use , Kaplan-Meier Estimate , Male , Middle Aged , Monitoring, Intraoperative/methods , Platelet Aggregation Inhibitors/therapeutic use , Recurrence , Retrospective Studies , Risk Factors , Stroke/etiology , Stroke/mortality , Time Factors , Treatment Outcome , UltrasonographyABSTRACT
To investigate whether further, diagnostic procedures should be recommended in patients with slight increase of preoperative serum basal calcitonin (bCT) levels in whom surgical treatment can be recommendable. Fourteen consecutive patients with nodular thyroid disease underwent thyroidectomy in our center for suspected medullary thyroid microcarcinoma (MTC) because their serum bCT levels were slightly higher than the upper limit of normal range. Serum bCT was measured by radioimmunoassay, normality range = 0-20 ng/L. Surgical specimens were examined by the same pathologist using histologic and immunohistochemistry techniques. An extensive search for parafollicular C-cell hyperplasia (CCH) and/or microscopic MTC foci was performed. At preoperative ultrasound, a single thyroid nodule was depicted in three patients while a multinodular goiter in 11. The bCT values ranged between 24.4 and 94.6 ng/L, median 42.2 ng/L while the pentagastrin-stimulated CT (sCT) values by pentagastrin test ranged between 61.5 and 1,262 ng/L, median 245.0 ng/L. Total thyroidectomy was performed in 13 patients, and lobectomy in the other one; central node dissection was also performed in eight cases. At histology, MTC was diagnosed in nine patients (64.3 %), showing a median maximum diameter of 6.1 mm (range, 1.5-17 mm); CCH was diagnosed in the other five patients (35.7 %). The pentagastrin stimulation test was obtained in all patients. It is worth noting that a very high increase of sCT >100 ng/mL was observed in 5/9 patients with MTC and in 2/4 patients with HCC, therefore suggesting the absence of a relationship between the entity of response to pentagastrin test with a specific pathology (MTC vs. HCC). In six patients, the MTC was the nodule on which preoperative FNAC had been performed, while in other three patients preoperative FNAC had been performed on a different nodule from the MTC. Based on our experience, in case of the pentagastrin stimulation test with sCT <100 ng/L and a single nodule, the CT assay on FNAC may be useful, subsequently lobectomy with definitive histological diagnosis is recommended. In case of the Pg test with sCT <100 ng/L and bilateral goiter, total thyroidectomy with histological diagnosis is recommended. In this way, as for the surgical procedure, total thyroidectomy is recommended in cases of bilateral goiter, while lobectomy can be offered for cases with single nodes with serum dosage of bCT in the strict follow up. In case of the pentagastrin stimulating test with sCT <100 ng/L and bilateral goiter, total thyroidectomy with histological diagnosis is recommended.