Endovenous laser treatment of groin and popliteal varicose veins recurrence.

Objectives Recurrent varicose veins following surgery is a common, complex and costly problem in vascular surgery. Treatment for RVV is technically more difficult to perform and patient satisfaction is poorer than after primary interventions. Nevertheless, traditional vein surgery has largely been replaced by percutaneous office-based procedures, and the patients with recurrent varicose veins have not benefited from the same advantages. In this paper, we propose an endovascular laser treatment that allows reducing the invasiveness and complications in case of SFJ and SPJ reflux after ligation and stripping of the great and small saphenous vein. Methods 8 SFJ and 1 SPJ stumps were treated by endovascular laser treatment in out-patient clinic. Endovascular laser treatment was performed with a 1470 nm diode laser and a 400 µc radial slim™ fiber. Intraoperative ultrasoud was used to guide the fiber position and the delivery of tumescent anesthesia. The gravity of chronic venous disease was determined according to the CEAP classification and the severity of symptoms was scored according to the revised Venous Clinical Severity Score (VCSS). Results The average linear endovenous energy density was 237 J/cm. Patients return to daily activities after a mean of 1.9 days after. The VCSS improved drastically from a mean of 8 pre-interventional to 1 at day 30 and until one year. During the follow-up period (mean 8 months, range: 5-17 months), all the stumps except one were occluded. All patients were very satisfied or satisfied with the method. No severe complications occurred. Conclusions Office-based endovascular laser treatment of groin and popliteal recurrent varicose veins with 1470 nm diode laser and radial-slim fiber is a safe and highly effective option, with a high success rate in the early post-operative period.

Endovenous ablation of incompetent saphenous veins with a new 1,540-nanometer diode laser and ball-tipped fiber.

BACKGROUND: Endovenous laser ablation (EVLA) is an efficient method to treat incompetent saphenous veins with high occlusion rates. The major side effects are postoperative pain and bruising. Laser systems with higher wavelengths, associated with new energy delivery devices, have recently shown excellent short-term results, while reducing the previously reported side effects. The aim of this study is to show the first outcome after EVLA of incompetent saphenous veins with a newly developed ball-tipped fiber and a new wavelength 1,540-nm diode laser. METHODS: Forty-five incompetent saphenous veins in 35 patients (27 women) were treated: 33 great saphenous veins, 6 short saphenous veins, and 6 anterior saphenous veins. The gravity of chronic venous disease was determined according to the clinical-etiology-anatomy-pathophysiology (CEAP) classification, and the severity of symptoms was scored according to the revised Venous Clinical Severity Score. Patient satisfaction was assessed on a 0-3 scale. RESULTS: The average linear endovenous energy density was 63.5 J/cm of vein length. Patients returned to daily activities after a mean of 1.7 days (SD: 2) after treatment. The modified CEAP clinical severity score improved drastically from a preintervention mean of 4.9 (SD: 2.6) to 0.17 (SD: 0.38) at day 30. During the follow-up period (mean: 168 days [range: 90-240 days]), all the veins were occluded. All patients except 1 were satisfied or very satisfied with the method. No severe complications occurred. Two patients (5%) developed mild paresthesia in the treated area, which spontaneously resolved after 3 months. Postoperative ecchymoses are frequent (83%). Sixteen patients (43%) experienced pain, but only 5 patients (14%) described it as quite intense and required analgesic therapy. CONCLUSION: EVLA of saphenous veins with a 1,540-nm diode laser using a ball-tipped fiber is a safe and efficient therapy option, with a high success rate in the early postoperative period.

Endovenous laser ablation of great saphenous veins performed using tumescent cold saline solution without local anesthesia.

BACKGROUND: In recent years, laser systems with higher wavelengths, associated with new optical fibers, have shown excellent short-term results in treating saphenous veins and reducing the side effects and, in particular, the postoperative pain. However, if the patients are not anesthetized, they may feel pain even when using low energy with the high-wavelength laser; the only tumescent local anesthesia often does not guarantee a complete pain control during endovenous laser ablation (EVLA). Aim of this study was to demonstrate that the local anesthesia during EVLA of great saphenous veins (GSVs) is not essential for the perioperative comfort of the patient if a mild sedation is made. METHODS: Forty-nine incompetent GSVs were treated by EVLA with a cold saline tumescent solution (CSTS) without local anesthetic drugs. EVLA was performed with a 1540-nm diode laser and a 600-µc ball-tipped fiber. Intraoperative ultrasonography was then used to guide delivery of CSTS (cold saline solution 0.9% at 5°C) using a motor pump under intravenous sedation. The gravity of chronic venous disease was determined according to the clinical-etiology-anatomy-pathophysiology classification. Patients rated surgery global pain according to 4 types: "extremely," "rather," "slightly," and "not at all" painful. RESULTS: Twenty-five cases (51%) were classified as C3, 20 (41%) as C2, 6 (13%) as C4, and 1 (2%) as C6. Midazolam 2.5 mg + a mean of 0.16 mg of fentanil (minimum: 0.10; maximum: 0.20; standard deviation [SD]: 0.4) + a mean of 178.21 mg of propofol (minimum: 100; maximum: 300; SD: 47.1) were administrated as intravenous sedation. The total average linear endovenous energy density was 57.7 J/cm. Approximately 250 mL (minimum: 100; maximum: 780) of CSTS was administered. No Patient has had pain during the procedure. All patients were discharged 2.5 hrs after surgery. CONCLUSIONS: EVLA under sedation using CSTS without diluted anesthetic drugs is a suitable technique in an outpatients clinic, especially useful if the ablation of the saphenous vein is combined with an extended phlebectomy or if a bilateral treatment is performed, to eliminate the risks of overdose with local anesthesia and with the aim of improving the comfort of the patient.

Laparoscopic pancreatectomy for solid pseudo-papillary tumors of the pancreas is a suitable technique; our experience with long-term follow-up and review of the literature.

BACKGROUND: Solid pseudopapillary tumors (SPTs) are rare pancreatic neoplasms of low malignant potential that occur mainly in young women. Only 17 cases of SPT treated laparoscopically have been published in the literature and long-term follow-up data are still lacking. METHODS: Retrospective analysis of ten patients (8 women, 2 men; mean age, 25.4 years) (DS: 12.1; minimum 11, maximum 51) who underwent laparoscopic distal pancreatectomy with a definitive histological diagnosis of SPT. Long-term follow-up data were collected. RESULTS: The average tumor size was 43.8 mm (minimum 20, maximum 65 mm). The mean operative time was 177.5 minutes (DS: 53.7; minimum 120, maximum 255). In all, five patients underwent distal splenopancreatectomy; five patients underwent spleen-preserving distal pancreatectomy of whom three with splenic vessel preservation and two with the Warshaw technique. The conversion rate was nil and no case of perioperative mortality was recorded. The mean hospital stay was 7 days (DS: 2.7; minimum 4, maximum 12). Six patients had an uneventful postoperative course and four had postoperative complications. Two of them underwent reoperation, and the other two had nonsurgical complications. After a median follow-up of 47 (range, 5-98) months, all patients were alive and disease-free. CONCLUSIONS: Laparoscopic pancreatic resection is a safe and feasible procedure that could become the treatment of choice for patients affected by pancreatic SPT. Distal pancreatectomy should be performed, if possible, with spleen-preserving technique, especially in young patients. To avoid metastatic spread, laparoscopic or laparotomic biopsy should not be performed in patients affected by SPT.

Endoscopic transmural drainage of pseudocysts associated with pancreatic resections or pancreatitis: a comparative study.

BACKGROUND: Endoscopy has been regarded as an effective modality for draining pancreatic collections, pseudocysts, and abscesses. This study analyzes our experience with endoscopic transmural drainage of pancreatic pseudocysts and compares the outcomes in patients with postsurgical and pancreatitis-associated ones. METHODS: Patients who underwent endoscopic drainage of a pancreatic pseudocyst from January 1999 through June 2008 were included in this retrospective analysis. The specific indication for attempting the procedure was the presence of direct contact between the pseudocyst and the gastric wall. All the drainages were carried out via a transgastric approach, and one or two straight plastic stents (10 or 11.5 French) were positioned. A comparative analysis of short- and long-term results was made between patients with postoperative pseudocysts (group A) and patients with pancreatitis-associated pseudocysts (group B). RESULTS: Fifty-five patients were included in the study, 25 in group A and 30 in group B. Overall, a single stent was inserted in 84.0% of patients, while two stents were needed in the remaining 16.0%. The technical success rate was 78.2%, whereas procedure-related complications were 16.4%. Complications included pseudocyst superinfection and major bleeding and were managed mainly by surgery. Mortality rate was 1.8% (1 patient). There were no significant differences in the technical success rate and procedure-related complications between the two groups (p=0.532 and 0.159, respectively) Recurrences were 13.9% and significantly more common in group B (p=0.021). In such cases, a second endoscopic drainage was successfully performed. CONCLUSION: Transmural endoscopic treatment of pancreatic pseudocysts is feasible and has a technical success rate of 78.2%, without differences related to the pseudocyst etiology. Recurrences, on the other hand, are more common in patients with pancreatitis. Given the severe complications that may occur after the procedure, we recommend that endoscopic drainage be performed in a tertiary-care center with specific expertise in pancreatic surgery.

Pancreatoblastoma in adults: a review of the literature.

BACKGROUND: Pancreatoblastoma is a very uncommon neoplasm in adults and its management represents a great challenge with regards to different treatment options. Given the rarity of the disease, the aim of this study was to review our personal experience with adult pancreatoblastoma as well as the cases reported in the literature in order to support clinicians observing this entity. METHODS: Adult patients with histologically proven pancreatoblastoma were identified from our prospective database of pancreatic resections. After a search on the Medline database, a review of all cases was performed as well, focusing on clinical, radiological and hystopathological features and treatment options. RESULTS: At our Institution, 2 adult males, 26 and 69 years old, underwent successful pancreatic resection for pancreatoblastoma. The diagnosis of pancreatoblastoma mainly depends on the pathological findings characterized by squamoid corpuscles at histopathology. Only 21 cases of adult pancreatoblastoma have been identified in the literature. In general, despite aggressive treatment, pancreatoblastoma in adults is associated with poorer outcome than in children, with a median survival time of 18.5 months. Both our patients are disease free after 15 months (case 2) and 51 months (case 1). The latter represents the most successful result in long-term disease-free survival. CONCLUSION: Pancreatoblastoma is a rare neoplasm in adults. The differential diagnosis includes nonfunctional pancreatic endocrine tumor, acinar cell carcinoma, solid pseudopapillary tumor and adenocarcinoma. Surgical resection is the only treatment associated with long-term survival. Chemotherapy may play a role as palliative treatment in advanced disease.

Laparoscopic distal pancreatectomy in children: case report and review of the literature.

BACKGROUND: Laparoscopic resection of benign tumors of the pancreas has been reported in adults, but only four cases of partial laparoscopic pancreatectomy in children have been described in the English-language literature. METHODS: We describe the case of an 11-year-old girl with a solid pseudopapillary tumor who was treated with a laparoscopic, spleen-preserving, distal pancreatectomy. The specimen was extracted in an endoscopic bag retrieval system through a Pfannenstiel incision. Operative time was 120 minutes, and minimal blood loss occurred. The literature is reviewed. RESULTS: The postoperative course was uneventful. Twenty-two months after the operation, clinical follow-up (including assessment of exocrine and endocrine pancreatic function) revealed nothing abnormal. The functional and aesthetic results were satisfactory. CONCLUSIONS: The technique used for our case is simple and reproducible, was completed safely within a reasonable operative time, and yielded a good result.

The thigh extension of the small saphenous vein: a hypothesis about its significance, based on morphological, embryological and anatomo-comparative reports.

The small saphenous vein in its modal pattern flows into the popliteal vein by means of a terminal arch (sapheno-popliteal junction), and frequently gives off an anastomotic branch, ascending on the medial aspect of the thigh, to the great saphenous vein. This branch has often been termed thigh extension of the small saphenous vein. As resulted in this report from autopsy, the venous extension coursed on the midline of the posterior aspect of the thigh, tributary to the deep femoral vein, and the small saphenous vein presented neither a sapheno-popliteal terminal arch, nor evident intersaphenous anastomoses. As a consequence, the small saphenous vein by means of its prolongation continued directly from the calf into the deep femoral vein. In the human embryo the small saphenous vein appears as direct communication with the posterior cardinal vein, and accompanies the developing ischiatic artery and nerve, as the main vein (ischiatic vein) of the lower limb bud. At the end of development, its proximal part persists as inferior gluteal vein. Comparative anatomy indicates that in animals the small saphenous vein is the only superficial vein well developed and that in humans its termination into the popliteal one might be an adaptation to the elongation and relative rigidity of the lower limb. In the horse a posterior vein of the thigh connects the small saphenous with the ischiatic one, and ascends along the ischiatic nerve to anastomose with the deep femoral vein. It would appear also that in the lower animals the small saphenous vein ascends to a higher level on the posterior aspect of the thigh. Thus, a venous extension like that we observed might be an atavism. Therefore, on the basis of these embryological and phylogenetical data, the Authors hypothesized that a small saphenous vein and a thigh extension of such a feature might be regarded as a unique venous channel, wholly axial throughout its course, formed by the small saphenous vein proper in the leg and by a persistent and functional sciatic (ischiatic) vein, which usually disappears, satellite of the ischiatic nerve, in the thigh.