Long-term results of a randomized controlled trial analyzing the role of systematic pre-operative coronary angiography before elective carotid endarterectomy in patients with asymptomatic coronary artery disease.

OBJECTIVES: To evaluate the potential benefit of systematic preoperative coronary-artery angiography followed by selective coronary-artery revascularization on the incidence of myocardial infarction (MI) in patients undergoing carotid endarterectomy (CEA) without a previous history of coronary artery disease (CAD). METHODS: We randomised 426 patients who were candidates for CEA, with no history of CAD, a normal electrocardiogram (ECG), and a normal cardiac ultrasound. In group A (n = 216) all patients underwent coronary angiography before CEA. In group B (n = 210) CEA was performed without coronary angiography. Patients were not blinded for relevant assessments during follow-up. Primary end-point was the occurrence of MI at 3.5 years. The secondary end-point was the overall survival rate. Median length of follow-up was 6.2 years. RESULTS: In group A, coronary angiography revealed significant coronary artery stenosis in 68 patients (31.5%). Among them, 66 underwent percutaneous Intervention (PCI) prior to CEA and 2 received combined CEA and coronary-artery bypass grafting (CABG). Postoperatively, no MI was observed in group A, whereas 6 MI occurred in group B, one of which was fatal (p = .01). During the study period, 3 MI occurred in group A (1.4%) and 33 were observed in group B (15.7%), 6 of which were fatal. The Cox model demonstrated a reduced risk of MI for patients in group A receiving coronary angiography (HR,.078; 95% CI, 0.024-0.256; p < .001). In addition, patients with diabetes and patients <70 years presented with an increased risk of MI. Survival analysis at 6 years by Kaplan-Meier estimates was 95.6 ± 3.2% in Group A and 89.7 ± 3.7% in group B (Log Rank = 6.54, p = .01). CONCLUSIONS: In asymptomatic coronary-artery patients, systematic coronary angiography prior to CEA followed by selective PCI or CABG significantly reduces the incidence of late MI and increases long-term survival. (ClinicalTrials.gov number, NCT02260453).

Long-term Evaluation of a Modified Double Staple Technique for Low Anterior Resection.

BACKGROUND: When performing low anterior resection for rectal cancer with the double staple technique, -closing the rectum with a linear stapler in the abdomen can be challenging, especially when dealing with a narrow pelvis. For such instances we proposed to modify this technique by pulling the rectal stump through the anus, doing an extra-anal resection of the tumor and linear suture of the rectal stump, before performing a standard, stapled colorectal anastomosis. The purpose of this study was to assess the adequacy of this modification of the double staple technique. METHODS: Retrospective review of 108 patients undergoing a stapled, low colorectal or coloanal anastomosis, after -eversion, extra-anal resection of the tumor and linear closure of the rectal stump for colorectal cancer, from January 1990 to December 2012. RESULTS: Operative mortality was 0.9%. Fourteen patients (13%) presented early, surgery-related complications -consisting of 7 anastomotic leaks, 5 wound infections, 1 ureteral lesion, and 1 peristomal abscess. Late complications related to surgery included 5 incisional hernias (4.6%), 4 anastomotic strictures (3.7%), 4 neurogenic bladders (3.7%) and 2 fecal incontinences (1.8%). The incidence of local disease recurrence was 10%. CONCLUSIONS: Surgical and oncological results validate the proposed modification of the double staple technique, when facing difficulties in suturing the rectum from the abdomen.

First case of bronchiolar-pleural fistula repair with platelet-leukocyte rich gel.

Bronchiolar-pleural fistulas are a frequent complication of thoracic surgery. Current treatment strategies and their invasiveness are quiet different, but often surgeons decide for a new surgical intervention and definitive closure of the breach. We report the case of a bronchiolar-pleural fistula in a 75 years old man with important co-morbidities that we treated with instillation of platelet-leukocyte rich gel (PLR-G). We discuss actual indications for PLR-G as well as its possible role in thoracic surgery.

Surgical treatment of pararenal aortic aneurysms in the elderly.

AIM: Until fenestrated endografts will become the standard treatment of pararenal aortic aneurysms, open surgical repair will currently be employed for the repair of this condition. Suprarenal aortic control and larger surgical dissection represent additional technical requirements for the treatment of pararenal aneurysms compared to those of open infrarenal aortic aneurysms, which may be followed by an increased operative mortality and morbidity rate. As this may be especially true when dealing with pararenal aneurysms in an elderly patients' population, we decided to retrospectively review our results of open pararenal aortic aneurysm repair in elderly patients, in order to compare them with those reported in the literature. METHODS: Twenty-one patients over 75 years of age were operated on for pararenal aortic aneurysms in a ten-year period. Exposure of the aorta was obtained by means of a retroperitoneal access, through a left flank incision on the eleventh rib. When dealing with interrenal aortic aneurysm the left renal artery was revascularized with a retrograde bypass arising from the aortic graft, proximally bevelled on the ostium of the right renal artery. RESULTS: Two patients died of acute intestinal ischemia, yielding a postoperative mortality of 9.5%. Nonfatal complications included 2 pleural effusions, a transitory rise in postoperative serum creatinine levels in 3 cases, and one retroperitoneal hematoma. Mean renal ischemia time was 23 min, whereas mean visceral ischemia time was 19 min. Mean inhospital stay was 11 days. CONCLUSION: Pararenal aortic aneurysms in the elderly can be surgically repaired with results that are similar to those obtained in younger patients.

Treatment for persistent chronic neuralgia after inguinal hernioplasty.

Following an inguinal hernia repair with open or laparoscopic technique, 1-15% of patients show persistent neuralgia, a severe, potentially debilitating, complication. Several therapeutic procedures have been proposed, but consensus regarding choice of treatment has not yet been achieved. We performed a prospective study on 32 such cases. Patients underwent anaesthetic infiltration to identify, when possible, the involved nerve, and we then carried out a step-by-step therapeutic protocol. In the initial phase, patients were treated with oral analgesic and afterwards with repeated infiltrations of anaesthetic and cortisone. Surgery was reserved for patients not responding to the infiltrations, though with no good success. The authors believe that noninvasive methods are to be preferred, whereas neurectomy interventions should be reserved for selected cases.

Malignant fibrous histiocytoma of the mesentery: report of two cases and review of the literature.

Malignant Fibrous Histiocytoma (MFH) rarely affects the abdomen and only a few cases arising in the mesentery have to date been discovered. In this paper, two cases of MFH of the mesentery are described and a review of the literature is reported.

[Intraoperative injuries of the superior laryngeal nerve in thyroid surgery]. / Lesioni intraoperatorie del nervo laringeo superiore in chirurgia tiroidea.

The intraoperative injury of the external branch of the Superior Laryngeal Nerve (SLN) is a disregarded complication of thyroid surgery that becomes a serious one for particular professional groups. The Authors retrospectively evaluate 124 cases of total thyroidectomies performed by the same surgeon from 1999 to 2002. Clinically evaluated SLN lesions (hypomobility of the vocal cord) was registered in six patients (4.8%). Routine identification of SLN and meticulous dissection of the superior thyroid vessels must be the technical benchmark to avoid nerve injury, even if bulky disease, anatomic variations and previous surgery may increase the chance of nerve damaging.

The treatment of chronic intestinal ischemia.

BACKGROUND AND AIMS: Due to the rarity of the condition, large and prospective series defining the optimal method of digestive arteries revascularization, for the treatment of chronic intestinal ischemia, are lacking. The aim of this consecutive sample clinical study was to test the hypothesis that flexible application of different revascularization methods, according to individual cases, will yield the best results in the management of chronic intestinal ischemia. PATIENTS AND METHODS: Eleven patients, of a mean age of 57 years, underwent revascularization of 11 digestive arteries for symptomatic chronic mesenteric occlusive disease. Eleven superior mesenteric arteries and one celiac axis were revascularized. The revascularization techniques included retrograde bypass grafting in 7 cases, antegrade bypass grafting in 2, percutaneous arterial angioplasty in 1, and arterial reimplantation in one case. The donor axis for either reimplantation or bypass grafting was the infrarenal aorta in 4 cases, an infrarenal Dacron graft in 4, and the celiac aorta in one case. Grafting materials included 5 polytetrafluoroethylene (PTFE) and 3 Dacron grafts. Concomitant procedures included 3 aorto-ilio-femoral grafts and one renal artery revascularization. Mean follow-up length was 31 months. RESULTS: There was no operative mortality. Cumulative survival rate was 88.9% at 36 months (SE 12.1%). Primary patency rate was 90% at 36 months (SE 11.6%). The symptom free rate was 90% at 36 months (SE 11.6%). CONCLUSIONS: Direct reimplantation, antegrade and retrograde bypass grafting, all allow good mid-term results: the choice of the optimal method depends on the anatomic and general patients status. Associated infrarenal and renal arterial lesions can be safely treated in the same time of digestive revascularization. Angioplasty alone yields poor results and should be limited to patients at poor risk for surgery.

The surgical treatment of ilio-femoral venous obstruction.

METHODS: A series of 9 patients of a mean age of 48 years, operated on for compression of the ilio-femoral venous axis is reported. The cause of obstruction was external compression in 3 cases, a retroperitoneal sarcoma in 1 case, and an infrarenal aortic aneurysm in 2. Two patients presented with a Cockett's syndrome, 3 with a chronic ilio-femoral thrombosis, and one with a post-traumatic segmentary stenosis. Treatment consisted in a resection/Dacron grafting of 2 infrarenal aortic aneurysms, one femoro-caval bypass graft, 2 transpositions of the right common iliac artery in the left hypogastric artery for Cockett's syndrome, 3 Palma's operations for chronic thrombosis, and one internal jugular vein interposition for segmentary stenosis. RESULTS: There were no postoperative deaths and no early thromboses of venous reconstructions performed. All the patients were relieved of symptoms during the follow-up period, whose mean length was 38 months. CONCLUSION: The cause of venous obstruction and the presence of symptoms which are resistant to medical treatment are the main indications to ilio-femoral venous revascularization. The choice of the optimal treatment in each single case yields satisfactory results.

Treatment of gunshot wounds to the colon: experience in a rural hospital during the civil war in Somalia.

BACKGROUND: In the last few decades there has been a clear tendency in civilian practice towards primary repair of gunshot wounds to the colon, resulting in a substantial decrease in the number of colostomies performed for this type of injury. METHODS: The series described here comprises 24 patients with gunshot wounds to the colon treated at the hospital of Jowar in the Middle Shebelle region of Somalia between 1999 and 2001. All injuries were caused by war arms firing high-velocity projectiles. RESULTS: In 18 patients surgery consisted of resection and immediate anastomosis, while in the remaining six patients colostomies were performed including five loop colostomies and one terminal colostomy. The sepsis-related mortality was 25% (6/24). CONCLUSION: Our experience had a peculiar setting, namely that of a civil war in a developing country. In this kind of "difficult" situation there probably exists no ideal procedure and the decisions taken at the operating table are influenced by various factors that are often related to subjective assessment.

[Revascularization of the carotid and vertebral arteries in the elderly]. / La chirurgia delle carotidi e delle arterie vertebrali nell'anziano.

From January 1994 to July 2004, 323 patients underwent 348 revascularization of carotid bifurcation for atherosclerotic stenoses. Eighty eight patients (group A) were 75 year-old or older, whereas 235 (group B) were younger than 75 years. Postoperative mortality/neurologic morbidity rate was 1% in group A, and 1.4% in group B. At 5 years, patency and freedom from symptoms/stroke were, respectively, 91% and 92% in group A, and 89% and 91% in group B. None of these differences was statistically significant. In the same time period, 26 internal carotid arteries were revascularized in 24 patients, 75 or more aged, for a symptomatic kinking. Postoperative mortality/morbidity rate was absent, whereas, at 5 years, patency and freedom from symptoms/stroke were, respectively, 88% and 92%. Twelve vertebral arteries were revascularized in 12 patients, 75 or more aged, for invalidating symptoms of vertebrobasilar insufficiency. Postoperative mortality/neurologic morbidity rate was absent. In one case postoperative recurrence of symptoms occurred, despite a patent revascularization. Patency and freedom from symptoms/stroke were 84% and 75%, at 5 years. Revascularization of carotid and vertebral arteries in the elderly can be accomplished with good results, superposable to those of standard revascularization of carotid bifurcation in a younger patients' population.

[Surgical treatment of lung metastasis: experience with 108 cases]. / Il trattamento chirurgico delle metastasi polmonari: esperienza su 108 casi.

In this study the Author's analyze their experience (between September 1973 and December 2002) with 108 pulmonary resections for metastatic tumors to the lungs to evaluate prognostic factors and the impact on survival of extended metastasectomy. Overall mortality and major morbidity were 1.85% and 2.78%. The actuarial survivals at 5 and 10 years were respectively 46.6% and 39.9%. The best mean survivals are observed in patients with metastases from breast, colorectal, thyroid and urinary tract carcinomas, in cases with disease free interval > 12 months and in the patients who underwent sequentially surgery and chemotherapy. Patients with pulmonary metastases also potentially benefit from iterative pulmonary resection.

[Reoperations in lung surgery]. / I reinterventi in chirurgia polmonare.

A second thoracotomy in patients who have undergone previous chest surgery can be performed soon or immediately after the first operation and is usually aimed at resolving severe or even life-threatening postoperative complications. Late reoperations, on the other hand, are either performed to resolve complications of previous surgery or to remove second primary lung tumors (SPLCs) or metastases. The most exacting reoperation in this context is completion pneumonectomy, which is particularly indicated in the case of failure of the residual lobe to re-expand after primary surgery; it is also used for--rarely occurring--fistulas of the lobar bronchi and for new ipsilateral primary lung tumors. This type of surgery is technically complicated and has been associated, in our experience and that of others, with a certain mortality. Technically less difficult is a second ipsilateral thoracotomy for exploratory purposes or minor parenchymal resection, and the same is true of contralateral lobar or sublobar resections. Lastly, Abruzzini's operation, for fistulas of the primary bronchus, is relatively complicated but often leads to good results; we have performed 15 such operations with only one death occurring due to acute myocardial infarction.

NM23 expression as prognostic factor in colorectal carcinoma.

BACKGROUND: The current most important prognostic indicator in colorectal carcinoma is tumor stage at the moment of diagnosis. The role of NM23 gene as prognostic factor is controversial. The aim of this study was to investigate NM23 expression. PATIENTS AND METHODS: The study population included 104 unselected patients who underwent surgery for colorectal carcinoma between 1992 and 1997. NM23 expression was quantified by estimating the percentage of tumor cells with unequivocal reactivity. The percentage was scored: 0 when no tumor cells showed immunoreactivity; 1 when less than 10% of cells showed immunoreactivity; 2 when 11-50% of cells were positive; 3 when more than 51% of cells were positive. RESULTS: Four cases belonged to group 0.21 to group 1.55 to group 2 and 24 to group 3. CONCLUSION: NM23 cannot be considered an independent prognostic variable.

[Complications of inguinal hernia repair]. / Complicanze dell'ernioplastica inguinale.

It's shown by literature and confirmed by Author's experience that, on account of the excellent results, prosthetic repair of inguinal hernia is more effective than "conventional" (Bassini, Mc Vay, Shouldice). Between January 1993 and December 2000 were observed 875 patients with inguinal hernia (814 monolateral, 61 bilateral); all patients underwent a Lichtenstein repair both in the primary version and in its variations (internal ring plastic, trasversalis plicate, plug repair). The patients were discharged from hospital within 24 hours after surgery in 90% of cases. No important intraoperative complications were observed; the patients restarting work varied from 3 to 15 days after the discharging in relation to patient anxiety, onset of complications and to the type of work. The complications observed were: urine retention (1.6%), superficial haematoma (1.3%), superficial infection (1%), wound suppuration (0.5%), serous effusion (0.7%), postsurgery pain (2.1%), scrotal edema (1.7%), persistent inguinal neuralgia (0.6), local hypoesthesia (4.3%), ischemical orchitis (0.1%), recurrence (0.2%). In conclusion Authors assert that "tension free" repair allows optimal results both for the surgery point (easiness of the technique, repeatability, less invasivity, scanty incident of recurrences, low frequency of postoperative complications) and in economic terms, allowing an early mobilization of the patients. A further improvement would be obtained with more care in surgical and patient management, with more excellent results.

[Pre- and postoperative external biliary drainage in patients with obstructive jaundice caused by neoplasm of the pancreatic head]. / Drenaggio biliare esterno pre- e postoperatorio in pazienti con ittero ostruttivo da neoplasia della testa del pancreas.

The external biliary drainage in severe jaundice secondary to pancreatic carcinoma acts differently in pre, intra, and postoperative period. In the preoperative period the drainage enables to lower the direct bilirubinemia and the intrahepatic biliary stasis and consequently the complications linked to the impaired hepatic and renal function. During the operation the catheter acts as a guide in performing the biliodigestive anastomosis. In the postoperative period the external drainage of most of daily biliary secretion protects the biliodigestive anastomosis during the postoperative paralytic ileus, and prevents the fistula development along the pancreatic jejunal anastomosis.

[Photodynamic therapy in cardiac and vascular surgery]. / Terapia fotodinamica in chirurgia cardiaca e vascolare.

One of the major drawbacks to therapeutic cardiovascular intervention is intimal hyperplasia and constrictive remodeling, which result in vascular restenosis. Neointimal hyperplasia is characterized by proliferation and migration of smooth muscle cells. These cells also produce new extracellular matrix, leading to narrowing of vessels. Photodynamic therapy (PDT) represents one of the most promising approaches to the inhibition of intimal hyperplasia. PDT requires the interaction among 3 factors: a source of light, usually a laser, a photosensitizer and oxygen. When the inert photosensitizer absorbs light of a specific wavelength, it is activated to an excited triplet state, generating reactive oxygen species. These free radicals are able to induce apoptosis of the smooth muscle cells that had absorbed the photosensitizer; they also induce changes in the extracellular matrix, reducing cell migration. Because of continued success of PDT in inhibiting intimal hyperplasia in experimental animal models, it is now being tested in clinical trials for vascular diseases. PDT offers many advantages to the surgeon since it can act on numerous factors responsible for vascular lesions. In the future PDT could be used in helping to overcome the inherent failures associated to vascular reconstruction. This treatment modality is emerging as an encouraging therapeutic option, either alone or as an adjunct to conventional treatment. However, more detailed clinical investigation are necessary to determine its full potential.

Gemcitabine as single agent therapy in advanced non small cell lung cancer and quality of life in the elderly.

BACKGROUND: The aim of this study is to test the efficacy of gemcitabine as single agent therapy in advanced non-small cell lung cancer in the elderly by the evaluation of the clinical response, the survival increase and the quality of life. METHODS: Nineteen patients (age >65 years) with a PS >2, bearing an advanced non-small cell lung cancer (IIIb-IV) not treated with chemotherapy before, were charged between December 1996 and December 1998. Sixteen patients were treated with gemcitabine at the dose of 1000 mg/mq 1-8-15 every 28 days. CT scan, X-rays and skeletal scintigraphy were used in the evaluation of the therapeutic response. The toxicity was estimated by following WHO indexes. The quality of life and the modification of the specific symptoms were estimated by particular tests (Spitzer Index, IADL, EORTC-LC13). RESULTS: One complete response (6%), 4 partial responses (25%), 7 cases of illness stabilization (43%), 4 cases of illness progression, were shown. One year of survival was found in 43% of cases with a 14 week of therapeutic response and a global survival ratio of 12.4 weeks. Only 2 cases (12.5) of medium grade G3-leucopenia were found. All patients improved their quality of life (IADL and Spitzer indexes) with reduction of symptoms, (EORTC-LC13) and increase of self-agin and relationships. CONCLUSIONS: The effectiveness of gemcitabine as single agent therapy as not yet been tested due to the scanty number of patients, nevertheless it must be considered in relation to the improvement of the patient s quality of life.

[The diagnostic activity within the compass of a day hospital surgical unit: a proposed organizational model]. / L'attività diagnostica nell'ambito di una unità chirurgica di Day Hospital: proposta di un modello organizzativo.

The authors report their own experience about the activity in a surgical day hospital. Day surgery should play a main role; nevertheless, some resources could be used in a diagnostic activity, to improve the turn-over of patients and minimize the time of charge in the surgical units.