Shifting paradigms: a pivotal study on laparoscopic resection for colovesical fistulas in diverticular disease.

Background: Colovesical fistulas (CVFs) pose a challenge in diverticulitis, affecting 4% to 20% of sigmoid colon cases. Complicated diverticular disease contributes significantly, accounting for 60%-70% of all CVFs. Existing studies on laparoscopic CVF management lack clarity on its effectiveness in diverticular cases compared to open surgery. This study redefines paradigms by assessing the potentiality, adequacy, and utility of laparoscopy in treating CVFs due to complicated diverticular disease, marking a paradigm shift in surgical approaches. Methods: Conducting a retrospective analysis at Ospedale Monaldi A.O.R.N dei Colli and University Federico II, Naples, Italy, patients undergoing surgery for CVF secondary to diverticular disease between 2010 and 2020 were examined. Comprehensive data, including demographics, clinical parameters, preoperative diagnoses, operative and postoperative details, and histopathological examination, were meticulously recorded. Patients were classified into open surgery (Group A) and laparoscopy (Group B). Statistical analysis used IBM SPSS Statistic 19.0. Results: From January 2010 to December 2020, 76 patients underwent surgery for colovesical fistula secondary to diverticular disease. Laparoscopic surgery (Group B, n = 40) and open surgery (Group A, n = 36) showed no statistically significant differences in operative time, bladder suture, or associated procedures. Laparoscopy demonstrated advantages, including lower intraoperative blood loss, reduced postoperative primary ileus, and a significantly shorter length of stay. Postoperative morbidity differed significantly between groups. Mortality occurred in Group A but was unrelated to surgical complications. No reoperations were observed. Two-year follow-up revealed no fistula recurrence. Conclusion: This pivotal study marks a paradigm shift by emphasizing laparoscopic resection and primary anastomosis as a safe and feasible option for managing CVF secondary to diverticular disease. Comparable conversion, morbidity, and mortality rates to the open approach underscore the transformative potential of these findings. The study's emphasis on patient selection and surgeon experience challenges existing paradigms, offering a progressive shift toward minimally invasive solutions.

Endovascular treatment of an aortocaval fistula caused by a late type II endoleak.

An aortocaval fistula (ACF) is a rare complication of abdominal aortic aneurysms (AAAs) and constitute <1% of all AAAs, which increases from 2% to 6.7% in ruptured AAAs. Unlike other aortic ruptures, most ACFs are not associated with significant blood loss on admission. The traditional treatment strategy has been open surgery, which is associated with a high mortality rate. Endovascular repair has been performed; however, the results are difficult to interpret due to the low incidence of ACFs and the absence of cases reported with a long follow-up duration. We report the case of a 78-year-old man with previous endovascular aneurysm repair performed in 2015, who presented to our emergency department 6 years later with abdominal pain. A computed tomography angiography scan showed type Ia, Ib, and II endoleaks and an ACF. The endoleaks were selectively treated, and the ACF was covered with a polytetrafluoroethylene endograft inserted in the inferior vena cava. In our single-case experience with a medium-term follow-up of 24 months, our treatment was safe and effective for ACF closure, with no further signs of endoleak or graft thrombosis. We conducted a literature review of reported cases in which a covered stent graft was used for ACF treatment. Although no guidelines are currently available regarding this rare late complication after endovascular aneurysm repair, using a covered stent placed in the inferior vena cava to treat an ACF could be a viable option in selected cases.

The use of mixed reality in the preoperative planning of colorectal surgery: Preliminary experience with a narrative review.

New advanced technologies have recently been developed and preliminarily applied to surgery, including virtual reality (VR), augmented reality (AR) and mixed reality (MR). We retrospectively review all colorectal cases in which we used holographic 3D reconstruction from February 2020 to December 2022. This innovative approach was used to identify vascular anomalies, pinpoint tumor locations, evaluate infiltration into neighboring organs and devise surgical plans for both training and educating trainee assistants. We have also provided a state-of-the-art analysis, briefly highlighting what has been stated by the scientific literature to date. VR facilitates training and anatomical assessments, while AR enhances training and laparoscopic performance evaluations. MR, powered by HoloLens, enriches anatomic recognition, navigation, and visualization. Successful implementation was observed in 10 colorectal cancer cases, showcasing the effectiveness of MR in improving preoperative planning and its intraoperative application. This technology holds significant promise for advancing colorectal surgery by elevating safety and reliability standards.

Metalloproteinases as Biomarkers and Sociomarkers in Human Health and Disease.

Metalloproteinases (MPs) are zinc-dependent enzymes with proteolytic activity and a variety of functions in the pathophysiology of human diseases. The main objectives of this review are to analyze a specific family of MPs, the matrix metalloproteinases (MMPs), in the most common chronic and complex diseases that affect patients' social lives and to better understand the nature of the associations between MMPs and the psychosocial environment. In accordance with the PRISMA extension for a scoping review, an examination was carried out. A collection of 24 studies was analyzed, focusing on the molecular mechanisms of MMP and their connection to the manifestation of social aspects in human disease. The complexity of the relationship between MMP and social problems is presented via an interdisciplinary approach based on complexity paradigm as a new approach for conceptualizing knowledge in health research. Finally, two implications emerge from the study: first, the psychosocial states of individuals have a profound impact on their overall health and disease conditions, which implies the importance of adopting a holistic perspective on human well-being, encompassing both physical and psychosocial aspects. Second, the use of MPs as biomarkers may provide physicians with valuable tools for a better understanding of disease when used in conjunction with "sociomarkers" to develop mathematical predictive models.

Mid-Term Results of an Italian Multicentric Experience with the RoadsaverTM Dual-Layer Carotid Stent System.

BACKGROUND: Carotid artery stenting (CAS) using first-generation single-layer stents is widely accepted as a good alternative to standard carotid endarterectomy (CEA) but it is associated with worse outcomes in terms of both plaque prolapse and cerebral embolization. AIM: To evaluate the perioperative and midterm outcomes of CAS using the new-generation RoadsaverTM dual-layer micromesh-covered carotid stent. METHODS: Herein, we present the results of an observational, retrospective, multicentric study on non-consecutive patients who underwent the CAS procedure between January 2017 and December 2022 at three Italian, high-volume vascular surgery centers. The inclusion criteria were the patients' eligibility for the CAS procedure in accordance with the current Italian guidelines, and the implantation of a Roadsaver stent. Both symptomatic and asymptomatic patients were included in the study. The patients requiring reintervention for carotid restenosis following CEA were also included. Perioperative data regarding procedural success was defined as the successful implantation of the device in the desired position, less than 30% residual stenosis, and the absence of intraoperative neurological complications. The primary outcome was any adverse cerebrovascular event such as stroke or transient ischemic attack (TIA) during the procedure and/or after discharge. The secondary outcomes were the need for further intervention, and all-cause death following procedure. RESULTS: Three-hundred-fifty-three (353) patients were included in our study; the mean age was 74.3 years. A total of 5.9% of the patients were symptomatic on their operated side, while 7.3% had contralateral carotid occlusion. A cerebral embolic protection device (CPD) was employed in all patients. A total of 13.3% of the patients were operated on for restenosis after CEA Technical success was achieved in 96.9% of the cases with an intraoperative report of six TIAs (1.7%) and six ipsilateral strokes (1.7%). The mean hospital stay was 1.8 days. The thirty-day follow up showed one TIA and one more stroke. At the mean 35-month follow-up time, the primary outcome was present in six patients (1.7%), where four TIAs (1.1%) and two strokes (0.5%) were reported. Restenosis occurred in five patients (1.4%). Death for any cause was reported in 11 patients (3.1%). CONCLUSIONS: As most recent, high-quality studies show, the CAS procedure with second-generation devices such as the Roadsaver stent is safe and effective in preventing carotid-related cerebrovascular events in both symptomatic and asymptomatic patients. The intraoperative and postoperative cerebrovascular complication rate in high volume centers is very low, ensuring confidence in its employment for the CAS procedure along with a CPD as a valid alternative to CEA.

A Randomized Phase III Trial of Complete Mesocolic Excision Compared with Conventional Surgery for Right Colon Cancer: Interim Analysis of a Nationwide Multicenter Study of the Italian Society of Surgical Oncology Colorectal Cancer Network (CoME-in trial).

BACKGROUND: Although complete mesocolic excision (CME) is supposed to be associated with a higher lymph node (LN) yield, decreased local recurrence, and survival improvement, its implementation currently is debated because the evidence level of these data is rather low and still not supported by randomized controlled trials. METHOD: This is a multicenter, randomized, superiority trial (NCT04871399). The 3-year disease-free survival (DFS) was the primary end point of the study. The secondary end points were safety (duration of operation, perioperative complications, hospital length of stay), oncologic outcomes (number of LNs retrieved, 3- and 5-year overall survival, 5-year DFS), and surgery quality (specimen length, area and integrity rate of mesentery, length of ileocolic and middle-colic vessels). The trial design required the LN yield to be higher in the CME group at interim analysis. RESULTS: Interim data analysis is presented in this report. The study enrolled 258 patients in nine referral centers. The number of LNs retrieved was significantly higher after CME (25 vs. 20; p = 0.012). No differences were observed with respect to intra- or post-operative complications, postoperative mortality, or duration of surgery. The hospital stay was even shorter after CME (p = 0.039). Quality of surgery indicators were higher in the CME arm of the study. Survival data still were not available. CONCLUSIONS: Interim data show that CME for right colon cancer in referral centers is safe and feasible and does not increase perioperative complications. The study documented with evidence that quality of surgery and LN yield are higher after CME, and this is essential for continuation of patient recruitment and implementation of an optimal comparison. Trial registration The trial was registered at ClinicalTrials.gov with the code NCT04871399 and with the acronym CoME-In trial.

An international Delphi consensus for surgical quality assessment of lymphadenectomy and anastomosis in minimally invasive total gastrectomy for gastric cancer.

BACKGROUND: Minimally invasive total gastrectomy (MITG) is a mainstay for curative treatment of patients with gastric cancer. To define and standardize optimal surgical techniques and further improve clinical outcomes through the enhanced MITG surgical quality, there must be consensus on the key technical steps of lymphadenectomy and anastomosis creation, which is currently lacking. This study aimed to determine an expert consensus from an international panel regarding the technical aspects of the performance of MITG for oncological indications using the Delphi method. METHODS: A 100-point scoping survey was created based on the deconstruction of MITG into its key technical steps through local and international expert opinion and literature evidence. An international expert panel comprising upper gastrointestinal and general surgeons participated in multiple rounds of a Delphi consensus. The panelists voted on the issues concerning importance, difficulty, or agreement using an online questionnaire. A priori consensus standard was set at > 80% for agreement to a statement. Internal consistency and reliability were evaluated using Cronbach's α. RESULTS: Thirty expert upper gastrointestinal and general surgeons participated in three online Delphi rounds, generating a final consensus of 41 statements regarding MITG for gastric cancer. The consensus was gained from 22, 12, and 7 questions from Delphi rounds 1, 2, and 3, which were rephrased into the 41 statetments respectively. For lymphadenectomy and aspects of anastomosis creation, Cronbach's α for round 1 was 0.896 and 0.886, and for round 2 was 0.848 and 0.779, regarding difficulty or importance. CONCLUSIONS: The Delphi consensus defined 41 steps as crucial for performing a high-quality MITG for oncological indications based on the standards of an international panel. The results of this consensus provide a platform for creating and validating surgical quality assessment tools designed to improve clinical outcomes and standardize surgical quality in MITG.

Which inflammatory marker, between systemic immune-inflammation index and neutrophil to eosinophil ratio, is associated with Peyronie's disease and are there any implications for a better understanding of its mechanisms?

BACKGROUND: Peyronie's disease affects up to 9% of men and is often accompanied by pain and/or erectile dysfunction. It is characterized by an inflammatory process that is the grassroots of the subsequent fibrosis stage. There is an unmet need to evaluate its onset and progression. Among the newly proposed biomarkers of inflammation, authors developed a novel systemic immune-inflammation index (SII) based on lymphocyte, neutrophil, and platelet counts. Similarly, a recent study reported that a neutrophil-to-eosinophil ratio (NER) represents systemic inflammation. RESULTS: A 49-patient group with Peyronie's disease as confronted with 50 well-matched for age and BMI controls. As laboratory evaluation of inflammation, SII, NER and the eosinophil to neutrophil ratio (ENR) were studied. As a likely risk factor for the presence of Peyronie's disease, a higher prevalence of hypercholesterolemia, hyperglycemia and hypertension was discovered in the patients compared to controls. A significant difference was found in the median values of the NER between the two selected groups, i.e., 32.5 versus 17.3 (p = 0.0021). As expected, also ENR was significantly different. The receiver operating characteristic curves for SII, ENR and NER were 0.55, 0.32 and 0.67, respectively, highlighting the best performance of NER. The cut-off for NER was 12.1, according to the Youden test. CONCLUSIONS: According to our results, any evaluation of circulating eosinophil, evaluated as NER, beyond being a signature of immuno-inflammatory response, help assess tissue homeostasis, since eosinophils are now considered multifunctional leukocytes and give a picture of the inflammatory process and repair process belonging to Peyronie's disease.

RéSUMé: CONTEXTE: La maladie de La Peyronie touche jusqu'à 9% des hommes et s'accompagne souvent de douleurs et/ou de dysfonction érectile. Elle se caractérise par un processus inflammatoire qui est. à la base de l'étape de fibrose ultérieure. Il existe un besoin non satisfait d'en évaluer son apparition et sa progression. Parmi les biomarqueurs de l'inflammation nouvellement proposés, les auteurs ont développé un nouvel indice d'inflammation immunitaire systémique (SII) basé sur le nombre de lymphocytes, de neutrophiles et de plaquettes. De même, une étude récente a rapporté qu'un rapport neutrophiles/éosinophiles (NER) représente une inflammation systémique. RéSULTATS: Un groupe de 49 patients atteints de la maladie de La Peyronie a été confronté à 50 témoins étroitement appariés sur l'âge et l'IMC. Dans le cadre de l'évaluation de l'inflammation au laboratoire, le SII, le NER et le rapport éosinophiles/neutrophiles (ENR) ont été étudiés. En tant que facteur de risque probable de la présence de la maladie de La Peyronie, une prévalence plus élevée d'hypercholestérolémie, d'hyperglycémie et d'hypertension a été découverte chez les patients par rapport aux témoins. Une différence significative a été constatée pour les valeurs médianes du NER entre les deux groupes sélectionnés, c'est-à-dire 32,5 contre 17,3 (p = 0,0021). Comme on pouvait s'y attendre, le ERN était également significativement différent. Les courbes caractéristiques de fonctionnement du récepteur pour le SII, l'ENR et le NER étaient respectivement de 0,55, 0,32 et 0,67, ce qui met en évidence les meilleures performances du NER. Le seuil pour le NER était de 12,1 (test de Youden). CONCLUSIONS: D'après nos résultats, toute évaluation de l'éosinophilie circulante, sous la forme NER, au-delà d'être une signature de la réponse immuno-inflammatoire, permet d'évaluer l'homéostasie tissulaire, puisque les éosinophiles sont maintenant considérés comme étant des leucocytes multifonctionnels, et donne une image du processus inflammatoire et du processus de réparation appartenant à la maladie de La Peyronie. MOTS-CLéS: Maladie de La Peyronie Rapport Neutrophiles/Eosinophiles Rapport Eosinophiles/Neutrophiles Indice d'Inflammation immunitaire systémique Réponse Immuno-inflammatoire.

Trends and perioperative mortality in gastric cancer surgery: a nationwide population­based cohort study.

This study aimed to investigate changes and perioperative mortality over a 6-year period within the Italian Hospital Information System among patients with gastric cancer (GC) who underwent gastrectomies and to identify risk factors associated with 90-day mortality. Additionally, nationwide differences between high and low-volume hospitals were evaluated. A nationwide retrospective study was conducted using patient hospital discharge records (HDRs) based on the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) classification. The HDRs were linked to the National Tax Registry records using deterministic record linkage. The data were obtained from the Italian National Outcomes Evaluation Programme (PNE). Multivariate logistic regression was used to examine risk factors for 90-day mortality among patients with GC who underwent partial or total gastrectomies over the period from 2018 to 2020 with adjustment for comorbidities. Overall, the number of patients with GC who underwent total or partial gastrectomies steadily decreased in Italy from 5765 in 2015 to 4291 in 2020 (p < 0.001). The use of the laparoscopic approach more than doubled from 2015 (10.8%) to 2020 (26.3%), with a concomitant conversion rate from laparoscopy to open surgery decreasing from 7.7 to 5.8%. The 30 and 90-day mortality rates remained stable over time (p > 0.05). Low-volume hospitals had higher inpatient, early, and late mortality compared to high-volume hospitals (5.9% vs 3.8%, 6.3% vs 3.8%, and 11.8% vs 7.9%, respectively; p < 0.001). Multivariate logistic regression analysis showed that an advanced age (adjusted odds ratio: 3.72; 95% [CI]: 3.15-4.39; p < 0.001), an open approach (adjusted-OR: 1.69, 95% CI: 1.43-1.99, p < 0.001) and a total gastrectomy (adjusted-OR: 1.44, 95% CI: 1.27-1.64, p < 0.001) were independent risk factors for 90-day mortality. Additionally, patients with GC who referred to high-volume hospitals were 26% less likely to die within 90 days after a gastrectomy than those who underwent surgery in low-volume hospitals. During the 6-year period, surgeons implemented a minimally invasive approach to reduce the conversion over time. Centralisation was associated with better outcomes while advanced age, an open approach, and total gastrectomy were identified as risk factors for 90-day mortality.

Hyperkalemia in CKD: an overview of available therapeutic strategies.

Hyperkalemia (HK) is a life-threatening condition that often occurs in patients with chronic kidney disease (CKD). High serum potassium (sKsK) is responsible for a higher risk of end-stage renal disease, arrhythmias and mortality. This risk increases in patients that discontinue cardio-nephroprotective renin-angiotensin-aldosterone system inhibitor (RAASi) therapy after developing HK. Hence, the management of HK deserves the attention of the clinician in order to optimize the therapeutic strategies of chronic treatment of HK in the CKD patient. The adoption in clinical practice of the new hypokalaemic agents patiromer and sodium zirconium cyclosilicate (SZC) for the prevention and chronic treatment of HK could allow patients, suffering from heart failure and chronic renal failure, to continue to benefit from RAASi therapy. We have updated a narrative review of the clear variables, correct definition, epidemiology, pathogenesis, etiology and classifications for HK among non-dialysis CKD (ND CKD) patients. Furthermore, by describing the prognostic impact on mortality and on the progression of renal damage, we want to outline the strategies currently available for the control of potassium (K+) plasma levels.

A Systematic Review on the Role of Matrix Metalloproteinases in the Pathogenesis of Inguinal Hernias.

The recurrence rate in patients who undergo surgery for abdominal wall hernias (AWHs) is high. AWHs have been hypothesized to be a disease of the extracellular matrix, which is supported by evidence showing a high incidence of AWHs in patients with connective tissue disorders. This study aimed to investigate the most recent literature studies describing the levels of several matrix metalloproteinases (MMPs) in the blood and fascia, with the objective of better clarifying the pathogenetic role of matrix metalloproteinases (MMPs) and their inhibitors in inguinal hernias (IHs). A systematic literature search was conducted using the PubMed, Scopus, and Web of Science electronic databases to identify eligible studies. The identified studies were included in the analysis, and a qualitative synthesis of the results is provided to describe the most recent findings. Seventeen studies were included. An association between MMP-2 and direct IHs has also been demonstrated. MMP-1, MMP-2, MMP-9, MMP-12, and MMP-13 levels were increased in both the serum and fascia of patients with IHs. The analysis of inhibitors showed an increase in tissue inhibitors of metalloproteinases (TIMPs), specifically TIMP-1 in IHs, particularly in direct hernias, and a reduction in TIMP-2 in the biopsy samples of the transversalis fascia. In contrast, a reduction in TIMP-1 and an increase in TIMP-2 levels have been reported only in the serum of patients with IHs. Metalloproteinases play a crucial role in the pathogenesis of IHs. The analysis of other molecules, such as TIMPs or their correlation with specific genes, is enhancing our understanding of the pathophysiology of IHs. However, more prospective studies, including comprehensive clinical and laboratory data collection, are required to confirm the relationship between the studied biomarkers and the risk of IHs.

Preservation of the inferior mesenteric artery VS ligation of the inferior mesenteric artery in left colectomy: evaluation of functional outcomes-a prospective non-randomized controlled trial.

Vascular approach during elective laparoscopic left colectomy impacts post-operative outcomes. The aim of our study was to evaluate how different approaches impact positively defecatory, urinary and sexual functions and quality of life during elective laparoscopic left colectomy. A prospective non-randomized controlled trial at two tertiary center was conducted. All patients who underwent elective laparoscopic left colonic resection from January 2019 to July 2022 were analyzed. They were divided into two groups based on Inferior Mesenteric Artery (IMA) preservation with distal ligation of sigmoid branches close to a colonic wall for complicated diverticular disease and IMA high tie ligation for oncological disease. Patients were asked to fulfil standardized, validated questionnaires to evaluate pre and post-operative defecatory, urinary and sexual functions and quality of life. Defecatory disorders were assessed by high-resolution anorectal manometry preoperatively and six months after surgery. A total of 122 patients were included in the study. The 62 patients with IMA preservation showed a lower incidence of defecatory disorders also confirmed by manometer data, minor incontinence and less lifestyle alteration than the 60 patients with IMA high tie ligation. No urinary disorders such as incomplete emptying, frequency, intermittence or urgency were highlighted after surgery in the IMA preservation group. Evidence of any sexual disorders remained controversial. The IMA-preserving vascular approach seems to be an effective strategy to prevent postoperative functional disorders. It is a safe and feasible technique especially for diverticular disease. New prospective randomized and highly probative studies are needed to confirm the effectiveness in specific clinical situations.

Focus on the Most Common Paucisymptomatic Vasculopathic Population, from Diagnosis to Secondary Prevention of Complications.

Middle-aged adults can start to be affected by some arterial diseases (ADs), such as abdominal aortic or popliteal artery aneurysms, lower extremity arterial disease, internal carotid, or renal artery or subclavian artery stenosis. These vasculopathies are often asymptomatic or paucisymptomatic before manifesting themselves with dramatic complications. Therefore, early detection of ADs is fundamental to reduce the risk of major adverse cardiovascular and limb events. Furthermore, ADs carry a high correlation with silent coronary artery disease (CAD). This study focuses on the most common ADs, in the attempt to summarize some key points which should selectively drive screening. Since the human and economic possibilities to instrumentally screen wide populations is not evident, deep knowledge of semeiotics and careful anamnesis must play a central role in our daily activity as physicians. The presence of some risk factors for atherosclerosis, or an already known history of CAD, can raise the clinical suspicion of ADs after a careful clinical history and a deep physical examination. The clinical suspicion must then be confirmed by a first-level ultrasound investigation and, if so, adequate treatments can be adopted to prevent dreadful complications.

Prospective minimally invasive pancreatic resections from the IGOMIPS registry: a snapshot of daily practice in Italy on 1191 between 2019 and 2022.

This retrospective analysis of the prospective IGOMIPS registry reports on 1191 minimally invasive pancreatic resections (MIPR) performed in Italy between 2019 and 2022, including 668 distal pancreatectomies (DP) (55.7%), 435 pancreatoduodenectomies (PD) (36.3%), 44 total pancreatectomies (3.7%), 36 tumor enucleations (3.0%), and 8 central pancreatectomies (0.7%). Spleen-preserving DP was performed in 109 patients (16.3%). Overall incidence of severe complications (Clavien-Dindo ≥ 3) was 17.6% with a 90-day mortality of 1.9%. This registry analysis provided some important information. First, robotic assistance was preferred for all MIPR but DP with splenectomy. Second, robotic assistance reduced conversion to open surgery and blood loss in comparison to laparoscopy. Robotic PD was also associated with lower incidence of severe postoperative complications and a trend toward lower mortality. Fourth, the annual cut-off of ≥ 20 MIPR and ≥ 20 MIPD improved selected outcome measures. Fifth, most MIPR were performed by a single surgeon. Sixth, only two-thirds of the centers performed spleen-preserving DP. Seventh, DP with splenectomy was associated with higher conversion rate when compared to spleen-preserving DP. Eighth, the use of pancreatojejunostomy was the prevalent reconstruction in PD. Ninth, final histology was similar for MIPR performed at high- and low-volume centers, but neoadjuvant chemotherapy was used more frequently at high-volume centers. Finally, this registry analysis raises important concerns about the reliability of R1 assessment underscoring the importance of standardized pathology of pancreatic specimens. In conclusion, MIPR can be safely implemented on a national scale. Further analyses are required to understand nuances of implementation of MIPR in Italy.

Risk Factors for Bleeding Varicose Veins in Patients with Chronic Venous Disease.

Background and Objectives: Chronic venous disease (CVD) is a widespread clinical condition that is very common in western countries in the adult general population with a wide range of clinical manifestations, such as varicose veins (VVs) that in certain circumstances may complicate with rupture and subsequent bleeding that may even be fatal. The aim of this study is to evaluate risk factors for bleeding VVs. Materials and Methods: This is a retrospective study conducted in patients with CVD complicating with bleeding of VVs over a 4-year period (2019-2022). A random sample, for the same 4-year period and with a 3:1 ratio, was selected from other CVD patients without VVs bleeding that served as the control group. Results: From a global population of 1048 patients with CVD over a 4-year period, a total of 33 patients (3.15%) with VVs bleeding were selected. A group of 99 patients without VVs bleeding were randomly selected from the total population of 1048 patients with CVD. Findings of this study showed that advanced clinical stage of CVD (i.e., C4b stage), advanced age, living alone, suffering from cardiovascular co-morbidity (i.e., hypertension and CHF), assuming certain drugs that act on blood coagulation (i.e., aspirin, anticoagulants), assuming psychotropic medication, having particular venous reflux patterns (i.e., below-knee GSV reflux, non-saphenous veins reflux, Cockett's perforators reflux), and not having been assessed and treated previously for CVD (i.e., with VADs, CT, or surgery) may predispose a high risk for bleeding VVs. Conclusions: Bleeding VVs may be a life-threatening complications of CVD patients, and monitoring risk factors found in this study and others that, hopefully, may be discovered in the future through further focused research will help to reduce the impact of this problem in this patient population.

Endovascular treatment of a wide-necked renal artery aneurysm with a flow diverter stent.

Renal artery aneurysm (RAA) is a rare, often asymptomatic disease (0.1% incidence in general population) and can be incidentally diagnosed during an abdominal imaging workup. The traditional, gold standard of treatment is open surgery, carrying with it, however, a high risk of nephrectomy, mortality, and collateral morbidity. The endovascular approach is currently the most valid alternative to treating RAAs reducing, as it does, the risks associated with the surgical approach/open surgery. Herein we report on our experience with a case of wide-necked RAA treated with the Pipeline Vantage (Medtronic) flow diverter stent. Wide-neck aneurysms are defined as having neck diameters greater than 4 mm. Our choice of endovascular treatment was preferred over the surgical option notwithstanding the large size of the neck and the involvement of the branching vessels.

Laparoscopic Radical Nephrectomy with Transperitoneal Approach for Large Renal Tumors: Standardized Surgical Technique and Outcomes.

Background: Minimally invasive surgery is used only in selected cases of renal masses greater than 7 cm, and few studies exist in this setting. This study aimed to evaluate the safety and effectiveness of a laparoscopic surgical approach for the treatment of large renal tumors using a standardized technique. Materials and Methods: Data of patients who underwent laparoscopic nephrectomy (LN) using the transperitoneal approach were retrospectively evaluated from December 2019 to September 2022. The study population was divided into two groups: patients with renal masses <7 cm (Group A) and those with renal masses ≥7 cm in diameter (Group B). The intraoperative and postoperative outcomes were compared. Results: Forty patients were enrolled (16 in Group A and 24 in Group B) in this study. Although significant difference in terms of age and American Society of Anesthesiologists score were detected, the two groups did not differ in mean operative time (130 minutes standard deviation [SD] ± 64 versus 148 minutes DS ± 56; P = .376), intraoperative complications (0% versus 8.3%; P = .508), need for postoperative transfusion (12% versus 12%; P > .999), and length of stay (3.38 DS ± 0.62 days versus 3.92 DS ± 2.47; P = .313). One patient had a local recurrence and died ∼13 months after surgery. Furthermore, 2 patients developed trocar-site incisional hernia in Group B. Conclusion: In this cohort of patients, LN for large renal tumors appeared to be safe and feasible. Larger mass dimension does not appear to influence the outcomes when the surgery is performed using a standardized technique by experienced surgeons.