Perioperative risk prediction using the POSSUM and V-POSSUM models in symptomatic carotid stenosis.

Background: This study aimed to evaluate risk factors for adverse outcomes and perioperative stroke and death in patients with symptomatic carotid stenosis undergoing open endarterectomy (CEA). The second objective was to assess the predictive value of the POSSUM and V-POSSUM models for predicting morbidity and mortality from CEA in symptomatic carotid stenosis. Patients and methods: A retrospective observational study of all patients admitted to a single center who underwent CEA for symptomatic carotid stenosis was performed. 320 patients from 1999 to 2013 were included. Postoperative complications, 30-day survival, and stroke rates were recorded. The observed outcomes were compared to the POSSUM and V-POSSUM expected mortality (observed to expected ratio (O:E)). Results: The mean age was 68.1±10.0 years. 215 patients were male (67%). Risk factors for surgical complications were: age, with a higher risk in both groups of less than 60 years and more than 75 years of age (p=0.04), a higher ASA score (p=0.04), and hyperlipidemia (p=0.017). Risk factors for the combined endpoint stroke or death were a higher ASA category (p<0.001), stroke as indication for CEA (p 0.022), and a high degree of stenosis (p=0.019). For POSSUM predicted mortality, there was a good O:E ratio in the two lowest risk groups, but a 2-fold overprediction of death or stroke in the two high-risk strata. The area under the curve (AUC) was 0.58 (95% CI: 0.43-0.73). The V-POSSUM showed a better fit in the high-risk groups, but an underprediction of mortality in the low-risk strata. Conclusions: Age and comorbid conditions are risk factors for adverse outcomes after CEA. The V-POSSUM model is better than POSSUM to predict postoperative death and stroke after CEA in patients with symptomatic carotid stenosis and a high preoperative physiological score. In patients with low physiological scores, both POSSUM and V-POSSUM show a limited predictive value.

[Histologic Remission following Neoadjuvant Immunotherapy in a Patient with Lynch-Syndrome and Primarily Unresectable Relapse of Rectum Carcinoma]. / Histologische Vollremission nach neoadjuvanter Immuntherapie bei einem Patienten mit Lynch-Syndrom und primär inoperablem Rezidiv eines Rektumkarzinoms.

Clinical History A 43-year-old male patient was diagnosed to have rectum carcinoma cT4N2M0 with underlying Lynch-Syndrome. After initializing neoadjuvant radio-chemotherapy followed by operation, the patient presents with an extensive locoregional relapse within a short time. In order to achieve resectability, a second line treatment with FOLFOXIRI protocol in addition to Bevacizumab was conducted. However, after completing six cycles of this intensiv treatment protocol, the tumour showed further progression. Clinical Course Having no evidence of distance metastasis, we decided to initiate off-label use of Pembrolizumab, a PD-1-receptor inhibitor. Clinical symptoms decreased rapidly and after receiving six cycles, PET/CT imaging showed regression. The side effects were limited to subclinical autoimmune thyroiditis. After re-operation no evidence of malignancy were found in the resectates of exenteration of the pelvis. Currently the patient is capable of working with only limited symptoms. Conclusion Pembrolizumab offers new treatment options for patients with DNA-repair-deficiency mismatch, e. g. Lynch-Syndrome. A phase II study already showed effectiveness in this particular group of patients. The striking and unexpected histo-pathologic results showing full remission should draw attention to the use of Pembrolizumab in neoadjuvant settings.

Aortic Foreign Body Caused by Rupture of Endobag after EVAS Using the Nellix Aneurysm Sealing System-A Case Report.

The Nellix aneurysm sealing system aims at sealing the cavity of the sac of the aneurysm, to reduce typical complications such as migration or endoleak. We report on a case of a unique device-associated complication: rupture and displacement of the filling material into the aortic lumen, causing peripheral ischemia and imminent renal and visceral occlusion, in a patient with anastomotic ulcer after an open aortobiiliac bypass and calcified and tortuous iliac arteries. The material was removed by open surgery. The patient recovered completely. The device should be handled with great caution in cases with hostile access routes, and in secondary interventions.