Postoperative nausea and vomiting (PONV) in outpatient repair of inguinal hernia.

PURPOSE: Nausea and vomiting are among the most frequent complications following anesthesia and surgery. Due to anesthesia seems to be primarily responsible for post operative nausea and vomiting (PONV) in Day Surgery facilities, the aim of the study is to evaluate how different methods of anesthesia could modify the onset of postoperative nausea and vomiting in a population of patients undergoing inguinal hernia repair. METHODS: Ninehundredten patients, aged between 18 and 87 years, underwent open inguinal hernia repair. The PONV risk has been assessed according to Apfel Score. Local anesthetic infiltration, performed by the surgeon in any cases, has been supported by and analgo-sedation with Remifentanil in 740 patients; Fentanyl was used in 96 cases and the last 74 underwent deep sedation with Propofol . RESULTS: Among the 910 patients who underwent inguinal hernia repair, PONV occurred in 68 patients (7.5%). Among patients presenting PONV, 29 received Remifentanil, whereas 39 received Fentanyl. In the group of patients receiving Propofol, no one presented PONV. This difference is statistically significant (p < .01). Moreover, only 50 patients of the total sample received antiemetic prophylaxis, and amongst these, PONV occurred in 3 subjects. CONCLUSIONS: Compared to Remifentanil, Fentanyl has a major influence in causing PONV. Nonetheless, an appropriate antiemetic prophylaxis can significantly reduce this undesirable complication. Key words: Day Surgery, Fentanyl, Inguinal, Hernia repair, Nausea, Vomiting.

Results of Infrageniculate Bypasses Using the Profunda Femoris Artery as Inflow Source.

BACKGROUND: When the common femoral artery is not accessible for infrainguinal bypass grafting, the profunda femoris artery (PFA) can be a valuable alternative inflow source for distal arterial revascularization. The purpose of this retrospective study was to evaluate the results of infrageniculate bypass grafting via the PFA as inflow source for critical limb ischemia. METHODS: Between 1994 and 2016, 68 patients, 51 men of a mean age of 74 years, underwent an infrageniculate arterial bypass grafting for critical limb ischemia, using the PFA as inflow site. PFA was exposed at the Scarpa's triangle in 38 patients (56%) and at its medio-crural segment in 30 patients (44%). The distal anastomosis was performed on the infragenicular popliteal artery in 33 patients (48%), the peroneal artery in 14 patients (20%), the tibioperoneal trunk in 8 patients (12%), the posterior tibial artery in 8 patients (12%), and the dorsalis pedis artery in 5 patients (8%). The graft material consisted of a reversed great saphenous vein (GSV) in 62 patients (91%) and a 6-mm polytetrafluoroethylene graft in 6 patients (9%). The median duration of follow-up was 51 months (range, 6-72 months). As main results, postoperative mortality and morbidity, overall late patients' survival, primary grafts' patency, and limb salvage rate were considered. RESULTS: Operative mortality and morbidity were 3% and 4%, respectively. Overall patients' survival, primary patency and limb salvage rate, at 36 and 60 months were, respectively, 62% and 53%, 66% and 59%, and 92% and 77%. CONCLUSIONS: The PFA, both exposed at the Scarpa's triangle and at mid-thigh, is an excellent inflow source for infrageniculate revascularizations. It should remain an important part of the technical armamentarium of vascular surgeons, even in the endovascular era.

Infrarenal aorta as the donor site for bypasses to the superior mesenteric artery for chronic mesenteric ischemia: A prospective clinical series of 24 patients.

BACKGROUND: Treatment of symptomatic, chronic mesenteric ischemia is indicated to relieve symptoms and prevent acute ischemia and death. Current therapeutic options include endovascular and open surgery. The purpose of this prospective study was to evaluate the results of bypasses to the superior mesenteric artery arising from the infrarenal aorta or infrarenal aortic grafts. METHODS: From January 1999 to December 2016, 24 consecutive patients with a mean age of 61 years underwent a prosthetic bypass to the superior mesenteric artery. Nine patients (37%) presented with an associated clinically important stenosis of the celiac artery and 10 (42%) of the inferior mesenteric artery. Five patients (21%) received preoperative parenteral nutrition. Four patients (17%) underwent dual antiplatelet treatment. The donor site was the infrarenal aorta in 19 patients (79%) and an infrarenal, Dacron graft was used in 5 (21%). The origin of the bypass was from the distal infrarenal aorta or Dacron graft in 19 patients (79%) and from the proximal infrarenal aorta in 5 patients (21%). The graft material consisted of 7 mm polytetrafluoroethylene in 19 cases (79%) and 7 mm Dacron in 5 cases (21%). A concomitant bypass to the inferior mesenteric artery was performed in 4 patients (17%). The primary end points were postoperative mortality, morbidity, graft infection, late survival, primary patency, and symptom-free rate. The secondary end point was postoperative hemorrhagic complications. RESULTS: No postoperative mortality occurred. Postoperative morbidity included a prolonged postoperative ileus in 4 patients (17%), transitory postoperative increases in serum creatinine concentrations in 3 patients (12%), and myocardial ischemia in 2 patients (8%). No postoperative hemorrhagic complications or graft infection were observed. Overall, the cumulative survival rate was 77% at 60 months. The overall late-patency rate and freedom from recurrence of symptoms were both 87% at 60 months. CONCLUSION: Infrarenal aorta and infrarenal aortic grafts are an excellent source for the revascularization of the superior mesenteric artery. Bypasses to the superior mesenteric artery from the infrarenal aorta, either isolated or associated with adjunctive bypass to the inferior mesenteric artery, yield results that are comparable with those obtained with complete digestive artery revascularization using other donor sources.

Schwannoma of the descending loop of the hypoglossal nerve: Case report.

INTRODUCTION: Schwannomas of the descending loop of the hypoglossal nerve are very rare. They are slow-growing tumors that may masquerade a carotid body tumor. PRESENTATION OF CASE: A 60-year-old female was referred for a latero-cervical mass appearing as a chemodectoma at CT-scan. At operation, a 2cm mass arising from the descending loop of the hypoglossal nerve was resected en bloc with the loop itself and a functional lymphadenectomy was associated. Post-operative course was uneventful and the patient is free from disease recurrence at one year follow-up. DISCUSSION: En bloc resection remains the real curative treatment of Schwannomas, ensuring unlimited freedom from disease, although causing functional impairment which may be significant. Nonetheless recurrence should be prevented as, beside requiring reintervention, it may harbor a malignant evolution towards sarcoma. CONCLUSION: Schwannomas of the descending lop of the hypoglossal nerve may masquerade a chemodectoma of the carotid bifurcation and can be curatively resected without any functional impairment.

Outcome of Resection and Chemotherapy versus Chemotherapy Alone for Retroperitoneal Recurrence of Testicular Cancer Involving the Inferior Vena Cava: A Retrospective Cohort Study of 22 Consecutive Patients.

BACKGROUND/AIM: Optimal treatment strategy for retroperitoneal recurrence of testicular cancer involving the inferior vena cava (IVC) is uncertain. The purpose of this study was to validate the hypothesis that surgical resection, en-bloc with the involved segment of IVC and its subsequent reconstruction followed by chemotherapy, would yield better oncologic results than chemotherapy alone. PATIENTS AND METHODS: Two consecutive series of patients with retroperitoneal recurrence of testicular cancer involving the IVC, treated with surgical resection plus chemotherapy (group A, n=14) or chemotherapy alone (group B, n=8) were retrospectively reviewed. The mean duration of follow-up was was 65 months (range=8-184). Operative mortality and morbidity in group A, response to chemotherapy in group B, disease-specific survival and quality adjusted life-years (QALY) for both groups, were primary end-points of the study. RESULTS: Postoperative mortality and morbidity (group A) were, respectively, nil and 14%. In group B, two patients (25%) fully responded to chemotherapy and remained free from disease progression. Disease-specific survival at 3 and 5 years was 81% and 54% in group A and 36% in group B both at 3 and 5 years, respectively (p=0.02). QALY was 3.92 in group A and 0.77 for both 3 and 5 years in group B, respectively, (p=0.031). CONCLUSION: En bloc resection of retroperitoneal recurrence of testicular tumors invading the IVC, followed by chemotherapy, allows a better survival rate compared to chemotherapy alone.

Perceived quality in Day Surgery Units Proposal of an enquiry postoperative questionnaire.

INTRODUCTION: Assessing patient satisfaction could be particularly useful in Day Surgery Units, as it helps maintaining and increasing medical care demand. Moreover, it provides feedback that turns out useful for improving quality in departments, and for assessing competence and skill of the whole staff. Background and aim - The purpose of this study was to evaluate the quality perceived in a day surgery unit through a questionnaire, covering the 10 main aspects of the care pathway. MATERIALS AND METHODS: The results of a questionnaire filled by patients undergoing Day Surgery between January 2007 and December 2012 were retrospectively reviewed. Patients undergoing surgery between 2007 and 2009 filled up the questionnaire at the time of the discharge, whereas those operated on between 2009 and 2012 filled up the same questionnaire 30 days after discharge. RESULTS: The results were good in terms of number of returned questionnaires, underlining its comprehensibility and suitability to be filled out. The questionnaires' scores were good in both groups, although quality perceived by the group that completed it in 30 days after surgery were lightly better than the other group's. CONCLUSIONS: The advantages of the questionnaire consisted of an overall improvement of the quality of care, whereas limitations consisted of the difficulty in setting up the questionnaire accurately, interpreting patients' answers correctly, and dispensing the questionnaire in a timely fashion, in order to evaluate the quality perceived by the patients without any bias related to delay, pain and anxiety. KEY WORDS: Day Surgery, Nursing, Questionnaire, Quality.

Superiority of resection over enucleation for schwannomas of the cervical vagus nerve: A retrospective cohort study of 22 consecutive patients.

INTRODUCTION: Schwannoma of the cervical vagus nerve is rare. Treatment options include intracapsular enucleation and en bloc resection. The purpose of this study was to compare the outcomes of enucleation and resection in terms of postoperative mortality and morbidity, freedom from vocal cord palsy, freedom from local recurrence, quality-adjusted life-year (QALY) and vocal handicap index (VHI). METHODS: Twentytwo consecutive patients were divided into two groups. Patients in group A (n = 9) underwent intracapsular enucleation, whereas patients in Group B (n = 13) underwent en bloc resection. Main endpoints of the study were postoperative mortality and morbidity, freedom from vocal cord palsy, freedom from local recurrence and quality of life. The quality of life after surgery was assessed according to the quality-adjusted life-year (QALY) EQ-5D-5L methodology, and calculation of the voice handicap index (VHI). RESULTS: Postoperative mortality was nil. Morbidity included 1 wound dehiscence in group A and 2 transitory dysphagias in group B. Freedom from vocal cord palsy was 22% in group A and zero in group B (p = 0.15). Operation-specific local recurrence rate was 33% (3/9 patients) in group A and nil in group B (0/23 patients) (p = 0.05). QALYs was 0.55 in group A and 0.54 in group B (p = 1.0). VHI was 23.77 in group A and 26.15 in group B (p = 1.00). CONCLUSION: Resection is superior to enucleation in terms of freedom from local recurrence. Functional results are comparable for both techniques.

Outcome of inferior vena cava and noncaval venous leiomyosarcomas.

BACKGROUND: Leiomyosarcoma (LMS) is a rare tumor arising from the smooth muscle cells of arteries and veins. LMS may affect both the inferior vena cava (IVC) and non-IVC veins. Because of its rarity, the experience with the outcome of the disease originating from the IVC compared with that with non-IVC offspring is overall limited. In this study, we compared the clinical features and outcomes after operative resection of IVC and non-IVC LMS to detect possible significant differences that could affect treatment and prognosis. METHODS: Twenty-seven patients undergoing operative resection of a venous LMS at a single tertiary care center and one secondary care hospital were reviewed retrospectively and divided into 2 groups: IVC-LMS (Group A, n = 18) and non-IVC LMS (Group B, n = 9). As primary end points, postoperative mortality and morbidity, disease-specific survival and, if applicable, patency of venous reconstruction were considered. Bivariate differences were compared with the χ(2) test. Disease-specific survival was expressed by a life-table analysis and compared using the log-rank test. RESULTS: No postoperative mortality was observed in either group. Postoperative morbidity was 28% in group A and 11% in group B (P = .33). The mean duration of follow-up was 60 months (range, 13-140). Disease-specific survival was 60% in group A and 75% in group B at 3 years (P = .48), and it was 54% in group A and 62% in group B at 5 years (P = .63). Seven grafts were occluded in group A (39%) and 1of 3 were occluded in group B (33%) (P = .85). CONCLUSION: IVC and non-IVC LMS exhibit similar outcomes in terms of postoperative course and survival. Operative resection associated with vascular reconstruction, if applicable, eventually followed by radiation and chemotherapy may be curative and is associated with good functional results.

Internal carotid artery rupture caused by carotid shunt insertion.

INTRODUCTION: Shunting is a well-accepted method of maintaining cerebral perfusion during carotid endarterectomy (CEA). Nonetheless, shunt insertion may lead to complications including arterial dissection, embolization, and thrombosis. We present a complication of shunt insertion consisting of arterial wall rupture, not reported previously. PRESENTATION OF CASE: A 78-year-old woman underwent CEA combined with coronary artery bypass grafting (CABG). At the time of shunt insertion an arterial rupture at the distal tip of the shunt was detected and was repaired via a small saphenous vein patch. Eversion CEA and subsequent CABG completed the procedure whose postoperative course was uneventful. DISCUSSION: Shunting during combined CEA-CABG may be advisable to assure cerebral protection from possible hypoperfusion due to potential hemodynamic instability of patients with severe coronary artery disease. Awareness and prompt management of possible shunt-related complications, including the newly reported one, may contribute to limiting their harmful effect. CONCLUSION: Arterial wall rupture is a possible, previously not reported, shunt-related complication to be aware of when performing CEA.

Hemangiopericytoma of the spleen.

INTRODUCTION: Hemangiopericytoma of the spleen is a very rare tumor, with 14 isolated reports. It was our aim to review our experience and compare it with all the reported cases in an attempt to standardize surgical treatment, adjuvant treatment and follow-up protocol of this infrequent condition. METHODS: A consecutive case series study, with a mean follow-up of 44 months. Five patients (mean age, 49 years) underwent simple splenectomy for hemangiopericytoma limited to the spleen followed by adriamycin-based chemotherapy in one patient. RESULTS: All the patients are alive and free from disease. CONCLUSIONS: For tumors confined to the spleen, simple splenectomy can be considered curative, without any need for further adjuvant treatment. On review of the medical literature, cure can still be achieved with complete resection of recurrences, when feasible, with adjuvant chemotherapy being also indicated. The slow-growing pattern of the tumor suggests a 10-year follow-up.

Outpatient repair for inguinal hernia in elderly patients: still a challenge?

BACKGROUND: Elective inguinal hernia repair as a day case is a safe and suitable procedure, with well-recognized feasibility. The increasing number of elderly patients requiring inguinal hernia repair leads clinicians to admit a growing number of outpatients. The aim of the current study was to analyze the outcomes (feasibility and safety) of day case treatment in elderly patients. METHODS: Eighty patients >80 years of age and 80 patients ≤55 years of age underwent elective inguinal hernia repairs under local anesthesia. RESULTS: There were no mortalities or major complications in the elderly undergoing inguinal herniorraphies as outpatients, and only one unanticipated admission occurred in the younger age group. CONCLUSIONS: Elective inguinal hernia repair in the elderly has a good outcome, and age alone should not be a drawback to day case treatment.

Endovascular strategy for the elective treatment of concomitant aortoiliac aneurysm and symptomatic large bowel diverticular disease.

BACKGROUND: The purpose of this study was to evaluate the strategy for treatment of patients presenting with asymptomatic diverticular disease of the large bowel associated with an asymptomatic aortoiliac aneurysmal (AAA) disease. METHODS: Sixty-nine patients were included in this retrospective study. The patients were divided into 5 groups according to the type and sequence of the surgical treatment: 32 patients (47%) underwent colectomy followed by a staged open AAA repair (group A); 10 patients (14%) were treated with open AAA repair followed by a staged colectomy (group B); 13 patients (18%) received endovascular aneurysm repair (EVAR) followed by a staged bowel resection (group C); 8 patients (12%) had a bowel resection followed by staged EVAR (group D); and 6 patients (9%) underwent simultaneous open AAA repair and bowel resection (group E). Primary end points were mortality and complications after any of the procedures. Secondary end point was the time interval between the staged procedures. RESULTS: The cumulative death rate for delayed treatment of AAA was 6.5% and 0% for delayed treatment of diverticular disease [P=0.22]. The mean time interval between the staged procedures was 11 days for EVAR/colon resection (group C and group D) and 73 days for open AAA repair/colon resection (group A and group B; P<0.01). CONCLUSIONS: EVAR allows a significant reduction in the time required between AAA repair and colon resection, but no definite rule can be established regarding the sequence of staged procedures. Combined procedures should be reserved for selected cases.

Endovascular treatment of false-aneurysm ten years after dacron patch aortoplasty for coarctation of the aortic isthmus. Report of a case.

False aneurysm degeneration is a known complication of patch aortoplasty for coarctation of the aortic isthmus. Open surgical treatment consists of prosthetic graft repair of the involved aorta, often requires circulatory arrest to achieve a safe proximal aortic control and perform proximal anastomosis, and finally is associated with substantial perioperative morbidity. Endografting of the diseased aorta is a valuable alternative to open repair, when feasible, with good short and long term results. We now report one more case of false aneurysm ten years after Dacron patch aortoplasty for isthmic coarctation in a 26-year-old woman, successfully treated by endovascular repair via the left common iliac artery, and a complete exclusion of the aneurysm at two year follow-up.

Colorectal cancer associated with abdominal aortic aneurysm: results of EVAR followed by colectomy.

The association of colorectal cancer and abdominal aortic aneurysm (AAA) is infrequent but poses special problems of priority of treatment under elective circumstances. The purpose of this study was to retrospectively evaluate the outcome of 16 consecutive patients undergoing endovascular aneurysm repair (EVAR) followed by colectomy. Operative mortality was nil. Operative morbidity included two transient rise of serum creatinine level and one extraperitoneal anastomotic leakage which evolved favourably with conservative treatment. EVAR allowed a very short delay of treatment of colorectal cancer after aneurysm repair, minimizing operative complications.

Dual antiplatelet treatment in patients candidates for abdominal surgery.

UNLABELLED: With the increasing diffusion of percutaneous interventions (PCI), surgeons are often faced with the problem of operating on patients under dual antiplatelet treatment. Replacing dual antiplatelet regiment with low molecular weight heparin may expose to the abrupt thrombosis of coronary stent and massive myocardial infarction. The purpose of this study was to test the hypothesis that abdominal operations can be safely performed under dual antiplatelet treatment. Eleven patients underwent 5 colectomies, 3 nefrectomies, 2 gastrectomies and 1 hysterectomy under aspirin and plavix without any significant perioperative hemorrhage. These preliminary results show that abdominal operations can be safely performed under dual antiplatelet regimen. KEY WORDS: Abdominal surgery, Dual antiplatelet treatment.

Outpatient treatment for liposarcoma of the spermatic cord.

Liposarcoma of the spermatic cord is a very rare neoplastic disease. In effect little more than two hundred cases are described in literature. Natural history of this tumour is characterized by high local recurrence rate although hematogenic and lymphatic spread is usually a late event and involves high-grade tumours. The clinical diagnosis of spermatic cord liposarcoma can be difficult particularly for non expert surgeons, and is often mistaken for different diagnoses. Radical orchiectomy with high cord ligation is the treatment of choice to prevent local recurrence. Otherwise than commonly advised, the treatment is suitable to be performed under local anaesthesia and the patient easily and safely discharged few hours after surgery.

Modified PADSS (Post Anaesthetic Discharge Scoring System) for monitoring outpatients discharge.

The decision to discharge a patient undergoing day surgery is a major step in the hospitalization pathway, because it must be achieved without compromising the quality of care, thus ensuring the same assistance and wellbeing as for a long-term stay. Therefore, the use of an objective assessment for the management of a fair and safe discharge is essential. The authors propose the Post Anaesthetic Discharge Scoring System (PADSS), which considers six criteria: vital signs, ambulation, nausea/vomiting, pain, bleeding and voiding. Each criterion is given a score ranging from 0 to 2. Only patients who achieve a score of 9 or more are considered ready for discharge. Furthermore, PADSS has been modified to ensure a higher level of safety, thus the "vital signs" criteria must never score lower than 2, and none of the other five criteria must ever be equal to 0, even if the total score reaches 9. The effectiveness of PADSS was analyzed on 2432 patients, by recording the incidence of postoperative complications and the readmission to hospital. So far PADDS has proved to be an efficient system that guarantees safe discharge.

Long-term survival after resection of a primary leiomyosarcoma of the innominate vein Report of a case.

Leiomyosarcoma of the innominate vein is a rare but usually lethal disease. We report the case of a 50-year-old woman, undergoing a curative resection of the tumor. She is alive and free of disease at 88-month follow-up. Surgical excision remains the current optimal treatment able to provide a chance of cure. KEY WORDS: Late survival, Venous leiomyosarcoma.