Postoperative Anticoagulation in Vascular Reconstructions Associated with Malignancies.

BACKGROUND: The invasion of truncal arteries and veins by malignant neoplasms is rare and the surgical treatment remains a challenge. Several techniques can be used to re-establish blood flow in a resected vessel and choice of the ideal vascular substitute frequently arises a debate. Comparative studies between prosthetic and autologous grafts disclose conflicting patency results. The aim of this study is to compare patency outcomes of vascular reconstructions performed using autologous or prosthetic replacement grafts in surgical oncology, in light of a standardized antithrombotic protocol used in our institution since 1997. METHODS: This retrospective study compared patency of prosthetic versus autologous interposition grafts following the resection of malignancies in 117 patients between September 1997 and February 2020. The 181 reconstruction procedures performed were analyzed according to the body segment involved, and divided into: head and neck, thorax, abdomen, and extremities. RESULTS: Overall survival estimates after 24 and 60 months were 53.2% (standard error 4.8%) and 38.1% (standard error 4.9%), respectively. No significant difference was observed between overall arterial patency, using autologous or synthetic grafts (P = 0.41). Overall venous patency showed a tendency to be lower in synthetic grafts, although no significant difference was observed (P = 0.062). For both arterial and venous reconstructions in the extremities (upper and lower limbs), significantly higher patency was observed using autologous grafts. CONCLUSIONS: Autologous long-term graft patency may be superior to prosthetic in vascular reconstructions associated with malignancies of the extremities. This outcome was obtained using a standardized post-operative anticoagulation protocol.

Informed consent and a risk-based approach to oncologic surgery in a cancer center during the COVID-19 pandemic.

BACKGROUND: Cancer patients configure a risk group for complications or death by COVID-19. For many of them, postponing or replacing their surgical treatments is not recommended. During this pandemic, surgeons must discuss the risks and benefits of treatment, and patients should sign a specific comprehensive Informed consent (IC). OBJECTIVES: To report an IC and an algorithm developed for oncologic surgery during the COVID-19 outbreak. METHODS: We developed an IC and a process flowchart containing a preoperative symptoms questionnaire and a PCR SARS-CoV-2 test and described all perioperative steps of this program. RESULTS: Patients with negative questionnaires and tests go to surgery, those with positive ones must wait 21 days and undergo a second test before surgery is scheduled. The IC focused both on risks and benefits inherent each surgery and on the risks of perioperative SARS-CoV-2 infections or related complications. Also, the IC discusses the possibility of sudden replacement of medical staff member(s) due to the pandemic; the possibility of unexpected complications demanding emergency procedures that cannot be specifically discussed in advance is addressed. CONCLUSIONS: During the pandemic, specific tools must be developed to ensure safe experiences for surgical patients and prevent them from having misunderstandings concerning their care.

Early postoperative outcomes among patients with delayed surgeries after preoperative positive test for SARS-CoV-2: A case-control study from a single institution.

BACKGROUND: There are limited data on surgical complications for patients that have delayed surgery after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. We aimed to analyze the surgical outcomes of patients submitted to surgery after recovery from SARS-CoV-2 infection. METHODS: Asymptomatic patients that had surgery delayed after preoperative reverse-transcription polymerase chain reaction (RT-PCR) for SARS-CoV-2 were matched in a 1:2 ratio for age, type of surgery and American Society of Anesthesiologists to patients with negative RT-PCR for SARS-CoV-2. RESULTS: About 1253 patients underwent surgical procedures and were subjected to screening for SARS-CoV-2. Forty-nine cases with a delayed surgery were included in the coronavirus disease (COVID) recovery (COVID-rec) group and were matched to 98 patients included in the COVID negative (COVID-neg) group. Overall, 22 (15%) patients had 30-days postoperative complications, but there was no statistically difference between groups -16.3% for COVID-rec and 14.3% for COVID-neg, respectively (odds ratio [OR] 1.17:95% confidence interval [CI] 0.45-3.0; p = .74). Moreover, we did not find difference regarding grades more than or equal to 3 complication rates - 8.2% for COVID-rec and 6.1% for COVID-neg (OR 1.36:95%CI 0.36-5.0; p = .64). There were no pulmonary complications or SARS-CoV-2 related infection and no deaths within the 30-days after surgery. CONCLUSIONS: Our study suggests that patients with delayed elective surgeries due to asymptomatic preoperative positive SARS-CoV-2 test are not at higher risk of postoperative complications.

Evaluation of compensatory hyperhidrosis after sympathectomy: The use of an objective method.

OBJECTIVE: To investigate the prevalence of compensatory hyperhidrosis following videothoracic sympathectomy to treat palmoplantar hyperhidrosis and its effect on sweating in the chest, abdomen, back and thighs. Furthermore, to evaluate the concordance between a subjective and an objective method of assessment for compensatory hyperhidrosis. METHODS: Forty patients with combined palmar and plantar hyperhidrosis who underwent video-assisted thoracoscopic sympathectomy (15 women and 25 men, with a mean age of 25 years) were prospectively followed for 1 year. Subjective and objective parameters were evaluated, using respectively a questionnaire and a sudorometer (Vapometer). RESULTS: In the subjective analysis, in the first month, only 10% of patients did not have compensatory hyperhidrosis, and 70% continued to report it at 1 or more sites after 1 year. In the objective analysis, 35% of the patients did not present compensatory hyperhidrosis after 1 month, and this number persisted stable, with 30% of patients remaining free of compensatory hyperhidrosis after 1 year. The most frequent area affected by compensatory hyperhidrosis was the back in both assessments. There was no positive concordance between the results of the objective and subjective analysis at any time in any of the 4 regions studied. CONCLUSIONS: Compensatory hyperhidrosis is a very common postoperative side effect after videothoracic sympathectomy, occurring early after the procedure and persisting for prolonged periods of time. The most frequently affected body area is the back, and no concordance between objective and subjective assessments was observed.

Inferior Vena Cava Filter in Cancer Patients: On Whom Should We Be Placing Them?

BACKGROUND: Standard treatment for venous thromboembolism is anticoagulation; vena cava filter placement is an alternative in special situations. We aimed to evaluate the outcomes in patients with cancer undergoing filter placement in a cancer center during a 10-year period and assess which preoperatory variables were associated with poorer survival. METHODS: Retrospective unicenter analysis during a 10-year period was carried out in patients with cancer who had undergone placement of vena cava filter. Early deaths were those that occurred less than 30 days after the filter placement or that occurred during the same hospital stay of the placement. RESULTS: About 250 patients were analyzed. About 51.6% were females; 77.2% had proximal lower limb deep vein thrombosis; 34.8% had contraindications to anticoagulation; 32.8% presented bleeding after the onset of anticoagulation; and 18.4% had the filter implanted because they were going to undergo surgery and could not be anticoagulated immediately after. About 51.2% of the filters were removable. However, only 2 had the filter removed. About 59.2% had metastatic disease at the time of filter placement. About 31.2% fulfilled criteria for early death. Of those, 34 patients were put in palliative care after filter insertion (median, 13.5 days). Body mass index >18 kg/m2, the absence of metastatic disease, and filter placement during the same anesthesia of another surgery (especially if elective and curative) were associated with a higher chance of survival. CONCLUSIONS: Multidisciplinary evaluation (and possibly consideration for palliation) should take place before the decision to insert a vena cava filter in severe oncologic cases depending on overall status. Patients with a greater chance of survival at a 3 or 5 years interval seem to be those whose filters were placed in the perioperative context of other surgeries (specially elective and curative), who were not undernourished, and whose disease was not metastatic at that time. For patients who survived, an active investigation protocol for filter removal should be implemented.

An alternative approach to treatment of inferior vena cava filter perforation.

We report a case of inferior vena cava filter perforation immediately after filter implantation, recognized intraoperatively in a patient undergoing laparotomy for resection of locally advanced ovarian cancer. We describe an alternative approach with strut resection, less invasive than filter removal, enabling the device to be maintained and bleeding to be controlled.

Relatamos um caso de perfuração de veia cava inferior imediatamente após o implante de um filtro. A complicação foi reconhecida no intraoperatório de uma laparotomia para ressecção de um câncer de ovário localmente avançado. Descrevemos uma abordagem alternativa, menos invasiva do que a remoção do filtro, consistindo na ressecção das hastes do dispositivo. Essa abordagem permitiu a manutenção do filtro e o controle efetivo do sangramento.

Twenty years of experience in vascular reconstructions associated with resection of malignant neoplasms in a single cancer center.

OBJECTIVE: Vascular invasion is no longer considered to be an absolute contraindication to tumor removal, and complex reconstructions are part of the daily activity of vascular surgeons in specialized cancer centers. Our aim was to report a single-center experience of complex vascular reconstructions involving en bloc resection of tumors and patients' long-term survival and graft patency outcomes. To the best of our knowledge, this is the largest report of vascular reconstructions published to date, with the longest follow-up. METHODS: Between September 1997 and January 2016, there were 91 patients who underwent 92 arterial and 47 venous reconstruction procedures in this retrospective cohort study. Long-term survival and patency outcomes were analyzed for all study patients and individually assessed in different body segments (head and neck, thorax, upper limbs, abdomen, and lower limbs). RESULTS: The estimated mean and median follow-up times were 112.66 and 100 months, respectively. The 24- and 60-month survival estimates for the patients overall were 55.3% and 31.1%, respectively. Survival estimates were significantly lower in the head and neck cases compared with the other body segments. The primary arterial patency rates at 24 and 60 months were 96.7% and 84.9%, respectively, and they were similar in all body segments. The venous patency rates were 71.4% and 64.2% at 24 and 60 months, respectively. Seven cases (7.6%) of arterial vascular complications were observed. CONCLUSIONS: Vascular reconstruction performed in conjunction with oncologic resection is a feasible treatment option for tumors with vessel involvement. When surgery is performed in specialized centers, low perioperative morbidity and long-term patency rates are expected irrespective of the vascular territory undergoing intervention.

Number of Preoperative Hyperhidrosis Sites Does Not Affect the Sympathectomy Postoperative Results and Compensatory Hyperhidrosis Occurrence.

BACKGROUND: Patients with primary hyperhidrosis present with sweating in two or more sites in nearly 85% of cases. In this study, we examined whether the number of hyperhidrosis sites is related to the surgery outcomes. METHODS: One hundred ninety-three hyperhidrosis patients who underwent bilateral videothoracoscopic sympathectomy after failure or dissatisfaction with clinical treatment were distributed into three groups based on the number of hyperhidrosis sites (one site, two sites, and three or more sites of hyperhidrosis). The primary endpoints in the study were as follows: quality of life prior to surgery, improvement of quality of life after surgery, clinical improvement of sweating, presence or absence of compensatory hyperhidrosis, and general satisfaction after 1 month of surgery. RESULTS: Patients with two or more hyperhidrosis sites had worse quality of life before surgery than patients with a single hyperhidrosis site. There was an improvement in the quality of life in more than 95% of the patients, clinical improvement in more than 95% of patients, severe compensatory hyperhidrosis in less than 10%, and low general satisfaction after 1 month of surgery in only 2.60% of the patients, with no differences among the three groups. CONCLUSIONS: Patients with more than one preoperative hyperhidrosis site present worse quality of life prior to surgery than those with a single hyperhidrosis site, but the number of hyperhidrosis sites before surgery does not affect surgery outcomes.

Comparison between Saline Solution Containing Heparin versus Saline Solution in the Lock of Totally Implantable Catheters.

BACKGROUND: There are only 3 studies comparing the efficacy of 2 different types of lock used in totally implantable catheters regarding occlusion or reflux dysfunction. The present study contains the largest published casuistry (862 patients) and is the only one that analyzes 3 parameters: occlusion, reflux dysfunction, and flow dysfunction. METHODS: This was a retrospective study of patients operated at a large oncology center and followed up in the outpatient clinic between 2007 and 2015. The patients were divided into 2 groups according to the type of lock: the Hep group (heparine), whose lock was composed of saline solution 0.9% with heparin (100 IU/mL) and the SS group (saline solution), whose lock was composed of saline solution 0.9%. RESULTS: The Hep group was composed of 270 patients (31%) and the SS group of 592 patients (69%). Regarding occlusion, there were 8 cases in the Hep group (2.96%) and 8 in the SS group (1.35%; P = 0.11); in relation to reflux dysfunction, there were 8 cases in the Hep group (2.96%) and 8 in the SS group (1.35%; P = 0.11); in relation to flow dysfunction, there was 1 case in the Hep group (0.37%) and 4 cases in the SS group (0.68%; P = 1). CONCLUSIONS: There was no statistically significant difference between the groups regarding occlusion, reflux dysfunction, and flow dysfunction.

Treatment of Abdominal Aortic Aneurysms in Cancer Patients.

BACKGROUND: The aim of this study was to analyze the outcomes of oncologic patients with associated aneurysm of the abdominal aorta (AAA), treated at a specialized cancer (Ca) hospital more than a 10-year period. METHODS: This was a retrospective study, and the data were obtained from our institution's prospective database. Between September 2003 and 2013, a total of 36 consecutive patients with AAA in association with Ca underwent surgical repair. Of these, 9 patients were excluded because the Ca treatment was performed at another service. Most of the patients were male (22) and the most frequent form of neoplasia was prostate Ca. Surgery for AAA repair was performed after the Ca treatment in 19 cases, before Ca treatment in 7 cases and concomitantly in 1 case. The intraoperative characteristics, treatment technique used, complications, patients' clinical evolution, and survival outcomes were analyzed. RESULTS: Endovascular aneurysm repair (EVAR) was used in 19 cases (70.4%) and conventional open repair (OR) in 8 cases (29.6%). Surgical treatment was uneventful in 19 cases, however, when present, postoperative complications occurred more frequently with EVAR (36.84% vs. 12.5%). There were no cases of death related to the aneurysm surgery. Most of the patients in both groups were alive at the end of the study. The probability of survival in our study was 65.8% at 3 years and 53% at 5 years, with no statistically significant difference between the EVAR and OR groups. The main cause of death was progression of the neoplastic disease. CONCLUSIONS: Patients who present Ca in association with AAA benefit from surgical treatment of both conditions, simultaneously or not. In these cases, it is important for the treatment to be individualized, and the disease of greater severity should be treated first. The endovascular and conventional open techniques were shown to be equivalent.

Severe visceral ischemia and death after multilayer stent deployment for the treatment of a thoracoabdominal aortic aneurysm.

The treatment of thoracoabdominal aortic aneurysms, both surgical and endovascular, has always been challenging. In the last years, the multilayer stent has emerged as an alternative device for the treatment of this condition. In this paper, we describe a catastrophic complication of the multilayer stent in a patient with thoracoabdominal aortic aneurysm, a case of massive visceral ischemia and death 3 months after stent deployment.

Surgical outcomes of vascular reconstruction in soft tissue sarcomas of the lower extremities.

BACKGROUND: Limb-sparing procedures are currently considered the standard treatment for lower limb soft tissue sarcoma (STS). Surgical excision combined with vascular resection may be necessary to provide an adequate safety margin and to improve the oncologic outcomes. In this scenario, vascular reconstruction is required to preserve limb function. We evaluated the long-term patency and survival outcomes of arterial and venous reconstruction after resecting lower limb STS in the largest single-center case series to date. METHODS: Between November 1995 and July 2014, 25 patients with lower limb STS and vascular invasion underwent surgical resection followed by arterial or venous reconstruction. Patients were followed up at regular outpatient visits, at which clinical examinations and duplex ultrasound mapping were performed to assess graft patency. RESULTS: A total of 44 revascularization procedures were performed. The median follow-up time for the arterial and venous groups combined was 25.2 months (range, 0.26-225.6 months). The 5-year survival probability was 42.1%. The graft occlusion rate was significantly higher after reconstruction with synthetic grafts than after reconstruction with saphenous vein substitutes (P = .02). The occlusion rate was not significantly different between arterial reconstruction and venous reconstruction (P > .05). CONCLUSIONS: Arterial and venous reconstruction is feasible after surgical resection of lower limb STS. Vascular reconstruction provides favorable long-term patency outcomes and low complication rates, allowing limb preservation and disease control in a select group of patients. Vascular reconstruction using venous grafts had a significantly higher patency rate than reconstruction with artificial venous substitutes.

Late surgical outcomes of carotid resection and saphenous vein graft revascularization in patients with advanced head and neck squamous cell carcinoma.

BACKGROUND: In head and neck squamous cell carcinoma, invasion of the carotid artery is a severe mortality predictor. We report an updated experience of 19 patients who underwent head and neck resection for squamous cell carcinoma with concomitant carotid reconstruction. This study aims to analyze overall survival rates, primary patency of the reconstructions, vascular and nonvascular complications, radiotherapy dosing as well as late follow-up and outcomes. METHODS: From September 1997 to 2011, 19 patients with advanced squamous cell carcinoma with carotid artery invasion were submitted to resection and concomitant vascular reconstruction in a single referred oncological institution. Patient follow-up was done by means of periodic outpatient returns, where clinical and duplex scan evaluations were performed to study graft patency. RESULTS: The average length of follow-up was 23.3 (± 34.4) months. Nonvascular complications occurred in 6 patients (31.6%). Only 1 (5.3%) vascular complication was observed, resulting from the immediate occlusion of the carotid graft. All patients were submitted to preoperative, adjuvant, or curative intent radiotherapy during the course of the oncologic treatment, with varying doses. Overall disease-free survival, primary patency, and survival with patent graft rates in 5 years are respectively 12.9%, 93.1%, and 13.0%. Three patients (15.9%) are still alive, all without tumor recurrence, and present a disease-free long-term follow-up with patent grafts 21 months, 68 months, and 151 months after surgery. CONCLUSIONS: Aggressive surgical approach for patients with advanced squamous cell head and neck carcinoma with carotid invasion can lead to cure in a select group of patients. Saphenous vein grafts demonstrated favorable outcomes with low infection and high patency rates, suggesting a valid alternative for arterial reconstruction in these cases.

Comparative study of valved and nonvalved fully implantable catheters inserted via ultrasound-guided puncture for chemotherapy.

BACKGROUND: Fully implantable catheters are important for oncology treatments. They can be functionally categorized as valved or nonvalved. Theoretically, a valve prevents spontaneous blood reflux into the catheter, reducing the incidence of complications. We sought to compare the results from the implantation of valved and nonvalved fully implantable 8-French catheters inserted via ultrasound-guided puncture in cancer patients undergoing chemotherapy treatment. METHODS: A retrospective analysis of 100 patients who underwent long-term catheter implantation guided by ultrasound was performed looking for early (≤30 days) or late (≥90 days) complications. They were evaluated regarding the use of valved or nonvalved catheter and assessed on univariate model. RESULTS: The only early complication (hematoma) was identified in the valved group. Twenty-two late complications were identified (72.72% in the valved group and 27.27% in the nonvalved group; P = 0.009). Blood reflux dysfunction, which occurred in 12 patients in the valved and none in the nonvalved devices group, was the only complication with an incidence that was significantly different between the groups. CONCLUSION: Fully implantable valved catheters with Groshong (Bard Medical Division, Covington, GA) valves have a higher rate of blood reflux dysfunction compared with nonvalved catheters, but this did not interfere with the efficacy of the treatment.

Technical difficulties and complications of sympathectomy in the treatment of hyperhidrosis: an analysis of 1731 cases.

BACKGROUND: The aim of this study was to ascertain the technical difficulties and complications of video-assisted thoracic sympathectomy (VTAS) in the treatment of hyperhidrosis in a large group of patients. METHODS: Between October 1995 and February 2008, 1731 patients with palmar, axillary, or craniofacial hyperhidrosis, who were treated using bilateral VTAS, were studied. We assessed the technical difficulties, early and late complications, and the approaches that were used to resolve them. RESULTS: Therapeutic success was achieved in 91% of the cases as evidenced by anhidrosis. The most common and severe technical difficulty during the procedure was pleural adhesions in 116 cases (6.7%); azygos lobes were seen in 7 patients (0.4%) and apical blebs in 3 patients (0.2%). The most frequent postoperative immediate complication was postoperative pain in 1685 (97.4%) patients; pneumothorax with chest drainage was seen in 60 cases (3.5%), neurologic disorders involving the upper limbs in 36 cases (2.1%), Horner's syndrome in 11 cases (0.9%), significant bleeding in 8 cases (0.4%), and 1 patient had extensive subcutaneous emphysema. The most frequent late complication was compensatory hyperhidrosis, which occurred in 1531 cases (88.4%). Although 27.2% of the patients reported severe compensatory hyperhidrosis, only 2.5% expressed regret for undergoing surgery. Gustatory sweating occurred in 334 patients (19.3%). No deaths occurred in this series. CONCLUSIONS: VTAS is safe and has shown good results. The major complication is compensatory hyperhidrosis and, when severe, the patient may express regret for undergoing surgery. Improvements in instrumentation, adequate training, and careful patient selection may help to reduce the number of drawbacks associated with VTAS.

An alternative to treat palmar hyperhidrosis: use of oxybutynin.

PURPOSE: To evaluate the effectiveness and patient satisfaction with the use of oxybutynin at low doses for treating palmar hyperhidrosis in a large series of patients. METHODS: From January 2007 to June 2009, 180 consecutive patients with palmar hyperhidrosis were treated with oxybutynin. Data were collected from 139 patients (41 patients were lost to follow-up). During the first week, patients received 2.5 mg of oxybutynin once per day; from the 8th to the 42nd day, 2.5 mg twice per day; and from the 43rd day to the end of the 12th week, 5 mg, twice per day. All of the patients underwent three evaluations before and after the oxybutynin treatment (at 6 and 12 weeks), using a clinical questionnaire and a clinical protocol for quality of life (QOL). RESULTS: More than 80% of the patients experienced an improvement in palmar hyperhidrosis. Most of the patients showed improvements in their QOL (74.6%). The side effects were minor, with dry mouth being the most frequent (70.5%). CONCLUSION: The use of oxybutynin is an alternative as the first step in the treatment of palmar hyperhidrosis, given that it presents good results and improves QOL.

Quality of life before surgery is a predictive factor for satisfaction among patients undergoing sympathectomy to treat hyperhidrosis.

PURPOSE: The objective of this study was to evaluate the postoperative quality of life (QOL) experienced among a group of 1167 patients who underwent video-assisted thoracoscopic sympathectomy (VATS) to treat primary hyperhidrosis, as compared with the presurgical QOL. METHODS: Between February 2002 and June 2007, 1167 patients who had undergone VATS were surveyed. The majority had presented with palmar hyperhidrosis (794 patients; 68%), while 340 (29%) had presented with axillary hyperhidrosis. Based on data obtained from the QOL protocol applied to all of the patients preoperatively, the patients were divided into two groups according to the level of their QOL: group 1 consisted of 312 patients (27%) with poor QOL and group 2 of 855 patients (73%) with very poor QOL. The same protocol was applied postoperatively, and five different levels of satisfaction were obtained. The same parameters were evaluated for both the palmar and the axillary hyperhidrosis subgroups. RESULTS: The patients with very poor QOL had much better results in terms of improvement in QOL than did those with poor QOL (P < .05). The same result was observed for both the palmar and axillary hyperhidrosis subgroups (P < .05). CONCLUSION: The worse the preoperative QOL among patients undergoing sympathectomy to treat primary hyperhidrosis is, the better the postoperative improvement in QOL will be.

Covered stent treatment for an aneurysm of a saphenous vein graft to the common carotid artery.

Aneurysmal degeneration of a saphenous vein graft is a rare complication and, so far, only three cases involving a carotid artery have been described. We report the case of a patient with a cervical neoplasm presenting carotid invasion, who underwent en bloc tumor resection and carotid reconstruction with a saphenous vein graft. Six years later, during follow-up, an aneurysm of the carotid graft was detected. Endovascular intervention was performed using a covered stent. Three years after this intervention, the patient was found to be asymptomatic, and computed tomography showed that the covered stent was patent, without complications.