N0 Stage colon cancer: prognostic role of age in relation to tumor site.

This work investigates the prognostic role of advanced age as a risk factor for recurrence in a population of patients undergoing surgery for N0 stage colon cancer, and also evaluates whether that role is affected by tumor location. A population of 129 con- secutive patients who underwent radical surgery for N0 stage colon cancer was selected. Patients were subdi- vided into three age groups: 80. The only correlation found in the examined population between age and clinical-pathological features was be- tween advanced age (>80) and tumor location in the right side of the colon. Overall survival (OS) and dis- ease-free survival (DFS) were significantly lower in pa- tients over 80 than in the other two classes. Two mul- tivariate analyses were carried out: when tumor loca- tion was not considered, age >80 represented a neg- ative prognostic factor for risk of recurrence, regardless of the other factors examined. This role was also con- firmed when tumor location was considered. As hy- pothesized by several authors, the role of advanced age which emerges from this study is mainly due to the in- creased fragility of elderly patients caused by multiple pathophysiological factors, but it does not necessarily represent an absolute contraindication to surgery. The role played by tumor location remains contro- versial, as more and more studies show that right colon cancer (RCC) is a biological entity distinct from left colon cancer (LCC). Further studies are required to examine right and left colon cancers as two separate diseases

Choices in surgical treatment of diverticulitis

Complications after surgical treatment of diverticulitis are not very frequent, in view of the total number of patients affected by this pathology, but they do become significant in absolute terms because of the high prevalence of the disease itself. Surgeons continue to debate which option is better: Hartmann re- section or combined resection and anastomosis. Since age is a crucial factor when surgery is being considered, we evaluated the outcome of surgical treatment for di- verticulitis in patients treated in our unit over a six- month period, in view of the number of elderly patients generally admitted. Between January 2001 and June 2012, 77 patients underwent surgery for diverticular disease in the Geriatric Surgery Unit of the Department of Surgical and Gastroenterological Sciences, Univer- sity of Padova Hospital. Gastrointestinal resection and anastomosis were performed in 75 patients (97%), re- sulting in an overall complication rate of 37% and a mortality rate of 1%. This surgical strategy was chosen because, when it is performed by experienced sur- geons, it offers the same results in terms of mortality and morbidity as Hartmann resection, while presenting significant advantages as regards the patient's quality of life. Various factors such as the timing of surgery, severity of the disease defined according to the Hinchey classification, patient’s clinical condition, and sur- geon's experience and expertise can all influence the surgical choice. Several studies in the literature confirm that combined resection and anastomosis is safe and ef- ficacious, but more research is needed to confirm these data

Infrapopliteal arterial reconstructions for limb salvage in patients aged > 80 years according to preoperative ambulatory function and residential status.

IF. 3.406 Abstract Objective: Although numerous studies have addressed peripheral revascularizations for critical limb ischemia (CLI) in patients aged 80 years or more, only a few have focused exclusively on infrapopliteal arterial reconstructions. This study aimed to analyze early and long-term outcomes in very elderly patients who underwent surgical infrapopliteal revascularization for CLI according to their preoperative ambulatory function and residential status. Patients and Methods: Over an 18-year period, all consecutive patients aged 80 years or more referred to our institution for CLI requiring primary infrapopliteal or inframalleolar arterial reconstruction were enrolled in the study. All procedures were completed by the same surgeon with patients under regional anesthesia. Patency, limb salvage, amputation-free survival and cumulative survival rates were assessed by Kaplan-Meier analysis. The patient\u2019s pre- and postoperative ambulatory function and residential status (at home vs in a nursing home) were also analyzed. The mean follow-up was 6.2 years (range, 0.1-11.5 years) and was obtained for 97.5% of the patients. Results: In all, 197 patients (134 men, mean age, 82.8 \ub1 1.7 years) with 201 critically ischemic limbs were enrolled in the study. No deaths or fatal major complications occurred in the perioperative period (30-day), while the local complication rate was 5.6%. After 1 and 7 years, the primary patency rates were 87.9% and 67.8%, the limb salvage rates were 96% and 86.7%, the amputation-free survival rates were 87.6% and 38.9%, and the survival rates were 91% and 44.2%. At last follow-up or death, 79.7% of the patients were ambulatory and 20.3% were not, 80.2% lived at home and were independent and another 9.1% lived at home with assistance, while 75.6% of the sample were living at home and were ambulatory. Conclusions: Infrapopliteal arterial revascularization in the very elderly with CLI proved safe, effective and durable, confirming that age per se and concomitant comorbidities do not necessarily affect technical and clinical outcomes. Ambulatory function and independent living status are well preserved since, despite a relatively short life expectancy, the majority of very elderly revascularized CLI patients can be expected to spend their remaining years ambulatory and at home. On the other hand, patients with poor ambulatory function or who needed assistance before surgery were less likely to improve their status after limb revascularization, despite a successful technical result

Lower extremity arterial reconstruction for critical limb ischemia in diabetes.

Background: The impact of diabetes mellitus on the technical and clinical outcomes of infrainguinal arterial reconstruction (IAR) for critical limb ischemia (CLI) remains controversial. This study analyzed the outcome of IAR in diabetic patients with CLI over a 17-year period. Methods: Details on all consecutive patients undergoing primary IAR at our institution were stored prospectively in a vascular registry from 1995 to 2011. Demographics, risk factors, indications for surgery, inflow sources and outflow target vessels, types of conduit, and adverse outcomes were analyzed. Postoperative surveillance included clinical examination, duplex scans, and ankle-brachial index measurements in all patients at discharge, 1 and 6 months after surgery, and every 6 months thereafter. End points were patency, limb salvage, survival, and amputation-free survival rates, and were assessed using Kaplan-Meier life-table analysis. The c2 or Fisher exact, Student t, and log-rank tests were used to establish statistical significance. Results: Overall, 1407 IARs were performed in 1310 patients with CLI by the same surgeon, 705 (50.2%) in 643 diabetic patients and 702 in 667 nondiabetic patients. Autogenous vein conduits were used in 87% of the IARs. There were no perioperative deaths. Diabetic patients had significantly more major (16.7% vs 11.8%; P [ .02) and minor complications (9.7% vs 6.5%; P [ .02) than nondiabetic patients. At 5 and 10 years, there were no significant differences between diabetic and nondiabetic patients in the rates of primary patency (65% and 46% vs 69.5% and 57%; log-rank test, P[.09), secondary patency (76% and 60% vs 80% and 68%; log-rank test, P [ .20), limb salvage (88% and 76% vs 91% and 83%; log-rank test, P [ .12) survival (51% and 34% vs 57% and 38%; log-rank test, P [ .41), or amputation-free survival (45.5% and 27% vs 51% and 29%; log-rank test, P [ .19). The type of conduit did not affect patency or limb salvage rates in either group. Conclusions: Diabetic patients receiving IAR for CLI can have the same survival and amputation-free survival rates as nondiabetic patients. Their comparable technical and clinical outcomes strongly demonstrate that diabetics with CLI can expect the same quantity and quality of life as nondiabetics with CLI, and aggressive attempts at limb salvage in patients with diabetes mellitus, including distal and foot level bypass grafting, should not be discouraged

Natural history of common iliac arteries after aorto-aortic graft insertion during elective open abdominal aortic aneurysm repair.

Abstract Background This study aimed to determine the natural history of common iliac arteries (CIAs) after elective open infrarenal abdominal aortic aneurysm (AAA) repair with an aorto-aortic prosthetic graft. Methods All patients who had a straight tube graft inserted during elective AAA repair at our institution between 1995 and 2005 were prospectively followed up with pre- and post-operative computed tomography (CT) scans to monitor changes in CIA diameter and had their latest CT scan in 2007. Based on preoperative CIA diameter, patients were divided into group A (both CIAs normal, up to 12 mm in diameter), B (at least one ectatic CIA, 13 -18 mm) and C (at least one aneurysmal CIA, 19 - 25 mm). The mean follow-up was 7.1 years (range, 2.1 to 12.3). Results Among 201 patients eligible for the study, 92 (45.8%) were in group A, 63 (31.3%) in group B and 46 (22.9%) in group C. Overall, the diameter increased in 119 CIAs (29.6%) by a mean 1.1, 1.8 and 2.4 mm in groups A, B, and C, respectively; 14 CIAs (5.4%) progressed from \u201cnormal\u201d to \u201cectatic\u201d, and 9 (10.2%) from \u201cectatic\u201d to \u201caneurysmal\u201d. Three aneurysmal CIAs slightly exceeded the 25 mm threshold, but were no repaired. No patients showed a progression or development of occlusive iliac artery disease, or required repeat surgery due to excessive CIA enlargement. Conclusions This analysis showed that most CIAs do not expand after tube graft insertion during AAA repair and, when they do, the degree of dilation is minimal. Tube graft insertion during AAA repair is justified even for ectatic or moderately aneurysmal CIAs, and the procedure is safe and durable. The skepticism surrounding its selective use instead of a systematic bifurcated graft placement appears to be unwarranted

Elective abdominal aortic aneurysm repair in the very elderly: a systematic review.

ABSTRACT Background Abdominal aortic aneurysm (AAA) is an age related disease, so the people aging has led to an increased number of elderly undergoing AAA repair. To analyze the perioperative mortality and complications rates and long-term survival of elderly people after AAA repair, we conducted a systematic review of the literature. Methods The literature was searched using the Medline, Embase and Cochrane library databases up to May 2008. All studies reporting on perioperative and long-term outcomes of patients 80 years old or more undergoing elective open (OAR) or endovascular AAA repair (EVAR) were considered. The risk of perioperative mortality and morbidity were calculated using the odds ratio (OR), with 95% confidence intervals (CIs), and the \u3c72 test. Results Thirty-five studies on OAR, five on EVAR and four on both OAR and EVAR were included. In the OAR group, the mortality rate (38 studies/1793 patients) was 5.6% (95% CI, 4.5 to 6.7) and the morbidity rate (18 studies/725 patients) 26.9% (95% CI, 23.7 to 30.1). Twenty studies reported a median 5-year survival rate of 60% (range, 14% to 86%). In the EVAR group, the mortality rate (9 studies/1159 patients) was 4.5% (95% CI, 3.3 to 5.7) and the morbidity rate (8 studies/1078 patients) 16.9% (95% CI, 23.7 to 30.1). Follow-up data lasted < 5 years in 5 studies. Although the perioperative death rate was higher after OAR than after EVAR, the difference was not statistically significant (p = .170; 95% CI, 0.90 to 1.78). The rate of major systemic morbidity was significantly higher after OAR (p < .01; 95% CI, 1.43 to 2.26). Conclusions Although the perioperative mortality rate was comparable between the two surgical procedures, the high levels of selection bias cannot be ignored and could actually indicate higher mortality rates for both procedures. Although mid- and long-term survival rates after OAR and EVAR were acceptable, more information on long-term outcome after EVAR with a greater sample size is needed to evaluate the durability of the less invasive procedure

Using protamine can significantly reduce the incidence of bleeding complications after carotid endarterectomy without increasing the risk of ischemic cerebral events

Abstract Background Controversy persists regarding the use of protamine sulfate (PS) during carotid endarterectomy (CEA), chiefly because of conflicting experiences reporting both less bleeding and a higher stroke risk. The goal of the present study was to test the hypothesis that reversing heparin with PS after CEA significantly reduces the incidence of bleeding complications without increasing the risk of postoperative stroke. Methods From January 2010 to December 2012 all consecutive patients undergoing CEA under general anesthesia at our institution received 5,000 U of heparin prior to carotid clamping, which was partially (half-dose) reversed with PS 25 mg immediately after declamping (group I). Heparinization had never been reversed with PS in earlier CEAs performed from 1998 to 2009 at the same institution (group II). All patients were assessed preoperatively and postoperatively by a neurologist, and cerebral magnetic resonance imaging was performed in all group I patients to exclude any silent cerebral infarction. End points of the study were bleeding complications, perioperative (30-day) stroke, and death. Results Overall, 219 CEAs (201 patients) were performed in group I, and 1,458 CEAs (1,294 patients) in group II. Demographics, risk factors, and preoperative antiplatelet medication were comparable in the two groups. The incidence of adverse events (group I vs group II) was as follows: stroke (0 vs 0.5 % [8/1,458], p = 0.27); death (0 vs 0 %); neck bleeding (0 vs 8.2 % [120/1,458], p\0.001). Conclusions The results of the present study demonstrate that (1) partially neutralizing heparin with PS after CEA can significantly reduce the risk of bleeding complications, and (2) there is no association between the administration of PS and the incidence of postoperative stroke

Predictors of neck bleeding after eversion carotid endarterectomy

IF: 3.851 ABSTRACT Objective To identify predictors for neck bleeding after eversion carotid endarterectomy (eCEA). Methods A prospectively compiled, computerized database of all primary eCEAs performed at a tertiary referral center between September 1998 and December 2009 was analyzed. The endpoint was represented by any neck bleeding after eCEA. Endpoint predictors were identified by univariate analysis. Results Out of 1458 eCEAs performed by the same surgeon on 1294 patients under general anesthesia with continuous electroencephalographic monitoring and selective shunting, there were 5 major and 3 minor perioperative strokes (0.5%), and no deaths. Neck bleeding after eCEA occurred in 120 cases (8.2%), 69 (4.7%) of which needed re-exploration. At univariate analysis preoperative antiplatelet treatment with clopidogrel (odds ratio [95% confidence interval] 1.77 [1.20-2.62], p = .004), particularly when continued up to the day before CEA (3.84 [2.01-7.33], p < .001), and postoperative hypertension (9.44 [6.34-14.06], p < .001) were identified as risk factors for neck bleeding in general and for neck bleeding requiring re-exploration (4.50 [1.85-10.89], p = .001; 15.27 [2.08-104.43], p = .006 and 2.44 [1.12-5.30], p = .02, respectively). An increased risk of neck bleeding in general was associated with clopidogrel plus aspirin (12.00 [2.59-56.78], p = .005), aspirin alone (4.37 [1.99-9.57], p < .001), and ticlopidine (2.49 [1.10-5.63], p = .02) only when they were continued up to the day before CEA. Preoperative dipyridamole or warfarin treatment or no medication were not associated with neck bleeding. No further complications occurred in the re-explored patients. Conclusions The results of this single center University hospital based study show that neck bleeding after CEA is relatively common, but it is not associated with an increased risk of stroke or death. Preoperative treatment with clopidogrel, particularly when it is continued up to the day before surgery, and postoperative arterial hypertension seem to be associated with a higher risk of neck bleeding after CEA, requiring re-exploration in most cases. Other antiplatelet agents appear to be associated with an increased risk of postoperative neck bleeding only if they are continued up to the day before CEA. Larger studies are warranted to confirm our findings and prevent this feared surgical complication

Carotid endarterectomy for symptomatic low-grade carotid stenosis

Objective: Although the management of carotid disease is well established for symptomatic lesions $70%, the surgical treatment for a symptomatic #50% stenosis is not supported by data from randomized trials. Factors other than lumen narrowing, such as plaque instability, seem to be involved in cerebral and retinal ischemic events. This study analyzes the early-term and long-term outcomes of carotid endarterectomy (CEA) performed in patients with low-grade (#50% on North American Symptomatic Carotid Endarterectomy Trial criteria) symptomatic carotid stenosis. Methods: The study involves 57 consecutive patients undergoing CEA for symptomatic low-grade carotid disease at our institution over 5 years, and 21 (36.8%) had experienced more than one ischemic event. Overall, 48 (84.2%) had a minor stroke, and nine (15.8%) had an episode of retinal ischemia. Diagnosis was made by a vascular neurologist based on an ultrasound examination combined with noninvasive imaging studies, after ruling out other possible causes of embolization. Before CEA, all patients were receiving antiplatelet treatment, and 87% were taking statins. All patients underwent eversion CEA under general deep anesthesia, with selective shunting. All carotid plaques were examined histologically. Long-term follow-up (median, 28 months; mean, 32 6 5 months; range, 3-56 months) was obtained for 55 patients. Results: No 30-day strokes or deaths occurred, and no patients had recurrent neurologic events related to the revascularized hemisphere during the follow-up. No late carotid occlusions were detected, but one asymptomatic moderate restenosis was documented. There were seven late deaths (12.7%), none of which were stroke-related. Survival rates were 98% at 1 year and 90% at 3 years. All removed carotid plaques showed different features of ulceration or rupture, with underlying hemorrhage associated with a thrombus. Conclusions: This study shows that CEA is a safe, effective, and durable treatment for patients with symptomatic lowgrade carotid stenosis associated with unstable plaque. Patients had excellent protection against further ischemic events and survived long enough to justify the initial surgical risk. Plaque instability seems to play a major part in the onset of ischemic events, regardless the entity of lumen narrowing