Complex Reconstruction with Flaps After Abdominoperineal Resection and Groin Dissection for Anal Squamous Cell Carcinoma: A Difficult Case Involving Many Specialities.

BACKGROUND Anal squamous cell carcinoma accounts for about 2-4% of all lower gastrointestinal malignancies, with a distant disease reported in less than 5%. Although surgical treatment is rarely necessary, this often involve large dissections and difficult reconstructive procedures. CASE REPORT We present a complex but successful case of double-flap reconstruction after abdominoperineal resection and groin dissection for anal squamous cell carcinoma (cT3N3M0) with metastatic right inguinal lymph nodes and ipsilateral threatening of femoral vessels. A multi-specialty team was involved in the operation. A vascular and plastic surgeon performed the inguinal dissection with en bloc excision of the saphenous magna and a cuff of the femoral vein, while colorectal surgeons carried out the abdominoperineal excision. The 2 large tissue gaps at the groin and perineum were covered with an oblique rectus abdominis myocutaneous flap and a gluteal lotus flap, respectively. A partially absorbable mesh was placed at the level of the anterior sheath in order to reinforce the abdominal wall, whereas an absorbable mesh was used as a bridge for the dissected pelvic floor muscles. The post-operative period was uneventful and the follow-up at 5 months showed good results. CONCLUSIONS An early diagnosis along with new techniques of radiochemotherapy allow patients to preserve their sphincter function. However, a persistent or recurrent disease needs major operations, which often involve a complex reconstruction. Good team-work and experience in specialized fields give the opportunity to make the best choices to perform critical steps during the management of complex cases.

Efficacy and Safety of Augmenting the Preclose Technique with a Collagen-Based Closure Device for Percutaneous Endovascular Aneurysm Repair.

PURPOSE: To report our experience of selectively augmenting the preclose technique for percutaneous endovascular aneurysm repair (p-EVAR) with an Angio-Seal device as a haemostatic adjunct in cases of significant bleeding after tensioning the sutures of the suture-mediated closure devices. MATERIALS AND METHODS: Prospectively collected data for p-EVAR patients at our institute were analysed. Outcomes included technical success and access site complications. A logistic regression model was used to analyse the effects of sheath size, CFA features and stent graft type on primary failure of the preclose technique necessitating augmentation and also on the development of complications. RESULTS: p-EVAR was attempted via 122 CFA access sites with a median sheath size of 18-French (range 12- to 28-French). Primary success of the preclose technique was 75.4% (92/122). Angio-Seal augmentation was utilised as an adjunct to the preclose technique in 20.5% (25/122). The overall p-EVAR success rate was 95.1% (116/122). There was a statistically significant relationship (p = 0.0093) between depth of CFA and primary failure of preclose technique. CFA diameter, calcification, type of stent graft and sheath size did not have significant effects on primary preclose technique failure. Overall 4.9% (6/122) required surgical conversion but otherwise there were no major complications. CONCLUSION: Augmentation with an Angio-Seal device is a safe and effective adjunct to increase the success rate of the preclose technique in p-EVAR.

Results of a seven-year, single-centre experience of the long-term outcomes of bovine ureter grafts used as novel conduits for haemodialysis fistulas.

PURPOSE: To report the long-term outcomes of bovine ureter grafts as novel conduits for haemodialysis fistulas. MATERIALS AND METHODS: Thirty-five patients underwent placement of a total of 40 SynerGraft 100 (SG100; CryoLife Europa(®), Guildford, UK) bovine ureter grafts between April 2002 and February 2009. Prospective data were collected on all patients, including active surveillance with blood flow studies and 6-monthly duplex ultrasound studies. Main outcome measures were primary and secondary patency rates. RESULTS: Mean follow-up time was 97 weeks (range 4-270). Thirteen patients died from unrelated causes during the study period; 12 of these patients had a functioning graft at the time of death. Five patients underwent transplantation, and all had a functioning graft at transplantation. Twelve patients had a functioning graft at the end of the study period. One hundred and ten stenoses were detected, and 97 venoplasty procedures were performed. Of the stenoses, 41.8% were located at the venous anastomosis, 12.7% within the graft, 17.3% in the outflow veins, and 28.1% in central veins. No arterial stenoses were detected. Primary patency rates were 53% at 6 months and 14% at 1 year. Secondary patency rates were 81% at 6 months, 75% at 1 year, and 56% at 2 years. CONCLUSIONS: Active surveillance and intervention was able to achieve satisfactory long-term secondary patency for these novel conduits compared with those made of PTFE seen in other studies [1].

The pathology of depopulated bovine ureter xenografts utilized for vascular access in haemodialysis patients.

AIMS: Vascular access for long-term haemodialysis is obtained through the surgical fashioning of arteriovenous fistulae, utilizing the patients' native blood vessels, or by insertion of synthetic grafts or non-synthetic gluteraldehyde cross-linked biological xenografts. These non-native grafts have high complication rates and a depopulated bovine ureter xenograft has recently been developed as an alternative. The aim was to undertake the first systematic review of the histopathology of bovine ureter xenografts (n = 25) utilized for haemodialysis vascular access in humans. METHODS AND RESULTS: Pre-insertion specimens (n = 7) showed preservation of some cellular architecture and histological antigenicity. Uncomplicated segments of post-insertion specimens (n = 18) showed myofibroblastic in-growth but no luminal endothelialization and no vascularization of the wall, other than at sites of needle puncture. Post-insertion, 50% showed a severe adventitial host inflammatory response with a dominant granulomatous and eosinophil-rich infiltrate. Inflammation was present in grafts with various complications (stenosis, thrombosis, aneurysm), but there was no clear pathogenic link. CONCLUSIONS: We conclude that repopulation of bovine ureter xenografts by host cells is limited and that, in specimens removed for complications, an inflammatory reaction to the xenograft is common. This could reflect retention of some antigenicity following pre-insertion 'depopulation' of the grafts.

Diagnostic imaging of and radiologic intervention for bovine ureter grafts used as a novel conduit for hemodialysis fistulas.

OBJECTIVE: The objectives of our study were to review the appearances on diagnostic imaging and amenability to imaging-guided intervention of a novel bovine ureter graft (Syner-Graft 100 [SG 100]) for use as a conduit for hemodialysis fistulas. CONCLUSION: The SG 100 shows initial promise as a conduit for hemodialysis fistulas in patients with difficult vascular access. The SG 100 has characteristic appearances on diagnostic imaging and is prone to similar pathologic processes that affect autogenous venous and synthetic grafts. These grafts are readily amenable to imaging-guided percutaneous intervention, which plays a major role in prolonging graft function.

Low-dose valaciclovir prophylaxis against cytomegalovirus disease in renal transplant recipients.

High-dose valaciclovir at up to 8 g/day has been shown to be effective in prophylaxis against cytomegalovirus (CMV) disease in renal transplant recipients. We report our experience with low-dose valaciclovir prophylaxis of up to 3 g/day, adjusted to creatinine clearance. A group of patients at high risk of developing CMV disease who received prophylaxis were selected as the study group. This included all CMV-positive patients who received antilymphocyte therapy (R+, n=20) and all CMV-negative recipients of CMV-positive organs (D+R-, n=15). D+R- patients receiving antilymphocyte therapy were excluded, as most of the patients in the control group had received ganciclovir prophylaxis. A historical control group was used, which consisted of patients who did not receive prophylaxis. Low-dose valaciclovir prophylaxis resulted in a statistically significant decrease (8.5 vs 37%, P=0.004) in CMV disease in the study group at 6 months. On subgroup analysis the decrease was statistically significant only in the R+ group (5 vs 45%, P=0.003), not in the D+R- group (13.3 vs 26.6%, P=0.651). Low-dose valaciclovir prophylaxis seems to be adequate for R+ patients receiving antilymphocyte therapy. The role of low-dose valaciclovir prophylaxis needs to be assessed further in a prospective trial.