In Search of Variables Affecting Mental Adjustment and Acceptance of Cancer among Urological Patients.

Background/Objectives: Genitourinary cancers are now considered a major problem in modern medicine. In urological oncology, the most frequently occurring diseases are prostate, bladder and renal cancer. Any cancer has a profound effect on the life of a patient. Therefore, disease acceptance and mental adjustment to the condition are the key elements in coping with cancer. Aim: The main aim of the study was the determination of the level of acceptance of illness and mental adjustment to cancer in urological patients undergoing surgical treatment and the assessment of the effect of mental adjustment on disease acceptance. Material and Methods: The study group comprised 150 patients treated at the Department of Urology and Urological Oncology at the Independent Public Clinical Hospital No 2 in Szczecin. The study made use of the diagnostic survey method with the original questionnaire and standardized research tools: Acceptance of Illness Scale (AIS) and Mental Adjustment to Cancer Scale (Mini-MAC). Results: The analysis of mental adjustment to cancer according to Mini-MAC revealed that the respondents most frequently adopted the fighting spirit strategy (M; 22.22). Slightly less frequently adopted strategies were positive re-evaluation (M; 21.28) and anxious preoccupation (M; 17.07). The least frequently adopted strategy was the helplessness-hopelessness strategy (M; 13.14). The analysis of data showed a statistically significant negative correlation (r = -0.245; p = 0.003) between disease acceptance according to AIS and age. The data analysis revealed a statistically significant positive correlation with helplessness-hopelessness and destructive style (p < 0.05). Conclusions: Mental adjustment to cancer was found to affect the acceptance of illness. When providing comprehensive care to cancer patients, it is equally crucial to consider the physical as well as mental health aspect, taking into account the aforementioned factors which affect both acceptance as well as adjustment to disease.

Questionable Long-Term Results of the Extended Provisional Extension to Induce Complete Attachment (E-PETTICOAT) Technique in the Management of Chronic Type B Aortic Dissection.

BACKGROUND: Published interim results of the extended provisional extension to induce complete attachment (e-PETTICOAT) technique suggested favorable remodeling in chronic type B Aortic Dissection (cTBAD). This report presents long-term results of the e-PETTICOAT technique for the management of cTBAD (without aneurysmal dilatation). METHODS: Patients with cTBAD below the 55 mm aortic size were eligible for the management using the e-PETTICOAT technique. Follow-up was conducted at 1, 2 and 5 years based on the computed tomography angiogram. All the presurgery risk factors (entry >1 cm, inner curve entry, fusiform index >0.65, false lumen > 22 mm, aortic size >40 mm, recurrent pain or hypertension, and Stanford Dissection Risk Calculation) and postsurgery complications were examined in the study. RESULTS: A total of 20 patients underwent the e-PETTICOAT surgery. The survival rate at 1, 2, and 5 years was 75%, 70%, and 64%, respectively, and the percentage of patients without any reinterventions was 100%, 93%, and 18%. Aortic degeneration was recognized in 30%, 55%, and 85% of the patients. Only 3 of the 20 patients were alive and without any reintervention after 5 years. The receiver operating curve analysis does not indicate any factor that would predict the remodeling result in the long-term follow-up. CONCLUSIONS: The use of e-PETTICOAT technique in cTBAD might not have a beneficial influence on the long-term results.

Physician-modified endograft in ruptured aortic arch.

We present the case of a 27-year-old motorcyclist after a multi-organ trauma. He suffered a rupture of the aortic arch located in zone 2 and was disqualified from surgical replacement of the aortic arch due to active bleeding from parenchymal organs. Instead, he was provided with a physician-modified endograft (PMEG) to complete fenestrated thoracic endovascular aortic repair as a damage control procedure. No reports in the world literature are found regarding the use of PMEG technology in truly ruptured post-traumatic pseudo-aneurysm on the border of zone 1 and 2 of the aortic arch in emergency settings. The surgery provided temporary supply of the aorta and allowed all of the other surgical and orthopedic procedures to be completed. Endovascular treatment of aortic arch damage with PMEG is possible and can be effectively used for urgent indications when an open operation is not possible.

Initial Experience with Fenestrated Physician-Modified Stent Grafts Using 3D Aortic Templates.

The goal of this study was to describe the surgical results of physician-modified endografts (PMEG) utilizing a 3D aortic template in a center with no prior experience in complex endovascular aortic repairs. Forty-three patients underwent physician-modified graft stent implantation using a 3D aortic model. The inclusion criteria were juxtarenal and suprarenal aortic aneurysms, type IV thoracoabdominal aneurysms, and type IA endoleak after endovascular aortic repair. In asymptomatic patients, the diameter threshold for aneurysm repair was 5.5 cm in males and 5.0 cm in females. 3D aortic templates were prepared from the patient's computed tomography angiography scans and sterilized before use in the operating suite. Forty-three stent grafts were modified with the use of a 3D printing template. A total of 162 reinforced fenestrations (37 celiac, 43 right renal, 39 left renal, 43 superior mesenteric) with a mean of 3.8 per patient were performed. All PMEGs had a posterior reducing-diameter tie and a preloaded guidewire. The mean modification time was 86 ± 12 min. The mean follow-up was 14 ± 12 months. The 30-day mortality was 12%. During the follow-up period, the patency rate was 95% per the superior mesenteric artery, 93% per right renal artery, 95% per left renal artery, and 89% per celiac trunk. Twelve (28%) patients had endoleak, of which type I or III was present in 5 (12%) patients, and type II in 7 (16%). 3D printing can be successfully integrated into the physician's everyday practice of stent graft modification. However, the use of this approach in centers without experience performing complex aortic procedures results in worse surgical metrics than those previously reported.

The Impact of Socio-Demographic Factors on the Functioning of Liver Transplant Patients.

(1) Background: The aim of this study was to evaluate the influence of socio-demographic factors and the time elapsed since liver transplantation on the functioning of patients after liver transplantation; (2) Methods: This is a survey-based prospective cohort study of 112 patients, performed using: The Inventory of Socially Supportive Behaviors (ISSB), The Acceptance of Illness Scale (AIS), the Beck Depression Inventory (BDI), and a questionnaire concerning sociodemographic data prepared using the Delphi method; (3) Results: Subjects under 40 years of age reported the highest social support. The longer the time since surgery, the lower the levels of adherence and support; (4) Conclusions: 1. In the study group, most support was received by women, people under 40 years of age, and those with secondary education. However, the level of social support decreased over time after the liver transplant operation. Patients who had undergone previous transplantation showed lower levels of adherence to therapeutic recommendations. 2. Patients who were in a relationship showed higher levels of illness acceptance than single ones. Women were more likely to experience depressive symptoms than men. 3. The time since liver transplantation is an important factor that affects patients' functioning. This is a time when patients need more care, social support, and assistance in maintaining adherence to therapeutic recommendations.

Multidisciplinary aortic arch procedures within the "Aortic Team".

Introduction and aim: The European societies EACTS (European Association for Cardio-Thoracic Surgery) and ESVS (European Society for Vascular Surgery) recommend the establishment of "Aortic Teams" from 2019. In Poland, the first such team was officially established in Specialist University Hospital no. 2 in Szczecin in 2021. Material and methods: Sixty-four patients were treated for aortic arch pathology using frozen elephant trunk (n = 3), branch custom made devices (n = 12), physician-modified endo-grafts (PMEG; n = 30) and the thoracic endovascular aortic repair "plus" technique (n = 19). Results: Among thoracic endovascular aortic repair (TEVAR) plus (chimneys/periscopes, n = 7, extra-anatomical bypasses, n = 12) there was 100% technical success and 4% bad outcomes (stroke or death). Among "customized" stent grafts there were Bolton Relay (n = 8), Brail Endo-Branch (n = 1) and Castor branched stent graft (n = 3) with 91% technical success and 18% bad outcomes. In the group of PMEG there were 14 cases with one fenestration, 5 cases with two fenestrations and 11 cases with triple fenestration to all vessels of the aortic arch. In this group, technical success was achieved in 91% and poor outcome ended treatment in 11%. In total we noted a 91% technical success rate and a good treatment outcome was achieved in 89%. The cooperation of cardiac surgeons and vascular surgeons in one team brought competence benefits for both specialties. It allowed for good clinical and economic results despite new logistical complexities and fits into the currently changing perspective of cardiac surgery development worldwide. Conclusions: Implementation of the recommendation to create aortic teams within cardiac surgery departments is possible and may be cost-effective in Polish conditions.

The extended PETTICOAT technique does not guarantee favorable remodeling after acute type B aortic dissection.

Introduction: Favorable remodeling is not always observed after thoracic endovascular aortic repair (TEVAR) in acute complicated type B aortic dissection (TBAD). Existing distal re-entries might be the cause of that. Many more extensive techniques have been introduced and evaluated. None of them achieve proven benefit in long-term follow-up. Aim: A new technique called extended PETTICOAT (provisional extension to induce complete attachment) or e-PETTICOAT technique was published in 2018. It allows one to cover proximal and distal re-entries and consists of: combined implantation of a thoracic stent graft to seal the proximal entry; self-expandable stents in the visceral aorta to expand the true lumen; plus two parallel kissing iliac stent grafts below the renal arteries. Despite encouraging medium term results, it has unknown long-term consequences. Material and methods: The prospective observational single center study included 11 patients with complicated acute TBAD qualified for endovascular treatment using the e-PETTICOAT technique. Complicated acute TBAD was identified only in cases of clinical manifestation before or at the time of intervention; radiological findings were not sufficient to identify complications in our study. Method: The 5-year follow-up, based on clinical outcome including survival, re-interventions and angio-CT-assessed remodeling, was examined. Results: The e-PETTICOAT technique achieves good remodeling in 38% of primary and 88% of secondary procedures. Conclusions: The E-PETTICOAT does not guarantee favorable remodeling during a 5-year follow-up in acute complicated TBAD. Complex aortic repair after e-PETTICOAT might be needed.

Incidents and risk factors of biliary complications after orthotropic liver transplantation.

ABSTRACT: Biliary complications (BC) especially stenosis and strictures are the most common complications after orthotropic liver transplantation (OLT) procedure in adult recipients. The intention of this study was analyzed BC in 273 patients after OLT for the last 4 years in our department.Retrospective study of 273 patients underwent cadaveric donor liver transplantation between January 2014 and December 2017. Most of them (n = 268) have anastomosed bile duct in end to end, rest of them (n = 5) underwent hepaticojejunostomy. Statistical analysis was performed using Fischer exact test and Student t test. A P value <.05 was considered significant.BC were developed in 48/273 transplants (17.6%). The most frequent was biliary stricture (n = 42, 87.5%) followed by bile leak (n = 4, 8.3%) and choledocholitiasis (n = 2, 4.2%). Treatment was usually using endoscopic retrograde cholangiopancreatography. Recipients with hypotension during and after OLT treated by norepinephrine have a higher index of BC.Self-expanding metal stents implantation seems to be more effective than repeated balloon dilatation of anastomotic strictures with subsequent plastic biliary stent placement and associated with similar complication rate. Good fluid management against inotropic therapy may reduce risk of BC.

The Impact of a Simplified Hydrostatic Bypass Flow Technique on Error Detection during Surgical Limb Revascularization.

Technical errors have an impact on the results of surgical lower limb revascularization. Use of ultrasound scanning or angiography on the operating table is inconvenient and, in case of angiography, carries a certain risk of radiation and contrast exposure. A simpler method of screening for errors is required. This study assessed the accuracy of a new simple hydrostatic bypass flow technique during surgical limb revascularization. In all, 885 patients were included in the retrospective study. All were treated for Chronic Limb-Threatening Ischemia (CLTI) with a femoropopliteal bypass. Preoperatively, the radiological Vascular Surgery/International Society of Cardiovascular Surgery (SVS/ISCVS) score was used to assess the complexity of the anatomical changes. The surgeon made a subjective runoff assessment for every surgery. In 267 cases, the hydrostatic bypass flow (HBF) technique was used, and, in 66 cases, a digital subtraction angiography (DSA) was used. In each case, a postoperative Doppler ultrasound (DUS) examination was performed following the HBF. Good early results were achieved in 89.46%, and 154 errors (17.4%) were detected (85 were detected on the operating table, including 57 technical errors). Independent efficacy in error detection was proven with a postoperative Doppler examination (Aera Under Curve (AUC) = 0.89; criterion mid-graft peak systolic velocity (PSV) <24 cm/s, p = 0.00001) and hydrostatic bypass flow (AUC = 0.71, criterion HBF < 53 mL/min, p = 0.00001) during surgery. The hydrostatic bypass flow technique is an effective intraoperative screening method in bypass surgery. Algorithmic use of HBF, DSA if needed, and DUS postoperatively improves the outcome. HBF sufficiently reduced the need for on-table angiography.

Complete Entry and Re-entry Neutralization protocol in endovascular treatment of aortic dissection.

There have been indisputable developments in techniques for stabilizing acute aortic syndromes. However, aneurysmal degeneration following aortic dissection remains a problem to be solved. The currently available treatment options for aortic dissection still fail to take into account the known risk factors for aneurysmal degeneration. This is why we introduced a new approach to treating patients with an aortic dissection, called Complete Entry and Re-entry Neutralization (CERN). This is our initial report on the promising interim results. MATERIAL AND METHODS: 68 patients qualified for endovascular treatment of an acute or chronic aortic dissection. Computed tomography was performed post-operatively to assess aortic remodeling after 1/6/12/24/36 months. RESULTS: the 30-day mortality rate was 4.4%. In 29 cases (43%) unfavorable remodeling was noted in the follow-up. The most important factors leading to unfavorable remodeling were: uncovered re-entry tear including the infra-renal segment, no relining of dissection membranes and insufficient coverage of the descending aorta. We analyzed these factors to develop the CERN protocol. This concept consists of six basic rules: A. cover all entry tears, B. amplify the BMS radial force, C. use the STABILISE technique, D. consider using thrombus plugs, E. avoid stenting the visceral branches, F. spare the intercostal and lumbar side branches. CERN improves the rate of favorable remodeling from 25% to 85% (P = 0.0067). CONCLUSION: Introduction of the Complete Entry and Re-entry Neutralization protocol improves the rate of favorable remodeling following endovascular treatment of aortic dissection in mid-term follow-up in patients with diffused aortic dissection.

Aortic Remodeling After Extended PETTICOAT Technique in Acute Aortic Dissection Type III B.

BACKGROUND: The aim of this paper was to evaluate a new technique called an "extended" provisional extension to induce complete attachment (e-PETTICOAT) technique. METHODS: In this prospective single-center clinical study, the primary safety end mid-term remodeling is evaluated for the new endovascular technique. It was based on a standard Petticoat and limited Stabilize technique, extended by the placement of 2 covered stents within the abdominal bare metal stent as parallel iliac stent grafts down to the iliac bifurcations. Computed tomographic angiography was performed postoperatively to assess aortic remodeling after 12 and 24 months. Changes in aortic size and volumes of the false and true lumen were assessed. RESULTS: Between January 2014 and December 2015, 17 patients were treated due to acute, complicated aortic dissection type III B, according to the DaBekey classification. All patients presented with branch vessel obstruction/compromise, including six cases with aortic impending rupture. A 100% technical success rate was recorded regarding the resolution of complications. Favorable remodeling was achieved in 100% of the cases. Complete false lumen thrombosis in the thoracic, infra-renal aorta and the iliac artery was noted. A small volume (9.51 ± 6.9 mL) contrast-enhanced false lumen in the abdominal aorta was observed in 76% of cases with stable aortic size after 1 and 2 years. No visceral branch occlusion, type I endo-leak, renal insufficiency or paraplegia was recorded in follow-up. CONCLUSIONS: The expanded PETTICOAT technique was feasible in achieving favorable remodeling in acute extensive aortic dissection. Extended followup is needed to ascertain long-term results. This article presents a series of 17 cases of a new endovascular method called E-PETTICOAT (EJVES 2018 https://doi.org/10.1016/j.ejvs.2018.07.038) used in complicated acute and extensive type IIIB dissections. Favorable remodeling was achieved in 100% cases with stable aorta diameter after 1 and 2 years. It was shown that the extended PETTICOAT technique gives good remodeling in acute and extensive aortic dissection. This method can potentially provide a one-step solution and an easier alternative to FEVAR/BEVAR procedures. In order to ensure favorable results, further research is needed on a wider scale with long-term followup.

External Validation Of The Surgical Mortality Probability Model (S-MPM) In Patients Undergoing Non-Cardiac Surgery.

BACKGROUND: Preoperative risk assessment is a key issue in the process of patient preparation for surgery and the control of quality improvement in health care and certification programs. Hence, there is a need for a prognostic tool, whose usefulness can be assessed only after validation in the center other than the home one. The aim of the study was to validate the Surgical Mortality Probability Model (S-MPM) for detecting deaths and complications in patients undergoing non-cardiac surgery and to assess its suitability for various surgical disciplines. METHODS: This retrospective study involved 38,555 adult patients undergoing non-cardiac surgery in a single center in 2012-2015. The observation period concerned in-hospital mortality. RESULTS: In-hospital mortality for the total population was 0.89%. Mortality in the S-MPM I class amounted to 0.26%, S-MPM II 2.51%, and in the S-MPM III class 22.14%. This result was in line with those obtained by the authors. The discriminatory power for in-hospital mortality was good (area under curve (AUC) = 0.852, 95% CI: 0.834-0.869, p = 0.0000). The scale was the most accurate in general surgery (AUC = 0.89, 95% CI: 0.858-0.922) and trauma (AUC = 0.89; 95% CI: 0.87-0.915). In the logistic regression analysis, the scale showed a perfect fit/goodness of fit in the cross-validation method (v-fold cross-validation): Hosmer-Lemeshow (HL) = 7.945; p = 0.159. This result was confirmed by the traditional derivation and validation data set method (1:3; 9712 vs 22.748 cases): HL test = 3.073 (p = 0.546) in the teaching derivation data set and 10.77 (p = 0.029) in the test sample (validation data set). CONCLUSION: The S-MPM scale by Glance et al has proven to be a useful tool to assess the risk of in-hospital death and can be taken into account when considering treatment indications, patient information, planning post-operative care, and quality control.

Expanded Petticoat technique to promote the reduction of contrasted false lumen volume in patients with chronic type B aortic dissection.

OBJECTIVE: This study examined the outcomes of our novel concept of expanded provisional extension to induce complete attachment strategy (Petticoat) for safety, durability, and remodeling of chronic type B dissections. METHODS: Twenty patients with chronic type B aortic dissection with aneurysmal degeneration qualified for an expanded Petticoat strategy (stent graft in the thoracic, plus additional distal bare stent into the abdominal and infrarenal aorta, followed by parallel stent grafts into common iliac arteries). Computed tomography was performed preoperatively and at 1, 6, and 12 months after surgery. RESULTS: The primary technical success was 100%. The 30-day mortality rate was 0%. At 12 months, favorable aortic remodeling and complete false lumen (FL) thrombosis were noted as 100% in the thoracic and infrarenal aorta. The volume of contrast-enhanced FL decreased from 186 ± 75.4 mL all along the dissection preoperatively (range, 70-360 mL), to 6.32 ± 5.4 mL postoperatively (range, 0.0-19.6 mL) and was only observed in the visceral aorta (P = .000089). Despite persistent flow in a small area of the FL, the maximal aortic size was stable in follow-up. Neither paraplegia nor visceral branch occlusion were noted in the follow-up. CONCLUSIONS: The treatment of aortic dissections with an expanded Petticoat strategy seems to be safe and offers good early results. It significantly reduced the volume of contrast enhanced FL. Further investigation of any subsequent results will be necessary.

Cosmetic effects of skin-crease camouflage incision versus longitudinal incision following carotid endarterectomy.

INTRODUCTION: Despite the increasing use of carotid angioplasty and stenting (CAS), carotid endarterectomy (CEA) nonetheless remains a more medically beneficial method of treatment for carotid artery stenosis. Therefore, one possibility for progress within this procedure may be to use minimally invasive carotid surgery, especially when the scar is in plain sight: the use of the natural wrinkles (skin crease) as a camouflage of the skin incision provides significant cosmetic improvements. AIM: To compare the cosmetic effects of classic and trans-wrinkle CEA. To assess the distance between the carotid artery bifurcation (CAB) and the skin-crease incision whilst attempting CEA. MATERIAL AND METHODS: It was a randomized prospective study with two groups: patients undergoing classic surgery (control group; n = 100) and skin-crease trans-wrinkle camouflaged CEA (study group; n = 100). Follow-up was at 2 months and 1 year. RESULTS: The medical results of the treatment were similar in both groups. The cumulative count of strokes and myocardial infarctions was 0.5% within 30 days, and after one year 3.5% (and 5.5% including cases of death). The superiority of the transverse crease being hidden compared to the conventional longitudinal technique was proven in the Patient and Observer Scar Assessment Scale (POSAS) score, respectively 11.4 ±1.0 vs. 14.1 ±3.4 (p = 0.0001) after 2 months and 13.5 ±2.8 vs. 14.1 ±3.4 (p = 0.039) after a year. CONCLUSIONS: Trans-wrinkle incision gives better cosmetic results, can be safely performed in most cases, and offers a comfortable approach during CEA.

The role of neck wrinkles for cosmetic effect during carotid artery endarterectomy.

INTRODUCTION: Minimally invasive procedures in carotid endarterectomy are currently preferred. Smaller skin incisions (transverse or longitudinal) and the mapping of carotid artery bifurcation with Doppler ultrasound are promoted. There is a lack of papers about cosmetic effects and patients' preferences. The aim of this study was to qualify natural skin wrinkles as potential anatomical markers of carotid artery bifurcation and scar camouflage. MATERIAL AND METHODS: 50 patients underwent carotid endarterectomy in 2013-2014 in the Vascular Surgery Department of the Pomeranian Medical University in Szczecin. The positions of wrinkles were compared with the anatomical location of carotid artery bifurcation with the use of Doppler - Duplex Ultrasound. Patients' preferences and cosmetic effect were also assessed. RESULTS: 50% of patients declared the cosmetic effect important. Nevertheless, every patient preferred a transverse incision along a wrinkle line. The wound scar was invisible in 76% of cases 3-6 months after surgery. Wrinkles were close, within 1 centimeter, to carotid artery bifurcation in 80% of cases. It was mainly 4-5 cm from the angle of the mandible. Surgical access along wrinkles located 3, 4, 5, 6, 7 cm from the gonial angle was technically easy in 55%, 77%, 79%, 45%, and 21% of cases, respectively. Using ultrasound before surgery allows the planning of the optimal incision in 98% of cases. CONCLUSIONS: Transverse incision hidden in the wrinkles of the neck gives a good cosmetic effect and allows carotid endarterectomy in every case when carotid artery bifurcation is marked prior to surgery.

Leucocytosis as a specific risk predictor after abdominal aortic aneurysm open repair.

INTRODUCTION: Prediction of early death in abdominal aortic aneurysm - open repair is widely described. There is no superiority of any risk stratification tool. Some of the risk calculators are quite accurate, but very complicated (e.g. P-POSSUM, V-POSSUM). Some are simpler but never used in vascular surgery (e.g. ECOG). Therefore, only leucocytosis itself appears to be an independent and highly specific factor in prediction of early death prior to surgery. This might be used as an early warning factor raising surgeons' attention, especially in centers not using any risk calculators on a regular basis. The aim of this study was to comparison of commonly used early death prediction calculators for abdominal aortic aneurysm - open repair. We took into account the following scales: Glasgow Aneurysm Score (GAS), V-POSSUM, Eagle score, American Society of Anesthesia Score, ECOG, Goldman/Detsky. However, we also have been looking for independent risk factors of early postoperative death. MATERIAL AND METHODS: Retrospective analysis of 79 patients who underwent elective open repair of abdominal aortic aneurysm over 3 years (2011-2013 Szczecin, Poland). We have excluded patients treated due to ruptured aneurysms and with the use of a stentgraft. Receiver operating curve analysis was used to asses all prediction abilities. RESULTS: We noted 6 deaths (7.59%). Receiver operating curve analysis confirms good prediction force for V-POSSUM (p = 0.0001, criterion over 1.9%) and GAS (p = 0.0109, criterion over 73 pt.). Areas under curve are respectively 0.806 and 0.743. However, leucocytosis itself over 10 T/L was the most specific (over 88%) risk factor in early death prediction (p < 0.0001). CONCLUSION: V-POSSUM and GAS are suitable risk calculators for abdominal aortic aneurysm - open repair. Leucocytosis discovered prior to the surgery is a highly specific early death predictor.