Laparoscopic ventral incisional hernia repair: evidence-based guidelines of the first Italian Consensus Conference.

PURPOSE: The laparoscopic treatment of ventral incisional hernias is the object of constant attention and is becoming increasingly widespread in the international scientific-surgical community; however, there is ample debate on its technical details and indications. In order to establish a common approach on laparoscopic ventral incisional hernia repair, the first Italian Consensus Conference was organized in Naples (Italy) on 14-15 January 2010. METHODS: The format of the Consensus Conference was freely adapted from the standards of the National Institute of Health and the Italian Health Institute. The parties involved included the followings: a Promotional Committee, a Scientific Committee, a group of Experts, the Jury Panel and a Scientific Secretariat. RESULTS: Eleven statements, regarding three large chapters on the indications, the technical details and the management of complications were drafted on the basis of literature references collected by the Scientific Committee, documents developed by the Experts, reports presented and discussed during the Consensus Conference, and discussion among the members of the Jury. CONCLUSIONS: The laparoscopic approach is safe and effective for defects larger than 3 cm in diameter; old age, obesity, previous abdominal operations, recurrence and strangulation are not absolute contraindications. Ensuring an adequate overlap, careful adhesiolysis and correct fixing of the prosthesis are among the technical details recommended. Complications and recurrences are comparable to, and in some cases, less numerous than with the open approach.

Eversion versus conventional carotid endarterectomy: late results of a prospective multicenter randomized trial.

OBJECTIVE: The durability of carotid endarterectomy (CEA) may be affected by carotid restenosis. The data from randomized trials show that the highest incidence of restenosis after CEA occurs from 12 to 18 months after surgery. The optimal CEA technique to reduce perioperative complications and restenosis rates is still undefined. This study examines the long-term clinical outcome and incidence of recurrent stenosis in patients who undergo eversion CEA. Previously published perioperative results of this study did not show statistically significant differences in study endpoints between the eversion and standard techniques. METHODS: From October 1994 to March 1997, 1353 patients with surgical indications for carotid stenosis were randomly assigned to undergo eversion (n = 678) or standard CEA (n = 675; primary closure, 419; patch, 256). Withdrawal from the assigned treatment occurred in 1.6% of the patients (in 13 assigned to eversion CEA, and in nine assigned to standard CEA). The clinical and duplex scan follow-up examination was 99% complete, and the mean follow-up interval was 33 months (range, 12 to 55 months). The primary outcomes were perioperative and late major stroke and death, carotid restenosis (stenosis >/= 50% of the lumen diameter detected at duplex scanning), and carotid occlusion. The primary evaluation of study outcomes was conducted on the basis of an intention-to-treat analysis. RESULTS: Restenosis was found at duplex scanning in 56 patients (19 in the eversion group, and 37 in the standard group). Within the standard group, the restenosis rates were 7.9% in the primary closure population and 1.5% in the patched population. Of the patients with restenosis, 36% underwent cerebral angiography that confirmed restenosis in all cases. The cumulative restenosis risk at 4 years was significantly lower in the group that underwent treatment with eversion CEA as compared with the standard group (3.6% vs 9.2%; P =.01), with an absolute risk reduction of 5. 6% and a relative risk reduction of 62%. Eighteen patients would have had to undergo treatment with eversion CEA to prevent one restenosis during the 4-year period. The incidence rate of ipsilateral stroke was 3.3% in the eversion population and 2.2% in the standard group. There were no significant differences in the cumulative risks of ipsilateral stroke (3.9% for eversion, and 2.2% for standard; P =.2) and death (13.1% for eversion, and 12.7% for standard; P =.7)) in the two groups. Of the 18 variables that were examined for their influence on restenosis, eversion CEA (hazard ratio, 0.3; 95% confidence interval, 0.2 to 0.6; P =.0004) and patch CEA (hazard ratio, 0.2; 95% confidence interval, 0.07 to 0.6; P =. 002) were negative independent predictors of restenosis with multivariate Cox proportional hazards regression analysis. CONCLUSION: The EVEREST (EVERsion carotid Endarterectomy versus Standard Trial) showed that eversion CEA is safe, effective, and durable. No statistically significant differences were found in late outcome between the eversion and standard techniques at the available follow-up examination.

Experience with the Stentor endograft at four Italian centers.

PURPOSE: To report the outcome of an Italian multicenter trial of endovascular abdominal aortic aneurysm (AAA) exclusion using the Stentor device. METHODS: Between April 1995 and July 1996, 66 patients (63 men; average age 69 years, range 53 to 84) with infrarenal AAAs meeting the inclusion criteria were enrolled. The average diameter of the aneurysm was 4.6 cm (range 4.2 to 7). Three (4.5%) of the 66 AAAs were anastomotic aneurysms. RESULTS: Sixteen (25%) tubular and 50 (76%) bifurcated endograft procedures were attempted; 4 (6.1%) were converted and 1 terminated owing to technical faults with the bifurcated graft's second limb. One tube graft was too short and failed to exclude an anastomotic aneurysm. Sixty (91%) endograft procedures were completed successfully. Six (9.1%) vascular complications occurred, three in one patient who subsequently died of pulmonary embolism 72 hours postoperatively (1.5% mortality). There were four (6.1%) proximal endoleaks; two sealed spontaneously in < 1 month, and a third was converted (7.6% conversion rate). The fourth is being observed. Clinical success (aneurysm exclusion with no death or endoleak) at 30 days was 86.3% (57/66). In the 23-month follow-up of 57 eligible patients, 2 patients died of unrelated causes and 1 graft limb thrombosed, requiring a crossover femoral bypass. One patient was converted to surgical repair at 5 months postoperatively when increasing aneurysm size signaled an undisclosed endoleak (1.8% late conversion rate). Five other secondary endoleaks were treated with endovascular techniques. CONCLUSIONS: The Stentor was technically feasible in 10% to 40% of AAA candidates in this study, although deployment of the second limb was problematic in the bifurcated device. Introduction of the second-generation Vanguard endograft brought this study to an end.

Totally laparoscopic aortobifemoral bypass: a review of 10 patients.

The main purpose of this study is to evaluate the feasibility of totally laparoscopic aortobifemoral bypass for occlusive aortoiliac disease. Ten patients who had incapacitating claudication have been included to date in this investigation. We have designed a transabdominal retroperitoneal technique that allows performance of the procedure without the problems associated with retraction of intraperitoneal organs. During the study, surgery time decreased from 510 to 245 min. Mean total aortic clamping time was 121 min, and the mean time required to perform the aortic anastomosis was 66 min. Mean blood loss was 820 ml. Three patients needed conversion. Postoperative complications developed in three patients. One had an aortoureteral fistula, which needed reoperation; one experienced complications related to a retroaortic left renal vein; and the third had a mild compartment syndrome of the right leg. Totally laparoscopic aortobifemoral bypass is feasible. Laparoscopic aortobifemoral bypass appears to ease the patient's postoperative course and could become in the not so distant future part of the repertoire of the surgeon performing vascular surgery.

A randomized study on eversion versus standard carotid endarterectomy: study design and preliminary results: the Everest Trial.

PURPOSE: The EVEREST Trial was designed to determine whether the surgical technique influences the durability and complications of carotid endarterectomy (CEA). The current report focuses on the study design and preliminary results. METHODS: EVEREST is a randomized multicenter trial. A total of 1353 patients with carotid stenosis requiring surgical treatment were randomly assigned to received standard (n = 675) or eversion (n = 678) CEA. Primary end points included carotid occlusion, major stroke, death, and restenosis rate. RESULTS: The rate of perioperative major stroke and death (1.3 for each study group) and the incidence of early carotid occlusion (0.6% for eversion vs 0.4% for standard) were similar. No significant differences were found between eversion and standard CEA with respect to incidence of perioperative transient ischemic accident, minor stroke, cranial nerve injuries, neck hematoma, myocardial infarction, or surgical defects as detected with intraoperative quality controls. Clamping time was significantly shorter for eversion CEA compared with patch standard procedures (31.7 +/- 15.9 vs 34.5 +/- 14.4 minutes, p = 0.02). A shunt was inserted in 11% of patients undergoing eversion CEAs and in 16% of patients undergoing standard procedures. Overall 30-day events occurred in 13.3% of the eversion group and in 11.4% of the standard group (p = 0.3). At a mean follow-up of 14.9 months (range, 1 to 38 months), 16 (2.4%) restenoses occurred in the eversion group and 28 (4.1%) occurred in the standard group (odds ratio, 0.56; 95% confidence interval, 0.3 to 1.1; p = 0.08). CONCLUSION: The preliminary results of the EVEREST Trial suggest that eversion CEA is a safe and rapid procedure with low major complication rates. No significant differences in restenosis rates were observed between eversion and standard CEA at the available follow-up. Longer-term results are necessary to assess whether the eversion technique influences the durability of CEA.

European multicentre experience with modular device (Medtronic Aneurx) for the endoluminal repair of infrarenal abdominal aortic aneurysms.

OBJECTIVE: Transfemoral endoluminal repair of AAA, introduced for the first time in the early 90's, has become a very promising alternative to conventional open repair and more and more centers are reporting satisfactory postoperative results in a high percentage of cases. Straight and bifurcated grafts represent the devices available on the market at present and aortic, as well as iliac aneurysmal lesions can be safely treated through a transfemoral approach. The possibility to indicate an endovascular AAA repair is related to the configuration (length and size) of the proximal and distal necks, tortuosity and calcification of the access arteries and to vascular and non-vascular comorbidities, which afflict the patients. The objective of our study was to evaluate the early and late postoperative results in a series of patients affected by infrarenal AAA, who underwent endoluminal repair. MATERIALS AND METHODS: From December 1996 to 31 October 1997 in 5 different European Centers, 100 Medtronic AneuRx bifurcated stent grafts were implanted for infrarenal abdominal aortic aneurysms. The diameter of the AAA varied from 33 to 77 mm (average 64 mm) and the mean age of the patients was 70.8 years (51-87 years). In one patient with a 33 mm diameter of the aneurysm, the surgical procedure was indicated because the size of the aneurysm had increased by 5 mm, compared to the previous control made 2 months before. In addition the aneurysm became symptomatic. There were 92 male and 8 female patients. The average time of the surgical procedure was 150 minutes (75-480 minutes) with an average blood loss of 570 ml (100-2,600 ml).

Morgagni-Larrey hernia correction by laparoscopic surgery.

A new method of closure of Morgagni-Larrey hernia by video-assisted surgery is described in a child. Laparoscopy could in our opinion be an advantageous method for treatment of diaphragmatic defects.

Pain therapy in elderly cancer patients.

In most (65-80%) cancer patients at an advanced stage of illness we find significant, invalidating symptoms of pain. Cancer pain is a complex pain (with a nociceptive, neuropathic and deafferentation component), which requires a multidisciplinary approach (surgery, radiochemotherapy, and pain therapy). Pain therapy has various pharmacological strategies at its disposal (opiates, anti-inflammatory and adjuvant drugs) together with modulation and neurodestructive techniques, which must be applied taking account of both the stage of the disease and the pain intensity. In elderly patients, a careful, tailored management of pharmacological therapy is required. In older age, personality disorders are also to be found (anxiety, depression, hypocondria and feeling of abandonment), which make therapy more complex and varied. Knowledge of these problems will, however, make it possible to control cancer pain in elderly patients to the best possible effect and improve the quality of life in the advanced and terminal stages.

[Laparoscopic repair of bilateral and/or recurrent inguinal hernia]. / L'alloplastica laparoscopica nel trattamento dell'ernia inguinale bilaterale e/o recidiva.

The Authors report their three-year experience in the laparoscopic management of bilateral or recurrent hernia using a polypropylene mesh through a transabdominal extraperitoneal approach: out of a total of 500 laparoscopic hernioplasties performed, 162 patients with bilateral hernias and 51 with recurrent hernia underwent this procedure. In bilateral hernias a single wide patch was used to cover both the myopectineal foramen, therefore performing a Stoppa procedure by laparoscopy. Two major complications were registered in this series: 1 bleeding and 1 intestinal obstruction, both managed laparoscopically. Minor complications were: 2 cases of neuralgia and 6 seromas which required single or multiple evacuations. Patients were carefully followed up (1-31 months), and no relapses were recorded. Although the follow up is still too short, the Authors stress the characteristics of this technique which shows great advantages mainly represented by a good compliance, quick return to normal work and sport activity; in fact, recovery is obtained in a shorter period as compared to traditional surgery even when the latter includes the use of prosthetic mesh.

[Diverticulosis of the sigmoid colon: when to operate and which surgical treatment to use]. / La diverticolosi del colon sigma: quando intervenire e che trattamento chirurgico eseguire.

Diverticulosis of the colon is an increasing frequent disease: 50% of all subjects over 70 are affected by this pathology. The paper reports a series of cases and a therapeutic approach for simple, symptomatic and complicated diverticulosis. The long-term results are also reported.

Pancreatectomy and metabolic alterations.

The authors describe problems about anaesthesia management in peri- and post-operative periods in seven patients undergoing total pancreatectomy. They underline that metabolic alterations in these cases show, until now, some unsolved problems. Sometimes artificial pancreas is very useful in post-operative management of these patients.

Intubating conditions with propofol under muscle relaxation with vecuronium bromide. A time-related comparison with thiopental.

In the present study a comparison has been made between intubating condition obtainable after anesthesia induction with Thiopental or Propofol, using Vecuronium Bromide to achieve muscle relaxation. Data were collected about hemodynamic parameters, vocal cords position, coughing or bucking, and involuntary movements. Three-hundred patients, males and females, ASA classes I and II, not premedicated, were included in the study; they all had to undergo surgery requiring tracheal intubation. The patients were divided in six different groups, and in each of them intubation was performed at different times from injection of inducing agents (2-2, 30-3-4-5-6 minutes). Overall results show a lack of satisfying intubating conditions on the extreme of selected times (2 and 5-6 minutes), with no significant difference between Thiopental and Propofol, except for a minimal unlike behaviour in hemodynamics. Therefore, on the basis of our data, as far as intubating conditions are considered, we can conclude that there is no reason to prefer one of the two inducing agents.

[Prevention of colonic ischemia during surgery of the aorta]. / Prevención de la isquemia colónica durante la cirugía de aorta.

The authors report the results of 53 revascularizations of the Inferior Mesenteric Artery, performed during 315 aortic reconstructive procedures, in 19 (35.85%) cases out of a group of 102 aortic aneurysms and 34 (74.15%) cases in a group of 213 aorto-iliac obstructive lesions. The "Carrel patch" technique was always used for the aneurysms of the aorta abdominal cases, whilst this technique was always adopted for only 21 obstructive patients; in the remaining 13 a personal technique was used and is here described. The long term results show a good patency rate (63.7%) for the reimplanted artery, planted artery, but above all no case of colonic ischemia in this group to compare with the 3 cases occurred in the no reimplanted group.

Effect of different intravenous nutrients on metabolic changes in short-term fasted man.

It is well documented (1-3) that a balanced use of nutritive solutions is important to maintain metabolic homeostasis and a better control of nutrient flux in fasting patients. In this trial, 10 healthy males, aged 30-50 years, fasted for 12 h, were subjected to intravenous nutrient loads in three separate trials. In the first trial they received only a fat emulsion, in the second fat emulsion and L-amino acid solution, and in the third fat emulsion, L-amino acid solution and glucose solution, 240 and 480 min after intravenous infusion plasma triglycerides, serum cholesterol, free fatty acids, lactate, glucose and plasma amino acids were determined. Significant biochemical changes were detected with regard to triglycerides, lactic acid, free fatty acids, alanine, glutamine, lysine and proline concentrations, depending on the different mixtures utilized.