Worsening of chronic pain: the treatment

Chronic pain is a symptom that inevitably goes along with a condition of critical ischemia of the lower limbs, termed also as "obstructive peripheral arteriopathy". This sometimes displays worsening, provoking difficult physical and psychological behaviors of the patients. The complexity of this kind of patients results in difficulties in their clinical management. A multidisciplinary team, namely the close and coordinated collaboration of various kinds of professionists, could give better results, than an individual approach, thanks to strategies of re-equilibrating the systemic homeostasis of the given patient.     

Psychological aspects of pain

The patients affected by critical limb ischemia (CLI) are patients generally considered difficult cases, destined to repeated approach to the sanitary structures. They are patients affected by many pathologies since years, that they know to be potentially lethal often have already faced many interventions, with partial and not long-lasting benefits, they go from one specialist to another and sometimes they entrust themselves to alternative medicine. Physicians have to take in charge not the pathology but to take in charge the patient. For the control of the pain it turns out essential, near the block of the perception of the pain, to act with psychological participation, in order to interfere with the perception of the pain and the meant one of the pain, modify the feelings associated to the pain, modify the behavior induced by pain.     

Hepatic artery aneurysm treatment with heparin-bonded covered stent: a case report

The hepatic artery is the second most common site for aneurysms formation within the splanchnic circulation. Most hepatic artery aneurysms (HAA) are diagnosed incidentally by a computed tomography(CT) scan or a Doppler ultrasonography. We present the case of a HAA diagnosed preoperatively in a 82-year old man, who was treated with an endovascular procedure. An abdominal ultrasonography revealed by chance the presence of a HAA. The abdominal CT scan confirmed an aneurysm of the common hepatic artery, specifically at the origin of the gastroduodenal artery. The gastroduodenal artery was embolized using coils then a heparin-bonded covered stent was deployed into the common hepatic artery to exclude the aneurysm. Final arteriogram documented the regular patency of the stent and the complete exclusion of the aneurysm. No complication occurred and the patient was discharged on the second postoperative day. Six months later, a follow-up with a Duplex scan confirmed the regular patency of the stent, and the patient was in good clinical conditions.     

Endovascular Treatment of Ruptured Abdominal Aortic Aneurysms: Is Now EVAR the First Choice of Treatment?

Objective

This study was designed to evaluate the effectiveness of endovascular treatment (EVAR) for ruptured abdominal aortic aneurysms (rAAAs).

Methods

Between September 2005 and December 2012, 44 patients with rAAA suitable for endovascular repair underwent emergency EVAR. We did not consider hemodynamic instability to be a contraindication for EVAR.

Results

Successful stent-graft deployment was achieved in 42 patients, whereas 2 required open surgical conversion. The overall 30-day mortality was 10 of 44 patients (5/34 in stable patients, 5/10 in unstable patients). Postoperative complications were observed in 7 of 44 patients (16 %): 5 patients developed abdominal compartment syndrome requiring decompressive laparotomy; 1 patient developed bowel ischemia; 1 patient had limb ischemia, and 1 had hemodynamic shock. Mean length of intensive care unit stay was 2.9 (range 2–8) days, and mean length of hospital stay was 8.6 (range 0–18) days. At a mean follow-up of 22.2 (range 1–84) months, the overall incidence of endoleak was 23.5 %: 1 type I and 7 type II endoleaks.

Conclusions

Our study demonstrates that EVAR of rAAA is associated with acceptable mortality and morbidity rates in dedicated centers.     

Mismatch repair,p53 and beta-catenin proteins in colorectal cancer

BACKGROUND: Mismatch repair (MMR) proteins (MSH2 and MLH1) deficiency is responsible for microsatellite instability (MSI) status. We evaluated p53 and beta-catenin expressions in colorectal cancer specimens with known microsatellite status, previously assessed by means of the polymerase chain reaction (PCR). We also analyzed the MMR proteins immunostaining and compared the results with those ascertained by PCR. MATERIALS AND METHODS: Twenty-five colorectal cancer patients were analyzed for immunohistochemical expression of p53, beta-catenin, MSH2 and MLH1 proteins. RESULTS: The microsatellite status was only significantly correlated with p53 expression and MRR proteins pattern. CONCLUSION: We demonstrated a significantly higher p53 expression in MSI colorectal specimens. The concordance rate between immunohistochemistry and PCR was so high (80%) that the immunohistochemical technique can be proposed as a method to select MSI patients for improved outcome and response to chemotherapy.     

The use of comprehensive complication Index® in pancreatic surgery: a comparison with the Clavien-Dindo system in a high volume center

BackgroundThe Clavien-Dindo classification (CDC) system and Comprehensive Complication Index (CCI®) are both widely used methods for reporting the burden of postoperative complications. This study aimed to compare the accuracy of the CDC and CCI® in predicting outcomes associated with pancreatic surgery.MethodsThe CCI® and CDC were applied to 668 patients who underwent pancreatic resection. Length of postoperative stay (LOS) was chosen as the primary outcome variable. The comparison between CCI® and CDC was made with the Spearman test, reporting þs with standard error (SE) and logistic regression, reporting the Odds Ratio (OR) and Area Under the Curve with SE.ResultsThe median value with the interquartile range (IQR) of CCI® was 20.9 (0–29.6). Both CCI® (þs = 0.609) and CDC (0.590) were significantly (P < 0.001) correlated to LOS. CCI (OR 1.056 and OR 1.052) and CDC (OR 1.978, and OR 1.994) predicted (P < 0.001) LOS over the median and 75th percentile. The accuracy of CCI® was superior to CDC for LOS over 50th (0.785 vs. 0.740; P = 0.004) and over 75th (0.835 vs. 0.761; P < 0.001) percentile.ConclusionThe accuracy of CCI® in measuring the complicated postoperative course was superior to CDC, correctly classifying eight patients every ten tested.     

Peripancreatic paraganglioma: Lesson from a round table

We described the case of a peripancreatic paraganglioma (PGL) misdiagnosed as pancreatic lesion. Surgical exploration revealed an unremarkable pancreas and a large well-defined cystic mass originating at the mesocolon root. Radical enucleation of the mass was performed, preserving the pancreatic tail. Histologically, a diagnosis of PGL was rendered. Interestingly, two previously unreported mutations, one affecting the KDR gene in exon 7 and another on the JAK3 gene in exon 4 were detected. Both mutations are known to be pathogenetic. Imaging and cytologic findings were blindly reviewed by an expert panel of clinicians, radiologists, and pathologists to identify possible causes of the misdiagnosis. The major issue was lack of evidence of a cleavage plane from the pancreas at imaging, which prompted radiologists to establish an intra-parenchymal origin. The blinded revision shifted the diagnosis towards an extra-pancreatic lesion, as the pancreatic parenchyma showed no structural alterations and no dislocation of the Wirsung duct. Ex post, the identified biases were the emergency setting of the radiologic examination and the very thin mesocolon sheet, which hindered clear definition of the lesion borders. Original endoscopic ultrasonography diagnosis was confirmed, emphasizing the intrinsic limit of this technique in detecting large masses. Finally, pathologic review favored a diagnosis of PGL due to the morphological features and immonohistochemical profile. Eighteen months after tumor excision, the patient is asymptomatic with no disease relapse evident by either radiology or laboratory tests. Our report strongly highlights the difficulties in rendering an accurate pre-operative diagnosis of PGL.