Treatment of Nonmalignant Obstructive Iliocaval Lesions by Stent Placement: Mid-term Results

This report describes mid-term results of endovascular treatment of obstructive iliocaval lesions. Between November 1995 and December 1999, a total of 15 patients were treated by angioplasty and stent placement in the iliac vein. These patients were divided into two groups. Group I consisted of six patients with acute iliofemoral thrombosis of less than 10 days duration, with associated caval involvement in three cases. Angioplasty was performed after surgical thrombectomy, and creation of an arteriovenous fistula as a one-stage procedure in four cases and as a two-stage procedure in two cases. The underlying chronic lesion was stenosis of the left iliocaval junction (Cockett syndrome) in five cases and retroperitoneal fibrosis in one. Group II comprised nine patients with chronic symptomatic stenosis or occlusion. The etiology was Cockett syndrome in seven cases, post-thrombotic syndrome in three cases, including two associated with Cockett syndrome, and retroperitoneal fibrosis in one case. The mean number of stents per patient was 1.5. The mean duration of follow-up was 23.5 months. Evaluation of clinical outcome according to CEAP criteria for chronic syndromes showed significant improvement. Given good mid-term findings, venous angioplasty with stent placement appears to be a safe and effective technique for treatment of acute or chronic obstructive iliocaval lesions.     

Treatment of an early type II endoleak causing hemorrhage after endovascular aneurysm repair for ruptured abdominal aortic aneurysm

We report a case of ruptured abdominal aortic aneurysm emergently treated by endovascular aneurysm repair (EVAR) that developed a primary type II endoleak leading to persistent blood loss and retroperitoneal hematoma increase. Coil embolization resolved this. Although to our knowledge there are no recommendations regarding this, our report suggests that early type II endoleaks occurring after emergency EVAR for ruptured AAA should be treated when it is associated with blood extravasation outside the aneurysm sac.     

Surgical exclusion of a symptomatic circumflex coronary to right atrium fistula

Coronary artery fistulas are rare and half of them are symptomatic. Diagnosis is confirmed by echocardiography and coronarography and can be precisely located by multislice CT-scan. We report the case of a 56-year-old female patient with congestive heart failure caused by a coronaro-cardiac fistula established between the proximal circumflex coronary artery and the right atrium. Surgical exclusion of the fistula was achieved by ligation of both extremities and a running suture on the aneurysmal vessel. Follow-up at 6 months was satisfactory with an asymptomatic patient and absence of recurrence of the fistula on echocardiography.     

Challenges in accessing multidisciplinary pain treatment facilities in Canada

PURPOSE: The objective of this survey was to examine the services offered by multidisciplinary pain treatment facilities (MPTFs) across Canada and to compare access to care at these MPTFs. METHODS: A MPTF was defined as a clinic that advertised specialized multidisciplinary services for the diagnosis and management of patients with chronic pain, having a minimum of three different health care disciplines (including at least one medical speciality) available and integrated within the facility. The search method included approaching all hospital and rehabilitation centre administrators in Canada, the Insurance Bureau of Canada, the Workplace Safety and Insurance Board or similar body in each province. Designated investigators were responsible for confirming and supplementing MPTFs from the preliminary list for each province. Administrative leads at each eligible MPTF were asked to complete a detailed questionnaire regarding their MPTF infrastructure, clinical, research, teaching and administrative activities. RESULTS: Completed survey forms were received from 102 MPTFs (response rate 85%) with 80% concentrated in major cities, and none in Prince Edward Island and the Territories. The MPTFs offer a wide variety of treatments including non-pharmacological modalities such as interventional, physical and psychological therapy. The median wait time for a first appointment in public MPTFs is six months, which is approximately 12 times longer than non-public MPTFs. Eighteen pain fellowship programs exist in Canadian MPTFs and 64% engage in some form of research activities CONCLUSION: Canadian MPTFs are unable to meet clinical demands of patients suffering from chronic pain, both in terms of regional accessibility and reasonable wait time for patients' first appointment.     

Surgery for small-bowel neuroendocrine tumors: Is there any benefit of the laparoscopic approach?

Background

Surgery of small-bowel neuroendocrine (SBNE) tumors is demanding because of the need for associated extensive node dissection and assessment of possible synchronous lesions. For this reason, possible benefit of laparoscopy in SBNE tumors has not been reported to date.

Methods

From 1996, all patients operated on in Beaujon Hospital for SBNE tumors were retrospectively extracted from a prospectively maintained database of intestinal resections.

Results

Overall, 73 patients [55 % males, median age 55 years (range 27–79)] underwent small bowel resection (n = 38; 54 %), ileocolectomy (n = 25; 36 %), or both (n = 7; 10 %). In 18 patients, resection of synchronous liver metastasis was performed simultaneously. Resection was performed laparoscopically in 12 patients (16 %). Resection was R0 in 40 patients (55 %), R1 in 1 patient (1 %), and R2 in 32 patients (44 %) because of unresectable liver metastases (n = 29), nodal involvement (n = 1), or both (n = 2). Laparoscopy was associated with similar R0 (p = 0.06) and morbidity (p = 0.95) rates, but a shorter hospital stay (p = 0.003) compared with laparotomy. Median follow-up was 39 months. Progression-free survival (PFS) at 1, 3, and 5 years were 95, 83 and 75 %, respectively, for R0 patients without liver metastasis; 92, 83, and 57 %, respectively, for R0 patients with resected liver metastasis; and 82, 58 and 30 %, respectively, for R2 patients (p = 0.045). Overall survival and PFS did not show any difference when comparing the laparoscopic and open groups.

Conclusion

Complete resection of primary SBNE tumors with or without liver metastasis is associated with good long-term survival. In selected patients, laparoscopy for SBNE tumors is feasible and associated with a shorter hospital stay than laparotomy.     

Prospective Evaluation of an Extended 21-Core Biopsy Scheme as Initial Prostate Cancer Diagnostic Strategy

Background

The debate on the optimal number of prostate biopsy core samples that should be taken as an initial strategy is open.

Objective

To prospectively evaluate the diagnostic yield of a 21-core biopsy protocol as an initial strategy for prostate cancer (PCa) detection.

Design, setting, and participants

During 10 yr, 2753 consecutive patients underwent a 21-core biopsy scheme for their first set of biopsy specimens.

Intervention

All patients underwent a standardized 21-core protocol with cores mapped for location.

Outcome measurements and statistical analysis

The PCa detection rate of each biopsy scheme (6, 12, or 21 cores) was compared using a McNemar test. Predictive factors of the diagnostic yield achieved by a 21-core scheme were studied using logistic regression analyses.

Results and limitations

PCa detection rates using 6 sextant biopsies, 12 cores, and 21 cores were 32.5%, 40.4%, and 43.3%, respectively. The 12-core procedure improved the cancer detection rate by 19.4% (p = 0.004), and the 21-biopsy scheme improved the rate by 6.7% overall (p < 0.001). The six far lateral cores were the most efficient in terms of detection rate. The diagnostic yield of the 21-core protocol was >10% in prostates with volume >70 ml, in men with a prostate-specific antigen level < 4 ng/ml, with a prostate-specific antigen density (PSAD) <0.20 ng/ml per gram. A PSAD <0.20 ng/ml per gram was the strongest independent predictive factor of the diagnostic yield offered by the 21-core scheme (p < 0.001). The 21-core protocol significantly increased the rate of PCa eligible for active surveillance (62.5% vs 48.4%; p = 0.036) than those detected by a 12-core scheme without statistically increasing the rate of insignificant PCa (p = 0.503).

Conclusions

A 21-core biopsy scheme improves significantly the PCa detection rate compared with a 12-core protocol. We identified a cut-off PSAD (0.20 ng/ml per gram) below which an extended 21-core scheme might be systematically proposed to significantly improve the overall detection rate without increasing the rate of detected insignificant PCa.     

Effect of body mass index on the outcomes of patients with upper and lower urinary tract cancers treated by radical surgery: Results from a Canadian multicenter collaboration

ObjectiveTo evaluate the effect of body mass index (BMI) on the outcomes of patients with urinary tract carcinoma treated with radical surgery.Materials and methodsData were collected from 10 Canadian centers on patients who underwent radical cystectomy (RC) (1998–2008) or radical nephroureterectomy (RNU) (1990–2010). Various parameters among subsets of patients (BMI<25, 25≤BMI<30, and BMI≥30 kg/m²) were analyzed. Kaplan-Meier and multivariate analyses were performed to assess the effect of BMI on overall survival, disease-specific survival, and recurrence-free survival (RFS).ResultsAmong the 847 RC and 664 RNU patients, there was no difference in histology, stage, grade, and margin status among the 3 patient subsets undergoing either surgery. However, RC patients with lower BMIs (<25 kg/m²) were significantly older (P = 0.004), had more nodal metastasis (P = 0.03), and trended toward higher stage (P = 0.052). RNU patients with lower BMIs (<25 kg/m²) were significantly older (P = 0.0004) and fewer received adjuvant chemotherapy (P = 0.04) compared with those with BMI≥30 kg/m²; however, there was no difference in tumor location (P = 0.20), stage (P = 0.48), and management of distal ureter among the groups (P = 0.30). On multivariate analysis, BMI was not prognostic for overall survival, disease-specific survival, and RFS in the RC group. However, BMI≥30 kg/m² was associated with more bladder cancer recurrences and worse RFS in the RNU group (HR = 1.588; 95% CI: 1.148–2.196; P = 0.0052).ConclusionsIncreased BMI did not influence survival among RC patients. BMI≥30 kg/m² is associated with worse bladder cancer recurrences among RNU patients; whether this is related to difficulty in obtaining adequate bladder cuff in patients with obesity requires further evaluation.     

Neoadjuvant Chemotherapy with Bevacizumab May Improve Outcome after Cytoreduction and Hyperthermic Intraperitoneal Chemoperfusion (HIPEC) for Colorectal Carcinomatosis

Background

In selected patients with colorectal peritoneal carcinomatosis (PC), cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemoperfusion (HIPEC) may improve survival. We aimed to assess whether neoadjuvant chemotherapy with or without bevacizumab is indicated in this patient population.

Methods

Colorectal PC patients were treated with CRS and HIPEC using oxaliplatin (200–460 mg/m²) or mitomycin C (35 mg/m²). Postoperative outcome and long-term survival were prospectively recorded. The impact of clinical variables on overall survival (OS) was assessed using univariate and Cox multivariate analysis.

Results

Between October 2002 and May 2012, 166 patients were treated with CRS and HIPEC. Neoadjuvant chemotherapy alone was administered to 21 % and neoadjuvant chemotherapy with bevacizumab to 16 % of patients. Postoperative mortality and major morbidity were 2.4 and 35 %, respectively. Half of the patients received adjuvant chemotherapy. After a median follow-up of 18 months, OS was 27 months (95 % confidence interval 20.8–33.2). On univariate analysis, OS was associated with extent of disease (P < 0.001), neoadjuvant chemotherapy with bevacizumab (P = 0.021), completeness of cytoreduction (CC) (P < 0.001), and adjuvant chemotherapy (P = 0.04), but not with primary disease site, synchronous presentation, or chemoperfusion drug. In multivariate Cox regression, independent predictors of OS were CC (hazard ratio 0.29, P < 0.001) and neoadjuvant therapy containing bevacizumab (hazard ratio 0.31, P = 0.019).

Conclusions

Long-term OS after CRS and HIPEC for colorectal cancer is associated with CC and neoadjuvant therapy containing bevacizumab. This regimen merits prospective study in patients with resectable PC of colorectal origin.     

Perioperative cardiorespiratory complications in adults with mediastinal mass: incidence and risk factors

BACKGROUND: Patients with a mediastinal mass are at risk for cardiorespiratory complications in the perioperative period. The authors' objectives were to evaluate the incidence of life-threatening intraoperative cardiorespiratory and postoperative respiratory complications in adult patients and to study the usefulness of clinical signs and symptoms, radiologic evaluation, and pulmonary function tests in the determination of the perioperative risk. METHODS: The authors reviewed the investigation and treatment of adult patients presenting with anterior or middle mediastinal masses for surgery under anesthesia between January 1994 and July 2000. RESULTS: Ninety-eight patients underwent 105 anesthetic cases. The incidences of intraoperative cardiorespiratory and postoperative respiratory complications were 4 in 105 and 11 in 105, respectively. No collapse of the airways occurred during anesthesia. However, a high incidence of early postoperative life-threatening respiratory complications was observed (7 in 105). In a multivariate logistic regression analysis model, perioperative complications were predicted by the occurrence of cardiorespiratory signs and symptoms at the initial presentation (odds ratio [OR], 6.2) and the presence of combined obstructive and restrictive patterns (mixed pulmonary syndrome) on pulmonary function tests (OR, 3.9). Intraoperative complications were associated with pericardial effusion on computed tomography scan (OR, 19.8). Postoperative respiratory complications were related to tracheal compression of more than 50% on preoperative computed tomography scan evaluation (OR, 7.4) and mixed pulmonary syndrome on pulmonary function tests (OR, 15.1). CONCLUSION: Obstruction of the airway in an adult with a mediastinal mass is a rare event in the intraoperative period. Nevertheless, caution should be observed for the occurrence of early postoperative life-threatening respiratory complications. Patient at high risk of perioperative complications can be identified by the occurrence of cardiopulmonary signs and symptoms at presentation, combined obstructive and restrictive pattern on pulmonary function tests, and computed tomography scan findings (tracheal compression > 50%, pericardial effusion, or both).     

Natural history of parathyroid function and calcium metabolism after kidney transplantation: a single-centre study.

BACKGROUND: The natural history of parathyroid function after successful renal transplantation (RT) and the factors predisposing to persistent hyperparathyroidism (HPT) are not well established. A better knowledge of these data may be helpful in the development of algorithms for optimal surveillance and treatment of HPT after successful RT. Our aim was to evaluate the post-transplant natural history of parathyroid function and calcium metabolism in patients with a functional renal graft and to identify risk factors for persistent HPT. METHODS: Charts of 1165 allograft kidney recipients transplanted between 1989 and 2000 were reviewed. Patients with an intact parathyroid hormone (iPTH) level available at the time of transplantation were identified. The charts of the latter patients were checked for a variety of demographic and clinical data, and all determinations of the iPTH concentration available since transplantation were recorded. Serum levels of calcium, phosphorus, alkaline phosphatases and creatinine, concurrently determined, were also registered. RESULTS: After an initial fall, iPTH levels showed a slow but steady decline towards the upper normal limit. The prevalence of persistent HPT, defined as an iPTH level > or =2.5 times the upper normal limit or the need for parathyroidectomy following transplantation, remained stable at approximately 17% up to 4 years after transplantation. Patients with persistent HPT had significantly elevated serum levels of iPTH, calcium and phosphorus at the time of RT, and had spent a longer time on dialysis. Post-transplant iPTH levels correlated significantly with transplant kidney function. CONCLUSION: Kidney transplant recipients with a high iPTH and calcium x phosphate product at the time of transplantation are at risk for persistent HPT especially when renal function is suboptimal. Therapy for persistent HPT, if considered, should be initiated 3 months post-transplantation since further spontaneous improvement of parathyroid function thereafter is limited.