BACKGROUND:The aim of this case-control study was to determine whether preoperative duplex imaging could predict the outcome of varicose vein surgery without saphenofemoral junction (SFJ) disconnection. The duplex protocol included a reflux elimination test (RET) and assessment of the competence of the terminal valve of the femoral vein.METHODS:One hundred patients with chronic venous disease who had a positive RET result and an incompetent terminal valve were compared with 100 patients matched for age, sex, clinical class (Clinical Etiologic Anatomic Pathophysiologic (CEAP) class C2-C6) and disease duration, but who had a positive RET result and a competent terminal valve. All patients underwent ligation and proximal avulsion of the incompetent tributaries from the great saphenous vein trunk without SFJ disconnection. Clinical and duplex follow-up lasted for 3 years, and included Hobbs' clinical score.RESULTS:Of legs with a competent terminal valve, 100 per cent were rated as cured (Hobbs' class A or B) and 14.0 per cent developed recurrent varices. Patients with an incompetent terminal valve had significantly worse results: 29.0 per cent had Hobbs' class A or B and 82.0 per cent developed recurrence (P < 0.001).CONCLUSION:Preoperative duplex assessment of the terminal valve could be used to identify patients suitable for varicose vein surgery without the need for SFJ disconnection.

Primary sciatic nerve varices (SNV) lie within the sciatic nerve possibly causing chronic venous disease and sciatic pain as well. We report a series of 12 consecutive patients affected by symptomatic SNV. All of them were treated by echo-guided Tessari foam sclerotherapy (EGFSCL). Mean follow up lasted two years. Reflux through the sciatic veins, as the connected superficial varicose veins, disappeared in the entire cohort and only minor complications have emerged. EGFSCL seems to be both safe and effective, so representing a reliable and minimally invasive treatment.

Restricted accessAbstractFirst published online September 18, 2009Tenth Meeting of the European Venous Forum: Copenhagen, Denmark, 5–7 June 2009Volume 24, Issue 5https://doi.org/10.1258/phleb.2009.09a003

Objectives. To compare the long-term results of stripping vs. haemodynamic correction (Ambulatory Conservative Haemodynamic Management of Varicose Veins, CHIVA) in the treatment of superficial venous incompetence resulting in chronic venous disease (CVD).Design. Randomised comparative trial.Patients. 150 patients affected by CVD, CEAP clinical class 2-6, were randomised to saphenous stripping or to CHIVA.Methods. The clinical outcome was assessed by an independent observer who recorded the Hobbs clinical score for treated limbs. A subjective report of the outcome was provided by the patients. Recurrence of varices was assessed by both clinical examination and duplex ultrasonography.Results. The mean follow-up was 10 years, 26 patients were lost to follow-up. The Hobbs score similar in the stripping and CHIVA groups. However recurrence of varicose veins was significantly higher in the stripping group (CHIVA 18%; stripping 35%, P < 0.04 Fisher's exact test), without significant differences in the rate of recurrences from the sapheno-femoral junction. The associated risk of recurrence at ten years was doubled in the stripping group (OR 2.2, 95% CI 1-5, P = 0.04).Conclusions. Recurrent varices occurred more frequently following saphenous stripping than after CHIVA treatment. The deliberate preservation of the saphenous trunk as a route of venous drainage in the CHIVA group may have been a factor reducing the recurrence rate. (c) 2007 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

Chronic venous disease (CVD), mainly due to venous reflux or, sometimes, to venous outflow obstruction, produces a microcirculatory overload leading to the impairment of venous drainage. Venous drainage depends primarily on a major hemodynamic parameter called trans-mural pressure (TMP). TMP is increased in patients affected by CVD, leading to impaired tissue drainage, and, consequently, facilitating the beginning of the inflammatory cascade. Increased TMP determines red blood cell extravasation and either dermal hemosiderin deposits or iron laden-phagocytes. Iron deposits are readily visible in the legs of all patients affected by severe CVD. Local iron overload could generate free radicals or activate a proteolytic hyperactivity of metalloproteinases (MMPs) and/or downregulate tissue inhibitors of MMPs. These negative effects are particularly evident in carriers of the common HFE gene's mutations C282Y and H63D, because intracellular iron deposits of mutated macrophages have less stability than those of the wild type, inducing a significant oxidative stress. It has been demonstrated that such genetic variants increase the risk of ulcers and advance the age of ulcer onset, respectively. The iron-dependent vision of inflammation in CVD paves the way to new therapeutic strategies including the deliberate induction of iron deficiency as a treatment modality for non-healing and/or recurrent venous leg ulcers. The inflammatory cascade in CVD shares several aspects with that activated in the course of multiple sclerosis, an inflammatory and neurodegenerative disease of unknown origin in which the impairment of cerebral venous outflow mechanisms has been recently demonstrated.

AIMS:Lymph node metastases for papillary thyroid carcinoma are associated with an increased incidence of locoregional recurrence. The use of preoperative lymphoscintigraphy and intraoperative gamma probe detection to localize the sentinel lymph node in papillary thyroid carcinoma was investigated. METHODS:From February 2004 to December 2005 the sentinel lymph node technique was studied in 64 consecutive patients with cytological evidence of papillary thyroid carcinoma. The day before surgery, patients were submitted to US-guided peri-tumoural injection of the radiotracer and a lymphoscintigraphy was performed. In the operating room a total thyroidectomy was done, and thanks to a hand-held gamma probe the sentinel lymph node and all lymph nodes, belonging to the sentinel node compartment, were removed. RESULTS:The gamma probe identified the sentinel lymph node in 62 patients (96.8%). We found 48 (77.5%) sentinel lymph node without metastases; 12 (19.3%) with metastases and 2 (3.2%) with micrometastases. In 7 cases (11.3%), with a negative sentinel lymph node, metastases in other nodes of the same region were recorded. In 22 cases (34.3%) the ultrasound give an erroneous indication (P=0.004). Five patients (8.0%), 4 with multifocal cancer, had a positive postoperative lymphoscintigraphy. CONCLUSION:This study shows that the sentinel lymph node technique for papillary thyroid carcinoma is feasible, repeatable, and more accurate than preoperative ultrasound. In cases of multifocal thyroid lesions more patients should be enrolled to establish the utility of the radio-guided technique.

Background and aims The province of Ferrara has one of the highest incidences of colorectal cancer (CRC) in Italy. In January 2000, we set up a colonoscopy screening program focussing on first-degree relatives of CRC patients. We now report the results 5 years after the beginning of the project. Screenees and methods In October 1999, we started a campaign stressing the usefulness of colonoscopy for the first-degree relatives of CRC patients. Subjects included in the screening program were aged between 45 and 75 years with at least one first-degree relative affected by CRC. They were invited to an interview where a physician suggested colonoscopy as a screening option. Results In 5 years, 776 subjects were interviewed and 733 (94.4%) agreed to an endoscopic examination (M/F:375/401; mean age 55 years): 562 colonoscopies were performed. Adenomas and cancers were found in 122 (21.7%) and 12 (2.1%) subjects, respectively. Histological examination in 181 persons with lesions (32.8%) showed (most serious lesion quoted) 47 hyperplastic polyps (26% of all lesions), 2 serrated adenomas (1.1%), 68 tubular adenomas (48%), 24 tubulovillous adenomas (13.3%), 9 adenomas with high grade dysplasia (5%) and 12 adenocarcinomas (6.6%). The majority of the cancers were at an early stage (8 Dukes A and 3 Dukes B). Sedation was used in only 42 colonoscopies (7.5%). Conclusions A colonoscopy-based screening in this selected high-risk population is feasible. Even without sedation subjects readily agreed to the endoscopic procedure. We identified a significant number of advanced neoplasms and cancers at an early stage suggesting that this could be a useful tool in early identification of CRC.

No ideal localization technique is available; thus, the choice still depends on surgeon's preference and local availability of both specialists and instruments.

Preoperative dexamethasone may reduce disabling symptoms such as pain, nausea and vomiting after laparoscopic cholecystectomy.

uneventful and the patient was discharged home 5 days after the operation, symptom-free, and tolerated a soft diet. Six months postoperatively she had no symptoms, ate without restrictions, had gained 8 kg, and showed a normal-sized oesophagus with regular emptying on barium swallow ( fi g. 1 C). At the 6-year follow-up, the patient was free of symptoms and had gained 19 kg of weight. Specifi cally, she had no dysphagia, regurgitation, heartburn or cough; a new barium swallow showed a normalsized oesophagus with tertiary contractions and a 2-cm epiphrenic diverticulum ( fi g. 1 D). Long-term results of laparoscopic treatment for oesophageal achalasia with epiphrenic diverticulum are reported in a 75-year-old woman presenting with a 10-year history of dysphagia, regurgitation, cough, and a 10-kg weight loss. Preoperative barium swallow showed a dilated sigmoid oesophagus with a 6-cm enlarging epiphrenic diverticulum ( fi g. 1 A, B). Endoscopic biopsies were negative for cancer and oesophageal manometry showed no peristalsis. Laparoscopic diverticulectomy and a 7-cm distal oesophageal myotomy with Dor fundoplication were performed. The postoperative course was Published online: April 20, 2006

Background: Several techniques for localizing pulmonary nodules have been described, but the advantages and disadvantages of each method remain unclear. We reviewed ultrasound, endofinger, finger palpation and wait and watch, radioguided, vital dye, fluoroscopic, agar marking, and needle wire methods for localizing pulmonary nodules.Methods: Original, peer-reviewed, and full-length articles in English were searched with PubMed and ISI Web of Sciences. Case reports and case series with less than 10 patients were excluded.Results: All localization techniques showed good reliability, but some carry a high rate of major or minor complications and drawbacks.Conclusion: No ideal localization technique is available; thus, the choice still depends on surgeon's preference and local availability of both specialists and instruments.

Background. Our aim was to evaluate the best intrathoracoscopic localization technique in patients with single pulmonary nodule and a history of malignancy.Methods. We divided 50 patients in two groups, well matched for diameter and depth of the pulmonary lesion. In 25 patients we performed intrathoracoscopic ultrasound to locate the pulmonary nodule (group A), whereas in the other 25 patients the radio-guided technique was adopted (group B). In both group A and group B, the localization techniques were compared with finger palpation. In group A, 12 nodules were in the left lung and 13 in the right one; in group B, 11 lesions were in the left and 14 in the right lung. In both groups, the distance of the nodule from the pleural surface was 2.6 +/- 0.5 cm (2 to 2.5 cm in 14 patients, and >2.5 cm for the remaining 11). The diameter of the nodule was 1.26 +/- 0.22 (<= 1 cm in 10 patients, and 1 to 1.5 cm in 15) in both groups. All patients underwent thoracoscopic wedge resection, and 10 patients with a primary pulmonary lesion underwent posterior-lateral thoracotomy for lobectomy and mediastinal lymphadenectomy.Results. In group A, ultrasound localized the nodule in 24 of 25 patients (96%) whereas finger palpation localized it in 19 of 25 (76%; not significant). In group B, both the radio-guided and finger palpation techniques localized the nodule in 20 of 25 patients (80%; not significant). No complications were recorded with the ultrasound technique; however, 10 cases of pneumothorax were detected after the radio-guided technique (p < 0.01).Conclusions. Both the ultrasound and radio-guided techniques are accurate to detect solitary pulmonary nodules, but the radio-guided method yields complications as compared with the ultrasound.

We would like to congratulate Janssen-Heijnen et al 1 on their well performed study and on their significant contribution to resolving the problem of treatment in patients with non-small cell lung cancer (NSCLC) and co-morbidity. However, we could not find a description of the surgical approach used and would like to ask the authors to provide details of the surgical procedures adopted and the accompanying survival rates. We think,2 in agreement with other authors3 that, for patients with early stage NSCLC and co-morbidity, a less invasive surgical approach should be used. This view is supported by studies in elderly patients or in patients with co-morbidity showing that a less invasive approach does not influence survival rates. Only the recurrence …

We would like to comment on the article by Daniel and associates [1Daniel T.M. Altes T.A. Rehm P.K. et al.A novel technique for localization and excisional biopsy of small or ill-defined pulmonary lesions.Ann Thorac Surg. 2004; 77: 1756-1762Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar]. We congratulate the authors on the well-conducted study, with experimental studies followed by human application. Most notably, it seems that the authors have solved the problem [2Chella A. Lucchi M. Ambrogi M.C. et al.A pilot study of the role of TC-99 radionuclide in localization of pulmonary nodular lesions for thoracoscopic resection.Eur J Cardiothorac Surg. 2000; 18: 17-21Crossref PubMed Scopus (130) Google Scholar, 3Sortini D. Feo C.V. Carrella G. et al.Thoracoscopic localization’s techniques for patients with single pulmonary nodule and positive oncological anamnesis. A prospective study.J Laparoendosc Adv A. 2003; 13: 371-375Crossref PubMed Scopus (5) Google Scholar] with the use of a radio-guided technique to locate pulmonary nodules. However, we have some questions and remarks. We agree that macroaggregated albumin does not spread into perinodular lung parenchyma, and localizes radioactivity, which is an advantage compared with other tracers. Regarding surgical technique and histopathology, did Daniel and associates search for the sentinel node or did they only use the radio-guided technique to locate the pulmonary nodule? We think that the main advantage of the radio-guided technique is to locate a sentinel node in patients with very small pulmonary nodules or to guide lymphoadenectomy, to detect N2 lung cancer [4Choi Y.S. Shim Y.M. Kim J. Kim K. Mediastinoscopy in patients with clinical stage I non-small cell lung cancer.Ann Thorac Surg. 2003; 75: 364-366Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar]. Did the authors see hematoma intraoperatively, or in the specimen after injection of macroaggregated albumin [3Sortini D. Feo C.V. Carrella G. et al.Thoracoscopic localization’s techniques for patients with single pulmonary nodule and positive oncological anamnesis. A prospective study.J Laparoendosc Adv A. 2003; 13: 371-375Crossref PubMed Scopus (5) Google Scholar]? The majority of the pulmonary nodules described in the article were close to the pleural surface, and we wonder whether any preoperative localization technique was needed [5Susuky K. Nagai K. Yoshida J. et al.Video-assisted thoracoscopic surgery for small indeterminate pulmonary nodules indication for preoperative marking.Chest. 1999; 115: 563-568Crossref PubMed Scopus (356) Google Scholar]. In fact, 8 of 13 nodules (61%) were within 1 cm of the pleural surface. Preoperative localization should not be necessary, because complete deflation of the lung would allow localization. The authors also report a nodule deeper than 4 cm; in our opinion, this patient should have had a lobectomy because wedge resection removes considerable parenchyma. In our opinion, intrathoracoscopic ultrasonography can locate pulmonary nodules not seen by chest computed tomography and offers several advantages over other preoperative localization techniques. Ultrasonography is simple and quick, and is the only technique without side effects or complications [3Sortini D. Feo C.V. Carrella G. et al.Thoracoscopic localization’s techniques for patients with single pulmonary nodule and positive oncological anamnesis. A prospective study.J Laparoendosc Adv A. 2003; 13: 371-375Crossref PubMed Scopus (5) Google Scholar]. Lastly, we would like to know the authors’ opinion about the ultrasound rotary probe. In our experience, missed localizations were limited to posterior and deep nodules, owing to the size and rigidity of the ultrasound probe. Therefore, we think that a rotary probe could be of help [3Sortini D. Feo C.V. Carrella G. et al.Thoracoscopic localization’s techniques for patients with single pulmonary nodule and positive oncological anamnesis. A prospective study.J Laparoendosc Adv A. 2003; 13: 371-375Crossref PubMed Scopus (5) Google Scholar]. ReplyThe Annals of Thoracic SurgeryVol. 79Issue 6PreviewWe enjoyed the comments by Dr Sortini and associates regarding our technique and experience with radiotracer lung nodule localization and excisional biopsy. Full-Text PDF

OBJECTIVE:Chronic venous disease (CVD) is the most common vascular disorder, progressing in approximately 10% of cases toward chronic venous leg ulceration, whereas the hemochromatosis gene (HFE) C282Y mutation is the most common recognized genetic defect in iron metabolism. Because CVD leads to local iron overload in the affected legs, we investigated whether two common HFE mutations could increase the risk of chronic venous leg ulceration.METHODS:This was a case-control study at the Vascular Diseases Center, University of Ferrara, Italy. From a cohort of 980 consecutive patients affected by severe CVD (CEAP clinical classes C4 to C6) we selected 238 cases with the exclusion of any other comorbidity factor potentially involved in wound etiology (group A). They were subdivided into group B, including 137 patients with ulcer (classes C5 and C6: 98 primary and 39 postthrombotic cases), and group C, including 101 cases with no skin lesions (class C4). They were completely matched for sex, age, and geographic origin with 280 healthy controls (group D). A total of 518 subjects were polymerase chain reaction genotyped for HFE mutations (C282Y and H63D). We assessed the risk of ulceration by comparing the prevalence of ulcer in homogenous cases with and without the HFE variants. Other main outcome measures were the sensitivity, specificity, and predictive values of the genetic test in CVD cases.RESULTS:C282Y mutation significantly increases the risk of ulcer in primary CVD by almost seven times (odds ratio, 6.69; 95% confidence interval, 1.45-30.8; P = .01). Application of the HFE test in primary CVD demonstrated increased specificity and positive predictive values (98% and 86%, respectively), with negligible sensitivity and negative predictive values.CONCLUSIONS:The overlap of primary CVD and the C282Y mutation consistently increases the risk of developing venous leg ulceration. These data, which have been confirmed in other clinical settings, suggest new strategies for preventing and treating primary CVD.CLINICAL RELEVANCE:The number of patients affected by primary CVD is so great that the vast majority of ulcers are also related to this common problem. On the other hand, there is not a reliable way for identifying in advance, from the broad base of primary CVD patients (20-40% of the general population), the high risk minority (10% of primary CVD cases) who will develop a venous ulcer. In such cases, a simple C282Y blood genetic test demonstrated an elevated specificity in predicting ulcer development (98%, CI 95%, 92.8-99.7). The genetic test could be applied starting from the C2 class, varicose veins, the most common situation observed in clinical practice. In perspective, the presence of the C282Y mutation would strengthen the indications and priorities for surgical correction of superficial venous insufficiency.