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Pisano U, Stevenson K, Kasthuri R, Kingsmore D. Cephalic arch stenosis: an analysis of outcome by type of first intervention. CVIR Endovasc 2024; 7:13. [PMID: 38240913 PMCID: PMC10798936 DOI: 10.1186/s42155-023-00424-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Accepted: 12/21/2023] [Indexed: 01/22/2024] Open
Abstract
BACKGROUND Cephalic arch stenoses (CAS) occur in near 70% of elbow arteriovenous fistulas. Percutaneous transluminal angioplasty (PTA) remains first-line treatment despite documented stent-grafts (SG) efficacy. The study aim is to report long-term outcomes based on initial treatment of CAS. METHODS Retrospective review of 12-year data in single tertiary centre. Outcomes included technical success, rupture rate, primary patency (PP), dialysis performance; categorical variables assessed via χ2 or Fisher's; nonparametric tests used for skewed data. Kaplan-Meier analysis used for PP and cumulative patency. Cox proportional hazard regression model to assess explanatory variables in PP. RESULTS One hundred one brachio- and radiocephalic fistulas with CAS were included. SG as first intervention had higher success than PTA (85% vs 61%, p = 0.003). Rupture occurred in 9/85 (10.6%) PTA vs 0% in SG (p = 0.046). In a subgroup with poor urea reduction rate (URR), both PTA and SG improved dialysis performance post-intervention (p = 0.002). SG demonstrated better PP than PTA (79,73,60% patency at 3, 6, 9 months; versus 71,51,47%; p = 0.195) and cumulative patency (73,61,61% at 1, 2, 3 years; versus 60,34,26%; p < 0.001). Of the variables analyzed, technical success of PTA was the only discriminating factor (coeff.-1.01; RR 35%, p = 0.035). Accesses that underwent secondary stenting performed better than primarily stented CAS (p = 0.01). CONCLUSIONS SG superiority is confirmed in CAS, particularly when angioplasty is unsuccessful. While PTA has short-lived benefits, it can improve dialysis performance. Other than higher success rate, primary CAS stenting did not have advantages compared to post-PTA stenting in our study. Other factors related to inflow, outflow, conduit characteristics are presumed to be involved in access longevity.
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Affiliation(s)
- Umberto Pisano
- Radiology Department, Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde, 1345 Govan Road, Glasgow, G51 4TF, UK.
| | - Karen Stevenson
- Renal Transplant Surgery, Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde, 1345 Govan Road, Glasgow, G51 4TF, UK
| | - Ram Kasthuri
- Radiology Department, Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde, 1345 Govan Road, Glasgow, G51 4TF, UK
| | - David Kingsmore
- Renal Transplant Surgery, Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde, 1345 Govan Road, Glasgow, G51 4TF, UK
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Pisano U, Soon VL, Douglas P. Corona mortis injury causing delayed presentation of pelvic pseudoaneurysm. Radiol Case Rep 2021; 16:1095-1098. [PMID: 33717390 PMCID: PMC7921174 DOI: 10.1016/j.radcr.2021.02.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 02/06/2021] [Accepted: 02/07/2021] [Indexed: 01/03/2023] Open
Abstract
Pseudoaneurysms are rare complications in urological surgery. Typically, they would present with pain, haematuria or anaemia. We report a 60-year-old patient who was found to have a chronic pseudoaneurysm via a corona mortis vascular variant, 3 months after a robotic-assisted prostatectomy. Unlike other rare reports of delayed vascular complications after minimally invasive urological surgery, the patient was entirely asymptomatic.Apart from careful intraoperative dissection, a high index of suspicion and low threshold for imaging are also required in the follow up period. Percutaneous trans-arterial embolization is safe and effective in dealing with post-surgical pseudoaneurysms.
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Affiliation(s)
- Umberto Pisano
- Interventional Radiology Department, Queen Elizabeth University Hospital, 1345 Govan Road, G51 4TF, Glasgow, United Kingdom,Corresponding author.
| | - V-Liem Soon
- Diagnostic Radiology Department, Queen Elizabeth University Hospital, 1345 Govan Road, G51 4TF, Glasgow, United Kingdom
| | - Peter Douglas
- Interventional Radiology Department, Queen Elizabeth University Hospital, 1345 Govan Road, G51 4TF, Glasgow, United Kingdom
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Mela Q, Ruggiero V, Montaldo L, Pisano U, Matta L, Maria Pasetto C, Onali S, Cacace E, Carta MG, Barca L, Chessa L. Bone mass preservation with high-dose cholecalciferol and dietary calcium in HIV patients following antiretroviral therapy. Is it possible? HIV Clin Trials 2018; 19:188-196. [PMID: 30445888 DOI: 10.1080/15284336.2018.1525841] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To evaluate whether treatment with 100,000 IU/month (equivalent to 3200 IU/day) of cholecalciferol and 1 g/day of dietary calcium supplementation in HIV patients following different cART regimens yields normal levels of vitamin D3 and PTH as well as whether changes in bone mineral density are clinically significant. METHODS Consecutive HIV patients following different cART regimens received 100,000 IU/month (equivalent to 3200 IU/day) of cholecalciferol and 1 g/day of dietary calcium supplementation. The participants underwent BMD assessment via dual energy X-ray absorptiometry of the spine and hip at baseline (T0) and after 24 months (T1). Levels of 25(OH) vitamin D3 and parathyroid hormone (PTH) were assessed at T0 and T1. Quantitative variables were assessed with a paired t-test, independent t-test or analysis of variance, as appropriate. A chi-squared analysis was used to assess the association between qualitative variables. A p-value <0.05 was considered significant. Patients were divided into three groups depending on the cART regimen. RESULTS A total of 79 patients were included (40 males, 51% and 39 females, 49%), with a mean age of 46.6 (SD ±11.2) years, a baseline CD4 count of 649 cells/µl and a mean 25 hydroxycholecalciferol (25(OH) D3) value of 25 + 10 ng/ml. After 24 months, the 25(OH) D3 increased to 40 + 11 ng/ml. The initial BMDs at T0 were estimated as 0.919 (±0.27) and 0.867 (±0.14) g/cm2 at the spine and hip, respectively. After 24 months, the BMD was 0.933 (±0.15) g/cm2 at the spine and 0.857 (±0.14) g/cm2 at the hip. Based on a BMD change exceeding 3%, a worsening was observed in 23% of patients at the spine and 27% at the hip, whereas stability or improvement was demonstrated in 77% of patients at the spine and 73% at the hip. Subgrouping patients based on antiretroviral therapy indicated that, at T1, there was a statistically significant increase in vitamin D3 concentration in all patients, while PTH concentration was not significantly reduced in patients taking tenofovir or efavirenz. BMD stability or improvement was demonstrated in 77% of patients at the spine and 73% at the hip after 24 months. The multivariate analysis confirms a decrease in vitamin D3 and an increase in PTH levels in smokers, as well higher vitamin D3 concentrations in males and lower spine BMDs in menopausal females. CONCLUSION The proposed protocol of cholecalciferol and dietary calcium supplementation is safe and valid for correcting vitamin D abnormalities in almost all patients as well as reducing PTH levels in a high percentage of patients; however, it is not sufficient for normalization, particularly in patients exposed to tenofovir or efavirenz. At the spine, no significant BMD change was found in any of the therapy groups. At the hip, our data confirm a modest negative effect on bone mass caused by tenofovir and efavirenz.
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Affiliation(s)
- Quirico Mela
- a Department of Medical Sciences and Internal Medicine , University Hospital, University of Cagliari , Cagliari , Italy
| | - Valeria Ruggiero
- a Department of Medical Sciences and Internal Medicine , University Hospital, University of Cagliari , Cagliari , Italy
| | | | - Umberto Pisano
- c Clinical and Interventional Radiology Department , Western General Hospital Royal Victoria , Edinburgh , UK
| | - Laura Matta
- a Department of Medical Sciences and Internal Medicine , University Hospital, University of Cagliari , Cagliari , Italy
| | | | - Simona Onali
- a Department of Medical Sciences and Internal Medicine , University Hospital, University of Cagliari , Cagliari , Italy
| | - Enrico Cacace
- a Department of Medical Sciences and Internal Medicine , University Hospital, University of Cagliari , Cagliari , Italy
| | - Mauro Giovanni Carta
- a Department of Medical Sciences and Internal Medicine , University Hospital, University of Cagliari , Cagliari , Italy
| | | | - Luchino Chessa
- a Department of Medical Sciences and Internal Medicine , University Hospital, University of Cagliari , Cagliari , Italy
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Pisano G, Erdas E, Medas F, Pisano U, Calò PG. Small bowel transanal evisceration mimicking a rectal prolapse. A case report and review of literature. Ann Ital Chir 2017; 6:S2239253X17027839. [PMID: 29372693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
UNLABELLED Transanal intestinal evisceration is a very uncommon and dramatic occurrence, linked most frequently to rectal prolapse rupture or, very rarely, to traumatic pathology. The Authors describe a case of a 74-year-old female patient who required urgent hospital admission because of a seemingly strangulated rectal prolapse. During surgical preparation the protruding mass was recognized as small bowel loops herniating from the anus. Evisceration was due to spontaneous rectal wall rupture, most likely caused by increased abdominal pressure and consequent breach through the weakened rectum. Surgical treatment consisted in small bowel resection combined with an Hartmann's procedure. Spontaneous rectal rupture without a pre-existing rectal prolapse is a rather infrequent and challenging condition; its mechanism is still incompletely explained. The management is surgical and may range from primary repair up to extensive intestinal resection to include a defunctioning colostomy. KEY WORDS Rectal prolapse, Spontaneous rectal rupture, Transanal evisceration.
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Pisano U, Irvine L, Szczachor J, Jawad A, MacLeod A, Lim M. Anismus, Physiology, Radiology: Is It Time for Some Pragmatism? A Comparative Study of Radiological and Anorectal Physiology Findings in Patients With Anismus. Ann Coloproctol 2016; 32:170-174. [PMID: 27847787 PMCID: PMC5108663 DOI: 10.3393/ac.2016.32.5.170] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Accepted: 09/22/2016] [Indexed: 02/07/2023] Open
Abstract
Purpose Anismus is a functional disorder featuring obstructive symptoms and paradoxical contractions of the pelvic floor. This study aims to establish diagnosis agreement between physiology and radiology, associate anismus with morphological outlet obstruction, and explore the role of sphincteric pressure and rectal volumes in the radiological diagnosis of anismus. Methods Consecutive patients were evaluated by using magnetic resonance imaging proctography/fluoroscopic defecography and anorectal physiology. Morphological radiological features were associated with physiology tests. A categorical analysis was performed using the chi-square test, and agreement was assessed via the kappa coefficient. A Mann-Whitney test was used to assess rectal volumes and sphincterial pressure distributions between groups of patients. A P-value of <0.05 was significant. Results Forty-three patients (42 female patients) underwent anorectal physiology and radiology imaging. The median age was 54 years (interquartile range, 41.5–60 years). Anismus was seen radiologically and physiologically in 18 (41.8%) and 12 patients (27.9%), respectively. The agreement between modalities was 0.298 (P = 0.04). Using physiology as a reference, radiology had positive and negative predictive values of 44% and 84%, respectively. Rectoceles, cystoceles, enteroceles and pathological pelvic floor descent were not physiologically predictive of animus (P > 0.05). The sphincterial straining pressure was 71 mmHg in the anismus group versus 12 mmHg. Radiology was likely to identify anismus when the straining pressure exceeded 50% of the resting pressure (P = 0.08). Conclusion Radiological techniques detect pelvic morphological abnormalities, but lead to overdiagnoses of anismus. No proctographic pathological feature predicts anismus reliably. A stronger pelvic floor paradoxical contraction is associated with a greater likelihood of detection by proctography.
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Affiliation(s)
- Umberto Pisano
- Department of General Sugery, Raigmore Hospital, Inverness, United Kingdom.; Department of Clinical and Interventional Radiology, Royal Victoria Hospital, Belfast, United Kingdom
| | - Lesley Irvine
- Department of Clinical Physiology, Raigmore Hospital, Inverness, United Kingdom
| | - Justina Szczachor
- Department of General Surgery, Raigmore Hospital, Inverness, United Kingdom
| | - Ahsin Jawad
- Department of General Surgery, Raigmore Hospital, Inverness, United Kingdom
| | - Andrew MacLeod
- Department of Radiology, Raigmore Hospital, Inverness, United Kingdom
| | - Michael Lim
- Department of General Surgery, Raigmore Hospital, Inverness, United Kingdom
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Pisano U, Deosaran J, Leslie SJ, Rushworth GF, Stewart D, Ford I, Watson AJM. Nicorandil, Gastrointestinal Adverse Drug Reactions and Ulcerations: A Systematic Review. Adv Ther 2016; 33:320-44. [PMID: 26861848 DOI: 10.1007/s12325-016-0294-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Nicorandil is a popular anti-anginal drug in Europe and Japan. Apart from some common adverse drug reactions (ADR), its safety is satisfactory. Several reports have suggested a link between nicorandil, gastrointestinal (GI) ulceration and fistulas. The review aims to critically appraise, synthesize and present the available evidence of all known GI ADR per anatomical location. METHODS The study complied with the PRISMA statement. Literature and pharmacovigilance databases were used to provide rate and/or calculate parameters (median age, median dose, history of symptoms, length of therapy and healing time after withdrawal of the drug). Differences in distribution of quantitative variables were analyzed via Mann-Whitney test. Correlation between quantitative variables was assessed with a Spearman's correlation coefficient. A p value <0.05 was significant. RESULTS Oral ulcerations occur in 0.2% of the subjects, anal ulcerations are present between 0.07% and 0.37% of patients. Oral and distal GI involvements are the most common ADR (28-29% and 27-31% of all GI ADR, respectively). The hepatobiliary system, the pancreas and salivary glands are not affected by nicorandil exposure. The time to develop oral ulcerations is 74 weeks among people on <30 mg/day compared to only 7.5 weeks in individuals on higher regimens (p = 0.47). There is a significant correlation between dose and ulcer healing time (Spearman's 0.525, p < 0.001). CONCLUSIONS Ulcerative disease is a very commonly reported GI ADR. A delayed ulcerative tendency supports the hypothesis of an ulcerogenic metabolite. Nicorandil seems to act as a cause of the ulcerations, but appears to also work in synergy with other promoting factors. Whether the action of the metabolites relies on a specific mechanism or a simple chemical ulceration is still to be established.
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Affiliation(s)
- Umberto Pisano
- Department of General Surgery, Raigmore Hospital, Inverness, UK.
| | | | | | | | - Derek Stewart
- School of Pharmacy and Life Sciences, Robert Gordon University, Aberdeen, UK
| | - Ian Ford
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
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Jones A, Pisano U, Elsobky S, Watson AJM. Grossly delayed massive subcutaneous emphysema following laparoscopic left hemicolectomy: A case report. Int J Surg Case Rep 2014; 6C:277-9. [PMID: 25562467 PMCID: PMC4334876 DOI: 10.1016/j.ijscr.2014.10.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Revised: 10/05/2014] [Accepted: 10/06/2014] [Indexed: 10/27/2022] Open
Abstract
INTRODUCTION Surgical emphysema is a known early complication of laparoscopic surgery, common during upper gastrointestinal and gynaecological surgery; the authors present the first case of delayed subcutaneous emphysema following a laparoscopic left hemicolectomy. PRESENTATION OF CASE A 52-year-old woman underwent a laparoscopic left hemicolectomy for a sigmoid malignancy; on the third post-operative day after an uneventful procedure, she developed a massive surgical emphysema involving her face, neck and chest with associated pneumoperitoneum but without any evidence of pneumothorax. A gastrograffin enema ruled out an anastomotic leak. Apart from a borderline tachycardia, mildly low saturations and an area of erythema in her right flank, she was totally asymptomatic. The emphysema resolved spontaneously around the 6th post-operative day. DISCUSSION Massive subcutaneous surgical emphysema after laparoscopic colorectal surgery is a rare complication and can me managed conservatively with a good outcome. CONCLUSION To our knowledge, this represents the first case of delayed massive surgical emphysema following colorectal surgery, the aetiology of which has still not been clearly explained, after exclusion of the most common causes.
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Affiliation(s)
- Angharad Jones
- Department of General Surgery, Raigmore Hospital, Old Perth Road, Inverness IV2 3UJ, United Kingdom
| | - Umberto Pisano
- Department of General Surgery, Raigmore Hospital, Old Perth Road, Inverness IV2 3UJ, United Kingdom
| | - Sherif Elsobky
- Department of General Surgery, Raigmore Hospital, Old Perth Road, Inverness IV2 3UJ, United Kingdom
| | - Angus J M Watson
- Department of General Surgery, Raigmore Hospital, Old Perth Road, Inverness IV2 3UJ, United Kingdom.
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Pisano G, Calò PG, Piras S, Pisano U, Nicolosi A. Laparoscopic adrenalectomy in a case of congenital duplication of the inferior vena cava. Case report. Ann Ital Chir 2013; 84:S2239253X1302135X. [PMID: 23841958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
INTRODUCTION Congenital duplication of the inferior vena cava is frequently associated with other vascular anomalies of its venous tributaries. Awareness of such occurrence facilitates laparoscopic surgery and avoids inadvertent vascular injuries. CASE REPORT An adrenal mass of increasing size was discovered in a 39 years old lady previously submitted to restorative proctocolectomy for Familial Polyposis Coli. Since the first preoperative work up, Computerized Tomography showed a duplicated inferior vena cava as well as other visceral and vascular anomalies. During laparoscopic adrenalectomy a double adrenal vein was discovered: the first one draining normally into the vena cava and the second one into the righ renal vein. Both of them were clipped and divided and surgical outcome was succesful. DISCUSSION The progress in cross-sectional imaging made easily recognisable congenital anomalies of the inferior vena cava in patients otherwise asymptomatic. Its occurrence has been evaluated through previous reports on venous anomalies during adrenal and renal surgery as well as through angiographic studies. Knowledge of these anomalies is very important for interventional radiologists, urologists and for general surgeons. However when facing adrenal surgery the operator should be aware that a double vein can be found in up to 10% of the cases and such occurrence is more predictable in case of pheochromocytoma and of large adrenal mass. Surgeons should rely both on preoperative dignostic imaging and careful dissection through laparoscopic magnified view to avoid harmful bleeding complications.
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