Which differences do elderly patients present in single-stage treatment for cholecysto-choledocholithiasis?

Patients with symptomatic gallstones present common bile duct stones in approximately 10% of cases. It is possible to resolve both gallbladder and bile duct stones with a single procedure. The aim of this study is to determine the effectiveness of a single stage procedure for gallbladder and bile duct stones in the elderly patients and to expose the differences between the various techniques. From January 2008 to December 2013, we treated 1540 patients with gallbladder stones. In 152 cases, we also found bile duct stones. 150 of these were treated in a single stage procedure. We divided our patients into 2 groups: Group A was younger than 65 (104 patients); Group B was 65 or older (46 patients). We retrospectively compared sex, ASA score, conversion rate, success rate, post-operative complications, hospital stay, and treatment method. We had no intra-operative mortality. 1 patient in Group B, heart condition (ASA 4), died with multiple organ failure (MOF) 10 days after his operation. ASA score: 3.5 ± 0.5 in A vs 2 ± 0.9 in B (P 0.001), post-operative complications 6% in A vs 18.1% in B (P 0.0325) and hospital stay 4.1 ± 2.3 in A vs 9.5 ± 5.5 in B (P 0.0001) were significantly higher in Group B. No differences were found in term of success rate: 94% in A vs 90% in B (P 0.4944). The procedure used to obtain the clearance of the bile duct showed a different success rate across the two groups: for the patients under 65 years old, trans-cystic clearance (TC-CBDE) was successful in 90% of cases, and only 51% for those older than 65, where we had to recall 49% for laparo-endoscopic rendez-vous (RV-IOERC) (P 0.0014). In conclusion, single stage treatment is safe and effective also to elderly patients. The methods used in patients being younger than 65 years old is what appeared to be significantly different.

Early biomarkers of hypocalcemia following total thyroidectomy.

Hypocalcemia is the most frequent major complication following total thyroidectomy (TT), delaying timely hospital demission. We prospectively evaluated the diagnostic utility of parathyroid hormone (PTH) measured one hour after TT and the delta (post-minus pre-surgery) PTH in order to determine which biomarker best predicted post-surgery hypocalcemia. Ninety-six consecutive patients, with either plurinodular goiter, Graves' disease or cervico-mediastinal goiter (22 (23%) men and 74 (77%) women, mean age 48.5 ± 15.2 and 47.9 ± 13.2 years, respectively), scheduled to undergo TT were enrolled. PTH was measured prior and one hour after surgery. Delta PTH was defined as one-hour post-surgery values minus pre-surgery PTH level. Hypocalcemia was defined as a calcemia under 8.0 mg/dL. Receiver operating characteristic (ROC) analysis was used to evaluate the Area Under Curve (AUC), sensibility and specificity of the two biomarkers for the occurrence of hypocalcemia. Forty-nine (51%) patients presented biochemical values under the cut-off but only 17 (18%) had clinical symptoms. Both variables yielded statistically significant AUC (PTH one-hour post surgery: 0.654; p = 0.0403; 95%CI: 0.519-0.773 and delta PTH: 0.659; p = 0.0263; 95%CI: 0.527-0.776). Although comparison of the two ROC curves did not yield significant differences, delta PTH yielded a better sensitivity and PTH one-hour post-TT yielded a marginally better specificity (sensitivity of 50% and 87% and specificity of 76% and 67% for cut-offs of <39.8 pg/dl and <54.5 pg/dl, respectively). Both biomarkers have similar diagnostic accuracy for hypocalcemia, and can be used to indicate when supplemental therapy should be implemented in order to favor a timely discharge.

Thyroid surgery with harmonic focus, ligasure precise and conventional technique: a retrospective case-matched study.

BACKGROUND: New surgical technologies have been introduced in thyroid surgery, to achieve vessel sealing and hemostasis. The aim of the study was to examine their effectiveness and compare the outcome of total thyroidectomy using the Harmonic Focus™, the LigaSure® Precise and the conventional technique of suture ligation. METHODS: A retrospective case-matched study of all total thyroidectomies between October 2008 through May 2010 was conducted. Patients (n=240) underwent total thyroidectomy using three different methods; the Harmonic Focus™ (Group F, n=80), the LigaSure Precise® (Group L, n=80) and the conventional technique of suture ligation (Group C, n=80). RESULTS: No significant differences were identified between the 3 groups in terms of demographics, thyroid gland weight, pathologic diagnosis, preoperative and postoperative calcium levels, postoperative complications, duration of hospital stay, and final outcome. The operative time was shorter with Harmonic Focus® by about 15%. Statistical analysis revealed a statistically significant difference between operations with F (62.7±14.1 minutes) and C (72.7±13.6minutes) with (p=0.019). CONCLUSION: Both devices were safe and efficient. A significant reduction of the operative time was found with Harmonic Focus® compared to the other two techniques with no statistically significant differences in postoperative complications in the 3 groups.

[Comparison of conventional technique, Ligasure Precise and Harmonic Focus in total thyroidectomy]. / Studio comparativo tra tecnica tradizionale, Ligasure Precise ed Harmonic Focus nella tiroidectomia totale.

The aim of this study was to compare the results obtained using an electrothermal bipolar vessel sealing system (Ligasure Precise), a harmonic curved shears (Harmonic Focus) and traditional technique in total thyroidectomy. We have enrolled 93 patients and assigned randomly to three groups of 31 pt: groups L (Ligasure Precise), F (Harmonic Focus) and C (traditional thecnique). Recorded data were demographics, preoperative serum calcium levels, operation time, length of hospital stay, weight of exported gland and pathology, postoperative calcemia at one and two days and recurrent laryngeal nerve paralysis. The three groups did not present statistically significant differences in term of age, gender and pathology classification. No postoperative haemorrhages were observed. The overall incidence of hypocalcemia was 38.9% (36 pt) and the mean days of hospitalization were 2.3 days without statistically significant differences between the three groups. Only one patient (group F) presented temporary recurrent laryngeal nerve paralysis. Mean operation time (minutes) was significantly reduced by approximately 15% in group F (62.7+/-14.1) compared with group C (72.7+/-13.6; Kruskal-Wallis test: p<0.05). Both devices resulted safe and efficient. The only advantage observed was a significant reduction operation time when using Harmonic Foscus curved shears compared to the other techniques.

Why is there recurrence after transcystic laparoscopic bile duct clearance? Risk factor analysis.

AIM: Incidence of common bile duct stones (CBDS) is approximately 10% in patients with symptomatic gallstones undergoing laparoscopic cholecystectomy. Transcystic laparoscopic common bile duct exploration (TC-CBDE) is safe and efficient in achieving bile duct clearance from stones, with a success rate of between 85% and 95%. The aim of this retrospective study is the evaluation of risk factors and recurrence in patients treated with TC-CBDS. METHODS: From October 2003 until September 2007, 110 consecutive patients with common bile duct stones and gallbladder were included in the study. Average age was 64 years (range 21-82 years). The procedure was completed laparoscopically in 106 patients (96.4%): with TC-CBDE in 90 patients (85%), who are the object of this study; and with TC-CBDE + perioperative guide wire papillotomy ("rendezvous") in 16 cases (15%). In the 90 patients treated with TC-CBDE which we examined, the risk factors were: preoperative liver function tests, diameter of the common bile duct (normal 8 mm or less), number of stones (3 with biliary sludge predicted a recurrence (p < 0.05) while the other factors did not show important clinical variables. CONCLUSION: TC-CBDE is safe and effective in the majority of cases of CBDS. The incidence of recurrence is low but there are some risk factors, such as number of stones >3 with biliary sludge, which do not favor the successful outcome of the procedure. In such cases, it is essential that the TC-CBDE is integrated with other procedures which, although more complex, assure the clearance of the bile duct.

[Preliminary results in the use of a new composite prosthesis in incisional hernia repair]. / Risultati preliminari sull'utilizzo di una nuova protesi intraperitoneale nel trattamento del laparocele.

The repair of incisional hernias with the use of prosthetic biomaterials is the standard of care today. There are different prosthetic biomaterials that can be used to repair incisional hernias. These materials can be divided into products that are single component or a combination. Incisional hernia repair using the intraperitoneal implantation of a prosthesis requires mesh with impervious properties. This is preliminary study with a new composite non resorbable mesh in polyethylene terephthalate-polyurethane (HI-TEX PARP MP) used for incisional hernia repair in intraperitoneal implantation. This mesh has one permeable side in polyethylene terephthalate (PET) for rapid tissue fixation and another side in polyurethane (PEU), hydrophobic in order to avoid cell penetration. This is a preliminary study of medical records of 24 patients (17 women and 7 men) in whom intraperitoneal placement of composite prosthetics in polyethylene terephthalate-polyurethane (HI-TEX PARP MP) was used between September 2004 and September 2006. The incisional hernias were recurrent in 8 patients. The underside of the mesh was placed in direct contact with the visceral peritoneum, whereas the upper side made contact with the subcutaneous tissue. No intraoperative complications occurred. Postoperatively, 1 had seromas, 1 had phlegmon of the wound without removing prosthetics. There was 1 death but not dependent of the surgical performance. The follow-up, was 12 months (range 1 month-2 years); none had discomfort; only one patient had recurrence. Intraperitoneal placement of HI-TEX PARP MP has several advantages over other techniques including minimal adhesions, a decreased risk of infection and recurrences. In addition this mesh is more economics than the other prosthetics in use.

[Laparoscopic cholecystectomy in acute cholecystitis: predictors of conversion to open cholecystectomy and preliminar results]. / L'approccio laparoscopico alla colecistite acuta. Risultati e fattori predittivi di conversione.

Inspite of increased technical difficulties and high incidence of conversion to open procedures and complications, laparoscopic cholecystectomy is a well established treatment for acute cholecystitis. In this study we reported our results in patients with acute cholecystitis undergoing laparoscopic cholecystecomy from 1998 to 2003. We found out that laparoscopic cholecystectomy was safe and was carried out with acceptable conversion rate and low morbidity. Predictors of complications were delay of surgery more than 48 hours following the onset of symptoms, leucocytosis > 15.000 U/microl and gallbladder wall ultrasonography thickness > 7mm.

Should female patients undergoing parathyroid-sparing total thyroidectomy receive routine prophylaxis for transient hypocalcemia?

Hypocalcemia following parathyroid-sparing total thyroidectomy is frequent and can prolong hospital stay. We undertook this study to identify preoperative predictors of postoperative hypocalcemia useful in the postoperative management of these patients. We examined patients undergoing total thyroidectomy for benign disease with preservation of at least three parathyroids from January 2000 to January 2001. Low serum calcium was considered below 8.0 mg/dL. Age, gender, preoperative serum calcium, thyroid stimulating hormone (TSH), T3, T4, albumin, cholesterol, and tryglicerides were compared in patients with normal and low serum calcium level on the second postoperative day and on discharge day by using chi2 test and a model of logistic regression. Data were reported using their frequency distribution among the two groups of patients. Eighty patients, 60 females (F) and 20 males (M), underwent parathyroid-sparing total thyroidectomy. On second postoperative day, hypocalcemia occurred in 42 patients, and 56 per cent were symptomatic. Only female gender (88% F vs 12% M) (P < 0.05) and TSH <0.27 mUI/mL (38% vs 18%) (P < 0.05) predicted hypocalcemia. Similarly, female gender predicted hypocalcemia in a logistic regression analysis (P < 0.05). On the day of discharge, 22 patients had low serum calcium levels, and 50 per cent were symptomatic. At this time, only TSH value < 0.27 mlU/mL significantly predicted hypocalcemia (48% vs 17%) (P < 0.05). This was confirmed in a logistic regression analysis (P < 0.05). All but one patient (98%) eventually returned to normal serum calium levels. Despite preservation of parathyroids, transient symptomatic hypocalcemia is common after total thyroidectomy. Female gender and low TSH serum level predicted hypocalcemia. Therefore, female patients undergoing total thyroidectomy with preoperative low TSH levels should receive calcium prophylaxis to decrease morbidity, shorten hospital stay, and decrease costs.

Surgical controversies in the treatment of recurrent achalasia of the esophagus.

BACKGROUND/AIMS: Surgery remains the first choice for achalasia of the esophagus with good results in 90% of cases. METHODOLOGY: We studied the cause of failure for surgical treatment and the results of a second operation in 20 patients that were followed up for at least three years. RESULTS: The results were good in 70% of the cases. CONCLUSIONS: To improve this procedure, according to the authors, it is essential for a careful presurgery evaluation, an early reoperation in case of failure and a careful surgical technique in order to avoid periesophageal sclerosis.

[Ultrasound-guided trans-parietohepatic cholecystostomy in the critical patient: current indications]. / La colecistostomia trans-parietoepatica ecoguidata nel paziente critico: attuali indicazioni.

The appearance of acute cholecystitis can make to complicate a natural history of cholelitiasis or post-operating time of patients that have concomitant predisposition factors. The best therapy is the cholecystectomy but somewhere for the critical general conditions is too much dangerous to make a surgical procedure. However we need to stabilize patients conditions, also for a short time. Our experience suggest us that percutaneous transhepatic cholecystostomy is a simple method without any complications, efficacious to resolve the acute sepsis in patients with cholecystitis that not be able to tolerate a surgical procedure.

[Classification of varices with Doppler ultrasonography mapping. Clinical and hemodynamic correlation]. / Classificazione delle varici con mappaggio eco Doppler. Correlazione clinica ed emodinamica.

The authors report their experience concerning the outpatient echo Doppler mapping of peripheral venous circulation in the lower limbs. Out of a total of 240 patients examined, 190 showed monolateral venous insufficiency and 50 bilateral. These results were correlated to the age of the patients and showed that saphenous pathology tended to affect the entire vein in elderly patients, whereas only partial damage was observed in young patients. Varices seemed to appear with the first signs of the insufficiency of collateral veins before signs of saphenous insufficiency became manifest.

[Intraoperative ultrasonic evaluation of the residual thyroid weight in thyroidectomy in diffuse toxic goiter]. / Valutazione ecografica intra-operatoria del peso tiroideo residuo nelle tiroidectomie per gozzo tossico diffuso.

The amount of thyroid tissue to be ablated in unresponsive Basedow disease has mainly, until now, been empirically evaluated. An attempt has been made, using intraoperative ultrasonography, to evaluate the residual tissue. This method allows weight calculation of the thyroid lobe to be ablated through two sonographic measurements of the superior pole axes. This technique provides a precise codification of the intervention and reduces the incidence of recurrence. The results six months after operation prove just two cases of latent hypothyroidism (10%).

[Intraoperative echography as a therapeutic aid in the treatment of nephrolithiasis]. / Ecografia intraoperatoria quale ausilio terapeutico nel trattamento della litiasi renale.

Intraoperative ultrasonography was performed in 24 patients with intrarenal pelvis or with recurrent or multiple stones. The stones were located by a 22 or 25 gauge needle, manually introduced under ultrasonography: they were then extracted through a small incision performed along the tract of the exploratory needle. This preliminary experience has shown that the real time B-mode intraoperative ultrasound can provide valuable results in urologic surgery.

[Gynecomastia: our experience in surgical treatment]. / La ginecomastia: nostra esperienza nel trattamento chirurgico.

A group of 78 patients with gynecomastia was observed between 1974-1987. Idiopathic gynecomastia was referred in 33 cases, cirrhosis in 31 cases, prostatic hypertrophy in 2 cases, while in 12 cases gynecomastia was induced by drugs. All patients with idiopathic form and 11 patients with secondary form were surgically treated by mastectomy (20 bilaterally and 24 unilaterally). The authors emphasize that, in this pathology, is much more important restoring the masculine feature of thorax without esthetic damage than removing the hypertrophic gland.