Surgery for colorectal cancer in elderly: a comparative analysis of risk factor in elective and urgency surgery.

INTRODUCTION: Colon cancer therapy is primarily surgical. Advanced age does not represent a contraindication to surgery. We analyse the results of surgery in ultra 75 patients undergoing surgery for colorectal cancer by examining the correlation between the comorbidity and any post-operative complications. MATERIALS AND METHODS: We surgically treated 66 patients for colorectal cancer, aged over 75. The examined subjects were compromised for various reasons. We have evaluated the different influences of risk factors in elective and urgency operation. DISCUSSION: Several studies have shown that age alone is not a significant prognostic factor in survival after colonic surgery. The assessment of general conditions in elderly patients, as demonstrated by the literature, is a fundamental moment in the management of colorectal cancer. CONCLUSIONS: The surgical choice should be made case by case (custom-made), not based on age only.

Is it safe and useful, laparoscopic peritoneal lavage in the treatment of acute diverticulitis of octogenarian patients? A multicenter retroprospective observational study.

BACKGROUND: Diverticular disease of the colon also affects older people. Generally, older patients with diverticulitis may be regarded as too risky to undergo surgery. This retroprospective multicentric observational study aims to assess the safety and benefits of laparoscopic peritoneal lavage (LPL) in elderly patients with perforated sigmoid diverticulitis. PATIENTS AND METHOD: We hospitalized in urgency 100 patients, aged over 75, for sigmoid diverticulitis. Sixty-nine patients were treated with conservative medical therapy, while 31 were treated surgically, in which the surgery was performed in urgency in 18 cases, while in election in 13 cases. Laparoscopic peritoneal lavage was made in urgency in five cases. RESULTS: The mean age of the sample was 81.72. Thirty-one patients underwent surgery, and five patients were treated in urgency with laparoscopic peritoneal lavage. Perioperative mortality was zero. None of the patients who underwent laparoscopic peritoneal lavage showed recurrent disease. CONCLUSION: Diagnostic laparoscopy can be useful in elderly patient, since these patients may benefit from a more conservative surgical strategy. The selection of patients to be subjected to laparoscopic lavage must be very rigorous.

Laparoscopic peritoneal lavage: a definitive treatment for diverticular peritonitis or a "bridge" to elective laparoscopic sigmoidectomy?: a systematic review.

To this day, the treatment of generalized peritonitis secondary to diverticular perforation is still controversial. Recently, in patients with acute sigmoid diverticulitis, laparoscopic lavage and drainage has gained a wide interest as an alternative to resection. Based on this backdrop, we decided to perform a systematic review of the literature to evaluate the safety, feasibility, and efficacy of peritoneal lavage in perforated diverticular disease.A bibliographic search was performed in PubMed for case series and comparative studies published between January 1992 and February 2014 describing laparoscopic peritoneal lavage in patients with perforated diverticulitis.A total of 19 articles consisting of 10 cohort studies, 8 case series, and 1 controlled clinical trial met the inclusion criteria and were reviewed. In total these studies analyzed data from 871 patients. The mean follow-up time ranged from 1.5 to 96 months when reported. In 11 studies, the success rate of laparoscopic peritoneal lavage, defined as patients alive without surgical treatment for a recurrent episode of diverticulitis, was 24.3%. In patients with Hinchey stage III diverticulitis, the incidence of laparotomy conversion was 1%, whereas in patients with stage IV it was 45%. The 30-day postoperative mortality rate was 2.9%. The 30-day postoperative reintervention rate was 4.9%, whereas 2% of patients required a percutaneous drainage. Readmission rate after the first hospitalization for recurrent diverticulitis was 6%. Most patients who were readmitted (69%) required redo surgery. A 2-stage laparoscopic intervention was performed in 18.3% of patients.Laparoscopic peritoneal lavage should be considered an effective and safe option for the treatment of patients with sigmoid diverticulitis with Hinchey stage III peritonitis; it can also be consider as a "bridge" surgical step combined with a delayed and elective laparoscopic sigmoidectomy in order to avoid a Hartmann procedure. This minimally invasive staged approach should be considered for patients without systemic toxicity and in centers experienced in minimally invasive surgery techniques. Further evidence is needed, and the ongoing RCTs will better define the role of the laparoscopic peritoneal lavage/drainage in the treatment of patients with complicated diverticulitis.

Incidental finding of carcinoid tumor on Meckel's diverticulum: case report and literature review, should prophylactic resection be recommended?

Meckel's diverticulum (MD) is the most common congenital anomaly of the gastrointestinal tract and is caused by incomplete obliteration of the vitelline duct during intrauterine life. MD affects less than 2% of the population. In most cases, MD is asymptomatic and the estimated average complication risk of MD carriers, which is inversely proportional to age, ranges between 2% and 4%. The most common MD-related complications are gastrointestinal bleeding, intestinal obstruction and acute phlogosis. Excision is mandatory in the case of symptomatic diverticula regardless of age, while surgical treatment for asymptomatic diverticula remains controversial. According to the majority of studies, the incidental finding of MD in children is an indication for surgical resection, while the management of adults is not yet unanimous. In this case report, we describe the prophylactic resection of an incidentally detected MD, which led to the removal of an occult mucosal carcinoid tumor. In literature, the association of MD and carcinoid tumor is reported as a rare finding. Even though the strategy for adult patients of an incidental finding of MD during surgery performed for other reasons divides the experts, we recommend prophylactic excision in order to avoid any further risk.

Preliminary study on radioguided sentinel node identification in colon cancer.

The purpose of this study was to prove the prognostic value of the sentinel node (SN) in colon tumors, and to validate radioguided surgery in identifying the SN. Nodal metastases are a strong prognostic factor in patients operated on for colon or rectal cancer, decreasing the 5-year survival rate by approximately 20 per cent and dropping it to 30 per cent. Unfortunately, of 50 per cent of patients judged to be nodal disease-free at surgery, about 20 to 30 per cent will die from a local tumor relapse or distant metastases within 5 years of diagnosis. These data suggest that other steps are needed for more precise staging of patients, and specifically, to accurately harvest and study the nodes on which to base the prognosis. Mapping lymph nodes predictive of the whole basin status, referred to as SN, may help focus the pathologist's attention on a small but representative target, and achieve correct nodal harvesting, which includes atypical drainage pathways, when present. Twenty selected patients with colon tumor were administered a subserosal, peritumoral, intraoperative injection of blue dye and 99mTc-marked colloidal particles. The SN was identified visually and with a handheld gamma probe and was subsequently stitch-labeled. The operation was then conducted after standard surgical procedures, and the required lymphadenectomy was performed. Later, the probe was used to confirm radioactivity in the excised specimen and the absence of radioactivity in the operative field after resection; the purpose of the latter was to exclude the presence of aberrant routes of lymphatic drainage. The labeled SN were stained with hematoxylin and eosin and, in case of negative findings, cytokeratin immunostaining was performed. The remaining resected nodes were stained with hematoxylin and eosin. The probe identification of SN was 95 per cent overall (19/20); in 13 patients, a single SN was labeled, and two were labeled in six patients, harvesting 25 SN. In the 19 patients in whom a radioemitting SN was labeled, we recorded only one false-negative; in one case, a micrometastasis in the SN was the only extracolonic site. The blue dye identified the SN in 14 cases; in some of them, the number of nodes was overestimated (five single, seven double, and two triple SN) in comparison with the radioisotope, but at least one of the dyed nodes was also radioemitting. SN identification in colon cancers is a safe, fast, and easy procedure for ultrastaging the nodal basin. The technique involves a relatively flat learning curve and could become standard care for identifying the presence of nodal micrometastases at a low cost, thereby also making it affordable at small health centers.

Rectal cancer surgery in the elderly: a multivariate analysis of outcome risk factors.

BACKGROUND AND OBJECTIVES: Geriatric population life expectancy is rapidly increasing and the impact of major surgical procedures is not well defined. The purpose of this study was to compare short term surgical results assessing mortality and morbidity and long-term survival and disease-free interval in elective rectal surgery patients older than 65 years of age. The main independent risk factors of mortality, morbidity, and overall and disease-free survival were also identified. METHODS: Out of 177 rectal cancer accepted consecutively from 1991 to 2002, we studied the main clinical and pathological parameters comparing patients older and younger than 65 years. Data have been collected in a database and variables considered were studied by univariate analysis; independent predictive factors of 30-day mortality and morbidity were identified by multiple logistic regression analysis. Overall, cancer specific and disease-free survival curves were obtained with the Kaplan-Meier method and results compared with the log-rank test. Independent risk factors of overall and disease-free survival have been identified by multivariate logistic regression analysis. RESULTS: In patients younger and older than 65 years postoperative mortality (3.2% vs. 9.6%) and morbidity (30% vs. 29%) were not significantly different. Variables independently associated with 30-day mortality were the duration of surgical procedures and postoperative complications. The Kaplan-Meier survival curves showed a significantly worst overall survival (P = 0.003), cancer specific survival (P = 0.02), and disease-free survival (P = 0.03) in patients aged 65 years or more. Multivariate analysis showed that pT, grading, preoperative CEA level, gender, and site of the tumor along the rectum, the number of blood transfusion and the age group of more than 65 years are independent risk factors for both overall survival and disease-free interval. The presence of residual disease was an adjunctive factor of overall survival, whereas the Astler and Coller staging was a risk factor for the disease-free survival. CONCLUSION: The short-term prognosis for elective rectal cancer procedure in patients over 65 years of age was comparable to that of younger patients, whereas long term cancer-related survival was statistically worst in older patients.

[Thyroidectomy for thyroid carcinoma. Our experience]. / Linfectomia per carcinoma della tiroide. Nostra esperienza.

The surgical management of thyroid carcinoma involves different degrees of lymphadenctomy, according to features such as the nature, the site and the severity of the disease. The authors present their experience in order to contribute to the debate on the standard management of nodal metastasis in well-differentiated thyroid cancers. The authors describe their six years of experience in 302 thyroid cancer patients with a total of 291 thyroidectomies performed. According to the different pathological findings, the treatment involved a monolateral dissection in 42 patients and a bilateral modified neck dissection in 21. A number of anatomical considerations regarding the pathway of lymphatic drains are summarized and follow-up results are also presented. The slow progression of the disease and its low incidence make long-term prospective studies difficult, thus hindering any definitive assessment of lymph node management in well-differentiated thyroid cancers.