[Laparoscopic surgery for acute cholecystitis in the elderly. Our experience]. / Approccio laparoscopic nella colecistite acuta dell'anziano. La nostra esperienza.

Acute cholecystitis in the elderly is a severe illness with high operative risks and mortality, which, even if less than in the past, is still too high. The surgical approach has significantly changed over the past 10 years: conservative therapy in the early 1990's was considered the only sure approach, while the laparoscopic surgical approach is recommended today for the emergency treatment of acute cholecystitis, also in the elderly. The aim of this retrospective study was to define the safety and effectiveness of early surgery for acute cholecystitis with the laparoscopic approach in the elderly. From September 2002 to September 2006, 287 patients were admitted to our unit for cholelithiasis, including 135 for acute cholecystitis. The patients with acute illness and age > 70 yrs numbered 73. After immediate monitoring of vital parameters and a brief diagnostic and therapeutic interval to restore the patient's general condition in intensive care (fasting, SNG, antibiotics, parenteral fluid therapy and analgesic drugs) all patients underwent emergency surgery within 24-96 hours. Fifty-nine (80.8%) underwent laparoscopic cholecystectomy, whereas the remaining 14 (19.2%) underwent open cholecystectomy due to their high-risk for cardiovascular, respiratory and metabolic status (ASA III-IV). In group 1 treated laparoscopically, morbidity was 11.9% versus 35.7% in group 2 treated with open cholecystectomy (p < 0.001). Mortality was 0 in group 1; and 7% (1 patient) in group 2 (p < 0.05). The median hospital stay was 3.87 (2-9) days in group 1 vs 10.5 (8-29) days in group 2 (p < 0.001). The results of our study confirm the safety and effectiveness of laparoscopic cholecystectomy in expert hands in the management of acute cholecystitis in elderly patients. This choice allowed a statistically significant reduction in morbidity and overall hospital stay. Nevertheless, open cholecystectomy remains a valuable procedure for high-risk elderly patients undergoing emergency surgery. Poor outcome is related to the almost constant presence of comorbidity in the elderly = ASA score (ASA II vs. IV: p < 0.001) and independent of the type of surgical intervention (laparoscopic cholecystectomy vs open cholecystecotmy: p = n.s.). Early cholecystectomy in case of symptomatic cholelithiasis, before infectious complications set in, could partly reduce the poor prognosis in the elderly.

Sphincter-saving surgery in low rectal cancer.

A correct surgical approach to rectal cancer today has to make due allowance for both improved overall survival with local control of disease and preservation of the sphincter and urinary and genital functions. Increased understanding of the natural history, the importance of preoperative accurate staging and new surgical techniques may influence future treatment strategies. The aim of this study was to review and make a reappraisal of the role of sphincter-preserving surgery in the treatment of carcinomas of the lower third of the rectum. From January 1999 to June 2004, 63 consecutive total rectal resections were performed at our surgical department. Thirty-five of these patients, who underwent surgery for a primary adenocarcinoma of the distal rectum (3.5 to 8 cm from the anal verge), were reviewed retrospectively. The preoperative clinical assessment was based largely on T staging, tumor size, fixation and distance from the anal verge. Patient stratification, based on the definitive pathological report, was 3 Dukes' stage A (T1 N0), 21 stage B (T2 N0) and 11 stage C (T2-3-4 N+). The distance from the anal verge was > 5 cm in 30 patients and < 5 cm in 5. Sphincter-saving procedures were performed in 28/35 patients (80%); 7 (20%) had abdominoperineal resections of the rectum for very distal, locally extensive tumours or local recurrence (2 patients). The overall recurrence rate was 11.4%. Postoperative morbidity related to the procedures was low: anastomotic leakage occurred in 10.7% (3/28). Perfect continence was documented in 86.3%. The minimum follow-up time is 12 months. Our data, in agreement with the findings of other Authors, appear to bear out the validity of sphincter-saving procedures in the treatment of cancer of the lower third of the rectum. This approach is possible for the majority of patients. Functional results are good, using an accurate nerve-sparing technique, and may be improved by employing a colonic reservoir in selected cases.

Endoscopic dilation of benign colorectal anastomotic stricture after low anterior resection: A prospective comparison study of two balloon types.

BACKGROUND: Benign strictures arise in 5.8% to 20% of colorectal anastomoses. For such strictures, endoscopic dilation has proven to be a valid and safe treatment. A variety of endoscopic techniques have been proposed, but controlled prospective trials are lacking. This study compared dilation of this colorectal anastomotic stricture with an over-the-wire balloon designed for treatment of achalasia and with a through-the-scope balloon. METHODS: Thirty patients with symptoms caused by benign colorectal anastomotic stricture were randomly allocated to two treatment groups: 15 underwent dilation with a through-the-scope balloon and 15 had dilation with an over-the-wire balloon. Success was defined as an anastomotic lumen wide enough to allow passage of a standard 13-mm-diameter colonoscope, with resolution of symptoms. The success of dilation, the number of sessions required, the complications, and the duration of the dilation were recorded. Patients were followed for 24 months. RESULTS: Dilation was successful in all patients, with no procedure-related complication. The mean number of sessions required was 2.6 (0.98) in the through-the-scope group and 1.6 (0.77) in the over-the-wire group ( p = 0.009). The duration of response in days was greater in the over-the-wire group vs. the through-the-scope group, 560.8 (248.5) days vs. 294.2 (149.3) days, respectively, p = 0.016. CONCLUSIONS: Through-the-scope and over-the-wire dilation techniques are both effective and safe for treatment of benign colorectal anastomotic strictures. Using a greater diameter over-the-wire pneumatic balloon reduces the number of dilation sessions required and provides a longer-lasting response to dilation.

Relationship between hiatal hernia and inguinal hernia.

Several theories explain the development of hiatal hernia (HH). Since inguinal hernia (IH) is due to abdominal wall herniation, we hypothesized that if HH is caused by an excessive "push" from increased intraabdominal pressure, there would be a greater than chance association between HH and IH. The aim of this prospective case-control study was to determine the relationship between HH, identified at endoscopy, and IH, found on clinical examination. Outpatients, who were referred for elective upper GI endoscopy at the Endoscopic Unit, from January 1999 to December 1999, were evaluated. Data were collected regarding gender, age, BMI, presence or absence of HH, length of HH, and presence of IH on detailed abdominal examination of each subject. Five hundred fifty-nine outpatients were enrolled in this study. Of these, 128 (23%) had HH, whereas 431 (77%) patients did not. The average length of the HH was 2.7 +/- 0.9 cm (range, 1.5-6 cm). The overall risk of IH in patients with HH is 2.5-fold compared to those without HH (OR = 2.59). Obesity (BM, >25) was an additional risk factor for IH in patients with HH compared with normal weight (BMI, 21-25) (P < 0.05). Males with HH were more likely to have IH than females (OR = 2.86; 95% CI = 1.35-6.08). Inguinal and hiatal hernias occur together more often than expected by chance alone. Male gender and obesity increase the risk of association. These results suggest that a common etiology may exist for both IH and HH, at least in some patients, and support the hypothesis that "push" factors may contribute to the etiology of HH.

[Small intestinal polyposis in Peutz-Jeghers syndrome: combined treatment with surgery and intra-operative endoscopy]. / La poliposi del tenue nella sindrome di Peutz-Jeghers: trattamento combinato chirurgia-endoscopia intraoperatoria.

Polyps occur throughout the gastrointestinal tract in Peutz-Jeghers syndrome, but the most serious problems are encountered in the management of small bowel polyposis. We report here on a case of Peutz-Jeghers syndrome admitted to hospital for intestinal obstruction and anaemia. The patient was submitted to colonoscopy, oesophagogastro-duodenoscopy and small bowel enema. At laparotomy, multiple intussusceptions were found and we conducted a combined surgical-endoscopic approach. Most of the polyps were identified and removed endoscopically (snare polypectomy). Five enterotomies were performed to remove 18 very large polyps (> 3 cm). Finally, a limited portion of the jejunal tract (20 cm) was resected owing to the presence of multiple, large, obstructive polyps. None of the polyps showed cancerous transformation. The shortcomings of the traditional surgical approach include repeated small bowel resections and often early reoperation to manage complications caused by polyps missed at the time of previous surgery. If surgical intervention is required, intraoperative endoscopy is always indicated. Conservative surgical management, the role of intraoperative endoscopy, planned medical follow-up and the need for a national registration system are stressed.