Colorectal surgery in patients over 80 years old.

BACKGROUND/AIMS: We analyzed colorectal resections in patients over 80 years old, performed for all benign and malign diseases. METHODOLOGY: We collected 300 consecutive colorectal resections between 2002 and 2008. Patients were divided into two groups: group A was composed by patients younger than 80 years old and group B by patients older than 80. Data were evaluated with t-test and chi-square test. RESULTS: We analyzed 180 women and 120 men. The median age was 66 years old (range, 30-90). Most frequent indications were colorectal cancer (46%), diverticulitis (35%) and extra-colic cancers (10%). Group B was composed of 60 patients (20%). Old patients had more concomitant diseases (62% vs. 33%, p<0.005), but complications, mortality and hospital stay were comparable in both groups. Surgical emergency increases morbidity (38% vs. 9%) and mortality (13.45 vs. 0.8%). CONCLUSIONS: Colorectal resections can be performed with good results in elderly patients. A colic disease must be detected before the patient develops a surgical complication because urgent surgery has more complications and deaths compared to elective surgery, especially for older patients.

Localized hepatic ischemia after liver resection: a prospective evaluation.

OBJECTIVE: To prospectively assess the frequency, severity, and extension of localized ischemia in the remaining liver parenchyma after hepatectomy. BACKGROUND: Major blood loss and postoperative ischemia of the remnant liver are known factors contributing to morbidity after liver surgery. The segmental anatomy of the liver and the techniques of selective hilar or suprahilar clamping of the Glissonian sheaths permit identification of ischemia on the surface of the corresponding segments for precise section of the parenchyma. Incomplete resection of a segment, or compromised blood supply to the remaining liver, may result in ischemia of various extension and severity. METHODS: Patients undergoing hepatectomy received enhanced computerized tomodensitometry with study of the arterial and venous phases within 48 hours after resection. We defined hepatic ischemia as reduced or absent contrast enhancement during the venous phase. We classified the severity of ischemia as hypoperfusion, nonperfusion, or necrosis. The extension of ischemia was identified as marginal, partial, or segmental. Factors that may influence postoperative ischemia were analyzed by univariate and multivariate analyses. RESULTS: One hundred fifty consecutive patients (70 F, 80 M, mean age 62 +/- 12 years) underwent 64 major and 81 minor hepatectomies and 5 wedge resections. We observed radiologic signs of ischemia in 38 patients (25.3%): 33 hypoperfusions (17 marginal, 12 partial, and 4 segmental), 3 nonperfusions (1 marginal, 1 partial, and 1 segmental), and 2 necroses (1 partial, 1 segmental). One patient with a segmental necrosis underwent an early reoperation. In all other cases, the evolution was spontaneously favorable. Postoperative peak levels of serum aspartate aminotransferase and alanine aminotransferase were significantly higher in patients with ischemia. Patients with ischemia had a significantly higher risk of developing a biliary leak (18.4% vs. 2.6%, P < 0.001). There was no correlation between liver ischemia and mortality (2%). None of the following factors were associated with ischemia after univariate and multivariate analysis: age, preoperative bilirubin level, liver fibrosis, malignant tumor, type of hepatectomy, surface of transection, weight of resected liver, Pringle maneuver, blood loss, and number of transfusions. CONCLUSIONS: Some form of localized ischemia after hepatectomy was detected in 1 of 4 of our patients. Its clinical expression was discreet in the large majority of cases, even if it might have been one of the underlying causes of postoperative biliary fistulas. Clinical observation is sufficient to detect the rare patient with suspected postoperative liver ischemia that will require active treatment.

Preoperative embolization of collateral side branches: a valid means to reduce type II endoleaks after endovascular AAA repair.

PURPOSE: To report the results of preprocedural embolization of collateral branches arising from abdominal aortic aneurysms (AAA) scheduled for endovascular repair. METHODS: Twenty-three consecutive AAA patients (all men; mean age 73 years, range 56-82) had coil embolization of patent lumbar and inferior mesenteric arteries (IMA) in a staged procedure prior to endovascular repair. Embolization with microcoils was attempted in 37 of the 52 identified lumbar arteries and 14 of 15 inferior mesenteric arteries. Follow-up included biplanar abdominal radiography, spiral computed tomography, and duplex ultrasonography at 1, 30, 90, and 180 days after the stent-graft procedure and at 6-month intervals thereafter. RESULTS: Successful embolization was obtained in 24 (65%) of lumbar arteries, while all 14 (100%) IMAs were occluded with coils. No complication was associated with embolotherapy. Over a mean 17-month follow-up of 22 patients (1 intraoperative death), there was only 1 (4.5%) type II endoleak from a patent lumbar artery, with no sac expansion after 2 years. There were 4 (18%) type I and 1 (4.5%) type III endoleaks. CONCLUSIONS: The embolization of side branches arising from an infrarenal aortic aneurysm before endovascular repair is feasible, with a high success rate; this maneuver may play a relevant role in reducing the rate of type II endoleak, improving long-term outcome.