Laparoscopic surgery in the elderly: personal experience in 141 cases.

INTRODUCTION: As life expectancy increases, the number of elderly patients presenting with surgically correctable diseases will rise as well. For advantages, which are well recognized in young patients, laparoscopic surgery has been proposed also for older patients. Because of underlying chronic diseases, however, elderly patients have been considered at high risk for the laparoscopic approach. Several studies have pointed out the risks related to cardiac, respiratory, or general comorbidities when elderly patients are proposed for laparoscopic treatment of their surgical disease. PATIENTS AND METHODS: In this study, we reported our experience in 141 patients older than 65 years who were submitted to laparoscopic procedures for several indications. According to American Society of Anesthesiologists (ASA) score, patients were classified as ASA I in 70.9% of cases, ASA II in 27.6%, and ASA III in 1%. RESULTS: No mortality has been reported. Conversion rate was 5.3% for bleeding in 4 cases or intraoperative hypotension in 2 cases. Mean hospital stay was 5 days. Postoperative complication was reported in 1 case and consisted of a hearth attack. CONCLUSIONS: Laparoscopic surgery in the elderly is a safe procedure, if preoperative selection of the patients is accomplished. An experienced surgical team and multidisciplinary approach are mandatory.

Surgical repair of type II paraesophageal hernia: our experience.

Type II paraesophageal hiatal hernia is a rare entity that is rarely discussed in the literature. This report is intended to depict the clinical profile of the disease and to discuss several controversial issues involved in the repair, including indications for surgery, the most appropriate surgical approach, and the need for a concomitant antireflux procedure. This study retrospectively reviews the experience with 12 patients affected by paraesophageal hernia who underwent a surgical repair between 1973 and 2001. Ten were women and two were men, with a mean age of 56.8 years. Clinical features and diagnostic assessment, as well as operative findings, are presented. Nine patients underwent an elective operation, and three patients underwent an emergency procedure for hernia complications. A thoracic approach was used in one patient, whereas the remaining 11 patients underwent an abdominal repair; the hernia sac was resected, and the hiatus was reconstructed in all of the patients. No postoperative deaths occurred; complications occurred in one patient, and only one recurrence was observed. Type II paraesophageal hernia seems to be a rare primary diaphragmatic defect. Its surgical repair is mandatory, because paraesophageal hernia is a potentially life-threatening disease because of the risk of severe complications; an elective repair should be performed wherever possible, even in asymptomatic patients. The main problems of the management are the choice of the surgical approach and the usefulness of an associated antireflux procedure to the hiatoplasty; in our opinion, a fundoplication should be added to all repairs.

[Uncommon abdominal sites of hydatid disease. Our experience with the surgical treatment of 15 cases]. / L'idatidosi addominale a rara localizzazione. La nostra esperienza nel trattamento chirurgico di 15 casi.

The aim of this retrospective study is to report on a series of 15 patients with abdominal hydatid disease in uncommon sites submitted to surgery in our unit over the period 1974-2003. Eight women and 7 men (mean age: 48.4 years) were included in the study. The hydatid cysts were located in the peritoneum in 8 patients, in the spleen in 5, in the kidney in 1 and in the retroperitoneum in 1. In 4 cases the peritoneal cysts were solitary, while 4 patients in this subgroup presented multiple cysts and 2 had concomitant liver hydatidosis. The splenic cysts were solitary in 2 cases, associated with a hepatic cyst in 2 and with a lung cyst in 1. The renal and retroperitoneal cysts were both solitary. The diagnosis was made at operation in 3 cases, while in 12 patients it was made by serological tests, ultrasonography and/or CT. All patients were operated on: we performed a total cystectomy in 7 patients with peritoneal cysts and in the patient with a retroperitoneal location, splenectomy in the 5 splenic cysts and a partial cystectomy with external drainage of the residual cavity in 1 peritoneal cyst and in the renal location. The postoperative course was regular with no mortality and no major morbidity in 14 patients, while 1 patient submitted to splenectomy developed a subphrenic abscess that required surgical drainage. Two recurrences occurred in patients with peritoneal cysts 71 and 20 months, respectively, after the first operation and these were managed by total cystectomy. The diagnosis of uncommon abdominal sites of hydatid disease is more accurate today because of the new imaging techniques, which are often able to show specific radiological signs of hydatid disease. The treatment of choice is surgical and complete removal of the cyst is the gold standard, but its feasibility is related to the location of the cyst.

[Surgical treatment of para-esophageal hernia. Our experience]. / Il trattamento chirurgico dell'ernia paraesofagea. Esperienza personale.

The authors report on 12 cases of para-oesophageal hernia surgically managed over the period from 1973 to 2001. They describe the etiopathogenetic factors responsible for the disease and the normal evolution of the clinical picture with the main complications, which are often the first manifestations. The main problems of surgical treatment are discussed with particular regard to the operative approach and to the usefulness of combining an antireflux procedure with the hiatoplasty.

[Surgical treatment of hepatic hydatidosis. Analysis of results of conservative and radical surgery in our experience]. / Il trattamento chirurgico dell'idatidosi epatica. Analisi dei risultati della chirurgia conservativa e radicale nell'esperienza personale.

The authors review a series of 194 cases of hepatic hydatidosis submitted to surgery over the period from July 1973 to December 2001, comparing the results of conservative and radical operatins. In this period we performed 164 conservative operations (140 indirect marsupialisations, 5 delaminations with capitonnage of the residual cavity and 19 partial pericystectomies), 26 total pericystectomies and 4 liver resections. The main outcome measures analysed were postoperative hospital stay, mortality, morbidity and recurrence rates. The median postoperative hospital stay was 17.5 days for conservative operations and 12.5 days for radical surgical procedures. No deaths occurred in either group. The morbidity was 26.8% after conservative treatment (34 biliary fistulas, 3 cases of jaundice, 5 residual cavity infections and 2 subphrenic abscesses) and 13.3% after total pericystectomy and liver resection (3 wound infections and 1 pleural effusion). Recurrences occurred only in the group treated by marsupialisation (12/140 = 8.5%) and were managed by total pericystectomy in 5 cases and by a second drainage procedure in 7. The surgical procedure for the treatment of hepatic hydatidosis should be tailored to the needs of each patient, depending on the size, location and complications of the cyst and high surgical risk should be avoided in view of the benign nature of the disease. No deaths occurred in either of our patient groups, but postoperative hospital stay, morbidity and recurrence rates were better in those undergoing radical treatment.

[Etiopathogenic and clinico-therapeutic considerations on Spigelian lateral ventral hernia. A caseload and review of the literature]. / Considerazioni etiopatogenetiche e clinicoterapeutiche sull'ernia ventrale laterale di spigelio. Contributo casistico e revisione della letteratura.

The authors report on 6 cases of Spigelian hernia surgically managed over the period from 1973 to 2002. They describe the anatomy of the anterolateral abdominal wall and the etiopathogenetic factors of this rare type of hernia. The clinical features of the disease are discussed and the diagnostic usefulness of a thorough physical examination is stressed, as is the value of imaging procedures when the hernia is not evident. They, then, go on to describe the repair techniques currently available that are capable of yielding an excellent long-term outcome.

[Our experience with the use of a plastic prosthesis and self-expanding stents in the palliative treatment of malignant neoplastic stenoses of the esophagus and cardia. Comparative analysis of results]. / La nostra esperienza con le protesi plastiche e gli stent autoespansibili nel trattamento palliativo delle stenosi neoplastiche maligne dell'esofago e del cardias. Analisi comparativa dei risultati.

Rapid palliation of malignant dysphagia is usually possible by means of the endoscopic implantation of a plastic prosthesis, but this device has a high morbidity rate. Recently, expandable metal stents have become available and may reduce the morbidity and mortality rates. The aim of this retrospective study was to evaluate self-expanding metal stents compared with conventional plastic prosthesis in malignant strictures of the oesophagus and cardia. One hundred and thirteen endoscopic tube implantations were carried out in 120 patients with malignant stenosis of the oesophagus and cardia using a plastic prosthesis over the period 1980-1993 (72 cases) and self-expanding metal stents over the period 1993-2001 (48 cases). The underlying causes of strictures were oesophageal or cardial cancer in 108 cases and oesophageal invasion by lung cancer in 12. The indications for endoscopic intubation were advanced tumour stage and/or risk factors which made resection inadvisable. The stents used in the conventional group were the Celestin pulsion tube in 18, the Atkinson prosthesis in 23 and the Wilson-Cook tube in 27, while the Ultraflex stent was always employed in the other group. Dysphagia was scored according to the Atkinson and Ferguson classification and the preoperative median score (3.6) was comparable in the two groups. The technical success rate was 94.4% with the plastic prosthesis (68/72) and 93.7% with the self-expanding metal stents (45/48) because in 4 and 3 patients, respectively, it proved impossible to implant the stent. After intubation the dysphagia score was improved in both groups (median score = 0.9) and the functional success rates were 85.2% (58/68) and 88.8% (40/45), respectively, while 10 and 5 patients showed no improvement of symptoms. The early complication rate was 5.9% (4/68) in the conventional stent group (1 perforation, 2 severe bleedings and 1 stent proximal migration) and nil in the other group. Late complications occurred in 14 (20.6%) (7 food obstruction, 4 neoplastic obstructions and 3 dislodgements) and 9 patients (20%) (3 neoplastic obstructions, 1 food obstruction, 3 distal migrations and 2 bleedings), respectively, but all the complications were easily corrected. Three deaths occurred with the plastic prosthesis (4.4%), while the mortality was nil with the metal stents. The median survival times were 183 (range: 58-486) and 151 days (range; 25-545), respectively. Our experience suggests that endoscopic placement of self-expanding metal stents is effective and safe for the management of dysphagia in malignant strictures of the oesophagus and cardia and has to be preferred to conventional plastic prostheses for easier implantation. The technical and functional success rates are similar in both groups, but the acute complication and mortality rates of the Ultraflex prosthesis are lower as compared to the traditional prosthesis.

[Stromal tumors of the small intestine. Retrospective analysis of 9 cases surgically treated]. / I tumori stromali dell'intestino tenue. Analisi retrospettiva di 9 casi trattati chirurgicamente.

The authors report on their experience with 9 patients with small bowel stromal tumours who underwent surgical treatment over the period 1974-2001. Seven were males and 2 females, with an average age of 63.1 years (range: 49-72 years). Histologically, 4 tumours showed evidence of differentiation towards smooth muscle elements (1 benign and 3 malignant), 4 towards neural elements (all malignant) and 1 lacked differentiation towards either cell type. Five tumours were located in the ileum, 3 in the jejunum and 1 in the duodenum. The main symptoms were abdominal pain and an abdominal mass, and the most sensitive diagnostic technique was abdominal CT scan. In the 8 jejunal or ileal stromal tumours we performed a typical intestinal resection, while undifferentiated duodenal stromal tumours were managed by pancreaticoduodenectomy. The diagnosis was only histological. There was no operative mortality, while 2 postoperative complications (1 pancreatic fistula and 1 myocardial infarction) occurred. The patient with jejunal benign muscular stromal tumour is still alive and in good health 73 months after the operation. Of the 3 patients with malignant muscular ileal stroma tumours, 1 is alive and free from disease 63 months after the operation, while the other 2 died of metastatic disease 39 and 29 months after surgery. Of the 4 patients with malignant neural stromal tumours (2 jejunal and 2 ileal) 1 with jejunal and 1 with ileal tumour were lost to follow-up, while 1 is still alive and in good health 101 months postoperatively; the 4th patient, with jejunal disease, developed liver metastasis 14 months after small bowel resection and died 12 months later. The patient with undifferentiated duodenal stromal tumour died of liver metastases 38 months after pancreaticoduodenectomy. Small bowel stromal tumours are more often than not malignant. The most frequent symptoms are abdominal pain and a palpable mass, but no specific signs have been detected. Abdominal CT scan is the most sensitive diagnostic technique in the evaluation of the location, size, invasion of adjacent organs and metastases. The treatment must be intestinal resection, and prognostic prediction on the basis of histological findings is difficult.