Cholecystectomy for gallbladder disease in elderly aged 80 years and over.

BACKGROUND/AIMS: Patients aged 80 years and over show greater risk of complicated gallbladder diseases and associated comorbidities. The aim of the study is to evaluate the prognosis after laparoscopic or open cholecystectomy in these patients. METHODOLOGY: 100 patients aged between 80 and 92 years (group 1) and 241 patients aged between 70 and 79 years (group 2), undergoing cholecystectomy for gallbladder disease, are the subject of the study. Types of disease and surgery and p.o. morbidity and mortality have been evaluated. RESULTS: The patients of group 1 have shown a significant greater incidence of p.o. morbidity (20%) than group 2 (2.3%) (chi2 = 39.5; p < 0.001), regardless to the type of cholecystectomy. Endoscopic sphincterotomy for lithiasis of common biliary duct seems an important risk factor (chi2 = 7.1; p < 0.001). In group 2, the morbidity rate after laparoscopic cholecystectomy was lesser than after open surgery (X2=5.3; p < 0.02). In both groups, postoperative hospital stay was longer after open cholecystectomy and endoscopic sphincterotomy. CONCLUSIONS: Patients aged 80 years and over, undergoing cholecystectomy, specially after endoscopic sphinterotomy., have a greater risk of p.o. morbidity and mortality than younger. Laparoscopic and open cholecystectomy seems to bear the same poor p.o. prognosis.

Acute ischaemic colitis: outcome in elderly patients.

The Authors report the results of the management of ischaemic colitis in a surgical unit dedicated to elderly patients. Sixty-two elderly patients affected by ischaemic colitis were observed consecutively in the Surgery Unit of the University of L'Aquila from 1986 to 2004. The clinical records of the patients were retrospectively reviewed in order to assess clinical, biohumoral, endoscopic and x-ray findings pre- dictive of the most suitable type of treatment. Clinical follow-up was performed to evaluate the long-term prognosis after a mean period of 8 years post-treatment. Forty-six patients (74.1%) were treated by medical therapy only for a mean period of 7 days with a positive outcome and no mortality. Sixteen patients (25.9%) underwent surgery. Postoperative morbidity and mortality rates were 62.5% and 43.7%, respectively. Absence of bowel sounds (chi2 = 61.9, p < 0.001), ileus (chi2 = 17.8, p < 0.001) and air fluid levels in plain abdominal x-rays (chi2 = 18.6, p < 0.001) were risk factors for surgery. At follow-up a favourable outcome, without findings of recurrent acute or chronic ischaemic colitis, was observed in 55 patients. In conclusion, the results seem to suggest that medical therapy is the mainstay of treatment for acute ischaemic colitis in elderly patients with good clinical results. Peritonitis is an indication for surgery.

[New orientations in the management of advanced, metastatic gastrointestinal stromal tumors (GIST): combination of surgery and systemic therapy with imatinib in a case of primary gastric location]. / Nuovi orientamenti nella cura dei tumori stromali gastroenterici (GIST) avanzati e metastatici: trattamento combinato intervento chirurgico-terapia sistemica con imatinib in un caso a localizzazione primitiva gastrica.

Gastrointestinal stromal tumours (GIST) are rare neoplasms originating from connective tissue in the digestive tract with an incidence of less than 1% and account for most non-epithelial primitive digestive tumours. Metastasis diagnosed at the time of disease discovery confirms GIST malignancy. Kit protein, a trans-membrane tyrosine kinase receptor of staminal cells, is characteristically expressed by GIST. Most GIST have a mutation in the kit proto-oncogene. Resistance to conventional chemotherapy is commonly shown by malignant GIST. Most patients with advanced malignant GIST achieve clinical benefit with imatinib mesilate, an orally administered selective inhibitor of the tyrosine kinase receptor. We treated a 43-year-old male patient suffering from a gastric GIST diagnosed during a surgical emergency operation for peritonitis caused by gastric perforation. At the time of the first operation the patient had lost 10 kg body weight over the previous months and was seriously cachectic. During the emergency operation the perforation was sutured. The biopsy results showed the presence of CD1 17 (c-kit) and CD34 markers. A total body CT scan documented the substantial size of the gastric wall lesion, an increased volume of abdominal lymph nodes and compression of the splenic vein with alternative collateral circulation. The liver presented no less than 5 large metastases distributed in both the left and right lobes. There was also a pulmonary metastasis. Because of frequent spontaneous bleeding and starvation the patient was seriously anaemic. Considering the action mechanism of imatinib and the extent of the lesion we decided to perform a total gastrectomy procedure. At the time of the operation the stomach seemed to have a modified volume and shape: it appeared to be divided into two sacs, the larger and deeper of which was the original gastric cavity, while the superficial, smaller one seemed to be a protrusion of the organ. The stomach was indistinguishable from the spleen, the transverse colon and the distal pancreatic tract. The neoplasm was directly linked to the left liver and to the inferior diaphragmatic surface. We performed total gastrectomy and resection of the tail of the pancreas, the spleen, and the transverse colon all in one and the same session. The patient was discharged on postoperative day 8 and commenced imatinib therapy 30 days after the operation with 4 tablets per day. In the following months the patient repeated the CT scan to monitor the progressive volume reduction of the liver and lung lesions and a PET scan confirmed that the lesions were not active; the patient experienced a 13 kg body weight increase. One year after the operation the outcome appears to be lasting and the patient has tolerated the drug treatment well.

Is there a place for intraperitoneal onlay mesh repair (IPOM) of inguinal hernia among laparoscopic techniques?

BACKGROUND/AIMS: The Authors report their experience on laparoscopic hernioplasty using the intraperitoneal onlay mesh repair in 56 patients. METHODOLOGY: Thirty patients had a monolateral hernia, 9 of which were recurrent and 26 had a bilateral hernia, 6 of which were recurrent. Overall, a total of 90 hernias were treated. The hernia repair was performed by using "GORETEX Dual Mesh Plus biomaterial with holes" in the first 32 cases and the latest "Corduroy" type in the following 24 cases. The prostheses were fixed with titanium spiral tacks (Protack, Auto Suture, Tyco Healthcare). RESULTS: No intraoperative complications occurred and no conversion was necessary. Five minor postoperative complications (5.5%), 2 seromas and 3 transient paresthesias, were observed. Four patients (7.1%) needed analgesics after the first 24 hours. Mean hospital stay was 36 hours with a minimum of 24 and a maximum of 48. Mean resumption of normal activity was 8 days with return to work within two weeks. At an average 18 months follow-up, 3 recurrences were recorded (3.3%). CONCLUSIONS: The results of this study as well as the meta-analysis of the series presented in the literature, indicate that the intraperitoneal onlay mesh repair may be a feasible, safe and effective procedure in the treatment of recurrent and bilateral hernias or when a hernia repair is performed during other laparoscopic procedures. The intraperitoneal onlay mesh repair has in fact been shown to be faster and easier than the other more commonly performed laparoscopic hernioplasties (trans-abdominal preperitoneal repair and total extra-peritoneal repair). These data may also suggest utilizing this technique in particular cases of primitive hernia such as very active young males or heavy-duty workers. However the limited series and the short follow-up ask for randomized prospective long-term studies to definitely ascertain the true incidence of recurrence and therefore the effectiveness of this attractive procedure.

[Ergonomic and cosmetic aspects of laparoscopic appendectomy: personal technique]. / Ergonomia ed estetica nell'intervento di appendicectomia laparoscopica: tecnica personale.

We analyzed our case series in order to evaluate the evolution of our laparoscopic technique in ergonomic and cosmetic terms, leading to the right compromise between these aspects. We retrospectively analyzed 136 diagnostic laparoscopies for suspected appendicitis, using scheme A in the first 98 cases (one 10/12-mm umbilical trocar for the optics and two 5-mm operative trocars placed above the pubis on the right and left side) and scheme B in the other 38 cases (one 10/12-mm umbilical trocar for the optics and two 5-mm operative trocars, one placed over the pubis and the other one on the right hip, just on the umbilical line). The diagnosis of appendicitis was confirmed in 117 patients, while other diseases were present in 19 patients. There were no differences between the two groups in mean operative time (45 min), postoperative complications (0.7%) and clinical course (hospital stay: 36 hours on average). We believe that the right compromise between ergonomic and cosmetic considerations is the one shown in scheme B. In this way it is possible to perform all diagnostic and therapeutic manoeuvres such as pulling the appendix out through the umbilical trocar and using suprapubic trocars as an access route for a possible drainage.

["Low-pressure" laparoscopic cholecystectomy in high risk patients (ASA III and IV): our experience]. / La colecistectomia laparoscopica a "bassa pressione" nei pazienti ad alto rischio (ASA III ed ASA IV) nella nostra esperienza.

The insufflation pressure used for laparoscopic cholecystectomy is usually 12-15 mm Hg, and a pneumoperitoneum with carbon dioxide has a significant effect on both cardiovascular and respiratory function. These effects are transient in young, healthy patients, but may be dangerous in ASA III and IV patients with a poor cardiac reserve. This study was designed to assess the feasibility of performing laparoscopic cholecystectomy at 6.5-8 mm Hg insufflation pressure in "high-risk" patients. Thirteen patients, 10 ASA III and 3 ASA IV, with cholelithiasis, were included in this study The insufflation pressure was 6.5-8 mm Hg, with a 10 degrees anti-Trendelenburg position. The cardiovascular and blood gas variables studied were: mean arterial blood pressure, heart rate, respiratory rate, and end-tidal CO2 pressure. The authors reported no conversions and no intra- or postoperative complications. During insufflation heart rate and mean arterial blood pressure increased minimally if compared with laparoscopic cholecystectomy at 12-15 mm Hg. Pa CO2 increased after insufflation (+5 mm Hg), and the end-tidal CO2 pressure gradient was moderate (3.5 mm Hg) and unchanged during surgery. A low-pressure pneumoperitoneum is feasible for laparoscopic cholecystectomy and minimizes the adverse haemodynamic effects of peritoneal insufflation.

[Postoperative pain as complication of hernia surgical repair with mesh and plug]. / Il dolore postoperatorio come complicanza dell'ernioplastica inguinale con mesh e plug.

The authors assess the incidence of locoregional chronic pain after inguinal hernia repair. One hundred consecutive patients, with a mean age of 65.4 years, suffering from primary monolateral inguinal hernia, underwent suture-less mesh-plug hernioplasty. In all cases the inguinal nerves were identified. In the early postoperative period, a questionnaire was given to all patients in order to assess the frequency, type and intensity of postoperative locoregional pain and the impact of the pain on their quality of life. Sixty patients were available for follow-up with clinical examination and these were given the same questionnaire 2-4 years after hernioplasty. Pain intensity was scored by means of a visual-analogue scale (from 0 to 10). The incidence of locoregional pain after hernioplasty was 13.0% in the early postoperative period and 25.0% after a longer period of follow-up. None of the patients presented recurrent hernia. The symptomatic patients reported mild or moderate neurogenic pain. Severe pain was not reported. On the whole, the presence of mild-to-moderate chronic pain had no impact on the patients' quality of life. Our study confirms the high incidence of locoregional chronic pain even after sutureless mesh-plug hernioplasty, but that this has no serious effects on the patients' quality of life.