Surgery of abdominal aorta in octogenarians. Can indications be extended?

BACKGROUND: This paper describes the authors' experience with the management of the abdominal aorta in patients aged over 80 years. METHODS: Ten urgent procedures were performed on patients older than 80 years during a 2 year period. In 4 cases surgery was performed because of a ruptured aneurysm of the subrenal abdominal aorta, in 2 cases for active symptomatic aneurysms, in 3 cases for severe lower limb ischemia (occlusion of the iliac and femoral arteries) and in 1 case for a secondary aortoenteric fistula. RESULTS: The operative mortality rate was 20% (2 cases with a ruptured aneurysm). Five patients are still alive in good health conditions (one of them had been operated twice for two different diseases). Even if our findings refer to a small number of patients, although similar series on emergency operations found in the literature are not substantially larger, the results do not advise against operative treatment of the abdominal aorta in cases requiring a direct approach, even in patients over 80 years of age. CONCLUSIONS: If this treatment strategy is obviously adopted in emergency conditions, as with the patients we are reporting on, since the alternative to operation is usually death, it should also be carefully considered in elective circumstances, where alternative treatments such as endovascular stents did not to date obtain better results. In the elective scenario all the necessary biological and physical parameters as well as the patient's age should be taken into proper account in deciding whether to operate. This is specially true now that the average life spans of an individual is longer so that patients, who may incur serious problems if left untreated, may be offered a better quality of life.

Restoration of the pelvic circulation in patients with abdominal aortic aneurysms receiving aortobifemoral grafts.

When operating on abdominal aortic aneurysms associated with stenoses or occlusions of iliac vessels, surgeons may face the problem of reestablishing circulation to pelvic or gluteal territories. A new technique consists of anastomosing a posterior opening in the body or one of the branches of a bifurcated graft, distally sutured to the femoral artery, to the distal aortic stump, which contains all the patent vessels arising from the end of the aorta, such as inferior mesenteric and lumbar arteries. This technique, successfully performed in two cases, has the advantages of avoiding closure of the distal aortic stump and a possible backflow leak and of ensuring adequate pelvic circulation.

[Did the arrival of prostanoids modify therapeutic indications in peripheral obstructive arteriopathies? Considerations based on our experience]. / L'avvento dei prostanoidi ha modificato le indicazioni terapeutiche nell'arteriopatia periferica ostruttiva (PAOD)? Considerazioni sulla base della nostra esperienza.

Prostaglandins, particularly PGE1, are now widely used in PAOD as they act on the balance of microcirculation and endothelial function. The Authors report their experience in 21 patients (19 males, 2 females; median age 64) treated with PGE1, 80 micrograms per day i.v. and subcutaneous heparin 0.2 ml twice a day and followed from September 1993 to March 1995. Twenty patients were affected by PAOD; in this group 8 (5 diabetics) were suffering from claudicatio intermittens, II from critical ischaemia, while 1 patient had thromboangiitis obliterans. One of the 8 claudicating patients did not complete the protocol because he underwent a femoropopliteal bypass, while the other 7 experienced a significant and stable improvement (two of these walk quite freely). Only 7 of the 11 patients with C.L.I. received a medical treatment alone; 4 had healing of necrotic ulcers and in the other 3 the treatment was stopped because of the onset of severe hypertension or because they were non-responders. In 4 patients with C.L.I. PGE1 was associated with a surgical revascularization procedure, and its role has to be better defined. From the analysis of the results reported treatment with PGE1 may be an important step in Fontaine class IIb patients, before planning a surgical approach. Also in most cases of C.L.I. it proved its efficacy, however, the initial therapeutic option (either medical or surgical) should be evaluated in each single case.

[Diverticula of the small intestine: the authors' own experience]. / I diverticoli dell'intestino tenue: contributo d'esperienza.

The Authors report the experience acquired in the management of small bowel diverticula at the Emergency Surgical Department of the University of Bari, from 1987 to 1993. After a brief illustration of the few cases observed, the Authors discuss the problems of this rare pathology, which as all types of bowel diverticula, is diagnosed with difficulty. In fact, only in case of complications, with a specific check-up, the lesions may be discovered. Although rarely, emergency surgery may be needed when complications such as bleeding or occlusion occur. Usually the treatment of minor complications (dyspepsia, gripes, steatorrhoea, constipation and diarrhoea) consists of dietetic indications and symptomatic drugs.

[Intrahepatic cholangiojejunostomy on the third segment in non-operable neoplasms of the hepatic hilum]. / La colangiodigiunostomia intraepatica al III segmento nelle neoplasie inoperabili dell'ilo epatico.

The authors report their experience in 19 cases of primitive or secondary tumor of the hilus of the liver which couldn't benefit from radical operation. Palliative treatments--to resolve the jaundice (which is often the only responsible for a short-term exitus)--include surgical (intrahepatic bilio-digestive derivations) and non surgical procedures (PTDB, percutaneous transtumoral intubation). Considering the ephemeral results of the latter, the Authors take peripheral derivative operations into account and particularly the Soupault and Couinaud technique (intrahepatic colangiojejunostomy) performed in 7 patients with satisfying results. It is an easy and quick technique--because of constant anatomical situation of the left intrahepatic biliary distribution and of the superficial location of the duct of the III segment--which allows a lasting biliary decompression with a good residual life.