Elective abdominal aortic aneurysm repair in the very elderly: a systematic review.

Abdominal aortic aneurysm (AAA) is an age related disease, so the aging of the population has meant to more elderly people undergoing AAA repair. The authors conducted a systematic review of the literature to analyze the perioperative mortality and complication rates and long-term survival of elderly people after AAA repair. The literature was searched using the Embase, Cochrane library and Medline databases as at May 2008. All studies reporting on the perioperative and long-term outcomes of patients aged 80 years or more undergoing elective open (OAR) or endovascular AAA repair (EVAR) were considered. The risk of perioperative mortality and morbidity were calculated using the odds ratio (OR), with 95% confidence intervals (CIs), and the chi(2) test. Thirty-five studies on OAR, five on EVAR and four on both were considered. In the OAR group, the mortality rate (38 studies, 1793 patients) was 5.6% (95% CI, 4.5 to 6.7) and the morbidity rate (18 studies, 725 patients) was 26.9% (95% CI, 23.7 to 30.1). Twenty studies reported a median 5-year survival rate of 60% (range, 14% to 86%). In the EVAR group, the mortality rate (9 studies, 1159 patients) was 4.5% (95% CI, 3.3 to 5.7) and the morbidity rate (8 studies, 1078 patients) was 16.5% (95% CI, 14.3 to 18.7). The follow-up data covered less than 5 years in five studies. Although the perioperative death rate was higher after OAR than after EVAR, the difference was not statistically significant (P=0.170; 95% CI, 0.90 to 1.78). The major systemic morbidity rate was significantly higher after OAR (P<0.001; 95% CI, 1.47 to 2.34). Although the perioperative mortality rate was comparable between the two surgical procedures, the marked selection bias cannot be ignored and may well mean that the mortality rates are actually higher for both procedures. Although the mid- and long-term survival rates after OAR and EVAR could seem acceptable, more information is needed on the long-term outcome after EVAR in larger samples in order to assess the durability of this less invasive procedure.

Palliative surgery for gastric cancer in elderly patients.

Poor survival rate of elderly patients affected by locally advanced or metastatic gastric cancer is related to primary tumour complications. Bleeding is the most important adverse event, other major complications are gastric outlet obstruction and nutritional deprivation. Rarely the patients will perforate the stomach cancer and there is a sudden end to their life; contamination of the ascites result in a rapid death. Thus, an aggressive approach toward palliation of this condition is resection: in this manner the expected survival is approximately one year. Derivation techniques or endoscopic treatments are applied in those patients whose operative risk is inacceptable; in these cases poor median survival is expected. The aim of this report in to refer about the experience in palliative surgery for gastric cancer in the Department of Geriatric Surgery of the University of Padua.

[Usefulness of chromogranin A determination in the diagnosis of neuroendocrine neoplasia]. / Utilità del dosaggio della cromogranina A nella diagnosi delle neoplasie neuroendocrine.

Neuroendocrine gastroenteropancreatic tumor diagnosis is a very difficult and expensive procedure. This study compared Chromogranin A (CgA) to Neuron-specific enolase (NSE) in 55 patients affected by neuroendocrine tumors. Advanced local or metastatic neoplasia was found in 43 patients. Radical operation was performed in 12 patients. Seventeen cases of lung microcystoma, 23 cases of other intestinal tumors and 19 patients affected by irritable bowel syndrome were used as controls. CgA sampling demonstrated sensitivity of 73% and specificity of 66%, a positive predictive value of 77% and a negative predictive value of 61% while NSE sampling showed sensitivity of 100%, specificity of 36%, a positive predictive value of 15% and a negative predictive value of 100%. CgA values demonstrated a statistically significant difference between patients with neuroendocrine tumors and tumor-free resected patients (p = 0.0015), microcystoma patients (p = 0.0087), other types of neoplasia (p = 0.01) and irritable bowel syndrome patients (p = 0.0004). No significant difference was found among the same groups when NSE values were analyzed. The high diagnostic accuracy of CgA sampling renders it very useful in early neoplastic detection, even in cases of nonfunctioning neoplasms or absence of liver metastases. In addition, CgA sampling may be an effective screening test in patients with irritable bowel syndrome or with liver or lung metastases when there is no evidence of the primitive tumor.

[Physiopathology of intestinal anastomoses and dehiscences]. / Fisiopatologia delle anastomosi intestinali e delle deiscenze.

A lot of mechanisms of healing of intestinal anastomoses has been explained. A leading role in the intestinal wall is made by the submucosal tunica, where collagen synthesis and degradation process take place, but local and systemic factors are present by a definite causal action. Technique of suture, materials and surgeon's experience are of fundamental importance for the success of operation, even if in some cases it is important to take in consideration the clinical situation: emergency or not, the patient's state and age, concomitant diseases, pharmacological or radiotherapeutic treatments. Nowadays surgical research tends towards biochemical and molecular field to identify the factors, that speed up the healing process to use them in suturing materials getting a quick healing as soon as possible.

[Breast cancer in elderly women]. / Il carcinoma della mammella nell'anziana.

Breast cancer represents an important epidemiological and clinical problem, and the elderly age represents a large proportion of women with breast cancer. In patients older than 65-year, the frequency of breast cancer is 50% and more. Early diagnosis and adequate therapy may play an important role also in the elderly. We performed a retrospective analysis of 146 women older than 65-year to determine the effect of age in management of the disease.

[Complications of peptic ulcer disease in the elderly]. / Le complicanze della malattia peptica nell'anziano.

Peptic disease is even more described in the elderly patients. Is it different from the young people peptic disease? Is it a specific syndrome? These questions are debated by the authors from their experience about in the old age surgery. In 1997, out of 569 oesophago-gastro-duodenoscopies positive for peptic disease, about 2/5 of the patients were older than 65-year with a high percentage of hypersecretive patients. Also the incidence of complications is similar in the aged and young patients, but their course is much more serious in the elderly. NSAID therapy was not always demonstrated as a determining factor of complications in the elderly. The ulcer perforation is the most serious complication; in the over-70 year aged persons a very severe course is often demonstrated. In conclusion in the elderly a specific diagnostic and therapeutic care is recommended to avoid the high incidence of deadly complications.

[Stomach cancer in the elderly]. / Il cancro gastrico nell'anziano.

Gastric cancer often affect very old patients even if it is not a typical disease of the elderly. The Authors report their experience on 108 patients (mean age of 77.8 years) affected by gastric cancer; early diagnosis and surgical technique are discussed.

[Surgery of inguinal and femoral hernia in the elderly]. / La chirurgia dell'ernia inguinale e crurale nell'anziano.

Old people are continuously increasing in frequency but age is not a significant factor to value the operative risk in hernia surgery. From June 1985 to December 1996, 189 patients, aged > 80-year, were submitted to hernia surgery. No complications were noted when elective surgery was performed. Emergent procedure was undertaken in 7% of the patients major perioperative complications and one death were registered in this group of patients. Mean hospital stay has decreased in the period of the study: was 2.2 days in the last two years. Local anesthesia permitted a day surgery procedure in 60% of cases.