Factors influencing delayed discharge after day-surgery laparoscopic cholecystectomy: the DeDiLaCo study protocol.

OBJECTIVE: Laparoscopic cholecystectomy (LC) is the gold standard for most benign gallbladder diseases. Early discharge (<24 hours) has the same outcomes as longer (>24 hours) hospital stay. Nevertheless, the rate of delayed discharge >24 hours range from 4.6% to 37%. The primary endpoint of this Italian nationwide study is to analyze the prevalence of patients undergoing elective LC who experienced a delayed discharge >24 hours and identify potential limiting factors of early discharge. Results from these analyses will be used to select patients who can be safely discharged on the same day after surgery. Secondary endpoints will be to evaluate the patient's quality of life (QoL), assess the direct health costs associated with late discharge, and quantify the patient's involvement in the treatment process. PATIENTS AND METHODS: This prospective, observational study was conducted following a resident-led model and the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) guidelines. All patients were treated according to the local hospital protocol and received routine care as standard therapy. RESULTS: We expected to obtain the enrollment of at least 500 patients based on an assumed difference in discharge delay between the reference and the recruitable population of 6% and the identification of factors related to discharge failure within 24 h. Early discharge after LC leads to advantages both in terms of clinical outcomes and quality of life of the patient, and it is highly effective in terms of health costs and shortening the waiting list. However, clinical reality differs from the results of randomized studies by a complex series of non-objectionable real-world data influencing treatment plans. Therefore, we expected to identify independent predictors and factors of failure of early discharge. CONCLUSIONS: Clinical reality often differs from randomized trial results. In Italy, the vast majority of delayed discharges after LC may not be related to surgery and can be prevented both with logistical reorganization and with a readjustment of the trust reimbursement policies.

GIST: a clinical dilemma.

The authors report a clinical case of malignant gastric and duodenojejunal GIST, in which the only surgical treatment seems to be definitive. In a 69-year-old female, a surgical resection of the gastric and duodenojejunal tumor was performed. Histological analysis showed two spindle cells stromal tumors with mitotic rate >20/10 HPF and its uncommitted origin was demonstrated. Despite the high malignancy degree, the patient refused chemotherapy treatment and there were no local recurrence nor metastasis at a follow-up of 8 years. For this reason and because of the uncertain behavior of histologically benign GIST, the authors propose a lifelong follow-up of all patients managed with potentially curative surgical resection.

One-stage treatment in emergency setting for obstructing colorectal cancer.

The aim of this study was to evaluate the indications for one-stage treatment of obstructing colorectal cancer. From January 1998 to December 2003, 19 patients were operated on at our department for obstructing colorectal cancer. Thirteen patients underwent one-stage operation with immediate anastomosis without diversion, while 6 patients were managed palliatively. We performed resection and anastomosis following intraoperative irrigation in obstructing sigmoid cancer without colonic wall lesions, while subtotal colectomy was carried out in case of massively distended colon with ischemic lesions. Colostomy was indicated in 6 high-risk patients with unresectable lesions. In case of obstructing left colorectal cancer, an experienced surgeon can perform one-stage resection and anastomosis on good general status patients, conversely defunctioning colostomy may be ideal for surgeons with little experience in colorectal surgery and in very poor prognosis patients.