Laparoscopic hepatectomy for HCC in elderly patients: risks and feasibility.

BACKGROUND: Laparoscopic liver resection (LLR) appears to be safe and effective as open liver resection (OLR) for hepatocellular carcinoma (HCC). However, studies comparing LLR with ORL in elderly patients are limited. The purpose of this study is to compare the clinical outcomes of LLR versus OLR for HCC in elderly patients. METHODS: A retrospective analysis was made comparing laparoscopic (n = 11) and open (n = 18) liver resections in elderly patients performed at the University of Naples "Federico II" between January 2010 and December 2014. Demographic data, operative and postoperative outcomes were analyzed. RESULTS: Demographic and tumor characteristics of laparoscopic and OLRs were similar. There were also no significant differences in operating room time. Patients undergoing OLR had increased rate of minor complications (33 vs. 0%), longer lengths of stay (6 vs. 3 days) and higher blood loss (310 ± 84 vs. 198 ± 34 ml). There were no significant differences in major complication rates or 90-day mortality. DISCUSSION: LLR is safe and feasible as OLR for treatment of HCC in selected elderly patients.

Outcomes after non-cardiac surgery: mortality, complications, disability, and rehospitalization.

In the last 25 years, the number of patients aged ≥75 years undergoing non-cardiac surgery has greatly increased. In elderly patients, frailty is significantly associated with an increased risk of adverse events, functional decline, procedural complications, prolonged hospitalization, and mortality. The relationship between frailty and increased mortality and morbidity requires an appropriate tool of assessment to accurately quantify the patient's clinical and perioperative conditions. The preoperative evaluation of elderly patients candidate for non-cardiac surgery should include assessment of frailty, sarcopenia and malnutrition, as these are related to high surgical risk. For colon-rectal surgery as also for gastric cancer surgery, especially early gastric cancer, the introduction of laparoscopy has yielded considerable benefits in terms of short-term postsurgical outcomes, e.g. lower rate of intraprocedural bleeding and reduced length of hospital stay. Despite the progress made in preoperative assessment, surgical procedures and postoperative management, the improvement of outcomes after non-cardiac surgery in elderly patients remains a challenge and calls for future, well-designed clinical studies.

Evolution of surgical techniques for a progressive risk reduction.

Advanced age is a strong predictor of high perioperative mortality in surgical patients and patients aged 75 years and older have an elevated surgical risk, much higher than that of younger patients. Progressive advances in surgical techniques now make it possible to treat high-risk surgical patients with minimally invasive procedures. Endovascular techniques have revolutionized the treatment of several vascular diseases, in particular carotid stenosis, aortic pathologies, and severely incapacitating intermittent claudication or critical limb ischemia. The main advantages of the endovascular approach are the low complication rate, high rate of technical success and a good clinical outcome. Biliary stenting has improved the clinical status of severely ill patients with bile duct stricture before major surgery, and represents a good palliative therapy in the case of malignant biliary obstruction.

Transurethral Resection of the Prostate, Bladder Explosion and Hyponatremic Encephalopathy: A Rare Case Report of Malpractice.

We present an original case report of a bladder explosion during a TURP intervention for benign prostatic hypertrophy, that was brought on by the absorption of about 5 liters of glycine 1.5% and then onset of a severe hyponatremia. The quick and inappropriate correction of this electrolyte imbalance led the onset of encephalopathy and the death of the patient. The authors discuss the pathogenesis of these uncommon diseases and, considering the most recent Italian Legislation, they highlight the importance to respect good clinical practice standards and guidelines to ensure the most appropriate treatments for the patient and remove any assumptions of medical liability.

Uncommon primary hydatid cyst occupying the adrenal gland space, treated with laparoscopic surgical approach in an old patient.

Hydatid disease (HD) is caused by Echinococcus Granulosus (EG), which is a larva endemic in many undeveloped areas. The most common target is the liver (59%-75%). The retroperitoneal space is considered as a rare localization. We report an uncommon case of HD located in the adrenal gland space. PRESENTATION OF CASE: This is a 78-year-old Moroccan woman, with right flank pain for eight months previously. She denied contact with dogs or sheep. Her physical examination was normal. There was no pathological alteration of laboratory exams. CT scan measuring 5 cm without clear signs for a sure diagnosis found a round lesion in the right adrenal gland. An abdominal MRI showed a round mass of 34 x 27 mm with fluid component without a clear plane of dissection from kidney and liver. A laparoscopic procedure was performed to obtain a histological diagnosis. We reached a conclusive diagnosis of Hydatid cyst of right adrenal gland space. Hydatid cysts often develop in the liver. The location in the adrenal bed is rare without clinical signs related to alteration of the gland's secretion. Hydatid cyst identification in the adrenal gland space is based on ultrasonography, CT or MRI scans. The differential diagnosis includes various benign and malignant lesions. Laparoscopic procedure is the best approach available to obtain a histological diagnosis and a curative treatment. The best treatment for HD is the pericystectomy. Laparoscopic surgery can guarantee a radical resection of these lesions when it performed by an expert surgeon.

Use of a simplified consent form to facilitate patient understanding of informed consent for laparoscopic cholecystectomy.

BACKGROUND: Surgical informed consent forms can be complicated for patients to read and understand. We created a consent form with key information presented in bulleted texts and diagrams combined in a graphical format to facilitate the understanding of information during the verbal consent discussion. METHODS: This prospective, randomized study involved 70 adult patients awaiting cholecystectomy for gallstones. Consent was obtained after standard verbal explanation using either a graphically formatted (study group, n=33) or a standard text document (control group, n=37). Comprehension was evaluated with a 9-item multiple-choice questionnaire administered before surgery and factors affecting comprehension were analyzed. RESULTS: Comparison of questionnaire scores showed no effect of age, sex, time between consent and surgery, or document format on understanding of informed consent. Educational level was the only predictor of comprehension. CONCLUSIONS: Simplified surgical consent documents meet the goals of health literacy and informed consent. Educational level appears to be a strong predictor of understanding.