Bowel obstruction and peritoneal carcinomatosis in the elderly. A systematic review.

BACKGROUND: There are not guidelines for surgical management of malignant bowel obstruction (MBO) caused by peritoneal carcinomatosis (PC), mainly when it involves elderly; so its treatment is still debated. AIM: To outline indications and benefits of palliative surgery for obstructive carcinomatosis and determine what prognostic factors, including age, have independent and significant association with outcome. METHODS: We conducted English-language MEDLINE and EMBASE searches of articles published between 1998 and 2016, which reported outcome data after palliative surgery for MBO due to PC. We excluded all articles lacking of surgical cohort and those with main interest in conservative treatment. Of 1275 articles identified, 12 satisfied selection criteria and were included in our analysis. RESULTS: Overall, these studies involved 548 patients undergoing palliative surgery for MBO caused by PC. The median age was 58 (range 19-93). Relief of symptoms was achieved in 26.5-100% of cases. Postoperative morbidity ranged between 7 and 44%. Mortality was high (6-22%). The median survival was longer in surgical patients than in those receiving conservative therapy (8-34 vs 4-5 weeks). Factors associated with surgery failure were poor performance status, diffuse carcinomatosis, previous radiotherapy, and obstruction of small bowel. Old age was significantly associated with a poor prognosis upon univariate analysis, while this association vanished upon multivariate analysis. CONCLUSIONS: Surgical palliation can provide relief of obstructive symptoms as well as improved survival in well-selected patients, even if elderly.

Can only histological evaluation determine the allocation of ECD kidneys?

INTRODUCTION: There is a recent debate on the "transplantability" of ECD (Expanded Criteria Donors) kidneys and the selection criteria used to allocate them to single or double transplantation. Remuzzi et al. have defined a protocol incorporating pre-transplant donor biopsy to guide the use of older donor organs. They allocated organs as single or double transplants on the basis of histological findings. We aim to show the pros and cons of the only histological evaluation in the allocation of ECD kidneys, to compare the different experiences in United States and Europe and thus to discuss whether this tool should be used alone or included in a comprehensive clinical and histopathological evaluation. DISCUSSION: In the United States many Authors stated that the biopsy actually increases the percentage of kidney discarded and they raised questions about the importance of the biopsy in evaluating ECD kidneys for transplantation. On the other hand, the experiences of the majority of european transplant centers showed that allocating kidneys as single or dual transplant based on biopsy findings may achieve good graft and patient outcomes. Moreover, the experience of some centers as ours showed that kidneys allocated as DKT (Dual Kidney Transplant) on the basis of Remuzzi's score could have been suitable for single transplantation suggesting the need of an adjustment of the Remuzzi Score System. Many Authors, who are in favor of histological evaluation, actually believe that a comprehensive clinical and histopathological assessment before transplantation remains necessary. We lack precise national- or international-based selection criteria to guide clinicians. An adjustment of the Remuzzi Score System could be taken into consideration such as narrowing the indication for DKT from those ECD kidneys with higher scores and including the histological evaluation in a multifactor score.

Intraperitoneal dedifferentiated liposarcoma showing MDM2 amplification: case report.

BACKGROUND: Liposarcoma is the most common type of soft tissue sarcoma (STS). It is divided into five groups according to histological pattern: well-differentiated, myxoid, round cell, pleomorphic, and dedifferentiated. Dedifferentiated liposarcoma most commonly occurs in the retroperitoneum, while an intraperitoneal location is extremely rare. Only seven cases have been reported in literature. Many pathologists recognize that a large number of intra-abdominal poorly differentiated sarcomas are dedifferentiated liposarcomas. We report a case initially diagnosed as undifferentiated sarcoma that was reclassified as intraperitoneal dedifferentiated liposarcoma showing an amplification of the MDM2 gene. CASE PRESENTATION: A 59-year-old woman with abdominal pain and constipation was referred to the Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy, in November 2012. On physical examination, a very large firm mass was palpable in the meso-hypogastrium. Computed tomography (CT) scan showed a heterogeneous density mass (measuring 10 × 19 cm) that was contiguous with the mesentery and compressed the third part of the duodenum and jejunum.At laparotomy, a large mass occupying the entire abdomen was found, adhering to the first jejunal loop and involving the mesentery. Surgical removal of the tumor along with a jejunal resection was performed because the first jejunal loop was firmly attached to the tumor.Macroscopic examination showed a solid, whitish, cerebroid, and myxoid mass, with variable hemorrhage and cystic degeneration, measuring 26 × 19 × 5 cm. Microscopic examination revealed two main different morphologic patterns: areas with spindle cells in a myxoid matrix and areas with pleomorphic cells. The case was initially diagnosed as undifferentiated pleomorphic sarcoma. Histological review showed areas of well-differentiated liposarcoma. Fluorescence in situ hybridization (FISH) analysis was performed and demonstrated an amplification of the MDM2 gene. Definitive diagnosis was intraperitoneal dedifferentiated liposarcoma.No adjuvant therapy was given, but 5 months after laparotomy, the patient presented with a locoregional recurrence and chemotherapy with high-dose ifosfamide was started. CONCLUSIONS: No guidelines are available for the management of intraperitoneal dedifferentiated liposarcoma. We report this case to permit the collection of a larger number of cases to improve understanding and management of this tumor. Moreover, this study strongly suggests that poorly differentiated sarcomas should prompt extensive sampling to demonstrate a well-differentiated liposarcoma component and, if possible, FISH analysis.

The role of mutation analysis of the APC gene in the management of FAP patients. A controversial issue.

BACKGROUND: A correlation between the location of mutation in the adenomatous polyposis coli (APC) gene and clinical manifestations of familial adenomatous polyposis (FAP) has repeatedly been reported. Some Authors suggest the use of mutational analysis as a guide to select the best surgical option in FAP patients. However, data coming from studies on large series have raised questions on this issue. The aim of this study is to discuss the role of the genetic tests in the management of FAP. METHODS: A literature review was performed considering only peer-reviewed articles published between 1991-2015. All the studies examined the role of genetic as a guide for surgical management of FAP. RESULTS: Of 363 articles identified, 21 were selected for full-text review. We found different positions with regard the use of genetic tests to determine surgical management of FAP. In particular, while consistent correlations between the APC mutation site and FAP phenotype were observed in large series, 8 studies reported a wide variation of genotypephenotype correlation in patients with the same mutation and they recommended that decisions regarding surgical strategy should be based not only on genotype but also on the clinical factors and the will of the patient who must be fully informed. CONCLUSIONS: The decision on the type and the timing of surgery should be based on the assessment of many factors and genotype assessment should be used in combination with clinical data. KEY WORDS: Disease severity, Familial adenomatous polyposis, Genetic tests, Genotype-phenotype correlations, Surgical management.

Perioperative care of elderly outpatients. A review.

INTRODUCTION: Epidemiological data show a continuous expansion of elderly population in Europe. Older individuals require more medical services relative to their younger counterparts. The aim of this review was to summarize the most recent considerations in regards to preoperative assessment, postoperative outcomes, patient satisfaction and cost-effectiveness analysis of day surgery in the elderly. METHODS: This review considered studies that included older patients who were undergoing day surgery general procedures (such as inguinal hernia repair, excision of breast lump, haemorrhoidectomy). The interventions of interest to this review included selection criteria, perioperative care, management of postoperative pain. RESULTS: According to a large number of studies, old age does not constitute a contraindication for elderly to undergo ambulatory surgery but this population may require more careful intraoperative cardiovascular management. Hospitalization of older patients is frequently associated with postoperative cognitive dysfunction (POCD). Management of postoperative pain in older patients may be complicated by a number of factors, including a higher risk of age- and disease-related changes in physiology and disease-drug and drug-drug interactions. Early studies evaluating approaches to facilitating the recovery process have demonstrated the benefits of multimodal analgesic techniques. CONCLUSIONS: A lot of studies show that even elderly patients can successfully undergo day surgery procedures by implementing evidence-based perioperative care programs, minimizing operative duration and tissue trauma and providing a comfortable setting.

Perioperative care of elderly outpatient: a review.

INTRODUCTION: Epidemiological data show a continuous expansion of elderly population in Europe. Older individuals require more medical services relative to their younger counterparts. The aim of this review was to summarize the most recent considerations in regards to preoperative assessment, postoperative outcomes, patient satisfaction and cost-effectiveness analysis of day surgery in the elderly. METHODS: This review considered studies that included older patients who were undergoing day surgery general procedures (such as inguinal hernia repair, excision of breast lump, haemorrhoidectomy). The interventions of interest to this review included selection criteria, perioperative care, management of postoperative pain. RESULTS: According to a large number of studies, old age does not constitute a contraindication for elderly to undergo ambulatory surgery but this population may require more careful intraoperative cardiovascular management. Hospitalization of older patients is frequently associated with postoperative cognitive dysfunction (POCD). Management of postoperative pain in older patients may be complicated by a number of factors, including a higher risk of age- and disease-related changes in physiology and disease-drug and drug-drug interactions. Early studies evaluating approaches to facilitating the recovery process have demonstrated the benefits of multimodal analgesic techniques. CONCLUSIONS: A lot of studies show that even elderly patients can successfully undergo day surgery procedures by implementing evidence-based perioperative care programs, minimizing operative duration and tissue trauma and providing a comfortable setting.

Advantages and disadvantages of day surgery in a department of general surgery.

INTRODUCTION: We make our study of day surgery to awaken health worker that is possible to reduce the mean hospitalization time for each type of procedure: it needs improvement in communication, organizational and medical skills with a specific training both for medical and nursing staff. MATERIAL OF STUDY: A retrospective study on all patients who underwent day surgery procedures from 1st January 2008 to 31st December 2011. Out of 486 hospitalizations for programmed surgery, 177 (36.41%) were made in Day Surgery (DS) for a total of 450 operations. Of those patients, 105 (59.3%) stayed Overnight. RESULTS: Re-conversion rate of day surgery hospitalization reached 1% and referred to haemorrhagy post-hemorroidectomy. DISCUSSION: Nowadays in Italy many surgical procedures that could be performed in day surgery, are made in routine hospitalization with an higher cost for NHS. In our department DS is made for small surgery but even other procedures (hernioplasty, hemorroidectomy, stripping of vein safena, etc.). Our day surgery activity has had some negative aspects both for the availability of operating rooms and for the possibility of improvement of specific skills in our health staff. CONCLUSIONS: Day surgery permits a better use of resources and also a cut of costs. The dates of our series demonstrate the necessity of improving DS, considering trends of the most part of European Countries. The Authors highlight the importance of creating specific Units for Day-Surgery activity to permit a training for all health staff.

Clinical management of Crohn's disease in the elderly.

INTRODUCTION: Crohn's Disease (CD) occurs in the elderly in 5 - 25% of cases. Aim of our study: to define the features of clinical presentation, diagnostic tools and therapy of CD in old age. METHODS: In the last ten years we observed in our Department 47 patients affected by CD. We divided them into two groups: A (42 patients < 65 years old) and B (5 patients ≥ 65 years old). A retrospective survey evaluated the clinical presentation, diagnosis and treatments with relative outcomes. RESULTS: Group A: 23/42 patients (54,76%) were operated on. The most important indication for surgery was intestinal obstruction (15/42 pts, 65,2%). Small bowel resection was the most frequent surgical procedure (13/42 pts, 56,2%). Overall, 2/23 (8,7%) of the patients developed postoperative complications. There was no postoperative mortality. 8 pts (34,7 %) developed recrudescence of CD. Group B: 3 of 5 pts were operated on. Intestinal obstruction was the indication for surgery in all cases (100%). Two patients underwent small bowel resection (66,6%) and the third patient was submitted to an ileo-colic resection (33,3%). There was no mortality in the aftermath of surgery. In 2/3 operated patients (66,6%) recurrence occurred. All operations in the old patients were performed in urgency. CONCLUSIONS: Surgery of CD in the elderly appears in our experience to have the same indications and procedures as in young patients. The postoperative morbidity, mortality and recurrence rates are similar in two groups even if we observed slightly higher postoperative morbidity rates in elderly due to the presence of comorbidity.