Influence of splanchnic artery stenosis on the in-hospital clinical course of elderly patients.

BACKGROUND: Chronic mesenteric ischaemia (CMI) has a long asymptomatic period, but little is known about the clinical implications of this phase of the disease, particularly in the elderly, who are most exposed to the condition. AIMS: The aim of the present observational study was to survey the in-hospital clinical course of elderly patients during the non-specific phase of the disease due to occlusion of at least one splanchnic artery. METHODS: For a median of 29 months, we followed up 85 patients aged 65 and over who, for various clinical reasons, had undergone computed tomographic and magnetic resonance angiography during 2010 at Padua Teaching Hospital, assessing economic impact and reasons for admission. RESULTS: Thirty-four of these patients had at least one occluded artery, and 68 % of them had at least one hospital admission. Elderly CMI patients were characterised by a higher number of admissions (median 2 vs 1 p = 0.05) and a higher cost (6044 vs 1733 Euros p = 0.04), but did not present typical gastrointestinal symptoms. The higher number of hospital admissions was not due to specific clinical risks (admitting wards: general medicine: 32 vs 29 %, p = 0.77; general surgery 8 vs 14 %, p = 0.73; vascular surgery: 26.5 vs 20 %, p = 0.46). CONCLUSIONS: In the asymptomatic phase of CMI, hospitalised elderly patients with at least one occluded splanchnic artery can be subject to a more challenging in-hospital clinical course.

Current practice in colonoscopy in the elderly.

Colonoscopy in the elderly is a reliable practice of great diagnostic and management value. However, patient's age has long been considered to affect the success of the procedure, achieved when the cecum is intubated, there is a good view of the colon if preparation has been properly carried out, and the examination does not cause excessive discomfort or complications. Substantial improvements have been made to the latter two aspects, due to more widespread use of deep sedation with propofol and cardiocirculatory monitoring during the procedure. The aim of our work was to assess whether, in the everyday practice of an open-access, digestive endoscopy teaching center, staffed by various providers delivering screening for polyposis, age is still a limitation to the success of the procedure and whether appropriate measures have been taken to improve colonoscopy in geriatric patients. We analysed 1480 consecutive colonoscopies, of which 319 were performed in patients aged over 73 years. The examination was significantly less successful in this group of patients (88.1 vs 94.4, p=0.0001), but there were no major technical or use-related complications connected with administration of propofol for sedation purposes, despite lower doses to the elderly (2.2 ± 1.1 mg/kg total dose, mean 151 ± 72.4 mg vs 2.9 ± 1.3 mg/kg total dose, mean 199 ± 77.9 mg in younger patients, p<0.001). More experienced technical staff were not allocated to these colonoscopies (for endoscopic or anesthesiological purposes) and, according to the results of multivariate stepwise logistic regression analysis, inadequate preparation was the main factor affecting the success of the procedure in elderly patients (OR 5.9, 95% CI 2.25-15.72; p=0.0003). Only body weight over 60 kg facilitated it (weight ≥ 60 kg, OR 0.46, 95% CI 0.26-0.83). In colonoscopy in the elderly, safety appears to be the primary concern and, good outcomes can be achieved, but sometimes at the expense of diagnostic accuracy. This could probably be improved through better pre- and post-procedure care, not currently differentiated between young and elderly patients.

Death after an accidental fall of a 101 year old hospitalized patient. Medico-legal implication of falling in geriatrics.

BACKGROUND: The case presented by the authors gives the opportunity to discuss the medico-legal issues related to lack of prevention of falls in elderly hospitalized patients. CASE PRESENTATION: A 101 year old Caucasian female was admitted to a surgery division for evaluation of abdominal pain of uncertain origin. During hospitalization, after bilateral bed rails were raised, she fell and reported a femoral fracture. Before surgical treatment of the fracture, scheduled for the day after injury, the patient reported a slight reduction in hemoglobin. She received blood transfusion but her general condition suddenly worsened; heart failure was observed and pulseless electrical activity was documented. The patient died 1 day after the fall. Patient relatives requested a judicial evaluation of the case.The case was studied with a methodological approach based on the following steps: 1) examination of clinical records; 2) autopsy; 3) evaluation of clinicians' behavior, in the light of necroscopic findings and a review of the literature. CONCLUSIONS: The case shows that an accurate evaluation of clinical and environmental risk factors should be always performed at the moment of admission also in surgery divisions. A multidisciplinary approach is always recommended also with the involvement of the family members. In some cases, as in this one a fall of the patient is expectable but not always avoidable. Physical restraint use should be avoided when not necessary and used only if there are no practical alternatives.

Usefulness of a fast track list for anxious patients in a upper GI endoscopy.

BACKGROUND: To determine whether patients with no alarm signs who ask the endoscopist to shorten their waiting time due to test result anxiety, represent a risk category for a major organic pathology. METHODS: At our open-access endoscopy service, we set up an expedite list for six months for outpatients who complained that the waiting time for gastroscopy was too long. Over this period we studied 373 gastroscopy patients. In addition to personal details, we collected information on the presence of Hp infection and compliance with dyspepsia guideline indications for gastroscopy. RESULTS: Average waiting time was 38.2 days (SD 12.7). The 66 patients who considered the waiting time too long underwent gastroscopy within 15 days. We made 5 diagnoses of esophageal and gastric tumour and gastric ulcer (7.6%) among the expedite list patients and 14 (4.6%) among those on the normal list (p=0.31). On including duodenal peptic disease in the analysis, the total prevalence rate rose to 19.7% in the short-wait group and to 10.4% (p=0.036) in the longer-wait group. DISCUSSION AND CONCLUSIONS: Our data suggests that asking to be fast-tracked does not have prognostic impact on the diagnosis of a major (gastric ulcer and cancer) pathology.

Local recurrence of gastric cancer after total gastrectomy: an unusual presentation.

A 71 years old Italian man had type 3 gastric cancer of the greater curvature. Total gastrectomy with splenectomy and D2 lymph node dissection were performed. After discharge chemotherapy ELF regimen was administered for 6 months. After 16 months from the operation a local recurrence was discovered by CT scan. Surgical en-bloc resection was performed removing pancreatic tail, splenic colic flexure and a portion of left diaphragm. Histological examination confirmed local recurrence of gastric adenocarcinoma infiltrating pancreas, colon and diaphragm with lymph node metastasis.

Difficult colonoscopies in the propofol era.

BACKGROUND: To study the relationship between endoscopic practice and adverse events during colonoscopy under standard deep sedation induced and monitored by an anesthetist. METHODS: We investigated the routine activity of an endoscopy center at the Padova University teaching hospital. We considered not only endoscopic and cardiorespiratory complications, but also the need to use high-dose propofol to complete the procedure, and the inability to complete the procedure. Variables relating to the patient's clinical conditions, bowel preparation, the endoscopist's and the anesthetist's experience, and the duration of the procedure were input in the model. RESULTS: 617 procedures under deep sedation were performed with a 5% rate of adverse events. The average dose of propofol used was 2.6 ± 1.2 mg/kg. In all, 14 endoscopists and 42 anesthetists were involved in the procedures. The logistic regression analysis identified female gender (OR=2.3), having the colonoscopy performed by a less experienced endoscopist (OR=1.9), inadequate bowel preparation (OR=3.2) and a procedure lasting longer than 17.5 minutes (OR=1.6) as the main risk factors for complications. An ASA score of 2 carried a 50% risk reduction (OR=0.5). DISCUSSION AND CONCLUSIONS: Our model showed that none of the variables relating to anesthesiological issues influenced which procedures would prove difficult.

Maximizing the general success of cecal intubation during propofol sedation in a multi-endoscopist academic centre.

BACKGROUND: Achieving the target of 95% colonoscopy completion rate at centres conducting colorectal screening programs is an important issue. Large centres and teaching hospitals employing endoscopists with different levels of training and expertise risk achieving worse results. Deep sedation with propofol in routine colonoscopy could maximize the results of cecal intubation. METHODS: The present study on the experience of a single centre focused on estimating the overall completion rate of colonoscopies performed under routine propofol sedation at a large teaching hospital with many operators involved, and on assessing the factors that influence the success rate of the procedure and how to improve this performance, analyzing the aspects relating to using of deep sedation. Twenty-one endoscopists, classified by their level of specialization in colonoscopic practice, performed 1381 colonoscopies under deep sedation. All actions needed for the anaesthesiologist to restore adequate oxygenation or hemodynamics, even for transient changes, were recorded. RESULTS: The "crude" overall completion rate was 93.3%. This finding shows that with routine deep sedation, the colonoscopy completion rate nears, but still does not reach, the target performance for colonoscopic screening programs, at centers where colonoscopists of difference experience are employed in such programs.Factors interfering with cecal intubation were: inadequate colon cleansing, endoscopists' expertise in colonoscopic practice, patients' body weight under 60 kg or age over 71 years, and the need for active intervention by the anaesthesiologist. The most favourable situation--a patient less than 71 years old with a body weight over 60 kg, an adequate bowel preparation, a "highly experienced specialist" performing the test, and no need for active anaesthesiological intervention during the procedure--coincided with a 98.8% probability of the colonoscopy being completed. CONCLUSIONS: With routine deep sedation, the colonoscopy completion rate nears the target performance for colonoscopic screening programs, at centers where colonoscopists of difference experience are employed in such programs. Organizing the daily workload to prevent negative factors affecting the success rate from occurring in combination may enable up to 85% of incomplete procedures to be converted into successful colonoscopies.

Perioperative albumin ratio is associated with post-operative pancreatic fistula.

BACKGROUND: Despite improvements in surgical techniques and perioperative management, post-operative pancreatic fistula (POPF) remains a serious complication after pancreaticoduodenectomy (PD). The aim of this study was to evaluate the role of perioperative clinical variables of patients, including albumin level, in predicting pancreatic fistula. METHODS: A total of 86 patients underwent PD for pancreas cancer between 2011 and 2017 at our institution. We prospectively investigated the relation between patient's characteristics and the incidence of clinically relevant (CR)-POPF. Perioperative albumin ratio was defined as post-operative day 1 (POD1) albumin level/preoperative albumin level. RESULTS: A total of 23 patients (26.7%) developed CR-POPF. At univariate analysis POPF correlated with soft pancreas (P = 0.045), low POD1 albumin (P = 0.02), POD1 and POD3 amylase levels in drainage fluid (P = 0.003 and P = 0.014, respectively) and perioperative albumin ratio (0.58 ± 0.10 versus 0.69 ± 0.12 in patients without POPF; P = 0.003). No significant correlations with POPF were demonstrated for surgical time, serum amylase levels and preoperative albumin levels. At multivariate analysis POD3 amylase level in drainage fluid and perioperative albumin ratio were the only significant independent parameters (P = 0.027 and P = 0.047, respectively). CONCLUSIONS: Perioperative albumin ratio can predict POPF after PD.

Autologous great saphenous vein tailored graft to replace an infected prosthetic graft in the groin.

The authors propose a technique using the autologous great saphenous vein to replace an infected prosthetic limb graft at the groin. The whole great saphenous vein is incised longitudinally and divided into 2 approximately equal segments, which are sewn side to side. The longitudinal edges of the resulting great saphenous vein are then joined and anastomosed side to side to form a conduit, whose caliber is twice the original vein's diameter. The authors have used this technique to replace 1 limb of a prosthetic aortofemoral bypass infected at the groin. After 5 years, the new venous conduit is patent, with no recurrent infection, dilation, or aneurysmal degeneration. If validated by further experiences, this might be an attractive alternative to restoring flow through clean tissue planes using extra-anatomic bypass or the femoral vein in the infected fields.

Does the Multidimensional Prognostic Index (MPI), based on a Comprehensive Geriatric Assessment (CGA), predict mortality in cancer patients? Results of a prospective observational trial.

OBJECTIVE: Despite the lack of definitive data on the impact of Comprehensive Geriatric Assessment (CGA) in the geriatric oncology setting, the broad use of any form of CGA is strongly recommended before any treatment decision in elderly cancer patients (ECP); currently there is no consensus about the best format for this geriatric assessment. The aim of this study was to firstly test the Multidimensional Prognostic Index (MPI) in ECP with locally advanced or metastatic disease. MATERIALS AND METHODS: Patients aged ≥70years with inoperable or metastatic solid cancer consecutively admitted to our Program of Geriatric Oncology were assessed by a multidisciplinary team and received a basal CGA to calculate the MPI score. RESULTS: A hundred and sixty patients entered the study. In the Cox's regression model, MPI, CIRS-SI, BSA, GDS, MMSE, chemotherapy and a diagnosis of primary lung cancer were associated with mortality at 6 and 12months. The ROC curves confirmed the prognostic value of MPI, with the best discriminatory power for mortality at both 6 and 12months. CONCLUSION: The present study is the first to indicate that the MPI retains its prognostic value even in elderly cancer patients with advanced stage of disease. The CIRS-SI and the GDS may potentiate the prognostic value of MPI.

Infrapopliteal arterial reconstructions for limb salvage in patients aged > or =80 years according to preoperative ambulatory function and residential status.

BACKGROUND: Although numerous studies have addressed peripheral revascularizations for critical limb ischemia (CLI) in patients aged > or =80 years, few have focused exclusively on infrapopliteal arterial reconstructions. This study aimed to analyze early and long-term outcomes in very elderly patients who underwent surgical infrapopliteal revascularization for CLI according to their pre-operative ambulatory function and residential status. METHODS: Over an 18-year period, all consecutive patients aged > or =80 years referred to our institution for CLI requiring primary infrapopliteal or inframalleolar arterial reconstruction were enrolled in the study. All procedures were completed by the same surgeon with patients under regional anesthesia. Patency, limb salvage, amputation-free survival, and cumulative survival rates were assessed by Kaplan-Meier analysis. The patient's pre- and postoperative ambulatory function and residential status (at home vs in a nursing home) were also analyzed. The mean follow-up was 6.2 years (range, 0.1-11.5) and was obtained for 98% of patients. RESULTS: In all, 197 patients (134 men; mean +/- SD age, 82.8 +/- 1.7 years) with 201 critically ischemic limbs were enrolled in the study. No deaths or fatal major complications occurred in the peri-operative period (first 30 days); the local complication rate was 6%. After 1 and 7 years, the primary patency rates were 88% and 68%, the limb salvage rates were 96% and 87%, the amputation-free survival rates were 88% and 39%, and the survival rates were 91% and 44%, respectively. At last follow-up or death, 80% of the patients were ambulatory and 20% were not; 80% lived at home and were independent, another 9% lived at home with assistance, and 76% of the sample lived at home and were ambulatory. CONCLUSION: Infrapopliteal arterial revascularization in the very elderly with CLI proved safe, effective, and durable, confirming that age per se and concomitant comorbidities do not necessarily affect technical and clinical outcomes. Ambulatory function and independent living status are well preserved because, despite a relatively short life expectancy, the majority of very elderly revascularized CLI patients can be expected to spend their remaining years ambulatory and at home. In contrast, patients with poor ambulatory function or who required assistance pre-operatively were less likely to improve their status after limb revascularization despite a successful technical result.

Revascularization to an isolated ("blind") popliteal artery segment: a viable procedure for critical limb ischemia.

BACKGROUND: The purpose of this study was to analyze our experience of bypass procedures to an isolated ("blind") popliteal artery segment (IPAS) to revascularize the perigeniculate arteries in patients with critical limb ischemia (CLI), to establish whether such revascularizations could yield acceptable results in terms of patency and limb salvage (LS) rates. METHODS: Over a decade, 347 above-knee arterial revascularizations were performed in 293 patients and in 51 (14.7%) of these the outflow vessels were the perigeniculate arteries arising from an IPAS, through a reversed saphenous vein or spliced veins (n = 30, 58.8%; group I) or polytetrafluoroethylene (n = 21, 41.2%; group II) prosthetic grafts. Patency, LS, and survival rates were assessed using Kaplan-Meier life-table analysis. A complete follow-up (range, 0.1-10.4 years; mean, 5.6 years) was obtained in 49 patients. RESULTS: The IPAS was chosen as the last resort in 39 patients (76.5%) because no other infrapopliteal artery was identified as being available at angiography; in 12 patients (23.5%) it was chosen because of an invasive foot infection or ischemic necrosis overlying the dorsalis pedis or the posterior tibial arteries. The study series was mainly male, with significantly more younger patients in group I (72 +/- 1 years vs 74 +/- 5 years, P = .037). Group I had a statistically higher incidence of diabetes mellitus (76.6% vs 47.6%, P = .033), insulin dependence (56.7% vs 28.6%, P = .047) and history of smoking (80% vs 47.6%, P = .016) than group II. None of the patients died in the perioperative period. There were 3 early graft failures (2 in group I), prompting 3 major amputations. Kaplan-Meier analysis identified 5-year patency and LS rates of 51.4 +/- 9.6% and 90 +/- 4.3%, respectively, in the series as a whole, and the 2 groups had comparable 5-year patency, LS and survival rates. CONCLUSION: Revascularizations to an IPAS can be performed with acceptable results in terms of patency and LS rates, even when there is no infrapopliteal runoff vessel. Finding perigeniculate arteries arising from an IPAS with no tibio-peroneal vessel reconstitution at arteriography does not justify a pessimistic attitude to the performance of such revascularizations for LS.

Infrapopliteal arterial revascularization for critical limb ischemia: is the peroneal artery at the distal third a suitable outflow vessel?

PURPOSE: Though the peroneal artery (PA) often remains patent despite disease or occlusion of other infrapopliteal arteries, there is skepticism about using the terminal PA as the outflow tract in distal revascularizations for limb salvage, especially when a patent inframalleolar artery is available. We analyzed our experience of using the distal PA and inframalleolar or pedal branches arteries as outflow tracts in revascularizations for critical limb ischemia. METHODS: Over a decade, among 651 infrapopliteal arterial reconstructions performed in 597 patients, the PA was the outflow vessel in 214, its distal third being involved in 69 vein revascularizations (study group). During the same period, 187 vein bypass grafts were performed to 179 inframalleolar and 8 pedal branches arteries (control group). Patency, limb salvage and survival rates were assessed using Kaplan-Meier life-table analysis. Complete follow-up (range, 0.1-10.2 years; mean, 5.8 years) was obtained in 245 (95.7%) patients (66 were in the study group). RESULTS: The distal PA was chosen as the target vessel: (1) because the proximal, mid-PA was occluded or severely diseased and no other adequate inframalleolar or pedal branches arteries were identified preoperatively (n = 30; 43.5%); (2) because an alternative inframalleolar target vessel was present but severely diseased (n = 9; 13%); (3) because of the length limitations of the available vein (n = 12; 17.4%; or (4) because of the presence of invasive infection or necrosis overlying the dorsalis pedis or posterior tibial arteries (n = 18; 26.1%). The study group was significantly younger than the control group (68 +/- 7 years vs 70 +/- 6 years, P = .039), and included significantly more patients with diabetes mellitus (65.2% vs 50.2%, P = .033) and insulin dependence (52.2% vs 37.9%, P = .041), dialysis-dependent chronic kidney disease (5.8% vs 1.1%, P = .047), and history of smoking (75.3% vs 58.2%, P = .012). None of the patients died in the perioperative period. Although the overall need for minor amputation was statistically higher in the PA group (78.2% vs 63.1%, P = .022), especially as concerns partial calcanectomy (8.7% vs 2.1%, P = .026), the proportion of wounds completely healed during the follow-up and the mean time to wound healing were comparable in the two groups. Kaplan-Meier analysis showed comparable long-term patency, limb salvage, and survival rates in the two groups. CONCLUSIONS: Revascularization to the distal third of the PA can achieve much the same outcome in terms of patency and limb salvage rates, wound healing rate and timing, as when other inframalleolar or pedal branches are used. The skepticism surrounding use of the terminal PA as an outflow vessel appears to be unwarranted.

Open abdominal aortic aneurysm repair in octogenarians before and after the adoption of endovascular grafting procedures.

OBJECTIVE: This study evaluated (1) elective open abdominal aortic aneurysm repair (OAR) in patients aged > or =80 years before and after stent graft devices for endovascular aneurysm repair (EVAR) became commercially available and (2) the effect on perioperative (30-day) outcome of the anatomic constraints that led to EVAR being excluded for many of them. METHODS: A review was conducted on the records of 111 patients aged > or =80 years who underwent elective OAR during a 14-year period at the University of Padua School of Medicine. Patients were separated into two groups: group 1 (n = 65) had OAR before and group 2 (n = 46) after an EVAR program was adopted at the medical school in mid-2000. Perioperative death and morbidity, location of proximal aortic clamp, management of the left renal vein, associated iliac aneurysmal or occlusive diseases, the type of surgical reconstruction, operating time, and lengths of stay in the intensive care unit and the hospital were recorded. All the data were compared between the two groups. RESULTS: Retroperitoneal approach, suprarenal clamping, left renal vein division, and longer operating room time were statistically more common in group 2 (36.9% vs 12.3%, P = .002; 15.2% vs 3.1%, P = .032; 23.9% vs 7.7%, P = .026; and 117 +/- 8 min vs 95 +/-7 min, P < .001, respectively). Although group 2 had significantly more iliac aneurysms (52.1% vs 32.3%; P = .036), the number of bifurcated reconstructions was comparable. The overall perioperative mortality rate was 1.8% (2 of 111), and the figures for groups 1 and 2 were comparable (3.1% vs 0%; P = .510). No deaths were cardiac related. Group 2 had a significantly higher incidence of kidney failure (8.7% vs 0%; P = .027). Kaplan-Meier analysis showed an overall 3-, 5-, and 10-year survival rate of 80.6%, 67.2%, and 59.4%, respectively, with a 3- and 5-year survival rate comparable between groups 1 and 2 (77.8% and 66.7% vs 87.8% and 45.8%, respectively; log-rank test, P = .921). CONCLUSIONS: Octogenarians can tolerate OAR with acceptable rates of perioperative mortality and morbidity. Although the complexity of OAR has increased significantly in the era of EVAR, the perioperative outcome has not changed.