Outcomes and cost analysis of laparoscopic versus open appendectomy for treatment of acute appendicitis: 4-years experience in a district hospital.

BACKGROUND: Laparoscopic appendectomy is not yet unanimously considered the "gold standard" in the treatment of acute appendicitis because of its higher operative time, intra-abdominal abscess risk, and costs compared to open appendectomy. This study aimed to compare outcomes and cost of laparoscopic and open appendectomy in a district hospital. METHODS: A retrospective analysis of 230 patients who underwent appendectomy at the Division of General Surgery of the Civil Hospital of Ragusa, Italy, from May 2008 to May 2012 was performed. The variables analyzed included patients data (age, gender, previous abdominal surgery, preoperative WBC count, duration of symptoms, ASA risk score), rate of uncomplicated or complicated appendicitis, operative time, postoperative complications, length of hospital stay, and total costs. The patients were divided in two groups according to the surgical approach and compared for each variable. The results were analyzed using the t Student test for quantitative variables, and the Chi-square test with Yates correction and Fisher exact test for categorical. RESULTS: Laparoscopic appendectomy was performed in 139 patients, open appendectomy in 91. Two cases (1.4%) were converted to open procedure and included in the laparoscopic group data. Patient data and rate of complicated appendicitis were similar in the two study groups. There was no statistical difference (p = 0.476) in the mean operative time between the laparoscopic (52.2 min; range, 20-155) and open appendectomy (49.3 min; range, 20-110) groups. The overall incidence of minor and major complications was significantly lower (p = 0.006) after laparoscopic appendectomy (2.9%, 4 cases) than after open appendectomy (13.2%, 12 cases); rate of intra-abdominal abscess were similar. The length of hospital stay was significantly shorter (p = 0.001) in laparoscopic group (2.75 days; range, 1-8) than in open group (3.87 days; range, 1-19). The mean total cost was 2282 Euro in laparoscopic group and 2337 Euro in open group, with a no significant difference of 55 Euro (p = 0.812). CONCLUSION: Laparoscopic appendectomy is associated with fewer complications, shorter hospital stay, and similar operative time, intra-abdominal abscess rate, and total costs, compared with open appendectomy. Therefore, laparoscopic appendectomy can be recommended as preferred approach in acute appendicitis.

Laparoscopic splenectomy for splenic hamartoma in elderly patien Case report and review of the literature.

AIM: We proved the feasibility and the safety of the laparoscopic splenectomy for splenic hamartoma in elderly patients. MATERIAL AND METHODS: We present the first case of laparoscopic splenectomy for splenic hamartoma in elderly patients and we reviewed the English literature regarding the laparoscopic approach. RESULTS: A 74-year-old man with a 6-month history of left upper quadrant abdominal and back pain was referred to our hospital for the evaluation of a splenic mass detected by ultrasonography. Computerized tomography scan (CT) revealed the presence of a solid tumor in the upper pole of the spleen (size 5.3 x 4.5 cm). The diagnosis of a malignant tumor was not excluded completely and because of increasing severe left upper quadrant pain, after three days the patient underwent laparoscopic splenectomy and the final pathological diagnosis was splenic hamartoma. The patient's postoperative course was uneventful and the patient was discharged by the sixth postoperative day. CONCLUSIONS: Splenectomy is still necessary for diagnostic and therapeutic purposes and mini-invasive surgical technique today represents the standard procedure for the management of any space-occupying lesions of the spleen also in elderly patients. KEY WORDS: Elderly patients, Hamartoma, Laparoscopic splenectomy, Management.

Metastatic lymph node ratio: a new staging system for gastric cancer.

BACKGROUND: This study was designed to analyze the prognostic significance of the staging system based on the ratio of metastatic lymph nodes (TRM) compared with the TNM staging system in patients with gastric cancer. METHODS: We reviewed the data of 219 patients who underwent gastrectomy for node-positive M0 cancer. Node Ratio (NR) categories (NR1: 1-15%; NR2: 16-40%; NR3: >40%) were determined by the best cutoff approach at log-rank test. After confirming the prognostic validity of NR in a collinearity-free Cox regression analysis, among different combinations of pT and NR categories we selected five prognostically homogeneous TRM classes. To compare the prognostic power of the TRM vs. TNM systems, we plotted TRM and TNM classes against the mortality estimates. RESULTS: Both of the TRM and TNM classifications significantly stratified patients outcomes (p < 0.0001), but the TRM system identified prognostic subgroups more homogeneous than the TNM system. CONCLUSIONS: The TRM staging system is a simple and reliable tool to stratify patients with gastric cancer and has a higher prognostic power than the current system.

Determinants of surgical morbidity in gastric cancer treatment.

BACKGROUND: The occurrence of early surgical complications after gastrectomy as a treatment for gastric cancer has been reported to have a negative impact on longterm survival. The aim of this study was to identify treatment-related factors that can predict morbidity and mortality in patients undergoing operations for gastric cancer. STUDY DESIGN: The charts of 388 patients who underwent different operations for gastric cancer at A Gemelli General Hospital, Catholic University of Rome, Italy, between January 1992 and April 2007, were reviewed. Patients were grouped according to the type of surgical treatment performed. The study end points were postoperative morbidity, mortality, and the length of hospital stay after surgery. RESULTS: Overall morbidity and mortality rates were 16.2% (63 patients) and 2.3% (9 patients), respectively. Overall morbidity rates were higher in patients more than 64 years of age, when a gastric tumor was resected along with the spleen, and when an extended lymphadenectomy was performed. Patients older than 64 years had longer postoperative hospital stays, and Roux-en-Y gastrojejunostomy was predictive of a shorter stay. Mortality was not influenced by any surgically related factors. CONCLUSIONS: Age, splenectomy, and extended lymphadenectomy were independently associated with the development of complications after gastric cancer operations. After subtotal gastrectomy, Roux-en-Y gastrojejunostomy was associated with a shorter postoperative length of stay than conventional Billroth I and Billroth II reconstructions.

Cavernous hemangioma of the gallbladder. Case report and review of the literature.

UNLABELLED: Hemangiomas are common benign tumors; they frequently occur in the liver but very rarely in the gallbladder, with only seven cases reported in the scientific literature to date. We here report an additional patient, a 49-year-old white woman presenting with an echogenic lesion of the gallbladder that was incidentally discovered. Cholecystectomy was performed after computed tomography had revealed a gallbladder neoplasm; pathological examination showed the mass to be a cavernous hemangioma. No postoperative complications occurred and the patient is alive and free of recurrence five years after the operation. We present a review of the literature on this topic with special emphasis on the diagnostic and therapeutic challenges these lesions may entail. Hemangiomas of the gallbladder may have extremely variable presentations (from non-specific abdominal pain to acute syndromes resembling cholangitis or choledocholithiasis) and can mimic different lesions (liver tumors, sarcoma). Only surgical exploration can provide a correct diagnosis. Excision is indicated as these lesions may grow to huge sizes, compress adjacent structures or bleed. CONCLUSIONS: Gallbladder hemangiomas are uncommon benign tumors. A preoperative diagnosis is difficult to make. Surgical excision is mandatory both in reaching a final diagnosis and in preventing bleeding or compression of vital structures.

Gastric adenocarcinoma associated with granulomatous gastritis. Case report and review of the literature.

AIMS: We describe the fourth reported case of granulomatous gastritis associated with gastric adenocarcinoma, with a review of the literature and considerations about the prognostic implications of this association. RESULTS: A 48-year-old woman who had been suffering from gastritis for ten years was admitted to our institute for increasing left epigastric pain associated with vomiting. After an endoscopic biopsy had revealed an ulcerated signet ring cell carcinoma, the patient was submitted to subtotal gastrectomy with regional lymph node dissection. Pathological examination of the resected specimen revealed a superficial signet ring cell carcinoma (early cancer) associated with multiple granulomas. The granulomas, which were observed within the mucosa and the submucosa at the periphery of the carcinoma, were composed of CD68-positive, CD15-negative epithelioid and giant cells of the Langhans type, confirming their true histiocytic nature, and were also extensively found within the dissected lymph nodes. Since no ocular, skin, pulmonary or other gastrointestinal lesions were found and the granulomas were negative for acid-fast and fungal stain, a diagnosis of granulomatous gastritis was made. CONCLUSIONS: To the best of our knowledge this is the fourth example of gastric adenocarcinoma and granulomatous gastritis. These cases suggest an association between granulomatous gastritis and early gastric cancer.