Diagnostic and therapeutic role of laparoscopy in perforated peptic ulcer in the elderly patients.

AIM: The purpose of this study is to analyze the outcome of elderly patients with perforated peptic ulcer comparing laparoscopic treatment versus open approach. METHODS: In our General and Emergency Surgery Unit in the last 3 years, 20 elderly patients with perforated peptic ulcer were performed. We considered elderly all patients over the age of 65 years (10 females and 10 males; the mean age was 75 years). 16 patients (80%) were submitted to laparoscopic repair with omentoplasty and 4 (20%) to open repair. The patients were classified using the Boye's score which influenced the choice of surgical treatment and the outcoEmergency Romame. The two groups were compared in terms of operative surgery times, complication rate, mortality and postoperative outcomes. DISCUSSION: Perforated peptic ulcer is a common abdominal disease that is treated by surgery. The potential advantages of laparoscopy, both in terms of diagnosis and therapy, are clear and the major advantages may be observed in cases with peritonitis secondary as a perforated peptic ulcer where laparoscopy allows the confirmation of the diagnosis, the identification of the position of the ulcer and the repair. With the age the risks of comorbidities increases multidisease syndrome. Elderly patients suffer from frailty syndrome. All these factors make the elderly patient a major challenge for a laparoscopy treatment. CONCLUSION: The laparoscopic approach is an effective method for treatment of perforated peptic ulcer in the elderly with a great diagnostic and therapeutic role. Nowadays more prospective randomized studies are needed to evaluate the effectiveness of laparoscopic versus open repair.

[Left laparoscopic adrenalectomy for pheochromocytoma in MEN 2B: case report]. / Surrenectomia laparoscopica sinistra per feocromocitoma in MEN 2B: caso clinico.

INTRODUCTION: Multiple endocrine neoplasia syndromes (MEN) are genetic disease with many pathologic models. MEN 2B is a autosomal dominant syndrome characterized by medullary thyroid carcinoma, pheochromocytoma, mucosal ganglioneuromatosis and marfanoid habitus. Laparoscopic surgery is the gold standard for the treatment of pheochromocytoma. CASE REPORT: Woman 25 years old, suffering from medullary thyroid carcinoma in MEN 2B syndrome, underwent total thyroidectomy, with emptying of the lymphonodal central and lateral cervical (bilaterally) compartments and radioreceptor therapy. The patient was then submitted to four plastic surgery for cervical keloid. In January 2010, follow-up blood and instrumental tests show, in the lower portion of left adrenal gland, a round lesion, with smooth margins 17 mm diameter, attributable to pheochromocytoma. In March 2010 the patient underwent laparoscopic surgery for left adrenalectomy. DISCUSSION: The benefits of laparoscopic adrenalectomy for a single lesion are well documented in the literature; this type of intervention is indicated in cases of pheochromocytoma in patients with MEN 2B. Our case demonstrates the feasibility of this technique.

[Update on the laparoscopic adrenal surgery in the second decade of the century: "doubts no more?]. / Update sulla chirurgia laparoscopica del surrene nel secondo decennio del secolo: "doubts no more?"

Laparoscopic adrenal surgery has significantly improved during the last years. Thus at the moment it is possible to define such technique as the therapeutic "Gold Standard" option in the treatment of the adrenal tumors. However, some doubts are still remaining concerning the feasibility of laparoscopic adrenalectomy in case of malignant adrenal tumors, hyper-vascular tumors (pheochromocytoma) and indeterminate incidentaloma. This study aimed to review all the literature of the last three years (only article with abstracts) using the criteria of selection of the Cochrane Library, in order to find class I and class II-III studies which are able to surely or, respectively, probably respond to the various questions yet to be answered Two hundred and twelve papers have been selected. The class I studies stated the following evidences: laparoscopic treatment of pheochromocytoma is the Gold Standard too, independently from the dimension; the short term results of laparoscopic anterior and posterior approach are equivalent to those of the lateral one. Doubts still remain concerning the role of laparoscopy in the treatment of metastases, big pheochromocytomas, small size incidentalomas (risk of over-treatement). Nearly no respond has been given to others issues such as "the single port techniques" in laparoscopic adrenalectomy, the role of radiofrequency laparoscopic ablation of the adrenal tumor, the kind of treatment of stadium I and II adrenocortical carcinoma and big size (> 8 cm) tumors, the management of non-functioning incidentaloma of 4-6 cm, the role of the robot, and, finally, the approach of the bilateral tumors. We conclude that, despite many issues on the feasibility and safety of laparoscopy in the adrenal surgery have been definitely clarified, so that such technique has been declared the "Gold Standard" method in the treatment of the adrenal tumor, doubts still remain in some aspects of this method. However, since the researches in this field are proceeding with high evolution velocity, in the next future most of the questions that are still present should be definitively adressed.