Updates on the multidisciplinary management of elderly patients with rectal cancer: a narrative review.

INTRODUCTION: The burden of rectal cancer in the elderly population continues to increase. The aim of this narrative review is to assess evidence updates on the management of elderly patients with rectal cancer. EVIDENCE ACQUISITION: The subject of rectal cancer in patients ≥70 years old was divided into different topics and, based on the research items, the literature review searched relevant studies from MEDLINE (via PubMed), Cochrane Central Register of Controlled Trials, and EMBASE between January 2000 and November 2022. Systematic reviews with or without meta-analyses, narrative reviews, randomized trials, and non-randomized cohort studies were included. EVIDENCE SYNTHESIS: For the fit elderly patient with preserved sphincter tone, standard-of-care surgical therapy should be pursued, whereas frail patients with more advanced disease could benefit from local excision as a palliative approach in combination with neoadjuvant chemoradiotherapy or more intensive radiotherapy options. Laparoscopic total mesorectal excision is recommended after carefully evaluating the patient's medical history, performance status, and tumor characteristics. Conversely, local excision can be implemented when balancing frailty, oncological outcomes, functional outcomes, and life expectancy. A watch and wait strategy can be considered in selected frail elderly patients with low-rectal tumors in case of complete clinical response after neoadjuvant chemoradiotherapy, with a stringent surveillance protocol, at least in the first three years. CONCLUSIONS: In elderly patients with rectal cancer, the adoption of strategies for patient involvement in healthcare decision-making is essential, as well as the evaluation of the social background and a discussion with the patient about therapeutic modalities.

Association Between Gastrointestinal Stromal Tumors and Other Malignancies: It Is Only a Matter of Time ? A Case Series and an Overview of Systematic Reviews.

PURPOSE: Little is known about the sporadic coincidence of gastrointestinal stromal tumors (GISTs) with second primary tumors (SPTs). The aim of this study is to clarify if there is a clinicopathologic correlation responsible for the synchronous or metachronous occurrence of SPTs in GIST patients. METHODS: We carried out a single-center, retrospective analysis on patients with GISTs surgically treated at our institution from January 2019 to June 2019. Two groups of patients were identified: isolated GIST (group A) and GIST associated with SPT (group B). A meta-review was conducted with the aim to examine the published systematic reviews that included studies assessing the SPT risk in GIST patients. RESULTS: Thirty-nine patients were surgically treated for GIST during the study period, with seven (17.9%) of them having other SPTs. SPTs were most frequent in the colon. Group A patients had a lower mean age at initial diagnosis (56.8 ± 15.2 vs. 73.4 ± 16.6, P = 0.012). No statistically significant difference was found between the two groups in terms of tumor location, mitotic index, Ki-67 expression, risk classification, and imatinib therapy. The overview showed that the cumulative prevalence rate of SPTs ranged from 9.3 to 18.0%. SPTs were more frequent in the gastrointestinal tract (37.9-95.0%), followed by the genitourinary tract. CONCLUSION: GIST patients under our care experienced a 17.9% overall risk of developing SPTs with different histology. When comparing patients with isolated GIST and patients with GIST and SPT, age was the only variable significantly related to the development of other neoplasms. However, the potential non-random association and causal relationship between GISTs and SPTs remain to be investigated.

Gastric cancer in the young: is it a different clinical entity? A retrospective cohort study.

Background. The rate of gastric cancer in young patients has increased over the past few decades. The aim of this study was to search for independent risk factors related to patients of younger age. Methods. From January 1996 to December 2012, a series of 179 consecutive patients were admitted to our surgical department because of a gastric cancer. We carried out a retrospective cohort study in 20 patients younger than 50 and in 112 patients aged 50 and older treated by curative gastrectomy. The comparison involved the evaluation of patient and tumor characteristics. Results. Younger patients had significantly less comorbidities and a more favorable American Society of Anesthesiology score; they had significantly less preoperative weight loss and a significantly longer duration of symptoms; Helicobacter pylori infection and diffuse histological type were significantly associated with younger age. There was no statistically significant difference regarding overall and cancer-related 5-year survival; advanced cancer stage and diffuse histological type were the independent negative prognostic factors influencing cancer-related survival. Conclusions. We do not have sufficient evidence to consider gastric cancer in younger patients as a different clinical entity. Further studies are needed to understand carcinogenesis in younger patients and to improve gastric cancer classification.

Systematic review with meta-analysis of studies comparing intraoperative neuromonitoring of recurrent laryngeal nerves versus visualization alone during thyroidectomy.

BACKGROUND: The role of intraoperative neuromonitoring (IONM) of the recurrent laryngeal nerve (RLN) during thyroid surgery is still debatable. The aim of this meta-analysis was to evaluate the potential improvement of IONM versus RLN visualization alone (VA) in reducing the incidence of vocal cord palsy. METHODS: A literature search for studies comparing IONM versus VA during thyroidectomy was performed. Studies were reviewed for primary outcome measures: overall, transient, and permanent RLN palsy per nerve and per patients at risk; and for secondary outcome measures: operative time; overall, transient and permanent RLN palsy per nerve at low and high risk; and the results regarding assistance in RLN identification before visualization. RESULTS: Twenty studies comparing thyroidectomy with and without IONM were reviewed: three prospective, randomized trials, seven prospective trials, and ten retrospective, observational studies. Overall, 23,512 patients were included, with thyroidectomy performed using IONM compared with thyroidectomy by VA. The total number of nerves at risk was 35,513, with 24,038 nerves (67.7%) in the IONM group, compared with 11,475 nerves (32.3%) in the VA group. The rates of overall RLN palsy per nerve at risk were 3.47% in the IONM group and 3.67% in the VA group. The rates of transient RLN palsy per nerve at risk were 2.62% in the IONM group and 2.72% in the VA group. The rates of permanent RLN palsy per nerve at risk were 0.79% in the IONM group and 0.92% and in the VA group. None of these differences were statistically significant, and no other differences were found. CONCLUSIONS: The current review with meta-analysis showed no statistically significant difference in the incidence of RLN palsy when using IONM versus VA during thyroidectomy. However, these results must be approached with caution, as they were mainly based on data coming from non-randomized observational studies. Further studies including high-quality multicenter, prospective, randomized trials based on strict criteria of standardization and subsequent clustered meta-analysis are required to verify the outcomes of interest.

Intratumoral sampling variability in hepatocellular carcinoma: a case report.

The differential diagnosis between hepatocellular carcinoma (HCC) and regenerative liver nodules and other primary liver tumors may be very difficult, particularly when performed on liver biopsies. Difficulties in histological typing may be often minimized by immunohistochemistry. Among the numerous markers proposed, CK18, Hep Par1 and glypican 3 (GPC3) are considered the most useful in HCC diagnosis. Here we report a case of HCC in a 72-year-old male with HBV-related chronic liver disease, characterized by a marked morphological and immunohistochemical intratumoral variability. In this case, tumor grading ranged from areas extremely well differentiated, similar to regenerative nodule, to undifferentiated regions, with large atypical multinucleated cells. While almost all sub nodules were immunostained by Hep Par 1, immunoreactivity for glypican 3 and for Ck18 was patchy, with negative tumor region adjacent to the highly immunoreactive areas. Our case stresses the relevance of sampling variability in the diagnosis of HCC, and indicates that caution should be taken in grading an HCC and in the interpretation of immunohistochemical stains when only small core biopsies from liver nodules are available.

A rare case of vagus nerve schwannoma.

Schwannomas of the vagus nerve are very rare and the differential diagnosis is extremely difficult. They are very often asymptomatic and imaging techniques are helpful, but fine needle biopsy is often inconclusive. Total resection is the treatment of choice.

Intussusception of the appendix by mucinous cystadenoma. Report of a case with an unusual clinical presentation.

Appendiceal mucocele is a very rare clinical condition. Associated ascites and an ovarian mass could suggest synchronous ovarian cystadenocarcinoma with pseudomyxoma peritonei. We describe the case of a 36-year-old female with a mucinous cystadenoma of the appendix causing intussusception, diagnosed by CT but not by US scan, since the associated anomalous fixation of the caecum was misleading in defining the precise anatomical site. Although the CT findings were accurate, the synchronous presence of an ovarian cyst and ascites did not allow us to rule out preoperatively a concurrent cystadenocarcinoma of the ovary with pseudomyxoma peritonei. The appropriate surgical treatment was performed on the basis of intraoperative frozen section examination. Surgical treatment depends on the nature of the mucocele: retention forms are effectively treated by appendectomy, while neoplastic conditions require a more extended resection. Treatment of associated ovarian cystadenocarcinoma and pseudomyxoma peritonei includes right colectomy, bilateral ovariectomy and omentectomy. Although a precise preoperative diagnosis of mucocele associated with intussusception of the appendix has been reported as possible, concomitant ascites and ovarian masses, as in the present case, could mimic pseudomyxoma peritonei from concurrent ovarian cystadenocarcinoma. Intraoperative histopathology is required in order to perform the most appropriate treatment.

Complete pancreatic heterotopia of gallbladder with hypertrophic duct simulating an adenomyoma.

The gallbladder is an unusual location of pancreatic heterotopia, defined as the presence of pancreatic tissue lacking anatomical and vascular continuity with the main body of the gland. A 28-year-old man presented with anorexia, nausea and pain in the right upper abdomen. On physical examination, the abdomen was tender to palpation and Murphy sign was positive. The patient underwent a cholecystecomy. This case, in our opinion, is very interesting since it permits to consider a controversial issue in the pathology of the gallbladder. The histological appearance of ductal structure in pancreatic heterotopia resembles the histological picture of both Aschoff-Rokitansky (AR) sinuses and adenomyomas. This finding suggests that these lesions are linked by a common histogenetic origin. We suggest that the finding of an adenomyoma in the gallbladder should prompt an extensive sampling of the organ in order to verify the coexistence of pancreatic rests.

Can intraoperative cholangiography be avoided during laparoscopic cholecystectomy?

Controversy exists as to whether intraoperative cholangiography should be performed routinely or selectively during laparoscopic cholecystectomy. The aim of the present study was to assess in which circumstances intraoperative cholangiography can be avoided during laparoscopic cholecystectomy. From January 1999 to June 2002, 168 patients undergoing laparoscopic cholecystectomy for cholelithiasis without intraoperative cholangiography were prospectively evaluated at our Department. Inclusion criteria were established according to a preoperative diagnostic protocol, considering only those patients with normal liver function tests and ultrasound common bile duct diameters < or = 5 mm or > 5 mm, but with normal magnetic resonance cholangiopancreatography findings. Laparoscopic cholecystectomy was carried out without intraoperative cholangiography and postoperative results and follow-up data were recorded and analysed. No major biliary injuries were encountered and no patients had residual bile duct stones after at least a one-year postoperative follow-up. A complete preoperative diagnostic work-up proved to be of fundamental importance for decreasing the incidence of residual bile duct stones. When protocol criteria are satisfied, intraoperative cholangiography may be safely omitted during laparoscopic cholecystectomy and meticulous laparoscopic technique is the main way to reduce the incidence of iatrogenic biliary lesions to a minimum.

Surgical indications for toxic multinodular goitre.

The aim of this study was to clarify the surgical indications and the effectiveness of total thyroidectomy in the treatment of toxic multinodular goitre. From January 1998 to May 2004, 70 patients underwent total thyroidectomy in our department because of toxic multinodular goitre. In 46 patients (65.7%) the indications for total thyroidectomy were: 25 compressive goitres, 12 cervico-mediastinal goitres, 2 cases of Pemberton's sign, 5 follicular nodules with cytological atypia, and 2 cases of suspected papillary carcinoma. In 24 patients (34.3%) with failure or intolerance of previous treatment, surgical indications were: 9 persistent and 5 recurrent hyperthyroidism after medical treatment; 6 patients with cardiotoxicity; 3 patients with recurrent disease after percutaneous ethanol injection; 1 patient with antithyroid drug intolerance. The mean postoperative hospital stay was 3.2 days (range: 2-9). Transient hypocalcaemia occurred in 6 patients (8.6%) and transient unilateral recurrent laryngeal nerve injury in another 3 patients (4.2%). None of the patients had permanent hypocalcaemia or permanent recurrent laryngeal nerve injury. All 70 treated patients relieved their symptoms and became biochemically hypothyroid after the operation. Total thyroidectomy results in a rapid, reliable resolution of hyperthyroidism and removal of multinodular goitre, requires no re-treatment, removes any coexisting malignancy, and post-surgical hypothyroidism is simple to treat.

Current indications for laparoscopic adrenalectomy in the era of minimally invasive surgery.

The aim of this study was to clarify the current indications for laparoscopic adrenalectomy, reviewing both our own experience and the literature data. Since January 2000, 22 patients have undergone adrenalectomy in our department: 17 (77.3%) with the laparoscopic approach and 5 (22.7%) with the traditional one. The indications for laparoscopy were: 6 Cushing's adenomas, 4 aldosterone-producing adenomas, 4 non-functional adenomas, 2 pituitary-dependent bilateral adrenocortical hyperplasias and 1 metachronous adrenal metastasis. The conversion rate to laparotomy was 11.7%. The indications for the open approach were: tumours greater than 7 cm and previous abdominal surgery. The mean size of laparoscopic specimens was smaller than those removed by the open procedure (3.9 cm versus 6.7 cm). The mean postoperative hospital stay in the laparoscopic group was 4.9 days as compared to 10.2 days in the open group. Morbidity was encountered in 2/17 laparoscopically treated patients (11.7%) and in 2/5 patients in the open group. In our early experience, laparoscopic adrenalectomy has been the procedure of choice for removing unilateral or bilateral tumours measuring less than 7 cm in diameter. Nevertheless, apart from diameter cut-off, on the basis of evidence from the literature, an invasive carcinoma is currently considered the only absolute contraindication to laparoscopy.

Surgical treatment of perforated diverticular disease: evaluation of factors predicting prognosis in the elderly.

Diverticulitis free perforation carries a high mortality rate in the elderly, and this motivates the search for specific prognostic factors. The aim of this study was to assess prognostic factors in patients over 70 years of age that were operated on for generalized peritonitis caused by perforated colonic diverticulitis. A retrospective study in 22 patients was performed: demographic data, American Society of Anaesthesiology grading, site and diameter, degree of perforation according to Hinchey's classification, duration of symptoms, Manheim Peritonitis Index (MPI) score, and surgical treatment were evaluated. Patients over 70 years of age were grouped in deceased and not deceased. In this subgroup, postoperative mortality rate was 40%, and diameter of perforation, duration of symptoms, and MPI score seemed significantly related to postoperative death. In the elderly, prognosis is strongly related to duration of symptoms, and treatment delay is caused by late hospitalization because of a low sensibility to the disease symptoms in old people.

Surgery for perforated peptic ulcer in the elderly. Evaluation of factors influencing prognosis.

BACKGROUND/AIMS: The frequency of perforated peptic ulcer is decreasing among the overall population but it is becoming more frequent among old people. The higher mortality rate in the old population, justifies the search of prognostic factors specific for the elderly. Aim of this study is to analyze and define factors influencing surgical prognosis in patients older than 70 years who were operated for perforated peptic ulcer. METHODOLOGY: A retrospective analysis of 37 patients was performed: age, sex, ASA status, site of perforation, diameter of perforation, duration of symptoms, MPI score, surgical treatment (suture vs. resection) were studied. All patients were grouped as deceased and not deceased after surgery: a statistical univariate analysis was performed regarding the whole series and regarding the patients 70 years and older. RESULTS: Postoperative mortality rate was 18.92% in the whole series but 41.8% among the elderly. In the whole series age, ASA status, diameter of perforation, duration of symptoms, and MPI score were significantly related to postoperative death. In the patients 70 years and older the duration of symptoms, the size of perforation and the MPI score were significantly related to postoperative death. CONCLUSIONS: The duration of symptoms is a known factor that influences the prognosis after surgery for perforated peptic ulcer. This factor is still the most important in the elderly being responsible of the high mortality rate. The delay in treatment is due to a delayed hospitalization of old patients, who show a low reactivity to the disease.

Coexisting Hashimoto's thyroiditis with differentiated thyroid cancer and benign thyroid diseases: indications for thyroidectomy.

Hashimoto's thyroiditis is a medical disease that affects about 5% of the population. In cases of goitre, hashitoxicosis or associated differentiated thyroid cancer, surgical treatment is recommended. The aim of this study was to evaluate the indications for thyroidectomy in Hashimoto's thyroiditis, the frequency of coexistence of Hashimoto's thyroiditis and differentiated thyroid cancer, and the impact of Hashimoto's thyroiditis on the management of differentiated thyroid cancer. From January 1998 to May 2002, 344 patients underwent thyroidectomy in our department. Among 44 patients with HT, the authors carried out a retrospective comparative study of 33 patients with a cytological diagnosis of differentiated thyroid cancer (group A) and 11 patients with non-neoplastic conditions (group B). Surgical indications based on cytological findings and management characteristics were considered. The frequency of the association of Hashimoto's thyroiditis and differentiated thyroid cancer was 23.8% as compared to a 6.7% frequency of coexisting Hashimoto's thyroiditis and benign thyroid diseases (P = 0.000). The sensitivity of cytology in the diagnosis of papillary carcinoma in Hashimoto's thyroiditis was 92%. Cytological diagnosis of hyperplastic follicular and hyperplastic Hürthle cell nodules in Hashimoto's thyroiditis was impossible in some cases. Intraoperatively distinguishing between chronic lymph-node reactivity and tumour involvement was difficult, but the morbidity rate was not increased very much by Hashimoto's thyroiditis. In conclusion, an adequate follow up of patients with Hashimoto's thyroiditis may permit an early diagnosis of differentiated thyroid cancer and its appropriate management.

Factors predicting outcome of hypocalcaemia following total thyroidectomy.

Postoperative hypocalcaemia is often observed after total thyroidectomy. In patients requiring calcium replacement therapy after 1 year, hypocalcaemia must be considered permanent. The aim of this study was to assess the incidence of hypocalcaemia following total thyroidectomy and to evaluate the risk factors predicting delayed outcome such as hypoparathyroidism. From January 1998 to September 2001, 310 patients underwent total thyroidectomy in our department. In a total of 37 patients experiencing hypocalcaemia, the authors carried out a comparative study of 34 patients with transient hypocalcaemia (group A) and 3 patients with permanent hypocalcaemia (group B). The incidences of transient and permanent hypocalcaemia were 11.9% and 0.9%, respectively. Central neck lymph-node dissection performed in cases of thyroid carcinoma correlated with permanent hypoparathyroidism. The most significant factors predicting long-term outcome of hypocalcaemia were low serum calcium levels (< 8 mg/dl) and high serum phosphorus levels (> 5 mg/dl) measured on postoperative day 7, despite oral calcium replacement. The indications for lymph-node dissection in the central neck area should be very strictly selected. When delayed serum calcium and phosphorus levels are unfavourable, thorough follow-up of patients is mandatory in order to administer the correct therapy and prevent the consequences of chronic hypocalcaemia.

Laparoscopic management of non-parasitic splenic cysts.

Non-parasitic cysts are an infrequent disease of the spleen. Most likely congenital in their origin, epithelial splenic cysts require surgical treatment if enlarged or symptomatic. The aim of this study was to assess the impact of the laparoscopic technique in the management of splenomegaly due to cystic disease. From July 2001 to September 2002 4 patients underwent laparoscopic splenectomy in our department for symptomatic enlarged non-parasitic splenic cysts. Cystic lesions were evaluated by ultrasonography, CT scan and magnetic resonance of the abdomen. The choice of total laparoscopic splenectomy according to the "hanged spleen" procedure was conditioned by the technical difficulty of performing conservative treatment due to the site of the upper pole of the enlarged lesions, adherent to the diaphragm in 3 cases, and by the presence of multiple trabeculated splenic cysts in 1 case. Laparoscopy was always completed and all patients obtained relief of their symptoms. When conservative treatment such as partial splenectomy or decapsulation may jeopardize the good outcome of the operation, the management of nonparasitic splenic cysts can be successfully achieved by total laparoscopic splenectomy.