[Laparoscopic versus mini-cholecystectomy: analysis of hospital costs and social costs in a prospective randomized study]. / Video-colecistectomia versus mini-colecistectomia: analisi dei costi ospedalieri e dei costi sociali in uno studio prospettico randomizzato.

The aim of the study was to calculate the hospital and social costs in relation to efficacy of clinical outcome, hospital stay and time off work in two groups of patients randomly treated with laparoscopic or mini-cholecystectomy. One hundred and eighty-one patients with simple, symptomatic gallstone disease were included in the study; of these, 9 cases were excluded because of conversion to conventional cholecystectomy. Eighty-six cases underwent laparoscopic cholecystectomy and 86 mini-cholecystectomy. Operative time (median time: 35 minutes) and hospital stay (median stay: 3 days) were the same for both surgical procedures. The median time off work was 10 days for laparoscopic cholecystectomy and 20 days for mini-cholecystectomy (P = 0.007). Hospital expenses showed a saving of 820.48 euros for each patient undergoing mini-cholecystectomy. Since laparoscopic cholecystectomy is associated with a shorter period off work, it seems to be cheaper with a daily saving of 164.96 and 146.51 Euros per patient, according to cost/effectiveness and cost/utility analyses, respectively. Consequently, although laparoscopic cholecystectomy shows a better outcome in terms of socioeconomic aspects and patient compliance, in an attempt to rationalize hospital expenditure, we would advocate mini-cholecystectomy for those patients who do not need to return to work early.

[Paget-Schroetter disease: clinical and therapeutic considerations]. / La malattia di Paget-Schroetter: considerazioni clinico-terapeutiche.

A case of subclavian-axillary vein thrombosis prompted us to review the recent literature on the subject. Paget-Shroetter disease is an uncommon disease, which is still associated with high early and late morbidity rates and the prevention of which requires early diagnosis and treatment. The importance of trauma (in the form of physical strain) in determining the symptoms of the disease is universally accepted. We observed subclavian-axillary vein thrombosis in a young 22-year-old athlete who complained of unexpected onset of pain in the left armpit, spreading to the arm and to the shoulder on the same side, functional impotence of the upper arm and swelling of the hand and forearm, and engorgement of the vessels in the arm, shoulder and clavipectoral region, which in the course of time developed the characteristics of a collateral circulation. The patient underwent phlebography which documented lack of opacification of the axillo-subclavian axis and showed the presence of a collateral circulation with dilation of the vein of the shoulder and arm. We first attempted to dissolve the thrombus by locoregional infusion of urochinase and later started anticoagulative therapy with an intravenous infusion of heparin (10,000 IU/h after a bolus of 500 units). Because of the poor result of thrombolysis and anticoagulative therapy and the progressive worsening of the disease, the patient underwent surgery to restore the continuity of the venous axis. The surgical procedure was performed through a skin incision along the upper edge of the collar-bone. This was dissected and the two stumps were well separated to allow a clear view of the subclavian vein. Phlebotomy, thrombectomy and reconstruction of the venous axis with an expanded polytetrafluoroethylene patch were performed. The postoperative course was uneventful and the patient underwent phlebography again on postoperative day 8, which demonstrated complete patency of the subclavian vein, and was discharged on postoperative day 20 on oral anticoagulative therapy.

Efficacy and cost of risk-adapted follow-up in patients after colorectal cancer surgery: a prospective, randomized and controlled trial.

AIMS: This paper aims to evaluate the diagnostic efficacy and costs of follow-up tailored according to risk of recurrence compared with minimal surveillance. METHODS: A total of 358 patients treated by surgery alone for colorectal cancer were prospectively divided into two groups of 200 and 158 patients considered at high and low risk of recurrence respectively, according to prognostic factors. They were further randomized into two subgroups: group 1, 192 patients undergoing risk-adapted follow-up, intensive and low-intensity; group 2, 145 patients undergoing minimal surveillance. Twenty-one cases dropped out. Median follow-up was 61.5 months and 42 months for cases at high risk (intensive follow-up) and at low risk (low-intensity follow-up) respectively. RESULTS: At the end of the study, 52.6% of patients undergoing risk-adapted follow-up and 57.2% undergoing minimal follow-up had developed recurrence. In patients at high risk, a significant difference in the incidence of curative re-operations was observed between the subgroups undergoing risk-adapted follow-up and subgroups undergoing minimal surveillance (P<0.05). The actuarial 5 year survival of patients at high and at low risk of recurrence undergoing risk-adapted follow-up is significantly better than that of cases undergoing minimal follow-up. The economic costs for 34 patients in the intensive follow-up group and for the 57 patients in the low-intensity follow-up group who were free from disease after primary surgery was very similar. CONCLUSIONS: Risk-adapted follow-up has significantly improved the targeting of curative re-operations and overall survival of patients independently of risk of recurrence and has allowed a reduction in the costs of following up of disease-free patients.