Doppler-Guided Transanal Hemorrhoidal Dearterialization (DG-THD) Versus Stapled Hemorrhoidopexy (SH) in the Treatment of Third-Degree Hemorrhoids: Clinical Results at Short and Long-Term Follow-Up.

INTRODUCTION: The stapled hemorrhoidopexy (SH) and the Doppler-guided transanal hemorrhoidal dearterialization (DG-THD) are minimally invasive procedures for the surgical treatment of hemorrhoids. This study aims to verify the efficacy of the DG-THD versus the SH in the treatment of third-degree hemorrhoids. METHOD: One hundred consecutive patients were causally allocated to either procedure, obtaining two groups of 50 pts. A clinical examination was performed at 3, 7, 15, and 30 days after the operation. Quality of life, anal symptoms, recurrence of hemorrhoids, and reoperation were assessed by means of a questionnaire and of a clinical examination at long-term follow-up (7.0 year average). RESULTS: At short-term follow-up, the median postoperative pain score was significantly lower in DG-THD group compared to SH group, (V.A.S 2 vs 6; t = 2.65, p < 0.01). The morbidity rate and the return to normal life and work were similar after the two procedures. At long-term follow-up, the incidence of piles was not statistically different between the two groups (DG-THD 10.0 %; SH 14.0 %). No differences were reported by patients in terms of satisfaction for surgery. CONCLUSION: SH and DG-THD procedures do not show significantly different results with regard to the patients outcome. However, considering the lower p. o. pain, the DG-THD might be proposed as the first line treatment in third-degree hemorrhoids.

Intestinal Intussusception by Monophasic Synovial Sarcoma: Case Report and Literature Review.

INTRODUCTION: Synovial sarcomas are rare malignant tumors of soft tissues, arising mainly from periarticular structures. Gastrointestinal localizations are unusual presentation of these rare sarcomas. METHODS: We present the case of a 56- years old man with monophasic synovial sarcoma, arising primarily from the ileum, and causing intussusception. A review of the literature was conducted to gather information about this rare sarcoma. RESULTS: We found that the criteria normally used to determine the prognosis in patients with monophasic synovial sarcoma of soft tissue are poorly applicable for gastrointestinal localizations. CONCLUSIONS: A better characterization of these tumors could identify them as a distinct entity, compared with monophasic synovial sarcomas of soft tissues.

Sigmoid intramural hematoma and hemoperitoneum: an early severe complication after stapled hemorrhoidopexy.

Stapled hemorrhoidopexy is a widely used surgical technique for treating hemorrhoids, although severe complications have been reported. The authors report a rare case of extensive ascending intramural hematoma of the sigmoid colon complicating stapled hemorrhoidopexy, with perforation and hemoperitoneum. Diagnosis was established at CT scan and treatment consisted of drainage, suturing, and diverting colostomy. This reported case is the ninth described in the literature, but, so far, it is not known what preventive measures to use in order to avoid such a rare complication. Adoption of a correct surgical technique remains the step of utmost importance in order to prevent such a severe postoperative complication.

Randomized clinical trial examining the effect of music therapy in stress response to day surgery.

BACKGROUND: Music therapy could reduce stress and the stress response. The aim of this study was to investigate the role of music therapy in alleviating stress during day surgery. METHODS: Sixty patients undergoing day surgery were randomized to one of three groups, each containing 20 patients. Before and during surgery, patients in group 1 listened to new age music and those in group 2 listened to a choice of music from one of four styles. Patients in group 3 (control group) heard the normal sounds of the operating theatre. Plasma levels of cortisol and subpopulations of lymphocytes were evaluated before, during and after operation. RESULTS: Plasma cortisol levels decreased during operation in both groups of patients who listened to music, but increased in the control group. Postoperative cortisol levels were significantly higher in group 1 than in group 2 (mean(s.d.) 14.21(6.96) versus 8.63(2.72) ng/dl respectively; P < 0.050). Levels of natural killer lymphocytes decreased during surgery in groups 1 and 2, but increased in controls. Intraoperative levels of natural killer cells were significantly lower in group 1 than in group 3 (mean(s.d.) 212.2(89.3) versus 329.1(167.8) cells/microl; P < 0.050). CONCLUSION: Perioperative music therapy changed the neurohormonal and immune stress response to day surgery, especially when the type of music was selected by the patient.

[Hyperthyroidism in the elderly]. / L'ipertiroidismo nell'anziano.

UNLABELLED: Hyperthyroidism in elderly patients is not to be under-evaluated, since it is characterized in such age range by particular clinical and prognostic features. Based upon literature survey and their clinical experience, the authors discuss in the present paper clinical, diagnostic and therapeutic problems of hyperthyroidism in geriatric patients. MATERIAL AND METHOD: In the period between 1978-2003 out of 1804 patients surgically treated for thyroid disease (non neoplastic in 1470 pts.), 180 subjects presented hyperthyroidism (17%). 36 were in geriatric age-range (mean age 76 yr.; 29 females and 7 males). 26 presented a Multinodular Toxic Goiter (72.2%), whereas 9 patients complained of Plummer Adenoma (25%); only 1 patient showed Basedow disease (2.7%). RESULTS: As far as ASA classification, there were 7 ASA I, 27 ASA II and 2 ASA III. Compression of digestive tract and/or respiratory airway represented a surgical indication in 15 patients (41.6%). 12 (33.4%) were operated due to predominant cardiac symptoms (tachycardia, atrial fibrillation). The remaining 9 patients (25%) were treated for the concomitance of atypical symptoms of hyperthyroidism. We performed 15 total thyroidectomy, 7 "near totally", 8 sub-total, 6 hemithyroidectomy in case of Plummer adenoma. Postoperative mortality was nihil; p.o. morbidity was 5.5% for medical conditions (pneumonia) and surgery-related (1 laryngeal recurrent paralysis and 1 hypoparathyroidism) in 5.5%. Post-operative follow-up, conducted at 6 and 12 months from the operation, showed regression of hyperthyroidism and regression or improvement of all clinical symptoms complained by the patient. CONCLUSION: Surgical treatment seems to be the only immediate and definitive cure for hyperthyroidism. Geriatric age does not seem to be a surgical contraindication.

[Recurrent parastomal hernia and middle incisional hernia: surgical treatment through midline incision with wide prosthetic mesh]. / Ernia parastomale recidiva e laparocele mediano: trattamento chirurgico con ampia rete protesica per via mediana.

Parastomal hernia is a frequent complication of stoma surgery. The results of parastomal hernia repair however are poor, showing an high incidence of postoperative recurrences. In the last years, hernia repair with prosthetic mesh has given better postoperative results. The parastomal hernia, however, is associated with middle incisional hernia. The authors review the problem of surgical repair of parastomal hernia and report a case of recurrent parastomal hernia associated to middle incisional hernia. The technique of surgical repair using, through midline incision, one, wide, prosthetic polypropylene mesh, in sublay position, according to Rives' technique, is described. The mesh has been incised in a trasverse direction for the stoma crossing. At 6 years follow-up the patient does not show postoperative recurrence. According literature and the authors' results, the parastomal hernia might be considered an incisional hernia and, therefore, a sing of diffuse abdominal wall disease. The Rives' surgical technique might be the gold standard for treatment of parastomal hernia, even if not associated to incisional hernia. The more complexity of Rives' technique compared to local fascial mesh repair is compensated by the result of total abdominal wall reinforcement.

Perianal acquired tufted angioma associated with pregnancy: case report.

Tufted angiomas are rare lesions described as slowly growing/spreading erythematous macules especially located in the upper trunk and neck. Herein we report the case of perianal location of a tufted angioma in a young pregnant woman. She came to our observation complaining of perianal pain accompanied by bleeding at defecation. A lesion resembling a perianal fissure was observed. Mild hypertonia of the internal sphincter was confirmed at manometry. After one week of ineffective medical treatment, surgery was planed at the end of the sixteenth week under local anaesthesia. The lesion was excised and a minimal sphincterotomy was performed; histopathology report described features of a tufted angioma. The pregnancy proceeded regularly, without anal symptoms, followed by normal vaginal delivery at the thirty-eighth week. This case showed three peculiar features: the association of tufted angioma and pregnancy, the perianal location, and the clinical appearance suggestive of an anal fissure. The clinical manifestation of a perianal tufted angioma, mimicking an anal fissure, is of utmost importance to the differential diagnosis and treatment plan, especially in a pregnant woman.

[Acute cholecystitis in patients over 70 years old]. / La colecistite acuta nell'ultrasettantenne.

BACKGROUND: Gallstone disease is the most common surgical indication in the elderly. Post-operative prognosis is severe in elderly with acute cholecystitis. Aim of this paper is to investigate the factors responsible for the severe prognosis and to detect how it could be improved. METHODS: One hundred fifty-seven patients, aged between 70 and 85 years (average 82 years), undergoing cholecystectomy between the years 1990 and 2000 have been studied; 65 patients (group A) had acute cholecystitis; 92 (group B) had uncomplicated gallbladder stones. RESULTS: Acute cholecystitis was the first symptom of gallstone disease in 69.2%. Laparocholecystectomy was performed in 31 cases (47.6%) of group A and in 58 cases (63.7%) of group B. In those cases with acute cholecystitis the postoperative morbidity (18.4%) was higher than in group B (1.0%), (A vs B: chi(2)=15.3; p<0.001). Similarly, postoperative mortality was higher (6.1% vs 1.0%; chi(2)=3.2; p<0.05) The severe postoperative prognosis was correlated significantly to index ASA (ASA II vs IV: chi(2)=7.0; p<0.001) but not to the technique adopted for cholecystectomy (VLC vs open: (chi)2=0.01; p=n.s.). The results obtained seem to confirm that the high incidence of postoperative complications in acute cholecystitis is due to the presence of associated diseases in elderly patients accompanied by the septic state. CONCLUSIONS: Early colecystectomy, in those cases with symptomatic, uncomplicated gallstone disease, might avoid severe postoperative prognosis in the elderly.

[An intramural hematoma of the duodenum]. / L'ematoma intramurale del duodeno.

Intramural hematoma of the duodenum is a rare event which is usually associated with trauma. Because of the rarity of this problem, there has been little conformity of opinions as to diagnosis and treatment of this disease. The authors report on a case of intramural hematoma of the duodenum post-traumatically occurred in a young woman. Etiopathogenesis, diagnosis and treatment of hematoma of the duodenum are thoroughly examined in the present study. Plain abdominal radiography, oral barium study, ultrasound examination, CT and RNM are diagnostic tools in this disease. It appears that most patients with intramural hematoma of the duodenum would respond well to conservative management; surgery should be reserved for those cases that remain obstructed over seven days or have evidence of peritonitis. However surgery is mandatory in cases of uncertain diagnosis. The evacuation of hematoma is considered the most effective and safest surgical treatment.

[Blood levels of cholesterol and postoperative septic complications]. / Livelli ematici del colesterolo e complicanze settiche postoperatorie.

Hypocholesterolemia seems to represent a significant predictive factor of morbidity and mortality in critically ill patients. The authors, on the basis of recent literature data, aim to clarify the possible correlation between preoperative hypocholesterolemia and the risk of septic postoperative complications .205 patients undergoing to surgery for gastrointestinal diseases were the object of the study. Patients undergoing "minor" abdominal surgery or video-laparoscopic surgery and classified ASA III-IV were excluded. In all the patients, we considered retrospectively risk factors for postoperative septic complications as follows: preoperative blood concentration of cholesterol, malnutrition, obesity, diabetes, neoplasm, preoperative sepsis, type and duration of operations, antibiotics and regimen of use. Type and incidence of postoperative local or systemic septic complications were recorded. The patients have been stratified according to blood concentration of cholesterol and to the presence or absence of other risk factors. The incidence of postoperative sepsis was 35.1%. The highest incidence of postoperative septic complications (72.7%) was encountered, significantly (X2 = 7.6, p < 0.001), in the patients (11 cases, 5.9%) with cholesterol levels below 105 mg/dl). The results of this study seems to indicate a significant relationship between preoperative hypocholesterolemia and the incidence of septic complications after surgery. Moreover, evaluation of blood cholesterol levels before major surgery might represent a predictive factor of septic risk in the postoperative period.

[Recurrent abdominal pain and "chronic appendicitis"]. / Dolore addominale ricorrente e "appendicite cronica".

BACKGROUND: Chronic appendicitis may be the cause of recurrent abdominal pain. This hypothesis is the subject of controversy. The aim is to clarify the possible existence of a chronic inflammation of the appendix by a clinical and histopathologic study. METHODS: The case history and the preoperative symptoms and serum findings of 269 patients with appendectomy have been studied. All the appendices have been histologically examined. Chronic appendicitis was diagnosed when at least two typical histological factors of chronic inflammation were present. The histological findings of the appendices have been correlated with preoperative clinical and serum findings of the patients. 14-46 months after the appendectomy, the patients have been examined. RESULTS: Histological examination revealed 187 cases (69.5%) with acute appendicitis, 44 cases (16.3%) with non disease of appendix and 38 cases (14.2%) with chronic appendicitis. Recurrent abdominal pain and normal leukocyte count were closely correlated (chi 2 = 18.3, p < 0.001; chi 2 = 21.3, p < 0.001 respectively) with diagnosis of chronic appendicitis. 81.8% of 33 patients with chronic appendicitis who underwent follow-up had relief of all the symptoms after appendectomy. CONCLUSION: Therefore, the study seems to confirm the existence of a clinico-pathological condition that can be defined as chronic appendicitis, resolvable with appendectomy.

[Mesh repair of inguinal and femoral hernia]. / Chirurgia protesica delle ernie inguinali e crurali.

The authors describe a 6-year experience with mesh repair of inguinal and femoral hernia in a surgical teaching department. Two hundred and ninety-seven hernioplasties were performed in 256 consecutive patients: 237 Trabucco sutureless and 11 Lichtenstein tension-free hernioplasties for inguinal hernia; 21 tension-free hernioplasties for femoral hernia; 20 Wantz GPRVS and 8 Rutkow tension-free hernioplaties for recurrences. Local anaesthesia was used in 59% of cases. Seventy-two patients (28.1%) refused this type of anaesthesia. The hospital stay was two days in all cases. The local postoperative morbidity rate was 8.7% (wound infections: 1.0%; neuralgia: 1.3%; haematomas: 2.0%; seromas: 2.3%; no testicular atrophies). The recurrence rate was 1.9% in the group of patients undergoing surgery from 1994 to 1997 (103 herniorrhaphies; follow-up: 3-6 years) and 0% in the group of patients operated on after 1997 (170 herniorrhaphies; follow-up: 2 years-6 months). The results confirm that the use of a prosthetic mesh (patch and plug) is the treatment of choice for hernia repair. Moreover, this experience in a surgical teaching department shows that these procedures can be safely and effectively performed by all surgeons.

[Therapeutic strategy in symptomatic diverticular disease of the colon]. / La strategia terapeutica nella malattia diverticolare conclamata del colon.

Diverticular disease of the colon has been recorded with increasing frequency and approximately 25-30% of symptomatic patients require surgery for complications. Controversy still surrounds the best operative approach for the management of diverticular disease, particularly when it presents with complications. The three-stage operation has, for the most part, been abandoned because of its unacceptably high morbidity and mortality rates. Today it is generally believed that performing two-stage surgery is a wise decision, namely segmentary resection either without (Hartmann's procedure) or with anastomosis, protected by a covering colostomy. However, the ideal intervention is a one-stage surgical procedure (segmentary resection and primary anastomosis without a covering colostomy), but this can only be performed in selected patients. The aim of this study was to analyse the clinical course and the medical and surgical therapy retrospectively in 79 patients with symptomatic diverticular disease in order to identify the best therapeutic procedure; specifically, the severity of septic complications was evaluated using Hinchey's classification. The authors conclude that most patients with symptomatic diverticular disease require specific medical therapy. If surgical treatment is necessary (complicated diverticular disease), Hartmann's procedure is still a valid surgical option, particularly in the presence of diffuse faecal peritonitis. Colonic resection and primary anastomosis are certainly a satisfactory treatment, because of their low morbidity and mortality rates, but this surgical approach is only feasible in selected patients. Finally, it is a matter for the individual surgeon's experience to select the best surgical procedure in any particular situation, depending on age and general state, local findings and the extent of peritonitis.

[The role of melatonin in the immediate postoperative period in elderly patients]. / Il ruolo della melatonina nell'immediato decorso postoperatorio dei pazienti anziani.

BACKGROUND: Melatonin induces sleep and modulates immune system. Aim of the paper is to show a possible relation between impaired rhythm of melatonin secretion and the onset of postoperative septic complications and insomnia in old patients undergoing surgery. METHODS: Fifty old patients, aged from 60 to 94 years, have been studied; 39.5% of the patients had neoplastic disease. Melatonin serum levels have been evaluated by ELISA technique at 12 p.m., 3 a.m. 8 a.m. immediately before operation. Postoperative clinical findings of insomnia and septic complications have been recorded. RESULTS: The melatonin serum mean values of all the patients were 16.3 pg/ml at 12 p.m., 22.4 pg/ml at 3 a.m. and 7.1 pg/ml at 8 a.m. Neoplastic patients showed the higher values of melatonin (26.696 pg/ml, 33.143 pg/ml, 9.185 pg/ml), long-lived patients (> 90 years) the lower. The melatonin secretion curve of the old patients with postoperative insomnia (19.961 pg/ml, 20.297 pg/ml, 9.378 pg/ml) or postoperative septic complications (20.695 pg/ml, 16.183 pg/ml, 6.036 pg/ml) was significantly different compared with that of other patients. The peak was advanced, lower and decreased slowly in the midnight. CONCLUSIONS: The study seems to show a possible correlation between impaired rhythm of melatonin secretion and postoperative insomnia and postoperative sepsis in old patients undergoing surgery.

[Treatment of acute biliary pancreatitis in the aged in the endolaparoscopic era]. / Il trattamento della pancreatite acuta biliare nell'anziano nell'era endolaparoscopica.

BACKGROUND: Acute biliary pancreatitis (ABP) still retains high morbidity (15-50%) and mortality (20-35%). Therefore it appears to be crucial to clearly assess the aetiological factors (50% of idiopathic are in fact biliary pancreatitis) and to establish the severity in order to plan the appropriate treatment. METHODS: In this study we have considered 61 patients divided into 2 groups. Group 1 had 29 ABP patients aging less than 65 years, group 232 patients aging more than 65 years; the diagnosis was made by ultrasound and serological values in 78.5% of cases, while in the remaining 21.5% was only serological. Following Ranson and APACHE II scoring 18 cases (29.5%) were classified as severe [6 (20.6%) in group 1; 12 (37.5%) in group 2: p < 0.01], 43 (70.4%) as mild. All patients with severe ABP had emergency ERCP + ES (within 24-48 hrs) followed by LC (< or = 10 days). Patients with mild ABP had LC within 10 days; in these cases IOC was always done. RESULTS: In severe cases operative endoscopy cured pancreatic inflammation in 13 cases. Subsequent LC never showed serious morbidity, apart subcutaneous emphysema in one case. In 5 cases laparotomy was required since pancreatic necrosis was present, with 60% mortality. In patients with mild pancreatitis LC was successfully performed in all cases, with 6.9% morbidity. IOC showed choledochal stones in 32.5% of cases, while in severe cases stones in the biliary tree were showed in 88.8% of cases. No significant differences were detected between group 1 and 2. CONCLUSIONS: In conclusion ABP treatment is always surgical, and almost always with minimally-invasive procedures in severe cases (ERCP + ES with LC < or = 10 days) if surgery is performed within 24-48 hrs as well as in mild cases (LC + IOC) when surgery is done within 10 days, independently from the age of the patients.

[Aortic dissection: role of the general surgeon in diagnostic-therapeutic procedure]. / Dissecazione aortica: ruolo del chirurgo generale nell'iter diagnostico-terapeutico.

Aortic dissection occurs when there is a tear or separation of the aortic intima from the media; flow of blood into the intima-media space allows the tear to develop into a dissecting hematoma. Aortic dissection is a rare condition which represents an acute cardiovascular emergency for which the appropriate therapy is immediate surgical correction. Patients with aortic dissection show a heterogeneous constellation of symptoms; hence, clinical suspicion is often difficult. Only a minority of patients has "classic" symptomatology, the electrocardiogram is often misleading and the chest radiogram is almost always non-specific. In Italy, the usual "hospital routine practice" assigns the key-role in the emergency diagnostic procedure for these patients to the general surgeon. In view of the necessity of immediate cardiac surgery and the overwhelming likelihood of adverse events when surgery is delayed, techniques for diagnosis must be accurate, widely available and easily and quickly used. The present study consists of four case-reports of aortic dissection thoroughly examined and confronted with the literature. Management strategy based on emergency echocardiography is a reliable, feasible and successful technique for evaluating patients with aortic dissection. It allows a rapid accurate diagnosis with a single examination that can also be performed in the emergency room and provides information of sufficient diagnostic value to allow immediate cardiovascular surgery. CT scan and/or MRI are also valid tools for the emergency diagnosis of aortic dissection. However, a major problem still exists: the range of symptoms is sufficiently broad that a high index of "personal suspicion" of aortic dissection is required on the part of the general surgeon when he performs the role of "emergency-team leader".

[DRG and gastrointestinal surgery]. / DRG e chirurgia gastrointestinale.

The diagnosis-related-groups (DRG) is the cost-based system for hospital reimbursement. However, the proceeds does not coincide with the costs. Aim of the study was to identify the profit, which we could gained with 147, 155, 158, 162, 165, 198 gastrointestinal surgery DRG. 30 consecutive patients, undergone to surgery in Clinica Chirurgica of L'Aquila University, had been studied. We had calculated the daily costs of medical and nursing practice, diagnostic tests, drugs, hospitalization, surgical instruments for every patient's therapy. The DRG-proceeds had been correlated with the DRG-costs. The "major gastrointestinal surgery" had not profit (147 DRG: anterior resection of rectum = -354428 Pounds, Miles = -94020 Pounds; 155 DRG: total gastrectomy = -1920641 Pounds). On the contrary, "minimal surgery" had good profits (158 DRG: hemorroidectomy with local anestesia = 1469605 Pounds;162 DRG: sutureless groin hernioplasty = 1561200 Pounds; 198 DRG: videolaparochole-cystectomy: 1208807 Pounds). The study seems to demonstrate the disparity of the reimbursement system related to DRG. However, the surgeons, as managers, must employ warily the resources for producing DRG.

[The use of prosthetic meshes in the surgical treatment of inguinal hernia: the costs and profits for the local health screening unit]. / Utilizzazione delle reti protesiche nel trattamento chirurgico dell'ernia inguinale: costi e guadagni per la ULSS.

BACKGROUND: Inguinal hernioplasty represents one of the most frequently performed surgical operation. The recent introduction of prosthetic mesh made Bassini operation obsolete, with more space gained by the newly developed "tension-free" and "sutureless" surgical techniques. This new approach, however, results in increased initial costs for the hospital, due to the purchase of mesh materials. On the other hand a reduction of overall expenses for a single hernia repair should be expected. In this work an attempt is made to verify this, by calculating the cost-benefit ratio of different techniques for hernia repair. METHODS: The type and amount of materials used in a standard Bassini hernia repair, Lichtenstein and Trabucco have been examined. The amount of anesthetic drugs required, the average hospital stay and time away from work were recorded too. The costs of the three operations considered, not including routine expenses (operating room, bed sheet, etc.) have been estimated. RESULTS: Lichtenstein and Trabucco repair performed in local anesthesia (L. 1.354.120, L. 1.567.120) were cheaper than Bassini (L. 2.820.950). CONCLUSIONS: Since the system of diagnosis-related group offers a fixed amount of reimbursement for hernia repair (L. 3.247.000), the extensive use of tension free and sutureless methods, offers better profit for the Hospital. Last but not least, tension free hernia repair ensures short hospital stay, less postoperative pain, good compliance and better quality of life for the patient.

[Risk of surgery in geriatric age: prospective evaluation of risk factors]. / Rischio chirurgico in età geriatrica: valutazione prospettica d'indici di rischio.

The use of Risk Index in surgery is aimed to plan surgical strategy in order to achieve a better post-operative prognosis. This is especially true in geriatric surgery where ASA Index and, more recently, Reiss Index are widely employed. Since the mentionated Risk Indices are calculated on the basis of different factors, in this prospective study we compared the two Risk Indices with the aim of verify which index offers better prognostic indications. 125 consecutive patients, aged older 70 years, undergoing surgical treatment, were investigated. The patients were grouped according to ASA Index and Reiss Index and postoperative morbidity and mortality rate was calculated. Both Indices resulted good predictive for the postoperative prognosis (ASA: G Statistic = 31.531, p < 0.001; Reiss: G Statistic = 18.416, p < 0.001), but ASA Index sensitivity was better (Specificity = 100%, sensitivity = 28%, false negative rate = 72%) than Reiss Index (Specificity = 100%, sensitivity = 0, false negative rate = 100%). Therefore ASA Index has clinical valid role in valuing surgical risk in elderly.

[Video laparoscopic cholecystectomy in acute cholecystitis: when,how and why?]. / La videolaparocolecistectomia nella colecistite acuta. Quando, come e perché?

Acute cholecystitis has been previously considered as contraindication for laparoscopic cholecystectomy (LC), but recently, several studies have demonstrated that the laparoscopic approach can also be effective in such cases, although iatrogenic lesions of the biliary tree have been increasingly reported. Aim of this study was to verify the effectiveness of LC in patients presenting with acute cholecystitis on the basis of preoperative and intraoperative findings, postoperative mortality and morbidity, in order to assess those conditions which still can be considered as contraindications for LC. From September 1992 to January 1995, 133 patients have been consecutively admitted and operated for LC. 46 cases (36.5%) had histologically proven acute cholecystitis. Moreover we have compared preoperative date (clinical history, laboratory findings, Rx and ultrasound evaluation) with intraoperative findings to assess a correlation with intraoperative difficult conditions evaluated according to De Manzini score. Our results demonstrate that clinical data significantly correlate with intraoperative difficult situations. Hepatobiliary ultrasound also has shown good correlation between the thickness of gallbladder wall and difficult operations (73.9 sensibility-70.1 specificity). Therefore, in patients with clinically severe acute cholecystitis, and thickened gallbladder demonstrated by ultrasound it is very likely that the surgeon will experience difficult in intraoperative situations. In these conditions laparoscopy may be considered mainly as a diagnostic procedure in order to evaluate the entity of inflammatory changes considering the possibility of an open conversion that must be done before any iatrogenic lesion occur. This policy has allowed us to avoid in our series postoperative complications such as lesions of the biliary tree. In conclusion we believe that LC for acute cholecystitis should be considered as a therapeutical option only for selected cases.