Routine laparoscopic cholecystectomy after endoscopic sphincterotomy for choledocholithiasis in octogenarians: is it worth the risk?

BACKGROUND: No unanimous consensus has been reached as to the need for routine laparoscopic cholecystectomy (LC) after endoscopic sphincterotomy (ES) for choledocholithiasis in very elderly patients, who are considered as high-risk subjects for surgery. METHODS: From 1991 through 1997, 170 patients were referred to undergo preoperative ES and routine LC for common bile duct (CBD) stones. The results for 27 patients (age 80 years or older) were compared with those achieved for younger patients. Successively, in a retrospective case-control study, the results for the selected patients were compared with those for 27 very elderly patients who underwent endoscopic retrograde cholangiopancreatography (ERCP), but did not receive LC. The mean follow-up period was 126 months. RESULTS: Octogenarians showed longer surgery time (79 vs 51 min) and postoperative hospital stay (2.8 vs 1.2 days), as well as more early low-grade complications (15% vs 3%), whereas there were no differences in conversion rate or serious complications. Recurrent symptoms or complications developed in 48% of octogenarians not undergoing routine LC, and 30% finally needed surgery. One patient in the control group died after emergency cholecystectomy for acute cholecystitis. The results of surgery were significantly poorer for the control group. CONCLUSIONS: Although a "wait-and-see" policy allowed two-thirds of LCs to be avoided in octogenarians, biliary-related events developed for every second patient, often requiring delayed surgery, with poorer results. Sequential treatment (ES followed by elective LC) is a safe procedure for octogenarians, and should be considered as a standard, definitive treatment for cholecystocholedocholithiasis even after the age of 80 years.

Endoscopic treatment of bilateral pheochromocytoma in MEN 2A syndrome: case report and review of the literature.

The benefits of laparoscopic adrenalectomy for single adrenal lesion have been well documented in literature; less experience though has been reported with simultaneous bilateral laparoscopic adrenalectomy. This operation is indicated in case of primary hypercortisolism caused by bilateral adrenocortical hyperfunction, Cushing's disease after failure of pituitary surgery, ectopic adrenocorticotropic hormone (ACTH) production by a tumour inaccessible for surgical intervention, and pheochromocytoma when it occurs bilaterally in case of multiple endocrine neoplasia type 2A and 2B. Different laparoscopic approaches have been described to perform this operation, such as the "anterior" approach (transperitoneal), the "lateral" approach (transperitoneal and retroperitoneal), and the "posterior" approach (retroperitoneal). We report a case of bilateral laparoscopic adrenalectomy in a 33 years old female affected with bilateral pheochromocytoma due to multiple endocrine neoplasia type 2A treated with a bilateral transperitoneal laparoscopic adrenalectomy and disease free after 18 months follow-up.

Anorectal reconstruction by electrostimulated graciloplasty as part of abdominoperineal resection.

AIMS: To report the outcomes of anorectal reconstruction by electrostimulated graciloplasty as part of abdominoperineal resection, on data prospectively collected over 10 years. PATIENTS AND METHODS: Twenty-three abdominoperineal resections were associated to coloperineal pull through, double graciloplasty and loop abdominal stoma. Fifteen patients also received an implantable pulse generator, either for unsatisfactory result after external-source intermittent electrostimulation and biofeedback (five cases) or during graciloplasty (10 cases). Follow-up was to a maximum of 10 years. Functional outcome was followed up in sixteen patients who underwent stoma takedown. RESULTS: Mean actuarial survival at 5 years was 72.3%. Satisfactory results (score < or =8) occurred in 75% of patients (three without and 13 with stimulator) in the early stages, decreasing to 57% at 1 year and gradually increasing up to 100% at 5 years and over. CONCLUSIONS: Total anorectal reconstruction yields a good functional outcome over time. Thus, despite, and because of, a high complication rate and a great drain on resources, it should be considered a suitable procedure only for selected, strongly motivated patients.

Quality of life assessment in geriatric surgery.

An excessive number of studies on health-related quality of life (HRQOL) has rendered results often contradictory and difficult to interpret. HRQOL evaluation in the aged is even more difficult, due to intrinsic conceptual and methodological problems. Since no structured instruments are available for use in geriatric surgery, it would be necessary either to work out a new specific instrument or to adapt/adopt an already existing method. Properties and methodological steps for development and validation are set forth. The Functional Assessment for Cancer Therapy (FACT) scale was developed for patients with cancer and has been recently validated also in the elderly. The Multidimensional Assessment for Cancer in the Elderly (MACE) was originally developed for elderly cancer patients. Since both methods are irrespective of subjects undergoing surgery, its use requires further validation. The MACE gives a broad information spectrum, but in geriatric surgery it seems too complex. The FACT-G is a simple core item questionnaire which can be integrated by disease-specific items and seems more compliant. A disease-specific and treatment-specific application of FACT questionnaires by multicenter studies might be useful in evaluating surgical procedures in patients in whom significant advantages in survival cannot be expected, but QOL can still significantly improve.

Delay in the diagnosis and outcome of colorectal cancer: a prospective study.

AIMS: The aim of this study was to examine the incidence of the delay in the diagnosis of colorectal carcinoma, possible causes of this delay and its effects on outcome. METHODS: A prospective study was performed on 100 patients affected by colorectal cancer. Duration of symptoms was calculated from the date of onset of symptoms to the date of surgery. RESULTS: Sixty-nine patients suffered delays in treatment of more than 12 weeks from the onset of symptoms. In patients with symptoms of less than 12 weeks' duration there was a higher incidence of radical surgery and none of these patients presented, at the time of surgery, a neoplastic dissemination. Multivariate analysis, however, showed that the only factors with an independent effect on 5-year survival and disease-free survival were Dukes' stage and the presence of pre-operative complications. CONCLUSIONS: The results of this study suggest that, independent of the diagnostic delay, the outcome of the colorectal cancer is only conditioned by tumour stage and by complicated cancer.

Laparoscopic diagnosis of gallbladder agenesis.

In this article, we report two cases of gallbladder agenesis that were incorrectly diagnosed as cholelithiasis on preoperative sonography. In the first case, the diagnosis was made by laparoscopic surgery and confirmed by postoperative CT scan. The second case was confirmed by laparoscopic abdominal examination and by laparoscopic sonography. Both patients had undergone preoperative IV cholangiography. Preoperative cholangiography and laparoscopic exploration completed by laparoscopic sonography should be considered adequate modalities for the diagnosis of gallbladder agenesis, without the need for laparotomy and thorough postoperative workup.

Laparoscopically assisted treatment of acute abdomen in systemic lupus erythematosus.

The incidence of abdominal pain in patients with systemic lupus erythematosus (SLE) is very high. Most patients do not require surgical treatment (serositis). Some cases such as appendicitis, perforated ulcer, cholecystitis or, rarely, intestinal infarction are surgical. Differential diagnosis is difficult, partly because noninvasive examinations do not provide enough evidence to rule out a diagnosis. On the other hand, in patients with SLE who have acute abdomen, it is dangerous to delay surgery by attempting conservative therapy. In fact, a better survival rate has been associated with early laparotomy. We report a case of acute abdomen in a patient affected by SLE, in which the diagnostic problem was solved by means of laparoscopy and the treatment was laparoscopically assisted. A 45-year-old woman with a 25-year history of SLE was admitted with abdominal pain and fever. Her physical examination revealed a painful right iliac fossa with rebound tenderness. Her WBC count was normal. Abdominal x-ray, ultrasonography, paracentesis, and peritoneal lavage did not provide a diagnosis. A diagnostic laparoscopy was performed, showing segmentary small bowel necrosis. The incision of the umbilical port site was enlarged to allow a small laparatomy, and a small bowel resection was performed. The histopathologic finding was "leucocytoclasic vasculitis, with infarction of the intestinal wall." The patient recovered uneventfully. In conclusion, this case report shows that emergency diagnostic laparoscopy is feasible and useful for acute abdomen in SLE. Currently, this diagnostic possibility could be considered the technique of choice in these cases, partly because, when necessary, it also can allow for mini-invasive treatment therapy.

Diverticulitis of the caecum and ascending colon: an unavoidable diagnostic pitfall?

PURPOSE: The infrequency of right-sided colonic diverticulitis prompted this presentation of our experiences, with emphasis on the diagnostic aspects. PATIENTS AND METHODS: Charts and documentation regarding 20 patients who underwent surgery for diverticulitis of the caecum and/or ascending colon over 22 years were reviewed. RESULTS: Eleven patients underwent pre-operative instrumental examinations: right-sided diverticulitis was recognized in five patients (two by barium enema, two by both ultrasonography and computerized tomography, one by all three examinations) and was suspected in another four. All diagnoses on merely clinical grounds--acute appendicitis in 10 patients and perforated peptic ulcer in one--were erroneous. Surgery consisted of 13 right standard or limited hemicolectomies, six conservative procedures and one Mickulicz' operation and subsequent right hemicolectomy. No operative deaths or long-term failures were reported. CONCLUSIONS: In the presence of clinical features atypical of acute appendicitis, right-sided colonic diverticulitis should be taken into account; pre-operative instrumental examinations might increase diagnostic accuracy, thereby leading to a more correct therapeutic approach.

[Method and application limitations of decision support systems in acute pancreatitis]. / Limiti metodologici e applicativi dei sistemi di supporto alle decisioni nella pancreatite acuta.

Several decision support systems (DSSs) for acute pancreatitis (AP) were analyzed with reference to development methods, procedure limits and operational performances. Almost all the DSSs have been addressed to the early definition of severity, which appears the only decisional point in the approach to the management of AP. None of the three groups of methods, multifactor, scoring and bayesian systems, provides an explicit evidence of effectiveness. The multifactor systems (Ranson and successive) show inadequacy of design and operational limits which involve poor reliability and conflicting indications from the different centers. The scoring systems (APACHE, SAPS) have been projected and developed for clinical situations quite different from the AP at the onset, and seem more properly to be applicable to the monitoring of its complications. The bayesian systems, although the models used until now present important methodological shortcomings, are those which furnished the best results but are lacking in clinical validation and present a form hardly accepted by the clinician. Despite the disappointing operative results and their limited use in the AP, the DSSs probably constitute one of the most effective tools to improve the management of the severe forms, on condition that the methodology of design enad trial is correctly adjusted.

[Caecal-rectal antiperistaltic anastomosis without torsion of the vascular pedicle]. / Anastomose caecorectale antipéristaltique sans torsion du pédicule vasculaire.

Caecorectal anastomosis by Deloyers' procedure has the disadvantage of creating torsion of the vascular pedicle. The technique reported here is a simple mechanical anti-peristaltic anastomosis without inversion of the caecum. This technique was performed successfully in 26 patients after subtotal colectomy for multiple colonic carcinomas or severe constipation.

[Personal case series of intrahepatic lithiasis]. / Osservazioni personali in tema di calcolosi intraepatica.

Fifteen cases of intrahepatic lithiasis are reported, on 1798 operations for non malignant diseases of the biliary tract (0.8%), carried out by the Authors in the last 11 years. Two cases were described separately, consisting respectively of an "eastern" hepatolithiasis, and a secondary form, due to stenosis of a choledochoduodenostomy, which had been performed after surgical injury of the common bile duct. The other 13 patients had a "mixed" form. Jaundice was present in 8 of these cases, cholangitis in 4. Intrahepatic stones were diagnosed preoperatively in 3 cases and intraoperatively in 10. A bilioenteric anastomosis was carried out in 9 cases, a sphincteroplasty in 3, and a T-tube drainage in a patient with suppurative cholangitis. Two patients died postoperatively, both from sepsis: the first in the early postoperative phase, after emergency operation for cholangitis; the other, with "primitive" hepatolithiasis, 3 months after the operation. Clinical results are satisfactory after 1-11 years. On the basis of data from current literature, diagnostic and therapeutic aspects are set forth, with specific reference to the mixed and secondary forms: the bilioenteric anastomoses seem to give better chances of success, but the need to have access to lobar ducts may sometimes impose hilar derivations. Spincteroplasty may have a few indications, solely in selected patients.

[Research on correlations between immuno-nutritional parameters and oncologic stage in patients operated on for cancer of the stomach]. / Ricerca di correlazione tra parametri immunonutrizionali e stadio oncologico in soggetti operati per cancro dello stomaco.

A correlation was sought, in 40 patients operated on for gastric cancer, between a number of immunological and nutritional variables and oncological stage. Prealbumin, transferrin, C3, C4, total complement (CH100), total serum lymphocytes, IgG, IgA and IgM were evaluated preoperatively prior to commencing any nutritional treatment. Statistical analysis was performed with a view to assessing whether the values of the above-mentioned parameters, taken singly or as a whole, differed in the 4 in the 4 oncological stages (UICC 1978). Analysis of individual parameter values showed a significant difference between stage I and stage IV with regard to prealbumin and between stages I and II with regard to C3 (p = 0.0165 and p = 0.0329, respectively). When evaluating the 9 parameters as a whole, no significant differences emerged, though such differences might be detected on increasing the study population and by adopting statistical procedures aimed at eliminating the least significant variables from the model.

[Design criteria for a computerized clinical database]. / Criteri di progettazione di un archivio clinico computerizzato.

The techniques of data management constitute a principal field in medical informatics, both for systems oriented to sole information retrieval, and basic-systems for more sophisticated applications. The operative utility of a data base depends on a careful planning based on foreseen requirements, and on the observance of some methodological rules. Such as, a precised preliminary study for the selection of clinical data to include in the data base, the choice of better tools and methodologies for the data collection and the right programming of software for the management of the archives. The knowledge of these problems allows, in many cases, the programming of computerized data base to use efficiently in the management of clinical information and in the planning of research. These problems, which do not depend on the hardware used, are commonly found in these applications. However, they have to be solved either for the use of large data base in hospital, which run on mainframe, or for the archives of the department, which can be built by every clinician on his own personal computer.

[Efficacy of a low-residue diet in the prevention of immuno-nutritional changes caused by the preparation of the colon for surgery]. / Efficacia di una dieta a basso residuo nella prevenzione delle alterazioni immunonutrizionali indotte dalla preparazione del colon.

Twenty-four patients about to undergo colorectal resection for cancer were randomly divided into two groups of 12: A and B. All had an uninterrupted colonic preparation for colonoscopy and surgery involving dietary restrictions for 4-8 days (450 calories; 25 g. proteins daily). In the group B an additional intake of 1200 Kcal. and 32 g. protein daily was given by a low-residue diet. Body weight, lymphocytes, albumin, prealbumin, C3, C4 and Complement activity (CH100) were evaluated on admission and after bowel preparation. In group A statistically significant decrease were found in all the parameters. In group B significant reduction occurred only in C4. The data confirm a relationship between immuno-nutritional state and preparation for colonic surgery, and suggest that a preoperative nutritional support may avoid or limit bio-humoral changes, indicative of an immuno-nutritional impairment.

[Surgical aspects of thrombosis in the portal system (author's transl)]. / Aspetti chirurgici delle trombosi nel territorio portale.

The Authors present and discuss clinical and therapeutic aspects of several cases of chronic portal thrombosis, troncular and radicular, either isolated or variously associated. Splenoportography and selective arteriography do not always provide a clear-cut picture of the vascular situation, particularly in the presence of mural thrombi. Surgery may be needed as an emergency measure in cases of hemorrhage, but the best results are obtained if it can be done electively. Indications, however, must be evaluated very carefully in each individual case, especially for thrombosis not associated with cirrhosis of the liver, in which the tendency to a more favorable natural evolution may invite a more conservative approach. The choice of surgical procedures is dictated essentially by the site of obstruction in the portal system. After discussing the indications for various methods, the authors present some cases of thrombosis involving only the superior mesenteric vein, managed successfully by disobliteration and mesenterocaval anastomosis.

[Gastric carcinoma in the elderly (clinical findings and results)]. / Il carcinoma gastrico nell'anziano (rilievi clinici e risultati).

On the basis of a series of 643 patients operated on for gastric cancer, the Authors seek to establish whether this disease presents clinical differences with advancing age of such a nature as to have a significant effect on therapeutic management. The series is divided into two groups, the first consisting of patients aged below 70 and the second of patients aged over 70. The following aspects were evaluated: sex, tumour site, oncological stage, type of surgery performed, operative mortality, postoperative survival, as assessed in overall terms and also differentiated in relation to curative or palliative surgery and oncological stage. Analysis of the data confirms that, apart from certain particular aspects, carcinoma of the stomach in the elderly benefits from the same sort of indications and techniques as those proposed for younger patients, with comparable postoperative survival rates, but with a higher operative mortality. To achieve better operative results, what is needed, in addition to correction of metabolic and functional abnormalities, is thorough assessment of risk factors. In patients with tumours at advanced stages, usually characterized by very poor postoperative results, the presence of major risk factors may raise serious doubts as to the actual advisability of the surgical indication itself.

[Treatment of hemorrhagic syndrome caused by peritoneovenous shunt with a flow regulation device]. / Trattamento di sindrome emorragica da shunt peritoneo-venoso mediante dispositivo di regolazione del flusso.

A case of severe coagulopathy after peritoneovenous shunting for intractable ascites and hepatorenal syndrome in a cirrhotic patient is reported. It was controlled and solved without removal of the shunt, using a vascular tourniquet which allowed a regulation of the ascitic flow. The method seems susceptible of improvement and could be routinely used in risk patients.

[Multimodal treatment of intrahepatic lithiasis with traditional surgery, endoscopy, and extracorporeal lithotripsy. Report of a clinical case]. / Trattamento multimodale della calcolosi intraepatica mediante chirurgia tradizionale, endoscopia e litotripsia extracorporea. A proposito di un caso clinico.

A patient with residual intra-/extra-hepatic bile duct stones, previously admitted in emergency for acute necrotic pancreatitis and cholangitis, underwent the following procedures: 1) endoscopic sphincterotomy and naso-biliary tube drainage; 2) surgical operation (choledocholithotomy, operative choledochoscopy and T-tube external biliary drainage); 3) extracorporeal shock-wave lithotripsy; 4) endoscopic sessions of fragmented stones removal. The above mentioned multimodal treatment, which resolved the intrahepatic lithiasis as shown 12 months later by endoscopic retrograde cholangiography, is therefore suitable in order to avoid, at least initially, invasive radiologic or surgical procedures, i.e. transparenchymal approaches, intrahepatic derivations and hepatic resections.

[Clinical implications of the infiltration level of early gastric cancer]. / Implicazioni cliniche del livello di infiltrazione nell' "early" gastrico.

Sixty-nine cases of early gastric cancer (EGC) were taken into consideration, out of a series of 585 operations for gastric cancer, carried out between January 1976 and June 1988. Differences between two groups (I: EGC limited to the mucosa; II: EGC with invasion of both the mucosa and submucosa) have been assessed with reference to familiarity for gastric cancer, previous gastric and duodenal pathology, symptoms, site of the lesion, histological features, lymph node metastatic involvement and results. Despite some pathological and clinical differences, modification of current surgical treatment with endoscopic management is not justified by any features, even when dealing with intramucosal, intestinal type EGC, because of possible lymph node involvement or long-term recurrences.