Early outcomes of colon laparoscopic resection in the elderly patients compared with the younger

Background

The aim of this study was to define any benefits in terms of early outcome for laparoscopic colectomy in patients over 75 years old (OP) compared with the outcomes of a younger populations (YP).

Methods

Forty elderly patients undergoing laparoscopic colectomy for colorectal cancer between 2007-2011 were studied, the patients are divided for gender, age, year of surgery, site of cancer, and comorbidity on admission and compared with 40 younger patients.

Results and discussion

Mean (standard deviation) age was 81.3 in OP and 68.3 YP Conversion rate was the same between the two groups. There was no difference in operative mean time . The overall mortality rate was 0% percent. The surgical morbidity rate was the same but there was an increased in cardiologic e bronchopneumonia complications in older population. Patients treated with laparoscopic approach had a faster recovery of bowel function and a significant reduction of the mean length of hospital stay not age related. Laparoscopy allowed a better preservation of postoperative independence status.

Conclusions

Laparoscopic colectomy for cancer in elderly patients is safe and beneficial including preservation of postoperative independence and a reduction of length of hospital stay.

     

Laparoscopic Hyperthermic Intraperitoneal Chemotherapy: Indications, Aims, and Results: A Systematic Review of the Literature

Purpose

To evaluate laparoscopic hyperthermic intraperitoneal chemotherapy (HIPEC) with neoadjuvant, adjuvant, or palliative purpose in order to discuss potential clinical implications.

Methods

A systematic search of PubMed??s Medline through August 2011 using the keywords laparoscopic, hyperthermic, and chemotherapy.

Results

Eight studies encompassing a total of 183 patients were considered. The indications for laparoscopic HIPEC was neoadjuvant in 5 patients, adjuvant in 102 patients, and palliative in 76 patients. There were 13 minor complications not requiring repeat operation, and no deaths related to procedure were recorded. When performed to treat refractory malignant ascites, the procedure was effective in 95?% of cases.

Conclusions

Laparoscopic HIPEC appears to be a safe and effective procedure when performed to treat malignant ascites refractory to less aggressive treatments. The effectiveness of laparoscopy to perform HIPEC with neoadjuvant or adjuvant purpose needs to be confirmed by further studies.     

Gender-related differences in morbidity and mortality during combined valve and coronary surgery

BACKGROUND: Gender-related differences in morbidity and mortality are well described for coronary artery bypass grafting but are not well understood for combined valve and bypass surgery. METHODS: We reviewed retrospectively the morbidity and mortality of 1570 consecutive patients who underwent combined valve and bypass procedures at the Toronto General Hospital between January 1990 and October 2000. RESULTS: There were 1073 men (68%) and 497 women (32%). The mean ages (+/- 1 SD) of women and men were 69 +/- 9 and 68 +/- 9 years, respectively (P =.02). Of the 1570 total patients, 973 patients (62%) underwent aortic valve and coronary bypass surgery, 481 patients (31%) had mitral valve and coronary bypass operations, and 116 (7%) patients had double or triple valve and coronary bypass operations. Preoperative hypertension (P =.002), diabetes (P =.001), and atrial fibrillation (P =.001) were seen more frequently in women. Body surface area was significantly lower in women (P =.0001). At presentation, more women were in congestive heart failure (69% vs 58%, P =.001) and in New York Heart Association functional class III or IV (25% vs 19%, P =.001). Although there was no difference in the number of women with three or more diseased vessels (32% vs 38%), only 35% of women received three or more grafts compared with 44% of men (P =.001). The use of left internal thoracic grafts, although uncommon in the whole study population (36%), was less common in women than in men (26% vs 41%, P =.001). Multivariable logistic analyses for morbidity and mortality showed female gender to be an independent risk factor. Mitral valve replacement, age, left ventricular dysfunction, New York Heart Association classes III and IV, and association of tricuspid valve disease, diabetes, peripheral vascular disease, and preoperative renal failure were found to be independent risk factors for mortality. CONCLUSION: Female gender is an independent risk factor for combined morbidity and mortality during and after combined valve and coronary bypass surgery. As with isolated coronary artery bypass grafting, women undergoing combined procedures have more premorbid conditions, are more often in heart failure, had an equal incidence of triple vessel disease but received fewer grafts than men, and, therefore, were more frequently incompletely revascularized.     

The descending branch of lateral femoral circumflex artery in arterial CABG: early and midterm results

BACKGROUND: Different arterial conduits have been used for coronary artery bypass grafting (CABG), avoiding remote cardiac events associated with graft failure and improving the quality and expectancy of life in patients with coronary artery disease. The goal of this study was to evaluate the early and midterm results of total arterial CABG with the descending branch of the lateral femoral circumflex artery (DLFCA). METHODS: Between February 1997 and December 2001, 147 patients underwent arterial CABG using the DLFCA at our department. The patients were followed to determine perioperative cardiac events. Angiographic follow-up controls were performed at the end of surgery in 81 patients (55.1%), within 1 year in 82 patients (55.7%), and within 3 years in 48 patients (32.6%). The actuarial survival and event-free rates, the occurrence of late cardiac events and death, the cumulative rate of the DLFCA graft patency, and the incidence of spasm were investigated. RESULTS: The DLFCA was used in all patients (113 men and 34 women, with a mean age of 56 +/- 12.6 years). The proximal anastomoses of the DLFCA was performed with the left internal mammary artery (LIMA) in 95% and with the right internal mammary artery (RIMA) in 5% of patients. The distal anastomoses of the DLFCA was performed with the left anterior descending (LAD) coronary artery in 3.5%, with the diagonal artery in 17%, with the intermedius ramus in 7.5%, with the posterior interventricular artery in 2%, and with the branch of circumflex artery in 70% of patients. The in-hospital mortality and morbidity rates were 0% and 7.4%, respectively. Complications related to DLFCA harvesting was transient dysesthesia of the thigh, observed in 6 patients (4%). No postoperative myocardial infarction attributable to DLFCA bypass was observed. During the late follow-up period of 22.09 +/- 16.8 months, cardiac events were observed in 14 patients (9.5%), including recurrence of angina in 6, arrhythmia requiring hospitalization in 4, congestive heart failure in 2, percutaneous transluminal angioplasty in 1, and sudden death in 1 patient. Actuarial 1- and 3-year survival rates after surgery were 100% and 99.3%, respectively. Actuarial 1- and 3-year event-free rates were 97.3% and 90.5%, respectively. Actuarial 1- and 3-year patency rates were 97.5% and 93.7%, respectively. CONCLUSIONS: No adverse effects were exhibited after CABG using the DLFCA graft in this early and midterm follow-up period. The excellent patency rate of DLFCA and the low incidence of spasm stimulate us to continue and extend the use of the DLFCA in CABG.     

Long-Term Results of Subtotal Colectomy with Antiperistaltic Cecoproctostomy

Purpose. To evaluate the clinical role of subtotal colectomy with cecorectal anastomosis (CRA) and its postoperative results, based on our surgical experience. Methods. We retrospectively analyzed 26 patients who underwent subtotal colectomy with CRA during an 8-year period (1992–1999) in our university hospital. The indications for CRA were intractable constipation, colon tumors, diverticulitis, Crohns disease, and postactinic colitis. CRA was performed using a new technique of end-to-end antiperistaltic anastomosis. Postoperative and late complications, and functional results, defined as the number of bowel movements per day and quality of life, were evaluated. Results. None of the patients experienced postoperative or late complications. Two patients died from progression of colon cancer. The mean follow-up period was 4.5 years (range 1–8 years). By 1 month after surgery, 58% of the patients were passing frequent bowel movements, and by 1 year after surgery, only 23% of the patients were passing frequent bowel movements. The last follow-up revealed a mean 1.7 bowel movements per day, and only one patient was taking medication for diarrhea. All patients were satisfied with the results of their surgery and reported that their quality of life was good or improved, and even very good in six cases. Conclusions. Subtotal colectomy with our new CRA technique is appropriate for treating inflammatory diseases of the bowel, colon tumors, and intractable constipation in selected patients.     

Control results on a sample of patients subjected to total thyroidectomy for papillary carcinoma: proposal for a personal diagnostic-therapeutic follow-up

Well-differentiated thyroid neoplasms may be included among the most frequently occurring thyroid carcinomas. Papillary ca. is without doubt the best behaved type. The aim of the present work is to perform a retrospective case history study to assess patients with con papillary ca. who have been treated surgically over the last 17 years and have been subjected to periodic checks. A sample of patients was therefore extrapolated who had all undergone total thyroidectomy for papillary ca. of the thyroid. The incidence of local recurrence of the disease was verified, together with the results at distance. Furthermore, the assessments performed were evaluated and compared. From the sample of patients observed we inferred that papillary carcinoma of the thyroid can have a good prognosis over time provided periodic random checks are carried out.     

Reoperation on the femoral arterial bifurcation: technical notes and surgical strategy

Femoral bifurcation reoperation is a stern test for skilfull surgeons, owing to the presence of thick scar tissue from the previous operations, especially when prosthetic grafts are used. In cases of aorto-femoral graft thrombosis, if thrombectomy of the entire graft is possible, one could isolate the anastomotic tract with all the afferent vessels and construct a new anastomosis downstream in tissue which allows a better run-off. Often in our experience we executed a by-pass, with a vein or short tract of new graft, from the previous prosthetic branch to a distal part of the deep femoral artery. In this way the reoperation is faster and safer, limiting dangerous dissection times. In infected inguinal pseudo-aneurysms we prefer an axillo-femoral by-pass, with isolation of the deep femoral artery by lateral incision, outside the infected field. In the non-infected ones, the reconstruction involves the use of a new small-sized graft between the previous structures. In cases of femoro-femoral occlusion we think it is better, first of all, to evaluate the possibility of an orthotopic graft from the aorta or iliac artery.     

Laparoscopic cholecystectomy in the morbidly obese

In the early days of video-assisted laparoscopic cholecystectomy (VLC), obesity was considered a contraindication for the procedure. We reviewed charts from 304 patients undergoing VLC; 90 patients were obese, and among these, according to a classification currently used by medical nutritionists and based on BMI, 45 were overweight (BMI > or = 25 < or = 29.9), 27 were considered conventionally obese (BMI > or = 30 and < 40) and 18 morbidly obese (BMI > or = 40). In this study we considered only the morbidly obese patients (5 males and 13 females). The average age was 42.3 years (range: 21-65) and the average weight 275 Ib (range: 186-331 Ib). Six patients had previously undergone abdominal surgery. All patients were symptomatic for gallstones, and 5 of them were suffering from acute cholecystitis. Mean operative time was 20 minutes (range: 10-45 minutes) longer than that of non-obese patients. No open conversion was necessary. No major postoperative morbidity and no cases of mortality occurred. The mean hospital stay and resumption of normal diet were similar to those of non-obese patients. Regardless of the higher postoperative risks after open cholecystectomy in obese patients (pulmonary complications, thromboembolism, wound infections and cardiovascular complications), we suggest VLC as the procedure of choice for cholecystectomy in these patients.     

Neuroprotective effects of propofol in models of cerebral ischemia: inhibition of mitochondrial swelling as a possible mechanism

BACKGROUND: Propofol (2,6-diisopropylphenol) has been shown to attenuate neuronal injury in a number of experimental conditions, but studies in models of cerebral ischemia have yielded conflicting results. Moreover, the mechanisms involved in its neuroprotective effects are yet unclear. METHODS: The authors evaluated the neuroprotective effects of propofol in rat organotypic hippocampal slices exposed to oxygen-glucose deprivation, an in vitro model of cerebral ischemia. To investigate its possible mechanism of action, the authors then examined whether propofol could reduce Ca2+-induced rat brain mitochondrial swelling, an index of mitochondrial membrane permeability, as well as the mitochondrial swelling evoked by oxygen-glucose deprivation in CA1 pyramidal cells by transmission electron microscopy. Finally, they evaluated whether propofol could attenuate the infarct size and improve the neurobehavioral outcome in rats subjected to permanent middle cerebral artery occlusion in vivo. RESULTS: When present in the incubation medium during oxygen-glucose deprivation and the subsequent 24 h recovery period, propofol (10-100 microM) attenuated CA1 injury in hippocampal slices in vitro. Ca2+-induced brain mitochondrial swelling was prevented by 30-100 microM propofol, and so were the ultrastructural mitochondrial changes in CA1 pyramidal cells exposed to oxygen-glucose deprivation. Twenty-four hours after permanent middle cerebral artery occlusion, propofol (100 mg/kg, intraperitoneal) reduced the infarct size by approximately 30% when administered immediately after and up to 30 min after the occlusion. Finally, propofol administered within 30 min after middle cerebral artery occlusion was unable to affect the global neurobehavioral score but significantly preserved spontaneous activity in ischemic rats. CONCLUSIONS: These results show that propofol, at clinically relevant concentrations, is neuroprotective in models of cerebral ischemia in vitro and in vivo and that it may act by preventing the increase in neuronal mitochondrial swelling.     

The Role of Minimally Invasive Surgery in the Treatment of Lung Metastases

Introduction: The ideal surgical approach for pulmonary metastasectomy remains controversial. Thoracoscopic surgery may offer advantages in quality of life outcomes, with equivalent oncologic long-term results. This study aimed to demonstrate the validity of video-assisted thoracoscopic surgery (VATS) in the treatment of lung metastases. Methods: In all 224 patients who underwent 300 VATS metastasectomies from January 2000 to December 2013 were retrospectively reviewed. Sixty-nine patients underwent major resection (68 thoracoscopic lobectomies and one pneumonectomy) and 155 patients underwent a wedge resection/segmentectomy. Complete curative pulmonary resections were performed in 219 (97%) cases. The Kaplan–Meier method was used to estimate survival curves. Univariate and subsequent multivariate Cox model regression were performed to identify independent factors of overall survival. Results: One hundred eighty-six patients developed lung metastases from epithelial tumors, 28 from sarcomas, seven from melanomas, and three from germ cell tumors. The final pathological examination revealed no cases of R1 disease. After a mean follow-up of 40 months, 118 patients (53%) had died. According to a multivariate analysis, a better prognosis was not observed for patients with a particular histological type; in addition, disease-free interval time, age, number of metastases, and type of surgery did not have any statistical influence on long-term survival. Conclusions: Thoracoscopic surgery is a safe and efficacious procedure, with a five-year overall survival that is equivalent to open surgery.