Emergency hernia repair in the elderly. multivariate analysis of morbidity and mortality from an Italian registry

Purpose The incidence of inguinal hernia is higher in elderly because of aging-related diseases like prostatism, bronchitis, collagen laxity. A conservative management is common in elderly to reduce surgery-related risks, however watchful waiting can expose to obstruction and strangulation. The aim of the present study was to assess the impact of emergency surgery in a large series of elderly with complicated groin hernia and to identify the independent risk factors for postoperative morbidity and mortality. The predictive performance of prognostic risk scores has been also assessed. Methods This is a prospective observational study carried out between January 2017 and June 2018 in elderly patients who underwent emergency surgery for complicated hernia in 38 Italian hospitals. Pre-operative, surgical and postoperative data were recorded for each patient. ASA score, Charlson's comorbidity index, P-POSSUM and CR-POSSUM were assessed. Results 259 patients were recruited, mean age was 80 years. A direct repair without mesh was performed in 62 (23.9%) patients. Explorative laparotomy was performed in 56 (21.6%) patients and bowel resection was necessary in 44 (17%). Mortality occurred in seven (2.8%) patients. Fifty-five (21.2%) patients developed complications, 12 of whom had a major one. At univariate and multivariate analyses, Charlson's comorbidity index >= 6, altered mental status, and need for laparotomy were associated with major complications and mortality Conclusion Emergency surgery for complicated hernia is burdened by high morbidity and mortality in elderly patients. Preoperative comorbidity played a pivotal role in predicting complications and mortality and therefore Charlson's comorbidity index could be adopted to select patients for elective operation

Secretory breast cancer. Case report

Secretory carcinoma of the breast is a rare tumor initially described in children but occurring equally in adult population. This unusual breast cancer subtype has a generally favorable prognosis, although several cases have been described in adults with increased aggressiveness and a risk of metastases. However, surgery is still considered the most appropriate treatment for this pathology. We describe the case of a 50 –year-old woman who has undergone a breast conservative surgery for a little tumor, preoperatively diagnosticated by a fine needle aspiration biopsy (FNAB) as a well differentiated infiltrating carcinoma

Secretory breast cancer. Case report

Secretory carcinoma of the breast is a rare tumor initially described in children but occurring equally in adult population. This unusual breast cancer subtype has a generally favorable prognosis, although several cases have been described in adults with increased aggressiveness and a risk of metastases. However, surgery is still considered the most appropriate treatment for this pathology. We describe the case of a 50 - year-old woman who has undergone a breast conservative surgery for a little tumor, preoperatively diagnosticated by a fine needle aspiration biopsy (FNAB) as a well differentiated infiltrating carcinoma. © 2013, CIC Edizioni Internazionali, Roma

Importance of perforating vessels in nipple-sparing mastectomy: an anatomical description

Claudio Amanti,1 Valeria Vitale,1 Augusto Lombardi,1 Stefano Maggi,1 Laura Bersigotti,1 Gianni Lazzarin,1 Emiliano Nuccetelli,1 Camilla Romano,1 Laura Campanella,1 Lara Cristiano,2 Alessandra Bartoloni,2 Giuseppe Argento2 1Breast Surgery Unit, 2Radiology Unit, University of Roma, La Sapienza Sant'Andrea Hospital, Rome, Italy Background: Nipple-sparing mastectomy (NSM), understood as an oncologically valid procedure, is relatively new, and is an evolution of traditional mastectomy, particularly in relation to breast-conserving surgery. The anterior perforating branches are responsible for the cutaneous vascularization of the breast skin, and their preservation is a fundamental step to avoid possible postoperative necrosis. Therefore, evaluating the potential complications of cancer-related reconstructive surgical procedures such as NSM, both the distance of the tumoral lesion from the skin and the surgical incision site should be carefully considered. The preferred site of incision corresponds to the inframammary fold or possibly the periareolar area.Methods: We retrospectively reviewed 113 patients who underwent NSM from January 2005 to October 2012 to evaluate skin complications. The anatomical study was performed by magnetic resonance imaging of the breast.Results: Only one of the 113 women who had undergone a NSM procedure had total necrosis (0.9%) and six patients had partial necrosis (5.8%) of the nipple-areola complex. Keywords: nipple-sparing mastectomy, breast, magnetic resonance imaging, breast perforating vessels, breast anatom

The BREAST-Q Assessment: Sant'Andrea experience

Mastectomy is still indicated in approximately 30% of cases, for large invasive carcinoma, but also for multicentric tumors and intraductal diffuse carcinomas or prophylactic. We achieved a significant improvement of the aesthetic result performing Nipple sparing mastectomy (NSM), joined with reconstruction techniques. This approach has a positive impact on psychology and quality of life (QOL) of breast cancer patients. To evaluate these important aspects, we retrospectively applied the BREAST-Q questioner to 101 patients underwent a NSM. BREAST-Q is an instrument designed by the Evelyn H. Lauder Breast Center, MSKCC (NY), to assess outcomes among women undergoing different types of breast surgery: we chose reconstruction module that is comprised of two domains: patient satisfaction and QOL. There are six subthemes (physical, psychosocial and sexual well-being patient, satisfaction with breast, satisfaction with overall outcomes and satisfaction with care). We performed 157 NSMs with immediate breast reconstruction on a court of 117 patients. Selection criteria included women with tumor at least 1 cm from nipple-areola complex (NAC) without nipple discharge or NAC retraction. The median follow-up was 40 months with an age range between 19 and 72 y. We recorded 2 deaths for breast cancer, with a overall survival of 97% and a rate of local recurrence of 8.5% (10 cases). Our follow-up program included medical interview, examination of routine clinical and imaging findings, and collecting information by the BREAST-Q survey. 101 patients agreed the questioner. Our results confirm that BREAST-Q is an useful to evaluate QOL and obtain a more tailored surger

The Emergency Surgery Frailty Index (EmSFI): development and internal validation of a novel simple bedside risk score for elderly patients undergoing emergency surgery

none115noBackground: Frailty assessment has acquired an increasing importance in recent years and it has been demonstrated that this vulnerable profile predisposes elderly patients to a worse outcome after surgery. Therefore, it becomes paramount to perform an accurate stratification of surgical risk in elderly undergoing emergency surgery. Study design: 1024 patients older than 65 years who required urgent surgical procedures were prospectively recruited from 38 Italian centers participating to the multicentric FRAILESEL (Frailty and Emergency Surgery in the Elderly) study, between December 2016 and May 2017. A univariate analysis was carried out, with the purpose of developing a frailty index in emergency surgery called “EmSFI”. Receiver operating characteristic curve analysis was then performed to test the accuracy of our predictive score. Results: 784 elderly patients were consecutively enrolled, constituting the development set and results were validated considering further 240 consecutive patients undergoing colorectal surgical procedures. A logistic regression analysis was performed identifying different EmSFI risk classes. The model exhibited good accuracy as regard to mortality for both the development set (AUC = 0.731 [95% CI 0.654–0.772]; HL test χ2 = 6.780; p = 0.238) and the validation set (AUC = 0.762 [95% CI 0.682–0.842]; HL test χ2 = 7.238; p = 0.299). As concern morbidity, our model showed a moderate accuracy in the development group, whereas a poor discrimination ability was observed in the validation cohort. Conclusions: The validated EmSFI represents a reliable and time-sparing tool, despite its discriminative value decreased regarding complications. Thus, further studies are needed to investigate specifically surgical settings, validating the EmSFI prognostic role in assessing the procedure-related morbidity risk.openCosta, Gianluca; Bersigotti, Laura; Massa, Giulia; Lepre, Luca; Fransvea, Pietro; Lucarini, Alessio; Mercantini, Paolo; Balducci, Genoveffa; Sganga, Gabriele; Crucitti, Antonio; Agresta F, Alemanno G, Anania G, Antropoli M, Argenio G, Atzeni J, Avenia N, Azzinnaro A, Baldazzi G, Balducci G, Barbera G, Bellanova G, Bergamini C, Bersigotti L, Bianchi PP, Bombardini C, Borzellino G, Bozzo S, Brachini G, Buonanno GM, Canini T, Cardella S, Carrara G, Cassini D, Castriconi M, Ceccarelli G, Celi D, Ceresoli M, Chiarugi M, Cillara N, Cimino F, Cobuccio L, Cocorullo G, Colangelo E, Costa G, Crucitti A, DallaCaneva P, De Luca M, de Manzoni Garberini A, De Nisco C, De Prizio M, De Sol A, Dibella A, Falcioni T, Falco N, Farina C, Finotti E, Fontana T, Francioni G, Fransvea P, Frezza B, Garbarino G, Garulli G, Genna M, Giannessi S, Giofrè A, Giordano A, Gozzo D, Grimaldi S, Gulotta G, Iacopini V, Iarussi T, Laracca G, Laterza E, Leonardi A, Lepre L, Lorenzon L, Luridiana G, Malagnino A, Mar G, Marini P, Marzaioli R, Massa G, Mecarelli V, Mercantini P, Mingoli A, Nigri G, Occhionorelli S, Paderno N, Palini GM, Paradies D, Paroli M, Perrone F, Petrucciani N, Petruzzelli L, Pezzolla A, Piazza D, Piazza V, Piccoli M, Pisanu A, Podda M, Poillucci G, Porfdia R, Rossi G, Ruscelli P, Spagnoli A, Sulis R, Tartaglia D, Tranà C, Travaglino A, Tomaiuolo P, Valeri A, Vasquez G, Zago M, Zanoni E.Costa, Gianluca; Bersigotti, Laura; Massa, Giulia; Lepre, Luca; Fransvea, Pietro; Lucarini, Alessio; Mercantini, Paolo; Balducci, Genoveffa; Sganga, Gabriele; Crucitti, Antonio; Agresta, F; Alemanno, G; Anania, G; Antropoli, M; Argenio, G; Atzeni, J; Avenia, N; Azzinnaro, A; Baldazzi, G; Balducci, G; Barbera, G; Bellanova, G; Bergamini, C; Bersigotti, L; Bianchi, Pp; Bombardini, C; Borzellino, G; Bozzo, S; Brachini, G; Buonanno, Gm; Canini, T; Cardella, S; Carrara, G; Cassini, D; Castriconi, M; Ceccarelli, G; Celi, D; Ceresoli, M; Chiarugi, M; Cillara, N; Cimino, F; Cobuccio, L; Cocorullo, G; Colangelo, E; Costa, G; Crucitti, A; Dallacaneva, P; De Luca, M; de Manzoni Garberini, A; De Nisco, C; De Prizio, M; De Sol, A; Dibella, A; Falcioni, T; Falco, N; Farina, C; Finotti, E; Fontana, T; Francioni, G; Fransvea, P; Frezza, B; Garbarino, G; Garulli, G; Genna, M; Giannessi, S; Giofrè, A; Giordano, A; Gozzo, D; Grimaldi, S; Gulotta, G; Iacopini, V; Iarussi, T; Laracca, G; Laterza, E; Leonardi, A; Lepre, L; Lorenzon, L; Luridiana, G; Malagnino, A; Mar, G; Marini, P; Marzaioli, R; Massa, G; Mecarelli, V; Mercantini, P; Mingoli, A; Nigri, G; Occhionorelli, S; Paderno, N; Palini, Gm; Paradies, D; Paroli, M; Perrone, F; Petrucciani, N; Petruzzelli, L; Pezzolla, A; Piazza, D; Piazza, V; Piccoli, M; Pisanu, A; Podda, M; Poillucci, G; Porfdia, R; Rossi, G; Ruscelli, P; Spagnoli, A; Sulis, R; Tartaglia, D; Tranà, C; Travaglino, A; Tomaiuolo, P; Valeri, A; Vasquez, G; Zago, M; Zanoni, E

The Emergency Surgery Frailty Index (EmSFI): development and internal validation of a novel simple bedside risk score for elderly patients undergoing emergency surgery

Frailty assessment has acquired an increasing importance in recent years and it has been demonstrated that this vulnerable profile predisposes elderly patients to a worse outcome after surgery. Therefore, it becomes paramount to perform an accurate stratification of surgical risk in elderly undergoing emergency surgery

The Emergency Surgery Frailty Index (EmSFI): development and internal validation of a novel simple bedside risk score for elderly patients undergoing emergency surgery

Background: Frailty assessment has acquired an increasing importance in recent years and it has been demonstrated that this vulnerable profile predisposes elderly patients to a worse outcome after surgery. Therefore, it becomes paramount to perform an accurate stratification of surgical risk in elderly undergoing emergency surgery. Study design: 1024 patients older than 65 years who required urgent surgical procedures were prospectively recruited from 38 Italian centers participating to the multicentric FRAILESEL (Frailty and Emergency Surgery in the Elderly) study, between December 2016 and May 2017. A univariate analysis was carried out, with the purpose of developing a frailty index in emergency surgery called “EmSFI”. Receiver operating characteristic curve analysis was then performed to test the accuracy of our predictive score. Results: 784 elderly patients were consecutively enrolled, constituting the development set and results were validated considering further 240 consecutive patients undergoing colorectal surgical procedures. A logistic regression analysis was performed identifying different EmSFI risk classes. The model exhibited good accuracy as regard to mortality for both the development set (AUC = 0.731 [95% CI 0.654–0.772]; HL test χ2 = 6.780; p = 0.238) and the validation set (AUC = 0.762 [95% CI 0.682–0.842]; HL test χ2 = 7.238; p = 0.299). As concern morbidity, our model showed a moderate accuracy in the development group, whereas a poor discrimination ability was observed in the validation cohort. Conclusions: The validated EmSFI represents a reliable and time-sparing tool, despite its discriminative value decreased regarding complications. Thus, further studies are needed to investigate specifically surgical settings, validating the EmSFI prognostic role in assessing the procedure-related morbidity risk

Emergency hernia repair in the elderly: multivariate analysis of morbidity and mortality from an Italian registry

Purpose: The incidence of inguinal hernia is higher in elderly because of aging-related diseases like prostatism, bronchitis, collagen laxity. A conservative management is common in elderly to reduce surgery-related risks, however watchful waiting can expose to obstruction and strangulation. The aim of the present study was to assess the impact of emergency surgery in a large series of elderly with complicated groin hernia and to identify the independent risk factors for postoperative morbidity and mortality. The predictive performance of prognostic risk scores has been also assessed. Methods: This is a prospective observational study carried out between January 2017 and June 2018 in elderly patients who underwent emergency surgery for complicated hernia in 38 Italian hospitals. Pre-operative, surgical and postoperative data were recorded for each patient. ASA score, Charlson’s comorbidity index, P-POSSUM and CR-POSSUM were assessed. Results: 259 patients were recruited, mean age was 80 years. A direct repair without mesh was performed in 62 (23.9%) patients. Explorative laparotomy was performed in 56 (21.6%) patients and bowel resection was necessary in 44 (17%). Mortality occurred in seven (2.8%) patients. Fifty-five (21.2%) patients developed complications, 12 of whom had a major one. At univariate and multivariate analyses, Charlson’s comorbidity index ≥ 6, altered mental status, and need for laparotomy were associated with major complications and mortality Conclusion: Emergency surgery for complicated hernia is burdened by high morbidity and mortality in elderly patients. Preoperative comorbidity played a pivotal role in predicting complications and mortality and therefore Charlson’s comorbidity index could be adopted to select patients for elective operation