Role and outcomes of laparoscopic cholecystectomy in the elderly.

Introduction: Laparoscopic cholecystectomy is the standard of treatment for gallstones disease and acute colecystitis. The prevalence of this disease increases with age and the population is aging in industrialized countries. So, in this study we report our experience in the treatment of gallstone disease in elderly patients, particularly analyzing the outcomes of laparoscopic approach. Methods: Between January 2010 and May 2014 we performed a total of 1227 cholecystectomies. In this retrospective study age group was the primary independent variable: 351 patients were 65-79 years of age and 65 were 80 years of age or older. Results: Only 65 patients (5.3%) of all population had primary open cholecystectomy, but the rate in young group was 3.7% respect the highest frequency (9.2%) in the elderly group. The conversion rate was higher (1.2%) in the older group but there was no significant difference with younger group. LC in emergency setting was performed in 10.3% of young patients and in 13.8% of elderly group. Conclusion: Laparoscopic cholecystectomy is a feasible and safe procedure in elderly patients and might be performed during the same hospitalization like definitive treatment of gallstone disease. The old age and subsequent comorbidity are the fundamental predictor of surgical outcomes. Elective treatment should be recommended when repeated gallstone symptoms have occurred in the elderly patient before the development of acute cholecystitis and related complications

Laparoscopic management of adrenal tumors: a four-year experience in a single center

AIM: Today laparoscopy is considered the first choice treatment of many adrenal tumors, although its use is still controversial for large adrenal masses and incidentally found adrenal cortical carcinoma. METHODS: From January 2009 to February 2014 we performed 42 lateral transperitoneal laparoscopic adrenalectomies. The indications for surgery were non-functioning adenoma larger than 4 cm or rapid growth and hormone-secreting tumor. The diagnosis was confirmed in all cases with computed tomography and magnetic resonance imaging and also metaiodobenzylguanidine scintigraphy if pheochromocytoma was suspected. In all cases we realized a complete preoperative hormonal study. We describe and analyzed retrospectively: age, side, indication for surgery, tumor size, length of hospital stay, complication and conversion rate. RESULTS: Twenty-two patients with functional tumors and 20 with non functional tumor were subjected to laparoscopic adrenalectomy. There was no conversion to open surgery. Mean operative time was 120 min and estimated blood loss was 80 mL (range 50-350). There was no mortality or major complications. The average length of hospital stay was 3.5 day. During pheocromocitoma removal hypertension occurred in 2 cases. Patient with aldosteroma became normotensive and no required postoperative antihypertensive therapy. CONCLUSION: Laparoscopic adrenalectomy is a standard safe procedure for adrenal surgery. The risk of encountering incidental adrenal cortical cancer increases for large lesions and additional attention is required in these cases to observe oncologic surgical principles. Pre-operative work –up has a primary role in adrenal surgery. An accurate management of adrenal tumors requires an agreement among radiologist, endocrinologist, oncologist and surgeon. Previus abdominal surgery does not constituite a contraindication to laparoscopic transperitoneal adrenalectomy

Right diaphragmatic injury and lacerated liver during a penetrating abdominal trauma: case report and brief literature review.

INTRODUCTION: Diaphragmatic injuries are rare consequences of thoracoabdominal trauma and they often occur in association with multiorgan injuries. The diaphragm is a difficult anatomical structure to study with common imaging instruments due to its physiological movement. Thus, diaphragmatic injuries can often be misunderstood and diagnosed only during surgical procedures. Diagnostic delay results in a high rate of mortality. METHODS: We report the management of a clinical case of a 45-old man who came to our observation with a stab wound in the right upper abdomen. The type or length of the knife used as it was extracted from the victim after the fight. CT imaging demonstrated a right hemothorax without pulmonary lesions and parenchymal laceration of the liver with active bleeding. It is observed hemoperitoneum and subdiaphragmatic air in the abdomen, as a bowel perforation. A complete blood count check revealed a decrease in hemoglobin (7 mg/dl), and therefore it was decided to perform surgery in midline laparotomy. CONCLUSION: In countries with a low incidence of inter-personal violence, stab wound diaphragmatic injury is particularly rare, in particular involving the right hemidiaphragm. Diaphragmatic injury may be underestimated due to the presence of concomitant lesions of other organs, to a state of shock and respiratory failure, and to the difficulty of identifying diaphragmatic injuries in the absence of high sensitivity and specific diagnostic instruments. Diagnostic delay causes high mortality with these traumas with insidious symptoms. A diaphragmatic injury should be suspected in the presence of a clinical picture which includes hemothorax, hemoperitoneum, anemia and the presence of subdiaphragmatic air in the abdomen

Three-dimensional (3D) versus two-dimensional (2D) laparoscopic adrenalectomy: A case-control study

Laparoscopic adrenalectomy is today considered the gold standard of treatment for adrenal tumors. The development of high definition cameras does not eliminate the major limitation of two-dimensional (2D) laparoscopy: lack of depth perception and loss of spatial orientation. Tree-dimensional (3D) HD laparoscopy was developed as an alternative to conventional 2D laparoscopy

Whipple's pancreaticoduodenectomy: Surgical technique and perioperative clinical outcomes in a single center

Introduction: Pancreatic cancer is the fourth cause of death from cancer in Western countries. The radical surgical resection is the only curative option for this pathology. The prevalence of this disease increases with age in population. The causes of pancreatic cancer are unknown, but we consider risk factors like smoke and tobacco usage, alcohol consumption coffee, history of diabetes or chronic pancreatitis. In this study we report our experience in the treatment of resectable pancreatic cancer and periampullary neoplasms with particular attention to evaluate the evolution of surgical technique and the clinical postoperative outcomes. Methods: In our Department between January 2010 and December 2014 we performed a total of 97 pancreaticoduodenectomy. We considered only resectable pancreatic cancer and periampullary neoplasms defined by absence of distant metastases, absence of local tumor extension to the celiac axis and hepatic artery as the lack of involvement of the superior mesenteric vasculature. None of these patients received neoadjuvant chemotherapy. Results: The mean age of these patients was 64.5 years. Jaundice was the commonest presenting symptom associated to anorexia and weight loss. The mean operative time was 295min (±55min). The mean blood loss was 450ml and median blood transfusion was 1 units. 12.1% of patients had an intra-abdominal complication. The commonest complication was Delayed Gastric Emptying responsable of increased length of hospital stay and readmission rate. Postoperative pancreatic fistula of grade C occurred in 4 patients. 2 patients developed a postpancreatectomy hemorrhage. Perioperative mortality was 4.1%. Conclusion: Pancreaticoduodenectomy is a complex surgical technique and the associated high morbidity and mortality resulted in initial reluctance to adopt this surgery for the management of pancreatic and periampullary tumors. Surgical outcomes of pancreatic surgery are better at high-volume experienced center reporting mortality rates below 5%. We perform an end-to-side duct-to-mucosa pancreaticojejunostomy with routinely use of internal pancreatic stent. However no one technique has been shown to definitely be the solution to the problem of postoperative pancreatic fistula. At our center we have a reasonable volume and our data are comparable to literature data

Appendiceal mucinous neoplasms: An uncertain nosological entity. Report of a case

Introduction: Appendiceal mucocele is a relatively rare condition characterized by progressive dilation of the appendix caused by intraluminal accumulation of mucoid substance. Its incidence is 0.07 - 0,63% of all appendectomies performed. Case report: We report the case of a 70-year-old man who came to our observation with gravative pain in right lower abdominal region. A computed tomography abdominal scan revealed a cystic/tubular structure like an appendicular mass with wall enhancement but without calcifications suggestive of a mucocele. Into peritoneal cavity we found profuse mucinous material with a 1,5 cm size parietal nodule. We also identified a free perforation of the cecum with consensual spillage of gelatinous material mimicking a pseudomyxoma peritonei. We decided to perform a right hemicolectomy with excision of peritoneal lesion. Discussion: The controversy in the pathologic terminology can give rise to a clinical dilemma in terms of the management and follow-up plans. For mucosal hyperplasia and cystadenoma simple appendectomy is curative. Only in case of large base of implantation it may be necessary the resection of the ileum and caecum or right hemicolectomy. In case of mucinous cystoadenocarcinoma authors perform a right hemicolectomy. Conclusion: Appendiceal mucinous neoplasms are different pathological entities. The correct surgical management depends on size and location of lesion. A preoperative diagnosis is obviously needed in order to perform the correct treatment. CT abdominal scan is the better diagnostic tool, but different authors show their inability to reach a preoperative diagnosis in the larger majority of cases

Terminal or truncal ligation of the inferior thyroid artery during thyroidectomy? A prospective randomized trial

INTRODUCTION: Thyroidectomy is a common procedure in general and endocrine surgery. The technique of ligation of inferior thyroid artery (ITA) has been invoked as a possible cause of appearance of postoperative hypocalcemia. METHODS: We performed a prospective randomized study involving 184 patients undergoing total thyroidectomy to evaluate the differences of truncal ligation versus distal ligation of ITA in terms of postoperative hypocalcemia, vocal fold palsy, voice and swallowing impairment. The patients were divided into group A (trunk ligation of ITA) and group B (terminal branches ligation of ITA). RESULTS: We evaluated postoperative PTH and calcemia (immediate, 6 and 12 months after thyroidectomy), postoperative day of discontinuation of calcium and vitamin D supplementation, voice and swallowing complaints, evaluated by mean of two specific tests available in literature, day of hospital discharge. CONCLUSION: The only significant differences between the two groups were a higher immediate postoperative calcemia and a greater number of patients discharged without calcium and vitamin-D supplementation in the group B. In conclusion, no substantial differences were found between the two groups. The choice depends on the experience of the surgeon

Endometrial cancer: Robotic versus Laparoscopic treatment. Preliminary report

Laparoscopic approach is today the standard treatment for benign and malignant gynecological pathologies. To traditional laparoscopic surgery in the last 10 years we can add the possibility to use a robotic platform. The adoption of this system allows undoubted advantages as the three-dimensional vision, the absence of the physiological tremor with enhanced ergonomics and possibility of using articulable tools. In this study we analyzed the results of 18 patients with endometrial cancer (Stage I) treated with robotic approach. The results were compared with a selected sample of 26 patients, with the same characteristics, treated with traditional laparoscopic approach in the same period by the same surgical team. The mean total operative time was significantly longer for robotic than laparoscopic group (125.6 min vs 102.3 min). However, if to this operative time we remove the time of preparation (docking time) we obtain the following results: 102.5 min for robotic group and 95.7 min for the laparoscopic control group. Intra-operative blood loss are significantly lower in the robotic group than in laparoscopic group. The robotic treatment of gynecological cancer is a safe and feasible technique. The oncological results are also equivalent to those of traditional laparoscopic surgery with advantages in terms of precision and reduction of intraoperative bleeding. Additional clinical studies on larger samples and heterogeneous patients are necessary in order to clarify the real advantages of robotic treatment

Laparoscopic adrenalectomy: Preoperative data, surgical technique and clinical outcomes

Background: laparoscopic adrenalectomy has become the standard treatment for adrenal lesions. The better clinical outcoms of laparoscopic technique are valid for treatment of small benign masses (< 5-6 cm), instead there are still open questions in literature regarding the correct management of larger lesions (> 6 cm) or in case of potentially malignant adrenal tumors. The aim of this study is to evaluate the outcomes of laparoscopic adrenalectomy in a referral surgical department for endocrine surgery. Methods: at the University Hospital Policlinico "P. Giaccone" of Palermo between January 2010 and December 2017 we performed a total of 81 laparoscopic adrenalectomy. We created a retrospective database with analysis of patients data, morphologic and hormonal characteristics of adrenal lesions, surgical procedures and postoperative results with histological diagnosis and complications. Results: Mean size of adrenal neoplasm was 7,5 cm (range 1.5 to 18 cm). The mean operative time was 145 min (range 75-240). In statistical analysis lenght of surgery was correlated to the lesion diameter (p < 0.05) but not with pre-operative features or histological results. 5 intraoperative complications occurred. Among these patients 4 presented bleeding and 1 a diaphagmatic lesion. No conversion to open surgery was necessary and no intraoperative blood transfusion were required. Mean estimated blood loss was 95 ml (range 50-350). There was no capsular disruption during adrenal dissection. Mean length of hospital stay was 3.7 days (range 3-6 days). Conclusions: Laparoscopic adrenalectomy is a safe procedure with low rate of morbidity. An accurate preoperative radiological examination is fundamental to obtain a stringent patients selection. The lesion diameter is related to longer operative time and appeares as the main predictive parameter of intraoperative complications but these results are not statistically significant. On the other side secreting adrenal tumors require more attention in operative management without increased rate of postoperative complications

Adrenal cavernous hemangioma: which correct decision making process?

Introduction: Cavernous hemangioma of the adrenal gland is a rare benign tumor characterized by the presence of blood-fil- led, dilated vascular spaces. These adrenal masses are usually non-functioning and the patients have no symptoms so the diagnosis is incidental. Methods: We performed a systematic literature review for all articles published until April 2015. The initial search identified 98 publications. We considered some characteristics: the mean age of the patients at diagnosis was 59 years (range 19 - 84); there were approximately 1.7 times more female patients than male patients; mean diameter of the lesions was 10.3 cm (range 2 - 25). Surgical treatment was more often open with midline or subcostal incision. Results: From literature analysis we know that small adrenal hemangiomas are usually asymptomatic. Only four patients in our literature review show endocrinologic disturbances with three cases of subclinical Cushing’s syndrome and a case of hyperaldo- steronism. The pre-operative radiologic features play a fundamental role for correct surgical approach. On enhanced Computed Tomography (CT) scan adrenal hemangiomas tend to be heterogeneous, hypodense lesions with high-density rim of tissue at the periphery. On Magnetic Resonance Imaging (MRI) common findings associated with adrenal hemangiomas are hypointense inhomo- geneous masses with central hyperintensity on T1 images and a high intensity peripheral rim on T2 images due to hemorrhage or necrosis. Conclusion: Laparoscopic adrenalectomy is considered the standard treatment in case of benign lesions. Some authors sugge- st that the main limitation during laparoscopic dissection for large and potentially malign adrenal tumors is incomplete resection and capsular disruption with increased risk of local recurrence and intra-abdominal neoplastic dissemination. We recommend for these patients an integrated multidisciplinary approach that considers endocrine studies, preoperative radiologic findings and the expe- rience of surgical team