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Background Most cancer patients undergoing surgery are aged ≥ 70, with 1/3 considered frail and at poor surgical risk. Preoperative assessment of oncogeriatric patients may expand survival and improve quality of life. Preoperative Assessment of Cancer in the Elderly (PACE) was useful in identifying those individuals with a poor surgical risk. Instrumental Activities of Daily Living (IADL), Brief Fatigue Inventory (BFI) and Performance Status (PS) correlate with operative 30-day mortality, while Activities of Daily Living (ADL), IADL and PS associate with a lengthy post-operative hospital stay. PACE administration (Table 1) allows personalized oncological management but it's time-consuming (30 mins/ pt). Newly developed screening tools might be as effective, but were never tested in a surgical scenario. Groningen Frailty Index (GFI), Vulnerable Elders Survey (VES-13) and the "up and go test" (Table 1) are quick tools, capable of identifying frail individuals. PREOP is an international prospective investigation aiming to analyzing the predictive value of these new tools which are due to be compared against PACE. Materials and methods A prospective series of patients aged ≥ 70 years, undergoing elective cancer surgery will be recruited. PACE, GFI, VES-13 and "up and go" will be pre-operatively administered. Pre-, peri- and post-operative data will be collected and entered into the database. 326 patients will need to be recruited within 2 years to allow analysis. [ABSTRACT FROM AUTHOR]

Background The colorectal cancer has a high incidence and mortality in the geriatric population. However the advanced age does not represent a contraindication for the surgery, and a radical cancer surgical treatment guarantees the same life expectation of younger patients. In this study we analyzed the correlation between comorbidities, postoperative complications and mortality. Material and methods In our retrospective study we analyzed the clinical notes of 66 patients over 75 years. We assessed the risk factors of the surgical treatment in the elective and emergency management. Among the 47 patients electively treated, 33 were affected by cardiocirculatory diseases, 23 by kidney diseases, 14 by metabolic and endocrine diseases, and 11 patients by respiratory diseases. In the 19 patients, who underwent emergency surgery, 75% had intestinal obstruction, and 25% had intestinal perforation. In election were performed 14 anterior resection of rectum, 7 abdomino-perineal resections, 4 Hartmann procedures, 11 left hemicolectomies, 8 right hemicolectemies and 3 explorative laparotomies. In emergency were performed 5 ileostomies, 3 colostomies, 5 left hemicolectomies, 3 right hemicolectomies, 2 Hartmann procedures, and 1 explorative laparotomy. Results In elective surgery the complications were represented by suppuration of surgical wound (21.2% of cases), cystitis (21.2% of cases), bronchopneumonia (6.3% of cases), dehiscence of the anastomosis (2.1% of cases), thrombophlebitis of the lower limbs (2.1% of cases). In emergency the complications were represented by suppuration of the surgical wound in 60% of cases, arrhythmias in 21% of cases, and acute renal failure in 5%. In both elective and emergency surgery for patients without comorbidities there were not deaths. The mortality in patients with comorbidities was 2.1% in elective surgery and 26.5% in emergency surgery. In election the comorbidities strictly related to the post-operative complications and mortality were the renal diseases, while the cardiocirculatory diseases influenced on post-operative complications only. Contrary, in emergency the cardiocirculatory diseases influenced significantly the post-operative complications and mortality, while the renal diseases influenced only the post-operative complications. Conclusion The colorectal cancer in advanced age does not present different characteristics from younger age. Because of the more accurate pre-operative and post-operative therapies it is possible to give geriatric patient the same radical surgery as younger patients. Particularly in elective surgery, thanks to an adequate preoperative preparation, the comorbidities can be corrected ensuring the same prognostic result of younger patients. Contrary in emergency, a considerable disagreement persists in terms of prognosis between geriatric patients and younger patients. This is related to the impossibility of performing an adequate pre-operatory preparation. [ABSTRACT FROM AUTHOR]

Background The role of laparoscopic cholecystectomy in geriatric population is not yet well defined. The purpose of this study is to evaluate the convenience of laparoscopic treatment in over 70 years old patients with acute lithiasic cholecystitis. Materials and methods We performed a retrospective study from 1998 until 2007 for two groups of patients. The first group is composed by 110 patients underwent to laparoscopic cholecystectomy (group A) and the second group composed by 60 patients underwent to traditional laparotomy (group B). Both groups were compared for the duration of surgical procedures, for intra-operative and post-operative complications and for post-operative pain. Results The surgical intervention of group B had shorter operative times (70 minutes) than group A (95 minutes). The patients of group A had shorter post-operative hospital stay (3 days) than group B (7 days) and a reduction of post-operative pain. The group B had a major incidence of surgical wound sepsis (33%) and incisional hernias (5%). The post-operative complication of group A was 6.3% (7 cases) and the incidence of conversion to laparotomy was 12.7% (14 cases). Conclusion The correct selection of patients that undergo to laparoscopic cholecystectomy permits better results than the traditional laparotomic cholecystectomy. In fact there is a reduction of infections, hospital stay and post-operative pain. [ABSTRACT FROM AUTHOR]

Background The aim of this trial is to evaluate the importance of an early diagnosis and of a correct surgical timing in geriatric patients with sigmoid volvulus. Materials and methods We performed a retrospective analysis of all the patients treated for sigmoid volvulus at the Department of General and Emergency Surgery, S. Maria Hospital in Terni of the University of Perugia, from January 1996 to March 2008. We treated 23 patients with sigmoid volvulus; mean age was 81 years. Eleven patients were admitted with a diagnosis of intestinal occlusion, 12 patients came to us from Medical divisions. Results The best prognostic results were for the group whose diagnosis of sigmoid volvulus was precocious and the surgical indication was precociously given. In those cases with difficult diagnosis due to an unclear symptoms or patient's confounding factors or a negative abdominal plain film, the CT scan leaded us towards a correct diagnosis. The abdominal CT was performed only in 3 cases (8%) and its specificity was 100%. Perioperatory mortality was 38% in those patients treated without any sign of peritonism and 100% for patients with peritonitis. Discussion The clinical manifestation of a volvulus of the sigmoid colon is generally not clear at its onset and in a geriatric patient it can be even more confounding and the diagnosis can be achieved with difficulty. The instrumental exams (Abdominal plain film and CT) allow the identification of pathological signs in all cases of volvulus. The abdominal plain film shows the typical signs of mechanical ileus and the CT underlines the aspects related to the intestinal torsion. Conclusion The preoperative diagnosis of volvulus of the sigmoid colon can be quite difficult and it all can lead to a delay in the treatment. When the intervention is late the strangulation ileus will cause irreversible intestinal lesions. An early diagnosis is therefore fundamental and in geriatric patients who are often affected by more than one disease, the employment of a CT scan can be very useful. [ABSTRACT FROM AUTHOR]

Background We report here a case of a biliary fistula in a 73-year-old man who underwent an urgent open cholecystectomy. The aim of this paper is to assess the treatment of the biliary fistulas in the elderly patients and to compare the result with the international literature. Materials and methods A 73-year-old man came to our observation with pain to upper quadrants of the abdomen, fever, signs of peritoneal involvement, leucocytosis, and the increment of cholestasis markers, while US scan showed an acute cholecystitis. The patient underwent a laparoscopic cholecystectomy (LC) but we converted the procedure. We positioned a T-tube and an abdominal drainage. Postoperative bilirubin level began to increase, the abdominal drainage began to drain bile despite the patient's conditions were good. A parenteral nutrition was instituted, deficits of electrolytes and vitamins were corrected and octreotide was delivered. We decided to position a PTHBD on the right biliary emisystem and to perform ERCP to reconstruct biliary tract. Post-operative control showed a well-positioned drainage but a biliary leakage so we decided to perform a hepaticojejunostomy. During the 9th day after hepaticojejunostomy the patient developed a severe episode of hemobilia due to a big pseudoaneurysm on the right hepatic artery, which was covered by stenting. After that general conditions of the patient improved day by day and was discharged after 48 days. Results In the case above, conservative treatment had been made immediately because spontaneous closure of the fistula is often usual. Endoscopic treatment of fistula by sphincterotomy, stenting or both is indicated in most patients. Operation is indicated when non-operative measures are not suitable, such as in patients with diffuse bile peritonitis. The increased use of interventional procedures is associated with an increased incidence of vascular injuries and hemobilia. Angiography could detect significant hemobilia in over 90% of patients, and allow the localization of vascular lesions and therapeutic embolization. Conclusion Management of bile duct injuries is complex because of physiopathologic effects especially in elderly patients, which present associated co-morbidities. It's most important to assess the adequacy of bile drainage to avoid bile collection and peritonitis. About vascular injuries, transarterial embolization has a high success rate of around 80% to 100%, and the placement of a covered stent may be a valid therapeutic alternative. According to us therapeutic interventional procedures constitute the treatment of choice for diagnosis and treatment in a single session to avoid complex surgical procedures in patients who are often haemodynamically unstable and therefore at high anaesthetic and surgical risk. [ABSTRACT FROM AUTHOR]

Background The aim of this work is to evaluate the reliability and the immediate results of laparoscopy versus conventional open surgery for acute small bowel obstructions by post-operative adhesions. Materials and methods We considered 190 patients (median age 78 years, 64-93) operated for acute small bowel obstruction by postoperative adhesions in the Unit of General and Emergency Surgery. We performed preoperative urgent blood tests and abdominal x-ray to all the patients; 163 patients were treated with traditional laparotomic access, while 27 selected patients underwent laparoscopy. Results For 3 (11.1%) of the 27 patients treated with laparoscopy a conversion was necessary because of the adhesions localization in the posterior abdominal wall. The median stay in hospital was 4.7 days for patients who underwent laparoscopy and 14.3 days for patients treated with traditional laparotomy. None of the first group's patients were reoperated on within 30 days of surgery, while 5 patients (3.1%) of the patients who underwent laparotomy needed to be reoperated because of obstruction recurrence by new adhesions. Conclusion Laparoscopic adhesiolysis is possible only after a careful selection and in these selected patients it shows more advantages than open surgery, otherwise in unselected cases it can be disadvantageous. Morbidity is low if the operation is performed by skilled. The immediate benefits are a rapid intestinal motility and a shorter stay in hospital. Long-term effect is the prevention of small bowel obstruction recurrence by postoperative adhesions. [ABSTRACT FROM AUTHOR]

Background TEM is a surgical procedure characterized by full thickness excision with curative purpose. After pathologist staging, though the high accuracy of diagnostic studies, as we will describe, an understaging may be reported. Materials and methods We present a case of rectorrhagia in an 83-years old patient. On rectal exploration a little hard lesion was found. A colonoscopy with biopsy was performed to search for synchronous lesions. A virtual colonoscopy and CT total body were performed to stage the patient and integrate the endoscopy and they both were negative. The endoscopy confirmed the lesion (adenocarcinoma G2) and described it as sessile, with a diameter of 22 mm, in the right wall of the middle rectum. A transanal ultrasonography was performed and staged the lesion as T1, N0. The hematological investigations showed lymphocytosis in relation with an anamnestic LLC, tumor markers (CEA, Ca 19.9) were in normal range. Considering stage (T1, N0, M0), age and clinical status, the decision of performing TEM was taken. The cancer was completely removed and sent for histological examination. Results The postoperative period was regular. The patient was able to mobilize at first postoperative day, evacuate at second and he was discharged at fourth. A minimal episode of disorientation was noticed in first postoperative day. The rectal suture didn't show early or late complications. The definitive histological was an adenocarcinoma pT2 G2. The patient, informed of the histological result, refused to undergo radical surgery. So we addressed him to radiotherapic evaluation. He performed an adjuvant radiotherapy and underwent ultrasonography, CT and hematological follow-up, all negative at 6 months. Conclusion In order to obtain a curative TEM resection, the resection limits must be cancer free and the excision must be full thickness. TEM is well tolerated by the elderly patient with co morbidity versus the classical abdominal resections. Oncologic results are comparable to the classical resections for T1 either for recurrences or 5 years survival. Moreover TEM allows evaluation of the stage of the lesion and, if under stage, send to radical surgery or alternative therapeutic protocol as we presented with interesting results; but these data should be further defined. [ABSTRACT FROM AUTHOR]