Andrea Bruttocao

Infrahepatic Terminolateral Cavo–Cavostomy as a Rescue Technique in Complicated “Modified” Piggyback Liver Transplantation

Orthotopic liver transplantation is a well-known and widely applied codified procedure. Milestones of the standard technique are the use of the veno– venous bypass (1, 2), and the resection, en bloc with the liver, of the retrohepatic vena cava (3–5). Since its original description by Starzl (3–4), many modifications of the original technique have been suggested to reduce risks and time and to make the technique more flexible. Also, the graft caval implant has undergone gradual evolution through the introduction of variants that render the surgical procedure more adaptable toward problems. These techniques apply the dissection of the recipient liver from the vena cava during hepatectomy (6); then the graft implant may be performed preserving the recipient vena cava, according to the piggyback procedure (7, 8), anastomosing the donor’s suprahepatic vena cava and a “cuff” made out of the recipient’s suprahepatic veins, or, as described by some authors (9), using a side-to-side cavo–caval anastomosis after stitching the donor’s suprahepatic caval stumps. In both cases, the remnant of the donor’s infrahepatic vena cava must be ligated. Since 1992 we have used a modified piggyback technique, by performing an end-to-side cavo– caval anastomosis between the suprahepatic donor’s vena cava and the recipient’s vena cava, using the caudally enlarged hole of the common left and middle suprahepatic veins stump, after stitching the recipient’s right suprahepatic vein (10). Also by this technique, the remnant of the donor’s infrahepatic vena cava must be ligated. A drawback of these techniques may be either hepatic venous outflow obstruction because of stenosis or kinking of the caval anastomosis, or obstruction of the recipient’s inferior vena cava (11). We report a case of hepatic venous outflow obstruction at liver reperfusion because of kinking of the caval anastomosis. The stenosis was overcome performing an end-to-side cavo–caval anastomosis using the infrahepatic stump of the donor’s vena cava.

Ethical and medico-legal implications of capacity of patients in geriatric surgery.

Objectives The aim of this study was to assess the decision-making capacity of elderly patients hospitalized in a geriatric surgery division, and the clinician’s ability to assess that capacity. Subjects and methods The study was conducted on patients (aged >66 years) undergoing surgical procedures. Exclusion criteria were a diagnosis of psychogeriatric disorders interfering with decision-making capacity; hearing or visual impairment; and inability to communicate. Patients previously declared legally incompetent were also excluded. The methodological approach consisted of additional interviews to collect data on patients’ awareness of the reasons for their hospitalization, their informed consent, and their ability to sign a consent form. The interview was integrated with a clinical-behavioral assessment by means of the Mini-Mental State Examination and the Clock Drawing Test. Data were collected anonymously. Results The inclusion criteria were met by 123 patients, with a mean age ± SD of 77.65 ± 7.91 years (range 67–98). Their mean (±SD) Mini-Mental State Examination and the Clock Drawing Test scores were 24.53 ± 4.29 and 5.36 ± 2.41, respectively. Mild-to-severe cognitive impairment was identified in 39 patients (31.7%). The consent form was signed by 111 patients (90.25%), including 33 patients (29.72%) with mild-severe cognitive impairment; 18 patients (16.21%) were unaware of the reason for their admission to hospital. Discussion Many factors may interfere with elderly patients’ ability to give their valid consent to treatment, and this study reveals that clinicians may overestimate their patients’ decision-making capacity. Physicians should be aware of this problem, and intellectual capacity assessments and/or enhanced consent procedures should be considered when treating elderly patients.

Surgery of diabetic foot in the elderly: early Vs deferred treatment

Background In 1996, the overall prevalence of diabetic patients was 120 million and it will more than double by the year 2025. The most important complication in these patients is the diabetic foot (sepsis, abscess etc.). The aim of this study was to assess the role and results of surgery, performed in emergency or deferred emergency, in older population affected by acute septic foot.

The clinical management of diabetic foot in the elderly and medico-legal implications.

Diabetic foot is a complex and challenging pathological state, characterized by high complexity of management, morbidity and mortality. The elderly present peculiar problems which interfere on one hand with the patients compliance and on the other with their diagnostic-therapeutic management. Difficult clinical management may result in medico-legal problems, with criminal and civil consequences. In this context, the authors present a review of the literature, analysing aspects concerning the diagnosis and treatment of diabetic foot in the elderly which may turn out to be a source of professional responsibility. Analysis of these aspects provides an opportunity to discuss elements important not only for clinicians and medical workers but also experts (judges, lawyers, medico-legal experts) who must evaluate hypotheses of professional responsibility concerning diabetic foot in the elderly.

N0 colorectal cancer in the elderly: prognostic role of advanced age and correlation with adjuvant chemotherapy

Materials and methods 129 patients who underwent radical surgery for N0 colorectal cancer were selected and grouped into three age classes: 80. A subpopulation of 44 patients with colorectal cancer in stage II was selected from the initial group for a comparison with a control population consisting of 63 patients who underwent radical surgery and adjuvant chemotherapy for neoplasms at the same stage.

Rate of amputation and mortality in new-onset diabetic foot ulcers in the elderly

Background Foot ulcers and their complications are an important cause of morbidity and mortality in diabetes. The present study aims to examine the long-term outcome in terms of amputations and mortality in patients with new-onset diabetic foot ulcers in subgroups stratified by etiology.

Treatment of Jehovah’s witness patients. Surgical and medico-legal considerations

Background Surgical treatment of Jehovah’s witnesses, even if elective, is a difficult situation for the surgeon from a clinical, deontological and ethical point of view. Any lesion or the death of the patient can result in civil and penal consequences for the surgeon and the anesthetist. The aim of the present study was to present our experience regarding operative mortality and early clinical outcome in the surgical treatment of Jehovah’s witnesses compared to non-Jehovah’s witness patients.

Informed consent: results of a study in a geriatric surgery division

Conclusions Informed consent is relevant from an ethical and legal point of view. The analysis of the data highlights the importance of the physician – patient relationship in the collection of the informed consent. In some cases the physician should be aware of the possibility of identifying the patient’s characteristics associated with impaired capacity; in such cases formal capacity evaluations and/ or enhanced consent procedures may be most appropriate.

Site of ulcer lesions in diabetic foot of the elderly

Clinical background In diabetic patients, especially if elderly, skin ulcers of the foot are among the most debilitating complications. The main risk factors for the ulcer development are diabetic neuropathy (sensory, autonomic), lower limb ischemia (diabetic arteriopathy), limited mobility and altered plantar pressure. The aim of the study was to evaluate the different sites of the diabetic ulcers with regard to their origin.

Elderly surgical “not transfusible” patients

Background Non transfusible patients’ care presents complex ethical, legal and medical problems when their refusal is related to a religious belief. This kind of patient may need both elective and emergency treatment that they generally accept, with the exception of blood transfusion.