Edoardo Saladino

Acute gallstone cholecystitis in the elderly: treatment with emergency ultrasonographic percutaneous cholecystostomy and interval laparoscopic cholecystectomy.

BackgroundThe treatment of acute cholecystitis in the elderly is still a subject of debate, particularly with reference to the timing of surgery and the role of laparoscopy.PatientsFrom January 1994 to June 2002 we observed 27 patients aged over 70 years with acute calcolous cholecystitis. The patients were submitted to ultrasonographic percutaneous cholecystostomy within 12 h of the acute attack. For two patients (7.4%) at high operative risk, we chose a conservative treatment. Twenty-five patients (92.6%) were submitted, in 15 cases (60%) within 5 days and in 10 patients (40%) within 8 days, to a laparoscopic cholecystectomy. Statistical significance was accepted when the value of p was less than 0.05.ResultsUltrasonographic percutaneous cholecystostomy was performed successfully in all patients, without major morbidity or mortality, and complete resolution of clinical symptoms was obtained within 48 h. The conversion rate of laparoscopy was 20% (13.3% in patients submitted to surgery within 5 days and 30% in the group submitted within 8 days — p > 0.05). The postoperative morbidity rate was 24%; it was higher (40% versus 15%) in patients converted to laparotomy (p > 0.05); mortality was 4%. The period of hospitalization was 11 days in patients operated laparoscopically and 21 days in those converted to open cholecystectomy (p < 0.001).ConclusionsThe more rational treatment of acute calcolous cholecystitis in elderly patients is represented by ultrasonographic percutaneous cholecystostomy followed, within 5 days, by laparoscopic cholecystectomy using an abdominal insufflation maximum to 12 mmHg and a limited 10–15° head-up tilt.

Rare localizations of echinococcosis: personal experience

Background:  The rare localizations of hydatidosis represent an interesting topic, especially with reference to epidemiological and diagnostic problems. Hydatid disease, common in Mediterranean countries, still remains endemic in some regions of Italy.

Peritoneal carcinomatosis of colorectal origin

Peritoneal carcinomatosis is, after liver metastases, the second most frequent cause of death in colorectal cancer patients and at the present time, is commonly inserted and treated as a stage IV tumour. Because there is no published data that outlines the impact of new therapeutic regimens on survival of patients with peritoneal surface diffusion, the story of carcinomatosis can be rewritten in light of a new aggressive approach based on the combination of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. Also if these treatment perhaps allow to obtain better results than standard therapies, we suggest, that a large prospective randomised control trial is needed to compare long-term and progression-free survival under the best available systemic therapy with or without cytoreductive surgery and hyperthermic intraperitoneal chemotherapy.

Rationale and techniques of cytoreductive surgery and peritoneal chemohyperthermia.

The evolution of loco-regional treatments has occurred in the last two decades and has deeply changed the natural history of primitive and secondary peritoneal surface malignancies. Several phase II-III studies have proved the effectiveness of the combination of cytoreductive surgery with peritoneal chemohyperthermia. Cytoreductive surgery allows the reduction of the neoplastic mass and increases tumoral chemosensitivity. The development of chemohyperthermia finds its origins in the necessity to exceed the limits of intraperitoneal chemotherapy performed in normothermia. It permits a continuous high concentration gradient of chemotherapeutic drugs between the peritoneal cavity and the plasma compartment to and a more uniform distribution throughout the abdominal cavity compared to systemic administration.

The role of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in the treatment of ovarian cancer relapse

Nowadays the standard clinical management for advanced epithelial ovarian cancer is constituted by primary cytoreductive surgery associated to adjuvant systemic chemotherapy. Even if this first-line chemotherapy shows a high rate of complete responses, the disease recurrences occur especially in stage-III patients. Actually an option for this subset of patients is represented by secondary cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy that represents a promising therapy, having shown positive results in terms of median overall survival, progression free survival and overall survival. However, a much more research is still required especially by prospective randomised trials to improve outcomes in recurrent ovarian cancer.

Giant retroperitoneal liposarcoma: Case report and review of the literature

Highlights • The origin from perirenal fat is very uncommon.• The occurrence of hematogenous metastasis is a rare finding at the time of diagnosis.• The undifferentiated and pleomorphic type are neoplasm with high grade of malignancy.• In case of diagnostic doubt and in presence of recurrence, magnetic resonance imaging (MRI) may be useful because can identifying in a reliable manner the satellite localizations of the main lesion.• The complete surgical (R0) resection represents the only possibility of radical treatment.• Following surgical resection, the 50–100% of liposarcomas recur from residual tissue, which is the primary cause of death.• Percutaneous biopsy has low accuracy in the diagnosis of retroperitoneal dedifferentiated liposarcoma (DDLS).

The treatment of peritoneal carcinomatosis in elderly patients

Background Peritoneal carcinomatosis is a frequent evolution of gastrointestinal and gynecologic malignancy and it has been regarded as a lethal clinical entity. Treatment options for these patients have improved significantly in the past few years. CytoReductive Surgery (CRS) plus Hyperthermic IntraPEritoneal Chemotherapy (HIPEC) is an aggressive and promising treatment for patients with peritoneal malignancies. Whether this type of major cancer surgery is feasible in elderly patients is an ongoing question.

Wernicke encephalopathy as rare complication of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

Highlights • Peritoneal carcinomatosis (PC) of gastric origin is a frequent event even in the early phase of the disease.• This is the first case, to our knowledge, of Wernicke Encephalopathy (WE) complicating CRS plus HIPEC used as treatment of peritoneal carcinomatosis of gastric origin.• WE is an uncommon neurological disorder characterized by a classical triad of symptoms: ataxia, ocular motor cranial neuropathies and changes in consciousness.• A deficiency of thiamine is responsible for the WE syndrome.• The application of Cytoreductive Surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) gives encouraging results.• A deficiency of thiamine is responsible for the WE syndrome.

Reply to “The incidence of cisplatin nephrotoxicity post hyperthermic intraperitoneal chemotherapy (HIPEC) and cytoreductive surgery”

We read an article by Hakeam, Breakiet, Azzam, Nadeem, and Amin, with interest and would like to congratulate the authors for the effort that they have put in a field so challenging. Cytoreductive Surgery plus Hyperthermic Intraperitoneal Chemotherapy (HIPEC) is, in fact, a promising approach to treat peritoneal surface malignancies, but it is characterized by high morbidity and mortality. In literature it is reported that a major morbidity rate ranges from 12% to 57% in highvolume centres; the mortality incidence ranges from 0.9% to 11%. The short-term outcome is related to surgery, but also to chemoperfusion. We agree with the conclusions made by the authors, confirming, on the basis of our experience, that nephrotoxicity can complicate HIPEC, above all if it is performed using cisplatin. As this topic has not yet been fully elucidated, we measured the plasma level of cisplatin before, during and after HIPEC, in order to identify the period within which there is the higher risk of toxicity linked to the intraperitoneal chemotherapy. Our experience had demonstrated that the peak of serum level of cisplatin is reached during the perfusion; until the 4th post-operative (p.o.) day high levels remain and, in 7th p.o. day, the value returns to that before the intervention. At the light of these considerations, we retain that, for 4 days after the procedure, is necessary to ensure the hyperhydration, and the infusion of albumin and of fresh frozen plasma, in order to dilute the effective quantity of circulating cisplatin, to increase the proportion of albuminbound cisplatin, and to maintain a normal blood volume and perfusion.

Rectal perforation by inadvertent ingestion of a blister pack: A case report and review of literature

The accidental ingestion of a foreign body (FB) is a relatively common condition. In the present study, we report a peculiar case of rectal perforation, the first to our knowledge, caused by the inadvertent ingestion of a blister pill pack. The aim of this report is to illustrate the difficulties of the case from a diagnostic and therapeutic viewpoint as well as its unusual presentation. A 75-year-old woman, mentally impaired, arrived at our emergency department in critical condition. The computed tomography scan revealed a substantial abdominopelvic peritoneal effusion and free perigastric air. The patient was therefore submitted to an urgent exploratory laparotomy; a 2-cm long, full-thickness lesion was identified in the anterior distal part of the intraperitoneal rectum. Hence, we performed a Hartmann’s procedure. Because of her critical condition, the patient was eventually transferred to the Intensive Care Unit, where she died after 10 d, showing no surgical complication. The ingestion of FBs is usually treated with observation or endoscopic removal. Less than 1% of FBs are likely to cause an intestinal perforation. The intestinal perforation resulting from the unintentional ingestion of an FB is often a difficult challenge when it comes to treatment, due to its late diagnosis and the patients’ deteriorated clinical condition.