Loredana Iannone

Breast reconstruction in older women: a growing request

Results During this time period, 153 (27%) of patients with breast cancer were 60 years or older. Approximately, one third (49 patients) required or elected mastectomy as primary treatment. Of the 49 women evaluated, 17 (28%) elected delayed implant-based breast reconstruction. No patients experienced major complications at the longest follow up. Conclusion Elderly women undergoing with mastectomy should be offered breast reconstruction as part of their treatment. Physicians and patients need to be educated regarding surgical options, the minimal associated morbidity and mortality, and excellent functional and cosmetic outcomes. With extended life expectancy, breast reconstruction enhances these aspects of quality of life. Future management guidelines should include breast reconstruction in the algorithm. from XXI Annual Meeting of The Italian Society of Geriatric Surgery Terni, Italy. 4–6 December 2008

Anorectal avulsion: Management of a rare rectal trauma

INTRODUCTION Traumatic injuries of the rectum are unusual even though their treatment is challenging and often lead to high morbidity and mortality rate. PRESENTATION OF CASE This paper reports a rare case of complete rectal avulsion with multiple fracture and hemoperitoneum treated with a multistep approach in our department. DISCUSSION The anorectal avulsion is a rare rectal trauma; only few reports are available. Treatment key points of rectal trauma are: direct repair, diverting stoma and sacral drainage. CONCLUSION We reported a case of anorectal avulsion with complete detachment of external sphincter muscle. A multidisciplinary approach was mandatory in this kind of lesions.

Complete rectal prolapse in the elderly: systematic review of surgical treatment.

Background Complete rectal prolapse is a disease characterized by the complete protrusion of rectal wall through the anus. This disability affects mostly elderly women (>65 years). Several surgical techniques have been described for the treatment of this condition with both perineal and abdominal approach. Under trial condition none of them have been demonstrated to be the best choice in terms of recurrence, postoperative faecal incontinence or stipsis and cost-effectiveness. The aim of our study was to compare different surgical techniques for complete rectal prolapse in the elderly.

Effect of beta blockers on the incidence of atrial fibrillation in elderly patients after abdominal surgery

Background Post operative AF is a common problem in patients following surgery. The incidence of such arrhythmia has been reported to range from 20–35% and increase to the age and to presence of comorbidities [1-3]. Also, AF is related to many complications and it is still debated what is the best interventions, especially in the elderly [4]. Sympathetic nervous system activation is strictly related to surgery stress [5] and treatment with Beta Blockers may reduce this overactivation that predispose to AF occurence [6-10].

Prevention of perioperative atrial fibrillation with beta blockers in elderly patient during abdominal surgery

Background Peri-operative AF is the consequence of stress activation of Sympathetic Nervous System (SNS) following surgery [1,2]. The incidence of AF increase with the aging and in presence of comorbidities [3-5]. Clinical consequences include reduced cardiac output, lengthened hospitalization, an increase in the risk of cerebral thromboembolism and in many cases the need for systemic anticoagulation [6]. SNS overactivation could be treated with Beta Blockers and may reduce the occurrence of AF [7-10].

When should we discontinue antiarrhythmic therapy for atrial fibrillation after abdominal surgery

Aim of the studyThe purpose of this study was to determine whether theduration of antiarrhythmic therapy after discharge fromthe hospital following abdominal surgery is related to theincidence of atrial fibrillation (AF) recurrence in elderlypatients with the occurrence of peri-operative AF.BackgroundThe occurrence of peri-operative AF after abdominal sur-gery is a clinical condition burdened by several complica-tions, especially in the elderly [1-3]. When AF issuccessfully converted to sinus rhythm, it is unlikely torecur, and nearly all of these patients are discharged fromthe hospital in sinus rhythm. It is not clear how soonthese patients may discontinue antiarrhythmic therapy toavoid drugs side effects without risking recurrence of AF.The recurrence of AF needs different kind of treat-ment. Medical therapy includes various antiarrhythmicdrugs to control heart rate and restore sinus rhythm andanticoagulation to reduce the tromboembolic risk [4].Overactivation of sympathetic nervous system, related tosurgery stress [5], could be reduced by the treatmentwith antiarrhythmic drugs, such as Beta Blockers, andmay reduce the incidence of AF recurrence [6-10].MethodsA pilot study was conducted in 19 elderly patients (age> 65 years) who underwent abdominal surgery (rightemicolectomy, sigmoidectomy and anterior rectal resec-tion) and with occurrence of peri-operative AF thatsuccessfully reverted to sinus rhythm. They were pro-spectively randomized at dismissal to receive antiar-rhythmic therapy for 1 week (six patients in group A), 3weeks (seven patients in group B), or 6 weeks (sixpatients in group C). Patients were followed up for anadditional 4 weeks after discontinuation of antiarrhyth-mic therapy for detection of recurrence of AF.ResultsThere was no significant difference in the recurrenceof AF among groups (0%, 2%, and 0% for groups A, B,and C, respectively).ConclusionsIn elderly patients with peri-operative AF after abdominalsurgery, converted to normal sinus rhythm before hospitaldischarge, have a benign course and the duration of antiar-rhythmic therapy shorter than one week is appropriate.

Exercise training and post-operative prognosis after coronary intervention

Aging is worldwide recognized as a dominant risk factor for most forms of cardiovascular disease [1-3]. However, mechanisms by which it exerts its role and determines poor outcome have been only partially clarified. Numerous evidence indicate that aging is associated with alteration of several mechanisms whose integrity confers protective action on the heart and vasculature [5-9]. Autonomic status derangement, diminished efficacy of ischemic preconditioning, impaired angiogenic responses after ischemic injury, increased oxidative stress, and abnormal left ventricular remodelling after myocardial infarction are all putative mechanisms potentially involved in the vulnerability of cardiovascular system occurring with aging. Interestingly, many of the alterations that take place in the aged heart and vasculature are very similar to those observed in pathologic conditions, such as heart failure (HF), and, most importantly, are at least in part revertible. Exercise training plays a pivotal role in primary and secondary prevention of cardiovascular disease, in counteracting the age-related deterioration of some mechanisms that are crucially involved in the homeostasis of cardiovascular system and that may condition the outcome of cardiovascular disease in the elderly. Moreover, it is associated to reduction of the post-operative atrial fibrillation with reduction of the number of prescribed drugs [10]. Preconditioning represent the strongest form of in vivo protection against myocardial ischemic injury, consisting in brief episodes of myocardial ischemia able to reduce cellular damage subsequent to a more prolonged ischemic injury. Remote preconditioning is the phenomenon by which ischemia in one region of the heart causes protection in a remote region of the heart itself or of another organ, thus suggesting that circulating factors or a neural reflex triggers protection in the remote region. Aging is associated with higher rates of morbidity after coronary intervention and a progressive loss in efficacy of ischemic preconditioning with age has been indicated as a potential mechanism explaining the worse prognosis in the elderly. A diminished norepinephrine release in response to transient ischemic stress has been indicated having role in the loss of preconditioning protection occurring with age. Preinfarction angina is considered one of the strongest clinical equivalent of ischemic preconditioning being associated with both reduction in infarct size and prevention of left ventricular dysfunction. Evidences demonstrate the loss of the protective effect of preinfarction angina with age, resulting in a no more protective effect on both early and late mortality in the elderly after acute cardiac events. In adult and elderly humans, high levels of physical activity preserve the protective role of preinfarction angina against in-hospital mortality and cardiogenic shock after myocardial infarction. More recent data indicate that higher levels of physical activity performed before primary coronary angioplasty may independently predict the reduction of early and late cardiac mortality in older infarcted patients [11]. Accordingly, it has been reported a robust association between physical activity habits of elderly participants prior to coronary artery bypass grafting and survival free from both all-cause and cardiac death, [12]. Interestingly, in these studies, the greatest benefits of exercise on survival were observed in the more sedentary patient groups, thus strongly supporting the importance of implementation of physical activity levels in the elderly also as secondary prevention strategy.