Tommaso Bianco

Surgical resection of carotid body paragangliomas: 10 years of experience

BACKGROUND Carotid body tumors (CBTs) are relatively rare neoplasms, and even if they are considered predominantly benign, there is an indication for early surgical removal. The objective of this study was to conduct a review of the surgical management of CBTs. METHODS A retrospective study identified 34 cases (12 men and 19 women) of tumors in patients who had undergone surgical resection of pathologically confirmed CBTs over a period of 10 years from 2001 to 2011 in 2 academic departments of general surgery in Italy. RESULTS In our series, 10 CBTs (31%) were Shamblin class I, 13 (41%) were class II, and 9 tumors (27%) were class III. Two patients (6%) had transient cerebral ischemia immediately after operation. One patient (3%) died of postoperative cerebral ischemia after surgery for internal carotid artery thrombosis. CONCLUSIONS The experience of this casuistry shows that the procedure is relatively low risk for Shamblin I and II classes, whereas there is an increasing risk of neurovascular complications for Shamblin III class.

Feasibility of inguinal hernioplasty under local anaesthesia in elderly patients

BackgroundThe aim of this study is to evaluate the feasibility and the safety of hernioplasty under local anaesthesia in elderly patients with significant comorbidity.MethodsA total of 218 patients underwent inguinal hernia repair with mesh between June 2009 and July 2012. Presence of comorbid conditions and complications were compared between patients younger and older than 70 years.ResultsHernia repair in older patients were more likely associated with comorbid conditions than in their younger counterparts ( hypertension: 25% vs 8.16%; cardiovascular diseases: 50% vs 22%; benign prostatic hypertrophy 60% vs 30%). The most common postoperative complications in both groups were recurrence, wound infection, urinary retention. There was a slightly higher rate of complication in elderly group.ConclusionsInguinal hernia repair with local anaesthesia is quite safe and results in a good success rate in elderly patients despite a higher rate of comorbidity typical of this kind of patient.

Fast track for elderly patients: is it feasible for colorectal surgery?

BACKGROUND Fast-track program has been applied in several surgical fields. However, currently many surgical patients are elderly over 70 years of age, and discussion about the application of such protocols for elderly patients is inadequate. MATERIALS AND METHODS The present study was designed to consider the safety and feasibility of application of a fast-track program after colorectal surgery in elderly patients. A total of 76 elderly patients with colorectal cancer who underwent laparoscopic colorectal resection were randomly assigned to receive either the fast-track care program (n = 40) or the conventional perioperative care protocol (control group, n = 36). The fast track protocol included no preoperative mechanical bowel irrigation, immediate oral alimentation and earlier postoperative ambulation exercise. The length of postoperative hospital stay, the length of time to regain bowel function and the rate of postoperative complications were compared between the two groups. RESULTS The length of time to regain bowel function, including the passage of flatus [32 (24-40) h vs 42 (32-52) h], and to start a liquid diet (13 [10-16] h v/s 43 [36-50] h) were significantly shorter in patients receiving the fast track care protocol compared with those receiving the conventional care protocol. A shorter duration of postoperative hospital stay was recorded in patients receiving the fast-track program than in those receiving conventional care [6 (5-7) days v/s 9.5 (7-12) days]. A reduced percentage of patients who developed general complications was also observed in the fast-track group (5.0% v/s 18%). CONCLUSION Fast-track after laparoscopic colorectal surgery can be safely applied in carefully selected elderly patients older than age 70 years. The fast-track recovery program resulted in a more rapid postoperative recovery, earlier discharge from hospital and fewer general complications compared with a conventional postoperative protocol.

Emergency groin hernia repair: implications in elderly

BackgroundGroin hernia is one of the most frequently encountered pathologies occurring in old age and it is often the cause of emergency procedures. In our study we evaluate the impact of emergency procedures in over 75 patients compared to younger patients.MethodsWe conducted a retrospective study about patients who underwent emergency hernioplasty between September 2007 and January 2013. Bilateral hernias and recurrences were excluded. We divided patients into two groups by age (under and over 75 years old) and then analyzed the early postoperative surgical complications.ResultsA total of 48 patients were enrolled, 18 were included in under 75 group and 30 in over 75. In the older group we found a higher rate of comorbidity and also a significant higher rate of postoperative complications. Two patients of over 75 group died.ConclusionsOur data suggests that a quick diagnosis and elective surgical procedures are desirable in order to avoid the complications that occur in emergency operations.

Peripheral blood mono-nuclear cells implantation in patients with peripheral arterial disease: a pilot study for clinical and biochemical outcome of neoangiogenesis.

AbstractBackgroundSubstantial progresses in the management of peripheral arterial disease (PAD) have been made in the past two decades. Progress in the understanding of the endothelial-platelet interaction during health and disease state has resulted in better antiplatelet drugs that can prevent platelet aggregation, activation and thrombosis during angioplasty and stenting. A role in physiological and pathological angiogenesis in adults has been recently shown in bone marrow–derived circulating endothelial progenitors (BM-DCEPs) identified in the peripheral blood. These findings have paved the way for the development of therapeutic neovascularization techniques using endothelial progenitors.MethodsThis pilot study includes five patients, aged 60 to 75, with a history of claudication and recruited from September 2010 to February 2011 at the A.O.U. Federico II of Naples.PBMNCs have been implanted three times in the limb with the worst ABI value in all the patients included in the study.The clinical follow up was performed during the subsequent 12 months from the beginning of the treatment.ResultsIn four patients there was a regression of ulcerative lesions.One patient’s condition improved after the first implantation but later did not respond to the further treatments.All patients achieved a pain relief as judged by the numeric pain scale. Pain relief remained satisfactory in three patients for one year. Pain gradually returned to the pre-treatment level in two patients.All patients referred an ameliorating in their quality of life expressed even by an improvement in claudication free walking distance.These improvements are reflected also by intra-arterial digital subtraction angiography (IADSA) that shows an improvement of arterial vascularization.ConclusionsThe data from this study suggest an efficacy of BM-DCEPs implantation in terms of improvement of the vascularization and quality of life in patients affected by Peripheral Arterial Disease. Nevertheless a double-blind placebo-controlled study is needed to confirm our findings.

Minimally invasive radioguided parathyroid surgery: A literature review

The minimally invasive approach to parathyroid glands represents an important field of application of radioguided surgery. As always happens, in all cases pertaining to hyper-specialized skills, scientific production has long been the prerogative of a few Authors, but the ever increasing technological diffusion, combined with excellent results often achieved, increases the interest in this technique. This is particularly true in the era of minimally invasive surgery. The Authors realize a review of the existing literature to allow an overall view of current knowledge on this particular topic and to guide future research.

Day-surgery inguinal hernia repair in the elderly: single centre experience.

BackgroundInguinal hernioplasty is well established as a day-surgery procedure, our purpose is to assess the safeness of this approach in elderly patients.MethodsA total of 292 inguinal hernioplasty were performed between June 2009 and February 2013. Patients were divided into 3 groups depending on the age and postoperative complications were compared in these groups.ResultsDespite of a large number of higher risk (ASA 3-4) patients and a higher rate of comorbidity in older patients, unplanned admission postoperative, symptoms and complications were comparable with those for the younger patients.ConclusionsAmbulatory surgery is feasible also in older patients. Age, comorbidity and higher ASA risk should not be a barrier to elective day surgery.

One-step mini-invasive treatment of abdominal aortic-iliac aneurysm associated with colo-rectal cancer

BACKGROUND Endovascular aneurysm repair (EVAR) is still now a controversial technique, which remains the subject of a number of prospective randomised trials. Although questions remain regarding its long-term durability, objective evidence exists which demonstrates its reduced physiological impact compared with conventional open repair, especially for older population and for the concomitant treatment of aortic abdominal aneurysm (AAA) and abdominal neoplas, such as colo-rectal cancer (CRC). In these patients it may reduce the high perioperative mortality. PATIENTS AND METHODS Abdominal aortic aneurysm and colo-rectal neoplasm are occasionally discovered concurrently. Simultaneous operative treatment may be in these cases an effective management strategy, alternative to a staged procedure. The medical record of three consecutive patients undergoing mini-invasive colectomy for cancer and abdominal aortic aneurysm repair were reviewed. Data collected included mode of presentation, preoperative evaluation, colo-rectal pathology and in-hospital morbidity and mortality. Long term follow-up was obtained through office records and telephone contact. RESULTS In one patient a asymptomatic colo-rectal mass was identified in the course of CT-scan evaluation for AAA; in the other two patients AAA was discovered during CT-scan oncological evaluation for symptomatic CRC. All patients underwent successfully concomitant repair of AAA and CRC by means of EVAR procedure and mini-invasive colo-rectal resection. Pathology revealed adenocarcinomas in all three cases. Perioperative follow-up revealed minor postoperative complications. Two years follow-up showed no cases of graft infection, and no interference of vascular procedure on oncological course of the colo-rectal malignancies.

Adrenocortical carcinoma: What the surgeon needs to know. Case report and literature review

Adrenocortical carcinoma is a rare and aggressive cancer and its prognosis is frequently unsatisfactory. Due to its rarity theres a lack of prospective randomized studies. Without experience in the approach of this kind of tumor, managing becomes challenging and, moreover, we have only few recommendations, based on weak evidence. We report a case that has some peculiarities and is an excellent food for thought. Then we deal with a literature review to highlight and summarize most significant aspects of epidemiology, clinic, diagnosis, therapy and prognosis in an exquisitely surgical point of view.

Local anesthesia for treatment of hernia in elder patients: Levobupicavaine or Bupivacaine?

BackgroundInguinal hernia is one of the most common diseases in the elderly. Treatment of this pathology is exclusively surgical and relies almost always on the use of local anesthesia. While in the past hernia surgery was carried out mainly by general anesthesia, in recent years there has been growing emphasis on the role of local anesthesia.MethodsThe aim of our study was to compare intra-and postoperative analgesia obtained by the use of levobupivacaine to the same obtained by bupivacaine. Bupivacaine is one of the main local anesthetics used in the intervention of inguinal hernioplasty. Levobupivacaine is an enantiomer of racemic bupivacaine with less cardiotoxicity and neurotoxicity. The study was conducted from March 2011 to March 2013. We collected data of eighty patients, male and female, aged between 65 and 86 years, who underwent inguinal hernioplasty with local anesthesia.ResultsEvaluation of intra-operatively pain shows that minimal pain is the same in both groups. Mild pain was more frequent in the group who used levobupivacaine. Moderate pain was slightly more frequent in the group who used bupivacaine. Only one reported intense pain. Two drugs seem to have the same effect at a distance of six, twelve, eighteen and twentyfour hours. Bupivacaine shows a significantly higher number of complications, as already demonstrated by previous studies. Degree of satisfaction expressed by patients has been the same in the two groups. Levobupivacaine group has shown a greater request for paracetamol while patients who experienced bupivacaine have showed a higher request of other analgesics.ConclusionsClinical efficacy of levobupivacaine and racemic bupivacaine are actually similar, when used under local intervention of inguinal hernioplasty. In the field of ambulatorial surgery our working group prefers levobupivacaine for its fewer side effects and for its easy handling.