La Laparoscopia in Urgenza

Transcription

1 La Laparoscopia in Urgenza L URGENZA ADDOMINALE NEL PAZIENTE ANZIANO dr. V. Fiscon Legnago (Vr) 21 Aprile 2018 Chir. Generale, Cittadella -PD- ULSS 6 Euganea

2 Background Mayo Clinic, 231 elderly pts with abdominal pain: T, physical examination, blood tests --- limited sensitivity in discriminating surgical cases Parker JS et al., Fam Med % of elderly evaluated in ER for abdominal pain discharged with diagnosis of NSAP (non specific abdominal pain) Tran BK et al., Rev Med Suisse 2012 Emergency laparotomy in octogenarians: a 5-year study mortality 44%. Green G. et al World J Gastrointest Surg, 2013 In pts >80 yrs --- mortality appendectomy 7%, cholecystectomy 8%, parietal surgery 9% Arenal JJ et al., Can J Surg 2003

3 Background Extreme uncertainty Good surgical practice: LAPAROTOMY Quick and essential damage control Principles of LAPAROSCOPY Good indication in frail patients (especially!)

4 Should a Minimally Invasive Approach Be -a Priori- Ruled Out in Frail Patients? No anesthetic or surgical factors based on frailty only formally contraindicate a laparoscopic procedure But in everyday practice this indication is often disregarded 430 pts aged over 65: >80% of operations straight laparotomy 112 LAP procedure: 26% converted to open surgery Pt age + AF + ASA 3 + open surgery increased mortality Ukkonen M et al., World J Surg 2015

5 May a Minimally Invasive Approach Be Beneficial In Frail Patients? No benefits of cosmetics! Yes post-operative pain, wound infections, mobilization, transit, nutrition resumption Actually even of GREATER relevance in elderly!

6 May a Minimally Invasive Approach Be Beneficial In Frail Patients? 65,464 elderly pts ( 65 yrs) NIS (Nationwide Inpatient Sample, US) Morbidity LAP vs OPEN - Perf. appendicitis: 36% vs. 47% (p<0.01) - Non perf. appendicitis: 16% vs. 23% (p<0.01) In hosp. mortality (1.5% vs. 2.6%, p<0.01), shorter hosp. stay (5.8 vs. 8.7 dd, p<0.01), mean hosp. charges ($43,000 vs. 58, 000, p<0.01) Masoomi H et al., World J Surg 2012 Concerns on post-operative DELIRIUM and COGNITIVE IMPAIREMENT same (>30-40%) as open surgery?

7 What Are the Essential Conditions to Approach Acute Abdomen in Frail Patients by minimally invasive surgery? Patient suitable to pathophysiological changes during LAP - Penumoperitoneum (< venous return, > respiratory P) - Extreme positions (Trendelenburg, lateral rotation) Surgical team with expertise in LAP Antiplatelet therapy: >> bleeding risk [LAP and OPEN surgery]

8 Should the Indications for Laparotomy Conversion Be Different in Frail Patients? Standard reasons bleeding difficult to control, jatrogenic injury difficult to repair, etc Duration of operation if significantly (30-60 min?) longer than open surgery.conversion! 430 pts >65 yrs; 112 LAP procedure: 26% conv. to open surgery >> than general population! Ukkonen M et al., World J Surg 2015

9 What Are the Clinical Pictures of Potential Emergency Abdominal Surgery in Frail Patients? % of cases are obstructive syndromes inguinal hernia and colorectal cancer are the most frequent causes % peritonitis perforated acute diverticulitis and acute cholecystitis are the most frequent acute appendicitis is less 53 % of cholecystitis and 44 % of appendicitis were gangrenous 5 % visceral ischemia 10 % hemorrhagic issues

10 What Are the Acute Abdominal Diseases Potentially Treatable by Laparoscopy in Frail Patients? (1) Ac. cholecystitis: same rules as lap surgery in younger pts Ac. appendicitis: especially to exclude other diseases in elderly (cancer!) Ac. diverticulitis: Hinchey stage 3 washing/drainage better than terminal colostomy (<< chances of subsequent 2 nd operation) Hinchey 4 formally contraindicated

11 What Are the Acute Abdominal Diseases Potentially Treatable by Laparoscopy in Frail Patients? (2) Perforated peptic ulcer: (?) concerns on malignant nature of gastric ulcer Small bowel obstruction: Increased surgical time, underestimation of suffering intestinal loops, increased risk of jatrogenic injury Non specific abdominal pain: Better to rule out with imaging techniques (no concerns on rx-toxicity as in younger pts)

12 What Are the Acute Abdominal Diseases Potentially Treatable by Laparoscopy in Frail Patients? (3) Obstructing colo-rectal cancer: Hartmann procedure quickly by laparotomy (?) Mesenteric ischemia: to take into account Management of post-surgical complications: anectodal or must be recommended?

13 Outcomes Morbidity & Mortality: HIGH as expected (!) Morbidity Mortality 430 pts >65 yrs, 112 lap procedure 24.1% 3.6% Ukkonen M et al., World J Surg ,765 ac. perforated appendicitis >65 yrs 36.3% 1.4% 20,301 ac. non perforated appendicitis >65 yrs 15.8% 0.4% Masoomi H et al., World J Surg 2012

14 Baiocchi GL, Anania G, Agresta F, et al. Emergency laparoscopy, Springer 2016

15 URGENZE TRIENNIO Su 3945 interventi su pazienti ricoverati 963 sono stati eseguiti in urgenza Di questi 326 (34%) > 65aa RAPPORTO FRA OVER 65 E INTERVENTI IN URGENZA URG>65aa 34% URG<64 aa 66%

16 URGENZE TRIENNIO % URGENZE VLS NELL'ANZIANO Triennio VLS 42% OPEN 58% % URGENZE IN VLS NEI GIOVANI OPEN 43% VLS 57%

17 URGENZE TRIENNIO TRIENNIO % CONVERSIONE NEI PAZIENTI ANZIANI IN URGENZA conv 18% % DI CONVERSIONE NEI PAZIENTI GIOVANI IN URGENZA vls 82% CONVERS 5% VLS 95%

18 SI PUO MIGLIORARE? Siamo passati dal 36% al 42% di VLS in urgenza nell anziano e soprattutto da 30% al 18% di conversione % URGENZE VLS NELL'ANZIANO Triennio CONVERSIONI NELL'ANZIANO OPEN 64% VLS 36% CONVERSIONI 30% VLS 70%

19 Appendicectomie % 90% 80% 70% % 50% % 30% 20% % 0% : : : : : : : : : : :110 OPEN VLS

20 Conversioni Mini Conversioni ,20% 6,20% 10,10% 3,60% 5,50% 5,10% 5,60% 5% 4,30% 4,36%

21 Se è vero che la VLS in urgenza nell anziano migliora la sopravvivenza e riduce le complicanze Si può dare di più? Allenando bene il team