Salvaging of severely ruptured living-related renal allograft secondary to acute antibody mediated rejection

AbstractINTRODUCTIONSpontaneous renal allograft rupture (RAR) is a serious and potentially life-threatening complication of kidney transplantation. Debate on the management of RAR has focused on graft nephrectomy versus salvaging in cases where: the allograft rupture site is surgically manageable; the bleeding can be controlled; and/or leaving the renal allograft in situ does not compromise patient survival.PRESENTATION OF CASEA 45-year-old, living-related, female, kidney allograft recipient experienced RAR on the fourth day post transplantation. Surgical exploration showed 12cm laceration along the convex border of the graft. Histologically the graft demonstrated mild acute kidney injury and linear deposition of C4d along the cortical peritubular capillaries; morphological features for violent humoral or cellular rejection were not identified. The graft was surgically salvaged with excellent clinical and biochemical improvement.DISCUSSIONObservations arising from this case are: (1) RAR caused by rejection is still encountered in clinical practice despite effective immunosuppressive management; (2) the severity of the histopathological features of rejection does not necessarily correlate with the extent of graft rupture; and (3) salvaging the graft should be attempted whenever possible as current immunosuppression and advances in surgical techniques may have an impact on long-term graft function and survival, differing from those previously published.CONCLUSIONWith modern immunosuppression therapy and proven surgical procedures, the efficacy of salvaged renal grafts and graft survival rates may improve substantially

Global management of a common, underrated surgical task during the COVID-19 pandemic: Gallstone disease - An international survery

Background: Since the Coronavirus disease-19(COVID-19) pandemic, the healthcare systems are reallocating their medical resources, with consequent narrowed access to elective surgery for benign conditions such as gallstone disease(GD). This survey represents an overview of the current policies regarding the surgical management of patients with GD during the COVID-19 pandemic. Methods: A Web-based survey was conducted among 36 Hepato-Prancreato-Biliary surgeons from 14 Countries. Through a 17-item questionnaire, participants were asked about the local management of patients with GD since the start of the COVID-19 pandemic. Results: The majority (n = 26,72.2%) of surgeons reported an alarming decrease in the cholecystectomy rate for GD since the start of the pandemic, regardless of the Country: 19(52.7%) didn't operate any GD, 7(19.4%) reduced their surgical activity by 50–75%, 10(27.8%) by 25–50%, 1(2.8%) maintained regular activity. Currently, only patients with GD complications are operated. Thirty-two (88.9%) participants expect these changes to last for at least 3 months. In 15(41.6%) Centers, patients are currently being screened for SARS-CoV-2 infection before cholecystectomy [in 10(27.8%) Centers only in the presence of suspected infection, in 5(13.9%) routinely]. The majority of surgeons (n = 29,80.6%) have adopted a laparoscopic approach as standard surgery, 5(13.9%) perform open cholecystectomy in patients with known/suspected SARS-CoV-2 infection, and 2(5.6%) in all patients. Conclusion

The usefulness of laparoscopic hernia repair in the management of incisional hernia following liver transplantation

Introduction: The reported incidence of incisional hernia following orthotopic liver transplantation (OLT) varies from 4% to 23%. Postoperative wound complications are less frequent after laparoscopic repair while maintaining low recurrence rates. We present our experience in managing this complication. Materials and Methods: Retrospectively, collected data of all patients who underwent liver transplant and developed incisional hernias were analyzed. Patients′ demographic data, anthropometric data, transplantation-related data, and repair-related operative and postoperative data were collected. Risk factors for post-transplant incisional hernia were appraised in our patients. Patients were divided into two groups: Group A included patients who had their incisional hernia repaired through the laparoscopic approach, and Group B included patients who had their incisional hernia repaired through open conventional approach. Results: A total of 488 liver transplantations were performed at our institution between May 2001 and end of December 2012. Thirty-three patients developed incisional hernias after primary direct closure of the abdominal wall with an overall incidence of 6.9%. Hernia repair was done in 25 patients. Follow-up ranged from 6.4 to 106.1 months with a mean of 48.3 ± 28.3 months. All patients were living at the end of the follow up except four patients (16%). Group A included 13 patients, and Group B included 12 patients. The size of defects and operative time did not differ significantly between both the groups. On the other hand, hospital stay was significantly shorter in laparoscopic group. Complication rate following laparoscopic repair was insignificantly different for open repair. Conclusion: In experienced hands, laparoscopic incisional hernia repair in post-liver transplant setting proved to be a safe and feasible alternative to open approach and showed superior outcome expressed in shorter hospital stay, with low recurrence and complication rate

Global management of a common, underrated surgical task during the COVID-19 pandemic: Gallstone disease - An international survery

Background: Since the Coronavirus disease-19(COVID-19) pandemic, the healthcare systems are reallocating their medical resources, with consequent narrowed access to elective surgery for benign conditions such as gallstone disease(GD). This survey represents an overview of the current policies regarding the surgical management of patients with GD during the COVID-19 pandemic. Methods: A Web-based survey was conducted among 36 Hepato-Prancreato-Biliary surgeons from 14 Countries. Through a 17-item questionnaire, participants were asked about the local management of patients with GD since the start of the COVID-19 pandemic. Results: The majority (n = 26,72.2%) of surgeons reported an alarming decrease in the cholecystectomy rate for GD since the start of the pandemic, regardless of the Country: 19(52.7%) didn't operate any GD, 7(19.4%) reduced their surgical activity by 50-75%, 10(27.8%) by 25-50%, 1(2.8%) maintained regular activity. Currently, only patients with GD complications are operated. Thirty-two (88.9%) participants expect these changes to last for at least 3 months.In 15(41.6%) Centers, patients are currently being screened for SARS-CoV-2 infection before cholecystectomy [in 10(27.8%) Centers only in the presence of suspected infection, in 5(13.9%) routinely]. The majority of surgeons (n = 29,80.6%) have adopted a laparoscopic approach as standard surgery, 5(13.9%) perform open cholecystectomy in patients with known/suspected SARS-CoV-2 infection, and 2(5.6%) in all patients. Conclusion: In the ongoing COVID-19 emergency, the surgical treatment of GD is postponed, resulting in a huge number of untreated patients who could develop severe morbidity. Updated guidelines and dedicated pathways for patients with benign disease awaiting elective surgery are mandatory to prevent further aggravation of the overloaded healthcare systems. Keywords: COVID-19 pandemic; Cholecystectomy; Elective surgery; Gallstone disease; SARS-CoV-