Il trapianto di rene da donatore anziano: "a tailored approach"

In questo studio sono stati analizzati i risultati di 275 trapianti di rene eseguiti da donatori ultrasessantenni sia viventi che cadavere, dal Gennaio 2000 al Dicembre 2012 presso il reparto di Chirurgia Generale e dei Trapianti dell’Università degli Studi di Pisa, con un follow-up massimo di 120 mesi. Abbiamo, inoltre, eseguito dei confronti tra i risultati dei trapianti nelle seguenti sottopopolazioni: - CKT (Cadaveric donors Kidney Transplant; 226 tx) vs LKT (Living donors Kidney Transplant; 49); - SKT (Single Kidney Transplant; 137 tx) vs DKT (Dual Kidney Transplant; 89 tx); - Trapianti effettuati dopo biopsia (183 tx) vs trapianti effettuati senza biopsia (83 tx); - SKT con score bioptico di 4-5 (42 tx) vs DKT con score bioptico di 4-5 (48 tx); - SKT con score bioptico di 4-5 (42 tx) vs SKT con score bioptico inferiore o uguale a 3 (48 tx). La selezione del donatore vivente è stata effettuata sulla base di criteri clinici, di imaging e tramite la valutazione del filtrato renale ottenuto mediante scintigrafia renale. Abbiamo, invece, basato la nostra scelta di utilizzare il rene del donatore cadavere non solo sulla base delle caratteristiche cliniche del donatore (età, BMI, diabete, ipertensione, funzione renale, CMV IgG+) e dello score bioptico del graft pre-trapianto secondo Karpinski (quando è stata effettuata la biopsia) ma anche analizzando attentamente in ogni singolo caso le caratteristiche del ricevente (età, BMI, mesi dialisi pre-trapianto, CMV IgG+) per ottenere il miglior “match” possibile donatore-ricevente. I nostri risultati mostrano, in pieno accordo con la letteratura, che la sopravvivenza del graft e del paziente sia migliore nel gruppo LKT rispetto al gruppo CKT (graft: 92,12% vs 61,59% p=0,004; paziente: 92,12% vs 74,25% p=0,05 paziente). Confrontando, invece, i gruppi SKT e DKT, che risultano omogenei per le principali caratteristiche generali, abbiamo visto come non vi siano differenze statisticamente significative tra i due gruppi in termini di sopravvivenza del graft (55,64% vs 74,82%, p=NS) e del paziente (71,29% vs 80,96%, p=NS). La popolazione dei riceventi un trapianto dopo esecuzione di biopsia pre-trapianto per l’allocazione dell’organo non presenta un miglior outcome di quella in cui non è stata eseguita la biopsia (sopravvivenza del graft: 63,10% vs 56,81% p=NS; sopravvivenza del paziente: 78,12% vs 64,56% p=NS). Risultati interessanti derivano dall’analisi del confronto tra i gruppi SKT 4-5 vs DKT 4-5 e SKT 4-5 vs SKT ≤ 3. In entrambi i confronti non abbiamo riscontrato differenze statisticamente significative per sopravvivenza del graft (SKT 4-5 56,83% vs DKT 4-5 63,10%; SKT 4-5 56,83% vs SKT ≤ 3 50,5%) e del paziente (SKT 4-5 86,31% vs DKT 4-5 86,20%; SKT 4-5 86,31% vs SKT ≤ 3 66,30%). Questi dati sembrano avvalorare il nostro approccio circa la possibilità di eseguire trapianti singoli anche con score bioptico secondo Karpinski di 4 o 5, grazie ad una accurata selezione della coppia donatore-ricevente. In questo modo si riuscirebbe a garantire il trapianto di rene ad un maggior numero di pazienti in lista di attesa per trapianto; questo aspetto, in accordo con la letteratura internazionale, porterebbe direttamente ad un allungamento della sopravvivenza e ad un miglioramento della qualità di vita di questi pazienti. Nel caso del donatore cadavere ultrasessantenne, quindi, un’attenta valutazione dei parametri clinici, accompagnata dalla valutazione istopatologica del rene, quando necessaria, permette di raggiungere buoni risultati anche a lungo termine per quanto riguarda sopravvivenza del graft e del paziente. Questo approccio sembra essere una valida risposta alla carenza di organi, all’invecchiamento della popolazione dei donatori e al sovraffollamento delle liste d’attesa

Goodbye Hartmann trial: a prospective, international, multicenter, observational study on the current use of a surgical procedure developed a century ago

Colorectal cancer; Emergency surgery; Hartmann’s procedureCàncer de colorectal; Cirurgia d'urgència; Procediment de HartmannCáncer colorrectal; Cirugía de emergencia; Procedimiento de HartmannBackground Literature suggests colonic resection and primary anastomosis (RPA) instead of Hartmann’s procedure (HP) for the treatment of left-sided colonic emergencies. We aim to evaluate the surgical options globally used to treat patients with acute left-sided colonic emergencies and the factors that leading to the choice of treatment, comparing HP and RPA. Methods This is a prospective, international, multicenter, observational study registered on ClinicalTrials.gov. A total 1215 patients with left-sided colonic emergencies who required surgery were included from 204 centers during the period of March 1, 2020, to May 31, 2020. with a 1-year follow-up. Results 564 patients (43.1%) were females. The mean age was 65.9 ± 15.6 years. HP was performed in 697 (57.3%) patients and RPA in 384 (31.6%) cases. Complicated acute diverticulitis was the most common cause of left-sided colonic emergencies (40.2%), followed by colorectal malignancy (36.6%). Severe complications (Clavien-Dindo ≥ 3b) were higher in the HP group (P < 0.001). 30-day mortality was higher in HP patients (13.7%), especially in case of bowel perforation and diffused peritonitis. 1-year follow-up showed no differences on ostomy reversal rate between HP and RPA. (P = 0.127). A backward likelihood logistic regression model showed that RPA was preferred in younger patients, having low ASA score (≤ 3), in case of large bowel obstruction, absence of colonic ischemia, longer time from admission to surgery, operating early at the day working hours, by a surgeon who performed more than 50 colorectal resections. Conclusions After 100 years since the first Hartmann’s procedure, HP remains the most common treatment for left-sided colorectal emergencies. Treatment’s choice depends on patient characteristics, the time of surgery and the experience of the surgeon. RPA should be considered as the gold standard for surgery, with HP being an exception

Goodbye Hartmann trial: a prospective, international, multicenter, observational study on the current use of a surgical procedure developed a century ago

Background: Literature suggests colonic resection and primary anastomosis (RPA) instead of Hartmann's procedure (HP) for the treatment of left-sided colonic emergencies. We aim to evaluate the surgical options globally used to treat patients with acute left-sided colonic emergencies and the factors that leading to the choice of treatment, comparing HP and RPA. Methods: This is a prospective, international, multicenter, observational study registered on ClinicalTrials.gov. A total 1215 patients with left-sided colonic emergencies who required surgery were included from 204 centers during the period of March 1, 2020, to May 31, 2020. with a 1-year follow-up. Results: 564 patients (43.1%) were females. The mean age was 65.9 ± 15.6&nbsp;years. HP was performed in 697 (57.3%) patients and RPA in 384 (31.6%) cases. Complicated acute diverticulitis was the most common cause of left-sided colonic emergencies (40.2%), followed by colorectal malignancy (36.6%). Severe complications (Clavien-Dindo ≥ 3b) were higher in the HP group (P &lt; 0.001). 30-day mortality was higher in HP patients (13.7%), especially in case of bowel perforation and diffused peritonitis. 1-year follow-up showed no differences on ostomy reversal rate between HP and RPA. (P = 0.127). A backward likelihood logistic regression model showed that RPA was preferred in younger patients, having low ASA score (≤ 3), in case of large bowel obstruction, absence of colonic ischemia, longer time from admission to surgery, operating early at the day working hours, by a surgeon who performed more than 50 colorectal resections. Conclusions: After 100&nbsp;years since the first Hartmann's procedure, HP remains the most common treatment for left-sided colorectal emergencies. Treatment's choice depends on patient characteristics, the time of surgery and the experience of the surgeon. RPA should be considered as the gold standard for surgery, with HP being an exception

Infected pancreatic necrosis: outcomes and clinical predictors of mortality. A post hoc analysis of the MANCTRA-1 international study

: The identification of high-risk patients in the early stages of infected pancreatic necrosis (IPN) is critical, because it could help the clinicians to adopt more effective management strategies. We conducted a post hoc analysis of the MANCTRA-1 international study to assess the association between clinical risk factors and mortality among adult patients with IPN. Univariable and multivariable logistic regression models were used to identify prognostic factors of mortality. We identified 247 consecutive patients with IPN hospitalised between January 2019 and December 2020. History of uncontrolled arterial hypertension (p = 0.032; 95% CI 1.135-15.882; aOR 4.245), qSOFA (p = 0.005; 95% CI 1.359-5.879; aOR 2.828), renal failure (p = 0.022; 95% CI 1.138-5.442; aOR 2.489), and haemodynamic failure (p = 0.018; 95% CI 1.184-5.978; aOR 2.661), were identified as independent predictors of mortality in IPN patients. Cholangitis (p = 0.003; 95% CI 1.598-9.930; aOR 3.983), abdominal compartment syndrome (p = 0.032; 95% CI 1.090-6.967; aOR 2.735), and gastrointestinal/intra-abdominal bleeding (p = 0.009; 95% CI 1.286-5.712; aOR 2.710) were independently associated with the risk of mortality. Upfront open surgical necrosectomy was strongly associated with the risk of mortality (p &lt; 0.001; 95% CI 1.912-7.442; aOR 3.772), whereas endoscopic drainage of pancreatic necrosis (p = 0.018; 95% CI 0.138-0.834; aOR 0.339) and enteral nutrition (p = 0.003; 95% CI 0.143-0.716; aOR 0.320) were found as protective factors. Organ failure, acute cholangitis, and upfront open surgical necrosectomy were the most significant predictors of mortality. Our study confirmed that, even in a subgroup of particularly ill patients such as those with IPN, upfront open surgery should be avoided as much as possible. Study protocol registered in ClinicalTrials.Gov (I.D. Number NCT04747990)

Laparoscopic gastric bypass with remnant gastrectomy in a super-super obese patient with gastric metaplasia: a surgical hazard?

The endoscopic inaccessibility of the gastric remnant after Roux-en-Y gastric bypass (RYGBP) for morbid obesity represents an important issue for patients with familiar history of gastric cancer (GC) or affected by premalignant lesions, such as intestinal metaplasia. If a different bariatric procedure is contraindicated, RYGBP with remnant gastrectomy represents a reasonable alternative, significantly reducing the risk of GC but potentially increasing postoperative morbidity. For this reason, only few cases have been reported in the recent Literature and none regarding a super-super obese patient. We present the case of a 55-year-old super-super obese man with a family history of GC and antral gastritis with extensive intestinal metaplasia at preoperative upper endoscopy, who underwent laparoscopic RYGBP with remnant gastrectomy

Conservative Management of Complicated Colonic Diverticulitis in Early and Late Elderly

Background and Objectives: The management of complicated diverticulitis in the elderly can be a challenge and initial non-operative treatment remains controversial. In this study, we investigate the effectiveness of conservative treatment in elderly people after the first episode of complicated diverticulitis. Materials and Methods: This retrospective single-centre study describes 71 cases of elderly patients with complicated acute colonic diverticulitis treated with conservative management at Parma University Hospital from 1 January 2012 to 31 December 2019. Diverticulitis severity was staged according to WSES CT driven classification for acute diverticulitis. Patients was divided into two groups: early (65&ndash;74 yo) and late elderly (&gt;75 yo). Results: We enrolled 71 elderly patients conservatively treated for complicated acute colonic diverticulitis, 25 males and 46 females. The mean age was 74.78 &plusmn; 6.8 years (range 65&ndash;92). Localized abdominal pain and fever were the most common symptoms reported in 34 cases (47.88%). Average white cells count was 10.04 &plusmn; 5.05 &times; 109/L in the early elderly group and 11.24 &plusmn; 7.89 in the late elderly group. CRP was elevated in 29 (78.3%) cases in early elderly and in 23 late elderly patients (67.6%). A CT scan of the abdomen was performed in every case (100%). Almost all patients were treated with bowel rest and antibiotics (95.7%). Average length of stay was 7.74 &plusmn; 7.1 days (range 1&ndash;48). Thirty-day hospital readmission and mortality were not reported. Average follow-up was 52.32 &plusmn; 31.8 months. During follow-up, home therapy was prescribed in 48 cases (67.6%). New episodes of acute diverticulitis were reported in 20 patients (28.1%), elevated WBC and chronic NSAID therapy were related to a higher risk of recurrence in early elderly patients (p &lt; 0.05). Stage IIb-III with elevated WBC during first episode, had a higher recurrence rate compared to the other CT-stage (p = 0.006). Conclusions: The management of ACD in the elderly can be a challenge. Conservative treatment is safe and effective in older patients, avoiding unnecessary surgery that can lead to unexpected complications due to co-morbidities

The Challenge of Pneumatosis Intestinalis: A Contemporary Systematic Review

Purpose: Pneumatosis intestinalis is a radiological finding with incompletely understood pathogenesis. To date, there are no protocols to guide surgical intervention. Methods: A systematic review of literature, according to PRISMA criteria, was performed. Medline and PubMed were consulted to identify articles reporting on the items “emergency surgery, pneumatosis coli, and pneumatosis intestinalis” from January 2010 up to March 2022. This study has not been registered in relevant databases. Results: A total of 1673 patients were included. The average age was 67.1 ± 17.6 years. The etiology was unknown in 802 (47.9%) patients. Hemodynamic instability (246/1673–14.7% of the patients) was associated with bowel ischemia, necrosis, or perforation (p = 0.019). Conservative management was performed in 824 (49.2%) patients. Surgery was performed 619 (36.9%) times, especially in unstable patients with bowel ischemia signs, lactate levels greater than 2 mmol/L, and PVG (p = 0.0026). In 155 cases, surgery was performed without pathological findings. Conclusions: Many variables should be considered in the approach to patients with pneumatosis intestinalis. The challenge facing the surgeons is in truly identifying those who really would benefit and need surgical intervention. The watch and wait policy as a first step seems reasonable, reserving surgery only for patients who are unstable or with high suspicion of bowel ischemia, necrosis, or perforation

Effects of Bariatric Surgery on COVID-19: a Multicentric Study from a High Incidence Area

Introduction The favorable effects of bariatric surgery (BS) on overall pulmonary function and obesity-related comorbidities could influence SARS-CoV-2 clinical expression. This has been investigated comparing COVID-19 incidence and clinical course between a cohort of patients submitted to BS and a cohort of candidates for BS during the spring outbreak in Italy. Materials and Methods From April to August 2020, 594 patients from 6 major bariatric centers in Emilia-Romagna were administered an 87-item telephonic questionnaire. Demographics, COVID-19 incidence, suggestive symptoms, and clinical outcome parameters of operated patients and candidates to BS were compared. The incidence of symptomatic COVID-19 was assessed including the clinical definition of probable case, according to World Health Organization criteria. Results Three hundred fifty-three operated patients (Op) and 169 candidates for BS (C) were finally included in the statistical analysis. While COVID-19 incidence confirmed by laboratory tests was similar in the two groups (5.7% vs 5.9%), lower incidence of most of COVID-19-related symptoms, such as anosmia (p: 0.046), dysgeusia (p: 0.049), fever with rapid onset (p: 0.046) were recorded among Op patients, resulting in a lower rate of probable cases (14.4% vs 23.7%; p: 0.009). Hospitalization was more frequent in C patients (2.4% vs 0.3%, p: 0.02). One death in each group was reported (0.3% vs 0.6%). Previous pneumonia and malignancies resulted to be associated with symptomatic COVID-19 at univariate and multivariate analysis. Conclusion Patients submitted to BS seem to develop less severe SARS-CoV-2 infection than subjects suffering from obesity

Preoperative Localization in Colonic Surgery (PLoCoS Study): a multicentric experience on behalf of the Italian Society of Colorectal Surgery (SICCR)

: The aim of this prospective multicentric study was to compare the accurate colonic lesion localization ratio between CT and colonoscopy in comparison with surgery. All consecutive patients from 1st January to 31st December 2019 with a histologically confirmed diagnosis of dysplastic adenoma or adenocarcinoma with planned elective, curative colonic resection who underwent both colonoscopy and CT scans were included. Each patient underwent conventional colonoscopy and CT to stage the tumour, and the localization results of each procedure were registered. CT and colonoscopic localization were compared with surgical localization, adopted as the reference. Our analysis included 745 patients from 23 centres. After comparing the accuracy of colonoscopy and CT (for visible lesions) in localizing colonic lesions, no significant differences were found between the two preoperative tools (510/661 vs 499/661 correctly localized lesions, p = 0.518). Furthermore, after analysing only the patients who underwent complete colonoscopy and had a visible lesion on CT, no significant difference was observed between conventional colonoscopy and CT (331/427 vs 340/427, p = 0.505). Considering the intraoperative localization results as a reference, a comparison between colonoscopy and CT showed that colonoscopy significantly failed to correctly locate the lesions localized in the descending colon (17/32 vs 26/32, p = 0.031). We did not identify an advantage in using CT to localize colonic tumours. In this setting, colonoscopy should be considered the reference to properly localize lesions; however, to better identify lesions in the descending colon, CT could be considered a valuable tool to improve the accuracy of lesion localization