Equity, Diversity and Inclusion (EDI) in Organ Transplantation: An ESOT Survey About EDI Within ESOT as an Organization and its Educational Activities, and Transplantation Research and Science.

The European Society of Organ Transplantation (ESOT) strives to promote equity, diversity, and inclusion (EDI) across all its activities. We surveyed the transplant community's experiences and perspectives regarding EDI within ESOT as an organization and its educational activities, and research in general. A total of 299 respondents completed the questionnaire. About half agreed that ESOT's Executive Committee, Council, and Sections/Committees are diverse and inclusive (51%) and that ESOT promotes EDI in its live and digital educational activities (54%). Forty percent of respondents agreed that scientific and clinical trials in the field of transplantation are diverse and inclusive. Despite the wide distribution of the survey, most of the respondents self-identified as White and were either physician or surgeon. However, the results contribute a unique insight into the experiences and perspectives of the transplantation community regarding EDI. Whilst ESOT is committed to the principles of EDI, perceptions and the high number of proposals show the apparent need to prioritize efforts to embed EDI across ESOT and transplantation science. These data should constitute a starting point for change and provide guidance for future efforts to promote EDI within the transplantation community.

Serial transverse enteroplasty (STEP) in case of short bowel syndrome: did we achieve our goal? A systematic review.

Surveys on Serial Transverse Enteroplasty (STEP) published in international literature (1 January 2003- 31 May 2021) were searched. Articles were included from 17 countries: 1/23 comparative and 22/23 cohort studies. STEP was performed on 308 patients: pediatrics, adults, and mixed ages. Pediatric group included 16 studies and the adult 6. Pre-STEP residual small bowell (SB) length for pediatrics and adults ranged from 18 to 26 cm and from 30 to 70 cm, respectively. Post-STEP increased SB length for pediatrics and adults ranged between 42 and 100% and 50% and 176%, respectively. For pediatrics, enteral autonomy was reached in 32.22% of cases, parenteral nutrition (PN) dependence was 36.11%, a repeated STEP procedure (Re-STEP) was needed in 17.22%, and a bowel transplant was performed in 6.11%. In adults, enteral autonomy was achieved in 52.38%, while PN dependence was 37.1%, and no Re-STEP or transplantation were required. For the mixed group, post-STEP bowel length increased from 2 to 50 cm, enteral autonomy was obtained in 43%, PN dependence was 57%, without reported Re-STEP or transplantation. Mortality rates were between 5.55% (pediatric) and 7.14% (adults). Preoperative length with preservation of ileocecal valve represented the main predictive factors to achieve enteral autonomy.

Destiny for Rendezvous: Is Cholecysto/Choledocholithiasis Better Treated with Dual- or Single-Step Procedures?

Biliary lithiasis is common worldwide, affecting almost 20% of the general population, though few experience symptoms. The frequency of choledocholithiasis in patients with symptomatic cholelithiasis is estimated to be 10-33%, depending on patients' age. Unlike gallbladder lithiasis, the medical and surgical treatment of common bile duct stones is uncertain, having changed over the last few years. The prior gold standard treatment for cholelithiasis and choledocholithiasis was open cholecystectomy with bile duct clearance, choledochotomy, and/or surgical sphincterotomy. In the last 10-15 years, new treatment approaches to the complex pathology of choledocholithiasis have emerged with the advent of endoscopic retrograde cholangiopancreatography (ERCP), laparoscopic surgery, and advanced diagnostic procedures. Although ERCP followed by laparoscopic cholecystectomy is the preferred mode of management, a single-step strategy (laparo-endoscopic rendezvous) has gained acceptance due to lesser morbidity and a lower risk of iatrogenic damage. Given the above, a tailored approach relying on careful evaluation of the disease is necessary in order to minimize complication risks and overall costs. Yet, the debate remains open, with no consensus on the superiority of laparo-endoscopic rendezvous to more conventional approaches.

Resuming elective surgical activity after the COVID-19 wave: what the patients need to know.

As COVID-19 outbreak enters its second phase of lockdown ease, healthcare plans involve elective surgery re-establishment to provide essential life-saving care. Patients are increasingly requesting information about their facility's readiness for safely performing surgery. This information should be open and transparent including patient's education with objective data regarding the state of the pandemic in the country and the control measures undertaken by the facility.

Improving the quality of operative notes for laparoscopic cholecystectomy: Assessing the impact of a standardized operation note proforma.

INTRODUCTION: Operative notes are the recognized standard for documenting the details of an operation yet key procedural details are frequently missing. With the aim of improving standards, based on the Royal College of Surgeons (RCS) and Dutch Society of Surgery (DSS) Guidelines, we introduced an operation note proforma for use following laparoscopic cholecystectomy in a tertiary centre in the UK. METHODS: This study audited 130 consecutive laparoscopic cholecystectomy operation notes against accepted guidelines across three hospital sites within the same NHS Trust. Following analysis of these operation notes a standardized operation note proforma was designed and introduced across the Trust, which included all items from the DSS and RCS guidelines in the form of keyword prompts or simple yes/no responses. A further 128 operation notes were analysed. Guideline compliance was compared pre- and post-introduction of the proforma. Non-parametric data were analysed using Fisher's exact and Mann-Whitney U tests. Statistical significance was set at p < 0.05. RESULTS: On a global assessment of operation note completeness against all guideline items, introduction of an operation note proforma significantly improved documentation rates for both DSS guidelines (p < 0.001) and RCS guidelines (p < 0.001). DISCUSSION: We have demonstrated that the introduction of a procedure-specific proforma to assist with writing the post-operative note following laparoscopic cholecystectomy can result in significant improvements in documentation of generic and procedure-specific items that should be recorded for every operation. Procedure-specific proformas, based on established guidelines can help to produce more complete and medico-legally robust operation notes.

Ambulatory therapy with combined hemorrhoidal radiocoagulation.

BACKGROUND: This is a prospective randomized study to analyze results obtained in two groups of patients affected of grade II hemorrhoids and treated with Radiofrequency Coagulation (RFC) or Combined Hemorrhoidal Radiocoagulation (CHR). PATIENTS AND METHODS: The study comprehended 30 patients of which 27 had at least 6 months of follow-up. Two groups of patients were considered: group A, represented by 12 individuals treated with RFC, and group B, consisting of 15 patients treated with CHR. Our purpose was to determine: grade of pain felt immediately after procedure and at first evacuation (score from 1 to 10), bleeding, patient's satisfaction 15 days and 6 months after treatment (score from 1 to 10) and incidence of failures. RESULTS: Mean pain score reported immediately after procedure was 2.08 ± 0.9 for group A and 2.40 ± 1.5 for group B (p = NS). At first evacuation, mean pain score for group A and for group B was 2.16 ± 1.1 vs 2.33 ± 1.17, respectively (p = NS). Satisfaction score during first 15 days was 6.75 ± 2.76 for patients treated with RFC and 6.08 ± 2.20 for patients who received CHR (p = NS), while mean score of overall satisfaction after 6 months was 6.33 ± 1.96 (group A) vs 7.83 ± 2.05 (group B) (p < 0.05). At 6 months of follow-up, we observed 8 patients free from pain in group A (66.7%) and 13 patients in group B (86.7%). CONCLUSIONS: Results reported in both groups of patients confirm validity and efficacy of the two techniques used in this study, even if later in time CHR showed better results than RFC.        

Bariatric surgery in moderately obese patients: a prospective study.

Introduction. Moderate obesity (BMI 30-35 kg/m(2)) affects 25% of the western population. The role of bariatric surgery in this context is currently debated, reserved for patients with comorbidity, as an alternative to conservative medical treatment. We describe our experience in moderately obese patients treated with bariatric surgery. Materials and Methods. Between September 2011 and September 2012, 25 patients with grade I obesity and comorbidities underwent bariatric surgery: preoperative mean BMI 33.2 kg/m(2), 10 males, mean age 42 years. In presence of type 2 diabetes mellitus (T2DM) (56%), gastric bypass was performed; in cases with hypertension (64%) and obstructive sleep apnea (OSA) (12%), sleeve gastrectomy was performed. All operations were performed laparoscopically. Results. Mean follow-up was 12.4 months. A postoperative complication occurred: bleeding from the trocar site was resolved with surgery in local anesthesia. Reduction in average BMI was 6 points, with a value of 27.2 kg/m(2). Of the 14 patients with T2DM, 12 (86%) discontinued medical therapy because of a normalization of glycemia. Of the 16 patients with arterial hypertension, 14 (87%) showed remission and 2 (13%) improvement. Complete remission was observed in patients with OSAS. Conclusions. The results of our study support the validity of bariatric surgery in patients with BMI 30-35 kg/m(2). Our opinion is that, in the future, bariatric surgery could be successful in selected cases of moderately obese patients.

Everolimus and enteric-coated mycophenolate sodium ab initio after liver transplantation: midterm results.

BACKGROUND AND AIM: Everolimus (EVR) use in liver transplantation (OLT) has been prescribed with calcineurin inhibitors (CNIs), steroids, and monoclonal antibodies. The aim of our study was to evaluate the safety, feasibility, and impact on renal function of EVR ab initio, in combination with enteric-coated mycophenolate sodium (EC-MPS) without the use of induction treatment, steroids, or CNIs. PATIENTS AND METHODS: We retrospective analyzed nine consecutive patients who underwent OLT at our institution. The initial dose of EVR (1.5 mg/d) was adjusted to achieve trough levels of 8 to 12 ng/mL. EC-MPS introduced at 1080 mg/d was maintained at the same dose over time. RESULTS: At a mean follow-up of 21.48 (standard deviation [SD] 1.4) months from OLT, 7/9 recipients were alive with stable graft function. The 2-year patient and graft survivals were 77%. One recipient died due to cerebral hemorrhage and one, lung failure. No clinical evidence of an acute rejection episode was observed. Mean estimated glomerular filtration rate value, according to the Modification of Diet in Renal Disease formula increased from 59.5 (SD 9.89) mL/min/1.73 m(2) at OLT to 100.2 (SD 47.5) mL/min/1.73 m(2) (P = .03) after 12 months and 98.71 (SD 33.74) mL/min/1.73 m(2) (P = .03) after 24 months' follow-up. CONCLUSION: A double immunosuppression therapy with EVR and EC-MPS ab initio seemed to be efficacions and safe, representing a valid alternative to CNIs to prevent renal failure after OLT.

The role of radiofrequency surgery in the treatment of hemorrhoidal disease.

BACKGROUND: In this article we reported results obtained in our previous studies concerning application of radiofrequency (RF) in proctology and in particular for hemorrhoids treatment. METHODS: We compared radiofrequency submucosal hemorrhoidectomy (RSH) and conventional Parks' hemorrhoidectomy (CPH) (group 1), radiofrequency open hemorrhoidectomy (ROH) and Milligan-Morgan hemorrhoidectomy (MMH) (group 2), radiofrequency closed hemorrhoidectomy (RCH) and Ferguson hemorrhoidectomy (FH) (group 3), combined hemorrhoidal radiocoagulation (CHR) and rubber band ligation (RBL) (group 4). In this work primary endpoints were determined as evaluation of the grade of pain felt immediately after the procedure and at the first evacuation, bleeding, operation time, readmission to work, incidence of failures and patient's satisfaction. RESULTS: Group 1 - In comparison to Parks' technique, use of radiofrequency scalpel reduced mean operation time (61.2 min, range 50-75, vs. 37.4 min, range 30-51; p < 0.05), first postoperative day pain score (5.9, range 3-10, vs. 4.0, range 1-10; p < 0.05), pain score at first evacuation (5.7, range 2-10, vs 4.2, range 1-8; p < 0.05) and pain score on postoperative days (3.6, range 1-9, vs. 2.8, range 1-8; p < 0.05). Group 2 - Results show a substantial similarity between these techniques, however the procedure lasted 7 minutes less with RF scalpel (18.6 min, range 16-21, vs. 25.55 min, range 20-30; p < 0.05). Group 3 - Patients treated with RF showed significant reduction in surgical time (23 min, range 21-31, vs. 33 min, range 24-35; p < 0.01), in pain at 1st post-operative day (VAS score 3.4 +/- 1.3 vs. 4.8 +/- 1.0; p < 0.05) and at the first evacuation (3.4 +/- 1.0 vs. 5.0 +/- 0.8; p < 0.05). Group 4 - The study confirmed validity of both the used techniques, however CHR seems to allow a reduction in incidence of failures. CONCLUSIONS: Results obtained from radiofrequency surgery compared with those achieved with classic surgery for hemorrhoidal disease show in the majority of cases that radiosurgery facilitates, accelerates and improves surgical procedures.

Prospective randomised comparison of rubber band ligation (RBL) and combined hemorrhoidal radiocoagulation (CHR).

BACKGROUND: In this prospective randomized study we compared two groups of patients with grade II hemorrhoids treated with standard Rubber Band Ligation (RBL) and Combined Hemorrhoidal Radiocoagulation (CHR), respectively. METHODS: Out of 90 patients initially randomized, a total of 75 patients regularly returned to visit controls at least for 6 months of follow-up. Consequently, two groups of patients were considered: Group A, represented by 36 individuals treated with RBL, and Group B, consisting of 39 patients treated with CHR. In this study primary endpoints were determined as evaluation of the grade of pain felt immediately after the procedure and at the first evacuation (score from 1 to 10), bleeding, patient's satisfaction after 15 days and after 6 months from the treatment (score from 1 to 10), appearance of failures. RESULTS: Comparing two techniques, the mean pain score reported immediately after the procedure was 2.08 +/- 1.1 for Group A and 2.13 +/- 1.26 or Group B. At the first evacuation, the mean pain score for Group A and for Group B was 2.69 +/- 1.12 vs. 2.38 +/- 1.18, respectively. The satisfaction score during the first 15 days from the procedure was 6.61 +/- 2.35 for patients treated with RBL and 6.72 +/- 2.28 for patients who received CHR, while the mean score on overall satisfaction after 6 months was 7.11 +/- 2.11 (Group A) vs. 7.31 +/- 2.04 (Group B). At 6 months of follow-up, we observed remission of symptoms in 25 patients in Group A (69.4%) and 31 patients in Group B (79.5%). CONCLUSIONS: Satisfactory results were reported in both groups of patients after different treatments, which confirm the validity and efficacy of the two techniques used in this study. At least all patients reported positive results in terms of immediate and long-term comfort after both procedures. CHR showed better results than standard RBL, but further studies are required to evaluate the validity of these methods.

Conversion to rapamycin immunosuppression for malignancy after kidney transplantation.

INTRODUCTION: Malignancies are a well-known complication of immunosuppressive therapy among renal transplant recipients, representing an important cause of long-term morbidity and mortality. Rapamycin has been shown to limit the proliferation of a number of malignant cell lines in vivo and in vitro. METHODS: Fifteen patients developed the following malignancies at a mean of 90.3 months (range = 10-252) after kidney transplantation: metastatic gastric cancer (n = 1), metastatic colon cancer (n = 1), bilateral nephrourothelioma (n = 1), skin cancer (n = 2), Kaposi's sarcoma (n = 2), posttransplant lymphoproliferative disorder (PTLD; n = 4), renal cell carcinoma T1 (n = 1), MALT lymphoma (n = 1), intramucous colon carcinoma (n = 1), liposarcoma of the spermatic cord (n = 1). After the diagnosis of malignancy, the patients were switched from calcineurin inhibitor-based immunosuppression to rapamycin (monotherapy, n = 3), or associated with steroids (n = 6) or with mycophenolate mofetil (n = 6). RESULTS: Both patients with metastatic cancer underwent chemotherapy but succumbed after 6 and 13 months. Two patients with PTLD who underwent chemotherapy died after 12 and 36 months. At a mean follow-up of 32.7 months (range = 7-56), the remaining 11 patients are cancer-free. Two patients lost their grafts after 24 and 36 months after the switch due to chronic rejection. Renal graft function remained stable in all other patients from diagnosis throughout follow-up. CONCLUSION: Our observations suggested that rapamycin-based immunosuppression offers the possibility for regression of nonmetastatic tumors. Nevertheless, it is difficult to assess whether tumor regression was due to rapamycin treatment or to the reduced immunosuppression.

Clinical operational tolerance after kidney transplantation: a short literature review.

The clinical era of solid organ transplantation started with a renal transplantation (RT) performed between identical twins in Boston in 1954. The patient did not receive any immunosuppression, thus representing the very first case of operational tolerance (Tol). However, more than half a century later, we must admit the inadequacy of our knowledge regarding such a fundamental aspect of transplant immunology, as demonstrated by the fact that Tol has never been achieved in an intention-to-treat protocol. Herein we aim to shortly review the worldwide experience on clinical operational Tol after RT. Thus far, reports on successful cases of Tol after RT have been anecdotal: the largest series included no more than 10 individuals. We will understand that Tol can develop even in the presence of either HLA mismatches or blood group incompatibility at baseline, in the presence of anti-HLA antibodies during follow-up, as well as in patients having experienced acute rejection. Despite the lack of robust evidence, the fact that Tol is often accidentally discovered by transplant physicians during follow-up in noncompliant patients justifies the hypothesis that the real number of Tol cases might be much higher than currently reported.