Mesh-related visceral complications following inguinal hernia repair: an emerging topic.

The use of meshes in inguinal hernia repair (IHR) has gained popularity but new complications have been observed. Mesh-related visceral complications (MRVCs) are generally considered rare and hence are not studied in depth. We carried out a thorough literature search and collected 101 clinical reports published from 1992 to 2018. The reported complications seem to have tripled in the last decade. Ninety-seven cases met the inclusion criteria and they were subdivided into four groups (group A-onlay IHR, group B-3-D IHR, group C-preperitoneal IHR, group D-laparoscopic IHR) to be analyzed, according to the herniorraphy technique. Every prosthetic IHR can be followed by MRVCs but, according to the present review, the highest incidence is related to laparoscopic repairs, the lowest to Lichtenstein technique. Time-to-event was shorter in case of preperitoneal position of the prosthesis than when the mesh was implanted over the transversalis fascia. Urinary bladder involvement predominantly occurred after laparosopic IHR. A pathogenic correlation between the most frequently complained clinical signs and the previous mesh herniorraphy was rarely reported. The diagnosis was generally made at laparotomy, which was usually performed as an emergency. Removing the infected mesh and resecting or suture repairing the involved viscera was the challenging surgical treatment. Prevention of MRVCs after inguinal hernia repair appears to be an important significant issue. It is important to pay attention to the choice of a proper implantation site, avoiding direct contact between the mesh and viscera, and to select a proper device.

Comparison of Two Questionnaires on Informed Consent in "Marginal" Donor Liver.

The necessity of liver donors has contributed to overcoming the traditional criteria and to propose new ones for the acceptance of livers for transplantation. For this reason expanded or extended criteria donation (ECD) or even overextended criteria for marginal or high-risk organ donors have been developed. Ethical, Legal and Psychological Aspects of Organ Transplantation (ELPAT) and European Liver and Intestine Transplant Association (ELITA) - European Liver Transplantation Registry (ELTR) coordinated the distribution of a previously reported questionnaire that was sent to 53 European liver transplant centers. Criteria were divided based on the response rate. Donor criteria such as steatosis and serum sodium >165 mmol/L, as well as recipient criteria such as previous history of cancer, were not considered contraindications to transplantation in more than 60% of cases. Criteria such as ICU (intensive care unit) stay, body mass index >30, serum bilirubin >3 mg/dL, and HIV infection or critical illness were not considered adequate for transplantation in 30% to 59% of cases. On the other hand, there was no agreement on other extended liver donor and recipient criteria, such as age up to 80 years, serum glutamic oxaloacetic transaminase >90 U/L, serum glutamic pyruvic transaminase >105 U/L, high-risk sex practices, drug users, patients older than 65 years, and patients younger than 65 years, respectively. Criteria such as serum sodium could not be considered ECD criteria. In conclusion, development of more studies and inclusion of more liver transplantation centers are required to confirm these data.

Paid Organ Donation: An Italian Perspective.

The only countries that have allowed financial incentives for organ donation are Iran since 1988, and later on, Singapore and Saudi Arabia. In Europe, and of course in Italy, financial incentives for donors are prohibited. The author has completed extensive research via the Internet (PubMed) of worldwide scientific literature on paid organ donation, also researching studies concerning public opinion on organ commercialism and "regulated markets". Italian transplant laws also have been reported and analyzed.

A preliminary European Liver and Intestine Transplant Association-European Liver Transplant Registry study on informed recipient consent and extended criteria liver donation.

The European Liver and Intestine Transplant Association (ELITA) and the European Liver Transplant Registry (ELTR) coordinated the distribution to European liver transplantation centers of an electronic questionnaire, developed by the first author, concerning the definition of extended criteria liver donation (ECD) and the implication for informed consent of transplant recipients. Completed questionnaires were received from 35 centers. All centers accepted ECD liver donors. The criteria for defining a liver donor as ECD were as follows: steatosis in 33 centers (94%); age up to 80 years in 15 centers (43%); serum sodium >165 mmol/L in 25 centers (71%); intensive care unit (ICU) stay with ventilation longer than 7 days in 17 centers (48%); aspartate aminotransferase (AST) >90 U/L, in 6 centers (17%); body mass index (BMI) >30 in 19 centers (54%); alanine aminotransferase (ALT) >105 U/L in 8 centers (23%); serum bilirubin >3 mg/dL in 15 centers (43%); and all criteria together in 2 centers (6%). Thirty-one centers informed the transplantation candidate of the ECD status of the donor, 20 (65%) when the patient registered for transplantation, 1 (3%) when an ECD liver became available, and 10 centers (32%) on both occasions. Thirteen centers required the liver transplantation candidate to sign a special consent form. Twenty centers informed the potential recipient of the donor's serology. Only 6 centers informed the potential recipient of any high-risk behavior of the donor.

A preliminary European study on extended-criteria liver donation and transplant recipient consent.

ELPAT (Ethical, Legal, and Psychologic Aspects of Organ Transplantation) coordinated the distribution to European liver transplant centers of an electronic questionnaire regarding the definition of extended-criteria liver donation (ECD) and its implication for informed consent by transplant recipients. Completed questionnaires were received from 30 centers in 13 countries including 28 who accepted ECD liver donors. The criteria to define a liver donor as ECD were: steatosis in 24 centers (85%); age up to 80 years in 23 centers (82%); serum sodium >165 mmol/L in 17 centers (60%); ICU stay with ventilation >7 days in 16 centers (57%); serum glutamic oxaloacetic transaminas >90 U/L, in 12 centres (42%); body mass index >30 kg/m(2) in 10 centers (35%); serum glutamate pyruvate transaminase >105 U/L in 10 centers (35%); serum bilirubin >3 mg/dL in 10 centers (35%); and other criteria in 13 centers (46%). Twenty-three centers informed the transplant candidate of the ECD status of the donor: 10 (43%) when the patient registered for transplantation, 3 (14%) when an ECD liver became available, and 10 (43%) on both occasions. Ten centers required the liver transplant candidate to sign a special consent form. Ten centers informed the potential recipient of the donor's serology. Only 3 centers informed the potential recipient of any high-risk behavior of the donor.

Extended criteria liver donation and transplant recipient consent: the European experience.

The organization known as ELPAT (Ethical, Legal and Psychological Aspects of Organ Transplantation) coordinated the distribution of an electronic questionnaire concerning the definition of extended criteria liver donation (ECD) and the implication for informed consent of transplant recipients to European liver transplant centers. Completed questionnaires were received from 30 centers in 13 countries. Twenty-eight centers accepted ECD liver donors. The criteria for defining a liver donor as ECD were: steatosis in 24 centers (85%); age up to 80 years in 23 centers (82%); serum sodium levels higher than 165 mmol/L in 17 centers (60%); intensive care unit stay with ventilation longer than 7 days in 16 centers (57%); serum glutamic oxalo-acitic transaminase levels higher than 90 U/L in 12 centers (42%); body mass indeces more than 30 in 10 centers (35%); serum glutamic pyruvic transaminase levels higher than 105 U/L in 10 centers (35%); serum bilirubin levels higher than 3 mg/dL in 10 centers (35%); and other criteria in 13 centers (46%). Twenty-three centers informed the transplant candidate of the ECD status of the donor: 10 centers (43%) when the patient registered for transplantation, 3 centers (14%) when an ECD liver became available, and 10 centers (43%) on both occasions. Ten centers required the liver transplant candidate to sign a special consent form. Ten centers informed the potential recipient of the donor's serology. Only three centers informed the potential recipient of any high risk behavior of the donor.

Financial incentives for organ donation: a slippery slope toward organ commercialism?

Financial incentives for organ donation (from living or brain-dead donors) have been considered ethically acceptable by some authors and have been accepted locally in some countries. In the United States of America, eight federal proposals have been rejected, while some kind of incentives have been approved at a local or state level. There is still a widespread concern that the acceptance of economic incentives could bring a commodification of the human body, constituting a "slippery slope" toward organ commercialism.

Ethical and legal issues in donation after cardiac death in Italy.

In Italy death of a human being must be declared either after brain death or after 20 minutes of cardiac arrest, certified by continuous electrocardiography (EKG) recording. It is my personal opinion that in such circumstances after cardiac death (DCD) will allow at best only the retrieval of few marginal kidneys and some tissues, and therefore will not be very helpful for our waiting list patients. I suggest instead modifying first the Italian law in order to be able to declare cardiac death after only 5 minutes of cardiac arrest, certified by continuous EKG recording.

Kidney instant monitoring (K.IN.G): a new analyzer to monitor kidney function.

AIM: The key role of the kidney in the regulation of body fluids and acid-base status is well known. Nonetheless, urine analysis has not received great attention in critically ill patients, likely due to the common practice of only analyzing 24-hour collected specimens. We hypothesized that the kidney may react more rapidly to minimal hemodynamic and acid-base status variations than can be assessed by a 24-hour analysis. Accordingly, we developed and tested a urine analyzer, allowing quasi-continuous urinary analysis. METHODS: A novel analyzer (Kidney INstant monitorinG--K.IN.G) was developed that allows non-invasive, quasi-continuous analysis of urine pH, sodium, chloride, potassium and ammonium levels. Analytic measurement accuracy was calculated for urine samples of patients admitted to ICUs as well as medical staff, using standard techniques as references. For clinical investigation, approximately 200 patients were connected to the analyzer after ICU admission until discharge. Clinically relevant parameters were recorded. Here, three cases are presented. RESULTS: For each analytic parameter, the accuracy of measurements obtained with the K.IN.G analyzer appeared to be acceptable as compared to those of the reference techniques. In case 1, urine analysis revealed increased urinary sodium and chloride excretion strictly in parallel with mean arterial pressure, and increased ammonium excretion which was associated with moderate hypercapnia. Case 2 showed increases in urinary pH and sodium and chloride levels following awakening after sedation suspension. In case 3, urine analysis revealed an impairment of renal concentrative power, which was associated with hypovolemia. CONCLUSION: The K.IN.G analyzer, allowing quasi-continuous monitoring of urinary pH and principal electrolyte levels, may represent a novel tool for clinical and research purposes.

Legal aspects of organ transplantation in Italy.

Informed consent is of paramount importance in any field of surgery, both from the ethical and the legal points of view. Concerning organ transplantation, potential recipients are fully informed before entering the waiting list. However, according to Italian law, they have to sign another informed consent form before entering the operating room. In our opinion, not only should recipients be informed of the quality of the donor and of the particular organ(s) they are going to receive, but also before entering the waiting list they should accept or refuse the future possibility of receiving an organ from a so-called marginal or extended criteria donor (ECD) and/or a non-heart-beating donor (NHBD).

Religious aspects of organ transplantation.

No religion formally forbid donation or receipt of organs or is against transplantation from living or deceased donors. Only some orthodox jews may have religious objections to "opting in." However, transplantation from deceased donors may be discouraged by Native Americans, Roma Gypsies, Confucians, Shintoists, and some Orthodox rabbis. Some South Asia Muslim ulemas (scholars) and muftis (jurists) oppose donation from human living and deceased donors because the human body is an "amanat" (trusteeship) from God and must not be desecrated following death, but they encourage xenotransplantation research. No religion formally obliges one to donate or refuse organs. No religion formally obliges one to consider cadaveric organs "a societal resource" or considers organ donation "a religious duty" (except some rabbis and isolated Muslim and Christian scholars) No religion has a formal position on "bonus points," which is priority on the waiting list. Living organ donation is strongly encouraged only between jesus christians (15 of 28 jesus christians worldwide have donated a kidney). No religion forbid this practice. Directed organ donation to people of the same religion has been proposed only by some Orthodox Jews and some Islamic Ulemas/Muftis. Only some Muslim Ulemas/Muftis and some Asian religions may prefer living donation over cadaveric donation. No religion prefers cadaveric over living donation. No religion formally forbid non-heart-beating donors (nhbd) cadaveric donation or cross-over donation. Due to the sacrad of human life, the Catholic Church is against donation from anencephalic donors or after active euthanasia. No religion formally forbid xenotransplantation. Addressing the participants of the First International Congress of the Society for Organ Sharing in 1991, Pope John Paul II said "There are many questions of an ethical, legal and social nature which need to be more deeply investigated. There are even shameful abuses which call for determined action on the part of medical association and donor societies, and especially of competent legislative bodies" and later on "In effect, the human body is always a personal body, the body of a person. The body cannot be treated as a merely physical or biological entity, nor can its organs and tissues ever be used as item for sale or exchange". Addressing the participants at the XVIII International Congress of the Transplantation Society in 2000, Pope John Paul II said "Accordingly, any procedure which tends to commercialize human organs or to consider them as items of exchange or trade must be considered morally unacceptable, because to use the body as an object is to violate the dignity of the human person" and later on added "The criteria for assigning donated organs should in no way be discriminatory (i.e. based on age, sex, race, religion, social standing, etc.) or utilitarian (i.e. based on work capacity, social usefulness, etc.)." To conclude, according to the Catechism of the Catholic Church Compendium signed by Pope Benedict XVI on june 28, 2005, 476. Are allowed transplantation and organ donation, before and after death? Organ transplantation is morally acceptable with the consent of the donor and without excessive risks for him/her. For the noble act of organ donation after death, the real death of the donor must be fully ascertained.

Ethical aspects of renal transplantation from living donors.

Kidney transplantation from living donors is widely performed all over the world. Living nephrectomy for transplantation has no direct advantages for the donor other than increased self-esteem, but it at least remains an extremely safe procedure, with a worldwide overall mortality of 0.03%. This theoretical risk for the donor seems to be justified by the socioeconomic advantages and increased quality of life of the recipient, especially in selected cases, such as pediatric patients, when living donor kidney transplantation can be performed in a preuremic phase, avoiding the psychological and physical stress of dialysis, which in children is not well tolerated and cannot prevent retarded growth. According to the Ethical Council of the Transplantation Society, commercialism must be effectively prevented, not only for ethical but also medical reasons. The risks are too high, not only for the donors, but also for the recipients, as a consequence of poor donor screening and evaluation with consequent transmission of human immunodeficiency virus (HIV) or other infective agents, as well as of inappropriate medical and surgical management of donors and also recipients, who are often discharged too early. Most public or private insurance companies consider kidney donation a safe procedure without long-term impairment and therefore do not increase the premium, whereas recipient insurance of course should cover hospital fees for the donors. "Rewarded gifting" or other financial incentives to compensate for the inconvenience and loss of income related to the donation are not advisable, at least in our opinion. Our Center does not perform anonymous living organ donation or "cross-over" transplantation.

Historical aspects of hepatocyte transplantation.

Hepatocyte transplantation has been used for temporary metabolic support of patients in end-stage liver failure awaiting whole organ transplantation as a method to support liver function and facilitate regeneration of the native liver in cases of fulminant hepatic failure and as a "cellular therapy" for patients with genetic defects in vital liver functions. The aim of this paper was to discuss the basic research that led to clinical hepatocyte transplantation, the published clinical experience with this experimental technique, and some possible future uses of hepatocyte transplantation.

Early enteral immunonutrition vs. parenteral nutrition in critically ill patients without severe sepsis: a randomized clinical trial.

OBJECTIVES: We compared early parenteral nutrition (PN) and early enteral immunonutrition (iEN) in critically ill patients, distinguishing those with and without severe sepsis or septic shock (SS) on admission to intensive care units (ICUs). DESIGN AND SETTING: Multicenter, randomized, unblinded clinical trial in 33 Italian general ICUs. PATIENTS AND PARTICIPANTS: The study included 326 patients, 287 of whom did not have SS on ICU admission. Eligibility criteria excluded the two tails in the spectrum of critical conditions, i.e., patients either too well or too ill. Of the patients recruited 160 were randomized to iEN (142 without SS) and 166 to PN (145 without SS). INTERVENTIONS: Patients were randomized to two arms: early iEN or early PN. MEASUREMENTS AND RESULTS: Primary endpoint was 28-day mortality for all patients and the occurrence of SS during ICU stay for patients admitted without such condition. While 28-day mortality did not differ between iEN and PN (15.6% vs. 15.1%), patients without SS who received iEN had fewer episodes of severe sepsis or septic shock (4.9% vs. 13.1%). ICU length of stay was 4 days shorter in patients given iEN. CONCLUSIONS: Compared to parenteral nutrition iEN appears to be beneficial in critical patients without severe sepsis or septic shock. Parenteral nutrition in these patients should be abandoned, at least when enteral nutrition can be administered, even at an initial low caloric content.

Giant hemangiomas of the liver: surgical strategies and technical aspects.

The incidence of hemangiomas is 2-7% in the general population. We evaluated more than 300 patients with hepatic hemangiomas. Surgical removal of hepatic hemangiomas was performed in 48 cases due to uncertain diagnosis (2 cases), intractable symptoms (26 cases), size increase (18 cases), and liver failure in 2 cases that were treated by hepatic transplantation. In all, 26 patients underwent enucleation of hemangiomas or segmentectomies, while the remaining 20 patients underwent right lobectomies or left lateral segmentectomies. Blood transfusions were required in four cases (including two liver transplants); mean post-resection hospital stay was 6.3 days. We observed no perioperative mortality and only two cases of major morbidity (bile leaks not requiring reoperation). Our experience confirms that, after adequate patient selection, surgical treatment of hepatic hemangiomas is a very effective therapeutic choice with no mortality and low morbidity.

Ethical considerations on kidney transplantation from living donors.

Kidney transplantation from living donors is widely performed all over the world. Living nephrectomy for transplantation has no direct advantage for the donor other than increased self-esteem, but at least remains an extremely safe procedure, with a worldwide overall mortality rate of 0.03%. This theoretical risk to the donor seems to be justified by the socioeconomic advantages and increased quality of life of the recipient, especially in selected cases, such as pediatric patients, when living donor kidney transplantation can be performed in a preuremic phase, avoiding the psychological and physical stress of dialysis, which in children is not well tolerated and cannot prevent retarded growth. According to the Ethical Council of the Transplantation Society, commercialism must be prevented, not only for ethical but also medical reasons. The risks are too high not only for the donors, but also for the recipients, as a consequence of poor donor screening and evaluation with consequent transmission of human immunodeficiency virus or other infectious agents, as well as inappropriate medical and surgical management of donors and also of recipients, who are often discharged too early. Most public or private insurance companies are considering kidney donation a safe procedure without long-term impairment and, therefore, do not increase the premium, whereas recipient insurance of course should cover hospital fees for the donors. "Rewarded gifting" or other financial incentives to compensate for the inconvenience and loss of income related to the donation are not advisable, at least in our opinion. Our center does not perform anonymous living organ donation or "cross-over" transplantation.

Heat stress: characteristics, pathophysiology and avoidable mistakes.

In August 2003 an exceptional heatwave was recorded in Europe. The authors would like to describe 6 patients for which the intensivist was called as a consultant. All patients had a skin temperature >40 degrees C, central nervous system impairment, severe hyponatremia [124.7 mEq/l+/-5.6 (range 117-130)] and severe metabolic acidosis [BE -6.28 mEq/l+/-3.55 (range -9.5-0), HCO3- 17.75 mEq/l+/-3.25 (range 13.4-21.9)]. All patients had decreased platelet count and coagulation abnormalities. Two patients were hypertensive, 4 hypotensive. The heat stress due to the hot environment is characterized by systemic inflammatory response (as in severe sepsis) and hemodynamic impairment (as in hypovolemic shock). The association between hypovolemia and altered microcirculation leads to cell energy failure with metabolic lactic acidosis. The energy failure may induce structural irreversible damage of mitochondria. It is possible to differentiate, during energy failure, the irreversible or reversible condition by volume loading and vasoactive drugs challenge tests. In fact, if the hemodynamic correction is associated with normalization of SvO2 with disappearance of metabolic acidosis, this suggests hemodynamic impairment with intact mitochondrial function. In contrast, if the hemodynamic improvement with normalization of SvO2 is associated and acidosis persists, this suggests irreversible structural mitochondrial damage. The threshold between reversibility and irreversibility is likely time dependent, as suggested by biochemical consideration and by 2 large randomized studies on hemodynamic treatment. The comparative analysis of these 2 studies suggests that the time of intervention may lead to significant differences in mortality. In these patients time is essential.