Living Donor Lung Transplantation After Hematopoietic Stem Cell Transplantation From the Same Donor: A Risk Worth Taking.

Living donor (LD) lung transplantation (LT) represents an exceptional procedure in Western countries. However, in selected situations, it could be a source of unique advantages, besides addressing organ shortage. We report a successful case of father-to-child single-lobe LT, because of the complications of hematopoietic stem cell transplantation from the same donor, with initial low-dose immunosuppressive therapy and subsequent early discontinuation. Full donor chimerism was hypothesized to be a mechanism of transplant tolerance, and this postulated immunological benefit was deemed to outweigh the risks of living donation and the possible drawbacks of single compared with bilateral LT. Favorable size matching and donor's anatomy, accurate surgical planning, and specific expertise in pediatric transplantation also contributed to the optimal recipient and donor outcomes. Ten months after LD LT, the patient's steadily good lung function after withdrawal of immunosuppressive therapy seems to confirm the original hypothesis.

Improving outcomes of in situ split liver transplantation in Italy over the last 25 years.

BACKGROUND & AIMS: Split liver transplant(ation) (SLT) is still considered a challenging procedure that is by no means widely accepted. We aimed to present data on 25-year trends in SLT in Italy, and to investigate if, and to what extent, outcomes have improved nationwide during this time. METHODS: The study included all consecutive SLTs performed from May 1993 to December 2019, divided into three consecutive periods: 1993-2005, 2006-2014, and 2015-2019, which match changes in national allocation policies. Primary outcomes were patient and graft survival, and the relative impact of each study period. RESULTS: SLT accounted for 8.9% of all liver transplants performed in Italy. A total of 1,715 in situ split liver grafts were included in the analysis: 868 left lateral segments (LLSs) and 847 extended right grafts (ERGs). A significant improvement in patient and graft survival (p <0.001) was observed with ERGs over the three periods. Predictors of graft survival were cold ischaemia time (CIT) <6 h (p = 0.009), UNOS status 2b (p <0.001), UNOS status 3 (p = 0.009), and transplant centre volumes: 25-50 cases vs. <25 cases (p = 0.003). Patient survival was significantly higher with LLS grafts in period 2 vs. period 1 (p = 0.008). No significant improvement in graft survival was seen over the three periods, where predictors of graft survival were CIT <6 h (p = 0.007), CIT <6 h vs. ≥10 h (p = 0.019), UNOS status 2b (p = 0.038), and UNOS status 3 (p = 0.009). Retransplantation was a risk factor in split liver graft recipients, with significantly worse graft and patient survival for both types of graft (p <0.001). CONCLUSIONS: Our analysis showed Italian SLT outcomes to have improved over the last 25 years. These results could help to dispel reservations regarding the use of this procedure. IMPACT AND IMPLICATIONS: Split liver transplant(ation) (SLT) is still considered a challenging procedure and is by no means widely accepted. This study included all consecutive in situ SLTs performed in Italy from May 1993 to December 2019. With more than 1,700 cases, it is one of the largest series, examining long-term national trends in in situ SLT since its introduction. The data presented indicate that the outcomes of SLT improved during this 25-year period. Improvements are probably due to better recipient selection, refinements in surgical technique, conservative graft-to-recipient matching, and the continuous, yet carefully managed, expansion of donor selection criteria under a strict mandatory split liver allocation policy. These results could help to dispel reservations regarding the use of this procedure.

Outpatient Non-operative Management of Uncomplicated Acute Appendicitis: A Non-inferiority Study.

INTRODUCTION: Non-operative management (NOM) of uncomplicated acute appendicitis is a well-established alternative to upfront surgery. The administration of intravenous broad-spectrum antibiotics is usually performed in hospital, and only one study described outpatient NOM. The aim of this multicentre retrospective non-inferiority study was to evaluate both safety and non-inferiority of outpatient compared to inpatient NOM in uncomplicated acute appendicitis. METHODS: The study included 668 consecutive patients with uncomplicated acute appendicitis. Patients were treated according to the surgeon's preference: 364 upfront appendectomy, 157 inpatient NOM (inNOM), and 147 outpatient NOM (outNOM). The primary endpoint was the 30-day appendectomy rate, with a non-inferiority limit of 5%. Secondary endpoints were negative appendectomy rate, 30-day unplanned emergency department (ED) visits, and length of stay. RESULTS: 30-day appendectomies were 16 (10.9%) in the outNOM group and 23 (14.6%) in the inNOM group (p = 0.327). OutNOM was non-inferior to inNOM with a risk difference of-3.80% 97.5% CI (- 12.57; 4.97). No difference was found between inNOM and outNOM groups for the number of complicated appendicitis (3 vs. 5) and negative appendectomy (1 vs. 0). Twenty-six (17.7%) outNOM patients required an unplanned ED visit after a median of 1 (1-4) days. In the outNOM group, the mean cumulative in-hospital stay was 0.89 (1.94) days compared with 3.94 (2.17) days in the inNOM group (p < 0.001). CONCLUSIONS: Outpatient NOM was non-inferior to inpatient NOM with regard to the 30-day appendectomy rate, while a shorter hospital stay was found in the outNOM group. Further, studies are required to confirm these findings.

Hyperthermic intraperitoneal chemotherapy (HIPEC) as adjuvant and therapeutic options for patients with advanced gastric cancer at high risk of recurrence or established peritoneal metastases: a single-centre experience.

Peritoneal metastases from gastric cancer (PM-GC) have a detrimental prognostic impact on survival and there is a lack of consensus regarding treatment. Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) may offer a chance for prolonged survival as compared to standard chemotherapy. This study aims to present our experience in the management of GC with CRS and HIPEC. This is a single-centre retrospective study. Patients were divided into two groups: patients with GC at high risk for developing PM-GC (adjuvant HIPEC group) and patients with PM-GC or positive peritoneal cytology (therapeutic CRS and HIPEC group). Overall survival (OS) and disease-free survival (DFS) were considered as outcome measures. A total of 41 patients with a GC primary received surgery and HIPEC: 14 patients (34.1%) were in the adjuvant HIPEC group, while 27 patients (65.9%) were in the therapeutic CRS and HIPEC group. In the adjuvant HIPEC group, the 1- and 3-year OS were 85.7% and 71.4%, while 1- and 3-year DFS were 71.4% and 64.3%, respectively. In the therapeutic CRS and HIPEC group, OS was 60.3% and 35.1% at 1 and 3 years, whereas 1- and 3-year DFS were 38% and 32.6%, respectively. Univariate survival analysis of patients in the therapeutic CRS and HIPEC group showed that the presence of lymph node metastasis and signet ring cell histology predicted worse OS, while PCI > 12 and lymph node metastasis were associated with decreased DFS. Treatment of highly selected patients with GC at high risk of peritoneal recurrence or established PM with CRS and HIPEC showed satisfactory results in terms of OS and DFS.

Locally Advanced Glomus Tumor of the Stomach With Synchronous Liver Metastases: Case Report and Literature Review.

Gastric glomus tumors (GGTs) are usually rare mesenchymal neoplasms. They are typically benign, with very few metastatic cases reported and no specific guidelines on their management. Here, we present a patient with a locally advanced GGT with synchronous liver metastases. One month after resection of the GGT, emergency laparotomy was required for massive hemoperitoneum due to bleeding from the largest metastasis. Indeed, a dramatic progression of liver metastases was observed in just one month. A wide local excision is considered the treatment of choice for GGTs. In particular, this case report suggests that the resection of any liver metastases should possibly be performed at the same time as the GGT excision and not at a later stage.

Delayed-release oral mesalamine tablet mimicking a small jejunal gastrointestinal stromal tumor: A case report.

BACKGROUND: Enteric-coated medications are supposed to pass intact through the gastric environment and to release the drug content into the small intestine or the colon. Before dissolution of the enteric coating, they may appear hyperdense on computed tomography (CT). Unfortunately, few reports have been published on this topic so far. In this case report, the hyperdense appearance on contrast-enhanced CT of an enteric-coated mesalamine tablet was initially misinterpreted as a jejunal gastrointestinal stromal tumor (GIST). CASE SUMMARY: An asymptomatic 81-year-old male patient, who had undergone laparoscopic right nephrectomy four years earlier for stage 1 renal carcinoma, was diagnosed with a jejunal GIST at the 4-year follow-up thoraco-abdominal CT scan. He was referred to our hub hospital for gastroenterological evaluation, and subsequently underwent 18-fluorodeoxyglucose positron emission tomography, abdominal magnetic resonance imaging, and video capsule endoscopy. None of these examinations detected any lesion of the small intestine. After reviewing all the CT images in a multidisciplinary setting, the panel estimated that the hyperdense jejunal image was consistent with a tablet rather than a GIST. The tablet was an 800 mg delayed-release enteric-coated oral mesalamine tablet (Asacol®), which had been prescribed for non-specific colitis, while not informing the hospital physicians. CONCLUSION: Delayed-release oral mesalamine (Asacol®), like other enteric-coated medications, can appear as a hyperdense image on a CT scan, mimicking a small intestinal GIST. Therefore, a detailed knowledge of the patients' medications and a multidisciplinary review of the images are essential.

Association between Kasai portoenterostomy at low caseload centres and transplant complications in children with biliary atresia.

BACKGROUND: Kasai portoenterostomy (KPE) is the preferred treatment for biliary atresia (BA) patients. It has been shown that the center caseload of KPE impacts on native liver survival. We aimed to define the impact of KPE caseload on complications at the time of liver transplantation (LT). METHODS: Retrospective data collection of LT for BA performed in our tertiary center between 2010 and 2018. The patients were grouped according to the caseload of the center that performed KPE: Group A (≥5 KPE/year) and Group B (<5 KPE/year). We analyzed total transplant time (TTT), hepatectomy time, amount of plasma and red blood cell (RBC) transfusions, occurrence of bowel perforations at LT. RESULTS: Among 115 patients, Group A (n 44) and Group B (n 71) were comparable for age, sex, PELD score, TTT. The groups differed for: median hepatectomy time (57 min, IQR = 50-67; vs 65, IQR 55-89, p = 0.045); RBC transfusions (95 ml, IQR 0-250; vs 200 ml, IQR 70-500, p = 0.017); bowel perforations (0/44 vs 15/71, p = 0.001). One-year graft loss in Group A vs Group B was 1/44 vs 7/71 (p = 0.239), whereas deaths were 0/44 vs 5/71 respectively (p = 0.183); 5/15 patients who had a perforation eventually lost the graft. CONCLUSIONS: This study found an association between KPE performed in low caseload center and the incidence of complications at LT. These patients tend to have a worse outcome. The centralization of KPE to referral center represents an advantage at the time of LT. MINI ABSTRACT: We studied the impact of Kasai portoenterostomy (KPE) caseload on complications at the time of liver transplantation (LT), in 115 patients. We found an association between KPE performed in low caseload center and increased bowel perforations and blood transfusions. We suggest to centralize to experienced center all children requiring KPE.

The decrease of non-complicated acute appendicitis and the negative appendectomy rate during pandemic.

BACKGROUND: During pandemic, admissions for surgical emergencies dropped down dramatically. Also acute appendicitis decreased. The aim of the present study was to evaluate the change in volume and clinical presentation of patients with acute appendicitis during pandemic and the variation in treatment. METHODS: This is a retrospective study of patients admitted in 11 Italian hospital for acute appendicitis during the lockdown period (March-April 2020) compared with the same period of the previous 2 years (2018-2019). The number and the rate of complicated and non-complicated acute appendicitis were recorded and compared between the two study periods; non-operative vs operative treatment and negative appendectomy rate were also recorded. RESULTS: The study included 532 patients, 112 in the study period and 420 in the control period; Hospital admission for acute appendicitis dropped by 46% (OR 0.516 95% CI 0.411-0.648 p < 0.001) during the 2020 lockdown. The number of complicated acute appendicitis did not change (- 18%, OR 0.763 95% CI 0.517-1.124 p = 0.1719), whereas the number of non-complicated acute appendicitis significantly decreased (- 56%, OR 0.424 95% CI 0.319-0.564 p < 0.001). Non-operative treatment rate remained similar (12.1% vs. 11.6% p = 0.434). The negative appendectomy rate also significantly decreased (6.1% vs. 17.3%, p = 0.006). CONCLUSIONS: The present study found a significant reduction of both admissions for non-complicated acute appendicitis and negative appendectomy rate during the pandemic period. Conversely, admissions for complicated acute appendicitis did not change. TRIAL REGISTRATION: NCT04649996.

Laparoscopic Witzel jejunostomy.

The placement of a feeding jejunostomy can be indicated in malnourished patients with gastric and oesophagogastric junction cancer to allow for enteral nutritional support. In these patients, the jejunostomy tube can be suitably placed at the time of staging laparoscopy. Several techniques of laparoscopic jejunostomy (LJ) have been described, yet the Witzel approach remains neglected, due to the perceived difficulty of suturing the bowel around the tube and securing them to the abdominal wall. Here, we describe a novel technique for LJ, using a single barbed suture for securing the bowel and tunnelling the jejunostomy catheter according to the Witzel approach.

Magnetic Sphincter Augmentation Placement for Recalcitrant Gastroesophageal Reflux Disease Following Bariatric Procedures: A Systematic Review and Bayesian Meta-Analysis.

Background: This study aims to consolidate all available articles on this topic and evaluate MSA effectiveness in the management of gastroesophageal reflux disease (GERD). Matherials and Methods: We conducted an electronic systematic search using MEDLINE databases (PubMed), EMBASE, and Web of Science. An electronic systematic search of articles comparing preoperative and postoperative health-related quality of life (GERD-HRQL) scores in patients who underwent MSA placement for management of GERD following bariatric surgery was performed. Three retrospective studies totaling 33 patients met the inclusion criteria and were included in this meta-analysis. Results: The pooled mean difference in change from preoperative GERD-HRQL score was 17.5 (95% CrI; -22.88 to -12.20) and it was statistically significant. The between-study variability is 3.621 (95% HPD; 1.39 4.99) with low heterogeneity (I2 = 15%; 95% HPD; 2.1 26.2%). Conclusions: MSA for refractory GERD following bariatric surgery appears feasible. Prospective randomized controlled with standardized surgical technique and objective follow-up evaluation is needed to better assess short- and long-term efficacy.

Prosthetic Reinforcement in Hiatal Hernia Repair, Does Mesh Material Matter? A Systematic Review and Network Meta-Analysis.

Background: Hiatal hernia repair (HHR) is a complex surgical procedure and its management is not standardized. Several meta-analyses have compared cruroplasty with hiatus reinforcement with mesh, and crura augmentation appears to have better outcomes. However, heterogeneity in type of mesh and placement techniques has differed significantly. Materials and Methods: A systematic review and network meta-analysis were carried out. An electronic systematic research was carried out throughout Pubmed, CENTRAL, and Web of Science, of articles analyzing HHR with cruroplasty, nonabsorbable mesh (NAM), and absorbable mesh (AM) reinforcement. Results: Seventeen articles based on 1857 patients were enrolled in this article. The point estimation showed that when compared against the control group (NAM), the HH recurrence risk in AM and cruroplasty group was higher (relative ratio [RR] 2.3; CrI 0.8-6.3, RR 3.6; CrI 2.0-8.3, respectively). Postoperative complication rates were alike in all groups. The prevalence of mesh erosion after HHR is low. Conclusions: This network meta-analysis showed that prosthetic reinforcement significantly reduced HH recurrence when compared with cruroplasty alone. However, there is not enough evidence to compare different mesh compositions.

Endoluminal vacuum-assisted closure (E-Vac) therapy for postoperative esophageal fistula: successful case series and literature review.

BACKGROUND: Treatment of esophageal perforations and postoperative anastomotic leaks of the upper gastrointestinal tract remains a challenge. Endoluminal vacuum-assisted closure (E-Vac) therapy has positively contributed, in recent years, to the management of upper gastrointestinal tract perforations by using the same principle of vacuum-assisted closure therapy of external wounds. The aim is to provide continuous wound drainage and to promote tissue granulation, decreasing the needed time to heal with a high rate of leakage closure. CASES PRESENTATION: A series of two different cases with clinical and radiological diagnosis of esophageal fistulas, recorded from 2018 to 2019 period at our institution, is presented. The first one is a case of anastomotic leak after esophagectomy for cancer complicated by pleuro-mediastinal abscess, while the second one is a leak of an esophageal suture, few days after resection of a bronchogenic cyst perforated into the esophageal lumen. Both cases were successfully treated with E-Vac therapy. CONCLUSION: Our experience shows the usefulness of E-Vac therapy in the management of anastomotic and non-anastomotic esophageal fistulas. Further research is needed to better define its indications, to compare it to traditional treatments and to evaluate its long-term efficacy.

2020 World Society of Emergency Surgery updated guidelines for the diagnosis and treatment of acute calculus cholecystitis.

BACKGROUND: Acute calculus cholecystitis (ACC) has a high incidence in the general population. The presence of several areas of uncertainty, along with the availability of new evidence, prompted the current update of the 2016 WSES (World Society of Emergency Surgery) Guidelines on ACC. MATERIALS AND METHODS: The WSES president appointed four members as a scientific secretariat, four members as an organization committee and four members as a scientific committee, choosing them from the expert affiliates of WSES. Relevant key questions were constructed, and the task force produced drafts of each section based on the best scientific evidence from PubMed and EMBASE Library; recommendations were developed in order to answer these key questions. The quality of evidence and strength of recommendations were reviewed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria (see https://www.gradeworkinggroup.org/ ). All the statements were presented, discussed and voted upon during the Consensus Conference at the 6th World Congress of the World Society of Emergency Surgery held in Nijmegen (NL) in May 2019. A revised version of the statements was voted upon via an online questionnaire until consensus was reached. RESULTS: The pivotal role of surgery is confirmed, including in high-risk patients. When compared with the WSES 2016 guidelines, the role of gallbladder drainage is reduced, despite the considerable technical improvements available. Early laparoscopic cholecystectomy (ELC) should be the standard of care whenever possible, even in subgroups of patients who are considered fragile, such as the elderly; those with cardiac disease, renal disease and cirrhosis; or those who are generally at high risk for surgery. Subtotal cholecystectomy is safe and represents a valuable option in cases of difficult gallbladder removal. CONCLUSIONS, KNOWLEDGE GAPS AND RESEARCH RECOMMENDATIONS: ELC has a central role in the management of patients with ACC. The value of surgical treatment for high-risk patients should lead to a distinction between high-risk patients and patients who are not suitable for surgery. Further evidence on the role of clinical judgement and the use of clinical scores as adjunctive tools to guide treatment of high-risk patients and patients who are not suitable for surgery is required. The development of local policies for safe laparoscopic cholecystectomy is recommended.

The association of KRAS mutation with primary tumor location and survival in patients undergoing resection of colorectal cancers and synchronous liver metastases.

BACKGROUND: Recent evidence suggests that a mutation in the KRAS gene has a significant impact on the clinical behavior and prognosis of patients with metastatic colorectal cancer. The KRAS mutation (m-KRAS) has been associated with decreased survival among patient undergoing treatment with a curative and palliative intent. This is believed to be secondary to a reduced response to anti-EGFR chemotherapy agents and a more intrinsically aggressive biology. The aims of this study were to identify risk factors for m-KRAS in patients with curatively resected colorectal cancer and synchronous liver metastases and to assess its association with disease-specific survival (DSS). METHODS: The Surveillance, Epidemiology and End Results (SEER) Database was surveyed for patients undergoing resection of colorectal cancer and synchronous liver metastases from 2010 to 2015. RESULTS: A total of 806 patients were included, of which 40% hadm-KRAS. Right-sided primary lesions (OR 2.56, 95% CI: 1.90-3.44, P<0.001) and African-American ethnicity (OR 1.58, 95% CI: 1.05-2.40, P=0.03) were independently associated with m-KRAS on multivariable analysis. Compared to wild-type KRAS (wt-KRAS), m-KRAS was associated with decreased 3- and 5-year DSS (59% vs. 50% and 29% vs. 21%, respectively, P=0.024). After adjusting for confounders, a decreased DSS was observed in patients with right-sided lesions (HR 1.68, 95% CI: 1.32-2.12, P<0.001), while m-KRAS was associated with a trend toward decreased DSS (HR 1.15, 95% CI: 0.91-1.46, P=0.24). CONCLUSIONS: In patients undergoing surgical resection of colorectal cancer and synchronous liver metastases, m-KRAS was associated with right-sided lesions and African-American ethnicity. Compared to wt-KRAS, m-KRAS was associated with a reduced DSS. Additionally, right-sided lesions were an independent negative prognostic factor for DSS.

Tension hemothorax due to iatrogenic subclavian artery perforation: Hybrid management of a very rare complication.

BACKGROUND: Tension hemothorax is a rare event, due to different causes: trauma, ruptured thoracic aorta aneurysms, or as a complication of central venous line placement due to inadvertent artery puncture or cannulation. Tension hemothorax leads to both hypovolemic and obstructive shock and can require emergency management. PRESENTATION OF CASE: A 63 years old lady underwent a complicated surgical procedure for a postoperative small bowel obstruction after radical cystectomy. During the procedure, a central venous catheter was placed, under ultrasound guidance, in the right jugular vein but an unknown puncture of the right subclavian artery occurred. In the early phase of the postoperative course, a hypovolemic/obstructive shock developed because of a tension hemothorax. The patient underwent an emergency thoracotomy in the hybrid room, followed by an endovascular repair of the arterial laceration. A recurrent hemothorax developed a few hours later because of an endoleak that was treated successfully with a second endovascular approach and a balloon dilatation of the stent. CONCLUSIONS: tension hemothorax due to inadvertent subclavian artery laceration can be life-threatening and should be managed in a hybrid room with endovascular and surgical capabilities.