Ethical Issues in the Use of Suboptimal Kidneys for Transplants: An Italian Point of View.

The shortage of organs leads to the need for utilizing suboptimal kidneys for transplantation. The distinction between optimal, marginal, and suboptimal kidneys leads surgeons to face not only technical problems but also ethical and legal issues related to clinical advantages offered by the transplant of a nonstandard kidney and the acquisition of consent. Between 1999 and 2015, we performed 658 transplants, 49 (7.5%) using suboptimal kidneys. All patients were alive and with vital graft throughout follow-up. We did not encounter any major surgical complications. From a technical point of view, our experience and literature review confirm that transplant of suboptimal kidney leads to good clinical results but exposes patients to a increased risks of surgical complications. Therefore, these interventions must take place in hospitals fully prepared for this type of surgery and performed by experienced transplant surgeons with proper matching between organ and recipient. Considering the insufficient resources available, from an ethical and legal point of view, doctors play an essential role in optimizing the use of these kidneys by avoiding wastage of organs, ensuring that transplants are done in suitable patients, and that patients are fully informed and aware of the risks and benefits associated with the specific suboptimal kidney being transplanted. We believe that, in highly specialized centers, the number of suboptimal kidney transplants should be increased, as their use has shown good clinical results and carries fewer ethical issues compared with marginal kidneys. Further, suboptimal kidneys may also be proposed for use in young patients with end-stage renal disease.

Our Timing to Remove Peritoneal Catheter Dialysis After Kidney Transplant.

BACKGROUND: Patients on peritoneal dialysis treatment represent 15% of the global dialysis population. The major complication of peritoneal dialysis is catheter and peritoneal infection. Peritoneal dialysis patients who receive kidney transplants are at increased risk of infection because of immunosuppressive therapy. AIM: The purpose of this study is to show our ideal timing to remove peritoneal catheter after kidney transplant, which gives adequate security on renal function recovery and reduction of septic risk. METHOD OF STUDY: We analyzed the outcomes of 65 patients on peritoneal dialysis who underwent kidney transplant between 2000 and 2016. RESULTS: In 61 cases there was an immediate graft functional recovery. In 4 cases there was a delayed graft function (DGF), and we performed a hemodialysis with temporary placement of a venous catheter. In all patients we removed peritoneal dialysis catheter 30 to 45 days after transplant. There has been 1 case of catheter infection, which was treated with antibiotic therapy. DISCUSSION: Our average time to remove the peritoneal dialysis catheter was shorter than times in previous studies, between the 30th and 45th postoperative day. In the 4 cases in which there has been a DGF, we performed hemodialysis treatment to avoid, in the immediate postoperative period, direct insults to the peritoneum by local dialysis procedures. CONCLUSION: Our experience show that the 30th to 45th postoperative day is a good time frame, better yet a good watershed between the safe removal of peritoneal catheter when patients have a stabilized renal function and the possibility of leaving it in situ, to resume peritoneal dialysis in case of persistent DGF.

[Functional results of colorectal and coloanal anastomosis with and without pouch]. / Considerazioni sui risultati funzionali delle anastomosi colorettali e coloanali con e senza pouch.

In the last two decades one of the main targets of anorectocolonic surgery has been to develop sphincter saving procedure able to achieve good results with acceptable five-years survivals, optimal local control of the diseases and low rate of local cancer recurrence. Partially the development of new operative techniques such as low colorectal and coloanal anastomoses with or without pouch, the TME operation and the nerve sparing procedure have reach this target. In fact, often after these operations we can observe a functional syndrome called "Post Anterior Resection Syndrome". The basis of this syndrome have to researched in anatomical and physiological alterations that followed a reconstructive operation. It is characterized by frequency and fragmentation of the stool, feeling of incomplete evacuation, tenesmus and urgency. Fecal continence may be compromised to different levels: usually with alteration limited to soiling and impaired control of flatus, occasionally with loss of liquid stool, rarely with loss of solid stools. The anorectal function will be altered for long time following the surgical procedure and the stabilization of functional results may require 1-3 years. On the basis of these considerations, the authors examine the etiopathogenesis and clinical presentation of the "Post Anterior Resection Syndrome", suggesting some expedients to prevent the functional problems. Analysing our experience and a wide specific bibliography, they also underline the indispensable point to achieve a good functional results after a reconstructive procedure. The author conclude asserting that the absence of these points have to be carefully valued because, in these situations, a simply colostomy is able to guarantee a better quality of life that a colorectal/coloanal anastomoses with or without pouch but associated to functional problems.

Cystic dilation of extrahepatic bile ducts in adulthood: diagnosis, surgical treatment and long-term results.

To evaluate the long-term results of surgery for choledohal cyst in adulthood, a series of 13 patients over the age of 16 operated on for choledochal cyst during a period of six years and followed-up for a minimum of 3 years was analyzed. Patients with type I and IVa cysts underwent extrahepatic cyst resection and Roux-en-Y hepatico-jejunostomy. Choledochoceles (type III) were managed endoscopically. No operative mortality or morbidity occurred. Type I and III cysts showed almost ideal follow-up with no sign of stricture on HIDA scan. One type IVa cyst patients developed recurrent cholangitis due to anastomotic stricture, managed percutaneously. Whenever possible, complete cyst resection and Roux-en-Y reconstruction is the treatment of choice for all extrahepatic biliary cysts. Intra- and extrahepatic dilatations are adequately treated by extrahepatic resection and careful endoscopic or radiologic surveillance. Small choledochoceles can be safely managed by endoscopic sphincterotomy.

Pelvic recurrence following resection of rectal cancer: a multivariate predictive model.

Local recurrence of rectal cancer (LR) after "curative" surgery is a major clinical problem, with a low resectability rate and a dismal prognosis. Prediction of LR might permit more targeted postoperative surveillance with earlier diagnosis of recurrent disease and might help in selecting the patients to be assigned to the most suitable adjuvant treatment protocol. To evaluate if a simple multivariate model could predict the LR and survival probability in the single case, we retrospectively evaluated 118 consecutive patients (63 males, 55 females; mean age 62 +/- 12 years) operated on for rectal cancer and followed up for a minimum of 4 years (range 51-111 months). Local recurrence rate was 28%, with a 6% of local + distant failure. Age and sex of patients, type of surgery, location of tumour in the rectum, size, morphology and grading of the tumour were all unrelated to the event under investigation. At Cox regression, the Dukes' stage and the postoperative radiotherapy were the only independent prognostic factors for LR (p < 0.001). The multivariate model was able to correctly reclassify the patients and predict local recurrence in 86.2% of the cases. Prevention of LR by adequate surgery and adjuvant therapy as well as its early detection offer the best prospect of improving the results of surgery for rectal cancer.

Transanal excision and postoperative radiation therapy in selected patients with cancer of the low rectum.

Preliminary results of 24 patients (15 males, 9 females; age range 30-81 years) with localized low rectal cancer treated with transanal excision and postoperative radiation therapy are reported. Preoperative endosonographic staging was T1 (10), T2a (12) and T2b (2). All had negative resection margins, except one patient who underwent salvage major resection (no tumor found in the specimen). The mean follow-up was 33 months (range 29-61 months). Twenty patients (83.3%) are alive with no sign of local or distant failure. Two patients (9%) developed a local recurrence and were both salvaged with major surgery. Operative and radiotherapy-related morbidity was minor, with diarrhoea and perianal discomfort occurring in most patients following irradiation. Long-term sphincter function was satisfactory in 90% of cases. Rectal endosonography provided a reliable preoperative staging of T (100% correlation with histology) and, indirectly, N parameter, appearing as the key investigation in selecting candidates for conservative treatment. Postoperative radiotherapy might also be proposed after excision of T1 cancers as it produced few side effects and has the potential to control any residual disease. Additional experience is needed to determine long-term results of this combined radiosurgical approach.

Impact of computed tomography vs. intrarectal ultrasound on the diagnosis, resectability, and prognosis of locally recurrent rectal cancer.

The use of modern techniques of imaging in the postoperative follow-up is reported to allow an earlier diagnosis of local recurrence in patients operated on with anterior resection for rectal cancer and, consequently, to allow a higher percentage of local recurrence resection to be performed. Although intrarectal ultrasound (IU) has proved highly reliable in preoperative staging, its value in relapse detection has been investigated only in retrospective studies and rarely compared with that of computed tomography (CT). The present prospective study aims at evaluating the role of IU vs. CT in the diagnosis of local recurrence and at verifying whether an earlier diagnosis and a higher resectability rate of recurrence result in an acceptable long-term survival. Thirty-seven patients who had undergone low and ultralow anterior resection for rectal cancer (anastomosis within 10 cm of the anal verge) were investigated prospectively. All the patients have been followed up by IU and CT at predetermined intervals. Six local recurrences were detected. CT correctly identified all the local recurrences (sensitivity = 100 percent, specificity = 93 percent, and accuracy = 94.5 percent); IU correctly identified only four of six local recurrences (sensitivity = 66.6 percent, specificity = 93 percent, and accuracy = 89 percent). Four patients with local recurrence underwent surgical treatment (resectability rate = 66.6 percent). Abdominoperineal resection in three patients and Hartmann's procedure in one patient were performed. In the other two patients, extensive metastatic liver involvements contraindicated surgery. All the resected patients were alive after one year; two of them are disease free, and the other two experienced recurrent disease. In conclusion, CT seems to have a higher sensitivity and accuracy in relapse detection. The increase in the local recurrence resectability rate does not result in a significant improvement in long-term survival. However, the good quality of life justifies the high cost of an intensive follow-up and a more aggressive surgical approach.

Severe hemorrhage associated with pancreatic pseudocysts: report of two cases.

Severe hemorrhage from pancreatic pseudocysts is a rare condition that poses a diagnostic and therapeutic challenge. Two cases of preoperative intracystic bleeding and massive postoperative gastrointestinal hemorrhage observed during the last year form the basis of the present report. In the first patient, transcystic suture ligation of the bleeding vessel was necessary to control this life-threatening and dramatic condition--External drainage of the cyst was followed by an uneventful postoperative course. In the second patient, massive gastrointestinal bleeding occurred after cysto-gastrostomy, and neither endoscopy nor arteriography was able to identify the source. Despite aggressive medical and surgical therapy, the patient died. Massive intracystic or gastrointestinal hemorrhage caused by rupture of pseudoaneurysms into pancreatic pseudocysts still remains a rare but severe condition, difficult to treat and affected by high mortality rates. Angiography should be performed routinely in the preoperative assessment of pancreatic pseudocysts, even when the other diagnostic techniques do not raise the suspicion of pseudoaneurysm formation. After internal drainage procedures early surgery is recommended whenever GI bleeding occurs in the postoperative course.

Biliary bypass for an "accessory" biliary duct. A case report.

A case of accessory biliary duct draining segments V and VI of the liver, accidentally injured during cholecystectomy and repaired by biliary-enteric anastomosis, is reported. An accessory bile duct may occur in 15-20% of these patients. Ligation or repair is always recommended depending on the size and volume of bile flow. Roux-en-Y loop reconstruction is to be preferred as it provides the best results with the lowest risk of leakage, stenosis and cholangitis.

HIDA scan in the follow-up of biliary-enteric anastomoses.

In order to assess the patency and function of biliary-enteric anastomoses performed in our Department of Surgery, 21 patients entered the following study, provided an informed consent was obtained. All the patients were affected by benign biliary tract diseases and underwent either Roux-en-Y hepaticojejunostomy (11 cases), or side-to-side choledochoduodenostomy (10 cases). The 21 patients were evaluated with Tc-99m-HIDA scanning at intervals of 20 days-36 months after the surgical procedure (mean 14 months). The images were obtained after intravenous injection of the radioactive medium (5 mCi) and the scans were taken at 1 min (1 frame/s), 3 min (1 frame/10 s), and 56 min (1 frame/2 min). THe data were analyzed by a Digital PDP 11/34 Computer System. This method allowed us to assess each individual patient for the patency of the anastomosis and, by computer analysis, to build up a profile of the timing of the passage of the radioactive medium through the anastomosis, a delayed passage across the anastomosis was always pathological. In conclusion, the 99m-Tc-HIDA scanning used in our study for long-term follow-up of biliary-enteric anastomoses is reliable and allows an assessment of prognosis.

Sexual function after resection for rectal cancer.

Major rectal operation, that is, abdominoperineal or anterior resection, for cancer frequently damages the autonomic pelvic nerve supply with resultant sexual dysfunction. The anatomic characteristics and function of the autonomic nervous system in the pelvis has been reviewed. Sexual function after rectal excision for cancer was studied in 25 male patients who were less than 60 years of age and exhibited normal sexual activity preoperatively. Of nine patients who had abdominoperineal resection, four were impotent and two reported no ejaculation with normal potency postoperatively. Of 4 patients who had high anterior resection, only 1 reported no ejaculation, whereas of 12 patients with low anterior resection, 4 were impotent and 3 reported no ejaculation. A higher incidence of sexual dysfunction was noted after abdominoperineal resection compared with after anterior resection (66 percent and 50 percent, respectively). However, the incidence after low and very low anterior resection was comparable with that after abdominoperineal resection (58 percent and 66 percent, respectively). Advanced patient age and very low resection were the two main factors effecting sexual dysfunction after major rectal operation. Although we believe that careful operative technique might reduce the incidence of sexual disturbances attributable to sympathetic fiber damage, avoidance of parasympathetic damage during operation cannot be accomplished because the most likely site of injury, namely the periprostatic plexus, is usually within the operative field, the exception being cases in which the tumor is small, thus allowing preservation of the rectoprostatic fascia.

Role of ileorectal anastomosis in the treatment of ulcerative colitis and familial polyposis.

A 25-year experience with 109 patients treated with ileorectal anastomosis over 147 patients observed for ulcerative colitis and 25 patients undergoing the same surgical procedure for familial polyposis, is reported. Excellent functional results were obtained, associated to satisfactory ones with respect to inflammatory recurrence and cancer development in the rectal stump. Of 86 patients with ulcerative colitis who were followed-up, only 7 (8.1%) required proctectomy at long-term for a severe inflammatory recurrence, and 4 (4.6%) have developed a cancer in the following 3 to 20 years. Of the 17 followed-up patients, over the 25 operated for familial polyposis, only 1 (5.8%) has developed a cancer between 3 and 20 years. It is concluded that ileorectal anastomosis with a close follow-up still plays a major role because is an easier surgical procedure as compared to ileoanal anastomosis, with excellent functional results, a shorter hospitalization and mainly a lower number of severe complications, which are presently burdening the results of ileoanal anastomosis.

Surgical treatment of chronic pancreatitis.

To contribute to the solution of the problems related to the treatment of chronic pancreatitis, a retrospective study was carried out on 60 cases of chronic pancreatitis treated by surgery over a period of 20 years. On the basis of the obtained results, it is believed that the derivative procedures are more likely to be successful in the treatment of the disease. Pancreaticojejunostomy according to Puestow should be the procedure of choice, since it shows a lower pre-and postoperative risk while preserving the endocrine and exocrine function of the organ.

Intrarectal ultrasound and computed tomography in the pre- and postoperative assessment of patients with rectal cancer.

The ability of intrarectal ultrasound to recognize the local extent of disease was investigated in 23 patients with histologically proven adenocarcinoma of the lower two-thirds of the rectum before operation. Two probes, 12 cm long, working at a frequency of 3.5 and 7.5 MHz, were used. The results were compared with those of pre-operative computed tomography (CT) and with the pathological report of the resected specimens. Sonography correctly staged 20 of 23 tumours with two false negatives and one false positive, while CT correctly staged 19 of 23 tumours with two false negatives and two false positives. The results of ultrasound were found to be as accurate as those of CT; the low cost and simple use of ultrasound makes it preferable in the pre-operative assessment of the depth of invasion of rectal cancer. In addition, intrarectal ultrasound was routinely performed in 42 patients, operated on for rectal cancer by means of sphincter-saving procedures, at variable intervals in the first 2 years postoperatively. Eight local recurrences were recognized and confirmed by CT. Based on the low cost, reliability and simple use, intrarectal ultrasound is proposed as first examination for local recurrence detection in the follow-up of patients with low anterior resection for rectal cancer.

A study of the pathology of the crush syndrome.

Subsequent to the earthquake which occurred in Southern Italy in November 1980, 19 patients were admitted to the University of Naples--II Medical School with crush syndrome. Clinical and biochemical studies were carried out in eight of them. The most interesting observation was the inconstant relation between the type of lesion and the clinical course, leading to the assumption of two diverse physiopathologic mechanisms--one for crush and the other for compression. The timely recognition of the two syndromes is difficult; an elevated creatine-creatinine ratio has been found in those patients with an irreversible crush syndrome. We believe this to be the only element which would permit a prompt distinction between the two pathologic states and which would provide an indication for early, life-saving amputation.