Bowel obstruction and peritoneal carcinomatosis in the elderly. A systematic review.

BACKGROUND: There are not guidelines for surgical management of malignant bowel obstruction (MBO) caused by peritoneal carcinomatosis (PC), mainly when it involves elderly; so its treatment is still debated. AIM: To outline indications and benefits of palliative surgery for obstructive carcinomatosis and determine what prognostic factors, including age, have independent and significant association with outcome. METHODS: We conducted English-language MEDLINE and EMBASE searches of articles published between 1998 and 2016, which reported outcome data after palliative surgery for MBO due to PC. We excluded all articles lacking of surgical cohort and those with main interest in conservative treatment. Of 1275 articles identified, 12 satisfied selection criteria and were included in our analysis. RESULTS: Overall, these studies involved 548 patients undergoing palliative surgery for MBO caused by PC. The median age was 58 (range 19-93). Relief of symptoms was achieved in 26.5-100% of cases. Postoperative morbidity ranged between 7 and 44%. Mortality was high (6-22%). The median survival was longer in surgical patients than in those receiving conservative therapy (8-34 vs 4-5 weeks). Factors associated with surgery failure were poor performance status, diffuse carcinomatosis, previous radiotherapy, and obstruction of small bowel. Old age was significantly associated with a poor prognosis upon univariate analysis, while this association vanished upon multivariate analysis. CONCLUSIONS: Surgical palliation can provide relief of obstructive symptoms as well as improved survival in well-selected patients, even if elderly.

R0 surgical resection of giant dedifferentiated retroperitoneal liposarcomas in the COVID era with and without nephrectomy: A case report.

Retroperitoneal sarcomas (RPSs) are rare findings that can grow into large masses without eliciting severe symptoms. At present, surgical resection is the only radical therapy, whenever it can be performed with the aim to achieve a complete removal of the tumor. The present report describes two consecutive cases of RPSs that resulted in dedifferentiated liposarcomas (DDLPSs) and these patients underwent R0 surgical resection with and without a nephron-sparing procedure. The diagnostic workup, the surgical approach, the impact of late surgical management due to the COVID pandemic and the latest literature on the topic are discussed and analyzed. The patients, who refused to undergo any medical examination during the prior 2 years due to the COVID pandemic, were admitted to Federico II University Hospital (Naples, Italy) complaining about weight loss and general abdominal discomfort. In the first case, a primitive giant abdominal right neoplasm of retroperitoneal origin enveloping and medializing the right kidney was observed. The second patient had a similar primitive retroperitoneal giant left neoplasm, which did not affect the kidney. Given the characteristics of the masses and the absence of distant metastases, after a multidisciplinary discussion, radical surgical removal was carried out for both patients. The lesions appeared well-defined from the surrounding tissues, and markedly compressed all the adjacent organs, without signs of infiltration. In the first patient, the right kidney was surrounded and undetachable from the tumor and it was removed en bloc with the mass. The second patient benefited from a nephron-sparing resection, due to the existence of a clear cleavage plane. The postoperative courses were uneventful. Both the histological examinations were oriented towards a DDLPS and both patients benefited from adjuvant chemotherapy. In conclusion, the treatment of giant RPS is still challenging and requires multidisciplinary treatment as well as, when possible, radical surgical removal. The lack of tissue infiltration and the avoidance of excision or reconstruction of major organs (including the kidney) could lead to an easier postoperative course and an improved prognosis. When possible, surgical management of recurrences or incompletely resected masses must be pursued. Since the COVID pandemic caused limited medicalization of a number of population groups and delayed diagnosis of other oncologic diseases, an increased number of DDLPSs could be expected in the near future.

Relation Between Wound Complication and Lymphocele After Kidney Transplantation: A Monocentric Study.

INTRODUCTION: Wound complication frequently arises after kidney transplantation and its risk factors are well known. In a previous paper we analyzed these factors, and in this new retrospective study we evaluate the influence of lymphocele in the development of wound complications. PATIENTS AND METHODS: From January 2000 to December 2018, 731 consecutive kidney transplants have been performed in our center. We have analyzed the incidence of wound complication and lymphocele and their risk factors. RESULTS: Out of 731 kidney transplants, we have observed wound complications in 115 patients (15.7%) and lymphocele in 158 patients (21.7%). Of these, 70 patients developed both complications (9.5%), but 6 patients have been excluded because they were in therapy with mammalian target of rapamycin inhibitors. Twenty-nine patients (45.3%) presented a first level and 35 patients (54.7%) showed second level wound complications. Lymphocele was the only present factor in just 3 cases (4.6%). The other patients showed diabetes in 28 cases (43.7%), overweight/obesity in 38 (59.3%), delayed graft function in 17 (26.5%), and 60 years or more in 38 (57.8%). The association has been found in 30 out 64 patients treated with tacrolimus (46.8%) and in 34 with cyclosporine (53.1%); 40 patients did not receive muscular layer's reconstruction (62.5%). CONCLUSION: Our experience shows that lymphocele alone is not a predisposing factor for wound dehiscence after kidney transplantation, and they often coexist because they share the same risk factors, the most important being obesity, diabetes and delayed graft function, older age, and surgical techniques. No relation has been observed with calcineurin inhibitor therapy.

COVID-19 and Living Donor Kidney Transplantation in Naples during the Pandemic.

INTRODUCTION: SARS-CoV-2 is a virus that causes a potentially deadly syndrome that affects especially the respiratory tract. Kidney-transplanted patients are immunosuppressed and more susceptible to viral infections. We have examined our transplantation activity to explore the future role of kidney transplantation from deceased and living donors in COVID-19 era. Patients and Methods. The activity of our transplant center of Naples (one of the two transplant centers in Campania, South Italy) continued during the COVID-19 pandemic. We have analysed the kidney transplants carried out between March 9 and June 9, 2020, comparing these data with the numbers of procedures performed in the two previous years. Moreover, we have considered the possibility of performing living donor transplants during a worldwide pandemic. RESULTS: From March 9, 2020, when the Italian lockdown begun, till June 9, 2020, five kidney transplants have been performed at our transplant center in Naples, all from deceased donors. The donors and the recipients have been screened for COVID-19 infection, and the patients, all asymptomatic, followed strict preventive measures and were fully informed about the risks of surgery and immunosuppression during a pandemic. All the transplanted patients remained COVID negative during the follow-up. The number of transplants performed has been constant compared to the same months of 2018 and 2019. In agreement with the patients, we decided to postpone living donor transplants to a period of greater control of the SARS-CoV-2 spread in Italy. CONCLUSION: Deceased donor kidney transplantation should continue, especially in a region with moderate risk, like Campania, with a more careful selection of donors and recipients, preferring standard donors and recipients without severe comorbidities. Living donor transplantation program, instead, should be postponed to a period of greater control of the SARS-CoV-2 spread, as it is an elective surgery and its delay does not determine additional risks for patients.

Is day-surgery laparoscopic cholecystectomy contraindicated in the elderly? Results from a retrospective study and literature review.

BACKGROUND AND AIM: Ideally, day-surgery laparoscopic cholecystectomy (DLC) combines patient satisfaction with cost-effectiveness. However, DLC has not yet been widely applied in the elderly. Thus, to challenge the current perception of DLC as a contraindication, several parameters were investigated for the feasibility of DLC within the general and elderly population. A retrospective study was conducted to analyse age, along with other relevant patient characteristics, as factors leading to successful 24-h discharge. METHODS: Data were collected from 207 patients who underwent laparoscopic cholecystectomy (LC) between 2010 and 2013. Of these patients, 154 were aged <75 years and 53 > 75 years, with a median age of 59.3 years. Comparisons of the length of post-surgical hospital stay were made. Further, the parameters influencing the surgeon's decision to discharge patients within a 24-h period were investigated: demographic data; patient characteristics such as age, sex and concomitant diseases; disease presentation; surgical experience; intraoperative complications; and post-operative course. The numbers of hospital readmissions and reoperations were established as parameters of failure. RESULTS: Forty-five (21.7%) patients remained hospitalized up to 24 h. The majority of them had no co-morbidities, low American Society of Anesthesiologists (ASA) grades, adenomas and uncomplicated gallstone disease. Eleven patients were aged >75 years. None of the patients died, whereas one patient was readmitted following DLC. CONSIDERATIONS: Age itself did not prove to be a contraindication for DLC. The patient's general health, disease presentation and the surgeon's attitude were the main factors favouring early discharge. Patient selection and patient-care facilities were crucial for successful outcomes. Some problems due to the logistical organization of the hospital and the surgical approach, which may impede DLC acceptance, are described herein.

The role of mutation analysis of the APC gene in the management of FAP patients. A controversial issue.

BACKGROUND: A correlation between the location of mutation in the adenomatous polyposis coli (APC) gene and clinical manifestations of familial adenomatous polyposis (FAP) has repeatedly been reported. Some Authors suggest the use of mutational analysis as a guide to select the best surgical option in FAP patients. However, data coming from studies on large series have raised questions on this issue. The aim of this study is to discuss the role of the genetic tests in the management of FAP. METHODS: A literature review was performed considering only peer-reviewed articles published between 1991-2015. All the studies examined the role of genetic as a guide for surgical management of FAP. RESULTS: Of 363 articles identified, 21 were selected for full-text review. We found different positions with regard the use of genetic tests to determine surgical management of FAP. In particular, while consistent correlations between the APC mutation site and FAP phenotype were observed in large series, 8 studies reported a wide variation of genotypephenotype correlation in patients with the same mutation and they recommended that decisions regarding surgical strategy should be based not only on genotype but also on the clinical factors and the will of the patient who must be fully informed. CONCLUSIONS: The decision on the type and the timing of surgery should be based on the assessment of many factors and genotype assessment should be used in combination with clinical data. KEY WORDS: Disease severity, Familial adenomatous polyposis, Genetic tests, Genotype-phenotype correlations, Surgical management.

A multidisciplinary approach to an unusual medical case of locally advanced gastric cancer: a case report.

INTRODUCTION: Complete abdominal wall infiltration with neoplastic gastrocutaneous fistula is an unexpected and out of the ordinary presentation of locally advanced gastric cancer. It is very rare to encounter case reports presenting diffuse abdominal wall invasion, but a complete parietal destruction is an exceptional event. CASE PRESENTATION: Here we describe the case of an 81-year-old Caucasian woman presenting a carcinoma perforating her anterior gastric wall and infiltrating all layers of her abdominal wall. The gastric tumor infiltrated her transverse mesocolon, the rectus abdominis muscles bilaterally and overran them anteriorly, causing a large parietal deficit and a complete external fistula. Treatment consisted of a complex surgical procedure requiring general and reconstructive surgery cooperation in order to perform an en bloc gastric resection including colon and abdominal wall, followed by a parietal reconstruction through positioning of prosthesis and reverse abdominoplasty. CONCLUSIONS: Clinical presentation, histology and therapeutic options are discussed. The importance of a multidisciplinary approach when encountering extremely rare clinical presentations is emphasized.

Immunosuppression and Multiple Primary Malignancies in Kidney-Transplanted Patients: A Single-Institute Study.

Immunodeficiency is associated with higher cancer incidence. However, it is unknown whether there is a link between immunodeficiency and development of multiple primary malignancies. In the present study we analyse this link focusing on kidney-transplanted patients, as they are at higher risk of developing cancer due to the chronic assumption of immunosuppressants. We followed up 1200 patients who underwent kidney transplantation between 1980 and 2012. A total of 77/1200 kidney-transplanted patients developed cancer and 24 of them developed multiple cancers. Most multiple cancers were synchronous with a nonsignificant association between cancer and rejection episodes. In the general cancer population, one-ninth of patients are at higher risk of developing a second tumor over a lifetime; hence it would be reasonable to conclude that, from a merely theoretical and statistical viewpoint, long-term transplanted patients potentially have a higher risk of developing MPMs. However, data did not confirm this assumption, probably because these patients die before a second primary malignancy appears. Despite many observations on the increased incidence of different tumor types in immunodeficient patients and despite immunosuppression certainly being a predisposing factor for the multicancer syndrome, data so far are not robust enough to justify a correlation between immunodeficiency and multiple primary malignancies in transplanted patients.

Multiple splenic hamartomas and familial adenomatous polyposis: a case report and review of the literature.

INTRODUCTION: Splenoma or splenic hamartoma is a rare primary splenic tumor most often discovered radiologically and incidentally. Splenic hamartomas have a strong association with solid and hematological malignancies and, in rare cases, with tuberous sclerosis, but to the best of our knowledge no reports of splenic hamartomas associated with familial adenomatous polyposis have been documented, although it is recognized that familial adenomatous polyposis presents a variety of extracolonic manifestations. CASE PRESENTATION: We report on a very rare case of multiple splenic hamartomas in a 46-year-old white woman who had previously undergone surgery for restorative proctocolectomy for familial adenomatous polyposis. A computed tomography scan of her spleen revealed multiple small lesions which measured less than 1cm in diameter. A splenectomy was performed and a histologic examination of the splenectomy specimen revealed the presence of multiple hamartomas. CONCLUSION: Incidence, differential diagnosis, diagnostic procedures, pathologic findings and treatment of splenic hamartomas are discussed here and hamartomas are considered in a differential diagnosis of splenic tumors. A splenectomy is indicated in cases where malignancy cannot be excluded and in cases of associated hematologic disorders. To the best of our knowledge our patient is the first reported case to have splenic hamartomas identified in a familial adenomatous polyposis-affected patient with mutation in exon 15 of the APC gene. At this time it is not possible to correlate with certainty our multiple splenic hamartomas and familial adenomatous polyposis case as a clinical manifestation of the mutation of APC gene; however, we believe that this case report could be important for further observation of similar cases in the future.

Rare multiple primary malignancies among surgical patients-a single surgical unit experience.

BACKGROUND: A remarkable number of patients presents with multiple primary malignancies (MPM) over their lifetimes. In most cases inherited syndromes, iatrogenic, or viral factors are implicated, while in some cases it is not possible to ascertain a clear aetiopathogenesis. METHODS: Starting from a series of 315 patients with MPM, we focused our attention on those with extremely infrequent combinations of tumours. We retrospectively analysed patients' characteristics, type of first and second tumour and the interval between the two tumours. We made a comparison between our own data and data from surveillance, epidemiology, and end results cancer registries, the largest global series on this topic. RESULTS: Six patients presented with unusual associations, namely, central nervous system (CNS)/colon, testis/stomach, colon/CNS, CNS/kidney, uterus/soft tissue, and bone/breast. The median age was 50.5 years at the diagnosis of second neoplasm and the male:female ratio was 1:1. All six patients underwent surgery for both tumours. The median interval between the first and the second tumour was 11.3 years (range 1-36 years). Five patients were given chemotherapy as adjuvant systemic treatment, and two of them with CNS tumours also received radiotherapy. DISCUSSION: We analysed the behaviour of these rare tumours as first and second neoplasms. More frequent combinations and possible aetiological factors were evaluated. CONCLUSIONS: Follow-up for patients recovering from a first tumour must be strict, as there is the risk of developing MPM, even after a long time period. Advancement in biomolecular knowledge and cooperation among different specialists are strongly needed to reduce mortality related to MPM and to foresee their occurrence.

Total colectomy for cancer: analysis of factors linked to patients' age.

Total colectomy (TC) is a valid option for cancer treatment in selected cases. Emergency presentation, association to familial adenomatous polyposis (FAP) or intestinal bowel disease (IBD), hereditary non-polyposis cancer (HNPCC), and synchronous tumors are the common indications to TC for cancer. Despite potential high morbidity and mortality rates for worse general health conditions of the advanced age it has even suggested for elderly patients. We reviewed our experience to analyze the current role of TC comparing different results between young and elderly patients. During the period 1990-2012, 76 patients were operated on TC for cancer. Patients were divided in two groups according to the age [<65 - group A (young) and >65 years old - group B (elderly)] and were compared their systemic and surgical complication, considering the presence of comorbidities, ASA score, lifestyle habits, elective or emergency presentation. Morbidity rate was 7.7% and 38.8% in young and elderly patients respectively. 21 systemic complications (3 in group A and 18 in group B) occurred in 17 patients (22.36%) (with the coexistence of two complications in 4 patients belonging to the group B. There were 6 surgical complications (7.9%) (3 in group A and 3 in group B): anastomotic leakage 3, major wound infections 2, postoperative bleeding 1; no intra-abdominal abscess were observed. In 2 cases (2.6%) (1 anastomotic leak and 1 intra-abdominal postoperative hemorrhage) was needed a reoperation. We observed only 2 deaths in the elderly. High ASA score and emergency were associated with worst results. Systemic complications were more frequent in elderly patients cause of significant comorbidities, while the incidence of surgical complications was similar and according to literature. Besides the classic indications, it is a viable surgical option also in cancer associated with complicated diverticulitis. Our data show that TC is a safe and effective procedure providing good results even in elderly patients, when combined with a careful preoperative evaluation and age is not an absolute controindication to this procedure.

Intraluminal migration of a surgical drain. Report of a very rare complication and literature review.

INTRODUCTION: Gastric or intestinal foreign bodies may cause heterogeneous symptoms ranging from asymptomatic conditions to chronic pain and, in some cases, occlusion and/or perforation. There are sporadic reports of intraluminal migration of medical devices. Most commonly they are sponges, hernia meshes, gastrotomy tubes, while surgical drains are very rarely reported. METHODS: A 79 year-old female who consulted our department in May 2009 for abdominal pain and constipation. Her symptomatology started in 2006 some months after an anterior resection for sigmoid diverticulitis associated to obstructed incisional hernia. The symptoms had begun a few months after the operation and were progressively increased month by month. An abdominal CT- scan showed the presence of an intra-peritoneal foreign body and at laparotomy a drain fragment was found inside a small bowel loop and pulled out through a small enterotomy. RESULTS: Post-operative course was regular and the patient was discharged at 7th day. DISCUSSION: The observation of this case and a literature review led us to analyze the origin and the clinical problems of this very rare complication. Incidence, symptomatology, diagnosis and treatment were analysed. CONCLUSIONS: The intraluminal migration of a surgical drain is very rare. The diagnosis is easy by abdominal plan radiogram or CT-scan, but it is casually achieved, because, as it almost always occurs in case of intra-peritoneal foreign bodies, the clinical suspicion is focused on other conditions that most frequently cause abdominal symptoms. When a foreign body is found in intraluminal position and its endoscopic removal is not feasible, then surgery is mandatory and resolutive.

Kidney transplantation and large anastomotic pseudoaneurysm. Transplant management considerations.

AIM: Pseudoaneurysm (PA) at the anastomosis site in kidney transplantation is a rare but serious complication that usually requires graft nephrectomy. Literature reports are sporadic and usually focused on limb rather than graft salvage. In this paper we focus on this last point. MATERIAL OF STUDY: 6 patients presenting large PA at the anastomosis between iliac and graft artery were identified in our series. The diagnosis was performed with US, AngioTC scan and angiography. Blood cultures and labeled leukocyte scintigraphy were also performed. All patients underwent open surgery. RESULTS: Transplant nephrectomy was needed in all cases except one, in which it was possible to perform a graft replanting on hypogastric artery. Our perioperative mortality and morbidity rate was recorded. DISCUSSION: Etiology of PA is multifactorial, however an association with chronic rejection or infection must be also considered. Our mortality and morbidity rates are in accordance to literature. In our experience we observed only large PA so to require an open surgery but this approach has allowed the rescue of graft functioning just in a single case. Endovascular procedures are linked to higher rate of graft salvage than surgery but they can be used just in selected cases. CONCLUSIONS: Our experience and literature review led us to believe that the rate of graft salvage in patients with large PA at anastomosis site could be improved only by a planned therapeutic program that includes surgical and endovascular approach, taking the advantages of both technique and overcoming their limits.