Cost analysis of living donor liver transplantation: the first Italian economical data.

BACKGROUND: Over a period of 30 months, the Niguarda Ca'Granda Hospital performed 12 living donor liver transplants (LDLT) on adult subjects using the split-liver technique and transplant of the right lobe. The purpose of this work is to evaluate the financial obligation that this technique will bring, the ethical and cultural aspects, and the mortality related to surgery on a healthy donor whose only reward is in the knowledge of having done everything possible for a loved family member. METHODS: The analysis of the costs of the surgical process takes into account the simultaneous consideration of both types of patients: the donor and the recipient. The diagnostic course is subdivided into seven functional phases of the cost centers, and the transitory sequences of the foreseeable events of the entire process. The method used consists in the appraisal of all the clinical activities in chronological order several the centers of cost. The direct expenses are evaluated according to an analytical method, and the indirect costs has been carried out on the criterion of the activities of support to the process (management of the orders, recording and programming of the activities) and support to the organization (maintenance, management supplying and contests of contract, programming of the business production, management warehouses, supplyings, marketing and relations with the public). RESULTS: The cost of all the patients evaluated that were not able to donate has been added to the direct expenses of 12 donor and 12 recipient patients, in all 30 patients, so as to shift the added expenses only to the donor patient, since these costs are not included in the typical costs of transplantation from a cadaver. The indirect cost calculated for each patient has been added to the direct costs of the donor and recipient patients. The total calculated cost of LDLT is 175, 210.78 Euros. CONCLUSION: The analysis of the economical obligation that this practice brings is the starting point for an accurate evaluation of all the new technology that, in conjunction with the results of clinical efficacy and efficiency trials, is part of program of a larger scope to fulfil the general social principles of equity and justice.

Early and late residual renal function and surgical complications in living donors: a 15-year experience at a single institution.

Living donation in the field of renal transplantation has increased over time as well as the use of laparoscopic nephrectomy. We present a 15-year experience on 162 living donors (105 women, 57 men; mean age, 46.7 years; range, 31-74 years) who underwent nephrectomy using different surgical approaches as open lombotomic nephrectomy (OLN), open transperitoneal nephrectomy (OTN), and laparoscopic hand-assisted nephrectomy (LHAN). We collected data on residual donor and recipient renal function, as well as early versus late medical and surgical complications. With a mean follow-up of about 8 years, we observed normal residual renal function in all donors and similar results of early and late graft function independent of the surgical procedure. Long-term incidence of hypertension and noninsulin-dependent diabetes in living donors was similar to the general population. OLN and OTN donors showed higher incidences of early and late complications, readmissions, and reoperations than LHAN donors. Our results confirmed that living donor nephrectomy is a safe procedure without serious side effects in terms of renal function and long-term quality of life. LHAN should be the preferred technique because of a lower incidence of early and late complications.

Pancreas retransplantation: ideal timing and early and late results.

Surgical complications are the leading cause of pancreatic graft loss among diabetic patients who undergo pancreas transplantation alone (PTA), or combined with kidney transplantations (PK) or after kidney transplantations (PAK). Therapeutic effects on secondary complications of diabetes justify pancreas retransplantation (re-PT) when the first graft is lost. However, the appropriate timing for retransplant and related problems is not known. We present our initial experience on re-PT performed on seven diabetic patients who lost their first pancreas grafts (PK) due to surgical complications (venous thrombosis in five and enteric fistula in two). Five re-PT were performed a few days after the first PT without a second course of induction therapy, while two patients received re-PT some months later with reinduction therapy. In the early re-PT group, one patient died some hours after the second surgical procedure due to pulmonary embolism, while four patients lost their second grafts due to accelerated rejection within 2 years from re-PT. In the late re-PT group, both patients have good graft function without signs of rejection. Our initial experience showed discouraging results in the group of early re-PT, due to accelerated rejection episodes leading to a high incidence of graft loss. Late re-PT accompanied by reinduction therapy seemed to have better results.

Laparosopic hand-assisted living donor nephrectomy: the Niguarda experience.

Perioperative donor morbidity, a barrier to living organ donation, may be mitigated by the laparoscopic approach. From September 2002 to September 2004, 15 living donors, of ages ranging from 36 to 59 years, underwent laparoscopic nephrectomy. We used a hand-assisted device to increase the safety of the procedure. The average operating time was 200 minutes. The average blood loss was about 100 mL. The patients resumed oral intake and started walking within 1 day. The average postoperative hospital stay was 6 days. Although laparoscopic operating times were longer than those for traditional surgery, we showed benefits to the laparoscopic donor to be less postoperative pain, better cosmesis, shorter recovery time, and faster return to normal activities. We therefore consider laparoscopic nephrectomy a good alternative to traditional surgery for selected patients. Despite a lack of strong evidence, such as large prospective randomized studies, laparoscopic donor nephrectomy is likely to become the gold standard for donor nephrectomy in the near future.

Advantages of short-time ureteric stenting for prevention of urological complications in kidney transplantation: an 18-year experience.

We retrospectively studied the incidence of urological complications in a consecutive series of 590 patients (group B) who received a kidney transplant (KT) with a ureteral stent from January 1994 to December 2002. The ureteral stent was sewn to the bladder catheter during the surgical procedure and left in situ for a mean time of 10 days (range 8 to 12 days). The results were compared to a consecutive series of 414 patients who received a KT from March 1986 to December 1993 without a ureteral stent (group A). The two groups were comparable in terms of donor and recipient gender, ischemia time, delayed graft function, and chronic rejection incidence, but differed in mean donor age (44.1 vs 36.0 years), mean recipient age (45.4 vs 39.1 years), living/cadaveric donor rate (19.8% vs 11.9%), arterial lesions and bench reconstruction rate (11.1 vs 3.5%), as well as acute rejection episodes (11.7% vs 29.2%). Complications were seen in nine patients in group B (1.5%) and 17 patients in group A (4.1%) (P < .0001). Urinary leaks presented in two patients in group B (0.3%) and 11 patients in Group A (2.6%; P < .0001), while stenosis was present in six patients in group B (1.5%) and 7 in group A (1.2%) (P = NS). Urological complications such as urinary tract infection and macroscopic hematuria were similar in both groups. Time to presentation of a leak was within 2 weeks from KT in 10 patients (92.3%), while stenosis presented early in four patients (one in group B and four in group A). Of the stenoses, 69.3% presented late (beyond 12 weeks) in five patients in group B and three in Group A. In conclusion, our data suggest that routine use of double pigtail ureteral stent significantly decreased the incidence of leaks and early stenoses, but it did not modify late stenosis incidence. In the last decade, risk factors for urological complications have been increasing over time, namely, older donors and older recipients, living donation, length of dialysis, and the use of grafts with arterial lesions. Therefore we believe that a ureteral stent should be routinely considered to afford the advantage to protect the urinary anastomosis in the early postoperative period when the incidence of complications is highest, without the need of cystoscopy for its removal.

[Acute biliary pancreatitis. Therapeutic trends]. / La pancreatite biliare acuta. Nostro orientamento terapeutico.

BACKGROUND: Treatment of biliary pancreatitis includes suppression of the biliary cause by cholecystectomy and common bile duct clearance. Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy for eradication of biliary stones and laparoscopic cholecystectomy (L.C.) for residual gallbladder stones would be ideal but were once considered to be contraindicated by most surgeons. The timing of definitive biliary tract surgery and the role of ERCP have been the focus of discussion in recent years. METHODS: During a two-year study period 51 patients with acute biliary pancreatitis were studied. Seven patients (14%) underwent emergency laparotomy, necrosectomy, cholecystectomy, exploration of the common bile duct and T-tube insertion, because unstable clinical conditions, with evidence of pancreatic and peripancreatic necrosis on CT-scan. Elective open cholecystectomy and CBD exploration were performed in 7 patients after the resolution of acute pancreatitis during the same hospital admission. RESULTS: Early ERCP and L.C. were associated with favourable outcomes. 33 patients underwent ERCP preoperatively: 17 within 72 hours of admission and 16 after signs of clinical improvement. Laparoscopic cholecystectomy performed 3-25 days after admission was successful in 27 of 29 patients. Postsphincterectomy bleeding occurred in one patient and was treated successfully by endoscopic epinephrine injection. For median hospital stay and recurrence there were statistical differences between early and delayed ERCP. CONCLUSIONS: ERCP and sphincterectomy have a certain role in conjunction with laparoscopic cholecystectomy in the management of patients with acute biliary pancreatitis, particularly in institutions where there is easy access to expert interventional endoscopic techniques. This policy should reduce the risk of cholangitis and recurrent pancreatitis.

Hepatic adenoma and focal nodular hyperplasia: diagnosis and criteria for treatment.

UNLABELLED: Focal nodular hyperplasia (FNH) and adenoma are rare benign hepatic tumors, and the standards for diagnosis and treatment still remain controversial. Usually adenoma is an indication for resection, due to its tendency to bleed and to degenerate; FNH, on the contrary, may be treated conservatively. Preoperation differential diagnosis is, however, difficult, often impossible. MATERIALS AND METHODS: Thirty-eight patients with presumed hepatic adenoma and/or FNH were studied at our department from 1984 to 1996. Preoperative assessment included clinical evaluation and symptoms, laboratory tests, liver biopsy, ultrasound scan, computed tomography scan, magnetic resonance imaging, scintigraphy, and angiography. Thirteen patients had a presumed diagnosis of FNH, 16 of adenoma, and 9 of undetermined benign lesions; 27 had hepatic resections (3 with laparoscopic technique), and 11 were not operated on and are actually under a strict follow-up observation. RESULTS: The final diagnosis was 19 FNH and 19 adenomas (2 of which contained areas of hepatocarcinoma). Presumed diagnosis was confirmed in 71% of cases. Use of oral contraceptives, abdominal symptoms, and pathologic liver test results were frequent in patients with adenomas. There were no deaths after surgery. All resected patients were tumor free during the follow-up, and in 10 of the 11 nonoperated cases, the size of the nodules remained unchanged. We conclude that precise diagnosis of these benign liver tumors remains difficult and sometimes impossible, despite new imaging techniques. Hepatic resections can be performed under very safe conditions; laparoscopic surgery may play a role in selected cases. Adenomas and uncertain cases are clear indications for surgery. Only when a diagnosis of FNH can be firmly confirmed in asymptomatic patients is strict observation without surgery recommended.

[Contusion of the liver. Importance of associated lesions in polytraumatized patients]. / Les contusions du foie. Importance des lésions associées chez les polytraumatisés.

Between January 1984 and June 1993, we treated 120 contusions of the liver in a situation of polytrauma. There were 24 patients in Stage I, 47 in Stage II, 22 in Stage III, 13 in Stage IV and 14 in Stage V according to the Organ Injury Scaling Committee of the American Association for the Surgery of Trauma. A total of 107 patients were operated. Polytrauma related mortality was high. Besides the gravity of the liver lesion, prognosis was a function of other associated intra or extra abdominal lesions. In our series, other associated lesions were the cause fo death in 26 patients (64%) and 15 deaths (36%) were directly related to the hepatic lesion. The gravity of the Stage V lesions was related both to the state of shock of operation and the difficulties in reestablishing haemostasis. Packing decreased the effect of hypovolaemia and coagulopathy. The prognosis of supra hepatic venous lesions and hepatic resections remain disastrous. Our surgical schema has changed towards more conservative surgery and, when haemodynamic stability has been achieved, to abstention and careful monitoring. Different extra-hepatic trauma causing damage to other organs directly compromises simple hepatic lesions. The result of our series confirms the correlation between mortality and the gravity of the polytrauma as evaluated according to the Injury Severity Score proposed by Baker.

[Postoperative high digestive-cutaneous fistula. Advantages of nutritional treatment]. / Fistole digestivo-cutanee alte postoperatorie. Vantaggi del trattamento nutrizionale.

Twenty-four patients (18 male and 6 female) with high post-surgery digestive fistulas (8 pancreatic-cutaneous, 7 duodenal-cutaneous, 4 jejunum-cutaneous, 4 ileal-cutaneous, 1 gastric cutaneous) were treated with T.P.N. and/or E.N. between 1980-1983. 17 patients (71%) recovered with spontaneous healing of fistulas in 9-92 (average 39) days. 3 patients underwent a second operation. 3 patients (12.5%) died: 2 for sepsis, 1 for cachexia. A.E. and T.P.N. were able to improve serious catabolic state and to get a better prognosis.

[Intestinal occlusion in colo-rectal cancer]. / L'occlusione intestinale nel cancro del colon-retto.

A comparison was made between 73 patients with colon-rectum neoplasia operated urgently due to occlusion and 85 electively operated in the absence of mechanical ileus. Six parameters were examined: 1) Duration of preoperative symptomatology; 2) Seriousness of preoperative symptomatology; 3) Extention of neoplasia at surgery; 4) Type of operation; 5) Postoperative mortality; 6) Long-term survival. It was found that obstruction often occurs within 5 months after the onset of symptoms and in cases where the tumour is still local (55%). It is attended by higher postoperative mortality (22%) and shorter survival (18 as opposed to 23 months).

[Combined therapy of colonic and rectal neoplasms in an advanced phase]. / Trattamenti associati nella terapia delle neoplasie del colon retto in fase avanzata.

The results obtained in a series of 75 patients suffering from advanced cancer of the colon-rectum are examined. Survival of these patients is looked at as a function of the extent of surgical demolition, and as a function of postoperative chemotherapy. Demolition interventions were followed by much higher survival than was observed following palliative operations. At the same time, survival was higher in patients who underwent post-operative chemotherapy. The results therefore justify a more aggressive approach in advanced cancer of the colon-rectum.