Renal Resistance Trend During Hypothermic Machine Perfusion Is More Predictive of Postoperative Outcome Than Biopsy Score: Preliminary Experience in 35 Consecutive Kidney Transplantations.

Hypothermic machine perfusion (HPM) grants a better postoperative outcome in transplantation of organs procured from extended criteria donors (ECDs) and donors after cardiac death (DCD). So far, the only available parameter for outcome prediction concerning those organs is pretransplant biopsy score. The aim of this study is to evaluate whether renal resistance (RR) trend during HPM may be used as a predictive marker for post-transplantation outcome. From December 2015 to present, HMP has been systematically applied to all organs from ECDs and DCD. All grafts underwent pretransplantation biopsy evaluation using Karpinski's histological score. Only organs that reached RR value ≤1.0 within 3 hours of perfusion were transplanted. Single kidney transplantation (SKT) or double kidney transplantation (DKT) were performed according to biopsy score results. Sixty-five HMPs were performed (58 from ECDs and 7 from DCD/ECMO donors). Fifteen kidneys were insufficiently reconditioned (RR > 1) and were therefore discarded. Forty-nine kidneys were transplanted, divided between 21 SKT and 14 DKT. Overall primary nonfunction (PNF) and delayed graft function (DGF) rate were 2.9 and 17.1%, respectively. DGF were more common in kidneys from DCD (67 vs. 7%; P = 0.004). Biopsy score did not correlate with PNF/DGF rate (P = 0.870) and postoperative creatinine trend (P = 0.796). Recipients of kidneys that reached RR ≤ 1.0 within 1 hour of HMP had a lower PNF/DGF rate (11 vs. 44%; P = 0.033) and faster serum creatinine decrease (POD10 creatinine: 1.79 mg/dL vs. 4.33 mg/dL; P = 0.019). RR trend is more predictive of post-transplantation outcome than biopsy score. Hence, RR trend should be taken into account in the pretransplantation evaluation of the organs.

Laparoscopic TME with APPEAR (Anterior and Perineal PlanE for ultra-low Anterior Resection of the Rectum) technique for distal rectal cancer.

BACKGROUND: Laparoscopic sphincter saving rectal resection for low rectal cancer is hampered by narrow pelvis and limitations of current stapling devices. The APPEAR (Anterior Perineal PlanE for Ultra-low Anterior Resection of the Rectum) was proposed by Williams et al. as an alternative to the abdominal-perineal resection to perform very low rectal resection and anastomosis through a perineal wound. We adapted the original technique to the laparoscopic approach, avoiding any other abdominal incision. METHODS: Between December 2011 and April 2012, five patients (2 females; median age 72 years (range 60-78)) with rectal cancer not involving the sphincters underwent laparoscopic total mesorectal excision (TME) with APPEAR. Mean distance of the tumor from anal verge was 3.2 ± 1.1 cm (range 2-5). RESULTS: All of the procedures were completed laparoscopically. All of the anastomoses were stapled, and a protective stoma was always constructed. The surgical specimens were retrieved from the perineal wound, and the stoma performed through one of the port sites, without any further abdominal incision. Mean operative time was 333 ± 47 min (range 295-405), postoperative stay 12 ± 5 days (range 6-17). Perineal wound infection was observed in three patients, two of whom also had anastomotic fistula, and was treated conservatively with prolonged suction drainage. Histological examination showed three pT3N+, one T2N0, and one complete response after neoadjuvant radiochemotherapy, with a mean distal clear margin of 1.27 ± 0.5 cm (range 0.5-1.7). After a median follow-up of 9 months (range 8-12), one stoma reversal has been performed and the patient is fully continent. CONCLUSIONS: Our experience shows the feasibility of the APPEAR technique with laparoscopic TME, without any other abdominal incision. This technique offers advantage over the limitations of current laparoscopic stapling devices and their scanty maneuverability in the pelvis, allowing resection and anastomosis under direct vision, with adequate distal clearance, while sparing the anal sphincters.

Does inferior mesenteric artery ligation affect outcome in elective colonic resection for diverticular disease?

BACKGROUND: The aim of our study was to analyse the role of inferior mesenteric artery (IMA) ligation during elective colonic resection for diverticular disease (DD) with respect to surgical outcome. METHODS: All patients who underwent elective laparoscopic or open colonic resection for DD from January 2006 to December 2012 were studied. The patients were divided into two groups based on IMA ligation or preservation. The primary end point was to compare anastomotic leakage in the two groups. The secondary end points were operative time, stoma formation, overall post-operative complications, restoration of bowel function and length of post-operative hospital stay. RESULTS: During the study period, 219 elective colonic resections with primary anastomosis for DD were performed. A laparoscopic technique was employed in 132 (60.3%) cases. IMA ligation was performed in 66 patients (30.1%). Overall anastomotic leakage rate was 4.1%, 4.5% in IMA ligation and 3.9% in IMA preservation group, respectively (P = ns). Mean operative time was 225 ± 43.4 and 191 ± 41.7 min in IMA ligation and preservation group, respectively (P = 0.002). No differences were observed in the rate of overall complications, stoma formation, restoration of bowel function and post-operative length of hospital stay. CONCLUSIONS: No differences were observed in surgical outcome in IMA ligation and preservation groups, particularly preservation or ligation of the IMA did not affect leakage rate.

Experience on surgical treatment of gastrointestinal stromal tumor of the stomach.

In spite of their rarity, gastrointestinal stromal tumors (GISTs) represent a complex clinical problem, mainly diagnostic and therapeutic, for their unpredictable biological course and their long-term prognosis, the most involved site being the stomach. Although a great number of tyrosine-kinase inhibitors has been developed for blocking their proliferative pathways (constitutive CD117 and PDGFRa activation), surgical treatment still remains the only curative one. Nevertheless, their particular non-lymphatic spread and their tendency to peritoneal seeding have emphasized technical issues that are still greatly debated. The definition of the best surgical procedure aiming at the complete R0 resection of the tumor has changed in the recent years and, with the improvement of laparoscopic techniques, the minimally invasive approach of gastric GIST has become feasible in most cases. In this paper we present our experience on surgical treatment of 43 gastric GISTs observed from 2001 to 2008 taken from our case study (75 patients from 1994). The risk class, treatment and long-term follow-up (mean 36 months) has been analyzed. All patients underwent a surgical procedure; 10 of them were also treated with molecular tyrosine-kinase inhibitors as adjuvant treatment. Overall survival at 60 months was 89.3%, with a disease-free survival of 87.68%.