Colorectal resection in end-stage renal disease (ESRD) patients: experience from a single tertiary center

BACKGROUND

End-stage renal disease (ESRD) and renal replacement therapy (RRT) are important risk factors for post-operative morbidity and mortality but remains poorly reported in colorectal surgery. This study aims to evaluate postoperative outcomes of ESRD patients under RRT undergoing colorectal resection.

METHODS

All ESRD patients under RRT who underwent colorectal resection between 2006 and 2019 were retrospectively reviewed. Perioperative outcomes were analysed, such as risk factors of postoperative complications.

RESULTS

Forty-two patients were analysed, including 27 emergency and 15 elective surgeries. The most frequent indication was acute colonic ischemia for emergency and malignancy for elective procedures. Laparoscopic approach was used in 12 patients (29%), without difference between elective and emergency groups. Postoperative severe complications rate (including deaths) was 50% (21/42), including 56% (15/27) and 40% (6/15) in emergency and elective groups, respectively (p = .334). Anastomotic leak was observed in 3 of the 23 patients (13%) undergoing digestive anastomosis, (1 in emergency and 2 in elective groups, p = .246). The postoperative mortality rate was 29%, not significantly different between groups. The median hospital stay was 14.5 days (8-42). At univariate analysis, history of cardiac event (p = .028) and open approach (p = .040) were associated with severe complications, and ASA score >3 (p = .043), history of cardiac event (p = .001) and diabetes (p = .030) associated with mortality.

CONCLUSIONS

Colorectal surgery in ESRD patient exposes to high risk of morbidity and mortality, even in the elective setting, especially in patients with comorbidities like cardiac event and diabetes. Careful patient selection and closed management is required in such fragile patients.

Deciduosis of the appendix: a rare cause of acute abdomen during pregnancy (a case report)

Appendectomy is the most common non-obstetric surgical intervention in pregnant patients. In rare cases, deciduosis can develop during pregnancy in the appendix and cause inflammation through appendiceal occlusion by ectopic decidua tissue. We report a 28-year-old woman at 32 weeks of pregnancy, who presented at the emergency room with the diagnosis of an acute appendicitis. After successful appendectomy and histopathological examination of the appendectomy specimen, a diagnosis of appendiceal deciduosis with acute appendicitis was established. Here, we discuss the origin of appendiceal deciduosis, as well as its clinical and histopathological presentation.

Mucin-producing hepatic cystic neoplasms: an uncommon but challenging disease often misdiagnosed and mismanaged

Background: Mucin-producing hepatic cystic neoplasms (MHCN) are uncommon and potentially malignant.Methods: Nine MHCN were encountered in our centre for over 32 years. Patients' clinical, biological, radiological and pathological features were reviewed. Lesions were classified into Mucinous Cystic Neoplasms (MCN) and Intraductal Papillary Neoplasms of the Bile duct (IPNB) (WHO 2010 classification).Results: Five MCN and 4 IPNB were reviewed. Serum and intracystic tumour markers were insufficient to diagnose malignancy. Complications were encountered in five out of nine patients (56%), mean symptom duration was 26 months (range: 1-132). Three patients were mismanaged pre-referral. Radiological features enabled preoperative diagnosis in eight out of nine patients (89%). Greater tumour size, unilocular lesion and mural nodularity indicated malignancy. Radical tumour excision was achieved in eight patients. One IPNB patient was misdiagnosed and underwent unroofing. For 103 months median follow-up, five out of six patients with benign tumours were alive and disease-free, whereas the misdiagnosed IPNB recurred with fatal malignant transformation seven years later. Among the three patients with malignancies (median follow-up: 77 months), two IPNB died, one from cancer recurrence and one from unrelated causes, whereas the malignant MCN was alive and disease-free.Conclusions: Appropriate MHCN diagnosis is crucial, yet it is often misdiagnosed and mismanaged. The prognosis after complete excision is favourable.

Kidney transplantation in infantile myofibromatosis and fibromuscular dysplasia: a case report

Introduction

We report what we believe to be the first case of a child affected by two rare vascular diseases complicated by kidney failure and successfully treated by kidney transplantation.

Case presentation

A 3-year-old Caucasian girl with fibromuscular dysplasia and infantile myofibromatosis presented with arterial hypertension and renal failure. She received a deceased donor kidney transplantation distal to an iliac graft. The technical peculiarities of this transplantation are described, as well as her favorable long-term outcome.

Conclusion

Kidney transplantation may be considered in a patient with vascular diseases and a history of iliac surgery.

Successful emergency resection of a massive intra-abdominal hemophilic pseudotumor

An intra-abdominal pseudotumor is a rare complication of hemophilia. Surgical treatment is associated with high morbidity and mortality rates and reported cases are scarce. We present a 66-year-old Caucasian male suffering from severe hemophilia type A treated for 10 years with Factor VIII. Major complications from the disease were chronic hepatitis B and C, cerebral hemorrhage and disabling arthropathy. Twenty-three years ago, retro-peritoneal bleeding led to the development of a large intra-abdominal pseudotumor, which was followed-up clinically due to the high surgical risk and the lack of clinical indication. The patient presented to the emergency department with severe sepsis and umbilical discharge that had appeared over the past two days. Abdominal computed tomography images were highly suggestive of a bowel fistula. The patient was taken to the operating room under continuous infusion of factor VIII. Surgical exploration revealed a large infected pseudotumor with severe intra-abdominal adhesions and a left colonic fistula. The pseudotumor was partially resected en bloc with the left colon leaving the posterior wall intact. The postoperative period was complicated by septic shock and a small bowel fistula that required reoperation. He was discharged on the 73^rd hospital day and is well 8 mo after surgery. No bleeding complications were encountered and we consider surgery safe under factor VIII replacement therapy.