Severe dysphagia after antireflux surgery: a rare case of esophageal hiatal stenosis

Severe and persistent dysphagia (PD) due to a stenosis of the esophageal hiatus is a serious and rare complication after antireflux procedures. In the case report presented here, the treatment of dysphagia, which arose eight weeks after surgery and progressively worsened, required a new laparoscopic approach. The re-intervention undertaken allowed us to identify the cause of the dysphagia, a tight hiatal stenosis, and to treat it successfully.

Complete Fundus Mobilization Reduces Dysphagia After Nissen Procedure

Background. Anti-reflux surgery is an effective treatment for gastroesophageal reflux disease (GERD). Nevertheless, surgery is still indicated with great caution in relation to the risk of complications, and in particular to postoperative dysphagia (PD). Objective. To compare the clinical outcomes, with particular focus on the incidence and severity of PD, of laparoscopic Nissen-Rossetti fundoplication (NRF) and floppy Nissen fundoplication (FNF) with complete fundus mobilization, in the surgical treatment of GERD. Methods. Ninety patients with GERD were enrolled. Forty-four patients (21[47.7%] men, 23[52.2%] women; mean age 42.4 ± 14.3 years) underwent NRF (Group A), and 46 patients (23[50%] men, 23[50%] women; mean age 43.3 ± 15.4 years) received laparoscopic FNF with complete fundus mobilization (Group B). Clinical assessment was performed using a structured questionnaire and SF-36 quality of life (QoL) score. PD was assessed using a validated classification, and an overall outcome was also determined by asking the patient to score it. Results. At 24-month follow-up, 38 (88.3%) patients in Group A vs 39 (86.6%) in Group B reported to be completely satisfied with reflux relief and free of protonic pump inhibitors (PPIs), while 3 (6.9%) in Group A vs 2(4.4%) in Group B reported occasional PPI intake and 2(4.6%) in Group A vs 4(8.8%) in Group B needed regular PPI use. Persistent PD was observed in 8(18.6%) patients in Group A and in 2(4.4%) in Group B (P = .03). No significant differences were found in the QoL score and in the overall outcome perceived by the patients. Conclusion. FNF, with complete fundus mobilization, appears to be associated with a lower rate of postoperative persistent dysphagia.

Physical activity in elderly kidney transplant patients with multiple renal arteries

INTRODUCTION

Kidney transplantation (KT) is the gold standard for treatment of patients with end- stage-renal disease. To expand the donor reserve, it is necessary to use marginal/suboptimal kidneys.

METHODS

We retrospectively evaluated the short/long-term outcome of 34 KT elderly patients who received allografts with vascular abnormalities (MRA group), in comparison with 34 KT patients who received a kidney with a single renal artery (SRA group) pair-matched by age, length of time on dialysis, comorbidity and donor age.

RESULTS

All participants completed the International Physical Activity Questionnaire at KT, and then 4, 8, and 12 weeks after transplantation. Our data indicate that kidney with vascular anatomical variants may be successfully transplanted, since the overall rate of surgical complications was 20.6% in the SRA group and 17.6% in the MRA group and that the 5-year survival rate after KT was 100% in both groups.

CONCLUSIONS

The data also underline that individualized physical activity programs induced similar excellent results in both groups, improving physical capacities, arterial pressure, lipid metabolism, insulin sensitivity, quality of life and physical and mental status.

Familial Polyposis Coli: The Management of Desmoid Tumor Bleeding

Background

There is currently no standard treatment for desmoid tumors (DTs) associated with familial polyposis coli (FAP). Familial adenomatous polyposis in DT patients is sometimes a life-threatening condition.

Methods

We enrolled all consecutive patients with FAP treated at Unit of General Surgery and Transplant, University of Naples Federico II and evaluated the incidence of DTs on FAP between 1996 and 2016.

Results

We observed 45 consecutive patients with FAP; of these 5 were DT-FAP-associated. All 5 cases with FAP were young women, age 25 to 65 years, previously treated by colectomy. Of these, 4 patients presented a parietal localization and had been treated with a wide surgical exeresis; one patient had an intra-abdominal, mesenteric tumor that was unresectable at laparotomy. We performed CT-guided drainage, ureteral stenting, medical therapy (sulindac+tamoxifene), and chemotherapy (dacarba-zine+doxorubicine).All patients were alive and underwent follow-ups for 5 years post-surgery; only 1 patient with parietal localization showed a local relapse after 2 years.

Conclusions

We propose a modulated approach to the single patient with FAP, with surgery as treatment of choice for parietal localization disease and integrating different kinds of therapies (surgery alone or associated with RT, CT) for the intra-abdominal tumor.

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.