Successful Needle Aspiration of a Traumatic Pneumothorax: A Case Report and Literature Review

Traumatic pneumothorax (PTX) occurs in up to 50% of patients with severe polytrauma and chest injuries. Patients with a traumatic PTX with clinical signs of tension physiology and hemodynamic instability are typically treated with an urgent decompressive thoracostomy, tube thoracostomy, or needle decompression. There is recent evidence that non-breathless patients with a hemodynamically stable traumatic PTX can be managed conservatively through observation or a percutaneous pigtail catheter. We present here a 52-year-old woman who presented to the emergency department with a 55 mm traumatic PTX. Following aspiration of 1500 mL of air, a clinical improvement was immediately observed, allowing the patient to be discharged shortly thereafter. In hemodynamically stable patients with a post-traumatic PTX, without specific risk factors or oxygen desaturation, observation or simple needle aspiration can be a reasonable approach. Although the recent medical literature supports conservative management of small traumatic PTXs, guidelines are lacking for hemodynamically stable patients with a significantly large PTX. This case report documents our successful experience with needle aspiration in such a setting of large traumatic PTX. We aimed in this article to review the available literature on needle aspiration and conservative treatment of traumatic pneumothorax. A total of 12 studies were selected out of 190 articles on traumatic PTX where conservative treatment and chest tube decompression were compared. Our case report offers a novel contribution by illustrating the successful resolution of a sizable pneumothorax through needle aspiration, suggesting that even a large PTX in a hemodynamically stable patient, without other risk conditions, can be successfully treated conservatively with simple needle aspiration in order to avoid tube thoracostomy complications.

Prostate Artery Embolization in the Treatment of Massive Intractable Bleeding from Prostatic Neoplasms: A Case Report and Systematic Review

Lower urinary tract symptoms (LUTS) and hematuria are common symptoms in men with neoplasms, mainly affecting the elderly population. Prostatic arterial embolization (PAE) is a minimally invasive procedure that has shown promising results in managing LUTS and massive intractable prostatic hematuria in patients with benign prostatic hyperplasia (BPH) and prostate cancer (PCa). A few studies, however, have provided valuable insights into the durability and efficacy of PAE focusing on the long-term effectiveness, quality of life, and cancer-specific control of hemostasis and urinary symptoms. As a result of concomitant cardiovascular conditions, these patients often take anticoagulants or antithrombotics, which can worsen their hematuria and clinical status. Transurethral resection of the prostate (TURP) is considered a very high-risk procedure, even without massive bleeding, and requires discontinuation of vitamin K antagonists and antiplatelet therapies. Such patients usually have their surgery postponed, and PAE should be considered a safe alternative treatment. We aimed to report a narrative review from 1976 to June 2023 of the current state of PAE for massive and intractable hematuria, highlighting recent developments in this technique, including prospective cohort studies, and focusing on long-term outcome, safety, and complication management of patients with prostatic neoplasms who develop significant hemorrhagic symptoms. Additionally, we present a case report and a simple algorithm for treating intractable bleeding in a 92-year-old man with PCa and massive hematuria.

Endoscopic Ultrasound to Identify the Actual Cause of Idiopathic Acute Pancreatitis: A Systematic Review

Idiopathic acute pancreatitis (IAP) presents a diagnostic challenge and refers to cases where the cause of acute pancreatitis remains uncertain despite a comprehensive diagnostic evaluation. Endoscopic ultrasound (EUS) has emerged as a valuable tool in the diagnostic workup of IAP. This review explores the pivotal role of EUS in detecting the actual cause of IAP and assessing its accuracy, timing, safety, and future technological improvement. In this review, we investigate the role of EUS in identifying the actual cause of IAP by examining the available literature. We aim to assess possible existing evidence regarding EUS accuracy, timing, and safety and explore potential trends of future technological improvements in EUS for diagnostic purposes. Following PRISMA guidelines, 60 pertinent studies were selected and analysed. EUS emerges as a crucial diagnostic tool, particularly when conventional imaging fails. It can offer intricate visualization of the pancreas, biliary system, and adjacent structures. Microlithiasis, biliary sludge, chronic pancreatitis, and small pancreatic tumors seem to be much more accurately identified with EUS in the setting of IAP. The optimal timing for EUS is post-resolution of the acute phase of the disease. With a low rate of complications, EUS poses minimal safety concerns. EUS-guided interventions, including fine-needle aspiration, collection drainage, and biopsies, aid in the cytological analysis. With high diagnostic accuracy, safety, and therapeutic potential, EUS is able to improve patient outcomes when managing IAP. Further refinement of EUS techniques and cost-effectiveness assessment of EUS-guided approaches need to be explored in multicentre prospective studies. This review underscores EUS as a transformative tool in unraveling IAP's enigma and advancing diagnostic and therapeutic strategies.

Systematic Review and Meta-Analysis of Oral Anticoagulant Therapy in Atrial Fibrillation Cancer Patients

(1) Introduction: Cancer and atrial fibrillation (AF) are increasingly coexisting medical challenges. These two conditions share an increased thrombotic and bleeding risk. Although optimal regimens of the most suitable anti-thrombotic therapy are now affirmed in the general population, cancer patients are still particularly understudied on the matter; (2) Aims And Methodology: This metanalysis (11 studies (incl. 266,865 patients)) aims at evaluating the ischemic-hemorrhagic risk profile of oncologic patients with AF treated with oral anticoagulants (vitamin K antagonists vs. direct oral anticoagulants); (3) Results: In the oncological population, DOACs confer a benefit in terms of the reduction in ischemic, hemorrhagic and venous thromboembolic events. However, ischemic prevention has a non-insignificant bleeding risk, lower than Warfarin but significant and higher than the non-oncological patients; (4) Conclusions: Anticoagulation with DOACs provides a higher safety profile with respect to VKAs in terms of stroke reduction and a relative bleeding reduction risk. Further studies are needed to better assess the optimal anticoagulation strategy in cancer patients with AF.

Diagnostic Accuracy of Endoscopic Ultrasonography in Selecting Patients for Endoscopic Submucosal Dissection for Early Gastrointestinal Neoplasms

Tumor invasion depth and lymph node metastasis determine the prognosis of gastrointestinal (GI) neoplasms. GI neoplasms limited to mucosa (m1 or m2) and superficial submucosa (sm1) can be treated effectively with minimally invasive endoscopic therapy, while the deep invasion of the submucosa (sm2 or sm3) is associated with lymph node metastasis, and surgical resection is required. Correct staging is therefore crucial for preoperative evaluation and planning. Endoscopic ultrasonography (EUS) can be used to detect the depth of invasion due to its close proximity to the lesion. The diagnostic accuracy of EUS, when compared to conventional endoscopic staging, is debated as it can under- or overstage the lesion. We aim in this study to determine if EUS can accurately differentiate mucosal from submucosal GI neoplasms to select patients with early GI lesions for endoscopic submucosal dissection (ESD) or surgery. From March 2014 to February 2022, 293 patients with early superficial GI neoplasms were admitted to our endoscopic unit for EUS staging. To evaluate the accuracy of EUS, we compared the preoperative EUS findings with the definitive histopathologic findings on the resected specimen. Overall, 242 of 293 lesions were correctly staged by EUS (82.59%). In the evaluation of submucosal invasion or deeper, EUS understaged 38 of 293 (12.96%) and overstaged 13 of 293 (4.43%) lesions. EUS has excellent accuracy in staging superficial GI neoplasms; its use is highly recommended before ESD since it can also detect lymph node metastases around the lesions, thus changing the indication from ESD to surgery.

Primary angioembolization in liver trauma: major hepatic necrosis as a severe complication of a minimally invasive treatment-a narrative review

The liver is the second most commonly solid organ injured in blunt abdominal trauma. Liver injuries are classified according to the American Association for the Surgery of Trauma Injury Scale. The choice of Non-Operative Management is based on generalized clinical patients’ conditions combined with the evidence on CT scan imaging. To date, there are no consensus guidelines on appropriate patient selection criteria for those who would benefit from angiography and angioembolization. Major hepatic necrosis is a clinical condition of extended liver damage and is the most common complication after angioembolization. Large amounts of necrotic liver require therapy, but it is unclear if the better technique is debridements supplemented by percutaneous drainage procedures or definitive resection. A systematic review of the literature was performed with a computerized search in a database such as Medline for published papers on the use of angioembolization in trauma patients with hepatic injuries and on the most common complication, the major hepatic necrosis. The systematic review was conducted according to the recommendations of the 2020 updated Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. A total of 3643 patients were included in the study, suffering liver trauma and 1703 (47%) were treated with Non-Operative Management; angioembolization was performed 10% of cases with a variable rate between 2 and 20%. Patients developed different complications. Hepatic necrosis accounted for 16% ranging from 0 to 42%. 74% of patients underwent operative management with a mortality rate of 11%. High-grade liver injuries pose significant challenges to surgeons who care for trauma patients. Many patients can be successfully managed nonoperatively. In hemodynamically stable patients with arterial blush, without other lesions requiring immediate surgery, selective and super-selective AE of the hepatic artery branches is an effective technique. However, these therapies are not without complications and major hepatic necrosis is the most common complication in high-grade injures. Level III, Systematic review

The Comprehensive Facial Injury (CFI) Score Is an Early Predictor of the Management for Mild, Moderate and Severe Facial Trauma

Identifying groups of patients with homogeneous characteristics and comparable outcomes improves clinical activity, patients' management, and scientific research. This study aims to define mild, moderate, and severe facial trauma by validating two cut-off values of the Comprehensive Facial Injury (CFI) score and describing their foreseeable clinical needs to create a useful guide in patient management, starting from the first evaluation. The individual CFI score, overall surgical time, and length of hospitalization are calculated for a sample of 1400 facial-injured patients. Receiver Operating Characteristic (ROC) analysis and the corresponding Area Under the Curve (AUC) is tested, and a CFI score ≥4 is selected to discriminate patients undergoing surgical management under general anesthesia (Positive Predictive Value, PPV of 91.4%), while a CFI score ≥10 is selected to identify patients undergoing major surgical procedures (Negative Predictive Value, NPV of 91.7%). These results are enhanced by the consensual trend of Length of Stay outcome. The use of the CFI score allows us to distinguish between the "Mild facial trauma" with a low risk of hospitalization for surgical treatment, the "Moderate facial trauma" with a high probability of surgical treatment, and the "Severe facial trauma" that requires long-lasting surgery and hospital stay, with an increased incidence of Intensive Care Unit admission.

Water immersion sigmoidoscopy versus standard insufflation for colorectal cancer screening: A cohort study

BACKGROUND

Although the efficacy of water-assisted colonoscopy is well established, the role of water immersion sigmoidoscopy (WIS) remains unclear. We compared WIS with carbon dioxide insufflation sigmoidoscopy (CO₂S) on patient outcomes.

METHODS

We conducted an analysis of prospectively collected data from a single-center quality improvement program about patients undergoing unsedated screening sigmoidoscopy (WIS and CO₂S) between May 2019 and January 2020. Outcomes studied included the following: Rates of severe pain <17% (score of ≥7 on a numeric rating scale of 0-10, and on a Likert scale), willingness to repeat the procedure without sedation, adequate bowel cleanliness >75% (proportion of Boston Bowel Preparation Scale score: 2-3) and adenoma detection rate (ADR).

RESULTS

In total, 234 patients (111 WIS; 123 CO₂S) were included. All patients were aged 58 years and 58.9% were female; baseline characteristics were comparable between groups. There were no significant differences in rates of severe pain (WIS: 16.5%, CO₂S: 13.8%; P = 0.586), willingness to repeat the unsedated procedure (WIS: 82.3%, CO₂S: 84.5%; P = 0.713), adequate bowel cleanliness (WIS: 78.4%, CO₂S: 78%, P = 0.999) or ADR (WIS: 25.2%, CO₂S: 16.3%; P = 0.106) between groups. However, average procedure times were longer with WIS (9.06 min) compared to CO₂S (6.45 min; P < 0.001). Overall, 29.6% of women reported that they would repeat sigmoidoscopy only if sedated.

CONCLUSIONS

WIS does not ameliorate tolerance to and quality of sigmoidoscopy screening measured by several scores. When offered a choice, the women's willingness to repeat WIS or CO₂S without sedation was poor and raises concern on the opportunity of screening sigmoidoscopy without sedation in these subjects.

Standardized Nursing Approach to Acute Aortic Dissection Patient: A Practice Update

Background

Acute aortic dissection (AAD) is a rare condition but represents a time-sensitive disease for which a wrong and untimely identification in the triage phase could compromise the subsequent diagnostic, therapeutic path and patient's prognosis. The emergency nurse plays a crucial role in identifying and managing patients with possible AAD. The aim of this paper is to describe the emergency department nursing approach to critical patients with suspected hyperacute/acute AAD.

Purpose

It is crucial to examine the emergency departments nursing approach to patients with suspected AAD. It is fundamental to have a rapid and standardized approach related to life-saving procedures, practices, and management of critical patients during the triage phase, with the assessment of the most common presentation of clinical signs and symptoms and patient management during each step in the emergency department.

Conclusion

Early identification and diagnosis in ED allow prompt treatment that improves prognosis. The emergency nurse plays a crucial role in correctly identifying and managing patients with acute aortic dissection. High clinical suspicion from the triage stages, early diagnosis, monitoring, and initial clinical stabilization in the emergency department plays a key role while awaiting definitive treatment.

Impact of the COVID-19 Pandemic on Urologic Oncology Surgery: Implications for Moving Forward

The COVID-19 pandemic has caused the destruction of routine hospital services globally, leading to an increase in the backlog of elective surgery cases. The aim of the study was to retrospectively investigate the pandemic's impact on the urologic oncology surgical activity of a high-volume center located in Milan, Italy. The number and type of procedures performed in 2020 during the COVID-19 pandemic was evaluated using 2019 data as control. Waiting times for each surgical procedure were compared, on a bimonthly basis, between the two different years. Overall, a 26.7% reduction in the number of urologic oncology surgeries between 2019 and 2020 was observed (2019: 720, 2020: 528). Both the main indication for surgery and the type of procedure performed significantly differed between 2019 and 2020 (all p < 0.0001), with a decrease in the number of radical prostatectomies and an increase in the number of radical cystectomies and radical nephrectomies/nephroureterectomies performed in 2020. Waiting time decreased by 20% between 2019 and 2020, with the most significant reduction seen after the first wave of the COVID-19 pandemic (July-October 2020), in particular for partial nephrectomy and radical prostatectomy, possibly due to the underdiagnosis of cases. In conclusion, in accordance with recommendations by international urological societies on prioritization strategies for oncological procedures, a higher proportion of surgeries for high-risk tumors was performed in 2020 at our center at the expense of procedures for lower risk diseases; however, future implications for patients' prognosis still need to be determined.

Hybrid Additive Fabrication of a Transparent Liver with Biosimilar Haptic Response for Preoperative Planning

Due to the complexity of liver surgery, the interest in 3D printing is constantly increasing among hepatobiliary surgeons. The aim of this study was to produce a patient-specific transparent life-sized liver model with tissue-like haptic properties by combining additive manufacturing and 3D moulding. A multistep pipeline was adopted to obtain accurate 3D printable models. Semiautomatic segmentation and registration of routine medical imaging using 3D Slicer software allowed to obtain digital objects representing the structures of interest (liver parenchyma, vasculo-biliary branching, and intrahepatic lesion). The virtual models were used as the source data for a hybrid fabrication process based on additive manufacturing using soft resins and casting of tissue-mimicking silicone-based blend into 3D moulds. The model of the haptic liver reproduced with high fidelity the vasculo-biliary branching and the relationship with the intrahepatic lesion embedded into the transparent parenchyma. It offered high-quality haptic perception and a remarkable degree of surgical and anatomical information. Our 3D transparent model with haptic properties can help surgeons understand the spatial changes of intrahepatic structures during surgical manoeuvres, optimising preoperative surgical planning.

Safety of Endoscopic Snare Ampullectomy for Adenomatous Ampullary Lesions: Focus on Pancreatic Stent Placement to Prevent Pancreatitis

BACKGROUND

Ampullary tumors, although relatively uncommon, are increasingly diagnosed due to ongoing progress in imaging technology and the diagnostic accuracy of endoscopic ultrasound and magnetic resonance cholangiopancreatography. Endoscopic ampullectomy (EA) has become the preferred treatment option over surgery due to its lower morbidity for benign ampullary adenomas. This study aims to evaluate the efficacy, safety, and outcome of EA in 30 patients with benign-appearing ampullary lesions with particular emphasis on the accuracy of preampullectomy histology and technical details of the pancreatic duct drainage to prevent postprocedural pancreatitis.

MATERIALS AND METHODS

Data from a cohort of 30 patients who underwent EA were retrospectively analyzed. Histologic characteristics of the ampullomas, accuracy of histology of pre-EA biopsy specimen, safety of the procedure, recurrence rate, as well as the clinical outcome of all patients, are analyzed and discussed.

RESULTS

Endoscopic resection was successful as a definitive treatment in 25 patients (83.3%). Five patients required additional surgery. In 8 patients, a definitive histologic specimen revealed an adenocarcinoma (3 in situ and 5 invasive). The diagnostic accuracy obtained by preresection biopsy specimen was low (0.70). Pancreatic duct stent placement after snare resection was unsuccessful in 9 patients, and 3 of them developed pancreatitis after EA.

CONCLUSIONS

EA appears to be a relatively safe alternative to surgery as the first therapeutic option for selected patients with benign-appearing ampullary adenomas. A correct preoperative evaluation by endoscopic ultrasound and magnetic resonance cholangiopancreatography can help to define the anatomy of the pancreatic duct to improve the success rate of pancreatic stent placement which seems to offer a protective role in the prevention of postprocedural pancreatitis.

Recurrent oncocytic adrenocortical carcinoma: implementing diagnostic criteria in a case report with the longest survival

INTRODUCTION

Oncocytic adrenocortical tumors represent a subtype of the adrenal cortex neoplasms. These tumors can be divided into oncocytomas, oncocytic neoplasms of uncertain malignancy and carcinomas (OACs). To date, only 34 cases of OAC have been reported.

CASE EXPERIENCE

We reported a case of a 54-year-old male patient with a history of laparoscopic right adrenalectomy for an OAC and subsequent chemotherapy for a recurrence. He was referred to our emergency room for diffuse abdominal pain, vomit, change in bowel habits, fever, asthenia. He underwent a laparotomy and a complete excision of the known bilobate lesion. The histopathological findings matched the features of a recurrent OAC. No chemotherapy was administered after surgery and the patient was disease-free after a follow-up of twenty-eight months.

RESULTS - DISCUSSION

The most questionable issue in treating adrenocortical oncocytic neoplasms is the determination of malignancy. According to the Helsinki Score, which is the best prognostic system, the primary lesion was an OAC. We also implemented the score systems to the recurrent lesion, that seemed to be malignant. We believe that the adjuvant treatment can delay a recurrent lesion development, but finally, radical surgical excision is necessary. Moreover, we reported the longest survival after the primary adrenalectomy.

CONCLUSIONS

This study described the first case of recurrent oncocytic adrenocortical carcinoma with the longest followup. Adrenocortical oncocytoma is an extremely rare tumor of the adrenal gland with variable biological behavior without definitive consensus about diagnostic criteria. This was also the first case in which different histopathological criteria have been implemented in a recurrence.

KEY WORDS

Oncocytic adrenocortical carcinoma, Surgical oncology, Survival.

Grade IV Liver Injury Following Mechanical Cardiopulmonary Resuscitation with Postoperative Three-dimensional Evaluation

A 48-year-old female presented to the emergency department with chest pain and collapsed at the front desk. She was reanimated with mechanical chest compression, and after coronary angiography, a left anterior descending/diagonal bifurcation mini-crush stenting was performed. Few hours after the procedure, the patient showed severe hypotension. Abdominal ultrasound and computed tomography (CT) scan evidenced a massive subcapsular liver hematoma (Grade IV, American association for the surgery of trauma (AAST) liver injury scale) of the right lobe with extrahepatic blushing. Transhepatic embolization was attempted but without benefit, so the patient underwent emergency laparotomy for damage control surgery with perihepatic packing. After hemodynamic stabilization, right hepatectomy was performed with a favorable outcome and full recovery. The patient CT scan was retrospectively processed to obtain a virtual model visualizable through a head-mounted display. The virtual reconstruction could improve the comprehension of the injury and the liver surgical anatomy for educational purpose, and it could represent a new tool for preoperative planning.

Emergency Department Resuscitative Thoracotomy: Indications, surgical procedure and outcome. A narrative review

BACKGROUND

Emergency Department Thoracotomy (EDRT) after traumatic Cardio-pulmonary Arrest (CPR) can be used to salvage select critically injured patients. Indications of this surgical procedure are widely debated and changed during last decades. We provide the available literature about EDRT in the effort to provide a comprehensive synthesis about the procedure, likelihood of success and patient's outcome in the different clinical setting, accepted indications and technical details adopted during the procedure for different trauma injuries.

METHODS

Literature from 1975 to 2020 was retrieved from multiple databases and reviewed. Indications, contraindications, total number and outcome of patients submitted to EDRT were primary endpoints.

RESULTS

A total number of 7236 patients received EDRT, but only 7.8% survived. Penetrating trauma and witnessed cardiopulmonary arrest with the presence of vital signs at the trauma center are the most favorable conditions to perform EDRT.

CONCLUSIONS

EDRT should be reserved for acute resuscitation of selected dying trauma patient. Risks of futility, costs, benefits of the surgical procedure should be carefully evaluated before performing the surgical procedure.

Endoscopic ultrasound-guided drainage of pancreatic fluid collections: The impact of evolving experience and new technologies in diagnosis and treatment over the last two decades

BACKGROUND

Endoscopic ultrasound (EUS)-guided drainage is the preferred approach for drainage of pancreatic fluid collections (PFCs) due to the better experience and significant progress using newer stents and access devices during last decade. This study aimed to evaluate the role of the evolving experience and possible influence of new technological devices on the outcome of patients evaluated for PFCs and submitted to EUS-guided drainage during two different periods: the early period at the beginning of experience when a standardized technique was used and the late period when the increased experience of the operator, combined with different stents quality were introduced in the management of PFCs.

METHODS

We retrospectively analyzed the clinical data of a cohort of 91 consecutive patients, who underwent EUS-guided drainage of symptomatic PFCs from October 2001 to September 2017. Demographic, therapeutic results, complications, and outcomes were compared between early years' group (2001-2008) and late years' group (2009-2017).

RESULTS

Endoscopic treatment was successfully achieved in 55.6% (20/36) of patients in the early years' group, and in 96.4% (53/55) in the late years' group. Eighteen patients (12 in early years' and 6 in the late year's group) required additional open surgery. Procedural complications were observed in 5 patients, 4 in early years' and 1 in late years' group. Mortality was registered in two patients (2.2%), one for each group.

CONCLUSIONS

During our long-term survey using EUS-guided endoscopic drainage of PFCs, significantly better outcomes in term of improved success rate and decrease complications rate were observed during the late period.

Emergency Aortic Control for Pedicle Screw Misplacement During Spinal Fixation

Aortic iatrogenic injuries during spinal instrumentation are rare but carry a high risk of mortality. In this report, we describe the case of a 26-year-old man with traumatic vertebral fracture and subsequent spinal cord injury who underwent posterior vertebral fixation at our trauma center. The neurosurgical procedure was complicated by the misplacement of a spinal pedicle screw, which almost penetrated the descending thoracic aorta. To avoid a possibly fatal bleeding, we safely removed the pedicle screw with the help of a prophylactic proximal compliant aortic balloon ready to be inflated in case of hemorrhage. Follow-up computed tomography scan did not detect any defect of the aortic wall, nor any sign of bleeding. After a 15-month follow-up, the patient is alive and in good physical conditions, with little residual neurologic deficit due to the spinal trauma.

Current concepts of perioperative monitoring in high-risk surgical patients: a review

A substantial number of patients are at high-risk of intra- or post-operative complications or both. Most perioperative deaths are represented by patients who present insufficient physiological reserve to meet the demands of major surgery. Recognition and management of critical high-risk surgical patients require dedicated and effective teams, capable of preventing, recognize, start treatment with adequate support in time to refer patients to the satisfactory ICU level provision. The main task for health-care planners and managers is to identify and reduce this severe risk and to encourage patient’s safety practices. Inadequate tissue perfusion and decreased cellular oxygenation due to hypovolemia, heart dysfunction, reduced cardiovascular reserve, and concomitant diseases are the most common causes of perioperative complications. Hemodynamic, respiratory and careful sequential monitoring have become essential aspects of the clinical practice both for surgeons and intensivists. New monitoring techniques have changed significantly over the past few years and are now able to rapidly identify shock states earlier, define the etiology, and monitor the response to different therapies. Many of these techniques are now minimally invasive or non-invasive. Advanced hemodynamic and respiratory monitoring combines invasive, non-invasive monitoring skills. Non-invasive ultrasound has emerged during the last years as an essential operative and perioperative evaluation tool, and its use is now rapidly growing. Perioperative management guided by appropriate sequential clinical evaluation combined with respiratory and hemodynamic monitoring is an established tool to help clinicians to identify those patients at higher risk in the attempt to reduce the complications rate and potentially improve patient outcomes. This review aims to provide an update of currently available standard concepts and evolving technologies of the various respiratory and hemodynamic monitoring systems for the high-risk surgical patients, highlighting their potential usefulness when integrated with careful clinical evaluation.

Hemoperitoneum in cirrhotic patients in the absence of abdominal trauma

Introduction: Hemoperitoneum can be a life-threating condition in cirrhotic patients who have a limited compensatory reserve during hemorrhagic shock. We aim to review the literature on the different etiologies associated with non-traumatic hemoperitoneum (NTH), summarizing the most relevant conditions associated with spontaneous and iatrogenic peritoneal and retroperitoneal bleeding that may occur in cirrhotic patients and to illustrate the most relevant diagnostic strategies and optimal management. Area covered: This review encompasses the current literature in hemoperitoneum in cirrhotic patients in the absence of abdominal trauma. Established diagnostic procedures, therapeutic interventions and potential novel targets are reported and discussed. Expert opinion: To ensure the optimal management regardless of the underlying etiology of NTH, the first goal for the clinician is to obtain immediate hemodynamic stabilization with supportive measures and to control the source of bleeding. The latter can be achieved with angiographic embolization, which is usually the first choice, or with open surgery. Other therapeutic options according to specific etiologies include transjugular intrahepatic portosystemic shunt (TIPS), balloon-occluded retrograde transvenous obliteration (BRTO), balloon-occluded anterograde transvenous obliteration (BATO) or intra operative radio frequency (RF).

A case of lockjaw in the emergency department

Tetanus with cephalic involvement is not a typical presentation of the disease; characteristic signs and symptoms are strictly localized in cranial district, although it could frequently progress to the classical generalized form. Tetanus is still spread worldwide, especially in particular subgroups as elderly and newborn babies and in countries with an inadequate vaccine coverage.We report a case of an adult man with generalized tetanus with cephalic presentation in Emergency Department. We aim to outline how difficult it was to diagnose in an adult patient without apparent exposition of previous minimal trauma or injury because of a lot of confusing factors and slow progressing clinical signs. Prompt recognition of signs and symptoms, opportune target therapy and supportive care, in association with correct vaccination schedule, are paramount to determine the prognosis for affected patients.

Penetrating cardiac stab wounds: A case report with management algorithm and review of the literature

A 57-year-old man attempted a suicide self-inflicting multiple scissors stab wounds in the chest. At the scene, Focused Assessment with Sonography in Trauma (FAST) showed an important left pleural effusion and pericardial fluid. Computed Tomography Angiography confirmed the pericardial effusion. The patient underwent immediate surgery. Three epicardial wounds of the anterior surface of the right ventricle were identified, one of which was actively bleeding. The lesion was sutured, the patient recovered uneventfully, and on the sixth postoperative day was transferred to a psychiatric unit. At 6-month follow-up, he is doing well and has returned to work. We discuss the importance of FAST for an early diagnosis of chest penetrating trauma leading to a rapid life-saving cardiac procedure and propose a clinical-based protocol for the management of patients with suspected penetrating cardiac injury which we have applied in our service for last six years. Midline sternotomy should be considered the incision of choice in patients with penetrating trauma in the cardiac box with evidence of injury to the heart and great vessels. Emergency Department Thoracotomy can be a possible option for those patients with impending cardiac arrest despite adequate resuscitation.

Respiratory distress due to platypnea-orthodeoxia syndrome: A diagnostic challenge in emergency setting

Platypnea-orthodeoxia syndrome (POS) is an unusual cause of hypoxia characterized by enormous variation in oxygen saturation during postural changes. We describe here the clinical presentation, the diagnostic challenge of POS and discuss the main pathophysiological etiologies of the disease in a 75-year-old woman who was admitted because shortness of breath. After ruling out the most important causes of dyspnea we observed that the symptoms improved when the patient was lying flat. The diagnostic workup with computed tomography scan and air bubble saline echocardiography lead us to a correct diagnosis.

Endoscopic submucosal dissection versus endoscopic mucosal resection for type 0-II superficial gastric lesions larger than 20 mm

Background:

Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are increasingly used for the treatment of superficial gastrointestinal neoplasia. However, the limits and the indications for each technique are still debated. Our retrospective study aimed to compare these techniques in patients with gastric flat lesions larger than 20 mm without the non-lifting sign.

Methods:

Between January 2013 and July 2016, a total of 36 patients with early gastric flat lesions larger than 20 mm and without the non-lifting sign were resected by ESD and were followed up by endoscopy. As a control group, 40 EMR cases from our database were matched. En bloc and curative resection were compared between the two groups according to histological assessment, tumor size, recurrence, complication rate, and procedure time. A Kaplan-Meier comparison was performed for both groups with a log-rank test to compare the survival curves; the chi-square test was employed for other parameters.

Results:

En bloc resection rate and curative resection rate were significantly higher in the ESD group than in the EMR group. Procedure time was significantly longer in the ESD group. No significant differences were found in the recurrence and complication rates, although the former were higher in the EMR group and the latter in the ESD group. Survival curves were similar for both groups.

Conclusions:

Our retrospective analysis seems to confirm a clear advantage for ESD over EMR in removing early superficial gastric neoplasm. Although ESD has expanded the endoscopic resectability of endoscopic gastric lesions, EMR may still be considered one of the therapeutic options for flat gastric lesions without the non-lifting sign.

Split liver technique with middle hepatic vein reconstruction on livers from transplant hepatectomies: a useful tool for surgical improvement

Livers removed during transplant hepatectomies could represent a useful anatomic ex vivo resource for surgical training, since they are intact and not altered by post-mortem changes yet. The aim of this study is to investigate the effectiveness of such kind of surgical training applied on some hepatic surgery techniques. In the present paper, we focused on split liver operation and middle hepatic vein (MHV) bipartition/reconstruction, since these procedures have a quite long learning curve. Seven native livers were submitted to split liver procedure by a senior resident assisted by a fully trained hepatic surgeon. Pre-splitting ultrasound mapping was compared to pre-operative CT scan. The whole graft was divided into two hemi-livers and the MHV into two hemi-confluents and reconstructed by venous or arterial patches obtained by deceased donor iliac homograft. Water tightness of the anastomosis was confirmed by hydro-pneumatic test and bench portal perfusion. Reduction in operating time was considered an indirect indicator of surgical skill improvement. In all cases, the US confirmed the anatomical distribution of MHV tributaries observed by pre-transplant CT scan. The "ex situ" splitting procedures and MHV bipartition and reconstruction were performed in all native livers in the usual time required for liver transplantation bench surgery (range 50-75 min). Liver grafts removed during hepatectomy could represent a useful resource of intact organs to perform surgical training and boost surgical confidence. In our initial experience, the study of venous drainage of the MHV and application of liver splitting technique and MHV reconstruction resulted technically feasible.

A rare cause of acute abdominal pain

Acute abdominal pain represents a challenge for the physician because it can hide a serious intra-abdominal pathology necessitating emergency intervention. A 65-year-old man presented to Emergency Department with sudden-onset abdominal pain. He underwent liver transplantation four years before. He complained tenderness on abdominal palpation. Blood chemistry and abdominal x-ray were normal. Contrast-enhanced computed tomography showed acute renal artery thrombosis. The patient underwent renal arterial thrombectomy and stent placement in less than two hours. Organ transplantation is a condition that makes patients at greater risk of life-threatening conditions. Renal artery thrombosis is a rare, severe and misdiagnosed condition which can benefit from a prompt cooperation among emergency physician, surgeon, and interventional radiologist. Transplant patients with acute abdominal pain should be considered at high risk of medical emergency. Acute renal artery thrombosis is a time dependent medical emergency in those patients with chronic drug-induced nephrotoxicity.

Percutaneous artery embolization of bleeding rectus sheath hematomas in hemodynamically unstable patients: Outcomes of 43 patients in a tertiary referral hospital

Rectus sheath hematoma (RSH) is an uncommon cause of abdominal pain that can lead to life-threatening bleeding, particularly in elderly patients receiving anticoagulation therapy. Type III RSHs, based on computer tomography (CT) evaluation, is characterized by active bleeding with intramuscular or intraperitoneal extension and hemodynamic instability. Medical contemporary knowledge of this condition is contentious and overall 20% of acute mortality has been reported. The purpose of this study was to retrospectively review our experience and outcomes in the management of RSHs treated with percutaneous arterial embolization of the epigastric vessels. We retrospectively analyzed 43 patients with RSH type III, submitted to percutaneous epigastric artery embolization from 2007 to 2015. Percutaneous arterial embolization was feasible and successful in patients with a high burden of comorbidities and receiving anticoagulation therapy. There was no acute mortality and a late mortality at 3 months of 9.1% (4/43) was not directly related to RSHs or arterial embolization. Patients with late mortality had lower ejection fraction, prolonged PTT, greater RDW and warfarin in overlapping with low-molecular-weight heparins. Transcatheter arterial embolization of the epigastric vessels was safe, feasible and effective in stopping the bleeding. Despite anti-platelets/anti-coagulation therapy and a high burden of comorbidities, there was no acute mortality related to RSH.

Air bubbles in the rectus abdominis muscle

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Advantage of endoscopic-ultrasound-fine-needle aspiration associated to Sendai clinical guidelines in detecting the malignant risk in patients with undetermined pancreatic cysts: Long-term follow-up

Aims: Contradictory information exists on whether different clinical guidelines are effective in detecting the malignant risk in patients with pancreatic cysts. We have retrospectively evaluated the accuracy and the long-term outcome in patients with pancreatic cysts with a diameter ≥ 2 cm when indication for surgery was established by clinical evaluation of their malignant risk according to Sendai Clinical Guidelines associated to endoscopic-ultrasound-fine-needle aspiration. Material and Methods: Patients with pancreatic cysts with a diameter ≥2 cm were evaluated for their potential malignant risk by endoscopic-ultrasound-fine-needle aspiration associated to the clinical evaluation by Sendai Clinical Guidelines. Long-term outcome and comparison in patients survival as well as the accuracy in detecting malignancies were evaluated with the combined clinical and endoscopic evaluation. Results: Two hundred eighteen patients with pancreatic cysts were observed during a nine-year period of the study and 74 of them (33.9%) presenting with a pancreatic cyst ≥2 cm were eligible for the study. Fourteen malignant neoplasms (18.9%) were detected. The accuracy in detecting malignancy of combined clinical and endoscopic evaluation was very high (0.99). The five-year survival rates for patients who underwent surgery with benign and malignant pancreatic cysts and for patients in observational follow-up were similar (70% and 85%). The cohort of patients with malignant pancreatic cysts with ductal adenocarcinoma showed a five-year survival rate of 41%. Conclusion: Endoscopic ultrasound fine-needle aspiration associated to Sendai clinical guidelines showed a high accuracy in detecting malignant risk in patients with pancreatic cysts with a diameter ≥ 2 cm. allowing appropriate selection for surgical treatment with satisfactory long-term survival.

Accuracy of point of care ultrasound to identify the source of infection in septic patients: a prospective study

Sepsis is a rapidly evolving disease with a high mortality rate. The early identification of sepsis and the implementation of early evidence-based therapies have been recognized to improve outcome and decrease sepsis-related mortality. The aim of this study was to compare the accuracy of the standard diagnostic work-up of septic patients with an integrated approach using early point of care ultrasound (POCUS) to identify the source of infection and to speed up the time to diagnosis. We enrolled a consecutive sample of adult patients admitted to the ED who met the Surviving Sepsis Campaign (SSC) criteria for sepsis. For every patient, the emergency physician was asked to identify the septic source after the initial clinical assessment and after POCUS. Patients were then addressed to the standard predefined work-up. The impression at the initial clinical assessment and POCUS-implemented diagnosis was compared with the final diagnosis of the septic source, determined by independent review of the entire medical record after discharge. Two hundred consecutive patients entered the study. A final diagnosis of the septic source was obtained in 178 out of 200 patients (89 %). POCUS-implemented diagnosis had a sensitivity of 73 % (95 % CI 66-79 %), a specificity of 95 % (95 % CI 77-99 %), and an accuracy of 75 %. Clinical impression after the initial clinical assessment (T0) had a sensitivity of 48 % (CI 95 % 41-55 %) and a specificity of 86 % (CI 95 % 66-95 %). POCUS improved the sensitivity of the initial clinical impression by 25 %. POCUS-implemented diagnoses were always obtained within 10 min. Instead the septic source was identified within 1 h in only 21.9 % and within 3 h in 52.8 % with a standard work-up. POCUS-implemented diagnosis is an effective and reliable tool for the identification of septic source, and it is superior to the initial clinical evaluation alone. It is likely that a wider use of POCUS in an emergency setting will allow a faster diagnosis of the septic source, leading to more appropriate and prompt antimicrobial therapy and source control strategies.

Endoscopic multiple metal stenting for the treatment of enteral leaks near the biliary orifice: A novel effective rescue procedure

Between April 2013 and October 2015, 6 patients developed periampullary duodenal or jejunal/biliary leaks after major abdominal surgery. In all patients, percutaneous drainage of the collection or re-operation with primary surgical repair was attempted at first but failed. A fully covered enteral metal stent was placed in all patients to seal the leak. Subsequently, we cannulated the common bile duct and, in some cases, and the main pancreatic duct inserting hydrophilic guidewires through the stent after dilating the stent mesh with a dilatation balloon or breaking the meshes with Argon Plasma Beam. Finally, we inserted a fully covered biliary metal stent to drain the bile into the lumen of the enteral stent. In cases of normal proximal upper gastrointestinal anatomy, a pancreatic plastic stent was also inserted. Oral food intake was initiated when the abdominal drain outflow stopped completely. Stent removal was scheduled four to eight weeks later after a CT scan to confirm the complete healing of the fistula and the absence of any perilesional residual fluid collection. The leak resolved in five patients. One patient died two days after the procedure due to severe, pre-existing, sepsis. The stents were removed endoscopically in four weeks in four patients. In one patient we experienced stent migration causing small bowel obstruction. In this case, the stents were removed surgically. Four patients are still alive today. They are still under follow-up and doing well. Bilio-enteral fully covered metal stenting with or without pancreatic stenting was feasible, safe and effective in treating postoperative enteral leaks near the biliopancreatic orifice in our small series. This minimally invasive procedure can be implemented in selected patients as a rescue procedure to repair these challenging leaks.

Spontaneous hepatic rupture during pregnancy in a patient with peliosis hepatis

Spontaneous hepatic rupture (SHR) during pregnancy is a rare but well known complication and it usually occurs alongside eclampsia or HELLP syndrome. SHR in uncomplicated pregnancy is extremely rare and can be associated to different undiagnosed pathological conditions. We report the case of a nulliparous woman, 27 weeks pregnant, with a peliosis hepatis, previously unknown, who was admitted to our unit due to SHR and massive hemoperitoneum. The conception was obtained by embryo transfer after multiple attempts of hormone-supported cycles using estrogens and progesterone. After emergency laparotomy the patient was submitted to deliver of the dead foetus and damage control of the hepatic bleeding source. At relaparotomy a right posterior sectionectomy (segments VI and VII) and segmentectomy of segment V were performed. The patient was discharged in good physical conditions after 18 days from admission. If hepatic rupture is suspected in a pregnant patient a collaborative multidisciplinary approach is mandatory. The cornerstones of medical and surgical management are highlighted. At the best of our knowledge this is the first case of SHR in a pregnant woman with peliosis hepatis. A possible correlation of an increased risk for SHR in a pregnant patient who was submitted to several attempts for embryo transfer is discussed. The relevant scientific literature of the possible causative role of the estrogen therapy in inducing politic liver damage is also reviewed.

Liver adenomatosis: a rare indication for living donor liver transplantation

Liver adenomatosis (LA) is a rare benign disease of the liver with unclear pathogenesis, which is characterized by multiple hepatic adenomas. The management of LA remains controversial. Herein we have reported a case of LA treated by living donor liver transplantation (LDLT). A 48-year-old woman developed multiple liver adenomas. In view of the sizes and localizations of the lesions, the patient underwent right hepatic resection and segment II nodulectomy. Thirty-four months later, she developed recurrence of multiple hepatic adenomas and 2 nodules were highly suspect for hepatocellular carcinoma. Re-resection was not indicated due to the whole liver being involved with adenomas. The patient underwent LDLT. At 45 months thereafter she is alive and disease-free. In conclusion, LDLT is indicated in cases of nonresectability; it may offer optimal results in view of the absence of portal hypertension and the elimination of waiting list time.

Living donor liver transplantation for hepatocellular carcinoma: long-term results compared with deceased donor liver transplantation

OBJECTIVE

Living donor liver transplantation (LDLT) may represent a valid therapeutic option allowing several advantages for patients affected by hepatocellular carcinoma (HCC) awaiting orthotopic liver transplantation (OLT). However, some reports in the literature have demonstrated worse long-term and disease-free survivals among patients treated by LDLT than deceased donor liver transplantation (DDLT) for HCC. Herein we have reported our long-term results comparing LDLT with DDLT for HCC.

PATIENTS AND METHODS

Among 179 patients who underwent OLT from January 2000 to December 2007, 25 (13.9%) received LDLT with HCC 154 (86.1%) received DDLT. Patients were selected based on the Milan criteria. Transarterial chemoembolization, radiofrequency ablation, percutaneous alcoholization, or liver resection was applied as a downstaging procedure while on the waiting list. Patients with stage II HCC were proposed for LDLT.

RESULTS

The overall 3- and 5-year survival rates were 77.3% and 68.7% versus 82.8% and 76.7% for LDLT and DDLT recipients, respectively, with no significant difference by the log-rank test. Moreover, the 3- and 5-year recurrence-free survival rates were 95.5% and 95.5% (LDLT) versus 90.5% and 89.4% (DDLT; P = NS).

CONCLUSIONS

LDLT guarantees the same long-term results as DDLT where there are analogous selection criteria for candidates. The Milan criteria remain a valid tool to select candidates for LDLT to achieve optimal long-term results.

Residual right portal branch flow after first-step ALPPS: artifact or homeostatic response?

BACKGROUND/AIMS

Mutual interactions between portal vein and hepatic artery can be documented during hepatobiliary surgery. Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) is a recently introduced surgical technique which can also represent a unique living human model to investigate intrahepatic blood circulation. We report three consecutive cases in which a residual right portal branch flow was clearly detectable after first-step ALPPS, and try to further investigate this unexpected finding with intraoperative clamping tests.

METHODOLOGY

Every patient was evaluated with CT scan 7 days after first-step ALPPS and Intraoperative Doppler Ultrasonography (IOUS) at both steps of the procedure.

RESULTS

In every patient, CT scan and second-step IOUS demonstrated a clear hepatopetal flow distally to the divided right portal branch. The flow was present after right biliary duct clamping and stopped after right total hilar clamping as well as after right hepatic artery occlusion.

CONCLUSIONS

Neither cross-portal circulation between the two hemilivers nor trans-sinusoidal backflow from the hepatic veins can explain these findings, which are rather consistent with a refilling of the occluded portal branch through the opening of intrahepatic arterioportal shunts (APS). APS could represent the simplest homeostatic mechanism that regulate intrahepatic blood flow.

Endoscopic ultrasound-guided fine-needle aspiration for suspected malignancies adjacent to the gastrointestinal tract

AIM: To investigate the impact of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) in association with a multidisciplinary team evaluation for the detection of gastrointestinal malignancies.

METHODS: A cohort of 1019 patients with suspected malignant lesions adjacent to the gastrointestinal tract received EUS-FNA after a standardized multidisciplinary team evaluation (MTE) and were divided into 4 groups according to their specific malignant risk score (MRS). Patients with a MRS of 0 (without detectable risk of malignancy) received only EUS without FNA. For patients with a MRS score ranging from 1 (low risk) - through 2 (intermediate risk) - to 3 (high risk), EUS-FNA cytology of the lesion was planned for a different time and was prioritized for those patients at higher risk for cancer. The accuracy, efficiency and quality assessment for the early detection of patients with potentially curable malignant lesions were evaluated for the whole cohort and in the different classes of MRSs. The time to definitive cytological diagnosis (TDCD), accuracy, sensitivity, specificity, positive and negative predictive values, and the rate of inconclusive tests were calculated for all patients and for each MRS group.

RESULTS: A total of 1019 patients with suspected malignant lesions were evaluated by EUS-FNA. In 515 patients of 616 with true malignant lesions the tumor was diagnosed by EUS-FNA; 421 patients with resectable lesions received early surgical treatment, and 94 patients received chemo-radiotherapy. The overall diagnostic accuracy for the 1019 lesions in which a final diagnosis was obtained by EUS-FNA was 0.95. When patients were stratified by MTE into 4 classes of MRSs, a higher rate of patients in the group with higher cancer risk (MRS-3) received early treatment and EUS-FNA showed the highest level of accuracy (1.0). TDCD was also shorter in the MRS-3 group. The number of patients who received surgical treatment or chemo-radiotherapy was significantly higher in the MRS-3 patient group (36.3% in MRS-3, 10.7% in MRS-2, and 3.5% in MRS-1).

CONCLUSION: EUS-FNA can effectively detect a curable malignant lesions at an earlier time and at a higher rate in patients with a higher cancer risk that were evaluated using MTE.

Living donor liver transplantation for hepatocellular carcinoma: the impact of neo-adjuvant treatments on the long term results

BACKGROUND/AIMS

LDLT may represent a valid therapeutic option allowing several advantages for patients affected by HCC and waiting for liver transplantation (LT). However, some reports show a worse long term survival and disease free survival among patients treated by LDLT for HCC than deceased donor liver transplantation (DDLT) recipients.

METHODOLOGY

Among 1145 LT patients, 63 received LDLT. From January 2000 to December 2008, 179 patients underwent LT due to HCC, 30 (16.7%) received LDLT and 154 (86.0%) received DDLT. Patients were selected based on the Milan criteria. TACE, radiofrequency ablation, percutaneous alcoholization, or liver resection were applied as downstaging procedures, while on the waiting list.

RESULTS

Overall 3- and 5-year survival rate was 77.3% and 68.7% vs. 82.8% and 76.7%, respectively for LDLT and DDLT recipient with not significant differences. Moreover, 3- and 5- years of recurrence free survival rate was 95.5% (LDLT) vs. 90.5% and 89.4% (DDLT) and resulted not significantly different.

CONCLUSIONS

LDLT guarantees same long term results than DDLT if the selection criteria of candidates are analogues. Milan criteria remains a valid candidate selection tool to obtain optimal long term results in LDLT. An aggressive downstaging policy seems to improve the long-term results in LDLT, thus LRT may be considered useful to prevent tumor progression waiting for transplantation as well as a neoadjuvant therapy for HCC. A literature detailed meta-analysis could definitely clarify if LDLT is an independent risk factor for HCC recurrence.

Repair of a mal-repaired biliary injury: A case report

Iatrogenic bile-duct injury post-laparoscopic cholecystectomy remains a major serious complication with unpredictable long-term results. We present a patient who underwent laparoscopic cholecystectomy for gallstones, in which the biliary injury was recognized intraoperatively. The surgical procedure was converted to an open one. The first surgeon repaired the injury over a T-tube without recognizing the anatomy and type of the biliary lesion, which led to an unusual biliary mal-repair. Immediately postoperatively, the abdominal drain brought a large amount of bile. A T-tube cholangiogram was performed. Despite the contrast medium leaking through the abdominal drain, the mal-repair was unrecognized. The patient was referred to our hospital for biliary leak. Ultrasound and cholangiography was repeated, which showed an unanatomical repair (right to left hepatic duct anastomosis over the T-tube), with evidence of contrast medium coming out through the abdominal drain. Eventually the patient was subjected to a definitive surgical treatment. The biliary continuity was re-established by a Roux-en-Y hepatico-jejunostomy, over transanastomotic external biliary stents. The patient is now doing well 4 years after the second surgical procedure. In reviewing the literature, we found a similar type of injury but we did not find a similar surgical mal-repair. We propose an algorithm for the treatment of early and late biliary injuries.

Atypical presentation of pioderma gangrenosum complicating ulcerative colitis: Rapid disappearance with methylprednisolone

Piodermal gangrenosum (PG) is an uncommon ulcerative cutaneous dermatosis associated with a variety of systemic diseases, including inflammatory bowel disease (IBD), arthritis, leukaemia, hepatitis, and primary biliary cirrhosis. Other cutaneous ulceration resembling PG had been described in literature. There has been neither laboratory finding nor histological feature diagnostic of PG, and diagnosis of PG is mainly made based on the exclusion criteria. We present here a patient, with ulcerative colitis (UC) who was referred to the emergency section with a large and rapidly evolving cutaneous ulceration. Laboratory and microbiological investigation associated with histological findings of the ulcer specimen allowed us to exclude autoimmune and systemic diseases as well as immuno-proliferative disorders. An atypical presentation of PG with UC was diagnosed. Pulse boluses of i.v. methyl-prednisolone were started, and after tapering steroids, complete resolution of the skin lesion was achieved in 3 wk. The unusual rapid healing of the skin ulceration with steroid mono-therapy and the atypical cutaneous presentation in this patient as well as the risk of misdiagnosis of PG in the clinical practice were discussed.

Renal Grafts From Elderly Donors: Histological Studies and Long-Term Results

To satisfy the increasing requests for renal grafts, elderly donors are increasingly accepted for kidney transplant at many centers. The main unresolved question is the long-term effect on graft survival of potential histological lesions due to donor age. We present a prospective histological study performed from January 1997 to December 2001 on 184 consecutively transplanted renal grafts in which the only criterion for graft acceptance was a normal value of serum creatinine upon admission to the intensive care unit independent of donor age. At the end of the study, 57 recipients (31%) of mean age 55 years (range 39 to 67 years) received a renal graft from donors aged more than 60 years (mean age 66 years; range 60 to 75 years), this cohort denoted as older donor kidney transplant group (ODKTG) and 127 recipients (69%) with a mean age of 49 years (range 21 to 63 years) received a renal graft from donors whose age was lower than 60 years (mean age 49 years; range 16 to 59 years), a cohort denoted as the younger donor kidney transplant group (YDKTG). The two groups were comparable for time of dialysis, cold ischemia time, immunosuppression therapy, grading of histological damage. At the end of the study with a mean follow-up of 5.6 years (range 3.5 to 7.5 years), primary graft nonfunction and delayed graft function were significantly more represented in the ODKTG than the YDKTG. Cumulative patient and graft survival was 84.3% and 79.4% in the ODKTG, respectively, and 93.8% and 85.9% in the YDKTG, respectively (P = NS). Cumulative serum creatinine values were 1.98 mg/100 mL in ODKTG and 1.65 mg/100 mL in YDKTG (P = NS). In conclusion, renal grafts from older donors presented histological damage comparable to that seen among renal grafts from younger donors.

De novo cancers and post-transplant lymphoproliferative disorder in adult liver transplantation

De novo cancer is one of the most serious complications after organ transplantation. Chronic immunosuppression, viral agents, pretransplant chronic alcohol-induced and other addictive behavior-induced injury are important conditions associated with the development of de novo cancers in solid organ transplants. The aim of the study was to evaluate types and clinical course of de novo cancers in adult liver transplant recipients. Data regarding 502 adult patients who underwent to 554 liver transplantations have been collected. Sex, age at transplantation, immunosuppressive regimen, time from transplantation to diagnosis of cancer, cancer type, surgical and non-surgical treatments and follow-up time have been analyzed as well as acute rejection episodes and viral status. Thirty patients developed 31 de novo cancers. The predominant tumors were carcinoma of the skin, lymphomas and Kaposi's sarcoma. Kaposi's sarcoma and lung cancer were associated with greater mortality. In lymphomas and Kaposi's sarcoma, a high rate of graft involvement was observed. In liver transplant recipients, de novo cancers demand strategies focusing on prophylactic and careful long-term screening protocols. Lymphomas and Kaposi's sarcoma should be ruled out in all patients with clinical manifestations of chronic biliary obstruction.

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.

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.

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.

Surgical Complications are the Main Cause of Pancreatic Allograft Loss in Pancreas-Kidney Transplant Recipients

We examined surgical complications among a group of diabetic type 1 patients (IDDM) with end-stage renal disease (ESRD) who had undergone pancreas-kidney transplantations (PK). Between October 1993 and August 2004, 70 SPK were performed using bladder (n = 14) or enteric (n = 56) drainage. Donors were selected according to standard criteria (mean age, 27.6 years; range, 17-49). All patients received cyclosporine-based immunosuppression. All pancreata functioned immediately, whereas 2 patients needed postoperative dialysis. Four patients (5.7%) lost their pancreatic graft due to vascular thrombosis; both patients underwent urgent allograft pancreaectomy and pancreas retransplantation (re-PT). One of them (1.4%) experienced a venous thrombosis and died due to a pulmonary embolism at 12 hours after re-PT. The other 3 patients had uneventful postoperative courses and were discharged with good pancreatic and renal function. Three patients in the bladder group (21.4%) had an anastomotic leak, which resolved with a bladder catheter. Four patients in the enteric group (7.1%) who experienced an anastomotic leak needed a second surgical procedure but in 3 of them allograft pancreatectomy was necessary. Relaparotomy was required in the other 3 patients due to hemorrhage (1 patient) or occlusion (2 patients). Acute rejection episodes, which occurred in 16 patients (22.8%), were treated with steroid boluses. With a mean follow-up of 72 months (range, 3-129), 2 patients have died at 8 and at 36 months, respectively, after SPK due to acute myocardial infarction (2.9%). Chronic rejection was the leading cause of pancreatic failure in 5 patients (7.1%) and of renal failure in 2 patients (2.8%). Patient, kidney, and pancreas survival rates were 95.8%, 92.9%, and 81.5%, respectively. Surgical complications were the leading cause of pancreatic allograft loss in IDDM and ESRD patients submitted to SPK.

Right Hemiliver Transplant: Results From Living and Cadaveric Donors

Although right hemiliver transplant from living donors (LD) is gaining acceptance as a way to overcome the critical organ shortage, splitting a liver for two adults from cadaveric donor (CD) is still controversial.

METHODS

From May 1999 to August 2004 we performed nine right hemiliver transplants using segments 5-6-7-8 from CD and 18 from LD.

RESULTS

We compared the two procedures to evaluate both the technical aspects and the patients' outcomes. In the CD group, three recipients died (33%), two of whom were UNOS Status 2A. Patient and graft survivals were 67% (median follow-up: 23 months). Among the LD group, three recipients died (17%) and two were retransplanted; one because of arterial thrombosis and the other as a consequence of small-for-size syndrome. Patient and graft survivals were 83% and 72%, respectively (median follow-up: 8 months). There were five early complications in the CD group (55%) and five (27%) in the LD group. Two patients in the LD group experienced a late stenosis of the biliary anastomosis.

DISCUSSION

Data from our early experience show that better results are achieved by right hemiliver transplants from LD; the morbidity and mortality are higher among the CD group. We believe that this finding is probably a consequence of better preoperative donor evaluation, shorter ischemia time, better logistics, and learning curve. Recipient selection is crucial; this kind of graft is at high risk of poor function, technical complications, and infections. Further experience will help to clarify the reliability of right hemiliver transplants from CD.

Massive haemoptysis after living donor liver transplantation

A 27 year old man with hereditary haemorrhagic telangiectasia who developed progressive liver dysfunction underwent living related right lobe transplantation. Pulmonary arteriography did not reveal arteriovenous malformation or abnormal intrapulmonary venous channels. The postoperative course was characterised by persistent hypoxaemia and respiratory failure developed. On day 6, a massive haemoptysis developed and the patient died shortly thereafter. The native liver showed a nodular pseudocirrhotic transformation, with highly dilated and irregularly interconnected vein-like or arterial-like structures in the fibrous septa. Pathological examination of both lungs showed irregular thickening of the wall of the arteries, secondary to eccentric and/or concentric myointimal hyperplasia. This case suggests that massive haemoptysis can develop even when arteriovenous malformations are undetectable by pulmonary arteriography, and it questions the role and the appropriateness of living donor liver transplantation in high risk patients.