Antonio Daniele Pinna

Use of porcine dermal collagen graft (Permacol) for hernia repair in contaminated fields

BackgroundComplicated hernias often involve contaminating surgical procedures in which the use of polypropylene meshes can be hazardous. Prostheses made of porcine dermal collagen (PDC) have recently been proposed as a means to offset the disadvantages of polypropylene meshes and have since been used in humans for hernia repairs. The aim of our study was to evaluate the safety and efficacy of incisional hernia repair using PDC as a mesh in complicated cases involving contamination.MethodsA prospective study of hernia repair of complicated incisional hernias with contamination using PDC grafts was carried out at the Department of General, Emergency and Transplant Surgery of St Orsola-Malpighi University Hospital.ResultsFrom January 2004 up to the writing of this article, seven patients were treated for complicated incisional hernias with a PDC prosthesis. In six out of seven patients a bowel resection was carried out. There were not surgical complications. Morbidity was 14.2%. No recurrences and wound infections were observed.ConclusionsIncisional hernioplasty using PDC grafts is a potentially safe and efficient approach in complicated cases with contamination.

Evaluation of extensive cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) in patients with advanced epithelial ovarian cancer.

Objective Although standard treatment for advanced epithelial ovarian cancer (EOC) consists of surgical debulking and intravenous platinum- and taxane-based chemotherapy, favorable oncological outcomes have been recently reported with the use of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). The aim of the study was to analyze feasibility and results of CRS and HIPEC in patients with advanced EOC. Materials/Methods This is an open, prospective phase 2 study including patients with primary or recurrent peritoneal carcinomatosis due to EOC. Thirty-nine patients with a mean (SD) age of 57.3 (9.7) years (range, 34–74 years) were included between September 2005 and December 2009. Thirty patients (77%) had recurrent EOC and 9 (23%) had primary EOC. Results For HIPEC, cisplatin and paclitaxel were used for 11 patients (28%), cisplatin and doxorubicin for 26 patients (66%), paclitaxel and doxorubicin for 1 patient (3%), and doxorubicin alone for 1 patient (3%). The median intra-abdominal outflow temperature was 41.5°C. The mean peritoneal cancer index (PCI) was 11.1 (range, 1–28); and according to the intraoperative tumor extent, the tumor volume was classified as low (PCI <15) or high (PCI ≥15) in 27 patients (69%) and 12 patients (31%), respectively. Microscopically complete cytoreduction was achieved for 35 patients (90%), macroscopic cytoreduction was achieved for 3 patients (7%), and a gross tumor debulking was performed for 1 patient (3%). Mean hospital stay was 23.8 days. Postoperative complications occurred in 7 patients (18%), and reoperations in 3 patients (8%). There was one postoperative death. Recurrence was seen in 23 patients (59%) with a mean recurrence time of 14.4 months (range, 1–49 months). Conclusions Hyperthermic intraperitoneal chemotherapy after extensive CRS for advanced EOC is feasible with acceptable morbidity and mortality. Complete cytoreduction may improve survival in highly selected patients. Additional follow-up and further studies are needed to determine the effects of HIPEC on survival.

Contrast-enhanced ultrasonography in blunt abdominal trauma: considerations after 5 years of experience

PurposeThe aim of the study was to evaluate the diagnostic capability of contrast-enhanced ultrasonography (CEUS) in a large series of patients with blunt abdominal trauma.Materials and methodsWe studied 133 haemodynamically stable patients with blunt abdominal trauma. Patients were assessed by ultrasonography (US), CEUS and multislice computed tomography (MSCT) with and without administration of a contrast agent. The study was approved by our hospital ethics committee (clinical study no. 1/2004/O).ResultsIn the 133 selected patients, CT identified 84 lesions; namely, 48 splenic, 21 hepatic, 13 renal or adrenal and two pancreatic. US identified free fluid or parenchymal alterations in 59/84 patients with positive CT and free fluid in 20/49 patients with negative CT. CEUS detected 81/84 traumatic lesions identified on CT and ruled out traumatic lesions in 48/49 patients with negative CT. The sensitivity, specificity and positive and negative predictive values of US were 70.2%, 59.2%, 74.7% and 53.7%, respectively, whereas those of CEUS were 96.4%, 98%, 98.8% and 94.1%, respectively.ConclusionsOur study showed that CEUS is an accurate technique for evaluating traumatic lesions of solid abdominal organs. The technique is able to detect active bleeding and vascular lesions, avoids exposure to ionising radiation and is useful for monitoring patients undergoing conservative treatment.RiassuntoObiettivoScopo di questo lavoro è stato valutare le possibilità diagnostiche dell’ecografia con mezzo di contrasto (CEUS) in un’ampia serie di pazienti con trauma chiuso dell’addome.Materiali e metodiSono stati studiati 133 pazienti con trauma addominale chiuso, emodinamicamente stabili. I pazienti sono stati valutati con ecografia (US), CEUS e tomografia computerizzata (TC) multistrato senza e con mezzo di contrasto (MdC). Lo studio è stato approvato dal comitato etico dell’Ospedale (studio clinico no1/2004/O).RisultatiNei 133 pazienti la TC ha identificato 84 lesioni, 48 spleniche, 21 epatiche, 13 renali o surrenaliche e 2 pancreatiche. L’US ha identificato versamento libero o alterazioni parenchimali in 59/84 pazienti positivi alla TC e versamento libero in 20/49 pazienti negativi alla TC. La CEUS ha riconosciuto 81/84 lesioni traumatiche identificate dalla TC e ha escluso lesioni traumatiche in 48/49 pazienti negativi alla TC. Sensibilità, specificità, valore predittivo positivo e negativo per l’US sono stati rispettivamente 70,2%, 59,2%, 74,7% e 53,7%; per la CEUS sono stati 96,4%, 98%, 98,8% e 94,1%.ConclusioniLo studio ha dimostrato che la CEUS è uno strumento accurato nella valutazione delle lesioni traumatiche degli organi solidi addominali. La metodica riconosce il sanguinamento attivo e le lesioni vascolari, evita l’esposizione a radiazioni ionizzanti ed è utile nel monitoraggio dei pazienti con trattamento conservativo.

Liver transplantation for “very early” intrahepatic cholangiocarcinoma: International retrospective study supporting a prospective assessment

The presence of an intrahepatic cholangiocarcinoma (iCCA) in a cirrhotic liver is a contraindication for liver transplantation in most centers worldwide. Recent investigations have shown that “very early” iCCA (single tumors ≤2 cm) may have acceptable results after liver transplantation. This study further evaluates this finding in a larger international multicenter cohort. The study group was composed of those patients who were transplanted for hepatocellular carcinoma or decompensated cirrhosis and found to have an iCCA at explant pathology. Patients were divided into those with “very early” iCCA and those with “advanced” disease (single tumor >2 cm or multifocal disease). Between January 2000 and December 2013, 81 patients were found to have an iCCA at explant; 33 had separate nodules of iCCA and hepatocellular carcinoma, and 48 had only iCCA (study group). Within the study group, 15/48 (31%) constituted the “very early” iCCA group and 33/48 (69%) the “advanced” group. There were no significant differences between groups in preoperative characteristics. At explant, the median size of the largest tumor was larger in the “advanced” group (3.1 [2.5‐4.4] versus 1.6 [1.5‐1.8]). After a median follow‐up of 35 (13.5‐76.4) months, the 1‐year, 3‐year, and 5‐year cumulative risks of recurrence were, respectively, 7%, 18%, and 18% in the very early iCCA group versus 30%, 47%, and 61% in the advanced iCCA group, P = 0.01. The 1‐year, 3‐year, and 5‐year actuarial survival rates were, respectively, 93%, 84%, and 65% in the very early iCCA group versus 79%, 50%, and 45% in the advanced iCCA group, P = 0.02. Conclusion: Patients with cirrhosis and very early iCCA may become candidates for liver transplantation; a prospective multicenter clinical trial is needed to further confirm these results. (Hepatology 2016;64:1178‐1188)

Liver transplantation for hepatic tumors: A systematic review

Improvements in the medical and pharmacological management of liver transplantation (LT) recipients have led to a better long-term outcome and extension of the indications for this procedure. Liver tumors are relevant to LT; however, the use of LT to treat malignancies remains a debated issue because the high risk of recurrence. In this review we considered LT for hepatocellular carcinoma (HCC), cholangiocarcinoma (CCA), liver metastases (LM) and other rare tumors. We reviewed the literature, focusing on the past 10 years. The highly selected Milan criteria of LT for HCC (single nodule < 5 cm or up to 3 nodules < 3 cm) have been recently extended by a group from the University of S. Francisco (1 lesion < 6.5 cm or up to 3 lesions < 4.5 cm) with satisfying results in terms of recurrence-free survival and the up-to-seven criteria. Moreover, using these criteria, other transplant groups have recently developed downstaging protocols, including surgical or loco-regional treatments of HCC, which have increased the post-operative survival of recipients. CCA may be treated by LT in patients who cannot undergo liver resection because of underlying liver disease or for anatomical technical challenges. A well-defined protocol of chemoirradiation and staging laparotomy before LT has been developed by the Mayo Clinic, which has resulted in long term disease-free survival comparable to other indications. LT for LM has also been investigated by multicenter studies. It offers a real benefit for metastases from neuroendocrine tumors that are well differentiated and when a major extrahepatic resection is not required. If LT is an option in these selected cases, liver metastases from colorectal cancer is still a borderline indication because data concerning the disease-free survival are still lacking. Hepatoblastoma and hemangioendothelioma represent rare primary tumors for which LT is often the only possible and effective cure because of the frequent multifocal, intrahepatic nature of the disease. LT is a very promising procedure for both primary and secondary liver malignancies; however, it needs an accurate evaluation of the costs and benefits for each indication to balance the chances of cure with actual organ availability.

Gastrointestinal Perforations Following Kidney Transplantation

This study reports major gastrointestinal (GI) complications among a group of 1611 patients following kidney transplantation. The immunosuppressive regimen changed somewhat during the course of the study but included azathioprine, prednisolone, antilymphocyte globulin, cyclosporine, tacrolimus, mycophenolate mofetil, and sirolimus. Perforations occurred in the colon (n=21), small bowel (n=15), duodenum (n=6), and stomach (n=4). Nearly 50% of the complications occurred while patients were being given high-dose immunosuppression to manage either the early postoperative period or acute rejection episodes. Of the 46 patients affected, 11 (24%) died as a direct result of the GI complication. This high mortality appeared to be related to the effects of the immunosuppression and the associated response to sepsis. Reduction of these complications may be achieved by improved surgical management, preventive measures, prompt diagnosis, and a reduced immunosuppressive protocol.

Adverse effects of porcine small intestine submucosa (SIS) implants in experimental ventral hernia repair

• Porcine small intestine submucosa has a wide literature [2] with many experimental and clinical data and these adverse effects are not reported. • The study was based only on a limited sample of 20 rats. • Experiments were not repeated. • There was not a control group (it is not possible to have one of the two randomized group serving as control). • All samples had extensive infectious problems (in scientific models, 100% value is sometimes caused by methodological errors). • SIS is reabsorbed after 8–10 months [3, 4]. • There are too many results totally discordant from the rest of the literature.

Kidney preservation: review of present and future perspective.

One of the main problems in transplant surgery is the preservation of the organ during the cold ischemic time. The interrupted blood supply triggers a cascade of biological modifications resulting in cell death, which predisposes to discharge of a large quantity of toxic metabolites at the moment of organ reperfusion. Many approaches have been studied to prevent the toxic processes. Immediately after procurement, kidneys are flushed with these solutions. Two main: techniques of organ preservation are cold static storage and hypothermic machine perfusion (HMP). Based on age and comorbidities, individuals can be generally divided into 2 groups: ideal and marginal donors. Characteristics of organs from marginal donors are associated with an increased rate of delayed graft function and primary graft nonfunction (PNF), which reduce transplant survival and increase the acute rejection risk. In the last 20 years, the United Network of Organ Sharing has reported a 170% increase in deceased donors older than 50 years of age. Techniques of perfusion have been demonstrated to play a pivotal role in graft function after transplantation. Some studies suggest that HMP may improve outcomes after transplantation.

Colonic perforation after renal transplantation: risk factor analysis.

INTRODUCTIONnThe incidence of gastrointestinal (GI) complication in renal transplantation is relatively high. These complications may be severe, leading to graft loss and patient death.nnnMATERIALS AND METHODSnWe reviewed 1651 patients who underwent renal transplantation between 1976 and 2007, analyzing the incidence of colonic perforations and the clinical prognostic factors.nnnRESULTSnTwenty-one patients (1.3%) developed colonic perforations with 7 subsequent deaths. Diverticulitis and ischemia were the most common causes of perforation. Eleven patients (52.3%) were diagnosed and treated within the first 24 hours; their mortality was 18.1%. The 10 patients (47.7%) who were diagnosed and treated 24 hours after the clinical event displayed an high mortality rate (50%). Diverting stoma procedures were performed in all cases.nnnCONCLUSIONSnThe follow-up of the kidney transplant patients should include a careful evaluation for possible GI complications and colonic perforations. Early diagnosis and timely treatment were associated with improved outcomes, regardless of the surgical procedures, the cause of perforation or the clinical and laboratory parameters.

Hemothorax caused by rupture of a primitive thoracic leiomyosarcoma of the thoracic aorta: Description of a case and literature review

T he first diagnosis of leiomyosarcoma of a large blood vessel (inferior vena cava) was made by Wirchow, as reported by Varela-Duran, Oliva, Rosai, and it was later described by Perl in 1871. In 1873 Brodowsky reported the first case of aortic leiomyosarcoma. Since then, 32 cases of aortic leiomyosarcoma have been reported in the literature but only 4 cases of thoracic leiomyosarcoma treated in an emergency setting (Table 1). The emergency diagnosis of aortic leiomyosarcoma can be problematic. Because of the initial presentation, the first strategy is always to treat a more common problem (ruptured thoracic aorta). It is then necessary to change the approach while the operation is being carried out according to oncologic surgery principles. Leiomyosarcomas are clinically silent until the moment of rupture, and the emergency operation has a high perioperative mortality related to hemorrhagic shock. Owing to its biologic properties, leiomyosarcoma frequently relapses and gives rise to metastasis with a high mortality rate within the first 2 years after diagnosis. In the present study we report a case of a patient with leiomyosarcoma of the descending thoracic aorta with contained rupture who required an emergency operation. We discuss diagnostic and therapeutic problems with a review of the literature.