Giovanni Capovilla

A single-center experience with 200 dual kidney transplantations

This study reports on a large series of 200 dual kidney transplantations (DKTs) from expanded criteria donors (ECDs) and proposes specific ways to optimize outcomes. Data concerning 200 DKTs performed in the last 14 yr were retrospectively analyzed. Kidneys from high‐risk ECD were allocated for use in DKTs on an old‐for‐old basis after histological assessment. Different surgical techniques and immunosuppressant regimens were used over time, and the outcomes are discussed. Donors and recipients were a median 73 (70–77) and a 62 (58–67) yr old, respectively. Delayed graft function occurred in 31.5% of cases, and acute rejection in 13.5%. Patient and graft survival at five yr were 90.4% and 85.8%, respectively. Unilateral kidney placement was preferred for 75% of patients, and was associated with a low rate of surgical complications. Our current standard therapy comprising low‐dose calcineurin inhibitors (CNIs) associated with mammalian target of rapamycin inhibitors (mTOR) and steroids appears to offer the best risk/benefit profile for elderly patients undergoing DKT. In our experience, outcomes after DKT can be improved by: (i) kidney clinical–histological assessment; (ii) unilateral kidney placement; (iii) minimal use of CNI associated with mTOR.

Lethal Effect of a Single Dose of Rasburicase in a Preterm Newborn Infant

This case report describes a preterm newborn infant who was treated with a single dose of rasburicase for an increase in uric acid level. He died on the third day as a result of complications of hemolysis, which appeared to be precipitated by rasburicase. The patient’s death was preceded by progressive respiratory insufficiency, lactic acidosis, and hyperbilirubinemia, culminating in refractory hypoxia and hypotension. A postmortem assay for glucose-6-phosphate dehydrogenase showed deficiency and the glucose-6-phosphate dehydrogenase Mediterranean genotype.

Mo1884 Inter-Rater and Inter-Device Agreement for the Diagnosis of Primary Esophageal Motility Disorders Based on Chicago Classification Between Solid-State and Water-Perfused HRM System -A Prospective, Randomized, Double Blind, Crossover Study

Background:High ResolutionManometry (HRM) is a new technique for intraluminal esophageal pressure measurement that employs an increased number of pressure sensors spaced closely together. Two systems have now become widely available: the 36 solid-state (SS) pressure transducers system, used to create the new Chicago Classification (CC) for Primary Esophageal Motility Disorders, and the recently introduced 24-channel water perfused (WP) system. Comparative data in terms of inter-device pressure parameters variability and diagnostic accuracy are lacking. Aim: To assess and compare normal values for pressure measurements between the 36-SS and the 24-WP HRM systems. Moreover, diagnostic inter-rater and inter-device agreement in a group of patients with esophageal symptoms were assessed. Methods: In this prospective, randomized, double blind, crossover study, 20 healthy volunteers [HVs; 11M/9F; median age 29 (IQR 26-33)] and 20 patients [11M/9F; 48 (43-55)] with esophageal symptoms (i.e. reflux symptoms, chest-pain or dysphagia) underwent HRM with both 36-SS (Given Imaging, Los Angeles, CA) and 24-WP (EB Neuro, Firenze, Italy) systems, in random order. Normal values from HVs were obtained and compared using non-parametric statistical analysis. Two expert reviewers (RS, ES) performed a blindfolded analysis of the patients tracings. Diagnoses based on CC in patients with esophageal symptoms were formulated. Inter-rater and inter-device agreement for each reviewer were evaluated by means of Cohens k value. Results: As shown in the Figure, there were significant differences between the 2 HRM systems, mainly regarding the measurements of Lower Esophageal Sphincter (LES) and Upper Esophageal Sphincter (UES) basal pressure (p<0.01 and p=0.02, respectively), wave amplitude at 3 cm above the LES (p<0.01) and wave duration at 3, 7 and 11 cm above the LES (p<0.01, p<0.01 and p=0.01, respectively). Almost, all CC parameters were significantly different between the two HRM systems: Integrated Relaxation Pressure (IRP) (p=0.01), Distal Contractile Integral (DCI) (p=0.02) and Distal Latency (DL) (p<0.01). Diagnostic inter-rater agreement was higher for SS system (k=1) than for WP system (k=0,68). Diagnostic inter-device agreement was moderate for both reviewers (k[RS]= 0.5; k[ES]=0.4).Conclusions:Compared to the SS system, theWP technique underestimated almost all pressure measurements, including the CC parameters. This is likely due to the increased compliance of the WP system at low water perfusion rates, leading to poor interrater diagnosis reproducibility and inter-device agreement. By contrast, the SS system appears high reproducible in terms of inter-rater agreement. Thus, caution about the interpretation and application of CC in all HRM systems is recommended.

Gastrointestinal stromal tumour (GIST) presenting as a strangulated inguinal hernia with small bowel obstruction

Gastrointestinal stromal tumours (GISTs) can arise everywhere along the gastrointestinal (GI) tract. Their presentation in unusual locations should always be taken into account. A 74-year-old man referred to the emergency department for small bowel obstruction caused by an incarcerated inguinal hernia. A CT scan showed a mesenchymal tumour originating from the herniated bowel loop and a mass in the ascending colon. Laparoscopic resection of the mass and laparoscopic right hemicolectomy were performed. The histology showed a ruptured GIST arising from the herniated small bowel and a high-grade dysplasia villous adenoma of the right colon. GISTs can present with symptoms spanning from vague abdominal discomfort to surgical urgencies. Strangulated hernia is an extremely rare presentation, with only two cases described in the literature. A safe surgical approach was obtained with laparoscopy, maintaining surgical radicality. The ileal localisation and the pseudocapsule rupture were the main risk factors on prognostic stratification.

Blood transfusions and steatohepatitis are independent risk factors for complications following liver resection for colorectal cancer liver metastases

The aim of the present study was to evaluate the risk factors for postoperative complications following liver resection for colorectal cancer liver metastases. Patients who underwent hepatic resection for colorectal cancer liver metastases were stratified according to chemotherapy administration and body mass index (BMI) to eliminate potential confounding factors. A univariate analysis was conducted to identify potential risk factors for postoperative complications following liver resection. Variables that exhibited a potential association were evaluated by multivariable logistic regression analysis to identify those independently associated with postoperative morbidity. Between January 2012 and March 2012, 100 patients underwent hepatic resection for liver metastases from colorectal carcinoma at the Treviso Regional Hospital (Treviso, Italy) and at the Regina Elena National Cancer Institute (Rome, Italy). Of the 100 patients, 61 received preoperative oxaliplatin- or irinotecan-based chemotherapy. A total of 25 the patients had a BMI of ≥28 kg/m2. On univariate analysis, BMI ≥28 kg/m2 was found to be positively correlated with the presence of steatosis (P<0.01) and steatohepatitis (P<0.01). The administration of preoperative chemotherapy was correlated with the development of steatosis (P<0.01), steatohepatitis (P=0.02) and postoperative complications (P=0.03). Even following stratification for the use of preoperative chemotherapy, BMI ≥28 kg/m2 maintained its positive association with steatohepatitis. On multivariate analysis, steatohepatitis (P=0.005, HR=0.118, 95% CI: 0.027–0.518) and blood transfusions (P=0.001, HR=0.131, 95% CI: 0.038–0.452) were independently associated with postoperative complications. BMI ≥28 kg/m2 (P=0.004, HR=8.30, 95% CI: 2.39–28.7) and irinotecan treatment (P=0.016, HR=0.16, 95% CI: 0.037–0.711) were independent risk factors for steatohepatitis. In conclusion, steatohepatitis and perioperative blood transfusions were found to be the main determinant of postoperative complications following liver resection for colorectal liver metastases. Overweight patients may be more prone to the cytotoxic effects of irinotecan, harboring a higher risk of developing steatohepatitis.

1011 Post-Operative Gastroesophageal Reflux After Laparoscopic Heller-Dor for Achalasia: True Incidence With an Objective Evaluation

Introduction The most common complication after laparoscopic Heller-Dor (LHD) is gastroesophageal reflux disease (GERD). The present study aimed (a) to analyze the true incidence of postoperative reflux by objectively assessing a large group of LHD patients and (b) to see whether the presence of typical GERD symptoms correlates with the real incidence of postoperative reflux.

455 Laparoscopic Heller Myotomy Can Be Used As Primary Therapy for Esophageal Achalasia Regardless of Age

Introduction Laparoscopic Heller-Dor surgery is the current treatment of choice for patients with esophageal achalasia, but elderly patients are generally referred for less invasive treatments (pneumatic dilations or botulinum toxin injections).