Paolo Gazzetta

Bariatric Surgery to Target Obesity in the Renal Transplant Population: Preliminary Experience in a Single Center

During the last century, obesity has become a global epidemic. The effect of obesity on renal transplantation may occur in perioperative complications and impairment of organ function. Obese patients have metabolic derangements that can be exacerbated after transplantation and obesity directly impacts most transplantation outcomes. These recipients are more likely to develop adverse graft events, such as delayed graft function and early graft loss. Furthermore, obesity is synergic to some immunosuppressive agents in triggering diabetes and hypertension. As behavioral weight loss programs show disappointing results in these patients, bariatric surgery has been considered as a means to achieve rapid and long-term weight loss. Up-to-date literature shows laparoscopic bariatric surgery is feasible and safe in transplantation candidates and increases the rate of transplantation eligibility in obese patients with end-stage organ disease. There is no evidence that restrictive procedures modify the absorption of immunosuppressive medications. From 2013 to 2016 we performed six bariatric procedures (sleeve gastrectomy) on obese patients with renal transplantation; mean preoperative body mass index (BMI) was 39.8 kg/m2. No postoperative complication was observed and no change in the immunosuppressive medications regimen was needed. Mean observed estimated weight loss was 27.6%, 44.1%, 74.2%, and 75.9% at 1, 3, 6, and 12 months follow-up, respectively. Our recommendation is to consider patients with BMI >30 kg/m2 as temporarily ineligible for transplantation and as candidates to bariatric surgery if BMI >35 kg/m2. We consider laparoscopic sleeve gastrectomy as a feasible, first-choice procedure in this specific population.

Renal Resistance Trend During Hypothermic Machine Perfusion Is More Predictive of Postoperative Outcome Than Biopsy Score: Preliminary Experience in 35 Consecutive Kidney Transplantations: RENAL RESISTANCE IN HYPOTHERMIC MACHINE PERFUSION

Hypothermic machine perfusion (HPM) grants a better postoperative outcome in transplantation of organs procured from extended criteria donors (ECDs) and donors after cardiac death (DCD). So far, the only available parameter for outcome prediction concerning those organs is pretransplant biopsy score. The aim of this study is to evaluate whether renal resistance (RR) trend during HPM may be used as a predictive marker for post-transplantation outcome. From December 2015 to present, HMP has been systematically applied to all organs from ECDs and DCD. All grafts underwent pretransplantation biopsy evaluation using Karpinskis histological score. Only organs that reached RR value ≤1.0 within 3 hours of perfusion were transplanted. Single kidney transplantation (SKT) or double kidney transplantation (DKT) were performed according to biopsy score results. Sixty-five HMPs were performed (58 from ECDs and 7 from DCD/ECMO donors). Fifteen kidneys were insufficiently reconditioned (RR > 1) and were therefore discarded. Forty-nine kidneys were transplanted, divided between 21 SKT and 14 DKT. Overall primary nonfunction (PNF) and delayed graft function (DGF) rate were 2.9 and 17.1%, respectively. DGF were more common in kidneys from DCD (67 vs. 7%; P = 0.004). Biopsy score did not correlate with PNF/DGF rate (P = 0.870) and postoperative creatinine trend (P = 0.796). Recipients of kidneys that reached RR ≤ 1.0 within 1 hour of HMP had a lower PNF/DGF rate (11 vs. 44%; P = 0.033) and faster serum creatinine decrease (POD10 creatinine: 1.79 mg/dL vs. 4.33 mg/dL; P = 0.019). RR trend is more predictive of post-transplantation outcome than biopsy score. Hence, RR trend should be taken into account in the pretransplantation evaluation of the organs.

Does inferior mesenteric artery ligation affect outcome in elective colonic resection for diverticular disease?: IMA ligation in diverticular disease

The aim of our study was to analyse the role of inferior mesenteric artery (IMA) ligation during elective colonic resection for diverticular disease (DD) with respect to surgical outcome.

New trends in management of colorectal cancer

The first two-day, San Raffaele meeting on the new trends in management of colorectal cancer took place on October 22 and 23 in Milan, a city renowned as the industrial and financial center of Italy, and one of the world’s major fashion and design capitals, which will host the EXPO 2015. The meeting was attended by more than 250 scientists and 61 speakers from 11 countries. The topics included preoperative workup, treatment options, surgical techniques, and advances in treatment for metastatic disease, with particular emphasis on liver metastases and peritoneal carcinomatosis. The genetic and molecular basis of colorectal cancer and the response of the disease to chemotherapy, especially neoadjuvant chemotherapy, were also investigated. Colorectal cancer is the third most common cancer worldwide and the second leading cause of cancer-related death; therefore, accurate prevention strategies are needed. The results of the first randomized trial, due about 10 years from now, are expected to clarify which is the best screening method to reduce colorectal cancer-related mortality. Accuracy of local staging is of pivotal importance in low rectal cancer, since locally advanced disease is currently an indication for neoadjuvant chemoradiotherapy. Magnetic resonance imaging is now considered to have the highest diagnostic accuracy, whereas endorectal ultrasound has a higher sensitivity in the evaluation of early lesions and can help to determine which ones are suitable for local excision. Concerns were raised about the reliability of both methods for correct staging of metastatic lymph nodes and for restaging after neoadjuvant treatment. Recent studies have suggested that positron emission tomography may be a promising tool in this setting. About 10–20 % of patients with locally advanced rectal cancer achieve a pathological complete response after primary chemoradiation. A careful wait-and-see policy could prevent patients with a complete clinical response from having surgery, as suggested by A. Habr-Gama. E. Lezoche proposed a minimally invasive transanal approach for selected early rectal tumors. Thanks to recent improvements in surgical techniques, sphincter-saving surgery is now feasible in up to 80 % of patients with very low rectal cancer, allowing a dramatic reduction in the number of permanent stomas. Two of the most recent approaches to restoring intestinal continuity, in patients who would otherwise require a permanent stoma, are the inter-sphincteric resection proposed by R. Schiessel, and the extra-sphincteric approach proposed by N. Williams with the anterior perineal plane approach (APPEAR technique). Both techniques can also be combined with a laparoscopic anterior dissection of the rectum, which is the preferred method at our institution. A lecture focusing on the role of minimally invasive surgery for colon and rectal cancer was given by C. Staudacher, the president of the meeting. The diagnosis of synchronous liver metastases is not rare in colorectal cancer (15–20 %). The timing of surgical treatment and liver resection is still debated and must take into account patients’ symptoms and performance status, which should be discussed in a multidisciplinary setting. Continuous progress in the development of laparoscopic techniques and devices has improved the feasibility and outcome of laparoscopic liver resections; yet, the indication P. De Nardi (&) P. Gazzetta Department of Surgery San Raffaele Scientific Institute, Milan, Italy e-mail: denardi.paola@hsr.it