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Hepatitis C virus (HCV) infection unfavorably affects the survival of both renal patients undergoing hemodialysis and renal transplant recipients. In this subset of patients, the effectiveness and safety of different combinations of interferon-free direct-acting antiviral agents (DAAs) have been analyzed in several small studies. Despite fragmentary, the available data demonstrate that DAA treatment is safe and effective in eradicating HCV infection, with a sustained virologic response (SVR) rates nearly 95% and without an increased risk of allograft rejection. This review article analyzes the results of most published studies on this topic to favor more in-depth knowledge of the readers on the subject. We suggest, however, perseverating in this update as the optimal DAA regimen may not be proposed yet, because of the expected arrival of newer DAAs and of the lack of data from large multicenter randomized controlled trials.

The prevalence of chronic pain is between 33% to 64% and is due to cancer pain, but it has also been observed in non-cancer patients. Chronic pain is associated with lower quality of life and higher psychological distress and depressive/anxiety disorders in patients without a history of disorder. In this study we evaluated in clinical practice the effectiveness of the intrathecal pump in 140 patients who underwent pain therapy at our Center. These patients were consecutively enrolled from January 2010 to July 2018. Follow-up was carried out over these eight years regarding the infusion modalities. Pain relief was obtained in 71 (50,7%) patients out of the 140 that experienced satisfactory pain control globally. Intrathecal therapy is one of the best options for chronic severe refractory pain. The greatest advantage of this therapy is due to the possibility of treating the pain with minimal dosages of the drug, avoiding the appearance of troublesome side effects.

Kidney transplantation is the surgical operation by which one of the two original kidneys is replaced with another healthy one donated by a compatible individual. In most cases, donors are recently deceased. There is the possibility of withdrawing a kidney from a consenting living subject. Usually, living donors are direct family members, but they could be volunteers completely unrelated to the recipient. A much-feared complication in case of kidney transplantation is the appearance of infections. These tend to arise due to immune-suppressor drugs administered as anti-rejection therapy. In this review, we describe the gastrointestinal complications that can occur in subjects undergoing renal transplantation associated with secondary pathogenic microorganisms or due to mechanical injury during surgery or to metabolic or organic toxicity correlated to anti-rejection therapy. Some of these complications may compromise the quality of life or pose a significant risk of mortality; fortunately, many of them can be prevented and treated without the stopping the immunosuppression, thus avoiding the patient being exposed to the risk of rejection episodes., Graphical abstract

Aims. We aimed to summarize available evidence about intraoperative and postoperative donors’ and recipients’ outcomes following stone surgery in renal grafts from living donors performed either before donation or as ex vivo bench surgery at the time of living-donor nephrectomy. Methods. A systematic review of PubMed, ISI Web of Knowledge, and Scopus databases was performed in September 2020. We included full papers that met the following criteria: original research, English language, human studies, and describing the results of stone surgery in renal grafts from living donors performed either before transplantation or as ex vivo bench surgery. Results. We identified 11 studies involving 106 patients aged between 22 and 72 years. Predonation and bench stone surgery was performed in 9 (8.5%) and 96 (90.6%) patients, respectively. Predonation stone surgery involved extracorporeal shock wave lithotripsy, retrograde intrarenal surgery, and percutaneous nephrolithotomy in 8, 1, and 1 patient, respectively. The overall success rate of predonation stone surgery was 78%, and the complication rate was 0%. Bench stone surgery involved ureteroscopy, pyelolithotomy, or a combination of both in 79 (82.3%), 10 (10.4%), and 7 (7.3%) cases, respectively, with an overall success rate of 95.8% and an overall complication rate of 9.37%. Conclusions. Predonation and bench stone surgery in grafts from living donors represents efficacious and safe procedures. Further studies on wider series with a longer follow-up are required.

Aims. We aimed to summarize available lines of evidence about intraoperative and postoperative donor outcomes following robotic-assisted laparoscopic donor nephrectomy (RALDN) as well as outcomes of graft and recipients.Methods.A systematic review of PubMed/Medline, ISI Web of Knowledge, and Scopus databases was performed in May 2018. The following search terms were combined: nephrectomy, robotic, and living donor. We included full papers that met the following criteria: original research; English language; human studies; enrolling patients undergoing RALDN.Results. Eighteen studies involving 910 patients were included in the final analysis. Mean overall operative and warm ischemia times ranged from 139 to 306 minutes and from 1.5 to 5.8 minutes, respectively. Mean estimated blood loss varied from 30 to 146 mL and the incidence of intraoperative complications ranged from 0% to 6.7%. Conversion rate varied from 0% to 5%. The mean hospital length of stay varied from 1 to 5.8 days and incidence of early postoperative complications varied from 0% to 15.7%. No donor mortality was observed. The incidence of delayed graft function was reported in 7 cases. The one- and 10-year graft loss rates were 1% and 22%, respectively.Conclusions.Based on preliminary data, RALDN appears as a safe and effective procedure.

Background Neoadjuvant chemoradiotherapy has a significant role in downstaging cancer. It improves the local control of the disease and can make conservative resection of rectal cancer possible. Methods We enrolled 114 patients with subperitoneal rectal cancer who underwent neoadjuvant chemoradio-therapy and radical excision with total mesorectal excision (TME). The primary endpoint was oncological outcomes and the secondary endpoint was surgical outcomes.We evaluate the experience of a multidisciplinary team and the role of neoadjuvant chemoradiotherapy in integrated treatment of cancer of the subperitoneal rectum. Results Surgical procedures performed were abdominal perineal resection in 4 cases (3.5%), anterior resection in 89 cases (78%), Hartmann’s procedure in 5 cases (4.4%), and ultralow resection with coloanal anastomosis and diverting stoma in 16 patients (14%). Local recurrence occurred in 6 patients (5.2%), the overall survival was 71.9% at 5 years and disease-free survival was about 60%. Conclusions The effect of pathological downstaging amounted to 58.8%, including cPR. The pathologic complete remission occurred in 8.8% of cases. The outcomes of neoadjuvant therapy can be achieved when this treatment is associated with correct surgical technique with TME and the prognosis is defined by an anatomopathological examination performed according to Quirke’s protocol.

Background There is currently no standard treatment for desmoid tumors (DTs) associated with familial polyposis coli (FAP). Familial adenomatous polyposis in DT patients is sometimes a life-threatening condition. Methods We enrolled all consecutive patients with FAP treated at Unit of General Surgery and Transplant, University of Naples Federico II and evaluated the incidence of DTs on FAP between 1996 and 2016. Results We observed 45 consecutive patients with FAP; of these 5 were DT-FAP-associated. All 5 cases with FAP were young women, age 25 to 65 years, previously treated by colectomy. Of these, 4 patients presented a parietal localization and had been treated with a wide surgical exeresis; one patient had an intra-abdominal, mesenteric tumor that was unresectable at laparotomy. We performed CT-guided drainage, ureteral stenting, medical therapy (sulindac+tamoxifene), and chemotherapy (dacarba-zine+doxorubicine). All patients were alive and underwent follow-ups for 5 years post-surgery; only 1 patient with parietal localization showed a local relapse after 2 years. Conclusions We propose a modulated approach to the single patient with FAP, with surgery as treatment of choice for parietal localization disease and integrating different kinds of therapies (surgery alone or associated with RT, CT) for the intra-abdominal tumor.

Background. Colorectal cancer (CRC) is one of the most spread neoplasia types all around the world, especially in western areas. It evolves from precancerous lesions and adenomatous polyps, through successive genetic and epigenetic mutations. Numerous risk factors intervene in its development and they are either environmental or genetic.Aim of the Review. Alongside common screening techniques, such as fecal screening tests, endoscopic evaluation, and CT-colonography, we have identified the most important and useful biomarkers and we have analyzed their role in the diagnosis, prevention, and prognosis of CRC.Conclusion. Biomarkers can become an important tool in the diagnostic and therapeutic process for CRC. But further studies are needed to identify a noninvasive, cost-effective, and highly sensible and specific screening test for their detection and to standardize their use in clinical practice.

Total colectomy (TC) is a valid option for cancer treatment in selected cases. Emergency presentation, association to familial adenomatous polyposis (FAP) or intestinal bowel disease (IBD), hereditary non-polyposis cancer (HNPCC), and synchronous tumors are the common indications to TC for cancer. Despite potential high morbidity and mortality rates for worse general health conditions of the advanced age it has even suggested for elderly patients.We reviewed our experience to analyze the current role of TC comparing different results between young and elderly patients.During the period 1990–2012, 76 patients were operated on TC for cancer. Patients were divided in two groups according to the age [65 years old – group B (elderly)] and were compared their systemic and surgical complication, considering the presence of comorbidities, ASA score, lifestyle habits, elective or emergency presentation.Morbidity rate was 7.7% and 38.8% in young and elderly patients respectively.21 systemic complications (3 in group A and 18 in group B) occurred in 17 patients (22.36%) (with the coexistence of two complications in 4 patients belonging to the group B. There were 6 surgical complications (7.9%) (3 in group A and 3 in group B): anastomotic leakage 3, major wound infections 2, postoperative bleeding 1; no intra-abdominal abscess were observed. In 2 cases (2.6%) (1 anastomotic leak and 1 intra-abdominal postoperative hemorrhage) was needed a reoperation.We observed only 2 deaths in the elderly.High ASA score and emergency were associated with worst results. Systemic complications were more frequent in elderly patients cause of significant comorbidities, while the incidence of surgical complications was similar and according to literature.Besides the classic indications, it is a viable surgical option also in cancer associated with complicated diverticulitis. Our data show that TC is a safe and effective procedure providing good results even in elderly patients, when combined with a careful preoperative evaluation and age is not an absolute controindication to this procedure.

There are not guidelines for surgical management of malignant bowel obstruction (MBO) caused by peritoneal carcinomatosis (PC), mainly when it involves elderly; so its treatment is still debated. AIM: To outline indications and benefits of palliative surgery for obstructive carcinomatosis and determine what prognostic factors, including age, have independent and significant association with outcome. METHODS: We conducted English-language MEDLINE and EMBASE searches of articles published between 1998 and 2016, which reported outcome data after palliative surgery for MBO due to PC. We excluded all articles lacking of surgical cohort and those with main interest in conservative treatment. Of 1275 articles identified, 12 satisfied selection criteria and were included in our analysis. RESULTS: Overall, these studies involved 548 patients undergoing palliative surgery for MBO caused by PC. The median age was 58 (range 19-93). Relief of symptoms was achieved in 26.5-100% of cases. Postoperative morbidity ranged between 7 and 44%. Mortality was high (6-22%). The median survival was longer in surgical patients than in those receiving conservative therapy (8-34 vs 4-5 weeks). Factors associated with surgery failure were poor performance status, diffuse carcinomatosis, previous radiotherapy, and obstruction of small bowel. Old age was significantly associated with a poor prognosis upon univariate analysis, while this association vanished upon multivariate analysis. CONCLUSIONS: Surgical palliation can provide relief of obstructive symptoms as well as improved survival in well-selected patients, even if elderly.

In this study we focus on kidney-transplanted patients in order to investigate the correlation between immunodeficiency (ID) induced by immunosuppressive treatments and the incidence of solid multiple primary malignancies (MPM). Material of Study: From 1980 to 2010 we followed up 1000 kidney-transplanted patients (637M, 363F). This group was homogeneous for age, immunology (e.g. miss-match index), number of rejection events and for immunosuppressive therapy. Results: Out of 1000 kidney-transplanted patients we observed 70 patients (53M, 17F) with cancer disease and in 22 of them a multiple cancer has been found. Most of multiple cancers were synchronous and the association between cancer and rejection episodes were not significant. Discussion: In general population 1 out of 9 patients with a cancer would develop a second neoplasia during the course of his life, so, it would be logical to conclude that, from a merely theoretical and statistical point of view, long term transplanted patients potentially have a higher risk to develop MPM. But our series and literature review did not confirm it, probably because these patients die before the appearance of a second primary malignancy. Conclusions: Despite many observations regarding different types of tumors/precancerous lesions and their increased incidence in ID patients and despite the fact that immune suppression is a predisposing factor for the multicancer syndrome, at least theoretically, nowadays there are no significant statistical data favouring a correlation between ID and MPM in kidney transplanted patients.

Immunodeficiency is associated with higher cancer incidence. However, it is unknown whether there is a link between immunodeficiency and development of multiple primary malignancies. In the present study we analyse this link focusing on kidney-transplanted patients, as they are at higher risk of developing cancer due to the chronic assumption of immunosuppressants. We followed up 1200 patients who underwent kidney transplantation between 1980 and 2012. A total of 77/1200 kidney-transplanted patients developed cancer and 24 of them developed multiple cancers. Most multiple cancers were synchronous with a nonsignificant association between cancer and rejection episodes. In the general cancer population, one-ninth of patients are at higher risk of developing a second tumor over a lifetime; hence it would be reasonable to conclude that, from a merely theoretical and statistical viewpoint, long-term transplanted patients potentially have a higher risk of developing MPMs. However, data did not confirm this assumption, probably because these patients die before a second primary malignancy appears. Despite many observations on the increased incidence of different tumor types in immunodeficient patients and despite immunosuppression certainly being a predisposing factor for the multicancer syndrome, data so far are not robust enough to justify a correlation between immunodeficiency and multiple primary malignancies in transplanted patients.

Background Colorectal cancer is a major cause of morbidity and mortality throughout the world. The likelihood of colorectal cancer diagnosis increases after the age of 40, increases progressively from age 40, rising sharply after age 50. The highest incidence rate is observed in persons aged ≥80 years. Fortunately, the vast majority of cases and deaths from colorectal cancer can be prevented by applying existing knowledge about cancer prevention, so targeted screening programs, more sophisticated diagnostic procedures and early therapeutic intervention could, in time, substantially reduce the morbidity and mortality associated with colorectal cancer.

Materials and methods A retrospective study was conducted on 204 patients affected by symptomatic cholelithiasis and other diseases of the gallbladder observed during the last four years (from January 2006 to December 2009). Patients were divided into two groups according to their age :a) = 75 y. o., to compare operative time, conversion rate to open cholecystectomy, complication rate and length of stay. Other parameters were evaluated such as sex, comorbidity (cardiovascular and respiratory diseases, hypertension, diabetes), previous abdominal surgery, diagnosis of acute cholecystitis and lithiasis of the common bile duct, biochemistry (leukocytosis, hyperbilirubinemia, transaminase) and ultrasonography.

Patients may develop multiple primary malignancies (MPM) due to the occurrence of many known predisposing factors (i.e. genetic background, environmental factors, hormonal unbalance, and acquired immunosuppression); however, in most cases, no obvious cause of has been found [1–3]. During the last few decades, accumulating evidence has pointed to the involvement of human papillomavirus (HPV) in the development of several neoplastic and preneoplastic lesions of anatomic sites beyond the uterine cervix. In particular, HPV has been associated with squamous cell carcinomas and related precursors in the oral cavity, esophagus, skin, larynx, conjunctiva, paranasal sinuses and bronchus, but even in non-Malpighian-derived tumors, such as urinary bladder carcinoma. At least for a subset of these cases, it has been suggested that exposure to HPV can precede the appearance of cancer by 10 or more years [4, 5]; nonetheless, the true prevalence of HPV DNA in pre-cancerous lesions remains uncertain.

Strategic innovations in the fight against cancer have resulted in improved diagnosis of multiple primary malignancies (MPM). In fact, early detection has translated into an increased reported incidence of MPM, due to the spread of screening programs and to increasingly sophisticated instrumental diagnostic surveys. The high sensitivity and specificity of modern diagnostic technologies are such that second primary malignant neoplasms can be identified in their early stages, during follow-up for the first primary malignant tumor and even if the symptomatology is vague or the findings incidental. Also, the combined approach (with or without a neoadjuvant) to cancer therapy has yielded better long-term survival. In turn, compared to 30 years ago, more patients are being diagnosed with a second primary tumor [1-4].

Given the recent advances in anesthesia, surgery, and monitoring technology, day surgery (DS) offers potential advantages for elderly patients undergoing elective surgery. Epidemiological data show a continuous expansion of elderly population, associated with an increased demand for surgical treatments by older patients. This review summarizes current selection criteria, anaesthesiology techniques and methods for perioperative management in geriatric outpatient surgery.

Methods We reviewed our series concerning 27 patients submitted to total colectomy for CRC between January 2000 and September 2010. Indications were: synchronous tumors, cancer in FAP, HNPCC, and emergency. We divided them into two groups according to their age: 11 (40.7%) 3 days) were compared in two groups.

Aims and Background The aim of our study was to assess the feasiblility of sentinel lymph node (SLN) detection in colon cancer using a radiochromoguided technique. The regional lymph node status is crucial for colorectal cancer staging and the stage of disease at the time of diagnosis is the main factor influencing therapeutic decision-making and patient survival. Methods and Study Design Between April and June 2001 eight patients with colon cancer were studied by radiochromoguided sentinel lymph node mapping. At the time of surgery 2 ml of patent blue dye was injected around the tumor, followed after 10 minutes by 2 ml of 99mTc-labeled albumin. After 30 minutes the SLN was identified by a gamma probe. Surgery was completed by standard resection. The SLN was processed for permanent hematoxylin and eosin staining and for immunohistochemical examination with anti-CEA and anti-cytokeratin antibodies. Results SLNs were identified in six patients; two were negative for metastasis by hematoxylin-eosin and immunohistochemical examination, two were positive for metastasis by both methods, and two were negative for metastasis by hematoxylin-eosin but positive by immunohistochemical examination. There were no false negative SLNs and no complications occurred. Conclusion The actual utility of SLN detection for prognostic purposes is still unknown, but intraoperative radiochromoguided SLN mapping is technically feasible in colon cancer, although it is associated with more technical difficulties than in breast cancer and malignant melanoma.