Andrés Varela

Pulmonary hydatidosis: surgical treatment and follow-up of 240 cases

OBJECTIVE We review a series of 240 patients treated surgically for pulmonary hydatid cyst in our center between 1966 and 1988, assessing the results with our surgical technique, which involves a novel needle aspiration device designed by Professor D. Figuera, and postoperative treatment protocol. PATIENTS AND METHODS The majority (60.4%) of the patients were from areas endemic for hydatid disease. The mean age of the patients at the time of the surgical procedure was 31.5 +/- 7.2 years (range: 4-70 years). A trocar-suction device was used for the needle aspiration of 276 (92%) of the 300 cysts encountered in the 240 patients. The remaining 24 cysts were removed integrally by means of different surgical techniques such as cyst enucleation, lobectomy, segmentectomy and atypical pulmonary resection. The residual cavity was treated by pericystectomy and eversion to the pleural surface in 238 cases (86.2%) and by capitonnage in 38 (13.7%). High vacuum suction (-30 cm H2O) was employed in every case. Depending on when the procedure was performed, the patients were treated with mebendazole or albendazole according to the protocol designed by Bekhti. RESULTS Clinical assessment of the symptoms and plain chest X-ray led to the correct diagnosis in 228 cases (95%). In six (2.5%), imaging studies such as ultrasonography, computed tomography and nuclear magnetic resonance were required, and in the remaining six cases (2.5%), the diagnosis was established intraoperatively or in the subsequent histopathological study. One hundred and seventy patients (70.8%) presented a solitary lung cyst, while the remaining 70 (29.2%) were found to have multiple cysts in one or more lobes of one or both lungs. In addition, 45 patients (18.7%) presented hepatic cysts and 25 (10.4%) had cysts in other locations. After 18 years of follow-up, the survival rate was 94.6%. Of the surviving patients, 98.3% were free of pulmonary hydatid disease and 95.1% were free of hydatid disease. CONCLUSIONS The trocar-suction device employed here for needle aspiration of hydatid cysts has demonstrated its efficacy in preventing the rupture of the cyst and its possible dissemination. With its use, the parasite is eradicated and the residual cavity can be excised.

Clinical lung transplantation from uncontrolled non–heart-beating donors revisited

BACKGROUND The aim of our study is to review and update the long-term results from our previously published series of lung transplantation in uncontrolled non-heart-beating donors (NHBDs). METHODS A prospective collection of data was undertaken from all lung transplants performed among uncontrolled NHBDs between 2002 and December 2009. The statistical analysis was performed using SPSS software and survival was estimated using the Kaplan-Meier method. RESULTS Twenty-nine lung transplants were performed. Mean total ischemic times for the first and second lung were 575 minutes (SD 115.6) and 701 minutes (SD 111.3), respectively. Primary graft dysfunction (PGD) G1, G2 and G3 occurred in 5 cases (17%), 5 cases (17%) and 11 cases (38%), respectively. Overall hospital mortality rate was 17% (5 patients). Statistical analysis revealed a statistically significant association of mortality with ischemic times and with PGD. In terms of overall survival, 3-month, 1-year, 2-year and 5-year survival rates were 78%, 68%, 57% and 51%, respectively, and the conditional survival rates in those who survived the first 3 months were 86%, 72% and 65%, respectively. The cumulative incidence of bronchiolitis obliterans syndrome (BOS) was 11%, 35% and 45% at 1, 3 and 5 years, respectively. CONCLUSIONS Lung transplantation from uncontrolled non-heart-beating donors shows acceptable results for both mid- and long-term survival and BOS; however, the higher rates of PGD and its impact on early mortality must make us more demanding with respect to the acceptance criteria and methods of evaluation used with these donors.

Improved Distribution of Pulmonary Flush Solution to the Tracheobronchial Wall in Pulmonary Transplantation

This report describes the experimental results obtained with conventional (pulmonary artery, PA) flushing versus retrograde perfusion (via left atrium, LA) using 99mTc-labeled macroaggregated albumin (MAA-99mTc) to ascertain the distribution throughout the tracheobronchial (TB) tree in 10 Large-White pigs. Lung preservation was achieved with 4 degrees C Euro-Collins solution (60 ml/kg) instilled via PA (n = 5) or LA (n = 5). Simultaneously, MAA-99mTc was given using the same respective route and the isotope uptake quantified at different TB levels after heart-lung block harvest and dissection of all tissue adjacent to TB: proximal and distal trachea and right and left main bronchi. Retrograde distribution resulted in a significantly higher 99mTc count compared to the PA route (p < 0.01).

Registro Español de Trasplante Pulmonar: primer informe de resultados (2006-2010)

The Spanish Lung Transplant Registry (SLTR) began its activities in 2006 with the participation of all the lung transplantation (LT) groups with active programs in Spain. This report presents for the first time an overall description and results of the patients who received lung transplants in Spain from 2006 to 2010. LT activity has grown progressively, and in this time period 951 adults and 31 children underwent lung transplantation. The mean age of the recipients was 48.2, while the mean age among the lung donors was 41.7. In adult LT, the most frequent cause for lung transplantation was emphysema/COPD, followed by idiopathic pulmonary fibrosis, both representing more than 60% the total number of indications. The probability for survival after adult LT to one and three years was 72% and 60%, respectively, although in patients who survived until the third month post-transplantation, these survival rates reached 89.7% and 75.2%. The factors that most clearly influenced patient survival were the age of the recipient and the diagnosis that indicated the transplantation. Among the pediatric transplantations, cystic fibrosis was the main cause for transplantation (68%), with a one-year survival of 80% and a three-year survival of 70%. In adult as well as pediatric transplantations, the most frequent cause of death was infection. These data confirm the consolidated situation of LT in Spain as a therapeutic option for advanced chronic respiratory disease, both in children as well as in adults.

Es útil el tratamiento endoscópico de las fístulas bronquiales

Objetivo: Se han desarrollado nuevas tecnicas endoscopicas como alternativa al tratamiento quirurgico de las fistulas bronquiales (FB). El objetivo de nuestro trabajo ha sido analizar nuestra experiencia en el tratamiento endoscopico de las FB. Material y metodos: Hemos realizado un estudio retrospectivo de los pacientes con FB diagnosticados por fibrobroncoscopia analizando sus caracteristicas, enfermedad causal de la fistula, tamano y resultados del tratamiento endoscopico. La tecnica endoscopica consistio en la instilacion mediante cateter a traves del fibrobroncoscopio de sustancias sellantes (SS) (Histoacryl® y/o Tissucol®). Resultados: Entre 1997 y 2004 diagnosticamos 18 FB a traves de fibrobroncoscopia, todas ellas en varones con una edad media (± desviacion estandar) de 62 ± 12 anos. En 16 pacientes la FB se produjo tras cirugia de neoplasia, en uno aparecio en la sutura bronquial de un trasplante pulmonar y en otro fue simultanea a un derrame pleural por hidatidosis. El tamano oscilo entre 1 y 10 mm (media de 3,6 ± 2,7 mm). Aplicamos SS en 14 pacientes, en 2 se realizo cirugia directamente tras el diagnostico y en otros 2 la FB cerro espontaneamente. Las SS utilizadas fueron Histoacryl® en 12 pacientes y Tissucol® en otros 2. Simultaneamente se empleo drenaje pleural y antibioterapia sistemica segun criterio del cirujano. En los 4 casos donde la FB estaba asociada a empiema se aplicaron ademas lavados pleurales. La tecnica endoscopica cerro la FB en 12 pacientes (85,7%) sin complicaciones asociadas. En el 85,7% fueron necesarias menos de 3 aplicaciones de SS. Conclusiones: La utilizacion de SS, mediante tecnicas de fibrobroncoscopia, permite el cierre de las FB con un alto porcentaje de exito, un numero reducido de aplicaciones y nula morbilidad, evitando la cirugia de la fistula.

Non-heart-beating donation in Spain

PurposeThe aim of our study was to describe our protocol of non-heart-beating-donor (NHBD) lung transplantation and discuss data regarding the situation of NHBD and lung transplantation in Spain.MethodsExperimental work regarding NHBD led our National Organization of Transplants to develop several working groups with the objective of investigating the possibility of using uncontrolled NHBD in our country. This turned into a flexible and useful legal mechanism that allowed immediate judicial permission to preserve—and harvest—those organs. Several harvesting programs for mainly abdominal organs (kidney and liver) started in Spain during the late 1980s, with good mid-term results. The collaboration between two hospitals in Madrid—Hospital Clinico San Carlos and Hospital Puerta de Hierro as transplantation hospital—led to the development of a successful NHBD lung program for uncontrolled donors that is a pioneer in the world.ResultsIn Spain, donation after cardiac arrest represents 6.7% of all transplants, mainly from types I (dead on arrival) and II (unsuccessful resuscitation) donors. NHBD for lung transplantation is concentrated in Madrid, with approximately 60 potential NHBDs per year. With this additional source of organs we have so far been able to perform 32 lung transplantations, which represents an increase of 13% of our annual transplantation rates.ConclusionNHBD is no longer just a promising source of organs for lung transplantations, it is a real one. We hope that in the near future many other units will develop similar protocols to improve the use of these grafts and decrease the mortality rate among those on the waiting lists.

Normativa para la selección de pacientes candidatos a trasplante pulmonar

The present guidelines have been prepared with the consensus of at least one representative of each of the hospitals with lung transplantation programs in Spain. In addition, prior to their publication, these guidelines have been reviewed by a group of prominent reviewers who are recognized for their professional experience in the field of lung transplantation. Within the following pages, the reader will find the selection criteria for lung transplantation candidates, when and how to remit a patient to a transplantation center and, lastly, when to add the patient to the waiting list. A level of evidence has been identified for the most relevant questions. Our intention is for this document to be a practical guide for pulmonologists who do not directly participate in lung transplantations but who should consider this treatment for their patients. Finally, these guidelines also propose an information form in order to compile in an organized manner the patient data of the potential candidate for lung transplantation, which are relevant in order to be able to make the best decisions possible.

Clinical experience with retrograde lung preservation

Abstract  Previous reports and our own experimental work suggest increased vascularity of the tracheo‐bronchial wall when retrograde lung preservation is used. This principle was clinically applied in 21 consecutive lung transplant recipients (10 single and 11 bilateral). Lung preservation was achieved via the left atrial appendage and drainage was obtained through the pulmonary artery. Pneumoplegic preservation was achieved with modified Euro‐Collins solution. Cardioplegia was induced by the standard method and the heart, harvested by different teams, did not exhibit left ventricular dilatation. Thirty‐two bronchial anastomoses without wrapping were performed. No primary lung graft failure was documented. Cardiopul‐monary bypass was instituted in three cases of pulmonary hypertension; however, this was deemed unnecessary in the remainder of the cases of bilateral transplantation while the second organ was being implanted. All bronchial anastomoses were followed between 2 and 28 months. A single instance of bronchial anastomosis dehiscence was observed on the 30th postoperative day. However, no stents were employed in this series, and no strictures or anastomotic granulomas have been reported so far. All the hearts could be used satisfactorily except for one primary graft failure. In conclusion, retrograde lung preservation is feasible in clinical lung transplantation, with simultaneous harvesting of the heart. The impact of retrograde lung preservation on the late clinical outcome remains to be seen.

Mejoras en la preservación pulmonar. Tres años de experiencia con una solución de dextrano bajo en potasio

Objetivo: La calidad de la preservacion pulmonar es uno de los aspectos mas determinantes en el exito del trasplante pulmonar. En octubre del ano 2000 modificamos nuestra solucion de preservacion pulmonar, que hasta entonces era el Euro-Collins (EC), y comenzamos a utilizar una solucion de dextrano bajo en potasio, comercializada como Perfadex (PER). El objetivo de este estudio es analizar los resultados de ambos metodos. Material y metodos: Hemos analizado los resultados de 68 trasplantes pulmonares con PER y los hemos comparado con los de una serie retrospectiva del mismo numero de trasplantes realizados con EC. Resultados: No existen diferencias significativas respecto a la edad o el diagnostico de los receptores entre ambos grupos. El tiempo en lista de espera fue mayor en el grupo de PER. La causa de muerte del donante mas frecuente del grupo EC fue el traumatismo craneoencefalico (62%), mientras que en el grupo de PER fue la hemorragia cerebral (54%). En el grupo de PER se realizaron mas trasplantes bipulmonares que en el de EC (el 78 y el 53%, respectivamente; p = 0,002). No hay diferencias en la indicacion de circulacion extracorporea o tiempos de isquemia entre ambos grupos. Se evaluo la funcion pulmonar temprana a traves del indice de oxigenacion (PaO2/FiO2) a la llegada a la unidad de cuidados intensivos, que fue comparable entre ambos grupos. La incidencia de disfuncion grave del injerto (PaO2/FiO2 < 150 mmHg) fue significativamente inferior en el grupo de PER frente al de EC (el 16 y el 37%, respectivamente; p = 0,01). No encontramos diferencias significativas respecto a las horas de ventilacion mecanica ni en cuanto a la mortalidad postoperatoria entre las 2 series. Conclusiones: Con la aplicacion clinica de esta nueva solucion de preservacion pulmonar se obtiene una reduccion del 50% en la incidencia de la lesion de isquemia-reperfusion grave del injerto en el postoperatorio inmediato del trasplante pulmonar.

Trasplante de pulmón con donantes no controlados a corazón parado. Factores pronósticos dependientes del donante y evolución inmediata postrasplante

INTRODUCTION Uncontrolled donation after cardiac death (DACD) has become an alternative to lung transplantation with encephalic-death donation. The main objective of this study is to describe the incidence of clinically relevant events in the period of thirty days after lung transplant with uncontrolled DACD and the influence of factors depending on the donor and donation process as well. PATIENTS AND METHODS Historical cohort study of 33 lung transplant receivers at Hospital Puerta de Hierro and Hospital Marqués de Valdecilla with 32 DACD from Hospital Clínico San Carlos from 2002 to 2008. We studied surgical and medical complications, primary graft dysfunction, acute rejection, pneumonia and mortality. We made an evaluation of the donor characteristics and donation procedure times (minutes). RESULTS Median age of recipients was 50.5 years (interquartile range, 38.5-58). There were 28 males and 5 females. Cumulative incidence of events in the first month was: pneumonia 10 (31.3%); primary graft dysfunction 15 (46.9%); rejection 12 (37.5%); mortality 4 (12.1%); medical complications 25 (78.1%); and surgical complications 18 (56.3%). Median time of cardiac arrest was higher in those who presented pneumonia (15 vs. 7.5; p = 0.027). Median time of cold ischemia was higher in those who presented surgical complications and mortality (436 vs. 343.5; p = 0.04; 505 vs. 410; p = 0.033, respectively), and median of total ischemia times were longer in the recipients who died (828 vs. 695; p = 0.036). CONCLUSIONS Uncontrolled DACD are a valid alternative for expanding the donor pool in order to mitigate the current shortage of lungs that are valid for transplantation. The incidence of complications is comparable with published data in the literature.