Mariano Boglione

Pre-arrest heparinization and ventilation during warm ischemia preserves lung function in non-heart-beating donors

BACKGROUND/PURPOSE To solve the problem of donor scarcity, many attempts have been made including improved community education, relaxed organ acceptance criteria, increased reliance on single lung transplantation, and the use of partial organ donation. Unfortunately, these efforts have produced only modest increases in lung allograft availability; therefore, the so-called non-heart-beating organ donation must be considered. The aim of this study is to assess the viability of the non-heart-beating donor (NHBD) lung transplant rat model and determine the best strategy to manage the donor before and after cardiac arrest. METHODS Fifty-five inbred Fischer rats were used as donors and recipients in an isogenic model of left lung transplantation. The rats were divided into 6 groups (n = 5): group I, normal controls without transplant; group II, heart-beating donor controls (HBD); group III, NHBD, no heparin, no ventilation during warm ischemia; group IV, NHBD, heparin, no ventilation; group V, NHBD, no heparin, ventilation; group VI, NHBD, heparin, ventilation. All lungs were stored at 4 degrees C for 4 hours. Animals were killed 24 hours after implantation. Gas exchange, pulmonary artery pressure, compliance, chest x-ray score, and histological score were assessed. RESULTS Heparinized and ventilated animals during warm ischemia (group VI) had similar performance than those transplanted without warm ischemia time in a scenario of heart-beating donor (group II). Groups III, IV, and V transplanted lungs showed severe damage. CONCLUSIONS The authors conclude that the rat lung transplantation model is useful to study the phenomena that occur in a setting of transplantation using NHBD and that heparinization and ventilation before cardiac arrest is the best strategy to manage non-heart-beating donors in this model.

Extrathoracic esophageal elongation (Kimura's technique): a feasible option for the treatment of patients with complex esophageal atresia

AIM The aim of this study was to evaluate the outcome of all patients who underwent an extrathoracic esophageal elongation (EEE) (Kimuras technique) and determine its role, among other surgical options, for the treatment of patients with complex esophageal atresia (EA) who have a previously created esophagostomy. METHODS Between March 1997 and September 2008, we performed 20 EEEs. Twelve patients were males and 8 were females. The diagnoses were type C EA (n = 12), type A EA (n = 5), type B EA (n = 2), and type D EA (n = 1). Mean age at the initiation of the EEE was 10 months (range, 3-25 months). RESULTS At the time of this report, 15 of the 20 patients have finished the treatment, 4 patients are still in the process of elongation, and one patient (premature, with a birth weight of 685 g) died before the final esophageal reconstruction. Of the 15 patients who finished the treatment, 12 (80%) completed it satisfactorily and 3 (20%) had to be prematurely interrupted. (In 2 patients, despite multiple attempts, the upper pouch could not be adequately elongated, and in one patient, an early perforation of the upper pouch precluded further elongations.) Of the 12 patients who completed the treatment satisfactorily, 10 (83%) are asymptomatic and exclusively on oral alimentation, whereas 2 (17%) have a pseudodiverticulum and esophageal dysmotility (requiring supplemental alimentation through a gastrostomy). Five of the 12 patients have gastroesophageal reflux (2 required a Nissen fundoplication and 3 are being treated medically). CONCLUSIONS We believe that the EEE is a useful surgical option for a selected group of patients with complex long-gap EA who required a primary esophagostomy and also for patients with any type of EA who developed severe complications after a primary repair and required a secondary esophagostomy. With this technique, we avoided an esophageal replacement in 80% of cases, and given that the EEE does not invalidate a later esophageal replacement, we believe that the EEE is a feasible initial option for these patients.

Reconstrucción laringotraqueal con aloinjerto de aorta criopreservada como rescate de una complicación de resección cricotraqueal en pediatría

Paciente de sexo femenino, traqueotomizada con estenosis laringotraqueal severa, secundaria a intubacion prolongada, es tratada a los 4 anos con reseccion cricotraqueal (RCT) extendida con split del chaton cricoideo e interposicion de cartilago posterior de ala tiroidea y colocacion de tubo en T n.◦ 8. La reseccion involucro la cara anterior del cricoides y los 3 anillos traqueales comprometidos, conservandose la mucosa de la pared posterior traqueal (fig. 1). Evoluciono con abundantes secreciones mucosas, nauseas y vomitos. Al octavo dia presento dehiscencia parcial de la sutura, y ante la imposibilidad de reanastomosis termino-terminal, incluso despues de realizar maniobras de liberacion suprahioidea y toracica, se realizo reconstruccion laringotraqueal (RLT) con aloinjerto de aorta criopreservado de 10 cm de longitud, como tecnica de rescate (fig. 2). Se cubrio injerto con un colgajo timopericardico. Se dejo tubo nasotraqueal. A los 20 dias se coloco canula de traqueotomia y una endoprotesis supraestomal.

Disseminated visceral Kaposi´s sarcoma in a pediatric bilateral lung transplant recipient

Cancer is a major adverse outcome of solid organ transplantation, and risks are especially high for malignancies caused by viral infections. HHV‐8 is the etiologic agent of Kaposi´s sarcoma (KS). We report a case of visceral KS occurring in a 15‐year‐old patient after lung transplantation. The evolution was dramatically fast and interestingly, KS lesions were diffusely observed, but not in the skin. The autopsy showed the presence of numerous tumoral lesions in many organs. Microscopically, they all had very similar features, regardless of the organ affected. KS presented without cutaneous involvement. The girl was not tested for HHV‐8 prior to transplantation as it was not part of our protocol. The donor was negative. The aim of the report is to alert other teams, especially those working in pediatrics, about this rare but potential complication in the setting of solid organ transplantation.

[Late diagnosis bilateral congenital diaphragmatic hernia: a case report].

Congenital diaphragmatic hernia (CDH) is a rare malformation, usually unilateral and left sided. Bilateral CDH (B-CDH) represents 1% of all CDH. Mortality is higher in right side and bilateral defects. We report a case of a patient with Bilateral CDH, initially diagnosed and treated as unilateral right CDH. At 8 months during a laparoscopic Ladd procedure a left side CDH was found.

Tratamiento quirúrgico de la estenosis traqueal en pediatría

Veinte pacientes con estenosis de traquea fueron intervenidos quirurgicamente entre julio de 2005y mayo de 2008, diez con estenosis congenita y diez de origen adquirido.La sobrevida global fue de 85 por ciento. Fallecieron tres pacientes, uno con estenosis adquirida y dos conestenosis congenita.De los diecisiete sobrevivientes, quince se encuentran asintomaticos; dos pacientes operados por estenosis congenita requieren controlesperiodicos (ambos con tutores endoluminales [stents] colocados).La estenosis traqueal adquirida presenta menos complicaciones, requiere menos asistencia respiratoria y menor estadia hospitalaria en el posoperatorio. Los pacientes con estenosis traquealcongenita necesitan, generalmente, masde un procedimiento terapeutico y presentan mayor mortalidad.