Stefano Nazari

Nutritional and Immunological Evaluations in Cancer Patients. Relationship to Surgical Infections

Several reports provide evidence of the synergism between malnutrition and infection in hospitalized patients. In this study, preoperative complete nutritional assessment (NA) was performed to: 1) evaluate NA modifications in 21 controls with benign minor surgical diseases and in 71 surgical cancer patients; 2) determine the relative value of nutritional and immunological indicators in relation to the postoperative septic complications in cancer patients. The following parameters were used: percent weight loss/month, percent standard arm circumference, percent standard triceps skinfold; hematocrit, hemoglobin, serum proteins, albumin, iron, transferrin, ceruloplasmin, retinol binding protein (RBP); serum creatinine, urine creatinine, creatinine/height index, percent arm muscle circumference; peripheral lymphocytes, white blood cells, complement (C3c), skin tests. In the cancer group percent usual body weight, percent arm muscle circumference, hematocrit, hemoglobin, albumin, iron, ceruloplasmin, retinol binding protein, C3c and delayed hypersensitivity response (DHR) were significantly different from controls. Ceruloplasmin and DHR were the only tests significantly different in the cancer patients who developed postoperative infections. Duration of anesthesia and operative field contamination are other important causative factors which, if associated with malnutrition, may determine a higher susceptibility to infections in surgical cancer patients.

Cluster analysis of nutritional and immunological indicators for identification of high risk surgical patients.

In spite of the many anthropometric, biohumoral, and immunologic parameters employed in the nutritional assessment of hospitalized patients, it is difficult in clinical practice to evaluate accurately the degree and type of malnutrition and to assess the prognostic significance of this determination. The purpose of this study is to evaluate nutritional status of surgical patients by means of cluster analysis in orderr to identify different nutritional patterns and to evaluate their clinical and prognostic significance. Nutritional assessment of 71 surgical patients was carried out at admission, and the sets of data were evaluated by means of cluster analysis. Four clusters with different nutritional patterns were identified. The incidence of clinical variables (type of disease, postoperative sepsis, palliative procedures, mortality at 6 months, etc.) in each cluster was determined in order to evaluate their clinical and prognostic significance. Cluster 1 showed minor variations of the indicators, including most of the controls presented the lowest incidence of sepsis, palliative procedures, and mortality at 6 months. It was then considered as a reference group representative of the normal nutritional condition at our institution. The other three clusters showed major variations of nutritional indicators and represent poorer risk clinical conditions. Sepsis, palliative procedures and mortality rate were significantly more frequent in these clusters (p less than 0.05, p less than 0.001, p less than 0.05). A different distribution in the clusters was recorded in gastrointestinal tract cancers and other neoplasms. Only the incidence of gastrointestinal tract cancers increases progressively in the clusters with poorer prognosis, suggesting that this type of neoplasia is more frequently associated with major changes of nutritional status.

Successful bronchial revascularization in experimental single lung transplantation

It is the purpose of this paper to report our experience with bronchial artery revascularization in an experimental model of single lung transplantation in swine. Thirty-three large white pigs weighing 20-40 kg underwent left lung allotransplantation. In 24 animals, bronchial artery revascularization was attempted by anastomizing the aortic patch containing the bronchial artery orifice with the recipient descending aorta. Eight survivors were put to death on postoperative days 11-15; five animals were put to death or died on postoperative days 2-9; the other animals died intra-operatively or within a few hours. Preservation of left bronchial vascularization was achieved in all cases attempted, as documented by post-mortem injection of dye (methylene blue) or contrast medium. Five of the 8 animals surviving for 11-15 days showed diffuse graft hepatization, associated with diffuse vascular thrombosis. Whether this was caused by damage to the endothelium due to poor graft preservation or by rejection was unclear. In animals surviving for 11-15 days without gross lung pathology, the anastomosis and bronchial mucosa were completely normal; in contrast, bronchial ischaemic changes were found in nonrevascularized animals and in survivors with graft hepatization. Our experience confirms that re-anastomosis of the bronchial arteries can prevent bronchial healing problems in single lung transplantation. The pig is an ideal model for these experiments since the bronchial arteries have a constant common aortic origin, allowing easy identification and preservation of left bronchial vascularization.

Evaluation of Possible Causes of Delayed Hypersensitivity Impairment in Cancer Patients

The separate roles of malnutrition, advanced age, and stage of tumor growth as causes of impairment of delayed hypersensitivity response (DHR) was studied in 111 patients with solid tumors and in 56 nonneoplastic control patients matched for age, anatomical site of disease, degree of illness, and nutritional status. Pretreatment DHR to recall antigens (tuberculin, Candida, streptokinase-streptodornase, trichophyton) and to dinitrochlorobenzene in cancer patients with 9% anergic, 43% hypoergic, and 48% normoergic; the distribution of DHR in controls was not significantly different. In cancer patients, the serum albumin level showed an inverse correlation with the stage of tumor (p less than 0.01) and a positive correlation with the DHR (p less than 0.001); the serum albumin level was also in the controls positively correlated with the DHR (p less than 0.01), indicating that malnutrition in neoplastic or benign disease may cause depression of DHR. In well-nourished controls, age was inversely correlated with DHR (p less than 0.05), showing that aging itself may be another relevant cause of depression of DHR. The results of this study indicate that DHR in patients with solid tumors is similar to the DHR of nonneoplastic patients if matched for age, sex, and nutritional status. DHR impairment in cancer patients appears to be caused mainly by aging and by malnutrition due to the advanced progression of cancer.

Bilateral open treatment of spontaneous pneumothorax: a new access

A new technique for bilateral apical bullectomy and pleurectomy via axillary minithoracotomy and transmediastinal access to the contralateral side, was used in 13 patients with bilateral apical blebs and/or pneumothorax. The contralateral space is reached at the posterior superior mediastinum, passing between the first thoracic vertebral bodies (T1-T4) and the oesophagus. The contralateral lung apex is then pulled into the thoracotomy side and apical bullectomy carried out by linear stapler. The obvious advantages of avoiding a second thoracotomy while providing complete solution to the clinical problem are particularly important in young patients with spontaneous pneumothorax caused by bilateral apical blebs.

Nutritional Assessment and Surgical Infections in Patients with Gastric Cancer or Peptic Ulcer

Recent reports provide evidence that cancer is frequently associated with malnutrition and infection. This is particularly evident when the gastrointestinal tract is involved. The purpose of this study is to investigate the difference between the nutritional status of patients with gastric cancer and with peptic ulcer, and to determine which of the nutritional indicators may be of value in identifying patients with high risk of postoperative infections. A complete nutritional assessment was performed at admission and the following parameters were determined: hemoglobin, total serum protein, albumin, ceruloplasmin, retinol binding protein, transferrin; Fe; urine creatinine, creatinine/height index, arm muscle circumference; ideal body weight, usual body weight, arm circumference, triceps skinfold; lymphocytes, white blood cells, C3c, skin tests to recall and primary antigens. In the cancer patient group, hemoglobin, total protein, albumin, Fe, percentage usual body weight, and delayed hypersensitivity response to skin antigens were significantly more impaired than in controls. Preoperative delayed hypersensitivity response was the only test in correlation with the tumor stage. It was also significantly different in the gastric cancer patients who developed postoperative infections.

Prosthesis for Aortic Arch Substitution

BACKGROUND The risk of neurologic complications in aortic arch prosthetic substitution is directly related to the duration of the circulatory arrest. The purpose of this article is to report the experiments on animals of a device for simplifying and quickening the vascular anastomosis in aortic arch substitution. METHODS The device consists of expandable loops of stainless steel wire, sewn to the proximal end of a Dacron prosthesis. An actuating removable guide allows the stainless steel wire loops to be expanded and tightened, in such a way that the prosthesis diameter is varied, while maintaining a regular cylindric shape. The prosthesis end is then transformed into a rigid cylindrical ring, approximately half the maximal diameter in length, with a variable and controllable diameter. A composite graft was prepared, fitted with the expandable device at the distal end of the main prosthesis as well as at each end of the branches for the supraaortic trunks. Cardiopulmonary bypass was established by cannulation of the right atrium and left iliac artery. The prosthesis was positioned very easily and quickly during a brief hypothermic circulatory arrest; ascending aorta anastomosis was carried out by the standard technique after central nervous system reperfusion was resumed. Acute experiments were carried out in 5 swine. RESULTS Four of 5 animals survived the procedure without detectable neurologic sequelae. At sacrifice the prosthesis was found to be properly sited without lumen distortion or thrombosis. CONCLUSIONS The main advantages of this device and modality of arch substitution in a clinical setting would include drastic reduction of the circulatory arrest time, easy and reliable hemostasis of the anastomosis line, and accurate and firm approximation of the dissection layers in case of dissecting aneurysms.

The Backflow from the Pulmonary Circulation for Identification of the Aortic Origin of the Bronchial Arteries in Experimental Left Single Lung Transplantation

The ideal solution to the bronchial healing problems in lung transplant would be the reconstruction of the bronchial arteries at time of transplantation. The problems with this approach are essentially technical being difficult to identify and preserve the bronchial arteries in humans. The purpose of this paper is to report our experience with an experimental model in dog to easily identify and preserve bronchial circulation in single lung transplantation. The technique is based on the preservation during harvesting of the aortic origin of the first five couples of arterial orifices. Identification of the orifice(s) connected with the bronchial circulation is carried out by the backflow which takes place from the pulmonary circulation after organ reperfusion is resumed. The identified orifice(s) is then anastomosed to the descending recipient aorta, tangentially clamped.

Continuous high vacuum and primary skin closure in sternotomy wound infection

An important message in the report of A.T.M. Tang and associates [1] concerns the essential role of continuous vacuum in sternotomy wound infections healing process. Dressings by polyurethane foam sealed by transparent adhesive drape in fact are changed only once every 48 h, since wound toilette and purulent material removal actually relies on a sophisticate intermittent high suction vacuum system. We have adopted a conceptually similar, closed technique for superficial wound infections. After a favourable experience with a two stage approach [2], consisting in preliminary debridement, followed, a few days later, by a surgical closure by means of advancement flaps and multiple high suctions drains, we now carry out primary closure of the infected superficial tissues. When a superficial sternal wound infection is diagnosed, surgical debridement is carried out; a sufficient number of small high suction drains (Riplast; Neukirchen-Saar, Germany) are positioned and the skin is immediately closed by means of a continuous monofilament suture. High suction is continued until no more material is drained, usually after 7‐8 days. We have treated 15 patients by this method with good results; only in one case a further debridement was necessary with second intention healing. Cosmetic results were very satisfactorily in the remaining 14 patients. Mean hospital stay after infection diagnosis was 9 ^ 2 days. We believe that, when possible, immediate skin closure after debridement over an efficient and continuous vacuum system, may be in most cases as effective as the polyurethane foam and adhesive sealant drape medication, offering better cosmetic results.

Thoracic-abdominal approach in primary pulmonary synovial sarcoma

We report a case of primary synovial sarcoma of the lung. The patient was a 32-year-old male who presented with a mass in the right hemithorax invading the peritoneal cavity. The neoplasm was resected through a thoracic-abdominal approach. The patient is doing well 21 months after surgery. Within the last decade thoracic localizations of synovial sarcoma are an emerging histopathological entity thanks to the molecular analysis of the SYT-SSX fusion gene transcript.