T. De Giacomo

Extracorporeal membrane oxygenation as bridge to lung transplantation

Lung transplantation (OLT) is a viable option for end-stage pulmonary diseases in selected patients with satisfactory long-term results. However, the paucity of available donors engenders a prolonged stay on the waiting list with progressive decline of lung function. In cases of sudden respiratory failure, admission to an intensive care unit with institution of extracorporeal membrane oxygenation (ECMO) may be an option while a waiting an emergency OLT. In 12 OLT candidates we started ECMO because of acute decline of lung function. Eleven patients had cystic fibrosis and the other subject, histiocytosis X. In 7 patients bilateral OLT was performed after a mean waiting time of 6 days from ECMO institution; 5 patients died on ECMO at a mean time of 11.6 days. After OLT 2 patients required reoperation for hemothorax; renal failure and acute leg ischemia occurred in 2 patients. The mean weaning time from ECMO after OLT was 2.14 days. No patient died in the perioperative period and 1-year survival was 85.7%. ECMO represents a valid option as a bridge to urgent OLT for selected candidates.

Extracorporeal Circulatory Support for Lung Transplantation: Institutional Experience

Lung transplantation (LT) represents the only available therapy for selected patients affected by end-stage pulmonary disease. Cardiopulmonary bypass (CPBP) is used, when required, during single and sequential double lung transplantation; however, it increases the risk of bleeding, early graft dysfunction, failure, and other potential side effects. We report our experience with 145 patients who underwent lung transplantations, among whom 34 required intraoperative CPBP. The indications for LT among these 34 patients were cystic fibrosis (n = 22), chronic obstructive pulmonary disease (n = 3), bronchiectasis (n = 2), primary pulmonary hypertension (n = 1), fibrosis (n = 2), pulmonary microlithiasis (n = 1), and retransplantation for obliterative bronchilitis (n = 3). CPBP was planned in 12 cases (group I) and unplanned in 22 (group II). The main reason for planning CPBP was primary and secondary pulmonary hypertension (mean pulmonary artery pressure >or=25 mm Hg). Acute right ventricular failure, hemodynamic instability, arterial desaturation, and increased pulmonary artery pressure were mandatory for unplanned CPBP. Among the 34 CPBP patients, the 30-day mortality rate was 35% (12/34) including 9 (70%) in group II (unplanned CPBP). The leading cause of death was multiorgan failure. The 1-year survival rates were 67% and 36%, and the 3-year survival rates were 47% and 18% for groups I and II, respectively. In conclusion, even if it represents a useful tool in the management of critical events, the use of unscheduled CPBP during LT procedures is associated with an increased postoperative morbidity and mortality.

Improved Results With Lung Transplantation for Cystic Fibrosis

YSTIC fibrosis (CF) is the most frequently inheritedlethal disorder among caucasians. Improvements intherapy have resulted in an average life span extending intothe third decade of life; however, no cure is available at thepresent time and 95% of deaths are related to chronicobstructive lung disease, bronchiectasis, and consequentrespiratory failure.

Lung Transplantation for Cystic Fibrosis After Thoracic Surgical Procedures

During their life, cystic fibrosis (CF) patients may require thoracic surgical procedures for a number of reasons before undergoing lung transplantation. In the past, this has been considered to be a contraindication to lung transplantation. However, a meticulous surgical technique and careful intraoperative management allows one to perform the transplantation safely. Herein we have reported our experience with CF patients undergoing lung transplantation after previous surgical treatment for pneumothorax or bronchiectasis.

Lung Transplantation for Cystic Fibrosis: Ten Years of Experience

Lung transplantation represents the only therapeutic option for patients affected by end-stage cystic fibrosis (CF). We performed 76 lung transplantations in 73 patients from 1996-2007. The mean time on the waiting list was 10+/-6 months. The median follow-up after the transplantation was 69.3 months. Twenty-one transplants (27.6%) were performed under cardiopulmonary bypass. Perioperative mortality, excluding retransplants, was 16.4% (12 patients) and the causes of death were sepsis, primary graft failure, and myocardial infarction. The overall survival was 74.5%+/-5%, 62.9%+/-5%, 54.1%+/-6%, and 43.4%+/-6% at 1, 3, 5, and 10 years, respectively. The accurate selection of potential recipients and the correct timing of referral and transplantation are factors that play crucial roles to obtain satisfactory results in term of improvement of quality of life and long-term survival.

Treatment of Complex Airway Lesions After Lung Transplantation With Self-Expandable Nitinol Stents: Early Experience

Airway complications (AC) are considered a serious cause of morbidity after lung transplantation (LT). Mechanical dilatation, laser vaporization, and silicone stent placement usually solve it. However, the use of self-expandable metallic stents (SENS) may be indicated in selected cases. Ten lung transplant recipients with AC were treated with SENS. Six patients underwent LT for cystic fibrosis, 2 for idiopathic pulmonary fibrosis, 1 for bronchiectasis, and 1 for emphysema. All patients received at least 1 treatment attempt with dilatation and silicone stent placement. The indications for SENS placement were the presence of a tortuous airway axis with stenosis and malacia of the right main bronchus in 5 patients; a long stenosis of the main and intermediate right bronchus involving the upper lobe orifice in 3 patients; or malacia that could not be stabilized with silicone stents in 3 cases. In 1 patient the procedure was bilateral. Functional improvement was immediate with a mean forced expiratory volume at 1 second (FEV(1)) gain of 35%. No stent dislocation was observed. Symptoms did not occur again in 5 patients with previous recurrent episodes of pneumonia. One stenosis, which was due to the ingrowth of granulation tissue occurred at 6 months after the procedure, was successfully treated with mechanical dilatation and laser vaporization. The deployment of SENS in a selected group of patients with AC after LT was easy, safe, and effective.

Il trapianto polmonare

Il trapianto polmonare rappresenta l’unica procedura salvavita per una varieta di patologie polmonari in fase avanzata. Dall’inizio degli anni ’90, nel mondo sono stati effettuati oltre 6400 trapianti polmonari. La sperimentazione su animali risale agli anni ’40–’50 con alcuni studi particolarmente interessanti di Demikhov e Metras che dimostrarono la fattibilita del trapianto. Hardy nel 1963 effettuo il primo trapianto polmonare singolo su un uomo che sopravvisse per 18 giorni. Dal 1963 al 1978 furono compiuti numerosi tentativi di trapianto che tuttavia fallirono per complicanze delle anastomosi bronchiali o per rigetto. Negli anni ’80, l’introduzione della ciclosporina A, un potente immunosoppressivo, il miglioramento delle tecniche di preservazione e delle anastomosi bronchiali si risveglio l’interesse per il trapianto polmonare. A Stanford nel 1981 fu effettuato il primo trapianto cuore-polmoni per ipertensione polmonare primitiva e Joel Cooper nel 1989 a Toronto, effettuo i primi trapianti singoli per fibrosi polmonare coronati da successo.

Recovery of chronic renal impairment with sirolimus after lung transplantation

BACKGROUND Standard immunosuppression after lung transplantation includes calcineurin inhibitors, azathioprine, and steroids. Calcineurin inhibitor administration is associated with an increased renal impairment. Sirolimus shows no renal toxicity and could be used in selected patients. METHODS We have prospectively administered sirolimus as an alternative to calcineurin inhibitors in 15 lung transplantation recipients with persistent drug nephrotoxicity. Eight patients had also bronchiolitis obliterans syndrome. The mean serum creatinine and azotemia were 2.7 +/- 1.1 mg/dL and 111 +/- 39 mg/dL. After starting sirolimus, azathioprine was reduced to 50%-25% of baseline, calcineurin inhibitors were gradually reduced and eventually stopped, and steroids were maintained stable. Patients started sirolimus with 2 to 5 mg/d orally; adjustments were made according to trough levels (4 to 12 ng/mL for combined sirolimus + calcineurin inhibitors; 12 to 20 ng/mL as monotherapy), toxicity, and perceived efficacy. Patients were monitored for renal and graft function and clinical status. RESULTS A significant creatinine decrease was observed after 6 months of treatment (p < 0.02); azotemia decreased after 1 month and remained stable (p < 0.01). Pulmonary function tests did not show any significant modification from before sirolimus baseline in patients without bronchiolitis obliterans syndrome. There were eight infectious complications and 10 episodes of toxicity (4 dermatitis, 2 epistaxis, 1 headache, 1 diarrhea, 1 nausea, 1 laryngeal cancer). Moderate leukocytopenia (n = 3) and hypertriglyceridemia (n = 6) responded to dose reduction. One patient was lost to follow-up. Three patients died of complications related to bronchiolitis obliterans. One patient underwent transplantation again. CONCLUSIONS Sirolimus administration allows amelioration of renal function with a relatively low morbidity and is useful for chronic renal impairment rescue after lung transplantation.

Induction chemotherapy for T4 lung cancer

SummaryBackground: The prognosis of patients with T4 nonesmall cell lung cancer (NSCLC) involving the mediastinum is uniformly poor, and surgery alone does not represent a successfull solution.Methods: In a 5-year period we entered 44 patients with histologically confirmed NSCLC in a prospective study intended to achieve the reconversion to surgery of unresectable T4 disease. Eligibility criteria for T4 where: Clinical (Superior Vena Cava syndrome [7 patients], vocal cord paralysis [6 patients]; Radiological [CT and MR evidence of infiltration — 8 patients]; Bronchoscopic [tracheal infiltration — 8 patients]; Thoracoscopic [histologically-proved mediastinal infiltration — 15 patients]). After 3 cycles of Cisplatin (120 mg/m2), Vinblastine (4 mg/m2) and Mitomycin (2 mg/m2) patients were reevaluated.Results: 33 patients (75 %) (29 men, 4 women; age range 46 to 75 years; mean 57 years) responded to therapy and underwent thoracotomy, 8 did not respond and 3 had major toxicity. 28 patients (85%) had complete resection. We performed 3 exploratory thoracotomies, 4 pneumonectomies, 26 lobectomies (16 procedures were associated with reconstruction of hilar-mediastinal structures). Overall, 2 patients had no histological evidence of disease. We had 2 bronchopleural fistulas with 1 death, 5 other major complications and 8 cases of delayed lung reexpansion. Adjuvant chemo- and/or radiotherapy was administered to N2 and N1 patients. The follow up ranges between 12 and 60 months (mean 20 months). Survival at 1 and 3 years is 75 % and 39 %. Of the initial group of 44 patients, 33 (75 %) underwent exploration with a 3-year survival of 39 %, and 28 (64) % had complete resection.Conclusions: Our data indicate that induction chemotherapy is effective for downstaging and surgical reconversion of centrally located, unresectable T4 NSCLC.ZusammenfassungGrundlagen: Die Prognose des T4-nichtkleinzelligen Bronchuskarzinoms (NSCLC)) ist allgemein schlecht. Die chirurgische Therapie allein bringt keine Verbesserung der Prognose.Methodik: Innerhalb von 5 Jahren wurden 44 Patienten mit histologisch verifiziertem nicht-kleinzelligem Bronchuskarzinom in einer prospektiven Studie inkludiert. Ziel war es, eine Operabilität bei nicht resezierbaren T4-Karzinomen zu erreichen. Einschlußkriterien für T4 waren: Klinische — [V. Cava Superior Syndrom (7 Patienten), Reccurensparese (6 Patienten)]; Radiologische — [Nachweis einer Infiltration im CT und MIR (8 Patienten)]; Bronchoskopische — [Infiltration der Trachea (8 Patienten)]; Thorakoskopische — [histologisch verifizierte mediastinale Infiltration (15 Patienten)]. Die Patienten wurden nach 3 Zyklen Chemotherapie mit Cisplatin (120 mg/m2), Vinblastin (4 mg/m2) und Mitomycin (2 mg/m2) reevaluiert.Ergebnisse: 33 Patienten [75 % (29 Männer, 4 Frauen; Alter Zwischen 46 und 75 Jahren; Mittelwert 57 Jahre)] sprachen auf die Chemotherapie an und wurden thorakotomiert. 8 sprachen nicht an, und bei 3 wurde eine schwere Toxizität beobachtet. Bei 28 Patienten (85 %) wurde anschließend eine komplette Resektion erreicht. Insgesamt wurden 3 explorative Thorakotomien, 4 Pneumonektomien, 26 Lobektomien (bei 16 Prozeduren wurde eine Rekonstruktion von hilären Strukturen durchgeführt) durchgeführt. 2 Patienten zeigten keine histologischen Zeichen der Erkrankung. Es wurden 2 bronchopleurale Fisteln (1 Todesfall), 5 andere schwere Komplikationen und 8 Fälle von verlängerter Lungenreexpansion beobachtet. Adjuvante Chemo- und/oder Strahlentherapie wurde bei N1- und N2-Patienten angewandt. Die Beobachtungszeit betrug zwischen 12 und 60 Monaten (Mittelwert 20). Das 1- und 3-Jahresüberleben war 73 % bzw. 39 %. Bei 33 (75 %) von den 44 initialen Patienten wurde eine Exploration mit einem 3-Jahresüberleben von 39 % durchgeführt. 28 (64 %) hatten eine komplette Resektion.Schlußfolgerungen: Unsere Daten indizieren, daß die Induktionschemotherapie für „downstaging“ und somit zum Erreichen einer Operabilität bei zentralliegendem, nicht-resezierbarem, nicht-kleinzelligem Bronchuskarzinom effektiv ist.

Long-Term Follow-Up of Heller Myotomy for Achalasia After Thoracic, Abdominal, and Thoracoabdominal Approach

The objective of therapy for achalasia of the esophagus is to relieve the functional obstruction at the esophagogastric junction avoiding at the same time gastroesophageal reflux (GER).