Application value of donor liver autologous portal venous blood rinse in orthotopic liver trans-plantation / 中华消化外科杂志

Objective:To investigate the application value of donor liver autologous portal venous blood rinse in orthotopic liver transplantation (OLT).Methods:The retrospective cohort study was conducted. The clinicopathological data of 35 pairs of donors and recipients who underwent OLT in the First Affiliated Hospital of University of Science and Technology of China from May 2018 to June 2019 were collected. Of the 35 donors, there were 31 males and 4 females, aged (48±9)years. Of the 35 recipients, there were 25 males and 10 females, aged (47±9)years. Of the 35 recipients, 16 recipients undergoing donor liver autologous portal venous blood rinse were allocated into the portal vein group, and 19 recipients undergoing donor liver albumin water rinse were allocated into the albumin group. Observation indicators: (1) surgical situations; (2) postoperative situations; (3) follow-up. Measurement data with normal distribution were represented as Mean± SD, and compari-son between groups was analyzed using the t test. Measurement data of skewed distribution were represented as M(range). Count data were descried as absolute numbers, and comparison between groups was analyzed using the Fisher exact probability. Results:(1) Surgical situations. The anhepatic phase time and arterial blood Ca 2+ concentration within 5 minutes after reperfusion of the recipients were (52±12)minutes and (0.99±0.10)mmol/L in the portal vein group, versus (64±12)minutes and (1.05±0.07)mmol/L in the albumin group, showing significant differences in the above indicators between the two groups ( t=2.94, 2.22, P<0.05). The mean arterial pressure, arterial blood K +concentration and arterial blood pH within 5 minutes after reperfusion of the recipients were (70±24)mmHg (1 mmHg=0.133 kPa), (4.7±1.3)mmol/L and 7.27±0.06 in the portal vein group, versus (71±28)mmHg, (4.6±1.1)mmol/L and 7.30±0.07 in the albumin group, showing no significant difference in the above indicators between the two groups ( t=0.14, 0.30, 1.22, P>0.05). (2) Post-operative situations. Cases with post-reperfusion syndrome (PRS), cases with severe PRS of cardiac arrest, cases with primary graft nonfunction of the recipients were 6, 0, 2 in the portal vein group, versus 8, 1, 1 in the albumin group, showing no significant difference in the above indicators between the two groups ( P>0.05). Total bilirubin on postoperative day 7 of the recipients was (90±52)μmol/L in the portal vein group, versus (166±112)μmol/L in the albumin group, showing a significant difference between the two groups ( t=2.66, P<0.05). International normalized ratio on postoperative day 7, the highest alanine aminotransferase and aspartate aminotransferase within 7 days after operation of the recipients were 2.1±2.0, (1 952±2 813)IU/L and (3 944±6 673)IU/L in the portal vein group, versus 1.8±0.6, (1 023±1 014) IU/L and (2 005±2 910)IU/L in the albumin group, showing no significant difference in the above indicators between the two groups ( t=0.66, 1.23, 1.08, P>0.05). Recipients with hepatic artery complication and biliary complication were 1 and 2 in the portal vein group, versus 0 and 4 in the albumin group, showing no significant difference in the above indicators between the two groups ( P>0.05). There were 3 cases and 2 cases died during the perioperative period in the portal vein group and the albumin group, respectively. (3) Follow-up. Of the 35 recipients, 30 recipients were followed up for 534(range, 28?776)days after operation. During the follow-up, there were 3 patients with postoperative complications in the portal vein group including 2 cases died and 1 case recovered after sympto-matic treatment. There were 5 patients with postoperative complications in the albumin group including 1 case died and 4 cases recovered after symptomatic treatment. Up to the follow-up date, 11 patients in the portal vein group and 16 patients in the albumin group were in good condition. Conclusion:Rinse of the donor liver with autologous portal venous blood during liver transplantation can shorten the time of anhepatic phase, without increasing the occurrence of post-reperfusion syndrome, ischemia re-perfusion injury and biliary tract complications.

Manejo del trauma vascular periférico en el servicio de cirugía cardiovascular del hospital Dr. Miguel Pérez Carreño. Estudio observacional / Management of peripheral vascular trauma in the cardiovascular surgery service of the Dr. Miguel Pérez Carreño hospital. observational study

El trauma se considera un problema de salud pública, siendo el trauma vascular un desafío para el cirujano de emergencia por su complejidad y morbimortalidad. Objetivo: Describir la experiencia en el manejo del trauma vascular periférico en el Servicio de Cirugía Cardiovascular del Hospital Dr. Miguel Pérez Carreño período enero 2.018 ­ enero 2.021. Métodos: Se realizó estudio retrospectivo, descriptivo, constituido por 410 pacientes, registrándose datos demográficos, mecanismo de lesión, tipos de lesión vascular, signos blandos y duros vasculares, grados de shock hipovolémico, vaso lesionado, procedimiento realizado, complicaciones y mortalidad. Se incluyeron 410 pacientes. La edad promedio fue 25,6 ± 18 años (14-72), sexo masculino en 89%. El mecanismo de lesión predominante fue el penetrante (92%), herida de arma de fuego (68%) y el trauma cerrado (7%). El diagnóstico fue clínico en 90% de los casos, el resto de la muestra fueron pacientes con lesiones crónicas como las fistulas AV y pseudoaneurismas. Las lesiones más frecuentes fueron en las extremidades inferiores (81%), extremidades superiores (17%) y cuello (2%). El tipo de lesión más común fue la transección arterial (49%) y lesión parcial (20%). Se presentó shock hipovolémico en 60% de los casos. La femoral superficial fue la más lesionada (70%) seguida de la poplítea (20%), la lesión asociada fue la fractura de huesos largos en un 30%. Se realizó interposición venosa autóloga en 89% de los casos. La infección de sitio operatorio registrada fue de 15% y la mortalidad de 0.4%. Conclusiones: El diagnóstico oportuno y manejo adecuado del trauma vascular demostró baja tasa de morbimortalidad y resultados favorables, incluso realizando reparación primaria, sin diferencia por grado de shock ni uso de shunt(AU)

Trauma is considered a public health problem, with vascular trauma being a challenge for the emergency surgeon due to its complexity, morbidity and mortality. Objetive: To describe the experience in the management of peripheral vascular trauma in the cardiovascular surgery department at Dr. Miguel Perez Carreño Hospital period January 2.018 - January 2.021. Methods: A retrospective, transversal and descriptive study was conducted, consisting of 410 patients, registering demographic data, injury mechanism, types of vascular injury, soft and hard vascular signs, degrees of hypovolemic shock, injured vessel, procedure performed, complications, and mortality. Results: 410 patients were included. The average age was 25.6 ± 18 years (14-72), 365 male (89%). The predominant injury mechanism was penetrating (92 %), gunshot wound (68%), and blunt trauma (7%). diagnosis by clinical in (90%), the rest of the sample was reserved for patients with chronic lesions such as AV fistulas and pseudoaneurysms. The most frequent lesions were in the lower extremities (81 %), upper extremities (17 %), and neck (2 %). The most common type of lesions were arterial transection (49%) and partial lesion (20%). Hypovolemic shock was present in (60%) of the cases. The superficial femoral artery was the most injured (70%) followed by the popliteal artery (20%), the associated injured was long bone fracture (30%). autologous venous interposition was performed in (89%) of cases. Registered surgical site infection was (15%) and mortality of 2 patients (0.4%). Conclusions: The timely diagnosis and proper management of vascular trauma showed a low rate of morbidity and mortality and favorable results, even carrying out primary repair, without difference by degree of shock or use of shunts(AU)

Immediate Revascularisation of Borderline Ischemic Limbs Followed by Replantation

Introduction: Salvage of complex limb injuries is not onlydependent on the skill, experience and attitude of the surgeonbut also on the ischemia time. If the revascularisation isnot possible within the golden period then the outcomeis unfavourable. There are very few reports of delayedreplantation. We are presenting a case series of replantationbeyond the golden hours i.e. 6 hours of warm ischemia byimmediate revascularisation before undertaking definitivereplantation. The definitive sequence of replantation is carriedout after the limb gets revascularised and the viscious cycle ofischemia is broken. Study aimed to salvage amputated limbs inthe borderline ischemia time by immediate revascularisation.Material and methods: A study was conducted between April2013 to March 2018 at SBM Plastic Surgery Hospital, cuttackand included all patients with limb amputations of 6-10 hoursduration. In this study the artery was anastomosed first to haltthe sequence of prolonged ischaemia. Temporary stability tothe repair was provided by taking deep bites to the proximaland distal muscle group with 2.0 vicryl sutures adjacent tothe anastomosis. After the limb was adequately revascularisedand proper hemostasis was achieved then the proper sequenceof replantation was started.Result: out of 31 patients presenting during this period, 9patients were excluded for poor preservation of the limb andpresenting after 10 hours of warm ischamia. Total no of casesincluded in the study were 22 patients who presented between4 to 9 hours of cold ischemia time. The break up accordingto the nature of injury was, 19 patients had avulsion injuries,two had assault with heavy sharp weapons and one hadcrush injury. Out of 22 cases of replantation 2 cases requiredamputation at a later date due to complications.Conclusion: In our country majority of patient come tohospital after 6-8 hrs of warm ischemia which is the upperlimit of ishaemia. If the ideal sequence of replantation willbe followed these limbs will undergo irreversible ischaemicdamage due to further delay. So the concept of immediatearterialisation gives the best opportunity for limb survival.

Embolectomía tardía en isquemia aguda de miembros inferiores / Late embolectomy in acute lower limb ischemia

La isquemia aguda es la interrupción brusca del aporte sanguíneo a un determinado territorio del organismo. Su causa más frecuente, la embolia arterial, consiste en la oclusión también brusca de una arteria sana por material trombótico formado en un territorio proximal al del accidente y que desencadena un cuadro que, de no diagnosticarse y tratarse adecuadamente, puede comprometer la vida del paciente. Existe una estrecha relación entre la gravedad del cuadro isquémico y el tiempo transcurrido de manera que si no se toman medidas agresivas a tiempo raramente se resuelve de manera satisfactoria. La revascularización es considerada menos efectiva después de 8 a 10 h de isquemia, tiempo después del cual muchos se abstienen de operar debido al temido síndrome de reperfusión; sin embargo, algunos refieren éxitos con embolectomías tardías. Se presenta un caso de embolismo arterial a miembro inferior derecho por arritmia cardiaca, que llegó al servicio de Cirugía Vascular del Hospital Provincial "Dr. Antonio Luaces Iraola", con 72 h de evolución. Se le realizó embolectomía femoral con catéter de Fogarty con resultados satisfactorios, lo que apoya la hipótesis de que se debe intentar reperfundir la extremidad siempre que se demuestre viabilidad de los tejidos y no exista gangrena, independientemente del tiempo transcurrido(AU)

Acute ischemia is the sudden interruption of the blood flow in a specific area of the body. Its most common cause is arterial embolism consisting of abrupt occlusion of a healthy artery by thrombotic residues formed in an area near the stroke and unleashing a clinical picture that should be adequately diagnosed and treated to avoid death. There is close relationship between the severity of ischemia and the time elapsed because if no aggressive actions are taken in due time, the results are rarely satisfactory. Revascularization is considered less effective 8 to 10 hours after ischemia. After this time many surgeons refrain from performing surgery due to the frightening reperfusion syndrome. However some had documented successful results with late embolectomy. Here is a case of arterial embolism in right lower limb owing to cardiac arrhythmia. The patient arrived to the Vascular Surgery service after 72 hours of the event; he was performed femoral embolectomy with Fogarty catheter and the achieved results were satisfactory, which supports the hypothesis of trying to reperfusing the affected limb whenever tissue viability exists and gangrene is not present, regardless of time elapsed(AU)

Mechanisms of oxidative stress and myocardial protection during open‑heart surgery.

Cold heart protection via cardioplegia administration, limits the amount of oxygen demand. Systemic normothermia with warm cardioplegia was introduced due to the abundance of detrimental effects of hypothermia. A temperature of 32–33°C in combination with tepid blood cardioplegia of the same temperature appears to be protective enough for both; heart and brain. Reduction of nitric oxide (NO) concentration is in part responsible for myocardial injury after the cardioplegic cardiac arrest. Restoration of NO balance with exogenous NO supplementation has been shown useful to prevent inflammation and apoptosis. In this article, we discuss the “deleterious” effects of the oxidative stress of the extracorporeal circulation and the up‑to‑date theories of “ideal’’ myocardial protection.

Sudden cardiac arrest after declamping of aorta during a bypass surgery for dissecting infra-renal aortic aneurysm: A case report / 대한마취과학회지

Significant hemodynamic change is rarely shown in the case of bypass surgery for infra-renal aortic aneurysm.However, a man underwent aortoiliac bypass surgery for dissecting infra-renal aortic aneurysm experienced sudden cardiac arrest and hypoxemia just after declamping of aorta and subsequent renal impairment.We supposed that transient myocardial dysfunction after declamping and release of inflammatory materials after reperfusion caused cardiac arrest and renal impairment.Therefore, careful anesthetic management is needed not only during the clamping of aorta but also at the time of declamping even in the infra-renal aortic bypass surgery.

Manifestações sistêmicas adversas em medicina intensiva após realização de perfusão isolada de membro com melfalan e hipertermia: relato de caso / Adverse systemic reactions in intensive care medicine after isolated limb perfusion with melphalan and hyperthermia: case report

JUSTIFICATIVA E OBJETIVOS: A presença de efeitos adversos, inerentes a todos os tratamentos, justifica a necessidade do profundo conhecimento pela equipe médica para prevenção e tratamento de eventuais disfunções orgânicas, reduzindo o seu impacto. O objetivo deste estudo foi relatar um caso de paciente que apresentou diversas manifestações sistêmicas, após a realização de perfusão isolada de membro com melfalan e hipertermia. RELATO DO CASO: Paciente do sexo feminino, 64 anos, branca, com diagnóstico de melanoma na região de maléolo medial do membro inferior esquerdo. Seis meses após a excisão da lesão, realizou-se perfusão isolada do membro, com melfalan e hipertermia para conter o processo em evolução de possível metástase. A admissão na UTI apresentou síndrome da resposta inflamatória sistêmica (SIRS) com instabilidade hemodinâmica refratária à expansão volêmica. Durante a internação evoluiu com quadro de edema agudo de pulmão e disfunção miocárdica, revertidos com sucesso, depois de adequada intervenção terapêutica. CONCLUSÕES: A presença de efeitos adversos, inerentes a todos os tratamentos oncológicos, justifica a necessidade do conhecimento pela equipe da terapia intensiva para prevenção e tratamento de eventuais disfunções orgânicas, reduzindo o impacto de sua morbimortalidade.

BACKGROUND AND OBJECTIVES: The presence of adverse reactions, inherent to all treatments, justifies the necessity of deep knowledge, by the medical team of the prevention and treatment of occasional organic dysfunctions, reducing its impact. The purpose of this paper is to report a case comprising the several systemic adverse reactions after perfusion of limb with melphalan and hyperthermia. CASE REPORT: A white female, 64-years old patient with diagnosis of melanoma in the medial malleoli region of the left lower limb. Six months after surgical removal of wound, an isolated perfusion of limb was carried out with melphalan and hyperthermia in order to curb the possible metastatic process in evolution. At admission in the ICU, the patient presented systemic inflammatory response syndrome (SIRS) with refractary hemodynamic instability to volemic expansion. During internation the patient evolved to acute lung edema and myocardial dysfunction, all reverted successfully. CONCLUSIONS: The potential presence of adverse reactions, inherent to all treatments, justify the necessity of knowledge by the intensive care team in the prevention and treatment of occasional organic dysfunctions, reducing the impact of morbidity and mortality.