Tracheomalacia associated with Mounier-Kuhn syndrome in the Intensive Care Unit: treatment with Freitag stent. A case report.

Tracheomalacia is a process characterized by softness of the supporting tracheal cartilages, by the extension of the posterior membranous wall and by reduction of the tracheal antero-posterior diameter. Exceptionally, tracheomalacia can be associated with tracheobronchomegaly or Mounier-Kuhn syndrome. Fibro-bronchoscopy represents the ''gold standard'' for diagnosis. The case of a 79-year-old male observed after hospitalization in a medical ward for chronic pulmonary obstructive disease (COPD) decompensation, and with basal left bronchopulmonary focus, is described. During this period, a progressive worsening of clinical conditions occurred, despite cortisone and antibiotic therapy, and the patient was transferred to the ICU for dyspnea, hypoxia, hypocapnia and with a diagnosis of pulmonary fibrosis. Bronchoscopy, performed during spontaneous breathing, revealed tracheomalacia which was responsible for tracheal dynamic complete stenosis during expiration and dynamic subtotal stenosis of the left primary bronchus in the first tract, together with sputum retention. Moreover, this investigation confirmed the diagnosis of tracheobronchomegaly already seen on CT. It was suggested to place a Freitag stent, since the insertion of another model would not have had enough chance of stability, due to the enormous extension of the tracheal lumen and could not have guaranteed good clearance of the secretions. Seven days after this intervention, performed in an outpatients' setting, the patient was dismissed from the ICU, without the help of O2, with good ventilation, saturation in line with his age and good expectoration.

Older adult multiorgan donors and misdiagnosed tumor.

BACKGROUND: In these last years, the increase in organ donations is mostly due to old patients died of primary vascular cerebral diseases. In this kind of patients some undiagnosed cancers can be present and can be transmitted to the receiver. Aim of this study is to carry out a research in order to identify any undiagnosed cancer which can be present during the period of encephalic death. METHODS: Perspective study: hospitals type II and type III. Polyvalent intensive care. From January 1999 to July 2000 encephalic death has been ascertained in 16 patients. The research of tumor markers has been carried out on these patients. Further diagnostic researches have been carried out on patients who had anomalous values. RESULTS: The organ donations have not been made by eight patients: five for family refusal, one for medical contraindications, two for the presence of undiagnosed tumor (PSA 1100 ng/ml and CEA 129.5 ng/ml) confirmed by prostatic and abdominal US imaging. A patient with CA 19-9 89.5 ng/ml has not been examined, because of the family refusal to donation. A patient with PSA of 135 ng/ml had a negative response from the anal scanner, and so the prosecution of the donation has not been interrupted. A blood sample has been taken and a biopsy of the prostate has been made to confirm the absence of neoplasm. CONCLUSIONS: It is necessary to make a careful examination of the organ donor to check if some cancers are present. Tumor markers cannot be used to make a diagnosis of a cancer, but they can be used as guide for further researches. In spite of all the diagnostic efforts, the objective evaluation of the surgeon is still the most important factor like the biopsy of all the suspected lesions during an operation and the autopsy.

A new surgical model of acute liver failure in the pig: experimental procedure and analysis of liver injury.

In this research, the effects of portocaval shunt plus 70% partial hepatectomy were evaluated in 11 pigs. Hepatic coma and death from progressive liver failure occurred in 5 pigs between 14 and 64 h from surgery, whereas 3 pigs, which also showed symptoms of progressive liver failure, died of presumed gastric hemorrhage between 17 and 19 h after surgery. In 3 pigs, transient liver failure was followed by complete recovery, as judged by clinical, electroencephalographic and biochemical parameters. No case of death occurred among the pigs treated with portocaval shunt alone or 70% partial hepatectomy alone as controls. This new model for acute liver failure is reproducible, seems to be potentially reversible, causes death due to hepatic failure after a time period sufficiently long to allow for the institution of support procedures, is applied to a large animal and lacks relevant biohazard. Therefore, this model may be used to evaluate possible support procedures during acute liver failure.

Veno-venous bypass in experimental liver transplantation: portal-jugular versus caval-portal-jugular.

This study was undertaken to compare the changes in physiologic variables caused by the use of two different types of pump-assisted veno-venous bypass during experimental liver transplantation. The experiments, performed on female pigs weighing 30 +/- 2 kg, were divided into two groups depending on the bypass used. During the anhepatic phase a pump-assisted portal-jugular (PJ) bypass was used in Group 1 (n = 8) at a flow rate of 15 ml kg-1-min-1, while a pump-assisted caval-portal-jugular (CPJ) bypass was used in Group 2 (n = 8) at a flow rate of 20 ml kg-1-min-1. Intraoperative haemodynamics, pulmonary gas exchange, haematological and serum biochemical parameters were evaluated. Postoperative animal survival rate and complications associated with the bypass used were evaluated. Mean pulmonary artery pressure (Ppa) and pulmonary vascular resistance (Pvr) showed significantly different behaviour in the two groups, whereas the remaining parameters all showed the same trend. Thus an earlier and more substantial increase in Ppa and Pvr values was found in Group 1 when compared to Group 2 during the anhepatic phase. The different behaviour shown by Group 1 may depend on the release of circulating vasoactive substances generated following pelvic venous congestion caused by the temporary clamping of the inferior vena cava. In conclusion, this study indicates that the pump-assisted CPJ bypass is more suitable than the pump-assisted PJ bypass. Furthermore, in order to obtain better results it should be used routinely in porcine liver transplantation.

Defibrotide in extracorporeal circulation on healthy rabbits.

Defibrotide, a partially depolymerized DNA fraction obtained from mammalian lung, was found to have significant antithrombotic and fibrinolytic activities. On the basis of this evidence defibrotide could be of clinical value during hemoperfusive treatment. The present study was designed to evaluate the biological tolerance of this technique in a model of extracorporeal circulation, using an original Silastic apparatus, with defibrotide (0.83 mg/kg-1/min-1 after a 50 mg/kg-1 bolus injection) and heparin (0.66 IU/kg-1/min-1 after a 400 IU/kg-1 bolus injection) in ten rabbits (Group 1) and heparin only in ten others (Group 2, control group). In this study defibrotide produced a significantly lower pressure inside the circuit compared to the control group and gave a protective effect against those pathological changes which appeared during extracorporeal circulation and that may be considered omens of a state of shock. However the use of defibrotide in addition to heparin seemed to have a poor effect on platelet and leukocyte count alterations during application of this technique.

[Orthotopic liver transplant in pigs: several variations of the surgical technic]. / Trapianto ortotopico di fegato nel suino: alcune varianti di tecnica chirurgica.

A technique of orthotopic liver transplantation in the pig is presented. The use of a veno-venous cava-portal-jugular shunt during the anhepatic phase helped by a roller pump with moderate systemic heparinization is described. Technical modifications of arterious and biliary anastomosis are described as well. This technique is not only similar to the procedure applied to man, but it also provides a safe and reproducible experimental model. It has produced good results according to a survival rate equal to 95% at 48 hour and 87.5% at one week in the orthotopic liver transplantation in the pig.

Biliary tract complications in orthotopic liver transplantation: an experimental study in the pig.

The results of 56 consecutive orthotopic liver transplants in the pig were reviewed to determine the incidence of primary biliary tract complications. There were 8 biliary tract complications in 56 grafts (14.2%) directly responsible for death. End-to-end choledochocholedochostomy (ee-CC) was the most frequently used technique (40 cases) with 4 technical failures (10.0%). Choledochojejunostomy with a Roux-en-Y jejunal loop (RYCJ) was used in 9 cases with 2 technical failures (22.2%). Side-to-side choledochocholedochostomy (ss-CC) was used in 7 cases with 2 technical failures (28.5%). Biliary leak and stenosis were the most common complications. End-to-end choledochocholedocostomy appears to be the most suitable and easy biliary reconstruction in the pig but possible gross disparity in the sizes of the donor and recipient ducts may represent and adverse factor.