Evolution and Risk Factors for Early Mortality After Lung Transplantation for Idiopathic Pulmonary Fibrosis: An Experience of 20 Years.

High early mortality after lung transplantation (LT) for idiopathic pulmonary fibrosis (IPF) is still not well controlled, and some aspects remain debated. The aim of this study was to evaluate our experience to identify factors that might improve the early outcomes. Among the 427 patients transplanted from October 1993 to December 2014, 117 IPF patients underwent LT at our department. There was an increasing age of transplant recipients, and the overall early (1-mo_ mortality was 25/117 (21.4%) with a progressive decrease over the years. Logistic regression analysis for early mortality was performed, and multivariate analysis identified recipient age <55 years (P = .042; odds ratio [OR], 2.98), single-lung transplants (P = .001; OR, 5.226), and previous corticosteroid treatment (P = .05; OR, 5.128) as independent risk factors for development of early mortality. In conclusion, despite the increasing age of transplant recipients, we observed a decrease in mortality to almost one-half compared with our initial results. According to our results, the mortality risk in patients <55 years old is independent from the type of transplant (single or double), being higher with a single transplant. In addition, corticosteroid treatment should be reduced to achieve lower early mortality.

Technique Resource for Difficult Auricular Anastomosis in Lung Transplantation.

OBJECTIVES: Atrial anastomosis in lung transplantation (LT) can present significant technical difficulties, especially when there is a very posterior left inferior pulmonary vein, in donor-recipient disproportion or excessive separation of the receptor's pulmonary veins owing to atrial dilatation; hence, its implementation requires excessive heart handling and longer ischemia time, which result in increased perioperative complications. This technique, which uses the recipient's superior pulmonary vein, avoids these problems, although it is not applicable in all cases because no pressure gradient at the suture level is required. Therefore, the suture diameter must be equal or greater than the sum of both graft pulmonary veins diameters. METHODS: This retrospective study recorded the age/gender (donor and recipient), preoperative morbidity, type of surgery, perioperative, vascular complications, mortality, and postoperative stay. Descriptive and inferential statistical study was made by SPSS. RESULTS: We performed 82 LTs between January 2009 and June 2012, 18 with the new technique (14 men/4 women; 52 ± 15 years). There were 14 single lung and 4 double lung transplants. The new technique does not increase the ischemic times when compared with the classic technique. No vascular dehiscence, fistulas, or thrombosis were found. There were observed fewer vascular complications (P = .042). Early mortality was presented in 4 cases (22.2%). CONCLUSIONS: This new technique achieves the objectives described (no increases in ischemic time, fewer vascular complications). However, an absolute confirmation requires a study comparing similar technical LT given that the new resource was only used in highly complex procedures.

Quimerismo donante-receptor como origen del desarrollo de bronquiolitis obliterante en un modelo experimental de retrasplante de tráquea en ratas / Donor-receiver chimerism as the ori gin of obliterative bronchiolitis in an experimental model for trachea re transplant in rats

OBJETIVOS: 1. Desarrollar un modelo de bronquiolitis obli-terante en ratas (BO), mediante trasplante heterotópico de tráquea; 2. Eliminar el componente de rechazo alogénico me-diante el reimplante del injerto en un animal isogénico; y 3. Estudiar la respuesta inflamatoria persistente que podría auto-perpetuar la lesión.MÉTODOS: Se utilizaron ratas de las razas Lewis (LW), Wistar (W) y Brown Norway (BN). Se realizaron trasplantes singéni-cos (LW-LW, n=14; W-W, n=6; y BN-BN, n=6) y alogénicos AB (LW-W, n=6; BN-LW, n=6; y W-LW, n=6), alojando el injerto en el tejido celular subcutáneo cervical. Tras 15 días, se explantó el injerto e implantó en una tercera rata singéni-ca o alogénica por otros 15 días, estableciendo un modelo de retrasplante A-B-A y A-B-B. Los injertos se procesaron para realizar estudios histológicos e inmunohistoquímicos. El ori-gen de las células epiteliales se analizó mediante PCR.RESULTADOS: El retrasplante de tráquea, tanto en el diseño A-B-B como A-B-A, dió lugar a la aparición de una rápida respuesta inflamatoria compatible con un proceso de BO, en aquellos animales que habían desarrollado rechazo por tras-plante alogénico previo. En trasplantes ♀-♂-♀, se detectaron células con el cromosoma Y en tráqueas del 2º receptor ♀.CONCLUSIONES: En el modelo de retrasplante de tráquea en ratas, junto a los hallazgos típicos de BO se produce una res-puesta inflamatoria leve-moderada compatible con un recha-zo celular MHC incompatible. Células procedentes del primer receptor se integrarían en la tráquea del segundo trasplante, produciéndose un quimerismo donante receptor, que sería el responsable, en último término, del desarrollo de BO

OBJECTIVES: 1. Develop an obliterative bronchiolitis (OB) model in rats, by means of heterotopic trachea transplant; 2. Eliminate the allogenic rejection component by re-implanting a graft in an isogenic animal; and 3. Study the persistent in-flammatory response that could self-perpetuate the injury. METHODS: The following rat breeds were used: Lewis (LW), Wistar (W) and Brown Norway (BN). Syngenic (LW-LW, n=14; W-W, n=6; and BN-BN, n=6) and allogenic AB (LW-W, n=6; BN-LW, n=6; and W-LW, n=6) transplants were performed, housing the graft in the cervical subcutaneous ce-llular tissue. After 15 days, the graft was removed and implan-ted into a third syngenic or allogenic rat for another 15 days, to establish a re-transplant model A-B-A and A-B-B. The grafts were processed to carry out histological and immunohistoche-mical studies. The origin of the epithelial cells was analyzed using PCR. RESULTS: The tracheal re-transplant, both in the A-B-B and A-B-A design, gave rise to the appearance of a rapid inflam-matory response compatible with OB process, in those ani-mals that rejected the transplant due to previous allogenic transplant. In ♀ -♂ -♀ transplants, cells were detected with the Y chromosome in trachea of the 2nd ♀ receiver. CONCLUSIONS: In the trachea re-transplant model in rats, together with typical OB discoveries, a compatible slight-moderate inflammatory response takes place with an MHC incompatible cellular rejection. Cells from the first receiver became integrated into the trachea of the second transplant, producing a donor-receiver chimerism that would, in the final location, be responsible for the development of OB. Key words: Lung transplant, chronic rejection, obliterative bronchiolitis, chronic dysfunction of the lung graft

Postoperative complications in the intensive care unit following lung transplantation in adults: results in University Hospital Reina Sofia.

The postoperative period following lung transplantation remains critical because of several complications. Infection, primary graft failure, acute rejection, and surgical complications are risk factors for mortality and morbidity. The recognition and early treatment of these complications is important to optimize outcomes. This article provides an overview of postoperative complications observed in our center during the last year. We were particularly interested in the influence of variables, such as inotrope usage and Acute Physiology and Chronic Health Evaluation (APACHE II) score, a well-known, and validated mortality prediction model for general intensive care unit (ICU) patients only infrequently reported in the transplantation literature. High APACHE II scores were significantly associated with prolonged mechanical ventilation (P = 0.041) and a tracheostomy requirement (P = .035). The factors significantly associated with an early postoperative death were older donor age (P = .005), prolonged donor ICU period (P = .004), need for cardiopulmonary bypass (CB; P = .005), and high inotrope requirements in the ICU (P = .034). CB data were biased because we selected the worst case patients. Donor age and high inotrope requirements in the ICU have been reported previously to be prognostic factors for poor graft function. We believe that control of these variables may improve outcomes.

2ª Mesa Redonda: Tratamiento quirúrgico de las metástasis pulmonares / No disponible

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Analisis secuencial y cronológico de la actividad de donación y trasplante pulmonar en Andalucía desde 1993 hasta 2007 / Sequential and chronological analysis of the activity of pulmonary donation and transplant in Andalusia between 1993 and 2007

Objetivo: la escasez de donantes pulmonares válidos es el principal factor que limita el desarrollo de un programa de trasplante pulmonar (TxP). Nuestra experiencia inicial analizando 280 donantes, demostró que solo el 54,7% eran válidos para trasplante. El presente trabajo pretende reexaminar el problema, analizando la evolución de las tasas de validez pulmonar con los años, identificando qué factores son susceptibles de mejorar para incrementar el número de donantes pulmonares, y determinando si el empleo de donantes subóptimos influye en los resultados del TxP a corto y largo plazo. Métodos: se revisaron todos los donantes ofertados a nuestra unidad desde octubre 1993 hasta diciembre 2007. La evaluación del donante pulmonar se dividió en tres fases: fase 1 (análisis de PaO2/FiO2, radiografía de tórax y hallazgos fibrobroncoscópicos); fase 2 (inspeccióny palpación pulmonar en campo operatorio); fase 3 (evaluación pulmonar después de la extracción donante). Se analizaron variables del donante y del receptor y se compararon entre dos periodos: donantes A (entre 1993 y 2001) y donantes B (entre 2002 y 2007). Se realizó un análisis adicional en un subgrupo de donantes con criterios de “subóptimo” (..) (AU)

Objective: The shortage of donors is a major problem limiting lung transplant programmes (LTx). Our early experience analysing 280 donors demonstrated that only 54.7% were (..) (AU)

Combined lung and liver transplantation-University Hospital Reina Sofia experience: two case reports.

OBJECTIVE: To analyze the results of combined lung and liver transplantation. METHODS: We performed two combined lung and liver transplantations for patients with cystic fibrosis with chronic respiratory failure accompanied by advanced liver disease. In each case, all thoracic and abdominal organs were obtained from a single donor by means of standard harvest techniques. In the recipient, a two-stage procedure was adopted with completion of the bilateral lung transplantation before the liver operation. Immunosuppression consisted of three-drug therapy used for isolated lung transplantation. RESULTS: The patients were both boys of 13 and 15 years old. Episodes of acute pulmonary rejection were successfully treated with intravenous steroids. Neither lung disorder was associated with a liver rejection episode. Airway complications that occurred in both cases were managed endoscopically. CONCLUSION: Combined transplantation of lung and liver is a feasible and therapeutically effective procedure for patients with cystic fibrosis complicated by advanced liver disease. Herein we have described our experience in two of the only three cases of combined liver and lung transplantation performed in Spain to date. Patient and graft survivals were comparable to isolated liver or isolated bilateral lung transplantations.

Cirugía broncoplástica en el tumor carcinoide bronquial típico. Descripción de tres casos en la infancia / Bronchoplastic surgery in typical bronchial carcinoid tumour

El tumor carcinoide bronquial típico (TCBT) asienta preferentemente en bronquios de grueso calibre produciendo fenómenos de obstrucción distal. Aunque la OMS lo clasifica dentro de las neoplasias malignas broncopulmonares, el TCBT se muestra poco agresivo y su pronóstico a largo plazo es bueno siempre que no exista diseminación linfática ni metástasis sistémicas. La mayoría de los autores son partidarios del tratamiento quirúrgico conservador, evitando la neumonectomía, siempre que este asegure la total resección del TCBT. Presentamos 3 casos de pacientes infantiles diagnosticados de TCBT en el eje bronquial principal con atelectasia de lóbulos inferiores en los que fue posible la resección con reimplante de lóbulos superiores en 2 casos, y un tercero con tumor en bronquio intermediario, resecándose el mismo con reimplante posterior de lóbulos medio e inferior

The typical bronchial carcinoid tumour (TBCT) is usually located in large bronchi, provoking distal obstruction. Although the WHO classifies it within the malignant bronco-pulmonary neoplasias, TBCT does not always present as very aggressive and its long-term prognosis is good, providing there are no lymphatic dissemination or distant metastasis. Most authors favour conservative surgical treatment, avoiding pneumonectomy, provided this assures the total resection of the TBCT. We present three cases of children diagnosed with TBCT in the main bronchi with atelectasis of the inferior lobes in which resection was possible, together with the re-implantation of the superior lobes in 2 cases. In the third case, the tumour in the intermediary bronchus was resected, with subsequent re-implantation of the midle and inferior lobes

Cirugía torácica mínimamente invasiva: Procedimientos. diagnóstico y tratamiento / No disponible

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[Perioperative morbimortality in pneumonectomy. Analysis of risk factors]. / Morbimortalidad perioperatoria de la neumonectomía. Análisis de los factores de riesgo.

UNLABELLED: Pneumonectomy continues to be associated with high rates of morbidity and mortality. OBJECTIVE: The aim of this study was to determine the mortality and morbidity rates after pneumonectomy and to analyze perioperative risk factors related to mortality. PATIENTS AND METHODS: The cases of 266 patients undergoing pneumonectomy between January 1986 and December 1997 were reviewed retrospectively: 241 patients with lung cancer, 4 with pulmonary metastasis, 9 with bronchiectasis and 12 with other benign diseases; 13% received neoadjuvant therapy. The bronchial stump was stapled in 92%, sutured in 8%, and covered with autologous tissue in 73%. Intrapericardial pneumonectomy was performed in 32%, pneumonectomy extended to the chest wall or diaphragm in 9%, and completion pneumonectomy was performed in 3%. We collected general demographic data, medical histories, pulmonary function data and surgical technique. Deaths and postoperative complications within the first 30 days after pneumonectomy were also known. RESULTS: Two hundred sixty-six pneumonectomies were performed [right 102 (38%); left 164 (62%)] in 249 men (93%) and 17 women (7%) who were 58 +/- 11 years of age (20 to 79 years). The rate of early postoperative death (30 days) was 5.6%. Mortality rates were higher among patients over 70 years of age (p = 0.045), diabetics (p = 0.038), patients undergoing neoadjuvant therapy (p = 0.031), those with FEV1 under 1,800 ml (p = 0.013), cases of right-sided pneumonectomy (p = 0.001), cases of extended pneumonectomy (p = 0.037) or those without coverage of the bronchial stump (p = 0.005). Mortality was also higher when complications appeared involving the bronchial stump (p < 0.01), heart (p < 0.001), respiration (p < 0.001) or digestion (p = 0.002). Overall morbidity was 40%. Surgical complications developed in 23%: postpneumonectomy empyema (10%), bronchopleural fistula (7%) (with no significant difference related to stapling or suturing), hemothorax (3%) and wound complications (3%). Twelve patients (4.5%) underwent second operations. Cardiac morbidity was 20% (atrial fibrillation in 12%), respiratory morbidity was 8% and other complications appeared in 19% of cases. CONCLUSION: In our experience, mortality after pneumonectomy is 5.6% with an overall complication rate of 40%, mainly due to surgical and cardiac complications. Coverage of the bronchial stump with autologous tissue reduces the risk of postoperative death due to fistula and/or empyema after pneumonectomy.

Morbimortalidad perioperatoria de la neumonectomía. Análisis de los factores de riesgo / Morbidity and mortality during and after pneumonectomy. An analysis of risk factors

Objetivo: Determinar la tasa de mortalidad y morbilidad tras neumonectomía y analizar factores de riesgo perioperatorios relacionados con la mortalidad. Pacientes y métodos: Se han revisado retrospectivamente 266 pacientes sometidos a neumonectomía entre enero de 1986 y diciembre de 1997: 241 casos por carcinoma broncogénico, metástasis pulmonares en 4, bronquiectasias en 9 casos y otra afección benigna en 12 pacientes; el 13 por ciento de los casos recibieron terapia neoadyuvante. El muñón bronquial se suturó mecánicamente en el 92 por ciento y manualmente en el 8 por ciento, y se realizó cobertura del mismo con tejido autólogo en el 73 por ciento de los casos. La neumonectomía fue intrapericárdica en el 32 por ciento, extendida a pared torácica o diafragma en el 9 por ciento y se completó neumonectomía tras resección menor previa en el 3 por ciento de los casos. Se recogieron datos demográficos generales, antecedentes patológicos, datos de función respiratoria y técnica quirúrgica. También se obtuvieron datos de mortalidad y complicaciones postoperatorias en los primeros 30 días tras la neumonectomía. Resultados: Se han realizado 266 neumonectomías, 102 derechas (38 por ciento) y 164 izquierdas (62 por ciento), en 249 varones (93 por ciento) y 17 mujeres (7 por ciento), con una media de 58 ñ 11 años (rango, 20-79 años). La mortalidad postoperatoria temprana (30 días) fue del 5,6 por ciento. La mortalidad fue superior en pacientes mayores de 70 años (p = 0,045), diabéticos (p = 0,038), sometidos a terapia neoadyuvante (p = 0,031), con FEV1 menor de 1.800 ml (p = 0,013), en las neumonectomías derechas (p = 0,001), extendidas (p = 0,037) o sin cobertura del muñón bronquial (p = 0,005). Asimismo, la mortalidad fue mayor cuando aparecieron complicaciones del muñón bronquial (p < 0,01), complicaciones cardíacas (p < 0,001), respiratorias (p < 0,001) y digestivas (p = 0,002). La morbilidad global fue del 40 por ciento. Aparecieron complicaciones quirúrgicas en un 23 por ciento de los casos: empiema posneumonectomía (10 por ciento), fístula broncopleural (7 por ciento) (sin diferencias entre sutura manual y mecánica), hemotórax (3 por ciento) y complicaciones de la toracotomía (3 por ciento). Doce pacientes se reoperaron (4,5 por ciento). La morbilidad cardíaca fue del 20 por ciento (fibrilación auricular en el 12 por ciento), la morbilidad respiratoria fue del 8 por ciento y otras complicaciones aparecieron en el 19 por ciento de los casos. Conclusión: En nuestra experiencia, la mortalidad tras neumonectomía es del 5,6 por ciento, con una morbilidad global del 40 por ciento, principalmente debida a complicaciones quirúrgicas y cardíacas. La cobertura del muñón bronquial con tejido autólogo reduce el riesgo de muerte postoperatoria por fístula y/o empiema posneumonectomía. (AU)

[Sequential double lung transplant in Kartagener's syndrome]. / Trasplante bipulmonar secuencial en el síndrome de Kartagener.

Very few cases of lung transplantation have been described for patients with Kartagener's syndrome. We report the first case to be published in Spain. A 15-year-old girl with complete Kartagener's syndrome underwent sequential transplantation of both lungs. Due to the unusual distribution of the organs in this syndrome, the bronchial stumps of donor and recipient had to be distributed differently. With the initial technical difficulties overcome, the patient now leads a normal life two years after transplantation.

Trasplante bipulmonar secuencial en el síndrome de Kartagener / A sequential double lung transplant in Kartagener's syndrome

Se han descrito muy pocos casos de trasplante pulmonar en pacientes con un síndrome de Kartagener. Describimos el primer caso que se publica en España. Una mujer de 15 años con un síndrome de Kartagener completo fue sometida a un trasplante bipulmonar secuencial. Debido a la disposición especular de los órganos en esta entidad clínica, se hizo necesario recurrir a modificaciones en la distribución habitual de los muñones bronquiales, tanto del donante como del receptor. Superadas las dificultades técnicas iniciales, la paciente realiza actualmente vida normal a los dos años postrasplante. (AU)

[Surgical treatment of cervicomediastinal goiter]. / Tratamiento quirúrgico del bocio cervicomediastínico.

To review our experience with the surgical treatment of cervicomediastinal goiters. Charts of patients with cervicomediastinal goiters undergoing thyroidectomy within the last 10 years were reviewed. Data regarding previous disease, clinical features, diagnostic procedures, surgical intervention and postoperative evolution were recorded. Twenty-eight patients (19 female and 9 male) 62 +/- 2 years old underwent surgery to treat cervicomediastinal goiter during the period reviewed. Among patients with compressive manifestations (75.6%), dyspnea was the most common (36.6%) symptom, followed by dysphagia and superior vena cava syndrome. An extrathoracic obstruction pattern was found in 3 (11.2%) cases. Thyroid scintigraphy showed increased thyroid size in 25 patients, and in 9 of them a cold nodule was present as well. Fine needle aspiration of the thyroid gland was performed in 5 patients; malignancy was found only in 1 case. Fiberoptic bronchoscopy was performed in 15 patients; in 7 (25%) tracheal compression was found. In these patients there was no higher rate of postoperative complications. Cervicotomy was the surgical approach used in 23 (82.1%) patients. Cervicosternotomy was used in 4 (14%), and thoracotomy in 1 (3.6%). The surgical procedure was bilateral subtotal thyroidectomy in 15 (53.6%), total thyroidectomy in 3 (10.7%), right lobectomy in 6 (21.4%), and left lobectomy in 4 (14.3%). Colloid goiter was the most common histological type (42.8%), followed by nodular hyperplasia (35.8%), cancer (10.7%) and adenoma (10.7%). Three patients showed transient recurrent paralysis in the postoperative period, and another 3 patients presented major complications: 1 case of postoperative bleeding and 2 cases of tracheomalacia requiring tracheostomy. Cervicomediastinal goiter is a disease that may involve compressive symptoms. In our experience, most cases were resected through cervicotomy, colloid goiter and the nodular hyperplasia being the most common histological types. There was no relationship between surgical procedure and the incidence of complications.