University of Modena Experience With Liver Grafts From Donation After Circulatory Death: What Really Matters in Organ Selection?

INTRODUCTION: The use of grafts from donation after circulatory death (DCD) is an important additional source to implement within the donor pool. We herein report the outcomes of our early experience with DCD grafts for liver transplantation (LT). METHODS: Ten patients successfully underwent LT with grafts from DCD donors between August 2017 and January 2019 at the Hepato-Pancreato-Biliary Surgery and Liver Transplant Unit of University of Modena and Reggio Emilia. All donors underwent normothermic regional perfusion after death declaration and, after the procurement, all the suitable grafts underwent ex situ hypothermic perfusion prior to transplantation. RESULTS: Mean postoperative hospital stay after transplant was 12.7 days (range, 5-26), and in 5 cases we placed a biliary drainage (Kehr tube) during surgery. Primary graft nonfunction did not occur after LT in this cohort, although, we registered one case of biliary anastomosis stricture that was managed endoscopically by endoscopic retrograde cholangiopancreatography. All patients are alive and none required retransplantation. CONCLUSIONS: In our experience with controlled DCD donors, the demonstration of: (1) a negative trend of lactate during normothermic regional perfusion; (2) an aspartate aminotransferase and alanine aminotransferase level lower than 2000 mU/dL; and (3) less than 1 hour of functional warm ischemia time along with no signs of microscopic or macroscopic ischemia of the grafts, are related to positive outcomes in the first year after transplant. A DCD risk score based on Italian population characteristics and regulations on death observation may improve donor-recipient match and avoid futile transplants.

A critical appraisal of the quality of analgosedation guidelines in critically ill patients.

BACKGROUND: The management of analgesia and sedation in critically ill patients is still a challenge due to the shortage of evidence-based treatments. The main objectives of the present study were to critically evaluate the quality of current clinical practice guidelines (CPGL) published on this matter and to identify the contrasting positions and unsolved questions. METHODS: Four members of the Italian Society of Anesthesia and Intensive Care (SIAARTI) council, with an extensive background in the management of critically ill patients and practice guidelines, evaluated CPGL on sedation and analgesia in critically ill patients published from January 2006 to December 2013. Evaluation was performed in accordance with the appraisal of guidelines for research and evaluation tool (AGREE II). RESULTS: Five documents proposed by European and American scientific societies of critical care medicine were identified and evaluated. The CPGL published in 2013 by the American Society of Critical Care Medicine showed the highest scores in all domains of the AGREE II tool, whereas scores for CPGL published in 2006 by SIAARTI showed the lowest scores. In all documents, most recommendations on the use of drugs or non-pharmacological strategies for analgesia, sedation and delirium treatment had low evidence. CONCLUSIONS: This quality evaluation indicated that CPGLs published by the German Association of Scientific Medical Societies, the American College of Critical Care Medicine and the PanAmerican and Iberica Federation of the Critical Care Medicine Societies should be recommended for use. Even in guidelines with a high quality rating, numerous recommendations have moderate or low levels of evidence.

Endoscopic treatment of benign tumors of the nose and paranasal sinuses: a report of 33 cases.

BACKGROUND: The endoscopic approach can be used successfully for the treatment of benign tumors such as fibroosseous and vascular lesions, pleomorphic adenoma, glioma, meningioma, and schwannoma. METHODS: Thirty-three patients diagnosed with benign tumors of the nasal cavity and paranasal sinuses and treated using an endoscopic approach were reviewed retrospectively. The endoscopic approach was simple in 28 cases and associated with an external approach in 5 cases (because of an intracranial extension of the tumor in four patients and its location at the level of the anterior wall of the frontal sinus in the last case). RESULTS: The resection of the lesions was complete in 32 patients and subtotal in one case. The mean follow-up was 28 months and only two recurrences (6%) were observed in the juvenile angiofibroma group and in the case of the fibrous dysplasia associated to aneurysmal bone cyst, respectively, 20 and 24 months postoperatively. CONCLUSION: In selected cases, endoscopic surgery can be considered an effective treatment for the resection of benign tumors involving the sinonasal tract.

Endoscopic treatment of benign tumors of the nose and paranasal sinuses.

OBJECTIVE: The endoscopic approach can be successfully employed for the treatment of benign tumors such as fibroosseus and vascular lesions, pleomorphic adenomas, gliomas, and schwannomas. STUDY DESIGN AND SETTING: Nineteen patients diagnosed with benign tumors of the nasal cavity and paranasal sinuses and treated using an endoscopic approach were retrospectively reviewed. The endoscopic approach was used exclusively in 15 cases and was associated with an external approach in 4 cases (due to an intracranial extension of the tumor in 3 patients and its location at the level of the anterior wall of the frontal sinus in the last case). RESULTS: The resection of the lesions was radical in 18 patients and subtotal in 1 case. The mean follow-up was 27 months and only 1 recurrence (5%) was observed in the juvenile angiofibroma group 20 months postoperatively. CONCLUSION: and significance In selected cases, endoscopic surgery can be considered an effective treatment for the resection of benign tumors involving the sinonasal tract.

Endoscopic treatment of an ethmoidal solitary fibrous tumour.

Solitary fibrous tumours are rare neoplasms, which occur most frequently during adulthood at the level of the pleura. Recently, these tumours have been demonstrated in extraserosal sites such as the nasal cavity. A case of a solitary fibrous tumour arising at the level of the ethmoid and presenting in a 54-year-old woman, is reported. The tumour was removed using an endonasal endoscopic approach that permitted the monobloc excision of the lesion. The patient is without evidence of disease 18 months after surgery.

Endoscopic treatment of congenital choanal atresia.

This report outlines the effectiveness of the transnasal endoscopic approach for the treatment of congenital choanal atresia. Fourteen patients with age between 5 days and 15 years were treated using this approach by means of 0 and 30 degrees 4 or 2.7 mm telescopes: three cases were bilateral while 11 were unilateral. The time of stenting ranged from 3 to 6 days (mean 4 days) in the three newborn patients and between 1 and 2 weeks (mean 1 week) in the other nine patients. In the last two cases, stenting was not carried out. The overall follow-up period ranged from 2 to 64 months (mean 31 months). Only one restenosis was observed in this series 2 months after surgery. This restenosis was successfully treated by endoscopic revision. The authors believe that a correct repositioning of mucosal flaps after the resection of the atretic plate is of paramount importance in avoiding restenosis of the neochoana and in reducing the time and/or the use of stenting.