Intestinal transplantation in children: the first successful Italian series.

The preliminary experience of the first Italian program of pediatric intestinal transplantation is presented herein. A multidisciplinary group with broad experience in pediatric solid organ transplantation started the program. Nine children with complications of chronic intestinal failure were listed for transplantation. One child died on the waiting list; one received an isolated liver transplantation; three isolated intestinal; three multivisceral; and one, a combined liver/intestine transplantation. There was no in-hospital mortality, and all children were weaned from parenteral nutrition. The recipient of the multivisceral graft died after 14 months for unknown causes. All other recipients are alive after a median follow-up of 13 months. Patient and graft actuarial survivals for recipients of intestinal grafts were 100% at 1 year and 75% at 2 years.

Lung transplantation with grafts from elderly donors: a single-center experience.

INTRODUCTION: Use of extended criteria donors is one of the strategies to face the scarcity of donors for lung transplantation. METHODS: Between November 2002 and May 2009, we performed 52 LTs in 50 recipients, 10 of whom (group A) received lungs from donors aged 55 years or older (median, 58.5; range, 56-66 years) for comparison with 28 patients (group B) transplanted with lungs from donors younger than 55 years (median, 25.5; range, 15-54 years). We excluded 9 children and 3 recipients of combined liver plus lung transplantations from the study. RESULTS: Recipient age, gender, and indications for transplantation did not differ significantly between the 2 groups. Neither were there significant differences in PaO2/FiO2 ratios before lung retrieval, or length of the ischemic time The first PaO2/FiO2 on arrival to the intensive care unit (ICU) and the median length of ICU stay were similar. All patients, except 2 who died in the operating theatre, were extubated between 3 and 216 hours after the transplantation. Hospital mortality was similar in both groups: 3 patients in group A and 2 in group B (P = .1). The median portions of the predicted 1-second forced expiratory volume (FEV1) at 6 months after transplantation did not differ in the 2 groups: 62.4% in group A versus 70% in group B (P = .85). CONCLUSION: Lung grafts from donors older than 55 years can be effectively used for transplantation, thus increasing the total organ pool.

Early portal vein thrombosis after pediatric split liver transplantation with left lateral segment graft.

Early portal vein thrombosis (PVT) represents a serious complication after liver transplantation (OLTx). From October 1997 through July 2004, 260 OLTx were performed in 231 children, including 189 of left lateral segments (LLS). We retrospectively analyzed the incidence and the outcome of early PVT in this group. A daily doppler US scan was performed during the first week after transplantation. Early PVT occurred in 14 patients (8%), 10 males and four females of median age 0.77 years. The main indication for primary transplantation was biliary atresia (10), followed by Byler's disease (2), acute liver failure on cryptogenetic cirrhosis (1), and Alagille syndrome (1). Four children underwent retransplantation; three cases of thrombectomy and revision of the anastomosis, two children were treated with beta blockers, one of whom had a later failed attempt at percutaneous revascularization and eventually a meso-caval shunt. Five patients were followed with observation and no treatment. Among the four patients who died, three were in the retransplantation group and one in the thrombectomy and revision of the anastomosis group; the overall mortality was 28%. With a median follow up of 399 days, 10 patients are alive with an actuarial survival at 1 and 5 years of 72%, and graft survival rates at 1 and 5 years of 64%. PVT represents a serious complication after pediatric OLTx with LLS grafts. Prompt detection and aggressive surgical treatment in selected cases are required to reduce the mortality and graft loss.

Liver transplantation in children weighting less than 6 kg: the Bergamo experience.

Liver transplantation (OLT) remains a major medical and surgical challenge in small patients. From October 1997 through July 2004, 17 babies less than 6 kg underwent 18 OLTs. Median age and weight were 3 months (range = 1 to 9) and 4.7 kg (range = 2.2 to 5.8). Two whole, one reduced, and 15 split-liver grafts (left lateral segments) were obtained from donors of median age and weight of 11.6 years (range = 0.5 to 62) and 50 kg (range = 7 to 63). Donor-to-recipient median weight ratio (D/R) was 9.1 kg (range = 1.3 to 17.6) and median graft-to-recipient weight ratio (GRWR) was 5% (range = 3.1 to 10). The incidence of biliary complications was 23%. The only vascular complication was a portal vein thrombosis (6%). Fourteen patients (79%) are alive with good graft function at a median follow-up of 39 months (range = 0.5 to 74). Three patients (all status 1) died on postoperative day 285 (brain death), 17 (multiorgan failure), and 229 (cardiovascular failure during retransplantation). Actuarial patient survivals at 6 months and 6 years are 94% and 78% while graft survivals are 89% and 74%, respectively. Currently all the patients listed as UNOS status 2 and 3 (73%) at the time of transplant are alive. During the same period one premature neonate (1.8 kg) who presented with fulminant hepatic failure died on the waiting list after 12 days. Our data confirm that the extensive use of a split-liver technique from small adult or pediatric cadaveric donors can offer the benefits of liver transplantation to small pediatric candidates with excellent results.

Use of extended right grafts from in situ split livers in adult liver transplantation: a comparison with whole-liver transplants.

INTRODUCTION: We report our experience of in situ split-liver transplantation (SLT) for adult patients and compare the results with those achieved with whole-liver transplantation (WLT). METHOD: From November 1997 to December 2003, 109 liver transplantation were performed in 104 adult patients including 90 WLT (83%) and 19 SLT (17%) grafts. Fifteen extended right grafts (ERG, segments I + IV to VIII) were obtained with in situ split-liver procedures, generating also left lateral segment grafts, which were transplanted at our institution or elsewhere. Four left lobe (LL, segments I to IV) and right lobe (segments V to VIII) grafts were obtained by a modified in situ procedure for adult recipients. UNOS status, percentage of primary or secondary transplantation, and underlying liver disease were similar among patients receiving whole versus split grafts. Donors were older in whole than ERG cohorts (53 vs 26 years, P < .001). Procurement parameters and intraoperative profiles of transplant procedure were comparable among the groups. RESULTS: Median follow-up was 18 months (range: 1 to 73). Four patients with whole (4%) and no patient with ERG underwent retransplantation (P = NS). One- and 3-year patient survivals were 86% and 79% with WLT versus 93% and 93% with ERG (P = NS). One- and 3-year graft survivals were 84% and 75% with WLT versus 93%, and 93% with ERG (P = NS). Incidence of vascular complications was 8% with WLT, 13% with ERG (P = NS). The incidence of biliary complications was 13% in WLT, 27% in ERG (P = NS). CONCLUSIONS: The use of ERG from in situ split livers for adult transplantation allowed us to obtain results comparable or even better than those obtained with WLT. Split-liver transplantation is an effective, safe mechanism to expand the cadaveric donor pool.

Lethal infection by Candida (Torulopsis) incospicua complicating orthotopic liver transplantation.

We report here an uncommon case of deep infection by Torulopsis incospicua, associated with multibacterial sepsis and complicated by several mycotic aneurysms of hepatic artery, liver graft necrosis, and hepatic acute failure in a liver orthotopic transplant recipient. Two successive emergency liver transplants were needed, but fast relapses of infection and mycotic aneurysms were experienced. The patient died soon after the third liver transplant; disseminated mycosis was demonstrated by post mortem examination. In conclusion, fungal infection should be considered in cases of spontaneous hepatic artery rupture.

Bilateral open treatment of spontaneous pneumothorax: a new access.

A new technique for bilateral apical bullectomy and pleurectomy via axillary minithoracotomy and transmediastinal access to the contralateral side, was used in 13 patients with bilateral apical blebs and/or pneumothorax. The contralateral space is reached at the posterior superior mediastinum, passing between the first thoracic vertebral bodies (T1-T4) and the oesophagus. The contralateral lung apex is then pulled into the thoracotomy side and apical bullectomy carried out by linear stapler. The obvious advantages of avoiding a second thoracotomy while providing complete solution to the clinical problem are particularly important in young patients with spontaneous pneumothorax caused by bilateral apical blebs.

Patterns of systolic stress distribution on mitral valve anterior leaflet chordal apparatus. A structural mechanical theoretical analysis.

Increasing diffusion and complexity of mitral valve repair procedures may prompt an interest in the evaluation of the patterns of stress distribution on the chords, which are, from the structural mechanical point of view, the weakest element of valve apparatus. This theoretical analysis concentrates in particular on the mitral valve anterior leaflet. As is known, the vast majority of the chordae are attached to the anterior leaflet within the coaptation area; during systole they are then necessarily parallel, aligned along the same plane as that of the leaflets' coaptation surface, to which they are attached; moreover the thickness of the chordae increases significantly from the marginal chordae to the more central ones. In normal conditions during systole the progressively wider coaptation surface causes the increasing stress to be supported by an increasing number of progressively thicker chords, which are substantially parallel and aligned on the coaptation surface plane in such a way that they can share the stress between them, according to their thickness; in other words chords form a multifilament functional unit which enrolls elements of increasing thickness in response to the mounting stress. The geometrical modifications of the valve apparatus architecture (annulus dilatation, leaflet retraction, chordal elongation or retraction) often associated with valve insufficiency due to chordal rupture, have the common result of causing, during systole, a radial disarrangement of the direction of most of the secondary chordae which are no longer parallel, aligned on the coaptation surface plane. Due to the negligible elastic module of the valve leaflet, in this new arrangement the various chordae cannot share the stress between themselves as they do in a normal physiological situation; on the contrary the thinner chordae nearer to the free margin are also loaded with the peak systolic stress, thus generating conditions favoring their rupture. It can, therefore, be hypothesized that the anatomopathological picture of valve insufficiency due to chordal rupture may be the final event of a series of geometrical modifications of valve apparatus architecture, the common consequence of which is to load thinner marginal chords with peak systolic stress from which they are normally spared, thus favoring their rupture.

Descending aorta substitution with expandable ends prosthesis. Case report.

A case of esophageal cancer infiltrating the left bronchus pars membranacea and the aneurysmal aortic wall was resected en bloc with the bronchial and aortic wall. Descending aorta was substituted by means of a Dacron prosthesis fitted with expandable devices at both ends, allowing a very significant reduction of the clamping time and simplification of this part of the procedure.

[Duodenal schwannoma. Clinical considerations]. / Schwannoma duodenale. Considerazioni cliniche.

The recent observation of a case of schwannoma in the second part of the duodenum lead the authors to a literature survey in order to state the present knowledge of this subject. Schwannoma is an ectodermal neoplasm arising from the nerve sheath that envelop axons. In the gastrointestinal tract these tumours can concern cells of the myentericus and submucosus plexus of the intestinal wall. A duodenal location is extremely rare. Gastroduodenal endoscopy, abdominal ultrasonography and CT scan were found as important investigatory tools, but only histological examination of the excised tissue suggests the definitive diagnosis. Therapy consists in the radical excision of the tumour; this is rarely obtained by endoscopic way because of the submucosal neoplastic growth. Then a surgical laparotomic approach is more often required and it allows to perform local excisions through a duodenotomy, partial duodenectomy or ampullectomy and more complex operations, like a cephalic duodenopancreatectomy, in front of extended papillar involvement. The latter was the suitable treatment for radical removing of the juxtapapillar schwannoma reported by the authors; the uneventful postoperative course, the patient's excellent general conditions and nutriture at 12 months confirm the validity of the therapeutic policy.

Internal mammary blood supply for ileo-colon interposition in esophagogastroplasty: a case report.

We report on a clinical case where microsurgical techniques successfully supported traditional surgery in a wide reconstruction between the oropharynx and small bowel. Several years ago, the patient sustained a severe corrosive injury of the upper digestive tract with subsequent esophageal stricture and stiffening; at that time, an emergency gastrectomy was performed. In this case, the restoration of the defect could not rely on the classic colonic interposition. During the operation the ileo-colic flap, well-fitted for tension-free reconstruction, revealed the foreseen inadequacy of its vascularization based on the sole middle colic vascular pedicle. The blood supply to its proximal part was then increased by microanastomosis between the right internal mammary and ileo-colic vessels. The revascularization ensured the viability of the interposed tissue. Oral intake resumed after 3 weeks; nowadays the patient is able to maintain her ideal weight with adequate nutrition.

Prosthesis for aortic arch substitution.

BACKGROUND: The risk of neurologic complications in aortic arch prosthetic substitution is directly related to the duration of the circulatory arrest. The purpose of this article is to report the experiments on animals of a device for simplifying and quickening the vascular anastomosis in aortic arch substitution. METHODS: The device consists of expandable loops of stainless steel wire, sewn to the proximal end of a Dacron prosthesis. An actuating removable guide allows the stainless steel wire loops to be expanded and tightened, in such a way that the prosthesis diameter is varied, while maintaining a regular cylindric shape. The prosthesis end is then transformed into a rigid cylindrical ring, approximately half the maximal diameter in length, with a variable and controllable diameter. A composite graft was prepared, fitted with the expandable device at the distal end of the main prosthesis as well as at each end of the branches for the supraaortic trunks. Cardiopulmonary bypass was established by cannulation of the right atrium and left iliac artery. The prosthesis was positioned very easily and quickly during a brief hypothermic circulatory arrest; ascending aorta anastomosis was carried out by the standard technique after central nervous system reperfusion was resumed. Acute experiments were carried out in 5 swine. RESULTS: Four of 5 animals survived the procedure without detectable neurologic sequelae. At sacrifice the prosthesis was found to be properly sited without lumen distortion or thrombosis. CONCLUSIONS: The main advantages of this device and modality of arch substitution in a clinical setting would include drastic reduction of the circulatory arrest time, easy and reliable hemostasis of the anastomosis line, and accurate and firm approximation of the dissection layers in case of dissecting aneurysms.

[Fibrous dysplasia of the facial bones. A CT study]. / La displasia fibrosa delle ossa facciali. Studio TC.

The authors report 7 cases of fibrous dysplasia of the facial bones which were evaluated with CT. The involvement of the facial bones by fibrous dysplasia is an uncommon event, which causes different syndromes according to the extent of bone invasion. In all the cases occurred to our observation CT allowed an exact spatial evaluation of the dysplasia, and therefore a correct surgical planning. Moreover, CT densitometric values and CT appearance of fibrous dysplasia often suggested the correct diagnosis.

Use of MoAb D612 in combination with a panel of MoAb for the immunocytochemical identification of metastases from colon-rectum carcinoma.

During the course of colon-rectum tumours a number of clinical events may occur in which conventional cytopathology can provide only a partial contribution to the definition of a differential diagnosis, i.e. effusions, distant recurrences and second neoplasias. In the present study we have evaluated whether monoclonal antibody (MoAb) D612, recognising a colon-rectum associated antigen, can be used in this context. To this end, MoAb D612 was employed in combination with a panel of MoAb of well defined tumour specificity in immunocytochemical tests. The immunocytochemical findings obtained were compared with the histological and clinical diagnosis. Of 62 effusions and 40 fine needle aspirates studied, MoAb D612 reactivity correlated with the correct diagnosis in 92.8% of the instances. These results indicate that this reagent may help to improve the current cytopathological diagnosis of colon-rectum tumours by identifying the colonic origin of metastases in patients with unknown primary tumour, differentiating ovarian carcinoma from colon metastases to the ovaries and establishing the presence of a second neoplasia in patients with a previous history other than colon carcinoma.

Combinations of monoclonal antibodies can distinguish primary lung tumors from metastatic lung tumors sampled by fine needle aspiration biopsy.

Transthoracic fine needle aspiration (FNA) biopsies performed under computed tomography (CT) scan (CT-FNA) have greatly improved the cytodiagnosis of lung tumors. However, the distinction between a primary lesion and a metastatic lesion still may be difficult on the basis of morphologic criteria. To evaluate whether a selected panel of monoclonal antibodies (MoAb) to tumor-associated antigens (TAA) can improve the diagnostic potential of FNA, we have immunocytochemically analyzed 122 pulmonary CT-FNA. Whereas conventional cytology was capable of recognizing only the neoplastic nature of the lesions, the immunocytochemical diagnosis could identify the primary or metastatic nature of the pulmonary masses in 92.5% of the cases. The immunocytochemical findings were confirmed by clinical-histopathologic data. The current results demonstrate that the use of immunocytochemical methods can significantly improve the diagnostic accuracy of conventional cytology of lung masses.

[Perforation of the bile ducts in adults. A case of covered perforation of the common bile duct diagnosed preoperatively by percutaneous cholangiography (author's transl)]. / Perforations de la voie biliaire chez l'adulte. A propos d'un cas de perforatin couverte du cholédoque diagnostiqué préopératoirement par cholangiographie percutanée.

Pre-operative percutaneous cholangiography in a woman with jaundice revealed the presence of an undetected covered perforation. Pre-operative diagnosis is rarely made in such cases, and the authors describe the present case more fully, and discuss various aspects of classification and therapy.