Extracorporeal membrane oxygenation to facilitate tracheal healing after oesophagogastric catastrophe.

Anastomotic leak after oesophagectomy is associated with poor outcomes. We report the successful utilization of venovenous extracorporeal membrane oxygenation in conjunction with tracheal stent to treat and heal multiple tracheal-neo-oesophageal fistulae following oesophagectomy.

Transplantation of high panel-reactive antibody left ventricular assist device patients without crossmatch using on-bypass pheresis and alemtuzumab.

BACKGROUND: Highly sensitized (HS) left ventricular assist device (LVAD) patients with high panel-reactive antibody (PRA) levels present a challenge. Alemtuzumab, a potent depleting agent for T and B lymphocytes (months to years), and plasmapheresis, offer an opportunity for heart transplantation to these patients who might die of VAD complications on the transplant waiting list. This study compared rates of acute rejection and survival of a HS LVAD cohort with a contemporaneous control group after heart transplant. METHODS: Clinical courses of 31 consecutive patients who underwent transplantation between January 2006 and January 2011 were reviewed. Eight patients with a T or B PRA of 70 or more (HS+) received non-crossmatched, ABO-compatible hearts using intraoperative plasmapheresis and alemtuzumab induction. Controls (HS-) received basiliximab induction. Acute rejection was defined as International Society for Heart and Lung Transplantation grades 2R or higher, or antibody-mediated rejection. RESULTS: The difference in survival between HS+ and HS- groups at 1 year (100% vs 94%) or at a mean follow-up of 2.3 and 2.4 years (75% vs 70%) was not significant. Retrospective lymphocytotoxic crossmatches were positive in 7 of 8 HS+ patients (6 T+ and B+, 1 B+) vs none in the HS- group (p < 0.001). There was a trend toward increased risk of cellular rejection per 100 patient-days beyond 1 year in the HS+ group (p = 0.07). Risk of humoral rejection was significantly increased in the HS+ group (38% vs 4%; p = 0.04). CONCLUSIONS: Heart transplantation with plasmapheresis and alemtuzumab in HS LVAD patients, most with a positive crossmatch, does not compromise midterm survival. The expected higher rates of rejection, especially beyond the first postoperative year, demand adjustments in surveillance strategies and immunosuppressive management.

[Descending necrotising mediastinitis: report of two cases]. / Descrizione di due casi di mediastinite discendente.

Descending necrotising mediastinitis is a severe infection spreading from the cervical region to the mediastinal connective tissue. It represents a virulent form of mediastinal infection, requiring prompt diagnosis and treatment to reduce the high mortality associated. An optimal debridement and drainage through an open thoracotomy access are the keys for a successful outcome. Two patients, males, 70 and 75-years-old with descending necrotising mediastinitis were treated in our Institution in April '05. One had an odontogenic abscess and the other had a retropharyngeal abscess. Operative procedures included thoracotomy with radical surgical debridement of the mediastinum and excision of necrotic tissue associated with transcervical surgical debridement and drainage. Postoperatively mediastinum-pleural and cervical irrigation with iodopovidone 2 per thousand was performed until a culture of pleural effusion become negative. Postoperatively both patients suffered from severe complication including septic shock and acute respiratory distress syndrome. The 70-years-old patient had an acute renal failure too. Postoperatively the length of the intensive care unit stay was 40 and 42 days, respectively. The outcome was favorable in both patients. Early detection and immediate open surgical treatment could be the best way to reduce morbidity and mortality rate. Descending Necrotising Mediastinitis cannot be adequately treated without mediastinal and cervical excision of necrotic tissue and drainage including an open thoracic and cervical approach.