Use of octogenarian donors for liver transplantation: a survival analysis.

Use of very old donors in liver transplantation (LT) is controversial because advanced donor age is associated with a higher risk for graft dysfunction and worse long-term results, especially for hepatitis C virus (HCV)-positive recipients. This was a retrospective, single-center review of primary, ABO-compatible LT performed between 2001 and 2010. Recipients were stratified in four groups based on donor age (<60 years; 60-69 years; 70-79 years and ≥80 years) and their outcomes were compared. A total of 842 patients were included: 348 (41.3%) with donors <60 years; 176 (20.9%) with donors 60-69 years; 233 (27.7%) with donors 70-79 years and 85 (10.1%) with donors ≥80 years. There was no difference across groups in terms of early (≤30 days) graft loss, and graft survival at 1 and 5 years was 90.5% and 78.6% for grafts <60 years; 88.6% and 81.3% for grafts 60-69 years; 87.6% and 75.1% for grafts 70-79 years and 84.7% and 77.1% for grafts ≥80 years (p = 0.065). In the group ≥80 years, the 5-year graft survival was lower for HCV-positive versus HCV-negative recipients (62.4% vs. 85.6%, p = 0.034). Based on our experience, grafts from donors ≥80 years may provide favorable results but require appropriate selection and allocation policies.

Organ sharing in the management of acute liver failure.

BACKGROUND: Liver transplantation (OLT) for acute liver failure (ALF) is associated with high morbidity and mortality rates in the early posttransplant course. An efficient organ-sharing organization may grant favorable results. METHODS: This is a retrospective analysis of prospectively collected data on patients wait listed for ALF at a single center. Patients were listed for OLT when matching King's College Criteria. Based on patients' clinical status, ABO-incompatible grafts were used. RESULTS: From January 2001 to December 2010, 37 patients were wait listed for ALF. Two patients were de-listed (5.4%) for improvement of their clinical conditions; two patients (5.4%) died on the list and 33 (89.2%) underwent OLT. Among these latter, 21 (63.6%) were Italian and 12 (36.4%) were foreign citizens, with four referred from their home country on the basis of international agreements on ALF management. Donors were procured in our region in 10 cases (30.3%), nationally in 22 (66.6%), and outside Italy in 1 (3.1%). Mean time from wait listing to OLT was 1 day (range 0-6), and seven patients received an ABO-incompatible graft. Graft and patient survivals at 1 month, 1 year, and 3 years were 78.8%, 72.7%, 66.5%, and 81.8%, 75.8%, and 72.7%, respectively. Five patients underwent retransplantation: two on postoperative day (POD) 2 for primary nonfunction of the liver graft, two on POD 8 and 95 for hepatic artery thrombosis, and one at 18 months for nonanastomotic biliary stenosis. CONCLUSIONS: Prompt referral to a OLT center and efficient organ-sharing system play a fundamental role in optimizing the outcome of the patient with ALF. Development of international organ exchange programs might further improve the results for this category of patients. In very selected cases, ABO-incompatible grafts may be a valuable resource.

Operative risks of domino liver transplantation for the familial amyloid polyneuropathy liver donor and recipient: a double analysis.

Although domino liver transplantation (LT) is an established procedure, data about the operative risks are limited. This study aimed at evaluating the operative risks of domino LT. Two retrospective analyses were conducted (comparison of familial amyloid polyneuropathy [FAP] liver donors [61 patients] vs. FAP nondonors [39 patients] and FAP liver recipients [61 patients] vs. deceased donor liver recipients [61 patients]). First analysis showed a 60-day mortality of 6.6% for FAP donors and 7.7% for FAP nondonors (p = 1.0). No patient developed primary graft nonfunction. Acute rejection was higher in FAP nondonors compared to FAP donors (38.5% vs. 13.1%). Both groups had similar vascular and biliary complication rates. ICU stay was similar, whereas total hospitalization was longer for FAP nondonors. Both groups had similar 1- and 5-year patient and graft survival rates (83.4% vs. 87.2%, and 79.8% vs. 71.8%, p = 0.7) and (83.3% vs. 87.2%, and 79.1% vs.71.8%, p = 0.7). The second analysis showed a 1.6% mortality for FAP liver recipients vs. 3.2% of the control group (p = 1). Both groups had similar morbidity and technical complication rates (18.0% vs. 13.1%, p = 0.45) and (0.18 vs. 0.15, p = 0.65). The domino procedure does not add any risk to FAP donor or recipient. It increases the organ pool allowing transplantation of marginal recipients who otherwise are denied deceased donor liver transplantation.

Laparoscopic vertical banded gastroplasty. A multicenter prospective study of 200 procedures.

BACKGROUND: The commonest surgical procedure for management of morbid obesity in Europe is laparoscopic adjustable gastric banding (LAGB), even though laparoscopic vertical banded gastroplasty (LVBG) is still considered to be a gold standard restrictive option in bariatric surgery. A multicenter prospective study was designed to to assess the efficacy of LVBG in terms of weight loss and complication rates for obese patients who have indications for a restrictive procedure. PATIENTS AND METHODS: Two-hundred morbidly obese patients (84.5% female) with a mean age of 41 years and mean body mass index (BMI) of 43.2 kg/m(2) underwent LVBG as described by MacLean. Five trocars were placed in standard positions as per laparoscopic upper gastrointestinal surgery. A vertical gastric pouch (30 ml) was created with circular (21 or 25mm) and endolinear stapling techniques, enabling definitive separation of the two parts of the stomach. The gastric outlet was calibrated with either a polypropylene mesh (5.5 cm in length and 1cm in width) or a nonadjustable silicone band. The median follow-up period was 30 months (range, 1-72 months). RESULTS: One case had to be converted to open surgery (gastric perforation) and there was one death secondary to peritonitis of unknown etiology. The morbidity rate was 24%, comprising the following complications: gastric outlet stenosis (8%); staple line leak (2.5%); food trapping (1.5%); peritonitis (1%); thrombophlebitis (1.5%); pulmonary embolism (0.5%); and gastroesophageal reflux (9%). The excess weight loss achieved was 56.7% (1 year), 68.3% (2 years), and 65.1% (3 years). CONCLUSIONS: Laparoscopic vertical banded gastroplasty is an effective procedure for the surgical management of morbid obesity, especially for patients who present hyperphagia but are unable to manage the constraints of adjustable gastric banding. Laparoscopic vertical banded gastroplasty is safe, as demonstrated by an acceptable complication rate, of which gastric outlet stenosis, staple line leakage, and gastroesophageal reflux predominate.

Biological markers in non-small cell lung cancer. Retrospective study of 10 year follow-up after surgery.

BACKGROUND: The biological markers in non-small cell lung cancer (NSCLC) have been widely studied and encouraging results have shown that products of some oncogenes and other molecular markers can predict the aggressiveness of the disease and the outcome of the patients. METHODS: To verify the reliability of these prognostic markers we have studied retrospectively the expression of c-erbB-2 and 67Ki (growth regulation), p53 (cell cycle regulation and apoptosis), bcl-2 (apoptosis) and CD31 and CD34 (angiogenesis) in 78 patients operated on for NSCLC with curative intent between January 1987 and December 1988 and followed up for 10 years. For the determination of the biological markers we have used the ABC (Avidin-Biotin-Peroxidase complex) immunohistochemical method. The Cox regression model was used for the univariate and multivariate analysis. RESULTS: Nineteen patients (24%) were alive after 10 years and 59 (76%) died. The univariate analysis of the relationship between the 10-year survival and the expression of the markers was significant only for p53 (p=0.0097). Stratifying the patients according to the 3 histological subtypes (squamous cell carcinoma, adenocarcinoma and large cell undifferentiated carcinoma) the correlation between markers and survival pointed out that the only significant one was p53 (p=0.0459) in adenocarcinoma. In the same way considering the stages p53 was significant in stage IIIa (p=0.0357). The multivariate analysis emphasized that p53 was the only significant marker with respect to the 10-year survival (p=0.0091). Examining the histological groups significant was only p53 in adenocarcinoma (p=0.0192) and in large cell undifferentiated carcinomas (p=0.0290). This marker is also significant in pathological stage II (p=0.0271) and IIIa (p=0.0402). Apart from histology and staging the 10-year survival was 33% for p53 negative versus 10% for p53 positive. In patients with adenocarcinoma the 10-year survival was 40% for p53 negative and 6% for p53 positive. CONCLUSIONS: In conclusion our results emphasize the importance of p53 as a prognostic factor in 10-year survival in patients with adenocarcinoma and in stage II and IIIa.

Aortic graft in the jejunum without bleeding. A real surprise at endoscopy.

It is known that prosthetic infection, graft-duodenal fistula, and erosion are possible late complications after aortic reconstruction, and that all these reported complications are accompanied generally by variable bleeding with different presentations. We report the case of a 63-year-old man who underwent a diagnostic upper gastrointestinal endoscopy for investigation of nausea, anorexia, asthenia, fever, and mild leukocytosis. The patient's medical history included a gastric resection for ulcer, with Billroth II gastrojejunostomy reconstruction and implantation of a Dacron vascular graft for abdominal aortic aneurysm 20 years and 3 years earlier, respectively. Abdomen ultrasonography showed hypoechoic area around an aortic prosthesis. Endoscopy found a foreign body corresponding to the vascular graft at the jejunum. No signs of bleeding were recorded. The patient was hospitalized and submitted to surgery that involved extra-anatomic axillofemoral bypass, bowel resection with a gastrojejunum Roux anastomosis, and prosthesis removal.

The bilobectomies for lung cancer.

BACKGROUND: The purpose of our retrospective study is to confirm that bilobectomy is a feasible operation with an oncological value. METHODS: From 1981 to 1998, 46 patients underwent bilobectomy for lung cancer. Eight upper and middle lobectomies (UML) and 38 middle and lower lobectomies (MLL) were performed. Intraoperative pneumoperitoneum was done in 11 MLL. We have considered operative mortality, postoperative complications, the persistence of drainage tubes and the length of hospital stay and the data were statistically compared with those relative to right lobectomies. Survival was estimated with the Kaplan-Meier method and the curves were compared with those of the right lobectomies and right pneumonectomies using the log-rank test. RESULTS: Overall morbidity was 43.4%. Mortality was 6.5%. Mean chest tube persistence was 7.8 days and mean hospital stay was 14 days. No statistical significance was found about these data comparing the UML and MLL separately and the bilobectomies with the right lobectomies. The pneumoperitoneum done in the MLL enabled a shorter hospital stay, statistically significant, in comparison with MLL without pneumoperitoneum. The overall 5-year survival rate was 38%. Considering the I and the II stages no statistical differences in survival were found considering the right lobectomies and right pneumonectomies. CONCLUSIONS: The bilobectomies can have a role in treatment of lung cancer that is equal to the other standard major resections.

Spontaneous intercostal pulmonary hernia.

A case of spontaneous intercostal pulmonary hernia as a result of vigorous coughing is reported in a 67-year-old man. The great majority of acquired pulmonary hernias are post-traumatic; rare cases are spontaneous, resulting from prolonged and/or repeated increased intrathoracic pressure. This hernia was successfully repaired with a polyglactin absorbable mesh and approximation of the ribs with heavy stitches. When required, surgical repair is the treatment of choice.

Pulmonary abnormalities in Cowden's disease.

Cowden's disease is an inheritable multiple neoplastic syndrome represented by benign and malignant lesions of skin, digestive tract, mucosae, breast and thyroid. The syndrome, first described by Lloyd and Dennis in 1963, includes benign lung lesions, described in the literature only as hamartomas. The unusual condition of our case consists of multiple and bilateral lipomatous lesions of the lung and of adipose colonic polyps, diagnosed respectively by video assisted mini-thoracotomy and by endoscopic biopsies.

Experimental tracheal transplantation using a cryopreserved aortic allograft.

BACKGROUND: The tracheal reconstruction after wide resections remains a critical surgical problem. Our aim was to replace trachea with a tissue easy to vascularize, which allows a simple reconstruction and does not require an immunosuppressive regimen. MATERIALS AND METHODS: A segment of cryopreserved aorta was used in order to verify its adequacy as tracheal substitute. In phase 1, the thoracic aorta of 10 rabbits was excised, obtaining 20 segments that were cryopreserved. Ten segments were implanted in the omentum of 10 rabbits that were sacrificed on postoperative days 7, 14 and 21, and the grafts were examined histologically. In phase 2, a segment of cryopreserved aorta arranged with a silicone prosthesis was transplanted in 10 rabbits and wrapped with omentum. The animals were sacrificed on postoperative days 7, 14 and 21. RESULTS: In phase 1, the neovascularization of the grafts was present after 7 days, and after 14 days the fibroblasts invaded the lumen of the aorta. In phase 2, 8 rabbits survived and the histologic examination after 7, 14 and 21 days showed neovascularization, the absence of rejection and the proliferation of fibroblasts inside the lumen of the aorta; this growth has been restrained by an endoluminal prosthesis. CONCLUSIONS: Our study demonstrated that replacing the trachea with cryopreserved aorta is technically feasible and does not evoke immunologic reactions. It requires, however, a silicone tube inside the allograft to limit the colonization of fibroblasts.

Postoperative pneumoperitoneum for prolonged air leaks and residual spaces after pulmonary resections.

BACKGROUND: Postoperative air leaks and pleural residual spaces are often encountered during partial lung resections and may adversely affect the immediate outcome prolonging the hospital stay. At present the only treatment consists of maintenance of the chest drainage under suction until resolution of the leaks. METHODS: From January 1995 to December 1997 the authors have operated on and subsequently treated 12 patients presenting prolonged air leaks with residual pleural spaces after lobectomies for lung cancer. The patients underwent respectively: left or right lower lobectomies (n=7), left upper lobectomies (n=3), right upper lobectomies (n=2). In this study the air leak was considered prolonged if it continued and delayed the discharge after surgery beyond the postoperative day 8. The pneumoperitoneum was carried out under local anesthesia. The air was insufflated through a needle inserted just above the umbilical scar as for laparoscopic surgery access up to an amount of about 1200 cc-1300 cc. RESULTS: We have obtained in all cases and without complications an immediate reduction in the air leaks and a complete resolution of the residual pleural spaces. Chest drainages were removed from 3 to 4 days after the procedure. CONCLUSIONS: The good results achieved suggest that this procedure might be considered for selected cases, being a minor procedure, performed under local anesthesia and with minimum discomfort for the patient.

[Treatment of duodenal ulcer with rosaprostol in patients resistant to treatment with anti-H2]. / Il trattamento dell'ulcera duodenale con rosaprostol in pazienti resistenti al trattamento con anti-H2.

The results obtained with the combined treatment Rosaprostol + anti-H2 in 10 patients with duodenal ulcer previously treated with insufficient results with anti-H2 drugs are described (in comparison with other 10 patients under the same conditions treated with anti-H2 alone). The results are clearly favourable (statistical significance) for Rosaprostol. The drug was well tolerated.