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.

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.

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.

[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.

[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.

[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.