Esophagectomy in esophageal cancer - is there an optimal approach?

INTRODUCTION: Esophageal cancer is a public health problem,with increasing incidence and postoperative morbidity over the past recent years. Although a number of new surgical techniques, including minimally invasive surgery, have been developed, mortality and morbidity have remained elevated.The element that seems to influence the early postoperative morbidity and mortality is the method of approach. MATERIAL AND METHODS: retrospective observational study which is carried out in the period 2003-2012 including esophageal neoplasm patients operated in the First Surgical Clinic -Hospital "Sf. Spiridon", Iasi. 140 patients were included, of which only 33 have received surgery with curative aim. SURGICAL TECHNIQUE: we consider 2 techniques in our study:transhiatal (TH) technique (without opening the chest)followed by esophagoplasty with cervical anastomosis and transthoracic esophagectomy (TT) with intrathoracic or cervical anastomosis. RESULTS: We performed 57.58 % (n = 19) of interventions by TT versus 42.42% (n = 14) by TH. The overall rate of postoperative morbidity rate was 78.8% (n = 26). Overall early postoperative mortality rate was 15.5% (n = 5) caused by pleuropulmonary sepsis (2 cases), lung emboli (1 case) and sepsis caused by anastomotic leak (2 cases). CONCLUSION: TT and TH esophagectomy have precise indications in esophageal surgery for malignancies, the mortality and morbidity rate being strongly influenced by the surgical approach.

Functional improvement between brain death declaration and organ harvesting.

INTRODUCTION: The quality of harvested organs is crucial for graft survival and for posttransplant evolution. This study sought to investigate the evolution of the functional status of brain death (BD) patients during the period between declaration and organ harvesting (BD duration). MATERIALS AND METHODS: The study included all BD patients who underwent organ harvesting between January 2006 and June 2009. We compared the functional status regarding hemodynamics, respiration, kidney and liver function, coagulation, water, electrolytes, and acid-base balance evaluated at the moment of BD declaration (P1) and just before organ harvesting (P2). The results of the comparison were expressed as improvement, stable, or aggravation. We calculated mean values of the functional parameters in P1 and P2 and the statistical significance of the differences. RESULTS: Twelve BD patients were included in the study. The time interval between P1 and P2 was 16.08 +/- 8.54 hours (range, 6-32). The number of patients with vasopressor support was 9/12 at P1 and 0/12 at P2, oxygenation disturbances 1/12 in P1 and 0/12 in P2, renal dysfunction 9/12 in P1 and 2/12 in P2, liver dysfunction 7/12 in P1 and 1/12 in P2, coagulopathy 4/12 in P1 and 0/12 in P2, hypernatremia 8/12 in P1 and 3/12 in P2, and metabolic acidosis 9/12 in P1 and 1/12 in P2. The overall assessment showed improvement in all patients. The most statistically significant improvement was registered in the cardiovascular, respiratory, renal, liver, and acid-base status (P < .05). CONCLUSION: With early, aggressive, protocolized donor management, functional improvement may be achieved during BD duration.

Presumed consent for organ donation: is Romania prepared for it?

INTRODUCTION: In November 2007, a legislative initiative regarding the presumed consent for organ donation was proposed for parliamentary debate in Romania and was followed by public debate. The study aimed to asses public opinions expressed in the Romanian media. MATERIALS AND METHODS: An Internet search was made. The pro and con reasons, the affiliation of parts involved in the debate and suggested future direction of action were identified. RESULTS: The Internet search had 8572 results. The parts involved in the pro and con debate consisted of governmental structures, physicians, ethicists, politicians, media, religious authorities, nongovernmental associations, and lay persons. The main pros were the low rate of organ donation and the long waiting lists, enhancement of organ procurement, avoidance of wasting valuable organs, avoiding responsibility, and the stress imposed to the family in giving the donation consent, humanitarian purposes (saving lives), going along with the scientific progress, and less bureaucracy. The main cons were an unethical issue, violation of human rights, denial of brain death, unethical advantage of public ignorance, unethical use of underprivileged people, little results in terms of organ procurement, but huge negative effects on public opinion, public mistrust in transplant programs and impossibility of refusal identification due to particularities of the Romanian medical system. CONCLUSION: The con opinions prevailed. For the moment, Romania seems to be unprepared to accept presumed consent. A future change in public perception regarding organ transplantation may modify the terms of a public debate.

The rate of organ and tissue donation after brain death: causes of donation failure in a Romanian university city.

AIM: To evaluate the rate of organ donation after brain death in 2 tertiary care medical centers of a Romanian city, the reasons for donation exclusion (donors or organs), and identification of potential strategies for improvement. MATERIAL AND METHODS: The study retrospectively evaluated potential organ donors with brain death (BD) who were identified between January 2006 and June 2009 in an university city of Romania. The potential donors were considered patients with severe intracranial pathology and clinical signs of brain death who were reported to the regional transplant team. The BD declaration was completed according to the Law of Transplant Procurement and Management in Romania: clinical signs of brain stem death, apnea test, and flat EEG, criteria that must be fulfilled twice at a 6 hour interval. According to Romanian law, family consent is mandatory for organ harvesting. RESULTS: The study included 35 potential donors, of whom 22 had a declaration of BD. Failure of potential donors to be declared BD was caused by positive viral serology (n = 7), improvement in clinical status (n = 2), sudden cardiac arrest (n = 2), and refusal of physician in charge (n = 2). Among the 22 with a BD declaration, organ harvesting was performed in only 12 cases due to family refusal (n = 10). In 4 cases the planned organ harvesting was aborted owing to unexpected intraoperative findings. DISCUSSION: Factors that generate the low rate of organ procurement include local organizational particularities, a high rate of viral infections, poor education, (both of lay persons and of medical personnel), restrictive criteria for BD declaration and the mandatory need for family approval. CONCLUSION: The rate of donation in this university city of Romania is still low. Several strategies have been identified to improve the rate: better identification of potential donors, better management, and education of the public and of health care personnel.