Perioperative benefit and outcome of thoracic epidural in esophageal surgery: a clinical review.

Surgery for esophageal cancer is a highly stressful and painful procedure, and a significant amount of analgesics may be required to eliminate perioperative pain and blunt the stress response to surgery. Proper management of postoperative pain has invariably been shown to reduce the incidence of postoperative complications and accelerate recovery. Neuraxial analgesic techniques after major thoracic and upper abdominal surgery have long been established to reduce respiratory, cardiovascular, metabolic, inflammatory, and neurohormonal complications.The aim of this review is to evaluate and discuss the relevant clinical benefits and outcome, as well as the possibilities and limits of thoracic epidural anesthesia/analgesia (TEA) in the setting of esophageal resections. A comprehensive search of original articles was conducted investigating relevant literature on MEDLINE, Cochrane reviews, Google Scholar, PubMed, and EMBASE from 1985 to July2017. The relationship between TEA and important endpoints such as the quality of postoperative pain control, postoperative respiratory complications, surgical stress-induced immunosuppression, the overall postoperative morbidity, length of hospital stay, and major outcomes has been explored and reported. TEA has proven to enable patients to mobilize faster, cooperate comfortably with respiratory physiotherapists and achieve satisfactory postoperative lung functions more rapidly. The superior analgesia provided by thoracic epidurals compared to that from parenteral opioids may decrease the incidence of ineffective cough, atelectasis and pulmonary infections, while the associated sympathetic block has been shown to enhance bowel blood flow, prevent reductions in gastric conduit perfusion, and reduce the duration of ileus. Epidural anesthesia/analgesia is still commonly used for major 'open' esophageal surgery, and the recognized advantages in this setting are soundly established, in particular as regards the early recovery from anesthesia, the quality of postoperative pain control, and the significantly shorter duration of postoperative mechanical ventilation. However, this technique requires specific technical skills for an optimal conduction and is not devoid of risks, complications, and failures.

Immediate and Catastrophic Antibody-Mediated Rejection in a Lung Transplant Recipient With Anti-Angiotensin II Receptor Type 1 and Anti-Endothelin-1 Receptor Type A Antibodies.

Preexisting donor-specific anti-HLA antibodies (DSAs) have been associated with reduced survival of lung allografts. However, antibodies with specificities other than HLA may have a detrimental role on the lung transplant outcome. A young man with cystic fibrosis underwent lung transplantation with organs from a suitable deceased donor. At the time of transplantation, there were no anti-HLA DSAs. During surgery, the patient developed a severe and intractable pulmonary hypertension associated with right ventriular dysfunction, which required arteriovenous extracorporeal membrane oxygenation. After a brief period of clinical improvement, a rapid deterioration in hemodynamics led to the patient's death on postoperative day 5. Postmortem studies showed that lung specimens taken at the end of surgery were compatible with antibody-mediated rejection (AMR), while terminal samples evidenced diffuse capillaritis, blood extravasation, edema, and microthrombi, with foci of acute cellular rejection (A3). Immunological investigations demonstrated the presence of preexisting antibodies against the endothelin-1 receptor type A (ETA R) and the angiotensin II receptor type 1 (AT1 R), two of the most potent vasoconstrictors reported to date, whose levels slightly rose after transplantation. These data suggest that preexisting anti-ETA R and anti-AT1 R antibodies may have contributed to the onset of AMR and to the catastrophic clinical course of this patient.

Complications of non-invasive ventilation techniques: a comprehensive qualitative review of randomized trials.

Non-invasive ventilation (NIV) has become a common treatment for acute and chronic respiratory failure. In comparison with conventional invasive mechanical ventilation, NIV has the advantages of reducing patient discomfort, procedural complications, and mortality. However, NIV is associated with frequent uncomfortable or even life-threatening adverse effects, and patients should be thoroughly screened beforehand to reduce potential severe complications. We performed a detailed review of the relevant medical literature for NIV complications. All major NIV complications are potentially life-threatening and can occur in any patient, but are strongly correlated with the degree of pulmonary and cardiovascular involvement. Minor complications can be related to specific structural features of NIV interfaces or to variable airflow patterns. This extensive review of the literature shows that careful selection of patients and interfaces, proper setting of ventilator modalities, and close monitoring of patients from the start can greatly reduce NIV complications.

Impact on grafted kidney function of rocuronium-sugammadex vs cisatracurium-neostigmine strategy for neuromuscular block management. An Italian single-center, 2014-2017 retrospective cohort case-control study.

BACKGROUND: The impact of sugammadex in patients with end-stage renal disease undergoing kidney transplantation is still far from being defined. The aim of the study is to compare sugammadex to neostigmine for reversal of rocuronium- and cisatracurium-induced neuromuscular block (NMB), respectively, in patients undergoing kidney transplantation. METHODS: A single-center, 2014-2017 retrospective cohort case-control study was performed. A total of 350 patients undergoing kidney transplantation, equally divided between a sugammadex group (175 patients) and a neostigmine group (175 patients), were considered. Postoperative kidney function, evaluated by monitoring of serum creatinine and urea and estimated glomerular filtration rate (eGFR), was the endpoint. Other endpoints were anesthetic and surgical times, post-anesthesia care unit length of stay, postoperative intensive care unit admission, and recurrent NMB or complications. RESULTS: No significant differences in patient or, with the exception of drugs involved in NMB management, anesthetic, and surgical characteristics, were observed between the two groups. Serum creatinine (median [interquartile range]: 596.0 [478.0-749.0] vs 639.0 [527.7-870.0] µmol/L, p = 0.0128) and serum urea (14.9 [10.8-21.6] vs 17.1 [13.1-22.0] mmol/L, p = 0.0486) were lower, while eGFR (8.0 [6.0-11.0] vs 8.0 [6.0-10.0], p = 0.0473) was higher in the sugammadex group than in the neostigmine group after surgery. The sugammadex group showed significantly lower incidence of postoperative severe hypoxemia (0.6% vs 6.3%, p = 0.006), shorter PACU stay (70 [60-90] min vs 90 [60-105] min, p < 0.001), and reduced ICU admissions (0.6% vs 8.0%, p = 0.001). CONCLUSIONS: Compared to cisatracurium-neostigmine, the rocuronium-sugammadex strategy for reversal of NMB showed a better recovery profile in patients undergoing kidney transplantation.

Impact of alcohol consumption on winter sports-related injuries.

INTRODUCTION: This study was carried out to evaluate data about trauma-related winter sports, including risk factors such as high speed, gender, age, alcohol consumption, details about the accident and snow conditions. METHODS: A retrospective review was conducted to determine the injury patterns and crash circumstances in holiday skiers and snowboarders. The data recorded were obtained from the database of the Pre-Hospital Emergency Registry of six skiing areas in the Dolomite mountains during the winter seasons November 2004-May 2009, injury data for major traumas from Ski Patrol Injury reports (helicopter, ambulance or ski slopes' patrol reports), and intrahospital Emergency Department data. Alcohol concentration in blood was detected in 200 individuals suffering from major trauma. RESULTS: A total of 4550 injured patients, predominantly male (69%), mean age 22 years (range 16-72), were included in the observational analysis. Knee, wrist and shoulder injuries were frequently associated with major thoracic, abdominal or head traumas (64% of cases). Suboptimal technical level, high speed, low concentration, snow or weather conditions, faulty equipment and protective devices were among the various causes of accidents. The analysis revealed that high alcohol blood concentration was present in 43% of 200 patients. CONCLUSIONS: Even though the major causes of accidents were excessive speed, excessive fatigue, technical errors and bad weather conditions, alcohol abuse was often discovered. Random sampling and a non-systematic detection of alcohol blood levels likely led to an underestimation of alcohol consumption-related injuries. It is recommended that investigations into alcoholic intoxication in injured skiers should be carried out on a large scale.

Transjugular intrahepatic portosystemic shunt in non-cirrhotic portal hypertension related to cystic fibrosis in a lung transplant patient.

Liver involvement is not uncommon in patients with cystic fibrosis (CF). Even if serious complications as non-cirrhotic portal hypertension, cirrhosis and liver failure rarely occur, they are associated with impaired survival and reduced quality of life. Herein, we have reported the first case of a patient with CF and non-cirrhotic portal hypertension who underwent transjugular intrahepatic portosystemic shunt placement for recurrent variceal bleeding after bilateral lung transplantation, and we have reviewed the available literature pertaining to this field.

Risk Factors for Early Mortality in Liver Transplant Patients.

BACKGROUND: Liver transplantation (LT) is an established treatment for patients with end-stage liver disease. The significant advances in surgical technique, immunosuppression therapy, and anesthesiological management have dramatically improved short- and long-term outcomes. The aim of this study is to correlate specific surgical and anesthesiological variables with causes of early death in LT recipients. METHODS: A retrospective observational analysis of adult patients who underwent LT in the period 2012 to 2016 and died within 90 days following LT was conducted. Exclusion criteria were intraoperative death, split liver, and domino transplant. Death was considered a dependent variable and classified into 3 different groups: death by sepsis, vascular events not related to the graft, and primary non-function. Donor and recipient variables were considered and analyzed using Fisher's exact test. RESULTS: Statistically significative associations (P value < .05) were found between renal function support, retransplantation, and the number of fresh frozen plasma units transfused in one group and early death due to sepsis in the other. CONCLUSIONS: This study identified some risk factors associated with the specific cause of early death in liver transplantation. The clinical implications of these findings are the ability to stratify patients at high risk of early death by planning more intensive and accurate management for them.

Epidural anesthesia and analgesia in liver resection and living donor hepatectomy.

Parenteral analgesics are still diffusely administered for postoperative pain after major liver resection, while epidural analgesia is widely criticized because of possible changes in the postoperative coagulation profile. The safety of regional anesthesia in liver resections is based on appropriate timing of needle placement and catheter removal and on the individual's skill in performing both the puncture and the catheterization. In the absence of liver failure or in cases of only moderate hepatic dysfunction, the risk of neurologic complications and spinal hematomas does not appear greater than when an epidural is performed for routine abdominal or thoracic surgery. Various anesthetic strategies have been adopted to prevent bleeding during liver resection, such as fluid restriction, diuretic administration, and vasodilator drugs. Lowering central venous pressure (CVP) seems to play a prominent role in prevention of bleeding since an elevated CVP may be associated with increased blood loss at various phases of liver resection. However, a low CVP may not be tolerated by all patients: intraoperative hemodynamic instability may, in fact, easily ensue because of the cardiovascular depressant effects of anesthetics, surgical blood losses, and manipulation of the inferior vena cava. We suggest combining intraoperative epidural anesthesia with general (light) anesthesia as a useful strategy to keep the CVP low during liver resection without vasodilators or diuretics. Epidural anesthesia does not lead to changes in intravascular volume, but only promotes redistribution of blood, decreasing both venous return and portal vein pressure, thus contributing to reduced hepatic congestion and surgical blood loss.

Noninvasive ventilation in adult liver transplantation.

Noninvasive ventilation (NIV) has proven to be a safe and effective technique in the treatment of respiratory failure complicating various medical and surgical diseases. In recent years, a growing interest has emerged in its adoption for ventilatory assistance in immunocompromised patients, such as those undergoing bone marrow, liver, lung, cardiac, and kidney transplantation. Weaning from the ventilator after liver transplantation can take longer because of unsatisfactory gas exchange during various attempts of T-piece trials. Rapid extubation followed by an immediate NIV application should be considered in this setting to shorten and accelerate the weaning process in those recipients who do not completely fulfill the criteria for safe extubation. By adding the pressure support (PS) mode with a continuous positive end expiratory pressure (PEEP), NIV could prevent the loss of vital capacity and impede severe lung derecruitment following extubation. Clinical experience has shown that properly delivered NIV mostly benefits moderately dyspneic recipients in acute respiratory failure, while it appears less promising and efficient in patients ventilated for extended periods of time. It has proven safe and efficient mainly as (1) a tool to promote an early ventilatory discontinuation and extubation; (2) a prophylactic strategy for preventing postoperative pulmonary complications; and (3) a simple method to start with in cases of acute hypoxic and/or hypercapnic respiratory failure. The improvements in arterial hypoxemia, the decreased ventilatory demand provided with an inspiratory support, as well as the scarcity of hemodynamic repercussions are among the major benefits of this method.

Activated recombinant protein C in septic shock early after liver transplantation: a case report.

Severe infectious diseases after liver transplant are associated with high risk of multiorgan failure and mortality. Septic shock is difficult to manage in this setting since it is often unresponsive to conventional aggressive therapy. Adjuvant therapies have been proposed in association with full combination treatment to sustain the failing organs and improve outcomes in severe sepsis. Recombinant human activated protein C drotrecogin alfa, Xigris) has been occasionally administered to treat posttransplant sepsis to modulate and downregulate the complex network of inflammatory and coagulopathic processes. Herein we have reported on a patient who was given drotrecogin alfa 15 days following liver transplant for acute septic shock originating from a nosocomially acquired pneumonia. Recombinant activated drotrecogin alfa, associated with conventional aggressive treatment, was efficacious to revert the life-threatening "slippery slope" of vasoplegia and uncontrolled diffuse inflammation.

Transesophageal echocardiography during lung transplantation.

Transesophageal echocardiography (TEE) is a semi-invasive monitoring technique increasingly used in cardiac surgery and in major noncardiac surgery for patients with known or supposed cardiac or coronary problems. During lung transplantation (LTx), the close interrelation between heart and lung function makes TEE an invaluable tool for instantly monitoring the physiopathological situation in the subsequent steps of the intervention. In patients scheduled for LTx, induction of anesthesia could be a dangerous moment with the possibility of cardiogenic shock if pulmonary hypertension (PH) exists; pneumatic tamponade is also possible in patients with emphysema caused by alpha(1)-antitrypsin deficiency, with subsequent cardiac insufficiency. One-lung ventilation is a critical phase during LTx; hypoxemia resulting from ventilation of a diseased dependent lung could impair heart oxygenation, particularly if tachycardia is present. Clamping of the pulmonary artery before pneumonectomy could exacerbate cardiac afterload, especially in patients with previous PH. High transmural pressure, linked with low systemic pressure, makes right ventricle (RV) perfusion pressure inadequate. Hypoxemia and PH are the most frequent causes of intraoperative RV decompensation. In this special setting, TEE is irreplaceable in informing the anesthesiologist about the correct time for extracorporeal oxygenation. Lung reperfusion brings with it the possibility of coronary gaseous embolism, easily detected with TEE. After LTx, TEE can be used to detect strictures, thrombi, or permeability of pulmonary venous anastomoses. To summarize, intraoperative TEE during LTx contributes to the immediate recognition of critical events and allows for rapid therapeutic interventions.

Microbiologic contamination of intraoperative blood salvaged during liver transplantation.

Bacterial contamination is one of the potential risks of blood salvage and reinfusion during orthotopic liver transplantation (OLT) because cell-saver machines lack antibacterial protection devices. This study was designed to analyze the potential bacterial contamination of blood salvaged during OLT; a secondary end point was to evaluate whether reinfusion of potentially contaminated blood may have been responsible for clinically manifested infective complications in the same patient. After induction of anesthesia, a blood sample was drawn from the central venous catheter (CVC) immediately after its positioning, to exclude potential coexisting hematic contamination of the recipient. During the procedure, 2 other samples of salvaged blood were collected for bacteriological analysis. Twenty-six of 38 samples of salvaged blood were positive for microorganisms, whereas 12 did not reveal the presence of infectious agents. In 19 of 26 positive samples, Staphylococcus species (73%) were isolated with only 2 of 38 samples drawn from CVC being contaminated. Candida Albicans was cultured in 2 samples. The high percentage (73%) of coagulase-negative Staphylococci indicates that blood contamination could have been caused by microorganisms from the air or suctioned from contact surfaces and the surgical field. Although almost 70% of processed and reinfused units tested positive for microbes, none of the postoperative blood cultures (at day 1 and day 3) revealed growth of the same species, not even in the 2 patients who had positive CVC cultures after induction of anesthesia.

Surgical treatment of posttransplant bronchial stenoses: case reports.

BACKGROUND: Bronchial stenoses are still a frequent complication after lung transplantation. The stenosis usually involves the anastomotic site, but rarely a distal site. The first choice treatment is an endoscopic balloon dilatation, laser ablation, and stenting. Unrelenting strictures may require an open surgical approach. MATERIALS AND METHODS: Between 1995 and 2006, 154 patients underwent lung transplantation, including 134 who survived the perioperative period and were followed to evaluate the incidence of bronchial stenosis. Among 219 anastomoses at risk, 13 (5.9%) stenoses occurred in 11 patients. Conservative endoscopic management was effective for eight patients, but a surgical approach was necessary for three patients with segmental distal stenosis. RESULTS: One patient received a lower sleeve bilobectomy; one patient, wedge bronchoplasty of the bronchus intermedius; and another patient, an isolated sleeve resection of the bronchus intermedius. All patients had good outcomes with resolution of stenosis. CONCLUSIONS: Although rare, the surgical approach for bronchial strictures after lung transplantation is a good option. Parenchyma-sparing techniques are feasible and effective.

Anesthetic concerns in lung transplantation for severe pulmonary hypertension.

Lung transplantation has become a consolidated treatment for patients with severe pulmonary hypertension (PH). Several difficulties are encountered during the procedure in such candidates, who are still recognized as more severely affected by perioperative morbility and mortality than those undergoing lung transplantation for other diseases. Right ventricular (RV) enlargement with tricuspid regurgitation, small left ventricle (LV) with an asymmetric hypetrophic wall, interventricular septal shift toward the left, with ventricular stiffness and diastolic incompetence, are typical preoperative echocardiographic findings of end-stage PH. A smooth induction and tracheal intubation will help prevent hypertensive crisis in highly susceptible candidates. Uncompensated vasodilatation or myocardial depression caused by anesthetics and mechanical ventilation may be responsible for acute RV dysfunction associated with low systemic blood pressure. Resuscitation and emergency adoption of cardiopulmonary by-pass (CPB) has been described for near-fatal anesthesia induction. Cardiovascular instability can develop after institution of one-lung ventilation and pulmonary artery clamping. An acute increase in pulmonary pressure results in a decrease in RV ejection fraction and then in acute RV failure. Interdependence of the right and left ventricles occurs such that RV function can alter LV function. Early detection of impending circulatory and/or respiratory deterioration is warranted to prevent an irreversible decline in cardiac output, resulting in hazardous cardiac arrest. Inhaled nitric oxide represents the first choice for treatment of PH and RV failure associated with systemic hypotension during lung transplantation. Intraoperative situations requiring CPB must be identified before development of systemic shock, which represents a late ominous sign of RV failure.

Liver Retransplantation for Hepatic Abscess Due to Hepatic Artery Thrombosis: A Case Report.

INTRODUCTION: Hepatic artery thrombosis (HAT) is a well-recognized complication of liver transplantation (LT). HAT is an important risk factor for infectious, in particular hepatic abscess, which can cause graft loss and increasing morbidity and mortality. CASE REPORT: We present a case report of complicated LT in a 52-year-old Caucasian man with primary sclerosing cholangitis. In 2007 the patient was included on the waiting list in Padua for LT. In 2012 the patient underwent percutaneous transhepatic biliary drainage for bile duct stricture, complicated with acute pancreatitis. A diagnostic laparoscopy was performed with choledochotomy and Kehr's T tube drainage. On February 14, 2012, the patient underwent LT with arterial reconstruction and choledochojejunostomy. The postoperative course was complicated with HAT, multiple liver abscesses, and sepsis associated with bacteremia due to Enterococcus faecium despite massive intravenous antibiotic therapy and percutaneous drainages. On November 28, 2012, the patient underwent retransplantation. Four years after transplantation the patient is still in good general condition. CONCLUSION: Hepatic abscess formation secondary to HAT following LT is a major complication associated with important morbidity and mortality. In selected cases retransplantation should be considered as our case demonstrates.

Cerebral blood flow in fulminant hepatitis.

Fulminant hepatic failure (FHF) is often complicated with cerebral edema, intracranial hypertension, and coma. Cytotoxic and vasogenic factors have been recognized in the etiology of cerebral edema. One of the main causes seems to be the accumulation of glutamine in astrocytes, which is produced from ammonia and the excitatory neurotransmitter glutamate. Ammonia is detoxified within the brain in astrocytes, where it increases the osmotic pressure for water. Ammonia-induced astrocytic water accumulation seems to act as an integrative trigger for the development of intracranial hypertension. While cerebral blood flow is sometimes reduced in the first stage of FHF, as compensatory cerebral vasoconstriction to reduce mean arterial pressure, it later increases as hyperammonemia decreases cerebral arteriolar tone. Despite vasodilation in the systemic and splanchnic beds at early stages of the disease, cerebral vessel resistance may increase, so that cerebral perfusion pressure may be preserved. When cerebral vascular tone is no longer effective in the course of illness, vasodilation gradually develops and rapidly becomes poorly responsive to carbon dioxide stimulation, which signifies loss of autoregulatory tone and cerebral hyperemia develops. Prolonged excessive flow may lead to brain swelling, vasogenic edema, and intracerebral hemorrhage. Brain edema further aggravates the critically reduced cerebral perfusion and is responsible for the high mortality.

Morbidity, mortality, and survival after bronchoplastic procedures for lung cancer.

OBJECTIVE: Bronchoplastic procedures represent an effective surgical therapy for benign lesions, tumors of low-grade malignancy and also bronchogenic carcinoma in patients with a limited pulmonary function. We analyzed our experience in order to verify the mortality, morbidity, and long term survival in our patients. METHODS: From 1980 to 1994, 217 patients underwent bronchoplastic procedures. We performed 92 bronchoplasties, 94 bronchial sleeves, and 31 tracheo-bronchial sleeves. Histologic examination revealed 133 epidermoid carcinomas, 28 adenocarcinomas, 11 small cells lung cancers, 5 large cells carcinomas, 2 adenosquamous carcinomas, 29 bronchial carcinoids, 6 adenoidocistic carcinomas, and 3 mucoepidermoid tumors. Regarding nodal status, 99 patients had N0 disease, 64 patients had N1 disease, and 54 patients had N2 disease. Thirty-six patients had preoperative irradiation and 181 patients had no preoperative irradiation. In 63 patients we used a perianastomotic pedicled flap; in 154 we did not use it. We considered all the 217 patients for the analysis of 30-day mortality and morbidity; of the 217 patients we analyzed long-term survival only in 179 because we excluded 38 patients with low grade malignant neoplasm. RESULTS: Twenty-seven patients (12.5%) had postoperative complications. The 30-day mortality was 6.2% (14 patients). Survival at 5 and 10 years for all patients but those with low grade malignant neoplasm was 49 and 38%, respectively. For patients with N0 status 5- and 10-year survival was 72.4 and 59.4%; for patients with N1 status these rates were 35.7 and 26.8%; for patients with N2 status, 5- and 10-year survival was 22 and 14.4%. Postoperative complication rates for patients with or without pedicled flap are not significantly different; however, the rates for patients with or without preoperative irradiation are significantly different. CONCLUSIONS: Bronchoplastic procedures are a safe and effective therapy for selected patients with pulmonary malignancy. Tracheo-bronchial sleeves are associated with high postoperative mortality and complication rates and these procedures should be limited to patients without N2 disease. Preoperative irradiation increases significantly the mortality and morbidity. A multivariate analysis shows that only the nodal status affects long-term survival (P = 0.0002).

Extreme marginal donor: severe hypothermia as a rare preservation condition for explantable organs--a case report.

UNLABELLED: The progressive increase in patients with end stage liver disease has lengthend the waiting- list for liver transplantation. Unfortunately this has not been followed by a suitable increase in the number of donors. The expanding "donor pool" has required use of "marginal" donors (ICU stay > 10 days, sepsi; steatosis > 30-40%, hypernatremia > 155 mmol/L, inotropic drugs). We report the case of a skier who remained for more than 1 hour in cardio-respiratory arrest under the snow; the 49-year-old women was extracted from the snow after 1 hour and 12 minutes and found to be asystolic, fixed pupils and deep hypothermia (27.2 degrees C). After cardiopulmonary resuscitation, partial cardio-respiratory activity was re-established. In the ICU severe hypothermia (26.7 degrees C) was treated with extracorporeal circulation until a re-establishment of satisfactory cardio-circulatory conditions was obtained. Unfortunately cerebral anoxic cerebral death was established and multiorgan procurement performed 3 days later. After liver transplantation into a 59 year-old patient with PNC-C was performed. The course was uneventful and the patient was discharged on the 19th postoperative day. CONCLUSIONS: Organ procurement from donors involved in accidental traumatic events with cardio-respiratory arrest and hypothermia, is similar to the non-heart-beating donor (NHBD) condition. Correct cardiopulmonary resuscitation and the use of extracorporeal circulation for gradual restoration of body temperature are necessary for optimal organ perfusion. In the present case the anoxic insult induced by the cessation of the cardio-respiratory function, was probably mitigated (if not even annulled) by the hypothermia.