Initial experience with cyclosporine C2 monitoring after lung transplantation.
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Cyclosporine↗
Biomedical subjects
Erino A Rendina
Publications and source records attributed to Erino A Rendina.
Intrapleural intercostal nerve block associated with mini-thoracotomy improves pain control after major lung resection.
OBJECTIVE: To prospectively assess the impact of intrapleural intercostal nerve block (IINB) associated with mini-thoracotomy on postoperative pain and surgical outcome after major lung resections. METHODS: Between January 2004 and February 2005, we randomly assigned 120 consecutive patients undergoing mini-thoracotomy (10-13 cm) for major lung resections, to receive or not IINB from the 4th to the 8th space at the moment of thoracotomy using 20 ml (7.5 mg/ml) ropivacain injection at the dose of 4 ml for each space. Postoperative analgesia consisted of continuous intravenous infusion of tramadol (10 mg/h) and ketoralac tromethamine (3 mg/h) for 48 h for all patients. RESULTS: The two groups (60 patients each) were comparable for age, sex, pulmonary function, type and duration of the procedure. Mortality and morbidity were 0% and 10%, respectively, for the IINB group and 3.3% and 15%, respectively, for the non-IINB group (p>0.05, NS). Mean postoperative pain measured by the 'Visual Analogue Scale' were as follows: 2.3+/-1 at 1 h, 2.2+/-0.8 at 12 h, 1.8+/-0.7 at 24 h, and 1.6+/-0.6 at 48 h for the IINB group; and 3.6+/-1.4 at 1 h, 3.4+/-2 at 12 h, 2.9+/-1.2 at 24 h, and 2.0+/-1 at 48 h for the non-IINB group. Differences were significant at 1 h, 12 h, 24 h, and 48 h (p<0.05). Mean postoperative hospital stay was 5.7 days in the IINB group and 6.5 days in the non-IINB group (p<0.05). CONCLUSION: IINB associated with mini-thoracotomy reduces postoperative pain and contributes to improve postoperative outcome after major pulmonary resections.
Aged↗
Bronchoscopic procedures for emphysema treatment.
Emphysema is a debilitating lung disease continuing to be a major source of morbidity and mortality in the developed countries. Medical treatment is the mainstay of therapy and consists of smoking cessation, pulmonary rehabilitation, administration of bronchodilators and, when indicated, steroids and supplemental oxygen. Various surgical procedures have been promoted in the past to relieve dyspnoea and improve quality of life in patients with advanced emphysema; whilst early results were often encouraging, a sustained objective functional improvement was rarely achieved and most of those procedures were progressively abandoned. Despite controversies, LVRS has been shown to be beneficial to selected patients with end-stage emphysema when medical therapy has failed. There is no doubt that LVRS allows a significative functional improvement in a selected group of patients; however, it still carries a substantial morbidity, even if mortality is low at the centres with the larger experience. Patients with a most advanced functional deterioration show a higher surgical mortality and less impressive functional results, suggesting that LVRS should be considered more carefully in these situations. Bronchoscopic alternatives to the surgical approach have been recently proposed and some of them may play an important role in the future; in particular, the airway bypass and bronchoscopic lung volume reduction with one-way valves are certainly one step beyond on their way to clinical application. We hereby report the initial experimental and clinical experience with these new treatment options.
Animals↗
A new technique for prosthetic reconstruction of the superior vena cava.
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Anastomosis, Surgical↗
Use of a polymeric sealant to reduce air leaks after lobectomy.
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Aged↗
Operative endoscopy of the airway with the old-fashioned esophageal dilators.
Bronchial dilation is usually required to treat a number of disorders; the most frequent are complications after airway surgery, including lung transplantation, stenosis after radiotherapy, and compression by an extraluminal mass. The procedure is performed by forcing the tip of a rigid bronchoscope through the stenosis using barrels of increasing size; however, when there is a clear discrepancy between the caliber of the rigid instrument and the stenosis, the first step may be difficult. In such cases, we have successfully employed two types of old-fashioned esophageal dilators rescued from the armamentarium of our endoscopy unit.
Airway Obstruction↗
Glutaraldehyde preserved autologous pericardium for patch reconstruction of the pulmonary artery and superior vena cava.
We describe a new employment of glutaraldehyde preserved autologous pericardium for patch reconstruction of the pulmonary artery (PA) and superior vena cava (SVC). This technique was devised to minimize technical problems related to the use of fresh pericardium such as excessive elasticity and tendency to curl. We have successfully employed this procedure in three cases of reconstruction of the PA and in two cases of reconstruction of the SVC.
Fixatives↗
Bronchoscopic lung-volume reduction with one-way valves in patients with heterogenous emphysema.
BACKGROUND: We evaluated the feasibility and short-term functional outcome after bronchoscopic lung-volume reduction performed with one-way valves in patients with severe heterogeneous emphysema. METHODS: Thirteen patients entered this pilot study. Endobronchial one-way valves were placed in the segmental bronchi supplying the most hyperinflated parts of the emphysematous lungs to allow lung deflation, reduce lung volume, and alleviate symptoms. The valves and delivery catheter were inserted under intravenous anesthesia and spontaneous assisted ventilation, with visual control through a flexible bronchoscope. We performed unilateral bronchoscopic lung-volume reduction in 11 patients and staged bilateral procedures in 2. Preoperative median forced expiratory volume in 1 second (FEV1) was 0.75 L/s (22%), residual volume was 5.3 L (233%), total lung capacity, 7.9 L (123%); intrathoracic gas volume, 6.5 L (176%); and 6-minute walk test, 223 meters. All patients required supplemental oxygen at rest (1.4 L/min). The median preoperative Medical Research Council (MRC) scale dyspnea score was 4. RESULTS: Six complications occurred in 3 patients: two bilateral and one contralateral pneumothorax, one pneumonia, and two episodes of bronchospasm. Functional results at 1 and 3 months showed a significant improvement in FEV1, residual volume, and 6-minute walk test; 43% of the patients were able to completely stop supplemental oxygen. The posttreatment MRC median dyspnea score at 1 and 3 months was 2. Bronchoscopic follow up at 1 and 3 months showed that the valves were correctly in place with no granulation. CONCLUSIONS: Bronchoscopic lung-volume reduction with one-way valves can be performed with acceptable short-term safety and worthwhile functional benefits.
Adult↗
Treatment of recurrent thymic tumors.
Surgery is the cornerstone of therapy for recurrent thymic tumors. The pattern of recurrence is, however, less defined. Between 1966 and 1988, we operated on 83 patients with thymoma, 11 of whom underwent surgery for recurrence (group I). In 1989, we initiated a prospective multimodality protocol and have enrolled 128 patients with 9 (7%) recurrences since (group II). In group I, 1 patient was originally at stage I, 2 were at stage II, 5 at stage III, and 3 at stage IV. The patients underwent 1 (#10) or 2 (#1) reoperations and 5 showed histological progression of malignancy. One patient died postoperatively, 6 died of disease, and 3 are alive and disease free 18 to 22 years after the first operation. In group 2, no patient was originally at stage I, 1 was at stage II, 4 were at stage III, and 4 at stage IV. Reoperation (5 patients) was followed by chemotherapy and 2 showed histological progression of disease. One patient died after 2 years, and 4 patients are alive after 6 to 11 years. All recurrent tumors were thymomas with cortical differentiation. Early onset of recurrence was a negative prognostic factor. Thymomas can recur also at early stages. A multimodality approach is indicated also for early stage lesions based on histology.
Adult↗
Recovery of chronic renal impairment with sirolimus after lung transplantation.
BACKGROUND: Standard immunosuppression after lung transplantation includes calcineurin inhibitors, azathioprine, and steroids. Calcineurin inhibitor administration is associated with an increased renal impairment. Sirolimus shows no renal toxicity and could be used in selected patients. METHODS: We have prospectively administered sirolimus as an alternative to calcineurin inhibitors in 15 lung transplantation recipients with persistent drug nephrotoxicity. Eight patients had also bronchiolitis obliterans syndrome. The mean serum creatinine and azotemia were 2.7 +/- 1.1 mg/dL and 111 +/- 39 mg/dL. After starting sirolimus, azathioprine was reduced to 50%-25% of baseline, calcineurin inhibitors were gradually reduced and eventually stopped, and steroids were maintained stable. Patients started sirolimus with 2 to 5 mg/d orally; adjustments were made according to trough levels (4 to 12 ng/mL for combined sirolimus + calcineurin inhibitors; 12 to 20 ng/mL as monotherapy), toxicity, and perceived efficacy. Patients were monitored for renal and graft function and clinical status. RESULTS: A significant creatinine decrease was observed after 6 months of treatment (p < 0.02); azotemia decreased after 1 month and remained stable (p < 0.01). Pulmonary function tests did not show any significant modification from before sirolimus baseline in patients without bronchiolitis obliterans syndrome. There were eight infectious complications and 10 episodes of toxicity (4 dermatitis, 2 epistaxis, 1 headache, 1 diarrhea, 1 nausea, 1 laryngeal cancer). Moderate leukocytopenia (n = 3) and hypertriglyceridemia (n = 6) responded to dose reduction. One patient was lost to follow-up. Three patients died of complications related to bronchiolitis obliterans. One patient underwent transplantation again. CONCLUSIONS: Sirolimus administration allows amelioration of renal function with a relatively low morbidity and is useful for chronic renal impairment rescue after lung transplantation.
Adult↗
Operative and non-operative treatment of benign subglottic laryngotracheal stenosis.
OBJECTIVE: Surgery is the first line of treatment for laryngotracheal stenosis; Montgomery tube or permanent tracheostomy have been so far the only alternatives. Nd-YAG laser resection and indwelling endotracheal stents have rarely been used in subglottic stenosis for anatomic and technical reasons. We have used the latter approach to optimize the timing of surgery or to achieve palliation without tracheostomy. METHODS: Between 1991 and 2001 we have treated 18 patients with subglottic stenosis (10 males, 8 females; age range 14-78, mean 34). The upper margin of the stricture was 2mm to 1cm below the vocal cords; the stenotic segment extended from 1.5 to 5 cm. Three patients had tracheostomy done elsewhere. Four patients (Group I) had laser and stenting by a Dumon prosthesis as the only treatment; six had laser and stenting (#4) followed after 1-6 months by laryngotracheal resection (Group II); eight had surgery alone (Group III). RESULTS: In Group I, one patient required repositioning of the stent and in two the stent was removed; two patients died of their underlying disease; at a follow-up of 2-9 years all living patients did well but required permanent aerosolized therapy and periodical bronchoscopy. In Group II, we had two wound infections due to airway colonization by staphylococcus aureus. In Group III, two patients developed anastomotic postoperative stenosis, treated by laser (#2) and stenting (#1), and one patient with previous tracheostomy had a wound infection. Overall, in the 14 surgical patients (Groups II and III) stenosis occurred in 14.2% and infection in 21.3%. After a follow up of 15 months to 12 years, all surgical patients breathe and speak well. CONCLUSIONS: Laser resection and endoluminal stenting can be a viable alternative to surgery or optimize the timing of operation in patients with subglottic stenosis.
Adolescent↗
Complete mechanical cervical anastomosis using a narrow gastric tube after esophagectomy for cancer.
OBJECTIVE: Fibrous stenosis of the esophagogastric cervical anastomosis remains a significant complication occurring in up to one-third of cases. Trying to reduce the incidence of this complication, we describe our technique of cervical esophagogastric anastomosis using endoscopic linear stapler which seems to reduce the incidence of fibrous stricture formation after resection of esophageal cancer. METHODS: Between March 2000 and June 2003, 26 patients (15 males and 11 females) underwent esophagectomy using tubulized stomach for reconstruction. Cervical esophagogastric anastomosis using linear endoscopic stapler was performed in all cases. The occurrence of post-operative anastomotic leak and development of anastomotic stricture were recorded and analyzed. RESULTS: All patients survived esophagectomy and were available for post-operative follow-up. Anastomotic leak developed in one case. No patient developed fibrous stenosis that required dilatation therapy. CONCLUSION: Complete mechanical esophagogastric anastomosis, using endoscopic linear stapler is effective and safe, even when a narrow gastric tube is used as esophageal substitute. This technique seems superior to other techniques to reduce the incidence of post-operative anastomotic complications.
Adult↗
Long-term outcome after multimodality treatment for stage III thymic tumors.
BACKGROUND: Surgery remains the cornerstone of therapy for thymic tumors, but the optimal treatment for advanced, infiltrative lesions is still controversial. The introduction of multimodality protocols has substantially modified survival and recurrence rate. We reviewed our 13-year prospective experience with multimodality treatment of stage III thymoma and thymic carcinoma. METHODS: Since 1989 we have prospectively used a multimodality approach in 45 stage III thymic tumors. Sixteen patients (35%) had myasthenia gravis. Twenty-three patients (51%) had pure or predominantly cortical thymoma (group 1), 11 (24.5%) had well-differentiated thymic carcinoma (group 2), and 11 (24.5%) had thymic carcinoma (group 3). Tumors that were not considered radically resectable at preoperative workup underwent biopsy and induction chemotherapy (15 patients, 33%) followed by surgical resection; all patients were referred for adjuvant chemoradiotherapy. RESULTS: No operative mortality was recorded; 1 treatment-related death during adjuvant chemotherapy was observed in group 1. Complete resection was feasible in 91% of patients in groups 1 and 2 and 82% in group 3. The overall 10-year survival was 78%. Ten-year survival for groups 1 and 2 was 90% and 85%, respectively; 8-year survival for group 3 was 56%. During follow-up, tumor recurrence was noted in 3 patients (13%) from group 1, 3 (27%) from group 2, and 3 (27%) from group 3. CONCLUSIONS: Multimodality treatment with induction chemotherapy (when required) and adjuvant chemoradiotherapy offers encouraging results for stage III thymic tumors; the outcome is more favorable for cortical thymoma and well-differentiated thymic carcinoma.
Aged↗
Feasibility and safety of the airway bypass procedure for patients with emphysema.
OBJECTIVE: We have proposed that direct passages created between pulmonary parenchyma and large airways (airway bypass) could take advantage of the extensive collateral ventilation present in emphysematous lungs to provide improvement in expiratory flow and respiratory mechanics. A critical step in the safe performance of these procedures is to create passages through the airway wall into lung parenchyma while avoiding injury to adjacent blood vessels. METHODS: The procedure consists of selection of a target site bronchoscopically, use of a Doppler catheter to detect and avoid peribronchial blood vessels, and creation of a passage through the airway wall with a cautery probe. To evaluate the safety of airway bypass, 10 patients were treated during prescheduled lobectomies for neoplasm. The procedure was done after thoracotomy and immediately before resection and was confined to airways in the lung identified for removal. Airway bypass was subsequently performed in 5 patients undergoing lung transplantation for emphysema just before lung excision to evaluate the procedure in emphysematous patients. RESULTS: Twenty-nine passages (1-5 per subject) were created in the patients undergoing lobectomy. Eighteen passages were created (3-4 per subject) in the patients undergoing transplantation. There were 2 instances of mild bleeding in the patients undergoing lobectomy and no bleeding in the patients undergoing transplantation. Both instances were treated with suction and topical application of epinephrine and resolved without incident. CONCLUSION: The results of this study confirm that passages can be made safely through the airways of human subjects. These clinical results support further investigation of the efficacy of the airway bypass procedure in patients with emphysema.
Adult↗
Bilateral sequential lung transplantation without sternal division.
OBJECTIVES: The 'clamshell incision' is considered the standard approach for bilateral sequential lung transplantation (BSLT); however, a considerable morbidity may be related to this incision. The bilateral anterolateral thoracotomy without sternal division is an alternative approach that may contribute to avoid chest wall complications. METHODS: We have employed this approach in a prospective series of 34 patients undergoing bilateral transplantation (Group I). The results were retrospectively compared with an historical control group of 37 patients (Group II) undergoing transplantation through the clamshell incision. RESULTS: The operative time in Groups I and II were 228+/-32 and 293+/-37 min, respectively; the difference between the ischemic time of the first and second lungs were 68+/-20 and 73+/-15 min. Intensive care unit stay was 5+/-6 vs. 13+/-10 days and length of hospitalization was 25+/-16 vs. 32+/-10 days. Vital capacity measured 3 weeks after the transplant was significantly higher in Group I (65+/-13 vs. 45+/-8% predicted) as well as FEV(1) (71+/-8 vs. 58+/-7% predicted). No wound related complication was observed in Group I; in Group II, there were 17 chest wall complications: sternal osteomyelitis in three patients (surgical debridement and closure with a muscle flap), migration of the Kirshner wire in three (removal of the wire), sternal override in three (surgical correction) and prolonged pain in eight. CONCLUSIONS: The bilateral anterolateral thoracotomy without sternal splitting is a safe and effective approach for BSLT; it allows to avoid sternal complications and contributes to improve respiratory function in the early postoperative period.
Adolescent↗
Mortality on the lung transplantation waiting list.
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Cystic Fibrosis↗
Thoracoscopic sympathectomy for symptomatic arterial obstruction of the upper extremities.
BACKGROUND: Severely symptomatic arterial insufficiency of the hand and upper extremities requires adequate treatment. Medical therapy and local care are usually unsuccessful, and thoracic sympathectomy can represent an effective procedure to control pain, to help ulcer healing, and to prevent or delay amputation. METHODS: We performed 20 thoracoscopic sympathectomies in 15 patients (13 men and 2 women) with upper extremity ischemia. Mean age was 47 years (range 21 to 72 years). All patients were thought to have organic blockage of digital arteries. The condition was unilateral in 10 patients and bilateral in 5. Primary diagnosis was digital arteriosclerosis in 8 patients, Buerger's disease in 4 patients and the remaining 3 were drug abusers with severe ischemia due to accidental intraarterial injection of drugs. Eleven patients (73%) presented with terminal digital necrosis, gangrene, or ulceration of the fingers associated with severe pain. Four patients complained of coldness, pain, and some degree of soft tissue infection without permanent loss of tissue. RESULTS: We performed 10 unilateral and five bilateral staged (mean interval was 3 months) thoracoscopic sympathectomies. We had two minor complications and no mortality. Mean duration of postoperative chest drainage was 2.5 +/- 0.4 days and mean postoperative hospital stay was 5.3 +/- 0.5 days. Follow-up ranged from 3 to 71 months, with a mean of 33 months. All patients demonstrated clinical benefit after operation. CONCLUSIONS: Thoracoscopic sympathectomy in patients with severe ischemia of upper limb extremities permits optimal symptomatic control and maximum tissue salvage. Because the procedure is minimally invasive, safe, and associated with a low rate of complications, it should be considered earlier the natural course of this disease.
Adult↗
Biopsy of anterior mediastinal masses under local anesthesia.
Treatment of most primary mediastinal tumors is based on positive histological diagnosis; we describe a variation of anterior mediastinoscopy under local anesthesia. After infiltration with local anesthetic, a transverse skin incision is made in the second, third, or fourth interspace. The endothoracic fascia is incised vertically adjacent to the periosteum and a mediastinoscope is inserted in the mediastinum. Between 1995 and 2001, we have employed this technique in 46 patients with anterior mediastinal tumors. Histological diagnosis was obtained in all patients. Pneumothorax (2 patients) was drained by a tube removed at the end of the procedures. No other complications occurred and all patients were discharged from hospital within 24 hours. Mediastinoscopy under local anesthesia proved safe and effective for diagnosing anterior mediastinal tumors.
Adolescent↗