ISSN:0003-4932    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Objective:To investigate the value of in situ preservation and ex vivo evaluation of lungs from a non-heart-beating donor (NHBD) prior to long-term cold storage.Summary Background Data:The use of pulmonary grafts from NHBD might alleviate the organ shortage. However, viability testing of these grafts is mandatory to transplant only those lungs with excellent function.Methods:Pigs were divided into two groups. In the control group, lungs were flushed, explanted, and stored for 4 hours (4°C). In the study group, pigs were killed and left untouched for 90 minutes. Thereafter, the lungs were cooled for 150 minutes via chest drains. Graft function of the left lung in both groups was assessed in an isolated ventilation and reperfusion circuit 4 hours after death. The lung was then cooled and stored. Twenty-four hours after death, the pulmonary graft was reassessed in the same model.Results:We did not observe a statistical significant difference between the two groups in pulmonary vascular resistance, mean airway pressure, and partial oxygen tension at each time point. There was also no statistical significant difference in wet-to-dry weight ratio. Finally, no statistical difference was found within both groups comparing the assessment at 24 hours with the interim evaluation at 4 hours.Conclusions:These data demonstrate that: 1) 90 minutes of warm ischemia and 150 minutes of intrapleural cooling do not affect pulmonary graft function; and 2) NHBD lungs can be safely preserved up to 24 hours. Finally, we have demonstrated that interim ex vivo evaluation of NHBD lungs is a valid and safe method to assess graft function.

ISSN:0003-4932    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Objective:To evaluate the suitability of microvascular flaps for the reconstruction of extensive full-thickness defects of the chest wall.Summary Background Data:Chest wall defects are conventionally reconstructed with pedicular musculocutaneous flaps or the omentum. Sometimes, however, these flaps have already been used, are not reliable due to previous operations or radiotherapy, or are of inadequate size. In such cases, microvascular flaps offer the only option for reconstruction.Methods:From 1988 to 2001, 26 patients with full-thickness resections of the chest wall underwent reconstruction with microvascular flaps. There were 8 soft tissue sarcomas, 8 recurrent breast cancers, 5 chondrosarcomas, 2 desmoid tumors, 1 large cell pulmonary cancer metastasis, 1 renal cancer metastasis, and 1 bronchopleural fistula. The surgery comprised 5 extended forequarter amputations, 5 lateral resections, 8 thoracoabdominal resections, and 8 sternal resections. The mean diameter of a resection was 28 cm. The soft tissue defect was reconstructed with 16 tensor fasciae latae, 5 tensor fascia latae combined with rectus femoris, and 3 transversus rectus abdominis myocutaneous flaps. In 2 patients with a forequarter amputation, the remnant forearm was used as the osteomusculocutaneous free flap.Results:There were no flap losses or perioperative mortality. Four patients needed tracheostomy owing to prolonged respiratory difficulties. The mean survival time for patients with sarcomas was 39 months and for those with recurrent breast cancer 18 months.Conclusions:Extensive chest wall resections are possible with acceptable results. In patients with breast cancer, the surgery may offer valuable palliation and in those with sarcomas it can be curative.

ISSN:0003-4932    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Objective:The purpose of the study was to compare in prospective randomized fashion a manually sutured esophagogastric anastomosis in the neck and a stapled in the chest after esophageal resection and gastric tube reconstruction.Summary Background Data:Despite the fact that all reconstructions after esophagectomy will result in a cervical or a thoracic anastomosis, controversy still exists as to the optimal site for the anastomosis. In uncontrolled studies, both neck and chest anastomoses have been advocated. The only reported randomized study is difficult to evaluate because of varying routes of the substitute and different anastomotic techniques within the groups. The reported high failure rate of stapled anastomoses in the neck and the fact that most surgeons prefer to suture cervical anastomoses made us choose this technique for anastomosis in the neck. Our routine and the preference of most surgeons to staple high thoracic anastomoses became decisive for type of thoracic anastomoses.Methods:Between May 9, 1990 and February 5, 1996, 83 patients undergoing esophageal resection were prospectively randomized to receive an esophagogastric anastomosis in the neck (41 patients) or an esophagogastric anastomosis in the chest (42 patients). To evaluate selection bias, patients undergoing esophageal resection during the same period but not randomized (n = 29) were also followed and compared with those in the study (n = 83). Objective measurements of anastomotic level and diameter were assessed with an endoscope and balloon catheter 3, 6, and 12 months after surgery. The long-term survival rates were compared with the log-rank test.Results:Two patients (1.8%) died in hospital, and the remaining 110 patients were followed until death or for a minimum of 60 months. The genuine 5-year survival rate was 29% for chest anastomoses and 30% for neck anastomoses. The overall leakage rate was 1.8% (2 cases of 112) with no relation to mortality or anastomotic method. All patients in the randomized group had tumor-free proximal and distal resection lines, but 1 patient in the nonrandomized group had tumor infiltrates in the proximal resection margin. At 3, 6, and 12 months after operation, there was no difference in anastomotic diameter between the esophagogastric anastomosis in the neck and in the thorax (P= 0.771), and both increased with time (P= 0.004, ANOVA repeated measures). Body weight development was the same in the two groups. With similar results in randomized and nonrandomized patients, study bias was eliminated.Conclusions:When performed in a standardized way, neck and chest anastomoses after esophageal resection are equally safe. The additional esophageal resection of 5 cm in the neck group did not increase tumor removal and survival; on the other hand, it did not adversely influence morbidity, anastomotic diameter, or eating as reflected by body weight development.

ISSN:0003-4932    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Objective:To evaluate if an integrin-retargeted adenoviral vector could establish a more efficient and tumor-specific gene transfer in esophageal carcinoma cells.Summary Background Data:Although preclinical data indicated that adenoviral gene therapy could be a promising novel treatment modality for various malignancies, clinical results are often disappointing. An important problem is the decreased tumoral expression of the Coxsackie and adenovirus receptor (CAR), which mediates adenoviral entry. Retargeting the adenoviral vector to other cellular receptors, by inserting an arginine-glycine-aspartate (RGD) tripeptide in the fiber knob, might overcome this problem.Methods:Four esophageal carcinoma cell lines and 10 fresh surgical resection specimens were cultured. All were infected with the native adenovirus (Ad) and the retargeted adenovirus (AdRGD), encoding for the reporter genes luciferase or Green Fluorescent Protein to analyze gene transfer efficiency.Results:In all cell lines, an increase in viral expression per cell and an increase in the percentage of transduced cells were seen with the retargeted adenovirus. Also, in the primary cultures of carcinoma cells, a more efficient gene transfer was seen when the retargeted vector was used. This phenomenon was less pronounced in normal cells, indicating that the RGD virus transduces tumor cells more efficiently than normal cells.Conclusions:This study demonstrates that an RGD retargeted adenovirus infects human esophageal carcinoma cells with enhanced efficiency, while in normal esophageal cells this effect is less pronounced. Therefore, this retargeted vector is expected to have a better performance in vivo, when compared with nonretargeted vectors used for cancer gene therapy so far.

ISSN:0003-4932    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Objective:To define whether laparoscopic rebanding or Roux-en-Y gastric bypass represents the best approach for failed laparoscopic gastric banding in patients with morbid obesity.Summary Background Data:Countless laparoscopic gastric bandings have been implanted during the recent years worldwide. Despite excellent short-term results, long-term failures and complications have been reported in more than 20% of patients. Which rescue procedures should be used remains controversial. Therefore, we analyzed our experience with the use of laparoscopic rebanding versus laparoscopic Roux-en-Y gastric bypass after failed gastric banding.Methods:Using a prospectively collected database, we analyzed the feasibility, safety, and effectiveness of laparoscopic rebanding versus laparoscopic conversion to Roux-en-Y gastric bypass after failed laparoscopic gastric banding.Results:A total of 62 consecutive patients were treated in our institution between May 1995 and December 2002 for failed primary laparoscopic gastric banding, including 30 laparoscopic rebandings and 32 laparoscopic conversions to Roux-en-Y gastric bypass. Rebandings were preferably done during the initial period of the study and Roux-en-Y gastric bypass in the last period. Both groups were comparable before the initial banding procedures. At the time of redo surgery, patients receiving a gastric bypass had more esophageal dysmotility (47% vs. 7%,P= 0.002) and higher body mass index (BMI) than those elected for rebanding procedures (BMI 42.0 vs. 38.4 kg/m2,P= 0.015). Feasibility and safety: Each procedure was performed laparoscopically. Mean operating time was 215 minutes for gastric bypass and 173 minutes for rebanding (P= 0.03). Early complications occurred in one case in the rebanding group and in 2 cases in the bypass group; all underwent a laparoscopic reexploration without the need for open surgery. There was no mortality in this series. Effectiveness: BMI in the gastric bypass group decreased from 42.0 to 31.8 kg/m2(P= 0.02) within 1 year of surgery, while it remained unchanged in the rebanding group.Conclusions:Laparoscopic conversion to a gastric bypass as well as laparoscopic rebanding are feasible and safe. Conversion to gastric bypass offers a significant advantage in terms of further weight loss after surgery. Therefore, this procedure should be considered as the rescue therapy of choice after a failed laparoscopic gastric banding.

ISSN:0003-4932    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Objective:To compare, in a prospective, randomized, single-institution trial laparoscopic adjustable silicone gastric banding (LASGB) with laparoscopic vertical banded gastroplasty (LVBG) in morbidly obese patients.Summary Background Data:LASGB is a simple and safe procedure, but some reports have suggested disappointing long-term results. Despite the recent widespread use of LASGB, there are no prospective nor randomized trials comparing LASGB with other laparoscopic procedures.Methods:A total of 100 morbidly obese patients, with body mass index (BMI) 40 to 50 kg/m2, without compulsive eating, were randomized to either LASGB (n = 49) or LVBG (n = 51). Minimum follow-up was 2 years (mean 33.1 months).Results:There were no deaths or conversions in either group. Mean operative time was 94.2 minutes in LVBGs and 65.4 in LASGBs (P< 0.05). Early morbidity rate was lower in LASGBs (6.1%) versus LVBGs (9.8%) (P= 0.754). Mean hospital stay was shorter in LASGBs versus LVBGs: 3.7 days versus 6.6 (P< 0.05). Late complications rate in LVBGs was 14% (7 of 50) and in LASGBs 32.7% (16 of 49) (P< 0.05). The most frequent complication was the slippage of the band (18%). Late reoperations rate in LVBGs was 0% (0 of 50) versus 24.5% (12 of 49) in LASGBs (P< 0.001). Excess weight loss in LVBGs was, at 2 years, 63.5% and, at 3 years, 58.9%; in LASGBs, excess weight loss, respectively, was 41.4% and 39%. BMI in LVBGs was, at 2 years, 29.7 kg/m2and, at 3 years, 30.7 kg/m2; in LASGBs, BMI was 34.8 kg/m2at 2 years and 35.7 kg/m2at 3 years. According to Reinhold's classification, a residual excess weight <50% was achieved, at 2 years, in 74% of LVBG and 35% of LASGB (P< 0.001).Conclusions:This study demonstrates that, in patients with BMI 40 to 50 kg/m2, LASGB requires shorter operative time and hospital stay but LVBG is more effective in terms of late complications, reoperations, and weight loss.

ISSN:0003-4932    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Objective:To evaluate the protective effects of ischemic preconditioning in a prospective randomized study involving a large population of unselected patients and to identify factors affecting the protective effects.Summary Background Data:Ischemic preconditioning is an effective protective strategy in several animal models. Protection has also been suggested in a small series of patients undergoing a hemihepatectomy with 30 minutes of inflow occlusion. Whether preconditioning confers protection in other types of liver resection and longer periods of ischemia is unknown. Therefore, we conducted a prospective randomized study to evaluate the impact of ischemic preconditioning in liver surgery.Methods:A total of 100 unselected patients undergoing major liver resection (> bisegmentectomy) under inflow occlusion for at least 30 minutes were randomized during surgery to either receive or not receive an ischemic preconditioning protocol (10 minutes of ischemia followed by 10 minutes of reperfusion). Univariate and multivariate analyses were performed to identify independent factors affecting the protective effects of ischemic preconditioning. ATP contents in liver were measured as a possible mechanism of protection.Results:Both groups (n = 50 in each) were comparable regarding age, gender, duration of inflow occlusion, and resected liver volumes. Postoperative serum transaminase levels were significantly lower in preconditioned than in control patients (median peak AST 364 U/L vs. 520 U/L,P= 0.028; ALT 406 vs. 519 U/L,P= 0.049). Regression multivariate analysis revealed an increased benefit of ischemic preconditioning in younger patients, in patients with longer duration of inflow occlusion (up to 60 minutes), and in cases of lower resected liver volume (<50%). Patients with steatosis were also particularly protected by ischemic preconditioning. ATP content in liver tissue was preserved by ischemic preconditioning in young but not older patients.Conclusions:This study establishes ischemic preconditioning as a protective strategy against hepatic ischemia in humans. The strategy is particularly effective in young patients requiring a prolonged period of inflow occlusion, and in the presence of steatosis, and is possibly related to preservation of ATP content in liver tissue. Other strategies are needed in older patients.

ISSN:0003-4932    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Objective:To present an institutional experience with the use of right liver grafts in adult patients and to assess the practicability and efficacy of this procedure by analyzing the results.Summary Background Data:Living donor liver transplantation (LDLT) for the pediatric population has gained worldwide acceptance. In the past few years, LDLT has also become feasible for adult patients due to technical evolution in hepatobiliary surgery and increased experience with reduced-size and split-liver transplants. Nevertheless, some graft losses remain unexplained and are possibly due to unrecognized venous outflow problems.Methods:From April 1998 to September 2002, we performed 74 right LDLTs (segments 5–8). The 74 donors were selected from 474 candidates according to standard protocol. The median age of the donors was 35 years (range 18–58 years) and 51 years (range 18–64 years) in recipients. Standard and extended indications for transplantation were considered. Over the period reported, technical modifications in the bile duct anastomosis (duct-to-duct, end-to-end, or end-to-side) and a new graft implantation technique that provides maximized venous outflow, leading to outcome improvement, were developed.Results:64.9% of patients had liver cirrhosis and 35.1% had malignancy. While 44 donors (59.5%) presented an uneventful postoperative course, 27% minor (pleural effusion, pneumonia, venous thrombosis, wound infection, incisional hernia) and 13.5% major (biliary leakage, death of a donor due to unrecognized hereditary liver disease, and consecutive liver insufficiency) complications were documented. In recipients, 23% biliary complications and 6.8% hepatic artery thrombosis occurred. The overall patient and graft survival rate after 1 year was 79.4% and 75.3%, respectively. In cases with extended indication, the patient survival rate was 74% and the graft survival rate 68% at 12 months. Using technical modifications in the last 10 recipients, including 2 critically decompensated cirrhotics, the survival rate was 100% at a median follow-up of 3.5 months.Conclusions:In our transplant program, living donor liver transplantation has become a standard option in the adult patient population. The critical issue of this procedure is donor morbidity. Technical improvements in the harvesting and implantation of right grafts can also offer hope to patients with challenging forms of end-stage liver disease or malignant liver tumors.

ISSN:0003-4932    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Objective:To define the technical factors that might contribute to hospital mortality of recipients of right lobe live donor liver transplantation (LDLT) so as to perfect the design of the operation.Summary Background Data:Right lobe LDLT has been accepted as one of the treatments for patients with terminal hepatic failure, but the design and results of the reported series vary and the technical factors affecting hospital mortality have not been known.Methods:The data of 100 adult-to-adult right lobe LDLT performed between 1996 and 2002 were prospectively collected and retrospectively analyzed. All grafts except one contained the middle hepatic vein, which was anastomosed to the recipient middle/left hepatic vein in the first 84 recipients and directly into the inferior vena cava (with the right hepatic vein in form of venoplasty) in the subsequent 15 patients. Venovenous bypass was used routinely in the first 29 patients but not subsequently.Results:Eight patients died within the same hospital admission for liver transplantation. There was no hospital mortality in the last 53 recipients. Comparison of data of patients with or without hospital mortality showed that graft weight/body weight ratio, graft weight/estimated standard liver weight ratio, technical error resulting in occlusion/absence of the middle hepatic vein, use of venovenous bypass, the lowest body temperature recorded during surgery, the volume of intraoperative blood transfusion, fresh frozen plasma, and platelet infusion were significantly different between the two groups. However, the pretransplant intensive care unit status of the recipients, cold and warm ischemic time of the graft, and occurrence of biliary complications were not. By multivariate analysis, low body temperature recorded during operation, low graft weight/estimated standard liver weight ratio (≤0.35), and the middle hepatic vein occlusion were independent significant factors in determining hospital mortality.Conclusions:To achieve a uniformly successful right lobe LDLT, the right lobe graft must contain a patent middle hepatic vein. With a completely patent middle hepatic vein, a graft size of >35% of the estimated standard graft weight may be sufficient for recipient survival. Hypothermia, which predisposes to coagulopathy and is enhanced by the use of venovenous bypass and massive blood, and blood product transfusion must be avoided.

ISSN:0003-4932    

出版商:OVID    

年代:2003

数据来源: OVID