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El presente artículo examina aquellas obras de arquitectura que reinterpretan en clave contemporánea estados de orden arraigados a lo largo de la historia de la arquitectura. Como estrategia básica de un estado de orden, el uso de la retícula ha sido uno de los sistemas de orden que ha caracterizado la evolución de la arquitectura. Lejos de ser una crítica a los sistemas consolidados, se intenta dar un paso más allá de la aparente seguridad que se ha mantenido al aplicar ciertas reglas de orden. En particular, esta reinterpretación supone una manipulación que altera específicamente el orden geométrico-estructural en el proyecto. Se intentará dilucidar que estas prácticas son resultado del uso de fuertes definiciones geométrico-estructurales como puntos de partida del proyecto, y no de procesos lúdicos y azarosos. Este nuevo patrón, que supone una estrategia de suavización y de intencionalidad poética, servirá para comprender el orden contingente en la arquitectura reciente.

En el presente artículo, se analiza la infracción aduanera de contravención, estatuida inicialmente en una ley del año 2010, pero que fue recogida en el Código Aduanero de la República Oriental del Uruguay, vigente desde marzo de 2015, y que tiene como finalidad reprimir la violación de determinadas normas que establecen deberes formales respecto de procedimientos aduaneros. En particular, se analizan las conductas atrapadas por el tipo, los requisitos para su imputación y sus consecuencias.

OBJECTIVES Bronchial anastomotic complications remain a major concern in lung transplantation. We aim to compare 2 different techniques, continuous suture (CS) versus interrupted suture (IS) by analysing airway complications requiring intervention. METHODS Lung transplantations between January 2015 and December 2020 were included. Airway complications requiring intervention were classified following the 2018 International Society for Heart and Lung Transplantation consensus and analysed comparing 3 groups of patients according to surgical technique: group A, both anastomosis performed with CS; group B, both with interrupted; and group C, IS for 1 side and CS for the contralateral side. RESULTS A total of 461 anastomoses were performed in 245 patients. The incidence of airway complications requiring intervention was 5.7% [95% confidence interval (CI): 2.8–8.6] per patient (14/245) and 3.7% (95% CI: 2.0–5.4) per anastomosis (17/461). Complications that required intervention were present in 5 out of 164 (3.1%) anastomosis with interrupted technique, and in 12/240 (5%) with CS. No significant differences were found between techniques (P = 0.184). No statistical differences were found among group A, B or C in terms of incidence of anastomotic complications, demographics, transplant outcomes or overall survival (log-rank P = 0.513). In a multivariable analysis, right laterality was significantly associated to complications requiring intervention (OR 3.7 [95% CI: 1.1–12.3], P = 0.030). Endoscopic treatment was successful in 12 patients (85.7%). Retransplantation was necessary in 2 patients. CONCLUSIONS In summary, although it seems that anastomotic complications requiring intervention occur more frequently with CS, there are no statistical differences compared to IS. Endoscopic treatment offers good outcomes in most of the airway complications after lung transplantation.

OBJECTIVES Controlled donation after circulatory death (cDCD) donors are becoming a common source of organs for transplantation globally. However, the graft survival rate of cDCD abdominal organs is inferior to that of organs from brain-dead donors. The rapid retrieval (RR) technique is used by most donor organ procurement teams. The abdominal normothermic regional perfusion (A-NRP) technique has been implemented to minimize warm ischaemic damage to the abdominal organs. However, there is limited information on the effect of A-NRP on the quality of the donor lungs. This study aimed to compare lung transplantation outcomes using lungs procured from cDCD donors using the A-NRP and abdominal RR techniques. METHODS A single-centre retrospective analysis of consecutive transplant recipients of cDCD lungs from June 2013 to December 2019 was performed. The recipients were divided into 2 cohorts according to the abdominal procurement technique used. The recipient and donor characteristics (age, sex, cause of brain injury, warm ischaemic time, diagnosis, lung allocation score and other factors), incidence of primary graft dysfunction and early survival were monitored. RESULTS Twenty-eight consecutive lung transplantation recipients were identified (median age 59 years; 61% male); 14 recipients received lungs using the A-NRP and 14 using abdominal RR for abdominal organ retrieval. There were no significant differences in the baseline characteristics, primary graft dysfunction (P = 0.70), hospital mortality (P = 1.0) and 1-year survival rate (P = 1.0) between the 2 groups. CONCLUSIONS No difference was observed in lung transplantation outcomes irrespective of the abdominal organ procurement technique used (A-NRP or abdominal RR).

OBJECTIVES We reviewed the incidence of coronavirus disease 2019 cases and the postoperative outcomes of patients who had thoracic surgery during the beginning and at the highest point of transmission in our community. METHODS We retrospectively reviewed patients who had undergone elective thoracic surgery from 12 February 2020 to 30 April 2020 and were symptomatic or tested positive for severe acute respiratory syndrome coronavirus 2 infection within 14 days after surgery, with a focus on their complications and potential deaths. RESULTS Out of 101 surgical procedures, including 57 primary oncological resections, 6 lung transplants and 18 emergency procedures, only 5 cases of coronavirus disease 2019 were identified, 3 in the immediate postoperative period and 2 as outpatients. All 5 patients had cancer; the median age was 64 years. The main virus-related symptom was fever (80%), and the median onset of coronavirus disease 2019 was 3 days. Although 80% of the patients who had positive test results for severe acute respiratory syndrome coronavirus 2 required in-hospital care, none of them were considered severe or critical and none died. CONCLUSIONS These results indicate that, in properly selected cases, with short preoperative in-hospital stays, strict isolation and infection control protocols, managed by a dedicated multidisciplinary team, a surgical procedure could be performed with a relatively low risk for the patient., Since the outbreak of the novel coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in Wuhan, China [1], over 4.9 million cases have been diagnosed around the world [2].

El presente artículo pretende hacer foco en algunas cuestiones del proceso judicial por infracciones aduaneras en Uruguay, en particular, se reflexiona en torno al contenido del Derecho Aduanero y a las infracciones aduaneras. Se analiza el contenido, necesidad y finalidad del Proceso Aduanero por Infracciones Aduaneras editado por el Código Aduanero de la República Oriental del Uruguay. Asimismo, mediante un análisis de las características de su contenido, se proponen recalificaciones a su pretendida ubicación como Proceso Civil, reconociéndolo como Proceso “Aduanero”, y con ello, como una categoría dentro de los Procesos Sancionatorios. Se analiza el objeto del Proceso Aduanero y su vinculación con la pretensión, para determinar que el mismo se forma progresivamente hasta su fijación en la Demanda Acusación Fiscal. This paper focuses on some issues regarding the judicial process for customs offenses in Uruguay, particularly, it reflexes about the content of Customs Law and customs offenses. The content, necessity and purpose of the customs offenses judicial process ruled by the Uruguayan customs code are analyzed. Also, through the assessment of the characteristics of the process, rectifications to its pretended ubication like a civil process are proposed, re-qualifying it as the "customs" process, falling as a category within the sanctionatory process. There is also an analysis of the object of the process, assessing its relationship with the claim, in order to determine if the claim is progressively construed throughout the process until its final determination in the State's representative accusation.

The Airborne Wind Energy (AWE) is a growing field of research that intends to develop solutions for harvesting wind energy using airborne vehicles. The main advantage of this concept is the capability to explore high altitude winds, which are typically stronger and less variable than in low altitudes. In addition, airborne vehicles tend to require only a fraction of infrastructure costs, when compared with the traditional wind turbines. One usual AWE design is the Leading Edge Inflatable (LEI) kites. In the current Airborne Wind Energy (AWE) literature, many modeling strategies for the dynamics of tethered wings are proposed. Important works explored the typical ground generation AWE system with flexible LEI wings, adopting a variety of combinations of wing structural, aerodynamic and tether models. Notably, flexible LEI wings have already been modeled using membrane and inflatable beam elements. The time-integration scheme included a static structural solution at each time step and simplified aerodynamic and tether models. On the other hand, the studies on flexible aircraft dynamics have been a well established subject of research. A useful idea in modeling flexible aircraft is adding the equations of the elastic degrees of freedom (DOFs) using modal coordinates. Aerodynamic forces can be provided by low fidelity methods. As LEI wings are usually very flexible structures, it emerges an opportunity to apply this same methodology to the AWE systems. Additionally, the tether dynamics can be included, taking into account the effects of flexibility, weight distribution and drag forces over the tether. This work will present an approach that unifies: 1) Flight dynamics, with the classical rigid-body 6 DOFs; 2) Structural dynamics, with wing elastic DOFs in modal coordinates; 3) Tether dynamics, including the DOFs of the flexible tether, as well as the control inputs in the bridle lines; and 4) Quasi-steady aerodynamics, using a Vortex Lattice Method (VLM) implementation, resulting in a seamless integration framework. Therefore, this work intends to bring to AWE an application of an established knowledge in the flexible aircraft dynamics, in order to provide a suitable methodology for the dynamics of a flexible tethered wing. A generic LEI kite design is studied. The mode shapes and frequencies are obtained via Finite Element Method (FEM).

Según temáticas patológicas farmacológicas y lesiones musculoesqueléticos, se indago en la necesidad de conocer las consecuencias que pueden influir en la salud de personas del común las consecuencias del consumo de sustancias, anabólicas, androgénicas o esteroides frente a la salud y las lesiones permanentes del sistema musculoesquelético frente a un mal asesoramiento. Para esto, se aplicó una encuesta cuantitativa de 20 preguntas donde 14 de ellas buscan indagar qué conocimiento se tiene frente a los procesos adecuados de prescripción del ejercicio. Una vez reunida la información, esta permitió analizar el desconocimiento del usuario frente al asesoramiento y los procesos adecuado que lleva practicar algún deporte o realizar actividad física si el debido conocimiento anterior a este. Se plantean como conclusiones empíricas que determinan en qué puntos relevantes se tiene falencia como entrenado y bajo qué parámetros se puede atender las necesidades de gozar de un buen estado físico, tener una buena salud o, incluso, llegar a un punto de profesionalización de la práctica deportiva. Por consiguiente, lo que impone un entrenador no es entrenado bajo su experiencia como exatleta ni gozando una composición corporal admirable, esto no determina que se debe contar con un conocimiento técnico dado por instituciones universitarias para poder imponer y compartir información con una persona del común.

OBJECTIVES Most transplant centres use donation after brain death (DBD) criteria to assess the quality of controlled donation after circulatory death (cDCD) lungs. However, research on the relationship between DBD extended criteria and cDCD lung transplantation outcomes is limited. We investigated the outcomes of using DBD extended criteria donor organs in cDCD lung transplantation, compared to the standard criteria cDCD lung transplantation. METHODS A retrospective chart review of consecutive cDCD lung referrals to Hospital Universitario Puerta de Hierro-Majadahonda from June 2013 to December 2019 was undertaken. Donors were divided into standard and extended criteria groups. Early outcomes after lung transplant were compared between these groups using the Kaplan–Meier method and log-rank test. RESULTS Thirty out of 91 cDCD donor lung offers were accepted for transplantation, of which 11 were from standard criteria donors and 19 were extended criteria donors. The baseline characteristics of the 2 recipient groups were similar. There were no differences in the rates of grade 3 primary graft dysfunction at 72 h after lung transplantation (21% vs 18%), duration of mechanical ventilation (48 h vs 36 h), total intensive care unit stay (10 days vs 7 days) and 1-year survival (89% vs 90%). CONCLUSIONS Carefully selecting cDCD lungs from outside the standard acceptability criteria may expand the existing donor pool with no detrimental effects on lung transplantation outcomes.

There are six major airway complications after lung transplantation: necrosis/dehiscence; infection; bronchial stenosis; granuloma tissue formation; tracheobronchomalacia; and fistula. Although their frequency has decreased in the recent past, such complications are associated with significant morbidity, reduction of quality of life, and an increased economic cost. Many risk factors have been described, ranging from surgical technique to immunosuppressive regimen. Bronchial stenosis is the most common airway complication. Options for treatment of symptomatic patients include dilation, bronchoscopic removal of scar tissue, stenting, and resection and reanastomosis. Dilation via balloon bronchoplasty, with or without scar tissue resection, is the safest and most effective first-line intervention. Stenting may be considered for stenosis refractory to dilation. Surgery is the most aggressive option and should be reserved for patients who have failed other interventions.

Airway complication (AC) after lung transplant, although rare nowadays, leads to increased costs, greater morbidity, and decreased quality of life of patients. Over the years, many risk factors have been described, ranging from surgical technique to immunosuppressive regimen. There are essentially 6 major airway complications (necrosis/dehiscence, infection, bronchial stenosis, granulomas, tracheo-bronchomalacia, and fistula) all of which require a multidisciplinary approach based on the performance status of patients. In this article, the authors review the risk factors, clinical presentation, diagnosis methods, and management options in the most common AC after lung transplantation.

Survival rates in patients with stage IIIA non-small cell lung cancer (NSCLC) remain low despite curative treatment. This is due to tumor recurrence at distant sites. The aim of neoadjuvant chemotherapy (NA-CT) is to eradicate occult micrometastatic disease and improve survival in patients that are not candidates for surgery following induction therapy. A total of 21 patients with ipsilateral mediastinal node involvement (N2) with potentially resectable disease, who had been diagnosed with stage IIIA (T1-3 N1-2 and T4N0) NSCLC and who had received cisplatin and vinorelbine as induction treatment were included in this retrospective study. Patients who responded to the treatment underwent surgery, and those who were unresponsive received radical radiotherapy. Follow-up was conducted between March 2008 and April 2014. The median age of patients was 61 years, and all patients exhibited a good Eastern Cooperative Oncology Group performance status. The majority of patients were histologically diagnosed with adenocarcinoma (48%) or squamous cell carcinoma (38%), which was a poor prognostic factor for overall survival (OS). A total of 7 patients underwent surgery (of which 6 were down-staged), with a 3-year survival rate of 42.8%. The most significant factor associated with response to induction treatment was multistation nodal involvement. The complete resection rate for surgical patients was 85.7%. Unresectable patients had a 3-year survival rate of 25.8%. OS time for the whole cohort was 28.5 months, and the 3- and 5-year OS rates were 28.5% and 4.7%, respectively. CT-induced toxicity did not affect any treatment regime or surgical procedures. In conclusion, the use of cisplatin plus vinorelbine is feasible in a neoadjuvant setting, with good response rates and acceptable toxicity. Multistation N2 involvement is the main prognostic factor for a poor response to induction treatment.

espanolEl presente articulo aborda el estudio del regimen de responsabilidad objetiva que subsiste en materia infraccional aduanera, los fundamentos sostenidos para su existencia o pervivencia, y sus consecuencias. Asimismo, se desarrollan los argumentos contrarios a dicho regimen de imputacion de la responsabilidad. Asi, y partido de ello, se tratan de encontrar soluciones juridicas que, sin vulneren los derechos de los administrados al juzgar las infracciones aduaneras, permitan resolver el fundamento de su sustitucion, y ello, mediante un correcto establecimiento de presunciones legales relativas que permitan presumir la intencion, cuando ella sea de dificil comprobacion para el Fisco. EnglishThis paper analyzes the strict liability system surviving in customs infringement procedures, the grounds for its existence or survival and its consequences. Also, the arguments against such system of liability attribution are examined. Thus, from such starting point, through a precise enumeration of statutory rebuttable presumptions whose intention can be presumed whenever it is difficult for Tax Authorities to prove such presumptions, I intend to find legal solutions to determine the grounds for its replacement without affecting the rights of the relevant individuals or legal entities when the customs infringements are decided.

Bronchiolitis obliterans (BO) is the most common expression of chronic allograft dysfunction in lung transplantation. Moreover, BO represents the major cause of death in the long-term after this procedure. On the other hand, mesenchymal stem cells have been tested in animal models of BO aiming to interfere in its development. The aim of this experimental study is to explore the role of bone-marrow derived stem cells (BMSCs) as a preventive intervention of BO occurrence.This an experimental randomized study. A bronchiolitis obliterans animal model in rats was reproduced: heterotopical tracheal transplant model in lung parenchyma. Five of these animals were used as control group. After setting up the model, individuals were divided in 3 groups of treatment (n=15), in which BMSCs were administered in 3 different time points after the tracheal transplant (tracheal transplantation and BMSCs administration occurred the same day, group G0; after 7 days, group G7; after 14 days, group G14. In addition, within each group, BMSCs were administered through 3 different routes: endotracheally, endovascular and topically in the lung parenchyma). Animals were sacrificed at 21 days. Histology, fluorescence in situ hybridization and immunohistochemistry techniques were performed for identifying stem cells.Compared to control group, animals receiving BMSCs showed large neovessels in a loose fibrous matrix. Group G7 showed less fibrosis (p0.033) and edema (p0.028). Moreover, G7 animals receiving stem cells endotracheally showed no fibrosis (p0.008). Alveolar-like patches of tissue were observed among all groups (53.4%, 46.7% and 40% in G0, G7 and G14 respectively), consisting of cells expressing both stem and alveolar cells biomarkers.BMSCs modify the course of bronchiolitis obliterans and differentiate into alveolar cells. Endotracheal administration of BMSCs 7 days after the heterotopical tracheal transplant might be considered an effective way to prevent BO in this animal model.

Introduction The aim of this study is to demonstrate our experience at a volunteer surgical program in Cameroon, which is of special interest given to the inability to adopt international treatment guidelines for thyroid surgery in areas of limited resources due to the lack of preoperative testing and to the difficulty to obtain sustitutive hormonal treatment. Methods This is a prospective observational study that includes 16 cases of thyroid surgery in Dschang (Cameroon) during June 2015. The patients were previously selected by a local medical team. All patients were black, 15 women and one man, with a mean age of 41 years. The surgical technique used for the removal of unilateral disease was hemithyroidectomy with isthmectomy and bilateral subtotal thyroidectomy for bilateral disease. Results Five subtotal thyroidectomies, 9 hemithyroidectomies and 2 isthmectomies were performed. Prethyroid muscles were divided only in one case. We visualized 86% of the parathyroid glands and 84% of the recurrent laryngeal nerves. The main complications observed were one symptomatic cervical hematoma that required reoperation and 2 surgical wound infections. There were no clinical episodes of hypocalemia or recurrent nerve lesion. The mean length of stay was 2.3 days. At follow-up, all bilateral thyroidectomies developed high TSH levels. Conclusions Thyroid surgery is safe in developing countries adopting protocols and techniques we use in our environment (avoiding total thyroidectomy). Bilateral thyroidectomies should not be performed unless functional studies are available in the follow-up and a thyroid hormone supplement stock guaranteed whenever necessary.

Resumen Introduccion Nuestro objetivo es describir la experiencia adquirida en un programa de cooperacion dedicado a la cirugia tiroidea en Camerun. Su interes radica en la imposibilidad para seguir las guias internacionales de tratamiento en areas de recursos imitados debido a la falta de estudios preoperatorios y a la dificultad para conseguir medicacion hormonal sustitutiva de por vida. Metodos Estudio observacional de una cohorte de 16 pacientes operados de enfermedad tiroidea en Dschang (Camerun) en junio de 2015. La tecnica quirurgica empleada fue la hemitiroidectomia con istmectomia en la enfermedad unilateral y la tiroidectomia subtotal bilateral en la enfermedad bilateral. Resultados Todos los pacientes eran de raza negra, 15 mujeres y un hombre, con edad media de 41 anos. Se realizaron 5 tiroidectomias subtotales, 9 hemitiroidectomias y 2 istmectomias. Cuatro pacientes presentaban componente intratoracico. Fue necesaria la seccion de musculos pretiroideos en un caso. Se visualizaron las glandulas paratiroides y los nervios laringeos recurrentes en el 86 y el 84% de los casos, respectivamente. Se dejaron drenajes en 7 casos y la mediana de duracion de la intervencion fue de 75 min. Como complicaciones cabe destacar un hematoma cervical que preciso reintervencion y 2 infecciones de herida quirurgica. No hubo hipocalcemias clinicas ni lesiones recurrenciales apreciables. La estancia media fue de 2,3 dias. A largo plazo, los pacientes con tiroidectomias bilaterales presentaban niveles elevados de TSH. Conclusiones La cirugia tiroidea en paises subdesarrollados, adaptando los protocolos y tecnicas que utilizamos en nuestro medio (evitando la tiroidectomia total), tiene una tasa de complicaciones asumible. No deben realizarse tiroidectomias bilaterales salvo que se disponga de estudios funcionales y se asegure previamente la disponibilidad de la hormona tiroidea.

Chest wall resection and reconstruction for neoplastic diseases has unique oncologic, structural, and functional challenges. In a young and fit patient with a mediastinal mass and extensive anterior chest wall invasion, purely structural solutions were deemed insufficient. We hereby present a novel three-dimensionally printed patient-specific titanium implant of sternum and ribs. This osteointegrable implant was designed with biomechanical capabilities using a unique "Greek wave" folding pattern. Postoperative dynamic computed tomography showed that the implant allowed for controlled flexing during the respiratory cycle. Three-dimensional printing with biocompatible materials could enable a new generation of chest wall implants strongly focused on functional reconstruction.

Uncontrolled donation after cardiac death is an appealing source of organs for lung transplantation. We compare early and long-term outcomes of lung transplantation with these donors with a cohort of transplants from brain death donors at our institution. Retrospective analysis of all lung transplantations was performed from 2002 to 2012. We collected variables regarding recipients, donors, recover and transplant procedures, early and late complications, and survival. We included 292 lung transplants from brain death donors and 38 from uncontrolled donors after cardiac death. Both groups were comparable except for sex mismatch (male recipient-female donor was more frequent in the brain death cohort, 17.8% vs 0%, P 0.002), total ischemic time (longer for donors after cardiac death, 657 minutes for the first lung and 822 minutes for the second vs 309 and 425 minutes, P

Summary Background Severe primary graft dysfunction (PGD) of grade 3 (PGD3) is a common serious complication following lung transplantation. We aimed to assess physiological donor lung preservation using the Organ Care System (OCS) Lung device compared with cold static storage. Methods In this non-inferiority, randomised, controlled, open-label, phase 3 trial (INSPIRE) recipients were aged 18 years or older and were registered as standard criteria primary double lung transplant candidates. Eligible donors were younger than 65 years old with a ratio of partial pressure of oxygen in arterial blood to the fraction of inspired oxygen of more than 300 mm Hg. Transplant recipients were randomly assigned (1:1) with permuted blocks, stratified by centre, to receive standard criteria donor lungs preserved in the OCS Lung device (OCS arm) or cold storage at 4°C (control arm). The composite primary effectiveness endpoint was absence of PGD3 within the first 72 h after transplant and 30-day survival in the per-protocol population, with a stringent 4% non-inferiority margin. Superiority was tested upon meeting non-inferiority. The primary safety endpoint was the mean number of lung graft-related serious adverse events within 30 days of transplant. We did analyses in the per-protocol and intention-to-treat populations. This trial is registered with ClinicalTrials.gov, number NCT01630434. Findings Between Nov 17, 2011, and Nov 24, 2014, we randomly assigned 370 patients, and 320 (86%) underwent transplantation (n=151 OCS and n=169 control); follow-up was completed in Nov 24, 2016. The primary endpoint was met in 112 (79·4%) of 141 patients (95% CI 71·8 to 85·8) in the OCS group compared with 116 (70·3%) of 165 patients (62·7 to 77·2) in the control group (non-inferiority point estimate −9·1%; 95% CI −∞ to −1·0; p=0·0038; and superiority test p=0·068). Patient survival at day 30 post-transplant was 135 (95·7%) of 141 patients (95% CI 91·0–98·4) in the OCS group and 165 patients (100%; 97·8–100·0) in the control group (p=0·0090) and at 12 months was 126 (89·4%) of 141 patients (83·1–93·9) for the OCS group compared with 146 (88·1%) of 165 patients (81·8–92·8) for the control group. Incidence of PGD3 within 72 h was reported in 25 (17·7%) of 141 patients in the OCS group (95% CI 11·8 to 25·1) and 49 (29·7%) of 165 patients in the control group (22·8 to 37·3; superiority test p=0·015). The primary safety endpoint was met (0·23 lung graft-related serious adverse events in the OCS group compared with 0·28 events in the control group [point estimate −0·045%; 95% CI −∞ to 0·047; non-inferiority test p=0·020]). In the intention-to-treat population, causes of death at 30 days and in hospital were lung graft failure or lung infection (n=2 for OCS vs n=7 for control), cardiac causes (n=4 vs n=1), vascular or stroke (n=3 vs n=0), metabolic coma (n=0 vs n=2), and generalised sepsis (n=0 vs n=1). Interpretation The INSPIRE trial met its primary effectiveness and safety endpoints. Although no short-term survival benefit was reported, further research is needed to see whether the reduced incidence of PGD3 within 72 h of a transplant might translate into earlier recovery and improved long-term outcomes after lung transplantation. Funding TransMedics Inc.

Resumen Debido a que los resultados del trasplante pulmonar son todavia inferiores a los obtenidos en otros trasplantes como el cardiaco, el renal o el hepatico, los retos de la medicina se deben centrar en aumentar la supervivencia funcional de los injertos. La intervencion provoca marcados cambios fisiopatologicos posquirurgicos a nivel del parenquima pulmonar, la caja toracica, las vias aereas y la circulacion pulmonar. No obstante, el paciente esta sometido a riesgos que es importante conocer y controlar, como las complicaciones atribuibles total o parcialmente al tratamiento inmunosupresor, entre ellas la patologia cardiovascular, la aparicion de tumores, infecciones y, por supuesto, la disfuncion cronica del injerto. El pronostico del paciente va a depender, en gran medida, de la mayor o menor eficacia en prevenir, diagnosticar precozmente y en su caso tratar de forma adecuada las posibles complicaciones. Por ello, independientemente del tiempo postrasplante, los receptores son sometidos a una estrecha monitorizacion funcional y clinica. En este articulo revisaremos las alteraciones funcionales caracteristicas del receptor de un trasplante pulmonar y la utilidad en el seguimiento del paciente de las diferentes tecnicas diagnosticas.

Although the number of lung transplants in Spain is increasing annually, more organs are required to ease waiting lists. Controlled non-heart beating donors (cNHBD) (Maastricht III) are a reality at international level, and contribute significantly to increasing donor numbers. In this study, we present our cNHBD protocol and the initial experience in Spain using lung grafts from this type of donor. Three bilateral lung transplants were performed between January 2012 and December 2014. Preservation was by ex vivo lung perfusion in 2 cases and by traditional cold perfusion in the other. None of the patients developed grade 3 primary graft dysfunction, no in-hospital mortality was recorded and 1-year survival was 100%. These initial results, and international experience, should help to develop similar protocols to encourage the use of controlled non-heart beating donors.

Although the number of lung transplants in Spain is increasing annually, more organs are required to ease waiting lists. Controlled non-heart beating donors (NHBD) (Maastricht III) are a reality at international level, and contribute significantly to increasing donor numbers. In this study, we present our NHBD protocol and the initial experience in Spain using lung grafts from this type of donor. Three bilateral lung transplants were performed between January 2012 and December 2014. Preservation was by ex-vivo lung perfusion in 2 cases and by traditional cold ischemia in the other. None of the patients developed grade 3 primary graft dysfunction, no in-hospital mortality was recorded and 1-year survival was 100%. These initial results, and international experience, should help to develop similar protocols to encourage the use of controlled non-heart beating donors.

Resumen El Registro Espanol de Trasplante Pulmonar (RETP) inicio su actividad en 2006, participando en el todos los equipos de trasplante pulmonar (TP) con un programa activo en Espana. Este informe presenta por primera vez de forma global la descripcion y resultados de los pacientes trasplantados de pulmon en Espana entre los anos 2006 y 2010. La actividad de TP ha ido en progresivo aumento, trasplantandose en este periodo 951 adultos y 31 ninos. La media de edad del receptor fue de 48,2 anos, siendo 41,7 anos en el donante pulmonar. En el TP adulto, la causa mas frecuente de trasplante fue el enfisema/EPOC, seguido de la fibrosis pulmonar idiopatica, representando ambas mas del 60% del total de las indicaciones. La probabilidad de supervivencia tras el TP adulto a uno y 3 anos es del 72 y del 60%, respectivamente, si bien en los pacientes que sobreviven al tercer mes postrasplante estas supervivencias son del 89,7 y del 75,2%. Los factores que mas claramente inciden en la supervivencia del paciente son la edad del receptor y el diagnostico que indico el trasplante. En los trasplantes pediatricos, la fibrosis quistica es la principal causa de trasplante (68%), y la supervivencia al ano es del 80, y del 70% a los 3 anos. Tanto en el trasplante adulto como en el pediatrico, la causa mas frecuente de fallecimiento es la infeccion. Estos datos confirman la consolidacion del TP en Espana como una opcion terapeutica para la enfermedad respiratoria cronica avanzada, tanto en ninos como en adultos.

Introduction: The scarcity of grafts remains to be the major limitation in lung transplantation. Uncontrolled non-heart-beating donors (UNHBDs) represent one way to alleviate this problem. Objectives: We present the early and late results of lung transplantation from UNHBDs and compare the outcomes with the recipient cohort receiving lungs from brain dead donors (BDDs). Methods: Between January 2002 and December 2012, 38 (11.5%) of the 330 lung transplantation performed in our institution used lungs from UNHBDs. Early and late outcomes for this recipient cohort were compared with those for recipients who received organs from BBDs (292 patients) over a median follow up of 41.7 months (0.3-133) for UNHBDs and 41 months (0.3-142.3) for BDDs (NS). Results: The incidence of primary graft dysfunction grade 3 (PGD3) in the UNHBDs group was similar to that of the BDDs group (p=0.17). The patient survival rates at 3 months, 1 year, 3, 5 and 10 years were 81.6%, 71.1%, 60.3%, 50.8% and 16.5% for the UNHBDs group and 80.5%, 75%, 66%, 58.4% and 38.1% for the BDDs groups (NS). Freedom from chronic lung allograft dysfunction (CLAD) at 1, 3, 5 and 10 years in the UNHBDs group was 96.3%, 76.6%, 54% and 27% respectively, and did not differ from the incidence of CLAD in the BDDs group (p=0.49). Conclusions: In our experience, both early and late results in UNHBDs lung transplantation were comparable to those with BDDs. Our findings support that the use of lungs from UNHBDs is safe and could substantially expand the donor pool for lung transplantation.

Introduction Bronchiolitis obliterans (BO) is the major cause of death in lung transplantation after 1 year. On the other hand, mesenchymal stem cells (MSC) have shown to participate in reparative processes. Objectives To reproduce a BO animal model and assess the effect of MSC for preventing the histologic lesion. Methods We developed an heterotopic tracheal transplantation rat model of BO. BO lesion was successfully reproduced at day 21 (control group). Then, we transplanted in 45 rats bone marrow-derived MSC through 3 routes (topical, endotracheal, endovascular) and at 3 time points (same day of tracheal grafting, at day 7 and 14) [5 individuals each group]. Variables: grade of tracheal lumen obliteration, fibrosis, neovascularization, histologic pattern. Flourescence In Situ Hibridation (FISH) and Inmunohistochemistry (IHQ) were used to detect MSC. Results All MSC groups had significant differences in histologic pattern with regard to control group (p 0.006), showing more neovessels and less fibrosis. The group who received MSC at day 7 presented less fibrosis (p 0.033), and the subgroup who received MSC at day 7 by endotracheal route showed less fibrosis and grade of lumen obliteration (p 0.048). FISH-IHQ showed MSC expressing type II neumocite markers and were localized into a neoformed alveolar-like tissue. Conclusions Reproducibility of a BO animal model is feasible. MSC transplanted in that model are able to modify the typical BO lesion, so a reparative effect might be attributed to MSC. Expression of a neumocite marker by MSC localized in neo alveolar-like tissue shows a certain degree of regenerative effect. Endotracheal route appears to be the best one to MSC transplantation.

Summary Background Cold flush and static cold storage is the standard preservation technique for donor lungs before transplantations. Several research groups have assessed normothermic perfusion of donor lungs but all devices investigated were non-portable. We report first-in-man experience of the portable Organ Care System (OCS) Lung device for concomitant preservation, assessment, and transport of donor lungs. Methods Between Feb 18, and July 1, 2011, 12 patients were transplanted at two academic lung transplantation centres in Hanover, Germany and Madrid, Spain. Lungs were perfused with low-potassium dextran solution, explanted, immediately connected to the OCS Lung, perfused with Steen's solution supplemented with two red-cell concentrates. We assessed donor and recipient characteristics and monitored extended criteria donor lung scores; primary graft dysfunction scores at 0, 24, 48, and 72 h; time on mechanical ventilation after surgery; length of stays in hospital and the intensive-care unit after surgery; blood gases; and survival of grafts and patients. Findings Eight donors were female and four were male (mean age 44·5 years, range 14–72). Seven recipients were female and five were male (mean age 50·0 years, range 31–59). The preharvest donor ratio of partial pressure of oxyen (PaO 2 ) to fractional concentration of oxygen in inspired air (F I O 2 ) was 463·9 (SD 91·4). The final ratio of PaO 2 to F I O 2 measured with the OCS Lung was 471·58 (127·9). The difference between these ratios was not significant (p=0·72). All grafts and patients survived to 30 days; all recipients recovered and were discharged from hospital. Interpretation Lungs can be safely preserved with the OCS Lung, resulting in complete organ use and successful transplantation in our series of high-risk recipients. In November, 2011, we began recruitment for a prospective, randomised, multicentre trial (INSPIRE) to compare preservation with OCS Lung with standard cold storage. Funding TransMedics and German Federal Ministry of Education and Research.

Background The aim of our study is to review and update the long-term results from our previously published series of lung transplantation in uncontrolled non–heart-beating donors (NHBDs). Methods A prospective collection of data was undertaken from all lung transplants performed among uncontrolled NHBDs between 2002 and December 2009. The statistical analysis was performed using SPSS software and survival was estimated using the Kaplan–Meier method. Results Twenty-nine lung transplants were performed. Mean total ischemic times for the first and second lung were 575 minutes (SD 115.6) and 701 minutes (SD 111.3), respectively. Primary graft dysfunction (PGD) G1, G2 and G3 occurred in 5 cases (17%), 5 cases (17%) and 11 cases (38%), respectively. Overall hospital mortality rate was 17% (5 patients). Statistical analysis revealed a statistically significant association of mortality with ischemic times and with PGD. In terms of overall survival, 3-month, 1-year, 2-year and 5-year survival rates were 78%, 68%, 57% and 51%, respectively, and the conditional survival rates in those who survived the first 3 months were 86%, 72% and 65%, respectively. The cumulative incidence of bronchiolitis obliterans syndrome (BOS) was 11%, 35% and 45% at 1, 3 and 5 years, respectively. Conclusions Lung transplantation from uncontrolled non–heart-beating donors shows acceptable results for both mid- and long-term survival and BOS; however, the higher rates of PGD and its impact on early mortality must make us more demanding with respect to the acceptance criteria and methods of evaluation used with these donors.

Resumen Introduccion El trasplante microquirurgico de pulmon en ratas ha permitido adquirir nuevos conocimientos sobre el trasplante de pulmon. Sin embargo, algunos aspectos de la tecnica de trasplante en humanos aun no han sido incluidos en este modelo, lo que podria interferir en la interpretacion clinica y en la extrapolacion de los resultados. Metodo Se han realizado 20 trasplantes pulmonares izquierdos con la tecnica de manguitos (cuff) incorporando algunas modificaciones tecnicas como la induccion de la muerte cerebral, el control del tiempo de isquemia, la perfusion retrograda en el donante y la reperfusion secuencial controlada del pulmon implantado en el receptor. Resultados La supervivencia ha sido del 80%. Los pulmones trasplantados mostraron una adecuada perfusion y ventilacion con buena permeabilidad de las anastomosis. Se han observado signos de isquemia-reperfusion en todos los animales, y de rechazo agudo leve en la mitad de ellos. Conclusiones El modelo que presentamos es valido y similar al procedimiento que se realiza en humanos, lo que reduciria el numero de posibles variables derivadas de la tecnica quirurgica a la hora de extrapolar los resultados a la clinica.

Introduction Uncontrolled donation after cardiac death (DACD) has become an alternative to lung transplantation with encephalic-death donation. The main objective of this study is to describe the incidence of clinically relevant events in the period of 30 days after lung transplant with uncontrolled DACD and the influence of factors depending on the donor and donation process as well. Patients and methods Historical cohort study of 33 lung transplant receivers at Hospital Puerta de Hierro and Hospital Marques de Valdecilla with 32 DACD from Hospital Clinico San Carlos from 2002 to 2008. We studied surgical and medical complications, primary graft dysfunction, acute rejection, pneumonia, and mortality. We made an evaluation of the donor characteristics and donation procedure times (min). Results Median age of recipients was 50.5 years (interquartile range, 38.5–58). There were 28 males and 5 females. Cumulative incidence of events in the first month was: pneumonia, 10 (31.3%); primary graft dysfunction, 15 (46.9%); rejection, 12 (37.5%); mortality, 4 (12.1%); medical complications, 25 (78.1%); and surgical complications, 18 (56.3%). Median time of cardiac arrest was higher in those who presented pneumonia (15 vs 7.5; P =.027). Median time of cold ischemia was higher in those who presented surgical complications and mortality (436 vs 343.5; P =.04; 505 vs 410; P =.033, respectively), and median of total ischemia times were longer in the recipients who died (828 vs 695; P =.036). Conclusions Uncontrolled DACD is a valid alternative for expanding the donor pool in order to mitigate the current shortage of lungs that are valid for transplantation. The incidence of complications is comparable with published data in the literature.

Resumen Introduccion La donacion en asistolia no controlada (DANC) constituye una alternativa al trasplante pulmonar con donantes en muerte encefalica. El objetivo principal del estudio es describir la incidencia de eventos al mes tras el trasplante con pulmones de DANC, y la influencia de los factores dependientes del donante y del proceso de donacion. Pacientes y metodos Estudio de una cohorte historica de 33 receptores de trasplante pulmonar realizados en los hospitales Puerta de Hierro y Marques de Valdecilla con 32 DANC procedentes del Hospital Clinico San Carlos durante el periodo 2002-2008. Se estudiaron los siguientes eventos: complicaciones quirurgicas y medicas, disfuncion primaria del injerto, rechazo agudo, neumonia y mortalidad. Se evaluaron las caracteristicas del donante y los tiempos del proceso de donacion (minutos). Resultados La mediana de edad de los receptores fue 50,5 anos (rango intercuartilico, 38,5-58); 28 hombres y 5 mujeres. La incidencia acumulada de los eventos al mes fue: neumonia, 10 (31,3%); disfuncion primaria del injerto, 15 (46,9%); rechazo, 12 (37,5%); mortalidad, 4 (12,1%); complicaciones medicas, 25 (78,1%), y quirurgicas, 18 (56,3%). La mediana del tiempo de asistolia fue mayor en los sujetos con neumonia (15 vs. 7,5; p = 0,027), la mediana del tiempo de isquemia fria fue superior en los sujetos que presentaron complicaciones quirurgicas y mortalidad (436 vs. 343,5; p = 0,04; 505 vs. 410; p = 0,033, respectivamente), y las medianas de los tiempos de isquemia total fueron superiores en los receptores que fallecieron (828 vs. 695; p = 0,036). Conclusiones Los DANC constituyen una alternativa valida para expandir el pool de donantes pulmonares ante la carencia actual de pulmones validos para el trasplante. La incidencia de complicaciones es comparable con los datos publicados en la literatura.

The present guidelines have been prepared with the consensus of at least one representative of each of the hospitals with lung transplantation programs in Spain. In addition, prior to their publication, these guidelines have been reviewed by a group of prominent reviewers who are recognized for their professional experience in the field of lung transplantation. Within the following pages, the reader will find the selection criteria for lung transplantation candidates, when and how to remit a patient to a transplantation center and, lastly, when to add the patient to the waiting list. A level of evidence has been identified for the most relevant questions. Our intention is for this document to be a practical guide for pulmonologists who do not directly participate in lung transplantations but who should consider this treatment for their patients. Finally, these guidelines also propose an information form in order to compile in an organized manner the patient data of the potential candidate for lung transplantation, which are relevant in order to be able to make the best decisions possible.

Resumen La presente normativa ha sido elaborada con el consenso de, al menos, un representante de cada uno de los hospitales con programa de trasplante pulmonar en Espana. Ademas, previamente a su publicacion, ha sido revisada por un grupo de revisores destacados por su reconocida trayectoria en el campo del trasplante pulmonar. En las siguientes paginas, el lector encontrara los criterios de seleccion de pacientes candidatos a trasplante pulmonar, cuando y como remitir un paciente a un centro trasplantador y, finalmente, cuando incluir al paciente en lista de espera. Se ha atribuido un nivel de evidencia a las cuestiones mas relevantes. Este documento pretende ser una guia practica para los neumologos que no participan directamente en el trasplante pulmonar pero que deben considerar este tratamiento para sus pacientes. Finalmente, se ha propuesto de una forma consensuada un documento que recoge de forma estructurada los datos del paciente potencial candidato a trasplante pulmonar que son relevantes para poder tomar la mejor decision.

M. Lazaro, A. Ramos, P. Ussetti, A. Asensio, R. Laporta, E. Munez, I. Sanchez-Romero, E. Tejerina, R. Burgos, V. Monivas, A. Varela. Aspergillus endocarditis in lung transplant recipients: case report and literature review. Transpl Infect Dis 2011: 13: 186–191. All rights reserved Abstract: We present a case of endocarditis caused by Aspergillus in a lung transplant (LT) patient and review 6 previously reported cases. All cases were caused by Aspergillus fumigatus. Five patients (71%) were transplanted due to cystic fibrosis. None of the patients had any previously known valvular heart disease. The time that elapsed between LT surgery and the diagnosis of Aspergillus endocarditis was 8±6 months. Large peripheral emboli were observed in 6 patients (85%); blood cultures were negative in all. Transthoracic echocardiography did not detect the presence of vegetations in 3 patients (43%); the vegetations measured >1.5 cm in all cases. Five patients (71%) died from disseminated disease. Both survivors underwent combined therapy with antifungal drugs and surgical treatment.

The aim of our study was to describe our protocol of non-heart-beating-donor (NHBD) lung transplantation and discuss data regarding the situation of NHBD and lung transplantation in Spain.Experimental work regarding NHBD led our National Organization of Transplants to develop several working groups with the objective of investigating the possibility of using uncontrolled NHBD in our country. This turned into a flexible and useful legal mechanism that allowed immediate judicial permission to preserve-and harvest-those organs. Several harvesting programs for mainly abdominal organs (kidney and liver) started in Spain during the late 1980s, with good mid-term results. The collaboration between two hospitals in Madrid-Hospital Clinico San Carlos and Hospital Puerta de Hierro as transplantation hospital-led to the development of a successful NHBD lung program for uncontrolled donors that is a pioneer in the world.In Spain, donation after cardiac arrest represents 6.7% of all transplants, mainly from types I (dead on arrival) and II (unsuccessful resuscitation) donors. NHBD for lung transplantation is concentrated in Madrid, with approximately 60 potential NHBDs per year. With this additional source of organs we have so far been able to perform 32 lung transplantations, which represents an increase of 13% of our annual transplantation rates.NHBD is no longer just a promising source of organs for lung transplantations, it is a real one. We hope that in the near future many other units will develop similar protocols to improve the use of these grafts and decrease the mortality rate among those on the waiting lists.

The identification of tumour biomarkers that detect the presence of disease using noninvasive diagnostic procedures is a key part of cancer research. We determined in plasma the vesicle-related microRNA (miRNA) expression profile of nonsmall cell lung cancer (NSCLC) and evaluate whether plasma miRNAs can be both discriminating (between patients and healthy controls) and prognostic markers. 365 human miRNAs were analysed by Taqman® low-density arrays (Applied Biosystems, Foster City, CA, USA) in the plasma from 28 NSCLC patients and 20 controls. Five selected miRNAs (let-7f, miR-20b, miR-30e-3p, miR-223 and miR-301) were validated independently by real-time PCR in plasma from 78 NSCLC and 48 controls and correlated with pathologic parameters and survival. Levels of let-7f, miR-20b and miR-30e-3p were decreased in plasma vesicles of NSCLC patients. Moreover, levels of let-7f and miR-30e-3p distinguished between two groups of patients for stage of disease and therefore possibility of surgery. Plasma levels of miR-30e-3p and let-7f were associated with short disease-free survival and overall survival, respectively. NSCLC patients and healthy controls differ in vesicle-related miRNAs in plasma. Levels of let-7f and miR-30e-3p in NSCLC patients are associated with poor outcome. Thus, plasma vesicle-related miRNAs obtained by noninvasive methods could serve as circulating tumour biomarkers of discriminating and prognostic value.

IntroducciónEl trasplante cardiopulmonar es un tratamiento quirúrgico reservado a pacientes candidatos a trasplante cardíaco o pulmonar que tienen de forma concomitante una grave enfermedad pulmonar o cardíaca, respectivamente.Material y métodosSe han analizado retrospectivamente los trasplantes cardiopulmonares realizados en nuestro centro desde el inicio del programa.ResultadosSe realizaron en total 19 trasplantes cardiopulmonares desde 1998-2006, tres de ellos de carácter urgente. La edad media de los pacientes fue de 33 años. La enfermedad que indicó el trasplante fue hipertensión pulmonar primaria en cinco casos (26%), síndrome de Eisenmenger en cuatro (21%), síndrome tóxico en tres (16%), cardiopatía congénita compleja con hipertensión pulmonar en tres, fibrosis quística más miocardiopatía dilatada en dos (11%), así como un caso de miocardiopatía restrictiva con hipertensión pulmonar grave (5%) y otro de cardiopatía isquémica más fibrosis pulmonar. La mortalidad hospitalaria fue del 52%, debido a fallo multiorgánico, sepsis de origen pulmonar y shock hemorrágico postoperatorio. Tras la fase hospitalaria hubo dos muertes en el seguimiento. La probabilidad de supervivencia al año y a los 5 años fue del 45 y el 27%, respectivamente. Hasta la fecha continúan vivos siete pacientes (37%), todos ellos en buena situación funcional.ConclusionesEn nuestra limitada experiencia el trasplante cardiopulmonar es un procedimiento complejo con una indudable mortalidad precoz. La supervivencia a corto y medio plazo es buena, y los pacientes que superan la fase hospitalaria experimentan una franca mejoría funcional.IntroductionHeart-lung transplantation is a surgical treatment destinated to patients eligible for heart or lung transplantation that have a severe concomitant pulmonary or cardiac disease respectively.MethodsWe report our experience with heart-lung transplantation since the beginning of our program in 1998.ResultsNineteen heart-lung transplantations were performed from 1998-2006. In three cases the patient needed an urgent transplant. Mean age of the candidates was 33 years. The clinical indication was primary pulmonary hypertension in five cases (26%); Eisenmenger syndrome in four (21%); toxic syndrome due to poisoned cooking oil in three cases (16%); complex congenital heart disease with pulmonary hypertension in three; cystic fibrosis plus dilated cardiomyopathy in two (11%); one case of restrictive cardiomyopathy with severe pulmonary hypertension (5%), and one case of ischemic heart disease plus pulmonary fibrosis. In-hospital mortality was 52%, due to sepsis, multiorgan failure, or hemorrhagic shock. Among patients who were discharged there were two deaths during follow-up. One-year survival and five-year survival were 45 and 27%, respectively. To date, seven patients stay alive (37%), all of them with good functional status.ConclusionsIn our limited experience, heart-lung transplantation is a complex technique with a high early mortality. Nevertheless short-term and mid-term survival is good and functional status of surviving recipients is optimal.

Historically, grafts were preserved by means of autoperfusion with extracorporeal circulation, topical cooling or donor core cooling. In the 1980s, the standard lung preservation method was single pulmonary artery flush perfusion, using modified Euro-Collins solution at 4°C [1]. However, reperfusion injury remained a significant factor for morbidity and early mortality after lung transplant. Since the early years of lung preservation strategies, some advances have emerged in transplant teams, such as adding prostaglandin E2 to prevent counteract temperature and potassium-induced vasoconstriction. The use of low potassium dextran glucose solutions shows better overall lung function, superior early oxygenation, higher lung compliance, lower incidence of severe primary graft dysfunction and 30-day mortality [2]. As Gohrbandt et al. point out, the route to administer the preservation solution may also have an impact on early lung graft performance [3]. Anterograde flush initiating the infusion through the pulmonary artery with pulmonary vein drainage was the traditional approach for many years [4]. This technique, however, presents a number of limitations. Flushing the pulmonary artery leaves the bronchial tissue to be preserved by topical cooling alone, raising the complication from the bronchial suture. Also, clots and fat or brain tissue emboli, especially in donors with major trauma and multiple bone fractures, may hamper uniform flushing and cooling and, therefore, impair graft function upon reperfusion. Adding a retrograde flush, whereby the preservation solution is administered via the left atrial appendage or four pulmonary veins into the pulmonary venous system and drained through the pulmonary artery, has the potential to flush not only pulmonary vessels, but also the bronchial network, contributing to the adequate perfusion of the tracheobronchial submucosa tissue, and also limiting the effect of hypothermic pulmonary arterial vasoconstriction. On the other hand, less ventilated areas, such as the posterior segments of lower lobes, are better flushed. Also residual blood and harmful constituents and any possible microthrombi that may obstruct the pulmonary vessels are washed out. The evidence from clinical series of this technique is limited [5]; authors such as Gohrbandt et al. show us that there are no clinical benefits of retrograde lung preservation alone and that it may cause or prolong mechanical ventilation and primary graft dysfunction at 72 h and prolong ICU stay [3]. On the other hand, some evidence has been published, showing that biphasic lung preservation is not only clinically feasible [6], but also related with better early oxygenation ratio, lower mean airway pressure and chest radiography score [7, 8]. Many transplant teams have now adopted a biphasic technique with an antegrade flush through the pulmonary artery followed by a retrograde flush through each of the pulmonary veins after heart excision with the lung still ventilated inside the cadaver. However, there is lack of controlled randomized studies.

Objetivo: Se han desarrollado nuevas tecnicas endoscopicas como alternativa al tratamiento quirurgico de las fistulas bronquiales (FB). El objetivo de nuestro trabajo ha sido analizar nuestra experiencia en el tratamiento endoscopico de las FB. Material y metodos: Hemos realizado un estudio retrospectivo de los pacientes con FB diagnosticados por fibrobroncoscopia analizando sus caracteristicas, enfermedad causal de la fistula, tamano y resultados del tratamiento endoscopico. La tecnica endoscopica consistio en la instilacion mediante cateter a traves del fibrobroncoscopio de sustancias sellantes (SS) (Histoacryl® y/o Tissucol®). Resultados: Entre 1997 y 2004 diagnosticamos 18 FB a traves de fibrobroncoscopia, todas ellas en varones con una edad media (± desviacion estandar) de 62 ± 12 anos. En 16 pacientes la FB se produjo tras cirugia de neoplasia, en uno aparecio en la sutura bronquial de un trasplante pulmonar y en otro fue simultanea a un derrame pleural por hidatidosis. El tamano oscilo entre 1 y 10 mm (media de 3,6 ± 2,7 mm). Aplicamos SS en 14 pacientes, en 2 se realizo cirugia directamente tras el diagnostico y en otros 2 la FB cerro espontaneamente. Las SS utilizadas fueron Histoacryl® en 12 pacientes y Tissucol® en otros 2. Simultaneamente se empleo drenaje pleural y antibioterapia sistemica segun criterio del cirujano. En los 4 casos donde la FB estaba asociada a empiema se aplicaron ademas lavados pleurales. La tecnica endoscopica cerro la FB en 12 pacientes (85,7%) sin complicaciones asociadas. En el 85,7% fueron necesarias menos de 3 aplicaciones de SS. Conclusiones: La utilizacion de SS, mediante tecnicas de fibrobroncoscopia, permite el cierre de las FB con un alto porcentaje de exito, un numero reducido de aplicaciones y nula morbilidad, evitando la cirugia de la fistula.

Objetivo: La calidad de la preservacion pulmonar es uno de los aspectos mas determinantes en el exito del trasplante pulmonar. En octubre del ano 2000 modificamos nuestra solucion de preservacion pulmonar, que hasta entonces era el Euro-Collins (EC), y comenzamos a utilizar una solucion de dextrano bajo en potasio, comercializada como Perfadex (PER). El objetivo de este estudio es analizar los resultados de ambos metodos. Material y metodos: Hemos analizado los resultados de 68 trasplantes pulmonares con PER y los hemos comparado con los de una serie retrospectiva del mismo numero de trasplantes realizados con EC. Resultados: No existen diferencias significativas respecto a la edad o el diagnostico de los receptores entre ambos grupos. El tiempo en lista de espera fue mayor en el grupo de PER. La causa de muerte del donante mas frecuente del grupo EC fue el traumatismo craneoencefalico (62%), mientras que en el grupo de PER fue la hemorragia cerebral (54%). En el grupo de PER se realizaron mas trasplantes bipulmonares que en el de EC (el 78 y el 53%, respectivamente; p = 0,002). No hay diferencias en la indicacion de circulacion extracorporea o tiempos de isquemia entre ambos grupos. Se evaluo la funcion pulmonar temprana a traves del indice de oxigenacion (PaO2/FiO2) a la llegada a la unidad de cuidados intensivos, que fue comparable entre ambos grupos. La incidencia de disfuncion grave del injerto (PaO2/FiO2 < 150 mmHg) fue significativamente inferior en el grupo de PER frente al de EC (el 16 y el 37%, respectivamente; p = 0,01). No encontramos diferencias significativas respecto a las horas de ventilacion mecanica ni en cuanto a la mortalidad postoperatoria entre las 2 series. Conclusiones: Con la aplicacion clinica de esta nueva solucion de preservacion pulmonar se obtiene una reduccion del 50% en la incidencia de la lesion de isquemia-reperfusion grave del injerto en el postoperatorio inmediato del trasplante pulmonar.