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Poster presentada en el 50th ERA-EDTA Congress (European Renal Association - European Dialysis Transplant Association), celebrado del 18 al 21 de mayo de 2013 en Estambul (Turquia)

A successful case of a hand-assisted laparoscopic splenectomy with low-pressure pneumoperitoneum for autoimmune thrombocytopenic purpura in a patient at 23 weeks' gestation is reported. Preoperative splenic arterial embolization was performed on the same day as the operation using painless contour embolic material and super-absorbent polymer microspheres. The abdominal wall retraction method first was applied to avoid the effects of pneumoperitoneum on systemic hemodynamic alterations. However, a sufficient surgical view could not be obtained, as the intra-abdominal organs were elevated because of the enlarged uterus. A surgical view with 4 to 6-mm Hg pneumoperitoneum was available for the hand-assisted splenectomy. The postoperative course was uneventful, and the patient vaginally delivered a healthy infant. A hand-assisted laparoscopic splenectomy with low-pressure pneumoperitoneum after splenic arterial embolization would be feasible for patients with autoimmune thrombocytopenic purpura during a relatively advanced pregnancy.

Increased work of breathing (WOB) and respiratory muscle weakness have been identified as major causes of respiratory failure after thoracic surgery. This study was undertaken firstly to characterize the mechanical impairment in patients with respiratory failure after cardio-thoracic surgery, and secondly, to determine how diaphragmatic paralysis affects deterioration in the ventilatory mechanics.We evaluated the respiratory mechanics of 24 patients following cardiac and thoracic surgery. Ten patients without respiratory problems were examined as control subjects. There were nine patients with phrenic nerve injury and five patients without phrenic nerve injury who required mechanical ventilation for more than 7 days. Phrenic nerve injury was assessed with a phrenic nerve stimulation test. We measured the respiratory variables, the esophageal, gastric and transdiaphragmatic pressure swing (deltaPes, deltaPga and deltaPdi, respectively), and the work of breathing during quiet tidal breathing.Both the groups requiring mechanical ventilation exhibited abnormally negative deltaPga/deltaPes values, compared with the control subjects. A significant increase in WOB with the normal generation of deltaPdi was seen in the patients without phrenic nerve injury. In contrast, the poor generation of deltaPdi with a slight increase in work of breathing was noted in patients with phrenic nerve injury.These results demonstrated two different types of respiratory failure in thoracic surgery patients, focusing on the impact of phrenic nerve paralysis. Diaphragmatic dysfunction should not be overlooked in postoperative care, and the amelioration of this compromise in respiratory mechanics is an important aspect of good patient management.

Congenital cystic lesions of the lung are uncommon but share similar embryologic and clinical characteristics. The purpose of this study is to review our institutional experience of congenital cystic lung disease, emphasizing the clinical spectrum of the disease related to age, and present some cases with unusual clinical manifestations.Between 1962 and 1996, 26 patients (9 females and 17 males) under 15 years old underwent evaluation and surgical treatment for congenital cystic lung disease. Seven patients were under 1 year old, and 19 were in over 1 year old. There were 13 bronchogenic pulmonary cysts, 6 pulmonary sequestrations, 4 congenital cystic adenomatoid malformations (CCAM), and 3 congenital lobar emphysemas.All patients under 1 year old showed respiratory distress with mediastinal shift but no episodes of infection. In contrast, 13 of the 19 patients over 1 year old had symptoms of recurrent infection without respiratory distress. Five patients over 1 year old were entirely asymtomatic from birth. There were significant differences (P0.05) in the frequencies of respiratory distress and infection between the two groups (chi2-test). Lobectomy was performed in 21 patients, excision in 3 patients, segmentectomy in one patient, and exploration in one patient. There was no incident of postoperative mortality or morbidity except for one patient with CCAM complicated by reexpansion lung edema. Twenty-one patients at long-term follow-up from 2 to 30 years after surgery are doing well with no subsequent limitation of physical activities due to lung resection.In patients under 1 year old, cystic lesions were discovered by respiratory distress; and in patients over 1 year old signs of infection were the most important clinical features. Early recognition of these relatively rare congenital cystic lung lesions would lead to the immediate, proper surgical intervention.

Fifteen lung cancer (LC) and 11 malignant mediastinal tumor (MMT) patients who received surgical treatment in association with a reconstruction of great vessel from 1981 to 1997 were retrospectively reviewed. The aorta was resected in 7 (AO group) of 15 LC patients and the superior vena cava in the remaining 8 patients (SVC group). Pathological examination revealed actual tumor invasion in one (14%) of AO group and 6 (75%) of SVC group. In 7 p-T4 patients, 6 (85.7%) were p-N2 or N3 diseases. Five of the 6 patients belonged to SVC group and one to AO group. Five-year survival rate was 10% in all LC patients, 20% in p-T3 patients, 0% in p-T4 cancers, 50% in p-N0 patients and 0% in p-N2 or N3 patients. Eleven MMT patients included 5 thymomas, 2 thymic cancers and 4 germ cell tumors. SVC was resected and replaced with ringed PTFE graft in all patients. Invasion of vessel wall was diagnosed pathologically in 10 of 11 patients. Fifteen-year survival rate was 60% in 5 thymoma patients but 4 of whom had distant metastasis. Five-year survival rate was 50% in thymic cancers and 0% in germ cell tumors. Since the prognosis of LC and MMT patients who have tumor invasion of the great vessel is very poor, induction therapy based on preoperatively pathological diagnosis is recommended.

After single lung transplantation for pulmonary hypertension, large mismatches in ventilation/perfusion distribution persist late after transplantation. The larger graft volume of the transplanted lung after transplantation, the better the exercise performance. Because the right lung is larger in volume than the left, we compared the left single lung transplant with the right single lung transplant regarding exercise performance with an animal model.To simulate significant ventilation/perfusion imbalance observed after single lung transplantation for pulmonary hypertension, we transplanted isogenic left or right pulmonary grafts to normal rats, and the contralateral pulmonary artery was ligated 2 weeks after transplantation. The treadmill test was performed weekly until 6 weeks after transplantation to measure maximum tolerated running speed and maximum oxygen uptake.Graft vital capacity of left and right pulmonary grafts were 4.5 +/- 0.43 ml (37% +/- 3.7% of recipient's predicted vital capacity) and 7.8 +/- 0.34 ml (63% +/- 2.4%), respectively (p0.01). Maximum tolerated speeds of left and right single lung transplants were 8 +/- 7.6 and 29 +/- 2.2 m/min, respectively, at 6 weeks after transplantation (p0.01). Maximal oxygen uptake values of left and right single lung transplants were 34 +/- 12.0 and 65 +/- 3.8 ml/kg/min, respectively (p0.01).Results suggest that right lung transplantation is superior to left lung transplantation for pulmonary hypertension in terms of exercise performance in this animal model.

On the assumption that lung mast cells might respond and release histamine after lung transplantation, the number of mast cells and tissue histamine content were investigated for 2 weeks after rat orthotopic left lung isotransplantation (Lewis rat to Lewis rat) and allotransplantation (Lewis rat to Brown Norway rat). The allografts were rejected histologically by day 7 (grade A4).In the isografts, both the numbers of mast cells and histamine content were lower (p0.05) on day 4 but higher (p0.001) on day 14 compared with the nontransplanted donor left lungs (control). In the allografts, the numbers of mast cells on day 7 and histamine content on day 1 were lower (p0.05) than controls and both continued to be low thereafter. On day 7, the histamine content of the allografts was low (p0.05) compared with the level of the isografts. Conversely, no significant change was found in histamine content of the untransplanted right native lungs except for on day 14 after isotransplantation, when the content was higher than the controls, suggesting the possibility of a systemic signal for proliferation of mast cells.Our data indicated that degranulation of the pulmonary mast cells and consequent histamine release localized in the grafts occurred under the microenvironment of reimplantation and rejection after rat lung transplantation.