The beneficial effects of hydrogen gas inhalation during ex vivo lung perfusion on donor lungs obtained after cardiac death in pig lung transplantation model

의과대학/박사INTRODUCTION Lung transplantation (LTx) is the optimal treatment for end-stage lung diseases. However, a shortage of donor lungs is the major obstacle to LTx. To overcome this problem, the donation after cardiac death (DCD) lungs are used. The use of DCD lungs brings several disadvantages including longer warm ischemic times compared to brain death donor lung, and absence of objective methods such as arterial blood gas analysis (ABGA) and pulmonary artery pressure to evaluate DCD lung function. Ex Vivo Lung Perfusion (EVLP) is a system that circulates normothermic perfusate into procured lungs, allowing for improved lung function and lung assessment. In this study, we investigated whether ventilation with hydrogen gas during EVLP improves DCD lung function, and whether this effect persists after actual transplantation. MATERIALS and METHODS 10 pigs were randomly divided into control group (n = 5) and hydrogen group (n = 5). After fibrillation by electric shock, no further treatment was administered in order to induce warm ischemic injury for 1 hour. Next, the lung was procured and EVLP was applied for 4 hours. During EVLP, the control group was given room air for respiration while the hydrogen group was given 2% hydrogen gas. After EVLP, the left lung graft was orthotopically transplanted into the recipient pig and reperfused for 3 hours. During EVLP and reperfusion, the functional parameters and ABGA were measured every hour. Superoxide dismutase (SOD), heme oxygenase (HO)-1, interleukin (IL)-6, IL-10, tumor necrosis factor-alpha (TNF-α) and NOD-like receptor protein 3 (NLRP3) were evaluated in lung tissue after reperfusion. Pathological evaluations were performed using lung injury severity (LIS) scores and the degree of apoptosis was evaluated by terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) assay. Wet/dry ratio was also measured. RESULTS During EVLP, pulmonary vascular resistance (PVR), and peak airway pressure (PAP) were lower in the hydrogen group, but lung compliance (LC) was lower in the control group. After LTx, oxygen capacity (p = 0.033), LC (p = 0.002), and PAP (p = 0.020) were significantly better in the hydrogen group. The expressions of SOD (p = 0.022) and HO-1 (p = 0.047) were significantly higher in the hydrogen group. The expressions of IL-6 (p = 0.024) and NLRP3 (p = 0.042) were higher in the control group, but IL-10 (p = 0.037) was higher in the hydrogen group. LIS score and the number of apoptotic cells were higher, and the degree of pulmonary edema was more severe in the control group than in the hydrogen group (LIS score: 2.2 ± 0.2 vs 0.7 ± 0.2; number of apoptotic cells: 3.4 ± 1.6 vs 2.1 ± 0.4; Wet/dry ration: 2.833 ± 0.354 vs 1.766 ± 0.078, respectively). CONCLUSION Hydrogen gas inhalation during EVLP improved DCD lung function via reduction of inflammation and apoptosis, and this effect persisted after LTx. Hydrogen gas inhalation during EVLP may increase the utilization of DCD lungs.ope

고령의 식도암 환자에서 다빈치 S 로봇을 이용한 식도 절제술

The postoperative respiratory complications such as pneumonia and ARDS, are poor prognostic factors after esophagectomy in patients with esophageal cancer. To avoid these complications, there have been attempts to use minimally invasive approach. Recently introduced daVinciTM S surgical system is used in esophagectomy because of its advantages of minimal invasiveness, clear 3-dimensional imaging and precise handling of robotic arms. We report a 83-year-old esophageal cancer patient who underwent daVinciTMS robot-assisted esophagectomy, laparoscopic stomach mobilization followed by cervical esophagogastrostomy.ope

Thoracoscopic Sympathetic Nerve Reconstruction with using an Intercostal Nerve Graft after Thoracoscopic Sympathetic Clipping for Facial Hyperhidrosis

From October 2005 to August 2006, sympathetic nerve reconstruction with using the intercostal nerve was per- formed in 4 patients with severe compensatory hyperhidrosis following thoracoscopic sympathetic surgery for facial hyperhidrosis. The interval between the initial sympathetic clipping and the sympathetic nerve reconstruction was a median of 23.1 months. The compensatory sweating after sympathetic nerve reconstruction was improved for 2 pa- tients, but it was not improved for 2 patients. Thoracoscopic sympathetic nerve reconstruction may be one of the useful treatment methods for the patients with severe compensatory hyperhidrosis after they under go sympathetic nerve surgery for hyperhidrosis. (ope

The Effects of N-acetylcystein and Epigallocatechin-3-Gallate in Ischemia-Reperfusion Injury of Rat Lungs

Background: Ischemia-reperfusion injury (IRI) is a major cause of early graft dysfunction after lung transplantation. The aim of this study was to assess the effects of N -acetylcystein (NAC) and epigallocatechin-3-gallate (EGCG) on IRI of rat lungs. Methods: Sprague-Dawley rats were divided into four groups. Sham group (n=6) did not receive IRI. Rats in the control group (n=6), NAC group (n=6), and EGCG group (n=6) were treated with an intraperitoneal injection of normal saline, NAC, and EGCG, respectively, prior to IRI. In the latter three groups, IRI was induced by clamping the left pulmonary artery, vein, and main stem bronchus for a period of 60 minutes. After ischemia, reperfusion and ventilation of the lung was allowed for a period of 180 minutes. The expression levels of inducible nitric oxide synthase (iNOS), hemeoxygenase-1 (HO-1), AMP-activated protein kinase-α (AMPK), and caveolin-1 in lung tissues were evaluated by Western blot. The pathological findings and the extent of pulmonary edema after IRI were compared among the groups. Results: The expression levels of iNOS decreased in the Sham and EGCG groups. The expression level of HO-1 was significantly higher in the EGCG group (P=0.0001). Although the expression levels of AMPK and caveolin-1 showed no differences, the extent of phosphorylation of AMPK and caveolin-1 was higher in the EGCG and NAC groups, respectively. In hematoxylin-eosin staining, the lungs in the NAC and EGCG groups showed fewer alveolar injuries and less hemorrhagic congestion compared with the control group. Conclusions: NAC and EGCG enhanced the phosphorylation of caveolin-1 and AMPK, respectively, and attenuated lung injury induced by ischemia-reperfusion.ope

Does overgrowth of costal cartilage cause pectus carinatum? A three-dimensional computed tomography evaluation of rib length and costal cartilage length in patients with asymmetric pectus carinatum

OBJECTIVES: To evaluate whether the overgrowth of costal cartilage may cause pectus carinatum using three-dimensional (3D) computed tomography (CT). METHODS: Twenty-two patients with asymmetric pectus carinatum were included. The fourth, fifth and sixth ribs and costal cartilages were semi-automatically traced, and their full lengths were measured on three-dimensional CT images using curved multi-planar reformatted (MPR) techniques. The rib length and costal cartilage length, the total combined length of the rib and costal cartilage and the ratio of the cartilage and rib lengths (C/R ratio) in each patient were compared between the protruding side and the opposite side at the levels of the fourth, fifth and sixth ribs. RESULTS: The length of the costal cartilage was not different between the more protruded side and the contralateral side (55.8 ± 9.8 mm vs 55.9 ± 9.3 mm at the fourth, 70 ± 10.8 mm vs 71.6 ± 10.8 mm at the fifth and 97.8 ± 13.2 mm vs 99.8 ± 15.5 mm at the sixth; P > 0.05). There were also no significant differences between the lengths of ribs. (265.8 ± 34.9 mm vs 266.3 ± 32.9 mm at the fourth, 279.7 ± 32.7 mm vs 280.6 ± 32.4 mm at the fifth and 283.8 ± 33.9 mm vs 283.9 ± 32.3 mm at the sixth; P > 0.05). There was no statistically significant difference in either the total length of rib and costal cartilage or the C/R ratio according to side of the chest (P > 0.05). CONCLUSIONS: In patients with asymmetric pectus carinatum, the lengths of the fourth, fifth and sixth costal cartilage on the more protruded side were not different from those on the contralateral side. These findings suggest that overgrowth of costal cartilage cannot explain the asymmetric protrusion of anterior chest wall and may not be the main cause of pectus carinatum.ope

Surgical Treatment for Empyema after Lung Transplantation

Empyema after lung transplantation causes dysfunction of the allograft, and it has the potential to cause mortality and morbidity, but the technical difficulty of surgically treating this empyema makes this type of treatment unfavorable. We report here on two cases of decortication for empyema after lung transplantationope

A successfully treated case of gorham-stout syndrome with sternal involvement

Gorham-Stout Syndrome (GSS) is a rare disease characterized by localized bone resorption. Any part of the skeleton may be affected; therefore, symptoms can vary depending on the site involved. Pathological analysis reveals lymphovascular proliferation and osteolysis in the affected lesion, but the etiology of the disease is poorly understood. When GSS occurs in the chest, chylothorax or respiratory failure may occur. Thus far, a standard treatment for GSS has not been established, and the prognosis remains unknown. The following case report describes a successfully treated case of GSS in a 16-year-old boy with an affected sternum and ribs.ope

흉막에서 발생한 석회화 섬유성 종양: 증례 보고1

Calcifying fibrous tumors (CFTs) are rare benign mesenchymal tumors consisting of hyalinized collagenous fibrotic tissue with a lymphoplasmacytic infiltrate and dystrophic calcifications. Radiographic features have seldom been described, and there are no reports describing magnetic resonance imaging (MRI) findings. Here, we report a pleural CFT in a 47-year-old woman. The tumor mimicked an intrapulmonary lesion on initial computed tomography scans but migrated inferiorly and presented as an extra-pulmonary lesion on MRI. The tumor showed iso-signal intensity on T1-weighted images (WIs), low signal intensity on T2WIs, and slight rim enhancement on enhanced T1WIs.ope

Da Vinci Robot-Assisted Pulmonary Lobectomy in Early Stage Lung Cancer - 3 cases report -

Video-assisted pulmonary lobectomy was introduced in the early 1990's by several authors, and the frequency of video-assisted thoracic surgery (VATS) lobectomy for lung cancer has been slowly increasing because of its safety and oncologic acceptability in patients with early stage lung cancer. However, VATS is limited by 2D imaging, an unsteady camera platform, and limited maneuverability of its instruments. The da Vinci Surgical System was re- cently introduced to overcome these limitations. It has a 3D endoscopic system with high resolution and magnified binocular views and EndoWrist instruments. We report three cases of da Vinci robot system-assisted pulmonary lo- bectomy in patients with early stage lung cancerope

Ex vivo Lung Perfusion Model in Lung Transplantation

Background Lung transplantation (LTx) is an effective treatment for end stage lung disease. However, the shortage of donor lungs has been a major limiting factor to increase the number of LTx. Ex vivo lung perfusion (EVLP) is a currently approved method to evaluate lung function and to repair donor lung with poor function. The purpose of this study was to develop EVLP system in pig model and to maintain lung function during 4 hours of EVLP. Methods Bilateral lung blocks were harvested from five 40 kg pigs. These blocks were applied in EVLP perfused with 37℃ Steen solution. We performed arterial blood gas (ABG) analyses before death and also every 1 hour for 4 hours after application of EVLP and calculated oxygen capacities (OC) using the results of ABG. We also calculated pulmonary vascular resistance (PVR) and peak airway pressure (PAP) every 1 hour for 4 hours. After EVLP procedure, we excised specimens for pathologic review. Results We found that OC gradually decreased during the 4 hour period of EVLP; however, no statistically significant difference was obtained. PVR declined sharply after 1 hour of EVLP (P=0.031) and then remained constant for 3 hours. PAP significantly increased after 3 hours (P<0.0001). Pathologic investigations revealed various findings from normal lung to severe pulmonary edema. Conclusions On the results of this study, we could preserve the lung function for 4 hours using EVLP. We conclude that application of EVLP in clinical setting can make more donor lungs available for LTx. However, we also understand that more studies and training are needed in clinical practice.ope