Management and Prevention of Cardiovascular Hemorrhage Associated With Mediastinitis

Georgiade, Gregory S.; Levan, Therese Anne; Anthony, James P.; Oldham, Newland; Hochberg, Júlio; Milano, Carmello; Ritter, E. Matthew

doi:10.1097/00000658-199801000-00021

Cited by 8 publications

(9 citation statements)

References 9 publications

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“…Bismuth et al [4]were the first to highlight the fact that perhaps the selection criteria being used were inappropriate, as most of the patients who were transplanted in the early era of transplantation had advanced disease. Extrahepatic micrometastases, tumour cell migration during liver manipulation and immunosuppression [5, 6, 7]were possible factors contributing to early recurrence.…”

Section: Introductionmentioning

confidence: 99%

Liver Transplantation in Cirrhotic Patients with Small Hepatocellular Carcinoma: An Analysis of Pre-Operative Imaging, Explant Histology and Prognostic Histologic Indicators

Bhattacharjya¹,

Bhattacharjya

Quaglia³

et al. 2004

Dig Surg

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Background: In recent years, liver transplantation in patients with hepatocellular cancers and cirrhosis has been restricted to those with small cancers (<5 cm for solitary and <3 cm for multifocal HCC with <3 nodules). The selection of patients for liver transplantation is based on pre-operative imaging. The accuracy of imaging correlated with explant histology and the effect of tumour stage has not been evaluated in this selected population. Methods: In this study, prospectively collected data for 30 patients who underwent orthotopic liver transplantation for cirrhosis complicated by small hepatocellular carcinoma (HCC) at a single centre have been reviewed with the aim of correlating radiological findings, explant histology and patient outcome. Patients who underwent orthotopic liver transplantation between 1995 and 1999 had plain and contrast-enhanced dual-phase spiral CT (DCT) scans of the liver. Patients suspected of having HCC on CT scan or due to elevated serum alpha-fetoprotein underwent iodized oil CT (IOCT). Following transplantation, the explanted liver was serially sectioned at 10-mm intervals and examined by a pathologist blinded to the results of imaging. Data collected prospectively on imaging and histology were compared with outcome data. The median period of follow-up was 1,139 days (range 690–1,955 days) after transplantation. All patients were followed up by clinical assessment, assessment of serum alpha-protein levels and imaging when indicated. Results: All the patients transplanted fulfilled the selective criteria on the basis of imaging (solitary HCC <5 cm in diameter or multifocal HCC <3 cm in diameter with <3 nodules). Of the 30 patients transplanted, 46 HCCs were detected on explant histology with a median size of 24 mm (range 6–75 mm). Ten patients had multifocal disease (median number of lesions 2, range 2–4). No significant difference was observed between IOCT and DCT with regards to the sensitivity (67.4 vs. 68%) and specificity (78.97 vs. 88.6%) of detecting HCCs. IOCT had a positive predictive value of 78.9% as compared to 82.8% for DCT. IOCT had an overall sensitivity of 40% as compared to 30% for DCT in detecting multifocal disease (not significant). Histological assessment of the explanted livers showed that 8 patients had well-, 17 moderate and 5 poorly differentiated HCCs. Tumour size and the presence of multifocal disease did not influence survival in this study. Microvascular invasion was more common with larger tumours (from 38% with lesions less than 40 mm in diameter to 60% with lesions >40 mm in diameter; p < 0.01) and with moderately (29.4%) or poorly differentiated (60%) HCCs than well-differentiated HCC (12.5%) (p < 0.04 and 0.01 for well- vs. moderately and poorly differentiated HCC, respectively). Microvascular invasion on explant histology was associated with poor survival. Of the 17 transplant recipients without vascular invasion, 15 were alive at 1 and 2 years in comparison to 7 of 9 with microscopic vascular invasion (p < 0.01). Four patients died in the post-t...

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Section: Introductionmentioning

confidence: 99%

Liver Transplantation in Cirrhotic Patients with Small Hepatocellular Carcinoma: An Analysis of Pre-Operative Imaging, Explant Histology and Prognostic Histologic Indicators

Bhattacharjya¹,

Bhattacharjya

Quaglia³

et al. 2004

Dig Surg

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“…The published mortality rate ranges between 0% and 100%. [1][2][3][4][5][6][7][8][9][10][11] The exact incidence is unknown, but several authors have suggested that RVD occurs in 0.8 to 14.6% of the cases of mediastinitis. 6,7 A review of the surgical literature reveals a total of 39 patients.…”

mentioning

confidence: 99%

“…6,7 A review of the surgical literature reveals a total of 39 patients. [1][2][3][4][5][6][7][8][9][10][11] Most of the publications present case reports or describe techniques of operative repair of the ventricular laceration. The three patients treated for RVD from this institution, along with the review of the literature, will be presented in order to better understand the pathogenesis of this problem and to suggest strategies for the prevention and treatment of this rare but potentially fatal complication of cardiac surgery.…”

mentioning

confidence: 99%

“…Right ventricular disruption (RVD) may occur after open sternal treatment of mediastinitis following heart surgery. The published mortality rate ranges between 0% and 100% 1–11 . The exact incidence is unknown, but several authors have suggested that RVD occurs in 0.8 to 14.6% of the cases of mediastinitis 6,7 .…”

mentioning

confidence: 99%

“…The exact incidence is unknown, but several authors have suggested that RVD occurs in 0.8 to 14.6% of the cases of mediastinitis 6,7 . A review of the surgical literature reveals a total of 39 patients 1–11 . Most of the publications present case reports or describe techniques of operative repair of the ventricular laceration.…”

mentioning

confidence: 99%

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Spontaneous Right Ventricular Disruption Following Treatment of Sternal Infection

Khoynezhad

Abbas

Palazzo

et al. 2004

Journal of Cardiac Surgery

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Spontaneous right ventricular disruption is a potentially preventable complication. To prevent this complication we recommend: (1) avoidance of delay between diagnosis and operative treatment of mediastinitis; (2) complete lysis of adhesions between the posterior sternal edge and anterior surface of the right ventricle under general anesthesia with heart-lung machine stand-by; (3) repair of the right ventricular tear using biologic patches with heart-lung machine stand-by; (4) early (if possible immediate) closure of the chest with a myocutaneous flap.

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Acute Mediastinitis

Warren¹,

Sundt²,

Polish³

2001

Critical Care Infectious Diseases Textbook

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Management and Prevention of Cardiovascular Hemorrhage Associated With Mediastinitis

Cited by 8 publications

References 9 publications

Liver Transplantation in Cirrhotic Patients with Small Hepatocellular Carcinoma: An Analysis of Pre-Operative Imaging, Explant Histology and Prognostic Histologic Indicators

Liver Transplantation in Cirrhotic Patients with Small Hepatocellular Carcinoma: An Analysis of Pre-Operative Imaging, Explant Histology and Prognostic Histologic Indicators

Spontaneous Right Ventricular Disruption Following Treatment of Sternal Infection

Acute Mediastinitis

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