[Chest wall tumors. Report of 17 cases]. / Tumeurs de la paroi thoracique. A propos de 17 observations.

The aim of this work was to evaluate the different approaches to surgical repair of the thoracic wall and to discuss technical indications. From June 1987 to June 1997, we cared for 17 patients, 14 males (82.3%) and 3 females (17.7%) with parietal neoplasia. All patients underwent a preoperative respiratory work-up to identify tumoral extension. In 6 patients, the morphology and location of the tumor led to CT-guided transthoracic needle aspiration. Tumoral excision in 14 patients (82.3%) included wide resection of osteomuscular structures. Reconstruction of the thoracic wall associated myoplasty in all cases. A prosthesis was installed in 5 cases and a rib transposition in 2. Pathology examination of the surgical specimen revealed 13 primary tumors (76.5%) and 4 secondary tumors (23.5%) CT-guided transthoracic needle aspiration confirmed the diagnosis in 82.2% of the cases. Twelve patients (70.5%) were alive and recurrence free at 85.6 +/- 40 months after surgery. Five patients died (29.5%) 12.2 +/- 10.1 months after surgery. There was one case of prosthesis infection (5.8%). The appropriate choice of the surgical technique and repair materials gave satisfactory oncological, esthetic and functional results independently of the extent of the parietal defect.

[A rare cause of hemoptysis]. / Une cause rare d'hémoptysie.

The existence of a bronchial foreign body is an unusual cause of haemoptysis. We observed a sixty two year-old women who presented several medium-abundance haemoptysis. They were associated with a systematic alveolar-interstitial radiological picture of the ventral upper right lobe. A right upper lobectomy showed that an old bronchial foreign body (piece of bone) was responsible for the systematic intra-alveolar bleeding. Though most of the breathed foreign bodies are expressed into immediate symptoms, some of them remained undiagnosed and may be responsible for haemoptysis, infectious complications, atelectasis and for bronchiectasis. Their extraction through endoscopy or most often surgery is necessary for a proper recovery. In spite of histopathological differences between foreign bodies, broncholithiasis and lung tumor the diagnosis may be difficult clinically and on radiology.

Respiratory bronchiolitis in smokers with spontaneous pneumothorax.

Respiratory bronchiolitis (RB) is defined by the accumulation of pigmented macrophages in the lumen and wall of respiratory and membranous bronchioles of smokers. The aim of this study was to determine whether spontaneous pneumothorax was associated with a high prevalence of RB. Seventy-nine consecutive patients who underwent a surgical procedure (thoracotomy or thoracoscopy) for recurrence or persistence of primary spontaneous pneumothorax despite thoracic drainage were studied retrospectively. RB was found in 70 of 79 (88.6%) smokers operated for spontaneous pneumothorax. Associated interstitial pathological abnormalities were present in 53 of 79 cases (67.1%). In nine patients, the pathological lesions were severe and resembled desquamative interstitial pneumonia. Emphysematous lesions were present in about one-third of the patients. Although the possible pathophysiological consequences of respiratory bronchiolitis remain speculative, this study demonstrates the high prevalence of this pathological abnormality in patients with pneumothorax requiring surgical treatment.

[Pleuro-peritoneal Denver shunt in treatment of chronic pleurisy]. / La place du shunt pleuro-péritoneal de Denver dans le traitement des pleurésies chroniques.

The first utilisation in our hospital of a pleuraperitoneal shunt for the treatment of chronic pleurisy enabled us to study, in the light of published data, the place for such a procedure in the management of resistant pleural effusion. The aetiology of the pleurisy in a 70-year old patient who underwent this mini-invasive surgery was unknown when the shunt was inserted, but his symtoms clearly improved afterwards. At the present time with a follow-up of 13 months, there are no local complications and the system is in good working order. In 1982, the material used for the first time in such a case was an adapted version of Denver's peritoneal venous shunt. This is composed of a pleural catheter linked by a pump that the patient controls himself, to a peritoneal catheter. This pump can be inserted under local anaesthetic. The principal indications in the literature, in which the series do not exceed 70 cases are: malignant pleurisy where it is preferable to introducing tale in the case of tissue retraction fastening to the underlying lung and also in chylous pleurisy, especially those secondary to congenital east disease in children. A complication rate of 25% is noted depending on the type of infection or obstruction leading to replacement of the shunt. No case of erosion has been noted. The long term patency, measured by radio-isotope injections (Tc99m), has not been studied but there is a significant reduction in the length of hospital stay which gives a clear economic advantage to such procedures.

Self-expanding metal stents for the management of bronchial stenosis and bronchomalacia after lung transplantation.

BACKGROUND: Airway stenosis or malacia after lung transplantation, usually as a result of anastomotic ischemia, remains a major problem. METHODS: The authors report their experience with the Gianturco expandable stent for the management of 23 bronchial stenoses in 18 patients following lung transplantation. Stent placement occurred an average of 5.6 months after transplantation. RESULTS: Stents were well tolerated and produced immediate symptomatic and functional improvement. The mean follow-up after implantation was 21 months (range, 4 to 48 mo). The authors removed five stents by endoscopy and replaced them, and removed one stent entirely. Laser resection was used to control granulomas or partial fibrosis stenosis that occurred in four stents (14.3%) after an average of 4 months. One stent broke but was still in place and effective 32 months later. One patient died of hemorrhage 4 months after stenting. CONCLUSION: Although it can still be improved, this expandable metal stent is suitable for the treatment of posttransplantation proximal bronchial stenosis.

[Results of 100 pulmonary and cardiopulmonary transplants in 95 patients at the Louis Pradel Hospital (Lyon) from 1988 to 1994]. / Risultati di 100 trapianti polmonari e cardio-polmonari in 95 pazienti all'ospedale Louis Pradel (Lyon) dal 1988 al 1994.

From June 1989 to December 1994, 95 patients underwent 100 pulmonary and cardiopulmonary transplants. The patients were 58 men and 37 women with an average age of 39 +/- 15 years. In 15 of the cases, indication for a transplant was infectious pathology, in 35 of the cases; vascular pathology, in 23 of the cases; emphysema and in 22 of the cases the causes were various. 31 of the patients underwent a heart/lung transplant, 14 underwent a sequential two-lung transplant, 14 underwent a sequential two-lung transplant and 50 underwent a single lung transplant; 5 patient underwent a second transplant. The global survival percentage is 56,4 +/- 5,2 to one year, 48,5 +/- 5,4 to two years, 42,9 +/- 5,7 to three years. There are non significant statistical differences for the survival level according to the type of transplant. The best functional results were obtained from patients affected with emphysema. The survival data for patients affected with infectious pathology are not very encouraging.

[Inflammatory pseudotumor of the superior vena cava: rare etiology of mediastinal tumor]. / Pseudotumeur inflammatoire de la veine cave supérieure: étiologie rare de tumeur médiastinale.

The patient reported here had no particular past history. He presented with effort dyspnea, jugular turgescence and positional vertigo suggestive of a superior vena cava obstruction syndrome. Bronchial fibroscopy was normal, but chest X-ray, CT scan and phlebography of the superior vena cava revealed an anterior mediastinal tumour compressing the superior vena cava. The tumour was excised with replacement of the vena cava by a PTFE n. 16 graft. Pathological examination showed this to be an inflammatory tumour by fibrosis with plasmocytes. This plasmocyte fibrosis is histologically benign and becomes malignant only when complications occur as a result of its spread.

[Surgery for bronchiectasis. Operative indications and results. 48 observations]. / Chirurgie des bronchectasies. Indications opératories et résultats. 48 observations.

Forty-eight patients: 27 women and 21 men, with mean age of 36 +/- 14 years were operated on for bronchiectasis from 1976 to 1989. In 20 cases bronchiectasis was the sequelae of acute bronchopathy of childhood, 6 cases of tuberculosis and 5 cases of inhalated foreign bodies. The bronchiectasis was apparently primitive in 12 occasions. Five varied etiologies were found of which 2 congenital hypogammaglobulinemias. The anatomic extension of the lesions was precised in 47 cases by bronchography and CT scan in 6 cases, in 1 case with CT scan only. The lesions were bilateral in 5 cases. One pneumonectomy, 42 lobectomies (of which 10 bilobectomies) and 5 segmentectomies were performed. The operative mortality was nil. The morbidity (14 cases among 48, i.e. 29%) was not negligible and was comparable with the literature data. The evalued results for 36 patients (mean post-operative follow-up: 54 +/- 58 months) showed that 24 patients (67%) were asymptomatic, 34 have taken their normal professional activities.

Single lung transplantation for primary pulmonary hypertension without cardiopulmonary bypass.

We report the first case, to our knowledge, of single lung transplantation for primary pulmonary hypertension carried out without cardiopulmonary bypass. This operation seems to be possible even if the right ventricular ejection fraction is low (0.17) and the pulmonary vascular resistance very high (1,096 dynes.s.cm5). Since 1981, heart-lung transplantation has been successfully performed in patients with primary pulmonary hypertension. If heart-lung transplantation results in resolution of pulmonary hypertension, the incidence of obliterative bronchiolitis is significant in heart-lung transplantation recipients. Single lung transplantation has been performed for end-stage interstitial and obstructive lung disease but has not been considered a good option for primary pulmonary hypertension due to concerns that a single transplanted lung would be unable to cope with the entire blood flow. However, recently single lung transplantation has been performed for primary pulmonary hypertension, the risk of obliterative bronchiolitis remaining unknown. The purpose of this communication is to report one case of single lung transplantation for primary pulmonary hypertension and the feasibility of this operation without the use of cardiopulmonary bypass, if cardiopulmonary bypass is thought to be dangerous.

Thoracic splenosis presenting with hemoptysis.

Thoracic splenosis (post-traumatic autotransplantation of splenic tissue) is rare and generally asymptomatic. We report a patient with thoracic splenosis presenting with repeated hemoptysis. The blood supply of the hypervascular splenic transplants originated from a bronchial and an intercostal artery. Hemoptysis improved after surgical exeresis of splenosis. Recognizing splenosis presenting with hemoptysis is important, since percutaneous embolotherapy could be hazardous because of the risk of ectopic splenic tissue infarction.

[Surgical lung biopsy]. / Biopsie pulmonaire chirurgicale.

Open lung biopsy enables a diagnosis to be made in cases of diffuse infiltrative pulmonary disease. It was developed to aid the diagnosis of opportunistic infectious disease observed in virus infections in immune deficiency states and during transplants. Open lung biopsy involves the partial resection of the lung parenchyma. The availability of the mechanical stapler has resolved the problem of parenchymal air leaks when suturing lung tissue. Open lung biopsy should be carried out when endoscopic techniques have failed to achieve a diagnosis, including bronchoalveolar lavage and transbronchial biopsy. The place of open biopsy continues to develop. It is becoming less important when other techniques have become available for certain diagnoses such as Pneumocystis carinii, histiocytosis X, alveolar proteinosis and the rejection of lung transplants.... It should be carried out early when a particular diagnosis might change the management of a patient.

[Spontaneous and recurrent pneumothorax. Surgical treatment. Apropos of 278 cases]. / Pneumothorax spontané et récidivant. Traitement chirurgical. A propos de 278 observations.

Over the past 19 years, 278 patients (238 men-40 women) have undergone 325 parietal pleurectomies: 311 transaxillary apical and 14 full pleurectomies. Mean age was 32 +/- 12 years. The overall male:female ratio was 6:1. Surgical treatment was performed for either recurrence of spontaneous pneumothorax or failure to respond adequately to management by tube drainage. Thirty-six patients underwent one stage bilateral apical pleurectomy. On the basis of our experience (idiopathic pneumothorax: 311; chronic obstructive lung disease: 12; histiocytosis X: 2), we advocate the use of transaxillary apical pleurectomy for the younger age group with recurrent idiopathic pneumothorax and a full pleurectomy in the older age group. Major complications occurred in 1.9% of cases (re-exploration for haemorrhage: 5 cases; for air leak: 1 case). The recurrence rate in this group of patients was 1% (3 in 278 patients: one of them has been reoperated).

[Our experience of the surgical treatment of thirty-nine tracheobronchial carcinoid tumors]. / Notre expérience du traitement chirurgical de trente-neuf carcinoïdes trachéo-bronchiques.

Thirty-nine patients were operated for bronchial carcinoid tumour between 1967 and 1988 out of a total of 97 so-called benign bronchial tumours. Based on a clinical, radiological and endoscopic assessment of this series, the authors discuss the modalities of surgical treatment which depend on the site of the tumour. Treatment consisted of enucleation for the two peripheral carcinoid tumours and tracheobronchectomy in 6 cases (15%) and pulmonary resection in 31 cases (79%) for the central tumours. Lung resection was performed alone in 25 cases (64%): 1 pneumonectomy, 2 bilobectomies, 19 lobectomies and 3 segmental resections. The lung resection was associated with bronchial resection-anastomosis in 6 cases (15%). The immediate postoperative course was uneventful. There were two deaths: one from myocardial infarction after one year and one from hepatic metastases (malignant carcinoid) after 7 years.

[Unusual clinical presentation of a thoracic form of a malignant dysembryoma. A case report]. / Présentation clinique inhabituelle d'un dysembryome malin à forme thoracique. A propos d'un cas.

We report here the medical history of a patient diagnosed with teratocarcinoma presenting with a pleural mass without mediastinal involvement as well as typical paraneoplastic hypertrophic osteoarthropathy. This atypical observation is discussed as well as data from the literature on thoracic localisations of extragonadal malignant germ cell tumours.

[Acute neoplastic arterial embolism after pneumonectomy for primary bronchial cancer. Clinical and therapeutic consequences apropos of a case]. / Embolie artérielle néoplasique aiguë après une pneumonectomie pour cancer bronchique primitif. Conséquences cliniques et thérapeutiques à propos d'un cas.

We report a case illustrating the therapeutic consequences of an intravenous metastasis to the left superior pulmonary vein following resection of a voluminous primary lung carcinoma. Arterial spread of malignant cells occurred because the size of the tumor did not allow immediate clamping of the left superior pulmonary vein. The embolism was situated at the aortic bifurcation and lower limb ischemia persisted despite also emergency embolectomy. Distal (lower popliteal) embolectomy was also unsuccessful, and lower limb amputation was inevitable. This case illustrates the problems encountered in surgical treatment of pulmonary vein invasion by lung carcinoma and the role of adjuvant chemotherapy and radiotherapy.