[Lung volume reduction surgery for emphysema and bullous pulmonary emphysema]. / Chirurgie de réduction volumique et des bulles géantes dans l'emphysème pulmonaire.

The improvement of respiratory symptoms for emphysematous patients by surgery is a concept that has evolved over time. Initially used for giant bullae, this surgery was then applied to patients with diffuse microbullous emphysema. The physiological and pathological concepts underlying these surgical procedures are the same in both cases: improve respiratory performance by reducing the high intrapleural pressure. The functional benefit of lung volume reduction surgery (LVRS) in the severe diffuse emphysema has been validated by the National Emphysema Treatment Trial (NETT) and the later studies which allowed to identify prognostic factors. The quality of the clinical, morphological and functional data made it possible to develop recommendations now widely used in current practice. Surgery for giant bullae occurring on little or moderately emphysematous lung is often a simpler approach but also requires specialised support to optimize its results.

[Respiratory support using veno-venous ECMO during lung resection for aspergilloma]. / Assistance ventilatoire par ECMO veino-veineuse pour résection d'aspergillome pulmonaire.

Respiratory support using extra corporeal membrane oxygenation (ECMO) is rarely used in the setting of adult lung surgery, with the exception of lung transplantation. We report the case of a patient with pulmonary aspergilloma, for whom selective bronchial intubation was required to facilitate surgery. Intolerance to unilateral ventilation was anticipated due to poor underlying lung function. Intra-operatively, an attempt to lung exclusion was responsible for severe hypoxemia. The use of veno-venous ECMO allowed to improve oxygenation and lung resection was carried out successfully at the expense of major intra-operative bleeding.

[Evaluation of thoracic surgical practice. The impact of specialisation and the effect of volume on the results of cancer treatment: resectability, post-operative mortality, and long-term survival]. / Evaluation des pratiques en chirurgie thoracique.

INTRODUCTION AND METHODS: The impact of the volume of activity and the specialisation of the surgeon and the hospital on the quality of health care for patients with non-small cell lung cancer (NSCLC) was evaluated from the publications over the last 20 years. RESULTS: The statistics, based mainly on administrative data, identified a significant decrease in post operative mortality (5 out of 7 studies) and improved long-term survival (2 out of 3 studies) in establishments undertaking large numbers of lung resections. The threshold for defining high volume groups varied from study to study (from 28 to 128 procedures per year). The same tendency was seen among the surgeons where specialisation in thoracic surgery led to higher levels of resectability and parenchymal preservation. CONCLUSIONS: These results should be interpreted with caution on account of the nature of the data and the methodology employed. A certification of referral centres, validated by the French Thoracic and Cardiovascular Surgical Society, based on the training, level of activity in cancer surgery, and the infrastructure of the hospital should lead to a more even standard of care for patients with NSCLC.

[Non-small cell lung cancer: surgical trends as a function of age]. / Cancer pulmonaire non à petites cellules: particularités chirurgicales en fonction de l'âge.

Most of the studies on lung cancer and age are usually done on very young or very old populations. We conducted a study of the evolution of surgical features over time in a population aged 24 to 89 years. The series included 1,809 men and 287 women (n = 2,096) who had undergone surgery between April 1984 and December 1990 (n = 1,026) and between January 1991 and December 1996 (n = 1,996). Patients were divided into 7 age groups with 2 subgroups for patients with or without prior medical history of cancer. We analyzed the type of surgery and pathology findings by age. Morbidity was recorded according to state of previous cardiovascular disease and long-term survival was analyzed. A significant increase in the number of female patients was noted during the last ten years. Adenocarcinomas were more frequent in young patients. Exploratory interventions, partial tumor resections and lung resections for metastasis were more frequently performed in young patients than in older patients. Excision of mediastinal nodes was less performed often in old patients. In case of curative resection, postoperative pTNM was not modified with age. Morbidity increased with age; mortality was more frequent in the elderly even when comorbidity was taken into account. Mortality was not related significantly with cardiovascular morbidity factors despite an increased frequency of previous cardiovascular disease with age. Survival according to age showed 3 main types of population: patients aged under 64 years, those between 65 and 74, and those over 75 years of age. Mortality increased with time but was less often related to recurrence of lung cancer. Nevertheless, survival for stage III and stage IV patients older than 75 years demonstrated that surgery was not indicated for these patients. This study shows that indications for surgery should not vary with age except for patients over 75 years who have locally advanced cancer and a risk of surgical death greater than the chances of survival. All non-small-cell lung cancers should be resected with no delay, even in the elderly population.

Lymphatic drainage of heart and lungs: comparison between pig and man.

In its anatomy and physiology the pig is comparable with humans and its organs can be considered for xenotransplantation. We have studied the lymphatic drainage of the heart and lungs in 15 pigs. A coloured mass was injected into the myocardium and/or beneath the visceral pleura. The first nodes coloured were directly injected again. No lymph node was observed inside the heart and lungs. The first lymph nodes coloured were the peritracheobronchial nodes. There was no node in front of the thoracic trachea (Barety's compartment in man). Left suprabronchial nodes were connected with the thoracic duct in the mediastinum. The lymphatics of the heart and lungs in the pig are similar to those of human. Phylogenesis explains "skipping" metastases and the significance of N1 disease in lung cancer, as well as chylothorax occurring after heart and lung surgery.

[Malignant mediastinal lymph node tumors with unknown primary cancers]. / Adénopathies tumorales du médiastin sans cancer primitif.

PURPOSE: Malignant mediastinal lymph nodes with unknown primary tumor is a rare occurrence. The purpose of this study is to specify some characteristics of the patients presenting with this disease and to define an adequate therapeutic approach. MATERIAL AND METHODS: Between 1985 and 1997, we have operated on 54 patients with isolated non-small cell malignancy to mediastinal lymph nodes. Forty-nine patients underwent surgical biopsy of the mediastinal mass, generally followed by radiation therapy and/or chemotherapy. A mediastinal lymph node resection was performed in 5 patients. RESULTS: Five patients were lost to follow-up (9.3%). The 5-year survival rate and the median survival were 12.4 +/- 5% and 7 months respectively. Four of the 7 patients who were still alive after follow-ups ranging from 10 to 68 months had undergone a lymph node resection. During the follow-up, a primary tumor was discovered in only 5 patients (11.4%). CONCLUSIONS: Patients with isolated malignant lymph nodes of the mediastinum have a poor prognosis. In order to improve their survival, we recommend a more aggressive therapeutic approach comprising a chemotherapy and a mediastinal lymph node resection, associated in some cases with a lung resection. Radiation therapy of the mediastinum can be administered, principally in case of incomplete resection.

[Purulent pleurisy and lung cancer. Non-iatrogenic forms and therapeutic management]. / Pleurésies purulentes et cancer du poumon. Formes non iatrogènes et prise en charge thérapeutique.

Thoracic empyemas may occur during the course of lung cancer as a post-thoracotomy complication, or after pleural drainage and/or chemotherapy in cases when surgery was unfeasible, or may complicate the natural history of the disease and appear as the clinical event that led to its discovery. This latter situation is a challenge requiring to cure the infection in order to further treat the underlying lung cancer. We reviewed the cases of 18 men aged between 46 and 79 years that were referred to our surgical department from 1984 to 1996 for management of a thoracic empyema with an underlying lung cancer. Initial presentation of empyemas, lung tumor characteristics, treatments performed and their results were analyzed so as to formulate guidelines if possible. Mean duration of 17 empyemas before arrival was 26 days (8 to 60 days) and in one case empyema occurred during diagnostic work-up of an excavated lesion. Frank pus was observed in all cases and micro-organisms were identified in 13 cases. Empyema and diagnosis of lung cancer were concomitant in 15 cases: in 3 cases lung neoplasia was already diagnosed but patients had refused surgery. Empyema was treated by under water-seal chest tube drainage with adjunct fibrinolytic therapy in all cases; 2 elderly and cachectic patients suffering metastatic diffusion died rapidly. The other 16 recovered within one month. In 7 cases management was limited to medical treatment (palliative n = 2, chemotherapy n = 1, chemo combined radiotherapy n = 2 and radiotherapy alone n = 2) but only short survivals were observed (inferior to 10 months). Surgery was possible in 9 (pneumonectomy n = 8, lobectomy n = 1); there was no death; postsurgical empyemas complicated the cause twice but were easily cured by drainage; long term survivals were observed in 3 cases that were p NO. Pleural empyema complicating lung cancer is a rare but challenging situation. Once the pleural empyema has been controlled, surgical resection must be performed when indicated: postoperative complications are rare and long-term survival is possible.

Cervical venous anastomoses of pulmonary lymphatic vessels.

The aim of this study was to describe in detail the anastomoses between the pulmonary lymphatic vessels and the veins of the neck so as to better understand their role in certain aspects of thoracic surgery. The lymphatic vessels of 687 pulmonary segments in 360 cadavers were injected. A detailed study of the proximal end of the right paratracheal, right tracheo-esophageal, left preaortocarotid and left recurrent lymph node chains was undertaken. The results showed the absence of any major right lymphatic "vein". There were, however, many lymphatic arches draining into the jugulo-subclavian confluence ipsilaterally, and, in 10 to 15% of cases, contralaterally as well. The intertracheobronchial lymph nodes also drained into the venous confluence of the neck via direct lymphatic vessels, without lymph node relays. Finally, the left mediastinal lymph node chains were frequently found to drain into the arch of the thoracic duct (40% of cases), and reflux due to valvular incompetence at this level may account for chylous pericarditis and some cases of chylothorax after surgery.

[Cervical venous anastomoses of pulmonary lymphatic origin]. / Connexions veineuses cervicales des lymphatiques d'origine pulmonaire.

The aim of this study was to describe in detail the anastomoses between pulmonary lymphatic vessels and veins of the neck so as to better understand certain complications in thoracic surgery. Lymphatic vessels of 687 pulmonary segments in 360 cadavers were injected. Detailed study of the end of the right paratracheal, right thoraco oesophageal, left preaorticocarotid and left recurrent lymph node chains was undertaken. The results showed the absence of any major right lymphatic duct. There were, however, many lymphatic arches draining into the jugulo-subclavian confluent ipsilaterally and, in 10 to 25% of cases, contralaterally, as well. The intertracheobronchial lymph nodes also drained into the venous confluents of the neck, via direct lymphatic vessels, without lymph node relays. Lastly, the left mediastinal lymph node chains were frequently found to drain into the arch of the thoracic duct (40% of cases), and reflux by valvular incompetence at this level could be an explanation for chylous pericarditis and some chylothoraxes after surgery.

[The surgical management of pneumothorax in patients with AIDS]. / Prise en charge chirurgicale des pneumothorax chez les patients au stade de SIDA.

The occurrence of a pneumothorax occurring as a complication of AIDS is a poor prognostic sign. We have undertaken a review of 26 patients admitted to hospital for a pneumothorax of whom 25 were admitted for therapy: five resolved under simple drainage; twenty required a pleurodesis which was performed on thirteen under video thoracoscopy: these were recurrent pneumothoraces and were bilateral in half the patients; all had failed under simple drainage. The hospital mortality was 30%; the follow-up was unusually long in the majority of cases and only 20% had a simple follow-up. The analysis of this population showed that the results were not tied to the proposed treatment but to the state of the disease and to the pre-existence of pulmonary lesions most often in relation to pneumocystis. Video thoracoscopy enables one to inspect the lung and to resect the diseased area at the origin of the air leak. The technique also enables the pleurodesis to be achieved and a pleural or lung biopsy to be obtained in a relative non-invasive fashion.

Acquired factor VII deficiency associated with pleural liposarcoma.

Isolated acquired factor VII (FVII) deficiency (0.15 U/ml) was identified in a 30-year-old man with pleural liposarcoma. The patient underwent surgery with continuous FVII concentrate infusion. No anti-FVII antibody or FVII/anti-FVII complex was detected. However, the short half-life and low recovery of FVII after concentrate infusion suggested the presence of an antibody. Whatever the mechanism, this FVII deficiency was related to the presence of the liposarcoma. FVII level normalized during tumour regression and fell again when the liposarcoma relapsed.

[Excision of mediastinal nodes using video-thoracoscopy]. / Exérèse d'adénopathie médiastinale sous vidéothoracoscopie.

A man of seventy-one years with gross respiratory failure was suspected of having a cancer of the right upper lobe with metastases to the right pretracheal and intertracheobronchial nodes. A diagnostic mediastinoscopy did not achieve a diagnosis, and a right sub-bronchial node biopsy was performed, using videothoracoscopy and this revealed the presence of tuberculosis without any further delay.

[Extrapulmonary intrathoracic pneumocystosis. Apropos of 4 cases in HIV positive patients]. / Pneumocystoses intra-thoraciques extra-pulmonaires.

The authors report 4 cases of intrathoracic extrapulmonary pneumocystosis; 3 of them involved the pleura and 1 the mediastinal lymph nodes. As in other rare but apparently increasingly frequent cases, everything seemed to incriminate the use of prophylactic Pentamidine aerosols, but only a prospective study of systemic versus aerosol prophylaxis can confirm this suspicion.