[Reoperations for persistent or recurrent gastroesophageal reflux after surgical treatment]. / Réinterventions pour reflux gastro-oesophagien persistant ou récidivé après correction chirurgicale.

Thirty one cases of failed antireflux surgery were analyzed. The first operation had been performed on 24 patients with uncomplicated reflux and 7 patients with complicated reflux. There was an abnormality of the cardia in all cases. Twenty eight patients had been operated through an abdominal approach and 3 through a thoracic approach. The failure was diagnosed during the first year in 12 patients. The reflux became complicated in 17 cases. Oesophageal stenosis was the most common complication. Twenty four patients were reoperated through an abdominal approach and 7 through a thoracic approach. In 29 cases out of 31, an anatomical cause of the failure was found and rectified. Mortality was nil. The results of iterative surgery were good in 80 p. cent of cases after a mean follow up of 6 years.

Postresection irradiation for T2 N0 M0 non-small cell carcinoma: a prospective, randomized study.

BACKGROUND: Stage I nonirradiated T2 N0 non-small cell lung carcinoma has a postoperative prognosis not very different from stage II irradiated T1 N1 carcinoma. The hypothesis was that more locoregional malignant sites are overlooked in T2 N0 M0 than in T1 N0 M0 tumors, considering the better prognosis of this last group, and that T2 N0 cancer might benefit from postresection irradiation. METHODS: From 1985 to 1991, 163 non-small cell lung carcinomas were classified T2 N0 M0 and randomized for irradiation or nonirradiation after operation. After revision of all the cases, 132 were included in this study: 60 were irradiated and 72 were not irradiated. All were followed up. The study was closed in October 1995. Statistical analysis was then performed considering volume, location, cell type, survival, and recurrence in the two groups. RESULTS: One hundred thirteen patients were followed up during a minimum of 5 years: the survival was 44.2%. There was no significant difference considering cell type or irradiation. There was no recurrence-free survivor beyond 5 years with a tumor invading the visceral pleura. At the close of the study (follow up, 4 years 3 months to 10 years 1 month), 49 of 132 patients were alive. The median survival was 3 years 11 months. Fifty-nine patients had died of local (21) or distant (40) recurrences (2 patients had both local and distant recurrence). There was again no significant difference considering cell type or irradiation, either in the survival or in the mode of recurrence. CONCLUSIONS: Stage I T2 N0 M0 non-small cell lung carcinoma tends to manifest distant metastasis. Prospective studies of stratified systemic adjuvant therapy should improve the present moderate result of radical resection in this group of tumors.

Bronchogenic cysts of the lung.

BACKGROUND: The clinical presentation of lung bronchogenic cysts (BC) is variable, from respiratory distress at birth to late appearance of symptoms. METHODS: This study of BC was based on a retrospective review of 41 cases: 21 infants and children and 20 adults, aged 1 day to 68 years. The diagnosis was antenatal in 4 cases. Three infants required mechanical ventilation, and 2 had their cyst drained before resection. Twenty infants and children and 17 adults underwent operations. RESULTS: Compression was the most important complication in infants and children. Cough, infection, and hemoptysis occurred later in life; 80% of the total population was symptomatic. Seven cysts were infected. There were no deaths after resection, and there was no recurrence of symptoms during the follow-up period (13 months to 21 years). CONCLUSIONS: Bronchogenic cysts originate from the foregut. Differentiation from other acquired or congenital lesions can be difficult. It is uncertain what proportion of BC remain asymptomatic. More than half of patients are diagnosed after the age of 15 years, and complications may appear late. Clinical findings and plain chest radiograms are often sufficient for diagnosis. Lobectomy is the standard treatment, whereas drainage is a temporary, palliative, and risky procedure in cases of life-threatening compression. We conclude that a symptomatic BC is an indication for resection and that the long-term prognosis of an asymptomatic BC is unpredictable. Thus, there is a role for preventive operations.

Plasma cell granuloma of the lung: difficulties in diagnosis and prognosis.

BACKGROUND: The nature of plasma cell granuloma of the lung is still not well defined. Its diagnosis can be difficult, and its long-term prognosis is uncertain. METHODS: Four patients, aged 4 1/2 to 45 years, had resection of a circumscribed plasma cell granuloma. In 1 of them, it was associated with a carcinoma. The fifth patient was treated by irradiation for an invasive form of plasma cell granuloma, which was diagnosed as malignant lymphoma 1 year later. The plasma cell granulomas had a similar polymorphic pattern and were polyclonal at immunohistochemistry. RESULTS: The 3 patients treated by lobectomy, including the patient with an associated carcinoma, were alive and well at 12, 12, and 11 years postoperatively. The patient treated by pneumonectomy had recurrence 9 years later and died 11 years after operation: irradiation was not effective. The patient with lymphoma was treated by chemotherapy and was alive and in remission 5 years later. CONCLUSIONS: An accurate preoperative diagnosis is difficult. The results of biopsy can be inconclusive, and an associated malignancy can be missed. Complete resection remains the best treatment. The long-term prognosis is unpredictable, and late and fatal recurrences are possible.

Bronchioloalveolar carcinoma and congenital cystic adenomatoid malformation.

We report on a 42-year-old woman in whom was discovered a symptomless peripheral radiologic excavated lesion of the lung, which actually existed 3 years before. All investigations were negative. A segmentectomy was performed. Histopathologic examination proved a bronchioloalveolar carcinoma in contact with a type I congenital cystic malformation of the lung. Such a malformation can be diagnosed late in adult life. The epithelial cells of the malformation might predispose to slow proliferation and malignancy, enhanced by smoking habits.

Bronchogenic cysts of the mediastinum.

During a 25-year period 69 patients whose ages ranged from 1 day to 64 years were treated for bronchogenic cyst of the mediastinum. The male-to-female sex ratio was 1:0.76. The cysts were symptomatic in 63.7%, compressive in 43.4%, and life threatening in 2.8% of cases. Symptoms and signs of compression were more frequent in infants and children than in adults. Such symptoms and signs were more dependent on the location of the cyst than on its volume. The preoperative diagnosis was wrong in 16% of cases. The cysts were approached through thoracotomy in 67 cases, including one conversion from thoracoscopy, and through cervicotomy and mediastinoscopy in one case each. The cysts opened into the respiratory tract in five cases. No communication with the esophageal lumen was observed. The cystic contents were apparently infected in three cases, but samples remained sterile at culture. There was one hospital death caused by a centrally located compressive cyst that was undiagnosed at thoracotomy. The postoperative morbidity rate was 13.4%. There were no further symptoms after operation in children, but five adults reported continuing pain or dyspnea. Resection of bronchogenic cysts is recommended because of uncertainties in diagnosis and in evolution.

[Colonic esophagoplasty for benign lesions]. / L'oesophagoplastie colique pour lésions bénignes.

68 patients underwent oesophageal replacement for benign disease: atresia (12), reflux oesophagitis (16), caustic stenosis (37), internal fistula (3). The transplant was the ileocolon (27), the transverse (5) or left colon (36). It was substernal (55) or posterior mediastinal (13). A by-pass was performed without oesophagectomy (51) or an interposition accompanied oesophagectomy (17). The superior anastomosis was cervical (52) or thoracic (16). The inferior anastomosis was on the stomach (46), duodenum (10) or jejunum (12). Hospital mortality was 8.8%, morbidity was 57.3%. Among the 62 survivors, 18 had another operation. At the end of the survey, 68% had near normal function.

[Thoracic tumors after treatment for Hodgkin disease]. / Tumeurs thoraciques après traitement de la maladie de Hodgkin.

Twenty-one patients were admitted to the surgical unit for management of an intra-thoracic mass following treatment of Hodgkin's disease (HD). They consisted of 14 males and 7 females, with a mean age of 34 years (range: 17-62). Seven had recurrent HD, 14 had a non-Hodgkin solid tumour. HD recurrences were treated with repeated chemotherapy with 4 prolonged survivals including 1 relapse (40 to 84 months follow-up). Non-Hodgkin tumours were 13 lung carcinomas, which were resected in 4 cases, with only 1 prolonged survival (54 months) and malignant schwannoma. HD recurrences are observed equally in both young males and females and are subsequent to a mediastinal location of the disease, after an average 3.2 years. They are located on the borders or irradiation fields. Repeated chemotherapy is effective. Carcinomas more often appear in males, at an older age, in a favorable clinical context, after an average 10.2 years. Their prognosis is very poor. Irradiation and chemotherapy contribute to their development. Long-term risks of HD treatment must be considered.

[Open thoracic surgery of giant bullous pulmonary emphysema in adults]. / Chirurgie à thorax overt des bulles géantes d'emphysème pulmonaire chez l'adulte.

Ninety-two adult patients underwent open surgery for unilateral (60) or bilateral (32) emphysematous bullae filling at least one third of an hemithorax: 56 were apical, 34 were basal and 2 were apical on one side and basal on the other side. A first group of 18 patients were admitted in critical care medicine, after an acute complication, in a state of respiratory distress which was not controlled by oxygen therapy and/or drainage, 17 of them being mechanically ventilated at time of operation. In this group 9 patients died, 8 of them with bilateral bullae and 5 with cor pulmonale. A second group of 74 patients underwent surgery after a delay during which symptoms appeared or worsened, complications were observed or a radiological opacity was discovered. In this group 5 patients died. During a mean 4.8 year follow-up, 55 patients among the 71 survivors with no associated cancer were in a better functional state and remained clinically stable. The patients history and the results of surgery suggest that: 1) giant bullae should be resected when they increase in volume, when they are bilateral and when symptoms progress; 2) criteria for surgery are not limited to patients having compression of lower lobes from apical bullae; 3) it is necessary to operate on both sides for bilateral disease in elective surgery; 4) when there is a state of respiratory distress after a complication of bilateral bullae, the mortality is prohibitive; 5) cor pulmonale is of poor prognosis; 6) diffuse lung disease and associated diseases add to mortality and morbidity.(ABSTRACT TRUNCATED AT 250 WORDS)

Multiple primary lung cancers.

Seventy-five cases of multiple primary lung cancers, representing 3.78% of a series of 1980 consecutively resected tumors, were divided into 24 synchronous and 51 metachronous cancers, according to the criteria of Martini and Melamed. They all concerned tobacco-smoking men. The synchronous tumors were symptomatic in 66% of the cases, the metachronous tumors in 37%. Nine synchronous locations were unilateral and 15 were bilateral; 20 metachronous locations were ipsilateral and 31 were contralateral. There were three third metachronous cancers. The resection of both tumours was performed for 15 synchronous cancers and for 19 metachronous cancers, including two third metachronous tumors. There were two deaths related to metachronous cancers. No patient with resected synchronous cancers survived 5 years, while 20% of patients with resected metachronous cancers survived this period. Synchronous cancers appear to represent an advanced stage. Metachronous cancers are often diagnosed too late.

Neurogenic tumors of the thorax.

We have conducted a retrospective review of 134 cases of neurogenic tumors of the thorax, including 66 in infants and children and 68 in adults. Nerve cell tumors were the majority in infants and children (84.8%) and were mostly malignant (67.2%). Nerve sheath tumors were more frequent in adults (73.5%). Nerve cell tumors were the most frequent tumors in males and nerve sheath tumors in females. Nineteen tumors were associated with von Recklinghausen's disease. The tumors were symptomatic in 76.4% of children and 36.7% of adults. Spinal cord compression was observed in 8 infants and children and in 2 adults. Neo-adjuvant treatment was administrated to 3 patients. Resection was complete for 80 benign tumors out of 86 (93%) and for 26 malignant tumors out of 48 (54%). Postoperative chemo- or radiotherapy (or both) was administrated to 17 children and 8 adults. The mean followup periods were 11 years for the infants and children and 8 years, 6 months for the adults. There was one postoperative death. There were no late deaths related to benign tumor. The prognosis of spinal cord compression depended on the malignancy and staging of the tumors. At 5 years postoperatively, 21 children out of 28 with neuroblastomas and 8 out of 9 with ganglioneuroblastomas were alive. The possibility of maturation of neuroblastomas and survival with hepatic metastases was confirmed. The prognosis in cases of chemodectoma depended on the extension. Patients with malignant schwannomas had very poor prognoses, especially when associated with von Recklinghausen's disease.

Pulmonary hamartoma and malignancy.

Sixty-five patients, aged 15 to 65 years, including 48 men (73.8%), were operated on for pulmonary (60) or endobronchial (5) hamartoma: there were 36 enucleations, 17 lobectomies (1 sleeve resection), 7 wedge resections, 4 segmentectomies, and 1 pneumonectomy. The average tumor diameter was between 2 and 4 cm; 15 were calcified. All were benign. Two were parts of an incomplete Carney's triad. Eight were associated with carcinomas, and three of these were bronchial carcinomas. Concerning these latter three tumors, a study of the incidence tables for northern France and of the standardized mortality ratio showed that the risk of bronchial cancer developing in patients with hamartoma, after a sufficient follow-up (61 patients), was multiplied by 6.66, and the chi 2 test showed a significant difference of incidence compared with that in the general population (p < 0.001). It is concluded that patients with hamartoma should be submitted to a complete evaluation and to a regular follow-up.