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.

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.

[New approach for implantation of automatic defibrillators using videothoracoscopy]. / Nouvelle approche pour l'implantation des défibrillateurs automatiques utilisant la vidéo-thoracoscopie.

Nonthoracotomy lead systems are increasingly used in patients (pts) with implantable cardioverter defibrillator (ICD). In this setting, due to high energy requirements, a subcutaneous patch may be necessary in addition to endocardial leads. However in some patients, high defibrillation threshold (DT) may persist leading to thoracotomy for epicardial patch placement. In a preliminary experience, 3 patients with high DT (> 20 J) following endocardial lead system, underwent the insertion of a extrapericardial patch under video-thoracoscopic control. A left subcostal incision extended to the left pleural cavity was performed. Using thoracoscopy the patch was positioned on the pericardium, sutured and connected to the defibrillator. DTs were 10, 10 and 20 J respectively in our 3 patients. Postoperative course was uneventful. Thoracoscopy allows other techniques such as a stellectomy, which we performed in a 33 year old woman with long QT syndrome. Patients were reassessed after 8 days and 2 months. Termination of induced ventricular fibrillation was achieved with the same minimal energy levels used peroperatively. In conclusion, extrapericardial patch insertion using thoracoscopy may help reduce DT in ICD patients with a non thoracotomy lead system. Comparison with other lead configurations requires further investigation.

Disseminated Scedosporium prolificans (S. inflatum) infection after single-lung transplantation.

This report concerns the first case of disseminated infection with Scedosporium prolificans (S. inflatum) that occurred in a patient who had received an organ transplant and was verified at autopsy. The patient underwent single (right)-lung transplantation and subsequently died on the 33rd postoperative day in a context of septic shock. S. prolificans was isolated from various specimens, including two cultured blood samples. The organism was associated with Candida albicans in some of these specimens. Autopsy revealed the presence of numerous nodular abscesses in the lungs, myocardium, kidneys, spleen, and gall bladder. These abscesses contained mycelial filaments and numerous oval conidia suggestive of Scedosporium species but no yeasts. MIC studies demonstrated the resistance of the S. prolificans isolate to amphotericin B, fluctyosine, miconazole, ketoconazole, and itraconazole, whereas the isolate of C. albicans was susceptible to amphotericin B, flucytosine, miconazole, and ketoconazole. From the data from our case and six published reports of cases of disseminated S. prolificans infection, it can be concluded that this filamentous fungus is a new agent responsible for the most serious mycoses in both neutropenic patients and patients who have undergone organ transplantation.

[Phlebitis of the right upper limb and thromboembolic pulmonary hypertension. Apropos of a case of heart-lung transplantation]. / Phlébite du membre supérieur droit et hypertension artérielle pulmonaire thrombo-embolique. A propos d'un cas traité par greffe coeur-poumons.

The authors report the case of a 25 year old man with unexplained pulmonary hypertension during his first hospital admission. However, a past medical history suggesting right arm vein thrombosis was obtained. Venography showed signs of thoraco-brachial compression. After heart-lung transplantation, pathological studies of the explanted organs showed changes of thrombo-embolic pulmonary hypertension. A spontaneous right arm venous thrombosis occurred during convalescence. The possibility of post-embolic pulmonary hypertension caused by venous thrombosis of the upper limbs is discussed.

[New approach to implantation of automatic defibrillators using video-thoracoscopy]. / Nouvelle approche pour l'implantation des défibrillateurs automatiques utilisant la vidéo-thoracoscopie.

Nonthoracotomy lead systems are increasingly used in patients (pts) with implantable cardioverter defibrillator (ICD). In this setting, due to high energy requirements, a subcutaneous patch may be necessary in addition to endocardial leads. However in some patients, high defibrillation threshold (DT) may persist leading to thoracotomy for epicardial patch placement. In a preliminary experience, 3 patients with high DT (> 20J) following endocardial lead system, underwent the insertion of a extrapericardial patch under video-thoracoscopic control. A left subcostal incision extended to the left pleural cavity was performed. Using thoracoscopy the patch was positioned on the pericardium, sutured and connected to the defibrillator. DTs were 10, 10 and 20 J respectively in our 3 patients. Postoperative course was uneventful. Thoracoscopy allows other techniques such as a stellectomy, which we performed in a 33 year old woman with long QT syndrome. Patients were reassessed after 8 days and 2 months. Termination of induced ventricular fibrillation was achieved with the same minimal energy levels used peroperatively. In conclusion, extrapericardial patch insertion using thoracoscopy may help reduce DT in ICD patients with a non thoracotomy lead system. Comparison with other lead configurations requires further investigation.

[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.

[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).

[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.

[Primary tumor of the thoracic wall unusual in aged patients: costal osteosarcoma]. / Une tumeur primitive de la paroi thoracique inhabituelle chez le sujet âgé: l'ostéosarcome costal.

Osteosarcoma is a tumour that is encountered in children and young adults but is exceptional in elderly people. Moreover, it is very rarely located in the chest. A case of costal osteosarcoma revealed by a pleural blood effusion is reported in a 66-year old male patient. Full surgical excision completed by parietal reconstruction was performed. The diagnosis of osteosarcoma was definitely confirmed at pathological examination. A few months later, a local recurrence associated with ipsilateral lung metastasis, was discovered and the patient was put on chemotherapy. The clinical, radiological and therapeutic aspects of this case are discussed.

[Acute arterial neoplastic 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.

[Surgery of the thoracic aorta. Value of tissucol]. / Chirurgie de l'aorte thoracique. Intérêt du tissucol.

The techniques for sealing with the Tissucol fibrin glue, used in repair of aortic dissections and aneurysms, are described. We applied this method to 24 patients operated upon for acute (9 cases) or chronic (15 cases) lesions of the thoracic aorta. No patients died of haemorrhage, and post-operative bleeding was only 500 ml on average. Provided strict precautions are taken, this adjuvant haemostatic method considerably improves the immediate prognosis of acquired aortic lesions. Other operations of cardiac surgery may benefit from these sealing techniques the cost of which must be weighed against the blood transfusion units that are saved.