Tracheal sleeve resection for iatrogenic stenoses (subglottic laryngeal and tracheal).

Since 1975 200 tracheal sleeve resections for iatrogenic tracheal and subglottic laryngeal stenoses have been performed in our institution. Preoperative Nd:YAG laser is of paramount help in opening the stenoses. Tracheography is usually performed to specify the length of the stenosis and the distance from the vocal cords. Operative procedures are described. One hundred seventy five (87.5%) patients are definitely cured, but in this group 16 patients required a Montgomery tube for 6 months to 1 year to recover a normal tracheal diameter. Two patients needed a second tracheal sleeve resection. Nine (4.5%) patients died, and 16 (8%) had recurrent stenoses. Stenoses in these patients were treated with use of a tracheostomy tube, a permanent Montgomery tube, or an endotracheal stent. Partial anterior cricoid resections performed in 21 patients have had the same results as those of the whole series. Twenty one laryngeal releases were performed and proved to be efficient and safe. In our experience complications can be avoided by good selection and preparation of the patients, accurate identification of the level and length of the stenosis, and meticulous technique.

[Injection of collagen in recurrent paralysis after thoracic surgery]. / L'injection de collagène dans les paralysies récurrentielles après chirurgie thoracique.

The author describes a new technique of treatment of recurrent laryngeal nerve paralysis by intra-cordal injection of collagen after thoracic surgery. After description of the collagen used and the technique of injection, the author presents the results. It is a new method, simple, efficient, well tolerated, giving patients a voice, and treating their swallowing troubles.

Laser in bronchology: methods of application.

The method of application for the endoscopic resection by Nd-YAG-Laser closely depends on the choice of indications. The use of rigid bronchoscope is compulsory in the field of Laser, because of tracheobronchial obstruction in patients which are more or less on the verge of asphyxia. The resection is achieved under general anesthesia. A Nd-YAG-Laser (1.06 wavelength) with 100 watts maximum power is satisfying. The new 200 microns fibers are nearly perfectly flexible and increase the range of endobronchial laser-application. For some time we used a superpulsed mode of laser emission which obtains a real evaporation of tissues instead of carbonization. Cryotherapy may be useful before some resections to minimize bleeding. Endoprotheses can prolong the therapeutic effect of recanalization achieved by laser in end stage carcinomas.

[Pulmonary papillomatosis]. / La papillomatose pulmonaire.

The authors report a case of a 30 year old woman with juvenile laryngeal papillomatosis (JLP) who subsequently developed intra-alveolar papillomas. These papillomas demonstrated a marked pseudo-neoplastic loco-regional invasive activity, but did not possess the histological criteria of malignancy and were treated by pneumonectomy and lobectomy.

[Adenoid cystic carcinoma of the trachea. Treatment by combined laser therapy and surgery]. / Carcinome adénoïde kystique de la trachée. Traitement par l'association laser-chirurgie.

In the group of adenomas of the trachea and bronchi, cystic adenocarcinomas or cylindromas are malignant tumours, whose outcome is much slower than those of the usual type of cancer. An unusual case is reported in which treated was firstly carried out with laser therapy and then surgery.

Indications and technique for endoscopic laser resections in bronchology. A critical analysis based upon 2,284 resections.

Over a period of 6 years, we have treated 1,310 patients in 2,284 sessions using a neodymium-yttrium aluminum garnet laser. Indications are more often palliative than curative, with the primary goal to relieve an obstructed airway in a single treatment. The effectiveness of such resections is widely recognized, but indications for such a technique with its limitations deserve emphasis. The use of a rigid bronchoscope is important to provide satisfactory operating conditions and especially to manage hemorrhage rapidly while maintaining a satisfactory airway.

[The treatment of tracheobronchial amyloidosis using a bronchial laser. Apropos of a series of 13 cases]. / Le traitement de l'amylose trachéo-bronchique par broncho-laser. A propos d'une série de treize cas.

We have encountered and successfully treated thirteen cases of tracheobronchial amyloidosis using a laser. The clinical data, radiology, endoscopic and histological appearance of these patients were similar to that described in the literature (48 published cases). A YAG laser was used, introduced through a rigid bronchoscope. The principal difficulties of this type of resection were related to the oozing of blood which they caused. Only lesions in the trachea, main and lobar bronchi could be destroyed. 8 of the 9 patients followed for sufficiently long were clearly improved but a patient whose lesions were very diffuse did not experience any benefit. The laser seems to us above all to be indicated when there is considerable obstruction by amyloid, limited to the trachea and/or several of the major bronchi.

[The YAG-Nd laser in bronchology. Its role in noncancer pathology]. / Le laser YAG-Nd en bronchologie. Sa place dans la pathologie non cancéreuse.

Whereas the CO2 laser has rapidly become an essential tool in laryngology, only a few teams use the YAG-Nd laser in bronchology. This is due to several factors, these explaining the reason for the slow diffusion of a method that has been available for 5 years. Firstly, indications are and will be very limited, and are mainly palliative in scope, particularly for tracheobronchial cancer, which represents half of the cases treated. Secondly, many endoscopic resections are dangerous and conducted at the price of a risk of asphyxia. They require an operative protocol and follow up surveillance of perfect security. Finally, it is evident that flexible endoscopic material is poorly adapted to this technique and indications have to be restricted by those who refuse to return to the archaic rigid tube.

[Diffuse hepato-pulmonary hydatidosis. Apropos of a case]. / Hydatidose hépato-pulmonaire diffuse. A propos d'une observation.

The authors report a case of diffuse hydatid disease of the lung and liver. This association accounts for about 20 per cent of cases. Diffuse lesions are, on the other hand, exceptional. In this case the lung and liver functions were both impaired. Surgical management involved resection of the top of the cyst protruding from the liver and pulmonary cystectomy. The relative simplicity of the postoperative course, restoration of liver function and improvement in lung function prompt the authors to recommend surgical management of these cases, which cannot be treated medically.

[Malignant ameloblastoma. Apropos of a case]. / Les améloblastomes malins. A propos d'un cas.

Ameloblastoma is a locally invasive, histologically nonmalignant tumor that may on very rare occasions give rise to metastases. A patient with a mandibular ameloblastoma presenting typical histologic appearances developed a pulmonary metastasis confirmed by histology as arising from the primary tumor. Two groups of these extremely rare malignant ameloblastomas can be distinguished: those without histologic signs of degeneration that give rise to metastases identical to the primary lesion, and those with degenerative signs provoking metastases with the histologic appearance of undifferentiated carcinoma. No relation appears to exist between size of primary tumor, histologic type of ameloblastoma, or its course and tendency to produce metastases.

[Diaphragmatic eventration in adults. Apropos of 20 cases]. / Eventrations diaphragmatiques de l'adulte. A propos de vingt cas.

Twenty adults with a mean age of 49 were operated on between 1972 and 1980 for eventration of the diaphragm. The etiology was probably traumatic in 11 cases; it was congenital in 2 and degenerative in 7. The functional signs were usually respiratory (55%) or digestive (10%). In all cases, the diagnosis was based on standard fluoroscopy showing superelevation of the hemidiaphragm, which was visualized fluoroscopically as immobile while a pneumoperitoneum showed a absense of any tear. Spirography confirmed a restrictive deficit which was sited broncho-spirometrically on the eventration side. Surgical repair was achieved in most cases by thoracotomy (19 cases) and consisted in plication (17 cases) or incision followed by suturing of the overlapping edges of the muscle (3 cases). Postoperative complications included the death of the patient with multiple trauma, on the eight postoperative day, as a result of the cerebrovascular accident, and in another case rutpure of the repair on the second day, requiring a second operation. Apart from one patient who died as a result of a fatal accident two years postoperatively, all the surgically treated cases are alive, and, with one exception, symptom free. After an average follow up period of 2 years and 2 months, the control respiratory function tests show a 21% improvement in vital capacity and a 20% increase in FEV1. On the basis of these results, the authors conclude that this functional surgery is justified in the case of patients presenting with typical clinical symptoms, and worth considering in cases where respiratory function tests show a restrictive deficit, but also in patients who do not complain of breathlessness.

Bronchoscopic management of tracheal lesions using the neodynium yttrium aluminium garnet laser.

We report our first clinical trials with the NdYAG laser in the treatment of tracheal and bronchial tumours and stenoses. The beam is carried through a flexible fibre delivering a power of 50 to 90 watts. It can be introduced through the biopsy channel of a standard bronchoscope, or through a fibrescope. Anaesthesia must avoid inflammable gases. In most cases, general anaesthesia was used, and ventilation achieved with a mixture of 50% nitrogen and oxygen, using a modification of the Sanders injector. One hundred and sixty-four cases have been treated in 317 sessions (from one to five sessions per patient). They comprised: 72 cancers, 24 of which had just been diagnosed and had acute respiratory obstruction. In 16, one single session restored the patency of the airway. Forty-eight other cases were recurrent carcinomas after either surgery or radiotherapy, nine of which were caused by cancers of other origin invading the trachea; 21 benign or moderately malignant tumours; 44 iatrogenic stenoses, including 31 narrow ones. Of those 31 cases, 17 had an immediate satisfactory result, but eight recurred; 24 granulomas on bronchial suture lines. There were two deaths not directly related to surgery or anaesthesia. Bleeding was never more than moderate. The main difficulty lies in the critical respiratory condition of the patients, sometimes seen in acute asphyxia, referred to us as a last resort, especially those with carcinomas involving the trachea or main bronchi.