Alain Badia

Postmastectomy neuropathic pain: results of microsurgical lymph nodes transplantation.

UNLABELLEDnPostmastectomy chronic pain may be divided into widespread and regional pain. Almost half patients with regional pain, which is more likely related to neuropathic phenomena, do not benefit any pain relief from medication. Our purpose was to report results on pain relief obtained by axillary lymph nodes autotransplantation.nnnMETHODSnSix patients presented with chronic regional neuropathic pains and upper limb lymphedema after breast cancer surgery and radiation therapy. Despite medication, pain was intolerable and daily activity dramatically reduced. Lymph nodes were harvested in the femoral region, transferred to the axillary region and transplanted by microsurgical procedures.nnnRESULTSnLymphedema resolved in 5 out of 6 patients. Pain was relieved in all, permitting return to work and daily activity; analgesic medication was discontinued.nnnCONCLUSIONnThis procedure proved efficient and may be advocated in case of neuropathic pain when discussing lymphedema management.

Bronchial sleeve resections: lung function resurrecting procedure

OBJECTIVEnMainstem bronchus obstruction results in lung function exclusion. The aim of this study was to revisit lung function restoration obtained by different types of bronchial sleeve resections in selected patients with endobronchial tumors.nnnMETHODSnEleven patients (9 women and 2 men, mean age 47 years) presented with endobronchial tumors and ipsilateral lung function exclusion. Mainstem bronchial sleeve resection was performed in 7 patients, right bilobar and mainstem bronchial sleeve resection in 2, and left upper sleeve lobectomy in 2. Tumors consisted in 8 bronchial carcinoids, 2 adenoid cystic carcinomas, and one inflammatory myofibroblastic tumor. Fiberoptic bronchoscopy and quantitative ventilation-perfusion lung scan were performed in all patients at work-up to assess lung function exclusion and during the first year following bronchoplastic procedure to study recovery. Long-term follow-up consisted of physical examination, thoracic computed tomographic scan and bronchoscopy every year.nnnRESULTSnThere was no postoperative death. The long-term follow-up was complete and ranged from 12 to 192 months (median: 102.7 months). The lung function was completely restored in all patients. The ventilation function was immediate, but the perfusion was restored in a mean interval of 8.2 months (ranging from 3 to 12 months). All patients are currently alive, and no local tumor recurrence was observed.nnnCONCLUSIONSnSome obstructing tumors may be removed by various types of bronchial sleeve resections that permit lung function restoration and long-term local control of the disease. However, at least one year is required for lung perfusion to completely recover, despite immediate ventilation restoration.

Role of video-assisted thoracoscopy in patients with ovarian cancer and pleural effusion.

Objectives: To evaluate the feasibility of video-assisted thoracoscopy (VAT) for staging advanced ovarian cancer, to measure the performance of preoperative computed tomography (CT) for diagnosing pleural metastases, to assess the correlation between pleural and abdominal involvement, and to measure the impact of VAT on patient management. Methods: We retrospectively evaluated 16 VAT procedures in 15 patients with advanced ovarian malignancies and pleural effusions. The reason for VAT was either to evaluate unilateral or bilateral pleural effusions (n = 15) or to evaluate pleural metastases after neoadjuvant chemotherapy (n = 1). Preoperative CT was performed routinely, and findings were compared with those of VAT. The rates of involvement of the hepatic pedicle, mesentery, and right side of the diaphragm were compared with the rate of pleural involvement. Results: The right side of the chest was examined 12 times; and the left side, 4 times. There were no complications; 1 procedure was stopped because of ventilatory intolerance. Video-assisted thoracoscopy identified metastases smaller than 1 cm in 5 patients and larger than 1 cm in 2 additional patients; there was no evidence of pleural involvement in 6 patients. Computed tomography had 14% sensitivity and 25% specificity for pleural status determination, using VAT biopsy as the reference standard. Pleural involvement did not correlate with involvement of the hepatic pedicle, mesentery, or right side of the diaphragm. Conclusions: Video-assisted thoracoscopy performs better than CT for evaluating pleural involvement in ovarian cancer. Video-assisted thoracoscopy supplies accurate data on thoracic involvement, which does not seem predictable from the peritoneal involvement. Video-assisted thoracoscopy may impact patient management.

Chylous reflux into localized pulmonary lymphangiectasis

Spontaneous chylothorax is uncommon and may originate from different etiologies either pleural, pulmonary, or mediastinal. Chyloptysis is a still rarer clinical problem and always of pulmonary origin. We report 2 cases: the first, a 63-year-old woman presenting with a chylothorax, and the second, a 28-year-old man with chyloptysis. Both were successfully treated with a medium chain triglyceride diet. Lymphangiograms demonstrated an identical origin for the 2 cases: reflux from the thoracic duct into right lower lobe lung lymphangiectasis. In our experience, chylous reflux into pulmonary lymphangiectasis is not as rare as believed and many cases probably remain undiagnosed.

Diaphragm pacing: the state of the art

Diaphragm pacing (DP) is an orphan surgical procedure that may be proposed in strictly selected ventilator-dependent patients to get an active diaphragm contraction. The goal is to wean from mechanical ventilation (MV) and restore permanent efficient breathing. The two validated indications, despite the lack of randomised control trials, concern patients with high-level spinal cord injuries (SCI) and central hypoventilation syndromes (CHS). To date, two different techniques exist. The first, intrathoracic diaphragm pacing (IT-DP), based on a radiofrequency method, in which the electrodes are directly placed around the phrenic nerve. The second, intraperitoneal diaphragm pacing (IP-DP) uses intradiaphragmatic electrodes implanted through laparoscopy. In both techniques, the phrenic nerves must be intact and diaphragm reconditioning is always required after implantation. No perioperative mortality has been reported and ventilator-weaning rate is about 72% to 96% in both techniques. Improvement of quality of life, by restoring a more physiological breathing, has been almost constant in patients that could be weaned. Failure or delay in recovery of effective diaphragm contractions could be due to irreversible amyotrophy or chest wall damage. Recent works have evaluated the interest of IP-DP in amyotrophic lateral sclerosis (ALS). After some short series were reported in the literature, the only multicentric randomized study including 74 ALS patients was prematurely stopped because of excessive mortality in paced patients. Then, another trial analysed the place of IP-DP in peripheral diaphragm dysfunction but, given the multiple biases, the published results cannot validate that indication. Reviewing all available literature as in our experience, shows that DP is an effective method to wean selected patients dependent on ventilator and improve their daily life. Other potential indications will have to be evaluated by randomised control trials.

Endométriose pleurale : une présentation inhabituelle

Resume Introduction Les etiologies des epanchements pleuraux chroniques exsudatifs sont nombreuses. L’endometriose est une cause rare d’epanchement pleural chronique unilateral avec pachypleurite diffuse. Cas clinique Nous rapportons un cas d’epanchement pleural chronique droit chez une jeune femme africaine âgee de 30 ans faisant decouvrir une endometriose pleurale dont le diagnostic a ete porte de facon fortuite apres decortication pleuro-pulmonaire. L’immunomarquage fut un apport indispensable au diagnostic dans cette situation. Conclusions Une endometriose pleurale doit etre evoquee devant tout epanchement pleural de nature indeterminee chez la femme. La presence de glandes endometriales ou de chorion cytogene au sein de la plevre est evocatrice. L’immunomarquage est un outil important du diagnostic.

Can mathematics replace anatomy to establish recommendations in lung cancer surgery

The greater the number of lymph node (LN) sampled (NLNsS) during lung cancer surgery, the lower the risk of underestimating the pN-status and the better the outcome of the pN0-patients due to stage-migration. Thus, regarding LN sampling to be or not to be, number is the question. Recent studies advocate removing 10 LNs. The most suitable NLNsS is unfortunately impossible to establish by mathematics. A too high NLNsS variability exists, based on anatomy, surgery and pathology. The methodology may vary according to Inter-institutional differences in the surgical approach regarding LN inspection and number sampling. The NLNsS increases with the type of resection: sublobar, lobectomy or pneumonectomy. Concerning pathology, one LN may be divided into several pieces, leading to number overestimation. The pathological examination is limited by the number of slices analyzed by LN. The examined LNs can arbitrarily depend on the probability of detecting nodal metastasis. In fact, the only way to ensure the best NLNsS and the best pN-staging is to remove all LNs from the ipsilateral mediastinal and hilar LN-stations as they are discovered by thoroughly dissecting their anatomical locations. In doing so, a deliberate lack of harvest of LNs is unlikely, number turns out not to be the question anymore and a low NLNsS no longer means incomplete surgery. This prevents from judging as incomplete a complete LN dissection in a patient with a small NLNsS and from considering as complete a true incomplete one in a patient with a great NLNsS. Precise information describing the course of the operation and furnished in the surgeons reports is also advisable to further improve the quality of LN-dissection, which ultimately might be beneficial in the long-term to patients. However, that procedure is of limited interest in pN-staging if LNs are not thoroughly examined and also described by the pathologist.

Lung transplantation in childhood and adolescence: unicentric 14-year experience with sex matching as the main prognosticator.

OBJECTIVESnLung transplantation (LTx) is an accepted therapy for selected infants, children and adolescents with end-stage lung and pulmonary vascular disease. It remains a challenge for a selected group of patients. In 2011, the number of paediatric lung transplantations (PLTxs) worldwide was 107. In France, a total of 131 PLTxs have been performed since 2000 (data from ABM: Agence de biomédecine), 65 of which were conducted at our institution.nnnMETHODSnAll patients under 18 (4.8-17.11) years of age matching inclusion and exclusion criteria, who underwent LTx at our institution were included in this study (n = 58). We analysed the outcomes of these patients in terms of survival rates, controlling for indications for transplantations and surgical procedures. Secondary outcomes were analysis of surgical and medical complications and identification of prognostic factors in the field of LTx in these categories of ages.nnnRESULTSnThe 30-day mortality rate was 10%. Kaplan-Meier survival rates at 1 month, 1, 3, 5 and 10 years were 90, 81, 66, 60 and 57%, respectively; the median survival was 91 months. Reduced-size transplantation was performed in 33% of double-lung transplantation (DLTx) patients without negatively impacting survival. In our series, female sex, the presence of a sex mismatching and, in particular, the occurrence of a male donor to a female recipient (F/M group) have been poor prognostic factors after PLTx.nnnCONCLUSIONSnThe overall survival after PLTx was encouraging (57% at 10 years). A PLTx should be offered to the small number of patients with end-stage pulmonary disease. The limited number of paediatric donor organs can be overcome by using reduced-size organs without a survival disadvantage to the patients. In our series, male sex and sex matching seemed to be positive predictive prognostic factors after PLTx but further studies are required to confirm these results and to also clarify the role of age of donor, time of cold ischaemia and body mass index in PLTx.

Chirurgie pulmonaire dans la tuberculose et les mycobactérioses atypiques

Tuberculosis and non-tuberculous mycobacteria are common indications of pleural and mediastinal surgery on a diagnostic intend. However, parenchymatous resection on a curative intend has been proven to benefit to patients with multiresistant tuberculosis in adjunction with prolonged antibiotic treatment. Furthermore, tuberculosis sequelae, i.e. destroyed lung, Aspergillus-infected cavitary tuberculosis, and related hemoptysis are eradicated by a surgical management after careful medical preparation. Finally, surgical resection of localized Mycobacterium avium and M.xa0xenopii infections is associated with a high rate of sputum conversion and a low morbidity.

Cancer du poumon en oncogériatrie : quelles possibilités chirurgicales dans le grand âge ?

Geriatric oncology is a rapidly expanding domain because of the deep epidemiological changes of the last decades related to the ageing of the population. Lung cancer treatment in patients 75 years and over is a major issue of thoracic oncology. Curative surgery remains the treatment offering the best survival rates to the patient whatever his age. The important variability observed within the elderly forces us to take into account their specificities, in particular for ageing physiology and associated comorbidities. Thus, preoperative workup permitting to assess the resectability of the tumor but also the operability of the patient is all the more essential in the advanced age that it must be adapted to the particular characteristics of the elderly. Thanks to recent data of the literature, morbidity and mortality associated to surgical treatment are now better characterized and considered as acceptable in accordance with long-term survival. Clinical investigation remains essential to acquire a better knowledge of potential benefit of multimodal treatments in the elderly, for which very few data are available.