Alain Wurtz

Resection of Adrenal Metastases From Non-Small Cell Lung Cancer: A Multicenter Study

BACKGROUND In recent case reports and limited series, adrenalectomy was recommended for an isolated adrenal metastasis from non-small cell lung cancer (NSCLC). METHODS We retrospectively studied patients with a solitary adrenal metastasis from NSCLC who had undergone potentially curative resection in eight centers. RESULTS Forty-three patients were included. Their adrenal gland metastasis was discovered synchronously with NSCLC in 32 patients, and metachronously in 11. It was homolateral to the NSCLC in 31 patients and contralateral in 12 (p < 0.01). Median survival was 11 months, and 3 patients survived more than 5 years. There was no difference between the synchronous and metachronous groups regarding recurrence rate or survival. Survival was not affected by the homolateral location of the metastasis, the histology of the NSCLC, TNM stage, any adjuvant and neoadjuvant treatment, or, in the metachronous group, a disease-free interval exceeding 6 months. CONCLUSIONS We confirm the possibility of long-term survival after resection of isolated adrenal metastasis from NSCLC, but no clinical or pathologic criteria were detected to identify patients amenable to potential cure.

Outcome at 2 years of infants with congenital diaphragmatic hernia: a population-based study

BACKGROUND Management of neonates with congenital diaphragmatic hernia (CDH) has undergone many changes associated with increased survival of high-risk CDH. However, little is known about the long-term outcome of CDH infants. METHODS Follow-up was performed in 85 newborn infants with CDH admitted in our neonatal intensive care unit between January 1991 and December 1998. Early (< 2 months) and late mortality (> or = 2 months), and respiratory, nutritional, musculoskeletal, and neurosensory outcome at 2 years were recorded. RESULTS Surgical repair was performed in 59 infants (69%) at a median postnatal age of 124 (range, 38 to 246) hours. Extracorporeal membrane oxygenation was used in 26 (30%) newborn infants. Survival at 2 years was 51 of 85 (60%) (early death, 28/85 [33%]; late death, 6/85 [7%]). Late deaths occurred because of persistent pulmonary hypertension or iatrogenic complications. Twelve of 51 (24%) newborn infants were oxygen dependant at the postnatal age of 28 days, and 1 of 51 (1.9%) was still oxygen dependant at 2 years. Growth failure was noted in 9 of 51 (18%), mainly related to severe gastroesophageal reflux and oral aversion. Scoliosis was diagnosed in 2 infants. Neurologic examination at 2 years was normal in 45 of 51 (88%). Cerebral palsy and developmental delay were observed in 2 and 4 infants, respectively. Four infants (8%) experienced associated problems. Respiratory, nutritional, and musculoskeletal morbidity was higher in infants treated by extracorporeal membrane oxygenation (p < 0.05). CONCLUSIONS CDH infants are at risk for adverse nutritional and respiratory outcome. Despite severe respiratory failure at birth, prolonged oxygen therapy above 2 years of age is uncommon. Conversely, failure to thrive related at least in part to gastroesophageal reflux and oral dysfunction remains the major problem at 2 years of age. However, both nutritional and respiratory problems tend to improve with age.

Randomized controlled trial of a synthetic sealant for preventing alveolar air leaks after lobectomy

BACKGROUND The intraoperative application of synthetic surgical lung sealant (SLS) to surfaces leaking air or at risk of air leaks has been advocated to reduce alveolar air leaks (AAL) after lobectomy. METHODS This study was designed to investigate the effectiveness of SLS in reducing AAL in patients considered intraoperatively to have moderate to severe AAL, after all conventional measures to reduce such leaks had been used. Over 17 months, 124 patients undergoing standard lobectomy were randomized to standard closure of parenchymal surgical sites, with or without SLS. RESULTS In treated patients, the mean numbers of intraoperative AAL after application of SLS were significantly smaller than in untreated patients (38.5 mL versus 59.9 mL, p = 0.0401). Postoperatively, the mean time to last observable AAL was shorter in the treated group (33.7 hours versus 63.2 hours, p = 0.0134) and the mean percentage of patients free of AAL at days 3 and 4 was smaller (87% versus 58.5%, p = 0.002). However, the occurrence of incomplete lung expansion after drain removal, and the length of the postoperative hospital stay due to prolonged AAL, were not different. In the treatment group, 4 patients developed localized empyema and incomplete lung expansion without bronchopleural fistula 7, 12, 15, and 20 days, respectively, after operation. In these 4 patients, inserted chest tubes drained infected sealant. CONCLUSIONS Surgical lung sealant may be a useful adjunct to conventional techniques for reducing moderate and severe AAL after lobectomy, but its use seems to increase the risk of postoperative empyema.

Pericardioscopy in the Etiologic Diagnosis of Pericardial Effusion in 141 Consecutive Patients

BACKGROUND Although previous small series have documented the utility of pericardioscopy for accurate etiologic diagnosis of pericardial effusion, this technique remains underused. The aim of our study was to assess the benefits and risks of surgical pericardioscopy in a large prospective series. METHODS AND RESULTS One hundred forty-one consecutive patients with unexplained pericardial effusion underwent 142 pericardioscopies with a rigid mediastinoscope. For each patient, the etiologic data obtained by pericardioscopy (visualization of pericardium, guided biopsies, subxiphoid window biopsy, and fluid analysis) were compared with the results that would have been obtained with only conventional surgical drainage and biopsy (subxiphoid window biopsy and fluid analysis). After complete workup, a specific cause was found in 69 cases (48.6%); the other 73 cases were considered idiopathic effusions (51.4%). Procedural and in-hospital mortality was 8 of 141 patients (5.6%). No death was directly attributable to pericardioscopy. During long-term follow-up (median duration, 24 months; range, 6 to 96), a previously unrecognized cause was discovered in 6 patients (4%). By comparing the areas under the receiver-operating characteristic curves, the diagnostic advantage of pericardioscopy was significant for the whole series (pericardioscopy, 0.98 +/- 0.011; conventional surgical drainage, 0.89 +/- 0.029; P < .001). The increase in sensitivity was more marked for some types such as neoplastic (21%), radiation-induced (100%), or purulent (83%) effusions. CONCLUSIONS Our data demonstrate that pericardioscopy increases the diagnostic sensitivity of surgical pericardial drainage and biopsy without specific risk.

The role of mediastinoscopy in the diagnosis of mediastinal lymphadenopathy

OBJECTIVE The reported experience of axial mediastinoscopy (MDS) performed in a diagnostic purpose only (rather than prognostic) is limited. Therefore, we designated the present study to clarify morbidity, sensitivity and accuracy of MDS performed to diagnose various mediastinal lesions. METHODS We prospectively performed 400 MDS in a diagnostic purpose on 398 patients for: (1) isolated mediastinal adenopathies in 271 patients (group 1), and (2) mediastinal adenopathies associated with a pulmonary or a hilar lesion of unknown aetiology in 127 patients (group 2). In group 1, most of the patients were suspected to have a sarcoidosis, a tuberculosis or a lymphoma. In group 2, most of the patients were suspected to have a lung cancer. In both groups, the other current diagnostic procedure usually used in each pathology had failed to give an accurate diagnosis. RESULTS A total of 76% of the samples were performed in the right laterotracheal lymph node station, 12.5% in the lower subcarinal and superior subcarinal lymph node station and 7.8% in the left laterotracheal lymph node station. The per- and post-operative mortality rates were nil. The per-operative morbidity accounted for six cases (1.5% of the examinations). The post-operative morbidity accounted for three cases (0.75% of the examinations). MDS data radically modified the pre-operative suspected diagnosis in 74 patients (18.5% of the patients). There were 17 false negative results (4.3% of the patients). The global sensitivity of MDS was 94%, the global specificity was 100% and the accuracy was 95%. In group 1, the sensitivity was 96% and in group 2 it was 92%. CONCLUSION According to the results, the few contraindications of the procedure and its low cost, we confirm that MDS is still the first choice procedure to diagnose lesions located in the axial mediastinum.

Management of superior sulcus tumors: experience with 139 cases treated by surgical resection.

BACKGROUND The management of non-small cell carcinomas of the lung involving the superior sulcus remains controversial. The goal of this retrospective study was to evaluate the role of surgery, radiotherapy, and chemotherapy for the treatment of superior sulcus tumors, to define the best surgical approach for radical resection, and to identify factors influencing long-term survival. METHODS Between 1983 and 1999, 139 patients underwent surgical resection of superior sulcus tumors in seven thoracic surgery centers. According to the classification of the American Joint Committee, 51.1% of cancers were stage IIB, 13.7% stage IIIA, 32.4% stage IIIB, and 2.9% stage IV. RESULTS The resections were performed with 74.1% using the posterior approach and 25.9% using an anterior approach. A lobectomy was accomplished in 69.8% of the cases and a wedge resection in 22.3%. Resection of a segment of vertebrae or subclavian artery was performed, respectively, in 19.4% and 18% of the cases. Resection was complete in 81.3% of cancers. The overall 5-year survival rate was 35%. Preoperative radiotherapy improved 5-year survival for stages IIB-IIIA. Surgical approach, postoperative radiotherapy, or chemotherapy did not change survival. CONCLUSIONS The optimal treatment for superior sulcus tumors is complete surgical resection. The surgical approach (anterior/posterior) did not influence the 5-year survival rate. Preoperative radiotherapy should be recommended to improve outcome of patients with a superior sulcus tumor.

Adrenalectomy for a Solitary Adrenal Metastasis From Lung Cancer

BACKGROUND Several case reports have shown that patients with truly solitary adrenal gland metastases can undergo resection with long-term survival. METHODS We assessed consecutive patients with operable or operated non-small cell lung cancer in whom the presence of a unilateral solitary adrenal metastasis was confirmed histologically. Synchronous homolateral adrenal metastases were resected at the same time as the non-small cell lung carcinoma through a transphrenic approach. Synchronous contralateral or metachronous adrenal metastases were resected through an elective approach. RESULTS Of 598 patients with operable or operated non-small cell lung carcinoma, 11 had a unilateral solitary adrenal gland metastasis and underwent adrenalectomy with no additional mortality or morbidity. One patient died of late postoperative complications and 7 patients died of other distant metastases between 4 and 24 months after adrenalectomy. Two patients are still alive and free of recurrent disease and 1 patient is still alive with brain metastasis 66, 6, and 10 months, respectively, after adrenalectomy. CONCLUSIONS In the absence of selection criteria to identify the subgroup of patients who will benefit from surgical resection, we suggest the resection of synchronous lesions in patients without N2 involvement and the careful selection of patients with metachronous adrenal metastases according to the evolution of their disease.

Tracheal Replacement With Cryopreserved Allogenic Aorta

BACKGROUND Radical resection of primary tracheal tumors may be challenging when more than one-half of the tracheal length is concerned. The present study evaluated the use of cryopreserved aortic allografts (CAAs) to replace long tracheal segments. METHODS Sixteen adult minipigs underwent tracheal replacement with a CAA. A silicone stent was used to splint the CAA for the first 12 months. Animals were followed-up using bronchoscopic evaluation and killed at predetermined times, for a period up to 18 months long. RESULTS Intense inflammation and progressive disappearance of typical histologic structures of the aorta were seen within the first 3 months. All animals studied for more than 3 months showed progressive transformation of the graft into a chimerical conduit sharing aortic and tracheal histologic patterns (eg, islands of disorganized elastic fibers/mature respiratory ciliated epithelium, respiratory glands, islets of cartilage). Stent removal was attempted after 12 months in 10 animals, and critical tracheal stenosis was found in six animals and moderate asymptomatic stenosis in four. Clinical course in these latter animals was uneventful until they were killed at 15 to 18 months. In situ hybridization showed that collagen2a1 mRNA was expressed in the cartilage islets at 1 year. Polymerase chain reaction analysis of the SRY gene demonstrated that the newly formed cartilage cells derived from the host. CONCLUSIONS CAA may be considered as a valuable tracheal substitute for patients with extensive tracheal tumors. Prolonged stenting will be probably mandatory for the clinical application of the procedure in humans.

Malignant pericardial effusions: Usefulness of pericardioscopy

In cases of malignant pericardial effusion, surgical subxiphoid biopsy sometimes fails to prove malignancy. To assess the usefulness of pericardioscopy, which allows an endoscopic investigation of the pericardial cavity, this technique was systematically performed during surgical drainage procedures that were performed on 40 patients who had pericardial effusions of suspected malignant origin. Twenty-six patients had a history of neoplasm, 10 had a history of hematologic malignancy, and four had recent tumors or lymphadenopathies that were suspected to be of malignant origin. Classical tests that are usually performed during a conventional surgical drainage procedure (fluid studies and subxiphoid biopsy) were combined with direct visualization of the pericardial surfaces and guided biopsies of suspicious areas. The follow-up period after pericardioscopy was at least 12 months. Two early deaths occurred after pericardioscopy, but no death was directly related to the endoscopy. According to all of the tests that were performed, diagnoses were malignant pericardial effusion in 15 of 40 patients (group I, 37%) and nonmalignant pericardial effusion in 25 of 40 patients (group II, 73%). In 3 of 13 patients (23%) in group I, the diagnosis was obtained only by pericardioscopy (results of cytologic studies and subxiphoid biopsy were negative). In two patients in group I, pericardioscopy could not be completed, but the diagnosis of malignant pericardial effusion was obtained by pericardiocentesis. In group II, effusion was considered to be postradiation pericarditis in five cases, infectious pericarditis in three cases (bacterial in one and tuberculous in two), hemopericardium induced by coagulation disturbances in three cases, and idiopathic pericarditis in 14 cases.(ABSTRACT TRUNCATED AT 250 WORDS)

Cardiopulmonary response following surgical repair of pectus excavatum in adult patients

OBJECTIVE Severe pectus excavatum are common in adult patients, often causing psychological complaints and physiological impairments. Although lung function at rest may minimally deteriorate after surgical correction, it remains unclear if surgery improves exercise capacity. The objective of present study is to assess whether the surgical repair of pectus excavatum in adults would improve exercise tolerance. METHODS A prospective study was performed to compare pulmonary and cardiovascular function at rest and at maximal exercise, before, and at 1 year after pectus excavatum repair. RESULTS From December 2005 to May 2009, 120 adult patients underwent pectus excavatum repair. Of these patients, 70 (nine women, 61 men) underwent thorough preoperative, 6-, and 12-month postoperative assessments, and were included in the present study. Age ranged from 18 to 62 years (mean 27 years). The pectus index (Haller index) was 4.5 ± 1.1. Lung function tests at rest were within the normal range, whereas maximal oxygen uptake (peak VO₂) was only 77 ± 2% of the predicted value. At 1-year follow-up, the pectus excavatum repair was associated with minor changes in lung function tests and significant increase (p=0.0005) in VO₂ (87 ± 2% of the predicted value). Postoperative O₂ pulse increase at maximal exercise suggested that aerobic capacity improvement was the result of better cardiovascular adaptation at maximal workload. CONCLUSION These results demonstrate sustained improvement in exercise cardiopulmonary function at 1-year follow-up of pectus excavatum surgical repair in adult patients.