Emmanuel Brian

Strategies and outcomes in pulmonary and extrapulmonary metastases from renal cell cancer

OBJECTIVE Resected renal carcinoma related lung metastases (LM) are associated with higher survival rates, but surgery for extrapulmonary metastases affords good results too. Patients operated on for extrapulmonary metastases before thoracotomy are at high risk of death. The purpose of our analysis was to explore the surgical impact on the outcome of patients with such association. METHODS We reviewed the data of 15 patients operated for LM and extrapulmonary metastases from 1984 to 2005. We studied demographic and clinical characteristics, surgical results and pathological staging of the primary tumour and LM in search of prognostic factors. RESULTS Nephrectomy and metastasectomies were synchronous in only one patient. For the others, mean time interval between nephrectomy and surgery for LM was 74.2 months (range 19-228). Metastases were resected synchronously in two patients and metachronously in 13 of them (mean time interval: 28 months). Five-year survival of this group was 32%, median value of 18 months. The prognosis was better when the resected extrapulmonary metastases were located in the perirenal (pancreas, adrenal gland) or intrathoracic structures (lymph nodes, diaphragm) than in distant visceral organs (brain, bone, thyroid gland). The lymphatic drainage for these structures connects with the thoracic duct in a similar manner as kidneys do. CONCLUSION Surgery for lung and extrapulmonary renal cell cancer-related metastases provides favourable results and is indicated when complete resection can be achieved. The role of the lymphatic system must be explored by further investigations.

Induction chemotherapy before sleeve lobectomy for lung cancer: immediate and long-term results.

BACKGROUND Induction chemotherapy does not increase the morbidity and mortality rates of bronchoplastic procedures, but the long-term efficiency remains unclear. The purpose of this retrospective study was to analyze the impact of chemotherapy on resectability and long-term survival. METHODS From 1984 to 2005, 159 consecutive patients with non-small cell lung cancer underwent sleeve lobectomy without (n = 117) or with induction chemotherapy (n = 42). Indications for chemotherapy were N2 lymph node involvement (n = 15), T3 or T4 tumor invasion with doubtful resectability (n = 13), need for tumor size reduction (n = 8), lung function precluding pneumonectomy (n = 4), and brain metastasis (n = 2). None of the patients received induction radiation therapy. We studied tumor characteristics and immediate and long-term results in both groups. RESULTS Clinical stage III was predominant in the induction chemotherapy group whereas stage II was predominant in the surgery-only group. Complication rates in the induction chemotherapy group and in the surgery-only group were 23.8% and 24.7%, respectively. We observed a greater rate of 1-month-delay smoking cessation before surgery in the induction chemotherapy group (40% versus 22%). The 5-year survival rates were 65.4% in the surgery-only group and 73.4% in the induction chemotherapy group (p = 0.5). The tumor size in the induction chemotherapy group was lower (17.5 versus 30.6 mm; p = 0.01), which reflected the positive impact of chemotherapy on sleeve resection feasibility. CONCLUSIONS Induction chemotherapy before sleeve lobectomy achieves good long-term results. Tumor reduction and limited resection feasibility seemed to be increased, which justify further prospective trials.

Le traitement chirurgical des éventrations et paralysies diaphragmatiques

Surgical treatment of eventration or paralysis of the diaphragm is symptomatic and non curative, and depends on whether the dysfunction is of peripheral or central origin. Elevation of a hemidiaphragm of peripheral origin, the most frequent situation, needs surgical treatment only in case of major functional effects (effort or positional dyspnoea, cardiac or digestive symptoms, or pain) that persists despite optimal conservative management. Selection of candidates for surgery depends on a thorough morphological and functional investigation of the neuromuscular and respiratory components. Surgical plication of the diaphragm through a lateral thoracotomy or by video-thoracoscopy is a recognized, safe and effective procedure. Its low morbidity and mortality, which are mainly associated with co-morbid factors, and its long-lasting functional benefit of around 100%, show that it is an effective procedure. In the case of bilateral dysfunction, occasional cases of bilateral plication have been reported. Some cases of diaphragmatic paralysis of central causation result in a life of ventilator dependence, even though the peripheral neuromuscular and respiratory systems are intact. In selected cases, following a complete functional investigation, phrenic nerve pacing may be attempted to achieve ventilator weaning. To date, there are two validated indications for this technique: Tetraplegia above C3 and alveolar hypoventilation of central cause. After thoracic implantation, a progressive reconditioning of the diaphragmatic muscle allows weaning from the ventilator in a few weeks in more than 90% of patients. Their quality of life is greatly improved thanks to independence from the ventilator, more physiological respiration, restoration of smell and better speech. Whether the diaphragmatic dysfunction is peripheral or central in origin, the success of surgical treatment depends on rigorous preoperative selection of patients.

Congenital bronchial atresia in adults: thoracoscopic resection

Congenital bronchial atresia (CBA) is a rare congenital malformation consisting in an interruption of a lobar or-more frequently-of a segmental bronchus. It leads to mucus impaction and hyperinflation of the obstructed lung segment. It causes infectious complications and, in the long term, destruction of the adjacent lung parenchyma. Thus, a surgical resection is usually indicated, even in asymptomatic patients.

Anévrisme médiastinal de l’artère bronchique : traitement par endoprothèse aortique

Mediastinal bronchial artery aneurysm is rare but potentially life-threatening, and requires prompt treatment to avert rupture with catastrophic results. Inflammatory conditions dominate the aetiologies. Conventional therapies are surgery via thoracotomy and endovascular embolization. We report a case of a giant saccular aneurysm of the bronchial artery described in an 80-year-old man, adjacent to the descending aorta, simulating aortic aneurysm and causing esophageal compression. It was totally excluded with an aortic stent-graft (TX2, Cook) performed through femoral access. Our case is the fourth reported of mediastinal bronchial aneurysm stent-graft exclusion. The analysis of success, complications rate and hospital stay duration favors endovascular grafting comparing with conventional techniques.

Concomitant aortic root and pectus deformity repair in Marfan syndrome patients

The role of concomitant aortic and pectus repair in Marfan patients remains controversial. We present our surgical technique for concomitant aortic repair of aortic root pathology and pectus correction. The concomitant surgery can be safely achieved in Marfan patients, thus, avoiding the need for a risky second stage operation.

Adult pulmonary intralobar sequestrations: changes in the surgical management

Background Until now, the traditional procedure to treat intralobar pulmonary sequestration (ILS) in adults has been a lobectomy performed by open chest surgery. We have reviewed our data to determine whether the surgical management of these lesions has evolved over the last years. Methods We retrospectively reviewed the records of patients who were operated on for an ILS by either posterolateral thoracotomy (PLT group), or by thoracoscopy (TS group) between 2000 and 2016. Results Eighteen patients were operated on for a ILS during this period. Before 2011, all resections were performed by thoracotomy (n=6) and after 2011 the approach was either a thoracotomy (n=5) or a thoracoscopy (n=7). There was one conversion because of dense pleural adhesions and this patient was integrated in the PLT group for further analysis. ILS presented more frequently on the left side (n=12, 66.7%) than on the right one (n=6, 33.3%) and exclusively in the lower lobes. All the PLT group patients underwent a lobectomy. In the TS group, five patients underwent a sublobar resection (2 segmentectomies S9+10, 1 basilar segmentectomy and 2 atypical resections). There was no mortality. In the PLT group, 5 patients (45%) had complications versus one patient (14%) in the TS group. The mean hospital stay was 7.4 days in the PLT group versus 5.4 days in the TS group. Conclusions These data confirm that ILS can be safely treated by a sublobar resection that should be performed, whenever possible, without opening the chest.

Planning and marking for thoracoscopic anatomical segmentectomies

Although sublobar resection (SLR) for treating non-small cell lung carcinoma (NSCLC) is still controversial, thoracoscopic segmentectomy is rising. Performing it by closed chest surgery is complex as it means confirming the location of the lesion, identifying vascular and bronchial structures, preserving venous drainage of adjacent segments, severing the intersegmental plane and ensuring an oncological safety margin with no manual palpation and different landmarks. Accurate planning is mandatory. We discuss in this article the interest of 3D reconstruction and mapping technics to enhance safety and reliability of these procedures.

Technical means to improve image quality during thoracoscopic procedures

Although high definition imaging systems are now available in the operating room (OR), the displayed image quality during video-assisted procedures is often poor. This is due to several factors such as inappropriate angle of vision, instable endoscope, lens soiling and fogging. The aim of this article is to provide information about some technical and technological means that make it possible to keep a perfect picture all along a thoracoscopic procedure.

Thoracoscopic Pulmonary Anatomic Segmentectomies

The number of publications about video-assisted and thoracoscopic lobectomies is although these procedures are still considered as technically difficult and their learning curve is steep. This observation is even more valid for anatomic segmentectomies. Few series of video-assisted pulmonary segmentectomies have been published and totally endoscopic – so-called complete VATS – segmentectomies are even more rare. Many different techniques of thoracoscopic major pulmonary resection have been described, depending on the use or non-use of an accessory mini-thoracotomy and on the use or non-use of endoscopic instrumentation and video display. One of these techniques is the totally endoscopic approach, in which only endoscopic instruments and monitor control are used. This is the technique that will be described in this chapter. By totally endoscopic we mean: 1) 100% video display, 2) no access incision and 3) only use of trocars and endoscopic instruments. The aim of this chapter is not to discuss the oncologic validity of segmentectomies for early stage lung carcinomas but to describe the technical aspects of totally endoscopic anatomic segmentectomies (TEAS) and their results.