F. Le Pimpec-Barthes

Tumeurs nerveuses du médiastin de l’adulte

In adults, mediastinal neurogenic tumours constitute the third group of mediastinal tumours, after thymomas and lymphomas. If the group of neurogenic tumour is frequent, each type of tumour is relatively unusual in everydays clinic. Among them, nerve sheath tumours are the more frequent, followed by tumour of the autonomic system. Askin tumour remains uncommon. Treatment of this tumour requires complete preoperative work-up, including standard radiography, CT-scan, MRI, and sometimes nuclear imaging. In most cases, the treatment is based on surgical resection, and may be associated with radiotherapy or chemotherapy in case of malignant tumour or incomplete resection. Better understanding of these tumours, including their molecular abnormalities, may lead to new changes in their classifications, and to their management.

Chirurgie du diaphragme paralysé

Resume Les paralysies diaphragmatiques correspondent a une ascension permanente d’une ou des deux coupoles, de retentissement fonctionnel variable, allant de l’absence de symptome a la non-ventilation spontanee. A l’origine de ces paralysies diaphragmatiques, deux grandes categories de mecanismes sont individualises : — les dysfonctionnements peripheriques, de cause neurologique ou musculaire ; — les dysfonctionnements centraux, en rapport avec une commande centrale absente ou non transmise. La prise en charge des paralysies diaphragmatiques passe par un bilan complet, tant morphologique que fonctionnel, oriente par les conditions de survenue et de decouverte ainsi que par leur caractere uni- ou bilateral. Toute la chaine phreno-diaphragmatique, allant du crâne jusqu’au muscle diaphragmatique, est analysee a la recherche d’une cause locale. Le bilan fonctionnel permet d’analyser la commande centrale et sa transmission, le fonctionnement du nerf phrenique et la capacite du muscle diaphragmatique a generer une pression suffisante pour obtenir une ventilation efficace. Les causes indirectes de surelevation de coupole etant eliminees (causes independantes du systeme phreno-diaphragmatique), une prise en charge chirurgicale sera proposee en cas de paralysie diaphragmatique symptomatique, permanente et irreversible. Les eventrations, associees ou non a une paralysie phrenique, pourront beneficier d’une remise en tension de la coupole par plicature. Les paralysies d’origine centrale pourront, dans certains cas bien selectionnes de lesions supra-spinales avec nerfs et muscles intacts, beneficier de l’implantation d’un stimulateur phrenique afin de supprimer la ventilation mecanique en pression positive en restaurant une ventilation plus physiologique.

Facteurs pronostiques cliniques et paracliniques dans la chirurgie du cancer du poumon non à petites cellules

INTRODUCTION Lung cancer prognosis is mainly based on the TNM, histology and molecular biology. Our aim was to analyze the prognostic value of certain clinical and paraclinical variables. PATIENTS AND METHODS We studied among 6105 patients operated on, divided during 3 time-periods (1979 to 2010), the following prognostic factors: type of surgery, pTNM, histology, age, sex, smoking history, clinical presentation, and paraclinical variables. RESULTS Postoperative mortality was 4% (243/6105), rate of complications was 23.3% (1424/6105). The 5-year overall survival was 43.2% and 10-year was 27%. Best survival was observed after complete resection (R0) (P<10(-6)), lobectomy (P<10(-6)), lymph node dissection (P=0.0006), early pTNM stages (P<10(-6)), absence of a solid component in adenocarcinoma. Other pejorative factors were: male gender (P=10(-5)), age (P=0.0000002), comorbidity (P=0.016), history of cancer (P<10(-5)), postoperative complications (P=0.0018), FEV lower than 80% (P=0.0000025), time-periods (P<10(-6)). All these factors were confirmed by multivariate analysis, except gender. Smoking was not poor prognostic factor in univariate analysis (P=0.09) but became significant in the multivariate one (P=0.013). CONCLUSION Medical and human factors, and the general physiological state, play an important role in prognosis after surgery. We do not know their exact meaning and, like studies on chemotherapy, they justify special research.

Dysfonctions et paralysies diaphragmatiques : de la physiopathologie au traitement chirurgical

The clinical presentations of diaphragm dysfunctions vary according to etiologies and unilateral or bilateral diseases. Elevation of the hemidiaphragm from peripheral origins, the most frequent situation, requires a surgical treatment only in case of major functional impact. Complete morphological and functional analyses of the neuromuscular chain and respiratory tests allow the best selection of patients to be operated. The surgical procedure may be proposed only when the diaphragm dysfunction is permanent and irreversible. Diaphragm plication for eventration through a short lateral thoracotomy, or sometimes by videothoracoscopy, is the only procedure for retensioning the hemidiaphragm. This leads to a decompression of intrathoracic organs and a repositioning of abdominal organs without effect on the hemidiaphragm active contraction. Morbidity and mortality rates after diaphragm plication are very low, more due to the patients general condition than to surgery itself. Functional improvements after retensioning for most patients with excellent long-term results validate this procedure for symptomatic patients. In case of bilateral diseases, very few bilateral diaphragm plications have been reported. Some patients with diaphragm paralyses from central origins become permanently dependent on mechanical ventilation whereas their lungs, muscles and nerves are intact. In patients selected by rigorous neuromuscular tests, a phrenic pacing may be proposed to wean them from respirator. Two main indications have been validated: high-level tetraplegia above C3 and congenital alveolar hypoventilation from central origin. After progressive reconditioning of the diaphragm muscles following phrenic pacing at thoracic level, more than 90% of patients can be weaned from respirator within a few weeks. This weaning improves the quality of life with more physiological breathing, restored olfaction, better sleep and better speech. The positive impact of diaphragm stimulation has also been evaluated in other degenerative neurological diseases, particularly the amyotrophic lateral sclerosis. For either central or peripheral diaphragm dysfunctions, a successful surgical treatment lies on a strict preoperative selection of patients.

Article originalThoraxApport du lymphoscanner pour le diagnostic de fuites lymphatiques : à propos de neuf casValue of CT lymphangiography in the detection of lymphatic leakage: A report of nine cases

PURPOSE To demonstrate the value of CT lymphangiography to detect lymphatic leakage, especially at the thoracic level, prior to therapeutic intervention. PATIENTS AND METHODS Between 2004 and 2008, nine patients underwent lymphangiography, followed by CT for the evaluation of intractable lymphatic leakage in spite of optimal medical management. Patients included seven females and two males, with age ranging between 25 and 58 years. Lymphangiography was performed after unilateral or bilateral foot injection(s) of Lipiodol ultrafluid followed by standard radiographs of the chest and abdomen and CT of the chest, abdomen and pelvis. The images were reviewed by two experienced radiologists. RESULTS Lipiodol leakage was observed in six patients, while three patients showed evidence of lymphangiectasia of the abdominal and/or thoracic lymphatics. Spontaneous resolution of leakage after lymphangiography occurred in three cases. CONCLUSION CT lymphangiography allows direct evaluation of lymphatics, from pelvis to chest, in order to detect the site of leakage at the origin of a chylous effusion and assist in its management.

Apport du lymphoscanner pour le diagnostic de fuites lymphatiques : à propos de neuf cas

PURPOSE To demonstrate the value of CT lymphangiography to detect lymphatic leakage, especially at the thoracic level, prior to therapeutic intervention. PATIENTS AND METHODS Between 2004 and 2008, nine patients underwent lymphangiography, followed by CT for the evaluation of intractable lymphatic leakage in spite of optimal medical management. Patients included seven females and two males, with age ranging between 25 and 58 years. Lymphangiography was performed after unilateral or bilateral foot injection(s) of Lipiodol ultrafluid followed by standard radiographs of the chest and abdomen and CT of the chest, abdomen and pelvis. The images were reviewed by two experienced radiologists. RESULTS Lipiodol leakage was observed in six patients, while three patients showed evidence of lymphangiectasia of the abdominal and/or thoracic lymphatics. Spontaneous resolution of leakage after lymphangiography occurred in three cases. CONCLUSION CT lymphangiography allows direct evaluation of lymphatics, from pelvis to chest, in order to detect the site of leakage at the origin of a chylous effusion and assist in its management.

Problemi chirurgici posti dalle pleuriti purulente

La pleurite purulenta (PP) o empiema pleurico e un’urgenza terapeutica, perche puo essere fatale in caso di gestione insufficiente o ritardata. Nel 70-80% dei casi, questa infezione del liquido pleurico e secondaria a un’infezione polmonare vicina (parapneumonica, ascesso polmonare, cancro sovrainfetto, bronchiectasia, sequestro, ecc.). Puo anche essere di origine iatrogena (postchirurgica con o senza fistola, post-traumatica) o, raramente, da cause extratoraciche (sottodiaframmatiche, oto-rino-laringoiatrica o stomatologica). Qualunque sia il meccanismo causale, l’urgenza consiste nel realizzare allo stesso tempo la diagnosi, attraverso una toracentesi, e il trattamento iniziale con un drenaggio pleurico per evacuare il liquido purulento. L’agente eziologico puo essere difficile da identificare se e gia stata instaurata precedentemente una terapia antibiotica o se si tratta di un microrganismo anaerobio, il che puo giustificare il ricorso alla biologia molecolare. A seconda dell’antichita della PP, si osservano diversi stadi della malattia, con conseguenze sul polmone sottostante che giustificano una gestione diversa. Il semplice drenaggio permette, in genere, un miglioramento clinico spettacolare, ma non e sufficiente di per se. E necessario associarvi una detersione locale, che puo essere chimica mediante fibrinolitici locali e/o strumentale attraverso videotoracoscopia. Proprio come la terapia antibiotica per via endovenosa rivolta contro la malattia responsabile della PP, la kinesiterapia respiratoria pluriquotidiana e un elemento indispensabile per la guarigione. Essa mira a favorire la riespansione polmonare e la mobilita diaframmatica per eliminare la tasca pleurica infetta. Alcuni gesti possono essere associati, a seconda della causa: chiusura di una fistola bronchiale o esofagea, recentazione di una distruzione di una struttura vicina, rimozione di materiale infetto e cosi via. La fenestrazione deve essere ipotizzata in caso di sepsi persistente nonostante il drenaggio. Infine, nelle forme incistate di scoperta tardiva, il deficit di riespansione polmonare richiede un trattamento specifico di decorticazione pleuropolmonare mediante toracotomia e/o un gesto parietale a volte complesso di toracoplastica, mioplastica od omentoplastica. I ritardi nella presa in carico spiegano gli alti tassi di mortalita, che possono arrivare fino al 41%. Tuttavia, in caso di diagnosi precoce e di trattamento ben condotto, la guarigione e quasi costante. I fattori prognostici sfavorevoli sono le comorbilita multiple, l’immunosoppressione, la necessita di un cambiamento di terapia antibiotica in corso di trattamento, l’identificazione di un microrganismo e, anche se in modo controverso, l’eta avanzata.

Chirurgie des métastases pulmonaires des cancers colorectaux : facteurs prédictifs de survie

INTRODUCTION Colorectal cancer is the 3rd commonest cause of death from cancer: 5% of patients will develop lung metastases. The management of oligometastatic disease is based on the objective of optimal local control. STATE OF THE ART To date, no results from randomized control trials support the resection of pulmonary metastases in oligometastastic colorectal cancer patients. However, numerous series, mainly retrospective, report long-term survival for highly selected patients, with 5-year survival ranging from 45 to 65% in the most recent series. The consensual predictive factors of a good prognosis are: a disease free-interval>36 months, a number of metastases≤3, a normal level of carcino-embryonic antigen and the absence of hilar or mediastinal lymph node involvement. PERSPECTIVES Around 20 to 40% of patients will develop recurrence, probably linked to the presence of undetectable micrometastases. Therefore, experimental work is being undertaken to develop new treatment techniques such as isolated lung perfusion, radiofrequency ablation and stereotactic radiation therapy. CONCLUSION Highly selected patients suffering from colorectal cancer lung metastases could benefit from resection with improved survival and disease-control.

Prise en charge chirurgicale cardiothoracique d’un cancer bronchique responsable d’une insuffisance cardiaque

Surgical resection is a validated therapeutic option for selected cases of pulmonary tumors invading the important mediastinal structures (caval vein, atrium, aorta or supra-aortic trunks). Here, we present a patient with a necrosed pulmonary tumor invading the left atrium, causing cardiac insufficiency. A complete surgical resection under extracorporeal circulation was performed by the thoracic and cardiac teams. Admitted in a bed-ridden state, the patient was discharged completely rehabilitated on postoperative day 13. He survived 1 year at home with a good quality of life.

Aspetti chirurgici della tubercolosi polmonare e dei micobatteri atipici

Descritta nel 1819, la tubercolosi polmonare ha accompagnato lo sviluppo della chirurgia toracica. Dopo l’abbandono delle tecniche di collassoterapia nel 1945 e il minor ricorso alla toracoplastica dopo gli anni ′80, le resezioni parenchimali restano il solo trattamento curativo possibile di situazioni cliniche complesse. La tubercolosi multiresistente (multidrug-resistant tuberculosis [MDR-TB]) deve beneficiare di una gestione chirurgica all’interno di equipe specializzate. Le caverne post-tubercolari, le distruzioni parenchimali e le dilatazioni dei bronchi da postumi possono complicarsi con un’emottisi e un’infezione da aspergillus o con infezioni recidivanti e devono, allora, essere operate. In queste indicazioni difficili, una preparazione preoperatoria rigorosa, una tecnica sistematica e delle cure postoperatorie vigili consentono di ottenere delle guarigioni definitive, al prezzo di una morbimortalita operatoria accettabile. Queste situazioni devono, quindi, essere conosciute dai chirurghi toracici, per non prolungare inutilmente dei trattamenti medici inefficaci e/o tossici.