H. Smadhi

Conservative management of postoperative bronchopleural fistulas.

OBJECTIVE A bronchopleural fistula (BPF) is a serious complication after pulmonary resection and carries a high mortality rate. It remains a therapeutic challenge. The lack of a consensus suggests that no optimal therapy is available; however, endoscopic closure of a fistula may avoid extensive and potentially risky surgery. METHODS Seventeen patients (15 men and 2 women) with a BPF after a pneumonectomy (n = 2) or a lobectomy (n = 15), seen between 1995 and 2010, were reviewed. Their median age was 50 years (range, 14-75 years). Underlying diseases were malignant (n = 4) and nonmalignant (n = 13). RESULTS The mean interval between surgery and fistula development was 20 days (range, 5-270 days). Clinical symptoms leading to a diagnosis of BPF were a persistent air leak (n = 2), a persistent air leak associated with pleural empyema (n = 3), pleural empyema alone (n = 11), and dyspnea (n = 1). Mean fistula size was 3.3 mm (range, 2-9 mm). Treatment consisted of oriented pleural drainage, adequate antibiotic therapy, and endoscopic closure of the fistula with local application of silver nitrate through a flexible bronchoscope (3-15 sessions, 3 times per week). Fistula closure was successful in 16 patients, but failed in 1 patient, who died from acute respiratory distress. CONCLUSIONS BPF is a severe complication in thoracic surgery. The combination of pleural drainage, adequate antibiotic treatment, and mucosal application of silver nitrate, through a flexible bronchoscope, is an efficient alternative and avoids extensive surgical intervention.

Surgery in thoracic actinomycosis.

Background: diagnosis and treatment of thoracic actinomycosis is difficult. In most cases, surgery is performed to rule out lung cancer or to control severe symptoms such as hemoptysis. Methods: 6 patients with a mean age of 42 years underwent pulmonary resection and were given a pathologic diagnosis of thoracic actinomycosis at our institution between 2003 and 2010. We reviewed preoperative clinical characteristics, computed tomography findings, surgical indication, postoperative clinical course and outcome. Results: All patients were symptomatic. One patient had a history of cervical actinomycosis. The mean interval between radiographic identification of the abnormality and surgical intervention was 8 months (range, 4–17 months). Radiographic findings in all cases included a mass-like appearance, simulating lung malignancy or chronic suppuration. The various histological and bacteriological examinations had failed to make the diagnosis. Thoracic actinomycosis was confirmed after thoracic surgery. All patients received penicillin-based antibiotic treatment for at least 2 to 3 months. Good clinical results were observed in 5 patients. In one patient, we noted recurrence of actinomycosis after 10 months; it was a multidrug-resistant form. Conclusion: diagnosis of actinomycosis can be problematic because of difficulty in isolating actinomyces. In these cases, surgery is very helpful.

What outcome after the prescription of neoadjuvant chemotherapy in lung cancer

Background The treatment of patients with locally advanced non-small-cell lung cancer is controversial. Surgery remains the gold standard, even in this group. Neoadjuvant chemotherapy could allow surgical resection in patients initially judged inoperable. Methods From January 2009 to May 2010, neoadjuvant chemotherapy was indicated in 27 patients with NSCLC (25 men, 2 women). Their mean age was 65 years. The stages were: IIB in 5, IIIA in 17 (6 in stage IIIAN2), IIIB in 2, and IV in 3. Results 23 patients received neoadjuvant chemotherapy, 2 refused induction treatment, and 2 had impaired status. The neoadjuvant chemotherapy regimen was gemcitabine-cisplatin in 17 patients and vinorelbine-cisplatin in 6. Only 5 patients underwent complete surgical treatment after induction: 1 in stage IIB, 1 in stage IIIAN0, 1 in IIIB, and 2 in stage IV (1 operated brain metastasis, and 1 operated adrenal metastasis). Surgical treatment was not achieved after neoadjuvant chemotherapy in 18 patients because of progressive disease. Conclusion Neoadjuvant chemotherapy offers several potential benefits, but it may delay surgery or eliminate eligibility as a surgical candidate. Rigorous patient selection for this type of multimodal treatment is essential.

Management of pulmonary tuberculosis sequelae

Introduction: Pulmonary tuberculosis still raises many problems. The delay in care can affect respiratory functional prognosis. We were interested to difficulties in management of tuberculosis sequelae. Patients and Methods: A retrospective study including patients treated for pulmonary tuberculosis between January 2012 and January 2014. We selected patients with pulmonary sequelae. Results: Sixty-five cases have been collected. 81.5 % were male and 18.5% female. The mean age was 55.6 years ± 13. Seventy seven percent of these patients were smokers. The mean time to the onset of respiratory symptoms related to pulmonary sequelae was 15.6 ± 8 years. The clinical symptoms were dominated by a chronic sputum (74%), dyspnea (68%) and hemoptysis (34%). The thoracic imaging showed: a destroyed lung (46%), bronchiectasis (31%), aspergilloma (14%), emphysema (12.3%), pulmonary fibrosis (7.7%), residual cavity (6.2%) and lung cancer (1.5%). Functional respiratory explorations found a restrictive ventilatory defect in 78% of cases, chronic respiratory failure in 24% of cases. Treatment was essentially medical consisting in ininhaled corticosteroids, theophyllin and long acting beta agonist. Long term oxygen therapy was indicated for 8 patients. Surgery was indicated for only 5 patients whose, 3 of them had symptomatic aspergilloma. During the period of study the average number of hospitalization per year for all patients was 1.68 ± 2. Conclusion: The prevention of tuberculosis sequelae requires both early diagnosis and available treatment of the disease. These lesions increase morbidity and a preventable mortality.

Prognostic factors in non-small cell lung cancer

Introduction : Lung cancer is one of the most frequently occurring neoplasms and usually has a poor prognosis because most of the patients present with advanced or metastatic disease at the time of diagnosis. Numerous prognostic factors (PF) have been studied. Aim: Study the prognostic factors in non small-cell lung cancer. Methods : A retrospective study had enrolled 269 cases of non small-lung cancer between January 2008 and December 2012. Results : The average age of ourpatients was61 years [44-80 years]. Lungcancer wasmore frequently observedin men (94,5%). Smoking wasnoted in 96% of patients. Histological types were adenocarcinoma (61%), squamous cell cancer (28%), non-smallcell carcinomacellsuntyped (11%) and large cell carcinoma (1%). TNM classification revealed stage IA (1,5%), IB (2%), IIA(3%), IIB (5%), IIIA (12%), IIIB (16%) and IV (60,5%). Median survival wasestimated at 575±70 days.Women , patients aged under 45 years and non-smoking patients have a better survival (p=0,005 ; 0,05 and 0,017 respectively). The other prognostic factors were the average intoxication tobacco, the stage of cancer, performance status, the number of metastases, the introduction of aspecific treatment, consultation delay and therapeutic delay (p=0,024; 0,031; 0,006; 0,001; 0,006; 0,46 and 0,001 respectively). Conclusion : Prognostic factors (PF) have a pivotal role in Clinical Oncology. They are helpful in the selection of treatment, provide insights into the disease process and the therapeutic response, and are fundamental in the design of clinical trials or in the interpretation of data from the literature.