Hazem Zribi

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.

Tumeurs carcinoïdes bronchopulmonaires : une série tunisienne de 115 cas opérés

INTRODUCTION Bronchial carcinoid tumors are rare well-differentiated, neuro-endocrine tumors, with low-grade malignancy. They are distinguished in two different groups: typical and atypical carcinoid. The purpose of this study was to review clinical, surgical and pathological characteristics in patients with primary bronchopulmonary carcinoid tumors. METHODS This retrospective study included 115 bronchial carcinoid tumors surgically treated at a single institution during a twenty-one-year period, between 1992 and 2012. RESULTS There were 56 men and 59 women, with a mean age of 43.73 years. Hundred patients had typical carcinoids and 15 atypical carcinoids. The majority of patients were symptomatic (96.52%). CT revealed a proximal mass in 51% which was obstructive leading to ventilator disorders in 80%. Bronchoscopy showed an endo-bronchial tumor in 83.48% of the cases. Anatomical resection had been achieved among 99 patients, and a conservative resection among 16 patients with typical carcinoid tumor. Lymph node metastases were present in 12.17% of the cases. Follow-up revealed recurrence in one patient and distant metastasis in 4 others. The 5-year survival rate was worse for atypical carcinoid with 45% than typical carcinoid with 95%. CONCLUSIONS Carcinoids are rare malignant tumors, and their outcome is usually favorable after surgery. However, local recurrence and/or metastases can occur with both typical and atypical carcinoid tumors, justifying the need of prompt diagnosis and long-term follow-up. The factors influencing the survival included the pathological type, distant metastasis and mediastinal lymph node involvement.

About a challenging mediastinal tumor

Mediastinal hemangiomas are rare, accounting for 0.5% of all mediastinal tumors. These tumors are challenging because of the lack of specific clinical and radiologic signs. We report a 10-year experience of 5 mediastinal hemangiomas in a single institution, with neurologic signs related to neuroforaminal extension in 2 cases. Surgical treatment was performed in all 5 patients, without complications after a follow-up period varying from 9 months to 2 years.

Surgery of thoracic paragangliomas. About 9 cases

Background: Paragangliomas are rare tumors with a slow progress representing difficulties in diagnosis and treatment. Thoracic location is exceptional. Methods: Our aim is to study this rare entity from a series of 9 thoracic paragangliomas (PG) and demonstrate the benefits of surgery. Results: Nine patients (5 men / 4 women) with a mean age of 42 year-old (range:5-17 years) were operated for thoracic PG. The majority of patients were symptomatic. The main symptoms were chest pain and hemoptysis. The predominant radiological aspect was that of a posterior hypervascularized mediastinal mass in 5 cases, a balloon release in 2 cases and a left lower lobe mass in 2 cases. Fibroscopy was normal in the majority of cases. Two patients had associated extrathoracic PGs (upper limb). Tumor markers were negative in all 9 cases. Patients were operated by Video-assissted thoracic surgery (2) or left posterolateral thoracotomy (6). Five patients had complete tumor resection. For one patient the resection was deemed impossible, he had a diagnostic biopsy by mediastinoscopy. Two patients had a lower left lobectomy associated in one case with a lingulectomy and with tumor resection in the other case. The surgical follow-up was simple for all patients. The two patients who had a complete resection had a survival of 6 and 8 months respectively. Non-metastatic patients who had R0 resection had prolonged survival. Conclusion: mediastinal PGs are suspected on the highly vascular aspect of the tumor on CTKey words: chest, mediastinal, tumor. The treatment of choice of thoracic PG is a surgical resection R0.

A unilocular thymic cyst associated with true thymic hyperplasia: a challenging diagnosis especially in a child

We report a new case of a mediastinal mass in a 19-year-old patient corresponding microscopically to an association of unilocular thymic cyst and true thymic hyperplasia. Our aim is to highlight the absence of specificity of clinical and radiological findings and the necessity of a thorough sampling of the tumor in order to establish the diagnosis.