Jacques F. Azorin

Long-term evaluation of the replacement of the trachea with an autologous aortic graft

BACKGROUND Tracheal reconstruction after extensive resection remains a challenge in thoracic surgery. The goal of this experimental study was to analyze the long-term evolution of tracheal replacement using an autologous aortic graft. METHODS In 21 sheep, a 5-cm segment of the cervical trachea was replaced by a segment of the descending thoracic aorta that was reconstructed to a prosthetic graft. Because of the airway collapse reported in a previous series, a permanent (n = 13) or temporary (n = 8) stent was systematically placed in the lumen of the graft. Clinical, bronchoscopic, and histologic examinations were performed up to 3 years after implantation. RESULTS All animals survived the operation with no paraplegia. In the group with a permanent stent, three complications occurred: one stent displacement, one laryngeal edema, and one infection. Stent removal was tolerated after 6 months in the group with a temporary stent. Histologic examination showed a progressive transformation of the arterial segment into first extensive inflammatory tissue with a squamous epithelium, and after 6 to 36 months well-differentiated tracheal tissue including a continuous mucociliary epithelium and regular rings of newly formed cartilage. CONCLUSIONS An autologous aortic graft used as a substitute for extensive tracheal replacement in sheep remained functional for periods up to 3 years. The progressive transformation of the graft into a structure resembling tracheal tissue seems to be a key factor in long-term patency. The mechanism of this regenerative process and the possibility of using arterial homografts, which would make clinical application easier, remain to be evaluated.

Role of Videothoracoscopy in Chest Trauma

BACKGROUND The aim of this study was to evaluate videothoracoscopic procedures in the setting of chest trauma. METHODS We retrospectively analyzed our experience of videothoracoscopy in patients with either blunt trauma or penetrating thoracic injuries. RESULTS Forty-three procedures involving 42 patients were performed between July 1990 and April 1996. Indications for videothoracoscopy included suspected diaphragmatic injury (14 patients), clotted hemothorax (12), continued hemothorax (6), persistent pneumothorax (5), intrathoracic foreign body (4), posttraumatic chylothorax (1), and posttraumatic empyema (1 patient). Ten patients (24%) required conversion to thoracotomy. Two patients suffered postoperative pneumonia. There was one perioperative death. Mean hospital stay was 17 days; 21 days for patients with blunt trauma and 13 days for patients with penetrating injuries. There was no procedure-related complication. Videothoracoscopy allowed precocious discharge of patients suffering penetrating injuries and allowed faster recovery in the majority of patients suffering severe blunt trauma. CONCLUSIONS Videothoracoscopy appears to be a safe, accurate, and useful approach in selected patients with chest trauma. It is ideal for the assessment of diaphragmatic injuries, for control of chest wall bleeding, for early removal of clotted hemothorax, for treatment of empyema, for treatment of chylothorax, for treatment of persistent pneumothorax, and for removal of intrathoracic foreign body. However, we do not recommend the use of this technique in the setting of suspected great vessel or cardiac injury.

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.

Thoracoscopic excision of mediastinal bronchogenic cysts: results in 20 cases

BACKGROUND We present our experience with thoracoscopic resection of mediastinal bronchogenic cysts in adults. METHODS From November 1990 to September 1993, 20 patients with mediastinal bronchogenic cysts were operated on by thoracoscopy. The average cyst size was 4.9 cm, and the largest diameter was 10 cm. Ten cysts were located in the middle mediastinum and 10 in the posterior mediastinum. Two cysts were complicated. RESULTS Thirteen bronchogenic cysts were resected completely by thoracoscopy. We had to convert thoracoscopy into thoracotomy because of bleeding in two cases and because of major adhesions to vital structures in five cases. There were no operative deaths and no postoperative complications. Mean hospital stay was significantly less in the completely thoracoscopically treated group. Long-term follow-up (range, 4.5 to 7.5 years) showed no late complications and no recurrence. CONCLUSIONS Preoperative complications, intraoperative injuries, and major adhesions to vital structures seem to be the only unfavorable conditions to thoracoscopic treatment of bronchogenic cysts. This study found encouraging results for thoracoscopic excision of mediastinal bronchogenic cysts in selected patients.

Complications of video-assisted thoracic surgery: A five-year experience

BACKGROUND Although thoracoscopy was originally described in 1910, recent developments in video-assisted surgical techniques and endoscopic equipment has expanded the application of video-assisted surgical procedures in the field of thoracic surgery. METHODS In an effort to define both high-risk patients for video-assisted thoracic procedures and high-risk video-assisted thoracic surgical procedures, we reviewed the experience of four surgical institutions from June 1991 through May 1995. We looked specifically at complications resulting from the 937 video-assisted thoracic procedures performed during this period. RESULTS Perioperative incidents or complications occurred in 35 patients (3.7%), and 116 procedures (12.4%) were converted to a thoracotomy. The in-hospital mortality rate was 0.5%, and death occurred principally in patients operated on for malignant pleural effusion. The overall incidence of postoperative complications was 10.9%, and the most prevalent complications were prolonged air leak (6.7%) and pleural effusion (0.7%). CONCLUSIONS The incidence of complications was acceptable and, except for that of prolonged air leak, did not differ significantly from that resulting from analogous open procedures. Video-assisted thoracic surgery appears safe and particularly useful for some indications. However, the possibility of dramatic life-threatening perioperative complications requiring emergency conversion to thoracotomy justifies the fact that only trained thoracic surgeons should perform video-assisted thoracic surgical procedures.

Videothoracoscopic lung biopsy in diffuse infiltrative lung diseases: a 5-year surgical experience

BACKGROUND To establish an accurate diagnosis of diffuse infiltrative lung disease, a surgical lung biopsy may be required. We report our experience with video-thoracoscopic lung biopsy over a period of 5 years. METHODS From March 1992 through December 1996, videothoracoscopic lung biopsy was performed in 64 patients (17 were women [26.5%]; age, 50.5+/-13 years) with a diagnosis of diffuse infiltrative lung disease of an unknown cause. All patients except one received general anesthesia. Single lung ventilation was used in 61 patients. All lung biopsies were obtained with an endoscopic stapler. RESULTS Single lung biopsies were performed in 39 patients (61%), two biopsies in 23 patients (36%), and three biopsies in 2 patients. Minithoracotomies were necessary in 10 patients (15.6%) owing to an iatrogenic pulmonary wound (1 patient), extensive pleural adhesions (6 patients), and a stiff lung (3 patients). Postoperative complications were rare and included five discrete pneumothoraces (7.8%), all resolving spontaneously, one prolonged air leak (1.6%), and one hemothorax requiring reoperation. Three preoperatively debilitated patients died (4.7%), 2 with progression of respiratory failure and 1 owing to septic shock. Average chest tube duration was 2.4+/-2 days and average hospital stay was 4.6+/-2.5 days. Lung biopsy contributed to the diagnosis in 59 patients (92%). CONCLUSIONS Videothoracoscopic lung biopsy using an endoscopic stapler is a safe and effective procedure in most cases and should be performed by trained thoracic surgeons.

Surgical resection of lung cancer in patients with underlying interstitial lung disease

BACKGROUND The association between interstitial lung disease (ILD) and an increased risk of developing lung cancer has been reported. The goal of this retrospective study was to determine the outcome of lung cancer resection among patients with ILD. METHODS Between January 1979 and March 1999, 27 patients with both lung cancer and ILD were identified. Seven patients with poor pulmonary function tests or distant metastases underwent medical treatment and were excluded from this study. Twenty patients treated by surgical resection were analyzed. RESULTS Various types of ILD such as sarcoidosis (n = 7), idiopathic interstitial pneumonia (n = 4), histiocytosis X (n = 4), pneumoconiosis (n = 4), and amiodarone-induced ILD (n = 1) were observed. Tumors were located in the peripheral part of the lung in 16 cases. The most frequent tumor cell types were squamous and adenocarcinoma. The resections consisted of lobectomy (n = 16), bilobectomy (n = 1), and pneumonectomy (n = 3). Most cancers were stage I (n = 10) or II (n = 6). There was no postoperative death. The postoperative course was uneventful in 16 cases. The majority of patients (70%) did not experience respiratory insufficiency during the follow-up period. The actuarial 2-year and 5-year survival rates were, respectively, 83.5% and 66.4%. CONCLUSIONS In this series, the long-term survival of patients who had lung cancer resection appeared to be not affected by the association with ILD. This could be explained by an adequate preoperative selection based on pulmonary function tests and a preferential choice for lobectomies. Thus, surgical resection should be offered to properly selected patients with lung cancer and underlying ILD.

Experimental study on the in vivo behaviour of a new collagen glue in lung surgery

OBJECTIVE To study the pneumostatic ability of a collagen polymerised with a polysaccharide (GAO) glue in lung surgery; its influence in pleuro-pulmonary adhesion formation; the pulmonary tissue reaction to it, its biodegradability, and the eventual alterations of pulmonary compliance induced by the glue. METHODS Two groups of ten rabbits (controls and treated) were operated under ventilatory assistance by thoracotomy to promote pleural adhesions, and injury to the lung. Repeated chest X-rays were carried out postoperatively. Lungs were examined histologically at day 40. In vitro tests were performed to study glue effects on pulmonary compliance. RESULTS Air leaks stopped 2 min after glue application. Persistent pneumothorax were likely seen in treated rabbits (ns). Glue induces a temporary reduction of pulmonary compliance. Glue did not increase adhesion formation, or interfere with the healing process. CONCLUSIONS For its properties, GAO seems to be a good and well-tolerated tool to reduce air leaks from the lung, without inducing residual pleural symphysis.

Métaplasie de tissu aortique en tissu trachéal. Perspectives chirurgicales

Abstract Tracheal reconstruction after extensive resection remains an unsolved surgical problem. Numerous attempts have been made using tracheal grafts or prosthetic conduits with disappointing results. In this study, we propose a new alternative using an aortic autograft as tracheal substitute. In a first series of experiments, a half circumference of two rings was replaced with an autologous carotid artery patch. In a second series, a complete segment of trachea was replaced with an autologous aortic graft supported by an endoluminal tracheal stent. No dehiscence or stenosis was observed. Microscopic examinations at 3 and 6 months showed the replacement of the aortic tissue by tracheal tissue comprising neoformation of cartilage and mucociliary or non-keratinizing metaplastic polystratified squamous epithelium. Although these results need to be confirmed by a larger series of experiments, they showed that a vascular tissue placed in a different environment with a different function can be submitted to a metaplastic transformation which tends to restore a normal structure adapted to its new function. These remarkable findings offer new perspectives in tracheal reconstruction in human.

Persistent symptomatic pleural effusion following coronary bypass surgery: clinical and histologic features, and treatment

Pleural effusions following coronary artery bypass grafting (CABG) have been reported in 65%–89% of the cases. The majority of pleural effusions are left-sided, of little significance, and resolve spontaneously. However, a few pleural effusions require specific therapeutics. We report clinical and pleural histologic features of three patients who had persistent post-CABG pleural effusions and underwent video-assisted thoracic surgery (VATS). These patients were studied because they had a persistent pleural effusion within the first 2 months after CABG without other identifiable causes. All patients underwent VATS for investigation and management of persistent pleural effusions. Three patients with a mean age of 63.6 ± 8.5 years were studied. The pleural effusion developed 38 ± 11.3 days after CABG (range: 22–46). The median period from CABG to VATS was 80 ± 21.6 days (range: 50–100). In all cases, the pleural effusion was large, and predominated on the left side. Pleural effusions were characterized by an exudative (n = 2) or transudative (n = 1) fluid with lymphocytosis. Histologic examination of pleural biopsies showed a follicular lymphoid hyperplasia involving the pleural serosa and a non-necrotizing granulomatous reaction with a mild inflammatory infiltrate. All patients underwent VATS with intrapleural injection of sclerosing agents. Video-assisted thoracic surgery talc pleurodesis led to symptomatic and radiologic improvement in all patients with a mean follow-up of 16.7 ± 4.5 months. No recurrence of pleural effusion has been observed in any patient. Large pleural effusions can develop in a small proportion of patients after CABG. The mechanism of pleural effusion remains unclear. Video-assisted thoracic surgery could play a significant role in the management of pleural effusion developing after CABG.