Jean-Pierre Hubsch

Visceral pleura invasion and pleural lavage tumor cytology by lung cancer: a prospective appraisal

BACKGROUND Despite an early-stage diagnosis, lung cancer presenting with visceral pleura invasion (VPI) or malignant pleural lavage cytology (PLC) has a poor prognosis. The purpose of this study was to correlate VPI to malignant PLC. METHODS One hundred forty-three consecutive patients scheduled for surgical lung resection having undergone preresectional pleural lavage cytology were reviewed. There were 121 malignant and 22 nonmalignant lesions. All cases were studied by pathology, histology, previous transthoracic puncture, VPI, and presence of pleural lymphatic involvement. RESULTS PLC was positive (n = 13) or suspected (n = 5) for malignant cells in, respectively, 10.7% and 4.1% of patients with lung cancer. There was no positive PLC in cases of nonmalignant disease. PLC was positive only in pT2 tumors and almost always when the tumor was exposed on the pleural surface, thus possibly exfoliating within the pleural space (12/17 patients, 70.6%; p < 0.01). Positive PLC was obtained whatever the histology but did not appear related to previous transthoracic puncture or involvement of pleural lymphatics by tumor cells. CONCLUSIONS VPI and positive PLC are linked, and the appearance of tumor cells within the pleural cavity can be explained by tumor desquamation. The role that visceral pleura involvement and parietal pleura reabsorption play in lung cancer is of paramount importance and deserves further research. A better understanding of their relationship could have major implications in the therapeutic management of non-small cell lung cancer.

Intrathoracic phrenic pacing: A 10-year experience in France

BACKGROUND Phrenic pacing is an alternative to positive-pressure ventilation in selected patients, mostly in cases of upper spinal cord injury. We evaluated results of phrenic pacing performed by video-assisted thoracic surgery (VATS). METHOD Between 1997 and 2007, after complete neuromuscular investigations, 20 patients requiring full-time ventilation were selected for phrenic pacing (19 with posttraumatic tetraplegia and 1 with congenital central hypoventilation syndrome). Quadripolar cuff electrodes were fixed around each intrathoracic phrenic nerve via bilateral VATS. They were connected to a subcutaneous radiofrequency receiver coupled to an external radiofrequency transmitter. All patients participated in a reconditioning program beginning 2 weeks after implantation and continued until ventilatory weaning. RESULTS Phrenic pacing was successful in all cases. No intraoperative complications or perioperative mortality were observed. Intraoperative testing detected stimulation thresholds in 19 patients (range, 0.05-2.9 mA). Ventilatory weaning was obtained in 18 patients. Median diaphragm reconditioning time was 6 weeks (2 weeks-11 months). Reconditioning was still in process in a young woman and was not achieved in an elderly woman with a 4-year history of tetraplegia. All the patients weaned from mechanical ventilation reported improved quality of life. Failure or delay in recovery of effective diaphragm contraction was due to nonreversible amyotrophy. CONCLUSIONS VATS implantation of 4-pole electrodes around the intrathoracic phrenic nerve is a safe procedure. Ventilatory weaning correlates with the degree of diaphragmatic amyotrophy. Phrenic pacing, performed as soon as neurologic and orthopedic stabilization is achieved, is the most important prognostic factor for successful weaning.

Cervical venous anastomoses of pulmonary lymphatic vessels

The aim of this study was to describe in detail the anastomoses between the pulmonary lymphatic vessels and the veins of the neck so as to better understand their role in certain aspects of thoracic surgery. The lymphatic vessels of 687 pulmonary segments in 360 cadavers were injected. A detailed study of the proximal end of the right paratracheal, right tracheo-esophageal, left pre-aortocarotid and left recurrent lymph node chains was undertaken. The results showed the absence of any major right lymphatic “vein”. There were, however, many lymphatic arches draining into the jugulo-subclavian confluence ipsilaterally, and, in 10 to 15% of cases, contralaterally as well. The intertracheobronchial lymph nodes also drained into the venous confluence of the neck via direct lymphatic vessels, without lymph node relays. Finally, the left mediastinal lymph node chains were frequently found to drain into the arch of the thoracic duct (40% of cases), and reflux due to valvular incompetence at this level may account for chylous pericarditis and some cases of chylothorax after surgery.

Lymphatic drainage of heart and lungs comparison between pig and man

In its anatomy and physiology the pig is comparable with humans and its organs can be considered for xenotransplantation. We have studied the lymphatic drainage of the heart and lungs in 15 pigs. A coloured mass was injected into the myocardium and/or beneath the visceral pleura. The first nodes coloured were directly injected again. No lymph node was observed inside the heart and lungs. The first lymph nodes coloured were the peritracheobronchial nodes. There was no node in front of the thoracic trachea (Barety’s compartment in man). Left suprabronchial nodes were connected with the thoracic duct in the mediastinum. The lymphatics of the heart and lungs in the pig are similar to those of human. Phylogenesis explains “skipping” metastases and the significance of N1 disease in lung cancer, as well as chylothorax occurring after heart and lung surgery.

Extra corporal membrane oxygenation in general thoracic surgery: a new single veno-venous cannulation

Extracorporeal membrane oxygenation (ECMO) is used in severe respiratory failure to maintain adequate gas exchange. So far, this technique has not been commonly used in general thoracic surgery. We present a case using ECMO for peri-operative airway management for pulmonary resection, using a novel single-site, internal jugular, veno-venous ECMO cannula.

Le role du chirurgien

Resume Le depistage des nodules pulmonaires impose une prise en charge multidisciplinaire afin d’optimiser les possibilites diagnostiques et therapeutiques pour proposer une technique qui soit rentable et la moins invasive possible. La Videothoracoscopie (VT), realisee sous anesthesie generale avec exclusion ventilatoire, est d’un apport fondamental dans cette indication. Elle est faite d’emblee en cas de suspicion de neoplasie pulmonaire primitive localisee chez un patient operable et constitue alors le premier temps du traitement curateur. Elle est egalement indiquee en cas d’impossibilite ou d’echec de la ponction sous scanner (micro-nodules multiples ou lesion benigne). Les caracteristiques du nodule determinent la faisabilite de la VT : sa taille (superieure a 5 mm), sa topographie (pres d’une scissure ou des faces mediastinale et diaphragmatique) et sa distance par rapport a plevre viscerale (classiquement inferieure a 1 cm ou 2 cm) ponderee par la capacite de retraction elastique du poumon. Le reperage per-operatoire du nodule repose sur les donnees tomodensitometriques, la palpation pulmonaire instrumentale et l’experience de l’operateur. En cas de difficultes previsibles, un reperage peut etre propose. Les limites de la VT (topographie du nodule ou symphyse pleurale complete) imposent parfois de faire un abord thoracique direct ou une mini-thoracotomie.