N. Cheynel

Identification of prognostic factors determining risk groups for lung resection

BACKGROUND Pulmonary resection belongs to a group of surgical procedures with significant morbidity and mortality. The aims of this study were to classify postoperative complications and to identify prognostic factors determining risk group. METHODS In a prospective study 500 patients undergoing lung resection (wedge resection, n = 141; lobectomies, n = 245; bilobectomies, n = 12; and pneumonectomies, n = 102) were included. In 178 patients (36%) pulmonary resections were extended to structures or thoracic organs. Sleeve resection of the bronchus to preserve lung parenchyma was performed in 22 patients. RESULTS Classification of postoperative complications fell into four categories: patients without postoperative complications; patients with moderate complications (n = 137); patients with severe complications (n = 38); and death (n = 33). Factors adversely affecting postoperative complications by multivariate analysis included pulmonary pathology, bronchoplastic technique, forced expiratory volume in 1 second (FEV1), extended resection, type of lung resection, comorbidity indices, and preoperative chemotherapy. Four risk groups were determined. Risk group I (n = 60) with the best prognosis included patients with FEV1 greater than or equal to 80% undergoing wedge resection for a benign lesion or metastasis. Risk group II (n = 161) included patients with FEV1 greater than or equal to 80% undergoing major pulmonary resection for a benign lesion or metastasis or lung cancer, or patients with FEV1 less than 80% undergoing wedge resection for benign lesion or metastasis. Risk group III (n = 233) with a fair prognosis included patients with comorbidity indices less than 4 and FEV1 greater than or equal to 80% undergoing extended pulmonary resection for a benign lesion or metastasis or lung cancer, or patients with FEV1 less than 80% and emphysema. Risk group IV (n = 46) with the worst prognosis included patients with FEV1 less than 80% undergoing an extended lung resection or bronchoplastic procedures for a benign lesion or metastasis or lung cancer, or patients with comorbidity indices greater than or equal to 4 undergoing extended lung resection for lung cancer. CONCLUSIONS In a prospective study, based on these prognostic factors, a practical, easy-to-use risk group system of lung resection is proposed as a tool to aid the decision to perform lung resection.

Immunologic effects of rituximab on the human spleen in immune thrombocytopenia

Immune thrombocytopenia (ITP) is an autoimmune disease with a complex pathogenesis. As in many B cell-related autoimmune diseases, rituximab (RTX) has been shown to increase platelet counts in some ITP patients. From an immunologic standpoint, the mode of action of RTX and the reasons underlying its limited efficacy have yet to be elucidated. Because splenectomy is a cornerstone treatment of ITP, the immune effect of RTX on this major secondary lymphoid organ was investigated in 18 spleens removed from ITP patients who were treated or not with RTX. Spleens from ITP individuals had follicular hyperplasia consistent with secondary follicles. RTX therapy resulted in complete B-cell depletion in the blood and a significant reduction in splenic B cells, but these patients did not achieve remission. Moreover, whereas the percentage of circulating regulatory T cells (Tregs) was similar to that in controls, splenic Tregs were reduced in ITP patients. Interestingly, the ratio of proinflammatory Th1 cells to suppressive Tregs was increased in the spleens of patients who failed RTX therapy. These results indicate that although B cells are involved in ITP pathogenesis, RTX-induced total B-cell depletion is not correlated with its therapeutic effects, which suggests additional immune-mediated mechanisms of action of this drug.

Preventing Lymphedema and Morbidity With an Omentum Flap After Ilioinguinal Lymph Node Dissection

BackgroundPedicled omentoplasty has been advocated to prevent the formation of lymphocysts and lymphedema after pelvic lymph node dissection, We evaluated the possible benefit of a pediculated omentoplasty placed in the groin for preventing complications after ilioinguinal lymph node dissection.MethodsIn this pilot study, we report a series of four women and three men with inguinal metastatic lymph nodes. Each was treated with a pediculated omentoplasty after groin dissection. We examined complications such as lymphedema, lymphorrhea, wound breakdown, skin necrosis, and lymphocysts.ResultsOnly one wound breakdown with skin necrosis was observed, and it healed satisfactorily in 10 days without exposing the femoral vessels. No lymphocele or infectious complications occurred, even though no antibiotic prophylaxis was used. Midthigh circumference increase ranged from 1.5 to 7 cm in four cases but remained asymptomatic. Furthemaore, lymphedema of the lower limb decreased in the three remaining patients, who previously had an enlargement of the thigh. No evidence of peritoneal carcinomatosis was noted during the 4-month follow-up.ConclusionsPedicled omentoplasty seemed to facilitate the absorption or transport of lymph fluids and resulted in less lymphedema in the lower limb even after radiotherapy. Pedicled omentoplasty reduces both short-term and long-term postoperative complications without affecting treatment outcome and could even be considered as a safe and effective therapy for lymphedema of the lower extremity.

Patterns of recurrence of obstructing colon cancers after surgery for cure: a population-based study

Little is known about patterns of recurrence in obstructing colon cancer (OCC) at a population level. The aim of this study was to determine the risk of recurrence following potentially curative surgery in OCC compared with that in uncomplicated colon cancer (CC).

Prothèse pariétale composite et non résorbable en polyéthylène téréphtalate-polyuréthane (HI-TEX®PARP NT): prévention des adhérences intrapéritonéales. Etude expérimentale chez le lapin

Resume Les auteurs rapportent les resultats d’une etude experimentale chez le lapin portant sur une nouvelle prothese composite non resorbable, en polyethylene terephtalate–polyurethane, implantable par voie intraperitoneale dans la cure des eventrations. Cette nouvelle prothese a une face permeable et macroporeuse en polyethylene terephtalate non tissee pour favoriser une fixation tissulaire rapide, et une face en polyruethane hydrophobe non poreuse, destinee a eviter la penetration cellulaire. Dix-huit lapins ont ete operes. La perte de substance creee etait a la fois aponevrotique, musculaire et peritoneale. Les protheses placees par voie intraperitoneale ont ete prelevees a quatre, neuf mois et 13 mois, pour analyse histologique et pour examen en microscopie electronique a balayage. L’etude a porte sur la tolerance, les adherences intraperitoneales, les reactions tissulaires, et la formation d’un neoperitoine. Les protheses ont toutes ete retrouvees intactes, bien integrees, et sans sepsis local. Des adherences intraperitoneales lâches et non occlusives ont ete observees chez trois lapins seulement. Ces protheses peuvent donc constituer une alternative interessante pour le traitement des eventrations par voie intraperitoneale.

Lateral approach to laparoscopic repair of left diaphragmatic ruptures

Video-assisted repairs of traumatic diaphragmatic ruptures have been described where thoracoscopy or laparoscopy in the supine position were used. This study aims to validate a new lateral laparoscopic approach for left diaphragmatic repairs. Six consecutive patients were operated on for left diaphragmatic rupture using a lateral approach (Gagner’s position). A series of 362 consecutive patients presenting with abdominal or thoracic trauma with or without diaphragmatic rupture over a 2-year period were reviewed retrospectively. Contraindications for immediate or delayed lateral laparoscopic approach were studied. The lateral approach provided complete visibility of the subdiaphragmatic space, easy reduction of herniated organs, easy thoracic inspection and cleaning, the use of low peritoneal pressure, full range of instrumental motion, and rapid diaphragmatic repair. No operative mortality or morbidity was noted. Altogether, 14% to 50% of the patients with diaphragmatic ruptures were candidates for immediate lateral laparoscopic repair. Associated spleen injury in 50% of the cases was the main contraindication. The lateral laparoscopic approach provides better exposure of the diaphragm on the left side and facilitates the diaphragmatic repair especially with a large herniation. Immediate repair is possible in selected cases (14–50%). There is no contraindication in case of delayed diagnosis.RésuméFond du problème: La réparation vidéo-assistée des ruptures traumatiques du diaphragme est déjà bien décrite. L’intervention a lieu en décubitus dorsal soit par thoracoscopie soit par laparoscopie. L’objectif de cette étude a été de valider une nouvelle approche latérale laparoscopique pour la réparation des ruptures diaphragmatiques gauches. Population et méthodes: (1) Six patients consécutifs ont été opérés pour rupture diaphragmatique gauche par I’approche latérale (position de Gagner). (2) On a revu 362 dossiers consécutifs de patients ayant eu un traumatisme abdominal et/ou thoracique avec ou sans rupture diaphragmatique pendant une periode de deux ans. Les contre-indicationsà une réparation latérale laparoscopique immédiate ou retardées ont été étudiées. Résultats: (1) L’approche latérale permet: une visibilité complète de I’espace sous-diaphragmatique, une réduction aisée des organes herniés, la possibilité d’inspection et de toilette thoraciques faciles, I’utilisation d’une pression intra-abdominale basse, un champs d’action des instruments sans gène et une réparation diaphragmatique rapide. On n’a noté aucune mortalité ou morbidité opératoire. (2) Quatorzeà 50 pour-cent des patients ayant une rupture diaphragmatique ont été candidatsà une réparation immédiate par cette approche. L’association de lésions spléniques dans 50% des cas a été la contre-indication majeure. Conclusions: L’approche latérale laparoscopique fournit une meilleure exposition du diaphragme du coté gauche et facilite la réparation surtout en cas d’orifice large. La réparation immédiate est possible dans un certain nombre de cas (14% à 50%). II n’existe aucune contre-indication en cas de diagnostic retardé.ResumenAntecedentes: Se sabe, que las rupturas traumáticas del diafragma pueden ser tratadas mediante viedo-cirugia. Normalmente se utiliza la toracoscopia o la laparoscopia en decúbito supino. Este estudio intenta revalidar un nuevo abordaje lateral para la reparación de las rupturas diafragmáticas izquierdas. Casuistica y Métodos: (1) Seis pacientes con rupturas del hemidiafragma izquierdo fueron intervenidos mediante abordaje lateral (en posición de Gagner). (2) Se revisaron retrospectivamente 362 pacientes con traumatismo abdominal y/o torácico con o sin ruptura diafragmática tratados en un periodo de dos anõs. Se estudiaron las indicaciones y contraindicaciones del tratamiento precoz o diferido por via laparoscópica. Resultados: (1) El abordaje lateral permite una completa visualización del espacio subdiafragmático, facilita la reducción de los órganos herniados, siendo la inspección torácica másfácil y más clara; la presión intrabdominal (neumoperitoneo) necesaria es menor y la movilidad de los instrumentos idónea, permitiendo una rápida reparación del defecto diafragmático. No se registró morbi-mortalidad alguna. (2) Entrel 15 y el 50% de pacientes con ruptura diafragmática fueron tratados precozmente mediante abordaje lateral laparoscópico. La contraindicación mayor, en el 50% de los casos, fue la ruptura concomitante del bazo. Conclusiones: El abordaje lateral laparoscópico permite una mejor exposición del hemidiafragma izquierdo y facilita la reparación diafragmática, sobre todo en casos de grandes hernias. La reparación precoz es posible en el 14 al 50% de casos seleccionados. La intervención no está contraindicada en pacientes diagnosticados tardiamente.

Le « pneumocou » dans la vidéocervicoscopie : technique opératoire et limites anatomiques

The aim of this study was to describe a technic in order to create a gas space “pneumoneck” during videoendoscopic surgery of the neck and to determine the anatomical limits of this space. Data were based on a surgical experience and on the dissection of two corpses. This space was located between the two layers of the pre-tracheal lamina of the cervical fascia. This space was enclosed and favourable to detachment with insufflated gas without subcutaneous emphysema. This approach can be used for parathyroid and thyroid surgery.

Liver injuries in frontal crash situations a coupled numerical—experimental approach

From clinical knowledge, it has been established that hepatic traumas frequently lead to lethal injuries. In frontal or lateral crash situations, these injuries can be induced by pure deceleration effects or blunt trauma due to belt or steering wheel impact. Concerning the liver under frontal decelerations, how could one investigate organ behaviour leading to the injury mechanisms? This work couples experimental organ decelerations measurements (with 19 tests on cadaver trunks) and finite element simulation, provides a first analysis of the liver behaviour within the abdomen. It shows the influence of the liver attachment system that leads to liver trauma and also torsion effects between the two lobes of the liver. Injury mechanisms were evaluated through the four phases of the liver kinematics under frontal impact: (1) postero-anterior translation, (2) compression and sagittal rotation, (3) rotation in the transverse plane and (4) relaxation.

Tubular duplication of the esophagus. Contribution of magnetic resonance imaging in anatomical analysis before surgery.

The authors report a tubular duplication of the thoracic esophagus in a 17-year-old male. This anomaly, rare in the adult, can be explained either by a failure of esotracheal compartmentalisation, or a notochordodysraphy or more probably by an error during vacuolisation of the esophagus. The anatomical characteristics of the duplication were clearly seen on MRI. This investigation showed the intramural duplication, with only a thin barrier without muscle, between the esophageal lumen and the duplication channel two communications were present between the esophageal lumen and the duplication. The esophagus was accessed by right thoracotomy. The close contact between the duplication and the esophagus did not allow them to be separated. A subtotal esophagectomy was necessary, with digestive continuity being restored by coloplasty after a left cervicotomy and a laparotomy. The anatomy seen on the MRI should have predicted that an esophagectomy was necessary and that a thoracotomy could have been avoided by performing the procedure with a closed thorax.

L’imagerie médicale dans la prise en charge non opératoire des traumatismes abdominaux

Resume La prise en charge non operatoire des traumatismes abdominaux fermes est devenue un standard chez le patient hemodynamiquement stable en absence de signes peritoneaux. Ce choix therapeutique impose la disponibilite d’une imagerie medicale diagnostique et/ou therapeutique pour guider la prise de decisions.