Olivier Ghez

Stage I non-small cell lung cancer: a pragmatic approach to prognosis after complete resection

BACKGROUND Long-term results of the surgical treatment of stage I non-small cell lung cancer (NSCLC) are disappointing. METHODS Univariate and multivariate analyses were conducted on 515 consecutive lung resections for stage I NSCLC performed from 1990 to 1999 and identified by reviewing a database into which data were entered prospectively. Tumors were staged as stages IA (n = 147) and IB (n = 348) according to the 1997 UICC (Union Internationale Contre le Cancer) pTNM classification. RESULTS Operative mortality rates were 6.2%, 5.3%, 2.3%, and 0% for pneumonectomy, bilobectomy, lobectomy, and lesser resections, respectively. Overall survival rate was 61.1% (55.8% to 66.5%) at 5 years. Univariate analysis identified three significant adverse prognosticators: arteriosclerosis as comorbidity, pathologic T2 status, and blood vessel invasion. Male sex (p = 0.056) and performance of pneumonectomy (p = 0.057) were at the threshold of statistical significance. At multivariate analysis, three independent prognosticators entered the model: arteriosclerosis, blood vessels invasion, and performance of pneumonectomy. CONCLUSIONS Long-term survival of patients with completely resected stage I NSCLC was adversely influenced in a relatively balanced way by factors related to the clinical status of the patient, to the tumor, and to the treatment.

Postoperative extracorporeal life support in pediatric cardiac surgery: recent results.

We retrospectively reviewed the files of 19 extracorporeal life support (ECLS) applications performed after cardiac surgery in 15 patients from January 2002 to December 2004. We placed 16 arteriovenous ECLS applications with oxygenator, 2 venovenous ECLS applications with oxygenator, and 1 biventricular ECLS application without oxygenator (graft dysfunction after heart transplant). Mean age was 4.9 ± 7 years (median 5.9 months, range 11 days to 21 years). All patients underwent surgery for congenital heart disease, except for one patient who had a heart transplant. Indications were hemodynamic failure in 12 cases, respiratory failure in 5 cases, and mixed failure in 2 cases. Four patients were undergoing cardiopulmonary resuscitation during ECLS placement (no deaths). Mean delay between surgery and ECLS placement was 3.2 ± 3.4 days (median 2 days). Mean ECLS duration was 3.4 ± 5.8 days (mean 6 days, range 3–16 days). Three patients had further surgery for residual lesions. Thirteen patients (86.7%) survived to ECLS weaning; 12 patients survived to hospital discharge (80%). No survivor presented obvious neurologic damage. Specific morbidity included re-entry for bleeding, multiple transfusions, and mediastinitis. These results support early placement of ECLS in children whenever a severe postoperative hemodynamic or respiratory failure, refractory to medical treatment, is present.

Is lung cancer surgery justified in patients with direct mediastinal invasion

OBJECTIVE To assess the results of the surgical treatment of patients with stage IIIB non-small cell lung carcinoma (NSCLC) invading the mediastinum (T4). METHODS Twenty-nine patients were operated on from 1986 to 1999. Histology was squamous cell carcinoma in 17 patients, adenocarcinoma in eight, large cell carcinoma in two and neuroendocrinal carcinoma in two. Three patients received a preoperative chemotherapy (n = 2) or radiochemotherapy (n = 1). The lung resection consisted of a pneumonectomy in 25 patients and a lobectomy in four. The procedure was extended to one of the following structures: superior vena cava (SVC) (n = 17), aorta (n = 1), left atrium (n = 5) and carina (n = 6). Seventeen patients had a postoperative regimen including radiochemotherapy (n = 12), radiotherapy (n = 4), or chemotherapy (n = 1). RESULTS Complete R0 resection was achieved in 25 patients, whereas four patients had a microscopically (n = 1) or macroscopically (n = 3) residual disease. The operative mortality rate was 7% (n = 2). Non-fatal major complications occurred in eight patients (28%). Overall 5-year survival rate was 28% (median 11 months), including the operative mortality. The median survival of the 18 patients with an N0 or N1 disease was 16 months whereas the median survival of the 11 patients with an N2 disease was 9 months. At completion of the study, 22 patients have died, two postoperatively and 10 from pulmonary causes without evidence of cancer. CONCLUSIONS Surgical management of T4 NSC lung cancer invading the mediastinum should be considered, in the absence of N2 disease, when a complete resection is achievable.

Delayed sternal closure: a life-saving measure in neonatal open heart surgery; could it be predictable

OBJECTIVES The tight syndrome after open-heart procedures in neonates renders delayed sternal closure (DSC) a life-saving measure. The goal of this study is to analyze the risk factors that may predict the need for DSC. METHODS Between January 1991 and December 2000, 312 consecutive open-heart procedures in neonates (180 males, 132 females) were studied retrospectively. Median age was 11.9 days (range 1-30 days) and weight 3.63 kg (range 1.8-4.2 kg). The major pathologies were transposition of the great arteries (153), interruption of the aortic arch (IAA) (33), total anomalous pulmonary venous drainage (TAPVD) (24) and single ventricle (19). Two hundred and twenty-eight patients had profound hypothermia with circulatory arrest and 74 normothermic cardiopulmonary bypass (CPB), 195 had crystalloid cardioplegia and 111 blood cardioplegia. Median CBP time was 146 min (range 37-284 min) and aortic clamping 67.6 min (range 0-164 min). Two hundred and fifty-five patients had a continuous ultrafiltration and 57 had a modified ultrafiltration. The criteria for DSC were hemodynamic instability, deterioration of the central venous saturation, metabolic status and/or high ventilatory pressures. RESULTS One hundred and nineteen patients had DSC (38.12%). Median CBP time was 145 min (range 37-284 min) and aortic clamping time 67.6 min (range 0-164 min). Twenty-one patients (6.7%) needed reopening in the intensive care unit (ICU) during the first 24 h. Among the studied factors, the age below 7 days (P=0.014), the diagnosis of IAA and TAPVD (P<0.05), CBP duration over 185 min (P=0.048), clamping time over 98 min (P=0.039) and central venous saturation below 51% P=0.024) were statistically significant risk factors. All the patients who had more than 106 min of clamping, more than 196 min of cardiopulmonary bypass or less than 47% of central venous saturation were either left opened or reopened in the ICU. CONCLUSIONS Many of the factors thought to be associated with the need for delaying the sternal closure had no statistical significance as risk factors. On the other hand, the diagnosis of IAA or TAPVD, an age less than 7 days, aortic clamping more than 98 min, CPB time more than 185 min and a post-bypass central venous saturation less than 51% were statistically significant risk factors that could be used in predicting the need for delaying the sternal closure.

Paclitaxel drug-eluting stent placement for pulmonary vein stenosis as a bridge to heart-lung transplantation.

Congenital pulmonary vein stenosis (PVS) presents as an isolated lesion or in association with other congenital heart anomalies. The most extensive forms of the disease are uniformly fatal because neither surgical repair nor transcatheter therapy results in long-term relief of the stenosis. A case is presented involving single-ventricle physiology associated with extensive and recurrent congenital PVS despite multiple attempts with surgical therapy. Heart–lung transplantation was ultimately performed after drug-eluting stents were placed in pulmonary veins as a bridge to the transplantation.

Absence of rapid deployment extracorporeal membrane oxygenation (ECMO) team does not preclude resuscitation ecmo in pediatric cardiac patients with good results.

We evaluated the results of using extracorporeal membrane oxygenation (ECMO) as resuscitation for cardiac patients undergoing cardiopulmonary resuscitation (CPR) in our setting where neither perfusionists nor surgeons are always on site, and no circuit may be ready. Between 2003 and 2006, we used ECMO for all cardiac patients who underwent cardiac arrest in the pediatric intensive care unit (PICU) or Cath Laboratory. We reviewed retrospectively 14 consecutive files (15 episodes). Mean CPR time before ECMO institution was 44 minutes (10–110 minutes). The surgeons, perfusionist, and scrub nurse, not on site for three of these patients, had to be called in simultaneously with institution of CPR. Two died on ECMO, the third one was successfully transplanted after 5 days. Globally, 10 patients could be weaned (66%). Eight patients (57%) survived to hospital discharge, seven without obvious neurological damage. One patient was bridged to a left ventricular assist device (LVAD) and was eventually successfully transplanted. He had an ischemic brain lesion with good recuperation and no sequel. We obtained good results with resuscitation ECMO in our setting where a permanently on-site rapid deployment ECMO team is not present at all times.

Surgical management of metachronous bronchial carcinoma

OBJECTIVE To assess the results of surgery for the treatment of metachronous bronchial carcinoma. METHODS From 1985 to 1999, 38 patients were operated on for a metachronous lung carcinoma, accordingly to the criteria of Martini. All tumors were staged using the new International Classification System revised in 1997. RESULTS Diagnosis of the second cancer was done at radiological follow-up in 30 asymptomatic patients. Seventeen metachronous locations were ipsilateral. Histology of the metachronous lesion was the same as that of the first tumour in 23 patients (60%). The first resection was a lobectomy (n=35), a pneumonectomy (n=2) and a carinal resection (n=1). The second one was a wedge resection (n=7), a segmentectomy (n=3), a lingulectomy (n=2), a lobectomy (n=9), a bilobectomy (n=1), and a pneumonectomy (n=16). There were five in-hospital deaths (13%). Completion pneumonectomy was performed in 15 patients, with one postoperative death (7%). The overall estimated 5 and 10-years actuarial survival rates from the treatment of the first cancer were 70 and 47% respectively. The 5-year survival rate after the treatment of the second cancer was 32% (median survival: 31 months), including the operative mortality. Survival was negatively affected by a resection interval of less than 2 years and the performance of atypical lung sparing pulmonary resection for the treatment of the second cancer. CONCLUSIONS Good long-term results are achievable by the means of a second pulmonary resection in selected patients with metachronous lung cancer. Optimal cancer operations should be applied whenever functionally possible.

Isolated cleft of the mitral valve: distinctive features and surgical management.

BACKGROUND Controversy remains as to whether isolated cleft of the mitral valve and cleft of the atrioventricular septal defect are different entities. Our objectives were to provide a precise description of isolated cleft of the mitral valve and to clarify its surgical management and outcome. METHODS Patients with surgical repair of isolated cleft of the mitral valve were included. RESULTS Ten patients (9 female) underwent repair at a mean age of 12.1 +/- 10.5 years and mean weight of 32.1 +/- 17.8 kg. Preoperative echocardiography showed mild or less than mild mitral regurgitation in 6 cases and moderate to severe regurgitation in 4. Intraoperative examination confirmed in all cases a cleft dividing the anterior leaflet of an otherwise normal mitral valve. Attachment of the cleft to the ventricular septum by accessory chordae was found in 3 cases whereas preoperative echocardiography found such attachments in 5. Direct suture of the cleft was performed in 9 cases, associated with repair of tricuspid valve straddling (n = 1), subaortic stenosis (n = 1), and ventricular septal defect (n = 1). One patient with thickened clefts edges required an Alfieri-type repair. After a mean follow-up of 4.9 years (range, 1.3 to 11.9), all patients are asymptomatic without significant mitral regurgitation. CONCLUSIONS Echocardiographic description of isolated cleft of the mitral valve is not always as accurate as intraoperative analysis. This is a distinct morphologic entity from the cleft of the left-sided valve of atrioventricular septal defect, and seems associated with a strong female predominance, with various cardiac and extracardiac features. Surgical repair is successful with excellent midterm results.

Systemic embolism: a serious complication after cardiac transplantation avoidable by bicaval technique

OBJECTIVE Systemic embolism is a serious complication after classical orthotopic transplantation, presumably originating from enlarged left atrium. We specifically studied this problem after classical and modified bicaval transplantation. METHODS Between December 1985 and March 1999 we consecutively performed 72 classical and 106 modified heart transplantation. Modification included bicaval anastomosis and recipient left atrium maximal reduction. Mean age was 47 years. All the patients received an antiplatelet therapy and were routinely followed. When clinical signs of systemic embolism were present, a neurological evaluation and transesophageal echocardiography were done. Sixty matched patients (30 of each group) had comparative transesophageal echocardiography study, at least 6 months after transplantation. RESULTS Perioperative mortality was 17.4%. Mean follow-up was 6.8 2+/47 years. All patients were in sinus rhythm. Among 147 survivors, 11 patients who underwent classical transplantation had a systemic embolism, 1 month to 12 years after transplantation, 15.3%, (11/72). Two limb ischemia and one mesenteric ischemia (needing surgery), seven strokes (one death, two permanent neurological deficit). There was no systemic embolism in the modified technique group (P=0.013). Left atrial comparative transesophageal echocardiography study showed a larger left atrial surface in classical transplantation. 33+/-4 cm(2) versus 20+/-3 cm(2) in a modified technique, P=0.01. Spontaneous echo contrast was present in 56% of classical technique group associated with atrial thrombosis in nine patients, there were no atrial thrombosis in modified technique group and spontaneous echocontrast was present in 0.5% (P=<0.001). CONCLUSION The occurrence of systemic embolism, left atrial spontaneous echocontrast and thrombosis when using classical technique, and the absence of these complications with the bicaval technique justified the use of this method. Our experience with atrial thrombosis and spontaneous echocontrast rises the question of anticoagulation in classical transplantation.

Complete Atrioventricular Canal Repair Under 1 Year: Rastelli One-Patch Procedure Yields Excellent Long-Term Results

BACKGROUND Considering more recently proposed techniques, we have evaluated our midterm and long-term results of Rastelli one-patch repair in complete atrioventricular canal. METHODS Between 1984 and 2005, 107 patients with a complete atrioventricular canal underwent a Rastelli one-patch procedure. Two groups were identified: 1984 to 1995 and 1995 to 2005 (respectively, 56 and 51 patients). Mean age at surgery was 5.3 +/- 3.4 months; mean weight was 5.5 +/- 3 kg; trisomy 21 was present in 81 patients; complete atrioventricular canal type A was found in 67 patients, type C in 40 patients. There were 12 cases of potentially parachute mitral valve and 14 associated anomalies treated simultaneously (pulmonary obstruction 11, coarctation 3). The coronary sinus was always left on the right side. After functional and anatomic evaluation, the cleft was closed completely in 8 and partially in 29, and was left intact in 70 cases. RESULTS Early survival was 86% +/- 3%. Five patients underwent early reoperation for residual ventricular septal defect (n = 2) and mitral valve repair (n = 3). Nine patients underwent late reoperations with successful repair: subaortic stenosis (n = 4) and mitral valve repair (n = 5). Late survival at 10 and 15 years was 84% +/- 3%. Freedom from reoperation for mitral regurgitation was 94% +/- 3% at 10 years, and 91% +/- 3% at 15 and 20 years. At last follow-up 30 patients had mild and 3 had moderate mitral regurgitation. CONCLUSIONS Rastelli single-patch repair in complete atrioventricular canal is a safe and reproducible technique. Among survivors, freedom from late reoperation for mitral regurgitation is very satisfactory. A properly taught, learned, and transmitted Rastelli one-patch technique compares very well with any other proposed technique.