Patrick Bagan

Catamenial pneumothorax: retrospective study of surgical treatment

BACKGROUND Catamenial pneumothorax is a rare entity characterized by recurrent accumulation of air in the thoracic space during menstruation. Catamenial pneumothorax is also associated with a high rate of postoperative recurrence. The aim of this study was to discuss the etiology and to determine the optimal surgical treatment of this entity. METHODS From December 1991 to September 2000, 10 patients with catamenial pneumothorax were treated at our institution. Median age at time of operation was 37 years (range, 21 to 44 years). We retrospectively evaluated the pathologic findings, the operation performed, and the results in all patients. The mean follow-up was 55.7 months. RESULTS Pleurodesis alone was performed in 5 patients and an associated diaphragmatic procedure was performed in 5 patients. In 5 patients, no diaphragmatic anomaly was discovered: 3 experienced one or more recurrences and all still suffer from chronic catamenial chest pain. Hormonal therapy temporarily improved outcome for 6 months in 2 patients. On the contrary, in 5 patients surgical pleurodesis was associated with the repair of diaphragmatic defects (simple closure or coverage by a polyglactin mesh): these patients experienced no recurrence (n = 0/5, p = 0.0016) and no subsequent catamenial chest pain. CONCLUSIONS The postoperative outcome is influenced by the diagnosis of diaphragmatic defects with or without endometriosis. Surgical treatment should be accomplished during menstruation for an optimal visualization of pleurodiaphragmatic endometriosis. Because diaphragmatic lesion is frequent and may be occult, we propose the systematic coverage of the diaphragmatic surface by a polyglactin mesh to prevent catamenial pneumothorax recurrence even when the diaphragm appears normal.

Fast-track rehabilitation for lung cancer lobectomy: a five-year experience

OBJECTIVE Fast-track rehabilitation is a group of simple measures that reduces morbidity, postoperative complication and accelerates postoperative rehabilitation reducing hospital stay. It can be applied to lung cancer lobectomy. Fast-track rehabilitation cornerstones are: minimally invasive surgical techniques using video-assisted and muscle sparring incisions, normovolemia, normothermia, good oxygenation, euglicemia, no unnecessary antibiotics, epidural patient-controlled analgesia, systemic opiods-free analgesia, early ambulation and oral feeding. Our objective is to describe a five-year experience with fast-track rehabilitation for lung cancer lobectomy. PATIENTS AND METHODS A retrospective non-controlled study including 109 consecutive patients submitted to fast-track rehabilitation in the postoperative care of lung cancer lobectomy was performed. Only collaborative patients who could receive double-lumen intubation, epidural catheters with patient-controlled analgesia, who had Karnofsky index of 100, previous normal feeding and ambulation, absence of morbid obesity, diabetes or asthma, were eligible. Postoperative oral feeding and aggressive ambulation started as soon as possible. RESULTS Immediate postoperative extubation even in the operation room was possible in 107 patients and oral feeding and ambulation were possible before the first hour in 101 patients. Six patients could not receive early oral feeding or ambulate due to hypnosis secondary to preoperative long effect benzodiazepines. Two patients could not ambulate immediately due to epidural catheter misplacement with important postoperative pain. Ninety-nine discharges occurred at the second postoperative day, four of them with a chest tube connected to a Heimlich valve due to air leak. No complication of early feeding and ambulation was observed. Postoperative hypnosis due to long duration benzodiazepines or pain does not allow early oral feeding or ambulation. Avoiding long duration preoperative benzodiazepines, immediate postoperative extubation, regional thoracic PCA and early oral feeding and ambulation were related to a lesser frequency of complication and a shorter hospital stay. CONCLUSION Fast-track rehabilitation for lung cancer lobectomies can be safely performed in a selected group of patients if a motivated multidisciplinary group of professionals is available and seems to reduce postoperative complication and hospital stay.

Nutritional Status and Postoperative Outcome After Pneumonectomy for Lung Cancer

BACKGROUND The influence of nutritional status on outcome after major lung resection remains controversial. Nutritional assessment is not included as a major recommendation in lung cancer guidelines. The purpose of this study was to assess the nutritional status of patients referred for pneumonectomy and to assess the predictive value of malnutrition in determining the surgical outcome. METHODS This study was a multicenter observational trial. The eligibility criterion for participants was pneumonectomy for lung cancer. Criteria for group classification according to nutritional status were albumin and transthyretin levels. Predicted outcomes were major infectious and noninfectious complications and 90-day mortality. Univariate analysis identified independent variables for the predictive model of age, sex, induction chemotherapy, extended resections, treatment side, smoking, and malnutrition. Predictive variables were then included in a logistic regression model. RESULTS Between January 2010 and December 2011, 86 (mean age, 61.5 years) consecutive patients referred for pneumonectomy (left side, n = 58; right side, n = 28) at 4 thoracic surgery centers were included. The malnutrition group included 33 patients (39%) and the normal nutritional status group included 53 patients. Univariate analysis elected malnutrition, recent active smoking, and extended resection to be included in a multivariate analysis. Multivariate analysis identified malnutrition, recent smoking, and extended resection as predictive variables for major complications and mortality. CONCLUSIONS The frequency of malnutrition detected by biological markers was dramatically high. Malnutrition, as well as recent active smoking and extended resection, is a predictive factor for infectious complications and mortality after pneumonectomy. Nutritional assessment with appropriate markers should be considered before pneumonectomy.

Aortic endostent followed by extended pneumonectomy for T4 lung cancer.

Pulmonary and aortic en bloc resection may be performed with cardiopulmonary bypass support, but is associated with high surgical morbidity and mortality. A 59-year-old man with left lower lobe cancer invading the aorta was considered to be unsuitable for such an extended operation because of previous myocardial infarction, coronary bypass grafts, and subsequent multiple coronary artery stenting. Pneumonectomy with en bloc resection of aortic adventitia and media was accomplished after thoracic aorta endovascular stent graft placement. The aortic defect was reinforced with an extrathoracic muscle flap. The postoperative course was uneventful, and the patient was faring well at the 23-month follow-up. An endovascular stent may be an alternative in selected patients with aortic involvement, avoiding the need for cardiopulmonary bypass.

Bronchial sleeve resections: lung function resurrecting procedure

OBJECTIVE Mainstem bronchus obstruction results in lung function exclusion. The aim of this study was to revisit lung function restoration obtained by different types of bronchial sleeve resections in selected patients with endobronchial tumors. METHODS Eleven patients (9 women and 2 men, mean age 47 years) presented with endobronchial tumors and ipsilateral lung function exclusion. Mainstem bronchial sleeve resection was performed in 7 patients, right bilobar and mainstem bronchial sleeve resection in 2, and left upper sleeve lobectomy in 2. Tumors consisted in 8 bronchial carcinoids, 2 adenoid cystic carcinomas, and one inflammatory myofibroblastic tumor. Fiberoptic bronchoscopy and quantitative ventilation-perfusion lung scan were performed in all patients at work-up to assess lung function exclusion and during the first year following bronchoplastic procedure to study recovery. Long-term follow-up consisted of physical examination, thoracic computed tomographic scan and bronchoscopy every year. RESULTS There was no postoperative death. The long-term follow-up was complete and ranged from 12 to 192 months (median: 102.7 months). The lung function was completely restored in all patients. The ventilation function was immediate, but the perfusion was restored in a mean interval of 8.2 months (ranging from 3 to 12 months). All patients are currently alive, and no local tumor recurrence was observed. CONCLUSIONS Some obstructing tumors may be removed by various types of bronchial sleeve resections that permit lung function restoration and long-term local control of the disease. However, at least one year is required for lung perfusion to completely recover, despite immediate ventilation restoration.

Individual risk prediction of nodal and distant metastasis for patients with typical bronchial carcinoid tumors

OBJECTIVE Bronchial typical carcinoid tumors are low-grade malignancies. However, metastases are diagnosed in some patients. Predicting the individual risk of these metastases to determine patients eligible for a radical lymphadenectomy and patients to be followed-up because of distant metastasis risk is relevant. Our objective was to screen for predictive criteria of bronchial typical carcinoid tumor aggressiveness based on a logistic regression model using clinical, pathological and biomolecular data. METHODS A multicenter retrospective cohort study, including 330 consecutive patients operated on for bronchial typical carcinoid tumors and followed-up during a period more than 10 years in two university hospitals was performed. Selected data to predict the individual risk for both nodal and distant metastasis were: age, gender, TNM staging, tumor diameter and location (central/peripheral), tumor immunostaining index of p53 and Ki67, Bcl2 and the extracellular density of neoformed microvessels and of collagen/elastic extracellular fibers. RESULTS Nodal and distant metastasis incidence was 11% and 5%, respectively. Univariate analysis identified all the studied biomarkers as related to nodal metastasis. Multivariate analysis identified a predictive variable for nodal metastasis: neo angiogenesis, quantified by the neoformed pathological microvessels density. Distant metastasis was related to male gender. DISCUSSION Predictive models based on clinical and biomolecular data could be used to predict individual risk for metastasis. Patients under a high individual risk for lymph node metastasis should be considered as candidates to mediastinal lymphadenectomy. Those under a high risk of distant metastasis should be followed-up as having an aggressive disease. CONCLUSION Individual risk prediction of bronchial typical carcinoid tumor metastasis for patients operated on can be calculated in function of biomolecular data. Prediction models can detect high-risk patients and help surgeons to identify patients requiring radical lymphadenectomy and help oncologists to identify those as having an aggressive disease requiring prolonged follow-up.

Complete thoracoscopic lobectomy for cancer: comparative study of three-dimensional high-definition with two-dimensional high-definition video systems

OBJECTIVES Common video systems for video-assisted thoracic surgery (VATS) provide the surgeon a two-dimensional (2D) image. This study aimed to evaluate performances of a new three-dimensional high definition (3D-HD) system in comparison with a two-dimensional high definition (2D-HD) system when conducting a complete thoracoscopic lobectomy (CTL). METHODS This multi-institutional comparative study trialled two video systems: 2D-HD and 3D-HD video systems used to conduct the same type of CTL. The inclusion criteria were T1N0M0 non-small-cell lung carcinoma (NSCLC) in the left lower lobe and suitable for thoracoscopic resection. The CTL was performed by the same surgeon using either a 3D-HD or 2D-HD system. Eighteen patients with NSCLC were included in the study between January and December 2013: 14 males, 4 females, with a median age of 65.6 years (range: 49-81). The patients were randomized before inclusion into two groups: to undergo surgery with the use of a 2D-HD or 3D-HD system. We compared operating time, the drainage duration, hospital stay and the N upstaging rate from the definitive histology. RESULTS The use of the 3D-HD system significantly reduced the surgical time (by 17%). However, chest-tube drainage, hospital stay, the number of lymph-node stations and upstaging were similar in both groups. CONCLUSIONS The main finding was that 3D-HD system significantly reduced the surgical time needed to complete the lobectomy. Thus, future integration of 3D-HD systems should improve thoracoscopic surgery, and enable more complex resections to be performed. It will also help advance the field of endoscopically assisted surgery.

Prevention of Pulmonary Complications After Aortic Surgery: Evaluation of Prophylactic Noninvasive Perioperative Ventilation

BACKGROUND In 40% of the cases, pulmonary complications are encountered after aortic surgery in patients suffering from chronic obstructive broncho-pneumopathy (COBP). The factors aggravating the occurrence of these complications are cumulated tobacco addiction of ≥40 packets per year and surgery for aneurysm. The aim of our prospective study was to evaluate the effect of pre- and postoperative noninvasive ventilation (NIV) preparation on the respiratory function of patients presenting with high pulmonary risks. METHODS Between September 2007 and May 2010, 30 patients were included in the present study. Inclusions criteria were male gender, patients suffering from COBP with tobacco addiction of ≥40 packets per year, and aortic surgery for aneurysm with or without occlusive lesions. In all, 14 of the 15 patients had effectively performed the preparation before and after surgery according to a fixed protocol (NIV group). We compared the respiratory rate complications and the mean hospital length of stay in intensive care with the non-NIV control group (15 patients). RESULTS Mean age, severity of COBP according to the classification of the French Society for Pneumology, surgery duration, and blood losses were comparable between the two groups. Conversely, pulmonary complications were significantly lower in the NIV group (0/14 [0%] vs. 5/15 [33%], p = 0.004). Hospital length of stay in intensive care was shorter in the NIV group (2.5 vs. 6.5 days, p < 0.001). CONCLUSION Preliminary results are encouraging, in favor of pulmonary preparation before aortic surgery with NIV at home, and carried on postoperatively in hospital for patients with COBP. These results prompt us to propose a multicenter study to validate these first observations.

Induction chemotherapy before sleeve lobectomy for lung cancer: immediate and long-term results.

BACKGROUND Induction chemotherapy does not increase the morbidity and mortality rates of bronchoplastic procedures, but the long-term efficiency remains unclear. The purpose of this retrospective study was to analyze the impact of chemotherapy on resectability and long-term survival. METHODS From 1984 to 2005, 159 consecutive patients with non-small cell lung cancer underwent sleeve lobectomy without (n = 117) or with induction chemotherapy (n = 42). Indications for chemotherapy were N2 lymph node involvement (n = 15), T3 or T4 tumor invasion with doubtful resectability (n = 13), need for tumor size reduction (n = 8), lung function precluding pneumonectomy (n = 4), and brain metastasis (n = 2). None of the patients received induction radiation therapy. We studied tumor characteristics and immediate and long-term results in both groups. RESULTS Clinical stage III was predominant in the induction chemotherapy group whereas stage II was predominant in the surgery-only group. Complication rates in the induction chemotherapy group and in the surgery-only group were 23.8% and 24.7%, respectively. We observed a greater rate of 1-month-delay smoking cessation before surgery in the induction chemotherapy group (40% versus 22%). The 5-year survival rates were 65.4% in the surgery-only group and 73.4% in the induction chemotherapy group (p = 0.5). The tumor size in the induction chemotherapy group was lower (17.5 versus 30.6 mm; p = 0.01), which reflected the positive impact of chemotherapy on sleeve resection feasibility. CONCLUSIONS Induction chemotherapy before sleeve lobectomy achieves good long-term results. Tumor reduction and limited resection feasibility seemed to be increased, which justify further prospective trials.

Cancer du poumon avant 40 ans et après 80 ans.

Lung cancer rarely affects patients at the extreme ages of life. However, changes in epidemiology and therapy led us to review characteristics of both these younger and older populations. We retrospectively reviewed epidemiologic, clinical and pathological characteristics of patients aged 40 years or less (group 1, n=113) and 80 years or more (group 2, n=78) who underwent surgery between 1983 and 2003. Carcinoid tumors were more frequent in the group 1 (n=59 vs 5). Non small cell lung cancer (NSCLC) occurrence rates decreased with time in group 1, whereas increasing rates were observed in group 2 (p=0.0017). Concomitant diseases were significantly more frequent in group 2. The pneumonectomy rates of non small cell lung cancer were the same in each group (group 1, 35.5%; group 2, 34.8%). Five-year survival rates were better in group 1 (58.9% vs 30%, p=0.0048). No 5-year survival was observed for N2 disease in group 2 and mortality unrelated to cancer was more frequent in this group. Otherwise, both groups were similar except for higher rates of adenocarcinomas in group 1. Lung cancer is more and more frequent in the octogenarians. Surgery remains the best treatment in this population except in case of stage III due to N2 involvement.