T. Mestiri

Conservative management of postoperative bronchopleural fistulas.

OBJECTIVE A bronchopleural fistula (BPF) is a serious complication after pulmonary resection and carries a high mortality rate. It remains a therapeutic challenge. The lack of a consensus suggests that no optimal therapy is available; however, endoscopic closure of a fistula may avoid extensive and potentially risky surgery. METHODS Seventeen patients (15 men and 2 women) with a BPF after a pneumonectomy (n = 2) or a lobectomy (n = 15), seen between 1995 and 2010, were reviewed. Their median age was 50 years (range, 14-75 years). Underlying diseases were malignant (n = 4) and nonmalignant (n = 13). RESULTS The mean interval between surgery and fistula development was 20 days (range, 5-270 days). Clinical symptoms leading to a diagnosis of BPF were a persistent air leak (n = 2), a persistent air leak associated with pleural empyema (n = 3), pleural empyema alone (n = 11), and dyspnea (n = 1). Mean fistula size was 3.3 mm (range, 2-9 mm). Treatment consisted of oriented pleural drainage, adequate antibiotic therapy, and endoscopic closure of the fistula with local application of silver nitrate through a flexible bronchoscope (3-15 sessions, 3 times per week). Fistula closure was successful in 16 patients, but failed in 1 patient, who died from acute respiratory distress. CONCLUSIONS BPF is a severe complication in thoracic surgery. The combination of pleural drainage, adequate antibiotic treatment, and mucosal application of silver nitrate, through a flexible bronchoscope, is an efficient alternative and avoids extensive surgical intervention.

Is magnesium sulfate by the intrathecal route efficient and safe

The polypharmacological approach to the treatment of postoperative pain has become routine in an attempt to minimize the adverse side effects of opioids. Magnesium sulphate is a noncompetitive antagonist of the N-methyl-d-aspartate (NMDA) receptor and thus can modify nociceptive modulation. Intravenous administration of magnesium sulphate can improve postoperative analgesia and decrease the requirement for postoperative opiates, but the effects are inconsistent and have not been reliably accompanied by a reduction in the incidence of morphine-related adverse events. Several studies have shown that the administration of magnesium by the intrathecal route is safe and, in combination with opiates, extends the effect of spinal anaesthesia in both animal and human studies. The analysis of these studies justifies further investigation of the use of magnesium sulphate by the intrathecal route.

What outcome after the prescription of neoadjuvant chemotherapy in lung cancer

Background The treatment of patients with locally advanced non-small-cell lung cancer is controversial. Surgery remains the gold standard, even in this group. Neoadjuvant chemotherapy could allow surgical resection in patients initially judged inoperable. Methods From January 2009 to May 2010, neoadjuvant chemotherapy was indicated in 27 patients with NSCLC (25 men, 2 women). Their mean age was 65 years. The stages were: IIB in 5, IIIA in 17 (6 in stage IIIAN2), IIIB in 2, and IV in 3. Results 23 patients received neoadjuvant chemotherapy, 2 refused induction treatment, and 2 had impaired status. The neoadjuvant chemotherapy regimen was gemcitabine-cisplatin in 17 patients and vinorelbine-cisplatin in 6. Only 5 patients underwent complete surgical treatment after induction: 1 in stage IIB, 1 in stage IIIAN0, 1 in IIIB, and 2 in stage IV (1 operated brain metastasis, and 1 operated adrenal metastasis). Surgical treatment was not achieved after neoadjuvant chemotherapy in 18 patients because of progressive disease. Conclusion Neoadjuvant chemotherapy offers several potential benefits, but it may delay surgery or eliminate eligibility as a surgical candidate. Rigorous patient selection for this type of multimodal treatment is essential.

Aspects cliniques et approche diagnostique des fibromes pleuraux

Resume Les fibromes pleuraux sont des tumeurs rares dont le caractere malin ou benin ne peut etre affirme que par l’histologie. Notre etude porte sur 7 patients consecutifs, operes entre janvier 1985 et janvier 2001. Il s’agit de 4 femmes et 3 hommes, d’âge moyen de 60 ans. La symptomatologie revelatrice a ete une douleur thoracique (3 cas), une dyspnee (2 cas), des arthralgies dans le cadre d’une osteo-arthropathie hypertrophiante pneumique (OAHP) de Pierre-Marie (1 cas), et des acces d’hypoglycemie (1 cas). Le bilan radiologique a ete decisif dans l’orientation diagnostique (radiographie thoracique, echographie, TDM et IRM). Le traitement est toujours chirurgical, permettant l’exerese de la tumeur et l’examen histologique de la piece. Les patients ayant ete operes pour fibrome pleural doivent etre surveilles compte tenu du risque de recidive, parfois sur un mode malin.

Un pneumothorax révélateur d’une hydatidose pleurale primitive hétérotopique

INTRODUCTION Hydatid cyst is a parasitic disease that is endemic in many countries. Pneumothorax may be a presentation of this disease that presents urgent problems of diagnosis and treatment. CASE REPORT We report the case of a 23-year-old woman, amenorrheic for 22 weeks, who presented with chest pain and dyspnoea. Chest x-ray revealed a right-sided tension pneumothorax. A check x-ray after drainage showed a homogeneous opacity of water density occupying the lower 2/3 of the right hemithorax. Thoracic ultrasound suggested an uncomplicated hydatid cyst at the right base. Surgical exploration revealed a hydatid cyst 14cm in diameter in the pleural space, and a cavity in the right lower lobe with two bronchial fistulae. Treatment consisted of removal of the cyst intact, closure of the bronchial fistulae and capitonnage of the residual cavity. The postoperative course was uncomplicated. CONCLUSION Primary heterotopic pleural hydatid cyst is an exceptional cause of pneumothorax that should considered in countries where hydatid disease is endemic. Treatment is surgical following drainage of the pneumothorax.

Tumeur de 5 cm chez une femme fumeuse

Resume L’hemangiome sclerosant du poumon est une tumeur benigne rare, a croissance lente. Son histogenese ainsi que son potentiel evolutif restent un sujet de controverse. Nous rapportons l’observation d’une femme âgee de 41 ans, admise pour une opacite du champ pulmonaire droit, de decouverte fortuite. Le bilan a la recherche d’une neoplasie primitive a ete negatif. La patiente a ete operee par thoracotomie postero-laterale. Une tumorectomie a ete realisee pour un nodule sous-pleural situe dans la grande scissure. L’examen histologique extemporane a conclu a un processus tumoral benin. Les suites operatoires ont ete simples et l’examen histologique definitif de la piece operatoire a conclu a un hemangiome sclerosant du poumon. Les hemangiomes sclerosants du poumon sont des tumeurs du parenchyme pulmonaire. Les dernieres etudes immunohistochimiques de cette tumeur sont en faveur d’une origine epitheliale pneumocytaire primitive. Leur pronostic est classiquement bon ; cependant, une extension ganglionnaire peut se voir. La sanction doit toujours etre chirurgicale, associee a un curage ganglionnaire systematique pour les tumeurs de grande taille.