Xavier Benoit D’Journo

Adenocarcinoma of the esophagus and esophagogastric junction in patients older than 70 years: Results of neoadjuvant radiochemotherapy followed by transthoracic esophagectomy

AIM The standard treatment of locally-advanced esophageal adenocarcinoma consists of neoadjuvant radiochemotherapy followed by surgical resection. Very little data are available concerning the feasibility of this strategy in patients older than 70 years of age. PATIENTS AND METHODS Between 1996 and 2008, 118 patients underwent transthoracic esophagectomy with lymphadenectomy for adenocarcinoma of the esophagus and gastric cardia (Siewert I and II). These were divided into three groups for comparison: Group I (age less than 70 years, neoadjuvant treatment followed by surgery; n=66); Group II (age greater or equal to 70 years, surgery alone; n=32); Group III (age greater or equal to 70 years, neoadjuvant treatment followed by surgery; n=20). Data concerning comorbidities, type of intervention, morbidity, mortality, survival and quality of life were analyzed. RESULTS There was no difference among the three groups with regard to comorbidity and preoperative evaluation. The patients in Groups I and III had more locally-advanced tumors (P<0.001). There was some disparity between the types of surgery proposed. The Lewis-Santy esophagectomy was most commonly used (90%, 50%, and 65% respectively). The 90-day mortality was 8%, 15%, and 15% respectively. There was no statistically significant difference in the incidence of postoperative pulmonary, cardiac, or digestive complications among the three groups. No difference was found in 5-year survival and quality of life. CONCLUSIONS Neoadjuvant radiochemotherapy for elderly patients (age above 70 years) with esophageal adenocarcinoma did not seem to increase postoperative morbidity or mortality, nor was there any difference in quality of life, nor any effect on survival, no matter what the age of the patient.

Intravascular Pulmonary Migration of a Subdermal Contraceptive Implant

2015 by The Society of Thoracic Surgeons Published by Elsevier A chest roentgenogram (Fig 1A; left, anteroposterior view; right, lateral view) and a 3-dimensional volumerendered computed tomography scan of the chest (Fig 1B) confirmed the migration of the implant in a branch of the left common basal pulmonary artery. Because the implant was too distal for a transluminal extraction, the patient was referred for surgical intervention. She underwent a left basal trisegmentectomy under video-assisted thoracoscopy (Fig 1C). Her postoperative outcome was uneventful.

Contraceptive Implant Embolism Into the Pulmonary Artery: Thoracoscopic Retrieval.

An 18-year old woman had migration of a subdermal contraceptive implant in a subsegmental branch of her left lower lobe pulmonary artery. She was managed successfully through a conservative surgical approach, as the implant was removed from the pulmonary artery thoracoscopically, thereby avoiding the need of thoracotomy or lung resection.

Long-term outcome of open versus hybrid minimally invasive Ivor Lewis oesophagectomy: a propensity score matched study†

OBJECTIVES: It has been suggested that laparoscopic Ivor Lewis (IL) oesophagectomy reduces postoperative morbidity and mortality rates. However, data related to the long-term outcomes of this hybrid minimally invasive procedure are scarce. METHODS: All of the patients who had an IL oesophagectomy for cancer were extracted from a prospective database. Patients were matched one to one according to the surgical approach (laparoscopy versus laparotomy) and on the basis of a propensity score including eight variables: age, gender, American Society of Anaesthesiologists score, forced expiratory volume in 1 s, surgery (first-line treatment, after neoadjuvant treatment and salvage surgery), histology, location and pathological stage. The first end point was the assessment of the 5-year survival and disease-free survival rates. The secondary end points were R0 resection rate, number of resected lymph nodes (LNs) and patterns of recurrence. RESULTS: Over a 12-year period, 272 IL oesophagectomies were performed. A total of 140 patients were matched in two homogeneous groups: laparotomy (n = 70) and laparoscopy (n = 70). The 5-year overall survival and disease-free survival rates were 65% and 48% in laparotomy group and 73% and 51% in the laparoscopy group (P = 0.891; P = 0.912). R0 resection rates were, respectively, 93% vs 97% (P = 0.441). The number and distribution of resected LNs were similar between the groups except at the level of the celiac axis (P < 0.001). Depending on the surgical approach, the patterns of recurrence were similar in both groups. CONCLUSIONS: Laparoscopic IL oesophagectomy does not compromise the long-term oncological outcome compared to open IL oesophagectomy. The quality of the operations is similar for both techniques except for the number of resected LNs at the level of the celiac trunk. Further randomized controlled trials are necessary to confirm these results.

Stratégie chirurgicale : quelles nouvelles techniques ? La chirurgie minimalement invasive (RATS/VATS). Les exérèses d’épargne parenchymateuse. Les parcours de soin accélérés

Resume La chirurgie thoracique a beneficie de nombreuses innovations techniques au cours des dernieres decennies. En parallele les programmes de depistage permettent de diagnostiquer des cancers bronchiques primitifs a des stades plus precoces. Les pratiques chirurgicales se sont donc modifiees d’une part par la generalisation des voies mini-invasives, d’autre part par l’apparition des resections anatomiques infralobaires (segmentectomies) que l’on pourraient qualifier de « chirurgie de precision » qui apparaissent comme des alternatives valables a la lobectomie dans des situations definies, et enfin par la mise en place de parcours de soins acceleres et personnalises, parfois meme ambulatoires. L’objet de cette revue, sera de detailler ces aspects modernes de la chirurgie thoracique au travers de ces trois points, intrinsequement lies les uns aux autres.

The use of correlation functions in thoracic surgery research

Correlation functions consist of a broad variety of statistical tests, used to describe the relationship between two, or more, sets of data. Those functions, whether they are parametric or non-parametric, are used in medical studies to characterize the strength of this relationship, and the direction of the relationship.

Cancers bronchiques non à petites cellules opérables : voies d’abord et techniques chirurgicales en 2014

Resume Les exereses pulmonaires pour cancer bronchique non a petites cellules reposent sur une resection anatomique adaptee a la taille et a la topographie de la tumeur pour permettre une resection histologiquement complete, associee systematiquement a une lymphadenectomie. Depuis les dernieres recommandations de la Societe francaise de chirurgie thoracique et cardiovasculaire (SFCTCV) en 2009, on constate l’evolution des pratiques concernant les voies d’abord et l’etendue des resections parenchymateuses. Les voies d’abord tendent vers une chirurgie minimalement invasive, notamment dans le traitement des tumeurs de stades precoces. Ces approches incluent la chirurgie thoracique video-assistee (CTVA), la chirurgie robotique et la chirurgie a trocart unique. On constate aussi le renouveau des resections infralobaires anatomiques, ou segmentectomies, largement utilisees il y a un demi-siecle pour le traitement de la tuberculose, en consequence du diagnostic plus precoce des cancers du poumon, alors que des politiques nationales de depistage s’organisent en Amerique du Nord et en Europe. On observe enfin l’augmentation du nombre de lesions en verre depoli qui correspondent souvent a des adenocarcinomes peu invasifs. Les techniques d’exereses conservatrices (lobectomie bronchoplastique et/ou angioplastique) permettent dans certaines conditions d’eviter la pneumonectomie. Enfin l’interet du curage systematique par rapport a l’evaluation ganglionnaire a ete recemment remis en question dans des groupes de patients selectionnes pour des tumeurs de stade precoces.

Résections pulmonaires majeures par vidéothoracoscopie: un nouveau standard pour le traitement chirurgical des cancers primitifs de stades précoces ?

Resume La chirurgie pulmonaire thoracoscopique a ete initialement limitee a des gestes simples, comme la resection de nodules peripheriques. Les techniques developpees pour les resections majeures (lobectomie-pneumonectomie) etaient nombreuses, heterogenes, et incluaient parfois une petite thoracotomie avec ecartement intercostal, leur faisant perdre leur potentiel benefice sur les suites operatoires, tout en ne levant pas certains doutes quant a leur efficacite oncologique. Un consensus s’est fait en faveur de techniques ayant en commun l’absence d’ecartement intercostal, et un controle visuel du champ operatoire indirect par les ecrans video. La diffusion de cette chirurgie « totalement thoracoscopique » est lente en Europe, contrairement aux Etats-Unis et au Japon. Deux meta-analyses suggerent pourtant une reduction du risque operatoire comparee a celui de la thoracotomie, ainsi qu’une non-inferiorite oncologique. La faisabilite des segmentectomies offre une option supplementaire dans la prise en charge des tumeurs de petite taille (cT1a) et des opacites pulmonaires en verre depoli, dont l’incidence est en augmentation avec la diffusion du depistage par tomodensitometrie. Dans un domaine devenu concurrentiel avec l’apparition de la radiotherapie stereotaxique et de la radiofrequence pulmonaire, la chirurgie minimalement invasive pourrait devenir le nouveau standard de traitement des cancers primitifs du poumon de stades precoces.