Interest of surgical vascular reconstructions aiming at preserving hemodialysis access.

BACKGROUND: Vascular hemodialysis access is a very precious asset for patients with end-stage renal failure. Ideally complications in these accesses should be detected early in order to treat them in time. The aim of this study was to evaluate the effectiveness of vascular reconstructions to preserve the vascular access for hemodialysis and to examine their benefits in terms of conserving the venous network, using hemodialysis catheters, time of cannulation after surgery, patency and postoperative morbi-mortality, by comparing them to those of newly created arterio-venous fistula (AVF). METHODS: This was a retrospective, descriptive and comparative study, performed from September 2012 to February 2015. It concerned patients operated for complications of their native AVF. Two groups were compared: reconstructed AVF (group 1) and newly created AVF (group 2). Demographic characteristics, comorbidities, preoperative clinical and paraclinical data, surgical techniques and outcomes were recorded. This data was analyzed and compared between the two groups. RESULTS: We collected 151 surgical interventions divided into two groups: 55 surgical reconstructions and 96 new AVF. The average age was 59.9±1.3 years [19.1-88.9], with a male predominance (59.6%). The two groups were comparable in terms of age, gender and comorbidities. Reconstructions were mostly indicated for stenosis (47.3%) and new vascular accesses for venous thrombosis (92.7%). Reconstruction had significantly better successful exploitation rates (95.7%) and time of cannulation (26.6 days) (respectively P=0.025 and P=0.000). Its primary failure rate was null. Its primary patency and primary functional patency were respectively 94.2% and 97.7% at 1 month and 82.2% and 87.1% at 2 years. Morbidity's global rates were comparable between both groups (41.8% vs. 43.8%). The rates of early morbidity and stenosis were significantly higher for reconstructions (respectively P=0.037 and P=0.047), while late morbidity and thrombosis' rates were significantly higher for new AVF (respectively P=0.021 and P=0.023). Mid-term permeabilities were better for reconstructions, but the differences were not statistically significant. CONCLUSION: Surgical reconstructions seem to be an effective alternative for the treatment of complicated AVF. Our results appear to be comparable to those of the literature. The benefits of these surgical techniques in terms of conserving venous network, use of hemodialysis catheters, time for cannulation after surgery, patency and postoperative morbi-mortality appear to be undeniable.

[A case of pulmonary arteriovenous malformation treated surgically]. / Bisegmentectomie pour une malformation artérioveineuse pulmonaire.

Pulmonary arteriovenous malformation is a rare abnormality consisting of a direct connection between the arteries and the pulmonary veins. Most of the malformations are related to hereditary hemorrhagic telangiectasia, although 10 to 20% cases are idiopathic. Clinical manifestations are due to right-to-left shunting. Embolization is the treatment of choice, when it is possible and accessible. Surgery continues to be appropriate in certain cases. We report the case of a woman who presented with an isolated complex arteriovenous malformation fed by two afferent arteries, a lingular one and an antero-basal one. Surgical treatment by lingual and antero-basal bisegmentectomy was undertaken with a good outcome.

A Delicate Surgical Resection to Treat a Proximal Pulmonary Adenoid Cystic Carcinoma.

Pulmonary adenoid cystic carcinoma (PACC) is an exceedingly rare tumor of low-grade malignancy. Diagnosis is often late, so the tumoral process may be huge at presentation. Surgical resection could be challenging, and the recurrence rate would be greater. We report, hereby, a case of proximal PACC with involvement of the carina in a young male adult, without respiratory distress. Surgical resection was performed through a left pneumonectomy followed by a complex trachea-bronchoplastic procedure. During the operative time, the assisted ventilatory mode was carefully chosen. No adjuvant treatment was needed. Our patient is still under clinicoradiological surveillance and remains disease-free.

[Diagnostic and therapeutic management of operable bronchopulmonary carcinoid tumours]. / Prise en charge diagnostique et thérapeutique des tumeurs carcinoïdes broncho-pulmonaires opérables.

INTRODUCTION: Bronchial carcinoid tumours (CT), divided into typical carcinoid (TC) or atypical carcinoid (AC), are rare tumours whose therapeutic management remains unspecified. METHODS: Retrospective study collecting cases of bronchial CT operated at the thoracic surgery department of Abderrahmane-Mami hospital of Ariana and recruited from the pneumology departments of Northern Tunisia, during a 12-year period. RESULTS: Ninety patients were collected (74 cases of TC and 16 cases of AC). The mean age was 45 years and the sex ratio H/F=0.5. The chest X-ray was normal in 11 cases, as well as flexible bronchoscopy in seven cases. The tumour was classified: stage IA (10 cases), IIA (28 cases), IIB (31 cases), IIIA (15 cases) and IIIB (six cases). Surgery resulted in a complete resection in 78 patients, an extensive resection in six patients, and a conservative resection in six patients. Adjuvant chemotherapy was given in 10 patients. The survival was 84% at five years and 42% at 10 years. CONCLUSION: The prognosis of CT depends directly on the histological subtype. It is excellent for TC after complete resection, unlike ACs that are similar to well-differentiated bronchial carcinomas.

[Primary benign schwannoma of the pleura: Report of 2 cases]. / Schwannome bénin primitif de la plèvre : à propos de deux cas opérés.

The preferred thoracic location of a schwannoma is the posterior mediastinum. A pleural location is very rare. To date there have been fewer than 20 cases in the literature. We report two operated cases of primary benign pleural schwannoma. The first occurred in a 52-year-old woman who presented with right-sided chest pain and chronic cough. The radiological appearance suggested a hydatid cyst of the lower right lobe. The second case concerned a 37-year-old, asymptomatic man with no past history, who presented with a left posterior mediastinal mass, discovered incidentally on imaging. Both patients underwent complete surgical resection via a posterolateral thoracotomy. The final anatomo-pathological investigation revealed two primary benign schwannomas of the pleura.

[Clinical and pathological profile of the pleural malignant mesothelioma: A retrospective study about 30 cases]. / Le profil anatomoclinique du mésothéliome pleural malin : une étude rétrospective à propos de 30 cas.

BACKGROUND: The malignant pleural mesothelioma (MPM) is a rare tumour usually associated to asbestos exposure. The delay between the exposure and the occurrence of the cancer can reach 40 years. This caused the pick of incidence described in many countries including Tunisia. The diagnosis is suspected based on clinical features but positive diagnosis is microscopic. Our aim was to describe the clinical and microscopic features of MPM through a single institution experience. PATIENTS AND METHODS: We conducted a retrospective study about 30 MPM diagnosed over a 20-year-period (1995-2015). We included only patients with complete records including clinical, radiologic and microscopic features. All the microscopic diagnoses were reviewed by 2 pathologists. A mean of 12 slides per case was reviewed. The diagnosis was based on the 2015 WHO classification. RESULTS: The mean age of the patients was 61 years, average 22 to 80 years. The sex ratio was 6,5. An asbetose exposition was reported in 21 cases. The most frequent symptoms was chest pain reported in 25 cases. Physical exam was normal in 9 cases. It revealed pleural syndorm in most patients (60 %). Imaging findings consisted mainly in diffuse pleural thickening in 17 cases. Twelve tumours were classified as stage I, 3 stage II, 14 stage III et 1 stage IV. Pleural biopsy was performed using needle in 18 cases, through thoracoscopy in 16 cases, thoracotomy in 3 cases and allowed the diagnosis in respectively 7 cases/18, 16 cases/16 and 3 cases/3. A lymph node biopsy was performed through mediastinoscopy in one case and yelded the diagnosis. The diagnosis was performed on surgical specimen in 2 patients: one bullectomy and one right upper lobectomy. The microscopic exam concluded to an EM in 17 cases, sarcomatoid mesothelioma (SM) in 4 cases and biphasic mesothelioma (BM) in 9 cases. Pan-cytokeratin antibody was used in all cases in association with 2 antibodies with positive diagnostic value and 2 antibodies with negative diagnostic value. It was repeated in 15 cases and the most used antibodies were the anti-calretinin and the TTF1. This was due to the lack of fixation in one case and in order to reach a quality criteria in the other cases. Surgical resection was possible in 2 patients. 15 patients were lost of view after a mean follow-up period of 3 months. Thirteen patients died before or during the follow-up. CONCLUSION: This work was about a Tunisian experience in the diagnosis and management of MPM. The major limits faced were the incomplete databases, the small number of patients included. Microsocpic positive diagnosis necessitates a degree of expertise and every laboratory has to determine the most valuable antibodies through its experience in order to optimize the diagnosis and to reduce the delay of diagnosis.

[Place of the microscopic examination in the diagnosis of costal fibrous dysplasia]. / Place de l'examen anatomopathologique dans le diagnostic de la dysplasie fibreuse costale.

BACKGROUND: Fibrous dysplasia of bone is a rare benign lesion characterized by the coexistence of a fibrous tissue and an immature osteogenesis. Costal localization is rare and may be monostotic or polyostotic. The diagnosis may be suspected based on clinical and radiological findings. Facing the development of radiological investigations, we tried to highlight the diagnostic role of the microscopic examination through the experience of our department. METHODS: We describe a retrospective study about 12 costal fibrous dysplasias diagnosed over a 17-year-period. Clinical records were retrieved from the department of thoracic surgery of the same hospital. RESULTS: Costal fibrous dysplasia is equally observed in men and women with predominance in the third and fourth decades. Clinical symptoms consist mainly in chest pain. Physical examination was normal in almost all cases. Based on the radiological findings, the diagnosis was suspected in 33% of the cases. Microscopic examination highlighted the diagnosis in all cases but it was challenging in one case and necessitated a multi-disciplinary approach. The difficulties encountered were due to artifact decalcification. CONCLUSION: Costal fibrous dysplasia is a benign lesion which diagnosis is based on microscopic features. Radiologic investigations show nonspecific features but allow to rule out a malignant tumor. The outcome of the patients is generally good except in rare cases with a malignant transformation.

The major prognostic factors of thymomas: about a Tunisian study of 100 cases.

AIM: Thymomas are characterised by their rarity, histologic variability and peculiar patterns of recurrence. Herein, we present the experience of a single institution and aim to highlight the major prognostic factors of these tumours. MATERIALS AND METHODS: We present a retrospective study on 100 thymomas diagnosed between 1994 and 2011. Statistical analyses were performed using version 18.0 SPSS. The Kaplan Meier method was used to estimate survival, and survival curves were compared using the Log-Rank test. A p < 0.05 was considered statistically significant. RESULTS: 50 men and 50 women underwent surgical resection for thymoma. Radiologic findings highlighted a diagnosis of thymoma in 51% of cases. The thymomas were classified as stage I in 25 cases, stage II in 47 cases, stage III in 25 cases and stage IV in 3 cases. According to the WHO classification, tumours were classified as type A in 14 cases, type AB in 24 cases, type B1 in 17 cases, type B2 in 20 cases, type B3 in 8 cases, B1/B2 in 8 cases and B2/B3 in 9 cases. The mean survival of patients was 136 months. Age, sex, tumour size, WHO classification and Masaoka stage were evaluated as prognostic factors. Univariate analysis showed that the major prognostic factors were WHO classification (p = 0.019) and Masaoka Stage (p = 0.0001). CONCLUSION: Our results place emphasis on the prognostic value of WHO classification and Masaoka stage in thymomas; in addition, the necessity of improving reproducibility of microscopic classification to avoid discrepancies among prognostic groups is highlighted.

[Bronchopulmonary carcinoid tumors: Tunisian experience with 115 surgically treated cases]. / Tumeurs carcinoïdes bronchopulmonaires : une série tunisienne de 115 cas opérés.

INTRODUCTION: Bronchial carcinoid tumors are rare well-differentiated, neuro-endocrine tumors, with low-grade malignancy. They are distinguished in two different groups: typical and atypical carcinoid. The purpose of this study was to review clinical, surgical and pathological characteristics in patients with primary bronchopulmonary carcinoid tumors. METHODS: This retrospective study included 115 bronchial carcinoid tumors surgically treated at a single institution during a twenty-one-year period, between 1992 and 2012. RESULTS: There were 56 men and 59 women, with a mean age of 43.73 years. Hundred patients had typical carcinoids and 15 atypical carcinoids. The majority of patients were symptomatic (96.52%). CT revealed a proximal mass in 51% which was obstructive leading to ventilator disorders in 80%. Bronchoscopy showed an endo-bronchial tumor in 83.48% of the cases. Anatomical resection had been achieved among 99 patients, and a conservative resection among 16 patients with typical carcinoid tumor. Lymph node metastases were present in 12.17% of the cases. Follow-up revealed recurrence in one patient and distant metastasis in 4 others. The 5-year survival rate was worse for atypical carcinoid with 45% than typical carcinoid with 95%. CONCLUSIONS: Carcinoids are rare malignant tumors, and their outcome is usually favorable after surgery. However, local recurrence and/or metastases can occur with both typical and atypical carcinoid tumors, justifying the need of prompt diagnosis and long-term follow-up. The factors influencing the survival included the pathological type, distant metastasis and mediastinal lymph node involvement.

[Surgery for thoracic tuberculosis]. / La chirurgie dans la tuberculose thoracique.

Tuberculosis is mainly a medical disease. Surgery has been the unique therapeutic tool for a long time before the advent of specific antituberculous drugs, and the role of surgery was then confined to the treatment of the sequelae of tuberculosis and their complications. The resurgence of tuberculosis and the emergence of multidrug-resistant TB combined to immunosuppressed patients represent a new challenge for tuberculosis surgery. Surgery may be indicated for a diagnostic purpose in patients with pulmonary, pleural, mediastinal or thoracic wall involvement, or with a therapeutic purpose (drainage, resection, residual cavity obliteration). Modern imaging techniques and the advent of video-assisted thoracic surgery allowed a new approach of this pathology; the majority of diagnostic interventions and selected cases requiring lung resection can be performed through a mini-invasive approach. Patients proposed for aggressive surgery may be treated with the best results thanks to a good evaluation of the thoracic lesions, of the patients' nutritional, infectious and general status combined with a good coordination between the specialized medical team for an optimal preparation to surgery.

[Tracheal tumor treated as asthma]. / Une tumeur trachéale traitée comme un asthme.

Primary tumors of the trachea are very rare. In adults, the majority of them are malignant. Schwannomas are exceedingly rare benign tumors in the tracheobronchial tree. We report a case of a 37-year-old man who was hospitalized for increasing dyspnea. He had been treated for bronchial asthma for the last 4 years with no benefit. The CT scan of the chest and bronchoscopy identified a tracheal mass that was prolapsed in the left stem bronchus. The patient did not remain free of disease after endoscopic laser resection. So, surgical resection was made. The tumor was excised at its base. A segment of the left stem bronchus was removed and primary anastomosis was performed. The histopathologic diagnosis was of a benign schwannoma without malignant elements. There was no recurrence during the follow-up period. This case demonstrates that intratracheal masses should be considered in patients with dyspnea or in patients with asthma refractory to conventional therapy.

About the necessity of improving the current nodal classification of non-small cell lung carcinoma.

BACKGROUND: The current classification of lymph node status in non-small cell lung carcinoma has not been revised since 1997. This fact has prompted many authors to point out the limits of this classification. METHODS: We tried to explore the prognostic relevance of the current TNM classification in comparison with the nodal classification based on the ratio of metastatic lymph nodes (LNR) and the nodal classification based on the number of metastatic LNs (nLN). Additionally, we tried to explore the recommended number of resected LNs. This was done through a retrospective study of 39 cases. We compared the survival curves of patients using the current, RLN and nLN classifications. In the nLN classification, we grouped patients into three categories: nNO (no metastatic LNs), nN1 (1 to 2 metastatic LNs) and nN2 (> 2 metastatic LN). In the LNR classification, we grouped patients into three categories: rNO (0%), rN1 (< or = 12) and rN2 (> 12). Concerning the total number of the resected LNs, patients were categorized into two groups according to the number of LNs: < 10 versus > or = 10 and < 15 versus > or = 15. RESULTS: Our results showed that the LNR classification highlighted a difference in prognosis between the rN1 and rN2 groups. Moreover, survival of patients seemed to be better when the number of the resected LNs was higher. CONCLUSION: The ratio of metastatic LNs seems to be an important prognostic factor, but further studies are necessary to standardize this classification.

[A rare pulmonary lesion association]. / Une association lésionnelle pulmonaire rare.

INTRODUCTION: Pulmonary amyloidoma or nodular amyloidosis is a localized form of amyloidosis, which can mimic a bronchopulmonary carcinoma. This form of amyloidosis may be associated to an infectious, a systemic disease or a lymphoma. OBSERVATION: We describe the case of a 36-year-old patient whose past medical history was consistent for a diabetes mellitus and a hypothyroidism treated by medical treatment. The patient presented a Gougerot-Sjögren syndrome and was explored for non-specific respiratory symptoms. Physical examination was normal. Laboratory tests revealed a monoclonal pic of immunoglobulin. Radiologic findings showed bilateral pulmonary nodules associated to mediastinal lymph nodes. A pulmonary biopsy was performed. Histologic examination revealed a tumoral nodule containing an abundant eosinophilic material, which was acellular and surrounded by a dense lymphomatous infiltrate destroying the pulmonary parenchyma. Histochemical and immunohistochemical study revealed an association of a nodular pulmonary amyloidosis with a MAT pulmonary lymphoma complicating a Gougerot-Sjögren syndrome. CONCLUSION: The association of MALT pulmonary lymphoma and localized amyloidosis is rarely observed in case of Gougerot-Sjögren syndrome. The pathogenesis of this association remains unknown and the management non-consensual because of the rarity of the cases reported. Whereas, it appears that localized amyloidosis associated to a MALT lymphoma seems to have a better prognosis than a disseminated amyloidosis.

[Conservative surgery in pulmonary aspergilloma]. / Place de la chirurgie conservatrice dans l'aspergillome pulmonaire.

INTRODUCTION: Pulmonary aspergilloma is a mycotic infection due to the deposit of mycelial fibres, usually in a pre-existing cavity within the lung. Surgical resection is the treatment of choice, with anatomical resection the most practiced technique. Simple aspergillomas are becoming more and more frequent urging this review of the place of conservative surgery. AIM: The aim of this study was to establish the characteristics of aspergillomas which may benefit from a conservative surgery. METHODS: We undertook a retrospective study of 64 cases that were operated on in the thoracic surgery unit in Abderrahmen-Mami Ariana's hospital between 1984 and 2008. RESULTS: Fourteen patients had conservative surgical treatment, with an atypical resection to remove the aspergilloma. The other 50 patients had undergone anatomical resection; segmental resection, lobectomy or pneumonectomy. The perioperative mortality rate was 5%. One case of aspergilloma recurrence had been recorded in a patient who had had conservative surgery for a complex aspergilloma. CONCLUSION: Surgery is the only effective treatment of aspergilloma. Conservative surgery may be an alternative in simple-peripheral forms, which have a diameter less than 4cm.

[A case of costal haemangioma]. / Un cas d'hémangiome costal.

UNLABELLED: Costal primary tumors are rare and dominated by malignant tumors. Haemangioma of the bone represents only 1% of bone tumors. Costal localization accounts only for 1% of the cases and only about fifty cases have been reported in the literature. AIM: The authors aim to describe a rare costal tumor, its histological features and the main differential diagnoses. OBSERVATION: The authors describe the case of a 46-year-old woman who presented with chest pain. Radiological findings did not permit a malignant tumor to be ruled out and the treatment consisted of a resection of the posterior arch of the rib. Microscopic examination concluded that the patient had a costal haemangioma and the patient didn't present any recurrence after a six-year follow-up. CONCLUSION: The costal haemangioma is a very rare tumor with a debated etiology. Some radiological features are specific such as the "soap bubble" or "honeycomb" aspect. However, the basis for diagnosis remains microscopic examination. These tumors have a good prognosis and no cases of recurrence have been reported following complete resection.

[Clinical characteristics of resected bronchial hamartoma. Study of seven cases]. / Particularités anatomocliniques des hamartochondromes endobronchiques opérés. Étude de sept cas.

INTRODUCTION: Endobronchial hamartoma is a benign tumour derived from peribronchial mesenchymal tissue. It is a form of intrapulmonary hamartoma and can cause irreversible pulmonary destruction due to bronchial obstruction. Early diagnosis and treatment is very important and endoscopic treatment is usually the first choice. In cases in which prolonged bronchial obstruction has produced irreversible lung destruction surgical, resection of the tumour is necessary. The aim of this study is to describe the clinicopathological characteristics of resected endobronchial hamartoma. PATIENTS AND METHODS: Seven cases of endobronchial hamartoma, diagnosed in our institution between January 1995 and December 2009, were reviewed retrospectively. RESULTS: The patient population consisted of four males and three females with mean age of 53.7 years (41-68 years). The most frequent clinical presentation was obstructive pneumonia. Endoscopy and imaging showed an endobronchial mass in most cases. Surgical treatment consisted of atypical resection in one case, lobectomy in five cases and pneumonectomy in one case. Tumour size ranged between 0.5 and 3.5 cm. The diagnosis was confirmed in all cases by histological examination. The outcome was favorable in all cases. CONCLUSION: Endoscopic techniques are effective for the diagnosis and treatment of endobronchial hamartochondroma. Treatment should be prompt to prevent irreversible lung damage due to chronic obstruction and suppuration, in which case, pulmonary resection may be necessary.

[Primary heterotopic pleural hydatid cyst presenting as a pneumothorax]. / 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.

[Primary mediastinal sarcomas]. / Les sarcomes primitifs du médiastin.

INTRODUCTION: Primary sarcomas of the mediastinum are rare and account for 2 to 8% of malignant mediastinal tumours. The aim of this study is to describe their clinical and pathological characteristics. PATIENTS AND METHODS: Fifteen cases of primary mediastinal sarcoma, diagnosed between 1993 and 2009, were reviewed retrospectively, noting the clinical, radiological and pathological findings, and the treatment given. RESULTS: The patient population consisted of eight females and seven males with mean age of 40 years (14 to 73 years). The symptomatology was predominately respiratory. Imaging showed a mediastinal mass invading adjacent organs in nine cases. The diagnosis was made in all cases by histological examination. These 15 mediastinal sarcoma comprised 12 malignant peripheral nerve tumours, two liposarcomas and one angiosarcoma. Three were grade III, six grade II and six grade I. Ten were treated surgically, of which seven had radical resections. Associated treatments were neoadjuvant (one case) or adjuvant (one case) chemotherapy and postoperative radiotherapy (five cases). Radiotherapy was undertaken alone in three inoperable tumours. Eight patients (53%) had died. CONCLUSION: Management of primary mediastinal sarcoma needs a multidisciplinary approach, and is based mainly on radical resection. The prognosis is poor and depends mainly on surgical excision and histological grade.