RESUMO
Relapsing polychondritis is a systemic auto-immune disease that mainly affects cartilage structures, progressing through inflammatory flare-ups between phases of remission and ultimately leading to deformation of the cartilages involved. In addition to characteristic damage of auricular or nasal cartilage, tracheobronchial and cardiac involvement are particularly severe, and can seriously alter the prognosis. Tracheobronchial lesions are assessed by means of a multimodal approach, including dynamic thoracic imaging, measurement of pulmonary function (with recent emphasis on pulse oscillometry), and mapping of tracheal lesions through flexible bronchoscopy. Diagnosis can be difficult in the absence of specific diagnostic tools, especially as there may exist a large number of differential diagnoses, particularly as regards inflammatory diseases. The prognosis has improved, due largely to upgraded interventional bronchoscopy techniques and the development of immunosuppressant drugs and targeted therapies, offering patients a number of treatment options.
Assuntos
Broncopatias , Policondrite Recidivante , Policondrite Recidivante/diagnóstico , Policondrite Recidivante/complicações , Humanos , Diagnóstico Diferencial , Broncopatias/diagnóstico , Broncopatias/patologia , Broncopatias/etiologia , Doenças da Traqueia/diagnóstico , Doenças da Traqueia/patologia , Broncoscopia/métodos , Traqueia/patologia , Brônquios/patologiaRESUMO
Tracheobronchomalacia is usually characterized by more than 50% expiratory narrowing in diameter of the trachea and the bronchi. The expiratory collapse includes two entities: (1) the TBM related to the weakness of the cartilaginous rings, and (2) the Excessive Dynamic Airway Collapse (EDAC) due to the excessive bulging of the posterior membrane. Patients have nonspecific respiratory symptoms like dyspnea and cough. Diagnosis is confirmed by dynamic tests: flexible bronchoscopy and/or computed tomographic scan of the chest. There are different forms of tracheobronchomalacia in adults: primary (genetic, idiopathic) or secondary to trauma, tracheotomy, intubation, surgery, transplantation, emphysema, infection, inflammation, chronic bronchitis, extrinsic compression; or undiagnosed in childhood vascular rings. Some management algorithms have been proposed, but no specific recommendation was established. Only symptomatic patients should be treated. Medical treatments and noninvasive positive pressure ventilation should be the first line therapy, after evaluation of various quality measures (functional status, performance status, dyspnea and quality of life scores). If symptoms persist, therapeutic bronchoscopy permits: (1) patient's selection by stent trial to determine whether patient benefit for surgical airway stabilization; (2) malacic airways stenting in patients who are not surgical candidates, improving QOL despite a high complication rate; (3) the management of stent-related complication (obstruction, plugging, migration granuloma); (4) alternative therapeutics like thermo-ablative solution. Lasty, the development of new types of stents would reduce the complication rates. These different options remained discussed.
RESUMO
The history of the first transplants is an ideal model for analyzing the different stages of disruptive innovation in surgery. Pioneers have often taken paths that were strewn with pitfalls, mistakes or failures. Sometimes victory, brilliant or more modest, lies at the end of this path. We propose to re-explore the extraordinary pathways that led to the first transplantations of the kidney, liver, lung and heart. That these first transplants should one day become possible required the concurrence of several factors: basic research, laboratory work to perfect the surgical techniques, a favorable legislative and societal context, and, above all, pioneering surgeons who would dare to apply their expertise to human subjects. Initial failures were not technical but immunological. Not everything would be perfect, especially ethical questions in some cases. Furthermore, initial results often humbled the greatest surgeons. Even though the historical and legislative contexts have evolved considerably as have science, society and the organization of the health system, this analysis of the past is rich in lessons for the modern surgeon who wishes to embark today along innovative pathways in the face of a still unresolved problem. Because nothing is ever carved in stone.
RESUMO
The history of the first transplants is an ideal model for analyzing the different stages of disruptive innovation in surgery. Pioneers have often taken paths that were strewn with pitfalls, mistakes or failures. Sometimes victory, brilliant or more modest, lies at the end of this path. We propose to re-explore the extraordinary pathways that led to the first transplantations of the kidney, liver, lung and heart. That these first transplants should one day become possible required the concurrence of several factors: basic research, laboratory work to perfect the surgical techniques, a favorable legislative and societal context, and, above all, pioneering surgeons who would dare to apply their expertise to human subjects. Initial failures were not technical but immunological. Not everything would be perfect, especially ethical questions in some cases. Furthermore, initial results often humbled the greatest surgeons. Even though the historical and legislative contexts have evolved considerably as have science, society and the organization of the health system, this analysis of the past is rich in lessons for the modern surgeon who wishes to embark today along innovative pathways in the face of a still unresolved problem. Because nothing is ever carved in stone.
Assuntos
Betacoronavirus , Infecções por Coronavirus/prevenção & controle , Alocação de Recursos para a Atenção à Saúde/ética , Acessibilidade aos Serviços de Saúde/ética , Pandemias/ética , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Saúde Pública/ética , Cirurgiões/ética , COVID-19 , Tomada de Decisão Clínica/ética , Humanos , Controle de Infecções , SARS-CoV-2 , Procedimentos Cirúrgicos Operatórios/éticaRESUMO
The medical expert witness testimony is a key moment in the pathway of patient complaints as well as in the line of defense of the defendant-physician. For the defendant, it is a difficult time, often experienced as humiliating, because his or her competences are questioned, appraised and discussed in public. However, the defendant must perceive and use this encounter as an opportunity to express his/her viewpoint on the medical accident. This article provides the principal juridical rules that govern the medical expert witness testimony that must be known, as well as some practical advice on how the medical expert witness testimony evolves and how to protect oneself from the complaints, In order to enable the defendant to best prepare for this confrontation between the involved parties.
Assuntos
Prova Pericial/legislação & jurisprudência , Prova Pericial/métodos , Medicina Defensiva , Documentação , Prescrições de Medicamentos , Humanos , Consentimento Livre e Esclarecido , Imperícia/legislação & jurisprudência , Erros Médicos , Prontuários Médicos , Complicações Pós-OperatóriasRESUMO
Health care professionals are usually at a loss when it comes to medical "complaints", essentially because they lack knowledge with regard to existing litigation procedures. After a short reminder of the different rights of appeal in France, we describe how medical appeals function in other European countries. Next, we give the details of how the evaluation of claims of bodily damage works, a process in which every physician may be called upon to participate several times in a career, either as the defendant, or as a medical counselor, or as an expert. The goal of this update is to understand the different compensation appeal circuits available to patients and help the surgeon demystify and dedramatize the situation while preparing for the medical expert witness testimony. All such testimony reports, via whatever appeal circuit, follow a similar procedure, even if they are not exactly identical.
Assuntos
Prova Pericial/legislação & jurisprudência , Imperícia/legislação & jurisprudência , Europa (Continente) , França , Humanos , Responsabilidade Legal , Erros Médicos/legislação & jurisprudênciaRESUMO
Trans-diaphragmatic intra-thoracic extension of recurrent hepatocellular carcinoma treated by electroporation can be performed via video-assisted thoracic surgery. Resection is followed by reconstruction with a synthetic mesh.
Assuntos
Carcinoma Hepatocelular/cirurgia , Diafragma/cirurgia , Neoplasias Hepáticas/cirurgia , Recidiva Local de Neoplasia/cirurgia , Procedimentos de Cirurgia Plástica/métodos , Cirurgia Vídeoassistida , Carcinoma Hepatocelular/diagnóstico por imagem , Carcinoma Hepatocelular/patologia , Ablação por Cateter/métodos , Terapia Combinada , Diafragma/patologia , Seguimentos , Hepatectomia/métodos , Humanos , Neoplasias Hepáticas/diagnóstico por imagem , Neoplasias Hepáticas/patologia , Masculino , Pessoa de Meia-Idade , Invasividade Neoplásica/patologia , Recidiva Local de Neoplasia/diagnóstico por imagem , Recidiva Local de Neoplasia/patologia , Telas Cirúrgicas , Tórax/patologia , Tomografia Computadorizada por Raios X/métodos , Resultado do Tratamento , Cirurgia Vídeoassistida/métodosRESUMO
The actinomycosis is a suppurative infection due to an anaerobic and microaerophillic bacteria called actinomyces. Only few case reports are described for the mediastinal locations of this rare entity. We report a new case of inflammatory pseudotumor in the mediastinum due to Aggregatibacte actinomycetemcomitans revealed by hemoptysis. The mediastinoscopy procedure with biopsy was needed to confirm the definitive bacteriological diagnosis by a positive culture. During the postoperative course, a cutaneous fistula was found which had a favourable evolution after appropriate antibiotherapy. Through this case report, the authors insist upon the importance of considering the diagnosis of mediastinal actinomycosis when facing non-specfic mediastinal mass symptoms and also about the interest of systematic bacterioscopic examination and histopathologic examination on nodes' biopsies to avoid to be lost on pathology of mediastinal tumor or tuberculosis. In practise, we caution the non-expert during biopsies because of this lesion's invasive characteristic especially in the confined space of the mediastinum.
Assuntos
Actinomicose/microbiologia , Aggregatibacter actinomycetemcomitans/isolamento & purificação , Doenças do Mediastino/microbiologia , Actinomicose/tratamento farmacológico , Actinomicose/patologia , Amoxicilina/uso terapêutico , Humanos , Masculino , Doenças do Mediastino/tratamento farmacológico , Doenças do Mediastino/patologia , Adulto JovemRESUMO
OBJECTIVE: Chyle fistula is a known complication in cervical surgery. It can lead to a postoperative lymphorrhea. There is no consensus on its management. The aim of this work is to propose a management strategy for postoperative chyle leak. MATERIALS AND METHODS: A literature review was conducted using PubMed database. RESULTS: Six prospectives articles were included. The enteral diet allowed a success in 57% of cases, and in these cases a lymph flow less than 580 mL/day. Parenteral nutrition was effective when the flow was less than 1050 mL/day. Reoperation was performed in case of failure of the nutritional treatments. CONCLUSION: Several therapeutics are available. From this meta-analysis, we developed a management strategy. We initiate an enteral diet when lymph flow is less than 500 mL/ day. Parenteral nutrition is used if the flow rate is between 500 and 1000 mL/day or in case of inefficiency of enteral diet during 10 days. Finally, revision surgery is necessary when the flow is greater than 1000 mL/day or when parenteral nutrition was ineffective in 10 days.
Assuntos
Quilo , Nutrição Enteral , Fístula/etiologia , Fístula/terapia , Esvaziamento Cervical/efeitos adversos , Nutrição Parenteral Total , Ducto Torácico/lesões , Algoritmos , Nutrição Enteral/métodos , Humanos , Nutrição Parenteral Total/métodos , Guias de Prática Clínica como Assunto , Reoperação , Resultado do TratamentoRESUMO
Surgical biopsy of lung parenchyma can be used to establish a diagnosis in interstitial lung disease both of acute and chronic presentation. The present article summarizes the current indications, the therapeutic implications, the different surgical techniques and postoperative complications of the procedure. Common controversies and problems related to surgical lung biopsy are also presented.
Assuntos
Pulmão/patologia , Pulmão/cirurgia , Procedimentos Cirúrgicos Pulmonares/estatística & dados numéricos , Biópsia/métodos , Biópsia/estatística & dados numéricos , Técnicas de Diagnóstico por Cirurgia/estatística & dados numéricos , Humanos , Doenças Pulmonares Intersticiais/diagnóstico , Doenças Pulmonares Intersticiais/diagnóstico por imagem , Doenças Pulmonares Intersticiais/patologia , Doenças Pulmonares Intersticiais/cirurgia , Modelos Biológicos , Complicações Pós-Operatórias/terapia , Procedimentos Cirúrgicos Pulmonares/métodos , Radiografia Torácica , Tomografia Computadorizada por Raios X/métodosRESUMO
Tracheal surgery has evolved progressively with advances in anaesthesia, the understanding of tracheal pathology and the efforts made by surgeons all over the world. In the era of organ transplantation, tracheal replacement remains an unsolved problem and one of the most important challenges in thoracic surgery. In animals, the use of a stent supported aortic graft as a tracheal substitute led to unexpected tissue regeneration in the form of a functional "neo-trachea" with respiratory epithelium and cartilage. These results led to the first clinical applications in France in patients with extensive, incurable, malignant tracheal tumors. Experimental and clinical research programs have to be increased in order, firstly to provide a standardized surgical technique for complex tracheal lesions and secondly to understand better the mechanisms of tracheal regeneration.
Assuntos
Traqueia/cirurgia , Animais , Humanos , Próteses e Implantes , Regeneração , Engenharia Tecidual , Traqueia/fisiologia , Traqueia/transplante , TraqueotomiaRESUMO
INTRODUCTION: Endometriosis is defined as the abnormal presence of endometrial tissue, including endometrial glands and stroma, outside the uterine cavity. The term "thoracic endometriosis" is classically referred to the respiratory manifestations which classically result from the presence and the cyclical changes of endometrial tissue in one of the thoracic structures. STATE OF ART: Although thoracic endometriosis is rare, four clinical entities are well-recognized: pneumothorax, hemothorax, haemoptysis and pulmonary nodule, with a respective frequency of 73%, 14%, 7% and 6%. These are characterized by the recurrence of symptoms within the menstruations, in women aged between 30 and 40, and mainly in the right hemi-thorax. Pelvic endometriosis is usually, if not constantly, associated. Catamenial pneumothorax is not always related to thoracic endometriosis and its mechanisms remain unclear. An exploratory and therapeutical surgery is required in most of the cases. Video-assisted-thoracoscopy is the best current approach of catamenial pneumothorax. It may visualize pathognomonic pleuro-diaphragmatic abnormalities, including diaphragmatic fenestrations and/or endometrial implants, in about one third of the patients. Surgical treatment is justified because of the frequent relapses under medical treatment alone. Surgery consists of diaphragmatic repair and excision of all apparent endometrial implants; pleural abrasion may complete the procedure. A combined prolonged hormonal therapy is increasingly recommended, Danazol or GnRH analogs being advantaged. PERSPECTIVES: Further prospective studies are needed to estimate the real incidence of thoracic endometriosis and to devise the best therapeutical option. CONCLUSIONS: Thoracic endometriosis is probably rare but its diagnosis is easy when accurately raised. The approach is multidisciplinary involving a pneumologist, a thoracic surgeon and a gynecologist.
Assuntos
Endometriose/complicações , Doenças Torácicas/complicações , Endometriose/diagnóstico , Endometriose/terapia , Feminino , Hemoptise/etiologia , Hemoptise/terapia , Hemotórax/etiologia , Hemotórax/terapia , Humanos , Menstruação , Pneumotórax/etiologia , Pneumotórax/terapia , Doenças Torácicas/diagnóstico , Doenças Torácicas/terapiaAssuntos
Aorta Abdominal/transplante , Aorta Torácica/transplante , Carcinoma de Células Escamosas/cirurgia , Traqueia/cirurgia , Neoplasias da Traqueia/cirurgia , Idoso , Animais , Aorta Abdominal/cirurgia , Aorta Torácica/cirurgia , Implante de Prótese Vascular , Carcinoma de Células Escamosas/radioterapia , Seguimentos , Humanos , Masculino , Polietilenotereftalatos , Dosagem Radioterapêutica , Radioterapia Adjuvante , Ovinos , Silicones , Stents , Fatores de Tempo , Neoplasias da Traqueia/radioterapia , Transplante Autólogo , Transplante Homólogo , Resultado do TratamentoRESUMO
Surgery remains the mainstay treatment of recurrent pneumothorax. We recall the therapeutic modalities and indications of surgery in case of pneumothorax. We then compare postoperative outcome, recurrence rate and chronic pain with regard to techniques and surgical approach. Current video-thoracoscopic or axillary thoracotomy procedures for bullous disease with pleurodesis allow a low rate of morbidity and recurrence after primary or secondary spontaneous pneumothorax.