[Full thoracoscopic lobectomy and segmentectomy for benign or metastatic conditions]. / Lobectomies et segmentectomies par thoracoscopie exclusive pour pathologie bénigne ou métastatique.

INTRODUCTION: Several techniques for video-assisted pulmonary lobectomy have been reported. However full thoracoscopic lobectomy, i.e., without the help of a utility incision has seldom been performed. We report our results based on a series of resections for benign or metastatic conditions where mediastinal lymphadenectomy is not indicated. PATIENTS AND METHODS: Fifty-six patients (29 males and 27 females) with a mean age of 46 years (range: 8-82 years) had an attempted major pulmonary resection (54 lobectomies and 2 segmentectomies) via thoracoscopy alone for either a benign lesion (30 cases) or a metastasis (26 cases). RESULTS: There was no operative mortality. Six patients required conversion to thoracotomy (11%). In the 50 remaining patients who underwent an exclusively thoracoscopic operation, there was 1 intra-operative complication that was managed thoracoscopically. The duration of the procedure ranged from 65 to 230 minutes (mean: 157 minutes). Intra-operative blood loss was 55 cc (range: 0 to 200 cc) in the "metastasis group" and 109 cc (range: 0 to 280 cc) in the "benign lesion group". There were 5 postoperative complications (10%). Postoperative duration of stay ranged from 3 to 15 days (Mean: 6.7 days). All patients were seen at the first postoperative month and no clinical or radiological complication was noticed. CONCLUSION: Full thoracoscopic lobectomies are feasible and safe provided appropriate equipment is used and the surgical team is experienced in endoscopic surgery.

[Pleural diffusion of amoxicillin 1 and vancomycin in patients treated for post-surgical empyema]. / Empyème après chirurgie d'exérèse pulmonaire: étude de la diffusion pleurale de l'amoxicilline et de la vancomycine.

INTRODUCTION: Treatment of post surgical thoracic empyema consists of chest tube drainage, antibiotic administration, and in some cases surgical lavage of infected spaces. Data in human on the diffusion of antibiotics in pleural cavity after post surgical empyema are lacking. METHODS: We studied on 9 patients with post surgical thoracic empyema (including 6 pneumonectomy) the diffusion of 2 antibiotics commonly used in this situation: amoxicillin (for 7 patients) and vancomycin (for 2 patients). Antibiotics concentrations were measured after at least 3 days of treatment (3-12 days), in order to reach a plateau concentration in the pleural space. RESULTS: The ratio pleural/plasma antibiotic concentration was 1.96 (range: 0.6-4.9). The pleural infection was cured for 8 on 9 patients. The last patients required thoracostomy, and the outcome was favorable after this procedure. CONCLUSION: That the penetration of amoxicillin and vancomycin in pleural space after post surgical empyema is good. Pleural antibiotics concentrations are in the majority of cases higher than plasmatic concentrations.

Thoracoscopic palliative treatment of malignant pleural effusions: results in 273 patients.

BACKGROUND: The aim of this study was to analyze the results of pleurodesis for malignant pleural effusion performed by surgeons. PATIENTS AND METHODS: A series of 273 patients with malignant pleural effusion underwent thoracoscopy with the aim of performing a palliative pleurodesis. There were 94 males (34.4%) and 175 females (64.1%), ranging in age from 15 to 94 years (mean age: 60.6 years). The effusion was on the right side in 136 patients (49.8%), on the left side in 110 (40.3%), and bilateral in 27 (9.9%). Thoracoscopy was performed under general anaesthesia in all patients. Pleural biopsy was performed in two thirds of the patients (70.7%). Pleurodesis was produced by instillation of 5g of sterile asbestos-free talc; the chest tube was left in place a minimum of 3 days. It was removed when fluid drainage was less than 200 ml/24 h. Patients were usually discharged the day after chest tube removal. RESULTS: There was no intraoperative mortality. Two patients (0.7%) had intraoperative complications; 17 (6.2%) underwent a bilateral pleurodesis, and 10 (3.7%) had a pericardiopleural window. In 32 patients (11.7%) no pleurodesis was done, either because the lung did not properly re-expand (5.2%), or because of suspected infection, e.g., false membranes (1.9%), or because of multiple adhesions (4.6%). Finally, only 241 patients (88.3%) had a talc poudrage at the time of thoracoscopy. Duration of postoperative pleural drainage ranged between 1 and 11 days (mean: 3.64 days). The postoperative hospital stay ranged from 2 to 21 days (mean: 7.1 days). Pleural empyema occurred in 4 patients (1.5%) and was lethal in one patient. The mean follow-up period was 8.39 (7.2 months, and 172 patients had regular follow up. In this group, there were 24 recurrences (14%), 12 of which were treated by repeat pleurodesis. The results were very good in 133 patients (77.3%), acceptable in 35 patients (20.3%), and there was a failure in 4 patients (2.4%). CONCLUSIONS: Results of surgical thoracoscopy for malignant pleural effusion are good, with low morbidity. However, in debilitated patients, bedside talc slurry may be preferable.

Videothoracoscopic excision of thoracic neurogenic tumors.

BACKGROUND: Videothoracoscopic surgery is a new procedure for treating neurogenic tumors of the thorax. Feasibility and utility of this technique are not yet well defined. METHODS: Over a 26-month period, 26 neurogenic tumors of the thorax were treated in five general thoracic surgery centers performing videothoracoscopic surgery. Indications and contraindications for this new procedure and initial results were retrospectively studied. RESULTS: Contraindications to videothoracoscopy included intraspinal extension of the tumor (n = 3), spinal artery involvement (n = 2), tumors more than 6 cm in diameter borderline located within the thorax (n = 2), and middle mediastinal location (n = 1). Videothoracoscopy was performed in 18 patients. Conversion to thoracotomy was required in 3. In 1 patients, subsequent chest wall resection was performed because of malignancy. Postoperative hospital stay was uneventful. It was shorter after videothoracoscopy. Postsurgical pain was more acute in patients who had thoracotomy or conversion to thoracotomy. CONCLUSIONS: Videothorascopy is a good alternative for managing neurogenic tumors of the thorax when deemed feasible. There is a tendency toward a shorter hospital stay with less pain in patients treated by this new procedure.

Late contralateral lobectomy after single-lung transplantation for emphysema.

Cases of hyperinflation of native emphysematous lung have been reported in the early period after single-lung transplantation. We report a case of a similar complication that occurred 2 years after transplantation and was successfully treated by lobectomy.

Early complications of thoracic endoscopic sympathectomy: a prospective study of 940 procedures.

BACKGROUND: Thoracic endoscopic sympathectomy (TES) has become the surgical technique of choice for treating intractable palmar hyperhidrosis and is usually considered as a simple and safe procedure. To evaluate the complication rate of TES, we conducted a prospective study of peri- and postoperative complications. METHODS: From 1995 to 1999, 467 consecutive patients were operated on for upper limb hyperhidrosis. There were 164 men and 303 women, ranging in age from 15 to 59 years (mean 31 years). In all but 5 cases, the procedure was bilateral. Eleven patients underwent a reoperation for failure; thus the total number of sympathectomies was 940. The procedure was performed in two stages in 182 patients and in one stage in 267 patients. All patients were seen 1 month after the operation. RESULTS: There was no mortality. The mean postoperative hospital stay was 2.3 days in the group of patients who were operated on in two stages and 1.1 day in patients who were operated on in one stage. There were three major complications: one tear of the right subclavian artery and two chylothoraces. There were 25 cases (5.3%) of bleeding (300 to 600 mL) during dissection of the sympathetic trunk due to injury to an intercostal vein; in all cases it was controlled thoracoscopically. There were 12 pneumothoraces (1.3%) after removal of chest tubes. All of these were unilateral. Four required chest drainage for a period of less than 24 hours. One patient had a mild pleural effusion. Four patients had a unilateral partial Horner Syndrome (0.4%) that disappeared within 3 months in 2 patients. The other 2 patients were lost to follow-up. One patient complained of rhinitis. CONCLUSIONS: Although morbidity was low, significant complications of TES occurred. Patients should be clearly warned that TES is not as minor a procedure as usually asserted. Complications as well as adverse effects should be considered when discussing this surgical indication.

Results of thoracoscopic pleural abrasion for primary spontaneous pneumothorax.

BACKGROUND: Several video-assisted techniques have been used to treat primary spontaneous pneumothorax (PSP). The aim of this study was to evaluate the results of thoracoscopic pleural abrasion for PSP. METHODS: From 1991 to 2003, 185 consecutive patients, 143 male and 42 female, aged 15 to 60 years (average 31.6) underwent thoracoscopic pleural abrasion for PSP. The indications for surgery were as follows: a first episode with persistent air leak in 33 patients (17.9%), a recurrent ipsilateral pneumothorax in 122 patients (65.9%), a previous contralateral pneumothorax in 23 patients (12.4%), and recurrence after surgical treatment in seven patients (3.8%). Bullae were resected in 163 patients (88.1%). Mechanical pleural abrasion was performed in all cases. RESULTS: There were no deaths. Intraoperative hemorrhage occurred in three patients. It was controlled via thoracotomy in one patient and via thoracoscopy in two patients. The postoperative complication rate was 8.1% (15/185). Complications included prolonged air leak in eight patients (4.3%), pleural effusion in two (1.1%), extrapleural hematoma in one (0.5%), chest wall infection in one (0.5%), atelectasis in one (0.5%), and hemorrhage in two (1.1%). Postoperative hospital stay ranged between 2 and 17 days (mean, 5). Mean duration of drainage was 3.8 days (range; 1-16). Postoperatively, 111 patients were contacted, with a mean follow-up of 36.5 months. Four of them had a recurrence (3.6%) that did not require reoperation. CONCLUSION: Thoracoscopic pleural abrasion associated with bullae resection is a safe and efficient treatment for PSP. Results remain stable in the long term.

Thoracoscopic removal of neurogenic mediastinal tumors: technical aspects.

BACKGROUND: Thoracoscopy is fast becoming the standard approach for the removal of neurogenic mediastinal tumors. However, there are risks for adjacent nervous structures (stellate ganglion, spinal cord). The aim of this study was to review the technical features of this approach. METHODS: Between December 1999 and January 2003, nine patients underwent thoracoscopic resection of a mediastinal neurogenic tumor at our hospital. Five of these patients were asymptomatic with incidentally found tumor; the other four patients had compression-related syndromes. Two tumors had developed in the superior sulcus, and one had a spinal canal component (dumbell-type tumor). RESULTS: Thoracoscopic dissection was possible in all cases. In one patient, resection of the tumor was performed via a combined neurosurgical and thoracoscopic approach. Seven tumors were benign nerve sheath tumors (schwannoma), and 2 were nerve cell tumors (ganglioneuroma). The postoperative course was uncomplicated in all patients. CONCLUSION: The thoracoscopic resection of mediastinal neurogenic tumors is technically easy, except for bulky tumors of the superior sulcus and dumbbell tumors, which require a combined thoracoscopic and neurosurgical approach.

Prognostic value of T and N in non small cell lung cancer three centimeters or less in diameter.

OBJECTIVE: Peripheral tumors 3 cm or less in diameter are classified T1, T2 when rupturing the visceral pleura, T3 when invading parietal pleura, chest wall, mediastinal pleura or pericardium and T4 when invading vertebra or mediastinal structures. Our objective was to assess the prognostic significance of T and N status according to the size of such tumors. PATIENTS AND METHODS: Patients (918) were operated upon between April 1984 and December 1991. Surgery included complete resection and mediastinal lymphadenectomy. Tumors 3 cm or less were studied concerning T, N status, histology and survival. RESULTS: There were 314 such tumors (T1 = 215, T2 = 64, T3 = 35, T4 = 6); N status was N0 60.2%, N1 21%, N2 18.8%. Global 5-year survival was 52.59%. In case of N0, survival was 64.63%: T1 = 63.76%, T2 = 71.48%, T3 = 45.71%, T4 = 66.6%; which was not significant. There were 48 tumors 1.0 cm or less in diameter (G1), 111 tumors 1.1-2.0 cm in diameter (G2) and 155 tumors 2.1-3 cm in diameter (G3). The incidence of N0, N1 and N2 disease was 77.1, 10.4 and 12.5%, respectively in G1, 64, 18 and 18% in G2, and 52.3, 26.5 and 21.3% in G3. The 5-year survival rate was 62.46% for G1, 52.91% for G2 and 49.36% for G3 (NS). In cases of N1 and N2, survival was 48.41% and 20.2% which was significant (P < 0.05) but differences between each T and each G were not significant. CONCLUSIONS: Small peripheral cancers spread into mediastinal nodes in 12.5-21.3% of cases, according to the size. This is a warning to perform nodes resections in cases where surgeons intend a videothoracoscopic approach. N2 status is not only an indicator but also a governor of prognosis. Neither T status nor size are determinants of prognosis as far as tumors 3 cm in diameter or less are concerned.

[Place of radical surgery in the treatment of non-small cell lung cancer. Apropos of 969 cases]. / Place de la chirurgie à visée curative dans le traitement du cancer bronchique non à petites cellules. A propos de 969 cas.

PURPOSE: Retrospective analysis of the results of radical surgery in a series of 969 patients presenting with non-small cell lung cancer. PATIENTS AND METHODS: From April 1984 to December 1981, 969 patients underwent radical surgery with mediastinal node dissection for non-small cell lung cancer. Surgery included 507 pneumonectomies, 447 lobectomies and 15 segmentectomies (for patients suffering from respiratory failure). RESULTS: The rate of intrahospital mortality was 4.3%. The rate of crude survival at 5-years was 45.8%. The tumor size (P = 0.004) and visceral pleura ruptures (P = 0.01) were significantly correlated to the 5-year survival rate that was reaching 56% for patients with no demonstrable metastasis to regional lymph nodes (NO), 46.6% for patients with metastasis to lymph nodes in the peribronchial or the ipsilateral hilar region (N1), and 20.8% for patients with metastasis to the ipsilateral mediastinal and subcarinal lymph nodes (N2) (P = 0.001). In case of stage N2 cancer, the 5-year survival rate was 28.7% when only one anatomical level was involved, and 8.7% when more than one anatomical level was involved (P < 0.0001). CONCLUSION: The main prognostic factor was nodal involvement.

[Pulmonary hyalinising granuloma with mediastinal fibrosis: a rare cause of dysphagia]. / Granulome pulmonaire hyalinisant avec fibrose médiastinale : une cause rare de dysphagie.

Pulmonary hyalinising granulomas (PHG) are rare. They are defined by the presence of collagen lamellar fibrosis. One third are associated with retroperitoneal or mediastinal fibrosis. Two cases of PHG are presented. They were revealed by dysphagia due to tight oesophageal stricture from associated mediastinal fibrosis. PHG are considered as a benign and slowly evolving disease, but associated mediastinal fibrosis may evolve on its own. Only steroid therapy may slow down progression. This makes an accurate diagnosis necessary. It relies on large surgical biopsies.

[Prognostic factors of survival in resected N2 bronchial cancer]. / Facteurs pronostiques de survie des cancers bronchiques N2 réséqués.

This study was based on 206 patients with non small cell lung cancer and N2 nodal disease submitted to curative surgery: pneumonectomy 163, lobectomy 39 and segmentectomy 4. All accessible mediastinal lymph nodes were removed and classified according to their anatomical location in lymph node chains; "skip" metastases were present in 24.8% of cases. N2 disease would have been missed in 20% of cases if routine removal of mediastinal nodes had not been performed. There was solitary nodal chain involvement by metastasis in 126 cases (61.2%). Overall 5-year survival was 18.3% +/- 3. Survival was not influenced by site, size or extension (T) of tumor, adjuvant radiotherapy, tumor histology or presence of vascular invasion. The prognosis was significantly worsened by the presence of microscopic residual disease (22 cases) and of satellite nodules (18 cases). Survival was significantly improved when metastases involved a single node chain (25% versus 8.5%). The location and number of involved nodes in the chain, "skip" metastasis and presence of extracapsular spread of carcinoma did not influence prognosis. Routine mediastinal lymph node dissection is necessary to improve survival and for classification of lung cancer. Anatomical description allows better understanding of N2 disease which is not a contraindication to surgery when a complete gross resection can be achieved.

[A rare tumor of the thoracic wall: synovial sarcoma]. / Une tumeur rare de la paroi thoracique: le synovialosarcome.

The synovial sarcoma is a tumour of the soft tissues. Its thoracic localisation is unusual. The authors report a case of a recurrent tumour of the scapula, whose excision required major plastic surgery to the dorsal chest wall. The diagnosis was revealed by the biphasic histological nature which was confirmed on immunological studies. Such tumours give rise to discussions on their histogenesis; their subsequent progress is slow and recurrences are common. Healing depends on the radical nature of their excision.

[Video thoracoscopy of pulmonary nodules. Can one avoid preoperative markers?]. / Vidéothoracoscopie des nodules pulmonaires. Peut-on se passer d'un repérage pré-opératoire?

For a period of 35 months, 50 patients presenting with a total of 61 peripheral pulmonary nodules were operated on under videothoracoscopy. As a matter of principle none of these nodules were marked radiologically pre-operatively. All the scanners were reviewed retrospectively by a radiologist and a thoracic surgeon without knowing the results of the thoracoscopic intervention: 23 of these patients on the evidence would have quite obviously required preoperative marking (group I), and 27 would have been presented for direct thoracoscopy (group II). In group I there was only one group of nodules which could not be localised and by necessity, a thoracotomy was required. In group II, two nodules could only be localised thanks to a mino-thoracotomy. The level of failure was between 4 and 7%, and was identical to that found in the literature for different techniques of pre-operative radiological marking: these techniques were often complicated by a pneumothorax and intrapulmonary haemorrhage. These techniques for marking are used extensively. Prospective studies based on precise and complete criteria should enable better definition of rare cases which might benefit.

[Pericardial effusion and mediastinal "tumor": case report of an unusual association]. / Epanchement péricardique et "tumeur" du médiastin. A propos d'une association particulière.

A young man aged 26 was admitted as an emergency to the thoracic surgical unit for a pericardial tamponade associated with a tumour in the left anterosuperior mediastinum. After pericardial drainage by the sub-xiphoid route a left anterior mediastinotomy showed that the tumour had disappeared and a flabby diverticulum of the pericardium was found which was resected. Pericardial diverticulae are coelomic cysts which are usually considered to be congenital in origin similar to the pleuro-pericardiac cysts to which they are attached. The clinical history, which had a particularly dramatic and alarming onset is in favour of an acquired disease which is equally possible in this type of lesion.

[Mediastioscopic management of pleuropericardial cysts]. / Abord des kystes pleuro-péricardiques par médiastinoscopie.

We report two cases of paratracheal cystic tumors where no preoperative diagnosis could be established. Mediastinoscopy provided the diagnosis of pleuropericardial cyst. The mediastinoscopic approach allowed partial removal in one case and complete removal in the other.

[The surgical management of pneumothorax in patients with AIDS]. / Prise en charge chirurgicale des pneumothorax chez les patients au stade de SIDA.

The occurrence of a pneumothorax occurring as a complication of AIDS is a poor prognostic sign. We have undertaken a review of 26 patients admitted to hospital for a pneumothorax of whom 25 were admitted for therapy: five resolved under simple drainage; twenty required a pleurodesis which was performed on thirteen under video thoracoscopy: these were recurrent pneumothoraces and were bilateral in half the patients; all had failed under simple drainage. The hospital mortality was 30%; the follow-up was unusually long in the majority of cases and only 20% had a simple follow-up. The analysis of this population showed that the results were not tied to the proposed treatment but to the state of the disease and to the pre-existence of pulmonary lesions most often in relation to pneumocystis. Video thoracoscopy enables one to inspect the lung and to resect the diseased area at the origin of the air leak. The technique also enables the pleurodesis to be achieved and a pleural or lung biopsy to be obtained in a relative non-invasive fashion.

[Endoscopic thoracic sympathectomy for isolated axillary hyperhidrosis]. / Sympathectomie thoracique endoscopique pour hyperhidrose axillaire isolée.

BACKGROUND: Endoscopic thoracic sympathectomy is accepted as the treatment of choice for palmar hyperhidrosis. But the interest and the results of endoscopic thoracic sympathectomy for isolated axillary hyperhidrosis are still discussed. PATIENTS AND METHODS: In a series of 435 patients operated on for hyperhidrosis of the upper limbs during the 5 past years, 23 were suffering from isolated axillary hyperhidrosis (5.2 p. 100). All patients had been previously treated by local agents and 3 had iontophoresis. All patients underwent a bilateral endoscopic thoracic sympathectomy that was performed in one stage. Sympathectomy was done according to the usual technique but was extended down to T5. All patients were then contacted by phone to answer a detailed questionnaire. Four patients were lost for follow-up. The mean follow-up of the 19 remaining patients was 26 months (ranging 3 to 41 months). RESULTS: There was no intraoperative or postoperative complication. All patients were discharged the day after surgery. All but one (95 p. 100) were cured from their axillary hyperhidrosis. All of them experienced compensatory sweating (100 p. 100). This compensatory sweating was considered as mild by 8 patients, as embarrassing in 8 and as distressing in 3. Eleven patients complained of excessive dryness of the hands. This was considered as a minor adverse effect by 8 patients and as problematic by 3 patients. Finally, 16 patients were satisfied while 3 claimed they regretted having been operated on. CONCLUSION: The rate of compensatory sweating and the rate of dissatisfaction are higher after endoscopic thoracic sympathectomy for axillary hyperhidrosis than after endoscopic thoracic sympathectomy for palmar hyperhidrosis. Endoscopic thoracic sympathectomy for axillary hyperhidrosis should be foreseen only when all other therapies have been attempted.

[Surgery of bronchial cancer in patients aged 75 and over]. / Chirurgie du cancer bronchique chez les sujets âgés de 75 ans et plus.

From April 1984 to December 1990, 66 patients 75 years of age or older underwent curative mediastinal lymph node dissection. There were 37 pneumonectomies. Post-operative mortality was 12% and was not affected by the type of dissection. Five-year survival was 16.2 +/- 6.29% (median 23 months) and was more than 45% in less elderly patients. Survival rate was highly affected by presence of metastasis in the mediastinal nodes and was zero in N2 cases. More than half of the patients died from cancer-related causes. Generally, we operate all the N2 cases which appear technically dissectable. Retrospectively, we think that N2 stage detected, and confirmed histologically in patients over 75, would be the only contra-indication for this attitude.

[Tuberculous adenopathies of the mediastinum: surgical experience in adults]. / Adénopathies tuberculeuses du médiastin: expérience chirurgicale chez l'adulte.

Fifty eight patients were treated for mediastinal tuberculous adenopathies in the thoracic surgery department from 1986 to 1992. Surgery was diagnostic in 49: mediastinoscopy n = 42, left anterior mediastinotomy n = 3, thoracotomy n = 3 and video assisted surgery n = 1. Surgery was in view of cure in 9: bronchial fistula despite medical treatment n = 6, recurrence under medical treatment n = 3. Mediastinal tuberculous adenopathies rarely complicate in adults. Surgical treatment is quickly effective in prolonging and complicating cases under medical treatment and also probably diminishes the risk of bronchial and pulmonary sequellaes.