Outcomes after Contralateral Anatomic Surgical Resection in Multiple Lung Cancer.

BACKGROUND: Patients treated surgically for lung cancer may present synchronous or metachronous lung cancers. The aim of this study was to evaluate outcomes after a second contralateral anatomic surgical resection for lung cancer. METHODS: We performed a retrospective two-center study, based on a prospective indexed database. Included patients were treated surgically by bilateral anatomic surgical resection for a second primary lung cancer. We excluded nonanatomic resections, benign lesions, and ipsilateral second surgical resections. RESULTS: Between January 2011 and September 2018, 55 patients underwent contralateral anatomic surgical resections for lung cancer, mostly for metachronous cancers. The first surgical resection was a lobectomy in most cases (45 lobectomies: 81.8%, 9 segmentectomies: 16.4%, and 1 bilobectomy: 1.8%), and a video-assisted thoracic surgery (VATS) procedure was used in 23 cases (41.8%). The mean interval between the operations was 38 months, and lobectomy was less frequent for the second surgical resection (35 lobectomies: 63.6% and 20 segmentectomies: 36.4%), with VATS procedures performed in 41 cases (74.5%). Ninety-day mortality was 10.9% (n = 6), and 3-year survival was 77%. Risk factor analysis identified the number of resected segments during the second intervention or the total number of resected segments, extent of resection (lobectomy vs. segmentectomy), surgical approach (thoracotomy vs. VATS), tumor stage, and nodal involvement as potential prognostic factors for long-term survival. CONCLUSION: A second contralateral anatomic surgical resection for multiple primary lung cancer is possible, with a higher early mortality rate, but acceptable long-term survival, and should be indicated for carefully selected patients.

Usefulness of a routine endoscopic assessment of laryngeal lesions after lung cancer surgery.

BACKGROUND AND OBJECTIVE: Laryngeal pathology following lung cancer surgery is associated with post-operative morbidity and mortality. The aim of our study was to evaluate the usefulness of routine endoscopic assessment. METHODS: We prospectively evaluated vocal cord pathology using laryngeal endoscopy within 24 h post-surgery. Over 25 months, 276 patients underwent thoracic surgery. We excluded 26 patients with previous laryngectomy or vocal cord paralysis, early post-operative reintubation or patients who did not consent to an endoscopy. Endoscopic data were reported using a standardized procedure, recording vocal cord paralysis, swallowing disorders with aspiration, detected using a blue-coloured water test and vocal cord haematoma. RESULTS: Among 250 patients, vocal cord paralysis was diagnosed in 13 patients (5.2%) and was associated with a higher rate of post-operative pneumonia (P = 0.03), post-operative bronchoscopy (P = 0.01), reintubation (P = 0.007) and a trend towards an increased 90-day mortality rate (P = 0.09). Swallowing disorders with aspiration were diagnosed in 18 patients (7.2%) and were associated with a higher rate of post-operative pneumonia (P = 0.007), post-operative bronchoscopy (P = 0.01), reintubation (P = 0.004) and 90-day mortality (P = 0.03). Vocal cord haematomas were diagnosed in 28 patients (11.2%) and were not associated with an increased post-operative morbidity or mortality. CONCLUSION: Post-operative endoscopic laryngeal assessment is effective for diagnosing laryngeal pathology following thoracic surgery. Routine laryngeal endoscopic assessment may detect clinically silent swallowing disorders early to allow prompt treatment, which may prevent respiratory complications.

Lymphatic drainage of lung segments in the visceral pleura: a cadaveric study.

PURPOSE: Although peribronchial lymphatic drainage of the lung has been well characterized, lymphatic drainage in the visceral pleura is less well understood. The objective of the present study was to evaluate the lymphatic drainage of lung segments in the visceral pleura. METHODS: Adult, European cadavers were examined. Cadavers with a history of pleural or pulmonary disease were excluded. The cadavers had been refrigerated but not embalmed. The lungs were surgically removed and re-warmed. Blue dye was injected into the subpleural area and into the first draining visceral pleural lymphatic vessel of each lung segment. RESULTS: Twenty-one cadavers (7 males and 14 females; mean age 80.9 years) were dissected an average of 9.8 day postmortem. A total of 380 dye injections (in 95 lobes) were performed. Lymphatic drainage of the visceral pleura followed a segmental pathway in 44.2% of the injections (n = 168) and an intersegmental pathway in 55.8% (n = 212). Drainage was found to be both intersegmental and interlobar in 2.6% of the injections (n = 10). Lymphatic drainage in the visceral pleura followed an intersegmental pathway in 22.8% (n = 13) of right upper lobe injections, 57.9% (n = 22) of right middle lobe injections, 83.3% (n = 75) of right lower lobe injections, 21% (n = 21) of left upper lobe injections, and 85.3% (n = 81) of left lower lobe injections. CONCLUSION: In the lung, lymphatic drainage in the visceral pleura appears to be more intersegmental than the peribronchial pathway is-especially in the lower lobes. The involvement of intersegmental lymphatic drainage in the visceral pleura should now be evaluated during pulmonary resections (and especially sub-lobar resections) for lung cancer.

Acute peripheral arterial occlusion: prospective study evaluating intra-arterial thrombolysis with a micro-porous balloon catheter.

PURPOSE: To assess the efficacy of a new in situ thrombolysis method using a low-pressure micro-porous balloon catheter (MPBC) compared to a traditional in situ infusion (ISI) of a fibrinolytic agent in the treatment of acute limb ischemia. METHODS: Between January 2010 and December 2011, 21 patients (14 men; mean age 64.6 years, range 40-92) treated for acute lower limb ischemia were prospectively enrolled in the study. Seven patients underwent in situ thrombolysis using the ISI method and 14 patients the MPBC method to deliver urokinase. The total urokinase dose injected and the length of stay in an intermediate care unit were compared between the groups. RESULTS: Recanalization was successful in 90% of cases (6/7 patients in the ISI group; 13/14 patients in the MPBC group). The morbidity was 7% (1 pseudoaneurysm). The dose of urokinase needed was significantly lower (p<0.001) in the MPBC group (0.7±0.44 IU, range 0.15-1.6) vs. the ISI group (1.66±0.71 IU, range 0.2-2). The average length of stay in the intermediate care unit was significantly shorter in the MPBC group (1.2 vs. 3.9 days, p<0.002). The overall 6-month limb salvage rate after recanalization was 90% (83% for the ISI patients vs. 93% for the MPBC group). CONCLUSIONS: Intra-arterial thrombolysis using a balloon catheter is an effective method in the treatment of acute peripheral arterial occlusions. In the case of occlusion caused by embolism, primarily in very elderly patients, it may reduce the risk of hemorrhage. A randomized study on high-risk patients is needed to confirm these initial results.

Evaluation of balloon catheter-guided intra-arterial thrombolysis for acute peripheral arterial occlusion.

BACKGROUND: The objective of this study was to evaluate the effectiveness of a new method of in situ thrombolysis using a porous balloon with low pressure compared with traditional in situ infusion of a fibrinolytic agent in the treatment of acute limb ischemia. METHODS: Between January 2010 and December 2011, 14 patients (mean age, 67.2 years; range, 40-89 years) treated for grade II acute lower limb ischemia for fewer than 14 days were included in the study. Thromboaspiration was tried initially in all the cases. All patients benefitted from a novel method of intra-arterial thrombolysis guided with a balloon catheter (ClearWay; Atrium Medical, Hudson, NH) and using the same agent thrombolytic (Actosolv). The total amount injected, the rate of morbidity associated with the thrombolytic treatment, and the duration of hospitalization in the continuous monitoring unit were analyzed. RESULTS: Recanalization was obtained in 92% of cases (13 of 14). The rate of morbidity related to the procedure was 7%. The amount of fibrinolytic agent necessary was relatively low (82,000 units/cm of occluded artery). The rate of limb salvage 6 months after recanalization was of 92%. The mean duration of stay in the continuous monitoring unit was 1.1 day. CONCLUSIONS: Intra-arterial thrombolysis using the ClearWay balloon catheter is an effective method in the treatment of acute peripheral arterial occlusion. In the event of embolic occlusion, mainly among very old patients, it could decrease the hemorrhagic risk. A randomized study in these high-risk patients could confirm these first results.

Descending mediastinitis with mediastinal abscess after supracricoid partial laryngectomy.

We document a rare and not-yet-reported condition after supracricoid partial laryngectomy: the development of descending mediastinitis with mediastinal abscess. We present a case in which early diagnosis and team management allowed for a successful outcome. The pathophysiology of this severe complication, as well as its diagnosis, management, and prevention, is discussed, together with a review of the medical scientific literature.

Anatomic lung resection after immune checkpoint inhibitors for initially unresectable advanced-staged non-small cell lung cancer: a retrospective cohort analysis.

Background: Patients with initially unresectable advanced non-small cell lung cancer (NSCLC) might experience prolonged responses under immune checkpoint inhibitors (ICIs). In this setting, Multidisciplinary Tumor Board (MTB) seldomly suggest surgical resection of the primary tumor with the ultimate goal to eradicate macroscopic residual disease. Our objective was to report the perioperative outcomes of patients who underwent anatomic lung resection in these infrequent circumstances. Methods: We set a retrospective multicentric single arm study, including all patients with advanced-staged initially unresectable NSCLC (stage IIIB to IVB) who received systemic therapy including ICIs and eventually anatomical resection of the primary tumor in 10 French thoracic surgery units from January 2016 to December 2020. Coprimary endpoints were in-hospital mortality and morbidity. Secondary endpoints were the rate of complete resection of the pulmonary disease, major pathologic response, risk factors associated with post-operative complications, and overall survival. Results: Twenty-one patients (median age 64, female 62%) were included. Eighteen patients (86%) progressed after first line chemotherapy and received second line ICI. The median time between diagnosis and surgery was 22 months [interquartile range (IQR) 18-35 months]. Minimally-invasive approach was used in 10 cases (48%), with half of these requiring conversion to open thoracotomy. Nine patients (43%) presented early post-operative complications, and one patient died from broncho-pleural fistula one month after surgery. Rates of complete resection of the pulmonary disease and major pathologic response were 100% and 43%, respectively. In univariable analysis, diffusing capacity for carbon monoxide (DLCO) was the only factor associated with the occurrence of postoperative complications (P=0.027). After a median follow-up of 16.0 months after surgery (IQR, 12.0-30.0 months), 19 patients (90%) were still alive. Conclusions: Anatomic lung resections appear to be a reasonable option for initially unresectable advanced NSCLC experiencing prolonged response under ICIs. Nonetheless, minimally invasive techniques have a low applicability and post-operative complications remains higher in patients who had lower DLCO values. The late timing of surgery may also contribute to complications.

Preclinical evaluation of Versius, an innovative device for use in robot-assisted thoracic surgery.

OBJECTIVES: The adoption of robot-assisted thoracic surgery (RATS) has helped to overcome some of the challenges associated with surgeons performing conventional video-assisted thoracic surgery. The Versius Surgical System (CMR Surgical, Cambridge, UK) has been developed iteratively in line with surgical team feedback to improve the surgeon's experience and patient outcomes. The goal of this study was to assess the use of the device in RATS in a preclinical setting and to fulfil Idea, Development, Exploration, Assessment, Long-Term Follow Up-Devices stage 1 (Idea). METHODS: Four cadaveric sessions were conducted between November 2018 and December 2020, during which device performance in a range of thoracic operations was assessed. Procedures were categorized as either completed or not completed, and surgeons evaluated the device's ability to successfully complete necessary surgical steps. Port and bedside unit positions were recorded. RESULTS: In total, 22/24 (91.7%) thoracic procedures were successfully completed, including 17/18 lobectomies, 2/3 thymectomies and 3/3 diaphragm plications, in 9 cadaver specimens. One thymectomy could not be completed due to cadaver anatomy and 1 lobectomy was not completed due a console system fault. Port and bedside unit configurations were successfully validated for all procedures, and lead surgeons deemed the device to be well-suited for thoracic surgery. CONCLUSIONS: This preclinical study demonstrated the successful use of the device in RATS in cadaveric models and supports progression to small-scale clinical studies, as part of Idea, Development, Exploration, Assessment, Long-Term Follow Up-Devices stage 2a (Development).

An Unusual Presentation of Mycotic Popliteal Artery Pseudoaneurysm due to Pasteurella multocida Infection.

Pasteurella multocida , a zoonotic infectious pathogen, is a rare cause of mycotic aneurysms in human hosts. A 76-year-old man was admitted at our emergency unit for a superinfection of his right limb. The patient was initially treated for a knee arthritis. After a first-line antibiotherapy, the patient was referred to the vascular department for the management of a right acute limb ischemia. The work-up revealed a ruptured pseudoaneurysm of the popliteal artery. The ruptured artery was surgically explanted, and a femoropopliteal bypass was then performed. Pasteurella multocida was detected after bacterial analysis of the aneurysm. The postoperative course was uneventful. This case is the first reported case, to our knowledge, of a popliteal artery pseudoaneurysm due to Pasteurella multocida infection.

Prevention of pulmonary complications after aortic surgery: evaluation of prophylactic noninvasive perioperative ventilation.

BACKGROUND: In 40% of the cases, pulmonary complications are encountered after aortic surgery in patients suffering from chronic obstructive broncho-pneumopathy (COBP). The factors aggravating the occurrence of these complications are cumulated tobacco addiction of ≥40 packets per year and surgery for aneurysm. The aim of our prospective study was to evaluate the effect of pre- and postoperative noninvasive ventilation (NIV) preparation on the respiratory function of patients presenting with high pulmonary risks. METHODS: Between September 2007 and May 2010, 30 patients were included in the present study. Inclusions criteria were male gender, patients suffering from COBP with tobacco addiction of ≥40 packets per year, and aortic surgery for aneurysm with or without occlusive lesions. In all, 14 of the 15 patients had effectively performed the preparation before and after surgery according to a fixed protocol (NIV group). We compared the respiratory rate complications and the mean hospital length of stay in intensive care with the non-NIV control group (15 patients). RESULTS: Mean age, severity of COBP according to the classification of the French Society for Pneumology, surgery duration, and blood losses were comparable between the two groups. Conversely, pulmonary complications were significantly lower in the NIV group (0/14 [0%] vs. 5/15 [33%], p = 0.004). Hospital length of stay in intensive care was shorter in the NIV group (2.5 vs. 6.5 days, p < 0.001). CONCLUSION: Preliminary results are encouraging, in favor of pulmonary preparation before aortic surgery with NIV at home, and carried on postoperatively in hospital for patients with COBP. These results prompt us to propose a multicenter study to validate these first observations.

Guidelines on enhanced recovery after pulmonary lobectomy.

OBJECTIVE: To establish recommendations for optimisation of the management of patients undergoing pulmonary lobectomy, particularly Enhanced Recovery After Surgery (ERAS). DESIGN: A consensus committee of 13 experts from the French Society of Anaesthesia and Intensive Care Medicine (Soci,t, franOaise d'anesth,sie et de r,animation, SFAR) and the French Society of Thoracic and Cardiovascular Surgery (Soci,t, franOaise de chirurgie thoracique et cardiovasculaire, SFCTCV) was convened. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence. METHODS: Five domains were defined: 1) patient pathway and patient information; 2) preoperative management and rehabilitation; 3) anaesthesia and analgesia for lobectomy; 4) surgical strategy for lobectomy; and 5) enhanced recovery after surgery. For each domain, the objective of the recommendations was to address a number of questions formulated according to the PICO model (Population, Intervention, Comparison, Outcome). An extensive literature search on these questions was carried out and analysed using the GRADE® methodology. Recommendations were formulated according to the GRADE® methodology, and were then voted by all experts according to the GRADE grid method. RESULTS: The SFAR/SFCTCV guideline panel provided 32 recommendations on the management of patients undergoing pulmonary lobectomy. After two voting rounds and several amendments, a strong consensus was reached for 31 of the 32 recommendations and a moderate consensus was reached for the last recommendation. Seven of these recommendations present a high level of evidence (GRADE 1+), 23 have a moderate level of evidence (18 GRADE 2+ and 5 GRADE 2-), and 2 correspond to expert opinions. Finally, no recommendation was provided for 2 of the questions. CONCLUSIONS: A strong consensus was expressed by the experts to provide recommendations to optimise the whole perioperative management of patients undergoing pulmonary lobectomy.

Long-term survival following lung surgery for cancer in high-risk patients after perioperative pulmonary rehabilitation.

OBJECTIVES: The benefits of a rehabilitation programme before lung surgical resection for cancer remain to be defined. The purpose of this observational study was to assess the efficacy of preoperative rehabilitation and postoperative rehabilitation on short- and long-term outcomes in patients who were at high operative risk. METHODS: Between January 2010 and December 2012, 20 consecutive non-operable patients (16 men and 4 women, mean age 66 years) with clinical N0 lung cancer were included. Eligibility criteria were lung function below guideline thresholds and/or associated severe comorbidities. The protocol included a cardiorespiratory perioperative rehabilitation programme. These patients were followed up at 5 years. RESULTS: The average increase in forced expiratory volume (FEV)1 and of VO2max preoperatively was 12% and 3.5 ml/kg/min, respectively. All patients underwent a pulmonary surgical resection procedure. The morbidity and mortality rates were 20% and 5%, respectively. Nineteen patients returned home upon the completion of postoperative rehabilitation. After 5-year follow-up, the Kaplan-Meier 5-year survival rate was 52%. CONCLUSIONS: Perioperative pulmonary rehabilitation seems to allow surgical management of lung cancer by lung resection in first-line, non-eligible patients. The long-term survival of operated high-risk patients is encouraging despite the high complication rate.

Intraoperative conversion during video-assisted thoracoscopy does not constitute a treatment failure†.

OBJECTIVES: Intraoperative conversion may be required during video-assisted thoracoscopic surgery (VATS) for lung cancer. We evaluated the morbidity and mortality rates associated with VATS for anatomical pulmonary resection with conversion to thoracotomy and compared this technique with full VATS and an open thoracotomic approach. METHODS: We performed a retrospective, single-centre study between January 2011 and January 2017 and included 610 consecutive patients having undergone either VATS (with or without intraoperative conversion) or open thoracotomy for anatomical pulmonary resection. Pneumonectomies and angioplastic/bronchoplastic/chest wall resections were excluded. After propensity score adjustment, we assessed the 90-day mortality and determined whether the surgical approach was a risk factor for mortality. RESULTS: Of the 610 patients, 253 patients underwent full VATS, 56 patients underwent VATS + conversion and 301 patients underwent up-front open thoracotomy. Relative to the open thoracotomy group, the VATS + conversion group had a higher incidence of cardiac or respiratory comorbidities and was more likely to have an early-stage tumour. Following adjustment, the 90-day postoperative mortality rate was 5.4% (n = 3/56) in the VATS + conversion group and 3.7% (n = 11/301) in the open thoracotomy group (P = 0.58). Likewise, the morbidity rate was similar in these 2 groups. In a multivariable analysis, the surgical approach was not a risk factor for postoperative mortality. CONCLUSIONS: Following anatomical resection for lung cancer, VATS with conversion and open thoracotomy were associated with similar early postoperative morbidity and mortality rates. When in doubt, VATS should be preferred to thoracotomy; it potentially provides the patient with benefits of a fully VATS-based resection but is not disadvantageous when intraoperative conversion is required.

Clinical and molecular characteristics of unicentric mediastinal Castleman disease.

BACKGROUND: Unicentric mediastinal Castleman disease (CD) is a rare condition, poorly characterized due to the small number of cases and the absence of genomic study. We analyzed clinical, radiological, histological and genomic patterns associated with mediastinal CD in a substantial case series.Methods: We retrospectively reviewed cases of unicentric mediastinal CD managed in 2 French thoracic surgery departments between 1988 and 2012. Clinical, radiological, surgical and pathological data were recorded. On available FFPE blocks we performed mutation screening by next-generation-sequencing, using AmpliSeq™ Cancer Hotspot v2 (Life Technologies) and immunohistochemistry (IHC) (AKT-mTOR pathway). RESULTS: Eleven patients were identified (mean age 41±15 years, sex-ratio 0.8, median follow-up 78 months). Surgical approach was thoracotomy (n=6), sternotomy (n=4), and VATS (n=1). Additional procedures included thymectomy in three cases, mediastinal lymphadenectomy in two cases, and bilobectomy in one case. One patient presented local relapse as a follicular dendritic cell sarcoma, leading to death 48 months after the first resection. Within 9 patients whose FFPE blocks were available, 2 mutations were found: VHL (p.F119L, 35%, n=1) and JAK3 (p.V718L, 53%, n=1). Phospho-AKT and phospho-mTOR stainings were negative in all cases, whereas phospho-S6RP staining was positive in eight cases, mainly in interfollicular cell cytoplasm. CONCLUSIONS: From this series of patients with unicentric mediastinal CD, we observed 2 cases of potential driver mutations and 8 cases of phospho-S6RP activation not related to AKT-mTOR. Larger studies are required to decipher more precisely the molecular abnormalities and potential therapeutic targets underlying this uncommon condition.

Quantitative computed tomography to predict postoperative FEV1 after lung cancer surgery.

BACKGROUND: Predicted postoperative FEV1 (ppoFEV1) must be estimated preoperatively prior to surgery for non-small cell lung cancer (NSCLC). We evaluated a lung volumetry approach based on chest computed tomography (CT). METHODS: A prospective study was conducted over a period of one year in eligible lung cancer patients to evaluate the difference between ppoFEV1 and the 3-month postoperative FEV1 (poFEV1). Patients in whom CT was performed in another hospital and those with factors influencing poFEV1, such as atelectasis, pleural effusion, pneumothorax, or pneumonia, were excluded. A total of 23 patients were included and ppoFEV1 was calculated according to 4 usual Methods: Nakahara formula, Juhl and Frost formula, ventilation scintigraphy, perfusion scintigraphy, and a fifth method based on quantitative CT. Lung volume was calculated twice and separately by 2 radiologists. Tumor volume, and emphysema defined by a -950 HU limit were subtracted from the total lung volume in order to estimate ppoFEV1. RESULTS: We compared 5 methods of ppoFEV1 estimation and calculated the mean volume difference between ppoFEV1 and poFEV1. A better correlation was observed for quantitative CT than for Nakahara formula, Juhl and Frost formula, perfusion scintigraphy and ventilation scintigraphy with respectively: R2=0.79 vs. 0.75, 0.75, 0.67 and 0.64 with a mean volume difference of 266±229 mL (P<0.01) vs. 320±262 mL (P<0.01), 332±251 mL (P<0.01), 304±295 mL (P<0.01) and 312±303 mL (P<0.01). CONCLUSIONS: Quantitative CT appears to be a satisfactory method to evaluate ppoFEV1 evaluation method, and appears to be more reliable than other approaches. Estimation of ppoFEV1, as part of the preoperative assessment, does not involve additional morphologic examinations, particularly scintigraphy. This method may become the reference method for ppoFEV1 evaluation.

Complete thoracoscopic lobectomy for cancer: comparative study of three-dimensional high-definition with two-dimensional high-definition video systems †.

OBJECTIVES: Common video systems for video-assisted thoracic surgery (VATS) provide the surgeon a two-dimensional (2D) image. This study aimed to evaluate performances of a new three-dimensional high definition (3D-HD) system in comparison with a two-dimensional high definition (2D-HD) system when conducting a complete thoracoscopic lobectomy (CTL). METHODS: This multi-institutional comparative study trialled two video systems: 2D-HD and 3D-HD video systems used to conduct the same type of CTL. The inclusion criteria were T1N0M0 non-small-cell lung carcinoma (NSCLC) in the left lower lobe and suitable for thoracoscopic resection. The CTL was performed by the same surgeon using either a 3D-HD or 2D-HD system. Eighteen patients with NSCLC were included in the study between January and December 2013: 14 males, 4 females, with a median age of 65.6 years (range: 49-81). The patients were randomized before inclusion into two groups: to undergo surgery with the use of a 2D-HD or 3D-HD system. We compared operating time, the drainage duration, hospital stay and the N upstaging rate from the definitive histology. RESULTS: The use of the 3D-HD system significantly reduced the surgical time (by 17%). However, chest-tube drainage, hospital stay, the number of lymph-node stations and upstaging were similar in both groups. CONCLUSIONS: The main finding was that 3D-HD system significantly reduced the surgical time needed to complete the lobectomy. Thus, future integration of 3D-HD systems should improve thoracoscopic surgery, and enable more complex resections to be performed. It will also help advance the field of endoscopically assisted surgery.

Catamenial pneumothorax: retrospective study of surgical treatment.

BACKGROUND: Catamenial pneumothorax is a rare entity characterized by recurrent accumulation of air in the thoracic space during menstruation. Catamenial pneumothorax is also associated with a high rate of postoperative recurrence. The aim of this study was to discuss the etiology and to determine the optimal surgical treatment of this entity. METHODS: From December 1991 to September 2000, 10 patients with catamenial pneumothorax were treated at our institution. Median age at time of operation was 37 years (range, 21 to 44 years). We retrospectively evaluated the pathologic findings, the operation performed, and the results in all patients. The mean follow-up was 55.7 months. RESULTS: Pleurodesis alone was performed in 5 patients and an associated diaphragmatic procedure was performed in 5 patients. In 5 patients, no diaphragmatic anomaly was discovered: 3 experienced one or more recurrences and all still suffer from chronic catamenial chest pain. Hormonal therapy temporarily improved outcome for 6 months in 2 patients. On the contrary, in 5 patients surgical pleurodesis was associated with the repair of diaphragmatic defects (simple closure or coverage by a polyglactin mesh): these patients experienced no recurrence (n = 0/5, p = 0.0016) and no subsequent catamenial chest pain. CONCLUSIONS: The postoperative outcome is influenced by the diagnosis of diaphragmatic defects with or without endometriosis. Surgical treatment should be accomplished during menstruation for an optimal visualization of pleurodiaphragmatic endometriosis. Because diaphragmatic lesion is frequent and may be occult, we propose the systematic coverage of the diaphragmatic surface by a polyglactin mesh to prevent catamenial pneumothorax recurrence even when the diaphragm appears normal.

Nutritional status and postoperative outcome after pneumonectomy for lung cancer.

BACKGROUND: The influence of nutritional status on outcome after major lung resection remains controversial. Nutritional assessment is not included as a major recommendation in lung cancer guidelines. The purpose of this study was to assess the nutritional status of patients referred for pneumonectomy and to assess the predictive value of malnutrition in determining the surgical outcome. METHODS: This study was a multicenter observational trial. The eligibility criterion for participants was pneumonectomy for lung cancer. Criteria for group classification according to nutritional status were albumin and transthyretin levels. Predicted outcomes were major infectious and noninfectious complications and 90-day mortality. Univariate analysis identified independent variables for the predictive model of age, sex, induction chemotherapy, extended resections, treatment side, smoking, and malnutrition. Predictive variables were then included in a logistic regression model. RESULTS: Between January 2010 and December 2011, 86 (mean age, 61.5 years) consecutive patients referred for pneumonectomy (left side, n = 58; right side, n = 28) at 4 thoracic surgery centers were included. The malnutrition group included 33 patients (39%) and the normal nutritional status group included 53 patients. Univariate analysis elected malnutrition, recent active smoking, and extended resection to be included in a multivariate analysis. Multivariate analysis identified malnutrition, recent smoking, and extended resection as predictive variables for major complications and mortality. CONCLUSIONS: The frequency of malnutrition detected by biological markers was dramatically high. Malnutrition, as well as recent active smoking and extended resection, is a predictive factor for infectious complications and mortality after pneumonectomy. Nutritional assessment with appropriate markers should be considered before pneumonectomy.