Impact of aerobic exercise capacity and procedure-related factors in lung cancer surgery.

Over the past decades, major progress in patient selection, surgical techniques and anaesthetic management have largely contributed to improved outcome in lung cancer surgery. The purpose of this study was to identify predictors of post-operative cardiopulmonary morbidity in patients with a forced expiratory volume in 1 s <80% predicted, who underwent cardiopulmonary exercise testing (CPET). In this observational study, 210 consecutive patients with lung cancer underwent CPET with completed data over a 9-yr period (2001-2009). Cardiopulmonary complications occurred in 46 (22%) patients, including four (1.9%) deaths. On logistic regression analysis, peak oxygen uptake (peak V'(O2) and anaesthesia duration were independent risk factors of both cardiovascular and pulmonary complications; age and the extent of lung resection were additional predictors of cardiovascular complications, whereas tidal volume during one-lung ventilation was a predictor of pulmonary complications. Compared with patients with peak V'(O2) >17 mL·kg⁻¹·min⁻¹, those with a peak V'(O2) <10 mL·kg⁻¹·min⁻¹ had a four-fold higher incidence of cardiac and pulmonary morbidity. Our data support the use of pre-operative CPET and the application of an intra-operative protective ventilation strategy. Further studies should evaluate whether pre-operative physical training can improve post-operative outcome.

[Pulmonary rehabilitation: a multidisciplinary and comprehensive intervention]. / La réadaptation pulmonaire: une médecine pluridisciplinaire de pointe.

Pulmonary rehabilitation is an evidence-based, multidisciplinary and comprehensive intervention for chronic pulmonary diseases, adressed to symptomatic patients and to patients with impairment of activities of daily life. The major outcomes of this intervention are an increased exercise capacity, a decrease in dyspnea and thereby a better quality of life. Underweight patients may benefit from a caloric and protein supplementation. Smoking cessation programs should be integrated in any pulmonary rehabilitation program.

[Bronchopleural fistula: a serious complication after thoracic surgery]. / La fistule bronchopteurale: une complication grave de la chirurgie thoracique.

Postsurgical bronchopleural fistula (BPF) is a serious complication accompanied with a high mortality, requiring early and correct diagnosis. The acute form of BPF is usually a technical failure of the surgical stump requiring an immediate surgical reoperation. The subacute or chronic BPF is more difficult to diagnose because of non specific symptoms. It requires well targeted antibiotics depending on microbiology, an adequate drainage of the thoracic cavity and very often repeated surgical or endoscopic procedures.

[Progress in bronchoscopy: ultrasound guided fine-needle aspiration (EBUS-TBNA)]. / Progrès en bronchoscopie: ponction guidée par ultrasonographie (EBUS-TBNA).

In case of lung cancer, evaluation of the extension disease is mandatory. Mediastinal nodes must also be evaluated: if a controlateral to the tumor node is metastatic (N3), surgery is no more indicated. As specificity of PET-CT scan is not satisfaying (78%), cytology or histology of a suspect node is necessary. Even if PT-CT scan is negative, node micrometastasis are not excluded. To investigate a mediastinal adenopathy, mediastinoscopy or mediastinotomy are gold standard. Cytoponction guided by ultrasonography (EBUS-TBNA) is a new method which has been proved to be efficient and safe, but necessating some expertise and regular practice. It could be a valuable alternative to mediastinoscopy.

Titrated sedation with propofol or midazolam for flexible bronchoscopy: a randomised trial.

In this study, we questioned whether propofol provided clinical benefits compared with midazolam in terms of neuropsychometric recovery, safety profile and patient tolerance. Patients, aged >18 yrs, were randomised to receive midazolam or propofol, given by non-anaesthetist physicians to achieve moderate levels of sedation as assessed by the electroencephalographic bispectral index (BIS; between 70 and 85). The primary end-point was the time delay until recovery of the BIS above 90. Other end-points included a neuropsychometric continuous performance test (CPT), serious respiratory adverse events, patient tolerance and physician satisfaction. Neuropsychometric recovery was improved in the propofol compared to the midazolam group as evidenced by faster normalisation of BIS index (5.4+/-4.7 min versus 11.7+/-10.2 min; p = 0.001) and better results at the CPT. In the midazolam group, 15% of patients presented profound sedation precluding CPT completion and one patient required mechanical ventilatory support. Patient tolerance was significantly better in the propofol group, whereas the operator's assessment was comparable in both groups. Compared with midazolam, propofol provided a higher quality of sedation in terms of neuropsychometric recovery and patient tolerance. BIS-guided propofol administration represents a safe sedation technique that can be performed by the non-anaesthesiologist.

Treatment of primary spontaneous pneumothorax by simple talcage under medical thoracoscopy.

Medical thoracoscopy under local anesthesia with simple talc poudrage is a safe and cost-effective technique to prevent recurrences in the case of primary spontaneous pneumothorax. Pathogenesis of primary spontaneous pneumothorax, i.e. a pneumothorax occurring without any underlying lung disease, remains unclear; there is no proof that the air leak leading to air escape into the visceral pleura is located in blebs or bullae visualized during the procedure. Therefore we do not have any evidence that blebs or small bullae cauterization or resection adds any further benefit to pleurodesis. Pulmonologists doing thoracoscopic talc pleurodesis should learn to better control pain due to thoracoscopic talcage as it has been shown that thoracoscopic talcage is not more painful than a chest tube drainage in patients providing they receive at least some opioids. There is also a debate on the best surgical approach to treat pneumothorax but minithoracotomy with pleurectomy remains the gold standard although more expensive and associated with some morbidity or mortality.

Management and outcome of patients undergoing thoracic surgery in a regional chest medical centre.

BACKGROUND AND OBJECTIVE: The main objective of this study was to assess mortality and morbidity after thoracic surgery in a medical centre, without resident chest surgeons and anaesthesiologists, and to determine specific risk factors. METHODS: A prospective cohort study using a local database which includes patients' clinical characteristics, results of preoperative investigations, surgical and anaesthesia data and all postoperative complications was undertaken. Two hundred and seventy-three consecutive patients undergoing thoracic surgery from 1992 to 1999 were studied. The referral chest medical centre was without resident thoracic surgeons or anaesthesiologists; postoperative care was led by local chest physicians according to standardized protocols and in close collaboration with university-based surgeons and anaesthesiologists. RESULTS: The majority of patients had lung cancer (71%) and underwent resection of at least one lobe (62%). Thirty-day mortality rate was 2.2% and one or more complications occurred in 74 patients (27%). Three patients had to be transferred to a university hospital for further treatment. Univariate predictors of complications included age (> 70 years), history of smoking, body mass index, as well as the extent and duration of surgery. After multiple logistic regression analysis, smoking (current or past), prolonged surgery (>120 min) and major lung resection (pneumonectomy or bilobectomy) remained the only independent risk factors. CONCLUSIONS: Overall perioperative mortality and morbidity rates did not exceed those reported from large teaching hospitals. In selected patients, thoracic surgery can be safely performed in a specialized chest medical centre without on-site surgeons and anaesthesiologists.

Exercise capacity and extent of resection as predictors of surgical risk in lung cancer.

Lung resection remains the most effective treatment for non-small cell lung cancer (NSCLC). However, there is no consensus about reliable operative risk assessment in these patients. The aim of this study was to identify predictors of postoperative complications and death after lung resection for NSCLC. In this prospective trial, 125 of 142 (88%) consecutive NSCLC patients from 1990 to August 1997 had complete data sets. All underwent functional assessment including spirometry and cardiopulmonary exercise tests and lung resection via thoracotomy. Complications occurred in 31 of 125 (25%) patients including 2 (1.6%) deaths. On logistic regression analysis, only maximal oxygen uptake (V'O2,max) x kg body weight(-1) expressed as a percentage of the predicted value (p<0.0001) and the estimated extent of lung tissue resection (p=0.02) were independent predictors of postoperative complications. Six of seven patients with a V'O2,max x kg body weight(-1) of <60% pred, but only eight of 65 with values >90% pred, exhibited postoperative complications. Maximal oxygen uptake and the estimated extent of lung tissue resection are independent predictors of postoperative complications. These simple parameters should be integrated into the preoperative decision analysis for operability in patients undergoing lung resection for lung cancer.

Perioperative mortality and major cardio-pulmonary complications after lung surgery for non-small cell carcinoma.

OBJECTIVES: A database of patients operated of lung cancer was analyzed to evaluate the predictive risk factors of operative deaths and life-threatening cardiopulmonary complications. METHODS: From 1990 to 1997, data were collected concerning 634 consecutive patients undergoing lung resection for non-small cell carcinoma in an academic medical centre and a regional hospital. Operations were managed by a team of experienced surgeons, anaesthesiologists and chest physicians. Operative mortality was defined as death within 30 days of operation and/or intra-hospital death. Respiratory failure, myocardial infarct, heart failure, pulmonary embolism and stroke were considered as major non-fatal complications. Preoperative risk factors, extent of surgery, pTNM staging, perioperative mortality and major cardiopulmonary complications were recorded and evaluated using chi-square statistics and multivariate logistic regression. RESULTS: Complete data were obtained in 621 cases. The overall operative mortality was 3.2% (n = 19). Cardiovascular complications (n = 10), haemorrhage (n = 4) and sepsis or acute lung injury (n = 5) were incriminated as the main causative factors. In addition, there were 13 life-threatening complications (2.1%) consisting in strokes (n = 4), myocardial infarcts (n = 5), pulmonary embolisms (n = 1), acute lung injury (n = 1) and respiratory failure (n = 2). Four independent predictors of operative death were identified: pneumonectomy, evidence of coronary artery disease (CAD), ASA class 3 or 4 and period 1990-93. In addition, the risk of major complications was increased in hypertensive patients and in those belonging to ASA class 3 or 4. A trend towards improved outcome was observed during the second period, from 1994 to 97. CONCLUSION: Our data demonstrate that perioperative mortality is mainly dependent on the extent of surgery, the presence of CAD and provision of adequate medical and nursing care. Preoperative testing and interventions to reduce the cardiovascular risk factors may help to further improve perioperative outcome.

[Value of thoracoscopy and talc pleurodesis in diagnosis and palliative treatment of malignant pleural mesothelioma]. / Stellenwert der Thorakoskopie und Talkpleurodese in der Diagnostik und palliativen Behandlung maligner pleuraler Mesotheliome.

Malignant pleural mesothelioma (MPM) remains a disease of very poor prognosis despite all new therapeutic approaches. We describe here 13 cases with MPM. The main symptoms at presentation were dyspnea (12/13) followed by weight loss (7/13), cough (3/13) and thoracic pain (2/13). On chest X-ray, all patients had pleural effusion associated with pleural thickening in 8/13 cases (62%). A definitive diagnosis was brought by thoracoscopy in 11/12 cases (diagnostic sensitivity 92%). In one patient, thoracoscopy was technically impracticable because of very important obesity. By thoracoscopic talc pleurodesis, we were able to control the pleural effusion in all patients with suppression of dyspnea (11). The mean survival after diagnosis was 6.8 +/- 5.0 months (range 1-16). At the present time, we believe that thoracoscopy is well indicated in any suspicion of MPM not only for diagnosis but also for palliative treatment of this pleural disease. However, there is a need for well controlled studies to improve the outcome of MPM.

End-stage cystic fibrosis: improved diabetes control 2 years after successful isolated pancreatic cell and double-lung transplantation.

Over a period of years, insulin-dependent diabetes and respiratory insufficiency developed in a 35-year-old patient with end-stage cystic fibrosis. After waiting more than 4 years while receiving maintenance treatment with continuous liquid O2 and nasal ventilation, the patient underwent double-lung and pancreatic islet cell transplantation. Subsequently, the patient has enjoyed a normal life with full employment and much better control of his diabetes. Pancreatic islet cell transplantation is a simple and innocuous technique easily added to the end of lung transplantation. These new pancreatic cells, although locally injected, are still secreting more than 2 years later as assessed by repeated C-peptide measurements.

Treatment of complicated spontaneous pneumothorax by simple talc pleurodesis under thoracoscopy and local anaesthesia.

BACKGROUND: Complicated (recurring or persistent) spontaneous pneumothorax requires treatment either by talc pleurodesis with bullae electrocoagulation or, more aggressively, by thoracotomy or video-assisted thoracoscopic surgery. However, the relative merits of bullectomy, pleurectomy, and pleurodesis have not yet been established in the treatment of spontaneous pneumothorax. METHODS: The complications, duration of drainage, length of hospital stay, and immediate and long term success rate of treating complicated spontaneous pneumothorax with talc pleurodesis under local anaesthesia supplemented with nitrous oxide were studied. RESULTS: Talc pleurodesis was performed in 93 patients without serious complication (two benign arrhythmias, two subcutaneous emphysema, two pneumonia, one bronchospasm). The procedure was immediately successful in 90 patients (97%) with a median duration of drainage of five days (range 2-40) and a median length of hospital stay of 5.2 days (range 3-40). After a mean follow up duration of 5.1 (range 1-9.4) years in 84 cases the long term success rate was 95%, although six cases developed a small localised recurrence of spontaneous pneumothorax which did not require further surgery. Macroscopic staging at thoracoscopy was only carried out in the last 59 cases of whom 10 (17%) had bullae with a diameter of > 2 cm. In this group of patients the risk of definitive failure requiring surgery was significantly higher than in those patients without such bullae (odds ratio 7; confidence interval 3.7 to 13.3; p = 0.03), although eight of these patients did not require thoracotomy. Total lung capacity was reduced immediately after talc pleurodesis (mean (SD) 75 (23)% predicted at 10 days) but had improved to 95 (14)% predicted at 12 months. CONCLUSIONS: This study shows that simple thoracoscopic talc pleurodesis under local anaesthesia is a safe and effective treatment for complicated spontaneous pneumothorax. However, patients with bullae of > 2 cm in diameter have a greater risk of treatment failure.

[Dangerous complication of transtracheal oxygen therapy with the SCOOP(R) system]. / Gefährliche Komplikation der transtrachealen Sauerstofftherapie mit dem SCOOP(R)-System.

A portable oxygen system in combination with transtracheal O2 delivery (SCOOP(R)) permits patients with respiratory failure optimal mobility and facilitates longterm oxygen therapy. This report describes a 70 year old female with COPD that developed acute respiratory distress 18 days after inserting PRESCOOP(R) and 11 days after changing to SCOOP 1 catheter. Catheter stripping had not revealed any pathology. Flexible bronchoscopy showed a mucus ball at the catheter tip leading to a 80% stenosis of the trachea. Trials to remove the ball with forceps and a loop were not successful until a rigid bronchoscop was inserted. Up to 10% of patients develop mucus ball formation with SCOOP 1 catheter which remains in situ for 6 weeks. In patients with high risk of mucus formation (high O2 flow, viscous mucus, low FEV1) the manufacturers of SCOOP recommend catheter stripping. We consider a control bronchoscopy being safer 1 week after changing from PRESCOOP to SCOOP because one patient has been reported to have died of this complication and our patient has developed a near fatal situation.

[Thoracic surgery for non-small cell lung cancer. Cost-benefit of its management in specialized intermediate care]. / Chirurgie thoracique pour cancer du poumon non à petites cellules. Coût-bénéfice d'une prise en charge en soins intermédiaires spécialisés.

In 1989, we reorganized acute and rehabilitation cares for patients operated for non small cell lung cancer (NSCLC) in order to decrease costs by setting up a specialised intermediate care unit (SICU). This report deals with the postoperative complications and the total cost of these cares (SICU, acute and rehabilitation cares) as well as their cost/benefit. From 1990 to 1994, we performed 95 thoracotomies, 7 exploratory and 88 with lung resection (24 pneumonectomies, 8 bilobectomies, 48 lobectomies and 8 segmentectomies or wedge resections). The postoperative staging was I in 52, II in 17, III a in 15, S III b in 2, IV in 2. Patients 30-days postoperative mortality was 2/95 (2.1%). We had in 11 patients respiratory complications (12%; 3 bronchopleural fistulas, 3 pneumonias, 3 pneumothorax > 7 days, 1 empyema, 1 chronic hypoxemia), in 15 patients cardiac arrhythmias which were easily controlled by medication and in 2 general complications (1 hemiplegia, 1 transitory stupor state). The total duration of hospital stay, including SICU, acute and rehabilitative cares, was 32 +/- 10 (3-70) days with a mean total cost of 14,722 Sfr. per case. In conclusion, surgery for NSCLC can be safely performed in intermediate cares without intensive care unit at low costs and with a low morbidity and mortality provided they are staffed by a specialised and well trained team.

[Campaign against smoking and the general practitioner. Evaluation of a simple method allowing immediate measurement of compliance with smoking cessation in the physicians office]. / Lutte contre le tabac et médecin praticien. Evaluation d'une méthode simple, permettant la mesure immédiate de l'efficacité de l'arrêt du tabac au cabinet médical.

Recently, the Swiss Medical Association and the Swiss Federal Office for Public Health started a campaign against smoking. Portable carbon monoxide (CO) devices measuring alveolar CO concentration are now available. It is important to know how accurate they are in discriminating smokers (S) from nonsmokers (NS) in different environmental conditions. We administered a smoking questionnaire and measured alveolar CO concentration in 241 people living in an urban area (PU) and 112 people living in a mountain area (PM). Smoking prevalence was 39% in PU and 17% in PM. Alveolar CO concentration was significantly higher in S than in NS (27 +/- 11, 11 to 60, vs. 14 +/- 9, 4 to 52, p < 0.01 in PU and 23 +/- 13, 4 to 48, vs. 9 +/- 7, 4 to 46, p < 0.01 in PM). We found significantly higher CO-values in NF of PU than PM (p < 0.01). This test has a sensitivity of 80%, a specificity of 78%/79% (PU/PM) and a predictive positive value of 74%/80% (PU/PM). The cut-off point has to be adapted depending on the environmental exposure (PU: 15 ppm, PM: 10 ppm CO). Alveolar CO measurement is a cheap accurate method whose results are immediately available to the general practitioner in his fight against smoking. This method merits higher application.

Retroperitoneal silicosis mimicking pancreatic carcinoma in an Alpine miner with chronic lung silicosis.

A miner, known to have had lung silicosis for 30 years, was investigated for abdominal pain. A retroperitoneal mass was found, in which histological examination showed an inflammatory reaction to silica.

[Thoracoscopy: diagnostic and therapeutic use]. / Thoracoscopie: utilité diagnostique et thérapeutique.

From 1986 to 1989, we performed 74 thoracoscopies in 70 patients (37 persisting or relapsing pneumothoraces, 30 chronic pleural effusions, 3 primary pleural tumors, 2 chylothoraces, 1 empyema, 1 persisting bronchopleural fistula). 29 supplementary diagnoses were established by thoracoscopy: 11 carcinomas, 4 cases of pleural tuberculosis, 12 of nonspecific pleurisy, 1 pleural fibroma, and 1 hamartoma. Pleurodesis was done with talc under thoracoscopy with success in 32/34 cases of pneumothorax (94%) and in 19/20 patient with chronic pleural effusion (95%). Talc was also successful in 2 instances of chylothorax and the bronchopleural fistula. The empyema was successfully treated by drainage under thoracoscopy and local instillation of streptokinase. Altogether, we recorded 3 deaths in the 30 days following thoracoscopy in 3 plurimetastatic patients. No other major complication was observed. The procedure is a well tolerated tool for diagnosis and treatment of pleural diseases. The indication should however be established with care in debilitated plurimetastatic patients.

[Chylothorax: treatment using talc pleurodesis]. / Chylothorax: traitement par pleurodèse au talc.

Chylothorax is a rare complication of lymphoma with a poor prognosis. The treatment is not well established. We report a case of lymphoma complicated by bilateral chylothorax in which, despite optimal chemotherapy and radiotherapy, pleural effusion persisted. Pleuroscopy was performed under local anesthesia, followed by pleural instillation of pure talc. The immediate result was satisfactory and six months later there was no recurrence of chylothorax. Talc pleurodesis appears to be a simple and safe way of treating chylothorax resistant to conventional therapy.