Diffusion of ofloxacin into human lung tissue.

Ofloxacin 200mg twice daily was administered to 17 patients with pulmonary disorders, which necessitated surgery, during the preceding 48 hours and 200mg was administered 1 hour before the operation. During surgery, blood samples and specimens of healthy and diseased lung tissues were taken simultaneously. Ofloxacin levels were determined by HPLC. The mean values of the tissue concentration/plasma concentration ratio were 3.5 +/- 0.4 for the healthy tissue and 3.9 +/- 0.4 for the diseased tissue. These values reflected good penetration of ofloxacin into both healthy and atelectasic pulmonary parenchyma.

Intermediate-term results after en bloc double-lung transplantation with bronchial arterial revascularization. Bordeaux Lung and Heart-Lung Transplant Group.

OBJECTIVE: Between May 1990 and January 1994, 18 patients underwent en bloc double-lung transplantation with tracheal anastomosis and bronchial arterial revascularization. Because at that time it was already suggested that chronic ischemia could be a contributing factor in occurrence of obliterative bronchiolitis, the purpose of this study was to evaluate, with a follow-up ranging from 22 to 69 months, the midterm effects of bronchial arterial revascularization on development of obliterative bronchiolitis. RESULTS: Results were assessed according to tracheal healing, functional results, rejection, infection, and incidence of obliterative bronchiolitis. There were no intraoperative deaths or reexplorations for bleeding related to bronchial arterial revascularization, but there were three hospital deaths and five late deaths, two of them related to obliterative bronchiolitis. According to the criteria previously defined, tracheal healing was assessed as grade I, IIa, or IIb in 17 patients and grade IIIa in only one patient. Early angiography (postoperative days 20 to 40) demonstrated a patent graft in 11 of the 14 patients in whom follow-up information was obtained. Ten patients are currently alive with a 43-month mean follow-up. Among the 15 patients surviving more than 1 year, functional results have been excellent except in five in whom obliterative bronchiolitis has developed and who had an early or late graft thrombosis. Furthermore, those patients had a significantly higher incidence of late acute rejection (p < 0.02), cytomegalovirus disease (p < 0.006), and bronchitis episodes (p < 0.0008) than patients free from obliterative bronchiolitis. CONCLUSION: We conclude that besides its immediate beneficial effect on tracheal healing, long-lasting revascularization was, at least in this small series, associated with an absence of obliterative bronchiolitis, thus suggesting but not yet proving the possible role of chronic ischemia in this multifactorial disease.

Tuberculosis in transplanted lungs.

Over a 4-year period in four of 61 patients (6.5%) who survived lung transplantation, pulmonary tuberculosis developed at a mean of 7.5 months (range 3 to 13 months) after operation. Clinical and radiologic features were atypical. Definitive bacteriologic diagnosis, which was established on bronchial, sputum, and pleural fluid samples, may be delayed by the concomitant presence of other infective organisms and the necessity for repeated sampling. All patients were treated successfully with antituberculous chemotherapy, but one patient also required lobectomy. At a mean follow-up of 2.25 years (range, 1 to 3 years), three patients are free of active disease, and one patient had a recurrence at 2 years. Tuberculosis in transplanted lungs is an uncommon but serious infection that may elude diagnosis but respond well to treatment.

Surgical treatment of nontumoral stenoses of the upper airway.

BACKGROUND: After 1970, the widespread use of nasotracheal intubation, avoiding tracheostomy and its pitfalls, resulted in more frequent laryngeal or laryngotracheal stenoses, which required more complex and sometimes multistaged procedures. METHODS: A series of 217 nontumoral stenoses of the upper airway were treated following the same therapeutic principles in the period 1978 to 1992. Two hundred one of them were iatrogenic postintubation strictures (92%); the others were posttraumatic (7), idiopathic (5), and various (4). RESULTS: One hundred twenty (55%) were tracheal stenoses and treated by resection and primary end-to-end anastomosis with 117 excellent or good results and three deaths. Length of the stenosis, old age, neuropsychological sequelae, and overall poor respiratory status of the patients made up the remaining difficulties in the treatment. Ninety-seven (45%) were laryngotracheal stenoses with much more complex surgical indications: 57 patients underwent tracheal and subglottic resection and anastomosis with 56 successes and one death, 7 had laryngotracheal resection and anastomosis with total cricoidectomy and consequently laryngeal stenting for 3 to 6 months (six successes, one death), 3 had supraglottic resection and anastomosis (three successes), 12 patients with glottic opening difficulties and short laryngeal stenosis underwent a laryngeal enlargement over a T tube without resection (11 successes, one death), and 18 were subjected to a complex combination of resection and modeling with 16 successes, 2 failures, and 1 death. Final results were successful in 208 cases (96%) with seven deaths and two failures. Mild phonetic sequelae were observed after laryngeal modeling. A minimal follow-up of 1 year has shown long-term stability of most repairs. CONCLUSIONS: Despite acceptable results, the therapeutic approach remains difficult for laryngotracheal stenoses involving the glottic and the supraglottic level as well as for those that have not responded to previous attempts at repair. In a few cases, despite a meticulous preoperative assessment, the surgical strategy can only be adopted intraoperatively. The key to surgical success is undoubtedly a careful preoperative treatment of infection and inflammation as well as a meticulous muco-mucosal approximation of healthy margins at the anastomosis.

Long-term functional results after bilateral lung transplantation. Bordeaux Lung and Heart-Lung Transplant Group.

Between February 1988 and January 1992, 61 patients have undergone bilateral lung transplantations (42 heart-lung and 19 double-lung) in Bordeaux. The underlying diseases were primary or secondary hypertension (20), emphysema (22), or other diseases including cystic fibrosis, pulmonary fibrosis, silicosis, and sarcoidosis (19). Actuarial survival for double-lung and heart-lung transplant recipients was 66% and 72% at 1 year and 57% and 53% at 3 years, respectively. Forty-two patients were still alive 6 months after operation, and we studied their pulmonary function at the short and long term. All parameters except arterial carbon dioxide tension had improved dramatically at 6 months (p < 0.0001). Vital capacity, forced expiratory volume in 1 second, and forced expiratory flow rate between 25% and 75% of vital capacity were at 79% +/- 3%, 92% +/- 5%, and 105% +/- 8% of the predicted values, respectively. Arterial oxygen tension was 88 +/- 3 mm Hg. Nine months after operation, a slight decrease in forced expiratory volume in 1 second and forced expiratory flow rate between 25% and 75% of vital capacity appeared but values remained more than 75% predicted. This was related to the occurrence of obliterative bronchiolitis in 6 patients (14%). At 9 months, flow rates and oxygen tension of these 6 patients were highly different from those of patients free of obliterative bronchiolitis (p < 0.0002 for flow rates and p < 0.01 for oxygen tension). Only 1 patient required retransplantation. The others are living an almost normal life. Our results are discussed in view of the published reports on single-lung transplantation. Short-term results of bilateral lung transplantation are thus excellent and maintained on a long-term basis. Therefore, in our opinion, bilateral lung transplantation is the therapy of choice for pulmonary hypertension and emphysema.

Expanding wire stents in benign tracheobronchial disease: indications and complications.

Prosthetic tracheobronchial stents provide palliative treatment for narrowed airways where surgical resection is inadvisable. Over a 1-year period, 28 Gianturco expanding wire stents were used in 15 patients for nonneoplastic indications: pure fibrous airway stenosis (6), fibroinflammatory stenosis (4), and tracheobronchial malacia (5). Insertion was technically straightforward. A satisfactory airway lumen with immediate improvement in ventilatory function was obtained in all patients. After insertion all patients had an irritation-type cough that either subsided spontaneously (10 patients) or was successfully suppressed with inhaled corticosteroid therapy (5 patients). The most common complication (12 patients) was granuloma formation leading to stent removal in 3 patients with fibroinflammatory stenosis. Other complications were dysphagia (1), suction catheter entrapment (1), and fatal massive hemoptysis (1). At a mean follow-up of 13 months (range, 3 to 19 months) all remaining stents are functioning well with no displacement or infection. Overall results were satisfactory in pure fibrous stenoses and tracheobronchial malacia but poor in the presence of inflammation. Tracheobronchial wire stents can be successfully used in selected patients.

Esophagectomy for cancer in the patient aged 70 years and older.

BACKGROUND: Advanced age increases the risk of any major surgical intervention, particularly esophageal resection. High morbidity and increased mortality have been reported in operations for esophageal cancer in the elderly. METHODS: To determine outcome, risk factors, and the advisability of esophageal resection in the elderly, a single-institution retrospective review was performed of esophagectomy for cancer over a 14-year period. From January 1, 1980, to December 31, 1993, 540 patients underwent esophageal resection for esophageal cancer. These patients were divided into two groups: group 1, n = 89, patients 70 years of age or older; and group 2, n = 451, patients younger than 70 years of age. The two groups were compared according to preoperative risk factors, morbidity rate, mortality rate, mean stay in the hospital after operation, and long-term survival. RESULTS: Adenocarcinoma of the esophagogastric junction was the most common tumor in group 1 and was usually managed with a single incisional approach. There were no significant differences between the groups concerning morbidity (24.7% in group 1), mortality (7.8% in group 1), mean stay in the hospital (23.3 days in group 1), or long-term survival (59%, 23%, and 13% at 1, 3, and 5 years, respectively, in group 1). CONCLUSIONS: These results suggest that esophagectomy can be performed in selected elderly patients without increasing morbidity or mortality and with long-term survival.

Bronchial revascularization in double-lung transplantation: a series of 8 patients. Bordeaux Lung and Heart-Lung Transplant Group.

Donor airway ischemia is the main cause for defective tracheal or bronchial healing after double-lung transplantation. Anatomical studies and bronchial arteriograms have shown that the right intercostal bronchial artery is constant (95% of instances) and provides an important blood supply to the distal trachea, the carina, and the right bronchial tree as well as to the left side through a subcarinal and periadventitial anastomostic network. To maintain this important bilateral bronchial circulation, it is of capital importance not to mobilize the arteries individually and to avoid large dissections around the carina. Both bronchi can thus be revascularized by indirect aortic reimplantation using a bypass graft to a single aortic patch that includes the origin of the right intercostal bronchial artery. Furthermore, the origin of other vessels (a common trunk and left arteries) can be found within a short distance of the right intercostal bronchial artery and possibly be contained within the same aortic patch. From a series of 56 lung transplantations, 8 patients underwent restoration of the bronchial vascularization using a recipient saphenous vein graft between the donor bronchial arteries and the anterior aspect of the recipient's ascending aorta. A lower tracheal anastomosis was performed. Bronchial arterial blood supply was evaluated both by endoscopy and by arteriography at about the 15th postoperative day. The bronchial circulation was visualized at this time in five of seven arteriographies, and this was associated with excellent tracheal healing in all 8 patients.

Acquired tracheoesophageal fistula and its management.

Tracheoesophageal fistulae (TEF) are severe lesions leading to serious and eventually fatal pulmonary complications. Currently, TEF are mainly iatrogenic, occurring in the course of tracheal intubation for resuscitation or malignant after invasion of both esophageal and tracheal walls. Difficulty in treatment results from the need to manage both the consequences of esophagotracheal communication and those of the illness responsible for fistula. Various carefully selected means may be used to achieve this aim: division and closure of the TEF, esophageal exclusion followed by gastric or colic bypass or push-through intubation. Abstention from treatment may be appropriate in hopeless situations.

Esophageal patching for an unsuturable tracheoesophageal fistula.

We herein report a case of unsuturable tracheoesophageal fistula developed after chemotherapy of a mediastinal lymphoma. Esophageal exclusion was primary performed to prevent continued contamination of the respiratory tract. In a second stage procedure the fistula was patched with the esophageal posterior wall and the digestive tract was restored by a substernal colic bypass. This case leads to discuss the management of extrinsic tumoral tracheal compression and reminds us of an old reported procedure for the cure of large tracheoesophageal fistula.

The surgical treatment of inflammatory and fibrous laryngotracheal stenosis.

Seventy-two patients with laryngeal or laryngo-tracheal stenotic lesions resulting from tracheal intubation or laryngo-tracheal injuries are reported. Prior to 1978, the method of surgical treatment consisted mainly of laryngoplasty supported by laryngeal stenting. Twenty-six patients were treated by this method with 2 mortalities. Twenty-one long term results were good and 3 were fair. After 1978, laryngo-tracheal resection was performed in 46 patients. Twenty-seven had a Pearson-type operation, 13 underwent total or subtotal cricoid plate resection and modelling, and the remaining 6 had modelling alone. Perfect results after resection depend on the treatment of infection and inflammation of the airway before surgery. Our preferred method is resection and end-to-end anastomosis whenever possible. In addition to the anatomical site of the lesion, the glottic opening has to be considered in planning the surgical operation since impairment necessitates enlargement of the glottis as part of the procedure.

The growth of circumferential scars of the major airways from infancy to adulthood.

The factors affecting the development and prognosis of scarred airways in children are presented from a long-term follow-up study of 14 cases of tracheobronchial lesions following either injury or operation. Four children managed by endoluminal treatment developed severe stenosis and required treatment, later as adults, by laser resection in 2 cases and by laryngotracheal plastic enlargement and resection with anastomosis in 1 case each. The follow-up of 7 children managed by plastic procedures showed inconsistent results: they were good or excellent in 3 cases but with a decrease in the laryngotracheal diameter of 36%, 28% and 7% respectively. The laryngotracheal calibre decreased in 2 patients to 45% due to partial fibrous stenosis. Resection and anastomosis was required in the remaining 2 patients after 11 and 12 years for severe re-stenosis. The 3 patients who underwent immediate surgical resection all had an excellent clinical and morphological result, with a decrease in the laryngotracheal diameter of only 7%, 13% and 19% after a follow-up of 18, 20 and 15 years, respectively. These results show that the growth capacity of scars in children's airways is closely related to residual sclerosis following the initial treatment. It is thus suggested that primary resection and anastomosis should be performed in as many cases as possible. In the performance of plastic procedures, special attention should be paid to complete resection of the fibrotic tissues. Finally, a very long postoperative follow-up is always required in children in order to assess the development of the airway.

Classification of airway anastomotic healing.

Airway complications remain a major problem after lung transplantation. There is no standardised method of assessment of airway healing. We propose a classification of airway healing based on the anastomotic appearances at endoscopy 15 days postoperatively. The system appears to correlate well with the subsequent development of anastomotic sequelae and can be used to assess the effectiveness of therapeutic modalities designed to reduce airway complications.

Post traumatic disruption of the laryngo-tracheal junction.

Of 43 tracheo-bronchial ruptures, 19 patients presented with disruption of the laryngo-tracheal junction which would appear to be a very specific anatomical lesion. The disruptions were secondary to blunt cervical trauma in 11 cases and strangulation in 8 cases. The disruption was complete in 14 cases and incomplete in 5. The lesion is very complex and involved the retraction of the lower part of the trachea into the mediastinum (14 cases), fracture of the cricoid ring (9 cases), bilateral recurrent nerve tears (14 cases), unilateral (4 cases) and retraction of the laryngeal mucosa with exposure of the cricoid cartilage in all cases. According to the complexity of the lesion, the treatment was: laryngo-tracheal resection and end-to-end anastomosis with treatment of the vocal cord palsy in 13 patients; simple end-to-end anastomosis in 4 patients who had an unilateral vocal cord palsy; 2 patients with a partial disruption were treated medically with endoscopic stenting and laser photocoagulation. All had restoration of airway patency and recovery of voice. The results contrast with the failures and reoperations reported in the literature and underline the necessity of complete evaluation and treatment of these complex lesions.

Experience of partial oesophagectomy in surgical treatment of lower and middle thoracic oesophageal cancer. From a follow-up of 366 cases.

Since carcinoma of the oesophagus is considered to be frequently multicentric, total oesophagectomy appears the only radical therapeutical approach. A follow-up of 366 patients who underwent partial oesophagectomy shows that this procedure can be curative as well as palliative and is sometimes the only procedure possible with a reasonable mortality. These patients had an oesophageal carcinoma located between the cardia and the level of the aortic arch (60.5% squamous, 37% adenocarcinoma). Of these, 22% were over 70 years of age. The surgical route was a left thoracotomy in 280 cases (with anastomosis below or above the aortic arch) or a laparotomy and right thoracotomy in 86 cases. The oesophagus was transected as high as possible and replaced by an isoperistaltic tube fashioned from the greater curvature of the stomach. Mediastinal tissues and the lesser curvature with their lymph nodes were removed. The overall operative mortality was 7% (4% in patients less than 70 and 15% over 70). Very few anastomotic fistulae were observed (6 cases) but they were always severe (6 deaths). The middle and long term results show acceptable functional sequelae and a good survival quality. The survival is 57% at 1 year, 30% at 3 years and 23% at 5 years (27% when the excision appeared curative). There was no significant difference in survival for patients whose cancer was in the mid-oesophagus compared to the lower oesophagus. There was no difference in survival in the cell type squamous or adenocarcinoma. Death was mainly due to metastatic lesions and mediastinal lymphatic recurrence.(ABSTRACT TRUNCATED AT 250 WORDS)

Lung and heart-lung transplantation for end-stage lung disease. The Bordeaux Lung and Heart-Lung Transplant Group.

Between February 1988 and December 1989, 15 combined heart-lung, 2 double lung and 5 single lung transplants were performed at our institution for end stage lung disease. The indication for heart-lung transplantation was primary lung disease with associated secondary heart failure in 11 cases, diffuse pulmonary disease with extensive adenopathy of the hilum in 2 cases and profuse and antibiotic-resistant tracheobronchial infection due to Pseudomonas in 2 cases. A double lung transplant was performed in 2 patients with hypertensive emphysema. The indication for a single lung transplantation was emphysema in 2 cases and pulmonary fibrosis in 3 cases; in this last indication, transplantation should be performed on the right side with a slight lengthening of the main bronchus to avoid the side-effects of mediastinal shift. There were 2 early deaths, 7 secondary deaths (from the 2nd to the 5th month) due to viral or bacterial infectious complications, and 1 late death in the 7th month (infection due to a syncitial virus). All 12 surviving patients have an excellent functional result; the size of the tracheal or bronchial anastomosis ranges from 85% to 100% of normal. From this experience, we conclude that specificity and severity of lung hazards are mainly related to bronchial infection, dependence on steroids and pleural adhesions. Moreover, posttransplant pulmonary oedema, mucociliary dysfunction and the differential diagnosis between rejection and infection require careful endobronchial suction and periodical sampling.

Foreign body perforation of the normal oesophagus.

Over an 11-year period, 12 patients with foreign body perforation of a previously normal oesophagus were treated in our institution. The foreign bodies were most commonly bones (10 cases), 5 of which were chicken bones; other species were pigeon, rabbit, veal, pork and fish (one each); 2 perforations were due to swallowed dentures. The mean age was 60 years (range 42-73) and 6 patients were female. A degree of psychosocial dysfunction was present in 3 patients. Seven patients presented late (> 48 h after ingestion). The commonest presenting symptoms were fever and pain (8 patients). Other symptoms included dysphagia (7), respiratory distress (3), and late cervical abscess formation (3). The diagnosis was established by contrast oesophagography or rigid oesophagoscopy. A third of the perforations were cervical, the remainder intrathoracic. All patients were treated by surgical drainage with or without primary closure of the perforation. There were no operative deaths. Five patients developed postoperative oesophageal leaks which required reoperation in 1 patient. All patients were well and swallowing normally on discharge from hospital. Follow-up endoscopy or oesophagography was carried out in all patients and confirmed the absence of oesophageal disorders. Foreign body perforation of the oesophagus is a rare but important subentity of oesophageal perforation which responds well to surgical treatment.

Post traumatic tracheobronchial lesions. A follow-up study of 47 cases.

This report concerns 47 ruptures of the tracheo-bronchial tree from the tracheal origin to the division of the lobar bronchi (trachea in 30 patients, main bronchus in 11, intermediate or lobar bronchus in 6). The disruption was circumferential in 24 cases and non-circumferential in 23. Injuries resulted from crush or blunt trauma in 35 cases, from seat belt or rope strangulation in 8 cases and in 4 cases, lesions were discovered following the tracheal intubation. The main symptoms were cervico-mediastinal emphysema (39), pneumothorax (31), acute dyspnea (28) and hemoptysis (11). The diagnosis was always confirmed endoscopically. In 8 patients, management of the lesions was delayed for more than 1 week due to misdiagnosis or severe associated injuries. Thirty-eight patients underwent tracheal or bronchial surgical repair associated in 13 cases with a temporary stenting, 4 patients underwent partial or total lung resection, 2 were managed by laser therapy and the 5 others received only medical care and endoscopic survey. Four patients died (8.5%), 2 from bleeding in the bronchial tree from a pulmonary artery tear, 1 from hypertensive pneumothorax under respiratory support and the last from mediastinitis due to delayed diagnosis of an associated oesophageal wound. All 43 other survived in spite of some very critical situations. This experience confirms that technical problems of surgical repair are nowadays overcome and that prognosis of tracheobronchial ruptures mainly depends on the initial control of respiratory failure and complications. Avoiding lethal anoxia or endobronchial damage in the emergency period before referring the patient to the surgeon is essential.

Bronchogenic carcinoma staging: CT versus MR imaging. Assessment with surgery.

One hundred and twenty patients with bronchogenic carcinoma were prospectively studied by both computed tomography (CT) and magnetic resonance imaging (MRI) during the 2 weeks preceding thoracotomy or mediastinoscopy. MRI scans included contiguous axial and coronal slices. Results of CT and MRI studies were compared with the surgical and pathological findings on the basis of the TNM classification. Although no significant difference was found between the two imaging methods for the evaluation of tumour extent, MRI appears to be a valuable imaging technique for left upper lobe and apical neoplasms. Comparison between the two techniques for mediastinal node evaluation showed that sensitivity of MRI is superior to CT in the left paratracheal, aortopulmonary and subcarinal node areas.

Lung transplantation with bronchial revascularisation. Surgical anatomy, operative technique and early results.

Ischaemic anastomotic complications are an important cause of mortality and morbidity after lung transplantation. Anatomical studies have demonstrated that the pattern of bronchial arterial supply is relatively constant and therefore amenable to attempts at revascularisation. From May 1990, 10 patients who had a double lung transplantation (tracheal anastomosis) and 1 patient who had a right lung transplantation underwent concomitant bronchial revascularisation. There were two early and one late deaths. There were no anastomotic complications. Regular endoscopic examination showed satisfactory healing in all patients. Early angiography showed patent grafts in 7 of 9 patients. At a mean follow-up of 11 months (range 6-17 months) 8 patients are well and leading a normal life. This report describes the anatomical basis, technical aspects and early results of a promising operative procedure in the field of lung transplantation.