Cardiac surgery and repair of pectus deformities: When and how?

OBJECTIVES: There is currently a lack of recommendations about patients with pectus deformities requiring cardiac surgery. This study reports the results of our surgical strategy on this issue. METHODS: Eleven patients, from three centers treated over a 9-year period were included in this study. Pectus deformities were operated with a modified Ravitch procedure. In the case of pectus excavatum repair and concomitant cardiac surgery, subperichondrial resection of abnormal rib cartilages was always performed before the sternotomy and an easily removable retrosternal metallic strut was inserted at the end of the procedure ensuring anterior chest wall stability. During follow-up patients had to estimate their current appearance with a numeric scale ranging from 0 to 100. RESULTS: Mean age was 27 ± 9.4 years. Pectus excavatum was present in 8 patients and pectus arcuatum in 3. There were 6 Marfan syndrome patients. Nine patients had concomitant surgery and, 2 underwent pectus repair after a history of cardiac surgery. There was no operative mortality. In the case of concomitant surgery, heart exposure through median sternotomy was facilitated by abnormal rib cartilage resection. Median follow-up was 54 months (range 16.7-119.7). Mean cosmetic result evaluated by the patients was 97.3 (±2.5). CONCLUSIONS: In adults, concomitant scheduled surgery is reliable and offers excellent long-term cosmetic results. Moreover, it allows a better thoracic exposition with no added perioperative risk. The modified Ravitch technique seems more adequate in these patients as it can be used in all types of pectus deformities.

Adjuvant antifungal therapy after pulmonary surgery for aspergilloma: is it useful?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether adjuvant antifungal therapy is useful after pulmonary surgery for aspergilloma. One hundred and sixteen papers were identified using the search described below, of which 5 papers presented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. No paper was greater than level-three evidence. One study compared the outcomes of 72 patients treated for pulmonary aspergilloma (PA) during a 23-year period. Despite no difference being found in outcomes, more complications were seen in the surgery-alone group. Another study included 14 patients treated with amphotericin B alone or with flucytocine. They found no benefit in the treatment of PA by systemic antifungal therapy. One retrospective study reported complete eradication of PA in patients treated with preoperative and postoperative oral itraconazole. One large cohort study reported their outcomes in 256 patients with PA, divided into two groups: Group A (simple aspergilloma, n = 96) and Group B (complex aspergilloma, n = 160) after aggressive surgical treatment and antifungal therapy. They found no difference in the postoperative morbidity between two groups (P = 0.27). A postoperative fungal relapse was found in 2 patients. One retrospective study reported the outcomes and mortality in 61 cases with PA. Thirty-five (60%) patients were treated with antifungal agents, and 15 (25%) patients were treated surgically. Many cases did not respond to antifungal therapy. Nineteen (31%) patients died. We did not find evidence to support the role of adjuvant antifungal therapy following definitive surgical removal of the fungus ball in immunocompetent patients; however, randomized control studies in multiple centres, with new antifungal therapy, are necessary to confirm these preliminary results.

Harvest technique for pedicled intrathoracic transposition of pectoralis major muscle.

Residual upper pleural spaces after subtotal pulmonary resection continues to pose great challenge for the thoracic surgeon. Although not all residual spaces deserve surgical attention, only in special situation (empyema with or without bronchopleural fistula). It increases morbidity, mortality, hospital stays, and costs. Transposition of extrathoracic muscle flaps has been the cornerstone of treatment of this complication. Sometimes use of latissimus or serratus muscle might have been compromised by the incision for the original operation. In this situation the pectoralis major muscle flap (PMF) can be used successfully to reach and obliterate upper residual pleural space by anterior approach. The technique has never been specifically described before in the literature. We describe our technique for mobilization of PMF by anterior approach to obliterate residual upper space after major pulmonary resections.

Primary pulmonary myoepithelial carcinoma.

Primary salivary gland-type tumors of the lung are rare neoplasms. The pulmonary myoepithelial carcinoma belongs to this group. Since it was first described in 1998, we have identified only seven actual cases reported in the literature so far. We describe the case of a non-smoker 60-year-old Caucasian female, who was referred to our institution for the treatment of three peripheral nodules. Her medical history revealed that a wedge resection, for pulmonary myoepithelial carcinoma, was performed in another center 15 months previously. After resection of the current nodules, the histological findings showed three myoepithelial carcinomas of the lung. There was no vascular or lymphatic invasion. The hilar and mediastinal lymph nodes were negatives. The patient is doing well without any sign of recurrence. Herein we shall discuss the case of a primary pulmonary myoepithelial carcinoma in a female and propose a brief review of the literature.

Cardiopulmonary response following surgical repair of pectus excavatum in adult patients.

OBJECTIVE: Severe pectus excavatum are common in adult patients, often causing psychological complaints and physiological impairments. Although lung function at rest may minimally deteriorate after surgical correction, it remains unclear if surgery improves exercise capacity. The objective of present study is to assess whether the surgical repair of pectus excavatum in adults would improve exercise tolerance. METHODS: A prospective study was performed to compare pulmonary and cardiovascular function at rest and at maximal exercise, before, and at 1 year after pectus excavatum repair. RESULTS: From December 2005 to May 2009, 120 adult patients underwent pectus excavatum repair. Of these patients, 70 (nine women, 61 men) underwent thorough preoperative, 6-, and 12-month postoperative assessments, and were included in the present study. Age ranged from 18 to 62 years (mean 27 years). The pectus index (Haller index) was 4.5 ± 1.1. Lung function tests at rest were within the normal range, whereas maximal oxygen uptake (peak VO2) was only 77 ± 2% of the predicted value. At 1-year follow-up, the pectus excavatum repair was associated with minor changes in lung function tests and significant increase (p=0.0005) in VO2 (87 ± 2% of the predicted value). Postoperative O2 pulse increase at maximal exercise suggested that aerobic capacity improvement was the result of better cardiovascular adaptation at maximal workload. CONCLUSION: These results demonstrate sustained improvement in exercise cardiopulmonary function at 1-year follow-up of pectus excavatum surgical repair in adult patients.

Postoperative ischemic bronchitis after lymph node dissection and primary lung cancer resection.

BACKGROUND: The purpose of this study was to determine the incidence and symptoms of postoperative ischemic bronchitis (POIB) after systematic lymph node dissection (LND) and evaluate the effect of hyperbaric oxygen therapy in patients with primary lung cancer. METHODS: From January 2004 to December 2009, 1,071 patients underwent a standard resection for non-small cell lung cancer and radical systematic lymph node dissection. Fiberoptic bronchoscopy was performed systematically between days 7 and 12. We analyzed the clinical and biologic signs of POIB. Once the diagnosis established a treatment by hyperbaric oxygen, therapy was undertaken. RESULTS: A POIB was observed in 34 patients (3.21%) (2 women and 32 men). Mean age was 59 ± 10 years (range, 25 to 79 years). A POIB occurred within 8 ± 3 days; after right pulmonary resection (n = 21; 62%) and after left resection (n = 13; 38%). A POIB appeared asymptomatically for 27 patients (80%), whereas only 7 patients (20%) presented with fever and hyperleukocytosis. Their localization were bronchial stumps (n = 21; 62%), homolateral bronchial tree (n = 11; 32%), or extension toward the contralateral bronchial tree (n = 2; 6%). The mean number of hyperbaric oxygen therapy sessions was 14 (1 to 48). A POIB worsening was observed in 6 patients (18%), requiring a surgical rescue therapy. CONCLUSIONS: The clinical presentation of POIB is poor and systematic fiberoptic bronchoscopy should be performed, especially in patients with a high risk of bronchopleural fistula. Hyperbaric oxygen therapy in the management of ischemic bronchitis may be a promising adjunctive treatment.

Postpneumonectomy cavity herniation through an intercostal space.

Mediastinal shift is common after pneumonectomy and herniation of the remaining lung into the opposite hemithorax has consequently been reported. In this case, we present the herniation of the pneumonectomy cavity contained by the calcified pleura through an intercostal space, in a patient who has undergone a left pneumonectomy 47 years previously. We repaired the intercostal muscular defect using a Mersuture mesh. The patient did well and there was no postoperative pain.

Indications and results of anterior mediastinal tracheostomy for malignancies.

BACKGROUND: This study was designed to assess the early and long-term results, and determine suitable indications of anterior mediastinal tracheostomy, after radical resection for cervicothoracic malignancies. METHODS: From 1985 to 2009, 13 patients ranging in age from 40 to 75 years underwent an anterior mediastinal tracheostomy for malignancy, 2 as an isolated procedure, 5 with concomitant laryngectomy, and 6 with concomitant laryngopharyngoesophagectomy. The patients had subglottic carcinoma, proximal tracheal carcinoma invading the subglottic larynx (n = 6), stomal recurrence following laryngectomy (n = 4), esophageal carcinoma invading the proximal trachea (n = 2), or tracheal recurrence after conventional resection (n = 1). The postoperative course and outcome were assessed in all patients. RESULTS: In 5 patients, the postoperative course was uneventful. There were 2 in-hospital deaths, and 6 patients experienced nonfatal complications including three pharyngocutaneous fistulas, two pharyngogastric or pharyngocolic anastomotic leaks, and one pulmonary embolism. Satisfactory airway was achieved in 7 patients presenting with proximal obstruction, and ability to tolerate oral feeding, in 2 patients with esophageal carcinoma. The mean follow-up time for survivors was 89 months (range, 9 to 201 months). Patients with esophageal carcinoma or recurrence of tracheal carcinoma showed a poor outcome. In contrast, in the subgroup of patients with head and neck malignancy, 3-year and 5-year survival rates were 57% and 43%, respectively. CONCLUSIONS: Our results and survival analysis from the literature suggest that suitable indications for anterior mediastinal tracheostomy are (1) carcinoma of the subglottic region or proximal trachea invading the subglottic larynx, (2) stomal recurrence after laryngectomy, and (3) well-differentiated thyroid carcinoma invading the trachea or recurrence.

Results of systematic nodal dissection in typical and atypical carcinoid tumors of the lung.

BACKGROUND: To determine the lymphatic spread frequency and location in patients, who underwent lung resection for carcinoid tumors, associated with systematic nodal dissection. METHODS: From January 1998 to June 2007, 54 patients underwent anatomic lung resection associated with systematic nodal dissection for tumors classified as typical (TC) or atypical carcinoid according to 1999 World Health Organization criteria. The number and location of the resected lymph nodes were specified. All patients were followed up. RESULTS: All patients underwent complete resection (R0) that were anatomic in 32 patients (59.2%), and associated with a bronchoplastic procedure in 22 (40.8%). Low morbidity was related to lymphadenectomy. The mean number of resected lymph nodes was of 18 (range, 7-44) per patient, which pathologic studies demonstrated lymphatic spread in 10 patients (18.5%). In the TC group (n = 42) 2 patients were classified N1 (4.8%) and 4 N2 (9.5%). In the atypical group (n = 12) 2 patients were classified N1 (16.6%) and 2 N2 (16.6%).Five of the 6 N2 patients showed a single skip metastasis not discovered by preoperative evaluation (83.3%).The lymphatic spread was correlated with age < or = 35 years (p = 0.01) and a tumor size > or = 3 cm (p = 0.002).Median follow-up was 57 months. Nine patients with lymphatic spread are disease free and one died from metastatic disease at 52 months. CONCLUSION: Systematic nodal dissection showed a high frequency of unpredictable lymphatic spread, mainly in the TC group. This procedure is mandatory to treat carcinoids in a curative intent.