[A case of pulmonary arteriovenous malformation treated surgically]. / Bisegmentectomie pour une malformation artérioveineuse pulmonaire.

Pulmonary arteriovenous malformation is a rare abnormality consisting of a direct connection between the arteries and the pulmonary veins. Most of the malformations are related to hereditary hemorrhagic telangiectasia, although 10 to 20% cases are idiopathic. Clinical manifestations are due to right-to-left shunting. Embolization is the treatment of choice, when it is possible and accessible. Surgery continues to be appropriate in certain cases. We report the case of a woman who presented with an isolated complex arteriovenous malformation fed by two afferent arteries, a lingular one and an antero-basal one. Surgical treatment by lingual and antero-basal bisegmentectomy was undertaken with a good outcome.

[Primary benign schwannoma of the pleura: Report of 2 cases]. / Schwannome bénin primitif de la plèvre : à propos de deux cas opérés.

The preferred thoracic location of a schwannoma is the posterior mediastinum. A pleural location is very rare. To date there have been fewer than 20 cases in the literature. We report two operated cases of primary benign pleural schwannoma. The first occurred in a 52-year-old woman who presented with right-sided chest pain and chronic cough. The radiological appearance suggested a hydatid cyst of the lower right lobe. The second case concerned a 37-year-old, asymptomatic man with no past history, who presented with a left posterior mediastinal mass, discovered incidentally on imaging. Both patients underwent complete surgical resection via a posterolateral thoracotomy. The final anatomo-pathological investigation revealed two primary benign schwannomas of the pleura.

[Surgery for thoracic tuberculosis]. / La chirurgie dans la tuberculose thoracique.

Tuberculosis is mainly a medical disease. Surgery has been the unique therapeutic tool for a long time before the advent of specific antituberculous drugs, and the role of surgery was then confined to the treatment of the sequelae of tuberculosis and their complications. The resurgence of tuberculosis and the emergence of multidrug-resistant TB combined to immunosuppressed patients represent a new challenge for tuberculosis surgery. Surgery may be indicated for a diagnostic purpose in patients with pulmonary, pleural, mediastinal or thoracic wall involvement, or with a therapeutic purpose (drainage, resection, residual cavity obliteration). Modern imaging techniques and the advent of video-assisted thoracic surgery allowed a new approach of this pathology; the majority of diagnostic interventions and selected cases requiring lung resection can be performed through a mini-invasive approach. Patients proposed for aggressive surgery may be treated with the best results thanks to a good evaluation of the thoracic lesions, of the patients' nutritional, infectious and general status combined with a good coordination between the specialized medical team for an optimal preparation to surgery.

Epicardial cavernous hemangioma: a two-case report.

AIMS: We report two-cases of cavernous hemangiomas arising from the epicardium in two women aged respectively 24 and 79 years old. The first patient was symptomatic and presented with palpitations. The second patient was referred after a random discovery at echocardiography. Chest CT and MRI were performed in the two cases and showed a mass located in the pericardial cavity. Coronary CT was necessary in the first case to ascertain the degree of coronary artery involvement. Both of our patients underwent surgical resection under cardiopulmonary bypass with an uneventful postoperative course for the first case. The second one, died postoperatively from pneumonia. CONCLUSION: Cardiac cavernous hemangiomas, although rare and well tolerated require prompt management and surgery at discovery to avoid further complications which may put at risk the patient's life prognosis.

[Conservative surgery in pulmonary aspergilloma]. / Place de la chirurgie conservatrice dans l'aspergillome pulmonaire.

INTRODUCTION: Pulmonary aspergilloma is a mycotic infection due to the deposit of mycelial fibres, usually in a pre-existing cavity within the lung. Surgical resection is the treatment of choice, with anatomical resection the most practiced technique. Simple aspergillomas are becoming more and more frequent urging this review of the place of conservative surgery. AIM: The aim of this study was to establish the characteristics of aspergillomas which may benefit from a conservative surgery. METHODS: We undertook a retrospective study of 64 cases that were operated on in the thoracic surgery unit in Abderrahmen-Mami Ariana's hospital between 1984 and 2008. RESULTS: Fourteen patients had conservative surgical treatment, with an atypical resection to remove the aspergilloma. The other 50 patients had undergone anatomical resection; segmental resection, lobectomy or pneumonectomy. The perioperative mortality rate was 5%. One case of aspergilloma recurrence had been recorded in a patient who had had conservative surgery for a complex aspergilloma. CONCLUSION: Surgery is the only effective treatment of aspergilloma. Conservative surgery may be an alternative in simple-peripheral forms, which have a diameter less than 4cm.

[Primary heterotopic pleural hydatid cyst presenting as a pneumothorax]. / Un pneumothorax révélateur d'une hydatidose pleurale primitive hétérotopique.

INTRODUCTION: Hydatid cyst is a parasitic disease that is endemic in many countries. Pneumothorax may be a presentation of this disease that presents urgent problems of diagnosis and treatment. CASE REPORT: We report the case of a 23-year-old woman, amenorrheic for 22 weeks, who presented with chest pain and dyspnoea. Chest x-ray revealed a right-sided tension pneumothorax. A check x-ray after drainage showed a homogeneous opacity of water density occupying the lower 2/3 of the right hemithorax. Thoracic ultrasound suggested an uncomplicated hydatid cyst at the right base. Surgical exploration revealed a hydatid cyst 14cm in diameter in the pleural space, and a cavity in the right lower lobe with two bronchial fistulae. Treatment consisted of removal of the cyst intact, closure of the bronchial fistulae and capitonnage of the residual cavity. The postoperative course was uncomplicated. CONCLUSION: Primary heterotopic pleural hydatid cyst is an exceptional cause of pneumothorax that should considered in countries where hydatid disease is endemic. Treatment is surgical following drainage of the pneumothorax.

Is magnesium sulfate by the intrathecal route efficient and safe?

The polypharmacological approach to the treatment of postoperative pain has become routine in an attempt to minimize the adverse side effects of opioids. Magnesium sulphate is a noncompetitive antagonist of the N-methyl-d-aspartate (NMDA) receptor and thus can modify nociceptive modulation. Intravenous administration of magnesium sulphate can improve postoperative analgesia and decrease the requirement for postoperative opiates, but the effects are inconsistent and have not been reliably accompanied by a reduction in the incidence of morphine-related adverse events. Several studies have shown that the administration of magnesium by the intrathecal route is safe and, in combination with opiates, extends the effect of spinal anaesthesia in both animal and human studies. The analysis of these studies justifies further investigation of the use of magnesium sulphate by the intrathecal route.

Cardiac cavernous haemangioma.

BACKGROUND: Cardiac haemangioma was first described in 1893. It is an infrequent and benign neoplasm which accounts for about 2.8% of all benign primary cardiac tumours, arising from the cardiac ventricles, valves, atria and rarely the epicardium. METHODS AND RESULTS: We report the case of a 24-year-old woman with a cardiac haemangioma detected by transthoracic echocardiography, computed tomography, and magnetic resonance imaging. The coronary CT showed a mass located in the pericardial cavity with close relationship to the myocardium. The mass surrounded completely the segments 2 and 3 of the left anterior descending coronary artery. At operation, the tumour was incompletely resected, leaving a remnant in the left anterior descending coronary artery contact, one diagonal branch has been sacrificed. Pathologic study diagnosed a cavernous haemangioma. Transthoracic echocardiography eight months later showed a remnant of haemangioma with a left ventricular ejection fraction estimated to 69%. The coronary CT 10 months after surgery showed the remnant of the tumour with normal cardiac cavities and absence of visualisation of the diagonal artery. The patient is currently asymptomatic and doing well 14 months after surgery. CONCLUSIONS: Cardiac haemangioma is a rare cardiac tumour with an unknown aetiology. The diagnosis is aided by imaging techniques. The coronary CT may be useful when more precise evaluation of the tumour extent is required. It allows specifying the relationship of the mass with the coronary vessels. Successful treatment usually requires timely surgery. However, periodic examinations and echocardiography are recommended.

The effect of adding intrathecal magnesium sulphate to morphine-fentanyl spinal analgesia after thoracic surgery. A prospective, double-blind, placebo-controlled research study.

BACKGROUND: We investigated whether intrathecally magnesium sulphate added to morphine and fentanyl reduces patients' postoperative analgesia requirements and prolongs spinal opioid analgesia after thoracotomy. METHODS: In a single-center, prospective, placebo-controlled, double-blind trial, we enrolled 58 adult patients undergoing elective posterolateral thoracotomy. Patients were randomized to receive either 25 µg of fentanyl citrate (0.5 mL)+300 µg of morphine+1.0 mL of preservative-free 0.9% sodium chloride (Group S) or 25 µg of fentanyl citrate (0.5 mL)+300 µg of morphine+50mg of magnesium sulphate 5% (1.0 mL) (Group MgSO(4)) for intrathecal analgesia. Opioid consumption and postoperative pain were assessed for 36 hours. RESULTS: VAS pain scores at rest and on coughing were similar in all groups. The total 36-h intravenous morphine requirements were significantly lower in group MgSO(4) (14 [9.50-26.50] mg vs. 33 [30-41] mg, p<0.001); i.e. 57% less for the group MgSO(4). The total dose of intravenous morphine administered during titration was significantly lower in this group (4 [2-8] mg vs. 8 [6-10] mg, p=0.001). Morphine consumption was significantly lower in the group MgSO(4) at intervals 0-12, 12-24 and 24-36 h. The number of patients requiring titration was significantly lower in group MgSO(4) (68% vs. 96%, p=0.001). There is no difference in opioid side effects. No patient experienced side effects resulting from lumbar puncture, or neurological deficit or signs of systemic magnesium toxicity. CONCLUSION: We found that in patients undergoing pulmonary resection with elective posterolateral thoracotomy, magnesium sulphate (50mg), when added to spinal morphine analgesia reduces postoperative morphine requirements, the number of patients requiring morphine titration without increasing opioid side effects.

A prospective, randomised comparison of continuous paravertebral block and continuous intercostal nerve block for post-thoracotomy pain

ABSTRACTBackground: This study aimed to compare paravertebral block and continuous intercostal nerve block after thoracotomy.Methods: Forty-six adult patients undergoing elective posterolateral thoracotomy were randomised to receive either acontinuous intercostal nerve blockade or a paravertebral block. Opioid consumption and postoperative pain were assessedfor 48 hours .Pulmonary function was assessed by forced expiratory volume in 1 s (FEV1) recorded at 4 hours intervals.Results: With respect to the objective visual assessment (VAS), both techniques were effective for post thoracotomy pain.The average VAS score at rest was 29±10mm for paravertebral block and 31.5±11mm for continuous intercostal nerve block.The average VAS score on coughing was 36±14mm for the first one and 4 ±14mm for the second group.Pain at rest was similar in both groups. Pain scores on coughing were lower in paravertebral block group at 42 and 48hours. Post-thoracotomy function was better preserved with paravertebral block. No difference was found among the twogroups for side effects related to technique, major morbidity or duration of hospitalisation.Conclusion: We found that continuous intercostal nerve block and paravertebral block were effective and safe methods forpost-thoracotomy pain