[Emergency interventional bronchoscopies]. / Bronchoscopies interventionnelles en urgence.

An emergency interventional endoscopic procedure is often the only way to overcome an asphyxic or pre-asphyxic situation. From November 1978 to June 2010 we performed 9950 interventional endoscopies among which 20% were performed in an emergency context. To obtain a homogeneous study group, we reviewed the last four years. 344 interventional emergency endoscopies were done for the following indications: cancers (n=240, 70%), iatrogenic stenosis (n=63, 18%), foreign bodies (n=29, 8.5%), hemoptysis (12, 3.5%). The same technique was used in all cases: operating room, general anesthesia, rigid bronchoscope, laser, cryotherapy. Outcome was favorable in 85% of cancers and 100% in all other indications. Apart from clear-cut cases, it remains difficult to define the true emergency. Whatever the definition retained, a well-trained anesthetic and endoscopic team is crucial for proper intervention in these potentially life-threatening situations.

A multicenter retrospective study investigating the role of interventional bronchoscopic techniques in the management of endobronchial lipomas.

BACKGROUND: Pulmonary lipomas are rare benign tumors that are usually found endobronchially. Undiagnosed, they can lead to the serious late sequelae associated with endobronchial obstruction. In the majority of cases, they are located in the first three subdivisions of the tracheobronchial tree, and therefore, they are amenable to endoscopic techniques for diagnostic and therapeutic purposes. OBJECTIVES: It was our aim to retrospectively study the bronchoscopic management and follow-up of a large series of endobronchial lipomas, as well as defining the demographic and endoscopic characteristics of patients. METHODS: A retrospective multicenter study was performed to identify all cases of lipomas that were treated endoscopically in 4 institutions in the period from 1981 to 2002. Demographic, radiological, endoscopic and histological data were collected. RESULTS: Thirty-eight patients were included in the study; 81.6% of cases were males and the average age was 63.5 +/- 15.2 years. The majority of the patients were symptomatic (63.2%). Lipomas were located proximally in 18 cases (47.4%) and distally in 20 subjects (52.6%). Specimens obtained by rigid bronchoscopy were diagnostic in all cases. Thirty-six out of 38 patients underwent therapeutic rigid bronchoscopy. Laser and mechanical debulking was performed in 29 cases (76.3%), cryotherapy and mechanical debulking in 7 subjects (18.4%), and mechanical debulking alone in 2 cases (5.3%). No cases of recurrence occurred during the follow-up period. CONCLUSIONS: This study demonstrates that endoscopic techniques are effective for the diagnosis and treatment of endobronchial lipomas when there is no evidence of severe distal bronchiectasis. This should be the treatment of choice after a full clinicoradiological evaluation.

[Diagnostic flexible bronchoscopy. Recommendations of the Endoscopy Working Group of the French Society of Pulmonary Medicine]. / Les bonnes pratiques de la bronchoscopie souple diagnostique, en 2007.

These guidelines on flexible bronchoscopy depict important clues to be known and taken into account while practicing flexible bronchoscopy, in adult, except in emergency situations. This is a practical clarification. Safety conditions, complications, anesthesia, infectious risks, cleaning and disinfection are detailed from a review of the literature. Intensive care practice of bronchoscopy requires more attention due to higher risks patients and is discussed extensively. Standards and performances of the various sampling techniques complete this work. Indications for bronchoscopy, therapeutic and paediatric bronchoscopy are not covered in these guidelines.

[Inflammatory pseudotumor: a rare cause of proximal bronchial obstruction]. / Une cause rare d'obstruction bronchique proximale récidivante: la pseudo-tumeur inflammatoire.

Inflammatory pseudotumor of the lung is a rare disease with usual benign course. Relapse after incomplete resection and aggressive forms have already been described. We report the case of a 67-year-old woman with atelectasis of the left lung related to an endobronchial inflammatory pseudotumor. After laser resection, relapse occurred 3 months later, requiring surgical treatment.

[The place of interventional endoscopy in the treatment of lung cancer]. / Place de l'endoscopie interventionnelle dans le traitement du cancer bronchique.

Interventional endoscopy, by eliminating an obstacle compromising the survival of a patient, has its place in the treatment of bronchial cancer whatever its stage of evolution. Forty percent of patients have not been treated yet, 30 still have therapeutic possibilities at the time of their relapse and for 30% all the possible treatments have been administered and interventional endoscopy remains their only chance of survival. A strict operational protocol ensures safety: operating theatre, general anaesthesia, rigid bronchoscopy, jet-ventilation, post-surgery ICU, and systematic post-surgery fibroscopy. Eighty percent of the patients retrieve normal ventilation. 12% are not sufficiently improved and 3% die either from uncontrollable haemorrhage or from the impossibility of repermeation. The nature of the tumour (primary bronchial cancer, metastasis at distance, invasion from a surrounding cancer) does not enter into the decision to intervene. The benefits of the latter are assessed by the pneumologist or oncologist who is in charge of the patient, but the final decision to intervene naturally remains with the endoscopist.

[Myxoid liposarcoma of the mediastinum]. / Liposarcome myxoïde du médiastin.

We describe a mediastinal myxoid liposarcoma case in a 47-year-old woman who complained of dyspnea. This kind of tumor is rare and becomes symptomatic by compression on mediastinal structures, especially on the respiratory tract. These neoplasms are therefore often voluminous at the time the diagnosis is made. Histopathologic examination is always necessary as much for diagnosis as prognosis. Surgery, whether radical or palliative, obtain the best therapeutic survival results in myxoid liposarcoma of the mediastinum.

[Tracheal resection-anastomosis for iatrogenic stenosis. Experience in 340 cases]. / Résection-anastomose trachéale pour sténose iatrogène. Une expérience de 340 cas.

Since 1975, 340 patients were treated by tracheal sleeve resection for tracheal or subglottic laryngeal iatrogenic stenoses in our unit. Preoperative iterative Nd YAG laser sessions have usually been performed, without success. The length of the sleeve specimen was an average of 3 1/4 cm. Twelve patients died on the post operative course (3.5%), 3 more patients died later after failure of the procedure (0.9%) and nineteen had recurrent stenoses treated with use of a tracheostomy tube, a permanent Montgomery tube, or an endotracheal stent (5.6%). Three hundred and six patients are definitely cured (90%), at the first attempt for 265 patients, after a laser session for granulomas for 20 patients, after a second tracheal resection for 6 patients and after a temporary Montgomery tube for 15 patients. Providing there is a good selection of the patients, tracheal sleeve resection is the best treatment for iatrogenic stenosis.

[Reduction of native lung volume after single-lung transplantation for emphysema]. / Réduction de volume du poumon natif après transplantation unipulmonaire pour emphysème.

We report three cases of volume reduction surgery in three single lung transplant recipients with emphysema. Each patient had a late decline in lung function with hyper-inflation of the native lung. Lung function was improved post-operatively for two patients. The relief of thoracic overdistension may be considered in single lung transplant recipients who exhibit clinical significant functional deterioration.

[Medical device surveillance]. / La matériovigilance.

The medical device vigilance system was set up in France in line with European directives. It consists of reporting of incidents or risks of incidents related to medical devices, evaluation of information, follow-up of files and conduct of device safety studies. Health establishments must appoint a local medical device vigilance correspondent responsible for sending declarations to the ministry. The Ministry of Health centralizes and evaluates the various declarations. The national medical device vigilance commission and the eight technical subcommittees consequently play an advisory role to the Minister of Health. When decided by the Minister, manufacturers of medical devices for which a declaration has been submitted may be required to modify them or withdraw them from the market. Medical device vigilance is therefore now an integral part of clinical practice.

[Bronchial anastomotic complications after pulmonary transplantation. X-ray computed tomographic evaluation]. / Complications anastomotiques bronchiques après transplantation pulmonaire. Evaluation tomodensitométrique.

PURPOSE: To determine the sensitivity and specificity of CT in depicting bronchial anastomotic complications after lung transplantation. MATERIALS AND METHODS: A retrospective, blinded review of 105 CT scans obtained after single (n = 17) or double (n = 10) lung transplantation in 27 patients was done by two radiologists in consensus. CT images, were analyzed with respect to the status of bronchial anastomoses, with three possible answers given to the readers: normal, dehiscence, or stenosis. CT features were correlated to bronchoscopic and follow-up findings, which were considered as standard of reference. RESULTS: CT had a 60% sensitivity and 98% specificity for the diagnosis of bronchial dehiscence, and 40% and 99% for the diagnosis of anastomotic stenosis. One case of bronchial disruption was diagnosed on CT scan only and subsequently confirmed by repeated bronchoscopy. CONCLUSION: In our study, CT has a low sensitivity but a high specificity in the detection of bronchial anastomotic complications after lung transplantation. However, CT remains useful in some cases, as it can show complications not seen bronchoscopically.

Bilateral pulmonary lobe transplantation: left lower and right middle and lower lobes.

It is difficult to find lungs of appropriate size for double-lung transplantation in teenagers and small adults. Nevertheless, many young patients suffering from cystic fibrosis are waiting for lung transplantation. We have performed two bilateral lobar transplantations (left lower lobe plus right middle and lower lobe) with good recovery. Details of the technique are described.

[Healing of bronchial anastomoses in single and double pulmonary transplantations]. / La cicatrisation des anastomoses bronchiques dans les transplantations uni- et bipulmonaires.

Bilateral single lung transplantation (BSLT) (the procedure of choice for double lung replacement) and single lung transplantation (SLT) have at present a low incidence of anastomotic problems. In our experience, we have recorded no death related to anastomotic problems and 4 complications occurred for 33 anastomoses with a follow up of at least 2 months. A stent was temporarily inserted for two patients. The decrease of anastomotic complications is confirmed in the literature. It is one of the reasons why the number of SLT and BSLT performed all over the world increases rapidily to the detriment of heart lung transplantation.

Tracheal sleeve resection for iatrogenic stenoses (subglottic laryngeal and tracheal).

Since 1975 200 tracheal sleeve resections for iatrogenic tracheal and subglottic laryngeal stenoses have been performed in our institution. Preoperative Nd:YAG laser is of paramount help in opening the stenoses. Tracheography is usually performed to specify the length of the stenosis and the distance from the vocal cords. Operative procedures are described. One hundred seventy five (87.5%) patients are definitely cured, but in this group 16 patients required a Montgomery tube for 6 months to 1 year to recover a normal tracheal diameter. Two patients needed a second tracheal sleeve resection. Nine (4.5%) patients died, and 16 (8%) had recurrent stenoses. Stenoses in these patients were treated with use of a tracheostomy tube, a permanent Montgomery tube, or an endotracheal stent. Partial anterior cricoid resections performed in 21 patients have had the same results as those of the whole series. Twenty one laryngeal releases were performed and proved to be efficient and safe. In our experience complications can be avoided by good selection and preparation of the patients, accurate identification of the level and length of the stenosis, and meticulous technique.

Physiologic studies of tracheobronchial stents in airway obstruction.

When airway obstruction is due to extraluminal compression and/or dynamic collapse, metal and silicone rubber prosthetic stents may stabilize the affected airway. Through a rigid bronchoscope, we inserted three metal stents in two patients and 18 silicone stents in 15 adult patients with symptomatic tracheobronchial compression and dynamic airway collapse. The underlying cause was malignancy in three patients; benign tracheobronchial malacia in three patients, two of whom refused surgical resection; and tracheobronchial stenosis that developed at the anastomotic site following lung transplantation in 11 patients. Clinical status and lung function studies were analyzed before and after stent insertion. Following stent insertion, airway diameter at least doubled and near normal patency of the affected tracheobronchial tree was achieved in every patient using stents of axial length 4 to 5 cm. The stents were well tolerated clinically, and all patients noted immediate relief of dyspnea. Following stent insertion, the forced vital capacity (FVC) increased from 64 +/- 21% predicted (mean +/- 1 SD) to 73 +/- 19% predicted, p less than 0.1; the forced expiratory volume in 1 s (FEV1) from 49 +/- 25% predicted to 72 +/- 26% predicted, p less than 0.02; the ratio of the FEV1/FVC from 59 +/- 16% to 78 +/- 15%, p less than 0.01; and the maximum flow at 50% expired FVC from 38 +/- 26% predicted to 72 +/- 31% predicted, p less than 0.01.

Bilateral single lung transplantation. Complications and results in 14 patients.

Between November 1989 and April 1991, 14 bilateral single lung transplantations (BSLT) were performed at our institution using the technique we have described without omentoplasty and rarely cardiopulmonary bypass. The indications included emphysema (8), cystic fibrosis (3), infected fibrosis (1), alveolar microlithiasis (1) and lymphocytic interstitial pneumonitis (1). Maximum mean pulmonary artery pressure was 53 mmHg and minimal right ventricular ejection fraction was 15%. Two patients experienced bronchial complications: 1 complete left bronchial dehiscence, 1 late partial stenosis which required a temporary insertion of a stent. One patient had a posterior dehiscence which healed spontaneously. Five patients died postoperatively (3 of infection, 1 after a volume mismatch and 1 after a circulating anticoagulant). BSLT is the technique of choice for double lung transplantation in adults and heart lung transplantation has very few indications in infected end-stage pulmonary disease. We hope that modification of our immunosuppressive regimen will decrease postoperative mortality.

Left lower lobe transplantation during a bilateral single lung transplantation (pulmonary lobe transplantation).

An isolated left lower lobe was used as a left graft, during a bilateral single lung transplantation procedure, in a patient with infected fibrosis. This technique is suitable for patients with small lung volume (especially cystic fibrosis) or asymmetric retraction.

[Single lung transplantation]. / La greffe unipulmonaire.

Thirteen single lung transplantations have been performed in our department for non-infected end-stage lung diseases. Two patients died after surgery; a female patient died of uterine carcinoma one year and six months after the operation. The remaining ten patients are alive; they have resumed an active life and often working. The number of single lung transplantation is rapidly growing in the world, whereas heart-lung transplantation is regressing considerably.

[Donor-recipient lung volume matching in double lung transplantation. Value of left lower lobe graft]. / Adéquation volumétrique donneur-receveur en greffe bipulmonaire. Intérêt de la greffe lobaire inférieure gauche.

For double lung transplantation, lung volume matching is easier comparing the predicted total lung capacities of the donor and recipient and the recipient's true TLC. The major concern in the inability to close the chest when the donor lungs are too large. The technique reported of left lower lobe implantation during bilateral single lung transplantation might be of great value in patients with small lung volume.