Adrenocortical carcinomas: surgical trends and results of a 253-patient series from the French Association of Endocrine Surgeons study group.

Because of the rarity of adrenocortical carcinoma, survival rates and the prognosis for patients who have undergone operation are not well known. The purpose of the French Association of Endocrine Surgery was to evaluate these factors over an 18-year period. A trend study was associated to assess changes in the clinical and biochemical presentations as well as the surgical evolution. A total of 253 patients (158 women, 95 men) with a mean age of 47 years were included. Cushing syndrome was the main clinical presentation (30%), and hormonal studies revealed secreting tumors in 66% of the cases. Altogether, 72% (n = 182) of patients underwent resection for cure, and 41.5% (n = 105) of them had an extensive resection because of metastatic cancer. A lymphadenectomy was performed in 32.5% (n = 89) of the cases. The operative mortality was 5.5% (n = 14). Patients were given mitotane as adjuvant therapy in 53.8% of the cases (n = 135). The results of staging were stage I in 16 patients (6.3%), stage II (local disease) in 126 patients (49.8%), stage III (locoregional disease) in 57 patients (22.5%), and stage IV (metastases) in 54 patients (21.3%). Neither tumor staging nor the rate of curative surgery changed during the study period. More subcostal incisions were performed, and the use of mitotane increased significantly. The 5-year actuarial survival rates were 38% overall, 50% in the curative group, 66% for stage I, 58% for stage II, 24% for stage III, and 0% for stage IV. Multivariate analysis showed that mitotane benefited only the group of patients not operated on for cure. A better prognosis was found in patients operated on after 1988 (p = 0.04), in those with precursor-secreting tumors (p = 0.005), and in those at local stages of the disease (p = 0.0003). Thus mitotane benefited only patients not operated on for cure. Curative resection, precursor secretion, recent diagnosis, and local stage were favorably associated with survival.

In vitro endothelialization of PTFE vascular grafts: A comparison of various substrates, cell densities, and incubation times.

To establish the optimal conditions for achieving endothelial cell coverage of the luminal surfaces of small-caliber vascular grafts in vitro, the attachment of endothelial cells (ECs) cultured from human umbilical veins to polytetrafluoroethylene (PTFE) grafts was studied. Cell attachment and spreading were compared after PTFE grafts were (a) precoated with fibronectin (HFN), type I collagen, type IV collagen, plasma and fibrin with or without thrombin, singly or in combination; (b) seeded with cell densities varying from 0.5 x 10(5) to 6 x 10(5) cells/cm2; and (c) incubated at 30, 60, or 90 min. Cell coverage and spreading were assessed by means of scanning electron microscopy. Quantification of graft surface coverage was performed with computer-assisted image analysis. To determine optimal conditions of endothelialization among the 189 treatment combinations, analysis of variance was used. We conclude that a virtually confluent cell monolayer can be established on small-caliber PTFE grafts when precoated with fibrin glue or plasma, seeded with cell densities >/=4 x 10(5) cells/cm2, and incubated for 60 min. These parameters are compatible with an operating room vascular procedure.

Femorodistal bypass using cryopreserved venous allografts for limb salvage.

Critical ischemia due to extensive femoropopliteal occlusive disease often leads to amputation in patients in whom an autologous vein is unavailable for reconstruction. The purpose of this nonrandomized prospective study is to evaluate the usefulness of cryopreserved venous allografts (CPVA) as an arterial substitute in these cases. Between October 1990 and March 1993, long bypass to a tibial or a foot artery using a CPVA was performed in 25 consecutive patients with ulcerations or gangrene. There were 19 women and six men with a mean age of 72 years (range: 51-90). The indication for allograft reconstruction was absence (17 cases) or unsuitability (eight cases) of an autologous vein graft. Greater saphenous vein allografts were harvested from multiple organ donors and frozen at -80 degrees C with 12% dimethylsulfoxide (DMSO). Sixteen patients had undergone one or more previous unsuccessful limb salvage attempts. The plantar arch was absent or incomplete in 16 patients (64%). Patients were followed up prospectively for a mean of 21 months (range: 3-32). One patient died early (32 days) and three patients died late with patent bypasses. Cumulative survival rate was 77% at 1 year and 72% at 2 years. Cumulative secondary patency rate (Kaplan-Meier) was 88% at 1 months, 72% at 6 months, and 52% at 1 year. The cumulative limb salvage rate was 78% at 2 years. When an autologous vein is unavailable, long bypass using a CPVA is a simple, quick, minimally traumatic, economical, and effective method to achieve limb salvage in patients with severe distal arterial occlusive disease. However, CPVA causes immunoreaction and there is a risk of proximal postanastomotic stenosis. Doppler ultrasound surveillance of a subcutaneous graft allows accurate assessment and repair of the abnormalities with no increase in mortality or morbidity.

Pulmonary retransplantation: does the indication for operation influence postoperative lung function?

OBJECTIVE: An international series of pulmonary retransplantation was updated to determine the factors associated with pulmonary function, bronchiolitis obliterans syndrome stage, and survival after operation. METHODS: One hundred sixty patients underwent retransplantation in 35 centers from 1985 to 1995. Logistic regression methods were used to determine variables associated with 3-month and 2-year survival after retransplantation. Values of forced expiratory volume in 1 second were contrasted between groups by unpaired, two-tailed t tests. RESULTS: The median follow-up in surviving recipients was 780 days. Actuarial survival was 45% +/- 4%, 41% +/- 4%, and 33% +/- 4% at 1, 2, and 3 years, respectively. On multivariable analysis, the only predictor of 3-month survival was preoperative ambulatory status (p = 0.005), whereas center experience with at least five pulmonary retransplantations was the sole predictor of 2-year survival (p = 0.04). The prevalence of stage 3 (severe) bronchiolitis obliterans syndrome was 12% at 1 year, 15% at 2 years, and 33% at 3 years after retransplantation. Retransplant recipients with stage 3 bronchiolitis obliterans syndrome at 1 year had a significantly worse actuarial survival than those with stages 0 to 2 (p < 0.01). By 3 years after retransplantation, the forced expiratory volume in 1 second was significantly lower in patients who underwent reoperation because of obliterative bronchiolitis than in patients who underwent retransplantation because of acute graft failure or an airway complication (p = 0.02). Only 31% of patients who underwent retransplantation because of obliterative bronchiolitis were free of bronchiolitis obliterans syndrome at 3 years versus 83% of patients who underwent retransplantation because of other indications (p = 0.02). CONCLUSIONS: Preoperative ambulatory status predicts early survival and center volume predicts intermediate-term outcome after retransplantation. Improved management strategies are necessary to prevent the development of progressive graft dysfunction after retransplantation for obliterative bronchiolitis.

Elution of six antibiotics bonded to polyethylene vascular grafts sealed with three proteins.

The elution of six antistaphylococcal antibiotics from vascular polyethylene grafts sealed with albumin, gelatin, or collagen were studied in an in vitro system. The antibiotics tested were pefloxacin, vancomycin, teicoplanin, fusidic acid, pristinamycin, and rifampicin. The grafts were impregnated by simple soaking in antibiotic (1 mg/ml). The data were fitted to an exponential model and antibiotic half-lives (t1/2) were calculated from the regression lines. All the antibiotics tested were bound to the protein sealants. Antibiotic release varied with the type of antibiotic and the sealant. Rifampicin was eluted most slowly, particularly with albumin- and gelatin-sealed grafts, with t1/2 at 4-5.5 hr and antibiotic activity was still found at 48 hr. The glycopeptides were also eluted more slowly from albumin or gelatin sealant than from collagen. Although large quantities of glycopeptides were initially bound, they were quickly eluted (t1/2 = 30-44 min) and there was no residual antibiotic activity at 24 hr. Pefloxacin, pristinamycin, and fusidic acid bound to collagen or gelatin sealants were the most rapidly eluted, with t1/2 of 3-14 min, but they were eluted more slowly from albumin-sealed grafts, with t1/2 of 22-90 min. In vitro studies can be useful for evaluating the binding of antibiotics to protein-sealed grafts before animal experiments or human testing.

[Pulmonary emphysema: surgical indications]. / Emphysème pulmonaire: indications chirurgicales.

Surgery for pulmonary emphysema, with the exception of lung transplantation, is limited at present to resection of the emphysematous areas. The resection of a unique bulla within an otherwise healthy parenchyma can be indicated in case of complications but rarely in asymptomatic patients. When the bullae are large (i.e. volume greater than one-third of the hemithorax) in a patient suffering from diffuse emphysema, bullectomy is the ideal indication. Mortality varies from 0 to 10%, essentially due to infection or acute respiratory failure. In most patients, the subjective improvement in terms of dyspnea and the objective improvement as measured by spirometry remains significative up to 5 years after surgery. Inversely, surgical resection is classically considered to be contraindicated in patients with small poorly-limited bullae. Recent data would however question this idea since subjective and objective improvement after reduction of the lung volume is still present 1 year after surgery in most patients, even those with severe obstruction. The mechanism is probably related to increased elastic recoil. Even if only temporary improvement can be achieved for a few years, the persisting course of emphysema would suggest that volume reduction should always be entertained as an alternative before lung transplantation.

[Blood salvage: a conditional safety]. / Récupérateurs de sang: une sécurité conditionnelle.

Recovery of shed blood is part of the allogenic blood saving policy of particular importance even though the risk of viral infection via transfusion has been considerably reduced. Blood transfusion requirements in vascular surgery are discussed together with alternatives to allogenic transfusion. Differed withdrawal of autologous blood can involve pre-operative autologous plasmapheresis and cytapheresis. Per-operative haemodilution is another variant of pre-operative isovolemic haemodilution and erythrocytapheresis. Recovery of shed blood can be done with or without lavage. Technical and pharmacologic measurements complete the method. Simultaneous use of different techniques can be useful. Recovery is particularly interesting in highly haemorhagic vascular procedures or those which must be done quite rapidly. Care must be taken to avoid the "recovery syndrome". Improvement in material will assure safety.

[Treatment of primary hyperhidrosis of the upper limbs by transthoracic endoscopic sympathectomy]. / Traitement de l'hyperhidrose primitive des membres supérieurs par sympathectomie endoscopique transthoracique.

Primary hyperhidrosis of the upper limbs has an important impact on the subject's social and psycho-affective equilibrium. These patients have two main problems. First physicians are not sufficiently aware of the therapeutic possibilities and secondly the generally poor reputation of surgery in this indication. Transthoracic endoscopic sympathectomy has completely changed the treatment of hyperhidrosis of the upper limbs. It is now considered to be the reference treatment in severe cases. The surgical procedure is simple and allows simultaneous treatment of both sides. There is no mortality and morbidity is extremely low quantitatively and of little consequence qualitatively. The therapeutic protocol is short and immediate and long-term results are excellent in 98 to 100% of the patients.

Recurrence of obliterative bronchiolitis and determinants of outcome in 139 pulmonary retransplant recipients.

An international series of pulmonary retransplantation was updated to identify the predictors of outcome and the prevalence and recurrence rate of obliterative bronchiolitis after operation. The study cohort included 139 patients who underwent retransplantation in 34 institutions in North America and Europe between 1985 and 1994. Eighty patients underwent retransplantation because of obliterative bronchiolitis, 34 because of acute graft failure, 13 because of intractable airway complications, 8 because of acute rejection, and 4 because of other indications. Survivors were followed up for a median of 630 days, with 48 patients alive at 1 year, 30 at 2 years, and 16 at 3 years after retransplantation. Actuarial survival was 65% +/- 4% at 1 month, 54% +/- 4% at 3 months, 45% +/- 4% at 1 year, 38% +/- 5% at 2 years, and 36% +/- 5% at 3 years; nonetheless, of 90-day postoperative survivors, 65% +/- 6% were alive 3 years after retransplantation. Life-table and univariate Cox analysis revealed that more recent year of retransplantation (p = 0.009), identical match of ABO blood group (p = 0.01), absence of a donor-recipient cytomegalovirus mismatch (p = 0.04), and being ambulatory immediately before retransplantation (p = 0.04) were associated with survival. By multivariate Cox analysis, being ambulatory before retransplantation was the most significant predictor of survival (p = 0.008), followed by reoperation in Europe (p = 0.044). Complete pulmonary function tests were done yearly in every survivor of retransplantation and bronchiolitis obliterans syndrome stages were assigned. Eleven percent of patients were in stage 3 at 1 year, 20% at 2 years, and 25% at 3 years after retransplantation. Values of forced expiratory volume in 1 second decreased from 1.89 +/- 0.13 L early after retransplantation to 1.80 +/- 0.15 L at 1 year and 1.54 +/- 0.16 L at 2 years (p = 0.006, year 2 versus baseline postoperative value). Most of this decrease occurred in patients who underwent retransplantation because of obliterative bronchiolitis, whereas the pulmonary function of patients who underwent retransplantation because of other conditions did not significantly change. We conclude that survival after pulmonary retransplantation is improving. Optimal results can be obtained in patients who are ambulatory before retransplantation. Compared with recent data after primary lung transplantation, bronchiolitis obliterans syndrome does not appear to recur in an accelerated manner after retransplantation. As long as early mortality as a result of infection can be minimized, pulmonary retransplantation appears to offer a reasonable option in highly selected patients.

Seventy-two pulmonary retransplantations for obliterative bronchiolitis: predictors of survival.

BACKGROUND: Obliterative bronchiolitis (OB) occurs in up to 40% of patients in the intermediate term after lung transplantation. In recent years an increasing number of recipients with end-stage OB have been treated with retransplantation. METHODS: Seventy-two patients with OB underwent retransplantation at 26 North American and European centers a median of 590 days after their first transplant operation. The predictors of survival were determined using life table and Cox proportional hazards methods, and the recurrence rate of OB was determined in survivors. RESULTS: The actuarial survival rate was 71% +/- 5% at 1 month, 43% +/- 6% at 1 year, and 35% +/- 6% at 2 years; nonetheless, of the 90-day postoperative survivors, 63% +/- 7% were alive 2 years after retransplantation. Institutional experience with more than three pulmonary retransplantations (p = 0.008), reoperation in Europe (p = 0.013), donor-recipient ABO blood group identity (p = 0.018), and more recent year of retransplantation (p = 0.03) were associated with survival. On multivariate analysis, reoperation after 1989 (p < 0.001), retransplantation performed in Europe (p = 0.017), and being ambulatory immediately before reoperation (p = 0.022) were found to be predictive of a positive outcome. Pulmonary function test analyses confirmed that the forced expiratory volume in 1 second decreased from postoperative baseline values by 11% +/- 9% at 1 year and 27% +/- 10% at 2 years (p = 0.02; year 2 versus baseline). Fourteen percent of patients were in stage 3 of the bronchiolitis obliterans syndrome at 1 year postoperatively, with 33% affected at 2 years. CONCLUSIONS: The results of pulmonary retransplantation for OB are improving. Current evidence indicates that OB does not recur in an accelerated manner after retransplantation, although pulmonary function does worsen again by 2 years. Pulmonary retransplantation is appropriate only in selected patients with OB who are ambulatory and are operated on at experienced centers.

[New techniques in thoracic surgery. II]. / Nouvelles techniques en chirurgie thoracique. 2e partie.

The surgical approach to affections of the chest wall and pleura, still the predominant indications for thoracic surgery, has greatly changed since the advent of thoracoscopic procedures, and is emphasized in this second part of a two-part review, together with other indications for mediastinal tumours. Indicated after lung exeresis or emergency chest surgery, protective chest wall reconstruction with muscular flaps is no longer an exceptional operation. Inversely, thoracic surgery for infectious complications have become less frequent, unusually limited to well established procedures for tuberculosis surgery, treatment of bronchial fistula or mediastinal supperations. The chest cavity is well adapted to new techniques of thoracoscopy and video-assisted thoracic surgery both for diagnosis and treatment. Indications for pleuroscopy have taken on a completely new aspect since 1989. These techniques are used for pericardial fenestration, thoracic sympathectomy for dyshidrosis, vagotomy, splanchnicectomy, chylothorax, spinal affections, empyema and trauma surgery. These new techniques have also had an impact on treatment of spontaneous pneumothorax. For tumour surgery, thoracoscopy has made possible a more adapted strategy currently based on an initial needle biopsy, with limited thoracoscopic exeresis and ultimate treatment depending upon the pathology report. Immediate thoracoscopy without prior biopsy appears excessive. Video-assisted thoracosurgery is also used for most malignant mediastinal tumour which, due to advances in chemotherapy surgery have transformed the prognosis of a large number of mediastinal tumours.

Mucosal T-lymphocytes in central airways of lung transplant recipients.

The immunohistochemical profile of mucosal lymphocytes was investigated in the central airways of lung transplant recipients. Bronchial and transbronchial biopsies (BB and TBB, respectively) and bronchoalveolar lavage for culture of bacteria and viruses were performed during a fibroscopic procedure in patients without evidence of chronic rejection, 3 to 10 mo after surgery. Analysis was restricted to samples without concurrent airway infection: 23 pairs of BB and TBB from 18 transplant recipients were analyzed. An immunohistochemical technique was used to identify and score mucosal cells that reacted with monoclonal antibodies against CD4, CD8, CD45-Ro (memory T-cells), and HLA-DR molecules. The same procedure was applied in nine nonsmoking control subjects (NS group). Data from transplant recipients were allocated to R+ (n = 11) or R- groups (n = 12), depending on the presence or absence of histologic evidence of acute rejection on TBB. A statistically significant depletion of every immunoreactive cell subset was observed in the R+ and the R- groups, but not in the NS group. Conversely, no significant difference for either score of immunoreactive cells were found between R+ and R- groups. The immunosuppressive regimen is suspected to play to play a major role in this depletion of bronchial mucosal T-cells. The acute lung rejection process does not appear to affect concurrently the immunohistochemical profile of immunoreactive cells in the bronchial mucosa.

[New techniques in thoracic surgery. I]. / Nouvelles techniques en chirurgie thoracique. 1ère partie.

Progress over the last 40 years has greatly reduced morbidity and mortality in the constantly changing field of thoracic surgery. The first part of this review focuses on current indications and limitations in lung surgery. Technical procedures for pneumonectomy, lobectomy, bronchial resection and conservative surgery are well established. Although major respiratory or cardiac failure still limit indications bronchogenic cancer extension is no longer a contraindication. Exeresis after 70 years of age is not an exception. Surgery for non-small cell lung cancer has given promising results with a 5-year survival rate of 60-80% for patients in stage I and II. For stage III, two recent comparative studies have demonstrated the effectiveness of preoperative adjuvant chemotherapy which should logically be proposed with or without radiotherapy in patients with resectable tumours. Surgical removal of lung metastases and mesotheliomas has also made considerable progress. Unfortunately, except for therapeutic trials, exeresis of small cell lung cancer does not provide any beneficial effect and cannot be proposed. Indications for surgery in patients with chronic obstructive pulmonary disease however has been quite successful and now goes beyond classical exeresis of large compressive bullae. In many situations patients with diffuse emphysema can benefit from surgical reduction in lung volume before proposing transplantation. Lung transplantation is indicated for pulmonary fibrosis, pulmonary vascular disease and obstructive lung pulmonary disease with an overall survival rate of 50% at 5 years and 43% at 6 years. The rate of successful bilateral lung transplantation for cystic fibrosis remains to be determined.

[Post-lung transplantation bronchiolitis obliterans]. / Bronchiolite oblitérante post-transplantation pulmonaire.

Bronchiolitis obliterans is an anatomical lesion with multiple aetiologies. In the lung transplant patient the pure forms of bronchiolitis obliterans are probably the consequence of a process of chronic rejection; in fact necropsy tissue or lungs removed which have been transplanted show that the lesions of bronchiolitis obliterans are often associated with parenchymal disorders, vascular and proximal bronchial disease, which are sequelae of phenomena of rejection or infection. The effect of bronchiolitis obliterans on lung function is constant; this may appear progressively or in stages. Increasing immunosuppressive treatment may arrest the progress. This rarely occurs and the development of respiratory failure tends to be the rule. It is exceptional to achieve the diagnosis of bronchiolitis obliterans from the examination of a transbronchial biopsy. It is a combination of features, both clinical and respiratory function, negative bacteriology and virological investigations as well as the absence of any efficacy of conventional treatment for rejection which leads to the diagnosis. In certain cases the question of a pulmonary re-transplantation is raised.

Above-knee femoropopliteal bypass grafting using endothelial cell seeded PTFE grafts: five-year clinical experience.

Early clinical trials using endothelial cells seeded vascular grafts failed to confirm the successful results observed in animals. Differences in seeding methods could at least partially account for this failure. The purpose of the present study was to ascertain the feasibility and intraoperative efficacy of a two-stage technique that allowed high-density seeding as in animals. The first stage of the technique consists of harvesting an autologous vein specimen under local anesthesia followed by enzymatic isolation and in vitro culture of endothelial cells. The second stage is vascular repair. During the procedure the prosthesis is precoated with autologous whole blood or plasma for 30 minutes and seeded at high density with endothelial cells incubated for 45 minutes. Between May 1988 and June 1993, 32 patients were enrolled in this study. In 11 of them, however, the technique could not be completed for various reasons including preoperative infarction in one case, failure to achieve isolation and/or cell cultures in nine cases, and contamination of cell culture in one case. Twenty-one patients (18 men and 3 women) whose mean age was 62 years (range 38 to 78) underwent above-knee femoropopliteal bypass using an endothelial cell seeded polytetrafluoroethylene graft (7 mm). The indication for surgery was intermittent claudication in 20 patients and rest pain in one. The mean size of the vein specimen was 10.5 +/- 3.5 cm2. The mean duration of in vitro cell culture was 23.5 +/- 8.5 days. The mean density of seeding was 2.9 +/- 0.8 x 105 cells/cm2 prosthesis. No major complications were encountered during the immediate postoperative period (30 days). During follow-up two patients with patent bypasses died of intercurrent causes at 2 and 36 months, respectively, one patient had an abscess in the femoral triangle that required removal of the prosthesis (75 days), and three patients presented with bypass failure (2 occlusions and 1 thromboembolic complication) at 3, 10, and 53 months, respectively. Mean follow-up in the 20 patients surviving at 3 months was 42 +/- 15 months. Cumulative primary patency (Kaplan-Meier analysis) was 95% (+/- 10) at 3 months, 89% (+/- 13) at 10 and 48 months, and 67% (+/- 39) at 53 and 76 months. The two-stage seeding technique described herein was feasible in 69% of patients not requiring emergency reconstruction and did not increase perioperative morbidity and mortality. Bypass patency in patients who underwent above-knee femoropopliteal bypass for intermittent claudication was promising.

Ex vivo inhibition of platelet aggregation in patients with severe limb arteriopathy treated with BAY U3405, a specific TX A2 receptor antagonist.

A double-blind, placebo-controlled randomized study with BAY U3405, a specific thromboxane A2 (TX A2) receptor blocker, was performed in patients suffering from severe stade II limb arteriopathy. BAY U3405 or placebo was administered in 16 patients at 20 mg four times a day (from day 1 to day 3). Hemostatic studies were done before therapy, and on day 2 and day 3 under therapy. On day 3, BAY U3405 was shown to induce a highly statistically significant decrease of the velocity and the intensity of the aggregations mediated by arachidonic acid (56 +/- 37% for the velocity, 58 +/- 26% for the intensity) or by U46619 endoperoxide analogue (36 +/- 35% for the velocity, 37 +/- 27% for the intensity). Similar results were already observed on day 2. By contrast, such a decrease was not noticed with ADP mediated platelet aggregation. Furthermore, plasma levels of betathromboglobulin and platelet factor 4 remained unchanged. Peripheral hemodynamic parameters were also studied. The peripheral blood flow was measured using a Doppler ultrasound; the pain free walking distance and the total walking ability distance were determined under standardized conditions on a treadmill. These last two parameters show a trend to improvement which nevertheless was not statistically significant. All together these results encourage further in vivo studies using BAY U3405 or related compounds on a long-term administration.