[Treatment of bilateral spontaneous pneumothorax during pazopanib therapy for pulmonary soft tissue sarcoma metastases. What to do when there is so few evidence?] / Traitement d'un pneumothorax spontané bilatéral au cours d'un traitement par pazopanib pour la prise en charge de métastases pulmonaires d'un sarcome. Quelle conduite à tenir ?

Soft tissue sarcomas are rare malignant tumors with a great variety of histological types and different response to multimodality treatment. Pazopanib has been recently introduced for the treatment of non-adipocytic metastatic soft tissue sarcomas which are resistant to conventional chemotherapy. Spontaneous pneumothorax is a rare but well recognized complication of this molecule and its treatment is quite challenging. The case reported herein describes the surgical management of a simultaneous bilateral spontaneous pneumothorax in a patient with pulmonary metastases treated with pazopanib. It underlines the fact that the main objective should be the maintenance of the treatment in patients who benefit from it. Close oncologic and surgical collaboration is crucial in order to deal with adverse effects due to the anti-angiogenic action of pazopanib.

[Staple line presenting as a suspicious pulmonary nodule]. / Une ligne d'agrafage imitant un nodule pulmonaire suspect.

The case reported herein concerns a 47-year-old female patient with a right apical pulmonary nodule, which was hypermetabolic on positron emission tomography scan. Eighteen years ago, she underwent a right axillary thoracotomy with apical blebectomy and pleurectomy for a recurrent primary spontaneous pneumothorax. Percutaneous transthoracic needle biopsy was unsuccessful. Surgical exploration revealed that the lesion was in fact the reinforcement material of the staple line that was used in the previous operation. Even though it is a rare presentation, previous use of surgical staples should alert the care team, especially when a new nodule is located near the ancient staple line, in order to avoid unnecessary invasive procedures.

Relationships between lung adenocarcinoma and gender, age, smoking and occupational risk factors: A case-case study.

BACKGROUND: The hypothesis that some risk factors for lung cancer may have more specific associations with particular histologic types remains controversial. The aim of this study was to investigate possible associations between adenocarcinoma and gender, age, smoking characteristics and selected occupational carcinogens in relation to other histologic types. METHODS: This study included all histologically confirmed lung cancer cases diagnosed consecutively in two French University hospitals from 1997 to 2006. All medical data were obtained by face-to-face patient interviews. Occupational carcinogen exposures of each patient were assessed by an industrial hygienist. Relationships between risk factors and adenocarcinoma were analyzed by case-case comparisons using unconditional logistic regressions (ULRs). RESULTS: A total of 1493 subjects were enrolled in this study, comprising 1303 men (87.3%), 67 nonsmokers (4.5%) and 489 adenocarcinomas (32.7%). Using ULR, no associations were observed between adenocarcinoma and age, gender or smoking characteristics except for a negative relationship with smoking duration (p<0.0001). Significant associations were observed between ADC and exposure to welding fumes and silica in the whole population and with polycyclic aromatic hydrocarbons in ever smokers. CONCLUSION: This study demonstrated that some risk factors, such as duration of smoking and certain occupational exposures but not gender or age, have a more important influence on the incidence of lung ADC than on other histologic types. As the distribution of histologic types may reflect underlying biological mechanisms, these findings also suggest that lung carcinogenesis pathways should be studied in relation to smoking duration and other lung cancer risk factors.

[A serious late complication of non-operative management of splenic trauma: rupture of splenic artery aneurysm]. / Une complication tardive et grave du traitement non-opératoire des traumatismes spléniques: la rupture d'un anévrysme de l'artère splénique.

Over the last five past years, three patients required urgent operation in our institution for hemorrhagic shock after rupture of a post-traumatic splenic artery aneurysm. Those patients had undergone non- operative management (NOM) of grade III, IV (AAST classification) splenic injury 9, 13, and 22 months earlier. Two of them had a CT scan 30 days after initial trauma with no evidence of a developing splenic artery aneurysm. All three patients survived after proximal ligature of splenic artery and hemostatic splenectomy. Our experience with these three cases suggests that a delayed follow-up for patients at high risk is indicated in order to prevent this dramatic complication by early intervention. The modality of this follow-up should be determined by a prospective multicenter study.

[The place of laparoscopy in the management of the patients with penetrating abdominal trauma]. / Place de la laparoscopie dans la prise en charge des blessés par arme blanche de la paroi abdominale antérieure.

INTRODUCTION: In patients with an abdominal knife wound, the main problem is to determine whether the abdominal trauma is penetrating. The aim of this work is to study the safety of the laparoscopic approach in the management of abdominal knife trauma. MATERIALS: A laparoscopy was performing in sixty patients. Patients were dispatched in four categories according to the laparoscopic findings. A laparotomy was performed after laparoscopy in case of peritoneal tear. RESULTS: Unnecessary laparotomy was avoided in 58% of the patients. The follow-up was favourable with nil mortality and a low morbidity (3%). CONCLUSION: Laparoscopic management of abdominal wound knife trauma is a reliable approach to identify a peritoneum tear. This specific situation requires a laparotomy to look for an intra abdominal tear.

Temporary intestinal occlusion induced by a "patency capsule" in a patient with Crohn's disease.

A 26-year-old woman was admitted for the investigation of abdominal symptoms related to ileal Crohn's disease. The patient had been diagnosed 3 years previously with systemic sclerosis, and had been experiencing digestive complaints for 6 months. A first computed tomography (CT) scan showed ileal intestinal mucosal alterations, associated with a sclerolipomatosis and suspicion of ileal stenosis. An ileocolonoscopy was then performed and showed ulcers in the terminal ileum with nonspecific inflammatory changes found on biopsies, both suggesting the diagnosis of Crohn's disease. The patient was admitted for M2A capsule endoscopy, in order to clarify the respective roles of systemic sclerosis and Crohn's disease with regard to the symptoms and secondarily to determine the anatomical extent of the Crohn's lesions. A patency capsule was administered, for detection of intestinal stenosis before capsule endoscopy was done. At 30 hours after capsule ingestion, the patient complained of abdominal pain and nausea and experienced intestinal obstruction due to the blockage of the patency capsule in the ileal stenosis. The capsule dissolved after 76 hours and the patient then improved. After a few days, the patient underwent ileocecal resection. Pathological examination of the surgical specimen confirmed the presence of an ileal stenosis 17 cm in length. In some circumstances a patency capsule may dissolve slowly, leading to transitory intestinal obstruction requiring medical intervention. It should thus be used cautiously under clinical surveillance in patients with Crohn's disease.

[CT diagnosis of acute gastric volvulus]. / Diagnostic tomodensitométrique d'un volvulus gastrique idiopathique aigu.

Acute gastric volvulus is an infrequent entity. Management is surgical. Diagnosis frequently is delayed because of the non-specific nature of presenting symptoms. The authors report a case of acute gastric volvulus diagnosed by computed tomography in a 92 year old woman that was confirmed at surgery. The pathophysiology, classification and different presentations of this entity are briefly reviewed. CT findings suggesting gastric volvulus are reviewed as well.

Intestinal intussusception in adults, treat it like a cancer.

Intussusception in adult is a rare condition. Pathologic process is identifiable in 90% of cases. Emergency clinical diagnosis is generally difficult and CT scan typical features are of use. Surgery is always necessary to treat bowel necrosis and to perform pathologic examination. Diagnosis of cancer must be in mind and lymphadenectomy must be done. We present two recent cases of intussusception in adults due to adenomatosis polyposis and Meckel's diverticulum.

[Endoscopic sympathectomy for palmar and plantar hyperhidrosis: results in 107 patients]. / Hyperhidroses palmoplantaires: traitement par sympathectomie endoscopique chez 107 malades.

INTRODUCTION: Transthoracic endoscopic sympathectomy for palmar hyperhidrosis is a safe and effective method. However, no radical and definite treatment exists for plantar hyperhidrosis. We report our experience, immediate post-operative and mid-term results after transthoracic and lumbar endoscopic sympathectomy for palmar and plantar hyperhidrosis. PATIENTS AND METHODS: One hundred and seven of 117 patients cured between January 94 and December 98, answered a questionnaire regarding their past history, the early post-operative results, side effects and complications caused by the operation and mid-term results with particular emphasis on patient satisfaction. RESULTS: Seventy-eight thoracic and lumbar endoscopic sympathectomies and 125 thoracic endoscopic sympathectomies were performed. The patients were 30 men (median age 30 years) and 77 women (median age 26 years). Only women underwent lumbar endoscopic sympathectomy because of risk of retrograde ejaculation. No severe complications were noted. The success rate was 96 p. 100 for palmar hyperhidrosis and 98,5 p. 100 for plantar hyperhidrosis. No recurrences were noted in 97 p. 100 of the patients with median follow-up of 28 months. The main side effect was compensatory sweating which was the reason for dissatisfaction for 5 p. 100 of the patients. Cutaneous dryness and gustatory sweating were also described. However, 95 p. 100 of the patients were "satisfied" or "very satisfied". CONCLUSION: Our experience proved that lumbar endoscopic sympathectomy is as safe and effective for treatment of plantar hyperhidrosis, as thoracic endoscopic sympathectomy for palmar hyperhidrosis.

Role of videothoracoscopy in chest trauma.

BACKGROUND: The aim of this study was to evaluate videothoracoscopic procedures in the setting of chest trauma. METHODS: We retrospectively analyzed our experience of videothoracoscopy in patients with either blunt trauma or penetrating thoracic injuries. RESULTS: Forty-three procedures involving 42 patients were performed between July 1990 and April 1996. Indications for videothoracoscopy included suspected diaphragmatic injury (14 patients), clotted hemothorax (12), continued hemothorax (6), persistent pneumothorax (5), intrathoracic foreign body (4), posttraumatic chylothorax (1), and posttraumatic empyema (1 patient). Ten patients (24%) required conversion to thoracotomy. Two patients suffered postoperative pneumonia. There was one perioperative death. Mean hospital stay was 17 days; 21 days for patients with blunt trauma and 13 days for patients with penetrating injuries. There was no procedure-related complication. Videothoracoscopy allowed precocious discharge of patients suffering penetrating injuries and allowed faster recovery in the majority of patients suffering severe blunt trauma. CONCLUSIONS: Videothoracoscopy appears to be a safe, accurate, and useful approach in selected patients with chest trauma. It is ideal for the assessment of diaphragmatic injuries, for control of chest wall bleeding, for early removal of clotted hemothorax, for treatment of empyema, for treatment of chylothorax, for treatment of persistent pneumothorax, and for removal of intrathoracic foreign body. However, we do not recommend the use of this technique in the setting of suspected great vessel or cardiac injury.

[Analgesia after laparoscopic cholecystectomy by intraperitoneal administration of bupivacaine]. / Analgésie après cholécystectomie par voie coelioscopique par administration intrapéritonéale de bupivacaïne.

OBJECTIVES: The aims of this study were to assess the analgesic effect of the intraperitoneal topical administration of 0.375% bupivacaine in patients undergoing laparoscopic cholecystectomy and to carry out a pharmacokinetic study of bupivacaine administered topically by intraperitoneal route. STUDY DESIGN: Randomized, double-blind controlled trial. PATIENTS AND METHODS: Twenty-four patients of ASA physical status 1 or 2, undergoing elective laparoscopic cholecystectomy, were included. Anaesthesia technique was the same for all patients. At the end of surgery, they were randomly assigned to one of two groups. Patients in group bupivacaine were administered 0.375% bupivacaine, 0.6 mL.kg-1 intraperitoneally in both subdiaphragmatic areas and the cholecystectomy wound, those of the control group were given the same volume of NaCl 0.9%. Analgesia was provided by morphine PCA. Postoperative pain, assessed on a 100 mm visual analogue pain scale (VAS), and administered morphine were recorded 30 min after extubation, and 0.5, 1, 2, 3, 6, 12, 24, 36 and 48 hours later. Blood samples were collected 2, 5, 15, 30, 60, 90, 120, 180, 300 and 480 min after the intraperitoneal administration of bupivacaine to measure bupivacaine plasma concentration. Statistics included Student t test and Chi square test. P < 0.05 was considered significant. RESULTS: There was no significant difference between the two groups with regard to VAS scores during the first 48 postoperative hours. Morphine requirements (total and at each point) were also similar. Plasma bupivacaine concentrations reached a plateau at 10-20 min, and then decreased slowly. The median plasma peak concentration was 0.94 +/- 0.47 microgram.mL-1. In one patient toxic concentrations (> 1.6 micrograms.mL-1) during the first 60 min after intraperitoneal administration were obtained, while in another patient a concentration of 1.58 micrograms.mL-1 was reached twice. CONCLUSIONS: Intraperitoneal administration of 0.6 mL.kg-1 of 0.375% bupivacaine is ineffective in reducing postoperative pain after laparoscopic cholecystectomy. Furthermore these high doses of bupivacaine may result in toxic plasma concentrations. This technique is not safe and cannot be recommended.

[Chylothorax following closed thoracic injury]. / Chylothorax après traumatisme fermé du thorax.

Chylothorax following blunt chest trauma is a rare event. The presence of a cloudy or milky persistent pleural effusion should suggest the possibility of its chylous origin. The diagnosis is made by analysis of the fluid obtained either from thoracentesis or tube thoracostomy. A lymphangiogram can show the site of the lesion, but computed tomography is a more recent and probably as helpful diagnostic test. An efficient control of the chylous effusion may be facilitated by using a fat-poor enteral nutrition and parenteral nutrition, which prevents malnutrition. Surgical ligation of the thoracic duct is relatively simple and efficient. It is indicated when the daily chylous flow is over 500 mL after 2 or 3 weeks of medical treatment or in case of weight loss.

[Do pericardial strips (Peri-Strip) facilitate the follow-up after pulmonary surgery in emphysematous patients?]. / Les bandelettes de péricarde (Peri-Strip) facilitent-elles les suites après chirurgie pulmonaire chez le patient emphysémateux?

The aim of this study was to evaluate the contribution of bovine pericardial strips (Peri-Strip) to achieve aerostasis within emphysematous lungs. A preliminary evaluation included 15 patients (13 men and 2 women, mean age 57 years) with severe emphysema (mean FEV-1: 28.6 +/- 10.2% of predicted, mean RV: 18.4 +/- 41.3% of predicted). Two patients were on ventilator owing to acute respiratory failure. Indication for surgery was elective surgery for emphysema in 9 patients, emergency surgery for emphysema in 2, and resection for bronchogenic cancer in 4 patients. The various procedures included single aerostasis in 1, unilateral bullectomy in 6, bilateral volume reduction in 4, thoracoscopic wedge resection for peripheral cancer in 1 and lobectomy for cancer in 3 (2 of which underwent simultaneous bullectomy) Peri-Strip were used to buttress the staple lines at the base of bullae, on parenchymatous transsection lines, and on the borders of fissures. One patient who underwent emergency thoracotomy for single aerostasis died 8 days post-operatively due to multiple organ failure. Another patient developed pneumonia which resolved under treatment. Mean duration of air leaks was 5.6 days (0-21, median 8). Two patients required tube thoracotomy for residual effusions. Mean hospital stay was 17 days (6-53; median 16). We conclude that use of Peri-Strip offered a real benefit to 12 patients; no evidence of benefit was noted in 3 patients.

[Spontaneous retroperitoneal hematoma: a rare cause of hemorrhagic shock]. / Hématome rétropéritonéal spontané: cause rare de choc hémorragique.

A spontaneous retroperitoneal haematoma is an uncommon cause of haemorrhagic shock. We report a case of spontaneous rupture of a renal angiomyolipoma resulting in haemorrhagic shock in a 52-year-old woman. The renal tumor was recognized by sonography and diagnosed by CT-scan. Renal angiography was performed, but embolization was not successful. During the surgical procedure, nephrectomy was required because of persistent bleeding, related to disseminated intravascular coagulation. Outcome was uneventful. Diagnosis and treatment of renal angiomyolipoma are discussed. The Lenk's triad, consisting of acute lumbar pain, symptoms of internal bleeding and lumbar tumefaction, is the usual clinical picture of retroperitoneal haemorrhage. The kidney is the most frequent cause and renal angiomyolipoma is the most frequent benign tumor. Renal angiomyolipoma is either isolated or associated with tuberous sclerosis in up to 20 per cent of patients. Diagnosis is suggested by sonography and confirmed by CT-scan. Renal angiography, performed in haemodynamically stable patients, shows the origin of bleeding and allows embolization. Considering the frequent bilaterality of angiomyolipoma, surgery should be as conservative as possible in order to preserve renal function.

[Comparative study of immunologic consequences of autotransfusion and homologous transfusion in lung cancer surgery]. / Etude comparative des conséquences immunologiques de l'autotransfusion et de la transfusion homologue en chirurgie carcinologique pulmonaire.

A study was carried out to determine the effects of transfusion with either autologous or homologous blood in 35 patients with lung cancer undergoing lung surgery. The patients were randomly allocated to two groups, "allo" receiving homologous blood (n = 10), and "auto" receiving autologous blood only (n = 13). A third control group included the patients (n = 12) who had not required any blood. In patients of "auto" group, two blood removals of 7 ml.kg-1 each were performed, provided their haemoglobin concentration was over 110 g.l-1 and their haematocrit over 34%. The following parameters were studied at t-1 (the day of inclusion), t0 (just before surgery and transfusion), t1 (one week after surgery), and t2 (one month later): haematocrit and haemoglobin concentration; IgG, IgA and IgM concentrations; polymorphonuclear and neutrophil leucocyte and lymphocyte numbers, lymphocyte subpopulations (CD4/CD8), activated natural killers (NK), polymorphonuclear leukocyte chemotaxis and chemoluminescence. Anaesthesia and surgery initiated initiated an early decrease in immunity in all three groups. The immune profile, and its time course in patients who received autologous blood only was similar to that of those who were not transfused at all. On the other hand, homologous blood transfusion seems to modify the recipient's non specific immune system. In group "allo", a decrease occurred in the number of auxiliary lymphocytes CD4, an increase in suppressor lymphocyte numbers CD8, with an increase in the CD4/CD8 ratio, and no increase in NK activity. These data suggest that autologous transfusion is well tolerated in cancer patients undergoing surgery.

[Value of limited resections in the surgical treatment of lung cancers]. / Valeur des exérèses limitées dans le traitement chirurgical des cancers bronchiques.

From 1969 to 1990, 88 limited lung resections were performed for the treatment of malignant lung tumours. These operations consisted of 73 typical resections (29 segmentectomies, 15 bisegmentectomies, 23 middle lobectomies, 6 lingulectomies) and 15 atypical resections. In 15 cases, they were completed by lymph node dissection. These operations were performed in patients with a mean age of 55.8 years (range: 24 to 76). The ventilatory functional status contraindicated wider resection in only 7 cases. The immediate postoperative mortality (7 cases, i.e. 8%) and the postoperative complications observed in 29.6% of cases were higher than those observed after wide resections, but do not constitute a specific argument in the indication for partial resection. Histological examination of the operative specimens revealed 80 primary lung cancers (42 squamous carcinomas, 28 adenocarcinomas, 8 anaplastic and unclassifiable tumours, 1 bronchiolo-alveolar tumour and 1 malignant carcinoid tumour). The primary nature of the tumour could not be definitely confirmed in the other 8 patients (history of head and neck neoplasm in 7 cases and bladder carcinoma in 1 case). The survival according to TNM stage, histological nature of the tumour, positivity of the resection margins and intraoperative tumour effraction was identical to that associated with lobectomies.

[Resection of lung neoplasm in patients aged 70 years and over. Apropos of a series of 193 resections]. / L'exérèse du néoplasme bronchique chez les sujets de 70 ans et plus. A propos d'une série de 193 exérèses.

Lung cancer in the elderly is an active cancer. Due to the poor tolerance of radiotherapy and chemotherapy, and the ever increasing life expectancy of patients over the age of 70 years, surgery remains the treatment of choice for these lesions. We report a series of 193 patients over the age of 70 years, the high postoperative mortality of 19% during the first month was counterbalanced by a 5-year survival of more than 20%. The criteria of operability must be rigorous and based on objective elements, especially lung function and the patient's good psychological state.

[Pulmonary metastasis of a dermatofibrosarcoma]. / Métastase pulmonaire d'un dermatofibrosarcome.

Progressive and recurrent dermatofibrosarcoma, described by Darier and Ferrand in 1924, is a fibrous skin tumour with essentially local malignancy. The authors report a case with pulmonary metastasis, a rare event as only 13 cases of visceral metastases have been reported in the literature. The clinical course of this case was favourable (follow-up of 5 years), in contrast with the usually pejorative nature of metastatic disease (death after several months to one year following the discovery of the first metastasis).