Intermediate-term results after en bloc double-lung transplantation with bronchial arterial revascularization

AbstractObjective: Between May 1990 and January 1994, 18 patients underwent en bloc double-lung transplantation with tracheal anastomosis and bronchial arterial revascularization. Because at that time it was already suggested that chronic ischemia could be a contributing factor in occurrence of obliterative bronchiolitis, the purpose of this study was to evaluate, with a follow-up ranging from 22 to 69 months, the midterm effects of bronchial arterial revascularization on development of obliterative bronchiolitis. Results: Results were assessed according to tracheal healing, functional results, rejection, infection, and incidence of obliterative bronchiolitis. There were no intraoperative deaths or reexplorations for bleeding related to bronchial arterial revascularization, but there were three hospital deaths and five late deaths, two of them related to obliterative bronchiolitis. According to the criteria previously defined, tracheal healing was assessed as grade I, IIa, or IIb in 17 patients and grade IIIa in only one patient. Early angiography (postoperative days 20 to 40) demonstrated a patent graft in 11 of the 14 patients in whom follow-up information was obtained. Ten patients are currently alive with a 43-month mean follow-up. Among the 15 patients surviving more than 1 year, functional results have been excellent except in five in whom obliterative bronchiolitis has developed and who had an early or late graft thrombosis. Furthermore, those patients had a significantly higher incidence of late acute rejection (p < 0.02), cytomegalovirus disease (p < 0.006), and bronchitis episodes (p < 0.0008) than patients free from obliterative bronchiolitis. Conclusion: We conclude that besides its immediate beneficial effect on tracheal healing, long-lasting revascularization was, at least in this small series, associated with an absence of obliterative bronchiolitis, thus suggesting but not yet proving the possible role of chronic ischemia in this multifactorial disease. (J THORAC CARDIOVASC SURG 1996;112:1292-300

A mediastinal germ cell tumor mimicking an ectopic pregnancy

The objective is to report the case of a 36 year-old female with a primary mediastinal germ cell tumor mimicking an ectopic pregnancy. The patient under birth control pill presented, at seven weeks of amenorrhea, a β-human chorionic gonadotropin (β-hCG) level of 850 UI and uterine vacuity with left lateral uterine heterogeneous mass but no bleeding and no pain. She received left adnexectomy, uterine curettage and further treatment by methotrexate because of persistent high β-hCG markers. Computed tomography scan finally permitted to discover a voluminous anterior mediastinal tumor. We may recommend investigating patients with a simple chest X-ray that present with persistent increased β-hCG despite efficient ectopic pregnancy treatment

Trials

BACKGROUND: Postoperative upper gastrointestinal fistula (PUGIF) is a devastating complication, leading to high mortality (reaching up to 80%), increased length of hospital stay, reduced health-related quality of life and increased health costs. Nutritional support is a key component of therapy in such cases, which is related to the high prevalence of malnutrition. In the prophylactic setting, enteral nutrition (EN) is associated with a shorter hospital stay, a lower incidence of severe infectious complications, lower severity of complications and decreased cost compared to total parenteral nutrition (TPN) following major upper gastrointestinal (GI) surgery. There is little evidence available for the curative setting after fistula occurrence. We hypothesize that EN increases the 30-day fistula closure rate in PUGIF, allowing better health-related quality of life without increasing the morbidity or mortality. METHODS/DESIGN: The NUTRILEAK trial is a multicenter, randomized, parallel-group, open-label phase III trial to assess the efficacy of EN (the experimental group) compared with TPN (the control group) in patients with PUGIF. The primary objective of the study is to compare EN versus TPN in the treatment of PUGIF (after esophagogastric resection including bariatric surgery, duodenojejunal resection or pancreatic resection with digestive tract violation) in terms of the 30-day fistula closure rate. Secondary objectives are to evaluate the 6-month postrandomization fistula closure rate, time of first fistula closure (in days), the medical- and surgical treatment-related complication rate at 6 months after randomization, the fistula-related complication rate at 6 months after randomization, the type and severity of early (30 days after randomization) and late fistula-related complications (over 30 days after randomization), 30-day and 6-month postrandomization mortality rate, nutritional status at day 30, day 60, day 90 and day 180 postrandomization, the mean length of hospital stay, the patient's health-related quality of life (by self-assessment questionnaire), oral feeding time and direct costs of treatment. A total of 321 patients will be enrolled. DISCUSSION: The two nutritional supports are already used in daily practice, but most surgeons are reluctant to use the enteral route in case of PUGIF. This study will be the first randomized trial testing the role of EN versus TPN in PUGIF. TRIAL REGISTRATION: ClinicalTrials.gov: NCT03742752. Registered on 14 November 2018.This research program is funded by the French Ministry of Health through Programme Hospitalier de Recherche Clinique 2016

Transplantation pulmonaire et dysfonction primaire du greffon

OBJECTIF : La transplantation pulmonaire est une option thérapeutique pour les pathologies respiratoires en phase terminale. L'objectif de cette étude est d'évaluer les pratiques de notre institution en transplantation pulmonaire. METHODE : Quatre-vingt dix patients ayant bénéficié d'une transplantation pulmonaire réalisée dans notre centre entre janvier 2004 et avril 2010 ont été inclus rétrospectivement. RESULTATS : Les indications furent la mucoviscidose et bronchectasies diverses (38 %), la BPCO (22 %), la fibrose pulmonaire idiopathique (11 %), la retransplantation (8 %) et autres pathologies (21 %). L'âge médian des receveurs fut de 46 ans. Nous avons réalisé une transplantation bipulmonaire dans 78 % des cas et monopulmonaire dans 22 % avec un greffon marginal dans 37 % des cas. Une CEC d'assistance fut mise en place en urgence dans 25 % des cas et à titre systématique avant réimplantation du deuxième greffon dans 10 %. La durée moyenne de CEC fut de 182 min avec une durée au-delà de 180 min dans 44 % des cas. Le séjour moyen en soins intensifs et moyen total fut de 19 et de 34 jours respectivement. L'incidence de dysfonction primaire du greffon (DPG) grade 3 fut de 25 % avec comme seul facteur de risque significatif retrouvé la mise en place d'une CEC en urgence (p = 0,015). La mortalité à 30 jours fut significativement plus élevée chez les patients atteints d'une DGP de grade 3 que pour les autres (33 % contre 12,5 %, p = 0,03) ainsi que chez les patients avec CEC prolongée au-delà de 180 min (43 % contre 12,5 %, p = 0,01). Une complication bronchique précoce grave se déclara chez 29 % des patients atteints de DPG de grade 3 (p = 0,014). CONCLUSION : Le développement d'une DPG de grade 3 est associé à une morbi-mortalité post-opératoire très élevée. La mise en place précoce d'une assistance circulatoire préviendrait des lésions induites par une poussée d'HTAP per-opératoire qui est un facteur de risque de DPG. Ses potenrielles complications ne doivent cependant pas être occultées.BORDEAUX2-BU Santé (330632101) / SudocSudocFranceF

Morbi-mortalité des patients opérés d'oesophagectomie pour cancer

BORDEAUX2-BU Santé (330632101) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Impact du curage ganglionnaire médiastinal sur les métastasectomies pulmonaires (expérience de 247 cas sur 9 ans)

Objectif : L intérêt du curage ganglionnaire médiastinal, lors de la chirurgie des métastases du poumon, reste mal défini. Le but de notre étude est d évaluer l impact du curage ganglionnaire sur la survie du patient. Patients et Méthodes : Il s agit d une étude rétrospective unicentrique de 247 patients débutant de janvier 2003 à décembre 2012. Les patients ont bénéficié d une ou plusieurs métastasectomies pulmonaires et d un curage ganglionnaire indépendamment du cancer primitif. La probabilité de survie sans décès a été analysée. Résultats : L étude portait sur 156 hommes et 91 femmes avec un âge moyen de 60,1 ans. La résection complète était réalisée dans 88,5 % des cas. Les cancers primitifs étaient d origine colique (82), rectale (21), rénale (40), mélanome malin (25), sarcome (10), voile du palais (12), oesophage (5), hépatique (4), thyroïdienne (4), autres (23). Le curage des ganglions lymphatiques médiastinaux était positif dans 32 cas avec 22 stations N2 positives et 17 stations N1 positives. 23 patients ont récidivé avec des métastases controlatérales dont 4 patients avec des métastases ganglionnaires en station N2 parmi les 31 cas. On retrouvait un patient avec une deuxième récidive de métastase ganglionnaire. Le taux de récidive de métastases était de 11,5 %. Il n avait pas de résultats significatifs d une récidive ou de décès liée à l âge (p = 0,861 et p = 0,984). Les courbes concernant la probabilité de survie sans décès montrait une tendance à une survie inférieure à 50 % jusqu à 5 ans. Conclusion: Le curage ganglionnaire améliore la survie sans décès et sans récidive de métastases.BORDEAUX2-BU Santé (330632101) / SudocSudocFranceF

Staged Radiofrequency Ablation and Surgical Resection for Multiple Lung Metastases of Germ Cell Tumors

Purpose: To evaluate the morbidity and efficacy of percutaneous radiofrequency ablation (RFA) performed before surgical resection for multiple residual lung metastases of germ cell tumors with negative tumor markers. Materials and Methods: This Review Board-approved retrospective study was carried out on five consecutive patients (mean age: 31 years, range: 22–41) treated successively with percutaneous RFA and surgery for multiple lung metastases of germ cell tumors. Mean number of lung metastases before treatment was 9.4. Staged procedures were performed on an average of 7.2 months (range: 1–16) after the primitive tumor resection. Results: The median clinical and imaging follow-up was 26 months (range: 24–36). Percutaneous RFA was technically feasible in one session under general anesthesia and CT guidance in all cases. On average, 2.8 tumors were ablated per patient (range: 1–6), and three of five procedures were bilateral. Three patients developed pneumothorax requiring drainage, but no severe complications were reported. Mean time between RFA and surgical resection of residual tumors was 2.5 months (range: 1–5). No local recurrences were noted, but one patient died due to metastatic evolution. Conclusion: Staged percutaneous RFA and surgical resection could be efficient with low morbidity for the management of multiple lung metastases of germ cell tumors

Patient risk factors for conversion during video-assisted thoracic surgery—the Epithor conversion score

International audienceAbstract OBJECTIVES Intraoperative conversion from video-assisted thoracic surgery (VATS) to thoracotomy may occur during anatomical lung resection. The objectives of the present study were to identify risk factors for intraoperative conversion and to develop a predictive score. METHODS We performed a multicentre retrospective analysis of French thoracic surgery departments that contributed data on anatomical lung resections to the Epithor database over a 10-year period (from January-2010 to December-2019). Using univariate and multivariate logistic regression analyses, we determined risk factors for intraoperative conversion and elaborated the Epithor conversion score (ECS). The ECS was then validated in a cohort of patients operated on between January- and June-2020. RESULTS From January-2010 to December-2019, 210,037 patients had been registered in the Epithor database. Of these, 55,030 had undergone anatomical lung resection. We excluded patients who had upfront a thoracotomy or robotic-assisted thoracoscopic surgery (n = 40,293) and those with missing data (6,794). Hence, 7943 patients with intent-to-treat VATS were assessed: 7100 with a full VATS procedure and 843 patients with intraoperative conversion to thoracotomy (conversion rate: 10.6%). Thirteen potential risk factors were identified among patients’ preoperative characteristics and planned surgical procedures and were weighted accordingly to give the ECS. The score showed acceptable discriminatory power (area under the curve: 0.62 in the development cohort and 0.64 in the validation cohort) and good calibration (P = 0.23 in the development cohort and 0.30 in the validation cohort). CONCLUSIONS Thirteen potential preoperative risk factors were identified, enabling us to develop and validate the ECS—an easy-to-use, reproducible tool for estimating the risk of intraoperative conversion during VATS

Am J Respir Crit Care Med

The rate of lung transplants is increasing, and these patients frequently develop respiratory complications necessitating mechanical ventilation (1). When treating these patients, the risks of mechanical ventilation constitute an important concern, and clinicians aim to simultaneously protect the lung while avoiding ventilator-induced diaphragm dysfunction by maintaining spontaneous breathing. Targeting the ideal VT for each patient is challenging. According to the underlying lung disease of the recipient and his or her previous total lung capacity (TLC), the size of the transplanted lungs may differ from the theoretical TLC based on height. Actual TLC can vary considerably from one transplanted patient to the next and is poorly correlated with height (2). Furthermore, bipulmonary transplanted patients have denervated lungs without vagal afferent fibers. As a consequence, some feedback mechanisms necessary for control of breathing may be lacking, which can result in large VT, as shown in animals (3) and during exercise in lung-transplanted patients (4). Neurally adjusted ventilatory assist (NAVA) is a mode of ventilation that delivers support in proportion to diaphragmatic electrical activity, the latter being a direct expression of neural inspiratory activity (5). Over a certain range of assist, the patient is able to fully control his or her VT, which is not the case with traditional modes of assist. We analyzed VT in patients ventilated with NAVA after bilateral lung transplantation. We compared these volumes with nontransplanted patients at a similar stage of difficult weaning, using the same approach to titrate NAVA. In addition, we examined the relationship between the patient’s VT under NAVA and their most recent TLC