Apport du modèle des transplantations uni-pulmonaires jumelées dans l'étude des résultats de greffe pulmonaire

STRASBOURG-Medecine (674822101) / SudocSudocFranceF

Intérêt de la chirurgie de kystes pulmonaires liés à des dépôts de chaînes légères

INTRODUCTION : La maladie des dépôts de chaînes légères d’immunoglobuline est une entité anatomoclinique entraînant, dans de rares cas, une destruction kystique du poumon. OBSERVATION : Nous rapportons le cas d’une patiente de 62 ans, suivie dans le cadre d’une gammapathie monoclonale de signification indéterminée, chez qui, suite à l’apparition d’une dyspnée croissante, des lésions pulmonaires kystiques diffuses sont découvertes au scanner thoracique. Une résection par thoracoscopie du lobe inférieur droit où prédominait l’atteinte kystique a permis le diagnostic histologique de maladie des dépôts de chaînes légères kappa non amyloïdes. La chirurgie a également eu un effet de réduction de volume pulmonaire s’accompagnant d’une amélioration clinique et fonctionnelle via l’amélioration de la ventilation des segments voisins. CONCLUSION : Cette observation de maladie des dépôts de chaînes légères avec atteinte kystique pulmonaire illustre les potentiels bénéfices cliniques et fonctionnels observés après chirurgie de réduction pulmonaire.[Effect of surgery of pulmonary cysts related to immunoglobulin light chain deposits] INTRODUCTION: Light chain deposition disease is a rare anatomo-clinical disorder, which rarely leads to cystic lung destruction. CASE REPORT: We report the case of a 62years old female patient with a history of a monoclonal gammopathy of unknown significance who developed progressive dyspnea. Thoracic CT-scan demonstrated a diffuse pulmonary cystic disorder with predominance in the right lower lobe. Thoracoscopic surgical resection of that lobe led to a diagnosis of non-amyloid kappa light chain deposits. Surgery also resulted in a lung volume reduction effect with clinical and functional benefits related to improved ventilation of adjacent segments. CONCLUSION: This report of pulmonary cystic disorder related to a light chain deposition disease highlights the potential clinical and functional benefits observed after lung volume reduction surgery

Vascular access for extracorporeal life support: tips and tricks.

In thoracic surgery, extracorporeal life support (ECLS) techniques are performed to (I) provide a short to mid term extracorporeal mechanical support; (II) realize the gas exchanges; and (III)-depending the configuration of the circuit-substitute the failed heart function. The objective of this review is to describe the rational of the different ECLS techniques used in thoracic surgery and lung transplantation (LTx) with a specific attention to the vascular access. Venovenous extracorporeal membrane oxygenation (VV ECMO) is the most common ECLS technique used in thoracic surgery and represents the best strategy to support the lung function. VV ECMO needs peripheral vascular access. The selection between his double-site or single-site configuration should be decided according the level of O2 requirements, the nosological context, and the interest to perform an ECLS ambulatory strategy. Venoarterial (VA) ECMO uses peripheral and/or central cannulation sites. Central VA ECMO is mainly used in LTx instead a conventional cardiopulmonary bypass (CPB) to decrease the risk of hemorrhagic issues and the rate of primary graft dysfunction (PGD). Peripheral VA ECMO is traditionally realized in a femoro-femoral configuration. Femoro-femoral VA ECMO allows a cardiocirculatory support but does not provide an appropriate oxygenation of the brain and the heart. The isolated hypercapnic failure is currently supported by extracorporeal CO2 removal (ECCO2R) devices inserted in jugular or subclavian veins. The interest of the Novalung (Novalung GmbH, Hechingen, Germany) persists due to his central configuration indicated to bridge to LTx patients suffering from pulmonary hypertension. The increasing panel of ECLS technologies available in thoracic surgery is the results of a century of clinical practices, engineering progress, and improvements of physiological knowledges. The selection of the ECLS technique-and therefore the vascular access to implant the device-for a given nosological context trends to be defined according an evidence-based medicine

Superior sulcus non-small cell lung carcinoma: A comparison of IMRT and 3D-RT dosimetry

AimA dosimetric study comparing intensity modulated radiotherapy (IMRT) by TomoTherapy to conformational 3D radiotherapy (3D-RT) in patients with superior sulcus non-small cell lung cancer (NSCLC).BackgroundIMRT became the main technique in modern radiotherapy. However it was not currently used for lung cancers. Because of the need to increase the dose to control lung cancers but because of the critical organs surrounding the tumors, the gains obtainable with IMRT is not still demonstrated.Material and methodsA dosimetric comparison of the planned target and organs at risk parameters between IMRT and 3D-RT in eight patients who received preoperative or curative intent irradiation.ResultsIn the patients who received at least 66[[ce:hsp sp="0.25"/]]Gy, the mean V95% was significantly better with IMRT than 3D-RT (p[[ce:hsp sp="0.25"/]]=[[ce:hsp sp="0.25"/]]0.043). IMRT delivered a lower D2% compared to 3D-RT (p[[ce:hsp sp="0.25"/]]=[[ce:hsp sp="0.25"/]]0.043). The IH was significantly better with IMRT (p[[ce:hsp sp="0.25"/]]=[[ce:hsp sp="0.25"/]]0.043). The lung V5[[ce:hsp sp="0.25"/]]Gy and V13[[ce:hsp sp="0.25"/]]Gy were significantly higher in IMRT than 3D-RT (p[[ce:hsp sp="0.25"/]]=[[ce:hsp sp="0.25"/]]0.043), while the maximal dose (Dmax) to the spinal cord was significantly lower in IMRT (p[[ce:hsp sp="0.25"/]]=[[ce:hsp sp="0.25"/]]0.043). The brachial plexus Dmax was significantly lower in IMRT than 3D-RT (p[[ce:hsp sp="0.25"/]]=[[ce:hsp sp="0.25"/]]0.048). For patients treated with 46[[ce:hsp sp="0.25"/]]Gy, no significant differences were found.ConclusionOur study showed that IMRT is relevant for SS-NSCLC. In patients treated with a curative dose, it led to a reduction of the exposure of critical organs, allowing a better dose distribution in the tumor. For the patients treated with a preoperative schedule, our results provide a basis for future controlled trials to improve the histological complete response by increasing the radiation dose