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Background Bronchial resection and reimplantation in surgical management of lung cancer is intended to spare lung parenchyma, with curative intent. We studied the incidence and management of anastomotic complications after such procedures. Methods We retrospectively reviewed charts of patients referred to our center for lung tumors who underwent bronchial resection and reimplantation from 1992 to 2011. Results A total of 108 patients were included. Sixty-eight percent were male, and mean age was 58 years. Sleeve lobectomies were performed in 100 patients, bronchial resections without lung parenchymal resection in 8 patients. Squamous cell carcinoma represented 46.3% of cases, carcinoid tumors 22.2%, and adenocarcinoma 18.5%. Mean time between surgery and first bronchoscopic examination was 4.47 days. During the follow-up, anastomotic abnormalities were detected in 23 patients (21.3%): malacic or fibrotic bronchial stenoses in 9 cases (39.1%), dehiscences in 7 (30.4%), obstructive granulomas in 4 (17.4%), and bronchopleural fistulas in 3 (13.0%). Endoscopic treatment was indicated in 14 patients (13%) and consisted of stent placement in 6 cases (26%), mechanical dilations in 3 (13%), laser treatment for 1 case of bronchomalacia (4.3%), and resection of granulomas in 4 (17.4%). No risk factors were identified as predisposing for bronchial complications. There was a trend toward lower 1-year survival in patients with bronchial complications compared with those without (71.9% versus 83.4%; p = 0.114). Conclusions Bronchial resection and reimplantation is a surgical procedure associated with an anastomotic complication rate of 21.3%, but only 13% required endoscopic management. Regular endoscopic surveillance is advised to detect and treat early complications. [ABSTRACT FROM AUTHOR]

Background: Bronchogenic cyst (BC) is a benign congenital mediastinal tumor whose natural course remains unclear. In adults, most BCs are removed by thoracotomy after complications. Currently, prenatal diagnosis is generally feasible and allows an early thoracoscopic intervention. The purpose of this retrospective study was to ascertain the best time for the operation. Methods: Reviewed were 36 patients (11 children, 25 adults) with a BC managed from 2000 to 2011. Clinical history, cyst size, duration of hospitalization, preoperative and postoperative complications, and detection of inflammatory elements were compared (Student t tests) between pediatric and adult patients. Results: In the pediatric group, diagnosis was made prenatally in 7 patients, during the neonatal period in 2, and later in 2. Nine were asymptomatic. In the adult group, 20 patients were treated for complications. Thoracotomy was performed in 2 children and thoracoscopy in 9 (no conversion). A thoracoscopic operation was performed in 9 adults (2 conversions), and 17 adults required additional procedures (4 pericardial and 9 lung resections, 3 bronchial, and 1 esophageal sutures). The average length of hospitalization was 4.45 days for children (3.33 days in the thoracoscopic subgroup) and 8 days for adults. Mean maximal cyst diameter was 2.2 cm in children and 6.5 cm in adults (p < 0.10). Pathologic study revealed inflammatory reaction in 2 children (18%) vs 21 adults (84%; p < 0.001). Conclusions: Early surgical resection of BCs provides better conservation of pulmonary parenchyma, a lower incidence of inflammatory lesions, and a reduced rate of complications, and should be proposed after prenatal diagnosis, between the 6th and 12th month of life. [ABSTRACT FROM AUTHOR]

Background: Whereas proximal airways of patients undergoing lung cancer surgery are known to present specific microbiota incriminated in the occurrence of postoperative respiratory complications, little attention has been paid to distal airways and lung parenchyma considered to be free from bacteria. We have hypothesized that molecular culture-independent techniques applied to distal airways should allow identification of uncultured bacteria, virus, or emerging pathogens and predict the occurrence of postoperative respiratory complications. Methods: Microbiological assessments were obtained from the distal airways of resected lung specimens from a prospective cohort of patients undergoing major lung resections for cancer. Microorganisms were detected using real-time polymerase chain reaction (PCR) assays targeting the bacterial 16s ribosomal RNA gene and Herpesviridae, cytomegalovirus (CMV), and herpesvirus simplex. All postoperative microbiological assessments were compared with the PCR results. Results: In all, 240 samples from 87 patients were investigated. Colonizing agents were exclusively Herpesviridae (CMV, n = 13, and herpesvirus simplex, n = 1). All 16s ribosomal RNA PCR remained negative. Thirteen patients (15%) had a positive CMV PCR (positive-PCR group), whereas the remaining 74 patients constituted the negative-PCR group. Postoperative pneumonia occurred in 24% of the negative-PCR group and in 69% of the positive-PCR group (p = 0.003). Upon stepwise logistic regression, performance status, percent of predicted diffusion lung capacity for carbon monoxide, and positive PCR were the risk factors of postoperative respiratory complications. The CMV PCR had a positive predictive value of 0.70 in prediction of respiratory complications. Conclusions: When tested by molecular techniques, lung parenchyma and distal airways are free of bacteria, but CMV was found in a high proportion of the samples. Molecular CMV detection in distal airways should be seen as a reliable marker to identify patients at risk for postoperative respiratory complications. [Copyright &y& Elsevier]

Background: Reflux esophagitis is a significant problem after esophagectomy and gastric reconstruction. When mixed reflux damages the esophageal remnant or results in aspiration problems, appropriate medical management is in order. If medical management fails, a surgical option is available. This study reports results of a Roux-en-Y diversion in postesophagectomy patients affected by debilitating reflux complications. Methods: Between 1990 and 2006, 4 of 223 esophagectomy patients required surgical correction for mucosal damage to their esophageal remnant or repeat aspirations. Patient, clinical, operative, histopathologic, and postoperative data were collected. Results: Two of 3 patients with a substernal reconstruction underwent antrectomy with a 60-cm Roux-en-Y diversion. One patient with significant reflux disease and aspiration episodes also had a gastrobronchial fistula. The gastric interposition was defunctionalized, and a staged reconstruction with antrectomy and a Roux-en-Y diversion was completed. One patient with a prevertebral reconstruction had a Roux-en-Y diversion without antrectomy. There was no mortality and minimal morbidity. Two patients are asymptomatic and 2 are improved. Endoscopic assessment documented normal mucosa in the esophageal remnant for 2 of the 4 patients postoperatively; in 2 others, metaplastic columnar mucosa persisted. Active inflammation regressed in all 4 patients. Conclusions: Complete duodenal diversion with a 60-cm Roux-en-Y gastrojejunostomy is an effective operation to correct debilitating reflux complications after esophagectomy. Reflux symptoms are corrected and the mucosa is allowed to heal. The surgical approach is influenced by the position of the gastric transplant. Protection of the vascular supply to the gastric tube is the challenge of the operation. [Copyright &y& Elsevier]

Background: Long-term outcome of patients treated for a spontaneous esophageal rupture (Boerhaave’s syndrome) is seldom reported. Methods: From 1989 to 2004, 62 esophageal perforations were treated in a single institution. Eighteen patients presented with a spontaneous esophageal rupture. Among them, 15 could be treated with a transthoracic primary repair and constituted the material of the present study. A chart review was performed with special attention to survival, residual symptoms, and anatomic and motility disorders. Results: Three patients died postoperatively (20%). At last follow-up, 10 patients were alive and 2 had died from unrelated causes. At a median delay of 13 months (3 to 74), 7 patients accepted to undergo complementary investigations. None of them had any anatomic abnormality as checked by barium swallow. Six patients complained of mild symptoms from gastroesophageal reflux. Six patients (85%) presented with esophageal motility disorders on manometry and 4 (54%) had nocturne chronic reflux disease on pH monitoring. Two patients underwent endoscopic ultrasonography, of which one presented with a focal absence of one layer of the esophageal wall within the area of the suture. With time, no patient experienced recurrence, but one developed a cancer in the cervical esophagus. Conclusions: These results suggest that esophageal functional disorders are the rule after primary repair of a Boerhaave’s syndrome. Whether or not these findings are causal, coincidental, or related to the surgical treatment remains unclear. However, performance of routine postoperative explorations is strongly encouraged for a better understanding of this challenging condition. [Copyright &y& Elsevier]

Clamshell incision with transverse sternotomy is the approach of choice for bilateral lung transplantation when cardiopulmonary bypass becomes necessary or to improve exposure. Sternal dehiscence is a well-known complication of this approach. This results in chronic thoracic pain and contributes to a delayed pulmonary rehabilitation. Sternal dehiscence can be treated with conservative therapy, but severe dehiscence requires secondary surgical closure. Several techniques of osteosynthesis have been reported with conflicting results. We describe the first use of the STRAsbourg Thoracic Osteosyntheses System (STRATOS) devices in three cases of secondary sternal closure without infection after bilateral lung transplantation. [Copyright &y& Elsevier]

• The number of octogenarians with an early-stage NSCLC almost doubled each 5-year interval of the study period. • The implementation of a dedicated geriatric pathway and the use of minimally invasive approaches were both associated with improved outcomes. • Overall survival was influenced by lower co-morbidity index, highest predicted postoperative DLCO values, and absence of diabetes mellitus. We investigated on the benefit/risk ratio of surgery in octogenarians with early-stage non-small cell lung cancer (NSCLC). From 2005–2020, 100 octogenarians were operated on for a clinical stage IA to IIA NSCLC. All patients had undergone whole body PET -scan and brain imaging. Operability was assessed according to current guidelines regarding the cardiopulmonary function. Since 2015, patients followed a dedicated geriatric evaluation pathway. Minimally invasive approaches were used in 66 patients, and a thoracotomy in 34. Clavien-Dindo grade ≥ 4 complications occurred in 15 patients within 90 days, including 7 fatalities. At multivariable analysis, the number of co-morbidities was their single independent prognosticator. Following resection, 24 patients met pathological criteria for adjuvant therapy among whom 3 (12.5 %) received platinum-based chemotherapy. Five-year survival rates were overall (OS) 47 ± 6.3 %, disease-free (DFS) 77.6 ± 5.1 %, and lung cancer-specific (CSS) 74.7 ± 6.3 %. Diabetes mellitus impaired significantly long-term outcomes in these 3 dimensions. OS was improved since the introduction of a dedicated geriatric assessment pathway (72.3 % vs. 6.4 %, P = 0.00002), and when minimally invasive techniques were used (42.3 % vs. 11.3 %; P = 0.02). CSS was improved by the performance of systematic lymphadenectomy (55.3 % vs. 26.9 %; P = 0.04). Multivariable and recursive partitioning analyses showed that a decision tree could be built to predict overall survival on the basis of diabetes mellitus, high co-morbidity index and low ppoDLCO values. The introduction of a dedicated geriatric assessment pathway to select octogenarians for lung cancer surgery was associated with OS values that are similar to outcomes in younger patients. The use of minimally invasive surgery and the performance of systematic lymphadenectomy were also associated with improved long-term survival. Octogenarians with multiple co-morbid conditions, diabetes mellitus, or low ppo DLCO values may be more appropriately treated with SBRT. [ABSTRACT FROM AUTHOR]

Mechanical characteristics of both the healthy ascending aorta and acute type A aortic dissection were investigated using in vitro biaxial tensile tests, in vivo measurements via transoesophageal echocardiography and histological characterisations. This combination of analysis at tissular, structural and microstructural levels highlighted the following: (i) a linear mechanical response for the dissected intimomedial flap and, conversely, nonlinear behaviour for both healthy and dissected ascending aorta; all showed anisotropy; (ii) a stiffer mechanical response in the longitudinal than in the circumferential direction for the healthy ascending aorta, consistent with the histological quantification of collagen and elastin fibre density; (iii) a link between dissection and ascending aorta stiffening, as revealed by biaxial tensile tests. This result was corroborated by in vivo measurements with stiffness index, β , and Peterson modulus, E p , higher for patients with dissection than for control patients. It was consistent with histological analysis on dissected samples showing elastin fibre dislocations, reduced elastin density and increased collagen density. To our knowledge, this is the first study to report biaxial tensile tests on the dissected intimomedial flap and in vivo stiffness measurements of acute type A dissection in humans. [ABSTRACT FROM AUTHOR]