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Objective: Cystic Fibrosis Foundation guidelines recommend annual diabetes screening by oral glucose tolerance test (OGTT) in pediatric patients with cystic fibrosis (CF) starting at the age of 10 years. Adherence to these guidelines proves to be challenging, and the nationwide screening rates are still considered suboptimal. The aim of this study was to assess and improve the screening rates at our large pediatric center., Methods: A 4-year retrospective audit of OGTT completion among pediatric patients with CF of age ≥10 years who are not yet diagnosed with diabetes was conducted. A collaborative working group was formed to identify the barriers to screening and formulate a quality improvement plan, which was monitored and evaluated for a 9-month period., Results: Diabetes screening rates determined by OGTT completion at our center showed a gradual decline during the COVID-19 pandemic from 2019 to 2022. Following the implementation of the quality improvement plan during the summer of 2023, there was a marked increase in OGTT ordering compliance by providers as well as test completion by patients. Notably, the fractional OGTT completion rate rose from 45% during the preintervention phase (January-April 2023) to 70% during the postintervention phase (May-September 2023)., Conclusion: Diabetes screening in pediatric patients with CF can be effectively improved by refining practices related to patient experience, care coordination, and laboratory testing strategies., (© The Author(s) 2024. Published by Oxford University Press on behalf of American Society for Clinical Pathology. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Aims: We aim to evaluate the clinical relevance and the prognostic value of arterial and venous renal Doppler in acute decompensated precapillary pulmonary hypertension (PH)., Methods and Results: The renal resistance index (RRI) and the Doppler-derived renal venous stasis index (RVSI) were monitored at admission and on Day 3 in a prospective cohort of precapillary PH patients managed in intensive care unit for acute right heart failure (RHF). The primary composite endpoint included death, circulatory assistance, urgent transplantation, or rehospitalization for acute RHF within 90 days following inclusion. Ninety-one patients were enrolled (58% female, age 58 ± 16 years). The primary endpoint event occurred in 32 patients (33%). In univariate logistic regression analysis, variables associated with RRI higher than the median value were non-variable parameters (age and history of hypertension), congestion (right atrial pressure and renal pulse pressure), cardiac function [tricuspid annular plane systolic excursion (TAPSE) and left ventricular outflow tract- velocity time integral], systemic pressures and NT-proBNP. Variables associated with RVSI higher than the median value were congestion (high central venous pressure, right atrial pressure, and renal pulse pressure), right cardiac function (TAPSE), severe tricuspid regurgitation, and systemic pressures. Inotropic support was more frequently required in patients with high RRI (P = 0.01) or high RVSI (P = 0.003) at the time of admission. At Day 3, a RRI value <0.9 was associated with a better prognosis after adjusting to the estimated glomerular filtration rate., Conclusion: Renal Doppler provides additional information to assess the severity of patients admitted to the intensive care unit for acute decompensated precapillary PH., Competing Interests: Conflict of interest: Over the last 3 years, J. Pichon declares no conflicts of interest. A. Roche declares no conflicts of interest. C. Fauvel reports grants or contracts from Pfizer and Novartis, consulting fees from Janssen and Payment or honoraria for lectures from Pfizer outside the submitted work. A. Boucly reports grants or contracts from Acceleron, Janssen, and MSD and Payment or honoraria for lectures from Janssen, Merck, and AOP Orphan outside the submitted work. O. Mercier reports grants or contracts from Edwards Lifescience, and consulting fees from MSD outside the submitted work. N. Ebstein declares no conflicts of interest. A. Beurnier declares no conflicts of interest. J. Cortese declares no conflicts of interest. M. Jevnikar declares no conflicts of interest. X. Jais declares grants or contracts from Acceleron, Janssen, Bayer, Merck, and payment or honoraria for lectures from Janssen and Merck outside the submitted work. M. Fartoukh reports grants or contracts from Funding: Fondation du Souffle (Profil COV), Funding: Fondation de l’AP-HP (Multicov trial), BioMérieux, and Payment or honoraria for lectures from Fisher & Paykel, BioMérieux, and Other financial or non-financial interests forme Pfizer outside the submitted work. E. Fadel declares no conflicts of interest. O. Sitbon reports honoraria for speaking, steering committees, and scientific advisory boards from Janssen, Bayer, Merck, Gossamer Bio, Ferrer, and United Therapeutics. D. Montani reports grants and personal fees from Acceleron, Janssen, Merck, and consulting fees from Accelron, Merck, Janssen, and payment or honoraria for lectures from Bayer, Janssen, and Merck outside the submitted work. G. Voiriot declares no conflicts of interest. M. Humbert reports grants and personal fees from Acceleron, Aerovate, Altavant, AOP Orphan, Bayer, Chiesi, Ferrer, Janssen, Merck, MorphogenIX, and United Therapeutics and payment or honoraria from Janssen and Merck outside the submitted work. L. Savale reports personal fees from Janssen and Janssen and MSD outside the submitted work., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

An aneurysm of the pulmonary artery is a rare but severe complication in patients suffering from pulmonary arterial hypertension. For these patients, a lung or heart-lung transplant is the only definitive therapy available. Our goal was to show a reconstruction strategy in a patient with a mismatch between the pulmonary artery and the donor aorta., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: Primary thoracic synovial sarcoma (SS) is a rare, high-grade, malignancy. Involvement of vital organs is frequent and may decrease the benefits of surgical resection. We reviewed our practice at a highly experienced thoracic-surgery centre to assess early- and long-term outcomes after surgery., Methods: We conducted a retrospective, observational, single-centre study of patients undergoing curative-intent surgery for primary thoracic SS between 1 January 2000 and 31 January 2021 as part of a multidisciplinary management. We assessed demographics, medical history, histopathology and follow-up information., Results: We enrolled 20 patients (13 males) with a median age of 40 years old and a median tumour size of 11 cm. Neoadjuvant chemotherapy was administered to 13 patients. Surgery consisted in extrapleural pneumonectomy (n = 7), extrapleural lobectomy (n = 5), chest wall resection (n = 4) or tumour resection (n = 4). R0 resection was achieved in 16 (80%) patients. Adjuvant therapy was given to 13 patients. 6 patients developed postoperative complications. The median hospital stay was 11.5 days. Overall survival at 2 and 5 years was 51% and 22%, respectively; median overall survival was 25 months and median disease-free survival was 8.5 months. Relapses occurred in 15 patients. By univariate analysis, incomplete resection was the only significant predictor of survival (P = 0.01)., Conclusions: Primary thoracic SS is an aggressive disease. Surgery included in a multimodal treatment may contribute to achieving a good outcome, providing that an R0 resection is obtained. Given the considerable technical challenges of surgery, patient selection and referral to an experienced centre are crucial to minimize morbidity and mortality., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

Objectives: Direct involvement of the superior vena cava (SVC) by non-small cell lung cancer (NSCLC) requires en-bloc tumour resection with complete vascular clamping and prosthetic replacement. We report the outcomes of this highly demanding procedure in the largest patient cohort to date., Methods: We searched our institution's database for patients who underwent complete en-bloc resection of NSCLC invading the SVC followed by prosthetic SVC replacement, between 1980 and 2018. Patients with cN2, cN3 or distant metastases were not eligible., Results: We identified 48 patients (38 males, 10 females; mean age of 57 years; tumour size, 1.9-17 cm). Neoadjuvant therapy was administered to 17 and adjuvant therapy to 31 patients. R0 resection was achieved in 41 (85%) patients; lymph node involvement was pN0 in 8, pN1 in 23, pN2 in 14 and pN3 in 3 patients. Five patients died within 30 days of surgery. Right pneumonectomy was significantly associated with postoperative death (P = 0.02). Postoperative complications developed in 13 other patients. No neurologic events related to SVC clamping occurred. Graft thrombosis developed in 2 patients. Median survival was 24 months; 3-, 5- and 10-year survival rates were 45%, 40% and 35%, respectively; and corresponding disease-free survival rates were 37%, 37% and 30%, respectively. By univariable analysis, only margin-free (R0) resection was associated with better survival (P = 0.02)., Conclusions: In highly selected patients with NSCLC involving the SVC, mortality is acceptable after complete en-bloc resection and prosthetic replacement done in an expert centre. SVC involvement should not preclude consideration of curative resection in selected patients., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: Echocardiographic right ventricular (RV) annular parameters are probably not as reliable to evaluate the surgical success in the postoperative period after pulmonary endarterectomy (PEA), whereas RV end-diastolic/left ventricular end-diastolic area ratio (RVEDA/LVEDA ratio) could be more useful. This study examined the relationship between RV annular parameters or RVEDA/LVEDA ratio and ideal cardiac index (ICI), before and after PEA., Methods: Among 80 patients who underwent PEA, the relationships between RVEDA/LVEDA ratio (21 patients), or tricuspid annular plane systolic excursion (32 patients), or systolic tricuspid annular velocity (55 patients) and ICI were modelled., Results: Forty-eight hours following PEA, mean pulmonary artery pressure decreased (26 ± 6 vs 46 ± 12 mmHg, P < 0.0001) and ICI improved (2.8 ± 0.8 vs 3.0 ± 0.9 l/min/m2, P = 0.02). In contrast to the moderate association between RV annular indices and ICI in the preoperative period, no significant relationship was found in the postoperative period (r = 0.54 and 0.17 for tricuspid annular plane systolic excursion and r = 0.46 and 0.16 for systolic tricuspid annular velocity, respectively). The RVEDA/LVEDA ratio significantly decreased postoperatively (0.97 ± 0.21 vs 1.19 ± 0.43, P = 0.002) and was correlated with ICI both in preoperative and postoperative periods (r = 0.57 and 0.57, respectively). There was a significant correlation between changes in RVEDA/LVEDA ratio and changes in total pulmonary resistance., Conclusions: Improved ICI and RVEDA/LVEDA ratio reflected the surgical success of PEA and lowering of total pulmonary resistances. In contrast to the RV/left ventricular area ratio, annular RV indices associated poorly with postoperative ICI. Recognizing this limitation is important in minimizing the overdiagnosis of RV dysfunction after PEA., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: Extracorporeal membrane oxygenation (ECMO) has become the standard of cardiopulmonary support during a sequential double lung transplant for pulmonary hypertension. Whether central or peripheral cannulation is the best strategy for these patients remains unknown. Our goal was to determine which is the best strategy by comparing 2 populations of patients., Methods: We performed a single-centre retrospective study based on an institutional prospective lung transplant database., Results: Between January 2011 and November 2016, 103 patients underwent double lung transplant for pulmonary hypertension. We compared 54 patients who had central ECMO (cECMO group) to 49 patients who had peripheral ECMO (pECMO group). The pECMO group had significantly more bridged patients who received emergency transplants (31% vs 6%, P = 0.001). The incidence of Grade 3 primary graft dysfunction requiring ECMO (14% vs 11%, P = not significant) and of in-hospital mortality (11% vs 14%, P = not significant) was similar between the groups. Groin infections (16% vs 4%, P = 0.031), deep vein thrombosis (27% vs 11%, P = 0.044) and lower limb ischaemia (12% vs 2%, P = 0.031) occurred significantly more often in the pECMO group. The number of chest reopenings for bleeding or infection was similar between the groups. The 3-month, 1-year and 5-year survival rates did not differ between the groups (P = 0.94)., Conclusions: Central or peripheral ECMO produced similar results during double lung transplant for pulmonary hypertension in terms of in-hospital deaths and long-term survival rates. Central ECMO provided satisfactory results without major bleeding provided the patient was weaned from ECMO at the end of the procedure. Despite the rate of groin and lower limb complications, peripheral cannulation remained the preferred solution to bridge the patient to transplant or for postoperative support.

Surgical strategy and long-term outcomes of patients with rupture of the ascending aorta, aortic arch and supra-aortic vessels following blunt thoracic trauma have been rarely reported. We reviewed our institutional experience between 1995 and 2016. We identified 2 patients with an innominate artery ruptures, 2 with an aortic arch ruptures and 1 with an ascending aorta rupture; all were induced by the posterior displacement of the anterior chest wall. All patients underwent open surgical repair. Cardiopulmonary bypass with antegrade cerebral perfusion was required in 2 cases. All patients were alive at the end of the follow-up (median 18 months; from 3 to 180 months) including 1 patient with cortical blindness.

Objectives: Surgery for thymic epithelial tumours (TETs) with pleural involvement is infrequently performed. Thus, the value of surgical therapy for primary or recurrent TETs with pleural involvement is not sufficiently defined yet., Methods: Twelve institutions contributed retrospective data on 152 patients undergoing surgery (1977-2014) on behalf of the ESTS Thymic Working group. Outcome measures included overall (OS), cause-specific (CSS) and disease-free (DFS) survival as well as freedom from recurrence (FFR)., Results: In 70.4% of cases, pleural involvement was present at the time of primary intervention, whereas 29.6% had surgery for recurrent disease involving the pleura. Pleural involvement resulted from thymomas (88.8%) and thymic carcinomas (11.2%). Forty extrapleural pneumonectomies (EPPs), 23 total pleurectomies (TPs), and 88 local pleurectomies (LPs) were performed (completeness of resection in 76.8%). OS for the entire patient population at 1, 3, 5 and 10 years was 96.4%, 91.0%, 87.2% and 62.7%, respectively. There was no statistically significant difference regarding FFR and OS for patients with local or advanced disease undergoing EPP, TP or LP. Thymic carcinomas in comparison with thymomas had a negative impact on OS [hazard ratio 6.506, P  = 0.002], CSS and FFR. Incomplete resections predicted worse OS [hazard ratio 6.696, P  = 0.003]., Conclusions: Complete resection remains the mainstay of treatment for TETs with pleural involvement. Study populations treated with EPP, TP and LP had similar survival that may be factual as observed, but in the presence of selection bias, we can further conclude from the results that EPP, TP and LP are equally effective procedures. Procedural choice depends upon the extent of tumour distribution. EPPs, TPs and LPs performed within a multimodality setting seem to be efficient procedures for local control of disease, as they yield excellent results regarding OS, DFS, CSS and FFR., (© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

We present the case of a 60-year old woman with a ruptured thoraco-abdominal aortic aneurysm (TAAA). It was a Type IV TAAA in the Crawford Classification. A mycotic origin was suspected as she had a known history of lymphocytic lymphoma. She underwent thoraco-abdominal aortic replacement with a good surgical result. Histopathological examination revealed destruction of the aortic layers due to inflammatory lymphomatous aortic infiltration. The patient fully recovered., (© The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: Locally advanced thymoma can often involve the phrenic nerve (PN) due to its location on the mediastinal pleura. However, en bloc resection including the PN may cause severe postoperative complications, especially in myasthenia gravis patients. The aim of the study was to determine whether a PN involved could be spared during thymoma resection., Methods: A retrospective study was conducted on patients who underwent resection of Masaoka Stage III and IV thymomas adherent, on digital palpation, to at least one PN in our institution between 1998 and 2012. An en bloc resection of the tumour with the invaded PN was performed unless patients with no preoperative PN paralysis had: both PN involved, compromised preoperative lung function, severe myasthenia gravis, severe comorbidities or minimal PN involvement (PN adherent to the edge of the tumour). All patients received postoperative radiation therapy., Results: There were 114 patients with a mean age of 57 years (range, 28-84). PN was spared in 73 patients (64%) and removed in 41 (36%). Sixty-five patients had Masaoka Stage III (57%) and 49 had Stage IV (43%); these were similar between both groups. On permanent histology, 6 (15%) of the resected PN were not involved, whereas a permanent postoperative PN palsy was found in 4 (5.4%) patients where the PN was spared. Postoperative mortality and morbidity were 0 and 15% in the spared group and 2.4 and 9.7% in the resected group, respectively (P = 0.56). Recurrence rate was significantly higher in the spared group (39.5 vs 19.5%; P = 0.02) but the 5-year disease-free survival rates (53.6 vs 66.8%, P = 0.14) and overall 5-year survival (85 vs 88%, P = 0.6) were not significantly different between the spared- and resected-PN groups, respectively., Conclusions: Sparing the PN during thymoma resection achieved good long-term and disease-free survivals in high-risk patients comparable with en bloc PN resection. However, it carried a higher risk of recurrence despite adjuvant radiation therapy.

Objectives: The management of malignant tumours invading the inferior vena cava (IVC) generally requires a high-risk surgery with low long-term benefits. Surgical treatment with resection and/or embolectomy of the IVC may, however, be beneficial in selected patients. We describe our experience with regard to patient selection, operative technique and outcomes through a standardized and simplified approach., Methods: Between 1996 and 2012, 37 patients underwent extended resection of malignant tumours invading the IVC. Tumour infiltration was located at the hepatic and suprahepatic segment in 23 patients (62%), the renal segment in 6 (16%), and the infrarenal segment in 8 (24%). Fourteen patients (38%) had right heart involvement, of whom 5 had a tumour thrombus located in the pulmonary arteries (PA)., Results: All the patients underwent a median laparotomy. A sternotomy with full liver mobilization was performed for tumours involving the PA, or the retrohepatic or supradiaphragmatic IVC. Cardiopulmonary bypass was performed in 15 patients (41%), with deep hypothermic circulatory arrest (DHCA) in 5 (14%). The 30-day mortality rate was 5.4%. The 1-, 5- and 10-year survival rates were 68.1, 45.7 and 40%, respectively, with a median survival of 18 months. Incomplete resection (R1 or R2) was the only parameter found to have a significant negative effect on survival (P = 0.003)., Conclusions: Radical resection of malignant tumours invading the IVC is feasible in carefully selected patients and may require CPB with or without DHCA. Morbidity and mortality are low and the survival rates acceptable, particularly in patients with complete resection of the tumour.

Bone is the most common metastatic site of breast cancer (BC) and sternal metastasis usually occurs in an isolated setting. We performed sternal reconstruction using a new total titanium custom-made neosternum after subtotal sternectomy for an isolated BC metastasis. Postoperative care was uneventful during a 7-day in-hospital stay. After a 6-month follow-up, the patient denied any shortness of breath, chest pain or limitation on her daily activities. The chest was stable without any paradoxical motion. Chest X-ray did not show any material fracture, pleural effusion or lung abnormalities. As it entails lower postoperative risk than previously existing reconstructive materials, the new material used in our sternal reconstruction may extend the existing range of indications of sternectomy for cancer with curative intent.

Aims: To investigate the physiological correlates of indices of RV function in a model of chronic pressure overload., Methods and Results: Chronic pulmonary hypertension (PH) was induced in piglets by ligation of the left pulmonary artery (PA) followed by weekly embolization of right lower lobe arteries for 5 weeks (the PH group, n = 11). These animals were compared with sham-operated animals (controls, n = 6). At 6 weeks, a subgroup of five PH pigs underwent surgical reperfusion of the left lung and four others were followed until 12 weeks without treatment. Right ventricular function was assessed using echocardiography and conductance catheter measurements. At 6 weeks, mean PA pressure was higher in PH group compared with controls (35 ± 9 vs. 14 ± 2 mmHg, P < 0.01). Although RV elastance (Ees) increased at 6 weeks in the PH group (0.55 ± 0.09 vs. 0.38 ± 0.05 mmHg/mL, P < 0.001), ventricular-arterial coupling measured by the ratio of Ees on PA elastance (Ea) was decreased (0.68 ± 0.17 vs. 1.18 ± 0.18, P < 0.001). There was a strong direct relationship between Ees/Ea and indices of RV function, while relationship between Ees and indices of RV function was moderate. Changes in indices of RV function with time and after left lung reperfusion were associated with changes in Ees/Ea., Conclusion: Usual indices of RV function are associated with ventricular-arterial coupling rather than with ventricular contractility in a model of chronic pressure overload.

Objectives: Local breast cancer recurrence is often viewed as an early sign of rapidly progressive metastatic disease for which chest wall resection (CWR) can provide no benefits. We retrospectively reviewed our experience with full-thickness CWR to determine whether long-term outcomes warranted this aggressive procedure., Methods: Between 2001 and 2012, 33 women (mean age, 50.7 years; range, 33-72 years) underwent en-bloc CWR with curative intent. Mean disease-free interval from initial tumour resection was 90.5 months (range, 2-252 months). Resection included skin, muscle and an average of 2.7 ribs (range, 1-8 ribs) and was extended to the sternum (n = 21), subclavian vessels (n = 9), lung (n = 8), pericardium (n = 8), phrenic nerve (n = 2) or T1 nerve root (n = 1). Complete R0 resection was achieved in 31 (94%) patients. Chest wall reconstruction was performed in 28 patients, with polytetrafluoroethylene mesh (n = 17) or titanium ribs (n = 11). A musculocutaneous flap was used in 17 (52%) patients., Results: Postoperative morbidity was 36%, with no deaths. Median follow-up was 33 months (range, 3-96 months). Median survival was 69 months and 1-, 3- and 5-year survival rates were 100, 81 and 63%, respectively. Recurrence developed in 13 patients, including 12 with distant metastases. Disease-free survival rates were 77, 57 and 50% after 1, 3 and 5 years, respectively. By univariate analysis, only resection extended to intrathoracic structures was associated with better survival (P = 0.033)., Conclusions: En-bloc full-thickness CWR eventually extended to adjacent structures provides acceptable morbidity and excellent long-term survival and should be considered the treatment of choice in locally recurrent breast cancer.

Objectives: The study aimed to determine the optimal surgical procedure to treat pulmonary artery sarcomas responsible for pulmonary hypertension., Methods: Between 1997 and 2010, 31 patients were treated surgically for pulmonary artery sarcomas. Sixteen patients were male; the mean age was 56 years (range, 26-78 years). Common symptoms were characteristic of acute or chronic pulmonary thromboembolic disease. Also, 21 patients experienced mild to severe pulmonary hypertension, with a mean total peripheral resistance of 473 dyn s cm(-5). Clinical presentation and preoperative work-up confirmed the suspicion of pulmonary artery sarcoma in 18 patients. The required surgical procedures included the following: pulmonary endarterectomy in 25 patients (combined with a right pneumonectomy in five and with a replacement of the main pulmonary artery by a homograft reconstruction in one), pneumonectomy only in five (three right and two left), with the use of cardiopulmonary bypass in three cases. In one patient, the right pulmonary artery only was replaced on cardiopulmonary bypass., Results: Final pathology showed 26 high-grade and five intermediate-grade sarcomas. The 30-day mortality was 13% (four patients). Repeat pulmonary resection was required in two patients due to recurrent disease. Moreover, 18 patients received adjuvant therapy. Mean follow-up was 19 months (range, 1-99 months); of the 11 patients alive at follow-up, four were noted to have recurrent disease. The 1-, 3- and 5- year survival was 63, 29 and 22%, respectively., Conclusions: The prognosis of this very infrequent disease remains poor. Bilateral pulmonary endarterectomy may yield significant survival rates because it provides completeness of resection without sacrificing the pulmonary vascular bed.

Objectives: The postoperative course following sternectomy for cancer carries significant morbidity due to paradoxical breathing, pulmonary infections and infectious complications. The purpose of this report is to evaluate the outcomes in patients undergoing sternal reconstruction using an innovative titanium rib bridge system (STRATOS)., Methods: From 2008 to 2011, 24 patients underwent sternectomy with a titanium rib bridge system reconstruction. Soft coverage tissue was performed concurrently using a prosthetic mesh and pedicled or free flaps. Postoperative data were collected prospectively., Results: The median age was 56 (31-85 years). The indications for sternal resection were primary sarcoma (n = 4), metastasis (n = 15) and radiation-induced sarcoma (n = 5). Twenty-one subtotal and three total sternectomies were performed. Resection margins included the anterior rib (n = 13, mean: 2/patient), clavicles (n = 9), breast (n = 4), superior vena cava (n = 1), pericardium (n = 5), phrenic nerve (n = 4), lung (n = 6) and diaphragm (n = 1). The stability of the chest wall typically required an average of two titanium bars and rib clips per patient. There was no perioperative mortality. Twenty-three patients were extubated within the first 24 h. The mean intensive care unit and hospital stay was 3.5 and 14 days, respectively. Wound infection did occur in one patient but did not require the removal of the titanium rib system. The postoperative forced expiratory volume in 1 s did not differ significantly from the preoperative status (P = 0.07)., Conclusions: After sternectomy for cancer, reconstruction with a titanium rib bridge system has low morbidity and permits a rapid return to baseline pulmonary mechanics.

Objective: Platinum-based chemotherapy followed by surgical resection of residual masses has become the standard treatment of patients with primary mediastinal non-seminomatous germ cell tumours (NSGCTs). Persistent serum tumour marker (STM) elevation after chemotherapy usually indicates a poor prognosis. We retrospectively assessed surgical outcomes in patients with high STM levels after chemotherapy for primary mediastinal NSGCT., Methods: Between 1983 and 2010, residual tumour excision was performed in 21 patients, 20 men and one woman with a median age of 30 years (range: 19-49 years), with primary mediastinal NSGCTs and high STM levels after platinum-based chemotherapy, followed by second-line chemotherapy in 11 patients., Results: Alpha-fetoprotein was elevated in all 21 patients and β-human chorionic gonadotropin in three patients. Permanent histology demonstrated viable germ cell tumour (n=13), teratoma (n=3) or necrosis (n=5). After surgery, the STM levels returned to normal in 11 patients. Eight patients are alive with a median follow-up of 98 months. The 5-year survival rate was 36% and was not significantly affected by the use of preoperative second-line chemotherapy. At univariate analysis, only postoperative STM elevation and residual viable tumour, indicating incomplete resection, were significantly associated with lower survival (P=0.018 and P=0.04, respectively)., Conclusion: In patients with primary mediastinal NSGCTs and elevated post-chemotherapy STMs, surgery is warranted when complete resection is deemed feasible. In specialized oncology centres, this aggressive approach can provide a cure in some patients.

Objective: Because pleuropneumonectomy is associated with a high mortality rate, its indication for the treatment of Masaoka stage IVa thymoma is debated. We reviewed retrospectively our single-center experience in order to determine if the benefits warrant the risk of such procedure., Methods: Between 1970 and 2009, 17 patients (12 men and 5 women) with a mean age of 44 years (range, 25-62 years) underwent a pleuropneumonectomy for a Masaoka stage IVa thymoma in our institution. Eight patients had recurrent thymoma after a mean postoperative period of 47 ± 28 months, and nine patients presented de novo with stage IVa disease. A multimodality treatment including chemotherapy, radiotherapy, or both was performed in 14 (82%) patients., Results: Eight patients (47%) experienced a major postoperative complication, including four broncho-pleural fistulae (23%). There were no operative deaths and the 30-day mortality was 17.6% (3/17). But two patients died at 2 and 3 months, increasing the postoperative mortality to 29.4% (5/17). Complete resection was achieved in 11 (65%) patients. By univariate analysis, myasthenia gravis was the only risk factor for broncho-pleural fistulae. With a median survival of 76 months and median follow-up of 59 months (range, 1-262 months), 5-year and 10-year survivals were 60% and 30%, respectively. During follow-up, a recurrence occurred in two patients at 26 and 87 months, respectively, which was treated medically without success., Conclusions: Pleuropneumonectomy for Masaoka stage IVa thymoma is associated with a high morbid-mortality rate. However, included in a multimodality strategy and in highly selected patients this procedure may provide good long-term survival., (Crown Copyright © 2011. Published by Elsevier B.V. All rights reserved.)

Objective: Whether double-lung transplantation (DLT) or heart-lung transplantation (HLT) is the best option in patients with pulmonary hypertension (PH) remains unclear. At our institution, patients with severe right ventricular dysfunction or congenital systemic-to-pulmonary shunt (CSPS) are preferentially treated with HLT. We sought to determine whether the outcomes warrant continuing this policy., Methods: We retrospectively reviewed cases of DLT (n=67) or HLT (n=152) performed for end-stage PH between 1986 and 2008 at our institution. According to the new clinical classification of PH, 147 patients were group I (pulmonary arterial hypertension group, of which 30 had CSPS), 24 were group III (PH associated with lung disease and/or hypoxaemia), 20 were group IV (chronic thrombo-embolic PH) and 20 were group V (sarcoidosis or histiocytosis X)., Results: Compared with the HLT group, the DLT group had less severe disease as reflected by a higher preoperative cardiac index (2.5 + or - 0.8 vs 2.0 + or - 0.4; P=0.0006), lower New York Heart Association (NYHA) functional class (3.4 + or - 0.4 vs 3.8 + or - 0.5; P<0.0001), lower rates of kidney failure (31% vs 66%; P<0.0001) and liver failure (13% vs 38%; P=0.0003) and less need for preoperative inotropic support (10% vs 25%; P=0.014). Nevertheless, survival after 1, 5, 10 and 15 years was not significantly different between the two groups (HLT group: 70%, 50%, 39% and 26%; and DLT group: 79%, 52%, 43% and 30%; respectively; P=0.932). Freedom from obliterative bronchiolitis-related death was significantly greater in the HLT group (100% at 1 year, 84% at 5 years and 74% at 10 years; compared with 98%, 70%, and 59%, respectively, in the DLT group; P=0.035)., Conclusions: In patients with end-stage PH, good long-term survival rates were obtained using either DLT or HLT. However, these results were achieved with preferential use of HLT in patients with right heart failure or CSPS. Obliterative bronchiolitis-related death was less common with HLT than with DLT., (Copyright 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.)

Bronchopulmonar intralobar sequestrations receive their arterial blood supply through anomalous arteries from the systemic circulation. Usually the lumen of the aberrant artery can be oversized, but it is unusual to find a true arterial aneurysm. Here, we report a case of a 40-year-old woman with this unusual evolution. Because of the potential risk of rupture, she was treated with a lobectomy associated with a resection of the aneurysm.

Objective: To identify factors that affect operative mortality and morbidity and long-term survival after completion pneumonectomy., Methods: We retrospectively reviewed the charts of consecutive patients who underwent completion pneumonectomy at our cardiothoracic surgery department from January 1996 to December 2005., Results: We identified 69 patients, who accounted for 17.8% of all pneumonectomies during the study period; 22 had benign disease and 47 malignant disease (second primary lung cancer, n=19; local recurrence, n=17; or metastasis, n=11). There were 50 males and 19 females with a mean age of 60 years (range, 29-80 years). Postoperative mortality was 12% and postoperative morbidity 41%. Factors associated with postoperative mortality included obesity (p=0.005), coronary artery disease (p=0.03), removal of the right lung (p=0.02), advanced age (p=0.02), and renal failure (p<0.0001). Preoperative renal failure was the only significant risk factor for mortality by multivariate analysis (p=0.036). Bronchopleural fistula developed in seven patients (10%), with risk factors being removal of the right lung (p=0.04) and mechanical stump closure (p=0.03). Overall survival was 65% after 3 years and 46% after 5 years. Long-term survival was not affected by the reason for completion pneumonectomy., Conclusion: Although long-term survival was acceptable, postoperative mortality and morbidity rates remained high, confirming the reputation of completion pneumonectomy as a challenging procedure. Significant comorbidities and removal of the right lung were the main risk factors for postoperative mortality. Improved patient selection and better management of preoperative renal failure may improve the postoperative outcomes of this procedure, which offers a chance for prolonged survival.

Two female patients aged 64 and 50 years, who had intra-pericardial tumors arising from the ascending aorta, are reported. Both patients were admitted with mediastinal mass. Surgery was performed by median sternotomy with complete excision. Histology revealed teratoma and ectopic thyroid. Tumors arising from the ascending aorta are very rare and should be considered in the differential diagnosis of the mediastinal masses.

Objective: Sleeve lobectomy is a widely accepted procedure for central tumors for which the alternative is pneumonectomy. The purpose of this study is to assess operative mortality, morbidity, and long-term results of sleeve lobectomies performed for non-small cell lung carcinoma (NSCLC)., Methods: A retrospective review of 218 patients who underwent sleeve lobectomy for NSCLC between 1981 and 2005 was undertaken. There were 186 (85%) men and 32 women with a mean age of 61.9 years (range, 19-82 years). Eighty patients (36.6%) had a preoperative contraindication to pneumonectomy. Right upper lobectomy was the most common operation (45.4%). Vascular sleeve resection was performed in 28 patients (12.8%) and was commonly associated with left upper lobectomy (n=20; 9.1%; p=0.0001). The histologic type was predominantly squamous cell carcinoma (n=164; 75%), followed by adenocarcinoma (n=46; 21%). Resection was incomplete in nine (4.1%) patients., Results: There were nine operative deaths; the operative mortality and the morbidity rates were 4.1% and 22.9%, respectively. A total of 14 (6.4%) patients presented with bronchial anastomotic complications: two were fatal postoperatively, seven patients required reoperation, three required a stent insertion, and two were managed conservatively. Multivariate analysis showed that compromised patients (p=0.001), current smoking (p=0.01), right sided resections (p=0.003), bilobectomy (p=0.03), squamous cell carcinoma (p=0.03), and presence of N1 or N2 disease (p=0.01) were risk factors for mortality and morbidity. Follow-up was complete in 208 patients (95.4%). Overall 5-year and 10-year survival rates were 53% and 28.6%, respectively. After complete resection, recurrence was local in 10 patients, mediastinal in 20, and distant in 25. By multivariate analysis, two factors significantly and independently influenced survival: nodal status (N0-N1 vs N2; p=0.01) and the stage of the lung cancer (stage I-II vs III, p=0.02)., Conclusions: For patients with NSCLC, sleeve lobectomy achieves local tumor control, even in patients with preoperative contraindication to pneumonectomy and is associated with low mortality and bronchial anastomotic complication rates. Postoperative complications are higher in compromised patients, smokers, N disease, right sided resections, bilobectomies, and squamous cell cancers. The presence of N2 disease and stage III significantly worsen the prognosis.

Objective: Several reports emphasize the importance of en-bloc resection as the optimal surgical treatment of lung cancer with chest wall invasion. We investigated possible factors which could affect long-term survival following radical resection of these tumors., Methods: Between 1981 and 1998, 100 patients (90 male; ten female), with a median age of 60 years (36-84), underwent radical en-bloc resection of non-small cell lung cancer (NSCLC) with chest wall involvement. Patients with superior sulcus tumors invading the thoracic inlet were excluded from this series. There were 43 squamous and 57 non-squamous tumors. The median number of resected ribs was three (1-5). Lung resection included 73 lobectomies, two bilobectomies, 18 pneumonectomies and seven segmentectomies. Chest wall resection also extended to the sternum in one patient, the transverse process in one, the costotransverse foramen and hemivertebrae in two. All patients had a complete resection. Sixty-three patients received postoperative radiotherapy and 12 received chemotherapy. Histological data, including differentiation and depth of chest wall invasion, were carefully reviewed. The effect of various factors on survival were studied., Results: There were four in-hospital deaths. Lymph node involvement was negative on surgical specimens in 65 patients, and 28 patients had positive N1 nodes; the final histology revealed seven N2 diseases. Chest wall invasion was limited to the parietal pleura in 29 patients and included intercostal muscles, bones and extrathoracic muscles in 67, 24 and seven cases, respectively. The overall 2-year survival rate was 41%. The 5-year survival for patients with N0, N1 and N2 disease was 22, 9 and 0%, respectively. A local recurrence occurred in 13 patients, with four having a new resection and 45 patients developing systemic metastases. The nodal status (N0-1 vs. N2; P=0. 026) and the number of resected ribs(<2 vs. >2; P=0.03) were survival predictors in univariate analysis. By multivariate analysis, the two independent factors affecting long-term survival were the histological differentiation (well vs. poorly differentiated; P=0. 01) and the depth of chest wall invasion (parietal pleura vs. others; P=0.024)., Conclusions: Histological differentiation and depth of chest wall involvement were the main factors affecting long-term survival in this series. The role of induction chemotherapy for tumors with poor prognosis should be investigated.

Objectives: To assess whether the use of video-assisted angioscopy would increase the outcome of pulmonary thromboendarterectomy (PTE)., Methods: PTE included a median sternotomy, intrapericardial dissection of the superior vena cava, institution of cardiopulmonary bypass, deep hypothermia and sequential circulatory arrest periods. It was always performed through two separate arteriotomies on both main intrapericardial pulmonary arteries, into which a rigid 5 mm angioscope connected to a video camera was introduced to increase the visibility and endarterectomies., Results: From January 1996 to July 1998, 68 consecutive patients (35 males and 33 females) aged 54.3 +/- 13.5 years underwent PTE. Patients were in New York Heart Association (NYHA) class II (n = 2), III (n = 43) or IV (n = 23) with the following hemodynamics: mean pulmonary arterial pressure (PAP) 54 +/- 13 mmHg; cardiac output (CO): 3.8 +/- 0.8 l/min, and total pulmonary resistance (TPR): 1207 +/- 416 dyne x s x cm(-5). The cumulated circulatory arrest time was 23 +/- 12 min and postoperative length of ventilatory support 10 +/- 12 days. Nine patients died, for an overall in-hospital mortality of 13.2%. The functional outcome in surviving patients was significantly improved (P < 0.0001) both clinically (NYHA class 3.2 +/- 0.5 vs. 1.3 +/- 0.6) and hemodynamically (PAP (mmHg) 53.1 +/- 13 vs. 30.2 +/- 11.8, CI (l/min per m2) 2.1 +/- 0.5 vs. 2.8 +/- 0.6, TPR (dyne x s x cm(-5)) 1174 +/- 416 vs. 519 +/- 250)., Conclusions: Video-assisted angioscopy improves the quality and degree of pulmonary endarterectomy expanding the indications to include patients with previously inaccessible distal disease.

Objective: To evaluate the influence of either incision on the lungs and chest wall., Methods: Ninety-two double lung (DLT) or heart-lung (HLT) transplantations were done since January 1990. There were 22 (24%) hospital deaths, leaving 70 patients with complete data for evaluation. We did 38 DLT and 32 HLT for end-stage chronic respiratory failure (n = 22) and primary (n = 34) or secondary (n = 14) pulmonary hypertension, using 37 fourth or fifth interspace clamshell incisions and 33 median sternotomies., Results: The clamshell group included a higher percentage of DLTs (73 vs. 33%, P = 0.001) but recipient age, gender, preoperative diagnosis, bronchial anastomotic complications, number of cytomegalovirus infection, episode of acute rejection per patient-months and incidence of bronchiolitis obliterans were not statistically different between the two groups. At a follow-up time of 3.7 +/- 2 years, the overall 5-year survival of 57% was not influenced by the type of incision. The clamshell incision caused sternal over-riding in 12 (32%) patients, and eight surgical clamshell revision were necessary as compared with one median sternotomy (P = 0.02). The clamshell incision was associated with a significantly higher incidence of postoperative chronic pain (27 vs. 6%, P = 0.02). Postoperative mechanical properties of the chest wall were significantly (P < 0.0001) worse in the clamshell-group patients while the intrinsic properties of the airways were not different., Conclusions: The clamshell incision results in more postoperative deformity, chronic pain, and impaired function as compared with median sternotomy. A bilateral anterolateral thoracotomy without division of the sternum is proposed for the sequential bilateral lung transplantation technique.

Background: Diarrhea is a serious side effect that may prevent the administration of high doses of the antitumor drug Irinotecan (CPT-11)., Purpose: Intensive, high-dose loperamide was used in an attempt to control or downstage CPT-11-induced diarrhea and thus permit the use of higher dose intensities of CPT-11., Methods: Twenty-three patients with various cancers were treated with doses of CPT-11 ranging from 400 to 600 mg/m2, administered as a 30-minute intravenous infusion every 3 weeks. Starting 8 hours or more after the administration of CPT-11, any episode of diarrhea was treated with 2 mg of loperamide taken every 2 hours. Patients stopped taking loperamide only after a 12-hour diarrhea-free period. If diarrhea was not controlled after 3 consecutive days of nonstop loperamide intake, or if the patient was dehydrated, loperamide was stopped and the patient was hospitalized for intravenous fluids. If blood or mucus were found in the stools at any time during diarrhea, loperamide was stopped and the patient was hospitalized., Results: Seventeen of 23 patients had diarrhea while on CPT-11 treatment. Eighty-two CPT-11 cycles were administered to these 17 patients, and diarrhea occurred in 49 of these cycles, at a median time-to-onset of 6 days after CPT-11 administration. The loperamide protocol was followed in 46 of the 49 episodes of diarrhea, with 21 capsules of loperamide the median number being taken (range, 5-72). Only one patient was hospitalized for failure to respond to loperamide, and no major toxicity was associated with loperamide use. Fourteen of the 17 patients who experienced diarrhea were rechallenged with CPT-11 three or more times, and seven patients six or more times., Conclusions: High-dose loperamide controlled diarrhea in patients receiving CPT-11 and allowed administration of higher doses of CPT-11., Implications: The effectiveness of CPT-11 might be increased by higher dose intensities, which can be made tolerable by control of diarrhea with loperamide.