Search

Objectives: It was previously shown that dehydroepiandrosterone (DHEA) reverses chronic hypoxia-induced pulmonary hypertension (PH) in rats, but whether DHEA can improve the clinical and hemodynamic status of patients with PH associated to chronic obstructive pulmonary disease (PH-COPD) has not been studied whereas it is a very severe poorly treated disease., Patients and Methods: Eight patients with PH-COPD were treated with DHEA (200mg daily orally) for 3 months. The primary end-point was the change in the 6-minute walk test (6-MWT) distance. Secondary end-points included pulmonary hemodynamics, lung function tests and tolerance of treatment., Results: The 6-MWT increased in all cases, from 333m (median [IQR]) (257; 378) to 390m (362; 440) (P<0.05). Mean pulmonary artery pressure decreased from 26mmHg (25; 27) to 21.5mmHg (20; 25) (P<0.05) and pulmonary vascular resistance from 4.2UI (3.5; 4.4) to 2.6UI (2.5; 3.8) (P<0.05). The carbon monoxide diffusing capacity of the lung (DLCO % predicted) increased significantly from 27.4% (20.1; 29.3) to 36.4% (14.6; 39.6) (P<0.05). DHEA treatment did not change respiratory parameters of gas exchange and the 200mg per day of DHEA used was perfectly tolerated with no side effect reported., Conclusion: DHEA treatment significantly improves 6-MWT distance, pulmonary hemodynamics and DLCO of patients with PH-COPD, without worsening gas exchange, as do other pharmacological treatments of PH (trial registration NCT00581087)., (Copyright © 2012 Elsevier Masson SAS. All rights reserved.)

Respiratory amyloidosis is a rare disease which refers to localized aberrant extracellular protein deposits within the airways. Tracheobronchial amyloidosis (TBA) refers to the deposition of localized amyloid deposits within the upper airways. Treatments have historically focused on bronchoscopic techniques including debridement, laser ablation, balloon dilation, and stent placement. We present the outcomes after rigid bronchoscopy to remove the amyloid protein causing the airway obstruction in 6 cases of tracheobronchial amyloidosis. This is the first report of primary diffuse tracheobronchial amyloidosis in our department; clinical features, in addition to therapy in the treatment of TBA, are reviewed. This paper shows that, in patients with TBA causing airway obstruction, excellent results can be obtained with rigid bronchoscopy and stenting of the obstructing lesion.

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.

Background: In the current practice of lung transplantation, donor and recipient genders are neither directly considered nor matched. However, some data have suggested a possible effect of gender combinations on survival following lung transplantation., Methods: A total of 249 adult lung transplant recipients at a single center between February 1988 and December 2008, were analyzed retrospectively for donor-recipient gender matching. We compared the mortality by calculating one-term survival rates after transplantation using the Kaplan-Meier method with comparisons using the log-rank (Mantel-Cox) test. Statistical significance of the mean effects of size matching was assessed by paired Student t tests and Wilcoxon signed rank tests., Results: Kaplan-Meier survival analysis shown that male compared to female recipients did not have an effect on outcomes after lung transplantation at 5 years (P=.5379), 10 years (P=.107), 15 years (P=.0841), 20 years (P=.0711). No effect of gender on lung transplantation outcomes was observed with donor-recipient gender mismatches at 5 years (P=.1804), 10 years (P=.1457), 15 years (P=.0731), or 20 years (P=.0629). Similarly, no differences were observed for each gender combination. The degree of size matching was defined as the ratio of donor-to-recipient predicted total lung capacity. The ratios were similar for the donor-recipient gender match and significantly different for the donor-recipient gender mismatch., Conclusions: These analyses suggested that gender was not a significant independent risk factor affecting survival after lung transplantation. Size mismatch caused by gender mismatch did not increase mortality., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Spontaneous haematoma of the oesophagus is a rare cause of chest pain. We report the case of a 63-year-old female in whom spontaneous rupture of the oesophagus was suspected, but who was subsequently, found to have a dissecting intramural haematoma of the oesophagus. She successfully underwent mediastinal and thoracic drainage by right video-assisted thoracoscopy. Although conservative treatment is widely described in the literature, surgical treatment by right video-associated thoracoscopy may be a suitable alternative if there is a diagnostic doubt.

Orthopedic pins and wires are regularly used for the treatment of bone fractures and dislocations. Migration of these devices from the shoulder into the thoracic cavity is an uncommon but well-known complication. However, great vessels' injuries by a migrated wire are extremely rare. We report the case of a 78-year-old woman with a penetrating injury of the ascending thoracic aorta and the superior vena cava caused by migration of a Steinman wire that was used for percutaneous fixation of a left-shoulder dislocation 5 years earlier. There was no hemothorax, hemomediastinum, or hemopericardia, but hemoptysis was present. Such a case has not been previously described. The patient was treated by an emergency median sternotomy with a favorable outcome., (Copyright © 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.)

Background: Cisplatin-based adjuvant treatment of non-small cell lung cancer (NSCLC) has become standard, thanks to the studies that have shown a significant survival advantage. The identification of patients who could benefit from this adjuvant treatment would allow ineffective and toxic administrations to be avoided. Immunohistochemical expression of the excision repair cross-complementation group (ERCC)-1 protein has been associated with response to platinum-based chemotherapy in patients with NSCLC, and some polymorphisms of the genes involved in DNA repair have been shown to be associated with survival in advanced NSCLC., Objective: The aim of our study was to evaluate the progression-free survival and tolerability of adjuvant treatment with platinum-based chemotherapy in patients with NSCLC, according to common DNA repair gene polymorphisms and ERCC1 expression., Methods: We investigated the association of three DNA repair gene polymorphisms - Asn118Asn in ERCC1 (rs11615), Lys751Gln in ERCC2 (rs13181), and Asp1104His in ERCC5 (rs17655) - with the progression-free survival of 85 patients treated with platinum-based chemotherapy after surgery for NSCLC., Results: We did not find significant associations between any of these polymorphisms and progression-free survival, nor did we observe any difference in progression-free survival according to ERCC1 expression., Conclusion: The previously reported impact of DNA repair gene polymorphisms on platinum-based chemotherapy treatment of advanced NSCLC was not observed in our study in the adjuvant setting.

Purpose: The aim of this work was to non-invasively establish the feasibility of assessing 2-deoxy-2-[(18)F]fluoro-D-glucose ((18)F-FDG) lung metabolism with the use of a late dynamic positron emission tomograpy (PET) acquisition, i.e., beyond 2 h after injection., Procedures: The present method has been probed in 11 patients without any respiratory disease, under fasting conditions, by assessing mean values of (18)F-FDG lung metabolism. A kinetic model analysis has been implemented on a simple calculation sheet. An arbitrary (population based) input function has been used in each individual, which was obtained from literature data., Results: In the healthy lung, no (18)F-FDG release was found, and the mean values (±SD) of the (18)F-FDG uptake rate constant and of the fraction of the free tracer in blood and interstitial volume were: K = 0.0016 min(-1) (±0.0005), and F = 0.18 (±0.10), respectively. These results were in very close agreement with literature data that were obtained by both three-compartment model analysis and Patlak graphical analysis (gold standards), and that used an invasive blood sampling. Furthermore, K and the standard uptake value index have been compared., Conclusion: We conclude that assessing lung metabolism of (18)F-FDG in humans with the use of late dynamic PET imaging is feasible. The arbitrary input function of this non-invasive feasibility study could be replaced in further experiments by an input function obtained by arterial sampling. It is suggested that this method may prove useful to quantify (18)F-FDG lung metabolism under pathological conditions.

Mediastinal germ cell tumors are a rare heterogeneous entity. This study tries to determine the prognostic factors of these tumors. We designed a retrospective study of 31 patients with primary mediastinal germ cell tumors treated in three centers, in France, from 1986 to 2009. The data were statistically reviewed; univariate and multivariate analyses were performed. Twenty-nine patients were males and two were females (sex ratio 14.5) with a median age of 28 years (range 16-60 years), including: non-seminomatous germ cell tumors 61.3% (n=19), seminoma 32.3% (n=10) and immature teratoma 6.4% (n=2). They had extramediastinal disease at diagnosis in 53% (n=16). The five-year overall survival (OS) was 56.3%. Univariate analysis showed that age, gender, extent of disease at diagnosis, tumor markers at diagnosis and normalization of markers after first-line chemotherapy were not statistically significant, meanwhile tumor histology (P=0.009), surgical resection of the tumor (P=0.023), and pathological evidence of persistent viable tumor in resected remnants (P=0.008) were statistically significant. Multivariate analysis identified surgical resection of the tumor as an independent favorable factor of OS (OR=5.10; 95% CI 1.49-17.45; P=0.009). Determining relevant prognostic factors has been difficult until now, largely because of the low incidence of these tumors. Raising the patient numbers by expanding the centers studied may allow the prognostic factors to be identified more precisely.

In this article, a new technique for turn-over jejunal graft without kinking of its mesenteric vessels is described. Graft necrosis occurred on a left colon oesophageal reconstruction performed for a 56-year-old-woman. A salvage oesophageal reconstruction was performed by a long-segment, supercharged, pedicled anisoperistaltic ileum. Regurgitations were permanent in spite of medical treatment. Segmental reverse of ileum loops was used to turn over the direction of peristaltism without mesenteric twisting. The technique has never been described previously., (Copyright 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.)

The purpose of this study was to assess the mortality and risk factors of complications after pneumonectomy for lung cancer. Between 1996 and 2001, we reviewed and analysed the demographic, clinical, functional, and surgical variables of 168 patients to identify risk factors of postoperative complications by univariate and multivariate analyses with Medlog software system. The mean age was 60+/-10 years, overall mortality and morbidity rates were 4.17% and 41.6%, respectively. All frequencies of respiratory complications were 1.2% for acute respiratory failure, 10.1% for pneumonia, 2.4% for acute pulmonary oedema, 4.17% for bronchopleural fistula, 2.4% for thoracic empyema and 18.5% for left recurrent nerve injuries. Postoperative arrhythmias developed in 46% of our patients. The risk factors for cardiopulmonary morbidity and mortality with univariate analysis were advanced age (P<0.01), preoperative poor performance status (P<0.015), and chronic artery disease (P<0.008). Factors adversely affecting morbidity with multivariate analysis included age (P=0.0001), associated cardiovascular disease (P=0.001), and altered forced expiratory volume in 1 s (P=0.0005). Complications after pneumonectomy are associated with high mortality. Careful attention must be paid to patients with advanced age and heart disease. Chest physiotherapy is paramount to have uneventful outcomes.

This retrospective study was carried out to evaluate the indications for and outcomes of the hemiclamshell (HCS) approach (longitudinal partial sternotomy with antero-lateral thoracotomy) in patients undergoing mass resection in thoracic surgery. All patients (50) who underwent a HCS procedure in our department, between July 1996 and July 2005, were studied retrospectively, analyzing the indications, morbidity and outcome (pain, neurological or shoulder defects, mortality) at one month and one year. The main indications were apical tumours (38%), tumours of the cervicothoracic junction (46%) and chest wall (10%), and 'bulky' tumours (6%). One-month mortality was 6%. Two patients suffered from a chylothorax and one from phrenic paralysis. The postoperative analgesic requirements were similar to those after other thoracic surgery approaches. Twelve percent of patients suffered pain at one month and 6% at one year. Shoulder dysfunction was observed in 10% of patients at one month and 6% at one year. In conclusion, the HCS surgical approach was associated with an uncomplicated postoperative course. This anterior approach is suitable for apical tumours, tumours of the cervicothoracic junction and 'bulky' lung tumours, providing good access for control of the large vessels and radical mediastinal clearance.

Congenital cystic adenomatoid malformation is rare in adults, and often asymptomatic. We describe a case of malignant degeneration of a congenital cystic adenomatoid malformation in a 77-year-old man. Congenital cystic adenomatoid malformation must be considered a premalignant lesion, even in older patients. Rigorous preoperative staging must be undertaken. Anatomic resection with extensive lymphadenectomy remains the treatment of choice.

Background: One of the characteristics of chronic obstructive pulmonary disease (COPD) is the tendency to develop acute exacerbation, defined by the presence of different clinical findings as worsening dyspnea, increase in sputum purulence and volume. This study was designed to verify if definition of acute COPD exacerbation is applicable to patients who underwent pulmonary surgery, and if it has any impact on postoperative morbidity and mortality., Methods: This study was designed to prospectively enrol 1000 patients undergoing pulmonary resection for lung cancer from five different centres. Postoperative exacerbation of COPD was defined by the concomitant presence of three of the following five signs: deteriorating dyspnea, purulent sputum, bronchial secretion volume >10 ml/24 h, fever without apparent cause, and wheezing. The presence of concomitant pulmonary complications excluded the diagnosis of exacerbation, as they may present one or more of these signs., Results: In the absence of respiratory complications, postoperative stay in exacerbated patients was significantly longer as compared to patients without exacerbation (6.3+/-1.3 vs 8.3+/-1.1, p=0.001). A postoperative exacerbation of COPD was recorded in 276 patients and 152 of them (55%) subsequently developed respiratory complications. Multivariate analysis established that risk factors for postoperative exacerbation are sex (female OR 0.54, CI 0.2-0.8), COPD class (OR 1.5, CI 1.1-8.1), and the postoperative prolonged use of antibiotics (OR 0.6, CI 0.2-0.9)., Conclusions: Postoperative exacerbation of COPD is an existing, frequent clinical entity after lung resection and, when present, it increases the risk of pulmonary complications. The existing guidelines for the treatment of acute exacerbation should be adapted for the management of patients after lung resection in order to test the hypothesis that they could reduce respiratory morbidity.

Introduction: In France, the average age for the diagnosis of bronchial carcinoma is 64. It is 76 in the population of over 70. In fact, its incidence increases with age linked intrinsic risk of developing a cancer and with general ageing of the population. Diagnosis tools are the same for elderlies than for younger patients, and positive diagnosis mainly depends on fibreoptic bronchoscopy, complications of which being comparable to those observed in younger patients., State of the Art: The assessment of dissemination has been modified in recent years by the availability of PET scanning which is increasingly becoming the examination of choice for preventing unnecessary surgical intervention, a fortiori in elderly subjects. Cerebral imaging by tomodensitometry and nuclear magnetic resonance should systematically be obtained before proposing chirurgical treatment. An assessment of the general state of health of the elderly subject is an essential step before the therapeutic decision is made. This depends on the concept of geriatric evaluation: Geriatric Multidimensional Assessment, and the Comprehensive Geriatric Assessment which concerns overall competence of the elderly., Perspectives: This is a global approach that allows precise definition and ranking of the patient's problems and their impact on daily life and social environment. Certain geriatric variables (IADL, BADL, MMSE, IMC etc) may be predictive of survival rates after chemotherapy or the incidence of complications following thoracic surgery. The main therapeutic principles for the management of bronchial carcinoma are applicable to the elderly subject; long term survival without relapse after surgical resection is independent of age. Whether the oncological strategy is curative or palliative, the elderly patient with bronchial carcinoma should receive supportive treatments. They should be integrated into a palliative programme if such is the case. In fact, age alone is not a factor that should detract from optimal oncological management., Conclusions: The development of an individual management programme for an elderly patient suffering from bronchial carcinoma should be based on the combination of oncological investigation and comprehensive geriatric assessment.

A simple technique to improve external surgical treatment of Zenker's diverticulum is presented. A rigid esophageal endoscopy is performed just before the operation. The diverticulum is explored and washed. A single lumen tracheal tube is inserted into the esophageal lumen to serve as a stent. The technique is safe and easy and improves the bacterial control of the operation field.

Background and Objectives: Patients undergoing thyroid surgery need postoperative pain management. Bilateral superficial cervical plexus block by administration of 0.25% bupivacaine with 1:200000 epinephrine at the end of surgery has been shown to improve postoperative analgesia. The objective of this study was to assess the analgesic efficacy in the first 36 postoperative hours after total thyroidectomy of bilateral superficial cervical plexus block with 0.75% ropivacaine administered before the incision or on completion of the surgical procedure., Methods: We performed a prospective double-blinded, randomized controlled trial that compared 3 parallel groups: the CONT group did not receive any block, the PRE group received bilateral superficial cervical plexus block before surgery while under general anesthesia, and the POST group received bilateral superficial cervical plexus block after surgery while under general anesthesia. The study included 111 patients (37 in each group). Postoperative pain was assessed every 4 hours by use of a 0 to 10 numeric rating scale. All patients received paracetamol every 6 hours. Morphine was administered following a standardized protocol if the numeric rating scale was 4 or higher. The main outcome variables were the proportion of patients given morphine during the 36 hours period, pain intensity scores, and morphine consumption., Results: No intergroup differences were observed in terms of percentage of patients who required morphine, morphine delivery, pain scores, and intraoperative opioid consumption., Conclusions: Bilateral superficial cervical plexus block with 0.75% ropivacaine administered before or after surgery does not improve postoperative analgesia after total thyroidectomy.

Objective: To define the role of interventional radiology and surgery respectively, in the treatment of massive haemoptysis. GENERAL CONSIDERATIONS: For the management of massive haemoptysis in non-terminal pathologies an intensive care facility and a multi-disciplinary team are necessary. It is of paramount importance to identify rapidly the pulmonary or bronchial source of the bleeding. CT scanning and bronchoscopy are essential to localise the bleeding and determine its cause. Initial management. An attempt to control the initial bleeding to allow localisation of its origin and determine the treatment., Treatment: Bronchial or systemic embolisation and surgery are the only effective medium and long-term treatments. Embolisation achieves excellent results in bleeding from bronchial or parietal systemic arteries prior to surgery and may be the only technique possible in the presence of major co-morbidity. Surgery is necessary in the case of failure, in certain specific conditions, and in the case pulmonary artery haemorrhage from a proximal lesion. Various surgical techniques are available depending on the type of lesion encountered and the facilities for post-operative care. Emergency surgery carries a high risk and deferred surgery gives better results., Conclusion: The management of massive haemoptysis should be multi-disciplinary. Intensive care, respiratory and radiological diagnosis, Surgical management and interventional radiology should be combined to improve the prognosis of this grave condition. Pulmonary arterial haemorrhage from a necrotic tumour constitutes a surgical emergency and should be operated on without delay.

Primitive liposarcomas of the pleura are exceptional tumours. We report a new case of primitive liposarcoma of the pleura revealed by chest pains in a 50 year old man. Computed tomography showed a large fat density mass in the left pleural cavity. Surgical resection was performed, completed with adjuvant radiotherapy. Few reports are available in the literary world. We present our case, review previously reported cases and discuss treatment.

Chylothorax is a rare but generally severe complication of surgery of congenital heart disease. The authors report the clinical history of a young boy with complex congenital heart disease operated on several occasions and who developed severe and recurrent unilateral chylothorac after a bicavo-bipulmonary derivation. Conservative treatment followed by continuous somatostatin infusion was ineffective. Diagnostic Lipiodol lymphography was required before the chylothorax was cured. The authors describe management of this difficult case and discuss the therapeutic possibilities with reference to a brief review of the literature.

Objectives: Boerhaave's syndrome is the most sinister cause of esophageal perforation responsible with mortality rate ranging from 20 to 30%. Combination of mediastinal contamination with microorganisms, gastric acid and digestives enzymes, long free interval between injury and initiation of treatment causes severe mediastinitis which is fatal in most untreated cases. The aim of this paper is to emphasize primary esophageal repair and resuscitation whatever the free interval from rupture and repair., Methods: A retrospective review of patients treated for Boerhaave's syndrome in our department from January 1980 to February 2003 was performed. The principle of treatment was surgical treatment and avoidance of esophageal exclusion or esophagectomy whichever was possible., Results: There were 25 patients (17 males and 8 females). All patients were operated on by primary esophageal repair, except for three who underwent immediate exclusion of the esophagus and one patient who deceased on arrival before being operated. Patients were classified according to free interval between perforation and treatment: group 1 (n=9; 36%) within the 24 h (range from 12 to 24 h) and group 2 (n=16; 64%) more than 24 h (range from 2 to 17 days). Altogether 6 patients deceased (24%). In hospital mortality rate for groups 1 and 2 was, respectively, 44% (four patients) and 13% (two patients), not significantly different. Mean hospital stay was 63 days. Two patients developed anastomotic leakage needing esophagectomy and retrosternal coloplasty in one or more steps. One patient developed pleural abscess treated by percutaneous drainage. Three patients presented temporary symptomatic esophageal stenosis, of whom one underwent dilation., Conclusions: Long free interval before treatment does not preclude primary esophageal repair in Boerhaave's syndrome. Esophageal exclusion may be more often than not avoided in most cases.

The degree of penetration of an antibiotic into the infection site is an important factor for its therapeutic efficacy, particularly in respiratory tract infections. In the present study, we examined the lung tissue diffusion of moxifloxacin at a dose of 400 mg administered intravenously or orally once-daily, and the results were correlated to microbiological data to estimate the clinical efficacy of moxifloxacin in lower community-acquired respiratory infections. This was a prospective, randomized, parallel-group trial, open-label, single-center study. Patients undergoing lung surgery for bronchial cancer which necessitates the removal of an anatomical piece of lung tissue were randomized into twelve treatment groups, dependent upon the time of surgery and the moxifloxacin formulation, i.v. or oral, administered. During surgery, one blood sample was taken at the time of tissue collection to determine moxifloxacin plasma concentration. At the same time, tissue samples were taken by pulmonary exeresis. A validated new high performance liquid chromatography assay was used to determine moxifloxacin concentrations in plasma and lung tissue. A total of 49 patients (25 for i.v. administration, 24 for oral administration, 44 men and 5 women, mean age, 61 years, mean body weight, 72 kg, mean creatinine clearance was 84 ml/min/1.73 m2) were enrolled. The mean +/- SD steady-state moxifloxacin ratios between lung and plasma concentrations were respectively: 3.53 +/- 1.89 and 4.36 +/- 1.48 for i.v. and oral administration. The mean steady-state moxifloxacin maximal lung concentrations (Cmax) were respectively 12.37 microg/g and 16.21 microg/g for i.v. and oral administration. Moxifloxacin both intravenously and orally exhibits high penetration in lung tissue, with tissue concentrations far above the MIC90s for most of the susceptible pathogens commonly involved, thus underlining its suitability for the treatment of community-acquired, lower respiratory tract infections.

Introduction: Zenker's diverticulum can be treated surgically or endoscopically. The aim of this study was to assess results of surgical approach with cervicotomy and diverticulectomy., Patients and Methods: We retrospectively studied the data of 73 patients (50 men and 23 women; mean age, 69 ans; extrêmes: 43-98) consecutively operated on for a Zenker's diverticulum between 1987 and 2000. Surgical procedure included diverticulectomy associated with a large myotomy and oesophageal calibration. Both early and long-term results were compared with those of published series of patients treated by stapled esophagodiverticulostomy., Results: Clinical manifestations were: dysphagia (97%), regurgitations (76%), aspirations (45%), weight loss (28%), lung infection (21%), or halitosis (3%). No patient died postoperatively. The early morbidity rate was 4% (3 patients). The mean delay for return of oral feeding and the mean length of hospital stay were respectively 6 and 8 days. At follow-up (mean follow-up, 6 years; extremes: 3 months-13 years), 72 patients (99%) were satisfied and 1 patient felt partially improved. Analysis of published results of series of endoscopic treatment revealed shorter lengths of hospital stay but less favourable long-term results., Conclusions: Early morbidity of surgical treatment of Zenker's diverticulum is low. Long term functional results could be better after surgical diverticulectomy with myotomy than after endoscopic stapled esophagodiverticulostomy.

A synchronous right pneumonectomy and left lung transplantation is reported in a case of asymmetric thorax. An extreme shift of the mediastinum and over distension of the transplanted lung is shown 3 years later. Post pneumonectomy syndrome must be seeking in this alternative technique., (Copyright 2002 Elsevier Science B.V.)

High grade lung neuroendocrine carcinomas, like small and large cell neuroendocrine carcinomas, pose therapeutic problems. Most initially respond to chemotherapeutic agents, but early relapses are frequent and are resistant to the presently available treatments. Our study reports for the first time the development and evaluation of a test for detecting the presence of circulating tumour cells by measuring chromogranin A gene transcripts with reverse transcriptase-polymerase chain reaction (RT-PCR) and Southern blotting. The test is specific and sensitive (detection of 10 cancer cells/ml blood), and only minimally invasive. Positivity is statistically correlated to high grade neuroendocrine carcinomas and to a poor prognosis with a 3-fold higher lethal risk. The test now needs to be assessed for its usefulness as a tool in the initial staging procedures and follow-up by comparison with the recent immunoradiometric assay (RIA) for detection of chromogranin A in the serum.

Primary cardiac tumors are rare and myxomas are the most frequent. Cystic lymphangiomas are most often of cervicomediastinal locations and are exceedingly rare in the mediastinum. Cystic lymphangioma involving the heart has never been reported. We report a case of cystic lymphangioma involving the posterior wall of left atrium mimicking a mediastinal tumor. Complete resection was performed via a median sternotomy under cardiopulmonary bypass and cardiac arrest after transection of the aorta and pulmonary trunk.

Objective: The objective of the study was to define timing of surgical treatment in management of massive hemoptysis., Methods: We performed a retrospective review of all patients admitted for massive hemoptysis in the intensive care unit of our thoracic surgery department. Treatment was managed according to the patient's status, the etiology of bleeding, the findings of bronchoscopy and computed tomographic scan. Therapeutic measures available were medical treatment, tracheal intubation (single or double lumen tube), interventional endoscopy, arterial embolisation and surgical treatment., Results: Between September 1996 and December 2001, 43 patients were treated (nine females and 34 males with mean age of 54 years, range from 32 to 79). The mean red cell blood transfusion per patient was 1.57 Units. The patients were classified into three groups: Group 1, 11 patients were operated on immediately close to the bleeding crise (five pneumonectomy and six lobectomy); Group 2, five patients for whom operation was delayed from the 7th to the 22nd day after cessation of bleeding (five lobectomy); Group 3, 27 patients were treated by non-surgical methods (medical treatment, endobronchial treatment, percutaneous embolisation). Fifteen patients underwent an arterial embolization, which was complete in 13 cases. Among the five patients of group 2, cessation of bleeding was obtained by bronchial embolisation in four cases. Considering the whole series, 10 (23%) patients died: three (19%) patients in group 1, zero in group 2, seven (26%) in group 3. In two patients who were suffering from tumor necrosis, hemoptysis relapsed leading to death., Conclusion: Emergency thoracotomy for massive hemoptysis is at high risk. In case of bleeding from the arterial bronchial vessels, embolization may enable to postpone surgery and operate secondarily. In case of bleeding from the pulmonary vessels (tumor necrosis), surgical treatment must be immediate. An algorithm for management is proposed.

A 39-year-old man complained of acute dysphagia and dorsal pain while eating fish. Radiologic and endoscopic studies revealed a retroesophageal mass, which was later shown to be a hematoma.

The Authors report a retrospective analysis of 29 patients who underwent thoracoplasty between 1990 and 1999. The mean follow-up period was 30 months. The median age was 55 years. The peri-operative mortality rate was 6.8%. The control of space obliteration, space infection and closure of the bronchopleural fistula was achieved in 27 patients. This article also discusses surgical history of thoracoplasty, technique adopted and its current application.

Gastrointestinal adenomas are neoplasms of glandular epithelium containing dysplasia of varying degrees. They are rare in esophagus. A case of villous tumor of the esophagus in a 71-year-old man is described. Histologically, this polypoid, villous lesion was developed on Barrett's esophagus and contained dysplastic epithelium and small adenocarcinomatous foci. This case illustrates that esophagus adenoma may be a premalignant lesion like other adenomas of the gastrointestinal tract. The term of polypoid dysplasia has therefore been recommended. This lesion, usually developed in gastric heterotopy or Barrett's esophagus, is often associated with high-grade dysplasia or carcinoma.

We describe the first case of infected mediastinitis associated with central venous catheter insertion. The rare occurrence of this complication may be explained by the fact that it results from central venous catheter-related bloodstream infection and catheter perforation of superior vena cava. The symptoms of this complication (chest pain, dyspnoea) are not specific. Diagnosis should be confirmed by chest x-ray and computerized tomography which show hydromediastinum and pleural effusion. Removal and subsequent culture of the catheter tip will confirm infection. Appropriate antibiotic therapy, guided by sensitivities of the cultured organisms, should be commenced. Any pleural effusion should be drained by thoracocentesis, and the pleural fluid cultured. In case of fever, bacteraemia or shock, a thoracotomy to drain mediastinal and pleural effusions may be considered.

A 68-year-old woman presented chest pain and exercise-induced dypnea for one year. Diagnosis was a thoracic solitary fibrous tumor. These tumors are very rare. Clinical outcome is generally good except in 13% of the cases with a malignant component. Complete surgical resection is required.

In the thymus, the relationship between lymphofollicular hyperplasia and mucosa-associated lymphoid tissue (MALT)-type lymphoma is uncertain. We analyzed 14 cases with a diagnosis of thymic follicular hyperplasia in patients with connective tissue disease (n = 2), myasthenia gravis (n = 11), or both (n = 1). In 11 cases, well-defined reactive lymphoid follicles were surrounded by a continuous layer of medullary epithelial cells. A polyclonal rearrangement of the immunoglobulin heavy chain gene (IgH) was observed. In 3 cases, ill-defined lymphoid follicles with sheets of centrocytic-like B cells disrupting the medullary cytokeratin epithelial network were observed on certain sections. These cells expressed the phenotypic features of memory B cells with CD20, CD79a, and bcl-2 positivity and CD5, CD10, CD23, and bcl-6 negativity, and a monoclonal rearrangement of the IgH gene was detected. Appropriate sampling, cytokeratin staining, and molecular analyses may help to identify early MALT-type lymphoma developing in the setting of thymic lymphofollicular hyperplasia.

Objective: To underline the severity of instrumental esophageal perforations and to discuss their management., Patients and Methods: Data from patients treated for instrumental esophageal perforation were collected retrospectively from 1980 to 1995 then prospectively since 1995 to 2000., Results: Fifty-four patients were treated for instrumental perforations. Perforation occurred after exploratory endoscopy (n = 24), endoscopic dilation (n = 13), attempted tracheal intubation (n = 5), foreign body extraction (n = 5), treatment of esophageal varices (n = 4), trans-esophageal echocardiography (n = 2), and duodenal prosthesis implantation (n = 1). Clinical manifestations were immediate in 18 cases and delayed in all others, with an interval before treatment ranging from 2 hours to 45 days (mean = 70 hours). All patients were operated after large spectrum antibiotherapy and intensive care, except 3 who were treated medically due to their poor general condition. Fourteen (26%) patients died, including the 3 non-operated ones., Conclusion: Instrumental esophageal perforations are associated with a high mortality, probably due to the poor general condition of the patients. Diagnosis of these perforations is often delayed. A good experience of endoscopic maneuveurs and adequate post-endoscopic monitoring could allow earlier surgical treatment with lower mortality.

Objective: To raise awareness of this complication of tracheal intubation, to emphasize the gravity due to delayed diagnosis, and to advocate a surgical treatment., Methods: Between April 1980 and January 2000, 97 patients were treated for esophageal perforation in our department. We reviewed the cases of perforation occurring after attempted tracheal intubation. Each case is presented. Discussion is focused on diagnosis and treatment., Results: Esophageal perforation occurred after attempted endotracheal intubation in five cases among 58 iatrogenic perforations. There were four women and one man (mean age 72 years). In all cases, it was for a planned operation. Intubation was performed by a single lumen tube in three cases and a double lumen tube in two cases. Presenting symptoms were acute in one case and insidious in four cases. Free interval before diagnosis and treatment was long in all but one case, with an average of 179 h (range 5--432). Two patients suffered from septic shock when they were transferred. All patients were operated on. Two patients died., Conclusion: Post intubation esophageal perforation is one of the most life threatening esophageal perforation. Delayed diagnosis is the first cause of gravity. Prevention of this complication begins with recognition of a potentially difficult intubation. Good outcome follows from rapid diagnosis and early surgical treatment.

Since January 1988 to December 1998, by the Department of Thoracic Surgery, Haut-Lévêque Hospital, University of Bordeaux, 68 consecutive patients were operated for myasthenia gravis. The aim of our study was to evaluate the results obtained in a group of patients who underwent a thymectomy for myasthenia gravis, in order to contribute for the determination of the prognostic factors which can influence the post-operative course. This series consists on 68 patients. Females were predominant, 41 patients (60.2%) versus 27 males (39.7%). The age extended between 15 and 80 years, average of 45.2 years. The follow-up concerned 52 patients (76.4%); out of there, 8 are in complete remission (15.3%), 31 (59.6%) are in a phase of clinical improvement, 11 patients did not benefit from thymectomy (21.1%), 1 patient died immediately after the surgical operation, I patient died some years after the surgical operation for another reason. In conclusion the thymectomy is a beneficial procedure for myasthenia gravis patients.

The Authors report a case of extraskeletal Ewing's sarcoma of thoracic wall in a 15-year-old sport-man, who complained about pain in the left upper extremity. The diagnosis was performed by radiology (ultrasound study, TC, RM) and pre-operative needle-aspiration biopsy. The patient was treated by neoadjuvant chemotherapy, wide surgical resection and, then, radiotherapy. Neither local recurrence nor metastases have developed for 8 months.

Known for its reliability, transoesophageal echocardiography is an investigation which is increasingly used in cardiology, cardiac surgery and intensive care units. It is a semi-invasive investigation of which oesophageal perforation is a very rare but serious complication. Two cases of oesophageal perforation after transoesophageal echocardiography are reported out of a series of 87 oesophageal perforations treated between January 1981 and February 1999. In both cases, transoesophageal echocardiography was performed in conscious patients without known pre-existing oesophageal pathology. The presentations were acute. Both patients underwent emergency surgery. One patient is alive and the other one died one month after a second operation related to the perforation. Nine cases of oesophageal perforation have been reported after transoesophageal echocardiography. The pathogenesis, means of prevention and treatment of oesophageal perforation are discussed.

The aim of this study was to develop a high-performance liquid chromatographic (HPLC) assay for the determination of moxifloxacin in human plasma and lung tissue. The assay was based on HPLC with a Supelcosil ABZ+ column and ultraviolet detection set at a wavelength of 296 nm. The extraction procedure was characterized by a fully automated liquid-solid extraction using an OASIS column for the solid phase. The assay has been found to be linear and validated over the concentration range 3.2 to 0.025 microg/ml for moxifloxacin in plasma and from 16 to 0.25 microg/g for moxifloxacin in lung tissue. In future, the assay will support the pharmacokinetic study of the penetration of moxifloxacin in human lung tissue.

Adult mediastinal lymphangiomas are rare lesions the diagnosis of which is difficult based on imaging studies. A retrospective study of CT, MR, and pathologic findings of mediastinal lymphangioma was performed in order to correlate pathological and imaging findings. Nine cases of adult lymphangiomas were identified in the records of our institution over a 12-year period. The CT, MR, and pathologic findings were reviewed. Lesions were classified pathologically as unilocular, cavernous, and intermediate types. Pathologic examination identified six cases of unilocular lesion, two cases of cavernous type, and one intermediate type. The CT features (n = 9) included a smoothly marginated non-enhancing mass of water attenuation (n = 7), a non-enhancing mass of soft tissue attenuation (n = 1), and an enhancing multiseptated mass (n = 1). Lesions were located in the anterior mediastinum (n = 2), right paratracheal (n = 4), subcarinal (n = 1), aortopulmonic window (n = 1) areas, and below the left hilum extending into the posterior mediastinum (n = 1). The MR features (n = 3) were characterized by an enhancing multicystic and multiseptated appearance, evocative of a cavernous type in two cases. The CT appearance of mediastinal thoracic lymphangioma is variable depending on the pathologic type. The most common unilocular type is a non-enhancing thin-walled mass on CT. A less frequent cavernous type can be suggested based on a multiseptated and loculated mass on CT and/or MR examination.

Background: Postintubation tracheobronchial rupture is usually responsible for unstable intraoperative or postoperative conditions, and its management is discussed. We insist on conservative treatment as a viable alternative after late diagnosis of postintubation tracheobronchial rupture., Methods: We conducted a retrospective study including 14 consecutive patients treated between April 1981 and July 1998., Results: Twelve tracheobronchial ruptures occurred after intubation for general surgery and two after thoracic surgery. In all cases, the tear consisted of a linear laceration of the posterior membranous wall of the tracheobronchial tree ranging from 2 to 6 cm. One death occurred in a very weak patient unfit to undergo a redo operation for surgical repair. Seven patients were treated conservatively and cured without sequelae. Six patients underwent surgical repair, of whom 2 were diagnosed and repaired intraoperatively., Conclusions: Aggressive surgical repair is not always mandatory after delayed diagnosis of iatrogenic tracheobronchial rupture. Conservative treatment must often be considered, except after lung resection.

Lung inflammatory myofibroblastic tumor is an uncommon cause of solitary lung nodule (0.7 % of lung tumors). The principal site of inflammatory pseudotumor is the lung, but it can also occur elsewhere in various organs. Although benign, they may be locally very aggressive. Recurrent and multifocal forms have been described. Since they are likely to mimic malignant neoplasms, accurate histopathologic diagnosis is necessary in order to guide appropriate surgical excision and avoid aggressive treatments. We report a case of lung involvement in a young adult with radiologic and pathologic correlations.

We herein report a case of unsuturable tracheoesophageal fistula developed after chemotherapy of a mediastinal lymphoma. Esophageal exclusion was primary performed to prevent continued contamination of the respiratory tract. In a second stage procedure the fistula was patched with the esophageal posterior wall and the digestive tract was restored by a substernal colic bypass. This case leads to discuss the management of extrinsic tumoral tracheal compression and reminds us of an old reported procedure for the cure of large tracheoesophageal fistula.

Lobar herniation is a rare complication of heart-lung transplantation (HLT). We describe a case of right lower lobe herniation through the pericardial window into the left pleural space diagnosed 54 days after operation. Extensive adhesions precluded a lobectomy through a right thoracotomy approach, therefore the lobe was simply excluded and left in situ. The subsequent postoperative course, a CT-scan 2 years later and the 7 years survival time demonstrated that the lobe became fibrosed without any major sequelae.

The Thiersch technique for treatment of rectal prolapsus has been largely abandoned because the metallic or non-resorbable wire is poorly tolerated and non-extensible. Silastic can fulfil these requirements and was used in 11 patients, including two who underwent reoperations. Good results were obtained in 9. This technique is simple and can be proposed when the general status of the patient does not allow surgical cure of the prolapsus.

The authors report a series of 217 non-neoplastic stenoses of the upper airways operated in the period 1978-1991. One hundred and twenty patients with tracheal stenoses underwent tracheal resection and end-to-end anastomosis, with 117 excellent results and 3 deaths. The treatment of 97 patients with laryngotracheal stenoses was much more complex and difficult to manage: Fifty-nine underwent tracheal and subglottic resection-anastomosis with 58 successes and 1 death--Seven had resection-anastomosis with total cricoidectomy and stenting. They were 6 successes and 1 death--Three had supraglottic resection-anastomosis with 3 successes--Twelve underwent laryngeal enlargement over a T-tube with successes in 11 cases and failure in 1 case. Sixteen had complex combinations of resection and modeling with 13 successes, 2 failures, and 1 death. In this series under the same therapeutic options, the results were successful in 96% of cases, with 4% of failures (7% of them resulting in death). The anatomical type, tracheal or laryngotracheal, length of the stenosis, neuropsychological sequelae, and overall poor respiratory status of the patients must be taken into account before deciding the therapeutic strategy. Old age is not a contraindication to tracheal resection, but is certainly a risk factor for morbidity and mortality. The key to success is undoubtedly careful preoperative preparation, treatment of local infection and inflammation, as well as meticulous mucomucosal approximation of healthy margins at the anastomosis.