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We report a case of intercostal muscle flap used in tracheobronchial reconstruction for extensive necrosis after burn lesions of the posterior wall. A 32-year-old man attempted suicide by ingestion of caustic material. He underwent emergency total esogastrectomy, tracheostomy, and feeding jejunostomy. Ten days later, endoscopy showed complete destruction of the membranous trachea, extending from the tracheostomy to the carina. Reconstruction was conducted with the patient under venovenous extracorporeal membrane oxygenation by use of a pedicled intercostal muscle flap. The patient was weaned from respiratory support on the 14th postoperative day. Examination of a biopsy specimen from the flap 7 months after tracheoplasty showed ciliated neoepithelium.

Objectif Les luxations cardiaques sont des pathologies rares a mortalite elevee. Complications connues de la chirurgie thoracique, en particulier dans les suites des pneumonectomies, elles peuvent egalement etre consecutives a un traumatisme thoracique ferme ou etre secondaire a une agenesie pericardique. Methode A partir de 4 cas cliniques se rapportant a des luxations cardiaques, nous avons etudie sur un cadavre les mecanismes physiopathologiques impliques dans les phenomenes de rupture pericardique puis de survenue des luxations cardiaques, explicitant ainsi leurs gravites. Resultat Apres un rappel de l’embryologie pericardique et des moyens de fixite du massif cardiaque au sein du sac pericardique, nous avons constate que les luxations cardiaques engendrent non seulement un etirement des veines pulmonaires du cote oppose a la luxation mais egalement une torsion de l’ensemble de l’axe cave en particulier lors des luxations dans la cavite pleurale droite. Cette situation engendre ainsi une insuffisance cardiaque aigue potentiellement fatale, constituant une urgence chirurgicale absolue. Conclusion Bien que rares, les luxations cardiaques doivent etre une entite parfaitement connue du chirurgien thoracique. Toutes suspicion d’un tel diagnostic justifierait d’une exploration chirurgicale compte tenu de la letalite de cette pathologie a court terme et de la faible sensibilite des examens para-cliniques.

Resume En chirurgie pulmonaire, l’evaluation du risque postoperatoire est toujours une preoccupation pour le clinicien. Il a ete demontre, lors de cette periode dans les lobectomies une perte disproportionnee de la capacite vitale (CV) et du volume expiratoire maximal par seconde (VEMS) par rapport aux valeurs predictives. L’objectif de ce travail a ete d’evaluer dans la periode postoperatoire precoce : (1) l’evolution des parametres fonctionnels respiratoires dans le cadre de lobectomies et de pneumonectomies pour cancer, (2) la part reversible de la restriction postoperatoire (effet thoracotomie). L’etude prospective a comporte l’evaluation de la fonction respiratoire en preoperatoire puis en postoperatoire au premier (j1), au cinquieme (j5) et au dixieme jours (j10) et au quatrieme mois (M4). Trente et un patients sans complication postoperatoire ont ete inclus. Les resections comportaient 19 lobectomies (âge moyen 59 ± 10 ans) et 12 pneumonectomies (âge moyen 56 ± 9 ans). Le mode ventilatoire dans les deux types de resection etait similaire jusqu’a j5. L’amputation de CV et de la capacite pulmonaire totale etait de l’ordre de 50 %. Les volumes de reserve expiratoire (VRE) et de reserve inspiratoire (VRI) etaient reduits n’atteignant que 40 % de la valeur preoperatoire. L’alteration du VEMS etait plus importante que sa valeur predictive surtout dans les lobectomies (52 ± 16 % a j5 versus 67 ± 14 % valeur predictive). Mais le VEMS/CV etait stable, temoignant d’un deficit restrictif dominant. Les resultats suggerent que l’amelioration du VEMS suit l’evolution des volumes mobilisables et notamment de la capacite inspiratoire et du VRI. Les conditions mecaniques et fonctionnelles respiratoires postoperatoires immediates justifient le developpement de l’entrainement inspiratoire.

Whether prophylactic tracheotomy can shorten the duration of mechanical ventilation (MV) in high risk patients eligible for lung cancer resection. The objective was to compare duration of MV and outcome in 39 patients randomly assigned to prophylactic tracheotomy or control.Prospective randomized controlled, single-center trial (ClinicalTrials.gov Identifier: NCT01053624). The primary outcome measure was the cumulative number of MV days after operation until discharge. The secondary outcome measures were the 60 days mortality rate, the ICU and the hospital length of stay, the incidence of postoperative respiratory, cardiac and general complications, the reventilation rate, the need of noninvasive ventilation (NIV), the need of a tracheotomy in control group and the tracheal complications.The duration of MV was not significantly different between the tracheotomy group (3.5±6 days) and the control group (4.7±9.3 days) (P=0.54). Among patients needing prolonged MV4 days, tracheotomy patients had a shortened duration of MV than control patients (respectively 11.4±7.1 and 20.4±9.6 days, P=0.04). The rate of respiratory complications were significantly lower in the tracheotomy group than in the control group (28% vs. 51%, P=0.03). Six patients (15%) needed a postoperative tracheotomy in the control group because of a prolonged MV7 days. Tracheotomy was associated with a reduced need of NIV (P=0.04). There was no difference in 60-day mortality rate, cardiac complications, intensive care unit and hospital length of stay. No death was related with the tracheotomy.Prophylactic tracheotomy in patients with ppo FEV150% who underwent thoracotomy for lung cancer resection provided benefits in terms of duration of prolonged MV and respiratory complications but was not associated with a decreased mortality rate, ICU and hospital length of stay and non-respiratory complications.

Only few reports of surgical approach to T4 lung carcinoma invading the heart have been reported in the medical literature. It is also controversial if such cancer should be treated by surgery. The aim of this review is to assess the current risk/benefit ratio of the surgical management of non-small cell lung cancer (NSCLC) invading the left atrium, especially in the light of a multidisciplinary approach. We also expose our surgical experience and the procedure we have developed in order to increase our rate of complete resection as this criterion appears to be mandatory as well as patients' nodal status in order to increase life expectancy.

International audience; BACKGROUND: Extended resection for lung cancer may improve survival of selected patients. Left-atrial resection is infrequently performed and surgical techniques are rarely reported; thus, oncologic results and survival rates remain uncertain. Our study describes surgical techniques, postoperative outcomes, and oncologic results of patients who received a combined multimodality treatment. METHODS: Between October 2004 and March 2012 in our institution, 19 patients underwent extended lung resection involving the left atrium without cardiopulmonary bypass. We reviewed perioperative treatments, surgical procedures, and postoperative morbidity, mortality, and long-term survival rates. RESULTS: Sixteen patients (68.4%) underwent neoadjuvant treatment including chemotherapy or radiotherapy. Eighteen pneumonectomies (94.7%) were performed, of which 12 (63.1%) were right sided. Dissection of the interatrial septum was complete in 4 patients (33.3%). Complete resection was achieved in 17 patients (89.4%) and 2 other patients (10.5%) were considered R1. The T-status was pT4 in all patients. Overall postoperative morbidity was 52.6%. The 30-day mortality rate was 10.5% and the 90-day mortality rate was 15.7%. Fifteen patients (93.7%) underwent adjuvant treatment. The mean follow-up time was 32.5 months. The 5-year probability of survival was 43.7%. Three patients (15.7%) were alive at greater than 6 years postsurgery. CONCLUSIONS: Extended lung surgery with partial resection of the left atrium is a feasible procedure with acceptable morbidity. An interatrial septum dissection, by increasing the length of the atrial cuff, allows complete resection. Long-term survival can be achieved in highly selected patients who have undergone multimodal therapy.

The arteries and veins of the left vagus (VN) and left recurrent laryngeal (RLN) nerves from the thoracic inlet to the subaortic region are described following vascular casting with red colored latex in 6 adult fresh non-embalmed cadavers. In all specimens the anterior bronchoesophageal artery supplied at least one vessel to the VN and RLN in the subaortic region. For the RLN other arterial sources were arteries arising from the aortic arch in 1 specimen, the subclavian artery in 3 specimens, the first intercostal artery in 1 specimen, and the inferior thyroid artery in all specimens. For the VN other arterial sources were arteries arising from the aortic arch in 2 specimens and the inferior thyroid artery in 1 specimen. For both the VN and RLN the veins were located under the pleura and directed towards the internal thoracic vein anteriorly and the thoracic intercostal veins posteriorly. In conclusion, the inferior thyroid artery at the thoracic inlet for the RLN and the anterior bronchoesophageal artery are the more consistent vessels supplying the VN and RLN. Vascular damage occurring during mediastinal lymph node excision to the VN and RLN, especially in the subaortic region, may explain postoperative vocal fold paralysis.

Objectives: To evaluate the prevalence, the impact-related postoperative complications and the risk factors of vocal cord dysfunction (VCD) after left lung resection for cancer. Methods: From February 1996 to April 1999, a review of prospectively gathered data was performed on 99 consecutive patients who underwent a pneumonectomy ðn ¼ 50Þ or a lobectomy ðn ¼ 49Þ with a mediastinal lymph node dissection. A fiber optic laryngeal examination was performed preoperatively for all patients and within the first week postoperatively in patients with symptom(s) or sign(s) of VCD or respiratory complications. Results: Thirty-one patients (31%) had a postoperative VCD (group VCD) and 68 (68%) did not (group non-VCD). Mortality rate was 19% in group VCD and 9% in group non-VCD ðP ¼ 0:13Þ. Group VCD patients developed more pulmonary complications ðP ¼ 0:014Þ and cardiac complications ðP , 0:001Þ compared to group non-VCD patients. A higher rate of reintubation ðP ¼ 0:005Þ, pneumonia ðP ¼ 0:06Þ, arrhythmia ðP ¼ 0:002Þ, cardiac failure ðP , 0:001Þ was noticeable in group VCD and may account for the higher rate of complications in this group. Using multivariate analysis, preoperative radiotherapy ðP ¼ 0:001Þ and pneumonectomy ðP ¼ 0:008Þ were predictive of postoperative VCD. Hospital stay was 22 ^ 16 days in group VCD and 13 ^ 9 days in group non-VCD ðP , 0:002Þ. Conclusion: VCD is a frequent event that can lead to dramatic pulmonary complications. We would recommend to track it and to treat it as early as possible. q 2001 Elsevier Science B.V. All rights reserved.

Objectives: We sought to prevent postoperative swallowing disorder, aspiration, and sputum retention in cases of recurrent laryngeal or vagus nerve section occuring during lung cancer resection. Methods: In 14 of 25 consecutive patients, type I thyroplasty and thoracic operations were performed during the same period of anesthesia. All patients had a preoperative laryngeal computed tomographic scan providing us with indispensable measurements for vocal fold medialization under general anesthesia (ie, without intraoperative phonatory control). Nine remaining patients had a type I thyroplasty delayed from thoracic operations because of intraoperative doubt about laryngeal innervation injury, and 2 did not need a laryngeal operation. Main postoperative records consisted of swallowing ability, respiratory complications, and quality of voice. Results: No swallowing disorder, aspiration, or sputum retention occurred in cases of concomitant laryngeal and thoracic operations. Of these 14 patients, a single case (7%) of major complication (vocal fold overmedialization) occurred and required an early and successful revision thyroplasty; one case of cervical hematoma that did not require surgical drainage was considered a minor complication (7%). Twelve (86%) patients who underwent the concomitant association of both operations were fully satisfied with their quality of voice. Conclusions: Type I thyroplasty and thoracic operation can be advantageously associated in case of injury to laryngeal motor innervation to prevent postoperative swallowing disability and dramatic respiratory complications. (J Thorac Cardiovasc Surg 2001;121:642-8)

Hypoxemia usually occurs after thoracotomy, and respiratory failure represents a major complication.To define predictive factors of postoperative hypoxemia and mechanical ventilation (MV), we prospectively studied 48 patients who had undergone lung resection. Preoperative data included, age, lung volume, force expiratory volume in one second (FEV1), predictive postoperative FEV1 (FEV1ppo), blood gases, diffusing capacity, and number of resected subsegments.On postoperative day 1 or 2, hypoxemia was assessed by measurement of PaO2 and alveolar-arterial oxygen tension difference (A-aDO2) in 35 nonventilated patients breathing room air. The other patients (5 lobectomies, 9 pneumonectomies) required MV for pulmonary or nonpulmonary complications. Using simple and multiple regression analysis, the best predictors of postoperative hypoxemia were FEV1ppo (r = 0.74, p0.001) in lobectomy and tidal volume (r = 0.67, p0.01) in pneumonectomy. Using discriminant analysis, FEV1ppo in lobectomy and tidal volume in pneumonectomy were also considered as the best predictive factors of MV for pulmonary complications.These results suggest that the degree of chronic obstructive pulmonary disease in lobectomy and impairment of preoperative breathing pattern in pneumonectomy are the main factors of respiratory failure after lung resection.