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The vessel-depleted neck situation is a challenge for the surgeon in search of suitable recipient vessels for microvascular reconstruction of the head and neck. The internal thoracic vessels (ITVs) have proven useful as "rescue" recipient vessel resource. The objective of this report is to assess the feasibility of using ITVs by rerouting the pedicle for free flap reconstruction of the head and neck by comparing two different approaches.Two surgical approaches were assessed: the classical one is parasternal, but cardiac surgeons commonly use median sternotomy. We conducted an anatomical study, comparing on the same subject the lengths and diameters of both internal thoracic artery (ITA) and internal thoracic vein (ITV) at the sixth, fifth, and fourth intercostal spaces (ICSs) through parasternal approach on one side and by median sternotomy on the other side.The study was performed on 13 subjects. We found a superiority of length of the ITVs with the median sternotomy approach. Regarding the mean length of the ITA, the sternotomy approach allowed a significant greater length with 119/89/67 mm, compared with parasternal approach with 91/62/42 mm, respectively at the sixth, fifth, and fourth ICS (p0.001). Similarly, we observed a significant greater length of the ITV with 116/85/63 mm versus 89/62/42 mm (p0.001). The mean arterial and venous diameters were 2.9 mm and 2.1 mm in the sixth ICS, 3.3 mm and 2.3 mm in the fifth ICS, and 3.9 mm and 2.9 mm in the fourth ICS, respectively.These results help to guide the choice of surgical approach and the level of harvesting.

OBJECTIVES Our goal was to evaluate the association between the distance of the tumour to the visceral pleura and the rate of local recurrence in patients surgically treated for stage pI lung cancer. METHODS We conducted a single-centre retrospective review of 578 consecutive patients with clinical stage IA lung cancer who underwent a lobectomy or segmentectomy from January 2010 to December 2019. We excluded 107 patients with positive margins, previous lung cancer, neoadjuvant treatment and pathological stage II or higher status or for whom preoperative computed tomography (CT) scans were not available at the time of the study. The distance between the tumour and the closest visceral pleura area (fissure/mediastinum/lateral) was assessed by 2 independent investigators who used preoperative CT scans and multiplanar 3-dimensional reconstructions. An area under the receiver operating characteristic curve analysis was performed to determine the best threshold for the tumour/pleura distance. Then multivariable survival analyses were used to assess the relationship between local recurrence and this threshold in relation to other variables. RESULTS Local recurrence occurred in 27/471 patients (5.8%). A cut-off value of 5 mm between the tumour and the pleura was determined statistically. In the multivariable analysis, the local recurrence rate was significantly higher in patients with a tumour-to-pleura distance ≤5 mm compared to patients with a tumour-to-pleura distance >5 mm (8.5% vs 2.7%, hazard ratio 3.36, 95% confidence interval: 1.31–8.59, P = 0.012). Subgroup analyses of patients with pIA and tumour size ≤2 cm identified local recurrences in 4/78 patients treated with segmentectomy (5.1%), with a significantly higher occurrence with tumour-to-pleura distances ≤5 mm (11.4% vs 0%, P = 0.037), and in 16/292 patients treated with lobectomy (5.5%) without significant higher occurrence in tumour-to-pleura distances of ≤5 mm (7.7% vs 3.4%, P = 0.13). CONCLUSIONS The peripheral location of a lung tumour is associated with a higher rate of local recurrence and should be taken into account during preoperative planning when considering segmental versus lobar resection.

OBJECTIVES The aim of this study was to describe the epidemiology of patients undergoing diagnostic and/or curative surgical pulmonary resections for lung opacities suspected of being localized primary lung cancers without preoperative tissue confirmation. METHODS We performed a single-centre retrospective study of a prospectively implemented institutional database of all patients who underwent pulmonary resection between January 2010 and December 2020. Patients were selected when surgery complied with the Fleischner society guidelines. We performed a multivariable logistic regression to determine the preoperative variables associated with malignancy. RESULTS Among 1392 patients, 213 (15.3%) had a final diagnosis of benignancy. We quantified futile parenchymal resections in 29 (2.1%) patients defined by an anatomical resection of >2 lung segments for benign lesions that did not modified the clinical management. Compared with patients with malignancies, patients with benignancies were younger (57.5 vs 63.9 years, P CONCLUSIONS Futile parenchymal lung resection for suspicious opacities without preoperative tissue diagnosis is rare (2.1%) while surgery for benign lesions represented 15.3% and has a satisfactory safety profile with very low postoperative morbi-mortality.

OBJECTIVES The aim of this study was to assess the long-term outcomes of patients treated by anatomical pulmonary resection with the video-assisted thoracoscopic surgery (VATS) approach, VATS requiring intraoperative conversion to thoracotomy or an upfront open thoracotomy for lung cancer surgery. METHODS We performed a retrospective single-centre study that included consecutive patients between January 2011 and December 2018 treated either by VATS (with or without intraoperative conversion) or open thoracotomy for non-small-cell lung cancer (NSCLC). Patients treated for a benign or metastatic condition, stage IV disease, multiple primary lung cancer or by resection, such as pneumonectomies or angioplastic/bronchoplastic/chest wall resections, were excluded. RESULTS Among 1431 patients, 846 were included: 439 who underwent full-VATS, 94 who underwent VATS-conversion (21 emergent, 73 non-emergent) and 313 treated with upfront open thoracotomy. The median follow-up was 37 months. There were no statistical differences in stage-specific overall survival between the full-VATS, VATS-conversion, and open thoracotomy groups, with 5-year OS for stage I NSCLC of 76%, 72.3% and 69.4%, respectively (P = 0.47). There was a difference in disease-free survival for stage I NSCLC, with 71%, 60.2% and 53%, respectively at 5 years (P = 0.013). Fewer complications occurred in the full-VATS group (pneumonia, arrhythmia, length of stay), but complication rates were similar between the VATS-conversion and thoracotomy groups. CONCLUSIONS VATS resection for NSCLC with intraoperative conversion does not appear to alter the long-term oncological outcome relative to full-VATS or open upfront thoracotomy. Postoperative complications were higher than for full-VATS and comparable to those for thoracotomy. VATS should be favoured when possible.

Riassunto Le fistole eso-tracheo-bronchiali benigne acquisite dell’adulto sono situazioni cliniche rare, ma sempre complesse. Questa patologia si verifica, il piu delle volte, in pazienti debilitati da un lungo ricovero in terapia intensiva e associa una contaminazione cronica dell’albero bronchiale a una grave malnutrizione. La strategia terapeutica e multidisciplinare e combina il trattamento medico con una gestione endoscopica e chirurgica. Deve concentrarsi sulla definizione del momento ottimale per la riparazione chirurgica, mentre la tecnica utilizzata dipendera dalla sede della fistola. Se si deve privilegiare la riparazione ideale, a volte puo essere necessaria l’esclusione temporanea o definitiva del tubo digerente. Dopo un breve richiamo fisiopatologico ed eziologico, la strategia terapeutica viene descritta in dettaglio e illustrata con l’ausilio di foto e video.

Background Patients treated surgically for lung cancer may present synchronous or metachronous lung cancers. The aim of this study was to evaluate outcomes after a second contralateral anatomic surgical resection for lung cancer. Methods We performed a retrospective two-center study, based on a prospective indexed database. Included patients were treated surgically by bilateral anatomic surgical resection for a second primary lung cancer. We excluded nonanatomic resections, benign lesions, and ipsilateral second surgical resections. Results Between January 2011 and September 2018, 55 patients underwent contralateral anatomic surgical resections for lung cancer, mostly for metachronous cancers. The first surgical resection was a lobectomy in most cases (45 lobectomies: 81.8%, 9 segmentectomies: 16.4%, and 1 bilobectomy: 1.8%), and a video-assisted thoracic surgery (VATS) procedure was used in 23 cases (41.8%). The mean interval between the operations was 38 months, and lobectomy was less frequent for the second surgical resection (35 lobectomies: 63.6% and 20 segmentectomies: 36.4%), with VATS procedures performed in 41 cases (74.5%). Ninety-day mortality was 10.9% (n = 6), and 3-year survival was 77%. Risk factor analysis identified the number of resected segments during the second intervention or the total number of resected segments, extent of resection (lobectomy vs. segmentectomy), surgical approach (thoracotomy vs. VATS), tumor stage, and nodal involvement as potential prognostic factors for long-term survival. Conclusion A second contralateral anatomic surgical resection for multiple primary lung cancer is possible, with a higher early mortality rate, but acceptable long-term survival, and should be indicated for carefully selected patients.

OBJECTIVES Intraoperative conversion from video-assisted thoracic surgery (VATS) to thoracotomy may occur during anatomical lung resection. The objectives of the present study were to identify risk factors for intraoperative conversion and to develop a predictive score. METHODS We performed a multicentre retrospective analysis of French thoracic surgery departments that contributed data on anatomical lung resections to the Epithor database over a 10-year period (from January-2010 to December-2019). Using univariate and multivariate logistic regression analyses, we determined risk factors for intraoperative conversion and elaborated the Epithor conversion score (ECS). The ECS was then validated in a cohort of patients operated on between January- and June-2020. RESULTS From January-2010 to December-2019, 210,037 patients had been registered in the Epithor database. Of these, 55,030 had undergone anatomical lung resection. We excluded patients who had upfront a thoracotomy or robotic-assisted thoracoscopic surgery (n = 40,293) and those with missing data (6,794). Hence, 7943 patients with intent-to-treat VATS were assessed: 7100 with a full VATS procedure and 843 patients with intraoperative conversion to thoracotomy (conversion rate: 10.6%). Thirteen potential risk factors were identified among patients’ preoperative characteristics and planned surgical procedures and were weighted accordingly to give the ECS. The score showed acceptable discriminatory power (area under the curve: 0.62 in the development cohort and 0.64 in the validation cohort) and good calibration (P = 0.23 in the development cohort and 0.30 in the validation cohort). CONCLUSIONS Thirteen potential preoperative risk factors were identified, enabling us to develop and validate the ECS—an easy-to-use, reproducible tool for estimating the risk of intraoperative conversion during VATS.

Thoracic and cardiovascular surgery requires learning both theoretical knowledge and technical skills. In this surgical field, several disparities exist between the different training programs around the world. This report describes the implementation of a portfolio in the teaching and assessment of French trainees in Thoracic and Cardiovascular surgery, following an electronic logbook model, aiming to improve the training program. The French surgical course is a twelve semesters' curriculum divided in 3 parts, each part containing knowledge, technical skills and behaviors objectives to be validated, defined by the French College of Thoracic and Cardiovascular surgery. The competencies are marked in the logbook, following a declarative model where the surgical trainee fills every surgical procedure attended (all or part) if he/she has observed, partially or fully performed, or supervised another trainee. All the surgical procedures are linked to theoretical e-learning lessons and each e-learning lesson includes a self-evaluation. This constitutes a competency-based assessment model with milestones both for surgeon trainees and their mentors. This portfolio also contains complementary tools such as an automated publication point calculation, a formatted curriculum vitae generator, and several contact tools between trainees. Implementation of a dedicated portfolio following an electronic logbook model appears to be a relevant pedagogic tool and survey element in the thoracic and cardiovascular surgery training program. Its use may lead to potential educational benefits for the trainee, reliable competency assessment for the supervising surgeon and for scientific society or national college.

International audience; Objective : To establish recommendations for optimisation of the management of patients undergoing pulmonary lobectomy, particularly Enhanced Recovery After Surgery (ERAS).Design : A consensus committee of 13 experts from the French Society of Anaesthesia and Intensive Care Medicine (Soci,t, franOaise d'anesth,sie et de r,animation, SFAR) and the French Society of Thoracic and Cardiovascular Surgery (Soci,t, franOaise de chirurgie thoracique et cardiovasculaire, SFCTCV) was convened. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence.Methods : Five domains were defined: 1) patient pathway and patient information; 2) preoperative management and rehabilitation; 3) anaesthesia and analgesia for lobectomy; 4) surgical strategy for lobectomy; and 5) enhanced recovery after surgery. For each domain, the objective of the recommendations was to address a number of questions formulated according to the PICO model (Population, Intervention, Comparison, Outcome). An extensive literature search on these questions was carried out and analysed using the GRADE® methodology. Recommendations were formulated according to the GRADE® methodology, and were then voted by all experts according to the GRADE grid method.Results : The SFAR/SFCTCV guideline panel provided 32 recommendations on the management of patients undergoing pulmonary lobectomy. After two voting rounds and several amendments, a strong consensus was reached for 31 of the 32 recommendations and a moderate consensus was reached for the last recommendation. Seven of these recommendations present a high level of evidence (GRADE 1+), 23 have a moderate level of evidence (18 GRADE 2+ and 5 GRADE 2-), and 2 correspond to expert opinions. Finally, no recommendation was provided for 2 of the questions.Conclusions : A strong consensus was expressed by the experts to provide recommendations to optimise the whole perioperative management of patients undergoing pulmonary lobectomy.

International audience; Objectives: Lung cancer tumors are known to be highly lymphophilic. There are two different pattern of lymphatic drainage of the lung: one peribronchial lymphatic pathway, and another one within the visceral pleura which appears to be more intersegmental than the peribronchial pathway. We aimed to assess the prevalence of an intersegmental pathway in the lymphatic drainage of lung tumors within the visceral pleura and determine potential influential factors. Methods: In this prospective study, we included all patients for whom a major pulmonary resection (lobar) was indicated and performed for suspected or proven lung cancer. An immediate ex-vivo evaluation of the surgical specimen after resection was conducted by trans-pleural injection of blue dye within the tumor. The pathways followed by the lymphatic vessels under the visceral pleura were assessed to define the occurrence of an intersegmental pathway, which was defined by the presence of blue dye within the lymphatic vessel crossing to a neighboring pulmonary segment, distinct from the tumorous segment. Results: Fifty-three patients met the inclusion criteria and were assessed over a three-year period. Lymphatic drainage within the visceral pleura followed an intersegmental pathway in 35 of 53 patients (66 %). When the lymphatic drainage of the tumor was intersegmental, it drained in a single other segment in 21/35 cases and two or more in 14/35 cases. Logistic regression with multivariate analysis showed a peripheral location of the tumor to be a risk factor for the intersegmental pathway of visceral pleura lymphatic drainage (OR = 0.87 [079-0.95], p = 0.003). Conclusion: These results confirm that lymphatic drainage of lung cancer in the visceral pleura appears to largely follow an intersegmental pathway, especially when the tumor is peripheral, close to the visceral pleura.

Background: Identification and section of pulmonary veins are an essential part of anatomical pulmonary resections. Intraoperative misunderstandings of pulmonary venous anatomy can lead to serious complications such as bleeding and delayed lung infarction or necrosis. We evaluated principally the rate of pulmonary veno­us anatomical variations, and secondarily the reliability and clinical outcomes of a preoperative morphological analysis. Materials and methods: Between November 2012 and October 2013, we studied 100 consecutive patients with highly suspected or diagnosed stage I-II primitive lung cancer lesion. The surgical procedure initially retained was video-assisted thoracoscopic surgery (VATS) pulmonary resections and we studied preoperatively the proximal pulmonary venous anatomy using 64 channels multi- -detector computed tomography (CT)-scan angiography to describe the venous anatomical variations. Results: There were 65 men and 35 women with a mean age of 63 years. A pulmonary venous anatomical variation was present in 36 (36%) patients, and right-sided anatomical variations were more frequent than on left-sided ones (25% vs. 11%). The most frequent variation encountered on the right side was the existence of three separate pulmonary veins (16%), and on the left side a single pulmonary vein (8%). Surgical conversion occurred in 21% and we didn’t experience a pulmonary venous lesion (0%) or a post-operative lung infarction (0%). Conclusions: We described pulmonary venous anatomical variations and their frequency. Anatomical variations exist and preoperative assessment of pulmo­nary venous anatomy using CT scan is a useful tool in VATS lobectomy to avoid unnecessary extension of pulmonary resections or iatrogenic complications in lung cancer surgery.

Background and objective Laryngeal pathology following lung cancer surgery is associated with post-operative morbidity and mortality. The aim of our study was to evaluate the usefulness of routine endoscopic assessment. Methods We prospectively evaluated vocal cord pathology using laryngeal endoscopy within 24 h post-surgery. Over 25 months, 276 patients underwent thoracic surgery. We excluded 26 patients with previous laryngectomy or vocal cord paralysis, early post-operative reintubation or patients who did not consent to an endoscopy. Endoscopic data were reported using a standardized procedure, recording vocal cord paralysis, swallowing disorders with aspiration, detected using a blue-coloured water test and vocal cord haematoma. Results Among 250 patients, vocal cord paralysis was diagnosed in 13 patients (5.2%) and was associated with a higher rate of post-operative pneumonia (P = 0.03), post-operative bronchoscopy (P = 0.01), reintubation (P = 0.007) and a trend towards an increased 90-day mortality rate (P = 0.09). Swallowing disorders with aspiration were diagnosed in 18 patients (7.2%) and were associated with a higher rate of post-operative pneumonia (P = 0.007), post-operative bronchoscopy (P = 0.01), reintubation (P = 0.004) and 90-day mortality (P = 0.03). Vocal cord haematomas were diagnosed in 28 patients (11.2%) and were not associated with an increased post-operative morbidity or mortality. Conclusion Post-operative endoscopic laryngeal assessment is effective for diagnosing laryngeal pathology following thoracic surgery. Routine laryngeal endoscopic assessment may detect clinically silent swallowing disorders early to allow prompt treatment, which may prevent respiratory complications.

An arteria lusoria is a well-known anatomic variant of the right subclavian artery. We describe a patient in whom an arteria lusoria injury was revealed by delayed-onset tension hemothorax following blunt trauma to the thorax.

Pneumonectomy is known to be associated with a high rate of morbidity and mortality and may be contraindicated in patients with altered lung function. Sleeve lobectomy is a treatment option, but it may be technically impossible in cases of large bronchial involvement. Here, we describe a patient with impaired lung function and right upper lobe lung cancer that involved the intermediate bronchial trunk. The patient was treated successfully with a right upper sleeve lobectomy and bronchial replacement with the use of a thoracodorsal artery perforator flap and a temporary endostent. Clinical outcomes were favorable, and no recurrence has been observed in the 4 years since the operation.

OBJECTIVES Health care-associated infections (HAIs) are serious issues following lung cancer surgery, leading to an increased risk of morbidity and hospital cost burden. The aim of this study was to evaluate the impact on postoperative outcomes of a preoperative screening and decolonization strategy of nasal carriers for Staphylococcus aureus prior to lung cancer surgery. METHODS We performed a retrospective study comparing 2 cohorts of patients undergoing major lung resection: a control group of patients from the placebo arm of the randomized Clinical Study to Evaluate the Efficacy of Chlorhexidine Mouthwashes operated on between July 2012 and April 2015 without any nasopharyngeal screening (N = 224); an experimental group, with preoperative screening for S. aureus of nasal carriers and selective 5-day decolonization in positive carriers using mupirocin ointment between January 2017 and December 2017 (N = 310). The 2 groups were matched according to a propensity score analysis with 1:1 matching. The primary outcome was the rate of postoperative HAIs, and the secondary outcome was the need for postoperative mechanical ventilation after surgery. RESULTS After matching, 2 similar groups of 108 patients each were obtained. In the experimental group, 26 patients had positive results for nasal carriage, and a significant decrease was observed in the rate of overall postoperative HAIs [control n = 19, 17.6%; experimental group n = 9, 8.3%; P = 0.043; relative risk 0.47 (0.22–1)] and in the rate of postoperative mechanical ventilation [control n = 12, 11.1%; experimental group n = 4, 3.7%; P = 0.038; relative risk 0.33 (0.11–1)]. After logistic regression and multivariable analysis, screening of S. aureus nasal carriers reduced the rate of HAIs [odds ratio (OR) 0.29, 95% confidence interval (CI) 0.11–0.76; P = 0.01] and reduced the risk of the need for postoperative mechanical ventilation (OR 0.19, 95% CI 0.05–0.74; P = 0.02). There was no significant statistical difference between the 2 groups regarding the rate of postoperative S. aureus-associated infection (control group n = 6, 5.6%; experimental group n = 2, 1.9%; P = 0.28). CONCLUSIONS Identification of nasal carriers of S. aureus and selective decontamination using mupirocin appeared to have a beneficial effect on postoperative infectious events after lung resection surgery.

Introduction. Osteoid osteoma is a benign bone-forming tumor with young male predilection. It occurs predominantly in the long bones. In the hand, osteoid osteoma is more commonly located in the phalanges and carpal bones. The metacarpals are the least common site for osteoid osteoma. Pain is the most common symptom. It usually increases at night and responds to nonsteroidal anti-inflammatory drugs. Case Presentation. The authors report the excision of an osteoid osteoma lying at the distal condyle of a metacarpal bone of the left hand. The clinical and radiological findings are exposed as well as the surgical management of the lesion. Pain and swelling disappeared after surgery, and there was no evidence of recurrence at follow-up. Discussion. They discuss this rare location and further radiological examination that was used leading to the diagnosis. The imputation of the traumatic factor has been discussed, along with the different therapeutic possibilities and the advantages of a total excision while preserving the integrity of the adjacent ligament and joint space. Conclusion. The surgical alternative appears to be a satisfying treatment for osteoid osteoma in this particular superficial location. Both the exact pathogenesis and the contribution of the traumatic factor remain unclear.

Objectives Intraoperative conversion may be required during video-assisted thoracoscopic surgery (VATS) for lung cancer. We evaluated the morbidity and mortality rates associated with VATS for anatomical pulmonary resection with conversion to thoracotomy and compared this technique with full VATS and an open thoracotomic approach. Methods We performed a retrospective, single-centre study between January 2011 and January 2017 and included 610 consecutive patients having undergone either VATS (with or without intraoperative conversion) or open thoracotomy for anatomical pulmonary resection. Pneumonectomies and angioplastic/bronchoplastic/chest wall resections were excluded. After propensity score adjustment, we assessed the 90-day mortality and determined whether the surgical approach was a risk factor for mortality. Results Of the 610 patients, 253 patients underwent full VATS, 56 patients underwent VATS + conversion and 301 patients underwent up-front open thoracotomy. Relative to the open thoracotomy group, the VATS + conversion group had a higher incidence of cardiac or respiratory comorbidities and was more likely to have an early-stage tumour. Following adjustment, the 90-day postoperative mortality rate was 5.4% (n = 3/56) in the VATS + conversion group and 3.7% (n = 11/301) in the open thoracotomy group (P = 0.58). Likewise, the morbidity rate was similar in these 2 groups. In a multivariable analysis, the surgical approach was not a risk factor for postoperative mortality. Conclusions Following anatomical resection for lung cancer, VATS with conversion and open thoracotomy were associated with similar early postoperative morbidity and mortality rates. When in doubt, VATS should be preferred to thoracotomy; it potentially provides the patient with benefits of a fully VATS-based resection but is not disadvantageous when intraoperative conversion is required.

Switching our approach intraoperatively from a minimally invasive to an open procedure, also known as intraoperative conversion, exist inherently since the implementation of the video-assisted thoracoscopic surgery (VATS). This intraoperative change of course has become a major concern especially with the spread of VATS in lung cancer surgery. Despite its prevention and because of its ineluctability, this intraoperative event is often seen as a complication or a failure, and remains somewhat of a taboo.

International audience; Anatomic variations of the pulmonary arterial tree can cause technical difficulties during pulmonary lobectomy in general and video-assisted thoracic surgery (VATS). Using CT angiography and 3D reconstruction, we sought to identify anatomic variations of the pulmonary arterial tree and assess their respective frequencies. We retrospectively studied 88 pulmonary arterial trees in 44 patients having undergone VATS lobectomy for lung cancer over an 18-month period in Amiens University Hospital's Department of Thoracic Surgery. Each CT angiography with 3D reconstruction of the pulmonary arterial tree was performed by two experienced operators, according to a standardized procedure. On the right side, the upper lobe was supplied with blood by a mediastinal artery in 100% of cases and by one or more fissural arteries in 88.6%. The middle lobe was usually supplied by two arteries (54.5%). The upper segment of the right lower lobe was usually supplied by a single artery (90.9%). We identified 11 variations in the vasculature of the basal segments. On the left side, the upper lobe was supplied by four arteries in 50% of cases, three culminal arteries (50%), and a fissural lingular artery (77.3%). The upper segment of the left lower lobe was usually supplied by a single artery (65.9%). We identified 15 anatomic variations in the vasculature of the basal segments. We observed that the origin of the apical artery of the right lower lobe was proximal to the origin of the middle lobe artery in 38.6% of cases. The origin of the apical artery of the left lower lobe artery was proximal to the origin of the lingular fissural artery in 65.9% of cases. The findings of the present CT angiography/3D reconstruction study agreed with the reference works on the anatomy of the pulmonary arterial tree and defined the frequency of anatomic variations. It is essential to assess the anatomy of the pulmonary arterial tree before VATS lobectomy.

Background: Predicted postoperative FEV1 (ppoFEV1) must be estimated preoperatively prior to surgery for non-small cell lung cancer (NSCLC). We evaluated a lung volumetry approach based on chest computed tomography (CT). Methods: A prospective study was conducted over a period of one year in eligible lung cancer patients to evaluate the difference between ppoFEV1 and the 3-month postoperative FEV1 (poFEV1). Patients in whom CT was performed in another hospital and those with factors influencing poFEV1, such as atelectasis, pleural effusion, pneumothorax, or pneumonia, were excluded. A total of 23 patients were included and ppoFEV1 was calculated according to 4 usual Methods: Nakahara formula, Juhl and Frost formula, ventilation scintigraphy, perfusion scintigraphy, and a fifth method based on quantitative CT. Lung volume was calculated twice and separately by 2 radiologists. Tumor volume, and emphysema defined by a −950 HU limit were subtracted from the total lung volume in order to estimate ppoFEV1. Results: We compared 5 methods of ppoFEV1 estimation and calculated the mean volume difference between ppoFEV1 and poFEV1. A better correlation was observed for quantitative CT than for Nakahara formula, Juhl and Frost formula, perfusion scintigraphy and ventilation scintigraphy with respectively: R²=0.79 vs . 0.75, 0.75, 0.67 and 0.64 with a mean volume difference of 266±229 mL (P vs . 320±262 mL (P Conclusions: Quantitative CT appears to be a satisfactory method to evaluate ppoFEV1 evaluation method, and appears to be more reliable than other approaches. Estimation of ppoFEV1, as part of the preoperative assessment, does not involve additional morphologic examinations, particularly scintigraphy. This method may become the reference method for ppoFEV1 evaluation.

Laryngeal pathology following lung cancer surgery is associated with post-operative morbidity and mortality. The aim of our study was to evaluate the usefulness of routine endoscopic assessment.We prospectively evaluated vocal cord pathology using laryngeal endoscopy within 24 h post-surgery. Over 25 months, 276 patients underwent thoracic surgery. We excluded 26 patients with previous laryngectomy or vocal cord paralysis, early post-operative reintubation or patients who did not consent to an endoscopy. Endoscopic data were reported using a standardized procedure, recording vocal cord paralysis, swallowing disorders with aspiration, detected using a blue-coloured water test and vocal cord haematoma.Among 250 patients, vocal cord paralysis was diagnosed in 13 patients (5.2%) and was associated with a higher rate of post-operative pneumonia (P = 0.03), post-operative bronchoscopy (P = 0.01), reintubation (P = 0.007) and a trend towards an increased 90-day mortality rate (P = 0.09). Swallowing disorders with aspiration were diagnosed in 18 patients (7.2%) and were associated with a higher rate of post-operative pneumonia (P = 0.007), post-operative bronchoscopy (P = 0.01), reintubation (P = 0.004) and 90-day mortality (P = 0.03). Vocal cord haematomas were diagnosed in 28 patients (11.2%) and were not associated with an increased post-operative morbidity or mortality.Post-operative endoscopic laryngeal assessment is effective for diagnosing laryngeal pathology following thoracic surgery. Routine laryngeal endoscopic assessment may detect clinically silent swallowing disorders early to allow prompt treatment, which may prevent respiratory complications.

Esophageal cancer resection usually requires a two-field or three-field surgical approach to perform the resection and the reconstruction. With the progress of anaesthesiology and surgical skills, the possibility to reduce the surgical trauma has grown up and minimally invasive esophagectomy (MIE) has widespread worldwide. The hybrid approaches to MIE are the combination of minimally invasive approaches mixed to open approaches by applying the minimally invasive techniques at one level of the two stages (abdomen or thorax) of the procedure. The hybrid techniques can be decided prior to surgery in the surgical decision-making strategy to focus and to keep open approach for one the two stages, either because of expected surgical issues or to obtain a better exposure for confection of the intrathoracic anastomosis. Sometimes, the decision to opt for hybrid techniques can also results from the necessity to convert intraoperatively at both stages during total MIE. The most described hybrid techniques are represented by the laparoscopic hybrid Ivor Lewis esophagectomy where the gastric mobilization is performed laparoscopically whereas the confection of the intrathoracic anastomosis is performed with an open approach. This technique appears safe, reproducible, and easy to teach. The recent MIRO trial has provided evidences that the unique use of laparoscopy for the abdominal part of the esophagectomy resulted in a strong benefit on postoperative respiratory outcomes, with the same magnitude to those observed with total MIE. The MIRO trial suggests that the maximum benefits of minimally invasive techniques are more provided by laparoscopy rather than thoracoscopy. Moreover the laparoscopic approach results in better short, mid and long-term outcomes compared to open approach, without any compromise regarding oncological outcomes. At last, laparoscopy seems to improve health-related quality of life. The laparoscopic approach has to be seen as a new standard approach and should be incorporated to all esophageal cancer resections whenever possible.

Although peribronchial lymphatic drainage of the lung has been well characterized, lymphatic drainage in the visceral pleura is less well understood. The objective of the present study was to evaluate the lymphatic drainage of lung segments in the visceral pleura. Adult, European cadavers were examined. Cadavers with a history of pleural or pulmonary disease were excluded. The cadavers had been refrigerated but not embalmed. The lungs were surgically removed and re-warmed. Blue dye was injected into the subpleural area and into the first draining visceral pleural lymphatic vessel of each lung segment. Twenty-one cadavers (7 males and 14 females; mean age 80.9 years) were dissected an average of 9.8 day postmortem. A total of 380 dye injections (in 95 lobes) were performed. Lymphatic drainage of the visceral pleura followed a segmental pathway in 44.2% of the injections (n = 168) and an intersegmental pathway in 55.8% (n = 212). Drainage was found to be both intersegmental and interlobar in 2.6% of the injections (n = 10). Lymphatic drainage in the visceral pleura followed an intersegmental pathway in 22.8% (n = 13) of right upper lobe injections, 57.9% (n = 22) of right middle lobe injections, 83.3% (n = 75) of right lower lobe injections, 21% (n = 21) of left upper lobe injections, and 85.3% (n = 81) of left lower lobe injections. In the lung, lymphatic drainage in the visceral pleura appears to be more intersegmental than the peribronchial pathway is—especially in the lower lobes. The involvement of intersegmental lymphatic drainage in the visceral pleura should now be evaluated during pulmonary resections (and especially sub-lobar resections) for lung cancer.

Introduction La connaissance des differentes variations anatomiques de l’arbre arteriel pulmonaire est indispensable lors de la realisation d’une lobectomie pulmonaire, surtout s’il s’agit de videochirurgie. Notre etude angioscannographique avec reconstruction 3D a pour principal objectif d’evaluer les variations anatomiques de l’arbre arteriel pulmonaire, ainsi que leurs frequences. Methode Nous avons etudie retrospectivement 88 arbres arteriels pulmonaires chez 44 patients ayant beneficie d’une lobectomie VATS pour cancer bronchique sur 18 mois, dans le service de chirurgie thoracique du CHU d’Amiens. Chaque reconstruction 3D de l’arbre arteriel pulmonaire etait realisee par 2 operateurs, en consensus, selon un protocole standardise par scanner thoracique spirale avec injection. Resultats A droite, le lobe superieur recevait constamment une artere mediastinale (88,6 %) ; le lobe moyen recevait plus frequemment 2 arteres (54,5 %) ; le segment apical du lobe inferieur recevait une artere unique (90,9 %) et nous avons identifie 11 variations au sein de la vascularisation de la pyramide basale droite. Le segment apical du lobe inferieur droit recevait une artere emergeant proximalement a l’artere lobaire moyenne dans 38,6 % des cas. A gauche, le lobe superieur recevait le plus souvent 4 arteres (50 %) : 3 arteres culminales (50 %) et 1 artere lingulaire (77,3 %) ; le segment apical du lobe inferieur recevait moins souvent une artere unique (65,9 %) et nous avons identifie 15 variations au sein de la vascularisation de la pyramide basale gauche. Le segment apical du lobe inferieur gauche recevait une artere emergeant proximalement a l’artere lingulaire dans 65,9 % des cas. Conclusion Les donnees angioscannographiques avec reconstruction 3D recueillies dans notre travail confirment les etudes anatomiques de reference, valident un referentiel anatomique pour les branches de l’artere pulmonaire et permettent de preciser ses variations anatomiques en termes de frequence. L’etude anatomique scannographique preoperatoire de l’artere pulmonaire est un outil fondamental en videochirurgie pulmonaire.

Introduction Le syndrome de la traversee thoraco-brachial (STTB) est une pathologie frequente, touchant 1 % de la population [1] , et responsable de manifestations cliniques parfois invalidantes liees a la compression permanente ou intermittente d’un ou plusieurs elements vasculaires ou nerveux lors de leur traversee dans ce defile. Il existe de nombreuses variations anatomiques, dont des anomalies osseuses a type de cotes cervicales surnumeraires, pouvant entrainer une compression dans la region interscalenique, avec modification des reperes anatomiques habituels influencant directement la prise en charge chirurgicale de ces STTB. Methode Nous avons realise une etude observationnelle descriptive, unicentrique, regroupant six cas de patients pris en charge pour une malformation de type cote surnumeraire cervicale responsable de manifestations cliniques, operes par voie sus-claviculaire, avec description anatomique des anomalies rencontrees a l’aide de schemas detailles et de photographies peroperatoires. Resultats Parmi les six cas repertories, un etait classe stade I de la classification de Gruber, trois stade II, un stade III et un stade IV. Dans quatre cas nous retrouvions une variation anatomique interessant le trajet d’un tronc du plexus brachial, dans un cas une variation anatomique du trajet de l’artere sous-claviere. Dans un sixieme cas, la cote surnumeraire s’inscrivait dans le cadre d’un syndrome polymalformatif. Conclusion Nous decrivons pour la premiere fois dans cette serie des variations anatomiques vasculonerveuses associees a la presence de cotes cervicales surnumeraires. Cette variabilite doit etre prise en compte afin d’eviter des lesions vasculonerveuses lors du traitement chirurgical des STTB lies a une cote cervicale surnumeraire.

Introduction : la chirurgie d’exérèse pulmonaire majeure avec curage ganglionnaire est le traitement de référence des cancers broncho-pulmonaires non à petites cellules (CBNPC) de stade localisé. La voie d’abord mini-invasive par thoracoscopie (video-assisted thoracoscopic surgery : VATS) est recommandée à l’approche par thoracotomie dans le traitement des CBNPC de stade localisé. L’analyse de la littérature ne permet pas de donner des recommandations avec un niveau de preuve suffisant concernant les stades localement avancés. Le but de cette étude est d’évaluer les résultats de l’abord par VATS pour les exérèses de CBNPC de stade localement avancé en termes de survie au long cours et de morbi-mortalité périopératoire. Matériel et méthode : nous avons réalisé une étude rétrospective, monocentrique, à partir d’une base de données prospective indexée. Tous les patients pris en charge par exérèse anatomique pour CBNPC étaient inclus et évalués selon leur stade tumoral et leur voie d’abord chirurgicale. Les patients déjà pris en charge pour CBNPC, ou de stade métastatique ont été exclus.Résultats : entre janvier 2013 et décembre 2018, 1213 patients ont été inclus, 431 patients présentaient un CBNPC de stade localisé et ont été opérés par VATS (groupe V), et 341 présentaient un CBNPC de stade localement avancé : 118 opérés par VATS (groupe V-LA) et 223 par thoracotomie (groupe T-LA). La survie globale du groupe V-LA était de 91,1 % à 1 an et 64,4 % à 5 ans avec une moyenne de survie de 49 mois, et celle du groupe T-LA de 76,4 % à 1 an et 46,2% à 5 ans, avec une moyenne de survie de 36 mois. Cette différence de survie n’est pas significative après réalisation d’un score de propension avec ajustement (p = 0,36). Il n’existait pas de différence entre les groupes V et V-LA concernant la mortalité précoce (1,9 % de mortalité à 90 jours contre 2,2 %, p = 0,71). Après régression logistique et analyse multivariée, la voie d’abord par VATS ne constituait pas un facteur pronostic défavorable (p = 0,55). Conclusion : la prise en charge par VATS des CBNPC de stade localement avancé est associée à une survie au long cours satisfaisante comparativement à l’abord par thoracotomie, avec une morbidité périopératoire acceptable.