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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.

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)

Objectives To explore the role of neuropathy in persistent pain after thoracotomy, combining a clinical follow-up and a psychophysical examination of the operated area. Methods Seventy-three patients were followed and examined at their discharge from hospital, 6 weeks and 4 months after pneumonectomy under thoracotomy. Spontaneous and evoked pain was assessed by clinical examination, a 7-day pain score, and the Neuropathic Pain Symptom Inventory. At the fourth month follow-up, pain and tolerance thresholds to pinprick, heat, and warm sensation threshold were measured on both sides of the thorax. Results The rate of spontaneous pain was 40% at discharge and went up to 59% at the sixth week follow-up. Evoked pain was rare at discharge (11%), most cases appearing at the sixth week follow-up (47%). The evolution profiles of pain between the sixth week and the fourth month follow-up were heterogeneous with a tendency to decrease. Young age, female sex, and spontaneous pain observed at discharge from hospital were identified as early predictive factors of spontaneous pain persisting at the fourth month follow-up. On the side of operation, thresholds tended to increase for warm and hot stimuli, and to decrease for mechanical stimuli. At the fourth month follow-up, spontaneous pain and evoked pain were associated to static hyperalgesia, persisting hypoesthesia, low mechanical thresholds, altered sensation of heat, and impaired quality of life. Discussion Peripheral neuropathy is common after thoracotomy, with variant characteristics, ranging from subclinical disturbances to severe pain. The process seems to develop between the discharge from hospital and the sixth week after thoracotomy.

This study evaluated prospectively the incidence of neuropathic pain after thoracotomy, described its clinical characteristics, and delineated landmarks for its diagnosis in daily practice. We evaluated clinically painful symptoms and sensory deficits in 54 patients after lateral/posterolateral thoracotomy for broncho-pulmonary carcinoma with standardized surgical and analgesic procedures. At 2months, 49 patients suffered from non malignant thoracic pain, and at 6months 38 patients (loss to follow-up for 7) reported persisting pain. In 35 patients, painful symptoms and sensory deficits could be evaluated using a standardized clinical bedside procedure. According to the grading system proposed by Treede et al. [41], neuropathic pain was considered probable in 21 patients, while use of the DN4 questionnaire concluded that neuropathic pain was probable in 17 patients. The two diagnostic procedures provided similar conclusions in 16 patients. Morphine consumption during the early post-operative period (mean 111.3±30.8mg/day) and pain intensity (VAS: mean 5.71±2.1) were significantly higher in patients suffering from neuropathic pain than in other patients with pain (mean 80±21.4mg/day; VAS: mean 3.9±2.4). The clinical picture in most patients with neuropathic pain included electric shocks and severe multimodal hypoesthesia in the sensory area of 5th/6th intercostal nerves. Thus, our results indicate a minimal incidence of chronic post-thoracotomy pain at 70% and that of neuropathic pain at 29%, this latter being clinically suggested by a combination of certain symptoms and reinforced by the DN4 questionnaire when sensory deficit at scar is present.

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.

Ventricular tachycardias occurring after myocardial infarction (MI) and resistant to medical treatment were successfully treated in 5 patients by encircling endocardial ventriculotomy. All patients had a history of MI. The delay between MI and ventricular tachycardias ranged from 1 month to 8 years. A reentrant mechanism was demonstrated by laboratory studies. Under cardiopulmonary bypass, the left ventricle was entered through the thin fribrous scar. Encircling endocardial ventriculotomy was carried out from the inside of the ventricle, through the whole thickness of the normal myocardium, and along the border of the endocardial fibrosis, which delineated the area of diseased myocardium. The ventriculotomy was placed in the free wall or in the septum or in both of these locations. It was repaired and the left ventricle was closed. Drug therapy was discontinued after operation. No ventricular tachycardias recurred during a follow-up period of 6 to 24 months. The effectiveness of encircling endocardial ventriculotomy is explained by the exclusion of the entire diseased area, especially the border zone and the septum. This technique is useful in any location of MI.