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International audience; Principles of surgical training have not changed, but methods of training are evolving very fast. Online tools are being adopted in both knowledge and skills training for surgical residents. As a result, to evaluate the outcome of these tools, online assessment is also developing. Knowledge resources are very diverse ranging from lectures, webinars, surgical videos to three-dimensional planning and printing. Skills resources include virtual reality simulators, remote skills training and interdisciplinary teamwork. Assessment of E-learning tools can be performed using online questions, task-based simulations, branching scenarios and online interviews/discussions. In thoracic surgery, video assisted thoracic surgery (VATS) lobectomy simulator has been developed and it appears to be an important tool for minimally invasive thoracic surgery education. Training programs incorporate e-Learning in their curriculum and online training and assessment will become an important part of thoracic surgical training as well.

There is no robust data regarding rib fixation in elderly patients. The aim of this study is to compare the postoperative outcomes of patients aged less and more than 65 years old.Patients operated from January 2012 to December 2018 were retrospectively analyzed. The following data were collected: age, sex, comorbidities, smoking habit, Injury Severity Score (ISS), number of fractured ribs, indication for surgery, associated injuries, time from trauma to surgery, number of fixed ribs, intrathoracic injuries, duration of intubation, ICU stay, postoperative cardiopulmonary complications, blood transfusion, overall and 30-day mortality, length of stay.There was no difference regarding the ISS (The outcomes of rib fixation in the elderly patients are comparable to younger patients. However, elderly patients experience more frequently postoperative cognitive complications and their hospitalizations are longer.

Resume Le cancer primitif du poumon est le premier en terme de mortalite en France avec 28 000 deces par an. Le traitement curatif de reference pour les cancers bronchiques non a petites cellules (CBNPC) reste la chirurgie d’exerese carcinologique. L’objectif de cet article est de passer en revu les nouveautes dans la prise en charge chirurgicale des CBNPC. Les indications d’exerese ont evolue avec l’elaboration de la 8e classification des cancers du poumon et la nouvelle classification pathologique des adenocarcinomes. On assiste a une augmentation des resections infra-lobaires, dont notamment les segmentectomies . Les differentes voies d’abord qui sont a la disposition du chirurgien presentent des avantages et des inconvenients. L’evolution s’est faite des thoracotomies conventionnelles aux thoracotomies avec epargne musculaire pour aboutir a la chirurgie mini-invasive, representee par la videothoracoscopie (VATS) et la chirurgie assistee par robot (RATS). L’optimisation de la prise en charge des patients se fait des la consultation avec l’inclusion dans des protocoles de recuperation acceleree apres chirurgie. Ceux-ci ont pour objectif de diminuer la morbi-mortalite post-operatoire ainsi que la duree d’hospitalisation.

Background Diaphragm pacing allows certain ventilator-dependent patients to achieve weaning from mechanical ventilation. The reference method consists in implanting intrathoracic contact electrodes around the phrenic nerve during video-assisted thoracic surgery, which involves time-consuming phrenic nerve dissection with a risk of nerve damage. Identifying a phrenic segment suitable for dissection-free implantation of electrodes would constitute progress. Study design This study characterizes a free terminal phrenic segment never fully described before. We conducted a cadaver study (n = 14) and a clinical observational study during thoracic procedures (n = 54). Results A free terminal phrenic segment was observed on both sides in 100% of cases, "jumping" from the pericardium to the diaphragm and measuring 60 mm [95% confidence interval; 48–63] and 72.5 mm [65–82] (right left, respectively; p = 0.0038; cadaver study). This segment rolled up on itself at end-expiration and became unravelled and elongated with diaphragm descent (clinical study). Three categories of fat pads were defined (type 1: pericardiophrenic bundle free of surrounding fat; type 2: single fatty fringe leaving the phrenic nerve visible until diaphragmatic entry; type 3: multiple fatty fringes masking the site of penetration of the phrenic nerve) that depended on body mass index (p = 0.001, clinical study). Hematoxylin-eosin and toluidine blue staining (cadaver study) showed that all of the phrenic fibers in the distal, pre-branching part of the terminal segment were contained within a single epineurium containing a variable number of fascicles (right: 1 [95%CI 0.65–4.01]; left 5 [3.37–7.63]; p = 0.03). Conclusion Diaphragm pacing through periphrenic electrodes positioned on the terminal phrenic segment should be tested.

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.

Background The coronavirus disease 2019 (COVID-19) outbreak was officially declared in France on March 14, 2020. The objective of this study is to report the incidence and outcome of COVID-19 after surgical resection of non-small cell lung cancer in Paris Public Hospitals during the pandemic. Methods We retrospective analyzed a prospective database including all patients who underwent non-small cell lung cancer resection between March 14, 2020, and May 11, 2020, in the 5 thoracic surgery units of Paris Public Hospitals. The primary endpoint was the occurrence of SARS-CoV-2 infection during the first 30 days after surgery. Results Study group included 115 patients (male 57%, age 64.6 ± 10.7 years, adenocarcinoma 66%, cT1 62%, cN0 82%). During the first month after surgery, 6 patients (5%) were diagnosed with COVID-19. As compared with COVID-negative patients, COVID-positive patients were more likely to be operated on during the first month of the pandemic (100% vs 54%, P = .03) and to be on corticosteroids preoperatively (33% vs 4%, P = .03). Postoperative COVID-19 was associated with an increased rate of readmission (50% vs 5%, P = .004), but no difference in 30-day morbidity (for the study group: grade 2, 24%; grade 3, 7%; grade 4, 1%) or mortality (n = 1 COVID-negative patient, 0.9%). Immediate oncologic outcomes did not differ significantly between groups (R0 resection 99%, nodal upstaging 14%, adjuvant chemotherapy 29%). Conclusions During the COVID-19 pandemic, surgical treatment of non-small cell lung cancer was associated with a rate of postoperative COVID-19 of 5% with a significant impact on readmissions but not on other outcomes studied.

Resume Le cancer primitif du poumon est le premier cancer en termes de mortalite en France avec 30 000 deces par an. Le seul traitement curatif pour les cancers bronchiques non a petites cellules reste la chirurgie d’exerese carcinologique. L’objectif de cet article est de passer en revue les standards actuels de la prise en charge des CBNPC. Le bilan d’operabilite avant chirurgie d’exerese carcinologique est d’abord aborde avec l’evaluation cardiologique puis respiratoire. Il est important pour determiner si le type de resection envisagee est compatible : pneumonectomie, lobectomie simple, lobectomie avec resection-anastomose, segmentectomie ou resection atypique. Les indications d’exerese ont evolue avec l’elaboration de la 8e edition de la classification des cancers du poumon et la nouvelle classification pathologique des adenocarcinomes. Differentes voies d’abords sont a la disposition du chirurgien avec chacune leurs avantages et leurs inconvenients : thoracotomie conventionnelle, thoracotomie avec epargne musculaire, la videothoracoscopie et la chirurgie assistee par robot. La prise en charge des patients s’oriente de plus en plus vers l’inclusion dans des protocoles de recuperation acceleree apres chirurgie.

Background Video-assisted thoracic surgery (VATS) is usually performed using three ports. Uniportal VATS has not yet been widely developed. We report our single institution experience in uniportal VATS for the surgical management of 351 patients with pneumothorax. Methods Between November 2009 and February 2016, we conducted a study in 351 patients treated for pneumothorax using uniportal VATS. Resection of apical bullae associated with partial pleurectomy, pleural abrasion, or talc effusion was performed. Results The mean age was 29.6 ± 10.1 years. Surgical indications were mainly persistence or recurrence of pneumothorax. Sixty-seven patients (19%) presented with complications. At the 30-day control, 60.1% of patients were asymptomatic; 85% of patients were satisfied with the single small scar. The recurrence rate was 3.6% at 24 ± 13 months. Conclusions Uniportal VATS is feasible, safe, and reproducible in the treatment of pneumothorax. Morbidity is similar to multiport VATS. The recurrence rate is comparable with best results after multiport VATS or thoracotomy. Patients were satisfied with the single small scar.

Human abdominal aortic aneurysm (AAA) pathophysiology is not yet completely understood. In conductance arteries, the insoluble extracellular matrix, synthesized by vascular smooth muscle cells, assumes the function of withstanding the intraluminal arterial blood pressure. Progressive loss of this function through extracellular matrix proteolysis is a main feature of AAAs. As most patients are now treated via endovascular approaches, surgical AAA specimens have become rare. Animal models provide valuable complementary insights into AAA pathophysiology. Current experimental AAA models involve induction of intraluminal dilation (nondissecting AAAs) or a contained intramural rupture (dissecting models). Although the ideal model should reproduce the histological characteristics and natural history of the human disease, none of the currently available animal models perfectly do so. Experimental models try to represent the main pathophysiological determinants of AAAs: genetic or acquired defects in extracellular matrix, loss of vascular smooth muscle cells, and innate or adaptive immune response. Nevertheless, most models are characterized by aneurysmal stabilization and healing after a few weeks because of cessation of the initial stimulus. Recent studies have focused on ways to optimize existing models to allow continuous aneurysmal growth. This review aims to discuss the relevance and recent advances of current animal AAA models. Visual Overview— An online visual overview is available for this article.

Introduction There is no data regarding the incidence and treatment of deep infection affecting the surgical implants after rib fixation. The aim of this study is to share our experience in the management of infected material after surgical rib fixation. Methods The medical records of operated patients from January 2012 to December 2018 were retrospectively analyzed. Results Three patients out of 87 (3.44%) developed an infection. One patient was treated conservatively and two patients were operated for hardware removal. Conclusions The lack of evidence prompts for the design of surgical databases to share experience and enhance available data.

Introduction: Saccular aneurysms are thought to have a worse prognosis than fusiform aneurysms in humans, due to hemodynamic reasons. However, data comparing hemodynamic and biology in saccular and fusiform aneurysms are lacking. The main objective was to evaluate the impact of aneurysm morphology on intra-luminal thrombus (ILT) formation and activity. Methods: Forty Lewis rats were ran­domly divided into 2 groups of 20: “saccular” (Group A) and “fusiform” (Group B) aneurysms. Decellularized thoracic aortas from guinea pigs were xenografted to create saccular or fusiform aneurysms. Final imaging evaluation of the aneurysms was carried out during the third week, by quantitative Doppler ultrasound and magnetic resonance imaging. Assays of myeloperoxidase (MPO), platelet factor 4 (PF4), advanced oxidation protein products (AOPPs) iron and matrix metallopeptidase-9 (MMP-9) were performed as biological criteria. Results: Quantitatively, saccular aneurysms are characterized by a more thicker ILT, lower inflow velocities and more important relative backflow velocities as compared to fusiform aneurysms. Compared to fusiform, saccular aneurysms released significantly more MPO (p = 0.004), PF4 (p = 0.02), AOPPs (p < 0.002), iron (p < 0.0001) and MMP-9 (p < 0.04). Conclusion: Experimental saccular and fusiform aneurysms show differential specific hemodynamics, which seem to impact the histology and the biology of the ILT in each type of aneurysm.

Background Ruptured descending thoracic aortic aneurysm (rDAA) is a rare but devastating condition. Open aortic surgery which uses cardiopulmonary bypass is associated with a high mortality. Thoracic endovascular aortic repair (TEVAR) is a less-invasive approach for which it remains unclear whether outcomes are superior or equivalent to open aortic surgery. In this study, we report our early and midterm outcomes with TEVAR for rDAA. Methods This is an observational, retrospective, single-center study which included patients with rDAA and treated by TEVAR. The main objective was the 30-day in-hospital mortality. Secondary end points were 30-day in-hospital morbidity, 2-year mortality, and technical problems encountered during procedures. Results Twenty-five patients were included: 14 men and 11 women with a median age of 76 years (69–82 years). Thirty-day in-hospital mortality rate was 36% (95% confidence interval [CI], 20.6–57.9; n = 9), and the 2-year mortality rate was 44% (95% CI, 27.94–66.72; n = 11). Fifteen patients (60%) presented at least 1 major complication, and 8 of those patients had a second surgery because of it. There were 9 technical problems encountered that required additional open procedures to successfully deploy the aortic stent graft: lack of vascular access in 2 cases (8%), short proximal neck in 3 cases (12%), and short distal neck in 4 cases (16%). Conclusions Mortality and morbidity remain high in patients treated for rDAA by TEVAR. Nonetheless, TEVAR remains an interesting alternative to open aortic surgery especially for older patients with a poor general health and functional status.

Tracheal reconstruction is one of the greatest challenges in thoracic surgery when direct end-to-end anastomosis is impossible or after this procedure has failed. The main indications for tracheal reconstruction include malignant tumours (squamous cell carcinoma, adenoid cystic carcinoma), tracheoesophageal fistula, trauma, unsuccessful surgical results for benign diseases and congenital stenosis. Tracheal substitutes can be classified into five types: 1) synthetic prosthesis; 2) allografts; 3) tracheal transplantation; 4) tissue engineering; and 5) autologous tissue composite. The ideal tracheal substitute is still unclear, but some techniques have shown promising clinical results. This article reviews the advantages and limitations of each technique used over the past few decades in clinical practice. The main limitation seems to be the capacity for tracheal tissue regeneration. The physiopathology behind this has yet to be fully understood. Research on stem cells sparked much interest and was thought to be a revolutionary technique; however, the poor long-term results of this approach highlight that there is a long way to go in this research field. Currently, an autologous tissue composite, with or without a tracheal allograft, is the only long-term working solution for every aetiology, despite its technical complexity and setbacks.

Recent evidence suggests that adaptive immunity develops during abdominal aortic aneurysm evolution. Uncertainties remain about the antigens implicated and their role in inducing rupture. Because antigens from the extracellular matrix (ECM) have been suspected, the aim of this experimental study was to characterize the role of adaptive immunity directed against antigens from the aortic ECM.In a first step, an experimental model of abdominal aortic aneurysm rupture based on adaptive immunity against the ECM was developed and characterized. Forty 4-week-old male Lewis rats were divided into two groups. In the ECM group (n = 20), rats were presensitized against the guinea pig aortic ECM before implantation of a decellularized aortic xenograft (DAX). In the control group (n = 20), rats were not presensitized before DAX implantation. In each group, half the rats were sacrificed at day 3 to analyze early mechanisms involved after DAX implantation. In a second step, we aimed to assess which ECM component was most efficient in inducing rupture. For this purpose, the nonfibrillar and fibrillar ECM components were sequentially extracted from the guinea pig aortic wall. Forty Lewis rats were then divided into four groups. Each group was presensitized against one ECM component (structural glycoproteins and proteoglycans, collagen, elastin alone, and elastin-associated glycoproteins) before DAX implantation. Apart from those that experienced rupture, rats were sacrificed at day 21. Xenografts were harvested for histologic, immunofluorescence, and conditioned medium analyses.In total, early aortic rupture occurred in 80% of the ECM group vs 0% of the control group (P .001). In the ECM group, major circumferential immunoglobulin deposits were observed in combination with the C3 complement fraction, without cell infiltration. Conditioned medium analysis revealed that matrix metalloproteinase 9 and myeloperoxidase levels and elastase activities were significantly increased in this group. Immunofluorescence analysis demonstrated that myeloperoxidase co-localized with tissue-free DNA and histone H4, highlighting local neutrophil activation and formation of neutrophil extracellular traps. Following differential presensitization, it appeared that rats presensitized against structural glycoproteins and proteoglycans were significantly more susceptible to rupture after DAX implantation.Stimulating adaptive immunity against the aortic ECM, especially structural glycoproteins and proteoglycans, triggers rupture after DAX implantation. Further studies are needed to assess the precise proteins involved.

The aim of this study was to evaluate, in a predominantly white population, correlations between radiological and pathological diagnoses based on the latest classifications of pulmonary adenocarcinomas. We analysed data from patients undergoing lung resection for ground glass nodules (GGNs) less than 3 cm and whose solid component was

Propionibacterium acnes, an anaerobic gram-positive bacillus that inhabits the skin, has rarely been incriminated in abdominal aortic endograft infection. It is usually responsible for typical delayed and low-grade postoperative infections. We report the case of a 66-year-old patient who developed acute P. acnes aortic stent-graft infection 9 days after percutaneous embolization for type II endoleak. The stent graft had been implanted 2 years before. Because of persistent signs of sepsis and discovery of a posterior periaortic abscess formation on the computed tomography scan, removal of the stent graft was necessary. Despite being described as a low virulence and slow growth bacteria, P. acnes was responsible for acute onset of postoperative infection with extensive life-threatening damages necessitating multiple interventions associated with long-term antibiotherapy.