Subtotal pleurectomy by video-assisted thoracic surgery for metastatic pleuritis

Metastatic pleuritis can be a severely disabling condition. Recurrent pleural effusion often leads to severe shortness of breath. Treatment should consist of removal of the fluid as well as prevention of the re-accumulation of the pleural effusion. We describe the technique of subtotal pleurectomy by video-assisted thoracic surgery. We show several methods of stripping of the pleura as well as the application of talc. Subtotal parietal pleurectomy provides an effective treatment and control of recurrent effusion, but due to its invasive nature, it should be offered only to patients with a reasonable life expectancy.

BRAVISSIMO: 12-month results from a large scale prospective trial

The BRAVISSIMO study is a prospective, non-randomized, multi-center, multi-national, monitored trial, conducted at 12 hospitals in Belgium and 11 hospitals in Italy. This manuscript reports the findings up to the 12-month follow-up time point for both the TASC A&B cohort and the TASC C&D cohort. The primary endpoint of the study is primary patency at 12 months, defined as a target lesion without a hemodynamically significant stenosis on Duplex ultrasound (>50%, systolic velocity ratio no greater than 2.0) and without target lesion revascularization (TLR) within 12 months. Between July 2009 and September 2010, 190 patients with TASC A or TASC B aortoiliac lesions and 135 patients with TASC C or TASC D aortoiliac lesions were included. The demographic data were comparable for the TASC A/B cohort and the TASC C/D cohort. The number of claudicants was significantly higher in the TASC A/B cohort, The TASC C/D cohort contains more CLI patients. The primary patency rate for the total patient population was 93.1%. The primary patency rates at 12 months for the TASC A, B, C and D lesions were 94.0%, 96.5%, 91.3% and 90.2% respectively. No statistical significant difference was shown when comparing these groups. Our findings confirm that endovascular therapy, and more specifically primary stenting, is the preferred treatment for patients with TASC A, B, C and D aortoiliac lesions. We notice similar endovascular results compared to surgery, however without the invasive character of surgery.

Fibromuscular dysplasia of the brachial artery associated with unilateral clubbing

A 46-year old male patient was admitted with a history of an extremely painful right upper arm, associated with unilateral clubbing. Duplex scanning and magnetic resonance imaging were suggestive of a pseudo-aneurysm of the brachial artery. Digital angiography showed an irregular brachial artery, associated with a small pseudo-aneurysm. The brachial artery was partially resected and reconstructed with a venous interposition graft. Pathological examination provided the final diagnosis of fibromuscular dysplasia. Although more encountered in women, this case report describes the occurrence of fibromuscular dysplasia in an unusual location in a male patient with a long-term follow-up.

TNM-classification for lung cancer: from the 7th to the 8th edition

Most tumors are staged according to the Tumor-Node-Metastasis (TNM) classification. For lung cancer a new edition was introduced in 2009 and generally applied since 2010. This 7th TNM-classification is based on a large, international retrospective database. Important changes were made regarding the T, N, M factors and specific subcategories were added. However, this 7th edition is still purely based on anatomical information. Other prognosticators such as laboratory results, histology, tumor markers and molecular genetic factors are not yet considered. To prepare the 8th TNM classification a prospective database developed by the International Association for the Study of Lung Cancer (IASLC), is currently enrolling patients from all continents. In this way, more precise and reliable data will become available on specific subdivisions of the T, N and M factors. If proven to be prognostically valid, other parameters will be included as histology, demographic data and specific biochemical and molecular predictive and prognostic factors. All centers with a large experience in thoracic oncology are encouraged to participate in this prospective database.

Endarterectomy combined with retrograde stenting for tandem lesions of the carotid artery

OBJECTIVES

Due to its location in the chest wall, surgical treatment of lesions at the origin of the brachiocephalic trunk or common carotid artery (CCA) is unattractive. Complete endovascular treatment of lesions at the origin of the common carotid artery or brachiochephalic trunk combined with high-grade lesions at the carotid bifurcation carries a high risk for distal emboli before cerebral protection is installed. Therefore, the combination of open carotid endarterectomy with retrograde stenting of the proximal lesion through one stage is most attractive.

METHODS

Eleven patients were treated with a combined procedure for tandem lesions at the origin of the brachiocephalic trunk or common carotid artery (CCA) and the carotid bifurcation. Endpoint of this evaluation was the 30-day MACE (Major Adverse Cardiovascular Events).

RESULTS

All procedures were finished as planned and no conversion was necessary. Thirty-day mortality was 0%. One patient developed a restenosis after only 4 days for which he underwent a re-PTA procedure. The 30-day MACE was 0%. None of the patients needed additional treatment during follow-up (mean follow-up 33 months; range: 11 to 60) although one patient developed a non-significant stenosis during follow-up.

CONCLUSIONS

Combined treatment of tandem lesions of the carotid artery is safe and effective in the long-term.

Restaging the mediastinum in non-small cell lung cancer after induction therapy: non-invasive versus invasive procedures

OBJECTIVE

Nodal status after induction therapy in patients with stage III non-small cell lung cancer (NSCLC) is an independent prognostic factor for survival. Prognosis is poor in patients with persisting mediastinal lymph node involvement.

METHODS

From February 2000 to September 2007, restaging for NSCLC was performed in 25 patients (23 men, 2 women) by computed tomography (CT), positron emission tomography (PET) as well as repeat mediastinoscopy. Initial proof of N2 or N3 disease was obtained by mediastinoscopy.

RESULTS

The non-invasive restaging modalities CT and PET had a rather low accuracy of 64% and 72%, respectively. Repeat mediastinoscopy performed better with an accuracy of 84%.

CONCLUSION

Histological proof of mediastinal involvement after induction therapy in NSCLC is necessary to select those patients who will benefit from surgical resection. When a first mediastinoscopy has been performed to obtain pathological proof of N2 or N3 disease, repeat mediastinoscopy proves to be more accurate than CT or PET scanning for mediastinal restaging.

TNM-Classification for Lung Cancer: From the 7(th) to the 8(th) Edition

Most tumors are staged according to the Tumor-Node-Metastasis (TNM) classification. For lung cancer a new edition was introduced in 2009 and generally applied since 2010. This 7(th) TNM-classification is based on a large, international retrospective database. Important changes were made regarding the T, N, M factors and specific subcategories were added. However, this 7(th) edition is still purely based on anatomical information. Other prognosticators such as laboratory results, histology, tumor markers and molecular genetic factors are not yet considered. To prepare the 8(th) TNM classification a prospective database developed by the International Association for the Study of Lung Cancer (IASLC), is currently enrolling patients from all continents. In this way, more precise and reliable data will become available on specific subdivisions of the T, N and M factors. If proven to be prognostically valid, other parameters will be included as histology, demographic data and specific biochemical and molecular predictive and prognostic factors. All centers with a large experience in thoracic oncology are encouraged to participate in this prospective database.

Quality of life after anterior mediastinal mass resection: a prospective study comparing open with robotic-assisted thoracoscopic resection

OBJECTIVE

To prospectively evaluate quality of life (QoL) evolution after robotic-assisted thoracoscopic or open anterior mediastinal tumour resection with the European Organisation for Research and Treatment of Cancer (EORTC) QoL Questionnaire-C30 and the lung cancer-specific module, LC-13.

METHODS

From January 2004 to December 2008, QoL was prospectively recorded in all patients undergoing surgery for mediastinal tumours. A total of 14 patients underwent thoracoscopic resection using the da Vinci robotic system (Intuitive Surgical, Inc., Mountain View, CA, USA), and 22 patients open resection through sternotomy. Questionnaires were administered before surgery and 1, 3, 6 and 12 months, postoperatively, with response rates of 100%, 86.1%, 94.4%; 75.0% and 86.1%, respectively.

RESULTS

Both approaches had comparable preoperative patients' characteristics and QoL subscales. Open resection by sternotomy was characterised by a significant decrease in general functioning 1 month after surgery (physical functioning p=0.001, role functioning p=0.001, and social functioning p=0.044). Patients also complained of increased thoracic pain in the first 3 months after surgery (p=0.017). After a da Vinci robotic resection QoL scores approximated baseline preoperative values 1 month after surgery, with the exception of increase in thoracic and shoulder pain the first 3 months after surgery (p=0.028 and 0.029, respectively).

CONCLUSIONS

Numerous techniques have been published with different degrees of invasiveness, generating the existing controversy as to which is the best surgical approach for anterior mediastinal tumours. The high burden of decreased physical functioning reported after sternotomy is not seen after a da Vinci robotic-assisted thoracoscopic resection. The initial experience and postoperative QoL data are excellent and, therefore, the da Vinci robot will stay our future technique of choice for the treatment of resectable mediastinal tumours smaller than 4 cm on imaging techniques.

Filters placed in the superficial femoral arteries for limb salvage in a high-surgical-risk patient with atheroembolism: results at 2 years

PURPOSE

To report the off-label use of Emboshield filters as a treatment for bilateral atheroembolism (trash foot) in an inoperable patient.

CASE REPORT

A 64-year-old man with a juxtarenal abdominal aortic aneurysm (jAAA) presented with necrotic wounds of the forefoot and toes of both feet. Doppler imaging showed triphasic signals. He was on oral anticoagulants because of a mechanical valve. The patient was admitted for evaluation and administration of intravenous antibiotics; other than the jAAA, no other source of emboli was detected. Since the patient was inoperable, Emboshield filters were placed bilaterally through antegrade femoral accesses at the level of the superficial femoral arteries to prevent embolism to the feet. Two years later, the patient has no symptoms; debris is present in both filters but does not compromise arterial flow into the legs.

CONCLUSION

This case demonstrates the successful off-label use of an Emboshield filter for trash foot in an inoperable patient.

Emergency endovascular aneurysm repair for ruptured abdominal aortic aneurysms: an institutional experience

OBJECTIVES

Emergency endovascular aneurysm repair (eEVAR) for ruptured abdominal aortic aneurysms (rAAA) is still under investigation. Since installation of an urgent eEVAR kit in our hospital, all patients with a rAAA or urgent thoracic aortic aneurysm are candidates for eEVAR or eTEVAR (emergency thoracic EVAR), respectively. For this study, we analyzed all rAAA patients treated with eEVAR.

METHODS

Data were recorded prospectively. Criteria for an eEVAR were an infrarenal neck > or = 15 mm, acceptable landing zone, angles below 70 degrees and a good femoral approach. We prefer preoperative angio CT-scan but in case of instability, an intra-aortic balloon can stabilize the patient during angiography (in the OR) to decide between open or eEVAR repair. Follow-up was performed on regular intervals by duplex or CT-scan. Thirty-day mortality and overall survival were calculated.

RESULTS

Since 2006, nine male rAAA patients with a mean age of 73 years (range : 62-82) had eEVAR repair. Aneurysm diameter was 8 cm (range : 5.8-11). The Hardman index was 1.5 (range : 0-3). In eight patients an aorto-uni-iliac device was placed succesfully followed by a femorofemoral crossover bypass. The 30-day operative mortality was 12.5% (one patient with septic shock). Three patients showed a type 2 endoleak with stable diameter during follow-up but one patient showed expansion 4 years after treatment.

CONCLUSIONS

Treating rAAA with eEVAR in selected patients with acceptable anatomy and a kit permanently available in the operating room yielded good results by a surgical team trained for both open and eEVAR repair. The conversion rate was low (11%) and the survival (immediate and 30-days) was excellent (87.5%).

Quality of life after lung cancer surgery: a review

The long-term goals of lung cancer surgery include cancer control, survival and quality of life (QoL). In a patient population with a high mortality rate, evaluation and preservation of QoL after treatment is imperative. Lung cancer patients already have a significant lower QoL compared to an age-matched healthy population with significant impairment in physical and emotional functioning. Lung cancer surgery causes further deterioration of QoL, especially in the first 3 to 6 months after surgery. While some studies suggest that QOL returns to baseline levels at 6 to 9 months postoperatively, others report that QOL is still significantly impaired at 6 and 12 months after surgery. Age, extent of surgery, preoperative lung function, access technique, and adjuvant treatment may all influence postoperative QoL. This review presents the basic concepts of QoL research, several commonly used QoL measurement instruments, and a summary of the available data on post-lung cancer surgery QoL.

Different indications for repeat mediastinoscopy: single institution experience of 79 cases

AIM

Different indications exist for repeat mediastinoscopy or remediastinoscopy (reMS). Presently, it is a valuable restaging tool in non-small cell lung cancer (NSCLC). Not only does it provide pathological evidence of mediastinal downstaging, it also selects those patients who will benefit from a subsequent surgical resection and determines prognosis. However, other indications for reMS exist. The authors reviewed their overall experience with reMS.

METHODS

From June 1994 until September 2007, 79 reMS were performed in 75 patients (65 men and 10 women). Mean age was 67.4 years (range 35 to 85 years).

RESULTS

ReMS was performed after induction therapy in 54 cases (68.4%), for recurrent lung cancer in 7 cases (8.9%), metachronous second primary lung cancer in 2 cases (2.5%), for lung cancer occurring after an unrelated disease such as sarcoidosis in 1 case (1.2%), for an inadequate first procedure in 8 cases (10.1%) and for a non-malignant disease such as sarcoidosis or lymphoma in 7 cases (8.9%). ReMS was technically feasible in all patients. There was no mortality. One hemorrhage was encountered from a bronchial artery during reMS which was controlled by packing and one tear in the bronchial wall which was treated conservatively. In patients with lung cancer (71 patients), reMS was positive in 29 cases (40.8%). ReMS provided a definitive diagnosis in 3 patients with sarcoidosis and in one patient with lymphoma .

CONCLUSIONS

Although mostly performed as a restaging procedure after induction therapy in non-small cell lung cancer, reMS can also safely be performed for other indications providing pathological evidence of mediastinal involvement.

Early endothelial dysfunction in young type 1 diabetics

OBJECTIVES

Endothelial dysfunction is a known precursor of atherosclerosis and can be assessed by measuring the brachial artery flow-mediated dilatation (FMD) via ultrasonography. This study investigated endothelial function in young type 1 diabetics without cardiovascular morbidity or diabetes-related pathology.

METHODS

Young diabetics and healthy controls were recruited, both meeting strict inclusion and exclusion criteria. To prove absence of subclinical atherosclerosis, intima-media thickness (IMT) measurements at the carotid bifurcation were done in all of them. FMD was measured at the brachial artery. The results were compared using the t-test and the influences of different variables on FMD were assessed using multiple linear regression.

RESULTS

Twenty-six diabetics (23.4+/-5.8 years) and 36 healthy volunteers (23.1+/-2.8 years) were recruited. The duration of diabetes was 9.2+/-5.3 years; metabolic control was moderate (HbA1c 7.6+/-1.0%) and IMT was normal in both groups. FMD was significantly impaired in type 1 diabetics (7.13+/-0.43 vs. 8.77+/-0.43%; p=0.002). The FMD grade was associated with diabetes and age. Patients with a good metabolic control (HbA1c</=7.0%) had a better FMD.

CONCLUSIONS

In type 1 diabetics, even without preclinical or clinical atherosclerosis, endothelial function is already disturbed and can be detected using ultrasonography.

[Stage III NSCLC. The surgeon's role in exploration and treatment]

The role of surgery in stage IIIA non-small cell lung cancer (NSCLC) remains controversial. Different restaging techniques exist to evaluate response after induction therapy and these are subdivided into non-invasive, invasive and alternative or minimally invasive techniques. Remediastinoscopy provides pathological evidence of response after induction therapy. Stage IIIA-N2 NSCLC represents a heterogeneous spectrum of locally advanced disease and different subsets exist. When N2 disease is discovered during thoracotomy a resection should be performed if this can be complete. Most patients with pathologically proven N2 disease detected during preoperative work-up will be treated by induction therapy followed by surgery or radiotherapy. In two large, recently completed, phase III trials there was no difference in overall survival between the surgical and radiotherapy arm. Surgical resection may be recommended in those patients with proven mediastinal downstaging after induction therapy who can preferentially be treated by lobectomy. Patients with bulky N2 disease are mostly treated with combined chemoradiotherapy although the precise treatment scheme has not been determined yet. Also, stage IIIB is mostly treated by concurrent or sequential chemoradiotherapy. Surgery is rarely indicated in T4N0-1 disease unless a complete resection can be obtained, in some selected cases after induction therapy.

Accuracy and survival of repeat mediastinoscopy after induction therapy for non-small cell lung cancer in a combined series of 104 patients

OBJECTIVE

Precise restaging of non-small cell lung cancer after induction therapy is of utmost importance. Remediastinoscopy remains a controversial procedure. In a combined, updated series of two thoracic centres, accuracy and survival of remediastinoscopy were determined.

METHODS

From November 1994 to August 2005, remediastinoscopy was performed in 104 patients (98 men, 6 women) after induction therapy for locally advanced non-small cell lung cancer. Mean age was 64.3 years (range 38-85). Neoadjuvant chemotherapy was given in 79 patients and chemoradiotherapy in 25. Follow-up data were completed in January 2007.

RESULTS

Remediastinoscopy was technically feasible in all patients except for one who died due to perioperative haemorrhage. Remediastinoscopy was positive in 40 patients and negative in 64; the latter group underwent thoracotomy. There were 17 false-negative remediastinoscopies. Sensitivity of remediastinoscopy was 71%, specificity 100% and accuracy 84%. Follow-up was complete for all patients. Sixty-nine died, mostly of distant metastases. Median survival time for the whole group was 18 months (95% confidence interval 11-25). Median survival time in patients with a positive remediastinoscopy was 14 months (95% confidence interval 8-20), with a negative remediastinoscopy 28 months (95% confidence interval 15-41) and with a false-negative remediastinoscopy 24 months (95% confidence interval 3-45). In univariate analysis the difference between positive and negative remediastinoscopies was highly significant (p=0.001). In a multivariate analysis including sex, age, histology, centre, and nodal status at remediastinoscopy, only nodal status was a significant independent prognostic factor (p=0.008).

CONCLUSIONS

Remediastinoscopy is a valuable restaging procedure after induction therapy. Persisting mediastinal nodal involvement proven at remediastinoscopy heralds a poor prognosis.

Quality of life evolution after surgery for primary or secondary spontaneous pneumothorax: a prospective study comparing different surgical techniques

The objective of the present study is to evaluate quality of life (QoL) evolution after video-assisted thoracic surgery (VATS) and anterolateral thoracotomy (AT) for primary and secondary spontaneous pneumothorax, which has not been studied prospectively until now. From January 2003 to December 2004, QoL was prospectively recorded in 20 consecutive patients, using the European Organisation for Research and Treatment of Cancer (EORTC) QoL Questionnaire-C30 and the lung specific module LC-13. Questionnaires were administered before surgery and 1, 3, 6 and 12 months postoperatively (MPO) with response rates of 100%, 85%, 80%, 65% and 60%, respectively. In this prospective, non-randomized study, all patients had wedge resection and apical pleurectomy, 45% by video-assisted thoracic surgery (VATS), and 55% by anterolateral thoracotomy (AT). In general, patients QoL subscales improved after surgery. After VATS, pain (3 MPO P=0.012), dyspnoea (1 MPO P=0.030) and thoracic pain (1 MPO P=0.038) decreased significantly. After AT, a significant increase was seen in general QoL (1 MPO P=0.036, 3 MPO P=0.034, 12 MPO P=0.025), physical (6 MPO P=0.025) and emotional functioning (12 MPO P=0.017). Dyspnoea (12 MPO P=0.042) and coughing (6 MPO P=0.046) decreased after AT. After surgery, AT and VATS are comparable in QoL evolution with the exception of a significant difference at 1 MPO in physical, role and cognitive functioning (P=0.002, P=0.002 and P=0.0018, respectively) and dyspnoea (P=0.041) in favour of VATS. Comparing VATS and AT in QoL evolution, significant differences are seen in thoracic pain evolution in favour of VATS (6 MPO P=0.037). After surgery, AT and VATS are comparable in QoL subscales with exception of a significant difference at 1 MPO in favour of VATS. Dyspnoea and coughing improved after surgery.

The Use of Positron Emission Tomography With (18)F-Fluorodeoxyglucose for the Diagnosis of Vascular Graft Infection

Vascular graft infection is associated with a high morbidity and mortality rate. Diagnosis is difficult, as there is no single diagnostic criterion that has a 100% accuracy. A combination of physical examination, laboratory tests, and several imaging techniques is mandatory. Beside a wide range of indications in the oncological field, positron emission tomography with (18)F-fluorodeoxyglucose (FDG-PET) has a well-known role in the diagnosis of bone and soft-tissue infections. Some authors have recently reported on the potential use of FDG-PET in the diagnosis of vascular graft infections. The aim of this study is to review personal experience. Five consecutive patients with a suspected prosthetic infection (1 aortobifemoral bypass, 3 femoropopliteal bypasses, and 1 femorofemoral bypass) underwent FDG-PET. All prostheses showed a moderate or intense FDG tracer uptake. All 3 patients with an intense FDG uptake proved to have a prosthetic infection (based on microbiologic examination). These preliminary results suggest that FDG-PET might be an interesting tool to confirm vascular graft infection.

Mycotic aneurysm of the descending thoracic aorta. Review and case report

A 74-year-old male presented with bilateral invalidating claudication. A bilateral percutaneous transluminal angioplasty (PTA) with stenting of both superficial femoral arteries was performed but complicated by an urosepsis with Escherichia coli and a septic phlebitis at the site of an intravenous line. The phlebitis was complicated by a local abcedation for which incision and drainage were performed. One month after discharge he was readmitted at our hospital with septic fever and positive hemocultures for Escherichia coli. Positron emission tomography-computed tomographic scan (PET/CT-scan) showed a mycotic aneurysm of the thoracic aorta. Because no cryopreserved donor aorta was available and the aneurysm size rapidly increased, an open in situ repair was performed with a Dacron silver prosthesis soaked in rifampicin. His recovery was further complicated by a perforated toxic megacolon for which a subtotal colectomy was performed. Further recovery was uncomplicated and 10 months after the aortic repair patient is still free from infection.

Decision making about operability in non-small cell lung cancer

With the introduction of combined modality therapy and better staging techniques, the role of surgical resection for non-small cell lung cancer is continuously redefined. The final aim of surgical treatment for lung cancer is complete resection, also after neoadjuvant or induction therapy. Precise criteria for complete resection have recently been defined. Definite indications for surgery include clinical stages I, II and resectable IIIA. The precise role for surgical resection in stage IIIA-N2 lung cancer remains controversial but only downstaged patients should be considered. Stage IIIB is mostly treated by chemoradiotherapy. Accurate peroperative or surgical staging is necessary, as well regarding the tumour as nodal factor, to determine the extent of resection. A systematic nodal dissection should be performed including at least three hilar and three mediastinal lymph node stations. Post-induction surgical therapy often represents a greater technical challenge due to a pronounced hilar and mediastinal fibrosis. Downstaging is an important prognostic factor and persisting mediastinal lymph node involvement carries a poor prognosis. The optimal restaging method has not been established yet, but a pathological proof should be obtained. Remediastinoscopy is feasible with an acceptable accuracy but less invasive techniques are currently evaluated.

Spontaneous pseudo-aneurysm of the deep femoral artery treated by a covered stent

PURPOSE

To present the management of a spontaneous pseudo-aneurysm of the deep femoral artery by an endovascular technique.

CASE REPORT

An 82-year-old man presented with a painless pulsating mass at the level of the upper right thigh without any previous history of trauma, surgery or puncture of the femoral artery. The mass proved to be a pseudo-aneurysm of the deep femoral artery. Thrombin injection with simultaneous balloon inflation at the neck of the aneurysm did not result in a long-lasting thrombosis. Since both general and epidural anaesthesia were absolutely contra-indicated, and because of severe stenotic lesions of the femoro-popliteal axis, we chose to exclude this aneurysm under local anaesthesia with a balloon-expandable covered Jo-stent in order to maintain patency of the deep femoral artery. Twenty months postoperatively, the aneurysm is still thrombosed while the patency of both the superficial and deep femoral artery is preserved.

CONCLUSIONS

This case demonstrates that an endovascular approach can be an excellent treatment for aneurysms of the deep femoral artery, thereby avoiding an open surgical procedure while preserving the patency of the deep femoral artery.

Quality of life evolution after lung cancer surgery: A prospective study in 100 patients

OBJECTIVE

To evaluate quality of life (QoL) evolution after thoracic surgery for lung cancer with the European Organisation for Research and Treatment of Cancer (EORTC) QoL Questionnaire-C30 and the lung cancer specific module LC13.

METHODS

A prospective QoL registration started in 2002 for all patients undergoing major pulmonary surgery for malignant disease. Between January 2002 and November 2004, 100 patients were included. Questionnaires were administered pre-operatively and 1, 3, 6 and 12 months post-operatively (MPO) with response rates of 100%, 71%, 77%, 83% and 76%, respectively.

PROCEDURES

lobectomy 61%, pneumonectomy 17%, and wedge resection 22%. Approaches: anterolateral thoracotomy 79%, posterolateral thoracotomy 13% and video-assisted thoracic surgery (VATS) 8%.

RESULTS

Lobectomy and wedge resection are comparable in QoL evolution. Both resections are characterized by a 1 month temporary decrease in QoL functioning scores and an increase in pain symptoms. Lobectomy patients report an increase in dyspnea in the first month post-operatively, not seen after wedge resection. With exception of thoracic pain after lobectomy, QoL scores approximated baseline values 3MPO indicating good recovery. After pneumonectomy, there is no return to baseline in physical functioning, role functioning, pain, shoulder function and dyspnea in a 12 months follow-up period. Other QoL scores were comparable with baseline values. Pneumonectomy was significantly associated with a less favorable QoL score evolution when compared with lobectomy. Comparing antero- and posterolateral thoracotomy, significant differences in pain and dyspnea were seen in favor of the anterolateral technique. Comparing thoracotomy to VATS, significant differences were seen in physical functioning, QoL and thoracic pain in favor of VATS.

CONCLUSIONS

The present study documented QoL evolution profiles comparing pre-operative status with deficits and changes at 1, 3, 6 and 12 months after pulmonary surgery. Lung cancer surgery is well tolerated by the majority of patients. Lobectomy patients have a more favorable physical functioning and less thoracic pain, compared to pneumonectomy. Antero- and posterolateral thoracotomy are comparable for QoL evolution. After posterolateral thoracotomy more post-operative pain and dyspnea was seen. Post-operative physical functioning, pain and QoL are in favor of VATS.

Remediastinoscopy

Indications for remediastinoscopy include recurrent and second primary lung cancer, an inadequate first procedure, lung cancer occurring after an unrelated disease such as lymphoma, and restaging after induction therapy. Nowadays, restaging is the most frequent indication for remediastinoscopy. Only patients with proven mediastinal downstaging will benefit from a subsequent surgical resection. In contrast to imaging or functional studies, remediastinoscopy provides pathologic evidence of response after induction therapy. Although technically more challenging than a first procedure, remediastinoscopy can select patients for subsequent thoracotomy and provides prognostic information. In most recent series, sensitivity of remediastinoscopy is higher than 70% with an accuracy of approximately 85%. Survival also depends on the findings at remediastinoscopy, with patients with persisting mediastinal involvement having a poor prognosis. An alternative approach consists of the use of minimally invasive staging procedures as endobronchial or endoscopic esophageal ultrasonography to obtain initial proof of mediastinal nodal involvement. Mediastinoscopy is subsequently performed after induction therapy to evaluate response. In this way, a technically more difficult remediastinoscopy can be avoided.

Superior sulcus tumor arising in an azygos lobe

A non-small cell lung cancer presenting as a superior sulcus tumor in an azygos lobe has not yet been reported. We present such a case in a 69-year-old man undergoing complete resection after induction chemoradiotherapy and discuss the specific location of a superior sulcus tumor and the aberrant anatomy of an azygos lobe.

Solitary fibrous tumor of the pleura with associated hypoglycemia: Doege-Potter syndrome: a case report

Tumor-associated hypoglycemia as a paraneoplastic phenomenon is a well-known entity and is referred to as Doege-Potter syndrome. A man was admitted because of acute confusion and drowsiness. Laboratory results showed profound hypoglycemia. All investigations proved to be normal, except for a chest x-ray, which showed a large pleural mass. On transthoracic puncture, a tumor of pleural origin was diagnosed. This tumor, presenting as a large, well-circumscribed encapsulated mass, was removed by thoracotomy. On pathologic examination, the diagnosis of a solitary fibrous tumor with benign characteristics was made. After surgical removal, the hypoglycemia resolved. Solitary fibrous tumors are localized tumors of the pleura with an unpredictable behavior. The therapy consists of resection.

Association of colonic atresia and Hirschsprung's disease in the newborn: report of a new case and review of the literature

Colonic atresia (CA) is an infrequent cause of lower gastrointestinal obstruction in the neonate. Coexistence with aganglionosis of the colon (Hirschsprung's disease) has been reported but is generally not recognized in the neonatal period. We report another case and present a review of the literature. A boy with a lower gastrointestinal obstruction, caused by a CA type III, had creation of a proximal colostomy and a distal mucous fistula on the 1st day of life. In the preoperative work-up before restoring the continuity, rectal suction biopsies revealed the presence of Hirschsprung's disease. When the boy was 6 months old, a distal colectomy and reanastomosis were done. Creation of a colostomy and reanastomosis in a second procedure is recommended for treating a type III CA unless distal aganglionosis has been ruled out.

Long-term results of primary stenting for long and complex iliac artery occlusions

OBJECTIVES

To evaluate the long-term results of recanalization with primary stenting for long and complex iliac artery occlusions.

DESIGN

Retrospective non-randomized study.

METHODS

Between 1996 and 2004, 38 patients underwent recanalization of an occluded iliac artery with subsequent stenting for TASC B lesions in 12 patients, TASC C in 10 and TASC D in 16. Thirty-one patients had Fontaine stage 2 B, four patients had stage 3 and one patient had stage 4. Two patients (5.4%) presented with acute ischemia and received trombolysis before recanalization. Patency results were calculated using Kaplan and Meier analysis. The mean follow-up was 26 months.

RESULTS

Technical success was 97.4%. Thirty-day mortality was 2.7%. The primary patency rate was 94%, 89% and 77% at 1, 3 and 5 years respectively. Three re-occlusions (8.1%) and one restenosis (2.7%) were observed during follow-up. The secondary patency (SP) rate was 100%, 94% and 94% after 1, 2 and 3 years. Fifteen patients underwent an associated procedure. A kissing stent procedure in three patients, a contralateral PTA of an iliac stenosis in 8, a femoro-femoral bypass in 2, a femoropopliteal bypass in 1 and an femoral endarterectomy in 2. The procedure related complication rate was 5.4%.

CONCLUSION

Long-term results of iliac recanalization are excellent without major complications if the procedure is technically successful. The endovascular procedure can be an alternative to an iliofemoral or aortobifemoral bypass in a high risk population.

Nodal status at repeat mediastinoscopy determines survival in non-small cell lung cancer with mediastinal nodal involvement, treated by induction therapy☆

OBJECTIVE

Remediastinoscopy is a valuable tool in restaging non-small cell lung cancer after induction therapy for mediastinal nodal involvement as it provides pathological evidence of response and may select patients for subsequent thoracotomy. However, long-term survival data after remediastinoscopy are scarce.

METHODS

From November 1994 to April 2003, a remediastinoscopy was performed in 32 patients (29 men, 3 women) after induction therapy for locally advanced non-small cell lung cancer. Mean age was 67.8 years (range, 47-83). Neoadjuvant chemotherapy was given in 26 patients and chemoradiotherapy in 6. Follow-up data were completed in January 2005.

RESULTS

Remediastinoscopy was technically feasible in all patients. There were five false-negative remediastinoscopies, resulting in a sensitivity of 71%, specificity of 100% and accuracy of 84%. Follow-up was complete in all patients. Median survival time for the whole group was 21 months (95% confidence interval [CI] 9-33). Median survival time in patients with a positive remediastinoscopy was 7 months (95% CI 5-9), with a negative remediastinoscopy 41 months (95% CI 13-69), and with a false-negative remediastinoscopy 24 months (95% CI 5-43). The difference between positive and negative remediastinoscopies was highly significant (p=0.003). In the combined group of patients with positive and false-negative remediastinoscopies (n=17), median survival time was 8 months (95% CI 3-13). The difference with negative remediastinoscopy remained significant (p=0.012). In a multivariate analysis, including sex, age, histology and nodal status at repeat mediastinoscopy, only nodal status was a significant independent prognostic factor (p=0.015).

CONCLUSIONS

Remediastinoscopy is a valuable restaging procedure after induction therapy. Prognosis is poor in patients with persisting mediastinal nodal involvement, proven at repeat mediastinoscopy.

Paravertebral schwannoma with high uptake of fluorodeoxyglucose on positron emission tomography

A paravertebral mass was discovered in a 27-year-old woman, while investigating a painful shoulder and arm. CT, MRI and fine needle aspiration cytology (FNAC) pointed in the direction of a benign mass, but positron emission tomography (PET) showed a high uptake of [(18)F]fluorodeoxyglucose (FDG), which was indicative of a malignant lesion. Pathological analysis of the thoracoscopically resected tumour gave us the final diagnosis of a benign schwannoma. This report demonstrates that a high uptake of FDG in a non-malignant mediastinal tumour is possible.

Video-assisted thoracic surgery (VATS) for primary spontaneous pneumothorax: how I do it ?

The precise management of primary spontaneous pneumothorax remains controversial due to the lack of large prospective randomized trials. This not only regards the indications for conservative or invasive treatment but also the precise technique for air evacuation and recurrence prevention. The technique of video-assisted thoracic surgery is described as it is performed in our centre for the treatment of primary spontaneous pneumothorax.

Lobectomy of the right lower lobe for lung cancer

Lobectomy is the treatment of choice for primary non-small cell lung cancer (NSCLC), provided that the patient is fit enough to undergo surgery, the primary tumour is confined to one lobe and there are no distant metastases. Other indications for lobectomy include metastatic disease (with multiple nodules in one lobe or central localisation of metastasis), centrally located benign tumours (such as hamartoma), extensive infectious diseases (such as lung abcess, bronchiectasis), and congenital anomalies (such as congenital cystic adenomatoid malformation-CCAM). A lobectomy of the right lower lobe for squamous cell carcinoma is presented in a 66-year old patient. As there was proven involvement of the mediastinal lymph nodes (stage IIIa-N2), induction chemotherapy consisting of four cycles of gemcitabin and cisplatinum was given. Control CT-scan and FDG-PET scan showed no mediastinal involvement anymore. He was scheduled for surgical treatment. Through a right anterolateral muscle-sparing thoracotomy, lobectomy of the lower lobe with a mediastinal lymphadenectomy was done. Apart from atrial fibrillation, the postoperative course was uneventful.

Extrapericardial pneumonectomy

Presentation of the technique of extrapericardial left and right standard pneumonectomy. After insertion of a disposable double-lumen endotracheal tube, the patient is positioned in lateral decubitus and a lateral thoracotomy is performed. One-lung ventilation is started after a thorough identification is performed followed by systematic nodal dissection. Centrally, the pulmonary artery and veins are encircled, cut on clamps and sewed. Alternatively, the vessels can be stapled. Next, the bronchus is dissected toward the trachea and transected by stapling or interrupted sutures as close to the trachea as possible. When there is a high risk of bronchopleural fistula, as after induction chemotherapy or radiotherapy, the bronchial stump is covered with viable tissue (as azygos vein, pericardial fat, intercostal muscle or pleural flap, omentum, or muscle flaps from the thoracic wall).

Aortic graft infection from appendicitis. A case report

Fifteen years after aortobifemoral bypass and five years after left femoropopliteal bypass, a 73-year old man presented with a vague abdominal pain syndrome. After an extensive work-up, aortobifemoral graft infection was suspected; an appendiceal abscess infiltrating the prosthesis was discovered during exploratory laparotomy. Appendectomy was performed followed by removal of the vascular graft, the latter being replaced by a bilateral axillofemoral prosthesis. Aortic graft infection from appendicitis is an extremely rare condition; a review of similar cases is presented.

Unusual complications of preperitoneal mesh implantation in the treatment of inguinal hernia

More and more prosthetic materials are being used in the treatment of inguinal hernia. This report deals with some unusual but devastating complications, occurring after preperitoneal mesh implantation. A 56-year old male patient underwent a Stoppa-repair for a bilateral inguinal hernia. Two years postoperatively, a localized abdominal wall abscess was treated with antibiotics and drainage. A barium enema and a CT-scan of the abdomen were performed to rule out an enteric fistula; the CT-scan unexpectedly revealed a tumoral mass involving the sigmoid colon, and an explorative laparotomy was done. Peroperatively, part of the mesh was found to penetrate the bowel wall and a sigmoidectomy with removal of the mesh was performed. Two years later, ingrowth of the urinary bladder by the remains of the mesh was the unfortunate peroperative finding when the patient was operated on for an inflammatory mass, involving the bladder wall. The patient needed two more interventions for persisting wound fistulas. All the remains of the mesh have been removed and all fistulas have been widely excised. Nowadays, the patient is recovering well with complete healing of all wounds. Although infection of prostheses used in the treatment of hernias has been described, late and serious complications related to mesh implantation, such as perforation of the colon and the bladder, have seldom been reported.

Intensive insulin therapy in critically ill patients

BACKGROUND

Hyperglycemia and insulin resistance are common in critically ill patients, even if they have not previously had diabetes. Whether the normalization of blood glucose levels with insulin therapy improves the prognosis for such patients is not known.

METHODS

We performed a prospective, randomized, controlled study involving adults admitted to our surgical intensive care unit who were receiving mechanical ventilation. On admission, patients were randomly assigned to receive intensive insulin therapy (maintenance of blood glucose at a level between 80 and 110 mg per deciliter [4.4 and 6.1 mmol per liter]) or conventional treatment (infusion of insulin only if the blood glucose level exceeded 215 mg per deciliter [11.9 mmol per liter] and maintenance of glucose at a level between 180 and 200 mg per deciliter [10.0 and 11.1 mmol per liter]).

RESULTS

At 12 months, with a total of 1548 patients enrolled, intensive insulin therapy reduced mortality during intensive care from 8.0 percent with conventional treatment to 4.6 percent (P<0.04, with adjustment for sequential analyses). The benefit of intensive insulin therapy was attributable to its effect on mortality among patients who remained in the intensive care unit for more than five days (20.2 percent with conventional treatment, as compared with 10.6 percent with intensive insulin therapy, P=0.005). The greatest reduction in mortality involved deaths due to multiple-organ failure with a proven septic focus. Intensive insulin therapy also reduced overall in-hospital mortality by 34 percent, bloodstream infections by 46 percent, acute renal failure requiring dialysis or hemofiltration by 41 percent, the median number of red-cell transfusions by 50 percent, and critical-illness polyneuropathy by 44 percent, and patients receiving intensive therapy were less likely to require prolonged mechanical ventilation and intensive care.

CONCLUSIONS

Intensive insulin therapy to maintain blood glucose at or below 110 mg per deciliter reduces morbidity and mortality among critically ill patients in the surgical intensive care unit.