Differential expression of the Groucho-related genes 4 and 5 during early development of Xenopus laevis

Recently, we demonstrated that the Xenopus Wnt effector XTcf-3 interacts with Groucho-related transcriptional repressors (Roose et al., 1998. Nature 395, 608-612). A long form of the Groucho-related genes, XGrg-4, was shown to repress axis formation in the Xenopus embryo, whereas a short form, XGrg-5, acted as a potentiator. In this study, the temporal and spatial expression of XGrg-4 and XGrg-5 is described in Xenopus laevis embryos. Both genes are maternally expressed. In the gastrula, transcripts of both genes are present in the animal as well as the vegetal region. At later stages, XGrg-4 and XGrg-5 show specific patterns of expression in the central nervous system (CNS), cranial ganglia, eyes, otic vesicles, stomodeal-hypophyseal anlage, cement gland, head mesenchyme, branchial arches, neural crest and derivatives, somites, pronephros, pronephric duct, heart and tailbud. Differences in the expression of XGrg-4 and XGrg-5 were found in the CNS, cranial ganglia, olfactory placodes, stomodeal-pharyngeal anlage, cement gland, head mesenchyme and ectoderm.

Predictive factors for complications of anatomical pulmonary segmentectomies

OBJECTIVES

The role of anatomical pulmonary segmentectomy is increasing, but there are few data about its complication rate. We have analysed the postoperative morbidity, mortality and risk factors in a consecutive series of 228 segmentectomies performed in our department.

METHODS

Between January 2007 and December 2011, 221 patients underwent 228 segmentectomies. There were 99 women (45%) and 122 men (55%). The mean age was 61 years (range 18-86 years). The mean forced expiratory volume in 1 s (FEV1) was 87%, and 30 patients had an FEV1 of ≤60%. Fifty-seven patients had a previous history of pulmonary resection. Indications for segmentectomy were: primary lung cancer (111 cases), metastases (71 cases), benign non-infectious (25 cases) and benign infectious diseases (21 cases). The approach was a posterolateral thoracotomy (Group PLT) in 146 patients (64%) and a thoracoscopy (Group TS) in 82 (36%). The two groups were homogenous in terms of age, gender, indications of surgery and type of segmentectomy.

RESULTS

The mortality rate at 3 months was 1.3% (3 patients). The overall complication rate was 34%. Ten patients were reoperated for the following reasons: haemothorax (4 cases), ischaemia of the remaining segment (3 cases), active bleeding (1 case), prolonged air leak (1 case) and dehiscence of thoracotomy (1 case). The average duration of drainage was 5 days (range 1-34 days) and the average length of stay was 9 days (range 3-126 days). On univariate analysis, FEV1, male gender and thoracotomy were statistically significant risk factors for complications. On multivariate analysis, the same three predictive factors of complications independently of age were found statistically significant: preoperative FEV1 < 60% [odds ratio (OR) = 5.9, 95% CI (2.5-13.7), P < 0.001] male gender [OR = 2.04, 95% CI (1.2-3.6), P < 0.013] and thoracotomy [OR = 2.14, 95% CI (1.33-3.46), P = 0.001].

CONCLUSIONS

Pulmonary anatomical segmentectomies have an acceptable morbidity rate. Postoperative complications are more likely to develop in male gender patients, with FEV1 ≤ 60% and operated by open surgery.

A totally thoracoscopic approach for pulmonary anatomic segmentectomies

Reported experience with video-assisted anatomic pulmonary segmentectomy is still limited. Over a 28-month period, totally thoracoscopic (TT) anatomic segmentectomies, i.e. using only endoscopic instrumentation and video-display without utility incision, were attempted on 50 patients (25 males and 25 females), aged 18-81 years (mean: 57 years). The indication was a clinical N0 non-small cell lung carcinoma in 25 cases, a solitary metastasis in nine cases and a benign lesion in 16 cases. The following segmentectomies were performed: right apicosuperior (9) right superior (6), right basilar (7), lingula sparing left upper lobectomy (7), left apicosuperior (4), lingula (4), left superior (6) and left basilar (7). It was associated with a radical lymphadenectomy in 20 cases. There was one conversion to thoracotomy. The mean operative time was 188±54 min, the mean intraoperative blood loss was 91±82 ml (range: 0-450 ml). There were four minor postoperative complications (11.7%). The median postoperative stay was 5.6±2.4 days. Out of the 25 patients operated on for a cN0 lung carcinoma, two were finally upstaged to N2. TT anatomic pulmonary segmentectomies are feasible and safe.

Oncological results of full thoracoscopic major pulmonary resections for clinical Stage I non-small-cell lung cancer

OBJECTIVES

The full thoracoscopic approach to major pulmonary resections is considered challenging and controversial as it might compromise oncological outcomes. The aim of this work was to analyse the results of a full thoracoscopic technique in terms of nodal upstaging and survival in patients with non-small-cell lung carcinoma (NSCLC).

METHODS

All patients who underwent a full thoracoscopic major pulmonary resection for NSCLC between 2007 and August 2016 were analysed from an 'intent-to-treat' prospective database. Overall survival and disease-free survival were estimated using the Kaplan-Meier curves and comparisons in survival using the log-rank test.

RESULTS

A total of 648 patients met the inclusion criteria, of whom 621 patients had clinical Stage I and 27 had higher stages (16 oligometastatic patients were excluded from the analysis, 11 cT3 or cT4). The mean follow-up was 34.5 months. There were 40 conversions to thoracotomy (6.3%). Thirty-day or in-hospital mortality was 0.95%. Complications occurred in 29.3% of patients. On pathological examination, 22.5% of clinical Stage I patients were upstaged. Nodal upstaging to N1 or N2 was observed in 15.8% of clinical Stage I patients. Five-year overall survival of the whole cohort was 75% and was significantly different between clinical Stages IA (76%) and IB (70.9%). For tumours <2 cm, no significant difference in overall survival was found for the segmentectomy group compared to the lobectomy group: 74% versus 78.9% (P = 0.634).

CONCLUSIONS

Long-term survival is not compromised by a full thoracoscopic approach. Our results compared favourably with those of video-assisted techniques.

Unplanned Procedures During Thoracoscopic Segmentectomies

BACKGROUND

Thoracoscopic sublobar resections (TSLRs) are gaining popularity, but are challenging. However, despite technical difficulties, the reported rate of adverse events, complications, and unplanned procedures is low. To understand this paradox, we have studied our series of TSLRs.

METHODS

We reviewed our prospective and intention-to-treat database on videothoracoscopic anatomical resections and extracted all planned thoracoscopic segmentectomies from January 2007 to July 2016. Intraoperative and postoperative data were analyzed. Unplanned procedures were defined as a conversion into thoracotomy or an unplanned additional pulmonary resection.

RESULTS

During the study period 284 thoracoscopic anatomical segmentectomies were performed in 280 patients. There were 124 men and 156 women with a mean age of 64 years (range, 18 to 86 years). Indication for segmentectomy was a proven or suspected non-small cell lung carcinoma in 184 patients, suspected metastasis in 51 patients, and benign lesion in 49 patients. In total, 23 patients had an unplanned procedure (8%). There were 10 unplanned thoracotomies (9 conversions and 1 reoperation; 3.1%) mainly for vascular injuries, and 15 unplanned additional resections (5.1%) distributed among oncological reasons (n = 7), per operative technical issues (n = 6) and postoperative adverse events (lingular ischemia, n = 2). Considering only the 235 patients operated on for cancer, the unplanned additional pulmonary resection rate for an oncological reason was 3%.

CONCLUSIONS

Although lower than for thoracoscopic lobectomies, the rate of unplanned procedure during TSLRs is of concern. It could most likely be reduced by technical refinements, such as a better preoperative planning.

Planning and marking for thoracoscopic anatomical segmentectomies

Although sublobar resection (SLR) for treating non-small cell lung carcinoma (NSCLC) is still controversial, thoracoscopic segmentectomy is rising. Performing it by closed chest surgery is complex as it means confirming the location of the lesion, identifying vascular and bronchial structures, preserving venous drainage of adjacent segments, severing the intersegmental plane and ensuring an oncological safety margin with no manual palpation and different landmarks. Accurate planning is mandatory. We discuss in this article the interest of 3D reconstruction and mapping technics to enhance safety and reliability of these procedures.

Strategies and outcomes in pulmonary and extrapulmonary metastases from renal cell cancer

OBJECTIVE

Resected renal carcinoma related lung metastases (LM) are associated with higher survival rates, but surgery for extrapulmonary metastases affords good results too. Patients operated on for extrapulmonary metastases before thoracotomy are at high risk of death. The purpose of our analysis was to explore the surgical impact on the outcome of patients with such association.

METHODS

We reviewed the data of 15 patients operated for LM and extrapulmonary metastases from 1984 to 2005. We studied demographic and clinical characteristics, surgical results and pathological staging of the primary tumour and LM in search of prognostic factors.

RESULTS

Nephrectomy and metastasectomies were synchronous in only one patient. For the others, mean time interval between nephrectomy and surgery for LM was 74.2 months (range 19-228). Metastases were resected synchronously in two patients and metachronously in 13 of them (mean time interval: 28 months). Five-year survival of this group was 32%, median value of 18 months. The prognosis was better when the resected extrapulmonary metastases were located in the perirenal (pancreas, adrenal gland) or intrathoracic structures (lymph nodes, diaphragm) than in distant visceral organs (brain, bone, thyroid gland). The lymphatic drainage for these structures connects with the thoracic duct in a similar manner as kidneys do.

CONCLUSION

Surgery for lung and extrapulmonary renal cell cancer-related metastases provides favourable results and is indicated when complete resection can be achieved. The role of the lymphatic system must be explored by further investigations.

Totally thoracoscopic pulmonary anatomic segmentectomies: technical considerations

BACKGROUND

While video-assisted thoracic surgery (VATS) lobectomies are being increasingly accepted, VATS segmentectomies are still considered as technically challenging. With the renewed interest for sublobar resection in the management of early stage lung carcinomas, the thoracoscopic approach may have a major role in a near future. We report our technique and results.

PATIENTS AND METHODS

Totally thoracoscopic anatomic segmentectomiy, i.e., using only endoscopic instrumentation and video-display without utility incision, was attempted on 117 patients (51 males and 66 females), aged 18 to 81 years (mean: 62 years). The indication was a clinical N0 non-small cell lung carcinoma in 69 cases, a solitary metastasis in 17 cases and a benign lesion in 31 cases. The following segmentectomies were performed: right apicosuperior [26] right superior [10], right basilar [18], lingula sparing left upper lobectomy [15], left apicosuperior [11], lingula [7], left superior [14], left basilar [13] and subsegmental resection [3]. Segmentectomy was associated with a radical lymphadenectomy in 69 cases.

RESULTS

There were 5 conversions to thoracotomy. The mean operative time was 181±52 minutes, the mean intraoperative blood loss was 77±81 cc. There were 12 postoperative complications (11.7%). The median postoperative stay was 5.5±2.2 days. Out of the 69 patients operated on for a cN0 lung carcinoma, 6 were finally upstaged.

CONCLUSIONS

Totally thoracoscopic anatomic pulmonary segmentectomies are feasible and have a low complication rate.

Electromagnetic navigation bronchoscopy localization of lung nodules for thoracoscopic resection

Background

Thoracoscopic localization of small peripheral pulmonary nodules is a concern. Failure can lead to larger parenchymal resection or conversion to thoracotomy. This study evaluates our experience in preoperative electromagnetic navigation bronchoscopy-guided localization of small peripheral lung lesions.

Methods

From January 2017 to March 2020 clinical, radiographic, surgical, and pathological data of patients who underwent electromagnetic navigation bronchoscopy (ENB)-guided methylene blue pleural marking of highly suspected pulmonary lesions before a full thoracoscopic resection were evaluated. Localization was performed for solid or mixed subpleural nodules measuring <10 mm, solid nodules measuring <20 mm located at more than 1 cm from the pleura and any pure ground glass opacity. Successful localization was defined as successful identification and thoracoscopic resection of target lesions.

Results

Forty-eight patients were included: 30 solid nodules (63%), 12 pure GGO (25%) and 6 mixed (13%). The median largest diameter at CT-scan was 11 mm (IQR, 9-14 mm) while the median distance from the pleural surface was 12 mm (IQR, 6-16 mm). The median ENB length was 25 min (19-33 min). Localization procedure was successful in 45 cases (94%). No procedural-related complications were reported.

Conclusions

ENB is a safe and accurate preoperative procedure to localize small lung peripheral lesions. The high successful rate, the absence of related complications, the possibility of performing the procedure in the same operating room with a single general anesthesia, make ENB-guided dye marking an advantageous tool for thoracoscopic pulmonary resection.

Second pulmonary resection for a second primary lung cancer: analysis of morbidity and survival

OBJECTIVES

Evaluating morbidity and survival of patients operated on for a second primary non-small-cell lung cancer (NSCLC).

METHODS

Retrospective collection of data from patients operated on for a second NSCLC between 2009 and 2018.

RESULTS

Fifty-two patients met the inclusion criteria. At the time of second pulmonary resection, the median time between the 2 surgeries was 25 months (5-44.5 months). Patients' median age was 65 years (61-68 years). Median tumour size was 16 mm (10-22 mm). Thoracoscopy was used in 75% of cases. The resection was a pneumonectomy (n = 1), bilobectomy (n = 1), lobectomy (n = 15), segmentectomy (n = 32) or wedge resection (n = 3). The length of stay was 7 days (5-9 days). Mortality was null and morbidity was 36.5%, mainly from grade I-II complications according to the Clavien-Dindo classification. The median follow-up was 28 months (13-50 months). The median overall survival was 67 months (95% confidence interval 60.8-73.1 months). Survival at 5 years and specific survival were 71.1% and 67.7%, respectively.

CONCLUSIONS

A second surgical resection of either synchronous or metachronous NSCLC has a morbidity that is not superior to the morbidity of the first operation. The new tumour is usually diagnosed at an early stage. An anatomical sublobar resection is most likely the best compromise. It might also be considered for the first operation when there is a suspicious synchronous lesion that may require surgery at a later stage.

Thoracoscopic anatomic segmentectomies for lung cancer: technical aspects

Although the interest for thoracoscopic sublobar resections (TSLR) is rising, its use for treating non-small cell lung carcinoma (NSCLC) is still controversial because publications dealing with survival and recurrence rate provide contradictory results. If applied to the resection of lung cancer, thoracoscopic segmentectomies must be performed according to oncological criteria. The aim of this technical paper is to give some technical details on thoracoscopic segmentectomies for the treatment of malignancies. Our experience is based on 235 thoracoscopic anatomical segmentectomies performed in 232 patients for a malignant lesion between January 2007 and July 2016. Indication for segmentectomy was a proven or suspected NSCLC in 184 and suspected metastasis in 51 patients. Intraoperative and postoperative data were recorded in a prospective manner. There were eight conversions into a posterolateral thoracotomy (3.4%) and seven unplanned additional pulmonary resections for an oncological reason (3%). We discuss some technical refinements that could minimize these adverse events and make thoracoscopic segmentectomy a safe and reliable procedure.

[Surgical treatment of diaphragmatic eventrations and paralyses]

Surgical treatment of eventration or paralysis of the diaphragm is symptomatic and non curative, and depends on whether the dysfunction is of peripheral or central origin. Elevation of a hemidiaphragm of peripheral origin, the most frequent situation, needs surgical treatment only in case of major functional effects (effort or positional dyspnoea, cardiac or digestive symptoms, or pain) that persists despite optimal conservative management. Selection of candidates for surgery depends on a thorough morphological and functional investigation of the neuromuscular and respiratory components. Surgical plication of the diaphragm through a lateral thoracotomy or by video-thoracoscopy is a recognized, safe and effective procedure. Its low morbidity and mortality, which are mainly associated with co-morbid factors, and its long-lasting functional benefit of around 100%, show that it is an effective procedure. In the case of bilateral dysfunction, occasional cases of bilateral plication have been reported. Some cases of diaphragmatic paralysis of central causation result in a life of ventilator dependence, even though the peripheral neuromuscular and respiratory systems are intact. In selected cases, following a complete functional investigation, phrenic nerve pacing may be attempted to achieve ventilator weaning. To date, there are two validated indications for this technique: Tetraplegia above C3 and alveolar hypoventilation of central cause. After thoracic implantation, a progressive reconditioning of the diaphragmatic muscle allows weaning from the ventilator in a few weeks in more than 90% of patients. Their quality of life is greatly improved thanks to independence from the ventilator, more physiological respiration, restoration of smell and better speech. Whether the diaphragmatic dysfunction is peripheral or central in origin, the success of surgical treatment depends on rigorous preoperative selection of patients.

Congenital bronchial atresia in adults: thoracoscopic resection

Congenital bronchial atresia (CBA) is a rare congenital malformation consisting in an interruption of a lobar or-more frequently-of a segmental bronchus. It leads to mucus impaction and hyperinflation of the obstructed lung segment. It causes infectious complications and, in the long term, destruction of the adjacent lung parenchyma. Thus, a surgical resection is usually indicated, even in asymptomatic patients.

Concomitant aortic root and pectus deformity repair in Marfan syndrome patients

The role of concomitant aortic and pectus repair in Marfan patients remains controversial. We present our surgical technique for concomitant aortic repair of aortic root pathology and pectus correction. The concomitant surgery can be safely achieved in Marfan patients, thus, avoiding the need for a risky second stage operation.

[Tracheal replacement using the abdominal aorta. Comments on a case report]

Tracheal replacement is an uncommon option because of the very limited number of indications and the large number of possibilities for resection anastomosis. There may nevertheless be situations were extensive resection leaves only one solution, tracheal replacement. To date, no prosthesis has provided long-term satisfaction. For tracheal replacement, the prosthesis must provide a large caliber airway which does not collapse during expiration and which enables the development of a ciliary lining, in addition to tolerance without rejection. Recent experimental work, then several clinical cases, would suggest that the abdominal aorta can be successfully transformed into a neotrachea. A temporary endoprosthesis is however necessary to prevent collapse until new tracheal rings develop. Experimental and early clinical work has provided promising results but with problems concerning the endoprosthesis. In our patient, we used the abdominal aorta as a tracheal substitute but replaced the endoprosthesis with an exoprosthesis leaving the aortic lumen free. The result was also encouraging, but the absence of integration of the aortic tissue did not confirm the observations reported by others. Other hypotheses concerning the regeneration of the neotrachea should be put forward.

Thoracoscopic complex basilar segmentectomies: an analysis of 63 procedures

Background

Thoracoscopic complex basilar segmentectomies are technically demanding and challenging. We review our experience to check whether this complexity can lead to specific surgical issues or increased post-operative morbidity.

Methods

Complex basilar segmentectomies were defined as the anatomical resection of at least one segment composing the basilar pyramid, excluding S⁶. Data of patients who had an intention-to-treat thoracoscopic complex basilar segmentectomy were retrospectively collected from 2007 to 2019: indications, preoperative assessment, clinical features, operative technical aspects and early post-operative outcome.

Results

Sixty-three patients, 26 men (41%) and 37 women (59%) with a median age of 66 years and a median body mass index (BMI) of 26 kg/m2 were included. Interventions performed were mostly S⁹⁺¹⁰ (n=32) and S⁸ (n=12) segmentectomies. Forty-five planned operations (71%) were completed. Extension to a larger resection was necessary in 17 patients (27%) and 4 patients underwent conversion to open surgery (6%). Median operative time was 168 minutes with a median intraoperative bleeding of 30 mL. Complications occurred in 11 patients (17%). There was no mortality. Median length of pleural drainage was 2 days (range, 1–2 days) and median hospital stay 4 days.

Conclusions

The extension rate of complex basilar segmentectomy is higher than that of other sublobar resections but their post-operative morbidity is identical.

Adult pulmonary intralobar sequestrations: changes in the surgical management

Background

Until now, the traditional procedure to treat intralobar pulmonary sequestration (ILS) in adults has been a lobectomy performed by open chest surgery. We have reviewed our data to determine whether the surgical management of these lesions has evolved over the last years.

Methods

We retrospectively reviewed the records of patients who were operated on for an ILS by either posterolateral thoracotomy (PLT group), or by thoracoscopy (TS group) between 2000 and 2016.

Results

Eighteen patients were operated on for a ILS during this period. Before 2011, all resections were performed by thoracotomy (n=6) and after 2011 the approach was either a thoracotomy (n=5) or a thoracoscopy (n=7). There was one conversion because of dense pleural adhesions and this patient was integrated in the PLT group for further analysis. ILS presented more frequently on the left side (n=12, 66.7%) than on the right one (n=6, 33.3%) and exclusively in the lower lobes. All the PLT group patients underwent a lobectomy. In the TS group, five patients underwent a sublobar resection (2 segmentectomies S9+10, 1 basilar segmentectomy and 2 atypical resections). There was no mortality. In the PLT group, 5 patients (45%) had complications versus one patient (14%) in the TS group. The mean hospital stay was 7.4 days in the PLT group versus 5.4 days in the TS group.

Conclusions

These data confirm that ILS can be safely treated by a sublobar resection that should be performed, whenever possible, without opening the chest.

Technical means to improve image quality during thoracoscopic procedures

Although high definition imaging systems are now available in the operating room (OR), the displayed image quality during video-assisted procedures is often poor. This is due to several factors such as inappropriate angle of vision, instable endoscope, lens soiling and fogging. The aim of this article is to provide information about some technical and technological means that make it possible to keep a perfect picture all along a thoracoscopic procedure.

[Pulmonary intralobar sequestration in adults: Evolution of surgical treatment]

BACKGROUND

Until now, the traditional procedure to treat intralobar pulmonary sequestration (ILS) in adults has been a lobectomy performed by open thoracotomy. We have reviewed our data to observe if the surgical management of these lesions has evolved over the last years.

METHODS

We retrospectively reviewed the records of the patients who were operated for an ILS either by posterolateral thoracotomy (PLT group), or by thoracoscopy (TS group) between 2000 and 2016.

RESULTS

Eighteen patients were operated for a SIL during this period. Prior to 2011, all resections were performed by thoracotomy (n=6) and after 2011 the surgical approach was either a thoracotomy (n=5) or a thoracoscopy (n=7). There was one conversion because of dense pleural adhesions and this patient was integrated in the PLT group for further analysis. ILS were more frequently encountered on the left side (n=12, 66.6 %) than on the right one (n=6, 33.3 %) and exclusively in the lower lobes. All patients of the PLT group underwent a lobectomy. In the TS group, 5 patients underwent a sublobar resection (2 segmentectomiesS⁹⁺¹⁰, 1 basilar segmentectomy and 2 atypical resections). There was no mortality. In the PLT group, 5 patients (45 %) had complications versus one patient (14 %) in the TS group. The mean hospital stay was 7.4 days in the PLT group versus 5.4 days in the TS group.

CONCLUSIONS

These data confirm that ILS can be safely treated by a sublobar resection that should be performed, whenever possible, thoracoscopically.

[Mediastinal bronchial artery aneurysm: treatment with stent-graft]

Mediastinal bronchial artery aneurysm is rare but potentially life-threatening, and requires prompt treatment to avert rupture with catastrophic results. Inflammatory conditions dominate the aetiologies. Conventional therapies are surgery via thoracotomy and endovascular embolization. We report a case of a giant saccular aneurysm of the bronchial artery described in an 80-year-old man, adjacent to the descending aorta, simulating aortic aneurysm and causing esophageal compression. It was totally excluded with an aortic stent-graft (TX2, Cook) performed through femoral access. Our case is the fourth reported of mediastinal bronchial aneurysm stent-graft exclusion. The analysis of success, complications rate and hospital stay duration favors endovascular grafting comparing with conventional techniques.