Catégorie : Vol. 20 JA2016 – thoracic

Vol. 20 JA2016 - thoracic

T-01 – Predictors of post-pneumonectomy respiratory failure and ARDS: usefulness of normalized pulmonary artery diameter
Marine Peretti, Rémi Hervochon, Émelyne Hamelin Canny, Kim Blanc, Aurélie Janet-Vendroux, Jean-François Régnard, Claude Guinet, Diane Damotte, Nicolas Roche, Antoine Rabbat, Antonio Bobbio, Marco Alifano Institution : Départements de chirurgie thoracique, de soins intensifs respiratoires, de radiologie et d’anatomopathologie, hôpital Cochin, AP-HP, Paris ; université Paris-Descartes, Paris Objectives : Hypothesizing that pulmonary artery diameter is a marker of subclinical pulmonary disease in patients requiring pneumonectomy, we assessed its impact on postoperative outcome, especially occurrence of respiratory failure and ARDS. Methods : Morphometric, clinical, and laboratory data were retrospectively retrieved from files of 161 consecutive patients treated by pneumonectomy for NSCLC. Pulmonary artery was measured at bifurcation level at CT scan. Crude and normalized (for body surface) measures were used for analysis. Results : All the patients had intraoperative protective ventilation and fluid restriction. Age > 70 years and increased normalized pulmonary artery diameter were associated to need of mechanical ventilation (p=0.0072 and 0.021) and occurrence of ARDS (p=0.017 and 0.039). Lower BMI, FEV1, and ppoFEV1 were also associated with need of mechanical ventilation (p=0.015, 0.021, and 0.0015, respectively), but not occurrence of ARDS. Age > 70 years (p=0.00088), increased normalized pulmonary artery diameter (p=0.041) and lower BMI (p=0.039) were associated to 120-day mortality. Neither measure of systolic pulmonary pressure at echocardiography, nor percentage of perfusion of resected lung correlated with outcome. Multivariate analysis showed that lower ppoFEV1 and higher normalized pulmonary artery diameter were independently associated with need of mechanical ventilation (p=0.03 and 0.014, respectively), and that only normalized pulmonary artery diameter was associated with occurrence of ARDS (p=0.038). Factors independently associated with 120-day mortality were age >70 years and increased normalized pulmonary artery diameter (p=0.0042 and 0.0029, respectively). Conclusion : Pre-operative normalized pulmonary artery diameter predicts the need of mechanical ventilation, the risk of ARDS and 120-mortality in patients undergoing pneumonectomy.
novembre 29, 2016
Vol. 20 JA2016 - thoracic

T-02 – Nodal upstaging for clinical stage I lung cancer : analysis of the new edition of the national database Epithor
Laurence Solovei, Pierre Rabinel, Mathilde Cazaux, Claire Renaud, Jean Berjaud, Marcel Dahan, Laurent Brouchet Institution : Service de chirurgie thoracique, hôpital Larrey, CHU de Toulouse Objectives : To analyse nodal upstaging for clinical T1-T2 N0 non-small cell lung cancer (NSCLC) in the mini-invasive techniques versus thoracotomy by analyzing the new edition of the French thoracic surgery database. Methods : The new Epithor database, available since December 2015, allows us to compare the clinical and pathological TNM stages of NSCLC. We retrospectively analyzed the data of patients with clinical stage I CBNPC who had surgery. The different surgical approaches were evaluated : open surgery (OS) versus mini-invasive techniques (MIT). The characteristics of population, clinical and pathological TNM, global, N1 and N2 nodal upstaging rates were studied. Results : Between December 2015 and September 2016, among 1787 CBNPC cT1-T2 N0 treated by surgery. 1399 lobectomies were listed (78.3%) : 644 (46%) by OS, 143 (10.2%) by video assisted thoracotomy (VA), 455 (32.5%) by thoracoscopy (VATS) and 156 (11.2%) by robotics (RATS). The global nodal upstaging was 12.4%. The rates of nodal upstaging according to the surgical approach : OS, VA, VATS and RATS are 12,6 / 16,1 / 11,9 and 10.3% respectively. No significant difference was found between these figures (p>0.05). An identical number of nodal upstaging cN0-pN1 and cN0-pN2 was found (50-50%). Conclusion : Nodal upstaging is considered as a tool to assess the oncologic quality of surgery. Controversy remains regarding the lymph node evaluation achieved by VATS. Many international studies report lower nodal upstaging rates versus OS and RATS. According to the new EPITHOR database, lymph node evaluation is not significantly different from a technique to an other. In other academic centers, similar results has been reported as well as long-term survival datas. The actual lack of randomized studies prevent us from eliminating selection biases to conclude on the superiority of a surgical approach from another one.
novembre 29, 2016
Vol. 20 JA2016 - thoracic

T-03 – Titanium thoracic implant failures: 6D analysis of complex chest wall movements
Laurence Solovei, Dominique Ambard, Robin Chastant, Charles Marty-Ané, Simon Le Floch, Jean-Philippe Berthet Institution : Service de chirurgie thoracique et vasculaire, CHU de Montpellier Objectives : Thoracic osteosynthesis implants commonly used in reconstructive surgery are rib-fixation device, made of titanium or titanium alloys. Severe complications have been reported following these surgeries when implants fracture occurs. The evolution of our surgical practice requires detailed understanding of the local constraint conditions due to respiratory movements. Methods : Displacements of tags, related to the fixation area of the rib implants, were studied by stereocorrelation first on the skin and then directly on the rib on patients in the operating room. The measures were done with six degrees of freedom: linear displacements x y z and rotations phy, psi and theta. Results : Six patients were included. The displacements of the tags , according to x, y and z are small, respectively 0.43 mm ±0.04, 1.36 ±0.06 mm and 2.66 mm ±0.13. The amplitudes of displacement are correlated with respiratory volumes. An increase of 4 mL/kg amplifies the movements by an average factor of 1.6. Conclusion : Numeric simulation of implants and constraints confirmed the phenomenon of fatigue failure for titanium and identify the flexion on y axis and lateral compression as the main mechanical stresses.
novembre 29, 2016
Vol. 20 JA2016 - thoracic

T-04 – Advantages of adsorbable pins for closure of transversal sternal sections
Anne Olland, Jérémie Reeb, Sophie Guinard, Joseph Seitlinger, Stéphane Renaud, Nicola Santelmo, Romain Kessler, Pierre-Emmanuel Falcoz, Gilbert Massard Institutions : Groupe de transplantation pulmonaire, hôpitaux universitaires de Strasbourg ; EA7293 Stress vasculaire et tissulaire en transplantation, Fédération de médecine translationnelle, faculté de médecine de Strasbourg Objectives : Clamshell incision is an invasive procedure that keeps an indication especially in lung transplantation. Nevertheless, post-operative sternal cicatrization may complicate to sternal instability with overriding, sternal instability, pain, and impair respiratory rehabilitation. We aimed at testing efficacy of adsorbable poly-L lactic acid pins to maintain sternal alignement until complete sternal healing. Methods : We recorded all bilateral lung transplantations requiring clamshell procedure and using adsorbable sternal pins for bone reinforcement. The sternum was closed with three PDS cross sutures: one sternal suture, and one suture on each side of the sternum with respect to the technique that evidenced lowest complication rate in international literature. We recorded patient’s caracteristics and sternal post-operative complications. Results : Starting January 1st 2016, we performed 40 lung transplants including 37 bilateral lung transplants; fourteen required clamshell incision either for cariopulmonary bypass (n=8), or for better surgical exposure (n=6). Eleven transversal sternotomies were closed using sternal pins in order to limit antero-posterior movements. For 3 patients we could not use this technique. None of the patients with sternal pins closure demonstrated postoperative sternal complications. Two patients among the three without sternal pins presented with complete sternal overriding, chest instability and impairing pulmonary rehabilitation. Both patients underwent reoperation for sternal closure placing sternal pins as a second intention Conclusion : Using adsorbable sternal pins ensures sternal stability until complete bone healing though immunosuppressive therapy without impairing pulmonary rehabilitation. Sternal pins may also be used as second intention when repairing sternal overriding.
novembre 29, 2016
Vol. 20 JA2016 - thoracic

T-05 – Real-time imaging with the O-Arm® of lung parenchyma during ex vivo lung reconditioning
Julien de Wolf, Philippe Puyo, Pierre Bonnette, Matthieu Glorion, Nicolas Salley, Antoine Roux, Ngai Liu, Alain Chapelier, Édouard Sage et le groupe de transplantation pulmonaire de Foch Institution : Service de chirurgie thoracique et transplantation pulmonaire, hôpital Foch, Paris Objectives : Ex vivo lung perfusion (EVLP) has been developed as a method to reassess and recondition marginal lungs. However, evaluation of the lung during procedure is limited to a combination of physiological variables. We aim to evaluate the feasibility and utility of a scan via the O-Arm® (Medtronic Inc., Minneapolis, MN, USA) imaging to help the evaluation of the lung during ex vivo lung reconditioning (EVLR) procedure in Operating Room. Methods : We used the Toronto protocol for the EVLP. For assessing the lung graft we used; a clinical and functionnal assessment associated with a parenchyma evaluation, using the O-Arm®. The decision to transplant was taken based on a recovered physiological function with P/F ratio more than 400 mmHg, as well as the associated improvement or stability of the other functional parameters. Results : We evaluated three consecutive extended-criteria brain-death donor lungs in July and August 2013. Two donors died after a stroke. In those two cases, CT scan showed a right lower lobe opacification and was associated with purulent secretion in the right lower lobe evidenced in the bronchoscopy. The other donor died after a high kinetic trauma with head and chest lesions. The CT scan showed left lung contusion. The O-Arm® evaluation highlight on 2 grafts an attenuation of ground-glass opacification and better lung inflation. Because they were associated with recovered physiological functions, the two grafts were transplanted. On the other hand, O-Arm® scan showed an increase in the parenchyma opacification for the other graft (died after a stroke). This evaluation was associated with deterioration of the clinical and functionnal assessment. The lungs were not transplanted. Conclusion : The use of a high-performance real-time imaging system, such as O-Arm®, to evaluate lung grafts from extended-criteria donors during EVLR show an additional argues to select and increase the lung transplants pool.
novembre 29, 2016
Vol. 20 JA2016 - thoracic

T-06 – Results of the first implantations of Ceramil® prosthesis, a new device for sternal replacement
Jérémy Tricard, Alessandro Piccardo, Nicolas Pichon, Denis Asselineau, François Bertin Institution : Service de chirurgie thoracique et cardiovasculaire et angiologie, CHU Dupuytren, Limoges Objectives : Many materials have been proposed to be used in reconstructive surgery of the chest wall but none has emerged as an ideal substitute. The Ceramil® prosthesis is an innovating material for replacement of the sternum. We present the device, the implantation technique and the follow-up of the first 4 recipients. Methods : The Ceramil® prosthesis is a porous alumina ceramic which is a pure compound of mineral origin that presents osteointegration and biocompatibility properties. Its size is adapted to the sternal defect and chosen before the surgery among different made-to-measure models. Its implantation does not require osteosynthesis equipment. From March 2015 to March 2016, 4 patients underwent surgery for sternal replacement and received the Ceramil® prothesis. A 54-year old patient (n°1) had a radiation-induced sarcoma after a radiotherapy for breast cancer, a 61-year old patient (n°2) had a sternal necrosis due to a mediastinitis after sternotomy, 2 patients of 53 and 37 years old (n°3 and 4) had sternal metastasis from breast neoplasia. Results : Patient n°1 was reoperated on D7 for a seroma. After an 19-month follow-up, she was not dyspneic (grade 1 of the CEE scale) and had no sternal pain or scarring disorder. Patient n°2 was reoperated after 3 months for wound care and closure as he presented with tissue necrosis due to a history of chest radiotherapy. After a 14-month follow-up, he presented with grade 2 dyspnea, sternal pain graded as 3 on the visual analog scale (VAS) and the operation wound was healed. After an 11-month follow-up, patient n°3 was not dyspneic and had no sternal pain or scarring disorder. After a 7-month follow-up, patient n°4 presented with grade 2 dyspnea, sternal pain graded as 3 on the VAS and no scarring disorder. Conclusion : The Ceramil® prosthesis implanted as a replacement for the sternum appears to be reliable, reproducible and promising. A monocentric study (STOIC) and a multi-center study (ISBA) are currently performed.
novembre 29, 2016
Vol. 20 JA2016 - thoracic

T-07 – Unplanned procedures during thoracoscopic anatomical segmentectomies: an intention-to-treat analysis of a consecutive series of 284 operations
Agathe Seguin-Givelet, Jon Lutz, Madalina Grigoroiu, Emmanuel Brian, Dominique Gossot Institution : Département thoracique, institut mutualiste Montsouris, Paris Objectives : Thoracoscopic sublobar anatomical resections (TSLR) are gaining popularity, but are still considered challenging. However, despite technical difficulties, the reported rate of adverse events, complications and unplanned procedures is low. In order to understand this paradox, we have studied our series of TSLRaccording to an intention-to-treat analysis Methods : From January 2007 to July 2016, 284 thoracoscopic anatomical segmentectomies have been performed in 280 patients. There were 124 males and 156 females with a mean age of 64 (range: 18-86). Indication for segmentectomy was a proven or suspected non-small cell lung carcinoma (NSCLC) in 184, suspected metastasis in 51 and benign lesion in 49 patients.Intraoperative and postoperative data were recorded in a prospective manner. Unplanned procedures were defined as a conversion into thoracotomy and/or an unplanned additional pulmonary resection. Segmentectomies were performed according to a full thoracoscopic and fissure-based approach Results : There were 10 unplanned thoracotomies mainly for vascular injuries (3.1%) (9 conversion and 1 reintervention), and 15 unplanned additional resection (5.1%) distributed among oncological reasons (n=7), technical issues (n=6) and postoperative adverse events (2 lingularischemias). Considering only the 235 patients operated on for cancer (primary NSCLC in 184 or metastasis in 51), the unplanned additional pulmonary resection rate for an oncological reason was 3%. In total, 23 patients had an unplanned procedure (8 %). Conclusion : Although lower than for thoracoscopic lobectomies, the rate of unplanned procedure during TSLR is of concern. It could most likely be reduced by technical and technological refinements, such as a better preoperative planning.
novembre 29, 2016
Vol. 20 JA2016 - thoracic

T-08 – Three-dimensional computed tomography reconstruction for operative planning in robotic segmentectomy: a pilot study
Julien Le Moal, Christophe Peillon, Jean-Nicolas Dacher, Jean-Marc Baste Institution : Service de chirurgie générale et thoracique, hôpital Charles-Nicolle, Rouen Objectives : The objective of our pilot study was to assess if three-dimensional reconstruction performed by Visible Patient™ could be helpful for the operative planning, efficiency and safety of robot-assisted segmentectomy. Methods : Between 2014 and 2015, three-dimensional reconstructions were provided by the Visible Patient™ online service and used for the operative planning of robotic segmentectomy. To obtain three-dimensional reconstruction, the surgeon uploaded the anonymized computed tomography image of the patient to the secured Visible Patient™ server and then downloaded the model after completion. Results : Nine segmentectomies were performed between 2014 and 2015 using a pre-operative three-dimensional model. All three-dimensional reconstructions met our expectations: anatomical accuracy (bronchi, arteries, veins, tumor, and the thoracic wall with intercostal spaces), accurate delimitation of each segment in the lobe of interest, margin resection, free space rotation, portability (smartphone, tablet) and time saving technique. Conclusion : We have shown that operative planning by three-dimensional computed tomography using Visible Patient™ reconstruction is useful in our practice of robot-assisted segmentectomy. The main disadvantage is the high cost. A larger study is warranted to confirm the utility of three-dimensional computed tomography reconstruction for operative planning and its effect on reducing surgical complications and improving efficiency.
novembre 29, 2016
Vol. 20 JA2016 - thoracic

T-09 – Launching a successful robotic thoracic surgery program: a focus on safety and quality in a learning curve setting
Henri de Lesquen, Ilies Bouabdallah, Diane Mège, Joséphine Chenesseau, Charles-Henri David, Bastien Orsini, Lucile Gust, Geoffrey Brioude, Delphine Trousse, Xavier-Benoît D’Journo, Christophe Doddoli, Pascal-Alexandre Thomas Institution : Service de chirurgie thoracique et maladies de l’œsophage, hôpital Nord, AP-HM, Marseille Objectives : The purpose of this study was to compare our initial experience with RATS pulmonary lobectomy with that of our well-established VATS program. Methods : We compared the early outcomes of those 76 patients having had a 3-port full thoracoscopic lobectomy performed by the most experienced VATS surgeon with those 87 patients having had a 3-arm RATS lobectomy performed by a single surgeon during a 24-month period. Results : Operative time was longer in the RATS group (mean: 134.5 ±154.2 vs 37,7 min ±47.3 min, p=0.004). Overall morbidity was similar (43.4% vs 39.1%, p=0.57). Five patients in the VATS group required blood transfusions and only one in the RATS group (P=0.12). Readmission rates at 90 days were similar (3.9% vs 6.9%; P=0.38). The 90-day mortality rates were 2.6% and 0% (P=0.12). More N2 nodes were removed in the VATS group (mean: 9.92 ±5.41 vs 6.24 ±5.584, p<0.0001). The proportion of lymph node upstaging was similar in both groups (16% vs 13%; p=0.65). Conclusion : Early experience with RATS pulmonary lobectomy appears to be as safe as mature VATS cases as regards to the 90-day post operative period.
novembre 29, 2016
Vol. 20 JA2016 - thoracic

T-10 – Very long-term survival following lung surgery for cancer in high-risk patients after perioperative pulmonary rehabilitation
Patrick Bagan, Viorel Oltean, Florent Couineau, Christine Raynaud, Rym Zaimi, Bassel Dakhil Institution : Service de chirurgie thoracique et vasculaire, CH Victor-Dupouy, Argenteuil Objectives : The benefits of a rehabilitation program before lung carcinologic resection on long term survival remain to define. The purpose of this observational study was to assess the effects of the rehabilitation on long term outcomes in patients who were at a high operative risk,which immediate outcome were previously reported (Rev Mal Respir. 2013;30[5]:414-9). Methods : Between January 2010 and december 2011, a cohort of 20 consecutive patients, with a clinical N0 non small cell lung cancer considered as non-operable were included. The protocol included a clinical examination and a Chest CT Scan every six months during two years and every twelve months the following years. Survival was calculated with the Kaplan-Meier method. Results : In this population, they were 16 men and 4 women with mean age of 66 years [44-79] Surgical resection was performed in all patients (lobectomy, n=15; pneumonectomy, n=3; bilobectomy, n=2). The morbidity rate was 20%, the mortality rate was 5%. Three pN+ patients received adjuvant chemotherapy. During follow-up, 6 patients died (cancer recurrence, n=5; respiratory failure, n=1). The kaplan meier five year survival rate was 70 %. Conclusion : Peri operative Pulmonary rehabilitation allows carcinologic surgery performance and a good long-term survival at first-line not eligible patients.
novembre 29, 2016