Catégorie : Vol. 20 JA2016 – thoracic

Vol. 20 JA2016 - thoracic

T-11 – VAC Therapy with delayed chest wall closure: a rescue solution in case of intraoperative DIC
Geoffrey Brioude, Brice Caput, Joséphine Chenesseau, Delphine Trousse, Xavier-Benoît D’Journo, Christophe Doddoli, Pascal-Alexandre Thomas Institution : Service de chirurgie thoracique et des maladies de l’œsophage, hôpital Nord, AP-HM, Marseille Objectives : VAC therapy is actually used routinely in infected thoracic wound. We reported in this presentation an original use in thoracic surgery: VAC therapy to maintain sterile an unclose chest wall in lung transplant after massive bleeding managed with damage control surgery or after brutal lung oedema. Methods : Lung transplant is an uncommun part in thoracic surgery, performed in specialized center. Surgeons are confronted to major bleeding due to patient’ background and the frequent use of ECMO in per-operating and post-operative. Furthermore lung tranplants are exposed to a major oedema included in the primary graft dysfunction. We decided to report an originally case series of management of catastrophic bleeding and lung oedema in lung transplantation. Results : Between January 2014 and august 2016, 100 bilateral lung transplant were performed in our unit. 19 patients were re-operated. Fourteen of them for postoperative hemothorax or bleeding, 4 for anastomotic leakage and 1 for a delayed chest wall closure. We identified 7 patients requiring a pleural packing or VAC therapy following surgery. Four of them had pleural packing for bleeding at the end of lung transplant more or less associated to VAC therapy. Two patients had a delayed strategy (day 2 or 3) for pleural packing. One patient had only a VAC therapy due to a major lung oedema. Five patients were weaned of the circulatory support and had a chest was closure in a period between day 5 and day 15. Two patients died of an uncontrolled bleeding. A mean of 3.4 intervention were realized onbed in ICU or in the OR. Conclusion : Pleural packing and delayed chest wall closure used in a spirit of damage control surgery is an efficient option in case of uncontrolled bleeding associed with lung oedema after lung transplantation
novembre 29, 2016
Vol. 20 JA2016 - thoracic

T-12 – Cardiac herniation, anatomical basis of a life-threatening condition
Geraud Galvaing1,2, Laura Filaire1, Marie M. Tardy1, Jean-Baptiste Chadeyras1, Adel Naamee1, Marc Filaire1,2 Institutions : 1. Service de chirurgie thoracique et endocrinienne, CRLCC Jean-Perrin, Clermont-Ferrand 2. Laboratoire d’anatomie, faculté de médecine, université d’Auvergne, Clermont-Ferrand Objectives : Cardiac herniations are rare and life-threatening conditions occurring after thoracic procedures especially pneumonectomies. They can also occur after blunt chest trauma but also as a consequence of pericardial agenesia. Methods : Based on 4 case-reports dealing with cardiac herniation, we studied on cadaver the physiopathology of pericardial rupture as well as cardiac herniations, explaining their severity. Results : After a brief recall of pericardial embryology and cardiac fixity means inside the pericardium, we found that cardiac herniation non only stretched the pulmonary veins on the opposite side of the cardiac herniation but also generated a twist of the all caval axis especially in case of right-sided cardiac hernia. This situation engender an acute cardiac insufficiency that could be lethal, therefore it should be considered an absolute surgical emergency. Conclusion : Although rare, cardiac herniation should be in every thoracic surgeon’s mind. Any suspicion of such a diagnosis should justified surgical exploration and repair as cardiac herniation are life-threatening and imaging technique are of poor support in its diagnosis.
novembre 29, 2016
Vol. 20 JA2016 - thoracic

T-13 – In-Vivo Lung Perfusion with Folfox as an adjuvant treatment for pulmonary metastasectomy: a preclinical study in a pig model
Pierre-Benoît Pagès, Mauricio Pipkin, Yui Watanabe, Daisuke Nakajima, Ricardo Zamel, Shaf Keshavjee, Marcelo Cypel Institutions : Laboratoire de chirurgie thoracique Latner, institut de recherche de l’hôpital général de Toronto, réseau universitaire de santé, Toronto, Ontario, Canada Objectives : In-Vivo Lung Perfusion is a promising technique to deliver high dose chemotherapy to the lung without systemic leakage. Oxaliplatin in combination with 5 Flurouracil is the standard chemotherapy regimen for metastatic colorectal cancer. Our objective was to evaluate the dose limiting toxicity and the maximum tolerated dose of Oxaliplatin and 5 Fluorouracil when delivered through In-Vivo Lung Perfusion in a pig model. Methods : Sixteen pigs underwent In-Vivo Lung Perfusion in the left lung for 4 hours. Oxaliplatin was administered at the following doses: 85 (group 1), 170 (Group 2) and 255 mg/m² (Group 3) in combination with 5 Fluorouracil at the dose of 400 mg/m² for the three groups. Group 4 was a control group without chemotherapy and group 5 received the same dose of chemotherapy as group 1 but intravenously. After lung perfusion, blood reperfusion was allowed for 4 hours. Lung physiology was assessed during the 2 periods, lung biopsies, perfusate and blood samples were taken for histological assessment, cytokines profiles and measurement of drugs concentration. Results : After reperfusion, animals from group 3 showed significant decreased of PaO2/FIO2 as compared to control group (366.85 ±36.66 mmHg vs 201.05 ±29.79 mmHg; p=0.005), high level of platinium elements in tissue as compared to group 1 (11314 ±1943.7 ng/g vs 3411 ±820.1 ng/g, p=0.0016), and increased of IL1-beta and TNF-alpha in the lung and in the blood as compared to group 4, (respectively p=0.02 and p=0.01). Conclusion : The dose limiting toxicity was defined for group 3 dose, and the maximum tolerated dose was defined for group 2 dose.
novembre 29, 2016
Vol. 20 JA2016 - thoracic

T-14 – Study of the effect of alveolar microparticles on alveolar epithelial cells type II during lung ischemia reperfusion
Sophie Guinard, Anne Olland, Jérémie Reeb, Mélanie Burban, Fatiha Zobairi, Ferhat Meziani, Pierre-Emmanuel Falcoz, Valérie Schini-Kerth, Laurence Kessler, Florence Toti, Gilbert Massard Institution : Service de chirurgie thoracique, nouvel hôpital civil, Strasbourg Objectives : In vitro study of paracrine effect of alveolar microparticles (MPs) generated during lung ischemia reperfusion, on alveolar epithelial cells (AEC) type II. Methods : The bronchoalveolar lavage (BAL) of rat lungs is collected after 20h of cold ischemia and 2h of reperfusion. MPs are isolated, concentrated and their cellular origin determined after capture on annexin-5 or on specific antibodies. Washed and concentrated MPs are applied, during 20 hours on rat AEC type II (RLE-6TN) at 70% of confluence. Cellular integration of MPs is evaluated after labeling with a fluorescent probe PKH26. Induced apoptosis is assessed by the percentage of cells carrying hypodiploide DNA, the cellular function by the presence of surfactant protein B and inflammation by the rate of interleukin 8 (IL8). Results : The yield of MPs gathered in BAL is 80% after 2h of ultracentrifugation. The microparticles are endothelial and leukocyte origin. More than 90% of MPs are integrated in cells after 24h of stimulation. The percentage of apoptosis induced by alvolar MPs at concentrations of 5, 10, 15 nMPhSer is 3±1.4%, 3±0.9%, 4.4±2.2% respectively, vs 3.4±1.4% for untreated cells and 9.9±4.5% for cells sitmulated by 0.1 µg/ml of actinomycin. Stimulation by alveolar MPs at concentrations of 10 and 15 nMPhSer significantly increase the concentration of SpB in cell supernatant compared to untreated cells (p<0.001). We have not highlighted IL8 in cell surpernatant after stimulation by MPs. Conclusion : Alveolar microparticles are integrated in alveolar epithelial cell type II and have a cell activator effect by the stimulation of the production of lung surfactant.
novembre 29, 2016
Vol. 20 JA2016 - thoracic

T-15 – Clinical and molecular characteristics of mediastinal Castleman disease
Antoine Legras, Anne Talet, Audrey Didelot, Aurélie Cazes, Angela Hin, Raphaël Borie, Bruno Crestani, Yves Castier, Françoise Le Pimpec-Barthes, Marc Riquet, Hélène Blons, Pierre Mordant Institution : Service de chirurgie thoracique et vasculaire et transplantation pulmonaire, hôpital Bichat, Paris Objectives : Mediastinal unicentric Castleman disease is a very rare condition, poorly known due to small number of cases and the absence of genomic study. We sought to characterize the clinical, radiological, histological and genomic patterns associated with unicentric mediastinal CD in the frame of a substantial case series. Methods : We retrospectively reviewed cases from 2 French thoracic surgery departments (1988-2012). Clinical, radiological, surgical and pathological data were recorded. On available paraffin-embedded blocks were performed mutation screening by next generation sequencing, with AmpliSeq™ Cancer Hotspot v2 (Life Technologies) and immunohistochemistry (AKT mTOR pathway). Results : Eleven patients were identified (mean age: 41, range 17-69; sex-ratio 0.8). Surgical approach was thoracotomy (n=6), VATS (n=1) or sternotomy (n=4). Bilobectomy was needed in 1 case and radical mediastinal lymphadenectomy in 2 cases. One patient presented local relapse as follicular dendritic cell sarcoma, leading to death. Within 9 patients, 2 mutations were found: VHL (p.F119L, 35%, n=1) and JAK3 (p.V718L, 53%, n=1). Stainings for phospho-AKT and phospho-mTOR were negative. Phospho-S6K staining was observed in 5 cases, mainly in cytoplasm of interfollicular cells. Conclusion : Here we presented the largest series of mediastinal unicentric Castleman disease, with genomic and cellular pathway data. We observed 2 potential driver mutations and phospho-S6K activation not related to mTOR nor AKT pathway. Knowledge may be improved by addressing all pathological specimens to a unique reference national centre.
novembre 29, 2016
Vol. 20 JA2016 - thoracic

T-16 Using bronchial biopsy as a tool for study of airway remodeling in severe or non-severe asthmatic patient
Matthieu Thumerel, Pierre-Olivier Girodet, Patrick Berger, Roger Marthan, Jacques Jougon Institution : Service de chirurgie thoracique, hopital Haut-lévêque, CHU Bordeaux, Pessac Objectives : Evaluate the use of bronchial biopsy during bronchoscopy as a tool for study of airway remodeling in severe or non-severe asthmatic patients. Methods : In two studies (Remodelasthme, NCT00896428 and Mitasthme, NCT00808730), were performed 92 bronchoscopies among patients with severe and non-severe asthma. Three biopsies per patient of spurs segmental or sub-segmental from the middle lobe were made for an analysis of 6-8 sections per biopsy of bronchial smooth muscle (BSM) area, a marker of asthmatic airway remodeling. Results : In Mitasthme study, 30 non-severe asthmatic patients were biopsied. Only 2 bronchoscopies were unusable. Between and within-biopsies variability of BSM area were similar in “small muscle” vs “big muscle” groups (coefficient of 0.32 vs. 0.34; p = 0.45). These study have identified a phenotype called “big muscle” in non-severe asthmatic patients whose clinical characteristics are similar to severe asthma. In Remodelasthme study, 31 patients with severe asthma were biopsied twice. Intra-observer and inter-observers reproducibility of BSM area was good. Between and within-biopsies variability of BSM area were similar in gallopamil vs. placebo groups to 2 times. The study concluded that gallopamil is able to reduce the BSM thickness in severe asthmatic patients. Conclusion : Bronchoscopy with biopsy is a good tool for an analysis of the bronchial smooth muscle. It remains invasive and development of other markers is needed.
novembre 29, 2016