Background The reconstruction of large full-thickness chest wall defects after resection of T3/T4 non-small cell lung carcinomas or primary chest wall tumors presents a technical challenge for ...thoracic surgeons and plays a central role in determining postoperative morbidity. The objective is to evaluate our results in chest wall reconstruction using a combination of expanded polytetrafluoroethylene (ePTFE) mesh and titanium plates. Methods Since 2006, 19 patients underwent reconstruction for wide chest wall defects using a combination of ePTFE mesh and titanium plates. The chest wall reconstruction was achieved by using a layer of 2-mm thickness ePTFE shaped to match the chest wall defect and sewed under maximum tension. The ePTFE is placed close to the lung and fixed onto the bony framework and onto the titanium plate, which is inserted on the ribs. Results Seventeen patients underwent a complete R0 resection with the removal of 3 to 9 ribs (mean, 4.8 ribs), including the sternum in 7 cases. Reconstruction required 1 to 4 horizontal titanium bars (mean, 1.7 bars). In 1 patient, a vertical titanium device was implanted for a large posterolateral defect. There were 2 cases of infection, which required explantation of the osteosynthesis system in 1 patient. One patient had partial skin necrosis that required prompt debridement. One patient had a major complication in the form of respiratory failure. Conclusions Our experience and initial results show that titanium rib osteosynthesis in combination with Dualmesh can easily and safely be used in a one-stage procedure for major chest wall defects.
Background The aim of the study was to provide a literature review of thoracic endovascular aortic repair (TEVAR) outcomes for penetrating ulcer of the aorta. Methods Relevant articles in the Embase, ...Medline, and Cochrane databases reporting the results of endovascular repair for penetrating ulcers of the thoracic aorta were systematically searched and reviewed. Results Thirty-one articles were integrated after a literature review, and 310 patients treated by TEVAR for penetrating ulcers of the aorta were identified. In this cohort, most patients were male (65.8%), had a history of smoking (60.4%), and systemic hypertension (90%). Only 9% were asymptomatic at initial presentation. Most cases (76%) occurred among patients with a single ulcer, located in the descending thoracic aorta (81%), with associated intramural hematoma in 45%. The technical success of TEVAR was 98.3%. Surgical conversion during the postoperative period with stent-graft explantation was required in 1 patient. The overall 30-day mortality was 4.8% (15 of 310). The most frequent complications were endoleaks (8%, 25 of 310) and access problems (16.1%, 26 of 161). After a mean follow-up of 17.7 months (range, 1 to 52), the all-cause mortality was 22.9% (71 of 310), and the aortic-related mortality was 4.1% (13 of 310). During follow-up, new endoleak and ulcer recurrence were observed in 5.4% (n = 15 of 274) and 4.5% (n = 5 of 110), respectively, requiring a new aortic endovascular procedure in 50% (n = 10). Conclusions Thoracic endovascular aortic repair of penetrating ulcer has excellent short-term and midterms results. The endovascular approach should be the first line management for aortic ulcer when intervention is indicated.
We hypothesized that staged repair of extensive thoracic aneurysms might mitigate the incidence and severity of spinal ischemia by facilitating structural remodeling of the spinal cord vasculature. ...Staged hybrid repair (in two or three stages) was undertaken in 7 patients with extensive thoracic aortic aneurysms. The 30-day mortality and spinal ischemia rates were 0%. The conceptual basis of staging extensive aortic repairs is the maintenance of adequate flow to a sufficient number of spinal arteries and that spinal perfusion is preserved during the early postoperative period when the patient is most vulnerable to hypotension, by deliberately allowing interval distal type I endoleak.
Objective The perioperative outcomes of the endovascular approach to aortobronchial fistula have been favorable. However, it is uncertain whether thoracic endovascular aneurysm repair (TEVAR) alone ...provides a complete and durable cure for an aortobronchial fistula. TEVAR does nothing to address the issue of the defect in the respiratory tract, leaving the patient at risk of aortobronchial fistula recurrence and/or stent graft infection. The authors believe that the bronchial defect should be addressed. Methods Over the last 10 years, 5 patients were treated for an aortobronchial fistula using a combined endovascular and surgical approach (primary treatment in 3 patients and secondary after TEVAR in 2 patients). All the patients underwent emergency stent graft placement and concomitant (n = 1) or staged (n = 4) open repair including pulmonary resection with coverage of the stent graft using muscle or pleural flaps. All patients received a 6-week course of broad-spectrum intravenous antibiotics followed by lifelong oral antibiotics. Results All patients survived the surgical procedure. After a mean follow-up of 23.2 months, 4 patients are asymptomatic and postprocedure computed tomography scans were unremarkable. One patient treated for an aortobronchial fistula after TEVAR was readmitted 4 months after surgical conversion. Stent graft explantation and silver-coated tube graft replacement of the descending thoracic aorta were performed for severe mediastinitis with associated thoracic stent graft infection. The postoperative course of this patient was uneventful. Conclusions Emergency TEVAR for an aortobronchial fistula is an appealing strategy for this devastating complication. However, to achieve a lasting result, direct contact between the stent graft and the pulmonary tissue should be avoided to prevent further erosive damage. Concomitant or staged repair should entail primary repair or resection and anastomosis of the bronchus and/or pulmonary resection with coverage of the stent graft using muscle or pleural flaps combined with broad-spectrum intravenous antibiotic therapy. Long-term surveillance and continued investigation are warranted.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
We present a case of right heart failure after left pneumonectomy as a result of an isolated, contralateral partial anomalous pulmonary venous return. We successfully treated this with percutaneous ...atrioseptostomy. For unstable patients with postoperative acute heart failure from an undetected partial anomalous pulmonary venous return, this minimally invasive procedure represents a useful primary option while allowing secondary conventional surgery if required.
OBJECTIVES
Recent studies have suggested that postoperative complications could have a potential negative effect on long-term outcome after oesophagectomy for cancer. Because respiratory failures ...represent the most frequent postoperative complication, we have investigated the prognostic impact of these complications on disease-free survival (DFS).
METHODS
From a prospective single-institution database of 405 consecutive patients who underwent transthoracic oesophagectomy for cancer, we retrospectively analysed medical charts of all patients with microscopically complete resection (R0, n = 384 patients). Complications were graded according to the modified Clavien classification. Respiratory complications were defined as atelectasis, pneumonia or acute respiratory distress syndrome in the absence of early surgical complications. Patients with grade 5 (postoperative mortality, n = 43, 11%) were excluded from the analysis. The remaining 341 patients were analysed for estimation of DFS according to the Kaplan-Meier method. Logistic regression analysis was conducted to discriminate predictive factors affecting DFS.
RESULTS
According to the modified Clavien classification, postoperative complications rates were grade 0: 147 (44%), grade 1: 7 (2%), grade 2: 56 (16%), grade 3: 69 (20%) and grade 4: 62 (18%). Five-year DFS rates were not significantly different between grade 0 (no complication, 38%, n = 147) and other grades (grade 1, 2, 3 and 4 (64, 45, 56 and 48%, respectively)). Respiratory complications occurred in 107 patients (31%) and the 5-year DFS in this subgroup was 47% compared with 38% observed in grade 0 patients (P = 0.75). Clavien classification and respiratory complications did not come out in the univariate analysis of factors affecting DFS. On logistic regression, only two variables affected DFS: c-N stage and extracapular lymph node involvement.
CONCLUSIONS
When postoperative mortality is excluded, postoperative complications do not affect DFS in patients with complete resection. This deserves substantial information regarding the prognosis of subgroup of patients in critical situations where incrementing intensive care is debated.
OBJECTIVES
The 7th edition of American Joint Committee on Cancer (AJCC) staging system of oesophageal cancer and gastro-oesophageal junction has re-staged positive nodes into N1-3 according to the ...number of invaded lymph nodes (LNs). However, this new classification does not consider the potential negative impact of the extracapsular breakthrough on survival. This study aims at assessing prognosis according to whether LN involvement is intracapsular (ICLNI) or extracapsular (ECLNI) on disease-free survival (DFS) among the three sub-groups of LN-positive patients.
METHODS
Four hundred and sixteen consecutive R0 patients who underwent transthoracic oesophagectomy for cancer between 1996 and 2011 were retrospectively re-classified using the latest AJCC TNM classification. Among them, 230 (55%) patients have received a neoadjuvant chemoradiotherapy. Prognostic impact of ICLNI and ECLNI on DFS was assessed according to their new LN status. Multivariate analysis was drawn to determine factors affecting DFS.
RESULTS
Among the 416 patients, there were 138 (33%) patients with positive LN: 79 (57%) with ICLNI and 59 (43%) with ECLNI. The proportion of ECLNI was 21 of 73 (28%), 21 of 41 (51%) and 17 of 24 (70%) in N1, N2 and N3 patients, respectively. In N1 patients, median DFS was 48 months in ICLNI and 13 months in ECLNI (P = 0.068). In N2 patients, median DFS was 19 months in ICLNI and 9 months in ECLNI (P = 0.07). In N3 patients, median DFS was not reached in ICLNI and was 6 months in ECLNI (P = 0.002). On multivariate analysis, the ECLNI (P < 0.001, hazard ratio, HR: 2.51) and the post-T stage (P = 0.03, HR: 1.62) were the two independent factors affecting DFS.
CONCLUSIONS
Based on our limited study population, the existence of an ECLNI seems to have an additive negative impact on DFS, regardless of the pN stage. This suggests that extracapsular breakthrough status should be added to the new TNM staging system. This information has to be validated by further investigations.
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