Sleeve lobectomy is a widely accepted procedure for central tumors for which the alternative is pneumonectomy. The purpose of this study is to assess operative mortality, morbidity, and long-term results of sleeve lobectomies performed for non-small cell lung carcinoma (NSCLC).A retrospective review of 218 patients who underwent sleeve lobectomy for NSCLC between 1981 and 2005 was undertaken. There were 186 (85%) men and 32 women with a mean age of 61.9 years (range, 19-82 years). Eighty patients (36.6%) had a preoperative contraindication to pneumonectomy. Right upper lobectomy was the most common operation (45.4%). Vascular sleeve resection was performed in 28 patients (12.8%) and was commonly associated with left upper lobectomy (n=20; 9.1%; p=0.0001). The histologic type was predominantly squamous cell carcinoma (n=164; 75%), followed by adenocarcinoma (n=46; 21%). Resection was incomplete in nine (4.1%) patients.There were nine operative deaths; the operative mortality and the morbidity rates were 4.1% and 22.9%, respectively. A total of 14 (6.4%) patients presented with bronchial anastomotic complications: two were fatal postoperatively, seven patients required reoperation, three required a stent insertion, and two were managed conservatively. Multivariate analysis showed that compromised patients (p=0.001), current smoking (p=0.01), right sided resections (p=0.003), bilobectomy (p=0.03), squamous cell carcinoma (p=0.03), and presence of N1 or N2 disease (p=0.01) were risk factors for mortality and morbidity. Follow-up was complete in 208 patients (95.4%). Overall 5-year and 10-year survival rates were 53% and 28.6%, respectively. After complete resection, recurrence was local in 10 patients, mediastinal in 20, and distant in 25. By multivariate analysis, two factors significantly and independently influenced survival: nodal status (N0-N1 vs N2; p=0.01) and the stage of the lung cancer (stage I-II vs III, p=0.02).For patients with NSCLC, sleeve lobectomy achieves local tumor control, even in patients with preoperative contraindication to pneumonectomy and is associated with low mortality and bronchial anastomotic complication rates. Postoperative complications are higher in compromised patients, smokers, N disease, right sided resections, bilobectomies, and squamous cell cancers. The presence of N2 disease and stage III significantly worsen the prognosis.
The commonest carotid artery lesions observed after cervical or mediastinal irradiation are steno-occlusive. The increasing incidence of ENT cancers, the treatment of which is essentially by radiotherapy alone or associated with surgery, explain the rising number of carotid lesions. The histopathological effects of radiation on the arterial wall are an acceleration of atherosclerosis and secondary ischaemic lesions due to radio-induced occlusion of the vasa vasorum. Irradiation acts in synergy with other sources of arterial aggression such as hyperlipidaemia, hypertension, and smoking. The diagnosis and evaluation of carotid stenosis are based on echo-Doppler ultrasonography and MRI angiography. The imputability of ionising radiation is retained on a series of arguments, none of which is specific, and remains very theoretical because of the common intrication of preexisting atheromatous disease. Arteriography of the supraaortic vessels is essential for the management of these patients because of the multifocal and extensive nature of the lesions. A previous history of irradiation increases the risk of usually transient cranial nerve paralysis and of cervical wound healing. Nevertheless, the incidence of morbi-mortality reported in series of carotid artery surgery for post-irradiation lesions, conforms to expert recommendations. Angioplasty and stenting probably have a role to plays in the management of these patients. Prospective studies are required to determine its place with respect to conventional surgery which remains the reference treatment at present.
To identify factors that affect operative mortality and morbidity and long-term survival after completion pneumonectomy.We retrospectively reviewed the charts of consecutive patients who underwent completion pneumonectomy at our cardiothoracic surgery department from January 1996 to December 2005.We identified 69 patients, who accounted for 17.8% of all pneumonectomies during the study period; 22 had benign disease and 47 malignant disease (second primary lung cancer, n=19; local recurrence, n=17; or metastasis, n=11). There were 50 males and 19 females with a mean age of 60 years (range, 29-80 years). Postoperative mortality was 12% and postoperative morbidity 41%. Factors associated with postoperative mortality included obesity (p=0.005), coronary artery disease (p=0.03), removal of the right lung (p=0.02), advanced age (p=0.02), and renal failure (p<0.0001). Preoperative renal failure was the only significant risk factor for mortality by multivariate analysis (p=0.036). Bronchopleural fistula developed in seven patients (10%), with risk factors being removal of the right lung (p=0.04) and mechanical stump closure (p=0.03). Overall survival was 65% after 3 years and 46% after 5 years. Long-term survival was not affected by the reason for completion pneumonectomy.Although long-term survival was acceptable, postoperative mortality and morbidity rates remained high, confirming the reputation of completion pneumonectomy as a challenging procedure. Significant comorbidities and removal of the right lung were the main risk factors for postoperative mortality. Improved patient selection and better management of preoperative renal failure may improve the postoperative outcomes of this procedure, which offers a chance for prolonged survival.
Les lesions carotides les plus frequemment observees apres irradiation cervicale ou cervico-mediastinale sont des lesions steno-occlusives. L'incidence croissante des cancers ORL dont le traitement repose principalement sur la radiotherapie seule ou associee a la chirurgie explique le nombre croissant de lesions carotides « radio-induites ». Les effets histopathologiques de l'irradiation sur la paroi arterielle correspondent a la fois a une acceleration de l'atherosclerose et a des lesions ischemiques secondaires a l'occlusion radio-induite des vasa vasorum. L'irradiation agit en synergie avec d'autres sources d'agression arterielle telles que l'hyperlipidemie, l'hypertension arterielle et le tabagisme. Le diagnostic et l'evaluation du degre de stenose carotide reposent sur l'echo-doppler et/ou l'angio-IRM. L'imputabilite des radiations ionisantes repose sur un faisceau d'argument dont aucun n'est specifique et reste tres theorique du fait des intrications frequentes avec une maladie atheromateuse preexistante. L'arteriographie des troncs supra-aortiques est indispensable dans la prise en charge therapeutique de ces patients du fait du caractere souvent multifocal et etendu des lesions. Les antecedents d'irradiation augmentent le risque de paralysies le plus souvent transitoires des nerfs crâniens et de probleme de cicatrisation cervicale. Neanmoins, les taux cumules de morbi-mortalite rapportes de la chirurgie carotide en milieu irradie sont conformes aux recommandations des experts. L'angioplastie avec stent a vraisemblablement un role a jouer dans la prise en charge therapeutique de ces patients. Seules des etudes prospectives permettront de preciser ce role par rapport a la chirurgie conventionnelle qui dans l'etat actuel des connaissances reste la technique de reference.
Two female patients aged 64 and 50 years, who had intra-pericardial tumors arising from the ascending aorta, are reported. Both patients were admitted with mediastinal mass. Surgery was performed by median sternotomy with complete excision. Histology revealed teratoma and ectopic thyroid. Tumors arising from the ascending aorta are very rare and should be considered in the differential diagnosis of the mediastinal masses.
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