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Microsurgery, developed in the 1960s from experimental work in animals, has not undergone technological evolution until today. Robotics could lead to a major technological leap for two main reasons, the reduction of the size of the incisions thanks to the endoscopy and the improvement of the surgical act by the reduction of the movements.

We describe a case of platypnea-orthodeoxia syndrome (POS) due to atrial septal defect (ASD) occurring in the early postoperative course of a right pneumonectomy. Deformation of the atrial septum after right pneumonectomy deviates the blood from the inferior vena cava to ASD during the sitting position creating, a massive right-to-left shunt. Diagnosis can initially be missed by making contrast bubble test through the superior vena cava. The atrial septal defect was then closed using the surgical technique, allowing an instantaneous improvement of hematosis.

Background Postpneumonectomy acute respiratory distress syndrome (ppARDS) is a life-threatening condition with a disastrous prognosis. This study assessed the efficacy of venovenous extracorporeal membrane oxygenation (VV-ECMO) in adult patients with unresponsive severe ppARDS. Methods We retrospectively reviewed data of all patients treated with VV-ECMO for ppARDS from January 2009 to December 2015. We calculated the Sequential Organ Failure Assessment score before ECMO insertion and monitored the subsequent mechanical ventilation settings. The primary end point was hospital survival. The secondary end point was the ability to achieve a protective ventilatory strategy allowing lung recovery on ECMO. Results VV-ECMO was indicated in 8 ppARDS patients for refractory hypoxemia (median partial pressure of arterial oxygen/fraction of inspired oxygen: 68 [range, 60 to 75] mm Hg). Median Sequential Organ Failure Assessment before ECMO was 15 (range, 12 to 17), predicting a mortality rate greater than 80%. Median duration of ECMO was 9.5 (range, 5 to 16) days. Tidal volumes and plateau pressures both decreased on ECMO (pre-ECMO tidal volume: 412 [range, 250 to 450 mL] vs ECMO tidal volume: 277 [range, 105 to 367 mL], p = 0.0156; pre-ECMO plateau pressure: 34 [range, 32 to 40] cm H 2 O vs ECMO plateau pressure: 24.5 [range, 23.3 to 27.3] cm H 2 O, p = 0.0195). ECMO could be weaned in 7 patients (87.5%). Hospital survival was 50%. Conclusions Hospital survival was better than predicted before ECMO insertion. In severe and refractory ppARDS, VV-ECMO allows lung recovery and therefore increased survival.

Background After lung transplantation (LT), early prediction of grade 3 pulmonary graft dysfunction (PGD) remains a research gap for clinicians. We hypothesized that it could be improved using extravascular lung water (EVLWi) and plasma biomarkers of acute lung injury. Methods After institutional review board approval and informed consent, consecutive LT recipients were included. Transpulmonary thermodilution-based EVLWi, plasma concentrations of epithelial (soluble receptor for advanced glycation endproducts [sRAGE]) and endothelial biomarkers (soluble intercellular adhesion molecule-1 and endocan [full-length and cleaved p14 fragment]) were obtained before and after LT (0 [H0], 6, 12, 24, 48 and 72 hours after pulmonary artery unclamping). Grade 3 PGD was defined according to the International Society for Lung and Heart Transplantation definition, combining arterial oxygen partial pressure (PaO2)/inspired fraction of oxygen (FiO2) ratio and chest X-rays. Association of clinical risk factors, EVLWi and biomarkers with grade 3 PGD was analyzed under the Bayesian paradigm, using logistic model and areas under the receiver operating characteristic curves (AUCs). Results In 47 LT recipients, 10 developed grade 3 PGD, which was obvious at H6 in 8 cases. Clinical risk factors, soluble intercellular adhesion molecule-1 and endocan (both forms) were not associated with grade 3 PGD. Significant predictors of grade 3 PGD included (1) EVLWi (optimal cutoff, 13.7 mL/kg; AUC, 0.74; 95% confidence interval [CI], 0.48-0.99), (2) PaO2/FiO2 ratio (optimal cutoff, 236; AUC, 0.68; 95% CI, 0.52-0.84), and (3) sRAGE (optimal cutoff, 11 760 pg/mL; AUC, 0.66; 95% CI, 0.41-0.91) measured at H0. Conclusions Immediate postreperfusion increases in EVLWi and sRAGE along with impaired PaO2/FiO2 ratios were early predictors of grade 3 PGD at or beyond 6 hours and may trigger early therapeutic interventions.

Background Atrial arrhythmias (AAs) are frequent after lung transplantation (LT) and late postoperatively. Several predictive factors of early postoperative AAs after LT have been identified but those of late AAs remain unknown. Whether AA after LT affects mortality is still being debated. This study assessed in a large cohort of LT patients the incidence of AAs early and late after surgery, their predictive factors and their effect on mortality.Methods and Results:We studied 271 consecutive LT patients over 9 years. Mean follow-up was 2.9±2.4 years. 33% patients developed postoperative AAs. Age (odds ratio (OR) 2.35; confidence interval (CI) [1.31-4.24]; P=0.004) and chronic obstructive pulmonary disease (OR 2.13; CI [1.12-4.03]; P=0.02) were independent predictive factors of early AAs. Late AAs occurred 2.2±2.7 years after transplant in 8.8% of the patients. Pretransplant systolic pulmonary arterial pressure (PTsPAP) was the only independent predictive factor of late AA (OR 1.028; CI [1.001-1.056]; P=0.04). Double LT was associated with long-term freedom from atrial fibrillation (AF) but not from atrial flutter (AFL). Early and late AAs after surgery had no effect on mortality. Double LT was associated with better survival. Conclusions Early AA following LT is common in contrast with the low occurrence of late, often organized, AA. Early and late AAs do not affect mortality. PTsPAP is an independent predictor of late AA. Double LT protects against late AF but not AFL.

IL-23/Th17 pathway has been identified to sustain inflammatory condition in several autoimmune diseases and therefore being targeted in various therapeutic and effective approaches. Patients affected with autoimmune myasthenia gravis exhibit a disease effector tissue, the thymus, that harbors ectopic germinal centers that sustain production of auto-antibodies, targeting proteins located in the neuromuscular junction, cause of the organ-specific chronic autoimmune disease. The present study aims to investigate the IL-23/Th17 cell pathway in the thymic inflammatory and pathogenic events. We found that thymuses of MG patients displayed overexpression of Interleukin-17, signature cytokine of activated Th17 cells. This activation was sustained by a higher secretion of Interleukin-23 by TEC, in addition to the increased expression of cytokines involved in Th17 cell development. The overexpression of Interleukin-23 was due to a dysregulation of interferon type I pathway. Besides, Interleukin-17 secreted, and Th17 cells were localized around thymic ectopic germinal centers. These cells expressed podoplanin, a protein involved in B-cell maturation and antibody secretion. Finally, production of Interleukin-23 was also promoted by Interleukin-17 secreted itself by Th17 cells, highlighting a chronic loop of inflammation sustained by thymic cell interaction. Activation of the IL-23/Th17 pathway in the thymus of autoimmune myasthenia gravis patients creates an unstoppable loop of inflammation that may participate in ectopic germinal center maintenance. To alleviate the physio-pathological events in myasthenia gravis patients, this pathway may be considered as a new therapeutic target.

Lobectomy for benign lung disease is renowned to be technically complex and to be subjected to an increased complication rate. The objective of this study was to evaluate whether the results obtained with video-assisted surgery (VATS) in benign disease are comparable to those obtained in oncologic surgery, where VATS has been validated. We have reviewed the files of 246 consecutive patients who underwent VATS lobectomy from January 2012 to August 2015. The cohort was divided into two groups according to pathology (benign or malignant). Outcome parameters on scrutiny were demographics, pathology, duration of air leak, drainage and hospital stay, conversion, and perioperative complication rate. Comparisons were made with the χ 2 test and Student’s t test; any p value ≤0.05 was considered as significant. Group 1 (36 patients) included patients who underwent lobectomy for benign disease and group 2 (210 patients) patients affected by lung cancer or pulmonary metastases. The two groups differed with reference to age (p

International audience; OBJECTIVES: Thymectomy may be part of the therapeutic strategy in patients with myasthenia gravis (MG) without thymoma. Median sternotomy is still considered as the gold standard, but during the last 15 years, several groups have demonstrated the non-inferiority of cervicotomy with upper sternotomy and minimally invasive techniques. To date, there is no consensus on surgical procedure choice. The aim of our study was to compare the morbidity and mortality of three techniques [cervicotomy with upper sternotomy versus sternotomy versus video-assisted thoracic surgery (VATS)/robotic-assisted thoracic surgery (RATS)] from the national database EPITHOR and to analyse French epidemiology. METHODS: From the national thoracic surgery database EPITHOR, we have extracted all the details regarding thymectomies performed for non-thymomatous MG. We have divided thymectomy into three groups: A-sternotomy; B-cervicotomy with upper sternotomy; C-VATS/RATS. We investigated the postoperative morbidity and mortality without analysis of the long-term evolution of the disease not available on EPITHOR. RESULTS: From 2005 to 2013, 278 patients were included: 131 (47%) in Group A, 31 (11%) in Group B and 116 (42%) in Group C. The sex ratio F/M was 2.3. The mean age was, respectively, 42 +/- 17, 42 +/- 16, 35 +/- 14 years old (P < 0.01). The number of patients without comorbidities was 63 (48%), 25 (81%) and 78 (65%), respectively (P < 0.01). The operative time was 94 +/- 37, 79 +/- 42 and 112 +/- 59 min, respectively (P < 0.01). The number of patients who presented at least one postoperative complication was 12 (14%), 0 and 3 (9%) (P = 0.03), respectively. The postoperative lengths of stay were 7.7 +/- 4.5, 5 +/- 1.7 and 4.5 +/- 2 days, respectively (P < 0.01). There was no death. CONCLUSIONS: In our study, we were unable to prove the superiority of minimally invasive techniques due to the important differences between the groups. However, this study shows us major changes in French surgical procedures during the last decade with an increase in minimally invasive procedures such as VATS and RATS.

The aim of this study was to report the feasibility of robotic intercostal nerve harvest in a pig model. A surgical robot, the da Vinci Model S system, was installed after the creation of 3 ports in the pig’s left chest. The posterior edges of the fourth, fifth, and sixth intercostal nerves were isolated at the level of the anterior axillary line. The anterior edges of the nerves were transected at the rib cartilage zone. Three intercostal nerve harvesting procedures, requiring an average of 33 minutes, were successfully performed in 3 pigs without major complications. The advantages of robotic microsurgery for intercostal nerve harvest include elimination of physiological tremor, free movement of joint-equipped robotic arms, and amplification of the surgeon’s hand motion by as much as 5 times. Robot-assisted neurolysis may be clinically useful for intercostal nerve harvest for brachial plexus reconstruction.

Objective To study patient survival and glycemic control before and after lung transplantation (LTx) according to the diabetes status in patients submitted to an organized management of diabetes mellitus (DM) at the Strasbourg University Hospital, France. Material and Methods Two hundred and sixty-seven LTx recipients were included retrospectively and analyzed according to diabetes status: pretransplant diabetes, new-onset diabetes mellitus after transplant (NODAT) or no diabetes. Organized DM management was coordinated by a diabetologist trained in DM management before and after transplantation and included pretransplant screening, a close monitoring of glycemia after transplant and optimized treatment before and after LTx. Results DM was well-controlled after transplantation: mean glycosylated hemoglobin and fasting blood glucose levels after LTx were 5.8 ± 0.2% and 5.4 ± 0.1 mmol/L respectively, in pretransplant DM patients and 5.7 ± 0.1% and 5.6 ± 0.2 mmol/L respectively, in NODAT patients. The overall median survival time was 8.3 ± 1.9 years. Pretransplant DM increased the risk of mortality (1.82-fold increase; 95% confidence interval, 1.08-3.06; P = .02) in LTx recipients. Conclusions Organized management of diabetes achieved very satisfactory glycemic control in both pretransplant DM and NODAT patients. However, no specific protocols have been created for managing DM following LTx. As DM continues to become an increasing comorbidity in LTx, there exist a significant need of studies in this area.

Emerging data highlight different clinical behaviors according to KRAS amino acid substitutions (AASs) in patients with non-small-cell lung cancer (NSCLC). We aimed to evaluate whether different KRAS AASs were associated with different responses to chemotherapy.We retrospectively reviewed data from 1190 patients with KRAS mutations who underwent first-line platinum-based chemotherapy for stage IV NSCLC. The response to different chemotherapy regimens was evaluated using the Response Evaluation Criteria In Solid Tumors criteria (v 1.1). Overall survival and time to progression (TTP) were secondary endpoints.Taxane was associated with the best response in the entire cohort (odds ratio, 2.52; 95% confidence interval [CI], 1.82-3.48; P .001), especially in G12V patients (odds ratio, 2.15; 95% CI, 1.05-4.41; P = .036). Taxane was associated with improved TTP in the entire cohort (hazard ratio [HR], 0.31; 95% CI, 0.26-0.38; P .001), especially in G13D patients (HR, 0.47; 95% CI, 0.22-1.01; P = .054). Pemetrexed was associated with the worst TTP in the entire cohort, particularly in G12V patients, who had the worst response rates (HR, 0.55; 95% CI, 0.30-0.99; P = .049). No impact on overall survival was observed according to different chemotherapy regimens and AASs.KRAS-specific AAS appears to induce different responses to chemotherapy regimens after first-line platinum-based chemotherapy in advanced NSCLC.

Background Adequate strategies using either transthoracic (TTE) or transesophageal (TEE) echocardiography in patients receiving cardiopulmonary resuscitation (CPR) is an ongoing area of research. Objectives As transthoracic point-of-care ultrasound (POCUS) during cardiac arrest resuscitation might result in an increased duration of interruptions in the delivery of chest compressions; the use of TEE has been proposed as an alternative. Methods No technical complications of either TTE nor TEE are so far being reported in the literature. Results We report the case of a left intramural atrial hematoma complicating TEE procedure during cardiac arrest. This highlights a unique and to our knowledge, first-in-man, described complicating TEE procedure during CPR. Conclusions Further research on the safety of transesophageal echo during CRP is mandatory and the question about any potential harm of particular interest.

We report a case of partial anomalous pulmonary venous return from the left upper lobe in a donor lung discovered during lung transplantation. The upper lobe vein could be implanted successfully into the donor atrial cuff to restore physiologic venous drainage. The abnormality was retrospectively identified on the donor's chest computed tomographic scan. Cardiac magnetic resonance imaging performed in the recipient 6 months after transplantation demonstrated patent left pulmonary venous drainage. This is the third reported case of partial anomalous pulmonary venous return in a donor lung, but the first description of direct ex vivo suture into the donor cuff.

Post-operative management of pIIIA-N2 non-small cell lung cancer (NSCLC) is still debated. Our objective was to identify subgroups of patients who could benefit from treatment based on invaded lymph node ratio (LNR). From January 2003 to December 2012, 297 pIIIA-N2 NSCLC patients treated with surgery followed by conformational radiation therapy (RT) were retrospectively analysed. Median follow-up time was 30 months. A correlation was observed between LNR and overall survival (OS) (R = −0.3, p

Clamshell (bilateral anterolateral thoracotomy combined to transverse sternotomy) is an invasive surgical approach that is helpful in particular situations, especially bilateral lung transplantation. The closure technique remains challenging because clamshell incision can end with override, separation, or sternal pseudarthrosis complications. We describe the use of new absorbable sternal pins to stabilize the sternal closure and to help avoid additional sternal complications.

Risk factors for lung cancer in lung transplant recipients are a history of smoking and immunosuppression, to which adds increasing use of lungs from donors with a smoking history. The three typical presentations are incidental diagnosis on the explanted lung, concerning less than 2%; lung cancer developing on the lung graft, accounting for less than 1%; and incidence of lung cancer on the native lung, estimated at 9%. Treatment along available guidelines may be hampered by decreased lung function owing to chronic rejection or adverse effects of immunosuppression. Prognosis is comparable to a general population in resected stage I cancer and is less favorable in advanced stages.

Management of stage IIIA-N2 non-small cell lung cancer is still matter of ongoing controversy. The debate is flawed by the heterogeneity of this group of patients, lack of strong evidence from controlled trials, diverging treatment strategies, and hesitating estimation of prognosis. Surgery is credited a survival advantage in a trimodality setting. For many teams, N2 is by principle managed with induction chemotherapy, followed by surgery if the patient is down-staged. However, surgery remains a suitable option even in case of persistent N2. On the other hand, outcomes are comparable, regardless whether chemotherapy has been given as induction or adjuvant treatment. Hence, upfront surgery without invasive staging, followed by adjuvant therapies, appears reasonable in resectable single station N2 disease, simplifying patient care and reducing cost. We expect that molecular biomarkers will improve estimation of prognosis and patient selection in the future.

To investigate whether prophylactic postoperative NIV prevents respiratory complications following lung resection surgery in COPD patients. In seven thoracic surgery departments, 360 COPD patients undergoing lung resection surgery were randomly assigned to two groups: conventional postoperative treatment without (n = 179) or with (n = 181) prophylactic NIV, applied intermittently during 6 h per day for 48 h following surgery. The primary endpoint was the rate of acute respiratory events (ARE) at 30 days postoperatively (ITT analysis). Secondary endpoints were acute respiratory failure (ARF), intubation rate, mortality rate, infectious and non-infectious complications, and duration of ICU and hospital stay. ARE rates did not differ between the prophylactic NIV and control groups (57/181, 31.5 vs. 55/179, 30.7 %, p = 0.93). ARF rate was 18.8 % in the prophylactic NIV group and 24.5 % in controls (p = 0.20). Re-intubation rates were similar in the prophylactic NIV and control group [10/181 (5.5 %) and 13/179 (7.2 %), respectively, p = 0.53]. Mortality rates were 5 and 2.2 % in the control and prophylactic NIV groups, respectively (p = 0.16). Infectious and non-infectious complication rates, and duration of ICU and hospital stays were similar between groups. Prophylactic postoperative NIV did not reduce the rate of ARE in COPD patients undergoing lung resection surgery and did not influence other postoperative complications rates, mortality rates, and duration of ICU and hospital stay.

Introduction: Diabetes mellitus (DM) is a risk factor for mortality and morbidity after solid organ transplantation (kidney, liver). The objective of our study was to determine the effect of DM on survival and unscheduled hospitalizations after lung transplantation. Patients and methods: We included retrospectively 256 patients who received a single or double lung transplantation at Strasbourg University Hospital between 2004 and 2014. The indications for lung transplantation were: COPD (43,4%), cystic fibrosis (21,9%), and pulmonary fibrosis (19,2%). 80% were bilateral transplantations. We grouped the patients into 3 relevant categories of DM: pre- and post-transplant DM, new onset (>3 months) diabetes after transplantation (NODAT) and the control group of non-diabetic patients. Results: 78 patients had pre&post DM and 48 patients developed NODAT. Cystic fibrosis patients had the highest prevalence (50%) of pre&post DM and NODAT. We found a significant difference for unscheduled hospital stays between the 3 groups: the duration of hospital stays [mean±SD] was 86±121 days/year for pre&post DM patients, 50±67 days/year for NODAT, and 78±120 days/year for non-diabetic patients (p=0,032). We observed a worse survival after transplantation in pre&post DM compared to patients without pre-transplant DM (3-months median conditional survival: 6.3 ± 1.6 vs 8.8 ± 0.7 years, p = 0.016). There was no difference in survival for NODAT patients compared to non-diabetic patients (3 months conditional median survival: 10.5 ± 2 years versus 8.4 ± 1.6, NS). Conclusion: DM might have an impact on survival after lung transplantation. An organized and cooperative management of pre&post DM and NODAT seems warranted.

OBJECTIVES The role of perioperative chemotherapy (POC) and targeted therapies in lung metastasectomy for colorectal cancer (CRC) is still subject to debate. We aimed to evaluate whether POC and targeted therapies were associated with different outcomes according to the mutational status. METHODS We reviewed data from 223 patients who underwent pulmonary metastasectomy for CRC from 1998 to 2015 and for whom the V-Ki-ras2 Kirsten sarcoma viral oncogene homologue (KRAS) and V-raf Murine sarcoma viral oncogene homologue B1 (BRAF) mutational statuses were known. RESULTS A total of 167 patients (74%) underwent POC: 62 (37%) received neoadjuvant therapy, 59 (35%) were in the adjuvant setting and 46 (28%) were in both the neoadjuvant and adjuvant settings. POC did not significantly influence either the loco-regional recurrence free survival (LRRFS) (P = 0.21) or the overall survival (OS) (P = 0.29). Furthermore, in cases of adjuvant chemotherapy, outcomes were not significantly different in cases of neoadjuvant chemotherapy or both neoadjuvant and adjuvant treatment (P = 0.26 for OS, P = 0.14 for LRRFS). For patients with KRAS mutation, perioperative bevacizumab was associated with a significant improvement in both LRRFS [70 months (41.58–98.42) vs 24 months (1.15–46.86), P = 0.001] and OS [101 vs 55 months (49.77–60.23), P = 0.004]. However, this benefit was only significant in cases of KRAS exon 2 codon 12 mutations [median OS: 101 months (83.97–118.02) vs 60 months (53–66.99), P

In thoracic surgery, extracorporeal life support (ECLS) techniques are performed to (I) provide a short to mid term extracorporeal mechanical support; (II) realize the gas exchanges; and (III)-depending the configuration of the circuit-substitute the failed heart function. The objective of this review is to describe the rational of the different ECLS techniques used in thoracic surgery and lung transplantation (LTx) with a specific attention to the vascular access. Venovenous extracorporeal membrane oxygenation (VV ECMO) is the most common ECLS technique used in thoracic surgery and represents the best strategy to support the lung function. VV ECMO needs peripheral vascular access. The selection between his double-site or single-site configuration should be decided according the level of O2 requirements, the nosological context, and the interest to perform an ECLS ambulatory strategy. Venoarterial (VA) ECMO uses peripheral and/or central cannulation sites. Central VA ECMO is mainly used in LTx instead a conventional cardiopulmonary bypass (CPB) to decrease the risk of hemorrhagic issues and the rate of primary graft dysfunction (PGD). Peripheral VA ECMO is traditionally realized in a femoro-femoral configuration. Femoro-femoral VA ECMO allows a cardiocirculatory support but does not provide an appropriate oxygenation of the brain and the heart. The isolated hypercapnic failure is currently supported by extracorporeal CO2 removal (ECCO2R) devices inserted in jugular or subclavian veins. The interest of the Novalung (Novalung GmbH, Hechingen, Germany) persists due to his central configuration indicated to bridge to LTx patients suffering from pulmonary hypertension. The increasing panel of ECLS technologies available in thoracic surgery is the results of a century of clinical practices, engineering progress, and improvements of physiological knowledges. The selection of the ECLS technique-and therefore the vascular access to implant the device-for a given nosological context trends to be defined according an evidence-based medicine.

Background After lung transplantation, bronchial complications are one of the major concerns for surgeons and physicians. In the era of evolving immunosuppressive regimens and surgical approaches, we have reassessed risk factors for bronchial complications after lung transplantation. Methods We undertook a retrospective study of all consecutive lung transplantations performed at a single center from 2004 to 2014. We monitored the incidence of symptomatic bronchial complications. Demographic data of donors and recipients were also studied. Our objective was to evaluate the impact of 3 subsequent immunosuppressive regimens (including the use of induction therapy), and of a technical modification of bronchial anastomosis on the incidence of airway complications. Results We performed 270 consecutive lung transplantations during the study period. On multivariate analysis, bronchial complications were not directly associated with the different immunosuppressive regimens. In subgroup analysis, when comparing different immunosuppressive regimens, primary graft dysfunction within 72 hours (odds ratio [OR] = 2.55; p = 0.08), lung infection within the first month (OR = 2.96; p = 0.039), diabetes before transplantation (OR = 2.66; p = 0.11) and chronic obstructive pulmonary disease (OR = 2.20; p = 0.04) appeared as major risk factors (c-index = 0.77 on multivariate analysis). The use of a modified bronchial suture technique was associated with fewer bronchial complications (OR = 0.47; p = 0.059) (c-index = 0.71 on multivariate analysis). Conclusions The mode of immunosuppression had no influence on airway complications. We were able to reproduce the beneficial effect of a modified suture technique.

OBJECTIVES The literature concerning relations between thoracic surgery and digestive motility is poor. The aim of our study was two-fold: (i) to show a link between thoracic surgery and gastric distension and (ii) between post-operative pneumoniae and gastric distension. METHODS A retrospective analysis was conducted in 262 patients who had undergone a thoracotomy for lung resection between January and December 2007. Transverse diameter of the stomach was measured on chest X-rays performed on Day 0 and on Day 1. Gastric distension was defined as a ratio (R) D1/D0 higher than 1.3 (min: 0.5; max: 4.1). Three groups were defined: Group 1 (absence of distension) R < 1.3; Group 2 (moderate distension) 1.3 ≤ R < 2.3; Group 3 (major distension) R ≥ 2.3. International criteria of the Center of Disease Control were used to define pneumonia. Appropriate statistical tests were carried out. RESULTS There were 73 women (27.9%) and 189 men (72.1%), ages ranged from 20 to 83 years (average: 59.9 years). As for gastric distension, 194 patients (74.04%) constituted Group 1, 53 (20.23%) Group 2 and 15 (5.73%) Group 3. Pneumonectomy significantly increased the incidence of gastric distension on Day 1 (P = 0.04). The side, mediastinal lymphadenectomy and personal medical past history of upper gastro-intestinal tract surgery had no statistically significant influence on the incidence of gastric distension. Univariate analysis showed that patients with gastric distension on D1 had significantly more infectious pneumonia on Day 5 (P < 0.0001): 16 (8.25%) patients in Group 1, vs 14 (26.41%) in Group 2 and 7 (46.67%) in Group 3. Furthermore, on Day 5, 33.33% (n = 8) of pneumectomies had pneumonia, against 12.18% (n = 29) of patients who had undergone another type of surgery (P = 0.01). On multivariate analysis, gastric distension was an independent predictive factor of infectious pneumonia on Day 5 (Group 3: odds ratio = 16.127 [4.267; 60 959], P < 0.0001). CONCLUSIONS We established, in our cohort of patients, a link between pneumonectomy and gastric distension on Day 1 and infectious pneumonia on Day 5. A prospective multicentre study would be desirable to verify these data.

Aim A dosimetric study comparing intensity modulated radiotherapy (IMRT) by TomoTherapy to conformational 3D radiotherapy (3D-RT) in patients with superior sulcus non-small cell lung cancer (NSCLC). Background IMRT became the main technique in modern radiotherapy. However it was not currently used for lung cancers. Because of the need to increase the dose to control lung cancers but because of the critical organs surrounding the tumors, the gains obtainable with IMRT is not still demonstrated. Material and methods A dosimetric comparison of the planned target and organs at risk parameters between IMRT and 3D-RT in eight patients who received preoperative or curative intent irradiation. Results In the patients who received at least 66 Gy, the mean V95% was significantly better with IMRT than 3D-RT ( p = 0.043). IMRT delivered a lower D2% compared to 3D-RT ( p = 0.043). The IH was significantly better with IMRT ( p = 0.043). The lung V 5 Gy and V 13 Gy were significantly higher in IMRT than 3D-RT ( p = 0.043), while the maximal dose ( D max ) to the spinal cord was significantly lower in IMRT ( p = 0.043). The brachial plexus D max was significantly lower in IMRT than 3D-RT ( p = 0.048). For patients treated with 46 Gy, no significant differences were found. Conclusion Our study showed that IMRT is relevant for SS-NSCLC. In patients treated with a curative dose, it led to a reduction of the exposure of critical organs, allowing a better dose distribution in the tumor. For the patients treated with a preoperative schedule, our results provide a basis for future controlled trials to improve the histological complete response by increasing the radiation dose.

Standards are needed to control the quality of the lungs from nonheart-beating donors as potential grafts. This was here assessed using the metabolomics 1H high-resolution magic angle spinning NMR spectroscopy. Selective perfusion of the porcine bilung block was set up 30 min after cardiac arrest with cold Perfadex®. Lung alterations were analyzed at 3, 6, and 8 h of cold ischemia as compared to baseline and to nonperfused lung. Metabolomics analysis of lung biopsies allowed identification of 35 metabolites. Levels of the majority of the metabolites increased over time at 4°C without perfusion, indicating cellular degradation, whereas levels of glutathione decreased. When lung was perfused at 4°C, levels of the majority of the metabolites remained stable, including levels of glutathione. Levels of uracil by contrast showed a reverse profile, as its signal increased over time in the absence of perfusion while being totally absent in perfused samples. Our results showed glutathione and uracil as potential biomarkers for the quality of the lung. The metabolomics 1H high-resolution magic angle spinning NMR spectroscopy can be efficiently applied for the assessment of the quality of the lung as an original technique characterized by a rapid assessment of intact biopsy samples without extraction and can be implemented in hospital environment.

Introduction Atrial arrhythmias (AA) frequently occur after thoracic surgery, and are usually transient and benign. Strokes are a rare but serious neurological complication after lung transplantation. Although their incidence is now well known, their predictive factors remain uncertain. Objective The objective of this study was to evaluate the occurrence of postoperative AA in a cohort of lung transplanted patients and their relationship with the onset of stroke. Patients, materials and methods In total, 271 consecutive lung transplanted patients between 2005 and 2014 were retrospectively studied and followed during a mean of 3.2 ± 2.4 years. The data collected included clinical features, preoperative assessment, surgical reports and clinical follow-up. All arrhythmias recorded since the transplantation were analyzed. All strokes were collected. Results Thirty-three percent of patients presented AA in the immediate postoperative period. Fifteen patients (5.5%) presented stroke after transplantation, in 13 cases of ischemic origin. For 80%, stroke occurred within the first 6 months postoperatively. Mean CHA2DS2-VASc score was 1.1. Per- or postoperative low cardiac output was found as the only independent predictive factor of stroke onset [OR 4.6; CI (1.18–17.86); P = 0.027]. Postoperative AA and CHA2DS2-VASc score were not significantly associated with stroke. Postoperative AA did not affect in-house and long-term mortality. Conclusion AA are frequent after lung transplantation and don’t affect mortality. Neither AA nor CHA2DS2-VASc score are related to the occurrence of stroke. In contrast, a perioperative low cardiac output is an independent predictive factor of stroke after lung transplantation.

Background Pneumonectomy remains a high-risk procedure. Comprehensive patient selection should be based on analysis of proven risk factors. Methods The records of 323 pneumonectomy patients were retrospectively reviewed. Multiple demographic data were collected. End points were operative mortality at 30 and at 90 days, major procedurally related complications, and cardiovascular events. Univariate and multivariate statistical analyses were performed. Results Smoking habits, chronic obstructive pulmonary disease (COPD) status, induction chemotherapy status, diabetes, and obesity had no statistical influence on short-term outcomes. After right pneumonectomy, 30-day mortality (p = 0.045) and the incidence of bronchopleural fistulas (p = 0.009) were increased. Multivariate analysis for postoperative bronchopleural fistulas discovered that right pneumonectomies are the sole risk factor (p = 0.015). Univariate analysis for postoperative atrial fibrillation showed that male gender, age 70 and older, hypertension, and dyslipidemia are risk factors. Multivariate analysis found no definite risk factor. Patients with coronary artery disease had more postoperative cardiovascular events (p = 0.003). Among patients free of coronary artery disease, COPD led to an increased 90-day mortality rate (p = 0.028). Conclusions Patients with right pneumonectomies are at increased risk. Postoperative cardiovascular events are more frequent in coronary artery disease patients. COPD is a risk factor in patients free of coronary disease.

Background Operative management of patients with persistent N2 disease after induction therapy is still debated. Methods One hundred fifty-three consecutive patients underwent pneumonectomy from January 1999 until July 2005; 28 patients (18.3%) had persistent N2 disease after induction therapy (group 1), 32 patients (20.9%) had pathologic stage N0 or N1 after induction therapy (group 2), and 93 patients (60.8%) with pathologic N2 disease underwent immediate surgery (group 3). Short-term end points were operative mortality at 30 and 90 days and major complications. Long-term end points were 5-year survival and disease-free survival rates. Results Demographics of the three groups were similar (age, sex, side of operation, type of chemotherapy, smoking status, and comorbidity such as coronary artery disease, diabetes, and chronic obstructive pulmonary disease). Thirty-day postoperative mortality was 10.7% in group 1, 3.1% in group 2 (p = 0.257), and 4.3% in group 3 (p = 0.201); 90-day postoperative mortality was 10.7% in group 1, 12.5% in group 2 (p = 0.577), and 9.7% in group 3 (p = 0.558). Incidence of major postoperative complications was similar. Five-year survival rate was 32.2% (median, 28 months; 95% confidence interval, 7 to 43) in group 1, 34.8% (median, 27 months; 95% confidence interval, 7 to 47) in group 2 (p = 0.685), and 12.4% (median, 15 months; 95% confidence interval, 11 to 19) in group 3 (p = 0.127). No statistical difference was found in terms of 5-year event-free survival, or regarding the side of pneumonectomy. Conclusions Our results suggest that pneumonectomy is justified in patients with persistent N2 disease after induction chemotherapy.

OBJECTIVES The management of pIIIA-N2 non-small-cell lung cancer (NSCLC) is still controversial. In particular, there are wide variations in overall survival (OS), suggesting the existence of subgroups among N2 patients. We aimed to evaluate the prognostic value of microscopic pN2 in NSCLC. METHODS Between 1996 and 2015, the data from all 982 pathologically stage IIIA-N2 patients who underwent surgery with curative intent for NSCLC were retrospectively reviewed. Microscopic pN2 disease was defined as a nodal metastasis ranging from 0.2 to 2 mm in size. RESULTS With a median follow-up of 17 months (2-101), the 5-year OS for the whole cohort was 31%. Microscopic N2 was observed in 309 (31.5%) patients. Microscopic N2 was associated with better median OS compared with macroscopic N2 [42 months (95% CI 36.85-47.15) vs 23 months (95% CI 19.7-26.29), P < 0.0001, with a corresponding 5-year OS rate of 39 and 21%, respectively]. In multivariate analysis, microscopic N2 remained a favourable independent prognostic factor [HR 0.681 (95% CI 0.481-0.967), P = 0.03]. The median OS of microscopic N2 patients who benefitted from simple follow-up was significantly better than those who underwent chemotherapy, radiation therapy or both [43 months (95% CI 24.22-61.78) vs 22 months (95% CI 17.43-26.47) vs 31 months (95% CI 27.66-34.34) vs 16 months (95% CI 14.6-17.4), P = 0.008]. CONCLUSION Microscopic N2 seems to be associated with better prognosis in patients with pIIIA-N2 NSCLC and these could benefit from a simple follow-up. Prospective cohort studies are necessary to confirm these preliminary results.

Following lung transplantation, bronchial healing is one of the main factors contributing to a good functional result. We aimed at identifying factors influencing bronchial healing following lung transplantation. We conducted a historical study from 2004 to 2014 in our center including all lung tranplantations. Demographic characteristics of recipients and donors, immunosuppressive regimens, and surgical technique for anastomosis were studied over time. Bronchial complications with clinical impact were recorded: bronchial dehiscence, hemoptysis and death, fistula and prolonged air leak, need for surgical repair, stenosis and need for repeated dilations. We recorded 262 lung transplants (211 bilateral and 51 single lung procedures). Overall, 18% of recipients presented with bronchial complications; in the latter, 8 patients died from hemoptysis. We found no difference inbetween the recipients, the donors, or lung ischemia. After 2009, the switch of immunosuppressive regimen to basiliximab/tacrolimus/mycophenolate/steroids resulted in a significantly increased number of bronchial complications (25%;p=0.03). From 2011, the surgical technique was modified to a wedge resection on the bronchius intermedius before anastomosis resulting in a significant decrease of bronchial complications (12%;p=0.02) though using the same unmodified immunosuppressive regimen. Overall, patients with primary graft dysfunction (n=74) presented with more bronchial complications (p=0.03) Primary graft dysfunction is a favoring factor for bronchial complications.The modified surgical technique enabled us to significantly decrease the negative impact of immunosuppressive regimen on bronchial healing.

OBJECTIVES: Multimodal management of N2 non-small-cell lung cancer is still a matter of debate. In particular, the place of surgery for persistent N2 after induction treatment is controversial and surgery is usually reserved for patients experiencing a mediastinal downstaging (pN1 and pN0). We aimed to evaluate whether there might exist subgroups of pN2 according to the lymph node ratio (LNR). METHODS: Between 1996 and 2012, we retrospectively reviewed the data from 152 potentially resectable cN2 patients who underwent an induction treatment before surgery. RESULTS: The median follow-up time was 32 months (2–112). The average age at the time of diagnosis was 58.52 ± 10.47 years. In univariate analysis, overall survival (OS) was significantly influenced by extracapsular spread (32 ± 5.33 vs 24 ± 12.73 months, P= 0.01), pN after surgery (65 ± 2.45 months for pN0, 44 ± 2.14 months for pN1 and 19 ± 1.72 months for pN2, P

Background Atrial arrhythmias (AA) are observed frequently early after lung transplant and also late after the surgery. Several predictive factors of post-operative AA after lung transplant have been already identified whereas those of late AA are still not known. Whether AA after lung transplant impacts mortality and the optimal strategy of rhythm management are still debated. The Purpose of the study was to assess in a large cohort of lung transplanted patients the incidence of AA early and late after surgery, their predictive factors and their impact on mortality. Methods and results We included 271 consecutive patients single or double lung-transplanted over a 9-years period in a large French center. We collected baseline clinical, surgery and post-operative data. The follow-up was 2,9±2,4 years. 33% patients developed post-operative AA. Age (HR=2,35; CI [1,31-4,24]) and chronic obstructive pulmonary disease (HR=1,028; CI [1,12-4,03]) were independant predictive factors of post-operative AA. Late AA occurred 2,2±2,7 years after transplant in 8.8% of the patients. Systolic pulmonary arterial pressure was the only independent predictive factor of late AA (HR=1,028; CI [1,001; 1,056]). Double lung transplant was associated with long term freedom from AF compared with single transplant (p=0,05) whereas the Kaplan-Meier curve for the development of late atrial flutter was similar in single and double lung transplant. Early and late AA after surgery showed no impact on mortality. Bilateral lung transplant was associated with a better survival. Conclusion Post-operative AA after lung transplantation are common with good outcome and contrast with the low occurrence of late organized AA. Double lung transplantation protects against AF but not AFL. Underlying electrophysiological mechanisms may explain these observations. Predictive factors of early and late AA after transplantation are different. Nevertheless these AA do not impact mortality after lung transplant (figure next page). Download : Download high-res image (108KB) Download : Download full-size image Abstract 0376 – Figure: Survival free of late AF and AFL by transplant

International audience; OBJECTIVES: Resection of pulmonary metastases originating from colorectal cancer is increasingly considered. While several adverse risk factors for long-term outcome are known, the selection of patients who may benefit from surgery remains unclear. In particular, few studies have addressed the impact of lymph node involvement, and signification of the hilar or mediastinal level of extent. METHODS: We retrospectively reviewed the data of 320 patients operated in two thoracic departments between 1992 and 2011. Appropriate statistical tests were used to compare groups at risk. RESULTS: There were 105 women and 215 men with a mean age of 63.3 years (range: 27–86) at the time of metastasectomy. Lymph node involvement appeared as a significant prognostic factor in both the univariate and multivariate analyses [median survival: 94 months N0 vs 42 months N+, P < 0.0001; OR = 0.573 (0.329–1), P = 0.05]. Survival was similar for hilar and mediastinal locations (median survival: 47 months vs 37 months, respectively, P = 0.14). Associated hepatic metastases had a negative impact on survival in both univariate and multi-variate analyses [median survival: 74 months vs 47 months, P < 0.01; OR = 0.387 (0.218–0.686), P = 0.001]. Multiple lung metastases significantly decreased survival in univariate analysis only (median survival: 81 months vs 55 months, P < 0.01). Disease-free survival and preoperative carcinoembryonic antigen had no impact on survival. CONCLUSIONS: While lymph node involvement was associated with decreased survival, the impact of mediastinal location on survival did not differ from that of hilar location. Consequently, these patients should not be excluded from surgical treatment.

Sir, It is with great interest that we read the letter entitled ‘KRAS and BRAF mutations are prognostic biomarkers in patients undergoing lung metastasectomy of colo-rectal cancer. Variation in survival associated with proto-oncogenes is not evidence for effectiveness of metastasectomy'. In their comment on the prognostic value of proto-oncogenes in lung metastasectomy of colo-rectal cancer (CRC) (Renaud et al, 2015), Cardillo and colleagues stated that ‘no difference in survival attributable to surgical removal of lung metastases has been shown in a control trial' and reached the conclusion on ‘the doubt on effectiveness of metastasectomy in colorectal cancer' (Cardillo et al, 2015). However, as stated by the authors, no randomised controlled trial has shown a survival benefit for follow-up compared with surgery. The very large majority of the published series shows that in metastatic CRC, medical treatment alone leads to poor overall survival (OS) (Rooney et al, 2015), while surgery leads to 5-y OS up to 70% (Riquet et al, 2010; Hawkes et al, 2012; Renaud et al, 2014). At this point a word of caution is essential and we would like to emphasise several points that we consider to be important. First, we agree that patients who underwent surgery were highly selected. However, the proper selection of candidates for surgery is the basis of surgical oncology. As an example, stereotactic ablative radiotherapy and radiofrequency are offered as alternatives to surgery in resectable NSCLC unfit for surgery, since poor medical condition is associated with worse outcomes (Boily et al, 2015; Dupuy et al, 2015). Consequently, the doubt of hyperselection can be applied to all the fields of surgical oncology. Second, the authors relevantly stated that ‘the study shows the influence of oncogenes on survival but these are likely to be general prognostic factors'. They are right! Our aim was to identify new prognostic factors. Indeed, despite known prognostic factors, there are wide variations of OS among patients after metastasectomy of CRC. It seems that, from the primary CRC tumour, the molecular status could predict the course and the aggressivity of CRC (Renaud et al, 2015). Consequently, molecular markers might help to a better selection of patients, from the primary CRC surgery. In addition, we further think that molecular analysis could be even more helpful. Indeed, it seems that KRAS specific amino-acid substitutions is associated with different activations of downstream effectors, which can induce different behaviours (Garassino et al, 2011; Ihle et al, 2012; Izar et al, 2014; Nadal et al, 2014). In particular, in CRC cell lines, KRAS G12V is known to overexpress CXCR4, implied in metastasis process, promoting higher aggressivity (Alamo et al, 2015). These interesting preliminary results may lead in the future to a molecular prognostic classification, which may help to select the best patients for surgery. Third, in the meta-analysis of Gonzalez et al (2013), CEA remained significant in multivariate analysis in only 9 out of 19 selected studies. Furthermore, CEA only reflects the total tumour mass. On the other hand, the absence of impact of disease free survival in our work probably reflects the proper selection of patients. Fourth, meta-analyses cited by the authors, such as the latest one, does not add supplementary reflexion to our discussion (Gonzalez et al, 2013). Indeed, it only identifies four risk factors of poor outcome, which have been included in our analysis. Fifth, CEA second look trial recruited patients who were randomised between surgery and follow-up according only to CEA elevation (Treasure et al, 2014). Obviously, this study cannot be generalised to lung metastasectomy of CRC: (1) patients with extra-abdominal recurrence were excluded, and different regimen of peri-operative treatment were used; (2) the use of CEA alone may have probably led to the inclusion of patients without recurrence, for whom surgery was futile. Indeed, patients were included in case of CEA >10 ng ml−1. However, when

Study design To determine the long-term results after surgical treatment of bronchioloalveolar lung carcinoma (BALC) and to identify prognostic factors. Patients and methods A retrospective study of 70 patients (49 men, 21 women), mean age 61 ±10 years, was carried out. Their carcinomas were classified into three clinicopathologic types: nodular or tumoral, pneumonic, and diffuse types. All the diagnosed BALC cases were reviewed and were classified into histologic types: mucinous, nonmucinous (including fibrotic center), and mixed tumors. Univariate and multivariate analyses were carried out. Results The nodular or tumoral type was identified in 42 patients, pneumonic in 21, and diffuse in seven. Histologically, there were 36 mucinous, 25 nonmucinous, and nine mixed tumors. Resection was complete in 61 instances (87%) and incomplete in five. The 5-year survival rate was 34% in patients with curative resections. Five prognostic factors were identified by univariate analysis, but in multivariate analysis, only three factors remained significant: the absence of symptoms, the TNM stage, and completeness of resection. Thirty-six patients with curative resection (59%) developed recurrences (in the lung in 26 patients; mediastinal lymph nodes, four; distant metastases, nine). The frequency of recurrence was significantly greater in patients with pneumonic-type BALC than in nodular or tumoral types (p Conclusions This study confirmed that the overall prognosis of BALC is not significantly different from that of the other non-small cell lung cancers. We found that the lungs are the predominant site of recurrence in BALC, especially in the pneumonic types. The complete surgical resection of localized BALC offers the best chances of long-term survival.

Trichosporon mycotoxinivorans is a novel pathogen recently found in cystic fibrosis patients. We report the first case of a disseminated fatal infection with T. mycotoxinivorans associated with invasive Aspergillus fumigatus and Scedosporium apiospermum infection after lung and liver transplantation in a cystic fibrosis patient.

Summary The aim of this study was to assess the functional preservation of the lung graft with anterograde lung perfusion in a model of donation after cardiac death. Thirty minutes after cardiac arrest, in situ anterograde selective pulmonary cold perfusion was started in six swine. The alveolo-capillary membrane was challenged at 3, 6, and 8 h with measurements of the mean pulmonary arterial pressure (mPAP), the pulmonary vascular resistance (PVR), the PaO2/FiO2 ratio, the transpulmonary oxygen output (tpVO2), and the transpulmonary CO2 clearance (tpCO2). Mitochondrial homeostasis was investigated by measuring maximal oxidative capacity (Vmax) and the coupling of phosphorylation to oxidation (ACR, acceptor control ratio) in lung biopsies. Inflammation and induction of primary immune response were assessed by measurement of tumor necrosis factor alpha (TNFα), interleukine-6 (IL-6) and receptor for advanced glycation endproducts (RAGE) in bronchoalveolar lavage fluid. Data were compared using repeated measures Anova. Pulmonary hemodynamics (mPAP: P = 0.69; PVR: P = 0.46), oxygenation (PaO2/FiO2: P = 0.56; tpVO2: P = 0.46), CO2 diffusion (tpCO2: P = 0.24), mitochondrial homeostasis (Vmax: P = 0.42; ACR: P = 0.8), and RAGE concentrations (P = 0.24) did not significantly change up to 8 h after cardiac arrest. TNFα and IL-6 were undetectable. Unaffected pulmonary hemodynamics, sustained oxygen and carbon dioxide diffusion, preserved mitochondrial homeostasis, and lack of inflammation suggest a long-lasting functional preservation of the graft with selective anterograde in situ pulmonary perfusion.

This review describes diagnosis and management of sequelae of post-primary tuberculosis. It addresses elementary lesions such as bronciectasis, fibrostenosis, cavitation and broncholithiasis, the more complex situation of destroyed lung, and complications such as aspergilloma, hemoptysis and broncho-esophageal fistula.

Extracorporeal membrane oxygenation (ECMO) is used for refractory respiratory failure. Normally, ECMO is implanted in intubated patients as a last resort. We report the case of a non-intubated patient who benefited from veno-venous (VV) ECMO. A 35-year old cystic fibrosis man presented a severe respiratory decompensation with refractory hypercapnia. We opted for an ECMO instead of mechanical ventilation (MV). We implanted a double lumen bi-cava cannula (DLC) (Avalon Elite(TM)) in the right jugular vein. Before ECMO implantation, the patient presented refractory respiratory failure (pH = 7.1, PaO(2) = 83 mmHg, PaCO(2 )= 103 mmHg). We proposed that the patient be placed on the high emergency lung transplantation waiting list after failure to wean him from ECMO. This registration was effective 10 days after ECMO implantation. The patient was grafted the next day. Under ECMO, mean PaO(2), PaCO(2) and TCA were 80.6 ± 14.2, 53.8 ± 6.4 mmHg and 56.2 ± 9.7 s, respectively. The patient could eat, drink, talk and practice chest physiotherapy. The evolution was uneventful under ECMO. Weaning from ECMO was done in the operating theatre after transplantation. VV ECMO with DLC is safe and feasible in non-intubated patients. It avoids potential complications of MV, and allows respiratory assistance as bridge to transplantation.

Objective: Epidural analgesia is the gold standard for post-thoracotomy pain relief but is contraindicated in certain patients. An alternative is paravertebral block. We investigated whether ropivacaine, administered through a paravertebral catheter placed by the surgeon, reduced postoperative pain. Methods: In a randomized double-blind study, adult patients with a paravertebral catheter placed by the thoracic surgeon after thoracotomy were randomly assigned to receive through this catheter, either a 0.1 ml kg 1 bolus of 0.5% ropivacaine, followed by a continuous infusion of 0.1 ml kg 1 h 1 for 48 h, or saline at the same scheme of administration. Patients also benefited from patient-controlled analgesia with intravenous morphine (bolus 1 mg, lockout time 7 min), paracetamol, and nefopam. The primary endpoint was pain intensity on a visual analog scale at rest and on coughing. Secondary endpoints were total morphine consumption and side effects during the first 48 postoperative hours. Surgeons, anesthesiologists, and all the nurses and caring staff involved in this study were blinded. Solutions of saline and ropivacaine were prepared identically by the central pharmacy, without any possible identification of the product. Results: Forty-seven patients with contraindications to epidural anesthesia were included. There were no significant differences between the groups receiving ropivacaine and salineintermsofpainseverityatrestandoncoughing,meanpostoperativemorphineconsumption(45.7 mgforropivacaine,43.2 mgincontrols), and incidence of morphine-related side effects (nausea and vomiting, urinary retention, pruritus, respiratory rate, and sedation). Conclusions: Paravertebral block using a catheter placed by the thoracic surgeon was ineffective on postoperative pain after thoracotomy and did not confirm the analgesic effect that has been observed after percutaneous catheter placement. A direct comparison of these two placement methods is required.

The Port-a-cath (PAC) is a catheter totally implanted under the skin. It is commonly used in oncology for permanent venous access. It provides a more simple way to infuse chemotherapies, antibiotics or parenteral nutrition, while offering improved comfort to patients. The usual complications of these devices (infections and catheter obstructions) are well documented. More exceptional events are catheter fractures with systemic migration, and endopleural perfusions due to a wrong positioning of the catheter. Since 1998, 10 cases of mediastinal infusion of cytotoxics have been reported. Surgical management was necessary in only two cases. We are reporting the case of a 57-year-old female suffering from a multimetastatic sigmoid adenocarcinoma. A mediastinal infusion of Folfiri and bevacizumab with a tracheal necrosis complicated the PAC use and required a latissimus dorsi myoplasty to fill up the tracheo-bronchial defect.

Purpose INSPIRE Trial is an international, FDA pivotal trial to assess the clinical efficacy and safety of OCS™ device to preserve, recruit and assess the donor lungs for transplantation as compared to current cold storage technique. Methods and Materials INSPIRE is a prospective, international, multi-center, randomized controlled trial comparing preservation of donor lungs using OCS-Lung perfusion device (Treatment Group) to Cold flush and storage (Control Group). A total of 264 primary lung transplant recipients will be randomized into the trial. Donor Inclusion Criteria: age Results Primary study endpoint is a composite of patient and graft survival at day 30 post transplantation, and incidence of ISHLT Primary Graft Dysfunction (PGD) Grade 3 at 72 hours post-transplantation. Secondary Endpoints: Incidence of ISHLT Primary Graft Dysfunction Grade 3 at 72 hours post-transplantation; Incidence of ISHLT Primary Graft Dysfunction Grade 2 or 3 at 72 hours post-transplantation; Patient survival at day 30; Graft survival at day 30. Other Endpoints: PGD score at T0, T24, and T48 hours; duration of invasive mechanical ventilation; length of post transplant ICU stay; length of post-transplant hospital stay; & additional hospital admission post initial discharge. Conclusions To-date 60 patients were transplanted in the trial. We will report the interim results at the late breaking clinical trial session at ISHLT 2013.

Aims Retrospective, monocentric analysis of localized superior sulcus non-small cell cancer (SS-NSCLC), article management. Materials and methods Between 2000 and 2010, 42 patients have been treated for a SS-NSCLC. Median age was 54.7 years (34.5-86.8). Nineteen tumors (45.2%) were stage IIB, 18 were stage IIIA (42.9%) and 5 were stage IIIB (11.9%). Twenty-two patients were treated by pre-operative radiotherapy or chemoradiotherapy, 20 received exclusive radiotherapy or chemoradiotherapy. Preoperative and exclusive median radiotherapy doses were 46 Gy (40–47 Gy) and 51.8 Gy (40–70 Gy), respectively. All patients treated with chemotherapy received at least platinum. Mean follow up was 44.1 months (0–128 months). Results Local, loco-regional and metastatic relapses occurred in 11 (26.2%), 2 (4.8%) and 15 patients (35.7%), respectively. Most common metastatic site was cerebral (7 patients, 46.7%). Median disease-free survival (DFS) was 9.7 months (8.9-10.4). One-, 2- and 5- years DFS rates were 44%, 33% and 26.5%, respectively. No prognostic factor was identified. Median overall survival (OS) was 22.6 months (10.4-34.8). One-, 2- and 5- years OS rates were 61.9%, 44.9% and 30.1%, respectively. Univariate prognostic factors for OS were WHO (p = 0.027) and tumoral response (p = 0.05). In multivariate analysis, independent favorable prognostic factors were WHO 0–1 (p = 0.017; OR = 0.316 [CI95% 0.123-0.81) and complete response to treatment (p = 0.035; OR = 0.312 [IC95% 0.106-0.919]). Conclusion This study highlighted that a good performans status and complete response to treatment are independent factors of OS, whatever the delivered treatment. Brain was the most common metastatic relapse site.