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Resumen Es necesario el conocimiento de la anatomia y de los accesos quirurgicos del desfiladero cervicotoracico para la practica de la cirugia cervical, por razones de seguridad vinculadas con la posibilidad de una hemorragia de un gran vaso de la base del cuello no controlable por via cervical pura y tambien para mejorar la calidad de una exeresis tumoral, o simplemente hacerla posible. Se podran elegir varios accesos segun las indicaciones y la eventual urgencia intraoperatoria. Manubriotomia simple o asociada a una linea divisoria horizontal que permite un acceso mas amplio sobre el mediastino anterior y superior, ante una urgencia vascular o para extirpar un bocio intratoracico. Desinsercion del manubrio, del tercio anterior de las claviculas y del extremo anterior de las primeras costillas, en caso de que se afecten las estructuras oseas y sobre todo ante la necesidad ocasional de constituir un traqueostoma bajo.

In lung or heart-lung recipients, an irreversible graft-failure may develop in connection with chronic rejection, infection or bronchial complications. A limited number of transplant-recipients have undergone a retransplantation procedure in several centres. First results are discouraging, especially in the case of early retransplantation. We decided, 3 yrs ago, to evaluate the feasibility and benefits of single-lung retransplantation in lung-transplant recipients with late graft-failure. Eight consecutive single-lung retransplantations were performed in patients with previous single-lung (n = 7), or double-lung (n = 1) transplant. Primary graft and native lung were removed in 5 and 3 patients, respectively. The delay between the two surgical procedures was 16 +/- 10 months (range 6-37 months). Three patients died within 3 months. Long-term survivors experienced stable and satisfactory functional results (forced expiratory volume in one second (FEV1 63 +/- 21% predicted; range 40-103% predicted), with survival values ranging 8-20 months. One patient died of septic shock 16.5 months after retransplantation. The remaining four patients are alive. These data suggest that the retransplantation option could be considered in selected patients with late graft-failure. The final decision for retransplantation, however, is largely influenced by the current shortage of donor lungs.

Surgery for pulmonary emphysema, with the exception of lung transplantation, is limited at present to resection of the emphysematous areas. The resection of a unique bulla within an otherwise healthy parenchyma can be indicated in case of complications but rarely in asymptomatic patients. When the bullae are large (i.e. volume greater than one-third of the hemithorax) in a patient suffering from diffuse emphysema, bullectomy is the ideal indication. Mortality varies from 0 to 10%, essentially due to infection or acute respiratory failure. In most patients, the subjective improvement in terms of dyspnea and the objective improvement as measured by spirometry remains significative up to 5 years after surgery. Inversely, surgical resection is classically considered to be contraindicated in patients with small poorly-limited bullae. Recent data would however question this idea since subjective and objective improvement after reduction of the lung volume is still present 1 year after surgery in most patients, even those with severe obstruction. The mechanism is probably related to increased elastic recoil. Even if only temporary improvement can be achieved for a few years, the persisting course of emphysema would suggest that volume reduction should always be entertained as an alternative before lung transplantation.

Primary hyperhidrosis of the upper limbs has an important impact on the subject's social and psycho-affective equilibrium. These patients have two main problems. First physicians are not sufficiently aware of the therapeutic possibilities and secondly the generally poor reputation of surgery in this indication. Transthoracic endoscopic sympathectomy has completely changed the treatment of hyperhidrosis of the upper limbs. It is now considered to be the reference treatment in severe cases. The surgical procedure is simple and allows simultaneous treatment of both sides. There is no mortality and morbidity is extremely low quantitatively and of little consequence qualitatively. The therapeutic protocol is short and immediate and long-term results are excellent in 98 to 100% of the patients.

The surgical approach to affections of the chest wall and pleura, still the predominant indications for thoracic surgery, has greatly changed since the advent of thoracoscopic procedures, and is emphasized in this second part of a two-part review, together with other indications for mediastinal tumours. Indicated after lung exeresis or emergency chest surgery, protective chest wall reconstruction with muscular flaps is no longer an exceptional operation. Inversely, thoracic surgery for infectious complications have become less frequent, unusually limited to well established procedures for tuberculosis surgery, treatment of bronchial fistula or mediastinal supperations. The chest cavity is well adapted to new techniques of thoracoscopy and video-assisted thoracic surgery both for diagnosis and treatment. Indications for pleuroscopy have taken on a completely new aspect since 1989. These techniques are used for pericardial fenestration, thoracic sympathectomy for dyshidrosis, vagotomy, splanchnicectomy, chylothorax, spinal affections, empyema and trauma surgery. These new techniques have also had an impact on treatment of spontaneous pneumothorax. For tumour surgery, thoracoscopy has made possible a more adapted strategy currently based on an initial needle biopsy, with limited thoracoscopic exeresis and ultimate treatment depending upon the pathology report. Immediate thoracoscopy without prior biopsy appears excessive. Video-assisted thoracosurgery is also used for most malignant mediastinal tumour which, due to advances in chemotherapy surgery have transformed the prognosis of a large number of mediastinal tumours.

The immunohistochemical profile of mucosal lymphocytes was investigated in the central airways of lung transplant recipients. Bronchial and transbronchial biopsies (BB and TBB, respectively) and bronchoalveolar lavage for culture of bacteria and viruses were performed during a fibroscopic procedure in patients without evidence of chronic rejection, 3 to 10 mo after surgery. Analysis was restricted to samples without concurrent airway infection: 23 pairs of BB and TBB from 18 transplant recipients were analyzed. An immunohistochemical technique was used to identify and score mucosal cells that reacted with monoclonal antibodies against CD4, CD8, CD45-Ro (memory T-cells), and HLA-DR molecules. The same procedure was applied in nine nonsmoking control subjects (NS group). Data from transplant recipients were allocated to R+ (n = 11) or R- groups (n = 12), depending on the presence or absence of histologic evidence of acute rejection on TBB. A statistically significant depletion of every immunoreactive cell subset was observed in the R+ and the R- groups, but not in the NS group. Conversely, no significant difference for either score of immunoreactive cells were found between R+ and R- groups. The immunosuppressive regimen is suspected to play to play a major role in this depletion of bronchial mucosal T-cells. The acute lung rejection process does not appear to affect concurrently the immunohistochemical profile of immunoreactive cells in the bronchial mucosa.

Bronchiolitis obliterans is an anatomical lesion with multiple aetiologies. In the lung transplant patient the pure forms of bronchiolitis obliterans are probably the consequence of a process of chronic rejection; in fact necropsy tissue or lungs removed which have been transplanted show that the lesions of bronchiolitis obliterans are often associated with parenchymal disorders, vascular and proximal bronchial disease, which are sequelae of phenomena of rejection or infection. The effect of bronchiolitis obliterans on lung function is constant; this may appear progressively or in stages. Increasing immunosuppressive treatment may arrest the progress. This rarely occurs and the development of respiratory failure tends to be the rule. It is exceptional to achieve the diagnosis of bronchiolitis obliterans from the examination of a transbronchial biopsy. It is a combination of features, both clinical and respiratory function, negative bacteriology and virological investigations as well as the absence of any efficacy of conventional treatment for rejection which leads to the diagnosis. In certain cases the question of a pulmonary re-transplantation is raised.

Infected median sternotomy often requires open wound management. A large thoracic defect usually results in subsequent exposure of heart, great vessels, aorto-coronary bypass grafting or vascular prosthesis. After thorough wound debridement, coverage with muscle transposition was carried out in a series of 167 cases observed over a period of 10 years. Transposition of both pectoralis major muscles on internal pedicles was performed in 75 cases. In 27 of these cases, internal mammary grafting did not preclude their use. Since 1986, intrathoracic transposition of the trapezius muscle has been our treatment of choice in 25 cases, most frequently combined with a double pectoralis major transposition. Rectus abdomini muscle flap was seldom used alone whereas latissimus dorsi was mainly used as a salvage flap. Muscle transposition provided effective heart and great vessel protection after acute hemorrhage in 18 cases. This series confirms that mortality and mean hospital stay have decreased dramatically since the routine use of muscle transposition.

Combined vertebral artery and carotid artery surgery may be performed in patients with proximal subclavian or vertebral artery stenosis provided that general anesthesia is not contraindicated? Others indications may be considered in patients with proved arterial thrombo-embolism or in patients for whom arteriography, cerebral angioscintigraphy and ultrasound velocimetry enable the physician to suspect a cerebral low flow and the lack of collateral pathways between the posterior and anterior cerebral system.

Because of the rarity of adrenocortical carcinoma, survival rates and prognosis for patients who have undergone operation are not well known. The purpose of the French Association of Endocrine Surgery was to evaluate these factors in all patients treated during a 12-year period by its members.One hundred fifty-six patients (95 women, 61 men) with a mean age of 47 years were included. Functional symptoms were found in 52% of patients, and hormonal studies revealed secreting tumors in 62% of cases. Ninety-four percent of the patients underwent resection of the adrenal tumor, and 20% of them had extensive resection because of invasive cancers. Complete resection was achieved in 127 patients (81%) and incomplete resection in 29 patients. Mean tumor weight was 714 gm (range, 12 to 4750 gm), and the mean diameter was 12 cm (range, 3 to 30 cm). The results of the tumor staging were stage I, eight patients (5%); stage II (local disease), 75 patients (48%); stage III (locoregional disease), 39 patients (25%); and stage IV (metastases), 34 patients (22%).The 5-year actuarial survival rates were 34% overall, 42% in curative group, 53% in local cancer group, 24% in regional disease group, and 27% in the reoperated group. One-year actuarial survival rate of the palliative group was 9% (median survival, 6 months). Multivariate analysis showed that better prognosis occurred in patients younger than 35 years of age (p = 0.01) and in patients with androgen-secreting tumors, precursor-secreting tumors, or nonsecreting tumors (p = 0.003). Mitotane improved the survival rate only in patients with metastases who received it after operation (vs non-mitotane-treated patients [p0.05]).In this study age, extent of disease, aspect of the surgical resection, and type of hormonal secretion influenced survival.

Aneurysms of the abdominal aorta associated with periaortic fibrosis (AFPA) are a different clinicopathological entity from atheromatous aneurysms and nonspecific inflammatory periaortitis. The physiopathology and diagnostic and therapeutic modalities for these AFPAs are controversial. Over a 12-year period, 23 aneurysms with periaortic fibrosis (4%) confirmed by a histological study were operated at Beaujon hospital. Four patients were operated at the rupture stage, 2 with acute rupture and 2 with contained chronic rupture. Uni- or bilateral ureteral obstruction was noted in 8 patients. The diagnosis was suspected preoperatively in 60% of cases. Surgery confirmed the accuracy of the anatomical information provided preoperatively by the CT examination performed in 9 patients. Debridement and grafting were performed in 22 patients. Three patients with associated ureteral obstruction were treated with ureterolysis during the same operative step at the beginning of our experience. Later on, 3 documented cases of hydronephrosis receded after the isolated debridement and grafting of the aneurysm. Hospital mortality was of 5% in 19 patients operated electively. Two patients died later, after 2 months and after 5 years, and 16 are still alive and without symptoms at present, after and average time lapse of 68 months.(ABSTRACT TRUNCATED AT 250 WORDS)

The aneurysms of the abdominal aorta requiring suprarenal clamping are rare. Suprarenal clamping was required for only 43 of 544 aneurysms operated electively from 1981 to 1989. Twenty-five patients had a juxtarenal aneurysm, without any normal aortic segment under the renal arteries, and suprarenal clamping was therefore necessary while the upper anastomosis was being established (group I). Eighteen patients had an aneurysm enclosing the root of at least one renal artery (group II). Several prognostic factors have been assessed: patient's age, presence of preoperative renal insufficiency, of arterial hypertension or of coronary insufficiency, and revascularization method. Five patients died. Four of them belonged to group II and were over 75 years old. All presented with a preoperative renal insufficiency. Two of these deaths were caused by mesenteric infarction. Four cases of regressive postoperative renal insufficiency were observed in patients for whom renal clamping had lasted longer than 45 minutes. This study allowed outlining three prognostic factors: the patient's age, preoperative renal insufficiency, a period of renal ischemia exceeding 40 minutes. On the other hand, the severity of hypertension had no predictive value. Coronary insufficiency requires a strict hemodynamic surveillance, but is not a contraindication for revascularization.

Despite improvements in the treatment of risk factors for atherosclerosis, the incidence and mortality rate for aneurysms of the abdominal aorta have increased during the past 40 years. The prevalence of these aneurysms is 2.5 percent in unselected populations but reaches 13.5 percent in selected populations. The pathogenesis of aneurysms involves multiple factors and the lesion is progressive, leading to lethal rupture in 25 percent of the cases. In elective surgery of abdominal aortic aneurysms the mortality rate is about 2 percent, as against 60 percent in emergency surgery for rupture. The presence of such aneurysms must be detected primarily in populations at risk, using physical examination and abdominal ultrasonography. If this is done, the ratio of detection costs to benefits of preventive surgery is in favour of a decidedly active approach of this dangerous disease.

The authors present the case of a patient with a carcinoid tumor of the left main bronchus. Conservative surgery by sleeve resection without pulmonary resection was performed. The underlying lung which was considered to be nonfunctioning during pre-operative evaluations, completely recovered within a year following surgery.

Ischemic damage of the gastrointestinal tract following aorto-iliac surgery was estimated in a retrospective study. Between 1984 and 1988, we observed 13 cases of intestinal ischemia from a total of 416 surgical patients (3 per cent): 7 cases of full-thickness necrosis and 6 cases of transient ischemia. They represent 23 per cent of complications in ruptured aneurysmal surgery, 2.8 per cent in elective aneurysmal surgery, and 1.6 per cent in operations for obstructive lesions. All deaths (5/13) followed necrosis. Diarrhea, sometimes bloody, was the main symptom. Its sensitivity was 70 per cent, and its specificity was 98 per cent. Leukocytosis (greater than 10000/mm3), was noted in 70 p. cent of the cases of ischemia. The diagnosis was established by colonoscopy in 7 cases and by surgical examinations in 6 cases. The endoscopic injuries were ulcerations, punctate hemorrhages, and pseudomembranes localized in the sigmoid (77 p. cent), left colon (38 per cent) and small bowel (15 per cent). Of 13 patients, 6 developed intraoperative hypotension. This study confirms the gravity of intestinal ischemia after aortic surgery. In high risk patients (ruptured aortic aneurysm, intraoperative hypotension, postoperative diarrhea) endoscopy offers the possibility of early diagnosis and appropriate treatment.

The authors report a case of intracaval leiomyomatosis diagnosed in a 11-year old female, who had been initially operated for a massive tumor of uterus (35 X 45 X 25) and who had had subtotal hysterectomy performed. The histologic diagnosis at was intravenous leiomyomatosis. Investigation of extent of neoplastic spread included echography, cavography and revealed inferior vena cava involvement. Cavotomy removed a tumor fragment. Intravenous leiomyomatosis has always its source in the uterus and spreads by progressive invasion of the vena cava. The right cardiac cavities and, at times, the pulmonary artery are also involved. Management of cardiac invasion is a determinant factor of the severity of the disease. Indication for surgery is systematic and should result in complete tumor excision.

We report six single-lung transplantations in emphysematous patients with end-stage disease. Compression of the graft or ventilation/perfusion imbalance were not observed. Rejection episodes were generally documented through transbronchial biopsies and the radiological changes related to acute infections or rejections were restricted to the transplanted lung. Three patients died from CMV pneumonia, status epilepticus and fibrosis of the graft following bronchography, respectively. The three remaining patients are well, with documented improvement of pulmonary function tests and arterial blood gases. Bronchial complications were observed in all patients and have in some cases required dilatation or insertion of a stent. Although requiring a longer follow up, single transplantation is feasible and beneficial in patients with end-stage emphysema.

In order to explore the possibility of serratus anterior muscle (SAM) flap transposition in head, neck and thoracic surgery, we performed an anatomic study including 40 dissections of the muscle's vascular pedicle, the subscapular-thoracodorsal axis, which is a branch of the axillary artery. The SAM is characterized by its location: extending from the anterior and lateral aspect of the thorax to the medial border of the scapula; its easy surgical access; its constant and reliable vascularization by the thoracodorsal artery, a branch of the subscapular artery; its long arc of rotation allowing utilization of the SAM flap in head and neck and mediastinal surgery without microvascular anastomoses; its versatility in comparison with other perithoracic muscles. These considerations prompted us to use the SAM in head and neck reconstructive surgery; chest wall surgery, including chest wall reconstruction following resection for tumor and breast reconstruction; intrathoracic and mediastinal surgery, including reinforcement of high-risk tracheobronchial sutures or anastomoses, management of bronchopleural fistulas and empyema spaces, and repair of tracheo-esophageal fistulas and tracheal or esophageal defects.

Timentin (ticarcillin + clavulanic acid) and cefamandole were compared in 484 patients undergoing elective thoracic or vascular surgery. Two hundred and forty eight patients received three 3 g/200 mg injections of Timentin and 236 patients received three 0.75 g injections of cefamandole. The patients were evaluated at discharge. Among the 248 patients given Timentin, only six (2.4%) had a post-operative infection, while nine (3.8%) of the 236 patients given cefamandole had a post-operative infection. There was no statistically significant difference between the two treatment regimes. This comparative study shows that Timentin may be used for antibiotic prophylaxis of clean vascular or thoracic surgery.

Spiramycin concentrations in lung tissue were studied in patients undergoing pulmonary surgical procedures. The first group of six patients received 500 mg spiramycin iv 16 h before surgery and 500 mg at anaesthetic induction (total 1 g). The second group of six patients received three doses of 500 mg spiramycin iv 24, 16 and 8 h before surgery, and 500 mg at anaesthetic induction (total 2 g). Samples were taken from lung tissue, pleura, fat tissue and muscle. In group 1, the mean lung tissue concentration of spiramycin was 1.15 +/- 0.14 mg/kg and 7.99 +/- 2.02 mg/kg in group 2 (P less than 0.02). The differences in concentration in pleura, fat tissue and muscle samples between treatment groups 1 and 2 were not statistically significant.

The authors review 6 cases of laryngeal trauma and 2 cases of laryngotracheal rupture which were seen after road accidents. They note that increasingly, as a result of the intervention of emergency medical ambulance teams, such injured patients are intubated at the site of the accident. Closed laryngo-tracheal rupture corresponds completely with cases described in the literature, forming a clinical picture which is a source of grave error by virtue of its latent nature. The management at the time of admission of the patient obviously is altered if intubation has already been performed, since the tube should never be removed for the purposes of clinical assessment before tracheotomy has been performed. If the patient is not intubated, the presence of respiratory distress necessitating emergency therapy reflect major lesions which therefore require surgical exploration. Rather than primary tracheotomy, the authors prefer intubation using a rigid bronchoscope which facilitates subsequent tracheotomy.

Aortic dissection continues to pose a real diagnostic problem as well as a therapeutic challenge; this condition being characterised by a high mortality rate at each step of its process. Often the surgeon forgets that he sees only patients already diagnosed.

The authors report 16 cases of cervical esophagus injuries. In two patients, they followed a closed injury to the neck, in six cases, wounds from firearms or other weapons. In five cases, tracheal intubation, and in three cases, perforations of various origins. All patients required operative treatment, and in six cases surgery was performed between the 3rd and 25th day following the injury. Only one of the 8 patients operated upon within 12 hours following injury developed cervicomediastinal complications, while seven of the 8 cases operated upon after this period developed mediastinitis or a fistula. Radiological examination with an opaque medium and urgent operation combining drainage and suture are essential when injury to the esophagus is suspected, in order to obtain early diagnosis and good results.

A new familial case of the Romano-Ward syndrome in a young girl of 21 years is reported. A progressive worsening of the condition with multiple syncopal attacks, together with difficulty in controlling the patient, lead us to carry out a left stellate ganglionectomy. The operation did not lead to any shortening of the QT interval. It appeared in the end that propranolol was the most effective way of preventing the syncopal attacks.

Hemophilia A was detected in a 40-year-old black Gabonese female prior to thoracic surgery for empyema. The diagnosis of mild hemophilia A was supported by the findings of low factor VIII coagulant activity (VIII:C 4%), normal levels of factors VIII related antigen (VIIIR:Ag) and VIII von Willebrand (VIIIR:WF), without detectable circulating anticoagulant. Neither the patient nor her immediate relatives had past histories of abnormal bleeding. The physical features were phenotypically female with developed breasts, pubic hair and normal external genitalia: however, she had primary amenorrhea, a blind vagina with no uterus and her karyotype was 46,XY. These findings are consistent with the diagnosis of testicular feminization thereby explaining the apparent contradiction between the phenotype and the known six-linked inheritance of hemophilia A. In addition to factor VIII deficiency a low level of factor XII (20%) was detected although it cannot be concluded whether the patient is truly factor XII deficient or whether she represents a low variant of the normal distribution.

The subject of whether an optimal duration of prophylactic antibiotic therapy exists was evaluated by comparing results of short and medium-term treatment in aseptic surgery during a double-blind, randomized, prospective trial in 507 patients undergoing vascular or thoracic operations. Patients were randomly allocated to receive either 3 injections of cefamandole: at induction of anesthesia and after 4 and 10 hours (251 cases) or 8 injections of the same antibiotic: at induction of anesthesia, after 4 hours and then every 6 hours up to 40 hours (256 cases). Evaluation on discharge showed that among the 251 patients receiving 3 injections, 21 (8.33%) were infected while in the group treated with 8 injections (256 cases) 25 (9.8%) were infected. The X2 was 0.25 and there is a lack of statistically significant difference between treatments. Duration of prophylactic antibiotic therapy can be shortened, without loss of efficacy in thoracic or vascular aseptic surgery, to reduce selection of resistant germs and to lower costs.

The authors report a case of adventitial cyst of the abdominal aorta. This would seem to be the first time that a cyst has been reported in the literature with this localization. A 54 year old female patient was treated surgically for a suspected aneurysm of the abdominal aorta. Her antecedents included syphilis treated with bismuth. The condition began with a lumbago with no clearly defined etiology. An abdominal X-ray without preparation visualized a calcified abdominal tumor in a retroperitoneal position, apparently attached to the aorta. Arteriography showed that the tumor was excluded from the circulation. Surgical exploration of the aorta demonstrated a cystic tumor, which was resected. A review of the literature concerning the pathology of arterial cysts shows no previous cases of aortic cyst. On the other hand, references to identical anomalies of the iliac, femoral, popliteal and radial arteries provide grounds for discussion of the etiology of this aortic disease. The macroscopic data and histological studies suggest a phenomenon of cystic degeneration rather than a constitutional anomaly of the artery, or, in this particular case, an anomaly connected with syphilitic lesions.

Since 1969, in a study of 100 patients hospitalized for severe caustic ingestion meeding intensive surgery, the authors have found 9 cases of critical tracheo-bronchic burns characterized by necrotic lesions. Those lesions constitute a severe complication (6 deaths amongst 9 patients) thus the obsolute necessity of precocius and repeated tracheobronchic fiber endoscopies. In case of an ulcerating or pre-splitting aspect appearing in localised necrotic lesions, the authors preconise in emergency a tracheobronchic plasty using a lung patch. Other treatments are discussed.

The value of the information provided by mediastinoscopy or cervical mediastinotomy was evaluated in 150 cases by means of tests measuring diagnostic efficiency with calculated agreement coefficient. An accurate histological diagnosis was made in 100 out of 116 mediastinal syndromes (adenopathy, mediastinal or paramediastinal tumors). In cases with negative results exploratory surgery is required. The operability of bronchial carcinoma was assessed in 34 cases selected for their location and radiological extension. A negative mediastinoscopy makes it very unlikely that an inoperable cancer will be found. In bronchial carcinoma, mediastinoscopy is recommended whenever the risk attending excision of a tumor with lymph node involvement is to be weighed against the high operative risk in a debilitated patient. The usefulness of these exploratory procedures is enhanced by anterior mediastinotomy in cases with anterior tumor and in some left-sided bronchial cancers.

Tracheo-bronchial ruptures are serious complications of thoracic trauma. The authors report their experience of 18 cases: 3 tracheal ruptures, 3 tears in the tracheal or bronchial membrane, 11 unilateral bronchial ruptures and 1 bilateral bronchial rupture. Diagnostic endoscopy was performed immediately in 9 cases, with a delay of 2 to 3 days in 6 cases and with a longer delay (15th, 23rd and 25th days) in 3 cases. The treatment was non-operative in the 3 cases with membranous tears. The other patients were operated by resection of the contused area and end-to-end anastomosis of the ruptured extremities: within 24 hours following the diagnosis in 10 cases, and after a delay in the 5 other cases. The post-operative course was uncomplicated in 13 cases; 1 patient developed a bronchial stenosis requiring pneumonectomy and 4 patients died, including 2 from infective lesions due to delay in the diagnosis.