Biomedical subjects
Publications and source records attributed to R Latreille.
A 42 year-old man was referred to surgery because of a symptomatic posterior mediastinal mass. Ablation was successfully performed via a video-thoracoscopic procedure avoiding a thoracotomy. The post-operative diagnosis was a bronchogenic cyst, as was the pre-operative diagnosis. The technical details are discussed.
A 58-year-old man underwent sequential bilateral lung transplantation. On the donor heart-lung block, it was discovered that the right apical segment was supplied by a tracheal bronchus. After the separate implantation of both lungs, a right apical segmentectomy was performed and the postoperative course was uneventful. The management of this problem is discussed.
We report two cases of pleural effusion in which a subdiaphragmatic cause was noted. In both cases it was necessary to obliterate a defect in the diaphragm via a thoracic incision. In one case, a left chylothorax occurred in a patient with hepatic cirrhosis. In this case, it was postulated that the normal lymphatic pathway through the right hemidiaphragm could have been stopped by pleural sequelae from right lobectomy. In the other case, a right pleural effusion occurred after peritoneal dialysis. It is a well known pathological entity: the structural defect can be observed by separation of collagen bundles in the tendinous diaphragm. This type of pleuro-peritoneal communication is well known in women suffering from menstrual pneumothorax or in patients treated by peritoneal dialysis.
Mediastinoscopy is the most reliable examination to determine the presence or absence of lymph node metastases in the preoperative evaluation of lung cancer extension. It is performed either by the cervical route to explore the peritracheobronchial spaces, or by the anterior route to explore the subaortic and anterior mediastinal spaces. It is carried out immediately before thoracotomy, and the rapid frozen section examination of the lymph nodes is accurate enough to decide whether or not resection should be attempted. When mediastinoscopy detects lymph node metastases that are contralateral to the tumour, resection is contra-indicated in view of its poor prognosis. When the metastases are ipsilateral to the tumour, lie low in the mediastinum and are contained in the lymph node capsule, resection is justified since a 5-year old survival can be obtained in almost 10% of the cases. Mediastinoscopy avoids many exploratory thoracotomies. Patients whose cancer is resectable but in whom resection is contra-indicated by this examination have statistically no chance of surviving.
We report two cases of pleural effusion in which a subdiaphragmatic cause was noted. In both cases it was necessary to obliterate a defect in the diaphragm via a thoracic incision. In one case, a left chylothorax occurred in a patient with hepatic cirrhosis. In this case, it was postulated that the normal lymphatic pathway through the right hemidiaphragm could have been stopped by pleural sequelae from right lobectomy. In the other case, a right pleural effusion occurred after peritoneal dialysis. It is a well known pathological entity: the structural defect can be observed by separation of collagen bundles in the tendinous diaphragm. This type of pleuro-peritoneal communication is well known in women suffering from menstrual pneumothorax or in patients treated by peritoneal dialysis.
Between 1975 and 1988, 965 cases of bronchogenic carcinoma were submitted to surgery. A cervical mediastinoscopy (CM) was performed in 548 cases (57%). A nodal involvement was found in 35% of these 548 cases, thus 4 patients out of 5 did not undergo thoracotomy. One patient out of 5 underwent a thoracotomy in case of right ipsilateral and intranodal metastasis. Among 803 thoracotomies,-sixty were purely exploratories (7.5%), mainly because of a non resectable tumor. The rate of exploratory thoracotomy (ET) is decreasing (1975-1977 = 15%, less than 5% in recent years) as the rate of CM is increasing (1975-1979: 10-20%, 60-70% in recent years). The study of 60 cases of ET shows that 16 upon 39 performed CM revealed some nodal or mediastinal involvement. Nevertheless, among these 16 patients, the need of thoracotomy was under the pressure of necessity. Twenty-three patients had a negative CM: half of them had a left upper lobe carcinoma. Thus CM was inefficient to establish nodal mediastinal involvement in these cases.
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Chondromatous hamartomas of the lung are usually intraparenchymal and are rarely located in the bronchial lumen. Mediastinal chondrohamartomas are rare. A case is reported in which the close relationship with the esophagus suggests that this tumor is a choristoma rather than a hamartoma. To our knowledge, such a theory has not been previously proposed.
We report the fracture of the poppet of a Lillehei-Kaster prosthesis. A 40 years old man was operated upon for endocarditis of the mitral valve. A Lillehei-Kaster tilting disc valve was implanted. Three years later the disc fractured and the two parts escaped in the aorto-iliac axis. Emergency surgical procedure permitted implantation of a Wessex bioprosthesis and removal of the fragments with good results.
In order to assess the value of nuclear magnetic imagery NMR in the diagnosis of the extent of bronchial cancers, 61 patients with operable bronchial carcinoma had both a CT scan and an NMR scan pre-operatively. Fifty one mediastinoscopies were performed. Twelve times there were mediastinal glandular enlargement. Ten times the thoracotomy was performed straight away. After pathological studies of the biopsy, 24 patients were N2, 25 N1, 12 N0; the sensibility of NMR to foresee lymph node invasions was 83% (specificity 70%), for CT scanning 75% (specificity 81%). Thirteen patients presented with a direct mediastinal or parietal invasion. The sensibility of detecting these invasions was only 38% for NMR (specificity 94.5%) and for CT scanning 54% (specificity 94.5%). There is little difference in the results and no statistical difference. This leads us to conclude that at present, NMR does not give more information than TDM in the diagnosis of operability in bronchial cancers.
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The authors report a number of rare traumatic lesions which can be described under the heading of "safety belt syndrome". The superficial haematoma which is invariably present ("seat belt sign") would seem to be a reliable indication of improper wearing of the seat belt which has been attached too loosely. The lesions seen were a vertebral arteriovenous fistula after cervical contusion, a closed rupture of a rectus abdominis muscle, associated with rupture of the homolateral renal artery and finally pelvi-ureteric disinsertion with laceration of the renal pelvis. It is important to be aware of such lesions which must be suspected in case of accident with a seat belt since the diagnosis is often difficult. The superficial haematoma is a valuable sign which should suggest the possibility of underlying deep lesions.
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