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From January 1 1980 to December 1993, 210 patients underwent exeresis of a cancer of the cardia or the lower third of the oesophagus. There were 193 males and 17 females (mean age 63.5 years, range 18-84). Cancers were in an advanced stage in 56.6% (stage 0, 0.95%; stage 1, 9.04%; stage 3, 43.3%; stage 4, 6.19%). Postoperative morbidity was 21% and hospital mortality was 3.81%. Actuarial survival rate at 1, 3, 5 and 10 years were 64.1%, 23.9%, 17.7% and 12.8% respectively. The advent of the CT scan, better patient selection and improved nutrition management and postoperative care have greatly improved hospital mortality (7 deaths for 118 operations before 1987, i.e. 5.93% and 1 death for 92 operations since 1987, i.e. 1.08%. Creating a circumferential instead of radial phrenotomy and the possibility of raising the anastomosis to upper thorax or in combination with left access and cervicotomy have led to excellent immediate results and confirm our choice in this method.

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A young patient presented with a rare tumour of the mediastinum. The first sign was liquid effusion in the right hemithorax. A major rise in alpha-foeto-protein level to 34,000 ng/ml rapidly led to diagnosis. Histological confirmation was obtained on a surgical biopsy specimen of the lung. Management included primary polychemotherapy followed by complete surgical exeresis. A second post-operative cycle of chemotherapy was given but only led to temporary normalization of alpha-foeto-protein levels and intensive chemotherapy followed by autograft to peripheral stem cells was performed. The vitellin tumour is a primary germ cell tumour usually observed in young men. It originates in extraembryonary primary mesenchymal tissue. Like other germ cell tumours, the diagnosis should be entertained for all tumours of the anterior mediastinum. Tumour markers useful for diagnosis and prognosis are beta-HCG, AFP and CEA. Levels above 500 ng/ml confirm vitellin tumour. Chemotherapy should be instituted rapidly using a BEP protocol (bleomycine, etoposide, cisplatinium) or a PVB protocol (cisplatinium, vinblastin, bleomycine). Using these new drugs and current therapeutic protocols, the rate of complete remission has risen from 13% to 40%.

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Ectopic ACTH-secreting tumours responsible for paraneoplastic Cushing's syndrome are invisible at radiography in about 50 percent of the cases. In this situation, the current attitude is to correct the hypercorticism and then embark on a regular morphological monitoring in search of the initial tumour with the purpose of removing it. We report the cases of 3 patients who had a paraneoplastic Cushing's syndrome of unknown origin in 1 case and consecutive, in 2 cases, to a bronchial carcinoid tumour initially occult and discovered 30 and 42 months respectively after the onset of the disease. Six to 10 months after hypercorticism was cured with ketoconazole and bilateral adrenalectomy, a thymic mass 2 to 5 cm in length was detected by computerized tomography or magnetic resonance imaging in all 3 patients. At resection of the thymus, performed in 2 cases, a benign hyperplasia of this organ with negative immunohistostaining for ACTH was discovered. This abnormality, seldom reported, seems to result from the abrupt cessation of hypercorticism. It must be known to avoid an unnecessary thymectomy during supervision of patients with paraneoplastic Cushing's syndrome related to a radiologically occult tumour.

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Over a 4-year period in four of 61 patients (6.5%) who survived lung transplantation, pulmonary tuberculosis developed at a mean of 7.5 months (range 3 to 13 months) after operation. Clinical and radiologic features were atypical. Definitive bacteriologic diagnosis, which was established on bronchial, sputum, and pleural fluid samples, may be delayed by the concomitant presence of other infective organisms and the necessity for repeated sampling. All patients were treated successfully with antituberculous chemotherapy, but one patient also required lobectomy. At a mean follow-up of 2.25 years (range, 1 to 3 years), three patients are free of active disease, and one patient had a recurrence at 2 years. Tuberculosis in transplanted lungs is an uncommon but serious infection that may elude diagnosis but respond well to treatment.

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Between February 1988 and January 1992, 61 patients have undergone bilateral lung transplantations (42 heart-lung and 19 double-lung) in Bordeaux. The underlying diseases were primary or secondary hypertension (20), emphysema (22), or other diseases including cystic fibrosis, pulmonary fibrosis, silicosis, and sarcoidosis (19). Actuarial survival for double-lung and heart-lung transplant recipients was 66% and 72% at 1 year and 57% and 53% at 3 years, respectively. Forty-two patients were still alive 6 months after operation, and we studied their pulmonary function at the short and long term. All parameters except arterial carbon dioxide tension had improved dramatically at 6 months (p < 0.0001). Vital capacity, forced expiratory volume in 1 second, and forced expiratory flow rate between 25% and 75% of vital capacity were at 79% +/- 3%, 92% +/- 5%, and 105% +/- 8% of the predicted values, respectively. Arterial oxygen tension was 88 +/- 3 mm Hg. Nine months after operation, a slight decrease in forced expiratory volume in 1 second and forced expiratory flow rate between 25% and 75% of vital capacity appeared but values remained more than 75% predicted. This was related to the occurrence of obliterative bronchiolitis in 6 patients (14%). At 9 months, flow rates and oxygen tension of these 6 patients were highly different from those of patients free of obliterative bronchiolitis (p < 0.0002 for flow rates and p < 0.01 for oxygen tension). Only 1 patient required retransplantation. The others are living an almost normal life. Our results are discussed in view of the published reports on single-lung transplantation. Short-term results of bilateral lung transplantation are thus excellent and maintained on a long-term basis. Therefore, in our opinion, bilateral lung transplantation is the therapy of choice for pulmonary hypertension and emphysema.

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Donor airway ischemia is the main cause for defective tracheal or bronchial healing after double-lung transplantation. Anatomical studies and bronchial arteriograms have shown that the right intercostal bronchial artery is constant (95% of instances) and provides an important blood supply to the distal trachea, the carina, and the right bronchial tree as well as to the left side through a subcarinal and periadventitial anastomostic network. To maintain this important bilateral bronchial circulation, it is of capital importance not to mobilize the arteries individually and to avoid large dissections around the carina. Both bronchi can thus be revascularized by indirect aortic reimplantation using a bypass graft to a single aortic patch that includes the origin of the right intercostal bronchial artery. Furthermore, the origin of other vessels (a common trunk and left arteries) can be found within a short distance of the right intercostal bronchial artery and possibly be contained within the same aortic patch. From a series of 56 lung transplantations, 8 patients underwent restoration of the bronchial vascularization using a recipient saphenous vein graft between the donor bronchial arteries and the anterior aspect of the recipient's ascending aorta. A lower tracheal anastomosis was performed. Bronchial arterial blood supply was evaluated both by endoscopy and by arteriography at about the 15th postoperative day. The bronchial circulation was visualized at this time in five of seven arteriographies, and this was associated with excellent tracheal healing in all 8 patients.

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Over an 11-year period, 12 patients with foreign body perforation of a previously normal oesophagus were treated in our institution. The foreign bodies were most commonly bones (10 cases), 5 of which were chicken bones; other species were pigeon, rabbit, veal, pork and fish (one each); 2 perforations were due to swallowed dentures. The mean age was 60 years (range 42-73) and 6 patients were female. A degree of psychosocial dysfunction was present in 3 patients. Seven patients presented late (> 48 h after ingestion). The commonest presenting symptoms were fever and pain (8 patients). Other symptoms included dysphagia (7), respiratory distress (3), and late cervical abscess formation (3). The diagnosis was established by contrast oesophagography or rigid oesophagoscopy. A third of the perforations were cervical, the remainder intrathoracic. All patients were treated by surgical drainage with or without primary closure of the perforation. There were no operative deaths. Five patients developed postoperative oesophageal leaks which required reoperation in 1 patient. All patients were well and swallowing normally on discharge from hospital. Follow-up endoscopy or oesophagography was carried out in all patients and confirmed the absence of oesophageal disorders. Foreign body perforation of the oesophagus is a rare but important subentity of oesophageal perforation which responds well to surgical treatment.

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Ischaemic anastomotic complications are an important cause of mortality and morbidity after lung transplantation. Anatomical studies have demonstrated that the pattern of bronchial arterial supply is relatively constant and therefore amenable to attempts at revascularisation. From May 1990, 10 patients who had a double lung transplantation (tracheal anastomosis) and 1 patient who had a right lung transplantation underwent concomitant bronchial revascularisation. There were two early and one late deaths. There were no anastomotic complications. Regular endoscopic examination showed satisfactory healing in all patients. Early angiography showed patent grafts in 7 of 9 patients. At a mean follow-up of 11 months (range 6-17 months) 8 patients are well and leading a normal life. This report describes the anatomical basis, technical aspects and early results of a promising operative procedure in the field of lung transplantation.

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This report concerns 47 ruptures of the tracheo-bronchial tree from the tracheal origin to the division of the lobar bronchi (trachea in 30 patients, main bronchus in 11, intermediate or lobar bronchus in 6). The disruption was circumferential in 24 cases and non-circumferential in 23. Injuries resulted from crush or blunt trauma in 35 cases, from seat belt or rope strangulation in 8 cases and in 4 cases, lesions were discovered following the tracheal intubation. The main symptoms were cervico-mediastinal emphysema (39), pneumothorax (31), acute dyspnea (28) and hemoptysis (11). The diagnosis was always confirmed endoscopically. In 8 patients, management of the lesions was delayed for more than 1 week due to misdiagnosis or severe associated injuries. Thirty-eight patients underwent tracheal or bronchial surgical repair associated in 13 cases with a temporary stenting, 4 patients underwent partial or total lung resection, 2 were managed by laser therapy and the 5 others received only medical care and endoscopic survey. Four patients died (8.5%), 2 from bleeding in the bronchial tree from a pulmonary artery tear, 1 from hypertensive pneumothorax under respiratory support and the last from mediastinitis due to delayed diagnosis of an associated oesophageal wound. All 43 other survived in spite of some very critical situations. This experience confirms that technical problems of surgical repair are nowadays overcome and that prognosis of tracheobronchial ruptures mainly depends on the initial control of respiratory failure and complications. Avoiding lethal anoxia or endobronchial damage in the emergency period before referring the patient to the surgeon is essential.

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The post operative evaluation and endoscopic follow-up of 34 tracheal or bronchial anastomoses after lung or heart-lung transplantation show some aspects of the tracheobronchial healing and difficulties in the healing process: primary type I mucomucosal healing in only 6 cases, secondary type II mucosal healing in 15, delayed type III healing after mucosal or deep parietal necrosis in 13, type IV distant ulcerations of mucosa and spur lesions in 12. Type III difficulties of healing mainly occur after double-lung transplantations which always suffer from ischemia. Autologous tracheal or bronchial sutures in 3 transplanted patients submitted to standard immunosuppressive therapy including corticosteroids were uneventful and type I. This experience suggests that among all factors having an influence on bronchial healing, ischemia of the donor tracheobronchial tree is predominant, justifying all attempts of bronchial revascularization after double-lung transplantation. The efficacy of the arterial revascularization is verified in 3 cases of tracheal anastomosis after double-lung transplantation with type I or II tracheal healing.

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A series of 35 oesophageal perforations from the period 1980-1987 is reported. Sixteen perforations followed oesophageal endoscopy, 10 were spontaneous, 8 were due to foreign bodies and one was post-operative. The delay in reaching the right diagnosis was less than 24 hours in 18 cases and more than 24 hours in 17 cases. Oesophageal leak was demonstrated in 86% of our cases by contrast study; in the others by rigid oesophagoscopy. Perforation occurred in the cervical oesophagus in 6 patients, thoracic oesophagus in 28 and abdominal oesophagus in 2 (one had a double perforation). Three patients were managed non operatively and survived. Cervical oesophagostomy and oesophageal diversion were used in 4 patients as primary treatment because of perforation occurring in caustic burn cases (2 cases, both survived) or late severe sepsis (2 cases, both died). Two patients with neoplastic stricture were treated by oesophago-jejunal bypass without resection and partial oesophago-gastrectomy respectively: both survived. Direct suture and closure of the perforation were performed in 26 patients. Two died, one because of oesophageal leak. Post-operative localized leaks developed in 5 other patients without any mortality and 4 healed with conservative management. The overall mortality rate was 11% (4 patients). All had a delayed diagnosis (more than 48 hours). We suggest that even in patients with delayed diagnosis of a non-malignant oesophageal perforation, direct suture and closure should be attempted under protection of functional oesophageal diversion and "contact drainage" to canalize a possible post-operative localized leak. Good oesophageal diversion can be achieved by naso-oesophageal suction and gastric suction through gastrostomy or with oesogastric antireflux procedure.(ABSTRACT TRUNCATED AT 250 WORDS)

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Computed tomography and magnetic resonance imaging have respectively decreased the incidence of exploratory thoracotomy by 11.6% to 5.7% then 5.3% after their successive inclusion in the assessment of the operability of lung cancers. Based on a systematic comparison of CT and MRI with exploratory thoracotomy in 111 patients, the yield, sensitivity and positive predictive value of these examinations was assessed in relation to tumour extension to various sites: to the chest wall, for which the sensitivity was poor (38% for CT, 54% for MRI) with a moderate predictive value (71% for CT, 77% for MRI); to the mediastinum with improved sensitivity (69% and 72%) but an uncertain predictive value (61% and 72%). The sensitivity and predictive value were then measured for lymph node involvement: N1: moderate sensitivity (69% and 76%) but a good predictive value (95% and 92%); N2 and N3: good sensitivity (79% and 93%) but a poor predictive value (70% and 66%). Apart from a few particular indications specific to MRI, especially in the apex, left hilum and in contact with the atrium, the efficacy of these two investigations is very similar. However, their lack of specificity means that certain exploratory thoracotomies are still justified in order to assess the operability of the tumour. A surgical or mediastinoscopic anatomical assessment is still necessary for a good classification of lymph node extension of lung tumours.

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Between February 1988 and December 1989, 15 combined heart-lung, 2 double lung and 5 single lung transplants were performed at our institution for end stage lung disease. The indication for heart-lung transplantation was primary lung disease with associated secondary heart failure in 11 cases, diffuse pulmonary disease with extensive adenopathy of the hilum in 2 cases and profuse and antibiotic-resistant tracheobronchial infection due to Pseudomonas in 2 cases. A double lung transplant was performed in 2 patients with hypertensive emphysema. The indication for a single lung transplantation was emphysema in 2 cases and pulmonary fibrosis in 3 cases; in this last indication, transplantation should be performed on the right side with a slight lengthening of the main bronchus to avoid the side-effects of mediastinal shift. There were 2 early deaths, 7 secondary deaths (from the 2nd to the 5th month) due to viral or bacterial infectious complications, and 1 late death in the 7th month (infection due to a syncitial virus). All 12 surviving patients have an excellent functional result; the size of the tracheal or bronchial anastomosis ranges from 85% to 100% of normal. From this experience, we conclude that specificity and severity of lung hazards are mainly related to bronchial infection, dependence on steroids and pleural adhesions. Moreover, posttransplant pulmonary oedema, mucociliary dysfunction and the differential diagnosis between rejection and infection require careful endobronchial suction and periodical sampling.

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Since January 1988, the Bordeaux group has performed 15 transplantations for lung disease: 9 heart-lung transplants, 1 heart + left lung, 1 double lung, 2 right lungs and 2 left lungs. The transplantations were performed for pulmonary emphysema (10 cases), pulmonary artery hypertension (2 cases), cystic fibrosis (1 case), pulmonary fibrosis (2 cases). Cardiopulmonary transplantation was not always performed because of associated heart failure but sometimes because of large intrahilar adenopathy or intractable bronchial infection. Pulmonary transplantation is recommended on the right side in cases of pulmonary fibrosis. One patient died postoperatively (ischaemia of the transplant). Four others died during the 2nd and 3rd months from poorly defined but probably infectious pulmonary syndromes. The tracheobronchial patency of the 10 survivors was 80% or 100% of the predicted value. The respiratory functional result was excellent in the short and intermediate term. Specific difficulties essentially consisted of pleural symphyses, hilar adenopathy, bronchial infection, steroid dependence of certain subjects, the difficulty of identifying the cause and treating lung opacities during the 2nd and 3rd months.

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Since carcinoma of the oesophagus is considered to be frequently multicentric, total oesophagectomy appears the only radical therapeutical approach. A follow-up of 366 patients who underwent partial oesophagectomy shows that this procedure can be curative as well as palliative and is sometimes the only procedure possible with a reasonable mortality. These patients had an oesophageal carcinoma located between the cardia and the level of the aortic arch (60.5% squamous, 37% adenocarcinoma). Of these, 22% were over 70 years of age. The surgical route was a left thoracotomy in 280 cases (with anastomosis below or above the aortic arch) or a laparotomy and right thoracotomy in 86 cases. The oesophagus was transected as high as possible and replaced by an isoperistaltic tube fashioned from the greater curvature of the stomach. Mediastinal tissues and the lesser curvature with their lymph nodes were removed. The overall operative mortality was 7% (4% in patients less than 70 and 15% over 70). Very few anastomotic fistulae were observed (6 cases) but they were always severe (6 deaths). The middle and long term results show acceptable functional sequelae and a good survival quality. The survival is 57% at 1 year, 30% at 3 years and 23% at 5 years (27% when the excision appeared curative). There was no significant difference in survival for patients whose cancer was in the mid-oesophagus compared to the lower oesophagus. There was no difference in survival in the cell type squamous or adenocarcinoma. Death was mainly due to metastatic lesions and mediastinal lymphatic recurrence.(ABSTRACT TRUNCATED AT 250 WORDS)

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One hundred anterior mediastinotomies performed between 1981 and 1987 resulted in the diagnosis of 90 malignant mediastino-hilar or anterior mediastinal tumours, 4 benign lymph node diseases and 6 non-specific lesions. This easy to perform biopsy technique was followed by low morbidity (7%) and one death after 48 hours due to major mediastinal compression. Its sensitivity and specificity make it a valuable alternative and, according to the authors, preferable to mediastinoscopy in the diagnosis of tumours of lymph node diseases in the anterior, pulmonary hila, especially on the left side, and anterior mediastinal lymph node chains.

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Of 43 tracheo-bronchial ruptures, 19 patients presented with disruption of the laryngo-tracheal junction which would appear to be a very specific anatomical lesion. The disruptions were secondary to blunt cervical trauma in 11 cases and strangulation in 8 cases. The disruption was complete in 14 cases and incomplete in 5. The lesion is very complex and involved the retraction of the lower part of the trachea into the mediastinum (14 cases), fracture of the cricoid ring (9 cases), bilateral recurrent nerve tears (14 cases), unilateral (4 cases) and retraction of the laryngeal mucosa with exposure of the cricoid cartilage in all cases. According to the complexity of the lesion, the treatment was: laryngo-tracheal resection and end-to-end anastomosis with treatment of the vocal cord palsy in 13 patients; simple end-to-end anastomosis in 4 patients who had an unilateral vocal cord palsy; 2 patients with a partial disruption were treated medically with endoscopic stenting and laser photocoagulation. All had restoration of airway patency and recovery of voice. The results contrast with the failures and reoperations reported in the literature and underline the necessity of complete evaluation and treatment of these complex lesions.

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The authors underline the value of MR in the diagnosis as pericardial of a rare congenital diverticulum situated in a right-sided latero-tracheal location.

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One hundred and twenty patients with bronchogenic carcinoma were prospectively studied by both computed tomography (CT) and magnetic resonance imaging (MRI) during the 2 weeks preceding thoracotomy or mediastinoscopy. MRI scans included contiguous axial and coronal slices. Results of CT and MRI studies were compared with the surgical and pathological findings on the basis of the TNM classification. Although no significant difference was found between the two imaging methods for the evaluation of tumour extent, MRI appears to be a valuable imaging technique for left upper lobe and apical neoplasms. Comparison between the two techniques for mediastinal node evaluation showed that sensitivity of MRI is superior to CT in the left paratracheal, aortopulmonary and subcarinal node areas.

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