Centre Chirurgical Marie Lannelongue

Therapeutic advances in chronic thromboembolic pulmonary hypertension (CTEPH) over the last 10 years have improved patient prognosis. As a result, the role of lung transplantation (LTx) for this indication has been greatly reduced. In this review article, we describe the evolution of treatments for CTEPH, the place that remains for lung transplantation, and the particularities of lung transplantation for this indication.

Single-stage tracheal resection and anastomosis represents the gold standard for benign subglottic stenosis' management. Nevertheless, also considering the complexity of the surgical procedure, some patients are considered unfit for tracheal surgery (stenosis involving vocal cords, comorbidities, and relapse after surgery). Until now, the only alternative was tracheostomy which represents the only real alternative to secure the patency of the airway. Thanks to the creation of "transcordal stents", patients considered unfit for surgery have a valid alternative to tracheostomy and the conformation of the stent reduces the risk of stent migration, preserving airway patency, swallowing, and phonation. This study aims to evaluate the use of a new custom-made transcordal stent, comparing its safeness with traditional transcordal stent. Between 2017 and 2021, 28 consecutive patients underwent transcordal stenting for benign tracheal stenosis in 3 centers. Patients were divided into 2 groups: 16 treated with the new custom-made stent (Group 1) and 12 treated with conventional stents (Group 2). Intra-, post-operative complications, swallowing capacity, quality of voice, granulation tissue, stent migration, and quality of life (QoL) were compared between the two groups. Group 2 showed reduced swallowing capacity (p = 0.0001), higher rate of stent migration (p = 0.0003), higher rate of granulation tissue (p = 0.0044), and higher rate of stent replacement (p = 0.0001). Voice reduction was not significantly different between the two groups. QoL was better in Group 1. Despite this represent the largest study analyzing transcordal stenting as definitive treatment of subglottic stenosis in patients unfit for surgery, results could not draw definitive conclusions because of the small number of patients, the lack of randomization, and the small follow-up. Nevertheless, the use of the new custom-made transcordal stent could be considered safe and effective, guaranteeing stable results with low rate of long-term complications and better QoL compared to the traditional stents.

BackgroundTo detect preload responsiveness in patients ventilated with a tidal volume (Vt) at 6 mL/kg of predicted body weight (PBW), the Vt-challenge consists in increasing Vt from 6 to 8 mL/kg PBW and measuring the increase in pulse pressure variation (PPV). However, this requires an arterial catheter. The perfusion index (PI), which reflects the amplitude of the photoplethysmographic signal, may reflect stroke volume and its respiratory variation (pleth variability index, PVI) may estimate PPV. We assessed whether Vt-challenge-induced changes in PI or PVI could be as reliable as changes in PPV for detecting preload responsiveness defined by a PLR-induced increase in cardiac index (CI) ≥ 10%.MethodsIn critically ill patients ventilated with Vt = 6 mL/kg PBW and no spontaneous breathing, haemodynamic (PICCO2 system) and photoplethysmographic (Masimo-SET technique, sensor placed on the finger or the forehead) data were recorded during a Vt-challenge and a PLR test.ResultsAmong 63 screened patients, 21 (33%) were excluded because of an unstable PI signal and/or atrial fibrillation and 42 were included. During the Vt-challenge in the 16 preload responders, CI decreased by 4.8 ± 2.8% (percent change), PPV increased by 4.4 ± 1.9% (absolute change), PIfinger decreased by 14.5 ± 10.7% (percent change), PVIfinger increased by 1.9 ± 2.6% (absolute change), PIforehead decreased by 18.7 ± 10.9 (percent change) and PVIforehead increased by 1.0 ± 2.5 (absolute change). All these changes were larger than in preload non-responders. The area under the ROC curve (AUROC) for detecting preload responsiveness was 0.97 ± 0.02 for the Vt-challenge-induced changes in CI (percent change), 0.95 ± 0.04 for the Vt-challenge-induced changes in PPV (absolute change), 0.98 ± 0.02 for Vt-challenge-induced changes in PIforehead (percent change) and 0.85 ± 0.05 for Vt-challenge-induced changes in PIfinger (percent change) (p = 0.04 vs. PIforehead). The AUROC for the Vt-challenge-induced changes in PVIforehead and PVIfinger was significantly larger than 0.50, but smaller than the AUROC for the Vt-challenge-induced changes in PPV.ConclusionsIn patients under mechanical ventilation with no spontaneous breathing and/or atrial fibrillation, changes in PI detected during Vt-challenge reliably detected preload responsiveness. The reliability was better when PI was measured on the forehead than on the fingertip. Changes in PVI during the Vt-challenge also detected preload responsiveness, but with lower accuracy.

To describe the technique and review the oncological and surgical results of the En Bloc resection assisted by retroperitoneal laparoscopy in a single prone position for tumors in the thoracolumbar region. Monocentric retrospective case study. Procedure was performed in a single prone position by a dual team of spine and thoracovascular surgeons. An endoscopic balloon was inflated in the right retroperitoneal cavity. A plan was developed between the anterior spine and vena cava as well as abdominal aorta with segmental vessels ligation. Structures at risk were safely protected under endoscopy during horizontal or sagittal osteotomies. From 2021, seven patients aged a median 52years old (range, 34-67) were included. Involved spinal segments went from T11 to L3. Surgery was aborted in one case due to massive bleeding and ventilating difficulties. There were two partial and four total vertebral resections. Median operating duration and estimated blood loss were 405min (range, 360-540) and 2.1 L (range, 1.2-19), respectively. Postoperative complications consisted of 1 urinary infection; 1 transient urinary retention; 1 posterior wound infection; 1 pneumothorax; 1 persistent partial motor deficit; 1 transient confusion; 1 pulmonary embolism; 1 CSF leak; 1 subdural hematoma; 1 retroperitoneal lymphocele. All margins were uncontaminated. All patients were alive and ambulatory at last follow-up. Early results suggest En Bloc resection assisted by retroperitoneal videoscopy in tumors from T11 to L3/4 disk space is feasible, less invasive and safe. Careful surgical planning and experience in endoscopic vascular surgery are mandatory.