Where is the boundary between N1 and N2 stations in lung cancer?

Background. The anatomical definition of N1 stations, its boundary to N2 stations, and its prognostic implication are yet to be defined in lung cancer. Metastasis in lymph nodes close to the pleural reflection has been classified differently as N1 or N2 according to the lymph node maps promulgated so far.

Methods. The pattern of lymphatic involvement and prognosis were retrospectively analyzed in 180 N1 patients who underwent at least lobectomy and complete hilar/mediastinal lymphadenectomy from 1987 through 1997. For comparison, the prognoses of 166 N2 patients were also analyzed.

Results. The overall 5-year survival of N1 and N2 patients was 67% and 37%, respectively, and the difference was statistically significant (p = 0.0000, log-rank test). The prognosis was compared between N1 without No. 10 involvement (N1⁻, N = 145), N1 with No. 10 involvement (N1⁺, N = 35), and N2 (n = 166). Their 5-year survival was 70%, 54%, and 37%, respectively. A significant difference was observed only between N1⁺ and N2 (p = 0.04), and not observed between N1⁻ and N1⁺. However, survival curves of single-node N2 (n = 66) and N1⁺ were superimposed.

Conclusions. In terms of prognosis, a pleural reflection does not seem an appropriate anatomical boundary between N1 and N2 stations in lung cancer.     

The enigma of the 1889 Russian flu pandemic: A coronavirus?

The “Russian flu”, which raged from 1889 to 1894, is considered as the first pandemic of the industrial era for which statistics have been collected. This planetary event started in Turkestan and hit the Russian Empire, before reaching all European countries, the United States of America, and the whole world. Contemporaries were surprised by its high contagiousness as evidenced by attack rates averaging 60% in urban populations, its rapid spread in successive waves circling the globe in a few months by rail and sea, and the tendency of the disease to relapse. Despite its low case-fatality rate (0.10%-0.28%), it is estimated to have caused one million deaths worldwide. On serological grounds, it is generally accepted that the causative agent of Russian influenza was Myxovirus influenzae, the virus identified for all influenza pandemics since the “Spanish flu” of 1918. In light of the Covid-19 pandemic, which has underscored the extraordinary epidemic potential of coronaviruses, this assumption has recently been questioned. Coronaviruses come from wild reservoirs (bats, rodents, birds, …). They induce respiratory symptoms mimicking influenza, possibly leading to respiratory distress with pneumonia. In addition to the Covid-19 pandemic, recent deadly and limited epidemics, such as SARS in 2002 and MERS in 2012, have occurred. Russian influenza presented as an influenza-like syndrome with clinical peculiarities (multivisceral and neurological involvement, skin rash, early iterative relapses), evoking some particularities of Covid-19. Four other coronaviruses circulating in the human population for decades (HCoV-229E, HCoV-NL63, HCoV-OC43, HCoV-HKU1) have been found to be responsible for 15 to 30% of seasonal colds. All of these viruses are of animal origin. Recently, phylogenetic studies have revealed the genetic proximity between a bovine coronavirus BCoV and the human virus HCoV-OC43, indicating that the latter emerged around 1890, at the time of the Russian flu, when an epizootic was raging among cattle throughout Europe. Could the current human virus be the attenuated remnant that appeared after the Russian flu in 1894? Was there a coronavirus pandemic before Covid-19 ?     

Enterovirus and type 1 diabetes: What is the matter?

A complex interaction of genetic and environmental factors can trigger the immune-mediated mechanism responsible for type 1 diabetes mellitus(T1DM) establishment. Environmental factors may initiate and possibly sustain, accelerate, or retard damage to β-cells. The role of environmental factors in this process has been exhaustive studied and viruses are among the most probable ones, especially enteroviruses. Improvements in enterovirus detection methods and randomized studies with patient follow-up have confirmed the importance of human enterovirus in the pathogenesis of T1 DM. The genetic risk of T1 DM and particular innate and acquired immune responses to enterovirus infection contribute to a tolerance to T1DM-related autoantigens. However, the frequency, mechanisms, and pathways of virally induced autoimmunity and β-cell destruction in T1 DM remain to be determined. It is difficult to investigate the role of enterovirus infection in T1 DM because of several concomitant mechanisms by which the virus damages pancreatic β-cells, which, consequently, may lead to T1 DM establishment. Advances in molecular and genomic studies may facilitate the identification of pathways at earlier stages of autoimmunity when preventive and therapeutic approaches may be more effective.     

CO2 elimination via extracorporeal circulation in respiratory assistance: artificial lung or kidney? Experimental study]

In the context of a respiratory assistance protocol dissociating oxygenation of the blood from elimination of carbon dioxide, it is possible to rest the lungs which are used for oxygen exchange by diffusion via functional zones. CO2 is eliminated via extracorporeal circulation. In order to simplify this method, the authors investigated the optimal conditions for this elimination at flow rates similar to those used for haemodialysis (0.33 l/min). This study was designed to evaluate the in vitro elimination of CO2 obtained by a membrane artificial lung with and without "doping" by acidification (10 ml/min of 0.01 N HCl) of the blood inlet compared with that obtained with a haemodialysis machine with and without alkalinisation (0.5 ml/min of 0.5 N NaOH) of the dialysate inlet. The results obtained showed that haemodialysis with an alkaline bath ensured CO2 elimination 36% superior to that of the artificial lung associated with acidification.     

Medically refractory gastroesophageal reflux disease in the obese: what is the best surgical approach?

Background

Obesity is a recognized risk factor for gastroesophageal reflux disease (GERD). Traditional antireflux surgery (fundoplication) may not be appropriate in the morbidly obese, especially when other effective alternatives exist (bariatric surgery).

Methods

A 13-item survey was designed to elicit professional opinions regarding the treatment of medically refractory GERD in obese patients. Members of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) were randomly selected and emailed a link to an online survey.

Results

A total of 550 surgeons were contacted via email, and 92 (17 %) completed the survey. Of the respondents, 88 % perform laparoscopic antireflux surgery, 63 % perform bariatric surgery, and 59 % perform both. Overall, 77 % completed a minimally invasive surgery fellowship. In response to the question “Would you perform a laparoscopic fundoplication in a patient with medically refractory GERD and a BMI of ‘X’?” surgeons were less likely to offer fundoplication at a higher body mass index (BMI). The majority of respondents felt that laparoscopic Roux-en-Y gastric bypass was the best option (91 %), followed by laparoscopic sleeve gastrectomy (6 %). Many had a morbidly obese patient with a primary surgical indication of GERD denied a bariatric procedure by their insurance company (57 %), and 35 % of those surgeons chose to do nothing rather than subject the patient to a fundoplication. Respondents uniformly felt that bariatric surgery should be recognized as a standard surgical option for treating GERD in the obese (96 %).

Conclusion

When surgical treatment of GERD is indicated in an obese patient, bariatric surgery is the optimal approach, in the opinion of surgeons responding to our survey. Unfortunately, third-party payers often decline to provide benefits for a bariatric procedure for this indication. Additional data is necessary to confirm our belief that the opinions elicited through this survey are consistent with the standard of care as defined by the medical community.     

Renal and hypertensive complications of extracorporeal shock wave lithotripsy: who is at risk?

Extracorporeal shock wave lithotripsy (ESWL) is now used in the treatment of about 90% of renal and ureteral stones. Because of the non-punctual delivery of energy to the stone, a small volume of renal parenchyma is injured giving place to a fibrous scar which can be shown by highly resolutive imaging techniques like magnetic nuclear resonance. Isotopic clearances point to a reduction of 15% in the renal plasma flow on the side of the lithotripsy, but this alteration appears to be transient in nature. In a few cases an abrupt onset of transient hypertension has been reported in clear relation to a compressive perirenal hematoma. The responsibility of ESWL in the late occurrence of permanent hypertension is, however, still uncertain, probably because of the difficulty in showing that this occurrence is not only related to the older age of the patient. The American Food and Drug Administration-sponsored multicentric study begun in 1992 should solve this issue in the future. Recent articles suggest that altered renal function prior to ESWL would predict the late occurrence of hypertension and worsening of renal failure. Furthermore, age and the resistance index of arcuate or interlobar renal arteries (measured by Doppler) could help to screen patients at risk of developing hypertension. In practice in patients over 60 years of age and/or with a plasma creatinine of >to 300 micromol/l, ESWL should be performed with caution, and renal function and blood pressure should be carefully monitored.     

Surgical intervention for small-cell lung cancer: what is the surgical role?

Small-cell lung cancer (SCLC) is an aggressive neuroendocrine carcinoma that accounts for approximately 10-15% of all lung cancer cases. This histological subtype is a distinct entity with biological and oncological features differing from non-small cell lung cancer (NSCLC). Treatment is mainly performed using systemic chemotherapy, although surgery in association with chemotherapy may be indicated for a minor proportion of limited-disease cases. Since the outcomes after surgical intervention in patients with very early disease are comparable to those for NSCLC, accurate clinical staging is required, particularly in terms of nodal involvement. In addition to conventional mediastinoscopy, positron emission tomography-computed tomography and endobronchial ultrasonography guided transbronchial needle aspiration have recently become available for node diagnosis. The significance of surgery for SCLC includes local disease control and treatment for cases showing mixed histology. However, only two randomized control studies have examined the efficacy of surgery in SCLC, and both yielded negative results and are out of date. We review herein several studies concerning surgery for SCLC and discuss the results from a practical standpoint. A prospective trial performed in collaboration with pulmonologists is required to address the significance of surgery, which is a limited option in the treatment of SCLC.     

Laser fistula surgery [Filac]: When and how?

Anorectal fistula repair is still one of the most challenging conditions treated by surgeons. Despite modern advances in surgical care, failure rate of surgical treatment exceeds 30%. One of the challenges that surgery cannot properly address is the obliteration of the fistula tract epithelium. Another challenge is the treatment of high fistulas which involve significant portion of the anal sphincter muscles. Unfortunately, surgical treatment of these fistulas may cause long term anal incontinence in some of the patients. Fistula-tract Laser Closure (FiLaC™, Biolitec AG, Jena, Germany) was developed to overcome these issues, by using a radially energy emitting laser probe that obliterate the epithelial tract while closing the defect without causing any damage to the sphincters. Up to date, 11 studies have been published with promising results. In this review, we will be evaluating the indications, the technical steps, short and long-term results of laser fistula surgery.