Ángel Salvatierra Velázquez

Normativa sobre el diagnóstico y tratamiento del derrame pleural. Actualización

Although during the last few years there have been several important changes in the diagnostic or therapeutic methods, pleural effusion is still one of the diseases that the respiratory specialist have to evaluate frequently. The aim of this paper is to update the knowledge about pleural effusions, rather than to review the causes of pleural diseases exhaustively. These recommendations have a longer extension for the subjects with a direct clinical usefulness, but a slight update of other pleural diseases has been also included. Among the main scientific advantages are included the thoracic ultrasonography, the intrapleural fibrinolytics, the pleurodesis agents, or the new pleural drainages techniques.

Recomendaciones SEPAR de diagnóstico y tratamiento del cáncer de pulmón de células no pequeñas

Felipe Villar Álvareza,*,1, Ignacio Muguruza Truebab,1, José Belda Sanchisc, Laureano Molins López-Rodód, Pedro Miguel Rodríguez Suáreze, Julio Sánchez de Cos Escuínf, Esther Barreirog, M. Henar Borrego Pintadoh, Carlos Disdier Vicentei, Javier Flandes Aldeyturriagaj, Pablo Gámez Garcíak, Pilar Garrido Lópezl, Pablo León Atancem, José Miguel Izquierdo Elenan, Nuria M. Novoa Valentíno, Juan José Rivas de Andrésp, Íñigo Royo Crespop, Ángel Salvatierra Velázquezq, Luis M. Seijo Maceirasr, Segismundo Solano Reinas, David Aguiar Bujandat, Régulo J. Ávila Martínezk, José Ignacio de Granda Oriveu, Eva de Higes Martínezv, Vicente Díaz-Hellín Gudek, Raúl Embún Florp, Jorge L. Freixinet Gilarte, María Dolores García Jiménezm, Fátima Hermoso Alarzak, Samuel Hernández Sarmientot, Antonio Francisco Honguero Martínezm, Carlos A. Jiménez Ruizw, Iker López Sanzn, Andrea Mariscal de Albak, Primitivo Martínez Vallinap, Patricia Menal Muñozx, Laura Mezquita Pérezl, María Eugenia Olmedo Garcíal, Carlos A. Rombolám, Íñigo San Miguel Arreguiy, María del Valle Somiedo Gutiérrezj, Ana Isabel Triviño Ramírezm, Joan Carles Trujillo Reyesc, Carmen Vallejoz, Paz Vaquero Lozanos, Gonzalo Varela Simóo y Javier J. ZuluetaaaThe Thoracic Surgery and Thoracic Oncology groups of the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR) have backed the publication of a handbook on recommendations for the diagnosis and treatment of non-small cell lung cancer. Due to the high incidence and mortality of this disease, the best scientific evidence must be constantly updated and made available for consultation by healthcare professionals. To draw up these recommendations, we called on a wide-ranging group of experts from the different specialties, who have prepared a comprehensive review, divided into 4 main sections. The first addresses disease prevention and screening, including risk factors, the role of smoking cessation, and screening programs for early diagnosis. The second section analyzes clinical presentation, imaging studies, and surgical risk, including cardiological risk and the evaluation of respiratory function. The third section addresses cytohistological confirmation and staging studies, and scrutinizes the TNM and histological classifications, non-invasive and minimally invasive sampling methods, and surgical techniques for diagnosis and staging. The fourth and final section looks at different therapeutic aspects, such as the role of surgery, chemotherapy, radiation therapy, a multidisciplinary approach according to disease stage, and other specifically targeted treatments, concluding with recommendations on the follow-up of lung cancer patients and surgical and endoscopic palliative interventions in advanced stages.

Sumario ejecutivo de las recomendaciones SEPAR de diagnóstico y tratamiento del cáncer de pulmón de células no pequeñas

The Thoracic Surgery and Thoracic Oncology groups of the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR) have backed the publication of a handbook on recommendations for the diagnosis and treatment of non-small cell lung cancer. Due to the high incidence and mortality of this disease, the best scientific evidence must be constantly updated and made available for consultation by healthcare professionals. To draw up these recommendations, we called on a wide-ranging group of experts from the different specialties, who have prepared a comprehensive review, divided into 4 main sections. The first addresses disease prevention and screening, including risk factors, the role of smoking cessation, and screening programs for early diagnosis. The second section analyzes clinical presentation, imaging studies, and surgical risk, including cardiological risk and the evaluation of respiratory function. The third section addresses cytohistological confirmation and staging studies, and scrutinizes the TNM and histological classifications, non-invasive and minimally invasive sampling methods, and surgical techniques for diagnosis and staging. The fourth and final section looks at different therapeutic aspects, such as the role of surgery, chemotherapy, radiation therapy, a multidisciplinary approach according to disease stage, and other specifically targeted treatments, concluding with recommendations on the follow-up of lung cancer patients and surgical and endoscopic palliative interventions in advanced stages.

Bronchiectasis due to pulmonary artery aneurysm

Pulmonary artery aneurysm (PAA) is a rare entity. We report what we believe to be the first case of bronchiectasis resulting from a PAA, which in turn developed after a previous Senning procedure for transposition of the great vessels during infancy. The patient had bronchiectasis secondary to compression of the left main bronchus because of a PAA. Bronchiectasis is a condition indicating lung resection. Despite the patient receiving medical therapy to treat recurrent pneumonia, lobectomy was necessary to prevent this and other possible complications.

Periareolar approach for thoracoscopic lobectomy.

In recent years advances in video-assisted thoracoscopic surgery have been aimed at reducing the number of video surgery ports, and especially major lung resections pose the greatest challenge. We describe a new minimally invasive as well as aesthetic approach for thoracoscopic lobectomy. The technique poses no difficulty for the surgeon and has certain advantages over other videothoracoscopic approaches.

Mesotelioma deciduoide pleural en un adolescente

1. Gómez Sanchez MA. Infecciones por gram negativos (BGN) en pacientes con hipertensión arterial pulmonar tratados con prostaciclinas intravenosas. Arch Bronconeumol. 2012. http://dx.doi.org/10.1016/j.arbres.2012.09.003, in press. 2. López-Medrano F, Fernandez Ruiz M, Ruiz Cano MJ, Barrios E, VicenteHernandez M, Aguado JM, et al. Alta incidencia de bacteriemia por bacilos gramnegativos en pacientes con hipertensión pulmonar tratados con treprostinil por vía intravenosa. Arch Bronconeumol. 2012, http://dx.doi.org/10.1016/ j.arbres.2012.06.005. 3. Kitterman N, Poms A, Miller DP, Lombardi S, Farber HW, Barst RJ. Bloodstream infections in patients with pulmonary arterial hypertension treated with intravenous prostanoids: insights from the REVEAL REGISTRY . Mayo Clin Proc. 2012;87:825–34. Francisco López-Medrano, Mario Fernández-Ruiz,∗ Maria José Ruiz-Cano, Pilar Escribano

Benchmarking en cirugía torácica. Tercera edición

INTRODUCTION Benchmarking entails continuous comparison of efficacy and quality among products and activities, with the primary objective of achieving excellence. OBJECTIVE To analyze the results of benchmarking performed in 2013 on clinical practices undertaken in 2012 in 17 Spanish thoracic surgery units. METHODS Study data were obtained from the basic minimum data set for hospitalization, registered in 2012. Data from hospital discharge reports were submitted by the participating groups, but staff from the corresponding departments did not intervene in data collection. Study cases all involved hospital discharges recorded in the participating sites. Episodes included were respiratory surgery (Major Diagnostic Category 04, Surgery), and those of the thoracic surgery unit. Cases were labelled using codes from the International Classification of Diseases, 9th revision, Clinical Modification. The refined diagnosis-related groups classification was used to evaluate differences in severity and complexity of cases. RESULTS General parameters (number of cases, mean stay, complications, readmissions, mortality, and activity) varied widely among the participating groups. Specific interventions (lobectomy, pneumonectomy, atypical resections, and treatment of pneumothorax) also varied widely. CONCLUSIONS As in previous editions, practices among participating groups varied considerably. Some areas for improvement emerge: admission processes need to be standardized to avoid urgent admissions and to improve pre-operative care; hospital discharges should be streamlined and discharge reports improved by including all procedures and complications. Some units have parameters which deviate excessively from the norm, and these sites need to review their processes in depth. Coding of diagnoses and comorbidities is another area where improvement is needed.

Es una buena opción terapéutica la cirugía pulmonar en pacientes mayores de 80 años

INTRODUCTION The number of geriatric patients with lung cancer is expected to increase in the next few years, especially patients over 80, and therefore it is important to know where the therapeutic limits should be drawn. Is surgery a good option in patients over 80? OBJECTIVE To show the results of lung resection in patients over 80 years of age to evaluate the safety and short-term results. MATERIAL AND METHODS Retrospective study of 21 patients who underwent lung resection between October 1999 and October 2011. RESULTS The mean age of the patients was 82 ± 2; 13 lobectomies were performed,5 transegmental resections, 2 segmentectomies, and 1 pneumonectomy. Postoperative complications (28.6%) were: respiratory 66.6%, cardiological 16.7% and digestive 16,7%. Perioperative mortality was 9,5% (2). There was a significant association between mortality and age (P=.023), or pneumonectomy (P=.002). We studied COPD as a risk factor for mortality and found a statistically significant relation with the need for ICU (P<.007), and the appearance of complications (P<.044). CONCLUSIONS Resective lung surgery is feasible and safe in selected patients over 80 years of age. In our experience, squamous cell carcinoma was the most frequent tumor. The most common procedure was lobectomy which is a safe technique with a low complication rate in elderly patients. Pneumonectomy should be avoided, as we have found a significant association with perioperative mortality.INTRODUCTION The number of geriatric patients with lung cancer is expected to increase in the next few years, especially patients over 80, and therefore it is important to know where the therapeutic limits should be drawn. Is surgery a good option in patients over 80? OBJECTIVE To show the results of lung resection in patients over 80 years of age to evaluate the safety and short-term results. MATERIAL AND METHODS Retrospective study of 21 patients who underwent lung resection between October 1999 and October 2011. RESULTS The mean age of the patients was 82 ± 2; 13 lobectomies were performed,5 transegmental resections, 2 segmentectomies, and 1 pneumonectomy. Postoperative complications (28.6%) were: respiratory 66.6%, cardiological 16.7% and digestive 16,7%. Perioperative mortality was 9,5% (2). There was a significant association between mortality and age (P=.023), or pneumonectomy (P=.002). We studied COPD as a risk factor for mortality and found a statistically significant relation with the need for ICU (P<.007), and the appearance of complications (P<.044). CONCLUSIONS Resective lung surgery is feasible and safe in selected patients over 80 years of age. In our experience, squamous cell carcinoma was the most frequent tumor. The most common procedure was lobectomy which is a safe technique with a low complication rate in elderly patients. Pneumonectomy should be avoided, as we have found a significant association with perioperative mortality.

Reconstrucción torácica con prótesis de metacrilato en el síndrome de Poland

Poland syndrome is a rare congenital malformation. This syndrome was described in 1841 by Alfred Poland at Guys Hospital in London. It is characterized by hypoplasia of the breast and nipple, subcutaneous tissue shortages, lack of the costosternal portion of the pectoralis major muscle and associated alterations of the fingers on the same side. Corrective treatment of the chest and soft tissue abnormalities in Poland syndrome varies according to different authors. We report the case of a 17-year-old adolescent who underwent chest wall reconstruction with a methyl methacrylate prosthesis. This surgical procedure is recommended for large anterior chest wall defects, and it prevents paradoxical movement. Moreover it provides for individual remodeling of the defect depending on the shape of the patients chest.

Ganglioneuroma mediastínico, un hallazgo fortuito en metastasectomía pulmonar y hepática de tumor de células germinales

152 Cir Esp. 2008;83(3):150-9 administracion diaria de dosis bajas. La agregacion plaquetaria se inhibe y alcanza una concentracion maxima estable despues de 4-7 dias, y por ello son necesarios 7 dias, despues de la ultima dosis, para que la funcion plaquetaria se restablezca. Recientemente, Payne et al investigaron el efecto del uso combinado del clopidogrel y la aspirina en el tiempo de sangria en voluntarios sanos, observaron que, tras 2 dias de tratamiento con clopidogrel 75 mg/dia y AAS 150 mg/dia, el tiempo de sangria era 3,4 veces mayor que el basal. La cirugia no demorable imposibilita actuar de manera acorde con lo establecido en las guias sobre uso de farmacos antiagregantes plaquetarios, ya que no es posible su demora un minimo de 6 semanas para minimizar los riesgos, ni es posible la sustitucion de los antiagregantes “mayores” (aspirina y tienopiridinas) por antiinflamatorios no esteroideos de vida media corta y con efectos antiagregantes reversibles. En la actualidad, es frecuente que tanto cirujanos como anestesiologos se encuentren con pacientes tratados con este tipo de farmacos, tanto en cirugia electiva como de urgencia, lo que plantea frecuentes controversias entre ambas especialidades en lo que se refiere al momento de realizar la intervencion. En nuestro caso, dado que nos encontrabamos ante una hemorragia grave, favorecida en gran medida por la toma de 2 antiagregantes, el tratamiento incluyo la transfusion de plaquetas, a pesar de aumentar asi el riesgo de trombosis coronaria y reinfarto, como posiblemente sucedio en nuestro enfermo. En ausencia de guias que orienten ante este tipo de situaciones, los riesgos y beneficios de nuestras actuaciones deberan valorarse ad hoc para cada paciente, considerando dos aspectos fundamentales: la posibilidad de complicaciones cardiologicas y la tecnica quirurgica, incluyendo aspectos como duracion, agresividad y sangrado.