Emilio Canalís

Surgical treatment of primary spontaneous pneumothorax with video-assisted thoracic surgery.

We report the results of our experience using video-assisted thoracoscopic surgery (VATS) to treat primary spontaneous pneumothorax (PSP) from January 1992 until December 1994 in a multicentered co-operative study. A total of 132 patients (110 males and 22 females, aged 13-38 yrs, mean age 26 yrs) were treated by VATS to deal with the PSP that they presented with. A standard VATS technique was used. Apical bullae were always removed, and mechanical pleural abrasion was performed, leaving a pleural drainage tube. In two cases (1.5%), a switch to thoracotomy was necessary. In eight cases (6%), air leakage persisted for 5 days after surgery, which resolved with pleural drainage. There were eight postoperative relapses (6%), which were treated with pleural drainage (n = 4), VATS (n = 3) or axillar thoracotomy (n = 1). The average postoperative stay was 5.6 days (range 2-15 days). We conclude that video-assisted thoracoscopic surgery is a viable alternative for the treatment of primary spontaneous pneumothorax. There is, however, a high relapse rate, and in a number of cases air leakage persists in the postoperative period.

Simpatectomía torácica por videotoracoscopia para el tratamiento del rubor facial: bisturí ultrasónico frente a diatermia

Objetivo Valorar las ventajas de la utilizacion del bisturi ultrasonico frente a la electrocoagulacion, en los pacientes operados de rubor facial incontrolable mediante simpaticolisis o simpaticotomia toracica por videotoracoscopia. Metodo Se han realizado 200 interrupciones del simpatico toracico bilaterales por videotoracoscopia en 100 pacientes afectados de rubor facial invalidante. Dos de ellas se realizaron mediante cirugia videoasistida por presentar sinfisis pleural. La edad media de los pacientes fue de 34 anos (rango: 15–67). La cadena simpatica fue interrumpida desde la porcion inferior de T1 hasta T3 inclusives. Resultados Todos los pacientes fueron dados de alta en 24 h, a excepcion del paciente en el que se realizo toracotomia de asistencia. En el grupo en que se utilizo el bisturi armonico no hubo complicaciones. En el grupo de diatermia hubo un caso de sindrome de Horner transitorio (4 meses) y tres casos de dolor toracico persistente (superior a dos semanas). En total, hubo 9 neumotorax parcelarios y asintomati-cos que no requirieron tratamiento ni prolongaron la estan-cia hospitalaria. Conclusiones El bisturi ultrasonico permite una seccion del simpatico mas firme y con mejor visualizacion. Evita lesiones perifericas en el parenquima pulmonar y tejidos adyacentes (vasos y nervios intercostales), asi como el sindrome de Horner que se puede producir por efecto calorifico. Produciria tambien una menor incidencia de neuralgias posquirurgicas.

Experiencia piloto de benchmarking en cirugía torácica: comparación de la casuística e indicadores de calidad en resección pulmonar

Objetivo En el presente articulo se describen los metodos y las conclusiones del primer estudio espanol de benchmarking en cirugia toracica. Los objetivos propuestos fueron: describir la casuistica de reseccion pulmonar desarrollada en 9 hospitales espanoles, comparar indicadores de calidad entre los 9 centros participantes e identificar y proponer areas de mejora comunes para los procesos de reseccion pulmonar. Metodos Se utilizo como fuente de informacion el conjunto minimo basico de datos de los anos 2002 y 2003 de los procesos de lobectomia o neumonectomia. Los indicadores de resultados seleccionados fueron: mortalidad hospitalaria, morbilidad, estancia y readmisiones urgentes en los 30 dias siguientes al alta, ajustadas por complejidad de los casos. Una vez presentados los resultados entre los participantes, se identificaron las unidades con mejores resultados y se discutieron diversas propuestas de mejora. Resultados Se ha estudiado un total de 1.666 procedimientos (1.276 lobectomias y 390 neumonectomias). Se detectaron diferencias en estancia media, mortalidad, tasa de readmisiones y morbilidad, que permitieron identificar unidades, de complejidad equiparable o superior, con baja mortalidad y estancia. Sin embargo, en estas unidades se apreciaron tasas de morbilidad y readmision mas elevadas. Conclusiones Se propusieron medidas encaminadas a registrar todos los diagnosticos relevantes en los informes de alta, disminuir las estancias inadecuadas y estandarizar los procedimientos que permitiran en el futuro establecer criterios fiables para mejorar la calidad de los procesos de reseccion pulmonar.

Video-assisted Thoracoscopic Sympathectomy for the Treatment of Facial Blushing: Ultrasonic Scalpel Versus Diathermy

OBJECTIVE To evaluate the advantages of the ultrasonic scalpel compared to electrocoagulation in patients undergoing video-assisted thoracoscopic sympatholysis or sympathectomy for uncontrolled facial blushing. METHODS Two hundred bilateral video-assisted thoracoscopic procedures to interrupt transmission in the thoracic sympathetic nerve were performed in 100 patients with incapacitating facial blushing. In 2 cases, the video-assisted approach was chosen because of pleural symphysis. The mean age of patients was 34 years (range: 15 to 67). The sympathetic chain was interrupted from the lower portion of the first thoracic ganglion through the third. RESULTS All patients were discharged within 24 hours with the exception of one on whom an emergency thoracotomy had been performed. No complications were reported in the group in which a harmonic scalpel was used. One case of temporary Horner syndrome (4 months) and 3 cases of persistent chest pain (more than 2 weeks) were reported in the diathermy group. There were 9 cases of partial and asymptomatic pneumothorax that resolved without treatment or prolonged hospital stays. CONCLUSION Dissection of the sympathetic nerve is accomplished more reliably and with better visualization with the ultrasonic scalpel. Peripheral lesions in lung parenchyma and adjacent tissues (intercostal vessels and nerves) are avoided, as is Horner syndrome, which can be caused by dispersion of heat. Use of the ultrasonic scalpel would also lead to a lower incidence of postoperative neuralgia.

Role of major resection in pulmonary metastasectomy for colorectal cancer in the Spanish prospective multicenter study (GECMP-CCR)

BACKGROUND Patients with pulmonary metastases from colorectal cancer (CRC) may benefit from aggressive surgical therapy. The objective of this study was to determine the role of major anatomic resection for pulmonary metastasectomy to improve survival when compared with limited pulmonary resection. PATIENTS AND METHODS Data of 522 patients (64.2% men, mean age 64.5 years) who underwent pulmonary resections with curative intent for CRC metastases over a 2-year period were reviewed. All patients were followed for a minimum of 3 years. Disease-specific survival (DSS) and disease-free survival (DFS) were assessed with the Kaplan-Meier method. Factors associated with DSS and DFS were analyzed using a Cox proportional hazards regression model. RESULTS A total of 394 (75.6%) patients underwent wedge resection, 19 (3.6%) anatomic segmentectomy, 5 (0.9%) lesser resections not described, 100 (19.3%) lobectomy, and 4 (0.8%) pneumonectomy. Accordingly, 104 (19.9%) patients were treated with major anatomic resection and 418 (80.1%) with lesser resection. Operations were carried out with video-assisted thoracoscopic surgery (VATS) in 93 patients. The overall DSS and DFS were 55 and 28.3 months, respectively. Significant differences in DSS and DFS in favor of major resection versus lesser resection (DSS median not reached versus 52.2 months, P = 0.03; DFS median not reached versus 23.9 months, P < 0.001) were found. In the multivariate analysis, major resection appeared to be a protective factor in DSS [hazard ratio (HR) 0.6, 95% confidence interval (CI) 0.41-0.96, P = 0.031] and DFS (HR 0.5, 95% CI 0.36-0.75, P < 0.001). The surgical approach (VATS versus open surgical resection) had no effect on outcome. CONCLUSION Major anatomic resection with lymphadenectomy for pulmonary metastasectomy can be considered in selected CRC patient with sufficient functional reserve to improve the DSS and DFS. Further prospective randomized studies are needed to confirm the present results.

Pilot Benchmarking Study of Thoracic Surgery in Spain: Comparison of Cases of Lung Resection and Indicators of Quality

OBJECTIVE This article describes the methods and conclusions of the first Spanish benchmarking study of thoracic surgery. The proposed aims were to describe cases of lung resection in 9 Spanish hospitals, compare indicators of quality among the 9 participating centers, and identify and propose common areas where lung-resection processes could be improved. METHODS Information was taken from the minimum basic data set for lobectomy and pneumonectomy processes performed in 2002 and 2003. The chosen outcome indicators were in-hospital mortality, morbidity, length of hospital stay, and emergency readmissions within 30 days of discharge, adjusted according to surgical complexity. Once the results had been analyzed, the participating centers with best outcomes were identified and a variety of proposed improvements were discussed. RESULTS A total of 1666 procedures (1276 lobectomies and 390 pneumectomies) were studied. We found differences in mean length of stay, mortality, readmission rate, and morbidity that identified centers with lower mortality or shorter hospital stay for comparable or more complex surgical procedures. However, higher morbidity and readmission rates were found in these centers. CONCLUSIONS Measures were proposed to ensure that relevant diagnostic information is recorded on discharge. It was also proposed to reduce unnecessarily long hospital stays and to standardize the procedures. With such an approach, reliable criteria that improve the quality of lung-resection processes can be established in the future.

Agreement Between Computed Tomography and Pathologic Nodule Counts in Colorectal Lung Metastases

BACKGROUND Computed tomography is the most common technique used to estimate the number of pulmonary metastases and their resectability. A lack of agreement between radiologic and surgical pathologic findings could potentially lead to incomplete resection or to rejection of patients for potentially curative treatments. The objective of this study was to estimate the disagreement between the number of radiologic lesions and the number of histologically confirmed malignant lesions excised from patients with pulmonary metastases from colorectal cancer. METHODS This was a multicenter longitudinal study using a national registry. All patients underwent open surgery for pulmonary metastasectomy. RESULTS Radiologic unilateral involvement was documented in 345 of 404 patients (85%); 253 (73%) presented with single nodules. The radiologic and malignant pathologic findings were concordant in 316 (78%) patients. The two independent predictors of discordance between computed tomography and the number of pathologic metastases were the bilateral involvement and the number of radiologic nodules. This model explained 28% of the variability in the disagreement frequency and discriminated between agreement and disagreement in 85% of the patients. Discrepancies increased with the nodule count with an odds ratio of 6.17 (95% confidence interval, 4.08 to 9.33) per additional nodule. For similar nodule counts, a lower disagreement frequency was observed among bilateral cases (odds ratio, 0.2; 95% confidence interval, 0.07 to 0.55). CONCLUSIONS Differences between the radiologic and pathologic findings were documented in 1 of every 5 patients. The correlation was very accurate in patients with single radiologic nodules. However, half of the patients with more nodules showed discrepancies.

Experiencia en el tratamiento quirúrgico de los tumores primarios malignos de la pared torácica

Resumen Analizamos de manera retrospectiva a 33 pacientes afectados de tumores malignos primarios de la pared toracica, intervenidos quirurgicamente entre enero de 1985 y enero de 2002. Valoramos los resultados de la tecnica quirurgica utilizada, la recurrencia tumoral y la supervivencia de los pacientes. En todos los casos se realizo una reseccion en bloque de la lesion con pretension radical. Se efectuaron 39 resecciones de pared toracica. El numero de arcos costales resecados oscilo entre dos y cinco (media, 2,6). En 27 casos fue necesario reconstruir la pared toracica con protesis de material sintetico, y en cinco de ellos se llevo a cabo, ademas, una mioplastia (cuatro injertos pediculados de musculo dorsal ancho y uno de musculo pectoral mayor). En 6 casos se realizo, ademas, una esternectomia parcial. El seguimiento medio de los pacientes fue de 45,6 meses (rango 3-140 meses). Once pacientes fallecieron a causa del tumor. Los 14 pacientes intervenidos de condrosarcoma tuvieron un seguimiento medio algo inferior (41,5 meses); diez de estos enfermos se hallan actualmente libres de enfermedad y dos han fallecido a consecuencia de la progresion tumoral. La supervivencia actuarial (Kaplan-Meier) a los 5 anos de los pacientes con condrosarcoma (n = 14) fue del 75 ± 21%. El resto de pacientes, exceptuando las fibromatosis agresivas (tumor desmoide) y el paracordoma (n = 14), tuvieron una supervivencia actuarial a los 5 anos del 26 ± 10%.

Seudoquistes pulmonares traumáticos

Presentamos 2 casos de seudoquistes pulmonares traumaticos (SPT) en pacientes jovenes. En ambos casos un accidente de trafico fue la causa de un traumatismo toracico cerrado y aparecieron cavidades aereas en la radiografia de torax a las 12 y una horas. En ambos casos una hemoptisis autolimitada precedio a la aparicion de un nivel hidroaereo en el control radiografico efectuado. El diagnostico se efectuo por exclusion y la evolucion fue favorable unicamente con tratamiento sintomatico y de las lesiones asociadas. Se discuten los aspectos mas importantes de la patogenia, clinica y radiologia de este tipo de lesiones.

Nuestra experiencia en el tratamiento de las lesiones obstructivas de la vía aérea principal mediante fotorresección con láser Yag-Nd

We performed 164 laser resections with a neodymiumyttrium-aluminum-garnet (Nd-Yag) laser in 116 patients between January 1992 and December 1997. Seventy-eight patients had malignant neoplasms, 5 had neoplasms of intermediate malignancy and 33 had inflammatory tracheal lesions. Eighteen resections were emergency procedures. All resections were performed with the patient under general anesthesia and preferably breathing spontaneously. Immediate results varied according to the nature and location of the lesion. Treatment was palliative for tumors showing intraluminal proliferation, providing successful reopening of the airway as shown endoscopically in 70% of patients. Mean survival of the 44 patients with malignant lesions who could be followed was 29 weeks, with a median of 15.19 (range, 1-120). The tracheas of patients with inflammatory stenosis were reopened rapidly and emergency tracheostomy was avoided in all cases. One patient with malignant tracheal tumors died during the procedure due to asphyxia related to tracheal hemorrhage.