Félix Heras

Early Complications in Surgical Treatment of Lung Cancer: A Prospective, Multicenter Study

BACKGROUND We prospectively analyzed the postoperative morbidity, mortality rate, and risk factors in 605 patients who underwent thoracotomy for bronchogenic carcinoma. METHODS Patients were categorized by postsurgical tumor stage: I, 287 patients (47.4%); II, 49 patients (8.1%); IIIA, 154 patients (25.5%); IIIB, 80 patients (13.2%); IV, 16 patients (2.7%); unavailable, 19 patients (3.1%). Two hundred ninety-four patients (48.6%) underwent lobectomy, 172 (28.4%) pneumonectomy, 20 (3.3%) bilobectomy, 29 (4.8%) segmentectomy, 27 (4.5%) wedge resection, and 63 (10.4%) exploratory thoracotomy. The importance of the factors that influence the morbidity and mortality rates was calculated from their relative risks. Univariate and multivariate methods for a logistic regression model were used for this analysis. RESULTS Postoperative complications developed in 196 patients (32.4%); there were 165 (27.3%) cases of operation-related complications and 152 (25.1%) cases of respiratory and cardiovascular complications. The morbidity rate was highest in patients with preexisting vascular disease (50.9%; odds ratio [OR], 2.20) or insulin-dependent diabetes mellitus (52.4%; OR, 2.77) and in patients who underwent pneumonectomy (40.1%; OR, 1.82). Forty patients (6.6%) died postoperatively, most commonly of respiratory failure (67.5%). The mortality rate was highest in patients with postoperative morbidity (OR, 31.9) or vascular disease (15.8%; OR, 2.83) and in patients who underwent pneumonectomy (13.4%; OR, 4.9). CONCLUSIONS Postoperative complications are more likely to develop in patients with peripheral vascular disease or insulin-dependent diabetes mellitus, or both. Postoperative mortality was found to be significantly higher in patients with vascular disease and those who underwent pneumonectomy.

Prognostic factors in neuroendocrine lung tumors: a Spanish multicenter study

Background. This study examines the experience of the Spanish Multicenter Study of Neuroendocrine Tumors of the Lung through the clinical data and behavior of patients treated for this pathologic process. Methods. From 1980 to 1997, 361 cases of neuroendocrine carcinomas (NEC) were treated surgically. Patients were enrolled in a protocol using the pathologic and follow-up reports. According to Dreslers’ criteria, the cases were segregated into grade 1 (typical carcinoid), grade 2 (atypical carcinoid), grade 3 large cell type, and grade 3 small cell type. Several variables were reviewed in all patients. Statistical analysis was performed to determine whether clinical characteristics and differentiation were associated with significant differences in the prognosis. Results. A total of 261 cases of NEC were identified with grade 1, 43 with grade 2, and with grade 3: 22 of large and 35 of small cells. Five-year survival for different grades was as follows: grade 1, 96%; 2, 72%; 3 large cell type, 21%; and 3 small cell type, 14%. When a comparative analysis between typical and atypical carcinoids was performed a significant difference for mean age, tumor size, nodal metastases, and recurrence was observed. However, female sex, nodal metastases, and recurrence rate differed between atypical carcinoids and grade 3 NEC of large cells. A difference in recurrence rate was found between patients with both types of grade 3 NEC. Conclusions. The progressive deterioration of tumor organization highlights that neuroendocrine tumors constitute a continuous spectrum. A careful observation of pathologic findings is necessary to individualize their prognostic factors.

Open-Window Thoracostomy and Thoracomyoplasty to Manage Chronic Pleural Empyema

BACKGROUND The purpose of this study is to report our 15-year experience treating chronic empyemas after pulmonary resection and tuberculosis. METHODS Open-window thoracostomy and thoracomyoplasty were used to treat 40 patients with chronic pleural empyema characterized by residual empyematic cavity, bronchopleural fistula, and persistent pleural infections that were secondary to tuberculosis (n = 22) or pulmonary resection (n = 18). Between 2 and 7 months after thoracostomy, thoracomyoplasty was performed to eliminate a persistent pleural cavity. In 2 patients with postpulmonary resection empyema and a large bronchopleural fistula, intrathoracic transposition of the latissimus dorsi flap and open-window thoracostomy were performed simultaneously to close the fistula. RESULTS The pleural space was eliminated per primam intentionem in 21 of 22 patients with tuberculosis and in 14 of 18 with a postpulmonary resection empyema. Another myoplasty was performed in an additional 3 patients to eliminate the pleural space. During open-window thoracostomy, the latissimus dorsi muscle was preserved with minimal injury to the anterior serratus muscle. One patient died postoperatively. CONCLUSIONS Successful treatment of chronic pleural empyema requires adequate timing of surgical procedures. Our two-procedure technique is relatively simple and safe.

Quistes hidatídicos de mediastino: 8 casos

La hidatidosis en el ser humano es una enfermedad parasitaria producida por el crecimiento quistico de la larva de la tenia Echinococcus granulosus . Los organos mas afectados son el higado y el pulmon. La localizacion mediastinica es muy rara y se han descrito aproximadamente 100 casos en la bibliografia. Presentamos 8 casos de quistes hidatidicos de mediastino (QHM) intervenidos en un periodo de 21 anos. La distribucion fue similar en ambos sexos. La edad oscilo entre 10 y 74 anos. En los QHM la sintomatologia depende del tamano, localizacion y afectacion de estructuras proximas. La complicacion mas grave es la rotura del quiste y el paso del material hidatidico a la sangre, lo que puede provocar shock anafilactico e incluso la muerte del paciente. Actualmente, la ecografia, la tomografia computarizada (TAC) y la resonancia magnetica (RM) facilitan el diagnostico. El tratamiento es la exeresis del quiste y de la periquistica. Se debe sospechar QHM en las lesiones quisticas mediastinicas en paises de alta incidencia de hidatidosis. Hydatidosis in humans is a parasitic disease produced by cystic growth of the larvae of the tapeworm Echinococcus granulosus, affecting mainly the liver and lung. Larvae are rarely present in the mediastinum, although approximately 100 cases have been described in the literature. We report eight cases of hydatid cysts of the mediastinum (HCM) treated surgically over a period of 21 years. The incidence was similar in males and females and ages ranged from 10 to 74 years. Symptoms depend on size, location and involvement of neighboring structures in HCM. The most serious complication is cyst rupture with consequent transfer of hydatid material to the blood, possibly causing anaphylactic shock and even death. Currently, sonography, computed tomography and magnetic resonance images facilitate diagnosis. Treatment involves excision of the cyst and pericystic tissue. CHM should be suspected when mediastinal cysts are found in countries where the incidence of hydatidosis is high.

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.

Schwannoma del nervio vago intratorácico

Schwannomas, or neurilemomas, are tumors that originate in the sheaths covering peripheral nerve fibers. They are usually encapsulated, slow growing, and asymptomatic. Such tumors may appear in any nerve, although most are found in the extremities. Intrathoracic vagus schwannomas are very rare and only 72 cases have been reported. We present a new case in a 39-year-old man in whom chest film showed a well-defined, homogeneous mass measuring 3 cm in diameter located in the left para-aortic region. The presence of a smooth tumor on the vagus nerve and recurrent loop was confirmed by left lateral thoracotomy. After removal, the tumor was shown to be a vagal nerve schwannoma.

Interleukin-8 Expression in Lung Tissue During Ischemia-Reperfusion

OBJECTIVE Local cytokine production is a pathogenic factor in ischemia-reperfusion injury in early graft dysfunction. This study analyzed interleukin 8 (IL-8) messenger RNA (mRNA) expression in lung tissue and the association between IL-8 mRNA levels and interstitial lung changes in an experimental model of warm lung ischemia-reperfusion. MATERIAL AND METHODS We studied 16 New Zealand rabbits divided into 3 groups: control, ischemia (tissue taken from right lower lobe after 1, 2, or 3 hours of ischemia), and reperfusion (tissue taken from right upper and middle lobes after 1 hour of ischemia and 1, 2, or 3 hours of reperfusion). Expression of IL-8 mRNA was determined by reverse transcription and polymerase chain reaction. Interstitial infiltration by polymorphonuclear neutrophils was determined. The Mann-Whitney U-test was used for statistical comparisons, with P< .05 considered to indicate a significant result. RESULTS During ischemia, IL-8 mRNA levels were elevated at the end of hour 1 (P=.009) with respect to the control group, but not thereafter. Interstitial changes were minimal. IL-8 mRNA levels during reperfusion were similar to those observed during ischemia, with a slight increase at the end of hour 2. There were no significant differences between hours 1, 2, and 3. Polymorphonuclear neutrophil recruitment occurred at the beginning of reperfusion (P=.014), but no significant differences were observed at hours 2 or 3. Progressive thickening of alveolar septa and edema was documented. CONCLUSIONS Changes in IL-8 mRNA expression during ischemia precede interstitial infiltration by polymorphonuclear neutrophils during reperfusion, suggesting that the 2 processes are related. Quantification of IL-8 mRNA expression could facilitate early diagnosis of graft dysfunction.

Tratamiento quirúrgico del cáncer de pulmón: evaluación comparativa de los sistemas de estadificación de 1986 y 1997. Resultados en 500 pacientes consecutivos

Objetivo Evaluar la influencia de diferentes variables en la supervivencia con referencia a la estadificacion de 1986 y 1997. Pacientes y metodos Se incluyeron en el estudio 500 pacientes afectados de cancer de pulmon no de celulas pequenas, tratados quirurgicamente de 1980 a 1997; 473 eran varones y 27 mujeres. Resecciones practicadas: 184 lobectomias, 16 bilobectomias, 244 neumonectomias, 2 lobectomias broncoplasticas y 54 segmentectomias. Histologia: 338 carcinomas epidermoides, 86 adenocarcinomas, 40 carcinomas de celulas grandes, 36 tumores mixtos. Diferenciacion: 216 G1, 91 G2, 193 G3. Estadios de 1986: I: 246 (49,2%) (T1: 32; T2: 214); II: 27 (5,4%); IIIa: 197 (39,4%) (N0: 84; N1: 2; N2: 111); IIIb 23 (4,6%) (N0: 12; N2: 11), y IV: 7 (1,4%) (N0: 4; N2: 3). Se utilizo la estadificacion de 1997 para la comparacion de la supervivencia entre los tumores Ia y Ib, y IIb y IIIa. Resultados Transcurridos entre 2 y 17 anos, 141 pacientes (28%) permanecen vivos, 26 (5%) perdidos y 333 han muerto. Mortalidad intraoperatoria: 2 (0,4%); postoperatoria: 36 (7,2%). De los 462 pacientes restantes, 295 fallecieron por diversas causas: metastasis 130 (44%), recidiva 81 (27%), causas funcionales 17 (6%), causas independientes 54 (18%), causas desconocidas 13 (4%). Supervivencia a 5 y 10 anos: global 36 y 26%; histologia: carcinomas epidermoides 36 y 26%; adenocarcinomas 35 y 26%; estadios: I: 51 y 41% (Ia, 81 y 75%; Ib, 44 y 33%); IIIa: 24 y 15 (IIb de 1997: 27 y 17%; IIIa de 1997: 20 y 13%); de acuerdo con factor N: N0: 44 y 34%; N2: 17 y 8% (1986) y 17 y 11% (1997). Conclusiones En este trabajo, la supervivencia hallada es concordante con otros estudios. La utilidad de la estadificacion de 1997 se puede establecer en funcion de las diferencias de supervivencia hallada entre los estadios Ia y Ib y IIb y IIIa. Se aprecia una influencia de factores N y T, la histologia y el estadio de la aparicion de metastasis, asi como el factor T en la de recidivas.

Experiencia de los Servicios de Cirugía Torácica españoles en el tratamiento del pectus excavatum mediante la técnica de Nuss

INTRODUCTION Although the Nuss technique revolutionized the surgical treatment of pectus excavatum, its use has not become widespread in our country. The aim of this study was to analyze the current use of this technique in a sample of Thoracic Surgery Departments in Spain. METHODS Observational rectrospective multicentric study analyzing the main epidemiological aspects and clinical results of ten years experience using the Nuss technique. RESULTS Between 2001 and 2010 a total of 149 patients were operated on (mean age 21.2 years), 74% male. Initial aesthetic results were excellent or good in 93.2%, mild in 4.1% and bad in 2.7%. After initial surgery there were complications in 45 patients (30.6%). The most frequent were wound seroma, bar displacement, stabilizer break, pneumothorax, haemothorax, wound infection, pneumonia, pericarditis and cardiac tamponade that required urgent bar removal. Postoperative pain appeared in all patients. In 3 cases (2%) it was so intense that it required bar removal. After a mean follow-up of 39.2 months, bar removal had been performed in 72 patients (49%), being difficult in 5 cases (7%). After a 1.6 year follow-up period good results persisted in 145 patients (98.7%). CONCLUSION Nuss technique in adults has had good results in Spanish Thoracic Surgery Departments, however its use has not been generalized. The risk of complications must be taken into account and its indication must be properly evaluated. The possibility of previous conservative treatment is being analyzed in several departments at present.

Detección de la afectación ganglionar y tratamiento quirúrgico de los procesos neoplásicos pulmonares. Estado actual de distintos procederes diagnósticos y terapéuticos

Resumen Este trabajo se basa en el analisis de distintas publicaciones relacionadas con la estadificacion y el tratamiento quirurgico de procesos neoplasicos pulmonares primitivos y metastasicos. En los pacientes con carcinoma broncogenico, determinar la afectacion ganglionar resulta imprescindible para programar un tratamiento adecuado. La indicacion y la secuencia del procedimiento a emplear (tomografia computarizada, tomografia por emision de positrones, puncion transbronquial, puncion aspirativa transbronquial guiada por ultrasonidos, videomediastinoscopia, mediastinotomia anterior, videotoracoscopia) se evaluan en razon de la sensibilidad, la especificidad y el valor predictivo positivo y negativo de los distintos metodos. Otro reto de interes es la definicion del criterio de indicacion de una reseccion sublobar en determinados tumores y pacientes. Se analizan distintos factores, como la edad, la funcion pulmonar, la localizacion tumoral y el tipo de reseccion sublobar. Tambien se consideran los niveles de evidencia y los grados de recomendacion del procedimiento. En el tratamiento de metastasis pulmonares de carcinoma colorrectal, la reseccion quirurgica es una opcion terapeutica aceptada. Se analiza de forma pormenorizada su indicacion, basada en la obtencion de tasas aceptables de supervivencia y el conocimiento de la repercusion de distintos factores pronosticos (intervalo libre de enfermedad, numero de metastasis, presencia de metastasis hepaticas, presencia de afectacion ganglionar, o valores preoperatorios elevados de antigeno carcinoembrionario).An analysis is made of different publications associated with the surgical staging and treatment of primary and metastasic pulmonary neoplastic processes. A suitable treatment program is essential to determine lymph node involvement in patients with bronchogenic carcinoma. The indication and sequence of the procedure to use (CT-PET, transbronchial puncture, videomediastinoscopic ultrasound guided transbronchial needle aspiration) is evaluated in accordance to the sensitivity, specificity and positive and negative predictive value of the different methods. Another interesting challenge is to define the criteria for indicating a sublobar resection in certain tumours and patients. Different factors, age, lung function, tumour location and type of sublobar resection, are analysed. Levels of evidence and recommendations of the procedure are also considered. Surgical resection is an accepted therapeutic option in the treatment of colorectal cancer lung metastases. Its indication is based on acceptable survival rates and knowledge of the impact of various factors (interval free of disease, number of metastases, presence of liver metastasis, presence of lymph node involvement, or increased pre-operative levels of carcinoembryonic antigen), is analysed in detail.