J. Freixinet

Side effects, complications and outcome of thoracoscopic sympathectomy for palmar and axillary hyperhidrosis in 406 patients

BACKGROUND Thoracic sympathectomy (TS) is the treatment of choice for severe primary hyperhidrosis. However, complications, side effects and satisfaction have not been well defined. OBJECTIVE To analyze the complications, side effects, satisfaction degree and quality of life of patients after TS for primary upper limb hyperhidrosis. METHODS One-year follow-up after 406 consecutive TS for primary upper limb hyperhidrosis. RESULTS Bilateral TS was completed in all patients. Complications arose in 23 cases (5.6%), with pneumothorax being the most frequent. The success rate after discharge, 6 and 12 months was respectively, 100%, 98.1% and 96.5% for palmo-axillary hyperhidrosis; 100%, 99.3% and 97.8% for isolated palmar hyperhidrosis and 100%, 85.7% and 71.4% for isolated axillary hyperhidrosis. No persistence of hyperhidrosis was observed. Global recurrence was 3.7% (28.5% axillary hyperhidrosis group). Compensatory sweating (CS) appeared in 55% and was not related to the extension of the TS. Being female was a predisposing factor of CS (p<0.004). Excessive dryness appeared at 9% and was associated with extensive TS (P<0.001). Plantar hyperhidrosis improved at 33.6%, worsened at 10% and remained stable during the follow-up. Satisfaction degree decreased with the passage of time and was associated with recurrence. Quality of life was excellent at discharge, 6 and 12 month in 100%, 100% and 97%, respectively. CONCLUSIONS Pneumothorax is the most frequent complication of TS. CS is the main and undesirable side effect, appears with the passage of time, and is not related to the extension of TS. Being female is the only predictor factor of suffering CS. Plantar hyperhidrosis improves initially, although tends to reappear. Excessive dryness appears in extensive TS and does not improve over time. Postoperative satisfaction degree is high but decreases over time owing to the appearance of recurrence. Effectiveness and the absence of CS determine an excellent quality of life. Six percent of the patients regret the surgery because of severe CS. Informing patients of possible side effects before TS is essential.

Extended cervical mediastinoscopy: Prospective study of fifty cases☆

To assess the usefulness of extended cervical mediastinoscopy (ECM) in the staging of bronchogenic carcinoma, an ECM was performed prospectively in 50 patients with bronchogenic carcinoma of the left lung. The ECM was used after evaluation of disease operability and computed tomographic findings, and was performed simultaneously with standard cervical mediastinoscopy. In ECM, using the same cervical incision as in a standard cervical mediastinoscopy, dissection is performed behind the anterior face of the sternum. The aortic arch is reached at the level of the origin of the innominate artery. The mediastinoscope is then passed by sliding it along the left anterolateral face of the aortic arch until it reaches the aortopulmonary window. Extended cervical mediastinoscopy was considered positive when a nodal biopsy result consistent with a neoformative process or direct invasion of the mediastinal structures was found. Four patients with positive standard cervical mediastinoscopy and negative ECM were excluded. A false negative ECM was defined as the presence of infiltrated adenopathies at the paraaortic level detected on postoperative histologic study. The ECM was positive in 5 patients in whom operation was contraindicated. Resectability in the remaining 41 patients was 97.6%. Postoperative pathologic study showed infiltrated adenopathy in 3 patients (2 subcarinal, 1 subaortic) accounting for 40 true negatives (the subcarinal group is inaccessible by ECM). This study suggests that ECM has outstanding specificity (100%), sensitivity of 83.3%, and a diagnostic accuracy of 97.8%. A positive predictive value of 100% and a negative predictive value of 97.5% were also identified by this study.(ABSTRACT TRUNCATED AT 250 WORDS)

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.

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.

Hepaticothoracic transdiaphragmatic echinococcosis

Between 1970 and 1985, seven patients were referred to us for surgical treatment of simultaneous hydatid cysts in the liver and the chest. Their mean age was 45.4 years (age range, 23-73 years), and they represented 46% of patients with hydatid cysts in the liver and thorax. Three patients had hepaticopleural involvement, and 3 patients had symptoms of pulmonary origin. In a single patient, only the diaphragm was involved along with the liver. Liver scintigraphy and ultrasonography were equally helpful in delineating the extent of the disease, but computed tomographic scanning is now the method of choice. The operations were through a thoracolaparotomy in 3 patients and a thoracotomy alone in 3 patients. A single patient had a thoracotomy with a transdiaphragmatic laparotomy. Complete drainage or excision of hydatid cavities was accomplished in all patients. Hydrogen peroxide instilled into the cysts was satisfactory for control of spread potentially secondary to possible intraoperative spillage. There have been no postoperative deaths. Follow-up has ranged from 6 months to 8 years, and 2 patients had relapsing hydatid disease 3 years postoperatively. These results suggest that, when hydatid disease of the liver is complicated by transdiaphragmatic extension and simultaneous pleural or pulmonary cysts, early surgical repair is indicated. Complete drainage and cyst excision are recommended.

Benchmarking in thoracic surgery

OBJECTIVE Presentation of an experience in benchmarking in 13 university Spanish thoracic surgery services. METHODS The minimum basic data set (MBDS) for hospitalization, corresponding to 2007, including all registered hospital discharges, was used. The performance of the hospitals was compared using an external reference pattern (SN) and internal average (BMG). Cases were chosen in which a major pulmonary resection (lobectomy or pneumonectomy) was done for bronchogenic carcinoma. Performance indicators were the complexity of the casuistry (average weight and relative weight). Performance results indicators included average length of stay (preoperative, postoperative, and global lengths of stay were analyzed separately for lobectomies as well as pneumonectomies), complications, mortality, and urgent readmissions. RESULTS A total number of 4778 cases were analyzed, with major thoracic surgeries being prominent with 1779 (37.3%). For average weight, there was a dispersion between 2.5 and 5.68, with an average of 3.45 for the BMG and 3.43 for the SN. There were some very significant differences in morbidity, with groups having a gross rate of few complications (2.6%) up to many (16.1%). The mortality rate ranged between 1.6% and 6.6%. There were considerable differences in urgent readmissions, with gross rates between 2.6% and 7.3%, considering as points of reference 5.4% (BMG) and 4.7% (SN). Concerning the results of pulmonary resections for bronchogenic carcinoma, the index of pneumonectomies was between 8% and 29%. The average length of stay for lobectomy was between 6 and 9.5, with an average of 7 in BMG. In the case of pneumonectomies, it was between 6 and 26 days, with an average of 9 for BMG. Average preoperative stay also varied widely, between 0.2 and 2.4, while postoperative stay was between 7.5 and 12.1. The gross global rate of complications ranged from 2.7% to 36.7%, with points of reference of 15.6% (BMG) and 13.8% (SN). The complication rate ranged from 3% to 33%, with an average of 14.5% for lobectomies, with higher variability for pneumonectomies (0-58%). CONCLUSIONS Benchmarking could be an effective method for improving clinical management. A considerable variability was detected in our study among the participating groups.

Parámetros de riesgo en la cirugía del carcinoma broncogénico

Objetivo Analizar la morbilidad y mortalidad asociadas a la cirugia de exeresis pulmonar por carcinoma broncogenico, como parametros definitorios del riesgo inherente a este tratamiento. Pacientes y metodos Estudio prospectivo y multicentrico, realizado en los 19 hospitales integrantes del Grupo Cooperativo de Carcinoma Broncogenico entre el 1 de octubre de 1993 y el 30 de septiembre de 1997. En este tiempo fueron sometidos a toracotomia 2.994 pacientes con carcinoma broncogenico. La morbilidad y mortalidad a los 30 dias se recogieron mediante un registro de datos unificado para todos los hospitales. Resultados Se practicaron 2.491 exeresis mayores y 212 menores. Se preciso reseccion extendida en 296 pacientes, mientras que en 291 se efectuo toracotomia exploradora. En 1.057 pacientes (35,2%) se objetivaron complicaciones postoperatorias, de las que las mas frecuentes fueron las relacionadas directamente con la intervencion quirurgica (22,9%), seguidas por las respiratorias (19,5%) y las cardiovasculares (10,7%). En 654 casos (21,8%) las complicaciones fueron de caracter unico, mientras que 403 (13,4%) presentaron mas de una. Atendiendo a su categoria, el 21 % de las complicaciones fueron menores, en tanto que las complicaciones mayores sucedieron en el 14,2 % de los casos. El analisis de la mortalidad en los 30 primeros dias mostro una incidencia del 6,8% (204 pacientes), y estuvo notablemente vinculada con la aparicion de complicaciones mayores (40,8%). Conclusiones En nuestro medio el tratamiento quirurgico del carcinoma broncogenico genera una morbilidad y una mortalidad elevadas, en el rango de las habitualmente referidas en relacion con la morbilidad y en el limite alto cuando se considera la mortalidad. La presencia de complicaciones mayores y/o su multiplicidad deben considerarse elementos sus-tancialmente moduladores del incremento del riesgo.

Colonisation with Aspergillus of an intralobar pulmonary sequestration.

Pulmonary sequestration is a term used to describe an area of embryonic lung tissue supplied by an anomalous systemic artery. Two forms are recognised-extralobar and intralobar-with different clinical presentations. A patient is reported with intralobar pulmonary sequestration in the left lung and colonisation with Aspergillus which was successfully treated by lower lobectomy.

Morbidity and mortality in a large series of surgical patients with pulmonary metastases of colorectal carcinoma: a prospective multicentre Spanish study (GECMP-CCR-SEPAR)

OBJECTIVE Little information is available on postoperative morbidity and mortality after pulmonary metastasectomy. We describe the postoperative morbidity and mortality in a large multicentre series of patients after a first surgical procedure for pulmonary metastases of colorectal carcinoma (CRC) and identify the pre- and intraoperative variables influencing the clinical outcome. METHODS A prospective, observational and multicentre study was conducted. Data were collected from March 2008 to February 2010. Patients were grouped into Groups A and B according to the presence or absence of postoperative complications. Variables in both groups were compared by univariate and multivariate analyses. P-values of <0.05 were considered statistically significant. RESULTS A total of 532 patients (64.5% males) from 32 hospitals were included. The mean (SD) ages of both study groups were similar [68 (10) vs 67 (10) years, P = NS). A total of 1050 lung resections were performed (90% segmentectomies or wedge, n = 946 and 10% lobectomies or greater, n = 104). Group A included 83 (15.6%) patients who developed a total of 100 complications. These included persistent air leaks in 18, atelectasis in 13, pneumonia in 13, paralytic ileum in 12, arrhythmia in 9, acute respiratory distress syndrome in 4 and miscellanea in 31. Reoperation was performed in 5 (0.9%) patients due to persistent air leaks in 4 and lung ischaemia in 1. The mortality rate was 0.4% (n = 2). Causes of death were sepsis in 1 patient and ventricular fibrillation in 1. In the multivariate analysis, lobectomy or greater lung resection [odds ration (OR) 1.9, 95% confidence interval (95% CI) 1.04-3.3, P = 0.03], respiratory co-morbidity (OR 2.3, 95% CI 1.1-4.6, P = 0.01) and cardiovascular co-morbidity (OR 2, 95% CI 1-3.8, P = 0.02) were independent risk factors for postoperative morbidity. Video-assisted surgery vs thoracotomy showed a protective effect (OR 0.3, 95% CI 0.1-0.8, P = 0.01). CONCLUSIONS The first episode of lung surgery for pulmonary metastases of CRC was associated with very low mortality and reoperation rates (<1%). The postoperative morbidity rate was 16%. Independent risk factors of postoperative morbidity were major lung resection and respiratory and/or cardiovascular co-morbidity. Video-assisted surgery showed a protective effect.

Pulmonary Arteriovenous Fistula Ruptured to Pleural Cavity in Pregnancy

Congenital pulmonary arteriovenous fistula is frequently associated with hereditary haemorrhagic telangiectasia (Rendu-Osler-Weber disease). With the increased blood flow in pregnancy such fistulas enlarge, occasionally giving rise to haemothorax, which generally has a poor prognosis. A familial case is presented in which massive haemothorax required emergency thoracotomy in the 27th week of pregnancy.