Jorge Freixinet Gilart

Extended cervical mediastinoscopy in the staging of bronchogenic carcinoma

BACKGROUND Extended cervical mediastinoscopy (ECM) is a technique in the staging of bronchogenic carcinoma described first by Ginsberg in 1984. To update our experience we have prospectively evaluated our results on 106 patients who underwent the technique from 1985 to 1998. METHODS The ECM technique is performed once the operability of the patient has been evaluated, according to the computed tomography findings. The intervention is carried out at the same time as a standard cervical mediastinoscopy through the same incision following the same technique as previously published. The ECM is considered positive when metastatic nodes or tumor involvement directly in the paraaortic or subaortic regions is detected and confirmed histologically. Negative cases of ECM and positive cases of standard cervical mediastinoscopy are excluded from this study. A false-negative ECM is defined as the presence of infiltrated adenopathies at the paraortic level detected on postoperative histologic study. RESULTS We had performed ECM in 106 patients, and a total of 13 were subsequently excluded for the reasons stated above. Of the remaining cases, 26 were positive, 61 negative and 6 had false-negative results with no false-positive results. Sensitivity was 81.2%, specificity 100%, accuracy 93.3%, positive predictive value 100%, and negative predictive value 91%. There were no complications with the technique. CONCLUSIONS We conclude that ECM is a useful technique for staging bronchogenic carcinoma that allows samples to be taken from paraortic and subaortic regions with minimally invasive techniques.

Textiloma intratorácico interpretado como carcinoma broncogénico. Otro falso positivo de la tomografía por emisión de positrones

Los textilomas, reacciones inflamatorias contra cuerpos extranos de tipo textil, representan una complicacion posquirurgica poco frecuente. La diversidad de sintomas y signos radiologicos con que se manifiestan contribuye a que su diagnostico se confunda con un proceso de tipo neoplasico. Los hallazgos descritos con la tomografia por emision de positrones (PET), tecnica poco habitual en el manejo diagnostico de esta entidad, pueden condicionar falsos positivos neoplasicos. Describimos el caso de un varon de 56 anos, que 23 anos despues de una cirugia de neumotorax presento una masa intratoracica indicativa de neoplasia en la PET, cuyo diagnostico final fue de textiloma.

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.

Guidelines for the Diagnosis and Treatment of Thoracic Traumatism

Thoracic trauma (TT) is a frequent problem in our setting, derived from the high incidence of traffic, domestic and work-related accidents. Other aggressions and accidents are also frequent, such as sports-related. There is an approximate associated mortality rate of 10%, in many cases after the patient has been admitted to hospital. In the United States, where the data are more reliable, trauma is calculated to cause around 100,000 deaths a year, out of which closed chest trauma are directly responsible for 20-25% and are an important contribution in another 50%. On most occasions, simple diagnostic and treatment measures can prevent extremely serious situations and even patient death. A small percent of cases require thoracotomy, not usually exceeding 10-20% of all TT.1,2

Treatment of complicated parapneumonic pleural effusion and pleural parapneumonic empyema

Summary Background We performed this observational prospective study to evaluate the results of the application of a diagnostic and therapeutic algorithm for complicated parapneumonic pleural effusion (CPPE) and pleural parapneumonic empyema (PPE). Material/Methods From 2001 to 2007, 210 patients with CPPE and PPE were confirmed through thoracocentesis and treated with pleural drainage tubes (PD), fibrinolytic treatment or surgical intervention (videothoracoscopy and posterolateral thoracotomy). Patients were divided into 3 groups: I (PD); II (PD and fibrinolytic treatment); IIIa (surgery after PD and fibrinolysis), and IIIb (direct surgery). The statistical study was done by variance analysis (ANOVA), χ 2 and Fisher exact test. Results The presence of alcohol or drug consumption, smoking and chronic obstructive pulmonary disease (COPD) were strongly associated with a great necessity for surgical treatment. The IIIa group was associated with increased drainage time, length of stay and complications. No mortality was observed. The selective use of PD and intrapleural fibrinolysis makes surgery unnecessary in more than 75% of cases. Conclusions The selective use of PD and fibrinolysis avoids surgery in more than 75% of cases. However, patients who require surgery have more complications, longer hospital stay, and more days on PD and they are more likely to require admittance to the Intensive Care Unit.

Long-term cardiopulmonary function after thoracic sympathectomy: Comparison between the conventional and simplified techniques

OBJECTIVE We sought to compare the long-term effects of conventional and simplified thoracic sympathectomy on cardiopulmonary function. METHODS We performed a prospective and randomized study of 32 patients with diagnoses of primary hyperhidrosis who were candidates for either conventional or simplified thoracic sympathectomy. Patients were randomized according to the type of procedure: conventional thoracic sympathectomy (18 patients) and simplified thoracic sympathectomy (14 patients). Before surgical intervention, forced spirometry, body plethysmography, measurement of the diffusing capacity of the lung for carbon monoxide (DLCO), and exercise tests were carried out in all patients. These evaluations were performed again 1 year after the procedure to assess the long-term effects of sympathectomy. RESULTS Lung function tests revealed a significant decrease in forced expiratory volume in 1 second (FEV(1)) and forced expiratory flow between 25% and 75% of vital capacity (FEF(25%-75%)) in both groups (FEV(1) of -6.3% and FEF(25%-75%) of -9.1% in the conventional thoracic sympathectomy group and FEV(1) of -3.5% and FEF(25%-75%) of -12.3% in the simplified thoracic sympathectomy group). DLCO and heart rate at rest and maximal values after exercise were also significantly reduced in both groups (DLCO of -4.2%, DLCO corrected by alveolar volume of -6.1%, resting heart rate of -11.8 beats/min, and maximal heart rate of -9.5 beats/min in the conventional thoracic sympathectomy group and DLCO of -3.9%, DLCO corrected by alveolar volume of -5.2%, resting heart rate of -10.7 beats/min, and maximal heart rate of -17.6 beats/min in the simplified thoracic sympathectomy group). Airway resistance increased significantly in the group of patients undergoing conventional thoracic sympathectomy (+13%). Despite all these changes, the patients remained asymptomatic. No significant differences were found between the conventional and simplified thoracic sympathectomy groups. CONCLUSIONS Simplified and conventional thoracic sympathectomy resulted in a long-term reduction in FEV(1), FEF(25%-75%), DLCO, and resting and maximal heart rate, as well as a mild but significant increase in airway resistance in the conventional thoracic sympathectomy group, without any clinical consequence to the patient. These changes were unrelated to the level of transection of the thoracic sympathetic chain.

Neumotórax complicado en una gestante a término: tratamiento mediante cesárea y videotoracoscopia simultáneas

Resumen El neumotorax espontaneo es infrecuente durante la gestacion. La causa mas frecuente esta relacionada con la presencia de blebs o bullas en el vertice pulmonar. Los sintomas mas comunes son el dolor pleuritico y la disnea y la radiografia de torax confirma el diagnostico. El tratamiento de eleccion es la colocacion de un drenaje pleural y la cirugia deberia considerarse en los casos de neumotorax recurrente o perdidas aereas persistentes. Los factores mas controvertidos del tratamiento del neumotorax durante la gestacion son el momento de la cirugia y la via de finalizacion de la gestacion. Presentamos el caso de una gestante que en su tercer trimestre gestacional presento un neumotorax espontaneo con perdidas aereas persistentes y que fue tratada mediante una cesarea electiva y una videotoracoscopia en el mismo acto quirurgico, de forma satisfactoria. Creemos que una alternativa valida para el tratamiento definitivo del neumotorax complicado en una gestante a termino es la extraccion fetal y la videotoracoscopia combinadas en el mismo acto quirurgico a fin de evitar riesgos materno y fetales.

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.