Juan Torres Lanzas

Guidelines for the Diagnosis and Treatment of Spontaneous Pneumothorax

This is the fourth update of the guidelines for the diagnosis and treatment of pneumothorax published by the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR). Spontaneous pneumothorax, or the presence of air in the pleural space not caused by injury or medical intervention, is a significant clinical problem. We propose a method for classifying cases into 3 categories: partial, complete, and complete with total lung collapse. This classification, together with a clinical assessment, would provide sufficient information to enable physicians to decide on an approach to treatment. This update introduces simple aspiration in an outpatient setting as a treatment option that has yielded results comparable to conventional drainage in the management of uncomplicated primary spontaneous pneumothorax; this technique is not, as yet, widely used in Spain. For the definitive treatment of primary spontaneous pneumothorax, the technique most often used by thoracic surgeons is video-assisted thoracoscopic bullectomy and pleural abrasion. Hospitalization and conventional tube drainage is recommended for the treatment of secondary spontaneous pneumothorax. This update also has a new section on catamenial pneumothorax, a condition that is probably underdiagnosed. The definitive treatment for a recurring or persistent air leak is usually surgery or the application of talc through the drainage tube when surgery is contraindicated. Our aim in proposing treatment algorithms for the management of pneumothorax in these guidelines was to provide a useful tool for clinicians involved in the diagnosis and treatment of this disease.

Massive hemoptysis caused by tracheal hemangioma treated with interventional radiology

Capillary hemangiomas of the tracheobronchial tree are extremely rare in adults, with hemoptysis being one of the most serious forms of presentation. An operation has been the treatment of choice, although it does involve high rates of morbidity and mortality, especially in emergency situations such as massive hemoptysis, which has led to the search for other therapeutic alternatives. There is no experience with embolization by interventional radiology when the hemoptysis is tracheal in origin, caused partly because the infrequency of this pathology; however, the foundations for it have been laid with the development of embolization for bronchopulmonary pathology. We report a case of a tracheal capillary hemangioma in a 66-year-old woman diagnosed with idiopathic thrombopenic purpura, which began as a massive hemoptysis and was treated successfully with embolization by interventional radiology. There has been no recurrence of the bleeding after 1 years follow-up, and the patients control fibrobronchoscopy is normal.

Analysis of the Current Situation and Outlook of Thoracic Surgery

Abstract Objective The objective of this descriptive study was to analyze the current situation and forecast the future requirements for specialists in thoracic surgery, taking into account the number of doctors entering and those possibly leaving this specialty. Material and methods The data for this study were taken from the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR) (n=304), Thoracic Surgeons’ Club (n=122), and the Spanish Council of Medical Associations (n=225). We also took into account the current number of resident surgeons (n=84). Other specialists were included who are not recorded in these databases but who are known to be practicing (n=10). The total number of practicing specialists obtained was 211. Results There are currently 52 working thoracic surgery departments and the highest number of practicing specialists was recorded in Madrid (n=44), Catalonia (n=33), and Andalusia (n=33). The forecast number of retirements (at age 65 years) and incorporations of new specialists means that there will be a surplus of 57 thoracic surgeons in the next 5 years. Conclusions Thoracic surgery needs to limit the intake of new trainee specialists for at least the next 5 years.

Neoplasias primarias del timo de estirpe no linfoide. Estudio de 58 casos

Fundamento y objetivo: Los tumores primarios del timo de estirpe no linfoide son infrecuentes, aunque presentan una gran variedad. El objetivo de este trabajo es identificar las variables clinicas, terapeuticas e histologicas que tienen valor pronostico. Pacientes y metodo: Se estudiaron 58 tumores primarios del timo de estirpe no linfoide que correspondieron a 52 neoplasias epiteliales (NEPT) (90%), 4 timolipomas (7%) y 2 tumores neuroendocrinos (3%). La clinica mas frecuente fue la miastenia grave (41%) y la disnea (21%). Cabe destacar la presencia de 13 pacientes asintomaticos (24%). Para el analisis estadistico se utilizaron las curvas de supervivencia de Kaplan-Meier y el modelo de regresion de Cox. Resultados: Se intervino a todos los pacientes con timectomia, excepto en 4 casos en que se efectuo una biopsia. La mortalidad perioperatoria fue del 3% (n = 2) y la morbilidad, del 31% (n = 18), principalmente por afecciones respiratorias y de la herida. Se administro tratamiento adyuvante con quimioterapia y/o radioterapia en las 24 NEPT grados de Masaoka III y IV, y en el carcinoma linfoepitelial. Con un seguimiento medio (DE) de 13 (5) anos, fallecieron 12 pacientes con NEPT y 1 con un tumor neuroendocrino, debido a evolucion de la enfermedad. La supervivencia acumulada fue del 80% a los 5 anos, del 71% a los 7 anos y del 63% a los 10 anos. Actualmente existen 2 recidivas locales en 2 NEPT, tras 9 y 8 anos de seguimiento, respectivamente. Los principales factores pronosticos son el tipo y subtipo histologicos, asi como el estadio clinico (p < 0,001). Conclusiones: El diagnostico precoz en los tumores primarios del timo de estirpe no linfoide es fundamental para instaurar un tratamiento correcto antes de que presenten un estadio clinico mas avanzado. Los principales factores pronosticos son el tipo y subtipo histologicos, asi como el estadio clinico.

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.

Cirugía de la pared torácica

Resumen La cirugia de la pared toracica, a pesar de las multiples diferencias de las diferentes patologias que presenta, comparte aspectos comunes en su tratamiento quirurgico. El tratamiento ha ido cambiando en el curso de los ultimos anos gracias a los avances producidos en las tecnicas diagnosticas, los procedimientos minimamente invasivos y en los materiales de reconstruccion, pero sobre todo en el manejo interdisciplinario de muchas de las patologias. La correccion minimamente invasiva de Nuss ha ido ganando adeptos en el tratamiento del pectus, aunque los abordajes abiertos cada vez se realizan a traves de incisiones mas pequenas, casi comparables a las incisiones laterales en la tecnica de Nuss. Los partidarios del abordaje abierto hacen referencia tambien a las desventajas evidentes de la necesidad de portar un implante de acero durante 2 o 3 anos y de una segunda intervencion para retirar dicho implante. Las tecnicas de reseccion en bloque con reconstruccion mediante materiales, cada vez mejores y cubiertos por injertos miocutaneos en colaboracion con los servicios de cirugia plastica, han supuesto un notable avance en el tratamiento de los tumores de pared. El tratamiento trimodal del tumor de Pancoast, consistente en una induccion con quimioterapia y radioterapia y posteriormente tratamiento quirurgico del tumor, es en la actualidad el que mejores resultados ofrece en terminos de resecabilidad y supervivencia.

Fe de errores: Análisis de la situación actual y previsión de futuro de la especialidad de cirugía torácica

a Servicio de Cirugia Toracica, Hospital Universitario Dr. Negrin, Las Palmas de Gran Canaria, Las Palmas, Espana b Unidad de Investigacion, Hospital Universitario Dr. Negrin, Las Palmas de Gran Canaria, Las Palmas, Espana c Deparmento de Economia Aplicada, Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Las Palmas, Espana d Servicio de Cirugia Toracica, Hospital Universitario de la Princesa, Madrid, Espana e Servicio de Cirugia Toracica de Aragon, Hospital Universitario Miguel Servet y Hospital Clinico Universitario Lozano Blesa, Zaragoza, Espana f Servicio de Cirugia Toracica, Hospital Universitario Reina Sofia, Cordoba, Espana g Servicio de Cirugia Toracica, Hospital Universitario Juan XXIII, Tarragona, Espana h Servicio de Cirugia Toracica, Hospital de Burgos, Burgos, Espana i Servicio de Cirugia Toracica, Hospital Universitario Virgen de la Arraixaca, Murcia, Espana j Servicio de Cirugia Toracica, Hospital Universitario de Salamanca, Salamanca, Espana k Servicio de Cirugia Toracica, Hospital Universitario San Millan, Logrono, La Rioja, Espana l Servicio de Cirugia Toracica, Hospital Clinico, Valencia, Espana