Manuela Iglesias

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.

Extended cervical mediastinoscopy in the staging of bronchogenic carcinoma of the left lung

OBJECTIVE To evaluate the technical feasibility and the sensitivity, specificity and accuracy of extended cervical mediastinoscopy (ECM) in the staging of bronchogenic carcinoma (BC) of the left lung. METHODS From 1998 to 2003, 89 patients underwent routine ECM for staging of BC of the left lung. In 2004, positron emission tomography (PET) was included in our staging protocol and ECM was reserved for those with positive mediastinal or hilar PET images, large lymph nodes on computed tomography (CT) scan or central tumours. From 2004 to 2007 we performed selective ECM in 67 patients. ECM was considered positive when metastatic nodes or tumour involvement directly in the subaortic or para-aortic regions was confirmed pathologically. One hundred and forty-three patients with negative ECM underwent subsequent thoracotomy for tumour resection and systematic nodal dissection. Pathological findings were reviewed and staging values were calculated. RESULTS One hundred and fifty-six patients underwent ECM (89 routine and 67 selective). In 13, ECM was positive and thoracotomy was contraindicated. The rest of the patients were operated. We performed 88 lobectomies, 34 pneumonectomies, 6 wedge resections, 13 exploratory thoracotomies and 2 parasternal mediastinotomies. Lymphadenectomy specimens showed tumour involvement of subaortic lymph nodes in 8 patients. Complication rate was 2%: two cases of mediastinitis, one ventricular fibrillation, and one superficial surgical wound infection. Sensitivity, specificity, positive predictive value, negative predictive value and accuracy of routine/selective ECM were: 0.45/0.75, 1/1, 1/1, 0.94/0.95, 0.94/0.95, respectively. CONCLUSION ECM is a feasible staging technique that allows ruling out subaortic and para-aortic nodal disease with high negative predictive value, accuracy and sensitivity. Its indication based on the CT and PET findings seems more advisable that its routine use to stage bronchogenic carcinoma of the left lung.

Survival of Patients With Unsuspected pN2 Non-Small Cell Lung Cancer After an Accurate Preoperative Mediastinal Staging

BACKGROUND The aim of this study is to analyze the survival of patients with non-small cell lung cancer (NSCLC) without clinical suspicion of mediastinal lymph node involvement who underwent complete resection and whose tumors were finally proven to be pathologic N2 (pN2). METHODS This is a retrospective study of a prospective database from January 2004 to December 2010. A total of 621 patients with NSCLC were staged and operated according to the European Society of Thoracic Surgeons guidelines. After exclusions (previous induction treatment, carcinoid tumors, small cell carcinomas), 540 patients were analyzed; 406 (75%) required surgical exploration of the mediastinum and 134 (25%) underwent surgery directly. Survival analysis was performed by the Kaplan-Meier method and the log-rank test was used for comparisons. RESULTS Thirty (5.5%) patients had unsuspected pN2 and complete resection was achieved in 27 (90%). Three- and 5-year survival rates were 87% and 81%, respectively, for patients with a true negative result of the protocol (pN0-1), and 79% and 40%, respectively, for those with a false negative result (unsuspected pN2) (p < 0.0001). CONCLUSIONS The rate of unsuspected pN2 in patients whose tumors were staged according to the European Society of Thoracic Surgeons guidelines was low. The survival of this group of patients was better than expected. Therefore, resection of properly staged unsuspected pN2 NSCLC is reasonable and should not be avoided if complete resection can be achieved.

Tumor carcinoide bronquial. Análisis retrospectivo de 62 casos tratados quirúrgicamente

Objetivo Evaluar los resultados del tratamiento quirurgico del tumor carcinoide pulmonar Pacientes y Metodo Se han revisado las historias clinicas de 62 pacientes intervenidos quirurgicamente por un tumor carcinoide pulmonar entre mayo de 1985 y octubre de 2000 Resultados Cincuenta y dos pacientes tenian un carcinoide tipico y 10 un carcinoide atipico. Nueve pacientes presentaban metastasis ganglionares hiliares o mediastinicas y 5 presentaban metastasis a distancia. Estas ultimas fueron mas frecuentes en el subtipo histologico carcinoide atipico con diferencias estadisticamente significativas. Cinco pacientes tenian clinica de sindrome carcinoide. La supervivencia global a los 15 anos fue del 70% y la supervivencia media de 138 ± 11 meses. No encontramos asociacion estadistica entre el habito tabaquico y el desarrollo de tumor carcinoide Conclusiones Aunque el tumor carcinoide se comporta como un tumor de bajo grado de malignidad, su tratamiento debe realizarse de modo similar al del resto de los tumores malignos pulmonares; la reseccion quirurgica con intencion curativa es la tecnica de eleccion siempre que sea posible

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.

Bronchial Carcinoid Tumor: a Retrospective Analysis of 62 Surgically Treated Cases

OBJECTIVE To evaluate the results of surgical treatment for lung carcinoid tumor. PATIENTS AND METHOD The medical records of 62 patients who underwent surgical intervention for lung carcinoid tumor between May 1985 and October 2000 were reviewed. RESULTS Fifty-two patients had typical carcinoid tumors and 10 had atypical carcinoid tumors. Hilar or mediastinal lymph node metastases were present in 9 patients. Distant metastasis occurred in 5 patients and was significantly more frequent in those with the atypical carcinoid histological subtype. The overall survival rate at 15 years was 70%, with a mean survival rate of 138 (SD 11) months, calculated with the Kaplan-Meier method. We found no statistically significant correlation between smoking and the development of carcinoid tumors. CONCLUSIONS Although carcinoid tumors behave like low-grade malignant tumors, they should be treated in the same way as other malignant lung tumors. Curative surgical resection is the technique of choice whenever possible.

Video-Assisted Mediastinoscopic Lymphadenectomy for Staging Non-Small Cell Lung Cancer

BACKGROUND The aim of this study was to evaluate the results of video-assisted mediastinoscopic lymphadenectomy (VAMLA) for staging of non-small cell lung cancer (NSCLC). METHODS This was a prospective observational study of all consecutive VAMLAs performed from January 2010 to April 2015 for staging NSCLC. For left lung cancers, extended cervical videomediastinoscopy was added to explore the subaortic and paraaortic nodes. Patients with negative VAMLA results underwent tumor resection and lymphadenectomy of the remaining nodes. Those with N2-3 disease underwent chemoradiation. The rate of unsuspected pathologic (p)N2-3 was analyzed in the global series and in the subgroups of patients according to their nodal status diagnosed by imaging and metabolic techniques. RESULTS One hundred sixty VAMLAs were performed for staging NSCLC (138 tumors were clinical (c)N0-1 based on imaging techniques). The rate of unsuspected N2-3 disease was 18% for the whole series: 40.7% for cN1, 22.2% for cN0 and tumor size greater than or equal to 3 cm, and 6.4% for cN0 and tumor size less than 3 cm. Staging values were sensitivity, 0.96 (95% confidence interval [CI], 0.81-99.3); specificity, 1 (95% CI, 0.97-1); positive predictive value, 1 (95% CI, 0.87-1); negative predictive value, 0.99 (95% CI, 0.95-0.99); and diagnostic accuracy, 0.99 (95% CI, 0.96-0.99). The complication rate was 5.9%. CONCLUSIONS VAMLA is a feasible and highly accurate technique. The high rate of unsuspected mediastinal node disease diagnosed by VAMLA in patients with cN1 or cN0 disease and tumor size larger than 3 cm suggests that preresection lymphadenectomies should be included in the current staging algorithms.

The pumpless extracorporeal lung membrane provides complete respiratory support during complex airway reconstructions without inducing cellular trauma or a coagulatory and inflammatory response

OBJECTIVE Our objective was to investigate the capacity of a pumpless extracorporeal lung membrane (iLA) (Novalung; Novalung GmbH, Hechingen, Germany) to provide adequate respiratory support and the impact on morbidity/mortality during complex airway reconstruction. METHODS Only patients unable to be ventilated via conventional intubation were eligible for the study. A larynx mask or orotracheal tubes were placed above the airway defect and the iLA was attached via femoral vessels (arteriovenous), providing extracorporeal gas exchange, apneic hyperoxygenation, and total tubeless airway reconstruction. Haptoglobulin, plasmin-antiplasmin complex, P-selectin activation, and interleukin 6 were measured before, during, and after iLA use and 72 hours postoperatively. RESULTS Fifteen consecutive patients (age, 42±17 years) underwent elective (n=7) or emergency (n=8) reconstruction of the airway owing to a variety of disorders or defects. The iLA was left in place for 185±61 minutes, diverted 1.70±0.48 L/min of the cardiac output, and provided an arteriovenous carbon dioxide removal and oxygen transfer of 173±94 and 144±83 mL/min, respectively. The arterial oxygen tension/inspired oxygen fraction (314±31 mm Hg), and arterial carbon dioxide tension (40±6 mm Hg) remained stable throughout the entire operations. The following procedures were performed: redo slide tracheoplasties (n=3), redo tracheoesophageal fistula repair (n=1), sleeve lobectomies (n=2), main carina reconstructions (n=7), and anastomotic stenting and myocutaneous coverages (n=2). Three patients required prolonged (9±2 days) postoperative iLA support. Two (13%) patients died during the hospital stay. The use of iLA was associated with significant (P<.05) but clinically nonrelevant and yet nonpathologic increases of haptoglobulin (hemolysis), plasmin-antiplasmin complex (coagulation activation), and P-selectin activation (platelet activation). Data normalized within 48 hours postoperatively. CONCLUSIONS Data suggest that iLA provides complete intraoperative respiratory support in patients who cannot receive conventional intubation/ventilation without relevant effects on cellular trauma, coagulatory response, and inflammatory response.

Optimal positive end-expiratory pressure during pumpless extracorporeal lung membrane support.

The aim of this study was to determine the optimal positive end-expiratory pressure (PEEP) required during extracorporeal lung membrane support (interventional lung assist [iLA]; Novalung GmbH, Hechingen, Germany). Twenty healthy pigs were initially (4 h) mechanically ventilated with a tidal volume (V(T)) of 10 mL/Kg, respiratory rate (RR) of 20 breaths/min, PEEP of 5 cm H(2)O, and fraction of inspired O(2) (FiO(2)) of 1.0. Thereafter, the iLAs were placed arteriovenously transfemorally and settings reduced to reach near static ventilation (V(T) < or = 2 mL/Kg, RR 4 breaths/min, PEEP of 5, FiO(2) 1.0). Then, animals were assigned to four study groups evaluating 5 cm H(2)O increasing levels of PEEP for 8 h. Gas exchanges with PEEP < or = 10 cm H(2)O were significantly worse than those with PEEP > 12 cm H(2)O, and this without hemodynamical imbalance. This study suggests that the iLA may provide adequate gas exchange during static ventilation only with PEEP levels > 10 cm H(2)O, and this without pulmonary or systemic hemodynamic imbalance.

Lobectomía videoasistida a través del triángulo auscultatorio en el tratamiento quirúrgico del carcinoma broncopulmonar. Experiencia preliminar

Objetivo Describir la tecnica de la lobectomia videoasis-tida a traves del triangulo auscultatorio (LVAA) y valorar los resultados, inmediatos y a medio plazo, obtenidos me-diante este procedimiento quirurgico en pacientes afectados de carcinoma broncopulmonar no microcitico, estadio I Pacientes Y Metodo Desde abril de 1999 hasta mayo de 2002 hemos realizado 25 LVAA (24 lobectomias y una bilo-bectomia), en 25 pacientes con una edad media de 63,6 anos (rango, 39-80) Resultados La mortalidad operatoria y postoperatoria fue nula. En dos casos se requirio la conversion a toracotomia convencional. Un paciente fue reintervenido por hemotorax y otro presento una fistula broncopleural que fue tratado con drenaje pleural. La estancia media hospitalaria fue de 6,3 dias. Con un seguimiento medio de 11,5 meses (rango, 1-36), 23 pacientes estan libres de enfermedad. La supervivencia ac-tuarial (Kaplan-Meier) a los dos anos fue del 93 ± 7% Conclusiones La LVAA constituye una intervencion se-gura, que requiere sin embargo un aprendizaje especifico. En nuestra serie, la morbilidad ha sido escasa y la mortali-dad nula. En los pacientes con carcinoma broncogenico en estadio I, los resultados en los dos primeros anos de segui-miento son superponibles a los obtenidos a traves de toraco-tomia convencional