Pedro Rodríguez Suárez

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.

Empiema pleural secundario a pionefrosis

Mujer de 51 años de edad, que acudió al servicio de urgencias por cuadro de disnea a esfuerzos moderados, acompañado de astenia y dolor en el costado izquierdo. Como antecedentes personales refirió diabetes mellitus tipo 2 en tratamiento con antidiabéticos orales y anemia ferropénica en tratamiento con hierro oral, además de haber presentado varios episodios de litiasis renal. En la exploración física sólo destacó en la auscultación una disminución del murmullo vesicular en el hemitórax izquierdo con soplo pleural, indicativo de derrame pleural. El hemograma objetivó una cifra de hemoglobina de 6,4 g/dl, con volumen corpuscular medio del 68 fl; 26.750/L leucocitos (el 95% polimorfonucleares), y cifra de glucemia de 220 mg/dl. En la radiografía de tórax se apreció un derrame pleural masivo izquierdo. Se practicó una toracocentesis y se extrajo un material purulento con 55.000/L leucocitos (el 90% polimorfonucleares), pH de 6,04, glucosa de 1 mg/dl y cifra de lactatodeshidrogenasa de 10.266 UI/l, motivo por el que se colocó un drenaje pleural y se instauró tratamiento antibiótico de amplio espectro. El cultivo microbiológico del líquido pleural demostró la presencia de bacilos gramnegativos (Proteus mirabilis y Escherichia coli). Varios días después, a pesar del tratamiento, la paciente continuaba febril, con malestar general y dolor en el costado izquierdo, por lo que se realizó una tomografía computarizada que evidenció un absceso renal izquierdo que fistulizaba a la cavidad pleural homolateral (figs. 1 y 2). Se decidió entonces llevar a cabo una nefrectomía izquierda y resección del trayecto fistuloso hasta el tórax. La anatomía patológica de la pieza quirúrgica demostró la existencia de pielonefritits xantogranulomatosa crónica con destrucción de prácticamente todo el riñón, con varios cálculos “coraliformes” y abundante material purulento.

Intrathoracic Gossypiboma Interpreted as Bronchogenic Carcinoma. Another False Positive With Positron Emission Tomography

Gossypibomas from inflammatory reactions to textile foreign bodies are a rare postoperative complication and are easily confused with neoplastic processes because of their diversity of symptoms and radiographic signs. Positron emission tomography (PET) is seldom used to diagnose gossypibomas and PET findings can result in false positives for a diagnosis of neoplastic disease. We describe the case of a 56-year-old man in whom PET findings showed an intrathoracic mass suggesting a tumor. The final diagnosis was gossypiboma, identified 23 years after pneumothorax surgery.

Morbilidad, mortalidad y supervivencia en las resecciones pulmonares en el carcinoma broncogénico

Major lung resections, particularly lobectomy, have advanced greatly, and are now regularly performed in thoracic surgery departments. These procedures have undergone particular scrutiny in inter-departmental benchmarking processes, and auditing can provide a good indication of the quality of the unit.1 There are, however, certain interventions that can be controversial in special circumstances, some of which are addressed in the articles reviewed below.2,3