Santiago Quevedo

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)

New minimally invasive technique for correction of pectus carinatum

We describe a new video-assisted operative technique for correction of pectus carinatum (PC) using a modified Nuss procedure. A new design of the steel bar was developed, so that it could be introduced and placed in a suitable position through very small skin incisions. Substantial modifications were introduced in the bar length and shape aimed at facilitating insertion and subsequent removal when required. All the surgical manoeuvres took place under direct vision using a 30° thoracoscope. Single unilateral fixation of the bar in a subpectoral pocket provided satisfactory stabilisation without the need for lateral stabilisers. Adequate correction of the deformity was achieved with minor postoperative scars. Our results support the view that minimally invasive surgical repair should be preferred over open surgery for correction of pectus carinatum in young adults and children.

Neumotórax espontáneo primario. Estudio retrospectivo sobre 495 casos

Con la finalidad de revisar nuestra experiencia en el tratamiento del neumotorax espontaneo primario (NEP), realizamos un estudio retrospectivo sobre los pacientes intervenidos en nuestro servicio por dicha patologia entre los anos 1986 y 1993. Los 495 casos tratados tenian edades comprendidas entre los 12 y 81 anos, con una media de 28,2. En 415 ocasiones (83,8%) fueron varones y en 80, mujeres (16,2%). En 262 se trataba de NEP derecho (52,9%) y en 215, izquierdo (43,5%). En 18 (3,6%) los episodios de NEP fueron bilaterales. El tratamiento inicial fue el drenaje pleural y se utilizaron en 85 casos drenajes de pequeno calibre. No existio morbilidad de los drenajes pleurales. La persistencia de fugas aereas, la recidiva y el sangrado agudo fueron indicaciones de tratamiento quirurgico, que se realizo en 185 ocasiones (37,3%). En 15 casos (8,1%) hubo complicaciones posquirurgicas. No existieron recidivas postoperatorias ni mortalidad. No hubo diferencias significativas en cuanto a recidivas de los drenajes convencionales y los de pequeno calibre. Tampoco las hubo en estancia media y complicaciones en la cirugia convencional y la videoasistida, de reciente introduccion. Se concluye que el NEP es una entidad que responde bien al tratamiento con drenaje pleural, constituyendo los drenajes de pequeno calibre una buena alternativa para el tratamiento de los primeros episodios de NEP. La intervencion quirurgica se indica en caso de recidiva o persistencia de fugas aereas. En la actualidad, la cirugia toracoscopica videoasistida sustituye con exito a la toracotomia axilar en la mayoria de ocasiones.

Videothoracoscopic repair of pectus excavatum with sternal transection for adult patients with nonelastic deformity

Minimally invasive repair techniques for pectus excavatum (PE) are thought to be contraindicated in patients with a rigid chest wall and to result in incomplete correction and more severe and prolonged postoperative pain for adult or late adolescent patients with a relatively malleable thorax. In these cases, additional procedures, such as osteotomy or insertion of a second bar, are required to achieve adequate correction. A new minimally invasive repair technique for PE successfully applied to patients with symmetric and rigid deformity is presented. This technique is a modification of the Nuss procedure, based on bilateral videothoracoscopic guidance and sternal transection, where the corrective bar has been modified in size and shape. Inasmuch as the involved bar is shorter and less bent than that in the original Nuss procedure, it can be inserted through minimal periareolar or submammary skin incisions with optimal cosmetic results. Sternal transection facilitates the elevation of the sternum, which results in highly satisfactory correction of the deformity and reduces the tension and pressure of the bar against the rib cage, thus potentially reducing postoperative pain.

Hemotórax traumático tratado mediante cirugía toracoscópica videoasistida

La introduccion de la cirugia toracoscopica videoasistida (CTV) ha permitido incrementar sustancialmente el papel de la toracoscopia en la cirugia toracica. En el caso que presentamos, un paciente de 79 anos de edad que presentaba un notable riesgo quirurgico y que ingreso por un hemotorax traumatico. Fue intervenido con exito a traves de CTV resolviendo un cuadro agudo que si hubiera sido tratado de forma convencional hubiera requerido una toracotomia posterolateral. Concluimos que la CTV puede tener un papel importante en el diagnostico y tratamiento de ciertos traumatismos toracicos, evitando la realizacion de intervenciones mas cruentas.

Minimally Access Repair of Pectus Excavatum- with Sternotomy in Adults

Correction of Pectus Excavatum by using the Minimal Access Repair of Pectus Excavatum (MARPE) produces excellent thoracic remodeling results in children and adolescents for whom this technique was originally designed. Placing a retrosternal bar in older adolescents or adults, who have less malleable ribcages, often fails to elevate depressed sternum enough thus producing unsatisfactory outcomes. Moreover, placing an implanted bar in the ribcage generates tension forces that may lead to complications such as severe or prolonged postoperative pain and/or bar displacement or rotation. Using two or more metal bars to counteract the sternum resistance may enhance thorax remodeling but requires more surgical wounds or larger ones, which worsens the cosmetic outcome of this intervention.

Hernia tóraco-abdominal postraumática

Hernias through the intercostal spaces are rare and few cases have been reported in the literature. They appear as a consequence of torn intercostal muscles, which allow the hernial sac to protrude with either lung parenchyma or abdominal viscera in its interior, when the intercostal space is low or when there is associated trauma with diaphragmatic rupture. We present the case of a large intercostal post-traumatic thoracic hernia with herniation of abdominal content. As a review of the literature provides no evidence-based recommendations for treatment, we report our experience in the surgical repair of this infrequent lesion. The patient is a 57-year-old obese male with COPD and hypertension who reported a history of chest trauma with a series of left rib fractures (from the 8th to the 11th) and hemothorax that required hospitalization and pleural drainage just 6 months earlier. He came to our consultation due to a painful and palpable mass in the ribcage area that had been previously injured. Thoracoabdominal CT confirmed multiple rib fractures that had not consolidated in the region of the posterior ribcage and herniation of abdominal content (Fig. 1a). Examination revealed truncal asymmetry caused by a soft, elastic, reducible herniated mass, and an extensive hernial orifice was palpated through the intercostal spaces (Fig. 1b). Preoperative nutritional therapy was initiated, and we decided on surgery. A lateral thoracotomy was performed over the hernia defect, which revealed several costal pseudoarthrosis in the area of the left 9th and 10th ribs with protruding abdominal content. We proceeded with the reduction of the hernia and approximation and cerclage of both ribs with thick, slow-absorbing sutures. Four months later, a symptomatic recurrence of the hernia was observed with a more anterior component, requiring reoperation. In this case, the lower half of the left rib cage was completely dissected, the fractured bone edges were refreshed, and plate osteosynthesis was performed with Judet struts along with approximation of the costal spaces using intercostal sutures (Fig. 2b). The abdominal content was reduced and the abdominal wall was closed and reinforced with synthetic mesh. The follow-up thoracic CT 3 months after surgery confirmed the integrity of the chest wall (Fig. 2a) and one year later the patient continues to be asymptomatic with no signs of recurrence. Herniations through the chest wall are very uncommon events that can arise after trauma or surgery, although there have also been reports of cases of herniations after intense physical effort, such as energetic coughing, vomiting or defecation. Mean age at presentation is after 50, and associations have been identified with COPD, obesity and asthma. In the case of COPD, the characteristic progressive weakness of the chest muscles in addition to frequent cough and, eventually, the existence of underlying