[Analysis of the current situation and outlook of thoracic surgery]. / Análisis de la situación actual y previsión de futuro de la especialidad de cirugía torácica.

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.

[Descending necrotizing mediastinitis: treatment by transcervical thoracic drainage]. / Mediastinitis necrosante descendente: tratamiento con drenaje torácico transcervical.

We report the case of a 29-year-old man with descending necrotizing mediastinitis and subcarinal spread secondary to oropharyngeal infection. The thoracic infection was treated by placement of a transcervical thoracic drain, which was removed 15 days after surgery. The outcome was satisfactory and no further invasive treatment was required. We believe that transcervical thoracic drainage is a useful initial treatment for descending necrotizing mediastinitis with subcarinal spread but no pleural cavity involvement.

Thoracic venous aneurysms. Clinical observation.

Venous aneurysms are infrequent vascular alterations. Their origin is not well known, but pathologic study reveals probably a similar natural history than the arterial aneurysms. Their clinical significance arises from the complications they can originate, specially in certain locations, which include pulmonary embolism, and, on the other hand, differential diagnosis with certain malignant pathologies may be necessary, depending upon the clinical context. A patient is presented whose radiographic findings, in association with clinical factors, led to surgical exploration to rule out malignant lung tumor. A left subclavian vein aneurysm was finally diagnosed using magnetic resonance imaging.

[Solitary adrenal metastasis of pulmonary cancer]. / Metástasis única suprarrenal por cáncer de pulmón.

We describe the case of a 46-year-old man with lung cancer and simultaneous solitary adrenal metastases. Adrenalectomy was performed 12 weeks after lung resection through a right subcostal laparotomy. Treatment was complemented with chemotherapy. Twelve months after adrenalectomy the patient was found free of signs of disease and was in satisfactory condition. The advantages of and indications for surgical resection of suprarenal metastasis are discussed in the light of published literature. In some cases, survival may improve with exeresis and chemotherapy.

[Thoracocentesis for the assessment of lung cancer with pleural effusion]. / La toracocentesis en la evaluación del cáncer de pulmón con derrame pleural

OBJECTIVE: To analyze the pleural and mediastinal effect of thoracentesis tumor-positive cytology in pleural effusions (PE) detected by chest X ray of lung cancer patients. PATIENTS AND METHODS: The study was performed in patients with lung cancer for whom PE was evident in chest X ray films, who then underwent thoracentesis followed by video-assisted thoracoscopy (VAT) to evaluate direct pleural tumor infiltration, mediastinal node involvement and the existence of pleural metastasis. Patients without contraindication underwent the procedure, even if tumor positive cytology was present. When pleural metastasis was found the treatment employed was talc pleurodesis and chemotherapy. Descriptive statistics were compiled and the validity of VAT for pleural metastasis diagnosis, of thoracentesis pleural cytology to detect infiltration of the tumor-adyacent pleura, N2 disease and pleural metastasis were calculated. Survival was also analyzed. RESULTS: PE was present in 188 of 971 consecutive lung cancer patients. Seventy two PEs were visible in the chest X ray films. Volume exceeded 425 mL. Tumor positive pleural cytology was detected in 29 cases (40%). Pleural metastasis were found in 54 patients, 23 of whom had tumor positive pleural cytology. In the other 6 patients with positive cytology the primary neoplasm infiltrated the visceral pleura, completely in 5. In 4 of those 5, the mediastinal pleura was also involved. The primary tumor and diseased lymph nodes were removed from 11 patients, 3 of them with tumoral pleural cytology. Visual pleural inspection by VAT had a sensitivity of 93%, specificity of 82%, positive predicted value (PPV) of 94% and negative predicted value (NPV) of 78% for the diagnosis of pleural metastasis. Thoracentesis cytology showed a sensitivity of 43%, specificity of 67%, PPV of 79% and NPV of 28% for pleural metastasis. For the evaluation of adjacent pleura infiltration, without pleural metastasis, the sensitivity of cytology was 40%, specificity 100%, PPV 100% and NPV 25%. For mediastinal node invasion clinically evaluated, the sensitivity of cytology was 55%, specificity of 62%, PPV 18% and NPV 90%. Survival after thoracotomy was 39% after 2 years, and the median survival time was 14.5 months. In the 11 resected patients, survival was 53% at two years. The difference in survival between patients treated by thoracotomy and those treated by talc pleurodesis after VAT was significant (p < 0.01). The 3 resected patients with pleural tumor-positive cytology survived 84, 39 and 25 months. CONCLUSIONS: Nineteen percent of patients with lung cancer have PE, of which 7% can be seen in chest X ray films. In such patients the likelihood of pleural metastasis is 75%. Pleural metastasis is not necessarily present when PE cytology indicates that tumor is present. VAT can be considered the ideal technique for the assessment of direct pleural invasion by the tumor or of pleural metastasis.

[Prognostic value of positive cytology found in pleural lavage of patients with cancer of the lung. Prospective study]. / Valor pronóstico de la citología positiva hallada en el lavado pleural de pacientes con cáncer de pulmón. Estudio prospectivo.

Pulmonary neoplasms can deposit malignant cells in the pleural cavity by a variety of mechanisms, depending not only on histological type but also on clinical stage. We investigated the effect on survival rate of a finding of malignant cells in pleural lavage. We also investigated the effect of the presence of pleural metastasis on postoperative course of disease. Two hundred surgical patients at Hospital General Universitario in Valencia between 1 February 1990 and 30 March 1993 were studied. Two groups were formed. Group one: 150 patients with lung cancer, none of whom had had pleural effusion prior to suffering transthoracic puncture during the preoperative study. Patients treated with parallel chemotherapy or radiotherapy were excluded in order to circumvent false positives. Group two: 50 patients with no tumors who underwent thoracotomy for reasons other than lung cancer. All patients underwent pleural lavage with saline before and after lung exeresis. We found 26.6% (40/150) positive cytologies in the pre-and postoperative lavages in the first group. None were found in the control group.

[Pulmonary tumorlet. Report of 5 cases]. / Tumorlet pulmonar. A propósito de cinco casos.

Lung tumorlets are small collections of neuroendocrine cells derived from Kulchitsky cells of the bronchial epithelium. Such cells are usually found by chance, are considered benign and rarely metastasize. We describe 5 cases of tumorlets diagnosed by chance in patients with prior lung disease requiring histology. Even though the behavior of tumorlets is benign, patients in whom they have been found should receive follow-up X-rays, as lymphatic metastasis in the region has occasionally been described.

[A patient with Rendu-Osler-Weber disease and pulmonary arteriovenous malformations treated satisfactorily by embolization]. / Paciente con enfermedad de Rendu-Osler-Weber y malformaciones arteriovenosas pulmonarares tratadas satisfactoriamente mediante embolización.

A 41-years-old woman with multiple arteriovenous lung malformations in a context of Rendu-Osler-Weber disease is described. The patient had a history of cutaneous and mucosal telangiectasia, frequent epistaxis and one episode of central artery embolism in the right retina. Malformations in the vascular territories of both lungs (right lower lobe and lingula) were detected by X-rays and magnetic resonance. Progressive dyspnea along with serious antecedents indicated that aggressive treatment was required. The malformations were embolized in the vascular radiology treatment center.

[Atypical carcinoid tumor of the thymus]. / Tumor carcinoide atípico del timo.

We report a male patient with atypical carcinoid tumor diagnosed by anterior mediastinotomy and biopsy after a mass was observed by chance on a chest film. The presence of neuroendocrine markers, notably chromogranin, cytokeratin, synapto-physin and neuro-specific enolase, facilitated diagnosis. Because the tumor was infiltrative, full surgical excision and radiotherapy to the mediastinum (50 Gy) were provided. We describe the incidence, clinical presentation, diagnosis, treatment and prognosis of these tumors.

[Congenital tracheoesophageal fistula in a 15-year-old male]. / Fístula traqueoesofágica congénita en un varón de 15 años.

We report a case of a 15-years-old boy with presumably congenital tracheoesophageal (H type) fistula. He has a history of recurrent bronchitis, bronchopneumonia and cough after liquid swallowing. Soon after an episode of blood stained sputum, a tracheal orifice in the pars membranacea that opened into the esophagus was found by fiberoptic bronchoscopy study. Chest and abdominal X-rays showed esophageal air and abdominal distention, respectively. The esophagram showed the passage of contrast agent to the tracheobronchial tree and no additional concurrent lesions. Cervical and thoracic magnetic resonance images revealed the location, morphology and anatomical relation to the neighbouring structures of the tracheoesophageal fistula, which was repaired surgically by left lateral cervicotomy and direct section and suture. The posterior wall of the trachea was reinforced with a muscle flap, with good results.

[Our experience in the treatment of hyperhidrosis of the upper limbs by video-assisted thoracoscopy: an analysis of our first 100 procedures]. / Nuestra experiencia en el tratamiento de las hiperhidrosis de los miembros superiores mediante videotoracoscopia: análisis tras las primeras 100 intervenciones.

Sympathectomy of the thoracic chain is an effective surgical procedure for treating axillary and palmar hyperhidrosis. The procedure has been performed with minimal invasion and good results in recent years through the use of videothoracoscopic surgery. This paper describes the technique and our experience with a series of 50 patients between 16 and 48 years old. The earliest approach was unilateral in successive operations. The procedure was later performed bilaterally, at first with the patients in sequential lateral decubitus positions and later in semi-seated position. Complications were 1 case of incomplete Claude-Bernard-Horner syndrome that resolved spontaneously two months after surgery; 1 failure when sympathectomy was performed without location of the chain, obliging rapid re-operation; laminar pneumothorax in 12% of the series; compensatory hyperhidrosis in 26%; 10% with chest pain due to intercostal involvement, resolving with time; and slight bleeding in 8%. Outcome was excellent, with complete disappearance of axillary and palmar perspiration. Patient satisfaction was 9.2/10 one year after surgery. Mean hospital stay was less than 36 h.

[Surgical treatment of non-small cell lung cancer with mediastinal node invasion. A retrospective study]. / Resultados del tratamiento quirúrgico y terapia neoadyuvante en el cáncer de pulmón no microcítico con invasión ganglionar mediastínica. Estudio retrospectivo.

OBJECTIVE: To analyze the survival of patients classified as N2M0 (N2 by cytohistology) with non-small cell lung cancer treated by surgical resection of the primary tumor and lymphadenectomy. PATIENTS AND METHODS: Among 1043 consecutive patients with lung cancer who were considered for surgery between 1990 and 2000, 155 were classified N2M0 by histology. Surgical exeresis of the primarily pulmonary tumor and lymphadenectomy were performed in 116 patients of the 130 patients who underwent thoracotomy. Among the 116 N2M0 patients undergoing surgical resection, 23 were diagnosed N2c(C3) by mediastinoscopy and/or mediastinotomy and were given induction chemotherapy (ChT) (mitomycin/ifosfami-de/cisplatin, 3 cycles) and 93 were diagnosed N2pM0 based on samples obtained from mediastinal lymph tissue during thoracotomy. Nineteen of the latter had previously been classified negative during surgical exploration. The patients diagnosed N2p after thoracotomy were given adjuvant ChT, radiotherapy or both. N2p patients who received induction therapy were given radiotherapy. Those found negative after lymphadenectomy and patients with severe disease were given no adjuvant treatment. RESULTS: Mean survival was 18 months for resected patients diagnosed N2 by mediastinoscopy/mediastinotomy and with induction ChT and survival at one, two and five years was 80%, 45% and 30%, respectively. No postoperative mortality was recorded in this group. One patient suffered bronchopleural fistula. Nine patients showed no residual mediastinal node disease after lymphadenectomy. The mean survival of resected patients diagnosed N2p by thoracotomy was 13 months, and one, two and five year survival rates were 56%, 31% and 19%, respectively. Fourteen patients died within 30 days of surgery. Nine patients developed a bronchopleural fistula. The difference in survival of the two groups was not significant. CONCLUSIONS: The prognosis after cytohistologic confirmation of N2 disease can be considered poor. Standard, complete surgery plus induction therapy in screened patients improved survival for those diagnosed N2 by thoracotomy, with no statistically significant differences.

[Approach to bronchopleural fistula in patients undergoing lung cancer surgery. A prospective study]. / Abordaje de la fístula broncopleural en pacientes intervenidos de cáncer de pulmón. Estudio prospectivo.

Twenty-four cases of bronchopleural fistula were found by fiberoptic bronchoscopy performed in 526 consecutive patients undergoing surgery for diagnosis or treatment of lung cancer between February 1990 and January 1997 in Hospital General Universitario in Valencia (Spain). In 327 of the patients lung resection was performed. Clinical symptoms included fever, purulent or bloodstained expectoration, chest pain, dyspnea and general unfitness, with 83.33% of the patients having pleural empyema. Treatment was based on pleural drainage and broad-spectrum antibiotic therapy, along with planning of the appropriate surgery technique to each patient. Surgery consisted in re-thoracotomy and bronchial closure in early detection cases without evidence of infection (< 48 h); thoracostomy (Clagett) and second stage myoplasty if confirmed pleural infection; thoracoplasty in cases of incomplete fistulas that were unresolved by pleural drainage. Biological glues were delivered by fiberoptic bronchoscope in one patient. The incidence of bronchopleural fistula was studied, as were associated factors and the results obtained by various surgical techniques.

[Surgery and combined therapy for non-small cell lung cancer with invasion of the mediastinal nodes. A retrospective study]. / Resultados del tratamiento quirúrgico y terapia combinada en el cáncer de pulmón no microcítico con invasión ganglionar mediastínica. Estudio retrospectivo.

OBJECTIVE: To analyze the survival of patients classified N2M0 (N2 cytology/histology)with non-small cell lung cancer treated by surgical resection of the primary tumor, lymphadenectomy and neo-adjuvant therapy. PATIENTS AND METHODS: Among 1,043 consecutive patients with lung cancer treated between 1990 and 2000, 155 were classified N2M0 by histology. Of 130 patients undergoing thoracotomy, excision of the primary pulmonary tumor and lymphadenectomy were performed in 116. Among the 116 N2M0patients undergoing surgical resection, 23 were diagnosed N2c(c3)by mediastinoscopy and/or mediastinotomy and received induction chemotherapy (CT) with mitomycin/ifosfamide/cisplatin (3 cycles)and 93 were diagnosed N2pM0 after examination of samples of mediastinal lymph tissue taken during thoracotomy; for 19 of these patients,earlier surgical exploration of the mediastinum had been negative. The patient diagnosed N2p after thoracotomy also received CT and/or radiotherapy (RT). N2p patients who received induction CT also received RT. Those who were negative after lymphadenectomy and severely ill patients received no adjuvant therapy of any type. RESULTS: Mean survival of resected patients (23/49) diagnosed N2(C3) by mediastinoscopy/mediastinotomy and who received induction CT was 18 months. Survival at 1, 2 and 5 years was 80%, 45% and 30%, respectively. No postoperative deaths occurred in this group. One patient developed a bronchopleural fistula. Nine patients showed no signs of residual mediastinal node disease after lymphadenectomy. The mean survival of resected patients (93/106) diagnosed N2p after thoracotomy was 13 months and survival rates at 1, 2 and 5 years were 56%, 31% and 19%,respectively. Fourteen patients in this group died within 30 days of surgery. Nine patient developed bronchopleural fistulas. The difference in survival between the two groups was not significant. CONCLUSIONS: Histologic or cytologic confirmation of N2 disease can be considered to indicate poor prognosis. Standard, complete surgery with induction CT in selected patients improves survival for those diagnosed N2 upon thoracotomy, with no statistically significant differences.

[Respiratory and hemodynamic effects of thoracic or lumbar epidural alfentanyl after thoracic surgery]. / Efectos respiratorios y hemodinámicos del alfentanilo epidural torácico o lumbar tras la cirugía torácica.

OBJECTIVES: The aim of this study was to evaluate the effects on pulmonary function and hemodynamics of three different types of analgesia after thoracotomy. MATERIAL AND METHODS: Forty-five ASA II-IV patients undergoing thoracotomy (for lobectomy or pneumonectomy) were randomized to three groups (n = 15 each) for double-blind study. After a test dose into the epidural space at T5-7 (groups T-A and T-AL) or L2-3 (group L-A) interspace, 10 micrograms/Kg of alfentanil was administered in all groups, followed by epidural infusion of 400 micrograms/h of alfentanil (group T-A and L-A) or 400 micrograms/h of alfentanil with 50 mg/h of lidocaine (group T-AL) during surgery and 24 hours postoperatively. The patients also used a patient-controlled analgesia device to administer intravenous morphine postoperatively. During the study period the following variables were recorded: hemodynamic parameters, lung function, quality of analgesia and respiratory complications. ANOVA was performed and Scheffé and Chi-square tests were applied with 0.05 as the level of statistical significance. RESULTS: No differences were found between groups with respect to patient characteristics or type of surgery. Rescue analgesia requirements were higher in group L-A than in the other groups. PaO2 (6 and 18 hours) and spirometric parameters (12 and 18 hours) were significantly higher in group T-AL than in the other groups (p < or = 0.05). No other statistically significant differences were found. CONCLUSIONS: Respiratory parameters were better after thoracic epidural analgesia with alfentanil and lidocaine than after the other analgesic techniques studied. Group L-A patients had greater need for rescue analgesia than did patients in the other groups.

[Lung function and quality of analgesia after lung resection with epidural alfentanyl]. / Función pulmonar y calidad de la analgesia tras cirugía resectiva pulmonar con alfentanilo epidural.

OBJECTIVES: To evaluate the effects on postoperative pulmonary function and quality of analgesia of two protocols for epidural infusion of alfentanil after lung resection. PATIENTS AND METHODS: After informed consent, 30 ASA I-IV patients undergoing chest surgery (lobectomy or pneumonectomy) were randomly assigned to two groups of 15. A catheter was inserted into the epidural space at T5-7 (group T) or L2-3 (group L). After a test dose, an initial bolus of alfentanil (10 micrograms/kg) was administered. After anesthetic induction, epidural analgesia was performed with an infusion of 400 micrograms/h of alfentanil (group L) during and after surgery. Endovenous patent-controlled anesthesia (PCA) was provided with morphine. During the first 24 h after surgery, the following variables were recorded: arterial blood gas concentrations, spirometric parameters, pain on a visual analog scale (VAS) and side effects. ANOVA and Scheffé and chi-square tests were used to analyze the results (p < or = 0.05). RESULTS: In group T, PaO2 was significantly higher at 6 and 18 h (p < or = 0.05), while FEV1 and FVC were significantly higher at 12 and 18 h. Pain assessed by VAS and PCA need for morphine was significantly less in group T. CONCLUSIONS: Thoracic epidural analgesia with alfentanil and lidocaine improves postoperative lung function and reduces the need for top-up analgesia in comparison with lumbar epidural infusion of alfentanil.

[Fastrach laryngeal mask, sevoflurane and remifentanil: an anesthetic alternative for the myasthenic patient]. / Mascarilla laríngea Fastrach, sevoflurano y remifentanilo: una alternativa anestésica del paciente miasténico.

A 46-year-old myasthenic man diagnosed two months earlier and experiencing nocturnal dyspnea was scheduled for transsternal thymectomy. The patient was premedicated with midazolam in the operating room. Anesthetic induction and maintenance were with inhaled sevoflurane and an intravenous infusion of remifentanil, with no need for neuromuscular relaxants. Airway management was achieved by inserting a Fastrach laryngeal mask (LM-Fastrach), through which an endotracheal tube could be inserted easily. The tube was withdrawn through the mask at the end of surgery and the mask was removed in the operating room 6 minutes later. Anesthesia in patients with myasthenia gravis is one of the greatest challenges in clinical anesthesiology. The interest of this case lies mainly in that the anesthetic technique chosen allows neuromuscular relaxants to be avoided. Moreover, airway access through the Fastrach laryngeal mask is highly useful for transsternal thymectomy of the patient with myasthenia gravis, providing immobility and adequate hemodynamic stability during sternotomy as well as facilitating safe and rapid postanesthetic recovery.

[Comparative study of preemptive and postincisional lumbar epidural morphine in pulmonary resection. Preliminary report]. / Estudio comparativo entre morfina epidural lumbar preventiva o postincisional en cirugía resectiva pulmonar. Informe preliminar.

OBJECTIVES: To evaluate the efficacy and incidence of side effects of two types of lumbar epidural analgesia with morphine, preemptive or postincisional, combined with total intravenous anesthesia in chest surgery. PATIENTS AND METHODS: This double-blind prospective study enrolled 20 patients (ASA I-IV) undergoing lobectomy or pneumonectomy. Anesthetic induction and maintenance was provided with propofol, atracurium and alfentanil. Lumbar epidural analgesia (L2-L3) with morphine was provided for group A patients with 2 to 4 mg upon excision of tissue and for group B with 2 to 4 mg during anesthetic induction. The following variables were recorded: arterial blood gas concentrations, heart rate, SpO2, EtCO2, postanesthetic recovery, arterial gases, side effects and pain on a visual analogue scale. Top-up analgesia was provided by intravenous metamizole and/or epidural morphine. For statistical analysis we used ANOVA, chi-square tests and Student-Newman-Keuls tests. RESULTS: The need for propofol and alfentanil during anesthesia, and for morphine and metamizole after surgery were statistically greater in group A. Pain 18 hours after surgery was also greater in group A. No significant differences between groups for other variables was observed. CONCLUSIONS: Preemptive analgesia with lumbar epidural morphine in addition to the general anesthesia described here seems to provide higher-quality analgesia with few side effects, reducing the need for propofol and alfentanil during surgery and for postoperative morphine and metamizole.