[Traumatic rupture of the diaphragm]. / Rotura diafragmática traumática.

OBJECTIVE: Traumatic rupture of the diaphragm (TRD) is a rare occurrence, with variable morbidity and mortality. The aim of this study was to analyze cases of TRD in a tertiary hospital and assess prognostic factors associated with mortality. PATIENTS AND METHODS: A retrospective study was performed of patients diagnosed with TRD in Hospital Universitario La Fe, Valencia, Spain, between 1969 and 2006. The following variables were analyzed: sex, age, cause, diagnosis, associated lesions, surgical procedure, side and size of the lesion, visceral herniation, and postoperative morbidity and mortality. RESULTS: The study group comprised 132 patients (105 men, 79.5%) with a mean (SD) age of 39.64 (17.04) years. Traffic accidents were the most common cause of TRD. Rupture involved the left hemidiaphragm in 96 cases (72.7%), and 113 patients (85.6%) had associated lesions, most often affecting the abdomen. Thoracotomy was performed in 83 cases (62.9%) and laparotomy in 41 (31.1%). Visceral herniation was reported in 90 patients (68.3%), most often involving the stomach. The rates of perioperative morbidity and mortality were 62.8% and 20.5%, respectively. Diagnostic delay and the presence of morbidity and serious associated lesions all had a statistically significant impact on mortality (P< .05). In the case of serious associated lesions, the odds ratio was 2.898 (95% confidence interval, 1.018-8.250) and for perioperative morbidity it was 1.488 (95% confidence interval, 1.231-1.798). CONCLUSIONS: TRD is an infrequent occurrence in young men, is generally caused by traffic accidents, and is more common on the left side. Associated lesions are present in most cases and represent the main prognostic factor affecting morbidity and mortality. TRD can be considered a relative surgical emergency when not accompanied by other lesions that in themselves constitute surgical emergencies.

[Lung transplantation in cystic fibrosis: perioperative mortality]. / Fibrosis quística y trasplante pulmonar. Mortalidad perioperatoria.

OBJECTIVE: To determine the incidence and causes of perioperative mortality following lung transplant for cystic fibrosis. PATIENTS AND METHODS: We analyzed the cases of 57 patients. Fifty-five patients received double lung transplants, 1 received a heart-double lung transplant, and 1 received a combined double lung and liver transplant. Information related to the organ donor, recipient, lung graft, and early postoperative period was gathered. Perioperative mortality was defined as death resulting from anesthesia or surgery regardless of how many days had passed. The Kaplan-Meier method was used to analyze survival. A Cox logistic regression model was used to determine variables affecting mortality. RESULTS: Survival was 83.7% at 1 year after transplantation, 77.3% at 2 years, and 66.9% at 5 years. Five (8.7%) patients died as a result of anesthesia or surgery. A ratio of PaO2 to inspired oxygen fraction (FiO2) less than 200 mm Hg in the early postoperative period was observed in 8 (14%) patients. Primary graft failure occurred in 4 patients, due to pneumonia in 2 and to biventricular dysfunction in 2. Three of those patients died. Two patients with PaO2/FiO2 greater than 200 mm Hg died after surgery, one from septic shock due to Pseudomonas cepacia and the other from massive cerebral infarction. PaO2/FiO2 upon admission to the recovery care unit was the only variable significantly associated with perioperative mortality in the logistic regression model (P=.0034). CONCLUSIONS: The only factor significantly related to perioperative mortality in patients receiving transplants for cystic fibrosis was PaO2/FiO2 upon admission to the recovery unit.

[T2N1M0 non-small cell lung cancer: surgery and prognostic factors]. / Carcinoma broncogénico no anaplásico de células pequeñas T2N1M0. Cirugía y factores pronósticos.

OBJECTIVE: To determine the prognostic factors for the survival in a group of patients operated on for a non-small cell lung cancer classified as T2N1M0. PATIENTS AND METHODS: Two hundred sixteen patients treated exclusively with surgery were studied. Kaplan-Meier survival and Cox multivariable regression analyses were used. RESULTS: The overall survival rate was 39.8% at 5 years and 29.9% at 10 years. Sex, age, presence or absence of symptoms, type of resection, number, and location of affected lymph nodes had no effect on survival. Tumor size (P=.04) and histologic type (P=.03) did significantly affect prognosis. Both variables entered into the Cox multivariable regression model. CONCLUSIONS: Patients operated on for non-small cell lung cancer classified as T2N1M0 have an overall probability of 5-year survival of approximately 40%. However, the prognosis for this group of patients is heterogeneous: in our study it was affected by the histologic type (45.5% for squamous cell and 25% for non-squamous cell cancers) and tumor size (53% for tumors with a diameter of 5 cm).

[Non-small cell bronchogenic cancer in stage IA: mortality patterns after surgery]. / Carcinoma broncogénico no anaplásico de células pequeñas en estadio IA. Cirugía y patrones de mortalidad.

OBJECTIVE: To determine the causes of death in patients treated surgically for nonsmall cell lung cancer (NSCLC) in stage IA and to evaluate the impact on survival of not performing systematic lymph node dissection and of the number of nodes resected. PATIENTS AND METHODS: The study sample consisted of 156 patients operated on for NSCLC and classified in stage IA according to TNM staging. Only palpable or visible lymph nodes were dissected. Kaplan-Meier survival curves were compared using a log-rank test. RESULTS: At the end of the study, 85 (54.5%) patients had died, 67 (42.9%) were alive, and 4 (2.5%) were lost to follow up. Twenty-three (14.7%) died from a recurrence of NSCLC: 2 with local tumors (1.2%), 2 with mediastinal node involvement (1.2%), and 19 (12.1%) with distant metastasis. The cause of death was unrelated to NSCLC in 62 (39.7%) cases: 33 (21.1%) had a new tumor, 18 of which were bronchogenic, and 29 (18.5%) had nonmalignant disease. The 5-year survival rate was 81.4%. The rate was 88.9% among patients from whom no lymph nodes were excised and 79.9% among those with node excision, although the difference was not statistically significant (P=.4073). CONCLUSIONS: Our experience suggests that neither the fact of not performing systematic lymph node dissection nor the number of nodes resected has an impact on survival. A substantial number of patients died of causes unrelated to the NSCLC for which they had been treated.

[Emergency lung transplantation]. / El trasplante pulmonar en situación de urgencia.

INTRODUCTION: Lung donors are scarce and lung transplantation resources limited, leading to a need to look at transplants in terms of efficiency. Because emergency transplants (C-0) are assumed to yield poor results, most countries do not perform them on a regular basis. Spain, however does accept the concept of emergency lung transplantation for patients who are on waiting lists. We assess outcome for our patients who have received scheduled and emergency transplants. MATERIAL AND METHOD: The survival of patients receiving lung transplants in our service from 1992 through 2001 was studied using, Kaplan-Meier, Cox regression and chi-squared statistical analyses. We compared outcome and perioperative mortality (over 30 days) for scheduled versus C-0 procedures, analyzing the influence of certain variables (age, sex, emergency status, type of transplant, mechanical ventilation and use of extracorporeal membrane oxygenation). RESULTS: Eleven of 183 lung transplants were C-0 and 172 were scheduled. Forty-one were single-lung and 142 were double-lung transplants. Perioperative mortality was 36.4% for emergency procedures and 8.7% for scheduled procedures (p = 0.0035). Survival was significantly better for scheduled patients than for C-0 patients (p = 0.0032), although outcome was similar when perioperative mortality was not taken into account (58.16% vs. 57.14% at 5 years for scheduled and C-0 patients, respectively). CONCLUSIONS: Long-term survival after lung transplantation shows that the procedure is effective and efficient in C-0 patients, in spite of perioperative risk, provided the patient has been adequately monitored.

[Model of mortality risk in stage I non-small cell bronchogenic carcinoma]. / Modelo de riesgo de mortalidad en el carcinoma broncogénico no anaplásico de células pequeñas en estadio I.

OBJECTIVE: To develop and validate a mortality risk model for patients with resected stage I non-small cell bronchogenic carcinoma (NSCBC). PATIENTS AND METHOD: Tumors from 798 patients with diagnoses of NSCBC were resected and classified in stage I. The Kaplan-Meier method and Cox's proportional hazard model were used to analyze the influence of clinical and pathologic variables on survival. RESULTS: Univariate analysis revealed that age (p = 0.0461), symptoms (p = 0.0383), histology (p = 0.0489) and tumor size (p = 0.0002) and invasion (p = 0.0010) affected survival. Size (p = 0.0000) and age (p = 0.0269) were entered into multivariate analysis. Each patient's risk was estimated by applying the regression equation derived from multivariate analysis; the mean was 1.47 +/- 0.31 (range 0.68 to 2.92). The series was divided into three groups by degree of risk (low, intermediate and high), establishing the cutoff points at 1.16 and 1.78 (standard deviation of the mean). Five-year survival rates were 85%, 62% and 46%, respectively (p = 0.0000). To validate the model's predictive capacity, the series was divided randomly into two groups: the study group with 403 patients and the validation group with 395. Age (p = 0.0295), symptoms (p = 0.0396), tumor size (p = 0.0010) and invasion (p = 0.0010) affected survival in the univariate analysis. Size (p = 0.0000) and age (p = 0.0358) were entered into Cox's model. Mean risk was 1.94 +/- 0.36 (range 0.98 to 3.32). The series was divided into three risk groups, with cut-off points established at 1.58 and 2.30. Five year survival rates were 90%, 62% and 46% for the low, intermediate and high risk groups, respectively (p = 0.0000). The same model proved able to identify risk when applied to the validation group, in which five-year survival rates were 78%, 61% and 48%, respectively (p = 0.0000). CONCLUSIONS: Risk models can identify patient subgroups, potentially influenced by co-adjuvant treatment, as well as facilitate comparison of patient series.

[Postoperative survival in stage II non-small-cell bronchogenic carcinoma]. / Supervivencia posquirúrgica en el estadio II del carcinoma broncogénico no anaplásico de células pequeñas.

OBJECTIVE: This study aimed to validate in our population changes in the stage II criteria for non-small cell bronchogenic carcinoma. PATIENTS AND METHODS: We retrospectively reviewed and followed the course of disease in 336 patients who underwent complete resection in our hospital between January 1969 and December 1995 with stage II disease, classified as T1N1M0 (41), T2N1M0 (144) and T3N0M0 (151). RESULTS: The expected five-year survival in our population was 43.19 +/- 2.90%. Estimated mean survival was 3 +/- 0.71 years (95% confidence interval: 1.60-4.40). Mean survival was 8.82 +/- 0.67 years (95% confidence interval 7.51-10.13). Five-year survival was 53.32 +/- 8.55% for tumors classified as T1N1M0, 38.57 +/- 4.40% for T2N1M0, and 44.46 +/- 4.30% for T3N0M0. We observed significant differences in survival depending on histological type, tumor size, and IIA or IIB staging, degree of tumor invasion (T), number of nodes involved (N1) and location. T3N0M0 tumors displayed great variation in expected survival rates in relation to structures involved (27.53% to 59.98%). Multivariate analysis confirmed degree of tumor invasion, size and histological type to be the main prognostic factors. CONCLUSIONS: We conclude that the new staging system gives a more realistic prognosis for patients in our practice. The stage IIA and IIB division is appropriate and gives significantly different prognoses. However, the T3N0M0 category is heterogeneous and is not significantly different from T1-2N1M0, such that stage II overall continues to be an indivisible, homogeneous group of patients. Other prognostic variables, such as histological type, affect survival in our patients.

[Prognosis of T3N0M0 small-cell non-anaplastic bronchogenic carcinoma]. / Pronóstico del carcinoma broncogénico no anaplásico de células pequeñas T3N0M0.

We analyzed the survival after surgery for non-small cell lung cancer (NSCLC) classified as T3N0. Between January 1969 and 1995, 151 patients underwent surgery for NSCLC in our hospital. Survival analysis was performed using the Kaplan-Meier statistical method and the curves were compared using Mantel-Cox, Breslow and Tarone-Ware tests. The estimated five-year survival in the studied population was 44.46 +/- 4.30%. Four groups were defined based on degree of tumoral invasion of mediastinal structures, parietal pleura, chest wall or superior sulcus. Significant differences in five-year survival were observed between groups. Patients in the mediastinal group (59.98 +/- 8.71%) had the best prognosis, followed by patients with parietal pleura involvement (52.79 +/- 6.69%). Survival in the chest wall group was 27.53 +/- 7.22%. No patients with superior sulcus tumors survived over five years (median survival 1.50 +/- 1.16 years; 95% confidence interval 0.00 to 3.77 years). Prognosis is clearly determined by degree of tumoral invasion in T3N0 patients. In spite of the evident conceptual improvements achieved with the revised International Staging System, the system still fails to fully define prognosis in such cases.

[Small-cell nonanaplastic bronchogenic carcinoma. The new stage I]. / Carcinoma broncogénico no anaplásico de células pequeñas. El nuevo estadio I.

OBJECTIVE: To validate updated guidelines for stage I classification of patients with differentiated small-cell bronchogenic carcinoma. METHODS: Seven hundred seventeen tumors of differentiated small-cell bronchogenic carcinoma were resected in our hospital and given a TNM classification of stage I based on guidelines recently issued by the Spanish Society of Pneumology and Chest Surgery (SEPAR). Survival was calculated using the Kaplan-Meier method and curves were compared with a log-rank test. The Cox proportional hazards model was used to analyze multiple variables. RESULTS: One hundred forty-two cases were classified as stage IA and 575 as stage IB. Survival was significantly longer for stage IA than for stage IB (p = 0.0021). The prognosis was significantly better for stage IA patients who were asymptomatic (p = 0.0380) or who had tumors < or = 2 cm in diameter (p = 0.0431). In stage IB, histologic grade (p = 0.0104) and tumor diameter (p = 0.0002) significantly affected survival. A noteworthy finding was the 82% survival at five years in a group of 66 patients with a maximum tumor diameter of 3 cm classified as T2N0M0 due to invasion of the visceral pleura or to proximal involvement of a lobar bronchus at a site > 2 cm from the carina; that survival rate was not significantly different from survival for stage IA (p = 0.1573). Multivariate analysis showed that tumor diameter (p = 0.0272) was of prognostic importance in stage IA, while tumor diameter (p = 0.0005) and histologic grade (p = 0.0092) were relevant in stage IB. CONCLUSION: The new staging guidelines for differentiated small-cell bronchogenic carcinoma are nearer to prognostic reality given that survival for stage IA patients is significantly longer than for stage IB patients. However, the method continues to have shortcomings in that it fails to achieve one of its main objectives, namely prognostic homogeneity for each subgroup, as indicated by problems related to variables of tumor extension such as diameter, involvement of the visceral pleura or bronchial location, apart from other factors that affect survival.

[Resection of bronchogenic carcinoma invading the diaphragm]. / Resección de carcinoma broncogénico con invasión diafragmática.

The prognosis for survival when small cell non-anaplastic bronchogenic carcinoma (SCN-ABC) invades the diaphragm has not been clearly established because the diagnosis is rare. We report a series of eight patients who underwent full resection of SCN-ABC with diaphragm invasion. One died during the postoperative period. Mean survival was eight months for the remaining seven and no patient lived five years. All died as a result of remote metastasis. Given these results, we question whether surgery is the most appropriate treatment for these patients.

[The prognosis following surgical resection of small-cell nonanaplastic bronchogenic carcinoma according to the new staging guideline: an analysis of 1433 patients]. / Pronóstico tras resección quirúrgica del carcinoma broncogénico no anaplásico de células pequeñas según la nueva normativa de estadificación: análisis de 1.433 pacientes.

OBJECTIVE: To validate current guidelines for staging bronchogenic lung carcinoma. METHODS: Between 1969 and 1996, small-cell non-anaplastic tumors of bronchogenic carcinoma classified by the recently proposed TNM guidelines of the Spanish Society of Pneumology and Chest Surgery (SEPAR) were resected from 1,433 patients. We used the Kaplan-Meier method to calculate survival and compared the curves using a log-rank test. RESULTS: A stage IA classification was given to 142 patients and IB to 575. Thirty-seven cases were classified IIA and 336 were IIB. Of the latter, 177 were T2N1M0 and 159 were T3N0M0. Two hundred forty-eight patients were in stage IIIA, 54 T3N1M0, 23 T1N2M0, 120 T2N2M0 and 51 T3N2M0. Ninety-five stage IIIB patients were classified as follows: 37 T4N0M0, 35 T4N1M0, and 23 T4N2M0. Five-year survival for IA patients, at 75% was significantly better than the 60% rate for IB patients (p = 0.0021). Likewise, the prognosis for stage IIA, where five-year survival was 57%, was significantly better than for IIB at 39% (p = 0.0434). The prognosis for patients classified as T1NM0 was better than for those classified as T2N1M0, which was 38% (p = 0.0320). The survival of those classified as T3N0M0 (42%) was not significantly different from that of T1N1M0 (p = 0.1754) or T2N1M0 (p = 0.5360) patients. We found no significant difference between T1N1M0 and stage IB (p = 0.3847) patients. Among stage III patients, we observed no difference in survival between stage IIIA and IIIB (p = 0.1914). In stage IIIA, patients classified as T3N2M0 had a significantly lower rate of survival (p = 0.0399). The presence of mediastinal ganglia in stage IIIB was associated with a lower survival rate (p = 0.0328). CONCLUSION: The new guidelines for staging non-small cell anaplastic lung carcinoma do not provide consistent prognoses for homogeneous groups of patients, at least not in certain categories.

[Benign acquired tracheoesophageal fistulas]. / Fístulas traqueoesofágicas benignas adquiridas.

Benign acquired tracheoesophageal fistula (TEF) is a rare though serious occurrence associated with a high degree of morbidity and mortality. We review 18 cases of TEF treated over 16 years in our hospital. The variables analyzed descriptively were demographic (age, sex and others), clinical (etiology, time of intubation, time and symptoms leading to clinical suspicion, diagnostic techniques, and others), and therapeutic (dependence on mechanical ventilation, location of tissues, tracheal resection, tissue interposition, postoperative course of disease, and others). Fifteen of the 18 patients required surgery. The rate of success (80%) was high in terms of respiration, swallowing and phonation. Surgery involved simple closure of the TEF, with half the patients requiring a second operation to correct tracheal stenosis. Resection and anastomosis were performed in the remaining 11 cases, with only one requiring a second operation for recurrence of stenosis. Two cases of perioperative mortality and one TEF recurrence related to assisted ventilation were recorded. Tracheoscopy was the most effective diagnostic technique, complemented by computerized tomography of the trachea. Presurgical evaluation of tracheal stenosis, the absence of mechanical ventilation, preoperative preparation and postoperative care are the factors that determine success in this type of surgery. When tracheal stenosis is associated with TEF, resection and anastomosis should be performed in the affected zone.

Blunt chest injuries in 1696 patients.

We review 1696 patients with blunt chest trauma. Road traffic accidents were the main cause of injury followed by domestic falls and labour accidents. Outdoor falls and sport accidents accounted for a small number of injuries. For clinical evaluation, Stoddart's score was used. The injuries were considered as minor in 710 patients, intermediate in 740 and severe in 246. Global in-hospital mortality was low (5%) but increased to 37% when only patients with multiple severe injuries were considered. Thoracic wall fractures were present in 1419 patients. Flail chest was diagnosed in 140 patients and pulmonary contusion in 275. Diaphragmatic rupture was present in 40 patients and tracheobronchial injury in 6. Cardiovascular injuries occurred in 55 patients. Associated extrathoracic injuries were seen in 611 patients: 923 patients were clinically observed and/or medically treated. An intercostal tube was inserted in 638 patients. Thoracotomy was undertaken in 105 patients. Surgical fixation for flail chest was carried out in 29 patients. The results were generally good: 9 patients did not need any mechanical ventilation and 11 were ventilated for a short period. No deaths were due to the surgical procedure. The authors maintain that a selective attitude restricting, but not ignoring, surgical stabilization is the best policy.

Motor activity of esophageal substitute (stomach, jejunal, and colon segments).

Manometric studies were performed to evaluate motor activity of several types of esophageal substitutes: total stomach (5 patients), isoperistaltic gastric tube (5 patients), jejunal Roux-en-Y loops (4 patients), and isoperistaltic left colon (15 patients). Motor behavior of substitutes was assessed following dry swallows and following several stimuli: intraluminar injection of 30 ml of water or 0.1N hydrochloric acid and swallowing pills. Following dry swallows, there was no response with either stomach or isoperistaltic gastric tube, jejunum showed a variable response, and a response was infrequent in patients with colon transplants. After dry swallows, transmission of the pressure wave through the anastomosis was not observed in any patient. Total stomach and isoperistaltic gastric tube did not respond to any stimulus. Jejunum responded with progressive waves after water and solid stimuli, and had a hyperkinetic response after acid injection. Colon had a constant (80 to 90%) and homogeneous response with progressive waves after all stimuli. After wet swallows, there was transmission through the anastomosis in 2 patients with colon transplants. Our data indicate that stomach and isoperistaltic gastric tubes do not contribute actively to the onward transmission of food in the digestive tract. Jejunum may contribute actively in digestive transit, but its responses are variable. Having steady and homogeneous responses, colon segments take an active part in transit.