Spontaneous pneumothorax and tuberculosis: long-term follow-up.

Though spontaneous pneumothorax (SP) is a well-known complication of pulmonary tuberculosis (TB), there are very few reports addressing this topic. For this reason, we retrospectively analysed the experience of SP in patients diagnosed with TB in our hospital between 1989 and 2010. Out of 872 patients treated for SP during this period, 47 (5.4%) had TB antecedents, 21 with active TB (0.95% of the 2,089 TB cases diagnosed during this period) and 26 with residual inactive TB. 46 cases were treated with pleural drainage (PD): 40 (85%) with only one PD, two with two, and four with three. The mean ± SD length of PD treatment was 12.9 ± 11.3 days. In 11 (23%) cases, a relapse of SP occurred, with no statistical relationship between the different studied variables. In 13 (28%) cases, it became necessary to carry out a resection (atypical segmentectomy in all cases) for persistent air leaks with PD. Survival statistics were unfavourable only in elderly patients and those infected with HIV. We conclude that the treatment of SP secondary to TB with PD is usually a sound response, with a good general prognosis and a low percentage of cases that require another PD and surgical treatment.

Composite anatomical-clinical-molecular prognostic model in non-small cell lung cancer.

The objective of the present study was to elaborate a survival model that integrates anatomic factors, according to the 2010 seventh edition of the tumour, node and metastasis (TNM) staging system, with clinical and molecular factors. Pathologic TNM descriptors (group A), clinical variables (group B), laboratory parameters (group C) and molecular markers (tissue microarrays; group D) were collected from 512 early-stage nonsmall cell lung cancer (NSCLC) patients with complete resection. A multivariate analysis stepped supervised learning classification algorithm was used. The prognostic performance by groups was: areas under the receiver operating characteristic curve (C-index): 0.67 (group A), 0.65 (Group B), 0.57 (group C) and 0.65 (group D). Considering all variables together selected for each of the four groups (integrated group) the C-index was 0.74 (95% CI 0.70-0.79), with statistically significant differences compared with each isolated group (from p = 0.006 to p < 0.001). Variables with the greatest prognostic discrimination were the presence of another ipsilobar nodule and tumour size > 3 cm, followed by other anatomical and clinical factors, and molecular expressions of phosphorylated mammalian target of rapamycin (phospho-mTOR), Ki67cell proliferation index and phosphorylated acetyl-coenzyme A carboxylase. This study on early-stage NSCLC shows the benefit from integrating pathological TNM, clinical and molecular factors into a composite prognostic model. The model of the integrated group classified patients with significantly higher accuracy compared to the TNM 2010 staging.

[Giant thymolipoma]. / Timolipoma gigante.

Thymolipoma is an uncommon benign tumor (accounting for 2% to 9% of thymus tumors). We present the case of a 26-year-old man who sought medical attention for left-sided pleural pain of 3 months duration. Computed tomography showed a mass in the left side of the chest occupying both the anterior mediastinum and the left pleural cavity. This mass caused lung collapse and mediastinal shift. Magnetic resonance imaging revealed a large fatty tumor and transthoracic biopsy with radiological guidance confirmed the diagnosis. The tumor was resected through a left thoracotomy. No postsurgical complications occurred and the histopathological diagnosis was thymolipoma.

Surgical treatment of childhood mediastinal tuberculous lymphadenitis.

Between 1985 and 1991, we treated 6 children, aged 2 months to 3 years, who required an invasive procedure for the management of complications caused by enlarged mediastinal lymph nodes secondary to tuberculosis. Radiologic and endoscopic studies revealed bronchial involvement by lymph nodes, with endobronchial granulomas and lobar or pulmonary obstruction in 4 patients and marked tracheal and esophageal stenosis produced by extrinsic compression in the remaining 2. Pathologic study of the lymph node or bronchial samples from the 6 patients disclosed granulomas with caseous necrosis and Langhans' giant cells. All the children were treated with a standard 6-month drug regimen consisting of isoniazid, rifampicin, and pyrazinamide. Five of the patients underwent thoracotomy for the purpose of nodal curettage or excision. In 1, upper right lobectomy and bronchoplasty were necessary. The sixth patient was treated by endoscopic resection of the granulomas. There was no postoperative morbidity, and radiologic and endoscopic evidence of resolution of the lesions was observed in all the patients. In our experience, surgical treatment, when performed as a coadjuvant treatment for tracheobronchial complications stemming from mediastinal tuberculous lymphadenitis, results in the resolution of the lesions and has no related morbidity.

Hepaticothoracic transdiaphragmatic echinococcosis.

Between 1970 and 1985, seven patients were referred to us for surgical treatment of simultaneous hydatid cysts in the liver and the chest. Their mean age was 45.4 years (age range, 23-73 years), and they represented 46% of patients with hydatid cysts in the liver and thorax. Three patients had hepaticopleural involvement, and 3 patients had symptoms of pulmonary origin. In a single patient, only the diaphragm was involved along with the liver. Liver scintigraphy and ultrasonography were equally helpful in delineating the extent of the disease, but computed tomographic scanning is now the method of choice. The operations were through a thoracolaparotomy in 3 patients and a thoracotomy alone in 3 patients. A single patient had a thoracotomy with a transdiaphragmatic laparotomy. Complete drainage or excision of hydatid cavities was accomplished in all patients. Hydrogen peroxide instilled into the cysts was satisfactory for control of spread potentially secondary to possible intraoperative spillage. There have been no postoperative deaths. Follow-up has ranged from 6 months to 8 years, and 2 patients had relapsing hydatid disease 3 years postoperatively. These results suggest that, when hydatid disease of the liver is complicated by transdiaphragmatic extension and simultaneous pleural or pulmonary cysts, early surgical repair is indicated. Complete drainage and cyst excision are recommended.

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)

Candida albicans costochondritis in heroin addicts.

The dramatic increase in the number of heroin addicts has led to an increase in the number of infective complications seen, especially those due to Pseudomonas aeruginosa and Candida albicans. In this report we describe our current experience in the surgical treatment of Candida albicans costochondritis. The clinical picture, diagnostic techniques, and surgical therapy receive comment, and a brief review of the literature is given.

Congenital bronchoesophageal fistula in adults. Report of three cases.

Persistence of congenital bronchoesophageal fistulae into adulthood is rare. Three patients, one male and two female, of 52, 27 and 63 years of age, respectively, are reported. All three presented with chronic respiratory symptoms and coughing spells associated with ingestion. The barium swallow confirmed diagnoses. Treatment was surgical and consisted of excision of the fistulous tract, suture of the oesophageal and bronchial orifices and the interposition of a parietal pleura flap in two cases, and of biological glue in one. All three patients recovered and are free of symptoms.

Experimental tracheal revascularization with omentum.

We assessed omental revascularization of heterotopic tracheal implants in rats, and investigated the influence of factors that can enhance revascularization. The trachea of the donor animal was excised in two parts, and each tracheal allograft was implanted in the omentum of two recipients. The influence of mechanical factors was evaluated by applying traction at both ends of the graft with and without drainage of the tracheal lumen, and the influence of pharmacologic factors by giving cefonicid, hydrocortisone, cefonicid plus hydrocortisone, or cyclosporine and azathioprine during the postoperative period. Revascularization of the graft from the omentum with preservation of the tracheal structure was established. Graft viability showed significant differences between the tracheal implants to which no traction had been applied and those with traction at both ends. Tracheal allografts from animals receiving immunosuppressants were completely viable and no significant differences were found between the controls and animals in this group.

Massive hemoptysis as a manifestation of fistulized thoracic aortic aneurysms into the bronchial tree.

Aortobronchial fistulas are an uncommon and serious cause of hemoptysis. We present three cases of aortobronchial fistulas that were diagnosed and treated at our hospital. They were presented as massive hemoptysis. The clinical suspicion of a leaking thoracic aortic aneurysm into the bronchial tree should prompt the correct diagnostic procedures since early surgery is the only way to manage this condition.

[Mediastinoscopy in the diagnosis of mediastinal disease. An analysis of 181 explorations]. / La mediastinoscopia para el diagnóstico de la enfermedad mediastínica: análisis de 181 exploraciones.

To validate our experience with standard cervical mediastinoscopy (SCM) and extended cervical mediastinoscopy (ECM) to diagnose mediastinal nodes and masses, we studied 181 patients between January 1992 and February 2001. SCM and ECM were indicated for diagnostic staging of nodes related to bronchogenic carcinoma (Group I) or of mediastinal masses (Group II). An SCM was performed in all cases to explore the paratracheal region (2R, 2L, 4R, 4L, 7, 10R and 10L); in 21 additional cases, an ECM was performed to explore the aortopulmonary window or the subaortic region (area 5) and the para-aortic region (area 6). In Group I, the sensitivity of SCM was 93.6% and specificity was 100%; the positive predictive value (PPV) was 100%, the negative predictive value (NPV) was 82.8%, and the diagnostic yield was 95.1%. The sensitivity of ECM was 91% and specificity was 100%; PPV was 100%, NPV 93.3% and yield was 96%. In Group II, the sensitivity was 93.3%, specificity 100%, PPV 100%, NPV 81.2% and diagnostic yield 94.8%. The sensitivity of ECM in this group was 80%, specificity was 100%, PPV 100%, NPV 66.7% and yield 85.7%. A 2.7% complication rate was observed, with one case of bleeding after injury to the superior vena cava, one tracheal lesion, one recurring paralysis and two cases of surgical wound infection. The mean postoperative stay was 36 hours and mortality was zero. We conclude that SCM is highly specific for the evaluation of mediastinal node involvement in bronchogenic carcinoma and it is the approach of choice when a diagnosis of lesions located in the mid-mediastinal region has not been reached. ECM is a valid, safe alternative to anterior mediastinotomy for staging nodes and masses occupying para-aortic zones or the aortopulmonary window, with good diagnostic yield, low morbidity and absence of mortality.

[Traumatic hemothorax treated by video-assisted thoracoscopic surgery]. / Hemotórax traumático tratado mediante cirugía toracoscópica videoasistida.

The introduction of video-assisted thoracic surgery (VTS) has significantly furthered the use of the thoracoscope in surgery. In the case we describe, a 79-years-old man at high risk for surgery came to our hospital with hemothorax due to trauma. The necessary procedure was performed successfully with VTS, which allowed for the repair of an acute condition that would otherwise have been treated conventionally by way of posterolateral thoracotomy. We conclude that VTS may play an important role in the diagnosis and treatment of certain thoracic injuries, so that surgery involving more extensive bleeding is rendered unnecessary.

[Primary spontaneous pneumothorax. A retrospective study of 495 cases]. / Neumotórax espontáneo primario. Estudio retrospectivo sobre 495 casos.

We conducted a retrospective study of patients treated in our department for primary spontaneous pneumothorax (PSP) between 1986 and 1993. The 495 patients were between 12 and 81 years old (mean 28.2 years). Four hundred fifteen (83.8%) were men and 80 (16.2%) were women. PSP was in the right lung in 262 cases (52.9%) and in the left lung in 215 (43.5%). Both sides were affected in 18 cases (3.6%). The initial treatment was pleural drainage; small caliber drains were used in 85 and no associated complications were observed. On 185 occasions (37.3%), patients required surgical repair as a result of air leaks, recurrence or acute hemorrhage. There were postsurgical complications in 15 cases (8.1%) but no recurrences or deaths after surgery. We observed no significant differences in the number of recurrences after use of conventional drains or small caliber drains. Nor were there differences in mean time of hospital stay or complications after conventional surgery or video assisted surgery, a technique that has only recently been introduced. We conclude that PSP responds well to treatment with pleural drains and that small caliber catheters offer a good alternative for treating first episodes. Surgery is indicated when there is recurrence or when air leaks are persistent. At present, video assisted thoracoscopic surgery has successfully replaced axillary thoracotomy for most patients.

[Recurring invasive thymoma of the diaphragm]. / Timoma invasor recidivante en el diafragma.

Diaphragmatic recurrence of a thymoma is rare. We report the case of a 70-year-old woman who underwent transternal thymectomy and adjuvant radiation therapy, and who was admitted four years later with recurrence of the thymoma in the left hemidiaphragm with infiltration of the inferior ipsilateral pulmonary lobe. The thymoma was excised along with the left hemidiaphragm, chest wall and three ribs and an atypical segmentectomy of the left lower lobe was performed. The hemidiaphragm was reconstructed and the chest wall was repaired with synthetic mesh. Surgery was complemented with radiotherapy.

[Transthoracic approach to the spinal column]. / Abordaje transtorácico de la columna vertebral.

Thoracotomy is used to approach and treat anterior spinal lesions arising from various causes. Between 1990 and 1997, we treated 56 patients (40 men and 16 women) between 14 and 67 years old (mean 38.4). All had spinal lesions that were impossible or difficult to reach by a posterior approach. Thirty-one (55.3%) had suffered spinal damage, 8 (14.3%) had spinal deformities, 7 (12.5%) had metastatic tumors, 5 (8.9%) had herniated discs, 4 (7.1%) had Pott's disease and 1 (1.8%) had osteolysis at D6. Thoracotomy was left-sided in 35 cases (62.5%) and right-sided in 19 (33.9%). Video-assisted thoracoscopy was used twice (3.6%). The level of incision was based on the site of the lesion, and the pleural cavity was opened in all cases except one. The posterolateral pleuro-diaphragmatic fold was dissected and the diaphragm opened for retroperitoneal access in 37 cases (66.1%) of thoracolumbar disease. Orthopedic treatment consisted of autologous bone grafts in all cases and placement of a Kaneda splint in 32 cases (57.1%). One patient had to undergo surgery a second time due to inappropriate placement of the vertebral splint. Pneumothorax occurred in one patient after removal of pleural drains. The incision became infected in one patient, and one case of ileal paralysis was observed. Overall, morbidity was 7.1%. We conclude that thoracotomy offers a good alternative approach to spinal lesions. Results are good and morbidity low.

[Evaluation of 2 techniques for ventilation support during single-lung ventilation]. / Evaluación de dos técnicas de asistencia ventilatoria en ventilación de un solo pulmón.

In a group of 22 patients undergoing thoracotomy we compared two techniques of ventilatory assistance to the nondependent lung during single lung ventilation. We simultaneously administered a 0.5% FiO2 to the dependent lung. We used a CPAP system with continuous O2 flow limited by an underwater valve at a pressure of +5 cmH2O. We performed 33 ventilatory assistances: in 15 cases to the nondependent lung (CPAP group) and in 18 patients to the lower lobe of the nondependent lung (lobar CPAP group). Evaluation of both techniques was performed by means of arterial blood gas measurement and the mean values were compared using the student's t test. During single lung ventilation the PaO2 in CPAP group increased from 85.86 +/- 22.28 mmHg to 155.52 +/- 59.54 mmHg (p less than 0.001) and in the lobar CPAP series it increased from 88.75 +/- 24.34 mmHg to 122.36 +/- 43.21 mmHg (p less than 0.01). In 11 out of the 22 patients we firstly applied the lobar CPAP and thereafter the CPAP to the whole lung in order to compare the efficacy of both techniques in the same patient. The PaO2 during single lung ventilation was 86.9 +/- 22.7 mmHg and it increased to 111.1 +/- 37.9 mmHg after lobar CPAP (p less than 0.01) ant to 163.3 +/- 64 mmHg after total lung CPAP ventilation (p less than 0.001). Our results confirm the usefulness of both techniques and they indicate that CPAP to the whole nondependent lung is the most effective.

[Ruptured mycotic aneurysm of the femoral artery]. / Aneurisma micótico femoral rupturado.

After several commentaries about mycotic aneurysms related to drug addicts, author exposes the case of a young man attached to heroin, presenting a ruptured femoral mycotic aneurysm, surgically treated. Surgery in these cases is commented on.