Challenges in understanding host genetics and severity of community-acquired pneumonia.

This study found no association of the top two associated FER variants with severity of community-acquired pneumonia. Precise characterisation of phenotypes may be required in order to unravel the genetic mechanisms predisposing to poor outcome in sepsis. https://bit.ly/3jc9SmR.

[Risk factors in bronchogenic carcinoma surgery]. / Parámetros de riesgo en la cirugía del carcinoma broncogénico.

OBJECTIVE: To analyze the factors that determine the risk of morbidity and mortality associated with lung resection in patients with bronchogenic carcinoma. PATIENTS AND METHODS: Prospective multicenter study conducted between October 1, 1993 and September 30, 1997 in the 19 hospitals that make up the Bronchogenic Carcinoma Cooperative Group. During the study period, 2994 patients with bronchogenic carcinoma underwent surgery. The morbidity and mortality data at 30 days from all centers were recorded in a single registry. RESULTS: Major resection was performed in 2491 patients, whereas 212 underwent minor resection. The resection had to be extended in 296 and exploratory thoracotomy was carried out in 291. Postoperative complications were reported in 1057 patients (35.2%). Complications directly related to surgery were the most common (22.9%), followed by respiratory (19.5%) and cardiovascular (10.7%) complications. Of the patients with complications, 654 patients (21.8%) had only 1, whereas 403 (13.4%) had more than 1. After classification of complications, 21% were found to be minor and 14.2% were major. Mortality at 30 days was 6.8% (204 patients), and strongly linked to the presentation of major complications--40.8% of those with such complications died. CONCLUSIONS: Surgical treatment of bronchogenic carcinoma in Spain is associated with high morbidity and mortality. The morbidity reported in the present study lies in the middle of the ranges found in the literature, whereas mortality lies at the high end of the range. The presence of major complications and/or multiple complications should be considered as strong risk factors.

Hospital volume: operative morbidity, mortality and survival in thoracotomy for lung cancer. A Spanish multicenter study of 2994 cases.

INTRODUCTION: It has been hypothesized that medical procedures performed in high-volume units carry less risk and achieve a better outcome. OBJECTIVE: To determine the relationship between the number of interventions and the operative morbidity, mortality and long-term survival in the surgery of bronchogenic carcinoma (BC). PATIENTS AND METHOD: Prospective, multicenter Spanish study was conducted in 19 departments of thoracic surgery on 2994 patients operated on consecutively with the aim of curing BC. The thoracic surgery departments have been classified into three groups, according to the number of interventions performed per year: I (1-43 cases/year; centers=7; n=565; 18.9%), II (44-54 cases/year; centers=6; n=1044; 34.9%) and III (55 or more cases/year; centers=6; n=1385; 46.3%). RESULTS: When the three groups were compared, the frequency of complete surgery was found to be 84% for group I, 76% for group II and 83% for group III (p=0.001, for comparisons between groups I/II and II/III). The pathological stages were identical in the three groups. The overall morbidity and the mortality in all patients or above the age of 75 or in pneumonectomies were not different among the groups. When considering all the patients with prognostic information (n=2758), no differences were found regarding the 5-year survival among the groups. When only patients in postoperative stage I-II and complete resection were evaluated, excluding operative mortality (n=1128), 5-year survival was 0.58 for group I, 0.57 for group II and 0.50 for group III (p=0.06 between groups II and III; p=0.08 between groups I and III). CONCLUSIONS: No significant differences that do not favor the hypothesis that there is increased surgical risk and worse survival in centers having a lower volume were found in this Spanish multicenter study.

[Pilot benchmarking study of thoracic surgery in Spain: comparison of cases of lung resection and indicators of quality]. / Experiencia piloto de benchmarking en cirugía torácica: comparación de la casuística e indicadores de calidad en resección pulmonar.

OBJECTIVE: This article describes the methods and conclusions of the first Spanish benchmarking study of thoracic surgery. The proposed aims were to describe cases of lung resection in 9 Spanish hospitals, compare indicators of quality among the 9 participating centers, and identify and propose common areas where lung-resection processes could be improved. METHODS: Information was taken from the minimum basic data set for lobectomy and pneumonectomy processes performed in 2002 and 2003. The chosen outcome indicators were in-hospital mortality, morbidity, length of hospital stay, and emergency readmissions within 30 days of discharge, adjusted according to surgical complexity. Once the results had been analyzed, the participating centers with best outcomes were identified and a variety of proposed improvements were discussed. RESULTS: A total of 1666 procedures (1276 lobectomies and 390 pneumectomies) were studied. We found differences in mean length of stay, mortality, readmission rate, and morbidity that identified centers with lower mortality or shorter hospital stay for comparable or more complex surgical procedures. However, higher morbidity and readmission rates were found in these centers. CONCLUSIONS: Measures were proposed to ensure that relevant diagnostic information is recorded on discharge. It was also proposed to reduce unnecessarily long hospital stays and to standardize the procedures. With such an approach, reliable criteria that improve the quality of lung-resection processes can be established in the future.

Causal Model of Survival After Pulmonary Metastasectomy of Colorectal Cancer: A Nationwide Prospective Registry.

BACKGROUND: Although numerous existing studies have analyzed the prognostic factors of patients who have had surgical intervention for lung metastases of colorectal carcinoma (CRC), many of the results obtained until now have been contradictory. As a consequence, there is no established consensus about which group of prognostic factors could have a greater value when considered together. METHODS: This was a multicenter prospective cohort study that included all patients who underwent a first pulmonary metastasectomy of CRC, with radical intent, during a 2-year period (March 2008 to February 2010). The follow-up continued until March 2013, and an analysis of disease-specific survival (DSS), determined from the first pulmonary metastasectomy, was implemented. The selection of the best submodel was taken based on their coefficient of determination (R(2)) and how parsimonious they were depending on the number of variables included. RESULTS: The series, consisting of 522 patients, presented the following survival rates: median, 54.9 months; 3-year DSS, 69.4% (95% confidence interval [CI], 65% to 73.8%); and 5-year DSS, 46.1% (95% CI, 38.5% to 53.7%). The resulting survival model consisted of disease-free interval of 12 months or less (hazard ratio [HR], 1.76; 95% CI, 1.21 to 2.54; p = 0.003), carcinoembryonic antigen level exceeding 5 ng/mL (HR, 1.50; 95% CI, 1.04 to 2.17; p = 0.028), bilateral lung disease (HR, 1.81; 95% CI, 1.20 to 2.75; p = 0.005), and thoracic lymph node involvement (HR, 2.71; 95% CI, 1.44 to 5.12; p = 0.002). CONCLUSIONS: According to these results from the Spanish Group of Lung Metastases of Colo-Rectal Cancer, the combination of these four variables-disease-free interval, carcinoembryonic antigen level, laterality, and thoracic lymph node involvement-constitutes the first-choice survival causal model based on the clinical and pathologic factors most frequently referenced in literature.

Spontaneous pneumomediastinum long-term follow-up.

BACKGROUND: Spontaneous pneumomediastinum (SP) is a rare disorder. METHODS: The objective of this study is to examine a series of patients treated during 19 years, analyzing risk, clinical, and diagnostic factors as well as treatment and long-term follow-up. MATERIALS AND METHODS: A descriptive, retrospective study was done from 1984 to 2003 on 32 patients admitted to the hospital with SP. RESULTS: The average age was 21.4+/-6.1 years, 24 (75%) males. 34.4% had developed some strain before arriving at the hospital. Nine of the cases were asthmatic (28.1%) and another nine were smokers (28.1%). The most frequent complaint was thoracic pain, 25 (78.1%). In the physical examination, subcutaneous cervical emphysema was observed in 25 patients (78.1%). A simple X-ray of the thorax was used in the diagnosis of 32 cases. In two patients, radiological signs of pneumothorax were discovered. An esophagogram was done on two patients but there were no significant findings. All of the cases were treated conservatively. The average hospital stay was 3.2+/-1.6 days. No relapses were noted in the follow-ups. CONCLUSION: SP is an entity that evolves correctly without treatment and has no long-term relapses. Once other occasionally associated entities are ruled out, outpatient management can be employed.

Esophagobronchial fistula caused by traction esophageal diverticulum.

Fistulization is a rare and not often described complication of esophageal diverticula. We present the case of a patient treated surgically in our service who had a history of diverticulum of the third distal of the esophagus, and was diagnosed for irritative post-ingestive cough with associated regurgitation and vomiting of undigested food.

Benchmarking in thoracic surgery.

OBJECTIVE: Presentation of an experience in benchmarking in 13 university Spanish thoracic surgery services. METHODS: The minimum basic data set (MBDS) for hospitalization, corresponding to 2007, including all registered hospital discharges, was used. The performance of the hospitals was compared using an external reference pattern (SN) and internal average (BMG). Cases were chosen in which a major pulmonary resection (lobectomy or pneumonectomy) was done for bronchogenic carcinoma. Performance indicators were the complexity of the casuistry (average weight and relative weight). Performance results indicators included average length of stay (preoperative, postoperative, and global lengths of stay were analyzed separately for lobectomies as well as pneumonectomies), complications, mortality, and urgent readmissions. RESULTS: A total number of 4778 cases were analyzed, with major thoracic surgeries being prominent with 1779 (37.3%). For average weight, there was a dispersion between 2.5 and 5.68, with an average of 3.45 for the BMG and 3.43 for the SN. There were some very significant differences in morbidity, with groups having a gross rate of few complications (2.6%) up to many (16.1%). The mortality rate ranged between 1.6% and 6.6%. There were considerable differences in urgent readmissions, with gross rates between 2.6% and 7.3%, considering as points of reference 5.4% (BMG) and 4.7% (SN). Concerning the results of pulmonary resections for bronchogenic carcinoma, the index of pneumonectomies was between 8% and 29%. The average length of stay for lobectomy was between 6 and 9.5, with an average of 7 in BMG. In the case of pneumonectomies, it was between 6 and 26 days, with an average of 9 for BMG. Average preoperative stay also varied widely, between 0.2 and 2.4, while postoperative stay was between 7.5 and 12.1. The gross global rate of complications ranged from 2.7% to 36.7%, with points of reference of 15.6% (BMG) and 13.8% (SN). The complication rate ranged from 3% to 33%, with an average of 14.5% for lobectomies, with higher variability for pneumonectomies (0-58%). CONCLUSIONS: Benchmarking could be an effective method for improving clinical management. A considerable variability was detected in our study among the participating groups.

Unusual primary pleural leiomyoma.

Primary pleural leiomyoma is extremely rare and has only been described a few times. We present a case of a young woman with right pleuritic pain. A computed tomography confirmed the existence of a solid right pleural tumor which had compressed and displaced the lung, mediastinum and heart. Percutaneous biopsy showed a 'proliferation of smooth muscle cells without evidence of malignancy'. Surgical excision was done and the tumor was not associated to vascular, broncho-pulmonary or mediastinal structures. The definitive diagnosis was primary pleural leiomyoma. Primary pleural leiomyoma should be included in a differential diagnosis of pleural tumors and suspected in asymptomatic patients with radiologically-apparent benign tumors and the presence of smooth muscle fibers in the biopsy. Complete resection and follow-up is advised because it can grow very large and has malignant potential.

Elastofibroma of the thoracic wall.

Soft tissue tumors of the chest wall are rare. Between 1998 and 2007 we treated eight cases of elastofibroma of the thoracic wall, an infrequent primary tumor of the chest. Seven females and one male between 44 and 62 years presented with dorsal subscapular tumors of months and even years of evolution. One case was a relapse from previous interventions and in three cases the tumor was bilateral. A surgical excision was performed in all cases, confirming the source of the tumor. There were no postoperative complications or relapses. We concluded that elastofibroma is a tumor that appears most frequently in middle aged women, and that diagnosis can be established through the use of imaging and fine needle aspiration biopsy. Given its benign character and slow growth, in cases where it is asymptomatic, its evolution can be controlled without surgical intervention.

Side effects, complications and outcome of thoracoscopic sympathectomy for palmar and axillary hyperhidrosis in 406 patients.

BACKGROUND: Thoracic sympathectomy (TS) is the treatment of choice for severe primary hyperhidrosis. However, complications, side effects and satisfaction have not been well defined. OBJECTIVE: To analyze the complications, side effects, satisfaction degree and quality of life of patients after TS for primary upper limb hyperhidrosis. METHODS: One-year follow-up after 406 consecutive TS for primary upper limb hyperhidrosis. RESULTS: Bilateral TS was completed in all patients. Complications arose in 23 cases (5.6%), with pneumothorax being the most frequent. The success rate after discharge, 6 and 12 months was respectively, 100%, 98.1% and 96.5% for palmo-axillary hyperhidrosis; 100%, 99.3% and 97.8% for isolated palmar hyperhidrosis and 100%, 85.7% and 71.4% for isolated axillary hyperhidrosis. No persistence of hyperhidrosis was observed. Global recurrence was 3.7% (28.5% axillary hyperhidrosis group). Compensatory sweating (CS) appeared in 55% and was not related to the extension of the TS. Being female was a predisposing factor of CS (p<0.004). Excessive dryness appeared at 9% and was associated with extensive TS (P<0.001). Plantar hyperhidrosis improved at 33.6%, worsened at 10% and remained stable during the follow-up. Satisfaction degree decreased with the passage of time and was associated with recurrence. Quality of life was excellent at discharge, 6 and 12 month in 100%, 100% and 97%, respectively. CONCLUSIONS: Pneumothorax is the most frequent complication of TS. CS is the main and undesirable side effect, appears with the passage of time, and is not related to the extension of TS. Being female is the only predictor factor of suffering CS. Plantar hyperhidrosis improves initially, although tends to reappear. Excessive dryness appears in extensive TS and does not improve over time. Postoperative satisfaction degree is high but decreases over time owing to the appearance of recurrence. Effectiveness and the absence of CS determine an excellent quality of life. Six percent of the patients regret the surgery because of severe CS. Informing patients of possible side effects before TS is essential.

Axillary thoracotomy versus videothoracoscopy for the treatment of primary spontaneous pneumothorax.

BACKGROUND: A prospective, randomized study was carried out on patients with primary spontaneous pneumothorax, with the aim of determining if video-assisted thoracoscopy is superior to axillary thoracotomy in the surgical treatment of this condition. METHODS: Patients were randomly assigned to two groups; video-assisted thoracoscopy (group A; n = 46) and axillary thoracotomy (group B; n = 44). All fit the established criteria for surgical indication (relapse or persistent air leakage after pleural drainage). In all cases the treatment consisted of apical segmentectomy of the blebs or dystrophic complex and pleural mechanical abrasion. The study evaluated the following factors: postoperative blood loss, respiratory function (maximum inspiratory and expiratory pressures, forced expiratory volume in the first second and forced vital capacity), postoperative pain (analog visual scale), supplementary doses of analgesics, postoperative complications, hospital stay, and resumption of normal activity. Relapses were evaluated for the minimum period of time of two years. RESULTS: No significant differences were found in any of the factors studied in either group. CONCLUSIONS: Video-assisted thoracoscopy and axillary thoracotomy offer similar results in the surgical treatment of primary spontaneous pneumothorax. The rate of complication is low and the level of pain is acceptable without long-term sequelae.

Role of surgery in pulmonary tuberculosis.

BACKGROUND: The purpose of our study was to analyze current indications for surgery in tuberculosis (TB). We present our experience with TB patients presenting with indications for surgery between 1990 and 1998. MATERIAL/METHODS: The indications for surgical intervention included 25 cases of pulmonary aspergilloma, 19 cases of pneumothorax, 16 cases of pulmonary nodes and masses without histological diagnosis, 15 cases of bronchiectasis, 12 cases of massive hemoptysis, 12 cases of pleural empyema, and 33 cases of other complications. No patients with multidrug-resistant tuberculosis required surgical intervention, although 56 were treated during this period. RESULTS: The techniques utilized included lobectomy in 45 cases, pleural drainage in 32 cases, segmented pulmonary resection in 32 cases, surgical procedures on the thoracic wall in 17 cases, pneumonectomy in 10 cases, pleuropulmonary decortication in 8 cases, mediastinoscopy in 6 cases, and thoracoscopy in 5 cases. In 25 cases two or more procedures were performed on the same patient. In 36 cases (27.3%) there were complications, of which persistent air leakage after pulmonary resection was the most frequent (n=10). There was a mortality rate of 5.3% (7 CONCLUSIONS: In our experience, surgery in the treatment of TB is indicated to resolve sequelae or complications, since cases of simple or multidrug-resistant TB can be managed pharmacologically. The morbidity and mortality rates in our series were acceptable.