Recommendations of the Society of Thoracic Surgery and the Section of Cardiothoracic and Vascular Surgery of the Spanish Society of Anesthesia, Resuscitation and Pain Therapy, for patients undergoing lung surgery included in an intensified recovery program.

In recent years, multidisciplinary programs have been implemented that include different actions during the pre, intra and postoperative period, aimed at reducing perioperative stress and therefore improving the results of patients undergoing surgical interventions. Initially, these programs were developed for colorectal surgery and from there they have been extended to other surgeries. Thoracic surgery, considered highly complex, like other surgeries with a high postoperative morbidity and mortality rate, may be one of the specialties that most benefit from the implementation of these programs. This review presents the recommendations made by different specialties involved in the perioperative care of patients who require resection of a lung tumor. Meta-analyzes, systematic reviews, randomized and non-randomized controlled studies, and retrospective studies conducted in patients undergoing this type of intervention have been taken into account in preparing the recommendations presented in this guide. The GRADE scale has been used to classify the recommendations, assessing on the one hand the level of evidence published on each specific aspect and, on the other hand, the strength of the recommendation with which the authors propose its application. The recommendations considered most important for this type of surgery are those that refer to pre-habilitation, minimization of surgical aggression, excellence in the management of perioperative pain and postoperative care aimed at providing rapid postoperative rehabilitation.

Recommendations of the Society of Thoracic Surgery and the Section of Cardiothoracic and Vascular Surgery of the Spanish Society of Anesthesia, Resuscitation and Pain Therapy, for patients undergoing lung surgery included in an intensified recovery program. / Recomendaciones de la Sociedad Española de Cirugía Torácica y de la Sección de Cardiotorácica y Cirugía Vascular de la Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor, para los pacientes sometidos a cirugía pulmonar incluidos en un programa de recuperación intensificada.

In recent years, multidisciplinary programs have been implemented that include different actions during the pre, intra and postoperative period, aimed at reducing perioperative stress and therefore improving the results of patients undergoing surgical interventions. Initially, these programs were developed for colorectal surgery and from there they have been extended to other surgeries. Thoracic surgery, considered highly complex, like other surgeries with a high postoperative morbidity and mortality rate, may be one of the specialties that most benefit from the implementation of these programs. This review presents the recommendations made by different specialties involved in the perioperative care of patients who require resection of a lung tumor. Meta-analyses, systematic reviews, randomized and non-randomized controlled studies, and retrospective studies conducted in patients undergoing this type of intervention have been taken into account in preparing the recommendations presented in this guide. The GRADE scale has been used to classify the recommendations, assessing on the one hand the level of evidence published on each specific aspect and, on the other hand, the strength of the recommendation with which the authors propose its application. The recommendations considered most important for this type of surgery are those that refer to pre-habilitation, minimization of surgical aggression, excellence in the management of perioperative pain and postoperative care aimed at providing rapid postoperative rehabilitation.

Scimitar syndrome: Anaesthetic management for pulmonary resection of the unaffected lung. / Síndrome de la cimitarra: manejo anestésico para resección pulmonar del pulmón no afecto.

Scimitar syndrome is a rare congenital anomaly characterized by anomalous drainage of the right pulmonary veins in the inferior vena cava, frequently associated with right lung and pulmonary artery hypoplasia, dextrocardia and abnormal systemic arterial supply to the lower lobe. Pulmonary resection surgery on healthy lung is exceptional, and there are no published records of it, as far as we know. A man with scimitar syndrome diagnosed with a lung nodule with malignant features in the contralateral lung. This situation implies huge anaesthetic complexity, mainly for intraoperative ventilation. Although spirometry and stress test did not contraindicate the planned lobectomy, scintigraphy showed a hypoplastic right lung with an uptake of 15%. From an anaesthetic point of view we discarded selective ventilation of the right lung, since the shunt made it functionally non-existent. In consequence we proposed four anaesthetic possibilities. After the placement of an epidural catheter and left selective intubation, thoracoscopy with intermittent apnoeas was our first choice, and we could complete the extirpation and avoid excessive complexity.

Recomendaciones de la Sociedad Española de Cirugía Torácica y de la Sección de Cardiotorácica y Cirugía Vascular de la Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor, para los pacientes sometidos a cirugía pulmonar incluidos en un programa de recuperación intensificada / Recommendations of the Society of Thoracic Surgery and the Section of Cardiothoracic and Vascular Surgery of the Spanish Society of Anesthesia, Resuscitation and Pain Therapy, for patients undergoing lung surgery included in an intensified recovery program

En los últimos años se están implementando programas multidisciplinares que incluyen diferentes actuaciones durante el periodo pre, intra y postoperatorio, encaminadas a disminuir el estrés perioperatorio y, por tanto, a mejorar los resultados de los pacientes sometidos a intervenciones quirúrgicas. Inicialmente, estos programas se desarrollaron para cirugía colorrectal y de ahí se han ido extendiendo a otras cirugías. La cirugía torácica, considerada de elevada complejidad, al igual que otras cirugías con una alta tasa de morbimortalidad postoperatoria, puede ser una de las especialidades que más se beneficien de la implantación de estos programas. En esta revisión se presentan las recomendaciones elaboradas por diferentes especialidades implicadas en los cuidados perioperatorios de los pacientes que requieren la resección de un tumor pulmonar. Para la elaboración de las recomendaciones presentadas en esta guía se han tenido en cuenta los metaanálisis, las revisiones sistemáticas, los estudios controlados aleatorizados y no aleatorizados y los estudios retrospectivos realizados en pacientes sometidos a este tipo de intervenciones. Para la clasificación de las recomendaciones se ha empleado la escala GRADE, valorando, por un lado, el nivel de evidencia publicado sobre cada aspecto concreto, y por otro, la fuerza de la recomendación con la que los autores proponen su aplicación. Las recomendaciones consideradas más importantes para este tipo de cirugía son las que se refieren a la prehabilitación, a la minimización de la agresión quirúrgica, a la excelencia en el manejo del dolor perioperatorio y a los cuidados postoperatorios encaminados a proporcionar una rápida rehabilitación postoperatoria.(AU)

In recent years, multidisciplinary programs have been implemented that include different actions during the pre, intra and postoperative period, aimed at reducing perioperative stress and therefore improving the results of patients undergoing surgical interventions. Initially, these programs were developed for colorectal surgery and from there they have been extended to other surgeries. Thoracic surgery, considered highly complex, like other surgeries with a high postoperative morbidity and mortality rate, may be one of the specialties that most benefit from the implementation of these programs. This review presents the recommendations made by different specialties involved in the perioperative care of patients who require resection of a lung tumor. Meta-analyses, systematic reviews, randomized and non-randomized controlled studies, and retrospective studies conducted in patients undergoing this type of intervention have been taken into account in preparing the recommendations presented in this guide. The GRADE scale has been used to classify the recommendations, assessing on the one hand the level of evidence published on each specific aspect and, on the other hand, the strength of the recommendation with which the authors propose its application. The recommendations considered most important for this type of surgery are those that refer to pre-habilitation, minimization of surgical aggression, excellence in the management of perioperative pain and postoperative care aimed at providing rapid postoperative rehabilitation.(AU)

Treatment of pulmonary sequestration by video-assisted thoracic surgery (VATS).

Pulmonary sequestration is a rare malformation of the respiratory tract that accounts for 0.15-6.4% of all congenital lung anomalies. Treatment requires resection of the lesion, provided that there is no technical contraindication. The lesion should first be evaluated using video thoracoscopy and then resected whenever possible by video-assisted thoracic surgery (VATS). We report a case of extralobar pulmonary sequestration in a 48-year-old woman. She underwent lobectomy by VATS and achieved an excellent outcome.

[Video-assisted thoracoscopic surgery in 3 cases of adult cystic adenomatoid malformation]. / Tres casos de malformación adenomatoidea quística en el adulto tratados por cirugía videotoracoscópica.

Congenital cystic adenomatoid malformation involving the lung is a rare hamartomatous condition that is usually diagnosed in the neonatal period. The presentation of this malformation in older patients is exceptional and usually manifests in a series of recurrent lung infections affecting a single lobe or segment. The treatment of choice is complete surgical exeresis. This report of 3 cases of late presentation focuses on the surgical approach used and the unusual manifestation of recurrent spontaneous pneumothoraces in 1 patient. The patients were females aged 15, 16, and 25 years with histories of various respiratory diseases (extrinsic asthma, recurrent pneumonias, and pneumothoraces). The patients were referred to us for surgery with suspected diagnoses that were different from the final diagnoses in all cases. All underwent diagnostic video-assisted thoracoscopy to explore the affected hemothorax, and definitive treatment was possible during the procedure for 2 patients (a lobectomy and an atypical segmentectomy) by video-assisted surgery. The third patient underwent lobectomy by lateral thoracotomy after exploratory video-assisted thoracoscopy. Short- and long-term outcomes were excellent for all 3 patients.

[Video-assisted thoracoscopic thymectomy for the treatment of myasthenia gravis]. / Timectomía videotoracoscópica para el tratamiento de la miastenia gravis.

OBJECTIVE: Traditionally, thymectomy for myasthenia gravis has been performed using either a transcervical approach or a median sternotomy. However, excision of the thymic tissue by video-assisted thoracoscopic surgery is less aggressive and recovery is faster. The aim of this study was to evaluate the usefulness and outcomes of video-assisted thoracoscopic thymectomy. PATIENTS AND METHODS: Over the past 10 years, we have performed 25 video-assisted thoracoscopic thymectomies on patients with myasthenia gravis at our unit. This study included 16 women and 9 men, with a mean age of 48.1 years (range, 14-74 years). Right-side (22 cases) or left-side (3 cases) thoracoscopic surgery was performed, with a mean intervention time of 110 minutes (range, 60-193 minutes). RESULTS: No patient required assisted ventilation for more than 4 hours and the maximum stay in intensive care was less than 24 hours. Complications from surgery included 3 cases of contralateral pneumothorax, 1 pleural effusion, and 2 intraoperative hemorrhages from the thymic vein, all of which were resolved by video-assisted thoracoscopy. Likewise, 3 cases required conversion (due to hemorrhaging in 2 patients and technical difficulties in 1) and 2 required a second thoracoscopic intervention. No deaths occurred and clinical outcome was excellent in 11 cases (medical treatment no longer required), good in 10 (reduced medical treatment), and poor in 4 (no changes). CONCLUSIONS: Video-assisted thoracoscopic thymectomy is effective in the treatment of myasthenia gravis and improves patient recovery. In addition, the excellent surgical view allows the thymectomy to be performed with absolute safety.

[Giant solitary fibrous tumor of the pleura treated by video-assisted surgery: a case report]. / Tumor fibroso solitario gigante de pleura: un caso tratado por cirugía videoasistida.

Solitary fibrous tumors of the pleura are rare, with unpredictable clinical manifestations. By the time of diagnosis, the size and consistency of the tumor usually preclude the use of minimally invasive surgical techniques. We present a case of a 34-year-old male with a solitary fibrous tumor of the visceral pleura masquerading as a mediastinal tumor. The tumor was removed by video-assisted thoracic surgery.

Síndrome de la cimitarra: manejo anestésico para resección pulmonar del pulmón no afecto / Scimitar syndrome: anaesthetic management for pulmonary resection of the unaffected lung

El síndrome de la cimitarra es una rara anomalía congénita caracterizada por drenaje anómalo de las venas pulmonares derechas en cava inferior, asociado frecuentemente a hipoplasia del pulmón y arteria pulmonar derecha, dextrocardia y aporte arterial sistémico anómalo al lóbulo inferior. La resección sobre el pulmón sano resulta excepcional, y no conocemos antecedentes publicados. Un varón con síndrome de la cimitarra es diagnosticado de nódulo pulmonar maligno del pulmón contralateral. Esta situación conlleva una enorme complejidad anestésica, fundamentalmente para la ventilación intraoperatoria. Aunque la espirometría y la prueba de esfuerzo no contraindicaban la lobectomía prevista, la gammagrafía objetivó un pulmón derecho hipoplásico con captación por debajo del 15%. Descartamos la ventilación selectiva del pulmón derecho, ya que el shunt lo hacía funcionalmente inexistente, y planteamos 4 posibilidades anestésicas. Tras la colocación de un catéter epidural e intubación selectiva izquierda, la toracoscopia con apneas intermitentes fue nuestra primera elección (AU)

Scimitar syndrome is a rare congenital anomaly characterized by anomalous drainage of the right pulmonary veins in the inferior vena cava, frequently associated with right lung and pulmonary artery hypoplasia, dextrocardia and abnormal systemic arterial supply to the lower lobe. Pulmonary resection surgery on healthy lung is exceptional, and there are no published records of it, as far as we know. A man with scimitar syndrome diagnosed with a lung nodule with malignant features in the contralateral lung. This situation implies huge anaesthetic complexity, mainly for intraoperative ventilation. Although spirometry and stress test did not contraindicate the planned lobectomy, scintigraphy showed a hypoplastic right lung with an uptake of 15%. From an anaesthetic point of view we discarded selective ventilation of the right lung, since the shunt made it functionally non-existent. In consequence we proposed four anaesthetic possibilities. After the placement of an epidural catheter and left selective intubation, thoracoscopy with intermittent apnoeas was our first choice, and we could complete the extirpation and avoid excessive complexity (AU)

Corrección del pectus excavatum por cirugía toracoscópica con la técnica de nuss / Correction of pectus excavatum with thoracoscopic surgery using the nuss technique

FUNDAMENTO: El pectus excavatum (PE) constituye ladeformación congénita más frecuente de la pared torácica, conimportantes consecuencias psicológicas y estéticas, además de funcionales.Hasta ahora la técnica más utilizada era la de Ravitch,consistente en la realización de condrectomías subpericóndricasbilaterales de los cartílagos afectos y osteotomías esternales transversalesy posterior estabilización.OBJETIVOS: Presentar nuestra experiencia en el tratamientoquirúrgico del pectus excavatum, siguiendo la técnica de correcciónmínimamente invasiva descrita por Nuss.MATERIALYMÉTODOS: A todos los pacientes se les realizóTAC de tórax con índices de Haller superiores a 3,25. Bajo anestesiageneral y mediante videotoracoscopia se colocó una barra estabilizadorasubesternal, realizando el abordaje mediante dos incisioneslaterales. Los extremos de la barra se fijaron medianteestabilizadores.RESULTADOS: Se trataron 11 pacientes (9 varones, 2 mujeres,rango de edad 10-31 años). El motivo de la intervención fue lacorrección estética. No se presentaron complicaciones intra ni postoperatoriasimportantes y no hubo ninguna muerte. El tiempooperatorio medio fue 58,6 min, el inicio de la deambulación mediafue 4,3 días y la estancia hospitalaria postoperatoria fue 7,2 días(tiempos menores que con la técnica de Ravitch). La complicaciónmás frecuente fue el dolor postoperatorio, bien controlado conanalgesia. Un paciente presentó intolerancia a la barra, siendonecesaria extraerla al año. En el 91% de nuestros casos se obtuvieronunos excelentes resultados estéticos.CONCLUSIONES: Consideramos que la técnica de Nussmínimamente invasiva debe de ser el procedimiento de elecciónpara corregir el pectus excavatum

THEORY: The pectus excavatum (PE) is the most frequentcongenital deformation of the thoracic wall, with major psychologicaland aesthetic, aside from functional, consequences. Until now,the Ravitch technique has been used, which consists of a bilateral,subperichondrial chondrectomy of the affected cartilage andtransverse, sternal osteotomy and subsequent stabilisation.OBJECTIVES: To present our experience in the surgicaltreatment of the pectus excavatum, using the minimally invasivecorrection technique described by Nuss.MATERIAL AND METHODS: A thoracic CAT-scan was performedon all the patients with a Haller indexes above to 3.25.Under general anaesthesia and using a video-thoracoscope, a stabilisingbar was placed under the sternum, approaching the areawith two lateral incisions. The ends of the bar were fixed with stabilisers.RESULTS: 11 patients were treated (9 men, 2 women, agerange 10-31 years of age). The intervention was carried out for aestheticreasons. There were no major complications during or afterthe intervention; there were no deaths. The average operating timewas 58.6 min; on average, patients were up within 4.3 days and thepostoperative hospital stay was 7.2 days (lower figures that withthe Ravitch technique). The most frequent complication was postoperativepain, which was well controlled with analgesics. Onepatient was unable to tolerate the bar; it had to be removed afterone year. In 91% of the cases excellent aesthetic results wereobtained.CONCLUSIONS:We consider that the Nuss technique is minimallyinvassive and should be the procedure of choice in the correctionof the pectus excavatum