Sternal resection and reconstruction: a review.

Sternal resection and reconstruction is a rare but sometimes challenging procedure due to its profound anatomical and functional implications. For these reasons, an adequate preoperative evaluation is crucial in each patient, especially when we are faced with malignant lesions that sometimes require extensive radical resections, thus demanding an integrated reconstructive strategy that allows stabilizing the chest wall, protecting the underlying mediastinum and minimize resulting deformity. The large number of available reconstruction techniques and the lack of quality studies for their analysis mean that sternal reconstruction depends to a great extent on the consensus of experts or, more frequently, on the simple preference of each surgical team. This article aims to provide an overview of sternal resection and reconstruction. Indications for partial versus total or subtotal sternectomy are suggested and their surgical and oncological outcomes are presented. The use of rigid or semi-rigid prostheses is an ongoing debate, although recent functional data advise reserving rigid reconstructions for extensive defects. Sternectomy for primary tumors or local tumor involvement has a good prognosis with an overall survival of 5 and 10 years: 67% and 58%, respectively, provided that a radical resection with free surgical margins is performed. Breast cancer is the most common secondary sternal tumor, and surgery can offer 5-year overall survival ranging from 20% to 50% provided an R0 resection is achieved, although radical surgery does not appear to decrease rates. of recurrence. Metastases of origin other than the breast give the worst results (less than 40% at 36 months and 0% at 5 years) and although the data available on these cases are limited, the radicality of the resection does not seem to modify the survival or recurrence rates, so a conservative approach is probably more appropriate.

Thoracic customized modular titanium-printed prosthesis.

Tridimensional custom-made titanium-printed prosthesis have gained certain relevance as an alternative for chest wall reconstruction although different limitations such as uncomfortable intraoperative placement, long manufacturing time or high costs hinder its use when compared to other standard devices. Trying to overcome these problems, we developed a new model of customized modular titanium-printed prosthesis (CM-TPP) for chest wall reconstruction after breast metastasis resection that seems to offer some advantages over other custom-made reconstructive devices.

Fight Recognition in video using Hough Forests and 2D Convolutional Neural Network.

While action recognition has become an important line of research in computer vision, the recognition of particular events such as aggressive behaviors, or fights, has been relatively less studied. These tasks may be extremely useful in several video surveillance scenarios such as psychiatric wards, prisons or even in personal camera smartphones. Their potential usability has led to a surge of interest in developing fight or violence detectors. One of the key aspects in this case is efficiency, that is, these methods should be computationally fast. "Handcrafted" spatiotemporal features that account for both motion and appearance information can achieve high accuracy rates, albeit the computational cost of extracting some of those features is still prohibitive for practical applications. The deep learning paradigm has been recently applied for the first time to this task too, in the form of a 3D Convolutional Neural Network that processes the whole video sequence as input. However, results in human perception of other's actions suggest that, in this specific task, motion features are crucial. This means that using the whole video as input may add both redundancy and noise in the learning process. In this work, we propose a hybrid "handcrafted/learned" feature framework which provides better accuracy than the previous feature learning method, with similar computational efficiency. The proposed method is compared to three related benchmark datasets. The method outperforms the different state-of-the-art methods in two of the three considered benchmark datasets.

Eyes of Things.

Embedded systems control and monitor a great deal of our reality. While some "classic" features are intrinsically necessary, such as low power consumption, rugged operating ranges, fast response and low cost, these systems have evolved in the last few years to emphasize connectivity functions, thus contributing to the Internet of Things paradigm. A myriad of sensing/computing devices are being attached to everyday objects, each able to send and receive data and to act as a unique node in the Internet. Apart from the obvious necessity to process at least some data at the edge (to increase security and reduce power consumption and latency), a major breakthrough will arguably come when such devices are endowed with some level of autonomous "intelligence". Intelligent computing aims to solve problems for which no efficient exact algorithm can exist or for which we cannot conceive an exact algorithm. Central to such intelligence is Computer Vision (CV), i.e., extracting meaning from images and video. While not everything needs CV, visual information is the richest source of information about the real world: people, places and things. The possibilities of embedded CV are endless if we consider new applications and technologies, such as deep learning, drones, home robotics, intelligent surveillance, intelligent toys, wearable cameras, etc. This paper describes the Eyes of Things (EoT) platform, a versatile computer vision platform tackling those challenges and opportunities.

Refraining from smoking shortly before lobectomy has no influence on the risk of pulmonary complications: a case-control study on a matched population.

Objectives: Whether or not smoking increases the risk of postoperative pulmonary complications (PPCs) in lung resection patients remains controversial. The objective of this study was to evaluate whether active smoking at the time of surgery increases the risk of PPCs compared to abstention shortly before the procedure. Methods: We conducted a case-control study on 378 patients who underwent non-extended lobectomy in our institution. Cases were active smokers at the time of surgery, and controls were patients who quit smoking at any time up to 16 weeks before surgery. All patients received the same perioperative care, including chest physiotherapy. The occurrence of PPCs was the considered outcome. PPCs were defined as pneumonia (American Thoracic Society criteria, 2004) or atelectasis requiring bronchoscopy. Cases and controls were matched according to age, body mass index, forced expiratory volume in the first second of expiration (FEV1%), FEV1/forced vital capacity, type of approach and diagnosis of non-small-cell lung cancer. We calculated the odds ratio (OR) with 95% confidence interval (CI) for PPCs. Results: The overall prevalence of PPCs was 4.7% (18/378); 5.3% (13 out of 244) in the active smokers group and 3.7% (5 out of 134) in the ex-smokers group. After matching, two sets of 134 patients each were compared. The prevalence was 4.5% (6/134) in active and 3.7% (5/134) in ex-smokers (OR 1.21 95% CI: 0.29-5.13, P = 0.76). Conclusions: In this population of patients strictly matched according to risk criteria for PPCs, smoking at the time of surgery was not identified as a risk variable. Therefore, the practice of postponing surgery until tobacco abstention has been achieved does not seem to be justified.

La discusión de casos por videoconferencia mejora la eficiencia de la consulta externa de cirugía torácica / e-Consultation Improves Efficacy in Thoracic Surgery Outpatient Clinics

Objetivo: El objetivo de este estudio es analizar si la discusión sistemática de casos frente a la ocasional de casos dudosos, mediante videoconferencia, se relaciona con una mejora en la eficiencia de la consulta externa presencial de un servicio de cirugía torácica. Método: Estudio retrospectivo y comparativo de los pacientes valorados por videoconferencia y consulta externa presencial en 2 periodos de tiempo equivalentes: grupo A (discusión ocasional de casos) entre 2008 y 2010, y grupo B (discusión sistemática semanal) entre 2011 y 2013. Los datos se han extraído de 2 bases de datos prospectivas e informatizadas. Se analizaron el número de pacientes evaluados por videoconferencia y en consulta presencial como primera consulta, y el número de pacientes intervenidos no urgentes bajo anestesia general en cada año y por cada periodo. Se creó el índice casos operados/casos nuevos vistos en consulta externa para cada año y cada periodo. Los datos se compararon usando el test no paramétrico de Wilcoxon. Resultados: En el grupo A se vieron una media de 563 pacientes en consulta externa frente a 464 en el segundo periodo. La mediana de casos discutidos por videoconferencia/año fue de 42 en el primer periodo frente a 136 en el segundo. La media del índice de casos operados/casos vistos en consulta externa pasó de 0,7 a 0,87 (p = 0,04) del primer al segundo periodo. Conclusiones: La discusión sistemática de casos mediante videoconferencia sí tiene una repercusión positiva sobre la eficiencia de la consulta externa medida en términos de casos operados/casos nuevos valorados al mejorar dicho índice

Objective: The aim of this study is analysing the impact of the systematic versus occasional videoconferencing discussion of patients with two respiratory referral units along 6 years of time over the efficiency of the in-person outpatient clinics of a thoracic surgery service. Method: Retrospective and comparative study of the evaluated patients through videoconferencing and in-person first visits during two equivalents periods of time: Group A (occasional discussion of cases) between 2008-2010 and Group B (weekly regular discussion) 2011-2013. Data were obtained from two prospective and electronic data bases. The number of cases discussed using e-consultation, in-person outpatient clinics evaluation and finally operated on under general anaesthesia in each period of time are presented. For efficiency criteria, the index: number of operated on cases/number of first visit outpatient clinic patients is created. Non-parametric Wilcoxon test is used for comparison. Results: The mean number of patients evaluated at the outpatient clinics/year on group A was 563 versus 464 on group B. The median number of cases discussed using videoconferencing/year was 42 for group A versus 136 for group B. The mean number of operated cases/first visit at the outpatient clinics was 0.7 versus 0.87 in group B (P = .04). Conclusions: The systematic regular discussion of cases using videoconferencing has a positive impact on the efficacy of the outpatient clinics of a Thoracic Surgery Service measured in terms of operated cases/first outpatient clinics visit

e-Consultation Improves Efficacy in Thoracic Surgery Outpatient Clinics. / La discusión de casos por videoconferencia mejora la eficiencia de la consulta externa de cirugía torácica.

OBJECTIVE: The aim of this study is analysing the impact of the systematic versus occasional videoconferencing discussion of patients with two respiratory referral units along 6 years of time over the efficiency of the in-person outpatient clinics of a thoracic surgery service. METHOD: Retrospective and comparative study of the evaluated patients through videoconferencing and in-person first visits during two equivalents periods of time: Group A (occasional discussion of cases) between 2008-2010 and Group B (weekly regular discussion) 2011-2013. Data were obtained from two prospective and electronic data bases. The number of cases discussed using e-consultation, in-person outpatient clinics evaluation and finally operated on under general anaesthesia in each period of time are presented. For efficiency criteria, the index: number of operated on cases/number of first visit outpatient clinic patients is created. Non-parametric Wilcoxon test is used for comparison. RESULTS: The mean number of patients evaluated at the outpatient clinics/year on group A was 563 versus 464 on group B. The median number of cases discussed using videoconferencing/year was 42 for group A versus 136 for group B. The mean number of operated cases/first visit at the outpatient clinics was 0.7 versus 0.87 in group B (P=.04). CONCLUSIONS: The systematic regular discussion of cases using videoconferencing has a positive impact on the efficacy of the outpatient clinics of a Thoracic Surgery Service measured in terms of operated cases/first outpatient clinics visit.

Diagnóstico y tratamiento de un hemotórax causado por un seudoaneurisma de arteria intercostal / Diagnosis and treatment of hemothorax caused by intercostal artery pseudoaneurysm

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Tridimensional titanium-printed custom-made prosthesis for sternocostal reconstruction.

A broad range of materials have been described for sternal reconstruction in order to guarantee not only the best preservation of respiratory mechanics, but also adequate mediastinal protection and acceptable cosmetic results. Today, titanium implants are preferred by many surgeons because of their optimal features. As a step forward, tridimensional (3D) laser sintering printing techniques allow us to virtually reproduce even more complex bony structures. Here, we present a case of sternocostal reconstruction by means of a 3D titanium-printed custom-made prosthesis after extensive resection of a chest wall sarcoma. The use of an intraoperative template to precisely set resection margins, the novel prosthetic design as well as a new and safer rib fixation system may offer some advantages over other custom-made reconstructive techniques.

Fast determination of 40 drugs in water using large volume direct injection liquid chromatography-tandem mass spectrometry.

This work describes a rapid analytical method based on direct sample injection of water samples for the simultaneous identification/quantification of 40 emerging compounds, including pharmaceuticals and drugs of abuse. The water samples were analyzed by ultra-high-performance liquid chromatography coupled to hybrid triple quadrupole mass spectrometer (UHPLC-MS/MS QqQ). Taking profit of the increasing sensitivity of nowadays tandem mass spectrometers, direct sample injection of large volumes has been an attractive alternative to pre-concentration steps. In this work, the developed methodology has been validated at three concentration levels (10, 100 and 1000 ng/L) in 10 different water samples of different types (5 effluent wastewater and 5 surface water samples). The majority of compounds could be satisfactory validated at these concentrations, showing good recoveries and precision. With only few exceptions, the limits of quantification (LOQs), estimated from the sample chromatogram at lowest spiked level tested, were below 3 ng/L. The method was applied to the analysis of 10 effluent wastewater and 10 surface water samples. Venlafaxine was the compound most frequently detected (80%) in surface water, followed by acetaminophen (70%). Regarding effluent wastewater, valsartan and 4-acetyl aminoantipyrine were detected in 9 out of 10 samples analyzed. These two compounds together with 4-formyl aminoantipyrine and naproxen showed the highest concentrations (>2000 ng/L). In these cases, a dilution step was required for a correct quantification. As an additional evaluation of the method performance, the same water samples were analyzed in another laboratory by a second analytical methodology, based on on-line solid-phase-extraction coupled to LC-MS/MS (QqQ).

[Clinical profile of patients with very high hypertriglyceridemia from the Registry of Hypertriglyceridemia of the Spanish Atherosclerosis Society]. / Perfil clínico de los pacientes con hipertrigliceridemia muy severa del Registro de Hipertrigliceridemias de la Sociedad Española de Arteriosclerosis.

BACKGROUND AND OBJECTIVE: To describe clinical and epidemiological characteristics of patients with very high hypertriglyceridemia (HTG) who were attended in lipid units of the Spanish Society of Atherosclerosis (SEA). PATIENTS AND METHOD: Patients of the HTG Registry of SEA with at least one triglyceride concentration greater than 1,000mg/dL (n=298, HTG severe group) and those whose baseline triglycerides were between 200 and 246mg/dL (HTG control group, n=272) were included. RESULTS: Patients with very high triglyceride levels were younger (46.9±11.5 years vs 52.7±13 years; p<0.0001), with a larger waist circumference (100.5±10.6cm vs 98.5±11.1cm; p=0.0426), higher alcohol intake (170.7±179.1g/wk vs 118.8±106.4g/wk; p=0,0473), active smoking status (45.6% vs 26.8%; p<0.0001) and a higher frequency of pancreatitis (10.2% vs 3%; p=0.0006) than HTG control group. There was a higher percentage of patients with atherogenic dietary pattern in severe HTG group compared with the control group (138 [46.3%] vs. 94 [34.5%]; p=0,001). The multivariate analysis showed that factors associated with a triglyceride concentration greater than 1,000mg/dl were age, male sex, weight, waist circumference, alcohol, physical inactivity in non-business hours and the presence of diabetes mellitus. CONCLUSIONS: Patients with very high HTG were usually men in the fourth decade of life, with abdominal obesity, smoking and alcohol consumption. In 60% of cases the HTG was primary, and pancreatitis the most frequently complication.

Perfil clínico de los pacientes con hipertrigliceridemia muy severa del Registro de Hipertrigliceridemias de la Sociedad Española de Arteriosclerosis / Clinical profile of patients with very high hypertriglyceridemia from the Registry of Hypertriglyceridemia of the Spanish Atherosclerosis Society

Fundamento y objetivo Describir las características clínico-epidemiológicas de los pacientes con hipertrigliceridemia (HTG) muy severa atendidos en las Unidades de Lípidos de la Sociedad Española de Arteriosclerosis (SEA).Pacientes y método Se incluyeron los pacientes del Registro de HTG de la SEA con al menos una trigliceridemia superior a 1.000mg/dl (n=298, grupo HTG muy severa) y aquellos cuya trigliceridemia basal fuese entre 200 y 246mg/dl (grupo HTG control, n=272). Resultados Los pacientes con HTG muy severa eran más jóvenes (46,9±11,5 vs 52,7±13 años; p<0,0001), con un perímetro de cintura abdominal mayor (100,5±10,6 vs 98,5±11,1cm; p=0,0426), mayor ingesta de alcohol (170,7±179,1 vs 118,8±106,4g/semana; p=0,0473), tabaquismo activo (45,6 vs 26,8%; p<0,0001) y una mayor frecuencia de pancreatitis (10,2 vs 3%; p=0,0006) que el grupo control. Hubo un mayor porcentaje de pacientes con un patrón de consumo aterógeno en el grupo de HTG muy severa comparado con el grupo control (138 [46,3%] vs. 94 [34,5%]; p=0,001). El modelo multivariante mostró que los factores asociados a alguna determinación de triglicéridos mayor de 1.000mg/dl fueron la edad, el sexo masculino, el peso, el perímetro de cintura abdominal, el alcohol, la inactividad física fuera de la jornada laboral y la presencia de diabetes mellitus. Conclusiones Los pacientes con HTG muy severa suelen ser varones en la cuarta década de la vida, con obesidad abdominal, fumadores y consumidores de alcohol. En el 60% de los casos la HTG fue primaria, y la pancreatitis fue la complicación más frecuente (AU)

Background and objective To describe clinical and epidemiological characteristics of patients with very high hypertriglyceridemia (HTG) who were attended in lipid units of the Spanish Society of Atherosclerosis (SEA).Patients and method Patients of the HTG Registry of SEA with at least one triglyceride concentration greater than 1,000mg/dL (n=298, HTG severe group) and those whose baseline triglycerides were between 200 and 246mg/dL (HTG control group, n=272) were included.ResultsPatients with very high triglyceride levels were younger (46.9±11.5 years vs 52.7±13 years; p<0.0001), with a larger waist circumference (100.5±10.6cm vs 98.5±11.1cm; p=0.0426), higher alcohol intake (170.7±179.1g/wk vs 118.8±106.4g/wk; p=0,0473), active smoking status (45.6% vs 26.8%; p<0.0001) and a higher frequency of pancreatitis (10.2% vs 3%; p=0.0006) than HTG control group. There was a higher percentage of patients with atherogenic dietary pattern in severe HTG group compared with the control group (138 [46.3%] vs. 94 [34.5%]; p=0,001). The multivariate analysis showed that factors associated with a triglyceride concentration greater than 1,000mg/dl were age, male sex, weight, waist circumference, alcohol, physical inactivity in non-business hours and the presence of diabetes mellitus. Conclusions Patients with very high HTG were usually men in the fourth decade of life, with abdominal obesity, smoking and alcohol consumption. In 60% of cases the HTG was primary, and pancreatitis the most frequently complication (AU)

Autologous fibrin scaffolds cultured dermal fibroblasts and enriched with encapsulated bFGF for tissue engineering.

Autologous fibrin scaffolds (AFSs) enriched with cells and specific growth factors represent a promising biocompatible scaffold for tissue engineering. Here, we analyzed the in vitro behavior of dermal fibroblasts (DFs) (cellular attachment, distribution, viability and proliferation, histological and immunohistochemical changes), comparing AFS with and without alginate microcapsules loaded with basic fibroblast growth factor (bFGF), to validate our scaffold in a future animal model in vivo. In all cases, DFs showed good adhesion and normal distribution, while in scaffolds with bFGF at 14 days, the cell counts detected in proliferation and viability assays were greatly improved, as was the proliferative state, and there was a decrease in muscle specific actin expression and collagen synthesis in comparison with the scaffolds without bFGF. In addition, the use of plasma without fibrinogen concentration methods, together with the maximum controlled release of bFGF at 14 days, favored cell proliferation. To conclude, we have been able to create an AFS enriched with fully functional DFs and release-controlled bFGF that could be used in multiple applications for tissue engineering.

Results of a simple exercise test performed routinely to predict postoperative morbidity after anatomical lung resection.

BACKGROUND AND OBJECTIVE: Exercise tests are considered the most reliable ones for the preoperative workup of lung resection candidates but frequently are indicated only in cases with low predicted postoperative forced expiratory volume in 1s (FEV1) and carbon monoxide diffusing capacity (DLCO). The aim of this investigation is to evaluate if a simple, standardised incremental bicycle exercise test routinely performed in patients considered operable is predictive of postoperative cardio-respiratory complication and if its performance is comparable to a logistic regression model including frequently cited clinical predictive variables. METHODS: A series of 103 lung resection candidates were included in a prospective observational study. All patients underwent a standardised, incremental exercise test on a bicycle up to exhaustion. The analysed outcome was the occurrence of postoperative cardio-respiratory complications prospectively recorded and codified. The correlation of distance reached at the end of the test and the outcome was estimated by non-parametric tests. A logistic regression model including age, BMI, predicted postoperative (ppoFEV1%) and predicted postoperative DLCO (ppoDLCO) was adjusted and the individual probability of complication calculated and set as a new variable. Finally, two receiver operating characteristic (ROC) curves were constructed and compared: one with distance at the exercise test and the other with logistic regression probability of complication. RESULTS: Mortality of the series was nil. Outcome prevalence was 14%. Distance reached at the end of the exercise test was lower in cases with a positive outcome (3498.6m vs 4543.5m, p=0.001). On logistic regression analysis, age of the patient (p=0.016) and ppoDLCO (p=0.000) were predictive for the outcome. On ROC analysis, C-indices were 0.77 (distance) and 0.78 (logistic model, p=0.95). CONCLUSION: Reached distance in a simple standardised exercise test is related to postoperative morbidity after lung resection; and the accuracy of prediction using this variable alone is comparable to a logistic regression model including age and ppoDLCO.

Chest drainage suction decreases differential pleural pressure after upper lobectomy and has no effect after lower lobectomy.

BACKGROUND AND OBJECTIVE: To our knowledge, no reports have been published describing the effect of suction on pleural pressures after different types of lobectomy. Improving knowledge of pleural physiology in the postoperative period could lead to better postoperative care. The aim of this investigation is to evaluate the effect of postoperative suction on inspiratory, expiratory and differential pleural pressures after upper or lower lobectomy. METHODS: Records of intrapleural pressures from 24 lobectomy patients (operated on in two different institutions) were selected for study. All patients had normal preoperative pulmonary function tests (forced expiratory volume in 1s (FEV1) >80% and forced vital capacity (FVC)/FEV1 >70%), and neither postoperative air leak nor any other postoperative complication. We selected six cases of each type of lobectomy (right upper lobectomy (RUL), right lower lobectomy (RLL), left upper lobectomy (LUL) and left lower lobectomy (LLL)). In three cases of each group, no suction was indicated, while in the other three cases, chest tubes were placed under 15 cm H(2)O suction, according to the standard local perioperative care protocol in each participating centre. Inspiratory and expiratory pleural pressures were measured at 2-min intervals by an electronic device using a DigiVent (Millicore A.B., Sweden) suction chamber. Recording started 5-10h after closing the chest, and included 5 consecutive hours during the first postoperative night, with the patients at rest in 30-45 degrees sitting position. There was no evidence of pneumothorax during the recording time. The influence of lobectomy site (upper or lower) and suction on inspiratory, expiratory and differential pressures were evaluated by Student's t-tests. RESULTS: In the group of cases under no suction, upper lobectomy patients had larger differential pressures (22.6 in upper vs 11.5 cm H(2)O in lower lobectomy cases, p<0.001), differential pressure decreased in patients under suction (9.1 in upper vs 11.1 cm H(2)O in lower lobectomy cases, p<0.001) and the effect was mainly due to a less negative inspiratory pressure. CONCLUSION: Pleural suction leads to a large decrease of differential pleural pressure after upper pulmonary lobectomy. The influence of this finding on postoperative work of breathing in the early postoperative period remains to be investigated.

Cost-effectiveness analysis of prophylactic respiratory physiotherapy in pulmonary lobectomy.

OBJECTIVE: To evaluate the cost-effectiveness balance of implementing an intensive program of chest physiotherapy in pulmonary lobectomy. DESIGN: cross-sectional study with historical controls. Cases are 119 patients operated on during a 15-month period of time, after implementation of an intensive chest-physiotherapy program. Controls are 520 patients operated on by the same team before the program started. In these patients, only incentive spirometry was indicated besides routine nursing care. In both series, operative selection criteria and anaesthetic management were similar. Population homogeneity was assessed by comparing age, body mass index (BMI) and estimated postoperative FEV1 (ppoFEV1) of the patients in both series. Selected outcomes were as follows: 30-day mortality, prevalence of respiratory morbidity (atelectasis and pneumonia) and hospital stay. Hospital stay was estimated by Cox regression using age, ppoFEV1, BMI, diagnosis and postoperative morbidity as covariates. Costs were calculated adding chest therapists' salaries and acquisition value of specific training and monitoring devices and its consumable items. Savings from avoided hospitalisation days was discounted. RESULTS: Prevalence of atelectasis and median hospital stay decreased in physiotherapy group. Cost of the program was 48,447.81 (407.12 per treated patient). An estimated total of 151.75 hospital days was saved in the physiotherapy group. Since daily hospitalisation cost is 590.00 in our centre, 89,532.50 savings was estimated from avoided hospitalisation days. CONCLUSIONS: We have found a significant decrease in the rate of postoperative atelectasis without additional costs. In fact, the program has produced considerable monetary savings.

Estimating hospital costs attributable to prolonged air leak in pulmonary lobectomy.

OBJECTIVE: Prolonged air leak (PAL) after pulmonary surgery is a frequent occurrence and is reported to cause increased length of stay (LOS) and hospital costs although the costs directly attributable to PAL have never been published. The present study aims to compare the prevalence of pulmonary complications (atelectasis, pneumonia and pleural empyema) in patients with or without PAL and to quantify economic costs directly incurred by PAL in a series of pulmonary lobectomies. METHODS: A series of 238 patients scheduled for pulmonary lobectomy (January 2001-December 2003) have been reviewed. PAL was defined as air leakage which prevented hospital discharge for 5 postoperative days or over. Hospital costs (excluding operating room) for pulmonary lobectomies have been obtained and calculated as mean daily costs. Age, body mass index, diagnosis, Charlson co-morbidity index, ppoFEV1 and major post-operative cardio-pulmonary morbidity have been used to construct a Cox-regression model for hospital stay, considering deaths as censored cases. Individual risk function has been used as a new variable and expected LOS calculated for each case. This data has been used to estimate total excess hospital stay and costs incurred by cases with PAL. RESULTS: Prevalence of PAL was 23 cases (9, 7%). Mean daily hospital cost for lobectomy was 632.49. For the whole series, mean hospital stay was 5 days (10 days for patients with PAL). PAL cases had more postoperative pulmonary morbidity (risk-ratio: 2.78). Variables showing independent influence on stay were: diagnosis of non-malignant disease (P=0.001); FEV1ppo (P=0.032) and cardio-respiratory morbidity (P<0.001). Calculated total excess stay for PAL patients was 62 days. A total expense of 39,437.39 (38,724.96 hospital and 712.43 pharmacy charges) were estimated to result from postoperative air-leak. CONCLUSIONS: PAL patients are prone to developing major postoperative morbidity. PAL calculated costs are over 13,000 per year. This data is useful for designing technical cost-effective strategies to avoid post-lobectomy PAL.

Emergency hospital readmission after major lung resection: prevalence and related variables.

OBJECTIVE: To evaluate the rate, causes and variables related to emergency hospital readmission after scheduled major lung resection. SETTING: An university general hospital in a managed care health system. METHODS: Databases of 727 patients undergoing scheduled major lung resection between 1994 and 2003 have been reviewed, excluding hospital mortality from the analysis. The studied outcome was the occurrence of emergency hospital readmission by any surgery-related cause, at any centre, during the first 30 days after discharge. Independent studied variables were: age of the patient, body mass index, predicted postoperative FEV1% (ppoFEV1%), type of surgery (lobectomy or pneumonectomy), postoperative morbidity and length of stay (LOS). Descriptive statistics have been performed and forward step-wise logistic regression has been used to select predictive variables. RESULTS: Rate of emergency readmission was 6.9% (50 cases); 3 patients (6%) died. Pleural empyema without bronchial fistula (18 cases) was the most frequent cause of readmission. On logistic-regression analysis, pneumonectomy (odds ratio 3.84; 95%CI: 1.98-7.45) and major postoperative morbidity (odds ratio 2.42; 95%CI: 1.26-4.66) showed independent correlation to the outcome. CONCLUSIONS: Readmission rate after lung resection is around 7% and it is not influenced by LOS; patients experiencing major postoperative morbidity and pneumonectomy cases have the highest probability to be readmitted within 30 days after lung resection.