Age as a Barrier to Surgical Stabilization of Rib Fractures in Patients with Flail Chest.

INTRODUCTION: Although randomized trials demonstrate a benefit to surgical stabilization of rib fractures (SSRF), SSRF is rarely performed. We hypothesized older patients were less likely to receive SSRF nationally. METHODS: The 2016 National Inpatient Sample was used to identify adults with flail chest. Comorbidities and receipt of SSRF were categorized by ICD-10 code. Univariable testing and Multivariable regression were performed to determine the association of demographic characteristics and comorbidities to receipt of SSRF. RESULTS: 1021 patients with flail chest were identified, including 244 (23.9%) who received SSRF. Patients ≥70 years were less likely to receive SSRF. (<70 yrs 201/774 [26.0%] vs ≥70 43/247 [17.4%], P = .006) and had higher risk of death (<70 yrs 39/774 [5.0%] vs ≥70 33/247 [13.4%], P < .001) In multivariable modeling, only age ≥70 years was associated with SSRF (OR .591, P = .005). CONCLUSION: Despite guideline-based support of SSRF in flail chest, SSRF is performed in <25% of patients. Age ≥70 years is associated with lower rate of SSRF and higher risk of death. Future study should examine barriers to SSRF in older patients.

Surgical Repair vs Stent for Esophageal Perforation: A Multi-institutional Database Analysis.

BACKGROUND: Endoscopic esophageal stenting is used as an alternative to surgical repair for esophageal perforation. Multi-institutional studies supporting stenting are lacking. The purpose of this study was to compare the outcomes of surgical repair and esophageal stenting in patients with esophageal perforation using a nationally representative database. We hypothesized that mortality between these approaches would not be different. METHODS: The Premier Healthcare Database was used to compare adult inpatients with esophageal perforation receiving either surgical repair or esophageal stenting from 2009 to 2019. Patients receiving intervention ≤7 days of admission were included in the analysis. Patients receiving both stent and repair on the same day were excluded. The composite outcome of interest was death or discharge to hospice. Logistic regression was used to evaluate independent predictors of death or hospice, adjusting for comorbidities. RESULTS: There were 2543 patients with esophageal perforation identified who received repair (1314 [51.7%]) or stenting (1229 [48.3%]). Stenting increased from 7.0% in 2009 to 78.1% in 2019. Patients receiving repair were more likely to be female and White and had fewer Elixhauser comorbidities. Death or discharge to hospice was more common after stent (134/1314 [10.2%] repair vs 199/1229 [16.2%] stent; P < .001); however, after adjustment for comorbidities, logistic regression suggested that death or hospice discharge was similar between approaches (stent vs repair: odds ratio, 1.074; 95% CI, 0.81-1.42; P = .622). Hospital length of stay was shorter after stenting (stent vs repair coefficient, -4.09; P < .001). CONCLUSIONS: In patients with esophageal perforation, the odds for death or discharge to hospice were similar for esophageal stenting compared with surgical repair.

Comparing Thoracoscopic and Robotic Lobectomy Using a Nationally Representative Database.

BACKGROUND: Studies of robotic lobectomy (Robot-L) have been performed using data from high-volume, specialty centers which may not be generalizable. The purpose of this study was to compare mortality, length of stay (LOS), and cost between Robot-L and thoracoscopic lobectomy (VATS-L) using a nationally representative database hypothesizing they would be similar. METHODS: The Premier Healthcare Database was used to identify patients receiving elective lobectomy for lung cancer from 2009 to 2019. Patients were categorized as receiving Robot-L or VATS-L using ICD-9/10 codes. Survey methodology and patient level weighting were used to correct for sampling error and estimation of a nationally representative sample. A propensity match analysis was performed to reduce bias between the groups. Primary outcome of interest was in-hospital mortality. Secondary outcomes were LOS and patient charges. RESULTS: Among 62 698 patients, 19 506 (31.1%) underwent Robot-L and 43 192 (68.9%) underwent VATS-L. Differences between the groups included age, race, comorbidities, and insurance type. A propensity matched cohort demonstrated similar in-hospital mortality for Robot-L and VATS-L (.9% vs .9%, respectively, P = .91). Patients who underwent Robot-L had a shorter LOS (4 vs 5d, respectively, P < .001) but higher patient charges (90 593.0 vs 72 733.3 USD, respectively, P < .001). CONCLUSIONS: In a nationally representative database, Robot-L and VATS-L had similar mortality. Although Robot-L was associated with shorter hospitalization, it was also associated with excess charges of almost $20,000. As Robot-L is now the most common approach for lobectomy in the U.S., further study into the cost and benefit of robotic surgery is warranted.

Wedge Resection Offers Similar Survival to Segmentectomy for Typical Carcinoid Tumors.

Current guidelines recommend anatomic lung resection of typical bronchopulmonary carcinoids. Typical carcinoid tumors have excellent prognosis and sublobar resection has been associated with noninferior long-term survival. It's unclear whether wedge resection is acceptable for small typical carcinoid tumors. We hypothesize there is no difference in survival between wedge resection and segmentectomy for Stage I typical bronchopulmonary carcinoid tumors. Using the National Cancer Database from 2010 to 2016, we identified clinical T1N0M0 typical bronchopulmonary carcinoid tumors by wedge resection or segmentectomy. Short-term outcomes included length of stay, lymph nodes evaluated, pathologic node status, positive margin status, and 90-day mortality. Primary outcome was overall survival and estimated using Kaplan-Meier survival analysis. 821 patients were identified: 677 receiving wedge resection, 144 receiving segmentectomy. Segmentectomy was more commonly performed in an academic setting (70.0% vs 57.3%, P = 0.005). The mean tumor size for segmentectomy was 1.7 cm versus 1.4 cm for wedge resection (P < 0.001). There was no difference in LOS, positive margin status, and 90-day mortality between groups. There were significantly more lymph nodes evaluated in segmentectomy patients (median 4 vs 0, P < 0.001), but there was no difference in positive lymph node status (5.3% vs 2.6%, P = 0.165). The OS was similar between wedge and segmental resection (P = 0.613): 3-year survival (93.5% vs 92.8%) and 5-year survival (83.8% vs 84.9%). Wedge resection and segmentectomy have similar survival for Stage I typical bronchopulmonary carcinoids in a large national database. This analysis suggests nonanatomic, parenchymal-sparing resection should be considered an appropriate alternative for Stage I typical bronchopulmonary carcinoids.

Drain Amylase: A Simple and Versatile Method of Detecting Esophageal Anastomotic Leaks.

BACKGROUND: Anastomotic leak after esophagectomy is a significant cause of morbidity. Perianastomotic drain amylase is accurate in detecting leaks, but it is unclear whether its accuracy is affected by comorbid conditions, anastomotic method, or anastomotic location. We hypothesized that drain amylase would accurately discriminate leak in a variety of settings. METHODS: We reviewed 290 consecutive patients undergoing esophagectomy with gastric conduit reconstruction. Patient comorbidities, operative variables, and drain amylase were collected. The diagnosis of a leak was based on the level of intervention required, and was characterized as clinically significant if it required wound opening or endoscopic or surgical intervention. Receiver-operating characteristic curves analysis was performed to determine the accuracy of amylase to detect leak for each patient variable. RESULTS: A total of 53 (18.3%) of 290 esophagectomies had an anastomotic leak, of which 33 (11.4%) of 290 were clinically significant. Drain amylase was a strong predictor of anastomotic leak on postoperative day (POD) 3 to POD 7, regardless of patient comorbidities, location of anastomosis, or technique of anastomosis, but was less accurate in the diagnosis of leak in current smokers (area under the receiver-operating characteristic curve, 0.530 vs 0.752; P = .006). A maximum drain amylase value no higher than 35 on POD 3, POD 4, or POD 5 was 88% sensitive in detecting leak at any point postoperatively. A value greater than or equal to 150 was 88% specific in diagnosing leak. CONCLUSIONS: Drain amylase is a versatile method for early detection of anastomotic leaks. Its accuracy is unaffected by neoadjuvant treatment, location or type of anastomosis, or patient comorbidities but may be less accurate in active smokers.

Robotic Approach Has Improved Outcomes for Minimally Invasive Resection of Mediastinal Tumors.

BACKGROUND: The optimal minimally invasive surgical approach to mediastinal tumors is unknown. There are limited reports comparing the outcomes of resection with robotic-assisted thoracoscopic surgery (RATS) and video-assisted thoracoscopic surgery (VATS) surgery. We hypothesized that patients who underwent RATS would have improved outcomes. METHODS: The National Cancer Database was queried for all patients who underwent a minimally invasive surgical approach for any mediastinal tumor from 2010 to 2016. Patients were determined to have an adverse composite outcome if they had any of the adverse perioperative outcomes: conversion to open procedure, 90-day mortality, 30-day readmission, and positive pathologic margins. Secondary outcomes of interest were length of stay and overall survival. Multivariable logistic regression was used to assess likelihood of having a composite adverse outcome based on surgical approach. RESULTS: The study included 856 patients: 402 (47%) underwent VATS and 454 (53%) underwent RATS. RATS resections were associated with fewer conversions (4.9% vs 14.7%, P < .001), fewer positive margins (24.3% vs 31.6%, P = .02), shorter length of stay (3.8 days vs 4.3 days, P = .01), and fewer composite adverse events (36.7% vs 51.3%, P < .001). Multivariate analysis showed RATS (odds ratio, 0.44; P < .001) was independently associated with a decreased likelihood of a composite adverse outcome, even among tumors exceeding 4 cm (odds ratio, 0.45; P = .001). Overall survival was similar between the 2 groups. CONCLUSIONS: Among patients who underwent a minimally invasive surgical approach for a mediastinal tumor, RATS had fewer adverse outcomes than VATS, even for tumors 4 cm or larger. These data suggests that RATS may be the preferred technique for patients who are candidates for minimally invasive resection of mediastinal tumors.

Monitoring for Recurrence After Esophagectomy.

BACKGROUND: Current guidelines for follow-up after esophagectomy suggest only history and physical examination (HPE). With recent advances in chemotherapy and immunotherapy for patients with recurrent esophageal cancer, we hypothesized that surveillance imaging (SI) would identify patients with cancer recurrence earlier and improve long-term survival. METHODS: A retrospective review of all patients undergoing esophagectomy for esophageal cancer at a single institution between 2007 and 2018 was conducted. Patients were categorized as recurrence detected through SI or recurrence detected through HPE alone. Patients were excluded if recurrence occurred within 3 months of esophagectomy. RESULTS: During the study period, 225 esophageal cancer patients underwent an esophagectomy. Among these, 101 (44.9%) had SI and 124 (55.1%) had routine follow-up with HPE. There were 88 recurrences (39.1%) with median follow-up of 12 months. Rate of recurrence was similar based on screening method: 41 of 101 (40.6%) by SI and 47 of 124 (37.9%) by HPE (P = .68). Among patients with recurrence, recipients of additional treatment were also similar between groups, 36 of 41 (87.8%) by SI and 34 of 47 (72.3%) by HPE (P = .468). Among those who had a recurrence, the median overall survival was significantly longer in those undergoing SI at 23 months compared with those who received HPE at 16 months (P = .047). CONCLUSIONS: SI after esophagectomy is not associated with improved detection of recurrence, but is associated with improved overall survival once recurrence is detected. These data suggest that earlier identification of esophageal cancer recurrence may have survival benefit. Standardizing SI may prove beneficial for patients after esophagectomy.

Are We Underestimating the Morbidity of Single Rib Fractures?

PURPOSE: Previous studies suggest that patients with multiple rib fractures have poor outcomes, but it is unknown how isolated single rib fractures (SRF) are associated with morbidity or mortality. We hypothesized that patients with poor outcomes after SRF can be identified by demographics and comorbidities. The purpose of this study was to model adverse outcome after single rib fractures. MATERIALS AND METHODS: We used the 2016 National Inpatient Sample to identify patients with SRF associated with blunt trauma using ICD-10 coding. Comorbidities and abbreviated injury score (AIS) were also extracted. Patients with non-chest trauma were excluded. The primary outcome was an adverse composite outcome of death, pneumonia, tracheostomy, or hospitalization longer than twelve days. One-third of the cohort was reserved for validation. Backward selection multivariable modeling identified factors associated with adverse composite outcome. The model was used to create a nomogram to predict adverse composite outcome. The nomogram was then tested using the validation cohort. RESULTS: 2,398 patients with isolated SRF were divided into training (n = 1,598) and validation sets (n = 800). The average age was 69 and the majority were male (66%) and received care at academic institutions (61.6%). The adverse composite outcome occurred in 20.8%: 61 deaths (2.5%), 67 tracheostomies (2.8%), 319 pneumonias (13.3%), and 165 patients with hospital length of stay greater than twelve days (6.9%). Results of stepwise multivariable modeling had a C-statistic of 0.700. The multivariable model was used to create a nomogram which had a c-statistic of 0.672 in the validation cohort. CONCLUSION: 20% of isolated SRF patients had an adverse outcome. Demographics and comorbidities can be used to identify and triage high-risk patients for specialized care and proper counseling.

Palliative Surgery Outcomes for Patients with Esophageal Cancer: An National Cancer Database Analysis.

INTRODUCTION: Many patients with esophageal cancer are not candidates for surgical resection with curative intent, given the advanced stage of disease at presentation. Palliative surgery is one treatment option, but relative survival of palliative surgery has not been described. This study aims to describe the outcomes of palliative surgery in patients with esophageal cancer. METHODS: We used the National Cancer Database to identify patients with esophageal cancer who received palliative surgery or non-surgical palliation-which consisted of palliative radiation and palliative chemotherapy without any surgery. The outcome of interest was overall survival. Characteristics of patients were compared between the palliative surgery group and the non-surgical group using rank sum test or chi square test. Survival differences between groups were compared using Kaplan Meier estimate and log rank test, and Cox proportional hazards model. RESULTS: A total of 14,589 patients were included in the analysis, including 2,812 (19.2%) receiving palliative surgery and 11,777 (80.7%) receiving non-surgical palliation (6,512 palliative radiation and 5,265 palliative chemotherapy). Median overall survival in palliative surgery patients was 5.5 mo, shorter than non-surgical palliation (6.4 mo, P = 0.004). However, when correcting for age, sex, nodal status, metastases, Charlson score, histology, academic center, and private insurance, there was no difference in survival between palliative surgery and non-surgical palliation in Cox proportional hazard modeling (HR 1.03 (0.975-1.090), P = 0.281). CONCLUSIONS: Palliative surgery in advanced esophageal cancer is associated with poor overall survival but is similar to other palliative modalities. Palliative Surgery for esophageal cancer patients should be used sparingly given these poor outcomes.

Concurrent diagnosis of anxiety increases postoperative length of stay among patients receiving esophagectomy for esophageal cancer.

OBJECTIVE: Psychiatric comorbidities disproportionately affect patients with cancer. While identified risk factors for prolonged length of stay (LOS) after esophagectomy are primarily medical comorbidities, the impact of psychiatric comorbidities on perioperative outcomes is unclear. We hypothesized that psychiatric comorbidities would prolong LOS in patients with esophageal cancer. METHODS: The 2016 National Inpatient Sample (NIS) was used to identify patients with esophageal cancer receiving esophagectomy. Concurrent psychiatric illness was categorized using Clinical Classifications Software Refined for ICD-10, creating 34 psychiatric diagnosis groups (PDGs). Only PDGs with >1% prevalence in the cohort were included in the analysis. The outcome of interest was hospital LOS. Bivariable testing was performed to determine the association of PDGs and demographic factors on LOS using rank sum test. Multivariable regression analysis was performed using backward selection from bivariable testing (α ≤ 0.05). RESULTS: We identified 1,730 patients who underwent esophagectomy for esophageal cancer in the 2016 NIS. The median LOS was 8 days (IQR 5-12). In bivariable testing, a concurrent diagnosis of anxiety was the only PDG associated with LOS (9 days (IQR 6-14) with anxiety diagnosis versus 8 days (IQR 5-12) with no anxiety diagnosis, p = 0.022). Multivariable modeling showed an independent association between anxiety diagnosis and increased LOS (OR 4.82 (1.25-25.23), p = 0.022). Anxiety was not associated with increased hospital cost or in-hospital mortality. CONCLUSIONS: This analysis demonstrates an independent effect of anxiety prolonging postoperative LOS after esophagectomy in the United States. These findings may influence perioperative care, patient expectations, and resource allocation.

Postoperative day 1 discharge after anatomic lung resection: A Society of Thoracic Surgeons database analysis.

OBJECTIVE: Although minimally invasive techniques have led to shorter hospitalizations, discharge on postoperative day 1 is still uncommon. We hypothesized that day 1 discharge could be performed safely and that there might be significant variation in day 1 discharge rates between hospitals. METHODS: We identified patients with lung cancer who underwent lobectomy and segmentectomy in the Society of Thoracic Surgeons Database from 2012 to 2017. The 10% longest hospital stay outliers were excluded. A multivariable regression model was created to assess for factors associated with day 1 discharge and readmission. RESULTS: A total of 46,325 patients were examined, and 1821 patients (3.9%) were discharged on day 1. This rate increased from 3.4% to 5.3% over the course of the study (P < .0001). In multivariable analysis, factors associated with day 1 discharge included age, Zubrod score, body mass index greater than 25, forced expiration value at 1 second, middle or upper lobectomy, minimally invasive technique, and procedure time. Outpatient 30-day mortality was similar (0.3% vs 0.4%, P = .472). Patients discharged on day 1 were not at increased risk of readmission. Readmission after day 1 discharge was associated with male sex, coronary artery disease, chronic obstructive pulmonary disease, and longer procedure time. There was substantial variation in day 1 discharge rate between institutions, with 11 centers (4.0%) discharging more than 20% of their patients on day 1, whereas 102 centers (36.7%) had no day 1 discharges. CONCLUSIONS: Day 1 discharge after anatomic lung resection is uncommon but is becoming more common. Carefully selected patients may be discharged on day 1 without an increased risk of readmission or death.

Early discharge after lung resection is safe: 10-year experience.

BACKGROUND: The average hospitalization after lung resection is 6 days, but some patients are discharged early in the post-operative period. The patient factors associated with early discharge (ED) and the safety of this approach are unknown. We hypothesized that specific patient populations are associated with ED, and that complications in this practice are low. METHODS: A prospective database of lung resections performed at an academic medical center between Jan 1, 2007 and Jan 1, 2017 was queried. Demographic and outcome variables were assessed using standard techniques. ED was defined as the length of stay (LOS) for the quintile with the lowest LOS for patients with anatomic resection (AR) or patients with wedge resection (WR). We then compared clinical factors between patients with ED to those patients discharged by day 7, to determine factors associated with ED (relative to "average" discharge). RESULTS: During the study period, there were 922 AR and 1,150 WR performed. A total of 448 (39.0%) patients had WRED and 211 patients (22.9%) had ARED. The rate of WRED varied by surgeon, but ARED did not. ARED and WRED patients was associated with several factors, including younger age, better lung function, and were less likely to have elevated American Society of Anesthesiologist (ASA) class. Multivariable analysis suggested that patient factors and primary surgeon influence ED. WRED was associated with 30-day mortality of 0.22% vs. 1.14% for longer LOS (P=0.08). After AR, there were no post-operative deaths within 30 days among 211 patients discharged on postoperative day 1 or 2 [(vs. 2/541, 0.4%, P=0.376) with longer LOS, P=0.048]. CONCLUSIONS: ED after lung resection is multifactorial but is safe among selected patients. Age, lung function, procedure duration, and surgeon all influence ED. Complications after ED were rare. Individual surgeon comfort with ED likely impacts LOS, and education or enhanced recovery protocols may help overcome this barrier. Standardized pathways would likely help identify low-risk patients for expeditious discharge.

Biomarkers for Predicting Malignant Pleural Mesothelioma in a Mexican Population.

Background: Diagnosis of malignant pleural mesothelioma (MPM) remains a challenge, especially when resources in pathology are limited. The study aimed to evaluate cost-effective tumor markers to predict the probability of MPM in plasma samples in order to accelerate the diagnostic workup of the tissue of potential cases. Methods: We conducted a case-control study stratified by gender, which included 75 incident cases with MPM from three Mexican hospitals and 240 controls frequency-matched by age and year of blood drawing. Plasma samples were obtained to determine mesothelin, calretinin, and thrombomodulin using enzyme-linked immunosorbent assays (ELISAs). We estimated the performance of the markers based on the area under the curve (AUC) and predicted the probability of an MPM diagnosis of a potential case based on the marker concentrations. Results: Mesothelin and calretinin, but not thrombomodulin were significant predictors of a diagnosis of MPM with AUCs of 0.90 (95% CI: 0.85-0.95), 0.88 (95% CI: 0.82-0.94), and 0.51 (95% CI: 0.41-0.61) in males, respectively. For MPM diagnosis in men we estimated a true positive rate of 0.79 and a false positive rate of 0.11 for mesothelin. The corresponding figures for calretinin were 0.81 and 0.18, and for both markers combined 0.84 and 0.11, respectively. Conclusions: We developed prediction models based on plasma concentrations of mesothelin and calretinin to estimate the probability of an MPM diagnosis. Both markers showed a good performance and could be used to accelerate the diagnostic workup of tissue samples in Mexico.

Severe Chronic Obstructive Pulmonary Disease Is Not Associated With Complications After Navigational Bronchoscopy Procedures.

BACKGROUND: Electromagnetic navigational bronchoscopy (ENB) is a commonly used technique to obtain biopsies of peripheral pulmonary lesions. Little is known about risk factors for complications with this procedure. The aim of this study was to assess the complication rate associated with ENB and the relationship of complications to patient- and procedure-related factors. METHODS: Consecutive ENB procedures at an academic medical center between May 11, 2011, and September 11, 2015, were reviewed retrospectively. Preoperative characteristics, including pulmonary function, procedure characteristics, and the occurrence of complications, were recorded. RESULTS: In all, 361 procedures were performed on 341 patients. Complications occurred in 30 of 361 (8.3%), the most common of which was pneumothorax (27, 7.5%). Complications were not related to age, sex, American Society of Anesthesiologists grade, or pulmonary function test result. Patients with complications had longer procedure times (50 versus 73 minutes, p = 0.03), and had more interventional modalities used (2.4 versus 3.2, p = 0.001). Multiple logistic regression demonstrated that bronchoalveolar lavage was significantly associated with complications (odds ratio 6.40; 95% confidence interval: 1.68 to 24.3, p = 0.006). CONCLUSIONS: Electromagnetic navigational bronchoscopy is safe, and the rate of complications is not elevated among patients with poor lung function. Bronchoalveolar lavage performed during ENB was associated with elevated risk of complications and should be studied further.

Malignant Pleural Mesothelioma: Accuracy of CT Against Immunohistochemical Test Among the Mexican Population.

BACKGROUND AND AIMS: Malignant pleural mesothelioma (MPM) is associated with occupational and environmental exposure to asbestos. The incidence is expected to increase as the use of asbestos is not prohibited in many countries, such as in Mexico. We undertook this study to determine sensitivity, specificity, predictive values and likelihood ratios of computed tomography (CT) in a sample from Mexican population with suspected MPM and other pleuropulmonary diseases. METHODS: CT films of 38 patients suspected of having MPM were analyzed. A single observer was blinded to MPM diagnoses. The frequencies of ten CT findings were identified. A cut-off point of ≥5 CT findings was established to determine high MPM probability. Sensitivity, specificity, predictive values and likelihood ratio of the CT against biopsy using immunohistochemical testing (IHC) for MPM were calculated. RESULTS: Of the 38 patients, 31 had MPM and seven had lung adenocarcinoma. The five key findings were mediastinal pleural thickening 96.7% (n = 30), nodular pleural thickening 93.3% (n = 29), pleural mass 83.9% (n = 26), diminished lung 70.9% (n = 22) and contracted hemithorax 70.9% (n = 22). Sensitivity 96.8% (83.2-99.4), specificity 85.7% (42.2-97.6), positive likelihood ratio 6.7 (1.1-41.6), and negative likelihood ratio of 0.04 (0.01-0.2) were reported. CONCLUSIONS: Sensitivity and specificity in this study was greater than previously reported, 96.8% and 85.7 vs. 93.2 and 65.6%, respectively. CT is an easily accessible and useful tool that should be incorporated into the medical education of general physicians to improve MPM diagnosis of suspected cases.

[National consensus of diagnosis and treatment of non-small cell lung cancer]. / Consenso nacional de diagnóstico y tratamiento del cáncer de pulmón de células no pequeñas.

Mexican specialists in oncology, oncologic surgery, thoracic surgery, pneumology, pathology, molecular biology, anesthesiology, algology, psychology, nutrition, and rehabilitation (all of them experts in lung cancer treatment) in order to develop the National Consensus on Lung Cancer. The consensus has been developed as an answer to the need of updated Mexican guidelines for the optimal treatment of the disease, as well as to the requirements that such guidelines be established by multidisciplinary panel, depicting the current attention given to cancer lung cases in Mexico. Thus, this paper analyses the epidemiological review, screening, diagnosis, staging, pathology, translational medicine, and the suitable therapies for early, locally advanced, and metastatic disease in the first, second, and third lines of management, as well as rehabilitation and palliative measures.

Enucleation of esophageal leiomyoma by video-assisted thoracic surgery.

Thoracoscopic enucleation of benign distal esophageal leiomyoma is a minimally-invasive procedure that is comprised of four basic steps: (1) port placement and exposure, (2) dissection, (3) reconstruction, and (4) drain placement and closure. The procedure can be performed with minimal perioperative pain, excellent morbidity and mortality, and a high-degree of patient satisfaction. Some patients may experience mild dysphagia or dyspepsia in the postoperative interval, which is managed medically with proton pump inhibitors or surgically with antireflux repair.

Thoracoscopic management of primary spontaneous pneumothorax.

Primary spontaneous pneumothorax is defined as that which appears in patients without history of previous pathology that could explain the event. Management includes pleural drainage with or without pleurodesis and surgical resection of affected lung tissue with pleurodesis. Thoracoscopic approach has proved to be useful with low morbidity and mortality as well as low recurrence rate. This paper describes the experience with thoracoscopic management of primary spontaneous pneumothorax with pulmonary wedge resection of affected tissue, parietal pleurectomy, and pleural abrasion of remaining parietal and diaphragmatic pleura. Fifty-five patients have been submitted to this approach (24 female, 31 male). Fifty-three patients had past history of at least one previous pneumothorax (second event, n=41; third event, n=9; fourth event or more, n=3). Computed tomography was abnormal in 19 patients. Operative time was 57 minutes (+/-17). There were no transoperative complications. Macroscopic findings were presence of small type I bullae in the lung apex in 48; three more had apical pleural thickening. None of the patients presented postoperative air leak. Chest tubes were removed after 24-48 hours on average. Adequate pain control was achieved in 51 patients; 4 patients presented mild chronic intercostal pain for 3-5 months. Median follow-up was 48 months (range 6-72); no recurrence has been observed. Primary spontaneous pneumothorax can be managed thoracoscopically; management should include wedge resection of affected lung, apical pleurectomy, and pleural abrasion of remaining parietal and diaphragmatic pleura.

Trasplante de pulmón / Lung transplantation

Lung transplantation (LT) has evolved to become an Important alternative in the management of patients with end-stage pulmonary disease and chronic respiratory failure. The beginnings of this technique can be traced back to the experiments of Carrel and Guthrie over a hundred years ago. However, it was not until 1963 when the first clinical experience was performed by Hardy. Clinical success did not arrive until the 1980's thanks to the works of the Toronto Lung Transplant Group. Well established criteria have been described in order to consider a patient as a potential candidate to receive a lung. Several diseases are capable of causing terminal lung damage and in general they can be classified according to their origin as obstructive (COPD, emphysema), restrictive (fibrosis), chronic infectious (cystic fibrosis, bronquiectasis), and vascular (primary pulmonary hypertension). The most frecuent diagnosis is COPD. Clynically relevant modes of LT include the implant of one lung (single LT), or both lungs (bilateral sequential LT). Transplantation of the cardiopulmonary block is reserved for special situations and lobar transplantation is still considered experimental. Donor condition is essential to the success of LT. The potential donor patient frecuently suffers deterioration in lung function due to edema formation or infection and both complications restrict lung's using for transplantation. Lung preservation is also limited to a short period of time which rarely exceeds 6 hours in spite of specially-designed preservative solutions such as the low potassium dextran. Outcome after LT shows current one-year survival between 65-70% with reduction to 40-45% after five years. Mortality within the first year is usually related to primary graft failure and infection. Long-term survival depends on controlling infectious problems due to immunosupresion as well as the development of bronchilitis obliterans as a manifestation of chronic rejection. LT is a therapeutic modality reserved for selected patients with chronic respiratory failure due to end-stage lung disease.

El trasplante de pulmón se ha desarrollado como parte del manejo de pacientes con enfermedad pulmonar terminal que presentan insuficiencia respiratoria. Si bien los inicios de la técnica se encuentran en los experimentos de Carrel y Guthrie a principios del siglo XX, no fue sino hasta 1963 en que Hardy efectuó el primer trasplante pulmonar. Sin embargo, el éxito clínico no se tradujo en realidad sino hasta fines de los años ochenta gracias al esfuerzo del Grupo de Trasplante de la Universidad de Toronto. Existen criterios bien establecidos para considerar cuando un enfermo pulmonar terminal se encuentra en condiciones de ameritar un trasplante. Las patologías capaces de producir daño pulmonar terminal son muy variadas, pero en términos generales pueden dividirse en aquellas de origen obstructivo (EPOC, enfisema), las de tipo intersticial (fibrosis pulmonar), las de origen infeccioso crónico (fibrosis quística, bronquiectasias) y las de patología vascular (hipertensión pulmonar primaria). Con mucho el diagnóstico más frecuente es la EPOC. Es posible trasplantar un solo pulmón (trasplante unilateral) o bien los dos pulmones (trasplante bilateral secuencial). El trasplante del bloque cardiopulmonar se reserva para situaciones especiales y el trasplante lobar se considera aún experimental. Las condiciones del donador son especialmente importantes y constituyen muchas veces el principal obstáculo a vencer debido al deterioro pulmonar que sufren estos pacientes durante el manejo previo a la toma de decisión sobre la donación de los órganos. El deterioro pulmonar y la infección sobreagregada son los principales problemas que limitan la procuración de pulmones. La preservación pulmonar aún se encuentra limitada a un tiempo corto que rara vez excede las seis horas a pesar de utilizar soluciones especialmente diseñadas como lo es la de dextrán baja en potasio. Los resultados muestran una sobrevida a un año de entre 65-70% disminuyendo a 40-45% a los cinco años. Las causas de mortalidad dentro del primer año se relacionan con falla primaria del injerto, así como infecciones oportunistas. A largo plazo, además de infecciones oportunistas por la inmunosupresión se agrega el problema del desarrollo de bronquiolitis obliterante como manifestación de rechazo crónico. El trasplante pulmonar es una modalidad de manejo adecuada para pacientes seleccionados con falla respiratoria crónica secundaria a enfermedad terminal, sin embargo, se encuentra limitada por la disponibilidad de órganos para trasplantar.

Extrapleural pneumonectomy for malignant pleural mesothelioma.

Extrapleural pneumonectomy was introduced in the 1940s for the treatment of extensive infections of the lung and pleural space. Over the past 20 years, the extrapleural pneumonectomy technique has been modified and applied to the treatment of locally advanced malignant pleural mesothelioma, achieving substantial reductions in mortality. The current mortality rate of 3.4% at the Brigham and Women's Hospital has permitted us to expand our use of this operation to treat locally advanced lung cancer and thymoma. The extrapleural pneumonectomy technique consists of five basic steps: (1) Incision and exposure of the parietal pleura: (2) Dissection of the tumor and parietal pleura from the chest wall, diaphragm, and mediastinum: (3) Division and control of the pulmonary vessels and bronchus followed by lymph node dissection: (4) En bloc resection of the lung, pleura, pericardium, and diaphragm; (5) Reconstruction of the diaphragm and pericardium. Extrapleural pneumonectomy is a complex and challenging operation. Accompanied by a 60% minor and major complication rate, it requires a unique management approach to achieve 3.4% mortality. Primary contributing factors to the reduction in mortality include a reduced operative time of 3 h, refinements in operative technique, and improved selection of patients. The technique discussed below is the culmination of 20 years' experience with malignant pleural mesothelioma at the Brigham and Women's Hospital/Dana Farber Cancer Institute, Boston, MA USA.