Experiencia de los Servicios de Cirugía Torácica españoles en el tratamiento del pectus excavatum mediante la técnica de Nuss / Experience with the Nuss technique for the treatment of Pectus Excavatum in Spanish Thoracic Surgery Departments

INTRODUCCIÓN: Aunque la introducción de la técnica de Nuss revolucionó el tratamiento quirúrgico del pectus excavatum, no se ha generalizado su uso en nuestro medio. El objetivo de este estudio es conocer la situacion actual del uso de esta técnica en una selección de Servicios de Cirugía Torácica de España. MÉTODOS: Estudio observacional retrospectivo multicéntrico que analiza los principales aspectos epidemiológicos y resultados clínicos tras 10 años de experiencia empleando técnica de Nuss. RESULTADOS: Entre 2001 y 2010 se intervino a 149 pacientes (media de edad 21,2 años), 74% varones. Los resultados estéticos iniciales fueron excelentes o buenos en el 93,2%, regulares en el 4,1% y malos en el 2,7% de los casos. Un total de 45 pacientes (30,6%) presentaron complicaciones tras la primera intervención. Las más frecuentes fueron la presencia de seroma en las heridas quirúrgicas, desplazamiento de la barra, rotura del estabilizador, neumotórax, hemotórax, infección de la herida, neumonía, pericarditis y un taponamiento pericárdico que requirió la extracción de la barra de urgencia. El dolor postoperatorio fue referido por todos los pacientes y 3 de ellos (2%) requirieron la extracción precoz de la barra por dolor intratable. Tras una media de 39,2 meses, se había retirado la barra a 72 pacientes (49%), con dificultades en la extracción en 5 (7%). Tras un seguimiento medio de 1,6 años se constató buen resultado en 145 pacientes (98,7%). CONCLUSIONES: La técnica de Nuss en adultos ha tenido buenos resultados en los Servicios de Cirugía Torácica españoles aunque no se ha generalizado su utilización. Las posibles complicaciones se han de tener en cuenta, por lo que la indicación debe ser muy bien valorada. La posibilidad de un tratamiento conservador previo es valorado por alguno de los servicios en la actualidad

INTRODUCTION: Up to 93% of patients undergoing abdominal surgery will develop intra-abdominal adhesions with the subsequent morbidity that they represent. Various substances have been tested for the prevention of adhesions with controversial results; the aim of our study is to compare the capability of pirfenidone in adhesion prevention against sodium hyaluronate/carboxymethylcellulose. METHODS: A randomized, prospective, longitudinal experimental study with Winstar rats. They were divided into 3 groups. The subjects underwent an exploratory laparotomy and they had a 4 cm2 cecal abrasion. The first group received saline on the cecal abrasion, and groups 2 and 3 received pirfenidone and sodium hyaluronate/carboxymethylcellulose respectively. All rats were sacrificed on the 21st day after surgery and the presence of adhesions was evaluated with the modified Granat scale. Simple frequency, central tendency and dispersion measures were recorded. For the statistical analysis we used Fisher's test. RESULTS: To evaluate adhesions we used the Granat's modified scale. The control group had a median adhesion formation of 3 (range 0-4). The pirfenidone group had 1.5 (range 0-3), and the sodium hyaluronate/carboxymethylcellulose group had 0 (range 0-1). There was a statistically significant difference to favor sodium hyaluronate/carboxymethylcellulose against saline and pirfenidone (P< 0 .009 and P< .022 respectively). CONCLUSIONS: The use of sodium hyaluronate/carboxymethylcellulose is effective for the prevention of intra-abdominal adhesions. More experimental studies are needed in search for the optimal adhesion prevention drug

Experience with the Nuss technique for the treatment of Pectus Excavatum in Spanish Thoracic Surgery Departments.

INTRODUCTION: Although the Nuss technique revolutionized the surgical treatment of pectus excavatum, its use has not become widespread in our country. The aim of this study was to analyze the current use of this technique in a sample of Thoracic Surgery Departments in Spain. METHODS: Observational rectrospective multicentric study analyzing the main epidemiological aspects and clinical results of ten years experience using the Nuss technique. RESULTS: Between 2001 and 2010 a total of 149 patients were operated on (mean age 21.2 years), 74% male. Initial aesthetic results were excellent or good in 93.2%, mild in 4.1% and bad in 2.7%. After initial surgery there were complications in 45 patients (30.6%). The most frequent were wound seroma, bar displacement, stabilizer break, pneumothorax, haemothorax, wound infection, pneumonia, pericarditis and cardiac tamponade that required urgent bar removal. Postoperative pain appeared in all patients. In 3 cases (2%) it was so intense that it required bar removal. After a mean follow-up of 39.2 months, bar removal had been performed in 72 patients (49%), being difficult in 5 cases (7%). After a 1.6 year follow-up period good results persisted in 145 patients (98.7%). CONCLUSION: Nuss technique in adults has had good results in Spanish Thoracic Surgery Departments, however its use has not been generalized. The risk of complications must be taken into account and its indication must be properly evaluated. The possibility of previous conservative treatment is being analyzed in several departments at present.

Radiologic progression of pulmonary infiltrates predicts a worse prognosis in severe community-acquired pneumonia than bacteremia.

BACKGROUND: It remains unknown whether bacteremia and rapid radiologic progression of pulmonary infiltrates increase the risk of shock and mortality in ICU patients with community-acquired pneumonia (CAP). The objective of this study was to investigate the relative importance of these two factors in the outcome of patients with severe CAP (sCAP). METHODS: A secondary analysis in a multicenter observational study was conducted in 457 patients with CAP admitted to the ICU. Patients were classified into four groups: group RB, rapid radiographic spread of pulmonary infiltrates and bacteremia (n = 48); group R, rapid radiographic spread but no bacteremia (n = 183); group B, bacteremia but without rapid radiographic spread (n = 39); and group C, neither rapid radiographic spread nor bacteremia (n = 187). RESULTS: Logistic regression analysis showed that group RB and group R had a greater risk for shock than group C (adjusted odds ratio [aOR], 8.9; 95% confidence interval [CI], 4.0 to 19.7; and aOR, 3.8; 95% CI, 2.5 to 5.9; respectively), while patients in group B had no increased risk. In addition, compared to group C, group RB and group R had an increased risk of ICU death (aOR, 3.4; 95% CI, 1.4 to 8.1; and aOR, 3.1; 95% CI, 1.7 to 5.7, respectively), while patients in group B had none. CONCLUSIONS: In this cohort of patients with severe CAP, radiologic progression of pulmonary infiltrates in the first 48 h is a significant adverse prognostic feature. In contrast, bacteremia does not affect outcomes.

Clinical value of p53, c-erbB-2, CEA and CA125 regarding relapse, metastasis and death in resectable non-small cell lung cancer.

The prognostic value of p53 and c-erbB-2 immunostaining and preoperative serum levels of CEA and CA125 was investigated in a prospective multicentric study including 465 consecutive non-small cell lung cancer (NSCLC) patients with resectable tumors. Four end-points were used: lung cancer death, first relapse (either locoregional or metastasis), loco-regional recurrence and metastasis development. Standard statistical survival methods (Kaplan-Meier and Cox regression) were used. The specificity of the prognostic effect across different types of tumors was also explored, as had been planned in advance. Our results showed, once again, that pathological T and N classifications continue to be the strongest predictors regarding either relapse or mortality. Three of the studied markers seemed to add further useful information, however, but in a more specific context. For example, increased CEA concentration defined a higher risk population among adenocarcinomas but not among people with squamous tumors; and p53 overexpression implied a worse prognosis mainly in patients with well differentiated tumors. The analysis of type of relapse proved to be very informative. Thus, CA125 level was associated with a worse prognosis mainly related with metastasis development. Another interesting result was the influence of smoking, which showed a clear dose-response relationship with the probability of metastasis. For future studies, we recommend the inclusion of different endpoints, namely considering the relationship of markers with the type of relapse involved in lung-cancer recurrence. They can add useful information regarding the complex nature of prognosis.