Aportación europea a la especialidad de cirugía torácica general. II parte: contribución británica / European contribution to the general thoracic surgery speciality. Part II: British contribution

Es a principios de la Primera Guerra Mundial cuando se multiplicaron las técnicas quirúrgicas en el Reino Unido. Los drenajes, el tratamiento de las heridas abiertas y las complicaciones como los empiemas eran el inicio de nuevas técnicas, innovadoras y resolutivas en estos casos. En esos años, muchos de los cirujanos britanicos abandonaron el país. Hemos de reseñar que se crearon nuevos hospitales, como el Brompton en Londres. Fue fundado por la Reina Victoria como "hospital para enfermedades del tórax". Hemos de mencionar al Dr. Barret que, procedente de Adelaida (Australia), forma parte del equipo quirúrgico de este hospital. En 1971, MacArthur consiguió una supervivencia de dos meses en un trasplante de pulmón, y se recuerda la influencia de R. Abbey Smith en estos años. Ya en años más recientes, el Dr. Peter Goldstraw ocupó la plaza de especialista en cirugía torácica del Brompton y desarrolló, entre otras técnicas, la cirugía del enfisema bulloso y estudios prospectivos sobre carcinoma broncogénico y estadificación ganglionar en cancer de pulmón (AU)

It was at the beginning of the First World War when the surgical techniques multiplied in the United Kingdom. Drainages, treatment of open wounds and complications such as empyemas were the initiation of new, innovating and resolving techniques in these cases. During these years, many of the British surgeons left the country. We must state that new hospitals, such as the Brompton in London, were created. It was founded by Queen Victoria as a "Hospital for diseases of the chest." Mention should be made of Dr. Barrett, who was from Adelaida (Australia) and who formed a part of the surgical team of this hospital. In the year 1971, Mac Arthur achieved a two-month survival after a lung transplantation and the influence of R. Abbey Smith during these years is remembered. In more recent years, Dr. Peter Goldstraw occupied the post of chest surgery consultant in Brompton and developed, among other techniques, surgery in bullous emphysema and prospective studies on bronchogenic carcinoma and lymph node staging in lung cancer (AU)

Aportación europea a la especialidad de cirugía torácica. Contribución de los países del continente / European contribution to the thoracic surgery speciality. Contribution of the countries of the continent

En anteriores trabajos, hemos analizado la contribución germana y británica a la Cirugía Torácica general y a continuación desarrollaremos lo que fue ocurriendo durante este mismo tiempo en el resto de Europa. Examinaremos la falta de una Sociedad profesional adecuada al desarrollo de la Cirugía Torácica, a pesar de la existencia de cirujanos que comenzaban a desarrollar técnicas novedosas durante estos años. En el norte de Europa la Cirugía Torácica se había iniciado con el Dr. Jacobeus de Estocolmo . En los Países Bajos se llevó a cabo la primera neumonectomía por cuadro de bronquiectasias en el año 1940. Durante este tiempo, se llevaron a cabo tratamientos quirúrgicos de cerca en 1.200 pacientes con procesos tuberculosos con una mortalidad operatoria en torno al 2%. La aportación en Bélgica evolucionó de manera favorable desde el año 1 930 y posteriormente se produjo una separación de la Cirugía General y Digestiva de la Cardiaca, Osteoarticular, Urología y Neurocirugía. Es en 1970 cuando se comienza a desarrollar el plombaje extrafascial con grasa, y el Dr. LeBrigand aporta nuevas tecnicas para el tratamiento tuberculoso, así como en los traumatismos torácicos y lesiones traqueobronquiales. Mientras tanto, en Marsella se llevaron a cabo las primeras prácticas de broncografías y se comienza sobre trabajos de trasplante pulmonar experimental. La contribución Ibérica y la Cirugía Italiana están recogidas en España con nombres como Dr. González Duarte o Gil Turner y la participación italiana se inicia fundamentalmente entre los años 1.900 y 1.976 con la realización de la cirugía pulmonar y esofágica destacando, entre otros, el Dr. Erino A Rendina. En Austria se comenzó con la colapsoterapia llevando a cabo toracoplastias, neumotórax artificiales y frenicectomías. En Turquía y en Grecia la equinocosis era un serio problema de salud y se desarrollaron numerosas técnicas para su tratamiento. De la misma manera, se llevaron a cabo funduplicaciones de esófago distal y se desarrolló la Escuela de Cirugía Torácica en Antalaya (Antalaya School of Thoracic Surgery). En cuanto a los bloques del Este ha sido difícil recopilar datos de dicha área. Hasta que no se produjo la caída del muro de Berlín, el problema fue encontrar fuentes fidedignas de información. Es en estos países donde se produce el desarrollo de la cirugía pulmonar y se va asimilando la cirugía esofágica, así en los años 30 se propone el abordaje mediastínico a través del abdomen y se realizan anastomosis esofagogástricas torácicas por Uglov. Finalmente señalaremos que la escuela de San Petersburgo se considera como la representante de la cirugía en la Federación Rusa y se comienzan importantes periodos de desarrollo, que han llegado hasta nuestras citas bibliográficas actuales (AU)

In previous works, we have analyzed the German and British contribution to general Thoracic Surgery and then we developed what had been occurring during the same time in the rest of Europe. We will examine the lack of a Professional Society suitable for the development of Thoracic Surgery, in spite of the existence of surgeons who had begun to develop novel techniques during these years. In the north of Europe, Thoracic Surgery had been initiated with Dr. Jacobeus of Stockholm. In the Netherlands, the first pneumonectomy was performed due to a picture of bronchiectasis in the year 1940. During that time, surgical treatment was performed in approximately 1200 patients suffering tuberculosis conditions with approximately 2% surgical mortality. The contribution in Belgium evolved favorably after the year 1930 and there was a subsequent separation of General and Digestive Surgery from Cardiac, Osteoarticular, Urology and Neurosurgery. In 1970, when extrafascial plombage with fat was begun, Dr. LeBrigand contributed new techniques for treatment of tuberculosis and in thoracic traumas and tracheal-bronchial lesions. Meanwhile, in Marcela, the first practices of bronchographies were conducted and works on experimental lung transplants were begun. The contribution of Iberia and of Italian Surgery were collected in Spain with names such as Dr. González Duarte or Gil Turner and the Italian participation was fundamentally begun between the years 1,900 and 1,976 with the performance of pulmonary and esophageal surgery, standing out, among others, Dr. Erino A Rendina. In Austria, they began with colapsotherapy, performing thoracoplasties, artificial pneumothorax and phrenicectomies. In Turkey and in Greece, the equinococosis was a serious health problem and many techniques were developed for its treatment. Similarly, distal esophageal fundoplications were performed and Antalaya School of Thoracic Surgery was developed. It has been difficult to gather data in regards to the said area of the Eastern Bloc. Until the Berlin Wall fell, the problem was to find reliable sources of information. It was in those countries in which pulmonary surgery was developed and in which esophageal surgical was assimilated. Thus, in the 1930's, the mediastinal approach through the abdomen was proposed and thoracic esophageal-gastric anastomeses were performed by Uglov. Finally, we point out that the School of St. Petersburg is considered as the representative of the surgery of the Russian Federation and in which important periods of development were begun, which have been included in our current bibliographic citations (AU)

Aportación europea a la especialidad de Cirugía Torácica. Contribución alemana / European contribution to the thoracic surgery specialty. German contribution

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Figuras pioneras de la cirugía torácica española / Pionnering figures of spanish chest surgery

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[Postoperative survival in stage II non-small-cell bronchogenic carcinoma]. / Supervivencia posquirúrgica en el estadio II del carcinoma broncogénico no anaplásico de células pequeñas.

OBJECTIVE: This study aimed to validate in our population changes in the stage II criteria for non-small cell bronchogenic carcinoma. PATIENTS AND METHODS: We retrospectively reviewed and followed the course of disease in 336 patients who underwent complete resection in our hospital between January 1969 and December 1995 with stage II disease, classified as T1N1M0 (41), T2N1M0 (144) and T3N0M0 (151). RESULTS: The expected five-year survival in our population was 43.19 +/- 2.90%. Estimated mean survival was 3 +/- 0.71 years (95% confidence interval: 1.60-4.40). Mean survival was 8.82 +/- 0.67 years (95% confidence interval 7.51-10.13). Five-year survival was 53.32 +/- 8.55% for tumors classified as T1N1M0, 38.57 +/- 4.40% for T2N1M0, and 44.46 +/- 4.30% for T3N0M0. We observed significant differences in survival depending on histological type, tumor size, and IIA or IIB staging, degree of tumor invasion (T), number of nodes involved (N1) and location. T3N0M0 tumors displayed great variation in expected survival rates in relation to structures involved (27.53% to 59.98%). Multivariate analysis confirmed degree of tumor invasion, size and histological type to be the main prognostic factors. CONCLUSIONS: We conclude that the new staging system gives a more realistic prognosis for patients in our practice. The stage IIA and IIB division is appropriate and gives significantly different prognoses. However, the T3N0M0 category is heterogeneous and is not significantly different from T1-2N1M0, such that stage II overall continues to be an indivisible, homogeneous group of patients. Other prognostic variables, such as histological type, affect survival in our patients.

Supervivencia posquirúrgica en el estadio II del carcinoma broncogénico no anaplásico de células pequeñas / Postoperative survival in stage II non-small cell bronchogenic carcinoma

Objetivo: El presente trabajo trata de validar en nuestra población las modificaciones del estadio II del nuevo sistema de estadificación del carcinoma broncogénico no anaplásico de células pequeñas. Pacientes y métodos: Revisamos retrospectivamente y seguimos en su evolución a 336 pacientes operados con resección completa en nuestro hospital desde enero de 1969 a diciembre de 1995, con estadio II patológico y distribuidos como T1N1M0 (41), T2N1M0 (144) y T3N0M0 (151). Resultados: La supervivencia esperada en nuestra población fue de 43,19 ñ 2,90 por ciento a los 5 años. La estimación de la mediana fue de 3 ñ 0,71 años (intervalo de confianza [IC] del 95 por ciento, 1,60-4,40). El tiempo medio de supervivencia fue de 8,82 ñ 0,67 años (IC del 95 por ciento, 7,51-10,13). Los tumores clasificados como T1N1M0 presentaron una supervivencia del 53,32 ñ 8,55 por ciento a los 5 años; en los T2N1M0 el porcentaje fue del 38,57 ñ 4,40 por ciento, y en los T3N0M0 fue del 44,46 ñ 4,30 por ciento. Encontramos diferencias significativas entre supervivencias en función del tipo histológico, tamaño tumoral, estadio II A o II B, grado de invasión tumoral (T), número de ganglios afectados (N1) y localización de los mismos. Los tumores clasificados como T3N0M0 presentaron una amplia variabilidad en los porcentajes esperados de supervivencia a los 5 años en función de las estructuras afectadas (27,53 a 59,98 por ciento). Un análisis multivariante confirmó como principales factores pronósticos el grado de invasión tumoral, el tamaño tumoral y el tipo histológico. Conclusiones: El nuevo sistema de estadificación está más cerca de la realidad pronóstica de los pacientes en nuestra población. La división en estadio II A y II B es adecuada y presenta diferencias pronósticas significativas. Sin embargo, el apartado T3N0M0 es heterogéneo y no presenta diferencias significativas respecto al T1-2N1M0, por lo que el estadio II, en conjunto, continúa sin estar configurado por un grupo homogéneo de pacientes. Otras variables pronósticas, como el tipo histológico, condicionaron la supervivencia en nuestra población. (AU)

[Prognosis of T3N0M0 small-cell non-anaplastic bronchogenic carcinoma]. / Pronóstico del carcinoma broncogénico no anaplásico de células pequeñas T3N0M0.

We analyzed the survival after surgery for non-small cell lung cancer (NSCLC) classified as T3N0. Between January 1969 and 1995, 151 patients underwent surgery for NSCLC in our hospital. Survival analysis was performed using the Kaplan-Meier statistical method and the curves were compared using Mantel-Cox, Breslow and Tarone-Ware tests. The estimated five-year survival in the studied population was 44.46 +/- 4.30%. Four groups were defined based on degree of tumoral invasion of mediastinal structures, parietal pleura, chest wall or superior sulcus. Significant differences in five-year survival were observed between groups. Patients in the mediastinal group (59.98 +/- 8.71%) had the best prognosis, followed by patients with parietal pleura involvement (52.79 +/- 6.69%). Survival in the chest wall group was 27.53 +/- 7.22%. No patients with superior sulcus tumors survived over five years (median survival 1.50 +/- 1.16 years; 95% confidence interval 0.00 to 3.77 years). Prognosis is clearly determined by degree of tumoral invasion in T3N0 patients. In spite of the evident conceptual improvements achieved with the revised International Staging System, the system still fails to fully define prognosis in such cases.

Pronóstico del carcinoma broncogénico no anaplásico de células pequeñas T3N0M0 / Prognosis of non-small cell lung cancer classified as T3N0M0

Estudiamos la supervivencia posquirúrgica del carcinoma broncogénico no anaplásico de células pequeñas (CB-NACP) clasificado como T3N0. Para ello seguimos prospectivamente a 151 pacientes intervenidos por este motivo en nuestro hospital desde enero de 1969 a diciembre de 1995. El análisis de la supervivencia se realizó por el método estadístico de Kaplan-Meier, y las curvas fueron comparadas empleando los tests de Mantel-Cox, Breslow y Tarone-Ware. El porcentaje de supervivencia esperado en nuestra población fue del 44,46 ñ 4,30 por ciento a los 5 años. En función del grado de invasión tumoral definimos cuatro grupos de pacientes según el tumor afectase a estructuras mediastínicas, pleura parietal, pared costal o sulcus superior. Los porcentajes de supervivencia a 5 años pusieron de manifiesto diferencias significativas entre grupos con un mejor pronóstico para los enfermos del grupo mediastínico (59,98 ñ 8,71 por ciento), seguido de la afectación de pleura parietal (52,79 ñ 6,69). Entre los casos del grupo de pared, la supervivencia fue del 27,53 ñ 7,22 por ciento, mientras que entre los pacientes con tumor de sulcus superior ninguno sobrevivió por encima de los 5 años (mediana de supervivencia de 1,50 ñ 1,16 años; límites del intervalo de confianza del 95 por ciento 0,00-3,77 años). En conclusión, en los T3N0 el mal pronóstico está determinado por el grado de invasión tumoral y, a pesar de las evidentes mejoras conceptuales conseguidas con la nueva revisión del International Staging System (ISS), éste continúa sin definir completamente el pronóstico de la afectación T3N0. (AU)

[The indications for and results of video thoracoscopic surgery. Reflections on 152 procedures]. / Indicaciones y resultados de la cirugía videotoracoscópica. Consideraciones sobre 152 procedimientos.

Since thoracoscopy was first described in 1910, its application has been confined mainly to diagnosis and symptomatic treatment of pleural diseases. Recent technological advances in endoscopy and the refinement of surgical technique have brought wider applications, giving rise to video-assisted thoracoscopy (VAT). VAT surgery allows us to view, access and act upon internal thoracic organs without recourse to thoracotomy, thus circumventing inherent risk. We have reviewed our experience from April 1994 through November 1998 in 152 procedures with 141 consecutive patients. Diagnoses were pneumothorax in 94 cases, sympathetic nervous system alteration in 10, diffuse lung disease in 10, lung tumors in 9, pulmonary metastasis in 4, pleural tumors in 5, mediastinal tumors in 2, pericardial effusion in 2, spinal disease in 2 and chronic pancreatitis in 1. No deaths associated with the procedure occurred. The incidence of non-fatal postoperative complication was 11%. The most common complications were prolonged air leak (5%) and bloody pleural effusion (3.5%). The mean length of postoperative hospital care was 3.8 days (range 1 to 18 days). Our experience indicates that VAT is increasingly used to diagnose and treat a variety of chest lesions. Complications are fewer than in procedures in which thoracotomy is needed. Prolonged air leakage does not occur significantly more often with VAT than with thoracotomy. VAT is apparently safe and is particularly useful in some situations, as postoperative morbidity is low and clinical tolerance good.

[Benign acquired tracheoesophageal fistulas]. / Fístulas traqueoesofágicas benignas adquiridas.

Benign acquired tracheoesophageal fistula (TEF) is a rare though serious occurrence associated with a high degree of morbidity and mortality. We review 18 cases of TEF treated over 16 years in our hospital. The variables analyzed descriptively were demographic (age, sex and others), clinical (etiology, time of intubation, time and symptoms leading to clinical suspicion, diagnostic techniques, and others), and therapeutic (dependence on mechanical ventilation, location of tissues, tracheal resection, tissue interposition, postoperative course of disease, and others). Fifteen of the 18 patients required surgery. The rate of success (80%) was high in terms of respiration, swallowing and phonation. Surgery involved simple closure of the TEF, with half the patients requiring a second operation to correct tracheal stenosis. Resection and anastomosis were performed in the remaining 11 cases, with only one requiring a second operation for recurrence of stenosis. Two cases of perioperative mortality and one TEF recurrence related to assisted ventilation were recorded. Tracheoscopy was the most effective diagnostic technique, complemented by computerized tomography of the trachea. Presurgical evaluation of tracheal stenosis, the absence of mechanical ventilation, preoperative preparation and postoperative care are the factors that determine success in this type of surgery. When tracheal stenosis is associated with TEF, resection and anastomosis should be performed in the affected zone.

[Cardiac hernia after intrapericardial pneumonectomy]. / Hernia Cardíaca tras neumonectomía intrapericárdica.

Cardiac herniation secondary to intrapericardial pneumonectomy is a rare complication, although its real incidence has surely been underestimated. We describe a patient with left cardiac herniation presenting after intrapericardial pulmonectomy for primary lung cancer. The signs were severe hemodynamic shock requiring additional surgery involving a wide opening in the pericardium. The outcome after surgery was fully satisfactory.

[1990-1996: the experience of the La Fe Lung Transplant Group (Valencia)]. / 1990-1996: experiencia del Grupo de Trasplante Pulmonar La Fe (Valencia).

Objective to review the experience of the lung transplantation unit at Hospital La Fe (Valencia). Between February 1990 and March 1996 we performed 40 lung transplants. The following causes were most common: cystic fibrosis (9 cases), emphysema (8), pulmonary fibrosis (8) and bronchiectasis (7). Types of intervention were 27 double lung transplants (25 sequential and 9 blocked), 9 single lung transplants, and 4 heart-lung transplants. We then reviewed the 36 single and double lung transplants. The main exclusion criteria were age over 65 years, malignant disease, kidney or liver disease, severe or non reversible central nervous system disease, and drug addiction. Prior surgery, mechanical ventilation and the presence of Aspergillus were considered lower-order contraindications. Mean patient age was 37.7 years (14-59). Six patients were colonized by Aspergillus before transplantation. Five had undergone earlier surgery and two were mechanically ventilated before the transplant. The most common complication was respiratory infection, which was present in 6 of the 7 patients who died. Other complications in order of frequency were dehiscence and/or bronchial stenosis, corticoid myopathy and postoperative bleeding. The actuarial survival rate of single and double lung transplants was 67.85 after 3 years, and 87.5% in patients with cystic fibrosis. Lung transplantation is a well-established procedure that is gradually being extended to treat more conditions. The main obstacle is the scarcity of donors. The main challenge at present is bronchiolitis obliterans.

Experimental study of a new porous tracheal prosthesis.

We studied the efficacy of a new tracheal prosthesis made of expanded polytetrafluorethylene reinforced with spiral silicone rings to repair circumferential tracheal defects in rabbits. Results showed an adequate consistency of prosthesis, adequate tolerance without producing tracheal stenoses, and impermeability to air, allowing a correct invasion by granulation tissue. This process was faster than any found in any other porous tracheal implant so far tested. We proved that epithelialization results from capillary invasion through the prosthetic pores and from growth from both tracheal ends. We conclude that this prosthetic material can be useful in repairing tracheal defects and may be the optimal tracheal graft for humans.

Leiomyoma of the lung. Literature review and case report.

Sixty-five cases of pulmonary leiomyomas previously have been reported. A new case is reported of a 23-year-old man. Electron microscopy showed typical ultrastructural smooth muscle differentiation. In a series of 66 cases from the world literature, the ratio of females to males was of 1.5:1. There is a slight preponderance of parenchymal localization versus bronchial. The average age of presentation was 37 years, and the tumor was found rarely in the aged or in children. The diagnosis of pulmonary leiomyoma should be made with the knowledge of recently-introduced concepts of smooth-muscle proliferation in the lung and the possibility that metastatic low-grade leiomyosarcoma may simulate a primary leiomyoma.

Fine structure of a malignant hemangioendothelioma of the esophagus.

The histology and electron-microscopy of a malignant hemangioendothelioma of the esophagus wall appearing in a 42 year old male is presented. By light microscopy the tumor is composed of vessels and capillary-like structures of an anastomosing nature covered by atypical endothelial cells. These cells infiltrate the interstitial spaces growing into the posterior mediastinal area. Electron microscopy confirms the endothelial nature of the neoplastic cells, showing characteristics of the cell type, as is the presence of Weibel-Palade bodies, filaments and active pinocytosis. Hemangioendothelioma should be differentiated from other vascular tumors (angiosarcoma) as are hemangiopericytoma or hemangioblastoma, being composed exclusively of malignantly transformed endothelial cells.