Perioperative pharmacological management in patients with glaucoma.

REVIEWS AIM: When a phacoemulsification, a filtration surgery or a combined surgery are necessary, questions about the convenience of continuing certain antiglaucomatous drugs could appear. The aim of this review article is to unify criteria that will guide daily clinical practice and including the developing algorithms of action in the preoperative and postoperative periods of filtration surgery and/or cataract surgery. PROPOSED PROTOCOLS: In the preoperative period of cataract surgery, the use of non-steroidal anti-inflammatory drugs is at the discretion of the surgeon, with the monodose presentation being recommended. The suspension of prostaglandines a fewdays before the surgery should be considered. Preservative-free drugs ensure a better recovery of the ocular surface (OS) after cataract surgery. Once all modifying factors of the intraocular pressure (IOP) have been removed, baseline IOP should be evaluated again, choosing preservative-free antiglaucomatous drugs when needed. The use of preservative-free ocular antihypertensive drugs and steroids in the preoperative period of glaucoma surgery reduces the risk of surgical failure. The interruption of prostaglandines is recommended. In the postoperative period of glaucoma surgery, steroids are the anti-inflammatory treatment of choice, the preservative-free ones being preferred. When reintroducing antiglaucomatous treatment, preservatives should be avoided to prevent scarring. The appropriate perioperative management of patients with glaucoma is essential to obtain a correct control of IOP, improve the situation of the OS, prevent complications and improve the result of the filtration surgery and cataract surgery. CONCLUSIONS: this protocol aims to unify the different lines of action in order to decrease the incidence of adverse events and maximize the surgical outcome.

Tabaquismo y oncología torácica / Smoking habit and thoracic oncology

No disponible

Lesión quística mediastínica de histología indeterminada / Mediastinal cystic lesion of unknown histology

Los quistes mediastínicos son malformaciones benignas de origen congénito que representan el 20% del total de lesiones primarias del mediastino. Se clasifican según el tipo celular de revestimiento epitelial que contienen. En un 20% de los casos, debido a procesos infecciosos y/o hemorrágicos, se produce una desestructuración del epitelio originario, y es enestos casos cuando los denominamos quistes de histología indeterminada o inespecífica. Aunque existe una amplia variedad, tanto en histología como en localización, cuando presentan clínica lo hacen de forma similar. El dolor torácico es el síntoma más frecuente seguido de la tos, la disnea y la disfagia. Presentamos el caso de un varón de 45 años de edad que consultó por un dolor centrotorácico intenso de aparición brusca. La tomografía axial computarizada (TAC) y la resonanciamagnética (RM) evidenciaron una gran lesión quística que ocupaba el mediastino posterior. La ecoendoscopiaesofágica descartó el origen esofágico de la lesión. Se intervino el paciente mediante toracotomía posterolateral derecha y se realizó la exéresis de la lesión. El curso postoperatorio transcurrió sin complicaciones. El diagnóstico histopatológicoconcluyó que se trataba de una lesión quística de histología indeterminada

Mediastinal cysts are uncommon congenital and benign malformations that represent 20% of all primary mediastinal lesions. They are classified by their specific histologic features. 20% of mediastinal cysts lack specific histologic features, possibly because of haemorrhage or infection, and are termed indeterminate or non-specific cysts. Despite varied location and histology, clinical presentation of mediastinal cysts is similar. Chest pain is the most common symptom followed by cough, dyspnoea and dysphagia. We report the case of a 45-year-old man who sought medical attention for acute chest pain. Computed tomography and magnetic resonance showed a large cystic lesion in the posterior mediastinum. Endoscopic ultrasound excluded a communication of the cyst with the oesophagus. The tumor was resected through a right thoracotomy. No postsurgical complications occurred. The histopathological diagnosis was cystic lesion of nonspecific histology2

Surgical sealant for preventing air leaks after pulmonary resections in patients with lung cancer.

BACKGROUND: Postoperative air leak is a frequent complication after pulmonary resection for lung cancer. It may cause serious complications, such as empyema, or prolong the need for chest tube and hospitalisation. Surgical sealants of different types have been developed to prevent or to reduce postoperative air leaks. A systematic review was therefore undertaken to evaluate the evidence on their effectiveness. OBJECTIVES: To evaluate the effectiveness of surgical sealants in preventing or in reducing postoperative air leaks after pulmonary resection for lung cancer. SEARCH STRATEGY: The electronic databases MEDLINE (1966 to 2004), EMBASE (1974 to 2004), Cancerlit (1993 to 2004), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 3/2004) and listed references were searched, and handsearching of conference proceedings was conducted to identify published and unpublished trials. SELECTION CRITERIA: Randomised controlled clinical trials were included in which standard closure techniques plus a sealant were compared with the same intervention with no use of any sealant in patients undergoing elective pulmonary resection provided that a large proportion of the patients included in the studies had undergone pulmonary resection for lung cancer. DATA COLLECTION AND ANALYSIS: Three reviewers independently selected the trials to be included in the review, assessed methodological quality of each trial and extracted data using a standardised form. Because of several limitations, narrative synthesis was used at this stage. MAIN RESULTS: Twelve trials, with 1097 patients in total, were included. In eight trials there was a statistically significant difference between treatment and control patients in reducing postoperative air leaks. However this reduction only proved a significant reduction of hospital stay in one trial. Only in one trial reduction of time of chest drain removal and reduction of percentage of patient with persistent air leak were significantly smaller in the treatment group. AUTHORS' CONCLUSIONS: Although surgical sealants seem to reduce postoperative air leaks, length of hospitalisation is not affected and infectious complications may be increased. Therefore, systematic use of surgical sealants in clinical practice cannot be recommended at the moment. More randomised controlled clinical trials are needed.

[Noninvasive diagnosis of posttraumatic thoracic splenosis]. / Diagnóstico no invasivo de la esplenosis torácica postraumática.

Thoracic splenosis is a rare occurrence that has usually been diagnosed by invasive procedures to allow a pathologic diagnosis to be reached. A firm diagnosis can now be made with the help of new, noninvasive imaging techniques. We report the case of a 34-year-old man with a history of severe thoracic-abdominal injury, including rupture of the spleen and left diaphragm. During computed tomography of the thorax related to a different diagnosis, nonspecific nodules were observed, although the patient was asymptomatic. A suspected diagnosis of thoracic splenosis was confirmed by technetium-99 sulfur colloid scintigraphy.

[Mediastinal enteric cyst: unusual clinical presentation and histopathology]. / Quiste entérico mediastínico: presentación clínica e histopatología inusuales.

A mediastinal enteric cyst is an uncommon entity which is rare in adults and usually found incidentally. In most cases the lesion is lined by gastrointestinal mucosa, and theories as to the origin of such lesions are diverse. We report an adult case of thoracic enteric cyst that presented with cardiac tamponade and for which histopathological examination revealed the presence of pancreatic tissue. Review of the literature yielded only 1 case of mediastinal enteric cyst with pancreatic tissue.

Diagnóstico no invasivo de la esplenosis torácica postraumática / Noninvasive diagnosis of posttraumatic thoracic splenosis

La esplenosis torácica es una entidad poco frecuente, que habitualmente se diagnostica mediante técnicas invasivas que proporcionan un diagnóstico anatomopatológico. Con el desarrollo de nuevas técnicas de imagen puede realizarse en la actualidad un diagnóstico seguro por métodos no invasivos. Presentamos el caso de un paciente varón de 34 años con antecedente de traumatismo toracoabdominal grave, con rotura esplénica y diafragmática izquierda, al que de forma casual, y encontrándose asintomático, se le hallaron nódulos inespecíficos en una tomografía computarizada torácica. Con la sospecha clínica de esplenosis torácica, se realizó una gammagrafía de coloide de sulfuro marcada con 99mTc metaestable que confirmó el diagnóstico (AU)

[Are blood lipids a risk factor for age-related macular degeneration?]. / Los lípidos séricos, factor de riesgo de la degeneración macular asociada a la edad?

PURPOSE: To study the levels of lipids in serum, in patients with age-related macular degeneration (AMD), and to establish its pathogenic relevance in the disease. METHODS: The serums of a total of 40 patients, distributed in a AMD group (25 patients) and a control group (15 patients, with similar ages and without ocular affectation) were studied, correlating the biochemical findings with the clinical examination of these patients. RESULTS: We have observed a mean level of serum total cholesterol statistically superior in AMD patients (control= 200.18+/-18.89 mg/dL; AMD= 227.28+/-5.46 mg/dL; p<0.01). These significant differences are repeated for different lipoproteins (triglycerides, LDL, VLDL and apolipoprotein B), not appearing for the HDL and apolipoprotein A-1. We have not found correlations of these concentrations with the clinical or functional stage of the AMD. CONCLUSIONS: Serum lipids could take part in the pathogenic mechanism of AMD, either by their relation with arteriosclerosis, which would diminish the choroidal flow, or by direct deposit in the Bruch's membrane. However, more longitudinal studies are needed to understand the relation of serum lipids and AMD, and to establish therapeutic approaches on the matter.

Los lípidos séricos ¿Factor de riesgo de la degeneración macular asociada a la edad? / Cholesterol ¿A risk factor for age-related macular degeneration?

Objetivo: Estudiar el patrón de los lípidos séricos en los pacientes con degeneración macular asociada a la edad (DMAE), y establecer su importancia patogénica. Material: Se han estudiado los sueros de un total de 40 pacientes distribuidos en un grupo DMAE (25 pacientes) y un grupo control (15 sujetos sin afectación ocular) del mismo rango de edad, correlacionándose los hallazgos bioquímicos con la exploración clínica de estos enfermos. Resultados: Hemos observado una concentración media de colesterol total sérico en los pacientes con DMAE estadísticamente superior que la hallada en el grupo control (control= 200,18ñ18,19 mg/dL; DMAE= 227,28ñ5,46 mg/dL; p<0,01). Estas diferencias significativas se repiten para las distintas lipoproteínas (triglicéridos, LDL, VLDL y apolipoproteína B), no apareciendo para la HDL y la apolipoproteína A-1. No hemos encontrado correlaciones de estas concentraciones con el estadio clínico o funcional de la DMAE. Conclusiones: Los lípidos séricos podrían intervenir en la patogenia de la DMAE, bien por su relación con la arteriosclerosis, que disminuiría el flujo coroideo, o bien por depósito directo en la membrana de Bruch. No obstante, se necesitan más estudios longitudinales para comprender la relación de los lípidos séricos y la DMAE, y establecer conductas terapéuticas al respecto. (AU)

Brown-Sequard syndrome associated with Horner's syndrome after a penetrating trauma at the cervicomedullary junction.

STUDY DESIGN: Case report of a 21-year-old man that had concurrence of Brown-Sequard syndrome and Horner's syndrome after a penetrating trauma in the neck. OBJECTIVES: This report analyzes the location of lesions that cause a combination of Horner's and Brown-Sequard syndrome. It is important to know the anatomic structure of spinal cord and the sympathetic nerve chain. SETTING: Spinal Cord Unit, Department of Physical Medicine and Rehabilitation, Hospital La Fe, Valencia, Instituto Oftalmologico de Alicante, Alicante, Spain. METHODS: Description of a single patient case report. RESULTS: The clinical findings and MRI showed a good correlation. The Horner's syndrome was confirmed with a 4% cocaine test. The patient received a conservative treatment with high-dose steroid therapy (NASCIS-3). CONCLUSION: The patient presented with Brown-Sequard syndrome and Horner's syndrome. Clinical examination and MRI made a quick and correct diagnosis. The patient recovered completely after the conservative treatment.

[Video thoracoscopy and video-assisted thoracic surgery. An analysis of 303 consecutive cases]. / Videotoracoscopia y cirugía torácica videoasistida. Análisis de 303 casos consecutivos.

OBJECTIVES: To present our experience in video thoracoscopy and video-assisted thoracic surgery from November of 1991 until November of 1997. PATIENTS AND METHODS: 303 endoscopic thoracic surgery procedures (210 males and 93 females with a mean age of 42.2 years) with the following indications: 151 spontaneous pneumothorax, 51 pulmonary biopsies, 50 pulmonary nodules, 15 mediastinal tumors, 13 pleuroparietal tumors, 8 pericardial windows and 15 thoracic sympathectomies. RESULTS: Mean postoperative stay was of 5.5 days. The thoracotomy conversion was necessary in 32 cases (10.9%). The morbimortality has been: one parietal recidive of a tumor in the way of one of the trocars and one death of a patient to who was accomplished a pulmonary biopsy by diffuse pneumopathy. CONCLUSIONS: The video thoracoscopy and thoracic surgery are effective and sure technical options for diagnosis and treatment of various thoracic affections.

Videotoracoscopia y cirugía torácica videoasistida.Análisis de 303 casos consecutivos / Videothoracoscopy and videoassisted thoracic surgery

Objetivos: Comunicar nuestra experiencia en videotoracoscopia y cirugía torácica videoasistida desde noviembre de 1991 hasta noviembre de 1997. Pacientes y métodos: Comprende 303 procedimientos de cirugía torácica endoscópica (210 varones, 93 mujeres y edad media de 42,2 años). Las indicaciones fueron: 151 neumotórax espontáneos, 51 biopsias pulmonares, 50 nódulos pulmonares, 15 tumores mediastínicos, 13 tumores pleuroparietales, 8 ventanas pericárdicas y 15 simpatectomías torácicas. Resultados: La estancia media postoperatoria fue de 5,5 días. La conversión a toracotomía fue necesaria en 32 casos (10,9%). La morbimortalidad ha sido: recidiva parietal de tumor en el trayecto de uno de los trócares y fallecimiento por sepsis de un paciente a quien se le realizó una biopsia pulmonar por neumopatía difusa. Conclusiones: La videotoracoscopia y cirugía torácica videoasistida son opciones técnicas seguras y eficaces para el diagnóstico y tratamiento de diversas afecciones torácica (AU)

[Pulmonary biopsy in diffuse interstitial disease: videothoracoscopy versus thoracotomy]. / Biopsia pulmonar en la enfermedad intersticial difusa: videotoracoscopia frente a toracotomía.

The aim of this work was to evaluate and compare the results of lung biopsies performed by videothoracoscopy (VT) and minithoracotomy (MT) in diffuse interstitial disease between 1992 and 1994, during which period 45 lung biopsies were performed on patients (20 women) with a mean age of 56 years. Thirty-one biopsies were performed by VT (group I) and 14 by MT (group II). For all patients we recorded duration of procedure, days to discharge after surgery, total time with a pleural drain in place, and volume of tissue sample. Diagnosis was possible in all cases. Mean duration of surgery was 49.3 minutes for group I and 58.2 minutes for group II. Mean time to discharge was 6.7 days for group I and 10.1 for group II. Mean time of pleural drainage was 3.8 days for group I and 5.9 days for group II. Mean volume of tissue sample was 6.5 cm3 for group I and 5.18 cm3 for group II. One patient died in group I from causes unrelated to surgical technique. In conclusion, lung biopsy with VT is effective and useful for diagnosing diffuse interstitial lung diseases. The sample obtained is in every way comparable to that obtained by thoracotomy. Mean hospital stay and mean time of postoperative drainage decreases significantly (p < 0.05) with VT.

[Rapid surgical exploration of the mediastinum]. / Cirugía de corta estancia en la exploración quirúrgica del mediastino.

This study aimed to evaluate the morbidity-mortality of surgical exploration of the mediastinum in patients with mediastinal masses or adenopathy in the context of a rapid-surgery program that has been operating over the past 8 years (1985-1993). A total of 93 mediastinal explorations have been carried out. Sixty-five involved transcervical mediastinoscopy, 20 were anterior mediastinotomies, 4 were combined procedures and 4 were video-thoracoscopies. We found 34 cases of lymphoma, 28 of metastasis of bronchopulmonary carcinoma and 16 of mediastinal-ganglionic tuberculosis; the 15 remaining cases were classified as miscellaneous. No deaths were directly related to the surgical procedures; morbidity involved 2 wound infections. Surgical exploration of the mediastinum is a safe diagnostic procedure, provided it is carried out by an experienced team, and allows care givers to take better advantage of therapeutic options with no loss of quality.