Correlation between preoperative CT scan and lung metastases according to surgical approach in patients with colorectal cancer.

INTRODUCTION: The number of lung metastases (M1) of colorectal carcinoma (CRC) in relation to the findings of computed tomography (CT) is the object of study. METHODS: Prospective and multicenter study of the Spanish Group for Surgery of CRC lung metastases (GECMP-CCR). The role of CT in the detection of pulmonary M1 is evaluated in 522 patients who underwent a pulmonary metastasectomy for CRC. We define M1/CT as the ratio between metastatic nodules and those found on preoperative CT. Disease-specific survival (DSS), disease-free survival (DFS), and surgical approach were analyzed using the Kaplan-Meier method. RESULTS: 93 patients were performed by video-assisted surgery (VATS) and 429 by thoracotomy. In 90%, the M1/CT ratio was ≤1, with no differences between VATS and thoracotomy (94.1% vs 89.7%, p=0.874). In the remaining 10% there were more M1s than those predicted by CT (M1/CT>1), with no differences between approaches (8.6% vs 10%, p=0.874). 51 patients with M1/CT>1, showed a lower median DSS (35.4 months vs 55.8; p=0.002) and DFS (14.2 months vs 29.3; p=0.025) compared to 470 with M1/CT≤1. No differences were observed in DSS and DFS according to VATS or thoracotomy. CONCLUSIONS: Our study shows equivalent oncological results in the resection of M1 of CRC using VATS or thoracotomy approach. The group of patients with an M1/CT ratio >1 have a worse DSS and DFS, which may mean a more advanced disease than predicted preoperatively.

National evaluation of risk factors for unplanned readmission after lung resection.

OBJECTIVES: Unplanned readmission is defined as the return to inpatient hospitalization within 30 days after discharge. Worldwide, its incidence after lung resection ranges between 8% and 50%, and it has been shown to impact both patient recovery and healthcare resources. Our goal was to identify the risk factors to prioritize early follow-ups. METHODS: We analysed data from the database of the Grupo Español de Cirugía Torácica Video-Asistida from 33 thoracic surgery departments over 15 months. Standard tests were used to compare the different risk groups. Our goal was to present the most relevant explanatory variables for readmission. RESULTS: A total of 174 of 2808 patients (6%) underwent unplanned readmission after a lobectomy. Of all the preoperative individual characteristics, only lung function was found to be a risk factor for readmission [forced expiratory volume in 1 s < 80%, risk ratio (RR) 1.78, P < 0.001; diffusing capacity of carbon monoxide <60%, RR 1.6, P = 0.02; and VO2 < 20 ml/kg/min, RR 1.59, P = 0.02]. The tumour's characteristics and the stage of the disease did not have an influence on the readmission rates. In the readmitted cohort, an open approach or thoracotomy was associated with more frequent readmissions (RR 1.77; P < 0.001). Strong adhesions (RR 1.81; P < 0.001) or adhesions occupying more than half of the hemithorax (RR 1.73, P < 0.001) were also found to be risk factors for readmission and for longer operative times. A length of stay of >10 days after a lobectomy was found to be a risk factor for readmission (RR 1.9). CONCLUSIONS: We identified preoperative, intraoperative and postoperative risk factors for readmission. This information can be a useful tool to help with the prioritization of early follow-ups, especially in centres with high workloads.

Correlation between preoperative CT scan and lung metastases according to surgical approach in patients with colorectal cancer.

INTRODUCTION: The number of lung metastases (M1) of colorectal carcinoma (CRC) in relation to the findings of computed tomography (CT) is the object of study. METHODS: Prospective and multicenter study of the Spanish Group for Surgery of CRC lung metastases (GECMP-CCR). The role of CT in the detection of pulmonary M1 is evaluated in 522 patients who underwent a pulmonary metastasectomy for CRC. We define M1/CT as the ratio between metastatic nodules and those found on preoperative CT. Disease-specific survival (DSS), disease-free survival (DFS), and surgical approach were analyzed using the Kaplan-Meier method. RESULTS: 93 patients were performed by video-assisted surgery (VATS) and 429 by thoracotomy. In 90%, the M1/CT ratio was ≤1, with no differences between VATS and thoracotomy (94.1% vs 89.7%, p=0.874). In the remaining 10% there were more M1s than those predicted by CT (M1/CT>1), with no differences between approaches (8.6% vs 10%, p=0.874). 51 patients with M1/CT>1, showed a lower median DSS (35.4 months vs 55.8; p=0.002) and DFS (14.2 months vs 29.3; p=0.025) compared to 470 with M1/CT≤1. No differences were observed in DSS and DFS according to VATS or thoracotomy. CONCLUSIONS: Our study shows equivalent oncological results in the resection of M1 of CRC using VATS or thoracotomy approach. The group of patients with an M1/CT ratio >1 have a worse DSS and DFS, which may mean a more advanced disease than predicted preoperatively.

Propuesta multidisciplinar respecto al algoritmo diagnóstico de la fibrosis pulmonar idiopática: papel de la criobiopsia transbronquial / A Multidisciplinary Proposal for a Diagnostic Algorithm in Idiopathic Pulmonary Fibrosis: The Role of Transbronchial Cryobiopsy

El diagnóstico de la fibrosis pulmonar idiopática (FPI) es un proceso complejo que precisa la integración multidisciplinar de variables clínicas, radiológicas e histológicas. Cuando es preciso obtener muestras de parénquima pulmonar, la biopsia pulmonar quirúrgica ha sido el procedimiento recomendado por su rendimiento diagnóstico. Pero dada la morbimortalidad de esta técnica, se han explorado alternativas con menores riesgos. La más importante es la biopsia transbronquial con criosonda (criobiopsia transbronquial), que permite obtener tejido pulmonar con menor comorbilidad, con un rendimiento inferior a la biopsia quirúrgica pero superior a la biopsia transbronquial con pinza convencional. Por ello, en las recientes guías clínicas para el diagnóstico de la FPI se ha valorado esta opción, sin llegar a obtener una recomendación. En este artículo, resultado de un foro de discusión multidisciplinar, se pretende revisar la evidencia actual y hacer propuestas sobre el uso de la criobiopsia transbronquial para el diagnóstico de la FPI

The diagnosis of idiopathic pulmonary fibrosis (IPF) is a complex process that requires the multidisciplinary integration of clinical, radiological, and histological variables. Due to its diagnostic yield, surgical lung biopsy has been the recommended procedure for obtaining samples of lung parenchyma, when required. However, given the morbidity and mortality of this technique, alternative techniques which carry a lower risk have been explored. The most important of these is transbronchial cryobiopsy -transbronchial biopsy with a cryoprobe- which is useful for obtaining lung tissue with less comorbidity. Yield may be lower than surgical biopsy, but it is higher than with transbronchial biopsy with standard forceps. This option has been discussed in the recent clinical guidelines for the diagnosis of IPF, but the authors do not go so far as recommend it. The aim of this article, the result of a multidisciplinary discussion forum, is to review current evidence and make proposals for the use of transbronchial cryobiopsy in the diagnosis of IPF

A Multidisciplinary Proposal for a Diagnostic Algorithm in Idiopathic Pulmonary Fibrosis: The Role of Transbronchial Cryobiopsy. / Propuesta multidisciplinar respecto al algoritmo diagnóstico de la fibrosis pulmonar idiopática: papel de la criobiopsia transbronquial.

The diagnosis of idiopathic pulmonary fibrosis (IPF) is a complex process that requires the multidisciplinary integration of clinical, radiological, and histological variables. Due to its diagnostic yield, surgical lung biopsy has been the recommended procedure for obtaining samples of lung parenchyma, when required. However, given the morbidity and mortality of this technique, alternative techniques which carry a lower risk have been explored. The most important of these is transbronchial cryobiopsy -transbronchial biopsy with a cryoprobe- which is useful for obtaining lung tissue with less comorbidity. Yield may be lower than surgical biopsy, but it is higher than with transbronchial biopsy with standard forceps. This option has been discussed in the recent clinical guidelines for the diagnosis of IPF, but the authors do not go so far as recommend it. The aim of this article, the result of a multidisciplinary discussion forum, is to review current evidence and make proposals for the use of transbronchial cryobiopsy in the diagnosis of IPF.

Perioperative outcome of lung cancer surgery in women: results from a Spanish nationwide prospective cohort study.

BACKGROUND: To assess possible differences in the perioperative profile between men and women in lung cancer surgery. METHODS: A prospective cohort multicenter study was design, in which consecutive patients undergoing curative intent surgery for lung cancer in 24 Thoracic Services throughout Spain were included. Clinical features, tumor- and surgery-related data, postoperative complications, and mortality were recorded. RESULTS: There were 2,566 men and 741 women. Women were younger than men [mean (SD) age, 61.8 (10.8) vs. 66.5 (9.1) years, P<0.0001] and showed a more favorable preoperative characteristics, with significantly higher percentages of ECOG grade 0 and lower percentages of active smokers (28.4% vs. 33.9%; pack-years 18.8 vs. 26.9) and comorbidities [chronic obstructive pulmonary disease (COPD), diabetes, hypertension, cardiac disorders]. There were significant differences (P<0.001) in histological types and TNM stages with adenocarcinoma (70.1% vs. 46.4%) and IA stage (41.5% vs. 33.6%) more frequent in women. The use of VATS or thoracotomy was similar. The rate of pneumonectomy was higher in men (10.9%) than in women (5.1%) (P<0.001) but the distributions of other procedures were similar. Postoperative complications (pneumonitis, atelectasis, air leak, hemorrhage, fistula, empyema, wound dehiscence, and need of reintubation) were lower in women. Significant differences (P<0.0001) in the severity of postoperative complications (Clavien-Dindo classification) were also found, with higher percentages of grades I (51.6% vs. 43%) and II (37.5% vs. 33%) and lower percentages of grades III and IV among women. The mean length of hospital stay was 7.8 (7.1) days in men versus 6.3 (5.0) days in women, and the 30-day mortality rate 0.3% in women versus 2.9% in men (P<0.0001). The percentage of readmissions within 30 days after surgery was also higher in men (8.6% vs. 2.8%). CONCLUSIONS: This multicenter nationwide study of lung cancer surgery with curative intent shows that the perioperative profile is better in women than in men.

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

Minimally invasive treatment of pectus excavatum.

Pectus excavatum (PE) is the most common congenital chest wall deformity. It consists of a concavity of the sternum, and the costal cartilages derived from an unbalanced growth of the costochondral regions of the anterior chest wall. The standard operative treatment for PE has been the Ravitch procedure. This technique requires a long incision in the anterior chest wall and bilateral resection of the affected costal cartilages, needing in most cases a posterior metal bar support. The belief that the treatment of PE is basically esthetic led Donald Nuss to develop in 1998 a minimally invasive surgical treatment based on the skeletal frame plasticity and reshape capacity applied to the thorax. Thereby he deviced a technique involving a retrosternal steel bar modifying the sternum´s concavity and supporting the shape of the amended thorax, all performed through two small incisions at each side of the thorax with the help of a thoracoscope. The bar is maintained from 2 to 3 years, and removed after this period. This procedure obtains >90% of positive results with significant esthetic improvement and patient satisfaction. This minimally surgical approach for PE is to be discussed in this review.

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.

Secuestro pulmonar intralobar / Intralobar pulmonary sequestration

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¿Influyen el número y volumen de las biopsias pulmonares en el rendimiento diagnóstico en la enfermedad pulmonar intersticial? Análisis mediante índice de propensión / Do the number and volume of surgical lung biopsies influence the diagnostic yield in interstitial lung disease? A propensity score analysis

Introducción: Nuestro objetivo fue evaluar si el número y el volumen de las biopsias pulmonares quirúrgicas (BPQ) influyen en el diagnóstico de la enfermedad pulmonar intersticial difusa (EPID). Métodos: Estudio retrospectivo de BPQ por sospecha de EPID en los pacientes de la Clínica Mayo desde enero de 2002 hasta enero de 2010. Los datos se recogieron y analizaron en la institución. Resultados: Se analizaron 311 pacientes. El número medio de biopsias fue de 2,05 (DE 0,6); una biopsia en 50 (16%), dos en 198 (63,7%), tres en 59 (19%) y cuatro en 4 (1,3%). El diagnóstico histopatológico fue: definitivo (específico) en 232 (74,6%), descriptivo (no específico) en 76 (24,4%) no hubo diagnóstico en 3 (1%). Tras excluir a los pacientes sin diagnóstico (n = 3), hubo 50 pacientes con solo una biopsia, 196 con dos y 62 con tres o cuatro. El rendimiento de diagnóstico definitivo fue similar en los tres grupos (37/50 [74%], 150/196 [77%] y 45/62 [73%]). El valor p de Chi-cuadrado fue 0,8. El análisis del índice de propensión entre pacientes con una BPQ y pacientes con más de una BPQ tampoco mostró ninguna diferencia en el rendimiento diagnóstico. En cuanto al volumen de las biopsias, el volumen total medio fue 34,4 cm3 (DE = 46). En los pacientes sin diagnóstico, 41,2 cm3 (3 casos), en pacientes con diagnóstico específico, 33,6 cm3 (232 casos [DE = 47]) y en pacientes con un diagnóstico descriptivo: 36,6 cm3 (76 pacientes [DE = 44]). El volumen de la biopsia no influyó en el rendimiento de la histopatología (ANOVA, p = 0,8). Conclusiones: El número o el volumen de las muestras de biopsia quirúrgica no parecen influir en el diagnóstico. Según nuestros resultados creemos que una sola muestra de un área representativa puede ser suficiente para el diagnóstico. Se deben realizar ensayos prospectivos aleatorizados para optimizar la BPQ en las EPID

Introduction: Our objective was to evaluate whether the number and volume of surgical lung biopsies (SLB) influence the diagnosis of diffuse interstitial lung disease (ILD). Methods: Retrospective study of SLB for suspected ILD in patients from the Mayo Clinic from January 2002 to January 2010. Data were collected in the institution and analyzed. Results: 311 patients were studied. Mean number of biopsies was 2.05 (SD 0.6); 1 biopsy in 50 (16%), 2 in 198 (63.7%), 3 in 59 (19%) and 4 in 4 (1.3%). Histopathologic diagnosis was: definitive (specific): 232 (74.6%), descriptive (non-specific): 76 (24.4%), no diagnosis: 3 (1%). After excluding patients without diagnosis (n = 3), there were 50 patients with only 1 biopsy, 196 with 2 and 62 with 3 or 4; the definitive diagnostic yield was similar in all 3 groups (37/50; 74%, 150/196; 77%, and 45/62; 73%) (Chi-square, p value 0.8). The propensity score analysis between patients with 1 SLB and patients with more than 1 SLB also showed no difference in diagnostic yield. Regarding the volume of biopsies, mean total volume was 34.4 cm3 (SD 46): 41.2 cm3 (3 cases) in patients with no diagnosis; 33.6 cm3 (232 cases, SD 47) in patients with specific diagnosis; and 36.6 cm3 (76 cases, SD 44) in patients with descriptive diagnosis. Biopsy volume had no influence on histopathology yield (ANOVA, p value 0.8).Conclusions: The number and volume of the biopsy specimens in SLB did not seem to influence diagnosis. Based on our results, we believe a single sample from a representative area may be sufficientfor diagnosis. Randomized prospective trials should be performed to optimize SLB for IL

A randomized prospective study of analgesic quality after thoracotomy: paravertebral block with bolus versus continuous infusion with an elastomeric pump.

OBJECTIVES: Paravertebral block (PVB) with infusion of local anaesthetic (LA) through a paravertebral catheter is an effective alternative to epidural analgesia in the management of post-thoracotomy pain. PVB can be done in two ways: either through administration of a bolus dose of the LA or continuous infusion via an infusion pump; currently, there is no consensus on which route is best. Our objective was to compare the efficacy of the PVB for post-thoracotomy pain control using bolus doses versus a continuous infusion pump. METHODS: We performed a prospective randomized study of 80 patients submitted to thoracotomy. Patients were divided into two independent groups (anterior thoracotomy--ANT--and posterolateral thoracotomy-POST). At the conclusion of the surgery, a catheter was inserted under direct vision in the thoracic paravertebral space at the level of the incision. In each group, patients were randomized to receive levobupivacaine 0.5% every 6 h ('Bolus' group) or levobupivacaine 0.25% in continuous infusion at 5 ml/h through an elastomeric pump ('Continuous infusion' group). Patients in both groups received the same dosage of LA: 300 mg/day. Metamizole (every 6 h) was administered as an adjunct. Subcutaneous meperidine was employed as a rescue medication. Pain scores were measured using the visual analogue scale (VAS) at 1, 6, 24, 48 and 72 h after surgery. RESULTS: Thirteen (16.2%) patients required meperidine for rescue (8 in continuous infusion and 5 in the bolus group). Mean VAS scores were the following: all the cases (n = 80): 5.0 ± 1.6, ANT (n = 36): 4.4 ± 1.8, POST (n = 44): 5.4 ± 1.6, Bolus (n = 40): 4.7 ± 1.7, Continuous infusion (n = 40): 5.2 ± 1.8, ANT with bolus (n = 18): 4.1 ± 1.7, ANT with continuous infusion (n = 18): 4.7 ± 1.8, POST with bolus (n = 22): 5.2 ± 1.5, POST with continuous infusion (n = 22): 5.6 ± 1.6. CONCLUSIONS: Post-thoracotomy pain control using a combination of PVB and a non-steroidal anti-inflammatory drug is a safe and effective approach. Patients submitted to ANT experienced less pain than those with POST 4.4 vs 5.4 (P = 0.02). Since no statistical differences were observed, it was not possible to confirm differences between the LA administered in a bolus versus continuous infusion.

Do the number and volume of surgical lung biopsies influence the diagnostic yield in interstitial lung disease? A propensity score analysis.

INTRODUCTION: Our objective was to evaluate whether the number and volume of surgical lung biopsies (SLB) influence the diagnosis of diffuse interstitial lung disease (ILD). METHODS: Retrospective study of SLB for suspected ILD in patients from the Mayo Clinic from January 2002 to January 2010. Data were collected in the institution and analyzed. RESULTS: 311 patients were studied. Mean number of biopsies was 2.05 (SD 0.6); 1 biopsy in 50 (16%), 2 in 198 (63.7%), 3 in 59 (19%) and 4 in 4 (1.3%). Histopathologic diagnosis was: definitive (specific): 232 (74.6%), descriptive (non-specific): 76 (24.4%), no diagnosis: 3 (1%). After excluding patients without diagnosis (n=3), there were 50 patients with only 1 biopsy, 196 with 2 and 62 with 3 or 4; the definitive diagnostic yield was similar in all 3 groups (37/50; 74%, 150/196; 77%, and 45/62; 73%) (Chi-square, p value 0.8). The propensity score analysis between patients with 1 SLB and patients with more than 1 SLB also showed no difference in diagnostic yield. Regarding the volume of biopsies, mean total volume was 34.4 cm(3) (SD 46): 41.2 cm(3) (3 cases) in patients with no diagnosis; 33.6 cm(3) (232 cases, SD 47) in patients with specific diagnosis; and 36.6 cm(3) (76 cases, SD 44) in patients with descriptive diagnosis. Biopsy volume had no influence on histopathology yield (ANOVA, p value .8). CONCLUSIONS: The number and volume of the biopsy specimens in SLB did not seem to influence diagnosis. Based on our results, we believe a single sample from a representative area may be sufficient for diagnosis. Randomized prospective trials should be performed to optimize SLB for ILD.

Localización de nódulos pulmonares con arpón guiado por tomografía axial computarizada previa a la resección videotoracoscópica. Experiencia en 52 casos / Locating pulmonary nodules with a computed axial tomography-guided harpoon prior to videothoracoscopic resection. Experience with 52 cases

Introducción La resección videotoracoscópica (VTC) de los nódulos pulmonares (NP) periféricos requiere en ocasiones la práctica de una minitoracotomía para su localización mediante palpación. El objetivo de este estudio es evaluar la eficacia como método de localización preoperatoria de los NP de la colocación de un arpón guiado por TAC. Material y métodos Desde noviembre de 2004 hasta enero de 2011, 52 pacientes fueron programados para localización preoperatoria de 55 NP mediante la colocación de un arpón guiado por TAC. Resultados Un total de 52 pacientes (31 hombres y 21 mujeres) con edades entre 28 y 84 años (media: 62,2 años) con NP < 20mm (media: 9,57mm). De ellos, 35 tenían historia oncológica. Se colocaron 55 arpones (a 3 pacientes, 2 arpones simultáneos). En la VTC, 52 arpones fueron hallados correctamente anclados al NP. No se observaron complicaciones. En el grupo de 35 pacientes con antecedentes oncológicos, los nódulos resultaron ser malignos en 26 (74,3%). En los 17 no oncológicos fueron malignos el 70,6%. La estancia hospitalaria osciló entre 4 y 72 h, con 19 pacientes incluidos en un programa de cirugía ambulatoria (36,5%).Conclusiones La identificación preoperatoria de los NP permite su resección VTC directa. La colocación de un arpón guiado por TAC en los NP constituye un procedimiento seguro y efectivo que puede llevarse a cabo en un programa de cirugía ambulatoria (AU)

Objective Videothoracoscopic (VTC) resection of peripheral pulmonary nodules (PN) occasionally requires performing a mini-thoracotomy to locate them using palpation. The aim of this study is to evaluate the usefulness of inserting a CT-guided harpoon as a method for locating PN prior to surgery. Material and methods A study was conducted on a total of 52 patients who were scheduled for locating 55 PN prior to surgery by inserting a CT-guided harpoon, from November 2004 to January 2011.ResultsOf the 52 patients, of whom 35 had a history of cancer, 31 were male and 21 were female, with ages between 28 and 84 years (mean: 62.2 years) with a PN <20mm (mean: 9.57mm). A total of 55 harpoons were inserted (3 patients had 2 simultaneous harpoons). Using the VTC it was observed that 52 harpoons were correctly anchored to the PN. There were no complications. In the group of 35 patients with an oncology history, the nodules were malignant in 26 cases (74.3%), and there were 17 (70.6%) with malignant PN in those with no oncology history. The hospital stay varied between 4 and 72h, with 19 patients (36.5%) included in a one-day surgery program. Conclusions The preoperative identification of peripheral pulmonary nodules enables them to be removed directly with VTC. The insertion of a CT-guided harpoon in the PN is a safe and effective procedure that can be performed in a one-day surgery program (AU)

A prospective study comparing three-port video-assisted thoracoscopy with the single-incision laparoscopic surgery (SILS) port and instruments for the video thoracoscopic approach: a pilot study.

BACKGROUND: Single-incision laparoscopic surgery (SILS) has proved its advantages in several procedures, mainly a shorter hospital stay, improved aesthetic results, and less postoperative pain. The authors have used this approach for several thoracic surgical procedures. METHODS: This prospective study compared 20 cases between standard three-port video-assisted thoracic surgery (VATS) and the single-incision approach using a standard abdominal SILS system. In both groups, postsurgical analgesia was provided with 15 ml of bupivacaine 0.5% at 3 h intervals via a paravertebral catheter. The hospital length of stay and chest drain duration (in hours) were recorded as well as postoperative pain using an analogic visual pain scale (AVPS). A telephone survey was conducted for all the outpatients. The Mann-Whitney U test was used for statistical analysis. RESULTS: This study of 20 procedures included 11 lung biopsies, 6 pneumothorax procedures, 2 mediastinic cystectomies, and 1 catamenial pneumothorax procedure. No statistically significant difference was reported in hospital length of stay or chest drain duration between the two groups. However, postoperative pain at 24 h was significantly less in the SILS group (AVPS, 4.40) than in the VATS group (AVPS, 6.20) (p = 0.035). The SILS group reported two minor surgical wound complications and one catamenial pneumothorax recurrence that did not require drainage. The VATS group reported one case of skin rash with no identifiable cause. CONCLUSIONS: The use of the SILS port in thoracic surgery results in less postoperative pain. This is related to the port's protective effect over the periostium and the intercostal nerve, relieving them of direct contact with surgical instruments. However, the findings showed a higher incidence of surgical wound complications with the SILS port, which can be attributed to increased pressure on the skin and soft tissues surrounding the port and to the fact that this same incision was used for chest drain placement, thus increasing the risk for complications.

Validation of the lung cancer staging system revisions using a large prospective clinical trial database (ACOSOG Z0030).

OBJECTIVES: A new revision of the international lung cancer staging system has been recently introduced. The revisions are largely focussed on the T descriptor. We sought to test the validity of this new system on a separate prospectively collected cohort of patients from a recent multicentre trial of early-stage lung cancer. METHODS: We reviewed the prospectively collected data from 1012 patients undergoing pulmonary resection for early-stage lung cancer in the ACOSOG Z0030 trial. TNM descriptors and overall staging were assessed using both the sixth and seventh editions of the American Joint Committee on Cancer and the Union Internationale Contre le Cancer (AJCC/UICC) lung cancer staging system. Survival results were analysed according to both staging allocations. RESULTS: Using the proposed criteria, the number of patients by stage in the sixth and seventh edition allocations, respectively, were as follows: IA (432, 431); IB (402, 303); IIA (39, 167); IIB (94, 70); IIIA (26, 40); IIIB (19,0); there were no stage IV patients by either version. Overall, 180 (18%) patients had a change in the stage group from the sixth to seventh edition versions with 76 (8%) being downstaged and 104 (10%) being upstaged. In the sixth edition staging system based on pathological stages, median survivals in years were as follows: IA, NA; IB, 7.7; IIA, 4.0; IIB, 3.6; IIIA, 2.6 and IIIB, 2.4. Five-year survivals were: IA, 76.4%; IB, 62.0%; IIA, 47.8%; IIB, 40.4%; IIIA, 31.3% and IIIB, 44.4%. In the new system, median survivals in years were as follows: IA, NA; IB, 8.2; IIA, 4.4; IIB, 3.6 and IIIA, 1.8. Five-year survivals were: IA, 76.9%; IB, 65.0%; IIA, 48.5%; IIB, 42.9% and IIIA, 30.6%. Survival analysis and Kaplan-Meier survival curves showed more monotonic progression, distinction and homogeneity within groups in the seventh edition. CONCLUSIONS: This study provides an external validation of the recently revised lung cancer staging system using a large multicentre database. The seventh edition of the AJCC/UICC lung cancer staging system appears to be an improvement over the preceding system.

[Locating pulmonary nodules with a computed axial tomography-guided harpoon prior to videothoracoscopic resection. Experience with 52 cases]. / Localización de nódulos pulmonares con arpón guiado por tomografía axial computarizada previa a la resección videotoracoscópica. Experiencia en 52 casos.

OBJECTIVE: Videothoracoscopic (VTC) resection of peripheral pulmonary nodules (PN) occasionally requires performing a mini-thoracotomy to locate them using palpation. The aim of this study is to evaluate the usefulness of inserting a CT-guided harpoon as a method for locating PN prior to surgery. MATERIAL AND METHODS: A study was conducted on a total of 52 patients who were scheduled for locating 55 PN prior to surgery by inserting a CT-guided harpoon, from November 2004 to January 2011. RESULTS: Of the 52 patients, of whom 35 had a history of cancer, 31 were male and 21 were female, with ages between 28 and 84 years (mean: 62.2 years) with a PN <20mm (mean: 9.57mm). A total of 55 harpoons were inserted (3 patients had 2 simultaneous harpoons). Using the VTC it was observed that 52 harpoons were correctly anchored to the PN. There were no complications. In the group of 35 patients with an oncology history, the nodules were malignant in 26 cases (74.3%), and there were 17 (70.6%) with malignant PN in those with no oncology history. The hospital stay varied between 4 and 72h, with 19 patients (36.5%) included in a one-day surgery program. CONCLUSIONS: The preoperative identification of peripheral pulmonary nodules enables them to be removed directly with VTC. The insertion of a CT-guided harpoon in the PN is a safe and effective procedure that can be performed in a one-day surgery program.