[Chest trauma]. / Traumatismos torácicos.

Chest trauma is a frequent problem arising from lesions caused by domestic and occupational activities and especially road traffic accidents. These injuries can be analyzed from distinct points of view, ranging from consideration of the most severe injuries, especially in the context of multiple trauma, to the specific characteristics of blunt and open trauma. In the present article, these injuries are discussed according to the involvement of the various thoracic structures. Rib fractures are the most frequent chest injuries and their diagnosis and treatment is straightforward, although these injuries can be severe if more than three ribs are affected and when there is major associated morbidity. Lung contusion is the most common visceral lesion. These injuries are usually found in severe chest trauma and are often associated with other thoracic and intrathoracic lesions. Treatment is based on general support measures. Pleural complications, such as hemothorax and pneumothorax, are also frequent. Their diagnosis is also straightforward and treatment is based on pleural drainage. This article also analyzes other complex situations, notably airway trauma, which is usually very severe in blunt chest trauma and less severe and even suitable for conservative treatment in iatrogenic injury due to tracheal intubation. Rupture of the diaphragm usually causes a diaphragmatic hernia. Treatment is always surgical. Myocardial contusions should be suspected in anterior chest trauma and in sternal fractures. Treatment is conservative. Other chest injuries, such as those of the great thoracic and esophageal vessels, are less frequent but are especially severe.

Traumatismos torácicos / Chest trauma

Los traumatismos torácicos (TT) constituyen un problema frecuente, consecuencia de lesiones originadas poractividades domésticas, laborales y, especialmente, accidentes de tráfico. Se pueden analizar desde diversospuntos de vista, considerando los más graves sobre todo en el contexto de los politraumatismos. Y también laspeculiaridades de los traumatismos cerrados y los abiertos.En este trabajo se estudian según la afectación de las diversas estructuras torácicas. Las fracturas costales sonlos TT más frecuentes, su diagnóstico y tratamiento es sencillo, aunque pueden ser graves en casos de afectaciónde más de 3 arcos costales y cuando el paciente presenta morbilidad asociada importante. La contusiónpulmonar es la lesión visceral más frecuente. Suele presentarse en TT graves y a menudo asociada a otras lesionestorácicas e intratorácicas. Su tratamiento se basa en medidas de soporte general. Son también frecuenteslas complicaciones pleurales como el hemotórax y neumotórax. Su diagnóstico es también sencillo y sutratamiento se basa en el drenaje pleural.Otras situaciones complejas también se analizan en este trabajo, destacando los traumatismos de la vía aérea,muy graves por lo general en los TT cerrados y con menor repercusión e incluso susceptibles de tratamientoconservador en los iatrógenos por intubación traqueal. Las roturas diafragmáticas suelen dar lugar a una herniadiafragmática. Su tratamiento es siempre quirúrgico. Las contusiones miocárdicas deben sospecharse enTT anteriores y fracturas de esternón. Su tratamiento es conservador. Otros TT como los de los grandes vasostorácicos y esofágicos son menos frecuentes, aunque de especial gravedad(AU)

Chest trauma is a frequent problem arising from lesions caused by domestic and occupational activities andespecially road traffic accidents. These injuries can be analyzed from distinct points of view, ranging fromconsideration of the most severe injuries, especially in the context of multiple trauma, to the specificcharacteristics of blunt and open trauma.In the present article, these injuries are discussed according to the involvement of the various thoracicstructures. Rib fractures are the most frequent chest injuries and their diagnosis and treatment isstraightforward, although these injuries can be severe if more than three ribs are affected and when there ismajor associated morbidity. Lung contusion is the most common visceral lesion. These injuries are usuallyfound in severe chest trauma and are often associated with other thoracic and intrathoracic lesions. Treatmentis based on general support measures. Pleural complications, such as hemothorax and pneumothorax, arealso frequent. Their diagnosis is also straightforward and treatment is based on pleural drainage.This article also analyzes other complex situations, notably airway trauma, which is usually very severe inblunt chest trauma and less severe and even suitable for conservative treatment in iatrogenic injury due totracheal intubation. Rupture of the diaphragm usually causes a diaphragmatic hernia. Treatment is alwayssurgical. Myocardial contusions should be suspected in anterior chest trauma and in sternal fractures.Treatment is conservative. Other chest injuries, such as those of the great thoracic and esophageal vessels, areless frequent but are especially severe(AU)

Videotoracoscopia exploradora y videopericardioscopia en la estadificación definitiva y valoración de la resecabilidad del cáncer de pulmón / Exploratory Videothoracoscopy and Videopericardioscopy in the Definitive Staging and Assessment of Resectability of Lung Cancer

Introducción: El objetivo del artículo es presentar nuestra experiencia en videotoracoscopia para laestadificación y valoración de la resecabilidad del cáncer de pulmón.Pacientes y métodos: Desde 1993 realizamos videotoracoscopia exploradora (VTE) para la estadificación y valoración de la resecabilidad del cáncer de pulmón. Cuando se sospecha que hay afectación vascularintrapericárdica, la exploración intrapericárdica de los vasos mediante videopericardioscopia (VPC) sirvepara valorar la resecabilidad en estos supuestos cT4. Hasta diciembre de 2007 intervenimos a 1.381pacientes con carcinoma broncogénico. En este grupo de pacientes se realizaron 91 VPC, 45 de ellas por sospecha previa de invasión hiliar y vascular en la tomografía computarizada o resonancia magnética; en los 46 restantes se indicó durante la VTE.Resultados: En 1.277 pacientes pudo llevarse a cabo la VTE, que no fue posible en 104 casos por adherenciaspleurales firmes —61 pudieron resecarse trastoracotomía y sólo 43(3,1%) fueron toracotomíasexploradoras—. En 141 casos (10,2%)se hallaron en la VTE causas de irresecabilidad: en 81 invasiónmediastínica, en 38 carcinomatosis pleural, en 6 concurrieron ambas causas y en 16 había invasióntranscisural y/o vascular que impedía la lobectomía en pacientes que no toleraban la neumonectomía. En 61 de los 91 pacientes a quienes se realizó VPC pudo llevarse a cabo la exéresis pulmonar; en los 30restantes había invasión intrapericárdica que impedía su disección: de la arteria pulmonar en 17 casos; de la arteria y vena pulmonar es superiores en 6; de la arteria pulmonar y vena cava superiores en 2, y ampliainvasión de la aurícula izquierda y venas pulmonares en 5.Conclusiones: La VTE y la VPC como primer paso de la intervención por cáncer de pulmón requiere pocosminutos, no añade morbilidad y evita una significativa proporción de toracotomías exploradoras(AU)

Objective: We present our experience in using videothoracoscopy for the staging and assessment of resectability of lung cancer.Patients and Methods: Since 1993 we have carried out exploratory videothoracoscopy (EVT) for lung cancerstaging and assessment of resectability. When intrapericardial vessel involvemen tissu spected, explorationby videopericardioscopy (VPC)is also useful for assessing resectability in the se cT4 cases. Up to December2007 we had studied 1381 patients with bronchogenic carcinoma. VPC was performed in 91 of these patients. In 45, the procedure was indicated because evidence of hilar and vascular invasion had been observed in the computed tomography or magnetic resonance images. In there maining 46, it wasperformed as a result of EVT findings.Results: We were able to perform EVT in 1277 patients. In 104 cases this procedure could not be performed because of firm pleural adhesions. The tumor was resected after thoracotomy in 61 of these patients;thoracotomy was thus only exploratory in only 43 (3.1%). In 141 cases(10.2%) tumors were consideredunresectable based on EVT, due to mediastinal invasion in 81 cases, pleural carcinoma tos is in 38 cases, and both findings in 6 cases. Lobectomy was ruled out because of spread across a fissure or vascular invasion in16 patients who were unable to tolerate pneumonectomy.In 61 of the 91 patients who underwent VPC we were able to perform lung resection; in the remaining 30, intrapericardial dissection was prevented by invasion of the pulmonary artery (17cases), of the upper pulmonary artery and vein(6cases), of the upper pulmonary artery and superior vena cava (2cases), or ofthe left a trium and pulmonary veins(5cases, in which the invasion was extensive).Conclusions: EVT and VPC as a first stepin lung cancer treatment require only a few minutes, do not contribute to morbidity, and avoid a significant proportion of exploratory thoracotomies(AU)

Utilidad de la videotoracoscopia para una correcta estadificación de tumores T3 por invasión de pared / Usefulness of Video-assisted Thoracoscopy for Correctly Staging Tumors as T3 Because of Chest Wall Invasion

IntroducciónLa videotoracoscopia exploradora (VTE) es una técnica que permite valorar la resecabilidad del carcinoma de pulmón. El objetivo de este trabajo ha sido comprobar su utilidad para diferenciar los verdaderos tumores T3 por invasión parietal de aquellos que se estadificaron de forma incorrecta por las pruebas de imagen.Pacientes y métodosDesde marzo de 1993 hasta diciembre de 2007 se estudió a 1.277 pacientes, de los que 150 (137 varones y 13 mujeres; rango de edad: 28 81 años) presentaron tumores estadificados como cT3 por invasión parietal en las pruebas de imagen.ResultadosTras la realización de la VTE, los tumores pT3 por invasión parietal confirmados intraoperatoriamente y mediante estudio anatomopatológico fueron 44. De ellos, 36 se habían clasificado correctamente como cT3 por tomografía computarizada o resonancia magnética. Se observó además que 6 casos habían sido infravalorados como cT2, y otros 2 supravalorados como cT4. La sensibilidad, especificidad y valor predictivo tanto positivo como negativo obtenidos en nuestra serie han sido del 100%.ConclusionesEn nuestra opinión, la VTE es una técnica claramente superior a la tomografía computarizada y/o resonancia magnética para detectar infiltración de pared, por lo que, además de estadificar correctamente la situación tumoral T3 por invasión parietal, permite decidir la vía de abordaje adecuada para cada caso(AU)

BackgroundExploratory video-assisted thoracoscopy (EVT) can be used to assess the resectability of lung carcinomas. The aim of this study was to investigate the usefulness of this technique for distinguishing between tumors that invade the chest wall and should be staged as T3 and tumors that have been incorrectly staged as T3 on the basis of imaging studies.Patients and MethodsFrom March 1993 through December 2007, we studied 1277 patients, of whom 150 (137 men and 13 women; age range, 28 81 years) presented tumors classified as cT3 because of chest wall invasion on the basis of imaging studies.ResultsAfter exploratory EVT, 44 pT3 tumors with chest wall invasion were confirmed intraoperatively and by histopathology. Of these, 36 had been correctly classified as cT3 by computed tomography or magnetic resonance imaging. However, tumors had been understaged as cT2 in 6patients and overstaged as cT4 in 2 patients. The sensitivity, specificity, and positive and negative predictive values obtained were 100%.ConclusionsWe believe that exploratory EVT is clearly better than computed tomography and/or magnetic resonance imaging for detecting chest wall invasion. In addition to correctly staging a tumor as T3 because of chest wall invasion, the technique can also help decide the best surgical approach in each case(AU)

[Exploratory videothoracoscopy and videopericardioscopy in the definitive staging and assessment of resectability of lung cancer]. / Videotoracoscopia exploradora y videopericardioscopia en la estadificación definitiva y valoración de la resecabilidad del cáncer de pulmón.

OBJECTIVE: We present our experience in using videothoracoscopy for the staging and assessment of resectability of lung cancer. PATIENTS AND METHODS: Since 1993 we have carried out exploratory videothoracoscopy (EVT) for lung cancer staging and assessment of resectability. When intrapericardial vessel involvement is suspected, exploration by videopericardioscopy (VPC) is also useful for assessing resectability in these cT4 cases. Up to December 2007 we had studied 1381 patients with bronchogenic carcinoma. VPC was performed in 91 of these patients. In 45, the procedure was indicated because evidence of hilar and vascular invasion had been observed in the computed tomography or magnetic resonance images. In the remaining 46, it was performed as a result of EVT findings. RESULTS: We were able to perform EVT in 1277 patients. In 104 cases this procedure could not be performed because of firm pleural adhesions. The tumor was resected after thoracotomy in 61 of these patients; thoracotomy was thus only exploratory in only 43 (3.1%). In 141 cases (10.2%) tumors were considered unresectable based on EVT, due to mediastinal invasion in 81 cases, pleural carcinomatosis in 38 cases, and both findings in 6 cases. Lobectomy was ruled out because of spread across a fissure or vascular invasion in 16 patients who were unable to tolerate pneumonectomy. In 61 of the 91 patients who underwent VPC we were able to perform lung resection; in the remaining 30, intrapericardial dissection was prevented by invasion of the pulmonary artery (17 cases), of the upper pulmonary artery and vein (6 cases), of the upper pulmonary artery and superior vena cava (2 cases), or of the left atrium and pulmonary veins (5 cases, in which the invasion was extensive). CONCLUSIONS: EVT and VPC as a first step in lung cancer treatment require only a few minutes, do not contribute to morbidity, and avoid a significant proportion of exploratory thoracotomies.

[Usefulness of video-assisted thoracoscopy for correctly staging tumors as T3 because of chest wall invasion]. / Utilidad de la videotoracoscopia para una correcta estadificación de tumores T3 por invasión de pared.

BACKGROUND: Exploratory video-assisted thoracoscopy (EVT) can be used to assess the resectability of lung carcinomas. The aim of this study was to investigate the usefulness of this technique for distinguishing between tumors that invade the chest wall and should be staged as T3 and tumors that have been incorrectly staged as T3 on the basis of imaging studies. PATIENTS AND METHODS: From March 1993 through December 2007, we studied 1277 patients, of whom 150 (137 men and 13 women; age range, 28-81 years) presented tumors classified as cT3 because of chest wall invasion on the basis of imaging studies. RESULTS: After exploratory EVT, 44 pT3 tumors with chest wall invasion were confirmed intraoperatively and by histopathology. Of these, 36 had been correctly classified as cT3 by computed tomography or magnetic resonance imaging. However, tumors had been understaged as cT2 in 6 patients and overstaged as cT4 in 2 patients. The sensitivity, specificity, and positive and negative predictive values obtained were 100%. CONCLUSIONS: We believe that exploratory EVT is clearly better than computed tomography and/or magnetic resonance imaging for detecting chest wall invasion. In addition to correctly staging a tumor as T3 because of chest wall invasion, the technique can also help decide the best surgical approach in each case.

[Resection of pulmonary metastases in 148 patients: analysis of prognostic factors]. / Cirugía de metástasis pulmonares en 148 pacientes. Análisis de sus factores pronósticos.

OBJECTIVE: To evaluate the prognostic factors for survival in a series of patients who underwent surgery for pulmonary metastases from primary tumors in distinct organs. PATIENTS AND METHODS: This was a retrospective study of 148 patients operated between May 2001 and May 2007. Multivariate analysis was used to evaluate overall survival. Patients scheduled for tumorectomy were included provided their primary tumor was controlled and they had no extrathoracic recurrence and adequate cardiorespiratory function. The influence of the following prognostic factors was analyzed: number and diameter of the metastases, lymph node infiltration, complete resection, and, above all, histological type. A significance level of 95% was used. RESULTS: A total of 90 men (60.81%) and 58 women (39.19%) were operated. The mean (SD) age was 56.5 (9.7) years. The actuarial survival at 6 years was 30.3% (n=45) and the median survival was 34 months. The factors that affected survival were the number of metastases (P< .05), diameter of the lesions (P< .05), lymph node infiltration (P< .05), complete resection (P< .05), and, above all, histological type (P< .05). Tumorectomy was the most commonly performed operation. CONCLUSIONS: These results suggest that, in the absence of other therapeutic options and contraindications, we should operate on patients in whom the primary tumor is controlled and in whom complete resection can be performed. Even if factors associated with poor prognosis are present, the outcomes are always better than when surgery is not performed, particularly in view of the relatively low morbidity and mortality associated with this type of surgery.

Cirugía de metástasis pulmonares en 148 pacientes. Análisis de sus factores pronósticos / Resection of pulmonary metastases in 148 Patients: analysis of prognostic factors

OBJETIVO: Evaluar los factores pronósticos de supervivenciaen una serie de pacientes intervenidos por metástasispulmonares de diferentes tumores y órganos.PACIENTES Y MÉTODOS: Se ha realizado un estudio retrospectivode 148 pacientes intervenidos entre mayo de 2001 ymayo de 2007, y se ha aplicado un análisis multivariantepara valorar la supervivencia global. Los criterios de inclusiónfueron: control del tumor primario, sin recurrencia extratorácicay función cardiorrespiratoria suficiente, siemprecon intención de tumorectomía. Se valoró qué influencia teníanen el pronóstico los siguientes factores: número de metástasis,diámetro de éstas, adenopatías invadidas, cirugíacompleta y, sobre todo, tipo histológico, para un nivel de significacióndel 95%.RESULTADOS: En total se intervino a 90 varones (60,81%)y 58 mujeres (39,19%). La edad media ± desviación estándarera de 56,5 ± 9,7 años. Se obtuvo una supervivencia actuariala 6 años del 30,3% (n = 45), con una mediana de supervivenciade 34 meses. Los factores que influyeron en elpronóstico fueron el número de metástasis (p < 0,05), el diámetrode éstas (p < 0,05), la presencia de adenopatías invadidas(p < 0,05), la cirugía completa (p < 0,05) y, sobre todo,el tipo histológico (p < 0,05). La tumorectomía fue la intervenciónmás realizada.CONCLUSIONES: Los resultados avalan que aceptemos paratratamiento quirúrgico a los pacientes sin otra posibilidadterapéutica a quienes pueda realizarse una resección completa,que tengan el tumor primario controlado y no presentenotras contraindicaciones, pues, aunque en presencia deciertos factores empeora la supervivencia, los resultados sonsiempre mejores que con la abstención quirúrgica, máximesi se tienen en cuenta las cifras relativamente bajas de morbilidady mortalidad con este tipo de cirugía

OBJECTIVE: To evaluate the prognostic factors for survivalin a series of patients who underwent surgery for pulmonarymetastases from primary tumors in distinct organs.PATIENTS AND METHODS: This was a retrospective study of148 patients operated between May 2001 and May 2007.Multivariate analysis was used to evaluate overall survival.Patients scheduled for tumorectomy were included providedtheir primary tumor was controlled and they had noextrathoracic recurrence and adequate cardiorespiratoryfunction. The influence of the following prognostic factorswas analyzed: number and diameter of the metastases, lymphnode infiltration, complete resection, and, above all,histological type. A significance level of 95% was used.RESULTS: A total of 90 men (60.81%) and 58 women(39.19%) were operated. The mean (SD) age was 56.5 (9.7)years. The actuarial survival at 6 years was 30.3% (n=45) andthe median survival was 34 months. The factors that affectedsurvival were the number of metastases (P<.05), diameter ofthe lesions (P<.05), lymph node infiltration (P<.05), completeresection (P<.05), and, above all, histological type (P<.05).Tumorectomy was the most commonly performed operation.CONCLUSIONS: These results suggest that, in the absence ofother therapeutic options and contraindications, we shouldoperate on patients in whom the primary tumor is controlledand in whom complete resection can be performed. Even iffactors associated with poor prognosis are present, theoutcomes are always better than when surgery is notperformed, particularly in view of the relatively low morbidityand mortality associated with this type of surgery

[Resection of 8 mediastinal bronchogenic cysts by video-assisted thoracoscopy]. / Quiste broncogénico de mediastino. Resección videotoracoscópica en 8 casos.

Mediastinal bronchogenic cysts are an uncommon entity and surgical experience of their removal by video-assisted thoracoscopy is limited. We present our patient outcomes and surgical technique in the treatment of bronchogenic cysts by video-assisted thoracoscopy. The study included 8 patients (4 females and 4 males between the ages of 4 and 52 years), 7 of whom presented clinical symptoms. The mean widest diameter of the cyst was 7.6 cm. In 5 patients the cyst was in the middle mediastinum and in 3, the posterior mediastinum. The intervention was performed using 3 or 4 entry points. Initial puncture of the cyst and removal of its contents greatly facilitated cyst manipulation and subsequent dissection of the cyst sac from the structures to which it was attached. In all 8 cases resection by video-assisted thoracoscopy was carried out with no intraoperative complications. The mean postoperative hospital stay was 3.3 days. During follow-up, which ranged from 4 months to 10 years, no patients presented late-onset or recurrent complications.

Quiste broncogénico de mediastino. Resección videotoracoscópica en 8 casos / Resection of 8 mediastinal bronchogenic cysts by video-assisted thoracoscopy

El quiste broncogénico de mediastino es una entidad poco frecuente y la experiencia quirúrgica de su extirpación por videotoracoscopia es limitada. Presentamos nuestros resultados y técnica quirúrgica en el tratamiento de los quistes broncogénicos por videotoracoscopia. El estudio incluye a 8 pacientes (4 mujeres y 4 varones, con un rango de edad comprendido entre los 4 y los 52 los años), de los que 7 presentaban síntomas clínicos. El tamaño medio del quiste en su diámetro mayor era de 7,6 cm. En 5 pacientes se localizaba en el mediastino medio y en 3 en el posterior. La intervención se realiza a través de 3-4 puertas de entrada, y la apertura y el vaciamiento del contenido del quiste desde el inicio constituye una maniobra que facilita enormemente la manipulación y posterior disección del saco quístico de las estructuras a las que se encuentra adherido. En los 8 casos se realizó la resección por videotoracoscopia sin complicaciones intraoperatorias. La estancia media postoperatoria fue de 3,3 días. Los pacientes no han presentado complicaciones tardías ni recidivas durante el seguimiento, que oscila entre los 4 meses y los 10 años

Mediastinal bronchogenic cysts are an uncommon entity and surgical experience of their removal by video-assisted thoracoscopy is limited. We present our patient outcomes and surgical technique in the treatment of bronchogenic cysts by video-assisted thoracoscopy. The study included 8 patients (4 females and 4 males between the ages of 4 and 52 years), 7 of whom presented clinical symptoms. The mean widest diameter of the cyst was 7.6 cm. In 5 patients the cyst was in the middle mediastinum and in 3, the posterior mediastinum. The intervention was performed using 3 or 4 entry points. Initial puncture of the cyst and removal of its contents greatly facilitated cyst manipulation and subsequent dissection of the cyst sac from the structures to which it was attached. In all 8 cases resection by video-assisted thoracoscopy was carried out with no intraoperative complications. The mean postoperative hospital stay was 3.3 days. During follow-up, which ranged from 4 months to 10 years, no patients presented late-onset or recurrent complications