Evaluation of Light's criteria in cytologically proved malignant pleural effusions.

BACKGROUND: Malignant pleural effusions are usually described as exudates. However, several studies have determined a high incidence of cytologically proved malignant effusions in transudates. The study aims to determine the compliance of cytologically proved malignant pleural effusions with Light's Criteria and to assess when it is necessary to perform more studies in transudates. METHODS: We have retrospectively reviewed all the cytologically positive effusions at our institution over six years. Biochemical characteristics were recorded, and Light's criteria were determined for each effusion. We analyzed the effusions' compliance with the criteria and determined whether its primary tumor or the presence of cirrhosis, acute kidney injury or congestive heart failure could interfere in the criteria being met. RESULTS: Overall, 224 patients presented malignant pleural effusions with biochemical pleural fluid analysis. Two (0.9%) were transudative effusions and two hundred and twenty-two (99.1%) were exudative effusions. Lung carcinoma, breast carcinoma and ovarian carcinoma were the most frequent primary tumors. One hundred and two (45.94%) patients met three Light criteria, 77 (34.68%) patients met two criteria and 43 (19.36%) met one criterion. Both patients with transudative malignant pleural effusions presented concomitant malignant ascites. CONCLUSIONS: Malignant transudative pleural effusions were 0.9% of our patients. We found no relation between transudative malignant effusions and the presence of cirrhosis, acute kidney injury or congestive heart failure, or the type of tumor. We found no difference between the tumor type and the distribution of Light's criteria met.

Modified Ravitch Procedure and Autologous Cartilage Graft for Pectus Arcuatum.

Pectus arcuatum presents with sternal angle protrusion and bilateral cartilage deformity. A modified Ravitch procedure is the most common surgical approach. A graft to fill up the osteotomy may be necessary to ensure a stable correction. Studies of the behavior of a cartilage graft transplanted to a human bone defect are scarce. We present a case of autologous rib cartilage graft for sternotomy stabilization during pectus arcuatum repair. Graft viability and new bone formation were proved by computed tomography. Autologous cartilage rib graft is a biocompatible substitute available in the same surgical field with satisfactory results and minimal morbidity.

Spanish Lung Cancer Group SCAT trial: surgical audit to lymph node assessment based on IASLC recommendations.

BACKGROUND: The Spanish Customized Adjuvant Therapy (SCAT) trial assessed the role of individualized adjuvant therapy in clinical N0 incidental pN1 and/or N2 non-small cell lung cancer (NSCLC) completely resected. We assessed surgical topics with an in-depth analysis of quality of lymphadenectomy based on International Association for the Study of Lung Cancer (IASLC) recommendations. METHODS: Patients with information about lymphadenectomy available were included (N=451). Prospectively collected data about tumor, type of resection, and postoperative morbidity and quality of lymph node dissection (LND) were retrospectively evaluated. Role of lymph node assessment on survival was analyzed using Kaplan-Meier curves, using regression models to identify prognostic factors. RESULTS: In 33.7%, 17.7% and 49.9% of cases, regions 7, 10 and 11 respectively were not assessed. In 21.1% of patients, less than three lymph node regions were biopsied, while in 19.6% of patients less than six lymph nodes were assessed. In 53,4% of patients only one N1 region was evaluated. From patients with positive N2, 8.9% had no N1 regions biopsied. Twenty-nine percent of patients with at least one N2 lymph node resected shown the highest region involved. Thirty-day postoperative mortality was unknown. Five-year overall survival (OS) was 61.7% (95% CI: 55.4-67.4%), 51.5% (95% CI: 39.2-62.4%) and 42.3% (95% CI: 32.1-52.2%) for patients with N1, N2 and N1+N2 disease, respectively (P<0.01). Both number of lymph nodes resected and number of lymph nodes involved by tumor were significantly related to prognosis. CONCLUSIONS: IASLC recommendations for surgical resections were not followed in a high proportion of surgical procedures. Hilar and mediastinal lymph node assessment and involvement showed to impact prognosis. Surgical issues such as postoperative mortality could not be evaluated owing to trial design.

A New Methodology for Intraoperative Monitoring of the Functional Integrity of the Phrenic Nerve During Cardiothoracic Surgery.

INTRODUCTION: The phrenic nerve could be easily injured during cardiothoracic surgeries because of its anatomical relationships. The aim of this study is to describe a new, feasible, and reproducible methodology to achieve a continuous intraoperative neuromonitoring of the phrenic nerve. METHODS: Consecutive patients who underwent open-chest surgery were included. The recording active electrode was placed 5 cm superior to the tip of the xiphoid process, and a hook wire inserted at the motor point of the ipsilateral hemidiaphragm was used as the reference electrode. RESULTS: We studied 45 patients (92% men, mean age 67 years). Mean height and weight were 167 ± 6.9 cm and 75.6 ± 12.3 kg, respectively. A reproducible compound motor action potential was recorded in 38 (85%) subjects. The mean latency and amplitude values were 9.68 ± 2.40 ms and 1.36 ± 3.83 mV, respectively. No intraoperative events were recorded. CONCLUSIONS: We reported a new methodology which allows the assessment of phrenic nerve functional integrity during surgical procedures.

Right sleeve S2 segmentectomy for lung carcinoid tumor in a patient with tracheal bronchus.

Carcinoid tumors are relative rare neuroendocrine tumors of the lung. Bronchial obstruction's symptoms as cough, hemoptysis and pneumonia may be present when they are centrally located and lung-sparing surgery is usually preferred. We describe the case of an adult patient with a central right upper lobe carcinoid tumor and a concurrent tracheal bronchus malformation. This peculiar bronchial malformation allowed a sleeve S2 segmentectomy sparing the S1-S3 segments and the middle and lower lobes. The patient was discharged on day 4 without complications.

Is it necessary to sample the contralateral nodal stations by EBUS-TBNA in patients with lung cancer and clinical N0 / N1 on PET-CT?

OBJECTIVES: Systematic mediastinal staging (sampling all visible nodes measuring ≥ 5 mm from N3 station to N1, regardless of PET/CT (positron emission tomography/computed tomography) by endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) is a decisive step in patients with non-small cell lung cancer (NSCLC). We analyzed the prevalence of N3 disease and the utility of systematic staging in the subgroup of patients who underwent EBUS-TBNA staging without showing mediastinal lesions on the PET/CT (N0/N1). MATERIAL AND METHODS: We conducted a retrospective analysis of a prospectively collected database that included 174 patients with a final diagnosis of NSCLC, with N0/N1 disease on PET/CT who underwent a systematic EBUS-TBNA staging. RESULTS: 174 consecutive patients were included. Systematic EBUS-TBNA detected N2 mediastinal involvement in 21 (12 %) cases, and no cases of N3 disease were detected (neither hilar nor mediastinal). Of the remaining 153 patients N0/N1 EBUS-TBNA, 122 underwent lung resection that revealed 4 cases of N2 disease while 117 were confirmed to be N0/N1. Thirty-three patients with N0/1 disease after EBUS-TBNA did not undergo surgery and were excluded for the NPV calculation. Sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV) and overall accuracy of systematic EBUS was 84 %, 100 %, 96.7 %, 100 % and 97 % respectively. CONCLUSION: Systematic EBUS-TBNA is a very accurate method for lymph node staging in patients with NSCLC without mediastinal involvement on PET/CT. Pending more studies, the absence of contralateral hilar nodal involvement in our series, questions the need for a contralateral hilar sampling in this subgroup of patients.

Atresia bronquial diagnosticada incidentalmente tras traumatismo torácico / Incidental diagnosis of bronchial atresia after chest trauma

No disponible

Systematic Compared With Targeted Staging With Endobronchial Ultrasound in Patients With Lung Cancer.

BACKGROUND: To evaluate the accuracy of systematic mediastinal staging by endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) (sampling of all visible nodes measuring ≥5 mm from stations N3 to N1 regardless of their positron emission tomography/computed tomography [PET/CT] features) and compare this staging approach with targeted EBUS-TBNA staging (sampling only 18F-fluorodeoxyglucose [FDG]-avid nodes) in patients with N2 non-small cell lung cancer on PET/CT. METHODS: Retrospective study of 107 patients who underwent systematic EBUS-TBNA mediastinal staging. The results were compared with those of a hypothetical scenario where only FDG-avid nodes on PET/CT would be sampled. RESULTS: Systematic EBUS-TBNA sampling demonstrated N3 disease in 3 patients, N2 disease in 60 (42 single-station or N2a, 18 multiple-station or N2b) and N0/N1 disease in 44. Of these 44, 7 underwent mediastinoscopy, which did not show mediastinal disease; 6 of the 7 proceeded to lung resection, which also showed no mediastinal disease. Thirty-four N0/N1 patients after EBUS-TBNA underwent lung resection directly: N0/N1 was found in 30 and N2 in 4 (1 N2b with a PET/CT showing N2a disease, 3 N2a). Sensitivity, specificity, negative predictive value, positive predictive value, and overall accuracy of systematic EBUS-TBNA were 94%, 100%, 90%, 100% and 96%, respectively. Compared with targeted EBUS-TBNA, systematic EBUS-TBNA sampling provided additional important clinical information in 14 cases (13%): 3 N3 cases would have passed unnoticed, and 11 N2b cases would have been staged as N2a. CONCLUSIONS: In clinical practice, systematic sampling of the mediastinum by EBUS-TBNA, regardless of PET/CT features, is to be recommended over targeted sampling.

Benchmarking en cirugía torácica. Tercera edición / Benchmarking in Thoracic Surgery. Third Edition

Introducción: Benchmarking hace referencia a la comparación continuada de la eficiencia y la calidad entre productos y actividades con el objetivo fundamental de alcanzar la excelencia. Objetivo: Analizar los resultados del benchmarking realizado en 2013 con la actividad asistencial de Cirugía Torácica en el año 2012 en 17 servicios de Cirugía Torácica españoles participantes. Métodos: La fuente de información para el estudio ha sido el conjunto mínimo básico de datos de hospitalización correspondiente al año 2012. Los datos han sido proporcionados por los centros participantes, a partir de los informes de alta hospitalaria, sin intervención de los responsables de los correspondientes servicios asistenciales. Los casos objeto del estudio han sido todas las altas de hospitalización registradas en los centros participantes. Los episodios incluidos han sido los de enfermedad quirúrgica respiratoria (CDM4-Q) y los del servicio de Cirugía Torácica. La identificación de estos casos se realizó usando los códigos de la novena edición de la Clasificación Internacional de Enfermedades, Modificación Clínica. Para valorar las diferencias en gravedad y complejidad de los casos se ha utilizado la clasificación de los grupos relacionados por el diagnóstico refinados. Resultados: Los diversos parámetros generales estudiados (casuística, estancia media, complicaciones, readmisiones, mortalidad y actividad) han tenido una gran variabilidad entre los participantes. El análisis concreto de intervenciones (lobectomía, neumonectomía, resecciones atípicas y neumotórax), también han oscilado considerablemente. Conclusiones: Se observa, al igual que en ediciones previas, una considerable variabilidad entre los grupos participantes. Existen áreas de mejora evidentes: estandarización de los procesos de admisión, evitando ingresos urgentes y mejorando la estancia preoperatoria; agilización de las altas hospitalarias y mejora de los informes de alta, reflejando toda la actividad y las complicaciones habidas. Algunas unidades de Cirugía Torácica deben hacer una revisión profunda de sus procesos porque pueden tener algunos parámetros con una desviación excesiva de la norma. También deben mejorarse los procesos de codificación de diagnósticos y comorbilidades

Introduction: Benchmarking entails continuous comparison of efficacy and quality among products and activities, with the primary objective of achieving excellence. Objective: To analyze the results of benchmarking performed in 2013 on clinical practices undertaken in 2012 in 17 Spanish thoracic surgery units. Methods: Study data were obtained from the basic minimum data set for hospitalization, registered in 2012. Data from hospital discharge reports were submitted by the participating groups, but staff from the corresponding departments did not intervene in data collection. Study cases all involved hospital discharges recorded in the participating sites. Episodes included were respiratory surgery (Major Diagnostic Category 04, Surgery), and those of the thoracic surgery unit. Cases were labelled using codes from the International Classification of Diseases, 9th revision, Clinical Modification. The refined diagnosis-related groups classification was used to evaluate differences in severity and complexity of cases. Results: General parameters (number of cases, mean stay, complications, readmissions, mortality, and activity) varied widely among the participating groups. Specific interventions (lobectomy, pneumonectomy, atypical resections, and treatment of pneumothorax) also varied widely. Conclusions: As in previous editions, practices among participating groups varied considerably. Some areas for improvement emerge: admission processes need to be standardized to avoid urgent admissions and to improve pre-operative care; hospital discharges should be streamlined and discharge reports improved by including all procedures and complications. Some units have parameters which deviate excessively from the norm, and these sites need to review their processes in depth. Coding of diagnoses and comorbidities is another area where improvement is needed

Benchmarking in Thoracic Surgery. Third Edition.

INTRODUCTION: Benchmarking entails continuous comparison of efficacy and quality among products and activities, with the primary objective of achieving excellence. OBJECTIVE: To analyze the results of benchmarking performed in 2013 on clinical practices undertaken in 2012 in 17 Spanish thoracic surgery units. METHODS: Study data were obtained from the basic minimum data set for hospitalization, registered in 2012. Data from hospital discharge reports were submitted by the participating groups, but staff from the corresponding departments did not intervene in data collection. Study cases all involved hospital discharges recorded in the participating sites. Episodes included were respiratory surgery (Major Diagnostic Category 04, Surgery), and those of the thoracic surgery unit. Cases were labelled using codes from the International Classification of Diseases, 9th revision, Clinical Modification. The refined diagnosis-related groups classification was used to evaluate differences in severity and complexity of cases. RESULTS: General parameters (number of cases, mean stay, complications, readmissions, mortality, and activity) varied widely among the participating groups. Specific interventions (lobectomy, pneumonectomy, atypical resections, and treatment of pneumothorax) also varied widely. CONCLUSIONS: As in previous editions, practices among participating groups varied considerably. Some areas for improvement emerge: admission processes need to be standardized to avoid urgent admissions and to improve pre-operative care; hospital discharges should be streamlined and discharge reports improved by including all procedures and complications. Some units have parameters which deviate excessively from the norm, and these sites need to review their processes in depth. Coding of diagnoses and comorbidities is another area where improvement is needed.

Pleuroparenchymal Fibroelastosis: A New Entity within the Spectrum of Rare Idiopathic Interstitial Pneumonias.

Pleuroparenchymal fibroelastosis (PPFE) is a rare entity that has been recently included in the official American Thoracic Society/European Respiratory Society (ATS/ERS) statement in 2013 as a group of rare idiopathic interstitial pneumonias (IIPs). PPFE is characterized by pleural and subpleural parenchymal thickening due to elastic fiber proliferation, mainly in the upper lobes. The etiology of the disease is unclear, although some cases have been associated as a complication after bone marrow transplantation, lung transplantation (LT), chemotherapy, and recurrent respiratory infections. The patients usually report progressive dyspnea and dry cough and are predisposed to develop spontaneous or iatrogenic pneumothoraces after surgical lung biopsy (SLB) for its diagnosis. That is why better awareness with the clinical and radiologic features can help optimal management by the multidisciplinary team. Novel invasive techniques such as cryobiopsy may become useful tools in these patients as it could spare SLB. We present the first reported cases in Spain.

Experiencia inicial de un programa de clipaje del sistema nervioso simpático para el tratamiento de la hiperhidrosis y el rubor facial / Initial experience of a program of clipping the sympathetic nervous system for the treatment of hyperhidrosis and facial flush

Introducción y objetivo Evaluar los resultados de nuestro programa de clipaje del sistema nervioso torácico simpático (SNTS) para el tratamiento del rubor facial y/o hiperhidrosis (HH) y comparar la metodología-resultados de la fase de desarrollo del programa (A: enero 2007-abril 2009) y la fase de consolidación del mismo (B: mayo 2009-marzo 2010).Población y métodos Se ha incluido a 44 pacientes (88 procedimientos) sometidos a clipaje videotoracoscópico del SNTS en régimen de cirugía mayor ambulatoria (CMA). Los datos fueron recogidos prospectivamente y analizados retrospectivamente. Se ha realizado estudio estadístico descriptivo y comparativo entre los 2 grupos. Resultados La morbilidad global fue de 5 casos (11,3%). La tasa de recidiva postquirúrgica de HH fue del 4,54% (2 casos), la incidencia de sudoración compensadora (SC) fue del 65,9% (mínima en 26 de los 29 casos). Al comparar el período B con el A, se aprecia: disminución significativa del tiempo quirúrgico, desaparición de la recidiva de HH, disminución de la morbilidad en un 30%, reducción a la mitad de la incidencia de SC moderada-severa e incremento del grado de satisfacción. En uno de los casos de SC mal tolerada se retiraron los clips consiguiéndose la desaparición de esta. Conclusiones El clipaje del SNTS es una técnica segura en régimen de CMA, con una curva de aprendizaje corta (20 casos) tras la cual se obtienen resultados equiparables o, incluso mejores, que los de la simpaticolisis. Estos resultados, junto a su potencial reversibilidad, la convierten, en nuestra opinión, en la técnica de elección en la cirugía del SNTS (AU)

Introduction and objective: To evaluate the results of our program of clipping the thoracicsympathetic nervous system (TSNS) for the treatment of facial (..) (AU)

[Initial experience of a program of clipping the sympathetic nervous system for the treatment of hyperhidrosis and facial flush]. / Experiencia inicial de un programa de clipaje del sistema nervioso simpático para el tratamiento de la hiperhidrosis y el rubor facial.

INTRODUCTION AND OBJECTIVE: To evaluate the results of our program of clipping the thoracic sympathetic nervous system (TSNS) for the treatment of facial flush and/or hyperhidrosis (HH), and to compare the methodology-results of the program development phase (A: January 2007-April 2009) and its consolidation phase (B: May 2009-March 2010). MATERIAL AND METHODS: The program included a total of 44 patients (88 procedures) subjected to videothoracoscopy and clipping of the TSNS in a one day surgery unit. Data were collected and analysed retrospectively, and a descriptive and comparative statistical analysis was performed between the two periods (A and B). RESULTS: The overall morbidity was 5 cases (11.3%). The post-surgical occurrence rate of HH was 4.54% (2 cases), and the incidence of compensatory sweating was 65.9% (minimal in 26 of the 29 cases). On comparing period B with period A, there was a significant decrease in surgical time, disappearance of recurrence of HH, a decrease of 30% in morbidity, reduction by half in the incidence of moderate to severe compensatory sweating, and an increase in the level of satisfaction. The clamps were removed in one of the poorly tolerated compensatory sweating cases, resulting in its disappearance. CONCLUSIONS: Clipping the TSNS is a safe technique in the one day surgery unit, with a short learning curve (20 cases) after which comparable, or even better, results are obtained than those of sympatholysis. These results, together with their potential reversibility, makes it, in our opinion, the technique of choice in the surgery of the TSNS.

Utilidad de una consulta monográfica de diagnóstico rápido de cáncer de pulmón. Aportaciones de la ecobroncoscopia / Usefulness of a Lung Cancer Rapid Diagnosis Specialist Clinic. Contribution of Ultrasound Bronchoscopy

ObjetivoAnalizar los resultados conseguidos en diagnóstico y estadificación del cáncer de pulmón (CP) por una unidad de diagnóstico rápido de cáncer de tórax (UDR-CT) que incorpora la ultrasonografía endobronquial con punción transbronquial aspirativa en tiempo real (USEB-PTBA-tr) a la evaluación clínica del paciente previa al tratamiento.MétodoSe ha realizado un estudio observacional del conjunto de pacientes valorados por sospecha diagnóstica de CP en una UDR-CT durante cuatro años, registrando los tiempos y la técnica requeridos para el diagnóstico, el tiempo para el tratamiento, y el grado de identificación de enfermedad en estadio inicial.ResultadosSeiscientos setenta y ocho pacientes fueron atendidos en la UDR-CT, en 352 casos el diagnóstico fue confirmado en una o más muestras anatomopatológicas. En 170 pacientes el diagnóstico se obtuvo con biopsias y/o citologías obtenidas por fibrobroncoscopia (48,2%), la USEB-TTBA-rt confirmó la sospecha clínica en 70 pacientes (19,9%). En 280 pacientes afectos de carcinoma de pulmón no célula pequeña (CPNCP) se practicaron 166 USEB-PRBA-tr de estadificación (59,3%) y en 105 de ellos la técnica mostró únicamente enfermedad local (37,5%). En 83 de estos pacientes se procedió a cirugía terapéutica, que fue radical en 73 casos (87,9%).ConclusiónEn la mitad de pacientes remitidos a la UDR-CT por sospecha de CP el diagnóstico se confirma, por técnicas endoscópicas en tres cuartas partes de los casos. La USEB-TTBA-rt es la técnica diagnóstica en una quinta parte de los casos y de estadificación en más de la mitad de ellos, y permite reducir los tiempos de espera hasta el diagnóstico y el inicio de tratamiento(AU)

ObjectiveTo analyse the results obtained in the diagnosis and staging of lung cancer (LC) by a Lung Cancer Rapid Diagnosis Unit (LC-RDU) in which real]time endobronchial ultrasound-guided transbronchial needle aspiration (RT-EBUS guided-TBNA) is performed as part of the clinical evaluation of the patient prior to treatment.MethodA four year observational study was conducted on a group of patients evaluated due to suspicion of LC in an LC-RDU. The times and the techniques required for the diagnosis and identifying the level of the disease in the initial staging were recorded.ResultsOut of a total of 678 patients seen in the LC-RDU, the diagnosis in 352 was confirmed in one or more histopathology samples. In 170 patients (48.2%) the diagnosis was made with biopsies and/ or cytology samples obtained by fibrobronchoscopy, and RT-EBUS guided-TBNA confirmed the clinical suspicion in 70 patients (19.9%). In the 280 patients with SCLC, 166 RT-EBUS guided-TBNA were performed for staging (59.3%), and in 105 of them the technique only showed local disease (37.5%). Therapeutic surgery was performed on 83 of these patients, and was radical in 73 cases (87.9%).ConclusionIn half of the patients referred to the LC-RDU due to suspected LC, the diagnosis was confirmed in 75% of cases using endoscopic techniques. RT-EBUS guided-TBNA was the diagnostic technique in 20% of the cases, for staging in more than half of them, and led to reduced waiting times for the diagnosis and starting treatment(AU)

[Usefulness of a lung cancer rapid diagnosis specialist clinic. Contribution of ultrasound bronchoscopy]. / Utilidad de una consulta monográfica de diagnóstico rápido de cáncer de pulmón. Aportaciones de la ecobroncoscopia.

OBJECTIVE: To analyse the results obtained in the diagnosis and staging of lung cancer (LC) by a Lung Cancer Rapid Diagnosis Unit (LC-RDU) in which real-time endobronchial ultrasound-guided transbronchial needle aspiration (RT-EBUS guided-TBNA) is performed as part of the clinical evaluation of the patient prior to treatment. METHOD: A four year observational study was conducted on a group of patients evaluated due to suspicion of LC in an LC-RDU. The times and the techniques required for the diagnosis and identifying the level of the disease in the initial staging were recorded. RESULTS: Out of a total of 678 patients seen in the LC-RDU, the diagnosis in 352 was confirmed in one or more histopathology samples. In 170 patients (48.2%) the diagnosis was made with biopsies and/ or cytology samples obtained by fibrobronchoscopy, and RT-EBUS guided-TBNA confirmed the clinical suspicion in 70 patients (19.9%). In the 280 patients with SCLC, 166 RT-EBUS guided-TBNA were performed for staging (59.3%), and in 105 of them the technique only showed local disease (37.5%). Therapeutic surgery was performed on 83 of these patients, and was radical in 73 cases (87.9%). CONCLUSION: In half of the patients referred to the LC-RDU due to suspected LC, the diagnosis was confirmed in 75% of cases using endoscopic techniques. RT-EBUS guided-TBNA was the diagnostic technique in 20% of the cases, for staging in more than half of them, and led to reduced waiting times for the diagnosis and starting treatment.

Pseudotumor associated with polytetrafluoroethylene sleeves.

We report the case of a patient who was operated on in February 2001. We performed a wedge resection of the upper right lobe. The pathologic examination demonstrated a lung adenocarcinoma (pT2N0M0, R0). We used staple line reinforcement material (ePTFE) during the operation because the patient had an important emphysema. We re-operated in January 2005 because during follow-up we observed a suspicious image that suggested a tumoral relapse. Histopathological study showed extrinsic material compatible with the one used in the original resection.