Nonintubated Video-Assisted Wedge Resections in Peripheral Lung Cancer.

Wedge resection in peripheral lung cancer is considered a suboptimal procedure. However, in elderly and/or frail patients it is a reliable and safer alternative. This procedure can be easily performed under nonintubated anesthesia, allowing the recruitment of patients considered otherwise marginal for a surgical treatment. Nonintubated anesthesia can reduce lung trauma, operative time, postoperative morbidity, hospital stay, and global expenses. Furthermore, nonintubated anesthesia produces less immunologic impairment and this may affect postoperative oncological long-term results. Wedge lung resection through nonintubated anesthesia can be performed for diagnosis with higher effectiveness given the similar invasiveness of computed tomography-guided biopsy.

Abordaje quirúrgico del carcinoma broncogénico de células no pequeñas con metástasis extrapulmonar / Surgical approach of non-small cell lung cancer with extrapulmonary metastasis

El carcinoma broncogénico es la causa más frecuente de muerte por cáncer en el mundo. Cerca del 75% de los pacientes presentan enfermedad diseminada en el momento del diagnóstico. Hasta un 50% de los pacientes con enfermedad localizada al inicio desarrollarán metástasis. Sin embargo, la evidencia científica actual ha demostrado que, cuando la enfermedad metastásica es limitada y sobre todo en determinadas localizaciones como la cerebral y la suprarrenal, su abordaje multidisciplinar con intención radical puede prolongar la supervivencia. El presente artículo revisa la evidencia clínica bibliográfica existente que apoya el tratamiento, no solo de la enfermedad primaria sino de la metastásica, además del estudio preoperatorio y las indicaciones más aceptadas

Bronchogenic carcinoma is the leading cause of death due to cancer worldwide. Nearly 75% of patients have a disseminated carcinoma at diagnosis. Up to 50% of patients with a localized disease will develop metastasis. Nevertheless, the current scientific evidence has demonstrated that when the metastatic disease is limited, particularly in specific locations such as the brain and the adrenal glands, a multidisciplinary approach with radical intent could achieve a longer survival. This review analyses the clinical evidence available in the literature that supports the treatment of both the primary and the metastatic disease, as well as the preoperative study and the most widely accepted indications

Unplanned readmission after lung resection surgery: A systematic review. / Reingreso no planificado tras cirugía de resección pulmonar: revisión sistemática.

Urgent readmissions have a major impact on outcomes in patient health and healthcare costs. The associated risk factors have generally been infrequently studied. The main objective of the present work is to identify pre- and perioperative determinants of readmission; the secondary aim was to determine readmission rate, identification of readmission diagnoses, and impact of readmissions on survival rates in related analytical studies. The review was performed through a systematic search in the main bibliographic databases. In the end, 19 papers met the selection criteria. The main risk factors were: sociodemographic patient variables; comorbidities; type of resection; postoperative complications; long stay. Despite the great variability in the published studies, all highlight the importance of reducing readmission rates because of the significant impact on patients and the healthcare system.

[Clinical application of high frequency jet ventilation in cryotherapy for tracheo-bronchial carcinoma via rigid bronchoscopy].

Objective: To analyze the clinical applications of high frequency jet ventilation(HFJV) in cryotherapy of the trachea and bronchial neoplasms by the rigid bronchoscope. Methods: The clinical data of 35 patients who were treated with tracheal neoplasms cryotherapy by the rigid bronchoscopy under HFJV were collected in China-Japan Friendship Hospital from August 2008 to February 2015.Under general anesthesia, HFJV was used in all patients. The mean arterial pressure (MAP), heart rates (HR), pulse oxygen saturation (SpO(2)), results of arterial blood gas analysis and the incidence of complications during the procedure were recorded. Results: In the 35 patients, one case had multiple operations experience, he had an airway spasm after HFJV 40 min during his second operation, and severe hypoxemia after HFJV 5 min during his third operation, endotracheal intubation was performed immediately. The patient has a serious accumulation of carbon dioxide (CO(2)) whose partial pressure of carbon dioxide in the artery (PaCO(2)) was up to 71 mmHg(1 mmHg=0.133 kPa). Other patients had stable hemodynamics and no severe CO(2) accumulation. Conclusion: High frequency jet ventilation can provide satisfactory ventilation effect in cryotherapy of the trachea and bronchial end-stage neoplasms by the rigid bronchoscope.

Diagnosis and Treatment of Three Cases of Bronchial Carcinoma In Situ.

As part of a retrospective study on bronchoscopies performed at the Clinic of Pneumonology and Phthisiatry of the University Hospital - Pleven by autofluorescence bronchoscopy we found 3 cases diagnosed with carcinoma in situ. They were treated in different ways - endobronchial electrocoagulation, extraction by forceps biopsy and open surgery, but the result was the same - clinical healing. The paper presents the three clinical cases and the analysis of the treatment.

The erector spinae plane block in 4 cases of video-assisted thoracic surgery. / Bloqueo del plano del músculo erector de la columna en 4 casos de cirugía torácica videoasistida.

Multimodal anaesthesia, combining epidural catheter and general anaesthesia, is a common technique in thoracic surgery, however, epidural catheter placement is not always possible. Recently, erector spinae plane block has been described, which provides analgesia like that of the epidural block, although unilateral, and which has been used in various procedures at thoracic level. At present, there are no studies comparing the efficacy or safety of this block with those commonly used in thoracic surgery. However, its safety profile and contraindications seem different from those of the epidural catheter, since its placement is done under ultrasound view, the needle introduction is done in plane and the ultrasound target, the transverse process, is easily identifiable and is relatively remote from major neural or vascular structures and the pleura. Unlike other blockages made by anatomical references, erector spinae plane block can be done with the patient in different positions. We describe our experience with erector spinae plane block as part of a multimodal anaesthetic approach in thoracic surgery.

Influence of nodal status on the surgical outcome for bronchogenic carcinoma involving the carina: a systematic review and meta-analysis.

INTRODUCTION: Bronchogenic carcinomas involving the carina or the tracheo-bronchial angle represents a challenging surgical procedure because of difficult surgical techniques and complex ventilation procedures. Even though surgical outcomes for this type of procedure has improved over time, the need for surgical management of patients with metastatic mediastinal nodes, that is those that are graded N2 or higher according to the TNM classification, is still controversial. EVIDENCE ACQUISITION: We searched PubMed, Embase, and CNKI for literature in English or Chinese reporting on this subject, with information on survival rates or survival curves for groups with different grades of nodal status. We then performed a meta-analysis by grouping N0 and N1 patients and compared the surgical outcomes to those graded as N2 or higher. Hazard Ratios for each study were derived from the Kaplan-Meier survival curve. EVIDENCE SYNTHESIS: Seven studies were included in this meta-analysis. The calculated hazard ratios ranged from 0.146 to 0.455. The weighted average hazard ratio for the N0/N1 group as compared to the N2/N3 group was 0.261 (CI: 0.154-0.441). The Galbraith plot confirmed the homogeneity of the studies included. CONCLUSIONS: Carinal resection and reconstruction remains a challenging surgical procedure and the rather poor surgical outcomes for patients graded as N2 or higher, according to nodal involvement points to the fact that better pre-operative management is required in terms of tumor grading, induction chemotherapy and radiotherapy to decrease the risks associated with metastatic mediastinal nodal status.

Is age a predisposing factor of postoperative complications after lung resection for primary pulmonary neoplasms? / ¿Es la edad un factor predisponente de complicaciones postoperatorias en las resecciones pulmonares por neoplasias pulmonares primarias?

INTRODUCTION: Age has been classically considered as a determining factor for the development of postoperative complications related to lung resection for bronchogenic carcinoma. The Postoperative Complications Study Group of the Spanish Society of Thoracic Surgery has promoted a registry to analyze this factor. METHODS: A total of 3,307 patients who underwent any type of surgical resection for bronchogenic carcinoma have been systematically and prospectively recorded in any of the 24 units that are part of the group. Several variables related to comorbidity and age, as well as postoperative complications, were analyzed. RESULTS: The mean age of patients was 65,44. Men were significantly more common than female. The most frequent complication was prolonged air leak, which was observed in more than one third of patients. In a univariant analysis, air leak presence and postsurgical atelectasis showed statistical association with patient age, when stratified in age groups. In a multivariate analysis, age was recognized as an independent prognostic factor in relation to air leak onset. However, this could not be confirmed for postoperative atelectasis. CONCLUSION: Age is a predisposing factor for the development of postoperative complications after lung resection. Other associated factors also influence the occurrence of these complications.

Es la edad un factor predisponente de complicaciones postoperatorias en las resecciones pulmonares por neoplasias pulmonares primarias / Is age a predisposing factor of postoperative complications after lung resection for primary pulmonary neoplasms?

INTRODUCCIÓN: La edad del paciente ha sido clásicamente interpretada como un factor condicionante de la aparición de complicaciones postoperatorias en cirugía de resección pulmonar por carcinoma broncogénico. El Grupo de Estudio de Complicaciones Postoperatorias de la Sociedad Española de Cirugía Torácica promovió un registro que permitiera analizar este hecho. MÉTODOS: Se recogieron de forma consecutiva, sistemática y prospectiva los datos de un total de 3.307 pacientes tratados con algún tipo de resección quirúrgica por carcinoma broncogénico en las 24 unidades que forman parte del grupo. Fueron analizadas variables relativas a la comorbilidad y la edad del paciente, así como a las complicaciones postoperatorias acaecidas. RESULTADOS: La edad media de los pacientes intervenidos fue de 65,44 años. La población masculina en la serie era significativamente mayor que la femenina. La complicación más frecuente fue la fuga aérea prolongada, que ocurrió en más de un tercio de los pacientes. En el estudio univariante, la aparición de fugas aéreas y de atelectasias posquirúrgicas mostraron asociación estadística con la edad de los enfermos, analizada por grupos etarios. En el análisis multivariante, la edad se presentó como un factor pronóstico independiente en relación con la aparición de fugas aéreas posquirúrgicas, no así en cuanto a las atelectasias posresección. CONCLUSIÓN: La edad es un factor predisponente para el desarrollo de complicaciones postoperatorias tras resección pulmonar en nuestro medio, si bien otros factores asociados condicionan también la aparición de estas complicaciones

INTRODUCTION: Age has been classically considered as a determining factor for the development of postoperative complications related to lung resection for bronchogenic carcinoma. The Postoperative Complications Study Group of the Spanish Society of Thoracic Surgery has promoted a registry to analyze this factor. METHODS: A total of 3,307 patients who underwent any type of surgical resection for bronchogenic carcinoma have been systematically and prospectively recorded in any of the 24 units that are part of the group. Several variables related to comorbidity and age, as well as postoperative complications, were analyzed. RESULTS: The mean age of patients was 65,44. Men were significantly more common than female. The most frequent complication was prolonged air leak, which was observed in more than one third of patients. In a univariant analysis, air leak presence and postsurgical atelectasis showed statistical association with patient age, when stratified in age groups. In a multivariate analysis, age was recognized as an independent prognostic factor in relation to air leak onset. However, this could not be confirmed for postoperative atelectasis. CONCLUSION: Age is a predisposing factor for the development of postoperative complications after lung resection. Other associated factors also influence the occurrence of these complications

Trombosis del muñón de la arteria pulmonar en paciente con neumonectomía derecha complicada con fístula broncopleural / Pulmonary artery stump thrombus in a patient with right pneumonectomy complicated by bronchopleural fistula

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Spontaneous right whole-lung torsion secondary to bronchial carcinoma: a case report.

BACKGROUND: Spontaneous whole lung torsion is an absolut rarity and most cases occur after previous surgery. CASE PRESENTATION: We present the case of a spontaneous whole-lung torsion in a 82-year old man. The patient was referred to our thoracic surgery department from the emergency department of a referring hospital with rapidly progressive dyspnea. CT-scan revealed a 180° degree counterclockwise torsion of the entire right lung with complete atelectasis and congestion of the upper lobe as well as pleural effusion. Thoracoscopy confirmed lung torsion and revealed hemorrhagic infarction of the upper lobe. Subsequently thoracotomy and upper lobectomy were performed. Most likely the lung torsion occurred due to a combination of pleural effusion and venous congestion with complete atelectasis of the upper lobe as a result of adenocarcinoma of the upper lobe. CONCLUSIONS: To our knowledge this is the first reported case of a patient presenting with lung torsion as the first symptom of lung cancer. When lung torsion is suspected rapid diagnosis is crucial in order to prevent hemorrhagic lung infarction.

Resultados de la resección pulmonar infralobar, comparada con la lobectomía, en el tratamiento quirúrgico del carcinoma broncogénico en estadio precoz / Outcomes of sublobar resection, compared with lobectomy, in the surgical management of early stage non-small cell lung cancer

OBJETIVOS: la resección infralobar (RI) en el carcinoma broncogénico de célula no pequeña (CBCNP) en estadio precoz está ganando popularidad. Sin embargo, la cantidad óptima de parénquima pulmonar a resecar sigue siendo objeto de controversia. Analizamos si la RI difiere de la lobectomía (L) como tratamiento quirúrgico estándar de los pacientes con CBCNP en estadio precoz. MÉTODOS: se analizaron 493 resecciones pulmonares consecutivas realizadas en un periodo de 14 años. 266 pacientes con CBCNP en estadio I fueron sometidos a una lobectomía (L = 178), o a una resección pulmonar atípica/segmentectomía (RI = 88). Se compararon factores demográficos, oncológicos, quirúrgicos y postoperatorios. RESULTADOS: no se observaron diferencias en las características de los pacientes, la mortalidad perioperatoria o la tasa de complicaciones. En los pacientes con CBCNP en estadio I (n = 266) la tasa de recurrencia loco-regional (RI vs L): 14% vs 16% (p = 0,06), metástasis a distancia: 8% vs 9% (p = 0,33), supervivencia (a los 3, 5 años): 78%, 74% vs 74%, 69% (p = 0,37), supervivencia libre de enfermedad (a los 3, 5 años): 82%, 36% vs 80%, 56% (p = 0,93), supervivencia libre de metástasis a distancia (a los 3, 5 años): 90%, 80% vs 86%, 83% (p = 0,73). Complicaciones postquirúrgicas: 30% vs 36% (p = 0,21), mortalidad perioperatoria: 2% vs 5% (p = 0,64). CONCLUSIONES: la resección pulmonar infralobar posee unas tasas aceptables de morbimortalidad y puede ser equivalente a la lobectomía, desde el punto de vista oncológico, en el CBCNP en estadio I

OBJECTIVE: sublobar resection (SLR) for early stage NSCLC is gaining acceptance in the recent years, especially in aging population or with decreased pulmonary function. The optimal extent of surgical resection in stage I NSCLC remains controversial. This study was designed to determine whether SLR differs from lobectomy (L) as the standard of care for the surgical treatment of patients with early stage NSCLC. METHODS: we retrospectively reviewed 493 consecutive lung resections performed over a 5-year period at a single center. A total of 266 patients with NSCLC underwent either lobectomy (L Group: 178 patients), or wedge/segmentectomy (SLR Group: 88 patients) for stage I NSCLC. Demographic, oncological, surgical and postoperative variables were compared between groups. RESULTS: overall, no differences were observed between SLR and L in patient characteristics, 30-day mortality and complications. In stage I patients (n = 266), local recurrence (SLR vs L): 14% vs 16% (p = .06), distant recurrence: 8% vs 9% (p = .33), survival (at 3, 5 years): 78%, 74% vs 74%, 69% (p = .37), local disease-free survival (at 3, 5 years): 82%, 36% vs 80%, 56% (p = .93), distant disease-free survival (at 3, 5 years): 90%, 80% vs 86%, 83% (p = .73). Postoperative complications: 30% vs 36% (p = .21), 30-day mortality: 2% vs 5% (p = .64). CONCLUSION: sublobar resection has acceptable morbidity and mortality rates, and could be oncologically equivalent to lobectomy in stage I NSCLC

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

Bronchogenic cancer: It still exists.

OBJECTIVES/HYPOTHESIS: Branchial cleft cysts rank among the most common differential diagnoses of cystic cervical masses. Rarely, classic cystic structures exhibit a squamous cell carcinoma differentiation that represents a bronchogenic carcinoma. The existence of bronchogenic carcinoma is controversial due to the lack of systematic immunohistologic workup. The present study aimed to identify the clinical and immunohistologic features of bronchogenic carcinoma to clearly distinguish this entity from other cystic cervical masses. METHODS: Immunohistologic (epidermal growth factor receptor; cytokeratin 5, 6, 7, 13; and p16) and epidemiologic assessments were performed for branchial cleft cysts (n = 63), bronchogenic carcinomas (n = 5), cystic metastasized oropharyngeal carcinomas (n = 97), and carcinomas of unknown primary (n = 51). The study was conducted as a retrospective case series study with comparison. RESULTS: The patients with bronchogenic carcinomas differed significantly in age and in the number of involved lymph nodes compared with the cystic metastasized oropharyngeal carcinoma (and carcinoma of unknown primary) patients. Regular histologic wall structures were only observed in the bronchogenic carcinomas and branchial cleft cysts. Solitary cytokeratin-7 staining was only observed in the bronchogenic carcinomas, and all of the bronchogenic carcinomas were p16 negative. CONCLUSIONS: The existence of bronchogenic carcinoma seems to be plausible based on clinical findings. Cytokeratin-7 and p16 staining might be helpful in the diagnostic workflow. LEVEL OF EVIDENCE: 4 Laryngoscope, 126:638-642, 2016.

Cirugía incompleta del carcinoma adenoide quístico bronquial: una alternativa terapéutica / Incomplete surgery for bronchial cystic adenoid carcinoma: A therapeutic alternative

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Bronchial carcinoid tumors: A rare malignant tumor.

Bronchial carcinoid tumors (BCTs) are an uncommon group of lung tumors. They commonly affect the young adults and the middle aged, the same age group affected by other more common chronic lung conditions such as pulmonary tuberculosis. Diagnosis is commonly missed or delayed due to a low index of suspicion. Surgery is the mainstay of treatment with an excellent outcome. There are many reports of this rare group of tumors in the Western and Asian regions. The only report around our sub-region is a post mortem report of an atypical variant. We wish to report a case of the typical variant and increase our index of suspicion. A 25-year-old male presented with a 4 years history of cough and haemoptysis. He was repeatedly treated for bronchial asthma and pulmonary tuberculosis with no improvement of symptoms. Chest X-ray and chest computed tomography scan revealed a left upper lobe tumor. Histology reported a typical variant of BCT which was confirmed by immunohistochemistry. He had a left upper lobectomy and has done excellently well thereafter. A high index of suspicion is needed to reduce the risk of missing or delaying the diagnosis.

Single-stage bilateral thoracic surgery via a combined VATS and open approach for left central bronchogenic carcinoma with carinal invasion: report of two cases.

BACKGROUND: Surgery for patients with left central bronchogenic carcinoma invading the carina is challenging due to the complexity of left sleeve pneumonectomy, carinal resection, and airway reconstruction and management. Here we describe a modified approach to overcome this problem. CASE PRESENTATION: Between March 2011 and September 2012, two patients with left central bronchogenic carcinoma invading the carina underwent single-stage bilateral thoracic surgery via a combined approach incorporating video-assisted thoracic surgery (VATS) and thoracotomy in our hospital. We reviewed our experience with this type of surgery and analyze its outcomes. CONCLUSIONS: Single-stage, bilateral thoracic surgery incorporating video assisted thoracic surgery (VATS) and thoracotomy provides optimal exposure of the operative field, reduces surgical trauma, and ensures the integrity of tumor excision and exactness of tracheobronchial anastomosis. This may be a safe and feasible alternative for left carinal pneumonectomy.