[Effectiveness and complications of video-assisted surgery for primary spontaneous pneumothorax]. / Eficacia y morbilidad del tratamiento con cirugía videoasistida del neumotórax espontáneo primario.

OBJECTIVE: To assess the effectiveness and describe the complications of video-assisted thoracoscopic surgery (VATS) for the treatment of primary spontaneous pneumothorax. PATIENTS AND METHODS: Between May 1997 and September 2003, our department scheduled 147 VATS procedures for spontaneous pneumothorax in 127 patients (102 men [80.5%]). The mean (SD) age for the series was 28.3 (11.6) years. Bullae and blebs were resected by endostapler and vigorous pleural abrasion was carried out. Vanderschueren staging was as follows: stage I, 10 (6.8%); stage II, 22 (15%); stage III, 71 (48.3%); and stage IV, 44 (29.9%). The procedure was indicated for the following reasons: third episode, 56 (38.1%); persistent air leak, 47 (32%); elective, 16 (10.9%); simultaneous bilateral pneumothorax, 28 (19%). VATS was performed on the right side only in 85 patients (57.8%), on the left in 62 (42.2%), and on both sides in 16 (11.6%). RESULTS: A total of 137 of the 147 VATS procedures scheduled (93.2%) were performed, and there were no deaths. The rate of conversion to thoracotomy was 6.8%, and the overall rate of complications was 13.7%. Postoperative complications were due to bleeding in 5 cases (3.6%), air leak (>5 days) in 10 (7.2%), wound infection in 2 (1.4%), residual pneumothorax in 4 (2.9%), need to insert a new pleural drain in 3 (2.1%), and pleural empyema in 1 (0.7%). Two patients took oral analgesics for more than 30 days after the procedure. Pneumothorax recurred during follow-up in 7 patients (5.1%). No significant correlation was found between recurrence of pneumothorax after VATS and Vandeschueren stage, age, bilaterality of the procedure, indication, or days of postoperative drainage (P>.05). CONCLUSIONS: VATS for resection of pleural lesions plus pleural abrasion is an efficacious and simple treatment for primary spontaneous pneumothorax regardless of intraoperative findings.

[Risk factors for atrial fibrillation after thoracic surgery]. / Factores de riesgo en el desarrollo de fibrilación auricular tras cirugía torácica.

OBJECTIVE: To determine the risk factors for atrial fibrillation after lung resection. PATIENTS AND METHODS: Between January 2002 and December 2003, 149 patients underwent lung resection in our hospital. For all these patients, clinical, surgical, analytical, and oncological data were prospectively collected. The data were subjected to univariate analysis. RESULTS: The mean (SD) age of the 127 men (85.2%) and 22 women (14.8%) who underwent lung resection was 61.8 (12.3) years (range, 17-79 years). Atrial fibrillation was documented in 17 patients (11.4%). Mortality at 30 days was 8.1%. The following risk factors for atrial fibrillation were identified: age 70 years or older (P<.0004), prior heart disease (P<.005), patients undergoing operations for lung cancer (P<.04), and type of resection--right bilobectomy (P<.05) and left pneumonectomy (P<.03). Hypertension, chronic obstructive pulmonary disease, and lung cancer stage were not risk factors. Likewise, systematic lymph node dissection and other forms of lung resection were not risk factors. CONCLUSIONS: After lung resection, atrial fibrillation is a common complication that seems to be associated with old age, history of heart disease, operations for lung cancer, left pneumectomy, and right bilobectomy. The identification of these risk factors may encourage prospective studies that assess the use of antiarrhythmic drugs to prevent atrial fibrillation during chest surgery.

[Medical and surgical management of noniatrogenic traumatic tracheobronchial injuries]. / Manejo médico-quirúrgico de las lesiones traqueobronquiales traumáticas no iatrogénicas.

OBJECTIVE: To describe the medical and surgical management of noniatrogenic traumatic tracheobronchial injuries. PATIENTS AND METHOD: From January 1993 to July 2004, 15 cases of traumatic tracheobronchial injury were treated in our department. The diagnosis was established by bronchoscopy and a computed tomography chest scan was performed on all patients. Surgical treatment was selected for patients with unstable vital signs, an open tracheal wound, associated esophageal lesions, progression of subcutaneous or mediastinal emphysema, mediastinitis or suspicious mediastinal secretions on imaging tests, or difficulties with mechanical ventilation due to the traumatic tracheobronchial injury. RESULTS: The mean (SD) age of the patients was 35.5 (18.9) years and 12 (80%) were male. Of the 15 cases, 13 (86.7%) had penetrating trauma and 2 (13.3%) blunt trauma. The most common location of the injury was in the bronchi (9 cases; 60%), followed by the cervical trachea (4 cases; 26.6%), followed by both the thoracic trachea and bronchi (2 cases; 13.4%). The most common initial symptom was subcutaneous emphysema, which presented in 11 (73.3%) patients. Chest (12 cases; 86.7%) and orthopedic injuries (9 cases; 60%) were the most common associated injuries. Surgery was the treatment of choice in 11 (73.3%) cases and conservative medical treatment in 4 (26.7%). An irreversible brain injury caused the death of 1 patient receiving conservative treatment. CONCLUSIONS: Tracheobronchial injuries may be treated conservatively if they meet strict selection criteria. Size and location should not be used as selection criteria for surgical treatment.

Acromegaly and bronchial carcinoid. Effect of removal of the latter.

A patient with a long-standing history of bronchial carcinoid and acromegaly was studied. There was pituitary enlargement with an intrasellar mass (brain computed tomography scan), high basal GH levels, and abnormal GH and other pituitary hormones response to oral glucose and a combined test (LHRH, TRH, insulin). After resection of the bronchial carcinoid, basal GH was normal, GH was normally suppressed during OGTT, pituitary function was within expected normal range, and there was regression of the pituitary tumor together with clinical improvement. These data suggest that the patient's acromegaly was secondary to pituitary stimulation due to the bronchial carcinoid.

Long tracheobronchial and esophageal rupture after blunt chest trauma: injury by airway bursting.

Tracheobronchial rupture can be associated with blunt thoracic trauma. An important factor in the physiopathology of these lesions is reflex closure of the glottis, which can be related to closed chest trauma. We report a case of nonpenetrating thoracic trauma that caused a long membranous tracheal rupture from the subcricoid area to the main carina, extending to both main bronchi. In addition, a complex esophageal rupture occurred due to the great energy liberated by the airway rupture acting as a real tracheal burst. Both lesions were diagnosed by flexible bronchoscopy. The postoperative period was without serious complications.

Conservative and bronchoplastic resection for bronchial carcinoid tumours.

From January 1974 to December 1987, 45 cases of bronchial carcinoid were surgically managed at our Unit, 44 of which were evaluated. All patients but 2 were submitted to fiberoptic bronchoscopy prior to surgery. A standard resection was performed in 19 cases (13 lobectomies, 4 bilobectomies and 2 pneumonectomies). In 11 cases, pulmonary resection was complemented with a bronchoplastic technique (6 lobectomies, 2 bilobectomies, 2 pneumonectomies, 1 segmentectomy). Four cases were managed by minimal resections (2 segmental, 1 wedge, 1 enucleation) and 8 others by bronchotomy and local resection without the sacrifice of lung tissue. There were two major postoperative complications and no operative mortality. Mean follow-up has been 53 months and no local bronchial recurrence has been observed although 2 patients have developed distant metastases, with 1 death. The absence of local recurrence in a series in which more than 50% of patients were treated with some form of conservative surgery seems to indicate that resection of lung tissue should be avoided whenever possible.

Successful management of a tracheo-innominate artery fistula following placement of a wire self-expandable tracheal Gianturco stent.

The authors report a case of tracheo-innominate artery fistula secondary to tracheal perforation in an 18-year-old patient who is tetraplegic following cervical trauma. The patient had a very long tracheal stenosis, secondary to tracheostomy, which was managed by laser resection and a Gianturco stent. One of the anterior struts of the stent had eroded the trachea and the posterior wall of the innominate artery. Surgical management consisted of arterial resection, a longitudinal tracheal split incision to withdraw the stent and placement of a Montgomery T-tube. The patient has no respiratory discomfort 7 months after surgery.

[Octreotide for conservative management of postoperative chylothorax]. / Tratamiento conservador con octreótido del quilotórax posquirúrgico.

Postoperative chylothorax after lung resection is a major problem leading to morbidity and mortality and requiring reoperation in a large number of cases. The most advisable and least aggressive option is conservative management in progressive stages: a diet rich in medium-chain fatty acids and/or total parenteral nutrition, in addition to chest tube drainage. Including octreotide in this regimen seems to be related to a higher success rate without the need for surgery. We report a case in which the effectiveness and safety of octreotide in the resolution of postoperative chylothorax was excellent.

[Delays in the diagnosis and surgical treatment of bronchogenic carcinoma. Cooperative Group on Bronchogenic Carcinoma of SEPAR (GCCB-S)]. / Demoras en el diagnóstico y en el tratamiento quirúrgico del carcinoma broncogénico. Grupo Cooperativo de Carcinoma Broncogénico de SEPAR (GCCB-S).

The aim of this study was to determine the delay between clinical suspicion and diagnosis of bronchogenic carcinoma, and between diagnosis and performance of therapeutic thoracotomy. The study population included 598 patients undergoing surgery between October 1995 and September 1996 registered in the Bronchogenic Carcinoma Cooperation Group of SEPAR (BCCG-S), and 49 patients from our hospital undergoing surgery during the same period. The mean delay between diagnosis and thoracotomy was 45.15 days (SD 34.7 days) for BCCG-S patients and 53.5 days (SD 22 days) for our hospital patients. In the second group, mean time elapsing between diagnosis suspicion and performance of bronchoscopy was known to be 9.5 days (SD 14.7 days), with the lowest periods recorded for inpatients (3.1 +/- 1.7 days) and for patients who did not require chest x ray guided bronchoscopy (5 +/- 5.8 days). These data are similar to those published for hospitals in other countries. They must be considered long delays and should be shortened.