Guía de práctica clínica de la SECT sobre el manejo de pacientes con neumotórax espontáneo / SECT Clinical practice guideline on the management of patients with spontaneous pneumothorax

Esta guía de práctica clínica (GPC) surge como iniciativa del comité científico de la Sociedad Española de Cirugía Torácica. Para elaborar dicha GPC se han formulado las preguntas PICO (paciente, intervención, comparación y outcome o variable resultado) sobre distintos aspectos del neumotórax espontáneo. Para la evaluación de la calidad de la evidencia y elaboración de las recomendaciones se han seguido las directrices del grupo de trabajo Grading of Recommendations, Assessent, Development and Evaluation (GRADE).(AU)

This clinical practice guideline (CPG) emerges as an initiative of the scientific committee of the Spanish Society of Thoracic Surgery. We formulated PICO (patient, intervention, comparison, and outcome) questions on various aspects of spontaneous pneumothorax. For the evaluation of the quality of evidence and preparation of recommendations we followed the guidelines of the Grading of recommendations, Assessment, Development and Evaluation (GRADE) working group.(AU)

[Sleeve lobectomy compared to pneumonectomy for the treatment of N0-N1 non-small cell lung cancer]. / La lobectomía broncoplástica frente a la neumonectomía en el tratamiento del carcinoma de pulmón no microcítico.

OBJECTIVE: To compare survival, morbidity, and mortality rates for a series of patients who underwent either bronchoplastic sleeve lobectomy or pneumonectomy to treat non-small cell lung cancer (NSCLC). PATIENTS AND METHOD: We reviewed the clinical records for patients who underwent sleeve lobectomy or pneumonectomy for NSCLC from January 1994 through December 2003. RESULTS: From January 1994 through December 2003, 35 sleeve lobectomies and 220 pneumonectomies were performed at our department on patients with NSCLC. The perioperative mortality rate was 2.8% for the lobectomy group and 9.1% for the pneumonectomy group. The mean survival time for the pneumonectomy group was 45 months (95% confidence interval [CI], 37-53), with a 5-year survival rate of 32% (SE, 5.1%). The mean survival time for the sleeve lobectomy group was 72 months (95% CI, 56-87) (P< or =.0041), with a 5-year survival rate of 56% (SE, 9.6%). If we stratify the groups according to node involvement, patients classified as N0-N1 had a mean survival time of 52 months (95% CI, 43-61), with a 5-year survival rate of 39% (SE, 6.2%) for the pneumonectomy group. The mean survival time for patients undergoing sleeve lobectomy was 75 months (95% CI, 59-92) (P< or =.018), with a 5-year survival rate of 60% (SE, 10.4%). Survival for patients with N2 disease was similar to that of patients with N0-N1 disease. CONCLUSION: For patients with N0-N1 non-small cell lung cancer, sleeve lobectomy offers better survival than pneumonectomy.

La lobectomía broncoplástica frente a la neumonectomía en el tratamiento del carcinoma de pulmón no microcítico / Sleeve lobectomy compared to pneumonectomy for the treatment of N0-N1 non-small cell lung cancer

Objetivo: Comparar la supervivencia, morbilidad y mortalidad de una serie de pacientes operados por cáncer de pulmón no microcítico (CPNM) mediante lobectomía broncoplástica o neumonectomía. Pacientes y método: Hemos revisado los datos de pacientes a quienes se realizó una lobectomía broncoplástica o una neumonectomía por CPNM entre enero de 1994 y diciembre de 2003. Resultados: Entre enero de 1994 y diciembre de 2003 se realizaron en nuestra unidad 35 lobectomías con broncoplastia y 220 neumonectomías en pacientes con CPNM. La mortalidad perioperatoria fue del 2,8% en el grupo de las lobectomías y del 9,1% para las neumonectomías. La media de supervivencia de las neumonectomías fue de 45 meses (intervalo de confianza [IC] del 95%, 37-53) y la supervivencia a los 5 años del 32% (error estándar [EE]: 5,1). En el grupo de lobectomías broncoplásticas la media de supervivencia fue de 72 meses (IC del 95%, 56-87) (p ≤ 0,0041) y la supervivencia a los 5 años del 56% (EE: 9,6). Si estratificamos los grupos según la afectación ganglionar, entre los pacientes clasificados como N0-N1 la media de supervivencia fue de 52 meses (IC del 95%, 43-61) y la supervivencia a los 5 años del 39% (EE: 6,2) en las neumonectomías. Los pacientes con lobectomía broncoplástica presentaron una media de supervivencia de 75 meses (IC del 95%, 59-92) (p ≤ 0,018) y la supervivencia a los 5 años del 60% (EE: 10,4). La supervivencia no fue diferente en caso de enfermedad N2. Conclusión: La lobectomía broncoplástica ofrece mejor supervivencia que la neumonectomía en pacientes con CPNM con afectación N0-N1

Objective: To compare survival, morbidity, and mortality rates for a series of patients who underwent either bronchoplastic sleeve lobectomy or pneumonectomy to treat non-small cell lung cancer (NSCLC). Patients and method: We reviewed the clinical records for patients who underwent sleeve lobectomy or pneumonectomy for NSCLC from January 1994 through December 2003. Results: From January 1994 through December 2003, 35 sleeve lobectomies and 220 pneumonectomies were performed at our department on patients with NSCLC. The perioperative mortality rate was 2.8% for the lobectomy group and 9.1% for the pneumonectomy group. The mean survival time for the pneumonectomy group was 45 months (95% confidence interval [CI], 37-53), with a 5-year survival rate of 32% (SE, 5.1%). The mean survival time for the sleeve lobectomy group was 72 months (95% CI, 56-87) (P≤.0041), with a 5-year survival rate of 56% (SE, 9.6%). If we stratify the groups according to node involvement, patients classified as N0-N1 had a mean survival time of 52 months (95% CI, 43-61), with a 5-year survival rate of 39% (SE, 6.2%) for the pneumonectomy group. The mean survival time for patients undergoing sleeve lobectomy was 75 months (95% CI, 59-92) (P≤.018), with a 5-year survival rate of 60% (SE, 10.4%). Survival for patients with N2 disease was similar to that of patients with N0-N1 disease. Conclusion: For patients with N0-N1 non-small cell lung cancer, sleeve lobectomy offers better survival than pneumonectomy

[Agreement between type of lung resection planned and resection subsequently performed on lung cancer patients]. / Concordancia entre el tipo de resección programada y la efectuada en pacientes con carcinoma pulmonar.

OBJECTIVE: To assess agreement between planned lung resections and the type subsequently performed on a series of patients, to assess whether tumor location (central or peripheral) affected the degree of discrepancy, and, in the case of unscheduled pneumonectomies, to examine why the planned resection had to be extended. METHOD: Prospective, observational clinical study of 199 patients scheduled for lung cancer surgery. Tumors were preoperatively classified as central or peripheral, and the type of operation planned--lobectomy (or bilobectomy) or pneumonectomy--was compared with the operation finally performed. Rates of agreement and Wilks' lambda statistic were calculated. RESULTS: Twenty unscheduled pneumonectomies were performed. Agreement between planned and performed operations was found in 86.9% of cases (76.9% in central tumors and 95.4% in peripheral tumors). Wilks' lambda statistic was 0.38 (0.42 for central tumors and 0.17 for peripheral tumors). Seven unscheduled pneumonectomies were performed due to hilar node involvement. CONCLUSIONS: The resections performed differed from the resections initially planned in 13% of the bronchial carcinoma operations, in most cases because the planned lobectomy had to be converted to pneumonectomy, a situation which occurred more often with central tumors and was more often due to direct invasion of anatomic structures rather than hilar spread.

Concordancia entre el tipo de resección programada y la efectuada en pacientes con carcinoma pulmonar / Agreement between type of lung resection planned and resection subsequently performed on lung cancer patients

OBJETIVO: Cuantificar la concordancia entre la cirugía de resección planeada y la efectuada en una serie de pacientes, evaluar si la localización del tumor (central o periférico) influye en el grado de discrepancia encontrado y valorar, en los casos de neumonectomías no programadas, la causa que obligó a ampliar la resección prevista. MÉTODO: Estudio clínico prospectivo observacional en 199 pacientes programados para intervención quirúrgica por cáncer de pulmón. Se clasificaron los tumores preoperatoriamente como centrales o periféricos, y el tipo de intervención programada –lobectomía (o bilobectomía) o neumonectomía– se comparó con la efectuada. Se han calculado las tasas de concordancia y el estadístico lambda. RESULTADOS: Se practicaron 20 neumonectomías no programadas. Se encontró concordancia entre lo programado y lo efectuado en el 86,9% de los casos (un 76,9% en tumores centrales y un 95,4% en periféricos). El valor del estadístico lambda es de 0,38 (0,42 en tumores centrales y 0,17 en periféricos). En 7 ocasiones la neumonectomía no programada se debió a afectación ganglionar hiliar. CONCLUSIONES: En el 13% de los pacientes sometidos a cirugía por carcinoma bronquial, la resección efectuada no coincide con la que se había programado inicialmente, la mayor parte de las veces debido a la necesidad de efectuar una neumonectomía cuando se había previsto una lobectomía. Este hecho es más frecuente en los tumores centrales y es debido con más frecuencia a invasión directa de las estructuras anatómicas que a extensión ganglionar hiliar

OBJECTIVE: To assess agreement between planned lung resections and the type subsequently performed on a series of patients, to assess whether tumor location (central or peripheral) affected the degree of discrepancy, and, in the case of unscheduled pneumonectomies, to examine why the planned resection had to be extended. METHOD: Prospective, observational clinical study of 199 patients scheduled for lung cancer surgery. Tumors were preoperatively classified as central or peripheral, and the type of operation planned—lobectomy (or bilobectomy) or pneumonectomy—was compared with the operation finally performed. Rates of agreement and Wilks’ lambda statistic were calculated. RESULTS: Twenty unscheduled pneumonectomies were performed. Agreement between planned and performed operations was found in 86.9% of cases (76.9% in central tumors and 95.4% in peripheral tumors). Wilks’ lambda statistic was 0.38 (0.42 for central tumors and 0.17 for peripheral tumors). Seven unscheduled pneumonectomies were performed due to hilar node involvement. CONCLUSIONS: The resections performed differed from the resections initially planned in 13% of the bronchial carcinoma operations, in most cases because the planned lobectomy had to be converted to pneumonectomy, a situation which occurred more often with central tumors and was more often due to direct invasion of anatomic structures rather than hilar spread

Prediction of early bronchopleural fistula after pneumonectomy: a multivariate analysis.

BACKGROUND: The aim of this study was to determine independent risk factors for early bronchopleural fistula (BPF) after pneumonectomy and to assess the efficacy of bronchial coverage in preventing this complication. METHODS: We reviewed 242 consecutive patients undergoing pneumonectomy for lung cancer. The bronchial stump was covered with autologous tissue in 178 patients (74%). Perioperative data were recorded to identify risk factors of BPF by univariate and multivariate analyses. RESULTS: Overall morbidity and mortality rates were 59% and 5.4%, respectively. The incidence of BPF was 5.4%. By univariate analysis, patients with chronic obstructive pulmonary disease (COPD; p = 0.017), hyperglycemia (p = 0.003), hypoalbuminemia (p = 0.017), previous steroid therapy (p < 0.001), poor predicted postpneumonectomy forced expiratory volume in 1 second (FEV1; p = 0.012), long bronchial stumps (p < 0.001), and mechanical ventilation (p = 0.015), were related with higher risk of BPF. In the multiple logistic regression model, the independent risk factors of BPF were the bronchial stump coverage and length, side of pneumonectomy, predicted postpneumonectomy FEV1, COPD, and mechanical ventilation. CONCLUSIONS: Bronchial stump coverage is highly recommended in all cases to minimize the risks of BPF. A shorter length of the bronchial stump and early extubation may prevent the development of BPF. Careful attention must be paid to those patients with COPD and poor predicted postpneumonectomy FEV1.

Airway complications after lung transplantation: a review of 151 anastomoses.

OBJECTIVE: To analyze the incidence, treatment and follow up of airway complications after lung transplantation. METHODS: From October 1993 to April 2000, 104 lung transplants were performed in 101 patients. One hundred and fifty one bronchial anastomoses at risk were included in the study (29 single lung and 61 sequential double lung). Donor lungs were flushed both antegradely and retrogradely with Eurocollins. In the recipients, either a single or a sequential bilateral lung transplantation was performed when indicated. The bronchial anastomosis was telescoped and covered with peribronchial tissue in all cases. Postoperative fiberoptic bronchoscopic examinations were dictated by clinical grounds. Recipient variables were recorded and analyzed to assess possible differences between both complicated and non-complicated groups. RESULTS: Eight bronchial anastomotic complications (5.3%) occurred in six patients (6.8%). All complicated cases developed in sequential bilateral lung recipients (P=0.08): stenosis (n=5), granulation tissue (n=2), and bronchial dehiscence (n=1). Treatment consisted of lobectomy and subsequent completion pneumonectomy in one patient, rigid bronchoscopy dilation in two, balloon bronchodilation in two, laser debridement and stenting in one, and conservative therapy in two cases. One patient with severe sepsis and bronchial dehiscence died on day +30. The rest of the patients remain well so far. Airway complications were related to longer intubation periods (P<0.01). Other perioperative donor and recipient factors including the incidence of infections and acute rejection episodes, and actuarial survival, did not differ between groups. CONCLUSION: In our experience, the incidence of airway complications after lung transplantation is 5.3%. The careful surgical technique and organ preservation, the close surveillance of rejection and infection, and early postoperative extubation might play a role in reducing this incidence. Either surgical therapy or bronchoscopic dilation and stenting methods may contribute to resolve these complications.

[Hyperhomocysteinemia is frequent in coronary disease patients. Study of 202 patients]. / La hiperhomocisteinemia es frecuente en pacientes con enfermedad coronaria. Estudio de 202 enfermos.

BACKGROUND: Previous studies have found that hyperhomocysteinemia is an independent risk factor for coronary disease. Homocysteine levels, and factors involved in their increase, are unknown in Spanish patients with coronary disease. PATIENTS AND METHODS: In 202 Spanish patients with coronary disease (174 men and 28 women) and age < 70 years old, homocysteine, creatinine, fibrinogen, lipoproteins, folic acid and vitamin B12 levels were determined. Controls were 40 healthy subjects whose age was not different from patients. RESULTS: Plasma homocysteine levels were increased in patients compared to controls (mean [SD] 11.7 [4.2], 95% confidence interval [CI]: 11.1-12.2, vs 8.4 [2.4], 95% CI: 7.7-9.2 mumol/l; p < 0.001). Hyperhomocysteinemia was found in 52 patients and in one control (26% vs 2.5%, odds ratio: 13.5, 95% CI: 1.8-100.8; p = 0.001). Homocysteine levels were positively associated in patients with creatinine level and negatively associated with folic acid level (p = 0.02 for both), but association with age, gender, fibrinogen, lipoproteins and vitamin B12 was not found. By multivariate analysis, folic acid was the only independent variable related with homocysteine levels (odds ratio: 0.32%, 95% CI: 0.122-0.882). In a subgroup of 30 patients with a low profile of cardiovascular risk (total-cholesterol < 225 mg/dl, nonsmokers and without diabetes and hypertension) an increase of homocysteine levels was also found, and 33% of them had hyperhomocysteinemia. CONCLUSION: Hyperhomocysteinemia was present in 26% of the patients with coronary disease. A similar percentage was found in the patients with a low profile of cardiovascular risk. Homocysteine levels were negatively associated with folic acid levels.

Lipoprotein abnormalities in long-term stable liver and renal transplanted patients. A comparative study.

Hyperlipidemia is a common feature after organ transplantation. Most studies have evaluated the lipid profile in recipients of a particular graft, usually renal. In the present work, we studied the lipid profiles of 30 long-term stable liver transplant patients (LTP) and compared their pattern with 40 long-term stable renal transplant patients (RTP) matched for gender, age, and time from transplantation. There were no significant differences between both groups in body mass index, serum glucose, serum creatinine, or urinary protein excretion. In contrast, RTP had higher pre-transplant total cholesterol and triglycerides, received higher doses of steroids (both average and cumulative) and had higher cycosplorine blood levels. After a mean time of 60 months after transplantation, RTP exhibited higher levels of total serum cholesterol (226 +/- 26 vs. 180 +/- 39 mg/dl; p = 0.000 002) and low-density lipoprotein (LDL) cholesterol (152 +/- 22 vs. 112 +/- 37 mg/dl; p = 0.00001). In contrast, there were no differences between RTP and LTP in high density lipoprotein (HDL) cholesterol, very low density lipoprotein (VLDL) cholesterol, total triglycerides, VLDL triglycerides, or lipoprotein (a) [Lp(a)]. By univariate analysis in the whole group, renal graft, prednisone daily dose, cyclosporine blood levels, pre-transplant cholesterol, and triglycerides were associated with increased post-transplant cholesterol levels. By multivariate analysis, prednisone daily dose was the only independent variable predicting increased post-transplant serum cholesterol levels. The present data show that hypercholesterolemia is more frequent among RTP than among LTP. In addition, our data suggest that corticosteroid therapy, rather than the transplanted organ, may be the major contributor to this difference.

Increased lipoproteins and fibrinogen in chronic renal allograft dysfunction.

Chronic rejection - also called chronic renal allograft dysfunction (CRAD) - is the main cause of long-term loss of the transplanted kidney, but its pathogenesis is not well known. The aim of this study was to know if lipoproteins, fibrinogen, plasminogen activator inhibitor-1 (PAI-1) and platelet aggregation show more abnormalities in renal transplant patients with CRAD than in those with stable renal function. Sixty patients with renal allograft have been studied; 20 patients with CRAD and 40 controls matched for age, gender and time after transplantation. In a univariate analysis patients with CRAD had higher total serum triglycerides (214+/-153 vs. 133+/-39 mg/dl; p = 0.04) and very-low-density lipoprotein (VLDL) triglycerides (128+/-116 vs. 59+/-29 mg/dl; p = 0.04). Apolipoprotein B levels were also increased in patients with CRAD although this difference was only borderline significant (131+/-58 vs. 98+/-16 mg/dl; p = 0.05). Similarly, there was a trend toward increased total, VLDL, and low-density lipoprotein (LDL) cholesterol and reduced high-density lipoprotein (HDL) cholesterol in CRAD patients, but these differences did not reach statistical significance. Apolipoprotein A-1 and lipoprotein(a) levels were similar in both groups. Neither platelet aggregation nor PAI-1 levels differed between both groups. In contrast, fibrinogen was increased in patients with CRAD (373+/-81 vs. 322+/-62 mg/dl; p = 0.01). In a multivariate analysis triglycerides and fibrinogen were positively correlated to CRAD. These findings add further support to the hypothesis that lipid abnormalities may be involved in the pathophysiology of CRAD. In addition, this is the first report showing that fibrinogen levels are increased in patients with CRAD. Further studies are needed to evaluate a potential role of fibrinogen in the development of CRAD.

[Multicenter comparative study on safety, tolerance, and effectiveness of lovastatin combined or not with cholestyramine, and gemfibrozil combined or not with cholestyramine in the treatment of primary hypercholesterolemia]. / Estudio multicéntrico comparativo de la seguridad, tolerancia y eficacia de la lovastatina asociada o no a colestiramina y del gemfibrozilo asociado o no a colestiramina en el tratamiento de la hipercolesterolemia primaria.

BACKGROUND: The well-known relationship between high plasma cholesterol levels and coronary heart disease makes the treatment of primary hypercholesterolemia an important issue. PATIENTS AND METHODS: A randomized, double-blind 12 week study to compare lovastatin (20-80 mg/day) and gemfibrozil (600 mg b.i.d.) was performed in 59 patients with primary hypercholesterolemia. Resincholestyramine was started on week 12, at a dose of 8-16 g/day for the next 12 weeks in any patient whose LDL-cholesterol exceeded 165 mg/dl at week 12. RESULTS: Total cholesterol, triglycerides and LDL-cholesterol decreased significantly (23.8%, 16.4% and 30.9%, respectively) after lovastatin therapy, whereas HDL-cholesterol increased (13.9%). The figures for the group treated with gemfibrozil were 12.8%, 30.3%, 17.2% and 14.6%, respectively. Mean changes between the two groups were statistically significant for all parameters except for HDL-cholesterol. LDL-cholesterol decreased below 165 mg/dl in 69% of patients receiving lovastatin and 36.7% of patients treated with gemfibrozil (p < 0.05). During the second phase there were no additional significant changes in the 9 patients of the lovastatin group and the 20 patients of the gemfibrozil group after cholestyramine, but LDL-cholesterol decreased below 165 mg/dl in 5 patients (55%) and 6 patients (30%), respectively. Side-effects were more prevalent in patients treated with gemfibrozil alone or in combination with cholestyramine. CONCLUSIONS: In patients with primary hypercholesterolemia, lovastatin alone or in combination with cholestyramine was more effective than gemfibrozil alone or in combination with cholestyramine to lower total cholesterol and LDL-cholesterol. The effect of both drugs on HDL-cholesterol was similar.

The fine structural localization of endogenous and exogenous peroxidase activity in human bone marrow mast cells under pathological conditions.

We have examined the ultrastructural characteristics of peroxidase activity in human bone marrow mast cells. These studies were performed in three patients with systemic mast cell disease, and in another six patients showing bone marrow mast cell hyperplasia. Endogenous peroxidase activity was localized in the perinuclear cisternae and strands of endoplasmic reticulum, but never in the granules. We have also demonstrated the "in vivo" existence of exogenous peroxidase activity in two of the three cases of systemic mast cell disease. The peroxidase internalization involved its binding to the plasma membrane, followed by its incorporation into the cell by a general endocytic process comprising the uptake of dispersed peroxidase-positive material mainly by phagocytosis of granular structures containing peroxidase. The exogenous peroxidase appeared in non-membrane bound granules, vacuoles or aggregates, but we have never seen the enzyme linked to the mast cell granules.