Comparison of gas exchange after lung resection with a Boussignac CPAP or Venturi mask.

BACKGROUND: Postoperative continuous positive airway pressure (CPAP) can improve lung function. The aim of our study was to assess the efficacy of prophylactic CPAP on the Pa(O2)/FI(O2) ratio measured the day after surgery in patients undergoing lung resection surgery (LRS). METHODS: The study population comprised 110 patients undergoing LRS. On arrival in the postanaesthesia care unit (PACU), patients were randomized to receive CPAP at 5-7 cm H2O during the first 6 h after surgery (CPAP group) or supplemental oxygen through a Venturi mask (Venturi group). The Pa(O2)/FI(O2) ratio was measured on arrival in the PACU, 7 h after admission, and the day after surgery. The Pa(O2)/FI(O2) ratio is the primary endpoint of our study. We also analysed the chest radiograph and assessed the postoperative course. We then analysed the impact of ventilatory management in the PACU depending on the respiratory risk of the patient. RESULTS: Baseline characteristics were similar in both groups. Patients who received CPAP had significantly higher Pa(O2)/FI(O2) at 24 h after surgery compared with patients managed conventionally (Venturi group) (48.6±14 vs 42.3±12, P=0.031), but there were no differences at 7 h. On subgroup analysis, we found that the benefits of CPAP were greater in higher risk patients. The incidence of postoperative pulmonary complications and stay in the PACU and hospital were similar in both groups. CONCLUSIONS: In patients undergoing LRS, prophylactic CPAP during the first 6 h after surgery with a pressure of 5-7 cm H2O improved the Pa(O2)/FI(O2) ratio at 24 h. This effect was more evident in patients with increased risk of postoperative pulmonary complications.

Abnormal mitochondrial function in locomotor and respiratory muscles of COPD patients.

Several cellular and molecular alterations have been described in skeletal and respiratory muscles of patients with chronic obstructive pulmonary disease (COPD), but information on potential abnormalities of mitochondrial function is scarce. The aim of the present study was to investigate mitochondrial function in the vastus lateralis (VL) and external intercostalis (EI) of COPD patients. Biopsies from VL and EI were obtained during surgery for lung cancer in 13 patients with mild to moderate COPD (age 68+/-6 yrs, forced expiratory volume in one second (FEV(1)) 66+/-15% predicted) and 19 control subjects (age 67+/-9 yrs, FEV(1) 95+/-18% pred). State 3 and 4 mitochondrial oxygen consumption (V'(O(2),m)), ATP synthesis, citrate synthase, cytochrome oxidase (COX) and complex I-III activities, as well as reactive oxygen species (ROS) production, were determined. In COPD patients, in both muscles, COX activity (VL: COPD 3.0+/-0.8 versus control 2.0+/-0.8; EI: 3.7+/-1.6 versus 2.4+/-0.9 micromol min(-1) mg(-1)) and ROS production (VL: 1,643+/-290 versus 1,285+/-468; EI: 1,033+/-210 versus 848+/-288 arbitrary units) were increased, whereas state 3 V'(O(2),m) was reduced (VL: 2.9+/-0.3 versus 3.6+/-0.4; EI: 3.6+/-0.3 versus 4.1+/-0.4 mmol min(-1) kg(-1)). Skeletal muscle mitochondria of patients with chronic obstructive pulmonary disease show electron transport chain blockade and excessive production of reactive oxygen species. The concurrent involvement of both vastus lateralis and external intercostalis suggests a systemic (rather than a local) mechanism(s) already occurring in relatively early stages (Global Initiative for Chronic Obstructive Lung Disease stage II) of the disease.

Carcinoma neuroendocrino de células grandes de pulmón. Análisis de una serie de once casos en un hospital universitario / Lung large-cell neuroendocrine carcinoma. Analysis of a series of eleven cases in a universitary hospital

Propósito: Los tumores pulmonares con diferenciación neuroendocrina (DN) son un grupo heterogéneode neoplasias que incluyen tumores carcinoides típicos, carcinoides atípicos, carcinomas neuroendocrinosde células grandes (CNCG) y carcinoma pulmonar de células pequeñas. Los CNCGconstituyen menos del 5% de los carcinomas pulmonares no células pequeñas (CPNCP). En este trabajose describe una serie de CNCG, tratados en un solo centro a lo largo de 10 años.Material y métodos: Se analizan 11 pacientes diagnosticados de CNCG (5 con histologías mixtas).Resultados: La edad media de los pacientes fue de 66 años, 5 fueron varones, 4 tuvieron enfermedadlocalizada, 5 localmente avanzada y 2 diseminada. Siete pacientes, con tumores localizados,fueron tratados con cirugía radical, 2 de ellos recibieron quimioterapia adyuvante; 1 quimioterapia yradioterapia y los otros 3 solo quimioterapia. La mediana de supervivencia de la serie es de 24 meses,y la supervivencia global a 2 y 5 años del 45% y 27% respectivamente.Conclusión: Los datos de nuestra serie corroboran las recomendaciones de que el manejo de losCNCG debe hacerse de forma similar al del resto de los CPNCP. La cirugía radical es el tratamientofundamental en los tumores localizados. No hay datos suficientes que indiquen una peor respuesta alos tratamientos de quimioterapia o radioterapia en este tipo de tumores

Purpose: Lung carcinomas with neuroendocrine differentiation are a heterogeneous group oftumors related to typical and atypical carcinoids, neuroendocrine large-cell carcinomas (NLCC) andsmall-cell lung cancer (SCLC). NLCC comprises less than 5% of non small-cell lung cancer (NSCLC).In this report, we describe a series of NLCC treated in a single institution in the last ten years.Material and methods: Eleven patients diagnosed as having NLCC (5 of them with mixedhistology).Results: At diagnosis, the mean age of the patients was 66 years (5 males and 6 females); 4 hadlocalized disease, 5 locally advanced disease, and 2 metastatic disease. Seven patients underwent initialradical surgery (2 of them followed by adjuvant chemotherapy), 1 patient received chemotherapy andradiotherapy, and 3 patients only chemotherapy. Median overall survival for the whole series was 24months, and the overall 2-year and 5-year survival were 45% and 27% respectively.Conclusion: Our data corroborate the general recommendation of treating NLCC in a similar wayas the rest of the non small-cell lung cancer (NSCLC) are treated. Radical surgery is the maintreatment for localized tumors. There are no data indicating a worse response of these tumors toradiation therapy or chemotherapy

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[Resection of a mediastinal parathyroid adenoma by video-assisted thoracoscopy radio-guided by a gamma probe. A case report]. / Extirpación de adenoma paratiroideo mediastínico mediante videotoracoscopia radioguiada por sonda gamma. Presentación de un caso.

We present a case of primary hyperparathyroidism in a 47 year old woman. The pre-operative 99mTc-sestaMIBI scan detected a single parathyroid adenoma located in the anterior or medium mediastinum. Surgery was carried out following 99mTc-sestaMIBI administration and using gamma probe radio-guided video-assisted thoracoscopy. The aim of this case report is to present this technique that allows adenoma resection with minimally invasive surgery. A reduction of surgical complications and an increase in the probability of surgical success could be obtained.

Toracotomía urgente en traumatismos penetrantes y cerrados: incidencia, características demográficas y análisis de resultados en un registro hospitalario de traumatizados graves / Urgent thoracotomy in blunt and penetrating trauma: incidence, demographic characteristics and analysis of results in a hospital registry of severe trauma

Objetivo. En países de nuestro entorno europeo la necesidad de toracotomía urgente por traumatismo es escasa. Nuestro objetivo ha sido analizar la gravedad de los pacientes con traumatismo penetrante (TP) y cerrado (TC) que han necesitado toracotomía urgente, con el fin de valorar si la toracotomía por traumatismo en nuestro medio no conlleva peores resultados, en términos de supervivencia, que el estándar internacional. Métodos. Hemos analizado las características demográficas, indicaciones, tipos, escalas de gravedad (RTS, AIS, ISS y NISS) y TPS (TRISS Probability of Survival), así como las muertes potencialmente evitables y posibles errores de manejo inicial de los pacientes traumatizados que han necesitado una toracotomía dentro de las primeras 48 h. Resultados. Entre agosto de 1993 y agosto de 2002 se ha recogido en nuestro registro de traumatizados graves un abordaje torácico urgente, único o combinado con otras vía de abordaje, en 51 pacientes. En 26 y 25 pacientes la toracotomía fue por TP y TC, respectivamente. En el grupo con TP el tiempo medio de transporte fue de 49 min. Las indicaciones del abordaje torácico fueron: 3 casos por situación in extremis en el Departamento de Urgencias, 11 por shock al ingreso, 10 por lesiones específicas en pacientes que no estaban en shock y 2 por hemorragia persistente a través de un tubo de drenaje. Un 11,5 por ciento necesitaron abordaje toracoabdominal combinado. La lesión más frecuente fue la herida por arma blanca cardíaca AIS V. El RTS, ISS y NISS medios fueron de 8,2, 23 y 30, respectivamente. La mortalidad a 30 días fue de 7 casos (27 por ciento). En función del TPS dos de los fallecidos aparecen como muertes potencialmente evitables. En el grupo con TC el tiempo medio de transporte fue de 63 min. Las indicaciones de la toracotomía fueron: 3 casos por situación in extremis, 3 por shock al ingreso, 14 por lesiones especificas en pacientes que no estaban en shock y 5 por hemorragia torácica persistente. Un 32 por ciento necesitaron un abordaje toracoabdominal combinado. Hubo lesiones cardíacas o de grandes vasos en 11 pacientes (44 por ciento). El RTS, ISS y NISS medios fueron de 8,9, 34 y 41, respectivamente. La mortalidad a los 30 días fue de 12 casos (48 por ciento), y 2 aparecen como muertes potencialmente evitables en función del TPS. Conclusiones. En las toracotomías por TP los "tiempos de transporte" parecen prolongados a la luz de las recomendaciones de la bibliografía. La necesidad de reanimación cardiopulmonar (RCP) avanzada in situ o durante el traslado ha sido un factor de pronóstico fatal en nuestra serie. En el TC una causa muy frecuente de toracotomía urgente ha sido la rotura aórtica y de cavidades cardíacas. La necesidad de laparotomía asociada ha sido frecuente, y conlleva una alta mortalidad. La baja incidencia global de toracotomía urgente por traumatismo en nuestro medio no parece influir negativamente en los resultados de supervivencia, aunque se han detectado errores de evaluación y manejo susceptibles de corrección (AU)

Figuras pioneras de la cirugía torácica española / Pionnering figures of spanish chest surgery

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[Thymectomy in myasthenia gravis]. / Timectomía en la miastenia gravis.

OBJECTIVE: To analyze outcome after thymectomy in patients with myasthenia gravis (MG). MATERIAL AND METHODS: Thirty-five patients with MG underwent surgery in our service between June 1987 and June 1998. Ten had associated thymomas. Preoperative Osserman classification showed 2 at level I, 20 at level IIA, 11 at level IIB and 2 at level III. Extended thymectomy through a medial sternotomy was performed in all. RESULTS: Postoperative complications developed in three patients (1 medullary aplasia, 1 postoperative reintubation, 1 myasthenic crisis). Mean follow-up was 89 months, with 22.8% achieving complete remission and 97.1% reporting improvements. The results were similar in the 10 patients with thymomas (20% full remission and 90% showing improvement). By DeFilippi classification, 22.8% were in class 1, 22.8% in class 2, 51.4% in class 3 and 2.8% in class 4. By Osserman classification, 9 were in the same category before and after surgery, 12 had improved one level, 10 had improved 2 levels, 3 had improved 3 levels and 1 patient had improved 4 levels. CONCLUSION: Thymectomy is an appropriate therapeutic procedure in the multidisciplinary treatment of patients with MG and it is the approach of choice for patients with associated thymomas. The intra- and post-operative complication rate is low and the rate of clinical improvement is high.

Timectomía en la miastenia gravis / Thymectomy in myasthenia gravis

OBJETIVO: Analizar los resultados de la timectomía en pacientes con miastenia gravis. MATERIAL Y MÉTODOS: Entre junio de 1987 y junio de 1998, se intervinieron en nuestro servicio 35 pacientes con miastenia gravis, en 10 de los cuales se asociaban timomas. Los pacientes se clasificaron en el preoperatorio según la clasificación de Osserman (dos grado I, 20 grado IIA, 11 grado IIB y dos grado III). En todos se realizó timectomía ampliada por esternotomía media. RESULTADOS: En 3 pacientes hubo complicaciones postoperatorias (una aplasia medular, una reintubación postoperatoria y una crisis miasténica). Tras una mediana de seguimiento de 89 meses, el 22,8 por ciento estaba en remisión completa y el 97,1 por ciento había mejorado. Los resultados son similares en los 10 pacientes con timoma (un 20 por ciento de remisiones completas y un 90 por ciento de mejorías). Según la clasificación de DeFilippi un 22,8 por ciento se encontraba en clase 1; un 22,8 por ciento, en clase 2; un 51,4 por ciento, en clase 3, y un 2,8 por ciento, en clase 4. Según la clasificación de Osserman, 9 pacientes presentaban el grado previo a la cirugía, 12 habían mejorado un grado, 10 habían mejorado 2 grados, 3 habían mejorado 3 grados y un paciente había mejorado 4 grados. CONCLUSIÓN: La timectomía es una opción terapéutica adecuada en el tratamiento multidisciplinario de los pacientes con miastenia gravis y es el tratamiento de elección en los pacientes en que se asocian timomas. El porcentaje de complicaciones intra y postoperatorias es bajo, y se obtiene un índice elevado de mejorías clínicas (AU)

[Granular cell myoblastoma localized in the thoracic wall]. / Mioblastoma de células granulosas localizado en la pared torácica.

We report the case or a 40-year-old man with a large right parasternal tumor. Computerized tomography (CT) and magnetic resonance (MR) imaging showed a soft tissue mass infiltrating contiguous structures with no sign of adenopathy and with disease limited the chest wall. The histological type was granular cell tumor (GCT) with discrete cell pleomorphism and nuclei that varied in form and size, with prominent nucleoli. Eighteen months after surgery, the patient was asymptomatic and disease free. GCT is a rare entity that is uncommonly found on the chest wall. A diagnosis of malignancy is established when metastasis is found to be of the same histological type as that of the primitive tumor. Neither cell pleomorphism or nuclei with nucleoli allows for a diagnosis of malignancy; only a size greater than 5 cm and locally invasive behavior should lead to an assumption that these tumors are of unspecified malignancy. We believe the treatment of choice for these lesions is radical removal

[Short and long term follow-up of spontaneous pneumothorax treated using video-thoracoscopy]. / Seguimiento a corto y largo plazo del neumotórax espontáneo tratado por videotoracoscopia.

The outcome of video-assisted thoracoscopic treatment of spontaneous pneumothorax was analyzed. Eighty-three procedures were performed in 79 patients (58 men, 21 women: mean age 28.3 years, range 16 to 76 years). The reasons for intervention were recurring pneumothorax in 53 patients, contralateral pneumothorax in 10 (one of whom was treated on both sides), bilateral involvement in 3, and persistent air leakage in 13. Seven patients (8.4%) also required open thoracotomy. In 72 (88%) of the remaining 76 procedures, only video thoracoscopy was used. Three patients (3.6%) underwent video-assisted thoracotomy. Mean postoperative hospital stay was 5.1 days (2 to 24 days). No related deaths occurred but surgical complications were reported for 3 (3.9%). Significant postoperative complications developed in 9 cases (11.8%). One patient with prolonged air leakage underwent a second procedure, video-assisted thoracotomy, 12 days after the first intervention. Seventy-one of the 72 patients received follow-up examinations, with a mean follow-up period of 28.1 months (range 54 days to 54 months). Three recurrences (3.9%) were recorded but there were no cases of chronic pain requiring analgesia. We conclude that video thoracoscopy is an effective approach, with the advantage of being minimally invasive. We therefore believe it should be the procedure of choice, once improved morbidity and recurrence rates are observed, as these factors are influenced by the learning curve.

[Necrotizing descendent mediastinitis of oropharyngeal origin]. / Mediastinitis descendente necrosante de origen orofaríngeo.

The spread of oropharyngeal infections to the mediastinum can give rise to descending necrotizing mediastinitis (DNM), which causes a high rate of mortality (around 40%), particularly when diagnosis is late and drainage inadequate. In the first case we report, successful drainage of the mediastinum was achieved at the cervical and sub-xiphisternum levels and by thoracotomy. Given the condition of the second patient, transcervical drainage alone was considered the best option, but this treatment was inadequate. Rapid start of appropriate drainage of the mediastinum is of great importance. Cervical drains, which may be adequate when there is perforation of the cervical esophagus, is insufficient in DNM, which calls for more aggressive, early drainage, such as can be achieved by thoracotomy. Computerized axial tomography of the chest is essential for rapid diagnosis, to plan the most appropriate surgical approach and for follow-up and evaluation of drainage.

[Localized fibrous tumor in the parenchyma. Report of 2 cases, one of them multiple and bilateral]. / Tumor fibroso localizado intraparenquimatoso. A propósito de dos casos, uno de ellos múltiple y bilateral.

Localized fibrous tumor is an uncommon neoplasm that is usually located in the visceral pleura. Histologically these tumors are composed of randomly arranged fascicles or networks of fusiform cells, among which there is a varying amount of collagen. Most authors consider that these cells originate in submesothelial mesenchymal cells. The condition is normally silent, though hypoglycemia, hypertrophic osteoarthropathy or other symptoms sometimes result. The treatment of choice is total resection and imaging techniques are extremely helpful for establishing surgical strategy, even though surgery is often performed before a histopathologic diagnosis is available. We present 2 patients with intrapulmonary fibromas that were histologically identical to localized fibrous pleural tumors. These tumors are rarely found in the parenchyma and multiple bilateral presentation is exceptional, having been described only once in the literature. One of our patients had a single pulmonary node that happened to be noticed on an X-ray. The other had multiple bilateral nodes that required several surgical procedures; the intraparenchymatous location for this type of tumor has not been described to date. We discuss clinical, therapeutic and histopathological aspects of these tumors and review the literature.