Lobectomías robóticas y cáncer de pulmón. Experiencia inicial en nuestro centro / Robotic lobectomies and lung cancer. Initial experience in our center

Objetivo: Analizar la seguridad y factibilidad en términos de resultados obtenidos en las primeras lobectomías robóticas realizadas en nuestro centro. Metodología: Estudio prospectivo desde mayo hasta diciembre de 2021 en 13 pacientes (11 hombres y 2 mujeres, edad media 59 años) con carcinoma de pulmón en estadios precoces tributarios de lobectomía robótica.Se utilizó el sistema da Vinci Xi con cuatro puertos y uno asistente. Resultados: Se realizaron 13 lobectomías robóticas. La conversión a cirugía videoasistida fue necesaria en 2 pacientes (15,4%). Se produjeron complicaciones en 3 pacientes (23%). La mediana de tiempo quirúrgico fue180 minutos [IQR 150-210]. La mediana de estancia hospitalaria fue de 4 días [IQR 3 - 6]. La mediana de duración del drenaje pleural fue de 4 días [IQR3 - 6]. La histología predominante fue carcinoma epidermoide en5 pacientes (39%). La media de ganglios linfáticos resecados fue de 15 (IC 95%: 11 - 19) y la de estaciones ganglionares de 5 (IC 95%: 4 - 5). No hubo mortalidad postoperatoria. El estadio postquirúrgico fue IA2 en 4 pacientes (31%), IB en 3 (23%), IIB en 2 (15%), y IIIA en 1 (7%). No se establecen diferencias estadísticamente significativas entre el IMC, el lóbulo resecado y la presencia de complicaciones (p = 0,5; p = 0,2), ni entre el número de ganglios resecados/número de estaciones ganglionares, y el estadio tumoral (p = 0,4; p = 0,9). Conclusiones: La lobectomía robótica con linfadenectomía hiliomediastínica es factible y segura. Es necesaria mayor experiencia y seguimiento a largo plazo para una adecuada evaluación de los resultados postoperatorios, la eficacia oncológica, y la comparación con las vías de abordaje convencionales. (AU)

Objectives: analyze the safety and feasibility in terms of results obtained in the first robotic lobectomies performed in our center. Method: prospective study from May to December 2021 in 13 patients (11 men and 2 women, mean age 59 years) with lung carcinoma in early stages requiring robotic lobectomy. The da Vinci Xi system was used with four ports and one assistant. Results: 13 robotic lobectomies were performed. Conversion to video-assisted surgery was necessary in 2 patients (15.4%). Complications occurred in 3 patients (23%). The median surgical time was 180 minutes [IQR 150-210]. The median hospital stay was 4 days [IQR 3 - 6]. The median duration of pleural drainage was 4 days [IQR3 - 6]. The predominant histology was squamous cell carcinoma in 5 patients (39%). The mean number of lymph nodes resected was 15 (95% CI: 11 - 19) and the number of lymph nodes resected was 5 (95% CI: 4 - 5). There was no postoperative mortality. The postsurgical stage was IA2 in 4 patients (31%), IB in 3 (23%), IIB in 2 (15%), and IIIA in 1 (7%). No statistically significant differences were established between BMI, the resected lobe and the presence of complications (p = 0.5; p = 0.2), nor between the number of resected lymph nodes/number of lymph node stations, and the tumor stage ( p = 0.4; p = 0.9).Conclusions: robotic lobectomy with hiliomediastinal lymphadenectomy is feasible and safe. Greater experience and long-term follow-up are necessary for an adequate evaluation of postoperative results, oncological efficacy, and comparison with conventional approaches. (AU)

Expresión de los factores de transcripción sensibles a la hipoxia, de la respuesta inflamatoria y del estrés oxidativo a nivel muscular en tres modelos clínicos de hipoxemia / Expression of transcription factors sensitive to hypoxia, of the inflammatory response and oxidative stress to muscle level in three clinical models of hypoxemia

OBJETIVO: Comparar la expresión de marcadores de respuesta a hipoxia, inflamatorios y de estrés oxidativo en biopsia muscular de grupos de pacientes con hipoxia crónica continua, crónica intermitente y ambas combinadas. Evaluar el estado de la musculatura periférica y compararla entre grupos. METODOLOGÍA: Incluimos varones mayores de 18 años, diagnosticados de EPOC, Apnea Obstructiva del Sueño (AOS) o AOS-EPOC, a los que se realizó biopsia muscular del cuádriceps. Los biomarcadores seleccionados para su estudio en músculo fueron factores de transcripción asociados a la hipoxia, como el factor inducible por hipoxia HIF-1, HIF-2 y el factor nuclear. También biomarcadores inflamatorios como factor de necrosis tumoral-α, interkeukina 6 y 8, factor de crecimiento endotelial vascular y proteína de adhesión celular vascular 1 (VCAM-1), así como biomarcadores de estrés oxidativo, como superóxidodismutasa (SOD) y actividad catalasa. Además se realizó evaluación de la función muscular en los tres grupos. RESULTADOS: Reclutamos 29 sujetos: 4 con EPOC, 12 con AOS y 13 EPOC-AOS. En el músculo, encontramos diferencias entre los grupos de estudio en VCAM-1 (casos de EPOC que expresan 2,1 veces más que AOS y 1,16 veces más que EPOC-AOS) y SOD (EPOC-AOS que expresan 3,48 veces más que EPOC, y AOS 3,02 veces más que EPOC). CONCLUSIONES: La expresión de biomarcadores estudiados es de intensidad similar en los tres grupos de pacientes referidos, con pocas excepciones.La fuerza muscular periférica y el porcentaje de masa libre de grasa es significativamente menor en los pacientes con EPOC que en los pacientes con AOS. (AU)

OBJECTIVE: Compare the expression of markers of response to hypoxia, inflammation and oxidative stress in biopsy muscle of groups of patients with continuous chronic hypoxia, intermittent chronic and both combined. Evaluate the state of the peripheral musculature and compare it between groups. METHODOLOGY: We included males older than 18 years, diagnosed of COPD, Obstructive Sleep Apnea (OSA) or OSA-COPD, to quadriceps muscle biopsy was performed. biomarkers selected for study in muscle were factors of transcription associated with hypoxia, such as the factor inducible by hypoxia HIF-1, HIF-2 and nuclear factor. Also biomarkers Inflammatory agents such as tumor necrosis factor-α, interkeukin 6, and 8, vascular endothelial growth factor and adhesion protein vascular cell 1 (VCAM-1), as well as stress biomarkers oxidative, such as superoxide dismutase (SOD) and catalase activity. In addition, evaluation of muscle function was performed in the three groups. RESULTS: We recruited 29 subjects: 4 with COPD, 12 with OSA and 13 COPD-OSA. In muscle, we found differences between the study groups in VCAM-1 (COPD cases expressing 2.1-fold more than OSA and 1.16 times more than COPD-OSA) and SOD (COPD-OSA than express 3.48 times more than COPD, and OSA 3.02 times more than COPD). CONCLUSIONS: The expression of studied biomarkers is of similar intensity in the three groups of referred patients, with few exceptions. Peripheral muscle strength and percentage of fat-free mass is significantly lower in patients with COPD than in patients with OSA. (AU)

Modelling Particle Transport and Deposition in the Human Healthy and Stented Tracheobronchial Airways.

The main goal of this study is the quantification of the particle transport and deposition within the human airways during light, normal and exercise breathing conditions using the computational fluid dynamics. In particular we presented a comparison between healthy and stented airways. The considered tracheobronchial model is based on the Weibel symmetric model in which we have inserted the Dumon prosthesis at different locations and on the CT-based geometries of a healthy and a stented airway. The results indicate an important redistribution of the particle deposition locations. Local overdoses can be found in the proximal regions of the prostheses, independently of the breathing conditions, of the particle size and of the considered geometry. The presented work is aimed to contribute to the understanding of the particle deposition in the human lung and to improve drug-aerosol therapies. For patients that underwent airways reconstructive surgery, it can give detailed information about the deposition efficiency and it may help targeting specific airways regions.

Anaesthetic management in thoracoscopic distal tracheal resection. / Manejo anestésico en la resección traqueal distal toracoscópica.

Surgical resection of tracheal tumours, especially distal tracheal tumours, is a challenge for the anaesthesiologists involved, mainly due to difficulties in ensuring adequate control of the airway and ventilation. We report the case of a patient undergoing tracheal resection and anastomosis by VATS, emphasizing the anaesthetic management.

Expresión de aquaporinas en tejido pulmonar de pacientes con enfermedad pulmonar obstructiva crónica / Aquaporin expression in the lung tissue of copd patients

INTRODUCCIÓN: Estudio de la expresión de aquaporinas (AQP1 y AQP5) en el tejido bronquial y parénquima pulmo-nar de pacientes con enfermedad pulmonar obstructiva cróni-ca (EPOC) y fumadores sin la enfermedad. MÉTODO: Utilizando un diseño caso-control, se seleccionó un grupo de 15 pacientes con EPOC (93,3% varones, con una edad media de 68 años, una media de FEV1 del 72% y 26,7% con corticosteroides inhalados) y 15 fumadores sin la enfermedad, a los cuales se les sometió a cirugía de resección pulmonar por neoplasia pulmonar. Se estudió la expresión de AQP1 y AQP5 en el tejido bronquial y en parénquima pulmo-nar mediante reacción en cadena de la polimerasa en tiempo real.RESULTADOS: No encontramos diferencias en la expresión génica de estas AQPs en ambos territorios pulmonares entre los pacientes con EPOC y los fumadores sin la enfermedad. Sin embargo, en los pacientes EPOC, la expresión de AQP1 era 2,41 veces mayor en el parénquima comparado con los controles, mientras que la AQP5 mostraba un patrón inverso, con 7,75 veces mayor expresión en el tejido bronquial de los sujetos control.CONCLUSIÓN: Los resultados del presente trabajo proporcio-nan evidencia inicial respecto a la expresión de AQP1 y AQP5 en pacientes con EPOC

INTRODUCTION: Study of aquaporin expression (AQP1 and AQP5) in the bronchial tissue and lung parenchyma of pa-tients with chronic obstructive pulmonary disease (COPD) and smokers without the disease. METHOD: Using a case-control design, a group of 15 patients with COPD was selected (93.3% males, with an average age of 68 years, an average FEV1 of 72% and 26.7% with inha-led corticosteroids) and 15 smokers without the disease, who underwent lung resection surgery due to lung neoplasm. The expression of AQP1 and AQP5 in the bronchial tissue and in lung parenchyma was studied using real-time polymerase chain reaction (PCR). RESULTS: No differences were found in the gene expression of these AQPs in either lung territories between the patients with COPD and the smokers without the disease. Nevertheless, in the COPD patients, the expression of AQP1 was 2.41 times greater in the parenchyma compared with the controls, while the AQP5 showed an inverse pattern, with 7.75 times greater expression in the bronchial tissue of the control subject. CONCLUSION: The results of this study provide initial evidence regarding the expression of AQP1 and AQP5 in patient with COPD

CFD analysis of the human airways under impedance-based boundary conditions: application to healthy, diseased and stented trachea.

A computational fluid dynamics model of a healthy, a stenotic and a post-operatory stented human trachea was developed to study the respiration under physiological boundary conditions. For this, outflow pressure waveforms were computed from patient-specific spirometries by means of a method that allows to compute the peripheral impedance of the truncated bronchial generation, modelling the lungs as fractal networks. Intratracheal flow pattern was analysed under different scenarios. First, results obtained using different outflow conditions were compared for the healthy trachea in order to assess the importance of using impedance-based conditions. The resulted intratracheal pressures were affected by the different boundary conditions, while the resulted velocity field was unaffected. Impedance conditions were finally applied to the diseased and the stented trachea. The proposed impedance method represents an attractive tool to compute physiological pressure conditions that are not possible to extract in vivo. This method can be applied to healthy, pre- and post-operatory tracheas showing the possibility of predicting, through numerical simulation, the flow and the pressure field before and after surgery.

Tecnología de simulación tridimensional para la planificación de la implantación de endoprótesis traqueales / Three-dimensional simulation technology for planning tracheal stenting

Objetivo: Se ha realizado un estudio observacional sobre pacientes con estenosis de la vía aérea principal con el objetivo de demostrar la mejorar en los resultados del tratamiento mediante broncoscopia rígida al realizar una planificación preoperatoria (..) (AU)

Objective: An observational study was made of patients with stenosis of the main airway in order to demonstrate the improved results of treatment by rigid bronchoscopy to perform preoperative planning with computer simulation (..) (AU)

FSI analysis of a human trachea before and after prosthesis implantation.

In this work we analyzed the response of a stenotic trachea after a stent implantation. An endotracheal stent is the common treatment for tracheal diseases such as stenosis, chronic cough, or dispnoea episodes. Medical treatment and surgical techniques are still challenging due to the difficulties in overcoming potential complications after prosthesis implantation. A finite element model of a diseased and stented trachea was developed starting from a patient specific computerized tomography (CT) scan. The tracheal wall was modeled as a fiber reinforced hyperelastic material in which we modeled the anisotropy due to the orientation of the collagen fibers. Deformations of the tracheal cartilage rings and of the muscular membrane, as well as the maximum principal stresses, are analyzed using a fluid solid interaction (FSI) approach. For this reason, as boundary conditions, impedance-based pressure waveforms were computed modeling the nonreconstructed vessels as a binary fractal network. The results showed that the presence of the stent prevents tracheal muscle deflections and indicated a local recirculatory flow on the stent top surface which may play a role in the process of mucous accumulation. The present work gives new insight into clinical procedures, predicting their mechanical consequences. This tool could be used in the future as preoperative planning software to help the thoracic surgeons in deciding the optimal prosthesis type as well as its size and positioning.

FSI Analysis of a healthy and a stenotic human trachea under impedance-based boundary conditions.

In this work, a fluid-solid interaction (FSI) analysis of a healthy and a stenotic human trachea was studied to evaluate flow patterns, wall stresses, and deformations under physiological and pathological conditions. The two analyzed tracheal geometries, which include the first bifurcation after the carina, were obtained from computed tomography images of healthy and diseased patients, respectively. A finite element-based commercial software code was used to perform the simulations. The tracheal wall was modeled as a fiber reinforced hyperelastic solid material in which the anisotropy due to the orientation of the fibers was introduced. Impedance-based pressure waveforms were computed using a method developed for the cardiovascular system, where the resistance of the respiratory system was calculated taking into account the entire bronchial tree, modeled as binary fractal network. Intratracheal flow patterns and tracheal wall deformation were analyzed under different scenarios. The simulations show the possibility of predicting, with FSI computations, flow and wall behavior for healthy and pathological tracheas. The computational modeling procedure presented herein can be a useful tool capable of evaluating quantities that cannot be assessed in vivo, such as wall stresses, pressure drop, and flow patterns, and to derive parameters that could help clinical decisions and improve surgical outcomes.

Patient-specific models of human trachea to predict mechanical consequences of endoprosthesis implantation.

Nowadays, interventions associated with the implantation of tracheal prostheses in patients with airway pathologies are very common. This surgery may promote problems such as migration of the prosthesis, development of granulation tissue at the edges of the stent with overgrowth of the tracheal lumen or accumulation of secretions inside the prosthesis. Among the movements that the trachea carries out, swallowing seems to have harmful consequences for the tracheal tissues surrounding the prosthesis. In this work, a finite-element-based tool is presented to construct patient-specific tracheal models, introducing the endotracheal prosthesis and analysing the mechanical consequences of this surgery during swallowing. A complete description of a patient-specific tracheal model is given, and a fully experimental characterization of the tracheal tissues is presented. To construct patient-specific grids, a mesh adaptation algorithm has been developed and the implantation of a tracheal prosthesis is simulated. The ascending deglutition movement of the trachea is recorded using real data from each specific patient from fluoroscopic images before and after implantation. The overall behaviour of the trachea is modified when a prosthesis is introduced. The presented tool has been particularized for two different patients (patient A and patient B), allowing prediction of the consequences of this kind of surgery. In particular, patient A had a decrease of almost 30 per cent in his ability to swallow, and an increase in stresses that were three times higher after prosthesis implantation. In contrast, patient B, who had a shorter trachea and who seemed to undergo more damaging effects, did not have a significant reduction in his ability to swallow and did not present an increase in stress in the tissues. In both cases, there are clinical studies that validate our results: namely, patient A underwent a further intervention whereas the outcome of patient B's surgery was completely successful. Notwithstanding the fact that there are a lot of uncertainties relating to the implantation of endotracheal prostheses, the present work gives a new insight into these procedures, predicting their mechanical consequences. This tool could be used in the future as pre-operative planning software to help thoracic surgeons in deciding the optimal prosthesis as well as its size and positioning.

FSI analysis of the coughing mechanism in a human trachea.

The main physiological function of coughing is to remove from the airways the mucus and foreign particles that enter the lungs with respirable air. However, in patients with endotracheal tubes, further surgery has to be performed to improve cough effectiveness. Thus, it is necessary to analyze how this process is carried out in healthy tracheas to suggest ways to improve its efficacy in operated patients. A finite element model of a human trachea is developed and used to analyze the deformability of the tracheal walls under coughing. The geometry of the trachea is obtained from CT of a 70-year-old male patient. A fluid structure interaction approach is used to analyze the deformation of the wall when the fluid (in this case, air) flows inside the trachea. A structured hexahedral-based grid for the tracheal walls and an unstructured tetrahedral-based mesh with coincident nodes for the fluid are used to perform the simulations with the finite element-based commercial software code (ADINA R&D Inc.). Tracheal wall is modeled as an anisotropic fiber reinforced hyperelastic solid material in which the different orientation of the fibers is introduced. The implantation of an endotracheal prosthesis is simulated. Boundary conditions for breathing and coughing are applied at the inlet and at the outlet surfaces of the fluid mesh. The collapsibility of a human trachea under breathing and coughing is shown in terms of flow patterns and wall stresses. The ability of the model to reproduce the normal breathing and coughing is proved by comparing the deformed shape of the trachea with experimental results. Moreover the implantation of an endotracheal prosthesis would be related with a decrease of coughing efficiency, as clinically seen.

Experimental characterization and constitutive modeling of the mechanical behavior of the human trachea.

BACKGROUND AND AIMS: Cartilage and smooth muscle constitute the main structural components of the human central airways, their mechanical properties affect the flow in the trachea and contribute to the biological function of the respiratory system. The aim of this work is to find out the mechanical passive response of the principal constituents of the human trachea under static tensile conditions and to propose constitutive models to describe their behavior. METHODS: Histological analyses to characterize the tissues and mechanical tests have been made on three human trachea specimens obtained from autopsies. Uniaxial tensile tests on cartilaginous rings and smooth muscle were performed. Tracheal cartilage was considered an elastic material and its Young's modulus and Poisson's coefficient were determined fitting the experimental curves using a Neo-Hookean model. The smooth muscle was proved to behave as a reinforced hyperelastic material with two families of collagen fibers, and its non-linearity was investigated using the Holzapfel strain-energy density function for two families of fibers to fit the experimental data obtained from longitudinal and transversal cuts. RESULTS: For cartilage, fitting the experimental curves to an elastic model, a Young's modulus of 3.33 MPa and nu=0.49 were obtained. For smooth muscle, several parameters of the Holzapfel function were found out (C(10)=0.877 kPa, k(1)=0.154 kPa, k(2)=34.157, k(3)=0.347 kPa and k(4)=13.889) and demonstrated that the tracheal muscle was stiffer in the longitudinal direction. CONCLUSION: The better understanding of how these tissues mechanically behave is essential for a correct modeling of the human trachea, a better simulation of its response under different loading conditions, and the development of strategies for the design of new endotracheal prostheses.

Obstrucción severa al flujo aéreo como forma de presentación de carcinoma epidermoide traqueal / No disponible

No disponible

Plasmocitoma endobronquial / Endobronchial plasmacytoma

El plasmocitoma extramedular se define como untumor poco frecuente de células plasmáticas originadoprimariamente en tejidos blandos (extraóseos)en ausencia de enfermedad generalizada. La localizaciónpulmonar es extremadamente rara, supone el5% de los mismos.Existen pocas aportaciones a la literatura sobreesta entidad. Presentamos un caso clínico de plasmocitomaendobronquial en una mujer de 67 añosque debutó con un cuadro de neumonía y derrameparaneumónico de repetición. Fue tratado con ablacióncon láser mediante broncoscopio rígido. Loscontroles fibrobroncoscópicos posteriores y el seguimientoclínico y analítico posterior confirman laausencia de enfermedad 14 meses después de sudiagnóstico

Extramedullary plasmacytoma is a little frequentplasma cell tumor originating mainly in the softtissues (extramedullary) in the absence ofgeneralized disease. Lung localization is very rare,comprising 5% of the cases.There are few literature contributions about thisentity. We present a clinical case of endobronchialplasmacytoma of a 67 year old woman presentedwith a picture of pneumonia and recurrentparapneumonic efussion. She was treated with laserablation using a rigid bronchoscope. Thesubsequent fibrobronchoscopic controls and theclinical and analytical follow up confirmed theabsence of disease 14 months after the diagnosis