Non-intubated video-assisted thoracic surgery management of secondary spontaneous pneumothorax.

Secondary spontaneous pneumothorax (SSP) is serious entity, usually due to underlying disease, mainly chronic obstructive pulmonary disease (COPD). Its morbidity and mortality is high due to the pulmonary compromised status of these patients, and the recurrence rate is almost 50%, increasing mortality with each episode. For persistent or recurrent SSP, surgery under general anesthesia (GA) and mechanical ventilation (MV) with lung isolation is the gold standard, but ventilator-induced damages and dependency, and postoperative pulmonary complications are frequent. In the last two decades, several groups have reported successful results with non-intubated video-assisted thoracic surgery (NI-VATS) with thoracic epidural anesthesia (TEA) and/or local anesthesia under spontaneous breathing. Main benefits reported are operative time, operation room time and hospital stay reduction, and postoperative respiratory complications decrease when comparing to GA, thus encouraging for further research in these moderate to high risk patients many times rejected for the standard regimen. There are also reports of special situations with satisfactory results, as in contralateral pneumonectomy and lung transplantation. The aim of this review is to collect, analyze and discuss all the available evidence, and seek for future lines of investigation.

Utilidad y versatilidad del titanio para la reconstrucción de la pared torácica / Use and versatility of titanium for the reconstruction of the thoracic wall

INTRODUCCIÓN: La resección y las deformidades/defectos de la pared torácica así como las fracturas costales complejas requieren de reconstrucción con diversos materiales protésicos para garantizar las funciones básicas de dicha pared. El titanio aporta múltiples características que lo hacen un material idóneo para esta cirugía. El objetivo es presentar nuestros resultados iniciales con este material en diversas afecciones. Material y métodos De 2008 a 2012 se ha intervenido a 14 pacientes en los que se ha empleado el titanio para la reconstrucción de la pared torácica. Un total de 7 pacientes presentaban tumores de pared torácica, 2 de ellos con resección esternal, 4 con deformidades/defectos de la pared torácica y 3 pacientes con traumatismo costal severo por accidente de tráfico. Resultados La reconstrucción fue satisfactoria en todos los casos, con extubación temprana y sin detectar problemas en la funcionalidad de la pared torácica a nivel respiratorio. Los pacientes con tumores de pared torácica, incluyendo las resecciones esternales, se extubaron en quirófano, así como las deformidades de pared torácica. Los casos de traumatismo torácico se extubaron en menos de 24 h desde la fijación costal interna. No hubo complicaciones en relación con el material utilizado ni con el método de implantación. Conclusiones El titanio es un material ideal para la reconstrucción de la pared torácica en diversas situaciones clínicas, al permitir una gran versatilidad y adaptabilidad en las diferentes reconstrucciones de pared torácica en que se quiera emplear

INTRODUCTION: Chest wall deformities/defects and chest wall resections, as well as complex rib fractures require reconstruction with various prosthetic materials to ensure the basic functions of the chest wall. Titanium provides many features that make it an ideal material for this surgery. The aim is to present our initial results with this material in several diseases. Material and methods From 2008 to 2012, 14 patients were operated on and titanium was used for reconstruction of the chest wall. A total of 7 patients had chest wall tumors, 2 with sternal resection, 4 patients with chest wall deformities/defects and 3 patients with severe rib injury due to traffic accident. Results The reconstruction was successful in all cases, with early extubation without detecting problems in the functionality of the chest wall at a respiratory level. Patients with chest wall tumors including sternal resections were extubated in the operating room as well as the chest wall deformities. Chest trauma cases were extubated within 24 h from internal rib fixation. There were no complications related to the material used and the method of implementation. Conclusions Titanium is an ideal material for reconstruction of the chest wall in several clinical situations allowing for great versatility and adaptability in different chest wall reconstructions

[Use and versatility of titanium for the reconstruction of the thoracic wall]. / Utilidad y versatilidad del titanio para la reconstrucción de la pared torácica.

INTRODUCTION: Chest wall deformities/defects and chest wall resections, as well as complex rib fractures require reconstruction with various prosthetic materials to ensure the basic functions of the chest wall. Titanium provides many features that make it an ideal material for this surgery. The aim is to present our initial results with this material in several diseases. MATERIAL AND METHODS: From 2008 to 2012, 14 patients were operated on and titanium was used for reconstruction of the chest wall. A total of 7 patients had chest wall tumors, 2 with sternal resection, 4 patients with chest wall deformities/defects and 3 patients with severe rib injury due to traffic accident. RESULTS: The reconstruction was successful in all cases, with early extubation without detecting problems in the functionality of the chest wall at a respiratory level. Patients with chest wall tumors including sternal resections were extubated in the operating room as well as the chest wall deformities. Chest trauma cases were extubated within 24h from internal rib fixation. There were no complications related to the material used and the method of implementation. CONCLUSIONS: Titanium is an ideal material for reconstruction of the chest wall in several clinical situations allowing for great versatility and adaptability in different chest wall reconstructions.

Mediastinitis descendente necrotizante de causa odontogénica. A propósito de un caso / Descending necrotizing mediastinitis of odontogenic origin A case REPORT

Introducción: La infección de origen dentario, constituye un motivo muy frecuente de consulta en nuestra práctica diaria. Ocasionalmente dicha infección puede extenderse a través de los espacios cervicales y llegar al mediastino, condicionando una mediastinitis necrotizante descendente (MND).Objetivo: Analizar las posibles causas odontogénicas desencadenantes, así como establecer los gérmenes implicados, sintomatología, tratamiento y evolución. Caso clínico: Paciente varón de 29 años de edad que acude al servicio de urgencias del hospital General universitario de Alicante presentando una mediastinitis descendente necrotizante derivada de una pericoronaritis aguda a nivel del 48. Conclusiones: Las causas más habituales de la MND de carácter odontogénico, son infecciones a nivel de los molares mandibulares, siendo frecuentes los casos derivados de pericoronaritis agudas de los terceros molares inferiores. Se trata de una infección polimicrobiana mixta, que refleja la naturaleza odontogénica. El tratamiento requerido consiste en medidas generales con drenaje adecuado de las colecciones purulentas (AU)

Introduction: This infection originating from the teeth is a frequent subject of consultation in daily practice. The infection may occasionally spread by way of cervical spaces and reach the mediastinum, giving rise to descending necrotising mediastinitis (DNM).Objective: Analyse the possible odontogenic causes and establish the microorganisms involved, symptoms, treatment and development. Clinical case: Male patient aged 29 attends the emergency department of General university hospital in Alicante suffering from descending necrotising mediastinitis deriving from severe pericononitis of level 48.Conclusions: The most common causes of DNM of an odontogenic nature are infectionsof the mandibular molars, cases deriving from severe pericononitis of the third lower molar being frequent. It is a mixed polymicrobial infection, which is a reflection of its odontogenic nature. The treatment required consists of general measures with adequate drainage of purulent collections (AU)

Preoperative chemotherapy plus surgery versus surgery plus adjuvant chemotherapy versus surgery alone in early-stage non-small-cell lung cancer.

PURPOSE: To address whether preoperative chemotherapy plus surgery or surgery plus adjuvant chemotherapy prolongs disease-free survival compared with surgery alone among patients with resectable non-small-cell lung cancer. PATIENTS AND METHODS: In this phase III trial, 624 patients with stage IA (tumor size > 2 cm), IB, II, or T3N1 were randomly assigned to surgery alone (212 patients), three cycles of preoperative paclitaxel-carboplatin followed by surgery (201 patients), or surgery followed by three cycles of adjuvant paclitaxel-carboplatin (211 patients). The primary end point was disease-free survival. RESULTS: In the preoperative arm, 97% of patients started the planned chemotherapy, and radiologic response rate was 53.3%. In the adjuvant arm, 66.2% started the planned chemotherapy. Ninety-four percent of patients underwent surgery; surgical procedures and postoperative mortality were similar across the three arms. Patients in the preoperative arm had a nonsignificant trend toward longer disease-free survival than those assigned to surgery alone (5-year disease-free survival 38.3% v 34.1%; hazard ratio [HR] for progression or death, 0.92; P = .176). Five-year disease-free survival rates were 36.6% in the adjuvant arm versus 34.1% in the surgery arm (HR 0.96; P = .74). CONCLUSION: In early-stage patients, no statistically significant differences in disease-free survival were found with the addition of preoperative or adjuvant chemotherapy to surgery. In this trial, in which the treatment decision was made before surgery, more patients were able to receive preoperative than adjuvant treatment.

Cell-free DNA concentration in pleural fluid and serum: quantitative approach and potential prognostic factor in patients with cancer and pleural effusions.

PURPOSE: The presence of pleural effusions in patients with tumors is often indicative of locally advanced or metastatic disease, and detection of malignancy in effusion samples frequently leads to a disease upstaging. Our purpose was to quantify the DNA in pleural effusion and serum in patients presenting pleural effusion in order to assess the potential prognostic impact. PATIENTS AND METHODS: The DNA level was determined by amplifying hRNase P in paired samples of serum and pleural fluid in 70 consecutive patients with cancer showing pleural effusion. A group of 30 patients without cancer was included. The correlation between serum and pleural DNA was calculated. Survival curves according to serum and pleural DNA were analyzed. RESULTS: Median DNA concentrations were greater in patients with neoplasia than in patients without malignancy: 105 ng/mL versus 40 ng/mL (P = 0.001) in serum samples, respectively; 93 ng/mL versus 21 ng/mL (P = 0.001) in pleural fluids, respectively. A positive correlation between serum and pleural levels was confirmed (r = 0.3; P < 0.05). Median survival time for patients with serum DNA < or = 105 ng/mL was 11.03 months in contrast to only 3.63 months for patients with higher values (P = 0.036). Accordingly, median survival time for patients with pleural DNA < or = 93 ng/mL was 12.3 months versus only 4.63 months in case of higher levels (P = 0.027). CONCLUSION: This study shows that there is a strong correlation between higher levels of free DNA in pleural fluid or serum and malignancy. Survival is worse for patients with higher DNA levels in serum and pleural fluid.

Potential diagnostic value of methylation profile in pleural fluid and serum from cancer patients with pleural effusion.

BACKGROUND: The objective of this study was to investigate the diagnostic value of methylation profiles for discrimination between malignant and benign pleural effusions. A secondary objective was to examine the concordance of methylation in samples of serum and pleural fluid. METHODS: The authors used methylation-specific polymerase chain reaction (MSP) analysis to examine the promoter methylation status of 4 genes in patients with pleural effusion: death-associated protein kinase (DAPK), Ras association domain family 1A (RASSF1A), retinoic acid receptor beta (RARbeta), and p16/INK4a. Pleural effusions were collected from 87 patients who had their diagnoses confirmed on cytologic and/or histologic examinations and clinical evolution. Pleural effusions were classified as malignant (n = 53 patients) or benign (n = 34 patients). RESULTS: Methylation was detected in serum from 45.3% of patients with malignant pleural effusions and from 0% of patients with benign pleural effusions, and it was detected in pleural fluid samples from 58.5% of patients with malignant pleural effusions and from 0% of patients with benign pleural effusions (P = .001). The sensitivity of MSP was greater than that of cytologic examination alone (39.1%; P = .001). When MSP was used together with cytologic examination, sensitivity increased to 69.8% (P = .001). CONCLUSIONS: Cell-free methylated DNA in pleural fluid can be detected in patients with neoplastic malignancy in a single extraction by thoracocentesis. Adequate management of the extracted pleural fluid can provide a rapid and reliable diagnosis in patients with pleural effusions who have suspected malignancy. MSP, used together with cytologic examination, may obviate the need for other invasive diagnostic tests.

Diagnóstico y tratamiento de los derrames pericárdicos no malignos por cirugía videotoracoscópica: ¿una técnica adecuada? / Diagnosis and treatment of nonmalignant pericardial effusion by video-assisted thorascopic surgery: an effective technique?

No disponible

Tratamiento quirúrgico de los tumores neuroendocrinos de localización broncopulmonar / Surgical treatment of bronchopulmonary neuroendocrine tumors

Introducción: El objetivo de este trabajo es revisar nuestra experiencia con los tumores neuroendocrinos de localización broncopulmonar, en especial el tipo de tratamiento quirúrgico aplicado en función del tipo histológico. Material y métodos: Hemos realizado un estudio retrospectivo sobre 45 pacientes: 35 casos de carcinoides típicos, 6 de carcinoides atípicos, 1 oat cell y 3 de carcinomas de células grandes. Los tumores fueron clasificados siguiendo los criterios de Travis. Resultados: El tratamiento quirúrgico practicado fue: 4 neumonectomías, 23 lobectomías, 6 bilobectomías, 3 resecciones atípicas por videocirugía, 7 broncoplastias con lobectomía y 2 broncoplastias sin resección pulmonar. En el 86 por ciento de los casos el estadio fue tipo I (9 IA y 30 IB), clasificándose 5 pacientes como IIIA, y 1 como IIIB. El estudio rutinario de los pacientes incluyó: radiología de tórax, analítica completa, tomografía computarizada toracoabdominal y broncoscopia. El seguimiento medio ha sido de 46,09 meses. Conclusiones: La gran mayoría de tumores neuroendocrinos tratables con cirugía son de bajo grado de agresividad (carcinoides típicos). El tratamiento quirúrgico también es el de elección en la mayoría de los carcinoides atípicos, aunque en éstos el grado de agresividad es mayor, al provocar diseminación ganglionar locorregional o metástasis en mayor proporción que los anteriores. En los carcinomas de célula grande con diferenciación neuroendocrina y en los cacinomas de células pequeñas, el tratamiento óptimo no está bien definido, aunque la cirugía parece ser una opción que debe plantearse siempre que sea posible, combinada o no con otras terapias (AU)