Inaccurate Clinical Stage is Common and Associated With Poor Survival in Patients With Lung Cancer.

INTRODUCTION: Clinical staging in lung cancer has implications for treatment planning and prognosis. We sought to determine the rate of inaccurate clinical stage (relative to pathologic), identify risk factors for inaccuracy, and evaluate the association of inaccuracy on survival. We hypothesized that inaccurate staging was associated with poor survival. METHODS: In this retrospective cohort study, adult patients who received surgical resection without neoadjuvant treatment for nonsmall cell lung cancer from 2004 to 2020 in the National Cancer Database were categorized by accuracy of clinical stage (relative to pathologic stage). Multivariate models were used to determine risk factors for inaccuracy. The association between inaccuracy and overall survival was also analyzed. RESULTS: We identified 255,598 patients with lung cancer, including 84,543 patients (33.1%) who were inaccurately staged. Stage inaccuracy was associated with higher tumor, node, metastasis stage (T-category 3: odds ratio [OR] = 1.2, 95% confidence interval [CI] 1.15-1.28; N-category 2: OR = 2.6, 95% CI 2.47-2.79), greater quantity of lymph nodes evaluated, and more extensive resection (extended lobectomy/bilobectomy: OR = 1.3, 95% CI 1.20-1.37; pneumonectomy: OR = 1.6, 95% CI 1.54-1.74). Patients undergoing robotic surgery were less likely to be inaccurately staged (OR = 0.89, 95% CI 0.852-0.939). Inaccurate staging was associated with worse overall survival (5-y 67.5% accurate versus 55.4% inaccurate, P < 0.001). Inaccurate staging was also associated with worse survival in a multivariate Cox model (hazard ratio [HR] = 1.3, 95% CI 1.29-1.33). Both "understaging" (path > clinical) and "overstaging" (clinical > path) were associated with inferior survival. CONCLUSIONS: Inaccurate clinical stage (relative to pathologic) occurs in one-third of patients receiving surgery for lung cancer. Inaccuracy is associated with poor survival. Quality improvement initiatives should focus on improving clinical staging accuracy.

The Society of Thoracic Surgeons Database Analysis: Comparing Sublobar Techniques in Stage IA Lung Cancer.

BACKGROUND: This study compares sublobar resections-wedge resection and segmentectomy-in clinical stage IA lung cancers. It tests the hypothesis that overall survival after wedge resection is similar to segmentectomy. METHODS: Adults undergoing wedge resection or segmentectomy for clinical stage IA lung cancer were identified from The Society of Thoracic Surgeons General Thoracic Surgery Database. Eligible patients were linked to the Centers for Medicare and Medicaid Services database using a matching algorithm. The primary outcome was long-term overall survival. Propensity scores overlap weighting (PSOW) adjustment of wedge resection using validated covariates was used for group difference mitigation. Kaplan-Meier and Cox regression models analyzed survival. All-cause first readmission, and morbidity and mortality were examined using PSOW regression models. RESULTS: Of 9756 patients, 6141 met inclusion criteria, comprising 2154 segmentectomies and 3987 wedge resections. PSOW reduced differences between the groups. Unadjusted perioperative mortality was comparable, but wedge resection showed lower major morbidity rates. Weighted regression analysis indicated reduced mortality and major morbidity risks in wedge resection. Kaplan-Meier analysis revealed no mortality difference between groups, which was confirmed by PSOW Cox regression models. The cumulative risk of readmission was also comparable for both groups, with Cox Fine-Gray models showing no difference in rehospitalization risks. CONCLUSIONS: In clinical stage IA lung cancer, relative to segmentectomy, wedge resection has comparable overall survival and lower perioperative morbidity, suggesting it is an equally effective option for the broader population of patients with clinical stage IA lung cancer, not only those at highest risk of complications.

National enrollment of lung cancer clinical trials is disproportionate based on race and health care access.

OBJECTIVE: Despite declining lung cancer mortality in the United States, survival differences remain among racial and ethnic minorities in addition to those with limited health care access. Improvements in lung cancer treatment can be obtained through clinical trials, yet there are disparities in clinical trial enrollment of other cancer types. This study aims to evaluate disparities in lung cancer clinical trial enrollment to inform future enrollment initiatives. METHODS: We analyzed patients with non-small cell lung cancer from the National Cancer Database (2004-2018), categorizing them as enrolled or not enrolled in clinical trials based on "rx_summ_other" data element. Clinical, demographic, and institutional factors associated with trial enrollment were assessed using bivariate and multivariate analysis, adjusting for institutional-level clustering. RESULTS: A total of 1924 (0.12%) patients with lung cancer were enrolled in clinical trials. Enrolled patients were predominantly non-Hispanic White (82%), with greater socioeconomic status, treated at academic programs (67%), and had private insurance (42%) or Medicare (44%). They also traveled further for treatment compared with unenrolled patients (56 vs 27 miles, P < .001). After adjusting for demographic and clinical factors, lung cancer trial enrollment was significantly less likely among Black (odds ratio, 0.55; 95% confidence interval, 0.5-0.7, P < .001) and Hispanic (0.66; 95% confidence interval, 0.5-0.9, P = .01) patients. Patients with Medicaid or uninsured, in the lowest socioeconomic status group, and those treated at community-based cancer programs were the least likely to enroll. CONCLUSIONS: Enrollment in lung cancer trials disproportionally excludes minority patients, those in the lowest socioeconomic status, community cancer programs, and the underinsured. These disparities in demographic and access for trial participation show a need for improved enrollment strategies.

Evaluating the Optimal Time Between Diagnosis and Surgical Intervention for Early-Stage Lung Cancer.

INTRODUCTION: There is no consensus on the optimal timing for lung cancer surgery. We aim to evaluate the impact of timing of surgical intervention. We hypothesize delay in intervention is associated with worse overall survival and higher pathologic upstaging in early-stage lung cancer. METHODS: We identified patients with cT1/2N0M0 nonsmall cell lung cancer in the National Cancer Database from 2004 to 2018. Patients were categorized by time to surgery groups: early (<26 d), average (26-60 d), and delayed (61-365 d). Primary outcome was overall survival and secondary outcome was pathologic upstaging. Multivariate models and survival analyses were used to determine factors associated with time from diagnosis to surgery, pathologic upstaging, and overall survival. RESULTS: In multivariate model, advanced age, non-Hispanic Black patients, nonprivate insurance, low median income and education, and treatment at low-volume facilities were less likely to undergo early intervention and compared to the average group were more likely to receive delayed intervention. Pathologic upstaging was more likely in the delayed group (odds ratio 1.11, 1.07-1.14) compared to early group (odds ratio 0.96, 0.93-0.99). Early intervention was associated with improved overall survival (hazard ratio 0.93, 0.91-0.95), while delayed intervention was associated with inferior survival (hazard ratio 1.11, 1.09-1.14). CONCLUSIONS: Expeditious surgical intervention is associated with lower rates of pathologic upstaging and improved overall survival in early-stage lung cancer. Delays in surgery are associated with social and economic factors, suggesting disparities in access to surgery. Lung cancer surgery should be performed as quickly as possible to maximize oncologic outcomes.

Computational risk model for predicting 2-year malignancy of pulmonary nodules using demographic and radiographic characteristics.

OBJECTIVES: To determine whether discriminatory performance of a computational risk model in classifying pulmonary lesion malignancy using demographic, radiographic, and clinical characteristics is superior to the opinion of experienced providers. We hypothesized that computational risk models would outperform providers. METHODS: Outcome of malignancy was obtained from selected patients enrolled in the NAVIGATE trial (NCT02410837). Five predictive risk models were developed using an 80:20 train-test split: univariable logistic regression model based solely on provider opinion, multivariable logistic regression model, random forest classifier, extreme gradient boosting model, and artificial neural network. Area under the receiver operating characteristic curve achieved during testing of the predictive models was compared to that of prebiopsy provider opinion baseline using the DeLong test with 10,000 bootstrapped iterations. RESULTS: The cohort included 984 patients, 735 (74.7%) of which were diagnosed with malignancy. Factors associated with malignancy from multivariable logistic regression included age, history of cancer, largest lesion size, lung zone, and positron-emission tomography positivity. Testing area under the receiver operating characteristic curve were 0.830 for provider opinion baseline, 0.770 for provider opinion univariable logistic regression, 0.659 for multivariable logistic regression model, 0.743 for random forest classifier, 0.740 for extreme gradient boosting, and 0.679 for artificial neural network. Provider opinion baseline was determined to be the best predictive classification system. CONCLUSIONS: Computational models predicting malignancy of pulmonary lesions using clinical, demographic, and radiographic characteristics are inferior to provider opinion. This study questions the ability of these models to provide additional insight into patient care. Expert clinician evaluation of pulmonary lesion malignancy is paramount.

Is Sarcomatoid Lung Cancer Associated With Inferior Overall Survival? A National Cancer Database Analysis.

INTRODUCTION: Sarcomatoid lung cancer has mainly been described in case series and single institution reviews. Although often associated with a poor prognosis, the overall survival compared to other forms of nonsmall cell lung cancer (NSCLC) is unknown. We hypothesize that sarcomatoid lung cancers have worse overall survival relative to other forms of NSCLC. MATERIALS AND METHODS: In this retrospective cohort study, we identified adult patients with nonmetastatic NSCLC from 2004 to 2018 in the National Cancer Database. Patients were categorized by histology as sarcomatoid, adenocarcinoma, or squamous cell carcinoma. We compared clinical and demographic characteristics between the groups. The primary outcome of overall survival was analyzed using Kaplan-Meier analysis. Multivariable Cox analysis was used to analyze factors associated with overall survival in sarcomatoid patients undergoing surgery. RESULTS: Among 1,259,109 patients with lung cancer, there were 5223 (0.4%) sarcomatoid cancers. Sarcomatoid patients were more likely to be male, of Hispanic ethnicity, have fewer comorbidities, and receive treatment at an academic program. Despite higher cT- and M-stages, patients with sarcomatoid cancer were more likely to undergo surgical resection in multivariate analysis (odds ratio = 1.8 [confidence interval 1.60-2.11]; P < 0.001). Among nonmetastatic patients, overall survival was lower for sarcomatoid cancer relative to other histologies in Kaplan-Meier analysis (median survival sarcomatoid 17.6 mo versus nonsarcomatoid 31.5 mo, P < 0.001). CONCLUSIONS: This National Cancer Database study confirms the findings of smaller studies that sarcomatoid cancer is associated with inferior overall survival compared to other NSCLCs. Given the inferior prognosis, further studies regarding optimal staging practices are appropriate.

[Malignant solitary fibrous tumor of the pleura: report of two cases]. / Tumor fibroso solitario maligno de la pleura. Reporte de dos casos.

BACKGROUND: Solitary fibrous tumors of the pleura are infrequent neoplasms of mesenchymal origin that are thought to arise from the submesothelial connective tissue and usually have a benign behavior. However, a small proportion of these tumors may recur or metastasize after surgical treatment, especially when they are associated with malignant morphological and histopathological features. CLINICAL CASES: Two female patients of 56 and 50 years of age who underwent surgical treatment for malignant solitary fibrous tumors of the pleura. The first patient was asymptomatic, whereas the second suffered from coughing, dyspnea and weight loss. The first patient underwent a lung wedge resection and en bloc resection of the chest wall along with the tumor. The second patient underwent multiple lung wedge resections. The histopathological examination showed multiple features associated with malignant behavior in these tumors. After 3 years and 1 year from the time of surgery, respectively, there is no evidence of recurrent or metastatic disease. CONCLUSIONS: Features associated with malignant behavior warrant the need for strict and long-term follow-up by means of chest imaging. It is still uncertain how often and how long this follow-up should be performed.

Resecciones pulmonares en cuña para estudio histopatológico: experiencia de Bucaramanga / Lung wedge resections for histopathologic study: experience in Bucaramanga, Colombia

Introducción. En la gran mayoría de los casos de enfermedad pulmonar intersticial difusa y de nódulos pulmonares indeterminados, se requiere la obtención de tejido pulmonar para llegar a un diagnóstico preciso. El presente estudio presenta la experiencia con las resecciones pulmonares en cuña en una sola institución. Materiales y métodos. Se llevó a cabo un estudio retrospectivo de los pacientes sometidos a resecciones pulmonares en cuña entre 2004 y 2009, en la Fundación Oftalmológica de Santander-Clínica Carlos Ardilla Lülle.Resultados. Se estudiaron 52 pacientes operados durante este periodo. Veintiocho (53,9%) eran hombres; la media de edad fue de 60,5 años. La indicación fue: nódulos en 29 (55,8%) y enfermedad pulmonar intersticial difusa en 23 (44,2%). Los pacientes con nódulos con mayor frecuencia no presentaban ningún síntoma ni hallazgos en el examen físico (p=0,008). El 88,5% de los pacientes fue operado mediante toracoscopia y 76,9% tuvieron una sola resección.La mediana del tiempo quirúrgico fue de 90 minutos fue menor cuando la técnica fue toracoscópica p=0,04) y cuando no se dejó tubo de tórax p=0,0006). No se dejó tubo de tórax en 23,1% de os casos. La media de estancia hospitalaria fue de dos días. La morbilidad y la mortalidad a 30 días fue de 5,8%. En 92% de los casos se estableció un diagnóstico preciso.Conclusiones. La resección pulmonar en cuña en los casos de enfermedad pulmonar intersticial difusa y nódulos indeterminados es segura y puede realizarse con una corta estancia hospitalaria. Puede omitirse el tubo de tórax. En más de 90% de los casos se establece un diagnóstico preciso.

Introduction: In most cases of interstitial lung disease (ILD) and indeterminate pulmonary nodules, lung tissue is needed to achieve a precise a diagnosis. This study seeks to present the experience with lung wedge resections at a single institution. Materials and methods: Retrospective study of patients undergoing lung wedge resections for histopathologic study in the period 2004-2009 at Fundación Oftalmológica de Santander – Clínica Carlos Ardilla Lülle in the city of Bucaramanga, Colombia,.Results: Fifty-two patients were operated on during this period. Twenty-eight (53.9%) were male; mean age was 60.5 years. Indications for surgery were nodules in 29 (55.8%) and ILD in 23 (44.2%). Patients with nodules presented more frequently without symptoms or findings at physical examination (p=0.008). In 88.5% and 76.9% of cases, the thoracoscopic technique was utilized and the number of resections was just one, respectively. Median operative time was 90min and it was shorter when the thoracoscopic technique was employed (p=0.04) and when a chest tube was not left in the pleural space (p=0.0006). A chest tube was not installed in 23.1% of cases. Median hospital length of stay was 2 days. Both morbidity and mortality were 5.8%, respectively. A precise diagnosis was achieved in 92% of patients. Conclusions: Lung wedge resection for ILD and indeterminate nodules is a safe procedure and can be done with a short length of stay. A chest tube can be omitted at the end of the procedure. In more than 90% of cases a precise diagnosis is achieved.

Carcinoma adenoide quístico primario de bronquio lobar: caso clínico / Primary adenoid cystic carcinoma of the lobar bronehus: case report

Primary airway adenoid cystic carcinoma is very uncommon. We report a 60 years old male consulting for hemoptysis and dyspnea. A chest CAT scan showed a mass in the right superior lobar bronehus. The patient was subjected to a right superior sleeve lobectomy and the pathological study of the surgical piece revealed an adenoid cystic carcinoma. The patient received adjuvant radiotherapy. Surgery and radiation therapy are the mainstay of treatment for this type of tumors.

El carcinoma adenoide quístico primario de la vía aérea es una neoplasia muy rara. Reportamos el caso de un paciente de 60 años de edad quien consultó por hemoptisis y disnea de esfuerzo. Una tomografía computarizada del tórax reveló una masa en el bronquio fuente y lobar superior del pulmón derecho. Se realizó una lobectomía superior derecha en manguito. El estudio histopatológico mostró un carcinoma adenoide quístico. Se administró radioterapia adyuvante. La cirugía y la radioterapia son las bases del manejo de este tipo de tumores.

Accidentes biológicos en médicos residentes de Bucaramanga, Colombia / Biological accidents in hospital resident physicians in the city of Bucaramanga, Colombia

Introducción. El riesgo biológico es el más frecuente en el ambiente laboral de los trabajadores del área de la salud. Los médicos residentes son particularmente vulnerables debido a su relativa inexperiencia y a que se encuentran expuestos a muchos pacientes y jornadas laborales largas. Objetivos. Determinar la prevalencia, caracterización y factores asociados a los accidentes biológicos en los médicos residentes.Materiales y métodos. Se realizó un estudio de corte transversal con los médicos residentes de las especializaciones médicas y quirúrgicas en la Universidad Industrial de Santander. Resultados. De 79 médicos residentes, respondieron la encuesta 73 (92,4%). De éstos, 49,3% utilizaban rutinariamente protección completa (guantes, tapabocas y gafas); 35 (48%) reportaron haber sufrido al menos un accidente biológico en su vida y 29 (39,8%) reportaron haber sufrido al menos uno durante la residencia. El 31% no reportó el último accidente. Como factores asociados, se encontró que cursar un programa de residencia quirúrgico comparado con un médico ofrece una razón de prevalencia de 3,17 (IC95% 1,27-7,94; p=0,014); por otra parte, el hecho de haber sufrido un accidente biológico como estudiante de medicina en pregrado da una razón de prevalencia de 2,55 (IC95% 1,53-4,27; p<0,001). Conclusiones. Los accidentes biológicos, especialmente los quirúrgicos y dentro de las salas de cirugía, son frecuentes en los médicos residentes. Se necesitan estrategias que reduzcan el número de accidentes biológicos de manera sistemática y que faciliten su reporte.

Introduction : Biological risk is most frequent among health care workers. Resident physicians are particularly susceptible due to their relative inexperience and exposure to high volume of patients and long workdays. Objectives : To determine the prevalence, characterization and associated factors of biological accidents among hospital resident physicians. Materials and methods : Cross-sectional study on resident physicians in surgical and medical services at Universidad Industrial de Santander (Bucaramanga, Colombia). Results : Of 79 resident physicians, 73 (92.4%) answered the survey. Of these, 49.3% routinely used complete protection (gloves, face mask and protective eyewear); 35 (48%) reported having sustained at least one accident in their lifetimes, and 29 (39.8%) reported at least one accident during the course of their residencies. The last accident was not reported by 31%.Factors found to be associated with a biological accident during residency were a surgical residency, which compared to a medical residency yields a PR=3.17 (CI 95% 1.27 – 7.94; p=0.014); also, having sustained abiological accident as an undergraduate medical student yields a PR=2.55 (CI 95% 1.53 – 4.27; p<0.001). Conclusions: Biological accidents are frequent among resident physicians, especially those on surgical residencies and most occur inside the operating room. Strategies aimed at reducing the number of biological accidents carried out in a systematic way and measures to make reporting easier are needed.

Perforación de íleon terminal y ciego causada por tuberculosis intestinal en un paciente positivo para VIH / Perforation of the terminal ileum and cecum caused by tuberculosis in an HIV positive patient

La tuberculosis es una de las enfermedades infecciosas más prevalentes y su presentación pulmonar es la más frecuente. Sin embargo, debido al aumento en la infección por el virus de la inmunodeficiencia humana (VIH), el envejecimiento de la población, el mayor uso de fármacos inmunosupresores, la inmigración desde áreas endémicas y la aparición de cepas resistentes de Mycobacterium tuberculosis, ha habido un aumento de las presentaciones extrapulmonares. Entre éstas, la tuberculosis abdominal y la gastrointestinal son raras y suelen presentarse clínicamente de manera inespecífica, por lo cual el diagnóstico sólo se logra por medio de imágenes o métodos invasivos para la obtención de tejido. La perforación como complicación de la tuberculosis intestinal es aún menos frecuente. Presentamos el caso de un paciente de 51 años, positivo para VIH, con tuberculosis con compromiso intestinal, quien presentó como complicación la perforación del íleon terminal y el ciego que resultó en su muerte.

Tuberculosis is one of the most prevalent infectious diseases, most frequent in its pulmonary presentation. However, due to the increase in HIV infection, the population getting older, the increase in the use of immunosuppressive drugs, immigration from endemic areas, and the appearance of resistant strains of M. tuberculosis, there has been a rise in the rate of extrapulmonary presentations. Among the extrapulmonary presentations, abdominal and gastrointestinal tuberculosis are rare and usually present with nospecific symptoms, and diagnosis is then achieved through imaging and invasive methods that allow tissue sampling. Perforation as a complication of intestinal tuberculosis is even less frequent. We report the case of a 51-year-old HIV-positive male patient with intestinal tuberculosis who developed perforation of the terminal ileum and cecum resulting in his death.

Accidentes biológicos en estudiantes de Medicina de la Universidad Industrial de Santander, Bucaramanga, Colombia / Biological accidents among Medical students from Universidad Industrial de Santander, Bucaramanga, Colombia

Introducción: Los accidentes biológicos representan un riesgo ocupacional significativo para los trabajadores de la salud, y para los estudiantes de medicina. Objetivos: Establecer la prevalencia de accidentes biológicos y los factores y comportamientos asociados en la población de estudiantes de medicina. Materiales y métodos: Se encuestaron los estudiantes de medicina del área clínica de la Universidad Industrial de Santander. El instrumento de encuesta preguntaba sobre utilización de elementos de protección, caracterización y comportamientos asociados al último accidente biológico sufrido. La información obtenida fue analizada mediante porcentajes y promedios. Para evaluar los factores asociados al accidente se calcularon Razones de Prevalencia y sus IC 95%. Resultados: Se encuestaron 330 estudiantes. El uso rutinario de guantes se reportó en un 99,3%, de doble guante en 13,9%, tapabocas en 77,4% y de gafas en 30,7%. La prevalencia de accidentes biológicos fue de 18%, la cual aumentaba de acuerdo al año de estudio. El accidente no fue reportado en 48% de los casos. Se encontró una asociación positiva entre el sufrimiento de al menos un accidente biológico durante lo cursado de la carrera y el uso completo de medidas de protección en tercer y cuarto año, RP=2,92 (IC 95% 0,95 – 8,93); y negativa para quinto y sexto año, RP=0,84 (IC 95% 0,50-1,41, p=0,0479). Conclusiones: Los accidentes biológicos son frecuentes en nuestros estudiantes de medicina. Se debe insistir desde los primeros semestres en la importancia del uso de elementos de protección, el reporte del accidente y los protocolos postexposición.

Introduction: Biological accidents represent a significant occupational risk to healthcare workers including medical students. Objectives: To establish the prevalence of biological accidents, and its associated factors and behaviors among medical students. Materials and methods: Medical students in clinical clerkships from Universidad Industrial de Santander were surveyed. The survey instrument asked about the use of protective elements, the characteristics and behaviors associated to the last biological accident suffered by the student. Gathered data were analyzed as percentages and means. To evaluate associated factors, Prevalence Ratios and its CI 95% were calculated. Results: Three hundred thirty students were surveyed. Routine use of gloves was reported by 99.3%, double gloving by 13.9%, disposable masks by 77.4% and protective eyewear by 30.7%. Prevalence of biological accidents was 18.0%, which increased with seniority. Accidents were not reported to the occupational health office in 48% of cases. A positive association was found between suffering at least one accident during the career and the complete use of protective elements in third and fourth year students, PR=2.92 (CI 95% 0.95-8.93); while for fifth and sixth year students it was negative, PR=0.84 (CI 95% 0.50-1.41, p=0.0479). Conclusions: Biological accidents are frequent among our medical students. The importance of using protective elements must be emphasized during the first years of training. Medical students must be educated about the key role of reporting accidents and about post-exposure protocols.

Miastenia gravis y el timo: pasado, presente y futuro / Myasthenia gravis and the thymus: past, present, and future

La miastenia gravis es una enfermedad neuromuscular autoinmune caracterizada por debilidad y fatiga muscular. Ha sido reconocida desde hace más de tres siglos, pero sólo hasta el siglo XX se desarrollaron intervenciones terapéuticas encaminadas a aliviar los síntomas y alterar el curso clínico de la enfermedad. En la fisiopatología, se destaca el papel del timo como órgano central que contiene todos los elementos necesarios para iniciar y montar una respuesta inmune contra antígenos propios, particularmente, el receptor de acetilcolina en la placa motora. Debido a esto, la timectomía extendida aparece como una alternativa terapéutica que logra la remisión completa de la enfermedad hasta en 75% de los pacientes y la mejoría hasta de 99%.Sin embargo, el abordaje abierto convencional (esternotomía) es bastante agresivo, por lo que, en los últimos años, la cirugía de tórax ha desarrollado técnicas quirúrgicas mediante toracoscopia asistida por video que permiten realizar el mismo procedimiento con menos complicaciones y mejores resultados cosméticos.Debido al beneficio hasta ahora mostrado, se debe ofrecer el tratamiento quirúrgico a todos los pacientes con miastenia gravis generalizada y a una buena proporción de los que padecen síntomas oculares.

Hernias diafragmáticas: desafío clínico y quirúrgico / Diaphragmatic hernias: a clinical and surgical challenge

Las hernias diafragmáticas se definen como el paso del contenido abdominal a la cavidad torácica a través de un defecto en el diafragma. Se dividen en congénitas (anteriores o de Morgagni y postero-laterales o de Bochdalek) y adquiridas (traumáticas).Las hernias diafragmáticas congénitas producen hipoplasia con hipertensión pulmonar en el recién nacido, lo cual genera alteraciones fisiológicas que amenazan gravemente la vida. El diagnóstico puede realizarse en la etapa prenatal mediante diferentes técnicas de imágenes. El tratamiento consiste en estabilizar los parámetros fisiológicos del neonato y, luego, sí se intenta la corrección quirúrgica del defecto.Las hernias diafragmáticas traumáticas se producen después de un traumatismo cerrado o penetrante. El trauma penetrante la produce con mayor frecuencia, cuando compromete la zona toraco-abdominal. La sensibilidad diagnóstica de las imágenes no es alta, lo que dificulta el diagnóstico; sin embargo, la laparoscopia y la toracoscopia presentan mejores rendimientos diagnósticos y pueden ser utilizadas como abordajes para el tratamiento. La corrección del defecto anatómico en el diafragma debe intentarse una vez se ha hecho el diagnóstico, lo que puede lograrse mediante abordajes quirúrgicos por vía abdominal o torácica.

Complicaciones de los tubos de tórax / Complications of tube thoracostomy

El drenaje del espacio pleural es una frecuente práctica clínica de valor diagnóstico y terapéutico. Las indicaciones más frecuentes de este procedimiento tienen que ver con situaciones en las que se producen depósitos de fluidos en esta cavidad, como aire, sangre, linfa, líquido pleural, pus y otros. Es importante conocer la técnica quirúrgica de inserción y las complicaciones más frecuentes derivadas de la colocación de los tubos de tórax.Realizamos una revisión de la literatura existente sobre el tema, enfatizando en estudios que evaluaran las tasas de complicaciones derivadas de las toracostomías cerradas con tubo. Encontramos que la gran mayoría de estudios sobre complicaciones de la colocación de los tubos de tórax son retrospectivos y en el contexto del trauma. Las complicaciones se han clasificado así: por inserción, posicionales e infecciosas. La tasa general de complicaciones se encuentra entre 3,4% y 36%. Las complicaciones por inserción ocurren en 0% a 7,9% de los casos, las posicionales en 2,4% a 33,3% y las infecciosas en 0,8% a 12%, con empiema en 1,1% a 2,7%. También, hay complicaciones anecdóticas reportadas.Las complicaciones producto de la colocación de un tubo de tórax en la cavidad pleural son frecuentes y en muchos casos clínicamente relevantes. El uso de la técnica de disección roma, la habilidad y el conocimiento, la identificación precoz y el manejo de las posibles complicaciones, pueden reducir la morbimortalidad de este procedimiento.

Primary cutaneous inoculation tuberculosis in a healthcare worker as a result of a surgical accident.

In May 2004, a 48-year-old male surgeon, resident in Bucaramanga, Colombia, suffered a superficial cut with a scalpel to the lateral aspect of the mid-phalanx of the second finger of the left hand while performing a pulmonary decortication surgical procedure for tuberculous empyema with pulmonary entrapment. The injury healed normally but, approximately 2 weeks after the event, an erythematous, nonpainful papule of approximately 3 mm in diameter developed, and increased progressively to 7 mm 3 days after its initial appearance. At this time, the papule showed spontaneous secretion of a clear liquid and superficial ulceration (Fig. 1). Approximately 3 weeks after the injury, a Gram stain of the liquid was performed; it showed no bacteria but a moderate leukocyte reaction. Because of the high suspicion of possible tuberculous infection, bacilloscopy of the liquid was performed, and was positive (++) for acid-fast bacteria (Fig. 2). The liquid was cultured and grew Mycobacterium tuberculosis. The culture was sent to the Laboratory of Mycobacteria at the National Institute of Health, Bogota, Colombia for drug resistance testing. Susceptibility was demonstrated against streptomycin, isoniazid, rifampicin, and ethambutol. During this time, the patient presented an ipsilateral painful axillary adenopathy of about 2.5 cm in diameter. The patient consulted with an infectologist, who initiated a Directly Observed Therapy Short Course (DOTS) regimen [first phase (8 weeks): daily, except Sundays, streptomycin 1 g intramuscularly, pyrazinamide 1500 mg orally, isoniazid 300 mg, and rifampicin 600 mg; second phase (18 weeks): twice weekly rifampicin 600 mg and isoniazid 500 mg], accompanied by daily pyridoxine to prevent secondary effects from isoniazid. After 3 weeks of treatment, the finger lesion had disappeared. Treatment was undertaken as described above, with the patient reporting symptoms of vertigo, nausea, epigastralgia, and mild myalgia as the adverse effects of medication. A chest x-ray was taken and reported to be normal. The axillary adenopathy disappeared approximately 6 months after the injury. Nearly 3.5 years after the incident, the patient has not presented any type of symptomatology.