Técnicas quirúrgicas de estadificación (mediastinoscopia, mediastinostomía, videotoracoscopia, TEMLA, VAMLA) / No disponible

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Metástasis incisional de carcinoma broncogénico tras linfadenectomía mediastínica transcervical extendida / Incisional metastasis from lung cancer after transcervical extended mediastinal lymphadenectomy

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[Perioperative morbimortality in pneumonectomy. Analysis of risk factors]. / Morbimortalidad perioperatoria de la neumonectomía. Análisis de los factores de riesgo.

UNLABELLED: Pneumonectomy continues to be associated with high rates of morbidity and mortality. OBJECTIVE: The aim of this study was to determine the mortality and morbidity rates after pneumonectomy and to analyze perioperative risk factors related to mortality. PATIENTS AND METHODS: The cases of 266 patients undergoing pneumonectomy between January 1986 and December 1997 were reviewed retrospectively: 241 patients with lung cancer, 4 with pulmonary metastasis, 9 with bronchiectasis and 12 with other benign diseases; 13% received neoadjuvant therapy. The bronchial stump was stapled in 92%, sutured in 8%, and covered with autologous tissue in 73%. Intrapericardial pneumonectomy was performed in 32%, pneumonectomy extended to the chest wall or diaphragm in 9%, and completion pneumonectomy was performed in 3%. We collected general demographic data, medical histories, pulmonary function data and surgical technique. Deaths and postoperative complications within the first 30 days after pneumonectomy were also known. RESULTS: Two hundred sixty-six pneumonectomies were performed [right 102 (38%); left 164 (62%)] in 249 men (93%) and 17 women (7%) who were 58 +/- 11 years of age (20 to 79 years). The rate of early postoperative death (30 days) was 5.6%. Mortality rates were higher among patients over 70 years of age (p = 0.045), diabetics (p = 0.038), patients undergoing neoadjuvant therapy (p = 0.031), those with FEV1 under 1,800 ml (p = 0.013), cases of right-sided pneumonectomy (p = 0.001), cases of extended pneumonectomy (p = 0.037) or those without coverage of the bronchial stump (p = 0.005). Mortality was also higher when complications appeared involving the bronchial stump (p < 0.01), heart (p < 0.001), respiration (p < 0.001) or digestion (p = 0.002). Overall morbidity was 40%. Surgical complications developed in 23%: postpneumonectomy empyema (10%), bronchopleural fistula (7%) (with no significant difference related to stapling or suturing), hemothorax (3%) and wound complications (3%). Twelve patients (4.5%) underwent second operations. Cardiac morbidity was 20% (atrial fibrillation in 12%), respiratory morbidity was 8% and other complications appeared in 19% of cases. CONCLUSION: In our experience, mortality after pneumonectomy is 5.6% with an overall complication rate of 40%, mainly due to surgical and cardiac complications. Coverage of the bronchial stump with autologous tissue reduces the risk of postoperative death due to fistula and/or empyema after pneumonectomy.

Morbimortalidad perioperatoria de la neumonectomía. Análisis de los factores de riesgo / Morbidity and mortality during and after pneumonectomy. An analysis of risk factors

Objetivo: Determinar la tasa de mortalidad y morbilidad tras neumonectomía y analizar factores de riesgo perioperatorios relacionados con la mortalidad. Pacientes y métodos: Se han revisado retrospectivamente 266 pacientes sometidos a neumonectomía entre enero de 1986 y diciembre de 1997: 241 casos por carcinoma broncogénico, metástasis pulmonares en 4, bronquiectasias en 9 casos y otra afección benigna en 12 pacientes; el 13 por ciento de los casos recibieron terapia neoadyuvante. El muñón bronquial se suturó mecánicamente en el 92 por ciento y manualmente en el 8 por ciento, y se realizó cobertura del mismo con tejido autólogo en el 73 por ciento de los casos. La neumonectomía fue intrapericárdica en el 32 por ciento, extendida a pared torácica o diafragma en el 9 por ciento y se completó neumonectomía tras resección menor previa en el 3 por ciento de los casos. Se recogieron datos demográficos generales, antecedentes patológicos, datos de función respiratoria y técnica quirúrgica. También se obtuvieron datos de mortalidad y complicaciones postoperatorias en los primeros 30 días tras la neumonectomía. Resultados: Se han realizado 266 neumonectomías, 102 derechas (38 por ciento) y 164 izquierdas (62 por ciento), en 249 varones (93 por ciento) y 17 mujeres (7 por ciento), con una media de 58 ñ 11 años (rango, 20-79 años). La mortalidad postoperatoria temprana (30 días) fue del 5,6 por ciento. La mortalidad fue superior en pacientes mayores de 70 años (p = 0,045), diabéticos (p = 0,038), sometidos a terapia neoadyuvante (p = 0,031), con FEV1 menor de 1.800 ml (p = 0,013), en las neumonectomías derechas (p = 0,001), extendidas (p = 0,037) o sin cobertura del muñón bronquial (p = 0,005). Asimismo, la mortalidad fue mayor cuando aparecieron complicaciones del muñón bronquial (p < 0,01), complicaciones cardíacas (p < 0,001), respiratorias (p < 0,001) y digestivas (p = 0,002). La morbilidad global fue del 40 por ciento. Aparecieron complicaciones quirúrgicas en un 23 por ciento de los casos: empiema posneumonectomía (10 por ciento), fístula broncopleural (7 por ciento) (sin diferencias entre sutura manual y mecánica), hemotórax (3 por ciento) y complicaciones de la toracotomía (3 por ciento). Doce pacientes se reoperaron (4,5 por ciento). La morbilidad cardíaca fue del 20 por ciento (fibrilación auricular en el 12 por ciento), la morbilidad respiratoria fue del 8 por ciento y otras complicaciones aparecieron en el 19 por ciento de los casos. Conclusión: En nuestra experiencia, la mortalidad tras neumonectomía es del 5,6 por ciento, con una morbilidad global del 40 por ciento, principalmente debida a complicaciones quirúrgicas y cardíacas. La cobertura del muñón bronquial con tejido autólogo reduce el riesgo de muerte postoperatoria por fístula y/o empiema posneumonectomía. (AU)

Surgical treatment of childhood mediastinal tuberculous lymphadenitis.

Between 1985 and 1991, we treated 6 children, aged 2 months to 3 years, who required an invasive procedure for the management of complications caused by enlarged mediastinal lymph nodes secondary to tuberculosis. Radiologic and endoscopic studies revealed bronchial involvement by lymph nodes, with endobronchial granulomas and lobar or pulmonary obstruction in 4 patients and marked tracheal and esophageal stenosis produced by extrinsic compression in the remaining 2. Pathologic study of the lymph node or bronchial samples from the 6 patients disclosed granulomas with caseous necrosis and Langhans' giant cells. All the children were treated with a standard 6-month drug regimen consisting of isoniazid, rifampicin, and pyrazinamide. Five of the patients underwent thoracotomy for the purpose of nodal curettage or excision. In 1, upper right lobectomy and bronchoplasty were necessary. The sixth patient was treated by endoscopic resection of the granulomas. There was no postoperative morbidity, and radiologic and endoscopic evidence of resolution of the lesions was observed in all the patients. In our experience, surgical treatment, when performed as a coadjuvant treatment for tracheobronchial complications stemming from mediastinal tuberculous lymphadenitis, results in the resolution of the lesions and has no related morbidity.

Experimental tracheal revascularization with omentum.

We assessed omental revascularization of heterotopic tracheal implants in rats, and investigated the influence of factors that can enhance revascularization. The trachea of the donor animal was excised in two parts, and each tracheal allograft was implanted in the omentum of two recipients. The influence of mechanical factors was evaluated by applying traction at both ends of the graft with and without drainage of the tracheal lumen, and the influence of pharmacologic factors by giving cefonicid, hydrocortisone, cefonicid plus hydrocortisone, or cyclosporine and azathioprine during the postoperative period. Revascularization of the graft from the omentum with preservation of the tracheal structure was established. Graft viability showed significant differences between the tracheal implants to which no traction had been applied and those with traction at both ends. Tracheal allografts from animals receiving immunosuppressants were completely viable and no significant differences were found between the controls and animals in this group.

[Mediastinoscopy: apropos of 100 cases]. / Mediastinoscopia: a propósito de 100 casos.

We have retrospectively reviewed 100 mediastinoscopies that were carried out in our hospital from 1985 to 1988. 12% the of patients had relative contraindications for that examination technique. There was no intraoperative mortality and 5% of the patients presented complications including severe hemorrhage in three patients, bilateral pneumothorax in one patient and loss of radial pulse in another patient who presented left hemiparesis during the immediate postoperative period. We conclude that mediastinoscopy provides essential information for classification and treatment of lung cancer despite its high potential morbidity; a proper anesthetic technique, correct monitoring and the close cooperation with the surgical team render mediastinoscopy a safe procedure.