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Introduction: The number of lung metastases (M1) of colorectal carcinoma (CRC) in relation to the findings of computed tomography (CT) is the object of study. Methods: Prospective and multicenter study of the Spanish Group for Surgery of CRC lung metastases (GECMP-CCR). The role of CT in the detection of pulmonary M1 is evaluated in 522 patients who underwent a pulmonary metastasectomy for CRC. We define M1/CT as the ratio between metastatic nodules and those found on preoperative CT. Disease-specific survival (DSS), disease-free survival (DFS), and surgical approach were analyzed using the Kaplan–Meier method. Results: 93 patients were performed by video-assisted surgery (VATS) and 429 by thoracotomy. In 90%, the M1/CT ratio was =1, with no differences between VATS and thoracotomy (94.1% vs 89.7%, p = 0.874). In the remaining 10% there were more M1s than those predicted by CT (M1/CT > 1), with no differences between approaches (8.6% vs 10%, p = 0.874). 51 patients with M1/CT > 1, showed a lower median DSS (35.4 months vs 55.8; p = 0.002) and DFS (14.2 months vs 29.3; p = 0.025) compared to 470 with M1/CT = 1. No differences were observed in DSS and DFS according to VATS or thoracotomy. Conclusions: Our study shows equivalent oncological results in the resection of M1 of CRC using VATS or thoracotomy approach. The group of patients with an M1/CT ratio >1 have a worse DSS and DFS, which may mean a more advanced disease than predicted preoperatively. Introducción El número de metástasis pulmonares (M1) de carcinoma colorrectal (CCR) en relación con los hallazgos de la tomografía computarizada (TC), es objeto de estudio. Métodos Estudio prospectivo y multicéntrico del Grupo Español de Cirugía de las metástasis pulmonares del CCR (GCMP-CCR). Se evalúa el papel de la TC en la detección de M1 pulmonares en 522 pacientes intervenidos de una metastasectomía pulmonar por CCR. Definimos como M1/CT al cociente entre los nódulos metastásicos y los hallados en la TC preoperatoria. Se analizó la supervivencia específica de enfermedad (SEE), la supervivencia libre de enfermedad (SLE) y el abordaje quirúrgico mediante el método de Kaplan-Meier. Resultados En 93 pacientes se utilizó la cirugía videoasistida (VATS) y 429 toracotomías. En un 90% el cociente M1/TC fue =1, sin diferencias entre VATS y toracotomía (94,1 vs. 89,7%; p = 0,874). En el 10% restante existían más M1 que las predichas por la TC (M1/CT > 1), sin diferencias entre abordajes (8,6 vs. 10%; p = 0,874). Cincuenta y un pacientes con M1/CT > 1, mostraron una menor mediana de SEE (35,4 vs. 55,8 meses; p = 0,002) y SLE (14,2 vs. 29,3 meses; p = 0,025) en comparación con 470 con M1/CT = 1. No se observaron diferencias en la SEE y la SLE según VATS o toracotomía. Conclusiones Nuestro estudio muestra unos resultados oncológicos equivalentes en la resección de M1 de CCR mediante abordaje VATS o toracotomía. El grupo de pacientes con un cociente M1/CT > 1 presentan una peor SEE y SLE, pudiendo significar una enfermedad más avanzada de la predicha preoperatoriamente.

The diagnosis of idiopathic pulmonary fibrosis (IPF) is a complex process that requires the multidisciplinary integration of clinical, radiological, and histological variables. Due to its diagnostic yield, surgical lung biopsy has been the recommended procedure for obtaining samples of lung parenchyma, when required. However, given the morbidity and mortality of this technique, alternative techniques which carry a lower risk have been explored. The most important of these is transbronchial cryobiopsy -transbronchial biopsy with a cryoprobe- which is useful for obtaining lung tissue with less comorbidity. Yield may be lower than surgical biopsy, but it is higher than with transbronchial biopsy with standard forceps. This option has been discussed in the recent clinical guidelines for the diagnosis of IPF, but the authors do not go so far as recommend it. The aim of this article, the result of a multidisciplinary discussion forum, is to review current evidence and make proposals for the use of transbronchial cryobiopsy in the diagnosis of IPF.

OBJECTIVES Unplanned readmission is defined as the return to inpatient hospitalization within 30 days after discharge. Worldwide, its incidence after lung resection ranges between 8% and 50%, and it has been shown to impact both patient recovery and healthcare resources. Our goal was to identify the risk factors to prioritize early follow-ups. METHODS We analysed data from the database of the Grupo Español de Cirugía Torácica Video-Asistida from 33 thoracic surgery departments over 15 months. Standard tests were used to compare the different risk groups. Our goal was to present the most relevant explanatory variables for readmission. RESULTS A total of 174 of 2808 patients (6%) underwent unplanned readmission after a lobectomy. Of all the preoperative individual characteristics, only lung function was found to be a risk factor for readmission [forced expiratory volume in 1 s 10 days after a lobectomy was found to be a risk factor for readmission (RR 1.9). CONCLUSIONS We identified preoperative, intraoperative and postoperative risk factors for readmission. This information can be a useful tool to help with the prioritization of early follow-ups, especially in centres with high workloads.

Introduction: In patients with acute respiratory distress syndrome (ARDS) lung-protective ventilation strategies using low tidal volume and low airway pressure ameliorated outcome but they lead to hypercapnia. Controversial effects of hypercapnia in ARDS patients are nowadays being discussed. Aim: Evaluate the effect of hypercapnia on inflammatory response, mediators of recruitment and apoptosis in human primary alveolar cells (hATII) injured with lipopolysaccharide (LPS). Methods: hATII from pulmonary biopsies of patients that underwent lobectomy were isolated and incubated at 37oC with 5% CO2 (Normocapnia) or 15% CO2 (Hypercapnia; pCO2=80 mmHg) with or without 15mM THAM buffer to maintain pH at 7.4. All groups were injured with 100 ng/ml LPS. Pro-inflammatory molecules (IL-1β, iNOS), mediators of cellular recruitment (IL-8, CCL-2) and apoptosis (caspase-3) were analyzed. Results: In hATII injured with LPS the expression of mediators of neutrophils (IL-8) and monocytes (CCL-2) recruitment was decreased when cells were exposed to hypercapnia (Figure). No effects of hypercapnia were found when analyzing pro-inflammatory markers and apoptosis. Conclusions: Hypercapnic conditions in hATII cells injured with LPS reduced the expression of mediators of recruitment of pro-inflammatory cells but did not affect pro-inflammatory molecules nor apoptosis. There is a need to better understand the biological and physiological effects of hypercapnia.

The diagnosis of idiopathic pulmonary fibrosis (IPF) is a complex process that requires the multidisciplinary integration of clinical, radiological, and histological variables. Due to its diagnostic yield, surgical lung biopsy has been the recommended procedure for obtaining samples of lung parenchyma, when required. However, given the morbidity and mortality of this technique, alternative techniques which carry a lower risk have been explored. The most important of these is transbronchial cryobiopsy -transbronchial biopsy with a cryoprobe- which is useful for obtaining lung tissue with less comorbidity. Yield may be lower than surgical biopsy, but it is higher than with transbronchial biopsy with standard forceps. This option has been discussed in the recent clinical guidelines for the diagnosis of IPF, but the authors do not go so far as recommend it. The aim of this article, the result of a multidisciplinary discussion forum, is to review current evidence and make proposals for the use of transbronchial cryobiopsy in the diagnosis of IPF.

BACKGROUND: To assess possible differences in the perioperative profile between men and women in lung cancer surgery. METHODS: A prospective cohort multicenter study was design, in which consecutive patients undergoing curative intent surgery for lung cancer in 24 Thoracic Services throughout Spain were included. Clinical features, tumor- and surgery-related data, postoperative complications, and mortality were recorded. RESULTS: There were 2,566 men and 741 women. Women were younger than men [mean (SD) age, 61.8 (10.8) vs. 66.5 (9.1) years, P

Objectives To investigate the capacity of a trained dog to identify LC in patients with malignant SPN. Methods We collected 90 exhaled gas samples from 30 patients with SPN (3 samples/patient). As controls we used 61 healthy volunteers and 18 COPD patients without SNP or LC, in each of whom we collected 5 exhaled gas samples (n = 395). The dog (Blat, a 4-year-old crossbreed between a Labrador Retriever and a Pitbull) and the methodology used were the same as previously reported by our group (see: https://drive.google.com/open?id=1R4mOtOtuZkTeb5iOEEv0K9r2kHKlPhWd ). Results Of 30 patients with SPN, Blat recognized 27 of them as positive for LC and 3 as negative for LC. These results fully matched post-surgical pathological results. Sensibility was 0.97, Specificity 0.99, Positive Predictive value 0.97 and negative predictive value 0.99. The AUC of the ROC curve was 0.985. Conclusions Trained dogs can identify accurately the malignant origin of SPN. It is now time to develop technology that can match canine olfaction and facilitate the implementation of this diagnostic approach in the clinic.

Background Idiopathic pulmonary fibrosis (IPF) is a progressive and fatal lung disease with limited response to currently available therapies. Alveolar type II (ATII) cells act as progenitor cells in the adult lung, contributing to alveolar repair during pulmonary injury. However, in IPF, ATII cells die and are replaced by fibroblasts and myofibroblasts. In previous preclinical studies, we demonstrated that ATII-cell intratracheal transplantation was able to reduce pulmonary fibrosis. The main objective of this study was to investigate the safety and tolerability of ATII-cell intratracheal transplantation in patients with IPF. Methods We enrolled 16 patients with moderate and progressive IPF who underwent ATII-cell intratracheal transplantation through fiberoptic bronchoscopy. We evaluated the safety and tolerability of ATII-cell transplantation by assessing the emergent adverse side effects that appeared within 12 months. Moreover, pulmonary function, respiratory symptoms, and disease extent during 12 months of follow-up were evaluated. Results No significant adverse events were associated with the ATII-cell intratracheal transplantation. After 12 months of follow-up, there was no deterioration in pulmonary function, respiratory symptoms, or disease extent. Conclusions Our results support the hypothesis that ATII-cell intratracheal transplantation is safe and well tolerated in patients with IPF. This study opens the door to designing a clinical trial to elucidate the potential beneficial effects of ATII-cell therapy in IPF.

BACKGROUND Patients with pulmonary metastases from colorectal cancer (CRC) may benefit from aggressive surgical therapy. The objective of this study was to determine the role of major anatomic resection for pulmonary metastasectomy to improve survival when compared with limited pulmonary resection. PATIENTS AND METHODS Data of 522 patients (64.2% men, mean age 64.5 years) who underwent pulmonary resections with curative intent for CRC metastases over a 2-year period were reviewed. All patients were followed for a minimum of 3 years. Disease-specific survival (DSS) and disease-free survival (DFS) were assessed with the Kaplan-Meier method. Factors associated with DSS and DFS were analyzed using a Cox proportional hazards regression model. RESULTS A total of 394 (75.6%) patients underwent wedge resection, 19 (3.6%) anatomic segmentectomy, 5 (0.9%) lesser resections not described, 100 (19.3%) lobectomy, and 4 (0.8%) pneumonectomy. Accordingly, 104 (19.9%) patients were treated with major anatomic resection and 418 (80.1%) with lesser resection. Operations were carried out with video-assisted thoracoscopic surgery (VATS) in 93 patients. The overall DSS and DFS were 55 and 28.3 months, respectively. Significant differences in DSS and DFS in favor of major resection versus lesser resection (DSS median not reached versus 52.2 months, P = 0.03; DFS median not reached versus 23.9 months, P < 0.001) were found. In the multivariate analysis, major resection appeared to be a protective factor in DSS [hazard ratio (HR) 0.6, 95% confidence interval (CI) 0.41-0.96, P = 0.031] and DFS (HR 0.5, 95% CI 0.36-0.75, P < 0.001). The surgical approach (VATS versus open surgical resection) had no effect on outcome. CONCLUSION Major anatomic resection with lymphadenectomy for pulmonary metastasectomy can be considered in selected CRC patient with sufficient functional reserve to improve the DSS and DFS. Further prospective randomized studies are needed to confirm the present results.

Resumen Introduccion Aunque la introduccion de la tecnica de Nuss revoluciono el tratamiento quirurgico del pectus excavatum, no se ha generalizado su uso en nuestro medio. El objetivo de este estudio es conocer la situacion actual del uso de esta tecnica en una seleccion de Servicios de Cirugia Toracica de Espana. Metodos Estudio observacional retrospectivo multicentrico que analiza los principales aspectos epidemiologicos y resultados clinicos tras 10 anos de experiencia empleando tecnica de Nuss. Resultados Entre 2001 y 2010 se intervino a 149 pacientes (media de edad 21,2 anos), 74% varones. Los resultados esteticos iniciales fueron excelentes o buenos en el 93,2%, regulares en el 4,1% y malos en el 2,7% de los casos. Un total de 45 pacientes (30,6%) presentaron complicaciones tras la primera intervencion. Las mas frecuentes fueron la presencia de seroma en las heridas quirurgicas, desplazamiento de la barra, rotura del estabilizador, neumotorax, hemotorax, infeccion de la herida, neumonia, pericarditis y un taponamiento pericardico que requirio la extraccion de la barra de urgencia. El dolor postoperatorio fue referido por todos los pacientes y 3 de ellos (2%) requirieron la extraccion precoz de la barra por dolor intratable. Tras una media de 39,2 meses, se habia retirado la barra a 72 pacientes (49%), con dificultades en la extraccion en 5 (7%). Tras un seguimiento medio de 1,6 anos se constato buen resultado en 145 pacientes (98,7%). Conclusiones La tecnica de Nuss en adultos ha tenido buenos resultados en los Servicios de Cirugia Toracica espanoles aunque no se ha generalizado su utilizacion. Las posibles complicaciones se han de tener en cuenta, por lo que la indicacion debe ser muy bien valorada. La posibilidad de un tratamiento conservador previo es valorado por alguno de los servicios en la actualidad.

Resumen Introduccion Nuestro objetivo fue evaluar si el numero y el volumen de las biopsias pulmonares quirurgicas (BPQ) influyen en el diagnostico de la enfermedad pulmonar intersticial difusa (EPID). Metodos Estudio retrospectivo de BPQ por sospecha de EPID en los pacientes de la Clinica Mayo desde enero de 2002 hasta enero de 2010. Los datos se recogieron y analizaron en la institucion. Resultados Se analizaron 311 pacientes. El numero medio de biopsias fue de 2,05 (DE 0,6); una biopsia en 50 (16%), dos en 198 (63,7%), tres en 59 (19%) y cuatro en 4 (1,3%). El diagnostico histopatologico fue: definitivo (especifico) en 232 (74,6%), descriptivo (no especifico) en 76 (24,4%) no hubo diagnostico en 3 (1%). Tras excluir a los pacientes sin diagnostico (n = 3), hubo 50 pacientes con solo una biopsia, 196 con dos y 62 con tres o cuatro. El rendimiento de diagnostico definitivo fue similar en los tres grupos (37/50 [74%], 150/196 [77%] y 45/62 [73%]). El valor p de Chi-cuadrado fue 0,8. El analisis del indice de propension entre pacientes con una BPQ y pacientes con mas de una BPQ tampoco mostro ninguna diferencia en el rendimiento diagnostico. En cuanto al volumen de las biopsias, el volumen total medio fue 34,4 cm3 (DE = 46). En los pacientes sin diagnostico, 41,2 cm3 (3 casos), en pacientes con diagnostico especifico, 33,6 cm3 (232 casos [DE = 47]) y en pacientes con un diagnostico descriptivo: 36,6 cm3 (76 pacientes [DE = 44]). El volumen de la biopsia no influyo en el rendimiento de la histopatologia (ANOVA, p = 0,8). Conclusiones El numero o el volumen de las muestras de biopsia quirurgica no parecen influir en el diagnostico. Segun nuestros resultados creemos que una sola muestra de un area representativa puede ser suficiente para el diagnostico. Se deben realizar ensayos prospectivos aleatorizados para optimizar la BPQ en las EPID.

Introduction Our objective was to evaluate whether the number and volume of surgical lung biopsies (SLBs) influence the diagnosis of diffuse interstitial lung disease (ILD). Methods Retrospective study of SLB for suspected ILD in patients from the Mayo Clinic from January 2002 to January 2010. Data were collected in the institution and analyzed. Results 311 patients were studied. Mean number of biopsies was 2.05 (SD 0.6); 1 biopsy in 50 (16%), 2 in 198 (63.7%), 3 in 59 (19%) and 4 in 4 (1.3%). Histopathologic diagnosis was: definitive (specific): 232 (74.6%), descriptive (non-specific): 76 (24.4%), no diagnosis: 3 (1%). After excluding patients without diagnosis (n=3), there were 50 patients with only 1 biopsy, 196 with 2 and 62 with 3 or 4; the definitive diagnostic yield was similar in all 3 groups (37/50; 74%, 150/196; 77%, and 45/62; 73%) (Chi-square, P value .8). The propensity score analysis between patients with 1 SLB and patients with more than 1 SLB also showed no difference in diagnostic yield. Regarding the volume of biopsies, mean total volume was 34.4 cm3 (SD 46): 41.2 cm3 (3 cases) in patients with no diagnosis; 33.6 cm3 (232 cases, SD 47) in patients with specific diagnosis; and 36.6 cm3 (76 cases, SD 44) in patients with descriptive diagnosis. Biopsy volume had no influence on histopathology yield (ANOVA, P value .8). Conclusions The number and volume of the biopsy specimens in SLB did not seem to influence diagnosis. Based on our results, we believe a single sample from a representative area may be sufficient for diagnosis. Randomized prospective trials should be performed to optimize SLB for ILD.

Objective: To determine if lung ultrasound semiology is applicable to the post-surgical hemithorax, and its value in the evaluation of lung expansion in the postoperative period when paired with the use of digital chest drain systems. Methods: Prospective observational study including all patients undergoing thoracic surgery from June 2012 to March 2013. Patients undergoing pleurodesis or hemodynamically unstable were not considered candidates. Final inclusion in the study was based on the availability of digital chest drain system. A transthoracic lung ultrasound evaluation of the anterior and anterolateral windows was performed 20 minutes after chest drain placement. Presence or not of lung sliding and air leak values taken from the digital chest drain system were recorded. Data were submitted to a binomial classification test for analysis. Results: Forty-nine patients were included, yielding a total of 64 hemithoraces. Lung sliding was seen in 53 cases (82.8%), and an air leak value of 20 ml/min or less in 56 cases (87.5%). Sensitivity was 92.8% (95% CI: 82.6% to 97.9%) and specificity 87.5% (95% CI: 47.3% to 97.9%). Positive predictive value was 98.1%, and negative predictive value was 63.6%. Conclusions: Transthoracic lung ultrasound is a useful technique that can complement the use of digital chest drain systems in the evaluation of post-surgical lung expansion. The incorporation of lung ultrasound can greatly reduce the need for chest radiographs in thoracic surgery departments.

Paravertebral block (PVB) with infusion of local anaesthetic (LA) through a paravertebral catheter is an effective alternative to epidural analgesia in the management of post-thoracotomy pain. PVB can be done in two ways: either through administration of a bolus dose of the LA or continuous infusion via an infusion pump; currently, there is no consensus on which route is best. Our objective was to compare the efficacy of the PVB for post-thoracotomy pain control using bolus doses versus a continuous infusion pump.We performed a prospective randomized study of 80 patients submitted to thoracotomy. Patients were divided into two independent groups (anterior thoracotomy--ANT--and posterolateral thoracotomy-POST). At the conclusion of the surgery, a catheter was inserted under direct vision in the thoracic paravertebral space at the level of the incision. In each group, patients were randomized to receive levobupivacaine 0.5% every 6 h ('Bolus' group) or levobupivacaine 0.25% in continuous infusion at 5 ml/h through an elastomeric pump ('Continuous infusion' group). Patients in both groups received the same dosage of LA: 300 mg/day. Metamizole (every 6 h) was administered as an adjunct. Subcutaneous meperidine was employed as a rescue medication. Pain scores were measured using the visual analogue scale (VAS) at 1, 6, 24, 48 and 72 h after surgery.Thirteen (16.2%) patients required meperidine for rescue (8 in continuous infusion and 5 in the bolus group). Mean VAS scores were the following: all the cases (n = 80): 5.0 ± 1.6, ANT (n = 36): 4.4 ± 1.8, POST (n = 44): 5.4 ± 1.6, Bolus (n = 40): 4.7 ± 1.7, Continuous infusion (n = 40): 5.2 ± 1.8, ANT with bolus (n = 18): 4.1 ± 1.7, ANT with continuous infusion (n = 18): 4.7 ± 1.8, POST with bolus (n = 22): 5.2 ± 1.5, POST with continuous infusion (n = 22): 5.6 ± 1.6.Post-thoracotomy pain control using a combination of PVB and a non-steroidal anti-inflammatory drug is a safe and effective approach. Patients submitted to ANT experienced less pain than those with POST 4.4 vs 5.4 (P = 0.02). Since no statistical differences were observed, it was not possible to confirm differences between the LA administered in a bolus versus continuous infusion.

Resumen Introduccion La reseccion videotoracoscopica (VTC) de los nodulos pulmonares (NP) perifericos requiere en ocasiones la practica de una minitoracotomia para su localizacion mediante palpacion. El objetivo de este estudio es evaluar la eficacia como metodo de localizacion preoperatoria de los NP de la colocacion de un arpon guiado por TAC. Material y metodos Desde noviembre de 2004 hasta enero de 2011, 52 pacientes fueron programados para localizacion preoperatoria de 55 NP mediante la colocacion de un arpon guiado por TAC. Resultados Un total de 52 pacientes (31 hombres y 21 mujeres) con edades entre 28 y 84 anos (media: 62,2 anos) con NP Conclusiones La identificacion preoperatoria de los NP permite su reseccion VTC directa. La colocacion de un arpon guiado por TAC en los NP constituye un procedimiento seguro y efectivo que puede llevarse a cabo en un programa de cirugia ambulatoria.

In order to develop a practical risk score for 90-day mortality following surgical lung biopsy (SLB) for interstitial lung disease (ILD) we reviewed 311 consecutive patients undergoing SLB for ILD between 2002 and 2009. Postoperative complication, 30-day and 90-day mortality rates were 11.5%, 9% and 10.6% respectively. Univariable and multivariable analyses, validated by bootstrap statistics, were used to identify factors associated with 90-day mortality. A scoring system was developed by proportionally weighting the regression coefficients of the significant predictors of 90-day mortality: age >67 (P 3 (86%); P

Objectives To evaluate whether the location and number of lung biopsies obtained by video-assisted thoracoscopy (VAT) influence the diagnosis of diffuse interstitial lung disease (ILD). To assess the applicability of an ambulatory surgery program (ASP). Methods Prospective, multicenter study of VAT lung biopsies due to suspected ILD from January 2007 to December 2009, including 224 patients from 13 Spanish centers (mean age 57.1 years; 52.6% females). Data were prospectively collected in every institution and sent to the coordination center for analysis. Results The most affected areas in high-resolution chest CT were the lower lobes (55%). Bronchoscopy was performed in 84% and transbronchial biopsy in 49.1%. In 179 cases (79.9%), more than one biopsy was performed, with a diagnostic agreement of 97.2%. A definitive histopathologic diagnosis was obtained in 195 patients (87%). Idiopathic pulmonary fibrosis was the most frequent diagnosis (26%). There were no statistically significant factors that could predict a greater diagnostic yield (neither anatomical location nor number of biopsies). Seventy patients (31.3%) were included in an ASP. After discharge, there were complications in 12 patients (5.4%), similar between patients admitted postoperatively (9/154: 5.8%) and those included in an ASP (3/70: 4.3%). Conclusions Anatomical location and number of lung biopsy specimens did not seem to influence the diagnosis. The patients included in an ASP had a complication rate comparable to that of the hospitalized, so this procedure can be included in a surgical outpatient program. Lung biopsy obtained by VAT is a powerful and safe tool for diagnosis of suspected ILD, resulting in a definitive diagnosis for the majority of patients with a low morbidity rate.

Resumen Introduccion La fuga aerea persistente es una de las mas frecuentes complicaciones despues de una reseccion pulmonar. Debido a las diferencias de parametros subjetivos para la retirada del drenaje en el postoperatorio, nosotros disenamos un estudio prospectivo, comparativo y consecutivo para evaluar de una manera objetiva como los dispositivos digitales (Thopaz® y Digivent®) pueden medir la fuga aerea comparandolos entre ellos y, a su vez, con Pleur-Evac®, en beneficio de una retirada precoz del drenaje toracico. Metodo Estudio prospectivo, comparativo y consecutivo de 75 pacientes a los que se les habia realizado de manera electiva una reseccion pulmonar debido a cancer de pulmon no microcitico. Comparamos los 2 dispositivos digitales entre si y, a su vez, con el dispositivo no digital. Resultados Los resultados poblaciones no fueron significativos entre los 3 grupos. La retirada del drenaje toracico fue el siguiente: Thopaz® a los 2,4 dias, Digivent® a los 3,3 dias y Pleur-Evac® a los 4,5 dias. Los pacientes y el personal de Enfermeria se encontraron subjetivamente mas comodos con el dispositivo digital. Los cirujanos obtuvimos informacion objetiva con el dispositivo digital. Los sistemas de alarma de Thopaz® fueron efectivos para el uso de un paciente de manera ambulatoria. Conclusion El sistema digital y continuo de medicion de la fuga aerea reduce el dia de la retirada del drenaje toracico, asi como los dias de estancia intrahospitalaria. El sistema de alarmas de Thopaz® es muy util para prevenir las deficiencias del sistema. Hace innecesaria la aspiracion desde un sistema centralizado. Las curvas de medicion de presion intrapleural y extrapleural pueden hacer predecible la necesidad de un tipo de drenaje para cada paciente segun su enfermedad.

Introduction Persistent air leaks represent the most common pulmonary complication after elective lung resection. Since there are insufficient data in the literature regarding variability in the withdrawal of postoperative pleural drainages, we have designed a prospective, consecutive and comparative study to evaluate if the use of digital devices (Thopaz and DigiVent) to measure postoperative air leak compared to a Pleur-Evac varies on deciding when to withdraw chest tubes after lung resection. Methods A prospective, consecutive and comparative trial was conducted in 75 patients who underwent elective pulmonary resection for non small cell lung cancer. This study compared two digitals devices with the current analogue version in 75 patients. The digital and analogue groups had 26, 24, and 25 patients, respectively. Results Clinical population data were not statistically different between the groups. The withdrawal of the chest tube was Thopaz, 2.4 days; Digivent, 3.3 days and PleurEvac, 4.5 days. Patients and nurses were subjectively more comfortable with digital devices. Surgeons obtained more objective information with digital devices. The safety mechanism of the Thopaz was also subjectively better, and one patient was discharged home without complications after one week. Conclusions The digital and continuous measurement of air leak instead of the currently used static analogue systems reduced the chest tube withdrawal and hospital stay by more accurately and reproducibly measuring air leak. Intrapleural pressure curves from the Digivent may also help predict the optimal chest tube setting for each patient. The Thopaz alarm mechanism is very useful to prevent deficiencies in the mechanism and do not required wall suction.

In summary, from the different alternatives to conventional hospitalization developed in the last decades, outpatient surgery has been the one with the greatest growth. However, only few studies have been reported on thoracic surgery and there is still great potential for an increase in outpatient thoracic surgery. The aim of this article has been to evaluate the clinical aspects, results, and economical impact of an outpatient thoracic surgery program (OTSP). Video-assisted mediastinoscopy, lung biopsy, and bilateral thoracic sympathectomy can be accomplished safely in a significant percentage of cases as ambulatory patients. The impact of the economical benefit of outpatient thoracic surgical program over the conventional hospitalization depends on the previous department's policy on hospital stay. Further experience is needed to increase the substitution index and expand the OTSP to other procedures.

Resumen Objetivo Valorar los resultados y complicaciones de la simpaticotomia toracica videotoracoscopica (VATS) en el tratamiento de los pacientes diagnosticados de rubor facial incontrolable y/o hiperhidrosis facial. Pacientes y metodo Entre mayo de 2000 y agosto de 2006, llevamos a cabo 82 simpaticotomias toracicas por VATS en 41 pacientes diagnosticados de rubor facial incontrolable y/o hiperhidrosis facial. Dos de ellos habian sido intervenidos anteriormente sin resultados satisfactorios. La tecnica empleada fue la simpaticotomia bilateral, variando los niveles en funcion de la presencia de hiperhidrosis palmar y/o axilar asociada y de las limitaciones anatomicas. Los resultados fueron evaluados a la semana y a los 3-6 meses en los 41 pacientes y al ano de la intervencion en 34 pacientes. Resultados Habia 22 varones y 19 mujeres, con una media de edad de 33,7 (intervalo, 18-56) anos. En 17 (41,5%) pacientes el sintoma principal era la hiperhidrosis facial y en 24 (58,5%), el rubor facial incontrolable. Todos los pacientes fueron dados de alta antes de las 24 h de la intervencion, 14 de ellos en un programa de cirugia sin ingreso. Se obtuvo mejoria de la hiperhidrosis facial en todos los casos 17/17 (100%). En el grupo de rubor la tecnica fue eficaz en 20/24 (83,3%) casos. Se obtuvo resultados satisfactorios con la segunda intervencion. Se constato sudoracion compensadora en 16/41 (39%) pacientes, que fue grave en 6 (14.6%). Conclusiones La simpaticotomia toracica por VATS es un procedimiento seguro y efectivo para el manejo de la hiperhidrosis facial y el rubor incontrolable. La sudoracion compensadora permanece como el principal efecto secundario.

Objectives: Paravertebral block is an effective alternative to epidural analgesia in the management of post-thoracotomy pain, however, there are no established guidelines regarding what is the most suitable strategy when varying drugs and dosages between different groups. Our objective was to evaluate the effectiveness of paravertebral block comparing the most frequently employed drugs in this procedure (bupivacaine vs ropivacaine). Methods: Prospective randomized study of 70 patients submitted to thoracotomy. Patients were divided in two independent groups (anterior thoracotomy (AT) and posterolateral thoracotomy (PT)). At the end of surgery a catheter was inserted under direct vision in the thoracic paravertebral space at the level of incision. In each group (ATor PT) patients were randomized to receive a bolus of 15 ml of bupivacaine 0.5% or 20 ml of ropivacaine 0.2% before closing the thoracotomy. They postoperatively received 10 ml of bupivacaine or 15 ml of ropivacaine every 6 h combined with methamizol (every 6 h). Subcutaneous meperidine was employed as rescue drug. The level of pain was measured with the visual analogic scale (VAS) at 1, 6, 24, 48 and 72 h after surgery. The need of meperidine as rescue drug and secondary effects was also recorded. Results: We did not register secondary effects in relation to the paravertebral catheter (paravertebral or cutaneous bleeding or hematoma, respiratory depression (respiratory rate

Resumen Introduccion Las causas mas frecuentes de derrame pericardico (DP) y/o taponamiento pericardico (TP) son los tumores malignos. Los mas habituales son el carcinoma broncogenico y el de mama. El tratamiento es el drenaje y/o ventana pericardica (VP) habitualmente realizados por via subxifoidea. En este estudio empleamos el abordaje por videotoracoscopia (VTC), un procedimiento poco referido en la literature medica. Objetivo Evaluar la eficacia del tratamiento del DP y/o TP mediante la realizacion de una VP por VTC. Pacientes y metodos Estudio retrospectivo de 12 pacientes diagnosticados de DP y a los que se practico una VP mediante VTC durante un periodo de 10 anos (entre febrero de 1994 y octubre de 2004). El procedimiento quirurgico empleado fue la VTC, con anestesia general, intubacion selectiva y decubito lateral. Se efectuo de manera sistematica una VP anterior al nervio frenico y el estudio del liquido pericardico y pleural. Se anadio pleurodesis con talco si habia derrame pleural neoplasico –filiado previamente mediante toracocentesis y citologia del liquido pleural–. Se dejo un drenaje pleural (24 F) que se retiro cuando el debito fue menos de 100 ml al dia. Resultados Se intervino a 12 pacientes, 4 varones y 8 mujeres, con una media (intervalo) de edad de 58,6 (32-78) anos. La mortalidad quirurgica fue nula. Hubo 8 casos de TP. Las causas de DP fueron: cancer de mama en 8 casos, carcinoma broncogenico en 3 casos y un caso de origen infeccioso. La duracion media del acto operatorio fue 30 min. Los 12 pacientes presentaron derrame pleural asociado. El abordaje quirurgico fue izquierdo en todos los casos. Se asocio pleurodesis con talco en 8 casos de los 12 que presentaban derrame pleural, en todos ellos la citologia previa del liquido habia sido compatible conderrame pleural paraneoplasico. No hubo mortalidad asociada al procedimiento. El ingreso medio fue 3,8 dias. La supervivencia media fue de 12 meses en el grupo de cancer de mama y 4 meses en el de carcinoma broncogenico. Conclusiones La realizacion de una VP por VTC es una tecnica adecuada para el manejo del DP masivo o el TP. En nuestra experiencia este procedimiento presento una mortalidad nula y una morbilidad minima, y se logro la mejoria sintomatica (en lo que se refiere a correccion del DP y pleural) en todos los casos. Este abordaje permite, ademas, valorar la cavidad pleural, obtener muestras de pleura parietal y, si fuera necesario, realizar pleurodesis con talco.

Pectus excavatum (PE) is the most common congenital chest wall deformity. It consists of a concavity of the sternum, and the costal cartilages derived from an unbalanced growth of the costochondral regions of the anterior chest wall. The standard operative treatment for PE has been the Ravitch procedure. This technique requires a long incision in the anterior chest wall and bilateral resection of the affected costal cartilages, needing in most cases a posterior metal bar support. The belief that the treatment of PE is basically esthetic led Donald Nuss to develop in 1998 a minimally invasive surgical treatment based on the skeletal frame plasticity and reshape capacity applied to the thorax. Thereby he deviced a technique involving a retrosternal steel bar modifying the sternum´s concavity and supporting the shape of the amended thorax, all performed through two small incisions at each side of the thorax with the help of a thoracoscope. The bar is maintained from 2 to 3 years, and removed after this period. This procedure obtains90% of positive results with significant esthetic improvement and patient satisfaction. This minimally surgical approach for PE is to be discussed in this review.

BackgroundThe aim of this study was to investigate the yield of cervical mediastinoscopy (CM) for pathologically diagnosed non-small cell lung cancer (NSCLC), with respect to lymph node size on computed tomography (CT), cell type, and the location of the primary tumor.MethodsWe reviewed 142 patients who underwent standard cervical mediastinoscopy from April of 1994 to June of 2003 for pathologically diagnosed NSCLC. The staging yield was determined by the percentage of “positive” CM (metastatic paratracheal or subcarinal nodes). Mediastinoscopy was performed when the lymph node diameter was >1 cm and, since 2001, whenever paratracheal or subcarinal lymph nodes were clearly seen on CT, regardless of size. Group A includes patients with lymph nodes on CT of ≥1 cm. Group B includes patients with lymph nodes of 1 cm), 37.9%, and group B (lymph nodes

Objective: To evaluate clinical aspects, results and the economic impact of the outpatient thoracic surgery programme (OTSP) developed in our Department. Methods: Prospective study of 300 patients who entered in the OTSP from April 2001 to March 2005. The procedures performed were videomediastinoscopy (MC), videothoracoscopic lung biopsy (LB) and videothoracoscopic bilateral thoracic sympathectomy (TS). All procedures were performed under general anaesthesia and patients were discharged in 4—6 h. We analyse demographic data, the substitution index (SI), the admission rate (AR) and readmission rate (RR) after the procedure. We calculate the economic impact of stay expenses on our hospitalandonotherSpanishhospitals.Results:Thefemale/maleratioofthe300patientswas83/217,withameanageof58.1years(range:15— 85 years). There were no deaths. Mediastinoscopy was performed as outpatient procedure in 210 patients (mean age: 65.6 years) out of 244 total MC (SI = 86.1%). Two patients were admitted (AR = 0.95%) to observe a minimal pneumothorax and because of late night end. There were no readmissions after MC (RR = 0%). We included 32 ambulatory patients for lung biopsy (mean age: 61.5 years) out of 64 total LB (SI = 50.0%). One patient was admitted because of air leak (AR = 3.1%) and there were no readmissions after LB (RR = 0%). Fifty-eight patients were included in the OTSP for bilateral sympathectomy (mean age: 27.1 years) out of 83 total TS (SI = 69.9%); there were no admissions (AR = 0%) and one patient was readmitted after 9 days because of a hemothorax (RR = 1.7%). Sixty-four patients out of the 91 not included in the OTSP were included in an ‘afternoon surgical programme’ and dismissed the morning after surgery, without contraindication for their inclusion in the OTSP. The hospital’s total stay saving was s12,668 (s88,226 if performed elsewhere), s42 per patient (s294 per patient if performed elsewhere). Conclusion:Videoassisted mediastinoscopy, lung biopsy and bilateral sympathectomy can be included safely in outpatient thoracic surgical programmes. The impact of the economic benefit of OTSP over the conventional hospitalisation depends on the Department’s previous policy on hospital stays. Further experience is needed to increase the substitution index and expand the OTSP to other procedures. # 2005 Elsevier B.V. All rights reserved.

Lung metastases limited to posterior segments can be removed through a posterior thoracotomy with the patient in the prone position. When these metastases are bilateral, a simultaneous approach can be performed. We present three cases of bilateral lung metastases of colorectal carcinoma removed through a simultaneous bilateral posterior thoracotomy with the patient in the prone position.

Our objective was to evaluate whether the number and volume of surgical lung biopsies (SLB) influence the diagnosis of diffuse interstitial lung disease (ILD).Retrospective study of SLB for suspected ILD in patients from the Mayo Clinic from January 2002 to January 2010. Data were collected in the institution and analyzed.311 patients were studied. Mean number of biopsies was 2.05 (SD 0.6); 1 biopsy in 50 (16%), 2 in 198 (63.7%), 3 in 59 (19%) and 4 in 4 (1.3%). Histopathologic diagnosis was: definitive (specific): 232 (74.6%), descriptive (non-specific): 76 (24.4%), no diagnosis: 3 (1%). After excluding patients without diagnosis (n=3), there were 50 patients with only 1 biopsy, 196 with 2 and 62 with 3 or 4; the definitive diagnostic yield was similar in all 3 groups (37/50; 74%, 150/196; 77%, and 45/62; 73%) (Chi-square, p value 0.8). The propensity score analysis between patients with 1 SLB and patients with more than 1 SLB also showed no difference in diagnostic yield. Regarding the volume of biopsies, mean total volume was 34.4 cm(3) (SD 46): 41.2 cm(3) (3 cases) in patients with no diagnosis; 33.6 cm(3) (232 cases, SD 47) in patients with specific diagnosis; and 36.6 cm(3) (76 cases, SD 44) in patients with descriptive diagnosis. Biopsy volume had no influence on histopathology yield (ANOVA, p value .8).The number and volume of the biopsy specimens in SLB did not seem to influence diagnosis. Based on our results, we believe a single sample from a representative area may be sufficient for diagnosis. Randomized prospective trials should be performed to optimize SLB for ILD.

Elastofibromas (EFD) are rare benign soft tissue tumors that are almost always located at the inferior pole of the scapula, deep to the serratus anterior muscle. They are more frequent in elderly women. Their anatomical location and a distinctive clinical symptom distinguish them from malignant soft tissue tumours. They can usually be diagnosed on the basis of their imaging characteristics. Despite their low incidence, these lesions should be kept in mind to differentiate them from malignant tumours and to avoid unnecessary biopsies and wide or radical surgery. We present the case of a 55-year-old woman who complained of chronic pain related to a right infrascapular mass. She was diagnosed by magnetic resonance imaging (MRI) of bilateral subescapular tumor masses both compatible with elastofibroma. She underwent resection of the symptomatic right lesion through an amyotomical approach.

Resume L'elastofibrome est une tumeur benigne rare des parties molles, presque constamment situee en dessous de la pointe de l'omoplate et a la profondeur du muscle serratus anterior (grand dentele). Il s'observe surtout chez la femme âgee. La localisation caracteristique et le tableau clinique evocateur le distinguent des tumeurs malignes des parties molles. Le diagnostic d'elastofibrome repose le plus souvent sur ses caracteristiques en imagerie. Malgre sa rarete, cette tumeur benigne doit etre connue pour eviter des biopsies inutiles, voire des gestes chirurgicaux de resection pratiques dans l'optique du diagnostic differentiel avec une tumeur maligne. Nous rapportons ici le cas d'une femme âgee de 55 ans, souffrant de douleurs chroniques liees a une masse situee a la partie inferieure de l'omoplate droite. L'imagerie par resonance magnetique (IRM) a permis de diagnostiquer des masses tumorales symetriques situees sous chacune des omoplates, compatibles avec un elastofibrome dorsal bilateral. Le traitement a comporte une resection de la lesion droite symptomatique par une voie d'abord intermusculaire.

We report our experience with a policy of early chest tube removal after video-assisted thoracic surgical lung biopsy (VATS-LB) in 146 patients. The chest tube (24F) was removed if four conditions were met: immediate extubation, complete expansion of the lung, drainage

Resumen Los quistes de duplicacion esofagica son alteraciones congenitas del esbozo digestivo. Su incidencia se ha estimado en 1/8.200 nacimientos, con una mayor preponderancia en varones. En adultos suele ser un hallazgo casual. Su tratamiento siempre debe ser quirurgico, incluso cuando los pacientes estan asintomaticos, dada la posibilidad de desarrollar sintomas y complicaciones durante el curso natural de la enfermedad y por el hecho de que el diagnostico definitivo solo puede establecerse con la pieza quirurgica. Presentamos el caso de un paciente varon de 37 anos al que se diagnostico radiologicamente de manera casual de un quiste de duplicacion esofagica y que preciso una toracotomia para su exeresis. Palabras clave: Quiste de duplicacion esofagica. Quistes esofagicos congenitos. Masas mediastinicas.

Resumen La perforacion traumatica del diafragma es una lesion que se caracteriza por diagnosticarse de forma tardia y producir una alta tasa de mortalidad. Su incidencia es cada vez mayor, ocurre en el 1-5% de los accidentes de automovil y en el 10-15% de las lesiones penetrantes en el torax bajo. El porcentaje de lesiones diafragmaticas que no se diagnostica inicialmente oscila entre el 12 y el 60%. El tratamiento es quirurgico y debe ser urgente. No existe unanimidad respecto a la via de abordaje. Suele llevarse a cabo preferentemente por la via abdominal, dado que permite un mejor control de las posibles lesiones intraabdominales asociadas. Exponemos el caso de un paciente que presento una herniacion del estomago y el bazo a traves de una rotura en el hemidiafragma izquierdo. La correccion quirurgica del cuadro, incluida una esplenectomia, fue llevada a cabo por abordaje toracico.

Single-incision laparoscopic surgery (SILS) has proved its advantages in several procedures, mainly a shorter hospital stay, improved aesthetic results, and less postoperative pain. The authors have used this approach for several thoracic surgical procedures. This prospective study compared 20 cases between standard three-port video-assisted thoracic surgery (VATS) and the single-incision approach using a standard abdominal SILS system. In both groups, postsurgical analgesia was provided with 15 ml of bupivacaine 0.5% at 3 h intervals via a paravertebral catheter. The hospital length of stay and chest drain duration (in hours) were recorded as well as postoperative pain using an analogic visual pain scale (AVPS). A telephone survey was conducted for all the outpatients. The Mann-Whitney U test was used for statistical analysis. This study of 20 procedures included 11 lung biopsies, 6 pneumothorax procedures, 2 mediastinic cystectomies, and 1 catamenial pneumothorax procedure. No statistically significant difference was reported in hospital length of stay or chest drain duration between the two groups. However, postoperative pain at 24 h was significantly less in the SILS group (AVPS, 4.40) than in the VATS group (AVPS, 6.20) (p = 0.035). The SILS group reported two minor surgical wound complications and one catamenial pneumothorax recurrence that did not require drainage. The VATS group reported one case of skin rash with no identifiable cause. The use of the SILS port in thoracic surgery results in less postoperative pain. This is related to the port’s protective effect over the periostium and the intercostal nerve, relieving them of direct contact with surgical instruments. However, the findings showed a higher incidence of surgical wound complications with the SILS port, which can be attributed to increased pressure on the skin and soft tissues surrounding the port and to the fact that this same incision was used for chest drain placement, thus increasing the risk for complications.

Purpose This study seeks to clarify the modern prognostic significance of visceral pleura invasion (VPI) in Stage IB (T2aN0M0) non-small cell lung cancer (NSCLC) within the context of the 7th edition TNM classification using the data set from a recent prospective multicenter trial. Patients and methods 1111 early-stage NSCLC patients participating in the ACOSOG Z0030 trial (1990–2004) underwent curative pulmonary resection. After excluding T2b tumours (>5 cm and ≤7 cm) and non-size-based T2 factors other than VPI, 289 patients were categorized as Stage IB NSCLC – T2aN0M0 – according to the AJCC 7th edition classification. The patients were divided into three groups according to size and VPI: tumours ≤ 3 cm with VPI (Group I, “VPI-alone”, n = 83), tumours > 3 cm and ≤5 cm without VPI (Group II, “Size-alone”, n = 156), and tumours > 3 cm and ≤5 cm with VPI (Group III, “VPI + Size”, n = 50). Multivariate Cox regression analysis was used to assess the association of VPI and size with survival, adjusting for age, gender, histology and type of resection. Results VPI in Stage IB was identified in 133 patients (46.0%). Survival analysis in these patients identified an optimal cutpoint for survival based on size of 3.1 cm. Group III (VPI + Size) had a 5-year survival rate of 55.0% significantly shorter when compared to Group I (VPI-alone = 68.3%, p = 0.009), and Group II (Size-alone = 67.2%, p = 0.021). No difference was found between Groups I and II. Multivariable analysis showed that VPI associated with size was an independent negative prognostic factor of long-term survival, along with older age and limited resection. Conclusions Stage IB patients with VPI and tumours >3 cm and ≤5 cm have significantly worse prognosis than those with ‘T2a’ tumours on the basis of VPI or tumour size alone. This finding would suggest upstaging these patients from the current IB status to Stage IIA.

Objectives A new revision of the international lung cancer staging system has been recently introduced. The revisions are largely focussed on the T descriptor. We sought to test the validity of this new system on a separate prospectively collected cohort of patients from a recent multicentre trial of early-stage lung cancer. Methods We reviewed the prospectively collected data from 1012 patients undergoing pulmonary resection for early-stage lung cancer in the ACOSOG Z0030 trial. TNM descriptors and overall staging were assessed using both the sixth and seventh editions of the American Joint Committee on Cancer and the Union Internationale Contre le Cancer (AJCC/UICC) lung cancer staging system. Survival results were analysed according to both staging allocations. Results Using the proposed criteria, the number of patients by stage in the sixth and seventh edition allocations, respectively, were as follows: IA (432, 431); IB (402, 303); IIA (39, 167); IIB (94, 70); IIIA (26, 40); IIIB (19,0); there were no stage IV patients by either version. Overall, 180 (18%) patients had a change in the stage group from the sixth to seventh edition versions with 76 (8%) being downstaged and 104 (10%) being upstaged. In the sixth edition staging system based on pathological stages, median survivals in years were as follows: IA, NA; IB, 7.7; IIA, 4.0; IIB, 3.6; IIIA, 2.6 and IIIB, 2.4. Five-year survivals were: IA, 76.4%; IB, 62.0%; IIA, 47.8%; IIB, 40.4%; IIIA, 31.3% and IIIB, 44.4%. In the new system, median survivals in years were as follows: IA, NA; IB, 8.2; IIA, 4.4; IIB, 3.6 and IIIA, 1.8. Five-year survivals were: IA, 76.9%; IB, 65.0%; IIA, 48.5%; IIB, 42.9% and IIIA, 30.6%. Survival analysis and Kaplan-Meier survival curves showed more monotonic progression, distinction and homogeneity within groups in the seventh edition. Conclusions This study provides an external validation of the recently revised lung cancer staging system using a large multicentre database. The seventh edition of the AJCC/UICC lung cancer staging system appears to be an improvement over the preceding system.

Videothoracoscopic (VTC) resection of peripheral pulmonary nodules (PN) occasionally requires performing a mini-thoracotomy to locate them using palpation. The aim of this study is to evaluate the usefulness of inserting a CT-guided harpoon as a method for locating PN prior to surgery.A study was conducted on a total of 52 patients who were scheduled for locating 55 PN prior to surgery by inserting a CT-guided harpoon, from November 2004 to January 2011.Of the 52 patients, of whom 35 had a history of cancer, 31 were male and 21 were female, with ages between 28 and 84 years (mean: 62.2 years) with a PN 20mm (mean: 9.57mm). A total of 55 harpoons were inserted (3 patients had 2 simultaneous harpoons). Using the VTC it was observed that 52 harpoons were correctly anchored to the PN. There were no complications. In the group of 35 patients with an oncology history, the nodules were malignant in 26 cases (74.3%), and there were 17 (70.6%) with malignant PN in those with no oncology history. The hospital stay varied between 4 and 72h, with 19 patients (36.5%) included in a one-day surgery program.The preoperative identification of peripheral pulmonary nodules enables them to be removed directly with VTC. The insertion of a CT-guided harpoon in the PN is a safe and effective procedure that can be performed in a one-day surgery program.

Resumen Introduccion Analizar si la localizacion y el numero de biopsias pulmonares obtenidas por videotoracoscopia (BP-VTC) influyen en el diagnostico de las enfermedades pulmonares intersticiales difusas (EPID) y evaluar la aplicabilidad de un programa de cirugia ambulatoria (CA). Pacientes y metodo Estudio prospectivo y multicentrico de BP-VTC practicadas en pacientes con sospecha de EPID desde enero de 2007 a diciembre de 2009, incluyendo 224 pacientes de 13 centros espanoles. Los datos fueron recogidos de manera prospectiva en cada centro y enviados al centro coordinador para su analisis. Resultados Las zonas mas afectadas en la TACAR toracica fueron los lobulos inferiores (55%). Se llevo a cabo broncoscopia en el 84%, y biopsia transbronquial en el 49,1%. En 179 casos (79,9%) se realizo mas de una biopsia (concordancia diagnostica: 97,2%). Se obtuvo un diagnostico histopatologico definitivo en 195 pacientes (87%). No se hallaron factores estadisticamente significativos que pudieran predecir un mayor rendimiento diagnostico (ni la localizacion anatomica de la biopsia ni el numero de ellas). Setenta pacientes (31,3%) fueron incluidos en un programa de CA. Los indices de morbilidad tras el alta fueron comparables entre ingresados (9/154: 5.8%) y ambulatorios (3/70: 4.3%). Conclusiones La localizacion anatomica y el numero de BP no parecen influir en el diagnostico de EPID. Los pacientes ambulatorios tuvieron un indice de complicaciones comparable a los casos que ingresaron, por lo cual este procedimiento podria ser incluido en un programa de CA. La BP-CVT es una herramienta fiable y segura para el diagnostico de los pacientes con sospecha de EPID.

Background The recalibrated thoracic revised cardiac risk index (ThRCRI) has been recently proposed as a specific tool for cardiac risk stratification before lung resection. However, the ThRCRI has never been externally validated in a population other than the one from which it was derived. The objective of this study was to validate the ThRCRI in an external population of candidates having undergone major lung resections to assess its reliability for cardiac risk stratification across different samples. Methods We analyzed 2,621 patients undergoing lobectomy (2,431) or pneumonectomy (190) in a single center from 2000 to 2009. Patients were grouped into four classes of risk (A, B, C, and D) according to the recalibrated ThRCRI. The outcome variable measured was the occurrence of major cardiac complications (cardiac arrest, complete heart block, acute myocardial infarction, pulmonary edema, cardiac death during admission). Incidence of major cardiac events was assessed in the four risk class groupings to assess the discriminative ability of the index score. Results The incidence of major cardiac morbidity was 2.2% (59 cases). Patients were grouped into four risk classes according to their recalibrated ThRCRI. Incidence of major cardiac morbidity in risk classes A, B, C, and D were 0.9%, 4.2%, 8%, and 18%, respectively ( p Conclusions The recalibrated ThRCRI is a reliable instrument that can be used during preoperative workup to differentiate patients needing further cardiologic testing from those who can proceed without any further cardiac testing.

Although lung transplantation became clinically widespread only during the 1990s, it is currently considered a standard treatment for a growing list of end-stage chronic lung diseases. With increasing experience, the range of ages of potential candidates for lung transplantation has been extended to now include more elderly patients. Although long term survival data shows an overall increased relative risk associated with elderly patients as compared with younger counterparts, lung transplantation remains a viable option for certain highly selected elderly patients. As is the case with most diseases, potential lung transplant patients at the upper extremes of age appropriately receive increased scrutiny in the preoperative evaluation process. Furthermore, in an effort to expand the donor organ pool, the age of potential cadaveric multiorgan donors considered for lung transplantation has extended into the elderly population. Considerations in lung transplantation particular to elderly recipients and elderly donors, including issues of patient selection as well as technical aspects relevant to lung transplantation in the elderly are the subject of this chapter.

Main cause of dissatisfaction after videothoracoscopic (VATS) sympathectomy in the treatment of hyperhidrosis (HH) and facial blushing (FB) is compensatory sweating (CS). Sympathetic nerve (SN) clipping obtains the same results as sympathectomy in terms of efficacy and safety and levels of CS are similar or lesser than with the standard procedure, with the advantage that if necessary - massive intolerable CS-, this technique theoretically allows to revert the sympathetic block by removing the clips. The surgical procedure is performed through two incisions of 10 mm at the mid axillary and anterior axillary lines (third and fifth intercostal spaces). Through two ports a 30° camera and a diathermy hook are introduced into the pleural cavity. After the identification of the SN, parietal pleura is opened and the chain is isolated. Under video assistance the SN is clipped at the correspondent level with a right-angled endoscopic clip applier. This surgical procedure is illustrated and an overview of the literature is presented.