La Toracoscopia en el manejo clínico – terapéutico de los derrames pleurales: una técnica vanguardista en el siglo XXI

Valorar el rendimiento diagnóstico de la toracoscopia en los derrames pleurales. Estudio prospectivo que incluye a 110 pacientes con derrames pleurales diagnosticados clínicamente como benignos (14,5%), malignos (34,5%) y no filiados (50,9%). A todos se les practicó toracoscopia con anestesia local y sedación consciente para el estudio de la cavidad pleural y la toma de muestras. La toracoscopia confirmó los siguientes diagnósticos: 30,35% como pleuritis inespecífica, 17,86% de mesotelioma y 1,79% de pleuritis tuberculosa. El resto de derrames fueron diagnosticados como malignos por carcinomatosis pleural. La toracoscopia es una técnica con baja morbilidad, de gran utilidad para obtener muestras histológicas para estudio y, por lo tanto, para poder establecer un diagnóstico definitivo en los derrames pleurales.The aim of this study was to investigate the effectiveness of thoracoscopy in the diagnosis of non-affiliated pleural effusions. A fiveyear prospective study including data from one hundred and ten patients that were clinically diagnosed as benign (14,5 %), malign (34,5 %) and non-affiliated (50,9%). Pleural effusions in patents without oncology disease and negative biopsy or cytology were considered as benign. Malignant diagnosis was established according to a pleural biopsy, compatible cytology and/or clinical features. Remaining cases were considered as non-affiliated. Thoracoscopy was done under local anesthesia and sedation. Thoracoscopy confirmed previous clinical diagnosis of benignity and malignity. Regarding non-affiliated patients the 30,35% were diagnosed after thoracoscopy as unspecific pleuritis, 17,86% of mesotelioma and 1,79% of pleural tuberculosis (TBC). The other 48,21% of patients reported as non-affiliated were diagnosed of pleural carcinoma. Our results indicate that thoracoscopy is a cost effective and reliable technique for obtaining histological diagnosis in PE, and also allows a directed pleurodesis if indicated.Medicin

La toracoscopia en el manejo clínico-terapéutico de los derrames pleurales: una técnica vanguardista en el siglo XXI

Objective: The aim of this study was to investigate the effectiveness of thoracoscopy in the diagnosis of non-affiliated pleural effusions. Methods: A five year prospective study including data from one hundred and ten patients that were clinically diagnosed as benign (14,5 %), malign (34,5 %) and non-affiliated (50,9%). Pleural effusions in patents without oncology disease and negative biopsy or cytology were considered as benign. Malignant diagnosis was established according to a pleural biopsy, compatible cytology and/or clinical features. Remaining cases were considered as non-affiliated. Thoracoscopy was done under local anesthesia and sedation. Results: Thoracoscopy confirmed previous clinical diagnosis of benignity and malignity. Regarding non-affiliated patients the 30,35% were diagnosed after thoracoscopy as unspecific pleuritis, 17,86% of mesotelioma and 1,79% of pleural tuberculosis (TBC). The other 48,21% of patients reported as non-affiliated were diagnosed of pleural carcinoma. Conclusions: Our results indicate that thoracoscopy is a cost effective and reliable technique for obtaining histological diagnosis in PE, and also allows a directed pleurodesis if indicated.Objetivo: valorar el rendimiento diagnóstico de la toracoscopia en los derrames pleurales. Material y métodos: estudio prospectivo que incluye a 110 pacientes con derrames pleurales diagnosticados clínicamente como benignos (14,5%), malignos (34,5%) y no filiados (50,9%). A todos se les practicó toracoscopia con anestesia local y sedación consciente para el estudio de la cavidad pleural y la toma de muestras. Resultados: la toracoscopia confirmó los siguientes diagnósticos: 30,35% como pleuritis inespecífica, 17,86% de mesotelioma y 1,79% de pleuritis tuberculosa. El resto de derrames fueron diagnosticados como malignos por carcinomatosis pleural. Conclusiones: la toracoscopia es una técnica con baja morbilidad, de gran utilidad para obtener muestras histológicas para estudio y, por lo tanto, para poder establecer un diagnóstico definitivo en los derrames pleurales

Protective ventilation with high versus low positive end-expiratory pressure during one-lung ventilation for thoracic surgery (PROTHOR): study protocol for a randomized controlled trial

Background: Postoperative pulmonary complications (PPC) may result in longer duration of in-hospital stay and even mortality. Both thoracic surgery and intraoperative mechanical ventilation settings add considerably to the risk of PPC. It is unclear if one-lung ventilation (OLV) for thoracic surgery with a strategy of intraoperative high positive end-expiratory pressure (PEEP) and recruitment maneuvers (RM) reduces PPC, compared to low PEEP without RM. Methods: PROTHOR is an international, multicenter, randomized, controlled, assessor-blinded, two-arm trial initiated by investigators of the PROtective VEntilation NETwork. In total, 2378 patients will be randomly assigned to one of two different intraoperative mechanical ventilation strategies. Investigators screen patients aged 18 years or older, scheduled for open thoracic or video-assisted thoracoscopic surgery under general anesthesia requiring OLV, with a maximal body mass index of 35 kg/m2, and a planned duration of surgery of more than 60 min. Further, the expected duration of OLV shall be longer than two-lung ventilation, and lung separation is planned with a double lumen tube. Patients will be randomly assigned to PEEP of 10 cmH2O with lung RM, or PEEP of 5 cmH2O without RM. During two-lung ventilation tidal volume is set at 7 mL/kg predicted body weight and, during OLV, it will be decreased to 5 mL/kg. The occurrence of PPC will be recorded as a collapsed composite of single adverse pulmonary events and represents the primary endpoint. Discussion: PROTHOR is the first randomized controlled trial in patients undergoing thoracic surgery with OLV that is adequately powered to compare the effects of intraoperative high PEEP with RM versus low PEEP without RM on PPC. The results of the PROTHOR trial will support anesthesiologists in their decision to set intraoperative PEEP during protective ventilation for OLV in thoracic surgery. Trial registration: The trial was registered in clinicaltrials.gov (NCT02963025) on 15 November 2016