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This article summarizes the clinical guidelines for the diagnosis and treatment of malignant pleural effusion (MPE) sponsored by the Spanish Society of Thoracic Surgery (SECT). Ten clinical controversies were elaborated under the methodology of PICO (Patient, Intervention, Comparison, Outcome) questions and the quality of the evidence and grading of the strength of the recommendations was based on the GRADE system. Immunocytochemical and molecular analyses of pleural fluid may avoid further invasive diagnostic procedures. Currently, the definitive control of MPE can be achieved either by pleurodesis (talc poudrage or slurry) or the insertion of a indwelling pleural catheter (IPC). It is likely that the combination of both techniques (i.e., thoracoscopy with talc poudrage and insertion of a IPC, or instillation of talc slurry through a IPC) will have a predominant role in the future therapeutic management.

BACKGROUND Phrenic nerve injury (PNI) is a complication of lung transplantation related to the surgical procedure and associated with increased morbidity. However, the incidence and risk factors, specifically regarding surgical techniques, have not been adequately studied. METHODS We conducted a prospective single-center study over 4-years, in recipients of lung transplantation with a normal pretransplant phrenic nerve conduction study (PNCS). Diaphragm ultrasound and PNCS were performed in the first 21 postoperative days and PNI was defined when both tests were abnormal. Patients were followed up until hospital discharge. The association between transplant characteristics and PNI was analyzed by using logistic regression models. RESULTS Two hundred eleven lung grafts implanted in 127 patients were included in the study. After lung transplantation, PNI was diagnosed in 43.3% of the subjects and 29% of the operated hemithorax. Regression logistic model showed that the variables related to PNI were female gender (p = 0.02), bilateral lung transplantation (BLT) (p = 0.001), right lung graft (p = 0.003), clamshell incision ( p = 0.01), mediastinal adhesions (p = 0.002), longer operative time (p = 0.003), intraoperative extracorporeal support ( p = 0.02), and blood transfusion ( p = 0.003). Conversely, age >61 years (p = 0.008) and higher thoracic diameter (p = 0.04) were protective factors. The use of electrocautery , cardiac mechanical retractors, and diaphragmatic traction was not associated with PNI. Morbidity was increased without any difference in mortality. CONCLUSIONS PNI is a frequent complication after lung transplantation, associated with higher morbidity. Mainly risk factors were age, BLT, female gender, and variables related to surgical difficulties. Lung graft in the right hemithorax and mediastinal adhesiolysis were the most relevant technical variables.

Controlled donation after circulatory death (cDCD) has contributed to increasing donor numbers all over the world. Experiences published in the last years confirm that the outcomes after lung transplantation from cDCD are similar to those from brain death donors; however, the utilization of lungs from asystole donors remains low. Several reasons may be involved: different legal frameworks among countries and centers with different premortem interventions, inadequate lung donor care before procurement, or even poor experience with cDCD procedures and protocols. Initially, the rapid recovery technique was commonly employed for the procurement of thoracic and abdominal organs in cDCD, but, in the last decade, abdominal normothermic regional perfusion (ANRP) with extracorporeal membrane oxygenation devices has become a useful method to restore blood flow to abdominal organs, allowing their quality improvement and their functional assessment prior to transplantation. This makes the donation procedure more complex and generates doubts about injury to the grafts due to dual temperature. The aim of this article is to describe a protocol based on a single center experience with Maastricht III donors combining lung cooling rapid recovery in the thorax and abdominal normothermic regional perfusion. Tips and tricks focused on premortem interventions and lung procurement procedure techniques are explained. This may help to minimize the reluctance among professionals to use this combined technique and encourage other donor centers to use it, despite the increased complexity of the procedure.

Introduction: Azithromycin (AZI) may be an effective immune modulator in lung transplant (LT) recipients, and can decrease chronic lung allograft dysfunction (CLAD) rates, the leading cause of mortality after the first year post-LT. The aim of the study is to assess the effect of AZI initiation and its timing on the incidence and severity of CLAD in LT recipients. Methods: Single-center retrospective study, including LT recipients from 01/01/2011 to 30/06/2020. Four groups were established: those who started AZI at the 3rd week post-LT (group A), those who received AZI later than the 3rd week post-LT and had preserved FEV1 (B), those who did not receive AZI (C) and those who started AZI due to a decline in FEV1 (D). The dosage of AZI prescribed was 250 mg three times per week. CLAD was defined and graduated according to the 2019 ISHLT criteria. Results: We included 358 LT recipients: 139 (38.83%) were in group A, 94 (26.25%) in group B, 91 (25.42%) in group C, and 34 (9.50%) in group D. Group A experienced the lowest CLAD incidence and severity at 1 (p = 0.01), 3 (p < 0.001), and 5 years post-LT, followed by Group B. Groups C and D experienced a higher incidence and severity of CLAD (p = 0.015). Initiation of AZI prior to FEV1 decline (groups A and B) proved to be protective against CLAD after adjusting for differences between the treatment groups. Conclusions: Early initiation of AZI in LT recipients could have a role in decreasing the incidence and severity of CLAD. In addition, as long as FEV1 is preserved, initiating AZI at any time could also be useful to prevent the incidence of CLAD and reduce its severity. This article is protected by copyright. All rights reserved. Funding Sources: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

ResumenAntecedentesLa colitis pseudomembranosa, producida por el Clostridium difficile, presenta una incidencia creciente en los últimos años, motivada principalmente por el uso indiscriminado de antibióticos. Aunque su tratamiento de inicio es médico, el papel de la cirugía de urgencias ha ido ganando terreno debido a una mortalidad elevada y a la aparición de cepas cada vez más virulentas. En nuestro medio su prevalencia aún es escasa, por lo que en ocasiones nuestra experiencia en su manejo es limitada.ObjetivoAnalizar nuestra experiencia quirúrgica en el tratamiento de esta dolencia y recordar el rol de la cirugía, así como alguno de sus aspectos técnicos.Casos clínicosPresentamos 2 casos clínicos de pacientes que han presentado un cuadro de colitis pseudomembranosa de presentación fulminante, sin respuesta al tratamiento médico inicial, por lo que se requiere una actuación quirúrgica urgente, con buena respuesta.ConclusionesEs importante siempre tener en mente la posibilidad quirúrgica en el tratamiento de la colitis pseudomembranosa, sobre todo cuando se presenta de manera fulminante, existen complicaciones asociadas o falla de respuesta al tratamiento médico.AbstractBackgroundPseudomembranous colitis, caused by Clostridium difficile, has an increased incidence in recent years, driven mainly by the indiscriminate use of antibiotics. Although initial treatment is medical, the role of emergency surgery has gained ground due to high mortality and the emergence of increasingly virulent strains. In our country the prevalence is still low so sometimes our experience in handling is limited.AimTo analyze our surgical experience in treatment of this disease and to remember the role of surgery as well as some technical aspects of it.Clinical casesWe present 2 cases of patients who have suffered a fulminant pseudomembranous colitis unresponsive to initial medical treatment at requiring urgent surgical intervention with a good response to it.ConclusionsIt is important to keep in mind surgical option in treatment of pseudomembranous colitis, especially when it presented as fulminant colitis, associated complications or failure to respond to medical treatment.

Background Pseudomembranous colitis, caused by Clostridium difficile , has seen an increased incidence in recent years, driven mainly by the indiscriminate use of antibiotics. Although initial treatment is medical, the role of emergency surgery has gained ground due to high mortality and the emergence of increasingly virulent strains. In our country the prevalence is still low so that sometimes our experience in handling is limited. Aim To analyze our surgical experience in treatment of this disease and to remember the role of surgery as well as some technical aspects of it. Clinical cases We present 2 cases of patients who have suffered a fulminant pseudomembranous colitis unresponsive to initial medical treatment and requiring urgent surgical intervention with a good response to it. Conclusions It is important to keep in mind the surgical option in treatment of pseudomembranous colitis, especially when it presents as fulminant colitis, there are associated complications or failure to respond to medical treatment.

Resumen Objetivo La aplicacion de la tecnica laparoscopica en la colecistitis aguda es aun hoy un tema controvertido. El objetivo del estudio es valorar la aplicabilidad, seguridad, beneficios y complicaciones del abordaje laparoscopico en pacientes con colecistitis aguda, asi como la evolucion y desarrollo de dicha via en la unidad de cirugia de urgencias de un hospital de tercer nivel, en comparacion con la laparotomica. Material y metodo El estudio consta de 354 pacientes con cuadros de colecistitis aguda intervenidos por via abierta o laparoscopica desde 2006 a 2009. Resultados Se han intervenido 253 pacientes por via laparoscopica, 101 por via abierta, apreciandose un predominio del sexo masculino (57,67%) y una edad media de 62,83 anos. El numero de colecistectomia laparoscopica ha pasado del 60% en el 2006, al 79% en 2009. La estancia media (englobando complicadas y no complicadas) hablan a favor del abordaje laparoscopico frente al abierto (mostrando una diferencia de aproximadamente 6 al dia). Las complicaciones postoperatorias a lo largo de estos cuatro anos en la via laparoscopica han experimentado un descenso, pasando de un 21,42 a un 11,3%. Las complicaciones locales y globales se correlacionaron significativamente con el tiempo transcurrido entre el inicio de los sintomas agudos y la cirugia, asi como con el estado anatomopatologico de la vesicula biliar. Conclusiones El abordaje laparoscopico va adquiriendo un papel cada vez mas primordial en el tratamiento de esta dolencia, convirtiendose en nuestro hospital en la principal opcion quirurgica.

The application of the laparoscopic technique in acute cholecystitis is still subject to controversy. The aim of this study is to asses the applicability, safety, benefits and complications of the laparoscopic approach in patients with acute cholecystitis, as well as the development of this technique in the emergency surgery department of a tertiary hospital, compared to laparotomy.The study consisted of 354 patients with acute cholecystitis syndromes operated either by open or laparoscopic surgery, during the years 2006 to 2009.The laparoscopic method was used in 253 patients, and 101 by the open route, with the slight majority being male (57.67%) and with a mean age of 62.83 years. The number of laparoscopic cholecystectomies increased from 60% in 2006, to 79% in 2009. The mean hospital stay (including those with and without complications) was shorter using the laparoscopic approach, compared to open surgery (showing a difference of approximately 6 days). The postoperative complications in laparoscopy during the four years studied decreased from 21.42 to 11.3%. The local and general complications were significantly associated with time since the start of the acute symptoms and the surgery, as well as the histopathological state of the gall bladder.The laparoscopic approach continues to play an increasing role in the treatment of this disease, becoming the main surgical option in our hospital.

Background Percutaneous cholecystostomy (PC) is an alternative treatment in acute cholecystitis (AC) in high-risk or elderly patients although its advantage over emergency cholecystectomy has not yet been established. Study Design AC prospective database analysis in high-risk patients treated by PC (group 1, 29 patients) or emergency cholecystectomy (group 2, 32 patients). Surgical risk was estimated by physiological POSSUM, Charlson, Apache II, and American Society of Anesthesiologists (ASA) scores. Results The groups showed homogeneity concerning age and surgical risk. PC allowed AC resolution in 19 patients (70.4%), but 8 (29.6%) needed emergency cholecystectomy. Morbidity and mortality rates were 31% and 17.2%, respectively. Mortality was significantly associated with ASA IV ( P = .01). In group 2, the morbidity rate was 28.1% without mortality. There was no statistical difference in morbidity ( P = .6) although mortality was significantly higher in group 1 ( P = .02). Conclusions PC seems of little benefit and ought to be left for those very old patients with surgical contraindication.

factores, entre los que se incluyen: aumento de la talla fetal, manipulacion durante maniobras prolongadas, etcetera. La cesarea continua siendo la tecnica de eleccion para evitar estos problemas, pero tambien se han descrito lesiones debidas a la tecnica, aunque en estos casos son realmente infrecuentes las lesiones genitourinarias. En nuestra revision solo hemos encontrado 3 articulos (tabla 1) en los que aparezca un dano genitourinario como los que presentamos. De ellos, dos se solucionaron con sutura directa del desgarro (al igual que en nuestro segundo caso) y en el tercer caso, presentado por Bhat et al, se realizo colostomia, pero la nina no sobrevivio. En nuestras pacientes la reparacion fue exitosa, tanto en el caso que preciso colostomia como en la sutura directa.

Hirschsprung's disease is characterized by absence of ganglion cells in submucosal and myenteric plexus of distal bowel. Most cases become manifest during the neonatal period, but in rare instances, this disease is initially diagnosed in adult age. It usually presents as severe constipation with colonic dilatation proximal to the aganglionic segment. The treatment is surgical, removing the aganglionic segment and restoring continuity of digestive tract. The disease rarely presents as an acute intestinal obstruction. We report a case not previously diagnosed, which presented as a massive colonic dilatation with a maximum diameter of 44 cm, with imminent risk of drilling that forced to perform an emergency surgery. We include a review of existing literature.