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Tratat de Chirurgie (sub red. Irinel Popescu Ed. Academiei Române 2008) Volumul IV - Chirurgie Toracicã

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Tratat de Chirurgie (sub red. Irinel Popescu Ed. Academiei Române 2008) Volumul IV - Chirurgie Toracicã

A.M. Botianu
Reviews, no. 6, 2008
* Clinica de Chirurgie Generalã si Toracicã, Spitalul Municipal Gheorghe Marinescu, UMF Tg. Mures


Volumul numãrul 4, din Tratatul National de Chirurgie, ce apare sub redactia Prof. Dr. Irinel Popescu, este dedicat Patologiei Chirurgicale Toracice, volum conceput de cãtre si sub îndrumarea Prof. Dr. Teodor Horvat. Volumul este structurat în 46 de capitole, împãrtite în 8 sectiuni. În cele aproape 900 de pagini este prezentatã pe larg patologia chirurgicalã toracicã si cea de granitã toraco-abdominalã si cervico-toracicã.
Se remarcã prezenta a trei autori strãini: Prof. Dr. Walter Klepetko, seful Departamentului de Chirurgie Cardio-Toracicã si Transplant Pulmonar - Vienna Medical University, Allgemeines Krankenhaus, Viena, Austria, Dr. Shahrokh Taghavi si Dr. Clemens Aigner - chirurgi cardio-toracici din aceeasi clinicã. Acestia prezintã douã capitole publicate în premierã într-un tratat de chirurgie toracicã româneascã: "Trombendarterectomia pulmonarã pentru hipertensiunea pulmonarã cronicã tromboembolicã" si "Transplantul pulmonar - aspecte curente".
Primul capitol din volum este dedicat istoriei chirurgiei toracice românesti si chirurgilor care au construit-o: "Dacã nu ar fi existat ei nu am fi existat noi" - afirmã Prof. Dr. Teodor Horvat.
"Anestezia în chirurgia toracicã" reprezintã o premierã pentru cãrtile românesti de chirurgie toracicã. Acest capitol este conceput de Dr.Radu Stoica, seful sectiei A.T.I. din Institutul de Pneumologie "Marius Nasta", si prezintã particu-laritãtile anesteziei si terapiei intensive în diverse patologii chirurgicale toracice, permitând încã o datã concluzia fireascã a necesitãtii colaborãrii strânse dintre chirurgul toracic si anestezist.
Sectiunea de traumatologie reuneste 4 capitole care descriu: managementul diagnostic si terapeutic al traumatismelor toracice (capitol adresat si medicilor de medicinã de urgentã, anestezisti si de terapie intensivã, chirurgilor generalisti si cardiovasculari etc.), abordul miniinvaziv cu indicatiile si contraindicatiile sale, traumatismele diafragmului si sechelele traumatismelor toracice.
În sectiunea alocatã patologiei chirurgicale a peretelui toracic sunt cuprinse: anatomia chirurgicalã a peretelui toracic, malformatiile congenitale ale peretelui toracic si tratamentul lor atât prin metode clasice cât si prin abord mini-invaziv, infectiile peretelui toracic si cura lor chirurgicalã, cu includerea sternotomiei dehiscente si infectate, si tumorile peretelui toracic. Sunt prezentate si posibilitãtile de reconstructie si stabilizare a peretelui toracic, problemã uneori delicatã pentru chirurgul toracic ce se confruntã cu o tumorã masivã de perete toracic, primarã sau secundarã, o infectie extensivã sau un traumatism cu distrugere de substantã; chirurgul plastician este de multe ori parte a echipei chirurgicale. Capitolele ce cuprind patologia peretelui toracic sunt scrise cu mult har didactic de cãtre Prof. Dr. Alexandru Nicodin, seful Clinicii de Chirurgie Toracicã a U.M.F. "Victor Babes" Timisoara.
Sectiunea "Patologia chirurgicalã a cavitãtilor pleurale si a cavitãtii pericardice" este conceputã integral de colectivul Clinicii de Chirurgie Toracicã II de la Spitalul Clinic de Urgentã Militar Central Bucuresti. Dupã capitolul de anatomie chirurgicalã este prezentat "Pneumotoraxul spontan" - atât cel primar cât si cel secundar diferitelor afectiuni; capitolul se adreseazã nu numai chirurgilor toracici ci si chirurgilor generalisti sau de alte specialitãti care se confruntã cu pneumotoraxul spontan - si se vrea a fi un îndemn la respectarea protocolului terapeutic pentru scãderea riscului de recidivã a pneumotoraxului.
Revãrsatele maligne pleurale si pericardice sunt prezentate separat fiecare; este pus accentul pe tratamentul miniinvaziv al acestora (abordul toracoscopic al pleureziilor si al pericarditelor, accesul subxifoidian etc.), menit sã amelioreze calitatea vietii pacientilor neoplazici.
"Pleureziile purulente" sunt prezentate datoritã frecventei lor de aparitie în practica medicalã, iar capitolul se adreseazã si altor medici decât chirurgilor toracici: pneumologilor, anestezistilor, chirurgilor generalisti, pneumoftiziologilor.
Sunt de asemenea prezentate tumorile pleurale, benigne si maligne - cu prezentarea detaliatã a mezoteliomului malign difuz si a tendintelor internationale de abord terapeutic.
Remarcãm faptul cã doi dintre autorii capitolului "Chilotoraxul" - Prof. Dr. Teodor Horvat si Dr. Claudiu Nistor, sef de lucrãri - sunt cei care au scris si publicat cartea "Ductul toracic" în anul 2007.
Cea mai vastã sectiune cuprinde "Patologia chirurgicalã trahealã si bronho-pulmonarã". Dupã capitolul menit anatomiei chirurgicale, în capitolul "Stenozele traheale" este sintetizatã o vastã patologie trahealã: congenitalã si dobânditã, benignã si malignã, primarã si secundarã; sunt prezentate de asemenea procedeele chirurgicale, indicatiile, complicatiile, managementul postoperator. Capitolul se remarcã prin puterea de sintezã a autorilor - cadrele didactice de la Catedra de Chirurgie Toracicã II, Spitalul Clinic de Urgentã Militar Central Bucuresti, prin valoarea didacticã a textului, la care se adaugã experienta chirurgicalã practicã.
"Chirurgia tuberculozei pulmonare" este prezentatã de cãtre Prof.Dr.Adrian Aldea si colaboratorii sãi din Clinica de Chirurgie Toracicã U.M.F. "Gr.T. Popa" Iasi, atrãgând atentia asupra particularitãtilor pacientilor cu tuberculozã pulmonarã chirurgicalã, a indicatiilor chirurgicale stricte si a evolutiei îndelungate a bolii în sine.
În capitolul "Malformatiile congenitale traheo-bronho-pulmonare" sunt descrise atât cele din practica medicilor neonatologi, cât si cazurile pediatrice sau de la pacienti adulti, întâlniti în practica chirurgilor toracici generalisti.
"Chistul hidatic pulmonar" reprezintã o patologie destul de frecvent întâlnitã de chirurgii toracici si de cei pediatri. Experienta clinicã este cea care îndrumã chirurgul în a alege care din multiplele procedee este cel mai potrivit în fiecare caz pentru a salva cât mai mult parenchim pulmonar.
Sunt prezentate în continuare subiecte precum: "Supuratiile bronho-pulmonare" - în care Prof. Dr. Alexandru Mihail Botianu, seful Clinicii de Chirurgie Generalã si Toracicã U.M.F. Tg. Mures, prezintã pe larg tipurile de supuratii bronho-pulmonare, indicatiile chirurgicale ale acestora si actualitãtile internationale în tratamentul chirurgical al acestor afectiuni care apartin în marea lor majoritate medicilor pneumologi; "Micozele pulmonare" - afectiuni care uneori intrã în sfera de activitate chirurgicalã toracicã, în special prin aspergiloamele pulmonare si prin hemoptiziile pe care acestea le produc; "Tumorile pulmonare benigne" - care de cele mai multe ori pot beneficia de tratament chirurgical prin chirurgie toracoscopicã sau chirurgie toracicã videoasistatã, iar uneori au rezolvare în mâna unui bronholog cu experientã în bronhologia interventionalã; "Metastazele pulmonare" - entitãti care, în anumite situatii, în functie si de tumora primarã, beneficiazã de cura chirurgicalã în scopul prelungirii intervalulul liber de boalã a pacientilor.
Importanta entitãtii radiologice "Nodulul pulmonar solitar" este redatã într-un capitol separat, redactat de Conf. Dr. Ioan Cordos si colaboratorii sãi din Clinica de Chirurgie Toracicã I de la Institutul de Pneumologie "Marius Nasta" din Bucuresti, la care contribuie în mod decisiv Dr. Tudor Ciprut, seful Sectiei de Tomografie Computerizatã din acelasi institut; reiese încã o datã concluzia cã orice nodul pulmonar impune diagnosticul histologic, iar în cazul (foarte frecvent) în care ne aflãm în fata unui cancer bronho-pulmonar incipient, tratamentul chirurgical de rezectie în limite oncologice este obligatoriu si influenteazã semnificativ supravietuirea la distantã a acestor pacienti.
"Carcinoidul bronsic" oferã autorilor ocazia de a prezenta, în cadrul tratamentului chirurgical al acestor tumori, tehnicile de rezectie bronsicã asociatã sau nu cu rezectie pulmonarã, menite sã "salveze" cât mai mult parenchim pulmonar: rezectii bronho-plastice, rezectii bronho-anastomoze, la care leziunea poate impune asocierea de rezectii angio-plastice sau rezectii angio-anastomoze.
"Cancerul bronho-pulmonar" reprezintã lupta zilnicã a chirurgilor toracici din întreaga lume: "În momentul stabilirii diagnosticului, doar 1/3 din cazuri se gãsesc într-o fazã terapeutic utilã." Prof. Dr. Teodor Horvat este prim-autor al acestui capitol care cuprinde toatã acumularea teoreticã, simtul clinic, experienta din sala de operatie si puterea de sintezã ce se constituie în lupta împotriva acestei cumplite boli. Se remarcã arsenalul de investigatii paraclinice, din care face parte recent în România si tomografia cu emisie de pozitroni - PET, aducerea la zi a stadializãrii TNM, prezentarea tehnicilor chirurgicale de rezectie oncologicã, accentul pus pe tratamentul multimodal al cancerului bronho-pulmonar.
Sectiunea a 7-a este alocatã mediastinului; dupã anatomia chirurgicalã, sunt prezentate infectiile mediastinale acute si cronice. Leziunile tumorale si pseudotumorale ale mediastinului cuprind o varietate de entitãti care trebuie, mãcar în parte, cunoscute de orice medic practician. "Sindromul de venã cavã superioarã" reprezintã un "update" sintetic al cãrtii cu acelasi nume publicatã în anul 2003. "Tratamentul chirurgical al miasteniei gravis" este prezentat explicit si complet de cãtre Dr. Victor Tomulescu, sef de lucrãri în Clinica de Chirurgie Generalã si Transplant Hepatic, Institutul Clinic Fundeni.
Din sectiunea rezervatã diafragmului, anatomia chirurgicalã si toate tipurile de hernii diafragmatice (fãrã hernia hiatalã) reprezintã capitole concepute de Dr. Lucian Alecu, seful sectiei de Chirurgie din Spitalul "Prof. Dr. A. Ionescu" Bucuresti; acelasi autor prezintã "Traumatismele diafragmului si herniile diafragmatice posttraumatice" din sectiunea de traumatologie. Sectiunea a 8-a mai cuprinde afectiuni mai rar întâlnite, precum "Relaxarea diafragmaticã", "Tumorile si chistele diafragmului". Un capitol aparte, al cãrui prim autor este Dr. Cezar Motas, asistent universitar, descrie sindromul diafragmului poros, ce apare frecvent în practica chirurgilor toracici sub forma hidrotoraxului hepatic si pune serioase probleme de management terapeutic.
Chirurgia toracicã de granitã este reprezentatã prin: "Sindromul de aperturã toracicã superioarã" - patologie cunoscutã îndeosebi de medicii neurologi, internisti, de kinetoterapeuti, si care atunci când necesitã tratament chirurgical este rezolvatã de cãtre chirurgii toracici sau cei vasculari; gusa cervico-mediastinalã - care necesitã de cele mai multe ori interventia chirurgului toracic, uneori prin sternotomie; toate afectiunile diafragmului etc.
Cei 25 de autori ai Volumului de Chirurgie Toracicã din Tratatul National de Chirurgie - 13 cadre universitare, dintre care 6 profesori universitari - reusesc sã adune într-un volum absolut complet studiul literaturii interne si internationale, experienta zilnicã din blocurile operatorii, metodele clasice de abord si tratament, precum si ultimele noutãti si tendinte în fiecare domeniu de activitate.
   

The 4-th volume of the National Textbook of Surgery which appears under the redaction of Prof. Dr. Irinel Popescu, is dedicated to the Thoracic Surgical Pathology, the volum being conceived by and under the guidance of Prof. Dr. Teodor Horvat. The volume is structured in 46 chapters, divided in 8 sections. In the almost 900 pages is presented in detail the thoracic surgical pathology and the border-line thoraco-abdominal and cervico-thoracic surgical pathology.
The presence of tree foreign authors can be singled out: Prof. Dr. Walter Klepetko - The chief of the Cardio-Thoracic Surgery and Pulmonary Transplantation Department - Vienna Medical University, Allgemeines Krankenhaus, Viena, Austria; Dr. Shahrokh Taghavi and Dr. Clemens Aigner - cardio-thoracic surgeons from the same Surgical Clinic. They present two chapters published for the first time in a romanian text book of thoracic surgery: "Pulmonary trombendarterectomy for chronic tromboembolic pulmonary hipertension" and "Pulmonary transplantation - current aspects".
The first chapter of the volume is dedicated to the history of the romanian thoracic surgery and of the surgeons that builded it up: "If they haven't been existed, we would not be here" says Prof. Dr. Teodor Horvat.
"Anaesthesia in thoracic surgery" also represents a first presentation in the romanian books of thoracic surgery. This chapter is conceived by Dr. Radu Stoica, chief of the Anaesthesia and Intensive Care Department from the "Marius Nasta" Pneumology Institute, and presents the particularities of anaesthesis and intensive care in various toracic surgical pathologies, underlining once again the conclusion that the thoracic surgeon and the anaesthesiologist must work tightly together.
The trauma section has 4 chapters that describe: the diagnostic and therapeutic management of the thoracic trauma (the chapter being addressed also to emergency medicine physicians, anaesthesiologists and physicians from intensive care units, general surgery and cardiovascular surgeons, etc), the mini-invasive approach with his indications and contraindications, the diaphragmatic trauma and the sequels of thoracic trauma.
In the section allocated to the surgical pathology of the thoracic wall are comprised: the surgical anatomy of the thoracic wall, the congenital malformations of the thoracic wall and their treatment both by classical methods and by mini-invasive approach, the thoracic wall's infections and their surgical treatment, including the dehiscent and infected sternotomy and the tumors of the thoracic wall. The possibilities for the reconstruction and stabilization of the thoracic wall are also presented, those being sometimes a delicate matter for the thoracic surgeon which is confronting a massive tumor of the thoracic wall, either primary or secondary, an extensive infection or a lack of substance secondary to a trauma; the plastic surgeon is often a part of the surgical team. The chapters that include the thoracic wall pathology are written with a lot of didactic talent by Prof. Dr. Alexandru Nicodin, chief of the Thoracic Surgery Clinic from the "Victor Babes" University of Medicine and Pharmacy Timisoara.
The section "Surgical pathology of the pleural cavities and of the pericardic cavity" is entirely conceived by the collective of the Second Thoracic Surgery Clinic from the Central Military Emergency Clinical Hospital Bucharest. After the chapter of surgical anatomy is presented "The spontaneous pneumothorax" - both primary and secondary to various diseases, the chapter being addressed not only to the thoracic surgeons, but to general surgeons or other physicians whom are confronted with the spontaneous pneumothorax as well - and is ment to be an impulse to respect the therapeutic protocol in order to decrease the relapsing risk of the pneumothrax. The malignant pleural and pericardic liquid accumulations are presented separately bringing forward their mini-invasive treatment (the thoracoscopic approach of the pleurisy and of the pericarditis, the underxifoidian approach, etc), which is ment to improve the quality of life in neoplastic patients.
"The purulent pleurisies" are presented because of their frequent apparition in the medical practice, and again the chapter is addressed also to other physicians but thoracic surgeons: pneumologists, anaestheologists, general surgeons.
The benign and malignant pleural tumors are also presented - with a detailed description of the malignant difuse mesothelioma with the international tendencies of his therapeutic approach.
We note that two of the authors of the chapter "The chilothorax" - Prof. Dr. Teodor Horvat and Dr. Claudiu Nistor, - are the writers of the book "The thoracic ducts" published in 2007.
The most extensive section comprises "The tracheal and broncho-pulmonary surgical pathology". After the chapter of surgical anatomy, in the chapter "Tracheal stenosis" is synthetized a wide tracheal patology: congenital and acquired, benign and malignant, primary and secondary; the surgical procedures, the indications, the complications and the postoperative management are also presented. The chapter excels by the authors - the didactic personnel of the Second Thoracic Surgery Clinic, Central Military Emergency Clinical Hospital Bucharest - skill to synthetize, by the didactic value of the writing, to which the surgical practice experience is added.
"The surgery of the pulmonary tuberculosis" is presented by Prof. Dr. Adrian Aldea his asistants form the Thoracic Surgery Clinic of the University of Medicine and Pharmacy "Gr. T. Popa" Iasi, emphasizing the characteristic features of the pulmonary tuberculosis surgical patients, the narrow indications for surgery and the long evolution of the disease itself.
In the chapter "Thracheo-broncho-pulmonary congenital malformations" are described the cases from the neonatologist's practice, the pediatric cases and the adult patients cases, incountered in the general thoracic surgery practice.
"The pulmonary hydatid" represents a rather frequent encountered pathology for the thoracic surgeons and the pediatric surgeons. The clinical experience is guiding the surgeon to choose which of the multiple procedures is the most appropriate for each case in order to save as much pulmonary tissue as possible.
Other subjects are next being presented: "The broncho-pulmonary suppurations" - in which Prof. Dr. Alexandru-Mihail Botianu, chief of the General and Thoracic Surgery Clinic from the University of medicine and Pharmacy Tg. Mures, extensively presents the types of broncho-pulmonary suppurations with their surgical indications and the international up-to-date in the surgical treatment of these diseases that belong in most cases to the pneumo-logical practice; "Pulmonary mycosis" - disease that can sometimes enter the field of thoracic surgery, especially trough pulmonary aspergiloma and the hemoptysis produced by it; "Benign pulmonary tumors" - which in most cases can benefit by surgical treatment trough thoracoscopic surgery or videoassisted thoracic surgery, and sometimes, in the hands of an experienced bronchologist, can be resolved by using interventional bronchology; "Pulmonary metastases" - which, in certain situations, depending also on the primary tumor, can benefit by surgical treatment in order to prolong the patient's disease-free survival.
The importance of the radiologic finding of a "Solitary pulmonary nodule" is presented in a separate chapter, edited by Conf. Dr. Ioan Cordos and his assistants from the First Thoracic Surgery Clinic of the "Marius Nasta" Institute of Pneumology in Bucharest, with the decisive contribution of Dr. Tudor Ciprut, chief of the Computer Tomography Department of the same institute; becomes once again clear that any pulmonary nodule must have a histological diagnose, and in the very frequent case in which we have to deal with a incipient broncho-pulmonary cancer, the surgical treatment by oncological margin-free resection is mandatory and significantly influences the long-time survival of these patients "Bronchical carcinoid" offers to the authors the opportunity to present, within the surgical treatment of these tumors, the bronchical resection techniques associated or not with pulmonary resection, intended to "save" as much pulmonary parenchyma as possible: broncho-plastical resections, broncho-anastomotical resections, in which cases the lesion may enforce the association of angio-plastical resections or angio-anastomotical resections.
"The broncho-pulmonary cancer" represents the day-to-day struggle of the thoracic surgeons around the world: "At the moment that the diagnose is established, only 1/3 of the cases are in a helpful therapeutic stage". Prof. Dr. Teodor Horvat is the first author of this chapter which comprises all the theoretical achievement, clinical sense, operating room experience and the skill to sinthetize the knowledge that can be used in the struggle against this terrible disease. We can emphasize the arsenal of paraclinical investigations, among them being recently part in Romania the positron-emission tomography - PET scan, the actualization of TNM classification, the presentation of the oncological resection surgical techniques and the underlining of the role of multimodal treatment in broncho-pulmonary cancer.
The 7-th section is allocated to the mediastinum; after the surgical anatomy, the acute and chronic mediastinal infections are presented. The tumoral and pseudotumoral mediastinal lesions comprise various elements that should be known at least partially by any physician. "The Superior vena cava syndrome" represents a synthetic update of the book with the same name published in 2003. "The surgical treatment of miastenia gravis" is explicitly and fully presented by Dr. Victor Tomulescu, Department of General Surgery and Liver Transplatation in Fundeni Clinical Institute Bucharest.
From the section reserved to the diaphragm, the surgical anatomy and all the types of diaphragmatic hernias (except the hiatal hernia) are chapters conceived by Dr. Lucian Alecu, chief of the Surgery Department of the "Prof. Dr. A. Ionescu" Hospital Bucharest; the same author presents "The diaphragmatic trauma and the posttraumatic diaphragmatic hernias" from the trauma section.
The 8th section also comprises rare diseases like "Diaphragmatical relaxation", "Diaphragmatic tumors and cysts". A separate chapter, having Dr. Cezar Motas (tutor) as first author, describes the porous diaphragm syndrome which frequently appears in the thoracic surgical practice as hepatic hidrothorax and gives serious therapeutical management problems.
Border-line thoracic surgery is represented by "The superior thoracic aperture syndrome" - pathology known mostly by neurologists, general practitioners, kinetotherapy practitioners, and which is resolved by thoracic surgeons or vascular surgeons when the surgical treatment is necessary; the cervico-mediastinal goiter that requires in most cases the intervention of the thoracic surgeon, sometimes by sternotomy; all the diaphragmatic injuries etc.
The 25 authors of the Thoracic Surgery Volume from the National Textbook of Surgery - 13 university teachers, 6 of them university professors - manage to gather up in a complete volume the entire interne and international literature study, the daily experience from the operating rooms, the classical approach and treatment methods, as well as the last information and trends in each field of activity.