Angelo Fernandez

Descending necrotizing mediastinitis: a retrospective surgical experience

OBJECTIVE Descending necrotizing mediastinitis (DNM) is a primary complication of cervical or odontogenical infections that can spread to the mediastinum through the anatomic cervical spaces. We reviewed the last 10 years of our surgical experience in DNM and commented on early diagnosis and aggressive surgical treatment in these patients. METHODS Five males (71%) and two females (29%), mean age 34 years, with DNM, were surgically treated. Primary oropharyngeal infection occurred in three (43%) and odontogenic abscess in four (57%) patients. All had serious cervical and mediastinal infections with severe respiratory and hemodynamic repercussions, i.e. bacteremia, systemic arterial hypotension and obnubilation. Diagnosis was confirmed by computerized chest tomography. RESULTS All patients underwent surgical drainage of the cervical region by bilateral transverse cervicotomy with debridement of the necrotic and infected tissues, associating ample mediastinal drainage with or without thoracotomy. Six patients (86%) evolved well and were discharged after a mean of 35 days. Two patients (29%) required reoperation due to local surgical complications: empyema and dehiscence of the sternum. One patient (14%) died on the second postoperative (p.o.) day due to renal and respiratory insufficiency. Cultures of DNM showed the development of associated aerobic and anaerobic flora in 71% of the operated patients and only aerobic in 29%. CONCLUSION Early diagnosis by CAT scan of the neck and thorax aids in rapid indication of a surgical approach of DNM. Performing ample cervicotomy with mediastinal drainage generally associated with thoracotomy can significantly reduce the mortality rate for this condition to 14%.

Repair of congenital sternal cleft in infants and adolescents

BACKGROUND Clinical and surgical aspects of sternal cleft repair are presented. Primary repair in the neonatal period is the best management for this rare condition, but none of the patients in this report were referred to us during that period. Autologous repair is suitable for older patients because it avoids problems related to the implant of prosthetic materials. METHODS This article reviews 8 cases of sternal cleft not associated with ectopia cordis in patients presenting between October 1979 and November 1997. Surgical repair consisted of three sliding chondrotomies, three posterior sternal wall repairs, one combination with the Ravitch technique for pectus excavatum repair, and one posterior sternal wall repair associated with total repair of Cantrells pentalogy. RESULTS All patients who submitted to surgical correction had good aesthetic and structural results. The postoperative period was uneventful except that a subcutaneous fluid collection developed in 1 patient. The mean hospital stay was 5.8 days. The patients were followed up from 4 months to 18 years. CONCLUSIONS Whether dealing with older children or young adults, the technique of reconstructing a new sternum with a posterior periosteal flap from sternal bars and chondral grafts is a simple, quick, inexpensive, and effective option.

Diagnóstico e estadiamento do câncer de pulmão

Carcinoma of the lung can present in a number of guises and a number of possible and often complementary diagnostic approaches are available. The choice of procedure should reflect the presentation of the tumor, local expertise, intended management and patient preference. There are different methods of investigation: sputum cytology, fiberbronchoscopy, transbronchial biopsy, transbronchial needle aspiration, transthoracic fine needle aspiration, etc. The association of all of these methods increases the power of diagnosis. Staging is the measurement of the anatomical extent of a tumor in any given patient. The staging of cancer began with Denoixs TNM classification system, and, although several modifications were developed, it remains the basis of lung cancer staging systems up to now. Assigning patients to a particular TNM stage allows choosing the most appropriate therapy and provides prognostic information. Also, the impact of new therapeutic methods can be evaluated for efficacy and a comparison of the expected survival rates can be predicted.

Pulmonary Artery Sarcoma Mimicking a Pulmonary Artery Aneurysm

Pulmonary artery sarcoma is an uncommon neoplasm, and its clinical and radiological presentation usually simulates chronic thromboembolic disease. We present the case of a 77-year-old woman admitted with dyspnea, chest pain, and hemoptysis. A chest computed tomographic scan showed moderate right-sided pleural effusion and a saccular dilatation of the interlobar portion of the right pulmonary artery, which was filled with contrast and surrounded by an irregular soft-tissue attenuation mass, suggesting a ruptured pulmonary artery aneurysm. The patient was operated on. Intraoperatively, a pseudoaneurysm and a solid mass were identified within the oblique fissure around the interlobar artery. Therefore, a right pneumonectomy was performed. Definitive pathologic examination was consistent with pulmonary artery sarcoma. The patient had a good outcome and is free of disease 2 years after surgery.

Open bedside tracheostomy: routine procedure for patients under prolonged mechanical ventilation

BACKGROUND Tracheostomy is electively performed in critically ill patients requiring prolonged respiratory support. The risk of transporting, the increasing associated cost and operative room schedule are some of the obstacles for wider acceptance of this procedure. The use of rigid selection criteria exclude many patients who would benefit of this approach. OBJECTIVE To determine the safety of open bedside tracheostomy (OBT) as a routine intensive care units (ICU) procedure without any selection criteria, considering its peri and postoperative complications. METHOD Retrospective medical chart review of all patients that underwent elective tracheostomy between April 1999 and December 2005 at ICU of three private hospitals. RESULTS The study group comprised 552 patients with a mean age of 69.6 +/- 15.8 years. The incidence of significant complications (until 30 days after the procedure) was 4.34% (24 cases): 9 minor bleeding, 9 major bleeding, 2 subcutaneous emphysema, 4 stomal infections. Late complications were: laryngotracheal stenosis in 2 and tracheoinomminate fistula in 1 patient. CONCLUSIONS OBT seems to be a safe and simple procedure, when performed by a team of experienced physicians under controlled circumstances, and should be considered as an option for ICU patients.

Derrame pleural secundário à hiperestimulação ovariana

Ovarian hyperstimulation syndrome (OHSS) is an iatrogenic complication that occurs in the luteal phase of an induced hormonal cycle. In most cases, the symptoms are self-limited and spontaneous regression occurs. However, severe cases are typically accompanied by acute respiratory distress. The objective of the present study was to describe the clinical presentation, treatment, and outcome of pleural effusion associated with OHSS in three patients undergoing in vitro fertilization. The patients ranged in age from 27 to 33 years. The onset of symptomatic pleural effusion (bilateral in all cases) occurred, on average, 43 days (range, 27-60 days) after initiation of hormone therapy for ovulation induction. All three patients required hospitalization for massive fluid resuscitation, and two required noninvasive mechanical ventilation. Although all three patients initially underwent thoracentesis, early recurrence of symptoms and pleural effusion prompted the use of drainage with a pigtail catheter. Despite the high output from the pleural drain (mean, 1,000 mL/day in the first week) and prolonged drainage (for 9-22 days), the outcomes were excellent: all three patients were discharged from hospital. Although pleural effusion secondary to OHSS is probably underdiagnosed, the associated morbidity should not be underestimated, especially because it affects potentially pregnant patients. In this study, early diagnosis and appropriate supportive measures yielded favorable results, limiting the surgical approach to adequate pleural drainage.

Isolated Epithelioid Trophoblastic Tumor Mimicking Non-small Cell Lung Cancer

A 31-year-old Bolivian woman, nonsmoker, mother of two children, whose last pregnancy had occurred 8 years before, presented in our hospital with vaginal bleeding and high levels of -human chorionic gonadotropin ( hCG) 320 mIU/ml (normal value 3 mIU/ml). She was submitted to a curettage due to suspected miscarriage. At this moment, the endometrial biopsy showed normal glands, without atypical cells. The gynecology team chose to perform seriated hCG measurements and carry out the clinical follow-up. After 2 months, a new bleeding episode occurred, and the hCG level was 700 mIU/ml; a new curettage was performed, which disclosed proliferative endometrium. At this time, radiological assessment was requested to investigate a second source of hCG production. A transvaginal ultrasound disclosed no abnormalities; however, a thoracic computed tomographic scan showed a mass with 5 cm in the right lower lobe (Figure 1). Percutaneous biopsy of this mass showed squamous cell carcinoma, which was confirmed by immunohistochemical analysis (positive immunoreactivity for p63 and cytokeratin but negative for hCG, human placental lactogen, placental alkaline phosphate, and thyroid transcription factor-1). In the absence of metastasis, after staging for non-small cell lung cancer, the patient was scheduled for complete tumor resection. The tumor was exposed through right posterolateral thoracotomy approach. Intraoperatively, a large mass without extensive involvement of other structures was identified. The right lower lobe was removed, and systematic mediastinal lymphadenectomy was performed. The anatomopathological study demonstrated that the tumor was an epithelioid trophoblastic tumor (ETT), which confirmed by immunohistochemical analysis (Figure 2), without mediastinal lymph node involvement. The patient had an uneventful recovery and was discharged 5 days after the surgery. The gynecology team chose not to perform a hysterectomy, as there was no histological evidence of tumor in any sample analyzed from the curettage procedure. One year after the surgery, the patient has had no further episodes of vaginal bleeding or signs of uterine or lung recurrence. The hCG levels normalized, and she did not require adjuvant chemotherapy.

Desmoid tumors of the chest wall: surgical challenges and possible risk factors

Desmoid tumors account for approximately 0.3% of all solid tumors.1 The chest wall represents 8-10% of all cases, and surgery is the primary treatment modality for sporadic resectable desmoid tumors.2,3 Currently, the term “sarcoma with low-grade malignancy” is preferred, due the tendency of these tumors toward local invasion and frequent recurrence, even after complete surgical resection.4 There have been few specific studies on chest wall tumors. However, its treatment may involve peculiarities, such as a difficulty in obtaining free surgical margins (particularly in the axillary region and in the cervicothoracic transition). We present our experience over the past eleven years in an attempt to identify the risk factors for recurrence in patients with desmoid tumors located exclusively on the chest wall.

Tratamento cirúrgico das estenoses traqueais congênitas

OBJETIVO: Analisar os desfechos dos pacientes submetidos ao reparo de estenose congenita de traqueia. METODOS: Analise retrospectiva dos pacientes com estenose traqueal congenita tratados no Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo entre 2001 e 2007. RESULTADOS: Seis meninos e uma menina (idade ao diagnostico entre 28 dias e 3 anos) foram incluidos. Cinco pacientes apresentavam malformacoes intracardiacas e/ou de grandes vasos associadas. A extensao das estenoses foi curta em tres pacientes, media em um e longa em tres. As tecnicas utilizadas foram traqueoplastia com enxerto de pericardio em tres pacientes, resseccao e anastomose em dois, traqueoplastia em bisel em um e correcao de anel vascular em um. Um paciente morreu no intraoperatorio por hipoxia e instabilidade hemodinâmica e outro no 11o dia pos-operatorio por choque septico. Outras complicacoes observadas foram pneumonia, arritmia, estenose na anastomose e estenose residual, malacia e formacao de granulomas. O tempo medio de seguimento pos-operatorio foi de 31 meses; quatro pacientes ficaram livres da doenca e um necessitou de tubo T para manter a via aerea pervia. CONCLUSOES: A estenose congenita de traqueia e uma doenca curavel. Entretanto, seu reparo e complexo e esta associado a taxas de morbidade e mortalidade significativas.

Pneumothorax after acupuncture: clinical presentation and management

INTRODUCTION Pneumothorax is a rare but dangerous complication of acupuncture. Because of its rarity, there are few reports in literature and, therefore little information regarding clinical and therapeutic aspects. This article aims to analyze the clinical presentation, management and follow-up of patients with pneumothorax after acupuncture. METHODS Retrospective study of patients with post-acupuncture pneumothorax evaluated in a tertiary hospital during a five-year period (2001-2006). RESULTS Five patients (3 male and 2 female), mean age 46 years (30-73) were included. All patients but one (who had a bilateral pneumothorax) had left-sided pneumothorax . Chest pain, which was the initial symptom in all patients was severe in three cases and mild in two. Four patients underwent tube thoracostomy (pig-tail catheter), three of them immediately after admission and the other after a failed 12-hour conservative treatment period. One patient had a successful conservative management. All had an excellent outcome and were asymptomatic and exhibited a normal chest X-ray at 6-month follow-up CONCLUSION In all patients, the initial symptom was chest pain, of varying intensity. Tube thoracostomy was the therapeutic modality most frequently employed. All patients had a successful outcome with no further complications.