Benoit Jacques Bibas

Predictors for Postoperative Complications After Tracheal Resection

BACKGROUND Tracheal resection and anastomosis is the gold standard for the treatment of tracheal stenosis. The objective of this study is to evaluate the complications after tracheal resection for benign stenosis and the predicting factors for such complications. METHODS A retrospective study was made involving patients with benign tracheal or laryngotracheal stenosis who underwent surgical resection and reconstruction between February 2002 and January 2009. Complications related and unrelated to the anastomosis were studied. Categorical variables were presented as percentage and continuous variables as mean and standard deviation. Predicting factors were determined by univariate analysis. Factors with p less than 0.05 were used for multivariate regression. Logistic regression models were also employed for dependent variables. Statistical significance was set for p less than 0.05. RESULTS Ninety-four patients (18 female, 76 male) were included. Complications occurred in 42 (44.6%). Twenty-one percent had anastomotic complications. The most common complication was restenosis (16%). Nonanastomotic complications occurred in 23.2%. Wound infection occurred in 10.6%. Clinical comorbidities, previous tracheal resection, and the length of tracheal resection were statistically significant factors for complications. Previous tracheal resection was the most significant factor and was highly associated with anastomotic complications (odds ratio 49.965, p=0.012). The greatest number of complications was found in the laryngotracheal reconstruction group, and in resections more than 4 cm. Mean follow-up was 19±14 months. At the end of the study, 86 patients (91.4%) were breathing normally. There was no mortality in this series. CONCLUSIONS Comorbidities, previous tracheal resection, and the length of tracheal resection more than 4 cm were statistically significant factors for the onset of complications.

Effectiveness and safety of outpatient pleurodesis in patients with recurrent malignant pleural effusion and low performance status

OBJECTIVES: To evaluate the effectiveness and safety of pleurodesis carried out entirely on an outpatient basis in patients with recurrent malignant pleural effusions and Karnofsky Performance Status scores ≤70. METHODS: This study was a prospective trial comprising patients with symptomatic recurrent malignant pleural effusion and Karnofsky Performance Status scores ≤70 but >30. All selected patients underwent pleural catheter placement (14 Fr) in an outpatient facility. When chest radiography revealed post‐drainage lung expansion of >90%, pleurodesis (3 g of talc) was performed. Catheters were maintained until the daily output was <100 mL/day. The patients were evaluated in the first month and every three months thereafter for fluid recurrence, the need for additional procedures, and complications. RESULTS: During the study period (January 2005 to July 2007), 64 patients (24 men, 40 women), with an average age of 61.4 years, underwent elective chest tube drainage. Primary sites of the underlying malignancy were breast (27), lung (22), and others (15). Sixty‐six pleural catheters were placed (bilaterally in 2 patients), and 52 talc pleurodesis procedures were performed. Fourteen patients had a trapped lung and were excluded from the trial. No complications were observed during catheter placement or pleurodesis. Post‐pleurodesis complications included catheter obstruction (4 patients) and empyema (1). The average drainage time was 9.9 days. The recurrence rate observed in patients that were alive 30 days after pleurodesis was 13.9% (5/36 patients). Six patients required additional procedures after the pleurodesis. The average survival time was 101 days. CONCLUSION: In this study, talc pleurodesis was safely performed in an outpatient setting with good efficacy and a reasonable complication rate, thereby avoiding hospital admission.

Decannulation in Tracheal Stenosis Deemed Inoperable Is Possible After Long-Term Airway Stenting

BACKGROUND Decannulation is the ultimate therapeutic goal for patients who undergo stenting because of inoperable benign tracheal stenosis. In this study, our objectives were to evaluate whether long-term airway stenting allows decannulation in patients with benign tracheal stenosis who were deemed inoperable and to identify possible predictive factors for successful decannulation (SD). METHODS Retrospective cohort study including all patients with inoperable benign tracheal stenosis who underwent tracheal stenting in our tertiary-care university-based institution from 1998 to 2008. For benign stenosis, we use only silicone stents (T tubes, Dumon stents, and Y stents). The main outcome was SD, which was defined as removal of the tracheal stent followed by absence of respiratory symptoms and no requirement for new dilation procedures for at least 6 months. A Kaplan-Meier curve was built to evaluate SD in 5 years, and we used a Cox model to evaluate predictors for a SD. RESULTS Ninety-two patients were included, and during the study period 21 were decannulated. However, 2 of them had to undergo new airway procedures and were considered to represent failure. Therefore, 19 patients were successfully decannulated. According to the Kaplan-Meier estimate, the SD rate in 5 years was 27.5%. The mean follow-up time after SD was 34.3 ± 33.9 months (range, 6 to 108 months). Cox regression showed only 1 significant factor: tracheostomy before stent insertion caused a threefold increase in the likelihood of the patient remaining with a tracheal stent (p = 0.048). CONCLUSIONS Tracheal stenting may be considered a curative therapeutic approach in as many as 27.5% of patients with inoperable benign tracheal stenosis.

Hemangioma subglótico e mediastinal em criança: tratamento com propranolol

A 6-month-old girl with upper airway obstruction was evaluated in the emergency room. The patient had been born prematurely (at gestational week 34). Prior to the emergency room visit, she had been treated for gastroesophageal reflux and recurrent respiratory infection. Physical examination revealed laryngeal stridor. All laboratory test results were normal. A CT scan of the chest, larynx, and trachea showed a heterogeneous, highly vascularized mass in the left hemithorax (Figure 1). However, there was no cardiac malformation. Rigid bronchoscopy performed under general anesthesia revealed a large pulsatile mass that obstructed approximately 80% of the larynx and trachea (Figure 2a; Video 1

Um caso raro de tumores torácicos malignos sincrônicos

Malignant neurogenic mediastinal tumors in adults are uncommon and extremely aggressive. We report the case of a 61-year-old male patient with the simultaneous occurrence of malignant mediastinal schwannoma and bronchioloalveolar carcinoma. Although bronchioloalveolar carcinoma is present in 4-7% of the resected synchronous thoracic tumors, this association has never been reported in the literature. However, it is a common finding in patients presenting apparently inflammatory infiltrates and ground-glass opacities, as in the case presented here.

Peripheral pulmonary artery aneurysm presenting as a solitary pulmonary nodule

We report the case of a 63-year-old female patient who was evaluated due to a solitary pulmonary nodule. The final diagnosis was a solitary peripheral pulmonary artery saccular aneurysm. The patient was submitted to a pulmonary lobectomy with excellent recovery. Peripheral pulmonary artery aneurysms that arise from segmental or intrapulmonary branches are extremely rare, and their management is still controversial.

Bonus? NO, just an onus

The program is expected to come into effect at the time of the public competitions for medical residence positions that will be available in 2013. The idea is to bring into the program 2000 physicians, 1000 nurses and 700 dentists, paid directly by municipalities. The municipalities that were to be included in the pro-gram would be defined by the end of 2011.

Healthcare systems: what do we want?

in which the present situation in 11 developed nations was compared. This study left the United States poorly placed in relation to others such as Australia, France and the United King-dom. After consulting 19,700 adults in the United States, Germany, Australia, Canada, France, Netherlands, Norway, New Zealand, United Kingdom, Sweden and Switzerland, it was con-cluded that the American people were the ones who had the greatest need to survive without seeking a physician, because of the difficulty of paying for healthcare.Because of the costs, adult Americans are much more inclined than those in the other ten industrialized nations to live without medical coverage. They have the greatest problems in deal-ing with the bills; they pay high prices even when they have medical insurance; and they get into disputes with their insurers regarding their coverage.

Giant multilocular thymic cyst in an HIV-infected adolescent

A girl with vertically acquired HIV infection presented with a 6-month history of dyspnea and chest pain. Computed tomography of the thorax showed a heterogenous mass measuring 13 × 9 × 17 cm located in the anterior mediastinum. Complete surgical resection was accomplished with no complications. The final diagnosis was multilocular thymic cyst, a distinct pathologic entity that is morphologically distinguishable and unrelated to congenital thymic cyst.

Leiomyomatous Hamartoma of the Posterior Mediastinum

A posterior mediastinal mass was found in a 72-year-old man who complained of progressive shortness of breath. Computed tomography of the thorax showed a well-defined, heterogenous mass measuring 9.5 x 4.0 x 3.0 cm, located in the right costovertebral angle. Complete surgical resection was accomplished through a right posterolateral thoracotomy. The final diagnosis was a leiomyomatous hamartoma of the posterior mediastinum. This is an unusual location for this type of tumor, and it has rarely been reported in the literature.