Bernardo Nogueira Batista

Atuação da cirurgia plástica no tratamento de feridas complexas

OBJECTIVE: To report the performance of plastic surgery in the treatment of complex wounds in a tertiary hospital, analyzing its characteristics, types of injuries and approaches adopted, with emphasis on surgical treatment. METHODS: We conducted a etrospective analysis of patients with complex wounds treated by plastic surgery in a tertiary hospital in a period of five years (2006 to 2010). Data collection was obtained from visits made, serial assessments and records of the medical charts. RESULTS: There were 1927 patients treated (32 queries / month), mean age 46.3 years, predominantly male (62%). The surgical specialties requested 1076 consultations (56%), and the clinical, 851 (44%). The distribution by type of wound showed predominance of pressure ulcers (635/33%), traumatic wounds (570/30%), complicated surgical wounds (305/16%) and necrotizing wounds (196/10%), with the remainder represented by vasculitis (83 / 4%), venous ulcers (79 / 4%), diabetes (41 / 2%) and post-radiation (18 / 1%). The treatment was surgical in 1382 patients (72%) and non-operative in 545 cases (28%). There were 3029 operations, predominantly debridement (1988/65%) and skin grafting (619/21%) associated or not with negative pressure therapy (vacuum), followed by pedicle flaps (237 / 8 %), digital reimplantation (81 / 3%), microsurgical flaps (66 / 2%) and other (38 / 1%). CONCLUSION: The plastic surgeon played an important role in the treatment of complex wounds by adopting early surgical treatment, contributing to the effective resolution of cases.

The etiology of extensive pleural effusions with troublesome clinical course among children

CONTEXT In São Paulo, pneumonia is the main infectious cause of death among children. Parapneumonic pleural effusion is a possible complication and has to be treated surgically when the patient does not respond to antibiotics. OBJECTIVE Assessment of the etiology of complicated parapneumonic pleural effusions that needed surgical intervention. TYPE OF STUDY Retrospective study. SETTING University hospital of the University of São Paulo. METHOD Analysis of 4,000 files on children hospitalized with pneumonia from November 1986 to November 1996 had shown that 115 of these children presented a total of 117 cases of pleural empyema that required surgical procedures. The childrens clinical condition was assessed in relation to radiological findings and to their nutrition and immunization status. Previous antimicrobial therapy and pleural effusion bacterioscopy were also evaluated. RESULTS Streptococcus pneumoniae was the agent found most commonly, as frequently in blood cultures as in pleural effusions. DISCUSSION Data on vaccination coverage, birth weight and nutritional status are analyzed and compared to other publications. We observed that pleural effusion has a high potential for discomfort, and in most cases it is not a complication of the first pulmonary disease episode. Previous use of antibiotics interfered with culture positivity. The agent most frequently found was Streptococcus pneumoniae, which is in accordance with the findings from other authors. Nonetheless, the antibiotics used to treat the patients after the procedure were the same used in non-complicated pneumonias, which has led us to conclude that the worse outcome in this cases was not due to drug resistance. CONCLUSION The bacteriological profile in our series of complicated pneumonia cases was similar to what has been described for non-complicated pneumonia cases. Future studies will be necessary to determine why these children presented a worse outcome.

Uso da terapia por pressão subatmosférica em feridas traumáticas agudas

OBJETIVO: avaliar a experiencia com o emprego de terapia por pressao subatmosferica no tratamento das lesoes traumaticas agudas das partes moles, em especial nos membros. METODOS: cento e setenta e oito pacientes com feridas traumaticas foram tratados pelo Centro de Feridas Complexas no periodo de janeiro de 2010 a dezembro de 2011 e, submetidos a terapia por pressao subatmosferica. RESULTADOS: dos 178 pacientes submetidos a terapia por pressao subatmosferica, 129 (72,5%) eram do sexo masculino e 49 (27,5%) apresentavam idade entre 18 e 40 anos. Os ferimentos descolantes nos membros foram o tipo de ferida traumatica mais comum, sendo responsaveis pela internacao de 83 (46,6%) pacientes. O tempo medio de internacao hospitalar foi 17,5 dias. Foram realizados 509 procedimentos cirurgicos (media de 2,9 por paciente). A terapia por pressao subatmosferica foi utilizada em 287 procedimentos, sendo 209 (72,8%) sobre feridas traumaticas e 78 (27,2%) sobre enxertos de pele. O numero de trocas de terapia por pressao negativa por paciente foi 1,6 e o tempo medio de utilizacao foi 8,5 dias por paciente. CONCLUSAO: os resultados foram considerados satisfatorios, diminuindo consideravelmente a morbidade e o tempo de cicatrizacao dessas lesoes em comparacao com tratamentos anteriormente executados como curativos. A terapia por pressao subatmosferica e um metodo util no tratamento de feridas agudas traumaticas, atuando como ponte entre o tratamento de urgencia e a cobertura cutânea definitiva destas lesoes, em comparacao com metodos mais tradicionais da cirurgia plastica.

Tratamento da síndrome da veia cava superior

The superior vena cava is formed by the union of the right and left brachiocephalic veins. It is located in the middle mediastinum, to the right of the aorta and anterior to the trachea. Superior vena cava syndrome consists of a group of signs (dilation of the veins in the neck, facial swelling, edema of the upper limbs, and cyanosis) and symptoms (headache, dyspnea, cough, orthopnea and dysphagia) caused by the obstruction of blood flow through the superior vena cava to the right atrium. This obstruction can be caused by extrinsic compression, tumor invasion or thrombosis. Such obstruction may also occur as a result of insufficient venous return secondary to intra-atrial or intraluminal diseases. From 73% to 93% of all cases of superior vena cava syndrome occur during the development of an intrathoracic tumor. Most patients presenting superior vena cava syndrome secondary to malignant neoplasms are treated without surgery, through radiotherapy, chemotherapy or the use of intraluminal stents. When the etiology of superior vena cava syndrome is benign, it can be treated with clinical measures (anticoagulation, raising the head, etc.) or, in refractory cases, with angioplasty, stents or surgery.

Intussuscepção intestinal em adultos jovens: relato de caso e revisão de literatura

Although intussusception is the main cause of intestinal obstruction in the pediatric population, it is a rare condition in adults, and when it happens, the clinical characteristics differ a lot from the pediatric group. The purpose of this article is to report a case of a 16 years-old male that was seen at the Emergency Room of the University Hospital of São Paulo with an intestinal intussusception as the first clinical presentation of a Burkitt lymphoma. A literature review was carried out and relevant aspects of the case are discussed.

Report of a case of anaplastic large cell lymphoma associated with a breast implant in a Brazilian patient

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a T-cell lymphoproliferative disorder that has recently been recognized as an independent entity in the World Health Organization (WHO) classification of lymphomas. Despite the small number of reports to date, the number of cases is rapidly increasing. Of the few hundred cases that have been reported so far, very few came from Brazil and none have been reported to the local authorities. We encountered a case of BIA-ALCL and believe that its report to the local plastic surgery community could raise awareness of this emerging pathology. The prognosis is very good in most of the diagnosed cases. However, little is known about how and why silicone implants could trigger a lymphoid response that results in ALCL. ■ ABSTRACT

Abdominoplastia vertical para tratamento do excesso de pele abdominal após perdas ponderais maciças

Background: Bariatric surgeries are becoming increasingly common in the treatment of morbidly obese patients. The enormous weight loss resulting from these procedures causes excessive skin and subcutaneous tissue throughout the body, especially in the abdominal region. The objective of this study was to present the technique of vertical abdominoplasty as an alternative for resection of excess skin in ex-obese patients. Methods: We retrospectively evaluated the records of 40 patients who underwent vertical abdominoplasty between 2004 and 2009. The degree of patient satisfaction was assessed through a subjective scale, with scores ranging from 0 to 10. Results: Twenty-five percent of the patients had minor complications (3 seromas, 3 minor dehiscences, and 5 hypertrophic scars), which were all treated on an outpatient basis. Sixty-seven percent of the patients reported high satisfaction and considered their results as good (grades 7 or 8) or excellent (grades 9 or 10). Conclusions: The vertical abdominoplasty technique appears to be a new option for the treatment of excess abdominal skin in ex-obese patients.

Nova técnica para o fechamento dinâmico da parede abdominal

Os avancos nos cuidados com o paciente traumatizado e com infeccoes abdominais graves sao responsaveis por um numero crescente de peritoneostomias. O manejo desta entidade e complexo e varias tecnicas foram descritas para seu tratamento. Recentemente foi introduzido na literatura o conceito de fechamento dinâmico da parede abdominal, com elevadas taxas de sucesso. O objetivo deste trabalho e de servir como nota previa de uma nova abordagem para o tratamento das peritoneostomias, desenvolvida no Hospital Universitario da Universidade de Sao Paulo. Trata-se de um procedimento simples e de baixo custo, facilmente realizado por cirurgiao geral. O procedimento tambem foi utilizado como reforco em fechamentos abdominais tensos, de maneira profilatica. O procedimento e descrito em detalhes, assim como os resultados nos primeiros pacientes. Apesar de promissora, refinamentos tecnicos e estudos complementares sao necessarios para a validacao da tecnica.