Cristiano Feijó Andrade

Malformações pulmonares congênitas

Congenital lung malformations are rare and vary widely in their clinical presentation and severity, depending mostly on the degree of lung involvement and their location in the thoracic cavity. They can manifest at any age and can be the source of significant morbidity and mortality in infants and children. Individuals with congenital lung malformations can present with respiratory symptoms at birth or can remain asymptomatic for long periods. Recently, there has been an increase in the early diagnosis of these malformations, a change that is attributable to the routine use of prenatal ultrasound. The clinical manifestation of these malformations varies from respiratory distress in the immediate postnatal period to an incidental finding on chest X-rays. Early diagnosis and prompt treatment offer the possibility of absolutely normal lung development. The treatment of asymptomatic patients with lung malformations is controversial, because the prognosis of these diseases is unpredictable. The management of these lesions depends on the type of malformation and symptoms. Because of the risk of complications, most authors recommend resection of the lesion at the time of diagnosis. Lobectomy is the procedure of choice and yields excellent long-term results. This article describes the principal congenital lung malformations, their diagnosis, and the controversies regarding treatment.As malformacoes congenitas do pulmao sao raras e variam muito na sua forma de apresentacao clinica e gravidade, dependendo principalmente do grau de envolvimento pulmonar e de sua localizacao na cavidade toracica. Elas podem se manifestar em qualquer idade e podem ser fonte de importante morbidade e mortalidade em lactentes e criancas. Os individuos com malformacoes congenitas do pulmao podem apresentar sintomas respiratorios ao nascimento, enquanto outros podem permanecer assintomaticos por longos periodos. Atualmente, com o uso rotineiro da ultrassonografia pre-natal, vem ocorrendo um aumento no diagnostico mais precoce dessas malformacoes. A manifestacao clinica dessas malformacoes varia desde uma disfuncao respiratoria pos-natal imediata a um achado acidental na radiografia de torax. O diagnostico precoce e o tratamento imediato oferecem a possibilidade de um desenvolvimento pulmonar absolutamente normal. Quando assintomaticos, a conduta para o tratamento dos pacientes com malformacoes pulmonares ainda e controversa, uma vez que o prognostico dessas afeccoes e imprevisivel. O manejo dessas lesoes depende do tipo de malformacao e de sintomas. Devido ao risco de complicacao, a maioria dos autores sugere a resseccao da lesao no momento em que essa e identificada. A lobectomia e o procedimento de escolha, fornecendo excelentes resultados a longo prazo. Este artigo descreve as principais malformacoes pulmonares congenitas, seu diagnostico e controversias quanto o tratamento.

Surgical treatment of bronchial carcinoid tumors: a single-center experience.

BACKGROUND Bronchial carcinoid is an infrequent neoplasm with a neuroendocrine differentiation. Surgical treatment is the gold standard therapy, with procedures varying from sublobar resections to complex lung sparing broncoplastic procedures. This study evaluates the results of surgical treatment of bronchial carcinoids and its prognostic factors. PATIENTS AND METHODS Retrospective review of 126 consecutive patients who underwent surgical treatment for bronchial carcinoid tumors between December 1974 and July 2007. RESULTS There were 70 females (55%) and the mean age was 46 years, ranging from 17 to 81 years. Upon clinical presentation, 38 patients (30%) have had recurrent respiratory tract infection, 31 (24%) cough, 16 (12%) chest pain and 25 (20%) were asymptomatic. Preoperative bronchoscopic diagnosis was obtained in 74 cases (58.7%). The procedures performed were: 19 sublobar resections (14,9%), 58 lobectomies (46%), 8 bilobectomies (6.3%), 6 pneumonectomies (4.7%), 2 sleeve segmentectomies (1.5%), 26 sleeve lobectomies (20.6%) and 9 bronchoplastic procedures without lung resection (7.1%). Operative mortality was 1.5% (n = 2) and morbidity was 25.8% (n=32), including 12 respiratory tract infections and 4 reinterventions due to bleeding (3) and pleural empyema (1). Among the 112 patients available for follow-up, the overall survival at 3, 5 and 10 years was 89.2%, 85.5% and 79.8%, respectively. Five and 10-year survival for typical and atypical carcinoids were 91, 89% and 56, 47%, respectively. Overall disease-free survival at 5 years was 91.9% Statistical analysis showed that overall disease-free survival correlated with histology--typical vs. atypical--(p = 0.04) and stage (p = 0.02). CONCLUSION Surgery provides safe and adequate treatment to bronchial carcinoid tumors. Histology and stage were the main prognostic factors.

Complicações relacionadas à lobectomia em doadores de transplante pulmonar intervivos

OBJECTIVE To evaluate post-operative complications in living lobar lung transplant donors. METHODS Between September of 1999 and May of 2005, lobectomies were performed in 32 healthy lung transplant donors for 16 recipients. The medical charts of these donors were retrospectively analyzed in order to determine the incidence of postoperative complications and alterations in pulmonary function after lobectomy. RESULTS Twenty-two donors (68.75%) presented no complications. Among the 10 donors presenting complications, the most frequently observed complication was pleural effusion, which occurred in 5 donors (15.6% of the sample). Red blood cell transfusion was necessary in 3 donors (9.3%), and 2 donors underwent a second surgical procedure due to hemothorax. One donor presented pneumothorax after chest tube removal, and one developed respiratory infection. There were two intra-operative complications (6.25%): one donor required bronchoplasty of the middle lobe; and another required lingular resection. No intra-operative mortality was observed. Post-operative pulmonary function tests demonstrated an average reduction of 20% in forced expiratory volume in one second (p < 000.1) compared to pre-operative values. CONCLUSIONS Lobectomy in living lung transplant donors presents high risk of post-operative complications and irreversible impairment of pulmonary function. Careful pre-operative evaluation is necessary in order to reduce the incidence of complications in living lobar lung transplant donors.

Prevalência de refluxo gastroesofágico em pacientes com doença pulmonar avançada candidatos a transplante pulmonar

OBJECTIVE: To assess the esophageal function profile and the prevalence of gastro-esophageal reflux (GER) in lung transplant candidates. METHODS: From July of 2005 to November of 2006, a prospective study was conducted involving 55 candidates for lung transplantation at the Santa Casa de Misericordia Hospital in Porto Alegre, Brazil. Prior to transplantation, patients underwent outpatient stationary esophageal manometry and 24-h esophageal pH-metry using one and two electrodes. RESULTS: Abnormal esophageal manometry was documented in 80% of the patients, and 24% of the patients presented pathological acid reflux. Digestive symptoms presented sensitivity and specificity for GER of 50% and 61%, respectively. Of the patients with chronic obstructive pulmonary disease, 94% presented abnormal esophageal manometry, and 80% presented lower esophageal sphincter hypotonia, making it the most common finding. Patients with bronchiectasis presented the highest prevalence of GER (50%). CONCLUSIONS: In patients with advanced lung disease, GER is highly prevalent. In the population studied, digestive symptoms of GER were not predictive of pathological acid reflux. The role that GER plays in chronic rejection should be examined and clarified in future studies.

Tratamento cirúrgico das malformações pulmonares congênitas em pacientes pediátricos

OBJECTIVE: To determine the main congenital lung malformations treated and the principal diagnostic methods employed, as well as the indications for surgical treatment and the results obtained, at a referral facility for pediatric thoracic surgery. METHODS: We reviewed the medical charts of 52 patients anatomopathologically diagnosed with congenital lung malformations and who had been submitted to pulmonary resection between January of 1997 and December of 2006. Exclusion criteria were age > 12 years and incomplete clinical data. The final sample comprised 35 patients. RESULTS: In this sample, the mean age was 31 months, and there was a predominance of males (n = 21). The anatomopathological findings were cystic adenomatoid malformation (n = 14), congenital lobar emphysema (n = 13), pulmonary sequestration (n = 8) and arteriovenous malformation (n = 1). The most common type of lung resection was left lower lobectomy (in 25.71%) followed by different types of segmentectomy (in 22.85%), left upper lobectomy (in 22.85%), right upper lobectomy (in 14.28%), right lower lobectomy (in 8.57%) and middle lobectomy (in 5.71%). Of the 35 patients, 34 (97.14%) were submitted to closed pleural drainage, with a mean duration of thoracic drainage of 3.9 days. Ten patients (28.5%) presented with postoperative complications. There were no deaths in our sample. CONCLUSIONS: Pulmonary resection for the treatment of congenital lung malformations is a safe procedure, presenting low morbidity and no mortality at a referral facility for pediatric thoracic surgery.

Bronquiectasias: aspectos diagnósticos e terapêuticos Estudo de 170 pacientes

BACKGROUND: Bronchiectasis is a frequently found disease in medical practice in Brazil leading to significant morbidity and decrease in quality of life of the affected individuals. OBJECTIVES: To study diagnostic and therapeutic aspects in a series of hospitalized patients with bronchiectasis in a department of pulmonary diseases. METHOD: Signs, symptoms, microbiological and radiographic data, and therapeutic results were studied in 170 hospitalized patients between 1978 and 2001 - females 62.4%, males 37.6%, and aged from 12 to 88 years (mean age 36.8 yrs). Previous history of pneumonia in childhood was detected in 52.5% of the patients, tuberculosis in 19.8%; 8.8% had bronchial asthma, and 2 had Kartageners syndrome. RESULTS: The most common symptoms were cough (100.0%), expectoration (96.0%) and pulmonary rales (66.0%). The pulmonary lesions were unilateral in 46.5% of the cases. Pneumococcus, H. influenzae or mixed flora were found in 85.0% of the examined sputa. All 170 patients received antibiotics and postural drainage, and 88 of them (younger and with a higher functional reserve) were also submitted to pulmonary resections (82 unilateral and 6 bilateral). Two deaths occurred, and repetitive hospitalizations were more frequent among the clinically treated patients. The follow up showed that most of the surgically treated patients had significant symptoms improvement and rarely needed to be re-hospitalized. CONCLUSIONS: In the majority of the patients, lung resection surgery improved permanently the prolonged bronchopulmonary symptoms of patients with bronchiectasis, differently from the patients who received only clinical treatment.

Nonfunctioning paraganglioma of the aortopulmonary window

Aortopulmonary paraganglioma is a rare tumor of the mediastinum. The only effective treatment is complete resection, which may pose a surgical challenge because of its proximity to the heart, great vessels, and trachea, often rendering a complete resection difficult to achieve. We report a case in which the tumor was excised under cardiopulmonary bypass and resulted in massive bleeding only controlled by means of packing the pleural cavity during 48 hours, known as damage control strategy. The patient survived and has been disease-free for 2 years.

N-Acetylcysteine administration confers lung protection in different phases of lung ischaemia–reperfusion injury

OBJECTIVES To verify the effects of N-acetylcysteine (NAC) administered before and after ischaemia in an animal model of lung ischaemia-reperfusion (IR) injury. METHODS Twenty-four Wistar rats were subjected to an experimental model of selective left pulmonary hilar clamping for 45 min followed by 2 h of reperfusion. The animals were divided into four groups: control group (SHAM), ischaemia-reperfusion, N-acetylcysteine-preischaemia (NAC-Pre) and NAC-postischaemia (NAC-Post). We recorded the haemodynamic parameters, blood gas analysis and histology. We measured the thiobarbituric acid reactive substances concentration; the expression of superoxide dismutase (SOD), inducible nitric oxide synthase (iNOS), nitrotyrosine, cleaved caspase 3, nuclear factor κB (NF-κB), NF-kappa-B inhibitor alpha (IκB-α), tumour necrosis factor alpha (TNF-α) and interleukin-1 beta (IL-1β); myeloperoxidase activity (MPO). RESULTS No significant differences were observed in the haemodynamic parameters, blood gas analysis and SOD activity among the groups. Lipid peroxidation was significantly higher in the IR and NAC-Pre groups (P < 0.01). The expression of nitrotyrosine, cleaved caspase 3, NF-κB, IκB-α, TNF-α and IL-1β were significantly higher in the IR group when compared with the SHAM and NAC groups (P < 0.01). The NAC-Pre group showed a significantly higher expression of these proteins when compared with the SHAM and NAC-Post groups (P < 0.05). After reperfusion, the expression of iNOS increased almost uniformly in all groups when compared with the SHAM group (P < 0.01). The histological analysis showed fewer inflammatory cells in the NAC groups. CONCLUSIONS The intravenous administration of NAC demonstrated protective properties against lung IR injury. The use of NAC immediately after reperfusion potentiates its protective effects.

Endobronchial perfluorocarbon administration decreases lung injury in an experimental model of ischemia and reperfusion

OBJECTIVE To verify the effects of liquid endobronchial perfluorocarbon (PFC) administered before reperfusion in an animal model of lung ischemia-reperfusion injury. METHODS Eighteen Wistar rats were subjected to an experimental model of selective left pulmonary artery clamping for 45 min followed by reperfusion for 2 h. The animals were divided into three groups: the ischemia-reperfusion (IR) group, the sham group, and the PFC group. We recorded the hemodynamic parameters, blood gas analysis, and histology. A Western blot assay was used to measure the inducible nitric oxide synthase, caspase 3, and nuclear factor қB (subunit p65) activities. Lipid peroxidation was assessed by the thiobarbituric acid reactive substances assay and the activity of the antioxidant enzyme superoxide dismutase. RESULTS No significant differences were observed in lipid peroxidation among the groups. The superoxide dismutase activity was increased (P < 0.05) in the PFC-treated group. The expressions of nuclear factor қB, inducible nitric oxide synthase, and caspase 3 were significantly lower in the PFC group than in the IR group (P < 0.05). The histologic analysis showed a reduction in lung injuries in the PFC group compared with the sham and IR groups. CONCLUSION The use of endobronchial PFC reduces the inflammatory response, preserves the alveolar structure, and protects the lungs against the hazardous effects of ischemia-reperfusion injuries.

Pleural Tuberculosis in Children

Pleural tuberculosis effusion (PTE) in children is a diagnosis which must be considered in isolated pleural effusions in non-toxemic children. It is more common in children over 5 years of age. A history of close contact with an adult with pulmonary tuberculosis reinforces the suspicion for its diagnosis. Pleural effusion without any parenchymal lesion is the characteristic finding on the chest x-ray. However, in 20% to 40% of patients, intrathoracic disease may also occur. Adenosine deaminase, interferon-gamma, analysis of pleural fluid and pleural biopsy are the main tools for diagnostic confirmation. Tuberculin skin test may provide supporting evidence of tuberculous infection. PTE has a good prognosis in children and no long term sequelae are expected.