Darcy Ribeiro Pinto Filho

Sequestro extralobar com hemotórax secundário a infarto pulmonar

Pulmonary sequestration is an uncommon condition that accounts for 0.5-6% of all pulmonary malformations and is typically diagnosed in childhood. Of the two forms of pulmonary sequestration, intralobar and extralobar, the latter is less frequently encountered. The current report describes the case of a 32-year-old female patient with chest and abdominal pain. Imaging (chest X-rays and CT scans of the chest) revealed consolidation and pleural effusion. The initial thoracocentesis revealed hemothorax. Subsequent diagnostic video-assisted thoracoscopy revealed extralobar pulmonary sequestration. Consequently, the therapeutic decision was to make the conversion to thoracotomy in order to resect the lesion and safely ligate the intercostal vascular pedicle.

Utilização conjunta de mediastinoscopia cervical e videotoracoscopia para a avaliação linfática mediastinal em pacientes com carcinoma de pulmão não-pequenas células

OBJECTIVE To evaluate the efficacy of the joint use of cervical mediastinoscopy and video-assisted thoracoscopy for the sampling of mediastinal lymph nodes in patients with non-small cell lung cancer (NSCLC) and candidates for pulmonary resection. METHODS Sixty-two patients diagnosed with NSCLC were submitted to cervical mediastinoscopy and video-assisted thoracoscopy. The samples obtained (from paratracheal chains, anterior and posterior subcarinal chains, paraesophageal chains and pulmonary ligament) were submitted to frozen section analysis. The following variables were also evaluated: age; gender; weight loss; diagnostic method; tomographic findings; histological type; staging; and location and size of the primary tumor. RESULTS In 11 patients, mediastinoscopy showed no involvement of the subcarinal chain, whereas such involvement was identified when video-assisted thoracoscopy was used: positive predictive value = 88.89% (95% CI: 51.75-99.72); negative predictive value = 94.34% (95% CI: 84.34-98.82); prevalence = 17.74% (95% CI: 9.2-29.53); sensitivity = 72.73% (95% CI: 39.03-93.98); and specificity = 98.77% (95% CI: 93.31-99.97). In 60% of the patients with involvement of the posterior subcarinal chain, the primary tumor was in the right inferior lobe. (p = 0.029) CONCLUSIONS The joint use of cervical mediastinoscopy and video-assisted thoracoscopy for the evaluation of posterior mediastinal lymph nodes proved to be an efficacious method. When there is no access to posterior chains by means of ultrasound with transbronchial or transesophageal biopsy, which dispenses with general anesthesia, this should be the method of choice for the correct evaluation of mediastinal lymph nodes in patients with NSCLC.

Video-assisted thoracoscopic surgery in swine: an animal model for thoracoscopic lobectomy training

OBJECTIVES Minimally invasive thoracic procedures have been increasingly used; however, only a small number of lobectomies are performed by videothoracoscopy, showing the need for training on this technique. The objective of this study is to demonstrate the technique of lobectomy using videothoracoscopy in swine, highlighting the steps to be taken during its use in surgical experimentation. METHODS During the advanced course on video-assisted and thoracoscopic procedures carried out at IRCAD Latin America, Barretos, Brazil, 40 swine were used for the hands-on course on video-assisted upper left lobectomy. Monopulmonary ventilation was performed by blocking the left main bronchus. Surgical procedures were performed using three ports and the anterior dissection technique (fissureless approach). The pulmonary hilar structures were dissected using conventional open surgery and video-assisted surgical tools. The first structure treated in the approach of the hilar structures was the upper lobe vein, followed by the bronchus and the branches of the pulmonary artery. RESULTS The mean time required to anaesthetize the animals was 3 h. Intraoperative hypoventilation was observed in 26 animals (65%) and 4 (10%) of them had a poor outcome and died in the last third part of the surgery. Eight (20%) animals had bradycardia, and six responded to the use of atropine. In two (5%), it was not possible to revert the bradycardia and the animals died at the end of the procedures. The surgical procedures had a mean duration of 3 h and the total time of anaesthesia was about 6 h. DISCUSSION Swine have been frequently used for hands-on training in surgery but there are no reports in the literature describing the anatomical, anaesthetic and technical peculiarities that must be observed during videothoracoscopic lobectomy training in swine. Video-assisted thoracoscopic surgery lobectomy using swine is an adequate method to train thoracic surgeons. For surgeons to make the best use of minimally invasive technique training, it is essential that issues related to the anatomy, anaesthesia, monopulmonary ventilation and surgical technique described in this study are taken into account.

General thoracic surgery workforce: training, migration and practice profile in Brazil

OBJECTIVES This study is aimed at drawing the profile of the Brazilian general thoracic surgeon. This experience has been fruitful in other areas, helping attract manpower and to better serve the interests of other Societies. This is the first survey of this kind in Brazil and in Latin America. METHODS An electronic invitation was sent to the members of the Brazilian Society of Thoracic Surgery to answer a web-based questionnaire and physicians potentially practising thoracic surgery, with 82 questions including demographic data, medical education, training in general and thoracic surgery, continued professional education, practice profile, research activities and certifications, participation in medical societies, income/compensation and career satisfaction. Quantitative and qualitative analyses are presented. RESULTS The estimated level of participation was 82% (468). The mean age of the active general thoracic surgeon is 43.2 (range 45.3±11.4) years. Women comprised 8% (37) of respondents, and 60% (277) of the participants had graduated from public medical schools. Four states nationwide trained 88% (391) of the thoracic surgeons. Only 32% (149) of the surgeons work exclusively with thoracic surgery. The public health system is the main provider of income for thoracic surgeons. Only 11 of 27 states have an adequate, although poorly distributed, number of thoracic surgeons. CONCLUSIONS Although Brazil has a reasonable number of general thoracic surgeons, inequalities in their distribution through the country arise as one of the most concerning problems of the speciality. The results of this study show that leadership actions and consistent government policies are required to improve work conditions and provide efficient workforce planning.

Anterior approach to the cervicothoracic junction: case series and literature review

OBJETIVO: relatar la experiencia de los autores en el acceso anterior de la union cervicotoracica C7 a T4, en relacion a la definicion de cuanto es necesaria la realizacion de la manubriotomia, cuales las particularidades de esta cirugia y la evaluacion de los resultados. METODOS: estudio de cohorte prospectivo de 14 pacientes que fueron tratados quirurgicamente de enfermedades de la transicion cervicotoracica, durante el periodo de Enero de 1996 a Enero de 2009. Los pacientes fueron evaluados en el pre operatorio con tomografia computadorizada y resonancia magnetica, a fin de identificar en cuales casos la manubriotomia seria necesaria. La cirugia fue realizada preferiblemente por el lado izquierdo utilizando la via de acceso anterior de Smith-Robinson y en caso de necesidad, seria combinado con una abertura del manubrio. Cuando realizada la corpectomia fueron utilizados Mesh y placa cervical para estabilizacion, mientras que en la cirugia de hernia discal C7-T1 la reconstruccion fue hecho con PEEK y placa cervical. RESULTADOS: la edad promedio fue de 63 anos, siendo siete de sexo masculino. La patologia mas comun fue la enfermedad metastasica (n=8), seguida por la hernia discal C7-T1 (n=4). Las complicaciones relacionadas al procedimiento quirurgico fueron dos: un paciente con disfonia causada por hematoma local y otro caso con infeccion pulmonar. El tiempo promedio de cirugia, el volumen de sangramiento, la intensidad del dolor, la necesidad de medicacion analgesica y el tiempo de hospitalizacion fueron menores en los pacientes en que la manubriotomia no fue necesaria. CONCLUSION: el acceso anterior a la union cervicotoracica es un acceso rapido y de baja morbilidad. Lesiones que envuelven el cuerpo vertebral de T1 o el espacio discal de C7-T1 fueron abordadas solamente por la via cervical sin abertura del manubrio. Las lesiones del cuerpo de T1 y/o de T2 fueron normalmente manejadas con abertura del manubrio a fin de obtener un adecuado campo de trabajo para la reseccion de las lesiones y estabilizacion. La abertura del manubrio aumenta el indice de complicaciones, tiempo quirurgico, sangramiento, intensidad del dolor y tiempo de internacion.

Video-assisted thoracoscopic surgery yields better outcomes than thoracotomy for anatomical lung resection in Brazil: a propensity score-matching analysis using the Brazilian Society of Thoracic Surgery database

OBJECTIVES The use of video-assisted anatomical lung resection is increasingly widespread for lung cancer and non-neoplastic diseases, showing excellent results. Nonetheless, a comparative analysis of the benefits of this technique has yet to be conducted in Latin America, a region with a completely different case mix from the USA or Europe. The purpose of this study was to compare the outcomes of video-assisted thoracoscopic surgery (VATS) and open thoracotomy (OT) for anatomical lung resection in patients included on the Brazilian Society of Thoracic Surgery (BSTS) database. METHODS Using propensity score matching, we conducted an analysis of 1355 patients who underwent anatomical lung resection (704 OT and 651 VATS) registered in the BSTS database between August 2015 and December 2016. Propensity score matching was performed using the following baseline characteristics: age at surgery, gender, comorbidities, pulmonary lung function, type of resection and cancer and non-cancer diagnosis. The propensity score-matched sample comprised a well-matched group of 890 patients. The main outcomes tested were mortality, complications and major cardiopulmonary complications based on the European Society of Thoracic Surgeons (ESTS) database definitions and terminology. RESULTS Standardized differences of means and proportions suggested that an adequate balance had been achieved. Major cardiopulmonary complications were shown to be more frequent in patients who underwent OT (16.0% compared with 9.2% in VATS patients; odds ratio  = 1.87, 95% confidence interval 1.25-2.80) and the overall complications rate was higher among patients who underwent OT (30.1% compared with 21.8% in VATS patients; odds ratio = 1.55, 95% confidence interval 1.17-2.05). No statistically significant difference in mortality rate was observed between OT (2.5%) and VATS (1.8%) (odds ratio = 1.38, 95% confidence interval 0.54-3.50). CONCLUSIONS In Brazil, the rate of complications associated with minimally invasive surgery (VATS) for anatomical lung resection is significantly lower than that of conventional OT.

Video-assisted thoracoscopic implantation of a diaphragmatic pacemaker in a child with tetraplegia: indications, technique, and results

We report the case of a child with tetraplegia after cervical trauma, who subsequently underwent diaphragmatic pacemaker implantation. We reviewed the major indications for diaphragmatic pacing and the types of devices employed. We highlight the unequivocal benefit of diaphragmatic pacing in the social and educational reintegration of individuals with tetraplegia.

Acesso anterior das lesões da junção cérvicotorácica: série de casos e revisão da literatura

OBJETIVO: relatar la experiencia de los autores en el acceso anterior de la union cervicotoracica C7 a T4, en relacion a la definicion de cuanto es necesaria la realizacion de la manubriotomia, cuales las particularidades de esta cirugia y la evaluacion de los resultados. METODOS: estudio de cohorte prospectivo de 14 pacientes que fueron tratados quirurgicamente de enfermedades de la transicion cervicotoracica, durante el periodo de Enero de 1996 a Enero de 2009. Los pacientes fueron evaluados en el pre operatorio con tomografia computadorizada y resonancia magnetica, a fin de identificar en cuales casos la manubriotomia seria necesaria. La cirugia fue realizada preferiblemente por el lado izquierdo utilizando la via de acceso anterior de Smith-Robinson y en caso de necesidad, seria combinado con una abertura del manubrio. Cuando realizada la corpectomia fueron utilizados Mesh y placa cervical para estabilizacion, mientras que en la cirugia de hernia discal C7-T1 la reconstruccion fue hecho con PEEK y placa cervical. RESULTADOS: la edad promedio fue de 63 anos, siendo siete de sexo masculino. La patologia mas comun fue la enfermedad metastasica (n=8), seguida por la hernia discal C7-T1 (n=4). Las complicaciones relacionadas al procedimiento quirurgico fueron dos: un paciente con disfonia causada por hematoma local y otro caso con infeccion pulmonar. El tiempo promedio de cirugia, el volumen de sangramiento, la intensidad del dolor, la necesidad de medicacion analgesica y el tiempo de hospitalizacion fueron menores en los pacientes en que la manubriotomia no fue necesaria. CONCLUSION: el acceso anterior a la union cervicotoracica es un acceso rapido y de baja morbilidad. Lesiones que envuelven el cuerpo vertebral de T1 o el espacio discal de C7-T1 fueron abordadas solamente por la via cervical sin abertura del manubrio. Las lesiones del cuerpo de T1 y/o de T2 fueron normalmente manejadas con abertura del manubrio a fin de obtener un adecuado campo de trabajo para la reseccion de las lesiones y estabilizacion. La abertura del manubrio aumenta el indice de complicaciones, tiempo quirurgico, sangramiento, intensidad del dolor y tiempo de internacion.

Acceso anterior de las lesiones de la unión cérvicotoracica: serie de casos y revisión de la literatura

OBJETIVO: relatar la experiencia de los autores en el acceso anterior de la union cervicotoracica C7 a T4, en relacion a la definicion de cuanto es necesaria la realizacion de la manubriotomia, cuales las particularidades de esta cirugia y la evaluacion de los resultados. METODOS: estudio de cohorte prospectivo de 14 pacientes que fueron tratados quirurgicamente de enfermedades de la transicion cervicotoracica, durante el periodo de Enero de 1996 a Enero de 2009. Los pacientes fueron evaluados en el pre operatorio con tomografia computadorizada y resonancia magnetica, a fin de identificar en cuales casos la manubriotomia seria necesaria. La cirugia fue realizada preferiblemente por el lado izquierdo utilizando la via de acceso anterior de Smith-Robinson y en caso de necesidad, seria combinado con una abertura del manubrio. Cuando realizada la corpectomia fueron utilizados Mesh y placa cervical para estabilizacion, mientras que en la cirugia de hernia discal C7-T1 la reconstruccion fue hecho con PEEK y placa cervical. RESULTADOS: la edad promedio fue de 63 anos, siendo siete de sexo masculino. La patologia mas comun fue la enfermedad metastasica (n=8), seguida por la hernia discal C7-T1 (n=4). Las complicaciones relacionadas al procedimiento quirurgico fueron dos: un paciente con disfonia causada por hematoma local y otro caso con infeccion pulmonar. El tiempo promedio de cirugia, el volumen de sangramiento, la intensidad del dolor, la necesidad de medicacion analgesica y el tiempo de hospitalizacion fueron menores en los pacientes en que la manubriotomia no fue necesaria. CONCLUSION: el acceso anterior a la union cervicotoracica es un acceso rapido y de baja morbilidad. Lesiones que envuelven el cuerpo vertebral de T1 o el espacio discal de C7-T1 fueron abordadas solamente por la via cervical sin abertura del manubrio. Las lesiones del cuerpo de T1 y/o de T2 fueron normalmente manejadas con abertura del manubrio a fin de obtener un adecuado campo de trabajo para la reseccion de las lesiones y estabilizacion. La abertura del manubrio aumenta el indice de complicaciones, tiempo quirurgico, sangramiento, intensidad del dolor y tiempo de internacion.

Cricotireoidotomia modificada: opção para remoção das secreções traqueobrônquicas

Introduction: Inhalations, postural drainage and respiratory physiotherapy are not always effective in removing tracheobronchial secretions. Objectives: To evaluate an alternative surgical technique, modified crichothyroidotomy, to aspirate tracheobronchial secretions. Method: Modified crichothyroidotomy is the introduction of a catheter number 8, 10 or 12 into the crichothyroid membrane in order to stimulate coughing and the aspiration of secretions. This is a descriptive study of the benefits as well as immediate and late complications caused by the use of this technique in 45 patients with excessive tracheobronchial secretions inadequately removed by usual methods. Results: Immediate surgical complications were bleeding (10 patients), oropharynx deviation (3), subcutaneous emphysema (1) and difficult introduction (1). Mean catheter permanence was 14 ± 16 days and, in all cases, the catheter provoked coughing and allowed the easy aspiration of secretions. The most frequent occurrence (17 patients) was the expulsion of the catheter by coughing, inadequate catheter handling during aspiration and moving of the patients. Conclusion: This is a simple technique with a low morbidity rate and represents constitutes an effective alternative to be used in the aspiration of tracheobronchial secretions.