José Maria Porcaro Salles

Laryngotracheal Separation Surgery: Outcome in 60 Patients

OBJECTIVE: To determine the outcome of laryngotracheal separation (LTS) in 60 patients in terms of the control and prevention of severe and persistent aspiration, morbidity and mortality, reversibility rate, and the influence of the presence of a tracheostomy. STUDY DESIGN: Retrospective study. RESULTS: LTS showed significant efficacy rates in terms of both treatment (87%) and prevention (100%) of pulmonary aspiration. Twenty-six (43%) patients developed postoperative complications. A tracheocutaneous fistula of the proximal tracheal stump was observed in 14 (23%) patients and was the most frequent complication, especially in patients with a therapeutic indication (P = 0.028) and in those with a tracheostomy (P = 0.058). Reversion of LTS was possible in 12 (20%) patients, mainly those with a prophylactic indication (P = 0.005). However, the rates of complications (58%) and inefficacy (27%) of reversion surgery were high. CONCLUSION: LTS is effective in the elimination and prevention of clinically intractable aspiration. The procedure is potentially reversible. However, the frequency of complications for both LTS and reversion surgery is significant.

Kikuchi-Fujimoto disease: three case reports

CONTEXT Kikuchi-Fujimoto disease (KFD) manifests in most cases as unilateral cervical lymphadenomegaly, with or without accompanying fever. The disease mainly affects young women and has a self-limited course. It is more common in oriental countries, with few reports of its occurrence in Brazil. KFD should be included in the differential diagnosis of suspected cases of viral infections, tuberculosis, reactive lymphadenitis, systemic lupus erythematosus and metastatic diseases. It can be histologically confused with lymphoma. The disease is benign and self-limiting and an excisional biopsy of an affected lymph node is necessary for diagnosis. There is no specific therapy. CASE REPORTS This study reports on three cases of non-Asian female patients with KFD who were attended at our service between 2003 and 2006. A review of the literature was carried out, with a systematic search on this topic, with the aim of informing physicians about this entity that is manifested by cervical masses and fever.

Fatores preditores para hipocalcemia pós-tireoidectomia

OBJECTIVE: To evaluate the incidence and predictors of post-thyroidectomy definitive hypocalcemia and hypoparathyroidism. METHODS: We assessed ionic calcium preoperatively and postoperatively (first, second and 30th day) in 333 patients undergoing thyroidectomy. In those presenting hypocalcemia, measurements were also made 90 and 180 days after surgery, when parathormone was also dosed. Patients were grouped according to the presence or absence of hypocalcemia and evaluated according to age, gender, thyroid function, thyroid volume, number of parathyroid glands identified and need to parathyroid reimplantation, type of operation, operative time, and histopathological diagnosis. RESULTS: The incidence of temporary hypocalcemia was 40.8% (136 patients), and of definitive hypoparathyroidism 4.2% (14 patients). Reoperation or total thyroidectomy, neck dissection, hyperthyroidism, operative time and age above 50 years were factors related to higher incidence of hypocalcemia and definitive hypoparathyroidism (p 50 years), total thyroidectomy, reoperation, neck dissection and operative time. The predictors of post-thyroidectomy definitive hypoparathyroidism included type of operation, histological diagnosis and hyperthyroidism.

Effectiveness of unsedated transnasal endoscopy with white-light, flexible spectral imaging color enhancement, and lugol staining for esophageal cancer screening in high-risk patients.

Background and Aims: Transnasal endoscopy (TNE) has been proposed to screen for esophageal squamous cell cancer (ESCC) in Asia. This study aimed to assess the feasibility and tolerance of Brazilian patients to undergo unsedated TNE for screening, the prevalence of ESCC in this population, and the effectiveness of white-light endoscopy (WLE) and digital chromoendoscopy [flexible spectral imaging color enhancement (FICE)] to diagnose esophageal neoplasia. Patients and Methods: This was a diagnostic test study that enrolled patients with head and neck squamous cell cancer (HNSCC) referred to ESCC screening. Patients’ tolerance was rated by a numeric pain intensity scale. Interventions included unsedated TNE with WLE and FICE examination of the esophagus, in a tandem manner with blinded operators, followed by lugol chromoscopy. Performance of WLE and FICE for neoplasia detection was compared with the reference standard (lugol chromoscopy plus histology). Results: A total of 106 patients were recruited. TNE was feasible in 99.1%, and 92% of the patients rated the discomfort as absent or minimal. Thirteen ESCC were detected (12.3%), with 10 early cancers (77%). The tests showed an excellent performance and there was no difference between WLE (sensitivity 92.3%, specificity 98.9%, accuracy 98.1%, area under curve 0.995) and FICE (sensitivity 100%, specificity 98.9%, accuracy 99%, area under curve 0.956) for esophageal neoplasia detection. Conclusions: Unsedated TNE is a feasible, well accepted, and efficient diagnostic tool for the screening of ESCC. The elevated rate of esophageal neoplasia strengthens the recommendations to screen patients with HNSCC. The yields of WLE and FICE were similar for ESCC detection.

Evolution of blood magnesium and phosphorus ion levels following thyroidectomy and correlation with total calcium values

CONTEXT AND OBJECTIVE magnesium ion concentration is directly related and phosphorus ion concentration is inversely related to calcemia. The aim of this study was to evaluate the evolution of magnesium and phosphorus ion levels in patients undergoing thyroidectomy and correlate these with changes to calcium concentration. DESIGN AND SETTING prospective study at the Alpha Institute of Gastroenterology, Hospital das Clínicas, Universidade Federal de Minas Gerais. METHODS the study included 333 patients, of both genders and mean age 45 ± 15 years, who underwent thyroidectomy between 2000 and 2005. Total calcium, phosphorus and magnesium were measured in the blood preoperatively and 24 and 48 hours postoperatively. Ionic changes were evaluated according to the presence or absence of postoperative hypocalcemia. RESULTS there were statistically significant drops in blood phosphorus levels 24 and 48 hours after thyroidectomy, compared with preoperative values, in the patients without hypocalcemia. In the patients who developed hypocalcemia, there was a significant drop in plasma phosphorus on the first postoperative day and an increase (also statistically significant) on the second day, in relation to preoperative phosphorus levels. A significant drop in postoperative magnesium was also observed on the first and second days after thyroidectomy in the patients with hypocalcemia, in relation to preoperative levels. In the patients without hypocalcemia, the drop in magnesium was significant on the first day, but there was no difference on the second day. CONCLUSION despite the postoperative changes, neither magnesium nor phosphorus ion levels had any role in post-thyroidectomy calcemia.

Laryngeal histoplasmosis in an immunocompetent patient from a non-endemic region: case report.

Histoplasma capsulatum infection involving the larynx is a rare manifestation, especially in immunocompetent individuals and a high index of suspicion is needed to establish the diagnosis correctly. We report a case of a 50‐year‐old Brazilian man who presented with progressive hoarseness and throat pain for 4 months. Laryngoscopy showed a supraglottic vegetant lesion, and the biopsies chronic granulomatous inflammation without any specific agent. A second laryngoscopy with biopsies was performed and after 17 days of incubation in specific medium, H. capsulatum was isolated. The patient was successfully treated with amphotericin B.

Cervical Lymph Node Dissection in Papillary Thyroid Cancer: Pattern and Predictive Factors of Regional Lymph Node Metastas

Background: Papillary thyroid carcinoma (PTC) exhibits a high index of cervical lymphatic dissemination. Methods: Retrospective study of 101 cases of PTC subjected to total thyroidectomy associated with cervical lymph node dissection. Results: The incidence of neck metastasis was 50.5%, and all the metastases wereipsilateral to the primary tumor. Although the participants with metastases (N+) hadmore dissected lymph nodes than the group without metastases (p = 0.01), the lymphnode size was not a determinant of malignancy (p=0.34). Uni and multivariate analyses showed tumor size ≥ 1.0 cm, angiolymphatic invasion, and multicentric diseases were associated with lymphatic dissemination (p < 0.05). Conclusions: Factors predictive of cervical lymph node metastasis were tumor size ≥ 1.0cm, multicentric disease and angiolymphatic invasion. All the metastases wereipsilateral to the primary tumor. Lymph node size was not a reliable predictor of thepresence or absence of metastasis.