Rafael Fagionato Locali

Lung perfusion during cardiac surgery with cardiopulmonary bypass: is it necessary?

Thirty-two pigs were randomized into group I (aortic cross clamping, antegrade cardioplegia, moderate hypothermia) and group II (normothermia, beating empty heart). Groups were subdivided into subgroups A, B and C, receiving no lung perfusion, perfusion with arterial blood and perfusion with venous blood. Swan-Ganz catheter was used to take mean pulmonary artery pressure which would be used as lung perfusion pressure. Cardiopulmonary bypass (CPB) was established through cannulating aorta and double venae cavae, mechanical ventilation was interrupted and lung perfusion was carried out for 30 min. Blood samples and pulmonary specimens were withdrawn pre- and postoperatively for gasometrical, histological and genic analyses. Postoperative comparison revealed that pulmonary vascular resistance was lower in IC than IA (P=0.01) and it was lower in IIC than IIA (P=0.005). Subgroup IIB had increasing venous oxygen tension (P=0.01) as well as arterial and venous oxygen saturation (P=0.01) compared to IIA. Arterial oxygen saturation was decreased in IIC vs. IIA (P=0.006). Histological differences were observed between subgroups A and B as well as A and C (P=0.003). Lung perfusion during CPB may improve pulmonary hemodynamic performance, optimize gas exchange and maintain cellular integrity.

Intralesional Triamcinolone Acetonide for Keloid Treatment: A Systematic Review

The keloid lesion is a hypertrophic scar dysfunction with continuous growth and tumoral shape that usually presents with a hyperemic aspect accompanied by pruritus and pain [6, 12]. This disease can have a prevalence reaching 16% in darkskinned populations. Those who carry the disease will experience psychosocial impairment and loss of quality of life [16]. The physiopathogenesis of keloids is not completely clear in the medical literature, although it has been the focus of many studies, and this has led to empirical treatments with debatable success [7, 15]. One of the most frequently used treatments is intralesional corticotherapy with triamcinolone acetonide, isolated or in association [10]. However, the literature presents no consensus on the ideal drug concentration for injection into the keloidal scar. Therefore, this study aimed to explore the most effective concentration and application periodicity of triamcinolone acetonide for intralesional injections in keloids.

[Should biatrial heart transplantation still be performed?: A Meta-analysis].

The outcomes of total and bicaval heart transplantation techniques are better than those of the biatrial technique; however, the latter is still considered the gold-standard. The objective of this study was to determine whether the total and bicaval heart transplantation techniques are, in fact, better than the biatrial technique. A systematic review with meta-analysis was carried out. Studies were retrieved from Pubmed, Lilacs, Web of Science, Scirus, Scopus, Google Scholar, and Scielo databases, identified by sensitive strategy. Randomized, prospective, and retrospective controlled studies were selected for inclusion. Intra and postoperative parameters were assessed. A total of 11,602 studies were identified and 36 were included in our review. The number of atrial arrhythmias, tricuspid valve regurgitation, deaths, and embolic events, as well as bleeding volume; temporary and permanent pacemaker requirement; and length of stay in the intensive care unit are significantly lower for the total and bicaval techniques than for the biatrial technique. Also, hemodynamic variables such as pulmonary capillary pressure, mean pulmonary artery pressure, and right atrial pressure are lower in total and bicaval transplantation. In prognostic terms, total and bicaval orthotopic heart transplantations are better, than the biatrial transplantation. Therefore, indication of the biatrial technique for transplantation should be the exception, not the rule.

A stratigraphic approach to the superficial musculoaponeurotic system and its anatomic correlation with the superficial fascia.

The superficial musculoaponeurotic system (SMAS) is not included in the International Anatomic Terminology, although it is a fundamental anatomical structure in plastic surgeons. In the literature, the concept of the SMAS is not clear, leading to repercussions in the treatment of the SMAS via the various techniques for rhytidoplasty. This review article, in its aim to conceptualize the SMAS, has as a referential parameter the basic stratigraphic pattern of the human body construction. A systematic review of the literature was performed through Medline, ISI-Web of Science, and Lilacs databases as well as through classical treatises of anatomy for analyses of the stratigraphic principle of SMAS and its relationship to the fascia. In fact, SMAS, an anatomic entity, is part of this construction model. The stratigraphic approach followed in this article to describe the SMAS is novel in the literature and allows for a unified anatomic understanding of SMAS for the scientific community.

Primeiro escore de risco inflamatório das endopróteses de aorta

OBJETIVO: Propor um escore de risco inflamatorio para tratamento endovascular dos aneurismas da aorta. METODOS: Vinte e cinco pacientes foram seguidos do periodo pre-operatorio ate 3o mes de pos-operatorio (1 hora, 6 horas, 24 horas, 48 horas, 7 dias, 1 mes, 2 meses e 3 meses). Variaveis inflamatorias avaliadas foram proteina C reativa, velocidade de hemossedimentacao, interleucinas (IL-6, IL8), fator de necrose tumoral alfa, L-selectina, molecula de adesao intercelular (ICAM-1), transfusao de hemaceas, volume de cristaloide, volume de contraste, material da protese, numero de proteses, contagem total de leucocitos e linfocitos. O teste de Spearman apontou as variaveis candidatas ao maior risco inflamatorio, segundo P < 20%. A regressao logistica apontou variaveis selecionaveis para escore final segundo P < 10%. A analise da curva ROC revelou valores de corte para variaveis selecionadas pela regressao logistica. RESULTADOS: Variaveis apresentadas pelo teste de Spearman foram: volume de cristaloide (P = 0,04), material da protese (P = 0,04), volume de contraste (P=0,02), IL-8 preoperatoria (P= 0,10), ICAM-1 1 mes (P=0,03) e L-selectina 1 mes (P = 0,06). A regressao logistica revelou que os valores do volume de cristaloide e IL-8 pre-operatoria sao primordiais para constituicao do escore de risco inflamatorio para tratamento endovascular dos aneurismas da aorta. O escore de risco seria dividido em tres categorias (leve, moderado e grave), com base em intervalos numericos das duas variaveis selecionadas e as categorias seriam correlacionadas com achados clinicos CONCLUSA: Volume de cristaloide e IL-8 pre-operatoria sao variaveis que poderiam contribuir para categorizar risco inflamatorio e, desse modo, ter um papel prognostico no tratamento endovascular dos aneurismas da aorta.

Perfusão da artéria pulmonar não melhora os índices de fator natriurético cerebral (BNP) em estudo experimental em suínos

OBJECTIVE Assess if the main pulmonary artery controlled perfusion over cardiopulmonary bypass (CPB) modifies BNP levels expressed by the ventricular myocardium. METHODS Experimental research involving 32 pigs, divided into two groups according to CPB strategy--group I (cardioplegia) and group II (beating heart). Both groups were allocated into three subgroups according to lung perfusion strategy--subgroup A (control: no lung perfusion), subgroup B (lung perfusion with arterial blood) and subgroup C (lung perfusion with venous blood). In subgroups B and C, lung was perfused for 30 minutes, using preoperative mean pulmonary artery pressure (MPAP) as perfusion pressure, which was monitored through manometer. MPAP and pulmonary vascular resistance (PVR) were measured after coming off CPB using Swan-Ganz catheter. At preoperative time and 30 minutes after lung perfusion, specimens were taken from the right ventricular myocardium aiming to assess brain natriuretic peptide (BNP) and histologic pattern. Immunohistochemical and hematoxylin-eosin techniques were used to determine, respectively, BNP expression and inflammatory myocardial lesions. RESULTS In animals submitted to controlled lung perfusion, there was a postoperative reduction of MPAP (P = 0.03) and PVR (P = 0.005).There was no differences among subgroups within the group, I (P = 0.228) and subgroups within group II (P = 0.325) as to postoperative BNP expression. There were no differences among subgroups with and without lung perfusion as to postoperative inflammatory lesions (P > 0.05). CONCLUSION Main pulmonary artery controlled perfusion for 30 minutes did not yield substantial modifications in BNP expression and histologic pattern of the right ventricular myocardium.

Use of the histopathology in the differential diagnosis of drowning in fresh and salty water: an experimental model establishment in rats

PURPOSE To develop a method of differential diagnosis to drowning, due to analysis of the alveolar macrophages quantitative, in rats submitted to induced drowning in fresh water and salty water. METHODS Were used 15 male adult rats Wistar EPM-1, weight 360g (SD=21,3), randomized in three groups: G1--Control; G2--Fresh water; G3--Salty water, each one with n=5. The animals have been anesthetized and tracheostomized to insert a cannula inside the trachea, for drowning induction. The lungs have been removed, weighed, prepared for histology and colored by immunohistochemistry. The macrophages have been counted in both lungs (right and left) of each animal. The statistical test used was ANOVA (SPSS.10) with p<0,05. RESULTS The amount of macrophages was G3>G2>G1 with p=0,0001 in each comparison. The weight of lungs of G3 and G2 was higher than G1, with p>0,0001, however G3 and G2 do not possess difference statistics in the weight of lungs. CONCLUSION The developed diagnostic method was efficient in rats. The results, if expanded, will be able to assist the Forensic Pathology for technique of low cost and high trustworthiness.

Tratamento da persistência de canal arterial em recém-nascidos prematuros: análise clínica e cirúrgica

BACKGROUND: The surgical treatment of patency ductus arteriosus is indicated when the clinical intervention fails. However, this treatment may have some complications. OBJECTIVE: To analyze clinical and surgical aspects involved on the treatment of patency ductus arteriosus in premature newborn. METHODS: Twenty two premature newborns, submitted to surgical treatment for patency ductus arteriosus from January, 2000 to June, 2006, were evaluated. There were 77,3% female patients, the mean birth weight was 952,5g and the mean gestational age was 27 weeks. The use of vasoactive drugs, indometacin, echocardiograph parameters and complications, in the pre and postoperative periods were evaluated. RESULTS: In this casuistic 59,1% patients needed intratracheal intubation at birth, 77,3% needed surfactants, 59,1% used vasoactive drugs preoperative. The mean doses of indometacin were 3,43, with dose range 0,1 to 0,25 mg/Kg/day. The mean caliber of arterial duct patent was 1,96 mm. The surgical procedure was carried out through extrapleural approach in 59.1% of the patients, the mean time of postoperative intubation was 30,9 days, and 50% of the patients used vasoactive drugs postoperative. There were 18,1% postoperative complications (postoperative non-fatal complications). CONCLUSION: More than the half of the patients needed intratracheal intubation at birth, surfactant use and vasoactive drugs in the preoperative period. There was greater prevalence of the extrapleural approach during the surgery. In the postoperative period, there was less demand of vasoactive use and there was not deaths related to the surgical procedure.

Uso da aprotinina na operação da aorta torácica associada à hipotermia profunda e parada circulatória: metanálise

OBJECTIVE: To evaluate complications involved in the use of aprotinin in patients after thoracic aortic aneurysm or dissection surgeries associated with deep hypothermic circulatory arrest. METHODS: A systematic review of literature was carried out, with a search strategy of low specificity, in the Medline® and LILACS® databases. Two independent researchers carried out article selection following the criteria adopted for inclusion of studies, grouping them into two groups, one where low doses of aprotinin were employed and the other with high doses. The results are presented as relative risk for the dichotomy variable, and as weighted mean differences for continuous variables, both with 95% confidence intervals. RESULTS: Seven articles were included in the systematic review selected from 2044 revised studies. Meta-analysis of the only randomized controlled trial did not demonstrate risks with the use of aprotinin, and presented a significant reduction in bleeding and blood transfusion requirements. Meta-analysis of the studies that used low doses of aprotinin was similar. On the other hand, meta-analysis of the studies that adopted high doses of aprotinin did not present statistical significance in any of the studied variables. CONCLUSION: Despite of the results not showing any effective risks with the use of aprotinin, the statistical power of the meta-analysis is low. Therefore, new randomized controlled trials are required, in order to detect possible complications in the use of aprotinin in this type of operation.

Renal and adrenal tumors with cardiac invasion: immediate surgical results in 14 patients

FUNDAMENTO: La reseccion del trombo tumoral en vena cava inferior (VCI) y atrio derecho (AD) aumenta la sobrevida del paciente con cancer renal/ suprarrenal. OBJETIVO: Evaluar la conducta quirurgica frente al trombo de la VCI y AD en el tratamiento de los tumores renales y suprarrenales. METODOS: De enero de 1997 a junio de 2007, se evaluaron, retrospectivamente, a 14 pacientes tratados quirurgicamente para retirada de trombo en VCI y/o AD que transcurre de tumor renal o suprarrenal. De estos, el 64,2% eran del sexo masculino; habia el 42,8% de casos de tumor de Wilms (TW), el 28,5% de adenocarcinoma suprarrenal (ACS) y el 28,5% de carcinoma de celulas claras (CC), con edades promedio de 4,5, 60,5 y 2,5 anos, respectivamente. Se evaluaron los aspectos epidemiologicos y tambien los parametros hospitalarios intra y postoperatorios. RESULTADOS: En todos los casos se encontro trombo tumoral en VCI suprahepatica, y en el 62,4% el trombo invadio el AD. Se realizo la trombectomia con el empleo de la circulacion extracorporea asociada a la hipotermia profunda; se verifico paro circulatorio total en el 85,7% de los casos, mientras que se mantuvo moderada en el restante del grupo. Se procedio a la ligadura de la VCI en el 7,1% de los pacientes, y se la reconstruyo por rafia en el 92,9%. Los tiempos de intubacion orotraqueal e internacion variaron conforme el tipo de tumor. Ocurrieron dos obitos hospitalarios en el grupo de ACS, provocados por paro cardiorrespiratorio intraoperatorio. CONCLUSION: Existe mayor numero de casos de trombo tumoral en VCI y AD que transcurre de TW. Los casos de ACS evolucionan con mas complicaciones en el periodo postoperatorio, mientras que el pronostico en el postoperatorio hospitalario de los pacientes con TW resulta mejor.