Ricardo Mingarini Terra

Remaining small bowel length: association with catheter sepsis in patients receiving home total parenteral nutrition: evidence of bacterial translocation.

Patients with short bowel syndrome (SBS) receiving total parenteral nutrition (TPN) have a high incidence of catheter-related sepsis, one of its major complications. The aim of this study was to correlate the length of remaining small bowel (RSB) with septic episodes related to the central venous catheter in a group of patients with severe SBS with home TPN. The length of the RSB (<50 cm or ≥50 cm) was related to the frequency of catheter sepsis, time until the first episode, and the agents responsible in eight SBS patients receiving home TPN. There were 13 episodes of catheter infection (0.88 per patient-year). The group with a shorter RSB length (five patients) presented 1.3 to 2.76 infections/year and 2 to 9 months until the first episode, compared to 0 to 0.75 infections/year (p= 0.0357) and 11 to 65 months until the first episode (p= 0.0332) in the group with the longer RSB. In the first group, the agents isolated were Enterobacteriae (Enterobacter sp., Klebsiella sp., Pseudomonas sp., and Proteus sp.) in eight episodes and Candida sp. in one. In the latter sepsis was caused by Staphylococcus sp. in three episodes and Pseudomonas sp. in one. Therefore patients with remaining small bowel shorter than 50 cm have a higher frequency of catheter-related sepsis, particularly by enteric microorganisms. This might be an evidence of the occurrence of bacterial translocation and its role in the pathogenesis of catheter-related sepsis in patients with an extremely short RSB receiving home TPN.

Is Full Postpleurodesis Lung Expansion a Determinant of a Successful Outcome After Talc Pleurodesis

STUDY OBJECTIVES To analyze and compare radiologic lung expansion after talc pleurodesis performed either by videothoracoscopy or chest tube and correlate it with clinical outcome. Secondary end points evaluated were as follows: clinical efficacy; quality of life; safety; and survival. METHODS Prospective randomized study that included 60 patients (45 women, 15 men; mean age, 55.2 years) with recurrent malignant pleural effusion between January 2005 and January 2008. They were randomized into the following two groups: video-assisted thoracic surgery (VATS) talc poudrage; and talc slurry (TS) administered through a chest tube. Lung expansion was evaluated through chest CT scans obtained 0, 1, 3 and 6 months after pleurodesis. Complications, drainage time, hospital stay, and quality of life (Medical Outcomes Study 36-item short form and World Health Organization quality-of-life questionnaires) were also analyzed. RESULTS There were no significant differences in preprocedure clinical and pathologic variables between groups. The immediate total (ie, > 90%) lung expansion was observed in 27 patients (45%) and was more frequent in the VATS group (60% vs 30%, respectively; p = 0.027). During follow-up, 71% of the patients showed unaltered or improved lung expansion and 9 patients (15%) needed new pleural procedures (VATS group, 5 recurrences; TS group, 4 recurrences; p = 0.999). No differences were found between groups regarding quality of life, complications, drainage time, hospital stay, and survival. Immediate lung expansion did not correlate with radiologic recurrence, clinical recurrence, or complications (p = 0.60, 0.15, and 0.20, respectively). CONCLUSION Immediate partial lung expansion was a frequent finding and was more frequent after TS. Nonetheless, no correlation between immediate lung expansion and clinical outcome was found in this study. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NTC00789087.

Efficacy and safety of iodopovidone pleurodesis in malignant pleural effusions

Background and objective:  Pleurodesis is one of the best methods of controlling malignant pleural effusions (MPE), a distressing complication of metastatic disease. In recent studies of a wide range of pleural diseases, iodopovidone was used as a sclerosing agent for pleurodesis and demonstrated good results with low morbidity. The aim of this study was to evaluate the efficacy and safety of iodopovidone pleurodesis in MPE.

Laryngeal split and rib cartilage interpositional grafting: Treatment option for glottic/subglottic stenosis in adults

OBJECTIVES Severe glottic/subglottic stenosis (complex laryngotracheal stenosis) is a rare but challenging complication of endotracheal intubation. Laryngotracheal reconstruction with cartilage graft and an intralaryngeal stent is a procedure described for complex laryngotracheal stenosis management in children; however, for adults, few options remain. Our aim was to analyze the results of laryngotracheal reconstruction as a treatment for complex laryngotracheal stenosis in adults, considering postoperative and long-term outcome. METHODS Laryngotracheal reconstruction (laryngeal split with anterior and posterior interposition of a rib cartilage graft) has been used in our institution to manage glottic/subglottic stenosis restricted to the larynx; laryngotracheal reconstruction associated with cricotracheal resection has been used to treat glottic/subglottic/upper tracheal stenosis (extending beyond the second tracheal ring). A retrospective study was conducted, including all patients with complex laryngotracheal stenosis treated surgically in our institution from January of 2002 until December of 2005. RESULTS Twenty patients (10 male and 10 female patients; average age, 36.13 years; age range, 18-54 years) were included. There were no deaths, and the postoperative complications were as follows: dysphonia, 25%; subcutaneous emphysema, 10%; tracheocutaneous fistula, 20%; wound infection, 15%; and bleeding, 5.0%. Eighty percent of the patients were completely decannulated after a mean of 23.4 months of follow-up (range, 4-55 months). CONCLUSIONS Laryngeal split with anterior and posterior cartilage graft interposition as an isolated procedure or associated with a cricotracheal resection is a feasible and low-morbidity alternative for complex laryngotracheal stenosis treatment.

Access Routes for Nutritional Therapy

Enteral nutrition (EN) and total parenteral nutrition (TPN) may provide life-sustaining therapy for surgical patients. The duration of nutritional therapy (enteral or parenteral) implies distinct access routes. We review the main aspects related to access routes for nutrient delivery. The enteral route, whenever feasible, is preferred. For EN lasting less than 6 weeks, nasoenteric tubes are the route of choice. Conversely, enterostomy tubes should be used for longer-term enteral feeding and can be placed surgically or with fluoroscopic and endoscopic assistance. The first choice for patients who will not be submitted to laparotomy is percutaneous endoscopic gastrostomy. Postpyloric access, although not consensual, must be considered when there is a high risk of aspiration. For intravenous delivery of nutrients lasting less than 10 days, the peripheral route can be used. However, because of frequent infusion phlebitis, its role is still in discussion. Central venous catheters (CVCs) for TPN delivery may be (1) nonimplantable, percutaneous, nontunneled—used for a few days to 3 to 4 weeks; (2) partially implantable, percutaneous, tunneled—used for longer periods and permanent access; or (3) totally implantable subcutaneous ports—also used for long-term or permanent access. The subclavian vein is usually the insertion site of choice for central venous catheters. Implantable ports are associated with lower rates of septic complications than percutaneous CVCs. The catheter with the least number of necessary lumens should be applied. Central venous nutrient delivery can also be accomplished through peripherally inserted central catheters, which avoid insertion-related risks.

Idiopathic tracheal stenosis: successful outcome with antigastroesophageal reflux disease therapy.

There is controversial evidence that gastroesophageal reflux disease (GERD) is an etiologic factor for idiopathic laryngotracheal stenosis. We present the case of a 44-year-old woman with symptomatic tracheal stenosis managed as idiopathic stenosis. She underwent six endoscopic dilations during 1 year, and before surgery she underwent 24-hour esophageal pH monitoring that documented GERD. Anti-GERD treatment was started, which was confirmed as effective with 24-hour esophageal pH monitoring 3 months later. At 2-year follow-up the patient remained free of symptoms and no additional airway procedure was necessary. A close relationship between anti-GERD therapy and clinical outcome was noted.

Predictors for Postoperative Complications After Tracheal Resection

BACKGROUND Tracheal resection and anastomosis is the gold standard for the treatment of tracheal stenosis. The objective of this study is to evaluate the complications after tracheal resection for benign stenosis and the predicting factors for such complications. METHODS A retrospective study was made involving patients with benign tracheal or laryngotracheal stenosis who underwent surgical resection and reconstruction between February 2002 and January 2009. Complications related and unrelated to the anastomosis were studied. Categorical variables were presented as percentage and continuous variables as mean and standard deviation. Predicting factors were determined by univariate analysis. Factors with p less than 0.05 were used for multivariate regression. Logistic regression models were also employed for dependent variables. Statistical significance was set for p less than 0.05. RESULTS Ninety-four patients (18 female, 76 male) were included. Complications occurred in 42 (44.6%). Twenty-one percent had anastomotic complications. The most common complication was restenosis (16%). Nonanastomotic complications occurred in 23.2%. Wound infection occurred in 10.6%. Clinical comorbidities, previous tracheal resection, and the length of tracheal resection were statistically significant factors for complications. Previous tracheal resection was the most significant factor and was highly associated with anastomotic complications (odds ratio 49.965, p=0.012). The greatest number of complications was found in the laryngotracheal reconstruction group, and in resections more than 4 cm. Mean follow-up was 19±14 months. At the end of the study, 86 patients (91.4%) were breathing normally. There was no mortality in this series. CONCLUSIONS Comorbidities, previous tracheal resection, and the length of tracheal resection more than 4 cm were statistically significant factors for the onset of complications.

Pulmonary Artery Sarcoma Mimicking a Pulmonary Artery Aneurysm

Pulmonary artery sarcoma is an uncommon neoplasm, and its clinical and radiological presentation usually simulates chronic thromboembolic disease. We present the case of a 77-year-old woman admitted with dyspnea, chest pain, and hemoptysis. A chest computed tomographic scan showed moderate right-sided pleural effusion and a saccular dilatation of the interlobar portion of the right pulmonary artery, which was filled with contrast and surrounded by an irregular soft-tissue attenuation mass, suggesting a ruptured pulmonary artery aneurysm. The patient was operated on. Intraoperatively, a pseudoaneurysm and a solid mass were identified within the oblique fissure around the interlobar artery. Therefore, a right pneumonectomy was performed. Definitive pathologic examination was consistent with pulmonary artery sarcoma. The patient had a good outcome and is free of disease 2 years after surgery.

Punção aspirativa guiada por ultrassom endobrônquico no diagnóstico e estadiamento de linfadenopatia mediastinal: experiência inicial no Brasil

OBJECTIVE: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a new method for the diagnosis and staging of mediastinal lymph nodes. The objective of this study was to evaluate the preliminary results obtained with EBUS-TBNA in the diagnosis of lesions and mediastinal lymph node staging. METHODS: We evaluated patients with tumors or mediastinal adenopathy, diagnosed with or suspected of having lung cancer. The procedures were performed with the patients under sedation or under general anesthesia. Material was collected by EBUS-TBNA, after which it was prepared on slides, fixed in either absolute alcohol (for cytology) or formalin (for cell-block analysis). RESULTS: We included 50 patients (30 males). The mean age was 58.3 ± 13.5 years. We performed 201 biopsies of 81 lymph nodes or mediastinal masses (mean of 2.5 punctures/biopsy). The quantity of material was considered sufficient for cytology in 37 patients (74%), 21 (57%) of whom were thus diagnosed with malignancy. Of the remaining 16 patients, 1 was diagnosed with tuberculosis, 6 entered clinical follow-up, and 9 underwent further investigation (2 diagnosed with neoplasm-false-negative results). The yield was higher when the procedure was performed for diagnostic purposes, as well as being higher in patients with lesions in multiple stations and in biopsies involving the subcarinal lymph node station. One patient had endobronchial bleeding, which was resolved with local measures. There were no deaths among the patients evaluated. CONCLUSIONS: This preliminary experience shows that EBUS-TBNA is a safe procedure. Our diagnostic yield, although lower than that reported in the literature, was consistent with the learning curve for the method.

Open bedside tracheostomy: routine procedure for patients under prolonged mechanical ventilation

BACKGROUND Tracheostomy is electively performed in critically ill patients requiring prolonged respiratory support. The risk of transporting, the increasing associated cost and operative room schedule are some of the obstacles for wider acceptance of this procedure. The use of rigid selection criteria exclude many patients who would benefit of this approach. OBJECTIVE To determine the safety of open bedside tracheostomy (OBT) as a routine intensive care units (ICU) procedure without any selection criteria, considering its peri and postoperative complications. METHOD Retrospective medical chart review of all patients that underwent elective tracheostomy between April 1999 and December 2005 at ICU of three private hospitals. RESULTS The study group comprised 552 patients with a mean age of 69.6 +/- 15.8 years. The incidence of significant complications (until 30 days after the procedure) was 4.34% (24 cases): 9 minor bleeding, 9 major bleeding, 2 subcutaneous emphysema, 4 stomal infections. Late complications were: laryngotracheal stenosis in 2 and tracheoinomminate fistula in 1 patient. CONCLUSIONS OBT seems to be a safe and simple procedure, when performed by a team of experienced physicians under controlled circumstances, and should be considered as an option for ICU patients.