Influence of different routes of flush perfusion on the distribution of lung preservation solutions in parenchyma and airways

Objective: The present study was performed to investigate the influence of different routes of perfusion on the distribution of the preservation solutions in the lung parenchyma and upper airways. Methods: Pigs were divided into four groups: control (n = 6), pulmonary artery (PA) (n = 6), simultaneous PA + bronchial artery (BA) (n = 8), and retrograde delivery (n = 6). After preparation and cannulation, cardioplegia solution and Euro- Collins solution (ECS) for lung preservation were given simultaneously. After removal of the heart, the double lung bloc was harvested. Following parameters were assessed: total and regional perfusion (dye-labeled microspheres), tissue water content, PA, aorta, left atrial and left ventricular pressures, cardiac output and lung temperature. Results: Our data show that flow of the ECS in lung parenchyma did not reach control values (9.4 ± 1.0 ml/min per g lung wet weight) regardless of the route of delivery (PA 6.3 ± 1.5, PA + BA 4.8 ± 0.9, retrograde 2.7 ± 0.9 ml/min per g lung wet weight). However, flow in the proximal and distal trachea were significantly increased by PA + BA delivery (0.970 ± 0.4, respectively, 0.380 ± 0.2 ml/min per g) in comparison with PA (0.023 ± 0.007, respectively, 0.024 ± 0.070 ml/min per g), retrograde (0.009 ± 0.003, respectively, 0.021 ± 0.006 ml/min per g) and control experiments (0.125 ± 0.0018, respectively, 0.105 ± 0.012 ml/g per min). Similarly the highest flow rates in the right main bronchus were achieved by PA + BA delivery (1.04 ± 0.4 ml/min per g) in comparison with 0.11 ± 0.03 in control, 0.033 ± 0.008 in PA, and 0.019 ± 0.005 ml/min per g in retrograde group. Flows in the left main bronchus were 0.09 ± 0.02 ml/min per g in control, 0.045 ± 0.012 ml/min per g in PA, and 0.027 ± 0.006 ml/min per g in retrograde group. The flow rates were significantly (P = 0.001) increased by PA + BA delivery of the storage solution (0.97 ± 0.3 ml/min per g). Conclusions: Our data show that the distribution of ECS for lung preservation is significantly improved in airway tissues (trachea and bronchi) if a simultaneous PA + BA delivery is used.

Perfil da atividade de pesquisa publicada nos anais dos congressos brasileiros de pneumologia e tisiologia nos últimos vinte anos

Objective: To increase the knowledge base regarding pulmonology research in Brazil. Methods: A retrospective, observational study of the abstracts published in the Annals of the Brazilian Pulmonology and Phthisiology Conferences held from 1986 to 2004, quantifying the institutions of origin by geographic distribution and type, as well as categorizing the abstracts by study design and topic. Results: A total of 6467 abstracts were published. The institutions of origin were located, variously, in the Southeast (3870 abstracts), South (1309), Northeast (783), Central-West (267) and North (84). There were 94 abstracts originating from foreign institutions, especially from institutions in Portugal (56.3%) and the United States (13.8%). Most of the studies (5825) were conducted in public Brazilian institutions. There were 4234 clinical studies, 1994 case reports and 239 original research articles. A marked, progressive increase was observed in the number of clinical studies and case reports during the period evaluated. Overall, the most common themes were tuberculosis and other infections diseases (25.2%), following by oncology (11.6%), interstitial lung diseases (8.8%) and thoracic surgery (8.5%). Nevertheless, the number of abstracts on each topic varied widely from year to year. Conclusion: Public Brazilian institutions are the principal sources of pulmonology research in Brazil. Such research activity is concentrated in the southeastern part of the country. Case reports account for one-third of this activity. Although there was great variability in the subjects addressed, diseases that are highly prevalent in Brazil, such as tuberculosis and other infections diseases, were the most common topics.

Time in the stair-climbing test as a predictor of thoracotomy postoperative complications

Objectives: The stair-climbing test as measured in meters or number of steps has been proposed to predict the risk of postoperative complications. The study objective was to determine whether the stair-climbing time can predict the risk of postoperative complications. Methods: Patients aged more than 18 years with a recommendation of thoracotomy for lung resection were included in the study. Spirometry was performed according to the criteria by the American Thoracic Society. The stair-climbing test was performed on shaded stairs with a total of 12.16 m in height, and the stair-climbing time in seconds elapsed during the climb of the total height was measured. The accuracy test was applied to obtain stair-climbing time predictive values, and the receiver operating characteristic curve was calculated. Variables were tested for association with postoperative cardiopulmonary complications using the Student t test for independent populations, the Mann-Whitney test, and the chi-square or Fisher exact test. Logistic regression analysis was performed. Results: Ninety-eight patients were evaluated. Of these, 27 showed postoperative complications. Differences were found between the groups for age and attributes obtained from the stair-climbing test. The cutoff point for stair-climbing time obtained from the receiver operating characteristic curve was 37.5 seconds. No differences were found between the groups for forced expiratory volume in 1 second. In the logistic regression, stair-climbing time was the only variable associated with postoperative complications, suggesting that the risk of postoperative complications increases with increased stair-climbing time. Conclusions: The only variable showing association with complications, according to multivariate analysis, was stair-climbing time. © 2013 by The American Association for Thoracic Surgery.

Complicações pós-operatórias em cirurgia torácica relacionadas aos índices e testes preditores de risco cirúrgico pré-operatórios

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

Testes de risco cirúrgico relacionados às complicações cardiopulmonares: comparação entre a cirurgia abdominal supra-umbilical e a torácica

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

Parada cardíaca e mortalidade perioperatória por trauma: estudo no período de 14 anos em hospital universitario de atendimento terciário

Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)

Preoperative therapy restores ventilatory parameters and reduces length of stay in patients undergoing myocardial revascularization

Introduction: The frequency of surgical procedures has increased steadily in recent decades, including the myocardial revascularization.Objectives: To demonstrate the importance of physiotherapy in the preoperative period of cardiac surgery in relation to the reduction of hospital stay, changes in lung volumes and respiratory muscle strength.Methods: We conducted a prospective study with patients undergoing myocardial revascularization, the Hospital das Clinicas da Universidade Estadual Paulista (UNESP)/Botucatu - SP. We evaluated 70 patients of both genders, aged between 40 and 75 years, subdivided into two groups: group I - 35 patients of both genders, who received a written protocol guidance, breathing exercises and respiratory muscle training in the preoperative period and group II - 35 patients of both genders, who received only orientation of the ward on the day of surgery. This study was approved by the Ethics Committee of UNESP /Botucatu - SP.Results: Maximal inspiratory pressure in third postoperative day and fifth postoperative day and significant difference between groups, being better for the intervention group. Expiratory pressure was significant in fifth postoperative day in the intervention group compared to controls. The difference of length of hospital stay in the postoperative was found between the groups with shorter hospital stay in the group receiving preoperative therapy.Conclusion: Physical therapy plays an important role in the preoperative period, so that individuals in the intervention group more readily restored the parameters evaluated before surgery, in addition, there was a decrease in the time of the postoperative hospital stay. Thus, it is thought the cost-effectiveness of a program of preoperative physiotherapy.

Post-operative mediastinitis in a Heart Hospital of Recife: contributions for nursing care

The objective of this study was to determine the prevalence of post-operative mediastinitis with the purpose to contribute to nursing care knowledge. To do this, an analysis was performed on 896 medical records of patients who underwent heart surgery involving sternotomy at the Cardiology Emergency Room of Recife-PE, in the period between June 2007 and June 2009. The following variables were considered: gender, age, type of surgery, personal history, length of stay, use of antibiotics, and culture of the surgical wound. A high death rate from mediastinitis was observed (33.3%). Several risk factors were identified, including: systemic arterial hypertension (80.9%); smoking (61.9%); diabetes mellitus (42.8%); and obesity (33.3%), most of which (76.2%) were identified in patients who underwent surgery for myocardial revascularization. It is concluded that mediastinitis is a serious infection that needs continuous nursing supervision and preventive measures to assure an early diagnosis and, thus, reduce mortality.

Does videothoracoscopy improve clinical outcomes when implemented as part of a pleural empyema treatment algorithm?

OBJECTIVE: We aimed to evaluate whether the inclusion of videothoracoscopy in a pleural empyema treatment algorithm would change the clinical outcome of such patients. METHODS: This study performed quality-improvement research. We conducted a retrospective review of patients who underwent pleural decortication for pleural empyema at our institution from 2002 to 2008. With the old algorithm (January 2002 to September 2005), open decortication was the procedure of choice, and videothoracoscopy was only performed in certain sporadic mid-stage cases. With the new algorithm (October 2005 to December 2008), videothoracoscopy became the first-line treatment option, whereas open decortication was only performed in patients with a thick pleural peel (>2 cm) observed by chest scan. The patients were divided into an old algorithm (n = 93) and new algorithm (n = 113) group and compared. The main outcome variables assessed included treatment failure (pleural space reintervention or death up to 60 days after medical discharge) and the occurrence of complications. RESULTS: Videothoracoscopy and open decortication were performed in 13 and 80 patients from the old algorithm group and in 81 and 32 patients from the new algorithm group, respectively (p < 0.01). The patients in the new algorithm group were older (41 +/- 1 vs. 46.3 +/- 16.7 years, p=0.014) and had higher Charlson Comorbidity Index scores [0(0-3) vs. 2(0-4), p = 0.032]. The occurrence of treatment failure was similar in both groups (19.35% vs. 24.77%, p= 0.35), although the complication rate was lower in the new algorithm group (48.3% vs. 33.6%, p = 0.04). CONCLUSIONS: The wider use of videothoracoscopy in pleural empyema treatment was associated with fewer complications and unaltered rates of mortality and reoperation even though more severely ill patients were subjected to videothoracoscopic surgery.

The Nuss procedure made safer: an effective and simple sternal elevation manoeuvre

The Nuss procedure requires the creation of a substernal tunnel for bar positioning. This is a manoeuvre that can be dangerous, and cardiac perforation has occurred in a few cases. Our purpose was to describe two technical modifications that enable the prevention of these fatal complications. A series of 25 patients with pectus excavatum were treated with a modification of the Nuss procedure that included the entrance in the left haemithorax first, and the use of the retractor to lift the sternum, with the consequent lowering displacement of the heart. These modified techniques have certain advantages: (i) the narrow anterior mediastinum between the sternum and the pericardial sac is expanded by pulling up the sternum; (ii) the thoracoscopic visualization of the tip of the introducer during tunnel creation is improved; (iii) the rubbing of the introducer against the pericardium is minimized; (iv) the exit path of the introducer can be guided by the surgeon's finger and (v) haemostasis and integrity of the pericardial sac can be more easily confirmed. We observed that with these manoeuvres, the risk of pericardial sac and cardiac injury can be markedly reduced.

Predicted preoperative maximal static respiratory pressures in adult cardiac surgeries: evaluation of two formulas

Objectives: Cardiac surgery (CC) determines systemic and pulmonary changes that require special care. What motivated several studies conducted in healthy subjects to assess muscle strength were the awareness of the importance of respiratory muscle dysfunction in the development of respiratory failure. These studies used maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP) values. This study examined the concordance between the values predicted by the equations proposed by Black & Hyatt and Neder, and the measured values in cardiac surgery (CS) patients. Methods: Data were collected from preoperative evaluation forms. The Lin coefficient and Bland-Altman plots were used for statistical concordance analysis. The multiple linear regression and analysis of variance (ANOVA) were used to produce new formulas. Results: There were weak correlations of 0.22 and 0.19 in the MIP analysis and of 0.10 and 0.32 in the MEP analysis, for the formulas of Black & Hyatt and Neder, respectively. The ANOVA for both MIP and MEP were significant (P <0.0001), and the following formulas were developed: MIP = 88.82 - (0.51 x age) + (19.86 x gender), and MEP = 91.36 -(030 x age) + (29.92 x gender). Conclusions: The Black and Hyatt and Neder formulas predict highly discrepant values of MIP and MEP and should not be used to identify muscle weakness in CS patients.

Videocirurgia na criança: estado da arte. Experiência com 1408 procedimentos no Instituto da Criança "Pedro de Alcântara"

A videocirurgia em Cirurgia Pediátrica encontra um imenso campo de aplicações ainda, infelizmente, pouco explorado. São poucos os serviços que utilizam rotineiramente essa via de acesso e são escassas as referências nacionais publicadas. O Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (ICr) há uma década e meia a utiliza e hoje a videocirurgia é a via de primeira escolha para tratar, entre outras doenças, o refluxo gastresofagiano, a colecistopatia calculosa, o testículo não palpável e o megaesôfago. Neste artigo relataremos a experiência em videocirurgia pediátrica do ICr, adquirida com 1408 pacientes operados, para divulgar e popularizar esta via de acesso, útil e benéfica para um grande número de situações e ainda subutilizada em Cirurgia Pediátrica.

Circulação extracorpórea e complicações no período pós-operatório imediato de cirurgias cardíacas

OBJETIVO: Comparar a frequência de complicações apresentadas pelos pacientes, durante o pós-operatório imediato (POI), de cirurgias cardíacas de acordo com o tempo de circulação extra-corpórea (CEC). MÉTODOS: Estudo de natureza quantitativa, descritivo e correlacional com 83 pacientes adultos divididos em dois grupos de acordo com o tempo de CEC. RESULTADOS: Do total de pacientes, 44 (53%) tiveram o tempo de duração da CEC de até 85 minutos e 39 (47 %) tiveram o tempo acima de 85 minutos. As complicações foram comuns para ambos os grupos, sendo as mais frequentes dor e oligúria. No entanto, hemotórax, pneumotórax e infarto agudo do miocárdio ocorreram apenas no grupo com maior tempo de CEC. CONCLUSÃO: A maioria das complicações ocorridas no POI apresentou frequencia semelhante para os pacientes, independente do tempo de CEC.

Carcinoma polmonare non a piccole cellule T1aN0M0: Ruolo prognostico della Microvessel Density

Obiettivi. Valutare l’angiogenesi tumorale mediante la Microvessel density (MVD) come fattore predittivo di mortalità per tumore polmonare non a piccole cellule (NSCLC) pT1aN0M0 trattato chirurgicamente. Metodi. I dati demografici, clinici e istopatologici sono stati registrati per 82 pazienti (60 maschi, 22 femmine) sottoposti a resezione chirurgica in due diverse Chirurgie Toraciche tra gennaio 2002 e dicembre 2007 per tumori polmonari non a piccole cellule pT1AN0M0. La MVD è stata valutata mediante il conteggio visivo dei microvasi positivi alla colorazione immunoistochimica con anticorpo monoclonale anti-CD31 e definita come il numero medio di microvasi per 1 mm2 di campo ottico. Risultati. Sono state eseguite 59 lobectomie (72%) e 23 resezioni sublobari (28%). Reperti istopatologici: 43 adenocarcinomi (52%) e 39 neoplasie non- adenocarcinoma (48%) pT1aN0M0; MVD media: 161 (CD31/mm2); mediana: 148; range 50-365, cut-off=150. Una MVD elevata (> 150 CD31/mm2) è stata osservata in 40 pazienti (49%), una MVD ridotta ( ≤ 150 CD31/mm2 ) in 42 pazienti (51%). Sopravvivenze a 5 anni: 70 % e 95%, rispettivamente per il gruppo ad elevata MVD vs il gruppo a ridotta MVD con una p = 0,0041, statisticamente significativa. Il tipo di resezione chirurgica, il diametro del tumore, le principali comorbidità e l’istotipo nono sono stati fattori predittivi significativi di mortalità correlata alla malattia. La MVD è risultata essere superiore nel gruppo “Adenocarcinoma” (MVD mediana=180) rispetto al gruppo “Non-Adenocarcinoma (MVD mediana=125), con un test di Mann-Whitney statisticamente significativo (p < 0,0001). Nel gruppo “Adenocarcinoma” la sopravvivenza a 5 anni è stata del 66% e 93 %, rispettivamente per i pazienti con MVD elevata e ridotta (p = 0.043. Conclusioni. Il nostro studio ha mostrato che la Microvessel density valutata con la colorazione immunoistochimica per CD31 ha un valore prognostico rilevante nel carcinoma polmonare in stadio precoce pT1aN0M0.

Inflammatory myofibroblastic tumour of the lung in a five-year-old girl

The inflammatory myofibroblastic tumour of the lung is considered a rare diagnosis of lung masses. We report the case of a five-year-old girl who presented with recurrent pyrexia, dry cough, and shortness of breath. Chest X-ray and computed tomography showed a total atelectasis of the left lower lobe and a segmental atelectasis of the left upper lobe. The mass was removed in toto, histopathology revealed the diagnosis of an inflammatory myofibroblastic tumour of the lung. The patient is without any signs of relapse 30 months after surgery.