Reconstrução da parede torácica nos defeitos adquiridos

Acquired chest wall defects present a challenging problem for thoracic surgeons. Many of such defects can be repaired with the use of local and regional musculocutaneous flaps, but larger defects compromising skeletal structure require increasingly sophisticated reconstructive techniques. The following discussion will review the options for repair acquired chest wall defects based in literature. The authors searched the Pubmed (www.pubmed.com) and found citations from January 1996 to February 2008. By reading the titles and the abstracts most of the citations were discharged because they focused in congenital chest wall defects or were cases report. However, many papers were found describing the outcome of large series of patients with acquired chest wall deformities. A review of recent literature shows that the repair of chest wall defects with soft tissues, if possible, remains the treatment of choice. Large chest wall defects require skeletal reconstruction to prevent paradoxical respiration. The selection of the most appropriate flap is primary dictated by the location and the size of the defect. It is important to transfer tissue with good vitality, so understanding the vascular supply is imperative. Autogenous grafts have been used in the past for skeletal reconstruction but a combination of synthetic materials with musculocutaneous flaps has been used lately. Based in the literature, the use of prosthetic material in chest wall reconstruction does not significantly increases the risk of wound infection.

Damage control surgery: it's evolution over the last 20 years

In less than twenty years, what began as a concept for the treatment of exsanguinating truncal trauma patients has become the primary treatment model for numerous emergent, life threatening surgical conditions incapable of tolerating traditional methods. Its core concepts are relative straightforward and simple in nature: first, proper identification of the patient who is in need of following this paradigm; second, truncation of the initial surgical procedure to the minimal necessary operation; third, aggressive, focused resuscitation in the intensive care unit; fourth, definitive care only once the patient is optimized to tolerate the procedure. These simple underlying principles can be molded to a variety of emergencies, from its original application in combined major vascular and visceral trauma to the septic abdomen and orthopedics. A host of new resuscitation strategies and technologies have been developed over the past two decades, from permissive hypotension and damage control resuscitation to advanced ventilators and hemostatic agents, which have allowed for a more focused resuscitation, allowing some of the morbidity of this model to be reduced. The combination of the simple, malleable paradigm along with better understanding of resuscitation has proven to be a potent blend. As such, what was once an almost lethal injury (combined vascular and visceral injury) has become a survivable one.

Avulsão da via biliar principal: relato de caso

Common bile duct disruption from blunt trauma is very rare. Management, diagnosis and therapy by a non-specialist surgeon can be difficult. We describe a bile duct injury after a motor vehicle crash in a young male, treated with cholecystojejunostomy at his third laparotomy. We also briefly review some diagnostic aspects and therapeutic options from the literature.

Incidence of deep vein thrombosis and quality of venous thromboembolism prophylaxis

OBJECTIVE: to determine the incidence of deep vein thrombosis and prophylaxis quality in hospitalized patients undergoing vascular and orthopedic surgical procedures. METHODS: we evaluated 296 patients, whose incidence of deep venous thrombosis was studied by vascular ultrasonography. Risk factors for venous thrombosis were stratified according the Caprini model. To assess the quality of prophylaxis we compared the adopted measures with the prophylaxis guidelines of the American College of Chest Physicians. RESULTS: the overall incidence of deep venous thrombosis was 7.5%. As for the risk groups, 10.8% were considered low risk, 14.9%moderate risk, 24.3% high risk and 50.5% very high risk. Prophylaxis of deep venous thrombosis was correct in 57.7%. In groups of high and very high risk, adequate prophylaxis rates were 72.2% and 71.6%, respectively. Excessive use of chemoprophylaxis was seen in 68.7% and 61.4% in the low and moderate-risk groups, respectively. CONCLUSION: although most patients are deemed to be at high and very high risk for deep vein thrombosis, deficiency in the application of prophylaxis persists in medical practice.

Arthroscopic treatment of refractory adhesive capsulitis of the shoulder

OBJECTIVE: to evaluate the results of arthroscopic treatment of refractory adhesive capsulitis of the shoulder associated as for improved range of motion after a minimum follow up of six years. METHODS: from August 2002 to December 2004, ten patients with adhesive capsulitis of the shoulder resistant to conservative treatment underwent arthroscopic surgery. One interscalene catheter was placed for postoperative analgesia before the procedure. All were in Phase II, with a minimum follow up of two years. The mean age was 52.9 years (39-66), predominantly female (90%), six on the left shoulder. The time between onset of symptoms and surgical treatment ranged from six to 20 months. Four adhesive capsulitis were found to be primary (40%) and six secondary (60%). RESULTS: the preoperative mean of active anterior elevation was 92°, of external rotation was 10.5° of the L5 level internal rotation; the postoperative ones were 149°, 40° and T12 level, respectively. Therefore, the average gain was 57° for the anterior elevation, 29.5° for external rotation in six spinous processes. There was a significant difference in movements' gains between the pre and post-operative periods (p<0.001). By the Constant Score (range of motion), there was an increase of 13.8 (average pre) to 32 points (average post). CONCLUSION: the arthroscopic treatment proved effective in refractory adhesive capsulitis of the shoulder resistant to conservative treatment, improving the range of joint movements of patients evaluated after a minimum follow up of six years.

Protecting the skin during thyroidectomy

In this note we describe the standard technical maneuver used in our department to protect the skin during thyroidectomy in order to get the best aesthetic result. We use surgical gloves to protect the skin during these operations to reduce the negative impact of thermal trauma and mechanical retractors and energy delivery devices at the edges of the skin incised. This practice is effective, inexpensive, rapid, reproducible and showed no complication in our experience of over 2,500 thyroidectomies.

An alternative experimental model for training in microsurgery

OBJECTIVE: to describe a new model of training in microsurgery with pig spleen after splenectomy performed by undergraduate students of the Discipline of Operative Technique of the UFPR Medical School. METHODS: after the completion of splenectomy we performed dissection of the vascular pedicle, distal and proximal to the ligation performed for removal of the spleen. After complete dissection of the splenic artery and vein with microscope, clamps were placed and the vessels were cut. We then made the anastomosis of the vessels with 9.0 nylon. RESULT: the microsurgical training with a well-defined routine, qualified supervision and using low cost experimental materials proved to be effective in the practice of initial microvascular surgery. CONCLUSION: the use of pig spleen, which would be discarded after splenectomy, is an excellent model for microsurgical training, since besides having the consistency and sensitivity of a real model, it saves the sacrifice of a new animal model in the initial learning phase of this technique.

Critical analysis of thoracotomies performed in the emergency room in 10 years

OBJECTIVE: To conduct a critical analysis of thoracotomies performed in the emergency rooms.METHODS: We analyzed mortality rates and survival as outcome variables, mechanism of injury, site of injury and anatomic injury as clinical variables, and gender and age as demographic variables of patients undergoing thoracotomy in the emergency room after traumatic injury.RESULTS: Of the 105 patients, 89.5% were male. The average age was 29.2 years. Penetrating trauma accounted for 81% of cases. The most common mechanism of trauma was wound by a firearm projectile (gunshot), in 64.7% of cases. Patients with stab wounds (SW) accounted for 16.2% of cases. Overall survival was 4.7%. Survival by gunshot was 1.4%, and by SW, 23.5%. The ERT following blunt trauma showed a 100%mortality.CONCLUSION: The results obtained in the Emergency Hospital of Porto Alegre POA-HPS are similar to those reported in the world literature.

Safety and tolerability of controlled-release oxycodone on postoperative pain in patients submitted to the oncologic head and neck surgery

Objective: To evaluate the safety and tolerability of controlled-release oxycodone in the treatment of postoperative pain of head and neck oncologic resections.Methods: We conducted a prospective, observational and open study, with 83 patients with moderate to severe pain after head and neck oncological operations. All patients received general anesthesia with propofol, fentanyl and sevoflurane. Postoperatively, should they have moderate or severe pain, we began controlled-release oxycodone 20 mg 12/12 b.i.d on the first day and 10 mg b.i.d. on the second. We assessed the frequency and intensity of adverse effects, the intensity of postoperative pain by a verbal numeric scale and the use of rescue analgesia from 12 hours after administration of the drug and between 7 and 13 days after the last oxycodone dose.Results: The most common adverse events were nausea, vomiting, dizziness, pruritus, insomnia, constipation and urinary retention, most mild. No serious adverse events occurred. In less than 12 hours after the use of oxycodone, there was a significant decrease in the intensity of postoperative pain, which remained until the end of the study. The rescue medication was requested at a higher frequency when the opioid dose was reduced, or after its suspension.Conclusion: Controlled release oxycodone showed to be safe and well tolerated and caused a significant decrease in post-operative pain.

Nuss procedure for Pectus excavatum repair: critical appraisal of the evidence

Objective: To evaluate the effectiveness and safety of correction of pectus excavatum by the Nuss technique based on the available scientific evidence.Methods: We conducted an evidence synthesis following systematic processes of search, selection, extraction and critical appraisal. Outcomes were classified by importance and had their quality assessed by the Grading of Recommendations Assessment, Development and Evaluation (GRADE).Results: The process of selection of items led to the inclusion of only one systematic review, which synthesized the results of nine observational studies comparing the Nuss and Ravitch procedures. The evidence found was rated as poor and very poor quality. The Nuss procedure has increased the incidence of hemothorax (RR = 5.15; 95% CI: 1.07; 24.89), pneumothorax (RR = 5.26; 95% CI: 1.55; 17.92) and the need for reintervention (RR = 4.88; 95% CI: 2.41; 9.88) when compared to the Ravitch. There was no statistical difference between the two procedures in outcomes: general complications, blood transfusion, hospital stay and time to ambulation. The Nuss operation was faster than the Ravitch (mean difference [MD] = -69.94 minutes, 95% CI: -139.04, -0.83).Conclusion: In the absence of well-designed prospective studies to clarify the evidence, especially in terms of aesthetics and quality of life, surgical indication should be individualized and the choice of the technique based on patient preference and experience of the team.

Vascular trauma in the Amazon - the challenge of great distances

ABSTRACTObjective:to evaluate the incidence of unfavorable outcomes in vascular trauma patients and their possible correlation to the distance between the city where the injury was sustained and the hospital where the patient received definitive treatment.Methods:descriptive and retrospective study. Data were collected from medical records of patients submitted to surgical procedures for arterial or venous injuries from February 2011 to February 2013 at the only trauma center providing vascular surgery in a vast area of the Amazon region. Trauma date, patient gender and age, mechanism and anatomic topography of injury, surgical management, need for surgical re-intervention, hospitalization period, postoperative complications, mortality and limb amputation rates were analyzed. The incidence of unfavorable outcomes was assessed according to the distance between the city where the vascular injury was sustained and the trauma center.Results: One hundred seventy-three patients with 255 vascular injuries were analyzed; 95.95% were male (p<0.05), mean age of 28.92 years; 47.4% were caused by firearm projectiles (p<0.05); topographic distribution: 45.66% lower limbs (p<0.05), 37.57% upper limbs, 6.94% abdominal, 5.2% thoracic and 4.62% were cervical vascular injuries; 51.42% of patients required hospitalization for seven days or less (p<0.05); limb amputation was necessary in 15.6% and the overall mortality was 6.36%.Conclusion:distances greater than 200Km were associated to longer hospitalization period; distances greater than 300Km were associated to increased limb amputation probability; severe vascular trauma have an increased death probability when patients need to travel more than 200Km for surgical treatment.

Basic skills for outpatient surgery in medical graduation

Medical students must have domain of basic surgery skills before starting more advanced stages of surgical learning. The authors present a practical and reproducible system of operative techniques circuit, idealized and often applied to the fourth year medical students of a private educational institution. This method has enabled accurate assessment of students' skills, improving their performance and preparing them for more advanced stages of the surgical learning.

Total esophagogastrectomy in the neoplasms of the esophagus and esofagogastric junction: when must be indicated?

Objective: to analyse the indications and results of the total esophagogastrectomy in cancers of the distal esophagus and esophagogastric junction. Methods: twenty patients with adenocarcinomas were operated with a mean age of 55 ± 9.9 years (31-70 years), and 14 cases were male (60%). Indications were 18 tumors of the distal esophagus and esophagogastric junction (90%) and two with invasion of gastric fundus (10%) in patients with previous gastrectomy. Preoperative colonoscopy to exclude colonic diseases was performed in ten cases. Results: the surgical technique consisted of median laparotomy and left cervicotomy, followed by transhiatal esophagectomy associated with D2 lymphadenectomy. The reconstructions were performed with eight esophagocoloduodenoplasty and the others were Roux-en-Y esophagocolojejunoplasty to prevent the alkaline reflux. Three cases were stage I / II, while 15 cases (85%) were stages III / IV, reflecting late diagnosis of these tumors. The operative mortality was 5 patients (25%): a mediastinitis secondary to necrosis of the transposed colon, abdominal cellulitis secondary to wound infection, severe pneumonia, an irreversible shock and sepsis associated with colojejunal fistula. Four patients died in the first year after surgery: 3 (15%) were due to tumor recurrence and 1 (5%) secondary to bronchopneumonia. The 5-year survival was 15%. Conclusion: the total esophagogastrectomy associated with esophagocoloplasty has high morbidity and mortality, requiring precise indication, and properly selected patients benefit from the surgery, with the risk-benefit acceptable, contributing to increased survival and improved quality of life

Fifty consecutive pancreatectomies without mortality

Objective: to report the group's experience with a series of patients undergoing pancreatic resection presenting null mortality rates. Methods: we prospectively studied 50 consecutive patients undergoing pancreatic resections for peri-ampullary or pancreatic diseases. Main local complications were defined according to international criteria. In-hospital mortality was defined as death occurring in the first 90 postoperative days. Results: patients' age ranged between 16 and 90 years (average: 53.3). We found anemia (Hb < 12g/dl) and preoperative jaundice in 38% and 40% of cases, respectively. Most patients presented with peri-ampullary tumors (66%). The most common surgical procedure was the Kausch - Whipple operation (70%). Six patients (12%) needed to undergo resection of a segment of the mesenteric-portal axis. The mean operative time was 445.1 minutes. Twenty two patients (44%) showed no clinical complications and presented mean hospital stay of 10.3 days. The most frequent complications were pancreatic fistula (56%), delayed gastric emptying (17.1%) and bleeding (16%). Conclusion : within the last three decades, pancreatic resection is still considered a challenge, especially outside large specialized centers. Nevertheless, even in our country (Brazil), teams seasoned in such procedure can reach low mortality rates.