Cirurgia do Timo num Servi��o de Cirurgia Geral

AIMS: Evaluation of thymectomy cases between 1990-2003, in a General Surgery Department. Evaluation of the therapeutic efficacy in Miastenia Gravis patients. PATIENTS AND METHODS: Retrospective study based on evaluation of data from Servi��o de Cirurgia, Neurologia and Consult de Neurology processes, between 1990-2003, of 15 patients submitted to total thymectomy. RESULTS: 15 patients, aged 17 to 72, 11 female and 4 male. Miastenia Gravis was the main indication for surgery, for uncontrollable symptoms or suspicion of thymoma. In patients with myasthenia, surgery was accomplish after compensation of symptoms. There weren't post-surgery complications. Pathology were divided in thymic hyperplasia and thymoma. Miastenia patients have there symptoms diminished or stable with reduction or cessation of medical therapy. CONCLUSIONS: Miastenia was the most frequent indication for thymectomy. Surgery was good results, with low morbimortality, as long as the protocols are respected.

A Unidade de Cirurgia de Ambulat��rio do Hospital Santo Ant��nio dos Capuchos - Interven����o do Enfermeiro

A realiza����o deste artigo visa apresentar a Unidade de Cirurgia de Ambulat��rio 2 (UCA), a funcionar no Hospital Santo Ant��nio dos Capuchos (HSAC) desde 16 de Junho de 2009. �� nosso intuito contextualizar a necessidade de cria����o desta Unidade, com uma breve resenha hist��rica da Cirurgia de Ambulat��rio (CA), evidenciando as principais vantagens deste regime cir��rgico. Pretendemos dar a conhecer a organiza����o e funcionamento da UCA, o circuito dos utentes, real��ando o papel do Enfermeiro em todo este processo.

Cirurgia Card��aca em Doentes de Muito Alto Risco

Purpose: To assess the results obtained in very high-risk patients, which are those patients with an EUROSCORE greater than 13 points. Material and methods: From September 2001 to September 2003, thirty-three very high-risk patients were operated on in our department, which represents 1.6% of all the surgical activity during that period of time, being 17 male and 16 female, with an average of 69 years old (maximum 86 and minimum 32). Diagnosis includes: post infarction CIV 5, coronary insufficiency 11, aortic dissection 3, mitral prosthesis 3, valvular disease 9, aortic prosthesis disfunction 2. Fifteen patients underwent an emergency procedure, 12 were urgent and the remaining 6 were electively operated on. Results: Overall post-operative mortality was 12 patients (36%), being 6 emergent, 5 urgent and 1 elective patient. Patients who survived the operation had longer intensive care and hospital admission periods, which will be analyzed in detail. Conclusion: Surgery can be justified in very high risk patients. Despite the high perioperative mortality and longer periods of hospital stay, they will be otherwise condamned to death, if surgery would not be performed.

Protec����o Cerebral na Cirurgia do Arco A��rtico

In this paper the authors proceed to a revision of the three main methods employed for cerebral protection in aortic arch surgery, namely the deep hypothermia and total circulatory arrest, the retrograde cerebral perfusion and the selective anterograde cerebral perfusion. After a deep analysis on their advantages and disadvantages, they proposed the utilization of an association of methods (integrated approach) that has proved to be extremely well succeed in their clinical practice, specially in high-risks patients.

Les��es Traum��ticas Iatrog��nicas das Veias Femorais no Decurso da Cirurgia de Varizes

Traumatic lesions of the femoral veins during varicose veins surgery are very uncommon and they raise several therapeutic difficulties. They occur in 1/1000 cases of varicose veins operated. The authors describe four cases of lesions of this type that were seen and treated for the last six years, probably because there was an increase in the number of varicose veins operated on in the Lisbon area. The authors discuss the surgical options and they concluded that these complications can be minimized with good anatomical and surgical skills, specially of the saphenous-femoral and saphenous-popliteal junctions.

Cirurgia de Repara����o Mitral em Crian��as com Valvulopatia Adquirida

BACKGROUND: Valve surgery in children is aimed at restoring correct hemodynamics with few reoperations and limited resort to prostheses, which would imply early deterioration or definitive hypocoagulation. OBJECTIVES: Report a series of paediatric pts with acquired mitral valve disease, mostly due to rheumatic disease, in whom it was possible, for the great majority, to repair the damaged valve. DEMOGRAPHICS: Fifty children with predominant mitral valve disease, 47 rheumatic (94%) and 3 after endocarditis were consequently operated by the same surgical team over the last five years. Ages were 12.5+/-3.1 yrs and weights 33.2+/-8.4 Kg, 30 pts presented with predominant mitral regurgitation and 20 pts had significant stenosis. In 8 pts there also moderate to severe aortic regurgitation and in 2 pts severe tricuspid regurgitation was present. Patients were not operated during the acute phase of the disease. Five pts were reoperations and from those, all but one received mechanical prosthesis. RESULTS: In all operations the intention was to repair the mitral valve. In 46 pts complex mitral valvuloplasties were performed extended comissurotomies, shortening of chordae, chordal replacement with PTFE, and reconstruction of valve leaflefts by direct patching or pericardial extension of the retracted posterior leaflet (78.2% cases), plus reshaping of the annulus by using a fixed prosthetic CE ring (sizes 26 to 32) in every case. Ring sizes correlated poorly with body weights, but correlation was close and positive for the use of pericardial advancement of the posterior leaflet (p<0.01). There was no operative mortality, but one pt died early from sepsis and there was no late mortality. Maximum follow up extends now to 50 months (median 28 months) and functional evaluation, at latest follow up, as assessed by Doppler Echocardiography, showed residual mitral regurgitation, mild-moderate in 4 pts and LA-LV gradients mild in 5 and moderate in 2 pts. NYHA functional class, at present follow-up is class I for 43 pts (88%) and class II in the remaining 6 pts. Along the follow-up period 2 pts had to be reoperated for early repair failures and other three for late failures, presently freedom for reoperation is 91.8% at 5 years. CONCLUSIONS: Mitral valve repair in children with rheumatic lesions can be achieved for the great majority of cases by using different techniques. Pericardial extension of the retracted posterior leaflet allowed the use of a bigger size prosthetic ring. Intermediate functional results are good with fair functional classes and few reoperations but follow-up is short and does not allow us to draw conclusions about the long-term results of the repair in these rheumatic patients.

Volumoso Pseudoaneurisma do Ventr��culo Esquerdo ap��s Cirurgia Card��aca

A 75-year old female patient, with previous inferior acute myocardial infarction (AMI) in December 2000, was admitted in April 2001 with angina and heart failure. Transthoracic echocardiography (TTE) was suggestive of a postero-inferior pseudoaneurysm (PA) of the left ventricle (LV), with 61x49 mm. of size and mitral regurgitation. Cardiac catheterization was suspected of a PA of the LV and revealed a three vessels coronary artery disease. On 20th April she was submitted to cardiac surgery with resection of a large LV aneurysm (AN) and triple coronary artery bypass surgery. Afterwards, she was on NYHA class III and subsequent TTE and transesophagic echocardiography (TEE) were suggestive of a 90x60 mm LV posterior PA (confirmed by nuclear magnetic resonance) and severe mitral regurgitation, with good LV systolic function. She underwent a new cardiac surgery on 31st May 2002, with resuturing of the LV postero-inferior wall patch and removal of the PA. The patient is in good condition and on NYHA functional class I-II.

T��cnicas e "Truques": Utiliza����es Diferentes para o Cat��ter de Foley na Cirurgia Cardiovascular

A utiliza����o do cat��ter de Foley na pr��tica da algalia����o est�� desde h�� muito definida. Os autores t��m, no entanto, utilizado o cat��ter Foley em diversas situa����es de recurso, no ��mbito da cirurgia card��aca. A utiliza����o deste m��todo de enorme simplicidade e de muito baixo custo representa um verdadeiro "ovo de Colombo" e deve fazer parte do armentarium cir��rgico alternativo de cada um de n��s. Descreve-se o uso do cat��ter Foley, como alternativa de recurso, nas seguintes situa����es: 1. Lacera����o de uma cavidade card��aca na re-esternotomia com hemorragia catastr��fica; 2. Realiza����o de anastomoses proximais em aortas que n��o devem ou podem ser clampadas (calcifica����es extensas); 3. Realiza����o de anastomoses de condutos ventr��culo-direito art��ria pulmonar com o cora����o a bater.

Endocardite a Nocardia ap��s Cirurgia de Substitui����o Valvular Mitral: Caso Cl��nico e Revis��o da Literatura

A Nocardia �� respons��vel por diversos tipos de infec����o quer em receptores imunocompetentes, quer imunocomprometidos e pode afectar qualquer ��rg��o. A endocardite a Nocardia spp �� muito rara e tem mau progn��stico. Segundo o nosso conhecimento e ap��s revis��o da literatura, foram reportados apenas 12 casos de endocardite a Nocardia, a maioria tratada com substitui����o valvular. Reportamos o primeiro caso descrito em Portugal de endocardite prot��sica a Nocardia, tratado com sucesso apenas com terap��utica antimicrobiana (trimetoprimsulfametoxazol), sem necessidade de substitui����o valvular.

Cirurgia de Ressec����o dos Tumores do P��ncreas Localmente Invasivos. Apresenta����o de uma Nova T��cnica de Revasculariza����o

A cirurgia dos tumores do p��ncreas continua a ser marcada pela pobreza dos resultados obtidos. No caso dos tumores localmente invasivos, os doentes s��o habitualmente sujeitos a uma mera cirurgia de deriva����o, com escassa sobreviv��ncia e m�� qualidade de vida. Os autores operaram sete doentes com tumores do p��ncreas localmente invasivos, sujeitos a cirurgia de ressec����o radical, com bons resultados. �� apresentada uma t��cnica original de reconstru����o da circula����o arterial hep��tica.

Ressec����es Multiorg��nicas na Cirurgia dos Tumores do Colon e Recto

Os tumores do c��lon e recto com invas��o locoregional ou metastizados constituem situa����es cl��nicas graves, com escassa esperan��a de sobreviv��ncia. A cirurgia oncol��gica radical alargada constitui a ��nica solu����o potencialmente curativa ou que pode proporcionar sobrevidas mais longas. Foram operados 32 doentes portadores de tumores colo-rectais metastizados ou com invas��o locoregional, quer primitivos quer recidivados, tendo sido obtidas sobrevidas at�� aos sete anos, com boa qualidade de vida.

���Uma Boa Morte��� ��� Cirurgia Paliativa na Trissomia 18

A trissomia 18 caracteriza-se por m��ltiplas anomalias, incluindo doen��a card��aca em 60 a 90% dos casos e elevada mortalidade. O mau progn��stico global, conduz habitualmente a uma politica de ���cuidados m��nimos��� mas, paliar, �� tamb��m nestas situa����es, um imperativo ��tico. Descreve-se o caso de uma rec��m-nascida sem diagn��stico pr�� natal, mas com confirma����o por cariotipo, com cardiopatia, que condicionou insufici��ncia card��aca congestiva e ang��stia respirat��ria crescente, inviabilizando alta hospitalar, como era desejo da fam��lia. Ap��s consenso entre os pais e o corpo cl��nico respons��vel, foi decidida interven����o cir��rgica card��aca paliativa, que possibilitou melhoria cl��nica e alta para o domic��lio. Os autores defendem que a cirurgia card��aca pode ser uma atitude a considerar em casos de trissomia 18, pois pode aliviar o sofrimento.

Aspectos Psicossociais Associados �� Percep����o da Dor P��s-Operat��ria em Indiv��duos Submetidos a Cirurgia Coron��ria

Objectivo: Identificar os factores psicossociais que influenciam a percep����o da dor p��s-operat��ria em doentes submetidos a cirurgia de revasculariza����o do mioc��rdio (CRM). Material e M��todos: Estudo explorat��rio correlacional de 91 doentes (71 homens e 20 mulheres) submetidos a CRM (pontagem aortocoron��ria) por esternotomia. A idade m��dia era de 63,8 �� 9,6 anos (entre 39 e 84). Foram utilizados os seguintes instrumentos: Escala Anal��gica Visual ��s 24, 48 e 96 horas do p��s-operat��rio; Question��rio de Caracteriza����o Demogr��fica; Mental Health Inventory de 5 itens; Percep����o de Sa��de Geral (SF-36); Escala de Expectativas de Dor; Escala de Percep����o de Apoio; Escala de Expectativas de Auto-efic��cia; Satisfa����o com o tratamento, m��dicos e enfermeiros (American Pain Society Questionnaire) aplicados ��s 96 horas ap��s a cirurgia. Resultados: Os doentes que apresentaram expectativas elevadas de dor, percepcionaram maior apoio, apresentaram n��veis elevados de auto-efic��cia para lidar com a dor ou, se pertenciam ao sexo masculino, sentiram menos dor. De igual modo, os doentes que apresentaram melhor sa��de mental, percepcionaram a sua sa��de como boa e os doentes que expressaram maior satisfa����o com o tratamento sentiram menos dor. A dor n��o foi influenciada pela idade, grau de escolaridade ou pela satisfa����o com a conduta de m��dicos e enfermeiros. Conclus��o: Ap��s as primeiras 48 horas do p��s-operat��rio, a experi��ncia de dor �� influenciada por factores psicossociais, em particular pela expectativa de dor, expectativa de auto-efic��cia, apoio percebido, percep����o da sa��de geral, percep����o de sa��de mental e satisfa����o com o tratamento para a dor. Perante os resultados, evidencia-se a necessidade de conjugar conhecimentos no sentido de dar respostas mais alargadas e de car��cter multidisciplinar no tratamento da dor p��s-operat��ria em CRM devendo, a par de outros aspectos, focar-se na gest��o das expectativas dos doentes.