Mediastinal reinforcement after induction therapy and pneumonectomy: comparison of intercostal muscle versus diaphragm flaps.

OBJECTIVE: Prospective non-randomised comparison of full-thickness pedicled diaphragm flap with intercostal muscle flap in terms of morbidity and efficiency for bronchial stump coverage after induction therapy followed by pneumonectomy for non-small cell lung cancer (NSCLC). METHODS: Between 1996 and 1998, a consecutive series of 26 patients underwent pneumonectomy following induction therapy. Half of the patients underwent mediastinal reinforcement by use of a pedicled intercostal muscle flap (IF) and half of the patients by use of a pedicled full-thickness diaphragm muscle flap (DF). Patients in both groups were matched according to age, gender, side of pneumonectomy and stage of NSCLC. Postoperative morbidity and mortality were recorded. Six months follow-up including physical examination and pulmonary function testing was performed to examine the incidence of bronchial stump fistulae, gastro-esophageal disorders or chest wall complaints. RESULTS: There was no 30-day mortality in both groups. Complications were observed in one of 13 patients after IF and five of 13 after DF including pneumonia in two (one IF and one DF), visceral herniations in three (DF) and bronchopleural fistula in one patient (DF). There were no symptoms of gastro-esophageal reflux disease (GERD). Postoperative pulmonary function testing revealed no significant differences between the two groups. CONCLUSIONS: Pedicled intercostal and diaphragmatic muscle flaps are both valuable and effective tools for prophylactic mediastinal reinforcement following induction therapy and pneumonectomy. In our series of patients, IF seemed to be associated with a smaller operation-related morbidity than DF, although the difference was not significant. Pedicled full-thickness diaphragmatic flaps may be indicated after induction therapy and extended pneumonectomy with pericardial resection in order to cover the stump and close the pericardial defect since they do not adversely influence pulmonary function.

Hérnia intercostal transdiafragmática após fratura espontânea de costelas secundária à crise de tosse

One case of transdiafragmatic intercostal hernia after intense coughing fit followed by rib fractures in patient with history of pneumonia is presented. He had a severe coughing fit, developed a right toracoabdominal hematoma and then a tumor that was gradually enlarging. Image exams confirmed the diagnosis. Treatment consisted of surgical repair with the use of a polypropylene prosthetic mesh. It is a rare type of hernia. Only four cases were found in literature. The sooner the disease is diagnosed and treated the better the prognoses will be since it will prevent hernia from strangulation and incarceration.

Intercostal and forearm muscle deoxygenation during respiratory fatigue in patients with heart failure: potential role of a respiratory muscle metaboreflex

The purpose of this study was to determine the effect of respiratory muscle fatigue on intercostal and forearm muscle perfusion and oxygenation in patients with heart failure. Five clinically stable heart failure patients with respiratory muscle weakness (age, 66±12 years; left ventricle ejection fraction, 34±3%) and nine matched healthy controls underwent a respiratory muscle fatigue protocol, breathing against a fixed resistance at 60% of their maximal inspiratory pressure for as long as they could sustain the predetermined inspiratory pressure. Intercostal and forearm muscle blood volume and oxygenation were continuously monitored by near-infrared spectroscopy with transducers placed on the seventh left intercostal space and the left forearm. Data were compared by two-way ANOVA and Bonferroni correction. Respiratory fatigue occurred at 5.1±1.3 min in heart failure patients and at 9.3±1.4 min in controls (P<0.05), but perceived effort, changes in heart rate, and in systolic blood pressure were similar between groups (P>0.05). Respiratory fatigue in heart failure reduced intercostal and forearm muscle blood volume (P<0.05) along with decreased tissue oxygenation both in intercostal (heart failure, -2.6±1.6%; controls, +1.6±0.5%; P<0.05) and in forearm muscles (heart failure, -4.5±0.5%; controls, +0.5±0.8%; P<0.05). These results suggest that respiratory fatigue in patients with heart failure causes an oxygen demand/delivery mismatch in respiratory muscles, probably leading to a reflex reduction in peripheral limb muscle perfusion, featuring a respiratory metaboreflex.

Retrospective study of thoracolumbar ventral fenestration through intercostal thoracotomy and paracostal laparotomy in the dog

Foram analisados os resultados da fenestração ventral dos discos toracolombares em 29 cães agrupados segundo a raça, sexo, peso, idade, graus de déficits neurológicos, duração dos sinais, discos intervertebrais envolvidos, tempo para recuperação e porcentagem de sucesso. A raça Dachshund representou 55,18% (n = 16), cães sem raça definida, 13,8% (n = 4), Poodle e Basset Hound e Cocker Spaniel Inglês 6,89% cada (n = 6), e Pastor Alemão, Beagle e Pinscher, 3,45% cada (n = 3), sendo 51,72%, machos e 48,28%, fêmeas, com idade média de 68,03 meses. O grau de déficits neurológicos correspondeu a: 13,8% dos cães pertencentes ao GI (dor), 41,8% ao GII (paresia), 27,6% ao GIII (paraplegia com dor profunda presente) e 17,2% ao GIV (paraplegia com dor profunda ausente). Os sinais clínicos variaram em duração entre 2 e 60 dias, correspondendo às médias de 18,5 (GI), 12,3 (GII), 8,28 (GIII) e 4,2 dias (GIV). A porcentagem de discos intervertebrais acometidos foi: T10/11 (10,81%), T11/12 (24,33%), T12/13 (40,55%), T13/L1 (16,21%) e L1/2, L2/3 e L3/4, 2,7% cada. O tempo médio de recuperação, em dias, foi: 16 (GI), 19,1 (GII), 20,6 (GIII) e 30,6 (GIV), onde 100% dos animais dos grupos I, II e III recuperaram ambas as funções neurológicas e motoras. O grupo IV apresentou 80% de sucesso. Conclui-se que a fenestração ventral produz excelentes resultados pós-operatórios desde que bem selecionados os casos.

Intercostal nerve mononeuropathy: study of 14 cases

Este trabalho apresenta estudo retrospectivo de 14 pacientes com mononeuropatia de nervo intercostal (MNI), obtidos dentre 5.560 exames eletromiográficos, realizados de janeiro de 1991 até junho de 2004, em nosso Hospital Universitário. MNI foi encontrada em 14 pacientes, tendo como causas prováveis intervenções cirúrgicas torácicas em 6 (43%), neuropatia por herpes-zoster em 4 (28%), provável neurite de nervo intercostal em 2 (14%), neoplasia pulmonar em 1 (7%) e radiculopatia em 1 (7%). As principais causas de MNI de nosso Serviço são similares às da literatura. Os antidepressivos tricíclicos e anticonvulsivantes foram os fármacos mais utilizados no controle da dor.

Cloreto de sódio a 0,9%, adicionado ou não de dexametasona, intrapleural, na prevenção de aderências pulmonares após toracotomia intercostal em cães

Pulmonary adhesions in dogs are a common sequel after surgical intervention, undermining any interventions. This study aimed to determine in dogs, the efficacy of sodium chloride solution 0.9% with or without dexamethasone in order to prevent adhesions after intercostal thoracotomy. Fifteen dogs were separated into three groups of five animals, A, B and C and underwent thoracotomy in the fifth left intercostal space. Three other dogs were submitted to a previous study. In the dogs of Group A it was performed only a thoracotomy and thoracorraphy; in group B, it was performed a thoracotomy, thoracorraphy and injection into the pleural cavity of isotonic sodium chloride (10ml) and dexamethasone (1mg kg-1). In the dogs of the group C, it was performed the thoracotomy thoracorraphy and injected isotonic sodium chloride (10ml kg-1) into the pleural cavity. After 15 days of thoracotomy, it was performed transdiaphragmatic thoracocospy to determine the presence and score of adhesions between the lung and chest wall. The results demonstrated the presence of adhesions in the majority of group A and reduced or no adhesions in the other groups. For statistical evaluation, it was pplied the chi-square test with significance level of 5% (P≤0.05). The sodium chloride solution 0.9% with or without dexamethasone in the pleural space prevented or reduced lung adhesions after intercostal thoracotomy.

Uso intrapleural de solução de cloreto de sódio 0,9%, adicionada ou não de dexametasona, na prevenção de aderências pulmonares após toracotomia intercostal em cães

Pós-graduação em Cirurgia Veterinária - FCAV

[Alternative sonographic determination of liver size by intercostal scans]

BACKGROUND: The evaluation of hepatic size is a daily question in abdominal ultrasound, especially to determine the presence of hepatomegaly. In the literature, different methods of measurement are described, mostly as a subcostal measured organ diameter in one direction. This method has its limits in patients with obesity, accumulation of abdominal gas or in uncooperative patients (lack of coordinative respiration) so that alternative measurements are necessary. METHODS: In 241 patients hepatic size was first measured in two conventional sections: midclavicular line (MCL) and anterior axillary line (AAL). Additionally, we measured the organs in midaxillary line craniocaudal (MAL) by determination of the cranio-caudal diameter. In 58 patients additional computed tomography was performed due to special diagnostical reasons so that liver size in MCL could be revealed and compared with ultrasonographical values. RESULTS: The mean value in MCL was 10.7 +/- 2.1 cm measured by ultrasound, 11.4 +/- 3.7 cm measured by computed tomography, 14.0 +/- 1.9 cm in AAL and 14.9 +/- 2.0 cm in MAL. In 5% of the cases the liver could not be measured in the conventional subcostal sections due to obesity or masking by gas, but this was possible in MAL. CONCLUSIONS: We revealed a good correlation of liver size in MCL between ultrasound and computed tomography, as well as in the measurement of AAL and MAL diameters. However, even in cases with difficult subcostal approach intercostal diameters allow for an accurate determination of hepatic size.

The role of intercostal nerve preservation in pain control after thoracotomy

OBJECTIVES Pain control after thoracotomy is an important issue that affects the outcome in thoracic surgery. Intercostal nerve preservation (ICNP) has increased interest in the outcomes of conventional thoracotomy. The current study critically evaluates the role of preservation of the intercostal nerve in early and late pain control and its benefit in patients undergoing thoracotomy. METHODS Data obtained prospectively between January 2006 and December 2010 by a study colleague at our division of General Thoracic Surgery were retrospectively analysed. There were 491 patients who underwent thoracotomy. Eighty-one patients were excluded from the study due to incompatible data. Patients were divided into two groups according to the intercostal nerve state: Group I consisted of patients with ICNP and Group II consisted of patients with intercostal nerve sacrifice. RESULTS Group I consisted of 288 patients [206 male (71%), P < 0.001, mean age 66 years]. Group II consisted of 122 patients [79 male (64%), P = 0.001, mean age 66 years]. There was less use of opiate in Group I (P = 0.019). Early mobilization of the patients was significantly higher in Group I (P = 0.031). The rate of pneumonia and re-admission to the intensive care unit was higher in Group II (P = 0.017 and 0.023, respectively). The rate of pain-free patients at discharge was significantly higher in Group I (P = 0.028). A 2-week follow-up after hospital discharge showed parasternal hypoesthesia to be more in Group II (P = 0.034). Significant patient contentment in Group I was noticed (P = 0.014). Chronic post-thoracotomy pain (CPTP) was higher in Group II (P = 0.016). CONCLUSIONS ICNP without harvesting an intercostal muscle flap achieves excellent outcomes in controlling acute post-thoracotomy pain and CPTP. ICNP is an effective, simple method to perform, and it should be considered as standard in performing thoracotomy.

Metodologia para analise da movimentação da caixa toracica durante a respiração

Universidade Estadual de Campinas . Faculdade de Educação Física

Outflow occlusion for circulatory arrest in dogs

The purpose of this study was to evaluate the possibility of producing circulatory arrest by occlusion of the pulmonary trunk as an alternative to the venous inflow occlusion through the left hemithorax. Eight healthy mongrel dogs were divided in two groups. Group I underwent 4 minutes of outflow occlusion and Group II was submitted to 8 minutes of circulatory arrest. Outflow occlusion was performed through left thoracotomy and pericardiotomy by passing a Rumel tourniquet around the pulmonary trunk. Physical examination, electrocardiography, echocardiography, blood gas analyses, hemodynamic, and oxygen transport variables were obtained before and after the procedure. The dogs from Group I did not have any clinical, electrocardiographic, echocardiographic, or hemo-dynamic abnormalities after anesthetic recover. In the Group II, only one dog survived, which had no clinical, electrocardiographic, or echocardiographic abnormalities. In this last dog, just after releasing the occlusion, it was detected increases in the following parameters: heart rate (HR), systolic, diastolic and mean arterial blood pressure (SAP; DAP; MAP), pulmonary artery pressure (PAP), pulmonary wedge pressure (PWP), central venous pressure (CVP), cardiac output (CO), systolic index (SI), cardiac index (CI), left and right ventricular stroke work (LVSW; RVSW), oxygen delivery index (DO2), oxygen consumption index (VO2), and oxygen extraction (O2 ext). Moreover, the oxygen content of arterial and mixed venous blood (CaO2; CvO2), and the arterial and mixed venous partial pressure of oxygen (PaO2; PvO2) were decreased 5 minutes after circulatory arrest. Outflow occlusion is a feasible surgical procedure for period of 4 minutes of circulatory arrest.

PHRENIC NERVE TRANSFER IN THE RESTORATION OF ELBOW FLEXION IN BRACHIAL PLEXUS AVULSION INJURIES: HOW EFFECTIVE AND SAFE IS IT?

OBJECTIVE: Phrenic nerve transfer has been used for treating lesions of the brachial plexus since 1970. Although, today, surgeons are more experienced with the technique, there are still widespread concerns about its effects on pulmonary function. This study was undertaken to evaluate the effectiveness and safety of this procedure. METHODS: Fourteen patients with complete palsy of the upper limb were submitted to phrenic nerve transfer as part of a strategy for surgical reconstruction of their plexuses. Two patients were lost to follow-up, and 2 patients were followed for less than 2 years. Of the remaining 10 patients, 9 (90%) were male. The lesions affected both sides equally. The mean age of the patients was 24.8 years (range, 14-43 years), and the mean interval from injury to surgery was 6 months (range, 3-9 months). The phrenic nerve was always transferred to the musculocutaneous nerve, and a nerve graft (mean length, 8 cm; range, 4.5-12 cm) was necessary in all cases. RESULTS: There was no major complication related to the surgery. Seven patients (70%) recovered functional level biceps strength (Medical Research Council grade >= 3). All of the patients exhibited a transient decrease in pulmonary function tests, but without clinical respiratory problems. CONCLUSION: On the basis of our small series and data from the literature, we conclude that phrenic nerve transfer in well-selected patients is a safe and effective procedure for recovering biceps function.

Cirurgia de revascularização do miocárdio através de minitoracotomia esquerda

OBJETIVO: Atualmente existe uma tendência mundial para a realização de cirurgias através de incisões mínimas, denominadas minimamente invasivas, tornando o ato operatório cada vez menos agressivo. A introdução desta nova técnica possibilita a dissecção da artéria torácica interna esquerda (ATIE) e sua anastomose com a artéria interventricular anterior (AIA), através de uma minitoracotomia esquerda. MÉTODOS: De maio/96 a outubro/97, 11 portadores de insuficiência coronária, com lesão única e proximal da AIA, foram submetidos a revascularização do miocárdio (RM). A abordagem cirúrgica consistiu de uma toracotomia ântero-lateral esquerda, de aproximadamente 10cm, através do 4º espaço intercostal esquerdo, e nos últimos 6 casos com ressecção de parte da cartilagem da 4ª e 5ª costelas, dissecção da ATIE, abertura e reparo do pericárdio adjacente à AIA. Todos pacientes receberam ponte única para AIA com enxerto da ATIE, sem auxílio de circulação extracorpórea (CEC). RESULTADOS: A idade variou de 46 a 76 (média = 58,55) anos, sendo 10 (90,90%) pacientes do sexo masculino e 1 (9,09%) feminino. O tempo de permanência hospitalar variou de 4 a 8 (média de 5,2) dias. Nenhum paciente apresentou alteração eletrocardiográfica no pós-operatório imediato. Um paciente apresentou no controle, trombose no 1/3 distal da ATIE com comprometimento importante de fluxo e, outro, estenose ao nível da anastomose, sendo ambos submetidos a angioplastia com sucesso. Não houve mortalidade no grupo estudado. CONCLUSÃO: A ausência de mortalidade, sugere que a cirurgia de RM através de cirurgia minimamente invasiva, em grupos selecionados, é uma excelente alternativa de revascularização da AIA.

Mini-sternotomy for the treatment of aortic valve lesions

OBJECTIVE: To compare inverted-L mini-sternotomy performed above the sternal furcula with conventional sternotomy in patients with aortic valve diseases who undergo surgical treatment. METHODS: We operated upon 30 patients who had aortic valve lesions that had clinical and hemodynamic findings. All patients underwent inverted-L sternotomy, which extended from above the manubrium of the sternum to the 3rd right intercostal space, without opening the pleural cavity. Their ages ranged from 32 to 76 years, and 18 were males and 12 were females. We used negative pressure in a venous ¼-inch cannula, and the patients were maintained in Trendelemburg's position. Twenty-seven patients received bioprostheses with diameters ranging from 23 to 29mm. Three patients underwent only removal of the calcifications of the aortic valve leaflets and aortic commissurotomy. RESULTS: The mean duration of anoxic cardiac arrest was 63.11min. Access was considered good in all patients. One death was due to pulmonary and renal problems not related to the incision. All patients had a better recovery in the intensive care unit, got out of bed sooner, coughed more easily, and performed prophylactic physiotherapeutic maneuvers for respiratory problems more easily and with less pain in the incision. Early ambulation was more easily carried out by all patients. CONCLUSION: Mini-sternotomy proved to be better than the conventional sternotomy because it provided morecomfort for the patients in the early postoperative period, with less pain and greater desire for early ambulation and all its inherent advantages.