Plastic surgery in chest wall reconstruction: relevant aspects - case series / A cirurgia plástica na reconstrução da parede torácica: aspectos relevantes - série de casos

Objective: to discuss the participation of Plastic Surgery in the reconstruction of the chest wall, highlighting relevant aspects of interdisciplinaryness. Methods: we analyzed charts from 20 patients who underwent extensive resection of the thoracic integument, between 2000 and 2014, recording the indication of resection, the extent and depth of the raw areas, types of reconstructions performed and complications. Results: among the 20 patients, averaging 55 years old, five were males and 15 females. They resections were: one squamous cell carcinoma, two basal cell carcinomas, five chondrosarcomas and 12 breast tumors. The extent of the bloody areas ranged from 4x9 cm to 25x40 cm. In 12 patients the resection included the muscular plane. In the remaining eight, the tumor removal achieved a total wall thickness. For reconstruction we used: one muscular flap associated with skin grafting, nine flaps and ten regional fasciocutaneous flaps. Two patients undergoing reconstruction with fasciocutaneous flaps had partially suffering of the flap, solved with employment of a myocutaneous flap. The other patients displayed no complications with the techniques used, requiring only one surgery. Conclusion: the proper assessment of local tissues and flaps available for reconstruction, in addition to the successful integration of Plastic Surgery with the specialties involved in the treatment, enable extensive resections of the chest wall and reconstructions that provide patient recovery.

Objetivo: discorrer sobre a participação da Cirurgia Plástica na reconstrução da parede torácica, ressaltando os aspectos relevantes das associações interdisciplinares. Métodos: foram analisados prontuários de 20 pacientes submetidos a extensas ressecções do tegumento torácico, no período entre 2000 e 2014, quanto à indicação das ressecções, à extensão e à profundidade das áreas cruentas, aos tipos de reconstruções realizadas e às complicações. Resultados: entre os 20 pacientes, com média de 55 anos de idade, cinco eram do sexo masculino e 15 do feminino. Foram ressecados: um carcinoma espinocelular, dois carcinomas basocelulares, cinco condrossarcomas e 12 tumores de mama. A extensão das áreas cruentas variou de 4x9 cm até 25x40 cm. Em 12 pacientes as ressecções abrangeram o plano muscular. Nos oito restantes, a retirada do tumor atingiu a espessura total da parede. Para reconstrução foram utilizados: um retalho muscular associado à enxertia de pele, nove retalhos miocutâneos e dez retalhos fasciocutâneos da região. Em dois pacientes submetidos à reconstrução com retalhos fasciocutâneos houve sofrimento parcial do retalho, resolvido com o emprego de retalho miocutâneo. Nos outros pacientes não houve intercorrências com as técnicas empregadas, sendo necessária somente uma cirurgia. Conclusão: a adequada avaliação dos tecidos locais e dos retalhos disponíveis para a reconstrução, além da boa integração da Cirurgia Plástica com as especialidades envolvidas no tratamento, possibilitam extensas ressecções da parede torácica e reconstruções que propiciam a recuperação do paciente.

Plastic surgery in chest wall reconstruction: relevant aspects - case series.

OBJECTIVE: to discuss the participation of Plastic Surgery in the reconstruction of the chest wall, highlighting relevant aspects of interdisciplinaryness. METHODS: we analyzed charts from 20 patients who underwent extensive resection of the thoracic integument, between 2000 and 2014, recording the indication of resection, the extent and depth of the raw areas, types of reconstructions performed and complications. RESULTS: among the 20 patients, averaging 55 years old, five were males and 15 females. They resections were: one squamous cell carcinoma, two basal cell carcinomas, five chondrosarcomas and 12 breast tumors. The extent of the bloody areas ranged from 4x9 cm to 25x40 cm. In 12 patients the resection included the muscular plane. In the remaining eight, the tumor removal achieved a total wall thickness. For reconstruction we used: one muscular flap associated with skin grafting, nine flaps and ten regional fasciocutaneous flaps. Two patients undergoing reconstruction with fasciocutaneous flaps had partially suffering of the flap, solved with employment of a myocutaneous flap. The other patients displayed no complications with the techniques used, requiring only one surgery. CONCLUSION: the proper assessment of local tissues and flaps available for reconstruction, in addition to the successful integration of Plastic Surgery with the specialties involved in the treatment, enable extensive resections of the chest wall and reconstructions that provide patient recovery.

[Traumatic lung hernia]. / Hérnia traumática do pulmão.

Traumatic lung herniation is an unusual clinical problem. We present a case of a large left post-traumatic lung hernia on the left, anterior, second intercostal space following blunt chest trauma. An important factor in the etiology of these lesions is the relative lack of muscular support of the anterior part of the chest. This report describes the diagnosis and management of a post-traumatic lung hernia.

Hérnia traumática do pulmão / Traumatic lung hernia

Traumatic lung herniation is an unusual clinical problem. We present a case of a large left post-traumatic lung hernia on the left, anterior, second intercostal space following blunt chest trauma. An important factor in the etiology of these lesions is the relative lack of muscular support of the anterior part of the chest. This report describes the diagnosis and management of a post-traumatic lung hernia.

[Clinicopathological aspects of and survival in patients with clinical stage I bronchioloalveolar carcinoma]. / Aspectos clínico-patológicos do carcinoma bronquioloalveolar e sobrevida em pacientes no estágio clínico I.

OBJECTIVE: To analyze the clinicopathological aspects of bronchioloalveolar carcinoma (BAC) and the survival in a sample of patients at clinical stage I. METHODS: A retrospective study involving 26 patients diagnosed with clinical stage I BAC and undergoing surgery at the Thoracic Diseases Institute of the Federal University of Rio de Janeiro, in the city of Rio de Janeiro, Brazil, between 1987 and 2007. We analyzed clinicopathological and radiological aspects, as well as mortality and survival. The data, which were collected from the medical charts of the patients, were statistically analyzed. RESULTS: Females predominated (n = 16). The mean age at diagnosis was 68.5 years. Most patients were active smokers (69.2%). The most common forms of presentation of BAC were the asymptomatic form (84.6%) and the nodular form (88.5%). Involvement of the upper lobes predominated (57.7%). Stage IB was the most common pathological stage, followed by stages IA and IIB (46.2%, 38.4% and 15.4%, respectively). There was no in-hospital mortality. Four patients died during the postoperative follow-up, with a mean disease-free survival time of 21.3 months. The overall five-year survival rate was 83%. The probability of survival for the patients diagnosed after 1999 showed a trend toward an increase when compared with that for those diagnosed up through 1999 (three-year survival rate: 92% vs. 68%; p = 0.07). CONCLUSIONS: The clinicopathological aspects of this study sample were similar to those of patients with BAC evaluated in previous studies.

Aspectos clínico-patológicos do carcinoma bronquioloalveolar e sobrevida em pacientes no estágio clínico I / Clinicopathological aspects of and survival in patients with clinical stage I bronchioloalveolar carcinoma

OBJETIVO: Analisar os aspectos clínico-patológicos do carcinoma bronquioloalveolar (CBA) e a sobrevida em uma amostra de pacientes com estadiamento clínico I. MÉTODOS: Foram estudados retrospectivamente 26 pacientes com diagnóstico de CBA e estágio clínico I, , segundo a classificação tumor-node-metastasis (TNM, tumor-linfonodo-metástase),(15)operados no Instituto de Doenças do Tórax da Universidade Federal do Rio de Janeiro, na cidade do Rio de Janeiro, RJ, entre 1987 e 2007, quanto a variáveis clínico-patológicas e radiológicas, mortalidade e sobrevida. Os dados foram colhidos dos prontuários médicos dos pacientes e analisados estatisticamente. RESULTADOS: Houve predomínio de mulheres (n = 16). A idade média ao diagnóstico foi de 68,5 anos. Houve predomínio de tabagistas (69,2 por cento). As formas de apresentação assintomática (84,6 por cento) e nodular (88,5 por cento) foram as mais comuns. Houve predileção pelos lobos superiores (57,7 por cento). O estágio patológico IB foi o mais comum, seguido pelos estágios IA e IIB (46,2 por cento, 38,4 por cento e 15,4 por cento, respectivamente). Não houve óbitos hospitalares. Quatro pacientes faleceram durante o seguimento pós-operatório, com tempo livre de doença médio de 21,3 meses. A taxa de sobrevida global em cinco anos foi 83 por cento. A probabilidade de sobrevida para os pacientes diagnosticados depois de 1999 tendeu a ser maior do que para aqueles diagnosticados até 1999 (taxa de sobrevida em três anos: 92 por cento vs. 68 por cento; p = 0,07). CONCLUSÕES: Os aspectos clínico-patológicos da amostra estudada foram semelhantes àqueles de estudos anteriores em pacientes com CBA.

OBJECTIVE: To analyze the clinicopathological aspects of bronchioloalveolar carcinoma (BAC) and the survival in a sample of patients at clinical stage I. METHODS: A retrospective study involving 26 patients diagnosed with clinical stage I BAC and undergoing surgery at the Thoracic Diseases Institute of the Federal University of Rio de Janeiro, in the city of Rio de Janeiro, Brazil, between 1987 and 2007. We analyzed clinicopathological and radiological aspects, as well as mortality and survival. The data, which were collected from the medical charts of the patients, were statistically analyzed. RESULTS: Females predominated (n = 16). The mean age at diagnosis was 68.5 years. Most patients were active smokers (69.2 percent). The most common forms of presentation of BAC were the asymptomatic form (84.6 percent) and the nodular form (88.5 percent). Involvement of the upper lobes predominated (57.7 percent). Stage IB was the most common pathological stage, followed by stages IA and IIB (46.2 percent, 38.4 percent and 15.4 percent, respectively). There was no in-hospital mortality. Four patients died during the postoperative follow-up, with a mean disease-free survival time of 21.3 months. The overall five-year survival rate was 83 percent. The probability of survival for the patients diagnosed after 1999 showed a trend toward an increase when compared with that for those diagnosed up through 1999 (three-year survival rate: 92 percent vs. 68 percent; p = 0.07). CONCLUSIONS: The clinicopathological aspects of this study sample were similar to those of patients with BAC evaluated in previous studies.

Surgical techniques: lung transplant and lung volume reduction.

Patients with end-stage emphysema can be offered lung volume reduction surgery (LVRS), lung transplantation, or unilateral lung transplantation combined with contralateral LVRS if necessary, depending on multiple factors including age, lung function parameters, lobar predominance, and whether the disease is uni- or bilateral. Lung transplant is a complex and well-established therapeutic modality for patients with end-stage lung disease. The ideal candidate for LVRS is a patient with severe upper-lobe predominant emphysema and markedly impaired exercise capacity. Other groups may benefit from the procedure, but results are likely to be less good. The objective of this chapter is to describe the surgical techniques of bilateral lung transplantation and lung volume reduction surgery as performed at the University of Toronto.

[Mitral valve obstruction by tumor embolus as a cause of irreversible cardiac arrest during right pneumonectomy]. / Obstrução de valva mitral por embolização tumoral per-operatória (pneumectomia direita) com parada cardíaca irreversível.

A 26-year-old patient with a voluminous primary pulmonary hemangiopericytoma in the right lung, diagnosed through previous surgical biopsy, presented irreversible cardiac arrest during the hilar dissection portion of a right pneumonectomy. The patient did not respond to resuscitation efforts. Autopsy showed total obstruction of the mitral valve by a tumor embolism. In cases of large lung masses with hilar involvement, as in the case presented, we recommend preoperative evaluation using transesophageal echocardiography, magnetic resonance imaging or angiotomography. If injury to the pulmonary vessels or atrial cavities is detected, surgery with extracorporeal circulation should be arranged in order to allow resection of the intravascular or cardiac mass, together with pulmonary resection. We recommend that care be taken in order to recognize and treat this problem in patients not receiving a preoperative diagnosis.

Obstrução de valva mitral por embolização tumoral per-operatória (pneumectomia direita) com parada cardíaca irreversível / Mitral valve obstruction by tumor embolus as a cause of irreversible cardiac arrest during right pneumonectomy

Um paciente de 26 anos, portador de volumoso hemangiopericitoma primário de pulmão direito, diagnosticado por biópsia cirúrgica prévia, apresentou parada cardíaca irreversível durante dissecção hilar de pneumectomia direita. O paciente não respondeu às manobras de ressuscitação. A necropsia mostrou obstrução total de valva mitral por êmbolo tumoral. Os autores recomendam, em casos de grandes massas pulmonares com envolvimento hilar, como no caso aqui apresentado, a avaliação pré-operatória com ecocardiografia transesofágica, ressonância magnética nuclear ou angiotomografia. Se for detectada lesão em vasos pulmonares ou cavidades atriais, deve-se programar a cirurgia com circulação extracorpórea, para permitir ressecção da massa intra-vascular ou cardíaca, combinada com a ressecção pulmonar. Os autores recomendam cuidados para reconhecer e tratar este problema, se o diagnóstico pré-operatório não for feito.

A 26-year-old patient with a voluminous primary pulmonary hemangiopericytoma in the right lung, diagnosed through previous surgical biopsy, presented irreversible cardiac arrest during the hilar dissection portion of a right pneumonectomy. The patient did not respond to resuscitation efforts. Autopsy showed total obstruction of the mitral valve by a tumor embolism. In cases of large lung masses with hilar involvement, as in the case presented, we recommend preoperative evaluation using transesophageal echocardiography, magnetic resonance imaging or angiotomography. If injury to the pulmonary vessels or atrial cavities is detected, surgery with extracorporeal circulation should be arranged in order to allow resection of the intravascular or cardiac mass, together with pulmonary resection. We recommend that care be taken in order to recognize and treat this problem in patients not receiving a preoperative diagnosis.

Forma acelerada da fibrose pulmonar idiopática no pulmão nativo após transplante pulmonar unilateral / Accelerated form of interstitial pulmonary fibrosis in the native lung after single lung transplantation

Relatamos o caso de um paciente de 56 anos submetido a transplante pulmonar unilateral esquerdo em decorrência de fibrose pulmonar idiopática (FPI). No pós-operatório imediato, sob intensa imunossupressão, houve progressão rápida da FPI no pulmão nativo direito, confirmada pela biópsia pulmonar videotoracoscópica, necessitando de ventilação mecânica durante 104 dias até a realização de outro transplante pulmonar à direita. Obteve alta hospitalar após o 26º dia do segundo pós-operatório.

We report the case of a 56-year-old patient who underwent left single lung transplantation for idiopathic pulmonary fibrosis (IPF). Despite the high level of immunosuppression after the surgery, there was rapid progression to IPF in the native (right) lung as demonstrated by thoracoscopic lung biopsy. After 104 days on mechanical ventilation (MV), the patient underwent right lung transplant and was discharged from the hospital on postoperative day 26.

Avaliação da influência do tempo e do diâmetro na obstrução da janela pleuropericárdica / Evaluation of the influence of time and diameter on the patency of TH pericardial window

OBJETIVO: Avaliar a influência do diâmetro e do tempo na obstrução da janela pleuro-pericárdica em cães com pericárdio normal. MÉTODO: Trinta e seis cães mestiços foram divididos em seis grupos: 1 a, 1 b,1 c, 2 a, 2 b, 2 c; n=6 por grupo. Nos grupos 1 a , 1 b, 1 c, à janela foi de 2cm de diâmetro e nos grupos 2 a, 2 b, 2 c, foi de 4cm. Os animais foram reoperados respectivamente após 2, 8 e 12 semanas. Na re-operação, avaliou-se o grau de obstrução através de uma escala de aderência pericárdio-epicárdica e a histopatologia das bordas do pericárdio. RESULTADOS: Numa análise global, observou-se 89 por cento de janelas abertas e 11 por cento de janelas totalmente obstruídas. No grupo com 2cm de diâmetro original, na reoperação, encontrou-se um diâmetro maior em 89 por cento dos cães, enquanto que nos cães com janela original de 4cm, isto ocorreu em 61 por cento. Quando comparou-se os resultados nos cães com janelas de diâmetro igual, mas re-operados em diferentes tempos de pós-operatório, não se observou diferença estatisticamente significante. O mesmo ocorreu quando comparou-se os cães com janelas de diâmetro diferente e re-operados em tempos iguais de pós-operatório. O grau de aderência pericárdio-epicárdica, de acordo com a escala de gradação, não foi diferente entre os vários grupos em função do tempo e diâmetro com exceção do grupo com janela de 4cm e re-operado com 8 semanas (Grupo 2b). As alterações histopatológicas não foram estatisticamente significantes entre os grupos. Em nenhum cão observou-se obstrução da janela pleuropericárdica pelo pulmão. CONCLUSÃO: o tempo e o diâmetro da janela pleuropericardica não influenciaram na obstrução da mesma.

BACKGROUND: to evaluate the influence of diameter and time on the patency of transthoracic pericardial window in normal pericardium. METHODS: Thirty-six mongrel dogs were divided into 6 groups: 1a, 1b and 1c; 2a, 2b and 2c; n=6 per group. In groups 1a, 1b and 1c the pericardial window diameter was 2cm and in groups 2a, 2b and 2c it was 4cm. Animals were sacrificed 2, 8 and 12 weeks , respectively and we evaluated the patency and histology of the pericardial margins. RESULTS: Eighty-nine per cent of the windows were open and 11 percent were completely obstructed by pericardial-epicardic adhesions. In the groups with a 2cm-pericardial window, we observed during sacrifice an increase of the original diameter in 89 percent of the animals. In dogs with a 4cm-pericardial window a greater diameter was observed in 61 percent of the animals. We did not observe statistical differences comparing animals with the same window diameter but sacrificed at different time points. Likewise, we did not observe differences among dogs with different window diameters but sacrificed at the same time points. The degree of pericardial-epicardic adhesions, according to a graduation score, was not different among the groups when analyzing the influence of time and diameter, except for the group 2b ( 4cm-window diameter and animals sacrificed at 8 weeks). Histopatology was not different among the different groups. We did not observe any lung blockade of the transthoracic pericardial windows. CONCLUSIONS: time and diameter did not influence the patency of the transthoracic pericardial window.

[Accelerated form of interstitial pulmonary fibrosis in the native lung after single lung transplantation]. / Forma acelerada da fibrose pulmonar idiopática no pulmão nativo após transplante pulmonar unilateral.

We report the case of a 56-year-old patient who underwent left single lung transplantation for idiopathic pulmonary fibrosis (IPF). Despite the high level of immunosuppression after the surgery, there was rapid progression to IPF in the native (right) lung as demonstrated by thoracoscopic lung biopsy. After 104 days on mechanical ventilation (MV), the patient underwent right lung transplant and was discharged from the hospital on postoperative day 26.

Pneumotorax e pneumopericárdio hipertensivo em cirurgia cardiotorácica / Pneumothorax and tension pneumopericardium following cardiothoracic surgery

São apresentados dois casos de pacientes com pneumotorax e pneumopericárdio hipertensivo, em pós-operatório de cirurgia cardiotorácica. Ambos tiveram abertura do pericárdio como um dos tempos cirúrgicos da operação inicial e apresentaram sintomas de tamponamento pericárdico como complicação. O tratamento foi uma drenagem pleural nos dois casos, que evoluíram para resolução do processo.

Pneumothorax and tension pneumopericardium following cardiothoracic surgery.

Herein, we report two cases of pneumothorax and tension pneumopericardium after cardiothoracic surgery. Both patients underwent pericardiotomy during the primary operation and developed pericardial tamponade as a complication. The treatment was tube thoracostomy, and both patients recovered completely.

Tratamento cirúrgico de cisto broncogênico paratraqueal por mediastinoscopia cervical / Surgical treatment of a paratracheal bronchogenic cyst using cervical mediastinoscopy

Os cistos broncogênicos do mediastino são lesões benignas congênitas, usualmente descobertas na idade adulta. O tratamento cirúrgico clássico, quando indicado, é a ressecção da lesão por toracotomia ou por videotoracoscopia. Descrevemos aqui um caso em que foi realizada a ressecção completa de um cisto broncogênico paratraqueal por mediastinoscopia cervical, com uma breve revisão e discussão da literatura.