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Bronchoscopy using a flexible bronchoscope is considered a safe procedure and has been used for diagnosing and treating airway and parenchymal lung diseases. Bronchoscopic interventions in selected patients with emphysema, airway stenosis, and air leaks provide new treatment options. The application of multidetector computed tomography (MDCT) planning prior to bronchoscopy is comprehensively addressed. Using MDCT scan for pre-procedural planning, ensures precise navigation and device placement during bronchoscopy, ultimately improving patient outcomes. Radiological features can be correlated with bronchoscopy findings, linking MDCT images with direct bronchoscopy observations. This educational statement provides a comprehensive overview of the integration of computed tomography and bronchoscopy in managing different pulmonary conditions treated with endobronchial valve and airway stent placement, focusing on key aspects to enhance understanding and application in clinical practice. Emphasis is placed on their role in treating airway stenosis (AS), air leaks, and chronic obstructive pulmonary disease (COPD), highlighting the conditions under which these procedures are most beneficial. It explores how MDCT imaging contributes to the diagnosis and treatment planning of these conditions and the correct interpretation of MDCT image findings during follow-up after the procedure.
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Implementing a structured COVID-19 lung ultrasound system, using COVID-RADS standardization. This case series exams revealed correlations between ultrasonographic and tomographic findings. Ventilatory assessments showed that higher categories required second-line oxygen. This replicable tool will aid in screening and predicting disease severity beyond the pandemic. OBJECTIVE: We aimed to share our experience in implementing a structured system for COVID-19 lung findings, elucidating key aspects of the lung ultrasound score to facilitate its standardized clinical use beyond the pandemic scenario. METHODS: Using a scoring system to classify the extent of lung involvement, we retrospectively analyzed the ultrasound reports performed in our institution according to COVID-RADS standardization. RESULTS: The study included 69 thoracic ultrasound exams, with 27 following the protocol. The majority of patients were female (52%), with ages ranging from 1 to 96 years and an average of 56 years. Classification according to COVID-RADS was as follows: 11.1% in category 0, 37% in category 1, 44.4% in category 2, and 7.4% in category 3. Ground-glass opacities on tomography correlated with higher COVID-RADS scores (categories 2 and 3) in 82% of cases. Ventilatory assessment revealed that 50% of cases in higher COVID-RADS categories (2 and 3) required second-line oxygen supplementation, while none of the cases in lower categories (0 and 1) utilized this support. CONCLUSION: Lung ultrasound has been widely utilized as a diagnostic tool owing to its availability and simplicity of application. In the context of the pandemic emergency, a pressing need for a focused and easily applicable assessment arose. The structured reporting system, incorporating ultrasound findings for stratification, demonstrated ease of replicability. This system stands as a crucial tool for screening, predicting severity, and aiding in medical decisions, even in a non-pandemic context. Lung ultrasound enables precise diagnosis and ongoing monitoring of the disease. Ultrasound is an effective tool for assessing pulmonary findings in COVID-19. Structured reports enhance communication and are easily reproducible.
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COVID-19 , Pulmão , Ultrassonografia , Humanos , COVID-19/diagnóstico por imagem , Feminino , Ultrassonografia/métodos , Masculino , Estudos Retrospectivos , Pessoa de Meia-Idade , Idoso , Criança , Adolescente , Adulto , Pulmão/diagnóstico por imagem , Idoso de 80 Anos ou mais , Adulto Jovem , Lactente , Pré-Escolar , Pandemias , SARS-CoV-2 , Tomografia Computadorizada por Raios X/métodos , Índice de Gravidade de DoençaRESUMO
ABSTRACT Objective We aimed to share our experience in implementing a structured system for COVID-19 lung findings, elucidating key aspects of the lung ultrasound score to facilitate its standardized clinical use beyond the pandemic scenario. Methods Using a scoring system to classify the extent of lung involvement, we retrospectively analyzed the ultrasound reports performed in our institution according to COVID-RADS standardization. Results The study included 69 thoracic ultrasound exams, with 27 following the protocol. The majority of patients were female (52%), with ages ranging from 1 to 96 years and an average of 56 years. Classification according to COVID-RADS was as follows: 11.1% in category 0, 37% in category 1, 44.4% in category 2, and 7.4% in category 3. Ground-glass opacities on tomography correlated with higher COVID-RADS scores (categories 2 and 3) in 82% of cases. Ventilatory assessment revealed that 50% of cases in higher COVID-RADS categories (2 and 3) required second-line oxygen supplementation, while none of the cases in lower categories (0 and 1) utilized this support. Conclusion Lung ultrasound has been widely utilized as a diagnostic tool owing to its availability and simplicity of application. In the context of the pandemic emergency, a pressing need for a focused and easily applicable assessment arose. The structured reporting system, incorporating ultrasound findings for stratification, demonstrated ease of replicability. This system stands as a crucial tool for screening, predicting severity, and aiding in medical decisions, even in a non-pandemic context.
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Pulmonary aspiration of gastric residues during anesthesia is a potentially fatal complication for which no specific treatment is available. The primary way to prevent its occurrence in the context of elective surgeries is adherence to fasting protocols. However, some clinical conditions can prolong the gastric emptying time, and the risk of aspiration may exist despite adequate fasting. Recognizing the risk factors for gastroparesis allows the adoption of preventive methods and is the primary way to reduce morbidity and mortality from pulmonary aspiration. In this scenario, the anesthesiologist can investigate the gastric content by using ultrasound, adjust the anesthetic technique, and even postpone elective surgeries. Here, we describe incidental computed tomography finding of solid contents in the stomach of a patient without prior identification of the risk factors for gastroparesis. The patient underwent elective renal nodule ablation under general anesthesia after fasting for 9 hours. During the procedure, solid contents in the stomach were noted on computed tomography. Subsequently, it was discovered that the patient had been using semaglutide for 6 days and had not disclosed this information. Semaglutide use may represent a new and significant risk factor for anesthesia-related pulmonary aspiration. Until studies provide information on the appropriate perioperative management of patients using semaglutide, anesthesiologists need to adopt preventive measures to avoid aspiration. Awareness of this potential association and open communication among patients, physicians, and anesthesia teams are essential for enhancing patient safety.
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Gastroparesia , Humanos , Anestesia Geral/efeitos adversos , Jejum , Aspiração Respiratória , Tomografia Computadorizada por Raios XRESUMO
OBJECTIVE: To describe the clinical, bronchoscopic, diagnostic, and therapeutic aspects between children and adults. METHODS: This retrospective study compared the clinical and bronchoscopic characteristics of adults and children who underwent bronchoscopy for suspected foreign body aspiration. Data on sex, outpatient or emergency origin, bronchoscopy results, characteristics of the aspirated foreign body, and complications were analyzed. RESULTS: In total, 108 patients were included in the analysis, with foreign body aspiration diagnosed in 69% of patients (30 children and 44 adults). In 91% of patients, there was a clinical history suggestive of aspiration. The mean age of the adults was 65.89 (±19.75) years, and that of the children was 2.28 (±1.78) years. Most of the children were under 3 years of age (80%), while adults were mostly 70 years of age or older (54.5%). Emergency care was more common among children than adults. The most common foreign bodies found in both age groups were organic bodies, primarily seeds. The most frequent locations of foreign bodies were the lobar bronchi in adults and the main bronchi in children. Flexible bronchoscopy is the primary method for diagnosis and treatment. Transient hypoxemia occurred particularly frequently in children (5%). CONCLUSION: Foreign body aspiration, particularly that involving seeds, is more common in the extremes of age. A clinical history suggestive of aspiration is crucial in determining the need for bronchoscopy, which should be performed as early as possible. Flexible bronchoscopy is an effective and safe diagnostic technique.
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Broncoscopia , Corpos Estranhos , Criança , Adulto , Humanos , Lactente , Pessoa de Meia-Idade , Idoso , Idoso de 80 Anos ou mais , Broncoscopia/métodos , Estudos Retrospectivos , Brônquios/diagnóstico por imagem , Aspiração Respiratória/etiologia , Corpos Estranhos/diagnóstico por imagem , Corpos Estranhos/cirurgiaRESUMO
OBJECTIVE: To describe the radiological characteristics of hepatocellular carcinoma (HCC) lesions that achieved a complete response following drug-eluting bead transarterial chemoembolization (DEB-TACE) preceding liver transplantation. METHODS: This single-center case-control study enrolled patients with hepatocellular carcinoma who underwent neoadjuvant DEB-TACE therapy, were followed up with contrast-enhanced magnetic resonance imaging or computed tomography, and were successively evaluated according to the modified Response Evaluation Criteria in Solid Tumors. The HCCs were divided into two groups based on their diameter (Group A: ≤3cm; Group B: 3cm). Viability was assessed using the Kaplan-Meier method according to tumor size categories. The relationship between tumor variables was analyzed using bivariate Cox regression. RESULTS: Three-hundred and twenty-eight patients with 667 hepatocellular carcinomas who underwent their first DEB-TACE session were enrolled. A total of 105 hepatocellular carcinomas in 59 patients exhibited complete response after the initial DEB-TACE session and were divided into Group A (92 HCCs) and Group B (13 HCCs). The diameter in Group A decreased significantly compared to the pre-procedure size until the second assessment (p<0.001), with no subsequent reduction in diameter, despite maintaining a complete response. In Group B, the reduction in diameter remained significant compared with the initial value until the sixth imaging evaluation (p=0.014). The average reduction was 45.1% for Group B and a maximum of 14.9% in Group A. CONCLUSION: HCCs >3cm exhibited a greater reduction in size and a longer time to recurrence. HCCs ≤3cm had a shorter relapse time. The recurrence rates were similar. These findings may aid in planning for liver transplantation.
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Carcinoma Hepatocelular , Quimioembolização Terapêutica , Neoplasias Hepáticas , Transplante de Fígado , Humanos , Carcinoma Hepatocelular/diagnóstico por imagem , Carcinoma Hepatocelular/terapia , Neoplasias Hepáticas/diagnóstico por imagem , Neoplasias Hepáticas/terapia , Estudos de Casos e Controles , Quimioembolização Terapêutica/métodos , Resultado do Tratamento , Recidiva Local de Neoplasia/diagnóstico por imagem , Recidiva Local de Neoplasia/terapia , Estudos RetrospectivosRESUMO
Primary transitional cell carcinoma of the ureter is a rare type of cancer with metastasis presented in approximately 25% at diagnosis. Due to its rarity and poor prognosis, the management of this neoplasm is still controversial, and the development of new therapies is of uttermost importance. Herein, we describe a case of a 54-year-old patient diagnosed with transitional cell carcinoma of the left ureter submitted to left nephroureterectomy (pT3N2M0) and methotrexate, vinblastine, doxorubicin, and cisplatin adjuvant chemotherapy. A single liver metastasis was detected and combination chemotherapy with gemcitabine and carboplatin was initiated along with stereotactic body radiation therapy. Despite these 2 previous chemotherapy regimens, the patient presented disease progression and transarterial selective internal radiation therapy (SIRT) with yttrium-90 was indicated. This locoregional treatment was performed with the administration of 1.2 GBq yttrium-90 resin microspheres (SIR-Spheres®, Sirtex Medical Limited, Sydney, NSW, Australia) into the right hepatic artery. Another systemic treatment was immunotherapy using nivolumab with excellent tolerability. After 10 years of follow-up, at the last clinical evaluation, the patient had no clinical symptoms and the last imaging follow-up using positron emission tomography-computed tomography scan showed complete response. This report introduces upper urinary tract urothelial carcinoma as a distinct type of malignancy in which SIRT can be safely implemented. As a transition method to nivolumab, it was successful. There might be a potential therapeutic synergism between these 2 treatment modalities.
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This study aims to describe a case series of patients who underwent thoracic duct embolization (TDE) to treat traumatic iatrogenic chylothorax (TIC). Three patients were included: Case #1, a 49-year-old woman with follicular lymphoma developed a TIC following video-assisted thoracoscopic surgery to resect a solid right paravertebral mass and was treated with TDE using microcoils and N-butyl cyanoacrylate (NBCA) glue. Case #2, a 68-year-old man with cardiac amyloidosis developed a TIC following heart transplantation and was treated with TDE using microcoils and ethylene vinyl alcohol copolymer. Case#3: A 6-year-old patient with congenital heart disease developed a TIC following a Fontan procedure and was treated with TDE using NBCA glue. All lesions were identified during lymphangiography and TDE was successfully performed in all cases. TDE is a safe and valuable technique that provides minimally invasive treatment for TCI.
Este estudo objetiva descrever uma série de casos de pacientes submetidos a embolização do ducto torácico (EDT) para tratamento de quilotórax iatrogênico (QI). Três pacientes foram incluídos. Caso 1: um homem de 49 anos com linfoma folicular apresentou QI após ressecção de uma massa paravertebral por toracoscopia vídeo-assistida e foi submetido a EDT com micromolas e n-butil-cianoacrilato (NBCA). Caso 2: um homem de 68 anos com amiloidose cardíaca apresentou QI após ser submetido a transplante cardíaco e foi submetido a EDT com micromolas e copolímero de etileno e álcool vinílico. Caso 3: um paciente de 6 anos com malformação cardíaca congênita apresentou QI após cirurgia de Fontan e foi submetido a EDT com NBCA. Todas as lesões foram identificadas durante a linfangiografia, e a EDT foi realizada com sucesso. A EDT é uma técnica segura e valiosa, que pode oferecer um tratamento minimamente invasivo em casos de QI.
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A 100-year-old male patient was admitted with a ruptured abdominal aortic aneurysm due to type IA endoleak. Given the proximity of the ruptured site to the superior mesenteric artery (SMA) and renal arteries, a ChEVAR was indicated. Catheterization of the target visceral vessels was a challenging procedural step because of an intensely tortuous thoracic aorta. This hostile aortic anatomy also inhibited exchange for a super stiff guide-wire and selective cannulation with the diagnostic catheter was repeatedly lost when guidewire exchange was attempted. To overcome this issue, a 5 x 40 mm balloon catheter was placed 3cm into the target arteries. The balloon was then inflated below the nominal pressure limit enabling safe exchange for a super stiff guidewire and placement of three 90-cm long 7Fr guiding sheaths. The procedure was thus safely performed with deployment of an aortic extension and the bridging stents.
Um paciente de 100 anos foi diagnosticado com um aneurisma de aorta abdominal roto por um endoleak 1A. Pela proximidade do ponto de ruptura com a artéria mesentérica superior (AMS) e as artérias renais, um ChEVAR foi indicado. A cateterização das artérias-alvo foi um passo desafiador pela intensa tortuosidade da aorta torácica. Essa anatomia aórtica hostil também impediu a troca por um fio-guia extra-rígido, e a cateterização seletiva foi repetidamente perdida quando a troca de fio-guia foi tentada. Para superar essa dificuldade, um cateter balão 5mm x 40mm foi posicionado nas artérias-alvo. O balão foi, então, insuflado abaixo da pressão nominal, permitindo uma troca segura do fio-guia por um fio-guia extra-rígido e o posicionamento de três bainhas longas 7Frx 90cm. Assim, o procedimento foi executado de forma segura, com o implante de uma extensão aórtica e dos stents recobertos.
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Neoplasias Pulmonares , Procedimentos Cirúrgicos Robóticos , Robótica , Nódulo Pulmonar Solitário , Humanos , Pulmão , Neoplasias Pulmonares/diagnóstico por imagem , Neoplasias Pulmonares/cirurgia , Toracoscopia , Cirurgia Torácica Vídeoassistida , Nódulo Pulmonar Solitário/diagnóstico por imagem , Nódulo Pulmonar Solitário/cirurgiaAssuntos
Adenocarcinoma , Laparoscopia , Neoplasias Retais , Procedimentos Cirúrgicos Robóticos , Humanos , Verde de Indocianina , Terapia Neoadjuvante , Excisão de Linfonodo , Linfonodos/patologia , Tomografia Computadorizada por Raios X , Adenocarcinoma/diagnóstico por imagem , Adenocarcinoma/cirurgia , Neoplasias Retais/cirurgia , Neoplasias Retais/patologia , Pelve/cirurgia , Pelve/patologiaRESUMO
ABSTRACT Purpose To analyze the learning curve regarding complication rates of transrectal prostate biopsy (TRPB) versus transperineal prostate biopsy (TPPB), using real time software-based magnetic resonance imaging ultrasound (MRI-US) fusion techniques, along with first year experience of transperineal approach. Materials and Methods retrospective unicentric cohort study at a quaternary care hospital. Medical records of all consecutive patients that underwent TPPB between March 2021 and February 2022, after the introduction of MRI-US fusion device, and those who underwent TRPB throughout the entire years of 2019 and 2020 were analyzed. All complications that occurred as consequences of the procedure were considered. Descriptive statistics, Chi-squared and Fisher tests were used to describe complications and compare the two groups. Results A total of 283 patients were included in the transperineal group and 513 in the transrectal group. The analysis of a learning curve for the transperineal method showed lower complications rates comparing the first six months of TPPB procedures (group 1); The complication rate for TPPB was lower than that of TRPB (55.1% versus 81.9%, respectively; p<0.01). TPPB showed specifically lower rates of hematuria (48.8% versus 66.3%;p<0.001) and rectal bleeding(3.5% versus 18.1%; p<0.001). There were no cases of prostatitis after transperineal biopsies and three cases (0.6%) after transrectal procedures. Conclusions We evidenced the learning curve for performing the transperineal biopsy, with a lower rate of complications for the experienced team, after 142 cases after 6 months of practice. The lower complication rate of TPPB and the absence of infectious prostatitis imply a safer procedure when compared to TRPB.
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PURPOSE: To analyze the learning curve regarding complication rates of transrectal prostate biopsy (TRPB) versus transperineal prostate biopsy (TPPB), using real time software-based magnetic resonance imaging ultrasound (MRI-US) fusion techniques, along with first year experience of transperineal approach. MATERIALS AND METHODS: retrospective unicentric cohort study at a quaternary care hospital. Medical records of all consecutive patients that underwent TPPB between March 2021 and February 2022, after the introduction of MRI-US fusion device, and those who underwent TRPB throughout the entire years of 2019 and 2020 were analyzed. All complications that occurred as consequences of the procedure were considered. Descriptive statistics, Chi-squared and Fisher tests were used to describe complications and compare the two groups. RESULTS: A total of 283 patients were included in the transperineal group and 513 in the transrectal group. The analysis of a learning curve for the transperineal method showed lower complications rates comparing the first six months of TPPB procedures (group 1); The complication rate for TPPB was lower than that of TRPB (55.1% versus 81.9%, respectively; p<0.01). TPPB showed specifically lower rates of hematuria (48.8% versus 66.3%;p<0.001) and rectal bleeding(3.5% versus 18.1%; p<0.001). There were no cases of prostatitis after transperineal biopsies and three cases (0.6%) after transrectal procedures. CONCLUSIONS: We evidenced the learning curve for performing the transperineal biopsy, with a lower rate of complications for the experienced team, after 142 cases after 6 months of practice. The lower complication rate of TPPB and the absence of infectious prostatitis imply a safer procedure when compared to TRPB.
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Neoplasias da Próstata , Prostatite , Masculino , Humanos , Próstata/patologia , Neoplasias da Próstata/patologia , Prostatite/patologia , Curva de Aprendizado , Estudos Retrospectivos , Estudos de Coortes , Biópsia/métodos , Biópsia Guiada por Imagem/métodos , Ultrassonografia de Intervenção/efeitos adversos , Ultrassonografia de Intervenção/métodosRESUMO
Diving thyroid nodules are a limitation of radiofrequency ablation because the mediastinal component cannot be adequately identified by ultrasound (US). We aim to describe a new technique, the iceberg technique, to overcome this issue and explain our three-year experience of using this novel method. The iceberg technique consists of a two-stage treatment. First, the ablation of the cervical portion of the nodules (easily visualized during the initial US exam) using trans-isthmic access is performed using the moving-shot technique. After three to six months, there is a volumetric reduction of the treated portion, leading to retraction of the thyroid parenchyma. This brings the mediastinal component to the cervical region, thereby enabling a perfect visualization by US. Then, the second stage of treatment is carried out with complete nodule ablation, and the region that was treated first is looked at a second time. From April 2018 to April 2021, nine patients with nine benign nodules were submitted for the iceberg technique. No complications occurred during the entire follow-up period. The patients displayed normal hormonal levels after the procedures, and there was a significant volume reduction of the nodules until three months post-ablation. The iceberg technique is an effective and safe option for the radiofrequency treatment of diving goiters.
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Ablação por Cateter , Mergulho , Ablação por Radiofrequência , Nódulo da Glândula Tireoide , Humanos , Nódulo da Glândula Tireoide/diagnóstico por imagem , Nódulo da Glândula Tireoide/cirurgia , Resultado do Tratamento , Ablação por Radiofrequência/métodos , Ablação por Cateter/métodos , Estudos RetrospectivosRESUMO
PURPOSE: To compare short-term and medium-term results of superior rectal artery embolization versus surgical hemorrhoidectomy in the treatment of patients with hemorrhoidal disease. MATERIAL AND METHODS: This study was a prospective randomized clinical trial following 33 patients with symptomatic hemorrhoidal disease Grades 2 and 3 who were randomly assigned to 2 different groups: the superior rectal artery embolization group (n = 15) and Ferguson closed hemorrhoidectomy surgical group (n = 14). Four patients were excluded from the analysis. Pain using the visual analog scale and the use of analgesics were evaluated 3 times daily during the first 7 days of the postoperative period. Recurrent symptoms and satisfaction with treatment were also evaluated in the subsequent first, third, sixth, and twelfth months. RESULTS: The mean pain during the first bowel movement after the procedure was 6.08 ± 4.41 in the surgery group and 0 in the embolization group (P = .001). The mean use of pain medication was higher in the surgery group (28.92 doses ± 15.78 vs 2.4 doses ± 5.21; P < .001). In the embolization group, the most prevalent preprocedural symptom was bleeding in 14 patients, with complete improvement in 12 (83.3%) patients. Mucus, skin tag, and pruritus were symptoms that showed little improvement in both groups. The frequency of symptoms (bleeding, pain, prolapse, and pruritus) was similar between the groups at 12 months (P = .691). No severe adverse events were observed in both groups. CONCLUSIONS: Despite no difference in outcomes, embolization of the superior rectal arteries for the treatment of hemorrhoidal disease showed pain levels lower than those observed after surgical treatment.
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Hemorroidectomia , Hemorroidas , Humanos , Hemorroidectomia/efeitos adversos , Hemorroidectomia/métodos , Hemorroidas/cirurgia , Resultado do Tratamento , Estudos Prospectivos , Recidiva Local de Neoplasia , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/etiologia , Dor Pós-Operatória/prevenção & controle , Hemorragia/etiologia , ArtériasRESUMO
ABSTRACT Objective To describe the radiological characteristics of hepatocellular carcinoma (HCC) lesions that achieved a complete response following drug-eluting bead transarterial chemoembolization (DEB-TACE) preceding liver transplantation. Methods This single-center case-control study enrolled patients with hepatocellular carcinoma who underwent neoadjuvant DEB-TACE therapy, were followed up with contrast-enhanced magnetic resonance imaging or computed tomography, and were successively evaluated according to the modified Response Evaluation Criteria in Solid Tumors. The HCCs were divided into two groups based on their diameter (Group A: ≤3cm; Group B: 3cm). Viability was assessed using the Kaplan-Meier method according to tumor size categories. The relationship between tumor variables was analyzed using bivariate Cox regression. Results Three-hundred and twenty-eight patients with 667 hepatocellular carcinomas who underwent their first DEB-TACE session were enrolled. A total of 105 hepatocellular carcinomas in 59 patients exhibited complete response after the initial DEB-TACE session and were divided into Group A (92 HCCs) and Group B (13 HCCs). The diameter in Group A decreased significantly compared to the pre-procedure size until the second assessment (p<0.001), with no subsequent reduction in diameter, despite maintaining a complete response. In Group B, the reduction in diameter remained significant compared with the initial value until the sixth imaging evaluation (p=0.014). The average reduction was 45.1% for Group B and a maximum of 14.9% in Group A. Conclusion HCCs >3cm exhibited a greater reduction in size and a longer time to recurrence. HCCs ≤3cm had a shorter relapse time. The recurrence rates were similar. These findings may aid in planning for liver transplantation.