Trans Oral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) in Brazil: Safety and complications during learning curve

ABSTRACT Background: The aim of this study was to address the first cases of TOETVA done in Brazil, by TOETVA-Bra study group, regarding safety and complications. Materials and Methods: Series of the first 93 TOETVAs cases in Brazil. All authors except LPK, AJG JOR and RPT received TOETVA training including cadaveric hands-on in Thailand or United States (Johns Hopkins Medicine) during 2017. After they came back to Brazil and started doing their first TOETVA cases in the cities of Rio de Janeiro, Sao Paulo and Chapecó they agreed to collaborate and gather data using an online spreadsheet. All patients were submitted to the technique described by Anuwong. Results: A total of 93 patients underwent TOETVA. Most patients (58.1%) were submitted to total thyroidectomy and 59.1% had benign disease. Two patients (2.2%) needed conversion to open surgery. Five patients (9.3%) developed transient hypoparathyroidism and there were 3 (2.0%) temporary recurrent laryngeal nerve palsy. There was one (0.7%) permanent unilateral palsy. Twenty patients had some sort of complication, 16.1% were minor and 5.4% were major. A total of 73 patients (78.5%) had an uneventful recovery. Conclusion: The technique is reproducible with a low complication rate. While further studies are needed to confirm equivalency, early efforts suggest that TOETVA is not inferior to traditional open thyroidectomy in appropriately selected patients.

Gastrostomia endoscópica percutânea ambulatorial em pacientes com de câncer de cabeça e pescoço / Outpatient percutaneous endoscopic gastrostomy in head and neck cancer patients

Introdução: A gastrostomia endoscópica percutanea (GEP) é um método relativamente simples e seguro para fornecimento de nutrição enteral, sendo normalmente realizado em pacientes hospitalizados. A utilização da GEP como procedimento ambulatorial ainda não está bem estabelecida. Objetivo: Investigar a viabilidade e a segurança da GEP como procedimento ambulatorial em pacientes com câncer de cabeça e pescoço. Métodos: Em estudo de coorte prospectivo, pacientes com câncer de cabeça e pescoço em bom estado geral foram selecionados e incluídos em um protocolo de acompanhamento de GEP ambulatorial. Resultados: 136 pacientes foram selecionados para realização de GEP ambulatorial. Destes, 129 (94,8%) receberam alta hospitalar três horas após o procedimento. Três pacientes foram excluídos do estudo no pré-operatório e quatro foram hospitalizados pós-procedimento. A taxa de complicações menores foi de 17,6% (dor local 7,4%; infecção de ferida 6,6%; dor abdominal 2,9%; hematoma 0,7%). Complicações maiores ocorreram em 2,2% dos procedimentos. Não houve óbito. Conclusão: A realização ambulatorial de GEPs é viável e segura em pacientes com câncer de cabeça e pescoço em boas condições clinicas. As taxas de complicações precoces são semelhantes às descritas para pacientes hospitalizados. Internações desnecessárias são evitadas e os custos hospitalares são reduzidos.

Introduction: Percutaneous endoscopic gastrostomy (PEG) is a relatively simple and safe method of providing access for enteral feeding, being usually performed in hospitalized patients. The feasibility of PEG as an outpatient procedure has not been well established. Objective: To investigate the feasibility and safety of PEG as an outpatient procedure in a selected group of head and neck cancer patients. Methods: In this prospective cohort study, head and neck cancer subjects in good clinical condition were selected and enrolled in a close follow-up protocol of outpatient PEG. Results: Out of a total of 136 PEG patients, 129 (94.8%) were discharged 3 hours after the procedure. Three were excluded from the study and four were hospitalized. The rate of minor complications was 17.6% (local pain, 7.4%; wound infection, 6.6%; abdominal pain, 2.9%; hematoma, 0.7%). Major complications occurred in 2.2% of the procedures (buried bumper syndrome, 1.5%; early tube displacement, 0.7%). There was no mortality. Conclusion: Ambulatory placement of gastrostomy tubes is viable and safe in head and neck cancer patients in good clinical condition. The early complication rates are similar to those described for hospitalized patients. Unnecessary admissions are avoided and costs of hospitalization are reduced.

Enxerto de gordura pós-parotidectomia: avaliação de absorção e prevenção da Síndrome de Frey. / Postparotidectomy fat graft: absorption evaluation and Frey's syndrome prevention.

Objetivo: Demonstrar a importância da enxertia de gordura autóloga no peroperatório como medida preventiva da síndrome de Frey, o grau de satisfação dos pacientes e o índice de absorção local. Delineamento: Estudo prospectivo intervencionista. Métodos: Estudo prospectivo de junho de 2006 a junho de 2008 em 40 pacientes, separados em dois grupos submetidos à parotidectomia com e sem enxerto de gordura. Foram realizadas avaliações de absorção do enxerto nos pacientes operados através de ressonância nuclear magnética, grau de satisfação estética dos pacientes por questionário aplicado e principalmente a comparação entre os grupos quanto à presença da síndrome de Frey por estímulo alimentar e queixas dos sinais apresentados que justifiquem sua presença. Resultados: O volume absoluto encontrado nos três momentos (peroperatório, primeiro e segundo exame de imagem) dos pacientes que receberam enxerto de gordura, demonstrou uma média de absorção final de aproximadamente 28% do tecido enxertado. Em 30% dos pacientes que não foram submetidos à enxertia houve presença da síndrome de Frey contra nenhum do grupo que recebeu o tecido autólogo (p=0,01). Em torno de 50% dos pacientes dos dois grupos apresentaram queixas estéticas. Conclusão: Foi demonstrada nessa amostra a importância no uso do enxerto de gordura autóloga como prevenção da síndrome de Frey. Não houve diferença significativa quanto às queixas estéticas nos grupos. A média de absorção é baixa dentro dos primeiros seis meses de seguimento através do diagnóstico por imagem e clinicamente não houve queixas significativas até junho de 2009, quando o estudo foi concluído.

Objective: The aim of this study was to demonstrate the importance of autologous dermal fat graft in the peroperatory to prevent Frey?s syndrome, evaluate patient satisfaction about the result and the rate of local absorption. Outline: We conducted an interventionist prospective study. Methods: This was a prospective study from June 2006 to June 2008, with 40 patients divided in two groups submitted to parotidectomy with and without the use of fat graft. Absorption was determined by MRI scans in each patient. The patient satisfaction about the results of the facial contour was evaluated through an applied questionnaire. We compared the two groups over the presence of Frey?s syndrome through stimulation with food. We also evaluated the complaints of the patient about the symptoms and signs that demonstrate this complication. Results: The absolute volume was demonstrated in peroperatory and in the first and second MRIs. Patients that received fat graft showed a final absorption average of 28% of the fat graft. About 30% of patients that weren?t submitted to fat graft presented Frey?s syndrome and none from the group that received the autologous tissue (p=0.01). Half of patients from both groups had aesthetic complaints. Conclusion: This study demonstrated the importance about the use of autologous fat graft as a prevention of Frey?s syndrome. There was no significant difference between the aesthetic complaints in both groups. The rate of absorption is low in the first six months following through image diagnosis and there were no significant clinically complaints until June 2009 when this study was concluded.