Respiratory muscle training with electronic devices in the postoperative period of hepatectomy: A randomized study.

BACKGROUND: Many studies have been developed with a focus on surgical techniques and drugs, but few that address the importance of rehabilitation in the pre and postoperative period, and the specific benefits for each surgical procedure or type of neoplasm, aiming to minimize respiratory complications in the postoperative period. AIM: To compare the strength of the respiratory muscles in the pre and postoperative periods of hepatectomy by laparotomy and to verify the incidence of postoperative pulmonary complications among the groups studied. METHODS: Prospective, randomized, clinical trial study that compared the inspiratory muscle training group (GTMI) with the control group (CG). After the collection of sociodemographic and clinical data, in both groups, preoperatively, on the first and fifth postoperative days, vital signs and pulmonary mechanics were evaluated and recorded. Albumin and bilirubin values were recorded for the albumin-bilirubin (ALBI) score. After randomization and allocation of participants, those in the CG underwent conventional physical therapy and those in the GTMI underwent conventional physical therapy plus inspiratory muscle, in both groups for five postoperative days. RESULTS: Of 76 subjects met eligibility criteria. The collection of 41 participants was completed: 20 in the CG and 21 in the GTMI. The most frequent diagnosis was 41.5% with liver metastasis, followed by 26.8% with hepatocellular carcinoma. As for respiratory complications in the GTMI, there was no incidence. In the CG, there were three respiratory complications. Patients in the CG classified as ALBI score 3 presented, statistically, a higher energy value compared to patients classified as ALBI score 1 and 2 (P = 0.0187). Respiratory variables, measured preoperatively and on the first postoperative day, had a significant drop in both groups from the preoperative to the first postoperative day (P ≤ 0.0001). When comparing the preoperative period and the fifth postoperative day between the GTMI and the CG, the maximal inspiratory pressure variable in the GTMI was statistically significant (P = 0.0131). CONCLUSION: All respiratory measures showed a reduction in the postoperative period. Respiratory muscle training using the Powerbreathe® device increased maximal inspiratory pressure and this may have contributed to a shorter hospital stay and better clinical outcome.

Hepatobiliary phases in magnetic resonance imaging using liver-specific contrast for focal lesions in clinical practice.

BACKGROUND: Challenging lesions, difficult to diagnose through non-invasive methods, constitute an important emotional burden for each patient regarding a still uncertain diagnosis (malignant x benign). In addition, from a therapeutic and prognostic point of view, delay in a definitive diagnosis can lead to worse outcomes. One of the main innovative trends currently is the use of molecular and functional methods to diagnosis. Numerous liver-specific contrast agents have been developed and studied in recent years to improve the performance of liver magnetic resonance imaging (MRI). More recently, one of the contrast agents introduced in clinical practice is gadoxetic acid (gadoxetate disodium). AIM: To demonstrate the value of the hepatobiliary phases using gadoxetic acid in MRI for the characterization of focal liver lesions (FLL) in clinical practice. METHODS: Overall, 302 Lesions were studied in 136 patients who underwent MRI exams using gadoxetic acid for the assessment of FLL. Two radiologists independently reviewed the MRI exams using four stages, and categorized them on a 6-point scale, from 0 (lesion not detected) to 5 (definitely malignant). The stages were: stage 1- images without contrast, stage 2- addition of dynamic phases after contrast (analogous to usual extracellular contrasts), stage 3- addition of hepatobiliary phase after 10 min (HBP 10'), stage 4- hepatobiliary phase after 20 min (HBP 20') in addition to stage 2. RESULTS: The interobserver agreement was high (weighted Kappa coefficient: 0.81- 1) at all stages in the characterization of benign and malignant FLL. The diagnostic weighted accuracy (Az) was 0.80 in stage 1 and was increased to 0.90 in stage 2. Addition of the hepatobiliary phase increased Az to 0.98 in stage 3, which was also 0.98 in stage 4. CONCLUSION: The hepatobiliary sequences improve diagnostic accuracy. With growing potential in the era of precision medicine, the improvement and dissemination of the method among medical specialties can bring benefits in the management of patients with FLL that are difficult to diagnose.

A influência do treinamento muscular respiratório pré-operatório na recuperação de pacientes submetidos à esofagectomia / The influence of the respiratory muscular training in the recovery of esophagectomies

OBJETIVO: Avaliar os efeitos do treinamento muscular respiratório (TMR) pré-operatório em pacientes que foram submetidos à esofagectomia e sua correlação com complicações pulmonares. MÉTODOS: Foram analisados 40 pacientes, randomizados em dois grupos: 20 submetidos à TMR durante 5 dias/semana (1 a 4 semanas pré-operatório) e 20 sem TMR. Foram coletados dados no grupo TMR de pressão inspiratória máxima (PImáx), pressão expiratória máxima (PEmáx), cirtometria torácica e prova de função pulmonar antes do início do protocolo de TMR, ao término de cada semana de treinamento e no sétimo dia pós-operatório. O TMR consistiu da utilização de bicicleta ergométrica (15 minutos); threshold (15 minutos), CPAP (15 minutos), Respiron (3 séries/15 repetições) e padrões ventilatórios (3 séries/15 repetições). Todos foram submetidos à esofagectomia. RESULTADOS: Houve aumento de PEmáx (P< 0,05) e PImáx (P< 0,05) durante o TMR, aumento significativo na medida da CVF ao término da 4ª semana, decréscimo dos valores de PImáx e PEmáx em ambos os grupos no pós-operatório. O tempo de internação na unidade de terapia intensiva e hospitalar do grupo treinado foi menor (1 a 4 dias e 12 a 18 dias) em relação ao grupo controle (1 a 17 dias e 19 a 46 dias). As complicações respiratórias diminuiram no grupo com TMR. CONCLUSÃO: O TMR aumentou a força muscular respiratória diminuindo as complicações pulmonares e contribuindo para menor tempo de internação na UTI e hospitalar.

AIM: To correlate the effects of the respiratory muscular training (RMT) in the pre-operative period of esophagectomies, with the post-operative pulmonary complications. METHODS: Forty patients were randomically submitted to two groups: 20 patients with RMT during 5 day/week (1 to 4 weeks pre-operatively) and 20 patients without RMT (control group). PImax, Pemax, pulmonary function test, arterial blood gas analyses and cirtometry data were collected before RMT, at the end of each week of training and in the 7th post-operative day. RMT consisted on bicycle (15 minutes); threshold (15 minutes), CPAP (15 minutes), inspirometer (3 series of 15 repetitions) and ventilatory patterns (3 series of 15 repetitions). All patients were treated by trans-mediastinal esophagectomies. RESULTS: An increase of PEmax (P< 0.05) and PImax (P< 0.05) during the 4 weeks of RMT was found. There was a decrease of PEmax and PImax in both groups in the post-operative period, however, the length on intensive care unit (1-4 days vs 1-17 days) and hospital stay (12-18 days vs 19-46 days) in the trained group was shorter. The respiratory complications were lower in RMT group. CONCLUSION: Respiratory muscular training is important in increasing the respiratory muscles force and endurance and, consequently, better surgical recovery with minor intensive unit and hospital staying.

Análise da função respiratória em pacientes obesos submetidos à operação Fobi-Capella / Respiratory function in obese patients submitted to Fobi-Capella operation

INTRODUÇÃO: O objetivo deste trabalho foi mensurar quantitativamente essas alterações respiratórias desses pacientes comparando-os até 30 dias de pós-operatório. MÉTODO: Foram realizadas avaliações respiratórias nos períodos pré e pós-operatório de cirurgia bariátrica em obesos mórbidos com IMC superior a 39kg/m², através de gasometria arterial, prova de função respiratória, manovacuômetria, incentivador da respiração e cirtometrias. Foram realizadas também orientações fisioterápicas respiratórias e tratamento no pós-operatório, com dados comparativos entre as avaliações feitas no préoperatório, no 1º, 14º·e 30º dia pós-operatórios. RESULTADOS: Até o 30º dia de pós-operatório, esses indivíduos não obtiveram diferença significativa nos parâmetros estudados, não havendo, em decorrência do tratamento fisioterápico, complicações respiratórias. CONCLUSÃO: Não houve alterações dos parâmetros analisados, nem complicações respiratórias neste estudo com intervenção fisioterápica pré e pós-operatório de cirurgia bariátrica. Estudos devem ser realizados, para mensuração de um tempo maior de pós-operatório e de exercícios específicos, podendo, assim apresentar resultados diferentes.

BACKGROUND: The objective this study was to measure quantitatively those breathing alterations until 30 days postoperative. METHOD: Breathing evaluations were accomplished before and after bariatric surgery, in morbid obese with IMC greater than 39 kg/m², through arterial gasometry, spirometry function, manovacuometry, to motivate breathing and circumferences. They were breathing physiotherapeutic accomplished, orientations and treatment in the postoperative, with comparative data among evaluations in the 1st, 14th ·e 30th postoperative day. RESULTS: Until the 30th postoperative day, those individuals didn't achieve significant differences in the evaluated parameters, and showed no breathing complications for physiotherapeutic treatment. CONCLUSION: There were no alterations in the analyzed parameters, nor breathing complications in this study with intervention physiotherapy before and after bariatric surgery. Studies should be accomplished, for a longer postoperative period, including specific exercises to achieve different results.

Estimulação elétrica nervosa transcutânea no alívio da dor pós-operatória relacionada com procedimentos fisioterapêuticos em pacientes submetidos a intervenções cirúrgicas abdominais / Transcutaneous electrical nerve stimulation in the relief of pain related to physical therapy after abdominal surgery

JUSTIFICATIVA E OBJETIVOS: A eletroestimulação nervosa transcutânea (TENS) tem sido pouco estudada como método facilitador da fisioterapia pós-operatória. O objetivo do estudo foi verificar a eficácia da TENS no alívio da dor relacionada com fisioterapia pós-operatória em pacientes submetidos a intervenções cirúrgicas abdominais. MÉTODO: Foi realizado um estudo clínico, prospectivo, com distribuição aleatória, incluindo 48 pacientes no primeiro dia de pós-operatório, que apresentavam escore de dor > 3 pontos na escala visual analógica (VAS), divididos em três grupos: Grupo Controle: com rotina analgésica habitual, sem TENS e com fisioterapia; Grupo Estudo, recebendo rotina analgésica habitual mais TENS, e fisioterapia; Grupo Contraste-Placebo, recebendo rotina analgésica habitual, fisioterapia e TENS desligada. Foi apresentada aos pacientes uma escala visual analógica de dor antes (M1), depois da TENS (M2) e após fisioterapia (M3) - tosse, incentivador respiratório, mudança de decúbito lateral e sentado - quantificando a efetividade da analgesia. O tempo de eletroestimulação foi 30 minutos. RESULTADOS: Houve alívio significativo da dor no Grupo Estudo, comparando-se os três grupos, apenas para o procedimento tosse, no M3 (p = 0,015). Dentro desse grupo houve diminuição significativa da dor para tosse (p = 0,003) [M1 versus M3]; para decúbito lateral (p = 0,025), sentar-se (p = 0,001) e utilizar o incentivador inspiratório (p = 0,017) [M1 versus M2]; e ao se mudar para decúbito lateral (p = 0,03) e sentar-se (p = 0,001) [M1 ï M3]. Não houve diferença significativa no Grupo Contraste-Placebo. CONCLUSÕES: Houve diminuição da dor no Grupo Estudo, em alguns momentos e parâmetros. Estudos adicionais são necessários, já que a utilização da TENS está indicada apenas como coadjuvante no controle da dor pós-operatória.

BACKGROUND AND OBJECTIVES: There are few studies on transcutaneous electrical stimulation (TENS) as an adjunct to postoperative physical therapy. The objective of this study was to determine the efficacy of TENS on relieving pain related to physical therapy after abdominal surgery. METHODS: A clinical, randomized, prospective study was undertaken with 48 patients on the first postoperative day, who presented a pain score > 3 on the visual analogic scale (VAS). Patients were divided in three groups: Control Group: treated with the usual analgesic routine, without TENS, and with physical therapy; Study Group: treated with the usual analgesic routine associated with TENS and physical therapy; Contrast-Placebo Group: treated with the usual analgesic routine associated with physical therapy but TENS was off. A visual analogic scale of pain was presented to the patients before (M1), after TENS (M2), and after physical therapy (M3) - cough, incentive spirometry, changing lateral decubitus and sitting - to quantify the efficacy of the analgesia. Electrical stimulation was done during 30 minutes. RESULTS: The Study Group presented a significant relief of the pain when compared to the other two groups only for coughing at M3 (p= 0.015). In this group, there was a significant reduction in pain associated with coughing (p= 0.003) [M1 versus M3]; with lateral decubitus (p= 0.025), sitting (p= 0.001), and with incentive spirometry (p= 0.017) [M1 versus M2]; and when changing to the lateral decubitus (p= 0.03) and sitting (p= 0.001) [M1xM3]. There were no significant differences in the Contrast-Placebo Group. CONCLUSIONS: The Study Group presented a reduction in pain in a few moments and parameters. Further studies are needed since TENS is indicated only as an adjuvant in controlling postoperative pain.

JUSTIFICATIVA Y OBJETIVOS: LA electroestimulación nerviosa transcutánea (TENS) ha sido poco estudiada como método facilitador de la fisioterapia postoperatoria. El objetivo del estudio fue el de verificar la eficacia de la TENS en el alivio del dolor relacionado a la fisioterapia postoperatoria en pacientes sometidos a intervenciones quirúrgicas abdominales. MÉTODO: Se realizó un estudio clínico, prospectivo, con distribución aleatoria, incluyendo 48 pacientes en el 1º día de postoperatorio, que presentaban un puntaje de dolor > 3 puntos en la escala visual analógica (VAS), divididos en tres grupos: Grupo Control: con rutina analgésica habitual, sin TENS y con fisioterapia; Grupo Estudio, recibiendo rutina analgésica habitual más TENS, y fisioterapia; Grupo Contraste-Placebo, recibiendo rutina analgésica habitual, fisioterapia y TENS desvinculada. Se presentó a los pacientes una escala visual analógica de dolor antes (M1), después de la TENS (M2) y después de la fisioterapia (M3) - tos, incentivador respiratorio, cambio de decúbito lateral y sentado - cuantificando la efectividad de la analgesia. El tiempo de electroestimulación fue de 30 minutos. RESULTADOS: Hubo un alivio significativo del dolor en el Grupo Estudio, comparándolo con los tres grupos, apenas para el procedimiento tos, en el M3 (p = 0,015). Dentro de ese grupo hubo una disminución significativa del dolor para tos (p = 0,003) [M1 versus M3]; para decúbito lateral (p = 0,025), sentarse (p = 0,001) y utilizar el incentivador inspiratorio (p = 0,017) [M1 versus M2]; y al cambiar para decúbito lateral (p = 0,03) y sentarse (p = 0,001) [M1xM3]. No hobo diferencia significativa en el Grupo Contraste Placebo. CONCLUSIONES: Hubo disminución del dolor en el Grupo Estudio, en algunos momentos y parámetros. Estudios adicionales se hacen necesarios, ya que la utilización de la TENS está indicada apenas como coadyuvante en el control del dolor postoperatorio.

[Transcutaneous electrical nerve stimulation in the relief of pain related to physical therapy after abdominal surgery.]. / Estimulação elétrica nervosa transcutânea no alívio da dor pós-operatória relacionada com procedimentos fisioterapêuticos em pacientes submetidos a intervenções cirúrgicas abdominais.

BACKGROUND AND OBJECTIVES: There are few studies on transcutaneous electrical stimulation (TENS) as an adjunct to postoperative physical therapy. The objective of this study was to determine the efficacy of TENS on relieving pain related to physical therapy after abdominal surgery. METHODS: A clinical, randomized, prospective study was undertaken with 48 patients on the first postoperative day, who presented a pain score > 3 on the visual analogic scale (VAS). Patients were divided in three groups: CONTROL GROUP: treated with the usual analgesic routine, without TENS, and with physical therapy; STUDY GROUP: treated with the usual analgesic routine associated with TENS and physical therapy; Contrast-Placebo Group: treated with the usual analgesic routine associated with physical therapy but TENS was off. A visual analogic scale of pain was presented to the patients before (M1), after TENS (M2), and after physical therapy (M3) - cough, incentive spirometry, changing lateral decubitus and sitting - to quantify the efficacy of the analgesia. Electrical stimulation was done during 30 minutes. RESULTS: The STUDY GROUP presented a significant relief of the pain when compared to the other two groups only for coughing at M3 (p= 0.015). In this group, there was a significant reduction in pain associated with coughing (p= 0.003) [M1 versus M3]; with lateral decubitus (p= 0.025), sitting (p= 0.001), and with incentive spirometry (p= 0.017) [M1 versus M2]; and when changing to the lateral decubitus (p= 0.03) and sitting (p= 0.001) [M1xM3]. There were no significant differences in the Contrast-Placebo Group. CONCLUSIONS: The STUDY GROUP presented a reduction in pain in a few moments and parameters. Further studies are needed since TENS is indicated only as an adjuvant in controlling postoperative pain.

Chemical pleurodesis for hepatic hydrothorax

BACKGROUND: Ascites can occur after hepatic diseases causing dyspnea, coughing and pain. When associated with pleural effusion it can also increase respiratory distress. In a bibliographic survey hydrothorax has been observed in up to 20% of the patients and the kind of treatment is still being discussed. OBJECTIVE: This case report shows the occurrence of a large volume of ascites and pleural effusion in a cirrhotic patient and his treatment. METHODS: Report the case of a patient with hepatic cirrhosis due to chronic alcoholism and massive pleural effusion and ascites. He was submitted to several pleural paracenteses without success. Scintigraphy showed the presence of ascites and confirmed a possible pleuroperitoneal communication. The thoracic surgery group was called and after evaluation it was decided to submit the patient to a pulmonary decortication and chemical pleurodesis. RESULTS: These procedures were carried out with success. The pleural effusion was solved and the treatment of ascites was decided upon because the patient did not accept any surgical procedure. CONCLUSION: This treatment could be applied to patients with hydrothorax who could not be submitted to a liver transplantation.