Extrapleural Closure of Patent Ductus Arteriosus: How We Do It.

Patent ductus arteriosus (PDA) is a clinical condition mostly found in premature newborns. Among several medical, surgical and interventional treatment options, extrapleural ligation through a left minithoracotomy is recognized as a safe, efficient and less expensive technique. In fact, it requires short surgical times, grants good exposure of the duct and nearby structures (e.g., thoracic duct, left recurrent laryngeal nerve), and avoids pleural space opening and subsequent pulmonary complications in preterm patients. This approach seems ideal due to its lower costs, especially in developing countries with a high birth rate and limited resources.

Extrapleural closure of patent Ductus Arteriosus: how we do it

Abstract Patent ductus arteriosus (PDA) is a clinical condition mostly found in premature newborns. Among several medical, surgical and interventional treatment options, extrapleural ligation through a left minithoracotomy is recognized as a safe, efficient and less expensive technique. In fact, it requires short surgical times, grants good exposure of the duct and nearby structures (e.g., thoracic duct, left recurrent laryngeal nerve), and avoids pleural space opening and subsequent pulmonary complications in preterm patients. This approach seems ideal due to its lower costs, especially in developing countries with a high birth rate and limited resources.

[The benefits of digital chest drainage in pleural decortication in thoracic empyema. Prospective, randomized, control trial]. / Beneficios del drenaje torácico digital en pleurodecorticación por empiema. Estudio prospectivo, comparativo aleatorizado.

BACKGROUND: Prolonged air leak after pleural decortication is one of the most frequent complications. OBJECTIVE: The aim of this study is to compare the effects of prolonged air leak between the digital chest drainage (DCD) system and the classic drainage system in patients with empyema class IIB or III (American Thoracic Society classification) in pleural decortication patients. MATERIAL AND METHODS: A total of 37 patients were enrolled in a prospective randomized control trial over one year, consisting of 2blinded groups, comparing prolonged air leak as a main outcome, the number of days until removal of chest drain, length of hospital stay and complications as secondary outcomes. RESULTS: The percentage of prolonged air leak was 11% in the DCD group and 5% in the classic group (P=0.581); the mean number of days of air leak was 2.5±1.8 and 2.4±2.2, respectively (P=0.966). The mean number of days until chest tube removal was 4.5±1.8 and 5.1±2.5 (P=0.41), the length of hospital stay was 7.8±3.7 and 8.9±4.0 (P=0.441) and the complication percentages were 4 (22%) and 7 (36%), respectively (P=0.227). DISCUSSION: In this study, no significant difference was observed when the DCD was compared with the classic system. This was the first randomized clinical trial for this indication; thus, future complementing studies are warranted.

Neumotórax espontáneo en embarazada: Reporte de un caso tratado por videotoracoscopia y revisión de la literatura / Spontaneous pneumothorax during pregnancy: case report of a patient treated with videothoracoscopy and literature review

RESUMEN El neumotórax espontáneo primario es la presencia de aire en la cavidad pleural como consecuencia de la ruptura de bulas o blebs subpleurales en un pulmón que por otro lado está sano y sin antecedentes traumáticos. Es más frecuente en hombres que en mujeres y es raro en el embarazo, habiéndose publicado menos de 60 casos en la literatura. El objetivo es reportar un neumotórax espontáneo en una embarazada y realizar una revisión del tema. El caso corresponde a una mujer de 19 años, primigestante que presenta un neumotórax espontáneo primario tratado inicialmente con pleurotomía, el cual evoluciona satisfactoriamente, pero a las 24 horas ser retirada esta, presenta recidiva por lo que se realiza videotoracoscopia con resección de bulas y pleurodesis. Evoluciona adecuadamente, se da de alta en buenas condiciones y posteriormente lleva a cabo su trabajo de parto vaginal sin complicaciones. El tratamiento del neumotórax en el embarazo es igual al de los pacientes no obstétricos. Los neumotórax espontáneos recurrentes, los persistentes, los con fuga aérea por el tubo más allá del cuarto día y los bilaterales son indicaciones de procedimiento quirúrgico por toracotomía o videotoracoscopia. Se debe considerar el diagnóstico en cualquier embarazada con dolor torácico agudo, disnea súbita o antecedentes de neumotórax previo y este debe ser confirmado con radiografía de tórax con la adecuada protección del feto. Su reconocimiento y manejo es esencial para evitar complicaciones a la madre y al feto. El tratamiento quirúrgico por videotoracoscopia fue seguro en este caso. MÉD.UIS. 2016;29(3):101-5.

ABSTRACT Primary spontaneous pneumothorax is the presence of air in the pleural cavity as a consequence of a rupture of bullae or subpleural blebs in an otherwise healthy lung, without a clear history of trauma. Is more frequent in men than in women, and rarely presents during pregnancy, less than 60 cases has been reported in literature. The objective is to report the case of a 19-year-old primiparous woman who presents spontaneous pneumothorax treated initially with pleurostomy. Initial evolution is satisfactory, but 24 hours after withdrawal of chest tube, patient recurs. Patient is managed with videothoracoscopic bullectomy followed by pleurodesis. The procedure was well tolerated and is discharged in optimum condition and subsequently goes into labor, giving birth without any complications. In conclusion, treatment of spontaneous pneumothorax during pregnancy can be safely managed in the same way as non-obstetric patients. Recurring, persistent, or with air leak beyond 4 days and bilateral spontaneous pneumothorax, are indication for thoracic surgery. The diagnosis of spontaneous pneumothorax must be considered in any pregnant woman with acute thoracic pain, sudden onset dyspnoea and past medical history of it. The diagnosis must be confirmed with chest X ray, considering fetus protecting measures. Recognition and opportune treatment of spontaneous pneumothorax in the pregnant woman is essential to avoid maternal or fetal complications. Videothoracoscopic treatment has been proven safe in this case. MÉD.UIS. 2016;29(3):101-5.

Pleurotomy with subxyphoid pleural drain affords similar effects to pleural integrity in pulmonary function after off-pump coronary artery bypass graft.

BACKGROUND: Exacerbation of pulmonary dysfunction has been reported in patients receiving a pleural drain inserted through the intercostal space in comparison to patients with an intact pleura undergoing coronary artery bypass grafting (CABG). Evidence suggests that shifting the site of pleural drain insertion to the subxyphoid position minimizes chest wall trauma and preserves respiratory function in the early postoperative period. The aim of this study was to compare the pulmonary function parameters, clinical outcomes, and pain score between patients undergoing pleurotomy with pleural drain placed in the subxyphoid position and patients with intact pleural cavity after off-pump CABG (OPCAB) using left internal thoracic artery (LITA). METHODS: Seventy-one patients were allocated into two groups: I (n = 38 open left pleural cavity and pleural drain inserted in the subxyphoid position); II (n = 33 intact pleural cavity). Pulmonary function tests and clinical parameters were recorded preoperatively and on postoperative days (POD) 1, 3 and 5. Arterial blood gas analysis and shunt fraction were evaluated preoperatively and in POD1. Pain score was assessed on POD1. To monitor pleural effusion and atelectasis chest radiography was performed routinely 1 day before operation and until POD5. RESULTS: In both groups a significant impairment was found in lung function parameters until on POD5. However, no significant difference in forced vital capacity and forced expiratory volume in 1 second were seen between groups. A significant decrease in partial pressure of arterial oxygen and an increase in shunt fraction values were observed on POD1 in both groups, but no statistical difference was found when the groups were compared. Pleural effusion and atelectasis until on POD5 were similar in both groups. There were no statistical differences in pain score, duration of mechanical ventilation and postoperative hospital stay between groups. CONCLUSION: Subxyphoid insertion of pleural drain provides similar effects to preserved pleural integrity in pulmonary function, clinical outcomes, and thoracic pain after OPCAB. Therefore, our results support the hypothesis that once pleural cavities are incidentally or purposely opened during LITA dissection, subxyphoid placement of the pleural drain is recommended.

Pleural opening impairs respiratory system compliance and resistance in off-pump coronary artery bypass grafting.

AIM: This study evaluated the effect of pleurotomy on respiratory system compliance and resistance in off-pump coronary artery bypass (OPCAB) using the left internal thoracic artery (LITA). METHODS: Thirty-two patients were prospectively allocated into two groups: OP group (n = 16 patients with open left pleural cavity); IP group (N.=16 patients with intact pleural cavity). Static and dynamic lung compliance and total respiratory system resistance calculation were recorded at anesthesia induction (before chest opening) and immediately after chest closure. RESULTS: Static lung compliance values significantly decreased after chest closure in both groups (P < 0.0001), but the OP group had a significantly greater decline (P = 0.0007). Dynamic lung compliance decreased in either groups after chest closure (P < 0.0001), however, no significant difference was found between groups (P = 0.228). Total respiratory system resistance increased in both groups (P < 0.05), however the OP group had a higher increase (P = 0.0005). Orotracheal intubation time (P = 0.041) and hospital stay (P = 0.0004) were higher in the OP group. CONCLUSION: Pleura opening and need of chest tube insertion induced significant reduction in static lung compliance and increase in total respiratory system resistance, furthermore contributing to impair pulmonary dysfunction in the early postoperative period after OPCAB.

Comparação dos dias de internação hospitalar em pacientes que foram submetidos à cirurgia de revascularização do miocárdio com e sem pleurotomia / Analysis of average days of hospitalization in patients undergoing coronary artery bypass grafting with or without pleurotomy

Introdução: A pleurotomia durante a cirurgia cardíaca pode danificar a função respiratória durante o período pós-operatório, podendo interferir no tempo de internação hospitalar. Objetivo: Comparar os dias de internação hospitalar em pacientes submetidos à cirurgia de revascularização do miocárdio com e sem realização de pleurotomia. Métodos: A pesquisa foi composta por 20 pacientes submetidos à cirurgia de revascularização do miocárdio com circulação extracorpórea, sendo divididos em dois grupos: G1 ? pacientes que realizaram pleurotomia (n=10) e G2 ? pacientes que não realizaram pleurotomia (n=10). Resultados: Os resultados mostraram que os pacientes do grupo G1 quando comparados aos pacientes do grupo G2 obtiveram média de internação semelhante (7,2±0,78 versus 6,8±0,42 dias). Conclusão: Não houve diferença significativa no tempo de internação entre os grupos de pacientes com e sem pleurotomia.

Introduction: Pleurotomy on cardiac surgery may damage the respiratory function during the postoperative period, and may also interfere on the length of hospital stay. Objective: To compare the length of hospital stay of patients that were submitted to myocardial revascularization surgery with or without pleurotomy. Methods: This research was composed by 20 patients submitted to myocardial revascularization surgery with cardiopulmonary bypass, and they were divided into two groups: G1 ? patients submitted to pleurotomy (n=10) e G2 ? patients not submitted to pleurotomy (n=10). Results: The results showed that the G1 patients when compared to G2 patients obtained similar average length of hospital stay (7.2±0.78 versus 6.8±0.42 days). Conclusion: There was no statistical difference regarding the length of hospital stay between the groups.

Persistent pleuropulmonary air leak treated with autologous blood: results from a university hospital and review of literature.

BACKGROUND: Persistent air leak after pulmonary resection is a difficult complication for thoracic surgeons to manage. OBJECTIVES: To show the results of our experience treating persistent pleuropulmonary air leak with autologous blood and review the literature on this specific method of treatment. METHODS: Retrospective study of patients with persistent aerial pleuropulmonary fistula treated with autologous blood. The patient's own blood was collected from a peripheral vein and directly introduced through the pleural drain. An inverted siphon was located in the drainage system to avoid prolonged clamping of the drain. This siphon impeded blood return but not air escape. RESULTS: Between January 2001 and August 2008, 27 patients were treated by the above method. Patient age ranged from 2 to 74 years, and 78% were male. Each procedure used a mean quantity of 92 ml blood. Mean persistent air leak time before pleurodesis was 10.6 days and mean time to fistula resolution after pleurodesis was 1.5 days. Twenty-three (85%) patients had persistent pleuropulmonary air leak closed with the above procedure. CONCLUSION: Treating persistent pleuropulmonary air leak with autologous blood is promising, but further studies are required to quantify its real effectiveness.

[Malignant pleural mesothelioma: multidisciplinary experience in a public tertiary hospital]. / Mesotelioma pleural maligno: experiência multidisciplinar em hospital público terciário.

OBJECTIVE: To evaluate the experience in diagnosing and treating malignant pleural mesothelioma (MPM) accumulated over 5 years in a tertiary public hospital. METHODS: The medical charts of the patients diagnosed with MPM between January of 2000 and February of 2005 were evaluated retrospectively. RESULTS: Of the 17 patients analyzed, 14 were male and 3 were female. The mean age was 54.1 years (range, 13-75 years). The biopsy specimens for histopathological examination were obtained through thoracoscopy in 9 patients (53%), Cope needle in 5 (29.5%), and open pleural biopsy in 3 (17.5%). The following histological types were identified: epithelial, in 14 patients (82%); sarcomatoid, in 1 (6%); and biphasic, in 2 (12%). The therapeutic approaches used were as follows: multimodal (pleuropneumonectomy and adjuvant radiotherapy and chemotherapy) in 6 patients (35%); chemotherapy and radiotherapy in 6 (35%); radiotherapy alone in 3 (17.5%); and chemotherapy alone in 2 (12%). The mean survival was 11 months (range, 1-26 months). CONCLUSIONS: In the cases studied, an integrated multidisciplinary approach was used, and a highly complex hospital infrastructure was available for the diagnosis and treatment of MPM, as recommended in the literature. However, the mean survival was only 11 months, reflecting the aggressiveness of the disease.

Mesotelioma pleural maligno: experiência multidisciplinar em hospital público terciário / Malignant pleural mesothelioma: multidisciplinary experience in a public tertiary hospital

OBJETIVOS: Avaliar a experiência com o diagnóstico e a terapêutica do mesotelioma pleural maligno (MPM) acumulada durante 5 anos em um hospital público terciário. MÉTODOS: Avaliação retrospectiva dos prontuários dos pacientes com diagnóstico de MPM entre janeiro de 2000 e fevereiro de 2005. RESULTADOS: Foram analisados 17 pacientes, 14 homens e 3 mulheres, com idade média de 54,1 (13-75) anos. Os espécimes de biópsia para exame histopatológico foram obtidos por meio de pleuroscopia em 9 pacientes (53 por cento), agulha de Cope em 5 (29,5 por cento) e biópsia pleural aberta em 3 (17,5 por cento). Os tipos histológicos foram: epitelial em 14 pacientes (82 por cento), sarcomatóide em 1 (6 por cento) e bifásico em 2 (12 por cento). As terapêuticas instituídas foram: multimodal (pleuropneumonectomia com radioterapia e quimioterapia adjuvante) em 6 pacientes (35 por cento), quimioterapia e radioterapia em 6 (35 por cento), radioterapia exclusiva em 3 (17,5 por cento) e quimioterapia exclusiva em 2 (12 por cento). A sobrevida média foi de 11 (1-26) meses. CONCLUSÕES: Na presente experiência foi empregada a abordagem multidisciplinar integrada, e contou-se com uma estrutura hospitalar de alta complexidade para o diagnóstico e tratamento do MPM, como preconizado na literatura. Apesar disso, a sobrevida média observada foi de apenas 11 meses, refletindo a agressividade da doença.

OBJECTIVE: To evaluate the experience in diagnosing and treating malignant pleural mesothelioma (MPM) accumulated over 5 years in a tertiary public hospital. METHODS: The medical charts of the patients diagnosed with MPM between January of 2000 and February of 2005 were evaluated retrospectively. RESULTS: Of the 17 patients analyzed, 14 were male and 3 were female. The mean age was 54.1 years (range, 13-75 years). The biopsy specimens for histopathological examination were obtained through thoracoscopy in 9 patients (53 percent), Cope needle in 5 (29.5 percent), and open pleural biopsy in 3 (17.5 percent). The following histological types were identified: epithelial, in 14 patients (82 percent); sarcomatoid, in 1 (6 percent); and biphasic, in 2 (12 percent). The therapeutic approaches used were as follows: multimodal (pleuropneumonectomy and adjuvant radiotherapy and chemotherapy) in 6 patients (35 percent); chemotherapy and radiotherapy in 6 (35 percent); radiotherapy alone in 3 (17.5 percent); and chemotherapy alone in 2 (12 percent). The mean survival was 11 months (range, 1-26 months). CONCLUSIONS: In the cases studied, an integrated multidisciplinary approach was used, and a highly complex hospital infrastructure was available for the diagnosis and treatment of MPM, as recommended in the literature. However, the mean survival was only 11 months, reflecting the aggressiveness of the disease.

Influence of pleurotomy on pulmonary function after off-pump coronary artery bypass grafting.

BACKGROUND: This study evaluated the influence of pleurotomy on pulmonary function after off-pump coronary artery bypass grafting (CABG) using the left internal thoracic artery (LITA). METHODS: Thirty patients were prospectively allocated into two groups: 15 patients with an opened left pleural cavity (OP group) and 15 patients with an intact pleural cavity (IP group). Bedside pulmonary function tests were recorded preoperatively and on postoperative days 1, 3, and 5. Arterial blood gas analyses and ratio of partial pressure of arterial oxygen (PaO2/fraction of inspired oxygen (FiO2) ratio were evaluated preoperatively and on postoperative day 1. RESULTS: A significant decrease of pulmonary function was observed in both groups until postoperative day 5. When compared with the percentage of the preoperative value, the forced vital capacity was significantly lower in the OP group than in the IP group on postoperative days 1 (33.3% +/- 8.3% versus 49.1% +/- 8.4%, p < 0.001), 3 (45.4% +/- 7.0% versus 62.1% +/- 8.6%, p < 0.001), and 5 (56.1% +/- 8.7% versus 77.5% +/- 11.6%, p < 0.001). Similar results were found for forced expiratory volume in 1 second on postoperative days 1 (35.7% +/- 8.6% versus 50.0% +/- 9.8%, p < 0.001), 3 (48.4% +/- 7.0% versus 61.5% +/- 9.02%, p < 0.001) and 5 (58.8% +/- 8.5% versus 75.9% +/- 10.2%, p < 0.001). The PaO2 value and the PaO2/FiO2 ratio dropped on postoperative day 1 in both groups (p < 0.05), with a higher fall in the OP group (p < 0.05). Orotracheal intubation time (p = 0.012) and hospital stay (p = 0.002) were lower in the IP group. CONCLUSIONS: Off-pump CABG using the LITA, independently of pleural opening, induced a significant reduction in early postoperative pulmonary function. However, the patients undergoing pleurotomy demonstrated more pronounced pulmonary dysfunction.

Perfil y manejo del trauma torácico en un hospital regional / Management of thoracic trauma in a chilean regional hospital

El trauma constituye la principal causa de muerte en la población menor a 40 años. Un 25 por ciento de ellos, como consecuencia de una lesión torácica. El objetivo del presente trabajo es conocer y caracterizar biodemográficamente la población afectada por trauma toráxico que consulta en el Hospital Base de Osorno. Se analizaron retrospectivamente los registros clínicos de 94 pacientes con traumatismos torácicos, atendidos en el Servicio de Urgencias y Cirugía, entre enero 2003 y junio de 2004, cuyos diagnósticos de egreso fueron codificados según la Clasificación Internacional de Enfermedades (CIE 10). El 91 por ciento de los accidentados correspondió al sexo masculino, con un promedio de edad de 29,6 años (rango de 8 a 85 años). El 28 por ciento de los pacientes sufrió un traumatismo abierto, en el 96 por ciento por arma blanca. La complicación más frecuente fue un hemoneumotórax. El tratamiento en orden de frecuencia fue: médico (52 por ciento), pleurotomía percutánea con tubo (35 por ciento) y toracotomía (7 por ciento). Esta última, en el caso de hemotórax masivos y heridas penetrantes cardíacas. El período promedio de estada fue de 2.5 días, prolongándose a 5,9 días en pacientes con pleurotomía, 10 días en caso de toracotomía y hasta 14, cuando requirió estar en la Unidad de Terapia Intensiva. En un 23 por ciento hubo fracaso de la pleurotomía percutánea, correspondiendo en un 14 por ciento a drenaje inadecuado, un 5,8 por ciento a empiema pleural y un 3 por ciento a hemotórax retenido. En conclusión, nuestro manejo es similar al del medio nacional. Sin embargo, destaca una elevada frecuencia de morbilidad asociada a la realización de la pleurotomía percutánea.

Pleuroneumonectomía ampliada en el tratamiento quirúrgico del mesotelioma maligno difuso de pleura: experiencia / Extended pleuroneumonectomy in surgical treatment of diffuse malignant pleural mesothelioma: our experience

Antecedentes: El rol de la pleuroneumonectomía para el tratamiento quirúrgico del mesotelioma pleural maligno difuso de pleura ha sido controvertido por su elevada mortalidad y resultados desalentadores a largo plazo. Objetivo: Evaluar la efectividad y resultados de la técnica de pleuroneumonectomía ampliada que proponemos. Lugar de aplicación: Sanatorio y Hospital de la comunidad. Diseño: Retrospectivo. Población: Trece pacientes, 10 hombres y 3 mujeres con una edad promedio de 54 años con un rango de 39 a 74 años portadores de mesotelioma maligno difuso pleural, 9 de ellos epiteliales, 2 sarcomatosos y 2 mixtos. Material y métodos: Se efectuó en todos una pleuroneumonectomía ampliada con la técnica de Sugarbaker completada con la técnica de jaula de pájaro de Ribeiro Netto, para resecar los tejidos blandos de la pared torácica y su reconstrucción mediante la técnica de la toracoplastía osteoplástica de Bj÷rk...(AU)

Decorticação pleural precoce no tratamento do empiema pleural complicado na criança / Early decortication in the management of complicated empyema in children

Os autores avaliam dez casos de empiema pleural tratados inicialmente pela drenagem pleural fechada e que tiveram evolução desfavorável e arrastada. Pacientes que evoluíram com septação do empiema, persistência de fístula broncopleural de alto débito ou de falta de expansão pulmonar após a drenagem pulmonar foram submetidos a estudo pela tomografia computadorizada e encaminhados para a decorticação pleural precoce como alternativa para o tratamento. Todos os pacientes tratados desta forma tiveram uma rápida melhora clínica, evoluindo com boa expansão pulmonar, recebendo alta hospitalar num prazo máximo de dez dias após a cirurgia. Concluem os autores que tal procedimento é seguro devendo ser considerado para o tratamento do empiema pleural de má evolução

Classificaçäo ultra-sonográfica do derrame pleural e do empiema parapneumônico / Ultrasonographic classification of pleural effusion and parapneumonic empyema

Os autores correlacionaram as alterações anatomopatológicas da cavidade pleural com os achados ultra-sonográficos do derrame pleural e no empiema parapneumônico e apresentaram um classificação baseados nesses dados. Concluem que a ultra-sonografia é método diagnóstico fidedigno para inferir a fase anatomopatológica da doença pleural, bem como auxiliar na escolha da alternativa de tratamento

Avenamiento pleural en un servicio de cirugía general / Pleural drainage in general surgical service

Antecedentes: el avenamiento pleural constituye una práctica del cirujano general. Objetivo: presentar los resultados iniciales de un estudio prospectivo de pacientes a los cuales se le realizó avenamiento pleural describiendo la técnica empleada y los resultados. Lugar de aplicación: Servicio de Emergencias y de Cirugía General del Hospital Interzonal de Agudos General San Martín. La Plata. Diseño: estudio observacional prospectivo. Población: muestra consecutiva de 99 avenamientos pleurales realizados en 83 pacientes en el período comprendido entre diciembre de 1997 y noviembre de 1998 inclusive. Método: se utilizó un protocolo que incluía datos personales, diagnóstico, etiopatogenia, gravedad, vía de abordaje, material utilizado y seguimiento clínico-radiológico. Resultados: de un total de 99 avenamientos pleurales, 47 fueron neumotórax (47,47 por ciento), 28 hemoneumotórax (28,28 por ciento), 14 empiema (14,14 por ciento), 8 hemotórax (8,08 por ciento), 1 hidrotórax (1,01 por ciento) y 1 hidroneumotórax (1,01 por ciento). Conscluiones: conocer la fisiopatología del espacio pleural, su tratamiento quirúrgico y seguimiento. (AU)

Video-toracoscopía / Video Thoracoscopy

La Video-Toracoscopía es un procedimiento que consiste en la inspección, toma de muestras y tratamiento de algunas condiciones patológicas de los órganos del tórax, mediante la introducción y manipulación de instrumentos quirúrgicos y ópticos especiales de la cavidad pleural. Durante los últimos años la tecnología ha sido perfeccionada no sólo desde el punto de vista óptico-eléctrico, sino con la proliferación de instrumentos sumamente ingeniosos y versátiles que han permitido el ataque de condiciones antes tratables solamente mediante la cirugía torácica convencional. Con el uso de este abordaje, el paciente experimenta mucho menos dolor, se recupera prontamente y egresa más rápido. Una desventaja obvia es la alta inversión inicial para obtener el equipo y la compra de material rehusable en cada caso. Debido a la falta de estos equipos en nuestros hospitales, los médicos costarricenses vamos haciendo nuestra experiencia muy despacio, ya que básicamente ésta se consigue solo en la práctica privada