Lung nodule localization in hybrid room before minimally invasive thoracic surgery: series of 20 cases and literature review.

OBJECTIVE: To describe an experience in the preoperative localization of small pulmonary nodules and ground-glass lesions to guide minimally invasive thoracic surgery; in addition, a literature review was conducted, including the main advantages and disadvantages of the different agents used, and site marking in a hybrid operating room. METHODS: A retrospective search was conducted in a Interventional Radiology Department database, between March 2015 and May 2019, to identify patients undergoing preoperative percutaneous marking of lung injuries measuring up to 25mm. RESULTS: A total of 20 patients were included and submitted to descriptive analysis. All patients were marked in a hybrid room, at the same surgical-anesthetic time. Most often used markers were guidewire, Lipiodol® and microcoils. Despite one case of coil displacement, two cases of pneumothorax, and one case of hypotension after marking, all lesions were identified and resected accordingly from all patients. CONCLUSION: Preoperative percutaneous localization of lung injuries in hybrid room is an effective and a safe technique, which can have decisive impact on surgical resection. The choice of marker and of the operating room scenario should be based on availability and experience of service. Multidisciplinary discussions with surgical teams, pathologists, and interventional radiologists are crucial to improve outcome of patients.

Lung nodule localization in hybrid room before minimally invasive thoracic surgery: series of 20 cases and literature review

ABSTRACT Objective To describe an experience in the preoperative localization of small pulmonary nodules and ground-glass lesions to guide minimally invasive thoracic surgery; in addition, a literature review was conducted, including the main advantages and disadvantages of the different agents used, and site marking in a hybrid operating room. Methods A retrospective search was conducted in a Interventional Radiology Department database, between March 2015 and May 2019, to identify patients undergoing preoperative percutaneous marking of lung injuries measuring up to 25mm. Results A total of 20 patients were included and submitted to descriptive analysis. All patients were marked in a hybrid room, at the same surgical-anesthetic time. Most often used markers were guidewire, Lipiodol® and microcoils. Despite one case of coil displacement, two cases of pneumothorax, and one case of hypotension after marking, all lesions were identified and resected accordingly from all patients. Conclusion Preoperative percutaneous localization of lung injuries in hybrid room is an effective and a safe technique, which can have decisive impact on surgical resection. The choice of marker and of the operating room scenario should be based on availability and experience of service. Multidisciplinary discussions with surgical teams, pathologists, and interventional radiologists are crucial to improve outcome of patients.

Applications for a hybrid operating room in thoracic surgery: from multidisciplinary procedures to --image-guided video-assisted thoracoscopic surgery.

The concept of a hybrid operating room represents the union of a high-complexity surgical apparatus with state-of-the-art radiological tools (ultrasound, CT, fluoroscopy, or magnetic resonance imaging), in order to perform highly effective, minimally invasive procedures. Although the use of a hybrid operating room is well established in specialties such as neurosurgery and cardiovascular surgery, it has rarely been explored in thoracic surgery. Our objective was to discuss the possible applications of this technology in thoracic surgery, through the reporting of three cases. RESUMO O conceito de sala híbrida traduz a união de um aparato cirúrgico de alta complexidade com recursos radiológicos de última geração (ultrassom, TC, radioscopia e/ou ressonância magnética), visando a realização de procedimentos minimamente invasivos e altamente eficazes. Apesar de bem estabelecido em outras especialidades, como neurocirurgia e cirurgia cardiovascular, o uso da sala hibrida ainda é pouco explorado na cirurgia torácica. Nosso objetivo foi discutir as aplicações e as possibilidades abertas por essa tecnologia na cirurgia torácica através do relato de três casos.

Applications for a hybrid operating room in thoracic surgery: from multidisciplinary procedures to ­­image-guided video-assisted thoracoscopic surgery / Usos da sala híbrida em cirurgia torácica: de procedimentos multidisciplinares à cirurgia toracoscópica videoassistida guiada por imagem

ABSTRACT The concept of a hybrid operating room represents the union of a high-complexity surgical apparatus with state-of-the-art radiological tools (ultrasound, CT, fluoroscopy, or magnetic resonance imaging), in order to perform highly effective, minimally invasive procedures. Although the use of a hybrid operating room is well established in specialties such as neurosurgery and cardiovascular surgery, it has rarely been explored in thoracic surgery. Our objective was to discuss the possible applications of this technology in thoracic surgery, through the reporting of three cases.

RESUMO O conceito de sala híbrida traduz a união de um aparato cirúrgico de alta complexidade com recursos radiológicos de última geração (ultrassom, TC, radioscopia e/ou ressonância magnética), visando a realização de procedimentos minimamente invasivos e altamente eficazes. Apesar de bem estabelecido em outras especialidades, como neurocirurgia e cirurgia cardiovascular, o uso da sala hibrida ainda é pouco explorado na cirurgia torácica. Nosso objetivo foi discutir as aplicações e as possibilidades abertas por essa tecnologia na cirurgia torácica através do relato de três casos.

Do Current Lung Cancer Screening Guidelines Apply for Populations With High Prevalence of Granulomatous Disease? Results From the First Brazilian Lung Cancer Screening Trial (BRELT1).

BACKGROUND: Low-dose computed tomography (LDCT) screening for lung cancer has been demonstrated to be effective in reducing cancer mortality. However, these studies have not been undertaken in countries where the incidence of granulomatous disease is high. The First Brazilian Lung Cancer Screening Trial (BRELT1) has completed initial accrual and is now in the follow-up phase. We present results from the initial prevalence round of screening. METHODS: The inclusion criteria were the same as those for the National Lung Cancer Screening Trial (NLST). Pulmonary nodules larger than 4 mm were considered positive and required evaluation by a multidisciplinary team. Indeterminate nodules were evaluated with fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) or biopsy when indicated. Statistical analysis was performed with Fisher's exact test to compare our positive findings with those of the NLST. RESULTS: From January 2013 to July 2014, 790 participants were enrolled. Positive LDCT scans were reported in 312 (39.4%) participants, with a total of 552 nodules larger than 4 mm. The comparison between positive findings in the NLST (7,191 of 26,722 cases) and those in the BRELT1 (312 of 790 cases) showed a significant difference (p < 0.001). The positive predictive value was lower in BRELT1 than in the NLST (3.2% versus 3.8%, respectively). Follow-up imaging was indicated in 278 of 312 (89.1%) participants; 35 procedures were performed in 25 participants. In 15 cases, benign lesions were diagnosed. Non-small-cell lung cancer (NSCLC) was diagnosed in 10 patients (prevalence of 1.3%). In 8 patients (stage IA/IB disease), treatment was by resection only, in 1 patient neoadjuvant chemotherapy was used (stage IIIA), and in 1 patient advanced disease was diagnosed (stage IV). CONCLUSIONS: Using NSLT criteria, a larger number of patients had positive scans (nodules), compared with previous lung cancer screening studies. However, the number of participants requiring surgical biopsy procedures and who were ultimately identified as having cancer was similar to other reports. This supports the role of screening in patient populations with a high incidence of granulomatous inflammation.

Randomized trial - oxybutynin for treatment of persistent plantar hyperhidrosis in women after sympathectomy.

OBJECTIVE: Hyperhidrosis is a common disease, and thoracoscopic sympathectomy improves its symptoms in up to 95% of cases. Unfortunately, after surgery, plantar hyperhidrosis may remain in 50% of patients, and compensatory sweating may be observed in 70%. This clinical scenario remains a challenge. Our objective was to evaluate the effectiveness of oxybutynin in the treatment of persistent plantar hyperhidrosis and compensatory sweating and its effects on quality of life in women after thoracoscopic sympathectomy. METHOD: We conducted a prospective, randomized study to compare the effects of oxybutynin at 10 mg daily and placebo in women with persistent plantar hyperhidrosis. The assessment was performed using a quality-of-life questionnaire for hyperhidrosis and sweating measurement with a device for quantifying transepidermal water loss. Clinicaltrials.gov: NCT01328015. RESULTS: Sixteen patients were included in each group (placebo and oxybutynin). There were no significant differences between the groups prior to treatment. After oxybutynin treatment, there was a decrease in symptoms and clinical improvement based on the quality-of-life questionnaire (before treatment, 40.4 vs. after treatment, 17.5; p=0.001). The placebo group showed modest improvement (p=0.09). The outcomes of the transepidermal water loss measurements in the placebo group showed no differences (p=0.95), whereas the oxybutynin group revealed a significant decrease (p=0.001). The most common side effect was dry mouth (100% in the oxybutynin group vs. 43.8% in the placebo group; p=0.001). CONCLUSION: Oxybutynin was effective in the treatment of persistent plantar hyperhidrosis, resulting in a better quality of life in women who had undergone thoracoscopic sympathectomy.

Randomized trial - oxybutynin for treatment of persistent plantar hyperhidrosis in women after sympathectomy

OBJECTIVE: Hyperhidrosis is a common disease, and thoracoscopic sympathectomy improves its symptoms in up to 95% of cases. Unfortunately, after surgery, plantar hyperhidrosis may remain in 50% of patients, and compensatory sweating may be observed in 70%. This clinical scenario remains a challenge. Our objective was to evaluate the effectiveness of oxybutynin in the treatment of persistent plantar hyperhidrosis and compensatory sweating and its effects on quality of life in women after thoracoscopic sympathectomy. METHOD: We conducted a prospective, randomized study to compare the effects of oxybutynin at 10 mg daily and placebo in women with persistent plantar hyperhidrosis. The assessment was performed using a quality-of-life questionnaire for hyperhidrosis and sweating measurement with a device for quantifying transepidermal water loss. Clinicaltrials.gov: NCT01328015. RESULTS: Sixteen patients were included in each group (placebo and oxybutynin). There were no significant differences between the groups prior to treatment. After oxybutynin treatment, there was a decrease in symptoms and clinical improvement based on the quality-of-life questionnaire (before treatment, 40.4 vs. after treatment, 17.5; p = 0.001). The placebo group showed modest improvement (p = 0.09). The outcomes of the transepidermal water loss measurements in the placebo group showed no differences (p = 0.95), whereas the oxybutynin group revealed a significant decrease (p = 0.001). The most common side effect was dry mouth (100% in the oxybutynin group vs. 43.8% in the placebo group; p = 0.001). CONCLUSION: Oxybutynin was effective in the treatment of persistent plantar hyperhidrosis, resulting in a better quality of life in women who had undergone thoracoscopic sympathectomy. .

Medida do fluxo intraoperatório com fluxômetro TTFM nos enxertos coronários: resultados de amostra nacional / Intraoperative coronary grafts flow measurement using the TTFM flowmeter: results from a domestic sample

OBJETIVO: Avaliar a perviedade dos enxertos no intraoperatório e identificar enxertos com risco de oclusão precoce. MÉTODOS: Cinquenta e quatro pacientes foram submetidos à revascularização do miocárdio e foi utilizado o fluxômetro (Medtronic Medi-Stim) que utiliza o método de tempo de trânsito (TTFM) para avaliação do fluxo nos enxertos. Três pacientes tinham lesão de tronco de artéria coronária esquerda e 48 apresentavam função ventricular normal ou pouco comprometida. RESULTADOS: A mortalidade hospitalar foi de dois (3,7%) pacientes, um por trombose mesentérica e outro por choque cardiogênico. Dezessete (31,4%) pacientes foram operados sem circulação extracorpórea (CEC). O fluxo no enxerto arterial variou de 8 a 106 ml/min, com média de 31,14 ml/min, e nos enxertos venosos de 9 a 149 ml/min, com média de 50,42 ml/min. CONCLUSÃO: O fluxômetro representa maior segurança para o cirurgião e para o paciente. Até mesmo sob o aspecto legal essa documentação dos enxertos pérvios evitará questionamentos futuros.

OBJECTIVE: To evaluate intraoperative graft patency and identify grafts under risk of early occlusion. METHODS: Fifty four patients were submitted to coronary artery bypass surgery and the graft flow was assessed by the Flowmeter (Medtronic Medistim), which utilizes the TTFM method. Three patients had left main disease and 48 had normal or mildly reduced left ventricular function. RESULTS: In hospital mortality was 3.7% (two patients), one for mesenteric thrombosis and one due to cardiogenic chock. Seventeen patients (34%) were submitted to off pump CABG. Arterial Graft flow measures ranged from 8 to 106 ml/min (average 31.14 ml/min), and venous grafts flow ranged from 9 to 149 ml/min (average 50.42 ml/min). CONCLUSION: Flowmeter use represents higher safety both for patients and surgeons. Even under legal aspects, the documentation provided by the device can avoid future questionings.

A video-assisted endotracheal suture technique for correction of distal tracheal laceration after intubation.

The incidence of tracheal laceration is 1 of 20,000 intubations. The most frequently affected area is the posterior tracheal wall (membranous). Risk factors include several forced attempts at intubation, inexperience of the clinician, tracheal introducers (guidewires) that protrude beyond the tip of the tube, and emergency procedures. Surgical treatment of tracheal lacerations can be by a transtracheal suture technique or a right thoracotomy. Using the concept of minimally invasive surgical procedures, we reported the treatment of 2 patients with tracheal lacerations greater than 5 cm in the distal trachea that were treated with endotracheal video-assisted suturing using a cervical incision.

Intraoperative coronary grafts flow measurement using the TTFM flowmeter: results from a domestic sample.

OBJECTIVE: To evaluate intraoperative graft patency and identify grafts under risk of early occlusion. METHODS: Fifty four patients were submitted to coronary artery bypass surgery and the graft flow was assessed by the Flowmeter (Medtronic Medistim), which utilizes the TTFM method. Three patients had left main disease and 48 had normal or mildly reduced left ventricular function. RESULTS: In hospital mortality was 3.7% (two patients), one for mesenteric thrombosis and one due to cardiogenic chock. Seventeen patients (34%) were submitted to off pump CABG. Arterial Graft flow measures ranged from 8 to 106 ml/min (average 31.14 ml/min), and venous grafts flow ranged from 9 to 149 ml/min (average 50.42 ml/min). CONCLUSION: Flowmeter use represents higher safety both for patients and surgeons. Even under legal aspects, the documentation provided by the device can avoid future questionings.

Ischemic preconditioning influence ventricular function in off-pump revascularization surgery.

BACKGROUND: Ischemic preconditioning is a method that prepares and protects cells to tolerate a long period of ischemia with the least possible injury. OBJECTIVES: Evaluate the influence of ischemic preconditioning over left ventricular function during off-pump myocardial revascularization. METHOD: Forty patients with clinical indication for off-pump myocardial revascularization were randomized in two groups, with or without ischemic preconditioning. Ischemic preconditioning was carried out by performing coronary occlusion for two minutes and releasing blood flow for one minute; two cycles were performed. Left ventricular contractility was evaluated through transesophageal Doppler by measuring blood flow acceleration in the descending aorta - Hemosonic 100. The acceleration measurements were performed at the start of the surgery, after heart positioning and five and ten minutes after coronary occlusion. RESULTS: There was no significant difference in left ventricular contractility between the two groups. At the beginning of the procedure flow acceleration was 9.37 +/- 2.9m/s(2) in the preconditioning group and 12.5 +/- 3.1 m/s(2) in no-preconditioning group (p = 0.23); after positioning of heart, it was 8.47 +/- 3.3 and 8.31 +/- 3.6 m/s(2) (p = 0.96); after five minutes - 8.7 +/- 4.1 and 7.94 +/- 2.9 m/s(2) (p = 0.80); and after ten minutes - 9.2 +/- 4.5 and 7.98 +/- 3.4 m/s(2) (p = 0.71). However, contractility evolution was different throughout time in each group. The preconditioning group maintained left ventricular contractility during the entire procedure, since the beginning (0.52), while the group without ischemic preconditioning presented reduction in left ventricular contractility (p = 0.0034). CONCLUSION: Ischemic preconditioning prevented the decrease in left ventricular contractility during off-pump myocardial revascularization surgery.

O pré-condicionamento isquêmico influencia a contratilidade ventricular na cirurgia sem extracorpórea / Ischemic preconditioning influence ventricular function in off-pump revascularization surgery

FUNDAMENTO: O pré-condicionamento isquêmico é um método que prepara e protege a célula para suportar um período de isquemia prolongada com menor dano celular possível. OBJETIVO: Avaliar a influência do pré-condicionamento isquêmico na contratilidade ventricular esquerda durante a cirurgia de revascularização do miocárdio sem circulação extracorpórea. MÉTODO: Quarenta pacientes com indicação para revascularização do miocárdio foram randomizados em dois grupos, com e sem pré-condicionamento isquêmico. O pré-condicionamento isquêmico foi obtido realizando a oclusão coronária por dois minutos e liberação do fluxo sanguíneo por um minuto, sendo realizados dois ciclos. A contratilidade ventricular esquerda foi avaliada por meio de Doppler pulsado da aorta torácica descendente (Hemosonic 100). As medidas da aceleração do fluxo sanguíneo na aorta foram obtidas antes do início do procedimento, após o posicionamento do coração e com cinco e dez minutos de oclusão coronária. RESULTADOS: No início do procedimento, a aceleração do fluxo foi de 9,37 ± 2,9m/s² no grupo com pré-condicionamento, e de 12,5 ± 3,1 m/s² no grupo sem pré-condicionamento (p = 0,23). Após o posicionamento do coração foi de 8,47 ± 3,3 e 8,31 ± 3,6 m/s² (p=0,96); com cinco minutos foi de 8,7 ± 4,1 e 7,94 ± 2,9 m/s² (p = 0,80); e com dez minutos foi de 9,2 ± 4,5 e 7,98 ± 3,4 m/s² (p=0,71), respectivamente. No entanto, o comportamento da contratilidade ventricular foi diferente ao longo do tempo. No grupo pré-condicionado houve manutenção da contratilidade ventricular em relação ao início do procedimento (p = 0,52), enquanto que no grupo sem pré-condicionamento houve redução da contratilidade ventricular (p = 0,0034). CONCLUSÕES: O Pré-condicionamento isquêmico evitou a redução da contratilidade ventricular esquerda durante a realização da revascularização do miocárdio sem circulação extracorpórea.

BACKGROUND: Ischemic preconditioning is a method that prepares and protects cells to tolerate a long period of ischemia with the least possible injury. OBJECTIVES: Evaluate the influence of ischemic preconditioning over left ventricular function during off-pump myocardial revascularization. METHOD: Forty patients with clinical indication for off-pump myocardial revascularization were randomized in two groups, with or without ischemic preconditioning. Ischemic preconditioning was carried out by performing coronary occlusion for two minutes and releasing blood flow for one minute; two cycles were performed. Left ventricular contractility was evaluated through transesophageal Doppler by measuring blood flow acceleration in the descending aorta - Hemosonic 100. The acceleration measurements were performed at the start of the surgery, after heart positioning and five and ten minutes after coronary occlusion. RESULTS: There was no significant difference in left ventricular contractility between the two groups. At the beginning of the procedure flow acceleration was 9.37 ± 2.9m/s² in the preconditioning group and 12.5 ± 3.1 m/s² in no-preconditioning group (p = 0.23); after positioning of heart, it was 8.47 ± 3.3 and 8.31 ± 3.6 m/s² (p = 0.96); after five minutes - 8.7 ± 4.1 and 7.94 ± 2.9 m/s² (p = 0.80); and after ten minutes - 9.2 ± 4.5 and 7.98 ± 3.4 m/s² (p = 0.71). However, contractility evolution was different throughout time in each group. The preconditioning group maintained left ventricular contractility during the entire procedure, since the beginning (0.52), while the group without ischemic preconditioning presented reduction in left ventricular contractility (p = 0.0034). CONCLUSION: Ischemic preconditioning prevented the decrease in left ventricular contractility during off-pump myocardial revascularization surgery.

Fratura de coluna vertebral torácica com perfuração esofágica e abscesso epidural em acidente automobilístico / Fracture of thoracic spine with simultaneous esophageal perforation and epidural abscess in a car accident

Objetivo: Apresentar e discutir a ocorrência de perfuração esofágica e formação de abscesso epidural relacionada à fratura da coluna vertebral dorsal. Métodos: Apresentamos uma paciente de 72 anos de idade, que dirigia seu carro e sofreu um acidente automobilístico, com colisão frontal em março de 2006. A paciente foi admitida na sala de emergência consciente e sem alterações neurológicas, com fratura do terço proximal da tíbia, fratura vertebrais em T2, T3 e T4. Neste último nível se notava um discreto achatamento, além de uma pequena espícula óssea na região anterior da vértebra T2. No terceiro dia de hospitalização a paciente manifestou dificuldade para deglutição e alterações sensitivas e motoras nos membros, principalmente no membro inferior direito. Realizaram-se exames que constataram a perfuração esofágica, com mediastinite e formação de abscesso epidural. A paciente foi submetida à toracotomia para tratamento da lesão esofágica e limpeza cirúrgica, optando-se pelo tratamento conservador do abscesso vertebral com antibioticoterapia. Resultado: A paciente teve recuperação progressiva do quadro infeccioso e neurológico e seis meses depois foi realizada cirurgia para restituição do trânsito esofágico. Atualmente a paciente consegue deambular com uma órtese para manter a extensão do pé direito, que tem força grau 2. Conclusão: Muitos autores relatam a dificuldade para o diagnóstico precoce da perfuração do esôfago, devido à pobreza de manifestações clínicas iniciais. Este fator pode prejudicar a sobrevida do paciente, principalmente se o tratamento ocorrer 24 horas após a lesão.

[Development and assessment of a multimedia computer program to teach pleural drainage techniques]. / Desenvolvimento e avaliação de um programa multimídia de computador para ensino de drenagem pleural.

OBJECTIVE: To develop a multimedia educational computer program designed to teach pleural drainage techniques to health professionals, as well as to evaluate its efficacy. METHODS: We planned and developed a program, which was evaluated by 35 medical students, randomized into two groups. Group 1 comprised 18 students who studied using the program, and group 2 comprised 17 students who attended a traditional theoretical class given by an experienced teacher. Group 1 students were submitted to two subjective evaluations using questionnaires, and both groups took an objective theoretical test with multiple choice questions and descriptive questions. The results of the theoretical test were compared using the Mann-Whitney test. RESULTS: The subjective evaluation of the technological aspects and content of the program ranged from excellent to very good and good. The software was considered highly instructive by 16 students (88.9%), and 17 students (94.4%) thought it might partially substitute for traditional classes. Between the two groups, there was no significant difference in the multiple choice test results, although there was such a difference in the descriptive question results (p < 0.001), group 1 students scoring higher than did those in group 2. CONCLUSIONS: The computer program developed at the Federal University of São Paulo Paulista School of Medicine proved to be a feasible means of teaching pleural drainage techniques. The subjective evaluation of this new teaching method revealed a high level of student satisfaction, and the objective evaluation showed that the program was as efficacious as is traditional instruction.