Randomized comparison of oblique and perpendicular stabilizers for minimally invasive repair of pectus excavatum.

OBJECTIVES: Bar dislocation is one of the most feared complications of the minimally invasive repair of pectus excavatum. METHODS: Prospective randomized parallel-group clinical trial intending to assess whether oblique stabilizers can reduce bar displacement in comparison with regular stabilizers used in minimally invasive repair of pectus excavatum. Additionally, we evaluated pain, quality of life and other postoperative complications. Participants were randomly assigned to surgery with perpendicular (n = 16) or oblique stabilizers (n = 14) between October 2017 and September 2018 and followed for 3 years. Bar displacements were evaluated with the bar displacement index. Pain scores were evaluated through visual analogue scale and quality of life through the Pectus Excavatum Evaluation Questionnaire. RESULTS: Control group average displacement index was 17.7 (±26.7) and intervention group average displacement index was 8.2 (±10.9). There was 1 reoperation in each group that required correction with 2 bars. Bar displacement was similar among groups (P = 0.12). No other complications were recorded. There was no statistically significant difference on pain score. There was a significant difference between pre- and postoperative composite scores of the participants' body image domain and psycho-social aspects in both groups. The difference between the pre- and postoperative participants' perception of physical difficulties was greater and statistically significant in the intervention group. CONCLUSIONS: There was no statistical difference in the use of perpendicular or oblique stabilizers, but the availability of different models of stabilizers during the study suggested that this can be advantageous. The trial is registered at ClinicalTrials.gov, number NCT03087734.

Video-assisted thoracoscopic surgery in swine: an animal model for thoracoscopic lobectomy training.

OBJECTIVES: Minimally invasive thoracic procedures have been increasingly used; however, only a small number of lobectomies are performed by videothoracoscopy, showing the need for training on this technique. The objective of this study is to demonstrate the technique of lobectomy using videothoracoscopy in swine, highlighting the steps to be taken during its use in surgical experimentation. METHODS: During the advanced course on video-assisted and thoracoscopic procedures carried out at IRCAD Latin America, Barretos, Brazil, 40 swine were used for the hands-on course on video-assisted upper left lobectomy. Monopulmonary ventilation was performed by blocking the left main bronchus. Surgical procedures were performed using three ports and the anterior dissection technique (fissureless approach). The pulmonary hilar structures were dissected using conventional open surgery and video-assisted surgical tools. The first structure treated in the approach of the hilar structures was the upper lobe vein, followed by the bronchus and the branches of the pulmonary artery. RESULTS: The mean time required to anaesthetize the animals was 3 h. Intraoperative hypoventilation was observed in 26 animals (65%) and 4 (10%) of them had a poor outcome and died in the last third part of the surgery. Eight (20%) animals had bradycardia, and six responded to the use of atropine. In two (5%), it was not possible to revert the bradycardia and the animals died at the end of the procedures. The surgical procedures had a mean duration of 3 h and the total time of anaesthesia was about 6 h. DISCUSSION: Swine have been frequently used for hands-on training in surgery but there are no reports in the literature describing the anatomical, anaesthetic and technical peculiarities that must be observed during videothoracoscopic lobectomy training in swine. Video-assisted thoracoscopic surgery lobectomy using swine is an adequate method to train thoracic surgeons. For surgeons to make the best use of minimally invasive technique training, it is essential that issues related to the anatomy, anaesthesia, monopulmonary ventilation and surgical technique described in this study are taken into account.

Diaphragmatic pacing stimulation in spinal cord injury: anesthetic and perioperative management.

OBJECTIVE: The standard therapy for patients with high-level spinal cord injury is long-term mechanical ventilation through a tracheostomy. However, in some cases, this approach results in death or disability. The aim of this study is to highlight the anesthetics and perioperative aspects of patients undergoing insertion of a diaphragmatic pacemaker. METHODS: Five patients with quadriplegia following high cervical traumatic spinal cord injury and ventilator-dependent chronic respiratory failure were implanted with a laparoscopic diaphragmatic pacemaker after preoperative assessments of their phrenic nerve function and diaphragm contractility through transcutaneous nerve stimulation. ClinicalTrials.gov: NCT01385384. RESULTS: The diaphragmatic pacemaker placement was successful in all of the patients. Two patients presented with capnothorax during the perioperative period, which resolved without consequences. After six months, three patients achieved continuous use of the diaphragm pacing system, and one patient could be removed from mechanical ventilation for more than 4 hours per day. CONCLUSIONS: The implantation of a diaphragmatic phrenic system is a new and safe technique with potential to improve the quality of life of patients who are dependent on mechanical ventilation because of spinal cord injuries. Appropriate indication and adequate perioperative care are fundamental to achieving better results.

Diaphragmatic pacing stimulation in spinal cord injury: anesthetic and perioperative management

OBJECTIVE: The standard therapy for patients with high-level spinal cord injury is long-term mechanical ventilation through a tracheostomy. However, in some cases, this approach results in death or disability. The aim of this study is to highlight the anesthetics and perioperative aspects of patients undergoing insertion of a diaphragmatic pacemaker. METHODS: Five patients with quadriplegia following high cervical traumatic spinal cord injury and ventilator-dependent chronic respiratory failure were implanted with a laparoscopic diaphragmatic pacemaker after preoperative assessments of their phrenic nerve function and diaphragm contractility through transcutaneous nerve stimulation. ClinicalTrials.gov: NCT01385384. RESULTS: The diaphragmatic pacemaker placement was successful in all of the patients. Two patients presented with capnothorax during the perioperative period, which resolved without consequences. After six months, three patients achieved continuous use of the diaphragm pacing system, and one patient could be removed from mechanical ventilation for more than 4 hours per day. CONCLUSIONS: The implantation of a diaphragmatic phrenic system is a new and safe technique with potential to improve the quality of life of patients who are dependent on mechanical ventilation because of spinal cord injuries. Appropriate indication and adequate perioperative care are fundamental to achieving better results.

The Nuss procedure made safer: an effective and simple sternal elevation manoeuvre.

The Nuss procedure requires the creation of a substernal tunnel for bar positioning. This is a manoeuvre that can be dangerous, and cardiac perforation has occurred in a few cases. Our purpose was to describe two technical modifications that enable the prevention of these fatal complications. A series of 25 patients with pectus excavatum were treated with a modification of the Nuss procedure that included the entrance in the left haemithorax first, and the use of the retractor to lift the sternum, with the consequent lowering displacement of the heart. These modified techniques have certain advantages: (i) the narrow anterior mediastinum between the sternum and the pericardial sac is expanded by pulling up the sternum; (ii) the thoracoscopic visualization of the tip of the introducer during tunnel creation is improved; (iii) the rubbing of the introducer against the pericardium is minimized; (iv) the exit path of the introducer can be guided by the surgeon's finger and (v) haemostasis and integrity of the pericardial sac can be more easily confirmed. We observed that with these manoeuvres, the risk of pericardial sac and cardiac injury can be markedly reduced.

Punción transbronquial con o sin EBUS: esta es la cuestión / TBNA or EBUS-TBNA? That is the Question

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Traqueostomia percutânea / Percutaneous tracheostomy

Este estudo é uma revisão atualizada a respeito das duas técnicas de traqueostomia percutânea disponíveis em nosso meio, expondo suas limitações e sua implicação na prática clínica.A técnica mostrou ser uma opção segura, com baixas taxas de morbidade e mortalidade, e aparentemente com menor incidência de complicações tardias quando comparada à técnica convencional cirúrgica, além da possibilidade de ser realizada à beira do leito, sem a necessidade de submeter um paciente de terapia intensiva a um transporte de risco até o centro cirúrgico. Esses fatos tem feito com que a traqueostomia percutânea seja um procedimento que vem sendo cada vez mais utilizado. Entretanto ainda há necessidade de mais estudos controlados comparando a traqueostomia convencional com a percutânea para definir qual dos métodos é mais benéfico para os pacientes.

This study is an updated review about the two percutaneous tracheostomy techniques available in Brazil, addressing their limitations and clinical implications.The method proved to be a safe option, with low rates of morbidity and mortality, and apparently with a lower incidence of late complications comparedto conventional surgical technique, plus the ability to be performed at the bedside, without theneed to transport a critically ill patient to the surgical ward. Consequently. percutaneous tracheostomy is a procedure that has been more widely used. However there is still need formore controlled studies comparing conventional with percutaneous tracheostomy to define which method is most beneficial for patients.

Endobronchial closure of total bronchopleural fistula with Occlutech Figulla ASD N device.

Bronchopleural fistula may be treated by medical, endoscopic, and surgical techniques, but large fistulas remain a challenge to be closed using endoscopic techniques. We describe the endoscopic closure of a bronchial total fistula with the Occlutech Figulla ASD N device (International Occlutech AB, Helsingborg, Sweden), originally designed for closure of an atrial septal defect. The procedure was conducted without general anesthesia or rigid bronchoscopy, bronchography, or radioscopy. An immediate reduction in the air leak was observed and also later on bronchoscopy, as the device was almost covered by granulation tissue. The endobronchial technique described seems to be safe and effective to manage large bronchopleural fistulas.

Endobronchial closure of total bronchopleural fistula with occlutech figulla ASD N device

Bronchopleural fistula may be treated by medical, endoscopic, and surgical techniques, but large fistulas remaina challenge to be closed using endoscopic techniques. We describe the endoscopic closure of a bronchial totalfistula with the Occlutech Figulla ASD N device (International Occlutech AB, Helsingborg, Sweden), originallydesigned for closure of an atrial septal defect. The procedure was conducted without general anesthesia or rigid bronchoscopy, bronchography, or radioscopy. An immediate reduction in the air leak was observed and alsolater on bronchoscopy, as the device was almost covered by granulation tissue. The endobronchial technique described seems to be safe and effective to manage large bronchopleuralfistulas.