Cirugía de revascularización miocárdica: comparación de supervivencia a 10 años de la cirugía coronaria con y sin circulación extracorpórea mediante Propensity Score Matching / Ten-year survival after off-pump coronary artery bypass grafting compared with traditional bypass grafting

BACKGROUND: Long-term outcomes of Off-Pump Coronary Artery Bypass Grafting (OPCAB) as an alternative to the traditional Coronary Artery Bypass Grafting (CABG) technique with cardiopulmonary bypass (CPB) are not well defined. AIM: To compare 10-year survival of isolated OPCAB versus CABG with CPB. MATERIAL AND METHODS: Analysis of information obtained from databases, clinical records and surgical protocols of patients treated with isolated CABG between January 2006 and November 2008 at a Regional Hospital. Of 658 isolated CABG, 192 (29.2%) were OPCAB and 466 (79.9%) CPB. Propensity Score Matching (PSM) was performed to compare both groups. After PSM, two groups of 192 cases were obtained. Mortality data was obtained from the Chilean public identification service. Ten-year survival was calculated and compared with Kaplan-Meier and log-rank methods. RESULTS: Follow-up data was obtained in all cases. No statistically significant differences were found when comparing 10-year survival between OPCAB versus CPB (78.6% and 80.2% respectively, p 0.720). There was also no statistical difference in cardiovascular death free survival (90.1% with CPB versus 89.1% OPCAB, p 0.737). Survival was comparable when analyzing subgroups with diabetes mellitus, left ventricular dysfunction or chronic kidney disease, among others. CONCLUSIONS: In our series, OPBAB has a comparable 10-year survival with CABG with CPB.

Associação entre os fatores de risco e complicações pós-operatórias em cirurgia cardíaca / Association between risk factors and postoperative complications in cardiac surgery / Asociación entre factores de riesgo y complicaciones postoperatorias en cirugía cardíaca

Objetivo: identificar a associação entre os fatores de risco e as complicações pós-operatórias em pacientes submetidos a cirurgia cardíaca. Método: estudo documental, retrospectivo, com abordagem quantitativa, realizado com 388 prontuários de pacientes submetidos à cirurgia cardíaca. A coleta de dados foi realizada entre agosto e setembro de 2018. Para verificar associações entre fatores de risco e complicação no pós-operatório imediato utilizou-se o teste de Qui-quadrado de Pearson. Utilizou p-valor <0,05. Resultados: verificou-se associação estatística significativa entre os fatores de risco infarto agudo do miocárdio, insuficiência cardíaca, insuficiência renal crônica cardiopatia isquêmica, balão intra-aórtico, doença pulmonar obstrutiva crônica e diabetes mellitus com complicações no pós-operatório imediato. Conclusão: ao conhecer os fatores de risco dos pacientes submetidos à cirurgia cardíaca com associação nas complicações pós-operatórias os enfermeiros poderão realizar um plano de cuidados individual além de ações de prevenção dos fatores de risco. (AU)

Objective: To identify the association between risk factors and postoperative complications in patients undergoing cardiac surgery. Methods: Documentary, retrospective, analytical, quantitative study with 388 medical records of patients undergoing cardiac surgery. Data collection was carried out between August and September 2018. To check associations between risk factors and complications in the immediate postoperative period, Pearson's chi square test was used. It used a p-value <0.05. Results: There was a significant association between risk factors for acute myocardial infarction, heart failure, chronic renal failure, ischemic heart disease, intra-aortic balloon, chronic obstructive pulmonary disease and diabetes mellitus with complications in the immediate postoperative period. Conclusion: By knowing the risk factors of patients undergoing cardiac surgery with an association with postoperative complications, nurses will be able to carry out an individual care plan in addition to actions to prevent risk factors. (AU)

Objetivo: Identificar la asociación entre factores de riesgo y complicaciones posoperatorias en pacientes sometidos a cirugía cardíaca. Métodos: Estudio documental, retrospectivo, analítico y cuantitativo con 388 historias clínicas de pacientes sometidos a cirugía cardíaca. La recolección de datos se realizó entre agosto y septiembre de 2018. Para verificar las asociaciones entre factores de riesgo y complicaciones en el postoperatorio inmediato, se utilizó la prueba de chi-cuadrado de Pearson. Usó un valor de p <0.05. Resultados: Hubo asociación significativa entre los factores de riesgo de infarto agudo de miocardio, insuficiencia cardíaca, insuficiencia renal crónica, cardiopatía isquémica, balón intraaórtico, enfermedad pulmonar obstructiva crónica y diabetes mellitus con complicaciones en el postoperatorio inmediato. Conclusión: Al conocer los factores de riesgo de los pacientes sometidos a cirugía cardíaca con asociación a complicaciones postoperatorias, el enfermero podrá realizar un plan de cuidados individualizado además de acciones para prevenir los factores de riesgo. (AU)

Secuestro pulmonar: caracterización y tratamiento en pacientes adultos y pediátricos / Pulmonary sequestration: characteristics and treatment in adult and pediatric patients

Resumen Introducción: El secuestro pulmonar (SP) es una malformación congénita caracterizada por tejido pulmonar con vascularización de una arteria sistémica anómala. Objetivo: Analizar las características y tratamiento de pacientes adultos y pediátricos con secuestro pulmonar. Materiales y Método: Estudio descriptivo transversal. Periodo: enero de 1988 a diciembre de 2018. La información se obtuvo de fichas clínicas y registros de anatomía patológica. Se describen edad, sexo, características clínicas, diagnóstico, tratamiento quirúrgico y hallazgos anatomopatológicos. Se realizó análisis estadístico mediante SPSS25® y se usó la prueba Mann-Whitney y X2, considerándose significativo p < 0,05. Resultados: Total 33 pacientes, 25 (75,8%) mujeres. Edad promedio 30,2 años, rango: 0-68. Adultos 23 (69,7%) pacientes y pediátricos (< 15 años) 10 (30,3%) pacientes. La presentación clínica fue sintomatología pulmonar en 23 (69,7%) casos y 9 (27,3%) eran asintomáticos. Tres (9,1%) presentaron malformación congénita asociada. Diagnóstico preoperatorio en 15 (45,5%) pacientes. La ubicación más frecuente fue lóbulo inferior izquierdo. El tipo intralobar fue el más frecuente en 23 (69,7%) casos. La cirugía más frecuente fue la lobectomía con identificación y ligadura del vaso sistémico. El vaso aberrante se originó en aorta torácica en 27 (81,8%) casos e infradiafragmático (no precisado) en 3 (9,1%) casos. Vaso único en 26 (78,8%) y doble en 5 (15,2%) casos. No hubo mortalidad. Existen diferencias en las características entre los secuestros en pacientes adultos y pediátricos. Discusión y Conclusión: Los SP son infrecuentes, se presentan principalmente en adultos jóvenes como neumopatías a repetición, se distinguen diferencias en las características entre los pacientes adultos y pediátricos, y tienen excelente pronóstico posoperatorio.

Background: Pulmonary sequestration (PS) is a congenital malformation characterized by lung tissue with vascularization from anomalous systemic arteries. Aim: To analyze characteristics and treatment of adult and pediatric patients with pulmonary sequestration. Materials and Method: Transversal descriptive study. Period: January-1988 to December-2018. Information was obtained from clinical files and pathological anatomy records. Age, sex, clinical characteristics, diagnosis, surgical treatment and pathological findings are described. Statistical analysis was performed using SPSS25® and the Mann-Whitney and Chi square test were used, considering p < 0.05 to be significant. Results: Total 33 patients, 25 (75.8%) women. Average age 30.2 years, range: 0-68. Adults 23 (69.7%) patients and pediatric (< 15 years) 10 (30.3%) patients. The clinical presentation was pulmonary symptoms in 23 (69.7%) cases and 9 (27.3%) were asymptomatic. Three (9.1%) presented another congenital malformation. Preoperative diagnosis in 15 (48.4%) patients. The most frequent location was the left lower lobe. The intralobar type was the most frequent: 23 (69.7%) cases. The most frequent surgery was lobectomy with identification and ligation of the systemic vessel. The systemic vessel originated in the thoracic aorta in 27 (81.8%) cases and infradiaphragmatic (not specified) in 3 (9.1%) cases. Single vessel in 26 (78.8%) and double in 5 (15.2%) cases. There was no mortality. Differences were found in characteristics between adult and pediatric patients. Conclusion: SP are infrequent, they mostly appear in young adults as recurrent lung diseases, differences in characteristics are distinguished between adult and pediatric patients and they have an excellent postoperative prognosis.

Robotic thoracic surgery for inflammatory and infectious lung disease: initial experience in Brazil / Cirurgia torácica robótica para doença pulmonar inflamatória e infecciosa: experiência inicial no Brasil

ABSTRACT Objective: in Latin America, especially Brazil, the use of a robotic platform for thoracic surgery is gradually increasing in recent years. However, despite tuberculosis and inflammatory pulmonary diseases are endemic in our country, there is a lack of studies describing the results of robotic surgical treatment of bronchiectasis. This study aims to evaluate the surgical outcomes of robotic surgery for inflammatory and infective diseases by determining the extent of resection, postoperative complications, operative time, and length of hospital stay. Methods: retrospective study from a database involving patients diagnosed with bronchiectasis and undergoing robotic thoracic surgery at three hospitals in Brazil between January of 2017 and January of 2020. Results: a total of 7 patients were included. The mean age was 47 + 18.3 years (range, 18-70 years). Most patients had non-cystic fibrosis bronchiectasis (n=5), followed by tuberculosis bronchiectasis (n=1) and lung abscess (n=1). The performed surgeries were lobectomy (n=3), anatomic segmentectomy (n=3), and bilobectomy (n=1). The median console time was 147 minutes (range 61-288 min.) and there was no need for conversion to open thoracotomy. There were no major complications. Postoperative complications occurred in one patient and it was a case of constipation with the need for an intestinal lavage. The median for chest tube time and hospital stay, in days, was 1 (range, 1-6 days) and 5 (range, 2-14 days) respectively. Conclusions: robotic thoracic surgery for inflammatory and infective diseases is a feasible and safe procedure, with a low risk of complications and morbidity.

RESUMO Objetivo: na América Latina, especialmente no Brasil, a adoção da plataforma robótica para cirurgia torácica está aumentando gradativamente nos últimos anos. No entanto, apesar da tuberculose e doenças pulmonares inflamatórias serem endêmicas em nosso país, faltam estudos que descrevam os resultados do tratamento cirúrgico robótico das bronquiectasias. Este estudo tem como objetivo avaliar os resultados cirúrgicos da cirurgia robótica para doenças inflamatórias e infecciosas, determinando a extensão da ressecção, complicações pós-operatórias, tempo operatório e tempo de internação hospitalar. Métodos: estudo retrospectivo a partir de um banco de dados envolvendo pacientes com diagnóstico de bronquiectasia e submetidos à cirurgia torácica robótica em três hospitais brasileiros entre janeiro de 2017 e janeiro de 2020. Resultados: foram incluídos 7 pacientes. A média de idade foi 47 + 18,3 anos (variação, 18-70 anos). A maioria dos pacientes apresentou bronquiectasia não fibrose cística (n=5), seguida de bronquiectasia tuberculosa (n=1) e abscesso pulmonar (n=1). As cirurgias realizadas foram lobectomia (n=3), segmentectomia anatômica (n=3) e bilobectomia (n=1). O tempo médio do console foi de 147 minutos (variação de 61-288 min.) e não houve necessidade de conversão para toracotomia. Complicação pós-operatória ocorreu em um paciente, tratando-se de obstipação com necessidade de lavagem intestinal. A mediana do tempo de drenagem torácica e internação hospitalar, em dias, foi de 1 (variação, 1-6 dias) e 5 (variação, 2-14 dias), respectivamente. Conclusões: a cirurgia torácica robótica para doenças inflamatórias e infecciosas é um procedimento viável e seguro, com baixo risco de complicações e morbidade.

Caracterização clínico-epidemiológica de crianças e adolescentes portadores de cardiopatia congênita / Clinical-epidemiological characterization of children and adolescents with congenital heart disease / Caracterización clínico-epidemiológica de niños y adolescentes con cardiopatía congénita

Objetivo: Analisar características clínico-epidemiológicas de crianças portadoras de cardiopatia congênita residentes do município de Rio das Ostras referenciadas para unidades especializadas no estado do Rio de Janeiro. Método: Pesquisa descritiva, transversal realizada em duas unidades hospitalares no município do Rio de Janeiro, através da técnica documental retrospectiva por meio de dados nos prontuários. A coleta ocorreu entre setembro de 2018 a fevereiro de 2019. Resultados: Foram analisados 48 prontuários, com maior proporção entre os escolares (33,3%); do sexo masculino (58,3%); Em relação as cardiopatias, verificou-se com maior proporção as acianóticas (62,5%); destacando a comunicação interatrial com (14,6%); seguida da comunicação interventricular (12,5%) e coarctação da aorta (12,5%). Conclusão: A identificação dessas crianças no município de Rio das Ostras e a distribuição destas pelo território nacional são informações imprescindíveis para o planejamento e implementação de programas e políticas públicas que atendam as reais demandas deste segmento populacional

Objetivo: Analizar las características clínicas y epidemiológicas de los niños con cardiopatía congénita que viven en la ciudad de Rio das Ostras remitidos a unidades especializadas en el estado de Río de Janeiro. Método: Investigación descriptiva, transversal realizada en dos hospitales de la ciudad de Río de Janeiro, a través de una técnica documental retrospectiva a través de datos en registros médicos. La recolección se realizó entre septiembre de 2018 y febrero de 2019. Resultados: Se analizaron 48 registros médicos, con una mayor proporción entre los estudiantes (33.3%); hombre (58,3%); Con respecto a la enfermedad cardíaca, hubo una mayor proporción de acianóticos (62.5%); destacando la comunicación interauricular con (14,6%); seguido de comunicación interventricular (12.5%) y coartación aórtica (12.5%). Conclusión: La identificación de estos niños en la ciudad de Rio das Ostras y su distribución en todo el territorio nacional son información esencial para la planificación e implementación de programas y políticas públicas que satisfagan las demandas reales de este segmento de la población

Objective: To analyze the clinical and epidemiological characteristics of children with congenital heart disease living in the city of Rio das Ostras referred to specialized units in the state of Rio de Janeiro. Method: Descriptive, cross-sectional research conducted in two hospitals in the city of Rio de Janeiro, through retrospective documentary technique through data in medical records. The collection took place between September 2018 and February 2019. Results: 48 medical records were analyzed, with a higher proportion among students (33.3%); male (58.3%); Regarding heart disease, there was a greater proportion of acyanotic (62.5%); highlighting interatrial communication with (14.6%); followed by interventricular communication (12.5%) and aortic coarctation (12.5%). Conclusion: The identification of these children in the city of Rio das Ostras and their distribution throughout the national territory are essential information for the planning and implementation of programs and public policies that meet the real demands of this population segment

Clinical and laboratory variables associated with mortality outcome in the post-operative pediatric cardiac surgery / Variables clínicos y laboratorios asociados al desfecho mortalidad en el post-operatorio de cirugía cardíaca pediátrica / Variáveis clínicas e laboratoriais associadas ao desfecho mortalidade no pós-operatório de cirurgia cardíaca pediátrica

Abstract Objective: To identify clinical and laboratory variables associated with mortality outcome in the post-operative pediatric cardiac surgery. Method: Descriptive, retrospective study carried out in three reference centers in Rio de Janeiro State, Brazil, from the collection in 120 medical reports of children with Congenital Heart Disease undergoing surgery. Data were analyzed by using central tendency measures and association tests between variables and mortality. p < 0.05 was considered. Results: We observed the mortality outcome in 10 (7.2%) of the children after analyzing all medical records. The dialysis and extracorporeal circulation times, aortic and surgical clamping variables were associated with mortality outcome (p < 0.05). Conclusion and Implications for practice: The identification of these variables is a major factor for the control of the main post-operative complications, allowing the recognition of subtle clinical alterations requiring attention and immediate intervention with consequent reduction of mortality.

Resumen Objetivo: Identificar las variables clínicas y de laboratorio asociadas con lo desfecho mortalidad en el post-operatório de cirugía cardíaca pediátrica. Método: Estudio descriptivo, retrospectivo, realizado en tres centros de referencia del estado de Rio de Janeiro a partir de la recolección de datos en 120 prontuarios de niños portadores de cardiopatía congénita, sometidos a cirugía. Los datos fueron analizados utilizando medidas de tendencia central y pruebas de asociación entre variables y mortalidad. Se consideró p < 0,05. Resultados: Lo desfecho mortalidad fue observada en 10 (7,2%) niños, del total de prontuarios analizados. Las variables diálisis y los tiempos de circulación extracorpórea, engrape aórtico y quirúrgico, presentaron asociación con lo desfecho mortalidad (p < 0,05). Conclusión e Implicaciones para la práctica: La identificación de esas variables configura factor preponderante para el control de las principales complicaciones derivadas del post-operatorio, posibilitando el reconocimiento de alteraciones clínicas sutiles exigiendo atención e intervención inmediata con consecuente reducción de la mortalidad.

Resumo Objetivo: Identificar as variáveis clínicas e laboratoriais associadas ao desfecho mortalidade no pós-operatório de cirurgia cardíaca pediátrica. Método: Estudo descritivo, retrospectivo realizado em três centros de referência no estado do Rio de Janeiro a partir da coleta em 120 prontuários de crianças portadoras de cardiopatia congênita, submetidos a cirurgia. Os dados foram analisados utilizando-se medidas de tendência central e testes de associação entre as variáveis e mortalidade. Considerou-se p < 0,05. Resultados: Do total de prontuários analisados, o desfecho mortalidade foi observado em 10 (7,2%) das crianças. As variáveis diálise e os tempos de circulação extracorpórea, clampeamento aórtico e cirúrgico apresentaram associação com a mortalidade (p < 0,05). Conclusão e Implicações para a prática: A identificação dessas variáveis configura fator preponderante para o controle das principais complicações decorrentes do pós-operatório, possibilitando o reconhecimento de alterações clínicas sutis exigindo atenção e intervenção imediata com consequente redução da mortalidade.

Cenário ambulatorial de pacientes com sítio cirúrgico infectado após intervenção cardíaca / Escenario ambulatorial de pacientes con sitio cirugía infectado después intervención cardíaca / Ambulatory setting of patients with surgical site infections after a cardiac intervention

Resumo OBJETIVO Verificar o perfil clínico-cirúrgico e os resultados de pacientes acompanhados em um ambulatório de ferida operatória após cirurgia cardíaca. MÉTODOS Coorte histórica com pacientes submetidos à cirurgia cardíaca e acompanhados por um ano em um ambulatório de feridas de um hospital especializado em cardiologia. Foram analisados os micro-organismos predominantes nas infecções, os produtos utilizados nos curativos, tempo de acompanhamento e o tipo de terapêutica instituída nos curativos. RESULTADOS Entre os 150 pacientes, predominaram sexagenários (61,7 ± 11,4 anos), hipertensos (75%), diabéticos (44,7%). Evidenciou-se 12 pacientes com mediastinite (8%) e 44 com infecção de sítio cirúrgico (29,3%). Utilizou-se para realização dos curativos os ácidos graxos (80%) e alginato de cálcio (19%). O tempo de acompanhamento foi de 35 ±71 dias. CONCLUSÃO Pacientes sexagenários, hipertensos, diabéticos e revascularizados constituíram a população acompanhada no ambulatório de feridas. As taxas de ISC e mediastinite encontradas foram aceitáveis e semelhantes às da literatura.

Resumen OBJETIVO Verificar el perfil clínico-quirúrgico y los resultados de pacientes acompañados en un ambulatorio de heridas operatorias después de cirugía cardiaca. MÉTODO Cohorte histórica con pacientes sometidos a la cirugía cardiaca y acompañados por un año en el ambulatorio de heridas de un hospital especializado en cardiología. Fueron analizados los microorganismos predominantes en las infecciones, los productos utilizados en las curaciones, el tiempo de seguimiento, o el tipo de tratamiento utilizado en las curaciones. RESULTADOS Entre los 150 pacientes predominaron el sexo masculino (58%), sexagenarios (61,7 ± 11,4 años), hipertensos (75%), diabéticos (44.7%). Se evidenciaron 12 pacientes con mediastinitis (8%) y 44 con infección en el sitio quirúrgico (29.3%). Se utilizó en las curaciones fueron los ácidos grasos (80%) y el alginato de calcio (19%). El tiempo medio de seguimiento fue de 35 ± 71 días. CONCLUSIÓN Los pacientes sexagenarios, hipertensos, diabéticos y revascularizados constituyeron la población acompañada en el ambulatorio de heridas. Las tasas de ISC y mediastinitis encontradas fueron aceptables y similares a las de la literatura.

Abstract OBJECTIVE Verifying the clinical-surgical profile and the results of patients monitored in an surgical wound ambulatory after a cardiac surgeries. METHODS This is a historical cohort research with patients submitted to cardiac surgery and monitored for a year in an outpatient surgical wound clinic from a hospital specialized in cardiology. The study analyzed the prevalent microorganisms in infections, the products used in the dressings, the time of follow-up, and the type of therapy established in the dressings. RESULTS Among the 150 patients, most were sexagenarians (61.7 ± 11.4 years), hypertensive patients (75%), and diabetic (44.7%). There were 12 patients with mediastinitis (8%) and 44 with surgical site infection (29.3%). Fatty acids (80%) and calcium alginate (19%) were used for wound healing. The mean follow-up time was 35 ± 71 days. CONCLUSION Sexagenary, hypertensive, diabetic and revascularized patients constituted the population monitored in the wounds outpatient clinic. The SSI and mediastinitis rates found were acceptable and similar to those in literature.

Acute kidney injury after cardiac surgery in patients without chronic kidney disease

Abstract Introduction: Among patients undergoing cardiac surgery, the occurrence of acute renal injury appears to be associated with worse prognosis and increased mortality. The objective of this study was to evaluate risk factors and the impact this complication on mortality and survival after cardiac surgery among patients without chronic kidney disease. Methods: In this retrospective study, we reviewed the medical records of 142 patients who underwent elective coronary artery bypass grafting, valve replacement (single or multiple), or both (simultaneously) at a tertiary care hospital. Results: Among the 142 patients evaluated, the mean age was 58.28±13.87 years and 80 (56.33%) were female. The postoperative incidence of acute renal injury was 43.66%. Univariate analysis between the groups with and without acute renal injury revealed no significant differences, whereas multivariate analysis showed that risk factors for acute renal injury included valve replacement (OR=4.7, P=0.002, 95% CI=1.76-12.62, age (OR=1.044, P=0.012, 95% CI=1.01-1.07), previous cardiac surgery (OR=36.1, P=0.015, 95% CI=1.99-653.85), postoperative use of the vasoactive drug norepinephrine (OR=3.32, P=0.013, 95% CI=1.29-8.58) and dobutamine (OR=5.3, P=0.019, 95% CI=1.32-21.64). In our sample, there were 30 deaths, of which 25 had acute kidney injury. Survival was also lower among the patients with this complication, especially those who had required hemodialysis (OR=2.60, P<0.001, 95% CI=1.01-6.70) or had previously undergone cardiac surgery (OR=3.68, P<0.001, 95% CI=1.09-12.37). Conclusion: Our findings underscore the importance of identifying risk factors for developing acute renal injury after cardiac surgery, which can further the development of effective renoprotective strategies.

Miastenia gravis: resultados inmediatos y alejados de la timectomía transesternal extendida / Results of extended transsternal thymectomy for Myasthenia gravis: experience with 58 patients

Background: Thymectomy improves clinical outcomes and decreases the need for medical treatment in patients with myasthenia gravis (MG). Aim: To describe the immediate and long-term results of extended transsternal thymectomy (ETT) in patients with MG. Material and Methods: A review of databases, surgical protocols, clinical records and interviews of patients subjected to extended transsternal thymectomy for MG between 1990 and 2016. Perioperative clinical characteristics, anticholinesterase treatment, immediate and remote surgical results were analyzed and patients were followed from one to 10years. Results: We studied 58 patients aged 35 ± 14years (72%) women. In the preoperative period, according to Osserman classification, nine patients (15,5%) were in grade I, eight (13,8%) in grade IIA 8 and 40 (69%) in grade IIB. The pathological study of the surgical piece showed thymic hyperplasia in 39 cases (67,2%). Four patients had postoperative complications but none died. In the Follow-up at 1, 3, 5, 8 and 10years the Masaoka palliation rate was 71.7, 77.5, 67.7, 70.0 and 70,6% respectively. The figures for remission rate were 13.0, 15.0,19.4, 35.0 and 35,3% respectively. The figures for Zielinski positive results were 79.6, 87.5, 87.1, 90.0 and 82,4% respectively. The DeFilippi score improved by 80.4, 87.5, 87.1, 90.0 and 82.4% respectively. The Myasthenia Gravis Foundation of America Post-Intervention State improved by 67.4, 77.5, 77.5, 75.0 and 70,6% respectively. Mean Myasthenia Gravis Activities of daily living (MGADL) and Myasthenia Gravis Quality of life scale 15 (MGQOL 15) were 1.65 and 6.31 respectively. Conclusions: In selected patients with MG, extended transsternal thymectomy in MG has good immediate and long-term results.

Fatores de risco de sangramento para pacientes submetidos à cirurgia cardíaca com circulação extracorpórea / Bleeding risk factors for patients undergoing cardiac surgery with extracorporeal circulation

Introdução: O sangramento é uma das principais causas de morbidade e mortalidade em cirurgia cardíaca com circulação extracorpórea e o risco para que ele aconteça tem sua importância reconhecida no diagnóstico de enfermagem da Taxonomia NANDA I, Risco de Sangramento. Objetivo: identificar os fatores de risco com significativa chance de estarem associados aos casos de sangramento em paciente submetidos à cirurgia cardíaca com circulação extracorpórea. Metodologia: Neste estudo, realizou-se um estudo de caso- controle retrospectivo em um hospital federal militar localizado na cidade do Rio de Janeiro para identificar os fatores de risco com significativa chance de estarem associados aos casos de sangramento para pacientes submetidos à cirurgia cardíaca com Circulação Extracorpórea. Resultados: Como resultado, após a aplicação da metodologia de caso- controle, as variáveis evidenciadas como associadas a sangramento anormal tendo valores com significância estatística foram IMC menor 25 kg/m2, Hipotermia menor que 32o Celsius e tempo de Tromboplastina Parcial Ativado acima de 40 segundos. Conclusão: Este estudo traz contribuições relevantes ao refinamento do diagnóstico de enfermagem Risco de sangramento, oferecendo relevante informação para a validação do diagnóstico de enfermagem, abrindo caminho para uma prática profissional disciplinar e multidisciplinar que articula os esforços da equipe de saúde na avaliação do paciente submetido a cirurgia cardíaca com circulação extracorpórea.

Bleeding is one of the main causes of morbidity and mortality in cardiac surgery with extracorporeal circulation and risk for it happen has its importance recognized in the nursing diagnosis of the taxonomy NANDA-I Bleeding Risk. Aim: to identify risk factors with significant chance of being associated with bleeding in patients submitted to cardiac surgery with extracorporeal circulation. Methodology: In this study, we've developed a retrospective case control study in a federal military hospital located in the city of Rio de Janeiro that aimed to identify risk factors with significant chance of being associated with cases of bleeding to patients submitted to cardiac surgery with Extracorporeal Circulation. Results: As a result, after applying case-control methodology, variables associated with abnormal bleeding having statistical significance value were IMC less than 25 kg/m2, Hypothermia less than 32o Celsius Partial Thromboplastin Time Activated above 40 seconds. Conclusion: This study brings relevant contributions to refinement of nursing dignosis Risk to Bleeding, opening a pathway to disciplinary and multi disciplinary professional practice that articulates health staff effords in evaluating patients submitted to cardiac surgery with extracorporeal circulation.

Diagnostic evaluation of risk for bleeding in cardiac surgery with extracorporeal circulation / Avaliação diagnóstica do risco de sangramento em cirurgia cardíaca com circulação extracorpórea / Evaluación diagnóstica del riesgo de hemorragia en cirugía cardíaca con circulación extracorpórea

ABSTRACT Objective: to identify the risk factors associated with cases of excessive bleeding in patients submitted to cardiac surgery with extracorporeal circulation. Method: case-control study on the factors of risk for bleeding based on the analysis of data from the medical charts of 216 patients submitted to cardiac surgery with elective extracorporeal circulation during a three-year period. Results: variables that are commonly associated with excessive bleeding in studies in the field were analyzed, and the following were considered as risk factors for the nursing diagnosis "risk for bleeding" (00206) in cardiac surgery with extracorporeal circulation: Body mass index lower than 26.35kg/m² (Odds ratio = 3.64); Extracorporeal circulation longer than 90 minutes (Odds ratio = 3.57); Hypothermia lower than 32°C (Odds ratio = 2.86); Metabolic acidosis (Odds ratio = 3.50) and Activated partial thromboplastin time longer than 40 seconds (Odds ratio= 2.55). Conclusion: such variables may be clinical indicators of an operational nature for a better characterization of the risk factor "treatment regimen" and a refinement of knowledge related to coagulopathy induced by extracorporeal circulation, which is currently presumably incorporated into the "treatment regimen" category of the nursing diagnostic classification by NANDA International, Inc.

RESUMO Objetivo: identificar os fatores de risco associados aos casos de sangramento excessivo em pacientes submetidos à cirurgia cardíaca com circulação extracorpórea. Método: estudo de caso-controle dos fatores de risco de sangramento com análise de dados de prontuários de 216 pacientes submetidos à cirurgia cardíaca com circulação extracorpórea de caráter eletivo durante o período de três anos. Resultados: foram analisadas variáveis comumente associadas ao sangramento excessivo em estudos na área, sendo considerados como fatores de risco para o diagnóstico de enfermagem "risco de sangramento" (00206) em cirurgia cardíaca com circulação extracorpórea: Índice de massa corporal menor que 26,35kg/m² (Odds ratio = 3,64); Circulação extracorpórea maior que 90 minutos (Odds ratio = 3,57); Hipotermia menor que 32°C (Odds ratio = 2,86); Acidose metabólica (Odds ratio = 3,50) e Tempo de tromboplastina parcial ativada maior que 40 segundos (Odds ratio = 2,55). Conclusão: tais variáveis podem ser indicadores clínicos de natureza operacional para melhor caracterização do fator de risco "regime de tratamento" e de um refinamento do conhecimento relacionado à coagulopatia induzida pela circulação extracorpórea, provavelmente hoje incorporada na categoria de "regime de tratamento" da classificação diagnóstica de enfermagem da NANDA International, Inc.

RESUMEN Objetivo: identificar los factores de riesgo asociados a casos de hemorragia excesiva en pacientes sometidos a cirugía cardíaca con circulación extracorpórea. Método: estudio de caso control de los factores de riesgo de hemorragia con análisis de datos de fichas médicas de 216 pacientes, sometidos a cirugía cardíaca, con circulación extracorpórea, de carácter electivo durante el período de tres años. Resultados: fueron analizadas variables comúnmente asociadas a hemorragia excesiva, en estudios en esta área, siendo considerados como factores de riesgo para el diagnóstico de enfermería "riesgo de hemorragia" (00206) en cirugía cardíaca con circulación extracorpórea, los siguientes: Índice de masa corporal <26,35 Kg/m² (Odds ratio= 3,64); Circulación extracorpórea mayor que 90 minutos (Odds ratio = 3,57); Hipotermia menor que 32°C (Odds ratio = 2,86); Acidosis metabólica (Odds ratio = 3,50); y Tiempo de tromboplastina parcial activada mayor que 40 segundos (Odds ratio = 2,55). Conclusión: esas variables pueden ser indicadores clínicos de naturaleza operacional para caracterizar mejor el factor de riesgo "régimen de tratamiento" y para perfeccionar el conocimiento relacionado a la coagulopatía inducida por la circulación extracorpórea; probablemente, actualmente incorporada a la categoría de "régimen de tratamiento" de la clasificación diagnóstica de enfermería de la NANDA International Inc.

Comparison of Arndt-endobronchial blocker plus laryngeal mask airway with left-sided double-lumen endobronchial tube in one-lung ventilation in thoracic surgery in the morbidly obese

This study aimed to evaluate the feasibility and performance of Arndt-endobronchial blocker (Arndt) combined with laryngeal mask airway (LMA) compared with left-sided double-lumen endobronchial tube (L-DLT) in morbidly obese patients in one-lung ventilation (OLV). In a prospective, randomized double-blind controlled clinical trial, 80 morbidly obese patients (ASA I-III, aged 20-70) undergoing general anesthesia for elective thoracic surgeries were randomly allocated into groups Arndt (n=40) and L-DLT (n=40). In group Arndt, a LMA™ Proseal was placed followed by an Arndt-endobronchial blocker. In group L-DLT, patients were intubated with a left-sided double-lumen endotracheal tube. Primary endpoints were the airway establishment, ease of insertion, oxygenation, lung collapse and surgical field exposure. Results showed similar ease of airway establishment and tube/device insertion between the two groups. Oxygen arterial pressure (PaO2) of patients in the Arndt group was significantly higher than L-DLT (154±46 vs 105±52 mmHg; P<0.05). Quality of lung collapse and surgical field exposure in the Arndt group was significantly better than L-DLT (effective rate 100 vs 90%; P<0.05). Duration of surgery and anesthesia were significantly shorter in the Arndt group (2.4±1.7 vs 3.1±1.8 and 2.8±1.9 vs 3.8±1.8 h, respectively; P<0.05). Incidence of hoarseness of voice and incidence and severity of throat pain at the post-anesthesia care unit and 12, 24, 48, and 72 h after surgery were significantly lower in the Arndt group (P<0.05). Findings suggested that Arndt-endobronchial blocker combined with LMA can serve as a promising alternative for morbidly obese patients in OLV in thoracic surgery.

[RETRACTED ARTICLE] Comparison of Arndt-endobronchial blocker plus laryngeal mask airway with left-sided double-lumen endobronchial tube in one-lung ventilation in thoracic surgery in the morbidly obese

This study aimed to evaluate the feasibility and performance of Arndt-endobronchial blocker (Arndt) combined with laryngeal mask airway (LMA) compared with left-sided double-lumen endobronchial tube (L-DLT) in morbidly obese patients in one-lung ventilation (OLV). In a prospective, randomized double-blind controlled clinical trial, 80 morbidly obese patients (ASA I-III, aged 20-70) undergoing general anesthesia for elective thoracic surgeries were randomly allocated into groups Arndt (n=40) and L-DLT (n=40). In group Arndt, a LMA™ Proseal was placed followed by an Arndt-endobronchial blocker. In group L-DLT, patients were intubated with a left-sided double-lumen endotracheal tube. Primary endpoints were the airway establishment, ease of insertion, oxygenation, lung collapse and surgical field exposure. Results showed similar ease of airway establishment and tube/device insertion between the two groups. Oxygen arterial pressure (PaO2) of patients in the Arndt group was significantly higher than L-DLT (154±46 vs 105±52 mmHg; P<0.05). Quality of lung collapse and surgical field exposure in the Arndt group was significantly better than L-DLT (effective rate 100 vs 90%; P<0.05). Duration of surgery and anesthesia were significantly shorter in the Arndt group (2.4±1.7 vs 3.1±1.8 and 2.8±1.9 vs 3.8±1.8 h, respectively; P<0.05). Incidence of hoarseness of voice and incidence and severity of throat pain at the post-anesthesia care unit and 12, 24, 48, and 72 h after surgery were significantly lower in the Arndt group (P<0.05). Findings suggested that Arndt-endobronchial blocker combined with LMA can serve as a promising alternative for morbidly obese patients in OLV in thoracic surgery.

Effect of prophylactic non-invasive mechanical ventilation on functional capacity after heart valve replacement: a clinical trial

OBJECTIVE: During cardiac surgery, several factors contribute to the development of postoperative pulmonary complications. Non-invasive ventilation is a promising therapeutic tool for improving the functionality of this type of patient. The aim of this study is to evaluate the functional capacity and length of stay of patients in a nosocomial intensive care unit who underwent prophylactic non-invasive ventilation after heart valve replacement. METHOD: The study was a controlled clinical trial, comprising 50 individuals of both sexes who were allocated by randomization into two groups with 25 patients in each group: the control group and experimental group. After surgery, the patients were transferred to the intensive care unit and then participated in standard physical therapy, which was provided to the experimental group after 3 applications of non-invasive ventilation within the first 26 hours after extubation. For non-invasive ventilation, the positive pressure was 10 cm H2O, with a duration of 1 hour. The evaluation was performed on the 7th postoperative day/discharge and included a 6-minute walk test. The intensive care unit and hospitalization times were monitored in both groups. Brazilian Registry of Clinical Trials (REBeC): RBR number 8bxdd3. RESULTS: Analysis of the 6-minute walk test showed that the control group walked an average distance of 264.34±76 meters and the experimental group walked an average distance of 334.07±71 meters (p=0.002). The intensive care unit and hospitalization times did not differ between the groups. CONCLUSION: Non-invasive ventilation as a therapeutic resource was effective toward improving functionality; however, non-invasive ventilation did not influence the intensive care unit or hospitalization times of the studied cardiac patients.

Quality of life of patients who undergone myocardial revascularization surgery / La calidad de vida de los pacientes sometidos a cirugía de revascularización del miocárdio / Qualidade de vida de pacientes submetidos à cirurgia de revascularização do miocárdio

ABSTRACT Objective: to evaluate the quality of life of patients who underwent revascularization surgery. Method: a descriptive, cross sectional study, with quantitative approach carried out with 75 patients. The questionnaire WHOQOL-Bref was used to evaluate the quality of life (QOL). Results: patients' QOL evaluation presented a moderate result, with need of improvement of all domains. Low income patients had the worst evaluation of QOL in the domain environment (p=0,021), and the ones from Recife/metropolitan area, in the domain social relationship (p=0,021). Smoker (p=0,047), diabetic (p=0,002) and alcohol consumption (p=0,035) patients presented the worst evaluation of the physical domain. Renal patients presented the worst evaluation of QOL in the physical (P=0,037), psychological (p=0,008), social relationship (p=0,006) domains and total score (p=0,009). Conclusion: the improvement of QOL depends on the individual's process of behavioral change and the participation of health professionals is essential to formulate strategies to approach these patients, especially concerning health education.

RESUMEN Objetivo: evaluar la calidad de vida de los pacientes sometidos a cirugía de revascularización. Método: estudio descriptivo, transversal, con abordaje cuantitativo llevado a cabo con 75 pacientes. Se empleó el cuestionario WHOQOL-Bref para evaluar la calidad de vida (CV). Resultados: Los pacientes tuvieron CV regular, necesitando mejoras en todos los dominios. Los pacientes de baja renta presentaron peores índices de CV en el dominio medioambiental (p=0,021), así como presentaron los provenientes de la ciudad de Recife y región en el dominio relaciones sociales (p=0,021). Los pacientes fumadores (p=0,047), diabéticos (p=0,002) y de la clase alta (p=0,035) tuvieron peores valores de CV en el dominio físico. Los pacientes con problemas renales presentaron peores índices de CV en los dominios físico (p=0,037), psicológico (p=0,008), relaciones sociales (p=0,006) y en el puntaje total (p=0,009). Conclusión: para mejorar la CV hay que cambiar la conducta individual, y es muy importante la participación de los profesionales de salud en la planificación de estrategias de abordaje a estos pacientes, en especial en la educación en salud.

RESUMO Objetivo: avaliar a qualidade de vida de pacientes submetidos à cirurgia de revascularização. Método: estudo descritivo, transversal, com abordagem quantitativa realizado com 75 pacientes. Foi utilizado o questionário WHOQOL-Bref para avaliação da qualidade de vida (QV). Resultados: Pacientes apresentaram avaliação da QV regular, com necessidade de melhora em todos os domínios. Pacientes de baixa renda tiveram pior avaliação da QV no domínio meio ambiente (p=0,021), e os procedentes de Recife/região metropolitana, no domínio relações sociais (p=0,021). Pacientes tabagistas (p=0,047), diabéticos (p=0,002) e etilistas (p=0,035) apresentaram pior avaliação da QV no domínio físico. Pacientes renais apresentaram pior avaliação da QV nos domínios físico (P=0,037), psicológico (p=0,008), relações sociais (p=0,006) e no escore total (p=0,009). Conclusão: a melhoria da QV depende de um processo de mudança de comportamento individual e a participação dos profissionais de saúde é essencial para elaborar estratégias de abordagem desses pacientes, principalmente no tocante à educação em saúde.

Anatomic pulmonary resection via video-assisted thoracic surgery: analysis of 117 cases at a referral center in Brazil / Ressecções pulmonares anatômicas por cirurgia torácica videoassistida: experiência de 117 casos em um centro de referência no Brasil

ABSTRACT Objective: To describe our experience with video-assisted thoracic surgery (VATS) for anatomic pulmonary resection at a referral center for thoracic surgery in Brazil. Methods: All patients who underwent anatomic pulmonary resection by VATS between 2010 and 2015 were included. Clinical and pathological data, as well as postoperative complications, were analyzed. Results: A total of 117 pulmonary resections by VATS were performed, of which 98 were lobectomies and 19 were anatomic segmentectomies. The mean age of the patients was 63.6 years (range, 15-86 years). Females predominated (n = 69; 59%). The mean time to chest tube removal was 2.47 days, and the mean length of ICU stay was 1.88 days. The mean length of hospital stay was 4.48 days. Bleeding ≥ 400 mL occurred in 15 patients. Conversion to thoracotomy was required in 4 patients. Conclusions: Our results are similar to those published in major international studies, indicating that VATS is an important strategy for pulmonary resection. They also show that VATS can be safely performed with adequate training. This technique should be used more often for the treatment of lung diseases in Brazil.

RESUMO Objetivo: Relatar a experiência com cirurgia torácica videoassistida (CTVA) para ressecções pulmonares anatômicas em um centro nacional de referência de cirurgia torácica no Brasil. Métodos: Foram incluídos todos os pacientes tratados com ressecções pulmonares anatômicas por CTVA entre 2010 e 2015 e analisados dados clínicos e patológicos, assim como complicações pós-operatórias. Resultados: Foram realizadas 117 ressecções pulmonares por CTVA, sendo 98 lobectomias e 19 segmentectomias anatômicas. A média de idade foi de 63,6 anos (variação, 15-86 anos), sendo a maioria mulheres (n = 69; 59%). A média de tempo de permanência com dreno foi de 2,47 dias e a de estada em UTI foi de 1,88 dias. A média de tempo de internação foi de 4,48 dias. Sangramento ≥ 400 ml ocorreu em 15 pacientes. Houve conversão para toracotomia em 4 pacientes. Conclusões: Nossos resultados vão ao encontro de publicações em grandes séries internacionais, corroborando que a CTVA é uma importante via de execução de ressecções pulmonares e que pode ser realizada com segurança quando há treinamento adequado, devendo ser mais utilizada no Brasil para o tratamento das doenças pulmonares.

Fatores associados à ocorrência de infecções relacionadas à assistência a saúde em pacientes submetidos a cirurgia cardíaca / Factors related to healthcare-associated infections in patients submitted to thoracic surgery

Introdução: As doenças cardiovasculares continuam sendo a principal causa de morte no Brasil e as cirurgias cardíacas são consideradas um procedimento de alta complexidade e apesar de melhorar a sobrevida e qualidade de vida dos indivíduos não está isento de riscos. Umas das principais complicações no pós-operatório é a infecção. Objetivo: identificar os fatores de risco associados à ocorrência de IRAS em pacientes submetidos à cirurgia cardíaca em um hospital, público, geral e de ensino, de Minas Gerais, no período de julho de 2005 a novembro de 2015. Métodos: trata-se de um estudo retrospectivo, de corte transversal, com abordagem quantitativa, que analisou 725 prontuários de pacientes adultos submetidos à cirurgia cardíaca. Ressalta-se que o paciente foi considerado no estudo uma única vez. Para a coleta de dados utilizou-se um instrumento contendo variáveis sociodemográficas, clínicas e referentes ao perioperatório o qual foi validado quanto à forma e conteúdo por cinco especialistas na temática. Os dados foram inseridos em uma planilha eletrônica do programa Excel® versão para Windows XP® validados por dupla entrada (digitação) para verificação de inconsistências e após a correção dos erros, os dados foram exportados para o programa Statistical Package for the Social Sciences (SPSS) versão 18.0 para Windows XP® onde foi construído o banco definitivo e procedeu-se a analise estatística descritiva e analítica Resultados: a população do presente estudo foi constituída por 725 prontuários, houve predominância do sexo feminino, média de idade de 55,8 anos e a taxa global de infecção relacionada à assistência à saúde (IRAS) foi de 26,9%, sendo a infecção do trato respiratório (20,8%) a mais frequente, seguida por infecção do sítio cirúrgico (ISC) (8,1%). Os principais preditores para a ocorrência de IRAS foram doença pulmonar obstrutiva crônica (DPOC), ter apresentado intercorrência no intraoperatório, tempo de intubação > 24 horas, reintubação e hemotransfusão no pós-operatório. A incidência de óbito foi maior entre os pacientes que desenvolveram IRAS (30,3%) quando comparado com os que não tiveram infecção (4,3%). O tempo médio de permanência hospitalar pós-operatória foi maior para os pacientes com IRAS (23,4 dias). Conclusão: O presente estudo permitiu identificar os principais preditores para a ocorrência de IRAS nos pacientes submetidos à cirurgia cardíaca. Medidas direcionadas para a promoção da saúde e para controle de IRAS durante a hospitalização podem contribuir para minimizar esse evento e garantir uma assistência à saúde mais segura

Introduction: Cardiovascular diseases are still the main cause of death in Brazil, and thoracic surgeries are considered a high-complexity procedure, as despite increasing the survival and improving the quality of life of individuals, it is not risk free. Infection is one of the main complications in the post-operative period. Objective: to identify the risk factors associated with the occurrence of healthcare-associated infections (HAI) in patients submitted to thoracic surgery in a public general teaching hospital, in Minas Gerais, from July 2005 to November 2015. Methods: a retrospective, cross section study, using a quantitative approach, was developed to analyze 725 medical records of adult patients submitted to thoracic surgery. It is noteworthy that patients were considered only once in the study. Data were collected using an instrument containing sociodemographic and clinical variables, as well as data on the perioperative period, which was validated as for its face and content by five experts on the theme. The collected data were inserted into an Excel® for Windows XP® spreadsheet and validated by double entry (typing) in order to verify the existence of inconsistencies and, after the correction of errors, the data were exported to the Statistical Package for the Social Sciences (SPSS) version 18.0 for Windows XP®, where the final database was built, proceeding to a descriptive and analytical statistical analysis. Results: the population of the study was made up of 725 medical records, in which there was a predominance of women, with a mean age of 55.8 years and an overall rate of HAI of 26.9%, with respiratory tract infections (20.8%) being the most frequent, followed by surgical site infection (8.1%). The main predictors for the occurrence of HAI were chronic obstructive pulmonary disease, having had a complication in the intraoperative period, length of intubation > 24 hours, reintubation and hemotransfusion in the post-operative period. The incidence of death was higher among patients who developed HAI (30.3%) when compared to those who did not have an infection (4.3%). The mean length of post-operative hospital stay was higher among patients with HAI (23.4 days). Conclusion: The present study allowed to identify the main predictors for the occurrence of HAI in patients submitted to thoracic surgery. Measures targeted at health promotion and HAI control during hospitalization can contribute to minimize this event and guarantee the delivery of safe health care

Anatomic pulmonary resection by video-assisted thoracoscopy: the Brazilian experience (VATS Brazil study) / Ressecção pulmonar anatômica por videotoracoscopia: experiência brasileira (VATS Brasil)

ABSTRACT Objective: The objective of this study was to describe the results of anatomic pulmonary resections performed by video-assisted thoracoscopy in Brazil. Methods: Thoracic surgeons (members of the Brazilian Society of Thoracic Surgery) were invited, via e-mail, to participate in the study. Eighteen surgeons participated in the project by providing us with retrospective databases containing information related to anatomic pulmonary resections performed by video-assisted thoracoscopy. Demographic, surgical, and postoperative data were collected with a standardized instrument, after which they were compiled and analyzed. Results: The surgeons provided data related to a collective total of 786 patients (mean number of resections per surgeon, 43.6). However, 137 patients were excluded because some data were missing. Therefore, the study sample comprised 649 patients. The mean age of the patients was 61.7 years. Of the 649 patients, 295 (45.5%) were male. The majority-521 (89.8%)-had undergone surgery for neoplasia, which was most often classified as stage IA. The median duration of pleural drainage was 3 days, and the median hospital stay was 4 days. Of the 649 procedures evaluated, 598 (91.2%) were lobectomies. Conversion to thoracotomy was necessary in 30 cases (4.6%). Postoperative complications occurred in 124 patients (19.1%), the most common complications being pneumonia, prolonged air leaks, and atelectasis. The 30-day mortality rate was 2.0%, advanced age and diabetes being found to be predictors of mortality. Conclusions: Our analysis of this representative sample of patients undergoing pulmonary resection by video-assisted thoracoscopy in Brazil showed that the procedure is practicable and safe, as well as being comparable to those performed in other countries.

RESUMO Objetivo: O objetivo deste estudo foi descrever os resultados de ressecções pulmonares anatômicas por videotoracoscopia no Brasil. Métodos: Cirurgiões torácicos (membros da Sociedade Brasileira de Cirurgia Torácica) foram convidados, por correio eletrônico, a participar do estudo. Dezoito cirurgiões participaram do projeto enviando seus bancos de dados retrospectivos referentes a ressecções anatômicas de pulmão por videotoracoscopia. Dados demográficos, cirúrgicos e pós-operatórios foram coletados em um instrumento padronizado e posteriormente compilados e analisados. Resultados: Dados referentes a 786 pacientes foram encaminhados (média de 43,6 ressecções por cirurgião), sendo 137 excluídos por informações incompletas. Logo, 649 pacientes constituíram nossa população estudada. A média de idade dos pacientes foi de 61,7 anos, 295 eram homens (45,5%), e a maioria - 521 (89,8%) - foi submetida à cirurgia por neoplasia, mais frequentemente classificada como estádio IA. A mediana do tempo de drenagem pleural foi de 3 dias, e a do tempo de internação, 4 dias. Dos 649 procedimentos realizados, 598 (91,2%) foram lobectomias. A taxa de conversão para toracotomia foi de 4,6% (30 casos). Complicações pós-operatórias ocorreram em 124 pacientes (19,1%), sendo pneumonia, escape aéreo prolongado e atelectasia as mais frequentes. A mortalidade em 30 dias foi de 2,0%, tendo como preditores idade avançada e diabetes. Conclusões: A casuística brasileira mostra que as ressecções pulmonares por cirurgia torácica videoassistida são factíveis e seguras, além de comparáveis àquelas de registros internacionais.

Robotic pulmonary lobectomy for lung cancer treatment: program implementation and initial experience / Lobectomia pulmonar robótica para tratamento do câncer de pulmão e de metástases pulmonares: implantação do programa e experiência inicial

ABSTRACT Objective: To describe the implementation of a robotic thoracic surgery program at a public tertiary teaching hospital and to analyze its initial results. Methods: This was a planned interim analysis of a randomized clinical trial aimed at comparing video-assisted thoracoscopic surgery and robotic surgery in terms of the results obtained after pulmonary lobectomy. The robotic surgery program developed at the Instituto do Câncer do Estado de São Paulo, in the city of São Paulo, Brazil, is a multidisciplinary initiative involving various surgical specialties, as well as anesthesiology, nursing, and clinical engineering teams. In this analysis, we evaluated the patients included in the robotic lobectomy arm of the trial during its first three months (from April to June of 2015). Results: Ten patients were included in this analysis. There were eight women and two men. The mean age was 65.1 years. All of the patients presented with peripheral tumors. We performed right upper lobectomy in four patients, right lower lobectomy in four, and left upper lobectomy in two. Surgical time varied considerably (range, 135-435 min). Conversion to open surgery or video-assisted thoracoscopic surgery was not necessary in any of the cases. Intraoperative complications were not found. Only the first patient required postoperative transfer to the ICU. There were no deaths or readmissions within the first 30 days after discharge. The only postoperative complication was chest pain (grade 3), in two patients. Pathological examination revealed complete tumor resection in all cases. Conclusions: When there is integration and proper training of all of the teams involved, the implementation of a robotic thoracic surgery program is feasible and can reduce morbidity and mortality.

RESUMO Objetivo: Descrever a implantação de um programa de cirurgia torácica robótica em um hospital terciário público universitário e analisar seus resultados iniciais. Métodos: Este estudo é uma análise interina planejada de um ensaio clínico aleatorizado cujo objetivo é comparar resultados da lobectomia pulmonar por videotoracoscopia com a robótica. O programa de cirurgia robótica do Instituto do Câncer do Estado de São Paulo, localizado na cidade de São Paulo (SP), foi uma iniciativa multidisciplinar que envolveu diversas especialidades cirúrgicas e equipes de anestesia, enfermagem e engenharia clínica. Nesta análise, avaliamos os pacientes incluídos no braço lobectomia robótica durante os primeiros três meses do estudo (de abril a junho de 2015). Resultados: Dez pacientes foram incluídos nesta análise. Eram oito mulheres e dois homens. A média de idade foi de 65,1 anos. Todos apresentavam tumores periféricos. Foram realizadas lobectomia superior direita, em quatro pacientes; lobectomia inferior direita, em quatro; e lobectomia superior esquerda, em dois. Os tempos cirúrgicos variaram bastante (variação, 135-435 min). Não foi necessária a conversão para técnica aberta ou videotoracoscópica em nenhum paciente. Não foram observadas complicações intraoperatórias. Apenas o primeiro paciente foi encaminhado à UTI no pós-operatório. Não houve mortalidade nem reinternações em 30 dias após a alta. A única complicação pós-operatória observada foi dor torácica (grau 3), em dois pacientes. O exame anatomopatológico revelou a ressecção completa do tumor em todos os casos. Conclusões: A implantação de um programa de cirurgia torácica robótica, quando há integração e treinamento adequado de todas as equipes envolvidas, é factível e pode reduzir a morbidade e a mortalidade.

Cirugía de cáncer de pulmón en combinación con cirugía reductora de volumen / Lung cancer surgery in combination with volume-reducing surgery

En cirugía torácica la evaluación de un paciente con enfermedad pulmonar obstructiva crónica muy grave constituye un reto para el equipo quirúrgico, dado que los resultados espirométricos pueden contraindicar la intervención. Este reporte de caso describe los criterios seguidos para definir las intervenciones quirúrgicas; la estrategia asumida por el grupo de tórax; el manejo anestésico y la evolución posterior del paciente, al cual se le realizó cirugía reductora del volumen pulmonar, con abordaje unilateral inicial en lóbulo superior derecho y cirugía definitiva al mes, con toracotomía posterolateral izquierda ulterior para resecar un tumor de Pancoast. Se evidenció disminución de la disnea e incremento gradual en la capacidad física después de cada proceder quirúrgico. El volumen espiratorio forzado en el primer segundo con relación a los valores predichos mejoró, de 25 por ciento a 38 por ciento, después de la cirugía y 41 por ciento a los seis meses. El índice de Tiffeneau varió de 0,43 a 0,57 y 0,60 después de dos cirugías torácicas. Como única complicación el paciente presentó dolor torácico crónico para el cual mantiene tratamiento médico. Se concluye que la realización de cirugía reductora del volumen pulmonar es una alternativa a evaluar en pacientes que presenten neoplasia de pulmón y enfisema pulmonar bulloso. El enfoque multidisciplinario perioperatorio es un pilar fundamental para lograr resultados satisfactorios(AU)

In thoracic surgery, assessing a patient with very severe chronic obstructive pulmonary disease is a challenge for the surgical team, since spirometric results may contraindicate the intervention. This case report describes the criteria used to define surgical interventions, the strategy assumed by the thorax group, the anesthetic management and subsequent evolution of the patient, who underwent lung volume reduction surgery, with an initial unilateral approach in the right upper lobe and final surgery a month later, with posterior left posterolateral thoracotomy to resect a Pancoast tumor. There was a decrease in dyspnea and a gradual increase in physical capacity after each surgical procedure. The forced expiratory volume in the first second in relation to the predicted values improved from 25 percent to 38 percent after surgery, and 41 percent six months later. Tiffeneau index varied from 0.43 to 0.57 and 0.60 after two thoracic surgeries. As a single complication, the patient presented chronic chest pain for which he maintains medical treatment. It is concluded that the performance of pulmonary volume reduction surgery is an alternative to gauge in patients with lung cancer and bullous pulmonary emphysema. The multidisciplinary perioperative approach is a fundamental pillar to achieve satisfactory results(AU)