Current morbimortality and one-year survival after pneumonectomy for infectious diseases

Abstract Objective: Identify the one-year survival rate and major complications in patients submitted to pneumonectomy for infectious disease. Methods: Retrospective data from all cases of infectious disease pneumonectomy over the past 10 years were collected from two reference centers. The authors analyzed: patient demographics, etiology, laterality, bronchial stump treatment, presence of previous pulmonary resection, postoperative complications in the first 30 days, the treatment used in pleural complications, and one-year survival rate. Results: 56 procedures were performed. The average age was 44 years, with female predominance (55%). 29 cases were operated on the left side (51%) and the most frequent etiology was post-tuberculosis (51.8%). The overall incidence of complications was 28.6% and the most common was empyema (19.2%). Among empyema cases, 36.3% required pleurostomy, 27.3% required pleuroscopy and 36.3% underwent thoracoplasty for treatment. Bronchial stump fistula was observed in 10.7% of cases. From all cases, 16.1% were completion pneumonectomies and 62.5% of these had some complication, a significantly higher incidence than patients without previous surgery (p = 0.0187). 30-day in-hospital mortality was (7.1%) with 52 cases (92.9%) and 1-year survival. The causes of death were massive postoperative bleeding (1 case) and sepsis (3 cases). Conclusions: Pneumonectomy for benign disease is a high-risk procedure performed for a variety of indications. While morbidity is often significant, once the perioperative risk has passed, the one-year survival rate can be very satisfying in selected patients with benign disease.

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.

Standardization of elective tracheostomies at the Central Institute of the Hospital das Clínicas in São Paulo during the COVID-19 pandemic / Padronização da realização de traqueostomias eletivas no Instituto Central do Hospital das Clínicas de São Paulo durante a pandemia de COVID-19

ABSTRACT The COVID-19 Pandemic has resulted in a high number of hospital admissions and some of those patients need ventilatory support in intensive care units. The viral pneumonia secondary to Sars-cov-2 infection may lead to acute respiratory distress syndrome (ARDS) and longer mechanical ventilation needs, resulting in a higher demand for tracheostomies. Due to the high aerosolization potential of such procedure, and the associated risks of staff and envoirenment contamination, it is necesseray to develop a specific standardization of the of the whole process involving tracheostomies. This manuscript aims to demonstrate the main steps of the standardization created by a tracheostomy team in a tertiary hospital dedicated to providing care for patients with COVID-19.

RESUMO A pandemia da COVID-19 tem gerado um número elevado de internações hospitalares e muitos pacientes são admitidos nas unidades de terapia intensiva para suporte ventilatório invasivo. A pneumonia viral provocada pelo Sars-cov-2 pode resultar na síndrome da disfunção respiratória aguda (SDRA) e em um tempo prolongado de ventilação mecânica, gerando uma demanda maior de traqueostomias. Diante do alto potencial de aerossolização desse procedimento, com risco de contaminação da equipe e do ambiente, é necessário criar uma padronização específica de todo o processo que envolve essa cirurgia. Este artigo visa demonstrar as principais etapas dessa padronização desenvolvida por um equipe dedicada à realização de traqueostomias em um hospital terciário dedicado ao atendimento de pacientes com suspeita ou confirmação de COVID-19.

Mini-thoracostomy with vacuum-assisted closure: a minimally invasive alternative to open-window thoracostomy / Minipleurostomia com curativo a vácuo: uma opção minimamente invasiva a pleurostomia

ABSTRACT Thoracostomy is a common treatment option for patients with stage III pleural empyema who do not tolerate pulmonary decortication. However, thoracostomy is considered mutilating because it involves a thoracic stoma, the closure of which can take years or require further surgery. A new, minimally invasive technique that uses the vacuum-assisted closure has been proposed as an alternative to thoracostomy. This study aims to analyze the safety and effectiveness of mini-thoracostomy with vacuum-assisted closure in an initial sample of patients.

RESUMO A pleurostomia é uma opção frequente de tratamento para pacientes com empiema pleural fase III que não toleram decorticação pulmonar. Todavia, esse tratamento é considerado mutilante por envolver a confecção de um stoma torácico, que pode demorar anos para se fechar ou requerer nova cirurgia. Descreveu-se recentemente uma técnica minimamente invasiva que associa uso intrapleural de curativo a vácuo como opção a pleurostomia. A presente comunicação objetiva demonstrar o resultado de uma série inicial de pacientes tratados com a minipleurostomia associada ao uso de curativo a vácuo no que tange a sua efetividade e segurança.

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.

Alternative solution for ex vivo lung perfusion, experimental study on donated human lungs non-accepted for transplantation

PURPOSE: To evaluate a new perfusate solution to be used for ex vivo lung perfusion. METHODS: Randomized experimental study using lungs from rejected brain-dead donors harvested and submitted to 1 hour of ex vivo lung perfusion (EVLP) using mainstream solution or the alternative. RESULTS: From 16 lungs blocs tested, we found no difference on weight after EVLP: Steen group (SG) = 1,097±526g; Alternative Perfusion Solution (APS) = 743±248g, p=0.163. Edema formation, assessed by Wet/dry weigh ratio, was statistically higher on the Alternative Perfusion Solution group (APS = 3.63 ± 1.26; SG = 2.06 ± 0.28; p = 0.009). No difference on PaO2 after EVLP (SG = 498±37.53mmHg; APS = 521±55.43mmHg, p=0.348, nor on histological analyses: pulmonary injury score: SG = 4.38±1.51; APS = 4.50±1.77, p=0.881; apoptotic cells count after perfusion: SG = 2.4 ± 2.0 cells/mm2; APS = 4.8 ± 6.9 cells/mm2; p = 0.361). CONCLUSION: The ex vivo lung perfusion using the alternative perfusion solution showed no functional or histological differences, except for a higher edema formation, from the EVLP using Steen Solution(r) on lungs from rejected brain-dead donors. .

Cold ischemia or topical-ECMO for lung preservation: a randomized experimental study / Preservacao pulmonar por isquemia fria ou ECMO-topico: um estudo aleatorio experimental

CONTEXT AND OBJECTIVE: Lung preservation remains a challenging issue for lung transplantation groups. Along with the development of ex vivo lung perfusion, a new preservation method known as topical-ECMO (extracorporal membrane oxygenation) has been proposed. The present study compared topical-ECMO with cold ischemia (CI) for lung preservation in an ex vivo experimental model. DESIGN AND SETTING: Randomized experimental study, conducted at a public medical school. METHOD: Fourteen human lungs were retrieved from seven brain-dead donors that were considered unsuitable for transplantation. The lung bloc was divided and each lung was randomized to be preserved by means of topical-ECMO or CI (4-7 °C) for eight hours. These lungs were then reconnected to an ex vivo perfusion system for functional evaluation. Lung biopsies were obtained at three times. The functional variables assessed were oxygenation capacity (OC) and pulmonary artery pressure (PAP); and the histological variables were lung injury score (LIS) and apoptotic cell count (ACC). RESULTS : The mean OC was 468 mmHg (± 81.6) in the topical-ECMO group and 455.8 (± 54) for CI (P = 0.758). The median PAP was 140 mmHg (120-160) in the topical-ECMO group and 140 mmHg (140-150) for CI (P = 0.285). The mean LIS was 35.57 (± 4.5) in the topical-ECMO group and 33.86 (± 6.1) for CI (P = 0.367). The ACC was 25.00 (± 9.34) in the topical-ECMO group and 24.86 (± 10.374) for CI (P = 0.803). CONCLUSIONS: The present study showed that topical-ECMO was not superior to cold ischemia for up to eight hours of lung preservation. .

CONTEXTO E OBJETIVO: A preservação pulmonar permanece um desafio para os grupos transplantadores. Com o desenvolvimento da perfusão pulmonar ex vivo, foi proposto um novo método de preservação chamado de ECMO-tópico (oxigenação de membrana extracorpórea). O presente estudo compara ECMO-tópico com isquemia fria (IF) para preservação pulmonar em um modelo experimental ex vivo. TIPO DE ESTUDO E LOCAL: Estudo experimental randomizado, conduzido em uma faculdade de medicina pública. MÉTODO: Quatorze pulmões humanos foram retirados de sete doadores de morte cerebral considerados não aptos a transplante. O bloco pulmonar foi dividido e cada um foi aleatorizado para preservação por ECMO-tópico ou IF (4-7 °C) durante oito horas. Esses pulmões foram então re-conectados a um sistema de perfusão ex vivo para avaliação funcional. Biópsias pulmonares foram obtidas em três tempos. As variáveis funcionais avaliadas foram: capacidade de oxigenação (CO) e pressão de artéria pulmonar (PAP). As variáveis histológicas estudadas foram escore de lesão pulmonar (ELP) e contagem de células apoptóticas (CCA). RESULTADOS: A média da CO foi de 468 mmHg (± 81.6) no grupo ECMO-tópico e 455.8 (± 54) no grupo IF (P = 0,758); a PAP média foi de 140 mmHg (120-160) para ECMO-tópico e 140 mmHg (140-150) para IF (P = 0,285); o ELP médio foi 35,57 (± 4,5) no ECMO-tópico e 33,86 (± 6,1) no IF (P = 0,367). A CCA foi 25,00 (± 9,34) no grupo ECMO-tópico e 24,86 (± 10,374) no IF (P = 0,803). CONCLUSÕES: O presente estudo demonstrou que o ECMO-tópico não é superior a IF para oito horas de preservação pulmonar. .