Laparoscopic pyeloplasty proficiency during a residency program after adoption of a standardized simulation training program is maintained during the COVID pandemic despite reduced surgery volume

ABSTRACT Purpose: To evaluate the effect of the standardized laparoscopic simulation training program in pyeloplasty, following its implementation and during the COVID-19 pandemic. Material and Methods: A retrospective chart review was performed at Hospital de Clínicas de Porto Alegre, a tertiary referral center in south Brazil, in which 151 patients underwent laparoscopic pyeloplasty performed by residents between 2006-2021. They were divided into three groups: before and after adoption of a standardized laparoscopic simulation training program and during the COVID-19 pandemic. The main outcome was a combined negative outcome of conversion to open surgery, major postoperative complications (Clavien-Dindo III or higher) or unsuccessful procedure, defined as need for redo pyeloplasty. Results: There was a significant reduction in the combined negative outcome (21.1% vs 6.3%), surgical time (mean 200.0 min vs 177.4 min) and length of stay (median 5 days vs 3 days) after the adoption of simulation training program. These results were maintained during the COVID-19 pandemic (combined negative outcome of 6.3%, mean surgical time of 160.1 min and median length of stay of 3 days) despite a reduction in 55.4% of the surgical volume. Conclusion: A structured laparoscopic simulation program can improve outcomes of laparoscopic pyeloplasty during the learning curve.

Trauma de Cólon: experiência de um centro de referência em Porto Alegre/RS / Colon trauma: the experience of a reference center in Porto Alegre/RS

Introdução: As lesões de cólon são comuns em pacientes vítimas de trauma. Seu tratamento é bastante variável e muito discutido. Objetivo: Analisar a experiência com trauma de cólon de um centro de referência em trauma por aproximadamente 4 anos, avaliando o perfil dos pacientes, mecanismo de trauma, lesões, evolução e desfecho. Métodos: Estudo retrospectivo em que foram incluídos todos os pacientes com trauma de cólon no período de setembro de 2009 a dezembro de 2013. Resultados: Foram identificadas 101 vítimas com trauma de cólon, sendo 92 casos (91%) devido a trauma penetrante. Os ferimentos abdominais foram preponderantes (85,1%), seguidos por ferimentos em dorso em 15,8% e em transição toracoabdominal em 9,9%. Apenas 6,9% apresentavam-se com PAS < 90 mmHg e 23,8% com FC > 100 bpm na admissão. Noventa e nove por cento dos pacientes foram levados ao bloco cirúrgico para laparotomia exploradora imediatamente após o atendimento na sala de emergência. Setenta e três (72,3%) apresentaram lesões de outros órgãos abdominais associadas, a mais comum foi de intestino delgado (49,5%). A mortalidade da série foi de 1%, e as complicações mais frequentes foram a pneumonia em 16,8%, a infecção de ferida operatória em 11,9% e a infecção urinária em 7,9%. Conclusões: O diagnóstico e tratamento precoce das lesões de cólon são fundamentais para uma boa evolução e para prevenção das complicações, principalmente infecciosas, que são responsáveis pela morbidade e mortalidade nesses pacientes. Os dados apresentados estão de acordo com os encontrados na literatura atual(AU)

Background: Colon lesions are common in trauma patients. Their treatment is very variable and much discussed. Objective: To analyze the experience with colon trauma of a reference center for trauma for about 4 years, evaluating patient profile, mechanism of trauma, injury, evolution and outcome. Methods: A retrospective study which included all patients with colon trauma from September 2009 to December 2013. Results: A series of 101 victims with colon trauma were identified, of which 92 cases (91%) were due to penetrating trauma. Abdominal injuries were prevalent (85.1%), followed by back (15.8%) and thoracoabdominal transition (9.9%) injuries. Only 6.9% presented with SBP 100 bpm at admission. Ninety-nine percent of patients were taken to the operating room for exploratory laparotomy immediately after evaluation in the emergency room. Seventythree (72.3%) had associated injuries to other abdominal organs, the most common being small intestine (49.5%). The mortality in this series was 1%, and the most frequent complications were pneumonia in 16.8%, wound infection in 11.9%, and urinary infection in 7.9%. Conclusions: Early diagnosis and treatment of colon lesions are critical for a good outcome and prevention of complications, mainly infectious diseases, which are responsible for morbidity and mortality in these patients. The data presented are consistent with the current literature(AU)

Technique for implanting intramuscular electrodes in the diaphragm by videolaparoscopy in pigs

PURPOSE: To describe a novel approach for implanting intramuscular electrodes in the diaphragm through videolaparoscopy. METHODS: We used twelve pigs for this videolaparoscopic technique, which permits at the same time to explore the diaphragm, to locate its motor points and to fix the electrodes in the diaphragm bilaterally. In this technique we used three trocars: one portal for a 10-mm 0° viewing angle laparoscope, one portal for the manipulation of structures and another for electrode implantation. RESULTS: All animals survived the procedure without pneumothorax/capnothorax or other complication. Implanted electrodes provided an appropriate interface between the muscle and the electrical current generator, and electroventilation was satisfactorily generated in all animals. CONCLUSION: This videolaparoscopic technique with three trocars enables the exploration and identification of motor points and an efficient fixation of one or two electrodes in each hemidiaphragm.

Análise epidemiológica dos adenocarcinomas gástricos ressecados em um serviço de cirurgia oncológica / Epidemiological analysis of resected gastric adenocarcinomas in a oncologic surgery service

Introdução: O adenocarcinoma de estômago é a quarta neoplasia mais incidente no mundo e a segunda causa de morte relacionada ao câncer. O objetivo deste estudo é determinar o perfil epidemiológico e patológico dos pacientes intervidos cirurgicamente por adenocarcinoma gástrico e sua sobrevida relacionada à classificação TNM. Métodos:Estudo de coorte histórica de 216 pacientes submetidos à gastrectomia por adenocarcinoma gástrico. Foram analisados dados epidemiológicos, patológicos e a sobrevida. Resultados: A média de idade foi de 61,84 anos. Foram 76 (35,2%) pacientes do gênero feminino e 140 (64,8%), masculino. Quanto à localização, 79 (36,6%) no antro, 45 (20,8%) na cárdia, 70 (32,4%) no corpo. Em relação à diferenciação celular, 5 (2,3%) bem diferenciados, 71 (32,9%) moderadamente diferenciados, 133 (61,6%) pouco diferenciados e 7 (3,2%) eram indeterminados. O estadiamento clínico demonstrou 11 (5,1%) pacientes com estádio 0, com sobrevida de 100%; 23 (10,6%) no estádio I, com sobrevida de 82%; 55 pacientes (25,5%), com sobrevida de 60% no estádio II; 101 pacientes (46,7%), com sobrevida de 25% no estádio III e 26 pacientes (12%), com sobrevida de 15% no estádio IV. Em relação às complicações pós-operatórias, 52,3% dos pacientes não tiveram complicações e 7,9% (17 pacientes) com óbito no período pós-operatório. Conclusões: Aproximadamente 70% das neoplasias eram distais, enquanto cerca de 30% eram proximais. A grande parte dos pacientes era de estádios mais avançados, o que conferiu um pior prognóstico, refletindo a necessidade de uma revisão das políticas públicas para câncer gástrico do Brasil, visando aprimorar o diagnóstico e tratamento, melhorando o prognóstico desses pacientes.

Introduction:The gastric adenocarcinoma is the fourth most frequent cancer worldwide and the second leading cause of cancer-related death. The aim of this study is to determine the epidemiological and pathological profile of gastric adenocarcinoma patients and their survival regarding the TNM classification. Methods: A historical cohort study of 216 patients undergoing gastrectomy for gastric adenocarcinoma. Epidemiological, pathological and survival data were analyzed. Results: The mean age was 61.84 years. There were 76 (35.2%) females and 140 (64.8%) males. Regarding location, 79 (36.6%) cases were in the antrum, 45 (20.8%) in the cardia, and 70 (32.4%) in the body. Regarding cell differentiation, 5 cases (2.3%) were well differentiated, 71 (32.9%) moderately differentiated, 133 (61.6%) poorly differentiated, and 7 (3.2%) were indeterminate. Clinical staging showed 11 (5.1%) patients with stage 0 with a survival rate of 100%, 23 (10.6%) in stage I with a survival rate of 82%, 55 patients (25.5%) in stage II with a survival rate of 60%,101 patients (46,7%) in stage III with a survival rate of 25% and 26 patients (12%) in stage IV with a survival rate of 15%. Regarding postoperative complications, 52.3% of the patients had no complications and 7.9% (17 patients) died in the postoperative period. Conclusions: Approximately 70% of tumors were distal, while approximately 30% were proximal. The majority of patients had more advanced stages, which conferred a worse prognosis, reflecting the need for a revision of public policies for gastric cancer in Brazil, aiming to improve the diagnosis and treatment and determining a better prognosis for these patients.

Effect of the systemic administration of methylprednisolone on the lungs of brain-dead donor rats undergoing pulmonary transplantation

OBJECTIVE: Most lung transplants are obtained from brain-dead donors. The physiopathology of brain death involves hemodynamics, the sympathetic nervous system, and inflammatory mechanisms. Administering methylprednisolone 60 min after inducing brain death in rats has been shown to modulate pulmonary inflammatory activity. Our objective was to evaluate the effects of methylprednisolone on transplanted rat lungs from donors treated 60 min after brain death. METHODS: Twelve Wistar rats were anesthetized, and brain death was induced. They were randomly divided into two groups (n = 6), namely a control group, which was administered saline solution, and a methylprednisolone group, which received the drug 60 min after the induction of brain death. All of the animals were observed and ventilated for 2 h prior to being submitted to lung transplantation. We evaluated the hemodynamic and blood gas parameters, histological score, lung tissue levels of thiobarbituric acid-reactive substances, level of superoxide dismutase, level of tumor necrosis factor-alpha, and level of interleukin-1 beta. RESULTS: After transplantation, a significant reduction in the levels of tumor necrosis factor-alpha and IL-1β was observed in the group that received methylprednisolone (p = 0.0084 and p = 0.0155, respectively). There were no significant differences in tumor necrosis factor-alpha and superoxide dismutase levels between the control and methylprednisolone groups (p = 0.2644 and p = 0.7461, respectively). There were no significant differences in the blood gas parameters, hemodynamics, and histological alterations between the groups. CONCLUSION: The administration of methylprednisolone after brain death in donor rats reduces inflammatory activity in transplanted lungs but has no influence on parameters related to oxidative stress. .

Barium swallow study in routine clinical practice: a prospective study in patients with chronic cough / Estudo radiografico com ingestao de bario na rotina clinica: um estudo prospectivo em pacientes com tosse cronica

OBJECTIVE: To assess the routine use of barium swallow study in patients with chronic cough. METHODS: Between October of 2011 and March of 2012, 95 consecutive patients submitted to chest X-ray due to chronic cough (duration > 8 weeks) were included in the study. For study purposes, additional images were obtained immediately after the oral administration of 5 mL of a 5% barium sulfate suspension. Two radiologists systematically evaluated all of the images in order to identify any pathological changes. Fisher's exact test and the chi-square test for categorical data were used in the comparisons. RESULTS: The images taken immediately after barium swallow revealed significant pathological conditions that were potentially related to chronic cough in 12 (12.6%) of the 95 patients. These conditions, which included diaphragmatic hiatal hernia, esophageal neoplasm, achalasia, esophageal diverticulum, and abnormal esophageal dilatation, were not detected on the images taken without contrast. After appropriate treatment, the symptoms disappeared in 11 (91.6%) of the patients, whereas the treatment was ineffective in 1 (8.4%). We observed no complications related to barium swallow, such as contrast aspiration. CONCLUSIONS: Barium swallow improved the detection of significant radiographic findings related to chronic cough in 11.5% of patients. These initial findings suggest that the routine use of barium swallow can significantly increase the sensitivity of chest X-rays in the detection of chronic cough-related etiologies. .

OBJETIVO: Investigar o uso rotineiro do estudo radiográfico com ingestão de bário em pacientes com tosse crônica. MÉTODOS: Entre outubro de 2011 e março de 2012, 95 pacientes consecutivos submetidos a radiografia de tórax devido a tosse crônica (duração > 8 semanas) foram incluídos no estudo. Como propósito do estudo, radiografias de tórax adicionais foram obtidas imediatamente após a administração oral de 5 mL de uma suspensão de sulfato de bário a 5%. Dois radiologistas avaliaram todas as imagens de forma sistemática para identificar alterações patológicas. O teste exato de Fisher e o teste do qui-quadrado para dados categóricos foram utilizados nas comparações. RESULTADOS: As imagens obtidas imediatamente após a ingestão de bário revelaram patologias significativas potencialmente relacionadas a tosse crônica em 12 (12,6%) dos 95 pacientes. Essas patologias, incluindo hérnia diafragmática, neoplasia de esôfago, acalasia, divertículo esofágico e dilatação anormal do esôfago, não foram detectadas nas imagens obtidas sem a administração do contraste. Após o tratamento adequado, os sintomas desapareceram em 11 pacientes (91,6%), enquanto o tratamento foi ineficaz em 1 (8,4%). Não foram observadas complicações relacionadas à ingestão de bário, como aspiração. CONCLUSÕES: A ingestão de bário melhorou a detecção de achados radiológicos significantes relacionados a tosse crônica em 11,5% dos pacientes. Esses resultados iniciais sugerem que a utilização rotineira da ingestão de bário aumenta significantemente a sensibilidade de radiografias de tórax na detecção de etiologias relacionadas a tosse crônica. .

Effectiveness of diaphragmatic stimulation with single-channel electrodes in rabbits / Efetividade da estimulacao diafragmatica com eletrodos monocanais em coelhos

Every year, a large number of individuals become dependent on mechanical ventilation because of a loss of diaphragm function. The most common causes are cervical spinal trauma and neuromuscular diseases. We have developed an experimental model to evaluate the performance of electrical stimulation of the diaphragm in rabbits using single-channel electrodes implanted directly into the muscle. Various current intensities (10, 16, 20, and 26 mA) produced tidal volumes above the baseline value, showing that this model is effective for the study of diaphragm performance at different levels of electrical stimulation.

A cada ano um grande número de pessoas perde a função do diafragma tornando-se dependentes de ventilação mecânica. As principais causas são o trauma raquimedular da região cervical e as doenças neuromusculares. Desenvolvemos um modelo experimental para avaliar o desempenho da estimulação elétrica do diafragma em coelhos com eletrodos monocanais implantados diretamente neste músculo. Foram aplicadas diferentes intensidades de correntes (10, 16, 20 e 26 mA), as quais geraram volumes correntes acima dos valores basais, mostrando que este modelo é eficaz para estudar o desempenho do diafragma sob diferentes tipos de estimulação elétrica.

Efeitos da metilprednisolona na atividade inflamatória e estresse oxidativo nos pulmões de ratos com morte cerebral / Effects of methylprednisolone on inflammatory activity and oxidative stress in the lungs of brain-dead rats

OBJETIVO: Avaliar os efeitos da administração sistêmica precoce e tardia de metilprednisolona nos pulmões em um modelo de morte encefálica em ratos. MÉTODOS: Vinte e quatro ratos Wistar machos foram anestesiados e randomizados em quatro grupos (n = 6 por grupo): sham, somente morte encefálica (ME), metilprednisolona i.v. (30 mg/kg) administrada 5 min após a morte encefálica (MP5) e 60 min após a morte encefálica (MP60). Os grupos ME, MP5 e MP60 foram submetidos à morte encefálica por insuflação de um balão no espaço extradural. Todos os animais foram observados e ventilados durante 120 min. Foram determinadas variáveis hemodinâmicas e gasométricas, relação peso úmido/seco, escore histológico, thiobarbituric acid reactive substances (TBARS, substâncias reativas ao ácido tiobarbitúrico), atividade de superóxido dismutase (SOD) e de catalase, assim como contagem diferencial de células brancas, proteína total e nível de desidrogenase lática no LBA. A atividade da mieloperoxidase, peroxidação lipídica e níveis de TNF-α foram avaliados no tecido pulmonar. RESULTADOS: Não foram observadas diferenças significativas nas variáveis hemodinâmicas e gasométricas, relação peso úmido/seco, análises do LBA, escore histológico, SOD, mieloperoxidase e catalase entre os grupos. Os níveis de TBARS foram significativamente maiores nos grupos MP5 e MP60 do que nos grupos sham e ME (p < 0,001). Os níveis de TNF-α foram significativamente menores nos grupos MP5 e MP60 do que no grupo ME (p < 0,001). CONCLUSÕES: Neste modelo de morte cerebral, a administração precoce e tardia de metilprednisolona apresentou efeitos semelhantes sobre a inflamação e a peroxidação lipídica no tecido pulmonar.

OBJECTIVE: To evaluate the effects that early and late systemic administration of methylprednisolone have on lungs in a rat model of brain death. METHODS: Twenty-four male Wistar rats were anesthetized and randomly divided into four groups (n = 6 per group): sham-operated (sham); brain death only (BD); brain death plus methylprednisolone (30 mg/kg i.v.) after 5 min (MP5); and brain death plus methylprednisolone (30 mg/kg i.v.) after 60 min (MP60). In the BD, MP5, and MP60 group rats, we induced brain death by inflating a balloon catheter in the extradural space. All of the animals were observed and ventilated for 120 min. We determined hemodynamic and arterial blood gas variables; wet/dry weight ratio; histological score; levels of thiobarbituric acid reactive substances (TBARS); superoxide dismutase (SOD) activity; and catalase activity. In BAL fluid, we determined differential white cell counts, total protein, and lactate dehydrogenase levels. Myeloperoxidase activity, lipid peroxidation, and TNF-α levels were assessed in lung tissue. RESULTS: No significant differences were found among the groups in terms of hemodynamics, arterial blood gases, wet/dry weight ratio, BAL fluid analysis, or histological score-nor in terms of SOD, myeloperoxidase, and catalase activity. The levels of TBARS were significantly higher in the MP5 and MP60 groups than in the sham and BD groups (p < 0.001). The levels of TNF-α were significantly lower in the MP5 and MP60 groups than in the BD group (p < 0.001). CONCLUSIONS: In this model of brain death, the early and late administration of methylprednisolone had similar effects on inflammatory activity and lipid peroxidation in lung tissue.