Proposed public policies to improve outcomes in vascular surgery: an experts' forum

ABSTRACT Objective To evaluate outcomes of vascular surgeries and identify strategies to improve public vascular care. Methods This was a descriptive, qualitative, and cross-sectional survey involving 30 specialists of the Hospital Israelita Albert Einstein via Zoom. The outcomes of vascular procedures performed in the Public Health System extracted through Big Data analysis were discussed, and 53 potential strategies to improve public vascular care to improve public vascular care. Results There was a consensus on mandatory reporting of some key complications after complex arterial surgeries, such as stroke after carotid revascularization and amputations after lower limb revascularization. Participants agreed on the recommendation of screening for diabetic feet and infrarenal abdominal aortic aneurysms. The use of Telemedicine as a tool for patient follow-up, auditing of centers for major arterial surgeries, and the concentration of complex arterial surgeries in reference centers were also points of consensus, as well as the need to reduce the values of endovascular materials. Regarding venous surgery, it was suggested that there should be incentives for simultaneous treatment of both limbs in cases of varicose veins of the lower limbs, in addition to the promotion of ultrasound-guided foam sclerotherapy in the public system. Conclusion After discussing the data from the Brazilian Public System, proposals were defined for standardizing measures in population health care in the area of vascular surgery.

Analysis of 45,507 surgical treatment of distal tibia and malleolar fractures over 14 years / Análise de 45.507 tratamentos cirúrgicos das fraturas distais da tíbia e do tornozelo ao longo de 14 anos

ABSTRACT The distal leg joint fractures are among the most common fractures in humans across all age groups, and 50% of them require surgical treatment. Few studies discuss the epidemiology and costs of this fracture in the global and national literature. Objective: To evaluate the annual incidence and reimbursement value of distal leg joint fractures requiring surgical treatment from 2008 to 2021. Methods: A retrospective study was conducted to analyze the complex structured data of high volume and high variability (Big Data), publicly available on the TabNet platform (DATASUS), via software with artificial intelligence. Data from 2008 to 2021 on surgical treatment for malleolar fracture, distal tibia fracture, and isolated fibula fracture were analyzed. Results: From 2008 to 2021, there was an average incidence of 28.8 fractures/105 inhabitants per year, representing 14.62% of all fractures. The total amount paid for hospitalizations due to these fractures was R$ 34,218,014.62 over these 14 years. Conclusion: The incidence of distal leg joint fractures follows the pattern of those recorded in other countries. The adjustment of reimbursement over the years was lower than the accumulated inflation. Level of Evidence II, Economic and Decision Analyses - Developing an Economic or Decision Model.

RESUMO As fraturas articulares distais da perna estão entre as fraturas mais comuns do ser humano ao longo de todas as faixas etárias, e 50% delas necessitam de tratamento cirúrgico. Existem poucos trabalhos discutindo a epidemiologia e os custos dessa fratura na literatura mundial e, principalmente, na nacional. Objetivo: Avaliar a incidência anual e o valor de reembolso das fraturas distais da perna com indicação para tratamento cirúrgico entre os anos de 2008 e 2021. Métodos: Estudo retrospectivo para analisar os dados complexos estruturados de alto volume e alta variabilidade (Big Data), disponibilizados publicamente na plataforma TabNet (Datasus), através de um software com inteligência artificial. Foram analisados os dados de 2008 a 2021 do tratamento cirúrgico de fratura maleolar, fratura distal da tíbia e fratura isolada da fíbula. Resultados: Entre 2008 e 2021, houve incidência média de 28,8 fraturas/105 habitantes-ano, representando 14,62% de todas as fraturas. O valor total pago pelas internações dessas fraturas foi de R$ 34.218.014,62 ao longo desses 14 anos. Conclusão: A incidência das fraturas articulares distais da perna acompanha o padrão daqueles registrados em outros países. O reajuste do repasse ao longo dos anos foi inferior à inflação acumulada. Nível de Evidência II, Análises Econômicas e de Decisão - Desenvolvimento de Modelo Econômico ou de Decisão.

Population-based analysis of the epidemiology of the surgical correction of hyperhidrosis in 1,216 patients over 11 years: a cross-sectional study

Abstract BACKGROUND: Endoscopic thoracic sympathectomy is the definitive surgical treatment for hyperhidrosis and a nationwide study has suggested that cultural and socioeconomic factors play a role in the numbers of operations performed. Thus, there is a need to evaluate local data in order to understand the local epidemiology and trends in hyperhidrosis treatment. OBJECTIVE: To study the epidemiology of sympathectomy for treating hyperhidrosis in São Paulo, the largest city in Brazil. DESIGN AND SETTING: Population-based retrospective cross-sectional study. METHODS: Data on sympathectomies for treating hyperhidrosis between 2008 and 2018 were assessed from the database of the Municipal Health Department of São Paulo, Brazil. RESULTS: 65.29% of the patients were female, 66.2% were aged between 20 and 39 years and 37.59% had registered with addresses outside São Paulo. 1,216 procedures were performed in the city of São Paulo from 2008 to 2018, and 78.45% of them were in only two public hospitals. The number of procedures significantly declined over the years (P = 0.001). 71.63% of the procedures were associated with 2-3 days of hospital stay, only 78 intensive care unit days were billed and we did not observe any intra-hospital death. CONCLUSION: The profile of patients operated on in São Paulo (young women) is similar to that described in other populations. Sympathectomy is a very safe procedure, with no mortality in our series. There was a decreasing trend in the number of surgeries over the years.

Epidemiological Analysis of 12 Years of Open Thoracoabdominal Aortic Aneurysm Repair in the Brazilian Public Health System

ABSTRACT Introduction: Although endovascular correction is a promising perspective, the gold-standard treatment for thoracoabdominal aortic aneurisms and type-B dissections with visceral involvement remains open surgery, particularly due to its well-established long-term durability. This study aims to describe and evaluate public data from patients treated for thoracoabdominal aortic aneurism in the Brazilian public health system in a 12-year interval. Methods: Data from procedures performed between 2008 and 2019 were extracted from the national public database (Departamento de Informática do Sistema Único de Saúde, or DATASUS) using web scraping techniques. Procedures were evaluated regarding the yearly frequency of elective or urgency surgeries, in-hospital mortality, and governmental costs. All tests were done with a level of significance P<0.05. Results: A total of 812 procedures were analyzed. Of all surgeries, 67.98% were elective cases. There were 328 in-hospital deaths (mortality of 40.39%). In-hospital mortality was lower in elective procedures (26.92%) than in urgency procedures (46.74%) (P=0.008). Total governmental expenditure was $3.127.051,56 — an average of $3.774,22 for elective surgery and $3.791,93 for emergency surgery (P=0.999). Conclusion: The proportion of urgency procedures is higher than that recommended by international literature. Mortality was higher for urgent admissions, although governmental costs were equal for elective and urgent procedures; specialized referral centers should be considered by health policy makers.

Cohort study on 20 years' experience of bilateral video-assisted thoracic sympathectomy (VATS) for treatment of hyperhidrosis in 2431 patients

Abstract BACKGROUND: Primary hyperhidrosis is a condition characterized by excessive sweating, inconsistent with the needs for thermoregulation. OBJECTIVE: To assess the effectiveness and the change in the quality of life of patients undergoing bilateral VATS (video-assisted thoracoscopic sympathectomy) for treatment of hyperhidrosis, in a large case series. DESIGN AND SETTING: Cohort study conducted in a tertiary hospital specializing in hyperhidrosis located in São Paulo, Brazil. METHODS: A total of 2,431 patients who underwent surgery consisting of bilateral video-assisted thoracoscopic sympathectomy between January 2000 and February 2017 were retrospectively assessed in an outpatient clinic specializing in hyperhidrosis. The patients underwent clinical and quality of life assessments on two occasions: firstly, prior to surgery, and subsequently, one month after the operation. The presence or absence of compensatory hyperhidrosis (CH) and general satisfaction after the first postoperative month were also evaluated. RESULTS: All the patients operated had poor or very poor quality of life before surgery. In the postoperative period, an improvement in the quality of life was observed in more than 90% of the patients. Only 10.7% of the patients did not present CH, and severe CH occurred in 22.1% of the patients in this sample. CONCLUSION: Bilateral VATS is a therapeutic method that decreases the degree of sweating more than 90% of patients with palmar and axillary hyperhidrosis. It improves the quality of life for more than 90% of the patients, at the expense of development of CH in approximately 90% of the patients, but not intensely.

Varicose Vein Stripping in 66,577 patients in 11 years in public hospitals in São Paulo

SUMMARY OBJECTIVES: The aim of this study was to evaluate the epidemiology of varicose vein stripping in Brazil's largest city, São Paulo. METHODS: Open and anonymous data regarding varicose vein surgeries between 2008 and 2018 were evaluated from the TabNet platform of the Municipal Health Secretary of São Paulo, Brazil. RESULTS: Most patients were female and adults. A total of 66,577 varicose vein surgeries were performed in public hospitals and outpatient clinics in São Paulo, with a statistically significant increase for both unilateral (p=0.003) and bilateral (p<0.001) procedures. Since 2016, unilateral procedures have been performed more frequently than bilateral procedures. Most procedures were associated with same-day (54.8%) or next-day (32%) discharge. The in-hospital mortality rate was 0.0045%. The total amount reimbursed was $20,693,437.94, corresponding to a mean value of $310.82 per procedure. CONCLUSION: Surgeries to treat chronic vein disease totaled 66,577 in 11 years, demanding $20,693,437.94 from the public health system. The majority of treated patients were female, over 40 years of age, and local residents. Procedure rates have increased over the years. The in-hospital mortality rate was very low (0.0045%).

Epidemiological analysis of 556 procedures of open thoracoabdominal aortic aneurysm repair in the Public Health System in the largest Brazilian city

ABSTRACT Objective Despite the development of endovascular procedures, open repair remains the gold standard for the treatment of aortic thoracoabdominal aneurysms and some type B dissections, with well-established good outcomes and long-term durability at high-volume centers. The present study described and analyzed public data from patients treated in the public system in a 12-year interval, in a city where more than 5 million inhabitants depend on the Public Health System. Methods Public data from procedures performed between 2008 and 2019 were extracted using web scraping techniques. The variables available in the database include sex, age, elective or emergency hospital admission, number of surgeries, in-hospital mortality, length of stay, and information on reimbursement values. Results A total of 556 procedures were analyzed. Of these, 60.79% patients were men, and 41.18% were 65 years of age or older. Approximately 60% had a residential address registered in the municipality. Of all surgeries, 65.83% were elective cases. There were 178 in-hospital deaths (mortality of 32%). In the elective context, there were 98 deaths 26.78% versus 80 deaths (42.10%) in the emergency context (p=0.174). Mortality was lower in the hospitals that performed more surgeries. A total of USD 3,038,753.92 was paid, an average of USD 5,406.95 for elective surgery and USD 5,074.76 for emergency surgery (p=0.536). Conclusion Mortality was no different between groups, and hospitals with higher volume presented more favorable outcomes. Specialized referral centers should be considered by health policy makers.

Epidemiological analysis of lower limb revascularization for peripheral arterial disease over 12 years on the public healthcare system in Brazil / Análise epidemiológica da revascularização de membros inferiores para doença arterial periférica em 12 anos no sistema público de saúde do Brasil

Abstract Background Worldwide, peripheral arterial disease (PAD) is a disorder with high morbidity, affecting more than 200 million people. Objectives Our objective was to analyze surgical treatment for PAD provided on the Brazilian Public Healthcare System over 12 years using publicly available data. Methods The study was conducted with analysis of data available on the Brazilian Health Ministry's database platform, assessing distributions of procedures and techniques over the years and their associated mortality and costs. Results A total of 129,424 procedures were analyzed (performed either for claudication or critical ischemia, proportion unknown). The vast majority of procedures were endovascular (65.49%) and this disproportion exhibited a rising trend (p<0.001). There were 3,306 in-hospital deaths (mortality of 2.55%), with lower mortality in the endovascular group (1.2% vs. 5.0%, p=0.008). The overall governmental expenditure on these procedures was U$ 238,010,096.51, and endovascular procedures were on average significantly more expensive than open surgery (U$ 1,932.27 vs. U$ 1,517.32; p=0.016). Conclusions Lower limb revascularizations were performed on the Brazilian Public Healthcare System with gradually increasing frequency from 2008 to 2019. Endovascular procedures were vastly more common and were associated with lower in-hospital mortality rates, but higher procedure costs.

Resumo Contexto A doença arterial periférica (DAP) é uma doença com alta morbidade global, afetando mais de 200 milhões de pessoas. Objetivos Neste estudo, analisamos o tratamento cirúrgico para DAP no sistema público de saúde do Brasil no período de 12 anos, com base em dados publicamente disponíveis. Métodos O estudo foi conduzido a partir da análise de dados disponíveis na plataforma do Departamento de Informática do Sistema Único de Saúde (DATASUS), do Ministério da Saúde, avaliando a distribuição da técnica cirúrgica utilizada, a mortalidade e o custo ao longo dos anos. Resultados Um total de 129.424 procedimentos foram analisados (para claudicantes e isquemia crítica, em proporção desconhecida). A maiora dos procedimentos foi via endovascular (65,49%), com tendência de aumento nessa desproporção (p < 0,001). Houve 3.306 mortes intra-hospitalares (mortalidade de 2,55%) com menor mortalidade no grupo endovascular (1,2% vs. 5,0%; p = 0,008). O investimento governamental total para esses procedimentos foi de US$ 238.010.096,51, e os procedimentos endovasculares foram significativamente mais caros que a cirurgia aberta convencional (US$ 1.932,27 vs. US$ 1.517,32; p = 0,016). Conclusões No sistema público de saúde brasileiro, as revascularizações de membros inferiores ocorreram com frequência crescente entre 2008 e 2019. Os procedimentos endovasculares foram mais comuns e relacionados a menor mortalidade intra-hospitalar, mas a maiores custos.

Surgical repair of abdominal aortic aneurysms on the public health system in the largest city in Brazil: a descriptive analysis of in-hospital data on 2693 procedures over 10 years / Correção cirúrgica do aneurisma de aorta abdominal em 2. 693 procedimentos ao longo de 10 anos no sistema público de saúde: uma análise descritiva na maior cidade brasileira

Abstract Background From 1990 to 2015, mortality from aortic aneurysms increased 16.8% in Brazil. São Paulo is the largest city in Brazil and about 5 million people depend on the public health system there. Objectives To conduct an epidemiological analysis of abdominal aortic aneurysm surgeries in the city of São Paulo. Methods Infra-renal aortic aneurysm procedures performed over a decade (from 2008 to 2017) were studied using publicly-available platforms from the Unified Health System and DATASUS. Results 2693 procedures were analyzed; 66.73% were endovascular; 78.7% of patients were male; 70.7% were aged 65 years or more; 64.02% were elective hospital admissions. There were 288 in-hospital deaths (mortality: 10.69%). In-hospital mortality was lower for endovascular surgery than for open surgery; both for elective (4.13% versus 14.42%) and urgent (9.73% versus 27.94%) (p = 0.019) admissions. The highest volume hospital (n = 635) had the lowest in-hospital mortality (3.31%). USD 24,835,604.84 was paid; an average of $ 2,318.63 for elective open, $ 3,420.10 for emergency open, $ 12,157.35 for elective endovascular and $ 12,969.12 for urgent endovascular procedures. Endovascular procedure costs were statistically higher than the values paid for open surgeries (p <0.001). Conclusions Endovascular surgeries were performed twice as often as open surgeries; they had shorter hospital stays and lower mortality.

Resumo Contexto No Brasil, a mortalidade por aneurisma de aorta aumentou 16,8% de 1990 a 2015. São Paulo é a maior cidade do Brasil, e cerca de 5 milhões de pessoas dependem do sistema público de saúde. Objetivos Análise epidemiológica das cirurgias do aneurisma de aorta abdominal na cidade de São Paulo. Métodos As cirurgias para correção do aneurisma de aorta infrarrenal realizadas no período de uma década (de 2008 a 2017) foram estudadas utilizando-se plataformas publicamente disponíveis do Sistema Único de Saúde e do Departamento de Informática do Sistema Único de Saúde. Resultados Foram analisados ​​2.693 procedimentos, entre os quais 66,73% eram endovasculares. Entre os pacientes, houve predominância do sexo masculino (78,7%) e daqueles com 65 anos ou mais (70,7%). Um total de 64,02% eram admissões hospitalares eletivas. Ocorreram 288 óbitos hospitalares (mortalidade: 10,69%). A mortalidade durante a internação foi menor para cirurgia endovascular do que para cirurgia aberta tanto no contexto eletivo (4,13% versus 14,42%) quanto urgente (9,73% versus 27,94%) (p = 0,019). O maior volume (n = 635) apresentou menor mortalidade intra-hospitalar (3,31%). Foi pago um total de $24.835.604,84, sendo uma média de $2.318,63 para cirurgia abertura eletiva, $3.420,10 para cirurgia abertura de emergência, $12.157,35 para cirurgia endovascular eletiva e $12.969,12 para cirurgia endovascular na urgência. Os custos dos procedimentos endovasculares foram estatisticamente superiores aos valores pagos para as cirurgias abertas (p < 0,001). Conclusões Foram realizadas duas vezes mais cirurgias endovasculares do que abertas, as quais apresentaram menor tempo de internação e menor mortalidade.

Endovascular correction of isolated descending thoracic aortic disease: a descriptive analysis of 1, 344 procedures over 10 years in the public health system of São Paulo

OBJECTIVES: In Brazil, descending thoracic aorta disease (TAD), including aneurysms and dissection, are preferentially managed by endovascular treatment (TEVAR) due to the feasibility and good results of this technique. In this study, we analyzed endovascular treatment of isolated TAD (ITAD) in the public health system over a 10-year period in São Paulo, a municipality in Brazil in which more than 5 million inhabitants depend on the governmental health system. METHODS: Public data from procedures performed between 2008 and 2019 were extracted using web scraping techniques. The following types of data were analyzed: demographic data, operative technique, elective or urgent status, number of surgeries, in-hospital mortality, length of hospital stay, mean length of stay in the intensive care unit, and reimbursement values paid by the government. Trauma cases and congenital diseases were excluded. RESULTS: A total of 1,344 procedures were analyzed; most patients were male and aged ≥65 years. Most individuals had a residential address registered in the city. Approximately one-third of all surgeries were urgent cases. There were 128 in-hospital deaths (9.52%), and in-hospital mortality was lower for elective than for urgent surgeries (7.29% vs. 14.31%, p=0.031). A total of R$ 24.766.008,61 was paid; an average of R$ 17.222,98 per elective procedure and R$ 18.558,68 per urgent procedure. Urgent procedures were significantly more expensive than elective surgeries (p=0.029). CONCLUSION: Over a 10-year period, the total cost of ITAD interventions was R$ 24.766.008,61, which was paid from the governmental system. Elective procedures were associated with lower mortality and lower investment from the health system when compared to those performed in an urgent scenario.

Epidemiological analysis of 5,595 procedures of endovascular correction of isolated descending thoracic aortic disease over 12 years in the public health system in Brazil

OBJECTIVES: In Brazil, descending thoracic aorta disease, including aneurysms and dissections, is managed preferentially by endovascular treatment, owing to its feasibility and good results. In this study, we analyzed endovascular treatment of isolated descending thoracic aortic disease cases in the Brazilian public health system over a 12-year period. METHODS: Public data from procedures performed from 2008 to 2019 were extracted using web scraping techniques to assess procedure type frequency (elective or urgency), mortality, and governmental costs. RESULTS: A total of 5,595 procedures were analyzed, the vast majority of which were urgent procedures (61.82% vs. 38.18%). In-hospital mortality was lower for elective than for urgent surgeries (4.96 vs.10.32% p=0.008). An average of R$16,845.86 and R$20,012.04 was paid per elective and emergency procedure, respectively, with no statistical difference (p=0.095). CONCLUSION: Elective procedures were associated with lower mortality than urgent procedures. There was no statistically significant difference between elective and urgent procedures regarding costs.

Symptoms of anxiety and depression in patients with primary hyperhidrosis and its association with the result of clinical treatment with oxybutynin

OBJECTIVES: Studies have identified correlations between the psychological characteristics of individuals with primary hyperhidrosis (HH), the degree of sweating, and the quality of life (QoL). This study aimed to evaluate the prevalence of anxiety and depression symptoms in patients with HH before and after oxybutynin treatment. METHODS: Data were collected from 81 patients. Palmar or axillary HH was the most frequent complaint (84.0%). All patients were evaluated before the medication was prescribed and after five weeks of treatment. The Beck Depression Inventory and Beck Anxiety Inventory were used to evaluate depression and anxiety. RESULTS: Improvement in HH occurred in 58 patients (71.6%), but there was no improvement in 23 patients (28.4%). The QoL before treatment in all patients was either "poor" or "very poor." Patients who experienced improvement in sweating rates also experienced a greater improvement in QoL than patients who did not experience improvement in sweating at the main site (87.9% vs. 34.7%) (p<0.001). A total of 19.7% of patients showed an improvement in their level of depression, and a total of 46.9% of patients exhibited improvements in their level of anxiety. A significant correlation was observed between sweating and anxiety (p=0.015). CONCLUSION: Patients with HH who experienced improvements in sweating immediately after treatment with oxybutynin exhibited small improvements in their levels of depression and significant improvements in their levels of anxiety and QoL.

Current treatment options for craniofacial hyperhidrosis / Opções atuais de tratamento para hiperidrose craniofacial

Abstract Hyperhidrosis (HH) is characterized by sweating exceeding the amount necessary to meet the thermal regulation and physiological needs of the body. Approximately 9.41% of individuals with HH have craniofacial hyperhidrosis (FH). The present study aims to review the most current data in the literature regarding craniofacial hyperhidrosis, including pathophysiology, diagnosis and clinical presentation, treatment options (clinical and surgical), and outcomes. VATS (videothoracoscopy sympathectomy) is considered the gold standard for definitive treatment of axillary or palmar hyperhidrosis. Recently, several studies have shown the usefulness of clinical treatment with oxybutynin hydrochloride, leading to clinical improvement of HH in more than 70% of users. Both clinical and surgical treatment of craniofacial hyperhidrosis have good results. However, surgical treatment of FH is associated with more complications. Clinical treatment with oxybutynin hydrochloride yields good results and can be the first therapeutic option. When the patient is not satisfied with this treatment and has good clinical conditions, surgical treatment can be used safely.

Resumo A hiperidrose (HH) é caracterizada por transpiração além da quantidade necessária para manter a regulação térmica e as necessidades fisiológicas do corpo. Aproximadamente 9,41% dos indivíduos com HH apresentam hiperidrose craniofacial (FH). Este estudo tem como objetivo revisar os dados mais atuais da literatura sobre FH, incluindo fisiopatologia, diagnóstico e apresentação clínica, opções de tratamento (clínico e cirúrgico) e desfechos. A simpatectomia por videotoracoscopia (VATS) é considerada o padrão-ouro para o tratamento definitivo da hiperidrose axilar ou palmar. Recentemente, vários estudos demonstraram a utilidade do tratamento clínico com cloridrato de oxibutinina, que leva à melhora clínica da HH em mais de 70% dos pacientes. O tratamento clínico e o cirúrgico apresentam bons resultados no tratamento da FH. No entanto, o tratamento cirúrgico da FH apresenta mais complicações. O tratamento clínico com cloridrato de oxibutinina fornece bons resultados e pode ser a primeira opção terapêutica. Quando o paciente não está satisfeito com esse tratamento e mostra boas condições clínicas, o tratamento cirúrgico pode ser usado com segurança.

Effectiveness of epicardial atrial pacing using a bipolar steroid-eluting endocardial lead with active fixation in an experimental model

PURPOSE: To assess the effectiveness of bipolar epicardial atrial pacing using an active fixation bipolar endocardial lead implanted on the atrial surface in an experimental model. METHODS: A total of ten Large White adult pigs underwent pacemaker implantation under general anesthesia. Atrial pacing and sensing parameters were obtained at the procedure, immediate postoperative period and on the 7th and the 30th postoperative in unipolar and bipolar configurations. RESULTS: All procedures were successfully performed. There were no perioperative complications and no early deaths. Atrial pacing and sensing parameters for both unipolar and bipolar modes remained stable throughout the study. We observed a progressive increase in atrial thresholds, ranging from 0.49 ± 0.35 (at implantation) to 1.86 ± 1.31 volts (30th postoperative day), in unipolar mode. Atrial impedance measurements decreased slightly over time, ranging from 486.80 ± 126.35 Ohms (at implantation) to 385.0 ± 80.52 Ohms (30th postoperative day). Atrial sensing measures remained stable from the immediate postoperative period until the end of the study. CONCLUSION: The bipolar active fixation endocardial lead implanted epicardially can provide stable conditions of pacing and sensing parameters throughout the postoperative follow-up.