Red neural artificial para predecir factores de riesgo asociados a complicaciones postoperatorias secundarias al tratamiento del neumotórax / Artificial neural network to predict risk factors associated with postoperative complications secondary to pneumothorax treatment

Introducción. Debido a la ausencia de modelos predictivos estadísticamente significativos enfocados a las complicaciones postoperatorias en el manejo quirúrgico del neumotórax, desarrollamos un modelo, utilizando redes neurales, que identifica las variables independientes y su importancia para reducir la incidencia de complicaciones. Métodos. Se realizó un estudio retrospectivo en un centro asistencial, donde se incluyeron 106 pacientes que requirieron manejo quirúrgico de neumotórax. Todos fueron operados por el mismo cirujano. Se desarrolló una red neural artificial para manejo de datos con muestras limitadas; se optimizaron los datos y cada algoritmo fue evaluado de forma independiente y mediante validación cruzada, para obtener el menor error posible y la mayor precisión con el menor tiempo de respuesta. Resultados. Las variables de mayor importancia según su peso en el sistema de decisión de la red neural (área bajo la curva 0,991) fueron el abordaje por toracoscopia video asistida (OR 1,131), el uso de pleurodesis con talco (OR 0,994) y el uso de autosuturas (OR 0,792; p<0,05). Discusión. En nuestro estudio, los principales predictores independientes asociados a mayor riesgo de complicaciones fueron el neumotórax de etiología secundaria y el neumotórax recurrente. Adicionalmente, confirmamos que las variables asociadas a reducción de riesgo de complicaciones postoperatorias tuvieron significancia estadística. Conclusión. Identificamos la toracoscopia video asistida, el uso de autosuturas y la pleurodesis con talco como posibles variables asociadas a menor riesgo de complicaciones. Se plantea la posibilidad de desarrollar una herramienta que facilite y apoye la toma de decisiones, por lo cual es necesaria la validación externa en estudios prospectivos

Introduction. Due to the absence of statistically significant predictive models focused on postoperative complications in the surgical management of pneumothorax, we developed a model using neural networks that identify the independent variables and their importance in reducing the incidence of postoperative complications. Methods. A retrospective single-center study was carried out, where 106 patients who required surgical management of pneumothorax were included. All patients were operated by the same surgeon. An artificial neural network was developed to manage data with limited samples. The data is optimized and each algorithm is evaluated independently and through cross-validation to obtain the lowest possible error and the highest precision with the shortest response time. Results. The most important variables according to their weight in the decision system of the neural network (AUC 0.991) were the approach via video-assisted thoracoscopy (OR 1.131), use of pleurodesis with powder talcum (OR 0.994) and use of autosutures (OR 0.792, p<0.05). Discussion. In our study, the main independent predictors associated with a higher risk of complications are pneumothorax of secondary etiology and recurrent pneumothorax. Additionally, we confirm that the variables associated with a reduction in the risk of postoperative complications have statistical significance. Conclusion. We identify video-assisted thoracoscopy, use of autosuture and powder talcum pleurodesis as possible variables associated with a lower risk of complications and raise the possibility of developing a tool that facilitates and supports decision-making, for which external validation in prospective studies is necessary

Lobectomías pulmonares en Colombia: una caracterización demográfica y clínico-patológica / Pulmonary lobectomies in Colombia: a demographic and clinicopathological characterization

Introducción. La lobectomía pulmonar es uno de los procedimientos más frecuentes en la cirugía torácica en Colombia y a nivel mundial. El objetivo de este estudio fue proporcionar información sobre el comportamiento clínico de los individuos sometidos a este tipo de cirugías. Métodos. Estudio observacional retrospectivo en un Hospital Universitario de Cali, Colombia, que incluyó todos los pacientes sometidos a lobectomía pulmonar, por causas benignas o malignas, entre los años 2010 y 2020. La información se extrajo del registro institucional de cirugía de tórax, obteniendo datos demográficos, clínicos y patológicos. Resultados. Se evaluaron los registros clínicos de 207 individuos. El 55,5 % eran mujeres, la edad promedio fue 58 años y el 41 % tuvieron antecedente de tabaquismo. En el 51,6 % de los casos se diagnosticaron neoplasias, de las cuales el 47,8 % eran primarias de pulmón, siendo el adenocarcinoma el subtipo más común. Las enfermedades benignas no tumorales representaron el 48,3 % de los casos y la causa más frecuente fueron las infecciones, dentro de las que se incluyeron 17 casos de tuberculosis pulmonar. La técnica más frecuente fue la cirugía toracoscópica video asistida (82,6 %). Presentaron un porcentaje de reintervención del 5,8 %, 10,6 % de complicaciones severas y una mortalidad hospitalaria del 4,3 %. Conclusión. La población evaluada muestra una carga alta de comorbilidades y riesgo operatorio elevado; de forma consecuente, al compararla con otras series internacionales, se encontró un porcentaje mayor de complicaciones perioperatorias y mortalidad.

Introduction. The pulmonary lobectomies is one of the most common procedures in thoracic surgery in Colombia and worldwide. The objective of this study is to provide information on the clinical behavior of individuals who underwent this type of surgeries. Methods. Retrospective observational study at a University Hospital in Cali, Colombia, including all individuals who had pulmonary lobectomies, between the years 2010 to 2020 for benign and malignant causes. The information was extracted from the institutional registry of thoracic surgery, obtaining demographic, clinical and pathological data. Results. The clinical records of 207 individuals were evaluated, 55.5% were women, the average age was 58 years, and 41% had a history of smoking. Of these cases, 51.6% were diagnosed with neoplasms, of which 47.8% were primary lung neoplasms, with adenocarcinoma being the most common subtype. As for benign diseases, they represented 48.3% of the cases and the most frequent cause was infections, including 17 cases of pulmonary tuberculosis. The most frequent technique was video-assisted thoracoscopic surgery in 82.6%, with a reoperation rate of 5.8%, up to 10.6% of severe complications, a median hospital stay of 6 days, and a hospital mortality of 4.3%.Conclusion. The population evaluated shows a high burden of comorbidities and high operative risk; consequently, when compared with other international series, it shows a higher percentage of perioperative complications, hospital stay, and mortality.

Endometriosis pleuropulmonar y neumotórax catamenial asociado: reporte de caso / Pleuropulmonary endometriosis and associated catamenial pneumothorax:A case report

Resumen ANTECEDENTES: El tórax es la localización extrapélvica más frecuente de la endometriosis; esto sin que su incidencia se haya determinado con estudios suficientes. Tampoco se ha establecido del todo su fisiopatología, pero aun así se han planteado diversas teorías. El neumotórax catamenial es una de las posibles manifestaciones que hacen complejo establecer el diagnóstico e indicar un tratamiento. CASO CLÍNICO: Paciente de 31 años, con antecedente de neumotórax espontáneo a repetición, que acudió a consulta debido a disnea y dolor torácico de un mes de evolución. La radiografía de tórax evidenció el neumotórax del 50% en la parte derecha y la necesidad de la toracostomía. Puesto que los episodios de neumotórax ocurrían en fase catamenial, pero sin poder establecer una causa clara del cuadro clínico, se procedió a la toracoscopia diagnóstica con toma de muestra para estudio histopatológico. Durante el procedimiento se detectaron múltiples lesiones pseudonodulares, de aspecto inflamatorio crónico a nivel pleural y del parénquima pulmonar. El reporte histopatológico fue compatible con endometriosis pleuropulmonar; se le indicó terapia hormonal. Ante la evolución clínica satisfactoria y posoperatorio sin complicaciones la paciente fue dada de alta del hospital. CONCLUSIÓN: El neumotórax catamenial, como consecuencia de una endometriosis pleuropulmonar, es un diagnóstico realmente excepcional y su sospecha debe vincularse con el ciclo menstrual. La atención médica de las pacientes con este diagnóstico debe ser interdisciplinaria, no solo por las estrategias diagnósticas sino por la complejidad del tratamiento y su seguimiento. El tratamiento de elección suele requerir intervenciones quirúrgicas, sumadas a la indicación de la medicación hormonal para prevenir recurrencias, con tasas de éxito favorables. Están pendientes los estudios que establezcan la respuesta del tejido endometrial ectópico torácico al tratamiento médico.

Abstract BACKGROUND: The thorax is the most frequent extrapelvic location of endometriosis, although its incidence has not been sufficiently studied. Its pathophysiology has not been fully established, but several theories have been put forward. Catamenial pneumothorax is one of the possible manifestations that make it difficult to establish the diagnosis and indicate treatment. CLINICAL CASE: A 31-year-old female patient, with a history of repeated spontaneous pneumothorax, presented for consultation due to dyspnea and chest pain of one month of evolution. Chest X-ray showed a 50% pneumothorax on the right side and the need for thoracostomy. Since the episodes of pneumothorax occurred in catamenial phase, but without being able to establish a clear cause of the clinical picture, diagnostic thoracoscopy with sampling for histopathological study was performed. During the procedure multiple pseudonodular lesions of chronic inflammatory aspect were detected at pleural and lung parenchyma level. The histopathological report was compatible with pleuropulmonary endometriosis; hormonal therapy was indicated. Given the satisfactory clinical evolution and postoperative course without complications, the patient was discharged from the hospital. CONCLUSION: Catamenial pneumothorax, as a consequence of pleuropulmonary endometriosis, is a truly exceptional diagnosis and its suspicion should be linked to the menstrual cycle. The medical care of patients with this diagnosis should be interdisciplinary, not only because of the diagnostic strategies but also because of the complexity of the treatment and its follow-up. The treatment of choice usually requires surgical interventions, added to the indication of hormonal medication to prevent recurrences, with favorable success rates. Studies establishing the response of thoracic ectopic endometrial tissue to medical treatment are pending.

Thoracoscopic Surgery in the Management of Idiopathic Scoliosis: Systematic Literature Review according to the Prisma Protocol / Cirurgia toracoscópica na abordagem da escoliose idiopática: Revisão sistemática de literatura

Abstract Idiopathic scoliosis is a three-dimensional spinal deformity with axial rotation and lateral inclination with an angle greater than 10º per the Cobb method. The approach to idiopathic scoliosis can be conservative or surgical, depending on the degree of angulation, musculoskeletal development, and age of the child or adolescent. It also depends on the functional impairment resulting from the condition. This study aimed to analyze the impact of video-assisted thoracoscopic surgery in idiopathic scoliosis management. This systematic literature review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol, and its PROSPERO registration number is CRD42022351466. Studies queries occurred from August to September 2022 in the bibliographic databases MEDLINE, The Cochrane Library, and Web of Science. The video-assisted thoracoscopic surgery is a minimally invasive alternative to thoracotomy with significant evolution in recent years. Its main advantages include lower blood loss during the procedure, shorter hospital stays, and improved post-surgical esthetics. Authors mentioned its disadvantages as greater complexity and technological requirement, longer surgical time, and the need for careful selection of the patients per vertebral deviation degree. The use of analgesic and anti-inflammatory drugs was not significantly different between traditional procedures (thoracotomy) and thoracoscopic surgery.

Resumo A escoliose idiopática é caracterizada por um quadro de deformidade tridimensional da coluna vertebral com rotação axial e inclinação lateral com angulação maior que 10º segundo o Método de Cobb. Sua abordagem pode se dar de maneira conservadora ou cirúrgica, a depender do grau de angulação, desenvolvimento osteomuscular e idade da criança ou adolescente acometido, ou ainda, a depender do comprometimento funcional advindo da condição. O objetivo deste estudo foi analisar o impacto da videotoracoscopia na abordagem da escoliose idiopática. Trata-se de uma revisão sistemática de literatura, construída conforme protocolo Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) e registrada no PROSPERO sob número CRD42022351466. A busca por estudos foi realizada entre agosto de 2022 e setembro do mesmo ano, em bancos de dados bibliográficos incluindo MEDLINE, The Cochrane Library e Web of Science. A técnica é uma alternativa minimamente invasiva à toracotomia que apresentou grande evolução nos últimos anos. Destacam-se como principais vantagens a menor perda sanguínea durante procedimento, menor tempo de internação e melhora da estética pós-cirúrgica. Uma das desvantagens citadas pelos autores é a maior complexidade e exigência tecnológica, maior tempo cirúrgico e necessidade de seleção criteriosa dos pacientes, conforme graus de desvio vertebral. O uso de analgésicos e anti-inflamatórios não teve diferença significativa entre os procedimentos tradicionais (toracotomia) ou videotoracoscopia.

Localización preoperatoria guiada por tomografía computada de nódulo pulmonar con verde de indocianina para resección toracoscópica uniportal asistida por robot. Reporte de caso

Introducción: El abordaje del nódulo pulmonar solitario tiene como objetivo la detección temprana del cáncer de pulmón en donde la resección quirúrgica es la piedra angular del tratamiento. La tecnología de imagen por fluorescencia combina un agente excitable en el espectro de luz cercano al infrarrojo y un sistema para visualizar selectivamente un tejido diana que permite su localización intraoperatoria. Caso clínico: Varón de 72 años fumador con un nódulo pulmonar de 9 milímetros con patrón en vidrio deslustrado en el lóbulo inferior derecho localizado bajo guía tomográfica con verde de indocianina y tratado mediante resección sublobar con linfadenectomía sistemática asistida por robot con abordaje uniportal. Conclusión: La técnica de marcaje preoperatorio con verde de indocianina y tecnología de imagen por fluorescencia es un método seguro y preciso que permite la identificación intraoperatoria de un nódulo pulmonar solitario durante la cirugía de mínima invasión. (provisto por Infomedic International)

Introduction: The solitary pulmonary nodule approach aims at early detection of lung cancer where surgical resection is the cornerstone of treatment. Fluorescence imaging technology combines an excitable agent in the near-infrared light spectrum and a system to selectively visualize a target tissue allowing its intraoperative localization. Case report: A 72-year-old male smoker with a 9-millimeter lung nodule with ground-glass pattern in the right lower lobe located under tomographic guidance with indocyanine green and treated by sublobar resection with robotic-assisted systematic lymphadenectomy with uniportal approach. Conclusion: The technique of preoperative labeling with indocyanine green and fluorescence imaging technology is a safe and accurate method that allows intraoperative identification of a solitary pulmonary nodule during minimally invasive surgery. (provided by Infomedic International)

Esophagocele due to two times caustic ingestions: resection through videothoracoscopy / Esofagocele por duas ingestões cáusticas: ressecção por videotoracoscopia

ABSTRACT BACKGROUND: Caustic ingestion is still a health problem of utmost importance in the West. In developing countries, this incident remains at increase and it is associated with unfavorable factors like social, economic, and educational handicaps, besides a lack of prevention. Esophagocele is a rare consequence of caustic ingestion. AIM: We aimed to describe a patient with multiple caustic ingestions who presented an esophagocele resected by videothoracoscopy. METHODS: A woman ingested caustic soda when she was only 17 years old in a suicidal attempt during a depressive crisis. Initially, she was submitted to a retrosternal esophagocoloplasty with the maintenance of her damaged esophagus. After 1 year of this first surgery, she ingested caustic soda again in a new suicidal attempt. Her transposed large bowel in the first surgery became narrow, being replaced in a second surgery by a retrosternal esophagogastroplasty. Still, at the second surgery, her damaged esophagus remained in its original position in the posterior mediastinum. However, after 5 years, she developed an esophagocele. RESULTS: The esophagocele was resected through videothoracoscopy in a prone position, employing four trocars. The postoperative was uneventful. CONCLUSION: Esophageal exclusion must always be recorded because esophagocele presents unspecific symptoms. The videothoracoscopy in a prone position is an excellent technical option to resect esophagoceles.

RESUMO RACIONAL: A ingestão de produtos cáusticos ainda é um problema de saúde de extrema importância no Ocidente. Nos países em desenvolvimento, este incidente continua em ascensão e está associada a fatores desfavoráveis como sociais, econômicos e educacionais, além da falta de prevenção. A esofagocele é uma consequência rara da ingestão de cáusticos. OBJETIVO: Nosso objetivo é descrever um paciente com múltiplas ingestões cáusticas que apresentou uma esofagocele ressecada por videotoracoscopia. MÉTODOS: Doente feminina que ingeriu soda cáustica com 17 anos de idade, como tentativa de suicídio, durante uma crise depressiva. Inicialmente, foi submetida a esofagocoloplastia retroesternal com manutenção do esôfago lesado. Após um ano desta primeira cirurgia, voltou a ingerir soda cáustica, em nova tentativa de suicídio. Seu intestino grosso transposto na primeira cirurgia tornou-se estenosado, sendo substituído em uma segunda cirurgia, por esofagogastroplastia retroesternal. Ainda assim, nesta segunda cirurgia, o esôfago lesado permaneceu em sua posição original no mediastino posterior. No entanto, após cinco anos, ela desenvolveu uma esofagocele. RESULTADOS: A esofagocele foi ressecada por videotoracoscopia, em decúbito ventral, empregando-se quatro trocartes. O pós-operatório transcorreu sem intercorrências. CONCLUSÕES: A exclusão esofágica deve ser sempre registrada, pois a esofagocele apresenta sintomas inespecíficos. A videotoracoscopia em posição prona é uma excelente opção técnica para ressecção de esofagoceles.

Neumotórax catamenial

RESUMEN Introducción: El neumotórax catamenial es aquel neumotórax espontáneo y recurrente que se presenta relacionado con el ciclo menstrual. Más frecuente en mujeres con edad fértil por encima de los 30 años de edad y a predominio del hemitórax derecho. El diagnóstico primario es difícil y el tratamiento que mejores resultados registra es la cirugía por técnicas de mínimo acceso, asociada a tratamiento hormonal. Objetivo: Presentar un caso de neumotórax catamenial, sus características clínicas y el procedimiento videotoracoscópico empleado. Caso clínico: Paciente de 48 años de edad, con antecedentes de dolor torácico y tos al inicio de la menstruación. Además, dos neumotórax espontáneos derechos anteriores. Ingresó de urgencia con el diagnóstico de neumotórax espontáneo derecho. Se realizó biopsia, frenorrafia y pleurodesis por videotoracoscopía. Conclusiones: Los elementos clínicos y radiológicos inducen a pensar en el diagnóstico de neumotórax catamenial, apoyado por la presencia de fenestraciones diafragmáticas y la no reaparición del cuadro de neumotórax después del cierre de los defectos diafragmáticos y el tratamiento satisfactorio con pleurodesis con talco, por cirugía de mínimo acceso.

ABSTRACT Introduction: The catamenial pneumothorax is that spontaneous and recurrent pneumothorax related with the menstrual cycle. More frequent in women with fertile age above the 30 years of age and predominance of the right hemithorax. The primary diagnosis is difficult and the treatment that best results recorded is the surgery by minimal access techniques associated with hormone treatment. Objective: Present a case of catamenial neumothorax, to describe their clinical characteristics and the videothoracoscopic proceeding used. Clinical case: 48 years old female patient, with history of chest pain and coughing at the beginning of menstruation and having suffered two spontaneous rights pneumothorax. We performed biopsy, phrenorraphy and pleurodesis by videothoracoscopy, after 18 months the symptomatology did not reappear. Conclusions: The clinical and radiological elements induce to think of the diagnosis of catamenial pneumothorax, supported by the presence of diaphragmatic fenestrations and the not reappearance of the pneumothorax frame after the closure of the diaphragmatic defects and satisfactory treatment with talc pleurodesis by minimal access surgery.

Eficacia terapéutica de la buprenorfina para tratamiento de dolor agudo postoperatorio en cirugía torácica por toracoscopía / Therapeutic efficacy of buprenorphine for treatment of acute postoperative pain in thoracic surgery by thoracoscopy

Resumen: Introducción: El dolor postoperatorio en toracoscopía tiene una incidencia del 80%. Estos procedimientos se realizan bajo anestesia general o sedoanalgesia. La buprenorfina en dosis de 4 μg/kg o más es un fármaco pilar para el tratamiento de dolor postoperatorio; sin embargo, dosis menores pueden ser suficientes. El objetivo de este estudio fue demostrar que dosis de 1-3 μg/kg de buprenorfina aporta una adecuada analgesia con menores efectos adversos durante el postoperatorio en pacientes sometidos a cirugía toracoscópica. Material y métodos: Se realizó el estudio prospectivo, transversal y doble ciego en 48 pacientes sometidos a toracoscopía, divididos en 3 grupos: A (1 μg/kg), B (2 μg/kg) y C (3 μg/kg) tratados con buprenorfina, se evaluaron efectos adversos, intensidad de dolor por escala verbal numérica (EVN) y sedación con escala de agitación-sedación de Richmond (RASS) de los 0 a los 120 minutos postanestesia. Resultados: Las dosis de 1 a 3 μg/kg de buprenorfina no ocasionaron efectos adversos. El mantenimiento de analgesia es mayor con 2 μg/kg (p = 0.019) y 3 μg/kg (p = 0.045). Las dosis de 1 y 2 μg/kg presentan un nivel de sedación menor. Conclusiones: La analgesia multimodal disminuyó un 200% el dolor postquirúrgico inmediato. Las dosis de 2-3 μg/kg de buprenorfina son efectivas para el control del dolor con menor incidencia de efectos adversos y un nivel de sedación superficial durante el postoperatorio.

Abstract: Introduction: Posterior pain in thoracoscopy has an 80% incidence. These procedures are done under general anesthesia or sedoanalgesia. The buprenorphin in dosage of 4 μg/kg it's the foundation for post-operatory pain treatment, nevertheless, smaller dosage can be sufficient. The objective of this study is to demonstrate that a dosage of buprenorphin from 1-3 μg/kg provides suitable analgesia with less side effects during post-operatory in patients who underwent thoracoscopic surgery. Material and methods: We conducted a double-blind, prospective, transversal study, in 48 patients which underwent a thoracoscopy divided in 3 groups: A (1 μg/kg), B (2 μg/kg), and C (3 μg/kg) treated with buprenorphin. We studied side effects, pain intensity (NVE), and sedative effect (RASS) from 0 to 120 minutes postanesthesia. Results: Dosage from 1 to 3 μg/kg did not generate side effects. The analgesia effect is higher with 2 μg/kg (p = 0.019) and 3 μg/kg (p = 0.045). Dosage of 1 and 2 μg/kg have lower sedative effect. Conclusion: The multimodal analgesia was diminished by 200% inmidiate postsurgical pain. Dosage from 2-3 μg/kg of buprenorphine are effective for pain control with less side effects and a superficial sedative effect during post-operatory.

Mediastinitis necrotizante descendente de origen odontogénico / Descending necrotizing mediastinitis of odontogenic origin

Introducción: las infecciones odontogénicas afectan al 80 %-90 % de la población y pueden dar lugar a complicaciones potencialmente mortales como la mediastinitis necrotizante descendente, una infección polimicrobiana aguda en el mediastino con una tasa de mortalidad entre el 11 % y 40 %. Su detección precoz y el tratamiento adecuado con manejo antibiótico y drenaje quirúrgico a cargo de un equipo multidisciplinario representan factores influyentes en el pronóstico de la enfermedad. Objetivo: en este artículo presentamos un caso de mediastinitis necrotizante descendente en un paciente masculino de 34 años, que se originó por una infección odontogénica que requirió un procedimiento dental. El paciente fue hospitalizado por el empeoramiento del estado clínico a pesar de la profilaxis antibiótica. La tomografía axial computarizada (TAC) confirmó la extensión de la infección al mediastino, y el paciente fue tratado con éxito con antibioterapia intravenosa y múltiples drenajes quirúrgicos intraorales, cervicotomía y toracoscopia. Materiales y métodos: se realizó una búsqueda en bases de datos globales y se seleccionaron los artículos por los siguientes términos MeSH y DeCS: "mediastinitis necrotizante descendente", "angina de Ludwig", "absceso", "toracoscopia" y sus respectivos en inglés, priorizando los referentes a la mediastinitis necrotizante descendente de origen odontogénico. Conclusiones: en la mediastinitis necrotizante descendente, la combinación de diagnóstico precoz, tratamiento antibiótico de amplio espectro, mantenimiento de la vía aérea y drenaje quirúrgico amplio y a cargo de un equipo multidisciplinario mejora de manera importante el pronóstico de la enfermedad.

Introduction: Odontogenic infections affect 80%-90% of the population and can lead to life-threatening complications such as descending necrotizing mediastinitis. Is an acute polymicrobial infection in the mediastinum with a mortality rate of 11%-40%. Its early detection and adequate treatment with antibiotic management and surgical drainage by a multidisciplinary team represent influential factors in the prognosis of the disease. Objective: In this article, we present a case of descending necrotizing mediastinitis in a 34-year-old male patient that originated from an odontogenic infection that required a dental procedure. The patient was hospitalized for worsening clinical status despite antibiotic prophylaxis. Computed axial tomography confirmed the extension of the infection to the mediastinum and the patient was successfully treated with intravenous antibiotherapy and multiple intraoral, cervicotomy, and thoracoscopic surgical drains. Materials and methods: A search was made in global databases, articles were selected by the following MeSH and DeCS terms: "descending necrotizing mediastinitis", "Ludwig's angina", "abscess", "thoracoscopy", and their respective English terms, prioritizing those referring to descending necrotizing mediastinitis of odontogenic origin. Conclusions: In descending necrotizing mediastinitis, the combination of early diagnosis, broad-spectrum antibiotic treatment, airway maintenance, and extensive surgical drainage by a multidisciplinary team significantly improves the prognosis of the disease.

Reparación toracoscópica de la atresia esofágica: implicaciones en el pronóstico del paciente / Thoracoscopic Repair of Esophageal Atresia: Implications in the prognosis of the patient

La reparación por toracoscopia de la atresia del esófago se ha constituido paulatinamente en la mejor alternativa terapéutica de los pacientes con esta entidad. Se analizaron 21 pacientes con diagnóstico de atresia esofágica operados por toracoscopia de Noviembre del 2017 a Agosto del 2020. La edad en que se efectuó la cirugía fue de 1 a 15 días de vida, promedio de 4.5. El procedimiento efectuado fue: sección y ligadura de la fistula con anastomosis termino terminal. El tiempo de cirugía fue de 90 a 240 minutos con una media de 158.5 minutos. Las complicaciones postoperatorias fueron: 02 pacientes dehiscencia parcial de la anastomosis, 05 pacientes estrechez de la anastomosis y 01 paciente divertículo traqueal. Hubo 03 pacientes que fallecieron. La reparación toracoscópica de la atresia de esófago es una opción terapéutica eficiente, con una tasa de complicaciones aceptable y una menor mortalidad. (AU)

Thoracoscopic repair of esophageal atresia has gradually become the best therapeutic alternative for patients with this entity. 21 patients with a diagnosis of esophageal atresia operated by thoracoscopy from November 2017 to August 2020 were analyzed. The age at which the surgery was performed was 1 to 15 days old, average 4.5. The procedure was: section and ligation of the fistula with end-to-end anastomosis. The surgery time was 90 to 240 minutes with a mean of 158.5 minutes. Postoperative complications were: 02 patients partial dehiscence of the anastomosis, 05 patients narrowing the anastomosis and 01 patient tracheal diverticulum. There were 03 patients who died. Thoracoscopic repair of esophageal atresia is an efficient therapeutic option, with an acceptable complication rate and lower mortality. (AU)

Esofagectomía minimamente invasiva / Minimally invasive esophagectomy

INTRODUCTION: Minimally invasive esophagectomy aims to reduce complications compared to open esophagectomy. In this report of the first patient undergoing this procedure at Hospital Pasteur, we highlight the importance of multidisciplinary management, and the main anesthesiological objectives. OBJECTIVE: To present the case report highlighting the anesthetic management, together with the bibliographic review carried out in order to update the anesthetic action protocols, with the main objective of reducing the appearance of perioperative complications. MATERIAL AND METHOD: Bibliographic search in PubMed bibliographic databases. Initially, 67 articles were obtained, selecting 20 considered relevant by the authors. CLINICAL CASE: It was a 46-year-old patient coordinated for esophagectomy for squamous neoplasm. Rapid sequence induction, selective endobronchial intubation and anesthetic maintenance with Isoflurane and epidural analgesia were performed. The hydroelectric replacement was restricti- ve. The surgical technique was performed in 3 stages: thoracic time by thoracoscopy; a second laparoscopic abdominal stage and a third stage for left cervicotomy. Extubation was carried out in the operating room with transfer to the ICU where she remained for 6 days to manage analgesia and due to the presence of a mild infectious complication, with good subsequent evolution. CONCLUSION: The use of perioperative multidisciplinary management protocols has fundamental importance as a strategy aimed at reducing morbidity and mortality. Advances in surgical technique added to anesthetic management constitute strategies that aim to reduce perioperative complications.

INTRODUCCIÓN: La esofagectomía minimamente invasiva tiene como objetivo disminuir las complicaciones en comparación con la esofagectomía abierta. En este reporte del primer paciente sometido a este procedimiento en el Hospital Pasteur destacamos la importancia del manejo multidisciplinario, y los principales objetivos anestesiológicos. OBJETIVO: Presentar el reporte de caso destacando el manejo anestésico, junto con la revisión bibliográfica realizada en vistas a la actualización de protocolos de actuación anestésica, con objetivo principal de disminuir la aparición de complicaciones perioperatorias. MATERIAL Y MÉTODO: Búsqueda bibliográfica en las bases bibliográficas PubMed. Inicialmente se obtuvieron 67 artículos, seleccionando 20 considerados relevantes por los autores. CASO CLÍNICO: Se trató de una paciente de 46 años coordinada para esofagectomía por neoplasma epidermoide. Se realizó inducción en secuencia rápida, intubación endobronquial selectiva y mantenimiento anestésico con Isofluorano y analgesia peridural. La reposición hidroelectrolítica fue restrictiva. La técnica quirúrgica se realizó en 3 tiempos: tiempo torácico por toracoscopía; un segundo tiempo abdominal laparoscópico y un tercer tiempo para cervicotomía izquierda. La extubación se realizó en sala de operaciones con traslado a CTI donde permaneció por 6 días para manejo de la analgesia y por presencia de complicación infecciosa leve, con buena evolución posterior. CONCLUSIÓN: Resulta de fundamental importancia el uso de protocolos de manejo multidisciplinario perioperatorio como estrategia destinada a disminuir la morbimortalidad. Los avances en cuanto a la técnica quirúrgica sumado al manejo anestésico constituyen estrategias que apuntan a disminuir las complicaciones perioperatorias.

Actualización y controversias en el tratamiento de las malformaciones congénitas de la vía aérea pulmonar / Update and disagreements in the treatment of congenital pulmonary airway malformations

Congenital pulmonary airway malformations (CPAM) are rare and occur due to a failure in lung embryological development. They are classified according to their pathological characteristics and their anatomical origin. They can occur from the antenatal period to adulthood, can be associated with hydrops fetalis, respiratory distress, recurrent infections, or in an otherwise asymptomatic patient. In this article we carry out a scope review of the literature to answer frequent questions of the clinical teams in charge of patients with CPAM, such as the antenatal approach, the different types of surgeries and the management of asymptomatic patients. Although the indication for surgery is clear in symptomatic patients, little is known about its natural history of this condition, including the possibility of spontaneous resolution and the development of complications or neoplasm. So, the treatment of asymptomatic patients continues to be controversial. Therapeutic decisions must be made by multidisciplinary teams with the informed participation of parents and patients. In our opinion, considering the excellent results of minimally invasive surgery, its low incidence of complications, and practically zero mortality when performed by experienced groups, it seems reasonable to consider elective resection of a MCVAP in asymptomatic patients.

Las malformaciones congénitas de la vía aérea pulmonar (MCVAP) son infrecuentes y ocurren debido a una falla en el desarrollo embriológico pulmonar. Se clasifican de acuerdo con sus características patológicas y a su origen anatómico. Se pueden presentar desde el periodo antenatal hasta la adultez, asociarse a cuadros de hidrops fetal, distrés respiratorio, infecciones recurrentes, o como un hallazgo en pacientes asintomáticos. En este artículo realizamos una revisión bibliográfica exploratoria para responder dudas frecuentes de los equipos clínicos a cargo de pacientes con MCVAP, como el enfrentamiento antenatal, los distintos tipos de cirugía y su abordaje, y el manejo de pacientes asintomáticos. Si bien la indicación de cirugía es clara en pacientes sintomáticos, poco se conoce acerca de su historia natural, incluyendo la posibilidad de resolverse de forma espontánea, de complicarse o de evolucionar hacia el desarrollo de una neoplasia, por lo que el tratamiento de pacientes asintomáticos continúa siendo controversial. Las decisiones terapéuticas deben ser tomadas por equipos multidisciplinarios con la participación informada de los padres y de los pacientes. En nuestra opinión, considerando los excelentes resultados de la cirugía mínimamente invasiva, su baja incidencia de complicaciones y prácticamente nula mortalidad, al ser realizada por grupos con experiencia, nos parece razonable plantear la resección electiva de una MCVAP en un paciente asintomático.

Preoperative computed tomography-guided localization of lung nodules with needle placement: a series of cases / Marcação pré-operatória de nódulo pulmonar com fio-guia orientado por tomografia computadorizada: uma série de casos

ABSTRACT Objective: to report the preoperative localization of pulmonary nodules with the placement of a guidewire oriented by Computed Tomography. Methods: the nodules were marked using a needle in the shape of a hook or another in the shape of a Q, guided by tomography. The choice of the location for the marking was the shortest distance from the chest wall to the nodule. The marking procedure was performed under local anesthesia and a tomographic control was obtained immediately at the end. Patients were referred to the operating room. Surgical resection occurred less than two hours after the needle placement. Results: between February 2017 and October 2019, 22 patients aged 43 to 82 years (mean 62.1) were included. The nodules had diameters that varied from 4 to 30 mm and the distance between the nodules and the pleural surface varied from 2 to 43 mm. The location and resection of the nodules were successfully performed in all cases. The guidewire was displaced in five cases. Five patients presented pneumothorax, with the space between the visceral and parietal pleura varying from 2 to 19 mm. In nine patients, an intraparenchymal hematoma of 6 to 35 mm in length was observed without signs, symptoms, or hemodynamic and ventilatory repercussions. The histopathological study was conclusive in all patients. Conclusions: the localization of pulmonary nodules through guidewires proved to be safe, reliable, and feasible in this series of cases. There was no need for surgical intervention to treat complications.

RESUMO Objetivo: relatar a marcação pré-operatória de nódulos pulmonares com o posicionamento de um fio-guia orientado por Tomografia Computadorizada. Métodos: os nódulos foram marcados utilizando-se agulha em formato de anzol ou outra em formato de Q, orientada por tomografia. A escolha do local para a realização da marcação foi o de menor distância da parede torácica até à lesão. O procedimento de marcação foi realizado sob anestesia local e controle tomográfico foi obtido imediatamente ao término da marcação. Os pacientes foram encaminhados ao centro cirúrgico. A ressecção cirúrgica ocorreu em tempo inferior a duas horas após a marcação. Resultados: entre fevereiro de 2017 e outubro de 2019, 22 pacientes, com faixa etária entre 43 e 82 anos (média 62,1) foram incluídos. Os nódulos apresentavam diâmetros que variaram de 4 a 30mm e, a distância entre os nódulos e a superfície pleural variou de 2 a 43mm. A localização e a resseção dos nódulos foram realizadas com sucesso em todos os casos. Houve deslocamento do fio-guia em cinco casos. Cinco pacientes apresentaram pneumotóraces, com o espaço entre as pleuras visceral e parietal variando de 2 a 19mm. Em nove pacientes, foi observado hematoma intraparenquimatoso com 6 a 35mm de extensão sem sinais, sintomas ou repercussão hemodinâmica e ventilatória. O estudo histopatológico foi conclusivo em todos os pacientes. Conclusões: a marcação de nódulos pulmonares por meio de fios marcadores se mostrou segura, confiável e factível nesta série de casos. Não houve necessidade de intervenção para o tratamento de complicações associadas ao método.

Evaluation of echocardiographic variables of morphometry and function in horses submitted to minimally invasive partial pericardiotomy / [Avaliação de variáveis ecocardiográficas morfométricas e funcionais em cavalos submetidos à pericardiotomia parcial minimamente invasiva]

This study aimed to evaluate the impact of minimally invasive partial pericardiotomy on echocardiographic variables of morphometry and function in healthy horses. Minimally invasive pericardiotomy was performed in six healthy horses. Echocardiographic evaluation was executed in different moments: prior to the surgical procedure (M0); 24 hours post procedure (M1); 72 hours post procedure (M2) and 28 days post procedure (M3). The following variables were measured: Right ventricular internal diameter in diastole and systole (RVd and RVs), interventricular septum thickness in diastole and systole (IVSd and IVSs), left ventricular internal diameter in diastole and systole (LVd and LVs), left ventricular free wall thickness in diastole and systole (LVFWd and LVFWs), aortic root diameter (Ao) and left atrial diameter (LA). From this data, the following variables were calculated: fractional shortening (FS%), fractional thickening of the interventricular septum (IVS%), fractional thickening of the left ventricular free wall (LVFW%) and the relationship between left atrial and aortic diameters (LA/Ao). After 28 days, a new thoracoscopy was performed for inspection of the thoracic cavity. In M1 and M2 ECO evaluations, a statistically significant change in LVFW and a decrease in RVd, LVd, LVFWs, LA, LVs, FS% and IVS was documented. Pericardiotomy is a promising technique in horses, with minor postoperative complication. The variations in the echocardiographic parameters were transient and did not cause hemodynamic damage to the animals.(AU)

O objetivo do presente estudo foi avaliar o impacto da pericardiotomia parcial minimamente invasiva sobre as variáveis ecocardiográficas morfométricas e funcionais em cavalos, visto que não há nenhum trabalho que tenha avaliado o impacto da pericardiotomia na espécie equina. Foram utilizados seis cavalos hígidos, nos quais se realizou pericardiotomia minimamente invasiva. Em todos eles, foi efetuado exame ecocardiográfico em diferentes momentos: previamente ao procedimento cirúrgico (M0); 24 horas após (M1); 72 horas após (M2) e 28 dias após (M3). Foram mensurados: diâmetro interno do ventrículo direito (VDd e VDs), espessura do septo interventricular (SIVd e SIVs), diâmetro interno do ventrículo esquerdo (VEd e VEs), espessura da parede livre do ventrículo esquerdo (PLVEd e PLVEs), diâmetro interno da aorta (Ao) e diâmetro atrial esquerdo (AE). Foram calculadas as variáveis fração de encurtamento (FEC%), espessamento fracional do septo interventricular (SIV%), espessamento fracional da parede livre do ventrículo esquerdo (PLVE%) e relação entre diâmetro do átrio esquerdo e diâmetro aórtico (AE/Ao). Após 28 dias, realizou-se nova toracoscopia para inspeção da cavidade torácica. Nas avaliações do ECO no M1 e no M2, houve alteração estatisticamente significativa no PLVE em diástole (28±5,5 e 31,7±2, respectivamente) e diminuição dos parâmetros VDd,(30,1±11,6 e 31,7± 10,7) VEd (113,3±21 e 121,7±13,7), PLVEs (42±8,2 e 43,9±2,8), AE (78,5±6,1 e 82,7±4,7), VEs (74,1±16 e 71,5±9,3), FEC (34,4±10,2 e 41,2±5,7) e SIV (27,1±8,7 e 42,3±27,9). A técnica de pericardiotomia empregada mostrou-se promissora em equinos. As variações dos parâmetros ecocardiográficos foram transitórias, não causando prejuízos hemodinâmicos aos animais.(AU)

Fístula traqueoesofágica en H en el período neonatal: dificultades en el diagnóstico y diferentes abordajes terapéuticos. Serie de casos / H-type tracheoesophageal fistula in neonatal period: Difficulties in diagnosis and different treatment approaches. A case series

La fístula traqueoesofágica congénita sin atresia esofágica asociada, conocida como tipo H, es una anomalía infrecuente. Se manifiesta con episodios de tos, ahogo y cianosis durante la alimentación y/o neumonía recurrente.Si bien los síntomas están usualmente presentes desde el nacimiento, el diagnóstico es difícil. La rareza de esta patología, los síntomas no específicos y las limitaciones en la demostración radiológica y endoscópica de la fístula contribuyen, a menudo, a la demora entre la presentación y la confirmación del diagnóstico.Se describen las manifestaciones clínicas, los métodos de evaluación y el tratamiento de 3 neonatos con esta patología, y se presentan recomendaciones para el diagnóstico a fin de evitar demoras innecesarias en el manejo de las fístulas en H.

Congenital tracheoesophageal fistula not associated with esophageal atresia, known as H-type fistula, is an uncommon anomaly. It presents with cough, choking, and cyanosis during feeding and/or recurrent pneumonia. Although symptoms are usually present from birth, diagnosis is difficult. The rarity of this disease, non-specific symptoms, and the limitations of radiological and endoscopic confirmation of the fistula often result in a delay between presentation and diagnosis confirmation. Here we describe the clinical manifestations, assessment methods, and management of 3 newborn infants with H-type tracheoesophageal fistula, together with diagnosis recommendations to prevent unnecessary delays in the management of this condition.

Leiomioma pulmonar primario / Primary pulmonary leiomyoma

El leiomioma primario de pulmón es un tumor benigno raro, de origen mesodérmico, que representa aproximadamente el 2 % de todos los tumores benignos de pulmón. Desde que fue descrito por primera vez por Forkel en 1910, se han reportado al menos 150 casos en la literatura. Se hace una revisión del tema a propósito del caso de una mujer posmenopáusica oligosintomática, con hallazgo de una lesión pulmonar sólida, asociada a una malformación vascular, en quien la biopsia inicial reportó un tumor fusocelular, por lo que fue llevada a lobectomía superior del pulmón derecho, y cuyo diagnóstico patológico definitivo fue leiomioma pulmonar primario. Este caso se presenta por su baja incidencia y la poca literatura sobre este tipo de lesiones tumorales benignas

Primary lung leiomyoma is a rare benign tumor of mesodermal origin, that accounts for approximately 2% of all benign lung tumors. Since it was first described by Forkel in 1910, at least 150 cases have been reported in the literature. A review of the subject is made regarding the case of an oligosymptomatic postmenopausal woman, with the finding of a solid lung lesion, associated with a vascular malformation, in whom the initial biopsy reported a spindle cell tumor, for which she was taken for a right upper lung lobectomy and whose definitive pathological diagnosis was primary pulmonary leiomyoma. This case is presented due to its low incidence and the little literature on this type of benign tumor lesions

Secuestro pulmonar intralobar y aspergilosis pulmonar: reporte de un caso / Intralobar pulmonary sequestration and pulmonary aspergilosis: a case report

El secuestro pulmonar es un tipo de malformación congénita pulmonar poco frecuente, con presentación clínica variable y de usual diagnóstico durante la infancia. Puede coexistir con otras patologías pulmonares, principalmente de tipo infecciosas y su manejo definitivo es mediante un procedimiento quirúrgico. Se presenta el caso de una paciente adulta con secuestro pulmonar, asociado a una infección fúngica, manejada con cirugía mínimamente invasiva

Pulmonary sequestration is a rare type of congenital pulmonary malformation, with variable clinical presentation and usually diagnosed during childhood. It can coexist with other pulmonary pathologies, mainly infectious, and its definitive management is through a surgical procedure. We present the case of an adult patient with pulmonary sequestration associated with a fungal infection, managed with minimally invasive surgery

Simpatectomia bilateral R5-R8 no tratamento de hiperidrose compensatória: análise de complicações e satisfação dos pacientes / Bilateral R5-R8 sympathectomy for compensatory hyperhidrosis: complications and patient satisfaction

RESUMO Objetivo: Avaliar a qualidade de vida de pacientes submetidos a simpatectomia torácica bilateral de R5 a R8 como forma de tratamento da hiperidrose compensatória (HC) grave e debilitante em pacientes que foram previamente submetidos a simpatectomia torácica bilateral para tratamento da hiperidrose localizada. Métodos: Doze pacientes com hiperidrose compensatória grave e debilitante foram submetidos a simpatectomia estendida no Hospital das Clínicas da Universidade Federal de Pernambuco, Brasil, entre setembro de 2016 e maio de 2019. Os seguintes desfechos foram estudados: nível de satisfação com a operação, escore de qualidade de vida e as possíveis complicações cirúrgicas. Resultados: Houve significativa melhora na qualidade de vida em 66% da amostra. Em todas as esferas de função, foi evidenciada relevância estatística no que se refere ao alívio dos sintomas relacionados à hiperidrose compensatória. Conclusões: A simpatectomia estendida de R5 a R8 mostrou-se efetiva na maioria dos casos operados, caracterizando este procedimento como promissor, podendo, após estudos futuros, ser incluído como uma opção terapêutica para a hiperidrose compensatória.

ABSTRACT Objective: The purpose of this study was to assess the quality of life of patients who had undergone bilateral thoracic sympathectomy from R5 to R8 as a treatment for severe and debilitating compensatory hyperhidrosis (CH). Methods: Twelve patients with severe and debilitating compensatory hyperhidrosis underwent extended sympathectomy (R5-R8) from September 2016 to May 2019 at the Hospital das Clínicas, Federal University of Pernambuco, Brazil. Outcomes such as the level of patient satisfaction with the operation, quality of life scores as well as postoperative complications were assessed. Results: There has been a substantial improvement in the quality of life score of 66% of the sample. In all four domains, a statistical significant difference was seen, regarding the relief of compensatory hyperhidrosis symptoms. Conclusions: Extended sympathectomy from R5 to R8 was shown to be quite effective in most cases, leading us to believe that this approach could be a therapeutic option for severe compensatory hyperhidrosis.

Oxigenoterapia posquirúrgica de alto flujo aplicada mediante cánula nasal bilateral en dos caninos sometidos a procedimientos de tórax: un reporte de caso / High-flow post-surgical oxygen therapy applied through bilateral nasal cannula in two canines undergoing thoracic procedures: a case report / Oxigeno terapia pós-cirúrgica de alto fluxo aplicada a través de cânula nasal bilateral em dois cães submetidos a procedimentos torácicos: um relato de caso

Resumen Las terapias convencionales para el aporte de oxígeno usadas en la clínica veterinaria pueden ser ineficientes al momento de ofrecer una recupe- ración satisfactoria de los pacientes posquirúrgicos bajo procedimientos a tórax con falla respiratoria hipoxémica, requiriendo estrategias que mejoren los indicadores de oxigenación. El presente trabajo describe el uso de cánulas nasales de alto flujo en dos pacientes sometidos a cirugías de tórax bajo anestesia general. El paciente #1 fue sometido a pericardiectomía subfrénica por toracoscopía y el paciente #2 fue sometido a una reducción percutánea de fractura de costillas con tubo a tórax. Ambos pacientes fueron recuperados en el posquirúrgico con oxigenoterapia de alto flujo a caudales de 600 y 1.071 mL/kg/minuto, respectivamente. El oxígeno fue en- tregado a través de un dispositivo comercial de humidificación activa, tubuladura no condensable con sistema de calefacción y cánula nasal bilateral, ofreciendo una temperatura del aire de 37 ºC, humedad del 98% y fracción inspirada de oxígeno de 50%. Se realizó gasometría percutánea (arteria dorsal metatarsiana) tras 15 minutos de ser extubado el paciente y una segunda muestra arterial fue colectada 60 minutos luego de la instalación del dispositivo de alto flujo. Se observó un aumento de la presión parcial de oxígeno (PaO2) sin cambios en la presión parcial de dióxido de car- bono (PaCO2). Adicionalmente, se reportó tolerancia satisfactoria al dispositivo por parte de ambos pacientes. Las cánulas de alto flujo deben ser consideradas dentro de las estrategias de soporte ventilatorio no invasivo durante la posextubación en pacientes sometidos a cirugías de tórax.

Abstract Conventional therapies for oxygen supply used in the veterinary clinic may be inefficient when offering a satisfactory recovery to post-surgical patients under chest surgical procedures with hypoxemic respiratory failure, de- manding strategies to improve oxygenation indicators. The present work describes the use of high-flow nasal cannulas in two patients submitted to chest surgeries and under general anesthesia. Patient #1 was submitted to a subphrenic pericardiectomy by thoracoscopy, and patient #2 was submitted to a percutaneous rib fracture reduction by a chest tube. Both patients were recovered with a high-flow oxygen therapy in the post-surgical phase at flow rates of 600 and 1,071 mL/kg/minute, respectively. The oxygen was delivered using a commercial device of active humidification, non-condensable suction with heating system and bilateral nasal cannula, offering an air temperature of 37 ºC, humidity of 98% and inspired fraction of oxygen of 50%. A percutaneous gasometry was performed (dorsal metatarsal artery) after 15 minutes of extubating of the patient, and a second arterial sample was collected 60 minutes after the installation of the high-flow device. An increase in the partial pressure of oxygen (PaO2) was observed without an increase in the partial pressure of carbon dioxide (PaCO2). Additionally, both patients reported satisfactory tolerance to the device. High-flow nasal cannulas should be considered within non-invasive ventilatory support strategies during post-extubating in patients submitted to chest surgeries.

Resumo As terapias convencionais para oxigênio usado na clínica veterinária podem ser ineficientes quando oferecendo uma recuperação satisfatória dos pacientes pós qirúrgicos sob procedimentos peito insuficiência respiratória hipoxêmica exigindo estratégias para melhorar os indicadores de oxigenação. O presente trabalho des- creve o uso de cânulas nasais de alto fluxo em dois pacientes submetidos a cirur- gias torácicas sob anestesia geral. Paciente #1 foi submetida a pericardiectomia subfrênica por toracoscopia e paciente #2 foi submetida a uma redução percutânea da fratura de costela com tubo torácico. Ambos os pacientes foram recuperados no pós-operatório com oxigeno terapia de alta vazão nas vazões de 600 e 1.071 mL/kg/ minuto, respectivamente. O oxigênio foi entregue através de um dispositivo comercial de umidificação ativa, tubuladura não condensável com sistema de aquecimento e cânula nasal bilateral, oferecendo temperatura do ar de 37 ºC, umidade de 98% e fração inspirada de oxigênio de 50%. A análise gasométrica percutânea (artéria metatarsal dorsal) foi realizada 15 minutos após a extubação do paciente e uma segunda amostra arterial foi coletada 60 minutos após a instalação do dispositivo de alto fluxo. Um aumento na pressão parcial de oxigênio (PaO2) foi observado sem alterações na pressão parcial de dióxido de carbono (PaCO2). Além disso, tolerancia satisfatória ao dispositivo foi relatada por ambos os pacientes. Cânulas de alto fluxo devem ser consideradas dentro das estratégias de suporte ventilatório não invasivo durante a pós-extubação em pacientes submetidos a cirurgias torácicas.

Cardiac sympathetic denervation for conventional treatment refractory arrhythmias / Denervación simpática cardíaca en arritmias refractarias al tratamiento convencional

Abstract Objective: Cardiac sympathetic denervation (CSD) using video-assisted thoracoscopy is a therapeutic alternative for cardiac arrhythmias refractory to conventional treatment in patients with ventricular structural heart disease, mainly due to ischemia, and in patients with hereditary conditions associated with sudden death such as long QT syndrome. In general, it is performed in cases with recurrent episodes of ventricular tachycardia or electrical storm, in spite of conventional treatment. The objective of this study is to show the experience of this institution with DSCI in refractory patients to conventional management and the results derived from its application. Methods: This was an observational retrospective study. The records of patients with a history of ventricular arrhythmias treated in our center with pharmacological treatment, catheter ablation, or implantation of an implantable cardioverter-defibrillator (ICD), who underwent video-assisted CSD were analyzed and described. Results: A total of six patients were included in the study. Patients with structural heart disease were the most frequent, median age was 56 � 16 years; 67% were male. The procedure evolved without complications in any of the patients and an overall significant improvement was observed. A 24-month follow-up was conducted; two patients had recurrence episodes presenting as slow ventricular tachycardia without severe symptoms and a third patient presented an episode of ventricular fibrillation aborted by the ICD. Conclusion: Video-assisted CSD should be considered as a treatment option for patients with potentially dangerous arrhythmias that do not respond to conventional treatment, especially in recurrent ventricular tachycardia.

Resumen Objetivo: La denervación simpática cardiaca izquierda (DSCI) por toracoscopia se ha convertido en una alternativa terapéutica para el manejo de arritmias cardíacas refractarias al tratamiento convencional en pacientes con cardiopatía estructural, principalmente isquémicos, y enfermedades hereditarias asociadas con muerte súbita como el síndrome de QT largo. Generalmente se realiza en quienes manifiestan episodios recurrentes de arritmias ventriculares o incluso tormenta eléctrica a pesar del tratamiento convencional. El objetivo de este estudio es mostrar la experiencia de esta institución con la DSCI en pacientes refractarios al manejo convencional y los resultados derivados de su aplicación. Métodos: Se revisaron los registros de 6 pacientes con antecedente de arritmias ventriculares tratados previamente con medicamentos y en algunos casos con ablación con catéter y la mayoría con desfibrilador automático implantable, que fueron llevados DSCI por toracoscopia video-asistida (VATS). Resultados: La principal enfermedad de base fue la cardiopatía estructural, la indicación más prevalente fue tormenta arrítmica incontrolable, la edad promedio fue de 56 +- 16 años, el 67% de los individuos fueron hombres. Este procedimiento no mostró complicaciones en ninguno de los pacientes y se encontró mejoría sintomática en todos los casos. Se realizó seguimiento por 24 meses; dos pacientes tuvieron recurrencias por taquicardia ventricular lenta sin síntomas severos y uno por fibrilación ventricular. Conclusion: La DSCI por VATS debe considerarse como opción terapéutica para pacientes con arritmias de difícil manejo.