Retiro de elementos de osteosíntesis en trauma maxilofacial / Osteosynthesis elements removal in maxillofacial trauma

Resumen Objetivo: Analizar la prevalencia y los factores en la remoción de elementos de osteosíntesis (OTS) de pacientes tratados quirúrgicamente debido a fracturas maxilofaciales. Materiales y Método: Estudio retrospectivo descriptivo, donde fueron incluidos todos los pacientes con diagnóstico de fractura maxilofacial y tratados mediante reducción abierta y fijación interna rígida en un intervalo de 10 años, en el Servicio de Cirugía Oral y Maxilofacial en el Hospital Clínico Mutual de Seguridad (HCMS). Resultados: En un total de 807 pacientes intervenidos, con un rango etario entre 22-66 años, fueron utilizados 2.421 OTS. Entre ellos, 58 pacientes (7,2%) fueron sometidos a un segundo procedimiento quirúrgico, retirándose un total de 129 OTS (5,3%). La principal causa de retiro fue infección (41,1%), comúnmente de carácter tardío. El tercio inferior facial fue el más afectado, específicamente, la zona parasinfisiaria. El 39% fue retirado antes de los 12 meses de posicionados. Conclusiones: El retiro de OTS, posterior a trauma maxilofacial tiene una baja prevalencia. El sitio más afectado es el hueso mandibular y la mayoría se retira dentro de los primeros 12-24 meses. La etiología es variable, sin embargo, la infección se mantiene como una de las principales. Los hallazgos sugieren que no sería recomendable realizar este procedimiento de forma universal para todos los pacientes.

Aim: To analyse the prevalence and factors regarding to osteosynthesis elements (OTS) removal from patients surgically treated due to maxillofacial fractures. Materials and Method: Retrospective study in which all patients with diagnosis of maxillofacial fractures and treated with open reduction and internal rigid fixation were included, in an interval of 10 years, in the Maxillofacial Surgery Service of HCMS. Results: In 807 surgically treated patients, with an age between 22-66 years, 2.421 OTS were used. Among them, 58 patients (7.2%) underwent a second surgical procedure, with a total of 129 OTS removed (5.3%). The main cause of removal was infection (41.1%), commonly of a chronic nature. The lower third of the face was the most affected, specifically, the parasymphysis region. 39% of OTS were withdrawn before 12 months. Conclusions: OTS removal after maxillofacial trauma has a low prevalence, the most affected site is the mandibular bone, within the first 12-24 months. The aetiology is variable, however, infection remains one of the main. The findings suggest that it would not be advisable to perform this procedure universally for all patients.

Early removal of etonogestrel subcutaneous contraceptive implant at a community health centre in Pretoria

The etonogestrel subcutaneous contraceptive implant offers efficacy for three years, but some women remove it earlier than prescribed. This study discusses factors associated with the early removal of these implants at a Pretoria community health centre between 01January 2020 to 30 June 2020.Methods: A cross-sectional study using a piloted and researcher assistant-administered questionnaire.Results: Of the 124 participants who removed their etonogestrel subcutaneous contraceptive implant earlier than prescribed, most were single, unemployed, in the age group 30­39 years, Christian, with secondary level education and with parity one or more. Etonogestrel subcutaneous contraceptive implant pre-insertion counselling was given to all participants, most of whom had not previously used contraceptives. Those participants with previous contraceptive use had used injectables. Long-term contraception was the main reason for getting the etonogestrel subcutaneous contraceptive implant. Most participants did not attend post-insertion counselling. Heavy bleeding was the most common side effect and reason for early removal. Fifty-one participants kept the etonogestrel subcutaneous contraceptive implant in for a longer period of 12­23 months. From participants' responses, it seems that Etonogestrel implants may be offered from as early as 15­20 years of age. Conclusion: Women having etonogestrel subcutaneous contraceptive implants removed early at a Pretoria community health centre tended to be young, single, unemployed, Christian, with a secondary level education and with parity one or more. All participants attended the etonogestrel subcutaneous contraceptive implant pre-insertion counselling services but not the post-counselling services. Heavy bleeding was the main reason for the early removal of the etonogestrel subcutaneous contraceptive implant.Keywords: early removal; etonogestrel; subcutaneous contraceptive; implant; Pretoria; community health centre; weight gain; vaginal bleeding.

Migração para veia hepática de cateter totalmente implantável para quimioterapia em paciente com carcinoma de mama: relato de caso / Hepatic vein migration of a totally implantable venous access port-a-cath for chemotherapy in a breast carcinoma patient: case report

Resumo O cateter totalmente implantável (CTI) é utilizado na administração da quimioterapia. Em menos de 1% dos casos de complicação, pode ocorrer migração do CTI para quimioterapia para a circulação sistêmica. O objetivo deste estudo foi descrever um caso de migração do CTI para a veia hepática. Uma paciente do sexo feminino, de 44 anos de idade, teve diagnóstico de câncer de mama com indicação de quimioterapia neoadjuvante. Realizou-se a implantação de cateter port-a-cath. Durante o procedimento de punção do cateter, houve retorno normal de sangue, e foi realizada infusão de soro fisiológico. Em seguida, houve um aumento de volume no local do port e não retorno de sangue à aspiração. A radiografia de tórax mostrou embolização do cateter em topografia hepática. Retirou-se o cateter pela técnica do laço (sem complicações), e a paciente recebeu alta no dia seguinte. Possíveis alterações no funcionamento do CTI devem chamar atenção da equipe responsável.

Abstract A totally implantable venous access port (TIVAP) is used for chemotherapy administration. Venous port migration to the systemic circulation occurs in less than 1% of complications. The aim of this study is to describe a case of TIVAP migration to the hepatic vein. A 44-year-old female patient with breast cancer was prescribed neoadjuvant chemotherapy. A port-a-cath was surgically implanted for chemotherapy. During the port puncture procedure, blood returned normally when aspirated. When the port was first accessed and flushed with saline solution, swelling was observed at the port site and blood could no longer be aspirated. A chest radiography showed catheter embolization in the region of the hepatic vein. The catheter was retrieved using a snare technique (without complications) and the patient was discharged the next day. The care team should be alert to possible TIIVAP malfunction.

Remoção Percutânea de Eletrodos de Estimulação Cardíaca Artificial em um Único Centro Sul-Americano / Percutaneous Removal of Cardiac Leads in a Single Center in South America

Resumo Fundamento: Nas últimas décadas, o número de dispositivos eletrônicos cardíacos implantáveis (DCEI) aumentou consideravelmente, assim como a necessidade de remoção destes. Neste contexto, a remoção percutânea apresenta-se como uma técnica segura e capaz de evitar uma cirurgia cardíaca convencional. Objetivos: Primário: descrever a taxa de sucesso e complicações da remoção percutânea de DCEI em um hospital público brasileiro. Secundário: estabelecer preditores de sucesso e complicações. Métodos: Serie de casos retrospectiva de todos os pacientes submetidos à remoção de DCEI em um hospital público brasileiro no período de janeiro de 2013 a junho de 2018. Remoção, explante e extração de eletrodos, complicações e desfechos foram definidos conforme a diretriz norte-americana de 2017. Variáveis categóricas foram comparadas pelos testes Qui-quadrado ou Fisher, enquanto variáveis contínuas, por testes não pareados. O nível de significância adotado nas análises estatísticas foi de 5%. Resultados: 61 pacientes foram submetidos à remoção de DCEI, sendo 51 extrações e 10 explantes. No total, 128 eletrodos foram removidos. Taxa de sucesso clínico foi 100% no grupo do explante e 90,2% no da extração (p=0,58). Complicações maiores foram encontradas em 6,6% dos pacientes. Falha do procedimento foi associada a eletrodos de ventrículo (p=0,05) e átrio (p=0,04) direito implantados há mais tempo. Duração do procedimento (p=0,003) e necessidade de transfusão sanguínea (p<0,001) foram associadas a maior índice de complicação. Conclusão: As taxas de complicação e sucesso clínico observadas foram de 11,5% e 91,8%, respectivamente. Remoções de eletrodos atriais e ventriculares mais antigos estiveram associados a menores taxa de sucesso. Procedimentos mais longos e necessidade de transfusão sanguínea foram associados a complicações.

Abstract Background: In the last decade, the number of cardiac electronic devices has risen considerably and consequently the occasional need for their removal. Concurrently, the transvenous lead removal became a safe procedure that could prevent open-heart surgery. Objective: The primary objective of this study was to describe the successful performance and the complication rates of pacemaker removals in a Brazilian public hospital. Our secondary aim was to describe the variables associated to successes and complications. Methods: A retrospective case series was conducted in patients submitted to pacemaker removal in a Brazilian public hospital from January 2013 to June 2018. Removal, explant, extraction, success and complication rates were defined by the 2017 Heart Rhythm Society Guideline. Categorical variables were compared using x2 or Fisher's tests, while continuous variables were compared by unpaired tests. A p-value of 0.05 was considered statistically significant. Results: Cardiac device removals were performed in 61 patients, of which 51 were submitted to lead extractions and 10 to lead explants. In total, 128 leads were removed. Our clinical success rate was 100% in the explant group and 90.2% in the extraction one (p=0.58). Major complications were observed in 6.6% patients. Procedure failure was associated to older right ventricle (p=0.05) and atrial leads (p=0,04). Procedure duration (p=0.003) and need for blood transfusion (p<0,001) were associated to more complications. Conclusion: Complications and clinical success were observed in 11.5% and 91.8% of the population, respectively. Removal of older atrial and ventricular leads were associated with lower success rates. Longer procedures and blood transfusions were associated with complications.

Decanulación traqueal en pediatría: ¿cuándo y cómo? / Tracheal decannulation in pediatrics: When and how?

La decanulación es el proceso de retirar la cánula de traqueotomía de forma definitiva, una vez que la patología original que motivó la traqueotomía se haya resuelto o mejorado significativamente.La predicción del éxito de decanulación es difícil debido a la influencia de varios factores. No existe un protocolo universalmente aceptado. Existen diversos protocolos y la elección depende, en gran medida, de cada institución y de la situación individual de cada paciente. Sin embargo, para lograr la decanulación exitosa deben tenerse en cuenta varios criterios esenciales que deben cumplirse independientemente del protocolo elegido.Se señalan las características que debe reunir el paciente apto para la decanulación y se presentan recomendaciones sobre los pasos necesarios para lograr el retiro de la cánula de traqueotomía en el niño de manera segura y minimizando el riesgo de fracaso.

Decannulation is the process of removing the tracheotomy cannula permanently, once the original pathology that led to the tracheotomy has been resolved or significantly improved. The prediction of decannulation success is difficult due to the influence of several factors. There is no universally accepted decannulation protocol. There are several protocols and the choice depends, largely, on each institution and the individual situation of each patient. However, in order to achieve successful decannulation, several essential criteria must be taken into account, which must be fulfilled regardless of the chosen protocol.We indicate the characteristics that the patient must meet for decannulation, and we present recommendations on the necessary steps to achieve the removal of the tracheotomy cannula in a child safely and minimizing the risk of failure.

Patients with encrusted ureteral stents can be treated by a single session combined endourological approach

ABSTRACT Purpose: To describe our experience in the management of retained encrusted ureteral stents using a single session combined endourological approach. Materials and Methods: Patients with retained encrusted ureteral stents who had been submitted to a single session combined endourological approach from June 2010 to June 2018 were prospectively evaluated. Patients were divided according to the Forgotten-Encrusted-Calcified (FECal) classification. The stone burden, surgical intervention, number of interventions until stone free status, operation time, hospital stay, complications, stone analysis, and stone-free rate were compared between groups. ANOVA was used to compare numerical variables, and the Mann-Whitney or Chi-square test to compare categorical variables between groups. Results: We evaluated 50 patients with a mean follow-up of 2.9±1.4 years (mean±SD). The groups were comparable in terms of age, sex, laterality, BMI, comorbidities, ASA, reason for stent passage, and indwelling time. The stone burden was higher for grades IV and V (p=0.027). Percutaneous nephrolithotomy was the most common procedure (p=0.004) for grades IV and V. The number of procedures until the patients were stone-free was 1.92±1.40, and the hospital stay (4.2±2.5 days), complications (22%), and stone analysis (66% calcium oxalate) were similar between groups. The stone-free rate was lower in grades III to V (60%, 54.5%, and 50%). Conclusions: The endoscopic combined approach in the supine position is a safe and feasible technique that allows removal of retained and encrusted stents in a single procedure. The FECal classification seems to be useful for surgical planning.

Energy Required for Fracture in Synthetic Proximal Femoral Models After Synthesis Material Removal: a Biomechanical Study Using Cannulated Screws, Dynamic Hip Screws, and Proximal Femoral Nails / Energia necessária para a ocorrência de fratura em modelos sintéticos de fêmur proximal após retirada de material de síntese: Um estudo biomecânico com parafuso canulado, parafuso dinâmico do quadril e haste femoral proximal

Abstract Objective The present study aims to identify the energy required for synthetic proximal femoral fracture after removal of three implant types: cannulated screws, dynamic hip screws (DHS), and proximal femoral nail (PFN). Methods Twenty-five synthetic proximal femur bones were used: 10 were kept intact as the control group (CG), 5 were submitted to the placement and removal of 3 cannulated screws in an inverted triangle configuration (CSG), 5 were submitted to the placement and removal of a dynamic compression screw (DHSG), and 5 were submitted to the placement and removal of a proximal femur nail (PFNG). All samples were biomechanically analyzed simulating a fall on the greater trochanter using a servo-hydraulic machine to determine the energy (in Joules [J]) required for fracture. Results All samples presented basicervical fractures. The energy required for fracture was 7.1 J, 6.6 J, 6 J, and 6.7 J for the CG, CSG, DHSG and PFNG, respectively. There was no statistically significant difference (considering a 95% confidence interval) in energy among the study groups (p = 0.34). Conclusion There was no statistically significant difference in the energy required to cause a synthetic proximal femoral fracture after removing all three implant types and simulating a fall over the greater trochanter.

Resumo Objetivo Identificar a energia necessária para ocorrência de fratura do fêmur proximal em osso sintético após retirada de três modelos de implantes: parafusos canulados, parafuso dinâmico do quadril (dynamic hip screw-DHS) e haste femoral proximal (proximal femoral nail-PFN). Métodos Foram utilizados 25 modelos de ossos sintéticos da extremidade proximal do fêmur: 10 unidades de grupo controle (GC), 5 unidades após colocação e retirada de 3 parafusos canulados colocados em configuração de triângulo invertido (GPC), 5 unidades após colocação e retirada do parafuso de compressão dinâmico (GDHS), e 5 unidades após colocação e retirada da haste de fêmur proximal (GPFN). Uma análise biomecânica foi realizada em todas as amostras simulando uma queda sobre o grande trocânter utilizando uma máquina servo-hidráulica com o objetivo de verificar a energia (em Joules [J]) necessária até a ocorrência de fratura nos diferentes grupos. Resultados Todos os grupos apresentaram fratura basocervical. Os grupos GC, GPC, GDHS e GPFN apresentaram, respectivamente, valores de 7.1J, 6.6J, 6J e 6.7J de energia até ocorrência da fratura. Não houve diferença estatisticamente significativa (intervalo de confiança de 95%) na energia entre os grupos de estudo (p = 0,34). Conclusão Não houve diferença estatisticamente significativa nos valores de energia necessária para ocorrência de fratura da extremidade proximal do fêmur após a retirada de três tipos de implantes utilizando modelos sintéticos simulando queda sobre o grande trocânter.

Efectos adversos y motivos de retiro de implante subdérmico Jadelle® en usuarias de Policlínica de salud Sexual y Reproductiva del Hospital de Clínicas en período junio 2015- diciembre 2017 / Adverse effects and reasons of remove of subdermico implant Jadelle® in users of Sexual and Reproductive Health Clinics of Hospital de Clinicas in period june 2015-december 2017

INTRODUCCIÓN: La anticoncepción hormonal, a través de implantes subdérmicos, es uno de los métodos anticonceptivos reversibles de larga duración más eficaces en la actualidad que está disponible en nuestro país en forma gratuita en el sistema público. OBJETIVO: Reconocer los efectos adversos y los motivos de retiro del Implante Jadelle® en usuarias del Hospital de Clínicas, así como evaluar la información recibida por las usuarias al momento de la colocación. MATERIAL Y MÉTODOS: Un total de 160 pacientes participaron en el estudio a través de una encuesta previo consentimiento informado. Se utilizó la estadística descriptiva en números absolutos y porcentuales. Resultados: Previo al uso, recibieron información sobre los probables efectos adversos del método el 83% de ellas, y acerca de la efectividad del método el 89 %. En cuanto a efectos adversos los presentaron el 80,6% de las usuarias, siendo la irregularidad de la menstruación la causa más frecuente constituyendo un 61%. CONCLUSIONES: Es alta la frecuencia de pacientes que presentan efectos adversos y que solicitan retiro del implante antes del tiempo a causa de ello, 35% de las usuarias, siendo el principal motivo la irregularidad menstrual en un 43% de los casos. Es recomendable realizar un correcto asesoramiento previo a la colocación e incentivar a las pacientes a concurrir a los controles médicos, luego de la colocación, para brindar asesoramiento y tratamiento si se presentara algún efecto adverso, con el fin de obtener una mejor continuidad de uso del método.

INTRODUCTION: Hormonal contraception, through subdermal implants, is one of the most effective long active reversal contraceptive methods currently available in our country for free in the public system. OBJETIVE: Recognize the adverse effects and the reasons for its withdrawal in users of the Hospital de Clínicas as well as to evaluate the information received by the users at the time of placement. METHODOLOGY: A total of 160 patients participated in the work with prior informed consent through a survey. Descriptive statistics were used in absolute and percentage numbers. They received information on the probable adverse effects of the 83% pre-use method, about the effectiveness of the 89% method. RESULTS: Regarding adverse effects, they were present in 80.6% of the users; the being irregularity of menstruation is the most frequent, constituting 61%. Concluding that the frequency of patients presenting with adverse effects and requesting removal of the implant before the time is high because of it, 35% of the users who requested removal menstrual irregularities were the main reason for 43% of patients. CONCLUSIONS: It is advisable to make a correct advice prior to placement and encourage patients to attend medical controls, after placement, to provide advice and treatment if any adverse effect occurs, in order to give better use in terms of method time.

Técnicas de extracción de clavos endomedulares retrógrados de fémur rotos. Presentación de tres casos / Retrograde femoral intramedullary nail extraction techniques. Report of three cases

Introducción: La indicación de realizar una osteosíntesis con un clavo endomedular retrógrado en las fracturas de fémur se ha incrementado en los últimos años y, con ello, la cantidad de complicaciones. Se describen tres técnicas quirúrgicas para el manejo del fragmento proximal de la osteosíntesis endomedular rota. Desde marzo de 2001 hasta enero de 2019, se realizaron 321 osteosíntesis con clavos endomedulares retrógrados de fémur en nuestra institución. La tasa de rotura del implante asociada a una seudoartrosis fue del 0,9%. Se realizaron técnicas mínimamente invasivas para la extracción del implante, preservando las partes blandas. Se logró la reosteosíntesis definitiva con la consiguiente consolidación en un tiempo medio de 140 días. Conclusiones: Las técnicas utilizadas fueron simples, seguras, mínimamente invasivas y muy reproducibles. Nivel de Evidencia: IV

background: The indication for osteosynthesis with a retrograde intramedullary nail in femur fractures has increased in recent years and with it, the number of complications. Three surgical techniques are described for the management of the proximal fragment of the broken intramedullary osteosynthesis. From March 2001 to January 2019, 321 osteosyntheses with retrograde femoral intramedullary nails were performed at our institution. The implant rupture rate associated with nonunion was 0.9%. Minimally invasive techniques were performed to remove the implant, preserving the soft tissues. Definitive reosteosynthesis was achieved with the consequent consolidation in an average time of 140 days. Conclusions: The techniques used were simple, safe, minimally invasive, and reproducible. Level of Evidence: IV

Soporte ventilatorio no invasivo como puente hacia el trasplante pulmonar: reporte de un caso / Bridging to lung transplant using noninvasive ventilatory support: a case report

El soporte ventilatorio no invasivo es una herramienta que ha demostrado mejorar la sobrevida de pacientes con falla muscular de la bomba respiratoria y el manejo de enfermedades pulmonares crónicas, incluso la ventilación no invasiva nocturna ha servido de puente hacia el trasplante pulmonar. Se presenta el caso de una adolescente de 14 años con enfermedad pulmonar crónica hipoxémica severa y falla ventilatoria secundaria, que requirió ventilación prolongada y traqueostomía en espera de trasplante pulmonar. Luego de reevaluar indemnidad de la vía aérea fue decanulada a soporte ventilatorio no invasivo, con uso alternado de mascarilla nasal nocturna y pieza bucal diurna, permitiendo descanso muscular respiratorio eficiente, y mejoría de flujo de tos con técnicas de apilamiento de aire. Este plan permitió una decanulación segura y realizar soporte continuo ventilatorio no invasivo con un programa de rehabilitación cardiorrespiratorio. Generalmente, el soporte ventilatorio no invasivo se utiliza en trastornos primarios de la bomba respiratoria. En este caso, se indicó para enfermedad pulmonar crónica hipoxémica, mostrando claros beneficios con oxigenación adecuada, buen rendimiento cardiovascular con mejor tolerancia al ejercicio y entrenamiento en el escenario de preparación al trasplante pulmonar.

Noninvasive Ventilatory Support has demonstrated to improve survival of patients with ventilatory pump muscle failure and nocturnal noninvasive ventilation is useful in chronic lung disease, even bridging to lung transplant. We present a 14 years old girl with severe hypoxemic chronic lung disease and secondary ventilatory failure, who required continuous long-term ventilation and underwent a tracheostomy waiting for lung transplant. After reevaluated the airway patency the patient was decannulated to Noninvasive Ventilation Support, alternating nocturnal nasal mask with diurnal mouth piece in order to provide efficient respiratory muscle rest, made air stacking and improved cough flow. This plan allows safe decannulation to continuous Noninvasive Ventilatory Support tailoring a rehabilitation cardiorespiratory program. Usually, Noninvasive Ventilation Support is prescribed for primary respiratory pump muscles failure, but in this case, it was applied for a hypoxemic chronic lung disease. Clear benefits were observed leading to appropriate oxygenation, good cardiovascular performance with better tolerance to exercise for training in the preparatory scenario of a lung transplant.

Efetividade e Segurança da Remoção de Cabos-Eletrodos Transvenosos de Marca-Passos e Desfibriladores Implantáveis no Cenário da Prática Clínica Real / Effectiveness and Safety of Transvenous Removal of Cardiac Pacing and Implantable Cardioverter-defibrillator Leads in the Real Clinical Scenario

Resumo Fundamento Remoção de cabos-eletrodos de dispositivos cardíacos eletrônicos implantáveis (DCEI) é procedimento pouco frequente e sua realização exige longo treinamento profissional e infraestrutura adequada. Objetivos Avaliar a efetividade e a segurança da remoção de cabos-eletrodos de DCEI e determinar fatores de risco para complicações cirúrgicas e mortalidade em 30 dias. Métodos Estudo prospectivo com dados derivados da prática clínica. De janeiro/2014 a abril/2020, foram incluídos, consecutivamente, 365 pacientes submetidos à remoção de cabos-eletrodos, independentemente da indicação e técnica cirúrgica utilizada. Os desfechos primários foram: taxa de sucesso do procedimento, taxa combinada de complicações maiores e morte intraoperatória. Os desfechos secundários foram: fatores de risco para complicações intraoperatórias maiores e morte em 30 dias. Empregou-se análise univariada e multivariada, com nível de significância de 5%. Resultados A taxa de sucesso do procedimento foi de 96,7%, sendo 90,1% de sucesso completo e 6,6% de sucesso clínico. Complicações maiores intraoperatórias ocorreram em 15 (4,1%) pacientes. Fatores preditores de complicações maiores foram: tempo de implante dos cabos-eletrodos ≥ 7 anos (OR= 3,78, p= 0,046) e mudança de estratégia cirúrgica (OR= 5,30, p= 0,023). Classe funcional III-IV (OR= 6,98, p<0,001), insuficiência renal (OR= 5,75, p=0,001), infecção no DCEI (OR= 13,30, p<0,001), número de procedimentos realizados (OR= 77,32, p<0,001) e complicações maiores intraoperatórias (OR= 38,84, p<0,001) foram fatores preditores para mortalidade em 30 dias. Conclusões Os resultados desse estudo, que é o maior registro prospectivo de remoção de cabos-eletrodos da América Latina, confirmam a segurança e a efetividade desse procedimento no cenário da prática clínica real. (Arq Bras Cardiol. 2020; 115(6):1114-1124)

Abstract Background Transvenous lead extraction (TLE) of cardiac implantable electronic devices (CIED) is an uncommon procedure and requires specialized personnel and adequate facilities. Objectives To evaluate the effectiveness and safety of the removal of CIED leads and to determine risk factors for surgical complications and mortality in 30 days. Methods Prospective study with data derived from clinical practice. From January 2014 to April 2020, we included 365 consecutive patients who underwent TLE, regardless of the indication and surgical technique used. The primary outcomes were: success rate of the procedure, combined rate of major complications and intraoperative death. Secondary outcomes were: risk factors for major intraoperative complications and death within 30 days. Univariate and multivariate analysis were used, with a significance level of 5%. Results Procedure success rate was 96.7%, with 90.1% of complete success and 6.6% of clinical success. Major intraoperative complications occurred in 15 (4.1%) patients. Predictors of major complications were: lead dwelling time ≥ 7 years (OR = 3.78, p = 0.046) and change in surgical strategy (OR = 5.30, p = 0.023). Functional class III-IV (OR = 6.98, p <0.001), renal failure (OR = 5.75, p = 0.001), CIED infection (OR = 13.30, p <0.001), number of procedures performed (OR = 77.32, p <0.001) and major intraoperative complications (OR = 38.84, p <0.001) were predictors of 30-day mortality. Conclusions The results of this study, which is the largest prospective registry of consecutive TLE procedures in Latin America, confirm the safety and effectiveness of this procedure in the context of real clinical practice. (Arq Bras Cardiol. 2020; 115(6):1114-1124)

Tratamiento del cuerpo extraño rectal en un Servicio de Urgencia / Rectal foreign body treatment at an urgency service

Resumen Introducción: El cuerpo extraño rectal (CER) es un problema de difícil manejo para el cirujano general. La vía anal es la puerta de entrada más habitual seguido de la oral. La sospecha clínica es fundamental para el diagnóstico, pudiendo apoyarse de imágenes. El tratamiento es su extracción por vía transanal o por vía anterior. Objetivos: Caracterizar, describir y presentar el tratamiento de los pacientes con CER que consultaron en urgencia del Hospital el Pino (HEP) entre los años 2011 y 2016. Material y Método: Estudio serie de casos. Se realiza revisión de fichas clínicas de pacientes con CER en un periodo de 5 años en el Servicio de Urgencia del HEP. Se identificó a los pacientes tratados en box y a aquellos tratados en pabellón. Se caracterizó según variables demográficas, tratamiento, complicaciones y días de hospitalización. Resultados: Se identificaron 18 pacientes, 13 hombres y 5 mujeres de 45 años (± 36-51) y 34 años (± 23-64) respectivamente. En 1 de ellos fue posible extracción manual transanal en box sin anestesia y en 17 se requirió tratamiento en pabellón, donde 12 fue por vía transanal y 5 por abordaje abdominal. En ningún caso se identificó lesión intestinal. Evolución postoperatoria adecuada. Días de hospitalización promedio 1,8 días. Conclusión: Este es un problema infrecuente y de difícil manejo. Existe mayor frecuencia en hombres de edades media siendo la puerta de entrada la vía anal en todos los casos. En la mayoría se requirió extracción en pabellón bajo anestesia siendo el abordaje transanal el más utilizado y con buenos resultados.

Introduction: The rectal forcing body (RFB) is a problem which involves a difficult management for surgeons. Anal via is the most frequent entrance area, followed by the oral via. Clinical suspicion is fundamental for diagnosis and it is possible to support it using imaging. Treatment considers extraction through transanal or frontal via. Aim: To describe and present the treatment of patients with rectal foreing body in the Urgency Service of El Pino Hospital during years 2011 to 2016. Materials and Method: Case studies. Clinical records revision of patients with rectal foreing body in the Urgency Service of El Pino Hospital considering a 5-year period. Patients are identified as those treated in the box and in a surgical pavilion. Patients were classified according to demographic variables, received treatment, associated complications and hospitalization time. Results: 18 patients are identified, 13 men and 5 women, 45 (± 36-51) and 34 (± 23-64) years respectively. It was possible to manually extract via trans-anal at box, in one of these cases; 17 of them required treatment at surgical pavilion, where 12 were via trans-anal and 5 via abdominal. None of these cases had intestinal injury. Post-surgery evolution was adequate. Average hospitalization was 1.8 days. Conclusion: RFB is a non-frequent problem which requires high diagnose suspicious to be able to carry out proper treatments. It is more frequent in middle age men, with transanal input. In most cases, the extraction was done in surgical pavilion and required anesthesia and were done via trans anal with good results.

Indicaciones y cuidados de la traqueostomía en pediatría / Indications and care of the tracheostomy in pediatrics

Tracheostomy in children is an extremely delicate procedure, which consists in the creation of a stoma between the trachea and the skin. Among the most frequent indications are neurological disorders, obstruction of the upper airway or prolonged mechanical ventilation. Pediatric versus adult airway differences should be considered during surgery. In the postoperative period, hemorrhage, pneumothorax, pneumomediatin can occur. In the late postoperative period, accidental decannulation, false pathway, infection of the tracheostomy, and later formation of periostomal or endotracheal granulomas may occur. The care of the tracheostomy in the clinical unit must be with trained personnel and the family environment must be prepared for home care. As long as the tracheostomy persists, control of the airway superior and inferior to the tracheostomy must be maintained by fiber optic. Patients with neurological compromise or cardiopulmonary damage have a lower decannulation rate and a longer hospital stay.

La traqueostomía en niños es un procedimiento extremadamente delicado, que consiste en la creación de un ostoma entre la tráquea y la piel. Entre las indicaciones más frecuentes se encuentran trastornos neurológicos, obstrucción de la vía aérea superior o ventilación mecánica prolongada. Consideraciones a las diferencias de la vía aérea pediátrica versus del adulto deben tenerse en cuenta durante la cirugía. En el postoperatorio se puede presentar hemorragia, neumotórax y neumomediastino. En el postoperatorio tardío puede ocurrir decanulación accidental, falsa vía, infección de la traqueostomía, y más tardíamente formación de granulomas periostomales o endotraqueales. El cuidado de la traqueostomía en la unidad clínica debe ser con personal capacitado y se debe preparar el entorno familiar para el cuidado en el domicilio. Mientras persista la traqueostomía se debe mantener control por fibra óptica de la vía aérea superior e inferior a la traqueostomía. Los pacientes con compromiso neurológico o daño cardiopulmonar tienen menor tasa de decanulación y mayor tiempo en el hospital.

Traqueostomía en niños: los desafíos de la decanulación, revisión y propuesta de trabajo / Tracheostomy in children: the challenges of decanulation, revision and work proposal

Tracheostomy (TQT) in pediatrics is a procedure that allows maintaining permeable airways and establishes prolonged mechanical ventilation. Continuous noninvasive ventilatory support (CNVS) can always be used for patients capable of cooperating with it and mechanical insufflation-exsufflation (MIE). Despite this, TQT continues to be indicated frequently, limiting home transfer and care, conditioning additional burden of morbidity and risks. In those with upper airway obstruction (OVAS), except in <2 years, the decanulation follows similar guidelines as in adults. Small children who require even only sleep ventilation cannot be decannulated to NVS if they cannot be relied on to use it via noninvasive interfaces. So, children under age 12 should not be decannulated unless they are ventilator weaned. For adolescents and adults, the principle criterion for safe decannulation is an MIE-peak exsufflation flows (MIE-EF) over 150 L/m whereas need for tracheotomy occurs when MIE-EF decrease below 120 L/m, irrespective of extent of ventilator dependence. The following article is a critical narrative review of different decannulation alternatives to ensure that this process can be safely carried out with effectiveness and efficiency. Patients with different ages and diseases have been considered, knowing that younger children and adult in transition tracheostomized patients significantly increases the challenges.

La traqueotomía (TQT) permite mantener la vía aérea permeable y la ventilación mecánica prolongada. El soporte ventilatorio no invasivo continuo (SVNI) junto con la insuflación-exuflación mecánica (MIE), son una alternativa en la mayoría de los casos. Pese a esto, la TQT sigue indicándose frecuentemente, limitando la transferencia al hogar, condicionando carga adicional de morbilidad. En los niños con obstrucción de la vía aérea superior (OVAS), salvo en los <2 años, la decanulación sigue lineamientos similares que en adultos. Los <12 años dependientes de ventilador, aun cuando sólo sea nocturna, son decanulados o extubados a SVNI más difícilmente que adultos con dependencia continua. La mejor estrategia es evitar la TQT e indicar SVNI en los pacientes colaboradores que cumplan criterios. Excepto pacientes con estridor por OVAS grave o enfermedad de la primera motoneurona y severo compromiso miopático. Para adolescentes y adultos, el criterio para la decanulación segura es un pico flujo exuflado máximo en MIE (PFE-MIE), con o sin tos, >150 L/m, mientras que la necesidad de traqueostomía ocurre cuando el MIE (PFE-MIE) esta bajo 120 ml/min, independiente del grado de dependencia del ventilador. En menores de 12 años, el éxito del SVNI reside en obtener interfaces confiables para su entrega, de lo contrario no podrían ser decanulados. Siendo escasos los protocolos de decanulación pediátrica. Nuestro objetivo es el de ponderar alternativas seguras y eficientes para la decanulación de la TQT. Siendo considerados pacientes con edades y enfermedades distintas, sabiendo que los más pequeños, no colaboradores y dependientes de ventilación aumentan el desafío.

Lead removal without extraction tools: a single-center experience

Abstract Introduction: Indications for cardiac devices have been increasing as well as the need for lead extractions as a result of infections, failed leads and device recalls. Powered laser sheaths, with a global trend towards the in-creasingly technological tools, meant to improve the procedure's outcome but have economic implications. Objective: The aim of this study is to demonstrate the experience of a Bra-zilian center that uses simple manual traction in most lead removals per-formed annually, questioning the real need for expensive and technically challenging new devices. Methods: This retrospective observational study included 35 patients who had a transvenous lead extraction in the period of a year between January 1998 and October 2014 at Hospital de Messejana Dr. Carlos Alberto Studart Gomes, in Fortaleza, CE, Brazil. Data were collected through a records review. They were evaluated based on age, type of device, dwelling time, indication for removal, technique used and immediate outcomes. Results: The median dwelling time of the devices was 46.22 months. Infec-tion, lead fracture and device malfunction were the most common indica-tions. Simple traction was the method of choice, used in 88.9% of the pro-cedures. Manual traction presented high success rates, resulting in com-plete removal without complications in 90% of the cases. Conclusion: This article suggests that lead extraction by simple manual traction can still be performed effectively in countries with economic diffi-culties as a first attempt, leaving auxiliary tools for a second attempt in case of failure or contraindications to the simple manual traction technique.

Presión inspiratoria mantenida en pacientes pediátricos traqueostomizados como indicador de tolerancia al uso de cánula tapada / Maintained inspiratory pressure in pediatric tracheostomized patients as an indicator of tolerance of capped tracheostomy

INTRODUCCIÓN: El uso prolongado de traqueostomía (TQT) conlleva a complicaciones que pueden minimizarse con una decanulación segura y temprana. La presión inspiratoria mantenida (PiMant) evalúa el comportamiento dinámico de la vía aérea en inspiración, la que puede relacionarse con la tolerancia a la oclusión de la TQT en pacientes en vía de decanulación. El OBJETIVO es el de describir la medición de PiMant y relacionar su valor con la tolerancia al uso de cánula tapada. METODOLOGÍA: Se evaluó la PiMant a 16 pacientes traqueostomizados, con vacuómetro anaeroide, registrando la moda de las presiones obtenidas, saturación de oxígeno, frecuencias respiratoria y cardíaca, uso de musculatura accesoria y estridor, a los minutos 1, 5, 10 y 15 de la oclusión de la TQT. RESULTADOS: mediana edad 60 meses, rango de presiones −2 a −40 cmH2O. Valores de PiMant > −7 cmH2O se asocian a mejor tolerancia al uso de cánula tapada. El estridor severo, asociado a aumento en frecuencia respiratoria, frecuencia cardiaca y uso de musculatura accesoria fueron los principales indicadores de fin de la prueba. CONCLUSIONES: PiMant es una prueba segura. PiMant> −7cmH2O, presentan mejor tolerancia a uso de cánula tapada.

INTRODUCTION: The prolonged use of tracheostomy leads to several complications, being necessary a prompt and safe decannulation. Maintained Inspiratory Airway Pressure (PiMant) is a functional evaluation of the dynamic changes of upper airway in inspiration which could indicate the tolerance to capped tracheostomy and adapting to this new airflow resistance, prior to decannulate. METHODS: Sixteen tracheostomized patients were evaluated with PiMant using a vacuum gauge, recording pressure value, oxygen saturation, respiratory rate, heart rate, accesory muscles use and presence of stridor during 15 minutes. RESULTS: Median age 60 months-old, pressure range −2 to −40 cmH2O. PiMant values > −7 cmH2O were associated with better tolerance to capped tracheostomy. Stridor was associated to increase of respiratory effort being the best criteria to bring to a halt the test. CONCLUSIONS: PiMant is a safe assessment, and indicates tolerance to capped tracheostomy when values > −7 cmH2O are found.

Cochlear implant revision surgeries in children / Cirurgias revisionais de implante coclear em crianças

Abstract Introduction: The surgery during which the cochlear implant internal device is implanted is not entirely free of risks and may produce problems that will require revision surgeries. Objective: To verify the indications for cochlear implantation revision surgery for the cochlear implant internal device, its effectiveness and its correlation with certain variables related to language and hearing. Methods: A retrospective study of patients under 18 years submitted to cochlear implant surgery from 2004 to 2015 in a public hospital in Brazil. Data collected were: age at the time of implantation, gender, etiology of the hearing loss, audiological and oral language characteristics of each patient before and after cochlear implant surgery and any need for surgical revision and the reason for it. Results: Two hundred and sixty-five surgeries were performed in 236 patients. Eight patients received a bilateral cochlear implant and 10 patients required revision surgery. Thirty-two surgeries were necessary for these 10 children (1 bilateral cochlear implant), of which 21 were revision surgeries. In 2 children, cochlear implant removal was necessary, without reimplantation, one with cochlear malformation due to incomplete partition type I and another due to trauma. With respect to the cause for revision surgery, of the 8 children who were successfully reimplanted, four had cochlear calcification following meningitis, one followed trauma, one exhibited a facial nerve malformation, one experienced a failure of the cochlear implant internal device and one revision surgery was necessary because the electrode was twisted. Conclusion: The incidence of the cochlear implant revision surgery was 4.23%. The period following the revision surgeries revealed an improvement in the subject's hearing and language performance, indicating that these surgeries are valid in most cases.

Resumo Introdução: A cirurgia para a implantação do dispositivo interno do implante coclear não é inteiramente livre de riscos e pode apresentar problemas que exigem cirurgias revisionais. Objetivo: Verificar a incidência das indicações de cirurgias revisionais para a implantação do dispositivo interno do implante coclear, sua efetividade e correlacionar às variáveis relacionadas às categorias de linguagem e audição. Método: Estudo retrospectivo de pacientes menores de 18 anos submetidos à cirurgia de implante coclear de 2004 a 2015 em um hospital público no Brasil. Os dados coletados foram: idade no momento da implantação, sexo, etiologia da surdez, características audiológicas e da linguagem oral de cada paciente no pré e pós-operatório, necessidade de revisão cirúrgica e razão para ela. Resultados: Foram feitas 265 cirurgias em 236 pacientes. Oito pacientes foram submetidos ao implante coclear bilateral e 10 necessitaram de cirurgia de revisão. Foram necessárias 32 cirurgias para essas 10 crianças (um implante coclear bilateral), das quais 21 foram cirurgias de revisão. Em duas crianças, a remoção do implante coclear foi necessária, sem realização de reimplante; uma delas apresentava malformação coclear, por partição incompleta tipo I; e a outra, devido a trauma. Quanto à causa da necessidade da cirurgia revisional, das oito crianças que permaneceram com implante coclear, quatro apresentaram calcificação coclear após meningite, seguida de trauma (1), malformação do nervo facial (1), falha do dispositivo interno da IC (1) e torção do feixe de eletrodos (1). Conclusão: A incidência de cirurgias revisionais foi de 4,23%. O pós-operatório das cirurgias revisionais permite uma melhoria no desempenho de audição e na linguagem dos pacientes, indicando que essas cirurgias são válidas na maioria dos casos.