Back to the future: a case series of minimally invasive repair of pectus excavatum with regular instruments / De volta para o futuro: série de casos de reparo minimamente invasivo do pectus excavatum com instrumentos comuns

ABSTRACT Objective: Minimally invasive repair of pectus excavatum (MIRPE) is a surgical treatment for PE. During the procedure, a specialized introducer is used to tunnel across the mediastinum for thoracoscopic insertion of a metal bar. There have been reported cases of cardiac perforation during this risky step. The large introducer can be a dangerous lever in unskilled hands. We set out to determine the safety and feasibility of using regular instruments (i.e., not relying on special devices or tools) to create the retrosternal tunnel during MIRPE. Methods: This was a preliminary study of MIRPE with regular instruments (MIRPERI), involving 28 patients with PE. We recorded basic patient demographics, chest measurements, and surgical details, as well as intraoperative and postoperative complications. Results: Patients undergoing MIRPERI had Haller index values ranging from 2.58 to 5.56. No intraoperative complications occurred. Postoperative complications included nausea/vomiting in 8 patients, pruritus in 2, and dizziness in 2, as well as atelectasis, pneumothorax with thoracic drainage, pleural effusion, and dyspnea in 1 patient each. Conclusions: In this preliminary study, the rate of complications associated with MIRPERI was comparable to that reported in the literature for MIRPE. The MIRPERI approach has the potential to improve the safety of PE repair, particularly for surgeons that do not have access to certain special instruments or have not been trained in their use.

RESUMO Objetivo: O minimally invasive repair of pectus excavatum (MIRPE, reparo minimamente invasivo do pectus excavatum) é um tratamento cirúrgico do PE. Durante o procedimento, utiliza-se um introdutor específico a fim de criar um túnel mediastinal para a colocação toracoscópica de uma barra metálica. Já houve casos relatados de perfuração cardíaca durante essa etapa arriscada. O introdutor grande pode ser uma perigosa alavanca em mãos inábeis. Propusemo-nos a determinar a segurança e viabilidade do uso de instrumentos comuns (isto é, sem contar com dispositivos ou ferramentas especiais) para criar o túnel retroesternal durante o MIRPE. Métodos: Estudo preliminar sobre o MIRPE with regular instruments (MIRPERI, MIRPE com instrumentos comuns), envolvendo 28 pacientes com PE. Foram registrados dados demográficos básicos dos pacientes, medições torácicas e detalhes cirúrgicos, bem como complicações intra e pós-operatórias. Resultados: Os pacientes submetidos ao MIRPERI apresentavam índice de Haller entre 2,58 e 5,56. Não ocorreram complicações intraoperatórias. As complicações pós-operatórias incluíram náusea/vômito em 8 pacientes, prurido em 2 e tontura em 2, bem como atelectasia, pneumotórax com drenagem torácica, derrame pleural e dispneia em 1 paciente cada. Conclusões: Neste estudo preliminar, a taxa de complicações associadas ao MIRPERI foi comparável à relatada na literatura para o MIRPE. A abordagem de MIRPERI tem o potencial de melhorar a segurança do reparo do PE, particularmente para cirurgiões que não têm acesso a certos instrumentos especiais ou não foram treinados para utilizá-los.

Diaphragmatic pacing stimulation in spinal cord injury: anesthetic and perioperative management

OBJECTIVE: The standard therapy for patients with high-level spinal cord injury is long-term mechanical ventilation through a tracheostomy. However, in some cases, this approach results in death or disability. The aim of this study is to highlight the anesthetics and perioperative aspects of patients undergoing insertion of a diaphragmatic pacemaker. METHODS: Five patients with quadriplegia following high cervical traumatic spinal cord injury and ventilator-dependent chronic respiratory failure were implanted with a laparoscopic diaphragmatic pacemaker after preoperative assessments of their phrenic nerve function and diaphragm contractility through transcutaneous nerve stimulation. ClinicalTrials.gov: NCT01385384. RESULTS: The diaphragmatic pacemaker placement was successful in all of the patients. Two patients presented with capnothorax during the perioperative period, which resolved without consequences. After six months, three patients achieved continuous use of the diaphragm pacing system, and one patient could be removed from mechanical ventilation for more than 4 hours per day. CONCLUSIONS: The implantation of a diaphragmatic phrenic system is a new and safe technique with potential to improve the quality of life of patients who are dependent on mechanical ventilation because of spinal cord injuries. Appropriate indication and adequate perioperative care are fundamental to achieving better results.

Ventilação elétrica: indicações e aspectos técnicos do implante cirúrgico do marca-passo de estimulação diafragmática / Electric ventilation: indications for and technical aspects of diaphragm pacing stimulation surgical implantation

OBJETIVO: Pacientes com lesão medular cervical alta em geral são dependentes de ventilação mecânica, que, embora salve vidas, está associada a complicações e redução da expectativa de vida devido a infecções respiratórias. A estimulação do diafragma por marca-passo, às vezes chamada de ventilação elétrica, induz a inspiração por estimulação dos músculos inspiratórios. Nosso objetivo foi destacar as indicações e alguns aspectos da técnica cirúrgica empregada no implante laparoscópico dos eletrodos, assim como descrever cinco casos de pacientes tetraplégicos submetidos à técnica. MÉTODOS: A seleção dos pacientes envolveu estudos de condução do nervo frênico por via transcutânea para determinar se os nervos estavam preservados. A abordagem cirúrgica foi laparoscopia clássica, com quatro trocartes. A técnica foi iniciada com o mapeamento elétrico para encontrar os "pontos motores" (pontos de contração máxima do diafragma). Se o mapeamento era bem-sucedido, dois eletrodos eram implantados na face abdominal de cada lado do diafragma para estimular ramos do nervo frênico. RESULTADOS: Dos cinco pacientes, três e um, respectivamente, eram capazes de respirar somente com o uso do marca-passo por períodos superiores a 24 e 6 h, enquanto um não era capaz. CONCLUSÕES: Embora seja necessário um acompanhamento mais longo para chegar a conclusões definitivas, os resultados iniciais são promissores, pois, no momento, a maioria dos nossos pacientes pode permanecer sem ventilação mecânica por longos períodos de tempo.

OBJECTIVE: Patients with high cervical spinal cord injury are usually dependent on mechanical ventilation support, which, albeit life saving, is associated with complications and decreased life expectancy because of respiratory infections. Diaphragm pacing stimulation (DPS), sometimes referred to as electric ventilation, induces inhalation by stimulating the inspiratory muscles. Our objective was to highlight the indications for and some aspects of the surgical technique employed in the laparoscopic insertion of the DPS electrodes, as well as to describe five cases of tetraplegic patients submitted to the technique. METHODS: Patient selection involved transcutaneous phrenic nerve studies in order to determine whether the phrenic nerves were preserved. The surgical approach was traditional laparoscopy, with four ports. The initial step was electrical mapping in order to locate the "motor points" (the points at which stimulation would cause maximal contraction of the diaphragm). If the diaphragm mapping was successful, four electrodes were implanted into the abdominal surface of the diaphragm, two on each side, to stimulate the branches of the phrenic nerve. RESULTS: Of the five patients, three could breathe using DPS alone for more than 24 h, one could do so for more than 6 h, and one could not do so at all. CONCLUSIONS: Although a longer follow-up period is needed in order to reach definitive conclusions, the initial results have been promising. At this writing, most of our patients have been able to remain ventilator-free for long periods of time.