Abordagem do segmento superior do corpo em pacientes ex-obesos com cirurgia única: toracobraquio-mamoplastia / Unique surgery for the upper body segment in patients with massive weight loss: thoracobrachio-mammoplasty

INTRODUÇÃO Os pacientes ex-obesos necessitam de uma abordagem complexa, diante do grande excesso de pele decorrente da perda ponderal. Em alguns casos, muitas cirurgias plásticas são necessárias, não havendo uma padronização na associação destas cirurgias. No segmento superior do corpo, a região dos braços, a lateral do tórax e as mamas normalmente são acometidas, principalmente nas mulheres. Diversas técnicas foram desenvolvidas com o objetivo de alcançar resultados melhores e com cicatrizes mais escondidas. Algumas técnicas podem ser associadas, sendo realizadas em um único tempo cirúrgico. Quando a equipe é bem estruturada, o tempo cirúrgico é reduzido, significando mais segurança para o paciente. MÉTODO: Os autores apresentam uma técnica que oferece padronização no tratamento do ex-obeso, que é realizada em tempo único: a Mamoplastia (pela técnica de Pitanguy ou com aposição de prótese mamária), a Toracoplastia (com a retirada do excesso de pele na lateral do tórax) e a Braquioplastia (realizada com um desenho retilíneo na parte mais inferior dos braços). RESULTADOS: Os sete casos foram avaliados quanto ao tempo cirúrgico, à localização das cicatrizes, à forma final e à simetria. Entre as complicações, houve deiscências parciais (14%) e cicatrizes hipertróficas (14%). O resultado estético foi satisfatório para os pacientes em 84% dos casos, sendo que a qualidade da cicatrização do paciente, queloide ou cicatrizes hipercrômicas, foi a maior causa de insatisfação. CONCLUSÃO: A utilização da técnica de Toracobraquio-mamoplastia em um único tempo se mostrou efetiva no tratamento do ex-obeso, oferecendo mais uma opção, diante das outras cirurgias que estes pacientes normalmente necessitam.

INTRODUCTION Ex-obese patients require a complex surgical approach because of the large amount of excess skin due to their massive weight loss. In some cases, several plastic surgeries are needed, and there is no existing standard in the coordination of these surgeries. In the upper segment of the body, the arms, side of the thorax, and breasts are usually affected, mainly in women. Several techniques have been developed with the aim of achieving better results with better hidden scars. Some techniques may be associated, being carried out in a single surgical procedure. A well-structured surgical team leads to a reduced surgical time, which means higher safety for the patient. METHOD: We present a technique for standardization in the treatment of ex-obese patients that is performed in a single step, comprising mammoplasty (according to Pitanguy's technique or with placement of breast prosthesis), thoracoplasty (with the removal of excess skin on the side of the chest), and brachioplasty (performed with a rectilinear drawing at the lowest part of the arms). RESULTS: Seven cases were evaluated in terms of surgical time, location of the scars, and final shape and symmetry. The complications included partial dehiscence (14%) and hypertrophic scars (14%). The aesthetic result was satisfactory for 84% of the patients; on the other hand, the quality of cicatrization, keloid, and hypertrophic scars were the major causes of dissatisfaction. CONCLUSION: The use of the thoracobrachio-mammoplasty technique in a single surgical time was effective in the treatment of ex-obese patients, offering yet another option among other surgeries that these patients usually need.

Mioplastia en el tratamiento de fistulas broncopleurales / Myoplasty in the treatment of bronchopleural fistulas

Las fístulas broncopleurales posoperatorias asociadas o no a empiema constituyen una fuente importante de morbimortalidad en pacientes que han sufrido resecciones pulmonares, principalmente cuando se tratan enfermedades malignas. El objetivo de este artículo es revisar los resultados obtenidos en el tratamiento de 6 pacientes tratados entre 1997 y 2003. La operación previa fue neumonectomía derecha en 5 pacientes y lobectomía superior derecha en uno. Las causas de la operación fueron traumatismo, tumores benignos y malignos y tuberculosis. En los 6 pacientes se utilizó mioplastia con el dorsal ancho para la obliteración de la cavidad pleural remanente. Las técnicas complementarias comprendieron el uso de colgajos pediculados de músculo intercostal (3 pacientes), mioplastia con el músculo pectoral mayor y toracoplastia parcial en un paciente cada una. La complicación más frecuente fue la fuga aérea mantenida por más de 10 días. Todos los pacientes mantenían el cierre bronquial al año de la operación(AU)

The postoperative bronchopleural fistulas associated or not with empyema are an important source of morbimortality in patients that have suffered from pulmonary resections, mainly when malignant diseases are treated. The purpose of this article is to review the results obtained in the treatment of six patients from 1997 to 2003. The previous operation was right pneumonectomy in five patients and upper right lobectomy in one. The causes of the operation were traumatism, benign and malignant tumors and tuberculosis. In the six patients, it was used myoplasty with the wide dorsal for the obliteration of the remaining pleural cavity. The complementary techniques comprised the use of pedicled flaps of intercostal muscle (3 patients), myoplasty with the pectoralis major and partial thoracoplasty in a patient, each one. The most frequent complication was the aerial leakage maintained for more than ten days. All the patients kept the bronchial closure a year after the operation(AU)

Thoracoplasty: an obsolete procedure?

After the advent of chemotherapy for pulmonary tuberculosis, the operation of thoracoplasty became rare in the developed countries. However, this was not the case in developing countries like India. Between July 1992 and June 1997, we performed thoracoplasty in 139 patients. Indications of surgery were tubercular empyema (84 patients), pyogenic empyema (33 patients), post-operative empyema with bronchopleural fistula (8 patients), drug resistant pulmonary tuberculosis (2 patients) and recurrent haemoptysis (2 patients). Successful outcome in the form of control of sepsis, closure of bronchopleural fistula, sputum conversion and control of haemoptysis was achieved in most cases. There were four deaths in the entire series. We conclude that with the persisting problem of pulmonary tuberculosis in the developing countries, thoracoplasty is still an operation of continued relevance.

Cuando la retirada de la ventilación mecánica es dificultosa en la UCIP: caso clínico / When the weaning from mechanical ventilation is difficult in the UCIP: report of a case

Paciente de 22 meses que presenta como complicación postquirúrgica, de cirugía torácica, sección del nervio frénico derecho con la consiguiente parálisis hemidiafragmática. Se comentan algunos aspectos fisiopatológicos de tal afección y se discuten las estrategias ante un weaning dificultoso