Enhanced recovery after surgery (ERAS®) protocol adapted to the Brazilian reality: a prospective cohort study for thoracic patients.

BACKGROUND: In Low-Middle Income Countries (LMICs), resource optimization and infrastructure availability are recurrently in debate. In order to assist the development and implementation of guidelines, LMICs often exemplify from High-Income Countries protocols. At the final, it will be: content adaption is often needed. In this study, we demonstrated the preliminary analysis of the Brazilian experience by adapting the ERAS® Protocol for thoracic surgery patients (PROSM). METHODS: Patients' data were extracted from the surgical group database that operated in the city of Sao Paulo. Patients' data were organized for analysis after the institution's ethics committee gave their approval. Patients' variables were analyzed and compared to a control group. Subgroup analysis included patients without ICU Admission. RESULTS: PROSM patients had reduced ICU length of stay (LOS) (Mean of 0.3±0.58 days, 1.2±1.65 days, P=0.001), Hospital LOS (Mean of 1.6±1.32 days, 3.9±3.25 days, P=0.001) and Chest Drain duration (Median 1.0±1.00 days, 3.0±3.00 days, P=0.001). Analyses of patients that were not admitted to the ICU demonstrated reduced Hospital LOS and Chest drain duration. Cost analysis, such as procedure, daily, and post-surgical costs were also significantly lower towards PROSM group. CONCLUSIONS: This study revealed important aspects for improvement of the delivered care quality and opportunity for expenditure management. We expect to assist more countries to improve knowledge under the implementation of enhanced protocols.

Histomorphometric evaluation of the Ki-67 proliferation rate and CD34 microvascular and D2-40 lymphovascular densities drives the pulmonary typical carcinoid outcome.

Ki-67 has shown promise as a prognostic factor in pulmonary carcinoids. In this study, we sought to validate the importance of Ki-67 and study the relationships between Ki-67 and other stromal biomarkers of vascular density. We examined Ki-67, CD34, and D2-40 in tumor tissues from 128 patients with surgically excised typical carcinoid of the lung. We used immunohistochemistry and morphometry to evaluate the amount of tumor staining for cellular proliferation (Ki-67), microvascular density (CD34-MVD), and D2-40 lymphovascular density. The main outcome was overall survival, considered as life expectancy until death from metastasis. Specimens from patients with central tumors showed high CD34-MVD (P = .01), which was also significantly associated with a compromised surgical margin, lymph node metastasis, and clinical stage Ib. Equally significant was high D2-40 lymphovascular density in central specimens with a compromised surgical margin and lymph node metastasis. A high Ki-67 proliferation rate was significantly associated with tumors from patients with clinical stage IIb, IIIa, and IV disease. Multivariate Cox model analysis demonstrated that tumor location and stage, surgical margin, tumor size, and N stage were significantly related to survival time (P < .05). Quantitative staining of the tumor for Ki-67 and CD34-MVD served as prognostic factors (P < .05), which were more relevant than the surgical and pathological stage. Ki-67 greater than 5% and CD34-MVD greater than 7% staining comprise a subset of patients with higher death hazard; this outcome may harbor evidence for further prospective studies of target therapy after surgical resection.

Left ventricular chamber geometry in cardiomyopathies: insights from a computerized anatomical study.

AIMS: Some authors have hypothesized that left ventricular chamber dilatation in ischaemic and idiopathic cardiomyopathies results in spherical transformation. Aiming to characterize how this transformation occurs, a study was performed by comparing normal and dilated specimens regarding sphericity and proportionality in left heart chambers. It is important to provide data for the development of therapeutic strategies in these diseases. METHODS AND RESULTS: An anatomical study was performed by comparing normal (n = 10), ischaemic (n = 15), and idiopathic (n = 18) dilated human cardiomyopathic specimens regarding left ventricular chambers and their segmental proportionality to normal hearts. It was performed by capturing and processing images with proper software in three different levels of left ventricular chamber (basal, equatorial, and apical). These obtained data were analysed based on sphericity and proportionality by two dedicated indexes. Spherical shape: Calculated segmental indexes showed that dilated specimens were not spherical because they were smaller than as expected for a spherical shape (all values were <70% of a perfect sphere). Proportionality: There was no difference between basal index perimeters among groups, but apical index was lower in dilated specimens than in normal hearts, and so dilatation was not proportional to normal hearts. CONCLUSIONS: Left ventricular chambers of anatomical specimens with dilated cardiomyopathies did not display a spherical shape and were not proportional to normal hearts.

Uniportal video-assisted thoracic surgery course in Mexico-first experience.

"The First Minimally Invasive Thoracic Surgery Uniportal Course" in Mexico was held from July 13th to 15th in Mexico City, at the National Institute of Respiratory Diseases (INER). Thoracic surgeons from around Mexico assisted the course. The special guests were the Spanish doctor Diego González-Rivas and the Brasilian doctor Joao Carlos das Neves-Pereira. The course included live surgery and wet lab. Demonstration of the uniportal video-assisted thoracic surgery (VATS) technique was done. The course was a success and Mexican thoracic surgeons were ready to adopt this technique.

Nutritional status and postoperative outcome after pneumonectomy for lung cancer.

BACKGROUND: The influence of nutritional status on outcome after major lung resection remains controversial. Nutritional assessment is not included as a major recommendation in lung cancer guidelines. The purpose of this study was to assess the nutritional status of patients referred for pneumonectomy and to assess the predictive value of malnutrition in determining the surgical outcome. METHODS: This study was a multicenter observational trial. The eligibility criterion for participants was pneumonectomy for lung cancer. Criteria for group classification according to nutritional status were albumin and transthyretin levels. Predicted outcomes were major infectious and noninfectious complications and 90-day mortality. Univariate analysis identified independent variables for the predictive model of age, sex, induction chemotherapy, extended resections, treatment side, smoking, and malnutrition. Predictive variables were then included in a logistic regression model. RESULTS: Between January 2010 and December 2011, 86 (mean age, 61.5 years) consecutive patients referred for pneumonectomy (left side, n = 58; right side, n = 28) at 4 thoracic surgery centers were included. The malnutrition group included 33 patients (39%) and the normal nutritional status group included 53 patients. Univariate analysis elected malnutrition, recent active smoking, and extended resection to be included in a multivariate analysis. Multivariate analysis identified malnutrition, recent smoking, and extended resection as predictive variables for major complications and mortality. CONCLUSIONS: The frequency of malnutrition detected by biological markers was dramatically high. Malnutrition, as well as recent active smoking and extended resection, is a predictive factor for infectious complications and mortality after pneumonectomy. Nutritional assessment with appropriate markers should be considered before pneumonectomy.

Preservation of α-3 neuronal nicotinic acetylcholine receptor expression in sympathetic ganglia after brain death.

The goal of this study was to evaluate if the immunohistochemical expression of alpha-3 neuronal nicotinic acetylcholine receptor subunit in sympathetic ganglia remains stable after brain death, determining the possible use of sympathetic thoracic ganglia from subjects after brain death as study group. The third left sympathetic ganglion was resected from patients divided in two groups: BD-organ donors after brain death and CON-patients submitted to sympathectomy for hyperhidrosis (control group). Immunohistochemical staining for alpha-3 neuronal nicotinic acetylcholine receptor subunit was performed; strong and weak expression areas were quantified in both groups. The BD group showed strong alpha-3 neuronal nicotinic acetylcholine receptor expression in 6.55% of the total area, whereas the CON group showed strong expression in 5.91% (p = 0.78). Weak expression was found in 6.47% of brain-dead subjects and in 7.23% of control subjects (p = 0.31). Brain death did not affect the results of the immunohistochemical analysis of sympathetic ganglia, and its use as study group is feasible.

Lung cancer invading the fissure to the adjacent lobe: more a question of spreading mode than a staging problem.

OBJECTIVES: Lung cancer invading beyond the interlobar pleura, classified as T2a in the new TNM, is a rare entity with a poor outcome. Our purpose was a better understanding of the mechanisms of this particular behaviour and its prognostic value. METHODS: Patients who underwent surgery between 1984 and 2007 were reviewed. We focused on T1 and T2 tumours. Tumours not traversing the pleural elastic layer were defined as PL0, extending through the layer as PL1 and extending to the surface of the visceral pleura as PL2. We considered three groups: group 1, tumours invading the lobar fissure, group 2, PL0-tumours and group 3, PL1 + PL2 tumours and studied their pathology and prognostic characteristics. RESULTS: The distribution was as follows: group 1 n = 154, group 2 n = 2310 and group 3 n = 651. Pneumonectomy was necessary in 55.2% and bilobectomy in 19.5% of group 1, and N-involvement was present in 55.8% (significantly more than other groups). The mean tumour size (42.7 ± 12 mm) was bigger in group 1. Post-operative mortality was as follows: -5.2, -3.5 and 3.2% in groups 1, 2 and 3, respectively (P = 0.49). Five-year survival rates were: group 1: 38.9%, group 2: 52.5% and group 3: 43.4%; P = 0.00002. Survival was not different between groups concerning pN1 and pN2, but poorer in groups 1 and 3 than in group 2 in pN0 patients, P = 0.0057. Survival was 48.1, 37.9 and 38.4% for tumours between 31 and 70 mm in groups 2, 1 and 3, respectively, P = 0.0024 (but P = 0.65 between groups 1 and 3). Pneumonectomy was a poor prognostic factor in all groups, but survival between pneumonectomy and bilobectomy was not different in group 1. Multivariate analysis confirmed intralobar invasion to be an independent factor of poor prognosis, as well as visceral pleura invasion. CONCLUSIONS: Tumours invading through the fissure have a significant effect on long-term survival in the first stages of lung cancer but also in all stages because of their size and important locoregional spread. Their prognostic value is due to pleural invasion, whose role in lung cancer dissemination is worth further research.

The search for stability: bar displacement in three series of pectus excavatum patients treated with the Nuss technique.

OBJECTIVES: To compare bar displacement and complication rates in three retrospective series of patients operated on by the same surgical team. METHOD: A retrospective medical chart analysis of the three patient series was performed. In the first series, the original, unmodified Nuss technique was performed. In the second, we used the ''third point fixation'' technique,and in the last series, the correction was performed with modifications to the stabilizer and stabilizer position. RESULTS: There were no deaths in any of the series. Minor complications occurred in six (4.9%) patients: pneumothorax with spontaneous resolution (2), suture site infection (2), and bar displacement without the reoperation need (2). Major complications were observed in eight (6.5%) patients: pleural effusion requiring drainage (1), foreign body reaction to the bar (1), pneumonia and shock septic (1), cardiac perforation (1), skin erosion/seroma (1), and displacement that necessitated a second operation to remove the bar within the 30 days of implantation (3). All major complications occurred in the first and second series. CONCLUSION: The elimination of fixation wires, the use of shorter bars and redesigned stabilizers placed in a more medial position results in a better outcome for pectus excavatum patients treated with the Nuss technique. With bar displacement and instability no longer significant postoperative risks, the Nuss technique should be considered among the available options for the surgical correction of pectus excavatum in pediatric patients.

Factors affecting long-term satisfaction after thoracic sympathectomy for palmar and plantar hyperhidrosis. Is the sudomotor reflex the only villain?

The main objective of this study was to determine if there are variations in the level of improvement of the palmar and plantar hyperhidrotic symptoms, as well as the incidence and intensity of the sudomotor reflex, throughout the seasons of the year, after thoracic sympathectomy for hyperhidrosis. The study also looks for the real impact of these variables in the long-term satisfaction. A cohort of 75 patients was followed through distinct seasons. A multivariate analysis was performed to identify possible variables responsible for dissatisfaction. Both the palmar (P=0.002) and plantar (P<0.001) symptoms and the presence and the intensity of the sudomotor reflex varies significantly throughout the seasons of the year. The sudomotor reflex was the main factor associated with low satisfaction in our patients in the summer (P=0.025) and winter (P<0.001) but in spring the lack of improvement in the hyperhidrosis in the foot was the unique factor related to dissatisfaction (P<0.001). The sudomotor reflex is the main negative factor in the summer and in the winter, independent of its intensity. However, at least in spring, the lack of removal of the plantar symptoms had a negative impact on satisfaction.

The search for stability: bar displacement in three series of pectus excavatum patients treated with the Nuss technique

OBJECTIVES: To compare bar displacement and complication rates in three retrospective series of patients operated on by the same surgical team. METHOD: A retrospective medical chart analysis of the three patient series was performed. In the first series, the original, unmodified Nuss technique was performed. In the second, we used the ''third point fixation'' technique,and in the last series, the correction was performed with modifications to the stabilizer and stabilizer position. RESULTS: There were no deaths in any of the series. Minor complications occurred in six (4.9 percent) patients: pneumothorax with spontaneous resolution (2), suture site infection (2), and bar displacement without the reoperation need (2). Major complications were observed in eight (6.5 percent) patients: pleural effusion requiring drainage (1), foreign body reaction to the bar (1), pneumonia and shock septic (1), cardiac perforation (1), skin erosion/seroma (1), and displacement that necessitated a second operation to remove the bar within the 30 days of implantation (3). All major complications occurred in the first and second series. CONCLUSION: The elimination of fixation wires, the use of shorter bars and redesigned stabilizers placed in a more medial position results in a better outcome for pectus excavatum patients treated with the Nuss technique. With bar displacement and instability no longer significant postoperative risks, the Nuss technique should be considered among the available options for the surgical correction of pectus excavatum in pediatric patients.

Intercostal-subcostal combined complete port-accessed video-assisted lobectomy.

Video-assisted lobectomy procedures include a broad spectrum of operative techniques that range from complete thoracoscopic surgery to minithoracotomy with a thoracoscope serving only as a light source. We describe a modified method for thoracoscopic approach for lobectomy with thoracic muscle sparing based on a combined complete port-accessed technique with a subcostal incision. We have successfully used this technique for lobectomies in stage I lung tumors. Intercostal muscles and nerve injury preservation allied to fast track rehabilitation perioperative care allowed rapid postoperative recovery.

Thoracoscopic approach in the treatment of breast cancer relapse in the internal mammary lymph node.

Regional recurrence of breast cancer may involve the surgical site of mastectomy, axillary lymph nodes and the internal mammary lymphatic chain. Treatment of regional recurrent mammary cancer rarely requires thoracic surgery intervention, except in some selected cases of recurrence in the chest wall. Concerning lymphatic recurrence in breast cancer, the therapeutic choice rarely includes surgical lymph node excision. Exclusive videothoracoscopic (VTS) resection of recurrence in internal mammary lymph nodes has not as yet been reported in the literature. Due to the rare surgical exploration of this lymphatic chain, the thoracoscopic approach is described only in three published studies involving humans, furthermore, in these three descriptions, the operation was performed only for mere staging but not for the whole resection of the recurrent lymphatic structure. We present a case of recurrence of breast cancer in lymph nodes of the internal mammary chain that was treated with complete resection by pure VTS surgery.

Technical modifications in stabilisers and in bar removal in the Nuss procedure.

Pectus excavatum is a congenital deformity that can require surgical treatment. Since Nuss proposed a correction technique, several modifications have been proposed in order to achieve more safety and efficiency in the placement and removal of both bars. Our objective is to describe the technique of placing and removing the bars by proposing three technical modifications: two in bar placement and one in the bar removal. We describe two cases where Nuss bars were placed and one case where the bar was removed as per the technical modification proposed herein. According to the original technique, bar stabilisers were placed close to the lateral bar edges. We propose a more medial position in order to reduce bar displacement. New stabilisers were designed with central grooves in the posterior surface, which allow better sliding. The technical modification suitable for bar removal was the use of a protective film around the bars to protect the surrounding tissues from the sharp edges, and thereby minimise the risk of injuries. All the proposed modifications were performed without any additional surgical risk or perioperative complication. These three technical modifications can be easily and safely performed, and seem to reduce the risk of bleeding with no additional perioperative complications.

Prosthesis for open pleurostomy (POP): management for chronic empyemas.

OBJECTIVES: We developed a prosthesis for open pleurostomy cases where pulmonary decortication is not indicated, or where post-pneumonectomy space infection occurs. The open pleural window procedure not only creates a large hole in the chest wall that is shocking to patients, also results in a permanent deformation of the thorax. prosthesis for open pleurostomy is a self-retained silicone tube that requires the removal of 3 cm of one rib for insertion, and acts as a mature conventional open pleural window. Herein, we report our 13-year experience with this device in the management of different kinds of pleural empyema. METHODS: Forty-four consecutive patients with chronic empyema were treated. The etiology of empyema was diverse: pneumonia, 20; lung resections, 12 (pneumonectomies, 7; lobectomies, 4; non-anatomical, 1); mixed-tuberculous, 6; and mixed-malignant pleural effusion, 6. After debridement of both pleural surfaces, the prosthesis for open pleurostomy was inserted and attached to a small recipient plastic bag. RESULTS: Infection control was achieved in 20/20 (100%) of the parapneumonic empyemas, in 3/4 (75%) of post-lobectomies, in 6/7 (85%) of post-pneumonectomies, in 6/6 (100%) of mixed-tuberculous cases, and in 4/6 (83%) of mixed-malignant cases. Lung re-expansion was also successful in 93%, 75%, 33%, and 40% of the groups, respectively CONCLUSIONS: Prosthesis for open pleurostomy insertion is a minimally invasive procedure that can be as effective as conventional open pleural window for management of chronic empyemas. Thus, we propose that the use of prosthesis for open pleurostomy should replace the conventional method.

Fast-track rehabilitation for lung cancer lobectomy: a five-year experience.

OBJECTIVE: Fast-track rehabilitation is a group of simple measures that reduces morbidity, postoperative complication and accelerates postoperative rehabilitation reducing hospital stay. It can be applied to lung cancer lobectomy. Fast-track rehabilitation cornerstones are: minimally invasive surgical techniques using video-assisted and muscle sparring incisions, normovolemia, normothermia, good oxygenation, euglicemia, no unnecessary antibiotics, epidural patient-controlled analgesia, systemic opiods-free analgesia, early ambulation and oral feeding. Our objective is to describe a five-year experience with fast-track rehabilitation for lung cancer lobectomy. PATIENTS AND METHODS: A retrospective non-controlled study including 109 consecutive patients submitted to fast-track rehabilitation in the postoperative care of lung cancer lobectomy was performed. Only collaborative patients who could receive double-lumen intubation, epidural catheters with patient-controlled analgesia, who had Karnofsky index of 100, previous normal feeding and ambulation, absence of morbid obesity, diabetes or asthma, were eligible. Postoperative oral feeding and aggressive ambulation started as soon as possible. RESULTS: Immediate postoperative extubation even in the operation room was possible in 107 patients and oral feeding and ambulation were possible before the first hour in 101 patients. Six patients could not receive early oral feeding or ambulate due to hypnosis secondary to preoperative long effect benzodiazepines. Two patients could not ambulate immediately due to epidural catheter misplacement with important postoperative pain. Ninety-nine discharges occurred at the second postoperative day, four of them with a chest tube connected to a Heimlich valve due to air leak. No complication of early feeding and ambulation was observed. Postoperative hypnosis due to long duration benzodiazepines or pain does not allow early oral feeding or ambulation. Avoiding long duration preoperative benzodiazepines, immediate postoperative extubation, regional thoracic PCA and early oral feeding and ambulation were related to a lesser frequency of complication and a shorter hospital stay. CONCLUSION: Fast-track rehabilitation for lung cancer lobectomies can be safely performed in a selected group of patients if a motivated multidisciplinary group of professionals is available and seems to reduce postoperative complication and hospital stay.

Twenty seven-year experience with sternal cleft repair.

Congenital sternal cleft is a rare disease, and primary repair in the neonatal period is its best management. In 1998 we presented three surgical techniques for sternal cleft correction, but since 1999 we have elected one of them as our procedure of choice. Our latest results are now presented. It is a review of 15 patients operated from October 1979 to December 2007. Surgical repair consisted of 3 sliding chondrotomies, 10 reconstructions based on a 'posterior sternal wall', 1 reconstruction combined to Ravitch operation for pectus excavatum and 1 associated with total repair of Cantrell's pentalogy. Data concerning epidemiological features, surgical reconstruction, aesthetic results, postoperative major complications, mortality and hospital stay, were collected from hospital charts. Follow-up ranged from 4 months to 27 years. All patients submitted to surgical correction had a good aesthetic and functional result. Neither postoperative mortality nor major complication was observed. Two patients had subcutaneous fluid collection that prolonged the drainage duration. The mean hospital stay was 6 days. In conclusion, reconstructing sternal cleft with a 'posterior periosteal flap from sternal bars and chondral graft' is an effective option with good aesthetic and long-term functional results.

Robotic versus human camera holding in video-assisted thoracic sympathectomy: a single blind randomized trial of efficacy and safety.

Our objective is to compare surgical safety and efficacy between robotic and human camera control in video-assisted thoracic sympathectomy. A randomized-controlled-trial was performed. Surgical operation was VATS sympathectomy for hyperhidrosis. The trial compared a voice-controlled robot for holding the endoscopic camera robotic group (Ro) to human assisted group (Hu). Each group included 19 patients. Sympathectomy was achieved by electrodessication of the third ganglion. Operations were filmed and images stored. Two observers quantified the number of involuntary and inappropriate movements and how many times the camera was cleaned. Safety criteria were surgical accidents, pain and aesthetical results; efficacy criteria were: surgical and camera use duration, anhydrosis, length of hospitalization, compensatory hyperhidrosis and patient satisfaction. There was no difference between groups regarding surgical accidents, number of involuntary movements, pain, aesthetical results, general satisfaction, number of lens cleaning, anhydrosis, length of hospitalization, and compensatory hyperhidrosis. The number of contacts of the laparoscopic lens with mediastinal structures was lower in the Ro group (P<0.001), but the total and surgical length was longer in this group (P<0.001). Camera holding by a robotic arm in VATS sympathectomy for hyperhidrosis is as safe but less efficient when compared to a human camera-holding assistant.

Individual risk prediction of nodal and distant metastasis for patients with typical bronchial carcinoid tumors.

OBJECTIVE: Bronchial typical carcinoid tumors are low-grade malignancies. However, metastases are diagnosed in some patients. Predicting the individual risk of these metastases to determine patients eligible for a radical lymphadenectomy and patients to be followed-up because of distant metastasis risk is relevant. Our objective was to screen for predictive criteria of bronchial typical carcinoid tumor aggressiveness based on a logistic regression model using clinical, pathological and biomolecular data. METHODS: A multicenter retrospective cohort study, including 330 consecutive patients operated on for bronchial typical carcinoid tumors and followed-up during a period more than 10 years in two university hospitals was performed. Selected data to predict the individual risk for both nodal and distant metastasis were: age, gender, TNM staging, tumor diameter and location (central/peripheral), tumor immunostaining index of p53 and Ki67, Bcl2 and the extracellular density of neoformed microvessels and of collagen/elastic extracellular fibers. RESULTS: Nodal and distant metastasis incidence was 11% and 5%, respectively. Univariate analysis identified all the studied biomarkers as related to nodal metastasis. Multivariate analysis identified a predictive variable for nodal metastasis: neo angiogenesis, quantified by the neoformed pathological microvessels density. Distant metastasis was related to male gender. DISCUSSION: Predictive models based on clinical and biomolecular data could be used to predict individual risk for metastasis. Patients under a high individual risk for lymph node metastasis should be considered as candidates to mediastinal lymphadenectomy. Those under a high risk of distant metastasis should be followed-up as having an aggressive disease. CONCLUSION: Individual risk prediction of bronchial typical carcinoid tumor metastasis for patients operated on can be calculated in function of biomolecular data. Prediction models can detect high-risk patients and help surgeons to identify patients requiring radical lymphadenectomy and help oncologists to identify those as having an aggressive disease requiring prolonged follow-up.

Left upper lobe pulmonary sequestration.

A 64-year-old non-smoking woman with a left upper lobe mass underwent a wedge resection by video-thoracoscopic approach. Intraoperative frozen section examination was unable to rule out a neoplastic disease and a lobectomy was performed. Microscopic analysis showed a typical pulmonary sequestration pattern including arteries with elastic layers in a systemic fashion. Pulmonary sequestration is a development lung disease: upper lobe location is considered uncommon and much controversy exists concerning this form which may be underrated.