Lung transplantation

Desde o primeiro transplante pulmonar bem sucedido na década de 80, essa se tornou uma terapia bem estabelecida para pacientes com pneumopatia crônica não-neoplásica em estágio terminal. São pacientes portadores de doença pulmonar obstrutiva crônica, fibrose pulmonar idiopática, fibrose cística e hipertensão pulmonar primária em um estágio no qual a terapia clínica não é mais efetiva. Atualmente, são cerca de 150 centros em todo o mundo realizando mais de 2500 transplantes de pulmão todo ano. O aprimoramento das técnicas cirúrgicas e anestésicas, bem como dos cuidados perioperatórios (terapia intensiva, imunossupressão, profilaxia de infecções) contribuíram para aumentar a sobrevida e a qualidade de vida dos pacientes transplantados. Nessa revisão, abordaremos os critérios de seleção de doadores e receptores, e as técnicas de preservação pulmonar atualmente utilizadas. Também discutiremos a técnica operatória adotada em nossa instituição para a extração e o implante dos órgãos. Por fim, citaremos as estatísticas mais recentes divulgadas pela International Society of Heart and Lung Transplantation, incluindo todos os transplantes realizados até o primeiro semestre de 2008.Since the first successful lung transplantation in the early 1980s, it has become the mainstay of therapy for patients with end-stage chronic non-neoplastic lung diseases. These are patients with chronic obstructive pulmonary disease, cystic fibrosis, idiopathic pulmonary fibrosis and primary pulmonary hypertension in an advanced stage with no effective response to medical therapy. Currently, there are about 150 centers around the world performing more than 2500 lung transplants each year. The improvement of surgical and anesthetic techniques, as well as perioperative care (intensive care, immunosuppression, infection prophylaxis) has contributed to increase survival and quality of life of lung recipients. In this review we will discuss the selection criteria of donors and recipients, and techniques of lung preservation currently used. We will also discuss the surgical technique adopted in our institution for harvesting and implantation of the lungs. Finally, we will quote the latest statistics released by the International Society of Heart and Lung Transplantation, including all transplants performed up to the first half of 2008

Clinical and haemodynamic evaluation of chronic thromboembolic pulmonary hypertension patients scheduled for pulmonary thromboendarterectomy. Is schistosomiasis hypertension an important confounding factor?

INTRODUCTION: Chronic thromboembolic pulmonary hypertension is a disease affecting approximately 4,000 people per year in the United States. The incidence rate in Brazil, however, is unknown. The estimated survival for patients with chronic thromboembolic pulmonary hypertension without treatment is approximately three years. Pulmonary thromboendarterectomy for select patients is a potentially curative procedure when correctly applied. In Brazil, the clinical and hemodynamic profiles of chronic thromboembolic pulmonary hypertension patients have yet to be described. OBJECTIVES: To evaluate the clinical and hemodynamic characteristics of chronic thromboembolic pulmonary hypertension patients scheduled for pulmonary thromboendarterectomy in a referral center for chronic thromboembolic pulmonary hypertension treatment in Brazil. METHODS: From December 2006 to November 2009, patients were evaluated and scheduled for pulmonary thromboendarterectomy. The subjects were classified according to gender, age and functional class and were tested for thrombofilia and brain natriuretic peptide levels. RESULTS: Thirty-five consecutive chronic thromboembolic pulmonary hypertension patients were evaluated. Two patients tested positive for schistosomiasis, and 31 were enrolled in the study (19 female, 12 male). The majority of patients were categorized in functional classes III and IV. Hemodynamic data showed a mean pulmonary vascular resistance (PVR) of 970.8 ± 494.36 dynas·s·cm-5 and a low cardiac output of 3.378 ± 1.13 L/min. Linear regression revealed a direct relation between cardiac output and pulmonary vascular resistance. Paradoxical septal movement was strongly correlated with pulmonary vascular resistance and cardiac output (p=0.001). Brain natriuretic peptide serum levels were elevated in 19 of 27 patients. CONCLUSIONS: In a referral center for pulmonary hypertension in Brazil, chronic thromboembolic pulmonary hypertension patients evaluated for pulmonary thromboendarterectomy had a hemodynamically severe status and had elevated brain natriuretic peptide serum levels. There was a predominance of females in our cohort, and the prevalence of hematological disorders and schistosomiasis was low (less than 10%)

Twenty Months of Evolution Following Sympathectomy on Patients with Palmar Hyperhidrosis: Sympathectomy at the T3 Level is Better than at the T2 Level

OBJECTIVE: To compare two surgical techniques (denervation levels) for sympathectomy using video-assisted thoracoscopy to treat palmar hyperhidrosis in the long-term. METHODS: From May 2003 to June 2006, 60 patients with palmar hyperhidrosis were prospectively randomized for video-assisted thoracoscopic sympathectomy at the T2 or T3 ganglion level. They were followed for a mean of 20 months and were evaluated regarding their degree of improvement of palmar hyperhidrosis, incidence and severity of compensatory hyperhidrosis and its evolution over time, and quality of life. RESULTS: Fifty-nine cases presented resolution of the palmar hyperhidrosis. One case of therapeutic failure occurred in the T3 group. Most of the patients presented an improvement in palmar hyperhidrosis, without any difference between the groups. Twenty months later, all patients in both groups presented some degree of compensatory hyperhidrosis but with less severity in the T3 group (p = 0.007). Compensatory hyperhidrosis developed in most patients during the first month after the operation, with incidence and severity that remained stable over time. An improvement in quality of life was seen starting from the first postoperative evaluation but without any difference between the groups. This improvement was maintained until the end of the follow-up. CONCLUSION: Both techniques were effective for treating palmar hyperhidrosis. The most frequent complication was compensatory hyperhidrosis, which presented stable incidence and severity over the study period. Sympathectomy at the T3 level presented compensatory hyperhidrosis with less severity. Nevertheless, the improvement in quality of life was similar between the groups

Endoscopic Lumbar Sympathectomy for Women: Effect on Compensatory Sweat

INTRODUCTION: Plantar hyperhidrosis is present in 50% of patients with hyperhidrosis. Thoracic sympathectomy is an important tool for the treatment of this condition, which is successful in about 60% of patients. For the remaining patients, lumbar sympathectomy is the procedure of choice. As new minimally invasive techniques have been developed, a significant demand for this type of access has led to its adaptation to the lumbar sympathectomy. The objective of this study was to evaluate the effectiveness of endoscopic retroperitoneal lumbar sympathectomy in controlling plantar hyperhidrosis and its effects on compensatory sweat. MATERIALS AND METHODS: Thirty female patients with persistent plantar hyperhidrosis after thoracic sympathectomy were enrolled. They were randomly assigned to laparoscopic retroperitoneal lumbar sympathectomy (Group A) or no surgical intervention (Group B - control) groups. Quality-of-life modifications were assessed by specific questionnaires before and after surgery. In the same manner, direct sweat measurements were also performed pre- and post-intervention by evaluating trans-epidermal water loss. Despite the lack of intervention, the control group was evaluated at similar timepoints. RESULTS: In Group A, no major complications occurred in the peri-operative period. During the immediate post-operative period, three patients (20%) experienced prolonged pain (more than ten days). Eight patients suffered from worsened compensatory sweating (53.3%). In Group A, after lumbar sympathectomy, the quality of life significantly improved (p<0.05, intra-group comparison) beyond that of the control group (p<0.05, inter-group comparison). Also, lumbar sympathectomy resulted in significantly lower values of foot sweat (pre- vs. post-operative periods, p<0.05; Group A vs. Group B, p<0.05). These patients also developed higher values of sweat measurements on specific points of their dorsal and abdominal regions after the procedure (p<0.05). CONCLUSIONS: The endoscopic retroperitoneal lumbar sympathectomy diminishes plantar sweat and improves the quality of life of women with plantar hyperhidrosis. However, about half of the patients develop increased compensatory hyperhidrosis in other areas of the body

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

Does aortic valve repair in valve-sparing aortic root reconstruction compromise the longevity of the procedure?

OBJECTIVES: The effect of performing aortic valve repair in combination with valve-sparing operation on the length of time for which patients are free from reoperation is unclear. The objective of this study was to determine if the performance of aortic valve repair during valve-sparing operation modified the freedom from reoperation time. METHODS: From January 2003 to July 2014, 78 patients with a mean age of 49±15 years underwent valve-sparing operation. Sixty-eight percent of these patients were male. Twenty-two (28%) aortic valve repair procedures were performed in this patient population. In the aortic valve repair + valve-sparing operation group, 77.3% of patients had moderate/severe aortic insufficiency, while in the valve-sparing operation group, 58.6% of patients had moderate/severe aortic insufficiency (ns = not significant). Additionally, 13.6% of patients in the aortic valve repair + valve-sparing operation group had functional class III/IV, while 14.2% of patients in the valve-sparing operation group had functional class III/IV (ns). RESULTS: The in-hospital and late mortality rates, for the aortic valve repair + valve-sparing operation and valve-sparing operation groups were similar, as they were 4.5% and 3.6%; and 0% and 1.8%, respectively. In the aortic valve repair + valve-sparing operation group, 0% of patients presented moderate/severe aortic insufficiency during late follow-up, while in the valve-sparing operation group, 14.2% of patients presented with moderate/severe aortic insufficiency during this period (ns). In the aortic valve repair + valve-sparing operation group, 5.3% of patients presented with functional class III/IV, while in the valve-sparing operation group, 4.2% of patients presented with functional class III/IV (ns). In the aortic valve repair + valve-sparing operation group, 0% of patients required reoperation, while in the valve-sparing operation group, 3.6% of patients required reoperation over a mean follow-up period of 1621±1156 days (75 patients). CONCLUSION: Valve-sparing operation is a safe and long-lasting procedure and performance of aortic valve repair when necessary does not increase risk of reoperation on the aortic valve

Lung transplantation waiting list in State of São Paulo: patients’ characteristics and predictors of death

Introdução: Atualmente, a alocação de pulmões no Brasil baseia-se, sobretudo,no tempo de espera em lista (Li) para transplante pulmonar (TxP). Objetivos: (1) Determinar operfi l dos pacientes em Li, e (2) Identifi car preditores de mortalidade em lista (PMLi). Casuísticae métodos: Analisamos os prontuários de 164 pacientes inscritos na Li por nosso serviço,de 2001 até 2008. Os PMLi foram obtidos por uma análise de riscos proporcionais de Cox.Resultados: Os pacientes foram inclusos na Li com 40,9 ± 15,7 anos, sobretudo por enfi sema(24,5%). Diagnóstico de enfi sema ou bronquiectasias (risco relativo [RR]=0,15; p=0,002), tempode tromboplastina parcial ativada &gt; 30 segundos (RR=3,28; p=0,002), albumina plasmática &gt;3,5 g/dl (RR=0,41; p=0,033) e saturação da hemoglobina &gt; 85% (RR=0,44; p=0,031) foramidentifi cados como PMLi. Conclusões: (1) Algumas variáveis podem predizer o risco de morteem Li para TxP; (2) Conhecer as características dos receptores de TxP é essencial para futurasmedidas de aprimoramento dos critérios de alocação de TxP.Introduction: Nowadays, lung allocation in Brazil is based mainly on waitingtime while on list (Li) for lung transplantation (LTx). Objectives: (1) To determine the profi leof the patients on Li; (2) To identify predictors of death on list (PDLi). Casuistic and methods:We analysed medical records of 164 patients inscribed on Li by our service, from 2001 to2008. The PDLi were obtained through Cox proportional hazards analyses. Results: Patientswere included onto Li with mean age of 40,9 ± 15,7 years, maily due to emphysema (24,5%).Diagnosis of emphysema or bronquiectasis (relative risk [RR]=0,15; p=0,002), activated partialthromboplastin time &gt; 30 seconds (RR=3,28; p=0,002), plasma albumin (RR=0,44; p=0,033)and hemoglobin saturation &gt; 85% (RR=0,44; p=0,031) were identifi ed as PDLi. Conclusions: (1)Some variables can predict probability of death on Li; (2) To know LTx recipients’ characteristicsis essential for future actions driven at improving LTx allocation criteria