Complicações do cateter de artéria pulmonar: relato de caso de formação de nó verdadeiro revisão da literatura

A particular event concerning a Swan-Ganz catheter complication is reported. A 41-year-old woman was admitted at the emergency room of our hospital with massive gastrointestinal bleeding. A total gastrectomy was performed. During the postoperative period in the intensive care unit , the patient maintained hemodynamic instability. Invasive hemodynamic monitoring with a pulmonary artery catheter was then indicated. During the maneuvers to insert the catheter, a true knot formation was identified at the level of the superior vena cava. Several maneuvers by radiological endovascular invasive techniques allowed removal of the catheter. The authors describe the details of this procedure and provide comments regarding the various techniques that were employed in overcoming this event. A comprehensive review of evidence regarding the benefits and risks of pulmonary artery catheterization was performed. The consensus statement regarding the indications, utilization, and management of the pulmonary artery catheterization that were issued by a consensus conference held in 1996 are also discussed in detail.É relatada uma complicação infreqüente , associada ao uso do Cateter de Artéria Pulmonar. Uma paciente de 41 anos foi admitida no Pronto Socorro do nosso hospital com hemorragia digestiva alta grave. A doente foi submetida à gastrectomia total. Na Unidade de Terapia Intensiva, evoluiu com instabilidade hemodinâmica, sendo indicada a monitorização hemodinâmica invasiva com cateter de artéria pulmonar. Durante as manobras para o correto posicionamento do cateter na artéria pulmonar, foi diagnosticado formação de nó verdadeiro, ao nível da veia cava superior. Os autores discutem as várias opções técnicas empregadas para a resolução desta complicação, através do emprego da radiologia intervencionista endovascular. Extensa revisão da literatura procurando discutir os benefícios e riscos envolvidos na monitorização hemodinâmica invasiva com o cateter de artéria pulmonar, no período peroperatório, foi realizada. Assim como as orientações práticas emitidas pela Conferência de Consenso sobre o cateter de artéria pulmonar, realizada nos EUA em 1996, são discutidas com profundidade

Insuficiência renal aguda secundária à síndrome compartimental abdominal: relato de quatro casos e revisão da literatura

We report on 4 cases of abdominal compartment syndrome complicated by acute renal failure that were promptly reversed by different abdominal decompression methods. Case 1: A 57-year-old obese woman in the post-operative period after giant incisional hernia correction with an intra-abdominal pressure of 24 mm Hg. She was sedated and curarized, and the intra-abdominal pressure fell to 15 mm Hg. Case 2: A 73-year-old woman with acute inflammatory abdomen was undergoing exploratory laparotomy when a hypertensive pneumoperitoneum was noticed. During the surgery, enhancement of urinary output was observed. Case 3: An 18-year-old man who underwent hepatectomy and developed coagulopathy and hepatic bleeding that required abdominal packing, developed oliguria with a transvesical intra-abdominal pressure of 22 mm Hg. During reoperation, the compresses were removed with a prompt improvement in urinary flow. Case 4: A 46-year-old man with hepatic cirrhosis was admitted after incisional hernia repair with intra-abdominal pressure of 16 mm Hg. After paracentesis, the intra-abdominal pressure fell to 11 mm Hg.Descrevemos quatro casos de síndrome compartimental abdominal complicadas por insuficiência renal aguda e prontamente revertidas por diferentes métodos de descompressão abdominal. Caso 1: paciente obesa de 57 anos no pós-operatório de correção de hérnia incisional gigante com pressão intra-abdominal de 24 mm Hg. Após sedação e curarização, a PIA caiu para 15 mm Hg. Caso 2: paciente de 73 anos com abdômem agudo inflamatório submetida à laparotomia exploradora quando foi diagnosticado pneumoperitôneo hipertensivo. Durante a cirurgia houve melhora da diurese. Caso 3: paciente de 18 anos submetido a hepactetomia apresentou coagulopatia e sangramento hepático necessitando tamponamento com compressas, evoluindo com oligúria e PIA de 22 mm Hg. Na reoperação, após remoção das compressas houve melhora importante do fluxo urinário. Caso 4: paciente de 46 anos com cirrose hepática foi admitido após correção de hérnia incisional com pressão intra-abdominal de 16 mm Hg. Após paracentese, a pressão intra-abdominal caiu para 11 mm Hg

Screening protocol for dysphagia in adults: comparison with videofluoroscopic findings

OBJECTIVES: To compare the videofluoroscopic findings of patients with suspected oropharyngeal dysphagia with the results of a clinical screening protocol. METHODS: A retrospective observational cohort study was conducted on all consecutive patients with suspected oropharyngeal dysphagia between March 2015 and February 2016 who were assigned to receive a videofluoroscopic assessment of swallowing. All patients were first submitted to videofluoroscopy and then to the clinical assessment of swallowing. The clinical assessment was performed within the first 24 hours after videofluoroscopy. The videofluoroscopy results were analyzed regarding penetration/aspiration using an 8-point multidimensional perceptual scale. The accuracy of the clinical protocol was analyzed using the sensitivity, specificity, likelihood ratios and predictive values. RESULTS: The selected sample consisted of 50 patients. The clinical protocol presented a sensitivity of 50% and specificity of 95%, with an accuracy of 88%. “Cough” and “wet-hoarse” vocal quality after/during swallowing were clinical indicators that appeared to correctly identify the presence of penetration/aspiration risk. CONCLUSION: The clinical protocol used in the present study is a simple, rapid and reliable clinical assessment. Despite the absence of a completely satisfactory result, especially in terms of the sensitivity and positive predictive values, we suggest that lower rates of pneumonia can be achieved using a formal dysphagia screening method

Fasceite necrotizante cervical secundária a amigdalite bacteriana

A fasceite necrotizante cervical é uma infecção grave de partes moles do pescoço. Trata-se de entidade rara, porém quando presente tem como principal origem um foco infeccioso odontogênico. São descritos 4 casos de fasceite necrotizante cervical a partir de tonsilites e abscesso peritonsilar, os quais, foram admitidos e tratados na unidade de terapia intensiva. Um dos pacientes era portador de Diabetes Melittus não insulino- dependente e outro paciente havia recebido corticoterapia antes do desenvolvimento da infecção. Em um dos casos ocorreu mediastinite, insuficiência respiratória e o paciente evolui para o óbito em decorrência de choque séptico. Durante o tratamento, 3 pacientes evoluíram satisfatoriamente devido ao diagnostico precoce, tratamento cirúrgico agressivo e utilização de antibiótico terapia de largo espectro. A bactéria mais comumente encontrada foi o Streptococcus sp, mas flora mista com germes anaeróbios foi encontrada em 3 dos casos descritos. CONCLUSÕES: Deve-se suspeitar de tonsilite e abscesso peritonsilar como causa de fasceite necrotizante cervical para que tratamento agressivo e precoce seja realizado.Necrotizing fasciitis is a severe and potentially fatal soft tissue infection, but involvement of the head and neck is rare. We report on 4 cases of cervical necrotizing fasciitis arising from tonsillitis. One patient was diabetic and one had received steroids before disease development. One patient developed acute respiratory failure and died of septic shock. Three patients recovered, helped by early recognition, aggressive surgical intervention, appropriate broad-spectrum antibiotics, and supportive therapy. The common bacteria found in all abscess samples were Streptococcus sp., but mixed flora with anaerobic organisms was seen in all but 1 case. Tonsillitis and peritonsillar abscess must be suspected as a cause of cervical necrotizing fasciitis and a successful result can be achieved with immediate aggressive treatment

The influence of tumor invasion in anastomotic line on survival of patient with gastric stump cancer

RACIONAL: O câncer do coto gástrico desenvolve- se no remanescente gástrico de gastrectomia realizada há pelo menos 5 anos por doença benigna e os sítios mais comuns de acometimento são próximo à anastomose e na pequena curvatura. Considera-se que o coto gástrico é estado pré-canceroso. OBJETIVOS: Identificar o padrão de disseminação de linfonodos acometidos, quantificar a invasão tumoral da linha de anastomose e correlacionar: a invasão da linha de anastomose com o comprometimento linfonodal e mesenterial, o acometimento linfonodal com sobrevivência e o acometimento da linha de anastomose com sobrevivência. MÉTODOS: Estudo retrospectivo com revisão de prontuários, peças cirúrgicas e exames anátomo-patológicos de 113 pacientes com diagnóstico de câncer de coto gástrico definido como adenocarcinoma desenvolvido no remanescente gástrico de gastrectomia realizada há pelo menos cinco anos por doença benigna. RESULTADOS: A disseminação linfonodal não se mostrou específica; 75% dos pacientes apresentaram invasão tumoral da linha de anastomose; em 66,7% dos casos ocorreu invasão da linha anastomótica e linfonodal concomitantes; menos de 10% dos casos exibiam invasão mesenterial; houve óbito em 86,5% dos casos com invasão linfonodal e 64,7% com invasão da linha de anastomose e em 100% com invasão mesenterial. CONCLUSÕES: 1) O câncer de coto gástrico não tem padrão de disseminação linfonodal específico; 2) a linha de anastomose sofre freqüente invasão tumoral; 3) apesar de freqüente a invasão da linha anastomótica, não apresenta correlação estatística significante com o comprometimento linfonodal regional ou mesenterial; 4) a presença de invasão linfonodal implica em sobrevida menor, em especial a de linfonodos do mesentério; 5) a presença de acometimento neoplásico da linha anastomótica não se correlaciona com pior resultado de sobrevivência.AIM: To identify the lymph node metastatic pattern for gastric stump cancer; to quantify the anastomotic site invasion by tumor growth; to correlate the invasion of anastomotic site with metastasis in lymph node in general and mesenterial lymph node involvement and the survival. METHODS: One hundred and thirteen patients with gastric stump cancer were retrospectively analyzed along with their medical records, surgical specimens and histopathologic exams. RESULTS: seventy five percent of patients had tumoral invasion in the anastomotic site. In 66.7% there was invasion of the anastomotic site with metastatic lymph nodes. Nine percent had mesenterial lymph node invasion. Fatal cases occurred in 86,5% with metastatic lymph node, 64,7% with invasion of the anastomotic site and 100% with mesenterial lymph node invasion. CONCLUSIONS: Metastatic lymph node dissemination is not specific to gastric stump cancer and does not present a pattern in the lymph node dissemination. Although frequent the tumor invasion in anastomotic line, there is no significant statistical correlation with the invasion of regional or mesenterial lymph nodes. Lymph node invasion reduces survival, mainly when mesenterial lymph node dissemination is present. Tumor invasion in anastomotic line does not reduce survival

Clinical dysphagia risk predictors after prolonged orotracheal intubation

OBJECTIVES: To elucidate independent risk factors for dysphagia after prolonged orotracheal intubation. METHODS: The participants were 148 consecutive patients who underwent clinical bedside swallowing assessments from September 2009 to September 2011. All patients had received prolonged orotracheal intubations and were admitted to one of several intensive care units of a large Brazilian school hospital. The correlations between the conducted water swallow test results and dysphagia risk levels were analyzed for statistical significance. RESULTS: Of the 148 patients included in the study, 91 were male and 57 were female (mean age, 53.64 years). The univariate analysis results indicated that specific variables, including extraoral loss, multiple swallows, cervical auscultation, vocal quality, cough, choking, and other signs, were possible significant high-risk indicators of dysphagia onset. The multivariate analysis results indicated that cervical auscultation and coughing were independent predictive variables for high dysphagia risk. CONCLUSIONS: Patients displaying extraoral loss, multiple swallows, cervical auscultation, vocal quality, cough, choking and other signs should benefit from early swallowing evaluations. Additionally, early post-extubation dysfunction recognition is paramount in reducing the morbidity rate in this high-risk population

Ingestão dietética de pacientes bariátricas femininas após gastroplastia anti-obesidade

PURPOSE: Roux-en-Y gastric bypass is a popular and successful operation for the treatment of morbid obesity. However, it greatly restricts ingestion and moderately interferes with absorption of food, thus potentially paving the way for undernutrition, especially during the first year before patients adapt to the new condition. Aiming to document actual dietary intake during this period, a prospective observational study was performed. METHODS: Forty consecutive patients were investigated using a 24-hour dietary recall technique every 3 months after surgery for 1 year. Females only were accepted for greater homogeneity of the sample. All received a vitamin and mineral supplement on a daily basis as a postoperative routine. A questionnaire was employed regarding general, nutritional, and gastrointestinal changes as well as consumption of medications. Dietary intake was analyzed after data processing using the Virtual Nutri software package (São Paulo, SP, Brazil). RESULTS: The surgical response was within the expected range, with about 67% excess weight loss at the end of the 1st year, and the same occurred with gastrointestinal symptoms and drug requirements. Daily energy intake on the 4 analyzed occasions was 529.4 ± 47.4, 710.9 ± 47.6, 833.2 ± 72.0, and 866.2 ± 95,1 kcal/day (mean ± SEM); protein intake was increased in the same proportion at 6 and 9 months, but reduced at 12 months. Thus, patients did not meet standard recommendations regarding calories and proteins, even at the end of the 1st year; iron and zinc intake were also inadequate, although deficiencies were probably staved off by the prescribed supplement preparation. CONCLUSIONS: 1) The risk for postoperative undernutrition was evidenced up to 1 year, while spontaneous improvement in food intake was slow and inefficient; 2) Specific protocols should be devised to improve nutrition and health during the postoperative phase until successful dietary adaptation is achieved.OBJETIVO: A gastroplastia com anastomose gastrojejunal em Y de Roux é uma operação popular e bem sucedida no tratamento da obesidade grave. Ela restringe seriamente a ingestão e moderadamente a absorção do alimento, potencialmente abrindo caminho para desnutrição especialmente no primeiro ano, antes que o paciente se adapte à nova condição. Com o propósito de documentar a real ingestão neste período, um estudo prospectivo observacional foi executado. MÉTODO: Quarenta pacientes consecutivos foram investigados por recordatório de 24 horas a cada três meses após a operação, até um ano. Apenas mulheres foram arroladas para maior homogeneidade da amostra. Todas receberam diariamente um suplemento vitamínico-mineral, como rotina pós-operatória. Um questionário foi empregado abordando alterações gerais, nutricionais e gastrointestinais assim como consumo de medicamentos. Os ganhos dietéticos foram analisados mediante o programa Virtual Nutri (São Paulo, SP, Brasil). RESULTADOS: A resposta cirúrgica situou-se dentro da faixa esperada, com perda de cerca de 67% do excesso de peso após um ano, e o mesmo ocorreu com sintomas gastrointestinais e necessidades medicamentosas. A quantidade de energia diária nas quatro ocasiões foi de 529,4±47,5, 710,9± 47,7, 833,2± 72,0 e 866,2± 95,1 kcal/dia (média ± erro padrão da média), e o aumento do consumo de proteína foi da mesma proporção nos 6 e 9 meses e com redução em 12 meses. Consequentemente mesmo após um ano as pacientes estavam abaixo das recomendações usuais de calorias e proteínas. A contribuição da dieta no tocante a ferro e zinco também mostrou-se inadequada, embora quadros deficitários tenham provavelmente sido abortados pelo suplemento utilizado. CONCLUSÕES: 1) O risco para desnutrição pos-operatória ficou demonstrado até um ano, e a melhora espontânea da ingestão de alimentos revelou-se lenta e ineficiente; 2) Protocolos específicos deveriam ser elaborados visando melhorar a nutrição e a saúde na fase pós-operatória, até que se verifique uma adaptação dietética satisfatória

Hiperfluxo portal na forma hepatosplênica da esquistossomose mansônica

PURPOSE: The purpose of this study was to assess portal hemodynamics in patients with portal hypertension due to hepatosplenic schistosomiasis as well as to assess the contribution of splanchnic hyperflow to the pathophysiology of the portal hypertension. METHODS: Sixteen patients with schistosomal portal hypertension and previous history of upper digestive bleeding due to esophageal varices rupture underwent elective esophagogastric devascularization and splenectomy and were prospectively studied. All patients underwent intraoperative invasive hemodynamic portal monitoring with a 4F-thermodilution catheter. The intraoperative portal hemodynamic assessment was conducted after laparotomy (initial) and after esophagogastric devascularization (final). RESULTS: The initial portal pressure was elevated (mean 28.5 ± 4.5 mm Hg), and a significant drop of 25% was observed at the end of the surgery (21.9 ± 4.9 mm Hg). The initial portal flow was elevated (mean 1766.9 ± 686.6 mL/min). A significant fall (42%) occurred at the end of the surgical procedure (1025.62 ± 338.7 mL/min). Fourteen patients (87.5%) presented a portal flow of more than 1200 mL/min, and in 5 cases, values greater than 2000 mL/min were observed. CONCLUSIONS: Esophagogastric devascularization and splenectomy promote a significant reduction of the elevated portal pressure and flow in schistosomal portal hypertension. These data favor the hypothesis of portal hyperflow in the physiopathology of portal hypertension of schistosomiasis.OBJETIVOS: o objetivo do presente estudo é estudar a hemodinâmica portal em pacientes com hipertensão portal secundária a forma hepatoesplênica da esquistossomose e avaliar a contribuição do hiperfluxo esplênico na sua fisiopatologia CASUÍSTICA E MÉTODOS: Foram estudados prospectivamente 16 pacientes portadores de hipertensão portal secundária à forma hepatoesplênica da esquistossomose mansônica com indicação de tratamento cirúrgico. Todos foram submetidos a avaliação hemodinâmica portal com cateter de termodiluição 4F antes e após a realização de desvascularização esofago-gástrica com esplenectomia. RESULTADOS: Na avaliação intra-operatória inicial observou-se pressão (28,5 + 4,5 mmHg ) e fluxo (1750,59 ± 668,14 ml/min) portais iniciais bem acima dos valores considerados normais. Houve queda significante de 25% na pressão (21,65 ± 5,55 mmHg ) e de 42% no fluxo (1011,18 ± 332,73 ml/min) ao término da cirurgia. Quatorze pacientes (87.5%) apresentavam fluxo portal superior a 1200 ml/min e, em 5 casos, valores superiores a 2000 ml/min foram observados. CONCLUSÕES: A pressão e o fluxo portais estão aumentados na hipertensão portal esquistossomótica. A desvascularização esofago-gástrica com esplenectomia reduz significativamente tanto a pressão quanto o fluxo portais. Estes dados favorecem a hipótese do hiperfluxo esplâncnico (esplênico e mesentérico) na fisiopatologia da hipertensão portal na esquistossomose forma hepatoesplênica

Detection value of free cancer cells in peritoneal washing in gastric cancer: a systematic review and meta-analysis

Intraperitoneal free cancer cells in gastric adenocarcinoma are associated with a poor outcome. However, the true prognostic value of intraperitoneal free cancer cells is still unclear, leading to a lack of consensus in the management of gastric cancer. The aim of the present study is to perform a systematic review and meta-analysis to analyze intraperitoneal free cancer cells-positive patients with regard to tumor oncologic stage, recurrence, grade of cellular differentiation, and survival rates and to analyze the clinical significance of intraperitoneal free cancer cells with regard to prognosis. Databases were searched up to January 2016 for prognostic factors associated with intraperitoneal free cancer cells, including oncologic stage, depth of neoplasm invasion, lymph nodal spread, differentiation grade of the tumor, and recurrence and survival rates. A total of 100 studies were identified. Meta-analysis revealed a clear association between intraperitoneal free cancer cells and a poor prognosis. intraperitoneal free cancer cells -positive patients had higher rates of nodal spread (risk difference: 0.29;

Impact of COVID-19 pandemic on the surgical treatment of gastric cancer

OBJECTIVE: The Coronavirus Disease 2019 (COVID-19) pandemic has been recognized as one of the most serious public health crises. This study aimed to evaluate the short-term impact of the pandemic on the surgical treatment of patients with gastric cancer (GC) in addition to their clinicopathological characteristics. We also verified adherence to the COVID-19 screening protocol adopted in the institution. METHODS: All patients with GC who underwent surgical treatment between 2015 and 2021 were retrospectively evaluated and divided into two groups according to the time period: control group (2015-2019) and COVID group (2020-2021). The institutional protocol recommends that patients referred for surgery undergo RT-PCR for severe acute respiratory syndrome coronavirus 2 infection. RESULTS: A total of 83 patients were classified into the COVID group and 535 into the control group. The number of surgical procedures performed in the control group was 107 (SD±23.8) per year. Diagnostic procedures (p=0.005), preoperative chemotherapy (p<0.001), and adenocarcinomas without Lauren’s subtype (p=0.009) were more frequent in the COVID group than in the control group. No significant difference was observed in the pathological characteristics and surgical outcomes of curative GC between the two groups. Evaluation of protocol compliance showed that of 83 patients with GC in the COVID group, 19 (22.9%) were not tested for COVID-19 before surgery. Two patients tested positive for COVID-19 (one preoperative and one postoperative). CONCLUSION: A decrease in the average number of surgeries and a higher frequency of diagnostic procedures occurred during the pandemic than in the previous time period. Tumor/node/metastasis classification, morbidity rates, and mortality rates in patients with GC during the pandemic did not differ from those in the previous time period. Accordingly, GC surgical treatment with acceptable screening protocol compliance could be safely performed during the COVID-19 pandemic