ABSTRACT Objective To describe an experience in the preoperative localization of small pulmonary nodules and ground-glass lesions to guide minimally invasive thoracic surgery; in addition, a literature review was conducted, including the main advantages and disadvantages of the different agents used, and site marking in a hybrid operating room. Methods A retrospective search was conducted in a Interventional Radiology Department database, between March 2015 and May 2019, to identify patients undergoing preoperative percutaneous marking of lung injuries measuring up to 25mm. Results A total of 20 patients were included and submitted to descriptive analysis. All patients were marked in a hybrid room, at the same surgical-anesthetic time. Most often used markers were guidewire, Lipiodol® and microcoils. Despite one case of coil displacement, two cases of pneumothorax, and one case of hypotension after marking, all lesions were identified and resected accordingly from all patients. Conclusion Preoperative percutaneous localization of lung injuries in hybrid room is an effective and a safe technique, which can have decisive impact on surgical resection. The choice of marker and of the operating room scenario should be based on availability and experience of service. Multidisciplinary discussions with surgical teams, pathologists, and interventional radiologists are crucial to improve outcome of patients.

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.

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.

ObjetivoDescrever a técnica para reparação de pectus excavatumcom o uso de bloco de silicone sólido de baixa dureza, que possibilita a adequação de suas dimensões no intraoperatório para melhor resultado estético.MétodosEntre maio de 1994 e fevereiro de 2013, pacientes do gênero masculino, portadores de pectus excavatum, foram submetidos à correção cirúrgica com bloco de silicone sólido de baixa dureza, de 10 a 30 Shore A, pré-fabricado em forma de paralelepípedo, com as dimensões da altura e da base coincidentes com as da falha óssea. Durante o ato cirúrgico, esse bloco foi esculpido até adequar-se ao formato do espaço dissecado. Os pacientes foram acompanhados por um mínimo de 120 dias de pós-operatório.ResultadosTrinta e quatro pacientes foram operados. Destes, 28 foram de tratamento primário e 6 secundário a outras técnicas cirúrgicas, ósseas ou de uso de implantes. As complicações foram dois casos de hematoma e oito de seroma. Foi necessária a retirada do implante em um dos casos devido à dor. Em outro caso, foi a realizada revisão cirúrgica das dimensões da prótese. Dois pacientes foram submetidos a enxerto de gordura, para melhorar o contorno da parede torácica. Não ocorreu nenhum caso de infecção. O resultado foi considerado satisfatório em 33 pacientes.ConclusãoO procedimento mostrou-se rápido e efetivo. Os resultados dos contornos obtidos foram considerados mais efetivos quando comparados aos obtidos com a utilização de próteses pré-moldadas.

Objective To describe a new surgical technique to treat pectus excavatumutilizing low hardness solid silicone block that can be carved during the intraoperative period promoting a better aesthetic result.Methods Between May 1994 and February 2013, 34 male patients presentingpectus excavatum were submitted to surgical repair with the use of low hardness solid silicone block, 10 to 30 Shore A. A block-shaped parallelepiped was used with height and base size coinciding with those of the bone defect. The block was carved intraoperatively according to the shape of the dissected space. The patients were followed for a minimum of 120 days postoperatively. The results and the complications were recorded.Results From the 34 patients operated on, 28 were primary surgeries and 6 were secondary treatment, using other surgical techniques, bone or implant procedures. Postoperative complications included two case of hematomas and eight of seromas. It was necessary to remove the implant in one patient due to pain, and review surgery was performed in another to check prothesis dimensions. Two patients were submitted to fat grafting to improve the chest wall contour. The result was considered satisfactory in 33 patients.Conclusion The procedure proved to be fast and effective. The results of carved silicone block were more effective for allowing a more refined contour as compared to custom made implants.

Objetivo : Analisar a efetividade da oxibutinina para tratamento da hiperidrose em pacientes com mais de 40 anos. Métodos : Oitenta e sete pacientes com idade superior a 40 anos foram divididos em dois grupos: o primeiro com 48 pacientes (55,2%), com idades entre 40 e 49 anos. O segundo com 39 pacientes (44,8%), com mais de 50 anos (intervalo: 50 a 74 anos). Uma análise comparativa da Qualidade de Vida e do nível de hiperidrose entre os grupos foi realizada 6 semanas após o início do tratamento com oxibutinina. Para isso, foi utilizado um questionário validado para Qualidade de Vida. Resultados : No grupo mais jovem, 75% dos pacientes referiram melhora “parcial” ou “ótima” no nível de hiperidrose após o tratamento. Esse número foi particularmente impressionante em pacientes acima de 50 anos, sendo que 87,2% apresentaram níveis similares de melhora. Mais de 77% dos pacientes, em ambos os grupos, demonstraram melhora na Qualidade de Vida. Desfechos excelentes foram observados em pacientes mais idosos, dentre os quais 87,1% dos pacientes apresentaram melhora “pouco melhor” (41%) ou “muito melhor” (46,1%). Conclusão : Os pacientes acima de 40 anos com hiperidrose tiveram excelentes resultados com o tratamento com oxibutinina. Esses desfechos foram particularmente importantes nos pacientes com mais de 50 anos, nos quais a maioria apresentou melhora da Qualidade de Vida e da hiperidrose.

Objective : Our aim was to analyze the effectiveness of oxybutynin for hyperhidrosis treatment in patients over 40 years. Methods : Eighty-seven patients aged over 40 years were divided into two groups. One group consisted of 48 (55.2%) patients aged between 40 and 49 years, and another was composed of 39 (44.8%) patients aged over 50 years (50 to 74 years). A comparative analysis of Quality of Life and level of hyperhidrosis between the groups was carried out 6 weeks after a protocol treatment with oxybutynin. A validated clinical questionnaire was used for evaluation. Results : In the younger age group, 75% of patients referred a “partial” or “great” improvement in level of hyperhidrosis after treatment. This number was particularly impressive in patients over 50 years, in which 87.2% of the cases demonstrated similar levels of improvement. Over 77% of patients in both groups demonstrated improvement in Quality of Life. Excellent outcomes were observed in older patients, in which 87.1% of patients presented “slightly better” (41%) or “much better” (46.1%) improvement. Conclusion : Patients aged over 40 years with hyperhidrosis presented excellent results after oxybutynin treatment. These outcomes were particularly impressive in the age group over 50 years, in which most patients had significant improvement in Quality of Life and in level of hyperhidrosis.

OBJECTIVES: To determine possible variations in the Anthropometric Index for pectus excavatum relative to age, race, and sex in individuals free of thoracic wall deformities. METHODS: Between 2002 and 2012, 166 individuals with morphologically normal thoracic walls consented to have their chests and the perimeter of the lower third of the thorax measured according to the Anthropometric Index for pectus excavatum. The participant characteristics are presented (114 men and 52 women; 118 Caucasians and 48 people of African descent). RESULTS: Measurements of the Anthropometric Index for pectus excavatum were statistically significantly different between men and women (11-40 years old); however, no significant difference was found between Caucasians and people of African descent. For men, the index measurements were not significantly different across all of the age groups. For women, the index measurements were significantly lower for individuals aged 3 to 10 years old than for individuals aged 11 to 20 years old and 21 to 40 years old; however, no such difference was observed between women aged 11 to 20 years old and those aged 21 to 40 years old. CONCLUSION: In the sample, significant differences were observed between women aged 11 to 40 years old and the other age groups; however, there was no difference between Caucasian and people of African descent.

Hérnias intercostais transdiafragmáticas são eventos raros e são geralmente relacionadas a traumas abertos ou fechados, com risco de complicações. Relatamos três casos semelhantes, decorrentes de crises de tosse, destacando o aspecto das alterações anatômicas nos exames de imagem obtidos em cada situação (radiografia, ultrassonografia, TC e ressonância magnética)

Transdiaphragmatic intercostal hernia is uncommon and mostly related to blunt or penetrating trauma. We report three similar cases of cough-induced transdiaphragmatic intercostal hernia, highlighting the anatomic findings obtained with different imaging modalities (radiography, ultrasonography, CT, and magnetic resonance) in each of the cases.

OBJECTIVE: The aim of the present study was to prospectively, randomly, blindly, and objectively investigate how surgery affects plantar sudoresis in patients with palmar and plantar hyperhidrosis over a one-year period using a sudorometer (VapoMeter). METHODS: From February 2007 to May 2009, 40 consecutive patients with combined palmar hyperhidrosis and plantar hyperhidrosis underwent video-assisted thoracic sympathectomy at the T3 or T4 ganglion level (15 women and 25 men, with a mean age of 25 years). RESULTS: Immediately after the operation and during the one-year follow-up, all of the patients were free from palmar hyperhidrosis episodes. Compensatory hyperhidrosis of varying degrees was observed in 35 (87.5%) patients after one year. Only two (2.5%) patients suffered from severe compensatory hyperhidrosis. There was a large initial improvement in plantar hyperhidrosis in 46.25% of the cases, followed by a progressive regression of that improvement, such that only 30% continued to show this improvement after one year. The proportion of patients whose condition worsened increased progressively (from 21.25% to 47.50%), and the proportion of stable patients decreased (32.5% to 22.50%). This was not related to resection level; however, a lower intensity of plantar hyperhidrosis prior to sympathectomy correlated with worse evolution. CONCLUSION: Patients with palmar hyperhidrosis and plantar hyperhidrosis who underwent video-assisted thoracic sympathectomy to treat their palmar hyperhidrosis exhibited good initial improvement in plantar hyperhidrosis, which then decreased to lesser degrees of improvement over a one-year period following the surgery. For this reason, video-assisted thoracic sympathectomy should not be performed when only plantar hyperhidrosis is present.

OBJETIVO: Avaliar os resultados do tratamento com baixas doses de oxibutinina em homens e mulheres com hiperidrose palmar e axilar. MÉTODOS: Análise retrospectiva de 395 mulheres e 170 homens acompanhados em nosso serviço com queixa de hiperidrose palmar e plantar, submetidos a um protocolo de 12 semanas de tratamento com oxibutinina. Melhora clínica da hiperidrose e da qualidade de vida foram estudadas por meio de um questionário específico, aplicado antes e após o tratamento. RESULTADOS: Dentre os pacientes em ambos os grupos, 70% apresentaram melhoria parcial ou grande no nível de hiperidrose após o tratamento. Os melhores resultados foram obtidos no grupo feminino, no qual 40% classificaram sua evolução como "ótima". Aproximadamente 70% dos pacientes em ambos os grupos melhoraram sua qualidade de vida após a terapia médica e 30% não apresentaram mudança da condição inicial. CONCLUSÃO: Gênero é um fator que não interfere significativamente nos resultados do tratamento com oxibutinina. Os índices de qualidade de vida e o grau de melhora clínica da hiperidrose foram semelhantes em homens e mulheres.

OBJECTIVE: To assess the results of palmar and axillary hyperhidrosis treatment in males and females using low doses of oxybutynin. METHODS: A retrospective analysis was conducted in 395 women and 170 men followed up in our service with complaint of palmar and axillary hyperhidrosis. RESULTS: A total of 70% of patients in both groups presented partial or great improvement in the level of hyperhidrosis after treatment. The best results were obtained in the female group, in which 40% classified their improvement as "great". Approximately 70% of the patients in both groups improved their quality of life after medical therapy and 30% presented no change in condition. CONCLUSION: Gender is not a factor that significantly interferes in oxybutynin treatment results. Quality of life indices and clinical improvement level were similar in men and women.

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.

OBJETIVO: Avaliar se o pneumotórax residual após simpatectomia torácica videotoracoscópica tem incidência diferente quando utilizada a drenagem pleural pós-operatória ou não e se este pneumotórax residual, quando presente, pode influenciar a dor pós-operatória até o 28º dia. MÉTODOS: Foram incluídos todos os pacientes com queixa de hiperidrose palmoplantar primária atendidos no Ambulatório de Cirurgia Torácica do Hospital Estadual Sumaré, de julho a dezembro de 2006. Todos foram submetidos à simpatectomia do terceiro gânglio torácico por videotoracoscopia e aleatorizados para receber ou não drenagem pleural pós-operatória por 3 h. Todos foram avaliados no pós-operatório imediato com radiogramas de tórax e tomografia computadorizada de tórax de baixa emissão de energia para detecção de pneumotórax residual. Foram avaliados quanto à dor pós-operatória em diferentes momentos até o 28º dia de pós-operatório, por meio de escala numérica visual e dosagem requerida de analgésicos opióides. RESULTADOS: Foram incluídos 56 pacientes neste estudo, 27 com drenagem pleural bilateral e 29 sem drenagem pleural. Não houve diferença estatística entre a incidência de pneumotórax residual após simpatectomia com e sem drenagem pleural. O pneumotórax residual, quando presente e diagnosticado por qualquer um dos métodos, não influenciou a dor pós-operatória até o 28º dia. CONCLUSÃO: Concluiu-se que a drenagem pleural tubular fechada, por um período de 3 h, no pós-operatório imediato de simpatectomia torácica videotoracoscópica, foi tão eficiente quanto a não drenagem, em relação à reexpansão pulmonar e à presença de pneumotórax residual. O pneumotórax residual, quando presente, não interferiu na dor pós-operatória até o 28º dia.

OBJECTIVE: To determine the incidence of residual pneumothorax after video-assisted thoracic sympathectomy, with and without postoperative pleural drainage, and to evaluate the possible influence of this type of pneumothorax on postoperative pain within the first 28 postoperative days. METHODS: All patients presenting symptoms consistent with primary palmoplantar hyperhidrosis and treated at the Thoracic Surgery Outpatient Clinic of the State Hospital of Sumaré between July and December of 2006 were included. All were submitted to sympathectomy up to the third ganglion using video-assisted thoracoscopy and were randomized to receive or not receive postoperative pleural drainage for 3 h. Chest X-rays and low-dose computed tomography scans of the chest were performed on the first postoperative day in order to determine the incidence of residual pneumothorax. At different time points up to postoperative day 28, patient pain was assessed using a visual numeric scale and by measuring the quantity of opioid analgesics required. RESULTS: This study comprised 56 patients, 27 submitted to bilateral pleural drainage and 29 not submitted to drainage. There was no statistical difference between the two groups in terms of the incidence of post-sympathectomy residual pneumothorax. Residual pneumothorax diagnosed through any of the methods did not influence pain within the first 28 postoperative days. CONCLUSION: Performing closed pleural drainage for 3 h immediately after video-assisted thoracic sympathectomy did not affect lung re-expansion or the incidence of residual pneumothorax. When residual pneumothorax was present, it did not affect pain within the first 28 postoperative days.