Objetivo: Avaliar a efetividade e o momento ideal da realização da toracoscopia vídeoassistida (TVA) para o tratamento de crianças com derrame pleural parapneumônico complicado (DPPC), bem como determinar se a drenagem torácica realizada como procedimento inicial pode influenciar os resultados da TVA. Métodos: Estudo retrospectivo de 79 crianças (idade média de 35 meses) submetidas à TVA, entre janeiro de 2000 e dezembro de 2011. Os pacientes foram tratados com o mesmo algoritmo de tratamento e os procedimentos cirúrgicos foram realizados ou supervisionados pelo mesmo cirurgião. As crianças foram divididas em dois grupos de acordo com o intervalo de quatro dias entre o diagnóstico do DPPC e a cirurgia. Resultados: Pacientes operados até o 4º dia após o diagnóstico do DPPC apresentaram menor tempo de internação (p=0,008), de uso de antibióticos (p=0,023) e de uso de dreno torácico (p=0,019), além de serem submetidos a menor número de procedimentos cirúrgicos (p<0,001). A drenagem pleural prévia retardou a realização da TVA em três dias, com consequente aumento no tempo de internação (p=0,050), no tempo de permanência do dreno torácico (p<0,001) e no tempo cirúrgico da TVA (p<0,001). TVA foi eficaz em 73 crianças (92,4%). Nem o intervalo entre o diagnóstico e a cirurgia, nem a drenagem pleural prévia, influenciaram a taxa de insucesso da TVA. Conclusões: TVA é um procedimento altamente efetivo em crianças com DPPC. TVA realizada até quatro dias após o diagnóstico do DPPC está associada à redução nos tempos de internação, de permanência do dreno torácico e do uso de antibióticos, além de diminuição no número de intervenções invasivas. / thoracoscopic surgery (VATS) in the treatment of children with complicated parapneumonic pleural effusion (CPPE) and to determine whether the use of initial chest tube drainage (CTD) may influence VATS outcome. Methods: We retrospectively reviewed medical records of 79 children (mean age, 35 months) undergoing VATS from January 2000 to December 2011. The same treatment algorithm was used in the management of all patients, and all surgical procedures were performed or supervised by the same surgeon. The children were divided into two groups according to a 4-day interval between CPPE diagnosis and surgery. Results: Patients undergoing VATS within 4 days of CPPE diagnosis had a shorter hospital stay (p=0.008), fewer number of antibiotics administered (p=0.023), and decreased time with a chest tube (p=0.019), in addition to undergoing fewer number of surgical procedures (p<0.001). Initial CTD resulted in a delay of 3 days in performing VATS, leading to longer hospital stay (p=0.050), increased time with a chest tube (p<0.001), and longer VATS operating time (p<0.001). VATS was effective in 73 children (92.4%). The interval from diagnosis to surgery and initial CTD had no influence on VATS failure rate. Conclusions: VATS is a highly effective procedure for treating children with CPPE. VATS performed within 4 days of CPPE diagnosis is associated with shorter hospital stay, decreased time with a chest tube, fewer antibiotics administered, and fewer invasive interventions.

Introdução: A simpatectomia torácica é o único tratamento, definitivo e eficaz, para a hiperidrose primária. A ramicotomia é um procedimento cirúrgico tão eficaz, mais conservador e com menos efeitos adversos que a simpatectomia convencional, contudo foi abandonada pela alta taxa de recidiva, atribuída, até então, à secção incompleta dos ramos comunicantes, ao desenvolvimento de outras vias de condução para o estímulo central e à regeneração neural. A avaliação histológica dos ramos comunicantes simpáticos após a ramicotomia, pode ajudar a entender o processo de recidiva dos sintomas da hiperidrose e, dessa forma contribuir para o desenvolvimento de estratégias para evitá-la. MATERIAL E MÉTODOS: 28 suínos foram submetidos à ramicotomia por videotoracospia e divididos randomicamente em 5 grupos, sacrificados com 15, 45, 90, 135 e 180 dias de pós-operatório (DPO). Os segmentos operados foram removidos cirurgicamente e submetidos à avaliação macroscópica da regeneração assim como análise histológica dos ramos comunicantes brancos e cinzentos para quantificação da reação inflamatória, deposição de fibras de colágeno grossas e finas, fibras reticulares e células de Schwann por imuno-histoquímica. Os dados foram comparados ao grupo controle, composto por segmentos intactos, não operados. RESULTADOS: Não houve regeneração macroscópica no grupo de 15 DPO sendo presente em 41,6% dos casos no grupo 180 DPO (p < 0,05). A reação inflamatória foi determinante no processo de degeneração Walleriana, com presença importante das células de Schwann nos ramos pré-ganglionares (p < 0,05), as células de Schwann apresentaram evolução semelhante nos dois ramos a partir do grupo de 45DPO, mantendo-se em menor número nos ramos cinzentos. As fibras de colágeno foram cruciais na cicatrização e as fibras reticulares importantes na regeneração neural, com correlação negativa entre elas (r = - 0,414; p < 0,01). A deposição de fibras de colágeno foi maior nos ramos cinzentos, apresentando pico de deposição no grupo 135 DPO e declínio importante no grupo 180 DPO (p < 0,05). CONCLUSÕES: A ramicotomia permite a secção completa de todos os ramos comunicantes do gânglio simpático. A taxa de regeneração histológica deve ser maior que a taxa de recidiva dos sintomas no humano, devido a regenerações não funcionais. O processo regenerativo é similar nos ramos brancos e cinzentos, com tendências menores para os últimos. A regeneração dos ramos comunicantes deve ser um dos principais fatores de recidiva da hiperidrose após a ramicotomia / INTRODUCTION: Thoracic sympathectomy is the only definitive and efficient treatment for primary hyperhidrosis. The ramicotomy is a surgical procedure that is as efficient as conventional sympathectomy but more conservative, having less adverse effects then conventional sympathectomy. This procedure was abandoned on account of the high recurrence rate, attributed to the incomplete section of the rami communicantes and to the development of new pathways of conduction to the central stimuli. MATHERIAL AND METHODS: Twenty-eight swine underwent bilateral videothoracoscopic ramicotomy and were randomly divided into 5 groups. The animals were sacrificed at 15, 45, 90, 135 and 180 days post-operative POD. The segments were removed and evaluated for macroscopic regeneration and histological analysis of the white and gray rami communicantes analyzing the inflammatory reaction, deposition of thin and thick collagen fibers, reticular fibers and Schwann cells. The data was compared to intact segments of sympathetic trunk as a positive control. RESULTS: There was neither macroscopic nor microscopic regeneration at the 15 POD group. The remaining groups had an average of 41,6% of regeneration, more significant at the 180 POD group (p<0.05). The inflammatory reaction was crucial in the process of Wallerian degeneration, with an important participation of the Schwann cells in the pre-ganglionic rami (p<0.05). The Schwann cells presented a similar evolution in both rami beginning at the 45 POD group, with a smaller count in the gray rami. The collagen fibers were significant in the cicatrization and the reticular fibers were important in neural regeneration, with a meaningful negative correlation between them (r = - 0,414; p < 0,01). The rate of deposition of the collagen fibers was greater in the white rami when compared to the gray rami in the first trimester and less important in the second trimester (p<0.05). CONCLUSIONS: Ramicotomy allows complete section of all rami communicantes of the sympathetic ganglia. The histological regeneration might be greater than the recurrence rates of clinical symptoms as seen in the human being due to non-functional regenerations. The restoration process is similar in both white and gray rami, with smaller tendencies in the last one. The regeneration of the could be one of the main factors for recurrence of hyperhidrosis following ramicotomy

Orientadores: Ricardo Kalaf Mussi, Ivan Felizardo Contrera Toro / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-24T06:52:15Z (GMT). No. of bitstreams: 1 Dias_LuciaraIrenedeNadai_M.pdf: 2177736 bytes, checksum: c5b98455a79296bccbd702f701b8ee15 (MD5) Previous issue date: 2013 / Resumo: Após simpatectomia torácica por videocirurgia para tratamento de hiperidrose primária comumente ocorre sudorese reflexa como efeito colateral e pode ser causa de insatisfação nos resultados. Objetivos: Avaliar a intensidade de sudorese reflexa com o grau de ansiedade e sua interferência na qualidade de vida de indivíduos submetidos à simpatectomia por videotoracoscopia nos períodos pré e pós-operatório. Método: Foram avaliados 54 pacientes, sendo 33 do gênero feminino e 21 do gênero masculino, através de dois questionários (Questionário de qualidade de vida em pacientes com hiperidrose primária e Escala para Ansiedade e Depressão) antes da cirurgia, 30 e 180 dias após a cirurgia. Os pacientes foram submetidos à simpatectomia em nível R3-R4. Resultados: Os pacientes apresentaram melhora significativa na qualidade de vida logo após 30 dias da realização da simpatectomia, resultado que se manteve após os seis meses. Houve significância estatística (p<0,025) para comprovar que quanto maior o nível de ansiedade do paciente, maior a intensidade da sudorese reflexa após 180 dias. Não houve complicação cirúrgica em nenhum paciente. Conclusões: A simpatectomia torácica por videocirurgia melhora a qualidade de vida dos pacientes com hiperidrose primária, mesmo com o surgimento da sudorese reflexa. A ansiedade está diretamente relacionada com a intensidade de sudorese reflexa, sem comprometer o grau de satisfação dos pacientes. Descritores: Hiperidrose. Qualidade de vida. Ansiedade. Simpatectomia, Cirurgia torácica videoassistida / Abstract: After video-assisted thoracic sympathectomy for treatment of primary hyperhidrosis commonly occurs reflex sweating as a side effect and can be a cause of dissatisfaction in the results. Objectives: Evaluate the intensity of reflex sweating with anxiety levels and their influence on quality of life of individuals undergoing thoracoscopic sympathectomy in the pre and postoperative. Method: Were evaluated 54 patients, being 33 females and 21 males, using two questionnaires (Quality of Life in Patients with Primary Hyperhidrosis and Anxiety and Depression Scale) before surgery, 30 and 180 days after surgery. Patients underwent sympathectomy at R3-R4 level. Results: The patients showed significant improvement in quality of life after 30 days of completion of the sympathectomy, a result that remained after six months. Statistical significance (p < 0.025) to prove that the higher the level of anxiety of the patient, the greater the intensity of compensatory sweating after 180 days. There were no postoperative complications in any patient. Conclusions: Video-assisted thoracic sympathectomy improves the quality of life of patients with primary hyperhidrosis, even with the emergence of reflex sweating. The anxiety is directly related to the intensity of reflex sweating, without compromising the degree of patient satisfaction. Descriptors: Hyperhidrosis. Quality of life. Anxiety. Sympathectomy, Video assisted thoracic surgery / Mestrado / Fisiopatologia Cirúrgica / Mestra em Ciências

Introduction: As the number of minimally invasive technologies increases in the field of thoracic surgery, so have the number of learning curve analyses performed for these innovations. Variation in learning curve methodology makes between-study comparisons and evidence syntheses difficult. Furthermore, poorly described and reported learning curve analyses make the results difficult to apply to different clinical settings. The objective of this systematic review is to characterize the variability in the methods used to construct and describe learning curves, with the goal of identifying shortcomings and potential areas for improvement in this line of research. Methods: A search of Ovid Medline, Ovid Embase, EBSCO CINAHL, and Web of Science was performed. Studies of learning curves of anatomical lung resection operations in adult patients published in the English language were eligible for inclusion. Two reviewers independently assessed studies for eligibility, and extracted relevant data. Results: The search yielded 56 articles eligible for inclusion in the present review. A variety of methods were used to construct the learning curve, with chronological grouping of cases being the most commonly used technique in 22 (39.29%) studies, followed by the cumulative sum method, employed in 21 (37.50%) studies. A total of 15 unique metrics were used for learning curve analyses; operative time was the most common metric, used in 39 (69.64%) studies. A large proportion of studies failed to provide details on learning curve parameters such as competency thresholds, surgeon’s prior experience, case complexity, and learning curve definition. Considerable heterogeneity was found in the methods and reporting standards of learning curve evaluations in minimally invasive thoracic surgery. Conflicts of Interest: None. Funding Source: Boris Family Centre for Robotic Surgery. / Thesis / Master of Science (MSc)

No description available.

<p>Uvod: Hirur&scaron;ko lečenje nodozne bolesti &scaron;titaste žlezde predstavlja jednu od najče&scaron;će izvođenih operacija u endokrinoj hirurgiji. Pored klasičnih hirur&scaron;kih metoda, poslednjih godina su se pojavile različite tehnike minimalno invazivne tireoidektomije kao rezultat sveukupnog trenda razvoja minimalno invazivnih hirur&scaron;kih tehnika. Kliničke indikacije i prednosti izvođenja minimalno invazivne video-asistirane tiroidektomije (MIVAT) u odnosu na klasičnu hirur&scaron;ku tehniku u lečenju nodozne bolesti &scaron;titaste žlezde su i dalje nedovoljno definisane i u fokusu su savremenih istraživanja. Cilj istraživanja je procena učestalosti komplikacija (intraoperativno i postoperativno krvarenje, pareza i paraliza laringealnog živca, hipoparatireoidizam) tokom i nakon minimalno invazivne tireoidektomije u nodoznim benignim oboljenjima &scaron;titaste žlezde uz poređenje sa klasičnom tireoidektomijom, da se ispita intenzitet postoperativnog bola, merenjem pomoću vizuelno analogne skale tokom sedam postoperativnih dana, nakon minimalno invazivne tireoidektomije u nodoznim benignim oboljenjima &scaron;titaste žlezde uz poređenje sa klasičnom tireoidektomijom, kao i da se ispita dužina bolničkog boravka nakon minimalno invazivne tireoidektomije u nodoznim benignim oboljenjima &scaron;titaste žlezde uz poređenje sa klasičnom tireoidektomijom. Metodologija: Ispitivanje je sprovedeno kao prospektivna, kontrolisana randomizirana studija, u trajanju od novembra 2014. do aprila 2016. godine i obuhvatila je analizu 100 pacijenata operisanih na Klinici za grudnu hirurgiju Instituta za plućne bolesti Vojvodine zbog nodozne bolesti &scaron;titaste žlezde. Svi ispitanici su podeljeni u dve osnovne grupe u odnosu na operativnu tehniku: klasična metoda (KM) i minimalno invazivna videoasistirana metoda (MIVAM). Faze u toku ispitivanja su obuhvatile: analizu podataka o preoperativnim morfo-funkcionalnim dijagnostičkim testovima za nodoznu bolest &scaron;titaste žlezde (karakteristike ultrazvučnog nalaza nodozne promene i vrednosti volumena izmenjenog režnja &scaron;titaste žlezde), nalaz citolo&scaron;kog pregleda punktata tiroidnog nodusa dobijenog tankom iglom, laboratorijski pokazatelji poremećaja &scaron;titaste žlezde u cilju definisanja funkcionog stanja, odnosno postojanja autoimunog oboljenja &scaron;titaste žlezde; analizu perioperativnih karakteristika hirur&scaron;kih metoda [dužina incizije (cm), operativno vreme (min), težina odstranjenog patoanatomskog supstrata (gr), intraoperativni gubitak krvi (ml)], analiza ranih postoperativnih komplikacija (krvarenje i hematom, povreda donjeg rekurentnog laringealnog živca (nalaz direktne laringoskopije na kraju operacije), hipokalcemija, kolaps traheje, edem larinksa, serom, infekcija, dehiscencija], analiza nehirur&scaron;kih komplikacija, dužina hospitalizacije u danima, intenzitet i dužina trajanja postoperativnih bolova [(upotreba vizuelno analogne skale (VAS) bola 1, 2 i 7 postoperativnog dana)], kasne postoperativne komplikacije (6 meseci nakon operacije), stepen zadovoljstva esteskim rezultatom (anketa sprovedena na kontrolnom pregledu 6 meseci nakon operacije-kozmetski skor). Rezultati: U periodu izvođenja studije od novembra 2014. do aprila 2016. godine, nakon primene kriterijuma za uključivanje/isključivanje iz studije od 175 preostalo je 102 ispitanika, zbog patohistolo&scaron;kog nalaza maligniteta ex tempore biopsije kod jednog pacijenta, a kao i zbog intraoperativno uočenih izraženih adhezivnih promena kod jednog pacijenta urađena je konverzija, odnosno promena operativne tehnike minimalno invazivne u klasičnu metodu. U statističku obradu je uključeno ukupno 100 ispitanika podeljenih u dve grupe: grupu I bolesnika - KM (n = 50) i grupu II bolesnika - MIVAM (n = 50). U ispitivanje je ukupno uključeno 78 žena i 22 mu&scaron;karca. U odnosu na polnu strukturu u ispitivanim grupama nije uočena postojanje statistički značajne zastupljenosti u zastupljenosti mu&scaron;kog (p = 0,18), odnosno ženskog pola (p = 0,59). Takođe, uočeno je da među grupama ispitanika ne postoji statistički značajna razlika po godinama života (p = 0,16). Nije bilo statistički značajne razlike između ispitivanih grupa u odnosu na vrstu oboljenja &scaron;titaste žlezde i funkcioni status, kao ni u odnosu na ultrazvučne karakteristike solitarnog (dominantnog) nodusa kod ispitanika (veličine nodusa, ehogenost nodusa, ivica nodusa, kalcifikacija, vaskularizacije), u odnosu na citolo&scaron;ku dijagnozu aspirata uboda tankom iglom (benigni, neodgovarajući, sumnjivi), te u odnosu na volemn izmenjenog režnja. Analizom perioperativnih pokazatelja hirur&scaron;kih metoda u grupi MIVAM je utvrđena statički značajno manja dužina incije u odnosu na KM grupu (2,0 &plusmn; 0,5 cm vs. 7 &plusmn; 1,9 cm, p = 0,00), dok se težina patoanatomskog supstata (18,3 &plusmn; 6,4 vs. 19,6 &plusmn; 5,2 gr, p = 0,21), operativno vreme za izvođenje lobektomije (54 &plusmn; 14 vs. 61 &plusmn; 16 min, p = 0,25), odnosno operativno vreme za izvođenje tireoidektomije (72 &plusmn; 27 vs. 85 &plusmn; 24 min, p = 0,36) nisu statitički značajno razlikovali između ispitivanih grupa. U grupi MIVAM, rane postoperativne komplikacije (krvarenje, povreda donjeg rekurentnog laringealnog živca I hipokalcemija) su se javile kod 8% (4/50), a u KM grupi kod je 10% (5/50), &scaron;to nije bilo statistički značajno (p = 0,72). U odnosu na kasne postoperativne komplikacije, samo je kod jednog pacijenta iz MIVAM grupe registrovano postojanje keloida, dok se (trajni hipoparatiroidizam, recidivantni hipertiroidizam, reakcija na strano telo) nije zabeleženo. Nije uočena statistički značajna razlika (p &gt; 0,005 za sve) u zastupljenosti vrste nalaza patohistolo&scaron;kog pregleda odstranjenog supstrata (koloidna struma, folikularni adenoma, cista, papilarni karcinom i Hashimoto tiroiditis). Pacijenti iz MIVAM grupe statistički značajno imaju manji prosečan intenzitet bola po VAS skali u vremenskim intervalima nakon operacije 6h, 24h i 48 h (p &lt; 0,05, za sve). Ukupni kozmetski skor je bio statistički značajno vi&scaron;i u MIVAM grupi u odnosu na KM grupu (18,9 &plusmn; 1,4 vs. 15,8 &plusmn; 1,3, p = 0,00). Zaključci:Učestalost ranih postoperativnih komplikacija (intraoperativno i postoperativno krvarenje, pareza i paraliza laringealnog živca, hipokalcemija) je bez signifikantne razlike, praktično podjedanaka kod pacijenata operisanih minimalno invazivnom metodom u komparaciji sa klasičnom metodom. Prosečna dužina trajanja minimalno invazivne tireoidektomije i klasične tireoidektomije je bez signifikatne razlike, &scaron;to može govoriti o odgovarajućem nivou hirur&scaron;ke tehnike koji omogućava prednosti minimalne invazivnosti kao hirur&scaron;kog principa. Dužina hospitalizacije nakon minimalno invazivne tireoidektomije je značajno kraća u odnosu na klasičnu tireoidektomiju, &scaron;to značajno doprinosi sveukupnom oporavku pacijenta, a na taj način i tro&scaron;kovi lečenja se umanjuju.Primena minimalno invazivne tireoidektomije u odnosu na klasičnu tireoidektomiju, dovodi do smanjenja subjektivnog osećaja postoperativnog bola, u toku hospitalizacije (6 i 24 h), kao i sedam dana nakon intervencije. Kozmetski skor, kao pokazatelj zadovoljstva pacijenta sa izgledom ožiljka je statistički značano vi&scaron;i kod pacijenata koji su operisani minimalno invazivnom hirur&scaron;kom tehnikom u odnosu na pacijente koji su operisani klasičnom metodom, &scaron;to je u odnosu na predominantnu zastupljenost ženskog pola u ispitivanim grupama od posebnog značaja pri odabiru terapijskog tretmana. Prema rezultatima studije, nameće se opravdanost i potreba uvođenja minimalno invazivne tiroidektomije u standardnu kliničku praksu kao metode hirur&scaron;kog lečenja nodozne bolesti &scaron;titaste žlezde kod pacijenata sa urednim funkcionim statusom &scaron;titaste žlezde, kod kojih je veličina solitarnog/dominantnog nodusa do 35 mm.</p> / <p>INTRODUCTION: Surgical treatment of nodular thyroid disease is one of the most commonly performed procedures in endocrine surgery. In addition to traditional surgical methods, different techniques of minimally invasive thyreoid surgery have been developed. Clinical indications for the surgical treatment of nodular thyroid disease with minimally invasive video-assisted surgical technique are still insufficiently defined. The aim of the study was to estimate the incidence of complications (intraoperative and postoperative bleeding, paresis and paralysis of the laryngeal nerve, hypoparathyroidism) during and after minimally invasive thyroidectomy in benign nodular thyroid disease with a comparison with conventional thyroidectomy, to examine the intensity of postoperative pain, measured by a visual analog scale for seven postoperative days after surgery, as well as to examine the length of hospitalisation after minimally invasive thyroidectomy with a comparison with conventional thyroidectomy. METHODOLOGY: The study was conducted as a prospective, randomized controlled studies, from November 2014 to April 2016 and included the analysis of 100 patients operated at the Clinic for Thoracic Surgery, Institute for Pulmonary Diseases due to nodular thyroid disease. All subjects were divided into two basic groups according to the surgical technique: classical method (KM) and minimally invasive video-assisted method (MIVAM). Stages during the study included: analysis of data on preoperative morpho-functional diagnostic tests for thyroid disease (characteristic ultrasound findings, nodule caracteristics, volume of exchanged thyroid gland lobe), cytologic examination of aspirates of thyroid nodules obtained by fine needle, laboratory indicators of thyroid disorders gland in order to define the functional status and the presence of autoimmune thyroid disease; analysis of perioperative characteristics of surgical methods [incision length (cm), operative time (min), weight of removed pathoanatomic substrate (gr), intraoperative blood loss (ml)], the analysis of early postoperative complications (bleeding and hematoma, injury to lower recurrent laryngeal nerve (finding direct laryngoscopy at the end of the operation), hypocalcemia, the collapse of the trachea, laryngeal edema, seroma, infection, dehiscence] analysis nonsurgical complications, length of hospitalisation in hours, the intensity and duration of postoperative pain [(use of the visual analog scale (VAS) pain 1, 2 and 7 postoperative days)], late postoperative complications (6 months after surgery), the level of aesthetic satisfaction score (on control examination 6 months after surgery-cosmetic score). RESULTS: In the period of the study from November 2014 to April 2016, from 175 patients with nodular thyreoid disease 102 was observed after application of the inclusion/exclusion criteria. Since in the further analysis two patients was exluded (due to histological findings of malignancy ex tempore biopsy in one patient, and because of a perceived intraoperatively expressed adhesive changes in one patient underwent conversion) in statistical analysis patients were devided into two groups: group I patients - KM (n = 50) and group II patients - MIVAM (n = 50). The study included a total of 78 women and 22 men, it was observed that between the groups there was no statistically significant difference according to age (p = 0,16). There were no statistically significant differences between the groups in terms of the type of thyroid gland function and functional status, as well as in relation to the ultrasonographic characteristics of solitary (dominant) nodule in the subjects (the size of nodules, echogenicity nodes, the edge nodes, calcification, vascularization), the cytological diagnosis of fine needle aspiration puncture (benign, inappropriate, suspicious) and with respect to the lobe volume. The analysis of indicators of perioperative surgical methods in the group MIVAM was significantly smaller length compared to KM group (2,0 &plusmn; 0,5 cm vs. 7 &plusmn; 1,9 cm, p = 0,00), until the weight of pathoanatomic supstrate (18,3 6 &plusmn; 4 vs. 19 &plusmn; 6 5 2 g, p = 0,21), the operating time for performing a lobectomy (54 &plusmn; 14 vs. 61 &plusmn; 16 min, p = 0,25) or operative time to perform the surgery (72 &plusmn; 27 vs. 85 &plusmn; 24 min, p = 0,36) were not significantly different between the groups. The group MIVAM, early postoperative complications (bleeding, injury to the lower recurrent laryngeal nerve and hypocalcemia) occurred in 8% (4/50), and KM group in 10% (5/50), which was not statistically significant (p = 0,72). Compared to late postoperative complications, only one patient from group MIVAM registered the existence of keloids, while (permanent hypoparathyroidism, recurrent hyperthyroidism, a reaction to a foreign body) was not recorded. There was no statistically significant difference (p &gt; 0,005 for all) in the presence of histological types of findings review the removed substrate (colloid goiter, follicular adenoma, cysts, papillary carcinoma and Hashimoto&#39;s thyroiditis). Patients in MIVAM groups have significantly lower average pain intensity by VAS scale at intervals after surgery 6h, 24h and 48 h (p &lt; 0,05, for all). Total cosmetic score was significantly higher in MIVAM group compared to the KM group (18,9 &plusmn; 1,4 vs. 15,8 &plusmn; 1,3, p = 0,00). CONCLUSIONS: The incidence of early postoperative complications (intraoperative and postoperative bleeding, paresis and paralysis of the laryngeal nerve, hypocalcemia) were without significant differences between patients operated with minimally invasive method in comparison to the classical method. The average duration of minimally invasive thyroidectomy and classical thyroidectomy were without statistical significance difference, suggesting the appropriate level of surgical technique that enables the advantages of minimal invasiveness as surgical principles. Length of hospitalization after minimally invasive thyroidectomy was significantly shorter compared to conventional thyroidectomy, which significantly contributes to the overall recovery of the patient, lowering the cost of treatment. Minimally invasive thyroidectomy compared to conventional thyroidectomy, decreases the subjective feeling of postoperative pain, during hospitalization (6 and 24 h), as well as seven days after the intervention. In one-fifth of patients who underwent minimally invasive surgery method in the postoperative course of the subjective sensation of pain was not recorded. Cosmetic score as an indicator of patient satisfaction with the appearance of the scar was statistically higher in patients who underwent surgery less invasive surgical technique compared to patients who were operated by the classical method. According to the study, minimally invasive thyroidectomy has been demonstrated to be safe and superior to conventional open techniques for surgical treatment of nodular thyroid disease in patients with normal thyroid function with solitary/dominant nodule size &lt; 35 mm.</p>

O trabalho teve como objetivo desenvolver uma proposta metodológica para análise dos custos de reprocessamento de pinças de dissecção, apreensão e corte, de uso único, utilizadas em cirurgia vídeo-assistida. O reuso desses artigos é prática freqüente, no Brasil e em diversos países, tendo como justificativa seu alto custo, embora sua viabilidade técnica não tenha sido comprovada. O reuso de artigos de uso único ainda é controverso e tem sido discutido e estudado sob os aspectos técnicos, legais, éticos e de segurança. Apesar da preocupação econômica, poucos estudos foram desenvolvidos sobre o real impacto econômico do reuso e reprocessamento. Neste trabalho, foi desenvolvida proposta metodológica para cálculo de custos e aplicada em três hospitais do Estado de São Paulo, seguindo o método de estudo de casos múltiplos. Foram coletados dados referentes a três meses nas instituições pesquisadas, por meio de observação e mensuração dos tempos das diversas fases do reprocessamento, revisão de registros da Central de Materiais e Esterilização e informações do Departamento de Recursos Humanos, Almoxarifado e Lavanderia. O custo do reprocessamento mensurado foi de R$9,374 no hospital Caso nº 1, de R$6,591 no Caso nº 2 e de R$3,312 no Caso nº 3. O baixo custo verificado deve ser analisado com grande cautela para que não seja interpretado como uma justificativa ao reuso desenfreado. Ao contrário, o baixo custo é motivo de preocupação, sobretudo quando se observa que o controle de qualidade, nos três casos analisados, tem pequena participação na composição do custo final. Nenhuma das instituições adota os controles de qualidade recomendados para garantir a segurança do reprocessamento. Segundo a Associação Canadense de Assistência à Saúde (Canadian Healthcare Association), devem ser realizadas a validação do reprocessamento e a avaliação anual que incluem inspeções da limpeza dos artigos, testes de esterilidade e análise de pirógenos e de resíduos dos agentes esterilizantes. Com os dados obtidos no estudo, foi elaborada uma estimativa do custo do reprocessamento, caso fossem realizadas a validação e a avaliação anual do reuso, empregando os testes de controle de qualidade. O custo do reprocessamento, considerando a possibilidade de dez reusos do artigo, passaria a ser de R$185,19 no Caso nº 1 e R$363,10 no Caso nº 3. No Caso nº 2, em razão da baixa utilização das pinças do estudo, somente haveria vantagem econômica se o número de reusos fosse restrito a três reutilizações; o custo do reprocessamento passaria a R$595,82 o que corresponderia a 58% do preço do artigo novo. A economia anual obtida pelo reuso da pinça de corte de uso único seria de R$577.818,36 no Caso nº 1, de R$51.501,60 no Caso nº 2 e de R$275.350,40 no Caso nº 3. A grande diferença observada na economia dos casos analisados está diretamente relacionada ao número de artigos empregados anualmente e aos gastos referentes à validação e avaliação anual do reprocessamento. A economia possível não elimina a necessidade de serem analisados outros aspectos relacionados ao reuso, em especial, os técnicos e de segurança. / This study aimed to develop a methodological proposal for reprocessing cost analysis of dissection, apprehension and cutting single use instruments used in video-assisted surgeries. Reuse of such articles is a frequent practice in Brazil and many other countries, justified by their high cost, although technical viability of the process hasn’t been established. Single use articles reuse is still a controversial issue and technical, legal, ethical and safety aspects have been discussed and studied. In spite of the financial concern involved, few studies have approached the real economic impact of reuse and reprocessing of single use items. In this study a methodological proposal developed for cost calculation was applied in three hospitals in São Paulo State, according to the multiple cases study method. Data was collected comprising a three month period in the researched institutions, through observation and time measuring of the various reprocessing phases, record revision from Central Supply and Sterilization Unit and information gathered at the Human Resources Department, Articles Supply and Laundry Units. Reprocessing costs measured were of R$9,374 in hospital Case number 1, R$6,591 in Case number 2 and R$3,312 in Case number 3. Low reprocessing costs found in this study should be analyzed with great care in order to avoid interpretation as a justification for unrestrained reuse. On the contrary, the low reprocessing cost gives reason to concern when it is observed that quality control, in all three analyzed cases, has little participation in the final cost. Neither one of the institutions adopts quality control protocols recommended for reprocessing safety assurance. According to the Canadian Healthcare Association, reprocessing process validation must be undertaken as well as annual evaluations which includes cleanliness inspection of the articles, pirogenic substances analyses, sterility testing and sterilizing agents residue analysis. An estimate of the reprocessing cost was elaborated considering a scenario where process validation and annual evaluations were performed, through quality assurance tests. Reprocessing costs, considering the possibility of 10 article reuses, would then be of R$ 185,19 in Case number 1 and of R$ 363,10 in Case number 3. Regarding Case number 2, due to the low rate of usage of the article, there would only be a financial advantage if the number of reuse would be restricted to 3 reutilizations: reprocessing costs would then be R$ 595,82 which corresponds to 58% of the price of a new article. Annual economic saving obtained through reuse of the single use cutting instrument would be of R$ 577.818,36 in Case number 1, of R$51.501,60 in Case number 2 and of R$ 275.350,40 in Case number 3. The great difference observed in the savings for the analyzed cases is directly related to the number of articles used annually and to the expenses related to validation processes and the reprocessing protocol annual evaluation. Financial saving obtained does not eliminate the need to analyze other aspects related to reuse, mainly those concerning technical and safety aspects.

INTRODUÇÃO: Com o avanço da tecnologia, alguns equipamentos vêm sendo incorporados ao ato operatório, dentre eles os robôs, que apesar da notoriedade ainda são considerados controversos. MÉTODO: Trabalho clínico aleatorizado, duplo cego, avaliando a segurança e a eficiência, na cirurgia torácica videoassistida, para o tratamento da hiperidrose palmar/axilar, comparando o grupo \"Hu\" (auxiliar humano) e o grupo \"Ro\" (auxiliar robô), na manipulação da ótica. Foram analisados 38 casos, 19 casos em cada grupo, \"Hu\" e \"Ro\". Todos os procedimentos foram realizados sob anestesia geral, com secção do nervo simpático ao nível T3, T4 e G3. Os procedimentos foram filmados e gravados, sendo que dois observadores independentes avaliaram: número de movimentos inadvertidos, toques em estruturas da cavidade torácica e número de vezes em que a ótica foi retirada para limpeza. Foram avaliados, ainda, os seguintes parâmetros: 1. quanto à segurança - intercorrências cirúrgicas, dor torácica e aspecto da cicatriz; 2. quanto à eficácia - tempos total, cirúrgico e de utilização de ótica, presença de anidrose palmar/axilar, permanência hospitalar, hiperidrose vicariante e satisfação com o resultado do procedimento. RESULTADOS: Os resultados obtidos comparando o grupo \"Hu\" e \"Ro\", quanto à segurança, mostram que não houve diferença estatisticamente significativa nos seguintes parâmetros: intercorrências cirúrgicas, movimentos inadvertidos, dor torácica e aspecto da cicatriz entre os dois grupos. Porém, o número de toques em estruturas na cavidade torácica foi menor no grupo \"Ro\" (p<0,001). Quanto à eficácia, não ocorreu diferença estatisticamente significativa entre os dois grupos nos seguintes parâmetros: número de vezes em que a ótica foi retirada para limpeza, presença de anidrose palmar/axilar, permanência hospitalar, hiperidrose vicariante e grau de satisfação com o resultado do procedimento. Porém, o grupo \"Hu\" apresentou menor tempos total, de cirurgia e de utilização da ótica (p<0,001), quando comparado ao grupo \"Ro\". CONCLUSÕES: Podemos concluir que o auxílio da robótica no manuseio da ótica, na cirurgia videoassistida para realização de simpatectomia torácica para tratamento da hiperidrose, é seguro e eficiente, quando comparado ao auxílio humano. / INTRODUCTION: With the advance of technology, some pieces of equipment have been incorporated into the surgical act, among which robots, that, in spite of their notoriety, are still considered controversial. METHOD: A randomized double blind clinical study to evaluate the safety and efficiency in video-assisted thoracic surgery for the treatment of palmar/axillary hyperhidrosis, comparing the \"Hu\" (human-assisted) group and the \"Ro\" (robot-assisted) group, in the manipulation of the optics. Thirty-eight cases were analyzed, 19 cases in each group, \"Hu\" and \"Ro\". All the procedures were conducted under general anesthesia, with the ablation of the sympathetic nerve at T3, T4 and G3 levels. The procedures were recorded, in that two independent observers assessed: the number of involuntary movements, contact with structures of the thoracic cavity, and the number of times in which the optics was removed to be cleaned. The following parameters were also assessed: 1. on safety - surgical events, thoracic pain and scar appearance; 2. on efficiency - total times, surgical and optics use, presence of palmar/axillary anhydrosis, hospital stay, vicarious hyperhidrosis and satisfaction with the result of the procedure. RESULTS: The results obtained by comparing the \"Hu\" and \"Ro\" groups on safety show there was no significant statistical difference in the following parameters: surgical events, involuntary movements, thoracic pain and scar appearance between the two groups. However, the number of contacts with structures in the thoracic cavity was less in the \"Ro\" group (p<0.001). On efficiency, there was no significant statistical difference between the two groups in the following parameters: number of times in which the optics was removed to be cleaned, presence of palmar/axillary anhydrosis, hospital stay, vicarious hyperhidrosis, and the level of satisfaction with the result of the procedure. However, the \"Hu\" group presented less total time of surgery and of optics use (p<0.001), when compared to the \"Ro\" group. CONCLUSIONS: We can conclude that the robot-assisted procedure in handling the optics in video-assisted thoracic sympathectomy for the treatment of hyperhidrosis is safe and efficient when compared to the human-assisted procedure.

1. INTRODUCTION Spontaneous pneumothorax is one of the most common types of aeropathic syndrome, caused by chronic obstructive pulmonary diseases, tuberculosis and complicated lung cancer. Nearly two hundred years have passed since the first description of the first cases of pneumothorax. Although during this period the scientist´s view of the etiology, pathogenesis, diagnostics and treatment methods has changed, a number of issues related to the diagnostics and treatment of this complication of pulmonary diseases remain unsolved. The aim of the treatment of spontaneous pneumothorax is to remove the cause of this condition, to perform the decompression of the pleural cavity, to induce the obliteration of the pleural cavity and to prevent the recurrence of the disease. Pleural puncture and drainage of the pleural cavity are not sufficiently effective – the incidence of incomplete lung expansion and rapid recurrence of the disease (relapse) reaches 25% [Mova VA, 1999]. Urgent thoracotomy is performed in cases when the drainage of the pleural cavity fails to reduce the symptoms of the aeropathic syndrome and breathing and blood circulation insufficiency caused by the spontaneous pneumothorax. Frequently thoracotomy is performed after pleural drainage in cases of exudative pleuritis or starting pleural empyema. The postoperative period is marked by a large number of complications and prolongation of hospital stay, and post-operative mortality in the group of geriatric... [to full text]

Conselho Nacional de Desenvolvimento Científico e Tecnológico / There are lot of respiratory diseases in small animals, as well as the possibilities of diagnoses, as laboratory and radiographic exams, bronchoalveolar lavage and biopsies, but all of them in association with a detailed physical examination. This research aimed at assessing of the results of transdiaphragmatic paraxiphoid thoracoscopies in pulmonary biopsies of thirteen clinically healthy dogs. Under general anesthesia, each dog was insufflated with 30ml kg-1 of air in each hemithorax; two trocars were placed between the xiphoid appendix and the costal arch through the diaphragm. An endoscope was introduced by the first portal; while the second portal was used to allow access to the nippers in the biopsy forceps. Then, these nippers were removed and replaced by chest tube drainage. During the procedures, respiratory frequency, heart rate, oxygen saturation, arterial pressure and central venous pressure (CVP), hemogasometric parameters were checked. Within 48 hours after the surgery, drains were or drain was removed, with minimal production of air and/or liquid. In conclusion, this is a fast and safe technique, which is free of trans and post surgical complications, thus allowing the collection of sufficient material for pulmonary histological evaluation. / São numerosas as enfermidades respiratórias na clínica médica de pequenos animais, assim como as possibilidades de diagnósticos. Dentre eles, encontram-se os exames laboratoriais, os estudos radiográficos, os lavados broncoalveolares e as biópsias, associados sempre a um criterioso exame físico. Nesta pesquisa, avaliaram-se os resultados da toracoscopia paraxifóide transdiafragmática para a realização de biópsia pulmonar em cães, sendo utilizados para tanto, 13 animais clinicamente sadios. Sob anestesia geral, produziu-se pneumotórax no volume de 30ml kg-1 de ar ambiente para cada hemitórax e foram posicionados dois trocartes, entre o apêndice xifóide e o arco costal, transpassando o diafragma. No primeiro, introduziu-se o endoscópio e no segundo uma pinça saca-bocado para a obtenção de biópsia. Em seguida, a pinça foi removida e foi alocado um dreno torácico. Durante os procedimentos, aferiram-se as freqüências respiratória e cardíaca, a saturação de oxigênio, as pressões arterial média e venosa central e os parâmetros hemogasométricos. Os drenos foram removidos num período de até 48 horas de pós-operatório, verificando-se mínima produção de ar e/ou líquido. Concluiu-se se tratar de uma técnica rápida, segura e sem complicações trans e pós-operatórias, permitindo aquisição de material suficiente para a avaliação histológica do pulmão.