“Cartas al editor” / Revisión por pares

Esta pesquisa utilizou a revisão sistemática com o objetivo de identificar os principais tratamentos da fístula faringocutânea após a laringectomia total e elaborar recomendações para as intervenções de enfermagem na assistência ao paciente submetido a laringectomia total, com a complicação fístula faringocutânea. Foram previamente localizados 1007 estudos, dos quais foram selecionados 37 estudos publicados em periódicos científicos indexados no Pubmed, Biomednet, Cinahl, Cochrane Library, MEDLINE e LILACS, desses 17 (46%) abordavam o tratamento da fístula faringocutânea, após laringectomia total, 10 (27%) discutiam os fatores de risco e os outros 10 (27%) as complicações após a laringectomia total. A análise desses artigos revelou que o delineamento da pesquisa predominante nos estudos foi o retrospectivo com 88,5%, e 11,5% prospectivos. A média de tempo de acompanhamento foi de 8,8 anos e a incidência de fístula faringocutânea, após a laringectomia total variou entre 8,7% e 27,0%, envolvendo um total de 635 pacientes. Os fatores de risco estudados pelos pesquisadores foram: radioterapia pré-operatória, técnica cirúrgica, traqueostomia pré-operatória, estadiamento do tumor, febre, doenças crônicas, vômito, nível de hemoglobina e reinício da alimentação oral, formando subgrupos com um número menor de pacientes e, conseqüentemente obtiveram percentuais individuais maiores de incidência da fístula faringocutânea, quando comparados com o índice geral de fístula proveniente da amostra inicial do estudo. O tratamento conservador e cirúrgico da fístula tem por finalidade preservar e restaurar a região lesada e envolve um processo complexo, dinâmico e sistêmico. Esta complicação aumentou o período de internação e de cicatrização, com médias de 28 e de 36 dias respectivamente. O tratamento predominante é ainda o conservador que implica cuidados higiênicos intensivos e o tratamento da ferida. O planejamento da assistência de enfermagem alicerçado em conhecimentos e habilidades técnico-científicas acerca do tratamento de feridas aliadas à dimensão psicossocial resultarão em intervenções de maior qualidade.A incorporação de conhecimentos oriundos da prática baseada em evidências na prática clínica, trará maior consistência à atuação do enfermeiro no cuidado do laringectomizado total e portador de fístula faringocutânea. / This research carried out a systematic review aimed at identifying the main treatments of pharyngocutaneous fistula after total laryngectomy and at elaborating recommendations for nursing interventions in care delivered to patients submitted to total laryngectomy, including the pharyngocutaneous fistula complication. In advance, 1007 studies were found, out of which we selected 37 studies published in scientific journals indexed in Pubmed, Biomednet, Cinahl, Cochrane Library, MEDLINE and LILACS. Among these, 17 (46%) dealt with the treatment of pharyngocutaneous fistula after total laryngectomy, 10 (27%) discussed the risk factors and the other 10 (27%) were about complications after total laryngectomy. The analysis of these articles revealed that the predominant research orientation was retrospective (88.5%) and 11.5% corresponded to prospective studies. Average follow-up time was 8.8 years and the occurrence of pharyngocutaneous fistula after total laryngectomy varied from 8.7% to 27.0%, involving 635 patients in total. Analyzed risk factors were: pre-operative radiotherapy, surgical technique, pre-operative tracheostomy, tumor stage, fever, chronic disease, vomiting, hemoglobin level and restarting oral feeding. These constitute subgroups with a lower number of patients which, consequently, obtained higher individual percentage values for the occurrence of pharyngocutaneous fistula in comparison with the general fistula rate from the initial study sample. The conservative and surgical treatment of fistula aims to preserve and restore the injured region and involves a complex, dynamic and systemic process. This complication increased the internment and healing periods, with an average duration of 28 and 36 days respectively. The conservative treatment still predominates and implies intensive hygienic care and wound treatment. The planning of nursing care, based on technical-scientific knowledge and abilities related to wound treatment, in association with the psychosocial dimension, will result in higher-quality interventions. Incorporating evidence-based knowledge into clinical practice will offer greater consistency to nursing actions in caring for patients after total laryngectomy who suffer from pharyngocutaneous fistula.

Objetivos - A Neurografia por ressonância magnética (RM) tem sido usada para avaliar estruturas nervosas (nervos e plexos nervosos) por proporcionar melhor contraste entre essas estruturas e os tecidos circundantes. O objetivo deste estudo é investigar a reprodutibilidade do uso da neurografia pela técnica de difusão por ressonância magnética (DW-MR) para avaliar o plexo lombar no planejamento de artrodese com acesso lateral transpsoas. Outro objetivo é avaliar se a frequência em que os ramos do plexo lombar são encontrados nas diferentes zonas nos interespaços L3-4 e L4-5 é alterada quando do uso de diferentes espessuras de retratores cirúrgicos. Métodos Noventa e quatro pacientes (188 plexos lombares) com dor lombar e doenças degenerativas da coluna foram submetidos a DW-MR do plexo lombar relativa aos espaços discais L3-4 e L4-5, e terço superior do corpo vertebral de L5. As imagens foram reconstruídas no plano axial, com cortes de alta resolução de 10 mm de espessura sobre o espaço discal e de 22 mm em L3-4 e L4-5, simulando a zona de trabalho de retratores usados de rotina no acesso transpsoas. As posições da raiz de L4 e do nervo femoral foram analisadas em relação ao disco L4-5 e confirmadas nos planos sagitais. Radiologista e um cirurgião de coluna experiente realizaram as avaliações das imagens de forma às cegas e independente. Para aferir o grau de concordância intra e interobservadores aplicamos o teste de Kappa. Resultados. O plexo lombar foi identificado com êxito em todos os pacientes. Em L3-4, todos, os componentes do plexo (exceto o nervo genitofemoral) foram localizados no quadrante mais posterior do espaço discal (zona IV), exceto em um caso. As raízes de L3 e de L4 coalesceram-se no nervo femoral abaixo do espaço discal L4-5 em todos os sujeitos. Variação lado a lado foi observada, estando o plexo localizado na zona IV em 86,2% pacientes à direita e 78,7 % à esquerda. No terço superior de L5, o plexo foi encontrado na zona III em 27,7 % à direita e em 36,2% à esquerda; e na zona II em 4,3% à direita e em 2,1% à esquerda. Encontramos uma concordância substancial intra e interobservadores (com valores de Kappa entre 0,6 e 0,79, para o índice de concordância intra e interobservador, nos grupos de 10 e 22 mm em ambos os lados). Conclusão: O mapeamento pré-operatório do plexo lombar por meio da neurografia por DW-MR se mostrou reprodutível intra e intraobservadores e, portanto, tem potencial para melhorar o perfil de segurança dos procedimentos por acesso lateral. / Purpose - Magnetic resonance (MR) neurography has been used to evaluate entire nerves and nerve bundles by providing better contrast between the nerves and the surrounding tissues. The purpose of the study was to validate diffusion-weighted MR (DW-MR) neurography in visualizing the lumbar plexus during preoperative planning of lateral transpsoas surgery. Methods - Ninety-four (188 lumbar plexuses) spine patients underwent a DW-MR examination of the lumbar plexus in relation to the L34 and L45 disc spaces and superior third of the L5 vertebral body. Images were reconstructed in the axial plane using high-resolution Maximum Intensity projection (MIP) overlay templates at the disc space and L34 and L45 interspaces. 10 and 22 mm MIP templates were chosen to mimic the working zone of standard lateral access retractors. The positions of the L4 nerve root and femoral nerve were analyzed relative to the L45 disc in axial and sagittal planes. Third-party radiologist and a senior spine surgeon performed the evaluations, with inter- and intraobserver testing performed (Kappa test). Results - In all subjects, the plexus was successfully mapped. At L34, in all but one case, the components of the plexus (except the genitofemoral nerve) were located in the most posterior quadrant (zone IV). The L3 and L4 roots coalesced into the femoral nerve below the L45 disc space in all subjects. Side-to-side variation was noted, with the plexus occurring in zone IV in 86.2 % right and only 78.7 % of left sides. At the superior third of L5, the plexus was found in zone III in 27.7 % of right and 36.2 % of left sides; and in zone II in 4.3 % right and 2.1 % left sides. Significant inter- and intraobserver agreement was found. (Kappa test values ranging from 0,6 to 0,79, for intra and interobserver concordance index, in 10 and 22 mm groups, both sides). Conclusions - By providing the surgeon with a preoperative roadmap of the lumbar plexus, DW-MR may improve the safety profile of lateral access procedures.

Pancreatic pseudocyst is a common complication of pancreatitis. Pseudocysts may require decompression when they become painful, infected, or start compressing surrounding organs. Decompression is achieved by endoscopic cystogastrostomy. Recently, the use of lumen-apposing metal stent (LAMS) for cystogastrostomy has gained popularity due to ease of use and high technical success. LAMS has a wider lumen, which allows for direct endoscopic necrosectomy in the cases of walled-off necrosis. Our patient is a 30-year-old male who presented with massive hematemesis and dizziness. He had a history of chronic alcohol-induced pancreatitis. Three weeks before the presentation, he underwent a cystogastrostomy with LAMS placement to treat a 10-cm walled-off necrosis. Urgent computed tomography (CT) scan did not reveal any acute finding suggestive of bleeding. Esophagogastroduodenoscopy showed blood protruding from the LAMS with a large clot formation. Attempts to stop bleeding were unsuccessful. He underwent CT angiography of the abdomen. CT angiography showed a bleeding pseudoaneurysm (PA) believed to be a complication of the LAMS. Subsequently, multiple coils were placed in the splenic artery near the PA. The patient continued to improve without a further drop in hemoglobin and was eventually discharged. PA formation and subsequent rupture is a rare delayed complication of LAMS. It may lead to massive gastrointestinal bleeding with a high mortality rate. Diagnostic delays have resulted in increased mortality by 60%. In this article, we present a case of massive gastrointestinal bleeding due to a ruptured splenic artery PA presenting as a delayed complication of LAMS.

Objective: This study was undertaken to determine the most appropriate management of the subcutaneous tissue of midline vertical incisions with 3 cm or more of subcutaneous fat. Study design: Patients undergoing surgery within the Division of Gynecologic Oncology at University of South Florida and East Tennessee State University with 3 cm or more of subcutaneous fat were randomly assigned to 1 of 3 groups: suture approximation of Camper's fascia, closed suction drainage of the subcutaneous space, or no intervention as a control group. Participants were evaluated daily during postoperative hospitalization and at 2 and 6 weeks postoperatively as an outpatient. Demographic information, perioperative data, and wound complications were recorded and then analyzed with χ2, t test, analysis of variance, and logistic regression where appropriate. Results: Two hundred twenty-five patients were enrolled with 222 eligible for evaluation. Wound complications were observed in 34 (15.3%) patients, and 25 of these women also had wound disruption. Overall wound complication and wound disruption rates were not significantly different between groups: suture (12.8%, 7.7%), drain (17.9%, 14.9%), control (15.6%, 11.7%); P = .70 and P = .39, respectively. Conclusion: Suture approximation or drainage of the subcutaneous tissues of women with 3 cm or more subcutaneous fat measured in midline vertical incisions resulted in no significant change in the incidence of overall wound complications or superficial wound disruption.

Postoperative corneal complications from pars plana vitrectomy surgery on the retina have been studied extensively in the literature. Researchers are aware of possible issues with oil tamponades, laser techniques, and other methods used. There could be clear markers to focus on a pattern of retina diagnoses of the patients that seem more prone to these problems in the front of the eye. Studies have noted refractive issues and increased cataract or posterior capsule opacification (PCO) progression but it is inconclusive in many studies on a corneal safety standpoint. Furthermore, a 23 or 27gauge pars plana vitrectomy has varying protocols depending on the diagnosis of the retina patient including endolaser, tamponade exchange, or even endoscopic cyclophotocoagulation. This study was conducted to research data looking at varying combinations of surgical type, diagnosis, and other patient characteristics to gain statistical evidence or relative frequency to better understand what type of retinal demographics cause corneal complications. The list of corneal complications in this study include: visual distortion involving anisometropia or photophobia, increased intraocular pressure including Uveitis-Glaucoma Hyphema syndrome, allergic conjunctivitis, a lens subluxation, herpes virus (zoster or simplex), a corneal scar or lesion, neurotrophic cornea, bullous keratopathy and corneal neovascularization. This was a retrospective case study evaulating 57 patients and 58 eyes that underwent a retinal surgery, with corneal complications at Beth Israel Deaconess Medical Center between October 2013 to December 2016. Number of patients, systemic demographics including frequency of hypertension and diabetes, and frequency of retina surgery per eye was analyzed. Moreover, we looked at different retina diagnoses to view which groups have a higher occurrence of complications after surgery. We used silicone oil as a way to divide the corneal complication patients to determine if the use of oil had an effect on a higher rate of issues after surgery. Eyes were divided into treatment with silicone oil group (n=23) and a non-silicone oil group (n=34), and we found that the silicone group had a significantly higher frequency of retinal surgeries (p<0.001). Moreover, there was no significant evidence between certain systemic factors (p<0.05), that allowed us to include the silicone oil and non-silicone oil patients as a unified group. When looking at our retina diagnoses we saw some groups had a higher percentage of complications when we took total number of problematic postoperative outcomes and divided that by total number of surgeries. Over one quarter of the surgeries per category leading to corneal complications occurred in the categories of subluxed lens, endophthalmitis, trauma, and uveitis-glaucoma hyphema Syndrome or neovascular glaucoma. Vitreomacular traction similarly had a high percentage of patients with corneal complications. Retinal detachment and epiretinal membrane were largest quantities of a specific retinal problem with low percentages of fewer than 15% with complications postoperatively. The study found that in our patient demographic silicone oil did not seem to be a factor in causing more corneal complications but it did cause more retinal surgeries. Moreover, certain retina diagnoses seem more prone to cause challenging outcomes, which leaves room for further studies distinguishing certain factors that could cause such specific issues.

Use of skilled care during antenatal visits and delivery is recommended to address the burden of maternal mortality. However there are few facility deliveries and insufficient knowledge of danger signs, especially in rural Tanzania.  The aim of this thesis was to explore the perceptions and challenges that the community faces while preparing for childbirth and to evaluate an intervention of the Home Based Life Saving Skills education programme on knowledge of danger signs, facility delivery and male involvement when delivered by rural community health workers in Tanzania. In Paper I, Focus Group Discussions explored the perceptions and challenges that the community encounters while preparing for childbirth. Structured questionnaires assessed men’s knowledge of danger signs and birth preparedness and complication readiness in Paper II. The effect of the Home Based Life Saving Skills education programme in the community was assessed with a before-and-after evaluation in two districts; one intervention and one comparison. Paper III assessed the effect of the programme on knowledge of danger signs and birth preparedness and facility delivery among women, while Paper IV evaluated its effect on male involvement. The community perceived that all births must be prepared for and that obstetric complication demands hospital care; hence skilled care was favoured. Men’s knowledge of danger signs was limited; only 12% were prepared for childbirth and complications. Preparedness was associated with knowledge of obstetric complications (AOR=1.4 95% CI 1.8 – 2.6). The intervention showed women utilizing antenatal care (four visits) significantly more (43.4 vs 67.8%) with a net effect of 25.3% (95% CI: 16.9 – 33.2; p &lt; .0001). The use of facility delivery improved in the intervention area (75.6 vs 90.2%; p = 0.0002), but with no significant net effect 11.5% (95% CI: -5.1 – 39.6; p = 0.123) when comparing the two districts. Male involvement improved (39.2% vs 80.9%) with a net intervention effect of 41.1% (CI: 28.5 – 53.8; p &lt; .0001). Improvements were demonstrated in men’s knowledge level, in escorting partners for antenatal care and delivery, making birth preparations, and shared decision-making. The intervention, in educating this rural community, is effective in improving knowledge, birth preparedness, male involvement and use of skilled care.

Background: Minor procedures in surgery and urology such as groin hernia and hydrocele repair, as well as prostate biopsies are very frequently done in routine practice. Complications and insufficient outcomes thus affecting many patients and the cumulative effect of this are of major importance in a population perspective. Aim: To explore complications and outcomes of surgical or diagnostic procedures and possible risk factors or predictors for adverse effects. Methods: By using both national quality and administrative registers, and by complementing registers with patient reported outcome measures, examine outcomes such as complications, persistent pain and recurrences. Also, in the case of hydro and spermatoceles, report incidence numbers. Further, by using a randomized trial, explore minimally invasive procedure such as sclerotheraphy compared to conventional surgery in respect to cure and adverse events. Results: When comparing with the open anterior mesh repair, endoscopic technique is advantageous in respect to the patient reported outcome of persistent pain. The drawback was an increased risk of postoperative complications and reoperation for recurrence. Incidence numbers for hydro and spematocele were 100/100000 men. Aspiration (± sclerotherapy) had a significantly lower rate of complications as compared to conventional surgery. In the interim analysis of the randomized trial, comparing sclerotherapy to Lord´s procedure for hydroceles, the cure rate was similar between treatments. Definite conclusions cannot be made due to the risk of type 2 errors, and the study will thus continue. In the case of trans-rectal prostate biopsy, the rates increased every year during the study time frame, up to an approximate risk of two per cent in 2012 for hospital readmission within 30 days, without an increased mortality within 30 days. Conclusions: The open anterior mesh procedure is still the preferred method for groin hernia repair in routine surgical practice. Hydro and spermatocele surgery is associated with high rates of complications, and the indication for repair should be scrutinized. The rates of infection after prostate biopsy is increasing and methods to reduce unnecessary biopsies as well as improved prophylaxis should be investigated.

Subciliary and transconjunctival approaches are commonly used to enter the orbital floor. Although both surgical approaches have been used for decades, there is no consensus regarding the most appropriate incision to prevent postoperative lower eyelid complications. The aim of this study was to compare the frequencies of lower eyelid complications after subciliary versus transconjunctival approaches to orbital floor fractures. The investigator implemented a retrospective cohort study and enrolled a sample consisting of subjects who had orbital floor repair. The predictor variable was two different surgical methods, subciliary or transconjunctival approch. The primary outcome variable was postoperative lower eyelid complications (ectropion, entropion, and eyelid retraction). Other variables were demographic backgrounds, anatomical consideration, or time to surgery. The samples were composed of 346 patients (98 [28.3%] females; 225 [65%] underwent a subciliary approach) with a mean age of 42.7 ± 21.1 years. The subciliary approach was significantly linked to the higher rates of ectropion and the lower rates of entropion at 7 days and 6 months postoperatively. There was no statistically significant difference in the frequency of eyelid retraction between both groups. In the setting of orbital floor fractures, these results suggest that the use of the subciliary approach increases the frequency of ectropion, while the transconjunctival approach increases the frequency of entropion. Consequently, the selection should be based on an individual patient basis and surgeon’s preference.

A common problem following general anesthesia is postoperative sore throat (POST) and postoperative hoarseness (PH). Symptoms directly correlated with less satisfaction according to the patients. The overall aim of this thesis was to describe patients' postoperative sore throat and hoarseness after general anesthesia with endotracheal intubation or laryngeal mask airway. As well as to investigate the risk factors that are associated with the symptoms, and to test methods that may prevent sore throat and hoarseness after a general anaesthetics. A total of 889 patients are included in the four studies. Incidence of POST varied from 21% up to 52 % depending on endotracheal tube (ETT) size in women (I-IV) and in men was the incidence 32-38% (III-IV). There were no gender difference in POST in study III and IV. The overall incidence of PH varied from 42- 59% (I-IV) in all patients, with no gender differences (III-IV). Following a laryngeal mask airway (LMA) 19% of the patients had POST and 33% of the patients reported PH. Patients with POST do seem to be able to localize their pain in the throat (IV). Different risk factors are shown to contribute to both POST and PH in men and women (II-III). To intubate with a smaller ETT size, 6.0 vs. 7.0 decreased POST in women in the early postoperative period as well as their discomfort from their POST (I). Only 6% of men who needed a laryngeal mask airway had POST compared to 26% of women. The symptoms are more discomforting after an ETT vs. an LMA up to 24 hours (IV). More patients have sore throat and hoarseness in the early postoperative period, but the symptoms can remain up to almost 5 days postoperatively (I, IV). In summary, sore throat and hoarseness following general anesthesia, affects many patients postoperatively. To intubate women with endotracheal size 6.0 decreases both sore throat and hoarseness postoperatively. Women are more likely than men to have a sore throat when a laryngeal mask airway is used.