Objective - To verify the incidence of the wounds of the pulmonary hilum in a public hospital Emergency Unit, and the mortality rate. Means of access, operative techniques and tatics of operation used were also evaluated. Patients and methods - One thousand, one hundred and twenty-four patients with chest trauma were registered at the thoracic surgery unit from April, 1992 to October, 1996. A hundred eighty-two thoracotomies (16.19%) were performed and indication for lung resection was present in only four cases (2.20%). Results - The way of access most commonly used was anterolateral, in three cases, and posterolateral in another case. Two lobectomies and one pneumonectomy were performed. In only one patient a clamping of the hilum was utilized, but the patient died due to massive bleeding. Two other patients died in a total of three deaths. There was only one survivor in this series, who did not present any complication. Conclusion - A low incidence of indication for lung resections was observed in trauma, however, mortality was extremely high due to the lesion involving a high life risk. The most commonly used access was the anterolateral because of the short time needed to clamp the pulmonary hilum, and it was used for all cases of success.

Keywords: Thoracic trauma. Lobectomy. Pneumonectomy.

Objective: To identify the risk factors for pulmonary complications after thoracotomy for the resection of pulmonary nodules in patients with sarcoma. Methods: A retrospective cohort study involving 68 consecutive patients diagnosed with sarcoma and submitted to a total of 174 thoracotomies for the resection of pulmonary nodules. The dependent variable was defined as the occurrence of any postoperative pulmonary complications. The independent variables were related to the patient, underlying diagnosis, and type of surgical procedure. We analyzed the data using a multivariate generalized estimating equations model with logistic link function and a symmetric correlation structure. Results: Complications were observed in 24 patients (13.8%, 95% CI: 9.0-19.8), and there was one death. The mean length of hospital stay was twice as long in the patients with postoperative complications as in those without (18.8 ± 10.0 days vs. 8.6 ± 6.0 days; p < 0.05). The variables that correlated with the outcome measure were the type of resection (wedge vs. anatomic; OR = 3.6; 95% CI: 1.5-8.8), the need for blood transfusion (OR = 9.8; 95% CI: 1.6-60.1), and the number of nodules resected (OR = 1.1; 95% CI: 1.0-1.1). The multivariate model showed an area under the ROC curve of 0.75 (95% CI: 0.65-0.85). Conclusions: Postoperative pulmonary complications were common after pulmonary nodule resection in patients with sarcoma, occurring in approximately 10% of the procedures. The occurrence of such complications can be expected when techniques other than wedge resection are employed, when blood transfusion is required, and when a great number of nodules are resected. Therefore, it is possible to identify patients at risk for pulmonary complications, who should be closely monitored in the immediate postoperative period. In such patients, all preventive measures should be taken.

Keywords: Sarcoma; Neoplasm metastasis; Risk; Thoracotomy; Thoracic surgery.

Objective: To evaluate the effects that pulmonary resection has on pulmonary function and quality of life (QoL) in patients with primary or metastatic lung cancer. Methods: This was a prospective cohort study involving all patients submitted to pulmonary resection for cancer between September of 2006 and March of 2007 at the A. C. Camargo Hospital in São Paulo, Brazil. Patients underwent spirometry in the preoperative period and at six months after the surgical procedure. After a postoperative period of six months, the patients completed an overall QoL questionnaire (the Medical Outcomes Study 36-item Short-form Health Survey) and another one, specific for respiratory symptoms (the Saint George's Respiratory Questionnaire). The scores obtained in our study were compared with those previously obtained for a general population and for a population of patients with COPD. Results: We included 33 patients (14 males and 19 females), ranging in age from 39 to 79 years. All of the patients, smokers and nonsmokers alike, presented significant worsening of pulmonary function. The mean scores on the overall QoL questionnaire were approximately 5% lower than those obtained for the general population. The scores of various domains of the symptom-specific QoL questionnaire were 50-60% lower than those obtained for the general population and approximately 20% higher than those obtained for the population with COPD. Conclusions: Pulmonary resection has a direct negative impact on pulmonary function and QoL, especially on the QoL related to aspects directly linked to pulmonary function. We highlight the importance of preoperative assessment of pulmonary function in patients undergoing pulmonary resection, in order to predict their postoperative evolution.

Keywords: Thoracic surgery; Lung neoplasms/surgery; Spirometry; Quality of life; Questionnaires.

Surgical resection is the primary treatment option for early-stage non-small cell lung cancer, lobectomy being considered the standard of care. In elderly patients, physiological characteristics can limit the suitability for surgery and the extent of resection. Sublobar resection (SLR) can be offered as an alternative. The aim of this real-world analysis was to compare lobectomy and SLR in terms of recurrence and survival rates in patients over 70 years of age.

Keywords: Carcinoma, non-small-cell lung/mortality; Carcinoma, non-small-cell lung/surgery; Recurrence; Aged; Aged, 80 and over.

Objective: Preoperative functional evaluation is central to optimizing the identification of patients with non-small cell lung cancer (NSCLC) who are candidates for surgery. The minute ventilation/carbon dioxide output (VE/VCO2) slope has proven to be a predictor of surgical complications and mortality. Pulmonary rehabilitation programs (PRPs) could influence short-term outcomes in patients with COPD undergoing lung resection. Our objective was to evaluate the effects of a PRP on the VE/VCO2 slope in a cohort of patients with COPD undergoing lung resection for NSCLC. Methods: We retrospectively evaluated 25 consecutive patients with COPD participating in a three-week high-intensity PRP prior to undergoing lung surgery for NSCLC, between December of 2015 and January of 2017. Patients underwent complete functional assessment, including spirometry, DLCO measurement, and cardiopulmonary exercise testing. Results: There were no significant differences between the mean pre- and post-PRP values (% of predicted) for FEV1 (61.5 ± 22.0% vs. 62.0 ± 21.1%) and DLCO (67.2 ± 18.1% vs. 67.5 ± 13.2%). Conversely, there were significant improvements in the mean peak oxygen uptake (from 14.7 ± 2.5 to 18.2 ± 2.7 mL/kg per min; p < 0.001) and VE/VCO2 slope (from 32.0 ± 2.8 to 30.1 ± 4.0; p < 0.01). Conclusions: Our results indicate that a high-intensity PRP can improve ventilatory efficiency in patients with COPD undergoing lung resection for NSCLC. Further comprehensive prospective studies are required to corroborate these preliminary results.

Keywords: Carcinoma, non-small-cell lung; Pulmonary disease, chronic obstructive/rehabilitation; Carbon dioxide/metabolism; Oxygen consumption/physiology; Risk assessment.

Objective: To describe our experience with video-assisted thoracic surgery (VATS) for anatomic pulmonary resection at a referral center for thoracic surgery in Brazil. Methods: All patients who underwent anatomic pulmonary resection by VATS between 2010 and 2015 were included. Clinical and pathological data, as well as postoperative complications, were analyzed. Results: A total of 117 pulmonary resections by VATS were performed, of which 98 were lobectomies and 19 were anatomic segmentectomies. The mean age of the patients was 63.6 years (range, 15-86 years). Females predominated (n = 69; 59%). The mean time to chest tube removal was 2.47 days, and the mean length of ICU stay was 1.88 days. The mean length of hospital stay was 4.48 days. Bleeding ≥ 400 mL occurred in 15 patients. Conversion to thoracotomy was required in 4 patients. Conclusions: Our results are similar to those published in major international studies, indicating that VATS is an important strategy for pulmonary resection. They also show that VATS can be safely performed with adequate training. This technique should be used more often for the treatment of lung diseases in Brazil.

Keywords: Lung neoplasms/therapy; Lung neoplasms/complications; Thoracic surgery, video-assisted.

Objective: To compare two thoracotomy closure techniques (pericostal and transcostal suture) in terms of postoperative pain and pulmonary function. Methods: This was a prospective, randomized, double-blind study carried out in the Department of Thoracic Surgery of the Luzia de Pinho Melo Hospital das Clínicas and at the University of Mogi das Cruzes, both located in the city of Mogi das Cruzes, Brazil. We included 30 patients (18-75 years of age) undergoing posterolateral or anterolateral thoracotomy. The patients were randomized into two groups by the type of thoracotomy closure: pericostal suture (PS; n = 16) and transcostal suture (TS; n = 14). Pain intensity during the immediate and late postoperative periods was assessed by a visual analogic scale and the McGill Pain Questionnaire. Spirometry variables (FEV1, FVC, FEV1/FVC ratio, and PEF) were determined in the preoperative period and on postoperative days 21 and 60. Results: Pain intensity was significantly greater in the PS group than in the TS group. Between the preoperative and postoperative periods, there were decreases in the spirometry variables studied. Those decreases were significant in the PS group but not in the TS group. Conclusions: The patients in the TS group experienced less immediate and late post-thoracotomy pain than did those in the PS group, as well as showing smaller reductions in the spirometry parameters. Therefore, transcostal suture is recommended over pericostal suture as the thoracotomy closure technique of choice.

Keywords: Thoracic surgery; Suture techniques; Acute pain.

Objective: To identify preoperative characteristics associated with complete surgical resection of primary malignant mediastinal tumors. Methods: Between 1996 and 2006, 42 patients with primary malignant mediastinal tumors were submitted to surgery with curative intent at a single facility. Patient charts were reviewed in order to collect data related to demographics, clinical manifestation, characteristics of mediastinal tumors and imaging aspects of invasiveness. Results: The surgical resection was considered complete in 69.1% of the patients. Cases of incomplete resection were attributed to invasion of the following structures: large blood vessels (4 cases); the superior vena cava (3 cases); the heart (2 cases); the lung and chest wall (3cases); and the trachea (1 case). Overall survival was significantly better among the patients submitted to complete surgical resection than among those submitted to incomplete resection. The frequency of incomplete resection was significantly higher in cases in which the tumor had invaded organs other than the lung (as identified through imaging studies) than in those in which it was restricted to the lung (47.6% vs. 14.3%; p = 0.04). None of the other preoperative characteristics analyzed were found to be associated with complete resection. Conclusions: Preoperative radiological evidence of invasion of organs other than the lung is associated with the incomplete surgical resection of primary malignant mediastinal tumors.

Keywords: Thoracic surgery; Survival rate; Mediastinal neoplasms; Diagnostic imaging.

Objective: To evaluate whether the acute pain experienced during in-hospital recovery from thoracotomy can be effectively reduced by the use of intraoperative measures (dissection of the neurovascular bundle prior to the positioning of the Finochietto retractor and preservation of the intercostal nerve during closure). Methods: We selected 40 patients who were candidates for elective thoracotomy in the Thoracic Surgery Department of the Federal University of São Paulo/Paulista School of Medicine, in the city of São Paulo, Brazil. The patients were randomized into two groups: conventional thoracotomy (CT, n = 20) and neurovascular bundle preservation (NBP, n = 20). All of the patients underwent thoracic epidural anesthesia and muscle-sparing thoracotomy. Pain intensity was assessed with a visual analog scale on postoperative days 1, 3, and 5, as well as by monitoring patient requests for/consumption of analgesics. Results: On postoperative day 5, the self-reported pain intensity was significantly lower in the NBP group than in the CT group (visual analog scale score, 1.50 vs. 3.29; p = 0.04). No significant differences were found between the groups regarding the number of requests for/consumption of analgesics. Conclusions: In patients undergoing thoracotomy, protecting the neurovascular bundle prior to positioning the retractor and preserving the intercostal nerve during closure can minimize pain during in-hospital recovery.

Keywords: Pain, postoperative; Analgesia; Thoracotomy.

Abstract Objective: To evaluate the influence of pleural drainage on the distance covered on the six-minute walk test, pain intensity and vital capacity in patients submitted to pulmonary resection. Methods: Thirteen consecutive patients from the Thoracic Surgery Infirmary of Hospital São Paulo, Brazil, submitted to closed pleural drainage (0.5-in multiperforated chest tube) in the postoperative period following pulmonary resection (lobectomy, segmentectomy and pulmonary nodule resection) were evaluated. The decision for chest tube removal followed clinical criteria defined by the surgical team, who did not participate in the study. Vital capacity, pain intensity (using a visual analog pain scale) and the distance covered on the six-minute walk test were determined 30 min prior to and 30 min after the removal of the chest tube. The statistical analysis was performed using paired t-tests, and the level of significance was set at 0.05. Results: After the removal of the chest tube, the visual analog scale pain scores were significantly lower (3.46 cm vs. 1.77 cm; p = 0.001) and the distance covered on the six-minute walk test was significantly higher (374.34 m vs. 444.62 m; p= 0.03). Vital capacity prior to and after chest tube removal was not significantly affected (2.15 L and 2.25 L, respectively; p = 0.540). Conclusions: The results of the present study suggest that the presence of a chest tube is a factor significantly associated with postoperative pain and functional limitation in patients submitted to pulmonary resection.

Keywords: Thoracic surgery; Exercise test; Respiratory function tests; Pain, postoperative.

Objective: To determine whether pre-operative nutritional status and post-operative time on mechanical ventilation, as well as others factors, are correlated with post-operative complications (general or pulmonary) in patients undergoing elective thoracic surgery. Methods: A prospective study was conducted, involving 71 patients undergoing elective pulmonary resection. The data collected pre-operatively included gender, age, smoking status, pre-albumin level, lymphocyte count, and body mass index. The peri-operative data included type of surgery and surgical time, as well as post-operative time on mechanical ventilation. Results: Post-operative complications were found to correlate with low pre-albumin concentration, type of resection, surgical time, and post-operative time on mechanical ventilation. Surgical time and post-operative time on mechanical ventilation were also implicated in the post-operative pulmonary complications observed in 22 (30.99%) of the patients studied. Conclusion: Our results suggest that pre-albumin concentration, type of surgery and surgical time, as well as post-operative time on mechanical ventilation, serve as predictive indices of post-operative complications in patients undergoing elective pulmonary resection. In the analysis of the post-operative pulmonary complications, statistically significant correlations were found between such complications and increases in surgical time or post-operative time on mechanical ventilation.

Keywords: Thoracic surgery; Postoperative complications; Mechanical ventilation; Nutritional status; Prealbumin

Pulmonary blastoma is a rare lung tumor that is composed of malignant epithelial and mesenchymal cells. It presents a pattern of rapid growth. Herein, we report the case of a patient with hemoptysis and a mass in the right upper lobe. The patient presented limited pulmonary function, and fiberoptic bronchoscopy revealed invasion of the intermediate bronchus. The patient underwent sleeve resection of right upper lobe, a technique never before described. After 36 months of follow-up, the patient remained asymptomatic. We also review the literature regarding treatment, clinical aspects and pathology.

Keywords: Pulmonary blastoma/surgery; Pneumonectomy; Case reports [Publication type]

Objective: To evaluate the health-related quality of life of patients submitted to resection of the pulmonary parenchyma due to neoplasia. Methods: The Medical Outcomes Study 36-item Short-Form Health Survey was used to evaluate patients in the preoperative period and on postoperative days 30, 90 and 180. We used the GEE statistical model, in which the dependent variable (quality of life) changes for each patient over the course of the evaluation. Independent variables were gender, age, educational level, type of surgery, radiotherapy, chemotherapy, forced vital capacity and 6-minute walk test. The level of significance adopted was 5%. Results: The final study sample comprised 36 patients, 20 of whom were men. Of those 36 patients, 17 were submitted to lobectomy, 10 to pneumonectomy, 6 to segmentectomy, and 3 to bilobectomy. Chemotherapy was used in 15 patients, radiotherapy in 2, and a combination of radiotherapy and chemotherapy in 2. Improved quality of life was seen in the following domains: social (on postoperative day 90); physical/functional (some patients presenting better forced vital capacity and 6-minute walk test performance); and physical (in patients undergoing smaller resections). Lowered quality of life was seen in the following domains: social (for female patients); physical/social (resulting from radiotherapy, chemotherapy or both); and physical/functional (by postoperative day 30). Conclusions: It is important that studies evaluating the various determinants of quality of life, as well as the impact that cancer treatment modalities have on such variables, be conducted. The knowledge provided by such studies can contribute to improving the quality of life of patients undergoing pulmonary resection due to neoplasia.

Keywords: Lung neoplasms/surgery; Pneumonectomy; Quality of life; Questionnaires

Objective: To determine whether the use of a set of preoperative variables can predict the need for postoperative ICU admission. Methods: This was a prospective observational cohort study of 120 patients undergoing elective pulmonary resection between July of 2009 and April of 2012. Prediction of ICU admission was based on the presence of one or more of the following preoperative characteristics: predicted pneumonectomy; severe/very severe COPD; severe restrictive lung disease; FEV1 or DLCO predicted to be < 40% postoperatively; SpO2 on room air at rest < 90%; need for cardiac monitoring as a precautionary measure; or American Society of Anesthesiologists physical status ≥ 3. The gold standard for mandatory admission to the ICU was based on the presence of one or more of the following postoperative characteristics: maintenance of mechanical ventilation or reintubation; acute respiratory failure or need for noninvasive ventilation; hemodynamic instability or shock; intraoperative or immediate postoperative complications (clinical or surgical); or a recommendation by the anesthesiologist or surgeon to continue treatment in the ICU. Results: Among the 120 patients evaluated, 24 (20.0%) were predicted to require ICU admission, and ICU admission was considered mandatory in 16 (66.6%) of those 24. In contrast, among the 96 patients for whom ICU admission was not predicted, it was required in 14 (14.5%). The use of the criteria for predicting ICU admission showed good accuracy (81.6%), sensitivity of 53.3%, specificity of 91%, positive predictive value of 66.6%, and negative predictive value of 85.4%. Conclusions: The use of preoperative criteria for predicting the need for ICU admission after elective pulmonary resection is feasible and can reduce the number of patients staying in the ICU only for monitoring.

Keywords: Thoracic surgery; Risk factors; Intensive care units.

Objective: The objective of this study was to describe the results of anatomic pulmonary resections performed by video-assisted thoracoscopy in Brazil. Methods: Thoracic surgeons (members of the Brazilian Society of Thoracic Surgery) were invited, via e-mail, to participate in the study. Eighteen surgeons participated in the project by providing us with retrospective databases containing information related to anatomic pulmonary resections performed by video-assisted thoracoscopy. Demographic, surgical, and postoperative data were collected with a standardized instrument, after which they were compiled and analyzed. Results: The surgeons provided data related to a collective total of 786 patients (mean number of resections per surgeon, 43.6). However, 137 patients were excluded because some data were missing. Therefore, the study sample comprised 649 patients. The mean age of the patients was 61.7 years. Of the 649 patients, 295 (45.5%) were male. The majority-521 (89.8%)-had undergone surgery for neoplasia, which was most often classified as stage IA. The median duration of pleural drainage was 3 days, and the median hospital stay was 4 days. Of the 649 procedures evaluated, 598 (91.2%) were lobectomies. Conversion to thoracotomy was necessary in 30 cases (4.6%). Postoperative complications occurred in 124 patients (19.1%), the most common complications being pneumonia, prolonged air leaks, and atelectasis. The 30-day mortality rate was 2.0%, advanced age and diabetes being found to be predictors of mortality. Conclusions: Our analysis of this representative sample of patients undergoing pulmonary resection by video-assisted thoracoscopy in Brazil showed that the procedure is practicable and safe, as well as being comparable to those performed in other countries.

Keywords: Thoracic surgery, video-assisted; Thoracoscopy; Pneumonectomy.