quinta-feira, 14 de março de 2013
MANIFESTO PELO SUS
CFM encaminha manifesto de defesa do SUS às autoridades
O Conselho Federal de Medicina (CFM) já encaminhou às autoridades brasileiras e entidades representativas da área da saúde o "Manifesto de Belém". O documento alerta a sociedade e as autoridades para o impacto que algumas das recentes medidas anunciadas pelo Governo podem ter sobre o exercício da Medicina e a sobre a qualidade da assistência em saúde.
O ofício foi repassado para a presidente da República, Dilma Rousseff, e também para os ministros da Casa Civil, Saúde, Educação, Secretaria de Relações Institucionais e Secretaria de Direitos Humanos. Complementa ainda a relação de destinatários os presidentes do Supremo Tribunal Federal, Senado, Câmara dos Deputados, Conselho Nacional de Justiça, Conselho Nacional de Saúde, além do Procurador-Geral da República e parlamentares.
A mensagem também foi compartilhada com entidades médicas nacionais e regionais como a Associação Médica Brasileira, Federação Nacional dos Médicos, Sociedades de Especialidades, Federa ção das Academias Brasileiras de Medicina, dentre outras.
O texto conclama representantes da sociedade civil organizada, sindicatos, associações, fóruns de usuários, pesquisadores, estudantes, professores e outros interessados para participar de uma cruzada em defesa do Sistema Único de Saúde (SUS). Ainda alerta para medidas que, se implantadas, podem comprometer o futuro da assistência à saúde dos brasileiros.
O manifesto - O documento, aprovado na plenári a de encerramento do I Encontro Nacional de Conselhos de Medicina de 2013, realizado em Belém (PA), chama a atenção da sociedade e das autoridades para o impacto que algumas das recentes medidas anunciadas pelo Governo podem ter sobre o exercício da Medicina e a qualidade da assistência em saúde.
No ofício de encaminhamento, o CFM reforçou a preocupação dos 27 Conselhos Regionais de Medicina (CRMs) com temas como a entrada de médicos estrangeiros e de brasileiros com diplomas obtidos no exterior sem respectiva revalidação, a ausência de carreira de Estado para o médico e o estreitamento nas relaçõe s entre o Governo e as operadoras de planos de saúde.
CONFIRA A ÍNTEGRA DO MANIFESTO LOGO ABAIXO
MANIFESTO DE BELÉM
UMA MENSAGEM DOS MÉDICOS À NAÇÃO BRASILEIRA
O Conselho Federal de Medicina (CFM) e os 27 Conselhos Regionais de Medicina (CRMs), reunidos em Belém (PA), manifestam seu repúdio às ações anunciadas, recentemente, pelo Governo Federal que ferem conquistas e diretrizes constitucionais da saúde pública. As entidades alertam a sociedade brasileira para as medidas, com as quais não concordamos, que se implementadas podem comprometer o futuro do sistema de saúde brasileiro:
1) A ent rada irresponsável de médicos estrangeiros e de brasileiros com diplomas de medicina obtidos no exterior sem sua respectiva revalidação fere a norma legal, coloca a qualidade da assistência à população em situação de risco e não garante a ampliação definitiva de acesso à assistência nas áreas de difícil provimento. Trata-se de proposta improvisada, imediatista e midiática, que ignora as questões estruturais do trabalho médico no Sistema Único de Saúde (SUS) e também o Revalida, exame criado pelo Governo que tem avaliado com justiça a competência e a capacidade desses médicos interessados em atuar no país;
2) A ausência de uma carreira de Estado para o médico do SUS, com a previsão de infraestrutura e de condições de trabalho adequadas para os profissionais, impede a presença efetiva de médicos e a melhoria do atendimento em pequenos municípios e nas periferias dos grandes centros. Somente a implementação dessa carreira trará solução eficaz para o preenchimento definitivo dos vazios assistenciais;
3) A intenção de reduzir impostos, dar subsídios e des tinar recursos públicos para as operadoras de planos de saúde, conforme anunciado após encontros de representantes do Governo com empresários do setor, demonstra, de forma contraditória, o favorecimento da esfera privada em detrimento da pública na prestação da assistência à saúde, cuja prática tem sido feita sob o signo do subfinanciamento público federal, principal responsável pelas dificuldades do SUS;
4) Os Conselhos de Medicina defendem o SUS público, integral, gratuito, de qualidade e acessível a toda a população. Para ta nto, exigimos o cumprimento de uma agenda mínima, a qual inclui a destinação de 10% da receita da União para a saúde e o aperfeiçoamento dos serviços públicos, dotando-os de infraestrutura e recursos humanos valorizados para atender de forma eficaz a população;
Conclamamos o Poder Legislativo; o Poder Judiciário; o Ministério Público; as entidades médicas e da área da saúde; os parlamentares; as universidades; a imprensa; e todos os movimentos da sociedade civil organizada a se irmanarem nesta cruzada em defesa de um sistema público de saúde de qualidade, como um dos maiores patrimônios sociais da Nação.
Não podemos admitir que interesses políticos subalternos, financeiros e de mercado decidam sozinhos os rumos e o futuro de um modelo enraizado na nossa Constituição e que pertence a 190 milhões de brasileiros.
Belém (PA), 8 de março de 2013.
CONSELHO FEDERAL DE MEDICINA (CFM)
CONSELHOS REGIONAIS DE MEDICINA (CRMs)
segunda-feira, 11 de março de 2013
POLÊMICA NA VIDEOCIRURGIA - COLECISTECTOMIA MINI VERSUS CONVENCIONAL LAPAROSCÓPICA
O artigo original publicado no Journal of Laparoendoscopic & Advanced Surgical Techniques:
Mini-Laparoscopic Versus Conventional Laparoscopic Cholecystectomy: A Randomized Controlled Trial
na edição de fevereiro 2013 (doi:10.1089/lap.2012.0349).
Autores do Departmento de Cirurgia Geral do Hospital Sint-Lucas, Ghent, Bélgica.
Luís Filipe Abreu de Carvalho, MD, Kjell Fierens, MD, and Marc Kint, MD
ABSTRACT
Background: Several studies have reported faster recoveries, lower pain scores, and superior cosmetic results after mini-laparoscopic cholecystectomy (MLC). The purpose of this study was to perform a randomized controlled trial, comparing MLC with conventional laparoscopic cholecystectomy (LC).
Subjects and Methods: Forty-one patients with symptomatic cholecystolithiasis were randomized between the two groups: 23 having undergone LC and 18 MLC. The primary end point was postoperative pain, which was evaluated during the first 24 hours postoperatively, using the numerical rating scale. Patient satisfaction with the cosmetic result was evaluated after 1 month.
Results: The two groups were comparable concerning age, sex, and body mass index. The median operating time (42 minutes versus 45 minutes; P=.386), complication rate, and duration of hospital stay (2 days; P=.611) were similar in both groups. The level of postoperative pain was analogous at every time. There was no difference in the analgesic requirements or cosmesis.
Conclusions: MLC showed similar results concerning postoperative pain and did not lead to a greater patient satisfaction with the cosmetic result, compared with LC. MLC did not take longer to perform, nor was it associated with major complications or a high conversion rate. MLC is a safe and feasible technique for the treatment of gallbladder disease in elective patients.
Resposta Dr. Gustavo Carvalho, "Papa" da minilap
Minilaparoscopic Surgery – Not Just a Pretty Face! - What can be found beyond the aesthetics reasons? – Letter to Editor
Authors:
Gustavo L. Carvalho MD, PhD. [1] - glcmd1@gmail.com
Leandro Totti Cavazzola [2] - cavazzola@hotmail.com
Prashant Rao [3] - pprao2@mac.com
Institutes:
[1] Oswaldo Cruz University Hospital and UNIPECLIN, Faculty of Medical Sciences, University of Pernambuco – Recife, Brazil
[2] Universidade Federal do Rio Grande do Sul - Porto Alegre, Brazil
[3] RAO Institute
We read with careful interest the paper entitled Mini-Laparoscopic Versus Conventional Laparoscopic Cholecystectomy: A Randomized Controlled Trial by Carvalho and cols. Although we can no more than agree with most of the ideas, several missing points still needs to be addressed.
The authors conclude, with a very small sample size and using a nonstandard technique for mini-chole, that there is no difference between laparoscopic (LC) and mini cholecistectomy (MLC). The authors used systematically a 5mm trocar and a drain, something that really runs out from the scope of minimalizing trauma. There are two main standard techniques for MLC, with over 1000 cases, and none of them use trocars with a diameter greater than 3mm outside the umbilical site. The proposed technique can be suggested as an hybrid between mini and Lap technique since the author used in a routine basis a 5mm port outside the umbilicus. In most MLC series, the use of a 5mm out of the umbilicus was considered a conversion to LC.
Most of the published works were inefficient to prove differences between LC e MLC, but none were performed with the new Low Friction equipment which can improve dexterity and cosmesis. Another issue to be adressed in this paper is the routine use of prophylactic drains, that usually are unnecessary and in fact can be responsible by an increase in costs, postoperative pain and worsen the cosmetic result, especially if a 5mm port is used.
The advent of Natural Orifice Translumenal Endoscopic Surgery (NOTES) and subsetquently Laparoendoscopic Single Site Surgery (LESS) has called the attention of the surgeons to look for even less invasive modalities of surgical access. Minilaparoscopy (MINI) is a natural advancement of laparoscopy, which proposes to diminish surgical trauma by reducing the diameter of the standard laparoscopic instruments, without loosing range of motion na triangulation, important aspects that can be a major issue in NOTES and LESS. Minilaparosocpy what was first described more than 12 years ago is not really a new modality of access, but really needs to be carefully revisited because several aspect have changed over this period of time:
- New instruments were developed, much well designed and with more resistant materials, which are now giving a totally new face to MINI,
- In procedures that enhanced visualization in a restritcted space is necessary, MINI offers advantages over regular LAP (for example, for mini TEP inguinal hernia repair, mini lumbar or thorax sypmpatectomies, mini common bile duct exploration and reconstructions) When it’s necessary to suture or even just to tie a knot the enhanced precision of the new low friction MINI equipments can have advantages in their handling over the conventional 5mm equipment that uses rubber sealings and valves that can preclude some amplitude of movement.
MINI is no longer na experimental procedure, and it’s here to stay. As a matter of fact, one may say the MINI has returned to stay. The same MINI that Michel Gagner and Peter Goh described on the 90s,5,6 that did not become popular because the instruments deemed too flimsy and surgeons were not used to work with very thin, fragile, and expensive scopes. Moreover, surgeons insisted on clipping every structure from the umbilical port, which resulted in changing the scope several times in a single procedure, making MINI not only complicated but also boring and time consuming.7 Stigmatized as an expensive and complicated surgery, at that time MINI seemed to have no major advantages and did not progress the way industry had imagined.
With some minor adjustments in the technique, what we have named Clipless technique, we could overcome the problem of the MINI optics simply by tying knots to the cystic duct. This technique is detailed described in recent publication of 1000 cases (in a series that now surpases 1700), without mortality, conversion to open surgery or common bile duct injuries. Using the new MINI instruments we could safely complete more than 97% of cases only with mini instruments. In the case of placement one 5mm trocars (what is standard by the author of the present paper), we consider it to be a conversion to laparoscopic cholecistectomy. In order to avoid the use of mini-scopes, all gallbladders are removed in a bag, and most of our cases are discharged in less than 24h with virtually no pain. Currently, MINI Clipless is a 1-day surgery, safe, with all the advantages of laparoscopy, highly reproducible, cost effective, and with great aesthetic appeal.
Another great advantage of the MINI that usually is forgotten by many authors (who are really wanting to address the cosmetic issue) is the enhanced view. A surgeon that uses MINI can work much closer to the subject without being disturbed by the 5mm fórceps. Mathematically speaking, we can find gains up to 2.7x in magnification when using MINI equipments.
In endoscopic surgery, peripheral vision is limited by the visual field of the laparoscope. In this tunnel vision, thinner instruments occupy less space, and a much better view can be obtained. MINI instruments fit well into the concept of amplified vision provided by laparoscopes. The increase in vision scale seen in laparoscopy does not find a perfect partnership with conventional 5-mm instruments, and they become a coarse instrument for dealing with more delicate situations, such as biliary anastomosis, resection of a sympathetic ganglion adherent to the vena cava, or dissection of the deferens duct from the hernia sac during hernia surgery. This is especially important in retroperitoneal surgeries, where the space is naturally restricted and inadvertent movements may result in peritoneal perforations thus causing gas escape and further space reduction. More delicate surgeries should be preferably done by minilaparoscopy, because you can get closer vision and work with more precision due to the size of the instruments.
Current technical limitations of MINI are being resolved by the efforts of the industry in crafting more resistant and higher performance instruments. Even though MINI instruments are more delicate, when properly used they do not need much more maintenance then 5-mm laparoscopy instruments. Current Low Friction MINI trocars (unlike their ancestors from the 90s) do not have a sealing membrane (what can be called as “mo rubber trocars”). They have very low friction and therefore almost no force is needed to move the instruments inside the trocars, which prevents the undesirable movement (and eventually the total displacement) of the trocars. Another important achievement of the new MINI trocars is that they have a ball shaped dilating tip with smooth transition between tip and cannul, allowing for minimal skin incision by radially dilating the skin, muscle layers and fascia. Adding this with the abscence of friction with rubber, there is no dislocation of trocar during operation and improved cosmesis at the site of penetration of the trocar.
The ball shaped tip introducer helps to minimize injuries to vessels and nerves when gently introducing the trocar, by dissecting instead of cutting. There is an extra-precise fit between instrument and cannula, resulting in extremely reduced friction and minimal gas leak (<0 .1l="" a="" and="" any="" as="" being="" by="" co2="" consequence="" corrected="" criticism="" for="" formerly="" in="" increase="" is="" leak="" min="" models.="" new="" of="" p="" performance="" procedure="" real="" reason="" regarded="" resultant="" successfully="" the="" these="" trocar="" without="">WE PLACE HERE TWO or 3 figures !!!
The author (Carvalho) declares to have a possible conflict of interest. He is a consultant, without financial interest, for Karl Storz for the development of the new minilaparoscopic low friction trocars. The other authors have no relevant disclosures to this article.
References:
1.Abreu de Carvalho LF, Fierens K, Kint M. Mini-Laparoscopic Versus Conventional
Laparoscopic Cholecystectomy: A Randomized Controlled Trial. J Laparoend Adv Surg Tech 2013; 23(2): 109-116.
2. Rao PP, Rao PP, Bhagwat S. Single-incision laparoscopic surgery - current status and controversies. J Minim Access Surg. 2011;7(1):6-16.
3.. Zorron R, Maggioni LC, Pombo L, et al. NOTES transvaginal cholecystectomy: preliminary clinical application. Surg endosc 2008;22:542-547
4/ Gagner M, Garcia-Ruiz A. Technical aspects of minimally invasive abdominal surgery performed with needlescopic instruments. Surg Laparosc Endosc. 1998; 8(3):171-179.
5. Cheah WK, Goh P, Gagner M, So J. Needlescopic retrograde cholecystectomy. Surg Laparosc Endosc. 1998;8(3):237-238.
6. Lee PC, Lai IR, Yu SC. Minilaparoscopic (needlescopic) cholecystectomy: a study of 1,011 cases. Surg Endosc. 2004;18(10):1480-1484.
7. Franklin ME Jr, George J, Russek K. Needlescopic cholecystectomy. Surg Technol Int. 2010;20:109-113.
8. Carvalho GL, Silva FW, Silva JS, et al. Needlescopic clipless cholecystectomy as an efficient, safe, and cost-effective alternative with diminutive scars: the first 1000 cases. Surg Laparosc Endosc Percutan Tech. 2009 Oct;19(5):368-372.
9. Carvalho GL, Chaves EFC, Gouveia RLP, et al. Cystic artery Electrocauterization as an efficient, safe and cost-effective alternative in the minilaparoscopic cholecystectomy. Poster Presented at the Society of American Gastrointestinal and Endoscopic Surgeons Congress (SAGES), 2011, Abstract P379.
10. Carvalho GL, Lima DL, Sales AC, Silva JSN, Fernandes Junior FAM. A new very low friction trocar to increase surgical precision and improve aesthetics in minilaparoscopy. Poster presented at the Society of American Gastrointestinal and Endoscopic Surgeons Congress (SAGES), 2011, Abstract ETP077.
11/ Blinman T. Incisions do not simply sum. Surg Endosc. 2010 Jul;24(7):1746-1751. Epub 2010 Jan 7.
12/ Carvalho GL, Cavazzola LT. Can mathematic formulas help us with our patients? Surg Endosc. 2011 Jan;25(1):336-337.
13. Carvalho GL, Loureiro MP,Bonim EA, Renaissance of Minilaparoscopy in the NOTES and Single Port Era: A Tale of Simplicity. JSLS (2011)15:585–588
14. Carvalho GL, Loureiro MP,Bonim EA, Claus CP, Silva FW, Cury AM, Fernandez FAM. Minilaparoscopic Technique For Inguinal Hernia Repair Combining The Best Features of Two Consagrated Approaches: Transabdominal Pre-peritoneal (TAPP) And Totally Extraperitoneal (TEP) - Less Trauma And Almost Invisible Scars. JSLS. 2012; 16(4):560-575.
15. Cavazzola LT, de Carvalho GL, Silva JS. Who should decide the best minimally invasive approach? Should we listen to our patients? Surg Endosc. 2011 Apr;25(4):1351-2.
0>
O artigo original publicado no Journal of Laparoendoscopic & Advanced Surgical Techniques:
Mini-Laparoscopic Versus Conventional Laparoscopic Cholecystectomy: A Randomized Controlled Trial
na edição de fevereiro 2013 (doi:10.1089/lap.2012.0349).
Autores do Departmento de Cirurgia Geral do Hospital Sint-Lucas, Ghent, Bélgica.
Luís Filipe Abreu de Carvalho, MD, Kjell Fierens, MD, and Marc Kint, MD
ABSTRACT
Background: Several studies have reported faster recoveries, lower pain scores, and superior cosmetic results after mini-laparoscopic cholecystectomy (MLC). The purpose of this study was to perform a randomized controlled trial, comparing MLC with conventional laparoscopic cholecystectomy (LC).
Subjects and Methods: Forty-one patients with symptomatic cholecystolithiasis were randomized between the two groups: 23 having undergone LC and 18 MLC. The primary end point was postoperative pain, which was evaluated during the first 24 hours postoperatively, using the numerical rating scale. Patient satisfaction with the cosmetic result was evaluated after 1 month.
Results: The two groups were comparable concerning age, sex, and body mass index. The median operating time (42 minutes versus 45 minutes; P=.386), complication rate, and duration of hospital stay (2 days; P=.611) were similar in both groups. The level of postoperative pain was analogous at every time. There was no difference in the analgesic requirements or cosmesis.
Conclusions: MLC showed similar results concerning postoperative pain and did not lead to a greater patient satisfaction with the cosmetic result, compared with LC. MLC did not take longer to perform, nor was it associated with major complications or a high conversion rate. MLC is a safe and feasible technique for the treatment of gallbladder disease in elective patients.
Resposta Dr. Gustavo Carvalho, "Papa" da minilap
Minilaparoscopic Surgery – Not Just a Pretty Face! - What can be found beyond the aesthetics reasons? – Letter to Editor
Authors:
Gustavo L. Carvalho MD, PhD. [1] - glcmd1@gmail.com
Leandro Totti Cavazzola [2] - cavazzola@hotmail.com
Prashant Rao [3] - pprao2@mac.com
Institutes:
[1] Oswaldo Cruz University Hospital and UNIPECLIN, Faculty of Medical Sciences, University of Pernambuco – Recife, Brazil
[2] Universidade Federal do Rio Grande do Sul - Porto Alegre, Brazil
[3] RAO Institute
We read with careful interest the paper entitled Mini-Laparoscopic Versus Conventional Laparoscopic Cholecystectomy: A Randomized Controlled Trial by Carvalho and cols. Although we can no more than agree with most of the ideas, several missing points still needs to be addressed.
The authors conclude, with a very small sample size and using a nonstandard technique for mini-chole, that there is no difference between laparoscopic (LC) and mini cholecistectomy (MLC). The authors used systematically a 5mm trocar and a drain, something that really runs out from the scope of minimalizing trauma. There are two main standard techniques for MLC, with over 1000 cases, and none of them use trocars with a diameter greater than 3mm outside the umbilical site. The proposed technique can be suggested as an hybrid between mini and Lap technique since the author used in a routine basis a 5mm port outside the umbilicus. In most MLC series, the use of a 5mm out of the umbilicus was considered a conversion to LC.
Most of the published works were inefficient to prove differences between LC e MLC, but none were performed with the new Low Friction equipment which can improve dexterity and cosmesis. Another issue to be adressed in this paper is the routine use of prophylactic drains, that usually are unnecessary and in fact can be responsible by an increase in costs, postoperative pain and worsen the cosmetic result, especially if a 5mm port is used.
The advent of Natural Orifice Translumenal Endoscopic Surgery (NOTES) and subsetquently Laparoendoscopic Single Site Surgery (LESS) has called the attention of the surgeons to look for even less invasive modalities of surgical access. Minilaparoscopy (MINI) is a natural advancement of laparoscopy, which proposes to diminish surgical trauma by reducing the diameter of the standard laparoscopic instruments, without loosing range of motion na triangulation, important aspects that can be a major issue in NOTES and LESS. Minilaparosocpy what was first described more than 12 years ago is not really a new modality of access, but really needs to be carefully revisited because several aspect have changed over this period of time:
- New instruments were developed, much well designed and with more resistant materials, which are now giving a totally new face to MINI,
- In procedures that enhanced visualization in a restritcted space is necessary, MINI offers advantages over regular LAP (for example, for mini TEP inguinal hernia repair, mini lumbar or thorax sypmpatectomies, mini common bile duct exploration and reconstructions) When it’s necessary to suture or even just to tie a knot the enhanced precision of the new low friction MINI equipments can have advantages in their handling over the conventional 5mm equipment that uses rubber sealings and valves that can preclude some amplitude of movement.
MINI is no longer na experimental procedure, and it’s here to stay. As a matter of fact, one may say the MINI has returned to stay. The same MINI that Michel Gagner and Peter Goh described on the 90s,5,6 that did not become popular because the instruments deemed too flimsy and surgeons were not used to work with very thin, fragile, and expensive scopes. Moreover, surgeons insisted on clipping every structure from the umbilical port, which resulted in changing the scope several times in a single procedure, making MINI not only complicated but also boring and time consuming.7 Stigmatized as an expensive and complicated surgery, at that time MINI seemed to have no major advantages and did not progress the way industry had imagined.
With some minor adjustments in the technique, what we have named Clipless technique, we could overcome the problem of the MINI optics simply by tying knots to the cystic duct. This technique is detailed described in recent publication of 1000 cases (in a series that now surpases 1700), without mortality, conversion to open surgery or common bile duct injuries. Using the new MINI instruments we could safely complete more than 97% of cases only with mini instruments. In the case of placement one 5mm trocars (what is standard by the author of the present paper), we consider it to be a conversion to laparoscopic cholecistectomy. In order to avoid the use of mini-scopes, all gallbladders are removed in a bag, and most of our cases are discharged in less than 24h with virtually no pain. Currently, MINI Clipless is a 1-day surgery, safe, with all the advantages of laparoscopy, highly reproducible, cost effective, and with great aesthetic appeal.
Another great advantage of the MINI that usually is forgotten by many authors (who are really wanting to address the cosmetic issue) is the enhanced view. A surgeon that uses MINI can work much closer to the subject without being disturbed by the 5mm fórceps. Mathematically speaking, we can find gains up to 2.7x in magnification when using MINI equipments.
In endoscopic surgery, peripheral vision is limited by the visual field of the laparoscope. In this tunnel vision, thinner instruments occupy less space, and a much better view can be obtained. MINI instruments fit well into the concept of amplified vision provided by laparoscopes. The increase in vision scale seen in laparoscopy does not find a perfect partnership with conventional 5-mm instruments, and they become a coarse instrument for dealing with more delicate situations, such as biliary anastomosis, resection of a sympathetic ganglion adherent to the vena cava, or dissection of the deferens duct from the hernia sac during hernia surgery. This is especially important in retroperitoneal surgeries, where the space is naturally restricted and inadvertent movements may result in peritoneal perforations thus causing gas escape and further space reduction. More delicate surgeries should be preferably done by minilaparoscopy, because you can get closer vision and work with more precision due to the size of the instruments.
Current technical limitations of MINI are being resolved by the efforts of the industry in crafting more resistant and higher performance instruments. Even though MINI instruments are more delicate, when properly used they do not need much more maintenance then 5-mm laparoscopy instruments. Current Low Friction MINI trocars (unlike their ancestors from the 90s) do not have a sealing membrane (what can be called as “mo rubber trocars”). They have very low friction and therefore almost no force is needed to move the instruments inside the trocars, which prevents the undesirable movement (and eventually the total displacement) of the trocars. Another important achievement of the new MINI trocars is that they have a ball shaped dilating tip with smooth transition between tip and cannul, allowing for minimal skin incision by radially dilating the skin, muscle layers and fascia. Adding this with the abscence of friction with rubber, there is no dislocation of trocar during operation and improved cosmesis at the site of penetration of the trocar.
The ball shaped tip introducer helps to minimize injuries to vessels and nerves when gently introducing the trocar, by dissecting instead of cutting. There is an extra-precise fit between instrument and cannula, resulting in extremely reduced friction and minimal gas leak (<0 .1l="" a="" and="" any="" as="" being="" by="" co2="" consequence="" corrected="" criticism="" for="" formerly="" in="" increase="" is="" leak="" min="" models.="" new="" of="" p="" performance="" procedure="" real="" reason="" regarded="" resultant="" successfully="" the="" these="" trocar="" without="">WE PLACE HERE TWO or 3 figures !!!
The author (Carvalho) declares to have a possible conflict of interest. He is a consultant, without financial interest, for Karl Storz for the development of the new minilaparoscopic low friction trocars. The other authors have no relevant disclosures to this article.
References:
1.Abreu de Carvalho LF, Fierens K, Kint M. Mini-Laparoscopic Versus Conventional
Laparoscopic Cholecystectomy: A Randomized Controlled Trial. J Laparoend Adv Surg Tech 2013; 23(2): 109-116.
2. Rao PP, Rao PP, Bhagwat S. Single-incision laparoscopic surgery - current status and controversies. J Minim Access Surg. 2011;7(1):6-16.
3.. Zorron R, Maggioni LC, Pombo L, et al. NOTES transvaginal cholecystectomy: preliminary clinical application. Surg endosc 2008;22:542-547
4/ Gagner M, Garcia-Ruiz A. Technical aspects of minimally invasive abdominal surgery performed with needlescopic instruments. Surg Laparosc Endosc. 1998; 8(3):171-179.
5. Cheah WK, Goh P, Gagner M, So J. Needlescopic retrograde cholecystectomy. Surg Laparosc Endosc. 1998;8(3):237-238.
6. Lee PC, Lai IR, Yu SC. Minilaparoscopic (needlescopic) cholecystectomy: a study of 1,011 cases. Surg Endosc. 2004;18(10):1480-1484.
7. Franklin ME Jr, George J, Russek K. Needlescopic cholecystectomy. Surg Technol Int. 2010;20:109-113.
8. Carvalho GL, Silva FW, Silva JS, et al. Needlescopic clipless cholecystectomy as an efficient, safe, and cost-effective alternative with diminutive scars: the first 1000 cases. Surg Laparosc Endosc Percutan Tech. 2009 Oct;19(5):368-372.
9. Carvalho GL, Chaves EFC, Gouveia RLP, et al. Cystic artery Electrocauterization as an efficient, safe and cost-effective alternative in the minilaparoscopic cholecystectomy. Poster Presented at the Society of American Gastrointestinal and Endoscopic Surgeons Congress (SAGES), 2011, Abstract P379.
10. Carvalho GL, Lima DL, Sales AC, Silva JSN, Fernandes Junior FAM. A new very low friction trocar to increase surgical precision and improve aesthetics in minilaparoscopy. Poster presented at the Society of American Gastrointestinal and Endoscopic Surgeons Congress (SAGES), 2011, Abstract ETP077.
11/ Blinman T. Incisions do not simply sum. Surg Endosc. 2010 Jul;24(7):1746-1751. Epub 2010 Jan 7.
12/ Carvalho GL, Cavazzola LT. Can mathematic formulas help us with our patients? Surg Endosc. 2011 Jan;25(1):336-337.
13. Carvalho GL, Loureiro MP,Bonim EA, Renaissance of Minilaparoscopy in the NOTES and Single Port Era: A Tale of Simplicity. JSLS (2011)15:585–588
14. Carvalho GL, Loureiro MP,Bonim EA, Claus CP, Silva FW, Cury AM, Fernandez FAM. Minilaparoscopic Technique For Inguinal Hernia Repair Combining The Best Features of Two Consagrated Approaches: Transabdominal Pre-peritoneal (TAPP) And Totally Extraperitoneal (TEP) - Less Trauma And Almost Invisible Scars. JSLS. 2012; 16(4):560-575.
15. Cavazzola LT, de Carvalho GL, Silva JS. Who should decide the best minimally invasive approach? Should we listen to our patients? Surg Endosc. 2011 Apr;25(4):1351-2.
0>
quinta-feira, 7 de fevereiro de 2013
REGANHO DE PESO PÓS-CIRURGIA BARIÁTRICA
Pacientes de cirurgia bariátrica voltam a ganhar peso, revela estudoA cirurgia de redução de estômago é o método mais usado no Brasil para tratamento de obesos com IMC (Índice de Massa Corporal) acima de 40. Um grupo de pesquisadores do Departamento de Nutrição da UnB (Universidade de Brasília) acompanhou 80 pacientes que operaram há mais de dois anos e, segundo a nutricionista Fernanda Bassan, 73% voltaram a engordar, sendo que 23% tiveram ganho de peso significativo, ou seja, 10% acima do menor peso que atingiram após a cirurgia. "O paciente precisa ter consciência de que só a cirurgia, sem mudança de hábitos alimentares, não vai funcionar", diz.
Restringir o consumo de açúcar leva a perda de quase 1 kg, mostra estudo.
O estudo detectou duas variáveis que contribuem para o ganho de peso após a cirurgia: a má qualidade da alimentação e o tempo passado desde a operação. A cada ano que passa, o ponteiro da balança sobe um pouco mais. "O tempo após o procedimento é diretamente proporcional ao ganho de peso", afirma Bassan. "Isso mostra que mesmo tendo cuidado, a pessoa vai ganhar". Essa operação, chamada de redução bariátrica, usa grampos para isolar boa parte do estômago e cerca de 100 centímetros do intestino delgado. Assim o corpo comporta – e absorve – menos alimento.
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O processo é irreversível, mas o ganho de peso pode ser favorecido pela ingestão de produtos que não saciam, mas são calóricos, como bebidas alcóolicas e açúcares. Engordando, o paciente também pode sofrer uma dilatação na ligação entre o estômago e o intestino que lhe permite acomodar mais comida.
A professora Kênia Baiocchi afirma que uma dieta saudável pode reduzir os efeitos do tempo pós-cirurgia, ainda que não totalmente. "O estudo reforça que a cirurgia é só um facilitador. Há risco de reganho de peso principalmente entre aqueles que não aproveitam o tempo para adotar um estilo de vida mais saudável. Mas a qualidade da dieta não garante emagrecimento. É apenas um amenizador", explica.
Perder peso não é o único parâmetro
De acordo com a Sociedade Brasileira de Cirurgia Bariátrica e Metabólica (SBCBM), o principal objetivo da cirurgia é melhorar a qualidade de vida do paciente através da compensação de problemas de saúde que o acompanham, chamados de comorbidades, tais como hipertensão arterial, diabetes, colesterol e triglicérides alterados, apneia do sono e doenças cardiovasculares. Portanto, a perda de perdo não é o único parâmetro para avaliar o resulto do tratamento cirúrgico do paciente.
Em comunicado, a SBCBM esclareceu também que o aumento de peso no longo prazo dentro de limites é aceitável. Portanto, o reganho de até 10% do peso perdido pode ser considerado normal e faria parte de uma adaptação do organismo ao novo metabolismo resultante da cirurgia.
Por fim, a SBCBM recomenda que a cirurgia deva ser realizada dentro de um contexto de programa de tratamento pré e pós-operatório com um atendimento multidisciplinar, com a participação de especialistas como endocrinologista, cardiologista, ortopedista, pneumologista, psicólogo e psiquiatra, além do cirurgião.
segunda-feira, 21 de janeiro de 2013
16/1/2013 08:36:33 - CFM veta o preenchimento de formulários de seguradoras por médicos assistentes
O Conselho Federal de Medicina (CFM), em nova diretriz, 2.003/12, publicada em novembro de 2012, veta ao médico assistente o preenchimento de formulários elaborados por empresas seguradoras.
A Resolução considera, entre outras informações, que a Constituição Federal assegura a tutela da intimidade, bem como preserva o sigilo profissional; e que o preenchimento, pelo médico, de formulários elaborados pelas companhias de seguros de vida não têm qualquer vínculo com a atestação médica relativa à assistência ou ao óbito.
Também é apontado na diretriz o constrangimento para o médico assistente ao preencher formulários, com quesitos próprios, de entidade com a qual não tem qualquer relação profissional ou empregatícia; e que seu preenchimento constitui atividade médica pericial, não podendo ser exercida pelo médico assistente.
O documento ainda afirma que viola a ética médica a entrega de prontuário de paciente internados para companhias seguradoras responsáveis pelo reembolso das despesas.
segunda-feira, 7 de janeiro de 2013
Cirurgião do Ano
O Colégio Brasileiro de Cirurgiões, a maior entidade de Cirurgiões da América Latina, com 6.445 Membros no Brasil, anualmente, desde 1970, escolhe o Cirurgião do Ano pelo acervo de atividades na assistência, ensino e pesquisa e que tenha contribuído significativamente para o desenvolvimento e progresso da Cirurgia brasileira.
Entre as destacadas figuras, encontram-se Ivo Pitangui (2006) Adib Jatene (2005) e Elyseo Paglioli (1978), esse o primeiro gaúcho até hoje distinguido.
Luiz Rohde, em solenidade especial, no dia 07/12/2012, receberá o Prêmio CBC no Rio de Janeiro, outorgado pelo Conselho Superior e Diretório Nacional.
Ele é natural de Paraíso do Sul, Livre Docente em Cirurgia, Professor Emérito da UFRGS, Membro Emérito do CBC e Benemérito do CBCD.
Cursos de pós-graduação não podem conferir título de especialista ao médico
TRF determina que pós-graduado não pode se inscrever nos conselhos de medicina como especialista ou anunciar títulos
Uma decisão do Tribunal Regional Federal (TRF) da Primeira Região, publicada em novembro, consolida entendimento do Conselho Federal de Medicina (CFM) de que cursos de pós-graduação lato sensu não conferem ao médico o direito de se inscrever nos conselhos de medicina como especialistas ou anunciarem tais títulos. A decisão indeferiu recurso de médicos que pleiteavam usar, em anúncios, a expressão "pós-graduados". Pleiteavam, ainda que o art. 3º, alínea "i" da Resolução CFM 1.974/11 tivesse seus efeitos suspensos.
O TRF, no entanto, entendeu e frisou que títulos acadêmicos (de pós-graduação lato sensu), ainda que reconhecidos pelo MEC, podem se confundir, aos olhos leigos, com a especialidade médica reconhecida pelos conselhos de medicina. "Portanto, para se reconhecer a especialidade médica, o conselho pode, legitimamente, ser mais exigente do que o MEC, ao regulamentar requisitos mínimos".
Em sua deliberação, o tribunal ressaltou que "de nenhuma maneira a atuação do CFM impede ou inibe a aquisição de graus superiores de educação". No documento, o juiz federal Renato Martins Prates argumenta que a decisão pretende impedir que o médico que somente tenha curso de pós-graduação possa ser admitido como especialista em determinada área médica sem possuir todos os requisitos necessários, induzindo a clientela à confusão.
Para o CFM, a decisão está de acordo com a legislação e as normas que disciplinam a matéria, tornando evidente a competência da entidade para determinar, por meio de resolução, as qualificações necessárias à publicidade de especialidades médicas. A decisão "estabelece de maneira inquestionável que cursos lato sensu não outorgam valores para a prática profissional ou habilitações para anúncio publicitário de especialidades médicas", avalia o 1º vice-presidente Carlos Vital.
De acordo com a resolução, é vetado o anúncio de pós-graduação realizada para a capacitação pedagógica, exceto quando estiver relacionado à especialidade ou área de atuação devidamente registrada no CRM.
CFM reforça entendimento aos médicos
Em diversos informes aos médicos, o CFM tem destacado que cursos de pós-graduação lato sensu, ainda que reconhecidos pelo MEC, não têm valor para a atividade profissional e não habilitam ao médico se anunciar como especialista, tendo somente valor acadêmico.
Apenas duas formas podem levar o médico a obter a especialização: por meio de uma prova de títulos e habilidades das sociedades de especialidades filiadas à Associação Médica Brasileira e/ou por residência médica reconhecida pela Comissão Nacional de Residência Médica.
A entidade tem debatido constantemente o assunto e está atenta a propagandas de alguns cursos que induzem a interpretação equivocada. Ressalta, ainda que a residência multiprofissional é uma modalidade lato sensu destinada às categorias profissionais da área da saúde, exceto a médica (Lei 11.129/05). Em se tratando dessas três opções (residência multiprofissional, cursos de especialização e residência médica), apenas aos que cursaram esta última pode ser conferido o título de especialista. O médico somente poderá anunciar especialidade quando o título estiver registrado no CRM.
Autor: CFM
Fonte: Isaúde.net
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