Importancia del conocimiento anatómico del espacio extraperitoneal y su utilidad en los abordajes quirúrgicos / Importance of anatomical knowledge of the extraperitoneal space and its usefulness in surgical approaches

Introducción. El espacio extraperitoneal, se define como el segmento topográfico ubicado entre el peritoneo parietal internamente y la fascia transversalis externamente. Como resultado del desarrollo y consolidación de la cirugía laparoscópica, en particular de la herniorrafia inguinal por esta vía, se ha presentado un renovado y creciente interés en esta área anatómica, debido a la importancia de su conocimiento detallado en la cirugía de mínima invasión. Métodos. Se hizo una revisión narrativa de la literatura para presentar una información actualizada y detallada sobre la anatomía del espacio extraperitoneal y su importancia en diferentes procedimientos quirúrgicos realizados actualmente. Resultados. Por fuera del espacio peritoneal, se encuentran las áreas anatómicas externas al peritoneo parietal, que incluyen la preperitoneal y la retroperitoneal. Mediante la laparoscopia, se pueden localizar en estos espacios cinco triángulos anatómicos, además de la corona mortis y el triángulo supra vesical. Conclusión. El conocimiento del espacio extraperitoneal es de gran importancia para el cirujano general, teniendo en cuenta los múltiples procedimientos que requieren el abordaje de esta área topográfica

Introduction. The extraperitoneal space is defined as the topographic segment located between the parietal peritoneum internally and the fascia transversalis externally. As a result of the development and consolidation of laparoscopic surgery, particularly inguinal herniorrhaphy by this route, there has been a renewed and growing interest in this anatomical area, due to the importance of its detailed knowledge in minimally invasive surgery. Methods. A narrative review of the literature was made to present updated and detailed information on the anatomy of the extraperitoneal space and its importance in different surgical procedures currently performed. Results. Outside the peritoneal space are the anatomical areas external to the parietal peritoneum, including the preperitoneal and extraperitoneal. Using laparoscopy, five anatomical triangles, in addition to the corona mortis and the supravesical triangle, can be located in these spaces. Conclusion. Knowledge of the extraperitoneal space is of great importance for the general surgeon, taking into account the multiple procedures that require the approach of this topographic area

Impacto da disseminação de informação sobre endometriose no autocuidado de adolescentes de escola pública / Impact of dissemination of information about endometriosis on self-care of public school adolescents

Objetivo: Averiguar o conhecimento das adolescentes sobre endometriose, que é uma doença estrogênio-dependente, podendo ser progressiva, e que se caracteriza pela presença do tecido endometrial fora do útero. Estima-se que a endometriose acometa cerca de 10% das mulheres em idade reprodutiva, sendo 4% a 17% das adolescentes. Métodos: A pesquisa foi desenvolvida com adolescentes estudantes do terceiro ano do ensino médio de escolas estaduais do município de Avaré (São Paulo) de forma descritiva, exploratória e quali-quantitativa, em três etapas: aplicação de questionário, realização de palestra e nova aplicação de questionário. Participaram quatro escolas, totalizando 80 adolescentes participantes na primeira fase e 48 adolescentes na terceira fase. Resultados: Houve aumento de 21,35 vezes no número de adolescentes que se beneficiaram dos conhecimentos gerados pelas palestras, além da replicação da informação para terceiros, possivelmente aumento no número de mulheres que tomaram conhecimento sobre o que é endometriose. Conclusão: Verificou-se que a aplicação de palestras informativas sobre sinais e sintomas de endometriose aumentou o grau de conhecimento de adolescentes entre 16 e 17 anos de escola pública.

Objective: To investigate the knowledge of adolescents about Endometriosis, which is a progressive, estrogen/dependent disease, which can be progressive and which is characterized by the presence of endometrial tissue outside the uterus. It is estimated that it affects about 10% of women of reproductive age, of which 2%-4% are postmenopausal, with or without hormonal treatment, and 4% to 17% of adolescents. Methods: The research was carried out with adolescent students in the 3rd year of high school from state schools in the city of Avaré (São Paulo) in a descriptive, exploratory and qualitative-quantitative manner in three stages: application of a questionnaire, holding a lecture and a new application of quiz. Four schools participated, totaling 80 adolescents participating in the first phase and 48 adolescents in the third phase. Results: There was a 21.35-fold increase in the number of adolescents who benefited from the knowledge generated by the lectures, in addition to the replication of information to third parties, possibly an increase in the number of women who learned about what endometriosis is. Conclusion: It was found that the application of informative lectures on signs and symptoms of endometriosis increased the level of knowledge of adolescents between 16 and 17 years of age in public school.

Diagnóstico, manejo y tratamiento de pacientes con peritonitis secundaria en una unidad de cirugía general / Diagnosis, management and treatment of patients with secondary peritonitis in a general surgery unit

La peritonitis es una inflamación aguda o crónica del peritoneo que generalmente tiene un origen infeccioso. Existen varios tipos, siendo la de tipo secundario la más frecuente. El término peritonitis secundaria se define como la inflamación localizada o generalizada de la membrana peritoneal causada por infección polimicrobiana posterior a la ruptura traumática o espontánea de una víscera o secundaria a la dehiscencia de anastomosis intestinales. Esta entidad se caracteriza por la presencia de pus en la cavidad peritoneal o de líquido; que, en el estudio microscópico directo, contiene leucocitos y bacterias. El tratamiento de esta patología constituye una urgencia y puede ser de tipo clínico y/o quirúrgico. El objetivo del manejo operatorio se basa en identificar y eliminar la causa de la infección, recoger muestras microbiológicas, realizar una limpieza peritoneal y prevenir la recidiva. El tratamiento clínico se ocupa de las consecuencias de la infección mediante la reanimación perioperatoria y el tratamiento antibiótico1. A pesar de los avances en diagnóstico, procedimientos quirúrgicos, terapia antimicrobiana y cuidados intensivos, la mortalidad asociada con la peritonitis secundaria grave es aún muy alta. El pronóstico y el manejo oportuno representan la clave para mejorar la sobrevida y reducir la mortalidad asociada a infecciones intraabdominales extensas2. Es importante establecer lineamientos en cuanto al diagnóstico, manejo antibiótico y pautas de tratamiento quirúrgico para disminuir la morbilidad y mortalidad asociada a esta enfermedad. Palabras clave: Peritonitis; Peritoneo; Cavidad Abdominal/cirugía; Cavidad Peritoneal; Líquido Ascítico/patología; Procedimientos Quirúrgicos Operativos.

Peritonitis is an acute or chronic inflammation of the peritoneum that generally has an infectious origin. There are several types, with secondary peritonitis being the most frequent. The term secondary peritonitis is defined as localized or generalized inflammation of the peritoneal membrane caused by polymicrobial infection following traumatic or spontaneous rupture of a viscus or secondary to dehiscence of intestinal anastomoses. This entity is characterized by the presence of pus in the peritoneal cavity or fluid which, on direct microscopic examination, contains leukocytes and bacteria. The treatment of this pathology constitutes an emergency and can be clinical and/or surgical. The aim of operative management is based on identifying and eliminating the cause of the infection, collecting microbiological samples, performing peritoneal cleansing and preventing recurrence. Clinical management deals with the consequences of the infection by perioperative resuscitation and antibiotic treatment1 . Despite advances in diagnosis, surgical procedures, antimicrobial therapy and intensive care, mortality associated with severe secondary peritonitis is still very high. Prognosis and timely management represent the key to improving survival and reducing mortality associated with extensive intra-abdominal infections2. It is important to establish guidelines for diagnosis, antibiotic management and surgical treatment guidelines to reduce the morbidity and mortality associated with this disease.

Experiencia en el tratamiento del divertículo de Meckel con abordaje abierto versus laparoscópico-asistido supraumbilical en niños / Experience in the treatment of Meckel's diverticulum with an open approach versus laparoscopic-assisted supraumbilical in children

Introducción: El divertículo de Meckel (DdM) es la malformación intestinal congénita más común diagnosticada intraoperatoriamente y requiere una resolución quirúrgica una vez conocido el diagnóstico. El presente estudio describe la experiencia en el tratamiento quirúrgico abierto y laparoscópico del DdM. Metodología: El presente estudio transversal retrospectivo, se realizó en niños tratados en el Hospital de Niños Dr. Roberto Gilbert Elizalde, Guayaquil Ecuador, en un periodo de 8 años con diagnóstico de divertículo de Meckel; se analizan variables como: edad, sexo, síntomas, diagnóstico posquirúrgico, técnica quirúrgica, estancia hospitalaria, complicaciones, resultados de biopsia, presentación clínica. Se utiliza estadística descriptiva univariada. Resultados: Se analizan 81 casos, 52 hombres (64%), 25 lactantes (31%), 23 adolescentes (28%). 50 casos (62%) se presentaron como abdomen agudo, 17 casos (21%) se presentaron como hemorragia intestinal. El DdM incidental durante una apendicitis aguda fue realizado en forma incidental en 23 casos (52%). Fueron 67 casos (83%) fueron sometidos a cirugía abierta y 14 casos (17%) fueron sometidos a cirugía combinada. Las complicaciones fueron 8/67 casos (11.9%) en cirugía abierta, y 1/14 casos (7.1%) en cirugía combinada (P=0.60). Conclusión: La resección laparoscópica de DdM no aumentó el riesgo de morbilidad o el tiempo operatorio.

Introduction: Meckel's diverticulum (MsD) is the most common congenital intestinal malformation diag-nosed intraoperatively and requires surgical resolution once the diagnosis is known. The present study de-scribes the experience in the open and laparoscopic surgical treatment of MsD. Methodology: This cross-sectional - retrospective study was carried out in children treated at the Dr. Roberto Gilbert Elizalde Children's Hospital, Guayaquil - Ecuador, for over eight years with a diagnosis of Meckel's diverticulum; variables such as age, sex, symptoms, post-surgical diagnosis, surgical technique, hospital stay, complications, biopsy results, clinical presentation are analyzed. Univariate descriptive statistics are used. Results: 81 cases were analyzed, 52 men (64%), 25 infants (31%), 23 adolescents (28%). 50 cases (62%) pre-sented as acute abdomen, and 17 cases (21%) presented as intestinal hemorrhage. Incidental MD during acute appendicitis was performed incidentally in 23 cases (52%). 67 cases (83%) underwent open surgery, and 14 (17%) underwent combined surgery. Complications were 8/67 cases (11.9%) in open surgery and 1/14 cases (7.1%) in combined surgery (P=0.60). Conclusion: Laparoscopic resection of MsD did not increase the risk of morbidity or operative time.

Is there a precise correlation between the lengths of the peritoneal reflection and the middle rectal valve?

Introduction: Pelvic anatomy remains a challenge, and thorough knowledge of its intricate landmarks has major clinical and surgical implications in several medical specialties. The peritoneal reflection is an important landmark in intraluminal surgery, rectal trauma, impalement, and rectal adenocarcinoma. Objectives: To investigate the correlation between the lengths of the middle rectal valve and of the peritoneal reflection determined with rigid sigmoidoscopy and to determine whether there are any differences in the location of the peritoneal reflection between the genders and in relation to body mass index (BMI) and parity. Design: We prospectively investigated the location of the middle rectal valve and of the peritoneal reflection via intraoperative rigid sigmoidoscopy in colorectal cancer patients undergoing elective colorectal surgery. Results: We evaluated 38 patients with a mean age of 55.5 years old (57.5% males) who underwent colorectal surgery at the coloproctology service of the Hospital Santa Marcelina, São Paulo, state of São Paulo, Brazil. There was substantial agreement between the lengths of the middle rectal valve and of the peritoneal reflection (Kappa = 0.66). In addition, the peritoneal reflection was significantly lower in overweight patients (p = 0.013 for women and p < 0.005 for men) and in women with > 2 vaginal deliveries (p = 0.009), but there was no significant difference in the length of the peritoneal reflection between genders (p = 0.32). Conclusion: There was substantial agreement between the lengths of the peritoneal reflection and of the middle rectal valve, and the peritoneal reflection was significantly lower in overweight patients and in women with more than two vaginal deliveries. (AU)

Causas infrecuentes de ascitis: Reporte de 5 casos / Uncommon causes of ascites: Report of 5 cases

Introducción: La ascitis se define como la presencia de líquido en la cavidad peritoneal. La etiología más común la constituyen las enfermedades hepáticas que cursan con hipertensión portal, dentro de ellas la cirrosis hepática reportada en un 40 por ciento, a 5 años de seguimiento de los casos. Estudios previos muestran que la ascitis por enfermedad cirrótica hepática es entre un 80-85 por ciento, también la carcinomatosis se presenta en un 10 por ciento, y dentro de las causas más raras están la insuficiencia cardiaca y la tuberculosis peritoneal en un 3 por ciento, junto con la trombosis de la vena porta, sarcoidosis, tumores intraperitoneales, ascitis pancreática y la enteritis eosinofílica. Objetivo: Describir presentaciones clínicas infrecuentes como causa de ascitis en pacientes hospitalizados en el Hospital Clínico Quirúrgico Hermanos Ameijeiras. Presentación de casos: Se presentan cinco casos que ingresaron en el Hospital Hermanos Ameijeiras con diagnóstico de Ascitis: quilosa, hemorrágica, eosinofílica y coloide, con las patologías que los llevaron a esa manifestación clínica y una breve descripción de la misma. Conclusión: El análisis de las presentaciones clínicas de los casos, los hallazgos en los estudios imagenológicos y en los exámenes de laboratorio, así como los resultados anatomopatológicos permitieron el diagnóstico de las entidades causantes de ascitis atípicas en estos pacientes(AU)

Introduction: Ascites is defined as the presence of fluid in the peritoneal cavity. The most common etiology is liver diseases with portal hypertension; among them liver cirrhosis is reported in 40 percent of cases with 5-year follow-up. Previous studies demonstrate that ascites due to cirrhotic liver disease occurs in 80-85 percent of the cases, that carcinomatosis is also present in 10 percent, and also that among the rarest causes, heart failure and peritoneal tuberculosis are present in 3 percent of cases along with portal vein thrombosis, sarcoidosis, intraperitoneal tumors, pancreatic ascites and eosinophilic enteritis. Objective: To describe uncommon clinical presentations as cause of ascites in patients admitted to Hermanos Ameijeiras Clinical Surgical Hospital. Case presentation: Five cases of patients admitted to Hermanos Ameijeiras Clinical Surgical Hospital with the diagnosis of ascites: chylous, hemorrhagic, eosinophilic and colloid as well as the pathologies that led them to this clinical manifestation and a brief description of it are presented. Conclusion: The analysis of the clinical presentation of the cases, the findings in the imaging studies and laboratory tests and the anatomopathological results allowed the diagnosis of the entities causing atypical ascites in these patients(AU)

Hernia gástrica atascada en ventana pericardio-peritoneal: Una rara complicación / Gastric hernia incarcerated into the pericardio-peritoneal window: A rare complication

Presentamos el caso de una paciente septuagenaria, con vómitos, neumonía por broncoaspiración y síndrome de impregnación neoplásica. Los estudios por imágenes muestran la totalidad del estómago herniado en el pericardio a través de una ventana pericardio-peritoneal realizada previamente. Se realizó la resolución quirúrgica del caso. Se hacen consideraciones sobre las opciones para el tratamiento del derrame pericárdico persistente, la hernia gástrica intrapericárdica como complicación, su presentación clínica, hallazgos intraoperatorios, forma de estudio y tratamiento.

We report the case of a 73-year- old female patient with vomiting, aspiration pneumonia and constitutional symptoms. The imaging tests showed total gastric herniation in the pericardial sac through a pericardio-peritoneal window previously created. The case was solved with surgery. The therapeutic options for persistent pericardial effusion are considered. Intrapericardial gastric hernia as a complication, its clinical presentation, intraoperative findings, complementary tests and treatment are discussed.

Peritonitis bacteriana secundaria a diálisis peritoneal / Bacterial peritonitis secondary to peritoneal dialysis

Resumen La diálisis peritoneal es uno de los métodos de reemplazo renal para pacientes con enfermedad renal crónica avanzada. Las infecciones representan la segunda causa de muerte y corresponden a gran morbilidad en este grupo de pacientes. La peritonitis asociada a diálisis peritoneal es una patología prevenible y es la principal complicación de este procedimiento. En la mayoría de ocasiones, la etiología es secundaria a bacterias Gram positivas colonizadoras de la piel, aunque no se puede subestimar la importancia de las bacterias Gram negativas. El diagnóstico se basa tanto en el criterio clínico como microbiológico. El tratamiento corresponde en antibióticos por un periodo de por lo menos dos semanas. Esta revisión de tema permite informar al personal de salud, pacientes y cuidadores sobre esta frecuente complicación con el fin de prevenirla, y en su defecto, un diagnóstico y tratamiento temprano con el fin de reducir la morbimortalidad y las complicaciones de dicho cuadro clínico.

Abstract Peritoneal dialysis is one of the main renal replacement therapies for end-stage renal disease. Infections represent the second leading cause of death and correspond to great morbidity in this group of patients. Peritonitis associated with peritoneal dialysis is a preventable disease, and it is also the main complication of this procedure. Most cases are secondary to Gram-positive bacteria skin colonizers; although the importance of Gram-negative bacteria cannot be underestimated. Diagnosis is based both on clinical and microbiological criteria. Treatment consists on at least a two-week period antibiotic scheme. This topic review allows health care providers, patients and caregivers to be informed about this usual complication in order to prevent it, diagnose it and initiate early treatment with the intention to minimize its morbidity, mortality and complications.

Multiple renal tumorectomy in a Von Hipple Lindau patient. Combined retro/transperitoneal approach with intracorporeal hypotermia

ABSTRACT Objective & Introduction: To show the feasibility of a combined transperitoneal (TP) and retroperitoneal (RP) laparoscopic approach in a Von Hipple-Lindau (VHL) patient with multiple kidney tumors. VHL is an autosomal dominant inherited syndrome characterized by a high incidence of benign and malignant tumors and cysts in many organs. Renal cell carcinoma is one of the most common and a leading cause of mortality (1). Surgical approach is usually complex because of its multiplicity and the need of maximum kidney function preservation due to the risk of future recurrences (2, 3). Intracorporeal renal hypothermia may be useful in these cases to prevent permanent renal function loss (4). Materials and Methods: A 40 years old male was being monitored for multiple bilateral renal masses. Family history included a VHL syndrome affecting his mother and sister. Past medical history included a VHL syndrome with multiple cerebellar and medular hemangioblastomas, a pancreatic cystoadenoma and bilateral kidney tumors which had significantly grown up during follow-up. The patient was scheduled for laparoscopic multiple partial nephrectomy. A combined TP and RP approach with intracorporeal hypothermia was chosen. Results: A total of six right kidney tumors were removed. Operative time was 240 min. Cold ischemia time was 50 min. Average kidney temperature was 23.7°C. Blood losses were negligible. The patient was discharged after 72 hours. No major changes in serum creatinine were found during the follow-up. Final pathology revealed a clear cell renal cell carcinoma, pT1a, ISUP grade 2 in most of the tumors but one ISUP grade 3. Surgical margins were negative. Conclusions: Combined TP and RP is a feasible alternative for the treatment of multiple renal tumors. It's safe and effective, allowing the use of intracorporeal hypothermia which may improve postoperative renal function. Consistent experience is needed before embarking on this surgery.

Peritoneal spaces: measurements of peritoneal surfaces / Espacios peritoneales: mediciones de las superficies peritoneales

In this work the quantitative data of the surfaces that limit the sub-spaces that constitute the peritoneal space are shown. The methodology of measurement of the two sheets (parietal and visceral) of the peritoneal serosa applied in our previous paper (Albanese et al., 2009), in non-eviscerated corpses, allowed us to know for the first time, the surface or total extension of the peritoneum "in situ". This methodology was useful to determine the surface or area of the two sheets of the peritoneum, which limit the peritoneal space. Our objective in this study was to determine the total peritoneal areas (visceral + parietal) in human corpses that are not eviscerated, which limit the different sub-spaces that make up the peritoneal space. Ten female cadavers fixed in 5 % formaldehyde solution were used. Small cellophane films were placed directly on the peritoneal sheets. The digital images were obtained by scanning these models. The surface was determined by the "Scion image for Windows" program. The results were expressed as mean +/- SE. The analysis of variance (ANOVA) was used for the statistical study. The results obtained showed that the peritoneal sub-space of greater surface area was retro-omental (mean +/- SE 7767.81 +/- 646.70 cm2 p <0.01 ANOVA), due to the large extension of its visceral surface ( mean +/- SE 7401.82 +/- 640.99 cm2). More than 50 % of the surface of the entire peritoneum corresponds to said sub-space. The smallest peritoneal sub-space (3 % of the total peritoneal surface) was the pelvic sub-space (mean +/- SE 431.30 +/- 41.62 cm2). We believe that this information may be useful in case of peritoneal pathological processes or those affected by prolonged peritoneal dialysis, and that knowledge of the surface and extension of the peritoneal space involved may contribute to the estimation of the peritoneal surface involved and help to plan the treatment.

En este trabajo se muestran los datos cuantitativos de las superficies que limitan el espacio peritoneal y los sub-espacios que lo componen. La metodología de medición de las dos hojas (parietal y visceral) de la serosa peritoneal empleada en cadáveres no eviscerados, permitió conocer por primera vez, la superficie o extensión total del peritoneo in situ. El objetivo en este trabajo fue determinar -en cadáveres humanos no evisceradoslas áreas peritoneales totales (visceral + parietal) que limitan los distintos sub-espacios que conforman el espacio peritoneal. Se han utilizado diez cadáveres femeninos no eviscerados fijados en solución de formaldehido al 5 %. Pequeñas películas de celofán se colocaron directamente sobre las hojas peritoneales. La obtención de imágenes digitales se realizó escaneando estos modelos. La superficie fue determinada por el programa "Scion image for Windows". Los resultados se expresaron como media +/- SE. Para el estudio estadístico se utilizó el análisis de varianza (ANOVA). Los resultados obtenidos demostraron que el sub-espacio peritoneal de mayor superficie fue el retro-omental (media +/- SE 7767,81 +/ - 646,70 cm2 p<0.01 ANOVA), debido a la gran extensión de su superficie visceral (media +/- SE 7401,82 +/- 640,99 cm2). Más del 50 % de la superficie de todo el peritoneo corresponde a dicho sub-espacio. El sub-espacio peritoneal más pequeño (3 % de la superficie peritoneal total) fue el sub-espacio pélvico (media +/SE 431,30 +/- 41,62 cm2). Esta información podrá ser de utilidad en el caso de procesos patológicos peritoneales o áreas afectadas por diálisis peritoneal prolongada. De esta manera el conocimiento de la extensión del espacio peritoneal involucrado, puede contribuir a la estimación de la magnitud y gravedad de la superficie peritoneal comprometida. Además puede ayudar a planificar el tratamiento.

Hyperbaric oxygenation on adhesions prevention after laparotomy in rats

Abstract Purpose: To evaluate the effects of hyperbaric oxygenation on prevention of adhesions in the abdominal cavity after laparotomy. Methods: Fifty four rats underwent laparotomy; stitches were made in the four quadrant parietal peritoneum and abdominal cavity closure. Animals were divided into three groups: 1 - control; 2 - subjected to high pressures and oxygenation; 3 - subjected to 100% hyperbaric oxygenation. The animals in groups 2 and 3 were daily submitted to oxygenation hyperbaric chamber after surgery. On the seventh day another laparotomy, registration of procedure, assessment of adhesions and biopsies of the peritoneum were held. Professionals analyzed the videos and the biopsies. Results: Peritoneal cavity adhesions occurred in animals of three groups with no difference between them. In Group 3, the adhesions presented more fragile and vascular proliferation more pronounced, and there was no difference in comparison with the first and second groups. However, there was no significant difference in the evaluation of these parameters between the animals in groups 1 and 2. Conclusions: Postoperative hyperbaric oxygenation in rats submitted to laparotomy did not alter the frequency, but reduced the density of adhesions in the peritoneal cavity and promoted vascular proliferation. The change in atmospheric pressure alone had no influence on the results.

Apendicitis perforada, ¿lavar o no lavar la cavidad peritoneal? / Perforated appendicitis, peritoneal lavage versus non-lavage?

Introducción. El tratamiento adecuado de la cavidad peritoneal en la peritonitis secundaria constituye una preocupación permanente de los cirujanos y es primordial en el manejo integral del paciente. Objetivo. Evaluar los resultados de lavar la cavidad abdominal frente al secado peritoneal en los casos de peritonitis secundaria, por apendicitis aguda perforada. Material y métodos. Estudio observacional retrospectivo en el Servicio de Cirugía General del Hospital de Especialidades Carlos Andrade Marín, período enero 2016 a diciembre 2017. Se incluyeron 301 historias clínicas de pacientes con diagnóstico de apendicitis aguda perforada. El objetivo principal del estudio fue evaluar las complicaciones presentadas con cada uno de los procedimientos quirúrgicos empleados. Resultados. Los registros de 301 pacientes, 212 (70,4%) sometidos a lavado peritoneal y 89 (29,6%) a secado del peritoneo. La frecuencia de complicaciones entre los grupos estudiados fue similar, no hubo diferencias significativas. La única variable significativa fue el tiempo operatorio (OR 1,01, p<0,005). Conclusiones. No se encontraron diferencias significativas con el tipo de manejo de cavidad en pacientes con peritonitis secundaria a apendicitis aguda perforada (lavado versus secado de cavidad) en cuanto a complicaciones posoperatorias. El lavado peritoneal requirió un tiempo quirúrgico mayor al secado de la cavidad.

Introduction. The adequate treatment of the peritoneal cavity in peritonitis is a primary concern in the comprehensive management of the patient. Objective. To compare the results of thoroughly washing the peritoneal cavity vs simply just drying the peritoneal cavity in cases of secondary peritonitis due to acute perforated appendicitis. Materials and methods. A retrospective observational study was carried out in the General Surgery Department at Carlos Andrade Marín Specialties Hospital, from January 2016 until December 2017. The study main end-point was assessing the postoperative complication between peritoneal lavage versus cavity drying. Results. The records of 301 patients, 212 (70.4%) who underwent peritoneal lavage and 89 (29.6%) with just drying the peritoneum. The frequency of complications between both groups did not reach statistical significance. The only significant variable was the operative time (OR 1.01, p<0.005). Conclusions. No statistically significant differences were found with the type of cavity management in patients with peritonitis secondary to perforated appendicitis (lavage versus cavity drying). Peritoneal lavage required more time than cavity drying.

Cirurgia citorredutora e quimioterapia intraperitoneal hipertérmica no tratamento primário dos tumores epiteliais de ovário: projeto terapêutico piloto para pacientes do SUS/PE / Cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy for treatment of epithelial ovarian cancer: a therapeutic pilot study for patients from SUS/PE

Contexto: O câncer ovariano representa a mais letal das neoplasias ginecológicas. Dada a predileção pela via peritoneal na disseminação desta neoplasia maligna (i.e.: carcinomatose peritoneal), a utilização de quimioterapia intraperitoneal hipertérmica (i.e.: HIPEC ­ hyperthermic intraperitoneal chemotherapy; sigla mantida em inglês) representa promissora opção de tratamento para seu manejo multidisciplinar. Assim, a adoção de um protocolo simplificado de HIPEC poderia incrementar os resultados de seu tratamento às custas de reduzida morbimortalidade. Objetivos: Avaliar a eficácia e a segurança de um protocolo de HIPEC para tratamento do câncer epitelial avançado de ovário em pacientes da rede pública de saúde ­ SUS, em Pernambuco. Métodos: Estudo transversal (análise interina) de dados oriundos de ensaio clínico prospectivo fase II, de braço único e aberta, ainda em curso. O protocolo em estudo envolve o tratamento multidisciplinar do câncer de ovário com quimioterapia sistêmica perioperatória (i.e.: neoadjuvante e adjuvante) associado à citorredução ciurgica com HIPEC. O protocolo de HIPEC utilizou o dispositivo Performer HT (RanD S.r.l., Medolla ­ MO, Itália) e envolveu o uso de cisplatina (25mg/m²/L) perfundida em solução glicosada de diálise peritoneal por 30 minutos, sob temperatura de 41 a 43°C. O estudo foi aprovado pela CONEP (CAAE: 04016212.5.0000.5201) e registrado no ClinicalTrial.gov (NCT02249013). Recebeu financiamento do Decit/SCTIE/MS ­ CNPq/FACEPE/SES-PE (APQ:0187-4.01/13) e do FAPE/IMIP. Resultados: Entre março de 2015 e junho de 2017 foram realizados nove procedimentos de HIPEC em nove pacientes portadoras de neoplasia epitelial de ovário em estádio FIGO IIIB (n=1) ou IIIC (n=8), dos sub-tipos histológicos endometrióide (n=1) e seroso (n=7) e misto (n=1), e com idade mediana foi de 43 (Min ­ Max: 19 ­ 63) anos. O valor mediano do marcador tumoral CA125 antes do início do tratamento foi de 692U/mL (Min ­ Max: 223,7 ­ 6550), o qual foi reduzido para 35,78U/mL (Min ­ Max: 18,5 ­ 374,6) após tratamento sistêmico com 3 (Min ­ Max: 2 ­ 4) ciclos de quimioterapia neoadjuvante baseada em platina, o que resultou em PCI (i.e.: índice de disseminação peritoneal) de 9 (Min ­ Max: 3 ­ 18) ao tempo do procedimento de HIPEC, realizado após 29 dias (Min ­ Max: 26 ­ 43) do último ciclo de quimioterapia pré-operatória. Oito procedimentos de citorredução associada à HIPEC resultaram em citorredução macroscópica completa, isto às custas de ressecção colônica em três pacientes ­ exenteração pélvica posterior (n=2) e colectomia parcial (n=1). O com tempo cirúrgico mediano foi de 395 minutos (Min ­ Max: 235­760), com tempo mediano de internamento hospitalar de 4 dias (Min ­ Max: 3 ­ 10). Todos os pacientes deixaram a UTI na manhã seguinte aos procedimentos, ao passo que 91% das morbidades compreenderam complicações menores grau I e II, de acordo com a classificação de Clavien-Dindo. Segundo a Common Terminology Criteria for Adverse Events ­ Versão 4 (CTCAE v4.03), as complicações mais comuns foram vômitos G1/G2 (n=2) e anemia G3 (n=2). Apenas uma paciente requereu re-operação ao quarto dia de pós-operatório devido hemorragia intraperitoneal sem foco de sangramento específico (complicação grau IIIB) e não houve registro de óbitos ou complicações tardias relacionadas aos procedimentos. O tempo mediano para reinício do tratamento sistêmico foi de 37 dias (Min ­ Max: 33 ­ 50) e todas as pacientes completaram tratamento sistêmico previsto no protocolo do estudo (i.e.: 6 ciclos de quimioterapia). Conclusões: Este protocolo de tratamento multidisciplinar parece ser factível e seus dados preliminares apontam para curto tempo de internação e baixa morbidade. Este é um ensaio clínico pioneiro no Brasil e também o primeiro a usar o dispositivo Performer HT

Context: Ovarian cancer is the main lethal gynecologic malignance. Due to its predilection for peritoneal route of spreading (i.e.: peritoneal carcinomatosis), the use of HIPEC-Hyperthermic Intraperitoneal Chemotherapy emerged as a promising treatment option for the comprehensive management of this malignancy. Thus, the adoption of a simplified protocol of HIPEC could increase the results of treatment with reduced morbidity and mortality. Objectives: To evaluate the efficacy and safety of a HIPEC protocol for treatment of advanced epithelial ovarian cancer patients from the Public Health System ­ SUS in Pernambuco. Methods: A cross-sectional study (interim analysis) was carried out on the women enrolled in our ongoing single-arm, open label, phase 2 clinical trial. The study involved the multidisciplinary treatment with perioperative systemic chemotherapy associated cytoreductive surgery (CRS) plus HIPEC. The HIPEC protocol used Performer HT device (RAND Srl, Medolla - MO, Italy) and involved the use of cisplatin (25mg/m²/L) perfused into dextrose peritoneal dialysis for 30 minutes under temperature of 41-43°C. The study was approved by CONEP (CAAE: 04016212.5.0000.5201) and recorded in ClinicalTrial.gov (NCT02249013). It received funding from Decit/SCTIE/MS - CNPq/FACEPE/SES-PE (APQ: 0187-4.01/13) and FAPE/IMIP. Results: From March 2015 to August 2016, nine patients with stage IIIB (n=1) or IIIC (n=8) epithelial ovarian carcinoma were enrolled into our trial, with sub-types endometrioid (n=1), serous (n=7) or mixed (n=1) adenocarcinoma, and median (range) age of 43 years (range: 19 ­ 63). The median preoperative serum CA125 levels at diagnosis was 692U/mL (range: 223.7­6550), which was reduced to 35.78U/mL (Min ­ Max: 18,5 ­ 374,6) after a median of 3 (range: 2 ­ 4) cycles of neoadjuvant chemotherapy, and peritoneal cancer index scores (PCI) of 9 (range: 3 ­ 18) at the time of CRS/HIPEC, developed after 29 days (range: 26 ­ 43) from the last neoadjuvant course of chemotherapy. Eight procedures resulted in no visible disease, and three patients required bowel resection as rectosigmoidectomy (n=2) or partial colectomy (n=1). Median operation time was 395 minutes (range: 235 ­ 760), with a length of hospital stay of 4 days (range: 3­10). All patients left the ICU on the morning after the procedure, whereas about 91% of postoperative complications were minor grade I and II complications, according to the Clavien­Dindo classification. The most common morbidities were minor G1/G2 vomiting (n=2) and G3 anemia (n=2), according to the National Cancer Institute Common Terminology Criteria for Adverse Events (NCI/CTCAE) classification version 4.0. Only one patient experienced reoperation at the fourth postoperative day because of G3 postoperative hemorrhage, but no deaths or long-term complications were recorded. Time to re-starts systemic chemotherapy (i.e.: adjuvant chemotherapy) was 37 days (range: 33 ­ 50) and all patients completed the systemic treatment protocol (i.e.: 6 cycles of chemotherapy). Conclusions: Our comprehensive multimodal protocol seems to be feasible and safe, with low rates of complications and a short length of hospital stay in this preliminary report. This is a pioneering clinical trial in Brazil and also the very first to use the Performer HT device

Tumor Desmoplásico de Pequenas Células Redondas: Relato de caso / Desmoplastic Small-Round-Cell Tumor: Case Report / Tumor Desmoplásico de Células Pequeñas y Redondas: Relato de Caso

Introdução: O tumor desmoplásico de pequenas células redondas é uma rara neoplasia que se inicia e se espalha pela superfície peritoneal. Foi descrito pela primeira vez em 1989 e, em 1991, houve seu reconhecimento como entidade clínica e patológica distintas. Relato do caso: Homem de 34 anos apresentou quadro de dor abdominal e perda de peso, evoluindo para obstrução intestinal dois meses após. A laparotomia demonstrou grande massa abdominopélvica irressecável. O laudo anatomopatológico associado à imuno-histoquímica evidenciou diagnóstico de tumor desmoplásico de pequenas células redondas. A tomografia computadorizada confirmou derrame pleural bilateral, implantes peritoneais e massas abdominais e pélvicas. Realizou-se quimioterapia com carbo/taxol com intervalo de 21 dias. Substituiu-se o esquema para VAC/IE com intervalo de 21 dias, com resposta parcial, porém ainda se mantendo um tumor irressecável. Houve piora progressiva da performance do paciente, com evolução ao óbito por obstrução intestinal no 15º mês de seguimento. Conclusão: O tumor desmoplásico de pequenas células redondas, em razão da sua raridade, continua sendo um desafio para o diagnóstico e o tratamento.

Introduction: The desmoplastic small round cell tumor is a rare neoplasm that starts and spreads through the peritoneal surface. It was first described in 1989 and in 1991 was recognized as a distinct clinical and pathological entity. Case report: A 34-year-old man presented with abdominal pain and weight loss, progressing to an intestinal obstruction after two months. Laparotomy showed an unresectable abdominopelvic mass. Anatomopathological an immunohistochemistry analysis showed a desmoplastic small-round-cell tumor. Computerized Tomography showed bilateral pleural effusion, peritoneal implants, along with masses in the abdominal and pelvic region. Chemotherapy with carbo/taxol was administered at intervals of 21-days. Later, the chemotherapy was changed to VAC/IE at a 21-day interval, with a partial response, but it was still an unresectable tumor. There was a worsening in patient performance, and he died of an abdominal obstruction on the 15º month of follow-up. Conclusion: Due to its rarity, the desmoplastic small-round-cell tumor, is still a diagnostic and treatment challenge.

Introducción: El tumor desmoplásico de células pequeñas y redondas es una neoplasia rara que comienza y se disemina a través de la superficie peritoneal. Fue descrito por primera vez en 1989 y en 1991 fue reconocido como una entidad clínica y patológica distintas. Relato del caso: Un hombre de 34 años presentó dolor abdominal y pérdida de peso, progresando a una obstrucción intestinal después de dos meses. La laparotomía mostró una masa abdominopélvica irresecable. El análisis anatomopatológico e inmunohistoquímico mostró un tumor desmoplásico de células pequeñas y redondas. La tomografía computarizada mostró derrame pleural bilateral, implantes peritoneales y masas en la región abdominal y pélvica. Se administró quimioterapia con carbo/taxol en un intervalo de 21 días. Más tarde, la quimioterapia cambió a VAC/IE con un intervalo de 21 días, con una respuesta parcial, pero seguía siendo un tumor irresecable. Hubo un empeoramiento en el estado del paciente, y murió de una obstrucción intestinal en el 15º mes de seguimiento. Conclusión: Debido a su rareza, tumor desmoplásico de células pequeñas y redondas, sigue siendo un desafío de diagnóstico y tratamiento.

Traumatic rupture of liver hydatid cysts into the peritoneal cavity of an 11-year-old boy: a case report from Iran

Abstract This is the first published case report of an 11-year-old patient with a rupture of a liver hydatid cyst (HC) into the peritoneal cavity after an abdominal trauma in Iran. The disease was diagnosed using focused abdominal sonography for trauma. To date, no cases of traumatic ruptures of liver HCs in children have been reported in Iran. In the endemic regions of the world, where patients suffer from a history of trauma and constant abdominal symptoms or anaphylactic shock, early diagnosis of HC is crucial as it may disseminate to other organs. The condition needs conservative surgery and follow-up.

Quimioterapia hipertérmica intraperitoneal transoperatória: o que a enfermagem precisa saber / Intraoperative hyperthermic intraperitoneal chemotherapy: what nurses should know / Quimioterapia intraperitoneal hipertérmica transoperatória: qué necesita saber la enfermería

Objetivo: apresentar o estado do conhecimento científico sobre quimioterapia hipertérmica intraperitoneal transoperatória no tratamento da carcinomatose peritoneal e os cuidados de enfermagem pós-operatórios para pacientes submetidos a essa terapia. Métodos: apresentam-se aspectos técnicos da quimioterapia hipertérmica intraperitoneal transoperatória, suas complicações potenciais e cuidados de enfermagem pós-operatórios envolvidos. Resultados: destaca-se a importância dos cuidados de enfermagem, quais sejam: monitorar sinais vitais, perfusão periférica, débito cardíaco e pressão venosa central; avaliar dor; encorajar tosse e realização de exercícios de respiração profunda; registrar drenagem de ferida operatória e drenos; investigar ruídos intestinais; medir volume residual gástrico; promover mudanças de decúbito; avaliar resultados laboratoriais de exames sanguíneos; instituir balanço hídrico e; aferir peso corporal. Conclusão: a quimioterapia hipertérmica intraperitoneal transoperatória é terapia promissora no tratamento de pacientes com carcinomatose peritoneal. Entretanto, para ser bem-sucedida, a prestação de cuidados de enfermagem é fundamental.

Objective: to present the current state of scientific knowledge about intraoperative hyperthermic intraperitoneal chemotherapy for the treatment of peritoneal carcinomatosis, and postoperative nursing care for patients undergoing this therapy. Methods: the study describes technical aspects of intraoperative hyperthermic intraperitoneal chemotherapy, the potential complications and post-operative nursing care involved. Results: emphasis was placed on the importance of nursing care, viz.: monitoring of vital signs, peripheral perfusion, cardiac output, and central venous pressure; pain assessment; encouraging coughing and deep breathing exercises; recording drainage of surgical wound and drains; investigating bowel sounds; measuring gastric residual volume; ensuring change of decubitus; evaluating laboratory blood test results; establishing water balance; and measuring body weight. Conclusion: intraoperative hyperthermic intraperitoneal chemotherapy has been shown to be a promising therapy in treatment of patients with peritoneal carcinomatosis. However, to be successful, the nursing care provided is fundamental.

Objetivo: presentar el estado del conocimiento científico sobre quimioterapia intraperitoneal hipertérmica transoperatoria en el tratamiento de la carcinomatosis peritoneal y los cuidados de enfermería posoperatorios para pacientes sometidos a ella. Métodos: se presentan aspectos técnicos de la quimioterapia intraperitoneal hipertérmica transoperatoria, sus complicaciones potenciales y cuidados de enfermería posoperatorios involucrados. Resultados: se destaca la importancia de los cuidados de enfermería: monitorear señales vitales, perfusión periférica, débito cardíaco, presión venosa central; evaluar dolor; estimular la tos y realización de ejercicios de respiración profunda; registrar drenaje de herida operatoria y drenes; investigar ruidos intestinales; medir volumen residual gástrico; promover cambios de decúbito; evaluar resultados de análisis de sangre en laboratorio; establecer balance hídrico; verificar peso corporal. Conclusión: la quimioterapia intraperitoneal hipertérmica transoperatoria es terapia prometedora en el tratamiento de pacientes con carcinomatosis peritoneal. Sin embargo, para ser exitosa, la prestación de cuidados de enfermería es fundamental.

Beneficio de la bursectomía en gastrectomía D2 para el cáncer gástrico: una revisión sistemática / Benefit of bursectomy in gastrectomy D2 for gastric cancer: a systematic review

Resumen Introducción: La resección quirúrgica ha demostrado ser la única opción curativa para el cáncer gástrico, al incluir linfadenectomía D2 como estándar de seguridad. Sin embargo, el beneficio de extender la resección a la bursa omentalis sigue siendo controvertido. La investigación publicada no ha arrojado evidencia categórica definiendo la eficacia. Realizamos una revisión sistemática de ensayos clínicos aleatorizados publicados (ECA), para evaluar el beneficio de la bursectomía en la sobrevida global (OS) y la sobrevida libre de enfermedad (SLE) de los pacientes. Como resultado secundario se consideró la seguridad del procedimiento. Métodos: Se realizó una búsqueda bibliográfica en las bases de datos de Pubmed, Cochrane, Scielo, Metabuscador PUC, Epistemonikos, Tripdatabase, Sciencedirect y Lilacs para ECA que compararan la bursectomía con la no bursectomía, publicados antes de marzo de 2016. Se establecieron y aplicaron criterios de inclusión y exclusión. Resultados: Se encontraron 3 ECA correspondientes a diferentes informes de la misma cohorte de pacientes. Se incluyeron 210 pacientes (104 en el grupo de bursectomía y 106 en el grupo de no bursectomía). La bursectomía no tuvo un efecto significativo ni en la OS a 5 años (HR: 1,4; IC del 95%: 0,87-2,25) ni en la SLE (HR: 1,25; IC del 95% 0,80-1,97). No se observó diferencia estadísticamente significativa en la tasa de complicaciones al comparar el grupo de bursectomía y el grupo de no bursectomía. Conclusión: La gastrectomía con bursectomía no es superior a la no bursectomía, ya sea en términos de OS a 5 años o de SLE.

Abstract Introduction: The surgical resection has proved to be the only curative option for Gastric Cancer, when including D2 linfadenectomy as security standard. The benefit of extending the resection to the bursa omentalis, however, is still controversial. The published research has not yielded categorical evidence on defining the efficacy of bursectomy. We conducted a systematic review of published randomized controlled trials (RCT), to evaluate the benefit of bursectomy in the overall survival (OS) and disease-free survival (DFS) of patients. As secondary outcome, was considered the safety of the procedure. Methods: A literature search was conducted in Pubmed, Cochrane library databases, Scielo, Metabuscador PUC, Epistemonikos, Tripdatabase, Sciencedirect, and Lilacs for randomized clinical trials comparing bursectomy with non-bursectomy, published before March 2016. Inclusion and exclusion criteria were established and applied. Results: We found three RCT corresponding to different reports of the same cohort of randomized patients. They included 210 patients (104 in the bursectomy group, and 106 in the non-bursectomy group). The bursectomy did not have a significant effect either on 5-years OS (HR: 1.4; 95%CI: 0,87-2,25), or on DFS (HR: 1.25; 95% CI: 0,80-1,97). No statistically significant difference was observed in the rate of complications, when comparing the bursectomy group and the non-bursectomy group. Conclusion: Gastrectomy with bursectomy is not superior to non-bursectomy either in terms of 5 years OS or on DFS.

Detection value of free cancer cells in peritoneal washing in gastric cancer: a systematic review and meta-analysis

Intraperitoneal free cancer cells in gastric adenocarcinoma are associated with a poor outcome. However, the true prognostic value of intraperitoneal free cancer cells is still unclear, leading to a lack of consensus in the management of gastric cancer. The aim of the present study is to perform a systematic review and meta-analysis to analyze intraperitoneal free cancer cells-positive patients with regard to tumor oncologic stage, recurrence, grade of cellular differentiation, and survival rates and to analyze the clinical significance of intraperitoneal free cancer cells with regard to prognosis. Databases were searched up to January 2016 for prognostic factors associated with intraperitoneal free cancer cells, including oncologic stage, depth of neoplasm invasion, lymph nodal spread, differentiation grade of the tumor, and recurrence and survival rates. A total of 100 studies were identified. Meta-analysis revealed a clear association between intraperitoneal free cancer cells and a poor prognosis. intraperitoneal free cancer cells -positive patients had higher rates of nodal spread (risk difference: 0.29; p<0.01), serosal invasion (risk difference: 0.43; p<0.01), recurrence (after 60 months of follow-up, risk difference: 0.44; p<0.01), and mortality (after 60 months of follow-up, risk difference: 0.34; p<0.01). Intraperitoneal free cancer cells are associated with a poor outcome in gastric cancer. This surrogate biomarker should be used to guide therapy both prior to and after surgery.

Novel retrograde puncture method to establish preperitoneal space for laparoscopic direct inguinal hernia repair with internal ring suturing

The aim of this study was to explore the clinical efficacy of a novel retrograde puncture approach to establish a preperitoneal space for laparoscopic direct inguinal hernia repair with inguinal ring suturing. Forty-two patients who underwent laparoscopic inguinal hernia repair with retrograde puncture for preperitoneal space establishment as well as inguinal ring suturing between August 2013 and March 2014 at our hospital were enrolled. Preperitoneal space was successfully established in all patients, with a mean establishment time of 6 min. Laparoscopic repairs were successful in all patients, with a mean surgical time of 26±15.1 min. Mean postoperative hospitalization duration was 3.0±0.7 days. Two patients suffered from postoperative local hematomas, which were relieved after puncturing and drainage. Four patients had short-term local pain. There were no cases of chronic pain. Patients were followed up for 6 months to 1 year, and no recurrence was observed. Our results demonstrate that preperitoneal space established by the retrograde puncture technique can be successfully used in adult laparoscopic hernioplasty to avoid intraoperative mesh fixation, and thus reduce medical costs.