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The role of wound protectors in laparoscopic surgeries is highly controversial in the literature. Some studies demonstrate their benefit in reducing the rate of surgical site infections; however, these results are not reproducible across all procedures. In addition to protecting the operative wound, these devices can be used at sites of surgical specimen extraction in laparoscopic procedures. Several commercially available devices serve this purpose but are scarcely available in resource-limited settings. One of the reasons for this limitation is the cost of the device. In this technical note, we aim to provide a cost-effective option utilizing materials readily available in the operating room and with a simple fabrication process.
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Laparoscopia , Laparoscopia/instrumentação , Laparoscopia/economia , Laparoscopia/métodos , Humanos , Desenho de Equipamento , Infecção da Ferida Cirúrgica/prevenção & controle , Infecção da Ferida Cirúrgica/economiaRESUMO
The article discusses the evolution of the Brazilian College of Surgeons (CBC) specialist title exam, highlighting the importance of evaluating not only theoretical knowledge, but also the practical skills and ethical behavior of candidates. The test was instituted in 1971, initially with only the written phase, and later included the oral practical test, starting with the 13th edition in 1988. In 2022, the assessment process was improved by including the use of simulated stations in the practical test, with the aim of assessing practical and communication skills, as well as clinical reasoning, in order to guarantee excellence in the assessment of surgeons training. The aim of this study is to demonstrate the performance of candidates in the last five years of the Specialist Title Test and to compare the performance results between the different surgical training groups of the candidates. The results obtained by candidates from the various categories enrolled in the test in the 2018 to 2022 editions were analyzed. There was a clear and statistically significant difference between doctors who had completed three years of residency recognized by the Ministry of Education in relation to the other categories of candidates for the Specialist Title..
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Avaliação Educacional , Brasil , Humanos , Avaliação Educacional/métodos , Competência Clínica , Cirurgiões , Fatores de Tempo , Sociedades Médicas , Especialidades Cirúrgicas/educaçãoRESUMO
ABSTRACT The article discusses the evolution of the Brazilian College of Surgeons (CBC) specialist title exam, highlighting the importance of evaluating not only theoretical knowledge, but also the practical skills and ethical behavior of candidates. The test was instituted in 1971, initially with only the written phase, and later included the oral practical test, starting with the 13th edition in 1988. In 2022, the assessment process was improved by including the use of simulated stations in the practical test, with the aim of assessing practical and communication skills, as well as clinical reasoning, in order to guarantee excellence in the assessment of surgeons training. The aim of this study is to demonstrate the performance of candidates in the last five years of the Specialist Title Test and to compare the performance results between the different surgical training groups of the candidates. The results obtained by candidates from the various categories enrolled in the test in the 2018 to 2022 editions were analyzed. There was a clear and statistically significant difference between doctors who had completed three years of residency recognized by the Ministry of Education in relation to the other categories of candidates for the Specialist Title..
RESUMO O artigo aborda a evolução da prova de título de especialista do Colégio Brasileiro de Cirurgiões (CBC), destacando a importância de avaliar não apenas o conhecimento teórico, mas também as habilidades práticas e o comportamento ético dos candidatos. A prova foi instituída em 1971, inicialmente com apenas a fase escrita, e posteriormente foi incluída a prova prática oral, a partir da 13ª edição em 1988. Em 2022, foi aprimorado o processo de avaliação, incluindo na prova prática o uso de estações simuladas, visando avaliar habilidades práticas e de comunicação, além do raciocínio clínico, buscando garantir a excelência da avaliação da formação dos cirurgiões. O objetivo deste estudo é demonstrar o desempenho dos candidatos nos últimos cinco anos da Prova de Título de Especialista e comparar os resultados dos desempenhos entre os diferentes grupos de formação cirúrgica dos candidatos. Foram analisados os resultados obtidos pelos candidatos das diversas categorias inscritas na prova nas edições de 2018 a 2022. Ficou evidente e estatisticamente significativa a diferença entre os médicos que fizeram três anos de residência reconhecida pelo MEC em relação aos demais categorias de candidatos ao Título de Especialista.
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ABSTRACT The role of wound protectors in laparoscopic surgeries is highly controversial in the literature. Some studies demonstrate their benefit in reducing the rate of surgical site infections; however, these results are not reproducible across all procedures. In addition to protecting the operative wound, these devices can be used at sites of surgical specimen extraction in laparoscopic procedures. Several commercially available devices serve this purpose but are scarcely available in resource-limited settings. One of the reasons for this limitation is the cost of the device. In this technical note, we aim to provide a cost-effective option utilizing materials readily available in the operating room and with a simple fabrication process.
RESUMO O papel dos protetores de ferida operatória em cirurgias laparoscópicas é bastante controverso na literatura. Alguns estudos demonstram seu benefício na redução da taxa de infeções de sítio cirúrgico, porém esses resultados não são reprodutíveis em todos os procedimentos. Além da proteção da ferida operatória, esses dispositivos podem ser utilizados nos sítios de extração de peças cirúrgicas em procedimentos laparoscópicos. Há vários dispositivos comercialmente disponíveis para esse fim, entretanto são pouco disponíveis nos serviços com menos recursos. Um dos motivos dessa limitação é o custo do dispositivo. Nesta nota, buscamos oferecer uma opção barata que utiliza materiais amplamente disponíveis no centro cirúrgico e cuja confecção é simples.
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INTRODUCTION: Pancreatic solid pseudopapillary neoplasm (SPN), or Frantz's tumor, is a rare tumor with low malignant potential and a high cure rate when treated by complete surgical resection. There have been few reports of metastatic disease as a result of blunt abdominal trauma. PRESENTATION OF CASE: A 13-year-old female patient was a victim of blunt abdominal trauma in 2019. A computed tomography (CT) scan showed a voluminous hemoperitoneum associated with a tumor in the pancreatic tail whose characteristics suggested a pseudopapillary tumor. The patient remained hemodynamically stable and nonoperative treatment was chosen. Two months later, a CT scan showed resolution of the hemoperitoneum and delimitation of the neoplasm in the tail of the pancreas. Elective body and tail pancreatectomy with laparoscopic splenectomy was performed. The patient remained asymptomatic for 15 months until she developed abdominal pain and constipation. A CT scan suggested peritoneal carcinomatosis, which was confirmed by biopsy of the lesions. CLINICAL DISCUSSION: A pancreatic SPN, in the context of an abdominal injury, can undergo metastatic progression despite surgical resection with curative intent and adherence to the precepts of minimally invasive oncological surgery. It is important to plan for the long-term follow-up of patients, as well as to understand the risk factors for recurrence. CONCLUSION: Although pancreatic SPN has a good prognosis, rupture of its capsule due to external trauma, as reported in the present case, may be a mechanism for peritoneal dissemination of the tumor with a consequent reduction in the length of disease-free survival.
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BACKGROUND: Trauma laparoscopy may provide a less invasive alternative to laparotomy by providing accurate diagnosis and minimally invasive management of selected trauma patients. The risk of missing injuries during the laparoscopic evaluation still refrains surgeons from using this approach. Our aim was to evaluate feasibility and safety of trauma laparoscopy in selected patients. METHODS: We performed a retrospective review of hemodynamically trauma patients who underwent laparoscopic management in a tertiary center in Brazil due to abdominal trauma. Patients were identified by searching through the institutional database. We collected demographic and clinical data, focusing on avoidance of exploratory laparotomy, and missed injury rate, morbidity, and length of stay. Categorical data were analyzed using Chi-square, while numerical comparisons were performed using Mann-Whitney and Kruskal-Wallis test. RESULTS: We evaluated 165 cases, of which 9.7% needed conversion to an exploratory laparotomy. One-hundred and twenty-one patients (73%) had at least one intrabdominal injury. Two missed injuries to retroperitoneal organs were identified (1.2%), of which only one was clinically relevant. Three patients died (1.8%), one of which was due to complications from an intestinal injury after conversion. No deaths were related to the laparoscopic approach. CONCLUSION: In selected hemodynamically stable trauma patients, the laparoscopic approach is feasible and safe, and reduces the need for exploratory laparotomy and its associated complications.
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Traumatismos Abdominais , Laparoscopia , Ferimentos Penetrantes , Humanos , Estudos Retrospectivos , Padrão de Cuidado , Traumatismos Abdominais/cirurgia , Laparoscopia/efeitos adversos , Laparotomia/efeitos adversos , Ferimentos Penetrantes/cirurgiaRESUMO
PURPOSE: To evaluate effect of N-acetylcysteine (NAC) associated with Ringer lactate or hypertonic saline in inflammation and bacterial translocation on experimental intestinal obstruction (IO). METHODS: Wistar rats was subjected to IO. Six or 24 hours after, rats were subjected to enterectomy and fluid resuscitation: IO, RL (subjected to the same procedures but with fluid resuscitation using Ringer's lactate solution); RLNAC (added NAC to Ringer's solution); and HSNAC (surgical procedure + fluid reposition with 7.5% hypertonic saline and NAC). After 24 h, tissues were collected to cytokines, bacterial translocation, and histological assessments. RESULTS: In kidney, interleukin-1beta (IL-1beta) was lower in the groups with fluid resuscitation compared to IO group. The RLNAC showed lower levels compared to the RL. Interleukin-6 (IL-6), interleukin-10 (IL-10), tumor necrosis factor-alpha (TNF-alpha), and (IFN-gamma) were lower in the treatment groups than in IO. In lung, IL-1beta and IL-6 were lower in RLNAC compared to IO. IL-10 was lower in RL, RLNAC and HSNAC compared to IO. TNF-alpha was higher in HSNAC compared to both RL and RLNAC. Bacterial translocation was observed in all animals of IO group. In kidneys, inflammation and congestion degrees were lower in HSNAC compared to RL. In lungs, inflammation levels were higher in RLNAC compared with the sham group. CONCLUSIONS: The data indicates that NAC associated with RL can promote a decrease in the inflammatory process in the kidneys and lungs in rats, following intestinal obstruction and ischemia in rats.
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Obstrução Intestinal , Choque Hemorrágico , Ratos , Animais , Ratos Wistar , Interleucina-10 , Acetilcisteína/farmacologia , Acetilcisteína/uso terapêutico , Interleucina-6 , Fator de Necrose Tumoral alfa , Translocação Bacteriana , Solução Salina Hipertônica/farmacologia , Isquemia , Inflamação/tratamento farmacológico , Ressuscitação/métodosRESUMO
INTRODUCTION: Splenic abscess secondary to endocarditis is a rare complication with high mortality. The treatment modality, splenectomy versus percutaneous drainage, and the best time, before or after valve replacement, are controversial. In the literature, there are only a few small case series about the subject. The objective of this study is to analyze the experience of a referral center in treating such condition. METHODS: Patients with splenic abscesses due to endocarditis from 2006 to 2020 were retrospectively analyzed. RESULTS: Thirteen patients (mean age 46 years old, 69% male) were identified. Eight patients (62%) had at least 2 comorbidities and 5 (38%) had a history of cardiac surgery. The diagnosis was incidental in 6 (46%). The mean time of abscess diagnosis after endocarditis definition was 14 days. Six patients (46%) had at least two organ dysfunctions. The median APACHE II score was 12 overall, and 24.5 in patients who died. Six patients (46%) had a valve replacement, and in two the abscess was diagnosed postoperatively. Of the other four patients, splenectomy was performed before the cardiac operation in three and at the same time in one. Splenectomy was performed immediately in 9 (69%) patients while three patients had percutaneous drainage (23%), one of which underwent splenectomy due to drainage failure. Exclusive antibiotic treatment was performed on only one patient. The median length of hospitalization was 24 days and mortality was 46%. CONCLUSION: Splenic abscess due to endocarditis is a life-threatening condition with controversial treatment that results in a prolonged length of stay and high mortality.
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Abscesso Abdominal , Endocardite , Esplenopatias , Abscesso/etiologia , Abscesso/cirurgia , Antibacterianos/uso terapêutico , Brasil/epidemiologia , Endocardite/complicações , Endocardite/diagnóstico , Endocardite/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Doenças Raras/complicações , Doenças Raras/tratamento farmacológico , Estudos Retrospectivos , Esplenopatias/etiologia , Esplenopatias/cirurgiaRESUMO
INTRODUCTION: The lack of standardized skill training reported by medical students in performing tube thoracostomies may be associated with higher complications. The ideal training model is yet to be determined. This study sought to evaluate three different models. METHODS: Between 2015 and 2017, 204 last-year medical students of Universidade de São Paulo with no prior training in tube thoracostomy were randomized into three groups: cadaver, pig, and synthetic models. All groups performed 1-d tube thoracostomy hands-on training and a 40-min theoretical class. The knowledge acquisition was measured by a comparison between a theoretical test before and 3 wk after the class, and the skills improvement was evaluated by a comparison between the skills test on the same day of the hands-on training and another after 24 wk (the retention skill test). A questionnaire was submitted to evaluate their satisfaction rate and self-reported confidence, as per a Likert scale. RESULTS: The theoretical post-test score was higher compared to the pretest score in all groups (P < 0.001). The retention skills test in the cadaver and synthetic groups decreased compared to the skills test (P = 0.01 and P = 0.007, respectively). There was no difference between the groups either in the theoretical test or in the skills test. Student satisfaction was higher in the cadaver and pig groups. The confidence perception increased in all groups after the training. CONCLUSIONS: The models used for tube thoracostomy training appear to have a similar impact on skills retention, knowledge acquisition, and confidence. Although the satisfaction rate is lower for the synthetic model, it has no biological risk or ethical issues and is more feasible.
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Estudantes de Medicina , Toracostomia , Animais , Humanos , Brasil , Cadáver , Tubos Torácicos , Competência Clínica , Suínos , Toracostomia/educaçãoRESUMO
Percutaneous tracheostomy has been considered the standard method today, the bronchoscopy-guided technique being the most frequently performed. A safe alternative is ultrasound-guided percutaneous tracheostomy, which can be carried out by the surgeon, avoiding the logistical difficulties of having a specialist in bronchoscopy. Studies prove that the efficacy and safety of the ultrasound-guided technique are similar when compared to the bronchoscopy-guided one. Thus, it is of paramount importance that surgeons have ultrasound-guided percutaneous tracheostomy as a viable and beneficial alternative to the open procedure. In this article, we describe eight main steps in performing ultrasound-guided percutaneous tracheostomy, highlighting essential technical points that can reduce the risk of complications from the procedure. Furthermore, we detail some precautions that one must observe to reduce the risk of aerosolization and contamination of the team when percutaneous tracheostomy is indicated in patients with COVID-19.
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COVID-19 , Traqueostomia , Broncoscopia/métodos , Humanos , Traqueostomia/métodos , Ultrassonografia , Ultrassonografia de Intervenção/métodosRESUMO
ABSTRACT Percutaneous tracheostomy has been considered the standard method today, the bronchoscopy-guided technique being the most frequently performed. A safe alternative is ultrasound-guided percutaneous tracheostomy, which can be carried out by the surgeon, avoiding the logistical difficulties of having a specialist in bronchoscopy. Studies prove that the efficacy and safety of the ultrasound-guided technique are similar when compared to the bronchoscopy-guided one. Thus, it is of paramount importance that surgeons have ultrasound-guided percutaneous tracheostomy as a viable and beneficial alternative to the open procedure. In this article, we describe eight main steps in performing ultrasound-guided percutaneous tracheostomy, highlighting essential technical points that can reduce the risk of complications from the procedure. Furthermore, we detail some precautions that one must observe to reduce the risk of aerosolization and contamination of the team when percutaneous tracheostomy is indicated in patients with COVID-19.
RESUMO A traqueostomia percutânea tem sido considerada o método padrão atualmente, sendo a técnica guiada por broncoscopia a mais realizada. Uma alternativa segura é a traqueostomia percutânea guiada por ultrassonografia, que pode ser feita pelo próprio cirurgião, evitando-se as dificuldades logísticas de disponibilidade de um especialista em broncoscopia. Estudos comprovam que a eficácia e a segurança da técnica guiada por ultrassonografia, comparada à guiada por broncoscopia, são semelhantes. Assim, é de suma importância que os cirurgiões tenham a traqueostomia percutânea guiada por ultrassonografia como alternativa viável e benéfica em relação ao procedimento aberto. Neste artigo, descrevemos oito passos principais da realização da traqueostomia percutânea ecoguiada, destacando pontos técnicos essenciais que podem reduzir o risco de complicações do procedimento. Ainda, detalhamos alguns cuidados que devem ser observados, com o intuito de reduzir o risco de aerolização e contaminação da equipe, quando a traqueostomia percutânea é indicada no paciente com COVID-19.
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Humanos , Traqueostomia/métodos , COVID-19 , Broncoscopia/métodos , Ultrassonografia , Ultrassonografia de Intervenção/métodosRESUMO
BACKGROUND: Pneumomediastinum is a rare complication of COVID-19 pneumonia, which may or may not be associated with invasive ventilatory support. Therefore, the report and findings associated with its evolution can be of great contribution in the management of this unknown disease. CASE PRESENTATION: Here, we present a series of four patients with severe pneumomediastinum requiring intensive care unit. These patients developed pneumomediastinum before or during orotracheal intubation (OTI) or without OTI. The four patients were three men and one woman with a mean age of 60.5 years (48-74 years). No patients had a known history of lung disease or traumatic events, except for one patient who had a history of smoking, but who was without parenchymal disease. All intubations were performed without complications. No cases of pneumomediastinum occurred after tracheostomy, and none of the patients had tomographic or bronchoscopic evidence of tracheal injury. Although the pneumomediastinum observed in our cases was apparently not related to a violation of the aerodigestive track, this complication was associated with a worse prognosis. CONCLUSION: Pneumomediastinum is a rare complication of COVID-19 pneumonia, and the most likely etiopathogenesis is severe pulmonary involvement, which may or may not be associated with invasive ventilatory support. Future studies with a greater number of cases should elucidate the relationship of pneumomediastinum to a probable prognostic factor.
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COVID-19/complicações , Enfisema Mediastínico/etiologia , Enfisema Mediastínico/terapia , Idoso , Antibacterianos/uso terapêutico , COVID-19/terapia , Feminino , Humanos , Masculino , Enfisema Mediastínico/diagnóstico por imagem , Pessoa de Meia-Idade , Respiração Artificial , Tomografia Computadorizada por Raios XRESUMO
PURPOSE: COVID-19 is associated with high morbidity and mortality in patients undergoing surgery. Contrary to elective procedures, emergency operations should not be postponed. We aim to evaluate the profile and outcomes of COVID-19 patients who underwent emergency abdominal surgery. METHODS: We performed a retrospective analysis of perioperative data of COVID-19 patients undergoing emergency surgery from April 2020 to August 2020. RESULTS: Eighty-two patients were evaluated due to abdominal complaints, yielding 22 emergency surgeries. The mean APACHE II and SAPS were 18.7 and 68, respectively. Six patients had a PaO2/FiO2 lower than 200 and more than 50% of parenchymal compromise on chest tomography. The most common indications for emergency surgery were hernias (6; 27.2%). The median length of stay was 30 days, and only two patients required reoperation. Postoperatively, 10 (43.3%) patients needed mechanical ventilation for a mean of 6 days. The overall mortality rate was 31.8%. CONCLUSION: Both postoperative morbidity and mortality are high in COVID-19 patients with respiratory compromise and abdominal emergencies.
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Abdome Agudo/cirurgia , COVID-19/complicações , Pneumonia Viral/complicações , APACHE , Abdome Agudo/mortalidade , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Brasil/epidemiologia , COVID-19/mortalidade , Emergências , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Pneumonia Viral/mortalidade , Pneumonia Viral/virologia , Respiração Artificial , Estudos Retrospectivos , SARS-CoV-2RESUMO
N-acetylcysteine (NAC) is a pharmacological alternative with great potential for reducing the deleterious effects of surgical procedures on patients with steatohepatitis. We evaluated the effect of NAC on hepatic ischemia/reperfusion (I/R) injury in C57BL/6J mice, 8 weeks-old, weighing 25-30 g, with steatohepatitis induced by a methionine- and choline-deficient (MCD) diet. Groups: MCD group (steatohepatitis), MCD-I/R group (steatohepatitis plus 30 min of 70% liver ischemia and 24 h of reperfusion), MCD-I/R+NAC group (same as MCD-I/R group plus 150 mg/kg NAC 15 min before ischemia), and control group (normal AIN-93M diet). Liver enzymes and histopathology; nitrite and TBARS (thiobarbituric acid reactive substances) levels; pro-inflammatory cytokines; antioxidants enzymes; Nrf2 (nuclear factor erythroid-2-related factor 2) expression; and apoptosis were evaluated. In the group treated with NAC, reductions in inflammatory infiltration; AST (aspartate aminotransferase), nitrite, and TBARS levels; GPx (gutathione peroxidase) activity; cytokines synthesis; and number of apoptotic cells were observed while the GR (glutathione reductase) activity was increased. No differences were observed in Nfr2 expression or in SOD (superoxide dismutase), CAT (catalase), and GST (glutathione S-transferase) activities. Thus, it may be concluded that NAC exerts beneficial effects on mice livers with steatohepatitis submitted to I/R by reducing oxidative stress, inflammatory response, and cell death.
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Acetilcisteína/farmacologia , Hepatopatia Gordurosa não Alcoólica/tratamento farmacológico , Traumatismo por Reperfusão/tratamento farmacológico , Alanina Transaminase/metabolismo , Animais , Antioxidantes/metabolismo , Apoptose/efeitos dos fármacos , Aspartato Aminotransferases/metabolismo , Morte Celular/efeitos dos fármacos , Citocinas/metabolismo , Fígado/efeitos dos fármacos , Fígado/enzimologia , Fígado/patologia , Camundongos Endogâmicos C57BL , Fator 2 Relacionado a NF-E2/metabolismo , Hepatopatia Gordurosa não Alcoólica/metabolismo , Hepatopatia Gordurosa não Alcoólica/fisiopatologia , Estresse Oxidativo/efeitos dos fármacos , Traumatismo por Reperfusão/metabolismo , Traumatismo por Reperfusão/patologiaRESUMO
PURPOSE: We analyzed the morbidity and mortality associated with Hartmann's reversal (HR) and the risk factors for major complications and mortality. METHODS: The subjects of this retrospective study were patients who underwent HR in a high-volume center. We evaluated complications as categorical variables using univariate analyses. RESULTS: Between 2003 and 2018, 199 patients underwent HR at our hospital [56.5 years; body mass index (BMI): 26.3 kg/m2; American Society of Anesthesiology score (ASA) 3: 7.5%; 36.2% had hernias]. The mean time to HR was 20.2 months and the mean operation time was 302 min. The anastomosis was stapled in 71.4% and was performed in the low/medium rectum in 21.6%. Midline hernias were repaired with mesh in 80.1%. The mean hospitalization period was 10.1 days. Surgical site infection (SSI) developed in 27.1% of the patients, 94.4% of whom were treated at the bedside. BMI was a risk factor for SSI (27.8 vs. 25.6; p = 0.047). Major complications (Clavien-Dindo III-V) developed in 27 patients (13.5%), including anastomosis dehiscence in 2.5%. ASA, BMI, age, hernia repair, and rectal stump size were not associated with major complications. The mortality rate was 2.5%. An ASA of 3 was associated with high mortality (p = 0.03). CONCLUSION: Hartmann's reversal remains challenging but can have low complication and mortality rates if performed on selected patients in a reference center. An ASA of 3 was the only predictor of mortality.
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Colostomia/métodos , Complicações Pós-Operatórias/epidemiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Brasil , Colostomia/mortalidade , Feminino , Hospitais/estatística & dados numéricos , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Seleção de Pacientes , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Fatores de Risco , Deiscência da Ferida Operatória/epidemiologia , Deiscência da Ferida Operatória/etiologia , Infecção da Ferida Cirúrgica/epidemiologia , Infecção da Ferida Cirúrgica/etiologia , Adulto JovemRESUMO
BACKGROUND: Fascial dehiscence (FD) occurs in up to 14.9% of high-risk patients undergoing emergency laparotomy. Although prophylactic mesh can prevent FD, its use in emergency operations remains controversial. STUDY DESIGN: A prospective randomized clinical trial was conducted at the Hospital das Clínicas from Faculdade de Medicina da Universidade de São Paulo in Brazil. It was performed among high-risk patients, defined according to Rotterdam risk model, undergoing midline emergency laparotomy. The patients were randomized into the suture group (SG), with slowly absorbable running sutures placed with a 36-mm-long needle at a suture-to-wound length ratio of 4:1, and the prophylactic mesh group (PMG), with fascial closure as in the SG but reinforced with onlay polypropylene mesh. The primary end point was incidence of FD at 30 days post operation. RESULTS: We analyzed 115 patients; 52 and 63 were allocated to the SG and PMG, respectively. In all, 77.4% of the cases were for colorectal resection. FD occurred in 7 (13.5%) patients in the SG and none in the PMG (p = 0.003). There was no difference between the groups in number of patients with surgical site occurrence (SSO) or SSO requiring procedural intervention. However, some specific SSOs had higher incidences in the mesh group: surgical site infection (20.6% versus 7.7%; p = 0.05), seroma (19.0% versus 5.8%; p = 0.03), and nonhealing incisional wound (23.8% versus 5.8%; p = 0.008). Of SSOs in the PMG and SG, 92.3% and 73.3%, respectively, resolved spontaneously or with bedside interventions. CONCLUSIONS: Prophylactic onlay mesh reinforcement in emergency laparotomy is safe and prevents FD. Surgical site infection, seroma, and nonhealing incisional wound were more common in the mesh group, but associated with low morbidity within 30 days post operation.
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Tratamento de Emergência , Laparotomia , Telas Cirúrgicas , Deiscência da Ferida Operatória/prevenção & controle , Suturas , Adulto , Idoso , Fáscia , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Deiscência da Ferida Operatória/epidemiologiaRESUMO
OBJECTIVES: Intestinal obstruction has a high mortality rate when therapeutic treatment is delayed. Resuscitation in intestinal obstruction requires a large volume of fluid, and fluid combinations have been studied. Therefore, we evaluated the effects of hypertonic saline solution (HS) with pentoxifylline (PTX) on apoptosis, oxidative stress and survival rate. METHODS: Wistar rats were subjected to intestinal obstruction and ischemia through a closed loop ligation of the terminal ileum and its vessels. After 24 hours, the necrotic bowel segment was resected, and the animals were randomized into four groups according to the following resuscitation strategies: Ringer's lactate solution (RL) (RL-32 ml/kg); RL+PTX (25 mg/kg); HS+PTX (HS, 7.5%, 4 ml/kg), and no resuscitation (IO-intestinal obstruction and ischemia). Euthanasia was performed 3 hours after resuscitation to obtain kidney and intestine samples. A malondialdehyde (MDA) assay was performed to evaluate oxidative stress, and histochemical analyses (terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling [TUNEL], Bcl-2 and Bax) were conducted to evaluate kidney apoptosis. Survival was analyzed with another series of animals that were observed for 15 days. RESULTS: PTX in combination with RL or HS reduced the MDA levels (nmol/mg of protein), as follows: kidney IO=0.42; RL=0.49; RL+PTX=0.31; HS+PTX=0.34 (p<0.05); intestine: IO=0.42; RL=0.48; RL+PTX=0.29; HS+PTX=0.26 (p<0.05). The number of labeled cells for TUNEL and Bax was lower in the HS+PTX group than in the other groups (p<0.05). The Bax/Bcl-2 ratio was lower in the HS+PTX group than in the other groups (p<0.05). The survival rate on the 15th day was higher in the HS+PTX group (77%) than in the RL+PTX group (11%). CONCLUSION: PTX in combination with HS enhanced survival and attenuated oxidative stress and apoptosis. However, when combined with RL, PTX did not reduce apoptosis or mortality.
Assuntos
Apoptose/efeitos dos fármacos , Obstrução Intestinal/metabolismo , Estresse Oxidativo/efeitos dos fármacos , Pentoxifilina/farmacologia , Ressuscitação/métodos , Solução Salina Hipertônica/farmacologia , Animais , Modelos Animais de Doenças , Imuno-Histoquímica , Marcação In Situ das Extremidades Cortadas , Obstrução Intestinal/mortalidade , Obstrução Intestinal/prevenção & controle , Intestino Delgado/efeitos dos fármacos , Intestino Delgado/metabolismo , Estimativa de Kaplan-Meier , Rim/efeitos dos fármacos , Rim/metabolismo , Peroxidação de Lipídeos/efeitos dos fármacos , Masculino , Malondialdeído/análise , Distribuição Aleatória , Ratos Wistar , Reprodutibilidade dos TestesRESUMO
OBJECTIVES: Intestinal obstruction has a high mortality rate when therapeutic treatment is delayed. Resuscitation in intestinal obstruction requires a large volume of fluid, and fluid combinations have been studied. Therefore, we evaluated the effects of hypertonic saline solution (HS) with pentoxifylline (PTX) on apoptosis, oxidative stress and survival rate. METHODS: Wistar rats were subjected to intestinal obstruction and ischemia through a closed loop ligation of the terminal ileum and its vessels. After 24 hours, the necrotic bowel segment was resected, and the animals were randomized into four groups according to the following resuscitation strategies: Ringer's lactate solution (RL) (RL-32 ml/kg); RL+PTX (25 mg/kg); HS+PTX (HS, 7.5%, 4 ml/kg), and no resuscitation (IO-intestinal obstruction and ischemia). Euthanasia was performed 3 hours after resuscitation to obtain kidney and intestine samples. A malondialdehyde (MDA) assay was performed to evaluate oxidative stress, and histochemical analyses (terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling [TUNEL], Bcl-2 and Bax) were conducted to evaluate kidney apoptosis. Survival was analyzed with another series of animals that were observed for 15 days. RESULTS: PTX in combination with RL or HS reduced the MDA levels (nmol/mg of protein), as follows: kidney IO=0.42; RL=0.49; RL+PTX=0.31; HS+PTX=0.34 (p<0.05); intestine: IO=0.42; RL=0.48; RL+PTX=0.29; HS+PTX=0.26 (p<0.05). The number of labeled cells for TUNEL and Bax was lower in the HS+PTX group than in the other groups (p<0.05). The Bax/Bcl-2 ratio was lower in the HS+PTX group than in the other groups (p<0.05). The survival rate on the 15th day was higher in the HS+PTX group (77%) than in the RL+PTX group (11%). CONCLUSION: PTX in combination with HS enhanced survival and attenuated oxidative stress and apoptosis. However, when combined with RL, PTX did not reduce apoptosis or mortality.
Assuntos
Animais , Masculino , Pentoxifilina/farmacologia , Ressuscitação/métodos , Solução Salina Hipertônica/farmacologia , Apoptose/efeitos dos fármacos , Estresse Oxidativo/efeitos dos fármacos , Obstrução Intestinal/metabolismo , Imuno-Histoquímica , Peroxidação de Lipídeos/efeitos dos fármacos , Distribuição Aleatória , Reprodutibilidade dos Testes , Ratos Wistar , Marcação In Situ das Extremidades Cortadas , Modelos Animais de Doenças , Estimativa de Kaplan-Meier , Obstrução Intestinal/mortalidade , Obstrução Intestinal/prevenção & controle , Intestino Delgado/efeitos dos fármacos , Intestino Delgado/metabolismo , Rim/efeitos dos fármacos , Rim/metabolismo , Malondialdeído/análiseRESUMO
PURPOSE: To evaluate the oxidative stress, resulting from ischemia and hepatic reperfusion, in mice with non-alcoholic hepatic steatosis and steatohepatitis. METHODS: C57BL/6 male mice were used. Part of them were ob/ob mice, and the other part was fed with standard or MCD diets - this last used to develop steatohepatitis. The animals - MCD-I/R, ob/ob-I/R and I/R groups - were submitted to 30 minutes of partial hepatic ischemia, followed by reperfusion for 24 hours. The blood was collected, for biochemical analysis of AST, and the liver removed for assessment of TBARS and nitrite, and of histology. RESULTS: After the I/R, the animal fed with MCD diet presented higher AST levels (MCD-I/R: 967±349U/L / ob/ob-I/R: 606±18 U/L / I/R: 311±172 U/L), TBARS (MCD-I/R: 7±1 nM/mg protein / ob/ob-I/R: 3±1 nM/mg protein / I/R: 3±1 nM/mg protein) and nitrite (MCD-I/R: 614±87 µg/mL / ob/ob-I/R: 512±81 µg/mL / I/R: 459±29 µg/mL) than the ob/ob mice, when both groups were compared to animals fed with standard diet. Regarding histology, the steatosis level (azonal macrovesicular steatosis of level 3 - >66%) and hepatic fibrosis (periportal and perisinusoidal of level 2) was also more intense, but both animal models presented lobular inflammation of level 3 (>66%). CONCLUSIONS: The murine model fed with MCD diet is suitable for the assessment of oxidative stress in hepatic I/R injury associated with the nonalcoholic fatty liver disease. Although both murine models showed inflammatory infiltrate and macro and micro vesicular steatosis.
Assuntos
Peroxidação de Lipídeos/fisiologia , Nitritos/metabolismo , Hepatopatia Gordurosa não Alcoólica/metabolismo , Estresse Oxidativo/fisiologia , Traumatismo por Reperfusão/metabolismo , Animais , Modelos Animais de Doenças , Masculino , Camundongos , Camundongos Endogâmicos C57BL , Hepatopatia Gordurosa não Alcoólica/patologia , Traumatismo por Reperfusão/patologiaRESUMO
Abstract Purpose: To evaluate the oxidative stress, resulting from ischemia and hepatic reperfusion, in mice with non-alcoholic hepatic steatosis and steatohepatitis. Methods: C57BL/6 male mice were used. Part of them were ob/ob mice, and the other part was fed with standard or MCD diets - this last used to develop steatohepatitis. The animals - MCD-I/R, ob/ob-I/R and I/R groups - were submitted to 30 minutes of partial hepatic ischemia, followed by reperfusion for 24 hours. The blood was collected, for biochemical analysis of AST, and the liver removed for assessment of TBARS and nitrite, and of histology. Results: After the I/R, the animal fed with MCD diet presented higher AST levels (MCD-I/R: 967±349U/L / ob/ob-I/R: 606±18 U/L / I/R: 311±172 U/L), TBARS (MCD-I/R: 7±1 nM/mg protein / ob/ob-I/R: 3±1 nM/mg protein / I/R: 3±1 nM/mg protein) and nitrite (MCD-I/R: 614±87 µg/mL / ob/ob-I/R: 512±81 µg/mL / I/R: 459±29 µg/mL) than the ob/ob mice, when both groups were compared to animals fed with standard diet. Regarding histology, the steatosis level (azonal macrovesicular steatosis of level 3 - >66%) and hepatic fibrosis (periportal and perisinusoidal of level 2) was also more intense, but both animal models presented lobular inflammation of level 3 (>66%). Conclusions: The murine model fed with MCD diet is suitable for the assessment of oxidative stress in hepatic I/R injury associated with the nonalcoholic fatty liver disease. Although both murine models showed inflammatory infiltrate and macro and micro vesicular steatosis.