An alternative classification of incisional hernias enlisting morphology, body type and risk factors in the assessment of prognosis and tailoring of surgical technique.

Incisional hernias occur in 5-10% of patients who have undergone laparotomy and are associated with a high morbidity and significant socioeconomic costs. Better understanding of the anatomy and improved methods for reinforcement of the abdominal wall with alloplastic meshes have reduced the recurrence rate to 1-10% depending on the type of hernia and the technique employed. A number of surgical repair techniques and mesh types are available. However, precise criteria for incorporating patient body type, risk factors for recurrence, hernia morphology, and the available biomaterials into planning of the surgical approach (open versus laparoscopic) have yet to be established. The elaboration of such criteria would require comparative evaluation of long-term results in a sufficiently large number of patients, e.g. in multicentre trials or meta-analyses of standardised data from different centres. Current classifications have the drawback that they fail to take account of prognostically relevant risk factors for recurrence and are not self-explanatory. The authors present a classification of incisional hernias that is self-explanatory and practicable in routine clinical practice. Based on the cornerstones of morphology (M), hernia size in cm (S), and risk factors for recurrence (RF), the scheme enables easy description and documentation of the hernia, and provides evidence for the indications and limitations of the main surgical repair techniques. Since randomised studies can scarcely be conducted on incisional hernias due to the numerous morphological variables, the classification presented here may offer an alternative means for comparative data analysis.

Effect of pantoprazole administered subcutaneously on the healing of sutured gastric incisions in rats.

BACKGROUND: The properties of proton pump inhibitors most investigated are related to peptic diseases and upper gastrointestinal bleeding, but their influence on the healing of sutured gastric incisions has not been assessed. In the present study we evaluated the effect of subcutaneously administered pantoprazole on the healing of sutured gastric incisions in rats. METHODS: Sixty rats were divided into a pantoprazole group and a control group. All rats were submitted to gastric suture in the gastric body and in the gastric fundus and had their gastric pH measured. The pantoprazole group received 20 mg/kg pantoprazole and the control group received 0.9% isotonic NaCl, both subcutaneously t.i.d. Healing analysis was carried out using collagen picrosirius red F3BA staining, and breaking strength was measured on the 4th and 7th postoperative days in all groups. RESULTS: Gastric pH was higher in the pantoprazole group. In the fundus, the pantoprazole group had a higher measurement of breaking strength and a higher proportion of type-I over type-III collagen on the 7th postoperative day. In the body, the pantoprazole group had a higher proportion of type-I over type-III collagen on the 4th and 7th postoperative days. CONCLUSIONS: Pantoprazole given subcutaneously promoted a reduction in gastric acid secretion and was associated with improved healing of the sutured gastric incision in the fundus (squamous epithelium) of rats. These findings suggest that pantoprazole has healing properties in sutured gastric incisions with potential benefits in gastric surgery.

[Terminolateral esophagojejunostomy after gastrectomy with the biofragmentable anastomosis ring in the dog model]. / End-zu-Seit Osophagojejunostomie mit dem biofragmentierbaren Anastomosenring nach Gastrektomie am Hundemodell.

INTRODUCTION: Esophagojejunostomy after total gastrectomy still remains a high risk anastomosis with a considerable morbidity and mortality. The majority of these anastomoses are performed by the intraluminal stapler technique, yet stenoses are a known late complication even after an uneventful postoperative course. In the present study, the osophagojejunostomy with the biofragmentable anastomosis ring (BAR) was examined in dogs. METHODS: 28 dogs were randomized into a group of manual suture (n = 14) and a BAR-group (n = 14). After gastrectomy, the esophagojejunostomy was performed by hand-suture with polypropylene 4-0 in the manual suture group, and with the 25/1.5 mm BAR in the BAR-group. In both groups the Roux-en-Y jejunojejunostomy was performed by hand-suture. The dogs were evaluated on postoperative days 4, 7 and 14 with regard to macroscopy, bursting strength, tissue hydroxyproline and histology. RESULTS: There was one leakage without clinical effect in the hand-sewn group on postoperative day 4; there was no leak in the BAR-group. In observing fibre-free enteral feeding, neither functional disorders nor obstruction of the BAR were observed. The general anastomosis parameters were matchable between the groups. CONCLUSION: The infracarinal BAR-esophagojejunostomy is comparable to the hand-sewn anastomosis in the dog-model.

[Comparative study between magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography in the diagnosis of the pancreatic and biliary obstruction]. / Estudo comparativo entre a colangiopancreatografia por ressonância magnética e a colangiopancreatografia endoscópica no diagnóstico das obstruções biliopancreáticas.

BACKGROUND: The endoscopic retrograde cholangiopancreatography and magnetic resonance cholangiopancreatography were methods used for diagnosis of the diseases in the biliary and pancreatic ducts. AIM: Compare the diagnostic concordance among, analyzing sensitivity, specificity, positive predictive value, negative predictive value and accuracy. PATIENTS/METHODS: There were 41 patients in the studied group, divided in two groups: I--without biliary or pancreatic tract obstruction, and II--with obstruction. Group II was further divided in A--obstruction due to lithiasis, and B--due to other causes. RESULTS: Concordance between the two methods was found in 67% in group I and 82% in group II. Sensitivity of endoscopic retrograde cholangiopancreatography was 94% and magnetic resonance cholangiopancreatography was 89%. Specificity of endoscopic retrograde cholangiopancreatography was 100% and magnetic resonance cholangiopancreatography was 67%. Magnetic resonance cholangiopancreatography positive predictive value was 93%, the negative predictive value was 50% and the accuracy was 85%. CONCLUSION: Both methods showed the same sensitivity.

Transperineal ultrasonography: new method to image the anorectal region.

PURPOSE: The aim of this preliminary study was to present an alternative method to assess the anal sphincters by ultrasonography using a conventional ultrasound surface probe by transperineal approach. METHODS: Transperineal ultrasonography was performed in 20 asymptomatic volunteers to assess the anal sphincters. Ultrasonographic findings were compared with conventional anal endosonography pictures available in the literature. RESULTS: Images of the anal sphincters obtained by transperineal ultrasound were found to be similar to those produced by conventional anal endosonography. Internal and external anal sphincters were easily demonstrated in addition to mucosal and submucosal layers. CONCLUSIONS: Transperineal ultrasonography is a new technique that enables imaging of anal sphincters and anal canal structures with potential application in functional and inflammatory anorectal disorders.

Pantoprazole versus ranitidine in the treatment of duodenal ulcer: a multicenter study in Brazil.

OBJECTIVE: The aim of this study was to compare the effectiveness and tolerance of pantoprazole versus ranitidine in the treatment of duodenal ulcers in the Brazilian population. METHODS: A total of 222 patients with active duodenal ulcers (DU) were randomly allocated to a double dummy blind treatment, either with ranitidine (RAN) 300 mg (111, aged from 20-68 yr old, 56 female) or with pantoprazole (PANT) 40 mg (111 patients, 18-70 yr old, 45 female). After a 2-wk course of treatment, each patient was clinically and endoscopically assessed for ulcer healing. Failure to heal required a further 2-wk course of treatment and a new evaluation thereafter. RESULTS: In all, 77 of the 103 patients in the PANT group (74.8%) and 42 of the 94 patients in the RAN group (44.7%) who completed the study had ulcer healing after one 2-wk treatment course, and an additional 23 in the PANT group (22.3%) and 28 in the RAN group (29.8%) after the second 2-wk treatment course, totaling 100 (97.1%) and 70 (74.5%), respectively. Therapeutic gain in favor of pantoprazole was significant both at the end of the first and the second 2-wk treatment course (p<0.001). At 2 wk, symptoms remission was significantly higher in the PANT group (97.6%) than with the RAN group (77.5%) (p<0.001). The Intention-to-treat analysis showed results statistically similar to those observed in the per-protocol analysis. Minor adverse events were reported by four patients in the PANT group and three in the RAN group. No relevant laboratory abnormalities were seen. No patient withdrew from the study due to adverse events. CONCLUSIONS: Our results show that pantoprazole is more effective than ranitidine in the treatment of duodenal ulcer providing faster ulcer healing in most patients (97.1%), in 4 wk. Adverse events were rare and were similar in both groups, and had no influence on the therapeutic outcome.

[Aorto-mesenteric artery compression syndrome]. / Das aortomesenteriale Kompressionssyndrom.

INTRODUCTION: The aim of this paper was to describe a rare gastrointestinal motility disorder caused by vascular compression of the duodenum. PATIENTS: The authors present two patients with vomiting and severe weight loss. Diagnostic evaluation revealed superior mesenteric artery syndrome. METHODS: After frustrane treatment with i.v. infusions, surgical intervention with laterolateral duodenojejunostomy or Roux-en-y reconstruction for restoration of the intestinal passage was performed. RESULTS: Following initial recovery, the first patient showed permanent anorexia. Psychosocial evaluation revealed a severe pathological mother-child relationship. Intensive psychological treatment finally achieved definite weight gain and complete recovery in this patient. The second case subsequently gained weight without psychological evaluation. CONCLUSION: The authors review the literature, pointing out the anatomy of the duodenojejunal angle, the etiology, and the predisposing factors, as well as diagnostic and therapeutic strategies.

[From Murphy's button to the Valtrac Ring. 100 years in search of a paradigm]. / Der Weg von Murphys Knopf zum Valtrac-Ring. 100 Jahre auf der Suche nach einem Paradigma.

In the context of continuous development in the area of anastomotic sutures leading to exceptional results in surgical practice, the biofragmentable anastomosis ring (BAR) described in 1985 by Hardy et al. represents a breakthrough in a 100 years' search of a paradigm. The first anastomotic button created in 1892 by J.B. Murphy was at once accepted as a quick and safe method of intestinal anastomosis. In 1896 Czerny demanded the following: "The task of technology is ... to create buttons with material that is entirely or partly dissolved in the intestinal lumen." Polyglycolic acid--developed in the sixties and now in widespread use for resorbable surgical sutures--was the material to fulfill the requirements already stated in the relevant literature 100 years ago, namely in the form of Hardy's BAR, which represents a redesigned Murphy button exploiting the recent biotechnological developments of this century.

Intragastric microflora study in patients with gastroduodenal disease

O conteudo normal de bacterias no estomago e menor que 10ü/ml de suco gastrico. A ausencia de bacterias na cavidade gastrica, muito frequente, e principalmente devida a secrecao acida e a motilidade do orgao. Varias situacoes podem comprometer esses mecanismos de defesa e levar a colonizacao bacteriana, com alta incidencia de complicacoes infecciosas pos-operatorias. Para avaliar a alteracao da microflora gastrica, estudaram-se 25 pacientes, 19 com doenca gastroduodenal e seis controles, divididos em quatro grupos distintos, de acordo com a afeccao de base. Dos portadores de doenca gastroduodenal, 18 (94,73 por cento) apresentaram cultura positiva para aerobios e seis (3,57 por cento), para anaerobios. Cinco pacientes (26,31 por cento) tiveram cultura positiva para Candida sp e cinco outros para S. fecalis. A principal contagem bacteriologica foi de 1,2x10 elevado a seis CFU/ml de suco gastrico, e de 1,4x10 elevado a um CFU/ml de suco gastrico, para anaerobios. As bacterias mais comumente isoladas foram E. coli, Enterobacter sp e Staphylococcus epidermidis.

Hernias incisionais. Resultados em 54 casos operados pela tecnica de Cattell. / Incisional hernia. Result of 54 cases operated by Cattell's technique

Os autores apresentam os resultados de 54 casos de correcao de hernias incisionais pela tecnica de Cattell em 5 planos. Essas hernias foram mais comuns apos cirurgias obstetricas e ginecologicas. A faixa de maior incidencia foi na 6a. decada da vida com idade media de 46,3 anos. As complicacoes pos-operatorias foram de pequena monta (7,1%) e ocorreu 1 obito (1,8%) no pos-operatorio imediato. Tiveram seguimento em 47% dos casos e, a maioria destes, acima de 5 anos. Houve 1 caso de recidiva (4%) no quarto ano de seguimento pos-operatorio. Os autores descrevem a tecnica empregada

Leiomiomas do trato digestivo. / Leiomyomas of the digestive tract

Sao apresentados 16 casos de leiomiomas do trato digestivo, sendo oito no esofago, quatro no estomago, dois no intestino delgado, um no colon e um no apendice cecal.Sao tumores raros e que apresentam caracteristicas especiais quanto as manifestacoes clinicas, variaveis de acordo com o orgao afetado e frequentemente na dependencia de complicacoes. Na presente serie houve seis casos de hemorragia digestiva e dois de suboclusao intestinal. Em dois o diagnostico foi ocasional e em dois havia tumor palpavel. Nos demais, o diagnostico foi orientado pela clinica de disfagia. Os metodos complementares mais uteis no diagnostico sao radiologia, endoscopia, e angiografia, na dependencia da porcao do trato digestivo afetada. Dos 16 casos de estomago foram realizadas quatro esofagectomias e quatro resseccoes extramucosas.Nos quatro casos de localizacao no estomago, em dois foi realizada gastrectomia e em dois resseccao foi local

Auditoria medica e suas implicacoes legais. / Medical audit and its legal involvement

Os autores conceituam Auditoria Medica e relatam seu historico. Tecem normas de conduta que tanto medicos auditores como auditados devem seguir no sentido de ser respeitada a Etica Medica. Concluem apresentando sugestoes onde os Conselhos Regionais de Medicina tomam parte ativa no controle etico das relacoes medicas no ambito da Auditoria

Diverticulo esofagiano. / Esophageal diverticula

Sao apresentados 20 casos de diverticulos esofagianos tratados pela Disciplina de Cirurgia do Aparelho Digestivo do Hospital de Clinicas da Universidade Federal do Parana, durante o periodo de 1977 a 1982.Dezessete pacientes tiveram diverticulo faringoesofagiano e tres, diverticulo epifrenico. Do grupo de doentes com diverticulo faringoesofagiano, um foi a obito por pneumonia aspirativa antes de receber tratamento cirurgico curativo; dezesseis doentes foram submetidos a resseccao primaria do diverticulo. De tres pacientes com diverticulo epifrenico, dois tiveram resseccao primaria acompanhada de procedimento anti-refluxo e o ultimo foi submetido a invaginacao do diverticulo acompanhada de um procedimento anti-refluxo. A morbidade operatoria foi baixa e nao foram observados morte operatoria ou recidiva

Cancer do coto gastrico. / Cancer of the gastric stump

Os autores apresentam 12 pacientes portadores de cancer do coto gastrico no periodo compreendido entre 1951 e 1980.Analisam sua incidencia frente a literatura e admitem ser o cancer do coto gastrico duas a tres vezes mais frequente no estomago operado. Seus resultados mostram somente quatro doentes submetidos a cirurgia radical.A maior parte deles foi submetida a tratamento paliativo e o uso de protese endoluminar foi o metodo preferencial. Contudo, somente em tres pacientes ele por ser usado. Ao final, tecem algumas recomendacoes no sentido de proteger os pacientes gastrectomizados dessa eventualidade

Uso do stapler em anastomoses gastrintestinais. / The stapled gastrointestinal tract anastomosis

Os autores apresentam 11 casos de pacientes submetidos a anastomoses com emprego de sutura mecanica. O intrumento EEA (Stapler) e aplicado principlamente para anastomoses em resseccoes colorretais e esofagogastricas.Analisam os resultados obtidos, a tecnica operatoria empregada e concluem que as primeiras experiencias com instrumento sao animadoras