La hernia umbilical en el paciente cirrótico: ¿tratamiento conservador o cirugía? / Umbilical hernia in cirrhotic patients: conservative treatment or surgery?

RESUMEN Antecedentes: la ascitis es una complicación de frecuente aparición en el paciente cirrótico que al producir un aumento de la presión intraabdominal puede originar una hernia de la pared abdominal; el defecto umbilical latente es su localización más habitual. Objetivo: presentar la incidencia y los beneficios que ofrece la resolución electiva de la patología um bilical en estos pacientes. Material y método: se presentan 15 pacientes, todos masculinos, que fueron intervenidos por hernia umbilical sintomática en forma electiva en el medio hospitalario. El período comprende desde enero del año 2015 a enero de 2019. El 100% de los enfermos cursa un cuadro de cirrosis hepática, con antecedentes de etilismo crónico. Se efectuó la reparación de la hernia con cierre del defecto y malla supraaponeurótica de polipropileno en la mayoría de los casos. Resultados: los pacientes fueron evaluados desde el punto de vista clínico con la escala (score) de Child en el preoperatorio. Se procedió a la evacuación de la ascitis en todos los casos y el control posoperatorio se efectuó cada 30 días los primeros 6 meses. Luego dos veces al año. No se evidenció recidiva. Dos pacientes no volvieron al control luego del año de la cirugía y 1 paciente falleció por la enfermedad de base a los 6 meses de la cirugía. Conclusiones: los enfermos con cirrosis hepática y hernia umbilical deben ser intervenidos quirúrgica mente en forma electiva. La observación y abstención quirúrgica conllevan el riesgo de rotura del saco herniario con alta morbimortalidad.

ABSTRACT Background: Background: Ascites is a common complication in patients with cirrhosis, and elevated intraabdominal pressure can lead to the development of abdominal wall hernias, particularly in patients with latent umbilical defects. Objectives: The aim of this study was to report the incidence and benefits of elective surgery for the management of umbilical hernias in cirrhotic patients with ascites. Material and methods: Between January 2015 and January 2019 15 patients with symptomatic umbi lical hernia underwent elective surgery in a public hospital; 100% were men with a history of alcoho lism and were hospitalized due to liver cirrhosis. The defect was closed, and a polypropylene mesh was placed in the supra-aponeurotic plane in most cases. Results: The preoperative risk was estimated using the Child-Pugh score. Ascites was evacuated in all the cases. Patients were followed-up every 30 days during the first 6 months and then twice a year. There were no hernia recurrences. Two patients were lost to follow-up 12 months after surgery and 1 patient died 9 months after the procedure due to progression of cirrhosis. Conclusions: Patients with liver cirrhosis and umbilical hernia should undergo elective surgery. Wat chful waiting is associated with higher risk of hernia rupture and high morbidity and mortality.

Abordagem cirúrgica em bezerros com onfalite / Surgical approach in calves with omphalitis

Pathological changes in the umbilical region are common in calves. Among such alterations, omphalitis is included. This term is used to define inflammation and infection of the external structures of the umbilicus. According to the affected structures, it can be subclassified into omphalophlebitis, omphaloarteritis, omphalourachitis and panvasculitis. These inflammations are usually associated with bacterial infections. There are predisposing conditions that include inadequate handling such as poor hygiene and neglect of primary care. Omphalitis can affect the animal in a multisystemic way, compromising its well-being and bringing economic losses. In treatment, the use of antimicrobials does not always solve the problem. Thus, surgical treatment can be used, which has good results and should be the choice in the disease. The objective of this work is to report 30 cases of omphalitis in calves, submitted to surgical or conservative treatment. Thirty cases of omphalitis in calves treated in the routine of the Veterinary Hospital of the Paranaense University was analyzed. On physical examination, the animals presented fever, apathy, hyporexia or anorexia and increase of umbilical volume, usually with purulent secretion. Some animals had sepsis and arthritis. In animals with sepsis, hyperemia of the episcleral vessels, dehydration and severe apathy were observed. In calves with arthritis, increased joint volume, pain on palpation and lameness were observed. In animals where the owners did not authorize the surgery, treatment was instituted with sulfadoxine and flunixim meglumine. In dehydrated calves, fluid therapy was used. Animals that were surgically treated received the same clinical treatment protocol as non-operated animals. The surgical procedure was performed under general anesthesia and consisted of resection of the affected umbilical structures. Omphalophlebitis was the most common illness. The most frequent complication was sepsis. Calves treated surgically had a higher survival rate (86.66%) than those treated clinically (46.67%). The clinical signs presented by all animals converged with the literature, allowing for clinical diagnosis. Clinical examination is essential for diagnosis in omphalitis cases. Complementary methods include ultrasound, thermography and laparoscopy, which are important to identify changes in intra-abdominal umbilical structures. Accurate diagnosis of the involved structures was only possible in animals surgically, as well as alterations in organs such as the liver and bladder. There is great variability related to the umbilical structures involved, according to initial care, breeds, seasonality or even the method of conception. Unlike what is observed in the literature, in the present study, there was a higher prevalence of omphalophlebitis, demonstrating variability in relation to the umbilical structures involved. Sepsis, observed in 16.7% of cases, results from bacterial ascension of the umbilical structures. Lameness due to polyarthritis was found in 10% of animals. Meningoencephalitis was observed in 3.3%. Hepatic and retroperitoneal abscedation were observed in 6.7% and 3.3% of cases, respectively. Conservative treatment with antibiotics and local antiseptics has a limited effect on this type of condition, which was proven in the present study, since the survival rate was statistically higher in animals surgically treated.(AU)

Ventral hernia secondary to giant omphalocele in a child: combined approach of botulinum toxin and preoperative progressive pneumoperitoneum.

Omphalocele is a congenital abdominal wall defect that occurs approximately 1 in 4000-6000 live births. The abdominal-visceral disproportion, large diameter of the defect, volume of liver in the sac along with high incidence of associated anomalies make the surgical management a real challenge. Currently, there are two strategies for managing giant omphaloceles, staged surgical closure and nonoperative delayed closure. The combined treatment with PPP and BoNT/A injection has recently been described in adults. There is strong evidence on safety and efficacy of the use of BoNT/As in other areas of pediatrics and no recent reports of PPP use in children. Also, there are no data available about the combination of both techniques in pediatric population. The purpose of this manuscript is to report a case of a 7-year-old female child that was referred to our institution with a large ventral hernia secondary to omphalocele. We opted for a combined approach with BoNT/A injection and PPP before the definitive surgery. The surgical result was great with midline closure with no tension and no need for prosthetic substitution or component separation needed. To our knowledge, this is the first case report of BoNT/A injection and PPP for large ventral hernias in children. BoNT/A application was safe and the PPP technique was also proved to be applicable on children. We believe that the combination of BoNT/A and PPP presented to be a safe approach with an excellent result, particularly for not needing abdominal wall prosthetic substitution.