BRAZILIAN HERNIA AND ABDOMINAL WALL SOCIETY STATEMENT ON LARGE HIATAL HERNIAS MANAGEMENT.

Large hiatal hernias, besides being more prevalent in the elderly, have a different clinical presentation: less reflux, more mechanical symptoms, and a greater possibility of acute, life-threatening complications such as gastric volvulus, ischemia, and visceral mediastinal perforation. Thus, surgical indications are distinct from gastroesophageal reflux disease-related sliding hiatal hernias. Heartburn tends to be less intense, while symptoms of chest pain, cough, discomfort, and tiredness are reported more frequently. Complaints of vomiting and dysphagia may suggest the presence of associated gastric volvulus. Signs of iron deficiency and anemia are found. Surgical indication is still controversial and was previously based on high mortality reported in emergency surgeries for gastric volvulus. Postoperative mortality is especially related to three factors: body mass index above 35, age over 70 years, and the presence of comorbidities. Minimally invasive elective surgery should be offered to symptomatic individuals with good or reasonable performance status, regardless of age group. In asymptomatic and oligosymptomatic patients, besides obviously identifying the patient's desire, a case-by-case analysis of surgical risk factors such as age, obesity, and comorbidities should be taken into consideration. Attention should also be paid to situations with greater technical difficulty and risks of acute migration due to increased abdominal pressure (abdominoplasty, manual labor, spastic diseases). Technical alternatives such as partial fundoplication and anterior gastropexy can be considered. We emphasize the importance of performing surgical procedures in cases of large hiatal hernias in high-volume centers, with experienced surgeons.

BRAZILIAN HERNIA AND ABDOMINAL WALL SOCIETY STATEMENT ON LARGE HIATAL HERNIAS MANAGEMENT / Posição da Sociedade Brasileira de Hérnia e Parede Abdominal sobre o tratamento de grandes hérnias de hiato

Large hiatal hernias (LHH) besides being more prevalent in the elderly, have different clinical presentation: fewer reflux, more mechanical symptoms and a greater possibility of acute, life-threatening complications such as gastric volvulus, ischemia and visceral mediastinal perforation. Thus, surgical indications are distinct from gastroesophageal reflux disease (GERD-related), sliding hiatal hernias. Heartburn tends to be less intense, while symptoms of chest pain, cough, discomfort, and tiredness are reported more frequently. Complaints of vomiting and dysphagia may suggest the presence of associated gastric volvulus. Signs of iron deficiency and anemia are found. Surgical indication is still controversial and was previously based on high mortality reported in emergency surgeries for gastric volvulus. Postoperative mortality is especially related to three factors: body mass index (BMI above 35), age over 70 years and presence of comorbidity. Minimally invasive elective surgery should be offered to symptomatic individuals with good or reasonable performance status, regardless of age group. In asymptomatic and oligosymptomatic patients, besides obviously identifying the patient's desire, case-by-case analysis of surgical risk factors such as age, obesity and comorbidities, should be taken under consideration. One should also pay attention to situations with greater technical difficulty and risks of acute migration due to increased abdominal pressure (abdominoplasty, manual workers, spastic diseases). Technical alternatives such as partial fundoplication and anterior gastropexy can be considered. We emphasize the importance of performing surgical procedures in cases of LHH in high-volume centers, with experienced surgeons.

As grandes hérnias de hiato (HHG), além de serem mais prevalentes em idosos, têm apresentação clínica diferente: menos refluxo, mais sintomas mecânicos e maior possibilidade de complicações agudas e potencialmente fatais, como vólvulo gástrico, isquemia e perfuração mediastinal visceral. Assim, as indicações cirúrgicas são distintas das hérnias de hiato por deslizamento, relacionadas à doença do refluxo gastroesofágico (DRGE). A azia tende a ser menos intensa, enquanto os sintomas de dor no peito, tosse, desconforto e cansaço são relatados com maior frequência. Queixas de vômitos e disfagia podem sugerir a presença de volvo gástrico associado. São encontrados sinais de deficiência de ferro e anemia. A indicação cirúrgica ainda é controversa e foi anteriormente baseada na alta mortalidade relatada em cirurgias de emergência para volvo gástrico. A mortalidade pós-operatória está especialmente relacionada a três fatores: índice de massa corporal (IMC acima de 35), idade superior a 70 anos e presença de comorbidades. A cirurgia eletiva minimamente invasiva deve ser oferecida a indivíduos sintomáticos, com desempenho bom ou razoável, independentemente da faixa etária. Em pacientes assintomáticos e oligossintomáticos, além de obviamente identificar o desejo do paciente, deve-se levar em consideração a análise caso a caso dos fatores de risco cirúrgico, como idade, obesidade e comorbidades. Deve-se atentar também para situações de maior dificuldade técnica e riscos de migração aguda por aumento da pressão abdominal (abdominoplastia, trabalhos manuais, doenças espásticas). Alternativas técnicas como fundoplicatura parcial e gastropexia anterior podem ser consideradas. Ressaltamos a importância da realização de procedimentos cirúrgicos nos casos de GHH em centros de grande volume, com cirurgiões experientes.

Sleeve Gastrectomy in Septuagenarians: a Case-Control Study.

PURPOSE: There are few studies published referring to bariatric surgery in patients older than 70 years. The aim of this study is to evaluate whether there are benefits to performing sleeve gastrectomy (SG) in patients over 70 years of age and to compare the results with a younger control group. MATERIALS AND METHODS: Data were retrospectively collected from a Private Clinic's electronic medical records of patients undergoing SG between June 2017 and September 2020. Inclusion criteria were patients older than 70 years [septuagenarian group (SpG)] who met all institutional protocols. Patients in the control group (CG) were selected with a 1:1 ratio and under 60 years of age, according to body mass index and comorbidities. The primary endpoint of the study was to evaluate the morbidity and mortality during the 30-day postoperative period and percentage of total weight loss (%TWL), and improvement of comorbidities after 1 year of follow-up. RESULTS: Fifty patients were included in the study. Both groups were similar regarding gender, weight, BMI, and presence of DM. The 30-day morbidity and mortality were similar between the groups. The patients in the SpG had 26.9% of %TWL and the CG, 28% (p = 0.32). The remission rate of DM (50% vs. 85% p = 0.01) and SAH (30% vs. 64% p = 0.04) was lower for septuagenarian patients. CONCLUSION: The sleeve gastrectomy surgery performed in patients over 70 years of age is safe. The early results suggest similar benefits regarding weight loss and improvement of comorbidities to those having SG before age 60.

Predictive factors for short gastric vessels division during laparoscopic total fundoplication.

OBJECTIVE: to determine clinical variables that can predict the need for division of the short gastric vessels (SGV), based on the gastric fundus tension, assessing postoperative outcomes in patients submitted or not to section of these vessels. METHODS: we analyzed data from 399 consecutive patients undergoing laparoscopic fundoplication for gastroesophageal reflux disease (GERD). The section of the SGV was performed according to the surgeon evaluation, based on the fundus tension. Patients were divided into two groups: not requiring SGV section (group A) or requiring SGV section (group B). RESULTS: the section was not necessary in 364 (91%) patients (Group A) and required in 35 (9%) patients (Group B). Group B had proportionally more male patients and higher average height. The endoscopic parameters were worse for Group B, with larger hiatal hernias, greater hernias proportion with more than four centimeters, more intense esophagitis, higher proportion of Barrett's esophagus and long Barrett's esophagus. Male gender and grade IV-V esophagitis were considered independent predictors in the multivariate analysis. Transient dysphagia and GERD symptoms were more common in Group B. CONCLUSION: the division of the short gastric vessels is not required routinely, but male gender and grade IV-V esophagitis are independent predictors of the need for section of these vessels.

Predictive factors for short gastric vessels division during laparoscopic total fundoplication / Fatores preditivos da necessidade de secção dos vasos gástricos curtos nas fundoplicaturas totais videolaparoscópicas

OBJECTIVE: To determine clinical variables that can predict the need for division of the short gastric vessels (SGV), based on the gastric fundus tension, assessing postoperative outcomes in patients submitted or not to section of these vessels. METHODS:We analyzed data from 399 consecutive patients undergoing laparoscopic fundoplication for gastroesophageal reflux disease (GERD). The section of the SGV was performed according to the surgeon evaluation, based on the fundus tension. Patients were divided into two groups: not requiring SGV section (group A) or requiring SGV section (group B). RESULTS:The section was not necessary in 364 (91%) patients (Group A) and required in 35 (9%) patients (Group B). Group B had proportionally more male patients and higher average height. The endoscopic parameters were worse for Group B, with larger hiatal hernias, greater hernias proportion with more than four centimeters, more intense esophagitis, higher proportion of Barrett's esophagus and long Barrett's esophagus. Male gender and grade IV-V esophagitis were considered independent predictors in the multivariate analysis. Transient dysphagia and GERD symptoms were more common in Group B. CONCLUSION:The division of the short gastric vessels is not required routinely, but male gender and grade IV-V esophagitis are independent predictors of the need for section of these vessels.

OBJETIVO: Determinar variáveis clínicas que possam predizer a necessidade de secção dos vasos gástricos curtos (VGC), baseado na tensão do fundo gástrico, avaliando os resultados pós-operatórios em pacientes submetidos ou não à secção destes vasos. MÉTODOS:Foram analisados os dados de 399 pacientes consecutivos submetidos à fundoplicatura total laparoscópica para a doença do refluxo gastroesofágico (DRGE). A secção dos VGC foi realizada de acordo com a avaliação do cirurgião, baseado na tensão do fundo gástrico. Os pacientes foram distribuídos em dois grupos: sem necessidade de secção dos VGC (grupo A) ou com necessidade de secção dos VGC (grupo B). RESULTADOS:A secção não foi necessária em 364 (91%) pacientes (Grupo A) e necessária em 35 (9%) pacientes (Grupo B). O Grupo B tinha proporcionalmente mais pacientes do sexo masculino e maior estatura média. Os parâmetros endoscópicos foram piores para o Grupo B, com maiores hérnias hiatais, maior proporção de hérnias com mais de quatro centímetros, esofagite mais intensa, maior proporção de esôfago de Barrett e esôfago de Barrett longo. O sexo masculino e as esofagites graus IV-V foram considerados fatores preditivos independentes na análise multivariada. A disfagia transitória e os sintomas de DRGE foram mais comuns no Grupo B. CONCLUSÃO:A secção dos vasos gástricos curtos não é necessária rotineiramente, porém o sexo masculino e as esofagites graus IV-V são fatores preditivos independentes da necessidade da secção destes vasos.

Dysphagia after laparoscopic total fundoplication: anterior or posterior gastric wall fundoplication?

CONTEXT: The occurrence of severe dysphagia after laparoscopic total fundoplication is currently an important factor associated with loss of quality of life in patients undergoing this modality of treatment for gastroesophageal reflux disease. OBJECTIVES: Compare the incidence and evaluate the causes of severe postoperative dysphagia in patients undergoing laparoscopic total fundoplication (LTF) without short gastric vessels division, using the anterior gastric wall (Rossetti LTF) or anterior and posterior gastric walls (Nissen LTF). METHODS: Analysis of the data of 289 patients submitted to LTF without short gastric vessels division from January 2004 to January 2012, with a minimum follow-up of 6 months. Patients were divided in Group 1 (Rossetti LTF - n = 160) and Group 2 (Nissen LTF - n = 129). RESULTS: The overall incidence of severe postoperative dysphagia was 3.11% (4.37% in group 1 and 1.55% in group 2; P = 0.169). The need for surgical treatment of dysphagia was 2.5% in group 1 and 0.78% in group 2 (= 0.264). Distortions of the fundoplication were identified as possible causes of the dysphagia in all patients taken to redo fundoplication after Rossetti LTF. No wrap distortion was seen in redo fundoplication after Nissen LTF. CONCLUSIONS: The overall incidence of severe postoperative dysphagia did not differ on the reported techniques. Only Rossetti LTF was associated with structural distortion of the fundoplication that could justify the dysphagia.

DYSPHAGIA AFTER LAPAROSCOPIC TOTAL FUNDOPLICATION: anterior or posterior gastric wall fundoplication? / Disfagia após fundoplicatura total laparoscópica: válvula com a parede gástrica anterior ou posterior?

Context The occurrence of severe dysphagia after laparoscopic total fundoplication is currently an important factor associated with loss of quality of life in patients undergoing this modality of treatment for gastroesophageal reflux disease. Objectives Compare the incidence and evaluate the causes of severe postoperative dysphagia in patients undergoing laparoscopic total fundoplication (LTF) without short gastric vessels division, using the anterior gastric wall (Rossetti LTF) or anterior and posterior gastric walls (Nissen LTF). Methods Analysis of the data of 289 patients submitted to LTF without short gastric vessels division from January 2004 to January 2012, with a minimum follow-up of 6 months. Patients were divided in Group 1 (Rossetti LTF – n = 160) and Group 2 (Nissen LTF – n = 129). Results The overall incidence of severe postoperative dysphagia was 3.11% (4.37% in group 1 and 1.55% in group 2; P = 0.169). The need for surgical treatment of dysphagia was 2.5% in group 1 and 0.78% in group 2 (= 0.264). Distortions of the fundoplication were identified as possible causes of the dysphagia in all patients taken to redo fundoplication after Rossetti LTF. No wrap distortion was seen in redo fundoplication after Nissen LTF. Conclusions The overall incidence of severe postoperative dysphagia did not differ on the reported techniques. Only Rossetti LTF was associated with structural distortion of the fundoplication that could justify the dysphagia. .

Contexto A ocorrência de disfagia grave após fundoplicatura total laparoscópica representa atualmente um importante fator associado à perda da qualidade de vida em pacientes submetidos a esta modalidade de tratamento para doença do refluxo gastroesofágico. Objetivos Comparar a incidência e avaliar as possíveis causas da disfagia grave pós-operatória em pacientes submetidos à fundoplicatura total laparoscópica (FTL) sem liberação dos vasos gástricos curtos utilizando apenas a parede gástrica anterior (FTL à Rossetti) ou as paredes gástricas anterior e posterior (FTL à Nissen). Métodos Análise de dados de 289 pacientes submetidos à FTL sem liberação dos vasos gástricos curtos no período de janeiro de 2004 a janeiro de 2012, com acompanhamento mínimo de 6 meses. Os pacientes foram divididos em Grupo 1 (FTL à Rossetti – n = 160) e Grupo 2 (FTL à Nissen – n = 129). Resultados A incidência global de disfagia grave pós-operatória foi de 3,11%, sendo 4,37% no grupo 1 e 1,55% no grupo 2 (P = 0.169). A necessidade de tratamento cirúrgico da disfagia foi de 2,5% no grupo 1 e 0,78% no grupo 2 (P = 0.264). Em todos os pacientes reoperados após FTL à Rossetti foram observadas distorções das válvulas que podem responder pela ocorrência de disfagia, ao passo que no paciente submetido à reoperação após FTL à Nissen nenhuma alteração foi observada. Conclusões A incidência global de disfagia grave pós-operatória não apresentou diferença entre as duas técnicas relatadas. A FTL à Rossetti foi associada a distorções estruturais das válvulas que podem justificar a disfagia, fato não observado após FTL à Nissen. .

Quality of life and prevalence of osteoarticular pain in patients submitted to bariatric surgery / Qualidade de vida e prevalência de dor osteoarticular em pacientes submetidos à cirurgia bariátrica

OBJECTIVE: To analyze quality of life and observe the prevalence of musculoskeletal pain in patients submitted to bariatric surgery. METHODS: A prospective, observational and comparative study with 26 individuals aged 18 to 60 years, 25 women, which included two evaluations, one preoperative and the other approximately 42 months after surgery. The Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) and the Human Body Diagram with Visual Analogue Scale were employed. RESULTS: The individual samples showed grade III obesity, with a predominance of postoperative overweight, hypertension and diabetes in 65.4% and 42.3% of the samples, with remission of hypertension in 50% and of diabetes mellitus in 38.5% (p<0.001). The SF-36 demonstrated improved quality of life, especially in aspects related to motricity; vitality and mental health showed no significant changes. Osteoarticular pain was reported and identified in various sites by the subjects; however, 87.5% of patients in the preoperative period and 88.5% in the postoperative period reported not having any physical therapy orientation, while 65.4% reported being engaged in some type of regular physical activity after surgery (p<0.001). CONCLUSION: Morbidly obese individuals have a high probability of suffering from clinical, psychic, and musculoskeletal alterations, compromising their quality of life and showing improvement after bariatric surgery; on the other hand, the psycho-emotional manifestations did not progress in the same way.

OBJETIVO: Analisar a qualidade de vida e observar a prevalência de dor musculoesquelética em pacientes submetidos à cirurgia bariátrica. MÉTODOS: Estudo prospectivo, observacional e comparativo, incluindo 26 amostras, idade entre 18 e 60 anos, sendo 25 mulheres e compreendendo duas avaliações, uma pré-operatória e outra cerca de 42 meses após a cirurgia, com aplicação do Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) e do Diagrama do Corpo Humano com Escala Visual Analógica. RESULTADO: As amostras apresentaram obesidade grau III, com predomínio de sobrepeso após cirurgia, hipertensão e diabetes presentes em 65,4% e 42,3% das amostras, com remissão da hipertensão em 50% e da diabete mellitus em 38,5% (p<0,001). O SF-36 evidenciou melhora da qualidade de vida, sobretudo nos aspectos relacionados à motricidade; vitalidade e saúde mental não apresentaram mudanças significativas. A dor osteoarticular esteve presente e foi apontada em diversos pontos pelos sujeitos da amostra; contudo, 87,5% dos pacientes no pré e 88,5% no pós-operatório relataram não ter realizado nenhum acompanhamento fisioterápico, enquanto 65,4% relataram fazer algum tipo de atividade física regularmente após a cirurgia (p<0,001). CONCLUSÃO: Obesos mórbidos apresentam alta probabilidade de sofrer com as alterações clínicas, psíquicas e musculoesqueléticas, comprometendo sua qualidade de vida e apresentando melhora após a cirurgia bariátrica; por outro lado, as manifestações psicoemocionais não tiveram a mesma evolução.

Ressecção laparoscópica dos cistoadenomas pancreáticos / Laparoscopic resection of pancreatic cystadenomas

RACIONAL: As ressecções pancreáticas por laparoscopia tem se tornado cada vez mais frequentes, com bons resultados relatados por vários centros. Entretanto, poucos estudos se concentraram no tratamento laparoscópico das lesões císticas pancreáticas. OBJETIVO: Analisar os resultados do tratamento minimamente invasivo das lesões císticas pancreáticas. MÉTODOS: Análise retrospectiva de um banco de dados prospectivo multicêntrico brasileiro. Foram incluídas todas as ressecções pancreáticas laparoscópicas realizadas em três centros. Os procedimentos cirúrgicos incluíram enucleações e ressecções do pâncreas esquerdo (com ou sem esplenectomia associada). As complicações pos-operatórias foram classificadas de acordo com a classificação proposta por Clavien e Dindo6. O diagnóstico de fístula pancreática foi confirmado se a dosagem de amilase do líquido de drenagem no 3o dia pós-operatório era superior a três vezes o valor da amilase sérica. RESULTADOS: Foram realizadas 44 ressecções pancreáticas por laparoscopia. Quinze pacientes foram operados com suspeita de cistoadenoma pancreático e 13 tiveram o diagnóstico confirmado. Foram operadas 12 mulheres (92%), e a idade média foi de 50 anos. Seis pacientes tiveram complicações pós-operatórias leves. Ocorreram cinco (38%) fístulas pancreáticas, nenhuma considerada grave (C) e apenas um paciente necessitou re-internação hospitalar e drenagem radiológica. Nesta série não houve conversões, re-operações ou mortalidade. CONCLUSÕES: O acesso videolaparoscópico é opção segura e eficaz para o tratamento das lesões císticas pancreáticas. As fístulas pancreáticas são quase sempre de evolução favorável e não diminuem os benefícios do acesso minimamente invasivo.

BACKGROUND: Laparoscopic pancreatic resections have become increasingly frequent with good results reported by several centers. However, few studies have focused on laparoscopic treatment of pancreatic cystic lesions. AIM: To analyze the results of minimally invasive treatment of pancreatic cystic lesions. METHODS: Were included all laparoscopic pancreatic resections performed at three centers. Surgical procedures included resection of the pancreas and left enucleations (with or without splenectomy). The post-operative complications were classified according to the classification proposed by Clavien and Dindo6. The diagnosis of pancreatic fistula was confirmed if the amylase dosage of the drainage liquid in the third postoperative day was more than three times the amount of serum amylase. RESULTS: Were performed 44 laparoscopic pancreatic resections. Fifteen patients underwent surgery for suspected pancreatic cystadenoma and 13 had this diagnosis confirmed. There were 12 women (92%), and the average age of patients was 50 years. Six patients had minor postoperative complications. There were five (38%) pancreatic fistulas, neither considered as severe (C), and only one patient required hospital readmission and radiological drainage. In this series, there were no conversions, reoperations, or mortality. CONCLUSIONS: The laparoscopic approach is a safe and effective option for the treatment of pancreatic cystic lesions. The incidence of pancreatic fistula has good evolution and not diminishes the benefits of minimally invasive surgery.

Quality of life and prevalence of osteoarticular pain in patients submitted to bariatric surgery.

OBJECTIVE: To analyze quality of life and observe the prevalence of musculoskeletal pain in patients submitted to bariatric surgery. METHODS: A prospective, observational and comparative study with 26 individuals aged 18 to 60 years, 25 women, which included two evaluations, one preoperative and the other approximately 42 months after surgery. The Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) and the Human Body Diagram with Visual Analogue Scale were employed. RESULTS: The individual samples showed grade III obesity, with a predominance of postoperative overweight, hypertension and diabetes in 65.4% and 42.3% of the samples, with remission of hypertension in 50% and of diabetes mellitus in 38.5% (p < 0.001). The SF-36 demonstrated improved quality of life, especially in aspects related to motricity; vitality and mental health showed no significant changes. Osteoarticular pain was reported and identified in various sites by the subjects; however, 87.5% of patients in the preoperative period and 88.5% in the postoperative period reported not having any physical therapy orientation, while 65.4% reported being engaged in some type of regular physical activity after surgery (p<0.001). CONCLUSION: Morbidly obese individuals have a high probability of suffering from clinical, psychic, and musculoskeletal alterations, compromising their quality of life and showing improvement after bariatric surgery; on the other hand, the psycho-emotional manifestations did not progress in the same way.

Laparoscopic resection of pancreatic cystadenomas.

BACKGROUND: Laparoscopic pancreatic resections have become increasingly frequent with good results reported by several centers. However, few studies have focused on laparoscopic treatment of pancreatic cystic lesions. AIM: To analyze the results of minimally invasive treatment of pancreatic cystic lesions. METHODS: Were included all laparoscopic pancreatic resections performed at three centers. Surgical procedures included resection of the pancreas and left enucleations (with or without splenectomy). The post-operative complications were classified according to the classification proposed by Clavien and Dindo6. The diagnosis of pancreatic fistula was confirmed if the amylase dosage of the drainage liquid in the third postoperative day was more than three times the amount of serum amylase. RESULTS: Were performed 44 laparoscopic pancreatic resections. Fifteen patients underwent surgery for suspected pancreatic cystadenoma and 13 had this diagnosis confirmed. There were 12 women (92%), and the average age of patients was 50 years. Six patients had minor postoperative complications. There were five (38%) pancreatic fistulas, neither considered as severe (C), and only one patient required hospital readmission and radiological drainage. In this series, there were no conversions, reoperations, or mortality. CONCLUSIONS: The laparoscopic approach is a safe and effective option for the treatment of pancreatic cystic lesions. The incidence of pancreatic fistula has good evolution and not diminishes the benefits of minimally invasive surgery.

Randomized trial of total fundoplication and fundal mobilization with or without division of short gastric vessels: a short-term clinical evaluation

PURPOSE: Evaluate short results after fundoplication procedure, concerning the division of short gastric vessels. METHODS: A prospective randomization of 90 patients with indication for hiatoplasty and total fundoplication with fundus mobilization was performed. They were divided into two groups: no SGV division (group A, n= 46) and with SGV division (Group B, n=44), although in both groups the gastric fundus was mobilized to perform a floppy valve. Early outcome with clinical follow up (1 year) was observed. RESULTS: Both groups were similar regarding preoperative parameters and severity of gastroesophageal reflux disease (GERD). No difference in morbidity was observed during hospital stay. Nevertheless, the median operating time was 80,2 minutes in group A and 94,1 minutes (p=0,021) in Group B. Transitory dysphagia during the first year was significantly lower in group B (46,6 percent versus 23,2 percent, p=0,012). However, in 12 months clinical outcome was similar in both groups (clinical symptoms of GERD, persistent dysphagia and reoperations). CONCLUSION: There was no improvement in routine division of SGV in total fundoplication procedure when the gastric fundus was mobilized.

OBJETIVO: Comparar os resultados imediatos e curto prazo segundo a secção ou não dos vasos gástricos curtos. MÉTODOS: Estudo prospectivo randomizado com 90 pacientes selecionados em dois grupos: 46 (grupo A) sem secção e 44 (Grupo B) com secção dos vasos gástricos curtos, seguidos de hiatoplastia e fundoplicatura total por laparoscopia. Analisaram-se os resultados até um ano de pós-operatório. RESULTADOS: Os dois grupos eram homogêneos quanto aos critérios demográficos e aos relacionados á doença do refluxo gastroesofágico. Não houve diferença quanto á morbidade ou tempo de internação, porém o tempo cirúrgico foi maior no Grupo B (80,2 minutos contra 94,1 minutos, p=0,021). Disfagia transitória foi mais freqüente no Grupo A (46,6 por cento versus 23,2 por cento,p=0,012), porém na avaliação final de primeiro ano do pós-operatório não existindo diferença quanto á disfagia persistente, reoperação ou recidiva. CONCLUSÃO: Não houve melhora quando da secção rotineira para a mobilização do fundo gástrico para a realização da fundoplicatura total por laparoscopia.

A exenteração pélvica no tratamento do câncer de reto estádio T4: experiência de 15 casos operados / Pelvic exenteration for T4 rectal cancer: a series of 15 ressectable cases

RACIONAL: A exenteração pélvica tem sido a melhor opção terapêutica radical para o tratamento dos tumores de reto T4. No entanto, essa operação ainda permanece com mortalidade significante e alta morbidade. OBJETIVO: Relatar série de 15 casos de exenteração pélvica para tumores de reto T4, analisando a morbidade, mortalidade e sobrevida dos pacientes. MÉTODOS: Foram estudados 15 pacientes com câncer de reto T4 no Serviço de Cirurgia Geral - Oncocirurgia do Hospital do Servidor Publico Estadual de São Paulo, SP, submetidos a exenteração pélvica no período de 1998 e 2006. Sete eram do sexo masculino enquanto oito eram do sexo feminino, com média de idade de 65 anos. Todos apresentavam sintomas incapacitantes. As operações foram: exenteração infra-elevadora (n = 6), exenteração supra-elevadora (n = 4), exenteração posterior (n = 3) e exenteração posterior com cistectomia e ureterectomia parciais (n = 2). RESULTADOS: A média de tempo cirúrgico foi de 403 minutos (280-485). A média de sangramento foi de 1620 mL (300-4800). A mortalidade pós-operatória foi de 6,66 por cento (n = 1). A morbidade pós-operatória foi de 53,3 por cento (n = 8). Os exames histológicos evidenciaram que todas as ressecções foram R0. Envolvimento linfonodal foi observado em quatro pacientes (26,66 por cento) sendo que todos faleceram em decorrência da neoplasia. A sobrevida global em cinco anos foi de 35,7 por cento. CONCLUSÃO: A exenteração pélvica ainda apresenta alta morbidade, no entanto permanece justificada, pois pode conferir maior controle do câncer de reto T4 em longo prazo.

BACKGROUND: Pelvic exenteration is the best therapeutic choice for treatment of T4 rectal cancer. Although, this operation still presents considerable mortality and high morbidity. AIM: To report on a series of 15 patients with a T4 rectal cancer at a general hospital and describe the outcomes (morbidity, mortality and long-term survival) following pelvic exenteration. METHODS: Complete follow-up data were available on 15 patients who underwent pelvic exenteration for T4 rectal cancer between 1998 and 2006. These subjects comprised seven men and eight women with a mean age of 65 years. All of them presented serious incapacitating complaints. The surgical procedures included: infraelevator exenteration (n = 6), supraelevator exenteration (n = 4), posterior exenteration (n = 3) and, posterior exenteration plus partial cystectomy and ureterectomy (n = 2). RESULTS: The mean duration of surgery was 403 minutes (280-485). The mean blood loss was 1620 mL (300-4.800). The postoperative mortality was 6,66 percent (n = 1). The overall rate morbidity was 53,3 percent (n = 8). The pathological examination showed that all resections were R0. Lymph node involvement was present in four patients (26,66 percent), and all of them died due to tumor recurrence. The overall 5-year survival rate was 35,7 percent. CONCLUSION: In spite of its aggressive nature and high morbidity, pelvic exenteration seems justified in rectal carcinoma when the disease extends to the urinary or genital tract. This procedure may offer long-term disease control.

Randomized trial of total fundoplication and fundal mobilization with or without division of short gastric vessels: a short-term clinical evaluation.

PURPOSE: Evaluate short results after fundoplication procedure, concerning the division of short gastric vessels. METHODS: A prospective randomization of 90 patients with indication for hiatoplasty and total fundoplication with fundus mobilization was performed. They were divided into two groups: no SGV division (group A, n= 46) and with SGV division (Group B, n=44), although in both groups the gastric fundus was mobilized to perform a floppy valve. Early outcome with clinical follow up (1 year) was observed. RESULTS: Both groups were similar regarding preoperative parameters and severity of gastroesophageal reflux disease (GERD). No difference in morbidity was observed during hospital stay. Nevertheless, the median operating time was 80,2 minutes in group A and 94,1 minutes (p=0,021) in Group B. Transitory dysphagia during the first year was significantly lower in group B (46,6% versus 23,2%, p=0,012). However, in 12 months clinical outcome was similar in both groups (clinical symptoms of GERD, persistent dysphagia and reoperations). CONCLUSION: There was no improvement in routine division of SGV in total fundoplication procedure when the gastric fundus was mobilized.

[Pelvic exenteration for T4 rectal cancer: a series of 15 ressectable cases]. / A exenteração pélvica no tratamento do câncer de reto estádio T4: experiência de 15 casos operados.

BACKGROUND: Pelvic exenteration is the best therapeutic choice for treatment of T4 rectal cancer. Although, this operation still presents considerable mortality and high morbidity. AIM: To report on a series of 15 patients with a T4 rectal cancer at a general hospital and describe the outcomes (morbidity, mortality and long-term survival) following pelvic exenteration. METHODS: Complete follow-up data were available on 15 patients who underwent pelvic exenteration for T4 rectal cancer between 1998 and 2006. These subjects comprised seven men and eight women with a mean age of 65 years. All of them presented serious incapacitating complaints. The surgical procedures included: infraelevator exenteration (n = 6), supraelevator exenteration (n = 4), posterior exenteration (n = 3) and, posterior exenteration plus partial cystectomy and ureterectomy (n = 2). RESULTS: The mean duration of surgery was 403 minutes (280-485). The mean blood loss was 1620 mL (300-4.800). The postoperative mortality was 6,66% (n = 1). The overall rate morbidity was 53,3% (n = 8). The pathological examination showed that all resections were R0. Lymph node involvement was present in four patients (26,66 %), and all of them died due to tumor recurrence. The overall 5-year survival rate was 35,7%. CONCLUSION: In spite of its aggressive nature and high morbidity, pelvic exenteration seems justified in rectal carcinoma when the disease extends to the urinary or genital tract. This procedure may offer long-term disease control.

Comparative study of inflammatory response and adhesions formation after fixation of different meshes for inguinal hernia repair in rabbits

OBJETIVO: Avaliar a resposta inflamatória e a formação de aderências das próteses de polipropileno e polipropileno associado a poliglactina sintética (Vypro®) implantadas no espaço pré-peritoneal de coelhos. MÉTODOS: Foram utilizados 14 coelhos albinos linhagem Nova Zelândia com três meses de idade, machos com peso variando de 2000 a 2500 gramas. O acesso à cavidade se deu por incisão mediana abaixo do apêndice xifóide com oito centímetros de extensão. Realizou-se o implante da tela de polipropileno no flanco esquerdo com um ponto de polipropileno em cada extremidade da prótese. No flanco direito a tela Vypro® foi fixada da mesma forma com pontos de polipropileno. A laparoscopia foi realizada 28 dias após o primeiro procedimento para avaliação de aderências intracavitárias. As próteses juntamente com o peritônio, musculatura e aponeurose adjacente foram retiradas em blocos individuais. Cada peça foi imersa em solução tamponada de formaldeido a 10% e encaminhada ao patologista. RESULTADOS: Todos os animais tiveram boa evolução pós-operatória não havendo infecção das incisões cirúrgicas ou óbito dos coelhos. Das quatorze próteses Prolene implantadas no peritônio intacto de coelho, em onze (78,6%) houve formação de aderências Das quatorze próteses Vypro®implantadas no peritônio intacto de coelho, em doze (85,7%) houve formação de aderências. Comparando as duas próteses entre si não houve diferença significante quanto ao numero de aderências formadas. Em relação a avaliação microscópica, nas próteses VYPRO® a reação granulomatosa do tipo corpo estranho e a fibrose foram predominantemente moderadas. Já a inflamação inespecífica foi proporcionalmente leve e moderada A inflamação inespecífica foi menos intensa nas próteses de polipropileno. CONCLUSÃO: Ambas as próteses implantadas na cavidade peritoneal de coelhos promovem a formação de aderências de forma semelhante. As próteses de polipropileno e associado a poliglactina promovem maior fibrose, apresentando melhor incorporação aos tecidos.

Comparative study of inflammatory response and adhesions formation after fixation of different meshes for inguinal hernia repair in rabbits.

PURPOSE: Compare, in a rabbit model, the inflammatory response and adhesions formation following surgical fixation of polypropilene and Vypro mesh in the inguinal preperitoneal space. METHODS: Fourteen male New Zealand rabbits, weighing between 2.000 to 2.500 g were used. A midline incision was made and the peritoneal cavity was exposed. The 2.0 x 1.0 cm polypropylene mesh was fixed in the left flank and secured to the margins with 3-0 prolene in a separate pattern. In the right flank, a 2.0 x 1.0 cm Vypro II mesh was sewn in the same way. After the post surgical period, the animals were again anesthetized and underwent laparoscopic approach, in order to identify and evaluate adhesions degree. Both fixed prosthesis were excised bilaterally with the abdominal wall segment, including peritoneum, aponeurosis and muscle and sent to a pathologist. RESULTS: Operative time ranged from 15 to 25 minutes and no difficulties in applying the mesh were found. From the 14 polypropylene meshes fixed to the intact peritoneum, 11 had adhesions to the abdominal cavity (78.6%). Concerning Vypro mesh, 12 animals developed adhesions from the 14 with mesh fixation (85.7%). Histological examination of tissues harvested revealed fibroblasts, collagen, macrophages and lymphocytes between the threads of the mesh. CONCLUSION: Polypropylene and Vypro mesh, when implanted in the peritoneal cavity of rabbits provoke similar amount of adhesions. Vypro mesh tissues had higher fibrosis resulting in better mesh incorporation to the abdominal wall.