Validação de checklist cirúrgico para prevenção de infecção de sítio cirúrgico / Validation of surgical checklist to prevent surgical site infection

Objetivo Construir e validar checklist cirúrgico para segurança do paciente e prevenção de infecção de sítio cirúrgico. Métodos Pesquisa quantitativa realizada para validar instrumento criado e utilizado em cirurgia segura. O instrumento foi validado por sete peritos. Para concordância entre os juízes utilizou-se o coeficiente de concordância de Kendall e para verificar se a opinião dos juízes diferiu significativamente, o teste de Cochran. O instrumento é validado se houver concordância entre os juízes e a clareza for significante. Resultados Na primeira avaliação do instrumento, obteve-se Kendall de 0,230 para pertinência e 0,390 para clareza, o que implicou em reformulação do checklist. Após a reformulação, obteve-se concordância absoluta para pertinência e não houve diferença significativa para clareza. Com o instrumento validado, foi criado um sistema informatizado para inserção dos dados coletados. Conclusão O instrumento criado foi validado e pode auxiliar na segurança do paciente e prevenção de infecção de sítio cirúrgico.

Objective To design and validate a surgical checklist to improve patient safety and prevent surgical site infection. Methods This quantitative study was carried out to validate an instrument created and used for surgical safety. Seven experts validated the instrument. For agreement among experts, was used Kendall’s concordance coefficient; if their opinions differed significantly, the Cochran’s test was adopted. An instrument is validated when concordance among experts is achieved and its clarity is significant. Results In the first assessment of the instrument, Kendall’s concordance coefficients were 0.230 in terms of pertinence and 0.390 for clarity. These results cauded a reformulation in the checklist. After reformulation, an absolute concordance was achieved for pertinence and no significant difference was seen in terms of clarity. After instrument validation, was created an information system to input data collected. Conclusion The instrument was validated. It can help improve patient safety and prevent surgical site infection.

ANTIBIOTIC PROPHYLAXIS IN BARIATRIC SURGERY: a continuous infusion of cefazolin versus ampicillin/sulbactam and ertapenem.

BACKGROUND: The incidence of surgical site infection in bariatric patients is significant and the current recommendations for antibiotic prophylaxis are sometimes inadequate. Objective: The aim of this study was to analyze the effect of three prophylactic antibiotic regimens on the incidence of surgical site infection. METHODS: A prospective, cross-sectional study was conducted between January 2009 and January 2013 in which 896 Roux-en-Y gastric bypasses were performed to treat obesity. The study compared three groups of patients according to the perioperative antibiotic prophylaxis administered intravenously and beginning at anesthesia induction: Group I consisting of 194 patients treated with two 3-g doses of ampicillin/sulbactam; Group II with 303 patients treated with a single 1-g dose of ertapenem; and Group III with 399 patients treated with a 2-g dose of cefazolin at anesthesia induction followed by a continuous infusion of cefazolin 1g throughout the surgical procedure. The rate of surgical site infection was analyzed, as well as its association with age, sex, preoperative weight, body mass index and comorbidities. RESULTS: The rates of surgical site infection were 4.16% in the group treated prophylactically with ampicillin/sulbactam, 1.98% in the ertapenem group and 1.55% in the continuous cefazolin group. CONCLUSION: The prophylactic use of continuous cefazolin in surgeries for morbid obesity shows very promising results. These findings suggest that some prophylactic regimens need to be reconsidered and even substituted by more effective therapies for the prevention of surgical site infections in bariatric patients.

ANTIBIOTIC PROPHYLAXIS IN BARIATRIC SURGERY: a continuous infusion of cefazolin versus ampicillin/sulbactam and ertapenem / Antibioticoprofilaxia em cirurgia bariátrica: infusão contínua de cefazolina versus ampicilina/sulbactam e ertapenem

Background The incidence of surgical site infection in bariatric patients is significant and the current recommendations for antibiotic prophylaxis are sometimes inadequate. Objective The aim of this study was to analyze the effect of three prophylactic antibiotic regimens on the incidence of surgical site infection. Methods A prospective, cross-sectional study was conducted between January 2009 and January 2013 in which 896 Roux-en-Y gastric bypasses were performed to treat obesity. The study compared three groups of patients according to the perioperative antibiotic prophylaxis administered intravenously and beginning at anesthesia induction: Group I consisting of 194 patients treated with two 3-g doses of ampicillin/sulbactam; Group II with 303 patients treated with a single 1-g dose of ertapenem; and Group III with 399 patients treated with a 2-g dose of cefazolin at anesthesia induction followed by a continuous infusion of cefazolin 1g throughout the surgical procedure. The rate of surgical site infection was analyzed, as well as its association with age, sex, preoperative weight, body mass index and comorbidities. Results The rates of surgical site infection were 4.16% in the group treated prophylactically with ampicillin/sulbactam, 1.98% in the ertapenem group and 1.55% in the continuous cefazolin group. Conclusion The prophylactic use of continuous cefazolin in surgeries for morbid obesity shows very promising results. These findings suggest that some prophylactic regimens need to be reconsidered and even substituted by more effective therapies for the prevention of surgical site infections in bariatric patients. .

Contexto A incidência de infecção de sítio cirúrgico em pacientes bariátricos é significativa e as recomendações atuais para a profilaxia antibiótica são por vezes inadequadas. Objetivo O objetivo deste estudo foi analisar o efeito de três esquemas de antibióticos profiláticos sobre a incidência de infecção de sítio cirúrgico. Método Estudo prospectivo, transversal, foi realizado entre janeiro de 2009 e janeiro de 2013, em que 896 derivações gástricas em Y de Roux foram realizadas para tratar a obesidade. O estudo comparou três grupos de pacientes de acordo com a profilaxia antibiótica administrada no perioperatória por via intravenosa, iniciada na indução anestésica: Grupo I constituído de 194 pacientes tratados com duas doses de 3 g de ampicilina/sulbactam; Grupo II com 303 pacientes tratados com uma única dose de 1 g de ertapenem; e Grupo III com 399 pacientes tratados com uma dose de 2 g de cefazolina no momento da indução da anestésica seguida de uma infusão contínua de cefazolina 1 g durante o procedimento cirúrgico. A taxa de infecção de sítio cirúrgico foi analisada, bem como a sua associação com a idade, sexo, peso pré-operatório, o índice de massa corporal e comorbidades. Resultados As taxas de infecção do sítio cirúrgico foram de 4,16% no grupo tratado profilaticamente com ampicilina/sulbactam, 1,98% no grupo de ertapenem e 1,55% no grupo de cefazolina contínua. Conclusão O uso profilático de cefazolina contínua em cirurgias para obesidade mórbida apresenta resultados muito promissores. Estes resultados sugerem que alguns regimes profiláticos precisam ser reconsiderados e até mesmo substituídos por terapias mais eficazes para a prevenção de infecções de sítio cirúrgico em pacientes bariátricos. .

Revision surgery for treatment of weight regain after Roux-en-Y gastric bypass.

BACKGROUND: This study aims to evaluate results on revision surgery for weight regain after gastric bypass, based on surgical technique and follow-up. METHODS: This study is a retrospective analysis of 29 patients who presented weight regain on follow-up after more than 5 years, divided into four groups according to revision surgery type: group 1 (n = 9) includes patients who underwent an increase in the length of the alimentary limb to 200 cm; group 2 (n = 13) are patients who underwent an increase in the length of the alimentary limb and placing of a silicon ring; group 3 (n = 2) are patients who underwent an increase in the length of the alimentary limb and gastric plication, and group 4 (n = 5) are patients who underwent gastric plication and placing of a silicon ring. RESULTS: The average preoperative weight before revision surgery was 117.8 kg, and the average postoperative follow-up for revision surgery was 13.7 months. Weight loss after revision surgery was observed in all groups but was greater in patients with longer revisional postoperative follow-up. Patients who underwent placing of a silicon ring presented greater weight loss than those who had had such a band since the original gastric bypass operation. CONCLUSIONS: Data suggest that revision surgery may be a useful tool in achieving weight loss in patients presenting weight regain following gastric bypass, obesity, bariatric surgery, gastric bypass, weight regain, and revision surgery.

Prediction of severe complications and death in superobese patients undergoing open gastric bypass with the Recife Score.

CONTEXT: Superobese patients who undergo gastric bypass have a greater incidence of complications. The greater incidence of comorbidity in this group leads to a higher surgical risk, and a need for special care. By analyzing the risk factors identified in the preoperative period, scoring them, constructing a score and assessing the occurrence of serious complications and death, we will have elements to identify which patients are at greater risk. OBJECTIVE: To determine the accuracy of the Recife Score for predicting serious postoperative complications and death in superobese patients who undergo Roux-en-Y gastric bypass surgery by the conventional method. METHODS: An ambidirectional study was conducted to validate the diagnostic test on 203 severely obese patients submitted to Roux-en-Y gastric bypass at the Hospital das Clínicas of the Federal University of Pernambuco, Recife, PE, Brazil, from September 1997 to May 2007. The dependent variables were major postoperative complications and death. The independent variable was the Recife Score. The data were analyzed using the Epi-Info 3.5.1 program. The accuracy of the Recife Score was analyzed considering the following parameters: sensitivity, specificity, positive predictive value, negative predictive value, positive verisimilitude ratio and negative verisimilitude ratio. RESULTS: The accuracy of the Recife Score with cut-off points higher than 3 and higher than 5 to predict serious postoperative complications was, respectively, a frequency of complications of 12.3%, with a risk ratio of 2.83, sensitivity of 57.1% and specificity of 69.8%, and 12.5%, with a risk ratio of 1.88, sensitivity of 7.1% and specificity of 96.3%. The accuracy of the Recife Score with cut-off points higher than 3 and higher than 5 to predict death was, respectively, a frequency of death of 7.7%, with a risk ratio of 10.62, sensitivity of 83.3% and specificity of 69.5%, and 12.5%, with a risk ratio of 4.88, sensitivity of 16.7% and specificity of 96.5%. CONCLUSION: A Recife Score >3 prior to conventional gastric bypass presents a high level of accuracy in the prediction of serious postoperative complications and death.

Influence of the inversion of the portal/splenic vein diameter in the results of the surgical treatment of schistossomotic portal hypertension.

OBJECTIVE: To evaluate the morbidity and mortality in surgical treatment of schistosomal portal hypertension in patients with inversion of the Portal/Splenic Vein diameter ratio. METHODS: We conducted a retrospective cross-sectional study of patients undergoing surgical treatment of portal hypertension in the period between September 1993 and January 2004. The study population was divided into two groups: a) Inversion--splenic vein diameter greater than or equal to portal vein's--and b) control group (portal vein diameter greater than the splenic vein's). Statistical comparisons used the Student t test for averages difference, chi-square test for proportions difference and Fisher's exact test for small samples. RESULTS: 169 patients were analyzed, with follow-up averaging 23.6 months. Twenty-one patients (12.4%) had splenic vein caliber greater of equal than the portal vein's (Inversion--study group). The mean preoperative diameter of the portal and splenic veins were respectively 1.49 and 1.14 cm in the control group, and 0.98 versus 1.07 cm in the inversion group. The portal vein diameter was significantly higher in the control group when compared to the inversion group (p <0.05). Varices in the gastric fundus were found in 33.3% of the inversion group and in 38.5% of patients in the control group. Postoperative rebleeding occurred in 23.1% of patients in the inversion group and in 13.4% of the control group ones (p > 0.05). In the postoperative evaluation with Doppler ultrasonography of portal vessels, no cases of portal vein thrombosis were observed in the inversion group, whilst in the control group portal thrombosis was identified in 16.9% of the patients (p <0.05). Death occurred in one (4.8%) individual from the inversion group; mortality was 4.1% in the control group (p>0.05). The mean serum level of platelets was significantly lower (65,950/mm²) in the inversion group than in the controls (106,647/mm²) (p<0.05). CONCLUSION: The results suggest that the reversal of portal/splenic vein caliber ratio does not represent a contraindication to surgical treatment of schistosomal portal hypertension.

Prediction of severe complicatons and death in superobese patients undergoing open gastric bypass with the Recife Score / Previsão de complicações graves e de morte em pacientes superobesos submetidos a gastroplastia em Y-de-Roux com utilização do Escore do Recife

CONTEXT: Superobese patients who undergo gastric bypass have a greater incidence of complications. The greater incidence of comorbidity in this group leads to a higher surgical risk, and a need for special care. By analyzing the risk factors identified in the preoperative period, scoring them, constructing a score and assessing the occurrence of serious complications and death, we will have elements to identify which patients are at greater risk. OBJECTIVE: To determine the accuracy of the Recife Score for predicting serious postoperative complications and death in superobese patients who undergo Roux-en-Y gastric bypass surgery by the conventional method. METHODS: An ambidirectional study was conducted to validate the diagnostic test on 203 severely obese patients submitted to Roux-en-Y gastric bypass at the Hospital das Clínicas of the Federal University of Pernambuco, Recife, PE, Brazil, from September 1997 to May 2007. The dependent variables were major postoperative complications and death. The independent variable was the Recife Score. The data were analyzed using the Epi-Info 3.5.1 program. The accuracy of the Recife Score was analyzed considering the following parameters: sensitivity, specificity, positive predictive value, negative predictive value, positive verisimilitude ratio and negative verisimilitude ratio. RESULTS: The accuracy of the Recife Score with cut-off points higher than 3 and higher than 5 to predict serious postoperative complications was, respectively, a frequency of complications of 12.3 percent, with a risk ratio of 2.83, sensitivity of 57.1 percent and specificity of 69.8 percent, and 12.5 percent, with a risk ratio of 1.88, sensitivity of 7.1 percent and specificity of 96.3 percent. The accuracy of the Recife Score with cut-off points higher than 3 and higher than 5 to predict death was, respectively, a frequency of death of 7.7 percent, with a risk ratio of 10.62, sensitivity of 83.3 percent and specificity of 69.5 percent, and 12.5 percent, with a risk ratio of 4.88, sensitivity of 16.7 percent and specificity of 96.5 percent. CONCLUSION: A Recife Score >3 prior to conventional gastric bypass presents a high level of accuracy in the prediction of serious postoperative complications and death.

CONTEXTO: Pacientes superobesos submetidos a gastroplastia apresentam maior incidência de complicações. Alto risco cirúrgico decorre da maior incidência de comorbidades nesse grupo, levando à necessidade de cuidados especiais. Analisando os fatores de risco identificados no pré-operatório, pontuando-os, construindo um escore e avaliando a ocorrência de complicações graves e óbito, serão fornecidos elementos para identificar quais os pacientes de maior risco. OBJETIVO: Determinar a precisão do Escore de Recife para predição de complicações pós-operatórias graves e óbito em pacientes superobesos submetidos a cirurgia de derivação gástrica em Y-de-Roux por via convencional. MÉTODOS: Estudo ambidirecional foi realizado para validação de teste diagnóstico em 203 pacientes superobesos submetidos a derivação gástrica em Y-de-Roux no Hospital das Clínicas da Universidade Federal de Pernambuco, Recife, PE, no período de setembro de 1997 a maio de 2007. As variáveis dependentes foram as complicações pós-operatórias graves e o óbito. A variável independente foi o Escore de Recife. A análise dos dados foi realizada utilizando-se o programa Epi-Info 3.5.1. A análise de precisão do Escore de Recife contemplou os seguintes parâmetros: sensibilidade, especificidade, valor preditivo positivo, valor preditivo negativo, razão de verossimilhança positiva e razão de verossimilhança negativa. RESULTADOS: A precisão do Escore de Recife com pontos de corte maior que 3 e maior que 5 para predição de complicações pós-operatórias graves foi, respectivamente, frequência de complicações de 12,3 por cento, com razão de risco de 2,83, sensibilidade de 57,1 por cento e especificidade de 69,8 por cento, e de 12,5 por cento, com razão de risco de 1,88, sensibilidade de 7,1 por cento e especificidade de 96,3 por cento. A precisão do Escore de Recife com ponto de corte maior que 3 e maior que 5 para predição de óbito foi, respectivamente, frequência de óbito de 7,7 por cento, com razão de risco de 10,62, sensibilidade de 83,3 por cento e especificidade de 69,5 por cento, e de 12,5 por cento, com razão de risco de 4,88, sensibilidade de 16,7 por cento e especificidade de 96,5 por cento. CONCLUSÃO: A pontuação >3 no Escore do Recife no pré-operatório de gastroplastia por via convencional apresenta elevada precisão para predição de complicação pós-operatória grave e óbito.

Atividade mioelétrica do intestino delgado de cães submetidos à oclusão parcial da veia porta / Myoelectric activity of the small bowel of dogs submitted to partial occlusion of the portal vein

RACIONAL: A oclusão temporária da veia porta causa estase esplâncnica e pode causar dismotilidade intestinal. OBJETIVO: Avaliar as alterações da atividade mioelétrica e da histologia do intestino delgado, além da pressão arterial média (PAM), frequência cardíaca (FC), pressão venosa central (PVC) e pressão portal (PP), na fase de pré-oclusão e de oclusão portal. MÉTODO: Realizou-se anestesia geral em seis cães, seguido de monitorização da PAM, FC e PVC, laparotomia, aferição da PP, fixação de três pares de eletrodos na parede intestinal, biópsias jejunais e oclusão parcial da veia porta, sendo programado aumento da PP entre 2,5 e 3 vezes. Os eletrodos foram conectados a um microcomputador com software de aquisição para armazenamento e análise da atividade mioelétrica, cujo registro ocorreu nos 30 minutos da fase de pré-oclusão e nos 60 minutos de oclusão. Determinouse a variância e a média do RMS (root mean square) da atividade mioelétrica. RESULTADOS: Na fase de oclusão, houve diminuição significativa da média do RMS e aumento da frequência de hemorragia da lâmina própria, sendo proporcional ao tempo de estase.Infiltrado inflamatório, dilatação vascular e desprendimento epitelial não apresentaram diferença entre as duas fases. Durante a estase, PAM, FC e PVC diminuíram (p=0,326; 0,375 e 0,008; respectivamente), e PP aumentou (p=0,015). CONCLUSÃO: A oclusão parcial da veia porta de cães promoveu diminuição da atividade mioelétrica e aumento da frequência percentual da hemorragia da lâmina própria, além de queda da PVC.

BACKGROUND: Temporary occlusion of the portal vein causes splancnic venous stasis and intestinal disfunction, that can produce alterations in the motility, and this fact is not vastly known. AIM: To evaluate the small bowel myoelectric activity and histology in the six dogs, also covering mean arterial blood pressure (AP), pulse rate (PR), central venous pressure (CVP) e portal pressure (PP), in two phases: pre-occlusion and occlusion. METHODS: It was done general anesthesia, invasive monitorization of the AP, PR e CVP, laparotomy, measure of the PP, fixation of the three pairs of electrodes in the intestinal wall, jejunal biopsy and parcial occlusion of the portal vein, being programmed the increase of the PP between 2.5 and 3 times baseline. Electrodes were connected to a computer system that captured electrical signals from the intestine. The computer has a software of acquisition to store and analyse the myoelectric activity after registering, what happened in 30 minutes of the pre-occlusion phase and in 60 minutes of occlusion. The variance and the mean RMS(root mean square) of the myoeletric activity were determined. The statistical analysis was done with Friedman, Dunn, Cochran and Students t tests. RESULTS: Mean RMS of myoeletric activity showed significant decrease in the phase of portal occlusion, in comparison to preocclusion phase. The frequency of hemorrhage of the lamina propria was major during occlusion. It was proportional at stasis time, with significant difference between the preocclusion and the occlusion of 60 minutes. Inflammatory infiltration, vascular dilation and epithelial detachment did not show any differences between two phases. During the stasis, AP, PR and CVP decreased (p=0,326; 0,375 e 0,008, respectively), and PP increased(p=0,015). CONCLUSIONS: Parcial occlusion of the portal vein produced reduction of the myoeletric activity and elevation of the percentage frequency of hemorrhage in lamina propria, and a fall of CVP, with relative hemodynamic stabilization.

Influência da inversão do diâmetro veia porta/veia esplênica nos resultados do tratamento cirúrgico da hipertensão portal esquistossomótica / Influence of the inversion of the portal/splenic vein diameter in the results of the surgical treatment of schistossomotic portal hypertension

OBJETIVO: Avaliar a morbidade e a mortalidade no tratamento cirúrgico da hipertensão portal esquistossomótica em pacientes portadores de inversão do diâmetro entre a veia porta e veia esplênica. MÉTODOS: Estudo transversal retrospectivo, de pacientes submetidos ao tratamento cirúrgico da hipertensão no período entre setembro de 1993 e Janeiro de 2004. A população do estudo foi distribuída em dois grupos: a) Inversão - calibre da veia esplênica maior ou igual ao da veia porta) e b) grupo controle (calibre da veia porta maior que o da veia esplênica). Na análise estatística foram utilizados o teste t de student para diferença de médias, quiquadrado para diferença de proporções e o exato de Fisher para amostras reduzidas. RESULTADOS: 169 pacientes foram analisados com seguimento pós-operatório médio de 23,6 meses. 21 pacientes (12,4 por cento) apresentavam a veia esplênica de igual ou maior calibre que a veia porta (Inversão - grupo de estudo). A média dos diâmetros pré-operatórios das veias porta e esplênica foram, respectivamente, 1,49/1,14cm no grupo controle, e 0,98/1,07cm no grupo de inversão. O diâmetro da veia porta foi significativamente maior no grupo controle quando comparado ao grupo de inversão (p<0,05). A presença de varizes de fundo gástrico foi identificada em 33,3 por cento do grupo de inversão e em 38,5 por cento dos pacientes do grupo controle. Recidiva hemorrágica pós-operatória ocorreu em 23,1 por cento dos pacientes do grupo de inversão e em 13,4 por cento no grupo controle (p>0,05). Na avaliação pós-operatória com ultrassonografia Doppler de vasos portais, não houve casos de trombose portal no grupo de inversão, e no grupo controle a trombose portal foi identificada em 16,9 por cento dos pacientes (p<0,05). O óbito ocorreu em um (4,8 por cento) paciente do grupo inversão, e a mortalidade foi de 4,1 por cento no grupo controle (p>0,05). A média do nível sérico de plaquetas foi significativamente menor (65.950/mm□) no grupo de inversão do que no grupo controle (106.647/mm□) (p<0,05). CONCLUSÃO: Os resultados sugerem que a inversão do calibre veia porta/esplênica não representa uma contraindicação ao tratamento cirúrgico da hipertensão portal esquistossomótica.

OBJECTIVE: To evaluate the morbidity and mortality in surgical treatment of schistosomal portal hypertension in patients with inversion of the Portal/Splenic Vein diameter ratio. METHODS: We conducted a retrospective cross-sectional study of patients undergoing surgical treatment of portal hypertension in the period between September 1993 and January 2004. The study population was divided into two groups: a) Inversion - splenic vein diameter greater than or equal to portal vein's - and b) control group (portal vein diameter greater than the splenic vein's). Statistical comparisons used the Student t test for averages difference, chi-square test for proportions difference and Fisher's exact test for small samples. RESULTS: 169 patients were analyzed, with follow-up averaging 23.6 months. Twenty-one patients (12.4 percent) had splenic vein caliber greater of equal than the portal vein's (Inversion - study group). The mean preoperative diameter of the portal and splenic veins were respectively 1.49 and 1.14 cm in the control group, and 0.98 versus 1.07 cm in the inversion group. The portal vein diameter was significantly higher in the control group when compared to the inversion group (p <0.05). Varices in the gastric fundus were found in 33.3 percent of the inversion group and in 38.5 percent of patients in the control group. Postoperative rebleeding occurred in 23.1 percent of patients in the inversion group and in 13.4 percent of the control group ones (p> 0.05). In the postoperative evaluation with Doppler ultrasonography of portal vessels, no cases of portal vein thrombosis were observed in the inversion group, whilst in the control group portal thrombosis was identified in 16.9 percent of the patients (p <0.05). Death occurred in one (4.8 percent) individual from the inversion group; mortality was 4.1 percent in the control group (p>0.05). The mean serum level of platelets was significantly lower (65,950/mm□) in the inversion group than in the controls (106,647/mm□) (p<0.05). CONCLUSION: The results suggest that the reversal of portal/splenic vein caliber ratio does not represent a contraindication to surgical treatment of schistosomal portal hypertension.

Analysis of plasma citrulline and intestinal morphometry in mice with hepatosplenic schistosomiasis.

BACKGROUND: Portal hypertension in the mucosa of the intestine and the presence of granulomas in the wall of this organ can alter digestive function in patients with schistosomiasis. Citrulline is a potential marker of intestinal function in some diseases that affect the morphometry of the mucosa because of its close association with enterocytes. The aims of the present study were to determine serum citrulline concentrations in mice with hepatosplenic schistosomiasis, analyze the morphologic repercussions for the mucosa of the small intestine, correlate citrulline concentrations with morphometric changes in the intestinal mucosa, and evaluate the effect of splenectomy on citrulline concentration. METHODS: After approval from the local ethics committee, 46 adult female albino Swiss mice were divided into two groups: Control (23 healthy mice) and experimental (23 mice with hepatosplenic schistosomiasis). Blood samples were collected for the analysis of plasma citrulline before and after splenectomy. A segment of the jejunum was resected for morphometric analysis. RESULTS: The average body mass in the control group was greater than that in the experimental group (p = 0.00062). The average citrulline concentration in the control group was greater than that in the experimental group both before and after splenectomy (p < 0.001). In the experimental group, the villi had less height and area, and there was a smaller perimeter of the mucosal surface (p = 0.003, <0.001, and p = 0.001, respectively). There was a direct correlation between citrulline concentration and the height and area of the villi (p = 0.003 and 0.04, respectively). There was no correlation between citrulline concentration and the perimeter of the surface of the jejunal mucosa. After splenectomy, there was a reduction in the mean citrulline concentration in the experimental group (p = 0.009). CONCLUSIONS: Serum citrulline concentrations were reduced in mice with schistosomiasis, and a direct correlation was found between the citrulline concentration and the morphometry of the jejunal villi. Moreover, there was a reduction in the plasma concentration of citrulline after splenectomy.

Diverticulite em adolescente com Síndrome de Williams: relato de caso / Diverticulitis in adolescent with Williams Syndrome: case report

A Síndrome de Williams é uma doença genética rara, atribuída a deleção do gene da elastina no cromossomo 7. É caracterizada por estenose de aorta, divertículos de bexiga, constipação, retardo mental leve, fácies dismórfica, fraqueza da parede da bexiga e do cólon que levam ao surgimento de divertículos. Relata-se um caso de diverticulite aguda em paciente de 18 anos, o resultado do tratamento clínico durante 5 anos e o diagnóstico diferencial de abdome agudo nesta doença. A indicação de colectomia eletiva é discutida, considerando o pouco conhecimento da história natural da diverticulite nesta síndrome.

The Syndrome of Williams is a rare genetic illness, attributed the deletion of the gene of the elastin in chromosome 7. It is characterized by aortic stenosis, bladder diverticula's, constipation, light mental retardation, dysmorphic facies, weakness of the wall of the bladder and colon that they lead to the sprouting of diverticula. A case of acute diverticulitis in patient of 18 years is told, the result of the clinical treatment during 5 years and the differential diagnosis of acute abdomen in this illness. The indication of elective colectomy is argued, considering the unfamiliarity of the natural history of the diverticulitis in the syndrome.

Obstructive sleep apnea-hypopnea syndrome--the role of bariatric and maxillofacial surgeries.

Obstructive sleep apnea-hypopnea syndrome (OSAHS) is a complex disease with multifactorial etiology. It is marked by the occurrence of apnea and hypopnea events caused by repeated obstructions of the upper airways. OSAHS is strongly associated with obesity, and the prevalence of this disease in morbidly obese patients is very high. Nevertheless, not all patients with OSAHS are obese, and for this reason, there may be other anatomical predispositions to airway collapse. In obese patients, fatty deposition in the parapharyngeal region results in airway reduction and predisposes to airway collapse, worsened by neurologic loss of the normal dilator muscle tone of the neck. However, in nonobese patients, specific craniofacial characteristics such as posterior air pharyngeal space, tongue length, hyoid position, and maxillomandibular deficiencies may predispose some people to develop OSAHS. Treatment strategies for OSAHS patients vary from clinical treatment with continuous positive airway pressure, oral appliances, or medications for mild and moderate OSAHS patients, bariatric surgery for severe obese OSAHS patients to maxillomandibular advancement for obese or nonobese OSAHS patients.

Evaluation of risk factors in superobese patients submitted to conventional Fobi-Capella surgery.

BACKGROUND: Obesity is one of the worlds greatest health problems. The Roux-en-Y gastric bypass is the gold standard treatment for severe obesity. Surgery in obese patients has an acceptable level of morbidity and mortality. The superobese patient, a subcategory of severe obese patients with a high surgical risk has not yet been analyzed as a group. METHODS: A retrospective and prospective cohort study was conducted enrolling 135 patients submitted to Roux-en-Y gastric bypass for treatment of severe obesity at the " Hospital das Clínicas" , Federal University of Pernambuco, Recife, PE, Brazil, between November 1997 and September 2003. The independent variables were possible risk factors of adverse outcomes: age, gender, weight, body mass index, diabetes, hypertension, hypercholesterolemia, sleep apnea, cardiopathy/coronariopathy, pneumopathy or any other co-morbidity. The dependent variables were major complications, minor complications and death. RESULTS: Diabetes (RR = 1.6 and CI = 1.02-2.40) and sleep apnea (RR = 1.8 and CI = 1.18-2.64) were associated to minor complications. Cardiopathy/coronariopathy were associated with major complications (RR = 5.42 and CI = 1.22-2.40) and death (RR = 16.25 and CI = 3.00-87.95). BMI >or=55 kg/m2 was associated with minor complications (RR = 1.58 and CI = 1.04-2.40), major complications (RR = 3.17 and CI = 1.03-9.80) and death (P = 0.007). After logistic regression, the body mass index >55 kg/m2 remained as a strong risk factor of death (OR = 3.6 and CI = 1.05-12.32). CONCLUSIONS: The body mass index >or=55 kg/m2 was the main risk factor for severe complications and death. Other risk factors affecting the outcome were diabetes, obstructive sleep apnea and cardiopathy/coronariopathy.

Evaluation of risk factors in superobese patients submitted to conventional Fobi-Capella surgery

BACKGROUND: Obesity is one of the world’s greatest health problems. The Roux-en-Y gastric bypass is the gold standard treatment for severe obesity. Surgery in obese patients has an acceptable level of morbidity and mortality. The superobese patient, a subcategory of severe obese patients with a high surgical risk has not yet been analyzed as a group. METHODS: A retrospective and prospective cohort study was conducted enrolling 135 patients submitted to Roux-en-Y gastric bypass for treatment of severe obesity at the " Hospital das Clínicas" , Federal University of Pernambuco, Recife, PE, Brazil, between November 1997 and September 2003. The independent variables were possible risk factors of adverse outcomes: age, gender, weight, body mass index, diabetes, hypertension, hypercholesterolemia, sleep apnea, cardiopathy/coronariopathy, pneumopathy or any other co-morbidity. The dependent variables were major complications, minor complications and death. RESULTS: Diabetes (RR = 1.6 and CI = 1.02-2.40) and sleep apnea (RR = 1.8 and CI = 1.18-2.64) were associated to minor complications. Cardiopathy/coronariopathy were associated with major complications (RR = 5.42 and CI = 1.22-2.40) and death (RR = 16.25 and CI = 3.00-87.95). BMI >55 kg/m² was associated with minor complications (RR = 1.58 and CI = 1.04-2.40), major complications (RR = 3.17 and CI = 1.03-9.80) and death (P = 0.007). After logistic regression, the body mass index >55 kg/m² remained as a strong risk factor of death (OR = 3.6 and CI = 1.05-12.32). CONCLUSIONS: The body mass index >55 kg/m² was the main risk factor for severe complications and death. Other risk factors affecting the outcome were diabetes, obstructive sleep apnea and cardiopathy/coronariopathy.

RACIONAL: A obesidade é um dos grandes problemas de saúde mundial. A gastroplastia em Y-de-Roux é o padrão-ouro para o tratamento do obeso severo. Cirurgia em pacientes obesos tem aceitáveis índices de morbidade e mortalidade. O paciente superobeso, subgrupo de obesos graves, apresenta risco cirúrgico elevado, ainda não avaliado. MÉTODOS: Foi realizado estudo retrospectivo e prospectivo envolvendo 135 pacientes superobesos submetidos a gastroplastia em Y-de-Roux para tratamento de obesidade severa no Hospital das Clínicas da Universidade Federal de Pernambuco, Recife, PE, no período de novembro de 1997 até setembro de 2003. As variáveis independentes foram possíveis fatores de risco: idade, sexo, peso, índice de massa corpórea, diabetes, hipertensão, hipercolesterolemia, apnéia do sono, cardiopatia/coronariopatia, pneumopatia ou qualquer outra co-morbidade. As variáveis dependentes foram as complicações graves, complicações leves e óbito. RESULTADOS: Diabetes (RR = 1.6 and CI = 1.02-2.40) e apnéia do sono (RR = 1.8 and CI = 1.18-2.64) foram associados a complicações leves. Cardiopatia/coronariopatia foram associadas a complicações graves (RR = 5.42 and CI = 1.22-2.40) e óbito (RR = 16.25 and CI = 3.00-87.95). Índice de massa corporal >55 kg/m² foi associado a complicações leves (RR = 1.58 and CI = 1.04-2.40), complicações graves (RR = 3.17 and CI = 1.03-9.80) e óbito. Após regressão logística, o índice de massa corporal >55 kg/m² permaneceu como forte fator de risco para óbito (OR = 3.6 and CI = 1.05-12.32). CONCLUSÃO: O índice de massa corporal >55 kg/m² foi o principal fator de risco para complicações severas e óbito. Outros fatores de risco que afetaram os resultados foram: diabetes, apnéia do sono e cardiopatia/coronariopatia.

Gastrobronchial fistula as a rare complication of gastroplasty for obesity: a report of two cases.

Gastrobronchial fistula is a rare condition as a complication following bariatric surgery. The management of this condition requires the active participation of a pulmonologist, who should be familiar with aspects of the main types of bariatric surgery. Herein, we report the cases of two patients who presented recurrent subphrenic and lung abscess secondary to fistula at the angle of His for an average of 19.5 months. After relaparotomy was unsuccessful, cure was achieved by antibiotic therapy and, more importantly, by stenostomy and endoscopic dilatation, together with the use of clips and fibrin glue in the fistula. These pulmonary complications should not be treated in isolation without a gastrointestinal evaluation since this can result in worsening of the respiratory condition, thus making anesthetic management difficult during endoscopic procedures.