Incisional Hernias after Vascular Surgery for Aortoiliac Aneurysm and Aortoiliac Occlusive Arterial Disease: Has Prophylactic Mesh Changed This Scenario?

BACKGROUND: Incisional hernia (IH) is an important surgical complication that has several ways of prevention, including modifications in the surgical technique of the initial procedure. Its incidence can reach 69% in high-risk patients and long-term follow-up. Of the risky procedures, open abdominal aortic aneurysmectomy is the one with the highest risk. Ways to reduce this morbid complication were suggested, and prophylactic mesh rises as an important tool to prevent recurrence. METHODS: A retrospective cohort study review of medical records of patients undergoing vascular surgery for abdominal aortoiliac aneurysm (AAA) or vascular bypass surgery due to aortoiliac occlusive disease. We identified 193 patients treated between 2010 and 2020. We further performed a one-to-nine matching analysis between the use of prophylactic mesh and control groups, based on estimated propensity scores for each patient. RESULTS: Prophylactic mesh group had a 18% lower risk of IH, compared with the control group (relative risk: 0.82; 95% confidence interval [CI] = 0.74-0.93). The difference in IH rates between the groups compared was 2.6% (95% CI: -19.8 to 25.5). From the perspective of the number needed to treat, it would be necessary to use prophylactic mesh in 39 (95% CI: 35-44) patients to avoid one IH in this population. CONCLUSION: Use of prophylactic mesh in the repair of AAA significantly reduces the incidence of IH in nearly one in five cases. Our data suggest that there is benefit in the use of prophylactic mesh in open aneurysmectomy surgery regarding postoperative IH development.

Intraoperative cholangiography with filling defects: comparative complication analysis of postoperative transcystic duct (TCD) catheter maintenance.

BACKGROUND: This is a retrospective cohort of patients undergoing laparoscopic cholecystectomy with intraoperative cholangiography (IOC) with positive findings for filling defects. We comparatively assessed differences in complication risks for patients that had their cholangiography catheter maintained in its transcystic duct (TCD) position postoperatively. This is a practice proposed to overcome the limited availability of Endoscopic Retrograde Cholangiopancreatography (ERCP) as well as to avoid surgical exploration of the common bile duct. METHODS: Retrospective medical record review of all positive IOC from January 2015 to December 2018 were assessed. Patients' demographic and perioperative data from the hospital stay period in which the cholecystectomy occurred until the last surgical ambulatory visit for perioperative characteristics were compared between groups (with vs. without TCD catheter). Complications were operationalized using the Clavien-Dindo scale. RESULTS: Univariate analysis of complications showed a 2.4-fold risk increase in complications (95% CI 1.13-5.1) between comparison groups. Number of ERCPs (18 vs. 30), and MRCPs (5 vs. 17) were not significantly different between maintaining or not the TCD catheter postop, respectively. Stratified analysis followed by exact logistic regression supported the findings that maintaining the TCD catheter postoperatively increased complication rates (OR = 5.34, 95% CI 1.22, 29.83, p = 0.022), adjusting for potential confounders. CONCLUSION: The maintenance of the TCD catheter postoperatively did not prove to be effective in significantly reducing the number of ERCP nor associated complications. Also, outcomes inherited from the practice caused adverse events that surpassed its potential benefits. Moreover, expectant follow-up is reasonable for patients with evidence of common bile duct stones, even in setting with limited resource availability. We do not recommend this practice, even in settings where there are limited resources of more modern management of choledocholithiasis.

Mapeamento e biópsia do linfonodo sentinela no melanoma cutâneo estágio I e II: revisão de literatura / Lymphatic mapping and sentinel node biopsy for stage I and II cutaneous melanoma: review of literature

A melhor abordagem de pacientes com melanoma cutâneo estágios I e II (American Joint Comitte on Cancer) é bastante controversa. Uma conduta intermediária entre a linfadenectomia eletiva (LE) e a observação consiste no mapeamento e biópsia do linfonodo sentinela (LS), proporcionando uma abordagem seletiva à linfadenectomia. O objetivo era revisar a indicação e técnica do mapeamento e biópsia do LS no tratamento do melanoma cutâneo estágios I e II. A técnica é indicada para pacientes cujo índice de BReslow seja maior que 1mm, o de Clark maior que III, apresentem melanoma ulcerado, com sinais histológicos de regressão ou com localização no tronco, na cabeça ou no pescoço. Obviamente não é indicada para pacientes com linfadenopatia regional metastática. Os melhores resultados com a técnica dependem da realização adequada de suas diferentes etapas: a. mapeamento linfático pré-operatório, pela linfocintilografia; b. mapeamento transoperatório, preferencialmente com a técnica combinada do corante azul e linfocintilografia com detector gama portátil, e biópsia do LS; e c. avaliação anatomopatológica (AP) adequada. A técnica de mapeamento e biópsia do LS avalia com elevada acurácia o estado histológico da cadeia linfática regional e acrescenta várias vantagens sobre a LE, enquanto ainda não existam estudos consistentes comparando a sobrevida dos pacientes submetidos à linfodenectomia seletiva e a outras abordagens. Os resultados relacionados ao sucesso da técnica são promissores, apesar de o segmento desses pacientes estar em fase de estudos