PERIOPERATIVE CARE IN DIGESTIVE SURGERY: THE ERAS AND ACERTO PROTOCOLS. BRAZILIAN COLLEGE OF DIGESTIVE SURGERY POSITION PAPER / Cuidados perioperatórios em cirurgia digestiva: protocolos eras e acerto ­ posicionamento do Colégio Brasileiro de Cirurgia Digestiva

Background: The concept introduced by enhanced recovery after surgery protocols modifies perioperative traditional care in digestive surgery. The integration of these modern recommendations components during the perioperative period are highly important to ensure less postoperative complications, reduced length of hospital stay and decreased surgical costs. Aims: The aim of this position paper is to emphasize the most important points of a multimodal perioperative care protocol. Methods:  A careful analysis of each recommendation of both ERAS and ACERTO protocols is presented, justifying its inclusion in the recommended multimodal care of digestive surgery patients. Results: Enhanced recovery programs (ERPs) such as ERAS and ACERTO protocols are a cornerstone in modern perioperative care. Nutritional therapy is highly important in digestive surgery and thus both preoperative and postoperative nutrition care are key to ensure less postoperative complications and to reduce the length of hospital stay. The concept of prehabilitation is another key element in ERPs. Management of crystalloid fluids in a perfect balance in vital. Fluid overload may delay the recovery of patients and increase postoperative complications. Abbreviation of preoperative fast for 2h before anesthesia is now accepted by various guidelines of both surgical and anesthesiology societies. Combined with early postoperative refeeding, these prescriptions are not only safe but can also enhance recovery of patients undergoing digestive procedures. Conclusions: This Brazilian College of Digestive Surgery position paper strongly emphasizes that the implementation of ERPs in digestive surgery represents a paradigm shift in perioperative care, transcending traditional practices and embracing an intelligent approach to patient well-being.   Background: The concept introduced by enhanced recovery after surgery protocols modifies perioperative traditional care in digestive surgery. The integration of these modern recommendations components during the perioperative period are highly important to ensure less postoperative complications, reduced length of hospital stay and decreased surgical costs. Aims: The aim of this position paper is to emphasize the most important points of a multimodal perioperative care protocol. Methods:  A careful analysis of each recommendation of both ERAS and ACERTO protocols is presented, justifying its inclusion in the recommended multimodal care of digestive surgery patients. Results: Enhanced recovery programs (ERPs) such as ERAS and ACERTO protocols are a cornerstone in modern perioperative care. Nutritional therapy is highly important in digestive surgery and thus both preoperative and postoperative nutrition care are key to ensure less postoperative complications and to reduce the length of hospital stay. The concept of prehabilitation is another key element in ERPs. Management of crystalloid fluids in a perfect balance in vital. Fluid overload may delay the recovery of patients and increase postoperative complications. Abbreviation of preoperative fast for 2h before anesthesia is now accepted by various guidelines of both surgical and anesthesiology societies. Combined with early postoperative refeeding, these prescriptions are not only safe but can also enhance recovery of patients undergoing digestive procedures. Conclusions: This Brazilian College of Digestive Surgery position paper strongly emphasizes that the implementation of ERPs in digestive surgery represents a paradigm shift in perioperative care, transcending traditional practices and embracing an intelligent approach to patient well-being.

Anatomy of the splenic artery: what does the surgeon need to know?

OBJECTIVE: to determine the prevalence and describe the main morphological and metric variations of the splenic artery in terms of its origin, path and polar and terminal branches. METHODS: cross-sectional study, carried out at Hospital de Clínicas between July and November 2020. Computed tomography scans were analyzed with intravenous contrast of the patients seen at the Radiology and Diagnostic Imaging Service. The findings were categorized as to origin, path and splenic ramifications. RESULTS: 1,235 patients were evaluated. As for the origin, the splenic artery appears in the celiac trunk in 99.11% of the individuals. Of these, 5.95% have a bifurcated celiac pattern, 92.17% trifurcated and 1.88% tetrafurcated. The mean arterial diameter was 5.92mm (±1.2), the highest one being in white men. As for the path, the splenic artery was unique in the entire sample. The suprapancreatic course was found in 75.63% of the individuals, with a higher occurrence in women, 78.87% (p<0.001). The terminal splitting pattern of the splenic artery was characterized by the bifurcated type (95.47%). The terminal branches seen most frequently were those with three arteries (34.90%) and most individuals did not have polar branches. CONCLUSION: the splenic artery presents a highly variable pattern of origin and its average caliber is influenced by sex and color. The suprapancreatic path was the most characteristic and predominant in females. The bifurcated pattern of final division, with three terminal branches and the absence of polar arteries, occurs more frequently.

Anatomy of the splenic artery: what does the surgeon need to know? / Anatomia da artéria esplênica: o que o cirurgião precisa saber?

ABSTRACT Objective: to determine the prevalence and describe the main morphological and metric variations of the splenic artery in terms of its origin, path and polar and terminal branches. Methods: cross-sectional study, carried out at Hospital de Clínicas between July and November 2020. Computed tomography scans were analyzed with intravenous contrast of the patients seen at the Radiology and Diagnostic Imaging Service. The findings were categorized as to origin, path and splenic ramifications. Results: 1,235 patients were evaluated. As for the origin, the splenic artery appears in the celiac trunk in 99.11% of the individuals. Of these, 5.95% have a bifurcated celiac pattern, 92.17% trifurcated and 1.88% tetrafurcated. The mean arterial diameter was 5.92mm (±1.2), the highest one being in white men. As for the path, the splenic artery was unique in the entire sample. The suprapancreatic course was found in 75.63% of the individuals, with a higher occurrence in women, 78.87% (p<0.001). The terminal splitting pattern of the splenic artery was characterized by the bifurcated type (95.47%). The terminal branches seen most frequently were those with three arteries (34.90%) and most individuals did not have polar branches. Conclusion: the splenic artery presents a highly variable pattern of origin and its average caliber is influenced by sex and color. The suprapancreatic path was the most characteristic and predominant in females. The bifurcated pattern of final division, with three terminal branches and the absence of polar arteries, occurs more frequently.

RESUMO Objetivo: determinar a prevalência e descrever as principais variações morfológicas e métricas da artéria esplênica quanto a sua origem, trajeto e ramos terminais e polares. Métodos: estudo transversal, realizado no Hospital de Clínicas entre julho e novembro de 2020. Foram analisadas tomografias computadorizadas com contraste endovenoso dos pacientes atendidos no Serviço de Radiologia e Diagnóstico por Imagem. Os achados foram categorizados quanto à origem, trajeto e ramificações esplênicas. Resultados: foram avaliados 1.235 pacientes. Quanto à origem, a artéria esplênica surge no tronco celíaco em 99,11% dos indivíduos. Desses, 5,95% apresentam padrão celíaco bifurcado, 92,17% trifurcado e 1,88% tetrafurcado. O diâmetro arterial médio foi de 5,92mm (±1,2), sendo a maior média em homens brancos. Quanto ao trajeto, a artéria esplênica se apresentou única em toda a amostra. O curso suprapancreático esteve em 75,63% dos indivíduos, com maior ocorrência em mulheres 78,87% (p<0,001). O padrão de divisão terminal da artéria esplênica caracterizou-se pelo tipo bifurcado (95,47%). Os ramos terminais visualizados mais frequentemente foram os com três artérias (34,90%) e a maioria dos indivíduos não apresentou ramos polares. Conclusão: a artéria esplênica apresenta padrão de origem altamente variável e seu calibre médio é influenciado por sexo e cor. O trajeto suprapancreático foi o mais característico e predominou no sexo feminino. O padrão bifurcado de divisão final, com três ramos terminais e ausência de artérias polares, ocorre com maior frequência.

Brazilian gastric cancer association guidelines (part 2): update on treatment / Diretrizes da associação brasileira de câncer gástrico (parte 2): atualização sobre o tratamento

ABSTRACT Background : The II Brazilian Consensus on Gastric Cancer of the Brazilian Gastric Cancer Association BGCA (Part 1) was recently published. On this occasion, countless specialists working in the treatment of this disease expressed their opinion in the face of the statements presented. Aim : To present the BGCA Guidelines (Part 2) regarding indications for surgical treatment, operative techniques, extension of resection and multimodal treatment. Methods: To formulate these guidelines, the authors carried out an extensive and current review regarding each declaration present in the II Consensus, using the Medline/PubMed, Cochrane Library and SciELO databases initially with the following descriptors: gastric cancer, gastrectomy, lymphadenectomy, multimodal treatment. In addition, each statement was classified according to the level of evidence and degree of recommendation. Results : Of the 43 statements present in this study, 11 (25,6%) were classified with level of evidence A, 20 (46,5%) B and 12 (27,9%) C. Regarding the degree of recommendation, 18 (41,9%) statements obtained grade of recommendation 1, 14 (32,6%) 2a, 10 (23,3%) 2b e one (2,3%) 3. Conclusion : The guidelines complement of the guidelines presented here allows surgeons and oncologists who work to combat gastric cancer to offer the best possible treatment, according to the local conditions available.

RESUMO Racional: O II Consenso Brasileiro de Câncer Gástrico da Associação Brasileira de Câncer Gástrico ABCG (Parte 1) foi recentemente publicado. Nesta ocasião inúmeros especialistas que atuam no tratamento desta doença expressaram suas opiniões diante declarações apresentadas. Objetivo: Apresentar as Diretrizes da ABCG (Parte 2) quanto às indicações de tratamento cirúrgico, técnicas operatórias, extensão de ressecção e terapia combinada. Métodos: Para formulação destas diretrizes os autores realizaram extensa e atual revisão referente a cada declaração presente no II Consenso, utilizando as bases Medline/PubMed, Cochrane Library e SciELO, inicialmente com os seguintes descritores: câncer gástrico, gastrectomia, linfadenectomia, terapia combinada. Ainda, cada declaração foi classificada de acordo com o nível de evidência e grau de recomendação. Resultados: Das 43 declarações presentes neste estudo, 11 (25,6%) foram classificadas com nível de evidência A, 20 (46,5%) B e 12 (27,9%) C. Quanto ao grau de recomendação, 18 (41,9%) declarações obtiveram grau de recomendação 1, 14 (32,6%) 2a, 10 (23,3%) 2b e um (2,3%) 3. Conclusão: O complemento das diretrizes aqui presentes possibilita que cirurgiões e oncologistas que atuam no combate ao câncer gástrico possam oferecer o melhor tratamento possível, de acordo com as condições locais disponíveis.

BRAZILIAN GASTRIC CANCER ASSOCIATION GUIDELINES (PART 1): AN UPDATE ON DIAGNOSIS, STAGING, ENDOSCOPIC TREATMENT AND FOLLOW-UP.

BACKGROUND: The II Brazilian Consensus on Gastric Cancer by the Brazilian Gastric Cancer Association (ABCG) was recently published. On this occasion, several experts in gastric cancer expressed their opinion before the statements presented. AIM: To present the ABCG Guidelines (part 1) regarding the diagnosis, staging, endoscopic treatment and follow-up of gastric cancer patients. METHODS: To forge these Guidelines, the authors carried out an extensive and current review regarding each statement present in the II Consensus, using the Medline/PubMed, Cochrane Library and SciELO databases with the following descriptors: gastric cancer, staging, endoscopic treatment and follow-up. In addition, each statement was classified according to the level of evidence and degree of recommendation. RESULTS: Of the 24 statements, two (8.3%) were classified with level of evidence A, 11 (45.8%) with B and 11 (45.8%) with C. As for the degree of recommendation, six (25%) statements obtained grade of recommendation 1, nine (37.5%) recommendation 2a, six (25%) 2b and three (12.5%) grade 3. CONCLUSION: The guidelines presented here are intended to assist professionals working in the fight against gastric cancer with relevant and current information, granting them to be applied in the daily medical practice.

Brazilian gastric cancer association guidelines (part 1): an update on diagnosis, staging, endoscopic treatment and follow-up / Diretrizes da associação brasileira de câncer gástrico (parte 1): atualização sobre o diagnóstico, estadiamento, tratamento endoscópico e seguimento

The II Brazilian Consensus on Gastric Cancer by the Brazilian Gastric Cancer Association (ABCG) was recently published. On this occasion, several experts in gastric cancer expressed their opinion before the statements presented. Aim: To present the ABCG Guidelines (part 1) regarding the diagnosis, staging, endoscopic treatment and follow-up of gastric cancer patients. Methods: To forge these Guidelines, the authors carried out an extensive and current review regarding each statement present in the II Consensus, using the Medline/PubMed, Cochrane Library and SciELO databases with the following descriptors: gastric cancer, staging, endoscopic treatment and follow-up. In addition, each statement was classified according to the level of evidence and degree of recommendation. Results: Of the 24 statements, two (8.3%) were classified with level of evidence A, 11 (45.8%) with B and 11 (45.8%) with C. As for the degree of recommendation, six (25%) statements obtained grade of recommendation 1, nine (37.5%) recommendation 2a, six (25%) 2b and three (12.5%) grade 3. Conclusion: The guidelines presented here are intended to assist professionals working in the fight against gastric cancer with relevant and current information, granting them to be applied in the daily medical practice.

O II Consenso Brasileiro de Câncer Gástrico da Associação Brasileira de Câncer Gástrico (ABCG) foi recentemente publicado. Nesta ocasião, inúmeros especialistas que atuam no tratamento desta doença expressaram sua opinião diante declarações apresentadas. Objetivo: Apresentar as Diretrizes da ABCG (Parte 1) quanto ao diagnóstico, estadiamento, tratamento endoscópico e seguimento dos pacientes com câncer gástrico. Métodos: Para formulação destas Diretrizes os autores realizaram extensa e atual revisão referente a cada declaração presente no II Consenso, utilizando as bases Medline/PubMed, Cochrane Library e SciELO com os seguintes descritores: câncer gástrico, estadiamento, tratamento endoscópico e seguimento. Ainda, cada declaração foi classificada de acordo com o nível de evidência e grau de recomendação. Resultados: Das 24 declarações, duas (8,3%) foram classificadas com nível de evidência A, 11 (45,8%) B e 11 (45,8%) C. Quanto ao grau de recomendação, seis (25%) declarações obtiveram grau de recomendação 1, nove (37,5%) grau 2a, seis (25%) 2b e três (12,5%) 3. Conclusão: As diretrizes aqui presentes têm a finalidade de auxiliar os profissionais que atuam no combate ao câncer gástrico com informações relevantes e atuais, permitindo que sejam aplicadas na prática médica diária.

Ii brazilian consensus on gastric cancer by the brazilian gastric cancer association / Ii consenso brasileiro de câncer gástrico realizado pela associação brasileira de câncer gástrico

ABSTRACT Background: Since the publication of the first Brazilian Consensus on Gastric Cancer (GC) in 2012 carried out by the Brazilian Gastric Cancer Association, new concepts on diagnosis, staging, treatment and follow-up have been incorporated. Aim: This new consensus is to promote an update to professionals working in the fight against GC and to provide guidelines for the management of patients with this condition. Methods: Fifty-nine experts answered 67 statements regarding the diagnosis, staging, treatment and prognosis of GC with five possible alternatives: 1) fully agree; 2) partially agree; 3) undecided; 4) disagree and 5) strongly disagree A consensus was adopted when at least 80% of the sum of the answers "fully agree" and "partially agree" was reached. This article presents only the responses of the participating experts. Comments on each statement, as well as a literature review, will be presented in future publications. Results: Of the 67 statements, there was consensus in 50 (74%). In 10 declarations, there was 100% agreement. Conclusion: The gastric cancer treatment has evolved considerably in recent years. This consensus gathers consolidated principles in the last decades, new knowledge acquired recently, as well as promising perspectives on the management of this disease.

RESUMO Racional: Desde a publicação do primeiro Consenso Brasileiro sobre Câncer Gástrico em 2012 realizado pela Associação Brasileira de Câncer Gástrico (ABCG), novos conceitos sobre o diagnóstico, estadiamento, tratamento e seguimento foram incorporados. Objetivo: Promover uma atualização aos profissionais que atuam no combate ao câncer gástrico (CG) e fornecer diretrizes quanto ao manejo dos pacientes portadores desta afecção. Métodos: Cinquenta e nove especialistas responderam 67 declarações sobre o diagnóstico, estadiamento, tratamento e prognóstico do CG com cinco alternativas possíveis: 1) concordo plenamente; 2) concordo parcialmente; 3) indeciso; 4) discordo e 5) discordo fortemente. Foi considerado consenso a concordância de pelo menos 80% da soma das respostas "concordo plenamente" e "concordo parcialmente". Este artigo apresenta apenas as respostas dos especialistas participantes. Os comentários sobre cada declaração, assim como uma revisão da literatura serão apresentados em publicações futuras. Resultados: Das 67 declarações, houve consenso em 50 (74%). Em 10 declarações, houve concordância de 100%. Conclusão: O tratamento do câncer gástrico evoluiu consideravelmente nos últimos anos. Este consenso reúne princípios consolidados nas últimas décadas, novos conhecimentos adquiridos recentemente, assim como perspectivas promissoras sobre o manejo desta doença.

Safety and quality in surgery: surgeons' perception in Brazil. / Segurança e qualidade em cirurgia: a percepção de cirurgiões no Brasil.

OBJECTIVE: to evaluate the perception of surgeons, members of the Brazilian College of Surgeons (CBC), on safety and quality issues in surgery, based on projects of Brazilian Ministry of Health (MS), CBC, World Health Organization (WHO), and American College of Surgeons (ACS). METHODS: a questionnaire based on WHO, CBC, and ACS initiatives was sent to all active and non-active CBC members, using Survey Monkey, in March 2018. RESULTS: out of 7,100 members, 171 professionals answered the questionnaire. Out of these, the majority (63.2%) declared to perform general surgery, 88.9% indicated knowing the project called Safe Surgery developed by MS, 73.1%, the CBC manual, and 14.6%, the ACS Strong for Surgery. Among those who indicated knowing the MS project, 73.1% said that they were accustomed to use it as a routine, and, among those who indicated knowing the CBC manual, 46.2% said that they were accustomed to use it. Most of the surgeons (81.3%) indicated that they had experienced severe surgical failures, being failures related to surgical material (49.7%) and presence of foreign bodies (8.2%) the most common ones. There were distinct opinions on who was responsible for checking over the checklist. CONCLUSION: the importance of safety and quality in surgery is well known by surgeons, but the practice is varied. Serious adverse events had been experienced by many surgeons, mainly related to surgical material and foreign bodies. The concept of interdisciplinarity did not seem to be common practice. Data indicated the need to develop education projects and the obligation of audits.

OBJETIVO: avaliar a percepção dos cirurgiões, membros do Colégio Brasileiro de Cirurgiões (CBC), sobre temas de segurança e qualidade em cirurgia, com base em Projetos do Ministério da Saúde (MS), do CBC, da Organização Mundial de Saúde (OMS) e do Colégio Americano de Cirurgiões (ACS). MÉTODOS: questionário com base nas iniciativas da OMS, do CBC e do ACS foi enviado pelo Survey Monkey a todos os sócios, ativos e não ativos, do CBC em março de 2018. RESULTADOS: responderam ao questionário 171 profissionais dentre os 7.100 sócios. Desses, a maioria (63,2%) declarou praticar Cirurgia Geral, 88,9% indicaram conhecer o Projeto Cirurgia Segura do MS, 73,1%, o Manual do CBC e 14,6%, o Strong for Surgery do ACS. Entre os que conhecem o Projeto do MS, 73,1% disseram usá-lo como rotina e, entre os que conhecem o Manual do CBC, 46,2% usam-no. A maior parte dos cirurgiões (81,3%) indicou que já vivenciou falha cirúrgica grave, sendo aquelas relacionadas com material cirúrgico (49,7%) e presença de corpos estranhos (8,2%), isoladamente, as mais comuns. Houve opiniões distintas sobre a responsabilidade de conferência do checklist. CONCLUSÃO: a importância da segurança e qualidade em cirurgia é conhecida pelos cirurgiões, mas a prática é variada. Eventos adversos graves foram vivenciados por muitos cirurgiões, principalmente relacionados com material cirúrgico e corpos estranhos. O conceito de interdisciplinaridade parece não ser prática comum. Os dados indicam a necessidade de desenvolver projetos de educação e a obrigatoriedade de auditorias.

Segurança e qualidade em cirurgia: a percepção de cirurgiões no Brasil / Safety and quality in surgery: surgeons' perception in Brazil

RESUMO Objetivo: avaliar a percepção dos cirurgiões, membros do Colégio Brasileiro de Cirurgiões (CBC), sobre temas de segurança e qualidade em cirurgia, com base em Projetos do Ministério da Saúde (MS), do CBC, da Organização Mundial de Saúde (OMS) e do Colégio Americano de Cirurgiões (ACS). Métodos: questionário com base nas iniciativas da OMS, do CBC e do ACS foi enviado pelo Survey Monkey a todos os sócios, ativos e não ativos, do CBC em março de 2018. Resultados: responderam ao questionário 171 profissionais dentre os 7.100 sócios. Desses, a maioria (63,2%) declarou praticar Cirurgia Geral, 88,9% indicaram conhecer o Projeto Cirurgia Segura do MS, 73,1%, o Manual do CBC e 14,6%, o Strong for Surgery do ACS. Entre os que conhecem o Projeto do MS, 73,1% disseram usá-lo como rotina e, entre os que conhecem o Manual do CBC, 46,2% usam-no. A maior parte dos cirurgiões (81,3%) indicou que já vivenciou falha cirúrgica grave, sendo aquelas relacionadas com material cirúrgico (49,7%) e presença de corpos estranhos (8,2%), isoladamente, as mais comuns. Houve opiniões distintas sobre a responsabilidade de conferência do checklist. Conclusão: a importância da segurança e qualidade em cirurgia é conhecida pelos cirurgiões, mas a prática é variada. Eventos adversos graves foram vivenciados por muitos cirurgiões, principalmente relacionados com material cirúrgico e corpos estranhos. O conceito de interdisciplinaridade parece não ser prática comum. Os dados indicam a necessidade de desenvolver projetos de educação e a obrigatoriedade de auditorias.

ABSTRACT Objective: to evaluate the perception of surgeons, members of the Brazilian College of Surgeons (CBC), on safety and quality issues in surgery, based on projects of Brazilian Ministry of Health (MS), CBC, World Health Organization (WHO), and American College of Surgeons (ACS). Methods: a questionnaire based on WHO, CBC, and ACS initiatives was sent to all active and non-active CBC members, using Survey Monkey, in March 2018. Results: out of 7,100 members, 171 professionals answered the questionnaire. Out of these, the majority (63.2%) declared to perform general surgery, 88.9% indicated knowing the project called Safe Surgery developed by MS, 73.1%, the CBC manual, and 14.6%, the ACS Strong for Surgery. Among those who indicated knowing the MS project, 73.1% said that they were accustomed to use it as a routine, and, among those who indicated knowing the CBC manual, 46.2% said that they were accustomed to use it. Most of the surgeons (81.3%) indicated that they had experienced severe surgical failures, being failures related to surgical material (49.7%) and presence of foreign bodies (8.2%) the most common ones. There were distinct opinions on who was responsible for checking over the checklist. Conclusion: the importance of safety and quality in surgery is well known by surgeons, but the practice is varied. Serious adverse events had been experienced by many surgeons, mainly related to surgical material and foreign bodies. The concept of interdisciplinarity did not seem to be common practice. Data indicated the need to develop education projects and the obligation of audits.

MAIN CONTROVERSIES IN THE NONOPERATIVE MANAGEMENT OF BLUNT SPLENIC INJURIES.

INTRODUCTION: The nonoperative management of traumatic spleen injuries is the modality of choice in patients with blunt abdominal trauma and hemodynamic stability. However, there are still questions about the treatment indication in some groups of patients, as well as its follow-up. AIM: Update knowledge about the spleen injury. METHOD: Was performed review of the literature on the nonoperative management of blunt injuries of the spleen in databases: Cochrane Library, Medline and SciELO. Were evaluated articles in English and Portuguese, between 1955 and 2014, using the headings "splenic injury, nonoperative management and blunt abdominal trauma". RESULTS: Were selected 35 articles. Most of them were recommendation grade B and C. CONCLUSION: The spleen traumatic injuries are frequent and its nonoperative management is a worldwide trend. The available literature does not explain all aspects on treatment. The authors developed a systematization of care based on the best available scientific evidence to better treat this condition.

Main controversies in the nonoperative management of blunt splenic injuries / Principais controvérsias do tratamento não operatório das lesões contusas do baço

Introduction: The nonoperative management of traumatic spleen injuries is the modality of choice in patients with blunt abdominal trauma and hemodynamic stability. However, there are still questions about the treatment indication in some groups of patients, as well as its follow-up. Aim : Update knowledge about the spleen injury. Method: Was performed review of the literature on the nonoperative management of blunt injuries of the spleen in databases: Cochrane Library, Medline and SciELO. Were evaluated articles in English and Portuguese, between 1955 and 2014, using the headings "splenic injury, nonoperative management and blunt abdominal trauma". Results: Were selected 35 articles. Most of them were recommendation grade B and C. Conclusion: The spleen traumatic injuries are frequent and its nonoperative management is a worldwide trend. The available literature does not explain all aspects on treatment. The authors developed a systematization of care based on the best available scientific evidence to better treat this condition.

Introdução: O tratamento não operatório das lesões traumáticas do baço é a modalidade de escolha nos pacientes com trauma abdominal contuso e estabilidade hemodinâmica. No entanto, ainda existem dúvidas sobre a indicação do tratamento em determinado grupo de pacientes, assim como o seu seguimento. Objetivo : Atualizar o conhecimento sobre as lesões do baço. Método: Realizou-se revisão da literatura sobre o tratamento não operatório das lesões contusas do baço nas bases de dados: Cochrane, Medline e SciELO. Foram incluídos os artigos em línguas portuguesa e inglesa entre 1955 e 2014, utilizando os descritores "splenic injury, nonoperative management e blunt abdominal trauma". Resultado: Foram selecionados 35 artigos. A maioria dos trabalhos eran em grau de recomendação B e C. Conclusão: As lesões traumáticas do baço são frequentes e o seu tratamento não operatório apresenta tendência mundial. A literatura disponível não esclarece todos os aspectos deste tratamento. Elaborou-se sistematização de atendimento baseada nas melhores evidências científicas disponíveis para facilitar seu manejo.

Correlação interobservador das alterações morfológicas das vias biliares em pacientes com esquistossomose mansoni pela colangiorressonância magnética / Evaluation of morphological changes of the biliary tree by magnetic resonance cholangiography in patients with schistosomiasis mansoni: interobserver agreement

OBJETIVO: Descrever as alterações das vias biliares pela colangiografia por ressonância magnética (CPRM) na esquistossomose hepatoesplênica e avaliar a concordância interobservador da CPRM na detecção de colangiopatia esquistossomótica. MATERIAIS E MÉTODOS: Estudo prospectivo e transversal em 24 pacientes com a forma hepatoesplênica da esquistossomose mansoni e em 6 pacientes sadios, como grupo controle, com avaliação da via biliar pela CPRM. As alterações da via biliar consideradas foram: distorção, afilamento, estenose, dilatação e irregularidade. Foi calculada a concordância interobsevador para alteração da via biliar com o teste de McNemar e o índice kappa (κ). RESULTADOS: A concordância interobservador na caracterização de distorção e afilamento da via biliar foi quase perfeita (κ = 0,867; intervalo de confiança [IC] 95 por cento [0,512-1,0] e κ = 0,865; IC 95 por cento [0,51-1,0], respectivamente). A concordância foi substancial para a estenose (κ = 0,78; IC 95 por cento [0,424-1,0]), moderada para dilatação (κ = 0,595; IC 95 por cento [0,247-0,942]) e regular para afilamento (κ = 0,229; IC 95 por cento [0,095-0,552]). CONCLUSÃO: As alterações observadas nas vias biliares foram, em ordem decrescente de ocorrência: distorção, afilamento, estenose, dilatação e irregularidade. A concordância interobservador para sinais de colangiopatia esquistossomótica foi quase perfeita para distorção e afilamento e substancial para estenose.

OBJECTIVE: To describe changes of the biliary tree demonstrated by magnetic resonance cholangiography (MRC) in patients with the hepatosplenic presentation of schistosomiasis mansoni, and evaluating the interobserver agreement in the detection of schistosomal cholangiopathy. MATERIALS AND METHODS: Prospective, cross-sectional study involving 24 patients with hepatosplenic schistosomiasis and 6 healthy patients (control group) submitted to biliary tree evaluation by MRC. The following changes of the biliary tree were considered: distortion, thinning, stenosis, dilation and irregularity. The interobserver agreement in the detection of biliary tree changes was calculated with the McNemar's test and the kappa index of agreement (κ). RESULTS: The interobserver agreement in the detection of distortion and thinning of the biliary tree was almost perfect (κ = 0.867; confidence interval [CI] 95 percent [0.512-1.0] and κ = 0.865; CI 95 percent [0.51-1.0], respectively). There was a substantial agreement for stenosis (κ = 0.78; CI 95 percent [0.424-1.0]), moderate agreement for dilation (κ = 0.595; CI 95 percent [0.247-0.942]) and mild agreement for thinning (κ = 0.229; CI 95 percent [0.095-0.552]). CONCLUSION: In a decreasing order of frequency, the changes of the biliary tree were observed: distortion, thinning, stenosis, dilation and irregularity. The interobserver agreement for signs of schistosomal cholangiopathy was almost perfect for distortion and thinning, and substantial for stenosis.

Comparative study of the healing process of the aponeurosis of the anterior abdominal wall of rats after wound closure using 3-0 nylon suture and N-butil-2-cyanoacrylate tissue adhesive / Estudo comparativo da cicatrização da aponeurose da parede abdominal anterior com a utilização do fio de poliamida monofilamentar 3-0 e o adesivo N-Butil-2-Cianoacrilato em ratos

PURPOSE: To investigate the healing process of the aponeurosis of the anterior abdominal wall of rats, comparing two different materials for wound closure: 3-0 nylon suture and tissue adhesive N-butyl-2-cyanoacrylate. METHODS: Forty-four Wistar rats were randomly divided into four groups according to the type of material used (suture or adhesive) and the number of days until reoperation (seven or 14 days). After a 4 cm incision in the aponeurosis, 22 rats underwent wound closure using 3-0 nylon suture and the other 22, the tissue adhesive. After seven days, 11 rats from each group were weighed again, submitted to reoperation and then euthanized. The same procedure was carried out after 14 days with the remaining rats. The surgical wound was macroscopically examined, the tensile strength was measured and the tissue edges were histologically examined. The statistical analysis was performed using analysis of variance and Cox's proportional hazards model. Significance level was set at p < 0.05. RESULTS: The animals lost on average 20 g over the period between the two operations. Wound closure was faster using the tissue adhesive. Only one animal, from the tissue adhesive group, had a small abscess with wound dehiscence. With regard to tensile strength, the best results were obtained with the tissue adhesive 14 days after the first surgery. The results of the histological examination showed no significant difference between groups. CONCLUSIONS: Upon morphological evaluation, the two types of material analyzed in this study (3-0 nylon suture and N-butyl-2-cyanoacrylate, a tissue adhesive) were not significantly different with regard to the healing process of the aponeurosis of the anterior abdominal wall of rats. Wound closure using the tissue adhesive was faster. Higher tensile strength was observed in the tissue adhesive group 14 days after the first surgery.

OBJETIVO: Investigar o processo de cicatrização da aponeurose da parede abdominal anterior em ratos, comparando dois diferentes materiais de sutura: fio de poliamida monofilamentar 3-0 e adesivo N-butil-2-cianoacrilato. MÉTODOS: Quarenta e quatro ratos Wistar, foram divididos aleatoriamente em quatro grupos, de acordo com o material de síntese (fio e adesivo cirúrgico) e o tempo de reoperação (7 e 14 dias). Após uma incisão de 4 cm na aponeurose, 22 animais foram submetidos à síntese com o fio de poliamida e os outros 22 animais com o adesivo proposto. Após o procedimento, aguardou-se um período de 7 e 14 dias, quando os animais, 11 de cada grupo, foram novamente pesados e submetidos à eutanásia, sendo realizada a avaliação macroscópica da ferida operatória, mensuração da força de ruptura da parede abdominal e estudo histológico das bordas da incisão. A análise estatística foi realizada através de um modelo de análise de variância e de riscos proporcionais de Cox, considerando significantes valores de p < 0,05. RESULTADOS: Os animais apresentaram uma perda média de 20 g, do dia da operação para o dia da reoperação. A síntese da aponeurose com o adesivo tecidual foi o método mais rápido. Apenas um animal, do grupo adesivo tecidual, apresentou pequeno abscesso local com deiscência de sutura. Com relação à força de ruptura da aponeurose, o melhor desempenho foi do grupo adesivo tecidual, com 14 dias de pós-operatório. Quanto ao estudo histológico, os resultados não mostraram diferença estatisticamente significante entre os dois grupos. CONCLUSÕES: O estudo do processo de cicatrização da aponeurose da parede abdominal anterior mostrou que tanto a síntese com o adesivo N-butil-2-cianoacrilato como com o fio de poliamida monofilamentar 3-0 não apresentou diferença estatisticamente significante na avaliação morfológica, enquanto que a síntese com o adesivo foi mais rápida e mais resistente ao teste de força de ruptura no 14° dia do que a síntese com o fio.

Comparative study of the healing process of the aponeurosis of the anterior abdominal wall of rats after wound closure using 3-0 nylon suture and N-butil-2-cyanoacrylate tissue adhesive.

PURPOSE: To investigate the healing process of the aponeurosis of the anterior abdominal wall of rats, comparing two different materials for wound closure: 3-0 nylon suture and tissue adhesive N-butyl-2-cyanoacrylate. METHODS: Forty-four Wistar rats were randomly divided into four groups according to the type of material used (suture or adhesive) and the number of days until reoperation (seven or 14 days). After a 4 cm incision in the aponeurosis, 22 rats underwent wound closure using 3-0 nylon suture and the other 22, the tissue adhesive. After seven days, 11 rats from each group were weighed again, submitted to reoperation and then euthanized. The same procedure was carried out after 14 days with the remaining rats. The surgical wound was macroscopically examined, the tensile strength was measured and the tissue edges were histologically examined. The statistical analysis was performed using analysis of variance and Cox's proportional hazards model. Significance level was set at p < 0.05. RESULTS: The animals lost on average 20 g over the period between the two operations. Wound closure was faster using the tissue adhesive. Only one animal, from the tissue adhesive group, had a small abscess with wound dehiscence. With regard to tensile strength, the best results were obtained with the tissue adhesive 14 days after the first surgery. The results of the histological examination showed no significant difference between groups. CONCLUSIONS: Upon morphological evaluation, the two types of material analyzed in this study (3-0 nylon suture and N-butyl-2-cyanoacrylate, a tissue adhesive) were not significantly different with regard to the healing process of the aponeurosis of the anterior abdominal wall of rats. Wound closure using the tissue adhesive was faster. Higher tensile strength was observed in the tissue adhesive group 14 days after the first surgery.

Reprodutibilidade da classificação ultra-sonográfica de Niamey na avaliação da fibrose periportal na esquistossomose mansônica / Reproducibility of ultrasonography in the assessment of periportal fibrosis according to Niamey criteria in patients with schistosomiasis mansoni

OBJETIVO: Medir a concordância intra- e interobservador da classificação ultra-sonográfica qualitativa para graduar a fibrose periportal adotada no encontro de Niamey em 1996. MATERIAIS E MÉTODOS: No período de fevereiro de 2005 a março de 2006 foi realizado estudo prospectivo, observacional e transversal em 30 pacientes esquistossomóticos, sem outras hepatopatias associadas, submetidos a ultra-sonografia abdominal e classificados segundo os critérios de Niamey. Os exames foram realizados por dois radiologistas de forma independente em diferentes momentos: durante o exame dinâmico (primeiro momento) e 30 e 90 dias depois (segundo e terceiro momentos) do exame, por meio da documentação fotográfica analisada em estação de trabalho. A concordância intra- e interobservador foi avaliada pelo teste kappa. RESULTADOS: A concordância intra-observador medida pelo teste kappa foi 0,43 para o observador 1 e 0,57 para o observador 2. A concordância interobservador durante o estudo dinâmico e na avaliação fotográfica foi, respectivamente, de 0,46 e 0,71. CONCLUSÃO: O uso do ultra-som para classificar a fibrose periportal segundo o protocolo de Niamey apresentou uma reprodutibilidade que variou de moderada a substancial.

OBJECTIVE: To determine the intra- and interobserver agreement in the classification of periportal fibrosis, according to the criteria defined at the Niamey Workshop of 1996. MATERIALS AND METHODS: A prospective, observational and transverse study was developed in the period between February, 2005 and March, 2006, in 30 schistosomal patients with no other hepatic findings associated, submitted to abdominal ultrasound. Ultrasonographic studies were independently performed and reviewed by two radiologists at three different moments: the dynamic examination itself (first moment), 30 and 90 days later (second and third moments), by means of the images review performed in a workstation. Intra- and interobserver agreement was evaluated by means of the kappa test. RESULTS: Intraobserver agreement was 0.43 for the first, and 0.57 for the second observer. Interobserver agreement as regards the dynamic examination and images review was respectively 0.46 and 0.71. CONCLUSION: Ultrasonography demonstrated moderate to substantial reproducibility in the classification of periportal fibrosis according to the Niamey criteria.

Avaliação da concordância entre ressonância magnética de ultra-sonografia na classificação de fibrose periportal em esquitossomóticos, segundo a classificação de Niamey / Agreement between magnetic resonance imaging and ultrasonography in the classification of schistosomal periportal fibrosis, according to Niamey's criteria

OBJETIVO: Avaliar a reprodutibilidade da ressonância magnética e a concordância entre a ultra-sonografia e a ressonância magnética na classificação da fibrose periportal em pacientes esquistossomóticos, segundo os critérios qualitativos de Niamey. MATERIAIS E MÉTODOS: Foi realizado estudo prospectivo e duplo-cego, entre fevereiro de 2005 e junho de 2006, em 20 pacientes (10 homens e 10 mulheres, idades entre 24 e 60 anos, média de 42,75 anos) com diagnóstico de esquistossomose mansônica. As imagens de ultra-sonografia e de ressonância magnética foram avaliadas por dois examinadores experientes de forma independente. Foi medida a concordância interobservador para a ressonância magnética e entre a ressonância magnética e a ultra-sonografia. RESULTADOS: A ressonância magnética apresentou resultados concordantes entre os observadores em 14 pacientes (70 por cento). Quando comparamos a ressonância magnética com a ultra-sonografia, obtivemos concordância em apenas seis pacientes pelo observador 1 (30 por cento) e em oito pacientes pelo observador 2 (40 por cento). CONCLUSÃO: A ressonância magnética tem boa reprodutibilidade na avaliação de fibrose periportal em pacientes com esquistossomose avançada, porém sua concordância com a ultra-sonografia é fraca.

OBJECTIVE: To evaluate the reproducibility of magnetic resonance imaging and the agreement between ultrasound and magnetic resonance imaging in the classification of periportal fibrosis in patients with schistosomiasis based on Niamey's qualitative criteria. MATERIALS AND METHODS: A prospective, double-blinded study was conducted between February 2005 and June 2006 with 20 patients (10 men and 10 women, with ages ranging between 24 and 60 years, mean age 42.7 years) diagnosed with schistosomiasis mansoni. Both ultrasound and magnetic resonance images were independently evaluated by two experienced observers. Interobserver agreement was evaluated for findings of periportal fibrosis on magnetic resonance images and in a comparison between magnetic resonance and ultrasound images. RESULTS: The analysis of magnetic resonance images showed total interobserver agreement in 14 patients (70 percent). The comparison between ultrasound and magnetic resonance imaging showed agreement between images in only six cases (30 percent) by observer 1, and in eight cases (40 percent) by observer 2. CONCLUSION: Magnetic resonance imaging presents a good reproducibility in the evaluation of periportal fibrosis in later stages of schistosomiasis, however, the correlation between magnetic resonance imaging and ultrasound is poor.

Complicações especificas em pós-operatórios de cirurgia de Nissen por via laparoscópica: ensaio iconográfico / Specific complications after laparoscopic Nissen fundoplicaton: iconographic essay

O objetivo do presente estudo é demonstrar, por meio de radiografias contrastadas, os aspectos de imagem de complicações específicas da cirurgia de Nissen realizada por via laparoscópica. Foram selecionados pacientes do setor de radiologia contrastada de um hospital universitário. Os pacientes foram submetidos a seriografias esôfago-estômago-duodeno, realizadas por residentes e sob a supervisão de um mesmo médico radiologista com experiência em trato digestivo. O tempo de pós-operatório e os sintomas apresentados eram variáveis. Apresentamos as seguintes imagens radiológicas descritas no pós-operatório de cirurgia de Nissen por via laparoscópica: formação de pseudotumor, estômago em ampulheta, migração da válvula e recidiva da hérnia. A fundoplicatura de Nissen é o tratamento cirúrgico mais utilizado para a doença do refluxo gastroesofágico. Diversas complicações têm sido observadas no pós-operatório desta cirurgia, podendo estar relacionadasou não a sintomas específicos. Os radiologistas devem estar familiarizados com o aspecto dessas complicações e aptos a reconhecê-las através da radiografia contrastada, método já consagrado na demonstração dessas alterações.

The purpose of this study is to demonstrate, through radiographicbarium swallow upper tract studies, radiographic aspect of specific complications of laparoscopic Nissen fundoplication. We selected patients from the radiology section of a university hospital. The patients underwent esophagus-stomach-duodenum seriographies. The examinations were conducted by residents under the supervision of a radiologist with experience in digestive tract. Time between surgery and examination and the patients' symptoms were variable. We present radiographic images described in patients after Nissen fundoplication: pseudo-tumor formation, hourglass stomach, migration of the wrap and recurrent hernia. Nissenfundoplication is the most used surgical treatment in the gastroesophagicreflux disease. Many complications have been reported after the surgery. They may be or may not be related to specificsymptoms. Radiologist should be familiar with the image aspect of these complications and should be able to recognize them using an upper gastrointestinal tract study.

Prevalência e fatores associados à bacteremia nos portadores de colecistite aguda litiásica / Bacteremia - prevalence and associated factors in patients with acute calculous cholecystitis

OBJETIVO: Determinar a prevalência de bacteremia e os fatores associados no período pré-operatório em portadores de colecistite aguda litiásica e analisar comparativamente as complicações e mortalidade nos pacientes com e sem bacteremia, que foram submetidos a colecistectomia de urgência. MÉTDODOS: Foram estudados, prospectivamente, 51 pacientes com diagnóstico histopatológico de colecistite aguda litiásica. O sistema Bactec foi o método utilizado para a detecção de bacteremia. As médias dos grupos foram analisadas quanto às variáveis clínicas e laboratoriais, relacionando-as com a bacteremia. RESULTADOS: A prevalência de bacteremia no pré-operatório foi de 15,68 por cento, e a idade (p=0,024), a freqüência cardíaca (p=0,026), a freqüência respiratória (p=0,028), a creatinina (p=0,028) e a presença da SIRS (Síndrome da Resposta Inflamatória Sistêmica, p=0,016) associaram-se positivamente com a bacteremia. Nos portadores de bacteremia verificou-se um óbito, maior número de complicações gerais (p=0,045) e infecciosas (p=0,039) e maior tempo de internação (p<0,005). CONCLUSAO: Nessa amostra, utilizando-se o sistema Bactec, a prevalência de bacteremia foi considerável. Fatores clínicos e laboratoriais estão associados à bacteremia e a sua presença associa-se à maior gravidade dos pacientes e pior prognóstico em relação às complicações no pós-operatório nos portadores de colecistite aguda litiásica.