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.

Encapsulating peritoneal sclerosis post liver transplant and peritoneal dialysis: case report and literature review.

Encapsulating peritoneal sclerosis (EPS) is a rare and debilitating condition. A fibrocollagenous membrane, which promotes encasement of the small intestine leaving a cocoon-like appearance, takes place. It is mainly associated with peritoneal infections, medications, peritoneal dialysis and systemic inflammatory diseases. Diagnosis is based on clinical history, intestinal obstruction and imaging exam. We report a case of EPS in a 68-year-old man with a medical history of liver transplantation and peritoneal dialysis, complaining of obstructive bowel symptoms.

Outcomes of Emergency Groin Hernia Repair in the Elderly: A Systematic Review.

Introduction: The number of surgeries for groin hernia (GH) among the elderly follows the increase in life expectancy of the population. The greater number and severity of comorbidities in this group increases the surgical risk, promoting discussion regarding the indication of elective surgery and the benefits of watchful waiting approach (WWA). The aim of the present study was to evaluate the outcomes of emergency hernia surgery among the elderly population. Materials and methods: A systematic review was performed in Pubmed and Scielo databases for the past early 10 years, until July 2022. The subject was groin hernia in the emergency setting focusing the elderly population. The PRISMA statement was followed and the classification of elderly was based on the World Health Organization's definition. Results: A total of 1,037 results were returned and we ended with nine original articles with emphasis in groin hernia in the emergency among the elderly population. In these subjects, the complications rate ranged between 21.2% and 28.9% and the mortality rate ranged between 1.2% and 6%. Cardiopulmonary disease, high ASA and Charlson's scales were associated with greater risk of complications and death. Conclusion: Emergency GH surgery in the elderly population carries an increased risk of complications and mortality. GH surgery is safe or, at least, less harmful when done electively. The risk and benefits of WWA and upfront surgery needs to be assessed and exposed to the patients. Our review sugest that elective surgery should be the option over WWA in this patient population.

Gallbladder agenesis a rare and underdiagnosed congenital anomaly: a case report and literature review.

Gallbladder agenesis (GA) is a rare congenital anomaly with conflicting epidemiology described in the literature. When present, it is misinterpreted as cholelitiasis, a highly prevalent condition. Nevertheless, surgeons and radiologists must be aware of it since it can lead to unnecessary invasive procedures. Diagnosis of GA is challenging due to the anatomical structures that sometimes resemble a shrunken gallbladder. We report the case of a 55-year-old man with preoperative diagnosis of cholelitiasis and further intraoperative find of GA. Since cholecystectomy is one of the most common surgeries worldwide, it demonstrates how relevant this case is to emphasize the need to recognize this diagnosis and be aware of its management to avoid unnecessary surgery.

Gastric adenocarcinoma in the excluded stomach 18 years after bariatric surgery: a case report.

Gastric cancer (GC) ranks fourth in overall cancer mortality. Bariatric surgical procedures, especially the gastric bypass surgery (GBS), raise a concern about the risk of GC in the excluded stomach (ES). Diagnosis of GC in the ES is challenging due to anatomical changes and impossibility of endoscopic access to the ES. There are few reports of GC after GBS, and it occurs more in the gastric stump than in the ES. We report a case of a 54-year-old female with GC in the ES 18 years after GBS. The increasing number of GBS and the aggressiveness of the GC show how relevant this case is to emphasize the need to consider this diagnosis in patients who develop upper abdominal symptoms, anemia or weight loss.

Inguinal hernia in southern Brazil - challenges in follow-up and recurrence rates.

INTRODUCTION: recurrence rates for primary hernia repair range from 0.5 to 15 percent depending upon the hernia site, type of repair, and clinical circumstances. Many risk factors are known and they must be considered before the procedure. In developing countries, follow up and maintenance of databases are critical to understand the real numbers. METHODS: a retrospective cohort study analyzed adult patients who have undergone inguinal hernia repair at Hospital de Clínicas de Porto Alegre, a tertiary care government public hospital, between 2013 and 2015. Medical records, telephone, and letter contact have been reviewed in order to complete the minimum period of 5 years of follow-up. The analyzed data focused on the surgeon's experience and the recurrence rate in 5 years of follow-up. RESULTS: a total of 1094 medical records were selected and a complete five years follow-up were possible in 454 patients - 538 inguinal hernia repairs due to bilateral approach in 84 patients. These 454 patients answered, in a validated questionnaire about symptoms of recurrence. The total recurrence rate was 9.29%. For the patients who had Nyhus IV, recurrence rate was 24.1% against 9.9% after primary hernia repair, with a 2.4 higher risk. There was no difference in recurrence between surgeons and training surgeons. CONCLUSION: our data reveal an acceptable recurrence rate in a tertiary care hospital with residents, and to our knowledge is the first Brazilian report with long term follow up. An increased re-recurrent hernia was found when compared with primary hernia repair.

Mesenteric venous thrombosis in a pregnant woman at first trimester gestation: a case report.

Mesenteric vein thrombosis (MVT) in a pregnant patient is a rare condition that seems to be associated with the pregnancy pró-thrombotic state. This can lead to severe circumstances such as intestinal hemorrhagic ischemia, sepsis, abortion and death. Abdominal assessment is challenging due to the anatomical and physiological changes during pregnancy. MVT clinical and complementary evaluation are nonspecific, making essential an image exam. We report a case of a 33-years-old woman at 11 weeks of gestation. She sought medical evaluation due to abdominal pain and had an appendicitis diagnosis, which was treated by laparoscopic surgery. One week later, she came back complaining of nonspecific abdominal pain. So an extensive evaluation was made, and the diagnosis of MVT and intestinal ischemia was concluded. She underwent laparotomy exploration and anticoagulation, having a good evolution and so was discharged on the sixth post-operative day.

Pneumatosis cystoides intestinalis with pneumoperitoneum in an 87-years-old male patient: a case report.

Pneumatosis cystoides intestinalis (PCI) is a rare condition, characterized by gas-filled cysts in the intestinal wall. The mesentery and intra-abdominal ligaments can be affected. PCI is classified as primary or secondary and associated with multiple predisposing factors. An asymptomatic 87-year-old man underwent an abdominal tomography for follow-up of bladder carcinoma. The examination revealed intestinal and mesenteric pneumatosis associated with pneumoperitoneum. At laparoscopy, intestinal and mesenteric pneumatosis without intestinal infarction was identified. He was discharged on the fifth postoperative day. PCI is a benign condition that can be confused with mesenteric ischemia. Treatment is conservative, with periodic clinical evaluations. Surgical procedure is unnecessary for its diagnosis or management.

Severe hepatopulmonary syndrome with hypoxemia refractory to liver transplant: Recovery after 67 days of ECMO support.

Hepatopulmonary syndrome (HPS) is a complication of end stage liver disease (ESLD) and is manifested by severe hypoxemia, which usually responds to liver transplantation (LT). As compared to patients undergoing LT for other etiologies, patients with HPS present an increased risk of postoperative morbidity and mortality. There is no effective treatment for patients whose hypoxemia does not respond to LT. This subset of patients is at a highly increased risk of death. There are very few reports on the use of extracorporeal membrane oxygenation (ECMO) in this setting with rapid response. However, there is no prior report of ECMO utilization for longer than 4 weeks. We present the case of a 17 year-old male patient who underwent LT for ESLD secondary to chronic portal vein thrombosis and HPS. He received a liver from a deceased donor and presented with severe HPS after LT, requiring ECMO support for 67 days. The patient was discharged home and is breathing in ambient air. He is currently asymptomatic and has a normal liver function.

Inguinal hernia in southern Brazil - challenges in follow-up and recurrence rates / Hérnia inguinal no Sul do Brasil - desafios no seguimento e taxas de recorrência

ABSTRACT Introduction: recurrence rates for primary hernia repair range from 0.5 to 15 percent depending upon the hernia site, type of repair, and clinical circumstances. Many risk factors are known and they must be considered before the procedure. In developing countries, follow up and maintenance of databases are critical to understand the real numbers. Methods: a retrospective cohort study analyzed adult patients who have undergone inguinal hernia repair at Hospital de Clínicas de Porto Alegre, a tertiary care government public hospital, between 2013 and 2015. Medical records, telephone, and letter contact have been reviewed in order to complete the minimum period of 5 years of follow-up. The analyzed data focused on the surgeon's experience and the recurrence rate in 5 years of follow-up. Results: a total of 1094 medical records were selected and a complete five years follow-up were possible in 454 patients - 538 inguinal hernia repairs due to bilateral approach in 84 patients. These 454 patients answered, in a validated questionnaire about symptoms of recurrence. The total recurrence rate was 9.29%. For the patients who had Nyhus IV, recurrence rate was 24.1% against 9.9% after primary hernia repair, with a 2.4 higher risk. There was no difference in recurrence between surgeons and training surgeons. Conclusion: our data reveal an acceptable recurrence rate in a tertiary care hospital with residents, and to our knowledge is the first Brazilian report with long term follow up. An increased re-recurrent hernia was found when compared with primary hernia repair.

RESUMO Introdução: a recorrência da hérnia inguinal após hernioplastia varia de 0,5 a 15 por cento, dependendo do local da hérnia, tipo de reparo e circunstâncias clínicas. Muitos fatores de risco são conhecidos e devem ser considerados antes do procedimento. Acompanhamento e adequado bancos de dados são fundamentais para entender a incidência de recidiva. Métodos: estudo de coorte retrospectivo analisou hernioplastias inguinais realizados no Hospital de Clínicas de Porto Alegre entre 2013 e 2015. Para concluir 5 anos de seguimento, analisamos o prontuário e fizemos contato telefônico e por correio. Resultados: o total de 1094 registros médicos foram selecionados e um seguimento de pelo menos 5 anos foi possível em 454 pacientes - 538 reparos de hérnia inguinal devido à abordagem bilateral em 84 pacientes. Os pacientes responderam um questionário validado sobre sintomas de recorrência. A taxa total de recorrência foi de 9,29%. No grupo masculino, a recorrência foi de 10% contra 4% no grupo feminino. Para os pacientes com hérnia Nyhus IV, a recidiva foi de 24% contra 8% após o reparo da hérnia primária, com um risco de 2,8 maior. Não houve diferença na recorrência entre cirurgiões experientes e em treinamento. Conclusão: nossos dados revelam uma taxa de recorrência aceitável em um hospital de ensino, e para o nosso conhecimento é o primeiro artigo com acompanhamento de longo prazo no sul do Brasil. A re-recidiva da hérnia foi maior quando comparada com o reparo da hérnia primária.

Retroperitoneal fetus in fetu in a 65-year-old man

Fetus in fetu (FIF) is a rare congenital anomaly in which a malformed fetus is incorporated within the body of its twin. It was first described in the late 18th century and has an incidence of 1:500,000 live births. In most cases, the diagnosis is made in infants or young adults. To date, the oldest patient reported in the literature was 47 years old. We describe the case of a 65-year-old patient with FIF, now the oldest reported in the literature. Our patient meets all the diagnostic criteria for FIF, including the presence of a limb in advanced formation inside the lesion. The treatment was surgical excision. FIF should be considered in the differential diagnosis of abdominal masses, typically recognized in infancy. Symptoms arise from mass effects. Surgical resection should be performed due to the potential for malignant transformation.

Biliary tract melanoma metastasis mimicking hilar cholangiocarcinoma: a case report.

Malignant melanoma is the 19th leading cause of cancer worldwide. It is an aggressive neoplastic disease in which pathophysiological understanding and management has been in constant evolution in recent decades. The primary site is the skin, uvea and mucous membranes and has the capacity to metastasize to any organ. There are few reports of primary or secondary involvement of the biliary tract. We present the case of a 73-year-old woman with a bile duct lesion suggestive of cholangiocarcinoma and a final diagnosis of a single melanoma metastasis. Surgical treatment was performed due to oligometastatic stage IV melanoma with possibility of R0 resection followed by immune checkpoint therapy.

The impact of COVID-19 and social avoidance in urgent and emergency surgeries - will a delay in diagnosis result in perioperative complications?

OBJECTIVE: The sudden COVID-19 outbreak has changed our health system. Physicians had to face the challenge of treating a large number of critically ill patients with a new disease and also maintain the essential healthcare services functioning properly. To prevent disease dissemination, authorities instructed people to stay at home and seek medical care only if they experienced respiratory distress. However, there are concerns those patients did not seek necessary health care because of these orientations. This study aims to see how the pandemic has influenced the severity of the disease, complication, and mortality of patients undergoing emergency cholecystectomy and appendectomy. METHODS: Retrospective review of medical records of patients admitted to the emergency department and undergoing to cholecystectomy and appendicectomy in the periods from March to May 2019 and 2020. RESULTS: We observed that COVID-19 did not change the severity of presentation or the outcome of patients with gallbladder disease, but caused a 24.2% increase in the prevalence of complicated appendicitis (p<0.05). However, disagreeing with what was expected, we did not identify a greater number of perioperative complications in patients undergoing an appendectomy. CONCLUSION: Therefore, it seems that in a university tertiary referral center COVID-19 did not influence the management and outcome of inflammatory diseases treated in the surgical emergency department.

Complex abdominal wall reconstruction after massive resection due to neoplastic invasion: a case report.

Complex reconstructions of the abdominal wall, necessary after resection of neoplasms, infection or trauma, are a challenge for the surgical team. Although ovarian carcinoma is commonly presented with peritoneal carcinomatosis and invasion of adjacent organs, it rarely can invade the abdominal wall. Invasion of the abdominal wall was documented on ultrasound and abdominal computed tomography. Surgery was discussed and performed in a multidisciplinary team and consisted of wide en bloc excision and reconstruction with open intraperitoneal onlay mesh with inorganic polypropylene-coated mesh (Bard/BD Sepramesh), a midweight macroporous mesh and abdominoplasty. Postoperative course was uneventful and the patient showed good evolution 1 year after the procedure. Our report highlights the main objectives in complex reconstructions, the importance of a multidisciplinary team and discusses the characteristics that the mesh must have in order to achieve the desired goal.

Wandering spleen as a cause of sinistral portal hypertension

Wandering spleen (WS) is a rare entity characterized by laxity of peritoneal ligaments that hold the spleen stationary. It is most commonly diagnosed in children and young women. Clinical presentation ranges from asymptomatic to acute abdomen. A 19-year-old woman came to the emergency department with history of progressive abdominal pain. She also had previous episodes of hematemesis. A computed tomography scan showed an ectopic spleen with a "whirlpool sign." Laparotomy and splenectomy were performed. WS is characterized by a long vascular pedicle and laxity of peritoneal attachments of the spleen. The etiology is usually congenital. Splenopexy is the main treatment; however, splenectomy is indicated when splenic infarction is present. Despite being rare, this condition may be considered in some cases of abdominal pain. An earlier diagnosis would have allowed us to perform a splenopexy, thus reducing morbidity. (AU)