The use of synthetic mesh in contaminated and infected abdominal wall repairs: challenging the dogma-A long-term prospective clinical trial.

BACKGROUND: Abdominal wall reconstruction in patients presenting with enteric fistulas and mesh infection is challenging. There is a consensus that synthetic mesh must be avoided in infected operations, and the alternatives to using synthetic mesh, such as component separation techniques and biologic mesh, present disappointing results with expressive wound infection and hernia recurrence rates. METHODS: A prospective clinical trial designed to evaluate the short- and long-term outcomes of 40 patients submitted to elective abdominal wall repair with synthetic mesh in the dirty-infected setting, and compared to a cohort of 40 patients submitted to clean ventral hernia repairs. Patients in both groups were submitted to a single-staged repair using onlay polypropylene mesh reinforcement. RESULTS: Groups' characteristics were similar. There were 13 (32.5%) surgical site occurrences in the infected mesh (IM) group, compared to 11 (27.5%) in the clean-control (CC) group, p = 0.626. The 30-day surgical site infection rate was 15% for the IM group vs. 10% for the CC cases, p = 0.499. One patient required a complete mesh removal in each group. The mean overall follow-up was 50.2 ± 14.8 months, with 36 patients in the IM group and 38 clean-controls completing a follow-up of 36 months. There was one hernia recurrence (4.2%) in the IM group and no recurrences in the CC group. CONCLUSION: We demonstrated that using polypropylene mesh in the infected setting presented similar outcomes to clean repairs. The use of synthetic mesh in the onlay position resulted in a safe and durable abdominal wall reconstruction. TRIAL REGISTRATION: Study registered at Plataforma Brasil (plataformabrasil.saude.gov.br), CAAE 30836614.7.0000.0068. Study registered at Clinical Trials (clinicaltrials.gov), Identifier NCT03702153.

A retrospective review and observations over a 16-year clinical experience on the surgical treatment of chronic mesh infection. What about replacing a synthetic mesh on the infected surgical field?

PURPOSE: To review the short- and long-term results in patients who underwent removal of infected or exposed mesh and reconstruction of the abdominal wall with simultaneous mesh replacement. METHODS: Patients undergoing removal of an infected or exposed mesh and single-staged reconstruction of the abdominal wall with synthetic mesh replacement over a 16-year period were retrospectively reviewed from a prospectively maintained database. Patients were operated and followed by a single surgeon. Outcome measures included wound complications and hernia recurrence. RESULTS: From 1996 until 2012, 41 patients (23 F, 18 M), with a mean age of 53.4 years and mean BMI of 31.2 ± 8 kg/m(2), were treated for chronic mesh infection (CMI). A suppurative infection was present in 27 patients, and 14 had an exposed mesh. The need for recurrent incisional hernia repair was observed in 25 patients; bowel resections or other potentially contaminated procedures were associated in 15 patients. The short-term results showed an uneventful post-operative course after mesh replacement in 27 patients; 6 (14.6%) patients developed a minor wound infection and were treated with dressings and antibiotics; 5 (12%) patients had wound infections requiring debridement and one required complete mesh removal. On the long-term follow-up, there were three hernia recurrences, one of which demanded a reoperation for enterocutaneous fistula; 95% of the patients submitted to mesh replacement were considered cured of CMI after a mean follow-up of 74 months. CONCLUSIONS: CMI can be treated by removal of infected mesh; simultaneous mesh replacement prevents hernia recurrence and has an acceptable incidence of post-operative acute infection. Standard polypropylene mesh is a suitable material to be used in the infected surgical field as an onlay graft.

Penetrating cardiac wounds: predictive value of trauma indices and the necessity of terminology standardization.

The authors evaluated the usefulness of different trauma indices in the prediction of outcome following penetrating cardiac wounds. Sixty-three patients were retrospectively reviewed. Age, mechanism of injury, Physiologic Index (PI) on admission, site of injury, associated injuries, ISS, RTS, Penetrating Cardiac Trauma Index (PCTI), Penetrating Thoracic Trauma Index (PTTI), Penetrating Trauma Index (PTI), TRISS and mortality rate were reviewed. There were 34 patients with a gunshot wound (GSW) and 29 with a stab wound (SW). Shock was present on admission in 88.9 per cent. Mortality was 83 per cent for GSW, 44 per cent for SW, and 39 per cent for patients arriving the hospital with measurable blood pressure. RTS, PI, PCTI, PTTI, PTI, and ISS reached statistical significance when comparing survivors and nonsurvivors. The probability of survival (PS) based on the TRISS methodology was 37.84 +/- 5.14. The observed survival rate was 38 per cent. Fourteen patients were considered "fatal" on admission and underwent an emergency thoracothomy. Mortality rate for this selected group was 100 per cent. We conclude that physiologic impairment, shock, and GSW are variables with high significance on mortality. Trauma indices such as PI, RTS, PCTI, PTTI, PTI, and ISS are good predictors of outcome. Trauma indices are an important tool to objectively compare results among different institutions.

Severely injured patients in the intensive care unit: a critical analysis of outcome and unexpected deaths identified by the TRISS methodology.

An analysis of the factors related to the morbidity and mortality of 64 patients sustaining abdominal trauma requiring intensive care during the postoperative period, and an evaluation of the unexpected deaths based on trauma indices was carried out to identify factors that could have contributed to the observed outcome. Head and chest injuries occurred in approximately 40% of all patients. Pneumonia was the most common complication. ISS (p = 0.03), but not TS was statistically significant as predictor of outcome. Probability of survival (TRISS) was 62.4 +/- 4.2%, while observed overall survival rate was 54.7%. Multivariate analysis identified age greater than 45 years (p = 0.02; RR = 2.5) and ISS greater than 20 (p = 0.03; RR = 4.0) as the most predictive factors for systemic complications. Mortality was directly influenced by age greater than 45 years (p = 0.05; RR = 2.4) and by the presence of a systemic complication (p = 0.003; RR = 5.5). Eleven patients were classified as "unexpected death"; 5 were considered preventable, 3 non preventable, 1 potentially preventable, and 2 cases had incomplete data and could not be classified. Changes in the care of the severely injured due to a review of complications and deaths may ultimately lead to a reduction in errors and a better quality of care.

Colonic (splenic flexure) necrosis due to thrombosis of the middle colic artery following blunt abdominal trauma.

We report an unusual case of a 28-year-old man who developed a colonic necrosis due to thrombosis of the middle colic artery 18 hours following blunt abdominal trauma. Although rare, this condition can occur in those patients whom non surgical treatment was initially performed.

Ostomy or intestinal anastomosis in cases of peritonitis.

Twenty-six patients showing peritonitis due to nontraumatic acute abdomen were submitted to ostomy. Mean age was 51 years (range 25-83), being 13 males and 13 females. Bowel obstruction (BO) was the most frequent cause of peritonitis (11 cases), followed by intestinal perforation (IP) (8 cases), acute mesenteric infarction (AMI) (5 cases), and acute abdomen of inflammatory/infectious origin (AAIO) (2 cases). Brook's ileostomy was performed on 65% of the patients. Jejunostomy was performed only in 4 patients, leading to a bad evolution. Overall mortality was 54%. Primary ostomy or anastomosis in cases of peritonitis constitute a highly controversial theme. Indications and problems involving the intestinal exteriorization in emergency surgery urgency are herein discussed.

[Use of transhepatic drainage in repair of the main bile duct]. / Emprego da drenagem trans-hepática na restaur da via biliar principal.

The transhepatic intubation to treat and minimize recurrent stricture after hepaticojejunostomy is analysed. This method was used in seven patients. Three of them had a malignant biliary stricture and four had bile duct injury during cholecystectomy. In four occasions the reconstruction of right and left hepatic ducts were done separately. In two the anastomosis with the jejunum was performed with the left hepatic duct and ducts of medial and lateral segments of right hepatic lobe and in two hepaticojejunostomy was performed. The transhepatic tube was maintained for three to ten months. The patients with malignant disease died after ten days, 35 days and nine months. In the four patients with benign disease, two had an excellent response. One did not and in one the follow up is short to assess the final result. The advantages and disadvantages of transhepatic intubation are discussed.

[Esophagogastric acute injury caused by a chemical agent]. / Lesão aguda esôfago--gástrica causada por agente químico.

UNLABELLED: Treatment of chemical agent ingestion remain controversial. The incidence of these episodes has increased over the several last decades due to a variety reasons. PURPOSE: To analyze the occurrence, complications and results of the treatment of chemically induced esophagogastric injury. METHODS: Twenty-one adult patients with chemically induced esophagogastric injury were retrospectively studied. The patients were admitted up to 23 days after ingestion of a chemical agent to the Emergency Department of Santa Casa of Sao Paulo University Hospital from August, in a 12-year period. The mean age was 32.1 years. Eleven patients were of the female gender, which attempted suicide. Soda was the most ingested agent (76.2%), muriatic acid was present in three cases (14.3%) followed by one case of sulfur acid and another one of ammonia (4.8% each). RESULTS: Injuries of the Larynx and Pharynx were frequently associated with those of the esophagus, accounting for 18 cases (85.7%). Esophageal, gastric and duodenal injuries were assessed and classified according to endoscopic features. Five cases each of severe esophageal or gastric lesions were present. CONCLUSION: Treatment and outcome varied and suggested placement of esophageal tube to be harmful. Global mortality rate was 28.6% with the highest rate related to esophageal injuries of the third degree.

[Inferior vena cava trauma: analysis of 36 cases]. / Traumatismo de veia cava inferior: análise de 36 casos.

The authors analysed 36 trauma patients with inferior vena cava injuries to evaluate different surgical approaches, as well as, important aspects related to morbidity and mortality. Gunshot wounds were the most frequent cause of inferior vena cava injuries and 55% of the patients had circulatory instability on admission. Retrohepatic inferior vena cava was frequently injured in association with liver injury. From those 20 unstable patients on admission, there were 17 deaths, and injury was in the retrohepatic portion of the inferior vena cava in 9, and in the supradiaphragmatic portion in 3. These data support the concept that site of injury and hemodynamic status on admission are the principal factors related to morbidity and mortality in inferior vena cava injuries.

[Esophageal injury due to pill ingestion]. / Lesão esofágica provocada por ingestão de pílula.

In recent years, many case reports concerning esophageal injuries caused by drugs have been published. The primary cause has apparently been the delay in passage and the adherence of the caustic drugs on the esophageal mucosa. The authors report a case of esophageal ulceration caused by an analgesic in a 26-year-old male with no esophageal symptoms. A review of the literature shows that a variety of medications have been implicated; size, shape and improper ingestion of pills affect esophageal transit.

Mesh cancer: long-term mesh infection leading to squamous-cell carcinoma of the abdominal wall.

PURPOSE: It is recognized that chronic inflammation can cause cancer. Even though most of the available synthetic meshes are considered non-carcinogenic, the inflammatory response to an infected mesh plays a constant aggression to the skin. Chronic mesh infection is frequently the result of misuse of mesh, and due to the challenging nature of this condition, patients usually suffer for years until the infected mesh is removed by surgical excision. METHODS: We report two cases of squamous-cell carcinoma (SCC) of the abdominal wall, arising in patients with long-term mesh infection. RESULTS: In both patients, the degeneration of mesh infection into SCC was presumably caused by the long-term inflammation secondary to infection. Patients presented with advanced SCC behaving just like the Marjolin's ulcers of burns. Radical surgical excision was the treatment of choice. The involvement of the bowel played an additional challenge in case 1, but it was possible to resect the tumor and the involved bowel and reconstruct the abdominal wall using polypropylene mesh as onlay reinforcement, in a single stage operation. He is now under adjuvant chemotherapy. The big gap in the midline after tumor resection in case 2 required mesh bridging to close the defect. The poor prognosis of case 2 who died months after the operation, and the involvement of the armpit, groin and mesenteric nodes in case 1 shows how aggressive this disease can be. CONCLUSION: Infected mesh must be treated early, by complete excision of the mesh. Long-standing mesh infection can degenerate into aggressive squamous-cell carcinoma of the skin.

A computerized tomography scan method for calculating the hernia sac and abdominal cavity volume in complex large incisional hernia with loss of domain.

Preoperative progressive pneumoperitoneum (PPP) is a safe and effective procedure in the treatment of large incisional hernia (size > 10 cm in width or length) with loss of domain (LIHLD). There is no consensus in the literature on the amount of gas that must be insufflated in a PPP program or even how long it should be maintained. We describe a technique for calculating the hernia sac volume (HSV) and abdominal cavity volume (ACV) based on abdominal computerized tomography (ACT) scanning that eliminates the need for subjective criteria for inclusion in a PPP program and shows the amount of gas that must be insufflated into the abdominal cavity in the PPP program. Our technique is indicated for all patients with large or recurrent incisional hernias evaluated by a senior surgeon with suspected LIHLD. We reviewed our experience from 2001 to 2008 of 23 consecutive hernia surgical procedures of LIHLD undergoing preoperative evaluation with CT scanning and PPP. An ACT was required in all patients with suspected LIHLD in order to determine HSV and ACV. The PPP was performed only if the volume ratio HSV/ACV (VR = HSV/ACV) was >or=25% (VR >or= 25%). We have performed this procedure on 23 patients, with a mean age of 55.6 years (range 31-83). There were 16 women and 7 men with an average age of 55.6 years (range 31-83), and a mean BMI of 38.5 kg/m(2) (range 23-55.2). Almost all patients (21 of 23 patients-91.30%) were overweight; 43.5% (10 patients) were severely obese (obese class III). The mean calculated volumes for ACV and HSV were 9,410 ml (range 6,060-19,230 ml) and 4,500 ml (range 1,850-6,600 ml), respectively. The PPP is performed by permanent catheter placed in a minor surgical procedure. The total amount of CO(2) insufflated ranged from 2,000 to 7,000 ml (mean 4,000 ml). Patients required a mean of 10 PPP sessions (range 4-18) to achieve the desired volume of gas (that is the same volume that was calculated for the hernia sac). Since PPP sessions were performed once a day, 4-18 days were needed for preoperative preparation with PPP. The mean VR was 36% (ranged from 26 to 73%). We conclude that ACT provides objective data for volume calculation of both hernia sac and abdominal cavity and also for estimation of the volume of gas that should be insufflated into the abdominal cavity in PPP.

Emergency department thoracotomy.

The emergency department thoracotomy as a ressuscitative measure is a controversial subject in trauma surgery. Indiscriminate indication has occurred due to unclearness upon the real value of this procedure, but further critical evaluation has reduced initial enthusiasm rather emphasizing a more rational approach by systematization of criteria for selective indication. Clinical outcome is related to injury mechanism and patients conditions upon admission. According to vital signs the patients conditions are classified as fatal, agonic and shock; survival rates oscillate between 0 to 40%. This study presents a review of the literature discussing indications, technical aspects, complications and clinical outcome of emergency department thoracotomy in trauma patients.

Factors related to the occurrence of postoperative complications following penetrating gastric injuries.

The aim of this study was to determine the relationship between diaphragmatic injury and gross contamination of the peritoneal cavity caused by gastric injuries and the occurrence of postoperative complications, especially those related to the pleural cavity. Charts of 73 patients sustaining gastric injuries due to penetrating trauma were retrospectively reviewed. There were 66 males and mean age was 28 years. Stab wounds were the most frequent mechanism of injury, occurring in 46 cases. Most of the injuries were treated using simple suture and minor debridement. Postoperative morbidity rate was 30 per cent and thoracic complications occurred in 11 patients. Twenty-six patients had diaphragmatic injuries; 54 per cent of them developed postoperative complications. Of the remaining 47 patients without diaphragmatic injuries, only eight developed complications. Of the 26 patients with diaphragmatic injuries, seven developed pleuropulmonary complications compared with 4 of 47 without diaphragmatic injury. Of sixteen patients who had gross contamination secondary to gastric injury, characterized by the presence of food or great amounts of gastric contents in the peritoneal cavity, 10 developed postoperative complications compared with 12 of 57 without gross contamination. Overall mortality rate was 11 per cent mostly due to sepsis. In conclusion, the presence of a diaphragmatic injury as well as gross contamination of the abdominal cavity are important factors related to the development of postoperative infections particularly in the pleural space.

The role of associated injuries on outcome of blunt trauma patients sustaining pelvic fractures.

In order to identify the prognostic factors and to evaluate the impact of associated injuries in the outcome of patients with pelvic fractures, a retrospective review of the medical records of patients admitted with a pelvic fracture during a 42-month period was carried out. Demographic data, the mechanism of injury, the physiologic status on admission, associated injuries, pelvic fracture classification, complications and mortality were analysed. One hundred and three patients were included in the study. Fifty-nine were male, and the mean age was 34. The mean Revised Trauma Score (RTS) and Injury Severity Score (ISS) were 7.1 and 20, respectively. Pedestrian vs vehicle (59%), was the most frequent mechanism of injury. Twenty patients died (19%) most frequently due to "shock". Complications developed in 37 patients (36%), pneumonia being the most frequent. Age greater than 40 years (p=0.02), "shock" upon admission (p=0.002), a Glasgow Coma Scale (GCS)<9, Head AIS>2 (p<0. 001), Chest AIS>2 (p=0.007), and abdominal AIS>2 (p=0.03) all correlated with increased mortality. No correlation between pelvic fracture classification or fracture stability with mortality was observed. The outcome of patients with pelvic fractures due to blunt trauma correlates with the severity of associated injuries and physiological derangement on admission rather than with characteristics of or the type of fracture.

[Gastrin changes in the gastric antrum G-cells and in serum gastrin levels after 80% jejunoileal resection in rats]. / Alterações da gastrina nas células G do antro gástrico e da gastrinemia após ressecção de 80% de jejunoíleo rem ratos.

A study was made of the changes in the cell population producing gastrin of the gastric antrum in rats submitted to resection of 80% of jejunum-ileum. Ninety days after surgery, the animals were killed after a 12 hour nightly fast and the gastric antrum was removed with the objective of specific histological preparations (PAP method) in order to count the G-cells and the blood was taken for serum doses of gastrin. An optical microscope was used to count the cells using a histometric integraded ocular of 42 points and the counting of 10 fields of each histological cut, and the radioimmunoassay method of double antibody was used for the seric dosing of gastrin. Histometry showed a significant drop in the G-cell population of the antrum of enterectomized animals when compared to the control group. Average percentage of G-cells found were 17.55% in the control group and 7.99% in the enterectomized ones. Blood dosing of hormone showed a significant increase of gastrin in the enterectomized animals when compared to controls. Average value of gastrin dosing the control group was 110 Pg/ml and 170 Pg/ml in enterectomized animals. Therefore, the present study permits to conclude that after resection of 80% of jejunum-ileum, there was a decrease in the G-cell population with gastrin in the gastric antrum even in the presence of increased serum gastrin.

Trauma in pregnant women: analysis of maternal and fetal mortality.

Twenty-seven traumatised pregnant women were analysed retrospectively over a period of 9 years. Mean age was 23.7 years (16-42 years). Gestational age ranged from 10 to 40 weeks (mean, 21.5 weeks), with most victims (46.1%) being in the second trimester. The predominant mechanism (65.3%) was blunt abdominal injury due to an automobile accident (the patient being run over or collision). At admission, 8 (30.7%) patients had haemodynamic alterations. 6 patients (23.0%) presented vaginal bleeding and 4 of these were haemodynamically normal. We analysed maternal mortality, fetal mortality and their causes. We also compared the median RTS and TRISS values for the groups with maternal-fetal survival and the group with maternal-fetal death. Fetal death occurred in all pregnant women admitted with vaginal bleeding. Maternal mortality due to haemorrhagic shock was 11.5%. Fetal mortality was 30.7%, with 37.5% of these deaths being caused by maternal death. The major cause of fetal mortality was a detached placenta (50.0%). The trauma indices, RTS and TRISS, were significantly lower (p = 0.0025 and p < 0.0001) in the group of maternal-fetal death but they were not of prognostic value in terms of fetal mortality.