Hartmann's reversal as a safe procedure for selected patients: analysis of 199 patients at a high-volume center in Sao Paulo.

PURPOSE: We analyzed the morbidity and mortality associated with Hartmann's reversal (HR) and the risk factors for major complications and mortality. METHODS: The subjects of this retrospective study were patients who underwent HR in a high-volume center. We evaluated complications as categorical variables using univariate analyses. RESULTS: Between 2003 and 2018, 199 patients underwent HR at our hospital [56.5 years; body mass index (BMI): 26.3 kg/m2; American Society of Anesthesiology score (ASA) 3: 7.5%; 36.2% had hernias]. The mean time to HR was 20.2 months and the mean operation time was 302 min. The anastomosis was stapled in 71.4% and was performed in the low/medium rectum in 21.6%. Midline hernias were repaired with mesh in 80.1%. The mean hospitalization period was 10.1 days. Surgical site infection (SSI) developed in 27.1% of the patients, 94.4% of whom were treated at the bedside. BMI was a risk factor for SSI (27.8 vs. 25.6; p = 0.047). Major complications (Clavien-Dindo III-V) developed in 27 patients (13.5%), including anastomosis dehiscence in 2.5%. ASA, BMI, age, hernia repair, and rectal stump size were not associated with major complications. The mortality rate was 2.5%. An ASA of 3 was associated with high mortality (p = 0.03). CONCLUSION: Hartmann's reversal remains challenging but can have low complication and mortality rates if performed on selected patients in a reference center. An ASA of 3 was the only predictor of mortality.

Popliteal lymph node dissection for metastases of cutaneous malignant melanoma.

Popliteal lymph node dissection is performed when grossly metastatic nodal disease is encountered in the popliteal fossa or after microscopic metastasis is found in interval sentinel nodes during clinical staging of cutaneous malignant melanoma. Initially, an S-shaped incision is made to gain access to the popliteal fossa. A careful en bloc removal of fat tissue and lymph nodes is made to preserve and avoid the injury of peroneal and tibial nerves as well as popliteal vessels, following the previous recommendations. This rare surgical procedure was successfully employed in a patient with cutaneous malignant melanoma and nodal metastases at the popliteal fossa. The technique described by Karakousis was reproduced in a step-by-step fashion to allow anatomical identification of the neurovascular structures and radical resection with no post-operative morbidity and prompt recovery. Popliteal lymph node dissection is a rarely performed operative procedure. Following a lymphoscintigraphic examination of the popliteal nodal station, surgeons can be asked to explore the popliteal fossa. Detailed familiarity of the operative procedure is necessary, however, to avoid complications.

Effect of low-dose gaseous ozone on pathogenic bacteria.

BACKGROUND: Treatment of chronically infected wounds is a challenge, and bacterial environmental contamination is a growing issue in infection control. Ozone may have a role in these situations. The objective of this study was to determine whether a low dose of gaseous ozone/oxygen mixture eliminates pathogenic bacteria cultivated in Petri dishes. METHODS: A pilot study with 6 bacterial strains was made using different concentrations of ozone in an ozone-oxygen mixture to determine a minimally effective dose that completely eliminated bacterial growth. The small and apparently bactericidal gaseous dose of 20 µg/mL ozone/oxygen (1:99) mixture, applied for 5 min under atmospheric pressure was selected. In the 2nd phase, eight bacterial strains with well characterized resistance patterns were evaluated in vitro using agar-blood in adapted Petri dishes (105 bacteria/dish). The cultures were divided into 3 groups: 1--ozone-oxygen gaseous mixture containing 20 µg of O(3)/mL for 5 min; 2--100% oxygen for 5 min; 3--baseline: no gas was used. RESULTS: The selected ozone dose was applied to the following eight strains: Escherichia coli, oxacillin-resistant Staphylococcus aureus, oxacillin-susceptible Staphylococcus aureus, vancomycin-resistant Enterococcus faecalis, extended-spectrum beta-lactamase-producing Klebsiella pneumoniae, carbapenem-resistant Acinetobacter baumannii, Acinetobacter baumannii susceptible only to carbapenems, and Pseudomonas aeruginosa susceptible to imipenem and meropenem. All isolates were completely inhibited by the ozone-oxygen mixture while growth occurred in the other 2 groups. CONCLUSION: A single topical application by nebulization of a low ozone dose completely inhibited the growth of all potentially pathogenic bacterial strains with known resistance to antimicrobial agents.

EUS-guided biliary drainage: a review article.

CONTEXT: To demonstrate a comprehensive review of published articles regarding EUS-guided biliary drainage. METHODS: Review of studies regarding EUS-guided biliary drainage including case reports, case series and previous reviews. RESULTS: EUS-guided hepaticogastrostomy, choledochoduodenostomy and choledochoantrostomy are advanced procedures on biliary and pancreatic endoscopy and together make up the echo-guided biliary drainage. Hepaticogastrostomy is indicated in cases of hilar obstruction, while the procedure of choice is choledochoduodenostomy in distal lesions. Both procedures must be done only after unsuccessful ERCP. The indication of these procedures must be made under a multidisciplinary view while sharing information with the patient or legal guardian. CONCLUSION: Hepaticogastrostomy and choledochoduodenostomy are feasible when performed by endoscopists with expertise in biliopancreatic endoscopy and advanced echo-endoscopy and should be performed currently under rigorous protocol in educational institutions.

Whole-body computerized tomography and concomitant spine and head injuries: a study of 355 cases.

The authors present a prospective study on the coexistence of spinal injury (SI) and severe traumatic brain injury (TBI) in patients who were involved in traffic accidents and arrived at the Emergency Department of Hospital das Clinicas of the University of Sao Paulo between September 1, 2003 and December 31, 2009. A whole-body computed tomography was the diagnostic method employed in all cases. Both lesions were observed simultaneously in 69 cases (19.4%), predominantly in males (57 individuals, 82.6%). Cranial injuries included epidural hematoma, acute subdural hematoma, brain contusion, ventricular hemorrhage and traumatic subarachnoid hemorrhage. The transverse processes were the most fragile portion of the vertebrae and were more susceptible to fractures. The seventh cervical vertebra was the most commonly affected segment, with 24 cases (34.78%). The distribution of fractures was similar among the other cervical vertebrae, the first four thoracic vertebrae and the lumbar spine. Neurological deficit secondary to SI was detected in eight individuals (11.59%) and two individuals (2.89%) died. Traumatic subarachnoid hemorrhage was the most common intracranial finding (82.6%). Spinal surgery was necessary in 24 patients (34.78%) and brain surgery in 18 (26%). Four patients (5.79%) underwent cranial and spinal surgeries. The authors conclude that it is necessary a judicious assessment of the entire spine of individuals who presented in coma after suffering a brain injury associated to multisystemic trauma and whole-body CT scan may play a major role in this scenario.

Extrahepatic anterograde covered self-expandable metallic stent placement across malignant biliary obstruction passed by endoscopic ultrasound guidance access: a challenging technique.

The authors report the case of a female patient submitted to endoscopic cholangiography intending to drain the biliary tree due to jaundice. The patient had gastrointestinal deviation due to an advanced gastric cancer that evolved with a distal extrahepatic mass. Abdominal CT scan demonstrated a distal mass, extrahepatic biliary dilation and a normal intra-hepatic tree. In this condition and after a multidisciplinary discussion, an endoscopic ultrasound guided extrahepatic access with the deployment of a partially covered self-expandable metallic stent was performed. The patient normalized her bilirubin levels after a successful procedure.

Splenic Abscesses in Endocarditis: A Rare Disease with High Mortality. The Experience of a Heart Institute in Brazil.

INTRODUCTION: Splenic abscess secondary to endocarditis is a rare complication with high mortality. The treatment modality, splenectomy versus percutaneous drainage, and the best time, before or after valve replacement, are controversial. In the literature, there are only a few small case series about the subject. The objective of this study is to analyze the experience of a referral center in treating such condition. METHODS: Patients with splenic abscesses due to endocarditis from 2006 to 2020 were retrospectively analyzed. RESULTS: Thirteen patients (mean age 46 years old, 69% male) were identified. Eight patients (62%) had at least 2 comorbidities and 5 (38%) had a history of cardiac surgery. The diagnosis was incidental in 6 (46%). The mean time of abscess diagnosis after endocarditis definition was 14 days. Six patients (46%) had at least two organ dysfunctions. The median APACHE II score was 12 overall, and 24.5 in patients who died. Six patients (46%) had a valve replacement, and in two the abscess was diagnosed postoperatively. Of the other four patients, splenectomy was performed before the cardiac operation in three and at the same time in one. Splenectomy was performed immediately in 9 (69%) patients while three patients had percutaneous drainage (23%), one of which underwent splenectomy due to drainage failure. Exclusive antibiotic treatment was performed on only one patient. The median length of hospitalization was 24 days and mortality was 46%. CONCLUSION: Splenic abscess due to endocarditis is a life-threatening condition with controversial treatment that results in a prolonged length of stay and high mortality.

EUS-guided antegrade transhepatic placement of a self-expandable metal stent in hepatico-jejunal anastomosis.

CONTEXT: To demonstrate an EUS-guided biliary drainage in patient with gastrointestinal tract modified surgically. CASE REPORT: An EUS guided access to the left intra hepatic duct, followed by an antegrade passage of a partially self-expandable metal stent that was removed by using an enteroscope, in one patient with hepatico-jejunal anastomosis. There were no early or delayed complications and the procedure was effective in relieving jaundice until the self-expandable metal stent was removed, 3 months later. A cholangiogram was obtained via enteroscopy, after removal of self-expandable metal stent, and found to be normal. The patient had an uneventful evaluation afterwards. CONCLUSION: The indication of these procedures must be made under a multidisciplinary view while sharing information with the patient or legal guardian. EUS-guided biliary drainage is feasible when performed by professionals with expertise in biliopancreatic endoscopy and advanced echo-endoscopy and should be performed currently under rigorous protocol in educational institutions.

Endoscopy Ultra- Sonography -guided biliary drainage in the surgical -endoscopy era.

BACKGROUND: US-guided hepatico - gastrostomy, choledocho-duodenostomy and choledocho-antrostomy are advanced procedures on biliary and pancreatic endoscopy and together make up the echo-guided biliary drainage. Hepatico - gastrostomy is indicated in cases of hiliar obstruction, while the procedure of choice is choledocho - duodenostomy in distal lesions. Both procedures must be done only after unsuccessful ERCP. AIMS: To clarify to the readers about indication of these procedures, they must be made under a multidisciplinary view while sharing information with the patient or legal guardian. METHODS: All series cases report and selected cohort studies were selected according to the DDTS system in which key words were EUS biliary drainage, choledocho-duodenostomy, hepatico-gastrostomy, EUS, palliation and pancreatic biliary advanced cancer. RESULTS: Separately it was stated definition on the EUS biliary drainage procedures and it includes the techniques details and critical analysis. CONCLUSION: Hepatico- gastrostomy and Choledocho- duodenostomy are feasible when performed by endoscopists with expertise in bilio pancreatic endoscopy and advanced echo-endoscopy and should be performed currently under rigorous protocol in educational institutions.

Surgical education in Brazil.

BACKGROUND: The surgical residency was implemented in Brazil in 1944. Gradually, several programs were created under the auspices of the National Committee of Medical Residency (Comissão Nacional de Residência). A candidate for a residency program is submitted to a selection process in various institutions. One of the greatest obstacles to medical education in Brazil is that the number of graduate students is much larger than the number of available vacancies. As a consequence, they end up looking for other alternatives to their professional training, and these cannot offer the same results as a formal residency. Regarding the current residency program in surgery, Brazil has roughly 200 general surgery programs, which offer 1,040 vacancies yearly. METHOD AND RESULTS: The surgical residency program lasts 2 years with rotation in various surgical specialties, which is a requirement for the following years in specific specialties. The 1,040 who are enrolled in the first 2 years of a residency in surgery take a new examination to continue their training. Here, there are only 573 vacancies; therefore, 45% of the newly trained surgeons start a practice or become apprentices. The 573 residents who move on to further education then pass 2 years in basic general surgery at an institution and continue in the same or are transferred to another department. The next training period should be 2 or 3 years, depending on the specialty. The General Surgery program lasts 4 years: two initial basic years and two more years of training in elective, emergency, and trauma surgery and intensive care. The objective is to become competent in the diagnosis and treatment of the most common diseases that affect the community. CONCLUSIONS: Medical entities in specialties have their own selection process to grant the title of specialist. The Brazilian College of Surgeons (Colégio Brasileiro de Cirurgiões) is responsible for granting the title "general surgeon," following the model of the American Board of Surgery.

Continuous peritoneal lavage with vacuum peritoneostomy: an experimental study.

OBJECTIVE: Despite advances in diffuse peritonitis treatment protocols, some cases develop unfavorably. With the advent of vacuum therapy, the use of laparostomy to treat peritonitis has gained traction. Another treatment modality is continuous peritoneal lavage. However, maintaining this technique is difficult and has been associated with controversial results. We propose a new model of continuous peritoneal lavage that takes advantage of the features and benefits of vacuum laparostomy. METHOD: Pigs (Landrace and Large White) under general anesthesia were submitted to laparostomy through which a multiperforated tube was placed along each flank and exteriorized in the left and lower right quadrants. A vacuum dressing was applied, and intermittent negative pressure was maintained. Peritoneal dialysis solution (PDS) was then infused through the tubes for 36 hours. The stability of peritoneostomy with intermittent infusion of fluids, the system resistance to obstruction and leakage, water balance, hemodynamic and biochemical parameters were evaluated. Fluid disposition in the abdominal cavity was analyzed through CT. RESULTS: Even when negative pressure was not applied, the dressing maintained the integrity of the system, and there were no leaks or blockage of the catheters during the procedure. The aspirated volume by vacuum laparostomy was similar to the infused volume (9073.5±1496.35 mL versus 10165±235.73 mL, p=0.25), and there were no major changes in hemodynamic or biochemical analysis. According to CT images, 60 ml/kg PDS was sufficient to occupy all intra-abdominal spaces. CONCLUSION: Continuous peritoneal lavage with negative pressure proved to be technically possible and may be an option in the treatment of diffuse peritonitis.

Hypertonic saline and pentoxifylline enhance survival, reducing apoptosis and oxidative stress in a rat model of strangulated closed loop small bowel obstruction.

OBJECTIVES: Intestinal obstruction has a high mortality rate when therapeutic treatment is delayed. Resuscitation in intestinal obstruction requires a large volume of fluid, and fluid combinations have been studied. Therefore, we evaluated the effects of hypertonic saline solution (HS) with pentoxifylline (PTX) on apoptosis, oxidative stress and survival rate. METHODS: Wistar rats were subjected to intestinal obstruction and ischemia through a closed loop ligation of the terminal ileum and its vessels. After 24 hours, the necrotic bowel segment was resected, and the animals were randomized into four groups according to the following resuscitation strategies: Ringer's lactate solution (RL) (RL-32 ml/kg); RL+PTX (25 mg/kg); HS+PTX (HS, 7.5%, 4 ml/kg), and no resuscitation (IO-intestinal obstruction and ischemia). Euthanasia was performed 3 hours after resuscitation to obtain kidney and intestine samples. A malondialdehyde (MDA) assay was performed to evaluate oxidative stress, and histochemical analyses (terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling [TUNEL], Bcl-2 and Bax) were conducted to evaluate kidney apoptosis. Survival was analyzed with another series of animals that were observed for 15 days. RESULTS: PTX in combination with RL or HS reduced the MDA levels (nmol/mg of protein), as follows: kidney IO=0.42; RL=0.49; RL+PTX=0.31; HS+PTX=0.34 (p<0.05); intestine: IO=0.42; RL=0.48; RL+PTX=0.29; HS+PTX=0.26 (p<0.05). The number of labeled cells for TUNEL and Bax was lower in the HS+PTX group than in the other groups (p<0.05). The Bax/Bcl-2 ratio was lower in the HS+PTX group than in the other groups (p<0.05). The survival rate on the 15th day was higher in the HS+PTX group (77%) than in the RL+PTX group (11%). CONCLUSION: PTX in combination with HS enhanced survival and attenuated oxidative stress and apoptosis. However, when combined with RL, PTX did not reduce apoptosis or mortality.

Morbimortality indicators in severe acute pancreatitis.

OBJECTIVE: The aim of this study was to determine the factors related to the development of systemic complications, mortality and pancreatic necrosis in patients with severe acute pancreatitis. PATIENTS: Thirty-nine patients (22.3%) out of 175 patients with acute pancreatitis who were admitted to our center, had an APACHE II score greater than 8; they were classified as having severe acute pancreatitis and were evaluated in the study. MAIN OUTCOME MEASURES: Sepsis-related Organ Failure Assessment (SOFA) and Marshall scores were obtained. The variables analyzed were age, sex, etiology, hematocrit, leukocyte count, CRP level, CT findings and length of hospital stay. These variables were related to the development of systemic complications, mortality and necrotizing pancreatitis. RESULTS: The mean APACHE II value of the patients included was 11.6+/-3.1, the mean SOFA score was 3.2+/-2.0 and the Marshall score was 1.5+/-1.9. Eleven patients developed necrotizing pancreatitis. The mortality rate among severe acute pancreatitis patients was 3 out of 39 (7.7%). Variables found to be related to systemic complications were the APACHE II score as well as SOFA and Marshall scores greater than 3. The variables related to mortality were SOFA score greater than 3 and leukocytosis greater than 19,000 mm(-3). CRP greater than 19.5 mg/dL and length of hospital stay were related to necrotizing pancreatitis. CONCLUSIONS: The scoring systems, especially the SOFA score, were related to the development of systemic complications and mortality. CRP showed a relationship to necrotizing pancreatitis. There was no relationship between the evaluated scoring systems and necrotizing pancreatitis in patients with severe acute pancreatitis.

Profile of the General Surgery resident: what are the changes in the 21 st Century?

OBJECTIVE: to verify the profile of the General Surgery residents of the Clinics Hospital (HC) of the Faculty of Medicine of the University of São Paulo (FMUSP). METHODS: we evaluated the residents approved in the public contest for the Medical Residency Program in General Surgery of HC-FMUSP in the years 2014, 2015 and 2016. We carried out the study by applying a questionnaire and gathering information from the Medical Residency Commission of the Institution. We analyzed data on identification, origin of the candidate, undergraduate school, surgical teaching received, reason for choosing Surgery, residency expectations, choice of future specialty and pretensions as to the end of medical residency. We also analyzed the result of the examination of access to specialties. RESULTS: the mean age was 25.8 years; 74.3% of residents were male. The majority (84.4%) had attended public medical schools, 68% of which were not in the Southeast region; 85,2% of the residents were approved in the first contest. The specialty choice was present for 75.9% of individuals at the beginning of the residency program, but 49.5% changed their minds during training. Plastic Surgery, Urology and Digestive System Surgery were chosen by 61.5%. Sixty hours per week work were considered adequate by 83.3%; 27.3% favored direct access to the specialty. At the end of the specialty, 53.3% intended to continue in São Paulo, and 26.2%, to return to their State of origin. A strict-sense post-graduate course was intended by 68.3%. CONCLUSION: the current profile of the resident reveals a reduction in the demand for General Surgery, an earlier definition of the specialty, options for increasingly specific areas and an activity that offers a better quality of life.

[Hemodynamic and respiratory changes caused by CO2 laparoscopy in an experimental model of diaphragmatic injury]. / Repercussões respiratórias e hemodinâmicas do pneumoperitônio na lesão do diafragma--estudo experimental.

OBJECTIVE: The objective of this study was to analyze the hemodynamic and respiratory changes caused by CO2 laparoscopy in an experimental model of diaphragmatic injury. METHODS: Fifteen animals chosen at random were submitted to diaphragmatic injury by means of CO2 laparoscopy. Evaluation consisted of drawing blood samples to analyze blood gases, as well as the hemodynamic and respiratory variables. RESULTS: Alterations occurred in APA, CPP, PAO2, ASO2, VSO2. CONCLUSION: We concluded that videolaparoscopy with pneumoperitoneum pressure under 15 mmHg is a safe procedure in patients with diaphragmatic injuries because this pressure level does not cause hemodynamic changes, such as decrease of the cardiac output.

Management of infected pancreatic necrosis: state of the art.

Pancreatic necrosis occurs in 15% of acute pancreatitis. The presence of infection is the most important factor in the evolution of pancreatitis. The diagnosis of infection is still challenging. Mortality in infected necrosis is 20%; in the presence of organic dysfunction, mortality reaches 60%. In the last three decades, there has been a real revolution in the treatment of infected pancreatic necrosis. However, the challenges persist and there are many unsolved questions: antibiotic treatment alone, tomography-guided percutaneous drainage, endoscopic drainage, video-assisted extraperitoneal debridement, extraperitoneal access, open necrosectomy? A step up approach has been proposed, beginning with less invasive procedures and reserving the operative intervention for patients in which the previous procedure did not solve the problem definitively. Indication and timing of the intervention should be determined by the clinical course. Ideally, the intervention should be done only after the fourth week of evolution, when it is observed a better delimitation of necrosis. Treatment should be individualized. There is no procedure that should be the first and best option for all patients. The objective of this work is to critically review the current state of the art of the treatment of infected pancreatic necrosis.

Pancreatic Necrosis and Gas in the Retroperitoneum: Treatment with Antibiotics Alone.

OBJECTIVE:: To present our experience in the management of patients with infected pancreatic necrosis without drainage. METHODS:: The records of patients with pancreatic necrosis admitted to our facility from 2011 to 2015 were retrospectively reviewed. RESULTS:: We identified 61 patients with pancreatic necrosis. Six patients with pancreatic necrosis and gas in the retroperitoneum were treated exclusively with clinical support without any type of drainage. Only 2 patients had an APACHE II score >8. The first computed tomography scan revealed the presence of gas in 5 patients. The Balthazar computed tomography severity index score was >9 in 5 of the 6 patients. All patients were treated with antibiotics for at least 3 weeks. Blood cultures were positive in only 2 patients. Parenteral nutrition was not used in these patients. The length of hospital stay exceeded three weeks for 5 patients; 3 patients had to be readmitted. A cholecystectomy was performed after necrosis was completely resolved; pancreatitis recurred in 2 patients before the operation. No patients died. CONCLUSIONS:: In selected patients, infected pancreatic necrosis (gas in the retroperitoneum) can be treated without percutaneous drainage or any additional surgical intervention. Intervention procedures should be performed for patients who exhibit clinical and laboratory deterioration.

Unintentionally retained foreign bodies after surgical procedures. Analysis of 4547 cases.

OBJECTIVE: this study aims to explore the experience of Brazilian surgeons on Unintentionally Retained Foreign Bodies (RFB) after surgical procedures. METHODS: A questionnaire was sent to surgeons by electronic mail, between March and July 2012. The questions analyzed their experience with foreign bodies (FB), foreign bodies' types, clinical manifestations, diagnoses, risk factors and legal implications. RESULTS: in the 2872 eligible questionnaires, 43% of the surgeons asserted that they had already left FB and 73% had removed FB in one or more occasions, totalizing 4547. Of these foreign bodies, 90% were textiles, 78% were discovered in the first year and 14% remained asymptomatic. Among doctors with less than five years after graduation, 36% had already left a FB. The most frequently surgical procedures mentioned were the elective (57%) and routine (85%) ones. Emergency (26%), lack of counting (25%) and inadequate conditions of work contributed (12.5%) to the occurrence. In 46% of the cases patients were alerted about the FB, and 26% of them sued the doctors or the institution. CONCLUSIONS: challenging medical situations, omission of security protocols and inadequate work conditions contributed to RFB. However, RFB occurs mostly in routine procedures such as cesarean or cholecystectomy, and at the beginning of the professional career, highlighting, particularly in poorest countries, the need for primary prevention. Textiles predominated causing clinical repercussions and they were diagnosed in the first postoperative months. Surgeons were sued in 11.3% of the RFB cases.

Active Staphylococcus aureus infection: Is it a contra-indication to the repair of complex hernias with synthetic mesh? A prospective observational study on the outcomes of synthetic mesh replacement, in patients with chronic mesh infection caused by Staphylococcus aureus.

INTRODUCTION: The management of chronic mesh infection is challenging and controversial. The use of synthetic material to repair the abdominal wall in the infected setting is not recommended, especially in the presence of active infection caused by Staphylococcus aureus. METHODS: This is a prospective observational study designed to evaluate the outcomes in patients with active mesh infection caused by Staphylococcus aureus. Patients underwent simultaneous removal and replacement of polypropylene mesh. The treatment protocol included the complete removal of infected mesh, followed by the anatomical reconstruction, and reinforcement of the abdominal wall using a new onlay polypropylene mesh. Early and late wound complications, medical complications, and hernia recurrences were analyzed. RESULTS: From 2006 until 2014, 22 patients with a mean age of 57.2 years and mean BMI of 29,3 kg/m2 were studied. Sinuses were present in 21 patients. A recurrent ventral hernia was observed in 14 patients; two patients required a complex abdominal wall reconstruction due to enteric fistulas. Bowel resections or other potentially contaminated procedures were associated in 10 patients. Fourteen patients (63.6%) had an uneventful postoperative course; 5 (22.7%) patients had wound infections requiring debridement and three required partial (2) or total (1) mesh removal. Two patients died due to medical complications. Adverse results on long-term follow-up included one hernia recurrence after complete mesh removal and one persistent sinus after partial mesh removal requiring a reoperation to remove mesh remnants. All of the patients were considered free of infection after a mean follow-up of 44 months. CONCLUSIONS: Synthetic mesh replacement in patients with active Staphylococcus aureus infection has an acceptable incidence of postoperative wound infection and prevents hernia recurrence. Large-pore polypropylene mesh is a suitable material to be used in the infected surgical field as an onlay graft.

Ischemic preconditioning modifies mortality and inflammatory response.

PURPOSE: To evaluate the effect of ischemic preconditioning on mortality, inflammatory mediators and oxidative stress after intestinal ischemia and reperfusion. METHODS: Male Wistar rats were allocated according to the period of ischemia with or without ischemic preconditioning which consist on clamping the superior mesenteric artery for 10 minutes followed by reperfusion for 10 minutes before the sustained ischemia period. Mortality was assessed in Phase 1 study, and the CINC-1, CINC-2 and MDA levels in the lungs were analyzed in Phase 2. RESULTS: Mortality was lower in the ischemic preconditioning group subjected to 90 minutes of ischemia compared to the group without ischemic preconditioning (I-90: 50% and IPC-90: 15%, p=0.018), and it was lower in the ischemic preconditioning group as a whole compared to the groups without ischemic preconditioning (IPC-14% and I=30%, p=0.006). Lower levels of MDA, CINC-1, and CINC-2 were observed in the animals that were subjected to ischemic preconditioning compared to the animals that were not (MDA: I-45=1.23 nmol/mg protein, and IPC-45=0.62 nmol/mg protein, p=0.0333; CINC-1: I-45=0.82 ng/mL and IPC-45=0.67 ng/mL, p=0.041; CINC-2: I-45=0.52 ng/mL and IPC-45=0.35 ng/mL, p=0.032). CONCLUSION: Ischemic preconditioning reduces mortality, inflammatory process and oxidative stress in rats subjected to intestinal ischemia and reperfusion.