A simple modification of the conventional figure-of-eight sternal closure technique

Abstract Objective: To describe a new technique of sternal closure, modified from the conventional figure-of-eight approach, which can provide a secure closure and prevent sternal complications. Methods: The modified technique is based on the intercalation of the caudal portion of each steel wire passed along the sternum. This is a retrospective analysis of patients operated with this modified technique at our institution between January 2014 and December 2016. Results: One hundred and forty-three patients underwent sternal closure with the modified technique. In-hospital mortality rate was 1.4% (n=2). No sternal instability was observed at 30 days postoperatively. Two patients developed mediastinitis that required extraction of the wires. Conclusion: Short-term results have shown that the modified sternal closure technique can be used safely and effectively, with complications rates being consistent with worldwide experience.

Aniridia after blunt trauma and presumed wound dehiscence in a pseudophakic eye / Aniridia após trauma contuso e deiscência presumida da incisão em um olho pseudofácico

ABSTRACT This was a report about a pseudophakic patient who experienced isolated total aniridia without damage to other intraocular structures following blunt trauma to the eye. This patient had a history of uneventful cataract surgery using a small clear corneal incision (CCI). This 71-year-old male presented at our clinic with glare in his left eye. He reported that he had fallen down while drunk and struck his left eye against a stone on the road 15 days earlier. He had undergone cataract surgery on his left eye nine months before the accident at another eye clinic. Slit-lamp examination showed total aniridia in his left eye, but there was no hyphema or cells in the anterior chamber. The intraocular lens in his left eye was stable, without decentration, dislocation, or zonular dehiscence and remained in an intact capsular bag. Review of the medical records from the surgical clinic at which he had undergone cataract surgery indicated no specific findings for any intraocular structure including the iris. He had previously undergone an uneventful phacoemulsification for his left eye through a 2.2 mm CCI, followed by the implantation of a single piece acrylic intraocular lens inside an intact capsular bag. This report showed that small-sized CCIs can be opened postoperatively by trauma and that this can result in isolated total aniridia without damage to other intraocular structures.

RESUMO Relatamos um paciente com história de cirurgia de catarata sem intercorrências usando uma pequena incisão na córnea clara (CCI), que apresentou aniridia total isolada, sem danos a outras estruturas intraoculares, após trauma contuso no olho. Um homem de 71 anos de idade apresentou-se em nossa clínica referindo brilho no olho esquerdo. Ele relatou que, 15 dias antes, havia caído enquanto estava bêbado e atingiu seu olho esquerdo contra uma pedra na estrada. Ele havia passado por uma cirurgia de catarata no olho esquerdo, nove meses antes do acidente em outro serviço. Exame de lâmpada de fenda mostrou aniridia total de olho esquerdo, sem hifema ou células na câmara anterior. A lente intraocular no olho esquerdo ficou estável, com o saco capsular restante intacto, sem descentralização, luxação ou deiscência zonular. O exame dos registros médicos do serviço em que ele havia se submetido a uma cirurgia de catarata não mostraram relatos específicos a qualquer estrutura intraocular, incluindo a íris. O olho esquerdo fora submetido à facoemulsificação sem complicações, através de um CCI de 2,2 mm, seguido pela implantação de uma lente intraocular acrílica peça única dentro do saco capsular intacto. Este relatório mostra que, mesmo pequenas CCIs podem ser abertas no pós-operatório por trauma e que isso pode resultar em aniridia total isolada, sem danos a outras estruturas intraoculares.

Dehiscencia y evisceración vaginal recidivante: a propósito de un caso / Recurrent vaginal dehiscence and evisceration: a case report

La dehiscencia de la cúpula vaginal, con o sin evisceración, es una complicación rara de la cirugía ginecológica. El principal factor de riesgo es el antecedente de una histerectomía, a lo que se añaden otros factores desencadenantes, entre los que destaca la atrofia vaginal. El diagnóstico de evisceración es fácil, al comprobar salida de material intestinal a través de la vagina, siendo más dificultoso el diagnóstico de dehiscencia, ya que puede acontecer con síntomas banales. El tratamiento supone una urgencia quirúrgica al existir riesgo de lesión intestinal y peritonitis, pudiéndose realizar diferentes vías de abordaje teniendo en cuenta sobre todo la clínica de la paciente y tras comprobar el estado del contenido eviscerado. Presentamos el caso de una paciente con varios factores de riesgo, que presentó dehiscencia de la cúpula vaginal con evisceración de intestino de manera reiterada, y a la que se le practicó tratamiento quirúrgico por diferentes vías de abordaje así como tratamiento médico.

Dehiscence of the vaginal vault with or without evisceration is a rare complication after gynaecological surgery. The main risk factor is a previous hysterectomy, with the addition of other trigger conditions, the most important is vaginal atrophy. The diagnosis of evisceration is easy by confirmation the loosing of intestinal contents through the vagina. Diagnosis of dehiscence is more difficult because its symptoms could be more generic. The treatment is an emergency surgery as there is a risk of intestinal injury and peritonitis. There could be different surgical approaches taking into consideration the patient's clinic symptoms and after checking the state of eviscerated tissues. We expose the case of a patient with several risk factors, who presented dehiscence of the vaginal vault with recurrent bowel evisceration, and who we performed surgical treatment by different approaches and medical treatment.

Traumatic wound dehiscence after corneal keratoplasty / Deiscência de sutura pós-trauma ocular em olhos submetidos a transplante de córnea

ABSTRACTPurpose:To assess patient characteristics, risk factors, outcomes, and the treatment of wound dehiscence (WD) in patients after corneal keratoplasty.Methods:Retrospective chart review of 11 eyes of 11 patients with corneal grafts who underwent repair of WD from January 1, 2004 to December 31, 2012 at Hospital Oftalmologico de Brasilia.Results:Eight (72.7%) patients were men and three were women. Six (54.5%) patients had deep anterior lamellar keratoplasty (DALK) and 5 had penetrating keratoplasty. The mean age at trauma was 31.1 years. The mean time from corneal keratoplasty to WD was 12.82 months (range, 3-33 months). The mean best-corrected visual acuity of patients before trauma was 20/60 (0.48 logMAR) and after final treatment was 20/160 (0.90 logMAR) (P=0.15). In one case, visual acuity decreased to no light perception because of retinal detachment and phthisis bulbi. Accidental blunt trauma and fall were the most common causes of WD.Conclusion:Patients who undergo corneal keratoplasty have a life-long risk of WD. The full-thickness rupture at the graft-host junction in our study suggests that the junction remains vulnerable, even following DALK, and can rupture with trauma. In our series, depending upon the severity of the trauma, postkeratoplastic WD can be associated with a good visual prognosis.

RESUMOObjetivo:Avaliar as características, os fatores de risco, resultados, e tratamento de pacientes que apresentaram deiscência traumática de sutura após transplante de córnea.Métodos:Estudo retrospectivo em que foram avaliados 11 olhos de 11 pacientes submetidos a transplante de córnea e que desenvolveram deiscência de sutura entre janeiro de 2004 e dezembro de 2012 no Hospital Oftalmológico de Brasília.Resultados:Oito (72,7%) pacientes eram homens e três mulheres. Seis (54,5%) pacientes foram submetidos a ceratoplastia lamelar anterior profunda (DALK) e 5 pacientes a ceratoplastia penetrante (PK). A média de idade dos pacientes no momento do trauma era de 31,1 anos. O tempo médio entre o transplante de córnea e a deiscência de sutura foi de 12,82 meses (variando de 3 a 33 meses). A melhor acuidade visual corrigida (AVCC) doa pacientes antes do trauma era de 20/60 (0,48 logMAR), e após o trauma era de 20/160 (0,90 logMAR) (P=0,15). Em um caso, a acuidade visual reduziu para sem percepção luminosa devido a descolamento de retina e posterior atrofia bulbar. O trauma ocular acidental e a queda da própria altura foram as principais causas de deiscência de sutura nos olhos transplantados.Conclusão:Pacientes previamente submetidos a transplante de córnea apresentam um risco prolongado de deiscência de sutura. A ruptura completa na junção doador-receptor no nosso estudo sugere que mesmo após um DALK a junção permanece vulnerável e pode romper com o trauma. Na nossa série, dependendo da severidade do trauma, a deiscência pós-ceratoplastia pode estar associada a um bom prognóstico visual.

Rotura e deiscência de cicatriz uterina: estudo de casos em uma maternidade de baixo risco do sudeste brasileiro / Rupture and dehiscence of uterine scar: cases study at a low-risk maternity in the Brazilian Southeast

OBJETIVO: Analisar os casos de rotura uterina e deiscência de cicatriz uterina ocorridos em uma maternidade de baixo risco e apontar possibilidades de aprimoramento na abordagem dessas complicações. MÉTODOS: Foi realizado um estudo descritivo em uma maternidade de baixo risco com 30 leitos, que presta assistência às usuárias do sistema público de saúde. A investigação foi realizada por meio de busca dos casos em livros de registros de sala de parto e posterior leitura dos prontuários para coleta dos dados. As informações foram inseridas em formulário previamente elaborado para este estudo. Foram incluídos os casos de rotura uterina e deiscência de cicatriz uterina diagnosticados no período de 1998 a 2012, avaliados incidência, aspectos relacionados aos fatores de risco e diagnóstico, associação com o uso de misoprostol e ocitocina e desfechos observados. RESULTADOS: No período mencionado foram registrados 39.206 partos nessa instituição. A cesárea foi a conduta adotada em 10 mil partos, o que equivale a uma taxa de 25,5%. Foram identificados 12 casos de rotura uterina e 16 de deiscência de cicatriz uterina. Os resultados mais relevantes foram a alta mortalidade perinatal associada à rotura uterina e o insucesso no diagnóstico da complicação. Não foi possível demonstrar associações com o uso de misoprostol ou ocitocina. CONCLUSÃO: Os desfechos adversos da rotura uterina podem ser minimizados se esforços forem direcionados para melhorar o desempenho diagnóstico das equipes assistentes. .

PURPOSE: To evaluate the cases of uterine rupture and dehiscence of the uterine scar at a low-risk maternity and to point out possibilities for an improved approach to these complications. METHODS: A descriptive study was conducted at a 30-bed low-risk maternity hospital that provides care to users of the public health system. The investigation was carried out by searching for cases in the delivery room registry book and later reading the medical records in order to obtain the data. The information was inserted on a form previously elaborated for this study. Cases of uterine rupure and dehiscence of the uterine scar diagnosed from 1998 to 2012 were included, with the determination of incidence, aspects related to risk factors and diagnosis, association with the use of misoprostol and oxytocin, and the outcomes observed. RESULTS: A total of 39,206 deliveries were performed in this maternity during the study period, with 12 cases of uterine rupture and 16 cases of dehiscence of uterine scar being observed. The most relevant results were a high perinatal mortality associated with uterine rupture and the unsuccessful diagnosis of this complications. It was not possible to demonstrate an association with the use of misoprostol or oxytocin. CONCLUSION: The adverse outcomes of uterine rupture could be minimized if efforts were directed at improving the diagnostic performance of the assisting teams. .

Post-thoracotomy wound separation (DEHISCENCE): a disturbing complication

OBJECTIVES: We described the treatment of dehiscence of thoracotomy incisions in patients who underwent thoracic surgery in the present study. METHODS: Twenty-four patients with either partial or complete dehiscence of their thoracotomy incisions were included in the study from 2005 to 2010. The patients were evaluated regarding their age, sex, indication for thoracotomy, and surgical approaches. We also described our method of re-closure. RESULTS: The male/female ratio was 17/7. The youngest and oldest patients were 15 and 75 years old, respectively, and the mean age was 43 years. Among the indications for thoracotomy, empyema was the most common reason (determined in eight [33%] patients), followed by vertebral surgery (determined in six [25%] patients). Bacterial growth was detected in the wound site cultures from 13 (54%) patients. For the patients with dehiscence of their thoracotomy incisions, an en block approximation technique with debridement was performed under general or local anesthesia in 16 (66%) and eight (33%) of the cases, respectively. Three patients exhibited an open thorax with dehiscence of the thoracotomy incision. Thoracoplasty was required in two patients. Using this method, successful closure was obtained in 91.7% (n = 22) of the patients with dehiscence of their thoracotomy incisions. CONCLUSION: Dehiscence of the thoracotomy incision is an important complication that causes concern in patients and their thoracic surgeons and strongly affects the success of the surgery. An en block approximation technique with significant debridement that enables removal of the necrotic tissues from the wound site can successfully be applied to patients with dehiscence of their thoracotomy incisions.

Liver cirrhosis on the colonic anastomotic healing in rats / Cirrose hepática na cicatrização de anastomose intestinal em ratos

PURPOSE: To investigate the effects of cirrhosis on colonic anastomosis healing in rats. METHODS: Fifty five Wistar male rats were used (23 in the control group and 32 in the cirrhosis group). On the first day of the procedure, the rats in the cirrhosis group underwent double ligation and folding of the common bile duct to induce liver cirrhosis, and the control rats underwent a laparotomy and intestinal manipulation. On the fourteenth and thirty-fifth days, all of the animals were biochemically assessed for serum aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase, bilirubin, total protein, and albumin and for liver histopathology. On the thirty-fifth day, cirrhosis was confirmed. On the twenty-eighth day, all of the animals were subjected to left colon transection and anastomosis. On the seventh day after the colonic anastomosis, the rats were sacrificed and macroscopically evaluated for dehiscence. The region of the colonic anastomosis was removed and subjected to hydroxyproline content measurement, conventional histology, and the immunohistochemical determination of vascular endothelial growth factor (VEGF) and matrix metalloproteinase type 1 (MMP 1). RESULTS: The biochemical and histopathological examinations confirmed cirrhosis in all of the animals in the cirrhosis group. More deaths occurred after anastomosis in the cirrhosis group (5/25) than in the control group (0/21), and anastomotic dehiscence was more frequent in the cirrhosis group (8/25) than in the control group (0/21). The average hydroxyproline concentration was lower in the cirrhosis group than in the control group. The immunohistochemical studies showed that the average VEGF expression in the cirrhosis group was lower than in the control group, and the average MMP1 expression was higher in the cirrhosis group. CONCLUSION: Hepatic cirrhosis leads to increased mortality and colonic anastomotic dehiscence, an increased distance between the mucosal edges of the anastomosis area, and a lower hydroxyproline concentration in the colonic anastomosis; therefore, these conditions are deleterious to healing.

OBJETIVO: Investigar os efeitos da cirrose hepática na cicatrização de anastomose intestinal em ratos. MÉTODOS: Este estudo avaliou o efeito da cirrose hepática na cicatrização de anastomoses em ratos. 55 ratos Wistar machos foram utilizados (23 controles e 32 no grupo cirrose). No primeiro dia os ratos do grupo cirrose for submetidos à dupla ligadura e enovelamento do ducto hepático comum para indução de cirrose e os ratos controles foram submetidos à laparotomia e manipulação das alças intestinais. No dia 14 e 35, todos os animais foram avaliados bioquimicamente para dosagem sérica da alanina aminotransferase (AST), alanina aminotransferase (ALT), fosfatase alcalina, bilurrubinas, proteínas totais, albumina e histologia do fígado. No dia 35 a cirrose foi confirmada. No dia 28 todos os animais foram submetidos à colectomia esquerda e anastomose. 70 dias após anastomose os ratos foram submetidos à eutanásia e foram avaliados macroscopicamente a procura de deiscência. A região da anastomose colônica foi removida para dosagem de hidroxiprolina, histologia convencional e imunohistoquímica para determinação do fator de crescimento endotelial vascular (VEGF) e metaloproteinase tipo 1 (MMP 1). RESULTADOS: A análise bioquímica e histológica confirmou a cirrose em todos os animais do grupo cirrose. Óbito ocorreu em maior freqüência após a anastomose no grupo cirrose (5/25) se comparado com grupo controle (0/21), e a deiscência da anastomose foi mais freqüente no grupo cirrose (8/25) se comparado com controle (0/21). A concentração média de hidroxiprolina foi menor no grupo cirrose se comparado com grupo controle. A análise imonuhistoquímica mostrou que a expressão VEGF no grupo cirrose foi menor que no grupo controle e a expressão média da MMP1 foi maior no grupo cirrose. CONCLUSÃO: A cirrose hepática leva a aumento de mortalidade e aumento na deiscência de anastomose, aumento na distância entre as pontes mucosas na area da anastomose, menor nível de hidroxiprolina na anastomose colônica e assim pior condição de cicatrização.

Laser in-situ keratomileusis for refractive error following radial keratotomy.

Aim: To evaluate the safety and efficacy of laser in-situ keratomileusis (LASIK) in eyes with residual/induced refractive error following radial keratotomy (RK). Design: Retrospective study. Materials and Methods: A retrospective analysis of data of 18 eyes of 10 patients, who had undergone LASIK for refractive error following RK, was performed. All the patients had undergone RK in both eyes at least one year before LASIK. Parameters like uncorrected visual acuity (UCVA), best-corrected visual acuity (BCVA), contrast sensitivity, glare acuity and corneal parameters were evaluated both preoperatively and postoperatively. Statistical Software: STATA-9.0. Results: The mean UCVA before LASIK was 0.16±0.16 which improved to 0.64 ± 0.22 (P < 0.001) after one year following LASIK. Fourteen eyes (out of 18) had UCVA of ≥ 20/30 on Snellen's acuity chart at one year following LASIK. The mean BCVA before LASIK was 0.75 ± 0.18. This improved to 0.87 ± 0.16 at one year following LASIK. The mean spherical refractive error at the time of LASIK and at one year after the procedure was –5.37 ± 4.83 diopters (D) and –0.22 ± 1.45D, respectively. Only three eyes had a residual spherical refractive error of ≥ 1.0D at one year follow-up. In two eyes, we noted opening up of the RK incisions. No eye developed epithelial in-growth till 1 year after LASIK. Conclusion: LASIK is effective in treating refractive error following RK. However, it carries the risk of flap-related complications like opening up of the previously placed RK incisions and splitting of the corneal flap.

Study on adhesion formation and the healing of colon anastomosis in rats with induced peritoneal sepsis / Estudo da formação de aderências e da cicatrização de anastomoses colônicas em ratos com sepse peritoneal induzida

PURPOSE: To evaluate the effects of abdominal sepsis on adhesion formation and colon anastomosis healing in rats. METHODS: Forty rats were distributed in two groups containing 20 rats each for left colon anastomosis in the presence (Group S) or absence (Group N) of induced sepsis by cecal ligation and puncture. Each group was divided into subgroups for euthanasia on the third (N3 and S3) or seventh (N7 or S7) post-operative day. The amount of adhesions was evaluated and a segment of the colon was removed for histopathologic analysis, bursting strength assessment, hydroxyproline and the determination of tissue collagen. RESULTS: The subjects which underwent cecal ligation and puncture presented a higher amount of intra-abdominal adherences in both third (p=0,00) and seventh (p=0,00) post-operatory days. Smaller bursting strengths were found in the S3 subgroup, and greater bursting strengths were found in the S7 subgroup. There was no difference in the variations on the concentrations of hydroxyproline, tissue collagen and histopathology. CONCLUSIONS: The peritoneal infection which was developed by cecal ligation and puncture raised the amount of intra-cavitary adhesions. There was a decrease in the amount of colonic anastomosis on the third post-operatory day with a following raise on the seventh without any effects on other healing parameters.

OBJETIVO: Avaliar os efeitos da sepse abdominal sobre a formação de aderências e a cicatrização de anastomoses colônicas em ratos. MÉTODOS: 40 ratos distribuídos em dois grupos contendo 20 animais, para anastomose do cólon esquerdo na presença (grupo S) ou ausência (grupo N) de indução de sepse por ligadura e punção do ceco (CLP). Cada grupo foi dividido em subgrupos para eutanásia no terceiro (N3 e S3) ou sétimo (N7 e S7) dia de pós-operatório (DPO). Foi avaliada a quantidade de aderências e removido um segmento colônico contendo a anastomose para análise histopatológica, força de ruptura, hidroxiprolina e conteúdo de colágeno tecidual. RESULTADOS: Os animais submetidos à CLP apresentaram maior quantidade de aderências intra-abdominais tanto no 3° DPO (p=0,00) quanto no 7° DPO (p=0,00). Tiveram menores valores de força de ruptura no 3° DPO (p=0,00), porém maiores valores no 7° DPO (p=0,00). Não houve diferença na variação da concentração de hidroxiprolina, conteúdo de colágeno e histopatologia. CONCLUSÕES: A infecção peritoneal desencadeada por CLP aumentou a quantidade de aderências intra-cavitárias. Houve diminuição da resistência de anastomoses cólicas no 3° DPO, com posterior aumento no 7° DPO, sem efeito sobre os outros parâmetros da cicatrização.

Reasons for removal of bone plates after orthognathic surgery

The aim of this prospective clinical trial was to evaluate the reasons for removal of miniplates from patients who had orthognathic surgery over a 7-year period. Fifty consecutive patients with fixed miniplates following orthognathic surgery [11 males and 39 females] aged 20 to 43 years [mean=28 +/- 6 years] were recruited into this study. Personal information, dental and medical history, type of orthognathic operation, indications for plate removal, placement site of plates and time between insertion and removal were recorded. The site of plate insertion was classified into right, left and anterior maxilla; right, left and anterior mandible; and chin. All plates were inserted and removed intra-orally under local or general anesthesia. The association between the variables was analyzed using the Pearson correlation and Chi-Square test. For all statistical analysis, the significance level was set at P<0.05. 312 titanium miniplates were inserted in 50 patients. A total of 108 plates [34.6%] were removed. The retention period for the removed plates ranged from 4 months to 4.5 years. The most common sites for plate removal were maxilla [22 patients, 44%] followed by mandible [19 patients, 38%]. The most common cause for plate removal was palpable plates [27 patients] followed by infection [13 patients], patient discomfort and preference [7 patients] and plate exposure and wound dehiscence [3 patients]. No significant relationships were found between plate removal [including number and location of removed plates and reason for plate removal] and age and gender [p<0.05]. Reason of plate removal was significantly related to the number of plates [p=0.001, r=0.441] and the location of removed plate [p<0.001, r= 0.62]. Type of removed plate had no significant relation with reason for plate removal [p=0.576, r=-0.081] number of plates [p= 0.62, r= 0.072] and location of removed plates [p= 0.467, r= -0.105]. Reason for performing the orthognathic surgery and type of the orthognathic surgery had no significant relations with the number and location of removed plates and reason for plate removal [p<0.05]. Plate removal was attributed to palpable plates, infection, subjective discomfort and patient preference, and plate exposure and wound dehiscence. Plate-related complications caused plate removal which was more likely to occur within the first year of insertion. This should be accounted for during the process of obtaining informed consent

Línea de sutura de anastómosis intestinales: efecto de la presión ejercida por el volumen intraluminal durante el tránsito intestinal normal: resultados preliminares: biomodelos / Intestinal anastomoses suture line: effects of pressure exerted by the intraluminal volume during the normal bowel transit: preliminary results: bionodels

Demostrar que la ingesta precoz de líquidos por vía oral no produce aumento de la opresión intraluminal sobre la línea de sutura en las anastomosis intestinales y por lo tanto no es causa de dehiscencia de la misma, aunado que este hecho produce una estancia hospitalaría menor del paciente. Un estudio prospectivo con 21 cerdos a quienes se les practicará resección y anastomosis T-T, sometidos a una presión intraluminal de líquidos VIT y VID, con un protocolo de seis cirugías en 18 días y estudio de la anastomosis resecada en microscopia óptica y electrónica. Unidad de Investigación Quirúrgica de la Escuela de Medicina José María Vargas, Facultad de Medicina UCV. La ingesta precoz de alimentos y líquidos no es causa de dehiscencia en anastomosis intestinales con tránsito intestinal normal. Los resultados preliminares de este estudio apuntan a que la ingesta precoz de líquidos no es causa de dehiscencia en anastomosis intestinales.

Demostrate that early fluid intake vía oral produces no increase of pressure intraluminal on the suture line in the intestinal anastomoses, and therefore is not cause of dehiscence of the same, combining this fact produces a smaller hospital stay of the patient. A prospective study with 21 pigs to who they shall resection and under pressure T-T, anastomoses VIT and VID, liquids with a protocol of six surgeries in 18 days intraluminal and study the resected anastomoses in optical microscopy and electronics. Research Surgical Unit of the Escuela de Medicina José María Vargas, Facultad de Medicina UCV: Early lood and fluid intake is nor cause of intestinal anastomoses dehiscence with normal intestinal transit. The preliminary results of this study suggest that early fluid intake is not cause of dehiscence in intestinal anastomoses.

Fatores de risco para deiscência de ferida cirúrgica em receptores de transplante renal / Risk factors for wound dehiscence in kidney transplant recipients

Introdução: As complicações cirúrgicas após o transplante renal são a principal causa de morbidade no período pós-operatório. A deiscência da ferida cirúrgica (FC) aumenta o tempo e o número de internações hospitalares e determina pior evolução a longo prazo do transplante renal. Método: Estudo prospectivo de 582 transplantes renais consecutivos realizados no período de 20/JAN/2005 a 20/DEZ/2005, no Hospital do Rim e Hipertensão. Os pacientes foram acompanhados por 16 a 24 dias no período pós-operatório, para determinar a incidência de deiscência da ferida cirúrgica e o risco atribuído aos seguintes fatores de risco para sua ocorrência: idade do receptor, índice de massa corporal, circunferência abdominal, tipo de doador, tempo de utilização de cateter vesical, diabetes mellitus pré-transplante, tempo de cirurgia, tipo de anastomose ureterovesical e tipo de imunossupressão (análise de regressão logística). Resultados. A incidência de deiscência da FC no período de internação hosar após o transplante foi de 11,6%. O modelo de regressão logística múltipla mostrou que os fatores de risco independentes para o desenvolvimento de deiscência da FC foram a idade do receptor superior a 42 anos (OR 2,7, p<0,05), a presença de diabetes mellitus pré-transplante (OR 2,3, p<0,05), a utilização de rins de doadores falecidos 9OR 2,2, p<0,05) e a utilização de sirolimo nos protocolos imunossupressores (OR 2,9, p<0,05). Conclusões. A incidência de deiscência da FC é elevada após o transplante renal e decorre da presença de fatores de risco prevalentes entre os receptores de transplante renal, sendo o uso de sirolimo o que apresenta o maior risco relativo (OR 2,9, p<0,05).

Introduction: Surgical complications after kidney transplantation are the major cause of morbidity in the postoperative period. The surgical wound dehiscence (HR) increases the time and number of hospitalizations and a poorer long-term outcome of renal transplantation. Method: Prospective study of 582 consecutive kidney transplants performed between the 20/JAN/2005 20/DEZ/2005 in Kidney and Hypertension Hospital. Patients were followed for 16 to 24 days post-operatively to determine the incidence of wound dehiscence and surgical risk attributed to the following risk factors for its occurrence: recipient age, body mass index, waist circumference, type of donor, time of use of bladder catheter, pre-transplant diabetes mellitus, duration of surgery, type of ureterovesical anastomosis and type of immunosuppression (logistic regression analysis). Results. The incidence of FC dehiscence hosar during hospitalization after transplantation was 11.6%. The multiple logistic regression model showed that independent risk factors for the development of FC dehiscence were recipient age above 42 years (OR 2.7, p <0.05), presence of diabetes mellitus pre-transplant (OR 2.3, p <0.05), the use of kidneys from deceased donors 9OR 2.2, p <0.05) and the use of sirolimus in immunosuppressive protocols (OR 2.9, p <0.05) . Conclusions. The incidence of FC dehiscence is high after renal transplantation and results from the presence of risk factors prevalent among renal transplant recipients, and the use of sirolimus that has the highest relative risk (OR 2.9, p <0, 05).

Hemorrhagic shock influence on colonic anastomoses in rats: evaluation of rupture by liquid distension resistance test / Influência do choque hemorrágico na anastomose de cólon em ratos: avaliação com teste de resistência à pressão de ruptura

PURPOSE: To evaluate the effect of hemorrhagic shock in colonic anastomoses in rats, with a rupture by liquid distension resistance test. METHODS: Wistar lineage rats, averaging 90 days old and weighing from 310 to 380 grams were divided into two groups. In the first group (G1), 10 animals were submitted to colonic anastomoses in normovolemic terms and the second group (G2), of 10 animals, was submitted to colonic anastomoses in hypovolemic conditions. The shock was caused by half milliliter of blood withdrawn, every two minutes, until the value of average 50mmHg arterial pressure or a total volume corresponding 30 percent withdrawal of volemia was reached. Serum lactate dosages were carried out at the beginning and end of the procedure. The average serum lactate values at the end of the surgery were 1.91 mmol/l in G1 group and 3.69 mmol/l in G2 group (p<0.05). On the fifth postoperative day, the animals were euthanized. The anastomoses were evaluated with a rupture by liquid distension resistance test. RESULTS: In G1, the average value of colonic rupture was 160.7 mmHg whereas in G2 it was 152.1mmHg (p>0.05). CONCLUSION: Hemorrhagic shock, under the established conditions of this study, had no influence on colonic anastomoses in rats evaluated with the rupture by liquid distention resistance test.

OBJETIVO: Avaliar o efeito do choque hemorrágico em anastomoses de cólon em ratos, com teste de ruptura à distensão por líquido. MÉTODOS: Foram utilizados ratos da linhagem Wistar, com idade aproximada de 90 dias e peso variando de 310 gramas a 380 gramas. Os animais foram divididos em dois grupos, sendo o grupo G1, composto por 10 animais submetidos à anastomose de cólon em condições de normovolemia e o grupo G2, composto por 10 animais submetidos à anastomose de cólon em condições de hipovolemia. O choque foi instalado através da retirada de meio mililitro de sangue a cada dois minutos, até que se atingissem valores de pressão arterial média (PAM) de 50mmHg ou volume total de retirada correspondente a 30 por cento da volemia. Foram realizadas dosagens séricas de lactato (mmol/l) no início do procedimento e ao término do mesmo. Os valores séricos médios de lactato ao término da cirurgia foram de 1,91 mmMol/l no grupo G1 e de 3,69 mmMol/l no grupo G2 (p<0,05) No quinto dia de pós-operatório, os animais foram submetidos à eutanásia e tiveram suas anastomoses testadas por teste de resistência à pressão de ruptura à distensão por líquido. RESULTADOS: No grupo G1, o valor médio da pressão de ruptura do cólon à distensão por líquido foi de 160,7mmHg enquanto que no grupo G2 foi de 152,1mmHg (p>0,05). CONCLUSÃO: A presença de choque hemorrágico, nas condições estabelecidas neste estudo, não exerce influência em anastomoses de cólon em ratos, avaliadas com teste de ruptura à distensão por líquido.

Burst abdomen-A preventable morbidity.

A burst abdomen is considered present, when intestine, omentum or other viscera's were seen in the abdominal wound following obstetric surgery. In our country no study found, but observational incidence in the tertiary hospital varies between 0.2-3%. It occurs mostly between the sixth and eight day after operation. Factors relating to the incidence of burst abdomen are suture, closure, incision, coughing, vomiting, distension, obesity, jaundice, malignancy, diabetes mellitus, hypoproteinaemia, anaemia, immuno-compromised patients and wound infection. During the period of February 2001 to February 2006 four cases of burst abdomen were managed in cooperation with team of surgery department. In these cases wound were closed by "May/Mary closure". Abdominal wound dehiscence remains a major cause of morbidity following any laparotomy whether elective or emergency. We should correct the primary risk factors for wound dehiscence. Transverse incisions are generally considered to dehiscence much less than the vertical incision. The suture should have excellent handling and knotting. Its prevention is important to reduce postoperative morbidity, mortality and increased cost of care both in terms of increased hospital stay and treatment of the complication.

Effects of preoperative pelvic irradiation on colonic anastomosis healing: an experimental study in rats / Efeito da radioterapia pélvica pré-operatória na cicatrização de anastomoses colônicas: estudo experimental em ratos

PURPOSE: Colorectal anastomosis is a constant worry-issue among surgeons because of high rates of complications, specially the dehiscence. The preoperative irradiation on cancer surgeries might interfere in the healing process, leading to an unfavorable outcome. METHODS: In the present study, two groups of rats were irradiated previously to a colorectal anastomosis surgery, with intervals of 4 and 8 weeks between the procedures. Seven days after the surgery, healing process was evaluated for dehiscence presence and histologic inflammatory characteristics. Also, levels of hydroxyproline, metalloproteinases and vascular endothelial growth factor were measured. RESULTS: Our results showed a higher incidence of dehiscences on the animals submitted to irradiation, compared to controls, with a reduced inflammatory activity in the healing tissue. DISCUSSION: Comparing both irradiated groups, those irradiated 8 weeks before surgery showed higher levels of hydroxyproline and metalloproteinases, indicating higher efficiency of the healing process. In conclusion, preoperative irradiation interferes with intestinal anastomosis healing and a larger time interval between both procedures is safer in terms of the healing quality.

INTRODUÇÃO: As anastomoses colorretais são motivos constante de preocupação por parte dos cirurgiões, em virtude do alto índice de complicações, principalmente as deiscências. O uso da radioterapia previamente à cirurgia, nos casos de doença neoplásica, pode interferir no processo cicatricial das anastomoses, e levar a uma evolução desfavorável. MÉTODOS: Os autores estudaram dois grupos de ratos, submetidos a radioterapia e à confecção de uma anastomose no cólon, com intervalo de 04 e de 08 semanas entre os dois procedimentos, comparando com um grupo controle. Após 07 dias da cirurgia, estudaram-se vários aspectos do processo cicatricial: presença de deiscência, características inflamatórias do tecido, dosagem de hidroxiprolina, de mateloproteinase e de VEGF. RESULTADOS: Os autores detectaram maior índice de deiscência nos animais submetidos à radioterapia, com prejuízo da atividade inflamatória característica de um tecido em cicatrização. DISCUSSÃO: Dentre os dois grupos irradiados, aquele com intervalo de oito semanas entre a radioterapia e a confecção da anastomose teve dosagem mais alta de hidroxiprolina e metaloproteinase, demonstrando maior eficiência do processo cicatricial. CONCLUSÃO: A radioterapia prévia interfere no processo de cicatrização das anastomoses intestinais, e que um maior intervalo de tempo entre os dois procedimentos é melhor para garantia de uma cicatrização satisfatória.

Surgical treatment of Chagas megacolon. Critical analysis of outcome in operative methods / Tratamento cirúrgico do megacólon chagásico análise crítica dos resultados dos métodos operatórios

PURPOSE: Surgical treatment of chagasic megacolon has suffered innumerable transformations over the years. Poor knowledge of the disease physiopathology is one of the reasons. METHODS: From January 1977 to December 2003, 430 patients were submitted to surgical treatment for chagasic megacolon. Of these procedures, 351 were elective and 79 emergency operations carried out at the University Hospital of Ribeirão Preto. Four elective operations, most frequently used, should be singled out: anterior rectosigmoidectomy (52.71 percent), left hemicolectomy (18.23 percent), Duhamel-Haddad operation(15.95 percent), and total colectomy (5.98 percent). From the 79 exploratory laparotomies performed on an emergency basis, 53 (67.09 percent) required intestinal resection. From the 430 patients operated upon, 268 (62.33 percent) progressed without recurrence of intestinal constipation, and 71 (15.51 percent) had a recurrence. RESULTS AND DISCUSSION: Based on the data collected, left hemicolectomy had the highest constipation recurrence rate compared to other operating procedures; anterior retosigmoidectomy had less complication episodes and a larger recurrence of intestinal constipation in comparison to the Duhamel-Haddad operation. Emergency operations, mainly for the treatment of volvulus and fecaloma, presented high morbidity and mortality and required extensive intestinal resections, stomas and reoperations.

INTRODUÇÃO: O tratamento cirúrgico do megacólon chagásico tem passado por sucessivas modificações ao longo do tempo. A multiplicidade das operações é explicada pelo conhecimento ainda incompleto da fisiopatologia da doença, MÉTODOS: No período de janeiro de 1977 a dezembro de 2003, 430 pacientes chagásicos foram submetidos a tratamento cirúrgico para o megacólon no Hospital das Clínicas de Ribeirão Preto. Foram realizadas 351 operações eletivas e 79 de urgência. Quatro tipos de operações realizadas em caráter eletivo mereceram destaque por terem sido as mais utilizadas: retossigmoidectomia anterior (52,71 por cento), hemicolectomia esquerda (18,23 por cento), abaixamento de cólon à Duhamel-Haddad (15,95 por cento) e colectomia total (5,98 por cento). Das 79 laparotomias exploradoras realizadas em regime de urgência, em 53 (67,09 por cento) houve ressecção intestinal. Dentre os 430 pacientes operados, 268 (62,33 por cento) evoluíram sem recidiva e 71 (16,51 por cento) com recidiva da constipação intestinal. RESULTADOS E DISCUSSÃO: Com base nos resultados obtidos concluiu-se que: a hemicolectomia esquerda, comparada às demais operações, apresentou maior recidiva da constipação intestinal; a retossigmoidectomia anterior comparada à operação de Duhamel-Haddad apresentou menor número de complicações e maior recidiva da constipação intestinal; as operações de urgência para o tratamento do volvo e do fecaloma apresentaram alta morbimortalidade, exigem resseções intestinais, estomas e reoperações.

Use of intraluminal protection in colonic anastomosis in dogs

PURPOSE: To test the use of intraluminal protection in colonic anastomosis without intestinal cleansing. The intraluminal liner was fashioned from porcine submucosa preserved in glycerin and then fixed 10 cm anteriorly to the anastomotic site. This technique was compared with the one used in termino-terminal colonic anastomosis without intraluminal protection. METHODS: Twenty-eight dogs were divided into two groups of fourteen animals each. Clinical and histopathological tests were performed on the fourth and twenty-first postoperative days. RESULTS: The morbidity and mortality rates were higher in animals that did not receive the intraluminal liner. Histopathological examinations in animals in which the intraluminal liner was used showed better healing, characterized by milder inflammation and increased amount of collagen. CONCLUSION: It can be concluded that the use of intraluminal protection decreases complication rates in colonic anastomosis and promotes better healing.

OBJETIVO: Testar o uso da proteção intraluminal na anastomose colônica sem preparo intestinal. O protetor intraluminal usado foi confeccionado a partir da submucosa de suíno conservada em glicerina, e fixado a 10 cm cranialmente ao sítio anastomótico. Essa técnica foi comparada com a técnica de anastomose colônica término-terminal sem uso do protetor intraluminal. MÉTODOS: Foram utilizados 28 cães divididos em dois grupos de 14 animais cada. A avaliação foi através de exames clínicos e histopatológicos. A avaliação anatomo-patológica foi realizada no quarto e vigésimo primeiro dias de pós-operatório. RESULTADOS: Um maior número de casos de morbi-mortalidade foi observado nos animais operados sem o protetor intraluminal. O exame histopatológico dos animais nos quais foram usados os protetores intraluminais mostrou melhor cicatrização, caracterizada por processo inflamatório mais discreto e maior quantidade de colágeno. CONCLUSÃO: O uso do protetor diminui o número de complicações em anastomoses de cólon e melhora a cicatrização.

Factores asociados a la dehiscencia clínica de una anastomosis intestinal grapada: análisis multivariado de 610 pacientes consecutivos / Analysis of risk factors for clinical dehiscence of stapled anastomosis in 610 patients

Propósito: La dehiscencia de una anastomosis intestinal (DA) es una complicación grave, lo que ha motivado la búsqueda de factores de riesgo asociados con ella. El propósito de este estudio es analizar los factores predictivos de DA en una serie consecutiva de pacientes con una anastomosis grapada. Material y Método: Estudio longitudinal prospectivo de 610 pacientes (54 por ciento mujeres) con un promedio de edad de 58,9 años (extremos 14-88). Las principales indicaciones quirúrgicas fueron el cáncer colorrectal (55 por ciento), la enfermedad diverticular (16 por ciento) y el megacolon (11 por ciento). Se utilizó un modelo de regresión logística para estudiar la posible asociación entre la DA y 17 variables. Resultados: La DA ocurrió en 23 pacientes (3,8 por ciento). Hubo un 3 por ciento (9/300) de DA en el grupo de las anastomosis colo-rectales altas y 12 por ciento (9/73) en el grupo de anastomosis bajas (p=0.001). De los 23 pacientes con DA, 14 requieren una reintervención y 9 fueron manejadas en forma conservadora. La mortalidad global fue 1 por ciento (6/610), la mitad debido a complicaciones sépticas de la DA. Al comparar los pacientes sin y con DA, la tasa de reoperaciones fue 6,4 por ciento y 61 por ciento (p<0.0001), la tasa de infección de herida operatoria fue 6,6 por ciento y 61 por ciento (p<0.0001), el tiempo de hospitalización promedio fue 11 y 29,9 días (p<0.0001) y la mortalidad operatoria fue 0,5 por ciento y 13 por ciento (p<0.0001), respectivamente. En el análisis univariado el género, la altura de la anastomosis, el diámetro de la grapadora circular, el tiempo operatorio, el drenaje a la pelvis y el antecedente de radioterapia fueron significativas. En el análisis multivariado sólo el género (masculino), la altura de la anastomosis al margen anal y el antecedente de radioterapia pélvica se mantienen como variables independientes asociadas al riesgo de DA. Conclusión: Las anastomosis bajas, la radioterapia preoperatoria y el género...

Background: The dehiscence of an intestinal anastomosis is a devastating complication. Aim: To analyze risk factors for dehiscence of stapled anastomosis in a consecutive series of patients. Material and methods: Prospective study of 610 patients (age range 14-88 years, 329 females) subjected to a stapled intestinal anastomosis. The main diagnoses that motivated surgery were colorectal cancer in 55 percent, diverticular disease in 16 percent and megacolon in 11 percent. A logistic regression model was used to study the association between the risk of dehiscence and 17 independent variables. Results: Twenty three patients had a dehiscence of the anastomosis. The complication occurred in nine of 300 patients (3 percent) subjected to a high colorectal anastomosis and in nine of 73 patients (12 percent) subjected to a low colorectal anastomosis. Fourteen patients with dehiscence required a new surgical intervention and nine were managed conservatively. Six patients (1 percent) died due to septic complications of the dehiscence. Among patients with and without dehiscence, the rate of re-operations was 61 and 6.4 percent respectively, p < 0.001, the rate of surgical wound infections was 61 and 6.6 percent respectively, p< 0.001, and the hospital stay was 29.9 and 11 days respectively, p< 0.01. The factors significantly associated with dehiscence determined by univariate analysis were gender, the height of the anastomosis, the diameter of the circular stapler, operative time, the drainage to the pelvis and the history of radiotherapy. In the multivariate analysis, only the male gender, the height of the anastomosis, using the anal margin as landmark and the history of pelvic radiation, remained as significant predictors. Conclusions: A low anastomosis, previous radiation therapy and male gender are risk factors for clinical dehiscence of stapled anastomosis. A protective ostomy should be considered in patients with multiple risk factors.

Preparación de colon: ¿es realmente necesario?: resultados de un modelo experimental / Bowel preparation: it is really necessary?: results of experimental model

En la práctica actual la preparación mecánica de colon (PMC) previo a la realización de cirugía colorrectal es discutible. No ha sito posible demostrar su utilidad e incluso, puede ser deletéreo para la cicatrización colónica. Sin embargo, se sigue utilizando ampliamente. El objetivo de este estudio fue evaluar el resultado de la anastomosis de colon en animales con intestino preparado. Se realizó un estudio prospectivo comparativo en un modelo animalporcina entre anastomosiscolónica en intestino preparado versus no preparado. Se intervinieron 33 cerdos consecutivos, 22 sin PMC y 11 con PMC (régimen hídrico más 2 Fleet orales administrados por sonda orogástrica previo a la cirugía). Se administró una dosis de antibióticos profilácticos endovenosos. En todos los animales se realizó sección de sigmoides y anastomosis manual laparoscópica colo-colónica término-terminal en un plano. Los cerdos fueron evaluados diariamente y realimentados al evidenciarse reanudación del tránsito intestinal. Al séptimo día posterior a la cirugía los animales fueron sacrificados. Los principales resultados evaluados fueron: dehiscencia de anastomosis, infección de herida operatoria, absceso intraperitoneal y muerte. Se pesquisó una dehiscencia subclínica en la autopsia de un cerdo sin PMC. En 3 animales se pesquisó infección de la herida operatoria (2 sin PMC y 1 con PMC), y hubo un seroma en el grupo sin PMC. No se registraron casos de abscesos intraperitoneales ni mortalidad en ningún grupo. Esta serie experimental en animales no demostró que la PMC tiene beneficios con respecto a colon no preparado en anastomosis manual laparoscópica de colon.