Early and late postoperative inflammatory and collagen deposition responses in three different meshes: an experimental study in rats.

PURPOSE: Although meshes reduce abdominal hernia recurrence, they increase the risk of inflammatory complications. This study aimed to compare the early and late postoperative inflammation and collagen deposition responses induced by three meshes. METHODS: Rats were allocated into three groups. In group I, a polypropylene (PP) mesh was implanted in the abdominal wall. In groups II and III, PP + polyglactin (PP + PG) and PP + titanium (PP + TI) meshes were employed, respectively. On the seventh (7th) postoperative day, collagen deposition and inflammation were evaluated, and immunohistochemistry was performed on abdominal wall biopsies. These data were compared with those obtained on the fortieth (40th) postoperative day in a previous study. RESULTS: The early inflammatory responses were the same in all groups. With time, it decreased in group I (p = 0.047) and increased in group II (p = 0.003). Group I exhibited early elevated VEGF (p < 0.001), COX2 (p < 0.001), and collagen (p = 0.023) levels, and group II exhibited the most severe inflammatory tissue response. On the 40th postoperative day, the VEGF (p < 0.001) and collagen (p < 0.005) were reduced as compared with the 7th postoperative day in all groups. CONCLUSIONS: Belatedly, the inflammatory reaction decreased in PP mesh group and increased in PP + PG mesh group. The PP mesh induced early great elevations in VEGF, COX2 and collagen levels, whereas the PP + PG mesh caused severe tissue inflammation with small elevation in these levels. PP + TI mesh induced inflammatory response levels between the others. In conclusion, the inflammatory response depends on the mesh density and also the mesh material with clinical implications.

Late clinical, biochemical, endoscopic and electroencephalographic evaluation of patients with schistosomal portal hypertension treated with distal splenorenal shunt.

The authors performed a late evaluation of a distal splenorenal anastomosis minimum of five years following operation on 13 patients with schistosomiasis of the compensated liver-splenic type. The study of the anastomosis had been proven patent when the evaluation took place. Each patient underwent clinical, laboratorial, endoscopic and electroencephalographic assessment. The results demonstrated that no patient had shown any sign of recurrence of upper gastrointestinal hemorrhage. Among the endoscopic aspects, esophageal varices disappeared in 46.1% of the cases. There was reduction in the number, extent and volume of esophageal varices in 46.1%, 38.4% and 53.8% of the cases. Gastric varices disappeared in 91.6% of the cases. Only one patient (7.6%) had shown clinical and electroencephalographic signs of hepatic encephalopathy in the late final evaluation (non-significant). Only one patient (7.6%) had shown late postoperative ascites (non-significant). There were no significant alterations in serum levels of sodium, potassium, urea and creatinine in all the 13 patients. The values of indirect serum bilirubin increased in 92.3% of the patients. There was regression of splenomegaly in all 13 patients, as well as a significant improvement in their hematological values. There were no significant changes in the serum levels of aspartate aminotransferase and alanine aminotransferase or in the activity of the plasma prothrombin. The authors concluded that the distal splenorenal anastomosis became a protection factor against upper gastrointestinal hemorrhage and led to long-term improvement in the endoscopic aspects of esophagogastric varices, a significant improvement in the laboratorial aspects of hypersplenism and a marked reduction of splenomegaly with no significant changes in the hydroelectrolytic metabolism, renal function and hepatic function and had not compromised, long term, the quality of life of the majority of patients.

Escleroterapia endoscópica de varizes esofagogástricas sangrantes e estado funcional do fígado / Endoscopic sclerotherapy of bleeding esophagogastric varices and functional liver status

Os autores analisam os resultados da esclerose endoscópica aplicada em 52 doentes com hemorragia digestiva por varizes de esôfago e estômago. A avaliaçäo funcional do fígado, de acordo com critérios de Child, permitiu a classificaçäo de 34,6// Child A, 23,1// Child B e 42,1// Child C. Os doentes foram submetidos a endoscopia digestiva alta após anestesia tópica do orofaringe com xilocaina 10// e sedaçäo com benzodiazepínico 10 mg endovenoso. Foi empregada soluçäo de oleato de etnolamina a 4// em volume médio total de 28mL injetada preferencialmente intravasal. Foi observado, durante exame endoscópico, sangramento ativo das varizes do esôfago em 46,1//, sangramento recente em 53,9//, neste último o local tendo sido identificado em mamilo varicoso. A hemostasia do sangramento foi obtida em 72,2// nos doentes Child A, 58,3// nos Child B e 45,4// Child C após primeira sessäo de esclerose. A recidiva hemorrágica ocorreu em 28,6// Child A, 41,7// Child B e 54,6// Child C. A hemostasia após segunda sessäo de esclerose foi de 94,4// Child A, 75// child B e 54,5// Child C. As complicaçöes ocorreram em 30,7// dos doentes por escara no nível do mamilo varicoso esofágico, em 19,2// por dor retro-esternal e em 11,5// por febre. A mortalidade foi de 68,1// para doentes Child C, dos quais 45,4 por hemorragia persistente das varizes esofagianas e 22,7// por coma hepático. Neste grupo ocorreram três casos nos quais o sangramento foi por varizes de fundo gástrico e que a esclerose endoscópica näo foi eficaz para coibi-lo e todos evoluíram para óbito. Nos doentes Child B o óbito esteve representado por coma hepático em 16,6//. Entre os doentes Child A näo ocorreram óbitos. A esclerose de varizes esofágicas sangrantes constituiu método hemostático eficaz; entretanto, essa eficácia esteve diretamente relacionada com o estado funcional do fígado. A esclerose de varizes sangrantes do fundo gástrico näo constituiu método hemostático eficaz e este fato näo esteve relacionado com a funçäo hepática

[Endoscopic sclerotherapy of bleeding esophagogastric varices and functional liver status]. / Escleroterapia endoscópica de varizes esofagogástricas sangrantes e estado funcional do fígado.

Endoscopic sclerotherapy of bleeding gastroesophageal varices was carried out in 52 patients within a sclerosis program for acute hemorrhage. According to Child's classification, 18 (34.6%) were A, 12 (23.1%) B and 22 (42.3%) C. The hemorrhagic focus was endoscopically proven in oesophageal varices in 45 (86.5%) and in 7 (13.5%) in gastric varices. The sclerotherapy was performed by both intra and extravascular injections of 3% ethanolamine according to treatment for emergency bleeding. The procedure was repeated on the 7th day or when necessary for recurrent hemorrhage. Hemostasis was achieved in 94.4% Child's class A, 75.0% Child's class B and 54.5% Child's class C, all of them with bleeding oesophageal varices. All patients with severe gastric hemorrhage (2 Child's class A, 2 Child's class B and 3 Child's class C) needed surgical treatment for uncontrolled bleeding. Liver failure and bleeding were the leading causes of death in 15 (68.1%) Child's class C and 2 (16.6%) Child's class B. There was no death in Child's class A. The conclusion was drawn that the results of endoscopic sclerotherapy of bleeding oesophageal varices was effective and clearly related to liver function. The endoscopic sclerotherapy, however, was not able to control severe hemorrhage from gastric varices and this was not related to liver function.