Prospective, randomized and controlled study of mesh displacement after laparoscopic inguinal repair: fixation versus no fixation of mesh.

INTRODUCTION: Repair of inguinal hernia is one of the most common elective operations performed in general surgery practice. Mesh hernia repair became the gold standard because of its low recurrence rate in comparison with non-tension-free repair. Laparoscopic approach seems to have potential advantages over open techniques, including faster recovery and reduced acute and chronic pain rate. Laparoscopic mesh fixation is usually performed using staples, which is associated with higher cost and risk for chronic pain. Recently, the role of mesh fixation has been questioned by several surgeons. AIM: To evaluate mesh displacement in patients undergoing laparoscopic inguinal hernia repair comparing mesh fixation with no fixation. METHODS: From January 2012 to May 2014, 60 consecutive patients with unilateral inguinal hernia were randomized into two groups: control group--10 patients underwent totally extraperitoneal (TEP) repair with mesh fixation; NO FIX group-50 patients underwent TEP repair with no mesh fixation. Mesh was marked with three 3-mm surgical clips at its medial inferior, medial superior and lateral inferior corners. Mesh displacement was measured by comparing an initial X-ray, performed in the immediate postoperative period, with a second X-ray obtained 30 days later. RESULTS: The mean displacement of all three clips in control group was 0.1-0.35 cm (range 0-1.2 cm), while in NO FIX group was 0.1-0.3 cm (range 0-1.3 cm). The overall displacement of control and NO FIX group did not show any difference (p = 0.50). CONCLUSION: Fixation of the mesh for TEP repair is unnecessary. TEP repair with no mesh fixation is safe and is not associated with increased risk of mesh displacement.

Laparoscopic inguinal hernioplasty after radical prostatectomy: is it safe? Prospective clinical trial.

INTRODUCTION: Despite inguinal hernia repair being one of the most common elective operations performed in general surgical practice, there are many controversies including indications for repair and selection of the surgical technique. In recent years, laparoscopic repair has gained wider acceptance because it is associated with fewer postoperative complications and less chronic pain when compared with conventional approaches with similar recurrence rate. However, patients with lower abdominal surgery are contraindicated for laparoscopic approach. There are few studies that evaluated whether patients who have been subjected to radical prostatectomy might be subjected to laparoscopic hernia repair with the same benefits as those without previous radical prostatectomy. METHODS: Between March 2010 and March 2013, 20 consecutive patients, who had been subjected to prior radical prostatectomy, underwent laparoscopic transabdominal inguinal repair and were followed prospectively. Surgical procedure was performed using a standard technique. RESULTS: Mean operative time was 67.5 min. There was only one (5%) intraoperative minor complication, an injury to the inferior epigastric vessels, which was managed by clipping of the vessels. There were no major postoperative complications. After 24 h and on the seventh postoperative day, 85 and 90% of patients had no pain or only complained of discomfort, respectively. Nine patients (45%) did not need any analgesics postoperatively. The mean time to return to leisure activities and to work was 3.1 and 5.6 days, respectively. There was no conversion to open surgery. All patients were discharged within 24 h. After a mean follow-up of 14 months, none of the patients presented recurrence. CONCLUSION: TAPP after prostatectomy is safe and effective. It seems that patients undergoing laparoscopic repair after radical prostatic resection have the same benefits as those without prostatectomy.

Effect of pantoprazole administered subcutaneously on the healing of sutured gastric incisions in rats.

BACKGROUND: The properties of proton pump inhibitors most investigated are related to peptic diseases and upper gastrointestinal bleeding, but their influence on the healing of sutured gastric incisions has not been assessed. In the present study we evaluated the effect of subcutaneously administered pantoprazole on the healing of sutured gastric incisions in rats. METHODS: Sixty rats were divided into a pantoprazole group and a control group. All rats were submitted to gastric suture in the gastric body and in the gastric fundus and had their gastric pH measured. The pantoprazole group received 20 mg/kg pantoprazole and the control group received 0.9% isotonic NaCl, both subcutaneously t.i.d. Healing analysis was carried out using collagen picrosirius red F3BA staining, and breaking strength was measured on the 4th and 7th postoperative days in all groups. RESULTS: Gastric pH was higher in the pantoprazole group. In the fundus, the pantoprazole group had a higher measurement of breaking strength and a higher proportion of type-I over type-III collagen on the 7th postoperative day. In the body, the pantoprazole group had a higher proportion of type-I over type-III collagen on the 4th and 7th postoperative days. CONCLUSIONS: Pantoprazole given subcutaneously promoted a reduction in gastric acid secretion and was associated with improved healing of the sutured gastric incision in the fundus (squamous epithelium) of rats. These findings suggest that pantoprazole has healing properties in sutured gastric incisions with potential benefits in gastric surgery.

Prevalence of type 2 diabetes mellitus in Brazilian liver transplant candidates: negative association with HCV status.

Recently, an epidemiological association between hepatitis C virus (HCV) infection and type 2 diabetes mellitus (DM) has been reported in several studies, although many of them did not consider known risk factors in the pathogenesis of type 2 DM. The aim of this study was to assess the prevalence of type 2 DM among Brazilian HCV (+) and HCV (-) liver transplant candidates, analyzing known confounding factors for the development of type 2 DM. We conducted a cross-sectional study to evaluate the prevalence of type 2 DM among 106 liver transplant adult candidates, comparing 36 HCV (+) cirrhotic patients with 70 HCV (-) patients who developed cirrhosis from other causes. Type 2 DM was diagnosed after two consecutive fasting glucose values > or =126 mg/dL. The age, sex, and race distribution, severity of liver disease (Child-Pugh score), and family history of DM were similar in both groups, but the mean body mass index (BMI) was higher in the HCV (-) subjects (26.81 +/- 5.29 vs 24.0 +/- 4.71, P < .01) Most of the patients were Caucasians (70.75%). Type 2 DM was detected in 36.11% of HCV (+) group and in 25.71% of the HCV (-) (P = .27). A multivariate analysis revealed that family history of DM was the only significant independent predictor for DM (odds ratio = 2.55, 95% CI = 1.03 to 6.31, P = .04). In conclusion, our study did not show an association between HCV infection and Type 2 DM in Brazilian liver transplant candidates. It confirmed that the family history of DM was a determinant factor for the development of type 2 DM.

Prevalence of new-onset diabetes mellitus in Brazilian liver transplant recipients: association with HCV infection.

New-onset diabetes melittus (NODM) is a serious complication following transplantation. Recent studies suggest an association between hepatitis C virus (HCV) infection and DM both in nontransplant settings as well as after liver transplantation (LT). The aim of this study was to assess the prevalence of NODM among Brazilian LT recipients, analyzing possible risk factors including HCV infection. We conducted a cross-sectional study to evaluate the prevalence of NODM in 82 LT recipients with a posttransplant follow-up > or =1 year including 29 HCV-positive patients and 53 with other causes for liver disease. Patients were considered to meet the criteria for DM if they had two consecutive fasting glucose values > or =126 mg/dL or if they were taking insulin or oral hypoglycemic agents at the time of the study. The overall prevalence of NODM was 18.29% with a median interval of 20 months between LT and diagnosis of DM. The age, sex, and race distribution, immunosuppressive regimen, number of rejection episodes treated with pulse therapy, and family history of DM were similar in both groups. However, the frequency of BMI > or = 30 in the pre- and posttransplant periods was higher among patients who developed NODM (P = .02). Upon multivariate analysis of the entire cohort, HCV infection was the only significant predictor of NODM (OR = 4.31, CI = 1.17 to 15.84, P = .02). In conclusion, our study confirmed an association between HCV infection and NODM among Brazilian liver transplant recipients, suggesting that HCV infection may have a potential role in the pathogenesis of posttransplantation DM.

Donor quality of life after living donor liver transplantation.

Living donor liver transplantation (LDLT) for children and adults has gained widespread acceptance due to the severe organ shortage. LDLT provides potential recipients with timely transplantation, but this procedure engenders a potentially significant risk to the donor. This study analyzed medical, functional, and psychological donor outcomes after LDLT. Nineteen donors (mean age 33.9 +/- 12 years), who underwent hepatectomy for LDLT (13 right lobectomy for adult LDLT) from March 1998 to November 2002, were interviewed at a median of 13 months after donation (range, 2 to 58 months). According to the Clavien System classification, major complications occurred in three donors (16%), and minor in four (21%). The mean length of hospital stay was 5.7 +/- 1.6 days. Five patients (27%) needed rehospitalization. Complete recovery was achieved at a mean time of 8.5 +/- 3.5 weeks. All 19 donors were able to return to predonation activities. The donor's relationship to the recipient and to their families was improved after donation in all cases; 12 (63%) cited a positive psychological impact on their lives. About 90% would donate again and 84% would recommend donation to someone contemplating it. In conclusion, all donors are alive and well after donation and were able to return to their predonation occupation. Most of them felt that this experience changed their lives for the better and would donate again. Donor safety and quality of life should remain the priority in all donation processes.

Prevalence of malnutrition in liver transplant candidates.

OBJECTIVE: To determine the prevalence of malnutrition among liver transplant (LT) candidates. MATERIALS AND METHODS: A prospective study evaluated 219 adult LT candidates including 141 men and 78 women. Cholestatic disease was present in 21 (Child: A = 1, B = 11, and C = 9) and noncholestatic disease in 198 (Child: A = 12, B = 93, and C = 93. The mean age was respectively 45.6 and 46.5 years. Anthropometric and biochemical assessments were performed for statistical analysis using Student t test (P <.05). RESULTS: In the noncholestatic group, 41.5% were obese according to keep a body mass index (BMI); 61.6% were depleted according to adequacy of tricipital skin fold (%TSF); and 71.1% were above normal levels for generalized adipose reserve (%F). In terms of adequacy of mid-upper arm muscle circumference (%MMC), 58% were depleted and 50.5% were depleted for the current body weight/usual body weight (%CBW/UBW). Otherwise 52.2% of current body weight/ideal body weight (%CBW/IBW) values were above normal. Serum albumin was below normal in 64.9% of cases. In the cholestatic group 62% were normal for BMI; 66.7% were depleted for %TSF; 77.8% were above normal for %F. As to %MMC, 47.6% were depleted and 47.6% were depleted for %CBW/UBW. Otherwise 47.6% were above normal weight for %CBW/IBW. Serum albumin was below normal in 53.9% and %MMC values showed statistically significant differences (P =.02) when compared with Child B and C in the noncholestatic group, as well as %F (P =.01) and serum albumin (P =.0002) in the cholestatic and noncholestatic groups. Serum albumin values also showed statistically significant differences (P =.0004) when noncholestatic Child B and C patients were compared. CONCLUSION: Patients with cholestatic disease were more affected by calorie depletion compared to noncholestatic patients who were more affected by protein depletion.

Impact of successful liver transplantation on reproductive function and sexuality in women with advanced liver disease.

Abnormalities in the reproductive function and sexuality, which are common among women with advanced liver disease, may reverse after successful liver transplantation (LT). To analyze reproductive function and sexuality in women who underwent successful LT, we interviewed 28 recipients (mean age 44.17 +/- 13.6 years old) at a median posttransplant survival of 36.5 months (range, 6 to 110 months), with good graft function and obeying regular follow-up at our institution. In addition to medical records, all subjects answered a questionnaire on their menstrual pattern, sexual activity, contraceptive practice, pregnancy, and sexuality domain. Nineteen of 22 patients in the child bearing age (86.4%) recovered menstrual function at a median of 1 month after LT (range, 1 to 7 months). Twenty of 28 recipients (71.4%) were sexually active. The most frequent contraceptive practices were barrier methods and tubal ligation. There were four successful pregnancies (one twin) in three patients; five healthy babies were delivered. Overall, 70% of sexually active patients indicated satisfaction with their relationship, 75% had weekly intercourse, and 70% experienced orgasm with intercourse. Eighty percent expressed a desire to receive information concerning sexuality. In conclusion, LT has a positive impact on sexuality and reproductive function in female recipients. It would desirable that LT programs included information regarding these issues for this population.

Custo do transplante hepático no Hospital de Clínicas da Universidade Federal do Paraná / Cost of liver transplantation at the Clinical Hospital of Parana, Brazil

Objetivo. Determinar o custo do transplante hepático no Hospital de Clínicas da Universidade Federal do Paraná. Método. Os dados do prontuário de 24 pacientes submetidos a 25 transplantes hepáticos foram avaliados do dia da internaçao para o transplante hepático até a data da alta hospitalar ou óbito para determinar o número de dias de internaçao, o local de internaçao, a quantidade de material e medicamentos usados, os exames complementares e procedimentos realizados. Honorários médicos nao foram incluídos no estudo. Resultados. A idade dos pacientes variou de 6 a 56 anos, tendo seis deles menos que 14 anos de idade. Cinco pacientes foram a óbito durante a internaçao hospitalar. Retransplante foi realizado em somente um paciente. O custo médio da retirada do fígado do doador foi de US$ 2,783.19. O custo total do transplante hepático variou amplamente entre os pacientes, na dependência de ocorrência de complicaçoes pós-operatórias, do número de dias de internaçao hospitalar e da quantidade de transfusao de hemoderivados. O custo total variou de US$ 6,359.84 a US$ 75,434.18, com média de US$ 21,505.53. O item mais caro do transplante hepático foi o custo com a hemoterapia, seguido do custo com medicamentos e diária hospitalar. Conclusao. O custo do transplante hepático varia muito entre os pacientes e pode ser realizado no Brasil a um custo inferior ao relatado nos Estados Unidos e na Europa.

Doaçäo de órgäos: opiniäo e conhecimento de médicos intensivistas da cidade de Curitiba / Organ donation: opinion and knowledge of intensive care unit physicians in the city of Curitiba

Com o objetivo de avaliar as opiniöes e conhecimentos de médicos intensivistas sobre doaçäo de órgäos, todos os intensivistas dos 13 hospitais de Curitiba com unidade de terapia intensiva de adulto participaram do estudo. De 81 intensivistas entrevistados, 75 (92,6 por cento) responderam o questionário. Todos responderam que säo favoráveis à doaçäo de órgäos, 74 (98,7 por cento) doariam seus próprios órgäos e 72 (96 por cento) autorizariam a doaçäo de órgäos de um membro da sua família. Sessenta e três (84 por cento) intensivistas näo conheciam ou näo souberam explicar a legislaçäo atual sobre doaçäo de órgäos. Quarenta e um (54,7 por cento) responderam errado ou näo sabiam os critérios médicos e legais para doaçäo de órgäos. Cinco (6,7 por cento) desconheciam a necessidade do doador ter morte encefálica, três (4 por cento) acreditavam que o doador deveria ter morte cardíaca para ser doador e 44 (58,7 por cento) näo souberam explicar o que é morte encefálica. A maioria desconhecia a sobrevida atual dos pacientes submetidos a transplante dos vários órgäos. Conclui-se deste estudo que quase todos os médicos intensivistas de Curitiba säo favoráveis a doaçäo de órgäos e estäo dispostos a participar ativamente na obtençäo de consentimento de familiares para doaçäo. O conhecimento básico sobre a legislaçäo brasileira e os vários aspectos médicos do transplante de órgäos é insatisfatório.

Electromyography of the small bowel following inversion of a jejunal segment in dogs

A atividade mioeletrica do intestino delgado foi estudada apos a inversao de um segmento jejunal em sete caes. Sete pares de eletrodos bipolares foram implantados na camada seromuscular do intestino delgado em diferentes locais, incluindo a alca jejunal invertida. Os registros eletromiograficos foram obtidos no 7§ e 10§ dias pos-operatorios, durante os periodos de jejum e alimentar. O complexo mioeletrico migratorio (CMM) estava presente em todos os locais registrados, inclusive na alca jejunal invertida. A duracao do CMM duodenal foi 70,3ñ14,8 minutos...

Intragastric microflora study in patients with gastroduodenal disease

O conteudo normal de bacterias no estomago e menor que 10ü/ml de suco gastrico. A ausencia de bacterias na cavidade gastrica, muito frequente, e principalmente devida a secrecao acida e a motilidade do orgao. Varias situacoes podem comprometer esses mecanismos de defesa e levar a colonizacao bacteriana, com alta incidencia de complicacoes infecciosas pos-operatorias. Para avaliar a alteracao da microflora gastrica, estudaram-se 25 pacientes, 19 com doenca gastroduodenal e seis controles, divididos em quatro grupos distintos, de acordo com a afeccao de base. Dos portadores de doenca gastroduodenal, 18 (94,73 por cento) apresentaram cultura positiva para aerobios e seis (3,57 por cento), para anaerobios. Cinco pacientes (26,31 por cento) tiveram cultura positiva para Candida sp e cinco outros para S. fecalis. A principal contagem bacteriologica foi de 1,2x10 elevado a seis CFU/ml de suco gastrico, e de 1,4x10 elevado a um CFU/ml de suco gastrico, para anaerobios. As bacterias mais comumente isoladas foram E. coli, Enterobacter sp e Staphylococcus epidermidis.