Different cellular and immunohistochemical abdominal wall cicatrization parameters evaluation in comparison with sublay, onlay, and ipom technique in an experimental rat model.

PURPOSE: Incisional hernia (IH) occurs when there is a partial or complete solution of continuity of a fascia previously incised. Systematic reviews demonstrate that surgical treatment of IHs with the use of meshes are approximately 16%. Meta-analyses have demonstrated the superiority of mesh placement using sublay technique, but without a pathophysiological explanation. Thus, we aim to evaluate the different techniques of mesh positioning in an experimental model. METHODS: Fifty rats were distributed into five groups; control; simulation (SM)-submitted to laparotomy only; onlay-the mesh was positioned in onlay fashion; retromuscular (SL)-the mesh was positioned in a sublay fashion; intraperitoneal (IPOM)-positioning of the mesh adjacent to the transversalis fascia, inside the cavity. After 60 days, adhesions, tensiometry, histology, and immunohistochemistry were addressed. RESULTS: The IPOM group had the most adhesions, together with the SL group, with significantly relevant results. The SL group had higher values of tensiometric evaluation, while the IPOM group had the lowest mean in the tensiometry evaluation, being even lower than the SM group. Regarding histological and immunohistochemical findings, the SL group had a higher pixel number count compared to the groups, with statistical significance, in addition to higher expression of polymorphonuclear infiltrate and CD68 markers. CONCLUSION: The mesh positioning in sublay compartment is associated with the development of more pronounce minimum tensile force required for detaching the surrounding abdominal wall tissues it was incorporated. The intensity of these findings correlates to the different histological and immunohistochemical profiles observed following each repair, since SL group was characterized by a higher proportion of collagen, inflammatory, and reparative elements. Characterizing these pro-healing elements and its counterparts will allow the development of new therapeutic tools which could be added to the still far-from-ideal current therapeutic options for IH treatment.

Sublay repair results in superior mesh incorporation and histological fibrogenesis in comparison to onlay and primary suture in an experimental rat model.

PURPOSE: To compare adhesion scores, repair strength and histological findings among sublay, onlay and primary repair incisional hernioplasty techniques. Surgical repairs were employed directly on healthy animals, without previous hernia induction, to avoid confounding factors related to hernia development. METHODS: Forty Wistar rats were divided into four groups, control, simulation, onlay and sublay. After 42 days, adhesion intensity, tensile strength of the abdominal wall and anatomopathological histological substrate were compared. RESULTS: SL group presented greater adhesion scores (p < 0.0001), higher tensiometric (p < 0.0001), and was characterized by more histiocytes, mononuclear cells, macrovacuolar granulomas and type I collagen on histological analysis. Pearson correlation between adhesions and tensiometry, and between tensiometry and neocollagenization showed a strong positive association (r = 0.8905 and 0.6757, respectively in SL group, p < 0.05). CONCLUSION: Mesh positioning in sublay compartment was followed by increased adhesion development and provides a stronger mesh-tissue attachment, in addition, resulted in a different histological profile of the inflammation/repair substrate. The intensity of these findings was directly correlated, suggesting they could be the result of a common biological phenomenon. Our findings indicate that mesh placement following the retromuscular technique generates a superior repair response, and give clues to a better understanding of the superiority of sublay repair in achieving lower recurrence rates. Characterization of the cellular and molecular elements responsible for the superiority of this technique is in our view an essential prerequisite aiming for improvements in the therapeutic options for the treatment of this disease.

Complex inguinal hernia repairs.

INTRODUCTION: Complex inguinal hernia treatment is a challenge for general surgeons. The gold standard for the repair of inguinal hernias is the Lichtenstein repair (anterior approach). However, when multiple recurrent hernias or giant hernias are present, it is necessary to choose different approaches because the incidence of poor results increases. There are many preperitoneal approaches described in the literature. For example: (a) open procedure-Nyhus and Stoppa (b) laparoscopic technique-transabdominal pre-peritoneal (TAPP) and totally extraperitoneal (TEP). In this study, we show how we repair complicated cases using open access in huge unilateral or bilateral, recurrent, or multiple recurrent inguinal hernias. METHODS: The present study includes the period from November 1993 through December 2007. One hundred and eighty-eight patients, divided into 121 with unilateral hernias and 67 with bilateral hernias, totaling 255 inguinal hernia repairs, were treated by the Nyhus or Stoppa preperitoneal approach, depending on whether they were unilateral or bilateral. We used progressive preoperative pneumoperitoneum for oversize inguinal hernias in all patients. RESULTS: Orchiectomy was necessary on only two occasions. Despite the repair complexity involved, we had only two known recurrences. The mortality was zero and the morbidity was acceptable. CONCLUSIONS: We conclude that an accurate open preperitoneal approach using mesh prosthesis for complex inguinal hernias is safe, with very low recurrent rates and low morbidity. Progressive preoperative pneumoperitoneum for giant hernias was shown to be an important factor in accomplishing good intraoperative and immediate postoperative results.

Management of infected and sterile pancreatic necrosis by programmed endoscopic necrosectomy.

INTRODUCTION: Necrosectomy is the gold standard treatment for infected pancreatic necrosis (IPN). A percutaneous and endoscopic approach has been accepted in selected cases. Endoscopic drainage (ED) of IPN can be performed by using transpapillary or transmural procedures, or a combination of both with or without endoscopic ultrasound. AIMS: The aim of this study was to determine the indications, complications, success rate, and the importance of assessment of main pancreatic duct integrity by endoscopic retrograde pancreatography (ERP) in patients with IPN. METHODS: Records of all patients who underwent endoscopic necrosectomy from January 2002 to December 2007 at Rio de Janeiro Federal University Hospital were reviewed. A total of 56 patients were included. ED was performed using daily transmural and transpapillary drainage. A diagnostic pancreatogram (ERP) to search for communications between the pancreatic duct and the collection were performed in all cases and in cases where communication existed. A pre-cut needle knife was used to puncture the cyst wall, aspirate the content and then enter at the cyst cavity (contrast was injected to ensure opacification of the cyst and subsequent drainage). Sphincterotomy catheter or balloons were used to enlarge and ensure a wide cystoenterostomy. All patients were followed with computerized tomography scans or ultrasound to ensure clinical resolution. Mean follow-up was 21 months. RESULTS: 49/56 patients could be successfully treated. ED was successful in 49 patients (87%) and in 3 (13%) it failed. Mean follow-up was 21 months. During this period, there were 2 (10.5%) pseudocyst recurrences and only 1 (5.2%) recurrence of new episodes of pancreatic necrosis, and all were managed clinically and/or endoscopically. No mortality was related to the procedure. CONCLUSION: ED with daily necrosectomy is a useful method to remove infected and sterile pancreatic necrosis.

Ileo biliar. / Biliary ileus

Os autores fizeram a revisao de oito pacientes portadores de ileo biliar. Esta e uma patologia pouco frequente. O quadro clinico nao e caracteristico e a omissao do estudo radiologico torna praticamente inviavel o diagnostico pre-operatorio. O tratamento cirurgico e relativamente simples, nao havendo como regra geral ser postergado a pretexto de evitar uma reintervencao eletiva, pois alem de nada trazer de beneficio a resolucao do quadro agudo, ainda aumenta a mortalidade. O ileo biliar, portanto, deve sempre ser lembrado pelos clinicos e cirurgioes entre as causas de obstrucao intestinal

Hipoglicemia induzida pelo alcool. / Alcohol induced hypoglycaemia

Os autores determinaram as glicemias de 25 individuos admitidos em servicos de emergencia em consequencia de ingestao alcoolica aguda, tendo observado a presenca de hipoglicemia estava relacionada com baixa ingestao de carboidratos ou jejum prolongado em 9 pacientes (69,2%) e provavelmente representando uma forma reativa em 4 pacientes (30,8%), os quais estavam sob dieta normal. Concluiram que a hipoglicemia induzida pelo alcool deve ser responsabilizada por grande parte das alteracoes psiquicas e neurologicas comumente atribuidas exclusivamente aos efeitos do alcool dai recomendando a determinacao de rotina da glicemia em todos os individuos com quadro de etilismo agudo