Abdominal wall reconstruction in patients presenting with enteric fistulas and mesh infection is challenging. There is a consensus that synthetic mesh must be avoided in infected operations, and the alternatives to using synthetic mesh, such as component separation techniques and biologic mesh, present disappointing results with expressive wound infection and hernia recurrence rates. A prospective clinical trial designed to evaluate the short- and long-term outcomes of 40 patients submitted to elective abdominal wall repair with synthetic mesh in the dirty-infected setting, and compared to a cohort of 40 patients submitted to clean ventral hernia repairs. Patients in both groups were submitted to a single-staged repair using onlay polypropylene mesh reinforcement. Groups' characteristics were similar. There were 13 (32.5%) surgical site occurrences in the infected mesh (IM) group, compared to 11 (27.5%) in the clean-control (CC) group, p = 0.626. The 30-day surgical site infection rate was 15% for the IM group vs. 10% for the CC cases, p = 0.499. One patient required a complete mesh removal in each group. The mean overall follow-up was 50.2 ± 14.8 months, with 36 patients in the IM group and 38 clean-controls completing a follow-up of 36 months. There was one hernia recurrence (4.2%) in the IM group and no recurrences in the CC group. We demonstrated that using polypropylene mesh in the infected setting presented similar outcomes to clean repairs. The use of synthetic mesh in the onlay position resulted in a safe and durable abdominal wall reconstruction. Study registered at Plataforma Brasil (plataformabrasil.saude.gov.br), CAAE 30836614.7.0000.0068. Study registered at Clinical Trials (clinicaltrials.gov), Identifier NCT03702153.

Preoperative progressive pneumoperitoneum (PPP) is a safe and effective procedure in the treatment of large incisional hernia (size > 10 cm in width or length) with loss of domain (LIHLD). There is no consensus in the literature on the amount of gas that must be insufflated in a PPP program or even how long it should be maintained. We describe a technique for calculating the hernia sac volume (HSV) and abdominal cavity volume (ACV) based on abdominal computerized tomography (ACT) scanning that eliminates the need for subjective criteria for inclusion in a PPP program and shows the amount of gas that must be insufflated into the abdominal cavity in the PPP program. Our technique is indicated for all patients with large or recurrent incisional hernias evaluated by a senior surgeon with suspected LIHLD. We reviewed our experience from 2001 to 2008 of 23 consecutive hernia surgical procedures of LIHLD undergoing preoperative evaluation with CT scanning and PPP. An ACT was required in all patients with suspected LIHLD in order to determine HSV and ACV. The PPP was performed only if the volume ratio HSV/ACV (VR = HSV/ACV) was ≥25% (VR ≥ 25%). We have performed this procedure on 23 patients, with a mean age of 55.6 years (range 31–83). There were 16 women and 7 men with an average age of 55.6 years (range 31–83), and a mean BMI of 38.5 kg/m2 (range 23–55.2). Almost all patients (21 of 23 patients—91.30%) were overweight; 43.5% (10 patients) were severely obese (obese class III). The mean calculated volumes for ACV and HSV were 9,410 ml (range 6,060–19,230 ml) and 4,500 ml (range 1,850–6,600 ml), respectively. The PPP is performed by permanent catheter placed in a minor surgical procedure. The total amount of CO2 insufflated ranged from 2,000 to 7,000 ml (mean 4,000 ml). Patients required a mean of 10 PPP sessions (range 4–18) to achieve the desired volume of gas (that is the same volume that was calculated for the hernia sac). Since PPP sessions were performed once a day, 4–18 days were needed for preoperative preparation with PPP. The mean VR was 36% (ranged from 26 to 73%). We conclude that ACT provides objective data for volume calculation of both hernia sac and abdominal cavity and also for estimation of the volume of gas that should be insufflated into the abdominal cavity in PPP.

OBJECTIVE:The aim of this work was to identify clinical data indicative of the number of hyperbaric oxygen therapy HBO2 sessions that should be prescribed for adjuvant treatment of tissue injuries of differing severity.PATIENTS:A total of 1730 cases of patients treated with HBO2 using an open protocol (without a predetermined number of sessions) was examined in this study.METHOD:A retrospective study involving charts review was conducted. Severity had been previously determined for the treatment of acute (fasciitis, myositis, gangrene, contaminated/infected perineal or lower extremity traumatic injuries) or chronic (osteomyelitis, pressure sore, diabetic or ischemic ulcer) injuries. Only patients that met or exceeded the supposed effective minimal treatment doses (5 sessions for acute, 10 sessions for chronic injuries) were included in the present study.RESULTS:The data analysis included 1506 cases. These consisted of 1014 patients with acute injuries, who required 11 to 18 sessions (depending on injury severity), and 492 patients with chronic injuries, who required a greater (p < 0.001) number of sessions (approximately 30/patient, independent of injury severity). Global mortality was 79/1506 patients.CONCLUSION:These results seem to support the initial indication of 15 HBO2 sessions for the treatment acute injuries, and 30 for treatment of chronic injuries. Prospective studies may better determine the number of sessions for the treatment of different types of injuries.

Asymptomatic tumors are not uncommon, may be diagnosed during clinical examination or during surgical interventions for other purposes such as treatment of a hemorrhage due a blunt trauma.Case report 6 year‐old boy had fallen, hitting his abdomen against a rock, and arrived at hospital ten hours later. Initial assessment he was complaining of diffuse abdominal pain; his physical examination showed: respiratory rate: 16 mov/min, blood pressure: 100 × 80 mmHg, heart rate: 100 bat/min, and Glasgow coma score: 15. His abdomen was distended, with guarding and rebound tenderness, and had a palpable mass. FAST ultrasound was positive; and Ct‐scan showed an abdominal mass with 15 × 12 × 7 cm dimension, and moderate amount of free blood in the abdominal cavity. Laboratory tests showed: hemoglobin 9.9 mg/dl, hematocritic 28.8%, white blood cells 6.900 cel/dl.Midline laparotomy was performed, a large, injured and bleeding mesenteric mass was found encircling superior mesentery artery and several small bowel loops; 500 ml of free blood was found in the peritoneal cavity. Mesenteric mass was partially removed with a segment of the small bowel. Findings of anatomico‐pathologic examination revealed an intestinal Burkitt lymphoma, with mesenteric linfonodes. Patient had an uneventful postoperative course, and started with quimotherapy.Comments This case report shows an unusual traumatic abdominal blending that could not be clearly diagnosed before laparotomy was performed. The emergency of this case was bleeding control, decision to remove mass was taken only for this purpose, and not to treat the tumor. As removal of the whole mass was impossible, a partial removal was performed.

Although uncommon, and despite the modern in diagnostic tools and therapeutic alternatives, retrohepatic and main hepatic veins injury remains associated with high mortality rate. Preoperative diagnosis is uncommon, and bullet trajectory may be a helpful sign in penetrating trauma patients.Patients and Methods Hospital records of patients sustaining retroheptic vena cava (RHVC) injury were retrospectively reviewed as to diagnosis, associated injuries, injury characteristics, surgical management, and outcome, last ten years.Results Eight male, 17 to 45 (mean 27.5) years‐old patients sustaining RHVC injury were reviewed. Mean trauma indexes for the 8 cases were: ISS 36.6, RTS 7.55 and TRISS 89.0; and for the group who died: ISS 41.6, RTS 7.18, and TRISS 80.5. Two patients had sustained blunt trauma (one died), and six had penetrating injuries (two died). The injury diagnosis was achieved during surgery in all cases. A transfixing RHV injury occurred in 4 (50% of the) patients, and was found in all the 3 patients who died. An atriocaval shunt was employed in four patients, 3 of them had with transfixing injury with two deaths. The number of associated injuries was higher in the patients who died. Overall mortality rate was 37.5%.Comments Despite advances in image diagnosis, injuries to RHVC are frequently diagnosed during surgery. Tangential injuries were managed with direct approach and sutures, and to control blending in transfixing injuries, were managed with atriocaval shunts, before suture.Conclusion Despite improvements in its diagnosis and management, RHVC injuries remain with a high mortality rate, mainly when transfixing, and associated with numerous associated injuries.

We hypothesized that early bleeding control associated with hypertonic saline solution (HTS) or HTS + dextran (HTSD) infusion improves tissue perfusion and oxygenation after hemorrhagic shock (HS). Methods: Eighteen dogs were submitted to controlled HS, MAP=40 mmHg during 15 or 30 minutes, and randomized in 3 treatment groups: GI early bleeding control + HTS; GII late bleeding control + HTS; GIII early bleeding control +HTSD. MAP, hemoglobin, cardiac index (CI), oxygen delivery index (DO2I), lactate and oxygen extraction rate (O2ER) were determined. Jejunal segments were histologically analysed. Results: The percentage of lost blood volume and MAP behavior was similar in the 3 Gs. All treatments increased CI and DO2I. Prolonged shock provoked a significant increase in lactate (p<0.01) and O-2 ER (p<0.05). Conclusions: Early control of bleeding associated with HTS or HTSD administration in HS led to early improvement in perfusion and tissue oxygenation as evaluated by lactate and O-2 ER indices. The histologic analysis didn't show differences among Gs.

The diagnostic approach to venous thromboembolism has many difficulties and limitations. Its clinical picture is not specific, and it has a very low positive predictive value, so the use of complementary examinations is necessary to confirm the presence of venous thromboembolism. To implement a better diagnostic investigation, reducing its inconvenience, this protocol was developed to evaluate D-dimer test efficacy in excluding acute venous thromboembolism.One hundred and twenty three patients were studied (70 women), who presented to the emergency department with signs and symptoms suggestive of pulmonary thromboembolism (PTE) or deep venous thrombosis (DVT), or both of these. Acute arterial occurrences were excluded.The prevalence of acute thrombosis among the study patients was 29%. The D-dimer examination (VIDAS) is effective and safe in excluding acute events of venous thromboembolism.The clinical picture of acute venous thromboembolism has a very low positive predictive value; therefore, it is essential to conduct complementary examinations to confirm its presence.

Candido, Marta; Poggetti, Renato S.; Fontes, Belchor; Birolini, Dario Author Information

Some preliminary data are needed to coherently analyze the present state of surgery in Brazil. Brazil is among the 10 greatest economies of the world, is the most populous South American country, and occupies an area of approximately 8500000 km 2 . Its borders make contact with all South American countries, except for Chile and Ecuador. The political administrative organization comprises 26 states, approximately 5500 municipalities, and the Federal District, the seat of the government. The country is divided into 5 great regions, whose characteristics are shown in Table 1.

In this paper, the authors make a brief review of history, indications and technique of percutaneous cervical pharyngostomy and its uses in surgery. They retrospectively analyse seven cases in which this procedure was applied for postoperative decompression and feeding after gastric and esophageal operations without any serious complications.

Blunt rupture of the pericardium is a rare injury. Strangulated cardiac hernia following blunt trauma is one cause of reversible cardiac arrest. Traumatic pericardial tears usually have delayed diagnoses and carry high mortality rates (64%). Clinical signs mimic cardiac tamponade during the primary survey. We report here two cases of blunt trauma. Both patients arrived alive in the emergency room and presented signs of cardiac tamponade caused by pericardial rupture.

The employment of synthetic mesh for incisional hernia repair in kidney-transplanted patients is rarely reported in the present literature. Many authors believe that mesh employment in such conditions is not safe due to fear of mesh related complications. From 1965 through 1999, a total of 1685 kidney transplants were performed at our Kidney Transplant Unit and 19 patients developed eventrations in the kidney transplant incision, an incidence of 1.1%. From September 1996 eight of these patients had prosthetic repair of the abdominal wall with onlay polypropylene mesh. All patients were under immunosuppressive therapy with prednisone, ciclosporine and azathioprine. Mean age was 48.8 years, mean body mass index was 22.5 and mean number of previous abdominal operations was 2.5. A large polypropylene mesh (Marlex® mesh) was fixed over the aponeurosis after primary closure of the aponeurotic borders, as an onlay graft. There was neither morbidity nor mortality associated to the surgical procedure. No recurrences or long-term complications associated with mesh employment were verified after a follow-up ranging from one year to three years. We concluded that prosthetic repair of incisional hernia in transplanted patients can be performed routinely.

Blunt Esophageal Trauma is a very rare injury. Delay in diagnosis worsens the prognosis. A high index of suspicion based in trauma mechanism, an accurate diagnostic investigation and immediate treatment are crucial in the approach of this atypical trauma. Our objective is to present two cases of blunt esophageal trauma admitted to our Emergency Department.

BACKGROUND Papillary adenocarcinomas are rare tumors of the gastrointestinal tract. There are few reports of this neoplasm diagnosed during pregnancy. CASE A case of adenocarcinoma of the papilla of Vater was diagnosed by sonographically guided biopsy during pregnancy. The patient underwent radical resection of the tumor at 25 weeks' gestation; pregnancy termination was not indicated. At 39 weeks' gestation, a cesarean-section was performed. The postoperative period entailed total parenteral nutrition until intestinal motility stabilized. This ensured the mother and fetus' well-being until delivery. CONCLUSION Papillary adenocarcinoma is associated with good prognosis since it is totally removed by radical resection, and pancreaticoduodenectomy can be performed successfully during pregnancy, but the patient must receive special prenatal care.

BACKGROUND Gut ischemia followed by reperfusion (I/R) is implicated as a prime initiating event in the mechanism of multiple organ failure after trauma and hemorrhagic shock. Several lines of evidence indicate that macrophages are involved in this prime event. Our purpose was to evaluate hydrogen peroxide (H2O2) and tumor necrosis factor (TNF) production and phagocytosis by lung macrophages in a gut I/R model of multiple organ failure in rats. METHODS In the experimental group (I/R), Wistar rats (n = 35) were anesthetized and subjected to a median laparotomy, and the superior mesenteric artery was clamped for 45 minutes followed by 60 minutes of reperfusion. In the control group (LAP) (n = 37), animals underwent sham laparotomy. After the period of reperfusion, bronchoalveolar lavage (BAL) was performed and the resulting BAL cells were assayed for H2O2 production using the horseradish peroxidase-mediated red phenol oxidation method. TNF release was determined using the L929 cells bioassay. Zymosan phagocytosis by BAL macrophages was quantitated using phase microscopy. RESULTS H2O2 release in BAL cells of I/R rats (19.90 +/- 7.98 nmol/L/2 x 10(5) cells) is statistically higher than in the LAP group (10.92 +/- 5.01 nmol/L per 2 x 10(5) cells) (p = 0.0155), and the TNF production by BAL cells of the I/R group (38.09 +/- 20.79 units per 10(6) cells) was significantly higher than that of LAP rats (17.16 +/- 13.35 units per 10(6) cells) (p = 0.0281). Phagocytic activity of BAL mac. Macrophages of I/R rats was not statistically different from LAP animals. CONCLUSION These results suggest that BAL macrophage play a role in the mechanism of acute lung injury after trauma and hemorrhagic shock.

BACKGROUND:Wound infection and sepsis leading to incisional hernia development are common after emergency colonic operations. Later on, while being operated on to correct an incisional hernia, most of these patients will need colonic resection or bowel continuity reestablishment. Simultaneous treatment of incisional hernias in patients with colostomy or colonic disease remains a difficult challenge, considering the reluctance of most surgeons to treat both conditions at the same time, especially when prosthetic repair is needed.STUDY DESIGN:The aim of this study was to analyze the short-term results of patients undergoing colonic resection or bowel continuity reestablishment and simultaneous incisional hernia repair with an onlay polypropylene mesh technique. Over a period of 6 years, 20 patients were operated on for colonic problems associated with incisional hernias, including 8 Hartmanns' colostomies, 6 colostomies or ileostomies with colonic mucous fistulas, 3 postoperative colocutaneous fistulas, a paracolostomic hernia, a Chagas' megacolon, and a pseudotumoral diverticulitis. A "rule of three" statistical analysis was used to estimate the maximum risk of adverse effects, concerning mesh-related morbidity, after 1- and 2-year followup.RESULTS:A major complication occurred in a patient who developed an anastomotic leakage and secondary wound infection; the patient was treated with parenteral nutrition and antibiotics. Other complications included a minor wound infection, a seroma, and a chronic sinus. One patient died from postoperative problems unrelated to the surgical technique. The occurrence of postoperative wound infection did not prevent mesh incorporation. Followup ranging from 1 to 7 years detected no hernia recurrences; 13 patients were followed for 2 years or more. Our results suggest that risk of mesh-related morbidity does not exceed 15.8% (3 of 19) within the first year and 23.1% (3 of 13) for 2 years followup, with 95% confidence.CONCLUSIONS:We concluded that prosthetic repair of incisional hernias associated with simultaneous colonic operations was possible, allowing abdominal wall anatomy reestablishment. There is no reason to believe that abdominal wall prostheses must be avoided in contaminated operations when an adequate surgical technique is used.

This article details new concepts in the management of patients with penetrating abdominal wounds. Diagnostic modalities, such as physical examination, evaluation and wound exploration, radiography, peritoneal lavage, CT, ultrasound, laparoscopy, and thoracoscopy; selective management; hemodynamic status; moribund, stable, and unstable patients; mechanism and location of injury; abbreviated laparotomy; abdominal hypertension; early enteral nutrition; antibiotics; packing; cost-constraints; guidelines and protocols; transplantation; and hypothermia are discussed.

Younes, R N; Itinoshe, M M; Yada-Langui, M M; Birolini, D; e Silva, M Rocha Author Information

To compare late results (recurrence) of three different techniques for treatment of inguinal hernias in the adult: Bassini, Shouldice and McVay.The operative late results of three surgical techniques: Bassini, Shouldice and McVay in 119 adult patients with inguinal hernias (some with bilateral pathology, totalizing 136 hernias) were analyzed. The majority of patients were males (93.3%). The analysis was prospective, randomized, with uniform distribution of all three types of inguinal hernia (direct, indirect and combined) among the three groups of operative techniques. The number of recurrences was submitted to an actuarial analysis for a period of 4 years. The results underwent statistical analysis by the Kaplan-Mayer test with actuarial survival curves.Eight hernia operations by the Bassini technique recurred in this time span, 3 in the Shouldice group and 2 in McVay. Among the Bassini recurrences, the worst results were observed with direct hernias (29% recurrence) when compared with indirect ones (16% recurrence). Overall recurrence rates plotted in an actuarial survival curve for 4 years, revealed statistically significant differences between Bassini and Shouldice: 35.7% versus 23.7%; the same happened when comparing Bassini to McVay: 35.7% versus 8.5%. The differences between Shouldice and McVay were not significant.A recurrence rate of 35.7% for inguinal herniorraphy with the Bassini technique in a General Surgery University Clinic was surprising and obliged us to interrupt the trial. Our observations point to a prohibitive high failure rate when dealing with the Bassini technique, which was, over a century, the most popular treatment of inguinal hernia all over the world. Shouldice and McVay techniques, even though more complex, should be preferred whenever one makes the choice for "conventional" hernia treatment.