Eduardo Neubarth Trindade

Experimental model to induce obesity in rats

The etiology of obesity is multifactorial and is becoming a problem of public health, due to its increased prevalence and the consequent repercussion of its comorbidities on the health of the population. The great similarity and homology between the genomes of rodents and humans make these animal models a major tool to study conditions affecting humans, which can be simulated in rats. Obesity can be induced in animals by neuroendocrine, dietary or genetic changes. The most widely used models to induce obesity in rats are a lesion of the ventromedial hypothalamic nucleus (VMH) by administering monosodium glutamate or a direct electrical lesion, ovariectomy, feeding on hypercaloric diets and genetic manipulation for obesity.

Collagen in the transversalis fascia of patients with indirect inguinal hernia: a case-control study

BACKGROUND The aim of this study was to analyze the constituents of total and types I and III collagen fibers in the transversalis fascias of patients with indirect inguinal hernias, compared with samples removed from nonherniated cadavers. METHODS Biopsy samples from 26 patients and 26 cadavers were analyzed. Hematoxylin-eosin and picrosirius staining techniques were used. The images obtained were analyzed using a video morphometric technique to determine the constituents of total collagen and types I and III collagen in the transversalis fascia. The picrosirius-stained tissues were submitted to observation under polarized-light microscopy. RESULTS The results showed 17.3% less total collagen in patients with hernias compared with the control group (P < .01). Type I collagen in patients with indirect inguinal hernias was 23.7% less than the control group (P < .01), type III collagen was 6.4% less in the controls (P < .01). CONCLUSION The lower percentages of total collagen and type I collagen in the transversalis fascias of patients with indirect inguinal hernias could be a factor in hernia formation.

Fibroplasia after polypropylene mesh implantation for abdominal wall hernia repair in rats

PURPOSE This study assessed the collagen deposition and correlated it with local inflammatory responses to evaluate the length of time required for fibroplasia when polypropylene meshes are used to repair incisional abdominal wall hernias in rats. METHODS Thirty-six male Wistar rats underwent longitudinal resection of a peritoneal and musculoaponeurotic tissue segment (3x2 cm) of the abdominal wall followed by defect reconstruction with polypropylene mesh bridging over aponeurosis. The animals were divided into 6 groups according to the time points for the analysis of fibroplasia: 1, 2, 3, 7, 21 and 30 days post-implantation. Animals were sacrificed at each time point, and the site where the polypropylene mesh was implanted was evaluated histologically to assess inflammatory response and percentage of collagen using computer-assisted videomorphometry. RESULTS Total collagen was found at the mesh site on the 3rd day post-implantation, and increased progressively on all subsequent days up to the 21st day, when it reached its highest percentage (p<0.001). Type III collagen increased progressively from the 3rd to the 21st days, when it reached its highest percentage (p<0.001); on the 30th day, it decreased significantly (p>0.001). Type I collagen was first found between the 7th and 21st days; it reached its highest percentage on the 21st day and then remained stable until the 30th day. The type I to type III collagen ratio increased significantly and progressively up to the 30th day (p<0.001). Neutrophils were found at the mesh site from the 1st to the 21st day post-implantation. Macrophages, giant cells and lymphocytes were seen on the 2nd day. Thirty days after mesh implantation, neutrophils disappeared, but the percentages of macrophages, giant cells and lymphocytes remained stable (p<0.001). CONCLUSIONS This study showed that total collagen was first seen on the 3rd day post-implantation, with a higher percentage of type I collagen at the last observational time point. The prolonged healing inflammatory response and the persistence of chronic inflammation surrounding to the mesh did not affect the length of time required for fibroplasia.

Acute gastric dilatation and necrosis: a case report.

Abstract Massive gastric dilatation with necrosis and rupture is a very rare event. Here we describe the case of a 13-year-old girl with acute gastric dilatation, infarction, necrosis and perforation. It began with acute abdominal pain, but an absence of vomiting after eating a heavy meal. Laparotomy showed massive gastric dilatation with infarction and perforation. Early diagnosis is essential to reduce morbidity and mortality, and therefore treatment must be started promptly.

Melanoma metastasis to the spleen: Laparoscopic approach

We report a case of minimally invasive surgery in the management of metastasis to the spleen. A 67-year-old male patient with possible splenic soft tissue melanoma metastasis was referred to our hospital. He had a history of an excised soft tissue melanoma from his back eight months earlier, and the control abdominal computer tomography (CT) scan revealed a hypodense spleen lesion. The patient underwent laparoscopic surgery to diagnose and treat the splenic lesion. The splenectomy was performed and the histological examination revealed a melanoma. The patient had a good postoperative course and was discharged on the second postoperative day. On his 12-month follow-up there was no sign of recurrence. The laparoscopic approach is a safe and effective alternative for treatment of splenic metastases.

Laparoscopic splenectomy for isolated splenic sarcoidosis.

Isolated splenic sarcoidosis is a rare manifestation of extrapulmonary disease and may be amenable to minimally invasive surgical technique.

The use of mesh and collagen in incisional hernias

Dear Editor We read with much interest the article by Vidovic et al., titled “Factors aVecting recurrence after incisional hernia repair [1]”. We fully agree with the authors’ conclusion that it is important to become familiar with the risk factors for recurrence of incisional hernia to eliminate or decrease recurrence, but we have a few remarks concerning the article. The authors claim that the routine use of synthetic mesh is not justiWed because of its potential for complications, and that the results of sutured repair of small to medium-sized hernias are satisfactory. However, according to a well-conducted randomized controlled trial that compared suture versus mesh repair of incisional hernia in patients with a primary or Wrst-time recurrent incisional hernia, the conclusion was that the routine use of mesh is superior to suture repair for both small and large incisional hernias, and the use of mesh repair results in lower recurrence rates. Mesh reduces the morbidity and costs associated with incisional hernias. In patients with small incisional hernias, the recurrence rates were 67% after suture repair and 17% after mesh repair (P = 0.003). Hence, concerning the potential for complications in the mesh repair group, 17% had a complication, compared with 8% in the suture repair group (P = 0.17), not a statistically signiWcant diVerence [2]. The authors also did not discuss collagen metabolism disorders in hernia patients. Collagen disorders play an important role in the development of inguinal hernia [3]; impaired proportions result in tissue alterations, and are one of the factors that lead to hernia formation. Collagen plays an important role in the pathogenesis of incisional hernias and is not mentioned. A recent study, conducted in our department, comparing the qualitative and quantitative aspects of total and types I and III collagen samples of linea alba aponeurosis in patients with hernias on the anterior abdominal wall, including incisional ones, and from cadavers without hernias, showed that individuals with hernia have a small amount of total and type I collagen. The amount of total collagen was 18.05% smaller and type I collagen was 20.50% smaller in patients with hernias (P < 0.05) [4]. The results of these and other studies [5] indicate a relationship between incisional hernias and collagen disorder. In the evaluations of incisional hernia repair we should never forget the important role of collagen imbalance in the pathophysiology of hernia formation. The use of mesh should be increasingly encouraged to avoid unnecessarily high rates of recurrence.

Monopolar electrosurgery on the extrahepatic bile ducts during laparoscopic cholecystectomy: an experimental controlled trial.

Introduction The purpose of this study is to investigate the occurrence of thermal injury in the extrahepatic bile ducts when monopolar electrosurgery is used to perform dieresis of the cystic duct and cystic vessels in laparoscopic cholecystectomy. Methods Female pigs (n=40) of the Large White breed were separated into 2 groups of 20 animals. In the experimental groups, dieresis of the cystic duct and cystic vessels was performed with monopolar electrosurgery using a hook-like dissector using a power setting of 20 W, whereas in the control group this procedure was performed with a pair of Metzenbaum scissors disconnected from any kind of thermal energy source. Occurrence of distal thermal injury was evaluated on 2 occasions, on the 3rd and 28th days postoperatively. It consisted of exploratory laparotomy, cholangiography and both macroscopic and microscopic examination of the surgical specimen, which included cystic duct stump, hepatic duct and choledochus. Results The presence of distal thermal injury, classified as second degree, 1.2 mm in the portion near the clipping area, was observed in only one of the cystic duct stumps after microscopic examination, without statistical significance. No thermal injury was observed in the extrahepatic bile ducts. Conclusions Monopolar electrosurgery produced negligible thermal injury in the extrahepatic bile ducts after laparoscopic cholecystectomy.

A via videolaparoscópica pode ser utilizada como rotina nas esplenectomias

BACKGROUND: Laparoscopic splenectomy is an alternative for the treatment of patients undergoing elective splenectomy. One of its main indications is in hematologic diseases non-responsive to pharmacological treatment. Videolaparoscopy presents advantages to patients when compared to laparotomy: less post-operative pain, recovery of the functions of the gastrointestinal tract, better cosmetic results and shorter hospitalization. AIM: To present a case series of laparoscopic splenectomy in a university hospital. METHODS: Were analyzed all the laparoscopic splenectomies between June 2005 and October 2012. The analysis was conducted prospectively divided into pre-, trans-, and post-operative data on: gender, age, indication for surgery, rate of conversion to open surgery, duration of surgery, spleen size, presence of an accessory spleen, time hospitalization and short-term response in eight weeks after the procedure, by analyzing hemoglobin and platelets pre- and post-operative, broken down by gender. RESULTS: Were analyzed 44 laparoscopic splenectomies performed in the period. Patients diagnosed with idiopathic thrombocytopenic purpura accounted for 56.8%, non-responsive to pharmacological treatment; autoimmune hemolytic anemia was 13.6%; spherocytosis, 11.3% and 18.3% by other non-hemolytic causes. Six patients had to be converted to open surgery (13.63%), four due to excessive bleeding. The mean operative time was 166.7 (60-319) minutes and the length of hospitalization was 12 days. Only four patients (9.1%) had post-operative complications, and none had bleeding after surgery and the positive response in the short term, after eight weeks of treatment, was achieved by 88% of patients. CONCLUSIONS: Laparoscopic splenectomy is a safe alternative for all major indications of splenectomy and can be routinely used.

Antireflux Surgery with Routine Mesh Hiatoplasty

We read with much interest the study of Kepenekci, ‘‘Laparoscopıc Fundoplicatıon with Prosthetic Hiatal Closure’’ [1]. It helps to dispel the fear of prostheses, showing that they are safe and important to use. However, we have a few concerns about the article. Failure of hiatal hernia surgery and the recurrence of hiatal hernia are due to excessive stress on the hiatoplasty suture and the hiatal diameter. Therefore, we could not agree more with the author that if hiatoplasty depends solely on the suture it is ineffectual and leads to disruption and thus high rates of recurrence [1, 2]. This is not seen in the corrections using mesh [3, 4, 5]. As in Kepenekci’s conclusion, we also advocate the routine use of mesh in hiatoplasty. However, one of our concerns is that there is no uniform protocol or standardized procedure for mesh fixation and size. Another important issue that the surgeon needs to be aware of but was not mentioned by Kepenekci is the biology of hernia formation/recurrence. Factors related to recurrence are vomiting, surgeon inexperience, trauma, and heavy lifting. However, we should not forget the possible role of collagen disorders/impairment [6]. Collagen plays an important role in the development of inguinal and incisional hernias [7, 8] and there is also a possible relationship between collagen impairment and hiatal hernia [6]. There is evidence of ultrastructural alterations in patients with hiatal hernia; the long-term results of antireflux surgery depend not only on the surgical technique but also on the underlying muscular diaphragmatic illness [9]. The use of mesh as in the repair of hernias of the abdominal wall and the ‘‘tension-free’’ principle would decrease the high rates of recurrence. The best mesh size and mesh fixation technique and the ultrastructural alterations in the pathogenesis of hiatal hernia needs to be clarified.