Fernando A. M. Herbella

Comparative study of inflammatory response and adhesions formation after fixation of different meshes for inguinal hernia repair in rabbits

OBJETIVO: Avaliar a resposta inflamatoria e a formacao de aderencias das proteses de polipropileno e polipropileno associado a poliglactina sintetica (Vypro®) implantadas no espaco pre-peritoneal de coelhos. METODOS: Foram utilizados 14 coelhos albinos linhagem Nova Zelândia com tres meses de idade, machos com peso variando de 2000 a 2500 gramas. O acesso a cavidade se deu por incisao mediana abaixo do apendice xifoide com oito centimetros de extensao. Realizou-se o implante da tela de polipropileno no flanco esquerdo com um ponto de polipropileno em cada extremidade da protese. No flanco direito a tela Vypro® foi fixada da mesma forma com pontos de polipropileno. A laparoscopia foi realizada 28 dias apos o primeiro procedimento para avaliacao de aderencias intracavitarias. As proteses juntamente com o peritonio, musculatura e aponeurose adjacente foram retiradas em blocos individuais. Cada peca foi imersa em solucao tamponada de formaldeido a 10% e encaminhada ao patologista. RESULTADOS: Todos os animais tiveram boa evolucao pos-operatoria nao havendo infeccao das incisoes cirurgicas ou obito dos coelhos. Das quatorze proteses Prolene implantadas no peritonio intacto de coelho, em onze (78,6%) houve formacao de aderencias Das quatorze proteses Vypro®implantadas no peritonio intacto de coelho, em doze (85,7%) houve formacao de aderencias. Comparando as duas proteses entre si nao houve diferenca significante quanto ao numero de aderencias formadas. Em relacao a avaliacao microscopica, nas proteses VYPRO® a reacao granulomatosa do tipo corpo estranho e a fibrose foram predominantemente moderadas. Ja a inflamacao inespecifica foi proporcionalmente leve e moderada A inflamacao inespecifica foi menos intensa nas proteses de polipropileno. CONCLUSAO: Ambas as proteses implantadas na cavidade peritoneal de coelhos promovem a formacao de aderencias de forma semelhante. As proteses de polipropileno e associado a poliglactina promovem maior fibrose, apresentando melhor incorporacao aos tecidos.PURPOSE Compare, in a rabbit model, the inflammatory response and adhesions formation following surgical fixation of polypropilene and Vypro mesh in the inguinal preperitoneal space. METHODS Fourteen male New Zealand rabbits, weighing between 2.000 to 2.500 g were used. A midline incision was made and the peritoneal cavity was exposed. The 2.0 x 1.0 cm polypropylene mesh was fixed in the left flank and secured to the margins with 3-0 prolene in a separate pattern. In the right flank, a 2.0 x 1.0 cm Vypro II mesh was sewn in the same way. After the post surgical period, the animals were again anesthetized and underwent laparoscopic approach, in order to identify and evaluate adhesions degree. Both fixed prosthesis were excised bilaterally with the abdominal wall segment, including peritoneum, aponeurosis and muscle and sent to a pathologist. RESULTS Operative time ranged from 15 to 25 minutes and no difficulties in applying the mesh were found. From the 14 polypropylene meshes fixed to the intact peritoneum, 11 had adhesions to the abdominal cavity (78.6%). Concerning Vypro mesh, 12 animals developed adhesions from the 14 with mesh fixation (85.7%). Histological examination of tissues harvested revealed fibroblasts, collagen, macrophages and lymphocytes between the threads of the mesh. CONCLUSION Polypropylene and Vypro mesh, when implanted in the peritoneal cavity of rabbits provoke similar amount of adhesions. Vypro mesh tissues had higher fibrosis resulting in better mesh incorporation to the abdominal wall.

Modern pathophysiology and treatment of esophageal diverticula

IntroductionEsophageal diverticula are rare. They may occur in the pharyngoesophageal area (Zenkers), midesophagus, or distally (epiphrenic). A motility disorder (either at the level of the esophageal sphincters or body) is frequently associated with esophageal diverticula. The risk of malignant transformation is low.MethodsA literature search was performed using Medline/PubMed database.ResultsThe treatment of esophageal diverticula must be based on the pathophysiology and natural history of the disease: (a) asymptomatic diverticula do not need a specific treatment, (b) small diverticula may be left in place and not resected, (c) medium-size diverticula may be either treated by diverticulectomy, diverticulopexy, or esophagodiverticulostomy in case of pharyngoesophageal diverticula, (d) resection is probably the ideal therapy for larger diverticula, and (e) a myotomy should always be included to the procedure.ConclusionsDue to its rarity, esophageal diverticula must be treated by esophageal surgeons since even in experienced hands the complication rate can be significant.

'Raccoon eyes' (periorbital haematoma) as a sign of skull base fracture

This is a study of the relationship between skull base fracture and the raccoon eyes sign in a prospective study in cadavers. Fifty cadavers were analysed with cranio encephalic trauma and skull base fracture or the raccoon eyes sign. Both conditions were present in 24 (48.0%) cases. The association was significantly higher in cases with a frontal basal fracture and epidural haematoma. The raccoon eyes sign is easily recognised and can be associated with basal fractures.

Surgical Treatment of Primary Esophageal Motility Disorders

Named primary esophageal motility disorders (PEMD) present with specific manometric patterns classified as: (1) hypertensive lower esophageal sphincter, (2) nutcracker esophagus (also hypercontratile, hypertensive, or hypercontracting esophagus), (3) diffuse esophageal spasm, and (4) achalasia. These conditions, with the exception of achalasia, are rare, poorly understood, and inadequately studied. Treatment of these conditions is based on symptoms and aimed at symptomatic improvement. The authors reviewed current literature on surgical treatment of non-achalasia PEMD. The review shows that: (a) surgical therapy may be an attractive alternative in patients with PEMD; (b) proper selection of patients based on symptoms evaluation and esophageal function tests is essential; (c) laparoscopic myotomy with proximal extent tailored to manometric findings seems to be the ideal surgical therapy; and (d) esophagectomy may be necessary as a last resource due to multiple failures of surgical conservative treatment.

CHANGES IN QUALITY OF LIFE AFTER SHORT AND LONG TERM FOLLOW-UP OF ROUX-EN-Y GASTRIC BYPASS FOR MORBID OBESITY

CONTEXT It is unclear whether health-related quality of life (HRQL) is sustained in a long-term follow-up of morbidly obese patients who underwent Roux-en-Y gastric bypass (RYGB). Objective This study aims to analyze the HRQL changes following RYGB in short and long-term follow-up. METHODS We compared the health-related quality of life among three separate patient groups, using the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36). Group A - 50 preoperative morbidly obese patients; Group B - 50 RYGB patients 1-2 years post-surgery; Group C - 50 RYGB patients more than 7 years post-surgery. RESULTS The groups were similar for gender, age and body mass index before surgery. We observed that physical functioning, social function, emotional role functioning and mental health scales did not vary between the three groups. The physical role functioning scale was unchanged in the short-term and decreased compared to the preoperative scale in the long-term follow-up. Bodily pain improved after the operation but returned to the initial level after 7 years. The vitality and general health perceptions improved after the operation and maintained these results after 7 years compared with the preoperative perceptions. CONCLUSIONS RYGB improved health-related quality of life in three SF-36 domains (bodily pain, general health perceptions and vitality) in the short-term and two SF-36 domains (general health perceptions and vitality) in the long-term.

When did the esophagus start shrinking? The history of the short esophagus

Even though the history of this condition extends for almost 100 years, the short esophagus (SE) is still one of the most controversial topics in esophageal surgery with its existence still denied by some distinguished surgeons. We reviewed the evolution behind the diagnosis and treatment of the SE and the persons who wrote its history, from the first descriptions by radiologists, endoscopists, and surgeons to modern treatment.

Human cadavers as an experimental model for esophageal surgery.

The use of cadavers in experimental esophageal surgery is reviewed. Items useful to cadaveric studies such as post-mortem changes, biosafety, ethics, and legislation are discussed. Tactics used in minimally invasive procedures (thoracoscopy and laparoscopy) are shown. Cadaveric use in studies concerning esophagectomy, gastroesophageal reflux disease, esophageal atresia, Boerhaaves syndrome, and Mallory-Weiss tears are discussed. It is concluded that human bodies represent a good but underused model for esophageal surgery.

Lesões fatais em trauma numa grande metrópole Brasileira: um estudo de autópsias

OBJECTIVE This study aims to review a series of deaths by trauma in a large metropolis. The intention is to identify preventable causes of death. METHODS We prospectively studied 500 unselected and consecutive cases of death associated with trauma. The study variables were: mechanism of injury, etiology, site of injury, surgical intervention, medical malpractice, damaged organs and the prevention of mortality. The cases were grouped according to the mechanism of injury in: penetrating trauma, blunt trauma, poisoning, drowning, burns and suffocation. RESULTS We examined 418 (83.6%) males and 82 (16.4%) females (mean age 39 ± 19.6 years, ranging from three to 91 years). Penetrating trauma accounted for 217 (43%) cases, while blunt trauma accounted for 40% of cases. The most common mechanism of injury in death by penetrating trauma was gunshot, representing 41% of cases. Within the set of blunt trauma, the most common mechanism was traffic accident, which represented 22% of total deaths. There were 71 (14%) cases of preventable deaths: thromboembolism in 35 (7%), infectious complications in 25 (5%), medical malpractice in seven (1%) and treatable lesions in outpatients in five (1%). CONCLUSION This study shows that traumatic death in the city of São Paulo is associated with serious and complex injuries. Prevention of these types of death would be related to the control of violence.

Short esophagus or bad dissected esophagus? An experimental cadaveric study

Short esophagus is defined as the inability to reduce the gastroesophageal junction below the diaphragm. One of the factors responsible for this inability can be inadequate esophageal mobilization. We evaluated esophageal lengthening achieved by means of dissection in a cadaveric model. Fifty-one cadavers were dissected (27 transthoracically and 24 transhiatally). Abdominal esophageal length was assessed before and after dissection of the esophagus from the hiatus to the carina. In the transthoracic group, a mean of 1.7 ± 1.3 cm (range0.3 to 5.0cm) was gained with dissection. In the transhiatal group, a mean of 1.8 ± 0.8 cm (range 0 to 3.0 cm) was gained with dissection. In a comparison of results of transthoracic and transhiatal approaches, the difference was not statistically significant. We concluded that a significant increase in esophageal length was achieved after dissection; however, the access route (thorax or abdomen) did not influence the results.

Extended Lymphadenectomy in Esophageal Cancer is Debatable

Surgery is an essential part of the treatment of patients with esophageal carcinoma. However, there is no consensus on whether the surgical technique can be improved to promote better survival outcome. Specifically, the real value of the addition of a radical lymphadenectomy to the esophageal resection is still elusive and controversial. This paper focuses on the debate of esophagectomy and lymphadenectomy for the treatment of esophageal cancer.