José Francisco de Mattos Farah

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.

Progression of diffuse esophageal spasm to achalasia: incidence and predictive factors

The progression of certain primary esophageal motor disorders to achalasia has been documented; however, the true incidence of this decay is still elusive. This study aims to evaluate: (i) the incidence of the progression of diffuse esophageal spasm to achalasia, and (ii) predictive factors to this progression. Thirty-five patients (mean age 53 years, 80% females) with a manometric picture of diffuse esophageal spasm were followed for at least 1 year. Patients with gastroesophageal reflux disease confirmed by pH monitoring or systemic diseases that may affect esophageal motility were excluded. Esophageal manometry was repeated in all patients. Five (14%) of the patients progressed to achalasia at a mean follow-up of 2.1 (range 1-4) years. Demographic characteristics were not predictive of transition to achalasia, while dysphagia (P= 0.005) as the main symptom and the wave amplitude of simultaneous waves less than 50 mmHg (P= 0.003) were statistically significant. In conclusion, the transition of diffuse esophageal spasm to achalasia is not frequent at a 2-year follow-up. Dysphagia and simultaneous waves with low amplitude are predictive factors for this degeneration.

Surgical management of gallbladder disease in the very elderly: are we operating them at the right time?

Background As life expectancy rises worldwide and the prevalence of gallstones increases with age, the number of very elderly patients requiring treatment for gallstone diseases is increasing. The aim of this study was to compare the results of cholecystectomy in patients 80 years or older according to different clinical presentations. Methods This is a retrospective study of 81 patients 80 years or older. Indications for surgery were stratified into three groups: outpatients (symptomatic chronic cholecystitis), inpatients (complicated gallstone diseases), and urgent patients (acute cholecystitis). Data analysis included age, sex, the American Society of Anesthesiologists score, indication for surgery, length of hospital stay, morbidity, and mortality. Results The mean age of the patients was 83.9 (range 80–94 years); there were 34 (42%) men. Thirty patients were operated on for acute cholecystitis. Patients in the urgency group significantly required the ICU more often, required a longer hospital stay, and had more complications, with 32% mortality. No differences were found between inpatients and outpatients, with both groups presenting low morbidity, no mortality, and the same postoperative length of stay. Conclusion More than 80% of the patients were operated on because of complicated gallstone disease. Although the outcomes of patients undergoing semielective cholecystectomy were similar to those of patients treated as outpatients, patients operated with acute cholecystitis presented extremely high morbidity and mortality rates. Thus, we can only recommend that early elective cholecystectomy be performed in elderly patients as soon as they are found to have symptomatic gallstones. Also, further trials are required to elucidate the optimal management of acute cholecystitis in elderly patients.

Randomized trial of total fundoplication and fundal mobilization with or without division of short gastric vessels: a short-term clinical evaluation

PURPOSE Evaluate short results after fundoplication procedure, concerning the division of short gastric vessels. METHODS A prospective randomization of 90 patients with indication for hiatoplasty and total fundoplication with fundus mobilization was performed. They were divided into two groups: no SGV division (group A, n= 46) and with SGV division (Group B, n=44), although in both groups the gastric fundus was mobilized to perform a floppy valve. Early outcome with clinical follow up (1 year) was observed. RESULTS Both groups were similar regarding preoperative parameters and severity of gastroesophageal reflux disease (GERD). No difference in morbidity was observed during hospital stay. Nevertheless, the median operating time was 80,2 minutes in group A and 94,1 minutes (p=0,021) in Group B. Transitory dysphagia during the first year was significantly lower in group B (46,6% versus 23,2%, p=0,012). However, in 12 months clinical outcome was similar in both groups (clinical symptoms of GERD, persistent dysphagia and reoperations). CONCLUSION There was no improvement in routine division of SGV in total fundoplication procedure when the gastric fundus was mobilized.

DYSPHAGIA AFTER LAPAROSCOPIC TOTAL FUNDOPLICATION: anterior or posterior gastric wall fundoplication?

CONTEXT The occurrence of severe dysphagia after laparoscopic total fundoplication is currently an important factor associated with loss of quality of life in patients undergoing this modality of treatment for gastroesophageal reflux disease. OBJECTIVES Compare the incidence and evaluate the causes of severe postoperative dysphagia in patients undergoing laparoscopic total fundoplication (LTF) without short gastric vessels division, using the anterior gastric wall (Rossetti LTF) or anterior and posterior gastric walls (Nissen LTF). METHODS Analysis of the data of 289 patients submitted to LTF without short gastric vessels division from January 2004 to January 2012, with a minimum follow-up of 6 months. Patients were divided in Group 1 (Rossetti LTF - n = 160) and Group 2 (Nissen LTF - n = 129). RESULTS The overall incidence of severe postoperative dysphagia was 3.11% (4.37% in group 1 and 1.55% in group 2; P = 0.169). The need for surgical treatment of dysphagia was 2.5% in group 1 and 0.78% in group 2 (= 0.264). Distortions of the fundoplication were identified as possible causes of the dysphagia in all patients taken to redo fundoplication after Rossetti LTF. No wrap distortion was seen in redo fundoplication after Nissen LTF. CONCLUSIONS The overall incidence of severe postoperative dysphagia did not differ on the reported techniques. Only Rossetti LTF was associated with structural distortion of the fundoplication that could justify the dysphagia.

Ressecção laparoscópica dos cistoadenomas pancreáticos

BACKGROUND: Laparoscopic pancreatic resections have become increasingly frequent with good results reported by several centers. However, few studies have focused on laparoscopic treatment of pancreatic cystic lesions. AIM: To analyze the results of minimally invasive treatment of pancreatic cystic lesions. METHODS: Were included all laparoscopic pancreatic resections performed at three centers. Surgical procedures included resection of the pancreas and left enucleations (with or without splenectomy). The post-operative complications were classified according to the classification proposed by Clavien and Dindo6. The diagnosis of pancreatic fistula was confirmed if the amylase dosage of the drainage liquid in the third postoperative day was more than three times the amount of serum amylase. RESULTS: Were performed 44 laparoscopic pancreatic resections. Fifteen patients underwent surgery for suspected pancreatic cystadenoma and 13 had this diagnosis confirmed. There were 12 women (92%), and the average age of patients was 50 years. Six patients had minor postoperative complications. There were five (38%) pancreatic fistulas, neither considered as severe (C), and only one patient required hospital readmission and radiological drainage. In this series, there were no conversions, reoperations, or mortality. CONCLUSIONS: The laparoscopic approach is a safe and effective option for the treatment of pancreatic cystic lesions. The incidence of pancreatic fistula has good evolution and not diminishes the benefits of minimally invasive surgery.

Nissen fundoplication for the treatment of gastroesophageal reflux disease in patients with Chagas disease without achalasia

Universidade Federal de Sao Paulo (UNIFESP), Escola Paulista de Medicina (EPM) Department of Surgery