Roberto Gonçalves

Influência de aderências peritoneais e fio cirúrgico na tensão de ruptura da parede abdominal em ratos

The recovery of an abdominal procedure depends on many factors, including adhesions. The present study was undertaken to evaluate the influence of four types of suture lines and of adhesions on the tensile strenght of surgical wounds. Sixty Wistar rats were submitted a 5cm laparotomy . The abdomen was closed in two layers with an interrupted suture, using monofilament nylon, polyglicolic acid, plain catgut and chromic catgut . The animals were dividided into three groups: 1- Control; 2- Addition of 0.3 grams of talc into abdominal cavity; 3- Instillation of sodium carboxymethylcellulose (CMC) and talc into abdominal cavity. The animals were assessed on the 7th and 21st postoperative days. The CMC reduced adhesions (p<0,01). The presence of adhesions was able to enhance the tensile strenght. The type of suture line did not influence the tensile strenght.

Vias de acesso aos grandes vasos mediastinais no trauma torácico

Trauma is the most common cause of death in the economically active population and thoracic trauma is directly or indirectly responsible for one quarter of these deaths. Lesions to the large thoracic vessels are associated with immediate or early death in the hospital setting. Patients admitted alive can be classified as stable or unstable. The access route to be elected for management of these veins will depend on this status, as well as on the anatomical particularities of the patient, which may require combined incisions for adequate access. This article provides a review and discussion of lesions to these structures as well as access routes to them.

Natural history of extensive diaphragmatic injury on the right side: experimental study in rats

OBJECTIVE To evaluate the natural healing of the rat diaphragm that suffered an extensive right penetrating injury. METHODS Animals were submitted to an extensive penetrating injury in right diaphragm. The sample consisted of 40 animals. The variables studied were initial weight, weight 21 days after surgery; healing of the diaphragm, non-healing of the diaphragm, and herniated abdominal contents into the chest. RESULTS Ten animals were used as controls for weight and 30 animals were operated. Two animals died during the experiment, so 28 animals formed the operated group; healing of the diaphragm occurred in 15 animals (54%), 11 other animals showed diaphragmatic hernia (39%) and in two we observed only diaphragmatic injury without hernia (7%). Among the herniated organs, the liver was found in 100% of animals, followed by the omentum in 77%, small bowel in 62%, colon in 46%, stomach in 31% and spleen in 15%. The control group and the diaphragmatic healing subgroup showed increased weight since the beginning of the study and the 21 days after surgery (p <0.001). The unhealed group showed no change in weight (p = 0.228). CONCLUSION there is a predominance of spontaneous healing in the right diaphragm; animals in which there was no healing of the diaphragm did not gain weight, and the liver was the organ present in 100% the diaphragmatic surface in all rats with healed diaphragm or not.

Toda lesão do diafragma por ferimento penetrante deve ser suturada

Wounds to the abdominal-thoracic region are associated with diaphragm wounds in up to 48% of cases. Lesions secondary to diaphragm trauma are present in the majority of cases, facilitating the diagnosis of diaphragm lesion and subsequent surgical management. However, diaphragm lesions are isolated in 8 to 10% of cases and because they present few or no symptoms may be overlooked. In such situations, can the diaphragm be treated conservatively without suturing? Based on experiments in animals and a review of the literature, we concluded there is currently insufficient evidence to affirm that diaphragm injuries require no suturing.

A fístula esôfago-gástrica cervical

OBJETIVO: Analisar a presenca de fistula esofago-gastrica cervical nos pacientes submetidos a esofagectomias por câncer apos reconstrucao do trânsito digestivo com o estomago nas tres vias: pre-esternal, retro-esternal e mediastino posterior. METODO: Em um total de 180 pacientes portadores de carcinoma de celulas escamosas de esofago toracico, tratados no Hospital Geral de Nova Iguacu e no Hospital EMCOR, de agosto de 1968 a marco de 2000, foram realizadas 97 esofagectomias e 70 (72,16%) reconstrucoes do trânsito digestivo. O tratamento considerado foi essencialmente cirurgico atraves da esofagectomia transpleural direita e da esofagectomia transhiatal. A anastomose esofago-gastrica cervical foi realizada inicialmente em parede anterior do estomago e depois em parede posterior. Paralelamente, foram realizados estudos experimentais em cadaveres frescos no IML (Instituto Medico Legal) de Nova Iguacu, para avaliacao das dimensoes das paredes gastricas e pesquisa de suas vascularizacoes. RESULTADOS: A incidencia de fistulas ficou reduzida a 7,69%, quando se passou usar a parede posterior do estomago. A reconstrucao do trânsito digestivo foi realizada em 52,86% pela via pre-esternal, 10% pela via retro-esternal e 37,14% pelo leito esofagico. As fistulas ocorreram em 20% dos pacientes (14 casos). Na via pre-esternal ocorreram 24,43% (9 casos), na via retro-esternal 42,85% (3 casos), e mediastino posterior 7,69% (2 casos).( X2= 3,39; p= 0,18) A mortalidade operatoria foi de 15,71%, sendo a insuficiencia respiratoria sua maior causa.((X2= 3,29; p= 0,19). A sobrevida em cinco anos foi de 13,5%. CONCLUSOES: A esofagectomia com anastomose esofago-gastrica cervical e o nosso metodo de escolha. Os melhores resultados foram obtidos com a execucao da anastomose esofago-gastrica cervical na parede posterior do estomago, e atraves do mediastino posterior.

Cirurgia de controle de danos torácico

The damage control surgery came up with the philosophy of applying essential maneuvers to control bleeding and abdominal contamination in trauma patients who are within the limits of their physiological reserves. This concept was extended to thoracic injuries, where relatively simple maneuvers can shorten operative time of in extremis patients. This article aims to revise the various damage control techniques in thoracic organs that must be known to the surgeon engaged in emergency care. RESUMO A cirurgia de controle de danos surgiu com a filosofia de se aplicar manobras essenciais para controle de sangramento e contaminação abdominal, em doentes traumatizados, nos limites de suas reservas fisiológicas. Este conceito se estendeu para as lesões torácicas, onde manobras relativamente simples, podem abreviar o tempo operatório de doentes in extremis. Este artigo tem como objetivo, revisar as diversas técnicas de controle de dano em órgãos torácicos, que devem ser de conhecimento do cirurgião que atua na emergência.

Tumor raro em mediastino: hamartoma

In the present paper we report a case of mediastinal tumor which we believe has never been reported. Since surgical treatment, the patient presented good evolution. We discuss the presentation, differential diagnosis and therapy. Finally, we stress the importance of the pathologic findings.

Validação técnica da drenagem pulmonar como tratamento do enfisema pulmonar avançado: estudo anatômico em cadáveres

OBJECTIVE: A cadaver-based study was carried out in order to describe the pulmonary drainage surgical technique, to determine whether the site for the insertion of the chest tube is appropriate and safe, and to determine the anatomical relationship of the chest tube with the chest wall, lungs, large blood vessels, and mediastinum. METHODS: Between May and November of 2011, 30 cadavers of both genders were dissected. The cadavers were provided by the Santa Casa de São Paulo Central Hospital Mortuary, located in the city of São Paulo, Brazil. A 7.5-cm, 24 F steel chest tube was inserted into the second intercostal space along the midclavicular line bilaterally, and we measured the distances from the tube to the main bronchi, upper lobe bronchi, subclavian vessels, pulmonary arteries, pulmonary arteries in the upper lobe, superior pulmonary vein, azygos vein, and aorta. Weight, height, and chest wall thickness, as well as laterolateral and posteroanterior diameters of the chest, were measured for each cadaver. RESULTS: Of the 30 cadavers dissected, 20 and 10 were male and female, respectively. The mean distance between the distal end of the tube and the main bronchi (right and left) was 7.2 cm (for both). CONCLUSIONS: The placement of a fixed-size chest tube in the specified position is feasible and safe, regardless of the anthropometric characteristics of the patients.

Gastric cancer with lesion extending to spleen and perforation into free peritoneum

Perforated gastric carcinoma is a rare condition that is hard to diagnose preoperatively. It is associated with advanced cancer stages and has a high mortality, particularly in cases presenting preoperative shock. Few studies have investigated the presentation and adequate management of these carcinomas. In addition, there are no reports in the literature on perforations extending to the spleen, as described in this case, making the management of these lesions challenging. Our article reports a case of gastric tumor perforation extending to the spleen, which presented as a perforated acute abdomen. The patient was treated with total gastrectomy and D2 lymph node resection with splenectomy and progressed well with current survival of one year at disease stage IV.