Samir Rasslan

Spontaneous intramural small bowel hematoma induced by anticoagulant therapy: review and case report

Of particular note among the causes of abdominal pain that necessitate surgery are appendicitis and intestinal obstruction. The most frequent causes of obstruction are adhesions (60%), hernias (15%), neoplasia (6%) and rare causes (6%). 2 In many cases, surgery comes to represent both a diagnostic and therapeutic measure. In some cases, however, we may be confronted by an obstructive condition in which more conservative measures are recommended. The aim of this article is to highlight the rare occurrence of acute abdominal obstruction due to spontaneous intramural small bowel hematoma resulting from the use of oral anticoagulants by reporting on a case attended at the General Surgery Service of the Clinical Surgery Division III of the Hospital das Clinicas - University of Sao Paulo Medical School (HC – FMUSP), as well as presenting a systematic review of the literature from the last 25 years.

Trauma in pregnant women: analysis of maternal and fetal mortality

Twenty-seven traumatised pregnant women were analysed retrospectively over a period of 9 years. Mean age was 23.7 years (16-42 years). Gestational age ranged from 10 to 40 weeks (mean, 21.5 weeks), with most victims (46.1%) being in the second trimester. The predominant mechanism (65.3%) was blunt abdominal injury due to an automobile accident (the patient being run over or collision). At admission, 8 (30.7%) patients had haemodynamic alterations. 6 patients (23.0%) presented vaginal bleeding and 4 of these were haemodynamically normal. We analysed maternal mortality, fetal mortality and their causes. We also compared the median RTS and TRISS values for the groups with maternal-fetal survival and the group with maternal-fetal death. Fetal death occurred in all pregnant women admitted with vaginal bleeding. Maternal mortality due to haemorrhagic shock was 11.5%. Fetal mortality was 30.7%, with 37.5% of these deaths being caused by maternal death. The major cause of fetal mortality was a detached placenta (50.0%). The trauma indices, RTS and TRISS, were significantly lower (p = 0.0025 and p < 0.0001) in the group of maternal-fetal death but they were not of prognostic value in terms of fetal mortality.

EUS-Guided Antegrade Transhepatic Placement of a Self-Expandable Metal Stent in Hepatico-Jejunal Anastomosis

CONTEXTnTo demonstrate an EUS-guided biliary drainage in patient with gastrointestinal tract modified surgically.nnnCASE REPORTnAn EUS guided access to the left intra hepatic duct, followed by an antegrade passage of a partially self-expandable metal stent that was removed by using an enteroscope, in one patient with hepatico-jejunal anastomosis. There were no early or delayed complications and the procedure was effective in relieving jaundice until the self-expandable metal stent was removed, 3 months later. A cholangiogram was obtained via enteroscopy, after removal of self-expandable metal stent, and found to be normal. The patient had an uneventful evaluation afterwards.nnnCONCLUSIONnThe indication of these procedures must be made under a multidisciplinary view while sharing information with the patient or legal guardian. EUS-guided biliary drainage is feasible when performed by professionals with expertise in biliopancreatic endoscopy and advanced echo-endoscopy and should be performed currently under rigorous protocol in educational institutions.

Evaluation of the effects of ozone therapy in the treatment of intra-abdominal infection in rats

INTRODUCTION The antibacterial effect of ozone (O3) has been described in the extant literature, but the role of O3 therapy in the treatment of certain types of infection remains controversial. OBJECTIVES To evaluate the effect of intraperitoneal (i.p.) O3 application in a cecal ligation/puncture rat model on interleukins (IL-6, IL-10) and cytokine-induced neutrophil chemoattractant (CINC)-1 serum levels, acute lung injury and survival rates. METHODS Four animal groups were used for the study: a) the SHAM group underwent laparotomy; b) the cecal ligation/puncture group underwent cecal ligation/puncture procedures; and c) the CLP+O2 and CLP+O3 groups underwent CLP+ corresponding gas mixture infusions (i.p.) throughout the observation period. IL-6, CINC-1 and IL-10 concentrations were determined by enzyme-linked immunosorbent assay (ELISA). Acute lung injury was evaluated with the Evans blue dye lung leakage method and by lung histology. P<0.05 was considered significant. RESULTS CINC-1 was at the lowest level in the SHAM group and was lower for the CLP+O3 group vs. the CLP+O2 group and the cecal ligation/puncture group. IL-10 was lower for the SHAM group vs. the other three groups, which were similar compared to each other. IL-6 was lower for the SHAM group vs. all other groups, was lower for the CLP+O3 or CLP+O2 group vs. the cecal ligation/puncture group, and was similar for the CLP+O3 group vs. the CLP+O2 group. The lung histology score was lower for the SHAM group vs. the other groups. The Evans blue dye result was lower for the CLP+O3 group vs. the CLP+O2 group and the cecal ligation/puncture group but similar to that of the SHAM group. The survival rate for the CLP+O3 group was lower than for the SHAM group and similar to that for the other 2 groups (CLP and CLP+O2). CONCLUSION Ozone therapy modulated the inflammatory response and acute lung injury in the cecal ligation/puncture infection model in rats, although there was no improvement on survival rates.

Controversies in the management of asymptomatic patients sustaining penetrating thoracoabdominal wounds

The most challenging diagnostic issue in the management of thoracoabdominal wounds concerns the assessment of asymptomatic patients. In almost one-third of such cases, diaphragmatic injuries are present even in the absence of any clear clinical signs. The sensitivity of noninvasive diagnostic tests is very low in this situation, and acceptable methods for diagnosis are limited to videolaparoscopy or videothoracoscopy. However, these procedures are performed under general anesthesia and present real, and potentially unnecessary, risks for the patient. On the other hand, diaphragmatic hernias, which can result from unsutured diaphragmatic lesions, are associated with considerable morbidity and mortality. In this paper, the management of asymptomatic patients sustaining wounds to the lower chest is discussed, with a focus on the diagnosis of diaphragmatic injuries and the necessity of suturing them.

Influence of time elapsed from end of emergency surgery until admission to intensive care unit, on Acute Physiology and Chronic Health Evaluation II (APACHE II) prediction and patient mortality rate

CONTEXT AND OBJECTIVEnPatients are often admitted to intensive care units with delay in relation to when this service was indicated. The objective was to verify whether this delay influences hospital mortality, length of stay in the unit and hospital, and APACHE II prediction. DESIGN AND SETITNG: Prospective and accuracy study, in intensive care unit of Santa Casa de São Paulo, a tertiary university hospital.nnnMETHODSnWe evaluated all 94 patients admitted following emergency surgery, from August 2002 to July 2003. The variables studied were APACHE II, death risk, length of stay in the unit and hospital, and hospital mortality rate. The patients were divided into two groups according to the time elapsed between end of surgery and admission to the unit: up to 12 hours and over 12 hours.nnnRESULTSnThe groups were similar regarding gender, age, diagnosis, APACHE II score and hospital stay. The death risk factors were age, APACHE II and elapsed time (p < 0.02). The mortality rate for the over 12-hour group was higher (54% versus 26.1%; p = 0.018). For the over 12-hour group, observed mortality was higher than expected mortality (p = 0.015). For the up to 12-hour group, observed and expected mortality were similar (p = 0.288).nnnCONCLUSIONnAPACHE II foresaw the mortality rate among patients that arrived faster to the intensive core unit, while the mortality rate was higher among those patients whose admission to the intensive care unit took longer.

Inflammatory activity modulation by hypertonic saline and pentoxifylline in a rat model of strangulated closed loop small bowel obstruction

BACKGROUNDnIntestinal obstruction is an abdominal disease associated to mortality, especially if complicated with sepsis. Resuscitation increases survival, although controversies remain concerning to therapeutic strategy.nnnMETHODSnTo assess the effects of hypertonic saline and pentoxifylline on the inflammatory response and oxidative stress, Wistar rats underwent a laparotomy loop intestinal obstruction and ischemia. After 24xa0h, the intestinal segment was resected (IO) without any other treatment and resuscitation/pentoxifylline were administered according to the group: Ringers lactate (RL); hypertonic saline (HS); pentoxifylline (PTX); Ringers lactate with pentoxifylline (RLxa0+xa0PTX); hypertonic saline with pentoxifylline (HSxa0+xa0PTX) and the control group (CG) that was not submitted to ischemia and obstruction. Mean arterial pressure (MAP) was recorded 4 times, and euthanasia was done 3xa0h after the resuscitation to obtain lung tissue, for malondialdehyde (MDA) by thiobarbituric acid reactive substances (TBARS) method, inflammatory cytokines were assessed using ELISA and NF-κΒ by Western blotting.nnnRESULTSnThe initial MAP levels were higher in the RL and HS groups than in the others; however, the last measurement was similar among all the groups. IL-1β, IL-6 and CINC-1 (Cytokine-Induced Neutrophil Chemoattractant-1) were lower in the HS, PTX and HSxa0+xa0PTX groups compared with the IO and RL groups. IL-10 was lower in the HSxa0+xa0PTX group than in the IO group. NF-κB in the HS, PTX and HSxa0+xa0PTX groups were lower than in the IO group; NF-κB in the HSxa0+xa0PTX group was lower than in the RL group. MDA in the lung was lower in the HSxa0+xa0PTX group compared with other groups.nnnCONCLUSIONnHypertonic saline and pentoxifylline, both alone and in combination, attenuated oxidative stress and the activation of NF-κB, leading to a decrease in the inflammatory response.

Effect of low-dose gaseous ozone on pathogenic bacteria.

BackgroundTreatment of chronically infected wounds is a challenge, and bacterial environmental contamination is a growing issue in infection control. Ozone may have a role in these situations. The objective of this study was to determine whether a low dose of gaseous ozone/oxygen mixture eliminates pathogenic bacteria cultivated in Petri dishes.MethodsA pilot study with 6 bacterial strains was made using different concentrations of ozone in an ozone-oxygen mixture to determine a minimally effective dose that completely eliminated bacterial growth. The small and apparently bactericidal gaseous dose of 20 μg/mL ozone/oxygen (1:99) mixture, applied for 5min under atmospheric pressure was selected. In the 2nd phase, eight bacterial strains with well characterized resistance patterns were evaluated in vitro using agar-blood in adapted Petri dishes (105 bacteria/dish). The cultures were divided into 3 groups: 1- ozone-oxygen gaseous mixture containing 20 μg of O3/mL for 5 min; 2- 100% oxygen for 5 min; 3- baseline: no gas was used.ResultsThe selected ozone dose was applied to the following eight strains: Escherichia coli, oxacillin-resistant Staphylococcus aureus, oxacillin-susceptible Staphylococcus aureus, vancomycin-resistant Enterococcus faecalis, extended-spectrum beta-lactamase-producing Klebsiella pneumoniae, carbapenem-resistant Acinetobacter baumannii, Acinetobacter baumannii susceptible only to carbapenems, and Pseudomonas aeruginosa susceptible to imipenem and meropenem. All isolates were completely inhibited by the ozone-oxygen mixture while growth occurred in the other 2 groups.ConclusionA single topical application by nebulization of a low ozone dose completely inhibited the growth of all potentially pathogenic bacterial strains with known resistance to antimicrobial agents.

A retrospective review and observations over a 16-year clinical experience on the surgical treatment of chronic mesh infection. What about replacing a synthetic mesh on the infected surgical field?

PurposeTo review the short- and long-term results in patients who underwent removal of infected or exposed mesh and reconstruction of the abdominal wall with simultaneous mesh replacement.MethodsPatients undergoing removal of an infected or exposed mesh and single-staged reconstruction of the abdominal wall with synthetic mesh replacement over a 16-year period were retrospectively reviewed from a prospectively maintained database. Patients were operated and followed by a single surgeon. Outcome measures included wound complications and hernia recurrence.ResultsFrom 1996 until 2012, 41 patients (23 F, 18 M), with a mean age of 53.4xa0years and mean BMI of 31.2xa0±xa08xa0kg/m2, were treated for chronic mesh infection (CMI). A suppurative infection was present in 27 patients, and 14 had an exposed mesh. The need for recurrent incisional hernia repair was observed in 25 patients; bowel resections or other potentially contaminated procedures were associated in 15 patients. The short-term results showed an uneventful post-operative course after mesh replacement in 27 patients; 6 (14.6xa0%) patients developed a minor wound infection and were treated with dressings and antibiotics; 5 (12xa0%) patients had wound infections requiring debridement and one required complete mesh removal. On the long-term follow-up, there were three hernia recurrences, one of which demanded a reoperation for enterocutaneous fistula; 95xa0% of the patients submitted to mesh replacement were considered cured of CMI after a mean follow-up of 74xa0months.ConclusionsCMI can be treated by removal of infected mesh; simultaneous mesh replacement prevents hernia recurrence and has an acceptable incidence of post-operative acute infection. Standard polypropylene mesh is a suitable material to be used in the infected surgical field as an onlay graft.

Surgical Education in Brazil

BackgroundThe surgical residency was implemented in Brazil in 1944. Gradually, several programs were created under the auspices of the National Committee of Medical Residency (Comissão Nacional de Residência). A candidate for a residency program is submitted to a selection process in various institutions. One of the greatest obstacles to medical education in Brazil is that the number of graduate students is much larger than the number of available vacancies. As a consequence, they end up looking for other alternatives to their professional training, and these cannot offer the same results as a formal residency. Regarding the current residency program in surgery, Brazil has roughly 200 general surgery programs, which offer 1,040 vacancies yearly.Method and resultsThe surgical residency program lasts 2xa0years with rotation in various surgical specialties, which is a requirement for the following years in specific specialties. The 1,040 who are enrolled in the first 2xa0years of a residency in surgery take a new examination to continue their training. Here, there are only 573 vacancies; therefore, 45% of the newly trained surgeons start a practice or become apprentices. The 573 residents who move on to further education then pass 2xa0years in basic general surgery at an institution and continue in the same or are transferred to another department. The next training period should be 2 or 3xa0years, depending on the specialty. The General Surgery program lasts 4xa0years: two initial basic years and two more years of training in elective, emergency, and trauma surgery and intensive care. The objective is to become competent in the diagnosis and treatment of the most common diseases that affect the community.ConclusionsMedical entities in specialties have their own selection process to grant the title of specialist. The Brazilian College of Surgeons (Colégio Brasileiro de Cirurgiões) is responsible for granting the title “general surgeon,” following the model of the American Board of Surgery.