Hernioplastia inguinal segundo procedimento de Stoppa: drenar ou não drenar

OBJETIVO: O objetivo do presente estudo é avaliar os benefícios da drenagem no procedimento de Stoppa no tratamento da hérnia inguinal. PACIENTES E MÉTODOS: O uso da drenagem de aspiração contínua foi randomizado ao final do procedimento cirúrgico em 26 pacientes submetidos à correção da hérnia inguinal e divididos em dois grupos: Grupo A, com 12 pacientes submetidos à drenagem e Grupo B, com 14 pacientes não submetidos à drenagem. No segundo dia de pós-operatório, todos os pacientes foram submetidos à tomografia computadorizada de abdome para a verificação de coleções abdominais. RESULTADOS: No Grupo A, nenhum paciente apresentou coleção no espaço pré-peritonial. Por outro lado, um paciente desenvolveu abcesso no espaço pré-peritonial no décimo quinto dia de pós-operatório. No Grupo B, 12 pacientes apresentaram coleção pré-peritonial à tomografia. Entretanto, somente três apresentaram complicações menores. Nenhum paciente apresentou complicação maior. CONCLUSÃO: O uso de drenagem de aspiração contínua no procedimento de Stoppa não traz nenhum benefício.OBJECTIVE: The objective of this study is to evaluate the benefits of drainage in the Stoppa procedure for inguinal repair. PATIENTS AND METHODS: The use of a suction drain was randomized at the end of the surgical intervention in 26 male patients undergoing inguinal hernia repair, divided into 2 groups: Group A, 12 patients undergoing drainage, and group B, 14 patients not undergoing drainage. On the second postoperative day, all patients underwent abdominal pelvic computed tomography scan examination to detect the presence of abdominal fluid collection. RESULTS: In group A, no patient developed fluid collection in the preperitoneal space, and 1 patient presented with an abscess in the preperitoneal space on the 15th postoperative day. In group B, 12 patients presented with fluid collections in the preperitoneal space on computed tomography scan evaluation. However, only 3 patients presented minor complications. None of the patients developed a major complication. CONCLUSION: The use of suction drainage with the Stoppa procedure does not provide any benefit

Como reduzir complicações relacionadas à drenagem pleural utilizando uma técnica guiada por ultrassom

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Prospective Analysis of Short- and Mid-term Knowledge Retention after a Brief Ultrasound Course for Undergraduate Medical Students

OBJECTIVES: The benefits of implementing point-of-care ultrasound (POCUS) in the emergency department are well established. Ideally, physicians should be taught POCUS during medical school. Several different courses have been designed for that purpose and have yielded good results. However, medical students need specifically designed courses that address the main objectives of knowledge acquisition and retention. Despite that, there is limited evidence to support knowledge retention, especially in the mid-term. The purpose of this study is to evaluate short- and mid-term knowledge retention after a student-aimed ultrasound course. METHODS: Medical students participating in a medical student trauma symposium (SIMPALT) in 2017 were included. Their profiles and baseline ultrasound knowledge were assessed by a precourse questionnaire (PRT). The same questionnaire was used one week (1POT) and three months (3POT) after the course. RESULTS: Most of the participants were 1st- to 4th- year medical students. None had prior ultrasound knowledge. They reported costs as the major barrier (65%) to enrollment in an ultrasound course. A comparison between the PRT and 1POT results showed a statistically significant difference (po0.02), while no difference was found between 1POT and 3POT (p40.09). CONCLUSION: Our findings support the use of a tailored ultrasound course for medical students. Knowledge acquisition and mid-term retention may be achieved by this specific population

Embolic shower following blunt aortic injury: a risky yet successful approach

Introduction: Blunt Aortic Injury (BAI) is a rare event in high-energy traumas. It has an estimated incidence of 20 to 30 per 1 million population per year. Its importance, however, rely in the outstanding mortality rates, in which 80 to 90% of the patients die at the scene of injury and 50% of the survivors die at the hospital (1). The majority of BAI occur in the thoracic aorta and there are less than 10 described cases of floating aortic thrombus (FAT) secondary a BAI, from which no thromboembolic complication was described (2). Objective: We report a case of a large thoraco-abdominal BAI following thrombotic dissemination with multiple ischemic foci, an extremely rare complication of high energy traumas, and its management. Case Report: A 38-year-old previously healthy man was brought to our emergency department with a history of a 10-meter fall from a paragliding. He underwent primary evaluation which revealed a hemothorax, that was promptly drained, and signs of hypovolemic shock with no signs of pelvic stability and a painful abdomen. He was stabilized with volume resuscitation and norepinephrine, and no bleeding was found in a FAST protocol ultrasound. Additionally, he had a flaccid paraplegia, crepitation in the 10th and 11th ribs on the right and 10th on the left and referred pain in the palpation of T12 to S1. No bleeding was seen in the urethral catheterization or in a digital rectal examination. A tomographic scan suggested an aortic hematoma in D9-D10, ischemic lesions in spleen and left kidney and fractures of the ribs and the right transverse processes of T12 to L5 (Image 1). Also, a thrombus imaging was visualized in the abdominal aorta (Image 2). A laparotomy was performed, which confirmed the ischemic splenic lesion and found many nonpulsatile hemorrhagic foci in mesocolon, intestines and in the retroperitoneal space (Image 3). As there was thromboembolic evidence, we introduced prophylactic heparin in the immediate post operative (PO) and sent the patient to the intensive care unit (ICU). He evolved with pulmonary thromboembolism in the 3rd PO, with therapeutic enoxaparin introduced. The patient was discharged from the ICU in the 7th PO, he evolved with progressive improvement of the cardiovascular, respiratory and pain parameters, a conservative management approach was applied by the neurosurgery and vascular teams and he was discharged from the hospital in the 33rd PO, still maintaining complete paraplegia. Image 1 - Initial tomographic scan, with ischemic splenic and renal lesions. Image 2 - Aortic angiography with a floating aortic thrombus Image 3 – Intra-operative findings: Ischemic lesions and hemorrhagic foci.Keywords: Embolic shower; Blunt aortic injury; Trauma.References1. McGwin G Jr, Reiff DA, Moran SG, Rue LW 3rd. Incidence and characteristics of motor vehicle collision-related blunt thoracic aortic injury according to age. J Trauma. 2002;52(5):859-65; discussion 65-6.2. Shalhub S, Starnes BW, Tran NT, Hatsukami TS, Lundgren RS, Davis CW, et al. Blunt abdominal aortic injury. J Vasc Surg. 2012;55(5):1277-85

Perforating pancreatic injury: new approaches and unexpected complications

Perforating Pancreatic Injury (PPI) is an uncommon event in trauma centers. One of its uncommon complications is Pancreatic Fluid Collection (PFC), which was only studied in acute pancreatitis cases. Other of its rare, but most feared complications is the Major Pancreatic Duct (MPD) disconnection, that most authors recommend to be treated immediately. We report a successful case of PPI that was initially approached by videolaparoscopy, had a infected PFC formation that was drained by endoscopy and a posterior MPD disconnection. In conclusion, we suggest that videolaparoscopy is possible in patients with PPI and minimally invasive approaches in the acute phase may postpone more aggressive procedures to an elective and well planned approach

Outcomes of Elderly Patients Undergoing Emergency Surgery for Complicated Colorectal Cancer: A Retrospective Cohort Study

OBJECTIVE: Colorectal cancer is one of the most frequent types of malignant neoplasms. Age is a risk factor for this disease, with 75% of cases diagnosed in patients older than 65 years. Complications such as obstruction, hemorrhage, and perforation are present in more than one-third of cases and require emergency treatment. We aim to analyze the profile of elderly patients undergoing surgery for complicated colorectal cancer, and to evaluate factors related to worse short-term prognosis. METHODS: A retrospective analysis of patients who underwent emergency surgical treatment for complicated colorectal cancer was performed. Demographics, clinical, radiological and histological data were collected. RESULTS: Sixty-seven patients were analyzed. The median age was 72 years, and almost half (46%) of the patients were female. Obstruction was the most prevalent complication at initial presentation (72%). The most common sites of neoplasia were the left and sigmoid colon in 22 patients (32.8%), and the right colon in 17 patients (25.4%). Resection was performed in 88% of cases, followed by primary anastomosis in almost half. The most frequent clinical stages were II (48%) and III (22%). Forty-three patients (65.7%) had some form of postoperative complication. Clavien-Dindo grades 1, 2, and 4, were the most frequent. Complete oncologic resection was observed in 80% of the cases. The thirty-day mortality rate was 10.4%. Advanced age was associated with worse morbidity and mortality. CONCLUSION: Elderly patients with complicated colorectal cancer undergoing emergency surgery have high morbidity and mortality rates. Advanced age is significantly associated with worse outcomes

Hypertonic saline and pentoxifylline enhance survival, reducing apoptosis and oxidative stress in a rat model of strangulated closed loop small bowel obstruction

OBJECTIVES: Intestinal obstruction has a high mortality rate when therapeutic treatment is delayed. Resuscitation in intestinal obstruction requires a large volume of fluid, and fluid combinations have been studied. Therefore, we evaluated the effects of hypertonic saline solution (HS) with pentoxifylline (PTX) on apoptosis, oxidative stress and survival rate. METHODS: Wistar rats were subjected to intestinal obstruction and ischemia through a closed loop ligation of the terminal ileum and its vessels. After 24 hours, the necrotic bowel segment was resected, and the animals were randomized into four groups according to the following resuscitation strategies: Ringer’s lactate solution (RL) (RL-32 ml/kg); RL+PTX (25 mg/kg); HS+PTX (HS, 7.5%, 4 ml/kg), and no resuscitation (IO-intestinal obstruction and ischemia). Euthanasia was performed 3 hours after resuscitation to obtain kidney and intestine samples. A malondialdehyde (MDA) assay was performed to evaluate oxidative stress, and histochemical analyses (terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling [TUNEL], Bcl-2 and Bax) were conducted to evaluate kidney apoptosis. Survival was analyzed with another series of animals that were observed for 15 days. RESULTS: PTX in combination with RL or HS reduced the MDA levels (nmol/mg of protein), as follows: kidney IO=0.42; RL=0.49; RL+PTX=0.31; HS+PTX=0.34 (po0.05); intestine: IO=0.42; RL=0.48; RL+PTX=0.29; HS +PTX=0.26 (po0.05). The number of labeled cells for TUNEL and Bax was lower in the HS+PTX group than in the other groups (po0.05). The Bax/Bcl-2 ratio was lower in the HS+PTX group than in the other groups (po0.05). The survival rate on the 15th day was higher in the HS+PTX group (77%) than in the RL+PTX group (11%). CONCLUSION: PTX in combination with HS enhanced survival and attenuated oxidative stress and apoptosis. However, when combined with RL, PTX did not reduce apoptosis or mortalit