Does staged closure have a worse prognosis in gastroschisis?

INTRODUCTION: Correction of gastroschisis can be accomplished by primary or staged closure. There is, however, no consensus regarding the best approach or criteria to favor one method over the other has been established. OBJECTIVE: To compare the outcome of primary and staged closure in newborns with gastroschisis using intravesical pressure (IVP) as the decision criterion. PATIENTS & METHODS: We prospectively analyzed 45 newborns with gastroschisis. An IVP with a threshold of 20 cm H2O was used to indicate primary or staged closure, and the outcomes between the two methods were compared. RESULTS AND DISCUSSION: Newborns in whom primary closure was feasible were born at a lower gestational age. There was no significant difference in the frequency of complications, time to begin oral feeding, length of parenteral nutrition or length of hospital stay. Compared with previous reports, our data showed higher rates of prenatal diagnosis and cesarean delivery, a lower average birth weight, a higher rate of small gestational age babies and a more frequent association with intestinal atresia. Conversely, our data showed a lower rate of postoperative necrotizing enterocolitis and a lower average length of hospital stay. CONCLUSION: No significant difference was observed in the outcome of newborns who underwent primary closure or staged closure of gastroschisis when using an IVP below 20 cm H2O as the criterion for primary closure

Not complicated acute appendicitis in adults: clinical or surgical treatment?

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DESINFETANTES DE ALTO NÍVEL ALTERNATIVOS AO GLUTARALDEÍDO PARA PROCESSAMENTO DE ENDOSCÓPIOS FLEXÍVEIS

Endoscópios flexíveis são fundamentais em diversas especialidades médicas; em geral são termossensíveis, semicríticos e submetidos à desinfecção de alto nível. O glutaraldeído é largamente utilizado para este fim, devido à alta compatibilidade e baixo custo, porém, a tolerância de micobactérias e a toxicidade ocupacional pressionam por adoção de germicidas alternativos. Foi realizada revisão sistemática com objetivo de buscar evidências sobre a efetividade, toxicidade e potenciais danos causados aos endoscópios pelos germicidas, alternativos ao glutaraldeído, disponíveis no mercado brasileiro. Foram identificadas, em 13 bases eletrônicas, 822 publicações, entre 2008 e 2013. Destas, foram selecionados 23 estudos, considerando a melhor qualidade de evidência disponível. As publicações apontaram para a superioridade do ácido peracético e do ortoftalaldeído quanto à eficácia na desinfecção de alto nível. Somente o ortoftalaldeído apresentou evento adverso claramente relacionado à sua utilização. Não há evidências suficientes para afirmar que algum destes germicidas possui maior potencial de danos aos equipamentos.Desinfecção; Endoscópios; Glutaraldeído; Toxicidade.Flexible endoscopes are fundamental in various medical specialities; in general they are heat-sensitive, semicritical, and subject to high level disinfection. Glutaraldehyde is largely used for this purpose, due to its high compatibility and low-cost. However, its tolerance of mycobacteria and occupational toxicity lead to pressure being applied for the adoption of alternative germicides. A systematic review was undertaken aiming to seek evidence regarding the effectiveness, toxicity and potential harm caused to the endoscopes by those germicides which are alternative to glutaraldehyde and which are available on the market in Brazil. A total of 822 publications was identified in 13 electronic databases, between 2008 and 2013. Of these, 23 studies were selected, considering the best quality of evidence available. The publications point to the superiority of peracetic acid and of orthophthaldehyde regarding efficacy in high level disinfection. Only orthophthaldehyde presented an adverse event clearly related to its use. There is insufficient evidence to assert that any of these germicides has greater potential for harm to the equipment.Fundamentales en diversas especialidades médicas, los endoscopios flexibles son, normalmente, termosensibles, semicríticos y sometidos a la desinfección de alto nivel. El glutaraldehído es muy utilizado para esa finalidad, en razón de la gran compatibilidad y bajo custo, pero la tolerancia de microbacterias y el hecho de ser o no tóxico de modo ocupacional presionan por la adopción de germicidas alternativos. Fue realizada revisión sistemática con el objetivo de buscar evidencias sobre la efectividad, toxicidad y potenciales daños causados a los endoscopios por los germicidas alternativos al glutaraldehído, disponibles en el mercado brasileño. Fueron identificadas, en 13 bases electrónicas, 822 publicaciones, entre 2008 y 2013. De estas, fueron seleccionados 23 estudios, considerando la mejor cualidad de evidencia disponible. Las publicaciones apuntaron para la superioridad del ácido peracético y del ortoftalaldehído cuanto a la eficacia en la desinfección de alto nivel. Solamente el or toftalaldehído presentó evento adverso claramente relacionado a su utilización. No hay evidencias suficientes para afirmar que algun de estes germicidas presenta mayor potencial de daños a los equipos

Laparoscopic splenectomy in hematological disorders

BACKGROUND: Laparoscopic splenectomy (LS) is becoming the procedure of choice in the treatment of children with hematological disorders. However, concerns remains regarding conversion rates, dissection and extraction of the spleen. The authors analyze their early experience at Boldrini's Children Cancer Center-Brazil in 40 LS performed in children and young adults. METHODS: Retrospective review of the charts of 40 patients (median age of 6.6 years; range 1 to 22.8) who underwent LS, between July/ 2000 and May/ 2002. The main indications were sickle cell disease (SCD) (20 - 50 %), hereditary spherocytosis (10 - 25 %) and idiopathic thrombocytopenic purpura (8 - 20 %). RESULTS: All but two splenectomies were performed exclusively by laparoscopy, and 12 patients also underwent a concomitant cholecystectomy. The mean operating time was 127.5 minutes (90-240m). In seven patients (17.5%) accessory spleens were found and removed. Intraoperative bleeding was significant only in the two cases that required conversion to an open procedure, although no transfusion was needed. The median weight of the spleen was 250 g (range 106g-1000g; n=36). Complications were observed in seven patients (17.5 %) with SCD that developed acute chest syndrome. There were no deaths in this series and the median postoperative stay at the hospital was two days (2 - 14). Follow-up ranged from 23 days to two years. CONCLUSIONS: On the basis of our experience, LS is a safe procedure, even to treat large spleens and became an attractive option that might replace the open procedure. In SCD patients, the rate of complications remains high, suggesting mechanisms other than the scope of the choice of surgical approach.OBJETIVO: Relatar a experiência inicial do Centro Infantil Boldrini com a esplenectomia laparoscópica (EL) em crianças e adultos jovens. MÉTODO: Foram revisados os prontuários de 40 pacientes (mediana da idade de 6,6 anos; 1 a 22,8) submetidos à EL entre Julho de 2000 e Maio de 2002. As principais indicações de acordo com a doença de base foram: doença falciforme (DF) em 20 pacientes (50%), esferocitose hereditária em 10 (25 %), púrpura trombocitopência idiopática em oito (20 %), doença de Hodgkin em um e anemia hemolítica a esclarecer em um. RESULTADOS: Trinta e oito esplenectomias foram completadas por via laparoscópica (duas conversões) e em doze foi realizada adicionalmente a colecistectomia. A mediana do tempo operatório foi de 127,5 minutos (90-240 min) e sete (17,5 %) baços acessórios foram encontrados. Sangramento intra-operatório foi significativo apenas nas duas conversões, mas não houve necessidade de transfusões. A mediana do peso dos baços foi de 250 g (106-1000; n=36). Complicações pós-operatórias ocorreram em sete (17,5 %) pacientes e, nos portadores de DF, 35% desenvolveram síndrome torácica aguda. A mediana da permanência hospitalar pós-operatória foi de dois dias (2 - 14). O seguimento variou de 23 dias a dois anos (mediana de 11 meses). CONCLUSÕES: A EL pode ser realizada de modo seguro mesmo em baços de grande tamanho e é opção atrativa que pode substituir o procedimento aberto. Em pacientes com DF, a taxa de complicações permanece alta, sugerindo mecanismos outros que vão além da escolha da via de acesso cirúrgica.38238

Evolution of critically ill patients with gastroschisis from three tertiary centers

OBJECTIVES AND INTRODUCTION: Gastroschisis is a congenital abdominal wall defect with increasing occurrence worldwide over the past 20-30 years. Our aim was to analyze the morbidity of newborns after gastroschisis closure, with emphasis on metabolic and hydroelectrolyte disturbances in patients at three tertiary university centers. METHODS: From January 2003 to June 2009, the following patient data were collected retrospectively: (A) Background maternal and neonatal data: maternal age, prenatal diagnosis, type of delivery, Apgar scores, birth weight, gestational age and sex; (B) Surgical modalities: primary or staged closure; and (C) Hospital course: levels of serum sodium and levels of serum albumin in the two first postoperative days, number of ventilation days, other postoperative variables and survival. Statistical analyses were used to examine the associations between some variables. RESULTS: 163 newborns were included in the study. Primary closure of the abdominal defect was performed in 111 cases (68.1%). The mean serum sodium level was 127.4¡6.7 mEq/L, and the mean serum albumin level was 2.35¡0.5 g/dL. Among the correlations between variables, it was verified that hyponatremia and hypoalbuminemia correlated with the number of days on the ventilator but not with the number of days on total parenteral nutrition (TPN); mortality rate correlated with infection. The final survival rate was 85.9%. CONCLUSION: In newborns with gastroschisis, more aggressive attention to hyponatremia and hypoalbuminemia would improve the outcome

Laparotomias na criança : estudo das complicações imediatas ; relacionadas a incisão cirurgica

Orientador: Luiz Sergio LeonardiDissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências MédicasResumo: O resumo poderá ser visualizado no texto completo da tese digitalAbstract: The abstract is available with the full electronic digital documentMestradoMestre em Medicin

Efeito da gastrofundoplicatura pela tecnica de Nissen, no esvaziamento gastrico de liquidos, em ratos

Orientador : Luiz Sergio LeonardiTese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciencias MedicasResumo: Com o objetivo de avaliar o efeito da gastrofundoplicatura pela técnica de Nissen no esvaziamento gástrico (EG) de líquidos foram estudados 96 ratos machos, da linhagem Wistar separados em 3 grupos: no grupo PRECOCE os animais receberam salina fisiológica como refeição de prova e foram avaliados 8 dias após a realização da cirurgia. No grupo TARDIO(T) a refeição de prova foi a mesma e os animais foram avaliados 29 dias após a cirurgia. No grupo GLICOSE os animais receberam como refeição de prova solução de glicose a 5% (P/v) e o EG foi avaliado 8 dias após a cirurgia. Em todos os grupos os animais foram subdivididos em 2 subgrupos de 16 animais: nos animais de um dos subgrupos (subgrupos atropina) foi administrado sulfato de atropina , na dose de 0,3 mg/l00g de peso do animal, por via endovenosa, para provocar bloqueio do EG, sendo 8 animais submetidos a fundoplicaturae 8 a cirurgia simulada. No outro subgrupo (subgrupos controles),os 16 animais receberam solução salina por via endovenosa e foram divididos também em cirurgia simulada e fundoplicatura. A refeição de prova foi acrescentado fenolsulfonftaleína, na concentração de 6mg/dI. A infusão orogástrica da refeição de prova foi realizada com uma sonda de metal multiperfurada na extremidade distal. As retenções gástricas foram determinadas pela avaliação da concentração do marcador presente no resíduo gástrico 10 minutos após a administração da refeição de prova. Nos animais do grupo PRECOCE a fundoplicatura aumentou significativamente o EG da solução salina fisiológica, tanto nos animais dos subgrupos controles, quanto naqueles atropinizados. Já no grupo TARDIO as diferenças não foram estatisticamente significantes, sugerindo uma adaptação gástrica à alteração anatômica provocada pela fundoplicatura. Nos animais do grupo GLICOSE, enquanto que entre os animais dos subgrupos controles a fundoplicatura aumentou o EG da solução de glicose, entre os animais atropinizados esse efeito não se verificou. Estes resultados podem indicar um possível efeito inibidor da atropina sobre o mecanismo de bomba antral, associado a um aumento de resistência duodenal provocado pela glicose. Estes resultados reforçam a importância dos estudo de EG no planejamento cirúrgico de pacientes encaminhados para cirurgia de fundoplicaturaAbstract: In order to investigate the effect of Nissen's fundoplication on the gastric emptying (GE) of liquids, we evaluated 96 male Wistar rats divided into three main groups: group E (EARLY) was formed by 32 rats that received physiologic saline as a test meal and whose gastric emptying was evaluated 8 days after surgery. Group L (LATE) consisted of 32 rats, receiving the same test meal but evaluated 29 days after surgery; finally, group G (GLUCOSE) received 5%' glucose in water as a test meal and ~as studied 8 days after surgery. Every group was further subdivided in two subgroups of 16 animals: in one of the subgroups (atropine) the animals received IV atropine sulphate (total dose=O.3 mg/l00mg rat weight) 60 minutes before GE test; 8 animals had been submited to fundoplication and 8 to a sham operation. The other subgroup of 16 animals (controls) consisted of 8 animals submited to fundoplication and 8 to sham operation that received IV physiologic saline. Every test meal, containing 6 mg% red fenol as a marker, was infused by gravity through a metalic catheter possessing a multiperforated olive in its extremity. Gastric retention was determined by measuring the concentration of the marker in the Iiquid recovered from the stomach 10 minutes after infusion. In the animals of EARLY group, fundoplication increased the gastric emptying of physiologic saline, both in the control and the atropine subgroups. On the other hand, in the LATE group, gastric retention values were similar in fundoplication and sham operated rats, suggesting an adaptation of the stomach to the anatomic changes induced by the fundoplication. Finally, in the GLUCOSE group, fundoplication enhanced GE among the control animals, but not among those receiving IV atropine sulphate. These results might indicate an inhibitory effect of atropine on the "antral pump" associated with a glucose-related increase of duodenaI resistance. These results support the importance of gastric enmptying studies in every patient to be submited to fundoplicationDoutoradoDoutor em Ciências Médica