Uso de prótese biológica no tratamento cirúrgico de hérnias paracolostômicas

BACKGROUND: Paracolostomy hernia is a frequent complication of intestinal stoma. Its correction can be made through relocation of the colostomy or by keeping it in place and performing abdominal wall reinforcement through direct suturing with or without a prosthesis. METHOD: Results of surgical treatment of paracolostomy hernias were analyzed in 22 patients who underwent surgery in our hospital during the past 15 years, with or without biological mesh (bovine pericardium). All patients had terminal colostomies after abdominoperineal excision of the rectum. RESULTS: In 15 (68.2%) patients, hernia correction was made by maintaining the colostomy in place, in 2 of them (9.1%) without reinforcement, and in the other 13 (59.1%) through reinforcement of the aponeurosis with biological mesh. In the 7 (31.8%) other patients, hernia correction was accomplished by relocation of the colostomy. The mean follow-up period was 50.2 months. Recurrence was observed in 3 (13.6%) patients after a median of 16 months post-correction. CONCLUSION: Paracolostomy hernia remains a surgical challenge due to its high recurrence rate. Primary repair using a prosthesis of biological material may be preferable since muscle-aponeurotic weakness is frequently observed.Hérnias paracolostômicas são complicações freqüentes de estomas intestinais. A correção pode ser realizada através do seu reposicionamento ou mantendo a mesma localização, associada ao reforço da parede abdominal com ou sem o emprego de prótese. MÉTODOS: Os resultados do tratamento cirúrgico de hérnias paracolostômicas são analisados em 22 pacientes em nosso serviço nos últimos 15 anos. Todos os pacientes eram portadores de colostomias terminais após ressecção abdominoperineal do reto. RESULTADOS: Em 15 (68,2%) pacientes, a correção da hérnia foi realizada mantendo-se a colostomia no local original, em 2 (9,1%) deles através de herniorrafia simples e em 13 (59,1%) com reforço da aponeurose com prótese biológica. Nos outros 7 (31,8%) pacientes, a correção foi realizada por reposicionamento da colostomia. O seguimento médio pós-operatório foi de 50,2 meses. Recidiva foi observada em 3 (13,6%) casos (em média 16 meses após correção). CONCLUSÃO: A hérnia paracolostômica continua a ser um desafio cirúrgico devido a sua elevada recidiva. Correção primária com prótese pode ser favorecida, uma vez que freqüentemente se observa fraqueza da aponeurose

Transplante de pâncreas e rim simultâneo com enxerto renal proveniente de doador vivo

O transplante de pâncreas e rim simultâneo (TPRS) assumiu na última década, importante papel no tratamento dos pacientes diabéticos insulino-dependentes com doença renal em fase terminal. A melhora nos resultados obtidos com esta terapia tornou a indicação deste procedimento mais freqüente, acarretando aumento na lista de receptores e, consequentemente, maior tempo de espera pelo transplante. Com o intuito de reduzir o tempo de espera em lista e associar os benefícios imunológicos e técnicos do transplante realizado com doador-vivo relacionado, alguns centros mundiais passaram a indicar o TPRS com o emprego de enxerto renal proveniente de doador-vivo relacionado. Apresentamos a seguir, o primeiro caso realizado no país desta modalidade de transplante de pâncreas.Simultaneous pancreas-kidney transplant (SPK) assumed in the last decade an important paper in treatment of insulin-dependent diabetic patients with end-stage renal disease. The improvement in the results obtained with this therapy made the indication of this procedure more frequent, causing an increase in the patient’s waiting list and, consequently, a larger waiting time for the transplant. Aiming to reduce the waiting time and to associate technical and imunologic benefits in the transplant accomplished with living related donor, some centers started to indicate SPK using the kidney graft obtained from a living related donor. We present the first case of this modality of pancreas transplant accomplished in Brazil

Avaliação perioperatória da viabilidade intestinal

The assessment of a intestinal segment’s viability and its degree of ischemia only by clinical criteria is often hard for the surgeon. Sometimes it’s necessary to use auxiliary methods to assess the degree of intestinal injury, which sometimes is imperceptible by clinical evaluation. This review presents the principal methods to undergo this evaluation, describing their technique and necessary equipament, as long as their results. The analized methods were divided in experimental: eletromiography, non-contact tissue laser Doppler and thermal imaging; and clinical: clinical criteria, Dopplerultrasonography, laser Doppler, intravascular dyes, surface oximetry, pulse oxymetry, thermography, pH measurement, tonometry and infrared photopletysmography. The results of second-look laparotomies in patients with mesenteric vascular insufficiency who were operated are described too. After reviewing all the literature, we found that Doppler ultrasound and fluorescein injection are, due to its costs and easymenagement, the most used and accepted methods to assess the perioperative intestinal viability. We had also observed that post-operative laparoscopy has a high value on the monitorization of the intestinal viability in patients that undergo surgical treatment for mesenteric vascular insufficiency, especially if the introperative assessment of their intestinal viability wasn’t do precise.A determinação da viabilidade de segmentos intestinais e do grau de isquemia a partir de critérios clínicos pode ser de extrema dificuldade para o cirurgião. Faz-se necessário lançar mão de métodos auxiliares para se atestar o grau de comprometimento da alça intestinal, muitas vezes inaparenteà avaliação clínica. O presente trabalho apresenta uma revisão de literatura dos principais métodos existentes para se fazer essa avaliação, descrevendo a técnica e equipamentos necessários para cada um, bem como os resultados da aplicação dos mesmos. Os principais métodos auxiliares encontrados na literatura se dividem em experimentais: eletromiografia, laser Doppler sem contato e Imagem térmica; e clínicos: avaliação exclusiva por critérios clínicos, Doppler ultrassom, laser Doppler, injeção intravascular de corantes, oximetria superficial, oximetria de pulso, termometria, pHmetria, tonometria e fotopletismografia infravermelha. São também reinterados os resultados da indicação e realização das relaparotomias no manejo de pacientes com insuficiência vascular mesentérica. Após a revisão de literatura, pudemos concluir que o Doppler ultrassom e a injeção intravenosa de fluoresceína representam os métodos auxiliares para a avaliação perioperatória da viabilidade intestinal mais utilizados devidoprincipalmente ao seu baixo custo e relativa facilidade de uso. Optamos por destacar o papel da laparoscopia pós-operatória no segmento de pacientes submetidos ao tratamento cirúrgico de insuficiência vascular mesentérica, em especial naqueles em que a avaliação da viabilidade intestinal foi duvidosa

Amputação do reto convencional x laparoscópica no tratamento do câncer do reto distal após quimioirradiação neoadjuvante: resultados de estudo prospectivo e randomizado

OBJECTIVE: The aims of this study were to evaluate the safety and efficacy of laparoscopic abdominoperineal resection compared to conventional approach for surgical treatment of patients with distal rectal cancer presenting with incomplete response after chemoradiation. METHOD: Twenty eight patients with distal rectal adenocarcinoma were randomized to undergo surgical treatment by laparoscopic abdominoperineal resection or conventional approach and evaluated prospectively. Thirteen underwent laparoscopic abdominoperineal resection and 15 conventional approach. RESULTS: There was no significant difference (pOBJETIVO: Comparar os resultados de eficácia e segurança do emprego da operação de amputação do reto por via laparoscópica e por via convencional no tratamento cirúrgico de pacientes com câncer do reto distal que apresentaram resposta incompleta a quimioirradiação pré-operatória. MÉTODO: Vinte e oito pacientes com adenocarcinoma de reto distal foram randomizados para se submeter à amputação do reto por via laparoscópica ou à amputação do reto por via convencional. Treze pacientes submeteram-se à amputação do reto por via laparoscópica e 15 à amputação do reto por via convencional. RESULTADOS: Não houve diferença significativa (

Gastric bypass versus best medical treatment for diabetic kidney disease: 5 years follow up of a single-centre open label randomised controlled trial

BACKGROUND: We compared the albuminuria-lowering effects of Roux-en-Y gastric bypass (RYGB) to best medical treatment in patients with diabetic kidney disease and obesity to determine which treatment is better. METHODS: A 5 year, open-label, single-centre, randomised trial studied patients with diabetic kidney disease and class I obesity after 1:1 randomization to best medical treatment (n = 49) or RYGB (n = 51). The primary outcome was the proportion of patients achieving remission of microalbuminuria after 5 years. Secondary outcomes included improvements in diabetic kidney disease, glycemic control, quality of life, and safety. For efficacy outcomes, we performed an intention-to-treat (ITT) analysis. This study was registered with ClinicalTrials.gov, NCT01821508. FINDINGS: 88% of patients (44 per arm) completed 5-year follow-up. Remission of albuminuria occurred in 59.6% (95% CI = 45.5–73.8) after best medical treatment and 69.7% (95% CI = 59.6–79.8) after RYGB (risk difference: 10%, 95% CI, −7 to 27, P = 0.25). Patients after RYGB were twice as likely to achieve an HbA1c ≤ 6.5% (60.2% versus 25.4%, risk difference, 34.9%; 95% CI = 15.8–53.9, P < 0.001). Quality of life after five years measured by the 36-Item Short Form Survey questionnaire (standardized to a 0-to-100 scale) was higher in the RYGB group than in the best medical treatment group for several domains. The mean differences were 13.5 (95% CI, 5.5–21.6, P = 0.001) for general health, 19.7 (95% CI, 9.1–30.3, P < 0.001) for pain, 6.1 (95% CI, −4.8 to 17.0, P = 0.27) for social functioning, 8.3 (95% CI, 0.23 to 16.3, P = 0.04) for emotional well-being, 12.2 (95% CI, 3.9–20.4, P = 0.004) for vitality, 16.8 (95% CI, −0.75 to 34.4, P = 0.06) for mental health, 21.8 (95% CI, 4.8–38.7, P = 0.01) for physical health and 11.1 (95% CI, 2.24–19.9, P = 0.01) for physical functioning. Serious adverse events were experienced in 7/46 (15.2%) after best medical treatment and 11/46 patients (24%) after RYGB (P = 0.80). INTERPRETATION: Albuminuria remission was not statistically different between best medical treatment and RYGB after 5 years in participants with diabetic kidney disease and class 1 obesity, with 6–7 in ten patients achieving remission of microalbuminuria (uACR <30 mg/g) in both groups. RYGB was superior in improving glycemia, diastolic blood pressure, lipids, body weight, and quality of life. FUNDING: The study was supported by research grants from Johnson & Johnson Brasil, Oswaldo Cruz German Hospital, and by grant 12/YI/B2480 from Science Foundation Ireland (Dr le Roux) and grant 2015-02733 from the Swedish Medical Research Council (Dr le Roux). Dr Pereira was funded by the Chevening Scholarship Programme (Foreign and Commonwealth Office, UK)

NOTES: present and future – a brief review

The evolution of minimally invasive surgery has resulted in improvedsurgical outcomes, such as faster wound healing, better cosmeticresults and early hospital discharge. Natural orifice transluminalendoscopic surgery (NOTES) is an alternative to laparoscopy withthe advantage of eliminating abdominal incisions since it combinesendoscopic and laparoscopic techniques that access the abdominalcavity through natural orifices. Although it is a developing technique, many advantages have already been attributed to NOTES, such as lower incidence of hernia, wound infection and adhesions. Indications and contraindications will arise in parallel to the development of this technique and are subject to scrutiny. In this article, the authors review the current status of NOTES as well as its perspectives for the future

Early and Late Results of Topical Diltiazem and Bethanechol for Chronic Anal Fissure: A Comparative Study

Background/Aims: Late efficacy of medical treatment of chronic anal fissure remains controversial due to high recurrence. This study aimed at analyzing safety and efficacy of topical diltiazem and bethanechol regarding healing and symptoms relief, safety, recurrence, and need for surgery. Methodology: This was a single-center non-randomized trial. Outcomes of 30 patients with chronic anal fissure treated with 2% diltiazem were compared to 30 patients treated with 0.1% bethanechol, both for eight weeks. Patients were assessed after seven days and eight weeks. Results: In diltiazem group, after seven days, 31% were symptomatic; after bethanechol, 71% (p=0.06). After seven days, fissure healing occurred in 19% after diltiazem and in 11% after bethanechol. After eight weeks, in both groups, 64% were asymptomatic; after diltiazem, 53% healed; after bethanechol, 50% (p=0.80). Success was the same for both groups: 63.3%. Groups were similar regarding complications. After diltiazem, 9 (30%) patients were operated on; and 11 (36.7%) after bethanechol (p=0.60). Recurrence occurred in 4 (13.3%) patients in both groups. Median time to recurrence after diltiazem was 15 (10-24) months and 7.5 (2-15) after bethanechol - p=0.15. Conclusions: Both treatments are safe and effective. Diltiazem may be associated to earlier relief and more sustained response