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

Pancreatic Necrosis and Gas in the Retroperitoneum: Treatment with Antibiotics Alone

OBJECTIVE: To present our experience in the management of patients with infected pancreatic necrosis without drainage. METHODS: The records of patients with pancreatic necrosis admitted to our facility from 2011 to 2015 were retrospectively reviewed. RESULTS: We identified 61 patients with pancreatic necrosis. Six patients with pancreatic necrosis and gas in the retroperitoneum were treated exclusively with clinical support without any type of drainage. Only 2 patients had an APACHE II score >;8. The first computed tomography scan revealed the presence of gas in 5 patients. The Balthazar computed tomography severity index score was >;9 in 5 of the 6 patients. All patients were treated with antibiotics for at least 3 weeks. Blood cultures were positive in only 2 patients. Parenteral nutrition was not used in these patients. The length of hospital stay exceeded three weeks for 5 patients; 3 patients had to be readmitted. A cholecystectomy was performed after necrosis was completely resolved; pancreatitis recurred in 2 patients before the operation. No patients died. CONCLUSIONS: In selected patients, infected pancreatic necrosis (gas in the retroperitoneum) can be treated without percutaneous drainage or any additional surgical intervention. Intervention procedures should be performed for patients who exhibit clinical and laboratory deterioration

Parotidite aguda pós-cirúgica: prevalência atual no Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo

Postsurgical acute suppurative parotitis is a bacterial gland infection that occurs from a few days up to some weeks after abdominal surgical procedures. In this study, the authors analyze the prevalence of this complication in Hospital das Clínicas/São Paulo University Medical School by prospectively reviewing the charts of patients who underwent surgeries performed by the gastroenterological and general surgery staff from 1980 to 2005. Diagnosis of parotitis or sialoadenitis was analyzed. Sialolithiasis and chronic parotitis previous to hospitalization were exclusion criteria. In a total of 100,679 surgeries, 256 patients were diagnosed with parotitis or sialoadenitis. Nevertheless, only three cases of acute postsurgical suppurative parotitis associated with the surgery were identified giving an incidence of 0.0028%. All patients presented with risk factors such as malnutrition, immunosuppression, prolonged immobilization and dehydration. In the past, acute postsurgical suppurative parotitis was a relatively common complication after major abdominal surgeries. Its incidence decreased as a consequence of the improvement of perioperative antibiotic therapy and postoperative support. In spite of the current low incidence, we believe it is important to identify risks and diagnose as quick as possible, in order to introduce prompt and appropriate therapeutic measures and avoid potentially fatal complications with the evolution of the disease.A parotidite supurativa pós-cirúrgica é infecção bacteriana da glândula que ocorre poucos dias até algumas semanas após procedimento cirúrgico. Os autores analisam a prevalência desta complicação cirúrgica nos últimos 25 anos do Hospital das Clínicas de São Paulo. Foram analisados os prontuários das cirurgias realizadas pelos serviços de Cirurgia do Aparelho Digestivo e Cirurgia Geral da Faculdade de Medicina da Universidade de São Paulo no período de 1980 a 2005, num total de 106790 cirurgias. Todos os prontuários que apresentaram entre os diagnósticos das altas complicações cirúrgicas, parotidite ou sialoadenite foram avaliados. Foram identificados 256 prontuários. Pacientes com outras complicações, ou que já apresentavam sialolitíase ou parotidite crônica anterior à internação foram excluídos do estudo. Foram identificados apenas três casos de parotidite aguda supurativa pós-cirúrgica, revelando incidência de 0,0028%. A parotidite supurativa pós-cirúrgica foi complicação relativamente comum de grandes cirurgias abdominais no passado, com acentuada redução atual da sua incidência decorrente da antibioticoterapia de amplo espectro, além de preparação pré-operatória adequada e suporte pós-operatório dos pacientes. Apesar da baixa incidência atual, consideramos importante identificar seus fatores de risco, assim como realizar diagnóstico precoce, conduta terapêutica apropriada para evitar complicações letais associadas a esta infecção

Lymphatic fistula after esophagectomy: what to do?

BACKGROUND: Lesions of the thoracic duct causing chylotorax are less frequent and normally happen during thoracic procedures and traumas, such as esophagectomies, mediastinal and pleuro-pulmonary surgeries. Therefore, surgery is suitable if there is no spontaneous resolution. AIM: To analyze the lymphatic fistula as a complication of esophagectomy regarding malignant and benign diseases. METHODS: Seven patients with an average age of 42 years, being five males, presented postoperative chylotorax after esophagectomies accomplished for the epidermoid carcinoma (five cases) and advanced chagasic megaesophagus (two cases). Total parenteral nutrition was indicated in all cases. RESULTS: The average drainage was of 2700 mL/day, and pleurodesis was the first procedure made, with minimal satisfactory results. Surgery was indicated with the persistence of the fistula. Three patients were submitted to right videothoracoscopy and one of these was reoperated by right thoracotomy. Another case had the need of immediate conversion to right thoracotomy. And in the last case, the thoracic duct was identified and joined by means of videothoracoscopy. The rest of the cases were submitted to right thoracotomy. Post-operative evolution was favorable for six of the operated patients, who received hospital discharge after an average period of 36 hospitalization days. One patient who had carcinoma passed away (15%) due to hepatic cirrhosis complications. CONCLUSION: Post-esophagectomy lymphatic fistulas are dangerous complications, which determines the significant nutritional deficit of the patients and demands frequent surgical treatment for the joining of ducts, being videothoracoscopy one of the first choice procedures.As lesões do ducto torácico ocasionando quilotórax são pouco freqüentes e ocorrem durante procedimentos torácicos e traumas, tais como esofagectomias, procedimentos cirúrgicos mediastinais e pleuro-pulmonares. A operação está indicada se não houver resolução espontânea. OBJETIVO: Analisar a fístula linfática como complicação de esofagectomias para doenças malignas e benignas. MÉTODOS: Sete doentes com idade média de 42 anos, sendo cinco masculinos, apresentaram quilotórax no pós-operatório de esofagectomias realizadas para o carcinoma epidermóide (cinco casos) e megaesôfago chagásico avançado (dois casos). A nutrição parenteral total foi indicada em todos os pacientes. RESULTADOS: A drenagem média foi de 2700 mL/dia, e a pleurodese foi o primeiro procedimento preconizado, com resultados pouco satisfatórios. Procedimento cirúrgico foi indicado na persistência da fístula. Três doentes foram submetidos à videotoracoscopia direita e em um deles houve necessidade de reintervenção por toracotomia direita. No outro caso, houve necessidade de conversão imediata para toracotomia direita. E no último, por meio da videotoracoscopia, o ducto torácico foi identificado e ligado. Os demais casos foram submetidos à toracotomia direita. A evolução pós-operatória foi favorável para os seis doentes operados, que receberam alta hospitalar após período médio de internação de 36 dias. Um doente com carcinoma faleceu (15%) por complicações decorrentes de cirrose hepática. CONCLUSÕES: A fístula linfática pós-esofagectomia é complicação grave, que determina déficit nutricional significativo e exige com freqüência tratamento operatório para ligadura do ducto, sendo a videotoracoscopia a primeira escolha2029092Lesions of the thoracic duct causing chylotorax are less frequent and normally happen during thoracic procedures and traumas, such as esophagectomies, mediastinal and pleuro-pulmonary surgeries. Therefore, surgery is suitable if there is no spontaneous resolution. AIM: To analyze the lymphatic fistula as a complication of esophagectomy regarding malignant and benign diseases. METHODS: Seven patients with an average age of 42 years, being five males, presented postoperative chylotorax after esophagectomies accomplished for the epidermoid carcinoma (five cases) and advanced chagasic megaesophagus (two cases). Total parenteral nutrition was indicated in all cases. RESULTS: The average drainage was of 2700 mL/day, and pleurodesis was the first procedure made, with minimal satisfactory results. Surgery was indicated with the persistence of the fistula. Three patients were submitted to right videothoracoscopy and one of these was reoperated by right thoracotomy. Another case had the need of immediate conversion to right thoracotomy. And in the last case, the thoracic duct was identified and joined by means of videothoracoscopy. The rest of the cases were submitted to right thoracotomy. Post-operative evolution was favorable for six of the operated patients, who received hospital discharge after an average period of 36 hospitalization days. One patient who had carcinoma passed away (15%) due to hepatic cirrhosis complications. CONCLUSION: Post-esophagectomy lymphatic fistulas are dangerous complications, which determines the significant nutritional deficit of the patients and demands frequent surgical treatment for the joining of ducts, being videothoracoscopy one of the first choice procedure

Pentoxifylline associated to hypertonic saline solution attenuates inflammatory process and apoptosis after intestinal ischemia/reperfusion in rats

PURPOSE:To evaluate intestinal inflammatory and apoptotic processes after intestinal ischemia/reperfusion injury, modulated by pentoxifylline and hypertonic saline.METHODS:It was allocated into four groups (n=6), 24 male Wistar rats (200 to 250g) and submitted to intestinal ischemia for 40 min and reperfusion for 80 min: IR (did not receive any treatment); HS group (Hypertonic Saline, 4ml/kg-IV); PTX group (Pentoxifylline, 30mg/kg-IV); HS+PTX group (Hypertonic Saline and Pentoxifylline). All animals were heparinized (100U/kg). At the end of reperfusion, ileal fragments were removed and stained on hematoxylin-eosin and histochemical studies for COX-2, Bcl-2 and cleaved caspase-3.RESULTS:The values of sO2 were higher on treated groups at 40 minutes of reperfusion (p=0.0081) and 80 minutes of reperfusion (p=0.0072). Serum lactate values were lower on treated groups after 40 minutes of reperfusion (p=0.0003) and 80 minutes of reperfusion (p=0.0098). Morphologic tissue injuries showed higher grades on IR group versus other groups: HS (p=0.0006), PTX (p=0.0433) and HS+PTX (p=0.0040). The histochemical study showed lesser expression of COX-2 (p=0.0015) and Bcl-2 (p=0.0012) on HS+PTX group. A lower expression of cleaved caspase-3 was demonstrated in PTX (p=0.0090; PTXvsIR).CONCLUSION:The combined use of pentoxifylline and hypertonic saline offers best results on inflammatory and apoptotic inhibitory aspects after intestinal ischemia/reperfusion.São Paulo University Medical SchoolUSP Medical SchoolFederal University of São Paulo Medical SchoolUSP School of MedicineUSP School of Medicine Department of SurgeryUSP Medical School Department of SurgeryUNIFESP, Medical SchoolSciEL

Effects of hypertonic saline and pentoxifylline on oxidative stress and inflammatory activity in sepsis-induced by intestinal obstruction and ischemia in rats

A obstrução intestinal representa uma das afecções abdominais agudas mais frequentes, com altas taxas de complicações e mortalidade, principalmente na vigência de sepse decorrente da isquemia intestinal. A reanimação volêmica precoce na sepse implica em ganho de sobrevida, entretanto, algumas discussões referentes ao fluido utilizado ou mesmo à terapêutica associada com drogas persistem atuais. Desta forma, o presente estudo propõe avaliar os efeitos da solução salina hipertônica e da pentoxifilina na resposta inflamatória e no estresse oxidativo, em modelo experimental que se assemelha ao problema clínico. Foram utilizados 36 ratos Wistar machos com peso entre 250 e 300 g. Os animais foram submetidos à laparotomia exploradora com ligaduras do íleo terminal a 10 cm e 1,5 cm da válvula íleo-cecal, além de oclusão do pedículo vascular responsável pela irrigação deste segmento intestinal. Após 24 horas, os animais foram reoperados e distribuídos em grupos (N=6), conforme o tratamento: sem reanimação volêmica (OI); Ringer lactato - 32 mL/kg (RL); solução salina hipertônica a 7,5% - 4 mL/kg (SH); pentoxifilina 25 mg/kg (PTX); Ringer lactato com pentoxifilina (RLPT) e solução salina hipertônica com pentoxifilina (SHPT). Ao término do tratamento, realizou-se ressecção do segmento intestinal isquêmico e anastomose para estabelecimento do trânsito intestinal. Os animais foram observados por duas horas, com medidas da pressão arterial média (PAM) registradas em 4 momentos. Após o período de observação, os animais foram submetidos à eutanásia com coleta do intestino e pulmão para análise. A quantificação do malondialdeído (MDA), no pulmão e intestino, foi realizada através do TBARS. No tecido pulmonar, também foram avaliadas as citocinas inflamatórias (IL-1?, IL-6, IL- 10 e CINC-1) pelo método de ELISA e o fator de transcrição nuclear fosforilado (NF-??) por Western blot. Os níveis da PAM, aos cinco minutos após o tratamento, ficaram mais elevados nos grupos RL e SH (p<0,05), com valor maior no SH em relação ao RL (p<0,05); aos 45 minutos, não se observou diferença nos níveis da PAM. A expressão das citocinas IL-1?, IL-6 e CINC-1 foi menor nos grupos SH, PTX e SHPT em relação ao OI e RL (p<0,05). Os grupos SH, PTX e SHPT apresentaram níveis inferiores de IL-1? e IL-6 comparadas ao RLPT (p<0,05) e os grupos SHPT e PTX foram iguais entre si. A expressão de IL-10 foi menor no grupo SHPT quando comparada ao OI (p<0,05). A expressão do NF-?B nos grupos SH, PTX e SHPT foi menor em relação ao OI (p<0,05), sendo que o SHPT ainda foi menor que o RL (p<0,05). Referente ao estresse oxidativo, no pulmão houve menor produção do MDA no grupo SHPT comparado aos demais (p<0,05) e no intestino, o MDA foi inferior nos grupos SH, PTX, RLPT e SHPT comparados aos OI e RL (p<0,05). Estes resultados permitem concluir que a solução salina hipertônica a 7,5% associada ou não à pentoxifilina, e a pentoxifilina isoladamente, atenuam o estresse oxidativo e inibem a ativação do NF-?B, implicando em menor atividade inflamatória com redução na produção de citocinasIntestinal obstruction is one of the most common acute abdominal diseases, with high rates of complications and mortality, especially in the presence of sepsis due to intestinal ischemia. The early volume resuscitation in sepsis involves survival gain, however, some discussions concerning the fluid used or even combination therapy with drugs persist today. The present study proposes to assess the effects of hypertonic saline and pentoxifylline on inflammatory response and oxidative stress in an experimental model resembling the clinical problem. The study included 36 male Wistar rats weighting between 250 and 300 g. The animals underwent laparotomy with ligation of the terminal ileum 10 cm and 1.5 cm from the ileocecal valve and occlusion of the vascular pedicle responsible for the irrigation of this intestinal segment. After 24 hours, the animals were reoperated and distributed in groups (N=6), according to treatment: without volume resuscitation (OI); Ringer lactate - 32 mL/kg (RL), hypertonic saline 7.5% - 4 mL/kg (HS); pentoxifylline 25 mg/kg (PTX); Ringer lactate with pentoxifylline (RLPT) and hypertonic saline with pentoxifylline (SHPT). After the infusion of the drugs, the ischemic bowel was resected and performed the anastomosis for establishment of intestinal transit. The animals were observed for two hours, with measurements of mean arterial pressure (MAP) recorded in 4 times. After the observation period, the animals were euthanized with bowel and lung collection for analysis. Inflammatory cytokines (IL-1?, IL-6, IL-10 and CINC-1) were assessed by ELISA and phosphorylated nuclear transcription factor (NF-??) was determined by Western blot, both measured in lung tissue. The quantification of the malondialdehyde (MDA) in the lung and intestine was performed using the TBARS assay. Initial levels of MAP were higher in groups RL and HS than others (p<0.05), but at the end levels were similar in all groups. The expression of IL-1?, IL-6 and CINC-1 was lower in the SH, PTX and SHPT groups compared to OI and RL (p <0.05). The SH, SHPT and PTX groups showed lower levels of IL-1? and IL-6 compared to RLPT (p <0.05) and SHPT and PTX groups were equal. The synthesis of IL- 10 was lower in SHPT compared to OI (p <0.05). The expression of NF-?B in SH, PTX and SHPT groups was lower compared to OI (p <0.05), whereas the SHPT was still less than the RL (p <0.05). MDA in the lung was lower in SHPT compared to the other groups (p<0.05) and in the intestine was lower in SH, PTX, RLPT and SHPT groups compared to OI and RL (p<0.05). The results indicate that hypertonic saline 7.5% with or without pentoxifylline, and pentoxifylline alone attenuate oxidative stress and inhibit the activation of NF-?B, resulting in lower inflammatory activity with reduced production of cytokine

Profile of the General Surgery resident: what are the changes in the 21 st Century?

<div><p>ABSTRACT Objective: to verify the profile of the General Surgery residents of the Clinics Hospital (HC) of the Faculty of Medicine of the University of São Paulo (FMUSP). Methods: we evaluated the residents approved in the public contest for the Medical Residency Program in General Surgery of HC-FMUSP in the years 2014, 2015 and 2016. We carried out the study by applying a questionnaire and gathering information from the Medical Residency Commission of the Institution. We analyzed data on identification, origin of the candidate, undergraduate school, surgical teaching received, reason for choosing Surgery, residency expectations, choice of future specialty and pretensions as to the end of medical residency. We also analyzed the result of the examination of access to specialties. Results: the mean age was 25.8 years; 74.3% of residents were male. The majority (84.4%) had attended public medical schools, 68% of which were not in the Southeast region; 85,2% of the residents were approved in the first contest. The specialty choice was present for 75.9% of individuals at the beginning of the residency program, but 49.5% changed their minds during training. Plastic Surgery, Urology and Digestive System Surgery were chosen by 61.5%. Sixty hours per week work were considered adequate by 83.3%; 27.3% favored direct access to the specialty. At the end of the specialty, 53.3% intended to continue in São Paulo, and 26.2%, to return to their State of origin. A strict-sense post-graduate course was intended by 68.3%. Conclusion: the current profile of the resident reveals a reduction in the demand for General Surgery, an earlier definition of the specialty, options for increasingly specific areas and an activity that offers a better quality of life.</p></div

Management of infected pancreatic necrosis: state of the art

ABSTRACT Pancreatic necrosis occurs in 15% of acute pancreatitis. The presence of infection is the most important factor in the evolution of pancreatitis. The diagnosis of infection is still challenging. Mortality in infected necrosis is 20%; in the presence of organic dysfunction, mortality reaches 60%. In the last three decades, there has been a real revolution in the treatment of infected pancreatic necrosis. However, the challenges persist and there are many unsolved questions: antibiotic treatment alone, tomography-guided percutaneous drainage, endoscopic drainage, video-assisted extraperitoneal debridement, extraperitoneal access, open necrosectomy? A step up approach has been proposed, beginning with less invasive procedures and reserving the operative intervention for patients in which the previous procedure did not solve the problem definitively. Indication and timing of the intervention should be determined by the clinical course. Ideally, the intervention should be done only after the fourth week of evolution, when it is observed a better delimitation of necrosis. Treatment should be individualized. There is no procedure that should be the first and best option for all patients. The objective of this work is to critically review the current state of the art of the treatment of infected pancreatic necrosis