ADOPTION OF MELD SCORE INCREASES THE NUMBER OF LIVER TRANSPLANT

Background

Liver transplantation is performed at large transplant centers worldwide as a therapeutic intervention for patients with end-stage liver diseases.

Aim

To analyze the outcomes and incidence of liver transplantation performed at the University of São Paulo and to compare those with the State of São Paulo before and after adoption of the Model for End-Stage Liver Disease (MELD) score.

Method

Evaluation of the number of liver transplantations before and after adoption of the MELD score. Mean values and standard deviations were used to analyze normally distributed variables. The incidence results were compared with those of the State of São Paulo.

Results

There was a high prevalence of male patients, with a predominance of middle-aged. The main indication for liver transplantation was hepatitis C cirrhosis. The mean and median survival rates and overall survival over ten and five years were similar between the groups (p>0.05). The MELD score increased over the course of the study period for patients who underwent liver transplantation (p>0.05). There were an increased number of liver transplants after adoption of the MELD score at this institution and in the State of São Paulo (p<0.001).

Conclusion

The adoption of the MELD score led to increase the number of liver transplants performed in São Paulo.     

ASSESSMENT OF THE GASTRO-JEJUNO-DUODENAL TRANSIT AFTER JEJUNAL POUCH INTERPOSITION

Background :

The jejunal pouch interposition between the gastric body and the duodenum after the gastrectomy, although not frequent in the surgical practice today, has been successfully employed for the prevention and treatment of the postgastrectomy syndromes. In the latter, it is included the dumping syndrome, which affects 13-58% of the patients who undergo gastrectomy.

Aim :

Retrospective assessment of the results of this procedure for the prevention of the dumping syndrome.

Methods :

Fourty patients were selected and treatetd surgically for peptic ulcer, between 1965 and 1970. Of these, 29 underwent vagotomy, antrectomy, gastrojejunalduodenostomy at the lesser curvature level, and the 11 remaining were submitted to vagotomy, antrectomy, gastrojejunal-duodenostomy at the greater curvature level. The gastro-jejuno-duodenal transit was assessed in the immediate or late postoperative with the contrasted study of the esophagus, stomach and duodenum. The clinical evolution was assessed according to the Visick grade.

Results :

Of the 40 patients, 28 were followed with the contrast evaluation in the late postoperative. Among those who were followed until the first month (n=22), 20 (90%) had slow gastro-jejuno-duodenal transit and in two (10%) the transit was normal. Among those who were followed after the first month (n=16), three (19%) and 13 (81%) had slow and normal gastric emptying, respectively. None had the contrasted exam compatible with the dumping syndrome. Among the 40 patients, 22 underwent postoperative clinical evaluation. Of these, 19 (86,5%) had excellent and good results (Visick 1 and 2, respectively).

Conclusions :

The jejunal pouch interposition showed to be a very effective surgical procedure for the prevention of the dumping syndrome in gastrectomized patients.     

SURGICAL TREATMENT OF HEMORRHOIDS: A CRITICAL APPRAISAL OF THE CURRENT OPTIONS

Introduction

Surgical treatment of hemorrhoids is still a dilemma. New techniques have been developed leading to a lower rate of postoperative pain; however, they are associated with a greater likelihood of recurrence.

Aim

To review current indications as well as the results and complications of the main techniques currently used in the surgical treatment of hemorrhoidal disease.

Methods

A systematic search of the published data on the options for treatment of hemorrhoids up to December 2012 was conducted using Medline/PubMed, Cochrane, and UpToDate.

Results

Currently available surgical treatment options include procedure for prolapse and hemorrhoids (PPH), transanal hemorrhoidal dearterialization (THD), and conventional hemorrhoidectomy techniques. Excisional techniques showed similar results regarding pain, time to return to normal activities, and complication rates. PPH and THD were associated with less postoperative pain and lower complication rates; however, both had higher postoperative recurrence rates.

Conclusion

Conventional surgical techniques yield better long-term results. Despite good results in the immediate postoperative period, PPH and THD have not shown consistent long-term favorable results.     

VOLUME CALCULATION OF RATS' ORGANS AND ITS APPLICATION IN THE VALIDATION OF THE VOLUME RELATION BETWEEN THE ABDOMINAL CAVITY AND THE HERNIAL SAC IN INCISIONAL HERNIAS WITH "LOSS OF ABDOMINAL DOMAIN"

Background

The calculation of the volume ratio between the hernia sac and the abdominal cavity of incisional hernias is based on tomographic sections as well as the mathematical formula of the volume of the ellipsoid, which allows determining whether this is a giant hernia or there is a "loss of domain". As the images used are not exact geometric figures, the study of the volume of two solid organs of Wistar rats was performed to validate these calculations.

Aim

To correlate two methods for determining the volume of the kidney and spleen of rats, comparing a direct method of observation of the volume with the mathematical calculation of this value.

Methods

The volume of left kidney, geometrically more regular, and spleen, with its peculiar shape, of ten animals was established in cubic centimeters after complete immersion in water with the aid of a beaker graduated in millimeters. These values ​​were compared with those obtained by calculating the same volume with a specific mathematical formula: V = 4/3 × π × (r1 x r2 x r3). Data were compared and statistically analyzed by Student''s t test. RESULTS: Although the average volume obtained was higher through the direct method (1.13 cm³ for the left kidney and 0.71 cm³ for the spleen) than the values ​​calculated with the mathematical formula (0.81 cm³ and 0.54 cm³⁾, there were no statistically significant differences between the values ​​found for the two organs (p>0.05).

Conclusion

There was adequate correlation between the direct calculation of the volume of the kidney and spleen with the result of mathematical calculation of these values ​​in the animals'' studies.     

ASSESSMENT OF MECHANICAL AND MANUAL SUTURE IN THE SURGICAL TREATMENT OF THE PHARYNGOESOPHAGEAL DIVERTICULUM

Background:

The occurrence of the pharyngoesophageal, or Zenker diverticulum is not frequent in the national scenario, and the technique of the diverticulectomy with cricomyotomy in medium and great dimension diverticula is still the most indicated. Because the resection of the diverticulum requires the suture of the pharynx, dehiscence can occur, thereafter delaying swallowing. Hence, the idea is to accomplish this surgical procedure, comparing the manual and mechanical suture, in order to evaluate the real benefit of the mechanical technique.

Aim:

To evaluate the results of the pharyngoesophageal diverticulectomy with cricomyotomy using manual and mechanical suture with regard to local and systemic complications.

Method:

Fifty-seven patients with pharyngoesophageal diverticula diagnosed through high digestive endoscopy and pharyngeal esophagogram were studied. The applied surgical technique was diverticulectomy with myotomy of the cricopharyngeal muscle, done in 24 patients (42.2%) the mechanical suture (group A) with the mechanical linear suture device and in 33 (57.8%) a manual closure of the pharynx (group B).

Results:

In the postoperative period, one patient of group A (4.1%) presented fistula caused by dehiscence of the pharyngeal suture, and three of group B (15.1%) presented the same complication, with a good outcome using a conservative treatment. In the same group, three patients (9.0%) presented stenosis of the suture of the pharynx, with good outcome and with endoscopic dilatations, and no patient from group A presented such complication. Lung infection was present in five patients, being two (8.3%) of group A and three (9.0%) on B, having good outcomes after specific treatment. In the late review, done with 43 patients (94.4%) of group A and 22 (88.0%) on B, the patients declared to be pleased with the surgical procedure, because they were able to regain normal swallowing.

Conclusion:

The diverticulectomy with myotomy and pharyngeal closure using mechanical suture was proven appropriate, for having restored regular swallowing in most of the patients, and the mechanical closure of the pharynx proved to be more effective in comparison to the manual one, because it provided a lower index of local post-surgical complications.     

EFFECTIVENESS OF THE LIGATION OF INTERSPHINCTERIC FISTULA TRACT (LIFT) IN THE TREATMENT OF ANAL FISTULA: INITIAL RESULTS

Background

The abscesses and anal fistulas represent about 70% of perianal suppuration, with an estimated incidence of 1/10000 inhabitants per year and representing 5% of queries in coloproctology.

Aim

To evaluate the effectiveness of the interesphincteric ligation technique of the fistulous tract in the treatment of anal fistula.

Methods

The records of eight patients who underwent this technique, evaluating age, gender and presence of incontinence were studied. Was named technical first-step the passage of cotton thread to promote the correct individualization of the fistula and, as the second, the surgical procedure.

Results

Two patients were men and eight women. The mean age was 42.8 years. Of these, seven (87.5%) had complete healing of the fistula; six were cured only with this procedure and one required additional operation with simple fistulotomy. Only one patient developed fecal incontinence which was documented by anorectal manometry. There were no deaths in this series.

Conclusion

The interesphincteric ligation technique of the fistulous tract proved to be effective for the treatment of anal fistula and should not be discouraged despite the occurrence of eventual fecal incontinence.     

NUTRITIONAL ASSESSMENT AND HAND GRIP STRENGTH OF CANDIDATES FOR SURGERY OF THE GASTROINTESTINAL TRACT

Background

The assessment of nutritional status in clinical practice must be done with simple, reliable, low cost and easy performance methods. The power of handshake is recognized as a useful tool to evaluate muscle strength, and therefore, it is suggested that can detect malnutrition.

Aim

To evaluate the nutritional status by subjective global assessment and power of handshake preoperatively in patients going to gastrointestinal surgeries and to compare the diagnosis obtained by subjective global assessment with traditional anthropometric methods and power of handshake.

Methods

A cross-sectional study was conducted with patients for surgery in the gastrointestinal tract and related organs. Socioeconomic and anthropometric data, applied to subjective global assessment and checked the power of handshake, were collected. The force was obtained by the average of three measurements of the dominant and non-dominant hand and thus compared with reference values ​​of the population by sex and age, for the classification of nutritional risk.

Results

The sample consisted of 40 patients, 24-83 years, and most women (52.5%) housewives (37,5%) and diagnosed with cancer (45%). According to subjective global assessment, 37.5% were classified as moderately malnourished; 15% were underweight by BMI measurements; 25% had arm circumference at risk for malnutrition (<percentil 5); 60% reported recent weight loss; and 37.5% low clamping force in power of handshake on non-dominant hand (left).

Conclusion

A significant association was observed for the diagnosis of nutritional subjective assessment with anthropometric methods and strength of the handshake only at the non-dominant limb.     

EFFECT OF OMEGA-3 FATTY ACID IN THE HEALING PROCESS OF COLONIC ANASTOMOSIS IN RATS

Background :

The use of long-chain polyunsaturated fatty acids has been studied in the context of healing and tissue regeneration mainly due to its anti-inflammatory, immunoregulatory and antioncogenic properties. Previous studies have demonstrated beneficial effects with the use of enteral immunonutrition containing various farmaconutrients such as L-arginine, omega-3, trace elements, but the individual action of each component in the healing of colonic anastomosis remains unclear.

Aim :

To evaluate the influence of preoperative supplementation with omega-3 fatty acids on the healing of colonic anastomoses of well-nourished rats.

Methods :

Forty Wistar adult male rats, weighing 234.4±22.3 g were used. The animals were divided into two groups: the control group received for seven days olive oil rich in omega-9 oil through an orogastric tube, while the study group received isocaloric and isovolumetric omega-3 emulsion at a dose of 100 mg/kg/day, also for seven days. Both groups were submitted to two colotomies followed by anastomosis, in the right and left colon, respectively. Parameters evaluated included changes in body weight, anastomotic complications and mortality, as well as maximum tensile strength by using a tensiometer and collagen densitometry at the anastomotic site.

Results :

There were no differences in body weight or mortality and morbidity between groups. The value of the maximum tensile strength of the control group was 1.9±0.3 N and the study group 1.7±0.2, p=0.357. There was, however, a larger amount of type I collagen deposition in the study group (p=0.0126). The collagen maturation índex was 1.74±0.71 in the control group and 1.67±0.5 in the study group; p=0,719).

Conclusions :

Preoperative supplementation of omega-3 fatty acid in rats is associated with increased collagen deposition of type I fibers in colonic anastomoses on the 5^th postoperative day. No differences were observed in the tensile strength or collagen maturation index.     

VARIATIONS IN THE GLIDING CHARACTERISTICS OF 10-ML PLASTIC SYRINGES USED TO LOCATE THE EXTRADURAL SPACE BY "LOSS OF RESISTANCE" TECHNIQUES

The gliding characteristics were evaluated of 10-ml plasticsyringes used to identify the extra - dural space by "loss ofresistance" techniques. This was undertaken quantitatively,by measuring the force necessary to depress syringe plungers,and qualitatively, by examining travel characteristics in termsof the force applied, together with the rate and uniformityof plunger travel. An important cause of inadvertent dural punctureis the use of syringes with plungers that do not move freely;this study has identified wide variations between makes whichmay be of particular relevance to anaesthetists inexperiencedin techniques of extradural analgesia.     

OBLIQUE VS. CIRCULAR ANASTOMOSIS IN THE CHILDREN UNDERWENT SOAVE’S PULL-THROUGH SURGERY FOR THE TREATMENT OF HIRSCHSPRUNG’S DISEASE: WHICH IS THE BEST?

​ Open in a separate windowOblique type of anastomosis     

EFFECTS OF DIFFERENT PERIODS OF GASTRIC ISCHAEMIA IN THE VIABILITY OF THE TISSUE OF BODY,FUNDUS AND ANTRUM REGION OF RABBIT STOMACH

BACKGROUND:

Despite the rich vascular arcade of the stomach, gastric ischemia represents an important medical challenge and can be the consequence of obstructive or non-obstructive vascular processes of pathological or iatrogenic origin.

AIM:

To assess the effects of acute gastric ischaemia on the different regions of the stomach.

METHOD:

Fifteen New Zeland rabbits were divided into three groups: group 1, animals were observed during 3 h; group 2, during 6 h; group 3, during 12 h. Rabbit stomachs were subjected to devascularization of the greater and lesser curvatures. After predetermined time, the stomachs were removed for macro and microscopic studies.

RESULTS:

Haemorrhagic necrosis was more marked in the gastric fundus and body. In contrast, the antropylorus remained preserved in 80% of the animals. Necrosis of the gastric body and fundus mucosa were observed in all animals after 6 h and 12 h of ischaemia.

CONCLUSION:

Acute gastric ischaemia in rabbits produces haemorrhagic necrosis of the gastric fundus and body even in a short period of time. Beside this, the antropyloric region was significantly more resistant to ischaemia.