Results of surgical treatment of massive localized lymphedema in severely obese patients

OBJECTIVE: to evaluate the importance of treatment of deformities caused by massive localized lymphedema (MLL) in the severely obese. METHODS: in a period of seven years, nine patients with morbid obesity and a mean age of 33 years underwent surgical resection of massive localized lymphedema with primary synthesis. This is a retrospective study on the surgical technique, complication rates and improved quality of life. RESULTS: all patients reported significant improvement after surgery, with greater range of motion, ambulation with ease and more effective hygiene. Histological analysis demonstrated the existence of a chronic inflammatory process marked by lymphomonocitary infiltrate and severe tissue edema. We observed foci of necrosis, formation of microabscesses, points of suppuration and local fibrosis organization, and pachydermia. The lymphatic vessels and some blood capillaries were increased, depicting a framework of linfangiectasias. CONCLUSION: surgical treatment of MLL proved to be important for improving patients' quality of life, functionally rehabilitating them and optimizing multidisciplinary follow-up of morbid obesity, with satisfactory surgical results and acceptable complication rates, demonstrating the importance of treatment and awareness about the disease.

Does a previous surgical experience interfere on psychic stress in patients submitted to major surgery?

OBJECTIVE: to evaluate the impact of stress in patients undergoing major surgeries under general anesthesia, relating their physical and psychic reactions to the different stages of stress. METHODS: we studied 100 adult patients of both genders, who were divided into two groups: Group 1 - 22 patients without experience with surgery; Group 2 - 78 patients previously submitted to medium and major surgery. To investigate the stress, we used the Inventory of Stress Symptoms for Adults, developed by Lipp, the day before the procedure and two days and seven days after the operation. The comparison of groups with respect to gender, pain, and percentage of stress were performed using the Chi-square test, and for the age variable the Student's t test was used. Differences were considered significant at p<0.05. RESULTS: the groups were not homogeneous as for the overall percentage of stress on the three measurements. G1 had decreased postoperative stress, whilst in G2 it increased. Psychological symptoms of stress prevailed in both groups. CONCLUSION: previous surgery reduced preoperative stress but did not affect postoperative emotional disorders.

Surgical techniques for maxillary bone grafting - literature review

For oral rehabilitation with implant-supported prostheses, there are required procedures to create the bone volume needed for installation of the implants. Thus, bone grafts from intraoral or extraoral donor sites represent a very favorable opportunity. This study aimed to review the literature on the subject, seeking to discuss parameters for the indications, advantages and complications of techniques for autogenous bone grafts.

An alternative experimental model for training in microsurgery

OBJECTIVE: to describe a new model of training in microsurgery with pig spleen after splenectomy performed by undergraduate students of the Discipline of Operative Technique of the UFPR Medical School. METHODS: after the completion of splenectomy we performed dissection of the vascular pedicle, distal and proximal to the ligation performed for removal of the spleen. After complete dissection of the splenic artery and vein with microscope, clamps were placed and the vessels were cut. We then made the anastomosis of the vessels with 9.0 nylon. RESULT: the microsurgical training with a well-defined routine, qualified supervision and using low cost experimental materials proved to be effective in the practice of initial microvascular surgery. CONCLUSION: the use of pig spleen, which would be discarded after splenectomy, is an excellent model for microsurgical training, since besides having the consistency and sensitivity of a real model, it saves the sacrifice of a new animal model in the initial learning phase of this technique.

Surgical treatment of subcostal incisional hernia with polypropylene mesh - analysis of late results

OBJECTIVE: To evaluate the results of subcostal incisional hernia repair using polypropylene mesh, the technical aspects of musculo-aponeurotic reconstruction, routine fixation of supra-aponeurotic mesh and follow-up for five years.METHODS: We conducted a retrospective study that assessed 24 patients undergoing subcostal incisional hernia repair with use of polypropylene mesh; 15 patients (62.5%) were female; ages ranged from 33 to 82, and 79.1% had comorbidities.RESULTS: Early complications: three cases (12.5%) of wound infection, three cases (12.5%) of seroma, one case (4.1%) of hematoma; and one case (4.1%) of wound dehiscence. Late complications occurred in one case (4.1%) of hernia recurrence attributed to technical failure in the fixation of the mesh and in one case (4.1%) of chronic pain. There were no cases of exposure or rejection of the mesh.CONCLUSION: The subcostal incisional hernia, though not very relevant, requires adequate surgical treatment. Its surgical correction involves rebuilding the muscle-aponeurotic defect, supra-aponeurotic fixation of polypropylene mesh, with less complexity and lower rates of complications and recurrences.

Low-fidelity bench models for basic surgical skills training during undergraduate medical education

It is remarkable the reduction in the number of medical students choosing general surgery as a career. In this context, new possibilities in the field of surgical education should be developed to combat this lack of interest. In this study, a program of surgical training based on learning with models of low-fidelity bench is designed as a complementary alternative to the various methodologies in the teaching of basic surgical skills during medical education, and to develop personal interests in career choice.

Surgical treatment of cleft lip

We performed a systematic review of the literature on the surgical treatment of cleft lip, emphasizing the prevalence, complications associated with the treatment and the points of disagreement between authors. We conducted a literature cross-sectional search that analyzed publications in books, articles and on the databases SciELO - Scientific Electronic Library Online, PubMed, of the National Center for Biotechnology Information. We conclude that: 1) the severity of the cleft will indicate the technique presenting more advantages; 2) the different approaches indicate that there is no consensus on the optimal technique; and 3) the surgeon experience contributes to choosing the best option.

Is there a role for pyloric exclusion after severe duodenal trauma?

Duodenal trauma is an infrequent injury, but linked to high morbidity and mortality. Surgical management of duodenal injuries is dictated by: patient's hemodynamic status, injury severity, time of diagnosis, and presence of concomitant injuries. Even though most cases can be treated with primary repair, some experts advocate adjuvant procedures. Pyloric exclusion (PE) has emerged as an ancillary method to protect suture repair in more complex injuries. However, the effectiveness of this procedure is debatable. The "Evidence Based Telemedicine - Trauma & Acute Care Surgery" (EBT-TACS) Journal Club performed a critical appraisal of the literature and selected three relevant publications on the indications for PE in duodenal trauma. The first study retrospectively compared 14 cases of duodenal injuries greater than grade II treated by PE, with 15 cases repaired primarily, all of which penetrating. Results showed that PE did not improve outcome. The second study, also retrospective, compared primary repair (34 cases) with PE (16 cases) in blunt and penetrating grade > II duodenal injuries. The authors concluded that PE was not necessary in all cases. The third was a literature review on the management of challenging duodenal traumas. The author of that study concluded that PE is indicated for anastomotic leak management after gastrojejunostomies. In conclusion, the choice of the surgical procedure to treat duodenal injuries should be individualized. Moreover, there is insufficient high quality scientific evidence to support the abandonment of PE in severe duodenal injuries with extensive tissue loss.

Choledochal cyst in childhood: review of 30 cases

Objective: To analyze and discuss the clinical data, diagnosis and treatment of a number of patients with cystic dilatation of the common bile duct of a Brazilian pediatric hospital.Methods: We analyzed 30 patients treated at the Martagão Gesteira Institute of Pediatrics and Child Care of the Federal University of Rio de Janeiro for 23 years ,with statistical analysis of epidemiological data, clinical manifestations, diagnosis, treatment and postoperative outcome.Results: We observed a marked female predominance (73.4% of cases), the diagnosis being made in the first decade of life in 90% of patients. The most prevalent clinical manifestation was jaundice (70% of cases) and the classic triad of choledochal cyst was not observed. Abdominal ultrasound was the first imaging examination performed, with a sensitivity of 56.6%, with diagnostic definition in 17 children. Two patients (6.6%) had prenatal diagnosis. All patients underwent surgical treatment, cyst resection with Roux-en-Y hepaticojejunostomy being performed in 80% of cases. The incidence of postoperative complications was 13.3% and the mortality rate was 6.6%, ie two patients were diagnosed with Caroli's disease.Conclusion: The non-observance of the classic triad of choledochal cyst suggests that its incidence is lower than that reported in the medical literature. The surgical treatment of choledochal cysts, with resection and bilioenteric anastomosis, is safe even for small children.

Assesment of the treatment of earlobe keloids with triamcinolone injections, surgical resection, and local pressure

OBJECTIVE: To evaluate the combined treatment of ear lobe keloids. METHODS: We studied 46 consecutive patients with 81 ear lobe keloids. Patients underwent local infiltration of triamcinolone acetonide (TCN) at concentrations of 40mg/ml (Group 1), 20 mg/ml (Group 2) and 10mg/ml (Group 3). The volume of TCN infiltrate varied according to the size of the lesion. Treatment consisted of three monthly injections before surgery, excision of keloid in the fourth month and perioperative infiltration, followed by two more leaks TCN within two months. Patients used earrings pressure on the scar after operation for four months. The pressure exerted by earrings in the ear lobe was measured electronically. Post-treatment follow-up of patients was 24 months. RESULTS: TCN at concentrations of 20mg/ml and 40mg/ml were effective for the treatment of keloids, no difference between the groups (p = 0.58). However, patients in which TCN was infiltrated the 10mg/ml had poor involution of keloid and the study of this group was stopped. CONCLUSION: the combination of infiltration TCN month to 20 mg/mL (1.2mg to 2.0mg per mm3 TCN injury), surgical excision and pressure application device is effective for treatment of keloid ear lobe.

Montreal classification of patient operated for Crohn's disease and identification of surgical recurrence predictors

OBJECTIVE: to evaluate Crohn's disease recurrence and its possible predictors in patients undergoing surgical treatment. METHODS: We conducted a retrospective study with Crohn's disease (CD) patients undergoing surgical treatment between January 1992 and January 2012, and regularly monitored at the Bowel Clinic of the Hospital das Clínicas of the UFMG. RESULTS: we evaluated 125 patients, 50.4% female, with a mean age of 46.12 years, the majority (63.2%) diagnosed between 17 and 40 years of age. The ileum was involved in 58.4%, whereas stenotic behavior was observed in 44.8%, and penetrating, in 45.6%. We observed perianal disease in 26.4% of cases. The follow-up average was 152.40 months. Surgical relapse occurred in 29.6%, with a median time of 68 months from the first operation. CONCLUSION: The ileocolic location, penetrating behavior and perianal involvement (L3B3p) were associated with increased risk of surgical recurrence.

Influence of preoperative supplementation of omega-3 fatty acid in the healing of colonic anastomoses in malnourished rats receiving paclitaxel

OBJECTIVE: To evaluate the effect of preoperative supplementation of omega-3 fatty acids on the healing of colonic anastomoses in malnourished rats receiving paclitaxel. METHODS: we studied 160 male Wistar rats, divided in two groups: one subjected to malnutrition by pair feeding (M) for four weeks, and another that received food ad libitum (W). In the fourth week, the groups were further divided into two subgroups that received omega-3 or olive oil by gavage. The animals were submitted to colonic transection and end-to-end anastomosis. After the operation, each of the four groups was divided into two subgroups that received intraperitoneal isovolumetric solutions of saline or paclitaxel. RESULTS: mortality was 26.8% higher in the group of animals that received paclitaxel (p = 0.003). The complete rupture strength was greater in well-nourished-oil Paclitaxel group (WOP) compared with the the malnourished-oil Paclitaxel one (MOP). The collagen maturation index was higher in well-nourished-oil saline group (WOS) in relation to the malnutrition-oil-saline group (MOS), lower in malnourished-oil-saline group (MOS) in relation to malnourished-ômega3-saline one (M3S) and lower in the well-nourished-omega3-saline group (W3S) compared with the malnourished-omega3-saline (M3S). The blood vessel count was higher in the malnourished-oil-saline group (MOS) than in the malnourished-oil-paclitaxel group (MOP) and lower in the malnourished-oil-saline group (MOS) in relation to the malnourished-omega3-paclitaxel group (M3P). CONCLUSION: supplementation with omega-3 fatty acids was associated with a significant increase in the production of mature collagen in malnourished animals, with a reversal of the harmful effects caused by malnutrition associated with the use of paclitaxel on the rupture strength, and with a stimulus to neoangiogenesis in the group receiving paclitaxel.

Risk factors for mortality in blunt abdominal trauma with surgical approach

ABSTRACTObjective:identify risk factors for mortality in patients who underwent laparotomy after blunt abdominal trauma.Methods:retrospective study, case-control, which were reviewed medical records of blunt trauma victims patients undergoing laparotomy, from March 2013 to January 2015, and compared the result of the deaths group with the group healed.Results:of 86 patients, 63% were healed, 36% died, and one patient was excluded from the study. Both groups had similar epidemiology and trauma mechanism, predominantly young adults males, automobilistic accident. Most cases that evolved to death had hemodynamic instability as laparotomy indication - 61% against 38% in the other group (p=0.02). The presence of solid organ injury was larger in the group of deaths - 80% versus 48% (p=0.001) and 61% of them had other associated abdominal injury compared to 25% in the other group (p=0.01). Of the patients who died 96% had other serious injuries associated (p=0.0003). Patients requiring damage control surgery had a higher mortality rate (p=0.0099). Only one of 18 patients with isolated hollow organ lesion evolved to death (p=0.0001). The mean injury score of TRISS of cured (91.70%) was significantly higher than that of deaths (46.3%) (p=0.002).Conclusion:the risk factors for mortality were hemodynamic instability as an indication for laparotomy, presence of solid organ injury, multiple intra-abdominal injuries, need for damage control surgery, serious injury association and low index of trauma score.

Use of surgical mesh of different compositions in the correction of the abdominal wall defect in rats

Objective: To analyze the performance of two surgical meshes of different compositions during the defect healing process of the abdominal wall of rats. Methods: thirty-three adult Wistar rats were anesthetized and subjected to removal of an area of 1.5 cm x 2 cm of the anterior abdominal wall, except for the skin; 17 animals had the defect corrected by edge-to-edge surgical suture of a mesh made of polypropylene + poliglecaprone (Group U - UltraproTM); 16 animals had the defect corrected with a surgical mesh made of polypropylene + polidioxanone + cellulose (Group P - ProceedTM). Each group was divided into two subgroups, according to the euthanasia moment (seven days or 28 days after the operation). Parameters analyzed were macroscopic (adherence), microscopic (quantification of mature and immature collagen) and tensiometric (maximum tension and maximum rupture strength). Results : there was an increase in collagen type I in the ProceedTM group from seven to 28 days, p = 0.047. Also, there was an increase in the rupture tension on both groups when comparing the two periods. There was a lower rupture tension and tissue deformity with ProceedTM mesh in seven days, becoming equal at day 28. Conclusion : the meshes retain similarities in the final result and more studies with larger numbers of animals must be carried for better assessment.