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ABSTRACT: To compare late results (recurrence) of three different techniques for treatment of inguinal hernias in the adult: Bassini, Shouldice and McVay.
The operative late results of three surgical techniques: Bassini, Shouldice and McVay in 119 adult patients with inguinal hernias (some with bilateral pathology, totalizing 136 hernias) were analyzed. The majority of patients were males (93.3%). The analysis was prospective, randomized, with uniform distribution of all three types of inguinal hernia (direct, indirect and combined) among the three groups of operative techniques. The number of recurrences was submitted to an actuarial analysis for a period of 4 years. The results underwent statistical analysis by the Kaplan-Mayer test with actuarial survival curves.
Eight hernia operations by the Bassini technique recurred in this time span, 3 in the Shouldice group and 2 in McVay. Among the Bassini recurrences, the worst results were observed with direct hernias (29% recurrence) when compared with indirect ones (16% recurrence). Overall recurrence rates plotted in an actuarial survival curve for 4 years, revealed statistically significant differences between Bassini and Shouldice: 35.7% versus 23.7%; the same happened when comparing Bassini to McVay: 35.7% versus 8.5%. The differences between Shouldice and McVay were not significant.
A recurrence rate of 35.7% for inguinal herniorraphy with the Bassini technique in a General Surgery University Clinic was surprising and obliged us to interrupt the trial. Our observations point to a prohibitive high failure rate when dealing with the Bassini technique, which was, over a century, the most popular treatment of inguinal hernia all over the world. Shouldice and McVay techniques, even though more complex, should be preferred whenever one makes the choice for "conventional" hernia treatment.
Revista da Associação Médica Brasileira 45(2):105-14. · 0.77 Impact Factor
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ABSTRACT: Lumbar hernias are rare lesions. They involve the extrusion of visceral contents through a defect in the posterolateral abdominal wall. Only 250 a 300 cases had been reported in the literature. They occur most often in the superior lumbar triangle (Grynfelt's hernia). All lumbar hernias must be treated with surgery and the preferable surgical approach is done retroperitoneally. Primary repair, autologous tissue or prosthetic material may be used to obliterate the defect. The authors report a case of Grynfelt's hernia in which polypropylene mesch was placed pre-peritonially.
Revista do Hospital das Clínicas 50(2):111-4.
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ABSTRACT: Duodenal diverticulum is a common anatomic abnormality. Its inflammatory perforation is a rare complication, with less than 100 cases reported in the available literature. Traumatic perforation is exceedingly rare (only 3 cases reported). In this report one more case of traumatic perforation is presented, and the literature is reviewed focusing on the pathogenic, diagnostic and therapeutic aspects of this severe disease.
Revista do Hospital das Clínicas 51(6):247-9.
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ABSTRACT: A young female patient had a recurrence of severe spherocytic anemia there years after having been submitted to splenectomy. The presence of two accessory spleens with a size of 3.5 cm and 4.0 cm, was demonstrated by technetium scanning and ultrasound images. Surgical removal of these noduli resulted again in prompt recovery. The development of the spleen beings in the fifth week of intrauterine life at the dorsal mesogastrium. The lack of fusion of splenic lobuli is responsible for the occurrence of accessory spleens. A surgeon performing splenectomy for the treatment of hemolytic anemia should always search for possible existences of accessory spleens.
Revista do Hospital das Clínicas 47(2):95-8.
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ABSTRACT: With the aim of aiding the accurate diagnosis and treatment of patients with pancreatic injuries, we reviewed the medical records of sixty-five patients, treated for traumatic pancreatic lesions at the Department of Surgery of the University of São Paulo in the 5-year period from 1989 through 1993. Records, including operative and pathology reports, were reviewed and the location of the pancreatic injury, associated intra-abdominal injuries, type of injury, trauma scores, treatment, complications and mortality rates recorded. There were 58 male and seven female patients with a mean age of 28.3 years (range, 2-77 years). Of the 65 pancreatic injuries, 45 (69.2%) were caused by penetrating wounds and twenty by blunt trauma. The most frequent site of lesion was the head of the pancreas (38.5%). Associated injuries were found in all but five of the patients. In the 65 patients, 170 intra-abdominal injuries were found (2.6 per patient). Twenty-eight of the 65 patients (43.1%) had liver lacerations. Lacerations of major abdominal vessels (27 patients), gastric lacerations (25 patients) and colorectal lacerations (17 patients) were the next most frequent injuries. Fifteen out of twenty patients died within two days after the accident from severe concomitant injuries. Simple drainage was performed in 33 patients, distal pancreatectomy in 17 and duodenopancreatectomy in six patients. Pancreas-related complications occurred in 20 (30.7%) out of 57 patients who survived the initial operation. We concluded that the type of repair employed in our series was related to the class of injury and clinical conditions (based on trauma scores). Therefore, whenever possible, conservative management (no pancreatic resection) was employed in patients that sustained class I and II injuries and pancreatic resection in class III and IV injuries.
Revista do Hospital das Clínicas 49(6):238-42.
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ABSTRACT: The aim of this work was to identify clinical data indicative of the number of hyperbaric oxygen therapy HBO2 sessions that should be prescribed for adjuvant treatment of tissue injuries of differing severity.
A total of 1730 cases of patients treated with HBO2 using an open protocol (without a predetermined number of sessions) was examined in this study.
A retrospective study involving charts review was conducted. Severity had been previously determined for the treatment of acute (fasciitis, myositis, gangrene, contaminated/infected perineal or lower extremity traumatic injuries) or chronic (osteomyelitis, pressure sore, diabetic or ischemic ulcer) injuries. Only patients that met or exceeded the supposed effective minimal treatment doses (5 sessions for acute, 10 sessions for chronic injuries) were included in the present study.
The data analysis included 1506 cases. These consisted of 1014 patients with acute injuries, who required 11 to 18 sessions (depending on injury severity), and 492 patients with chronic injuries, who required a greater (p < 0.001) number of sessions (approximately 30/patient, independent of injury severity). Global mortality was 79/1506 patients.
These results seem to support the initial indication of 15 HBO2 sessions for the treatment acute injuries, and 30 for treatment of chronic injuries. Prospective studies may better determine the number of sessions for the treatment of different types of injuries.
Undersea & hyperbaric medicine: journal of the Undersea and Hyperbaric Medical Society, Inc 35(1):53-60. · 0.80 Impact Factor
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AMB; revista da Associação Médica Brasileira 32(9-10):162-4.
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ABSTRACT: Ascariasis of the gallbladder, unlike ascariasis of the bile duct, is a rare entity. The authors add two cases to the 39 already reported in the literature, and discuss the clinical features, diagnosis and management of this condition.
International surgery 69(4):335-8. · 0.36 Impact Factor
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Revista do Hospital das Clínicas 39(6):251-3.
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Revista do Hospital das Clínicas 24(2):113-8.
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ABSTRACT: Gallstone ileus, a mechanical intestinal obstruction caused by the passage of a gallstone into the intestinal lumen through a fistula, although not common, deserves to more carefully studied due to its morbidity and mortality. Its incidence among older-age groups explains its association with chronic and degenerative diseases, which increase the complexity of the treatment choice. The need and appropriateness of a surgical approach to a cholecystenteric fistula to solve the obstructive emergency, in a one or two stage procedure, has been discussed in the literature. It has also been reported that gallstone ileus is an uncommon cause of upper intestinal obstruction. Intestinal obstruction is seen more frequently after a gallstone impacts at the ileocecal valve. The authors report a case of gallstone ileus as a cause of upper intestinal obstruction and discuss its diagnosis and treatment.
Sao Paulo Medical Journal 114(4):1239-43. · 0.71 Impact Factor
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ABSTRACT: Patients with Acquired Immunodeficiency Syndrome (AIDS) may present acute abdomen with modified clinical manifestations which may lead to errors and delays in preoperative diagnosis, with frequent delays in treatment.
To study clinical signs, diagnostic criteria, etiology, surgical management and mortality in patients with AIDS submitted to exploratory laparotomy.
We reviewed the records of thirty-one AIDS patients admitted in the period 1986-1993 at the Emergency Surgical Service--Hospital das Clínicas, University of São Paulo submitted to exploratory celiotomy due to acute abdome.
Abdominal pain was the most frequent symptom and the diagnosis of acute abdome was made based upon physical examination, laboratory tests and imaging techniques. Gastrointestinal tract perforation was the most frequent cause of acute abdome, mainly due to Cytomegalovírus infection. All patients presented postoperative complication, specially wound infection. Mortality rate was 42% due to sepsis and multiple organ failure.
Based upon these data we conclude that: AIDS patients usually present masked clinical signs of acute abdomen; stomas should be formally indicated. Mortality is extremely high due to immunocompromised state, delayed diagnosis and treatment and non therapeutic celiotomies.
Revista da Associação Médica Brasileira 42(1):19-24. · 0.77 Impact Factor
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ABSTRACT: Rupture of the diaphragm from blunt trauma is uncommon, but greatly improved prehospital care and transportation of victims has increased the frequency at which patients who sustain this injury arrive at the emergency room alive. We report a case of bilateral diaphragmatic rupture from blunt abdominal trauma in a 33-year old man. Diagnosis was established by laparoscopy after suggestive chest X-rays, liver scintigraphy, CT scan and magnetic resonance imaging. The methods used to diagnose this condition are analyzed.
Revista paulista de medicina 111(3):430-2.
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ABSTRACT: Gallbladder lesion is infrequent, occurring in approximately 0.5 to 8.5% of all patients with blunt and penetrating abdominal trauma. The incidence of gallbladder injury in such cases is low. This study reviewed 32 patients with gallbladder injury due to abdominal trauma over a 6-year period to determine the complications, associated injuries, and mortality rate.
Revista do Hospital das Clínicas 48(6):283-8.
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ABSTRACT: Reintervention in abdominal surgery involves the difficulty of precise indication and the limitations of surgical technics during the operation. It may bring to evidence professional errors. It presents a very high morbimortality index. In order to establish risk factors and death rate, we comparatively analysed the initial diagnoses, the number, the cause and the time of relaparotomy, the existence of associated diseases, the age and the illness severity, using APACHE-II after the first surgical intervention. During a two years period starting 1990 we retrospectively analysed charts of 40 patients submitted to relaparotomy in the Emergency Service of Hospital das Clínicas of Medicine University of São Paulo.
Revista do Hospital das Clínicas 49(1):17-20.
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ABSTRACT: Gastrointestinal hemorrhage continues to be a major medical problem. Even with improvements in both diagnostic and therapeutic, a significant number of patients still require surgical intervention for control of hemorrhage. When the source of persistent lower gastrointestinal hemorrhage is unknown, subtotal colectomy is a conceptually rational management choice. The authors present a case of massive lower gastrointestinal hemorrhage with unusual fatal outcome. A review of literature of this condition and a discussion about the diagnosis, treatment and etiopathogenesis are presented.
Revista do Hospital das Clínicas 49(4):179-82.
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ABSTRACT: Injury of the extra-hepatic biliary tract is infrequent, occurring in approximately 3.5% of all patients with blunt and penetrating abdominal trauma. The incidence of this injury caused by blunt abdominal trauma is rare. PURPOSE--Retrospective analysis of 5069 patients with abdominal trauma treated at the Department of Surgery University of São Paulo School of Medicine over a six-year period from 1986 through 1991. METHODS--Forty five patients with gallbladder and extra-hepatic ducts injury were identified (0.89%) and divided in two groups according to the nature of trauma: 12 caused by non-penetrating injuries and 33 to penetrating injuries. Records, including operative and pathology reports, were reviewed to study the site of injury, associated intra-abdominal injuries, incidence, trauma scores, treatment, morbidity, mortality rates and correlated with the nature of the trauma. RESULTS--Overall mortality was 24.4%. The incidence was greater in patients sustaining penetrating abdominal trauma (p < 0.05). Forty of the 45 patients (88.9%) had liver lacerations, the most commonly seen injuries. The patients with blunt abdominal trauma had significant different trauma scores (p < 0.05) than those with penetrating trauma, indicating greater severity in this group of patients. CONCLUSION--There is a relation between severity of trauma and incidence of extra-hepatic biliary tract injury. However, in the penetrating trauma, the incidence of trauma is correlated with the direction of the wound and there is no relation with the severity of trauma. The greater mortality seen in the patients sustaining non-penetrating injury (p < 0.05) supports this observation.
Revista da Associação Médica Brasileira 41(1):53-9. · 0.77 Impact Factor
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Revista paulista de medicina 99(3):30-3.
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Revista paulista de medicina 102(3):104-8.
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AMB; revista da Associação Médica Brasileira 30(9-10):192-4.
