Tubular Drains Research Articles

Effect of Programmed Sanitation on the Dynamics of Cytological Picture in the Surgical Treatment of Soft Tissue Phlegmon

The aim of the study was to investigate cytological features of healing processes in patients with soft tissue phlegmons using programmed sanitation technologies.Materials and methods. The study involved 245 patients with purulent phlegmon of soft tissues of various localizations. The patients were randomized into two groups. The patients of the main group (n=127) were exposed to programmed sanitation with AMP-01 device in the postoperative period. After the phlegmon opening and surgical treatment, tubular drains were installed into the wound cavity, the wound was sutured tightly, and the drains were removed through separate incisions and connected to the device. The device was used to detect the parameters of sanitation (speed, time, volume during injection or aspiration). The patients of the comparison group (n=118) received conventional local treatment after surgery. The dynamics of the healing processes of purulent wounds was assessed by the cytological examination findings of the material taken during surface or puncture biopsy.Results. A higher rate of cellular reactions was registered in patients of the main group. There was a statistically significant faster decrease in degenerative forms of neutrophils, higher values of the regenerative-degenerative index (p0.001) indicating an acceleration of the relief of the inflammatory process. In addition, in patients of the main group, the appearance of macrophages and fibroblasts (p0.001) was statistically significantly observed at an earlier time, which evidenced a higher rate of proliferative processes; on the 9th day of the postoperative period the cytological picture corresponded to the regenerative type of cytograms. In patients of the comparison group, a prolonged inflammation and regeneration phase was recorded.Conclusion. Cytological examination of smears in patients with soft tissue phlegmons exposed to programmed sanitation revealed a higher rate of cellular reactions, which contributed to a reduced inflammation phase and accelerated wound reparative processes.

Negative pressure wound therapy in the treatment of purulent wounds of the maxillofacial superficial cellular spaces

Relevance. The choice of the method for purulent wound management (open or closed) is a relevant problem in surgery. The way of drainage is the fundamental factor of the effect on the wound. The open-drainage systems are most frequent in maxillofacial surgery, and the drain is passive, combined with various drug administration. It has significant drawbacks: the short action of the injected substances, painful dressing changes, long wound healing time, etc. The instillation drainage therapy is not widely available and is used only in clinics with appropriate equipment. Active draining (negative pressure suction drainage system) allows closed wound management. Though, it is still rarely used in maxillofacial surgery.Purpose. The study aimed to increase the effectiveness of the treatment of maxillofacial purulent wounds formed after the incision of odontogenic soft tissue purulent inflammatory processes using negative pressure wound therapy.Material and methods. The study was a comparative analysis of clinical and laboratory indicators of 303 patients with purulent wounds formed after incision of superficial cellular spaces’ abscesses and phlegmons. The patients formed two groups: the main group had negative pressure wound therapy (NPWT), and the comparison group had wound treatment with the traditional open method. NPWT methodology included the tubular drain placement into the purulent cavity formed after the incision and administration of a surgical film on the wound. The distal tube end was attached to a vacuum source that simultaneously was a canister for exudate collection and analysis. We followed up on clinical manifestations and endointoxication indicators and studied the wound content toxicity and the dynamics of the respiratory enzyme succinate dehydrogenase activity.Results. The negative pressure system appears to allow fast and atraumatic wound management, reducing the inflammatory stage of the wound healing process, promoting quick normalization of endointoxication parameters, which improves the patient’s general condition (fast resolution of the clinical signs), and the effect of vacuum-assisted closure allows avoiding secondary wound closure.Conclusion. Low-dose negative pressure provides the wound healing process with specific characteristics. Continuous exudate aspiration promotes rapid elimination of bacteria and detoxification of the wound and surrounding tissues, normalization of endointoxication parameters, provides anti-oedematous and analgesic effects, early restoration of impaired functions, and the time of wound healing process reaches that of healing by primary tension, which allows us to reduce the number of medications, as well as treatment and rehabilitation time.

Ensuring the Stability of Channel Linings Under Unsteady Filtration

When assessing the stability of the slopes of the banks of reservoirs and channels, the filtration regime that occurs with a rapid decrease in the water level in the upstream, which is due to the nature of the operation of structures before floods, discharges, emergency situations, is of particular interest. A change in the water levels in the upstream causes a change in the position of the depression surface and the parameters of the filtration flow (pressure gradients, filtration rates and flow rates) in the coastal massif. At the same time, unsteady filtration occurs in the coastal massif and the stability of the slopes is reduced significantly due to the action of hydrodynamic forces directed towards the slope. The most reliable anchors of channel slopes in similar conditions are those that, under normal channel operation, when there is no groundwater support, the lining should exclude filtration from the channel, ie filtration losses of irrigated water, and if there is a backwater and with a rapid decrease in the water level in the channel, it should provide free access of the ground stream into the channel channel or its diversion in the other direction. This eliminates the occurrence of significant hydrodynamic pressures, and the destruction of the channel slope fasteners. The article presents the results of studies of 4 designs of channel linings operating under conditions of unsteady filtration. In the course of the study, we considered the following variants of structural schemes of linings. Fastening with combined deformation and filtration seams; fastening with self-collapsing seams; fastening with discharge tubular drains with water discharge into the channel; fastening with filtration and discharge holes arranged during the appearance of groundwater backup in the channel area. The results of calculating the stability of the fastening plates for overturning and surfacing are presented. According to the results of the calculation, the most acceptable fastening options are determined, their advantages and disadvantages are given. The proposed fastening design meets the above requirements and thereby ensures the strength and stability of the linings during the operation of the channel.

Obstructive lithiasis of the lower bile duct discovered four decades after cholecystectomy and its management by ideal choledochotomy: a case report

BackgroundResidual lithiasis is the presence of stones in the common bile duct, ignored after one or more biliary interventions. We report an atypical case of chronic symptomatic lithiasis of the lower bile duct occurring 41 years after biliary surgery, managed successfully by ideal choledochotomy.Case presentationA 68-year-old Black African female with several past laparotomies including a cholecystectomy forty-one years ago presented with hepatic colic-type pain that had been intermittent for several years but worsened recently. Her clinical, biological, and imaging test assessments were suggestive of a residual obstructive lithiasis of the lower common bile duct. Through an open right subcostal laparotomy approach, a dilated bile duct of approximately 3 cm was found and managed by transverse choledochotomy in which the stone was extracted in retrograde manner. After confirmation of disobstruction, a primitive bile duct suture without biliary drainage was performed and a tubular drain was positioned under the liver. The postoperative course was uneventful at follow-up of 30 days.ConclusionResidual choledocholithiasis can be avoided. We performed an ideal choledochotomy, of which the follow-up was simple.

A Case of Robot-Assisted Repair of Lymphatic Fistula with Chylous Ascites Following Robotic Retroperitoneal Lymph Node Dissection

Clinical History: A 47-year-old patient, with a history of testicular tumor treated with chemotherapy and robotic retroperitoneal lymph node dissection, experienced recurrent postoperative chylous ascites despite conservative management. Therefore, decision was made to perform robot-assisted exploration to find the source of chyle leakage and to repair it. Physical Examination: Shifting dullness refers to a sign elicited on abdominal examination for ascites, see: https://en.wikipedia.org/wiki/Shifting_dullness. The patient had this sign on abdominal examination at the time of the intervention, as explained in the video. Diagnosis: Inguinal intranodal lymphography was performed, showing an effusion at the level of the third lumbar vertebral body that was embolized. Intervention: On robot-assisted abdominal exploration, intraperitoneal lymphatic effusion was noted from the left para-aortic region, close to the left renal artery. The lymphatic vessels of greater caliber were then closed with metal clips, until all the major sources of lymph effusion were under control. Next, a continuous suture running over the remaining para-aortic lymphatic tissue was applied. Once the suture was completed, methylene blue was then introduced through the nasogastric tube, with no effusion resulting from the lymphatic tissue at any level in the abdomen. A layer of hemostatic matrix was then added and a tubular drain was placed in the retroperitoneum, with its tip laying on the effusion site. The peritoneum was closed and after a final check of the hemostasis, the robotic trocars were removed and the port sites closed. Follow-Up Outcomes: The drain was removed after 72 hours. Since the intervention, the patient did not experience any further recurrence. In this first description, robotic approach was feasible and efficient in management of postoperative chylous ascites not responding to conservative treatment. The authors have received and archived patient consent for video recording/publication in advance of video recording of procedure. The authors declare that they have not had any commercial associations during the past 3 years that might create a conflict of interest in connection with the video. This study is derived from the “IRCCS Azienda Ospedaliero-Universitaria di Bologna,” and there are no conflicts of interest or obligations resulting from it. Runtime of video: 4 mins 22 secs

НОВЫЕ ПОДХОДЫ В ЛЕЧЕНИИ ПАЦИЕНТОВ С ОСЛОЖНЕННЫМ ДЕСТРУКТИВНЫМ АППЕНДИЦИТОМ

Abstract. Introduction. The treatment of complicated forms of acute destructive appendicitis remains an urgent problem of urgent abdominal surgery. Aim. The aim of our investigation was to substantiate the use of VAC-therapy to improve the results of surgical treatment of patients with acute destructive appendicitis complicated by typhlitis and periappendicular abscess. Material and methods. The present investigation is based on the results analysis of 84 patients aged from 17 to 78 years with acute destructive appendicitis, complicated by typhlitis and periappendicular abscess, being treated at the department of surgery 2 of the State Medical Institution City Clinical Hospital 7 of Kazan. Open ligature appendectomy was performed in all cases due to pronounced infiltration of the cecum dome. Two groups of patients were singled out according to the method of ОБМЕН ОПЫТОМ ВЕСТНИК СОВРЕМЕННОЙ КЛИНИЧЕСКОЙ МЕДИЦИНЫ 2021 Том 15, вып. 2ВЕСТНИК СОВРЕМЕННОЙ КЛИНИЧЕСКОЙ МЕДИЦИНЫ 2022 Том 15, вып. 4110 surgical intervention completion. In 54 patients of the comparison group the surgical intervention was terminated by gauze- gingival drainage of the appendix bed, since there was a high probability of appendix residual limb failure and necessity of purulent process isolation from the free abdominal cavity. Penrose drainage was removed through the surgical wound. In addition, the pelvis was drained through the contraperitoneum with a tubular drain. In 30 patients of the main group after appendectomy for abdominal cavity drainage we connected a Vacuum–assisted closure-system using Vivano apparatus and consumables of Hartman, Germany. Statistical processing of the results was carried out using Statistiсa 10 software package and Miсrosoft Exсel 2010. The differences were considered statistically significant at p<0.05. Results and discussion. Analysis of the used surgical techniques showed that in the main group the wound postoperative complications decreased by 3 times and were 23,3%; formation of the abdominal cavity infiltrates was 2 times less; period of hospitalization decreased by 1,8 times. Conclusion. Ease of implementation of VAC-therapy method, therapeutic and economic feasibility allow us to recommend it as the final stage of treatment of acute destructive appendicitis complicated by typhlitis and periappendicular abscess

Bile Duct Injury and Repair: Case Series from 1989 to 2020

BACKGROUND: The benign lesion of the bile duct is a complication of difficult diagnosis and treatment; which has increased due to the use of laparoscopic cholecystectomy (LC) in the management of cholecystolithiasis. Rates of 0.2 to 0.4% of bile duct injuries have been reported, becoming a significant cause of mortality at the time of repair. METHODS: This is an observational, descriptive study, a retrospective case series, based on primary sources of information. The universe of the study are the patients who underwent surgery for bile duct injury from 1989 to 2020, in a private clinic in the city of Cuenca-Ecuador. RESULTS: In more than 30 years, 24 bile duct injury repairs were performed, which occurred: 6 during conventional surgery and 18 during laparoscopic surgery. 54.2% of the lesions occurred less than two centimeters from the confluence of the hepatic ducts. 58.4% of lesions were repaired with Roux-en-Y anastomosis. Antibiotic therapy and drainage were administered to 100% of the patients; 45.83% of the drains placed were tubular drains. 70.8% of the patients didn´t have complications after the repair procedure; the complications that occurred are: bilioma, fistulas, stenosis, cholangitis. CONCLUSION: In most patients who had bile duct injury, the injury occurred during laparoscopic surgery. The injury was most often located less than two centimeters from the confluence of the hepatic ducts. The most frequently performed repair procedure was the Roux-en-Y anastomosis. The most frequent complication after repair was cholangitis.

Determining patterns in the stressed­deformed state of the railroad track subgrade reinforced with tubular drains

The technical condition of the railroad track subgrade has been analyzed, as well as the issues related to ensuring its strength and stability when exposed to floodwaters and when the track's sections are overmoistened during operation. As a result, it has been established that it is necessary to develop methods aimed at improving the subgrade's carrying capacity. The georadar research has explored the problematic areas of the railroad track subgrade, based on which the distribution of subgrade heterogeneity in the vertical plane, as well as the boundaries of its location, were established. Therefore, georadar research makes it possible to detect hidden defective sites in the subgrade without disrupting its strength characteristics. A technique has been proposed to improve the carrying capacity of the failed subgrade of a railroad track using the combined arrangement of drainage pipes in the vertical and horizontal directions in the railroad embankment. The special feature of this technique is the possibility to drain water at the different levels of surface water, which provides for an increase in the carrying capacity of the failed subgrade. The strained-deformed state of the subgrade reinforced with tubular drainage has been investigated. The result has proven the effectiveness of the use of tubular drainages to improve the carrying capacity of the railroad track overmoistened subgrade exposed to constant and temporary loads. This study findings have established that the deformity of the subgrade increases when using tubular drainage, though this occurs only in the initial period of its arrangement, in further operation, when it removes water from the subgrade body, the carrying capacity of the subgrade, on the contrary, will improve due to the enhanced physical and mechanical properties of soils

PREDICTION OF THE STRESS-STRAIN STATE OF A ROAD STRUCTURE WITH SHALLOW TRANSVERSE TUBULAR DRAINAGE

The stress-strain state of a road structure with shallow tubular drainage, which is arranged on waterlogged sections of public highways, has been investigated. Three-dimensional models of the road structure with pipes made of various materials were built using the finite element method. Experimental studies on models were carried out for cases of normative and over-norm load on the basis of the SCAD Office software and calculation complex. The distribution of normal stresses, deformation values in the road structure and directly in the body of the tubular drain is obtained. The working conditions were determined and the expediency of using PVC pipes and concrete pipes on the road of III category was substantiated. Subject of research: stress-strain state of a road structure with shallow transverse tubular drainage. Investigated problem: determination of deformations in a road structure with tubular drains based on the distribution of normal stresses. Main scientific results: distribution of isopoles and isolines of normal stresses, deformation values in road structures with shallow transverse tubular drainage. The expediency of using the type of drainage pipes on waterlogged sections of roads under conditions of excess load has been determined. The area of practical use of the research result: design institutions and enterprises specializing in the road transport industry. An innovative technology product: stress and strain distribution in atypical road structures with tubular holes. Scope of application of the innovative technological product: for the design of atypical road structures with tubular holes on waterlogged road sections.

БАКТЕРИОЛОГИЧЕСКАЯ ХАРАКТЕРИСТИКА ЭФФЕКТИВНОСТИ РАЗЛИЧНЫХ СПОСОБОВ ДРЕНИРОВАНИЯ СЛУЧАЙНЫХ РАН

The article presents data on the bacteriological control of the effectiveness of various methods of draining fresh accidental wounds with a wide area of damage in different species of animals: semipermeable membranes and tubular perforated drains. Semi-permeable cellulose membranes (experimental group) were inserted into the wound of animals with absolute indications for drainage at the final stage of surgical treatment.These membranes were filled with a hyperosmolar dialysis solution containing antibacterial preparations. The comparison group used the introduction of antiseptics through perforated tubular drains. In order to study the quantitative and qualitative composition of microflora in the wound process, bacteriological studies of swabbings from the wound surface and from the wound canal were performed on 1-3-7-9 days. As the result, it was established that the degree of tissue contamination depends on the duration of surgical debridement ,type and conditions of animals. The study of quantitative composition of micro flora in 1 g of tissues, in farm animals, with accidental wounds was up to 105 . The appliance of wound dialysis gave rapid destruction of associations of 2 and 3 types of microorganisms, in contrast to the control group of animals. The effect of applying membrane dialysis devices, in case of accidental wounds, allows to achieve positive results for 3-4 days. Bacteriological studies confirm the high antibacterial activity of dialysate, which was provided by the introduction of antibiotics and antiseptics into its composition. The introduction of antibiotics and antiseptics into the membrane drainage cavity once a day in the amount of a single therapeutic dose, allows for 7.1±1.3 days (P>0.001) to suppress the microflora in the wound. Higher antiseptic effectiveness of dialysates from semipermeable membranes is connected with their ability to create a constant high concentration of antibacterial substances in the wound focus. The mechanism of therapeutic effect is in a gradual and constant flow of antiseptics into the paravulnar tissues, by diffusion. This improves the conditions for the development of the body’s own phylactic power against infection and raises regenerative processes in the wound.

Colocephalectomy for the Treatment of Capital Physeal Fracture of the Femoral Head in Pony

Background: Femoral capital physeal fractures occur in young animals and are generally associated with trauma. They have a poor prognosis and surgical therapy is the most indicated. There are few studies describing surgical treatment and postoperative results, so the objective of the present report was to present the first case in Brazil of a colocefalectomy for the treatment of femoral capital physeal fracture in a young pony, the post-surgical and the results obtained with the technique employed.Case: An 18-month-old pony, male, not castrated, , weighing 136 kg was referred to the Veterinary Hospital of the Federal University of Paraná (HV-UFPR) with a history of trauma for 4 days. On physical examination, the animal presented lameness grade 5 of the right pelvic limb, shortening and lateral deviation of the limb, crackling and painful sensation on abduction, and slight atrophy of the gluteal muscles on the affected side. In the radiographic examination, a femoral capital physeal fracture was found in the oblique ventro-dorsal projection. Once the diagnosis was performed, a colocefalectomy was realized, as the patient is a light and short horse. The patient underwent general anesthesia and was placed in the left lateral position. The access to the coxofemoral joint was made through the lateral face of the right hindlimb. The muscles of the region were incised and deviated, so a partial myotomy was performed in the deep gluteal and vastus lateralis. This procedure allowed to visualize the fracture, where the head of the femur remained congruent to the acetabulum. A hammer and a curved osteotome were used to section the round ligament, allowing the dislocation of the femoral head and with the aid of an oscillating orthopedic saw was performed the femoral neck ostectomy. Previously to the synthesis of the muscular planes and the skin, a passive tubular drain was fixed, in order to avoid the accumulation of exudate and consequent dehiscence of stitches, which was removed on the 6th postoperative day. For postoperative analgesia, epidural morphine was administered for 6 days and intravenous phenylbutazone for 3 days. Antibiotic therapy was performed with Ceftiofur and Metronidazole. The stitches were removed on the 15th postoperative day, after the correct healing of the surgical wound. The patient’s return to activity was gradual and he was pasture sound on the 42nd postoperative day. After medical discharge, contact with the owner was kept until the fifth postoperative month, and he related that the animal remained walking well and maintaining his reproductive function.Discussion: Femoral capital physeal fractures can occur in young animals, and are not common in clinical surgical care. Clinical signs are crackle of the joint on manipulation and presence of swelling in the affected region. The patient in question, in addition to evident lameness, had crackling and painful sensation during the abduction of the limb, but there was no local swelling, but an atrophy of the musculature of the limb, that occurs in cases of chronic femoral injury. Surgical intervention is the indicated method of treatment and should be performed as soon as possible after the injury has occurred, avoiding the worsening of bone and joint degeneration. Femoral head ostectomy is more suitable for animals less than 12 months old and weighing up to 100 kg. The technique has as a postoperative complication the contamination of the surgical wound, however the implantation of the passive tubular drain allowed rapid evolution of healing. Physical rehabilitation in the postoperative period is variable according to the progress of the animal’s locomotion. Therefore, the colocefalectomy technique aims to maintain the patient’s quality of life, even as in the case reported, it allowed the animal to maintain the reproductive function.

Abstract: Amount of Blood Drained after Pre-Pectoral Breast Implants. Analysis of a Cohort of 30 Patients Submitted to Primary Breast Augmentation with Silicone Gel Implants

GOALS/PURPOSE: The use of tubular drains in silicone gel breast augmentation remains a source of debate up to the risk of hematoma and capsular contracture as opposed to the risk of infection and the patient’s intolerance. The objective of the study was to determine the amount of blood drained after pre-pectoral breast implants. METHODS/TECHNIQUE: We retrospectively analyzed a cohort of 30 females under 45 years old, submitted to a first aesthetic breast augmentation by pre-pectoral silicone smooth gel implants as solo surgery during 2011 and 2012. Patients with any disease and/or intake of any medication compromising coagulation or bleeding were excluded from this study. All of them were operated by the same surgeon with 20 years’ experience in sub-pectoral technique, during 2011 and 2012. The patients were operated with general intravenously anesthesia and local infiltration with lidocaine and vasoconstrictors. The surgeries were performed by means of an inframammary incision. It was used a 4,8-mm bilateral tubular suctioning drain system until 72 hours post-surgery. The implants used were silicone round moderate projection type, with smooth envelope, gel filled with a constant brand. The amount of blood was collected and noted every 24 hours by the same method, with a 20-cc syringe. Patients were followed with a maximum of six years and a minimum of three years. All patients were submitted to magnetic resonance after three years of implantation. RESULTS/COMPLICATIONS: The mean age of the patients was 27 years (18–44). There were no complications during the procedure. The total amount of blood drained was from 86 cc to 355 cc, (normal distribution, average 187 cc); 56% of the total amount drained after 24 hours, 27% after 48 hours and 17 % after 72 hours. There was no hematoma, seroma, infection and capsular contracture. The patients didn’t present bruising in the breast region. The resonance magnetic exams were considered normal for all the patients. One presented a small amount of liquid around the implant, one side after four years. CONCLUSION: It is important to observe the unexpected large amount of blood collected even the patient presented no risk factors and submitted to a procedure with careful hemostasis and aseptic technique. The absence of late seromas, hematomas or dense capsule formation, even in this small number of participants suggest the necessity of drainage for breast implants. It’s important to emphasize the silicone characteristics as an inhibitor of clot formation that may result in a long-time presence of no coagulated blood around the implant. In the 1980’s, we observed the presence of fibrin and uncoagulated blood around tissue expanders in the removal surgery step, 3 to 6 months after introduction and It was the first opportunity to understand the behavior of the presence blood around silicone. Based on our results, we emphasize the importance to perform more prospective studies regarding drainage after breast augmentation with silicone implants.

Investigation of the work of the road construction at the sites by pipe drenes from materials of different origin

The paper reports research into operation of road structures with tubular drains made from materials with different physical-mechanical properties, which makes it possible to identify basic factors that affect operational conditions under the influence of own mass and the rated load from rolling stock in accordance with the building norms of Ukraine. Non-standard road structures were simulated in the SCAD environment. The results of numerical simulation allowed us to derive diagrams of normal stresses and deformations of structural layers in road surfacing, as well as in the body of tubular drains. The calculations were performed both for the standard and the actual compaction of material used as a trench backfill, for a PVC pipe and a concrete pipe. Consideration of tubular openings in solid layered road structures made it possible to estimate the actual stressed-deformed state at the sections of roads that require control over a water-heat mode. The proposed method of study enables the selection of individual design-structural parameters for drainages of shallow laying for general-purpose public roads of different technical categories as opposed to the standard approaches implied by the building regulations of Ukraine.

Composite fibrous glaucoma drainage implant

Glaucoma is a frequent reason of loss vision. It is usually caused by increased intraocular pressure leading to damage of optic nerve head. This work deals with the development of fibrous structure suitable for glaucoma drainage implants (GDI). Commercially produced metallic glaucoma implants are very effective in lowering intraocular pressure. However, these implants may cause adverse events such as damage to adjacent tissue, fibrosis, hypotony or many others [1]. The aim of this study is to reduce undesirable properties of currently produced drains and improve their properties by creating of the composite fibrous drain for achieve a normal intraocular pressure. Two types of electrospinning technologies were used for the production of very small tubular implants. First type was focused for production of outer part of tubular drain and the second type of electrospinning method made the inner part of shape follows the connections of both parts. Complete implant had a special properties suitable for drainage of fluid. Morphological parameters, liquid transport tests and in-vitro cell adhesion tests were detected.

Severe Acne Inversa - Dermatosurgical Approach in a Bulgarian Patient.

We present a 55-year-old male patient - a smoker, admitted to a Medical Institute of MVR (Ministry of the interior, Sofia, Bulgaria), on occasion of pain and swellings, located in the area of both axillae, accompanied by purulent discharge, with bloody admixtures. Bilateral localised cystic rose above the skin surface, hyperpigmented nodules interconnected with multiple fistulas, was observed within the dermatological examination, resulting in a limitation of the possibility of movement of the hands in all directions. A subjective complaint of pain was obtained on palpation. Solid bilateral axillar cicatrices - formation was also established, which additional impeded the movements of the upper limbs. The disease was generalised affecting additional inguinal, femoral and perineal areas, while at this stage the patient refused categorically eventual photo documentation of them. The diagnosis of acne inversa was made based on the available clinical and para-clinical data, as dual antibiotic therapy with Clindamycin 300 mg, two times per day was initiated for two months, in combination with rifampicin 300 mg, two times per day also for two months. This led to a significant improvement in the clinic symptoms and the patient was hospitalised for radical surgery. A surgical management of the clinical findings was planned by an interdisciplinary team including surgeons and dermatologists. The procedure was performed under general anaesthesia. After a thorough cleaning of the operative field, a radical excision of the lesion in the left axillary and para axillar region was performed, comprising the skin and subcutaneous tissue forward the fascia pectoralis. Tissue was dissected in depth in the form of number 4, thereby creating the conditions for adaptation of the initially encountered communicating with each other skin defects. Two tubular drains were placed, followed by gradual suturing of skin and subcutaneous tissue with final applying of a sterile dressing. Effective medical treatment of patients (as in our case) with severe AI is limited. Adalimumab is the first biological approved for moderate to severe AI but does not result in stable CR (cure rate). Therefore its use in a neoadjuvant setting is under investigation. Wide local excision significantly reduces pain and improves the quality of life of AI patients. While local recurrences rate is low, the satisfaction with the cosmetic results is high. The recurrence rate is dependent on the region affected and the type of surgery. While in the axillary region primary closure may be used to reduce the time to healing, anogenital AI has the lowest recurrence rate of healing by secondary intention.

Splenic Rupture by Tubular Drain in a Patient with Necrotizing Pancreatitis

Splenic Rupture by Tubular Drain in a Patient with Necrotizing Pancreatitis

Splenic Rupture by Tubular Drain in a Patient with Necrotizing Pancreatitis

Splenic Rupture by Tubular Drain in a Patient with Necrotizing Pancreatitis

Pneumoperitoneum due to perforated appendicitis: a rare anatomo-radiologic correlation

BACKGROUND: Pneumoperitoneum is usually associated with a perforated peptic ulcer. However, perforated appendicits may be evolved on it. In the medical literature, the anatomo-radiologic correlation between them is an uncommon event. CASE REPORT: Man with 56-year-old look for assistance with diffuse abdominal pain and distension associated with fever, vomit and absence of flatus and evacuation for about 14 days. The chest radiography revealed a pneumoperitoneum. Diffuse peritonitis was found during the exploratory laparotomy. Appendectomy, peritoneal cavity cleaning and drainage with tubular drains were carried out. However, severe sepsis occurred and the patient died on the 16th post-operative day with multiple systemic organ failure. CONCLUSION: Although rare as pneumoperitoneum ethiology, acute appendicitis may be thought as it's cause.

Morbidity and mortality assessment of modified Duhamel operation with immediate mechanical end-to-side colorectal anastomosis for chagasic megacolon: the role of the diverting stoma

Dear Editor, Sepsis secondary to anastomotic leakage is the most important surgical complication of rectal surgery. Anastomosis performed close to the anal sphincter is considered in high risk for leakage. The lower the anastomosis is in the rectum, the higher the risk of leakage. In total mesorectal excisions for rectal cancer, the rate of anastomotic leakage varied from 3% to 17%. Therefore, in this procedure, either a defunctioning ileostomy or a colostomy is still routinely performed in many specialized centers. In Brazil, Chagas’ disease affects people in the rural area with poor living conditions. Megacolon is the most common complication in the gastrointestinal tract. Surgery is indicated to treat patients with severe constipation. Several techniques have been reported in the surgical treatment for chagasic megacolon. All of them have high morbidity and mortality rates. The Duhamel–Haddad operation with delayed coloanal anastomosis was popular amongBrazilian surgeons. However, this time-consuming procedure has been abandoned in most centers in Brazil. To avoid a two-stage procedure, abdominal retosigmoidectomy with immediate posterior end-to-side colorectal mechanical anastomosis was proposed as a new technique for chagasic megacolon (modified Duhamel operation or Habr–Gama operation). The anastomosis is situated at the lower third of the posterior wall of the rectum. As occurs in rectal cancer surgery, the anastomosis is placed just above the anorectal ring. Therefore, intuitively, one should expect problems with this anastomosis. Another variable that could increase the risk for dehiscence in this group of patients is malnutrition; a usual finding in this group of patients. Therefore, a high rate of dehiscence should have been observed in this technique. However, a diverting stoma to avoid pelvic sepsis has not been recommended. Over the past 9 years, our own experience with chagasic megacolon has been based on 26 patients (11 females and 15 males) with a mean age of 56.0 years (range, 40–74 years) who underwent abdominal retosigmoidectomy with immediate posterior end-to-side colorectal mechanical anastomosis. After mechanical and systemic antibiotic preoperative preparation, all operations were performed through a median laparatomy. The dilated colon was excised. The rectum was sectioned at the level of anterior peritoneal reflection and closed with hand-sewn or mechanical suture. The posterior dissection of the rectum was performed to clean the posterior wall of the mesorectum. Therefore, the mesorectum was not incorporated at the anastomotic site. The mechanical endto-side colorectal anastomosis was performed in all patients just above the anorectal ring. The final result was quite similar to the Duhamel technique. The diverting stoma was performed according to the preference of the surgeon. Pelvic tubular drains were used in all operations. A diverting stoma was performed in 10 (38.5%) patients. Among them, eight were an ileostomy and two were a transverse colostomy. All patients had the stoma closed until August 2006. The groups with and without diverting stoma were comparable in terms of preoperative characteristics, Int J Colorectal Dis (2008) 32:215–216 DOI 10.1007/s00384-007-0297-8

A válvula de Heimlich no tratamento do pneumotórax

Objetivos: A válvula de Heimlich foi descrita para substituir os sistemas de drenagem sob selo d'água. O Serviço de Cirurgia Torácica do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo realizou este estudo com o objetivo de avaliar sua eficiência no tratamento do pneumotórax, bem como a facilidade de manipulação, segurança e tolerância pelo paciente. Métodos: Foram analisados 108 pacientes com pneumotórax de diferentes etiologias, de junho/97 a agosto/2000. A maioria (76%) apresentava pneumotórax classificado radiologicamente como médio ou grande, sendo três deles hipertensivos, dos quais um bilateral. Utilizaram-se para a drenagem da cavidade pleural cateteres plásticos de teflon ou poliuretano tipo pig-tail 10,2F, 14F ou retos 11F conectados à válvula de Heimlich. Nos pacientes pós-toracotomias, a válvula foi conectada diretamente ao dreno torácico. Resultados: O período de permanência da válvula variou de um a 120 dias (mediana de quatro dias). A tolerância ao sistema foi considerada boa por 89% dos pacientes. Não ocorreram complicações atribuíveis ao sistema. A presença de derrame associado em 20 pacientes (18,5%) não impediu o bom funcionamento do sistema. Apenas dois (1,8%) pacientes evoluíram com enfisema subcutâneo progressivo, optando-se então por dreno tubular 36F sob selo d'água. Em um paciente (0,9%) indicou-se toracotomia para descorticação pulmonar. Vinte pacientes (18,5%) foram tratados no ambulatório. Conclusões: A válvula de Heimlich mostrou-se eficiente na resolução do pneumotórax de diferentes etiologias e nas fístulas aéreas pós-operatórias. A manipulação foi mais simples do que as historicamente observadas nos sistemas convencionais. A boa tolerância e segurança referidas pelos pacientes foram fator determinante na precocidade da alta hospitalar e incentivo ao tratamento ambulatorial.