Os procedimentos de reconstrução de parede abdominal são importantes na rotina cirúrgica de pequenos animais e, apesar da sua baixa casuística, normalmente são realizados por consequência de traumas ou neoplasias. O material ideal a ser utilizado permanece sem unanimidade e sua busca é constante. Diversos materiais de origem sintética e biológica são pesquisados, apresentando prós e contras. Entretanto, a maior utilização aparenta ser a malha de polipropileno. Em contrapartida, a membrana amniótica é estudada atualmente, demostrando melhor aceitação dos pacientes, assim como menor reatividade. Junto às boas informações sobre a membrana amniótica, se tem estudado processos de decelularização de tecidos como técnicas de bioengenharia tecidual, o qual criam-se materiais imunologicamente compatíveis, aumentando sua biocompatibilidade, com melhor resposta cicatricial e menor inflamação do hospedeiro no período pós-operatório. O presente trabalho objetivou avaliar macro e microscopicamente a membrana amniótica equina mantida em meio de preservação tradicional (glicerina 98%) e tratada com solução utilizada para decelularização, em baixa concentração (detergente Dodecil Sulfato de Sódio Sodium Dodecyl Sulfate SDS 0,01%), a fim de mensurar possíveis diferenças de resultados apresentados pelos hospedeiros. Foram formados dois grupos (grupo I e grupo II) contendo 15 animais em cada. Os animais do grupo I receberam a membrana amniótica tratada com SDS 0,01%, assim como os animais do grupo II receberam a membrana preservada em glicerina 98%. Cada grupo foi dividido em três subgrupos, contendo cinco animais em cada. O primeiro subgrupo foi avaliado aos sete dias de pós-cirúrgico (M1), o segundo aos 20 dias (M2), e o terceiro aos 40 dias (M3). Após anestesia geral, segmento de aproximadamente 2,0cm x 1,5cm foi retirado da parede abdominal de cada rato, para criação de defeito abdominal, e substituído pelo material a ser avaliado, suturado com fio náilon 5-0 em padrão simples interrompido, seguido de sutura cutânea em U horizontal com fio náilon 4-0. Informações macro e microscópicas foram coletadas e analisadas estatisticamente. As avaliações macroscópicas não apresentaram diferenças estatísticas entre os grupos, mostrando bons resultados quanto a prevenção das aderências viscerais ao implante. A avaliação microscópica mostrou diferença importante de contagem celular no terceiro momento de avaliação (M3) entre os grupos, sendo que o grupo I apresentou menor intensidade de células inflamatórias em comparação ao grupo II (p=0,002973). A eficiência do detergente SDS 0,01% não foi boa, devido manutenção de conteúdo nuclear ao avaliar o material em lâminas histológicas. Pode-se concluir com o presente estudo que, a membrana amniótica equina pode ser utilizada para reconstrução de parede abdominal em ratos Wistar, pois, mostrou bom resultado, não causando aderências viscerais e, consequentemente, sem comprometimento de quaisquer funções. O grupo I mostrou importante queda na contagem celular em comparação ao grupo II, levantando a hipótese de possível efeito do tratamento com SDS 0,01%. Porém, a total eficiência para decelularização avaliada ao final, não foi boa, sugerindo melhores abordagens aos protocolos de decelularização, aumentando a concentração da substância, o tempo de tratamento, assim como a associação com outras técnicas para melhor efetividade na total remoção do conteúdo celular da membrana amniótica equina. / Abdominal wall reconstruction procedures are important in the surgical routine of small animals and, despite their low casuistry, are usually performed as a consequence of traumas or neoplasias. There is no unanimity as to the ideal material to be used in these procedures and, therefore, their demand is constant. Several materials, both of synthetic and biological origin, were and are researched nowadays, presenting advantages and disadvantages in its use. The preference, however, appears to be the polypropylene mesh. On the other hand, the amniotic membrane, currently studied, has demonstrated better patient acceptance as well as lower reactivity. In addition to the good information about the amniotic membrane, tissular decellularization processes have been studied as tissue bioengineering techniques, in which immunologically compatible materials are created, increasing their biocompatibility, with better cicatricial response and less inflammation of the host in the postoperative period. The aim of the present work was to evaluate the equine amniotic membrane maintained in a traditional preservation medium (glycerin 98%) and treated with a low concentration decellularization solution (Sodium Dodecyl Sulfate detergent - SDS 0,01%), in order to measure possible differences of results presented by the hosts. Two groups were formed (group I and group II) containing 15 animals each. The animals in group I received the amniotic membrane treated with SDS 0,01% while the animals in group II received the membrane preserved in glycerin 98%. Each group was divided into three subgroups, each containing five animals. The first subgroup (from each group) was evaluated at seven days postoperative (M1), second at 20 days (M2), and third at 40 days (M3). After a general anesthesia, a segment of approximately 2,0cm x 1,5cm was removed from the abdominal wall of each animal, to create abdominal defect, and replaced by the material to be evaluated, sutured with 5-0 nylon thread in a simple interrupted pattern, followed by horizontal U shaped skin suture with 4-0 nylon thread. Macro and microscopic information were collected and analyzed statistically. The macroscopic evaluations did not present statistical differences between the groups, showing good results regarding the prevention of the visceral adhesions to the implant. Microscopic evaluation showed a significant difference in cell counts in the third evaluation period (M3) between groups, and group I presented lower inflammatory cell intensity compared to group II (p=0,002973). The efficiency of the SDS detergent 0,01% was not good, due to the maintenance of nuclear content, verified when evaluating the material in histological slides. It is concluded with the present study that equine amniotic membrane can be used for abdominal wall reconstruction in Wistar rats, demonstrating good results in not causing visceral adhesions and without compromising any functions. Group I showed an important decrease in the cell count in comparison to group II, raising the hypothesis of possible treatment effect with SDS 0,01%. However, the efficiency for the total decellularization evaluated at the end was not good, suggesting that there are better approaches within the decellularization protocols, such as increasing the concentration of the substance, the time of treatment, and the association with other techniques for better effectiveness in the total removal of the cellular contents of the equine amniotic membrane.

El documento digital no refiere asesor / Determina cuáles son las complicaciones postoperatorias en los pacientes adultos mayores que han sido sometidos a cirugía abdominal de emergencia en el Hospital III Cayetano Heredia de Piura en los últimos 5 años. El estudio es de tipo Retrospectivo, Analítico de casos y controles. Se hizo revisión de libros de registros de altas del servicio de Cirugía y del Libro de registro de Sala de Operaciones; posteriormente, ubicamos las historias clínicas y se procedió a la revisión, recolección de datos y llenando la ficha. Durante el periodo de estudio se hospitalizaron 182 pacientes mayores de 65 años con abdomen agudo quirúrgico. Se calculó el tamaño muestral, utilizando un intervalo confianza del 95%, resultando 127 pacientes. En los pacientes mayores de 65 años según el sexo, fueron casi similares. La tasa de complicaciones post quirúrgicas representó el 41,2%. Factores asociados que incrementaron el riesgo de complicaciones fueron: La procedencia de zonas rurales (O.R.= 3,78), padecer enfermedades asociadas como la Insuficiencia Renal Crónica y las cardiopatías (O.R.=10,0 y 4,9). La laparotomía exploratoria como procedimiento quirúrgico (O.R.=2,07), y las cirugías sucias (O.R.=4,33). La frecuencia de complicaciones médicas y quirúrgicas fue del 44,1%. Las complicaciones médicas más frecuentes fueron neumopatías no infecciosas, infección urinaria y trastornos acido base. Y las complicaciones quirúrgicas: la infección de la herida operatoria seguido de los abscesos residuales y peritonitis. El 52% son de sexo masculino y el 42% son de sexo femenino La mayoría tienen edades entre 65 y 69 años. El 41,2% de ellos presentaron alguna complicación post quirúrgica. Factores clínico epidemiológicos de los pacientes mayores de 65 años con abdomen agudo quirúrgico como: tener edad entre 80 y 89 años, ser procedente de zona rural, tiempo de enfermedad menor a un día, someterse a una cirugía sucia y presentar enfermedades asociadas incrementan significativamente el riesgo de presentar complicaciones post quirúrgicas.Cuando existe enfermedades asociadas presentan mayor riesgo de complicaciones post quirúrgicas (OR=2,24), especialmente la insuficiencia renal crónica y las cardiopatías. Las cirugías tipo sucias presentan incremento significativo del riesgo para presentar complicaciones post quirúrgicas que los pacientes sometidos a otros tipos de cirugías (OR=4,33). El 36,3% de los pacientes presentaron complicaciones médicas post quirúrgicas, siendo más frecuentes la neumopatía no neumónica, infección urinaria y los trastornos acido-bases. El 22,9% de pacientes presentaron complicaciones quirúrgicas, las principales son: infección de herida operatoria, absceso residual, peritonitis, dehiscencia y sangrado. / Trabajo de investigación

El documento digital no refiere asesor / Describe la técnica quirúrgica simplificada para la histerectomía abdominal y determinar las principales diferencias de los resultados de esta técnica en términos de tiempo operatorio, presentación y tipo de complicaciones en comparación con la técnica de Richardson. En el Instituto Nacional Materno Perinatal se realizó un estudio descriptivo, transversal, retrospectivo y comparativo. Se comparó 26 pacientes operadas de histerectomía abdominal según la técnica simplificada entre el 01 de febrero del 2005 y el 31 de mayo del 2006 con igual número de pacientes operadas según la técnica de Richardson. El análisis estadístico se realizó con el programa SPSS 14.0. La indicación más frecuente de histerectomía abdominal fue la presencia de miomas uterinos (76,9%). Se presentó complicaciones en el 17,3 % de pacientes con histerectomía abdominal y no se evidenció diferencia estadísticamente significativa en la presentación y tipo de complicaciones entre la técnica simplificada y la de Richardson. Las complicaciones más frecuentes fueron la infección del sitio quirúrgico (7,6 %) y la infección de las vías urinarias (5,8 %). El tiempo operatorio (p < 0,01) y la estancia hospitalaria (p < 0,05) fueron significativamente menores para las pacientes operadas con la técnica simplificada. La frecuencia de complicaciones fue similar en las dos técnicas. El tiempo operatorio y la estancia hospitalaria son menores con la técnica simplificada. / Trabajo académico

Publicación a texto completo no autorizada por el autor / Identifica la morbimortalidad que causa el Hematoma Retroperitoneal Traumático en pacientes mayores de 15 años atendidos en el servicio de Cirugía en el Hospital Nacional Daniel Alcides Carrión, en el periodo de enero 2007 a diciembre del 2011. Se realizó un estudio descriptivo, transversal y retrospectivo, en el que se revisaron las historias clínicas y libro de reporte operatorio. Se obtuvo una muestra de 81 pacientes con los criterios de inclusión; 95 % fueron de sexo masculino. El rango de edad más frecuente fue de 15 a 34 años. La incidencia de trauma abierto fue de 77 %; y de trauma cerrado, de 23 %, siendo el principal mecanismo de lesión el producido por proyectil de arma de fuego (61.7%). El diagnóstico se realizó en el intraoperatorio en un 77 % y por tomografía en 15 %. Se realizó tratamiento quirúrgico en el 83%. El hematoma retroperitoneal se localizó con mayor frecuencia en la Zona II (70%), las estructuras lesionadas que predominaron fueron la vena cava en la Zona I (50%), los riñones en la Zona II (40%) y los vasos de mediano calibre en la Zona III (22%). La principal lesión asociada fue el trauma yeyunal. Se determinó una mortalidad de 3,7 %. El hematoma retroperitoneal traumático tiene su mayor incidencia en los pacientes adolescentes y adultos jóvenes de sexo masculino, con antecedentes de consumo de drogas. El diagnóstico fue principalmente por acto quirúrgico. El trauma abierto es el tipo de lesión más frecuente en el espacio retroperitoneal y la principal causa es por arma de fuego. La región anatómica donde se localizó con más frecuencia el hematoma retroperitoneal fue la Zona II, entre ellas el izquierdo, y el órgano más lesionado dependía de la zona retroperitoneal afectada. / Trabajo de investigación

Publicación a texto completo no autorizada por el autor / El documento digital no refiere asesor / Determina la validez de la ecografía abdominal en el paciente pediátrico con apendicitis aguda, en el HN. PNP. “LNS” enero - diciembre 2012. Se realizó un estudio observacional, retrospectivo, transversal, de 35 cuyas historias clínicas informan como diagnóstico apendicitis aguda que fueron operados en el HN. PNP. “LNS” desde el 1° de enero del 2012 hasta el 31 de diciembre del 2012 y se le realizó una ecografía abdominal. El 65.7 % (23) fueron varones y el 34.3 %(12) fueron mujeres. La media de la edad fue de 9.2+/-2.1 años, siendo la mínima de 3.8 años y la máxima de 12.3 años. El 71.4% de los pacientes presentaron dolor en fosa iliaca derecha. El 71.4 % presentaron vómitos. El 85.7 % de los pacientes tuvo ecografía positiva para apendicitis aguda. El 68.6 % tuvo imagen tubular apendicular no comprensible mayor o igual a 6mm.El 48.6 % tuvo coprolito en su interior. El 77.1 % tuvo engrosamiento de pared apendicular. El 80 % de los pacientes tuvo diagnóstico definitivo de apendicitis aguda según la anatomía patológica. Los pacientes con diagnóstico definitivo de apendicitis aguda presentaron una mayor media del tiempo de evolución (52.7 versus 37.6), y del conteo de los leucocitos (15739 versus 12488). La ecografía abdominal en el paciente pediátrico con apendicitis aguda, tiene una alta sensibilidad y un alto valor predictivo positivo. / Trabajo de investigación

El documento digital no refiere asesor / Determina las características clínicas y epidemiológicas y frecuencia por año del abdomen agudo en gestantes que se atendieron en el Hospital Nacional Daniel Alcides Carrión en el periodo 2005-2010. Describe las características socio demográficas y obstétricas de las gestantes con abdomen agudo. Así como los tipos y complicaciones de abdomen agudo de las gestantes. Encuentra que la prevalencia de abdomen agudo en gestantes desde el año 2005 hasta el 2010 fue de 42 casos, que representa el 0.85% y las características sociodemográficas de las gestantes fue edad promedio de 25.0 ± 7.8 años, estado civil soltera 40.5% y conviviente 40.5%, grado de instrucción secundaria (61.9%) en su mayoría y ocupación ama de casa 61.9%. Al momento que se les diagnosticó abdomen agudo a las gestantes, sus características obstétricas fueron edad gestacional promedio de 23.7 semanas, el 42.9% se encontraba en el III trimestre, el 45.2% eran nulíparas y la gran mayoría si tuvo controles prenatales 88.1%. Los tipos de abdomen agudo quirúrgico diagnosticados en la mayoría de gestantes que participaron en el estudio fueron a causa de apendicitis 59.6%, colecistitis 21.4% y quistes anexiales 23.8%. Las complicaciones presentes en las gestantes durante la intervención por abdomen agudo quirúrgico fueron parto pretérmino en el 11.9% de los casos y aborto en el 2.4%. No existe relación entre el tipo de cirugía y la presencia de complicaciones (p=0.355), al igual que no existe relación entre los controles prenatales y la presencia de complicaciones (p=0.331). / Trabajo académico

**Contexte :** Des récentes données indiquent que jusqu'à 30 % des budgets de santé aux États-Unis sont consacrés à des soins potentiellement non-nécessaires. Ces types de soins appelés ici "pratiques de faible valeur" ou encore "*low-value care*" (LVC), comprennent des procédures et traitements potentiellement inappropriés, inefficaces ou inefficients susceptibles d'exposer les patients à des dommages physiques, psychologiques ou sociaux. Bien que certaines informations sur ces pratiques soient disponibles dans la littérature, on manque de connaissances sur l'incidence, les variations inter-hospitalières et les facteurs qui contribuent à leur occurrence dans la prise en charge des patients ayant subi un traumatisme contondant des organes solides de l'abdomen appelés ici, "*Solid organ injuries*" (SOI) et leur impact sur les issues cliniques des patients. **Objectifs :** L'objectif global de ce projet était d'évaluer les pratiques de faible valeur dans le traitement des patients ayant une lésion contondante des organes solides de l'abdomen aux États-Unis. Les objectifs spécifiques étaient (1) d'évaluer l'efficacité de la tomodensitométrie (TDM) de routine, répétée pour détecter les lésions cliniquement significatives chez les adultes éligibles, bénéficiant d'une prise en charge non chirurgicale dite, *nonoperative management* (NOM) pour des lésions contondantes du foie et/ou de la rate ; (2) d'estimer l'incidence globale de la prise en charge chirurgicale de faible valeur des lésions contondantes des SOI, d'évaluer les variations de pratiques interhospitalières et évaluer l'association entre l'incidence ajustée de ces pratiques en fonction du volume des patients ; (3) d'estimer les associations entre la prise en charge chirurgicale de faible valeur des lésions contondantes des SOI et les issues cliniques des patients (mortalité hospitalière, complications et durée du séjour) ainsi que d'identifier les déterminants modifiables au niveau du patient et de l'hôpital. **Méthodes :** Pour répondre au premier objectif, nous avons effectué une revue systématique des essais contrôlés randomisés et non randomisés et des études observationnelles sur la TDM de routine, répétée dans le suivi des patients adultes ayant des blessures contondantes des SOI. Nous avons effectué une recherche d'articles potentiellement éligibles dans *Medline*, *Embase*, *Web of Science* et *Cochrane Central* depuis leur création jusqu'en octobre 2020 en utilisant les recommandations de Cochrane. Les issues primaires évaluées étaient la modification à la prise en charge initiale du patient (par exemple, chirurgie d'urgence, embolisation, transfusion sanguine, surveillance clinique), la mortalité et les complications. Les issues secondaires étaient la réadmission non planifiée et la durée du séjour à l'hôpital. Pour l'objectif 2, nous avons mené une étude de cohorte rétrospective multicentrique basée sur le registre de traumatologie Américain, notamment le *National Trauma Data Bank* (NTDB). Nous avons inclus les adultes ayant une blessure contondante des SOI éligibles à une prise en charge non chirurgicale, i.e. des patients présentant des blessures de grade I-III, hémodynamiquement stables à l'arrivée et aucun produit sanguin utilisé dans le service des urgences) qui ont été admis dans des centres de traumatologie en Amérique du Nord ayant soumis des données au NTDB entre 2016 et 2019. La prise en charge chirurgicale de faible valeur a été définie comme une laparotomie ayant eu lieu moins de 6h heures suivant l'admission du patient. La variation interhospitalière a été mesurée à l'aide du coefficient de corrélation intraclasse (ou *Intraclass Correlation Coefficient*; ICC en anglais). Les valeurs du ICC sont interprétées comme suit : ICC ; <5% faible, 5-20% modéré et >20% élevé. La mesure de la variation interhospitalière a également été ajustée en fonction de l'âge, du sexe, de la race/ethnicité, des comorbidités, du grade de la blessure, du statut de transfert et de la méthode de paiement du patient. Pour le troisième objectif, nous avons utilisé la même population d'étude que l'objectif 2. Grâce à la régression linéaire généralisée à plusieurs niveaux et la méthode d'appariement des scores de propension, nous avons généré des rapports de cotes (RC) ajustés et des rapports de moyennes géométriques (RMG) avec des intervalles de confiance à 95 % (IC) afin d'évaluer l'association entre la prise en charge chirurgicale de faible valeur et les issues cliniques des patients et avons identifié les déterminants des traitements de faible valeur au niveau du patient et de l'hôpital. **Résultats :** Dans notre revue systématique, 7 des 28 études éligibles ont indiqué si la répétition de la TDM était de routine ou motivée par des indications cliniques. Sur les 254 examens TDM répétés dans ces 7 études, 188 (74 %) étaient de routine et 8 (4 %) ont conduit à une modification de la prise en charge initiale. Pour les 66 (21,5 %) examens répétés restants, ceux-ci étaient motivés par des indications cliniques et 31 (47 %) ont conduit à une modification de la prise en charge initiale. Nous n'avons pas pu identifier de données permettant de comparer les autres issues entre nos groupes d'intervention. Notre deuxième étude a montré que les incidences ajustées d'une prise en charge chirurgicale de faible valeur étaient de 2,7 % au total (6,8 %, 2,1 %, 0,8 % pour les lésions de la rate, du foie et des reins, respectivement) et de 2,6 %, 2,5 % et 3,0 % pour les centres de niveau I, de niveau II accrédités par l'ACS et les centres désignés par l'État, respectivement. La variation interhospitalière était modérée à élevée avec un ICC global de 21 % et des ICC de 18 %, 25 % et 21 % pour les centres de traumatologie de niveau I et de niveau II accrédités par l'ACS et les centres désignés par l'État, respectivement. Dans notre troisième étude, les RC ajustés étaient de 1,92 (IC 95% 1,25-2,96) pour la mortalité et de 2,39 (1,99-2,87) pour les complications. Le RMG ajusté était de 1,52 (1,38-1,68) pour la durée du séjour. La prise en charge chirurgicale de faible valeur était plus fréquente dans les hôpitaux désignés par l'État et les centres de traumatologie accrédités par l'ACS de niveau II comparativement à ceux de niveau I et était moins fréquente dans les hôpitaux communautaires d'enseignement comparativement aux hôpitaux universitaires. **Conclusions :** Les résultats de notre revue systématique suggèrent que la répétition systématique de la TDM sans indication clinique n'est pas utile pour l'évaluation des patients ayant subi une blessure du foie et/ou de la rate. Ces résultats ont mené à l'élaboration de lignes directrices, en collaboration avec Choisir avec soin Canada et l'Association de traumatologie du Canada. Les résultats de notre seconde étude montrent que les recommandations concernant les NOM pour les patients adultes ayant subi une blessure contondante d'un SOI publiées par les organisations telles que le *Eastern Association for the Surgery of Trauma* (EAST), le *World Society of Emergency Surgery* (WSES) et le *American Association for the Surgery of Trauma* (AAST) ainsi que le American College of Surgeons Committee on Trauma (ACS COT) et étayées par la littérature, semblent bien respectées. Néanmoins, compte tenu des conséquences physiques, psychologiques et financières importantes d'une chirurgie non nécessaire, les variations dans les pratiques que nous avons observées entre les hôpitaux d'un même niveau suggèrent que les recherches futures devraient évaluer le problème dans les centres hospitaliers qui ne participent pas au NTDB, d'identifier les déterminants modifiables de ces variations de pratiques et d'évaluer l'impact de leur incidence sur les issues cliniques des patients. Dans notre troisième étude où l'incidence des LVC est associée à une mortalité et des complications plus élevées ainsi qu'une durée d'hospitalisation plus longue, des interventions conçues pour réduire ces pratiques pourraient améliorer les issues cliniques des patients. De telles interventions devraient être basées sur les barrières et les facilitateurs du NOM, qui peuvent inclure les déterminants au niveau du patient et de l'hôpital identifiés dans notre étude. / **Background:** Recent evidence indicates that up to 30% of healthcare budgets in the United-States (US) are spent on potentially unnecessary care. Unnecessary care, referred to here as "low-value care" (LVC), includes potentially inappropriate, ineffective, or inefficient procedures that may expose patients to physical, psychological, or social harm. While some information on LVC is available in the literature, knowledge of the occurrence, inter-hospital variations, and factors that contribute to LVC in the management of blunt solid organ injuries (SOI) and their impact on patient outcomes is lacking. **Objectives:** The overall aim of this project was to evaluate LVC in the management of blunt solid organ injuries in the US. Specific objectives were to (1) assess the effectiveness of routine, repeat computed tomography (CT) for detecting clinically significant injury in adults undergoing nonoperative management (NOM) for blunt liver and/or spleen injury; (2) estimate the global incidence of potentially low-value operative management of solid organ injuries, assess interhospital practice variations, and evaluate the association between the risk-adjusted incidence of low-value operative management and patient volume; and (3) estimate the associations between low-value operative management of solid organ injuries and patient's issues (hospital mortality, complications, and hospital length of stay) and identify modifiable patient- and hospital-level determinants of low-value clinical practices. **Methods:** To address the first objective, we conducted a systematic review of randomized and non-randomized controlled trials and observational studies of repeat CT in adult patients with blunt solid organ injury. We searched Medline, Embase, Web of Science, and Cochrane Central from their inception up to October 2020 using the Cochrane guidelines. Primary outcomes were change in clinical management (e.g., emergency surgery, embolization, blood transfusion, clinical surveillance), mortality, and complications. Secondary outcomes were unplanned hospital readmission and hospital length of stay. For objective 2, we conducted a retrospective multicenter cohort study based on the National Trauma Data Bank (NTDB). We included adults with blunt SOI eligible for non operative management (NOM), i.e., patients with; grade I-III injury, hemodynamically stable on arrival, and no blood products used in the emergency department) who were admitted to trauma centers in North America that submitted data to the NTDB between 2016 and 2019. Low-value operative management was defined as laparotomy within <6 hours of admission. Inter-hospital variation was measured using (ICCs; <5% low, 5-20% moderate, and >20% high) and adjusted for age, sex, race/ethnicity, comorbidities, injury grade, transfer status, and payment method. For the third objective, we used the same study population. We used multilevel generalized linear regression and propensity score matching to generate risk-adjusted odds ratios (OR) and geometric mean ratios (GMR) with 95% confidence intervals (CI) to evaluate the association between low-value operative management and patient's outcomes and to identify patient- and hospital-level determinants of low-value operative management. **Results:** In our systematic review, 7 of 28 eligible studies reported whether repeat CT was routine or prompted by clinical indications. Of the 254 repeat CT performed in these seven studies, 188 (74%) were routine and 8 (4%) led to a change in clinical management. Of the 66 (21.5%) repeated CT prompted by clinical indications, 31 (47%) led to a change in management. We did not identify any data to enable a comparison of other outcomes across intervention groups. Our second study showed that adjusted incidences of potentially low-value operative management were 2.7% overall (6,8 %, 2,1 %, 0,8 % for spleen, liver, and kidney injuries, respectively) and 2.6%, 2.5%, and 3.0% for American College of Surgeons (ACS) level I, ACS-level II, and state-designated centers, respectively. Inter-hospital variation was moderate to high with a global ICC of 21% and ICCs of 18%, 25%, and 21% for ACS- level I, ACS-level II, and state-designated trauma centers, respectively. In our third study, the adjusted ORs were 1.92 (95% CI 1.25-2.96) for mortality and 2.39 (1.99-2.87) for complications. The adjusted GMR was 1.52 (1.38-1.68) for length of stay. Low-value operative management was more frequent in Medicaid patients than those with private insurance and was less frequent in ACS level I trauma centers than level II, level III or state designated hospitals. **Conclusions:** The results of our systematic review suggested that routine repeat CT without clinical indications is not useful in the NOM of patients with liver and/or spleen injury. Results from the first article have been used by Choosing Wisely Canada to establish recommendations in collaboration with the Trauma Association of Canada. Results of our second study provide evidence of high compliance to the clinical practice guideline recommendations on NOM for adult patients with blunt SOI published by organisations such as the Eastern Association for the Surgery of Trauma (EAST), the World Society of Emergency Surgery (WSES) and the American Association for the Surgery of Trauma (AAST) as well as the American College of Surgeons Committee on Trauma (ACS COT) and supported by the literature. Nonetheless, given the important physical, psychological, and financial consequences of unnecessary surgery, the practice variation we observed suggests that future research should attempt to evaluate the problem in hospitals that do not participate in the NTDB, identify modifiable determinants of practice variations, and assess the impact on patient outcomes. In our third study in which low-value operative management is associated with higher incidence of mortality, complications and prolonged hospital LOS, interventions designed to reduce low-value operative management may improve the outcomes of patients with blunt SOI. Such interventions should be based on the barriers and facilitators of NOM, which may include the patient and hospital-level determinants identified in this study.

INTRODUÇÃO: A síndrome compartimental abdominal (SCA) é uma complicação frequente da cirurgia de controle de dano, podendo ocorrer em até 33% dos casos. A medida da pressão intra-abdominal para diagnóstico da SCA é avaliada através da pressão intravesical. OBJETIVO: Avaliar, através de modelo experimental, as repercussões da colocação de compressas sobre a pressão intravesical e em diferentes regiões do abdome. MÉTODO: Foram utilizados 10 porcos machos, entre 45 e 60 dias, com peso entre 15 e 18 kg, submetidos a laparotomia exploradora para colocação de compressas e avaliação de medidas de pressão no espaço supra-hepático (Psh), espaço infra-hepático (Pih), espaço subfrênico esquerdo (Psfe), veia cava inferior (Pvci), veia porta (Pvp) e bexiga (Pv). Foi também avaliada a pressão arterial média (PAM) e o débito cardíaco. As diferentes medidas de pressão foram comparadas no mesmo animal com diferentes tipos de fechamento da parede abdominal: bolsa de Bogotá (CCB), total da aponeurose (CCAF), pele (CCPF) e total da pele e aponeurose (CF). Os resultados foram submetidos a análise estatística. RESULTADOS: Não houve diferença (p>0,05) entre as medidas de PAM em todas as fases de fechamento do abdome. A pressão de veia cava inferior e a pressão intravesical foram diferentes (p<0,05) entre os grupos CF e CCAF. Psfe, Psfd e Psh foram diferentes (p<0,05) entre CF e CCB, CF e CCPF e CF e CCAF. Foram diferentes (p<0,05) Pv e Psfd, Pv e Psh e Psfe e Psfd nos grupos CCB, CCPF e CCAF. No grupo CCAF ainda foram diferentes (p<0,05) Pv e Psfe e Psh e Psfd. A avaliação de Pvp mostrou-se diferente (p<0,05) em relação ao grupo controle (CF) nos grupos CCB, CCPF e CCAF, e ainda entre CCB e CCAF. CONCLUSÃO: A pressão intra-abdominal não é uniforme quando são colocadas compressas na cavidade peritoneal. A pressão vesical é menor que em outras regiões da cavidade peritoneal. As pressões não ultrapassaram níveis de Síndrome Compartimental Abdominal. / INTRODUCTION: Abdominal compartment syndrome is a frequent complication of damage control surgery and can occur in approximately 33% of cases. Diagnosis of abdominal compartment syndrome depends on measurement of abdominal pressure which is usually assessed through intravesical pressure. OBJECTIVE: Evaluate the consequences of liver packing with sponges to the intravesical pressure and to pressures in different sites of the abdomen in an animal experimental model. METHODS: 10 adult male pigs, aged 45 to 60 days, weighing 15 to 18 kg, underwent laparotomies for liver packing and evaluation of pressures in suprahepatic space (Psh), infrahepatic space (Pih), left subphrenic space (Psfe), inferior vena cava (Pvci), portal vein (Pvp) and bladder (Pv). Other variables such as mean arterial pressure and cardiac output, were also measured. Different pressure measurements were compared in the same animal with different types of closures of the abdominal wall: Bogota bag (CCB), total closure of aponeurosis (CCAF), skin closure (CCPF) and total skin and aponeurosis closure (CF). Results were analyzed statistically. RESULTS: There was no difference (p>0,05) between mean arterial blood pressure in all phases of abdominal closure. Pressure in inferior vena cava and intravesical pressure were different (p<0,05) in groups CF and CCAF. Psfe, Psfd and Psh were different (p<0,05) between CF vs CCB, CF vs CCPF and CF vs CCAF. Pv vs Psfd, Pv vs Psh and Psfe vs Psfd were different (p<0,05) in groups CCB, CCPF and CCAF. In group CCAF, Pv vs Psfe and Psh vs Psfd were also different (p<0,05). Evaluation of Pvp has shown to be different (p<0,05) when compared to control group (p<0,05) in groups CCB, CCPF and CCAF, and also between CCB and CCAF. CONCLUSION: Intra-abdominal pressure is not uniform when sponges are placed in the abdomen. Intravesical pressure is lower than pressures in other sites of the peritoneal cavity. No pressure measurement reached levels of abdominal compartment syndrome.

Made available in DSpace on 2016-06-02T19:22:51Z (GMT). No. of bitstreams: 1 2443.pdf: 1570096 bytes, checksum: 27db268f8c997a54559bd609fc4ac9ce (MD5) Previous issue date: 2009-04-29 / INTRODUCTION: The incisional hernia (IH) is one of the most frequent complications after laparotomy, causing high rates of re-operations. Advances in suture material, in the guidelines for incisions, in the techniques of closure and use of dentures (screens), have failed in the elimination of this surgical complication. In this context, advances in the understanding of biological and structural changes of collagen may offer a new strategy in the treatment of IH, since the matrix disorders that induces the formation of primary hernia probably also affect the wound healing in laparotomies. OBJECTIVE: To investigate the effect of a recombinant desintegrin (DisBa-01) on the abdominal muscle healing process with incisional hernia (IH) regarding the fibroblasts and vessels proliferation and matrix metalopeptidase activity as well. The role of &#945;2 and anti- &#945;v&#946;3 integrins were investigated by antibody competition. METHODS: IH was induced by sectioning of the midline in 20 Wistar rats, divided into two groups: control that received the topical application of phosphate buffered saline (PBS) and DisBa-01 protein (0.5mg/Kg) dissolved in PBS. Another 10 rats were divided in two groups: one received anti-&#945;V&#946;3 antibodies and the second anti-&#945;2 subunit antibodies. At the end of 14 days, the animals were sacrificed and muscle fragments were stored in liquid nitrogen for determination of MMPs by zymography. The remaining fragments of the control and DisBa-01 groups were fixed in 10% formol in PBS (v/v). Blood vessels density, mononuclear cells, fibroblasts and collagen fibers were studied by optical microscopy in blue reticuline and Masson-trichrome. Data was analyzed by parametric tests were applied with critical level of 5%. RESULTS: All animals after surgical induction developed IH. However, after 14 days the persistence of the opened hernial ring in the controls but not in the DisBa-01 group. This protein induced the formation of a membrane that occluded the entire hernial ring. A significant increase in the number of mononuclear cells, fibroblasts, new vessels and MMP-2 activity was observed in DisBa-01 group (p<0.05). DisBa-01 group significant increased the collagen content. Anti-&#945;V&#946;3 integrin antibodies produced similar results but not anti-&#945;2 integrin blocking antibodies. CONCLUSION: These results indicate that DisBa-01 promoted vascular and fibroblastic cell proliferation and monocytic, and matrix remodeling. In addition, these results strongly indicate that &#945;V&#946;3 integrin has an important role in the control of would healing and the blocking of this integrin may be an interesting therapeutical strategy in tissue repair conditions, including IH. / INTRODUÇÃO: a hérnia incisional (HI) é uma das complicações mais freqüentes após laparotomia, causando altos índices de re-operações. Avanços nos materiais de suturas, nas orientações de incisões, nas técnicas de fechamento e do uso de próteses (telas), têm falhado para a eliminação desta complicação cirúrgica. Neste contexto, avanços no entendimento das alterações biológicas e estruturais do colágeno podem oferecer uma nova estratégia no tratamento da HI, uma vez que as desordens da matriz que induz a formação da hérnia primária provavelmente também prejudicam a cicatrização da ferida operatória nas laparotomias. OBJETIVO: Investigar os efeitos da desintegrina recombinante DisBa-01, sobre o processo de cicatrização da musculatura da parede abdominal com hérnia incisional (HI) com relação a proliferação de fibroblastos, vasos e a atividade das metalopeptidases de matriz. A função das integrinas anti-subunidade &#945;2 e anti- &#945;V&#946;3 foram investigadas pelo bloqueio de anticorpos. MÉTODOS: Foi induzida a HI por secção da linha alba em 20 ratos Wistar, distribuídos em dois grupos: controle que recebeu a aplicação tópica de solução salina tamponada com fosfato (PBS), e DisBa-01 (0,5mg/Kg) dissolvida em PBS. Outros 10 ratos foram divididos em dois grupos: um recebeu anti-&#945;V&#946;3 e outro anti-subunidade &#945;2. Ao final, de 14 dias, os animais foram sacrificados e fragmentos do músculo dos 04 grupos foram armazenados em nitrogênio liquido para determinação de MMPs por zimografia. O restante dos fragmentos dos grupos controle e DisBa-01, foram fixados em formol a 10% em PBS (v/v). A densidade de vasos sangüíneos, células mononucleares, fibroblastos e de fibras colágenas foram estudadas por microscopia óptica em reticulina e Tricromo de Masson. Para analise dos dados foram aplicados testes paramétricos com nível critico de 5%. RESULTADOS: Todos os animais após indução cirúrgica desenvolveram HI. Entretanto, após 14 dias nos animais do grupo Controle houve persistência do anel herniário aberto e nos animais do grupo DisBa-01 foi observado a formação de membrana que ocluía todo o anel herniário. Foi observado aumento significativo das células mononucleares, fibroblastos, neovascularização e da atividade da MMP-2 no grupo DisBa-01 (p<0,05). Houve aumento significativo da colagenização no grupo DisBa-01 em comparação ao controle. O grupo anti-&#945;V&#946;3 produziu resultados similares a proteína DisBa-01 mas não no grupo bloqueado anti-subunidade &#945;2. CONCLUSÃO: Estes resultados indicam que a DisBa-01 promoveu proliferação vascular, celular fibroblástica e monocítica, e remodelamento da MEC. Adicionalmente, estes resultados fortemente indicam que a integrina &#945;V&#946;3 tem importante função no controle da ferida cirúrgica e o bloqueio desta integrina pode ser uma interessante estratégia terapêutica nas condições de reparo tecidual, incluindo a HI.

INTRODUÇÃO: A síndrome compartimental abdominal (SCA) é uma complicação frequente da cirurgia de controle de dano, podendo ocorrer em até 33% dos casos. A medida da pressão intra-abdominal para diagnóstico da SCA é avaliada através da pressão intravesical. OBJETIVO: Avaliar, através de modelo experimental, as repercussões da colocação de compressas sobre a pressão intravesical e em diferentes regiões do abdome. MÉTODO: Foram utilizados 10 porcos machos, entre 45 e 60 dias, com peso entre 15 e 18 kg, submetidos a laparotomia exploradora para colocação de compressas e avaliação de medidas de pressão no espaço supra-hepático (Psh), espaço infra-hepático (Pih), espaço subfrênico esquerdo (Psfe), veia cava inferior (Pvci), veia porta (Pvp) e bexiga (Pv). Foi também avaliada a pressão arterial média (PAM) e o débito cardíaco. As diferentes medidas de pressão foram comparadas no mesmo animal com diferentes tipos de fechamento da parede abdominal: bolsa de Bogotá (CCB), total da aponeurose (CCAF), pele (CCPF) e total da pele e aponeurose (CF). Os resultados foram submetidos a análise estatística. RESULTADOS: Não houve diferença (p>0,05) entre as medidas de PAM em todas as fases de fechamento do abdome. A pressão de veia cava inferior e a pressão intravesical foram diferentes (p<0,05) entre os grupos CF e CCAF. Psfe, Psfd e Psh foram diferentes (p<0,05) entre CF e CCB, CF e CCPF e CF e CCAF. Foram diferentes (p<0,05) Pv e Psfd, Pv e Psh e Psfe e Psfd nos grupos CCB, CCPF e CCAF. No grupo CCAF ainda foram diferentes (p<0,05) Pv e Psfe e Psh e Psfd. A avaliação de Pvp mostrou-se diferente (p<0,05) em relação ao grupo controle (CF) nos grupos CCB, CCPF e CCAF, e ainda entre CCB e CCAF. CONCLUSÃO: A pressão intra-abdominal não é uniforme quando são colocadas compressas na cavidade peritoneal. A pressão vesical é menor que em outras regiões da cavidade peritoneal. As pressões não ultrapassaram níveis de Síndrome Compartimental Abdominal. / INTRODUCTION: Abdominal compartment syndrome is a frequent complication of damage control surgery and can occur in approximately 33% of cases. Diagnosis of abdominal compartment syndrome depends on measurement of abdominal pressure which is usually assessed through intravesical pressure. OBJECTIVE: Evaluate the consequences of liver packing with sponges to the intravesical pressure and to pressures in different sites of the abdomen in an animal experimental model. METHODS: 10 adult male pigs, aged 45 to 60 days, weighing 15 to 18 kg, underwent laparotomies for liver packing and evaluation of pressures in suprahepatic space (Psh), infrahepatic space (Pih), left subphrenic space (Psfe), inferior vena cava (Pvci), portal vein (Pvp) and bladder (Pv). Other variables such as mean arterial pressure and cardiac output, were also measured. Different pressure measurements were compared in the same animal with different types of closures of the abdominal wall: Bogota bag (CCB), total closure of aponeurosis (CCAF), skin closure (CCPF) and total skin and aponeurosis closure (CF). Results were analyzed statistically. RESULTS: There was no difference (p>0,05) between mean arterial blood pressure in all phases of abdominal closure. Pressure in inferior vena cava and intravesical pressure were different (p<0,05) in groups CF and CCAF. Psfe, Psfd and Psh were different (p<0,05) between CF vs CCB, CF vs CCPF and CF vs CCAF. Pv vs Psfd, Pv vs Psh and Psfe vs Psfd were different (p<0,05) in groups CCB, CCPF and CCAF. In group CCAF, Pv vs Psfe and Psh vs Psfd were also different (p<0,05). Evaluation of Pvp has shown to be different (p<0,05) when compared to control group (p<0,05) in groups CCB, CCPF and CCAF, and also between CCB and CCAF. CONCLUSION: Intra-abdominal pressure is not uniform when sponges are placed in the abdomen. Intravesical pressure is lower than pressures in other sites of the peritoneal cavity. No pressure measurement reached levels of abdominal compartment syndrome.