One-stage laparoscopic bisegmentectomy 7-8 and bisegmentectomy 2-3 for bilateral colorectal liver metastases

Bisegmentectomy 7-8 is feasible even in the absence of a large inferior right hepatic vein. To our knowledge, this operation has never been performed by laparoscopy. This study was designed to present video of pure laparoscopic bisegmentectomy 7-8 and bisegmentectomy 2-3 in one-stage operation for bilateral liver metastasis. A 67-year-old man with metachronous bilobar colorectal liver metastasis was referred for surgical treatment after neoadjuvant chemotherapy. CT scan disclosed two liver metastases: one located between segments 7 and 8 and another one in segment 2. At liver examination, another metastasis was found on segment 3. We decided to perform a bisegmentectomy 7-8 along with bisegmentectomy 2-3 in a single procedure. The operation began with mobilization of the right liver with complete dissection of retrohepatic vena cava. Inferior right hepatic vein was absent. Right hepatic vein was dissected and encircled. Upper part of right liver, containing segment 7 and 8, was marked with cautery. Selective hemi-Pringle maneuver was performed and right hepatic vein was divided with stapler. At this point, liver rotation to the left allowed direct view and access to the superior aspect of the right liver. Liver transection was accomplished with harmonic scalpel and endoscopic stapling device. Bisegmentectomy 2-3 was performed using the intrahepatic Glissonian approach. The specimens were extracted through a suprapubic incision. Liver raw surfaces were reviewed for bleeding and bile leaks. Operative time was 240 minutes with no need for transfusion. Recovery was uneventful. Patient was discharged on the fifth postoperative day. Patient is well with no evidence of disease 14 months after liver resection. Tumor markers are within normal range. Bisegmentectomy 7-8 may increase resectability rate in patients with bilateral lesions. This operation can be performed safely by laparoscopy. Preservation of segments 5 and 6 permitted simultaneous resection of segments 2 and 3 with adequate liver remnant.

Glissonian approach for laparoscopic mesohepatectomy

Experience with advanced techniques has increased the indications for laparoscopic liver resection. This video demonstrates technical aspects of a pure laparoscopic mesohepatectomy using intrahepatic Glissonian technique. To the best of our knowledge, this is the first case of anatomic laparoscopic mesohepatectomy using the Glissonian approach published in the English literature. A 62-year-old man with colorectal liver metastasis occupying central liver segments was referred for surgical treatment. The first step is the control of segment 4 pedicle. Using the round ligament as a guide, one incision is performed on its right margin and another is made at the bottom of segment 4. A vascular clamp is introduced through those incisions to occlude segment 4 Glissonian sheath. The next step is to control the right anterior pedicle. The first incision is made in front of the hilum and another is performed on the right edge of gallbladder bed. Laparoscopic clamp is introduced through these incisions and closed producing ischemic discoloration of segments 5 and 8. Vascular clamp is replaced by an endoscopic vascular stapling device and stapler is fired. Line of liver transection is marked along the liver surface following ischemic area. Liver transection is accomplished with bipolar vessel sealing device and endoscopic stapling device as appropriate. Specimen was extracted through a suprapubic incision. Liver raw surfaces were reviewed for bleeding and bile leaks. Operative time was 200 min with minimum blood loss and no need for blood transfusion. Recovery was uneventful, and the patient was discharged on the fifth postoperative day. Histological examination revealed clear surgical margins. Mesohepatectomy can be safely performed laparoscopically in selected patients and by surgeons with expertise in both liver surgery and laparoscopic techniques. The use of the intrahepatic Glissonian approach may help to identify the exact limits of the mesohepatectomy to avoid ischemic injury of the remnant liver.

The role of videopericardioscopy in evaluating indeterminate pericardial effusions

Background. The pericardial biopsy has opened a new perspective for the etiologic diagnosis of pericardial effusions, because adequate pericardial visualization via the use of a video camera can provide more accurate results. We assessed the usefulness of videopericardioscopy for the diagnosis and treatment of pericardial effusion of indeterminate origin. Methods. We conducted a retrospective study of clinical data from patients who underwent videopericardioscopy examination for pericardial effusion without an established diagnosis. The video-assisted pericardioscopy procedure was performed through a small incision in the xiphoid area. Results. From January 1998 to January 2007, 101 consecutive patients underwent videopericardioscopy evaluation for pericardial effusion. Ten patients were excluded because of lack of data. Fifty men and 41 women were included ( mean age, 50 years; range, 14-76 years). All of the patients had moderate or significant pericardial effusion as demonstrated by echocardiography or computed tomography. The following diagnoses for the pericardial effusions were established: nonspecific inflammation, 50 cases ( 54.94%); neoplastic disorders, 22 cases ( 24.17%); tuberculous, 11 cases ( 12.08%); bacterial inflammatory process, 3 cases ( 3.29%); chylopericardial, 2 cases ( 2.19%); fungal infection, 2 cases ( 2.19%); and viral infection, 1 case ( 1.09%). Pericardioscopy evaluation provided the definitive diagnosis via the pericardial biopsy in 36.26% of the cases and via the results of fluid analyses in 13.18% of the cases; the use of both methods established the definitive diagnosis in 45.05% of the cases in this group of patients. The overall morbidity rate was 4.3%, and the most common complication was arrhythmia due to intraoperative manipulation, which ceased with the removal of the instruments from the pericardial cavity. We had 1 death, by cardiac tamponade, in the perioperative period. Conclusion. Videopericardioscopy is a safe and efficient method for obtaining a better diagnosis of and satisfactory therapeutic results for pericardial effusions of indeterminate cause, and such results are obtained via an improved exploration of the pericardial cavity.

High and Low Frequency TENS Reduce Postoperative Pain Intensity After Laparoscopic Tubal Ligation A Randomized Controlled Trial

Background: Transcutaneous electrical nerve stimulation (TENS) is an effective adjunctive therapy for postoperative pain; however, effects of different frequencies Of stimulation have not been systematically investigated. Laparoscopic sterilization (LS) causes significant pain in the early postoperative period and requires substantial postoperative medication. Therefore, we studied the effects of TENS on postoperative pain after LS through placement of Yoon fallopian rings in a prospective, randomized, double-blinded, and placebo-controlled study. Methods: Sixty-four patients undergoing LS for uterine tube ligation were randomly allocated to receive either active TENS or placebo TENS. Postoperative pain was evaluated using a standard I I-point numeric rating scale and the McGill Pain Questionnaire (MPQ)-pain rating index and number of words chosen. Both high frequency (100 Hz) and low frequency (4 Hz) TENS, at strong, but comfortable sensory intensity, were applied for 20 minutes through 4 electrodes placed around the surgical incision immediately after Surgery. Pain was assessed before and after application of TENS when patients were at postanesthesia care unit (PACU). Results: Both high and low frequency TENS significantly decreased postoperative pain intensity when compared with before administration of TENS using the numeric rating scale (P = 0.001), pain rating index (P = 0.001), and number of words chosen (P 0.001) compared with placebo TENS (P = 0.001). TENS in combination with standard pharmacologic analgesic treatment was efficacious for postoperative pain relief after LS. Conclusions: We recommend regular use of multimodal therapy with TENS and analgesic drugs after LS with placement of Yoon rings.

ANGIOTENSIN III MODULATES THE NOCICEPTIVE CONTROL MEDIATED BY THE PERIAQUEDUCTAL GRAY MATTER

Endogenous angiotensin (Ang) II and/or an Ang II-derived peptide, acting on Ang type I (AT(1)) and Ang type 2 (AT(2)) receptors, can carry out part of the nociceptive control modulated by periaqueductal gray matter (PAG). However, neither the identity of this putative Ang-peptide, nor its relationship to Ang II antinociceptive activity was clarified. Therefore, we have used tail-flick and incision allodynia models combined with an HPLC time course of Ang metabolism, to study the Ang III antinociceptive effect in the rat ventrolateral (vi) PAG using peptidase inhibitors and receptor antagonists. Ang III injection into the vIPAG increased tail-flick latency, which was fully blocked by Losartan and CGP 42,112A, but not by divalinal-Ang IV, indicating that. Ang III effect was mediated by AT(1) and AT(2) receptors, but not by the AT(4) receptor. Ang III injected into the vIPAG reduced incision allodynia. Incubation of Ang II with punches of vIPAG homogenate formed Ang III, Ang (1-7) and Ang IV. Amastatin (AM) inhibited the formation of Ang III from Ang II by homogenate, and blocked the antinociceptive activity of Ang II injection into vIPAG, suggesting that aminopeptidase A (APA) formed Ang III from Ang II. Ang III can also be formed from Ang I by a vIPAG alternative pathway. Therefore, the present work shows, for the first time, that: (i) Ang III, acting on AT(1) and AT(2) receptors, can elicit vIPAG-mediated antinociception, (ii) the conversion of Ang II to Ang III in the vIPAG is required to elicit antinociception, and (iii) the antinociceptive activity of endogenous Ang II in vIPAG can be ascribed preponderantly to Ang III. (C) 2009 IBRO. Published by Elsevier Ltd. All rights reserved.

Dorsal root ganglionectomy for the diagnosis of sensory neuropathies. Surgical technique and results

Background: Inflammatory diseases stand out among sensory neuronopathies because, in their active phase, they can be treated with immunosuppressive agents. Immunosuppressive therapy may present severe adverse effects and requires previous inflammatory activity confirmation. Sensory neuronopathies are diagnosed based on clinical and EMG findings. Diagnostic confirmation and identification of inflammatory activity are based on sensory ganglion histopathological examination. We describe the surgical technique used for dorsal root ganglionectomy in patients with clinical/EMG diagnosis of sensory neuronopathies. Methods: The sensory ganglion was obtained from 15 patients through a small T7-T8 hemilaminectomy and foraminotomy to expose the C7 root from its origin to the spinal nerve bifurcation. In 6 patients, the dural cuff supposed to contain the ganglion was resected en bloc; and in 9 patients, the ganglion was obtained through a longitudinal incision of the dural cuff and microsurgical dissection from the ventral and dorsal roots and radicular arteries. All ganglia were histopathologically examined. Results: No ganglion was found in the dural cuff in 2 patients submitted to en bloc removal, and the ganglion was removed in all patients who underwent microsurgical dissection. All but 2 patients that had ganglion examination presented a neuronopathy of nerve cell loss, 3 with mononuclear inflammatory infiltrate. These patients underwent immunosuppressive therapy, and 2 of them presented clinical improvement. No surgical complications were observed. Conclusions: Microsurgical dorsal root ganglionectomy for diagnosing inflammatory sensory ganglionopathies was effective and safe. Although safe, en bloc resection of the proximal dural cuff was not effective for this purpose. (c) 2008 Published by Elsevier Inc.

POSTOPERATIVE ANALGESIA INDUCED BY INTRATHECAL NEOSTIGMINE OR BETHANECHOL IN RATS

P>Cholinergic agonists and acetylcholinesterase inhibitors, such as neostigmine, produce a muscarinic receptor-mediated antinociception in several animal species that depends on activation of spinal cholinergic neurons. However, neostigmine causes antinociception in sheep only in the early, and not late, postoperative period. In the present study, a model of postoperative pain was used to determine the antinociceptive effects of bethanechol (a muscarinic agonist) and neostigmine administered intrathecally 2, 24 or 48 h after a plantar incision in a rat hind paw. Changes in the threshold to punctate mechanical stimuli were evaluated using an automated electronic von Frey apparatus. Mechanical hyperalgesia was obtained following plantar incision, the effect being stronger during the immediate (2 h) than the late post-surgical period. Bethanechol (15-90 mu g/5 mu L) or neostigmine (1-3 mu g/5 mu L) reduced incision-induced mechanical hyperalgesia, the effects of both drugs being more intense during the immediate (2 h) than the late post-surgical period. The ED(50) for bethanechol injected at 2, 24 and 48 h was 5.6, 51.9 and 82.5 mu g/5 mu L, respectively. The corresponding ED(50) for neostigmine was 1.62, 3.02 and 3.8 mu g/5 mu L, respectively. The decline in the antinociceptive potency of neostigmine with postoperative time is interpreted as resulting from a reduction in pain-induced activation of acetylcholine-releasing descending pathways. However, the similar behaviour of bethanechol in the same model points to an additional mechanism involving intrinsic changes in spinal muscarinic receptors.

Hypoalgesic effect of the transcutaneous electrical nerve stimulation following inguinal herniorrhaphy: A randomized, controlled trial

We investigated the effect of transcutaneous electrical nerve stimulation (TENS) for inguinal herniorrhaphy postoperative pain control in a prospective, randomized, double-blinded, placebo-controlled study. Forty patients undergoing unilateral inguinal herniorrhaphy with an epidural anesthetic technique were randomly allocated to receive either active TENS or placebo TENS. Postoperative pain was evaluated using a standard 10-point numeric rating scale (NRS). Analgesic requirements were also recorded. TENS (100 Hz, strong but comfortable sensory intensity) was applied for 30 minutes through 4 electrodes placed around the incision twice, 2 and 4 hours after surgery. Pain was assessed before and after each application of TENS and 8 and 24 hours after surgery. In the group treated with active TENS, pain intensity was significantly lower 2 hours (P = .028), 4 hours (P = .022), 8 hours (P = .006), and 24 hours (P = .001) after the surgery when compared with the group that received placebo TENS. Active TENS also decreased analgesic requirements in the postoperative period when compared with placebo TENS (P = .001). TENS is thus beneficial for postoperative pain relief, after inguinal herniorrhaphy; it has no observable side effects, and the pain-reducing effect continued for at least 24 hours. Consequently, the routine use of TENS after inguinal herniorrhaphy is recommended. Perspective: This study presents the hypoalgesic effect of high-frequency TENS for postoperative pain after inguinal herniorrhaphy. This may reinforce findings from basic science showing an opioid-like effect provided by TENS, given that high-frequency TENS has been shown to activate delta-opioid receptors. (C) 2008 by the American Pain Society.

Evaluation of cortisol and glycemia levels of dogs anesthetized with sevoflurane and premedicated with either butorphanol or phetidine

The objective of this study was to compare the influence of butorphanol and phetidine as part of the preanesthetic medication, in 20 healthy dogs submitted to experimental orthopedic surgery. Dogs were randomly allocated in two groups: GI, acepromazine and butorphanol (0,05 mg.kg(-1) and 0,4 mg.kg(-1), respectively, i.m.) and, GII, acepromazine and phetidine (0,05 mg.kg(-1) and 4 mg.kg(-1), respectively, i.m.). Anesthesia was induced by administration of propofol (5 mg.kg-1) and maintained by the use of sevoflurane delivered in a 100% oxygen circuit. Plasma concentrations of cortisol and glucose were measured during several surgical procedures: T0, before preanesthetic medication; T1, 20 minutes after preanesthetic medication; T2, at skin incision; T3, at periostal stimulation; and, T4, at skin suture. Concentrations of plasma glucose were not significantly different between the surgical procedures and between the two groups evaluated. Concentrations of plasma cortisol were significantly higher in dogs administered with butorphanol between the surgical procedures of T0 and T3, compared with values for dogs administered with phetidine. These results suggest that phetidine is more adequate to control plasma cortisol in dogs submitted to orthopedic surgery than anesthesia with sevoflurane.

Mast cell concentration in the wound healing process of incisions made by different instruments

The aim of this study was to compare the concentration of mast cells (MCs) in the healing process of incisions. Thirty rats were submitted to six linear incisions each, performed in the dorsal skin by carbon dioxide (CO(2)) and diode lasers, electrocautery and conventional scalpel. The animals were euthanized at intervals of 0 h, 24 h, 48 h, 72 h, 7 days and 14 days after the incisions had been made. Histological sections were obtained and stained with toluidine blue for identification of MCs, which were manually counted by conventional microscopy in 20 microscopic fields in the border of the incision, near the granulation tissue, or in the area of new collagen formation, depending on intervals. The concentration of MCs was significantly higher in the wounds made by scalpel than in those made by other techniques at 48 h and 72 h. After 72 h the number of MCs was also significantly higher after electrocautery than after incisions made by 4 W CO(2) laser. On days 7 and 14, there was no significant difference in the MC count among the different types of incisions. In summary, the MC concentration varied after different surgical incisions at early phases of wound healing. At the end of the healing process, however, there were similar MC concentrations around the incisions, suggesting that, in standard incisions in the surgical techniques studied, the wound healing process ultimately occurred in a similar pattern.

Electrocardiographic Alterations During Endosseous Implant Placement Performed with Local Anesthetic Agents

Purpose: The purpose of this study was to analyze electrocardiographic alterations during dental implant surgeries when local anesthetic agents were used. Materials and Methods: Twenty implants were placed in 18 healthy patients. An electrocardiogram and Wincardio software were used to gather recordings from 12 static leads every 2 minutes, continuously record coronary artery (D2) derivations, and automatically measure the following electrocardiographic parameters: heart rate, duration and amplitude of the P wave, PR segment duration, ST segment deviation, QRS complex duration, and duration of the RR, QT, and corrected QT (QTc) intervals. Results: Analysis of variance of the values obtained at the different stages showed significant differences (P < .05) for the heart rate and for the duration of the RR and QT intervals. The heart rate increased during the anesthesia, incision, and bone drilling stages, reaching a peak during drilling. Duration of the RR and QT intervals decreased during the incision and drilling stages. Among the electrocardiographic parameters individually assessed, several altered values were found for the duration of the P wave, the QRS complex, and the QT and QTc intervals. Sinusal tachycardia and bradycardia, sinusal arrhythmia, supraventricular extrasystole, ventricular extrasystole, and T-wave inversion were detected. Conclusion: Dental implant placement surgery may induce electrocardiographic alterations. The most frequently found arrhythmias were extrasystole and sinusal tachycardia. The anesthesia, incision, and bone drilling stages exhibited the highest heart rate values and the shortest durations of the RR and QT intervals. INT J ORAL MAXILLOFAC IMPLANTS 2009;24:412-418

Biocompatibility evaluation of alendronate paste in rat`s subcutaneous tissue

Alendronate is a known inhibitor of root resorption and the development of alendronate paste would enhance its utilization as intracanal medication. Therefore, this study aimed to investigate the biocompatibility of experimental alendronate paste in subcutaneous tissue of rats, for utilization in teeth susceptible to root resorption. The study was conducted on 15 male rats, weighing similar to 180-200 grams. The rats` dorsal regions were submitted to one incision on the median region and, laterally to the incision, the subcutaneous tissue was raised and gently dissected for introduction of two tubes, in each rat. The tubes were sealed at one end with gutta-percha and taken as control. The tubes were filled with experimental alendronate paste. The animals were killed at 7, 15 and 45 days after surgery and the specimens were processed in laboratory. The histological sections were stained with hematoxylin-eosin and analyzed by light microscopy. Scores were assigned to the in. ammatory process and statistically compared by the Tukey test (P < 0.05). Alendronate paste promoted severe inflammation process at 7 days, with statistically significant difference compared to the control (P < 0.05%). However, at 15 days, there was a regression of in. ammation and the presence of connective tissue with collagen fibers, fibroblasts and blood vessels was observed. After 45 days, it was observed the presence of well-organized connective tissue, with collagen fibers and fibroblasts, and few in. ammatory cells. No statistical difference was observed between the control and experimental paste at 15 and 45 days. The experimental alendronate paste was considered biocompatible with subcutaneous tissue of rat.

Access to the frontal sinus and zygomatico frontal suture through the supratarsal fold

Precise repositioning of a fractured zygoma is difficult. The traditional approach is through an eyebrow incision, but it can produce a scar that causes aesthetic and psychological problems for the patient. We describe the supratarsal fold approach to expose the frontozygomatic suture and to reduce small displacements of frontal sinus anterior wall; it gives good access and excellent aesthetic results. (C) 2007 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Modified abbreviated transcavernous approach to basilar artery aneurysms-Case report

Background: Endovascular procedures and direct surgical clipping, are the main therapeutic modalities for managing of BAAs. Furthermore, giant or wide-necked aneurysms and those that involve the PCA or perforators at its neck usually are not embolized. Case Description: A 55-year-old man presented to the emergency room complaining Of Sudden and intense headache. Neurological examination evidenced meningismus. Computed tomography disclosed a subarachnoid hemorrhage (Fisher grade III). Arteriograms revealed BAA, whose neck was partially obseured by the PCP. A standard pterional craniotomy was performed, followed. by extensive drilling of the greater sphenoid wing. The neck was partially hidden by the PCP, and no proximal control was obtained without drilling the PCP and opening the CS (modified TcA). Drilling of the PCP was begun by cutting the overlying dura and extended caudally as much as possible. Next. opening, of the roof of the CS was performed by incising the dura in the oculomotor trigone medical and parallel 10 the oculomotor nerve and lateral to ICA: the incision progressed posteriorly toward the dorsum sellae. Further resection of the dorsum sellac and clivus was carried out. After performing these steps, proximal control was obtained, aneurysm was deflated, perforators were saved. and aneurysm was clipped. Conclusions: This study has demonstrated the clinical Usefulness of and abbreviated form of the TcA, which led the ""modified TcA."" in approaching complex low-lying, BAA. It provides additional surgical room by removing the PCP and partially, opening the CS, which permits further bone removal and improves exposure. (C) 2009 Elsevier Inc. All rights reserved.

Grain size and heavy minerals of the Late Quaternary eolian sediments from the Imbituba-Jaguaruna coast, Southern Brazil: Depositional controls linked to relative sea-level changes

The stratigraphic subdivision and correlation of dune deposits is difficult, especially when age datings are not available. A better understanding of the controls on texture and composition of eolian sands is necessary to interpret ancient eolian sediments. The Imbituba-Jaguaruna coastal zone (Southern Brazil, 28 degrees-29 degrees S) stands out due to its four well-preserved Late Pleistocene (eolian generation 1) to Holocene eolian units (eolian generations 2, 3, and 4). In this study, we evaluate the grain-size and heavy-mineral characteristics of the Imbituba-Jaguartma eolian units through statistical analysis of hundreds of sediment samples. Grain-size parameters and heavy-mineral content allow us to distinguish the Pleistocene from the Holocene units. The grain size displays a pattern of fining and better sorting from generation 1 (older) to 4 (younger), whereas the content of mechanically stable (dense and hard) heavy minerals decreases from eolian generation 1 to 4. The variation in grain size and heavy-mineral content records shifts in the origin and balance (input versus output) of eolian sediment supply attributable mainly to relative sea-level changes. Dunefields submitted to relative sea-level lowstand conditions (eolian generation 1) are characterized by lower accumulation rates and intense post-depositional dissection by fluvial incision. Low accumulation rates favor deflation in the eolian system, which promotes concentration of denser and stable heavy minerals (increase of ZTR index) as well as coarsening of eolian sands. Dissection involves the selective removal of finer sediments and less dense heavy minerals to the coastal source area. Under a high rate of relative sea-level rise and transgression (eolian generation 2), coastal erosion prevents deflation through high input of sediments to the coastal eolian source. This condition favors dunefield growth. Coastal erosion feeds sand from local sources to the eolian system. including sands from previous dunefields (eolian generation 1) and from drowned incised valleys. Therefore, dunefields corresponding to transgressive phases inherit the grain-size and heavy-mineral characteristics of previous dunefields, leading to selective enrichment of finer sands and lighter minerals. Eolian generations 3 and 4 developed during a regressive-progradational phase (Holocene relative sea level highstand). The high rate of sediment supply during the highstand phase prevents deflation. The lack of coastal erosion favors sediment supply from distal sources (fluvial sediments rich in unstable heavy minerals). Thus, dunefields of transgressive and highstand systems tracts may be distinguished from dunefields of the lowstand systems tract through high rates of accumulation (low deflation) in the former. The sediment source of the transgressive dunefields (high input of previously deposited coastal sands) differs from that of the highstand dunefields (high input of fluvial distal sands). Based on this case study, we propose a general framework for the relation between relative sea level, sediment supply and the texture and mineralogy of eolian sediments deposited in siliciclastic wet coastal zones similar to the Imbituba-Jaguaruna coast (C) 2009 Elsevier B.V. All rights reserved.