Physiological Responses to Brain Stimulation During Limbic Surgery: Further Evidence of Anterior Cingulate Modulation of Autonomic Arousal

Background: In view of conflicting neuroimaging results regarding autonomic-specific activity within the anterior cingulate cortex (ACC), we investigated autonomic responses to direct brain stimulation during sterecitactic limbic surgery. Methods: Skin conductance activity and accelerative heart rate responses to multi-voltage stimulation of the ACC (n = 7) and paralimbic subcauclate (n = 5) regions were recorded during bilateral anterior cingulotomy and bilateral subcauclate tractotomy (in patients that had previously received an adequate lesion in the ACC), respectively. Results: Stimulations in both groups were accompanied by increased autonomic arousal. Skin conductance activity was significantly increased during ACC stimulations compared with paralimbic targets at 2 V (2.34 +/- .68 [score in microSiemens +/- SE] vs. .34 +/- .09, p = .013) and 3 V (3.52 +/- .86 vs. 1.12 +/- .37, p = .036), exhibiting a strong ""voltage-response"" relationship between stimulus magnitude and response amplitude (difference from 1 to 3 V = 1.15 +/- .90 vs. 3.52 +/- .86, p = .041). Heart rate response was less indicative of between-group differences. Conclusions: This is the first study of its kind aiming at seeking novel insights into the mechanisms responsible for central autonomic modulation. It supports a concept that interregional interactions account for the coordination of autonomic arousal.

Safety Profile of Trocar and Insufflation Needle Access Systems in Laparoscopic Surgery

BACKGROUND: The most common laparoscopic complications are associated with trocar insertion. The purpose of this study was to develop an objective method of evaluating the safety profile of various access devices used in laparoscopic surgery. STUDY DESIGN: In 20 swine, 6 bladed and 2 needle access devices were evaluated. A force profile was determined by measuring the force required to drive the trocar or needle through the fascia and into the peritoneum, at 0 and 10 mmHg. The amount Of tissue deformation, the length of blade exposed, and the duration of exposure were measured using a high-speed digital imaging system. RESULTS: The needle system without the sheath required the least driving force and had the most favorable force profile. In contrast, the bladed, nonretractable trocar system required a higher driving force and a rapid loss of resistance. Insertion under a pneumoperitoneum did not significantly alter the force profile of the various access devices except for the amount of tissue deformation. With the bladed system, the blade itself was exposed for an average of 0.5 to 1.0 seconds for a distance of 4.5 to 5.0 cm. In comparison, the needle system was exposed for 0.2 seconds for a distance of 1.8 cm. CONCLUSIONS: We developed a reproducible method of measuring the forces required to place the access systems, their pattern of resistance loss, and the characteristics of the blade exposure. These parameters may provide an adjunctive and objective measurement of safety, allowing for more direct comparison between various trocar designs. (J Am Coll Surg 2009;209:222-232. (C) 2009 by the American College of Surgeons)

Endoscopic treatment of Roux-en-Y gastric bypass-related gastrocutaneous fistulas using a novel biomaterial

Background Roux-en-Y gastric bypass (RYGB) is amongst the commonest surgical intervention for weight loss in obese patients. Gastrocutaneous fistula, which usually occurs along the vertical staple line of the pouch, is amongst its most alarming complications. Medical management comprised of wound drainage, nutritional support, acid suppression, and antibiotics may be ineffective in as many as a third of patients with this complication. We present outcomes after endoscopic application of SurgiSIS (R), which is a novel biomaterial for the treatment of this complication. Design A case series of 25 patients. Methods Twenty-five patients who had failed conservative medical management of gastrocutaneous fistula after RYGB underwent endoscopic application of SurgiSIS (R)-an acellular fibrogenic matrix biomaterial to help fistula healing. Main outcome measures Fistula closure as assessed by upper gastrointestinal imaging and endoscopic examination. Results In patients who had failed medical management lasting 4-25 (median, 7) weeks, closure of the fistulous tract was successful after one application in six patients (30%), two applications in 11 patients (55%), and three applications in three patients (15%). There were no procedure-related complications. Conclusions Endoscopic application of SurgiSIS (R)-an acellular fibrogenic matrix-is safe and effective for the treatment of gastrocutaneous fistula after RYGB.

Evolution of Laparoscopic Colorectal Surgery in Brazil Results of 4744 Patients From the National Registry

Background: Since its introduction, laparoscopic colorectal surgery has raised intense debate and controversies regarding its safety and effectiveness. Methods: This multicentric registry reports the experience of 28 Brazilian surgical teams specializing in laparoscopic colorectal surgery. Results: Between 1992 and 2007, 4744 patients (1994 men-42% and 2750 women-58%) were operated upon, with ages ranging from 13 to 94 years (average 57.5y). Benign diseases were diagnosed in 2356 patients (49.6%). Most diseases were located in 50.7% of the left and sigmoid colon, 28.2% in the rectum and anal canal. 8.0% in the right colon, and diffuse 7.0%. There were 181 (3.8%) intraoperative complications (from 0% to 14%). There were 261 (5.5%) reported conversions to laparotomy (from 0% to 16.5%), mainly during the early experience (n = 119 - 59.8%). Postoperative complications were registered in 683 (14.5%) patients (from 5.0% to 50%). Mortality occurred in 43 patients (0.8%). Surgeons who performed less than 50 cases reported similar rates of intraoperative (4.2% vs. 3.8%,- P = 0.7), postoperative complications (20.8% vs. 14.3%; P = 0.07), and mortality (1.0% vs. 0.9%; P = 0.5) but the conversion rate was higher (10.4% vs. 5.4%; P = 0.04). Two thousand three hundred and eighty-nine (50.4%) malignant tumors were operated upon, and histologic classification showed 2347 (98%) adenocarcinomas, 30 (0.6%) spinocelular carcinomas, and 12 (0.2%) other histologic types. Tumor recurrence rate was 16.3% among patients followed more than I year. After an average follow-Lip of 52 months, 19 (0.8%) parietal recurrences were reported, 18 of which were in port sites and I in a patient with disseminated disease. There was no incisional recurrence in the ports used to withdraw the pathologic specimen. Compared with other registries, there was a 75% increase in the number of groups pet-forming laparoscopic colorectal surgery and a decrease in conversions (from 10.5%. to 5.5%) and mortality (from 1.5% to 0.9%) rates. Conclusions: (1) The number of patients operated upon increased expressively during the last years; (2) operative indications for benign and malignant diseases were similar, and diverticular disease of the colon comprised 40% of the benign ones; (3) conversion and mortality rates decreased over time; (4) Surgeon`s experience did not influence the complication rates, but was associated with a lower conversion; and (5) oncologic outcome expressed by recurrence rates showed results similar to those reported in conventional surgery.

Hemostatic changes and clinical sequelae after on-pump compared with off-pump coronary artery bypass surgery: a prospective randomized study

Objective To delineate the effects of extracorporeal bypass on biomarkers of hemostasis, fibrinolysis, and inflammation and clinical sequelae. Methods Patients were assigned prospectively and randomly to either on-pump (n=41) or off-pump (n=51) coronary bypass surgery. The concentrations of C-reactive protein, fibrinogen, D-dimer, and plasminogen activator inhibitor type-1 in blood were quantified before and after (1 and 24 h) surgery. Similar surgical and anesthetic procedures were used for both groups. Clinical events were assessed during initial hospitalization and at the end of I year. Results The concentrations of plasminogen activator inhibitor type-1 and D-dimer were greater compared with preoperative values 1 and 24 h after surgery in both groups, but their concentrations increased to a greater extent 24 h after surgery in the on-pump group (P<0.01). The concentration of C-reactive protein did not change appreciably immediately after surgery in either group but increased in a parallel manner 24 h after either on-pump or off-pump surgery (P<0.01). Bypass surgery in the on-pump group was associated with greater blood loss during surgery and more bleeding after surgery (P <= 0.01). The incidence of all other complications was similar in the two groups. Conclusion On-pump surgery was associated with biochemical evidence of a prothrombotic state early after surgery but no greater incidence of thrombotic events was observed. The prothrombotic state might be a consequence of extracorporeal bypass, compensation in response to more bleeding, or both in patients undergoing on-pump surgery. Coron Artery Dis 20:100-105 (C) 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins.

Optimizing Medical Therapy of Acromegaly: Beneficial Effects of Cabergoline in Patients Uncontrolled with Long-Acting Release Octreotide

Background: Previous data indicate a beneficial effect of cabergoline (CAB) association to somatostatin analogs (SA) in acromegalics resistant to SA monotherapy. Objective: To assess the efficacy of CAB association on acromegalics with high IGF-I on stable long-acting release octreotide (OCT-LAR) (30 mg/28 days). Design, Subjects and Methods: 34 patients (17 male, 25-85 years, 33 macroadenomas) were enrolled in this prospective study. OCT-LAR was administered as primary (n = 4) and as secondary (n = 30) treatment: after surgery (n = 16), after surgery + radiotherapy (RT) (n = 11), and after RT only (n = 3). Duration of OCT-LAR therapy prior to CAB was 24 8 12 months. The immunohistochemical features of the tumors disclosed GH/PRL co-secretion in 11/21 patients. 13 patients had high PRL levels prior to CAB. The initial CAB dose was 1.5 mg/week. No IGF-I normalization led to a dose increase to 3.5 mg/week. The OCT-LAR dose was kept stable during treatment. IGF-I, GH and PRL levels were compared before and after CAB association. OCT-LAR was withdrawn in patients who achieved IGF-I normalization, in order to assess the influence of CAB. Results: Comparing OCT-LAR to OCT-LAR/CAB treatment, there was a significant decrease in mean GH, IGF-I, %ULNR- IGF-I and PRL levels. During OCT-LAR/CAB treatment, IGF-I normalized in 19 patients (56%). IGF-I normalization was correlated to lowest IGF-I levels on OCT-LAR monotherapy, but not to baseline PRL levels or GH/PRL co-expression. OCT-LAR withdrawn in all who had achieved IGF-I normalization on combined therapy resulted in IGF-I elevation to abnormal levels in all patients. Gastro intestinal symptoms were reported by 12 patients. Conclusion: OCT-LAR and CAB association has been shown to be an effective alternative therapy for those acromegalics who still have active acromegaly despite monotherapy with SA, mainly for those with lower pretreatment IGF-I concentrations. According to previous studies, the beneficial effects of CAB occur even when pretreatment PRL is normal and/or there is no tumor GH/PRL co-expression. Copyright (C) 2009 S. Karger AG, Basel

Transanal Small Bowel Evisceration: An Unusual Presentation of Rectal Impalement

Traumatic transanal small bowel evisceration is a rare condition usually associated with suction injuries or blunt abdominal trauma. We report the first case of intestinal evisceration through the anus caused by penetrating trauma (rectal impalement). Additionally, we performed a literature review of all English language articles since 1970 concerned with traumatic transanal small bowel evisceration. Mechanisms of injury and the surgical management are discussed.

Early fetal cystoscopy for first-trimester severe megacystis

Objectives To report the feasibility of early fetal cystoscopy for the prenatal diagnosis and therapy of severe first-trimester megacystis. Methods Between January 2008 and February 2010, early fetal cystoscopy at 16 weeks of gestation was offered to 15 patients whose fetuses presented with severe first-trimester megacystis. All infants were followed up for 6-12 months after birth. Autopsy was always performed whenever fetal or neonatal deaths occurred. Results Seven patients decided to undergo fetal therapy, and eight elected to continue with expectant observation. One fetus died before early fetal cystoscopy was performed. Therefore, six fetuses underwent early fetal cystoscopy. Urethral atresia was diagnosed in three fetuses during fetal cystoscopy and confirmed at autopsy following termination of pregnancy at 19-20 weeks in all cases. Posterior urethral valves were diagnosed and successfully fulgurated by laser during early cystoscopy in three fetuses, two of which survived with normal renal and bladder function after birth; the remaining fetus had a postnatal diagnosis of megacystis-microcolon intestinal hypoperistalsis syndrome and died neonatally. In the expectantly managed group, no survivals were observed, even among cases with `isolated` posterior urethral valves. Conclusions Percutaneous early fetal cystoscopy is feasible for prenatal diagnosis and therapy of severe megacystis. Copyright (C) 2011 ISUOG. Published by John Wiley & Sons, Ltd.

Studies of RET gene expression and acetylcholinesterase activity in a series of sporadic Hirschsprung`s disease

The purpose is to present the studies of RET gene expression and acetylcholinesterase activity in 23 patients operated for Hirschsprung`s disease (HD). The patients underwent either transanal endorectal pull-through or Duhamell`s procedure. Full-thickness intestinal samples from the three different segments (ganglionic, intermediate and aganglionic) were collected. Each tissue sample was divided in two portions, one for AChE histochemical staining and the other for examination of RET mRNA expression level. All patients had an uneventful postoperative recovery. In all patients, the AChE stainings demonstrated the absence of activity in the ganglionic area, the marked increase of positive fibers in the aganglionic area, and little increase of positive fibers in the intermediate area. In the ganglionic and intermediate areas, all patients (100%) showed significant RET gene expression. In the aganglionic area, 18 patients (78.3%) did not present gene expression and the other five patients (21.7%) presented gene expression that was similar to the ganglionic and intermediate areas. The results reinforce the conclusion that the method of AChE staining is effective for the diagnosis of intestinal aganglionosis and confirm the knowledge that genes beyond RET may be implicated in the genesis of sporadic cases of HD.

Biological markers and prognosis in recurrent oral cancer after salvage surgery

Objective: To analyze the prognostic effect of epidermal growth factor receptor (EGFR), matrix metalloproteinases 2 and 9, and vascular endothelial growth factor expression in patients with locally recurrent oral carcinoma after salvage surgery. Design: Retrospective cohort study. Settings: Tertiary center cancer hospital. Patients: The charts of 111 patients with local recurrence of oral carcinomas were retrospectively analyzed. The previous treatment consisted of surgery in 33 patients (30.0%), radiotherapy with or without chemotherapy in 46 patients (41.0%), and surgery with adjuvant radiotherapy in 32 patients (29.0%). The expression of EGFR, matrix metalloproteinases 2 and 9, and vascular endothelial growth factor was analyzed with a tissue microarray immunohistochemical technique. Main Outcome Measures: Overall survival and cancer-specific survival (CSS). Results: The recurrences were diagnosed in less than 1 year in 69 patients (62.2%) and in more than 1 year in 42 patients (37.8%). The prognosis was worse in the group with the disease-free interval of less than 1 year (P=.01). Patients with more advanced disease (clinical stage of recurrence, III/IV) had worse rates of CSS (P=.04). Cases that were positive for EGFR had a 3-year CSS of 27.2%, while EGFR-negative cases had a 3-year CSS of 64.3% (P=.001). The expression of matrix metalloproteinases 2 (P=.83) and 9 (P=.15) and vascular endothelial growth factor (P=.86) was not significant in this group. In multivariate analysis, only the disease-free interval and the overexpression of EGFR were associated with a higher risk of cancer death. Conclusions: Local recurrence in oral carcinomas carries a poor prognosis. A disease-free interval of more than 1 year and a EGFR-negative expression are the main prognostic factors related to better CSS in patients treated with salvage surgery.

Quantitative parameters of facial motor evoked potential during vestibular schwannoma surgery predict postoperative facial nerve function

Background Facial motor evoked potential (FMEP) amplitude ratio reduction at the end of the surgery has been identified as a good predictor for postoperative facial nerve outcome. We sought to investigate variations in FMEP amplitude and waveform morphology during vestibular schwannoma (VS) resection and to correlate these measures with postoperative facial function immediately after surgery and at the last follow-up. Methods Intraoperative orbicularis oculi and oris muscles FMEP data from 35 patients undergoing surgery for VS resection were collected, then analysed by surgical stage: initial, dural opening, tumour dissection (TuDis), tumour resection (TuRes) and final. Findings Immediately after surgery, postoperative facial function correlated significantly with the FMEP amplitude ratio during TuDis, TuRes and final stages in both the orbicularis oculi (p = 0.003, 0.055 and 0.028, respectively) and oris muscles (p = 0.002, 0.104 and 0.014, respectively). At the last follow-up, however, facial function correlated significantly with the FMEP amplitude ratio only during the TuDis (p = 0.005) and final (p = 0.102) stages for the orbicularis oris muscle. At both time points, postoperative facial paresis correlated significantly with FMEP waveform deterioration in orbicularis oculi during the final stage (immediate, p = 0.023; follow-up, p = 0.116) and in orbicularis oris during the TuDis, TuRes and final stages (immediate, p = 0.071, 0.000 and 0.001, respectively; follow-up, p = 0.015, 0.001 and 0.01, respectively). Conclusions FMEP amplitude ratio and waveform morphology during VS resection seem to represent independent quantitative parameters that can be used to predict postoperative facial function. Event-to-baseline FMEP monitoring is quite useful to dictate when intraoperative changes in surgical strategy are warranted to reduce the chances of facial nerve injury.

Quality of life before surgery is a predictive factor for satisfaction among patients undergoing sympathectomy to treat hyperhidrosis

Purpose: The objective of this study was to evaluate the postoperative quality of life (QOL) experienced among a group of 1167 patients who underwent video-assisted thoracoscopic sympathectomy (VATS) to treat primary hyperhidrosis, as compared with the presurgical QOL. Methods: Between February 2002 and June 2007, 1167 patients who had undergone VATS were surveyed. The majority had presented with palmar hyperhidrosis (794 patients; 68%), while 340 (29%) had presented with axillary hyperhidrosis. Based on data obtained from the QOL protocol applied to all of the patients preoperatively, the patients were divided into two groups according to the level of their QOL: group 1 consisted of 312 patients (27%) with poor QOL and group 2 of 855 patients (73%) with very poor QOL. The same protocol was applied postoperatively, and five different levels of satisfaction were obtained. The same parameters were evaluated for both the palmar and the axillary hyperhidrosis subgroups. Results: The patients with very poor QOL had much better results in terms of improvement in QOL than did those with poor QOL ( P < .05). The same result was observed for both the palmar and. axillary hyperhidrosis subgroups (P < .05). Conclusion: The worse the preoperative QOL among patients undergoing sympathectomy to treat primary hyperhidrosis is, the better the postoperative improvement in QOL will be. (J Vase Surg 2010;51:1190-4.)

Change in blood flow velocity demonstrated by Doppler ultrasound in upper limb after axillary dissection surgery for the treatment of breast cancer

The aim of this study was to evaluate the arterial and venous blood flow in women who underwent upper limb axillary dissection surgery for the treatment of breast cancer. Sixty women were divided into two groups: group 1 (G1)-30 women who underwent breast surgery with axillary dissection level II or III (55.6 +/- A 8.6 years); group 2 (G2)-control, 30 women with no breast cancer (57.4 +/- A 7.0 years). Blood flow profile was evaluated by a continuous wave ultrasound Doppler device (Nicolet Vascular Versalab SE(A (R))) with an 8 MHz probe. Axillary, brachial arteries and veins, arm circumference, volumes, and the ankle-brachial index (ABI) were examined. Wilcoxon test and Mann-Whitney tests were applied to analyze blood flow velocity intra-group and between G1 and G2, respectively. The G1 results showed no lymphedema and no peripheral arterial disease (ABI > 0.9). Moreover, the mean blood flow velocity of the vessels ipsilateral to the surgery was significantly higher than the contralateral ones for all vessels examined (P < 0.05). The mean velocity of blood flow of the vessels contralateral to surgery was significantly higher than the axillary artery in G2 (P < 0.05). It can be concluded that women who underwent axillary dissection due to breast cancer showed probable stenosis in the arterial and venous axillary and brachial vessels of the upper limb ipsilateral to the surgery, confirmed by the increase of blood flow velocity, and such obstruction might affect the limb contralateral to the operation site.

Pediatric epilepsy surgery and sudden unexpected death epilepsy: the contribution of a Brazilian epilepsy surgery program

Individuals with epilepsy are at higher risk of death than those from the general population, and sudden unexpected death in epilepsy (SUDEP) is the most important direct epilepsy-related cause of death. Epilepsies in the pediatric group are more frequently associated with known potentially risk factors for SUDEP, and a treatment resulting in an improved seizure control may also decrease mortality. The aim of this study is to identify the incidence of SUDEP in a group of operated-on children and adolescents. We analyzed 267 patients up to 18 years old, with medically intractable epilepsy submitted to surgery. We considered the age at surgery, the seizure type, the pathological findings, and the seizure outcome. Data were prospectively collected, according to the protocols of our institution`s ethics committee. The percentage of boys was 58.05. A good outcome was achieved in 72.6% of the cases and a bad outcome in 27.4%. Nine patients died during follow-up, six from clinical complications, and one from SUDEP. All patients who died during the long-term follow-up had persisted with refractory postoperative seizures. The patient who died from SUDEP died during a generalized tonic-clonic seizure. Of the patients, 72.6% had excellent postoperative outcome, and one patient died of SUDEP. All patients who died had had disabling seizures` persistence. The surgical treatment of epilepsy in children and adolescents is an efficient therapy for the medically intractable symptomatic epilepsies and also for the reduction of mortality and SUDEP risks.

Nutritional Course of Patients Submitted to Bariatric Surgery

Background Surgical treatment has proved to be effective for weight loss, improving the quality of life of obese individuals. However, metabolic and nutritional deficiencies may occur during the late postoperative period. The objective of the present study was to assess the metabolic and nutritional profile of grade III obese individuals for 12 months after Roux-en-Y gastric bypass (RYGBP). Methods Forty-eight patients with mean body mass index (BMI) of 51.9 +/- 7.8 kg/m(2) were submitted to RYGBP. Anthropometric, food intake, and biochemical data were obtained before and for 12 months after surgery. Results There was an average weight and body fat reduction of 35% and 46%, respectively. Calorie intake was reduced, ranging from 773 +/- 206 to 1035 +/- 345 kcal during the study. Protein intake remained below recommended values throughout follow-up, corresponding to 0.5 +/- 0.3 g/kg/current body weight/day during the 12th month. Iron and fiber intake was significantly reduced, remaining below recommended levels throughout the study. Serum cholesterol, low-density lipoprotein cholesterol, and glycemia were reduced. Albumin deficiency was present in 15.6% of subjects at the beginning of the study vs 8.9% at the end, calcium deficiency was present in 3.4% vs 16.7%, and iron deficiency was present in 12.2% vs 14.6%. Conclusions RYGBP was effective for weight loss and for the reduction of obesity rates and risk factors for comorbidities. The diet of these patients, who frequently present inadequate intake of macronutrients and micronutrients, should receive special attention. Patient follow-up and assessment at short intervals are necessary for an early correction of nutritional deficiencies.