Submucous myomas: A new presurgical classification to evaluate the viability of hysteroscopic surgical treatment - Preliminary report

STUDY OBJECTIVE: To develop a new preoperative classification of submucous myomas for evaluating the viability and the degree of difficulty of hysteroscopic myomectomy.DESIGN: Retrospective study (Canadian Task Force classification II-3)SETTING: University teaching hospitals.PATIENTS: Fifty-five patients who underwent hysteroscopic resection of submucous myomas.INTERVENTION: the possibility of total resection of the myoma, the operating time, the fluid deficit, and the frequency of any complications were considered. The myomas were classified according to the Classification of the European Society for Gynaecological Endoscopy (ESGE) and by our group's new classification (NC), which considers not only the degree of penetration of the myoma into the myometrium, but also adds in such parameters as the distance of the base of the myoma from the uterine wall, the size of the nodule (cm), and the topography of the uterine cavity. The Fisher's exact test, the Student's t test, and the analysis of variance test were used in the statistical analysis. A p value less than .05 in the two-tailed test was considered significant.MEASUREMENTS AND MAIN RESULTS: In 57 myomas, hysteroscopic surgery was considered complete. There was no significant difference among the three ESGE levels (0, 1, and 2). Using the NC, the difference between the numbers of complete surgeries was significant (p < .001) for the two levels (groups I and H). The difference between the operating times was significant for the two classifications. With respect to the fluid deficit, only the NC showed significant differences between the levels (p = .02).CONCLUSIONS: We believe that the NC gives more clues as to the difficulties of a hysteroscopic myomectomy than the standard ESGE classification. It should be stressed that the number of hysteroscopic myomectomies used in this analysis was low, and it would be interesting to evaluate the performance of the classification in a larger number of patients. (c) 2005 AAGL. All rights reserved.

Endovascular treatment of pseudoaneurysm of the thoracic aorta from a firearm injury

A 24-year-old male patient was the victim of a firearm wound that penetrated the thorax. He arrived at another hospital hemodynamically unstable and was submitted to exploratory surgery by means of bithoracotomy. A lesion of the left branch of the pulmonary artery was detected and successfully repaired. He was submitted for computer-aided tomography on the fifth postoperative day, and a lesion of the mid-thoracic aorta was detected, which formed a saccular image. Considering that the patient had already been submitted to a bithoracotomy and that a direct approach to repair would involve another thoracotomy within a short period of time, endovascular treatment was chosen in our hospital. The procedure was performed under fluoroscopy. A second computer-aided tomography indicated adequate treatment of the lesion, with no indication of an endoleak. He has undergone ambulatory follow-up for 36 months without any problem related to the procedure. While endovascular treatment of the aorta has developed enormously, multicenter studies are needed to better define the long-term results of this approach. © 2008 Published by European Association for Cardio-Thoracic Surgery. All rights reserved.

Can repair increase the longevity of composite resins? Results of a 10-year clinical trial

The aim of this double-blind clinical trial was to assess the longevity of repairs to localized clinical defects in composite resin restorations that were initially planned to be treated with a restoration replacement. Methods Twenty-eight patients aged 18–80 years old with 50 composite resin restorations (CR) were recruited. The restorations with localized, marginal, anatomical deficiencies and/or secondary caries adjacent to CR that were “clinically judged” to be suitable for repair or replacement according to the USPHS criteria were randomly assigned to Repair (n = 25) or Replacement (n = 25) groups, and the quality of the restorations was scored according to the modified USPHS criteria. The restorations were blind and two examiners scored them at baseline (Cohen Kappa agreement score 0.74) and at ten years (Cohen Kappa agreement score 0.87) restorations. Wilcoxon tests were performed for comparisons within the same group (95% CI), and Friedman tests were utilized for multiple comparisons between the different years within each group. Results Over the decade, the two groups behaved similarly on the parameters of marginal adaptation (MA) (p > 0.05), secondary caries (SC) (p > 0.05), anatomy (A) (p < 0.05), and colour (C) (p > 0.05). Conclusions Given that the MA, SC, A and C parameters behaved similarly in both groups, the repair of composite resins should be elected when clinically indicated, because it is a minimally invasive treatment that can consistently increase the longevity of restorations. Clinical significance The repair of defective composite resins as an alternative treatment to increase their longevity proved to be a safe and effective treatment in the long term.

Surgical time and complications of total transvaginal (total-NOTES), single-port laparoscopic-assisted and conventional ovariohysterectomy in bitches

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Intervenções cirúrgicas para o tratamento do pectus excavatum: revisão sistemática

Pós-graduação em Bases Gerais da Cirurgia - FMB

Cirurgia aórtica totalmente laparoscópica para tratamento de isquemia crítica de membros: relato do primeiro caso no Brasil

A cirurgia videolaparoscópica (CVL) vem evoluindo como alternativa cirúrgica menos invasiva para o tratamento da doença aterosclerótica oclusiva aortoilíaca. O objetivo deste relato de caso foi demonstrar os resultados da primeira cirurgia aórtica totalmente laparoscópica relatada no Brasil para o tratamento da doença oclusiva aortoilíaca em paciente com isquemia crítica. Os tempos cirúrgicos totais de dissecção e exposição da aorta antes do clampeamento, exposição retroperitoneal da aorta, clampeamento total e da anastomose proximal com técnica totalmente laparoscópica foram de 220 minutos, 15 e 27 minutos, 42 minutos, 110 minutos e 78 minutos, respectivamente. A técnica videolaparoscópica é mais uma ferramenta minimamente invasiva, viável, segura e eficaz para o tratamento da doença oclusiva aortoilíaca extensa. Ela, que nada mais é do que a cirurgia convencional realizada sob visão laparoscópica, tem bons resultados a longo prazo, que se associam à elegância técnica.

Obtenção minimamente invasiva de veia safena para cirurgia de revascularização do miocárdio

OBJETIVO: Analisar, comparativamente, a obtenção minimamente invasiva com o uso do MINI-HARVEST® e com instrumental tradicional adaptado. MÉTODO: de junho de 1996 a janeiro de 1999, 63 pacientes submetidos à cirurgia de revascularização do miocárdio tiveram suas veias safenas retiradas segundo técnica minimamente invasiva. Nos 30 primeiros pacientes da série utilizou-se método de visão direta com auxílio de dois afastadores de Langenbeck, e nos 33 restantes utilizou-se o MINI-HARVEST®. RESULTADOS: A idade média dos pacientes era de 61 ± 8,75 anos, sendo 52 homens e 11 mulheres. Quarenta e cinco pacientes eram diabéticos, 45 apresentavam sobrepeso/obesidade, 25 eram tabagistas ativos, 32 apresentavam história pregressa de infarto do miocárdio. O tempo médio de retirada da veia safena com afastadores Langenbeck foi de 34,2 ± 8,14 minutos e com o MINI-HARVEST® de 39,20 ± 9,12 minutos. A extensão de veia retirada foi similar nos dois grupos, variando de 10 a 30 cm. Houve uma deiscência superficial no grupo com afastadores de Langenbeck. Houve necessidade de reversão para método tradicional de retirada em dois casos do grupo MINI-HARVEST® e um do grupo Langenbeck. A incidência de infarto transoperatório foi 4,5% (três) no grupo Langenbeck e 3,1%(dois) no grupo MINI-HARVEST®. CONCLUSÕES: Podemos concluir que o método de obtenção de veia safena minimamente invasivo sob visão direta é efetivo e seguro, tanto com o uso de instrumentos tradicionais adaptados para este fim, como com afastadores especialmente constituídos, ressaltando-se que o MINI-HARVEST® dispensa a presença de um auxiliar.

Cirurgia aorto-ilíaca videolaparoscópica para tratamento de isquemia crítica de membros: relato do primeiro caso no Brasil

A cirurgia videolaparoscópica vem evoluindo como alternativa cirúrgica menos invasiva para o tratamento da doença aterosclerótica oclusiva aorto-ilíaca. O objetivo deste relato é demonstrar os resultados da primeira cirurgia videolaparoscópica realizada no Brasil para o tratamento da doença oclusiva aorto-ilíaca, associada a procedimentos híbridos distais para lesões ateroscleróticas multissegmentares em paciente com isquemia crítica. A técnica videolaparoscópica é mais uma ferramenta minimamente invasiva, viável, segura e eficaz para o tratamento da doença oclusiva aorto-ilíaca extensa. A referida técnica, que nada mais é do que a cirurgia convencional realizada sob visão laparoscópica, tem bons resultados a longo prazo, associados à elegância técnica.

Pure-transvaginal natural orifice transluminal endoscopic surgery (NOTES) ovariohysterectomy in bitches: a preliminary feasibility study

Cirurgia endoscópica por orifícios naturais (NOTES) constitui um acesso cirúrgico relativamente novo para abordagem minimamente invasiva, a qual vem sendo amplamente estudada na medicina humana. Porém, poucos estudos envolvendo sua aplicação na prática cirúrgica de pequenos animais foram realizados até o momento. O objetivo do presente estudo foi avaliar a factibilidade da ovário-histerectomia transvaginal por NOTES pura em cadelas. Cinco cadelas foram avaliadas. A cavidade abdominal foi acessada por um trocarte de 11mm introduzido por uma incisão vaginal. Empregando-se um endoscópio rígido com canal de trabalho, os pedículos ovarianos foram coagulados e seccionados usando-se diatermia bipolar. O corno uterino foi tracionado para o interior do trocarte e exteriorizado juntamente com a cânula. O corpo e vasos uterinos foram coagulados ou ligados com sutura. O coto uterino foi reposicionado na cavidade abdominal e o pneumoperitônio, drenado. O procedimento foi realizado com sucesso em quatro das cinco cadelas. Na primeira tentativa, houve conversão para uma técnica de NOTES-híbrida, devido à quebra de uma pinça de coagulação. O tempo cirúrgico médio foi 52,1 (DP±11,5 minutos) para a técnica de NOTES pura. A OHE por NOTES pura é factível em cadelas, sem resultar em complicações maiores e proporcionando excelente recuperação pós-operatória.

Laparoscopic evaluation and treatment of the impalpable testis

Objectives: To evaluate the laparoscopic technique as a diagnostic and therapeutic tool in the management of patients with impalpable testis. Material and Methods: Fifty-nine patients with mean age of 6.3 years underwent laparoscopy to evaluate 85 impalpable testes that were classified as absent, canalicular and intra-abdominal. In the case of testicular absence, the procedure was terminated. In the case of canalicular testis, open inguinal exploration was performed. In intra-abdominal testis, either laparoscopic orchiopexy or orchiectomy was performed. According to the length of the vascular pedicle, orchipexy was performed either with or without vascular ligature. Post-operatively, the treated testes were evaluated according to size and location in the scrotum. Results: Seventeen (20%) of the 85 impalpable testes were diagnosed as absent, 21 (24.7%) as canalicular and 47 (55.3%) as intra-abdominal. Of the canalicular testes, 20 were explored by inguinotomy and one by laparoscopy. All the intra-abdominal testes were treated initially by laparoscopy, four being removed due to atrophy, 31 submitted to vascular ligature and 12 to primary orchipexy. Of those submitted to vascular ligature, 22 underwent a second stage orchipexy, of which 18 laparoscopically and 4 by inguinotomy. Of the 18 testes brought to the scrotum by staged laparoscopic orchipexy, 15 (83.3%) presented normal characteristics in the late follow-up, while of the 12 submitted to primary laparoscopic orchipexy, 8 (66.6%) were normal. There were no perioperative or late complications. Conclusions: Laparoscopy is a minimally invasive procedure with low morbidity that enables precise diagnosis of the impalpable testes. When intra-abdominal testes are found, either immediate laparoscopic orchiectomy, or primary and staged orchipexy are possible, with results equivalent to open procedures, with the advantage of smaller surgical incisions and shorter postoperative recovery.

Comparative Analysis of 2 Techniques of Double-Gloving Protection During Arch Bar Placement for Intermaxillary Fixation

Purpose: This study was conducted to comparatively evaluate, in a prospective and randomized manner, 2 techniques for providing double-gloving protection during arch bar placement for intermaxillary fixation. Materials and Methods: A total of 42 consecutive patients in whom application of an Erich bar was indicated for intermaxillary fixation were equally divided into 2 groups. In group 1, 2 sterile surgical gloves were used; in group 2, a nonsterile disposable inner glove was used under a sterile surgical glove. Wilcoxon, Mann-Whitney, Kruskal-Wallis, and binomial statistical tests were used to analyze the findings. Results: A total of 103 perforations were found in the outer gloves (47 in group 1 and 56 in group 2), along with 5 perforations in inner gloves in both groups (α = .01). No significant statistical difference was found between groups in terms of inner glove perforations (α = .05). The nondominant hand presented with 70.9% of the perforations, statistically significant to 1%. Conclusions: Both double-gloving techniques were found to provide effective clinician protection. The use of a nonsterile disposable glove under the surgical glove is possible for less-invasive procedures, offering the same safety as using 2 sterile surgical gloves while decreasing operational costs. This method does not eliminate the need to change gloves when a perforation is suspected or noted during the surgery, however. © 2007 American Association of Oral and Maxillofacial Surgeons.

Results of open pararenal abdominal aortic aneurysm repair: Tabular review of the literature

Open surgical repair of complex abdominal aortic aneurysms requires more extensive dissection and aortic clamping above the renal or mesenteric arteries. Although results of open surgical series have shown variation, morbidity and mortality is higher compared with infrarenal aortic aneurysm repair. Potential complications include renal insufficiency, mesenteric ischemia, multisystem organ failure, and death. Although endovascular treatment with fenestrated and branched endografts might potentially decrease the risk of complications and mortality, its role is not yet defined and the technology is not widely available. Issues related to durability of the procedure and secondary interventions might limit its application to patients with higher risk or those with hostile anatomy. This article summarizes the clinical results of open surgical repair of pararenal abdominal aortic aneurysms to provide a benchmark for comparison with results of endovascular treatment, using fenestrated and branched techniques. © Annals of Vascular Surgery Inc.

Repair bond strength of microhybrid, nanohybrid and nanofilled resin composites: Effect of substrate resin type, surface conditioning and ageing

Objectives: This study evaluated the microtensile bond strength (MTBS) of non-aged and aged resin-based composites (RBC) (nanohybrid and nanofilled) after two surface conditioning methods, repaired using the composite of the same kind or a microhybrid composite. Materials and methods: Nanohybrid (Tetric EvoCeram-TE) and nanofilled (Filtek Supreme-FS) RBC blocks (5 × 5 × 6 mm) (N = 128) were fabricated and randomly divided into two groups: (a) no ageing (control group) and (b) ageing (5.000 thermocycling, 5-55 °C). RBC surfaces were polished by up to 1,200-grit silicone carbide papers and conditioned with either (a) air abrasion with 30-μm SiO2 particles (CoJet Sand) for 4 s + silane coupling agent (ESPE-Sil) + adhesive resin (VisioBond) (n = 16) or (b) adhesive application only (Multilink A+B for TE; Adper ScotchBond 1XT for FS) (n = 16). In half of the groups, repair resin of the same kind with the RBC and, in the other half, a different kind of composite (microhybrid, Quadrant Anterior Shine-AS) with its corresponding adhesive (Quadrant UniBond) was used. The specimens were submitted to MTBS test (0.5 mm/min). Data were analysed using three-way ANOVA and Tukey's tests. Degree of conversion (DC) of non-aged and aged resin composites (TE, FS) (n = 3 per group) was measured by micro-Raman analyses. Results: RBC type (p = 0.001) and ageing affected the MTBS results significantly (p = 0.001). Surface conditioning type did not show significant difference (p = 0.726), but less number of pre-test failures was experienced with the CoJet system compared to adhesive resin application only. Repair strength on aged TE showed significantly less (p < 0.05) MTBS than for FS. FS repaired with the same kind of RBC and adhesive resin presented the highest cohesive failures (43 %). DC was higher for TE (71 %) than for FS (58 %) before ageing. Conclusion: On the aged RBCs, less favourable repair strength could be expected especially for nanohybrid composite. For repair actions, RBC surface conditioning could be accomplished with either adhesive resin application only or with CoJet system, providing that the latter resulted in less pre-test failures. Clinical relevance: Clinicians could condition the resin surface prior to repair or relayering with either CoJet system or adhesive resin application only, depending on the availability of the system. © 2012 Springer-Verlag Berlin Heidelberg.

Comparison of inflammatory cytokine profiles in plasma of patients undergoing otorhinological surgery with propofol or isoflurane anesthesia

Objective and design: The effects of anesthetics on cytokine release in patients without comorbidities who undergo minor surgery are not well defined. We compared inflammatory cytokine profiles in adult patients undergoing minimally invasive surgery who received isoflurane or propofol anesthesia. Methods: Thirty-four patients without comorbidities undergoing minor surgery were randomly assigned to receive an inhaled anesthetic (isoflurane; n = 16) or an intravenous anesthetic (propofol; n = 18). Blood samples were drawn before premedication and anesthesia (T1), 120 min after anesthesia induction (T2), and on the first post-operative day (T3). Plasma concentrations of interleukins (IL-) 1β, 6, 8, 10 and 12 and tumor necrosis factor (TNF)-α were measured using flow cytometry. Results: The pro-inflammatory cytokine IL-6 was increased in the isoflurane group at T2 and T3 compared to T1 (P < 0.01). In the propofol group, IL-6 and IL-8 were significantly increased at T3 compared to T1. However, there were no significant differences in cytokine concentrations between the isoflurane and propofol groups. Conclusion: An inflammatory response occurred earlier in patients who received an inhaled agent compared with an intravenous anesthetic, but no differences in plasma cytokine profiles were evident between isoflurane and propofol anesthesia in patients without comorbidities undergoing minimally invasive surgeries. © 2013 Springer Basel.

Estudo das alterações funcionais respiratórias em pacientes submetidos à colecistectomia videolaparoscópica

Pós-graduação em Bases Gerais da Cirurgia - FMB