Effects of circular myotomy on the healing of esophageal suture anastomosis: an experimental study

For esophageal reconstruction in newborns with esophageal atresia, esophageal reunion with an end-to-end anastomosis is the ideal procedure, although it may result in leaks and strictures due to tension on the suture line, mainly in cases with a wide gap between the ends. Circular myotomy (Livaditis' procedure) is the best method to elongate the proximal esophageal pouch and reduce anastomotic tension. This experimental investigation in dogs was undertaken to attempt to verify that circular myotomy decreases the anastomotic leak rate in newborns with wide gap esophageal atresia, and to analyze whether the technique promotes morphologic changes in the anastomotic scar. A pilot study demonstrated that it is necessary to resect more than 8 cm (40% of the total esophageal length) in order to obtain high leak rates. In the experimental project, such resection was performed in dogs divided into two groups (control group, anastomosis only, and experimental group, anastomosis plus circular myotomy in the proximal esophageal segment). The animals were killed in the 14th postoperative day, submitted to autopsy, and were evaluated as to the presence of leaks and strictures, as well as to the features (macroscopic and microscopic aspects) of the anastomosis. Leak rates were the same in both groups. Morphometric analysis revealed that in animals in the experimental group, the anastomotic scar was thinner than the control animals, and the isolated muscular manchette distal to the site of myotomy was replaced by fibrous tissue. Correspondingly, a decreased number of newly formed small vessels were noted in the experimental animals, compared to control animals. We concluded that circular myotomy does not decrease the incidence of anastomotic leaks, and it also promotes deleterious changes in anastomotic healing.

Size of gastroesophageal varices: its behavior after the surgical treatment of portal hypertension

The size of gastroesophageal varices is one of the most important factors leading to hemorrhage related to portal hypertension. An endoscopic evaluation of the size of gastroesophageal varices before and after different operations for portal hypertension was performed in 73 patients with schistosomiasis, as part of a randomized trial: proximal splenorenal shunt (PSS n=24), distal splenorenal shunt (DSS n=24), and esophagogastric devascularization with splenectomy (EGDS n=25). The endoscopic evaluation was performed before and up to 10 years after the operations. Variceal size was graded according to Palmer's classification: grade 1 -- up to 3 mm, grade 2 -- from 3 to 6 mm, grade 3 -- greater than 6 mm, and were analyzed in four anatomical locations: inferior, middle or superior third of the esophagus, and proximal stomach. The total number of points in the pre-operative grading minus the number of points in the post-operative grading gave a differential grading, allowing statistical comparison among the surgical groups. Good results, in terms of disappearance or decrease of variceal size, were observed more frequently after PSS than after DSS or EGDS - 95.8%, 83.3%, and 72%, respectively. When differential grading was analyzed, a statistically significant difference was observed between PSS and EGDS, but not between proximal and distal splenorenal shunts. In conclusion, shunt surgeries were more efficient than devascularization in diminishing variceal size.

The use of bone bridges in transtibial amputations

We sought to describe the bone bridge technique in adults, and present a variation for use in children, as well as to present its applicability as an option in elective transtibial amputations. This paper presents a prospective study of 15 transtibial amputations performed between 1992 and 1995 in which the bone bridge technique was employed. The patients' ages ranged from 8 to 48 years, with an average of 22.5 years. This technique consisted of the preparation of a cylinder of periosteum extracted from the tibia and with cortical bone fragments attached to it to promote a tibiofibular synostosis on the distal extremity of the amputation stump. We noted that the cortical bone fragments were dispensable when the technique was employed in children, due to the increased osteogenic capacity of the periosteum. This led to a variation of the original technique, a bone bridge without the use of the cortical bone fragments. RESULTS: The average time spent with this procedure, without any significant variation between adults and children, was 171 minutes. The adaptation to the definitive prosthesis was accomplished between 20 and 576 days, with an average of 180 days. Revision of the procedure was necessary in 3 amputations. CONCLUSIONS: This technique may be employed in transtibial amputations in which the final length of the stump lies next to the musculotendinous transition of the gastrocnemius muscle, as well as in the revision of amputation stumps in children, where the procedure has been shown to be effective in the prevention of lesions due to excessive bone growth.

The use of stents in the treatment of traumatic intimal flaps: case report

Treatment of arterial traumatic intimal lesions is controversial due to its unknown natural history. Current therapeutical options include arterial reconstruction and clinical observation. The idea of using stents to correct intimal flaps is based on their use to correct dissections, flaps, and arterial irregularities after angioplasty. We report the successful treatment of a traumatic intimal flap of the superficial femoral artery, caused by gunshot trauma, with a Palmaz stent in the acute period. One year after the operation, a duplex scan revealed normal flow in the artery and complete exclusion of the intimal flap; distal pulses were palpable, and the patient was completely asymptomatic.

Pelvic lymphoscintigraphy: contribution to the preoperative staging of rectal cancer

PURPOSE: Preservation of the anal sphincter in surgery for cancer of the distal rectum in an attempt to avoid colostomy has been a main concern of colorectal surgeons. Various proposed procedures contradict oncological principles, especially with respect to pelvic lymphadenectomy. Therefore, prior knowledge of pelvic lymph node involvement is an important factor in choosing the operative technique, i.e., radical or conservative resection. Introduction of ultrasound, computerized tomography, and magnetic resonance have made preoperative study of the area possible. Nevertheless, these resources offer information of an anatomical nature only. Lymphoscintigraphy enables the morphological and functional evaluation of the pelvic area and contributes toward complementing the data obtained with the other imaging techniques. The objective of this prospective study is twofold: to standardize the lymphoscintigraphy technique and to use it to differentiate patients with rectal cancer from those with other coloproctologic diseases. CASUISTIC AND METHODS: Sixty patients with various coloproctologic diseases were studied prospectively. Ages ranged from 21 to 96 years (average, 51 and median, 55 years). Twenty-six patients were male and 34 were female. Thirty patients had carcinoma of the distal rectum as diagnosed by proctologic and anatomic-pathologic examinations, 20 patients had hemorrhoids, 5 had chagasic megacolon, 2 had diverticular disease, 2 had neoplasm of the right colon, and 1 had ulcerative colitis as diagnosed by proctologic exam and/or enema. The lymphoscintigraphy method consisted of injecting 0.25 mL of a dextran solution marked with radioactive technetium-99m into the right and left sides of the perianal region and obtaining images with a gamma camera. The results were analyzed statistically with a confidence level of 95% (P < .05) using the following statistical techniques: arithmetic and medium average, Fisher exact test, chi-square test corrected for continuity according to Yates, and distribution tables for the number of patients. RESULTS: In rectal cancer, the tracer progresses unilaterally or is absent; in other patients, the progress of the tracer is bilateral and symmetrical, although its progress may be slow. Statistical tests showed with high significance that the agreement index between the clinical diagnosis and the result of the lymphoscintigraphic exam was 93%. CONCLUSIONS: Lymphoscintigraphy is a standardized, painless, and harmless test that can be performed in all cases; it differentiates patients with rectal cancer from those with other coloproctological diseases.

Appraisal of surgical treatment of 47 cases of patellofemoral instability

INTRODUCTION: Patellofemoral instability is a common knee disease. Its etiology is complex and variable, with many components making different contributions in each individual, resulting in several distinct clinical presentations. Our goal was to analyze the results of surgical treatment in our hospital over a period of 10 years. PATIENTS AND METHODS: We analyzed 55 knees of 47 patients who underwent surgery for patellofemoral instability and were classified into 2 main groups: proximal realignment and combined proximal and distal realignment. Three other groups were analyzed according to the duration of preoperative symptoms: less than 1 year (group I); 1 to 10 years (group II); and more than 10 years (group III). RESULTS: There were 62% good results overall, with 78% good results in groups I and II. Group III had 81% bad results, showing that a late diagnosis of advanced disease results in a poor prognosis. In addition to late diagnosis, bad results were usually associated with incorrect diagnosis or choice of surgical technique. There was no significant difference between isolated proximal realignment and combined proximal and distal realignment in groups I or II, but in group III, the combined technique yielded better results. DISCUSSION: Our results indicate that patellofemoral instability should be addressed in its early stages. Patients with long-lasting symptoms or more severe disease seem to achieve better results with combined techniques. CONCLUSION: Proximal and distal realignments produce better results than isolated proximal realignment in patients with joint degeneration or with greater duration of disease. The realignment surgery does not produce good results in patients with advanced disease.

Conventional approach x laparoscopic abdominoperineal resection for rectal cancer treatment after neoadjuvant chemoradiation: results of a prospective randomized trial

OBJECTIVE: The aims of this study were to evaluate the safety and efficacy of laparoscopic abdominoperineal resection compared to conventional approach for surgical treatment of patients with distal rectal cancer presenting with incomplete response after chemoradiation. METHOD: Twenty eight patients with distal rectal adenocarcinoma were randomized to undergo surgical treatment by laparoscopic abdominoperineal resection or conventional approach and evaluated prospectively. Thirteen underwent laparoscopic abdominoperineal resection and 15 conventional approach. RESULTS: There was no significant difference (p<0,05) between the two studied groups regarding: gender, age, body mass index, patients with previous abdominal surgeries, intra and post operative complications, need for blood transfusion, hospital stay after surgery, length of resected segment and pathological staging. Mean operation time was 228 minutes for the laparoscopic abdominoperineal resection versus 284 minutes for the conventional approach (p=0.04). Mean anesthesia duration was shorter (p=0.03) for laparoscopic abdominoperineal resection when compared to conventional approach : 304 and 362 minutes, respectively. There was no need for conversion to open approach in this series. After a mean follow-up of 47.2 months and with the exclusion of two patients in the conventional abdominoperineal resection who presented with unsuspected synchronic metastasis during surgery, local recurrence was observed in two patients in the conventional group and in none in the laparoscopic group. CONCLUSIONS: We conclude that laparoscopic abdominoperineal resection is feasible, similar to conventional approach concerning surgery duration, intra operative morbidity, blood requirements and post operative morbidity. Larger number of cases and an extended follow-up are required to adequate evaluation of oncological results for patients undergoing laparoscopic abdominoperineal resection after chemoradiation for radical treatment of distal rectal cancer.

Anatomic study of the dorsal arterial system of the hand

Historically, the dorsal arterial system of the hand received less attention than the palmar system. The studies concerning dorsal arterial anatomy present some controversies regarding the origin and presence of the dorsal metacarpal artery branches. Knowledge of the anatomy of dorsal metacarpal arteries is especially applied in the surgical planning for flaps taken from the dorsum of the hand. The purpose of this study is to analyze the arterial anatomy of the dorsum of the hand, compare our observations with those of previous studies from the literature, and therefore to define parameters for surgical planning for flaps supplied by the dorsal metacarpal arteries. METHOD: Twenty-six dissections were performed at the dorsum of the right hand of 26 cadavers by making a distal-based U-shaped incision. After catheterization of the radial artery at the wrist level, a plastic dye solution with low viscosity and quick solidification was injected to allow adequate exposure of even small vessels. The radial artery and its branches, the dorsal arterial arch, the dorsal metacarpal arteries, the distal and proximal communicating branches of the palmar system, and the distal cutaneous branches were carefully dissected and identified. RESULTS: The distal cutaneous branches originating from the dorsal metacarpal arteries were observed in all cases; these were located an average of 1.2 cm proximal from the metacarpophalangeal joint. The first dorsal metacarpal artery presented in 3 different patterns regarding its course: fascial, subfascial, and mixed. The branching pattern of the radial artery at the first intermetacarpal space was its division into 3 branches. We observed the presence of the dorsal arterial arch arising from the radial artery in 100% of the cases. The distance between the dorsal arterial arch and the branching point of the radial artery was an average of 2 cm. The first and second dorsal metacarpal arteries were visualized in all cases. The third and fourth dorsal metacarpal arteries were visualized in 96.2% and 92.3% of cases, respectively. There was proximal and distal communication between the dorsal arterial arch and the palmar system through the communicating branches contributing to the dorsal metacarpal artery formation. CONCLUSION: At the dorsum of the hand there is a rich arterial net that anastomoses with the palmar arterial system. This anatomical characteristic allows the utilization of the dorsal aspect of the hand as potential donor site for cutaneous flaps.

Microsatellite instability in solitary and sporadic gastric cancer

Recently, the presence of microsatellite instability (MSI) has been reported in gastric cancer and associated with older age of presentation, distal tumor location, early disease staging, and better overall prognosis. Different characteristics in presentation and in tumor behavior may be explained by different genetic alterations during carcinogenesis of gastric cancer. Identification of specific genetic pathways in gastric cancer may have direct impact on prognosis and selection of treatment strategies. PATIENTS AND METHODS: All 24 patients were treated by radical surgery. Fragments of normal and tumor tissues were extracted from the specimen and stored at -80ºC before DNA purification and extraction. PCR amplification utilizing microsatellite markers was performed. Tumors presenting PCR products of abnormal sizes were considered positive for microsatellite instability (MSI+). RESULTS: Five patients (21%) had tumors that were MSI+ in at least 1 marker. In the group of patients with Lauren's intestinal-type gastric carcinoma, 3 had tumors that were MSI+ (23%), while in the group of diffuse-type gastric cancer, 2 patients had tumors that were MSI+ (19%). The mean age of presentation and the male:female ratio was similar in both groups. Tumors that were MSI+ were more frequently located in proximal portion of the stomach compared to microsatellite-stable (MSS) tumors (40% vs. 16%). Although there was a trend of patients with MSI+ tumors towards a proximal gastric tumor location, early staging, and negative lymph node metastasis, there was no statistical significance compared to those with MSS tumors (P >.1). Comparison of overall and disease-free survival between gastric tumors that were MSI+ and those that were MSS found no statistically significant differences (P >.1). CONCLUSIONS: Microsatellite instability is a frequent event in gastric carcinogenesis and shows a trend towards distinct clinical and pathological characteristics of gastric cancer.

Gamidactylus bryconis sp. n. (COPEPODA, POECILOSTOMATOIDA, VAIGAMIDAE) DAS FOSSAS NASAIS DE PEIXES, Brycon pellegrini HOLLY, 1929 E Β. melanopterus (COPE, 1872) DA AMAZÔNIA BRASILEIRA

Gamidactylus bryconissp. n. foi coletada nas fossas nasais de Brycon pellegrinie Β. melanopterus.A nova espécie é semelhante a Gamidactylus jaraquensis,por possuir antena com espinhos móvel distal no terceiro segmento e garra terminal, além de um par de retroestiletes laterais móveis, no primeiro somito torácico. Difere da espécie já conhecida no comprimento e forma dos retroestiletes e na ornamentação das pernas.

Ergasilus coatiarus Sp. N. (Copepoda, Poecilostomatoida, Ergasilidae) parasita dos filamentos branquiais de Cichla monoculus spix, 1831 (Perciforme: Cichlidae) da Amazônia Brasileira

A fêmea de Ergasilus coatiarussp. n. (Copepoda, Poecilostomatoida, Ergasilidae) é descrita dos filamentos branquiais de Cichla monoculusSpix, 1831, capturado na ilha da Marchantaria, próximo a Manaus, Brasil. A nova espécie difere das demais do gênero por apresentar apenas um segmento no exopódito da 4a perna e um espinho serrilhado na parte distal da articulação entre o 3º e 4º segmento da antena.

Superação da dormência em sementes de visgueiro-do-igapó (Parkia discolor)

O presente trabalho teve como objetivo avaliar os efeitos da aplicação de tratamentos pré-germinativos de escarificação mecânica, bem como pré-tratamentos com calor, sobre a germinação de sementes de visgueiro-do-igapó (Parkia discolor Spruce ex Benth.). No primeiro experimento, sob delineamento inteiramente ao acaso, com quatro repetições, foram avaliados os pré-tratamentos: testemunha (sem pré-tratamento); desponte no lado distal; desponte no lado proximal; desponte nos lados distal e proximal; lixamento no lado distal; lixamento no lado proximal; lixamento nos lados distal e proximal; perfuração do tegumento com ferro-de-solda; e perfuração com pirógrafo. No segundo experimento, foi adotado o delineamento inteiramente casualizado, em esquema fatorial 2 (calor: seco e úmido) x 4 (temperatura: 40ºC, 50ºC, 60ºC e 70ºC) x 5 (período de condicionamento: 6, 16, 24, 30 e 48 horas), com três repetições. O desponte ou lixamento das sementes na porção proximal e porções proximal e distal possibilitaram uma embebição mais rápida (143-163%, aos três dias e meio) e, conseqüentemente, melhores resultados de germinação (98-100%, aos quatro dias), do índice de velocidade de germinação (1,351-1,460) e do tempo médio de germinação (3 dias). Os pré-tratamentos com calor (úmido e seco), sob diferentes temperaturas, e por vários períodos de condicionamento não superaram a dormência de sementes de P. discolor.

Refluxo gastroesofágico participando da cascata cognitiva do pânico

O transtorno do pânico (TP) é um transtorno ansioso não-fóbico que acomete de 1,5% a 4% da população mundial. É caracterizado por ataques imotivados de mal-estar psíquico e sintomas somáticos, além de ansiedade antecipatória à crise, com prejuízo funcional ao indivíduo. O objetivo deste relato de caso é descrever a associação entre transtorno do pânico e doença do refluxo gastroesofágico (DRGE). MCL, 25 anos, apresentava crises de pânico frequentes, pouco responsivas ao tratamento durante 6 meses, mesmo com readequação da farmacoterapia. Iniciou-se investigação, sendo fechado o diagnóstico de DRGE, cujo tratamento culminou em remissão das crises de pânico. A dor torácica aguda da DRGE era interpretada como ameaça proximal, ocasionando dúvidas sobre passar mal e hiperventilação, servindo como gatilho da cascata cognitiva do pânico, no mesencéfalo dorsal. A inflamação da mucosa esofágica funciona como ameaça distal, estimulando a amígdala e causando ansiedade antecipatória, mantendo a elevação dos hormônios de estresse. Segundo o modelo de Deakin-Graeff, embora a 5-HT iniba o ataque de pânico e facilite a ansiedade antecipatória, no TP esta última é estimulada por meio do núcleo dorsal da rafe. Portanto, casos que incluem a associação TP e DRGE devem ser mais bem examinados, para que haja diagnóstico e tratamento adequados.

Avaliação tardia por tomografia computadorizada espiral de enxertos de pericárdio bovino liso como substitutos aórticos

OBJETIVO: Avaliar, morfologicamente, por tomografia computadorizada espiral, enxertos de pericárdio bovino liso empregados como substitutos aórticos. MÉTODOS: Dez pacientes foram submetidos a exame por tomografia computadorizada espiral para reconstituição da imagem dos enxertos. Os critérios de seleção foram tempo de seguimento superior a 2 anos, enxertos de pericárdio liso não revestido, implantados na aorta ascendente ou descendente. RESULTADOS: Os exames demonstraram bom resultado cirúrgico em todos os casos, persistindo em alguns, a imagem de dissecção aórtica distal à anastomose. Um caso apresentava hematoma entre o enxerto e a parede aórtica, em 5 não foram encontradas alterações estruturais no pericárdio e, nos demais, foi detectada dilatação de grau leve, em relação ao diâmetro descrito do enxerto implantado. Não foram vistos sinais de calcificação ou pseudoaneurismas. CONCLUSÃO: Os enxertos tubulares de pericárdio bovino liso, não revestido, apresentam resultados satisfatórios quando empregados como substitutos aórticos. A médio prazo, não foram detectadas anormalidades estruturais relacionadas ao material empregado, pela tomografia computadorizada espiral, exceto dilatação em alguns casos.

Implante de stent dentro de stent recém-implantado em ponte de veia safena para otimização do resultado angiográfico

Mulher de 60 anos, com angina progressiva e revascularização do miocárdio, há oito anos, com ponte de veia safena para coronária direita e anastomose de artéria mamaria esquerda para artéria descendente anterior. Submetida a implante de stent Gianturco-Roubin II em terço proximal da ponte de veia safena para artéria coronária direita, com resultado insatisfatório pela persistência de lesão residual, provavelmente, decorrente de prolapso para dentro da luz de material aterosclerótico através dos coils. Foi implantado outro stent (Palmaz-Schatz biliar) dentro do stent GRII com sucesso e ótimo resultado angiográfico. Um 2º stent Palmaz-Schatz biliar foi implantado em lesão distal no corpo da ponte, ultrapassando os dois stents, anteriormente implantados, com sucesso. Em algumas situações, implante de stent dentro de outro stent é recurso útil para otimização de resultado angiográfico do implante de um stent.