Fatal pulmonary thromboembolism in gastrectomy intraoperative procedures by gastric adenocarcinoma: case report

The case of a patient with gastric adenocarcinoma with indication for gastrectomy is reported. The surgery took place without complications. A palliative, subtotal gastrectomy was performed after para-aortic lymph nodes compromised by neoplasm were found, which was confirmed by pathological exam of frozen sections carried out during the intervention. At the end of the gastroenteroanastomosis procedure, the patient began to show intense bradycardia: 38 beats per minute (bpm), arterial hypotension, changes in the electrocardiogram's waveform (upper unlevelling of segment ST), and cardiac arrest. Resuscitation maneuvers were performed with temporary success. Subsequently, the patient had another circulatory breakdown and again was recovered. Finally, the third cardiac arrest proved to be irreversible, and the intra-operative death occurred. Necropsy showed massive pulmonary embolism. The medical literature has recommended heparinization of patients, in an attempt to avoid pulmonary thromboembolism following major surgical interventions. However, in the present case, heparinization would have been insufficient to prevent death. This case indicates that it is necessary to develop preoperative propedeutics for diagnosing the presence of venous thrombi with potential to migrate, causing pulmonary thromboembolism (PTE). If such thrombi could be detected, preventative measures, such as filter installation in the Cava vein could be undertaken.

Unusual abdominal tumors with intracardiac extension. Two cases with successful surgical resection

Abdominal tumors that can grow through vascular lumen and spread to the right heart are rare. Although these tumors have different histologic aspects, they may cause similar abdominal and cardiac symptoms and are a serious risk factor for pulmonary embolism and sudden death when they reach the right atrium and tricuspid valve. The best treatment is radical surgical resection of the entire tumor using cardiopulmonary bypass with or without deep hypothermia and total circulatory arrest. We report the cases of two patients, the first with leiomyosarcoma of the inferior vena cava and the other with intravenous leiomyomatosis of the uterus that showed intravascular growth up to right atrium and ventricle, who underwent successful radical resection in a one-stage procedure with the use of cardiopulmonary bypass. We discuss the clinical and histologic aspects and imaging diagnosis and review the literature.

Surgical treatment of endocrine exophthalmos by removal of orbital fat: clinical experience

PURPOSE: To report a series of 73 patients with endocrine exophthalmos treated by removal of orbital fat using the transpalpebral approach during the period 1989 to 1999. METHODS: The operation was performed according to the technique described by Olivari. Aesthetic analysis was done preoperatively and postoperatively (more than 6 months after surgery). The number of complications was also observed. RESULTS: The average volume of resected fat was approximately 7.6 mL per orbit. No major complication was observed. In 9 patients with epiphora, all improved. One patient developed postoperative diplopia and 5 complained of temporary diplopia. Appearance improved in 62 patients (85%). CONCLUSION: Surgical removal of orbital fat associated with endocrine exophthalmos provides consistent improvement in appearance with a low rate of complications. Additional procedures may be indicated to improve the cosmetic outcome.

Surgical treatment of rectal prolapse: experience and late results with 51 patients

The "best" surgical technique for the management of complete rectal prolapse remains unknown. Due to its low incidence, it is very difficult to achieve a representative number of cases, and there are no large prospective randomized trials to attest to the superiority of one operation over another. PURPOSE: Analyze the results of surgical treatment of complete rectal prolapse during 1980 and 2002. METHOD: Retrospective study. RESULTS: Fifty-one patients underwent surgical treatment during this period. The mean age was 56.7 years, with 39 females. Besides the prolapse itself, 33 patients complained of mucous discharge, 31 of fecal incontinence, 14 of constipation, 17 of rectal bleeding, and 3 of urinary incontinence. Abdominal operations were performed in 36 (71%) cases. Presacral rectopexy was the most common abdominal procedure (29 cases) followed by presacral rectopexy associated with sigmoidectomy (5 cases). The most common perineal procedure was perineal rectosigmoidectomy associated with levatorplasty (12 cases). Intraoperative bleeding from the presacral space developed in 2 cases, and a rectovaginal fistula occurred in another patient after a perineal rectosigmoidectomy. There were 2 recurrences after a mean follow-up of 49 months, which were treated by reoperation. CONCLUSION: Abdominal and perineal procedures can be used to manage complete rectal prolapse with safety and good long-term results. Age, associated medical conditions, and symptoms of fecal incontinence or constipation are the main features that one should bear in mind in order to choose the best surgical approach.

Surgical revascularization of posterior coronary arteries without cardiopulomonary bypass

OBJECTIVE: To assess the results observed during the early postoperative period in patients who had the posterior coronary arteries revascularized without cardiopulmonary bypass (CPB), in regard to the following parameters: age, sex,bypass grafts types, morbidity and mortality. METHODS: From January 1995 to June 1998, 673 patients underwent myocardial revascularization (MR). Of this total, 607 (90.20%) MR procedures were performed without CPB. The posterior coronary arteries (PCA) were revascularized in 298 (44.27%) patients, 280 (93.95%) without CPB. The age of the patients ranged from 37 to 88 years (mean, 61 years). The male gender predominated, with 198 men (70.7%). The revascularization of the posterior coronary arteries had the following distribution: diagonalis artery (31 patients, 10%); marginal branches of the circumflex artery (243 patients, 78.7%); posterior ventricular artery (4 patients, 1.3%); and posterior descending artery (31 patients, 10%). RESULTS: Procedure-related complications without death occurred in 7 cases, giving a morbidity of 2.5%. There were 11 deaths in the early postoperative period (mortality of 3.9%). CONCLUSION: Similarly to the anterior coronary arteries, the posterior coronary arteries may benefit from myocardial revascularization without CPB.

A new surgical approach for treating dilated cardiomyopathy with mitral regurgitation

OBJECTIVE: To evaluate the early outcome of mitral valve prostheses implantation and left ventricular remodeling in 23 patients with end-stage cardiomyopathy and secondary mitral regurgitation (NYHA class III and IV). METHODS: Mitral valvular prosthesis implantation with preservation of papillary muscles and chordae tendinae, and plasty of anteriun cuspid for remodeling of the left ventricle. RESULTS: The surgery was performed in 23 patients, preoperative ejection fraction (echocardiography) varied from 13% to 44% (median: 30%). In 13 patients associated procedures were performed: myocardial revascularization (9), left ventricle plicature repair (3) and aortic prosthese implantation (1). Early deaths (2) occurred on the 4th PO day (cardiogenic shock) and on the 20th PO day (upper gastrointestinal bleeding), and a late death in the second month PO (ventricular arrhythmia). Improvement occurred in NYHA class in 82.6% of the patients (P<0.0001), with a survival rate of 86.9% (mean of 8.9 months of follow-up). CONCLUSION: This technique offers a promising therapeutic alternative for the treatment of patients in refractory heart failure with cardiomyopathy and secondary mitral regurgitation.

Influence of the echocardiographic score and not of the previous surgical mitral commissurotomy on the outcome of percutaneous mitral balloon valvuloplasty

OBJECTIVE: To evaluate prior mitral surgical commissurotomy and echocardiographic score influence on the outcomes and complications of percutaneous mitral balloon valvuloplasty. METHODS: We performed 459 complete mitral valvuloplasty procedures. Four hundred thirteen were primary valvuloplasty and 46 were in patients who had undergone prior surgical commissurotomy. The prior commissurotomy group was older, had higher echo scores, and a tendency toward a higher percentage of atrial fibrillation. RESULTS: When the groups were compared with each other, no differences were found in pre- and postprocedure mean pulmonary artery pressure, mean mitral gradient, mitral valve area, and mitral regurgitation . Because we found no significant differences, we subdivided the entire group based on echo scores, those with echo scores <=8 and those with echo scores >8 the mitral valve area being higher in the <=8 echo score group 2.06±0.42 versus 1.90±0.40cm² (p=0.0090) in the >8 echo score group. CONCLUSION: Dividing the groups based on echo score revealed that the higher echo score group had smaller mitral valve areas postvalvuloplasty.

Evaluation of adherence to measures for the prevention of surgical site infections by the surgical team

AbstractOBJECTIVEEvaluate pre- and intraoperative practices adopted by medical and nursing teams for the prevention of surgical infections.METHODA prospective study carried out in the period of April to May 2013, in a surgical center of a university hospital in Belo Horizonte, Minas Gerais.RESULTS18 surgeries were followed and 214 surgical gloves were analyzed, of which 23 (10.7%) had postoperative glove perforation detected, with 52.2% being perceived by users. Hair removal was performed on 27.7% of patients in the operating room, with the use of blades in 80% of the cases. Antibiotic prophylaxis was administered to 81.8% of patients up to 60 minutes prior to surgical incision. An average of nine professionals were present during surgery and the surgery room door remained open in 94.4% of the procedures.CONCLUSIONPartial adhesion to the recommended measures was identified, reaffirming a need for greater attention to these critical steps/actions in order to prevent surgical site infection.

Hepatectomia direita por videolaparoscopia

The first application of laparoscopic liver surgery consisted of wedge liver biopsies or resection of peripheral lesions, mostly benign. More recently, reports of anatomic left and right hepatectomy have been seen in the literature. Expertise in some centers has evolved to such an extent that even living related donor hepatectomy has been performed. The aim of this paper is to report a laparoscopic right hepatectomy and describe in detail the surgical technique employed. To our knowledge this is the first case performed in Brazil totally laparoscopically. The surgery followed four distinct phases: complete mobilization of the liver; hilum dissection with encircling of right portal vein and right hepatic artery, caval dissection using linear vascular stapler to divide right hepatic vein and parenchymal transection with harmonic shears and firings of linear staplers are used to divide segmental 5 and 8 branches of middle hepatic vein. The liver specimen was removed by Pfannenstiel incision. Intraoperative blood loss was estimated in 120 ml with no need for blood transfusion. Hospital stay was 5 days. Laparoscopic right hepatectomy is feasible, technically demanding but can be safely accomplished by surgeons who have experience in advanced laparoscopic procedures and open hepatic surgery. In Brazil laparoscopic liver surgery is still in its first years and there is a lack of technical description of this complex procedure.

Surgical techniques for maxillary bone grafting - literature review

For oral rehabilitation with implant-supported prostheses, there are required procedures to create the bone volume needed for installation of the implants. Thus, bone grafts from intraoral or extraoral donor sites represent a very favorable opportunity. This study aimed to review the literature on the subject, seeking to discuss parameters for the indications, advantages and complications of techniques for autogenous bone grafts.

Celiac artery in New Zealand rabbit: anatomical study of its origin and arrangement for experimental research and surgical practice

Rabbits have been used as an experimental model in many diseases and for the study of toxicology, pharmacology and surgery in many universities. However, some aspects of their macro anatomy need a more detailed description, especially the abdominal and pelvic arterial vascular system, which has a huge variability in distribution and trajectory. Thirty cadaveric adult New Zealand rabbits, 13 male and 17 female, with an average weight and rostrum-sacral length of 2.5 kg and 40cm, respectively, were used. The thoracic aorta was cannulated and the vascular system was filled with stained latex S-65. The celiac artery and its proximal branches were dissected and lengthened in order to evidence origin and proximal ramifications. The celiac artery emerged between the 12th and 13th thoracic vertebra in 11 (36.7%) rabbits; at the level of the 13th thoracic vertebra in 6 (20%) rabbits; between the 13th thoracic vertebra and the 1st lumbar vertebra in 12 (40%) rabbits; and at the level of the 1st lumbar vertebra in only one (3.3%) rabbit. The mean length of the celiac artery was 0.5cm. The celiac artery first branch was the lienal artery, the second branch was the left gastric artery and the hepatic artery arose from the left gastric artery in all the dissected rabbits. No relation was observed between the celiac artery length and the rostrum-sacral length in rabbits. The number of left gastric and lienal artery branches and the distribution of celiac artery origin are not gender dependent.

Reactivity of the isolated perfused rat tail vascular bed

Isolated segments of the perfused rat tail artery display a high basal tone when compared to other isolated arteries such as the mesenteric and are suitable for the assay of vasopressor agents. However, the perfusion of this artery in the entire tail has not yet been used for functional studies. The main purpose of the present study was to identify some aspects of the vascular reactivity of the rat tail vascular bed and validate this method to measure vascular reactivity. The tail severed from the body was perfused with Krebs solution containing different Ca2+ concentrations at different flow rates. Rats were anesthetized with sodium pentobarbital (65 mg/kg) and heparinized (500 U). The tail artery was dissected near the tail insertion, cannulated and perfused with Krebs solution plus 30 µM EDTA at 36oC and 2.5 ml/min and the procedures were started after equilibration of the perfusion pressure. In the first group a dose-response curve to phenylephrine (PE) (0.5, 1, 2 and 5 µg, bolus injection) was obtained at different flow rates (1.5, 2.5 and 3.5 ml/min). The mean perfusion pressure increased with flow as well as PE vasopressor responses. In a second group the flow was changed (1.5, 2, 2.5, 3 and 3.5 ml/min) at different Ca2+ concentrations (0.62, 1.25, 2.5 and 3.75 mM) in the Krebs solution. Increasing Ca2+ concentrations did not alter the flow-pressure relationship. In the third group a similar protocol was performed but the rat tail vascular bed was perfused with Krebs solution containing PE (0.1 µg/ml). There was an enhancement of the effect of PE with increasing external Ca2+ and flow. PE vasopressor responses increased after endothelial damage with air and CHAPS, suggesting an endothelial modulation of the tone of the rat tail vascular bed. These experiments validate the perfusion of the rat tail vascular bed as a method to investigate vascular reactivity

Gender differences in vascular expression of endothelin and ET A/ET B receptors, but not in calcium handling mechanisms, in deoxycorticosterone acetate-salt hypertension

We determined if the increased vascular responsiveness to endothelin-1 (ET-1) observed in male, but not in female, DOCA-salt rats is associated with differential vascular mRNA expression of ET-1 and/or ET A/ET B receptors or with functional differences in Ca2+ handling mechanisms by vascular myocytes. Uninephrectomized male and female Wistar rats received DOCA and drinking water containing NaCl/KCl. Control rats received vehicle and tap water. Blood pressure and contractile responses of endothelium-denuded aortic rings to agents which induce Ca2+ influx and/or its release from internal stores were measured using standard procedures. Expression of mRNA for ET-1 and ET A/ET B receptors was evaluated by RT-PCR after isolation of total cell RNA from both aorta and mesenteric arteries. Systolic blood pressure was higher in male than in female DOCA rats. Contractions induced by Bay K8644 (which activates Ca2+ influx through voltage-operated L-type channels), and by caffeine, serotonin or ET-1 in Ca2+-free buffer (which reflect Ca2+ release from internal stores) were significantly increased in aortas from male and female DOCA-salt compared to control aortas. DOCA-salt treatment of male, but not female, rats statistically increased vascular mRNA expression of ET-1 and ET B receptors, but decreased the expression of ET A receptors. Molecular up-regulation of vascular ET B receptors, rather than differential changes in smooth muscle Ca2+ handling mechanisms, seems to account for the increased vascular reactivity to ET-1/ET B receptor agonists and higher blood pressure levels observed in male DOCA-salt rats.

Vascular adaptive responses to physical exercise and to stress are affected differently by nandrolone administration

Androgenic anabolic steroid, physical exercise and stress induce cardiovascular adaptations including increased endothelial function. The present study investigated the effects of these conditions alone and in combination on the vascular responses of male Wistar rats. Exercise was started at 8 weeks of life (60-min swimming sessions 5 days per week for 8 weeks, while carrying a 5% body-weight load). One group received nandrolone (5 mg/kg, twice per week for 8 weeks, im). Acute immobilization stress (2 h) was induced immediately before the experimental protocol. Curves for noradrenaline were obtained for thoracic aorta, with and without endothelium from sedentary and trained rats, submitted or not to stress, treated or not with nandrolone. None of the procedures altered the vascular reactivity to noradrenaline in denuded aorta. In intact aorta, stress and exercise produced vascular adaptive responses characterized by endothelium-dependent hyporeactivity to noradrenaline. These conditions in combination did not potentiate the vascular adaptive response. Exercise-induced vascular adaptive response was abolished by nandrolone. In contrast, the aortal reactivity to noradrenaline of sedentary rats and the vascular adaptive response to stress of sedentary and trained rats were not affected by nandrolone. Maximum response for 7-10 rats/group (g): sedentary 3.8 ± 0.2 vs trained 3.0 ± 0.2*; sedentary/stress 2.7 ± 0.2 vs trained/stress 3.1 ± 0.1*; sedentary/nandrolone 3.6 ± 0.1 vs trained/nandrolone 3.8 ± 0.1; sedentary/stress/nandrolone 3.2 ± 0.1 vs trained/stress/nandrolone 2.5 ± 0.1*; *P < 0.05 compared to its respective control. Stress and physical exercise determine similar vascular adaptive response involving distinct mechanisms as indicated by the observation that only the physical exercise-induced adaptive response was abolished by nandrolone.

Vascular dysfunction by myofibroblast activation in patients with idiopathic pulmonary fibrosis and prognostic significance

In this study, we demonstrated the importance of telomerase protein expression and determined the relationships among telomerase, endothelin-1 (ET-1) and myofibroblasts during early and late remodeling of parenchymal and vascular areas in usual interstitial pneumonia (UIP) using 27 surgical lung biopsies from patients with idiopathic pulmonary fibrosis (IPF). Telomerase+, myofibroblasts α-SMA+, smooth muscle cells caldesmon+, endothelium ET-1+ cellularity, and fibrosis severity were evaluated in 30 fields covering normal lung parenchyma, minimal fibrosis (fibroblastic foci), severe (mural) fibrosis, and vascular areas of UIP by the point-counting technique and a semiquantitative score. The impact of these markers was determined in pulmonary functional tests and follow-up until death from IPF. Telomerase and ET-1 expression was significantly increased in normal and vascular areas compared to areas of fibroblast foci. Telomerase and ET-1 expression was inversely correlated with minimal fibrosis in areas of fibroblast foci and directly associated with severe fibrosis in vascular areas. Telomerase activity in minimal fibrosis areas was directly associated with diffusing capacity of the lung for oxygen/alveolar volume and ET-1 expression and indirectly associated with diffusing capacity of the lungs for carbon monoxide and severe fibrosis in vascular areas. Cox proportional hazards regression revealed a low risk of death for females with minimal fibrosis displaying high telomerase and ET-1 expression in normal areas. Vascular dysfunction by telomerase/ET-1 expression was found earlier than vascular remodeling by myofibroblast activation in UIP with impact on IPF evolution, suggesting that strategies aimed at preventing the effect of these mediators may have a greater impact on patient outcome.