Evaluation of piroxicam-β-cyclodextrin as a preemptive analgesic in functional endoscopic sinus surgery

The preemptive analgesic efficacy and adverse effects of preoperatively administered piroxicam-β-cyclodextrin for post-endoscopic sinus surgery pain was determined in a prospective, double-blind, randomized, clinical study. Seventy-five American Society of Anesthesiologists status I-II patients, aged 18-65 years, were divided into three groups with similar demographic characteristics: group 1 received 20 mg piroxicam-β-cyclodextrin, group 2 received 40 mg piroxicam-β-cyclodextrin and group 3 received placebo orally before induction of general anesthesia. A blinded observer recorded the incidence and severity of pain at admission to the post-anesthesia care unit (PACU), at 15, 30, and 45 min in the PACU, and 1, 2, 4, 6, and 24 h postoperatively. All patients received patient-controlled morphine analgesia during the postoperative period and consumption was recorded for 24 h. During the PACU period, mean visual analogue scale values were significantly lower in groups 1 and 2 compared to group 3 (P < 0.05). During the postoperative period, morphine consumption was 3.03 ± 2.54, 2.7 ± 2.8, and 5.56 ± 3.12 mg for each group, respectively (P < 0.05). As a side effect, bleeding was observed in groups 1 and 3, nausea and vomiting in all groups, and edema only in group 3. However, no significant differences were detected in any of the parameters analyzed, which also included epigastric pain, constipation/diarrhea and headache. Similar hematological test results were obtained for all groups. Preemptive administration of piroxicam-β-cyclodextrin effectively reduced analgesic consumption, and 40 mg of the drug was more effective than 20 mg piroxicam-β-cyclodextrin without side effects during the postoperative period.

Hepatectomia regrada por videolaparoscopia

With the improvement of laparoscopic techniques, endoscopic liver surgery has become feasible. While laparoscopic wedge liver resection are performed more frequently, laparoscopic (anatomical or nonanatomical) liver resection are still at an early stage of development and are somewhat controversial. We reporte laparoscopic hepatic resection without use of sophisticated laparoscopic instruments. A 47-year-old woman underwent radical mastectomy for adenocarcinoma in 1995. 1n the postoperative follow-up presented, a lesion in the left hepatic lobe and, after laparoscopic approach, left lateral segmentectomy was performed. The hepatic resection elapsed without complications. The surgical time was 4 hours and the blood loss was minimal, without transfusion being necessary.The abdominal drain was removed in 24 hours and the patient was discharged in the second postoperative day. Compared to the classic approach by laparotomy, this method was less traumatic, required a shorter hospital stay, and followed by faster recovery.

Massive infestation by Ascaris lumbricoides of the biliary tract: report of a successfully treated case

This is a report of a 25 years old black woman from the city of São Paulo, Brazil, who developed acute obstructive cholangitis of Ascaris lumbricoides with septicemia and multiple hepatic abscesses. The patient had sickle cell trait and normal delivery 3 months ago. Massive infestation of the biliary tract by Ascaris lumbricoides was diagnosed by abdominal ultrasonography and endoscopic retrograde cholangiography. Sixty worms were removed from the common bile duct and hepatic abscesses were drained by surgery. The infectious process was polymicrobial. The patient's recovery was complete after a long evolution with a wide spectrum antibiotic therapy. New surgeries were needed to remove residual worms in the biliary tract. The diagnostic methods, clinical-biochemical features and also the clinical and surgical management are presented. The biliary ascariasis pathophysiology is commented.

Clinical and endoscopic findings in the mucosae of the upper respiratory and digestive tracts in post-treatment follow-up of paracoccidioidomycosis patients

Systematic examination of the upper respiratory and digestive tracts (URDT) was performed in a group of 80 paracoccidioidomycosis (PCM) patients submitted to post-treatment follow-up ranging from 8 months to 17 years. Mucosae of the URDT had been involved prior to specific treatment in 74 patients, distributed as follows: oropharynx, 50 (41 alone, 7 in association with the larynx, and 2 with the nasal mucosa); larynx, 30 (23 alone and 7 in association); and nasal mucosa, 3(1 alone and 2 in association). Inactive lesions were observed in all the 50 patients with lesions of the oropharynx, 3 of whom with deforming scars (1 with retraction of the tongue and 2 with narrowing of the oral orifice). One case presented a destructive lesion, with perfuration of the palate. Of the other 46 cases, examination showed nacreous white striated scars which were nearly imperceptible in some cases and in others displayed partial retraction of anatomical structures without any alteration of their features. Patients presented a high rate of missing teeth. In 3 patients with involvement of the nasal mucosa, none of whom presented active PCM lesions, 2 still had nasal voices. In 30 patients with lesions of the larynx, 1 suffered a relapse of PCM and 2 developed epidermoid carcinoma. Of the other 27 cases, none of whom had active PCM lesions, 15 presented dysphonia, 3 were tracheotomized, and 9 were asymptomatic.

Histological and endoscopic features of the stomachs of patients with Chagas disease in the era of Helicobacter pylori

Introduction Most studies that have evaluated the stomachs of patients with Chagas disease were performed before the discovery of Helicobacter pylori and used no control groups. This study compared the gastric features of chagasic and non-chagasic patients and assessed whether gastritis could be associated with Chagas disease. Methods Gastric biopsy samples were taken from patients who underwent endoscopy for histological analysis according to the Updated Sydney System. H. pylori infection was assessed by histology, 16S ribosomal ribonucleic acid (rRNA) polymerase chain reaction (PCR), serology and the 13C-urea breath test. Patients were considered H. pylori-negative when all of these diagnostic tests were negative. Clinical and socio-demographic data were obtained by reviewing medical records and using a questionnaire. Results The prevalence of H. pylori infection (70.3% versus 71.7%) and chronic gastritis (92.2% versus 85%) was similar in the chagasic and non-chagasic groups, respectively; such as peptic ulcer, atrophy and intestinal metaplasia. Gastritis was associated with H. pylori infection independent of Chagas disease in a log-binomial regression model. However, the chagasic H. pylori-negative patients showed a significantly higher grade of mononuclear (in the corpus) and polymorphonuclear (PMN) (in the antrum) cell infiltration. Additionally, the patients with the digestive form of Chagas disease showed a significantly lower prevalence of corpus atrophy than those with other clinical forms. Conclusions The prevalence of H. pylori infection and of gastric histological and endoscopic features was similar among the chagasic and non-chagasic patients. Additionally, this is the first controlled study to demonstrate that H. pylori is the major cause of gastritis in patients with Chagas disease.

Pheochromocytoma treated by laparoscopic surgery

OBJECTIVE: To evaluate the results of the laparoscopic technique in the treatment of adrenal pheochromocytoma. METHOD: Ten patients, 7 men and 3 women, between 10 and 67 years of age (mean 48) with pheochromocytoma underwent transperitoneal laparoscopic adrenalectomy and were evaluated retrospectively, based on clinical, laboratory, and pathological diagnosis. In all cases there was a solid unilateral adrenal tumor, 5 on the left side and 5 on the right side, whose greater diameter varied from 7 to 80 mm (mean 32). Nine of the 10 patients were chronically hypertensive or had already had hypertensive crises. One patient was normotensive, but presented metabolic alterations suggestive of adrenergic hyperfunction. RESULTS: No deaths occurred in this series. There were two (20%) conversions to open surgery, one due to venous bleeding and one due to the difficulty of dissection behind the vena cava in a patient presenting a partially retro-caval tumor. Surgical time in the 8 non-converted cases ranged from 70 to 215 minutes (mean 136). One patient (10%) received blood transfusion, and another (10%) presented two complications - acute renal failure and a subcutaneous infection. Both had been converted to open surgery. None of the non-converted cases was transfused or presented complications. Hospital discharge occurred between the 2nd and 11th post-operative day (mean 3). The pathological exam of the surgical specimens confirmed the diagnoses of pheochromocytoma in all 10 cases, one of them associated with an aldosterone-producing cortical tumor. CONCLUSIONS: Laparoscopic adrenalectomy for selected patients presenting pheochromocytoma is feasible and provides good results.

Intestinal intussusception and occlusion caused by small bowel polyps in the Peutz-Jeghers syndrome. Management by combined intraoperative enteroscopy and resection through minimal enterostomy: case report

The Peutz-Jeghers syndrome is a hereditary disease that requires frequent endoscopic and surgical intervention, leading to secondary complications such as short bowel syndrome. CASE REPORT: This paper reports on a 15-year-old male patient with a family history of the disease, who underwent surgery for treatment of an intestinal occlusion due to a small intestine intussusception. DISCUSSION: An intra-operative fiberscopic procedure was included for the detection and treatment of numerous polyps distributed along the small intestine. Enterotomy was performed to treat only the larger polyps, therefore limiting the intestinal resection to smaller segments. The postoperative follow-up was uneventful. CONCLUSION: We point out the importance of conservative treatment for patients with this syndrome, especially those who will undergo repeated surgical interventions because of clinical manifestation while they are still young.

Microlaparoscopy in gynecology: analysis of 16 cases and review of literature

Microlaparoscopy represents the development of endoscopic surgery towards a minimally invasive surgical procedure. The advantages include fewer surgical complications, faster return to daily activities, more comfortable postoperative recovery, and satisfactory aesthetic results. The possibility of performing surgery under sedation may result in shorter hospitalization, lower hospital costs, and easier anesthetic procedures. The authors report their preliminary experience with the use of microlaparoscopy, using optics and 2mm instruments, as well as a review of the literature since the introduction of this new technique. The report of these 16 cases demonstrates that microlaparoscopy is a feasible technique with satisfactory results. On the other hand, this new technique requires precise indications and a training period for the development of the skills necessary for performing these surgeries.

Cataract surgery: expectations of patients assisted during a community project in São Paulo, state of São Paulo, Brazil

OBJECTIVE: To identify social characteristics and expectations of individuals seen during a community project for the treatment of senile cataracts. Expected results from their eye surgery and its consequences to their quality of life were studied as well. METHODOLOGY: Cataract patients (visual acuity equal to or lower than 0.2 in the more superior eye) aged 50 years or over, were surveyed by means of interviews held during their visit at the Cataract Project in São Paulo city, State of São Paulo, Brazil, in 1999. RESULTS: The sample was composed of 331 subjects of low socioeconomic level ranging in age from 50 to 97 years (average = 71.8 years). Expectation of total recovery from the cataract condition by means of surgery was declared by 80.0% of the respondents, with no significant differences between male and female subjects (P < 0.1723). Hope to resume manual activities was expressed by 59.8%. CONCLUSION: A predominance of expectations of resuming normal activity and achieving a better quality of life after cataract surgery were identified.

Tissue expander complications in plastic surgery: a 10-year experience

INTRODUCTION: Tissue expanders have been of great value in plastic surgery. Tissue expansion was developed for a specific indication; however, within a very short time, the concept of tissue expansion found wide applicability. From 1990 to 1999, 315 expanders in 164 patients were utilized. A retrospective analysis of complications and prognostic factors for complications were done. METHODS: The indications for tissue expansion were burns (50%), trauma (32%), and sequelae of previous surgery (8.8%). The expanders were inserted most frequently in the scalp, trunk and neck. RESULTS: There were 22.2% of complications and the most common were expander exposure (50%), infection (24%) and bad function of the expander (12.8%). The present study revealed an increased rate of minor complications in the group of 0 to 10 years of age and an increased rate of major complications for face and neck expansions compared to trunk expansion. There were no increased complication rates for the other age and anatomic site groups, previous expansion, concomitant expansion and type of expander used. CONCLUSIONS: The outcomes from tissue expansion procedures done in our hospital are similar to those reported in the literature. Tissue expansion is a good and safe technique.

Surgery information reduces anxiety in the pre-operative period

PURPOSE: Patients preparing to undergo surgery should not suffer needless anxiety. This study aimed to evaluate anxiety levels on the day before surgery as related to the information known by the patient regarding the diagnosis, surgical procedure, or anesthesia. METHOD: Patients reported their knowledge of diagnosis, surgery, and anesthesia. The Spielberger State-Trait Anxiety Inventory (STAI) was used to measure patient anxiety levels. RESULTS: One hundred and forty-nine patients were selected, and 82 females and 38 males were interviewed. Twenty-nine patients were excluded due to illiteracy. The state-anxiety levels were alike for males and females (36.10 ± 11.94 vs. 37.61 ± 8.76) (mean ± SD). Trait-anxiety levels were higher for women (42.55 ± 10.39 vs. 38.08 ± 12.25, P = 0.041). Patient education level did not influence the state-anxiety level but was inversely related to the trait-anxiety level. Knowledge of the diagnosis was clear for 91.7% of patients, of the surgery for 75.0%, and of anesthesia for 37.5%. Unfamiliarity with the surgical procedure raised state-anxiety levels (P = 0.021). A lower state-anxiety level was found among patients who did not know the diagnosis but knew about the surgery (P = 0.038). CONCLUSIONS: Increased knowledge of patients regarding the surgery they are about to undergo may reduce their state-anxiety levels.

Effects of bariatric surgery on the central nervous system and eating behavior in humans: a systematic review on the neuroimaging studies

INTRODUCTION: Neuroimaging studies suggest that obese people might show hyperactivity of brain areas regarding reward processing, and hypoactivity of brain areas concerning cognitive control, when exposed to food cues. Although the effects of bariatric surgery on the central nervous system and eating behavior are well known, few studies have used neuroimage techniques with the aim of investigating the central effects of bariatric surgery in humans. OBJECTIVES: This paper systematically and critically reviews studies using functional neuroimaging to investigate changes on the patterns of activation of central areas related to the regulation of eating behavior after bariatric surgery. METHOD: A search on the databases Medline, Web of Science, Lilacs and Science Direct on Line, was conducted in February 2013, using the keywords "Neuroimaging", "Positron-Emission Tomography", "Magnetic Resonance Imaging", "Gastric Bypass", "Gastroplasty", "Jejunoileal Bypass", "Bariatric Surgery". RESULTS: Seven manuscripts were included; the great majority studied the central effects of Roux en Y gastric bypass, using positron emission tomography or functional magnetic resonance. CONCLUSIONS: Bariatric surgery might normalize the activity of central areas concerned with reward and incentive salience processing, as the nucleus accumbens and mesencephalic tegmental ventral area, as well as circuitries processing behavioral inhibition, as the dorsolateral prefrontal cortex.

Detection of the viable myocardium. A perfusion scintigraphic study, before and after coronary bypass surgery in myocardial infarction patients

OBJECTIVE: To compare single-photon-emission computed tomography (SPECT) imaging scans using 201Tl and 99mTc-MIBI in detection of viable myocardium, in regions compromised by infarction. METHODS: Thirty-two (59.3±9.8 years old and 87% male) myocardial infarction patients were studied. All had Q waves on the ECG and left ventricle ejection fraction of <50%. They underwent coronary and left ventricle angiographies and SPECT before (including 201Tl reinjection) and after coronary artery bypass surgery (CABG). Improvement in perfusion observed after surgery was considered the gold standard for myocardial viability. RESULTS: Among 102 studied regions of the heart, there were 40 (39.2%) areas of transient perfusion defects in the conventional protocol with 201Tl and 52 (51.0%) after reinjection. Therefore, 12/62 (19.4%) more viable regions were identified by reinjection. Using 99mTc-MIBI, only 14 (13.7%) regions with transient defects were identified, all of which were seen also in 201Tl protocols. After surgery, 49 of a total of 93 regions analyzed (52.7%) were viable. Sensitivity, specificity, accuracy, positive and negative prediction values were, respectively, 201Tl SPECT scans - 65.3%, 90.9%, 77.4%, 88.9% and 70.2%, reinjection protocol with 201Tl scans - 81.6%, 81.8%, 81.7%, 83.3% and 80.0%; 99mTc-MIBI SPECT scans - 20.4%, 90.9%, 53.8%, 71.4% and 50.6%. Logistic regression demonstrated that the reinjection protocol with 201Tl was the best predictor of viability (P<0.001). CONCLUSION: Our data suggest the election of 201Tl for viability studies, especially when using the reinjection protocol.

Invasive hemodynamic monitoring in the postoperative period of cardiac surgery

OBJETIVE: To assess the hemodynamic profile of cardiac surgery patients with circulatory instability in the early postoperative period (POP). METHODS: Over a two-year period, 306 patients underwent cardiac surgery. Thirty had hemodynamic instability in the early POP and were monitored with the Swan-Ganz catheter. The following parameters were evaluated: cardiac index (CI), systemic and pulmonary vascular resistance, pulmonary shunt, central venous pressure (CVP), pulmonary capillary wedge pressure (PCWP), oxygen delivery and consumption, use of vasoactive drugs and of circulatory support. RESULTS: Twenty patients had low cardiac index (CI), and 10 had normal or high CI. Systemic vascular resistance was decreased in 11 patients. There was no correlation between oxygen delivery (DO2) and consumption (VO2), p=0.42, and no correlation between CVP and PCWP, p=0.065. Pulmonary vascular resistance was decreased in 15 patients and the pulmonary shunt was increased in 19. Two patients with CI < 2L/min/m² received circulatory support. CONCLUSION: Patients in the POP of cardiac surgery frequently have a mixed shock due to the systemic inflammatory response syndrome (SIRS). Therefore, invasive hemodynamic monitoring is useful in handling blood volume, choice of vasoactive drugs, and indication for circulatory support.