Acute alterations in anorectal manometry induced by proximal and distal sphincterotomy. Experimental studies on piglets

Anal incontinence causes psychological, social and adaptive troubles prejudicial to the quality of life both in children and adults. Therefore, the detailed knowledge of its causes and the improvement of diagnostic and therapeutic methods increase the possibilities of a more adequate social life to patients with congenital anomalies or sphincteric lesions or degenerations. In this work, a manometric study was developed through an experimental model so as to analyze alterations in behavior of muscle groups responsible for the anorectal sphincteric mechanism, previous to and after proximal and distal lesions. Twenty-two pigs aged between 25 and 30 days, weighing 5-7 kg, were randomly divided into two groups. They were submitted to lesions of different levels in the anorectal muscle. The animals were studied by anorectal manometry (rectoanal inhibitory reflex and vector volume) before and after the lesions. The Student t test and the Wilcoxon test were applied for the statistical analyses, considered p <= 0.05. The proximal lesion preserved sphincter relaxation, retarding its closure [speed of relaxation recovery 4.35 +/- 2.10 vs. 2.70 +/- 1.32 mm/s (p = 0.001)], but it reduced the maximum pressure [62.45 +/- 20.02 vs. 40.36 +/- 12.59 mmHg (p = 0.004)] and vector volume [2,749 +/- 921 vs. 1,591 +/- 1,379 mmHg(2)cm (p = 0.005)]. There was an increment in the high-pressure zone [5.09 +/- 1.04 vs. 6.36 +/- 1.50 mm (p = 0.005)], but the asymmetry percentage and the sphincter length were maintained. The distal lesion did not alter the rectoanal inhibitory reflex, the high-pressure zone length, the asymmetry percentage, or the vector volume. Nevertheless, the sphincter length increased [11.82 +/- 2.82 vs. 14.09 +/- 2.39 mm (p = 0.022)] and the maximum pressure decreased [60.55 +/- 22.05 vs. 40.91 +/- 13.41 mmHg (p = 0.004)]. The alterations observed due to proximal lesion of the anorectal sphincter suggest a direct and more important interference of the levator ani muscle in the function of the sphincteric musculature than that caused by the distal lesion.

Effects of Inspiratory Muscle Training on Muscular and Pulmonary Function After Bariatric Surgery in Obese Patients

This study seeks to assess the effect of inspiratory muscle training (IMT) on pulmonary function, respiratory muscle strength, and endurance in morbidly obese patients submitted to bariatric surgery. Thirty patients were randomly assigned to sham muscular training, or to IMT with a threshold device (40% of maximum inspiratory pressure, MIP), for 30 min/day, from the 2nd until 30th postoperative (PO) day. All of them were submitted to a standard respiratory kinesiotherapy and early deambulation protocol. Data on spirometry, maximum static respiratory pressures, and respiratory muscle endurance were collected on the PO days 2, 7, 14, and 30 in a blinded matter. IMT enabled increases in PO MIP and endurance, and an earlier recovery of the spirometry parameters FEV(1), PEF, and FEF(25-75%). Comparing to preoperative values, MIP was increased by 13% at the 30th PO day in the trained group, whereas control group had a reduction of 8%, with higher values for the IMT group (30th PO, IMT-130.6 +/- 22.9 cmH(2)O; controls-112.9 +/- 25.1 cmH(2)O; p < 0.05). Muscular endurance at the 30th PO day was increased in the trained group comparing to preoperative value (61.5 +/- 39.6 s vs 114.9 +/- 55.2 s; p < 0.05), a finding not observed in the control group (81.7 +/- 44.3 vs 95.2 +/- 42.0 s). IMT improves inspiratory muscle strength and endurance and accounts for an earlier recovery of pulmonary airflows in morbidly obese patients submitted to bariatric surgery.

Roux-en-Y Bypass Gastroplasty: Markers of Oxidative Stress 6 Months After Surgery

This study examined the effect of weight loss on energy intake, vitamin C, E, beta-carotene (diet/blood), reduced glutathione (GSH), C-reactive protein (CRP), thiobarbituric acid reactive substances (TBARS), catalase, and myeloperoxidase, in patients with Roux-en-Y bypass gastroplasty. Prospective clinical study with control (C) and bariatric (B) groups (n = 20 each). Age was 38.8 +/- 11.1 (C) and 37.8 +/- 11.2 years (B), and body mass indices (BMI) were 22.4 +/- 2.4 and 48.1 +/- 8.7 kg/m(2), respectively. Group C was assessed on a single occasion and B at three time points (basal period and 3 and 6 months after gastroplasty). BMI was decreased at three (38.3 +/- 1.7, P = 0.018) and 6 months after surgery (34.9 +/- 1.7, P < 0.001). Mean weight loss was 20.53 +/- 1.1 after three and 27.96 +/- 1.3 kg after 6 months. Serum vitamin C and beta-carotene (P < 0.01 and P < 0.001, respectively) were increased at 6 months compared to basal. Basal serum vitamin C (P = 0.001) and beta-carotene (P < 0.001) were lower compared to controls. Serum vitamin E corrected for cholesterol and triglycerides was higher in group B at three (P = 0.01) and 6 months (P = 0.001) and lower at basal (P < 0.001) compared to controls. GSH was higher in controls (P < 0.001) compared to basal. Catalase (P = 0.01) and TBARS (P < 0.001) were higher in group B at 6 months. TBARS were higher (P < 0.001) at basal compared to controls. Myeloperoxidase and CRP decreased in group B after three (P = 0.028, P = 0.010) and 6 months (P < 0.001, P = 0.001), respectively. Roux-en-Y bypass gastroplasty led to decreased proinflammatory parameters together with increased nutritional antioxidants, catalase, and TBARS, and decreased GSH 6 months after surgery.

Primary adenocarcinoma of the fallopian tube as an incidental finding during surgery in a postmenopausal patient with unspecific pelvic pain

Primary fallopian tube carcinoma (PFTC) is a rare gynecologic neoplasm and is usually diagnosed late and presents classically with a,characteristic group of symptoms. We describe a case of a 76-year-old woman who underwent TVS requested by the family physician due to unspecific pelvic pain. An adnexal mass was found with morphology associated with high levels of CA125 suggestive of a malignant tumor. During laparotomy, a mass located in the left tube was found. Histopathology confirmed PFTC. Total hysterectomy, salpingo-oophorectomy and adjuvant chemotherapy with carboplatin/paclitaxel were performed. The patient has not yet presented any signs of recurrence.

Breast conserving surgery after neoadjuvant therapy for large primary breast cancer

Aim: The aim of this study was to evaluate the safety of breast conserving surgery ill patients with breast tumours satisfactorily downstaged after neoadjuvant therapy. Methods: A retrospective cohort study was undertaken to analyze the loco-regional recurrence (LRR) after breast conserving surgery. We enrolled 88 patients with breast cancer subjected to neoadjuvant therapy (NAT group) who achieved an objective response due to neoadjuvant treatment and compared them with 191 patients with early breast cancer (EBC group) who were submitted to primary conserving surgery. Lumpectomy or quadrantectomy with axillary lymph node dissection was performed in all patients who received adjuvant radiotherapy. Systemic adjuvant therapy was offered to all patients. The mean periods of observation were 61.3 months in the NAT group and 67.5 months in the EBC group. Results: The mean age was 53 years in the NAT group and 56 years in the EBC group (p = 0.04). There was no histological type and histological grade difference between groups. In the NAT group, the mean diameter of residual tumour was lower and the mean volume of breast tissue resection was higher than in the EBC group (p = 0.01 and p = 0.002, respectively). The ipsilateral recurrence rate was 7.9% in the NAT group and 7.8% in the EBC group (p = 0.9). The most important predictive factor of recurrence in the NAT group was the age of patient. Conclusion: Breast conserving therapy is a safe procedure in satisfactorily downstaged breast cancer after neoadjuvant therapy. (c) 2008 Elsevier Ltd. All rights reserved.

Oral Medication With Diazepam or Midazolam Associated or Not With Clonidine for Oculoplastic Office Surgery Under Local Anesthesia

Purpose: To compare the level of sedation of oral administration of diazepam or midazolam associated or not with clonidine and their effects on upper eyelid margin position, heart rate, arterial pressure, and oxygen saturation. Methods: Seventy consecutive healthy patients American Society of Anesthesiologists (ASA) grade I-II scheduled for lower eyelid blepharoplasty were randomized into 4 groups according to the oral sedative agent used (group 1, diazepam 10 mg; group 2, diazepam 10 mg plus clonidine 0.15 mg; group 3, midazolam 15 mg; group 4, midazolam plus clonidine 0.15 mg). For all patients, the midpupil-to-upper eyelid margin distance, the heart rate, systolic and diastolic blood pressure, and oxygen saturation were recorded before and 1 hour after the administration of oral medication. The level of sedation at the time of surgery was measured with the Michigan University scale. Results: The depth of sedation was significantly more pronounced with midazolam (median score = 2) than with diazepam (median score = 1). Clonidine slightly increased the level of sedation of both diazepam and midazolam. The diastolic arterial blood pressure drop with midazolam associated or not with clonidine was significantly greater than with diazepam. The mean upper eyelid margin position shift (-1.42 mm) verified when clonidine was associated with midazolam was also significantly greater than with diazepam. Discussion: Oral sedation with diazepam or midazolam associated or not with clonidine is safe for ASA grade I-II patients. The systemic effects of diazepam and midazolam were small and very similar. The sedation induced by midazolam was clearly greater than that induced by diazepam. However, this higher level of sedation was accompanied by a more important shift in upper eyelid margin position.

Glaucoma and Keratoprosthesis Surgery Role of Adjunctive Cyclophotocoagulation

Purpose: To evaluate the efficacy and safety of diode laser transscleral cyclophotocoagulation (DLTSC) to control intraocular pressure (IOP) in keratoprosthesis patients with uncontrolled glaucoma. Patients and Methods: Between 1993 and 2007, 18 eyes of 18 patients underwent DLTSC, either before (n = 3), during (n = I), or after (n = 14) keratoprosthesis surgery. Keratoprosthesis type 1 was used in 72%. All but one of these patients received an Ahmed Glaucoma Valve, either with or after the keratoprosthesis placement. Best-corrected visual acuity, IOP (assessed by digital palpation), number of medications, and complications were recorded preoperatively, at day 7, at 1, 3, and 6 months then every 6 months postoperatively. Results: Mean follow-tip was 26.6 +/- 19.6 months (mean +/- SD) and mean age was 50.1 +/- 15.6 years. Glaucoma was identified in 1 I eyes before keratoprosthesis surgery and in 7 eyes after. Mean postoperative IOP was significantly reduced at 6, 12, 24, 36, and 48 months after DLTSC. DLTSC was repeated in 6 eyes. At final visit, mean best-corrected visual acuity was not decreased and there were no statistically significant differences in the number of glaucoma medications. Two patients had complications after DLTSC: a conjunctival dehiscence and a fungal endophthalmitis. Conclusions: DLTSC has beneficial long-term effects in the control of IOP and can be considered in the management of keratoprosthesis patients with refractory glaucoma.

The melatonin action on stromal stem cells within pericryptal area in colon cancer model under constant light

Constant light (LL) is associated with high incidence of colon cancer. MLT supplementation was related to the significant control of preneoplastic patterns. We sought to analyze preneoplastic patterns in colon tissue from animals exposed to LL environment (14 days; 300 lx), MLT-supplementation (10 mg/kg/day) and DMH-treatment (1,2 dimethylhydrazine; 125 mg/kg). Rodents were sacrificed and MLT serum levels were measured by radioimmunoassay. Our results indicated that LL induced ACF development (p < 0.001) with a great potential to increase the number of CD133(+) and CD68(+) cells (p < 0.05 and p < 0.001). LL also increased the proliferative process (PCNA-Li; p < 0.001) as well as decreased caspase-3 protein (p < 0.001), related to higher COX-2 protein expression (p < 0.001) within pericryptal colonic stroma (PCCS). However, MLT-supplementation controlled the development of dysplastic ACF (p < 0.001) diminishing preneoplastic patterns into PCCS as CD133 and CD68 (p < 0.05 and p < 0.001). These events were relative to decreased PCNA-Li index and higher expression of caspase-3 protein. Thus, MLT showed a great potential to control the preneoplastic patterns induced by LL. (C) 2011 Elsevier Inc. All rights reserved.

Exercise reduces inflammation and cell proliferation in rat colon carcinogenesis

Purposes: There is evidence that the risk of colon cancer is reduced by appropriate levels of physical exercise. Nevertheless, the mechanisms involved in this protective effect of exercise remain largely unknown. Inflammation is emerging as a unifying link between a range of environment exposures and neoplastic risk. The carcinogen dimethyl-hydrazine (DMH) induces an increase in epithelial cell proliferation and in the expression of the inflammation-related enzyme cyclooxigenase-2 (COX-2) in the colon of rats. Our aim was to verify whether these events could be attenuated by exercise. Methods: Four groups of eight Wistar rats were used in the experiment. The groups G1 and G3 were sedentary (controls), and the groups G2 and G4 were submitted to 8 wk of swimming training, 5 d wk(-1). The groups G3 and G4 were given subcutaneous injections of DMH immediately after the exercise protocols. Fifteen days after the neoplasic induction, the rats were sacrificed and the colon was processed for histological examination and immunohistochemistry staining of proliferating cell nuclear antigen (PCNA) and COX-2. Results: We found a significant increase in the PCNA-labeling index in both DMH-treated groups of rats. However, this increase was significantly attenuated in the training group G4 (P < 0.01). Similar results were observed in relation to the COX-2 expression. Conclusions: From our findings, we conclude that exercise training exerts remarkable antiproliferative and antiinflammatory effects in the rat colonic mucosa, suggesting that this may be an important mechanism to explain how exercise protects against colonic cancer.

Monitoring of protein catabolism in neonates and young infants post-cardiac surgery

Aims: To evaluate cell catabolism by balance of nitrogen and phosphate, and creatinine excretion in children post-cardiac surgery; to establish protein and energy requirements to minimize catabolism; and to assess nutritional therapy by following these parameters and serial anthropometric measurements. Methods: A prospective observational study of children with congenital heart disease undergoing cardiac surgery. Blood samples and 24-h urine collections were obtained postoperatively for creatinine measurement and nitrogen and phosphate balance. Anthropometric measurements (weight, mid-arm muscle circumference and triceps skinfold thickness) were obtained preoperatively and at paediatric intensive care unit and hospital discharge. Results: Eleven children were studied for 3-10 postoperative days. Anabolism was associated with higher protein and energy intakes compared to catabolism (1.1 vs. 0.1 g/kg/day and 54 vs. 17 kcal/kg/day, respectively). On days with anabolism, phosphate balance was greater compared with that on days with catabolism. Daily creatinine excretion did not correlate with protein balance. Anthropometric measurements did not change significantly over time. Conclusions: Children with congenital heart disease undergoing cardiac surgery achieved anabolism with > 55 kcal/kg/day and > 1 g/kg/day of protein. Balance of phosphate was useful to monitor cell breakdown. Anthropometric measurements were not valuable to evaluate nutritional therapy in this population.

Effect of Oral Hygiene with 0.12% Chlorhexidine Gluconate on the Incidence of Nosocomial Pneumonia in Children Undergoing Cardiac Surgery

OBJECTIVE. To evaluate the effect of oral hygiene with 0.12% chlorhexidine gluconate on the incidence of nosocomial pneumonia and ventilator-associated pneumonia (VAP) in children undergoing cardiac surgery. DESIGN. Prospective, randomized, double-blind, placebo-controlled trial. SETTING. Pediatric intensive care unit (PICU) at a tertiary care hospital. patients. One hundred sixty children undergoing surgery for congenital heart disease, randomized into 2 groups: chlorhexidine (n = 87) and control (n = 73). INTERVENTIONS. Oral hygiene with 0.12% chlorhexidine gluconate or placebo preoperatively and twice a day postoperatively until PICU discharge or death. RESULTS. Patients in experimental and control groups had similar ages (median, 12.2 vs 10.8 months; P =. 72) and risk adjustment for congenital heart surgery 1 score distribution (66% in category 1 or 2 in both groups; P =. 17). The incidence of nosocomial pneumonia was 29.8% versus 24.6% (Pp. 46) and the incidence of VAP was 18.3% versus 15% (Pp. 57) in the chlorhexidine and the control group, respectively. There was no difference in intubation time (P =. 34), need for reintubation (P =. 37), time interval between hospitalization and nosocomial pneumonia diagnosis (P =. 63), time interval between surgery and nosocomial pneumonia diagnosis (P =. 10), and time on antibiotics (P =. 77) and vasoactive drugs (P =. 16) between groups. Median length of PICU stay (3 vs 4 days; P =. 53), median length of hospital stay (12 vs 11 days; P =. 67), and 28-day mortality (5.7% vs 6.8%; P =. 77) were also similar in the chlorhexidine and the control group. CONCLUSIONS. Oral hygiene with 0.12% chlorhexidine gluconate did not reduce the incidence of nosocomial pneumonia and VAP in children undergoing cardiac surgery.

Risk stratification in neonates and infants submitted to cardiac surgery with cardiopulmonary bypass: A multimarker approach combining inflammatory mediators, N-terminal pro-B-type natriuretic peptide and troponin I

Low cardiac output syndrome (LCOS) is a common problem following cardiac surgery with cardiopulmonary bypass (CPB) in neonates and infants, and its early recognition remains a challenging task. We aimed to test whether a multimarker approach combining inflammatory and cardiac markers provides complementary information for prediction of LCOS and death in children submitted to cardiac surgery with CPB. Forty-six children younger than 18 months with congenital heart defects were prospectively enrolled. No intervention was made. Blood samples were collected pre-operatively, during CPB and post-operatively (PO) for measurement of interleukin (IL)-6, IL-8, IL-10, tumor necrosis factor (TNF)-alpha, cardiac troponin I (cTnI) and N-terminal pro-B-type natriuretic peptide (NT-proBNP). Clinical data and outcome variables were recorded. Logistic regression was used to identify predictors of LCOS and death. Multivariate logistic regression identified pre-operative NT-proBNP and IL-8 4 h PO as independent predictors of LCOS, while cTnI 4 h PO and CPB length were independent predictors of death. The use of inflammatory and cardiac markers in combination improved sensitivity, negative predictive value and accuracy of the models. In conclusion, the combined assessment of inflammatory and cardiac biochemical markers can be useful for identifying young children at increased risk for LCOS and death after heart surgery with CPB. (C) 2008 Elsevier Ltd. All rights reserved.

Effect of Multiple Cranial Burr Hole Surgery on Prevention of Recurrent Ischemic Attacks in Children with Moyamoya Disease

Moyamoya disease (MMD) is an uncommon cerebrovascular disorder characterized by progressive stenosis of the terminal portion of the internal carotid artery and its main branches. Direct and indirect bypass techniques have been devised with the aim of promoting neoangiogenesis. The current study aimed to investigate the role of multiple cranial burr hole (MCBH) operations in the prevention of cerebral ischemic attacks in children with MMD. Seven children suffering from progressive MMD were submitted to the MCBH and arachnoid opening technique. Ten to 20 burr holes were drilled in the fronto-temporo-parieto-occipital area of each hemisphere in each patient, depending on the site and extent of the disease. All patients were evaluated pre- and postoperatively by means of Barthel index (BI), CT, MR, angio-MR, and angiography. Patients had no recurrence of ischemic attacks postoperatively. Neoangiogenesis was observed in both hemispheres. One patient developed a persistent subdural collection after surgery, thus requiring placement of a subdural-peritoneal shunt. Postoperative BI was statistically significantly improved (P = 0.02). This report suggests that MCBH for revascularization in MMD is a simple procedure with a relatively low risk of complications and effective for preventing cerebral ischemic attacks in children. In addition, MCBH may be placed as an adjunct to other treatments for MMD.