Análise crítica das técnicas de tratamento cirúrgico da obesidade mórbida

Introdução: A obesidade é uma afecção com alta prevalência no Brasil e no mundo. É fator de risco para comorbidades como Diabetes tipo 2 (DM2), Hipertensão Arterial Sistêmica (HAS), Dislipidemia, Apneia Obstrutiva do Sono (AOS), entre outras. Seu tratamento é complexo e a cirurgia bariátrica, executada por diferentes técnicas, tem sido uma das opções. Objetivo: Analisar os resultados publicados na literatura em relação às técnicas cirúrgicas de Banda Gástrica Ajustável (BGA), Gastrectomia Vertical (GV), Gastroplastia com derivação em Y de Roux (GDYR) e Derivação Biliopancreática (DBP) - técnica de \"Scopinaro\" e de \"Duodenal Switch\" quanto às complicações operatórias, à mortalidade, à perda do excesso de peso (PEP) e ao reganho, e a resolução das comorbidades após a operação. Método: Foram analisados 116 estudos selecionados na base de dados MEDLINE por meio da PubMed publicados na Língua Inglesa entre 2003 e 2014. Para comparar as diferentes técnicas cirúrgicas (BGA, GV, GDYR e DBP), realizou-se estudo estatístico por meio da análise de variância (ANOVA) aplicando os testes de Duncan e de Kruskal Wallis avaliando: complicações pós-operatórias (fístula, sangramento e óbito); perda e reganho do excesso de peso, e resolução das comorbidades. Resultados: A ocorrência de sangramento foi de 0,6% na média entre todos os estudos, sendo 0,44% na BGA; 1,29% na GV; 0,81% na GDYR e 2,09% na DBP. Já a ocorrência de fístulas foi de 1,3% na média entre todos os estudos, 0,68% para BGA; 1,93% para GV; 2,18% para GDYR e 5,23% para DBP. A mortalidade nos primeiros 30 dias pós-operatórios foi de 0,9% na média entre todos os estudos, 0,05% na BGA; 0,16% na GV; 0,60% na GDYR e 2,52% na DBP. A PEP após cinco anos na média entre todos os estudos foi de 63,86%, especificamente na BGA, foi de 48,35%; 52,7% na GV; 71,04% na GDYR e 77,90% na DBP. A taxa de DM2 resolvida foi de 76,9% na média entre todos os estudos, sendo 46,80% na BGA; 79,38% na GV; 79,86% na GDYR e 90,78% na DBP. A taxa de Dislipidemia resolvida após a operação foi de 74,0% na média de todo o estudo, sendo 51,28% na BGA; 58,00% na GV; 73,28% na GDYR e 90,75% na DBP. A taxa de HAS resolvida após a operação foi de 61,80% na média de todo o estudo, sendo 54,50% na BGA; 52,27% na GV; 68,11% na GDYR e 82,12% na DBP. A taxa de AOS resolvida após a operação foi de 75,0% na média de todo o estudo, sendo 56,85% na BGA; 51,43% na GV; 80,31% na GDYR e 92,50% na DBP. Conclusão: quando analisadas e comparada as quatro técnicas observa-se que nos primeiros 30 dias pós-operatório a taxa de sangramento é superior nos pacientes submetidos à DBP e taxa de fístula inferior nos pacientes da BGA. Quanto à mortalidade observou-se taxa mais pronunciada nos pacientes submetidos à DBP e menos nos submetidos à BGA. Quanto à PEP observou-se uma uniformidade entre os pacientes submetidos à GV, GDYR E DBP até o terceiro ano. Após esse período observa-se reganho de peso nos submetidos à GV até o quinto ano de seguimento. Já nos pacientes submetidos à BGA observou-se taxas de PEP menos pronunciadas em relação às demais desde o início do seguimento. Quanto à resolução das comorbidades observou-se taxas de resolução de DM2 inferiores nos pacientes submetidos à BGA, e não houve diferença entre nenhuma técnica quanto à resolução das demais comorbidades: HAS, AOS e dislipidemia

Epicardial phrenic nerve displacement during catheter ablation of atrial and ventricular arrhythmias: procedural experience and outcomes.

BACKGROUND Arrhythmia origin in close proximity to the phrenic nerve (PN) can hinder successful catheter ablation. We describe our approach with epicardial PN displacement in such instances. METHODS AND RESULTS PN displacement via percutaneous pericardial access was attempted in 13 patients (age 49±16 years, 9 females) with either atrial tachycardia (6 patients) or atrial fibrillation triggered from a superior vena cava focus (1 patient) adjacent to the right PN or epicardial ventricular tachycardia origin adjacent to the left PN (6 patients). An epicardially placed steerable sheath/4 mm-catheter combination (5 patients) or a vascular or an esophageal balloon (8 patients) was ultimately successful. Balloon placement was often difficult requiring manipulation via a steerable sheath. In 2 ventricular tachycardia cases, absence of PN capture was achieved only once the balloon was directly over the ablation catheter. In 3 atrial tachycardia patients, PN displacement was not possible with a balloon; however, a steerable sheath/catheter combination was ultimately successful. PN displacement allowed acute abolishment of all targeted arrhythmias. No PN injury occurred acutely or in follow up. Two patients developed acute complications (pleuro-pericardial fistula 1 and pericardial bleeding 1). Survival free of target arrhythmia was achieved in all atrial tachycardia patients; however, a nontargeted ventricular tachycardia recurred in 1 patient at a median of 13 months' follow up. CONCLUSIONS Arrhythmias originating in close proximity to the PN can be targeted successfully with PN displacement with an epicardially placed steerable sheath/catheter combination, or balloon, but this strategy can be difficult to implement. Better tools for phrenic nerve protection are desirable.

Neogene radiolarian datum levels in the equatorial Indian and Pacific Oceans

Fifty radiolarian events of early Pleistocene and Neogene age were identified in an E-W transect of equatorial DSDP sites, extending from the Gulf of Panama to the western Pacific and eastern Indian Oceans. Our objective was to document the degree of synchroneity or time-transgressiveness of stratigraphically-useful datum levels from this geologic time interval. We restricted our study to low latitudes within which morphological variations of individual taxa are minimal, the total assemblage diversity remains high, and stratigraphic continuity is well-documented by an independent set of criteria. Each of the five sites chosen (503, 573, 289/586, 214) was calibrated to an "absolute" time scale, using a multiple of planktonic foraminiferal, nannofossil, and diatom datum levels which have been independently correlated to the paleomagnetic polarity time scale in piston core material. With these correlations we have assigned "absolute" ages to each radiolarian event, with a precision of 0.1-0.2 m.y. and an accuracy of 0.2-0.4 m.y. On this basis we have classified each of the events as either: (a) synchronous (range of ages <0.4 m.y.); (b) time-transgressive (i.e., range of ages >1.0 m.y.); and (c) not resolvable (range of ages 0.4-1.0 m.y.). Our results show that, among the synchronous datum levels, a large majority (15 out of 19) are last occurrences. Among those events which are clearly time-transgressive, most are first appearances (10 out of 13). In many instances taxa appear to evolve first in the Indian Ocean, and subsequently in the western and eastern Pacific Ocean. This pattern is particularly unexpected in view of the strong east-to-west zonal flow in equatorial latitudes. Three of the time-transgressive events have been used to define zonal boundaries: the first appearances of Spongaster pentas, Diartus hughesi, and D. petterssoni. Our results suggest that biostratigraphic non-synchroneity may be substantial (i.e., greater than 1 m.y.) within a given latitudinal zone; one would expect this effect to be even more pronounced across oceanographic and climatic gradients. We anticipate that the extent of diachroneity may be comparable for diatom, foraminiferal, and nannofossil datum levels as well. If this proves true, global "time scales" may need to be re-formulated on the basis of a smaller number of demonstrably synchronous events.

Radiolarians from ODP Leg 119, Kerguelen Plateau

Radiolarians are abundant and well preserved in the Neogene of the Kerguelen Plateau. They are common and moderately to well preserved in the Oligocene sequences of Site 738, where the Eocene/Oligocene boundary was observed for the first time in subantarctic sediments, and Site 744. Radiolarians are absent from all glacial sediments from Prydz Bay. Classical Neogene stratigraphic markers were tabulated at all sites. Correlations with paleomagnetic ages were made at Sites 745 and 746 for 26 Pliocene-Pleistocene radiolarian events. Many Miocene to Holocene species are missing from Sites 736 and 737, which were drilled in shallow water (less than 800 m). The missing species are considered to be deepliving forms. Occurrences and relative abundances of morphotypes at six sites are reported. Two new genera (Eurystomoskevos and Cymaetron) and 17 new species (Actinomma kerguelenensis, A. campilacantha, Prunopyle trypopyrena, Stylodictya tainemplekta, Lithomelissa cheni, L. dupliphysa, Lophophaena(?) thaumasia, Pseudodictyophimus galeatus, Lamprocyclas inexpectata, L. prionotocodon, Botryostrobus kerguelensis, B. rednosus, Dictyoprora physothorax, Eucyrtidium antiquum, E.(?) mariae, Eurystomoskevos petrushevskaae, and Cymaetron sinolampas) are described from the middle Eocene to Oligocene sediments at Sites 738 and 744. Twenty-seven stratigraphic events are recorded in the middle to late Eocene of Site 738, and 27 additional stratigraphic datums are recorded, and correlated to paleomagnetic stratigraphy, in the early Oligocene at Sites 738 and 744. Eight radiolarian events are recorded in the late Oligocene at Site 744. New evolutionary lineages are proposed for Calocyclas semipolita and Prunopyle trypopyrena.

Radiolarian assemblages of ODP Leg 117 sites

Significant numbers of radiolarians ranging in age from late middle Miocene to Recent were recovered from six sites drilled on the Oman margin and Owen Ridge. Sparse faunas were recovered from five additional sites on the Oman margin and one site on the Indus Fan. Detailed range charts and biozonations are presented for most sites. The radiolarian assemblages are peculiar in that numerous common tropical forms, some of which are biomarkers, are absent or very rare. In addition, some species not usually found in tropical assemblages are present. These forms, indicative of up welling conditions, fall into three categories: (1) endemic upwelling: species endemic to upwelling and not previously described from the Indian Ocean; (2) displaced temperate: temperate forms not usually found in tropical waters; and (3) enhanced tropical: tropical forms which are more abundant and/or robust in areas of upwelling. Comparison of the Oman margin/Owen Ridge fauna with that recovered from the Peru margin upwelling area (ODP Leg 112) suggests that the assemblage may be globally diagnostic of upwelling conditions. The onset of upwelling is marked by the appearance of siliceous biota at about 11.9 Ma, and there is some indication of a decrease in the strength of the upwelling signal at about 9.6 Ma. A strong pulse in, or strengthening of, the upwelling mechanism is indicated by a marked fauna change at 4.7 Ma. There is a weaker signal, implying a change in upwelling conditions, at about 1.5 Ma.

Traité de la fistule de l'anus ou du fondement, dans lequel on expose ses causes, ses signes, les remedes pour le guerir, & les moyens de s'en preserver /

Mode of access: Internet.

The chirurgical works of Percivall Pott, with his last corrections. : to which are added, a short account of the life of the author, a method of curing the hydrocele by injection, and occasional notes and observations /

Published in London in 1771 and 1808.

A study of large-bowel volvulus in urban Australia

Background: Large-bowel volvulus is a rare cause of bowel obstruction in the industrialized world. We analyzed the presentation and outcome of 49 patients at the Princess Alexandra Hospital, Brisbane, Australia, who received a diagnosis of colonic volvulus from 1991 to 2001. Methods: A retrospective chart study was carried out. Results: Twenty-nine patients had sigmoid volvulus (59%), 19 patients had cecal volvulus (39%) and 1 patient had a transverse colon volvulus (2%). The diagnosis of sigmoid volvulus was made accurately on plain abdominal radiography or contrast enema in 90% of cases (n = 26), compared with only 42% of cases (n = 8) of cecal volvulus. Twenty-two patients with sigmoid volvulus were treated initially with endoscopic decompression. The success rate was 64% (n = 14). There was a high early recurrence rate of sigmoid volvulus for those treated by endoscopic decompression alone (43%) during a mean period of 32 days. Of the 14 patients with cecal volvulus who were treated with right hemicolectomy, 12 had primary anastomosis and 2 had end ileostomy with mucous fistula formation. There was no anastomotic leak following right hemicolectomy with primary anastomosis, even though 6 of these patients had an ischemic cecum. Conclusions: Endoscopic decompression of the sigmoid volvulus was safe and effective as an initial treatment but has a high early recurrence rate. Any patient who is fit enough to undergo operation should have a definitive procedure during the same admission to avoid recurrence. Cecal volvulus is associated with a higher incidence of gangrene and is treated effectively by right hemicolectomy with or without anastomosis. The need for swift operative intervention is emphasized.

OSTEOTOMIA SEGMENTAR DE MAXILA CASO CLÍNICO

A Osteotomia Segmentar de Maxila ou Osteotomia Le Fort I Segmentada é um procedimento que tem se tornado, cada vez mais comum, nas cirugias para as correções das deformidades dentofaciais, conhecidas como Cirurgias Ortognáticas. Este procedimento é muito bem indicado para a correção das discrepâncias maxilares, nos diferentes planos e num único tempo cirúrgico, otimizando assim, o tempo de tratamento a que o paciente é submetido. A estabilidade esquelética transversal e a oclusal dos pacientes, que são submetidos a este tipo de osteotomia, tem sido objeto de estudo na literatura , assim como também, os potenciais riscos e complicações inerentes a este procedimento como, a desvitalização dentária, fístula oro-nasal, perda dentária, necrose de algum segmento da maxila ou até mesmo, de toda a maxila. O objetivo deste trabalho é apresentar o caso clínico de um paciente submetido à osteotomia segmentar de maxila, e fazer uma revisão da literatura abrangendo os últimos 10 anos, com artigos que abordam a estabilidade deste tipo de procedimento, assim como também os potenciais riscos e complicações aos pacientes submetidos a este procedimento. Utilizando algumas palavras chave na base de dados eletrônica PUBMED, 12 artigos foram selecionados para este trabalho, no período de 2002 a 2012. A Osteotomia Segmentar de Maxila é um procedimento estável e seguro, com baixo índice de complicação, quando indicado corretamente e com os devidos cuidados no pré, trans e pós operatórios.