Conduta terapêutica atual no adenocarcinoma da cárdia e da junção esofagogástrica

Adenocarcinomas of the cardia and gastroesophageal junction are peculiar entities with three different origins, which differ somewhat from other adenocarcinomas of the stomach in their clinical presentation and pathogenesis, and have a poorer prognosis. In this article the authors reviewed definitions, incidence and epidemiology, etiologic factors, genetic implications, clinical presentation, diagnosis, staging and treatment, with emphasis on the surgical approach, discussing the current management of these cancers. The prognostic factors related specifically to the cardia cancers are: esophageal invasion greater than 3cm, microscopic residual tumor and wall penetration (>T2). Preoperative workup should include computed tomography, and endoscopic ultrasonography and laparoscopy when available. Preoperative recognition of T3/ T4/N2 lesions should indicate inclusion in neo-adjuvant protocols whenever possible. The authors present the results of 46 resected cases of adenocarcinomas of the cardia and GE junction of the Instituto Nacional do Câncer- Brazil (1981-1995). Cure was intended in 29 and palliation in 17 patients. The most common type of resection was total gastrectomy with abdominal esophagectomy (28 cases). Morbidity (major and minor) occurred in 50% of the patients. The main causes were of respiratory origin and fistulas (19.6% each). Death occurred in 44% of the patients with fistula. Postoperative death until the 30th day occurred in 17.24% of the curative cases and in 23.52% of the palliative ones. The median survival time was 68.5 months for stage I, 25 months for stage II, 31 months for stage III and 12.5 months for stage IV diseases. The median survival time was 8 months for palliation and 28.5 months for cure. No long-term survival was obtained with the palliative group, whereas 25% survived five years of more in the curative group. The authors conclude that the surgical approach should be the one the surgeon feels more comfortable with. Complete removal of the disease proved by frozen section, splenectomy and D2 lymphadenectomy should be the standard therapy with curative intent.

Hérnia perineal após disjunçao da sínfise púbica: apresentação de caso e técnica para correção

Traunatic perineal hernia remains a rare clinical entity despite an overall increase in blunt trauma. Because of the incidence of other associated injuries, the mortality is high. Most of the perineal defects are repaired during the orthopaedics surgery to reconstitute the pelvis and few patients develop a true perineal hernia without pelvic instability. A 80-year-old woman was involved in a running over accident with disjunction of pubic symphysis, dislocation of sacrum-iliac junction and fracture of pubis and ischium. The patient was submitted to an orthopaedic surgery and latter development an perineal hernia through the genitalia. The diagnosis could be established with physical examination alone. Conventional radiology, computadorized tomography, and ultrasound should also be done to progran the surgery. The repair approach was performed using a marlex mesh, fixed in the pelvic bones, Cooper ligament, and the abdominal wall. The mesh was stood in a retro- peritoneal position, rebuilding the pelvic floor without reconstruction the pelvic bones. We conclude that this is an efficient approach to repair of traumatic postoperative perineal hernia, mainly in patients with high operative risk, when the osseous repair is not necessary.

Acalasia do esôfago: miotomia com transiluminação

Laparoscopic techniques have provided a new dimension to correct functional disorders of the esophagus, which has stimulated some investigators to recently report the use of laparoscopic cardiomyotomy in the treatment of esophageal achalasia. Now, a new instrument has been added to the current laparoscopic technique to offer a safer and easier method to proceed complete myotomy. After the dissection of the esophagogastric junction, a special catheter is introduced reaching the stomach. lt has an illuminated 10 cm extremity connected to a light source. lts withdrawal allows to visualize every muscle circular fiber by transillumination withan improved view provide by the laparoscopic optic system lens. This condition modifies the operative surgeon s attitude offering a better controlled situation over the procedure. The use of transillumination o fthe esophagogastric junction provides a good identification of the mucosa e submucosa avoiding the risk of esophageal perforation. It also helps to perform a complete myotomy preventing the ocurrence of persistent disphagia in the postoperative period. Cardiomyotomy with parcial fundoplication is possible by videolaparoscopic approach, now made easier with transillumination. This technique is safe and the functional results are similar to those observed in the literature for conventional open procedures, with the obvious advantages of the minimally invasive approach.

Banda gástrica ajustável laparoscópica: alternativa técnica

In these paper we are presenting a technical alternative to laparoscopic adjustable gastric banding. From January 1999 to April 2000, 60 patients with mean body mass index (BMI) of 40,7 kg/m2 underwent laparoscopic adjustable gastric banding. The new technique is performed in two steps. In the first step, an isolation instrument (laparoscopic finger) is inserted through the lesser sac, next to the junction of diaphragmatic crura, including the lesser omentum in order to pull the band catheter. The second step separates the lesser omentum from the right side of the stomach.There was no mortality and the morbidity was 11,6% (1 slippage of the band and 6 trocar port seroma). The new technique was performed in all patients with no conversion to open procedure. We didn't have respiratory complications. This technical alternative is safe and easily performed, helping to prevent transoperative perforations.

Volvo gástrico agudo perfurado

The authors report a case of acute gastric volvulus in a 20-year-old male, complicated by perforation near the gastroesophageal junction and generalized peritonitis. This is an uncommon and potentially lethal conditon although our patient has been handled successfully with a partial gastrectomy.

Necrose da mucosa esofágica como complicação da cardiomiotomia à heller para tratamento de megaesôfago chagásico

This article presents a complication of the laparoscopic technique for Heller cardiomyotomy and anterior fundoplication. This procedure is safe and provides excellent relief of disphagia in esophageal achalasia. Nevertheless, there are rare but dangerous complications, such as late active digestive bleeding, presented in this paper which was resistant to conservative treatment and led to hypovolemic shock. Urgent laparotomy performed to identify and control bleeding, revealed necrosis of esophageal mucosa with a bleeding gastric vessel. Inadequate exposure of the gastroesophageal junction and an incision very close to the lesser curvature might have damaged the esophageal branches of the left gastric artery, leading to ischemic necrosis of the mucosa and exposure of the gastric wall and its vessels.

Cisto de colédoco em adulto: anomalia da junção do colédoco com o ducto pancreático submetido à ressecção do cisto e à derivação biliar e pancreática

Common bile duct cysts are rare congenital anomalies which have been diagnosed only in twenty per cent of adults. The etiology is uncertain, but many patients have an anomalous pancreatobiliary junction anatomy. We present a case of a young man with a type I Alonso-Lej/ Todani common bile duct cyst and an anomalous common bile duct-pancreatic junction anatomy. Because the common bile duct did not have a segment of normal caliber, to avoid compromising with the pancreatic channel after the excision of the cyst, we performed a Roux-en-Y anastomosis by anastomosing the biliary duct to the proximal excluded jejunal loop and the common duct-pancreatic junction to the same more distally loop.

Anatomical and functional characteristics of the pelvic floor in nulliparous women submitted to three-dimensional endovaginal ultrasonography: case control study and evaluation of interobserver agreement

PURPOSE: To determine anatomical and functional pelvic floor measurements performed with three-dimensional (3-D) endovaginal ultrasonography in asymptomatic nulliparous women without dysfunctions detected in previous dynamic 3-D anorectal ultrasonography (echo defecography) and to demonstrate the interobserver reliability of these measurements. METHODS: Asymptomatic nulliparous volunteers were submitted to echo defecography to identify dynamic dysfunctions, including anatomical (rectocele, intussusceptions, entero/sigmoidocele and perineal descent) and functional changes (non-relaxation or paradoxical contraction of the puborectalis muscle) in the posterior compartment and assessed with regard to the biometric index of levator hiatus, pubovisceral muscle thickness, urethral length, anorectal angle, anorectal junction position and bladder neck position with the 3-D endovaginal ultrasonography. All measurements were compared at rest and during the Valsalva maneuver, and perineal and bladder neck descent was determined. The level of interobserver agreement was evaluated for all measurements. RESULTS: A total of 34 volunteers were assessed by echo defecography and by 3-D endovaginal ultrasonography. Out of these, 20 subjects met the inclusion criteria. The 14 excluded subjects were found to have posterior dynamic dysfunctions. During the Valsalva maneuver, the hiatal area was significantly larger, the urethra was significantly shorter and the anorectal angle was greater. Measurements at rest and during the Valsalva maneuver differed significantly with regard to anorectal junction and bladder neck position. The mean values for normal perineal descent and bladder neck descent were 0.6 cm and 0.5 cm above the symphysis pubis, respectively. The intraclass correlation coefficient ranged from 0.62-0.93. CONCLUSIONS: Functional biometric indexes, normal perineal descent and bladder neck descent values were determined for young asymptomatic nulliparous women with the 3-D endovaginal ultrasonography. The method was found to be reliable to measure pelvic floor structures at rest and during Valsalva, and might therefore be suitable for identifying dysfunctions in symptomatic patients.

Are alveolar bone changes a determinant factor for "cara inchada" in cattle?

In order to study possible alterations of the skeleton which might play a role in the pathogenesis of the periodontitis of "cara inchada" in young cattle, ribs from 20 affected calves, 2 to 10 months old, were examined. Electrolytically decalcified longitudinal sections of the costochondral junction and cross sections through the corpus costae, stained with Haematoxylin-Eosin, were studied. In five calves, longitudinal sections of the proximal humerus were examined as well. The status of mineralization was checked by microradiograms. Systemic alteration of the skeleton due to disturbances of mineral metabolism could not be shown in any of the animals. In seven 2 to 4 months old calves, no bone changes were found. The reduced osteogenesis in six 3 to 5 months old calves and the reduced osteogenesis and diminished chondral growth in seven 5 to 10 months old calves are therefore a consequence of the disease. The results show that the development of the alveolar bone was not defective, so this cannot be a determinant factor for the development of the periodontitis of "cara inchada" in cattle.

Expression and distribution of connexin 32 in rat liver with experimentally induced fibrosis

The connexin 32 (Cx32) is a protein that forms the channels that promote the gap junction intercellular communication (GJIC) in the liver, allowing the diffusion of small molecules through cytosol from cell-to-cell. Hepatic fibrosis is characterized by a disruption of normal tissue architeture by cellular lesions, and may alter the GJIC. This work aimed to study the expression and distribution of Cx32 in liver fibrosis induced by the oral administration of dimethylnitrosamine in female Wistar rats. The necropsy of the rats was carried out after five weeks of drug administration. They presented a hepatic fibrosis state. Sections from livers with fibrosis and from control livers were submitted to immunohistochemical, Real Time-PCR and Western-Blot analysis to Cx32. In fibrotic livers the Cxs were diffusely scattered in the cytoplasm, contrasting with the control livers, where the Cx32 formed junction plaques at the cell membrane. Also it was found a decrease in the gene expression of Cx32 without reduction in the protein quantity when compared with controls. These results suggest that there the mechanism of intercellular communication between hepatocytes was reduced by the fibrotic process, which may predispose to the occurrence of a neoplastic process, taken in account that connexins are considered tumor suppressing genes.

Rectal stenosis in pigs associated with Salmonella Typhimurium and porcine circovirus type 2 (PCV2) infection

Rectal stricture is an acquired annular fibrous constriction of the rectum that results from a variety of chronic necrotizing enteric diseases. In pigs, it is in most cases a sequel of Salmonella infection. Porcine circovirus type 2 (PCV2) is a known pathogen causing immunosuppression in pigs worldwide. PCV2 infected pigs may be predisposed to salmonellosis. In this report, rectal stenosis was observed in 160 pigs from a herd that experienced an outbreak of enteric salmonellosis over a 4-month period. Distension of the abdominal wall and diarrhea were the main clinical signs observed. Five animals were analyzed showing annular cicatrization of the rectal wall 5.0-7.0 cm anterior to the anorectal junction and Salmonella-positive immunostaining in the large intestine. Salmonella Typhimurium was isolated from fragments of the large intestine. Porcine circovirus type 2 antigen was observed in the mesenteric lymph-node in 4 pigs and in the large intestine in 3 pigs.

Histopathology of dairy cows' hooves with signs of naturally acquired laminitis

The purpose of this study was to investigate histological changes in dairy cows' hooves with or without injuries from naturally acquired laminitis. Cull cows with no clinical signs of hoof abnormalities (G1, n=9) and those with macroscopic lesions associated with laminitis without (G2, n=23) or with lameness (G3, n=7) were used in the study. After slaughter, samples of dermo-epidermal junctions of sole, axial and dorsal regions of the hoof were obtained and histologically processed using HE and PAS staining. Congestion, hemorrhage and inflammatory infiltrate in the dermis of sole, axial and dorsal regions were blindly and semiquantitatively evaluated by the same researcher. Inflammatory infiltrate was evaluated in the dermal laminae of axial and dorsal regions. The morphology of epidermal cells and the presence of irregularities in three regions of the basement membrane (BM) length were examined using PAS staining. Scores of lesions in different regions of the hoof in the same group and in different groups for each region of the hoof were compared using non-parametric analyses. Inflammatory infiltrate in the dermis of all regions of the hoof was detected in all groups with no significant statistical difference. Cows with no clinical signs of hoof abnormalities secondary to laminitis (G1) have inflammation scores and epidermal cell changes similar to those of groups with laminitis injuries, suggesting the existence of a prodromal phase for this disease in bovines. BM had irregularities with a variable intensity along its length, however, with no difference among groups. The pattern of BM irregularities found has not been reported so far and does not resemble the BM collapse described in horses and cattle with induced acute laminitis. Is it concluded that even in the absence of macroscopic hoof signs associated to laminitis, dairy cows have histological injuries compatible with inflammation of the dermo-epidermal junction as in affected animals. Basement membrane of cows with or without laminitis associated lesions had irregularities with an irregular distribution along its length which need to be further studied.

Anatomical and histological characteristics of teeth in agouti (Dasyprocta prymnolopha Wagler, 1831)

The agouti species Dasyprocta prymnolopha (D. prymnolopha) is a medium-sized rodent, diurnal, and characteristic of northeastern Brazil, south of the Amazon. Several studies have been made on these rodents. However, there is a lack of analysis of masticatory system, in particular morphology of the teeth. Thus, this research seeks to describe anatomical and histological aspects of the agouti teeth. For this purpose, we used adult agouti, in which measurements and descriptions of teeth and dental tissues were made. It was observed that the dental arch of D. prymnolopha comprises of twenty teeth, evenly distributed in the upper and lower arch, being inferior teeth larger than their corresponding higher. The incisors are larger, and between the posterior premolars and molars, there is a gradual increase in length in the anterior-posterior arch. In microscopic examination, a prismatic appearance was observed consisting of enamel prisms arranged in different directions, behind the enamel and dentin with standard tubular dentinal tubules with variable diameter and far between, also showing a sinuous path from the inner portion to the junction with more superficial enamel. Morphological analysis of dental tissues showed that an enamel with structural organization adapted to the act of chewing and high impact dentin compatible with standard tubular function resilience and mechanical damping of masticatory forces, as found in larger animals, confirming the understanding of eating habits that define much of its ecological functions within the ecosystem they inhabit.

Regulation of epidermal tight junctions by calcium ATPases and p38

The epidermis is the upper layer of the skin and keratinocytes are its most abundant cells. Tight junctions are cell junctions located in the granular layer of the epidermis. They maintain the polarity of the cells and regulate the movement of water-soluble molecules. Epidermal tight junctions may lose their integrity when there are defects in intercellular calcium regulation. Hailey-Hailey and Darier´s disease are dominantly inherited, blistering skin diseases. Hailey-Hailey disease is caused by mutations in the ATP2C1 gene encoding a calcium/manganese ATPase SPCA1 of the Golgi apparatus. Darier´s disease is caused by mutations in the ATP2A2 gene encoding a calcium ATPase SERCA2 of the endoplasmic reticulum. p38 regulates the differentiation of keratinocytes. The overall regulation of epidermal tight junctions is not well understood. The present study examined the regulation of tight junctions in the human epidermis with a focus on calcium ATPases and p38. Skin from Hailey-Hailey and Darier´s disease patients was studied by using immunofluorescence labeling which targeted intercellular junction proteins. Transepidermal water loss was also measured. ATP2C1 gene expression was silenced in cultured keratinocytes, by siRNA, which modeled Hailey-Hailey disease. Expression of intercellular junction proteins was studied at the mRNA and protein levels. Squamous cell carcinoma and normal human keratinocytes were used as a model for impaired and normal keratinocyte differentiation, and the role of p38 isoforms alpha and delta in the regulation of intercellular junction proteins was studied. Both p38 isoforms were silenced by adenovirus cell transduction, chemical inhibitors or siRNA and keratinocyte differentiation was assessed. The results of this thesis revealed that: i.) intercellular junction proteins are expressed normally in acantholytic skin areas of patients with Hailey-Hailey or Darier´s disease but the localization of ZO-1 expanded to the stratum spinosum; ii.) tight junction proteins, claudin-1 and -4, are regulated by ATP2C1 in non-differentiating keratinocytes; and iii.) p38 delta regulates the expression of tight junction protein ZO-1 in proliferating keratinocytes and in squamous cell carcinoma derived cells. ZO-1 silencing, however, did not affect the expression of other tight junction proteins, suggesting that they are differently regulated. This thesis introduces new mechanisms involved in the regulation of tight junctions revealing new interactions. It provides novel evidence linking intracellular calcium regulation and tight junctions.

Reducing contact resistance in graphene devices

In this thesis, the contact resistance of graphene devices was investigated because high contact resistance is detrimental to the performance of graphene field-effect transistors (GFET). Method for increasing so-called edge-contact area was applied in device fabrication process, as few nanometers thick Ni layer was used as a catalytic etchant during the annealing process. Finally, Ni was also used as a metal for contact. GFETs were fabricated using electron beam lithography using graphene fabricated by chemical vapor deposition (CVD). Critical part of the fabrication process was to preserve the high quality of the graphene channel while etching the graphene at contact areas with Ni during the annealing. This was achieved by optimizing the combination of temperature and gas flows. The structural properties of graphene were studied using scanning electron microscopy, scanning confocal μ-Raman spectroscopy and optical microscopy. Evaluation of electric transport properties including contact resistance was carried out by transmission line method and four-probe method. The lowest contact resistance found was about at 350 Ωμm. In addition, different methods to transfer CVD graphene synthesized on copper were studied. Typical method using PMMA as a supporting layer leaves some residues after its removal, thus effecting on the performance of a graphene devices. In a metal assisted transfer method, metal is used as an interfacial layer between PMMA and graphene. This allows more effective removal of PMMA. However, Raman spectra of graphene transferred by metal assisted method showed somewhat lower quality than the PMMA assisted method