Leiomiomas do esôfago removidos por vídeo-toracoscopia

This report describes three cases of esophageal leiomyomas successfully resected by thoracoscopy. Surgical enucleation through minimally invasive surgery is the treatment of choice for esophageal leiomyoma. The conventional approach through a formal thoracotomy has the potential of causing excessive pain and patient discomfort. Moreover, the hospital stay and the recovery period are prolonged. Indications for surgery were based mainly on the size of the mass (<4 cm) and the presence of dysphagia. In one case there was a clear suspicion of malignancy. The tumour was located in the lower thoracic esophagus (case 1), in the middle thoracic esophagus (case 2) and in the upper esophagus (case 3). The CT was useful in identifying the relationship between the lesion and the organs of the mediastinum. The barium swallow study was able to locate the lesion along the esophagus. The endosonography determined the boundaries of the lesions. A right thoracoscopic approach was undertaken. Dissection of the esophagus around its entire perimeter was never necessary because all tumours were anterior or right sided. The tumours were better grasped with a traction suture than with forceps. The hidrodissection was very helpful. The water-soluble contrast swallow, performed on the fourth postoperative day, was normal. Clinical results were satisfactory in all patients. Biopsies should never be performed when the mucosa overlying is normal.

Alpha2-Adrenoceptor-mediated vascular responses induced by dexmedetomidine

Alpha2-Adrenoceptors are cell-surface G protein coupled receptors that mediate many of the effects of the catecholamines noradrenaline and adrenaline. The three human α2-adrenoceptor subtypes are widely expressed in different tissues and organs, and they mediate many different physiological and pharmacological effects in the central and peripheral nervous system and as postsynaptic receptors in target organs. Previous studies have demonstrated that α2-adrenoceptors mediate both vascular constriction and dilatation in humans. Large inter-individual variation has been observed in the vascular responses to α2-adrenoceptor activation in clinical studies. All three receptor subtypes are potential drug targets. It was therefore considered important to further elucidate the details of adrenergic vascular regulation and its genetic variation, since such knowledge may help to improve the development of future cardiovascular drugs and intensive care therapies. Dexmedetomidine is the most selective and potent α2-adrenoceptor agonist currently available for clinical use. When given systemically, dexmedetomidine induces nearly complete sympatholysis already at low concentrations, and postsynaptic effects, such vasoconstriction, can be observed with increasing concentrations. Thus, local infusions of small doses of dexmedetomidine into dorsal hand veins and the application of pharmacological sympathectomy with brachial plexus block provide a means to assess drug-induced peripheral vascular responses without interference from systemic pharmacological effects and autonomic nervous system regulation. Dexmedetomidine was observed to have biphasic effects on haemodynamics, with an initial decrease in blood pressure at low concentrations followed by substantial increases in blood pressure and coronary vascular resistance at high concentrations. Plasma concentrations of dexmedetomidine that significantly exceeded the recommended therapeutic level did not reduce myocardial blood flow below the level that is observed with the usual therapeutic concentrations and did not induce any evident myocardial ischaemia in healthy subjects. Further, it was demonstrated that dexmedetomidine also had significant vasodilatory effects through activation of endothelial nitric oxide synthesis, and thus when the endothelial component of the blood vessel response to dexmedetomidine was inhibited, peripheral vasoconstriction was augmented. Hand vein constriction responses to α2-adrenoceptor activation by dexmedetomidine were only weakly associated with the constriction responses to α1-adrenoceptor activation, pointing to independent cellular regulation by these two adrenoceptor classes. Substantial inter-individual variation was noted in the venous constriction elicited by activation of α2-adrenoceptors by dexmedetomidine. In two study populations from two different continents, a single nucleotide polymorphism in the PRKCB gene was found to be associated with the dorsal hand vein constriction response to dexmedetomidine, suggesting that protein kinase C beta may have an important role in the vascular α2-adrenoceptor signalling pathways activated by dexmedetomidine.

Simpatectomia lombar retroperitoneal endoscópica

In the last few years, there has been an increase in the indication of lumbar sympathectomy for plantar hyperhidroses. There are few reports of the laparoscopic access for this operation, even when it seems to be a very apropriate method. A case of a left lumbar sympathectomy through the retroperitoneal endoscopic approach is presented. The total control of left plantar hiperhidroses was achieved, showing the effectiveness of this operation, completely feasible through extraperitoneal endoscopic route.

Effect of selective β-adrenoceptor blockade and surgical resection of the celiac-superior mesenteric ganglion complex on delayed liquid gastric emptying induced by dipyrone, 4-aminoantipyrine, and antipyrine in rats

There is evidence for participation of peripheral β-adrenoceptors in delayed liquid gastric emptying (GE) induced in rats by dipyrone (Dp), 4-aminoantipyrine (AA), and antipyrine (At). The present study aimed to determine whether β-adrenoceptors are involved in delayed GE induced by phenylpyrazole derivatives and the role of the prevertebral sympathetic nervous system in this condition. Male Wistar rats weighing 220-280 g were used in the study. In the first experiment rats were intravenously pretreated with vehicle (V), atenolol 30 mg/kg (ATE, β1-adrenergic antagonist), or butoxamine 25 mg/kg (BUT, β2-adrenergic antagonist). In the second experiment, rats were pretreated with V or SR59230A 2 mg/kg (SRA, β3-adrenergic antagonist). In the third experiment, rats were subjected to surgical resection of the celiac-superior mesenteric ganglion complex or to sham surgery. The groups were intravenously treated with saline (S), 240 µmol/kg Dp, AA, or At, 15 min after pretreatment with the antagonists or V and nine days after surgery. GE was determined 10 min later by measuring the percentage of gastric retention (%GR) of saline labeled with phenol red 10 min after gavage. The %GR (means±SE, n=6) values indicated that BUT abolished the effect of Dp (BUT+Dp vs V+Dp: 35.0%±5.1% vs 56.4%±2.7%) and At (BUT+At vs V+At: 33.5%±4.7% vs 52.9%±2.6%) on GE, and significantly reduced (P<0.05) the effect of AA (BUT+AA vs V+AA: 48.0%±5.0% vs 65.2%±3.8%). ATE, SRA, and sympathectomy did not modify the effects of treatments. These results suggest that β2-adrenoceptor activation occurred in delayed liquid gastric emptying induced by the phenylpyrazole derivatives dipyrone, 4-aminoantipyrine, and antipyrine. Additionally, the released neurotransmitter did not originate in the celiac-superior mesenteric ganglion complex.

Subepithelial collagen content in the peripheral airways of heaves-affected and control horses

Chez les patients asthmatiques, on retrouve un remodelage de la matrice extracellulaire des poumons, caractérisé par une augmentation du collagène ou fibrose de la couche sous-épithéliale des voies respiratoires. Le souffle, maladie inflammatoire chronique des voies respiratoires inférieures des chevaux matures, présente des similarités physiopathologiques avec l’asthme humain, incluant le remodelage. Ceci nous conduit à l’hypothèse que la fibrose de la couche sous-épithéliale pourrait être une composante des lésions pulmonaires chez les chevaux affectés, ce que notre étude avait pour objectif d’évaluer. Des biopsies pulmonaires périphériques réalisées par voie thoracoscopique ont été obtenues chez 5 chevaux témoins et 6 chevaux atteints du souffle, avant (T0) et après une stimulation antigénique de 30 jours avec du foin moisi et de la paille. Avant le début de l’étude, les sujets étaient en rémission clinique et ne démontraient aucun signe clinique de maladie. Un examen microscopique des échantillons prélevés a été réalisé après traitement au picrosirius-rouge, colorant spécifique des fibres de collagène. La surface du collagène de la couche sous-épithéliale a été mesurée et corrigée en fonction de la taille de la voie respiratoire en utilisant des techniques morphométriques standards. Les chevaux atteints de souffle ont une surface de collagène plus grande dans la couche sous-épithéliale (p<0.1) en comparaison avec les chevaux témoins. La fibrose de la couche sous-épithéliale demeure inchangée chez les chevaux malades après la stimulation antigénique de 30 jours. À T0, la fibrose de la couche sous-épithéliale est associée positivement aux variations maximales de pression pleurale et à la résistance pulmonaire chez les chevaux atteints de souffle. Les résultats de cette étude suggèrent qu’une fibrose de la couche sous-épithéliale est présente dans les voies respiratoires périphériques des chevaux atteints de souffle et contribue au déficit de fonction résiduel pulmonaire observé lors de rémission clinique.

Remodelage du muscle lisse péribronchique dans l’inflammation respiratoire chronique

Le souffle chez les chevaux et l’asthme chez l’humain sont des maladies respiratoires qui partagent plusieurs caractéristiques, notamment des épisodes de bronchospasme et de détresse respiratoire dus à une inflammation pulmonaire inappropriée en réponse à une inhalation de substances antigéniques. Les manifestations cliniques incluent des efforts respiratoires augmentés, des sifflements et de la toux. Au niveau des voies respiratoires, on observe une augmentation du muscle lisse péribronchique, une fibrose sous épithéliale, une métaplasie/hyperplasie épithéliale et du mucus en quantité augmentée. L’augmentation du muscle lisse est particulièrement importante car elle n’affecte pas seulement le calibre basal des voies respiratoires, mais elle accentue l’obstruction respiratoire lors de bronchoconstriction. Ces changements sont regroupés sous le terme de « remodelage » et sont associés à un déclin accéléré de la fonction respiratoire chez les patients asthmatiques. Alors que les traitements actuels contrôlent efficacement le bronchospasme et relativement bien l’inflammation, leurs effets sur le remodelage sont mal connus. Dans le cadre de thèse, la réversibilité du remodelage musculaire péribronchique a été investiguée chez des chevaux atteints du souffle dans deux études longitudinales. Ces études, faites principalement sur du tissu pulmonaire prélevé par thoracoscopie, sont difficilement réalisables chez l’humain pour des raisons éthiques, ou chez d’autres animaux, car ceux-ci présentent rarement une inflammation de type asthmatique de façon spontanée. Les résultats démontrent que les chevaux atteints du souffle ont approximativement deux fois plus de muscle péribronchique que les chevaux sains d’âge similaire gardés dans les mêmes conditions, et que la prolifération des myocytes contribue à cette augmentation. Ils démontrent aussi qu’une stimulation antigénique relativement brève chez des chevaux atteints du souffle depuis plusieurs années n’accentue pas le remodelage, ce qui suggère que l’augmentation du muscle lisse atteint un plateau. Nous avons également montré que le remodelage du muscle lisse chez des chevaux adultes est partiellement réversible et que cette réversibilité peut être accélérée par l’administration de corticostéroïdes par inhalation. Il semble toutefois qu’une portion du remodelage chronique est irréversible puisque les corticostéroïdes ont accéléré la diminution du muscle mais sans toutefois mener à une amélioration plus marquée au terme de l’étude qu’avec une modification environnementale stricte. La diminution de trente pourcent observée sur un an paraît modeste mais elle démontre clairement, et pour une première fois, que le remodelage du muscle lisse présent chez des chevaux adultes malades depuis plusieurs années est au moins partiellement réversible.

Inflammation of the Hypothalamus Leads to Defective Pancreatic Islet Function

Type 2 diabetes mellitus results from the complex association of insulin resistance and pancreatic beta-cell failure. Obesity is the main risk factor for type 2 diabetes mellitus, and recent studies have shown that, in diet-induced obesity, the hypothalamus becomes inflamed and dysfunctional, resulting in the loss of the perfect coupling between caloric intake and energy expenditure. Because pancreatic beta-cell function is, in part, under the control of the autonomic nervous system, we evaluated the role of hypothalamic inflammation in pancreatic islet function. In diet-induced obesity, the earliest markers of hypothalamic inflammation are present at 8 weeks after the beginning of the high fat diet; similarly, the loss of the first phase of insulin secretion is detected at the same time point and is restored following sympathectomy. Intracerebroventricular injection of a low dose of tumor necrosis factor a leads to a dysfunctional increase in insulin secretion and activates the expression of a number of markers of apoptosis in pancreatic islets. In addition, the injection of stearic acid intracerebroventricularly, which leads to hypothalamic inflammation through the activation of tau-like receptor-4 and endoplasmic reticulum stress, produces an impairment of insulin secretion, accompanied by increased expression of markers of apoptosis. The defective insulin secretion, in this case, is partially dependent on sympathetic signal-induced peroxisome proliferator receptor-gamma coactivator Delta a and uncoupling protein-2 expression and is restored after sympathectomy or following PGC1 alpha expression inhibition by an antisense oligonucleotide. Thus, the autonomic signals generated in concert with hypothalamic inflammation can impair pancreatic islet function, a phenomenon that may explain the early link between obesity and defective insulin secretion.

Hiperidrose compensatória após simpatectomia toracoscópica: características, incidência e influência na satisfação do paciente

Hyperhidrosis is an idiopathic condition characterized by excessive sweating. Symptoms generally begin in childhood or early adolescence, and rarely improve with age. The excessive localized sweating generally occurs either spontaneously, or in association with stressful or emotionally charged situations. This prospective study aimed to investigate predictive factors for compensatory hyperhidrosis after thoracoscopic sympathicotomy. From 2000 to 2002, 80 patients (53 female and 27 male) underwent hyperhidrosis surgery. The patients, ranging from 12 to 56 years old, were studied and followed-up for 42.51 ±5.98 months. A satisfaction grading using a visual analogue scale -VAS (0 = not at all satisfied, and 10 = fully satisfied) was used. The surgical procedure was performed bilaterally on the second ganglion (T2) for facial hyperhidrosis, on the third and fourth ganglia (T3 and T4) for axillary hyperhidrosis, and on the third ganglion (T3) for palmar hyperhidrosis. The results showed that, 68 patients (85%) presented with compensatory sweating (CS), which was classified as mild (33.8%), moderate (33.8%) and severe (32.4%). Considering the final surgical results, 70 patients (87.5%) were satisfied with the outcome of the operation, while 10 patients (12.5%) were dissatisfied. Degrees of satisfaction varied according to sex, age, BMI and extent of denervation. Moreover, the compensatory hyperhidrosis was more severe in abdomen and back than in legs. In conclusion, although CS is a frequent adverse effect of sympathicotomy, the degree of patient satisfaction was high. Some factors were related to the occurrence and severity of CS and the most adequate patients to be submitted to this operation are young adult women whose BMI is less than 24.9

alpha(1)-Adrenoceptors in proximal segments of tail arteries from control and reserpinised rats

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Tratamento da hiperidrose palmar com onabotulinumtoxinA veiculada por iontoforese ou fonoforese: relato de casos

Hiperidrose palmar idiopática é doença frequente, que tem grande impacto na qualidade de vida dos pacientes, e seu tratamento definitivo (simpatectomia) associa-se a risco cirúrgico e efeitos adversos. Fármacos, como onabotulinumtoxinA, podem ser veiculados percutaneamente por iontoforese ou fonoforese e contribuir no tratamento da hiperidrose. Os autores apresentam quatro casos em que houve melhora objetiva e subjetiva da sudorese após dez sessões consecutivas de iontoforese ou fonoforese, sem evidências de efeitos adversos. Os resultados clínicos mantiveram-se por 16 semanas de observação após a interrupção do tratamento. Técnicas de veiculação percutânea de medicamentos devem ser percebidas como opções nos tratamentos dermatológicos.

BLOQUEIO PERIDURAL E TERMOMETRIA CUTANEA COMO CRITERIO PARA INDICACAO CIRURGICA DE SIMPATECTOMIA LOMBAR

To find a valuable tool in achieving a good accuracy in predicting the outcome from sympathectomy, changes in limb skin temperatures (LST) before and after epidural lumbar anesthesia (ELA) and before and after lumbar sympathectomy were studied in 13 patients with thrombangiitis obliterans or arteriosclerosis obliterans. The results were compared with the clinical course and follow-up from 1 to 5 years. In seven patients there was a rise in LST after ELA and after sympathectomy, and this pattern of variation was associated with good clinical course. In three patients there was decrease in the LST after ELA and after sympathectomy and they did not do well. In two patients there was no change in temperature before or after the procedure; one of them had a good and the other a bad clinical course. The same measurements were performed in three other patients who had had a sympathectomy some years previously and the data showed that LST was lowered after ELA. It is concluded that the measurement of limb skin temperature before and after epidural lumbar anesthesia aids in determining which patients are more likely to benefit from sympathectomy.

Análise do sistema respiratório dos suínos por radiografia, broncoscopia e toracoscopia

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Segurança e eficácia da analgesia interpleural com ropivacaína em simpatectomia torácica videoassistida

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

Catecolaminas do aparelho reprodutor de ratos após simpatectomia química: metodologia analítica e comparação entre as variedades Wistar e Sprague-Dawley

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

Mensuração e análise do ph salivar em pacientes com hiperidrose submetidos a cirurgia de simpatectomia videotoracoscópica

The study was performed to verify if there are changes in salivary pH in patients with hyperhidrosis who were treated by Videothoracoscopic Sympathectomy. Twelve patients underwent sympathectomy with clamping the sympathetic chain along the vertebrae T2, T3 and T4, under inhalation and intravenous general anesthesia and with drainage of pneumothorax through probe N° 16. These patients had their saliva collected 1 day before and 7 days after surgery for measurement of pH by the colorimetric method with indicator paper. All patients showed no sign or symptom of hyperhidrosis in the immediate postoperative period, which demonstrates the success of sympathetic denervation on these levels. No patient had compensatory sweating and there was no post-operatively surgical complication. No drug or substance has been administered to patients for the study. The pH results obtained were analyzed using test ´´t´´ Student. Although the average pH in samples obtained after surgery was lower than the preoperative, the test revealed no statistically significant difference (p = 0.181). It is concluded that sympathectomy, an excellent therapeutic and definitive method for hyperhidrosis, does not alter the salivary pH, and so, did not influence the cariogenic process