Nervo alógeno conservado em glicerol: estudo experimental em ratos

A utilização de aloenxerto de nervo conservado em glicerol é uma alternativa a auto-enxertia em casos de lesões de nervos periféricos com perda de substância que diminui a morbidade cirúrgica e provem material suficiente para a reparação neural. O objetivo deste trabalho foi comparar o grau de reparação nervosa, utilizando análises histológica e funcional, através da interposição de enxerto autógeno (grupo A), de tubo de veia conservada em glicerol (grupo B) e de interposição de nervo alógeno conservado em glicerol (grupo C) em defeitos de 5 mm no nervo fibular de ratos Wistar. A análise histológica foi feita após o sacrifício dos animais( 6 semanas) , usando o corante azul de toluidina a 1%. No grupo A (auto-enxerto) verificou-se reação tecidual perineural e escape de fibras axonais mielinizadas para fora dos limites do epineuro que foi maior se comparada ao verificado no Grupo B (Veia autógena + glicerol) e Grupo C (aloenxerto de nervo).A avaliação funcional foi feita através da análise dos padrões das pegadas das patas posteriores dos ratos ("Walking Track Analysis"), nos períodos: pré-operatório, pós-operatório imediato, na terceira e sexta semanas. Na recuperação funcional, não houve diferença estatisticamente significativa entre os três grupos em nenhum dos períodos avaliados.

Estudo fotoelástico do controle vertical com o arco de dupla chave na técnica Straight wire

INTRODUÇÃO: em alguns casos, a extração de pré-molares torna-se necessária e nem sempre os espaços são completamente fechados após o alinhamento e nivelamento. O arco de dupla chave, ou Double Key Loop (DKL), é um arco retangular de aço para retração, com duas alças - uma mesial e outra distal ao canino. OBJETIVOS: este trabalho propôs-se a estudar o local onde a força é exercida, após a ativação desse arco, utilizando ativação na alça distal, ativação entre as alças e na alça distal, e ativação com Gurin®. MÉTODOS: foram montados nove modelos fotoelásticos de um arco dentário inferior, sem os primeiros pré-molares e os terceiros molares, com braquetes In-Ovation e arco DKL. O arco foi ativado e a região de incisivos, caninos e dentes posteriores foi fotografada, com interposição de filtros polarizadores de luz. RESULTADOS E CONCLUSÕES: após a análise do modelo fotoelástico, concluiu-se que a ativação com Gurin® pode produzir movimento de retração anterior com componente extrusivo; a ativação na alça distal pode produzir movimento de retração anterior sem componente extrusivo; e a ativação entre as alças e na alça distal pode produzir movimento de retração anterior com componente intrusivo.

Early morphological and histochemical alterations in rats subjected to ileocystoplasty

PURPOSE: To study morphologic and histochemical alterations arising at the ileocystoplasty site. METHODS: Sixteen Wistar female rats were subjected to ileocystoplasty and sacrificed after eight weeks. Material collected was divided into four groups for histological and histochemical studies: Group I (control) - isolated ileum segment removed during ileocystoplasty; Group II - ileoileal anastomosis; Group III - ileovesical anastomosis and Group IV - ileal segment from the neobladder. Histological and histochemical study assessed dysplasia, metaplasia, acute and chronic inflammation, fibrosis, atrophy, hypertrophy, total mucins, sialomucins and sulfomucins. The non-parametric Wilcoxon and Mann-Whitney tests were employed in statistical analysis. RESULTS: None of the groups presented dysplasia. Acute inflammation and atrophy occurred in Groups II, III and IV, not reaching statistical significance. Metaplasia was significant only in Group III (p=0.012). Chronic inflammation, fibrosis and hypertrophy were significant in Groups II, III and IV. There was a significant increase in total mucin content in Group IV (p=0.014) and a reduction in Group III (p=0.016). Increases in sialomucins were observed in samples for Groups III (p=0.003) and IV (p=0.002) along with reduced sulfomucins in samples from Groups III (p=0.013) and IV (p=0.008). CONCLUSION: Ileocystoplasty in female rats caused squamous metaplasia, chronic inflammatory infiltration, fibrosis, hypertrophy, increase in sialomucin content, reduction in sulfomucins, and alterations in total mucin content with statistical significance, as well acute inflammatory infiltration and muscular atrophy with less intensity.

Oral budesonide is as effective as oral prednisolone in active Crohn's disease

Background-The use of corticosteroids in active Crohn's disease often becomes limited by side effects. Budesonide is a potent corticosteroid with low systemic bioavailability due to an extensive first pass liver metabolism. Aims-To compare the efficacy and safety of two dosage regimens of budesonide and prednisolone in patients with active Crohn's disease affecting the ileum and/or the ascending colon. Patients and methods-One hundred and seventy eight patients were randomised to receive budesonide controlled ileal release (CIR) capsules 9 mg once daily or 4.5 mg twice daily, or prednisolone tablets 40 mg once daily. The treatment period was 12 weeks. The primary efficacy variable was clinical remission, defined as a Crohn's Disease Activity Index (CDAI) of 150 or less. Results-After eight weeks of treatment, remission occurred in 60% of patients receiving budesonide once daily or prednisolone and in 42% of those receiving budesonide twice daily (p=0.062). The presence of glucocorticoid associated side effects was similar in all groups; however, moon face was more common in the prednisolone group (p=0.0005). The highest frequency of impaired adrenal function, as measured by a short ACTH test, was found in the prednisolone group (p=0.0023). Conclusions-Budesonide CIR, administered at 9 mg once daily or 4.5 mg twice daily, is comparable to prednisolone in inducing remission in active Crohn's disease. The single dose administration is as promptly effective as prednisolone and represents a simpler and safer therapeutic approach, with a considerable reduction in side effects.

Rectal and Pouch Recurrences After Surgical Treatment for Familial Adenomatous Polyposis

Familial adenomatous polyposis (FAP) is a genetic disease characterized by multiple adenomatous colorectal polyps and different extracolonic manifestations (ECM). The present work is aimed to analyze the outcome after surgical treatment regarding complications and cancer recurrence. Charts from patients treated between 1977 and 2006 were retrospectively analyzed. Clinical and endoscopic data, results of treatment, pathological reports and information about recurrence were collected. Eighty-eight patients (41 men [46.6%] and 47 women [53.4%]) were assisted. At diagnosis, associated colorectal cancer (CRC) was detected in 53 patients (60.2%), whose average age was higher than those without CRC (40.0 vs. 29.5 years). At colonoscopy, polyposis was classified as attenuated in 12 patients (14.3%). Surgical treatment consisted in total proctocolectomy with ileostomy (PCI, 15 [17.4%]), restorative proctocolectomy (RPC, 27 [31.4%]), total colectomy with ileal-rectum anastomosis (IRA, 42 [48.8%]), palliative segmental resection (1 [1.2%]) and internal bypass (1 [1.2%]). Two patients were not operated on due to religious reasons and advanced disease. Complications occurred in 25 patients (29.0%), more commonly after RPC (48.1%). There was no operative mortality. Local or distant metastases were detected in six (11.3%) patients with CRC treated to cure. During the follow-up of 36 IRA, cancer developed in the rectal cuff in six patients (16.6%), whose average age was higher than in patients without rectal recurrence (45.8 vs. 36.6 years). Five of them have had colonic cancer in the resected specimen. Among the 26 patients followed after RPC, cancer in the ileal pouch developed in 1 (3.8%). (1) Within the present series, FAP patients presented a high incidence of associated CRC and diagnosis was generally established after the third decade of life; (2) operative complications occurred in about one third of the patients, being more frequent after the confection of an ileal reservoir; (3) rectal cancer after IRA was detected in 16.6% of patients and it was associated with greater age and previous colonic carcinoma; (4) both continuous and long-term surveillance of the rectal stump and ileal pouch are necessary during follow-up.

Intestinal mucosa-associated microflora in ulcerative colitis patients before and after restorative proctocolectomy with an ileoanal pouch

PURPOSE: This study was designed to identify the mucosa-associated microflora in patients with severe ulcerative colitis before and after restorative proctocolectomy with ileoanal pouch construction in comparison with historic controls. METHODS: Ten patients with a diagnosis of ulcerative colitis were evaluated. Mucus was collected during colonoscopy from all segments of the colon and terminal ileum before surgery, and from the ileal pouch two and eight months after ileostomy closure. The prevalence and mean concentration of the mucosa-associated microflora were compared over time and with historic controls. RESULTS: Veillonella sp was the most prevalent bacterium in patients and controls. Klebsiella sp was significantly more prevalent in the ileum of controls, was not found in patients with ulcerative colitis, and after proctocolectomy returned to values found in controls. Some bacteria such as Enterobacter sp, Staphylococcus sp (coag-), Bacteroides sp (npg), Lactobacillus sp, and Veillonella sp had higher mean concentrations in the ileal pouch of patients after surgery than in controls. CONCLUSION: No bacterium was identified that could be exclusively responsible for the maintenance of the inflammatory process. The mucosa-associated microflora of patients with ulcerative colitis underwent significant changes after proctocolectomy with ileal pouch construction and returned to almost normal values for some bacteria.

Partial lesions of the intratemporal segment of the facial nerve: Graft versus partial reconstruction

Objectives: In cases of partial lesions of the intratemporal segment of the facial nerve, should the surgeon perform an intraoperative partial reconstruction, or partially remove the injured segment and place a graft? We present results from partial lesion reconstruction on the intratemporal segment of the facial nerve. Methods: A retrospective study on 42 patients who presented partial lesions on the intratemporal segment of the facial nerve was performed between 1988 and 2005. The patients were divided into 3 groups based on the procedure used: interposition of the partial graft on the injured area of the nerve (group 1; 12 patients); keeping the preserved part and performing tubulization (group 2; 8 patients); and dividing the parts of the injured nerve (proximal and distal) and placing a total graft of the sural nerve (group 3; 22 patients). Results: Fracture of the temporal bone was the most frequent cause of the lesion in all groups, followed by iatrogenic causes (p < 0.005). Those who obtained results lower than or equal to III on the House-Brackmann scale were 1 (8.3%) of the patients in group 1, none (0.0%) of the patients in group 2, and 15 (68.2%) of the patients in group 3 (p < 0.001). Conclusions: The best surgical technique for therapy of a partial lesion of the facial nerve is still questionable. Among these 42 patients, the best results were those from the total graft of the facial nerve.

Hepatic Artery Graft in Pediatric Liver Transplantation: Single-Center Experience With 58 Cases

Introduction. The use of arterial grafts (AG) in pediatric orthotopic liver transplantation (OLT) is an alternative in cases of poor hepatic arterial inflow, small or anomalous recipient hepatic arteries, and retransplantations (re-OLT) due to hepatic artery thrombosis (HAT). AG have been crucial to the success of the procedure among younger children. Herein we have reported our experience with AG. Methods. We retrospectively reviewed data from June 1989 to June 2010 among OLT in which we used AG, analyzing indications, short-term complications, and long-term outcomes. Results. Among 437 pediatric OLT, 58 children required an AG. A common iliac artery interposition graft was used in 57 cases and a donor carotid artery in 1 case. In 38 children the graft was used primarily, including 94% (36/38) in which it was due to poor hepatic arterial inflow. Ductopenia syndromes (n = 14), biliary atresia (BA; n = 11), and fulminant hepatitis (n = 8) were the main preoperative diagnoses among these children. Their mean weight was 18.4 kg and mean age was 68 months. At the mean follow-up of 27 months, multiple-organ failure and primary graft nonfunction (PNF) were the short-term causes of death in 9 children (26.5%). Among the remaining 29 patients, 2 (6,8%) developed early graft thrombosis requiring re-OLT; 5 (17%) developed biliary complications, and 1 (3.4%) had asymptomatic arterial stenosis. In 20 children, a graft was used during retransplantation. The main indication was HAT (75%). BA (n = 15), ductopenia syndromes (n = 2), and primary sclerosing cholangitis (n = 2) were the main diagnoses. Their mean weight was 16.7 kg and age was 65 months. At a mean follow-up of 53 months, 7 children died due to multiple-organ failure or PNF. Among the remaining 13 patients, 3 developed biliary complications and 1 had arterial stenosis. No thrombosis was observed. Conclusion. The data suggested that use of an AG is useful alternative in pediatric OLT. The technique is safe with a low risk of thrombosis.

Long-term outcomes of radical cystectomy with preservation of prostatic capsule

We report our results of orthotopic ileal neobladder after radical cystectomy with prostatic adenomectomy with regard to urinary continence, sexual outcome and disease control. Between March 2003 and July 2004, 22 men with bladder transitional cell carcinoma (mean age 65.0) were analyzed. They underwent radical cystectomy with prostatic adenomectomy with preservation of the prostatic capsule, seminal vesicles and orthotopic ileal neobladder. Urinary continence was assessed after 2 days, 2 months, 6 months and 1 year. Preservation of sexual function was defined as the ability to have sexual intercourse and was assessed after 2-, 6-, and 12-months postoperatively. Overall survival and cancer-specific survival were assessed. Median postoperative follow-up was 60 months. Daytime and nighttime urinary continence after 48 h was 47 and 14%, respectively. After 2, 6 and 12 months, these rates were 74 and 16%, 85 and 26%, and 94 and 31%, respectively. Sexual intercourse was achieved in 69% of patients. Overall survival rate was 68%, and cancer-specific survival rate was 73%. Overall survival rates according to pathologic stage for pT0, pT1, pT2 and pT3 were 100, 60, 71 and 57%, and cancer-specific survival were 100, 80, 71 and 57%, respectively. Urinary continence and sexual function achieved by radical cystectomy with prostatic adenomectomy with orthotopic ileal neobladder seem to be similar to those achieved by the conventional technique with satisfactory oncologic results.

Bariatric Surgery in Adolescents: Preliminary 1-year Results with a Novel Technique (Santoro III)

Background Bariatric surgery (BS) was recognized as the only treatment for morbid obesity in adolescents. Classic surgical procedures are based on mechanical restriction and/or malabsorption, resulting in a large number of possible complications and demanding lifelong medical attention. A novel BS design, the Santoro III procedure, relies on modifying secretion of the satiogenic hormones GLP-1 and PYY. This approach avoids common BS complications such as prostheses, narrow anastomoses, excluded segments, and malabsorption. This study describes the 1-year follow-up of the first ten adolescents operated on using the Santoro III technique in a pediatric surgical service. Methods Ten adolescents, mean age 16.1 +/- 1.7 years with body mass index (BMI) greater than 40 kg/m(2) (range 44 to 72 kg/m(2)), refractory to at least 2 years of medical weight loss treatment were selected by a multidisciplinary team to undergo BS. This operation consists of a sleeve gastrectomy with enteroomentectomy and partial gastro-ileal derivation. Results After 1 year, mean body weight decreased from 140.3 to 88.6 kg, and BMI decreased from 52.8 +/- 9.5 kg/m(2) to 33.4 +/- 7.7 kg/m(2), with percent of excess BMI lost as 83.9 +/- 17.1%. Glucose, insulin, total cholesterol, LDL-cholesterol, and triglyceride levels decreased significantly, while HDL-cholesterol, hemoglobin, and albumin levels remained unchanged. There were no mortalities or reoperations. The two complications that presented during the trial (intraperitoneal abscess and polyneuritis) resolved with medical treatment without sequelae. All the patients returned to their normal activities and their BMI began to stabilize approximately 2 years following surgery. Conclusions The Santoro III procedure is an attractive option for adolescent BS, with promising 1-year follow-up results. These initial studies should be monitored for long-term outcomes and confirmed on a larger group of patients.

EUS-guided percutaneous endoscopic gastrostomy for enteral feeding tube placement

Background: Patients without adequate abdominal-wall transillumination are at a high risk of developing complications after PEG. Objective: We evaluated the feasibility and utility of EUS to guide PEG in patients lacking abdominal-wall transillumination. Design: Single-center case series. Setting: Tertiary-referral center. Patients: Six patients who lacked adequate abdominal-wall transillumination and 2 patients with a large laparotomy scar deemed to be at high risk of developing complications after PEG. Interventions: Patients underwent EUS-guided PEG and deployment of a standard enteral feeding tube. Main Outcome Measurements: Technical success and complication rates. Results: PEG was Successful Under EUS guidance in 5 of 8 patients. Causes of failure included all inadequate EUS window because of a prior Billroth 1 gastrectomy in one and suspected bowel interposition in 2 patients. There were no complications. Limitations: A small number of patients, uncontrolled study, and short follow-up period. Conclusions: This technique may facilitate deployment of PEG in patients who lack adequate abdominal-wall transillumination.

Laryngeal split and rib cartilage interpositional grafting: Treatment option for glottic/subglottic stenosis in adults

Objectives: Severe glottic/subglottic stenosis (complex laryngotracheal stenosis) is a rare but challenging complication of endotracheal intubation. Laryngotracheal reconstruction with cartilage graft and an intralaryngeal stent is a procedure described for complex laryngotracheal stenosis management in children; however, for adults, few options remain. Our aim was to analyze the results of laryngotracheal reconstruction as a treatment for complex laryngotracheal stenosis in adults, considering postoperative and long-term outcome. Methods: Laryngotracheal reconstruction (laryngeal split with anterior and posterior interposition of a rib cartilage graft) has been used in our institution to manage glottic/subglottic stenosis restricted to the larynx; laryngotracheal reconstruction associated with cricotracheal resection has been used to treat glottic/subglottic/upper tracheal stenosis (extending beyond the second tracheal ring). A retrospective study was conducted, including all patients with complex laryngotracheal stenosis treated surgically in our institution from January of 2002 until December of 2005. Results: Twenty patients (10 male and 10 female patients; average age, 36.13 years; age range, 18-54 years) were included. There were no deaths, and the postoperative complications were as follows: dysphonia, 25%; subcutaneous emphysema, 10%; tracheocutaneous fistula, 20%; wound infection, 15%; and bleeding, 5.0%. Eighty percent of the patients were completely decannulated after a mean of 23.4 months of follow-up (range, 4 -55 months). Conclusions: Laryngeal split with anterior and posterior cartilage graft interposition as an isolated procedure or associated with a cricotracheal resection is a feasible and low-morbidity alternative for complex laryngotracheal stenosis treatment.

Influence of Biliary Drainage on the Repair of Hepatic Lesions in Biliary Fibrosis

Background. Bilioduodenal (BD) and biliojejunal (BJ) derivation induce enterobiliary reflux and bile stasis. Decompression of the excluded loop of the Roux-en-Y (BJD) was proposed to minimize these effects. The aim of this study was to compare the influence of these three modalities of biliary bypass on hepatic lesion repair in rats with secondary biliary fibrosis. Materials and Methods. Rats with 15 d of biliary obstruction underwent BD, BJ, and BJD drainage and were compared with a group submitted to simulated operation (SO) and biliary obstruction (CBO). The serum values of total and fractional bilirubin, alkaline phosphatase (ALP), and aminotransferases (AST and ALT), as well as hepatobiliointestinal excretion determined with (99m)Tc-Disida, were used for comparison. In addition, we used morphometric analyses to estimate the mass of the hepatocytes, bile ducts, and liver fibrosis. We also counted hepatic stellate cells (SC). Results. For each of the three modalities of biliary drainage, there were significant reductions in bilirubin, AST, ALP, and the number of SCs. The recovery of the estimated mass of all histologic components occurred only after BJ and BJD; in the BD group, the estimated hepatocyte mass was reduced compared with the SO group. The residual hepatic radioactivity of (99m)Tc-Disida was greater in the BJD group than in the SO group. Conclusions. The interposition of the jejunal loop between the biliary tree and the intestine may slow hepatobiliary clearance of radioactivity, even though it provides the resolution of cholestasis and is effective in recovering from hepatic lesions. (C) 2011 Elsevier Inc. All rights reserved.

Bovine Peritoneum Protection Role on Intestinal Adhesions to a Vascular Graft: A Morphological Analysis

The present study aimed to experimentally evaluate the protection role of glycerin preserved bovine peritoneum (BP) against intestinal adhesions to a vascular graft. Experiments were performed on 24 adult rabbits, randomly dived into two groups. All animals were submitted to a vascular graft over the infra-renal aorta and vena cava. Group I (12 animals) was submitted to a BP patch on the retroperitoneal opening, between the vascular prosthetic graft and the intestinal loops. Group II (12 animals) had the retroperitoneal opening sutured. After 7, 14, 28 and 60 days, 3 animals of each group were randomly killed and the retro peritoneum, with or without the BP patch, was removed for histological analysis. The histological analysis showed that the BP stimulated a moderate to intense inflammatory reaction at the beginning of the experiments and on the 60-day evaluation, the inflammatory reaction was mild, limited to the BP border with its histological structure preserved. In conclusion, the BP is a safe and cheap interposition material to be used between vascular grafts and intestinal loops, presenting a protection role against adhesions between them.

Serum Vitamins in Adult Patients With Short Bowel Syndrome Receiving Intermittent Parenteral Nutrition

Background: Short bowel syndrome (SBS) occurs after massive intestinal resection, and parenteral nutrition (PN) therapy may be necessary even after a period of adaptation. The purpose of this study was to determine the vitamin status in adults with SBS receiving intermittent PN. Methods: The study was conducted on hospitalized adults with SBS who were receiving intermittent PN therapy (n = 8). Nine healthy volunteers, paired by age and sex, served as controls. Food ingestion, anthropometry, plasma folic acid, and vitamins B(12), C, A, D, E, and K were evaluated. Results: The levels of vitamins A, D, and B(12) in both groups were similar. SBS patients presented higher values of folic acid (21.3 +/- 4.4 vs 14.4 +/- 5.2, P = .01) and lower values of vitamin C (0.9 +/- 0.4 vs 1.2 +/- 0.3 mg/dL, P = .03), alpha-tocopherol (16.3 +/- 3.4 vs 24.1 +/-+/- 2.7 mu mol/L, P < .001), and phylloquinone (0.6 +/- 0.2 vs 1.0 +/- 0.5 nmol/L, P < .03). Eight-seven percent of patients had vitamin D deficiency, and all patients presented with serum vitamin E levels below reference values. Conclusions: Despite all efforts to offer all the nutrients mentioned above, SBS patients had lower serum levels of vitamins C, E, and K, similar to those observed in patients on home PN. These findings suggest that the administered vitamins were not sufficient for the intermittent PN scheme and that individual adjustments are needed depending on the patient`s vitamin status. (JPEN J Parenter Enteral Nutr. 2011;35:493-498)