Utilidad de la neuromonitorización vagal continua en cirugía tiroidea: experiencia y resultados en un hospital de tercer nivel / The role of continuous vagal intraoperative nerve monitoring in thyroid surgery: experience and results in a third-level hospital

Resumen Objetivo: La lesión del nervio laríngeo recurrente es una grave complicación en cirugía tiroidea. El propósito del presente estudio es analizar la utilidad de la neuromonitorización vagal continua intraoperatoria en un hospital terciario. Materiales y Método: Estudio observacional, analítico y retrospectivo que recoge pacientes intervenidos de cirugía tiroidea con neuromonitorización en un período de 14 meses. La pérdida de señal se define como amplitud final nerviosa < 100 ^V, realizándose laringoscopia postquirúrgica ante la sospecha de lesión nerviosa. El análisis estadístico se realizó con el programa SPSS® V25,0, con p < 0,05. Resultados: Se incluyeron 120 pacientes intervenidos, registrándose en el 24,2% pérdida de señal. Factores de riesgo para lesión fueron bocio intratorácico (OR 5,31; IC 95% 1,56-17,99; p = 0,007), cirugía cervical previa (OR 5,76; IC 95% 0,64-51,97; p = 0,119) y patología maligna (OR 1,44; IC 95% 0,16-12,79; p = 0,743). Fue posible el cambio de estrategia quirúrgica en 7 casos. En el seguimiento posterior se cuantificó parálisis recurrencial transitoria en 27 pacientes y permanente en 4. Discusión: La neuromonitorización parece reducir la incidencia de parálisis laríngea porque aumenta la seguridad en la identificación del nervio recurrente y reduce su manipulación durante la cirugía. Conclusiones: La neuromonitorización intraoperatoria es útil para identificar el nervio laríngeo recurrente y advierte del riesgo potencial de lesión, permitiendo cambiar la estrategia quirúrgica para evitar la parálisis bilateral de cuerdas vocales.

Aim: Recurrent laryngeal nerve injury is a serious complication in thyroid surgery. The purpose of the present study is to analyze the use of intraoperative continuous vagal neuromonitoring in a tertiary hospital. Materials and Method: Observational, analytical and retrospective study that includes patients who underwent thyroid surgery with neuromonitoring in a period of 14 months. Loss of signal is defined as final nerve amplitude < 100 ^V, and postsurgical laryngoscopy is performed due to suspicion of nerve injury. Statistical analysis was performed with the SPSS® V25.0 program, with p < 0.05. Results: 120 operated patients were included, registering loss of signal in 24.2%. Risk factors for injury were intrathoracic goiter (OR 5.31; 95% CI 1.56-17.99; p = 0.007), previous cervical surgery (OR 5.76; 95% CI 0.64-51.97; p = 0.119) and malignant pathology (OR 1.44; 95% CI 0.16-12.79; p = 0.743). A change in surgical strategy was possible in 7 cases. In the subsequent follow-up, transient recurrent paralysis was quantified in 27 patients and permanent in 4. Discussion: Neuromonitoring seems to reduce the incidence of laryngeal paralysis because it increases the security in the identification of the recurrent nerve and reduces its manipulation during surgery. Conclusions: Intraoperative neuromonitoring is useful to identify the recurrent laryngeal nerve and warns of the potential risk of injury, allowing to change the surgical strategy to avoid bilateral vocal cord paralysis.

Reducing VNS stimulation parameters: Is it safe?

Introduction Vagal nerve stimulation (VNS) is an adjuvant therapy used in the treatment of patients with refractory epilepsy who are not candidates for resective surgery or who have limited results after surgical procedures. Currently, there is enough evidence to support its use in patients with various types of epilepsy. Therefore, the present study was conducted to explore the possibility of optimizing therapy by reducing the consumption of the system's battery. Methods The prospective and double-blind analysis consisted in the evaluation of 6 patients submitted to VNS implantation for 3 months, followed by adjustment of the stimulation settings and continuity of follow-up for another month. The standard protocol was replaced by another with a frequency value of 20 Hz instead of 30 Hz to increase battery life. The safety of this procedure was evaluated through the assessment of two main variables: seizures and side effects. Results The stimulation at 20 Hz showed 68% reduction in the incidence of seizures (p»0.054) as well as low incidence of side effects. Conclusion The present study suggests that the reduction of the stimulation frequency from 30 to 20 Hz is a safe procedure, and it does not compromise the effectiveness of therapy.

Nervios olfatorio, trigémino, facial, glosofaríngeo y vago: vínculos con sars-cov-2 y prospectivas neurosemiológicas / Olfactory, trigeminal, facial, glossopharyngeal and vagus nerves: links with sars-cov-2 and neurosemiological prospects

Se presenta una breve revisión los nervios olfatorio, trigémino, facial, glosofaríngeo y vago, el primero funcionalmente relacionado con la inervación quimiosensitiva olfativa en la mucosa nasal, los siguientes para el registro de dolor endocraneal y para la mucosa orofaríngea, a efectos de transducción sensitiva gustativa. Estos nervios se vinculan con los síntomas en pacientes positivos para Covid-19, que manifiestan como dolor de cabeza, disosmia, anosmia, disgeusia, ageusia entre otras características neurosemiológicas. Se concluye que estas características semiológicas se puedan deber a mecanismos neurotrópicos y transinápticos por lo que se debe realizar un examen neurológico más riguroso sobre síntomas y signos de pacientes con Covid-19.

A brief review of olfactory, facial, glossopharyngeal and vagus nerves is presented, the first one functionally related to odoriferous chemosensory innervation in the nasal mucosa, the following four cranial nerves to endocranial headache and oropharyngeal mucosa for purposes of gustatory sensory transduction. These nerves are associated with symptoms in Covid-19 positive patients, which dysosmia, anosmia, dysgeusia, ageusia manifestation, among other neurosemiological characteristics. It is concluded that these semiological characteristics may be due to neurotropic and transynaptic mechanisms, therefore a more rigorous neurological examination should be performed on symptoms and signs of Covid-19 patients.

Anatomical study of jugular foramen in the neck / Estudo anatômico do forame jugular no pescoço

Abstract Introduction The anatomical complexity of the jugular foramen makes surgical procedures in this region delicate and difficult. Due to the advances in surgical techniques, approaches to the jugular foramen became more frequent, requiring improvement of the knowledge of this region anatomy. Objective To study the anatomy of the jugular foramen, internal jugular vein and glossopharyngeal, vagus and accessory nerves, and to identify the anatomical relationships among these structures in the jugular foramen region and lateral-pharyngeal space. Methods A total of 60 sides of 30 non-embalmed cadavers were examined few hours after death. The diameters of the jugular foramen and its anatomical relationships were analyzed. Results The diameters of the jugular foramen and internal jugular vein were greater on the right side in most studied specimens. The inferior petrosal sinus ended in the internal jugular vein up to 40 mm below the jugular foramen; in 5% of cases. The glossopharyngeal nerve exhibited an intimate anatomical relationship with the styloglossus muscle after exiting the skull, and the vagal nerve had a similar relationship with the hypoglossal nerve. The accessory nerve passed around the internal jugular vein via its anterior wall in 71.7% of cadavers. Conclusion Anatomical variations were found in the dimensions of the jugular foramen and the internal jugular vein, which were larger in size on the right side of most studied bodies; variations also occurred in the trajectory and anatomical relationships of the nerves. The petrosal sinus can join the internal jugular vein below the foramen.

Resumo Introdução A complexidade anatômica do forame jugular torna a realização de procedimentos cirúrgicos nessa região delicada e difícil. Devido aos avanços obtidos nas técnicas cirúrgicas, as abordagens do forame jugular têm sido feitas com maior frequência, o que requer uma melhoria correspondente no conhecimento de sua anatomia. Objetivo Estudar a anatomia do forame jugular, da veia jugular interna e dos nervos glossofaríngeo, vago e acessório, assim como as relações anatômicas entre estas estruturas na região do forame jugular e no espaço parafaríngeo. Método Foram examinados 60 lados de 30 cadáveres frescos algumas horas após a morte. Os diâmetros e suas relações anatômicas foram analisados. Resultados Os diâmetros do forame jugular e da veia jugular interna foram maiores no lado direito na maioria dos espécimes estudados. O seio petroso inferior terminava na veia jugular interna até 40 mm abaixo do forame jugular, em 5% dos casos. O nervo glossofaríngeo exibiu uma relação íntima anatômica com o músculo estiloglosso após a sua saída do crânio e o nervo vago exibiu uma relação semelhante com o nervo hipoglosso. O nervo acessório passou em torno da veia jugular interna via sua parede anterior em 71,7% dos cadáveres. Conclusão Foram encontradas variações anatômicas nas dimensões do forame jugular e da veia jugular interna, que apresentaram tamanhos maiores à direita na maioria dos espécimes estudados; variações também ocorreram na trajetória e nas relações anatômicas dos nervos. O seio petroso pode se unir à veia jugular interna abaixo do forame.

Hypercapnia attenuates ventilator-induced lung injury through vagus nerve activation

Abstract Purpose: To investigate the role of vagus nerve activation in the protective effects of hypercapnia in ventilator-induced lung injury (VILI) rats. Methods: Male Sprague-Dawley rats were randomized to either high-tidal volume or low-tidal volume ventilation (control) and monitored for 4h. The high-tidal volume group was further divided into either a vagotomy or sham-operated group and each surgery group was further divided into two subgroups: normocapnia and hypercapnia. Injuries were assessed hourly through hemodynamics, respiratory mechanics and gas exchange. Protein concentration, cell count and cytokines (TNF-α and IL-8) in bronchoalveolar lavage fluid (BALF), lung wet-to-dry weight and pathological changes were examined. Vagus nerve activity was recorded for 1h. Results: Compared to the control group, injurious ventilation resulted in a decrease in PaO2/FiO2 and greater lung static compliance, MPO activity, enhanced BALF cytokines, protein concentration, cell count, and histology injury score. Conversely, hypercapnia significantly improved VILI by decreasing the above injury parameters. However, vagotomy abolished the protective effect of hypercapnia on VILI. In addition, hypercapnia enhanced efferent vagus nerve activity compared to normocapnia. Conclusion: These results indicate that the vagus nerve plays an important role in mediating the anti-inflammatory effect of hypercapnia on VILI.

New determinants for casual peripheral mechanism of neurogenic lung edema in subarachnoid hemorrhage due to ischemic degeneration of vagal nerve, kidney and lung circuitry. Experimental study

Abstract Purpose: To evaluate whether there is a relationship between renal artery vasospasm related low glomerular density or degeneration and neurogenic lung edema (NLE) following subarachnoid hemorrhage. Methods: This study was conducted on 26 rabbits. A control group was formed of five animals, a SHAM group of 5 to which saline and a study group (n=16) injected with homologous blood into the sylvian cisterna. Numbers of degenerated axons of renal branches of vagal nerves, atrophic glomerulus numbers and NLE scores were recorded. Results: Important vagal degeneration, severe renal artery vasospasm, intrarenal hemorrhage and glomerular atrophy observed in high score NLE detected animals. The mean degenerated axon density of vagal nerves (n/mm2), atrophic glomerulus density (n/mm3) and NLE scores of control, SHAM and study groups were estimated as 2.40±1.82, 2.20±1.30, 1.80±1.10, 8.00±2.24, 8.80±2.39, 4.40±1.14 and 154.38±13.61, 34.69±2.68 and 12.19±1.97 consecutively. Degenerated vagal axon, atrophic glomerulus and NLE scores are higher in study group than other groups and the differences are statistically meaningful (p<0.001). Conclusion: Vagal complex degeneration based glomerular atrophy have important roles on NLE following SAH which has not been extensively mentioned in the literature.

Apparent origin of glossopharyngeal, vagus and accessory nerves: an aspect to consider in human neuroanatomy teaching / El origen aparente de los nervios glosofaríngeo, vago y accesorio: un aspecto para considerar en la enseñanza de neuroanatomía humana

In various neuroanatomy texts and articles related to this area of knowledge, there is a conceptual vacuum associated with the precise sites where the roots of the cranial nerves emerge. The objective of the study was to establish the exact location of the apparent origin of the glossopharyngeal, vagus and accessory cranial nerves in the medulla oblongata of the human being 120 human brainstems, previously fixed in formalin solution at 10 % were assessed, the location where such nerve roots emerge was identified by direct examination and once the piamater was removed at both right and left sides as it has been stated in the literature. It was found that in 100 % of the studied brainstems their nerve roots emerge on average at about 2.63 mm behind the retro-olivary groove, different to what has been stated in the literature. Glossopharyngeal, vagus and accessory human nerves do not emerge directly from the retroolivary groove, as commonly reported; instead, they emerge behind the said groove, specifically in the retro-olivary groove area, where they form a continuous line of nerve roots.

En diversos textos de neuroanatomía y artículos relacionados con esta área del conocimiento, se evidencia un vacío conceptual asociado con los sitios precisos por donde emergen los pares craneales. El objetivo de este estudio fue stablecer la ubicación exacta del origen aparente de los nervios craneales glosofaríngeo, vago y accesorio en el bulbo raquídeo de 120 tallos cerebrales humanos, previamente fijados en solución de formalina al 10 %. Fueron evaluados, el lugar donde surgen tales raíces nerviosas se identificó mediante examen directo y una vez que se retiró la piamadre tanto en el lado derecho como en el izquierdo como se ha dicho en la literatura. Se encontró que en el 100 % de los troncos cerebrales estudiados, sus raíces nerviosas emergen en promedio a unos 2,63 mm detrás del surco retroolivar, diferente a lo que se ha dicho en la literatura. Los nervios humanos glosofaríngeos, vago y accesorio no emergen directamente de la ranura retroolivar, como se informa comúnmente, sino que emergen detrás de dicha ranura, específicamente en el área de surco retroolivar, donde forman una línea continua de raíces nerviosas.

Preservation of the vagus nerves in subtotal esophagectomy without thoracotomy

Abstract Purpose: To evaluate the outcome of transhiatal esophagectomy without thoracotomy and with preservation of the vagal trunks for the treatment of advanced megaesophagus. Methods: Between March 2006 and September 2017, it was performed 136 transhiatal esophagectomies without thoracotomy by laparoscopy, with preservation of the vagus nerves. All patients were evaluated pre and postoperatively for respiratory and nutritional aspects Post operatively, some surgical aspects were evaluated like radiology and endoscopy of the digestive tract. Results: Follow-up for 7 months to 12 years by clinical, radiologic, endoscopic and pH monitoring revealed satisfactory and encouraging outcomes of the procedure. Conclusion: The laparoscopic transhiatal esophagectomy is a feasible and safe technique with good postoperative outcomes.

Cardiac vagal index varies according to field position in male elite football players / índice vagal cardíaco varia com a posição em campo de jogadores da elite do futebol

BACKGROUND: Cardiac vagal index (CVI) is supposedly higher in athletes and may differ between sports and/or between field positions. OBJECTIVE: To compare CVI: a) between elite football players vs. non-athletes and b) according to five football positions. METHOD: 242 football players of the first Brazilian/Angolan division were divided in five positions (N): goalkeepers (17), defenders (44), wingers (34), midfielders (87) and forwarders (60) and compared with 303 age-matched healthy non-athletes. CVI was estimated from a 4-second exercise test by quantifying the ratio of two cardiac cycle durations, before and at the end of a fast unloaded cycling exercise. RESULTS: Football players had resting and maximal heart rates of, respectively, 59 and 190 bpm and measured VO2max of 62.2 mL/(kg.min). Players and non-athletes showed similar CVI results (median-[P25-P75]) - 1.63-[1.46-1.84] vs 1.61-[1.41-1.81] (p = 0.22). Wingers tended to have a higher CVI (1.84-[1.60-1.99]), especially when compared to defenders (1.53-[1.41-1.72] (p = 0.01). There was a modest non-physiologically relevant association between VO2max and CVI (r = 0.15). CONCLUSIONS: Football players did not differ from non-athletes in CVI; however, among players, wingers were more often vagotonic, which may represent a hemodynamic advantage for match situations, where rapid heart rate transitions and faster oxygen delivery to muscles are required.

FUNDAMENTOS: O índice vagal cardíaco (IVC) é supostamente maior em atletas e pode diferir entre esportes e dentro do mesmo esporte. OBJETIVO: Comparar o IVC: a) entre futebolistas e não atletas e b) de acordo com cinco posições do futebol. MÉTODO: 242 jogadores da primeira divisão brasileira/angolana foram divididos em cinco posições (N): goleiros (17), zagueiros (44), laterais (34), meio-campistas (87) e atacantes (60) e comparados com 303 não-atletas saudáveis da mesma idade. IVC foi estimado a partir do teste de exercício de 4 segundos, quantificando a relação entre as durações de dois ciclos cardíacos - antes e ao final de uma pedalada rápida e sem carga RESULTADOS: As frequências cardíacas de repouso e máxima dos futebolistas foram, respectivamente, 59 e 190 bpm e o VO2max de 62,2 mL/(kg.min). Futebolistas e não-atletas mostraram resultados semelhantes de IVC (mediana- [P25-P75]) - 1,63- [1,46-1,84] vs 1,61- [1,41-1,81] (p = 0,22). Os laterais tenderam a ter maior IVC (1,84- [1,60-1,99]), especialmente quando comparados aos defensores (1,53- [1,41-1,72] (p = 0,01). Houve uma modesta associação fisiologicamente irrelevante entre VO2max e IVC (r = 0,15). CONCLUSÕES: jogadores da elite do futebol não diferem de não-atletas em IVC; entretanto, entre eles, os alas se mostraram mais frequentemente vagotônicos, o que pode representar uma vantagem hemodinâmica para situações de jogo, onde são necessárias transições rápidas da frequência cardíaca e um aporte mais rápido de oxigênio para os músculos ativos.

ACE gene dosage determines additional autonomic dysfunction and increases renal angiotensin II levels in diabetic mice

OBJECTIVES: The present study aimed to investigate cardiovascular autonomic modulation and angiotensin II (Ang II) activity in diabetic mice that were genetically engineered to harbor two or three copies of the angiotensin-converting enzyme gene. METHODS: Diabetic and non-diabetic mice harboring 2 or 3 copies of the angiotensin-converting enzyme gene were used in the present study. Animals were divided into 4 groups: diabetic groups with two and three copies of the angiotensin-converting enzyme gene (2CD and 3CD) and the respective age-matched non-diabetic groups (2C and 3C). Hemodynamic, cardiovascular, and autonomic parameters as well as renal Ang II expression were evaluated. RESULTS: Heart rate was lower in diabetic animals than in non-diabetic animals. Autonomic modulation analysis indicated that the 3CD group showed increased sympathetic modulation and decreased vagal modulation of heart rate variability, eliciting increased cardiac sympathovagal balance, compared with all the other groups. Concurrent diabetes and either angiotensin-converting enzyme polymorphism resulted in a significant increase in Ang II expression in the renal cortex. CONCLUSION: Data indicates that a small increase in angiotensin-converting enzyme activity in diabetic animals leads to greater impairment of autonomic function, as demonstrated by increased sympathetic modulation and reduced cardiac vagal modulation along with increased renal expression of Ang II.

Resting spontaneous baroreflex sensitivity and cardiac autonomic control in anabolic androgenic steroid users

OBJECTIVES: Misuse of anabolic androgenic steroids in athletes is a strategy used to enhance strength and skeletal muscle hypertrophy. However, its abuse leads to an imbalance in muscle sympathetic nerve activity, increased vascular resistance, and increased blood pressure. However, the mechanisms underlying these alterations are still unknown. Therefore, we tested whether anabolic androgenic steroids could impair resting baroreflex sensitivity and cardiac sympathovagal control. In addition, we evaluate pulse wave velocity to ascertain the arterial stiffness of large vessels. METHODS: Fourteen male anabolic androgenic steroid users and 12 nonusers were studied. Heart rate, blood pressure, and respiratory rate were recorded. Baroreflex sensitivity was estimated by the sequence method, and cardiac autonomic control by analysis of the R-R interval. Pulse wave velocity was measured using a noninvasive automatic device. RESULTS: Mean spontaneous baroreflex sensitivity, baroreflex sensitivity to activation of the baroreceptors, and baroreflex sensitivity to deactivation of the baroreceptors were significantly lower in users than in nonusers. In the spectral analysis of heart rate variability, high frequency activity was lower, while low frequency activity was higher in users than in nonusers. Moreover, the sympathovagal balance was higher in users. Users showed higher pulse wave velocity than nonusers showing arterial stiffness of large vessels. Single linear regression analysis showed significant correlations between mean blood pressure and baroreflex sensitivity and pulse wave velocity. CONCLUSIONS: Our results provide evidence for lower baroreflex sensitivity and sympathovagal imbalance in anabolic androgenic steroid users. Moreover, anabolic androgenic steroid users showed arterial stiffness. Together, these alterations might be the mechanisms triggering the increased blood pressure in this population.

The influence of distal colon irritation on the changes of cystometry parameters to esophagus and colon distentions

ABSTRACT The co-occurrence of multiple pathologies in the pelvic viscera in the same patient, such as, irritable bowel syndrome and interstitial cystitis, indicates the complexity of viscero-visceral interactions and the necessity to study these interactions under multiple pathological conditions. In the present study, the effect of distal colon irritation (DCI) on the urinary bladder interaction with distal esophagus distention (DED), distal colon distention (DCD), and electrical stimulation of the abdominal branches of vagus nerve (abd-vagus) were investigated using cystometry parameters. The DCI significantly decreased the intercontraction time (ICT) by decreasing the storage time (ST); nonetheless, DED and Abd-vagus were still able to significantly decrease the ICT and ST following DCI. However, DCD had no effect on ICT following the DCI. The DCI, also, significantly decreased the Intravesical pressure amplitude (P-amplitude) by increasing the resting pressure (RP). Although DED has no effect on the P-amplitude, both in the intact and the irritated animals, the abd-vagus significantly increased the P-amplitude following DCI by increasing the maximum pressure (MP). In the contrary, 3mL DCD significantly increased the P-amplitude by increasing the MP and lost that effect following the DCI. Concerning the pressure threshold (PT), none of the stimuli had any significant changes in the intact animals. However, DCI significantly decreased the PT, also, the abd-vagus and 3mL DCD significantly decreased the PT. The results of this study indicate that chemical irritation of colon complicates the effects of mechanical irritation of esophagus and colon on urinary bladder function.

Interval training based on ventilatory anaerobic threshold increases cardiac vagal modulation and decreases high-sensitivity c-reative protein: randomized clinical trial in coronary artery disease

Background: Autonomic dysfunction and inflammatory activity are involved in the development and progression of coronary artery disease (CAD), and exercise training has been shown to confer a cardiovascular benefit. Objective: To evaluate the effects that interval training (IT) based on ventilatory anaerobic threshold (VAT) has on heart rate variability (HRV) and high-sensitivity C-reactive protein (hs-CRP) levels, as well as the relationship between both levels, in patients with CAD and/or cardiovascular risk factors (RF). Method: Forty-two men (aged 57.88±6.20 years) were divided into two training groups, CAD-T (n= 12) and RF-T (n= 10), and two control groups, CAD-C (n= 10) and RF-C (n=10). Heart rate and RR intervals in the supine position, cardiopulmonary exercise tests, and hs-CRP levels were measured before and after IT. HRV was analyzed by spectral and symbolic analysis. The CAD-T and RF-T underwent a 16-week IT program of three weekly sessions at training intensities based on the VAT. Results: In the RF-T, cardiac sympathetic modulation index and hs-CRP decreased (p<0.02), while cardiac parasympathetic modulation index increased (p<0.02). In the CAD-T, cardiac parasympathetic modulation index increased, while hs-CRP, systolic, and diastolic blood pressures decreased (p<0.02). Both control groups showed increase in hs-CRP parameters (p<0.02). There was a strong and significant association between parasympathetic and sympathetic modulations with hs-CRP. Conclusion: The IT program based on the VAT promoted a decrease in hs-CRP associated with improvement in cardiac autonomic modulation.

Fast-track protocols in devascularization for cirrhotic portal hypertension / Protocolos rápidos em desvascularização para hipertensão portal por cirrose.

Summary Introduction/objective: fast-tract surgery (FTS) has been rapidly embraced by surgeons as a mechanism for improving patient care and driving down complications and costs. The aim of this study was to determine if any improvement in outcomes occurred after FTS protocol for selective double portazygous disconnection with preserving vagus (SDPDPV) compared with non-FTS postoperative care. Methods: patients eligible for SDPDPV in the period January 2012-April 2014 were randomly selected for the FTS group or non-FTS group. A designed protocol was used in the FTS group with emphasis on an interdisciplinary approach. The non-FTS group was treated using previously established standard procedures. The number of postoperative complications, time of functional recovery and duration of hospital stay were recorded. Results: patients in the FTS group (n=59) and non-FTS group (n=57) did not differ in terms of preoperative data and operative details (p>0.05). The FTS procedure led to significantly better control and faster restoration of gastrointestinal functions, food tolerance, rehabilitation and hospital discharge (p<0.05). Postoperative complications, including nausea/vomiting, severe ascites, wound infection, urinary tract infection and pulmonary infection were all significantly lower in the FTS group (p<0.05). According to the postoperative morbidity classification used by Clavien, overall complications and grade I complications were both significantly lower in the FTS group compared with the non-FTS group (p<0.05). Conclusion: adopting the FTS protocol helped to recover gastrointestinal functions, to reduce frequency of postoperative complications and to reduce hospital stay. The FTS strategy is safe and effective in improving postoperative outcomes. .

Resumo Objetivo: a cirurgia fast-track (FTS) foi rapidamente abraçada por cirurgiões como um mecanismo para melhorar o atendimento ao paciente e reduzir complicações e custos. O objetivo deste estudo foi determinar se qualquer melhoria nos resultados de um protocolo FTS para desconexão seletiva dupla porta (SDPDPV), quando comparado ao cuidado pós-operatório não FTS. Métodos: pacientes candidatos a SDPDPV, no período de janeiro de 2012 a abril de 2014, foram selecionados aleatoriamente para o grupo FTS ou grupo não FTS. Um protocolo projetado foi utilizado no grupo FTS, com ênfase em uma abordagem interdisciplinar. O grupo não FTS foi tratado por meio de procedimentos padrão, estabelecidos previamente. O número de complicações pós- -operatórias, o tempo de recuperação funcional e o tempo de internação hospitalar foram registrados. Resultados: os pacientes do grupo de FTS (n=59) e grupo não FTS (n=57) não diferiram em termos de dados pré-operatórios e detalhes cirúrgicos (p>0,05). O procedimento FTS levou à melhora significativa do controle e à restauração mais rápida das funções gastrointestinais, tolerância alimentar, reabilitação e alta hospitalar (p<0,05). Complicações pós-operatórias, incluindo náuseas/vômitos, ascite grave, infecção da ferida, infecção urinária e infecção pulmonar foram significativamente menores no grupo FTS (p<0,05). De acordo com a classificação de morbidade pós-operatória utilizado por Clavien, complicações gerais e complicações de classe I foram ambas significativamente mais baixas no grupo de FTS em comparação com o grupo não FTS (p<0,05). Conclusão: a adoção do protocolo FTS ajudou a recuperar as funções gastrointestinais, reduzir a frequência de complicações pós-operatórias e reduzir tempo de internação hospitalar. A estratégia FTS é segura e eficaz para melhorar os resultados pós-operatórios. .

Neural Mechanisms and Delayed Gastric Emptying of Liquid Induced Through Acute Myocardial Infarction in Rats / Mecanismos Neurais e Retardo do Esvaziamento Gástrico de Liquido Induzido no Infarto Agudo do Miocárdio em Ratos

Background: In pathological situations, such as acute myocardial infarction, disorders of motility of the proximal gut can trigger symptoms like nausea and vomiting. Acute myocardial infarction delays gastric emptying (GE) of liquid in rats. Objective: Investigate the involvement of the vagus nerve, α 1-adrenoceptors, central nervous system GABAB receptors and also participation of paraventricular nucleus (PVN) of the hypothalamus in GE and gastric compliance (GC) in infarcted rats. Methods: Wistar rats, N = 8-15 in each group, were divided as INF group and sham (SH) group and subdivided. The infarction was performed through ligation of the left anterior descending coronary artery. GC was estimated with pressure-volume curves. Vagotomy was performed by sectioning the dorsal and ventral branches. To verify the action of GABAB receptors, baclofen was injected via icv (intracerebroventricular). Intravenous prazosin was used to produce chemical sympathectomy. The lesion in the PVN of the hypothalamus was performed using a 1mA/10s electrical current and GE was determined by measuring the percentage of gastric retention (% GR) of a saline meal. Results: No significant differences were observed regarding GC between groups; vagotomy significantly reduced % GR in INF group; icv treatment with baclofen significantly reduced %GR. GABAB receptors were not conclusively involved in delaying GE; intravenous treatment with prazosin significantly reduced GR% in INF group. PVN lesion abolished the effect of myocardial infarction on GE. Conclusion: Gastric emptying of liquids induced through acute myocardial infarction in rats showed the involvement of the vagus nerve, alpha1- adrenergic receptors and PVN. .

Fundamento: Distúrbios da motilidade do intestino proximal no infarto agudo do miocárdio podem desencadear sintomas digestivos como náuseas e vômitos. O infarto do miocárdio ocasiona retardo do esvaziamento gástrico (EG) de líquido em ratos. Objetivo: Investigar se existe a influência do nervo vago (VGX), adrenoreceptores α-1, receptores GABAB do sistema nervoso central e participação do núcleo paraventricular (NPV) do hipotálamo no esvaziamento gástrico (EG) e complacência gástrica (CG) em ratos infartados. Métodos: Ratos Wistar (n = 8-15) foram divididos em: grupo infarto (INF), sham (SH) e subdivididos. O infarto foi realizado por ligadura da artéria coronária descendente anterior. A complacência gástrica foi estimada com curvas pressão-volume. Realizada vagotomia por secção dos ramos dorsal e ventral. Para verificar a ação dos receptores GABAB foi injetado baclofeno por via intra ventrículo-cerebral. Simpatectomia química foi realizada com prazosina intravenosa (iv), e na lesão do núcleo paraventricular do hipotálamo foi utilizada corrente elétrica de 1mA/10s, com esvaziamento gástrico determinado por medição da retenção gástrica (% RG) de uma refeição salina. Resultados: Não houve diferença significativa na CG. A vagotomia (VGX) reduziu significativamente a %RG; no grupo INF, o tratamento intra ventrículo-cerebral (ivc) com baclofeno reduziu significativamente a % RG; não houve conclusivamente envolvimento dos receptores GABAB em retardar o EG; o tratamento intravenoso com prazosina reduziu significativamente a %RG no grupo INF. A lesão do NPV aboliu o efeito do infarto do miocárdio no EG. Conclusão: O nervo vago, receptores α-adrenérgicos e núcleo paraventricular estão envolvidos no retardo do esvaziamento gástrico no infarto agudo do miocárdio em ratos. .

Características definidoras da Resposta Disfuncional ao Desmame Ventilatório como indicadores de acurácia do desmame ventilatório / Defining characteristics of the Dysfunctional Ventilatory Weaning Response as indicators of accuracy of ventilatory weaning / Características definitorias de la Respuesta Disfuncional al Destete Ventilatorio como indicadores de precisión del destete ventilatorio

Objetivou-se avaliar as características definidoras do diagnóstico Resposta Disfuncional do Desmame Ventilatório, como indicadores de acurácia das tentativas de desmame. Estudo observacional de 38 eventos de tentativa de desmame ventilatório em pacientes adultos internados em terapia intensiva. Para as características definidoras foram calculadas: sensibilidade, especificidade, valores preditivos positivos e negativos, acurácia ou sensibilidade, razão de verossimilhança e razão de chances diagnóstica. Também foram consideradas as medianas do número de características definidoras nos eventos de sucesso e insucesso. Foram consideradas acuradas: agitação, deterioração nos gases sanguíneos arteriais em relação aos parâmetros basais, uso moderado da musculatura acessória da respiração, aumento da frequência respiratória em relação aos parâmetros basais e frequência respiratória aumentada de forma significativa em relação aos parâmetros basais. Houve diferença estatística nas medianas do número de características definidoras observadas. Conclui-se que a característica definidora e o número delas influenciariam o sucesso da decisão sobre o desmame.

The study aimed to analyze the defining characteristics of the Dysfunctional Ventilatory Weaning Response as an indicator of the accuracy of ventilatory weaning. Observational study of 38 events of ventilatory weaning in adult patients admitted to intensive care. For the defining characteristics, it was calculated: sensitivity, specificity, positive and negative predictive values, accuracy or efficiency, likelihood ratio positive and negative, and diagnostic odds ratio. It was also considered the median number of defining characteristics in the event of success and failure. It was considered accurate: agitation, deterioration in arterial blood gases from baseline parameters, moderate use of accessory muscles of respiration, increased respiratory rate from baseline parameters and respiratory rate increases significantly with respect to baseline parameters. There was statistical difference in the median number of defining characteristics observed. It was concluded that the defining characteristic and the number of them would influence the success of the weaning decision.

El estudio tuvo como objetivo evaluar las características que definen el diagnóstico de Respuesta Disfuncional al Destete Ventilatorio como indicador de la exactitud del destete ventilatorio. Estudio observacional de 38 eventos de destete ventilatorio en pacientes adultos ingresados en cuidados intensivos. Para las características definitorias se calcularon: sensibilidad, especificidad, valores predictivos positivos y negativos, precisión o sensibilidad, cocientes de probabilidad y odds ratio diagnóstica. Fueran consideradas las medianas del número de características definitorias en casos de éxito o de fracaso. Se consideraron precisas: agitación, deterioro de los parámetros de gases en sangre arterial desde la línea de base, uso moderado de los músculos accesorios de la respiración, aumento de la frecuencia respiratoria a partir de parámetros de línea de base y frecuencia respiratoria aumentada significativamente en comparación con los parámetros de línea de base. Hubo diferencia estadísticamente significativa en la mediana del número de características definitorias observadas. Se concluye que la característica definitoria y el número de ellas influyen en el éxito de la decisión sobre el destete ventilatorio.

Impact of CPAP on physical exercise tolerance and sympathetic-vagal balance in patients with chronic heart failure / Impacto da CPAP sobre a tolerância ao exercício físico e a modulação simpatovagal de pacientes com insuficiência cardíaca crônica

Background: Chronic heart failure (CHF) leads to exercise intolerance. However, non-invasive ventilation is able to improve functional capacity of patients with CHF. Objectives: The aim of this study was to evaluate the effectiveness of continuous positive airway pressure (CPAP) on physical exercise tolerance and heart rate variability (HRV) in patients with CHF. Method : Seven men with CHF (62±8 years) and left ventricle ejection fraction of 41±8% were submitted to an incremental symptom-limited exercise test (IT) on the cicloergometer. On separate days, patients were randomized to perform four constant work rate exercise tests to maximal tolerance with and without CPAP (5 cmH2O) in the following conditions: i) at 50% of peak work rate of IT; and ii) at 75% of peak work rate of IT. At rest and during these conditions, instantaneous heart rate (HR) was recorded using a cardiofrequencimeter and HRV was analyzed in time domain (SDNN and RMSSD indexes). For statistical procedures, Wilcoxon test or Kruskall-Wallis test with Dunn's post-hoc were used accordingly. In addition, categorical variables were analysed through Fischer's test (p<0.05). Results: There were significant improvements in exercise tolerance at 75% of peak work rate of IT with CPAP (405±52 vs. 438±58 s). RMSSD indexes were lower during exercise tests compared to CPAP at rest and with 50% of peak work rate of IT. Conclusion: These data suggest that CPAP appears to be a useful strategy to improve functional capacity in patients with CHF. However, the positive impact of CPAP did not generate significant changes in the HRV during physical exercises. .

Contextualização: A insuficiência cardíaca (IC) crônica cursa com intolerância ao exercício físico. A ventilação não invasiva (VNI) tem se mostrado benéfica para a melhora da performance desses pacientes. Objetivos: Avaliar a eficiência da pressão positiva contínua nas vias aéreas (CPAP) sobre a tolerância ao exercício físico e a variabilidade da frequência cardíaca (VFC) de pacientes com IC crônica. Método: Sete homens com IC crônica (62±8 anos) e fração de ejeção do ventrículo esquerdo de 41±8% foram submetidos ao teste incremental (TI) sintoma-limitado em cicloergômetro. Posteriormente, foram aleatorizados para a realização de exercícios físicos de carga constante até a tolerância máxima com e sem CPAP (5 cmH2O) nas condições: i) 50% da carga pico do TI e ii) 75% da carga pico do TI. Em repouso e durante os testes, a frequência cardíaca (FC) instantânea foi obtida pelo cardiofrequencímetro, e a VFC foi analisada no domínio do tempo. A análise estatística foi realizada pelos testes de Wilcoxon ou Kruskall-Wallis com post-hoc de Dunn e as variáveis categóricas, pelo teste de Fischer (p<0,05). Resultados: Durante a CPAP, houve aumento significativo no tempo de exercício físico (405±52 vs. 438±58 s) e da FC pico (97±3 vs. 105±2 bpm) somente na intensidade de 75%. Em relação à VFC, observou-se que o RMSSD foi significativamente menor em exercício físico quando comparado ao repouso com CPAP na intensidade 50%. Conclusão: Em conclusão, a CPAP com 5 cmH20 mostrou-se um útil na melhora da capacidade funcional dos pacientes estudados com pouco impacto sobre a VFC. .

The recurrent laryngeal cardiac nerve in fetuses / El nervio laríngeo recurrente cardiaco en fetos

The recurrent laryngeal nerve has been reported to supply cardiac branches to the cardiac plexus. A review of anatomical literature on the existing term used to describe these branches revealed that varying interpretations and descriptions exist among various authors. Therefore, this study aimed to investigate the origin and incidence of branches from the recurrent laryngeal nerves to the cardiac plexus and their connections with sympathetic cardiac nerves. The sample comprised 40 cadaveric fetuses (n=80) (gestational ages: 16-30 weeks). The recurrent laryngeal cardiac nerve was described as the cardiac branch that originated directly from the recurrent laryngeal nerve and reached the superficial or deep parts of the cardiac plexus. This study found the recurrent laryngeal cardiac nerve in 76% of the cases contributing direct and indirect branches in 75% and 25% of the cases, respectively. This study recorded only two (2%) of these branches contributing to the superficial cardiac plexus while the rest (74%) of these branches contributed to the deep cardiac plexuses. The remaining 24% had no contributions from the recurrent laryngeal nerve to either the superficial or deep part of the cardiac plexus. The most common point of origin for the recurrent laryngeal cardiac nerve was at the lower distal part in 59% of the specimens. In the remaining 41% of branches, this nerve originated from the point of curvature, upper proximal part and both the point of curvature and lower distal part in 26%, 10% and 5% of the specimens.

El nervio laríngeo recurrente suministra las ramas cardiacas para el plexo cardíaco. Una revisión de la literatura anatómica nos muestra que existen diferentes interpretaciones y descripciones de estas ramas por parte de los distintos autores consultados. En consecuencia este estudio tuvo como objetivo investigar el origen, además de la incidencia de las ramas de los nervios laríngeos recurrentes al plexo cardíaco y sus conexiones con los nervios cardiacos simpáticos. La muestra incluyó 40 fetos (n=80) (edades gestacionales: 16-30 semanas). El nervio laríngeo recurrente cardiaco fue descrito como la rama cardíaca que se originó directamente del nervio laríngeo recurrente, que llega a las partes superficiales o profundas del plexo cardíaco. En este estudio observamos que el nervio laríngeo recurrente cardiaco en el 76% de los casos contribuye a las ramas directas e indirectas, en el 75% y el 25% de los casos, respectivamente. Se observó en este estudio que solamente dos (2%) de estas ramas contribuían en la formación del plexo cardíaco superficial, mientras que el resto (74%) de estas ramas contribuía a los plexos cardíacos profundos. El 24% restante no tenía contribuciones del nervio laríngeo recurrente ya sea para la parte superficial o profunda del plexo cardíaco. El punto de origen más común del nervio laríngeo recurrente cardiaco se observó en la parte distal inferior en un 59% de las muestras. En el 41% restante de las ramas este nervio se originó desde el punto de curvatura, la parte proximal superior y tanto en el punto de curvatura inferior como la parte distal en 26%, 10% y 5% de los especímenes.

Manejo del paraganglioma del nervio vago en cabeza y cuello / Management of the vagus nerve paraganglioma in the head and neck

Los paragangliomas son tumores infrecuentes, que tienen origen en las células de la cresta neural. Su presentación en el nervio vago representa tan solo el 5% de estas neoplasias en cabeza y cuello. Las manifestaciones clínicas más frecuentes son la presencia de masa indolora en cuello, disfonía y plenitud faríngea, seguidas por la parálisis del X y XII par craneal. La valoración imagenologíca inicial se realiza con tomografía computarizada contrastada del cuello, la cual se puede complementar con estudios de resonancia magnética y angiografía. El manejo quirúrgico de estos tumores es ampliamente aceptado, y existen controversias en cuanto a la embolización prequirúrgica. Se revisa la literatura y se presenta el caso de una paciente con masa cervical en nivel II derecho, de dos años de evolución, impresión diagnóstica clínica e imagenologíca de paraganglioma del vago, manejada en la E.S.E. Hospital Universitario del Caribe, con resección quirúrgica previa embolización...

Paragangliomas are rare tumors that originate in the neural crest cells. The involvement of the vagus nerve represents only 5% of such head and neck neoplasms. The most common clinical manifestations are the presence of painless mass in the neck, hoarseness, pharyngeal fullness, followed by the X and XII cranial nerve paralysis. The initial radiographical assessment of these patients is performed with an enhanced CT scan of the neck, and could be complemented with magnetic resonance and angiography. The surgical management of these tumors is widely accepted, and there are controversies regarding preoperative embolization. We performed a literature review and present a case on a female with two years of right neck mass involving the level II, whose clinical and imaging approach focus on vagal paraganglioma, which was treated at the ESE Hospital Universitario del Caribe with surgical resection and previous embolization...