Laparoscopic Liver Resection: A South American Experience with 2887 Cases.

BACKGROUND: Laparoscopic liver resections (LLR) have been increasingly performed in recent years. Most of the available evidence, however, comes from specialized centers in Asia, Europe and USA. Data from South America are limited and based on single-center experiences. To date, no multicenter studies evaluated the results of LLR in South America. The aim of this study was to evaluate the experience and results with LLR in South American centers. METHODS: From February to November 2019, a survey about LLR was conducted in 61 hepatobiliary centers in South America, composed by 20 questions concerning demographic characteristics, surgical data, and perioperative results. RESULTS: Fifty-one (83.6%) centers from seven different countries answered the survey. A total of 2887 LLR were performed, as follows: Argentina (928), Brazil (1326), Chile (322), Colombia (210), Paraguay (9), Peru (75), and Uruguay (8). The first program began in 1997; however, the majority (60.7%) started after 2010. The percentage of LLR over open resections was 28.4% (4.4-84%). Of the total, 76.5% were minor hepatectomies and 23.5% major, including 266 right hepatectomies and 343 left hepatectomies. The conversion rate was 9.7%, overall morbidity 13%, and mortality 0.7%. CONCLUSIONS: This is the largest study assessing the dissemination and results of LLR in South America. It showed an increasing number of centers performing LLR with the promising perioperative results, aligned with other worldwide excellence centers.

Reliability and precision of neural spike timing: simulation of spectrally broadband synaptic inputs.

Spectrally broadband stimulation of neurons has been an effective method for studying their dynamic responses to simulated synaptic inputs. Previous studies with such stimulation were mostly based upon the direct intracellular injection of noisy current waveforms. In the present study we analyze and compare the firing output of various identified molluscan neurons to aperiodic, broadband current signals using three types of stimulus paradigms: 1. direct injection in current clamp mode, 2. conductance injection using electrotonic coupling of the input waveform to the neuron, and 3. conductance injection using a simulated chemical excitatory connection. The current waveforms were presented in 15 successive trials and the trial-to-trial variations of the spike responses were analyzed using peri-stimulus spike density functions. Comparing the responses of the neurons to the same type of input waveforms, we found that conductance injection resulted in more reliable and precise spike responses than direct current injection. The statistical parameters of the response spike trains depended on the spectral distribution of the input. The reliability increased with increasing cutoff frequency, while the temporal jitter of spikes changed in the opposite direction. Neurons with endogenous bursting displayed lower reproducibility in their responses to noisy waveforms when injected directly; however, they fired far more reliably and precisely when receiving the same waveforms as conductance inputs. The results show that molluscan neurons are capable of accurately reproducing their responses to synaptic inputs. Conductance injection provides an enhanced experimental technique for assessing the neurons' spike timing reliability and it should be preferred over direct current injection of noisy waveforms.

Reliable circuits from irregular neurons: a dynamical approach to understanding central pattern generators.

Central pattern generating neurons from the lobster stomatogastric ganglion were analyzed using new nonlinear methods. The LP neuron was found to have only four or five degrees of freedom in the isolated condition and displayed chaotic behavior. We show that this chaotic behavior could be regularized by periodic pulses of negative current injected into the neuron or by coupling it to another neuron via inhibitory connections. We used both a modified Hindmarsh-Rose model to simulate the neurons behavior phenomenologically and a more realistic conductance-based model so that the modeling could be linked to the experimental observations. Both models were able to capture the dynamics of the neuron behavior better than previous models. We used the Hindmarsh-Rose model as the basis for building electronic neurons which could then be integrated into the biological circuitry. Such neurons were able to rescue patterns which had been disabled by removing key biological neurons from the circuit.

Extended dynamic clamp: controlling up to four neurons using a single desktop computer and interface.

The dynamic clamp protocol allows an experimenter to simulate the presence of membrane conductances in, and synaptic connections between, biological neurons. Existing protocols and commercial ADC/DAC boards provide ready control in and between < or =2 neurons. Control at >2 sites is desirable when studying neural circuits with serial or ring connectivity. Here, we describe how to extend dynamic clamp control to four neurons and their associated synaptic interactions, using a single IBM-compatible PC, an ADC/DAC interface with two analog outputs, and an additional demultiplexing circuit. A specific C++ program, DYNCLAMP4, implements these procedures in a Windows environment, allowing one to change parameters while the dynamic clamp is running. Computational efficiency is increased by varying the duration of the input-output cycle. The program simulates < or =8 Hodgkin-Huxley-type conductances and < or =18 (chemical and/or electrical) synapses in < or =4 neurons and runs at a minimum update rate of 5 kHz on a 450 MHz CPU. (Increased speed is possible in a two-neuron version that does not need auxiliary circuitry). Using identified neurons of the crustacean stomatogastric ganglion, we illustrate on-line parameter modification and the construction of three-member synaptic rings.

A comparison between topical and infiltrative bupivacaine and intravenous meperidine for postoperative analgesia after inguinal herniorrhaphy.

The purpose of the present study is to compare postoperative analgesia offered by the simple instillation of local anesthetic on the surgical wound, its infiltration with the same local anesthetic, and the use of an intravenous opioid. Sixty patients were divided into the three analgesia groups to be studied: instillation of local anesthetic (Group I), injection of local anesthetic (Group II), and intravenous opioid (Group III). The pain was quantified using the visual analogue scale. It was observed that there was better analgesia in Groups I and II during the first 6 hours postoperatively as compared with Group III (P < 0.0001). At the end of the 12 hours the three modes of analgesia proved comparable. However, after 24 hours there was better analgesic development in Group I, whereas Group II had greater postoperative morbidity. We conclude that the instillation of local anesthesia provides analgesia during the immediate postoperative period comparable to local infiltration using the same anesthetic. Both regional analgesia methods are more effective analgesics during the first 6 hours than are intravenous opioids. Furthermore the simple instillation of local anesthetic allows better analgesic evolution of the surgical wound after the first 24 hours considering the lower rate of resulting complications.

Pancreatic fistula after pancreaticoduodenectomy: a comparison between patients with periampullary tumors and chronic pancreatitis.

BACKGROUND/AIMS: Whether the frequency of anastomotic leak after pancreaticoduodenectomy for benign diseases is greater than for malignant conditions and whether fistula development is associated with surgical mortality remains controversial. The purpose of this study is to compare the incidence of anastomotic leak in patients operated on for chronic pancreatitis and periampullary tumors. METHODOLOGY: The authors retrospectively reviewed the charts of 67 patients (46 males, 21 females, mean age 47 years) submitted to pancreaticoduodenectomy for chronic pancreatitis and periampullary tumors between 1990 and 1996. RESULTS: In 44 patients with periampullary cancers, pancreatic fistula developed in 13 (29%) cases, and in 6 (26%) of the 23 patients with chronic pancreatitis (p>0.05). Of the 19 patients who developed this complication, 5 (26.3%) died, and in the remaining 48 cases, there was only one (2.1%) death (p<0.05). CONCLUSION: The frequency of pancreatic fistula after pancreaticoduodenectomy in patients with periampullary tumors and chronic pancreatitis is not different, but the presence of a fistula is strongly involved in postoperative mortality.

Comparative post-operative study of prostheses, with and without an anti-reflux valve system, in the palliative treatment of esophageal carcinoma.

BACKGROUND/AIMS: Palliative treatment of advanced esophageal carcinoma by esophageal tunnelization with a prosthesis allows immediate relief of dysphagia. However, the procedure is subject to a high rate of morbidity, including gastroesophageal reflux (GER) present in all patients with a prosthesis positioned through the gastroesophageal junction, resulting in complications (pyrosis, aspiration pneumonias, sleep disorders) and reduced quality of life in these patients who already have a lower rate of survival. In an attempt to reduce GER and its complications, the authors created a surgical prosthesis coupled to an anti-reflux valve system, comparing it to the use of an esophageal prosthesis without an anti-reflux valve mechanism. METHODOLOGY: Twenty-two patients were allocated to 2 tunnelization groups: esophageal prosthesis without an anti-reflux valve mechanism (group 1) and surgical prosthesis coupled to an anti-reflux valve system (group 2). The GER was quantified measuring esophageal-gastric pH, and using fluoroscopy, contrast radiographs and esophageal emptying scintigraphy. Initially, the pH of secretions in S1 (esophagus) and S2 (stomach) was determined using reagent strips after aspirating their contents with different syringes. First with the patient seated at rest in bed, later performing a Valsalva maneuver, deep breathing and forced coughing. The same procedure was performed with the patient in left lateral decubitus, right lateral decubitus, and dorsal decubitus with the head of the bed lowered to 20 degrees. After finishing these maneuvers, 15 ml of 1 molar acetic acid were infused through the catheter positioned in the antrum, and, after 5 min, S1 and S2 material sampling was repeated in the same positions as mentioned above. RESULTS: The pH values between the various positions and maneuvers performed in each group separately were not significantly different, but, if we compare the 2 groups, and the secretions obtained in S1 and S2, there was a significant difference in pH measures in all positions. In the patients in group 1, S1 presented a mean pH ranging from 2.87-3.62 in the initial measures, and between 2.17 and 3.5 after the infusion of 15 ml of 1 molar acetic acid. On the other hand, in group 2, the mean pH of S1 remained between 6.34 and 8.32 in the initial measures and between 4.99 and 7.33 in the presence of acid infusion. At the level of S2, the pH remained unchanged between 2 and 2.7, in both groups. CONCLUSIONS: The authors conclude that the association of an esophageal prosthesis with a valve system significantly reduces GER, as compared with its use alone. Furthermore, it allows marked reduction of the symptoms and resulting complications, and does not interfere clinically with esophageal emptying. It thus significantly improves the quality of life of these patients.

The role of liver transplantation in patients with Caroli's disease.

Caroli's disease, characterized by segmental or diffuse dilation of the intrahepatic biliary ducts, is a rare disease which is difficult to treat. The course of the disorder is characterized by recurrent episodes of cholangitis and hospital stays, with a consequent loss of quality-of-life and productive capacity, often ending in death due to uncontrolled infection. Endoscopic drainage of the bile duct, percutaneously or surgically, is palliative, and presents bad results in the follow-up of these patients. Orthotopic liver transplantation appears to be an effective curative option for the treatment of patients with Caroli's disease associated to complications. The authors present the course of two cases of this disease, associated with congenital fibrosis of the liver worsened by repeated episodes of cholangitis, submitted to orthotopic liver transplantation.

Synchronous behavior of two coupled electronic neurons.

We report on experimental studies of synchronization phenomena in a pair of analog electronic neurons (ENs). The ENs were designed to reproduce the observed membrane voltage oscillations of isolated biological neurons from the stomatogastric ganglion of the California spiny lobster Panulirus interruptus. The ENs are simple analog circuits which integrate four-dimensional differential equations representing fast and slow subcellular mechanisms that produce the characteristic regular/chaotic spiking-bursting behavior of these cells. In this paper we study their dynamical behavior as we couple them in the same configurations as we have done for their counterpart biological neurons. The interconnections we use for these neural oscillators are both direct electrical connections and excitatory and inhibitory chemical connections: each realized by analog circuitry and suggested by biological examples. We provide here quantitative evidence that the ENs and the biological neurons behave similarly when coupled in the same manner. They each display well defined bifurcations in their mutual synchronization and regularization. We report briefly on an experiment on coupled biological neurons and four-dimensional ENs, which provides further ground for testing the validity of our numerical and electronic models of individual neural behavior. Our experiments as a whole present interesting new examples of regularization and synchronization in coupled nonlinear oscillators.

Recovery of hidden information through synaptic dynamics.

The role of synaptic dynamics in processing neural information is investigated in a neural information channel with realistic model neurons having chaotic intrinsic dynamics. Our neuron models are realized in simple analogue circuits, and our synaptic connections are realized both in analogue circuits and through a dynamic clamp program. The information which is input to the first chaotic neuron in the channel emerges partially absent and partially 'hidden'. Part is absent because of the dynamical effects of the chaotic oscillation that effectively acts as a noisy channel. The 'hidden' part is recoverable. We show that synaptic parameters, most significantly receptor binding time constants, can be tuned to enhance the information transmission by the combination of a neuron plus a synapse. We discuss how the dynamics of the synapse can be used to recover 'hidden' information using average mutual information as a measure of the quality of information transport.

Tratamento cirúrgico de meningomielocele no período neonatal / Urgical trearment of meningomyelocele defects in neonatal period

As meningomieloceles são defeitos congênitos de fechamento do canal medular, com gravidade variável. Os defeitos são encontrados principalmente na região lombossacra e há hidrocefalia em 80-90% dos casos. O objetivo deste trabalho foi estudar uma série de pacientes operados por meningomielocele no período neonatal, no período de janeiro de 2001 a janeiro de 2003. Foram incluídos 22 pacientes no estudo, sendo 12 (54,5%) masculinos e 19 (86%) de etnia caucasiana. A maioria dos pacientes eram a termo (37,5±1,3 semanas) e com peso adequado para idade gestacional (2960,5±609,6 gramas). Foi realizada cesárea em 16 casos (72,7%). O fechamento foi executado da seguinte forma: primário em 5 casos (23%); "skin-over-skin" em 6 casos (27%); bipediculado fasciocutâneo bilateral em 5 casos (23%); bipediculado fasciocutâneo unilateral em 1 caso (5%); fasciocutâneo com pedículo superior em 2 casos (9%); bilobado fasciocutâneo em 1 caso (5%); fasciocutâneo em S em 2 casos (9%). Houve DVP em 18 casos (81,8%). As complicações ocorridas foram: deiscência de sutura (23%); necrose parcial (18%) e fístulas (14%). A técnica "skin-over-skin" e os retalhos fasciocutâneos são alternativas efetivas para o fechamento de meningomieloceles no período neonatal.

Purpose: To study the incidence surgical treatment oflargeth or acolumbar meningomyeloceles duringathree- year period in a Brazilian referral center. Patients and methods: We prospectively evaluated all patients submitted to surgical management of meningomyelocele by both the plastic surgery and neurosurgery teams of Hospital de Clínicas de Porto Alegre between September 2001 and August 2003. Results: Twenty four patients were included in this study, being 13 (54.2%) males and 21 (87.5%) of Caucasian ethnicity. Most patients were born at term (37,5±1,3 weeks) and with weight adjusted for gestacional age (2960,5±609,6 gram). The closing was executed of the following form: direct skin approximation in 5 cases (23%); "skin-over-skin" in 6 cases (27%); bilateral bipedicled fasciocutaneous flaps in 5 cases (23%);unilateral bipedicled fasciocutaneous flap sin 1 case (5%); superior pedicled asciocutaneous in 2 cases (9%); bilobed fasciocutaneous flap in 1 case (5%); bilateral fasciocutaneous flaps (S flap) in 2 cases (9%). V-P shunt was placed in 18 cases (81.8%). Suture dehiscence (23%); partial necrosis (18%) and fistulas (14%) were the main complications. Conclusion: Skin-over-skin and fasciocutaneous flaps are good alternative for reconstruction of meningomielocele sin the neonatalperiod.