The surgical management of parotid gland tumours.

BACKGROUND: The parotid tissue can give rise to a large variety of benign and malignant neoplasms. The objective of this study was to describe the management and outcome of parotid gland tumours over a 15-year period. METHOD: The records of consecutive patients treated by parotid gland excision from January 1995 to December 2008 were reviewed retrospectively. Data recorded were age, gender, history, physical findings, surgical procedure, fine-needle aspiration biopsy (FNAB), final pathological diagnosis and complications. RESULTS: The vast majority of patients (306) had benign neoplasms, and 14 patients had malignant neoplasms. Overall, pleomorphic adenoma contributed to 76% of the lesions, and Warthin's tumour to 17%. The sensitivity and specificity of FNAB was 79% and 100%, respectively. There were 15 cases of marginal mandibular transitory paresis and 12 cases of seroma. Marginal mandibular definitive paralysis was observed in three cases with malignant tumour. CONCLUSION: Standardised parotidectomy is a safe operation, with a low complication rate.

Prospective study using skin staplers in head and neck surgery.

BACKGROUND: A prospective trial was undertaken to investigate the advantages and disadvantages of stapled skin closure versus conventional nylon sutures in head and neck surgery. PATIENTS AND METHODS: The study included 20 consecutive patients who underwent extensive surgery in which their skin was closed with staples. Another group of 20 matched patients receiving a noncontinuous nylon suture closure was followed in parallel. RESULTS: The complications recorded occurred in 5 patients in the stapled group and 3 in the sutured group. Analysis of cosmetic results showed 16 patients (80%) in the stapled group with good wound appearance and 17 (85%) in the sutured group. The mean closure time was 5 minutes for the stapled group and 25 minutes for the sutured group. Cost was $19.75 for conventional closure and $22.00 for mechanical suture. CONCLUSION: The use of skin staples speeds up closure time by 80%, yields similar cosmetic results with no increase in complications, although at a slightly higher cost.

Results and prognostic factors in skull base surgery.

The charts of 81 patients who underwent skull base surgery between 1982 and 1993 were reviewed retrospectively. Data relative to demographic aspects, clinical stage, previous treatment, surgical approach, type of reconstruction, histology, extent of disease, complications, and follow-up were analyzed. The craniofacial approach for the anterior fossa was used in 53% of patients, the lateral skull base approach in 12%, and a combination of both in 17. Malignant tumors were diagnosed in 58 patients (72%), and histologically benign tumors in the remaining 23 (28%). Forty-one patients (51%) had skin cancer. There was dural invasion in 31 patients (38%), and 32 (40%) underwent microsurgical flap reconstruction. From the malignant group, 31 (53%) were alive with no evidence of disease (NED), and 6 (10%) were alive with disease. From the benign group, 19 (83%) were alive NED. The most common complications were cerebrospinal-fluid fistula (10%) and flap necrosis (9%). Statistical analyses of survival showed significantly different rates associated with histologic types (P = 0.0002), type of reconstruction (P = 0.0039), and previous treatment (P = 0.0018).

Galeal pedicle flap of the occipital region for pharynx reconstruction: anatomic and clinical considerations.

Surgeons are still searching for the ideal method for pharynx reconstruction after tumor ablation. The objective of this study was to prove the anatomic and clinical viability of an occipital galeal pedicle flap for hypopharynx reconstruction. We studied anatomic details in 50 fresh adult cadavers. The dissections were performed after posterior galea exposure, silicone injection in occipital vessels, and mobilization of the galeal flap with an 8 x 8 cm square of galea. We also used the proposed flap in three clinical cases after laryngopharyngectomy. The surgical technique and its problems are described. Some of the anatomic data obtained are as follows: occipital artery diameter, 2.69 mm (mean); occipital artery length, 134.25 mm; area of occipital vessels network on galea, 148.77 cm2; pedicle length, 116.63 mm; and success in rotation to pharynx region (100 percent). The flap showed good functional and cosmetic results when used in three patients. A partial necrosis occurred in one case. The pedicled galeal occipital flap has favorable anatomic characteristics for use in head and neck reconstruction. Additional studies are necessary to provide more substantial information about its clinical viability.

[Deep neck spaces and their significance in cervical infections]. / Os espaços cervicais profundos e seu interesse nas infecções da região.

BACKGROUND: Although rare, deep neck space infections are associated with high morbidity and mortality rates. The surgical approach is necessary in the majority of the cases, and the surgeon must know the complex anatomy of the cervical fasciae and deep neck spaces. PURPOSE: The anatomy of the cervical fasciae and deep neck spaces in reviewed. As an illustration, a series of deep neck space infections is presented. MATERIAL AND METHOD: Four clinical cases are reported: 1) a case of Ludwig's angina with several complications (mediastinitis, pericarditis, pneumonia, pleural effusion and empyema, esophageal fistula and septic shock), 2) a case of cervical abscess that appeared without apparent cause, in a young diabetic patient, 3) a case of abscess of the submandibular triangle, and 4) a case of parapharyngeal abscess that came forth after a dental treatment. Data from history taking, physical examination, X-rays, echography, CT scan and treatment and the follow-up are presented. The image tests were valuable and, in two of the cases, they demonstrated that more than one deep neck space were affected. CONCLUSIONS: The literature reinforces the high mortality and morbidity rates, the diversified etiology (dental infection, intravenous drug abuse, infections of the upper aerodigestive tract and others), and the tracheostomy indication made in about half of the cases. It stresses also the need for combined therapy (antibiotics and surgery). Evaluation with CT scan and other radiologic methods is indispensable to determine the site and extent of the process and to plan properly the treatment.

Contact endoscopy for identifying the parathyroid glands during thyroidectomy.

Aim of this study was to analyse contact endoscopy as an auxiliary method for identifying parathyroid glands during thyroid surgery and to identify other variables that may interfere with this correlation. Overall, 125 patients underwent thyroid surgery between January 2004 and February 2006. The variables analysed were: the total duration of surgery; time taken to locate and identify parathyroid glands; improvement in identifying these; numbers of parathyroid glands located by the surgeon and confirmed by contact endoscopy; histopathological diagnosis; presence of thyroiditis; thyroid weight; number of parathyroid glands left in thyroid specimens; and number of parathyroid gland autotransplantations. A total of 331 parathyroid glands were observed by the surgeon. However, 282 glands were identified by contact endoscopy. Nine parathyroid glands (7.2%) were observed together with thyroid specimens (Kappa = 0.534). The longer the total duration of surgery (p = 0.03) and time taken to locate and identify (p = 0.00) the parathyroid glands by contact endoscopy, the lower the observed agreement. The second year of performing contact endoscopy led to better agreement between the results (p = 0.02). In conclusion, contact endoscopy is an efficient auxiliary method for identifying parathyroid glands during thyroid surgery. During the period studied, association between total duration of surgery and time taken to locate and identify parathyroid glands was statistically significant.

Genomics and proteomics approaches to the study of cancer-stroma interactions.

BACKGROUND: The development and progression of cancer depend on its genetic characteristics as well as on the interactions with its microenvironment. Understanding these interactions may contribute to diagnostic and prognostic evaluations and to the development of new cancer therapies. Aiming to investigate potential mechanisms by which the tumor microenvironment might contribute to a cancer phenotype, we evaluated soluble paracrine factors produced by stromal and neoplastic cells which may influence proliferation and gene and protein expression. METHODS: The study was carried out on the epithelial cancer cell line (Hep-2) and fibroblasts isolated from a primary oral cancer. We combined a conditioned-medium technique with subtraction hybridization approach, quantitative PCR and proteomics, in order to evaluate gene and protein expression influenced by soluble paracrine factors produced by stromal and neoplastic cells. RESULTS: We observed that conditioned medium from fibroblast cultures (FCM) inhibited proliferation and induced apoptosis in Hep-2 cells. In neoplastic cells, 41 genes and 5 proteins exhibited changes in expression levels in response to FCM and, in fibroblasts, 17 genes and 2 proteins showed down-regulation in response to conditioned medium from Hep-2 cells (HCM). Nine genes were selected and the expression results of 6 down-regulated genes (ARID4A, CALR, GNB2L1, RNF10, SQSTM1, USP9X) were validated by real time PCR. CONCLUSIONS: A significant and common denominator in the results was the potential induction of signaling changes associated with immune or inflammatory response in the absence of a specific protein.

Farelo de manga na dieta de cordeiros em confinamento / Mango meal in diets of feedlot lambs

Avaliou-se o efeito da substituição do milho por farelo de manga em dietas para ovinos. As características avaliadas foram: consumo e digestibilidade aparente da matéria seca (MS), da proteína bruta (PB), da fibra em detergente neutro (FDN), da matéria orgânica (MO), do extrato etéreo (EE), da energia bruta (EB), da energia digestível (ED), dos carboidratos não fibrosos (CNF) e dos carboidratos totais (CT). Vinte e quatro cordeiros Santa Inês foram distribuídos em delineamento inteiramente ao acaso, com quatro tratamentos, constituídos pelas porcentagens de substituição do milho pelo farelo de manga - 0, 33, 66 e 100% -, com seis repetições. A matéria seca fecal foi estimada utilizando-se o indicador LIPE®. Não houve efeito da inclusão do farelo de manga sobre o consumo dos nutrientes e nos coeficientes de digestibilidade. Os consumos de EB e ED, em kcal/gMS, aumentaram linearmente com a inclusão do farelo de manga. O farelo de manga pode substituir o milho em dietas para ovinos, sem comprometer o consumo e a digestibilidade dos nutrientes, indicando a possibilidade de uso na dieta desses animais como alimento alternativo.

The effect of replacing corn meal with mango meal in diets of feedlot lambs was evaluated. Apparent digestibility and intakes of dry matter (DM), crude protein (CP), neutral detergent fiber (NDF), organic matter (OM) (EE), gross energy (GE), digestible energy (DE), non-fiber carbohydrates (NFC) and total carbohydrates (TC) were evaluated. Twenty-four Santa Inês lambs were distributed in a randomized design with four treatments, consisting of the replacement levels of corn meal by mango (0, 33, 66 and 100%) with six replicates. The fecal dry matter was estimated using LIPE ® external marker. There is no effect of mango meal inclusion levels on the intake and apparent digestibility. The intakes of GE and DE in kcal/gDM increase linearly with mango meal inclusion. The mango meal can replace corn in diets for lambs without compromising the intake and digestibility of nutrients, indicating potential as an alternative feed.

Valor nutricional de componentes da planta e dos coprodutos da Agave sisalana para alimentação de ruminantes / Nutrition value of plant components and Agave sisalana by-products for ruminant nutrition

Avaliaram-se a composição bromatológica, os nutrientes digestíveis totais (NDT), a digestibilidade in vitro da matéria seca (DIVMS) e a cinética de fermentação ruminal do bulbilho e pseudocaule da planta do sisal e dos coprodutos do desfibramento do sisal (CDS) na forma de silagem, feno e amonização com 5 por cento de ureia e do pó da batedeira das fibras de sisal. O delineamento experimental foi o inteiramente ao acaso, com três repetições. Os valores da matéria seca variaram de 11,4 a 89,7 por cento na silagem e no feno do CDS, respectivamente. O CDS amonizado destacou-se com o maior valor de proteína bruta, 22,7 por cento. Para o pseudocaule e o pó da batedeira, não foram detectadas a presença de extrato etéreo. Os teores de carboidratos não fibrosos (CNF) foram mais altos no pseudocaule, 72,7 por cento, e no bulbilho, 69,5 por cento. Não houve diferença nos valores de DIVMS entre os alimentos avaliados. O pó da batedeira apresentou os maiores valores de NDT. Os teores de fibra em detergente ácido, de CNF e de produção cumulativa de gases do pó da batedeira, bulbilhos e pseudocaule os qualificam como volumosos de baixo teor de fibra e alta digestibilidade.

The terms of chemical composition, total digestible nutrient, in vitro dry matter digestibility and in vitro gas production technique of plant components: steam base and braird and sisal co-products: SC (in natura, ammonization, and hay) and beater powder were evaluated. The experimental design was completely randomized with three replications. The dry matter values were 11.4 percent for silage and 89.7 percent for hay. Sisal co product ammonized with 5 percent urea present high values of CP, 22.7 percent and braird, 10.5 percent. The steam base and beater powder do not present values for ether extract. The steam base and braird present high values for nonfiber carbohydrates, 72.7 and 69.5 percent, respectively. There were no significant differences for IVDMD. The acid detergent fiber, neutral detergent fiber, and PCG values of braird, beater powder and steam base characterize as roughages with high fiber digestibility.

Consumo e desempenho produtivo de ovinos alimentados com dietas que continham coprodutos do desfibramento do sisal / Intake and productive performance of sheep fed sisal coproducts based diets

Avaliaram-se o desempenho produtivo e o consumo de nutrientes e frações fibrosas em ovinos alimentados com dietas contendo coprodutos do desfibramento do sisal, Agave sisalana. Foram utilizados 24 ovinos, machos, alojados em baias individuais. O delineamento experimental utilizado foi o inteiramente ao acaso, com quatro tratamentos e seis repetições. Os tratamentos consistiram em quatro dietas isoproteicas, em que: i) dieta padrão, contendo 38 por cento de volumoso (silagem de milheto) e 62 por cento de concentrado (milho, farelo de soja e ureia); ii) inclusão de 20 por cento da silagem de mucilagem do sisal em substituição à silagem de milheto; iii) inclusão de 20 por cento da silagem de mucilagem associada ao pó da batedeira como aditivo em substituição à silagem de milheto; iv) inclusão de 20 por cento do feno da mucilagem em substituição à silagem de milheto. O peso corporal final, os ganhos médio diário e total e a conversão alimentar dos ovinos não foram influenciados pelas dietas avaliadas (P>0,05). Os consumos dos nutrientes, em g/dia e em por centoPC e g/kg0,75, não sofreram influência das dietas. Os resultados indicam que as dietas à base de coprodutos do sisal podem ser utilizadas como alternativa volumosa, além de possibilitar o aumento da rentabilidade da atividade na região semiárida brasileira.

The objective of this study was to evaluate the productive performanceand mean daily intake of nutrients in sheep fed diets containing sisal, Agave sisalana, and co-products. Twenty-four male sheep were used in individual stalls. A completely randomized design was used, with four treatments and six replications. The treatments consisted of four isonitrogenous, in which: i) standard diet containing 38 percent forage (millet silage) and 62 percent concentrate (corn, soybean meal and urea), ii) inclusion 20 percent agave mucilage silage to replace millet silage in the standard diet, iii) inclusion of 20 percent agave mucilage silage associated with agave powder as additive to replace millet silage in the standard diet, iv) inclusion of 20 percent agave mucilage hay in substitution of millet silage. The final body weight, average daily gain, the total weight gain and feed conversion of sheep was not affected by the diets tested (P>0.05). Similarly, the intake of nutrients in g/day, percent BW and g/kg0,75 were not affected by the diets. The results indicate that the experimental diets based on the agave co-products can be used as alternative roughage in the semiarid region of Brazil, as well as help increase the profitability of cattle ranching in the region.

Características de fermentação da silagem de seis variedades de milho indicadas para a região semiárida brasileira / Fermentation parameters of silages of six maize varieties recommended for the Brazilian semi-arid region

Avaliaram-se as características fermentativas e a qualidade das silagens de seis variedades de milho, de ciclos precoce e superprecoce - BRS Caatingueiro, BRS Assum Preto, BR 5033 Asa Branca, BR 5028 São Francisco, Gurutuba e BRS 4103 - indicadas para a região semiárida brasileira. Foram utilizados silos experimentais, em delineamento inteiramente ao acaso, com seis tratamentos (variedades) e quatro repetições. Avaliaram-se: matéria seca (MS), matéria orgânica (MO), proteína bruta (PB), fibra em detergente neutro (FDN), fibra em detergente ácido (FDA), extrato etéreo (EE), carboidratos totais (CHO), carboidratos não fibrosos (CNF), pH, nitrogênio amoniacal como parte do nitrogênio total (N-NH3/NT), ácidos orgânicos e digestibilidade in vitro da matéria seca (DIVMS) das silagens. Os valores médios encontrados para a silagem foram: MS= 28,7 por cento; MO= 94,9 por cento; PB= 8,3 por cento; FDN= 49,9 por cento; FDA= 27,5 por cento; EE= 3,8 por cento; CHO= 82,7 por cento; CNF= 32,8 por cento; pH= 3,8; N-NH3/NT= 2,9 por cento/NT; ácido láctico = 7,6 por cento; ácido acético = 0,6 por cento; ácido butírico = 0,3 por cento e DIVMS= 57,9 por cento. As variedades BR 5028 - São Francisco e Gurutuba destacaram-se das demais em relação ao teor de matéria seca. A variedade BRS Caatingueiro apresentou maior teor de carboidratos não fibrosos em relação às demais. As silagens de todas as variedades foram classificadas como de excelente qualidade, por apresentarem potencial para ensilagem no semiárido brasileiro.

The fermentation characteristics and silage quality of six maize varieties of early and super early cycles were evaluated. They are recommended for the Brazilian semi-arid region (BRS Caatingueiro, BRS Assum Preto, BR 5033 - Asa Branca, BR 5028 - São Francisco, Gurutuba and BRS 4103). Experimental silos were used, in a completely randomized design, with six treatments (varieties) and four replicaties. The evaluated parameters were: dry matter (DM), organic matter (OM), crude protein (CP), neutral detergent fiber (NDF), acid detergent fiber (ADF), ether extract (EE), total carbohydrates (CHO), non-fibrous carbohydrates (NFC), pH, ammoniacal nitrogen as part of the total nitrogen (N-NH3/TN), organic acids, and in vitro dry matter digestibility (IVDMD) of the silages. The mean values found for silage were: DM= 29.6 percent; OM= 94.9 percent; CP= 8.2 percent; NDF= 49.9 percent; ADF= 27.5 percent; EE= 3.8 percent; CHO= 82.7 percent; NFC= 32.8 percent; pH= 3.8; N-NH3/TN= 2.9 percent/TN; lactic acid = 7.6 percent; acetic acid = 0.6 percent; butyric acid = 0.3 percent; and IVDMD = 57.9 percent. Varieties BR 5028 - São Francisco and Gurutuba stood out (P<0.05) from others in relation to dry matter. The BRS Caatingueiro showed higher (P<0.05) level of non-fiber carbohydrates in relation to the others. The silages from all the varieties were considered of excellent quality, with potential to be conserved as silage in the Brazilian semi-arid.

The importance of the ligation of the inferior thyroid artery in parathyroid function after subtotal thyroidectomy.

UNLABELLED: We prospectively studied the effects of the ligation of the inferior thyroid artery (ITA) on postoperative hypoparathyroidism in 48 patients who underwent functional subtotal thyroidectomy. Patients were randomized into two groups: A, with bilateral ligation of the ITA and B, without ligation of the ITA. Parathyroid function was checked preoperatively and after surgery by clinical examination and measurement of total calcium, intact PTH, urinary calcium, and AMPc. RESULTS: A significant incidence of postoperative hypocalcemia occurred: 17% in group A and 13% in B on the 4th postoperative day. Six months later, the incidence was 5% in Group A and 0% in Group B. These differences were not statistically significant between the two groups, and neither were any of the other clinical and laboratory observations. CONCLUSION: The ligation of the ITA was not an important causal factor for the occurrence of postoperative hypocalcemia after subtotal thyroidectomy.

Osteogaleal pedicle flap of the occipital region for head and neck reconstruction--anatomic study.

OBJECTIVE: This study was conducted to assess the anatomic viability of an occipital osteogaleal pedicle flap for head and neck reconstruction. DESIGN: Anatomic study in cadavers. METHOD: We studied anatomic details in 50 fresh adult cadavers (100 sides). The dissections were realized after total posterior galea exposition, silicone injection of occipital vessels, and mobilization of the osteogaleal flap, with a 8 x 8-cm square of galea and a 2.5 x 7-cm rectangle of outer-table calvarial bone. RESULTS: Occipital artery obstruction = 4%; artery diameter = 2.69 mm (mean); occipital artery length = 134.25 mm (mean); occipital vein running close to the artery = 93%; area of occipital vessel network on galea = 148.77 cm2 (mean); thickness of outer-table bone graft = 6.07 mm (mean); pedicle length = 116.63 mm; and success in rotation to nose (82%), mandible (70%) and cricoid region (100%). CONCLUSIONS: We concluded that the pedicle osteogaleal occipital flap has favourable anatomic characteristics for its use in head and neck reconstruction.

Microvascular flaps in head and neck reconstruction.

Twenty-six patients with head and neck tumors were submitted to 27 microvascular reconstructive procedures. In 15, the mandible was reconstructed using the rib (4), iliac crest (7), and scapula (4). Nine patients underwent craniofacial reconstructions with the latissimus dorsi (5), rectus abdominis (2), greater omentum (2), and scapular (1) flaps. Two patients received a jejunum (1) and a stomach plus greater omentum (1) flaps for pharyngoesophageal reconstruction. Three illustrative cases, one from each group, are presented in detail. Good results were obtained in 22 patients (85%), with both functional and morphological rehabilitation. There were five flap losses (two in the same patient) due to thrombosis of the microvascular anastomoses. There was no operative mortality, and the average operative time was 11 hours. The good results observed in these very advanced cases show that there is a place for these complex procedures in the treatment of selected cases of head and neck tumors.

Posterior trapezius myocutaneous flap.

Since last decade, myocutaneous flaps have appeared among the most versatile and safest options for the reconstruction of defects caused by large oncological resections, in the head and neck area. Undoubtedly, the myocutaneous flap of the pectoralis major muscle is the most widespread and accepted, due to the long experience obtained through its use. Nevertheless, it presents some restrictions related not only to its rotation arch, but also to the esthetic consequences for the donor site in females. Over the last years, there has been a growing interest in the posterior trapezius myocutaneous flap (PTMF), which proved to be a valuable alternative for reconstruction in selected cases. The experience of the Department of Head and Neck Surgery, at the University of São Paulo Medical School-Hospital das Clínicas, using this technique, is reported here in a detailed description.