Cord lipoma in minimally invasive surgical repairs of inguinal hernias: a prospective study.

Cord lipomas are frequent findings in laparoscopic inguinal hernia surgeries in male patients. The symptoms of lipoma and the potential benefits of removing them are often overlooked because the focus is on the primary pathology of the hernia itself. Current recommendations are to reduce this fatty content, when present. When inguinal cord lipomas are left untreated in inguinal hernia surgery they can potentially cause symptoms and be detected in follow-up imaging exams. The objective of this study was to study incidence of cord lipomas in a cohort operated on by a single group specializing in abdominal wall surgery, as well as to analyze the possible relationship of this finding with the patient's symptoms, the characteristics of the operated hernia and postoperative outcome. This is a prospective study of male patients operated on for inguinal hernia laparoscopically or robotically in a single reference center. Of the total of 141 hernias, the distribution according to European Hernia Society classification showed that 45.4% were lateral, 19.1% medial and 35.5% mixed, highlighting a variety in the presentation of hernias. Analysis of the size of the hernias revealed that the majority (35.5%) were ≤ 1.5 cm. Inguinal cord lipoma was present in 64.5% of the samples, with no statistically significant association between the presence of the lipoma and an indirect hernia sac or obesity. The incidence of surgical site occurrences (SSO) was 9,2%, with seroma and hematoma. No recurrences were observed during follow-up, indicating a successful approach. There were no statistically significant relationships between SSO, the presence of lipoma and indirect hernial sac.

Volumetry after botulinum toxin A: the impact on abdominal wall compliance and endotracheal pressure.

PURPOSE: Botulinum toxin type A (BTA) is an adjuvant tool used in the preoperative optimization of complex hernias before abdominal wall reconstruction (AWR). This study aims to investigate changes in the abdominal cavity and hernia sac dimensions after BTA application. METHOD: A prospective study with 27 patients with a hernia defect of ≥ 10 cm and loss of domain (LOD) ≥ 20% underwent AWR. Computed tomography (CT) measurements and volumetry before and after the application of BTA were performed. Intraoperative and postoperative outcomes were evaluated. RESULTS: Imaging post-BTA revealed hernia width reduction of 1.9 cm (p = 0.002), lateral abdominal wall muscle elongation of 3.1 cm (p < 0.001), hernia volume reduction (HV) from 2.9 ± 0.9L to 2.4 ± 0.8L (p < 0.001), increase in abdominal cavity volume (ACV) from 9.7 ± 2.5L to 10.3L ± 2.4L (p = 0.003), and a reduction in the HV/ACV ratio from 30.2 ± 5% to 23.4 ± 6% (p < 0.001). Fascial closure was achieved in 92.6% of cases and component separation was required in 78%. The average variation in pulmonary plateau pressure was 3.53 cmH2O, and there were no postoperative respiratory failure recorded. At the 90-day follow-up, the wound morbidity rate was 25%, unplanned readmissions were 11%, and hernia recurrence 7.4%. CONCLUSION: BTA produces measurable volumetric changes in abdominal wall and appears to facilitate fascial closure. Further studies are required to determine the role of BTA in the surgical armamentarium for complex hernia repair.

Systematic review and meta-analysis of the pre-operative application of botulinum toxin for ventral hernia repair.

PURPOSE: Surgical repair of large hernia defects requires detailed pre-operative planning, particularly in cases with loss of domain. This situation often hampers mid-line reconstruction, even after component separation, when the size of the hernia is disproportional to the volume of the abdominal area. In this case, other strategies may be needed to place the viscera back into the abdominal cavity after reducing the hernia sac. The administration of botulinum toxin prior to the surgical procedure has been indicated as an adjunct for more complex cases. This results in stretching of the lateral musculature of the abdomen, allowing midline approximation. In addition, the application of botulinum toxin alone has been investigated as a means of downstaging in the management of ventral hernias, thereby precluding component separation and enabling primary closure of the midline by placement of mesh within the retromuscular space using the Rives Stoppa technique. METHODS: Systematic review of the literature for observational studies involving patients undergoing pre-operative application of botulinum toxin for ventral hernia repair was conducted according to the PRISMA guidelines. RESULTS: Advance of the lateral musculature of the abdomen by an average of 4.11 cm with low heterogeneity, as well as low rates of surgical site infection (SSI), surgical site occurrences (SSO) and recurrence, was shown. CONCLUSION: Pre-operative application of botulinum toxin for ventral hernia repair promoted an increase in the length of the lateral musculature of the abdomen which can help improve the outcomes of morbidity and recurrence.

Epidemiological, clinical and laboratory aspects of Angiostrongylus cantonensis infection: an integrative review.

This integrative literature review study analyzes the findings of the last 5 years of the parasite Angiostrongylus cantonensis. It is known that this nematode is found in the pulmonary arteries of rats, where it remains as a definitive host. From mice, the cycle spreads to animals, such as snails, which in contact with humans can trigger the disease. In humans, the parasite causes several neurological, abdominal manifestations and mainly meningitis. Based on the review of studies, its epidemiology shows worldwide distribution, although there are endemic cases for this parasite, such as asian countries. Laboratory findings generally showed altered CSF with turbidity, increased protein and eosinophilia, which generated meningeal signs in the patient, moreover MRI exams showed multiple alterations. Rare findings of the nematode in the eyeball, lung and signs of peritoneal inflammation were reported, which requires further studies to understand the whole pathophysiology. Finally, conservative treatment based on anthelmintics and anti-inflammatories brought good responses, although there are reports of deaths, which demonstrates the importance in the prevention and therapy of this disease.

Prostaglandin treatment at the onset of norgestomet and estradiol-based synchronization protocols did not alter the ovarian follicular dynamics or pregnancy per timed artificial insemination in cyclic Bos indicus heifers.

The aim of the present study was to evaluate the effects of the PGF2α treatment given at the onset of a synchronization of ovulation protocol using a norgestomet (NORG) ear implant on ovarian follicular dynamics (Experiment 1) and pregnancy per AI (P/AI; Experiment 2) in cyclic (CL present) Bos indicus heifers. In Experiment 1, a total of 46 heifers were presynchronized using two consecutive doses of PGF2α 12 days apart. At first day of the synchronization protocol the heifers received implants containing 3mg of NORG and 2 mg of estradiol benzoate (EB). At the same time, heifers were randomly assigned to receive 150 mg of D-cloprostenol (n=23; PGF2α) or no additional treatment (n=23; Control). When the ear implants were removed 8 days later, all heifers received a PGF2α treatment and 1 mg of EB was given 24 h later. The follicular diameter and interval to ovulation were determined by transrectal ultrasonography. No effects of PGF2α treatment on the diameter of the largest follicle present were observed at implant removal (PGF2α=9.8±0.4 vs. Control=10.0±0.3 mm; P=0.73) or after 24 h (PGF2α=11.1±0.4 vs. Control=11.0±0.4 mm; P=0.83). No differences in the time of ovulation after ear implant removal (PGF2α=70.8±1.2 vs. Control=73.3±0.9 h; P=0.10) or in the ovulation rate (PGF2α=87.0 vs. Control=82.6%; P=0.64) between treatments were observed. In Experiment 2, 280 cyclic heifers were synchronized using the same experimental design described above (PGF2α; n=143 and Control; n=137), at random day of the estrous cycle. All heifers received 300 IU of equine chorionic gonadotropin (eCG) and 0.5 mg of estradiol cypionate (as ovulatory stimulus) when the NORG ear implants were removed. Timed artificial insemination (TAI) was performed 48 h after implant removal and the pregnancy diagnosis was conducted 30 days later. No effects on the P/AI due to PGF2α treatment were observed (PGF2α=51.7 vs. Control=57.7%; P=0.29). In conclusion, PGF2α treatment at the onset of NORG-based protocols for the synchronization of ovulation did not alter the ovarian follicular responses or the P/AI in cyclic Bos indicus beef heifers synchronized for TAI.

Correction of iatrogenic injury of the obturator nerve during pelvic laparoscopic lymphadenectomy by the use of sural nerve grafts.

•Intraoperative injury of the obturator nerve is not an infrequent complication of gynecological surgeries.•This injury can occur in association with pelvic lymphadenectomy for uterine or cervical cancer.•This manuscript demonstrates an alternative technique for the obturator nerve repair, when primary end to end anastomosis is not possible.

Intermodal interferometer for strain and temperature sensing fabricated in birefringent boron doped microstructured fiber.

We present a compact in-line fiber interferometric sensor fabricated in a boron doped two-mode highly birefringent microstructured fiber using a CO(2) laser. The intermodal interference arises at the fiber output due to coupling between the fundamental and the first order modes occurring at two fiber tapers distant by a few millimeters. The visibility of intermodal interference fringes is modulated by a polarimetric differential signal and varies in response to measurand changes. The proposed interferometer was tested for measurements of the strain and temperature, respectively, in the range of 20-700 °C and 0-17 mstrain. The sensitivity coefficients corresponding to fringe displacement and contrast variations are equal respectively for strain -2.51 nm/mstrain and -0.0256 1/mstrain and for temperature 16.7 pm/°C and 5.74×10(-5) 1/°C. This allows for simultaneous measurements of the two parameters by interrogation of the visibility and the displacement of interference fringes.

Modal interferometer based on hollow-core photonic crystal fiber for strain and temperature measurement.

In this work, sensitivity to strain and temperature of a sensor relying on modal interferometry in hollow-core photonic crystal fibers is studied. The sensing structure is simply a piece of hollow-core fiber connected in both ends to standard single mode fiber. An interference pattern that is associated to the interference of light that propagates in the hollow core fundamental mode with light that propagates in other modes is observed. The phase of this interference pattern changes with the measurand interaction, which is the basis for considering this structure for sensing. The phase recovery is performed using a white light interferometric technique. Resolutions of +/- 1.4 microepsilon and +/- 0.2 degrees C were achieved for strain and temperature, respectively. It was also found that the fiber structure is not sensitive to curvature.

Mucinous ovarian tumors associated with pseudomyxoma peritonei of adenomucinosis type: immunohistochemical evidence that they are secondary tumors.

Pseudomyxoma peritonei (PMP) is a clinical condition initially thought to be related to ovarian mucinous tumors; however, immunohistochemistry and molecular biology techniques have convincingly made the link to appendiceal mucinous neoplasms, resulting in changes in histologic and clinical approaches. The objective of this study was to compare the immunohistochemical profile of ovarian tumors associated with PMP and intestinal mucinous ovarian neoplasms without PMP. The study was retrospective and included 28 intestinal ovarian mucinous tumors selected from the files of the Division of Surgical Pathology of the University of Sao Paulo Medical School, from 1996 to 2005. Seven cases were associated with PMP of disseminated peritoneal adenomucinosis-type and all presented borderline histology. Immunohistochemical staining for mucin genes products (MUC1, MUC2, MUC5AC, and MUC6), CK7, CK20, CA19.9, and CA125 were performed in tissue microarrays. Of note, we detected differences in the expression of MUC2 and CK20 between cases with and without PMP. Comparisons of borderline histology with that of benign/malignant tumors also revealed differences in MUC2 and CK20. Our results confirm that there is a distinct profile of intestinal ovarian tumors associated with pseudomyxoma, particularly with respect to the expression of the gel-forming mucin MUC2. The profile of borderline tumors, even in cases without PMP, was distinct from that of other primary mucinous tumors of the intestinal type, suggesting that borderline histology may represent a secondary tumor or a less aggressive variant of PMP. An appendiceal origin seems the most probable for this group of neoplasias.

Squamous cell vulvar carcinoma associated with Fanconi's anemia: a case report.

Fanconi's anemia (FA) is a rare autosomal recessive syndrome associated with a strong predisposition to cancer, particularly squamous cell carcinoma (SCC) of various organs. A few cases of lower genital tract neoplasia have been described. We present a 14-year-old black girl with an advanced squamous cell vulvar carcinoma treated with cisplatin chemotherapy plus radiation therapy. The patient died because of fungal sepsis. Polymerase chain reaction (PCR) was positive to human papillomavirus (HPV)-16. Vulvar carcinoma is a very rare condition in teenagers, but the association of Fanconi's anemia and SCC of many sites is common. Vulvar carcinoma when associated with Fanconi's anemia is a great treatment challenge.

Uptake of a cholesterol-rich emulsion by neoplastic ovarian tissues.

OBJECTIVE: Previously, it was shown that a lipidic emulsion (LDE) composed of phospholipids and cholesterol esters which binds to low-density lipoprotein (LDL) receptors may concentrate in acute myeloid leukemia cells. In this study, we aimed to verify whether LDE also has the ability to concentrate in malignant ovarian cancer after being injected into the blood circulation of the patients. METHODS: Three groups of women scheduled for surgery were included in the survey: 13 bearing malignant tumors, 9 with benign ovarian tumors, and 13 without ovarian tumor who were scheduled to undergo oophorectomy due to malignant disease of the uterine cervix or endometrium. On the day prior to surgery they were injected with LDE labeled with [(14)C]cholesteryl oleate. Specimens of tumors and normal ovaries excised during surgery were lipid extracted and analyzed for radioactivity counting. Results were expressed in radioactive count (cpm) per gram of tissue. RESULTS: The mean of the uptakes of the emulsion radioactivity by the malignant tumors was roughly eightfold greater when compared with that of the contralateral normal ovaries (2261 +/- 1444 and 275 +/- 137 cpm/g, respectively, P < 0.012), benign tumors, and normal ovaries of the patients without ovarian tumors. CONCLUSION: LDE has the ability to concentrate in malignant ovarian tumor tissue. Therefore, it can be used as a vehicle to direct cytotoxic drugs against malignant ovarian tumors, thus diminishing the side effects of chemotherapy.

Streptococcus agalactiae endocarditis and giant pyomyoma simulating ovarian cancer.

Group B streptococcus (Streptococcus agalactiae) is a common etiology of bacteremia among adults. Pyomyoma is a rare infectious complication of uterine leiomyomas. We report the case of a diabetic postmenopausal woman with a giant pyomyoma simulating an ovarian cancer. It was associated with S. agalactiae endocarditis and deep venous thrombosis of the right external iliac and femoral veins. Treated initially with intravenous penicillin, amikacin, and anticoagulation, the patient later had abdominal hysterectomy with an uneventful recovery. We also review the cases of pyomyoma reported since 1945. Of 14 cases described (including ours), mortality was 21%. Endocarditis was never reported in association with pyomyoma. The presence of bacteremia and a leiomyoma should raise suspicion for this disease.

Conization, frozen section examination, and planned hysterectomy in the treatment of high-grade cervical intraepithelial neoplasia.

PURPOSE: We tested the role of frozen section examination of the cone specimen in the evaluation of the resection margin status and to rule out invasion in patients with high-grade cervical intraepithelial neoplasia. METHODS: Twenty-five patients with cervical intraepithelial neoplasia underwent conization followed by frozen section examination and planned hysterectomy. The results of the definitive paraffin exam were compared with frozen section examination. RESULTS: In the evaluation of the margins by frozen section examination, 16 patients (64%) had positive cone margins and 9 (36%) had negative margins. The definitive paraffin examination of margin status was concordant in all the cases. Intraoperative diagnosis of invasion was made in 5 cases, and 1 of these was microinvasive. Among the remaining 20 cases, we detected 2 additional microinvasive carcinomas after paraffin study, so the diagnosis of the frozen section examination was concordant with the paraffin sections in 23/25 cases (92%). Two cases of microinvasive carcinoma were diagnosed as cervical intraepithelial neoplasia by frozen section examination and had less than 2 mm stromal invasion. CONCLUSIONS: In high-grade cervical intraepithelial neoplasia, frozen section examination can provide immediate and precise evaluation of the cone margin status in high-grade cervical intraepithelial neoplasia. It can identify frank invasion and permit adequate treatment in a one-stage procedure. In early microinvasive disease, frozen section examination fails to detect the area of invasion but reliably detects clear resection margins.

Müllerian adenosarcoma of the uterus with sarcomatous overgrowth following tamoxifen treatment for breast cancer.

Müllerian adenosarcoma with sarcomatous overgrowth presented by a 52-year-old female patient after adjuvant tamoxifen treatment for breast carcinoma is described. The diagnosis was made on histological basis after curettage and complementary total hysterectomy with bilateral salpingo-oophorectomy. The immunohistochemical study showed high expression of estrogen receptors in the epithelial component of the lesion and irregularly positive findings in the stroma. The proliferative activity evaluated by Ki-67 immunoexpression was higher in the stroma than the epithelium. Some of the stromal cells showed rhabdomyoblastic differentiation. The association of tamoxifen use and development of mesenchymal neoplasms is discussed.

Wertheim-Meigs radical hysterectomy.

Wertheim-Meigs hysterectomy is the treatment of choice for invasive cervix cancer stage IB and IIA at the University of São Paulo Medical School. It was performed in 168 patients between 1974 and 1993. Pelvic lymph node metastases were found in 19 patients (11.3%) and 149 were negative lymph node. The recurrence rate was 21% in the positive lymph node and 6% in the negative lymph node patients. Complications occurred in 35 patients (20.83%) and were as follows: atonic bladder in 9.52%; fistulae in 5.59%; urinary incontinence in 4.76%; ureteral stenosis in 2.97%; dehiscence in 2.38% and lymphedema in 1.19%. Intraoperative complications occurred at a rate of 4.76% and involved injuries to the bladder, ureter and great vessels.

Control of cervical cancer in Brazil.

PIP: In Brazil, cervical cancer is the second most common cancer in women (20.1% of all cancers in women) after skin cancer (24.3%). It is responsible for about 5% of all cancer deaths among women in the State of Sao Paulo. The cervical cancer mortality rate does not differ among regions in Brazil, even though most health services are in metropolitan areas. In 1968, the Cervical Cancer Control Program began in Campinas. Its first phase (1968-1972) was characterized by a low number of Papanicolaou tests and a very high frequency of altered cervical cytologies. The second phase (1972-1978) was characterized by a higher number of repeat Pap tests, a high number of treatments of cervical benign lesions, and a lower frequency of altered cytologies. Geographical expansion of the program to 84 cities in the region (population of 3.5 million) characterizes the current phase, which corresponds with another increase in the frequency of altered cytologies. 85% of patients were in stages II, III, and IV before 1968 compared to only 3% after 1984. Before 1968, no one had cervical intraepithelial neoplasia while most cases (86%) had it after 1984. Therefore, the program achieved its goal of reversing the diagnosis of cervical cancer in the incurability phase to the treatable phase in the region of Campinas. In 1986, the State Health Secretariat of Sao Paulo began implementing a similar cervical cancer control program which was organized into the primary, secondary, and tertiary care levels. It increased its coverage of Pap tests from 8.38% in 1986 to about 40% in 1990. 82% of women who had undergone a consultation at Perola Byington Hospital had a Pap test during the last 2 years and almost all of these women (99%) knew that the Pap test should be repeated. Obstacles faced by the 2 programs included an increased demand in initial stages for specialized care (i.e., surgery), great exit of technicians and professionals from programs to the private sector, and inadequate follow-up of detected cases.^ieng