Beneficial effect of alpha-tocopherol in renal ischemia-reperfusion in rats.

We evaluated the effects of alpha-tocopherol (vitamin E) on the products of lipid peroxidation and serum creatinine levels in a rat model of renal ischemia-reperfusion. The animals were submitted to sham operation or renal ischemia-reperfusion, and they were pretreated with alpha-tocopherol or the vehicle saline. In four groups, we analyzed the lipid peroxidation products by measuring malondialdehyde and chemiluminescence levels. In the other three groups, we studied the serum creatinine levels after the procedures. In our study, the pretreatment with alpha-tocopherol reduced significantly the lipid peroxidation of renal cells and renal dysfunction induced by renal ischemia-reperfusion in rats.

Effects of L-arginine on the kidney levels of malondialdehyde in rats submitted to renal ischaemia-reperfusion.

OBJECTIVE: To evaluate the effects of L-arginine, a nitric oxide donor, on kidney levels of malondialdehyde (MDA, a product of cellular lipid peroxidation), serum creatinine levels, and urinary volume in rats undergoing unilateral renal ischaemia-reperfusion. MATERIALS AND METHODS: Wistar rats (117) were randomly distributed into three experimental groups (of four subgroups each) in which were assessed renal cell-lipid peroxidation (kidney levels of MDA), serum creatinine levels and urinary volume. The rats underwent unilateral nephrectomy followed by contralateral renal ischaemia-reperfusion with or with no pretreatment with L-arginine (200 mg/kg) given intraperitoneally. RESULTS: Pretreatment with L-arginine caused significantly higher kidney levels of MDA than in the untreated group (P < 0.05). Furthermore, L-arginine given before surgery attenuated the increase in serum creatinine and significantly increased urinary volume in rats subjected to renal ischaemia-reperfusion (P < 0.05). CONCLUSION: L-arginine tended to be of benefit for renal function during renal ischaemia-reperfusion in rats. Pretreatment with L-arginine (200 mg/kg intraperitoneally) seems to increase the renal damage by increasing kidney levels of MDA.

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.

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.

Role of the L-arginine/nitric oxide pathway in renal ischaemia-reperfusion in rats.

OBJECTIVE: To study the role of the L-arginine/nitric oxide (NO) pathway during renal ischaemia-reperfusion in rats. DESIGN: Randomised experimental study. SETTING: Teaching hospital, Brazil. ANIMALS: 97 male Wistar rats randomly assigned to 4 groups for the assessment of renal dysfunction and to 6 groups for the assessment of the oxidative stress induced on renal cell membranes by ischaemia-reperfusion. INTERVENTIONS: The animals underwent sham-operation or renal ischaemia-reperfusion (n = 9 each) with or without pretreatment with L-arginine (a NO donor) or L-NAME (N(omega)-nitro-L-arginine methyl ester--an inhibitor of NO production) (n = 10 each). MAIN OUTCOME MEASURES: Serum creatinine concentrations and oxidative stress by chemiluminescence initiated by the tert-butyl hydroperoxide technique. RESULTS: Renal ischaemia-reperfusion significantly worsened renal dysfunction and increased oxidative stress in the ischaemia-reperfusion group after 24 and 96 hours of reperfusion compared with the control group (p < 0.05). Pretreatment with L-NAME slightly but not significantly increased serum creatinine concentrations after 24 and 96 hours of reperfusion together with activity of reactive oxygen species during renal ischaemia-reperfusion. L-arginine also significantly protected renal function and reduced the increment in the amount of chemiluminescence induced by giving L-NAME during 24 and 96 hours of reperfusion (p < 0.05). CONCLUSION: The L-arginine/NO pathway seems to have a slightly protective effect on the kidney after renal ischaemia-reperfusion injury in rats. These results need to be confirmed by studies in human beings.

The effects of allopurinol in hepatic ischemia and reperfusion: experimental study in rats.

BACKGROUND/AIMS: Some studies have shown that postischemic hepatic dysfunction is mainly due to oxygen free radicals that are generated by xanthine oxidase. The present study was undertaken to determine the effect of allopurinol, an inhibitor of xanthine oxidase, on oxidative stress, liver injury and histologic alterations induced by hepatic ischemia-reperfusion in rats. METHODS: One hundred and sixty Wistar rats were used and divided into three groups. Group 1: sham operation; group 2: 50 min of ischemia followed by 1 h of reperfusion, and group 3: pretreatment with allopurinol and 50 min of ischemia followed by 1 h of reperfusion. The effect of allopurinol was evaluated by plasma levels of alanine aminotransferase and aspartate aminotransferase, histopathologic studies, and lipid peroxidation measured by the thiobarbituric acid reactive substances method and chemiluminescence initiated by tert-butyl hydroperoxide technique. RESULTS: Ischemia followed by reperfusion promoted an increase in lipid peroxidation of the hepatic cells when compared to the sham-operated group (p<0.05). This increase was attenuated in the group treated with allopurinol (p< 0.05). Allopurinol also showed a protective effect on hepatocellular necrosis (p<0.05), and the plasma levels of liver enzymes returned earlier to the normal range in rats pretreated with allopurinol in comparison to those that did not receive the drug (p<0.05). CONCLUSIONS: Allopurinol exerted a protective effect on hepatic ischemia and reperfusion in rats. The administration of this drug prior to liver operations should be considered to be submitted to trials in humans.

Effects of ischemia and reperfusion on oxidative stress in hepatic cirrhosis induced by carbon tetrachloride in rats.

The present study was undertaken to determine the effect of ischemia and reperfusion on oxidative stress in hepatic cirrhosis induced by carbon tetrachloride (CCl4) in rats by the evaluation of lipid peroxidation products (LPO). Cirrhosis of the liver was induced by CCl4 administration. This drug was dissolved in mineral oil and the control group received only mineral oil intraperitoneally. Forty-five minutes of ischemia followed by one hour of reperfusion were performed. LPO products were evaluated by the thiobarbituric acid reactive substances method (TBARS) and chemiluminescence initiated by tert-butyl hydroperoxide technique (CL). The liver was submitted to histologic evaluation to check whether cirrhosis was present. The results demonstrated that ischemia-reperfusion caused an increase of LPO products in cirrhotic rats when compared to the control group (p < 0.05). Hepatic cirrhosis was present in all animals treated with CCl4 and no significant histologic alterations were observed in the control group. According to this study, we can conclude that the effect of ischemia and reperfusion in a rat model of hepatic cirrhosis caused a significant increase of the hepatic-levels of LPO products when compared to the noncirrhotic livers.

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.

Liver resections for metastases from intraabdominal leiomyosarcoma.

This paper discusses liver resection for intraabdominal leiomyosarcoma metastases as a therapy for carefully selected patients. Of the 83 hepatectomies performed from 1992 to 1996, five were resections for liver metastases due to intraabdominal leiomyosarcoma, in 3 patients. The surgical indication was single liver metastases, without any evidence of extrahepatic disease. No mortality occurred during surgery and the longest survival was 38 months. We concluded that liver resection for leiomyosarcoma metastases can be performed, allowing a long term survival in an occasional patient.

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.

[Value of left cholangiojejunostomy in palliative treatment of malignant obstruction of the hepatic hilus]. / La valeur de la cholangio-jéjunostomie gauche dans le traitement palliatif de l'obstruction maligne du hile hépatique.

The aim of this study is to analyse the results of the intrahepatic cholangiojejunostomy in the duct of segment III for malignant hilar obstruction performed in a group of 17 consecutive patients. An index for life quality, named comfort index, allowing the numeric comparison of the results was evaluated. An important reduction of the jaundice in 100% of the cases that were discharged from the hospital was observed. The hospital mortality was 11.8% with a comfort index of 81.9%. These results allow the following conclusions: 1) the employed technique represent an effective method for the solution of the cholestasis caused by unresectable tumors of the hepatic hilus; 2) the comfort index of 81.9% showed that the method is suitable as a palliative treatment of malignant hilar biliary obstruction.

[Internal pancreatic fistula: surgical treatment]. / Fistule pancréatique interne: traitement chirurgical.

The authors present 13 cases of internal pancreatic fistula, of which 11 were secondary to a chronic pancreatitis and two were caused by an abdominal trauma. Beside the clinical picture, the diagnosis was anticipated by the high amylase levels present in the fluid obtained by paracentesis or thoracocentesis. The diagnosis was confirmed by the radiological analysis of the pancreatic duct system, when an endoscopic retrograde pancreatography was performed in seven patients, one pancreatography was carried out during surgery in five cases, and one patient underwent an injection of hydrosoluble contrast in the pleural cavity. The treatment was a latero-lateral pancreaticojejunoanastomosis in five cases, associated with a corpora-caudal pancreatectomy in four patients; a cephalic duodenopancreatectomy was performed in one case. Two patients underwent a cystoenteroanastomosis, while the option chosen in the last four cases was an external drainage. One patient refused to undergo surgical treatment. Operation mortality was null. The conclusion was that an adequate surgical treatment results in the occlusion of the internal pancreatic fistula and, furthermore, allows for the definitive resolution of underlying pancreatic affection.

Helicobacter pylori-associated gastritis: does it play a role in functional dyspepsia?

OBJECTIVES: The goal of this study is to averiguate whether Helicobacter pylori (Hp)-associated gastritis is involved in the etiology of functional dyspepsia (FD) or, at least in a subset of these patients. METHODS: 103 consecutive FD patients were prospectively analyzed and subdivided according to their main complaints into ulcer-like FD (n = 31), dysmotility-like FD (n = 24) or nonspecific FD (n = 48). After endoscopy with gastric biopsy, gastritis and Hp infection were assessed and graded by histology according to the Sydney System. The prevalence of gastritis, Hp and disease activity were analyzed among the three FD subtypes and against 42 age, sex and race matched controls. RESULTS: Hp was identified in 64 (62%) of the FD group and in 23 (55%) of the controls (p > 0.20, NS). We neither observed any increased prevalence of the infection among FD subgroups (dysmotility-like 58%, ulcer-like 58%, unspecified 67%), nor in the activity of gastritis among FD subgroups and controls. We conclude that Helicobacter pylori gastritis per se is not associated with functional dyspepsia.

Biliary reconstruction in benign postoperative stricture with transhepatic tubes.

This study reports our experience with 31 patients who underwent biliary reconstructions due to iatrogenic lesions of the main biliary tract. The technique of Hepp and Couinaud, associated with the use of transhepatic Silastic tubes, was utilized in 90% of the patients, and the mucosal graft was employed in only three patients. The recommended time for keeping the transhepatic tube in place was 6 months. In order to prevent subphrenic fluid collection between the tube exit orifice in the hepatic parenchyma and the abdominal wall, the tubes were protected with a Penrose drain over the course of their use. This tactic appeared effective. The immediate postoperative mortality was 9%, and the long-term results, with a mean follow-up period of 44 months, were considered good in 92% of the patients who survived surgery.

[Cholangiography: a routine procedure in elective cholecystectomy?]. / Cholangiographie: une opération de routine lors d'une cholécystectomie élective?

A prospective study to evaluate the selective or routine use of intraoperative cholangiography on elective cholecystectomy was performed. 178 patients were studied, listing criteria to explore the biliary tract with the cholangiography aspects. The criteria showing choledocholithiasis were the alkaline phosphatase and/or bilirubin increase, dilated common bile duct, large cystic duct, small stones and pancreatitis or jaundice on the past history. The patients were divided in 4 groups: 1) no criteria: 61 (34.3%); 2) one criterion: 53 (30%); 3) two criteria: 22 (12.3%); 4) more than two criteria: 42 (23.4%). The false-positive was 1.6% to the first group, 3.8% to the group 2 and 0% to the other groups. We concluded that the intraoperative cholangiography must be achieved on patients that have at least one choledocholithiasis criterion.

[Cholangiography: a routine test in elective cholecystectomy?]. / Cholangiographie: une opération de routine lors d'une cholécystectomie élective?

A prospective study to evaluate the selective or routine use of intraoperative cholangiography on elective cholecystectomy was performed. 178 patients were studied, listing criteria to explore the biliary tract with the cholangiographic aspects. The criteria showing choledocholithiasis were the alkaline phosphatase and/or bilirubin increase, dilated common bile duct, large cystic duct, small stones and pancreatitis or jaundice on the past history. The patients were divided in 4 groups: 1) No criteria: 61 (34.3%); 2) One criterion: 53 (30%); 3) Two criteria: 22 (12.3%); 4) More than two criteria: 42 (23.4%). The false-positive was 1.6% to the first group, 3.8% to the group 2 and 0% to the other groups. We concluded that the intraoperative cholangiography must be achieved on patients that have at least one choledocholithiasis criterion.

Pancreatic stromal tumor of nerve sheath origin treated by pancreatoduodenectomy.

A pancreatic sarcoma of nerve sheath origin is reported in a 28-year-old female patient, who presented with melaena. Preoperative imaging showed an 8.5 cm diameter mass in the head of pancreas. There was bleeding from the papilla of Vater at endoscopy and a highly vascular lesion on arteriography. The patient was submitted to proximal pancreatoduodenectomy and remains symptom-free at 1 year follow-up.

[Auxiliary drainage of the intraperitoneal course of transhepatic tubes in benign common bile duct stenosis]. / Drainage auxiliaire sur le parcours intrapéritoneal des tubes transhépatiques dans les sténoses bénignes de la voie biliaire principale.

The authors used Penrose drains around intraperitoneal portion of Silastic tubes to prevent subphrenic collections in transhepatic intubation. In 31 cases of benign stenosis of the biliary tree, this peritoneal drainage was employed in 18 and no collections were observed. In the other group, 3 patients developed subphrenic abscess. Even with a result not statistically significant (P less than 0.05), the authors consider the procedure useful in transhepatic intubation.

Surgical treatment of chronic pancreatic cholangiopathy.

In a consecutive surgical series of 70 patients with chronic calcifying pancreatitis, 18 presented with fixed stenosis of the terminal common bile duct. Nine patients presented with jaundice and two had a palpable gallbladder. The most relevant laboratory datum in the series was a persistently high serum alkaline phosphatase level. Long tapering of the terminal common bile duct was the characteristic radiological sign in 45 of our patients. In five of the 18 cases compression of the terminal bile duct was due to cephalic pseudocysts. Hepaticojejunostomy-en-Y was the type of drainage chosen in 16 cases, and an end-to-side technique was used in 15 patients. Side-to-side choledochoduodenostomy was performed in two cases. In 14 patients, biliary drainage was associated with other surgical procedures on the pancreatic parenchyma. No postoperative complications due to the biliary drainage occurred in this series.