Is aortic occlusion advisable in the management of massive hemorrhage? Experimental study in dogs.

Occlusion of the thoracic aorta is meant to improve cerebral and cardiac perfusion in the moribund, exsanguinating trauma patient. Yet clinical and experimental experience shows no evident benefit from this critical maneuver, and hind limb paralysis (HLP) is a feared complication. Our study is intended to verify whether aortic occlusion can decrease further blood loss and therefore be useful during treatment of hemorrhagic shock. Four groups of 10 dogs were submitted to hemorrhagic shock and treated with blood (40 mL/kg) and saline (35 mL/kg). Group I was then submitted to intermittent intra-aortic occlusion (IIAO), Groups II and III to IIAO and to a second bleeding (rebleeding), and Group IV to rebleeding only, without IIAO. All dogs received volume replacement during this rebleeding phase and were kept alive for 8 days. Five dogs died and seven had HLP in the three groups submitted to IIAO. Death and HLP occurred even in the dogs of Group I, which were not submitted to a second bleeding. IIAO reduced blood loss from 139 mL/kg to 48 mL/kg. There were no complications or deaths among the 10 dogs in Group IV. Although efficient in reducing blood loss, IIAO was associated with a 16% mortality and 23% of HLP, whereas volume replacement alone was tolerated without complications or death. We conclude that IIAO is dangerous while treating severe hemorrhagic shock even after volume replacement and hemodynamic stabilization.

DNA image cytometric analysis of differentiated thyroid adenocarcinoma specimens.

A total of 117 differentiated thyroid adenocarcinomas that had been removed by total thyroidectomy were studied. Seventy (60%) were papillary, 36 (30%) were follicular, and 11 (10%) were Hürthle cell adenocarcinomas. The mean length of follow-up was 57.7 months. Adverse prognostic factors according to multivariate analysis were adjacent tissue infiltration (p = 0.0004), histologic type (p = 0.0049), and patient age (p = 0.033). The nuclear DNA content of tumor cells and of morphologically normal adjacent tissue was assessed by image cytometry, and correlations between nuclear DNA content and prognostic factors were examined. Fifty-four (75%) adenocarcinomas were classified as aneuploid, 9 (13%) as diploid, and 9 (12%) as borderline. Thirty-four (60%) specimens of morphologically normal adjacent tissue were classified as aneuploid, 18 (32%) as diploid, and 5 (8%) as borderline. The correlation between tumor ploidy and selected prognostic factors was statistically significant for patient age (p = 0.004) and histologic type (p = 0.033). Despite the fact that ploidy could not be identified as a prognostic factor, we suggest that, because of its correlation with age and histologic type, it might prove prognostic if the number of patients were increased. We also emphasize the importance of evaluating morphologically normal adjacent tissue because of the high rates of aneuploidy in these areas.

[Duodenocolonic fistula. Report of a case and review of the literature]. / Fístula duodeno-cólica. Relato de um caso e revisão da literatura.

Malignant duodenocolic fistula due to carcinoma of the colon is an infrequent condition. The authors describe a case treated by right hemicolectomy associated with gastrectomy and partial duodenectomy. After a review of the literature, they discuss the surgical possibilities.

[Levels of hepatic fats in jejuno-ileal bypass. Experimental study]. / Níveis de gordura hepática nas derivações jejuno-ileais. Estudo experimental.

Liver failure is a serious complication when small bowel bypass is used for control of obesity. To analyse the changes in liver microscopic morphology and liver fatty acids content, 42 rabbits divided in two groups were studied. The 21 animals of group I had 50% of the distal jejuno-ileum excluded and anastomosed to the cecum. The proximal 50% were anastomosed to the distal 5 cm of the ileum. The 21 animals of group II were used as controls and were submitted to a laparotomy and small bowel manipulation. Liver histology and fatty acids content were studied at the time of these operations and in the 21st postoperative day. No signficant histologic changes were noticed in both groups. A significant decrease in liver fatty acids content was observed in groups I and II. However, the decrease in group II was less pronounced than in group I. This last observation appears to support the theory of liver lipid metabolism impairment after small bowel bypass, even in the absence of obesity.

Electron microscopic study on the elastic and elastic related fibres in the human fascia transversalis at different ages.

An electron microscopic study of the elastic fibre and elastic related fibres of the fascia transversalis of the human inguinal triangle was performed in 20 male patients aged 13 to 81 a with right indirect inguinal hernia submitted to surgical repair. The 3 fibre types comprising the elastic system (oxytalan, elaunin, and elastic fibres) tend to be ordered in a precise manner and sequence among the fibrils, fibres, and collagen fibre bundles, respectively. The present findings show that with aging, there is a decrease in the oxytalan fibres and an increase in the amorphous substance of the elastic fibres. The authors concluded that the decrease in oxytalan fibres as a function of age may be responsible for alteration in the resistance of the transversalis fascia.

[Surgical treatment of acute pancreatitis: experience at a general hospital]. / Tratamento cirúrgico da pancreatite aguda: experiência de um hospital geral.

The authors present a study of 15 cases of necrotizing acute pancreatitis treated surgically at the Surgery Department of the University Hospital of the University of São Paulo. All patients in the series were submitted to exploratory laparotomy with sequestrectomy and drainage. Etiology, sex, age, complications, and Ranson prognostic criteria were compared to mortality. Overall mortality was 33%.

Radiographic aspects and angioarchitectural arrangements in corrosion casts of the blood supply to the human sternocleidomastoid muscle by the sternocleidomastoid branch of the occipital artery.

The contribution of the sternocleidomastoid branch of the occipital artery (superior arterial pedicle-SAP) to the irrigation of the sternocleidomastoid muscle (SCM) was evaluated in fresh human cadavers by injecting radiological dye and a resin for microvasculature corrosion casts. From its insertion in the mastoid process of the temporal bone, the SCM was divided into superior, medium, and inferior thirds. In most of the SCM, The SAP are formed by two longitudinal parallel branches. In all specimens, the radiological dye injected into the SAP reached or trespassed the middle part of the studied SCM. The SAP was poorly distributed in the lowermost region of the inferior third of the SCM, suggesting the contribution of other arteries or pedicles. The corrosion casts of the microvasculature showed a profuse network of microscopic vessels in those levels where the SAP was detected.

Experimental injury to the spleen study of interaction: contamination/preservation.

Ablation of the spleen leads to a significant risk of postsplenectomy invasive sepsis. This concept has become very important in the last three decades because of awareness of the spleen's important role in immunological functions. Hence, this has led many research centers to study hemostasis of the injured spleen in order to preserve its function. The objective of this study is to analyze the use of nylon mesh for preservation of the wounded spleen in the presence or absence of local contamination. Twenty dogs were operated, randomly divided into two groups and followed postoperatively for eight weeks. A standard splenic injury was produced in all animals and hemostasis accomplished by attaching nylon mesh to the organ. Postoperatively, in one of the groups the "wounded organ + mesh" was contaminated with a bacterial count proportional to the animal's weight. The other group was not contaminated, maintaining it as control. Both groups were studied as to interaction of contamination/preservation, i.e., body weight, surgical findings, splenic size and histology, blood and tissue culture and hematological data. The dogs adequately withstood the standardized trauma regardless of local contamination. And the nylon mesh effectively arrested bleeding in all animals. At sacrifice inoculated germs were confirmed in the contaminated group by histological methods or tissue cultures. A cellular infiltrate of lymphocytes and plasmocytes was present close to the mesh only in the latter. The mesh attached to the injured spleen did not lead to abscesses, intrasplenic or intraperitoneal fluid collections. Based on analysis of the data, we can infer that local contamination of the injured spleen and the presence of non-absorbable material (nylon mesh) did not markedly alter the overall behavior of the dogs compared to the uncontaminated group.

[Acute abdomen in a patient with polyarteritis nodosa: report of a case]. / Abdome agudo em paciente com poliarterite nodosa: relato de um caso.

The authors present the case of a 31 year old woman admitted with abdominal pain, fever, weight loss and malignant hypertension. The ultrasonographic examination showed an image suggesting chronic nephropathy. On the 3rd day of hospitalization an exploratory laparotomy was performed with the diagnosis of acute abdomen. There was purulent peritonitis and a segment of ileum with multiple perforations, which was resected. The anatomopathologic finding of the surgical specimen revealed polyarteritis nodosa. The patient developed multiple organ failure and evolved to death. The difficulty in establishing the diagnosis is commented and, the authors according with some studies suggest treatment with plasmapheresis because the conventional therapy with methylprednisolone and cyclophosphamide proved to be insufficient in severe cases.

Blood supply to the human sternocleidomastoid muscle by the sternocleidomastoid branch of the occipital artery.

The contribution of the sternocleidomastoid branch of the occipital artery, superior arterial pedicle (SAP), to the irrigation of the sternocleidomastoid muscle (SCM) was evaluated in fresh human cadavers by injecting Neoprene-latex for minute dissection. From its insertion in the mastoid process of the temporal bone, the SCM was divided into six levels. The Neoprene-latex injected into the SAP reached the upper three levels in all SCMs studied, which corresponds to the middle part of the studied SCM. In 43.3% of the SCM, this branch reached level four and in 36.6%, it reached level five.

Variation of infrarenal aortic diameter: A necropsy study.

PURPOSE: To determine anatomicomorphological changes in the infrarenal portion of the abdominal aorta, we performed 645 dissections of the segment in corpses undergoing necropsy. METHODS: The aortas were removed from the corpses with a surgical technique; by means of a device that we designed, the external diameter of the artery was measured after luminal pressure was reestablished. This way, it was possible to avoid underestimation of the arterial diameter postmortem. The influence of age, sex, body size, arterial hypertension, chronic obstructive pulmonary disease, and coronary disease on the aortic diameter and the influence of different degrees of sclerosis on the infrarenal aorta wall were analyzed. Considering the diameters, aortas were regarded as "normal" when they did not present any ectasia, arteriomegaly, aneurysm, or hypoplasia. RESULTS: The sample involved 645 subjects whose ages ranged from 19 to 97 years (mean age, 55.8 years). Of the 645 subjects, 65.5% (423) were men, 34.5% (222) were women, 81% (523) were white, and 19% (122) were of another race. The diameters of arteries showing no anomalous dilatation (ectasis, arteriomegaly, or aneurysm) varied according to subject age, sex, body length, and the degree of atherosclerosis on the aorta wall (P <.01). Aortic diameters of those subjects with arterial hypertension, coronary disease, and chronic obstructive pulmonary disease were compared with the aortic diameters of control subjects, and significant differences were not shown (P >.05). Twenty-nine aneurysms were found (4.5% prevalence). Four were ruptured aneurysms, and all occurred in aortas with diameters larger than 5.0 cm. CONCLUSION: The infrarenal aortic diameter enlarges with aging, and this enlargement occurs earlier in men than in women. Those subjects who had a longer body length and advanced sclerosis on the aorta wall had larger aortic diameters. There was a high prevalence of infrarenal aneurysms (4.5%), with rupture found solely in aortas with diameters larger than 5.0 cm.

Aortoesophageal fistula caused by aneurysm of the thoracic aorta: successful surgical treatment, case report, and literature review.

Aortoesophageal fistula induced by atherosclerotic thoracic aortic aneurysm is rare, but is usually a fatal disorder, with few survivors reported. We report the case of a 72-year-old man with aortoesophageal fistula successfully treated in a two-stage operation. In the first stage, we performed resection and replacement of the aortic aneurysm with a prosthetic graft in situ, esophagectomy, cervical esophagostomy, and jejunostomy. After the patient recovered well postoperatively, a transmediastinal retrosternal interposition of the stomach was performed, with esophagogastroanastomosis in the cervical area, to re-establish the gastrointestinal tract. We include a discussion of the causes, diagnostic approach, management of the aorta and esophagus, and review of the literature.

How safe is ERCP to the endoscopist?

BACKGROUND: Interventional techniques in endoscopy such as endoscopic retrograde cholangiopancreatography (ERCP) have greatly increased since laparoscopic cholecystectomy has become widespread; mainly these techniques deal with common bile duct stones. Fluoroscopy is usually employed, and chronic exposure to X-ray, in spite of the relative low dose, can lead to potentially unhealthy conditions such as malignancies like bone marrow and other solid cancers. A median of 18 years of life is lost per fatal cancer, including the time of latency since exposure. Nor should one forget benign condition such as cataracts that can lead to partial or complete blindness and which surely impair life's quality. METHODS: Simulated examinations were carried at the University Hospital (São Paulo, Brazil) using an anthropomorphic phantom in place of the physician. Four sets of dosimeters were placed in the forehead, neck, torso, and lower abdomen (with and without a lead apron) and standard ERCP fluoroscopic techniques were employed. RESULTS: The dose equivalents were calculated and compared to the recommended exposure doses of national and international boards of radiation protection. CONCLUSIONS: Based on the results found and compared to standards, working safely means: (1) A lead (0.5 mm thickness) apron is fundamental. Without it less than one ERCP\month should be performed. (2) With an apron, 23 examinations/month are allowed. (3) No thyroid protection grants only 19 exams/month. (4) Performing ERCP without lead glasses is hazardous to the eye, allowing only seven ERCPs monthly.