RESUMO
Globally increasing concern related to municipal solid waste generation is encouraging research efforts on developing alternative routes to valorize mixed refused wastes. In this way, catalytic pyrolysis is emerging as an interesting and efficient technology due to its great flexibility in terms of feedstock. In the current work, upgrading of a Solid Recovered Fuel (SRF) has been investigated by catalytic pyrolysis over nanocrystalline ZSM-5 zeolite (n-ZSM-5), paying special attention to dechlorination effects due to the high Cl content of the raw waste. Thus, pretreatment of the SRF by water washing and mild thermal processing allows for a significant reduction of the Cl concentration. Regarding the catalytic pyrolysis step, the best conditions correspond with a temperature of 400 °C in the catalyst bed and 0.50 catalyst/SRF mass ratio, which lead to ca. 30 wt% oil yield (rich in aromatic hydrocarbons) together with about 40 wt% gas yield (rich in C3-C4 olefins). Accordingly, these products could find use as raw chemicals or for the production of advanced fuels. In addition, zeolite reutilization has been tested for several cycles, denoting a progressive modification of the products distribution because of coke deposition. However, an almost total recovery of the n-ZSM-5 zeolite catalytic performance is achieved after regeneration by air calcination, affording the production of an oil fraction with a Cl content as low as 40 ppm.
Assuntos
Hidrocarbonetos Aromáticos , Zeolitas , Zeolitas/química , Pirólise , Temperatura , Catálise , Temperatura AltaRESUMO
Objective: Laparoscopic Heller myotomy and Dor fundoplication has become the gold standard in treating esophageal achalasia and robotic surgical platform represents its natural evolution. The objective of our study was to assess durable long-term clinical outcomes in our cohort. Methods and Procedures: Between June 1, 1999 and June 30, 2019, 111 patients underwent minimally invasive treatment for achalasia (96 laparoscopically and 15 robotically). Fifty-two were males. Mean age was 49 years (20 - 96). Esophageal manometry confirmed the diagnosis. Fifty patients underwent pH monitoring study, with pathologic reflux in 18. Preoperative esophageal dilation was performed in 76 patients and 21 patients received botulin injection. Dysphagia was universally present, and mean duration was 96 months (5 - 480). Results: Median operative time was 144 minutes (90 - 200). One patient required conversion to open approach. Four mucosal perforations occurred in the laparoscopic group and were repaired intraoperatively. Seven patients underwent completion esophageal myotomy and added Dor fundoplication. Upper gastrointestinal series was performed before discharge. Median hospital stay was 39 hours (24 - 312). Median follow up was 157 months (6 - 240), and dysphagia was resolved in 94% of patients. Seven patients required postoperative esophageal dilation. Conclusions: Minimally invasive Heller myotomy and Dor fundoplication are feasible. The operation is challenging, but excellent results hinge on the operative techniques and experience. The high dexterity, three-dimensional view, and the ergonomic movements of robotic surgery allow application of all the technical elements, achieving the best durable outcome for the patient. Robotic surgery is the natural evolution of minimally invasive treatment of esophageal achalasia.
Assuntos
Transtornos de Deglutição , Acalasia Esofágica , Miotomia de Heller , Laparoscopia , Procedimentos Cirúrgicos Robóticos , Transtornos de Deglutição/cirurgia , Acalasia Esofágica/cirurgia , Feminino , Fundoplicatura/métodos , Humanos , Laparoscopia/métodos , Masculino , Pessoa de Meia-IdadeRESUMO
PURPOSE: Laparoscopic fundoplication is now a cornerstone in the treatment of gastro-esophageal reflux disease (GERD) with sliding hernia. The best outcomes are achieved in those patients who have some response to medical treatment compared to those who do not. Robotic fundoplication is considered a novel approach in treating GERD with large paraesophageal hiatal hernias. Our goal was to examine the feasibility of this technique. METHODS: Seventy patients (23 males and 47 females) with mean age 64 y old (22-92), preoperatively diagnosed with a large paraesophageal hiatal hernia, were treated with a robotic approach. Biosynthetic tissue absorbable mesh was applied for hiatal closure reinforcement. Fifty-eight patients underwent total fundoplication, 11 patients had partial fundoplication, and one patient had a Collis-Nissen fundoplication for acquired short esophagus. RESULTS: All procedures were completed robotically, without laparoscopic or open conversion. Mean operative time was 223 min (180-360). Mean length of stay was 38 h (24-96). Median follow-up was 29 mo (7-51). Moderate postoperative dysphagia was noted in eight patients, all of which resolved after 3 mo without esophageal dilation. No mesh-related complications were detected. There were six hernia recurrences. Four patients were treated with redo-robotic fundoplication, and two were treated medically. CONCLUSIONS: The success of robotic fundoplication depends on adhering to a few important technical principles. In our experience, the robotic surgical treatment of gastroesophageal reflux disease with large paraesophageal hernias may afford the surgeon increased dexterity and is feasible with comparable outcomes compared with traditional laparoscopic approaches.
Assuntos
Fundoplicatura/métodos , Refluxo Gastroesofágico/cirurgia , Hérnia Hiatal/cirurgia , Laparoscopia/métodos , Procedimentos Cirúrgicos Robóticos/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Viabilidade , Feminino , Refluxo Gastroesofágico/etiologia , Hérnia Hiatal/complicações , Humanos , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Resultado do Tratamento , Adulto JovemRESUMO
PREPROCEDURE: 1)We recommend that providers should be familiar with the operation of their specific ultrasound machine prior to initiation of a vascular access procedure. 2)We recommend that providers should use a high-frequency linear transducer with a sterile sheath and sterile gel to perform vascular access procedures. 3)We recommend that providers should use two-dimensional ultrasound to evaluate for anatomical variations and absence of vascular thrombosis during preprocedural site selection. 4)We recommend that providers should evaluate the target blood vessel size and depth during preprocedural ultrasound evaluation. TECHNIQUES: General Techniques 5) We recommend that providers should avoid using static ultrasound alone to mark the needle insertion site for vascular access procedures. 6)We recommend that providers should use real-time (dynamic), two-dimensional ultrasound guidance with a high-frequency linear transducer for central venous catheter (CVC) insertion, regardless of the provider's level of experience. 7)We suggest using either a transverse (short-axis) or longitudinal (long-axis) approach when performing real-time ultrasound-guided vascular access procedures. 8)We recommend that providers should visualize the needle tip and guidewire in the target vein prior to vessel dilatation. 9)To increase the success rate of ultrasound-guided vascular access procedures, we recommend that providers should utilize echogenic needles, plastic needle guides, and/or ultrasound beam steering when available. Central Venous Access Techniques 10) We recommend that providers should use a standardized procedure checklist that includes the use of real-time ultrasound guidance to reduce the risk of central line-associated bloodstream infection (CLABSI) from CVC insertion. 11)We recommend that providers should use real-time ultrasound guidance, combined with aseptic technique and maximal sterile barrier precautions, to reduce the incidence of infectious complications from CVC insertion. 12)We recommend that providers should use real-time ultrasound guidance for internal jugular vein catheterization, which reduces the risk of mechanical and infectious complications, the number of needle passes, and time to cannulation and increases overall procedure success rates. 13)We recommend that providers who routinely insert subclavian vein CVCs should use real-time ultrasound guidance, which has been shown to reduce the risk of mechanical complications and number of needle passes and increase overall procedure success rates compared with landmark-based techniques. 14)We recommend that providers should use real-time ultrasound guidance for femoral venous access, which has been shown to reduce the risk of arterial punctures and total procedure time and increase overall procedure success rates. Peripheral Venous Access Techniques 15) We recommend that providers should use real-time ultrasound guidance for the insertion of peripherally inserted central catheters (PICCs), which is associated with higher procedure success rates and may be more cost effective compared with landmark-based techniques. 16)We recommend that providers should use real-time ultrasound guidance for the placement of peripheral intravenous lines (PIV) in patients with difficult peripheral venous access to reduce the total procedure time, needle insertion attempts, and needle redirections. Ultrasound-guided PIV insertion is also an effective alternative to CVC insertion in patients with difficult venous access. 17)We suggest using real-time ultrasound guidance to reduce the risk of vascular, infectious, and neurological complications during PIV insertion, particularly in patients with difficult venous access. Arterial Access Techniques 18)We recommend that providers should use real-time ultrasound guidance for arterial access, which has been shown to increase first-pass success rates, reduce the time to cannulation, and reduce the risk of hematoma development compared with landmark-based techniques. 19)We recommend that providers should use real-time ultrasound guidance for femoral arterial access, which has been shown to increase first-pass success rates and reduce the risk of vascular complications. 20)We recommend that providers should use real-time ultrasound guidance for radial arterial access, which has been shown to increase first-pass success rates, reduce the time to successful cannulation, and reduce the risk of complications compared with landmark-based techniques. POSTPROCEDURE: 21) We recommend that post-procedure pneumothorax should be ruled out by the detection of bilateral lung sliding using a high-frequency linear transducer before and after insertion of internal jugular and subclavian vein CVCs. 22)We recommend that providers should use ultrasound with rapid infusion of agitated saline to visualize a right atrial swirl sign (RASS) for detecting catheter tip misplacement during CVC insertion. The use of RASS to detect the catheter tip may be considered an advanced skill that requires specific training and expertise. TRAINING: 23) To reduce the risk of mechanical and infectious complications, we recommend that novice providers should complete a systematic training program that includes a combination of simulation-based practice, supervised insertion on patients, and evaluation by an expert operator before attempting ultrasound-guided CVC insertion independently on patients. 24)We recommend that cognitive training in ultrasound-guided CVC insertion should include basic anatomy, ultrasound physics, ultrasound machine knobology, fundamentals of image acquisition and interpretation, detection and management of procedural complications, infection prevention strategies, and pathways to attain competency. 25)We recommend that trainees should demonstrate minimal competence before placing ultrasound-guided CVCs independently. A minimum number of CVC insertions may inform this determination, but a proctored assessment of competence is most important. 26)We recommend that didactic and hands-on training for trainees should coincide with anticipated times of increased performance of vascular access procedures. Refresher training sessions should be offered periodically. 27)We recommend that competency assessments should include formal evaluation of knowledge and technical skills using standardized assessment tools. 28)We recommend that competency assessments should evaluate for proficiency in the following knowledge and skills of CVC insertion: (a) Knowledge of the target vein anatomy, proper vessel identification, and recognition of anatomical variants; (b) Demonstration of CVC insertion with no technical errors based on a procedural checklist; (c) Recognition and management of acute complications, including emergency management of life-threatening complications; (d) Real-time needle tip tracking with ultrasound and cannulation on the first attempt in at least five consecutive simulation. 29)We recommend a periodic proficiency assessment of all operators should be conducted to ensure maintenance of competency.
Assuntos
Edema , Hipoproteinemia , Doenças do Jejuno , Idoso de 80 Anos ou mais , Índice de Massa Corporal , Meios de Contraste , Feminino , Seguimentos , Humanos , Hipoalbuminemia/diagnóstico , Hipoproteinemia/diagnóstico , Doenças do Jejuno/diagnóstico por imagem , Doenças do Jejuno/cirurgia , Laparotomia , Fatores de Tempo , Tomografia Computadorizada por Raios X/métodos , Resultado do TratamentoRESUMO
Fabry's disease is a rare congenic disorder of glycosphingolipid catabolism resulting from deficient activity of the alpha galactosidasa. Is an X-linked disorder and in hemizygous males the activity of this enzyme is very low, resulting in severe manifestations. Fabry disease is confirmed by the lack alfa-galactosidase in serum. In the literature have been reported a few cases of coexistent Fabry's disease and connective disorders, but there is not cases of rheumatoid arthritis coexistent. This report describes a case of a female with Fabry's disease who vas subsequently diagnosed with rheumatoid arthritis. The suspect diagnosis was very important because the two disorders are multisystem and new symptoms could be attributed to Fabry's disease. The accumulation of lipids may results in numerous pathogenic autoantibodies, which could make immunocomplex. This is the potential pathogenic mechanisms explaining the association between Fabry's disease and autoimmune diseases.
Assuntos
Artrite Reumatoide/etiologia , Doença de Fabry/complicações , Feminino , Humanos , Pessoa de Meia-IdadeRESUMO
We report the first known case of chronic relapsing thrombotic thrombocytopenic purpura associated with adult-onset Still's disease. The patient presented with diffuse arthralgias, sore throat, and a maculopapular rash involving the trunk and extremities; she was hospitalized with fever and confusion. Thrombocytopenia, renal failure, and microangiopathic hemolytic anemia developed within several days. After a diagnosis of thrombotic thrombocytopenic purpura was made, she responded well to a series of plasma exchanges. Evaluation for infection, autoimmune disorders, and malignancy was negative. She was discharged to home in good condition, with normal renal function and normal platelet count. Two more episodes of TTP developed 7 and 9 months after the first hospitalization. The diagnosis of adult-onset Still's disease was then determined on the basis of clinical and laboratory criteria. She was successfully treated with plasma exchange, prednisone, and azathioprine. She later had splenectomy and has subsequently been without recurrence of thrombotic thrombocytopenic purpura for 2 years.
Assuntos
Púrpura Trombocitopênica Trombótica/complicações , Doença de Still de Início Tardio/complicações , Feminino , Humanos , Pessoa de Meia-Idade , Púrpura Trombocitopênica Trombótica/cirurgia , Púrpura Trombocitopênica Trombótica/terapia , Recidiva , Doença de Still de Início Tardio/diagnóstico , Doença de Still de Início Tardio/terapiaRESUMO
INTRODUCTION: Extraadrenal paragangliomas are exceptional tumors. They prevail the carotid, jugulotympanic, and vagal ones. They are frequently multiple and its treatment is controversial in view of the fact that bilateral removal can go with severe morbidity. The case of a patient with bilateral paraganglioma and postoperative baroreflex dysfunction with severe arterial hypertension and hypotension episodes is presented. CLINICAL OBSERVATION: A 23-year-old woman with a diagnosis of left carotid and right vagal paraganglioma by TC and angiography. In January 1999 the left carotid paraganglioma was operated. The patient showed dysphonia, dysphagia, and lingual dysmotility in the postoperative course, with spontaneous improvement after some months. In December 1999, after the removal of the right vagal paraganglioma, the same complications appeared and hypertension crises (230/140), associated with headache, dizziness, and rash, and alternating with severe hypotension episodes (70/50). Blood biochemistry and the levels of cortisol, thyroid hormones, catecholamines, and metabolites were normal. Imaging techniques discarded tumor at another level and the registry of the ambulatory monitoring of blood pressure (AMBP) confirmed an important pressure lability. The neurophysiological study of the autonomous nervous system demonstrated the failure of the fast regulation mechanisms of the blood pressure. With the diagnosis of baroreceptors dysfunction and paralyses of cranial nerves IX, X and XII a treatment with clonidine was started with poor tolerability and incomplete response. DISCUSSION: This case illustrates the treatment difficulties of paragangliomas, especially when they are bilateral, and in which the surgery can go with severe morbidity. Baroreflex dysfunction should be entertained in the differential diagnosis of the extreme pressure lability.
Assuntos
Tumor do Corpo Carotídeo/cirurgia , Neoplasias Primárias Múltiplas , Procedimentos Neurocirúrgicos/métodos , Complicações Pós-Operatórias/prevenção & controle , Neoplasias Vasculares/cirurgia , Adulto , Tumor do Corpo Carotídeo/complicações , Tumor do Corpo Carotídeo/diagnóstico por imagem , Angiografia Cerebral , Doenças dos Nervos Cranianos/etiologia , Nervos Cranianos , Diagnóstico Diferencial , Feminino , Humanos , Tomografia Computadorizada por Raios X , Neoplasias Vasculares/complicações , Neoplasias Vasculares/diagnóstico por imagemRESUMO
OBJECTIVE: The aim of this study was to evaluate the main pathologic component of bile obtained by biliary drainage in patients with acute idiopathic pancreatitis and therapeutic implications. METHOD: Eighteen patients diagnosed with idiopathic acute pancreatitis underwent biliary drainage. Microscopic evaluation of bile was performed and pathologic components were classified in cholesterol microcrystals, bilirubinate granules, and calcium microspherolites. RESULTS: Five patients showed no abnormalities. In 11 patients, bilirubinate granules were found, cholesterol microcrystals in two, and Giardia lamblia in two. CONCLUSION: Bilirubinate granules are the main pathologic component of bile in patients with acute idiopathic pancreatitis. Cholecystectomy is the preferred therapeutic approach.