Understanding the anatomy of the Denonvilliers fascia: review article / Compreendendo a anatomia da fáscia de Denonvilliers: artigo de revisão

Abstract The postoperative outcome of rectal cancer has been improved after the introduction of the principles of total mesorectal excision (TME). Total mesorectal excision includes resection of the diseased rectum and mesorectum with non-violated mesorectal fascia (en bloc resection). Dissection along themesorectal fascia through the principle of the "holy plane" minimizes injury of the autonomic nerves and increases the chance of preserving them. It is important to stick to the TME principle to avoid perforating the tumor; violating the mesorectal fascia, thus resulting in positive circumferential resection margin (CRM); or causing injury to the autonomic nerves, especially if the tumor is located anteriorly. Therefore, identifying the anterior plane of dissection during TME is important because it is related with the autonomic nerves (Denonvilliers fascia). Although there are many articles about the Denonvilliers fascia (DVF) or the anterior dissection plane, unfortunately, there is no consensus on its embryological origin, histology, and gross anatomy. In the present review article, I aim to delineate and describe the anatomy of the DVF inmore details based on a review of the literature, in order to provide insight for colorectal surgeons to better understand this anatomical feature and to provide the best care to their patients.

Resumo O resultado pós-operatório do câncer retal foi melhorado após a introdução dos princípios da excisão total do mesorreto (TME, na sigla em inglês). A excisão total do mesorreto inclui a ressecção do reto e do mesorreto afetados com fáscia mesorretal não violada (ressecção em bloco). A dissecção ao longo da fáscia mesorretal pelo princípio do "plano sagrado" minimiza a lesão dos nervos autônomos e aumenta a chance de preservá-los. É importante seguir o princípio da TME para evitar: a perfuração do tumor; a violação da fáscia mesorretal, resultando em margem de ressecção circunferencial (CRM) positiva; ou a lesão aos nervos autônomos, especialmente se o tumor estiver localizado anteriormente. Portanto, a identificação do plano anterior de dissecção durante a TME é importante, pois está relacionada comos nervos autonômicos (fáscia de Denonvilliers). Embora existammuitos artigos sobre a fáscia de Denonvilliers (DVF, na sigla em inglês) ou o plano de dissecção anterior, infelizmente não há consenso sobre sua origem embriológica, histologia e anatomia macroscópica. No presente artigo de revisão, retendo delinear e descrever a anatomia da DVF em mais detalhes com base em uma revisão da literatura, a fim de fornecer subsídios para os cirurgiões colorretais entenderemmelhor esta característica anatômica e fornecer o melhor cuidado para seus pacientes.

Pharmacokinetic drug–drug interaction study between clindamycin and cyclosporin in rabbits

Cyclosporine A (CSA) is an immunosuppressant drug, metabolized mainly by CYP3A4 that is one of the CytochromeP450 enzymes. Clindamycin (CLN) is a lincosamide antibiotic, inducing CYP3A4 activity in vitro, and thereby mayalter CSA pharmacokinetics (PK). The current research was performed to investigate the PK parameters changes ofCSA up on co-administrating with CLN in healthy male rabbits. Twelve healthy male rabbits randomly were selectedand divided into two groups: Control set (n = 6) in which the rabbits were received oral normal saline CSA solution(10 mg/kg/day), meanwhile rabbits in the test group (n = 6) were treated with oral normal saline CSA solution (10 mg/kg/day) concomitantly with normal saline solution of CLN (8 mg/kg/day) at the same time for 7 days. Blood samples(2 ml) were collected and CSA concentrations were measured in whole blood at the predetermined time points byusing Chemiluminescent Immunoassay (CLIA) detection kit. PK profiles of CSA for both groups in the control andtest groups including Cmax, tmax, AUC0-24, the area under the blood concentration–time curve from 0 hour to infinity(AUC0-∞), t½, and Ke were compared. The results showed a statistically insignificant differences in the PK parametersof CSA alone or combined with CLN with p > 0.05. In conclusion, it has been found that CLN does not affect the CSAPK. Further confirmation of our findings is requiered in humans before these results can be applied in patient care.

Efficacy of olibanum and propolis medicinal extracts versus metronidazole in Giardia lamblia experimentally infected mice

Giardiasis is a common intestinal infection, recently included by the World Health Organization in the 'Neglected Diseases Initiative'. Despite the efficacy of nitroimidazoles; the main antigiardial chemotherapeutics, adverse effects and resistance enforced developing non-chemical alternatives. The present study aimed to assess the therapeutic efficacy of ethanol extract of olibanum (OL), propolis (PR), and their combination versus metronidazole (MTZ) against G. lamblia infection. Sixty Swiss male albino mice were randomly divided into 6 groups; 10 mice each,: Group I: normal control (non-treated; non-infected). Group II: infected with G. lamblia cysts, non-treated. On the 6th day postinfection (dPI), the remaining 4 infected groups were treated orally with: Group III: (OL). Group IV: (PR). Group V: combination of (OL+PR). Group VI: (MTZ). These mice were subjected to direct parasitological diagnosis of Giardia trophozoite in intestinal exudate, immunochromatographic test for antigen detection and histopathological studies. After 7 days therapy, complete clearance of Giardia trophozoites were in the combination of (OL+PR) and MTZ groups therapy. Lower percentages of reduction (91%) & (83%) were recorded in PR and OL-treated groups, respectively. Histopathological examination showed marked healing of intestinal mucosa using non-chemical combination and different degrees of dysplasia using MTZ, while partial healing was observed using olibanum and propolis separately. Olibanum, propolis and their combination were proved to enhance the clearance of Giardia trophozoites; with progressive improvement of the histopathological changes of jejunal mucosa, making good non-chemical alternative antigiardial therapeutics sidestepping the obstacles of metronidazole like dysplasia and teratogenicity

Pre-anesthesia evaluation leading to a diagnosis of long QT syndrome - a case study

Long QT Syndrome is a rare disorder characterized by prolongation of QT interval on an ECG. Patients with this disorder have an increased risk of developing life-threatening arrhythmias such as torsades de pointes, and occasionally sudden cardiac arrest. We present this case of undiagnosed Long QT Syndrome in a 7 years old boy, who presented to our service for incision and drainage of an abscess in the left axilla under general anesthesia. This case highlights the importance of proper and meticulous preanesthesia evaluation, even in low risk patients, so that potentially harmful medical conditions are diagnosed well in time and managed accordingly

Evaluation of calcium oxalate stones size using kidney, ureters and bladder, fluoroscopy and post lithotripsy procedures

This study aimed to measure renal stone using different modality [kidney, ureters and bladder [K.U.B], fluoroscopy and intravenous urography [I.VU]], to compare these three methods of measurements and to detect the variation of stones size after each lithotripsy shock for the same type of stones. A total of 26 patients males [19] and females [7] their age ranged between 18 and 70 years with renal stones, I.VU, K.U.B were done for all cases. In Al Nelain Medical Centre, The size of renal stone was measured in K.U.B and I.VU by using the Ruler exposure. Staghorn stones which were >4 cm needed >4 times of exposure to. Results: The findings were found to be that stone < 1 cm can be measured but does not disintegrated by lithotripsy and most of the stones that were > 1 cm were properly measured when using the fluoroscopy and were treated effectively after 2[nd] time of the shock waves. This study concluded that the surface area, site, number of stones after extracorporeal shock wave lithotripsy [ESWL] could be detected using K.U.B, I.VU and fluoroscopy, and could help in prospective selection of patients who will respond well to ESWL

Iron therapy for breath holding attacks in non-anemic infants and children

Breath holding attacks are common paroxysmal disorders in infants and children. Research trials showed good response to iron therapy. Most of these trials however, included anemic patients. To study the effect of iron therapy in the treatment of breath holding attacks in non anemic infants and children. This study has been carried out in the pediatric department, Sohag faculty of medicine in the period from 20 March 2005 to 20 February 2006. During this period all patients with breath holding spells were identified. Patients with anemia manifested clinically or with low Hb level or with low ferritin level were excluded from the study. We also excluded patients with abnormal neurological examination or abnormal electroencephalography [EEG]. The remaining patients [non-anemic neurologically normal patients] received oral iron in a dose of 6 mg/kg/day for 3 months. The response was determined either by disappearance [complete response] or decrease in the frequency and duration of attacks [partial response]. We identified 56 patients with breath holding spells. 27 patients were excluded from the study [20 were anemic, 4 had abnormal EEG and 3 had abnormal neurological examination]. The remaining 29 patients had been included in this study and received oral iron therapy. 3 patients received iron therapy but losses follow up. Concerning the 26 patients who had completed the study: 13 patients showed complete response, 4 patients showed partial response and 9 patients did not show any response. Iron therapy should be tried in all infants and children with breath holding attacks

Effect of some calcium channel blockers in experimentally induced diabetic nephropathy in rats

The aim of this study was to investigate the role of amlodipine and diltiazem [calcium channel blockers] in the prevention and treatment of diabetic nephropathy in rats. Eighty male albino rats weighing [130-180 g] were used in this study. These animals were subdivided into five groups; Group I: control group, Group II: diabetic ischaemic rats treated with insulin for 12weeks, Group III: diabetic ischaemic rats treated with insulin and captopril for 12 weeks, Group IV: diabetic ischaemic rats treated with insulin and diltiazem for 12 weeks, Group V: diabetic ischaemic rats treated with insulin and amlodipine for 12 weeks. At the end of the experiments, urine and blood samples were obtained for biochemical analysis and kidney samples were taken for histopathological evaluation. Diabetes mellitus [DM] produced a significant increase in rat kidney weight, creatinine clearance and a highly significant increase in kidney/body weight [K/B] ratio, random blood glucose, 24 h urine volume and protein and serum creatinine. While renal ischaemia alone produced a significant increase in systolic blood pressure [SBP], BUN and serum creatinine, it produced a significant decrease in creatinine clearance. Combination of renal ischaemia with DM also produced a significant increase in rat kidney weight and BUN levels and a significant increase in K/B ratio, random blood glucose, 24-h urine volume and protein and creatinine concentration. Moreover, this combination produced a significant decrease in creatinine clearance. Insulin, when given alone produced a significant reduction of the enlarged rat kidney weight and elevated K/B ratio, blood glucose and 24-h urine volume. Treatment with diltiazem or amlodipine significantly lowered the elevated SBP and 24-h urine volume. Furthermore, treatment with captopril significantly lowered the elevated SBP, serum creatinine, K/B ratio and proteinuria. Light microscopic examination of kidneys from diabetic animals revealed glomerulopathy characterized by thickening of the glomerular basement membrane, mesangial matrix expansion, arteriole hyalinosis and large proteinaceous deposits occluding capillary loops and hyaline proteinaceous droplets within the glomeruli. Moreover, examination of the kidneys of ischaemic animals by light microscopy revealed focal tubular necrosis at multiple points along the nephron, and occlusion of tubular lamina by eosinophilic hyaline casts or pigmented granular casts particularly in distal tubules. There was an interstitial oedema and accumulation of leukocytes within the dilated vasa recta. Treatment with insulin alone did not reverse the histopathological changes. Treatment with captopril did not reverse the morphological changes in the glomeruli and the casts did not disappear. However, treatment with diltiazem and amlodipine improved many histopathological changes. In conclusion, diltiazem and amlodipine ameliorated the signs of diabetic nephropathy

Allergic fungal rhinosinusitis: Current status

Allergic Fungal Sinusitis [AFS] resembles allergic bronchopulmonary aspergillosis, resulting from hypersensitivity reaction to fungi mediated by IgE and IgG. A study of 20 patients from 1990 to 1998 suffering from AFS revealed that all presented with nasal, polypi. Most had atopy with raised serum IgE and high eosinophil count. Sandwiched between polypi are dark greenish brown concretions with high metal contents. A high concentration of glycoproteins and macromolecular protein was found in the contents. The lesion showed high attenuation on CT and void signal on MRI due to the presence of metals. Aspergillus was the most frequently found fugus followed by Bipolaris, Helmenthosporium and Curvularia. Polypi are surrounded by allergic mucin and Charcot-Leyden crystals interspersed with fungal hyphae. The eosinophilic host response to the fungi in the susceptible individuals leads to cascade of inflammatory reactions initiating IgE mediated hypersensitivity, specific T-cells HLA receptor expression and aberration of local mucosal defence mechanism resulting in AFS