Lesão de isquemia e reperfusão após clampagem contínua ou intermitente do pedículo hepático em coelhos / Ischemia/reperfusion injury after continuous or intermittent hepatic pedicle clamping in rabbits

RACIONAL: O controle do sangramento na hepatectomia é um desafio para os cirurgiões. A clampagem do pedículo hepático é manobra cirúrgica que pode promover redução do sangramento, mas provoca isquemia hepatocelular. Isso, junto com a reperfusão depois que a clampagem termina, leva à lesão de isquemia e reperfusão. OBJETIVO: Examinar os efeitos da lesão de isquemia e reperfusão no fígado após clampagem contínua e intermitente do pedículo hepático, usando a quantificação de apoptose como ferramenta. MÉTODO: Vinte coelhos New Zealand foram divididos em grupos 1 (controle), 2 (60 minutos de isquemia contínua) e 3 (60 minutos de isquemia intermitente alternando 12 minutos de isquemia e três minutos de reperfusão). Biópsias hepáticas foram colhidas antes e ao fim da isquemia e após seis horas de reperfusão, quando os animais eram sacrificados. Os fragmentos obtidos foram submetidos à análise histológica e histoquímica (reação de Tunel). Campos microscópicos foram analisados para caracterização e quantificação de apoptose. RESULTADOS: A isquemia levou à elevação do índice apoptótico em ambos os grupos experimentais em relação aos controles, mas similar entre eles. Depois da reperfusão os índices voltaram aos valores iniciais. CONCLUSÃO: A clampagem do pedículo hepático, tanto contínua quanto intermitente, induz a apoptose em células hepáticas de modo igual.

BACKGROUND : The control of bleeding in hepatectomy is a challenge for surgeons. The hepatic pedicle clamping is a surgical maneuver that can provide reduction in bleeding, but it provokes a hepatocellular suffering. This, along with reperfusion after the clamping finishes, leads to an injury known as ischemia/reperfusion injury. AIM: To examine the effects of the ischemia/reperfusion injury on the liver after continuous and intermittent hepatic pedicle clamping in an animal model, using the quantification of apoptosis for evaluation. METHOD: Twenty New Zealand rabbits were assigned to groups 1 (control), 2 (60 minutes of continuous ischemia) and 3 (60 minutes of intermittent ischemia alternating 12 minutes of ischemia and three minutes of reperfusion). Liver biopsies were collected before ischemia, at its end and after six hours of reperfusion, when the animals were killed. The liver fragments were subjected to histological analysis (paraffinization and hematoxilin-eosin staining) and histochemical (Tunel reaction). Microscope fields of view were scanned for characterization and quantification of apoptosis. RESULTS : Ischemia led to an increased apoptotic index in both experimental groups in comparison to controls, but similarly between them. After the reperfusion, the indexes returned to baseline values. CONCLUSION: Clamping of the hepatic pedicle, either continuous or intermittent, induces apoptosis in liver cells in a similar way.

Laparoscopic hysterectomy using laparosonic coagulating shears: experience of 15 cases.

In conventional laparoscopic hysterectomy, adequate hemostasis is provided by bipolar coagulation, staple, and suture. The Laparosonic Coagulating Shears (LCS) have been proven to give both hemostasis and cutting. The objective of this study was to evaluate the efficacy of the LCS for laparoscopic hysterectomy. Fifteen patients indicated for hysterectomy were enrolled for laparoscopic hysterectomy using LCS. Each procedure was performed under general endotracheal anesthesia. The LCS were operated at power level 1 though 5. All pedicles, blood vessels, and tissues were coagulated and cut by LCS. The cardinal ligaments were cut and ligated transvaginally. The uterus was removed through the vagina. The operative finding, uterine volume and weight, operative time, CO2 volume, blood loss and hospital stay were recorded. Among the 15 cases, the indications were myoma uteri (7 cases), adenomyosis (6 cases) and adenomyosis with endometriomas (2 cases). The mean volume of the uterus was 226.8 cm3 (range 77-399 cm3) and mean weight was 188.8 g (range 85-320 g). Mean operative time was 171.6 min (range 114-210 min) and CO2 loss was 313.8 liters (range 120-650 liters). Blood loss was 366.7 ml (range 100-1,500 ml). LCS can be used for coagulation and cutting simultaneously. Minimal charring and smoke was observed during operation. In general, the hospital stay was 3 days (range 2-4 days), except for one case of recto-sigmoid injury and 2 cases of ureteric injury when the hospital stay was 7, 10, and 12 days, respectively. The injuries occurred in cases with anatomic distortion, profuse bleeding, and dense adhesion. LCS can be used as an alternative instrument for coagulation and dissection. According to our experience, it produces less charring and smoke compared to electrocoagulation. However, a high rate of complications were still encountered.

Alteraciones hemostáticas en pacientes de cirugía extracorpórea / Hemostatic alterations in extracorporeal surgical patients

Entre diciembre de 1986 y junio de 1988, se programaron 48 pacientes con anomalias cardiovasculares congenitas o adquiridas, para cirugia extracorpórea en el Hospital Universitario San Vicente de Paul de Medellin; 41 de tales pacientes fueron evaluables desde el punto de vista hemostático con pruebas sencillas de coagulación en el pre y posoperatorio. Desde el punto de vista hemostático, los pacientes sometidos a cirugia extracorporea mostraron principalmente trombocitopenia e hipofibrinogenemia leves (p < 0.001), como usualmente se informa en este tipo de cirugia. El tiempo de protrombina, (TP), el tiempo de tromboplastina parcial (TTPa) y el tiempo de trombina, (TT), tambien se prolongaron (p < 0.001) pero en ninguno de los casos fueron sintomáticos. La mortalidad fue del 7.3 por ciento, relacionada con hemostasia quirurgica deficiente. Se concluye que las alteraciones hemostaticas de los pacientes sometidos a cirugia extracorporea pueden ser asintomáticas pero que en casos particulares pueden contribuir al sangrado excesivo y en estos casos la transfusion de plaquetas y la administración de analogos sinteticos de la vasopresina pueden ser de utilidad.