Stress response to ovariohysterectomy in rabbits: role of anaesthesia and surgery.

The aim of this study was to evaluate the neuroendocrine and inflammation response to laparoscopic total ovariohysterectomy (TOH) in rabbits, by comparing surgical stress markers of laparoscopic group with those of conventional open ovariohysterectomy and open ovariohysterectomy with pre-incisional local anaesthesia groups. Blood was sampled from 18 rabbits, of which six underwent laparoscopic TOH, six conventional open TOH and six conventional open TOH with pre-incisional local anaesthesia, 30 min before induction of anaesthesia (T0), immediately after skin incision (T1), 90 min postoperatively (T2), and 24 h postoperatively (T3). Cortisol and C-reactive protein serum, and adrenocorticothrophic hormone, tumour necrosis factor-a (TNF-a), adrenaline, noradrenaline and IL-6 plasma concentrations were evaluated. Laparoscopic TOH in rabbits has advantages over the open surgical technique because it causes less surgical stress response in terms of serum cortisol concentrations immediately after skin incision (p = .04), as well as plasma adrenaline (p = .035) and TNF-a (p = .047) concentrations 24 h postoperatively. Impact statement What is already known on this subject? Hysterectomy is the second most common surgery performed on women after caesarean section. Research has focussed on methods to modify the stress response associated with surgery. Various studies both in humans and animals, have demonstrated the less systemic, immunological and neurohormonal response of the laparoscopic technique, which is expressed by less elevated serum enzymes' and proteins' concentrations. However, other studies have documented that the systemic stress response after open hysterectomy is similar to that following laparoscopic surgery. What do the results of this study add? Laparoscopic total ovariohysterectomy in rabbits has advantages over the open surgical technique because it causes less surgical stress response in terms of serum cortisol concentrations, as well as plasma adrenaline and TNF-a concentrations during the first 24 h postoperatively. What are the implications are of these findings for clinical practice and/or further research? There were no significant differences between the groups in number of surgical stress markers (p > .05) perioperatively. We cannot exclude the possibility that a later increase of surgical stress response might take place after the first 24 h postoperatively.

The secondary external inguinal ring and associated fascial planes: surgical anatomy, embryology, applications.

Classically, two inguinal rings are defined: internal and external. We previously introduced a third one, the secondary internal inguinal ring, deep to the classic internal. Here, we present a fourth ring, the secondary external inguinal ring, initially described by McGregor (Surg Gynecol Obstet 49:273-307, 1929), but now forgotten. Embryologically, this ring may be formed by evagination of Scarpa's fascia during testicular descent. Anatomically, it is located 2 cm below the pubic tubercle. It is formed by Scarpa's fascia that covers the spermatic cord anteriorly; medial and lateral fascial reflections delineate the ring and form the spermatic cord canal. The cord is attached to the posterior wall of the canal. The canal ends at the entrance of the scrotum, where Colles' fascia fuses with coverings of the cord. Adjoining the secondary external ring, at the same surgical layer and communicating with the subcutaneous abdominal space, are four subcutaneous pouches: laterally, the superficial inguinal pouch; medially, the perineal, femoral, and pubic pouches. Surgically, an inguinoscrotal hernia passes though the secondary external ring and obtains an extra outer layer by entering the spermatic cord canal. Underdevelopment of the ring leads to incomplete testicular descent or ectopic testis. We recommend reconstruction of Scarpa's ring after orcheopexies and herniotomies in children. After urethral rupture distal to the urogenital diaphragm, urine may fill the subcutaneous abdominal space, pouches, and scrotum, due to their communication around the secondary external ring. In females, this ring was not found, possibly because of the non-descent of the ovaries through (and beyond) the inguinal canal.

New experimental rabbit animal model for cervical spondylotic myelopathy.

STUDY DESIGN: Cervical spondylotic myelopathy (CSM) represents the most commonly acquired cause of spinal cord dysfunction among individuals over 55 years old. The pathophysiology of the disease involves static and dynamic mechanical factors, which are the result of chronic degeneration. The clinical course of the disease remains unpredictable. In the past, many experimental animal models have been developed to study the cellular and molecular mechanisms underlining the pathophysiology of the disease. OBJECTIVES: To create a new animal model of CSM, which will reproduce the temporal course of the disease and the local microenvironment at the site of spinal cord compression. METHODS: We performed posterior laminectomy to New Zealand rabbits at the level of C7, and a thin sheet (5-7 µm) of aromatic polyether was implanted with microsurgical technique at the epidural space underneath C5-C6 laminae. Motor function evaluation was performed after the operation and once a week thereafter. RESULTS: After 20 weeks, the animals were killed, and the histological evaluation of spinal cord at the site of compression above and below it, using eosin hematoxylin, immonohistochemistry and Kluver-Barrera techniques reveals axonal swelling and demyelination, interstitial edema and myelin sheet fragmentation. Moreover, histological evaluation of C5 and C6 laminae reveals osteophyte formation. CONCLUSION: We believe that this CSM model reproduces the temporal evolution of the disease and creates a local microenvironment at the site of spinal cord compression, which shares the same characteristics with that of human disease.

Parental exposures and risk of nonsyndromic orofacial clefts in offspring: a case-control study in Greece.

OBJECTIVE: To investigate the association between cleft lip and/or palate and nongenetic factors in Greece. METHODS: We designed a case-control study including 35 patients with nonsyndromic cleft lip and/or palate, retrospectively selected, and 35 control patients matched for prefecture of residence, prospectively selected from pediatric population hospitalized for abdominal pain or injury. Parents were interviewed about drug uptake, diseases, habits, non-occupational exposure to pollutants, and occupation. Questions covered the period from one year before until three months after conception. RESULTS: High-risk paternal occupations (mostly farmers) were significantly more frequent in cleft lip and/or palate than in controls (p=0.039) and increased significantly the cleft lip and/or palate risk in offspring (OR: 3.00; 95% CI: 1.03-8.70). Maternal occupation did not correlate with cleft lip and/or palate. Parental disease, drugs uptake, hazardous habits, maternal folate supplementation and non-occupational exposure to pollutants did not correlate with cleft lip and/or palate. There was a suggestion of increased risk with maternal passive exposure to tobacco (OR: 1.81; 95% CI: 0.69-4.74) and with residential proximity to industries (OR: 1.70; 95% CI: 0.61-4.74). CONCLUSIONS: Paternal high-risk occupations probably exert a teratogenic effect on spermatogenesis or result in maternal contamination, and deserve specific preventive policies. The relation of smoking and residential proximity to industries with occurrence of cleft lip and/or palate deserves further study.

Sonographic evidence for patency of the processus vaginalis in children with acquired undescended testis.

Testes do ascend, but for unknown reasons. A testis may ascend through a patent processus vaginalis (PV). However, data for PV patency in acquired undescended testes (aUDT) are inconclusive. In this article, we aim to assess the sonographic PV diameter in boys with aUDT in comparison with normal group boys (obliterated PV) and boys with hydrocele or inguinal hernia (patent PVs). This retrospective study included 43 boys operated unilaterally for aUDT (n = 16), communicating hydrocele (n = 11) and inguinal hernia (n = 16). All selected patients had a preoperative measurement of the ipsilateral PV diameter. In addition, 17 boys with phimosis (normal group boys) were prospectively included, and underwent a sonographic examination of the inguinoscrotal area of a randomly selected side to measure the diameter of the respective PV. In total, 60 sides were examined. An aUDT was defined as a testis that had been identified at least twice previously in scrotal position. The results indicated that in normal group boys, PV could not be detected by sonography. In contrast, PVs ipsilateral to aUDT were visualized as hypoechoic tubules connecting the peritoneal cavity with the scrotum, similar to patent PVs in hydroceles. PV diameter in the aUDT group did not differ from the hydrocele group. However, PVs in aUDT and hydrocele were significantly narrower than in inguinal hernias. This is the first report of a patent PV in aUDT, comparable with hydrocele. Our findings suggest high ligation of the patent PV during orchidopexy.

Serum beta-endorphin response to stress before and after operation under fentanyl anesthesia in neonates, infants and preschool children.

INTRODUCTION: The endogenous opioid beta-endorphin is a known indicator of stress and pain. Opioid anesthesia during operation may prevent postoperative beta-endorphin hypersecretion. We examine the effect on serum beta-endorphin of both preoperative stress and stress of operation under opioids in neonates, infants and preschool children. In order to eliminate the effect of hospitalization anxiety we compared with inpatients of similar age with non-surgical disease. MATERIAL AND METHODS: We included 74 surgical patients (25 neonates, 24 infants, 25 preschool children), and 44 non-surgical inpatients (14 neonates, 12 infants, 18 preschool children). Anesthesia comprised propofol and fentanyl. In presence of pain after extubation, supplementary morphine was administered. Sera were taken preoperatively and 2 h postoperatively in surgical patients, and once in non-surgical patients. Beta-endorphin was tested using ELISA (ng/ml). RESULTS: In all surgical patients beta-endorphin did not increase significantly after surgery. Neonates showed significantly elevated beta-endorphin preoperatively (mean+/-SD: 2.02+/-0.76) and postoperatively (2.07+/-0.90) compared to neonates with a non-surgical disease (1.05+/-0.34; p<0.005). In contrast, infants (preoperative values: 1.75+/-1.32, postoperative values: 2.00+/-1.83) did not differ from respective non-surgical inpatients (1.49+/-0.70). Before and after surgery, beta-endorphin was significantly elevated in preschool children (7.19+/-1.85, 6.42+/-1.31), as compared with neonates and infants (p<0.0005), and with preschool children with non-surgical disease (1.01+/-0.27; p<0.0005). CONCLUSIONS: Fentanyl/propofol anesthesia, supplemented by postoperative morphine where necessary, protects from surgical stress and postoperative pain, as denoted by no postoperative increase of beta-endorphin in all age groups. Preschool children, who exhibit increased emotional perception, have explicitly high serum beta-endorphin before and after surgery. Preoperative preparation programs might be worthy in this age group. Neonates show a moderate but still significantly high response of beta-endorphin to stress, retained after operation. In contrast, infants tolerated stress better (not increased beta-endorphin pre- and post-operatively).

Retroperitoneal perforation of a duodenal diverticulum with colonic necrosis -- report of a case.

Primary duodenal diverticula are usually asymptomatic. About 115 perforations have been reported, but none with right colon necrosis. We report a 45-year-old woman, with a five days history of high fever along with epigastric and periumbilical pain. Physical examination revealed right upper and lower quadrant tenderness with peritoneal signs. White blood cell count was 11 500/mm (3) while biochemical and hepatic biology tests were normal. Abdominal radiographs showed no pathologic findings. Ultrasound disclosed fluid in the lower pelvis. Computerized tomography revealed fluid collection in the right hepatorenal space. Intraoperative findings included purulent fluid in the lower pelvis, segmental necrotic changes of the right colon, and a perforated diverticulum on the antimesenteric border of the third part of the duodenum. Surgery consisted of right hemicolectomy and ileo-transverse anastomosis, diverticulectomy, and decompressive lateral duodenostomy at the second duodenal portion. The patient had an uneventful postoperative course. A contrast study from the duodenostomy tube on the 6 (th) postoperative day showed no leakage or obstruction. Duodenostomy tube was removed on the 14 (th) postoperative day. Histology confirmed the diagnosis of a primary duodenal diverticulum.

Sonographic measurement of the abdominal esophagus length in infancy: a diagnostic tool for gastroesophageal reflux.

OBJECTIVE: Our aim was to provide exact sonographic measurements of the abdominal esophagus length in neonates and infants with and without gastroesophageal reflux (GER) and to investigate its diagnostic value. GER severity and hiatal hernia presence were also evaluated and correlated with esophageal length. MATERIALS AND METHODS: This retrospective case-control study comprised 258 neonates and infants (150 without reflux and 108 with reflux). There were 50 children without reflux in each of three age categories: less than 1 month, 1-6 months, and 6-12 months. Of the children with reflux, 42 were less than 1 month old; 34, 1-6 months; and 32, 6-12 months. The abdominal esophagus was measured from its entrance into the diaphragm to the base of gastric folds in fed infants. The number of refluxes during a 10-min period were recorded; GER was categorized as mild, one to three refluxes; moderate, three to six refluxes; and severe, more than six refluxes. Presence of hiatal hernia was recorded. RESULTS: Neonates and infants with reflux had a significantly shorter abdominal esophagus than subjects without reflux: the mean difference in neonates, 4.8 mm; 1-6 months, 4.5 mm; 6-12 months, 3.4 mm. Children with severe reflux had a shorter esophagus compared with those with mild and moderate reflux only in the neonate group. In contrast, children with reflux associated with hiatal hernia had a significantly shorter esophagus compared with children with mild reflux in all three age groups. Sonographic sensitivity was 94%. CONCLUSION: Sonographic measurement of the abdominal esophagus length is highly diagnostic for GER in neonates and infants. In neonates, it can also indicate GER severity. Hiatal hernia is associated with a significantly shorter abdominal esophagus.

Not just an appendix: Sir Frederick Treves.

The history of the anatomy and surgery of the appendix is a beautiful chapter in medical education, and we appreciate the role of Sir Frederick Treves in its development.

Hemorrhage in the cavum septi pellucidi, and a brief review of the literature.

The aim of this study is to present the cases of four neonates with hemorrhage within the cavum septi pellucidi (CSP). The sonographic findings of this rare location of intracranial hemorrhage, the related pathology and the possible underlying mechanisms are discussed, with a brief review of the literature. Three out of four of the neonates were premature and the fourth was a full-term infant with Down's syndrome. In all the patients the hemorrhage in the CSP was associated with severe intracranial hemorrhage.

Sonographic detection of lymph nodes in the intussusception of infants and young children: clinical evaluation and hydrostatic reduction.

OBJECTIVE: Our aim was to assess the sonographic appearance of enlarged lymph nodes in the intussusception in infants and young children and to investigate whether the enlarged lymph nodes affect the hydrostatic reduction rate of intussusception. MATERIALS AND METHODS: This retrospective case control study included a total of 65 children with intussusception, consisting of two groups: a study group of 28 patients with lymph nodes detected in intussusception and a reference group of 37 patients of similar age without lymph nodes in intussusception. The selection criterion for the study group was the presence of a minimum of two lymph nodes, of which at least one had a long axis of 11 mm or greater. The intussusception patterns, target or doughnut-like, and the presence of trapped fluid in the intussusception were also evaluated. Clinical records were reviewed for associated disease. The reducibility of both study and reference groups was assessed and correlated with all the sonographic features mentioned. RESULTS: Twenty-two of the 28 patients in the study group and none in the reference group had a recent or a current history of gastroenteritis. The overall hydrostatic reduction rate was 46.4% in patients with enlarged lymph nodes in the intussusception and 81.1% (p < 0.005) in patients without enlarged lymph nodes in the intussusception. Larger rather than numerous lymph nodes significantly affected the reducibility rate. Most of the reference group patients had a hydrostatic reduction at first attempt, whereas a second attempt at hydrostatic reduction was required in most of the study group patients. CONCLUSION: Enlarged lymph nodes in the intussusception are mainly found in patients with a current or recent history of gastroenteritis and decrease the overall hydrostatic reduction rate.

Sonographic features indicative of hydrostatic reducibility of intestinal intussusception in infancy and early childhood.

The aim of the study was to investigate the various sonographic patterns of intussusception, which may be indicative of its reducibility by hydrostatic reduction. Seventy-one infants and children clinically suspected of having intussusception were studied sonographically and given barium enemas. Sonographic patterns of intussusception were correlated with its reducibility. When the head of intussusception appeared as a target-like mass the hydrostatic reduction rate was 100%. When demonstrated as a doughnut-like mass, the intussusception reducibility depended on the thickness of the hypoechoic external ring of the "doughnut". With a thickness equal to, or less than, 7.2 mm the reduction rate was 100%, with a thickness ranged between 7.5 and 11.2 mm the reduction rate was 68.9% and with a thickness measured 14 to 14.2 mm a surgical resection of bowel was required. When a small amount of fluid appeared within the head of intussusception, like a crescent hypoechoic area, the hydrostatic reduction was unsuccessful, regardless of the sonographic pattern of intussusception (target- or doughnut-like mass). The presence of a small amount of free peritoneal fluid did not affect the reducibility of intussusception. In conclusion, sonographic patterns of intussusception identify good and poor prognostic features for the success of hydrostatic reduction.

Absence of antisperm surface antibodies in prepubertal boys with cryptorchidism and other anomalies of the inguinoscrotal region before and after surgery.

PURPOSE: Although the prepubertal immune system cannot recognize postmeiotic germ cell antigens, an overall 21 to 28% incidence of antisperm antibodies directed at these antigens has been reported preoperatively in prepubertal children with cryptorchidism and other inguinoscrotal anomalies. We investigated the prevalence of antisperm antibodies in these prepubertal patients before and after surgery. MATERIALS AND METHODS: We examined 82 prepubertal boys 0.6 to 13.2 years old, including 33 with unilateral cryptorchidism, 21 with inguinoscrotal anomalies and 28 who were normal. IgG, IgM and IgA antisperm antibodies were determined by the indirect Immunobead test. Serum testing was repeated 1 and 2 years postoperatively and annually for 2 more years in the normal children. Also sera from 183 infertile men 21 to 47 years old with a history of cryptorchidism and/or inguinal hernia operated on in childhood were similarly studied. RESULTS: Of the adults 70 (39%) tested IgG positive, including 12 (7%) who were also IgA positive, and all tested IgM negative. Repeat measurements were negative for all IgG, IgA and IgM isotypes in all children, patients and controls. CONCLUSIONS: We conclude that there are no antibodies to sperm surface antigens in prepubertal children with cryptorchidism and inguinoscrotal anomalies before and within 2 years after surgery. Autoimmunity against postmeiotic sperm membrane antigens is apparent in adults only.

Ovarian cavernous hemangioma in an 8-year-old girl.

The case of an ovarian cavernous hemangioma with torsion in an 8-year-old girl is described. Current literature records less than 50 cases of which only 8 are in children. The presenting symptoms of acute abdomen and the ultrasonographic study led to the preoperative diagnosis of torsion of an ovarian tumor. Salpingo-oophorectomy and appendicectomy were performed with an uneventful postoperative course. The histological pattern of the tumor was that of an entirely cavernous hemangioma. The case is reported in view of its rarity.

Natural antibodies in childhood: development, individual stability, and injury effect indicate a contribution to immune memory.

Natural, often autoreactive antibodies are present in normal sera in large quantity and show alterations in specificity in diverse pathological situations. They have, however, usually not been studied longitudinally. Here we investigated some representative serum reactivities of natural antibodies in 67 normal children and 10 with injury during childhood, followed up for 3 years. Normal children showed an individually characteristic and relatively stable level of most IgM, IgG, and IgA reactivities when measured with ELISA by reference to a standard. Injured children showed some very rapidly enhanced reactivities within 3 days after trauma, which thereafter slowly diminished over years before coming back to a normal level. This period exceeds by far the lifetime of antibodies and plasma cells. We conclude that natural antibodies contribute to the establishment and maintenance of immune memory in a manner that is distinct from classical immune reactions.