A spectral analysis of the myoelectric activity of the left colon in patients with schistosomiasis mansoni.

The objective of the present study was to perform a spectral analysis of the electrical activity of the left colon of patients with hepatosplenic schistosomiasis. Thirty patients were studied, divided into 2 groups: group A was composed of 14 patients (9 males and 5 females) with hepatosplenic schistosomiasis and group B was composed of 16 female patients without schistosomiasis mansoni. Three pairs of electrodes were implanted in the left colon at the moment of the surgical treatment. The signals of the electric activity of the colon were captured after postoperative recovery from the ileus and fed into a computer by means of a DATAQ data collection system which identified and captured frequencies between 0.02 and 10 Hz. Data were recorded, stored and analyzed using the WINDAQ 200 software. For electrical analysis, the average voltage of the electrical wave in the three electrodes of all patients, expressed as millivolts (mV), was considered, together with the maximum and minimum values, the root mean square (RMS), the skewness, and the results of the fast Fourier transforms. The average RMS of the schistosomiasis mansoni patients was 284.007 mV. During a long period of contraction, the RMS increased in a statistically significant manner from 127.455 mV during a resting period to 748.959 mV in patients with schistosomiasis mansoni. We conclude that there were no statistically significant differences in RMS values between patients with schistosomiasis mansoni and patients without the disease during the rest period or during a long period of contraction.

A spectral analysis of the myoelectric activity of the left colon in patients with schistosomiasis mansoni

The objective of the present study was to perform a spectral analysis of the electrical activity of the left colon of patients with hepatosplenic schistosomiasis. Thirty patients were studied, divided into 2 groups: group A was composed of 14 patients (9 males and 5 females) with hepatosplenic schistosomiasis and group B was composed of 16 female patients without schistosomiasis mansoni. Three pairs of electrodes were implanted in the left colon at the moment of the surgical treatment. The signals of the electric activity of the colon were captured after postoperative recovery from the ileus and fed into a computer by means of a DATAQ data collection system which identified and captured frequencies between 0.02 and 10 Hz. Data were recorded, stored and analyzed using the WINDAQ 200 software. For electrical analysis, the average voltage of the electrical wave in the three electrodes of all patients, expressed as millivolts (mV), was considered, together with the maximum and minimum values, the root mean square (RMS), the skewness, and the results of the fast Fourier transforms. The average RMS of the schistosomiasis mansoni patients was 284.007 mV. During a long period of contraction, the RMS increased in a statistically significant manner from 127.455 mV during a resting period to 748.959 mV in patients with schistosomiasis mansoni. We conclude that there were no statistically significant differences in RMS values between patients with schistosomiasis mansoni and patients without the disease during the rest period or during a long period of contraction.

Late results on the surgical treatment of Chagasic megaesophagus with the Thal-Hatafuku procedure.

BACKGROUND: Chagas' disease has a wide distribution in Central and South America. It is endemic in 21 countries, with 16 to 18 million persons infected and 100 million at risk. Surgical treatment of achalasia from Chagas' disease is the first choice in advanced stages. The aim of this study was to analyze the late clinical followup of 50 patients operated on for Chagas megaesophagus with the Thal-Harafuku procedure. STUDY DESIGN: During the period of January 1966 to January 1993, 50 patients suffering from advanced achalasia from Chagas' disease were submitted to the Thal-Hatafuku procedure. The patients answered a questionnaire concerning the most relevant postoperative symptoms. The Thal-Hatafuku procedure was performed as the first surgical option (46 patients), and on reoperations because of failure of other surgical techniques (4 patients). RESULTS: The mean followup was 63.11 months for the 44 patients with longterm followup. Postoperative complications included surgical site infection (3 of 50 patients), urinary infections (3 of 50 patients), atelectasis (2 of 50 patients), pleural effusion (2 of 50 patients), and deep venous thrombosis (1 of 50 patients). The main symptoms found in the postoperative period were dysphagia (20 of 44 patients), heartburn (11 of 44 patients), vomiting (13 of 44 patients), and retrosternal pain (6 of 44 patients). Eleven patients of the 44 remained asymptomatic at the end of the followup period. Outcomes were analyzed according to the modified Visick classification. Visick classes I and II represented 25% and 27.3%, respectively. Eighteen patients (40.9%) were classified as Visick III. CONCLUSION: We conclude that the Thal-Hatafuku operation is a therapeutic option that should be considered in the treatment of achalasia of the esophagus secondary to Chagas' disease, in advanced cases.

Effects of propranolol on human postoperative ileus.

BACKGROUND: The sympathetic nervous hyperactivity present in response to surgical stress has been implicated as an important component of the postoperative paralytic ileus. A randomized and prospective study was conducted, evaluating the effects of the preoperative beta-adrenergic blockade with propranolol in schistosomotic patients during the period of postoperative ileus. METHODS: The study compared schistosomotic patients submitted, or not, to beta-adrenergic blockade. Basal cardiac frequency was determined and propranolol was used in a dose of 40 mg twice a day. The dose was adjusted weekly until a minimum decrease of 20% in cardiac frequency was achieved. Three coupled bipolar electrodes were placed in the left colon in both groups, and registration of myoelectric activity of the left colon was made twice a day during the period of postoperative ileus using a system of data collection (DATA Q Series 200). The electric signals were previously amplified, filtered and separated into Electric Control Activity (ECA) and Electric Response Activity (ERA). RESULTS: The dose of propranolol varied from 80 to 160 mg/day. The proportional decrease in basal heart frequency varied from 20 to 33%, with an average of 25.4 +/- 3.9% in the propranolol group, maintaining a mean of 24.3 +/- 3.6% decrease in the postoperative period. Differences on clinical recovery of the postoperative ileus were not found. Significant differences on electromyographic patterns were not observed between the groups, except for the presence of a greater number of short-duration contractions in the second postoperative day in the beta-blocked group. CONCLUSION: The authors suggest that the preoperative beta-adrenergic blockade with propranolol does not determine myoelectric activity changes that could contribute to an earlier resolution of postoperative ileus.

[Splenectomy plus left gastric vein ligature and devascularization of the great curvature of the stomach in the treatment of hepatosplenic schistosomiasis. Postoperative endoscopic sclerosis is necessary?]. / Esplenectomia com ligadura da veia gástrica esquerda e desvascularização da grande curvatura do estômago no tratamento da esquistossomose hepatoesplênica. E necessária a escleroterapia endoscópica pós-operatória?

OBJECTIVE: With the intention of evaluating the effectiveness and the maintenance of the postoperative endoscopic sclerosis as routine, in association to splenectomy with left gastric vein ligature and devascularization of the great curvature of the stomach, the present study was accomplished. METHOD: Between 1992 and 1998, 131 patient were operated in the General Division of the "Hospital das Clínicas" (Federal University of Pernambuco, Recife, PE, Brazil). The medium follow-up was 30 months. All patients were requested to come back to the clinic for accomplishment of clinical and laboratory control. Of the 111 patients that came back to the clinic, 80 patients had a digestive endoscopy done. Of these 80 patients, 36 followed the recommendation and underwent to a postoperative endoscopic sclerosis program (group 1), while 44 did not accomplish postoperative endoscopic sclerosis (group 2). RESULTS: Regarding the eradication of the esophagus varices, the authors found a statistical difference between the groups (52.7% of the group 1 vs. 18.2% of the group 2). Other analyzed items (mortality, rebleeding rate, thrombosis of the portal vein, gastric varices and degree of periportal fibrosis) statistical relevance was not observed. CONCLUSION: The association of the postoperative endoscopic sclerosis to the splenectomy with left gastric vein ligature and devascularization of the great curvature of the stomach, in the treatment of schistosomotic portal hypertension with digestive hemorrhage antecedent, should be maintained.

Surgical treatment of schistosomal portal hypertension.

Schistosomiasis mansoni is a widespread parasitic disease in the Brazilian territory that affects over 8 million individuals. Hepatosplenic schistosomiasis is a serious clinical presentation of this disease, associated with splenomegaly, liver fibrosis, and portal hypertension, and is responsible for approximately 7% of schistosomotic patients. The surgical treatment of portal hypertension in schistosomotic patients has distinct features when compared with cirrhotic patients, mostly because hepatic function is preserved in schistosomotic liver disease. Therefore, when attempting to reduce the portal pressure, the surgeon must be aware that the surgery might interfere with hepatic perfusion, and consequently with hepatic function. The aim of this study was to report the results achieved with splenectomy, division of the left gastric vein, devascularization of great gastric curvature, and postoperative endoscopic variceal sclerosis, as a surgical option to esophageal varices in hepatosplenic schistosomiasis. A total of 111 patients were studied, and the following is a list of inclusion criteria: age >16 years, history of gastrointestinal (GI) bleeding, presence of esophageal varices on preoperative endoscopy, hematocrit >22% and prothrombin enzymatic activity >50%, negative viral hepatitis on serologic tests (anti-HBV and anti-HCV), and definition, after liver biopsy, of exclusive schistosomotic liver disease. The following list includes exclusion criteria used: presence of liver disease other than schistosomotic, history of alcohol abuse, and preoperative thrombosis of the portal vein. The rebleeding rate was 14.4% during a mean 30-month follow-up period; portal vein thrombosis was 13.2%, and there was a global mortality of 5.4%. Gastric varices were present in 46.9% of the patients; for those patients, a gastrotomy and running suture of the varices achieved an eradication rate of the varices of 75.6%. The degree of periportal fibrosis was also analyzed. Periportal fibrosis staging revealed that patients with class II or III liver fibrosis had a significant increased risk of recurrent GI bleeding when compared with patients with class I liver fibrosis. Despite the elevation on alanine aminotransferase (ALT) and aspartate aminotransferase (AST), most other liver function tests showed no alteration or were corrected after surgery. We conclude that splenectomy, division of the left gastric vein, devascularization of great gastric curvature, and postoperative endoscopic variceal sclerosis showed good results globally and should be considered as therapeutic options in the treatment of hepatosplenic schistosomiasis.

Isquemia normotérmica y reperfusión de hígado en perros: evaluación de las concentraciones séricas en enzimas hepatocelulares / Normothermic ischemia and reperfusion in dogs

La lesion corriente de isquemia y reperfusion hepáticas normotermicas ha sido investigada a traves de varios modelos experimentales en perros. La intensidad de necrosis hepatocitica ha sido admitida como proporcional al tiempo de isquemia y a la cantidad de higado desvascularizado. En el presente trabajo, un modelo de isquemia y reperfusion hepáticas en perros fue evaluado a traves de enzimas indicativas de necrosis hepatocelular. Veinte perros mestizos con peso corporal de 15.25 ñ 1.25 kilos, bajo anestesia general, fueron agrupados de la siguiente manera: 1- Grupo test (n=10), los animales fueron sometidos a desvascularizacion hepática del 70 por ciento durante noventa minutos, con descompresion venosa esplénica a traves de los lobulos lateral derecho y caudado, seguido de revascularizacion del higado. 2- Grupo control (n=10), los perros fueron sometidos a operacion simulada. Se determinaron las concentraciones sericas de aspartato aminotransferasa, alanino aminotransferasa, deshidrogenasa lactica, 5 minutos antes de la isquemia (T0), 5 minutos antes de la revascularizacion (T1), 1 hora (T2) y 5 horas (T3) despues de la revascularizacion hepática, en la sangre de la vena cava inferior, a nivel de la auricula derecha. Con una seguridad del 95 por ciento, los resultados demostraron que: a) En el periodo de isquemia no se detectó alteracion alguna significativa en las Concentraciones de aspartato aminotransferasa, alanino aminotransferasa, deshidrogenasa lactica. b) Despues de la reperfusion hepática, hubo aumento significativo y persistente de los niveles de estas enzimas. Los resultados son indicativos de que el tiempo de isquemia y el volumen de higado desvascularizado fueron capaces de producir la necrosis hepática buscada.

Anti-neutrophil cytoplasmic antibodies (ANCA) in the clinical forms of leprosy.

Anti-neutrophil cytoplasmic antibodies (ANCA) are autoantibodies against enzymes present in primary granules of neutrophils and lysosomes of monocytes detected in systemic vasculitis and in other diseases, including infections. ANCA are markers of active Wegener granulomatosis, which presents some anatomo-pathologic and immune response features similar to those of leprosy. Thus, we raised the hypothesis that ANCA may be present in leprosy as markers specifically linked to the presence of vasculitis. The aim of this study was to determine the presence of ANCA in leprosy and its correlation with the clinical forms of the disease. Sera from 60 normal individuals and from 59 patients with different clinical forms of leprosy were studied. The patients were also allocated into reactional and nonreactional groups. By indirect immunofluorescence, ANCA were positive, an atypical pattern (A-ANCA), in 28.8% of the patient sera. A-ANCA predominated, although not significantly (p > 0.05), in the reactional groups 37.9% vs 20.0%), and in those at the lepromatous pole (41.6% vs 20.0%). There was no correlation between ANCA positivity and either disease duration, disease activity, or therapeutic regimen (p > 0.05). An interesting finding was the correlation between ANCA and gender: 94.1% of ANCA-positive patients were males (p < 0.01), a feature that so far has not been reported in ANCA-related diseases and for which there is no explanation at the moment. By ELISA, the sera of the lepromatous leprosy patients did not show activity against either PR3, MPO, HLE, the most common ANCA antigens. Because A-ANCA are nonspecific, this finding requires further investigation for the determination of the responsible antigen(s). In conclusion, A-ANCA are present in 28.8% of leprosy patients but are not related to vasculitis in the erythema nodosum leprosum reaction and are not a marker of a specific clinical form.

Avaliação do tempo de sobrevida pós-operatória em lesão de isquemia normotérmica e reperfusão hepática induzidas em cães / Evaluation of postoperative survival time in normothermic hepatic ischaemia and reperfusion lesion induced in dogs

Prolongamento do tempo de sobrevida em animais de experimentação tem sido requerido para melhor investigação da fisiopatologia e da modulação farmacológica em lesões decorrentes de isquemia e reperfusão hepática. Vinte cães mestiços, pesando 15,25+-1,21Kg, foram distribuídos em dois grupos de investigação: 1. Grupo Teste (n=10) - Os animais foram submetidos a isquemia normotérmica de aproximadamente, 70por cento do fígado, durante 90 minutos, com descompressão venosa esplâncnica translobar, sequida de reperfusão hepática; 2.Grupo controle (n=10)- os cães foram submetidos a operação simulada. O tempo de sobrevida foi analisado estatisticamente através do teste do chi quadrado . Com confiança de 95 por cento, os resultados revelaram que: o índice de sobrevida de 72 horas (30Por cento) verificado no grupo teste foi significativamente inferior aos constatado nos animais do Grupo Controle (100por cento), em igual período. Bem como, observou-se que a causa mais frequente de óbto nos animais do Grupo Teste foi insuficiência hepática diagnosticada clínicamente e com dados da necróspsia, associada a diátese hemorrágica ou peritonite (60por cento) e ocorrida emtre 2 a 96 horas de pós-operatório. No grupo controle, o sangramento digestiavo e deiscência de parede abdominal, ambos associados a peritonite clínica, constituíram causas de óbitos observadas em dois animais, entre o 4§ e o 6§ dia de pós-operatório

Atividade mioelétrica do cólon: efeitos do propranolol durante o período de íleo pararalítico pós-operatório / Colon myoeletric activity: effects of propranolol in the postoperative adynamic ileus

A hiperatividade simpática durante o período pós-opratório tem sido responsabilizada como competente causal do íleo paralitico pós-operatório. Foi realizado estudo prospectivo randômico, avaliando os efeitos do beta-bloqueio pré-operatório com propranolol, em pacientes esquistossomóticos hepatoesplênicos sobre a atividade mioelétrica do cólon esquerdo durante o período de íleo paralítico pós-operatório comparando com pacientes esquistossomóticos similares não beta-bloqueados. Três pares de eletrodos bipolares foram fixados no cólon esquerdo durante a cirurgia para o tratamento da hipertensão portal esquistossomótica em ambos os grupos e obtidos os registros duas vezes ao dia da atividade contrátil colônica durante o período de íleo paralítico, utilizando um sistema de aquisição de dados (DATA Q Série 200) que capta frequêcias entre 0,02 a 10 Hz, sendo os sinais previamente amplificados, filtrados e separados em Atividade Elétrica de Controle (AEC) e Atividade Elétrica de Resposta (AER). Não foi observado diferenças estatisticamente significativas nos parâmetros eletromiográficos entre dois grupos, exeto pela presença de um maior número de contrações de curta duração no segundo dia de pós-operatório no grupo beta-bloqueado. Pode-se concluir que o beta-bloqueio adrenérgico pré-operatório, com propranolol,não determina diferenças na atividade miolétrica do cólon esquerdo, compatíveis com uma resolução mais precoce ou mais tardia do íleo paralítico pós-operatório em pacientes esquistossomóticos

Urinary adenosine excretion in patients receiving amphotericin B.

BACKGROUND: Intravenous amphotericin B (AMB) administration in animals causes renal vasoconstriction, ischemia, and oliguria that may result in irreversible renal injury; the mechanism of AMB nephrotoxicity may be similar in human beings. Adenosine is excreted in urine by the ischemic kidney. We hypothesized that adenosine excretion and oliguria would be a marker for patients who later would manifest AMB-associated renal insufficiency and that pre-AMB saline administration (which ameliorates AMB nephrotoxicity) would negate the change in adenosine excretion and urine output. METHODS: Twenty hospitalized patients being treated at the direction of their attending physician and who were receiving AMB (15 to 75 mg intravenously) had urine collected for 1 hour before and for 2 hours during AMB infusion. Eleven patients received normal saline solution (500 ml intravenously) before the AMB infusion; the other nine formed the comparator group. An aliquot of each urine collection was precipitated with perchloric acid to remove protein and cellular elements and centrifuged, and the supernatant was assayed for adenosine by using high-pressure liquid chromatography. RESULTS: Infusion of AMB was associated with a decrease in mean urine output both in patients who received saline solution (245 before versus 149 ml/hr during AMB infusion, p = 0.04) and in patients in comparator group (139 versus 89 ml/hr, p = 0.027). The mean urinary adenosine excretion was unchanged in the saline-loaded group (0.1354 before versus 0.1255 mmol/hr during drug infusion, p = 0.25) and was decreased in the comparator group (0.2276 versus 0.1127 mmol/hr, p = 0.01). Development of renal insufficiency did not correlate with the change in urine output or adenosine excretion. CONCLUSIONS: AMB infusion in human beings results in decreased urine output and decreased adenosine excretion. The latter effect is prevented by a pre-AMB saline load. The changes in urine output and adenosine excretion are not predictive of the development of renal insufficiency.

Nonopioid analgesics shorten the duration of postoperative ileus.

Morphine inhibits propagating and stimulates nonpropagating colon contractions in monkeys and humans. The use of morphine or other opioids that inhibit propulsive contractions prolongs postoperative ileus. In contrast, ketorolac tromethamine, a nonsteroidal analgesic, has no effect on colon contractions in monkeys. In 14 patients having elective abdominal operations, bipolar electrodes were implanted on the right (n = 13) and left (n = 10) colon. Group A (n = 8) received ketorolac, 30 mg IM q6h, for pain relief. Group B (n = 6) needed supplemental morphine, 2-10 mg IV or IM, plus ketorolac to control their pain. Myoelectric activity was recorded from each subject on postop Days 1-5 and analyzed by computer for electrical control activity (ECA), short and long electrical response activity (ERA), and propagation of long ERA. There was a difference between the two groups in return of propagated long ERA bursts that correlated with clinical recovery from postoperative ileus. Postoperative analgesia with ketorolac resulted in faster resolution of ileus compared to morphine plus ketorolac because opioid-induced motor abnormalities in the colon were avoided.

Postdischarge surveillance for nosocomial wound infection: does judicious monitoring find cases?

From 1988 through 1992, we conducted a prospective study of postdischarge surgical wound infection surveillance in our institution. A total of 6604 patients were seen after discharge in a centralized outpatient clinic, supervised by the infection control commission. Wounds were inspected, stitches were removed, and dressings were changed. This care was followed by referral of patients to the appropriate specialized surgical clinic. Postdischarge patient return rates for the period studied ranged from 68.4% to 91.2%. Wound infection detection in the outpatient clinic ranged from 32.2% (20 patients in 1991) to 50% (44 patients in 1990) for general surgical procedures and 52.9% (18 patients in 1990) to 91.4% (32 patients in 1992) for cesarean sections. Most surgical wound infections (87.6%, 127 patients) were diagnosed between the first and fourteenth postoperative days. We conclude that centralized postdischarge surveillance, as practiced in our institution, has enhanced the retrieval of wound infection data. At present, there is no universally accepted strategy for monitoring postdischarge surgical wound infection; however, we must take a rigorous approach to detect patients at risk for infection in our continuous attempt to improve the quality of surgical and postoperative care.

Human colonic smooth muscle electrical activity during and after recovery from postoperative ileus.

Colon smooth muscle electrical control (ECA) and response activities (ERA) were recorded for up to 4 wk postoperatively for 48 patients after major abdominal operations. Bipolar electrodes were implanted into right and left colon circular muscle and exteriorized through the flanks, and signals were tape recorded for 2-24 h daily beginning on the 1st postoperative day. A computer program was used for data reduction and analysis. Recorded signals were digitized and filtered. The ECA frequency components were identified by fast Fourier transformation, and their relative tenancy in low, mid, and high frequency ranges was determined. Short and long ERA burst duration and frequency and number and velocity of propagating long ERA bursts were determined. ECA was omnipresent and exhibited a downshift of the dominant frequency from the mid to the low range as recovery from postoperative ileus progressed. Concurrently, first in the right and then in the left colon, the frequency of long ERA bursts increased, followed by the appearance of propagating long ERA. After the 6th postoperative day, no further significant changes in parameters of colon electrical activity occurred with time.

Opioid and nonopioid analgesic drug effects on colon contractions in monkeys.

Opioid drugs administered postoperatively for pain relief cause increased frequency of nonpropulsive phasic contractions but decreased to absent propulsive migrating contractions in the colon, thus importantly influencing the duration of postoperative ileus. Ketorolac is thought to permit earlier return of bowel function postoperatively compared to morphine. Four monkeys had sets of three strain gauge force transducers implanted on the right and left colon at laparotomy. After recovery, animals were fasted overnight and had colon contractions recorded. After a 1-hr baseline period, 200 micrograms/kg morphine sulfate or 1 mg/kg ketorolac tromethamine was injected intramuscularly and recording continued. Each animal received four injections of each drug. Records were analyzed visually for frequency of phasic on migrating contractions. There was no difference in the frequency of phasic or migrating contractions after injection of ketorolac. Morphine, as expected, increased the frequency of phasic and decreased the frequency of migrating contractions in the colon. Ketorolac does not affect the frequency of colon contractions.

Wound infection rates in clean surgery: a potentially misleading risk classification.

OBJECTIVES: To evaluate the incidence of wound infection in inguinal hernioplasties, incisional hernioplasties, splenectomies, and splenectomies performed in patients with hepatosplenic schistosomiasis, and to examine the relationship of surgical wound infection to antibiotic use, patient age, length of stay in the hospital prior to surgery, and the duration of the operation. DESIGN: Retrospective surveillance study. RESULTS: One thousand five hundred forty-two clean operations were analyzed. Comparing response (wound infection) and explanatory variables (age, length of hospital stay, duration of surgery, antibiotics, and surgery type), we found that age, use of antibiotics, and type of surgery were statistically significant, while length of hospital stay and duration of surgery were not significant. CONCLUSIONS: From these results, we can predict that the probability of wound infection in surgical patients considering these significant variables is lower for patients ages 14 to 30 years and higher for patients ages 31 to 60 years and lower for patients with prophylactic antibiotic use (up to 72 hours of use) and higher for patients with prolonged use (more than 72 hours); and lower for patients undergoing inguinal heria, followed in ascending order by nonschistosomotic patients undergoing splenectomy in schistosomotic patients.