IONM and minimally invasive videoassisted thyroidectomy.

BACKGROUND: We know that benefits of MIVAT are related to a better cosmetic result and lower post-operative pain in comparison to CT. The incidence of nerve cold palsy is related to a correct identification of the recurrent laringeal nerve (RLN) as standard procedure in thyroid surgery. From September 2014 we have introduced the use of intraoperative neural monitoring(I-IONM) in all thyroidectomies in the Unit of General Surgery of University Hospital of Parma, including in MIVAT. PATIENTS AND METHODS: We have considered all patients treated from September 2014 to September 2017 for thyroid diseases using MIVAT and IONM. Intermittent neuromonitoring with NIM-3.0 equipment (Medtronic, Jacksonville, FL, USA) was used during all operations. We have recorded all data about age, sex, diagnosis, surgical time, i-IONM signal, postoperative pain, postoperative hypocalcemia after 24 hours, haematoma and vocal cord palsy. The mean hospital stay was collected from surgical procedure to hospital discharge. We have considered vocal dysfunctions that persist six months after surgery as permanent. RESULTS: From September 2014 to September 2017 we treated consecutively with both MIVAT and i-IONM 100 patients. Considering the extent of surgery, 26 pts underwent to hemithyroidectomy and 74 pts to total thyroidectomy. The mean surgical time was 61.8 minutes. In 7 cases the patients were affected by preoperative clinical dysphonia. Using I-IONM during thyroidectomy, we recorded in 5 cases (5%) a loss of signal; in two cases (2%) we experienced a temporary postoperative vocal cord palsy. DISCUSSION: In our experience the use of IONM has improved the safety during thyroidectomy because precision that can be achieved by endoscopic procedures is further improved by complementary use of IONM. The costs associated to a potential reduction of medical litigation have not been investigated.

Wide nervous section to prevent post-operative inguinodynia after prosthetic hernia repair: a single center experience.

BACKGROUND: Chronic post-operative inguinodynia occurs in about 10 % of patients undergoing inguinal hernioplasty with prosthesis; it is characterized by a broad pleomorphism of symptoms, including relative to individual variability of algic perception. Its intensity can also potentially jeopardize patient's work and social activities. The most notorious cause of inguinodynia is neuropathy, resulting from the involvement of one or more inguinal nerves (iliohypogastric, ilioinguinal and genitofemoral nerves) in fibroblastic processes, or from nervous stimulation, caused by prosthetic material on adjacent nervous trunks. The aim of our study was to provide a comparative analysis between outcomes of wide nerve resection vs. nerve sparing. PATIENTS AND METHODS: In our hospital, between 2000 and 2010, 600 patients underwent monolateral prosthetic inguinal hernia repair, using the original Trabucco technique. In 345 cases, to avoid chronic post-operative pain, we carried out intentional neurectomy, between 3 and 8 cm in length of either the main and/or peripheral branches of the iliohypogastric nerve, ilioinguinal nerve and the genital branch of the genitofemoral nerve, deemed at risk of entrapment because of the prosthetic material. In the control group, which included the other 255 patients, nerves were identified and spared. Follow-up was scheduled at 1 week, 1 month and 1 year after surgery. CASE: 1 week after the operation, 135 patients (39.1 %) did not show pain, 201 (58.3 %) reported moderate pain and 9 (2.6 %) showed intense pain; 1 month after the procedure, 300 patients (87 %) did not have pain, 39 (11.3 %) complained of moderate pain and 6 (1.7 %) demonstrated severe pain; 1 year after surgery, only two patients (0.6 %) complained of persistent pain. CONTROL: At the 1-week follow-up, 114 patients (44.7 %) did not show pain, 111 (43.5 %) reported moderate pain and 30 (11.8 %) intense pain; 1 month after the procedure, 183 patients (71.8 %) did not have pain, 45 (17.6 %) complained of moderate pain and 27 (10.6%) showed severe pain; 1 year after surgery, 11 patients (4.3 %) had persistent pain, and two of them were re-submitted to surgery. The lower incidence of chronic pain after nerve resection is statistically significant (0.6 vs. 4.3 % p = 0.0048); the incidence of moderate pain 1 month after the operation is also lower (11.3 vs. 17.6 % p = 0.0097). In addition, among patients subjected to nerve resection there is a faster resolution of algetic symptomatology, over the course of a month; also noteworthy is the lower incidence of intense pain in the short-and medium-term (after 1 week, 11.8 vs. 2.6 % p = 0.0006 ; after 1 month, 10.6 vs. 1.7 % p < 0.0001). CONCLUSIONS: Despite the apparent paradox of an higher tissue damage, elective neurectomy of selected segments of inguinal nerves, appears an effective technique in preventing chronic postherniorraphy pain, considering both the lower incidence and the faster resolution of painful symptomatology.

Wide resection of inguinal nerves versus simple section to prevent postoperative pain after prosthetic inguinal hernioplasty: our experience.

BACKGROUND: In the literature, chronic groin pain (i.e. lasting >3 months) occurs in about 10 % of patients who undergo inguinal hernioplasty with prosthesis; it is characterized by a broad range of symptoms, and is relative to individual perceptions of pain. In 2-5 % of cases, the painful symptomatology is so intense that it interferes with daily activities, and can be debilitating in 0.5-6 % of cases. The best known cause of inguinodynia is neuropathy, due to implication of one or more inguinal nerves (iliohypogastric, ilioinguinal, and genitofemoral nerves) into fibroblastic processes; or from nervous stimulation caused by prosthetic material on adjacent nervous trunks. Many therapeutic strategies have been proposed to treat chronic groin pain, including intra-operative prophylactic neurectomy. OBJECTIVE: The purpose of our study was to perform a comparative analysis between outcomes from wide resections of inguinal nerves versus those from simple nervous section (or minimal resection). PATIENTS AND METHODS: We considered 350 patients who had undergone inguinal prosthetic hernioplasty with Trabucco's technique between 2004 and 2010. Wide nervous resection (removal of nerve segments 3-8 cm in length) was performed in 180. The other 170 patients underwent simple section or minimal resection. All patients were checked 1 week, 1 month, and 1 year after surgery. RESULTS: Group 1: At 1-week follow-up, 63 patients (35 %) reported no pain, 113 (63 %) reported moderate pain, and 4 (2 %) intense pain; 1 month after the procedure, 152 patients (84.4 %) reported no pain, 25 (14 %) complained of moderate pain, and 3 (1.6 %) of severe pain; 1 year after surgery, only 1 patient (0.5 %) complained of constant pain. Group 2: At 1 week follow-up, 48 patients (28 %) reported no pain, 101 (59 %) reported moderate pain, and 21 (13 %) intense pain; 1 month after the procedure, 81 patients (47.6 %) had no pain, 72 (42.4 %) complained of moderate pain, and 17 (10 %) of severe pain; 1 year after surgery, 11 patients (6.5 %) had constant pain, and two of them were re-admitted for surgery. The lower incidence of chronic pain after long nervous resection is statistically significant (0.5 vs. 6.5 %; p = 0.006); the incidence of moderate pain 1 month after operation is also lower (14 vs. 42.4 %; p < 0.0001); patients who underwent a long resection experienced faster resolution of pain symptomatology, during a month. Also noteworthy is the lower incidence of intense pain in the short and medium term (after 1 week, 13 vs. 2 %, p = 0.0005; after 1 month, 10 vs. 1.6 %, p = 0.0018). CONCLUSIONS: The prophylactic wide resection of selected segments of inguinal nerves, despite the apparent paradox of greater tissue damage, appears more effective than simple section at preventing postoperative inguinodynia, given both the lower incidence and the faster resolution of painful symptomatology.

Phosphoenolpyruvate carboxylase in cucumber (Cucumis sativus L.) roots under iron deficiency: activity and kinetic characterization.

Phosphoenolpyruvate carboxylase (PEPCase) activity was investigated in cucumber roots grown under iron starvation. The enzyme extracted from plants grown in the presence and in the absence of Fe was characterized both kinetically and biochemically. Extractable PEPCase activity was increased by 4-fold in the absence of Fe. This increase began about 5 d after Fe starvation. Western blot analysis revealed the presence of two polypeptides with apparent molecular masses of 103 and 108 kDa. At the beginning both the polypeptides were equally present in the control and in the Fe-deficient roots. After 10 d of Fe starvation the increase was clearly evident and concerned, in particular, the polypeptide of 103 kDa whose enhancement was around 3-fold with respect to the control. Re-supply of iron to Fe-starved roots decreased both the activity and the concentration of the enzyme to the control values. Determination of kinetic parameters revealed that the K:(m) values for the substrates were the same, while the V:(max) was increased by four times for the enzyme extracted from Fe-deficient roots. Also the responses to pH changes and to the allosteric modulators malate and glucose-6-phosphate were different. The kinetic data, the increase in PEPCase specific activity and in the PEPCase polypeptides concentration seem to indicate that under Fe deficiency the enzyme regulation might be, in part, exerted at the transcriptional level.

Development of Fe-deficiency responses in cucumber (Cucumis sativus L.) roots: involvement of plasma membrane H(+)-ATPase activity.

One of the mechanisms through which some strategy I plants respond to Fe-deficiency is an enhanced acidification of the rhizosphere due to proton extrusion. It was previously demonstrated that under Fe-deficiency, a strong increase in the H(+)-ATPase activity of plasma membrane (PM) vesicles isolated from cucumber roots occurred. This result was confirmed in the present work and supported by measurement of ATP-dependent proton pumping in inside-out plasma membrane vesicles. There was also an attempt to clarify the regulatory mechanism(s) which lead to the activation of the H(+)-ATPase under Fe-deficiency conditions. Plasma membrane proteins from Fe-deficient roots submitted to immunoblotting using polyclonal antibodies showed an increased level in the 100 kDa polypeptide. When the plasma membrane proteins were treated with trypsin a 90 kDa band appeared. This effect was accompanied by an increase in the enzyme activity, both in the Fe-deficient and in the Fe-sufficient extracts. These results suggest that the increase in the plasma membrane H(+)-ATPase activity seen under Fe-deficiency is due, at least in part, to an increased steady-state level of the 100 kDa polypeptide.

Metabolic responses in cucumber (Cucumis sativus L.) roots under Fe-deficiency: a 31P-nuclear magnetic resonance in-vivo study.

The metabolic responses occurring in cucumber (Cucumis sativus L.) roots (a strategy-I plant) grown under iron-deficiency conditions were studied in-vivo using 31P-nuclear magnetic resonance spectroscopy. Iron starvation induced activation of metabolism leading to the consumption of stored carbohydrates to produce the NAD(P)H, ATP and phosphoenolpyruvate necessary to sustain the increased activity of the NAD(P)H:Fe(3+)-reductase, the H(+)-ATPase (EC 3.6.1.35) and phosphoenolpyruvate carboxylase (EC 4.1.1.31). Activation of catabolic pathways was supported by the enhancement of glycolytic enzymes and concentrations of the metabolites glucose-6-phosphate and fructose-6-phosphate, and by enhancement of the respiration rate. Moreover, Fe-deficiency induced a slight increase in the cytoplasmic (pHc) and vacuolar (pHv) pHs as well as a dramatic decrease in the vacuolar phosphate (Pi) concentration. A comparison was done using fusicoccin (FC), a fungal toxin which stimulates proton extrusion. Changes in pHc and pHv were measured after addition of FC. Under these conditions, a dramatic alkalinization of the pHv of -Fe roots was observed, as well as a concomitant Pi movement from the vacuole to the cytoplasm. These results showed that Fe starvation was indeed accompanied by the activation of metabolic processes useful for sustaining the typical responses occurring at the plasma-membrane level (i.e. increases in the NAD(P)H:Fe(3+)-reductase and H(+)-ATPase activities) as well as those involved in the homeostasis of pHc. The decrease in vacuolar Pi levels induced by Fe-deficiency and FC and movement of Pi from the vacuole to the cytoplasm suggest a possible involvement of this compound in the cellular pH-stat system.

Calcium-dependent phosphorylation regulates the plasma-membrane H(+)-ATPase activity of maize (Zea mays L.) roots.

Phosphorylation/dephosphorylation of the plasma-membrane H(+)-ATPase (EC 3.6.1.35) could act as a regulatory mechanism to control its activity. In this work, a plasmalemma-enriched fraction from maize roots and a partially purified H(+)-ATPase were used to investigate the effects of Ca(2+) and calmodulin on the H(+)-ATPase activity and on its phosphorylation status. Both the hydrolytic and the proton-pumping activities were reduced approximately 50% by micromolar Ca(2+) concentrations while calmodulin did not show any effect either alone or in the presence of Ca(2+). The lack of effect of calmodulin antagonists indicated that calmodulin was not involved in this response. The addition of staurosporine, a kinase inhibitor, abolished the inhibitory effect of Ca(2+). Phosphorylation of plasma membrane and partially purified H(+)-ATPase showed the same behavior. In the presence of Ca(2+) a polypeptide of 100 kDa was phosphorylated. This polypeptide cross-reacted with antibodies raised against the H(+)-ATPase of maize roots. The autoradiogram of the immunodetected protein clearly showed that this polypeptide, which corresponds to the H(+)-ATPase, was phosphorylated. Additional clear evidence comes from the immunoprecipitation experiments: the data obtained show that the H(+)-ATPase activity is indeed influenced by its state of phosphorylation.

Metabolic Implications in the Biochemical Responses to Iron Deficiency in Cucumber (Cucumis sativus L.) Roots.

Strategy I plants respond to Fe deficiency by inducing morphological and biochemical modifications at the root level that are apt to make iron available for uptake. Cucumber (Cucumis sativus L.) grown in the absence of Fe has been shown to increase the capacity to acidify the rhizosphere and Fe3+ reduction activity. We have determined in these roots some metabolic activities that might be correlated with the increased proton extrusion. Proton efflux from roots may be followed by a mechanism regulating the cytosolic pH according to the pH-stat theory. Roots grown in the absence of Fe showed an increase in dark 14CO2 fixation and organic acid synthesis and a 6-fold increase in the extractable phosphoenolpyruvate carboxylase activity with respect to the control roots. Dehydrogenase activities producing cytosolic NAD(P)H were also increased under Fe deficiency. The presence of Fe2+, but not Fe3+, inhibited dark 14CO2 fixation in a range between 24 and 52% but did not show any effect on the in vitro phosphoenolpyruvate carboxylase activity.

[Use of fibrin glue in the treatment of entero-cutaneous fistulas]. / L'uso della colla di fibrina nel trattamento delle fistole entero-cutanee.

The Authors present methods and results of the treatment of chronic fistulas complicating abdominal surgery in 5 patients. The use of human fibrin glue is described and its therapeutical usefulness is pointed out.