Epicardial fat thickness correlates with P-wave duration, left atrial size and decreased left ventricular systolic function in morbid obesity.

BACKGROUND AND AIM: Epicardial fat (EF) is increased in obesity and has important interactions with atrial and ventricular myocardium. Most of the evidence in this scenario can be confused by the presence of comorbidities such as hypertension, diabetes and dyslipidemia, which are very common in this population. The influence of EF on atrial remodeling and cardiac function demands further investigation on morbidly obese without these comorbidities. METHODS AND RESULTS: We prospectively recruited 20 metabolically healthy morbidly obese and 20 normo-weights controls. The maximum P-wave duration (PWD) was analyzed by 12-lead electrocardiogram. Left atrial diameter (LAD), left ventricular ejection fraction (LVEF) and EF thickness (EFT) were evaluated by two-dimensional echocardiography. The mean of maximum PWD and LAD were significantly larger in the obese group as compared to the control group: 109.55 ± 11.52 ms × 89.38 ± 11.19 ms and 36.12 ± 3.46 mm × 31.45 ± 2.64 mm, (p < 0.0001). The mean LVEF was lower in the obese group: 63.15 ± 4.25% × 66.17 ± 3.37% (p < 0.017). The mean EFT was higher in the obese group: 7.72 ± 1.60 mm × 3.10 ± 0.85 mm (p < 0.0001). A positive correlation was found between EFT and PWD (r = 0.70; p = 0.001) and LAD (r = 0.667; p = 0.001). An inverse correlation was found between EFT and LVEF (r = -0.523; p = 0.001). In a multiple multivariate regression analysis the EFT remains correlated with LAD and LVEF. CONCLUSIONS: In a select group of morbidly obese, the excess of EF had a significant impact on atrial remodeling and cardiac function.

Modified body adiposity index for body fat estimation in severe obesity.

BACKGROUND: The body adiposity index (BAI) comprises a simple method for estimating body fat (BF) that needs to be validated in patients with severe obesity. The present study aimed to determine BAI accuracy with respect to the determination BF in patients with severe obesity. METHODS: A cross-sectional prospective study comparing two methods for BF estimation was conducted in 433 patients with severe obesity between August 2012 to December 2014. BF was estimated by bioelectrical impedance analysis (BIA) with specific equations developed for BF estimation in patients with severe obesity and BAI. The BF estimation in 240 patients with severe obesity (Group 1: G1) was used to evaluate BAI limitations and to develop a specific equation in this population. The new equation proposed was validated in another 158 patients with severe obesity (Group 2: G2). RESULTS: There was a significant difference between BF determination by BIA and BAI (P = 0.039). The mean (SD) BF in G1 was 52.3% (6.1%) determined by BIA and 51.6% (8.1%) determined by BAI. Sex, waist-hip ratio (WHR) and obesity grade determined significant errors on BF estimation by BAI. A new equation (modified body adiposity index; MBAI) was developed by linear regression to minimise these errors [MBAI% = 23.6 + 0.5 × (BAI); add 2.2 if body mass index ≥ 50 kg m-2 and 2.4 if WHR ≥ 1.05]. The new equation reduced the difference [1.2% (5.9%), P < 0.001 to 0.4% (4.12%), P = 0.315] and improved the correlation (0.6-0.7) between methods. CONCLUSIONS: BAI present significant limitations in severe obesity and MBAI was effective for BF estimation in this population.

Transabdominal midline reconstruction by minimally invasive surgery: technique and results.

BACKGROUND: The introduction of the minimally invasive approach changed the way abdominal surgery was carried out. Open suture and mesh reinforcement in ventral hernia repair used to be the surgeon's choice of procedure. Although the laparoscopic approach, with defect bridging and mesh fixation, has been described since 1993, the procedure remains largely unchanged. Evidence shows that defect closure and retro-muscular mesh positioning have the best outcomes and are the best surgical practice. We therefore aimed to develop and demonstrate a procedure which combined the good results of open surgery using the Rives-Stoppa principles, particularly in terms of recurrence, with all the benefits of minimally invasive surgery. METHODS: Between October 2012 and February 2014, 15 post-bariatric surgery patients underwent laparoscopic midline incisional hernia repair. The peritoneal cavity was accessed through a 5-mm optical view cannula at the superior left quadrant. A suprapubic and two right and left lower quadrant cannulas were inserted for inferior access and dissection. The defect adhesions were released. The whole midline was closed with an endoscopic linear stapler, including the defect, from the lower abdomen, 4 cm below the umbilicus, until the epigastric region, including posterior sheath mechanical suturing and cutting in the same movement. A retrorectus space was created in which a retro-muscular mesh was deployed. Fixation was done using a hernia stapler against the posterior sheath from the peritoneal cavity to the abdominal wall muscles. Selection was based on xifo-umbilical incisional midline hernias post open bariatric surgery. Pregnant women, cancer patients, or patients with clinical contraindications were excluded. RESULTS: The patients mean age was 51.2 years (range 39-67). Four patients were men and eleven women. Two had well-compensated fibromyalgia, four had diabetes, and five had hypertension. The mean BMI was 29.5 kg/m2 (range 23-31.6). Surgery was performed successfully in all cases through four ports; the number of incisional hernias was 3 ± 2, with a mean maximum width of 3.75 cm (range 2.1-9) and maximum length of 14 cm (7.5-20.5). The mean surgical time was 114.3 min (range 85-170), and the median hospital stay was 1.4 days. No intra-operative or immediate post-operative complication or death occurred. One patient had a seroma treated conservatively 1 week after surgery and another had a retro-muscular infection treated with percutaneous drainage. CT-Scans made before and after the procedure, showed total closure of the defect. QOL questionnaire showed satisfaction, acceptance, and no complaints. CONCLUSION: Although the study involved a small number of patients, it has proved the technique to be feasible, easy to perform, and have the combined benefits of laparoscopic and open surgery. The results, shown by CT-scan, peri-operative, and QOL findings, were good.

Use of multiple channel pH monitoring for evaluation of ultra-distal reflux in patients after fundoplication for treatment of Barrett's esophagus.

Dysplasia and esophageal adenocarcinoma may arise in patients with Barrett's esophagus after fundoplication esophageal pH monitoring showing no acid in esophagus. This suggests the need to develop methodology to evaluate the occurrence of ultra-distal reflux (1cm above the LES). The objective of the study was to compare acid exposition in three different levels: 5cm above the upper border of the LES, 1cm above the LES and in the intrasphincteric region. Eleven patients with Barrett's esophagus after Nissen fundoplication with no clinical, endoscopic and radiologic evidence of reflux were selected. Four-channel pH monitoring took place: channel A, 5cm above the upper border of the LES; channel B, 1cm above the LES; channel C, intrasphincteric; channel D, intragastric. The results of channels A, B and C were compared. There was significant increase in number of reflux episodes and a higher fraction of time with pH <4.0 in channel B compared to channel A. There was significant decrease in fraction of time with pH <4.0 in channel B compared to channel C. Two cases of esophageal adenocarcinoma were diagnosed in the studied patients. The region 1cm above the upper border of the LES is more exposed to acid than the region 5cm above the upper border of the LES, although this exposure occurred in reduced levels. The region 1cm above the upper border of the LES is less exposed to acid than the intrasphincteric region.

Níveis de mercúrio em piavas (Leporinus obtusidens) e em pintados (Pimelodus maculatus) do Lago Guaíba, Porto Alegre, Estado do Rio grande do Sul, Brasil / Level of mercury on Leporinus obtusidens (Valenciennes, 1847) e Pimelodus maculatus (L`cèpéde, 1803) from Guaíba Lake in Porto Alegre, RS

A presença de mercúrio foi avaliada em 27 amostras de Piava (Leporinus obtusidens) e de Pintado(Pimelodus maculatus) originárias do Lago guaíba, Porto Alegre-RS., por espectrofotometria de absorção atômica

Videolaparoscopic cholecystectomy. Analysis of the clinical and functional aspects of mechanical lifting of the abdominal wall.

BACKGROUND: Mechanical lifting of the abdominal wall, a method based on traction and consequent elevation of the abdominal wall, is an alternative procedure to create enough intra-abdominal space necessary for videolaparoscopic surgery, dispensing the need for intraperitoneal gas insufflation. OBJECTIVE: This study aims to evaluate the technical feasibility of this procedure to carry out a videolaparoscopic cholecystectomy, while analyzing the clinical and functional aspects of this technique. PATIENTS AND METHODS: In the Digestive Tract Surgery Discipline of the Medical School at the University of São Paulo, São Paulo, SP, Brazil, was created the equipment to perform videolaparoscopic surgery using this method. The equipment has two sections: an external part which consisted of a frame attached to the operating table, inside which there is a sliding steel cable, moved by a ratched which is located at the lower end of one of the frame rods; the internal rod, the support, has an "L" shape, and its horizontal branch is made up of three turning rods and which is connected to the steel cable after insertion into the abdominal cavity. Ten patients underwent videolaparoscopic cholecystectomy using this equipment. The time taken to install the equipment, the operating area characteristics, the interference from the lifting equipment on surgical movements and on the intra-operative cholangiography, the measurements made of the force used during traction and extension of the abdominal wall elevation, and the medication required for postoperative analgesia were all evaluated. RESULTS: There were no intra-operative complications, and in none of the cases was it found necessary to convert to open surgery. We considered the insertion a safe and uncomplicated procedure, and the traction system efficient. Apart from the elevation of the abdominal wall, the distribution of the viscera inside the abdominal cavity is fundamental for the operating area. Depending on the position of the epigastric trocar, the lifting equipment can interfere with the surgical instruments mobility. It may be necessary to reposition the support to perform the intra-operative cholangiography. The tensional force applied to the peritoneal surface by the lifting rods is small, and no additional postoperative pain was observed using this procedure. CONCLUSION: These results show that using the equipment described in this study, mechanical lifting of the abdominal wall is a feasible alternative for undertaking videolaparoscopic cholecystectomy.

Formaçäo do cirurgiäo em cirurgia laparoscópica do aparelho digestivo. Experiência de 1.818 intervençöes sem acidentes e sem mortalidade / Digestive tract laparoscopic surgeon formations. experience de 1.818 interventions whithout complications or mortality

Desde a instalação da cirurgia laparoscópica no Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, a Disciplina de Cirurgia do Aparelho Digestivo passou a estruturar um programa para a formação do cirurgião em laparoscopia do aparelho digestivo. Objetivo. A estrutura de ensino inclui a informação no ensino médico regular, extensão na Liga de Cirurgia Laparoscópica, formando o médico a partir de residência, principalmente em seu quarto ano, com estágio na Unidade de Cirurgia Laparoscópica de três meses. Método. Este modelo de formação e preparo do cirurgião do aparelho digestivo assim implantado, com rigor, profundidade e seriedade é, certamente, responsável pelos resultados de nível excelência obtidos. Resultados. Exemplo disso representam as 1818 colecistectomias laparoscópicas realizadas na Unidade de Cirurgia Laparoscópica no período de outubro de 1990 a dezembro de 1998, com índice de conversão de 0,9 por cento e sem mortalidade. A ausência de acidentes operatórios e de complicações verificadas na experiência adquirida nas operações realizadas por nosso grupo cirúrgico, dá consistente suporte à orientação assumida pela Disciplina. Conclusão. Reforçam-se os princípios que foram adotados dentro da atividade em hospital universitário, que são: necessidade de formação de profissionais dentro de programa bem estruturado, ensejando-lhes preparo educacional humanístico e técnico, em torno de projeto pedagógico longo, mas com grande e sólido embasamento informativo e prático.

[Training of surgeons in laparoscopic surgery of the digestive system. Experience in 1,818 interventions without accidents and mortality]. / Formação do cirurgião em cirurgia laparoscópica do aparelho digestivo. Experiência de 1.818 intervenções sem acidentes e sem mortalidade.

UNLABELLED: Since the beginning or laparoscopic surgery on University of Sao Paulo Medical School Clinics Hospital, the Digestive Surgery Division established an educational program for surgeons of the alimentary tract. PURPOSE: The course structure includes the information on medical school, extension in laparoscopic surgery league, and surgical formation during the residence, mainly in the fourth year, with a three months period in the Laparoscopic Surgery Unit. METHOD: This model of surgical formation is certainly responsible for the excellent results obtained. RESULTS: An example is the performing of 1818 cholecystectomies in the Laparoscopic Surgery Unit from 1990 till 1998, with 0.9% convertion, and no mortality. The absence of operative accidents or complications give support to the orientation assumed in our Division. CONCLUSION: In a university hospital there is the necessity of professional formation in a well structured program, with humanistic and technical education, in a large period of rotation, but with a solid information and practical structure.

Laparoscopic treatment of traumatic diaphragmatic hernia.

Traumatic diaphragmatic hernia is rare, but is of utmost importance due to its high morbidity and mortality. It is markedly important in patients with blunt abdominal trauma, and diagnosis is difficult because of the numerous associated injuries. A patient with few symptoms of chronic traumatic diaphragmatic hernia is described, who underwent surgery due to a gastric volvulus. Laparoscopic surgery permits repair of these injuries through an abdominal approach, avoiding a thoracic incision or selective intubation.

[Acute appendicitis following laparoscopic inguinal hernioplasty. Coincidence or complication?]. / Apendicite aguda após hernioplastia inguinal laparoscópica: coincidência ou complicação?

Intraperitoneal complications related to laparoscopic inguinal hernia repair by transabdominal approach had been described. The authors report the first case of postoperative acute appendicitis in a patient submitted to a transuretral prostate resection and bilateral inguinal hernioplasty by the TAPP technique, resulting in a second laparoscopic intervention.

[Synchronous esophageal and stomach neoplasm: importance of diagnosis and treatment]. / Neoplasias sincrônicas de esôfago e estômago: importância diagnóstica e terapêutica.

The association of esophageal and gastric cancer has been described because of the better technology in methods for diagnosis. In surgery for esophageal cancer, a gastric tube is often prepared to provide a new route for oral ingestion. Although patients with simultaneous esophageal cancer and gastric cancer have been reported, it is often difficult to diagnose the coexistence of gastric cancer preoperatively due to the presence of esophageal stenosis. In this paper we report on one case of the rare combination of squamous cell cancer of the esophagus and simultaneous adenocarcinoma of the stomach.

[Esophagectomy using videosurgery]. / Esofagectomia por videocirurgia]

This is a report of 10 cases of esophagetomy by videosurgery. Five patients had esophageal carcinoma and five had achalasia. The patients who had neoplasia were submitted to thoracoscopic, laparoscopic and cervicotomy and the others who had benign pathology were submitted to laparoscopic with transdiafragmatic approach and cervicotomy. The evolution was very satisfactory but there were complications that had no relation with the method. The follow up is being made and we have no sure about real results.

[Laparoscopic repair of chronic traumatic diaphragmatic hernia: case report and review of the literature]. / Correção laparoscópica de hérnia difragmática traumática crônica: relato de caso revisão da literatura.

The management of diaphragmatic injury would appear to be a simple matter of suturing the defect. However, preoperative diagnosis can be difficult and even at the time of surgery some diaphragmatic injuries can be overlooked if careful exploration in not done. Associated injuries tend to divert attention from the diaphragmatic injury. Laparoscopic diagnosis and repair have been described with successful.