Alfredo Luiz Jacomo

E-Cadherin Expression in Colonic Mucosa with and Without Fecal Stream

ABSTRACT The tissue content of E-cadherin changes in inflammatory bowel diseases; however, similar changes have not yet been evaluated in diversion colitis. Objective: The aim of this study was to evaluate the tissue expression of E-cadherin in the mucosa of the colon in both segments with and without a fecal stream. Methods: Sixty Wistar rats were subjected to deviation of fecal stream by proximal colostomy in left colon and a distal mucosal fistula. Animals were divided into three experimental groups that were sacrificed 6, 12, and 18 weeks after surgery. In each experimental group, five animals underwent laparotomy without intestinal deviation (control subgroup). Colitis was diagnosed based on the presence of three independent histological parameters: reduction of the crypt length, neutrophil infiltration of the mucosa and submucosa, and epithelial erosion or ulceration. The E-cadherin expression was evaluated by immunohistochemistry and the tissue levels by computerized morphometry. The Mann–Whitney and Kruskal–Wallis test were used to compare the groups adopting a significance level of 5% (p < .05). Results: Segments without fecal stream showed a reduction in E-cadherin content when compared with segments with fecal stream. In the segments with a fecal stream, E-cadherin was expressed at the apical surface of colon glands, while segments without fecal stream showed a decrease in the amount of apical E-cadherin. The content of E-cadherin was maintained over the entire time of the intestinal exclusion. Conclusions: Diversion of the fecal stream decreases the expression of E-cadherin of the colon epithelium.

Trigger Points: An Anatomical Substratum

This study aimed to bring the trapezius muscle knowledge of the locations where the accessory nerve branches enter the muscle belly to reach the motor endplates and find myofascial trigger points (MTrPs). Although anatomoclinical correlations represent a major feature of MTrP, no previous reports describing the distribution of the accessory nerve branches and their anatomical relationship with MTrP are found in the literature. Both trapezius muscles from twelve adult cadavers were carefully dissected by the authors (anatomy professors and medical graduate students) to observe the exact point where the branches of the spinal accessory nerve entered the muscle belly. Dissection was performed through stratigraphic layers to preserve the motor innervation of the trapezius muscle, which is located deep in the muscle. Seven points are described, four of which are motor points: in all cases, these locations corresponded to clinically described MTrPs. The four points were common in these twelve cadavers. This type of clinical correlation between spinal accessory nerve branching and MTrP is useful to achieve a better understanding of the anatomical correlation of MTrP and the physiopathology of these disorders and may provide a scientific basis for their treatment, rendering useful additional information to therapists to achieve better diagnoses and improve therapeutic approaches.

Doppler-guided hemorrhoidal artery ligation with rectal mucopexy technique: initial evaluation of 42 cases

The treatment of hemorrhoidal disease (HD) by conventional hemorrhoidectomy is associated with significant morbidity, mainly represented by the postoperative pain and the late return to daily activities. Doppler-guided hemorrhoid artery ligation (DGHAL) is a minimal-invasive surgical treatment for HD that has been used as an alternative method in order to reduce these inconveniences. OBJECTIVE: To analyze the initial results of the DGHAL technique associated with rectal mucopexy in the treatment of HD. METHODS:Forty-two patients with stage I, III and IV hemorrhoids who were submitted to DGHAL were analyzed from December 2010 to August 2011. Eleven patients (26%) were stage II; 21 (50%), stage III; and 10 (24%), stage IV HD. All patients were operated by the same surgeon under spinal anesthesia and using the same equipment and technique to perform the procedure. The 42 patients underwent ligation of six arterial branches followed by rectal mucopexia by uninterrupted suture. Nine patients needed concomitant removal of perianal skin tag. In the postoperative, the following parameters were evaluated: pain, tenesmus, bleeding, itching, prolapse, mucus discharge and recurrence. The mean postoperative follow-up lasted four months (one to nine months). RESULTS: Tenesmus was the most common postoperative complaint for 85.7% of patients followed by pain, in 28.6%, perianal burning, in 12.3%, mucus discharge and perianal hematoma in 4.7%. Two patients had severe postoperative bleeding and required surgical haemostasis, one of which needed blood transfusion. Ninety-five percent of the patients declared to be satisfied with the method. CONCLUSION: Even though DGHAL has complications similar to those of other surgical methods, its results present less postoperative pain, allowing faster recovery and return to work. Studies with more cases and a longer follow-up are still necessary to assess the late recurrence.

Description of a new experimental model skin flap for studying skin viability in rats

PURPOSE To describe a new experimental flap for studying skin viability in rats. METHODS Twenty male Wistar rats weighing between 250-300g were divided into two groups: group A - McFarlane technique, a 4 x 10cm flap was used (McFarlane); and in group B modified McFarlane technique, a 3 x 10cm flap was used. Seven days later, the animals were sacrificed and the area of necrosis was evaluated in both groups. RESULTS Group A presented necrosis in 3% of the total area of the flap (CI: 0.01-0.05), Group B presented necrosis in 37% of the total area of the flap (CI: 0.29-0.46), (p<0.001). CONCLUSION The modified McFarlane flap presented a larger area of necrosis and could be an adequate experimental model of skin flap viability.

Unusual Relationship between the Piriform Muscle and Sciatic, Inferior Gluteal and Posterior Femoral Cutaneous Nerves

El sindrome del musculo piriforme se ha reconocido cada vez mas como una causa de dolor en los miembros inferiores. Tension excesiva o variaciones anatomicas del nervio y del musculo piriforme se cree son las causas subyacentes de pinzamiento del nervio isquiatico. Se presenta una variacion no descrita anteriormente. Durante una diseccion de rutina en un cadaver de sexo masculino, se observo una division mas alta del nervio isquiatico y la presencia de un musculo piriforme accesorio. El nervio isquiatico se dividia bajo el musculo piriforme y el nervio fibular comun pasaba sobre el musculo piriforme accesorio. Por otra parte, el nervio tibial cruzaba entre los musculos piriforme accesorio y gemelo superior. Ademas, ambos nervios se comunicaban con un ramo lateral bajo el margen inferior del musculo piriforme accesorio y el nervio gluteo inferior se originaba desde el nervio fibular. Variaciones anatomicas y relaciones entre el musculo piriforme y nervio isquiatico pueden estar presentes hasta en el 17% de la poblacion. Seis variaciones diferentes se han descrito en este articulo y ninguna es similar a nuestra descripcion. A pesar del completo entendimiento de la fisiopatologia del sindrome del musculo piriforme, aun queda por esclarecer y conocer las posibles variaciones anatomicas que pueden ser utiles tanto para su diagnostico como para el tratamiento adecuado.

Cochlear implantation through the middle cranial fossa: a novel approach to access the basal turn of the cochlea

UNLABELLED The classic approach for cochlear implant surgery includes mastoidectomy and posterior tympanotomy. The middle cranial fossa approach is a proven alternative, but it has been used only sporadically and inconsistently in cochlear implantation. OBJECTIVE To describe a new approach to expose the basal turn of the cochlea in cochlear implant surgery through the middle cranial fossa. METHOD Fifty temporal bones were dissected in this anatomic study of the temporal bone. Cochleostomies were performed through the middle cranial fossa approach in the most superficial portion of the basal turn of the cochlea, using the meatal plane and the superior petrous sinus as landmarks. The lateral wall of the internal acoustic canal was dissected after the petrous apex had been drilled and stripped. The dissected wall of the inner acoustic canal was followed longitudinally to the cochleostomy. RESULTS Only the superficial portion of the basal turn of the cochlea was opened in the fifty temporal bones included in this study. The exposure of the basal turn of the cochlea allowed the visualization of the scala tympani and the scala vestibuli, which enabled the array to be easily inserted through the scala tympani. CONCLUSION The proposed approach is simple to use and provides sufficient exposure of the basal turn of the cochlea.

A Rare Pattern of Brachial Artery Variation: Case Report

A diferencia del sistema venoso, las variaciones en la anatomia arterial son menos frecuentes y la mayoria afecta a las arterias viscerales. En los miembros, las variaciones de la arteria braquial son las mas informadas y por lo menos seis diferentes patrones han sido descritos. La variacion mas comun es de la arteria braquial superficial que esta superficialmente al nervio mediano. Mucho menos frecuente es el origen alto de la arteria braquial radial (la arteria braquiorradial) o la existencia de una arteria braquial doble (arteria braquial accesoria). Presentamos un patron de variacion no descrito de la arteria braquial observado durante la diseccion del miembro superior derecho de un cadaver en un hombre de 60 anos de edad. Encontramos la bifurcacion de la arteria braquial en la porcion medial del brazo, pasando posterior al nervio mediano. Luego, esta rama medial se redirecciona lateralmente y cruza nuevamente al nervio mediano, esta vez, anterior a el, hasta alcanzar la region lateral del brazo. A nivel de la flexura del codo, la rama medial origina la arteria radial. La rama lateral de la arteria braquial se mantiene lateral al nervio mediano y continua como arteria ulnar y origina la arteria interosea comun.

Lymph drainage of the upper limb and mammary region to the axilla: anatomical study in stillborns

PurposeWe studied the lymphatic drainage of the upper limb and mammary region directing to the axilla to investigate whether independent pathways can be observed or whether anastomoses and shared drainage occur between them. This analysis aimed to assess the safety of axillary reverse mapping (ARM) in breast cancer treatment and to understand the development of lymphedema after sentinel lymph node biopsy (SLNB) alone.MethodsSeven unfixed stillborn fetuses were injected with a modified Gerota mass in the peri-areolar area, palm and dorsum of the hands, formalin fixed, and then submerged in 10% hydrogen peroxide solution. Microsurgical dissection was then performed on the subcutaneous cellular tissue of the upper limb, axillary region, and anterior thorax to expose the lymphatic vessels and lymph nodes.ResultsThe dye injected into the upper limb reached either the lateral axillary group, known to be exclusively responsible for upper limb drainage, or the anterior group, which is typically related to breast drainage. There was great proximity among the pathways and lymph nodes. Communicating lymphatic vessels among these groups of lymph nodes were also found in all studied cases.DiscussionLymphedema remains a challenging morbidity in breast cancer treatment. ARM and SLNB aim to avoid unnecessary damage to the lymphatic drainage of the upper limb. However, our anatomical study suggests that ARM may have potential oncological risks because preserved lymph nodes may harbor malignant cells due their proximity, overlapping drainage pathways, and connecting lymph vessels among lymph nodes.

Anatomy of the Lymphatic Drainage of the Upper Limb and Breast and its Role in Lymphedema Prevention after Breast Cancer Treatment

El tratamiento quirurgico del cancer de mama ha mejorado a lo largo de los anos con el fin de ofrecer resultados oncologicamente mas seguros y eficaces con menor impacto estetico y menos secuelas. El linfedema del miembro superior es todavia un resultado iatrogenico de gran incidencia y morbilidad despues de este tratamiento. La posible existencia de vias linfaticas de mama y de los miembros superiores independientes se ha convertido en un tema central de muchas investigaciones para lograr minimizar su ocurrencia. Esta revision tiene como objetivo comparar las vias linfaticas en la axila descritas en los libros de anatomia tradicionales con articulos recientemente publicados sobre Mapeo Reverso Axilar (MRA). Con este fin, se realizo un cuadro comparativo con las descripciones y un diagrama de flujo de las anastomosis entre los nodos, ademas de un dibujo analitico de las areas drenadas estadisticamente mas mencionadas. Se observo que existe una gran variabilidad en las descripciones sobre el drenaje y las anastomosis entre los nodos linfaticos, por lo que la descripcion universal no deberia ser considerada un consenso debido a que tambien presenta posibles variaciones anatomicas. Por otra parte, los resultados producidos por los estudios recientes muestran posibles anastomosis entre las vias y los nodos linfaticos, sin embargo, no se han tomado en consideracion cuando se propuso inicialmente el MRA. Por lo tanto, la reseccion axilar con la preservacion de la parte posterior y los nodos linfaticos axilares laterales es teoricamente posible para evitar el linfedema del miembro superior, pero el desarrollo de una descripcion universal actualizada, que incluya todas las posibles variaciones anatomicas, proporcionara un tratamiento mas seguro y eficaz.

Botulinum toxin type A on cutaneous flap viability in diabetic and tobacco-exposed rats

PURPOSE To investigate the effect of Botulinum toxin A (BoNTA) on skin flap viability in healthy, tobacco-exposed and diabetic rats. METHODS Ninety male Wistar rats (250-300g) were randomly divided into six groups: control+saline (C1), control+BoNTA (C2), tobacco-exposed+saline (T1), tobacco-exposed+BoNTA (T2) diabetes+saline (D1) and diabetes+BoNTA (D2). A dorsal cutaneous flap (3×10cm) was performed. Survival area and total area of the flaps were measured. Lumen diameter, external arterial diameter and lumen/wall thickness ratio were recorded. RESULTS Survival area increased in control group with BoNTA injection compared with control animals injected with saline (C2 x C1; 0.9±0.1 vs0.67±0.15, p= 0.001). A similar result was found in diabetes group injected with BontA (D2 x D1; 0.97±0.2 vs0.61±0.24, p=0.018). No difference was observed in skin flap viability in tobacco-exposed groups (T2 x T1; 0.74±0.24 vs 0.64±0.21, p=0.871). Lumen diameter (p= 0.004), external arterial diameter (p = 0.0046,) and lumen/wall thickness ratio (p= 0.003) were increased in diabetes+BoNTA-treated animals. This effect was not observed in control or in tobacco-exposed groups. CONCLUSIONS Botulinum toxin A increased skin flap viability in control and diabetic rats on the seventh post-operative day. Increased lumen diameter, external arterial diameter, and lumen/wall thickness ratio were observed in the diabetes+BoNTA group. BoNTA had no effect in the tobacco-exposed group on the seventh postoperative day.