Rogério Serafim Parra

Effect of hyperbaric oxygen therapy on the intestinal ischemia reperfusion injury

PURPOSE Adequate tissue oxygenation is essential for healing. Hyperbaric oxygen therapy (HBOT) has potential clinical applications to treat ischemic pathologies, however the exact nature of any protective effects are unclear at present. We therefore investigated the potential role of HBOT in modulating the ischemia/reperfusion (I/R) injury response in intestinal model of I/R injury. METHODS Male Wistar rats were subjected to surgery for the induction of intestinal ischemia followed by reperfusion. HBOT was provided before and/or after intestinal ischemia. Cell viability in the intestinal tissue was assessed using the MTT assay and by measuring serum malondealdehyde (MDA). Microvascular density and apoptosis were evaluated by immunohistochemistry. RESULTS The results indicate that HBOT treatment pre- and post-ischemia reduces lesion size to the intestinal tissue. This treatment increases cell viability and reduces the activation of caspase-3, which is associated with increased number of tissue CD34 cells and enhanced VEGF expression. CONCLUSION The hyperbaric oxygen therapy can limit tissue damage due to ischemia/reperfusion injury, by inducing reparative signaling pathways.

Spontaneous transvaginal small bowel evisceration: a case report

Spontaneous evisceration through the vagina was first described in 1907 by McGregor.1 To date, only eighty-five cases of transvaginal small bowel evisceration have been documented worldwide.1,2 The primary risk groups for spontaneous vaginal evisceration include postmenopausal women,1,3–7 vaginal surgery cases,1,8–10 multiparae,11 and women of older age.2,3 In postmenopausal woman, transvaginal evisceration is frequently associated with increased abdominal pressure,1 vaginal ulceration due to severe atrophy, and straining at stool.6,8 Vaginal evisceration is a medical emergency that requires prompt recognition and immediate surgical intervention.1 The associated mortality rate is 5.6 percent; however, the incidence of morbidity is higher3,8 when the bowel has become strangulated through the vaginal defect. Here, we report a case of vaginal vault rupture with evisceration through the vagina and highlight the risk factors, clinical presentation, and treatment options for this rare gynecological emergency.

Study on adhesion formation and the healing of colon anastomosis in rats with induced peritoneal sepsis

PURPOSE To evaluate the effects of abdominal sepsis on adhesion formation and colon anastomosis healing in rats. METHODS Forty rats were distributed in two groups containing 20 rats each for left colon anastomosis in the presence (Group S) or absence (Group N) of induced sepsis by cecal ligation and puncture. Each group was divided into subgroups for euthanasia on the third (N3 and S3) or seventh (N7 or S7) post-operative day. The amount of adhesions was evaluated and a segment of the colon was removed for histopathologic analysis, bursting strength assessment, hydroxyproline and the determination of tissue collagen. RESULTS The subjects which underwent cecal ligation and puncture presented a higher amount of intra-abdominal adherences in both third (p=0,00) and seventh (p=0,00) post-operatory days. Smaller bursting strengths were found in the S3 subgroup, and greater bursting strengths were found in the S7 subgroup. There was no difference in the variations on the concentrations of hydroxyproline, tissue collagen and histopathology. CONCLUSIONS The peritoneal infection which was developed by cecal ligation and puncture raised the amount of intra-cavitary adhesions. There was a decrease in the amount of colonic anastomosis on the third post-operatory day with a following raise on the seventh without any effects on other healing parameters.

Familial adenomatous polyposis and desmoid tumors

The desmoid tumor (DT) is a benign neoplasm that occursin 10%–20% of the patients with FAP. It originates fromfascial or muscle-aponeurotic structures that foster fibro-blast proliferation. DTs occur more frequently in the intra-abdominal region or the abdominal wall, although they canalso be detected in extra-abdominal areas. It is a rare type oftumor, representing 0.03% of neoplasms. Compared withthe general population, a patient with FAP is at an 852-foldincreased risk of developing a DT.

Crohn's disease and hyperbaric oxygen therapy

PURPOSE Evaluate the application of Hyperbaric Oxygen Therapy (HBO) in patients with Crohns disease (CD) refractory to pharmacologic therapy, who developed abdominal, anorectal or skin complications. METHODS Fourteen selected patients with refractory CD and treated at the School of Medicine of Ribeirao Preto, University of Sao Paulo (FMRP-USP) and at the Center of Hyperbaric Medicine, São Paulo Hospital (CEMEHI) were submitted to HBO. RESULTS Of the 14 patients evaluated, 11 had a satisfactory response. CONCLUSION HBO has shown benefits in patients with CD refractory to pharmacologic therapy.

Infliximab-associated fulminant hepatic failure in ulcerative colitis: a case report

IntroductionInfliximab, an antibody against tumor necrosis factor alpha, is used to treat inflammatory bowel disease and has well-established efficacy and proven safety. Complications of this treatment are related to immunosuppression and include higher risk of serious infections and malignant neoplasia. Although extremely rare, fulminant liver damage related to infliximab therapy has been reported.Case presentationWe present the case of a 38-year-old Afro-Brazilian woman with refractory ulcerative colitis who was started on infliximab. She had no previous history of liver disease, alcohol abuse, or infection. After the fifth dose of the medication, drug-induced liver injury was diagnosed. Treatment was discontinued but our patient’s condition was aggravated by severe cholestasis and grade III/IV encephalopathy, requiring liver transplantation.ConclusionDrug-induced liver injury is an uncommon complication of infliximab. Current consensus recommends screening for liver dysfunction prior to and during therapy. This case emphasizes the need for vigilance and highlights a rare and potentially lethal complication.

Melanoma of the anal canal

Anorectal melanoma is an uncommon and aggressive cancer with an unfavorable prognosis2-5,7,9-11 and a predilection for early infiltration and distant spread, resulting in poor overall survival.2 It represents approximately 1 percent of all anorectal malignancies.7,11 Between 0.4% and 1.6% of all melanomas arise in the anorectal region, and the anal canal is the most frequent site of melanoma after the skin and retina.11 Most patients are female.2,3 The first case of the disease was reported by Moore in 1857 and, so far, approximately 500 cases have been reported in the literature.11 Because anal melanoma is rare, only small case series have been reported in the literature, making it difficult for one to draw conclusions about optimal treatment and outcome.2 The surgical management of patients with anorectal melanoma is controversial.1 Some authors have stated that wide local resection is the first choice for primary anorectal melanoma if negative margins can be achieved when this is technically feasible and complete tumor resection is impossible.3,5 Abdominoperineal resection should be reserved for large tumors where wide local excision is not technically possible.5 Chemotherapy, radiotherapy, and immunotherapy should be considered in the treatment of anorectal melanoma in order to influence overall survival.3

Liver cirrhosis on the colonic anastomotic healing in rats

PURPOSE To investigate the effects of cirrhosis on colonic anastomosis healing in rats. METHODS Fifty five Wistar male rats were used (23 in the control group and 32 in the cirrhosis group). On the first day of the procedure, the rats in the cirrhosis group underwent double ligation and folding of the common bile duct to induce liver cirrhosis, and the control rats underwent a laparotomy and intestinal manipulation. On the fourteenth and thirty-fifth days, all of the animals were biochemically assessed for serum aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase, bilirubin, total protein, and albumin and for liver histopathology. On the thirty-fifth day, cirrhosis was confirmed. On the twenty-eighth day, all of the animals were subjected to left colon transection and anastomosis. On the seventh day after the colonic anastomosis, the rats were sacrificed and macroscopically evaluated for dehiscence. The region of the colonic anastomosis was removed and subjected to hydroxyproline content measurement, conventional histology, and the immunohistochemical determination of vascular endothelial growth factor (VEGF) and matrix metalloproteinase type 1 (MMP 1). RESULTS The biochemical and histopathological examinations confirmed cirrhosis in all of the animals in the cirrhosis group. More deaths occurred after anastomosis in the cirrhosis group (5/25) than in the control group (0/21), and anastomotic dehiscence was more frequent in the cirrhosis group (8/25) than in the control group (0/21). The average hydroxyproline concentration was lower in the cirrhosis group than in the control group. The immunohistochemical studies showed that the average VEGF expression in the cirrhosis group was lower than in the control group, and the average MMP1 expression was higher in the cirrhosis group. CONCLUSION Hepatic cirrhosis leads to increased mortality and colonic anastomotic dehiscence, an increased distance between the mucosal edges of the anastomosis area, and a lower hydroxyproline concentration in the colonic anastomosis; therefore, these conditions are deleterious to healing.

Chronic idiopathic intestinal pseudo-obstruction treated with jejunostomy: case report and literature review

CONTEXT Chronic idiopathic intestinal pseudo-obstruction is a very rare condition. CASE REPORT This study describes a male patient who had presented obstructive symptoms for 24 years. He had been treated clinically and had undergone two previous operations in different services, with no clinical improvement or correct diagnosis. He was diagnosed with intestinal obstruction without mechanical factors in our service and underwent jejunostomy, which had a significant decompressive effect. The patient was able to gain weight and presented improvements in laboratory tests. Jejunostomy is a relatively simple surgical procedure that is considered palliative but, in this case, it was resolutive.

Polipose múltipla familiar: análise de 44 casos tratados no Hospital das Clínicas da FMRP-USP

The authors present a retrospective analysis of forty-four patients with familiar adenomatosis polyposis treated at the School of Medicine of Ribeirao Preto Hospital and Clinics - University of Sao Paulo, from January 1991 to July 2005. Epidemiologic (age and gender) and genetic aspects were investigated as well as main symptoms, personal history and surgical treatment outcome. Data obtained were compared to the available literature. Our results show that 31 patients were male and 13 female, with average age of 32 years-old (14 to 60 years-old). The main symptoms were intestinal bleeding (62.5 %) and intestinal habit alteration (60 %). Less frequently, patients showed abdominal pain (45 %) and loss of weight (30 %). Familiar adenomatosis polyposis was reported by 67.5 % of the patients and relatives with neoplasms (intestinal and extra-intestinal) were referred by 62.5 % of the patients. By the time of the polyposis diagnosis, 32.5 % of the patients have already been diagnosed for colon cancer, with average age of 39 years old. Surgical treatment was performed in 95.4 % of the patients, total proctocolectomy was performed in 35.7 % (9 cases with ileal J- pouch and 6 with permanent ileostomy) and total colectomy with ileo rectal anasthomosis in 59.2%. From all patients evaluated, 57 % are still under follow up, 7 % died and 27 % gave up treatment.