Tarcizo Afonso Nunes

Single-injection femoral nerve block with 0.25% ropivacaine or 0.25% bupivacaine for postoperative analgesia after total knee replacement or anterior cruciate ligament reconstruction

STUDY OBJECTIVE To investigate the effects of single-injection femoral nerve block (FNB) in postoperative pain after total knee replacement (TKR) and anterior cruciate ligament (ACL) reconstruction. DESIGN Prospective, randomized, double-blind study. PATIENTS 96 ASA physical status I, II, and III patients, scheduled for TKR or ACL reconstruction. INTERVENTIONS All patients received a standard spinal anesthetic, then were randomly divided into three treatment groups as follows: Group B (n = 30) received an FNB with 40 mL of 0.25% bupivacaine containing epinephrine, 1:200,000; Group R (n = 32) received an FNB with 40 mL of 0.25% ropivacaine; and Group C (n = 28) received no FNB. MEASUREMENTS The following clinical outcomes were assessed at up to 6 hours (T1), 6 to 10 hours (T2), and 10 to 24 hours (T3) after spinal anesthesia was given: visual analog scale (VAS) for pain, both at rest and on movement (no or mild pain, moderate pain, or severe pain); morphine use; sensory block in the femoral, obturator, and lateral femoral cutaneous nerve dermatomes; and motor block of the femoral and obturator nerves. MAIN RESULTS Except for VAS during rest and on movement at time T3, there were more Group C patients who experienced moderate or severe pain than those who had no pain or mild pain, when compared with Groups R and B. Sensory block in the femoral and lateral femoral cutaneous nerve dermatomes did not differ between Groups R and B at any times. However, sensory block in the obturator nerve dermatome was lower in Group R than Group B only at T3. We observed a lower, significant use of morphine at T2 when comparing Groups R and B with Group C. No Group R patient and about 30% of Group B patients remained with motor block of femoral and obturator nerves at T3. Except for frequency of nausea, which was highest in Group C, the frequency of other side effects was similar among the three groups. CONCLUSIONS Femoral nerve block using 0.25% ropivacaine or 0.25% bupivacaine is an effective method of postoperative analgesia after TKR and ACL reconstruction, particularly for the first 10 hours after spinal anesthesia.

Laparoscopy grading system of acute appendicitis: new insight for future trials.

Background: The mini-invasive techniques have revolutionized the surgery; however, the superiority of laparoscopic access for complicated appendicitis is still controversial. The most critical point has been the dismal quality of the methodology found in the series comparing laparoscopic and laparotomic procedures. The lack of stratification criteria to evaluate the inflammation in the appendix and abdomen has been pointed out by several authors. Purpose: To validate the laparoscopic grading system for acute appendicitis. Methods: Prospective study of 186 patients with presumed acute appendicitis who underwent an appendectomy if diagnostic laparoscopy showed appendicitis or normal-looking appendix without any other intra-abdominal disease. The appendix was graded as to different levels based upon its visual appearance: grade 0 (normal looking), 1 (redness and edema), 2 (fibrin), 3A (segmental necrosis), 3B (base necrosis), 4A (abscess), 4B (regional peritonitis), and 5 (diffuse peritonitis). This was then compared with a histologic assessment of the removed appendix supplemented by a biochemical study of collected peritoneal fluid (gold standard) to determine the diagnostic indexes. Besides that, the &kgr; coefficient confirmed concordance between them. Results: Laparoscopic sensitivity, specificity, and accuracy for acute appendicitis diagnosis were 100%, 63.3%, and 84.1%, respectively, and presented substantial concordance [&kgr;=0.74 (95% confidence interval, 0.60-0.88)]. Sensitivity, specificity, and accuracy of the laparoscopic grading system were 63%, 83.3%, and 80.1%, respectively, and presented moderate concordance [&kgr;=0.39 (95% confidence interval, 0.23-0.55)]. The biochemical-histologic grading system changed for 48 (25.8%) patients who had been previously classified by surgeons during laparoscopy. Most incorrect graduation occurred in grades 0 and 1. The presence of exudates was confirmed in all cases classified as grades 4A, 4B, and 5. Conclusions: Laparoscopy showed good to excellent accuracy for diagnosis and grading of acute appendicitis. The better grading system allowed the evaluation of patients with acute appendicitis in the same clinical stage.

The appendiceal stump closure during laparoscopy: historical, surgical, and future perspectives.

During a laparoscopic appendectomy, the closure of the appendiceal stump is an important step because of postoperative complications from its inappropriate management. The development of life-threatening events such as stercoral fistulas, postoperative peritonitis, and sepsis is feared and unwanted. The tactical modification of the appendiceal stump closure with a single endoligature, replacing the invaginating suture, adjusted very well to laparoscopic appendectomy, and nowadays is the procedure of choice, whenever possible. Among the alternatives that do not make use of an invaginating suture, studies advocate the use of an endostapler, endoligature (endo-loop), metal clips, bipolar endocoagulation, and polymeric clips. All alternatives have advantages and disadvantages against the different clinical stages of acute appendicitis, and it should be noted that the different forms of appendiceal stump closure have never been assessed in prospective randomized studies. Knowledge about and appropriate use of all of them are important for a safe and more cost-effective procedure.

Effect of hyperbaric oxygen therapy in rats with subtotal splenectomy preserving the inferior pole

PURPOSE To evaluate the effect of hyperbaric oxygen therapy on the survival and weight of rats submitted to subtotal splenectomy and on the viability and growth of the inferior pole. METHODS Forty Wistar rats underwent subtotal splenectomy with preservation of the inferior pole and distributed into two groups: Group A (n=20) - not treated with hyperbaric oxygen, Group B (n=20) – treated with hyperbaric oxygen. These groups were divided into two subgroups of 10 animals each, according to the time of euthanasia, 15th and 45th days. The survival and weight of the animals were recorded. The inferior pole was measured, weighed and morphologically analyzed. RESULTS All animals survived. The weight of the animals increased in all subgroups, but decreased on the 10th day in the subgroups treated with hyperbaric oxygen (p<0.001). The viability of the inferior pole was more evident in animals treated on the 15th day, but did not differ on the 45th day. The growth of the inferior pole has not occurred on the 15th day but on the 45th day after surgery in untreated animals (p<0.01) and treated animals (p<0.05). Vascular and cellular increase in treated animals was significantly higher than in untreated ones. CONCLUSION Hyperbaric oxygen therapy did not affect the survival of animals but reduced their weight. It improved the viability of the inferior splenic pole, but did not interfere with their growth.

Classificação laparoscópica da apendicite aguda: correlação entre graus da doença e as variáveis perioperatórias

BACKGROUND: Laparoscopic classification of acute appendicitis is presented. The relationship between the grades of the disease with the time of symptoms, operating time, length of hospital stay, infectious complication rate and antimicrobials use is verified. METHODS: Consecutive patients (n= 105) who underwent a laparoscopic appendectomy from January 2000, through July 2001, were studied in a prospective way. A classification of the disease in five grade was proposed: grade 0 - Normal; 1 - Hyperemia and edema; 2 - Fibrinous exsudato; 3 - Segmentary necrosis; 4A - Abscess; 4B - Regional peritonitis; 4C - Appendix base necrosis; 5 - Diffuse Peritonitis. RESULTS: The distribution of the patients according to classification was: grade 0 (10.4%); 1 (40%); 2 (29.5%); 3 (2.9%); 4A (1.9%); 4B (4.8%); 4C (3.8%) and 5 (6.7%). The mean time of symptoms high than 40 hours was related with necrosis and peritonitis possibility. The mean operating time was 31,4 minutes (range 18 - 126 minutes). The mean length of hospital stay was 39,5 hours (range 12 - 192 hours). The infectious complications were greater in grade 4 and 5. The antibiotics was used as prophylactic in grades 0, 1 and 2 and therapeutically in the others. The conversion rate was 1.9% and there was no death. CONCLUSION: The laparoscopic classification of acute appendicitis contemplated all clinical forms of the disease, made possible correlation with the time of symptoms, operating time and length of hospital stay. It allowed also, to foresee infectious complications and to rationalize the antimicrobials.

Efeitos da oxigenoterapia hiperbárica em ratos submetidos à ligadura das veias hepáticas: avaliação da mortalidade e da histologia do fígado e baço

PURPOSE To evaluate the effects of hyperbaric oxygen therapy in rats submitted to instantaneously hepatic vein obstruction. METHODS 30 Holtzman adult male rats were utilised, distributed into two groups: 1) hepatic vein obstruction; 2) hepatic vein obstruction associated with hyperbaric oxygen therapy. General anaesthesia was utilized by a solution composed of ketamine chloride (40 mg/ml) and meperidine chloride (10 mg/ml) in a dose of 50/mg/weight, applied into the right gluteus muscle. The animals belonged to group 2 were submitted to hyperbaric oxygen therapy, 8 hours after the operations, in a 2,5 atmosphere, which lasts 120 minutes per day, in consecutive 20 days. The statistical analysis was made in relation to mortality and histological study of livers and spleens utilizing the Fisher test, and the results were considered statistically significant when p < 0.05. RESULTS Occurred seven (46.67%) deaths between animals belonged to group 1 and no deaths in the animals belonged to group 2. The histological studies made in the livers and spleens of the animals belonged to group 1 showed many alterations in the following percentages: thrombosis of hepatic, portal and center-lobular veins in five (33.3%), very extensive necrosis of liver cells in seven (46.7%), and light in eight (53.3%), Kupffer cells developed and hypertrophied in 14 (93.3%), high congestion of the spleen purple in six (40.0%) and moderate and severe hemossiderinosis spleen in 14 (93.3%). The analysis of this parameters in the group 2 only showed light necrosis of liver cells, Kupffer cells light developed and hypertrophied, moderated congestion of the spleen purple and light hemossiderinosis spleen. All these parameters analysed showed significantly difference (p < 0.05) between these two groups. CONCLUSIONS It could be concluded that the hyperbaric oxygen therapy applied in rats, with instantaneously hepatic vein obstruction decreased their post-surgical mortality and their early deleterious effects in the liver and spleen.

Índices diagnósticos da ultrassonografia abdominal na apendicite aguda: influência do gênero e constituição física, tempo evolutivo da doença e experiência do radiologista

OBJETIVO: Verificar o valor da ultrassonografia abdominal no diagnostico da apendicite aguda e a influencia do genero, constituicao fisica, experiencia do radiologista e o tempo evolutivo da doenca nos resultados dos indices diagnosticos. METODOS: Avaliou-se prospectivamente 156 pacientes com diagnostico clinico de apendicite aguda, submetidos a ultrassonografia abdominal e apendicectomia laparoscopica, acompanhado de estudo anatomopatologico dos apendices extirpados. Os pacientes foram alocados quanto ao IMC em dois grupos (abaixo ou acima de 25kg/m2) e os radiologistas, em tres grupos conforme a experiencia profissional (menos de cinco anos, entre cinco e 10 anos e mais de 10 anos). A pesquisa avaliou tambem a interferencia do genero e do tempo de evolucao da doenca utilizando-se a mediana de 36 horas. RESULTADOS: A sensibilidade e especificidade da ultrassonografia abdominal para o diagnostico da apendicite aguda foram 64,9 e 72%, respectivamente. O genero, o indice de massa corporea, o tempo de experiencia dos radiologistas nos tres grupos estudados e o tempo de inicio de sintomas da doenca, nao demonstraram diferencas significativas no estabelecimento do diagnostico ecografico da apendicite aguda. CONCLUSAO: A ultrassonografia abdominal apresentou baixa sensibilidade e especificidade e pouco contribuiu para diagnostico da apendicite aguda. O genero, a constituicao fisica, a experiencia do radiologista e tempo de inicio de sintomas da doenca nao interferiram no resultado do exame ecografico.

Importance of flexible bronchoscopy in decannulation of tracheostomy patients

OBJECTIVE: To evaluate the importance of flexible bronchoscopy in tracheostomy patients in the process of decannulation to assess the incidence and types of laryngotracheal injury and compare the presence of such lesions with clinical criteria used for decannulation. METHODS: We studied 51 tracheostomized patients aged between 19 and 87 years, with tracheal stent for a mean of 46 ± 28 days and with clinical criteria for decannulation. They were submitted to tracheostomy tube occlusion tolerance testfor 24 hours, and then to flexible bronchoscopy. We described and classified the diagnosed laryngotracheal changes. We compared the clinical criteria for decannulation indication with the bronchoscopy-diagnosed laryngotracheal injuries that contraindicated decannulation. We identified the factors that could interfere in decannulation and evaluated the importance of bronchoscopy as part of the process. RESULTS: Forty (80.4%) patients had laryngotracheal alterations. Of the 40 patients considered clinically fit to decannulation, eight (20%) (p = 0.0007) presented with laryngotracheal injuries at bronchoscopy that contraindicated the procedure. The most frequent laryngeal alteration was vocal cords lesion, in 15 (29%) individuals, and granuloma, the most prevalent tracheal lesion, in 14 (27.5%) patients. CONCLUSION: flexible bronchoscopy showed a large number of laryngotracheal injuries, the most frequent being the vocal cords injury in the larynx and the granuloma in the trachea, which contributed to increase the decannulation procedure safety.

Immunoexpression of proliferating cell nuclear antigen (PCNA) in spleen of splenectomized rats with preservation of inferior pole, submitted to hyperbaric oxygenation

PURPOSE To analyze PCNA immunoexpression on the inferior pole of the spleen of splenectomized rats submitted to hyperbaric oxygenation (HBO). METHODS Were analyzed fragments of the inferior pole of the spleen of 20 male Wistar rats submitted to splenectomy with preservation of the inferior pole. The rats were divided in two groups: group A (n=10) without HBO and group B (n=10) submitted to HBO at 2, 5 atmospheres per 120 minutes, twice a day for three days and once a day for seven days. The groups were then subdivided in four subgroups: A15 (n=5), with euthanasia on the 15th day; A45 (n=5), with euthanasia on the 45th day; B15 (n=5) with euthanasia on the 15th day and B45 with euthanasia on the 45th day. Respectively on these days, fragments of the inferior pole of the spleen of all animals were collected and analyzed with the immunohistochemistry technique in order to evaluate PCNA expression. RESULTS There was an expressive increase in PCNA immunoreactivity in the group B. The 45 day postoperative period resulted in a higher level of positivity than the 15 day postoperative period (p<0.01). CONCLUSION The quantitative analysis of proliferating cell nuclear antigen positive suggests that hyperbaric oxygenation increases cellular proliferation, contributing to splenic regeneration.

Clinical and three-dimensional computed tomographic comparison between ACL transportal versus ACL transtibial single-bundle reconstructions with hamstrings

BACKGROUND Anterior cruciate ligament (ACL) reconstruction using a single-bundle transtibial technique can achieve good or excellent results in more than 90% of patients, but anatomical and biomechanical studies have questioned its ability to restore knee function. The purpose of this study was to evaluate clinical and tomographic results (patient satisfaction, knee function, and tunnel location) of patients who underwent transportal or transtibial single-bundle ACL reconstruction. METHODS Seventy-one patients with ACL tears were included. Forty-one patients were treated by the single-bundle transportal technique and 30 patients were treated by the single-bundle transtibial technique. Clinical and tomographic data were analyzed in both groups. RESULTS After a minimum of 2-year period, the transportal group showed more patients with normal clinical tests than the transtibial group (Lachman [p=0.037], pivot shift [0.00], anterior drawer [0.002]; and arthrometer [0.002] tests). Regarding CT evaluation, transportal and transtibial groups obtained the following femoral central tunnel location (mean [SD]), as percentage: 30 (6.5) and 4.2 (6.4) in high-low axis; and 30.9 (5.9) and 33.2 (4.6) in the deep-shallow axis. Values in the tibial side were, respectively: 38 (6.5) and 46.0 (6.8) in the anterior-posterior axis; and 47.2 (2.5) and 46.9 (2.1) in the medial-lateral axis. CONCLUSION CT findings showed that the transportal single-bundle technique positions the ACL tunnel closer to the native ACL footprint in both femur and tibia compared with the transtibial single-bundle technique. Moreover, mild asymptomatic instability and extension deficit were observed more often in the transtibial group.