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PubMed1990

Innervation of bladder and bowel.

The autonomic neuromuscular junction is described and neurotransmission, co-transmission and neuromodulation are defined, as well as the 'chemical coding' of sympathetic, parasympathetic, sensory-motor and intrinsic neurons in the wall of the bladder and bowel. A detailed description of the patterns of innervation of smooth muscle of the bowel, bladder and urethra and of the urethral and anal sphincters by intramural and extrinsic autonomic nerves is presented, and the functional and pharmacological features of this innervation are summarized. Finally, changes in the pattern of innervation and expression of co-transmitters and receptors in the bladder and bowel that occur during development and old age and following trauma, surgery and disease are discussed.

Autonomic Nervous System↗
PubMed1992

Blood phobics and nonphobics: psychological differences and affect during exposure.

This study compared psychological dimensions of blood phobics and nonphobic controls, examined affect in response to phobic and neutral stimuli, and investigated the relationship between reported feelings of faintness and blood pressure. Blood phobics (24 adults with extreme Mutilation Questionnaire scores) and 24 nonphobics completed several psychological measures and viewed one of two 60 sec surgery scenes and a 60 sec neutral scene in counterbalanced order. Subjective, psychophysiologic, and motoric measures of affect were assessed. On questionnaires, phobics reported greater anxiety sensitivity, empathic distress, fear and insecurity, and nightmares, but no difference in autonomic arousal, muscle tension, motion sickness, or other empathy domains. During surgery scenes, phobics had more negative affect than controls; however, phobics were more anxious during only one of the two surgeries, and often only when the surgery was presented prior to the neutral scene. Fainting did not occur, and self-reported feelings of faintness were unrelated to blood pressure changes. The findings highlight the lack of information on blood phobic stimulus properties, fainting's relationship to self-reports and blood pressure, and the specific emotion experienced in blood phobia.

Adolescent↗
PubMed2001

Computer assisted oral and maxillofacial surgery--a review and an assessment of technology.

Advances in the basic scientific research within the field of computer assisted oral and maxillofacial surgery have enabled us to introduce features of these techniques into routine clinical practice. In order to simulate complex surgery with the aid of a computer, the diagnostic image data and especially various imaging modalities including computer tomography (CT), magnetic resonance imaging (MRI) and Ultrasound (US) must be arranged in relation to each other, thus enabling a rapid switching between the various modalities as well as the viewing of superimposed images. Segmenting techniques for the reconstruction of three-dimensional representations of soft and hard tissues are required. We must develop ergonomic and user friendly interactive methods for the surgeon, thus allowing for a precise and fast entry of the planned surgical procedure in the planning and simulation phase. During the surgical phase, instrument navigation tools offer the surgeon interactive support through operation guidance and control of potential dangers. This feature is already available today and within this article we present a review of the development of this rapidly evolving technique. Future intraoperative assistance takes the form of such passive tools for the support of intraoperative orientation as well as so-called 'tracking systems' (semi-active systems) which accompany and support the surgeons' work. The final form are robots which execute specific steps completely autonomously. The techniques of virtual reality and computer assisted surgery are increasingly important in their medical applications. Many applications are still being developed or are still in the form of a prototype. It is already clear, however, that developments in this area will have a considerable effect on a surgeon's routine work.

Computer Simulation↗
PubMed2005

Reinnervation for neurogenic bladder: historic review and introduction of a somatic-autonomic reflex pathway procedure for patients with spinal cord injury or spina bifida.

Neurogenic bladder caused by SCI or spina bifida is a major problem. Research in restoring functional micturition has mainly focused on electrical stimulation for many decades with good progress, but it is still not the definitive solution for majority of the SCI patients. An alternative approach has been to investigate restoring innervation to the lower urinary tract after spinal SCI. Different animal and clinical studies were reviewed historically in this article, focused on mainly cross over nerve surgery for reinnervation of the bladder. An artificial somatic-autonomic reflex pathway procedure and its mechanisms were introduced. Clinical application and the satisfactory results of the new procedure were reviewed in details in restoring voluntary bladder control in patients with SCI or spina bifida.

Autonomic Pathways↗
PubMed2006

Rural surgery in southern Sudan.

INTRODUCTION: This article reports a retrospective analysis of a 6-year experience of providing surgical care in remote areas of southern Sudan under extremely adverse conditions. METHODS: Teams of expatriate consultants (surgeon, anesthetist, scrub nurse) carried out 28 "surgical missions" with the aims of treating surgical cases previously selected and of training local personnel in basic surgery on the job. RESULTS: A total of 1642 patients (71% males, 30% under the age of 16) have undergone an operation. Altogether, 1264 elective procedures (77%) and 378 emergency procedures (23%) were performed. Hernia surgery comprised the main workload, followed by proctologic and gynecologic operations. Most operations were performed under spinal anesthesia. Other cases required ketamine, and a small number of patients had local anesthesia. There were 14 fatal complications, most of them related to the delay in obtaining medical attention. Based on the training results, the Sudanese personnel of two of the five health centers involved in the program are already fully autonomous. Two doctors and two nurses are proficient in essential surgery; two not qualified nurses are proficient in "primary" anesthesia; and others are proficient in scrubbing and surgical nursing. CONCLUSIONS: This report demonstrates that it is feasible to establish surgical services in rural areas of developing countries by utilizing simple facilities, providing them with basic equipment, and employing local personnel selected and trained on the job by teams composed of a consultant surgeon, anesthetist, and scrub nurse. This seems to be the only realistic possibility for providing surgical care to the rural populations of the least developed countries.

Anesthesia↗
PubMed2001

[Open versus video-endoscopic approach in the treatment of hypercortisolism by bilateral adrenalectomy].

Progress in the technique of the hypophysectomy and in the imaging procedures reduced drastically the indications of bilateral adrenalectomy (BA) in the treatment of hypercortisolism (HC). Indeed BA is indicated in 10 to 30% after failure of pituitary surgery, when HC is related to ACTH ectopic secretion, and in HC related to autonomous adrenal secretion. The purpose of this work is to demonstrate the validity of the bilateral video endoscopic adrenalectomy (BVA) in regard to open surgery. During the last 20 years, 88 patients were operated on by open adrenalectomy (Group 1), either by transperitoneal approach, or bilateral posterior lombetomy. From 1994, 62 patients (Group 2), were operated by video endoscopy. Two death occurred in group 1. The frequency of the preoperative complications were identical in each group, but postoperative morbidity were lower in the group 2. The fall in the postoperative pain, the simplicity of the follow up, the rapid hospital discharge, the low rate of parietal complications were observed in BVA. We conclude that the postoperative follow up is better after BVA a specialized training and time of adaptation are imposed to the surgeon.

Adrenalectomy↗
PubMed2001

Slow transit constipation: a disorder of pelvic autonomic nerves?

Slow transit constipation (STC) is a severe motility disorder, which in the majority of cases is of unknown etiology. In some, symptoms arise de novo in childhood, but a proportion of patients present in later life, including after pelvic surgery or childbirth. Our aims were: (1) to describe our current knowledge of the anatomy and function of the pelvic autonomic nerves with respect to colonic motility (experimental and observational studies); (2) to discuss evidence for pelvic nerve injury in STC arising after pelvic surgery or childbirth; and (3), on the basis that such patients are clinically indistinguishable from patients with chronic idiopathic STC, to evaluate whether there is evidence that pelvic autonomic neuropathy has an etiologic role in patients with chronic idiopathic STC. The outcome was as follows: (1) The clear importance of the pelvic autonomic nerves in colonic motor function is documented. (2) While there is an association between pelvic surgery and childbirth, and the onset of STC, there is little direct anatomical evidence that pelvic denervation occurs in these patients. However the phenotype of these patients is similar to results of experimental and observational studies. (3) Clinical, physiological, and histological similarities exist between patients whose symptoms arose following pelvic intervention and those whose symptoms arise de novo (idiopathic). We further present evidence for possible pathogenetic mechanisms underlying pelvic autonomic neuropathy in chronic idiopathic STC.

Autonomic Nervous System Diseases↗
PubMed2002

Intraoperative parasympathetic nerve stimulation with tumescence monitoring during total mesorectal excision for rectal cancer.

BACKGROUND: Unilateral or bilateral division of the parasympathetic nerves during resection of rectal cancer may result in sexual erectile dysfunction. The purposes of this project were twofold: to determine the ability to demonstrate penile tumescence in response to parasympathetic nerve stimulation after rectal cancer resection and to correlate the nerve stimulation response with clinical sexual function 6 months after operation. STUDY DESIGN: In 21 consecutive male patients with normal erectile function undergoing total mesorectal excision, cavernous nerve identification and integrity before and after pelvic dissection were assessed intraoperatively, both visually by an experienced surgeon and by using the CaverMap nerve stimulator. The minimal effective current necessary to produce a 2% increase in penile tumescence was recorded for both the left- and right-sided nerves, primarily the largest nerve trunk, S3. Postclearance stimulation data were then correlated with sexual function outcomes, specifically erection and orgasm at 6 months after surgery. RESULTS: The operating surgeon's visual assessment of the pelvic autonomic nerve's integrity after pelvic dissection was deemed intact in 20 of the 21 patients (95.2%). Of the 20 patients who were evaluated with CaverMap after completion of total mesorectal excision, 17 (85%) had tumescence response after nerve stimulation on either side, and 3 patients (15%) had unilateral response only. Of the 19 patients evaluated for sexual function 6 months after surgery, 18 (94.7%) had normal function, including the 3 patients with only unilateral nerve stimulation tumescence response. CONCLUSIONS: Intraoperative mapping of the parasympathetic nerve trunks with the CaverMap nerve stimulator may be a valuable aid to less experienced pelvic surgeons and may help in autonomic nerve preservation during total mesorectal excision clearance.

Adult↗
PubMedDate not supplied

[Avoidable hospitalization using ambulatory surgery in the Community of Valencia: a Delphi study].

BACKGROUND: To estimate the number of hospital admittance's avoidable by means of ambulatory surgery, according to surgeons and anaesthetists who currently work with the National Health System (NHS). METHOD: By means of a Delphi procedure of 25 surgeons or anaesthetists of the Valencia Health Survey (AServei Valencià de la Salut-SVS), a consensus was reached as to the objective criteria for excluding patients that could be treated outside a hospital and the percentage of certain operations that could be performed under day surgery. These criteria were applied to the Minimum Basic Data Set on hospital discharge within the Autonomous Region of Valencia in order to estimate the figure of hospital admittance and stays avoidable by means of ambulatory surgery in a selection of 29 surgery processes. RESULTS: 83% of medical personnel responded to the Delphi questionnaires. The median of the surveyed group's estimation on the proportion of cases that could be treated by means of external surgery varied from 40% for abdomen wall hernias or laparoscopic cholecystectomy and 90% for perianal tissue excision, anastomosis for dialysis or ganglionectomy. Application of the results of the Delphi survey would have meant that the SVS could have avoided 12,558 admittances in 1994, 75% of the operations surveyed, which is almost the same figure resulting from applying the medical personnel's opinion of the CMBD. CONCLUSIONS: SVS professionals consider it feasible to perform a much higher number of ambulatory operations than those currently carried out, and that it is likely that the causes for the lack of such operations lie in SNS financing and incentive criteria, rather than medical issues.

Ambulatory Surgical Procedures↗
PubMedDate not supplied

[Variability in hospital care. Nasosinus surgery in Spain].

OBJECTIVES: To describe variations in the management of nasosinus disorders among the Autonomous Communities and hospitals of Spain. METHODS: We analyzed the Minimum Basic Data Set of the public health system from 1998-2000 for the diagnoses of nasosinus polyps and chronic sinusitis. We studied the distribution by regions of the rate of hospitalizations and of 4 indicators of quality of care and efficiency: mean length of stay, percentage of discharges without surgery, percentage of functional endoscopic sinus surgery and surgical complications. A cluster analysis was performed to classify hospitals according to the values of these indicators. RESULTS: We analyzed 13061 discharges from 263 hospitals. Marked differences were found in age-adjusted hospitalization rates by regions. Cluster analysis classified the centers with more than 10 annual discharges in 3 categories: a) 32 hospitals in which the 4 quality indicators were above average; b) 35 hospitals in which 3 of the indicators were below average, and c) 74 hospitals in which 2 indicators were above average and 2 indicators were below average. CONCLUSIONS: Marked interregional variations were found in hospitalization rates, as well as in the characteristics of management of nasosinus disorders in Spanish hospitals. The centers examined could be grouped into three clearly defined patterns according to indicators of quality of care and efficiency.

Adolescent↗
PubMed1993

Autonomic dysfunction in gastrointestinal motility disorders.

The records of 113 consecutive patients with a suspected gastrointestinal motility disorder referred between January 1988 and July 1991 were retrospectively reviewed. The aims were to identify the prevalence of autonomic dysfunction in those with or without associated neurological disease and to determine the diagnostic value of testing for autonomic dysfunction. All patients had gastrointestinal manometry (3 hours fasting, 2 hours fed), 94 of 113 underwent testing of sympathetic adrenergic and cholinergic function and cardiovagal cholinergic function. All tests were scored in a standard manner. There was a significant (p < 0.05) but modest (r = 0.28) rank correlation between autonomic and motility scores. This correlation was stronger (r = 0.67, p = 0.01) in diabetic patients. The number of patients in each group with autonomic dysfunction was as follows: irritable bowel syndrome nine of 33, idiopathic upper gastrointestinal dysmotility six of 21, diabetes mellitus nine of 13, identified non-diabetic neurological syndromes six of nine, postvagotomy or abdominal surgery three of 11, and myopathic pseudo-obstruction two of seven. Autonomic testing is useful in the assessment of autonomic involvement outside the gastrointestinal tract. Logistic discriminant analysis showed that autonomic function testing did not add to the diagnostic value of motility tests in distinguishing between patients with and without irritable bowel syndrome, although a slight improvement was indicated for identifying neuropathic dysmotilities. Thus, the aetiological role of general autonomic dysfunction in irritable bowel syndrome and idiopathic and postvagotomy dysmotilities deserves further study. The addition of autonomic function tests does not add substantially to the diagnostic accuracy of clinical, radiological, endoscopic, and manometric techniques in most patients referred for evaluation of a suspected motility disorder.

Autonomic Nervous System Diseases↗
PubMed1976

[Place of neuroleptics in neurosurgical anesthesia-resuscitation].

The interest of neuroleptics in neurosurgery should be examined in the light of physiopathological and pharmacological data concerning cerebral circulatory autoregulation and intracranial pressure. The fairly favourable conclusions permit one to consider their wide use justified, especially, by the feeble hypnogenic effects, without any marked disturbance of the E.E.G., associated with an anticatecholaminergic and stabilizing effect on the autonomic nervous system. They therefore occupy a place of choice, in particular during induction of anesthesia in high risk patients, during operations requiring neurological or continuous E.E.G. investigations, in surgery of intracranial aneurysm and, finally, to obtain sedation and post-operative autonomic control.

Anesthesia↗
PubMed1993

Autonomic dysfunction in patients with chronic intestinal pseudo-obstruction.

We prospectively evaluated autonomic function in 50 patients with clinical and manometric features of a neuropathic form of chronic intestinal pseudo-obstruction (CIP). In 26 patients, there were underlying disease processes that may have affected extrinsic neural control to viscera: diabetes mellitus (n = 16), previous gastric surgery (n = 5), and other neurologic disorders (n = 5). Our aim was to characterize autonomic function in these patients, and those 24 with CIP unassociated with a known underlying neurologic disorder (idiopathic group). We assessed vagal function and sympathetic cholinergic and adrenergic function by means of standardized autonomic tests and quantitated postprandial antral pressure activity. We also measured postprandial levels of pancreatic polypeptide and neurotensin as indicators of vagal function and of the delivery of nutrients to the distal small bowel. Among the idiopathic group (n = 24), two had evidence of a generalized sympathetic neuropathy and five abdominal vagal dysfunction (one had both). Among diabetic patients, three had sympathetic adrenergic failure, six had orthostasis with normal plasma noradrenaline, ten had signs of generalized sympathetic neuropathy and eight had abdominal vagal dysfunction. Vagal dysfunction was identified in all three patients who underwent vagotomy as part of their previous gastric surgery. In the other neurologic syndromes, vagal function was abnormal in three of the five patients. Thus, autonomic and, particularly, vagal dysfunction are confirmed in a majority of patients with CIP associated with known diabetes or neurologic disorders; however, a previously unrecognized autonomic (chiefly vagal) neuropathy of undetermined cause has been identified in five of the 24 'idiopathic' CIP patients.

Autonomic Nervous System Diseases↗
PubMed2006

Leukocytosis and increased risk of atrial fibrillation after general thoracic surgery.

BACKGROUND: In older patients who are known to be at greater risk for atrial fibrillation, we aimed to determine whether patients who develop atrial fibrillation-flutter (AF) after major thoracic surgery have an exaggerated white blood cell (WBC) count in response to surgical stress compared with those who do not develop AF. METHODS: Using a prospective database, 272 patients 60 years or older who were in sinus rhythm before surgery and had elective lobectomy, pneumonectomy, or esophagectomy were studied. Patients did not receive perioperative medications to prevent AF. Clinical characteristics and preoperative 12-lead electrocardiogram were examined and WBC counts were recorded for patients prior to and for up to five days after surgery. RESULTS: Atrial fibrillation-flutter was observed in 74 of 272 (27%) patients a median of 3 days after surgery. The increase in WBC count from preoperative to postoperative day 1 and age were jointly significant predictors of AF by multiple logistic regression (area under the receiver operating characteristic curve = 0.69). Using this model, a twofold increase in WBC from presurgery to postoperative day 1 corresponded to a 3.3-fold increase in the odds of developing AF (95% confidence interval [CI] 2.0 to 8.3) and for each 10 year increase in age, a 1.8-fold increase in risk of AF (95% CI 1.1 to 2.8) was seen. CONCLUSIONS: Increments in WBC were greater in patients with AF and coincided with the peak onset of AF. These prospective data support an important role for stress-mediated autonomic mechanisms in the pathogenesis of AF after major thoracic surgery. We aim to examine further whether WBC elevations on postoperative day one can help further risk stratify patients younger than 60 years or those with the highest risk who could benefit from one or more AF prevention strategies.

Age Factors↗
PubMed1994

Con: antiarrhythmic drugs should not be used to suppress ventricular ectopy in the perioperative period.

The alterations in autonomic tone imposed by the conduct of anesthesia and surgery predispose patients to ventricular ectopy. It is important to initially view any ectopy as a warning sign and promptly check the adequacy of ventilation and oxygenation. Most commonly an inadequate depth of anesthesia, surgical manipulation or electrolyte abnormality will be causative. Treatment of this underlying problem will usually suffice to terminate the ectopy. Importantly, many patients have preexisting, chronic, complex ventricular ectopy that gets revealed because of perioperative electrocardiographic monitoring. All available pharmacologic agents have significant adverse side effects. To date, all investigations examining outcome of suppression of ventricular ectopy show that successful suppression of ventricular ectopy was associated with an increased mortality. Although the prognosis for patients is worse when complex ventricular ectopy is associated with cardiac structural abnormalities, the optimal therapeutic approach to such patients remains undefined. Unless new data supporting the use of antiarrhythmic drugs in the perioperative setting become available, the risk to benefit ratio is considered unfavorable.

Anti-Arrhythmia Agents↗
PubMed1995

Advances in the management of patients with thyroid disease.

Discoveries related to thyroid immunology, especially concerning the thyroid-stimulating hormone (TSH) receptor, may facilitate new immunologic approaches to the therapy of Graves' disease and the thyroiditis syndromes. Advances in genetics are being applied to the thyroid hormone resistance syndromes and papillary and medullary carcinomas. The development of ever more sensitive TSH assays has led to the detection of subclinical thyroid disease, which has special implications for the sick and elderly patients. Sensitive TSH assays also allow more precise titration of levothyroxine (T4) dosages, especially for patients with a past history of thyroid cancer. Evidence continues to accumulate suggesting that postmenopausal women on T4 doses that suppress the TSH level below 0.1 ulU/mL have lower bone mineral density than matched patients with healthy TSH levels. Also, pregnant hypothyroid women need higher T4 doses to normalize the TSH levels. In the evaluation of thyroid nodules, fine-needle aspiration biopsy is the single most definitive modality in selecting the patients for surgery. Scintigraphy provides a complimentary role, especially in defining autonomously functioning thyroid adenomas (AFTA), because these should not be treated with T4 suppression. Ultrasound-guided needle biopsy is occasionally helpful with nodules that are difficult to palpate. Concern for possible tracheal compression after treatment of toxic multinodular goiter with large doses of radioactive iodine (I-131) in the range of 50 to 150 mCi (1.85 to 5.5 GBq) does not seem warranted. Work, primarily out of Italy, suggests AFTA can be ablated with repeat ethanol injections. Residual tissues after thyroidectomy for differentiated carcinoma can be "stunned" by tracer doses of 131I greater than 3.0 mCi (111 MBq), which diminishes the uptake and effectiveness of a subsequent therapy dose. Positron emission tomograph, imaging with thallium-201, and Technetium 99m Sestamibi can identify a small number of patients shown to have metastases from differentiated thyroid carcinoma by increasing thyroglobulin levels in the absence of 131I uptake. Several groups have recently advocated treating such patients empirically with 131I.

Adult↗
PubMed2002

Does perifascial rectal excision (i.e. TME) when combined with the autonomic nerve-sparing technique interfere with operative radicality?

OBJECTIVE: The lymphatic drainage from the rectum was studied to evaluate if the autonomic nerve sparing dissection may interfere with the operative radicality and might result in metastatic lymph nodes being overlooked and left in situ. PATIENTS AND METHODS: 50 consecutive patients had an extended extrafascial rectal excision resection for cancer. In 19 of the 50 patients activated carbon particles (CH40) were injected preoperatively into the rectum. The autonomic nerves with surrounding connective tissue were serially dissected from the resected specimen, carefully sliced at 5-mm intervals and collected for histological study. Lymph nodes along the axial and lateral drainage routes were examined, and the inclusion of CH40 in the nodes was microscopically studied according to the site of CH40 injection. RESULTS: Lymph nodes within the connective tissue along the dissected autonomic nerves were demonstrated in 47 of the 50 cases. Two of 50 cases had positive nodes along preaortic plexus or pelvic plexus, and a case with nodal involvement along the pelvic plexus had poor prognosis in spite of nerve excision. CH40 when injected into the rectum above the peritoneal reflection was demonstrated in the vast majority of the axial nodes, while in only one lymph node along the preaortic plexus when injected in the rectum above the peritoneal reflection. On the other hand when injected in the rectum below the peritoneal reflection, CH40 was demonstrated both in axial and lateral nodes as well as in lymph nodes along bilateral pelvic plexuses, right hypogastric nerve, superior hypogastric plexus, preaortic plexus and mesenteric plexus as well. CONCLUSIONS: When located above the peritoneal reflection a rectal carcinoma will spread preferentially along the upper axial route, while a carcinoma located below the peritoneal reflection will also spread laterally and along the autonomic nerves. It was inferred that lymphatic flow along the autonomic nerves came up from the rectum below the peritoneal reflection mainly through a so-called lateral ligament but its clinical significance was negligible. Therefore doing TME with autonomic nerve preservation does not imply a less radical surgery from the point of lymphatic spread.

Journal Article↗