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PubMed1996

Male and female sexual and urinary function after total mesorectal excision with autonomic nerve preservation for carcinoma of the rectum.

BACKGROUND: We performed a study to assess sexual and urinary function after total mesorectal excision with autonomic nerve preservation for primary carcinoma of the rectum. STUDY DESIGN: We studied retrospectively postoperative sexual and urinary function in 136 (78 percent) of 175 eligible patients (82 males and 54 females) who responded to a standardized questionnaire. RESULTS: The ability to engage in intercourse was maintained by 86 percent of the patients younger than 60 years of age, and by 67 percent of patients 60 years and older. Eighty-seven percent of male patients maintained their ability to achieve orgasm. The type of surgery (abdominoperineal resection compared to low anterior resection), and age equal to or greater than 60 years were significantly associated with male sexual dysfunction. Of the female patients, 85 percent were able to experience arousal with vaginal lubrication and 91 percent could achieve orgasm. The majority of patients had few or no complaints related to urinary function. Serious urinary dysfunction such as neurogenic bladder was not encountered. CONCLUSIONS: Autonomic nerve preservation in association with total mesorectal excision reduces the operative morbidity rate and is successful in minimizing sexual and urinary dysfunction in the operative treatment of patients with carcinoma of the rectum.

Adult↗
PubMed2006

Use of BIS monitor in a child with congenital insensitivity to pain with anhidrosis.

We describe a case of a 14-year-old boy with congenital insensitivity to pain and anhidrosis (CIPA) who underwent tarsal tunnel release for tarsal tunnel syndrome. Because of abnormal pain perception, the patient's response to normally painful surgical stimuli is severely impaired and not adequately reflected in a corresponding rise in blood pressure or heart rate. This lack of autonomic feedback to pain stimuli may make it more difficult to assess whether anesthetic depth is adequate to prevent intraoperative awareness and thus to safely conduct anesthesia, especially if muscle paralysis is required for surgical indications. We describe for the first time the use of processed EEG monitoring with a BIS A-2000 monitor to gauge anesthetic depth in a patient with CIPA. Initial forehead bispectral index (BIS) values prior to induction were normal (98) and then ranged between 23 and 79 during the whole surgical procedure. Propofol and lidocaine were used for induction and deep extubation; isoflurane was used as the sole anesthetic for maintenance with concentrations ranging from 0.21% to 0.92% to maintain a target BIS of 40-60. Volatile anesthetic requirements remained low throughout the procedure and no narcotics were necessary during surgery. The BIS monitor served as an adequate tool to help avoid excessive use of volatile anesthetic while assuring a processed EEG consistent with unconsciousness and amnesia. After the patient had recovered and was oriented to place and time in the recovery room, he was asked whether he remembered anything about the surgery and the presence of a breathing tube in his mouth. He denied any recall of such events.

Adolescent↗
PubMed1999

[Surgery for hyperthyroidism].

The concept of therapy for hyperthyroidism combines endocrinology, nuclear medicine and surgery. For selection of the treatment of choice, pathophysiology as well as individual aspects are considered. Surgical therapy is mainly concerned with treatment of functional autonomy, Grave's disease and iodine-excess-related hyperthyroidism based on either autonomous or Grave's disease. For each of these three main groups of hyperthyroidism exist differentiated surgical concepts based on the underlying thyroid disease and its course: The various forms of functional autonomy, solitary autonomous nodules, multifocal autonomy or disseminated autonomy are dealt with selective enucleation-resection, functionally and morphologically oriented resection and extensive resection with little remaining thyroid tissue of about 5-6 ml, respectively. For Grave's disease extensive resections with thyroid-tissue remainders of about 2-4 ml or tatal thyroidectomy are established; the latter demonstrating in cases of concomittant endocrine ophthalmopathy the most convincing results. In cases of iodine-related hyperthyroidism the concept of early and radical surgical treatment, following stabilization of the patient in a reasonably short amount of time shows best results and is thus favored. In these cases, contrary to all other forms of hyperthyroidism, establishment of preoperative euthyroid metabolism is not mandatory.

Humans↗
PubMed2001

Criteria for extramural perineural invasion as a prognostic factor in rectal cancer.

BACKGROUND: An abundant extramural autonomic nerve network is an anatomical feature of the rectum. Extramural perineural invasion (PNI) may influence the prognosis after resection of rectal cancer, however, few assessment criteria exist. METHODS: PNI was investigated in 364 patients who underwent curative surgery for rectal cancer penetrating the muscular layer. A grading system was established based on the 'intensity' (number of PNI foci in a 20-power field) and 'depth' (distance from the muscularis propria) of PNI. PNI-0 was defined as without PNI, PNI-1 as 'intensity' of less than five foci and 'depth' less than 10 mm, and PNI-2 as five or more foci or 10 mm or greater 'depth' of invasion. RESULTS: PNI was observed in 52 patients (14 per cent) and strongly correlated with pathological tumour node metastasis (pTNM) stage. Five-year survival was related to PNI grade (74 per cent in PNI-0, 50 per cent in PNI-1 and 22 per cent in PNI-2). The rate of local recurrence was also related to PNI stage: 43 per cent in PNI-2 and 9 per cent in both PNI-0 and PNI-1. Multivariate analyses showed that graded PNI was associated both with local recurrence and long-term survival, independent of tumour depth (pTNM T) and nodal involvement (pTNM N). CONCLUSION: The PNI grading system may be useful in prognosis and allow case selection for intensive postoperative adjuvant therapy.

Adult↗
PubMed1998

The ligamento-muscular stabilizing system of the spine.

STUDY DESIGN: Electrical and mechanical stimulation of the lumbar supraspinous ligament of three patients with L4-L5 spinal deficits and of the feline model, respectively, was applied while recording electromyography on the multifidus muscles. OBJECTIVES: To determine if mechanoreceptors in the human spine can reflexively recruit muscle force to stabilize the lumbar spine, and to demonstrate, in the feline model, that such ligamento-muscular synergy is elicited by mechanical deformation of the lumbar supraspinous ligament (and possibly of other spinal ligaments), the facet joint capsule, and the disc. SUMMARY OF BACKGROUND DATA: The literature repeatedly confirms that ligaments have only a minor mechanical role in maintaining spine stability, and that muscular co-contraction of anterior and posterior muscles is the major stabilizing mechanism of the spine. The literature also points out that various sensory receptors are present in spinal ligaments, and that the ligaments are innervated by spinal and autonomic nerves. Data that describe how ligaments and muscles interact to provide stability to the spine were not found. METHODS: The supraspinous ligament at L2-L3 and L3-L4 was electrically stimulated in three patients undergoing surgery to correct deficits at L4-L5. Electromyography was performed from the multifidus muscles at L2-L3 and L3-L4, bilaterally. In 12 cats, the supraspinous ligaments from L1-L2 to L6-L7 were mechanically deformed, sequentially, while electromyography was performed from the multifidus muscles of the six levels. Loading of the ligament was applied before and after each of the two vertebrae were externally fixed to prevent motion. RESULTS: Electromyograms were recorded from the multifidus muscles, bilaterally, in the two of the three patients, demonstrating a direct relationship to receptors in the supraspinous ligament. Electromyograms were recorded from the feline multifidus muscle with mechanical loading of the supraspinal ligament at each of the L1-L2 to L6-L7 motion segments. In the free-spine condition the largest electromyographic discharge was present in the level of ligament deformation, and lower electromyographic discharge was recorded in two rostral and caudal segments. After immobilizing any two vertebrae, loading of the ligament resulted in electromyographic discharge in the muscles of the same level and at least one level above and/or below. CONCLUSIONS: Deformation or stress in the supraspinous ligament, and possibly in other spinal ligaments, recruits multifidus muscle force to stiffen one to three lumbar motion segments and prevent instability. Strong muscular activity is seen when loads that can cause permanent damage to the ligament are applied, indicating that spastic muscle activity and possibly pain can be caused by ligament overloading.

Animals↗
PubMed2004

Minimizing the risk of neurologic injury in gynecologic surgery.

OBJECTIVE: The association of intraoperative neurologic injuries with gynecologic surgical procedures is well established. The sequelae of such injuries are usually transient and resolve with minimal intervention, although long-term disability can and does occasionally occur. The purpose of this study was to examine the mechanisms by which these injuries occur in order to reduce the risk of their occurrence. DATA SOURCES: A MEDLINE search was performed cross-referencing the index terms "neurological injury" and "gynecological surgery," from January 1, 1960 to December 31, 2002. METHODS OF STUDY SELECTION: This article, based on the data and results (Level I-III) obtained from the MEDLINE search, examined the most common neurologic injuries that occur in association with abdominal and vaginal surgical procedures routinely performed by gynecologists. TABULATION, INTEGRATION, AND RESULTS: Neurologic injuries after pelvic surgery all generally share a common etiology, specifically injury to one or more components of the lumbosacral nerve plexus. Three major factors that predispose to neurologic injury at the time of gynecological surgery are 1) the improper placement or positioning of self-retaining or fixed retractors, particularly those with deep lateral retractor blades; 2) improper positioning of patients in lithotomy position preoperatively; and 3) radical surgical dissection resulting in autonomic nerve disruption. Level I data strongly implicate the improper placement of self-retaining or fixed retractors as the most common cause of femoral nerve injury arising in association with abdominal surgical procedures. CONCLUSION: A thorough understanding of the anatomy of the lumbosacral nerve plexus and the mechanisms by which operative injuries to this plexus occur will enable the gynecologic surgeon to reduce the subsequent risk of their occurrence in his or her own surgical practice.

Female↗
PubMed2005

Anatomical basis for nerve-sparing radical hysterectomy: immunohistochemical study of the pelvic autonomic nerves.

BACKGROUND: Autonomic nerve damage plays a crucial role in the etiology of bladder dysfunction, sexual dysfunction, and colorectal motility disorders that occur after radical hysterectomy. We investigated the extent and nature of nerve damage in conventional and nerve-sparing radical hysterectomy. METHODS: Macroscopical disruption of nerves was assessed through anatomical dissection after conventional and nerve-sparing surgery on five fixed and one fresh cadaver. Immunohistochemical analysis of surgical margins was performed to confirm nerve damage using a general nerve marker (S100) and a sympathetic nerve marker (anti-tyrosine hydroxylase) within sections of biopsies. RESULTS: Macroscopical dissection showed that in the conventional procedure, transsection of the uterosacral ligaments resulted in disruption of the major part of the hypogastric nerve. After nerve-sparing surgery, only the medial branches of the hypogastric nerve appeared disrupted. Division of the cardinal ligaments in the conventional procedure identified the inferior hypogastric plexus running into the most posterior border of the surgical margin. The anterior part of the plexus was disrupted. Dissection of the nerves after the nerve-sparing procedure showed that this anterior part of the plexus was not involved in the surgical dissection line. Dissection of the vesicouterine ligament disrupted only small nerves on the medial border of the inferior hypogastric plexus in both techniques. Microscopical evaluation of the surgical margins confirmed the macroscopical findings. CONCLUSION: Conventional radical hysterectomy results in disruption of a substantial part of the pelvic autonomic nerves. The nerve-sparing modification leads to macroscopic reduction in nerve disruption which is substantiated by microscopical evaluation of surgical margins.

Antibodies, Monoclonal↗
PubMed1990

Association between cardiovascular reactivity to stress and hypertension or behavior.

The spontaneously hypertensive rat (SHR) exhibits increased cardiovascular reactivity (CVR) to environmental stress and behavioral hyperactivity relative to the Wistar-Kyoto rat (WKY). This study sought to determine whether enhanced CVR to stress in the SHR is related to hypertension or to behavioral hyperactivity. By breeding SHR with WKY, followed by inbreeding, E. D. Hendley has developed two strains in which the hypertensive trait seems to be separated from the hyperactivity trait: the Wistar-Kyoto hypertensive (WK-HT) and the Wistar-Kyoto hyperactive (WK-HA) strains. Male SHR, WKY, WK-HT, and WK-HA rats were implanted with intravascular catheters and Doppler flow-velocity probes to record arterial pressure, heart rate (HR), and changes in regional vascular resistances. Five days after surgery, the rats were subjected to air-jet stress and pharmacological interventions. The hyperactive strains (SHR and WK-HA) exhibited enhanced pressor, renal, and mesenteric responses to stress, and higher HRs under all conditions, even after autonomic blockade. Both hypertension and hyperactivity were associated with reduced baroreceptor sensitivity. These data indicate that CVR to stress is related to behavioral traits.

Adrenergic beta-Antagonists↗
PubMed2005

[Multiple brown tumours in a patient with tertiary hyperparathyroidism].

We describe the case of a 49-year-old female with chronic renal failure and secondary hyperparathyroidism that not dissapeared after kidney transplant and turned into an autonomous form (tertiary hyperparathyroidism). The xRays and CT showed the presence of multiple brown tumors in iliac bones and tibia. We performed a parathyroidectomy removing a lower left adenoma confirmed in the histological exam the renal. After the surgery the osteoarticular manifestations improved and lithiasis dissapeared. There were not any postoperative complications such as hypocalcemia or recurrential palsy although Nephrology Department had to control her renal function.

Female↗
PubMed1981

[Teaching of microsurgery].

Referring to his personal experience, the author points out the possibilities of applying microsurgery, which confers an autonomous dignity to this medical branch. Therefore, it is to hope that a didactic and specialistic recognition of microsurgery will determine the formation of specifically trained teams. Lastly, the versatility of microsurgery as applied to modern biliary ducts surgery has been underlined, both for derivative and reparative interventions.

Animals↗
PubMed1976

[Anticholinergic treatment of Parkinson's disease (author's transl)].

Anticholinergic drugs retain their place even today in the treatment of Parkinson's disease in spite of the considerable success achieved by means of stereotactic surgery and substitution therapy with dopa or dopa derivatives. An investigation was made on 44 patients suffering from Parkinson's disease treated with the new anticholinergic drug, Sormodren (Knoll). Sormodren showed a selective action on the hyperkinetic and autonomic symptoms of this disease of the extrapyramidal system. Tolerance was good, no serious side effects being observed.

Adult↗
PubMed1999

Feedback regulation of thyrotropin-releasing hormone gene expression by thyroid hormone in the caudal raphe nuclei in rats.

Medullary TRH regulates autonomic activity, and altered thyroid status is associated with autonomic disorders. We investigated whether thyroid hormone exerts a negative feedback regulation on TRH gene expression in the medullary caudal raphe nuclei. Medullary pro-TRH messenger RNAs (mRNAs) were mainly located in the raphe pallidus and raphe obscurus neurons as shown by in situ hybridization and were significantly increased by 70% and 160-230% by Northern blot analyses in 24 h fasted rats at 1 and 3-5 weeks after thyroidectomy, respectively, when serum T4 levels were reduced by 75-87%. The increased pro-TRH mRNA on the 30th day after thyroidectomy was reversed to euthyroid levels by T4 replacement (2 or 4 microg/100 g x day). T4 injections (10 or 100 microg/100 g x day for 30 days) did not significantly influence medullary pro-TRH mRNA levels in sham-operated rats. Thyroidectomized rats fed normally showed a 500% increase in pro-TRH mRNA levels 30 days after the surgery, while those fasted for 24 h showed only a 180% increase. These data indicate that medullary TRH gene expression is enhanced during hypothyroidism due to the lack of negative feedback regulation by thyroid hormone, and this response is modulated by feeding state. These findings may have important relevance to understanding autonomic-related visceral alterations induced by hypothyroidism.

Animals↗
PubMed1994

A comparison of pipecuronium with pancuronium on haemodynamic variables and plasma catecholamines in coronary artery bypass patients.

Pipecuronium bromide, a new neuromuscular relaxant with steroidal structure, is devoid of effects on the autonomic nervous system and may be useful in patients where haemodynamic stability is mandatory. However, tracheal intubation may alter this haemodynamic profile. Therefore, we carried out a prospective double-blind study in 30 patients undergoing coronary artery bypass surgery with the purpose (1) of determining if intubation influenced the haemodynamic stability in patients paralyzed with pipecuronium and (2) of comparing plasma catecholamine concentrations after pipecuronium with those after pancuronium. Thirty patients were randomized into two groups receiving either pipecuronium 100 micrograms.kg-1 or pancuronium 150 micrograms.kg-1 after induction of anaesthesia with midazolam and fentanyl. Haemodynamic variables and plasma catecholamines were measured before and after induction, after the muscle relaxant three times and twice after intubation. After anaesthesia induction decreases in heart rate (HR), mean arterial pressure (MAP) and cardiac index (CI) were observed in both groups. These haemodynamic variables were unchanged after pipecuronium whereas after pancuronium HR increased from 53 +/- 11 b.min-1 to 64 +/- 9 b.min-1 after induction (P < 0.05) and CI from 2.5 +/- 0.5 L.min-1 to 3.0 +/- 0.8 L.min-1 (P < 0.05). Furthermore ECG signs of myocardial ischaemia appeared in four patients after pancuronium and the decay of plasma norepinephrine concentration was slower than with pipecuronium. We conclude that pipecuronium given after induction of anaesthesia is free of sympathomimetic or vagolytic activity and does not influence haemodynamic variables for up to ten minutes after tracheal intubation.

Anesthesia, Intravenous↗
PubMed1998

Ultrasound-guided percutaneous ethanol injection in the treatment of autonomous thyroid nodules--a review.

Percutaneous ethanol injection therapy (PEIT) in patients with autonomously functioning thyroid nodules (AFTN) has been evaluated with respect to indication for PEIT, treatment procedure, results of therapy and side effects of this treatment. As PEIT has not been tested against the standard procedure of radioiodine treatment and surgery up to now, PEIT should be an alternative treatment for selected patients who cannot or will not be treated by radioiodine therapy or surgery. The clinical data available demonstrate that better results are obtained in patients with euthyroid AFTN or AFTN with subclinical hyperthyroidism as compared to patients with AFTN and overt hyperthyroidism, particularly in small thyroid nodules (thyroid nodular volume less than 15 ml). After PEIT significant reduction of thyroid nodular volume can be achieved (reduction 21 to 88 %). Adverse events of PEIT are few and usually mild and with special respect to transient dysphonia, strongly correlated with the technical skills of the operator. Limitations of PEIT are mainly the need of repeat ethanol injections in order to achieve a complete cure of AFTN. In conclusion, a prospective controlled randomized clinical study has to be carried out in patients with AFTN in order to define the role of PEIT in comparison to the standard therapies (radioiodine treatment, surgery), in the treatment of patients with AFTN conclusively.

Adenoma↗
PubMed1987

Renal response to volume expansion in heart-transplant and kidney-transplant recipients.

The renal excretion of an intravenous sodium load by ten heart-transplant recipients with (five patients) or without (five patients) moderate renal failure was compared with the results obtained in two matched control groups of ten kidney-transplant recipients with similar renal function. All patients were treated with prednisone and cyclosporine except, for the latter treatment, the kidney-transplant recipients without renal failure. A supplementary control group of five healthy subjects who did not receive any treatment was also included in the study. Fractional sodium and osmolal clearances were greater in heart-transplant than in kidney-transplant recipients for both the patients with and the patients without renal failure. These two parameters were also greater in heart-transplant recipients without renal failure than in healthy subjects. Free water clearance was smaller in the heart-transplant recipients than in the corresponding control patients. Fractional potassium clearance was not different from group to group. These results demonstrate that heart-transplant recipients excrete a greater fraction of the filtered sodium load than their controls. This increased fractional excretion of sodium cannot be attributed to the cyclosporine treatment or the moderate chronic renal failure which both have been taken into account in the comparisons. The unchanged blood pressure during the saline load and the high or normal plasma renin activity levels in the heart-transplant recipients make it also unlikely that the exaggerated natriuresis was the consequence of the higher blood pressure observed in these patients. The chronic cardiac denervation which is the consequence of surgery in these patients could play a role in the mechanism of the saline diuresis.

Adult↗