Subcapsular hematoma of the graft after liver transplantation

Subcapsular hematoma of the graft is an underreported complication of liver transplantation (LT). Among 408 LT performed from September 1, 1985, to September 1, 2000, eight patients developed a subcapsular hematoma within 30 days after LT (8/408 = 2.0%). Among the six early cases observed, five required further surgical approaches due to hematoma progression, rupture, and hemorrhage. One patient underwent liver retransplantation due to uncontrollable hepatic hemorrhage. The two more recent cases were successfully treated by early opening of the Glisson's capsule with hemostasis of the hepatic raw bleeding surface. The five patients who developed acute renal failure required dialysis. Three patients died during hospitalization. Among the survivors, two were discharged on the postoperative (PO) day 15; the others on PO day 37, 38, and 56. In conclusion, subcapsular hematoma of the graft is a potentially serious complication of LT that may produce severe hemorrhage, shock, and in extreme cases, graft loss or even death. The severity of the complication is related to the extension of the decapsulated area of the graft. An early surgical approach with intentional opening of the hematoma before progression of the lesion seems to facilitate hemostasis and improve results.

Ionic radiocontrast inhibits endothelium-dependent vasodilation of the canine renal artery in vitro: possible mechanism of renal failure following contrast medium infusion

To determine if radiocontrast impairs vascular relaxation of the renal artery, segments (4-5 mm in length) of canine renal artery were suspended in vitro in organ chambers to measure isometric force (95% O2/5% CO2, at 37 C). Arterial segments with and without endothelium were placed at the optimal point of their length-tension relation and incubated with 10 microM indomethacin to prevent synthesis of endogenous prostanoids. The presence of nonionic radiocontrast (iohexol, Omnipaque 350, 1 ml in 25 ml control solution, 4% (v/v)) did not alter endothelium-dependent relaxation to acetylcholine in rings precontracted with both norepinephrine and prostaglandin F2alpha (N = 6). When the rings were precontracted with prostaglandin F2alpha, the presence of ionic contrast did not inhibit the relaxation of the arteries. However, in canine renal arteries contracted with norepinephrine, the presence of ionic radiocontrast (diatrizoate meglumine and diatrizoate sodium, MD-76, 1 ml in 25 ml control solution, 4% (v/v)) inhibited relaxation in response to acetylcholine, sodium nitroprusside (N = 6 in each group), and isoproterenol (N = 5; P < 0.05). Rings were relaxed less than 50% of norepinephrine contraction. Following removal of the contrast, vascular relaxation in response to the agonists returned to normal. These results indicate that ionic radiocontrast nonspecifically inhibits vasodilation (both cAMP-mediated and cGMP-mediated) of canine renal arteries contracted with norepinephrine. This reversible impairment of vasodilation could inhibit normal renal perfusion and act as a mechanism of renal failure following radiocontrast infusion. In the adopted experimental protocol the isoproterenol-induced relaxation of renal arteries precontracted with norepinephrine was more affected, suggesting a pivotal role of the cAMP system.

Anaglyphic three-dimensional stereoscopic printing: revival of an old method for anatomical and surgical teaching and reporting

The authors describe how to use the three-dimensional (3D) anaglyphic method to produce stereoscopic prints for anatomical and surgical teaching and reports preparation by using currently available nonprofessional photographic and computer methods. As with any other method of producing stereoscopic images, the anaglyphic procedure is based on the superimposition of two slightly different images of the object to be reproduced, one seen more from a left-sided point of view and the other seen more from a right-sided point of view. The pictures are obtained using a single camera, which following the first shot can be slid along a special bar for the second shot, or by using two cameras affixed to a surgical microscope. After the images have been distinguished from each other by applying different complementary color dyes, the images are scanned and superimposed on each other with the aid of nonprofessional imaging-manipulation software used on a standard personal computer (PC), and are printed using a standard printer. To be seen stereoscopically, glasses with colored lenses, normally one red and one blue, have to be used. Stereoscopic 3D anaglyphic prints can be produced using standard photographic and PC equipment; after some training, the prints can be easily reproduced without significant cost and are particularly helpful to disclose the 3D character of anatomical structures.

Intermittent anterograde normothermic blood cardioplegia: experimental study in rabbits

BACKGROUND

We investigated the degree of myocardial protection provided by intermittent anterograde normothermic blood cardioplegia infusion for 60 minutes at 37 degrees C in normal rabbit hearts.

METHODS

Thirty-two New Zealand rabbits were studied and divided into two groups: experimental group and control group. In the experimental group, normothermic blood cardioplegia was infused into the aortic root every 20 minutes over a one-hour period using a two-minute infusion dose. This amounted to an ischemic (unperfused) time of 52 minutes (or 86.6% of the total time). The biochemical investigation was carried out in two phases; Phase I: metabolic study after ischemia with no reperfusion and Phase II: metabolic and functional study after reperfusion. Reperfusion was carried out using a parabiotic perfusion system. Myocardial glycogen and mitochondrial respiration in the ventricular myocardium were established immediately after the end of intermittent cardioplegic solution infusion (Phase I) and after blood reperfusion (Phase II), when left ventricular function (dP/dt max) was also evaluated.

RESULTS

At the end of Phase I, there was a significant decrease in myocardial glycogen levels to 58% compared with the control group. In Phase II, the differences in myocardial glycogen between the experimental and the control group were not significant. Mitochondrial respiration analysis did not show significant differences between the experimental and control groups, either in Phase I or II. In Phase I, dP/dtmax values were 903.39 +/- 113.46 mmHg/sec and 1,043 +/- 256.94 mmHg/sec for the experimental and control group, respectively. These differences were not statistically significant.

CONCLUSIONS

Intermittent anterograde blood cardioplegia infusion every 20 minutes for 60 minutes at 37 degrees C was an effective myocardial protection method in normal rabbit hearts.

Prosthetic repair of incisional hernia in kidney transplant patients. A technique with onlay polypropylene mesh

The employment of synthetic mesh for incisional hernia repair in kidney-transplanted patients is rarely reported in the present literature. Many authors believe that mesh employment in such conditions is not safe due to fear of mesh related complications. From 1965 through 1999, a total of 1685 kidney transplants were performed at our Kidney Transplant Unit and 19 patients developed eventrations in the kidney transplant incision, an incidence of 1.1%. From September 1996 eight of these patients had prosthetic repair of the abdominal wall with onlay polypropylene mesh. All patients were under immunosuppressive therapy with prednisone, ciclosporine and azathioprine. Mean age was 48.8 years, mean body mass index was 22.5 and mean number of previous abdominal operations was 2.5. A large polypropylene mesh (Marlex mesh) was fixed over the aponeurosis after primary closure of the aponeurotic borders, as an onlay graft. There was neither morbidity nor mortality associated to the surgical procedure. No recurrences or long-term complications associated with mesh employment were verified after a follow-up ranging from one year to three years. We concluded that prosthetic repair of incisional hernia in transplanted patients can be performed routinely.

The value of teaching sectional anatomy to improve CT scan interpretation

A specific course on sectional anatomy was developed to help medical students improve their knowledge of cross-sectional imaging. The educational methodology consists of identifying anatomical structures displayed in plastinated sections from human cadavers and corresponding anatomical structures in computed tomography (CT) sections from healthy patients. The course has a self-study format. To assess and verify the impact of learning sectional anatomy on radiological knowledge, students were asked to identify ten anatomical structures in CT images. This test was applied to two groups of students: Group I had been taught sectional anatomy with CT images 2 years before the test; Group II had not received instruction in sectional anatomy prior to the test. Analysis of the results revealed a significant difference in test scores (median percentages of correctly identified structures) between Group I and Group II, with scores of 100% and 63.4%, respectively. These results provide evidence that the inclusion of sectional anatomy training in medical school curricula has a great impact on subsequent CT interpretation.

Differences in tumour growth, tumour cell proliferation and immune function after laparoscopy and laparotomy in an animal model

BACKGROUND

Clinical and experimental studies have shown that laparoscopy preserves the immune response and can give better clinical results than laparotomy. However, the use of laparoscopy for the treatment of cancer patients is still controversial due to the risk of port-site and haematogenous metastases and increased tumour growth. The purpose of this experimental study was to assess tumour growth and the mechanism of differential tumour behaviour after laparoscopy and laparotomy.

METHODS

Seventy-five young, male Wistar rats were randomly assigned to one of two experiments. Experiment 1: 45 animals were inoculated subcutaneously with Walker carcinosarcoma 256 cells and were subdivided into three groups of 15 rats. Control group la was submitted to anaesthesia only, group 1b received carbon dioxide (CO(2)) pneumoperitoneum,while group 1c received a laparotomy. Animals were sacrificed on postoperative day (POD) 7; tumours were excised and weighed to evaluate tumour growth. Nucleolar organiser regions identified by silver staining (AgNORs) were analysed to evaluate cell proliferation. Experiment 2: 30 rats were submitted to the same procedures as before, with ten animals in each group (2a, 2b, 2c), and a delayed-type hypersensitivity response (DTH) was used to evaluate the immune function.

RESULTS

The average tumour mass was 1.76 g in group 1a, 2.81 g in group 1b and 4.21 g in group 1c (p < 0.05). The AgNOR expression results were similar in the three groups. The immune function was better preserved in the control group (2a: average inflammatory area on POD1 = 106 mm(2) and on POD2 = 128.18 mm(2)), than in the pneumoperitoneum group (2b: average inflammatory area on POD1 = 79.75 mm(2) and on POD2 = 126.93 mm(2)); the worst results were in the laparotomy group (2c: average inflammatory area on POD1 = 33.33 mm(2) and on POD2 = 61.32 mm(2)).There were significant differences between groups 2a and 2c and between 2b and 2c.

CONCLUSION

Laparotomy stimulates a greater tumour growth than CO(2) pneumoperitoneum, but there is no difference in tumour cell proliferation. The cellular immune function is better preserved in animals submitted to CO pneumoperitoneum than in the laparotomized animals. These results suggest a relationship between a weaker immune response and a greater tumour growth.

Morphology and diameter of infrarenal aortic aneurysms: a prospective autopsy study

PURPOSE

To determine the diameter and morphology of infrarenal aortic aneurysms in 78 fresh autopsy specimens.

METHODS

To avoid underestimation of the arterial diameter postmortem and to re-establish aneurysm morphology, a device was designed and introduced into the vessel, inflated to 80 mm Hg, and the largest external diameter was measured.

RESULTS

The ages of the individuals ranged from 40 to 97 yr (mean 70). Thirty-eight aneurysms were ruptured with diameters ranging from 5.3 to 17.0 cm (mean 7.97), and 40 aneurysms were nonruptured with variations in diameters from 2.8 to 6.1 cm, mean 4.02 cm (P<0.01). Fusiform aneurysms were more frequent, and when they ruptured their diameters were smaller than the diameters of the spherical aneurysms (P<0.05). Aneurysms ruptured more frequently in the posterior wall (67%) and in the inferior portion (61%). A mural thrombus was found at the site of rupture in 80% of the specimens.

CONCLUSION

In our samples, rupture was found solely in those aneurysms with a diameter over 5.0 cm, ruptures occurred earlier in fusiform aneurysms, mural thrombus was not a protective factor, and finally, aneurysms ruptured mainly in the posterior and inferior portions.

Elective colonic operation and prosthetic repair of incisional hernia: does contamination contraindicate abdominal wall prosthesis use?

BACKGROUND

Wound infection and sepsis leading to incisional hernia development are common after emergency colonic operations. Later on, while being operated on to correct an incisional hernia, most of these patients will need colonic resection or bowel continuity reestablishment. Simultaneous treatment of incisional hernias in patients with colostomy or colonic disease remains a difficult challenge, considering the reluctance of most surgeons to treat both conditions at the same time, especially when prosthetic repair is needed.

STUDY DESIGN

The aim of this study was to analyze the short-term results of patients undergoing colonic resection or bowel continuity reestablishment and simultaneous incisional hernia repair with an onlay polypropylene mesh technique. Over a period of 6 years, 20 patients were operated on for colonic problems associated with incisional hernias, including 8 Hartmanns' colostomies, 6 colostomies or ileostomies with colonic mucous fistulas, 3 postoperative colocutaneous fistulas, a paracolostomic hernia, a Chagas' megacolon, and a pseudotumoral diverticulitis. A "rule of three" statistical analysis was used to estimate the maximum risk of adverse effects, concerning mesh-related morbidity, after 1- and 2-year followup.

RESULTS

A major complication occurred in a patient who developed an anastomotic leakage and secondary wound infection; the patient was treated with parenteral nutrition and antibiotics. Other complications included a minor wound infection, a seroma, and a chronic sinus. One patient died from postoperative problems unrelated to the surgical technique. The occurrence of postoperative wound infection did not prevent mesh incorporation. Followup ranging from 1 to 7 years detected no hernia recurrences; 13 patients were followed for 2 years or more. Our results suggest that risk of mesh-related morbidity does not exceed 15.8% (3 of 19) within the first year and 23.1% (3 of 13) for 2 years followup, with 95% confidence.

CONCLUSIONS

We concluded that prosthetic repair of incisional hernias associated with simultaneous colonic operations was possible, allowing abdominal wall anatomy reestablishment. There is no reason to believe that abdominal wall prostheses must be avoided in contaminated operations when an adequate surgical technique is used.

Comparative study of Mm. Multifidi in lumbar and thoracic spine

Imbalance of Mm. Multifidi may play a role in spinal disorders such as scoliosis in the thoracic spine, and lumbar disc herniation and lower back pain in the lumbar spine. Even though changes in these muscles are related to the etiology of these disorders, their anatomy is still poorly understood, especially in the upper regions of the spine. With the aim of gaining a better understanding of the anatomy of Mm. Multifidi in the lumbar and thoracic spine, 12 fresh and two embalmed cadavers were dissected. Our results indicate that Mm. Multifidi present differences in lumbar and thoracic spines concerning their deepness, fibre trajectory, muscle length, muscle mass and tendinous tissue. In the lumbar spine Mm. Multifidi are a superficial, thick and fleshy mass, and their fibres are more vertical in relation to the spinous processes. In the thoracic spine Mm. Multifidi are deeper, thinner, and their fibres are more tendinous and oblique than in the lumbar spine. These differences have implications on Mm. Multifidi architecture and consequently for their function in these two regions of the spine.

Age-related changes in the elastic fiber network of the human splenic capsule

The structural arrangement of elastic fibers in the splenic capsule from 16 human cadavers ranging in age from 1 month to 76 years was studied by histologic sections stained with selective methods for elastin. In infants the elastic fibers of the splenic capsule were homogeneously intermingled with collagen fibers, an arrangement that stabilizes the capsule during spleen growth and enlargement. With aging, collagen fibers predominate in the outer capsular surface over elastic fibers with the latter more evident in the deep lamina of the splenic capsule. In elderly individuals, the elastic fibers shorten, fragment, and thicken. The progressive decrease in the amount of elastic fibers in the splenic capsule with aging may restrict splenic distention and contribute to involution of the spleen as one grows older.

Variation of infrarenal aortic diameter: A necropsy study

PURPOSE

To determine anatomicomorphological changes in the infrarenal portion of the abdominal aorta, we performed 645 dissections of the segment in corpses undergoing necropsy.

METHODS

The aortas were removed from the corpses with a surgical technique; by means of a device that we designed, the external diameter of the artery was measured after luminal pressure was reestablished. This way, it was possible to avoid underestimation of the arterial diameter postmortem. The influence of age, sex, body size, arterial hypertension, chronic obstructive pulmonary disease, and coronary disease on the aortic diameter and the influence of different degrees of sclerosis on the infrarenal aorta wall were analyzed. Considering the diameters, aortas were regarded as "normal" when they did not present any ectasia, arteriomegaly, aneurysm, or hypoplasia.

RESULTS

The sample involved 645 subjects whose ages ranged from 19 to 97 years (mean age, 55.8 years). Of the 645 subjects, 65.5% (423) were men, 34.5% (222) were women, 81% (523) were white, and 19% (122) were of another race. The diameters of arteries showing no anomalous dilatation (ectasis, arteriomegaly, or aneurysm) varied according to subject age, sex, body length, and the degree of atherosclerosis on the aorta wall (P <.01). Aortic diameters of those subjects with arterial hypertension, coronary disease, and chronic obstructive pulmonary disease were compared with the aortic diameters of control subjects, and significant differences were not shown (P >.05). Twenty-nine aneurysms were found (4.5% prevalence). Four were ruptured aneurysms, and all occurred in aortas with diameters larger than 5.0 cm.

CONCLUSION

The infrarenal aortic diameter enlarges with aging, and this enlargement occurs earlier in men than in women. Those subjects who had a longer body length and advanced sclerosis on the aorta wall had larger aortic diameters. There was a high prevalence of infrarenal aneurysms (4.5%), with rupture found solely in aortas with diameters larger than 5.0 cm.

The effects of prenatal intraamniotic surfactant or dexamethasone administration on lung development are comparable to changes induced by tracheal ligation in an animal model of congenital diaphragmatic hernia: studies of lung glycogen content, elastic fiber density, and collagen content

BACKGROUND/PURPOSE

A new noninvasive therapeutic strategy, which consisted of prenatal intraamniotic administration of porcine surfactant or dexamethasone, was previously used to prevent the functional and structural immaturity of lungs associated with congenital diaphragmatic hernia (CDH), and its effects on lung development were comparable with the changes induced by tracheal ligation (TL). The purpose of this study is to verify if this novel therapeutic modality has any effect in the elevated concentration of lung glycogen and altered contents of lung elastic fiber and collagen promoted by CDH.

METHODS

A pilot study was performed to investigate in the rabbit model if the infused drugs in the amniotic cavity were aspirated by the CDH and non-CDH fetuses, and if there was correspondence between lung immaturity and high glycogen concentration in lung tissue. Experimental groups consisted of 50 pregnant rabbits that underwent surgery on gestational day 24 or 25 to create left-sided diaphragmatic hernias in 56 fetuses, which were divided in groups according to the procedures: CDH (n = 12), CDH plus TL (n = 16), CDH plus intraamniotic administration of Curosurf (40 mg, n = 12), and CDH plus intraamniotic administration of dexamethasone (n = 16). On gestational day 30, the fetuses were delivered by cesarean section, and 28 normal unoperated fetuses served as controls. The lungs were weighed and submitted to biochemical determination of glycogen, morphometric evaluation of elastic fibers, and colorimetric analysis of collagen.

RESULTS

In all CDH and non-CDH fetuses of the pilot study, the amniotic content was massively aspirated into the lungs and trachea. There was an increase in lung glycogen content of fetuses at 24 days' gestation in comparison with 20-day gestational age fetuses, followed by a decrease in the near full-term fetuses. In the fetuses of the experimental groups, CDH decreased the lung weight to body weight ratios of lungs ipsilateral to the hernia. These changes were reversed by TL but not by intraamniotic administration of surfactant or dexamethasone. Lung glycogen concentrations in the lungs of CDH fetuses were significantly higher than those in the control group. These changes were reversed by intraamniotic administration of surfactant but not by dexamethasone administration or TL. In the lungs ipsilateral to the hernia, surfactant administration promoted a significant decrease in glycogen content to levels lower than control lungs. CDH promoted a decrease in the linear density of elastic fibers in both lungs, ipsilateral and contralateral to the hernia. This alteration was partially corrected by TL and surfactant administration, although dexamethasone administration had no effect. The concentrations of collagen in both lungs were increased significantly by CDH, and these alterations could not be reversed by TL. In the lungs ipsilateral to the hernia, intraamniotic administration of surfactant or dexamethasone promoted a significant decrease in the lung concentration of collagen but not to control levels.

CONCLUSIONS

The positive effects of intraamniotic surfactant or dexamethasone administration on lung maturity of fetuses with CDH were observed. This therapy may be a substitute for TL.

The effects of prenatal intraamniotic surfactant or dexamethasone administration on lung development are comparable to changes induced by tracheal ligation in an animal model of congenital diaphragmatic hernia

BACKGROUND/PURPOSE

Lung surfactant deficiency contributes to the pathophysiology of congenital diaphragmatic hernia (CDH) and the high neonatal mortality rate. Acceleration of lung surfactant system maturation by prenatal administration of hormones has been described in animal models of CDH. However, in utero tracheal ligation (TL) is the best method to accelerate lung growth and reverse the pulmonary hypoplasia associated with CDH. Although this method offers promise, its application in humans is limited. The aim of this study was to investigate a new noninvasive therapeutic strategy, that is, the prenatal intraamniotic administration of exogenous porcine surfactant or dexamethasone, and compare it with the effects of TL in an animal model of CDH.

METHODS

Twenty-four pregnant New Zealand rabbits underwent surgery on gestational day 24 or 25 to create CDH in 26 fetuses. Five groups of animals were studied: (1) Control, nonoperated fetuses (n=14), (2) CDH (n=6), (3) CDH plus TL (n 6), (4) CDH plus intraamniotic administration of Curosurf (40 mg; n=6), and (5) CDH plus intraamniotic infusion of dexamethasone (0.4 mg; n=8). On gestational day 30, the fetuses were delivered by cesarean section. Functional studies (lung hysteresis curves and lung distensibility), weight and volume of lungs, histopathologic and histomorphometric analysis of lungs were performed.

RESULTS

The authors demonstrated that the hysteresis curve of CDH animals was shifted downward in comparison with controls. The analyses of curves standardized for lung weight indicated that intraamniotic administration of surfactant or dexamethasone improved lung compliance in comparison with controls and CDH fetuses, but TL had no effect on this parameter. Lung distensibility (maximum lung volume at 32 cm of water pressure per gram of lung) was reduced by CDH, but this parameter was increased by intraamniotic administration of drugs and not by TL (P< .05). CDH decreased the weight and volume of lungs (P< .05), and these changes were reversed only by TL, which prevented the herniation of the liver from the abdomen to the thorax. Histologically, CDH lungs treated with TL or intraamniotic administration of drugs demonstrated structural patterns similar to those of controls. Histomorphometric studies proved that CDH promoted significant thickening of septa walls (P< .05), and all the therapeutic methods could reverse this alteration to control values. The alveolar number per area in control lungs, CDH, and CDH plus TL lungs were similar, but in CDH plus surfactant and CDH plus dexamethasone lungs, the decreased number per area (P< .05) demonstrated that the alveolar airspace was increased.

CONCLUSION

From these data the authors conclude that intraamniotic surfactant or dexamethasone administration is capable of preventing pulmonary hypoplasia in fetuses with CDH, and thus, this method may be a substitute for TL.

Transabdominal or totally extraperitoneal laparoscopic hernia repair?

Laparoscopic repair of inguinal hernias follows some principles that have already proven its efficiency, as a posterior approach and the prosthetic repair that allows a "tension-free" repair with consequent early return to work and low recurrence rate. To determine the most appropriate laparoscopic repair, we compared the transabdominal preperitoneal (TAPP) and the totally extraperitoneal (TEP) approach. Patients undergoing TAPP and TEP were compared regarding technical feasibility and difficulties, time until return to work and follow-up, including intraoperative and postoperative complications. Seventy-eight patients (108 hernias) were submitted to TAPP and 67 (100 hernias) were repaired through TEP. All data were analyzed by Yates-corrected chi-square test to qualitative analysis of each group and p < or = 0.05 was considered significant. Both procedures were indicated mainly for bilateral and/or recurrent hernias (68%). The operative time was shorter in TAPP (not statistically significant). Surgeons complained of more technical difficulties while performing the TEP approach (70% complaints of difficulty in TEP--four conversions to TAPP). There was no difference in hospital stay (mean of 30 h) and return to work (TAPP 7 days and TEP 5.5 days). Regarding the complication rate (TAPP = 20.5% and TEP = 13.5%; not significant), none were related to the pneumoperitoneum technique or its systemic effects. In the TAPP approach, two trocar site hernias occurred, and in the TEP approach, one severe cellulitis occurred, which was managed without surgical intervention. The mean follow-up period for each procedure was not the same, so the recurrence rates are not comparable statistically (rate of 1.85% in TAPP and 0 in TEP). Both techniques are safe and have the same advantages, but TAPP is easier: a better view of the anatomy is achieved, shortening the learning curve. We suggest that TAPP can be an adequate laparoscopic approach to groin hernias. A longer follow-up period and more cases are needed to determine recurrence rates.

Laparoscopic extraperitoneal repair of inguinal hernias

The world of surgical laparoscopy is evolving. Laparoscopic prosthetic inguinal hernia repair is gaining rapid and wide acceptance. This experience consisted of 144 hernia repairs in 105 patients (40 bilateral, 31 recurrent, and 33 unilateral nonrecurrent hernias), treated through an extraperitoneal laparoscopic repair. When compared with transabdominal repair, operative time and postoperative recovery were similar, with some advantages related to the avoidance of intraabdominal manipulation and potential related complications. In spite of a relatively short follow-up (up to 40 months), there were no recurrences in this series. Morbidity rate was acceptable (16.1%), mainly reported as minor complications. Anatomical and technical skills to perform the operation are required and achieved through training. Extraperitoneal hernia repair with synthetic mesh is safe and feasible, with the advantages of being associated with less pain, rapid return to full activities, and the already proven milder systemic responses following interventional laparoscopy.

Cardiac tamponade: an unusual complication of pericardial cyst

Pericardial cysts are not common and rarely cause symptoms. We report a unique case of a 15-year-old male patient with cardiac tamponade clinically diagnosed who was referred for echocardiography. Transthoracic echocardiography revealed, in addition to a large pericardial effusion associated with echocardiographic signs of cardiac tamponade, an 8 x 5 cm echofree image suggesting a pericardial cyst adjacent to the right atrium. Immediately after pericardiocentesis, yielding a serosanguinous liquid, the patient showed striking clinical improvement and echocardiography demonstrated minimal pericardial effusion with persistence of the cystic image. At surgery a pericardial cyst containing a sanguinous fluid was found and the pathologic findings were consistent with hematic pericardial cyst. Thus echocardiography played a fundamental role for the diagnosis and treatment of the rare complication of a pericardial cyst documented in this patient.

Renal gammagraphy with 99mTc-phosphomycin

99mTc-Phosphomycin, a new radiopharmaceutical for kidney visualization, was used for animal experiments and tests of 171 patients. The results confirmed the usefulness of this product. The ease and yield of the labelling procedure, the low cost of the product, the excellent quality of the images and the functional information obtained showed that the use of 99mTc-phosphomycin as a radiopharmaceutical for kidney visualization has many advantages.

A nervous connection between the hepatic plexus and right atrium in man

The authors studied 43 necropsy specimens from adult individuals by dissection under a stereomicroscope and by staining methods (Cajal-De Castro and Palmgren silver impregnations, Kl uver Barrera and Pal-Weigert for the myelinated fibers, and Van Gieson and Azan trichromic methods). They suggest the presence of a direct nervous connection between the hepatic plexus (celiac plexus) and the right atrium via the left branches of the hepatic artery and portal vein, venous ligament, left hepatic vein, and V. cava inferior, passing through the foramen for the V. cava. This connection is made by very fine nerves from the upper part of the venous ligament until the left atrium, which generally are only visible on the microscopic level.

Ultrastuctural study on the relations among nerve elements and ependymal cells of the "Bradypus tridactylus"

On hand of the electonmicroscope, the authors study 24 parts of the encephalic ventricles in samples of Bradypus tridactylus, relating the nervous structures to the ependymal lining, chiefly emphasizing the presence of intraventricular unmyelinated fibres. In various of these regions, typical nerve fibres and other intraventricular cell projections, that cannot be taken as nerve structures, because of the continuity they show along with ependymal cells, were observed. Finally they make an analysis of some functions related to arrangements of this nature.