Preoperative progressive pneumoperitoneum (PPP) is a safe and effective procedure in the treatment of large incisional hernia (size > 10 cm in width or length) with loss of domain (LIHLD). There is no consensus in the literature on the amount of gas that must be insufflated in a PPP program or even how long it should be maintained. We describe a technique for calculating the hernia sac volume (HSV) and abdominal cavity volume (ACV) based on abdominal computerized tomography (ACT) scanning that eliminates the need for subjective criteria for inclusion in a PPP program and shows the amount of gas that must be insufflated into the abdominal cavity in the PPP program. Our technique is indicated for all patients with large or recurrent incisional hernias evaluated by a senior surgeon with suspected LIHLD. We reviewed our experience from 2001 to 2008 of 23 consecutive hernia surgical procedures of LIHLD undergoing preoperative evaluation with CT scanning and PPP. An ACT was required in all patients with suspected LIHLD in order to determine HSV and ACV. The PPP was performed only if the volume ratio HSV/ACV (VR = HSV/ACV) was>or=25% (VR >or= 25%). We have performed this procedure on 23 patients, with a mean age of 55.6 years (range 31-83). There were 16 women and 7 men with an average age of 55.6 years (range 31-83), and a mean BMI of 38.5 kg/m(2) (range 23-55.2). Almost all patients (21 of 23 patients-91.30%) were overweight; 43.5% (10 patients) were severely obese (obese class III). The mean calculated volumes for ACV and HSV were 9,410 ml (range 6,060-19,230 ml) and 4,500 ml (range 1,850-6,600 ml), respectively. The PPP is performed by permanent catheter placed in a minor surgical procedure. The total amount of CO(2) insufflated ranged from 2,000 to 7,000 ml (mean 4,000 ml). Patients required a mean of 10 PPP sessions (range 4-18) to achieve the desired volume of gas (that is the same volume that was calculated for the hernia sac). Since PPP sessions were performed once a day, 4-18 days were needed for preoperative preparation with PPP. The mean VR was 36% (ranged from 26 to 73%). We conclude that ACT provides objective data for volume calculation of both hernia sac and abdominal cavity and also for estimation of the volume of gas that should be insufflated into the abdominal cavity in PPP.

Azul de metileno no tratamento da síndrome vasoplégica em cirurgia cardíaca. Quinze anos de perguntas, respostas, dúvidas e certezasMethylene blue for vasoplegic syndrome treatment in heart surgery. Fifteen years of questions, answers, doubts and certainties AbstractObjective: There is strong evidence that methylene blue (MB), an inhibitor of guanylate cyclase, is an excellent therapeutic option for vasoplegic syndrome (VS) treatment in heart surgery. The aim of this article is to review the MB's therapeutic function in the vasoplegic syndrome treatment.Methods: Fifteen years of literature review.Results: 1) Heparin and ACE inhibitors are risk factors; 2) In the recommended doses it is safe (the lethal dose is 40 mg/ kg); 3) The use of MB does not cause endothelial dysfunction; 4) The MB effect appears in cases of nitric oxide (NO) upregulation; 5) MB is not a vasoconstrictor, by blocking of the GMPc system it releases the AMPc system, facilitating the norepinephrine vasoconstrictor effect; 6) The most used dosage is 2 mg/kg as IV bolus followed by the same continuous infusion because plasmatic concentrations strongly decays in the first 40 minutes; 7) There is a possible "window of opportunity" for the MB's effectiveness.Conclusions: Although there are no definitive multicentric studies, the MB used to treat heart surgery VS, at the present time, is the best, safest and cheapest option, being a Brazilian contribution for the heart surgery.

Age-related changes of muscle fiber and collagen content of the diaphragm (DIA) and rectus abdominis (RA) muscles were examined in rats aged 1, 4, 8 and 18 months. The cross-sectional areas of all muscle fiber types (I, IIa, IIb) and the amount of collagen in both DIA and RA increased up to the age of 8 months after which a decrease in growth following a parabolic curve was found. The older DIA showed an increase in the percentage of type I fibers while in RA there was a high percentage of type IIb fibers. The aged DIA became more resistant to fatigue but at the expense of slow contraction while older RA is faster and stronger. Aged DIA and RA muscles showed a low amount of collagen with great concentration of cross-linkings leading to a tissue with low viscoelastic properties and reduced compliance.

It is well known that anesthesia and certain surgeries predispose patients to changes in respiratory function, pulmonary volumes, and gas exchange. Cardiac surgery, which is considered a major surgery, may trigger respiratory complications in the postoperative period. These complications have various causes, such as heart and lung functions in the pre-operative, the use of cardiopulmonary bypass (CPB), and the level of sedation. In these extensive thoracic procedures, respiratory dysfunction may be significant, persisting in the postoperative period. Physiotherapy is offered to patients in the ICU as part of a multidisciplinary treatment plan. It is a time-consuming treatment, and is possible at various times during the patient's stay in the ICU. However, it is particularly valuable in postoperative recovery in order to avoid respiratory and motor complications. Thus, a literature review was performed, aiming to arrange current and relevant information on available resources for respiratory monitoring, as well as its importance in evaluating and treating lung function impairment, as this complication is a frequent cause of death in surgical patients. Bras Cir Cardiovasc 2008; 23(3): 400-410 For acquisition data in this study, scientific articles and an electronic research strategy was used for bibliographic reviews, mainly aiming to identify studies and guidelines that relate to physiotherapeutic performance and cardiothoracic surgery. The study was carried out based on articles that were published in the last 20 years, were available in the MEDLINE database, and used the terms "Physiotherapy", "cardiac surgery", "respiratory monitoring" and/or "respiratory complications". Relevant studies from Brazilian authors were also considered, particularly those published by the Brazilian Journal of Cardiovascular Surgery and the Brazilian Archives of Cardiology (official journals of dissemination of Brazilian cardiology) if the articles contained the key words "physiotherapy" and "monitoring". In addition to this research, additional data from postgraduate studies was found at the Division of Thoracic and Cardiovascular Surgery, FMRP-USP.ARCÊNCIO, L ET AL -Pre-and postoperative care in cardiothoracic surgery: a physiotherapeutic approach RevThe findings included randomized clinical trials, metaanalysis, review articles and consensus guidelines, and were related to physiotherapy, respiratory monitoring, and cardiac surgery and its complications. As the diagram of Figure 1 shows, 623 potentially relevant publications in MEDLINE were found, of which 55 fulfilled all of the scientific criteria.

To present our experience with penetrating cardiac injuries. We have retrospectively reviewed the records of 70 victims of penetrating cardiac injuries. A logistic regression has been performed in order to determine the association between death and clinical predictors. Penetrating injuries consisted of 43 stab wounds (61.4%) and 27 (38.6%) gunshot injuries (P=0.72). There were 63 (90%) male and 7 female (10%, P<0.001) victims. The mean age was 27.36+/-11.51, ranging from 3 to 65 years. The overall mortality was 32.9%, 47.8% for gunshot wounds and 52.2% for stab wounds (P=0.266). Eight victims (11.4%) had associated intra-thoracic great vessel injuries and 17 (24.3%) presented associated intra-abdominal organ injuries. The incidence of injured chamber was: right ventricle 37.1%, right atrium 27.1%, left ventricle 25.7%, and left atrium 5.7%. Non-survivors had lower systolic blood pressure (37.50+/-39.18 mmHg) than survivors (79.04+/-41.04 mmHg; P<0.001) upon arrival at the hospital. Thirteen non-survival (56.5%) and 10 (21.3%) survival victims had systolic blood pressure (SBP)