Hirschsprung's disease: the "Swiss roll” technique revisited

Purpose: During pull-through for Hirschsprung's disease (HSCR), the assessment of innervation is mainly based on the presence of ganglion cells when conventional Hematoxylin and Eosin (HE) staining is used. In hypoganglionosis, the evaluation is difficult. We adapted a standardized methodology for the examination of resected bowel after HSCR surgery, using the technique described by Moolenbeek on rodent intestine and later by Meier-Ruge in children. We have analysed the entire innervation of surgically resected bowels and compared the results with the follow up of patients. Methods: Three longitudinal strips of colon were harvested from the mesenteric, anti-mesenteric and intermediate part in the whole length of resected colon of six patients with HSCR. Each strip was divided into two parts. One of the contiguous strips was assessed with HE and Hematoxylin-Phloxin-Safran, and the other one with acetylcholinesterase (AChE) histochemistry. We analyzed the distribution of ganglion cells and nerve arrangement along the strips with both techniques and compared the results obtained in the three different regions of the bowel. Results: There was no significant difference in the pattern of innervation circumferentially. There was a correlation between a progressive increase of AChE activity and nerve hypertrophy and a decrease of ganglion cells from the proximal to the distal part of the resected colon in the submucosa and the myenteric plexus. Nerve hypertrophy and AChE-positive reaction in the mucosa were found at the resection border in patients who presented postoperative complications. Conclusions: Simultaneous assessment of nerve cells, nerve fibers and AChE activity is important in the evaluation of the innervation of the bowel segment proximal to the aganglionic zone. The method described is feasible and can be adapted to older children and adults with larger bowels. These results point out the importance of assessing nerve fibers in intraoperative biopsies during pull-through procedures to prevent uncomplete surgical bowel resectio

Education as a human right for reciprocal development

Considerado o panorama constitucional brasileiro, enquadrado na conjuntura social-democrática, desponta o direito social à educação como pilar à construção social. Porém, a inobservância da referida diretriz elaborada pelo constituinte conduz o quadro social à involução, no sentido de que não evoluem as pessoas, e tampouco o cenário sociopolítico. Hodiernamente, embora compreensível o comando pela implementação de políticas educacionais eficazes, não se pode afirmar pela efetividade desse ideário, haja vista a conjuntura fática que explicita as carências de um sistema educacional falho. Assim sendo, afigura-se necessário o vislumbre do direito à educação enquanto parâmetro humano básico, ou direito humano, com o objetivo de serem planejadas as bases educacionais mediante sólidos sistemas que, pragmaticamente, estruturem um quadro coletivo que impulsione, até mesmo, a formação do Estado democrático. Por meio do método dedutivo, analisam-se pensamentos doutrinários sobre o tema, culminando a discussão na compreensão de que, percebido enquanto direito humano, o direito à educação reclama efetivação pragmática e, além disso, não permite incursões restritivas por meio da atuação estatal, que em meio à discricionariedade, restringe, por vezes, de modo desarrazoado, a capacitação do ser humano. Entendeu-se, outrossim, que a educação otimiza tanto a esfera individual, quanto a própria estrutura estatal democrática.Considerando el panorama constitucional brasileño, enmarcado en la coyuntura socialdemócrata, el derecho social a la educación emerge como un pilar para la construcción social. Sin embargo, el incumplimiento de esta directriz elaborada por el constituyente lleva al marco social a la involución, en el sentido de que las personas no evolucionan, ni el escenario sociopolítico. Hoy, aunque el mandato para la implementación de políticas educativas efectivas es comprensible, no puede ser afirmado por la efectividad de esta idea, dada la coyuntura fáctica que explica las deficiencias de un sistema educativo fallido. Por lo tanto, es necesario vislumbrar el derecho a la educación como un parámetro humano básico, o derecho humano, para planificar las bases educativas a través de sistemas sólidos que, pragmáticamente, estructuran un marco colectivo que incluso impulsa la formación. del estado democrático. A través del método deductivo, se analizan los pensamientos doctrinales sobre el tema, culminando la discusión en el entendimiento de que, percibido como un derecho humano, el derecho a la educación exige una realización pragmática y, además, no permite incursiones restrictivas a través de la acción estatal, que, en medio de la discreción, a veces restringe irrazonablemente el empoderamiento del ser humano. Además, se entendió que la educación optimiza tanto la esfera individual como la propia estructura democrática del estado.Considering the Brazilian constitutional panorama, framed in the social-democratic conjuncture, the social right to education emerges as a pillar for social construction. However, the failure to comply with this guideline elaborated by the constituent leads the social framework to involution, in the sense that people do not evolve, nor does the sociopolitical scenario. Today, although the command for the implementation of effective educational policies is understandable, it cannot be affirmed by the effectiveness of this idea, given the factual conjuncture that explains the shortcomings of a failed educational system. Therefore, it is necessary to have a glimpse of the right to education as a basic human parameter, or human right, in order to plan the educational bases through solid systems that, pragmatically, structure a collective framework that even impels the formation of the democratic state. Through the deductive method, doctrinal thoughts on the subject are analyzed, culminating the discussion in the understanding that, perceived as a human right, the right to education demands pragmatic realization and, furthermore, does not allow restrictive incursions through state action, which, in the midst of discretion, sometimes unreasonably restricts the empowerment of the human being. Moreover, it was understood that education optimizes both the individual sphere and the democratic state structure itself

Pancreatic surgery outcomes: multicentre prospective snapshot study in 67 countries

Background: Pancreatic surgery remains associated with high morbidity rates. Although postoperative mortality appears to have improved with specialization, the outcomes reported in the literature reflect the activity of highly specialized centres. The aim of this study was to evaluate the outcomes following pancreatic surgery worldwide.Methods: This was an international, prospective, multicentre, cross-sectional snapshot study of consecutive patients undergoing pancreatic operations worldwide in a 3-month interval in 2021. The primary outcome was postoperative mortality within 90 days of surgery. Multivariable logistic regression was used to explore relationships with Human Development Index (HDI) and other parameters.Results: A total of 4223 patients from 67 countries were analysed. A complication of any severity was detected in 68.7 percent of patients (2901 of 4223). Major complication rates (Clavien-Dindo grade at least IIIa) were 24, 18, and 27 percent, and mortality rates were 10, 5, and 5 per cent in low-to-middle-, high-, and very high-HDI countries respectively. The 90-day postoperative mortality rate was 5.4 per cent (229 of 4223) overall, but was significantly higher in the low-to-middle-HDI group (adjusted OR 2.88, 95 per cent c.i. 1.80 to 4.48). The overall failure-to-rescue rate was 21 percent; however, it was 41 per cent in low-to-middle-compared with 19 per cent in very high-HDI countries.Conclusion: Excess mortality in low-to-middle-HDI countries could be attributable to failure to rescue of patients from severe complications. The authors call for a collaborative response from international and regional associations of pancreatic surgeons to address management related to death from postoperative complications to tackle the global disparities in the outcomes of pancreatic surgery (NCT04652271; ISRCTN95140761)