Treatment of gastrointestinal stromal tumor (GIST) during bariatric surgery

The gastrointestinal stromal tumor (GIST) is a rare mesenchymal tumor. One should pay special attention when the GIST comes in obese patients during surgery. The laparoscopic resections with standard techniques, such as gastric bypass, have been described with good results. However, GIST resection associated sleeve gastrectomy for the treatment of obesity is rare, but can be done safely, depending on the location of the tumor.

Long-term professional performance of minimally invasive surgery post-graduates

OBJECTIVE: to evaluate the contribution of a post-graduation program in surgeons professional careers. METHODS: participants were asked to answer a questionnaire with questions related to possible changes in their professional performance after the end of the course. RESULTS: forty-three (76.7%) of the 56 participants eligible for the study responded to the questionnaires. Most participants, 32 (74.4%), had previous contact with laparoscopic surgery; however, only 14 (32.5%) reported the experience as primary surgeon. The expectations on the course were reached or exceeded for 36 (83.7%) participants. Thirty-seven (86%) incorporated minimally invasive procedures in their daily surgical practice, 37 (86%) reported improvements in their income above 10% and 12% reported income increase of over 100%, directly related to their increase of laparoscopic activity. CONCLUSION: the program in minimally invasive surgery provides a high level of satisfaction to its participants, enables them to perform more complex technical procedures, such as sutures, and improves their professional economic performance.

Epidemiological profile and postoperative complications of women undergoing gynecological surgery in a reference center in the northern brazilian legal amazon

Objective: To evaluate the epidemiological profile and the operative complications of patients undergoing gynecological operations for benign diseases in a tertiary public hospital in the state of Roraima, Brazil. Methods: We conducted a retrospective survey through the analysis of 518 records of patients submitted to gynecological operations between January and June 2012. We included the three major operations during this period (n = 175): hysterectomy, colpoperineoplasty and suburethral sling placement. We excluded 236 cases of tubal ligation and 25 cases where it was not possible to access to medical records. Results: The mean age was 47.6 years; the education level of most patients was completed junior high (36.6%); 77% were from the State capital, 47.4% were in stable relationships and 26.3% were housewives. The majority of patients had given birth three or more times (86.6%), with previous vaginal delivery in 50.2%, and cesarean delivery, 21%. The main diagnostic indications for surgical treatment were uterine myoma (46.3%), urinary incontinence (27.4%) and genital dystopias (17.7%). We found three cases (1.7%) of high-grade intraepithelial lesions on Pap smear. The most common procedure was total hysterectomy (19.8%), 15.5% vaginally. The most common complication was wound infection (2.2%). Conclusion: Women undergoing gynecological operations due to benign disease had a mean age of 47 years, most had levels of basic education, came from the capital, were in stable relationships, predominantly housewives, multiparous and showed low operative complication rates.

Histerectomia Laparoscópica em um Hospital Geral Comunitário Experiência Inicial e Comparação de Custos Hospitalares

Objetivo: comparar os custos hospitalares entre a histerectomia vaginal assistida por laparoscopia (HVAL) e a histerectomia total abdominal (HTA), relatando a experiência inicial com a nova abordagem em um hospital geral comunitário. Pacientes e Métodos: foram comparados 11 casos de HVAL e 23 de HTA, realizados de setembro de 1998 a julho de 1999. Prontuários e demonstrativos das despesas hospitalares de cada paciente foram revistos para coletar as variáveis analisadas. Resultados: não houve diferença estatística entre os grupos quanto à idade, paridade e cirurgia abdominal prévia. A principal indicação cirúrgica para ambos os grupos foi leiomiomatose uterina. O grupo das HVAL apresentou tempo de internação menor, com mediana de 1 dia e o das HTA, de 2 dias (p<0,01). As HVAL mostraram-se 40,2% mais caras que as HTA (p<0,01). Os gastos de centro cirúrgico contribuíram com a maior parte dos custos hospitalares para ambos os grupos, correspondendo a 79,8 e 57,9% do total para as HVAL e HTA, respectivamente. Os gastos de enfermaria para as HVAL foram menores que para as HTA, com diferença estatisticamente significativa (p = 0,002). Conclusão: com menor tempo de internação e com custos de enfermaria menores demonstramos que a HVAL propicia melhores condições de pós-operatório e recuperação mais rápida que a HTA. A HVAL, quando executada em um hospital geral comunitário, apesar de mais cara que a HTA, é uma ótima opção para a remoção uterina, e deve fazer parte do arsenal terapêutico dos cirurgiões ginecológicos.

PTEN expression in patients with carcinoma of the cervix and its association with p53, Ki-67 and CD31

PURPOSE: To investigate protein expression and mutations in phosphatase and tensin homolog (PTEN) in patients with stage IB cervical squamous cell carcinoma (CSCC) and the association with clinical-pathologic features, tumor p53 expression, cell proliferation and angiogenesis.METHODS:Women with stage IB CSCC (n=20 - Study Group) and uterine myoma (n=20 - Control Group), aged 49.1±1.7 years (mean±standard deviation, range 27-78 years), were prospectively evaluated. Patients with cervical cancer were submitted to Piver-Rutledge class III radical hysterectomy and pelvic lymphadenectomy and patients in the Control Group underwent vaginal hysterectomy. Tissue samples from the procedures were stained with hematoxylin and eosin for histological evaluation. Protein expression was detected by immunohistochemistry. Staining for PTEN, p53, Ki-67 and CD31 was evaluated. The intensity of PTEN immunostaining was estimated by computer-assisted image analysis, based on previously reported protocols. Data were analyzed using the Student's t-test to evaluate significant differences between the groups. Level of significance was set at p<0.05.RESULTS:The PTEN expression intensity was lower in the CSCC group than in the Control (benign cervix) samples (150.5±5.2 versus 204.2±2.6; p<0.001). Our study did not identify any mutations after sequencing all nine PTEN exons. PTEN expression was not associated with tumor expression of p53 (p=0.9), CD31 (p=0.8) or Ki-67 (p=0.3) or clinical-pathologic features in patients with invasive carcinoma of the cervix.CONCLUSIONS: Our findings demonstrate that the PTEN protein expression is significantly diminished in CSCC.

Treatment of low-risk gestational trophoblastic neoplasia comparing biweekly eight-day Methotrexate with folinic acid versus bolus-dose Actinomycin-D, among Brazilian women

PURPOSE: To compare two single-agent chemotherapy (ChT) regimens evaluating, in first-line treatment, response and side effects and, in final single-agent treatment, the outcomes, among Brazilian patients with low-risk gestational trophoblastic neoplasia (GTN), according to International Federation of Gynecology and Obstetrics (FIGO) 2002. METHODS: Retrospective analysis of two concurrent cohorts with 194 low-risk GTN patients: from 1992 to 2012, as first-line treatment, 115 patients received 4 intramuscular doses of methotrexate alternated with 4 oral doses of folinic acid (MTX/FA) repetead every 14 days and, since 1996, 79 patients received an endovenous bolus-dose of actinomycin D (Act-D), biweekly. At GTN diagnosis, patient opinion was taken into consideration when defining the initial single-agent ChT regimen, and when there was resistance or toxicity to one regimen, the other drug was used preferentially. This study was approved by the Irmandade da Santa Casa de Misericórdia de Porto Alegre Ethical Committee. RESULTS: Both groups were clinically similar (p>0.05). In first-line treatments, frequency of complete response was similar (75.7% with MTX/FA and 67.1% with bolus Act-D); the number of ChT courses -median 3 (range: 1-10) with MTX/FA and 2 (range: 1-6) with bolus Act-D - and the time to remission -median 9 weeks (range: 2-16) with MTX/FA and 10 weeks (range: 2-16) with bolus Act-D) - were not different between the groups. In both groups, first-line side effects frequency were high but intensity was low; stomatitis was higher with MTX/FA (p<0.01) and nausea and vomit with Act-D (p<0.01). Final single-agent ChT responses were high in both groups (94.8% with MTX/FA and 83.5% with bolus Act-D; p<0.01) and 13% higher in the group initially treated with MTX/FA. Rates of hysterectomy and of GTN recurrence were low and similar. No patient died due to GTN. CONCLUSION: The two regimens had similar first-line ChT response. Final single-agent response rates were high and similar in both groups but the final single-agent remission rate was higher in the MTX/FA group.

The Influence of Education and Depression on Autonomy of Women with Chronic Pelvic Pain: A Cross-sectional Study

Objective Patient autonomy has great importance for a valid informed consent in clinical practice. Our objectives were to quantify thedomains of patient autonomy and to evaluate the variables that can affect patient autonomy in women with chronic pelvic pain. Methods This study is a cross sectional survey performed in a tertiary care University Hospital. Fifty-two consecutive women scheduled for laparoscopic management of chronic pelvic were included. Three major components of autonomy (competence, information or freedom) were evaluated using a Likert scale with 24 validated affirmatives. Results Competence scores (0.85 vs 0.92; p = 0.006) and information scores (0.90 vs 0.93; p = 0.02) were low for women with less than eight years of school attendance. Information scores were low in the presence of anxiety (0.91 vs 0.93; p = 0.05) or depression (0.90 vs 0.93; p = 0.01). Conclusions Our data show that systematic evaluation of patient autonomy can provide clinical relevant information in gynecology. Low educational level, anxiety and depression might reduce the patient autonomy in women with chronic pelvic pain.

Impact of Sacrospinous Colpopexy Associated with Anterior Colporrhaphy for the Treatment of Dome Prolapse on all Three Vaginal Compartments

Objective To evaluate the results of sacrospinous colpopexy surgery associated with anterior colporrhaphy for the treatment of women with post-hysterectomy vaginal vault prolapse. Methods This prospective study included 20women with vault prolapse, PelvicOrgan Prolapse Quantification System (POP-Q) stage≥2, treated between January 2003 and February 2006, and evaluated in a follow-up review (more than one year later). Genital prolapse was evaluated qualitatively in stages and quantitatively in centimeters. Prolapse stage < 2 was considered to be the cure criterion. Statistical analysis was performed using the Wilcoxon test (paired samples) to compare the points and stages of prolapse before and after surgery. Results Evaluation of the vaginal vault after one year revealed that 95% of subjects were in stage zero and that 5% were in stage 1. For cystocele, 50% were in stage 1, 10% were in stage 0 (cured) and 40% were in stage 2. For rectocele, three women were in stage 1 (15%), one was in stage 2 (5%) and 16 had no further prolapse. The most frequent complication was pain in the right buttock, with remission of symptoms in all three cases three months after surgery. Conclusions In this retrospective study, the surgical correction of vault prolapse using a sacrospinous ligament fixation technique associatedwith anterior colporrhaphy proved effective in resolving genital prolapse. Despite the low complication rates, there was a high rate of cystocele, which may be caused by posterior vaginal shifting due to either the technique or an overvaluation by the POP-Q system.

Celioscopic liver biopsy in silver catfish (Rhamdia quelen)

Endosurgery has been used for assessment of fish celomatic cavity, as well as for obtaining biopsies for organic analysis. Such minimally invasive access may also be used for the analysis of environmental impact on biomarkers of pollution. In Brazil, studies and literature regarding the use of celioscopy in fish are sparse. The purpose of the current study was to develop a two-port celioscopy technique to obtain liver biopsy in silver catfish (Rhamdia quelen). Six adult female silver catfish were used. The animals were anesthetized and the inspection of the celomatic cavity were performed using a telescope and celioscopic-guided liver biopsy were taken using laparoscopic Kelly forceps. On the early postoperative period, the animals were released in a confined water reservoir where mortality could be checked. The liver samples were sent for histological assessment. There were no complications during surgery on early postoperative period. It was possible to visualize meticulously several organs (liver, spleen, stomach, pancreas, swim bladder, ovaries, bowel and transverse septum). In conclusion, the surgical technique and the anesthetic protocol proposed were suitable to perform liver biopsies in silver catfish and provided low morbidity.

Complications of surgical treatment of cervical carcinoma

A total of 302 patients with stage Ib and IIa cervical carcinoma were submitted to radical hysterectomy and lymphadenectomy during the period from 1980 to 1994. The morbidity rate was 37.5% and the mortality rate 0.6%. The most common intraoperative complications were injuries to the great pelvic vessels and the most frequent postoperative complications involved the urinary tract. The leading causes of morbidity were urinary infection (20.8%), bladder dysfunction (9.2%) and ureteral fistulas (2.9%). Although the rate of complications was high, morbidity has been decreasing over the last five years. Thus, radical hysterectomy continues to be one of the methods for the treatment of early cervical carcinoma that presents an acceptable 5-year survival rate.

Bariatric and Post-Bariatric Surgery: from Metabolic Surgery to Plastic Surgery Indications

Background: Controversy exists concerning indications and outcomes of major bariatric surgery procedures. Massive weight loss after bariatric surgery leads to excess skin with functional and aesthetic impairments. The aim of this study was to investigate the major bariatric surgery procedures and their outcomes in two specific subgroups of morbidly obese patients, ≥55-year-olds and the superobese. Further aims were to evaluate whether the preoperative weight loss correlates with laparoscopic gastric bypass complications. The prevalence and impact of excess skin and the desire for body contouring after bariatric surgery were also studied. Patients and Methods: Data from patients who underwent Laparoscopic Adjustable Gastric Banding (LAGB) and Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) at Vaasa Central Hospital were collected and postoperative outcomes were evaluated according to the BMI, age and preoperative weight loss. Patients who had undergone bariatric surgery procedures were asked to complete a questionnaire to estimate any impairment due to redundant skin and to analyse each patient’s desire for body contouring by area. Results: No significant difference was found in operative time, hospital stay, or overall early postoperative morbidity between LAGB and LRYGB. Mean excess weight loss percents (EWL%) at 6 and 12 months after LRYGB were significantly higher. A significant difference was found in operative time favouring patients <55 years. Intraoperative complications were significantly more frequent in the group aged >55 years. No significant difference was detected in overall postoperative morbidity rates. A significant difference was found in operative time and hospital stay favouring all patients who lost weight preoperatively. Most patients reported problems with redundant skin, especially on the abdomen, upper arms and rear/buttocks, which impaired daily physical activity in half of them. Excess skin was significantly associated with female gender, weight loss and ΔBMI. Patients with a WL >20 kg, ΔBMI ≥10 kg/m2 and an EWL % > 50 showed a significantly surplus skin discomfort (p < 0.001). Most patients desired body contouring surgery, with high or very high desire for waist/abdomen (62.2%), upper arm (37.6%), chest/breast (28.3%), and rear/buttock (35.6%) contouring. Conclusions: LRYGB is effective and safe in superobese (BMI >50) and elderly (>55 years) patients. A preoperative weight loss >5% is recommended to improve the outcomes and reduce complications. A WL >20 kg, ΔBMI ≥10 kg/m2 and an EWL % > 50 are associated with a higher functional discomfort due to redundant skin and to a stronger desire for body contouring plastic surgery.

Efectividad de morfina intratecal versus endovenosa / histerectomía vaginal en el Hospital Occidente de Kennedy

Introducción: la histerectomía vaginal es una cirugía frecuente, esta investigación comparo dos vías de suministro de opiáceos: intratecal y endovenosa en un estudio realizado en el Hospital Occidente de Kennedy. Método: Estudio prospectivo observacional comparando dolor utilizando la escala de dolor numérica verbal y determinando los requerimientos de morfina de rescate y o Aines, describiendo la presencia de efectos secundarios del uso de opiáceos en dos grupos. Resultados: Participaron 48 mujeres entre 40 y 65 años con ASA I y II. Manejadas con morfina intratecal fueron 28 y 20 con morfina intravenosa, la dosis intratecal fueron de 80 microgramos y las intravenosas de entre 3 y 5 mg en bolo. El dolor se evaluó a las 6, 12 y 24 horas del procedimiento quirúrgico. A las 6, 12 y 24 horas se encontró diferencia significativa p< 0.0001). Se presentaron 28% que usaron el rescate con intratecal, 100% de los casos con morfina endovenosa lo requirió. El uso de AINES se encontró que solo el 3,6% de los casos manejado con morfina intratecal requirieron uso de AINES en cambio las manejadas con endovenosa fue 80%. El tiempo trascurrido entre la dosis de opiáceos y el requerimiento de morfina tuvo una diferencia que fue significativa (p=0,000008). Las nauseas en 14% y el vomito en 7,1% de los manejados con opiáceos intratecales en cambio con endovenosos tuvieron 70% y 35% respectivamente. Se encontró diferencia significativa en estas dos variables pero no en el prurito, a pesar que se encontró más frecuente en los casos manejados con intratecal. Conclusión: pacientes con morfina intratecal tiene más efecto prolongado de analgesia y es probable que necesiten menos dosis de rescate, con igual nausea, vomito y mas prurito.

Pielonefritis Xantogranulomatosa en la infancia: una rara enfermedad en niños menores de un año, reporte de un caso

La pielonefritis xatogranulomatosa es una inflamación crónica del riñón caracterizada por destrucción y sustitución de su parénquima por tejido granulomatoso cargado de células espumosas. Fue descrita por primera vez en 1916 por Schlagenhaufer y reportada en niños solo hasta 1963 por Avnet y Friedenberg. A la fecha se han reportado en la literatura alrededor de 300 casos de los cuales al año 2007 121 correspondían a la edad pediátrica. El grupo etáreo principalmente afectado en la mayoría de los reportes obedece a mujeres en edad media, sin embargo un creciente número de casos pediátricos han sido reportados concluyéndose que esta rara enfermedad puede ocurrir en todas las edades. Aún así continua siendo extremadamente rara en lactantes menores de 1 año pese a lo cual debería ser considerada dentro de los diagnósticos diferenciales cuando se comprueba la presencia de masa renal con o sin urolitiasis asociado a factores predisponentes, síntomas constitucionales, anemia y algún grado de elevación de los marcadores de respuesta inflamatoria sistémica. Dado que el proceso inflamatorio puede extenderse mas allá del riñón y un correcto diagnostico preoperatorio permitiría planear el mejor abordaje quirúrgico, en especial si de consideran técnicas laparoscópicas en búsqueda de una reducción de complicaciones intra y post operatorias

Impacto de la cesarea en la morbimortalidad materna y perinatal

Introducción: La cesárea es un procedimiento quirúrgico considerado como inocuo por algunas personas, sin tener en cuenta las posibles consecuencias en los embarazos siguientes. Existe literatura que evidencia un aumento en el riesgo para abrupcio de placenta, acretismo placentario, placenta previa, mortalidad materna, sepsis materna, ingreso a UCI, al igual que apgar bajo, bajo peso neonatal, distress respiratorio,entre otros.El objetivo de este estudio fue evaluar el impacto del antecedente de cesárea en la morbilidad materna y neonatal mediante una revisión sistemática de literatura. Metodología Se realizó una búsqueda en diferentes bases de datos desde 1996 hasta 2011 sobre el antecedente de cesárea y sus posibles riesgos en el desenlace maternos y perinatales. Se utilizaron variaciones de términos MeSH. Resultados La búsqueda arrojó un total de 2.483 artículos, entre los cuales fueron escogidos 247 por criterios de elegibilidad.Estos fueron evaluados en su totalidad. Posteriormente se realizó el análisis metanalítico de cada uno de los desenlaces. Los resultados deben interpretarse con precaución pues la calidad metodológica de algunos estudios fue variable. En el riesgo conjunto se encontraron resultados estadísticamente significativos en placenta previa, apgar bajo, histerectomía periparto. Discusión El antecedente de cesárea presenta un riesgo aumentado para los siguientes embarazos en la morbilidad tanto materna como neonatal. Faltan más estudios analíticos para definir el verdadero papel de la cesarea.

Cirugía bariatrica : gastrogastroplastia laparoscopica y bypass gástrico en pacientes con obesidad mórbida

La obesidad es un problema de salud global siendo la cirugía bariatrica el mejor tratamiento demostrado. El Bypass gástrico (BGYR) es el método más utilizado que combina restricción y malabsorcion; sin embargo los procedimientos restrictivos se han popularizado recientemente. La Gastro-gastroplastia produce restricción gástrica reversible por medio de un pouch gástrico con anastomosis gastrogástrica y propusimos su evaluación Métodos: Estudio retrospectivo no randomizado que evaluó archivos de pacientes con GG y BGYR laparoscópicos entre febrero de 2008 y Abril de 2011 Resultados: 289 pacientes identificados: 180 GG y 109 BGYR de los cuales 138 cumplieron criterios de inclusión, 77 (55.8%) GG y 61 (44,2%) BGYR, 18 (13%) hombres y 120 (87%) mujeres. Para GG la mediana del peso inicial fue 97,15 (± 17,3) kg, IMC inicial de 39,35 (± 3,38) kg/m2 y exceso de peso de 37,1 (±11,9). La mediana de IMC a los 1, 6 y 12 meses fue 34,8 (±3,58) kg/m2, 30,81 (±3,81) kg/m2, 29,58 (±4,25) kg/m2 respectivamente. La mediana de % PEP 1, 6 y 12 meses fue 30,9 (±14,2) %, 61,88 (±18,27) %, 68,4 (±19,64) % respectivamente. Para BGYR la mediana del peso inicial fue 108,1 (± 25,4) kg, IMC inicial 44,4 (± 8,1) y exceso de peso de 48,4 (±15,2) %. La mediana de IMC a los 1, 6 y 12 meses fue 39 (±7,5) kg/m2, 33,31 (±4,9) kg/m2, 30,9 (±4,8) kg/m2 respectivamente. La mediana de % PEP 1, 6 y 12 meses fue 25,9 (±12,9) %, 61,87 (±18,62) %, 71,41 (±21,09) % respectivamente. Seguimiento a un año Conclusiones: La gastro-gastroplastia se plantea como técnica restrictiva, reversible, con resultados óptimos en reducción de peso y alternativa quirúrgica en pacientes con obesidad. Son necesarios estudios a mayor plazo para demostrar mantenimiento de cambios en el tiempo