Use of Bichat"s buccal fat pad for the sealing of orosinusal communications. A presentation of 8 cases

Objectives: To determine the efficacy of the pediculate flap with the buccal fat pad in the sealing of orosinusal communications, describe the surgical technique used, and report the main complications. Patients and method: A retrospective study was made of 8 patients seen in the Service of Oral Surgery of the University of Barcelona Dental Clinic (Spain) for the treatment of orosinusal communications between the years 2007 and 2009. In all cases a pediculate flap with the buccal fat pad was used to solve the problem. Results: All of the orosinusal communications were successfully resolved with this technique. The immediate postoperative complications were pain (37.5%), inflammation (37.5%), edema (32.5%), trismus (37.5%), halitosis (14.3%), suppuration (12.5%) and rhinorrhea (12.5%). Conclusions: The use of Bichat"s buccal fat pad is not regarded as the technique of choice for sealing small to medium sized orosinusal communications. However, in the case of large communications, it is a good option, and the results obtained are optimum.

Conduta terapêutica atual no adenocarcinoma da cárdia e da junção esofagogástrica

Adenocarcinomas of the cardia and gastroesophageal junction are peculiar entities with three different origins, which differ somewhat from other adenocarcinomas of the stomach in their clinical presentation and pathogenesis, and have a poorer prognosis. In this article the authors reviewed definitions, incidence and epidemiology, etiologic factors, genetic implications, clinical presentation, diagnosis, staging and treatment, with emphasis on the surgical approach, discussing the current management of these cancers. The prognostic factors related specifically to the cardia cancers are: esophageal invasion greater than 3cm, microscopic residual tumor and wall penetration (>T2). Preoperative workup should include computed tomography, and endoscopic ultrasonography and laparoscopy when available. Preoperative recognition of T3/ T4/N2 lesions should indicate inclusion in neo-adjuvant protocols whenever possible. The authors present the results of 46 resected cases of adenocarcinomas of the cardia and GE junction of the Instituto Nacional do Câncer- Brazil (1981-1995). Cure was intended in 29 and palliation in 17 patients. The most common type of resection was total gastrectomy with abdominal esophagectomy (28 cases). Morbidity (major and minor) occurred in 50% of the patients. The main causes were of respiratory origin and fistulas (19.6% each). Death occurred in 44% of the patients with fistula. Postoperative death until the 30th day occurred in 17.24% of the curative cases and in 23.52% of the palliative ones. The median survival time was 68.5 months for stage I, 25 months for stage II, 31 months for stage III and 12.5 months for stage IV diseases. The median survival time was 8 months for palliation and 28.5 months for cure. No long-term survival was obtained with the palliative group, whereas 25% survived five years of more in the curative group. The authors conclude that the surgical approach should be the one the surgeon feels more comfortable with. Complete removal of the disease proved by frozen section, splenectomy and D2 lymphadenectomy should be the standard therapy with curative intent.

Adenoma viloso da ampola de Vater

The aim of this paper is to present a case of a 37-year-old female patient with a benign tumor of the Ampulla of Vater and a brief review of the literature. The patient presented with progressive obstructive jaundice and weigth loss due to the presence of two adenomas of the second portion of duodenum. Laboratory tests confirmed the presence of obstruction of the biliary tree. Ultrasound and CT scan of the abdomen revealed bile duct dilatation. ERCP showed a tumor at the site of the Ampulla of Vater. The biopsies revealed tubular adenoma. She was submitted to local resection of the tumors and sphincteroplasty, since the frozen biopsy at the time of surgery showed no malignancy. During the post-operative follow-up she presented recurrence of symptoms. An upper GI endoscopy revealed a tumor at the Ampulla of Vater. She was then submitted to Whipple procedure with an uneventful recovery.

Apendicite em hérnia femoral com formação de fístula estercoral

The presentation of acute appendicitis in femoral hernia is rare. The gastrointestinal symptons are overshadowed by the local findings. This may lead to delayed diagnosis and complications such as formation of fistula. The authors report a case of a 76-year-old female patient which presented with stercoral fistula after drainage of a right groin abscess ten months earlier.

Hemosuccus pancreaticus: causa rara de hemorragia digestiva maciça

Hemosuccus pancreaticus is a unusual syndrome manifested by hemorrhage into the pancreatic duct and by blood loss through the ampulla of Vater: It may be caused by tumors, arteriovenous malformation, pancreatic lithiasis, aneurism rupture from adjacent vessels, or erosion of pancreatic and peripancreatic vessels due to chronic pancreatitis. The authors describe a case of massive and recurrent gastrointestinal upper hemorrhage in a 26-year-old man without known risk factors for pancreatitis. This man underwent urgent surgery due to gastrointestinal bleeding during the ínvestigation. During the procedure, blood was found in the intestinal lumen and a tumor in the head of pancreas with two centimeters of diameter: A gastroduodenopancreatectomy was performed. Histological study showed chronic pancreatitis with a fistula from the pancreatic vessels to the Wirsung duct. The patient was discharged without postoperative complications and after months, remains assymptomatic.

Fístula pieloduodenal espontânea

Authors present two cases of spontaneous pyeloduodenal fistulas associated to suppurative kidney disease. In both cases the fistulas developed from pyonephrosis and perirenal abscesso Diagnosis was made through intravenous or retrograde pyelogram and two patients were successfully treated by nephrectomy and primary duodenorraphy. Authors present a literature review concluding that 72 additional cases of pyeloduodenal fistulas have been described.

Cisto de colédoco em adulto

Choledochal cyst is a rare congenital malformation of the biliary tree, and aproximately 25% of them are diagnosed in adults. Appropriate surgical management of these lesions depends on the anatomic site and extension of the cystic process. The recognized association of the bile duct cysts with hepatobiliary malignant disease has important surgical implications. Total cyst removal and cholecistectomy with Roux-en- Y hepaticojejunostomy was performed in a 47 year old female with a common bile duct cyst tipe 1 postoperative period was uneventful. A review of literature is presented.

Fístula colecistogástrica

The authors report two cases of cholecistogastric fistula, both in female patients. These patients presented abdominal pain and dispeptic hipostenic syndrome, being diagnosed as calculous cholecistopathy. ln one patient, gastroduodenoscopy showed a fistula orifice in the stomach. ln the other case, the diagnosis was only made during the operation. The surgical procedure was cholecistectomy and gastric suture, with satisfatory postoperative evolution.

Tuberculose entérica

The authors reports two patients with operated from enteric tuberculosis. Tuberculosis involving the intestinal tract may be due to either Mycobacterium tuberculosis or M. bovis. In the former situation, the disease is primary to the lungs and is carried to the intestinal tract by swallowing sputum. The latter organism produces infection associated with swallowed nonpasteurized milk. This condition is extremely unusual in most western countries, since pasteurization of milk is standardized. The diagnosis was performed through laparotomy because of symptoms suggestive of intestine obstruction. Inflammatory reactions were observed on the small intestine (jejunum-ileum) in both cases. The presence of tuberculosis of the lungs was observed in one patient. The chemotherapic treatment was estabilished after the histopathologic diagnosis. The distinction between tuberculosis and Crohn's disease may not be possible by radiography or endoscopy. Videolaparoscopy has been found to be an useful procedure for the early diagnosis of Enteric Tuberculosis. In spite of the epidemiology knowledge, clinical control and improvement in treatment, extra pulmonary tuberculosis rate from concealed focus has been increased, due to AIDS poverty in certain populational groups and immigration from Asia to wertern countries. Compared with immunocompetent patients, the proportion of extrapulmonary tuberculosis is much higher in patients with AIDS, justfying the increased frequency of reports of intestinal tuberculosis in these patients.

Perfuração espontânea de colédoco em adolescente

Spontaneous perforation of the common bile duct is rare. It happens predominantly in children and it is related to obstructive disease of the biliary tract. We present a case of an 18 year-old male patient, with ulcerative rectocolitis associated with malignant tumor of the head of pancreas. The patient developed an acute abdomen syndrome and laparotomy, a spontaneous perforation of common bile duct was evidenced. The authors make a revision of the clinical aspects of that pathology.

Adenomioma da papila de vater em adulto jovem

The authors report a case of adenomyoma of papilla of Vater in a young adult, a rare pathology in this age and site. The commonest clinical findings are abdominal pain, dyspepsia and jaundice, as in this case in which the patient referred these symptoms for several months. The diagnosis is usually difficult before surgery, because the radiological and endoscopic appearances are difficult to interpret, since they may only show obstruction and enlargement of the biliary tract; in this way, the endoscopic biopsy may be useful. In the present case the computed tomography, abdominal scan and intraoperative cholangiography only demonstrated obstruction and enlargement of the biliary tract, without the presence of gallstones. The treatment is usually lesion resection according to its size, performing the total resection in those cases of extensive involvement of the digestive tract, as it was performed in this case, due to the dimension of the lesion and its malignant appearance. The patient was discharged from hospital on the thirteenth postoperative day, with a histological diagnosis of adenomyoma of papilla of Vater. Three months after the procedure the patient was asymptomatic.

Istoadenoma do ducto biliar comum

Biliary duct cystoadenomas are rare neoplasms, with about 120 cases described in the literature, including cystoadenomas and cystoadenocarcinomas. The authors report a case of cystoadenoma of the common bile duct in a 45-year-old woman with history of jaundice. Ultrasound revealed a cystic mass located in the common bile duct. Endoscopic retrograde cholangiopancreatography showed a negative filling defect in the proximal third of the common bile duct, a finding unique to our case. Total excision of the mass, cholecystectomy and an end-total anastomosis with a T-tube choledochostomy, were performed. Histological examination revealed a multicystic lesion with cavities lined by mucinous columnar non-ciliated epithelium, with surrounding densely cellular stroma resembling ovarian stroma. Six years after surgery the patient is alive and well, with no complains referring to the hepatobiliary tract. No abnormalities are presently detected in the biliary tree, ultrasonographically.

Hérnia diafragmática traumática crônica e fístula gastropleurocutânea

Traumatic diaphragmatic hernia is defined as a laceration of the diaphragm with an abdominal viscera herniation into the thorax. It is usually asymptomatic, with the exception of the cases with obstruction, strangulation, necrosis or perforation of the herniaded viscera. It is classified as acute, latent or chronic, in accordance with the evolutive period. At the latent phase, symptoms are indefinite and the radiological signals, which are suggestive of thoracic affections, are frequent and can induce a diagnosis error, leading to inadequate treatment.This article presents a case of chronic traumatic diaphragmatic hernia which was complicated by a gastricpleuralcutaneous fistula, due to an inadequate thoracic drainage. Considering that this is a chronic affection with an unquestionable surgical indication, due to the complications risk, it is essential to have a detailed diagnostic investigation, which aims at both avoiding an intempestive or inadequate therapeutics behaviour and reducing the affection morbimortality. Recently, the videolaparoscopic approach has proved to be more precise when compared to the other diagnostic methods, by direct visualization of the diaphragmatic laceration, allowing its correction by an immediate suture.

Fístulas digestivas no trauma

Digestive fistulas are associated with significant morbidity and mortality, representing mayor challenges regarding diagnosis and the requiring management according physiopathologic basis, including hydroeletrolytic therapy, antibiotics, nutritional support, selected surgical handling and skin care. Most of these lesions are postoperative complications, especially in urgency and traumatic situations. Our objective is to revise important aspects regarding gastrointestinal tract fistulas secondary to trauma, emphasizing classification, physiopathology, diagnosis, complications and treatment.

Hepaticojejunostomia em "y" de roux videoassistida

Management of common bile duct stones in the era of laparoscopic surgery is controversial. The biliary anastomosis is indicated in case of large common bile duct, recurrent stones, giant stones and concomitant common bile duct stricture and duct stones. The development of laparoscopic techniques permits to perform this type of surgery laparoscopically as well as the open procedure.