Embolização pré operatória no tratamento de paraganglioma abdominal: relato de caso

Paragangliomas is a pheochromocytoma of extra adrenal localization. The case report is a male, 55 years old who presented symptoms of adrenergic hyperstimulation associated to an abdominal mass diagnosed as paraganglioma by a biopsy. Because of its size, localization and vascularization, an aortography with embolization of the nutrient branches of the tumor was done pre-operatively. Four days later, a surgical ressection was performed, and the tumor was adhered to the duodenum, infra-renal aorta and inferior vena cava. We believe that an angiographic study pre-operatively with embolization makes possible an analysis of the anastomosis and arterial supplement, making the ressecability of the tumor safer, although it seems the surgical intervention should have been done earlier.

Volvo de ceco complicado por icterícia séptica

Cecal volvulus is an uncommon cause of acute bowel obstruction in adults. The mechanism is torsion of the enlarged, poorly-fixed or hypermobile cecum. Patients with this condition may display highly variable clinical presentations, ranging from intermittent, self-limiting abdominal discomfort to acute abdominal pain associated with intestinal strangulation and sepsis. The treatment needs to be individualized for each case, but surgical management is required in almost every case. In the presence of gangrene or perforation of the cecum, resection and primary ileocolic anastomosis is recommended. However, in non-complicated cases detorsion and cecopexy are adequate. The authors report one case of cecal volvulus in a 55-year-old women treated with cecopexy that complicated with septic jaundice.

Complicated diverticular disease: the changing paradigm for treatment

The term "complicated" diverticulitis is reserved for inflamed diverticular disease complicated by bleeding, abscess, peritonitis, fistula or bowel obstruction. Hemorrhage is best treated by angioembolization (interventional radiology). Treatment of infected diverticulitis has evolved enormously thanks to: 1) laparoscopic colonic resection followed or not (Hartmann's procedure) by restoration of intestinal continuity, 2) simple laparoscopic lavage (for peritonitis +/- resection). Diverticulitis (inflammation) may be treated with antibiotics alone, anti-inflammatory drugs, combined with bed rest and hygienic measures. Diverticular abscesses (Hinchey Grades I, II) may be initially treated by antibiotics alone and/or percutaneous drainage, depending on the size of the abscess. Generalized purulent peritonitis (Hinchey III) may be treated by the classic Hartmann procedure, or exteriorization of the perforation as a stoma, primary resection with or without anastomosis, with or without diversion, and last, simple laparoscopic lavage, usually even without drainage. Feculent peritonitis (Hinchey IV), a traditional indication for Hartmann's procedure, may also benefit from primary resection followed by anastomosis, with or without diversion, and even laparoscopic lavage. Acute obstruction (nearby inflammation, or adhesions, pseudotumoral formation, chronic strictures) and fistula are most often treated by resection, ideally laparoscopic. Minimal invasive therapeutic algorithms that, combined with less strict indications for radical surgery before a definite recurrence pattern is established, has definitely lead to fewer resections and/or stomas, reducing their attendant morbidity and mortality, improved post-interventional quality of life, and less costly therapeutic policies.

Síndrome de Boerhaave: relato de caso

Spontaneous esophageal rupture carries high morbidity and mortality. The main prognostic factor is early diagnosis, before 12 hours, and appropriate treatment. This is a case report of a 41-years-old man with late esophageal rupture diagnosis treated successfully with transmediatinal esophagectomy and esophageal-gastric tube cervical anastomosis.

An alternative experimental model for training in microsurgery

OBJECTIVE: to describe a new model of training in microsurgery with pig spleen after splenectomy performed by undergraduate students of the Discipline of Operative Technique of the UFPR Medical School. METHODS: after the completion of splenectomy we performed dissection of the vascular pedicle, distal and proximal to the ligation performed for removal of the spleen. After complete dissection of the splenic artery and vein with microscope, clamps were placed and the vessels were cut. We then made the anastomosis of the vessels with 9.0 nylon. RESULT: the microsurgical training with a well-defined routine, qualified supervision and using low cost experimental materials proved to be effective in the practice of initial microvascular surgery. CONCLUSION: the use of pig spleen, which would be discarded after splenectomy, is an excellent model for microsurgical training, since besides having the consistency and sensitivity of a real model, it saves the sacrifice of a new animal model in the initial learning phase of this technique.

Four-arm single docking full robotic surgery for low rectal cancer: technique standardization

The authors present the four-arm single docking full robotic surgery to treat low rectal cancer. The eight main operative steps are: 1- patient positioning; 2- trocars set-up and robot docking; 3- sigmoid colon, left colon and splenic flexure mobilization (lateral-to-medial approach); 4-Inferior mesenteric artery and vein ligation (medial-to-lateral approach); 5- total mesorectum excision and preservation of hypogastric and pelvic autonomic nerves (sacral dissection, lateral dissection, pelvic dissection); 6- division of the rectum using an endo roticulator stapler for the laparoscopic performance of a double-stapled coloanal anastomosis (type I tumor); 7- intersphincteric resection, extraction of the specimen through the anus and lateral-to-end hand sewn coloanal anastomosis (type II tumor); 8- cylindric abdominoperineal resection, with transabdominal section of the levator muscles (type IV tumor). The techniques employed were safe and have presented low rates of complication and no mortality.

Is there a role for pyloric exclusion after severe duodenal trauma?

Duodenal trauma is an infrequent injury, but linked to high morbidity and mortality. Surgical management of duodenal injuries is dictated by: patient's hemodynamic status, injury severity, time of diagnosis, and presence of concomitant injuries. Even though most cases can be treated with primary repair, some experts advocate adjuvant procedures. Pyloric exclusion (PE) has emerged as an ancillary method to protect suture repair in more complex injuries. However, the effectiveness of this procedure is debatable. The "Evidence Based Telemedicine - Trauma & Acute Care Surgery" (EBT-TACS) Journal Club performed a critical appraisal of the literature and selected three relevant publications on the indications for PE in duodenal trauma. The first study retrospectively compared 14 cases of duodenal injuries greater than grade II treated by PE, with 15 cases repaired primarily, all of which penetrating. Results showed that PE did not improve outcome. The second study, also retrospective, compared primary repair (34 cases) with PE (16 cases) in blunt and penetrating grade > II duodenal injuries. The authors concluded that PE was not necessary in all cases. The third was a literature review on the management of challenging duodenal traumas. The author of that study concluded that PE is indicated for anastomotic leak management after gastrojejunostomies. In conclusion, the choice of the surgical procedure to treat duodenal injuries should be individualized. Moreover, there is insufficient high quality scientific evidence to support the abandonment of PE in severe duodenal injuries with extensive tissue loss.

Choledochal cyst in childhood: review of 30 cases

Objective: To analyze and discuss the clinical data, diagnosis and treatment of a number of patients with cystic dilatation of the common bile duct of a Brazilian pediatric hospital.Methods: We analyzed 30 patients treated at the Martagão Gesteira Institute of Pediatrics and Child Care of the Federal University of Rio de Janeiro for 23 years ,with statistical analysis of epidemiological data, clinical manifestations, diagnosis, treatment and postoperative outcome.Results: We observed a marked female predominance (73.4% of cases), the diagnosis being made in the first decade of life in 90% of patients. The most prevalent clinical manifestation was jaundice (70% of cases) and the classic triad of choledochal cyst was not observed. Abdominal ultrasound was the first imaging examination performed, with a sensitivity of 56.6%, with diagnostic definition in 17 children. Two patients (6.6%) had prenatal diagnosis. All patients underwent surgical treatment, cyst resection with Roux-en-Y hepaticojejunostomy being performed in 80% of cases. The incidence of postoperative complications was 13.3% and the mortality rate was 6.6%, ie two patients were diagnosed with Caroli's disease.Conclusion: The non-observance of the classic triad of choledochal cyst suggests that its incidence is lower than that reported in the medical literature. The surgical treatment of choledochal cysts, with resection and bilioenteric anastomosis, is safe even for small children.

Administration of Bifidobacterium animalis subsp. lactis BB-12 and xylitol with a novel pacifier in early childhood

Probiotic bifidobacteria are used in the prevention and treatment of childhood diseases. On the other hand, these bacteria are also connected to dental caries. The purpose of the present work was to test a food supplement containing Bifidobacterium animalis subsp. lactis BB-12 (B. lactis BB-12) and xylitol, and to investigate its health effects, properties and safety when used in a novel pacifier in early childhood. In a double-blind, placebo-controlled trial, newborn infants (n=163) were assigned randomly to receive B. lactis BB-12, xylitol, or sorbitol from the age of 1– 2 monthsto 2 years with a pacifier or a spoon. Children were followed up to four years of age. A part of the parents participating in the clinical trial evaluated the feasibility of the novel administration method. The pattern of tablet release from the pouch of the pacifier was tested in adults. The food supplement tablet containing B. lactis BB-12 and xylitol could be delivered in a safe and controlled way with the novel pacifier. The early administration of B. lactis BB-12 did not result in permanent oral colonization of this probiotic or affect the colonization of mutans streptococci in early childhood. Moreover, B. lactis BB-12 did not increase the occurrence of caries. Controlled administration of B. lactis BB-12 significantly reduced the incidence of respiratory infections during the first eight months of life in a Finnish population with breastfed infants. To conclude, administration of B. lactis BB-12 in early childhood is safe with regard to the future dental health of the child. In addition, B. lactis BB-12 may add to the protection against respiratory infections provided by human breast milk in infancy.

Influence of preoperative supplementation of omega-3 fatty acid in the healing of colonic anastomoses in malnourished rats receiving paclitaxel

OBJECTIVE: To evaluate the effect of preoperative supplementation of omega-3 fatty acids on the healing of colonic anastomoses in malnourished rats receiving paclitaxel. METHODS: we studied 160 male Wistar rats, divided in two groups: one subjected to malnutrition by pair feeding (M) for four weeks, and another that received food ad libitum (W). In the fourth week, the groups were further divided into two subgroups that received omega-3 or olive oil by gavage. The animals were submitted to colonic transection and end-to-end anastomosis. After the operation, each of the four groups was divided into two subgroups that received intraperitoneal isovolumetric solutions of saline or paclitaxel. RESULTS: mortality was 26.8% higher in the group of animals that received paclitaxel (p = 0.003). The complete rupture strength was greater in well-nourished-oil Paclitaxel group (WOP) compared with the the malnourished-oil Paclitaxel one (MOP). The collagen maturation index was higher in well-nourished-oil saline group (WOS) in relation to the malnutrition-oil-saline group (MOS), lower in malnourished-oil-saline group (MOS) in relation to malnourished-ômega3-saline one (M3S) and lower in the well-nourished-omega3-saline group (W3S) compared with the malnourished-omega3-saline (M3S). The blood vessel count was higher in the malnourished-oil-saline group (MOS) than in the malnourished-oil-paclitaxel group (MOP) and lower in the malnourished-oil-saline group (MOS) in relation to the malnourished-omega3-paclitaxel group (M3P). CONCLUSION: supplementation with omega-3 fatty acids was associated with a significant increase in the production of mature collagen in malnourished animals, with a reversal of the harmful effects caused by malnutrition associated with the use of paclitaxel on the rupture strength, and with a stimulus to neoangiogenesis in the group receiving paclitaxel.

Esophagectomy with gastroplasty in advanced megaesophagus: late results of omeprazole use

Objective: To analyze the late results of advanced Chagasic megaesophagus treatment by esophagectomy associated with the use of proton pump inhibitor (omeprazole) as for the incidence of esophagitis and Barrett's esophagus in the remaining stump. Methods : We studied patients with advanced megaesophagus undergoing esophagectomy and transmediastinal esophagogastroplasty. Patients were divided into three groups: A (20) with esophageal replacement by full stomach, without the use of omeprazole; B (20) with esophageal replacement by full stomach, with omeprazole 40 mg/day introduced after the first postoperative endoscopy and maintained for six years; and C (30) with esophageal replacement by gastric tube with use of omeprazole. Dysphagia, weight loss and BMI were clinical parameters we analyzed. Upper gastrointestinal endoscopy was performed in all patients, and determined the height of the anastomosis, the aspect of the mucosa, with special attention to possible injuries arising from gastroesophageal reflux, and the patency of the esophagogastric anastomosis. Results : We studied 50 patients, 28 males (56%) and 22 (44%) females. All underwent endoscopy every year. In the first endoscopy, erosive esophagitis was present in nine patients (18%) and Barrett's esophagus, in four (8%); in the last endoscopy, erosive esophagitis was present in five patients (8%) and Barrett's esophagus in one (2%). When comparing groups B and C, there was no evidence that the manufacturing of a gastric tube reduced esophagitis and Barrett's esophagus. However, when comparing groups A and C, omeprazole use was correlated with reduction of reflux complications such as esophagitis and Barrett's esophagus (p <0.005). Conclusion : The use of omeprazole (40 mg/day) reduced the onset of erosive esophagitis and Barrett's esophagus during the late postoperative period.

Peritonite meconial como diagnóstico diferencial de ascite fetal: relato de caso

Introdução: a peritonite meconial, como resultado da perfuração intestinal fetal, apresenta baixa incidência (1:30.000 nascimentos) e elevada mortalidade (em torno de 50%). Os achados ecográficos pré-natais incluem ascite e calcificações intra-abdominais. Há evidências de que o diagnóstico pré-natal possa melhorar o prognóstico pós-natal. Relato do Caso: R.C.M.S., 22 anos, II gesta O para, realizou ultra-sonografia em 02/12/98 com diagnóstico de ascite fetal. Fez investigação para hidropisia fetal, afastando-se causas imunes e não-imunes. Foram realizados ecografias seriadas em que se manteve a imagem de ascite fetal acentuada, sem calcificações. Parto normal em 02/01/99, com 36 semanas, observando-se volumoso poliidrâmnio. Recém-nascido do sexo feminino pesando 2.670 gramas, com sinais de desconforto respiratório, abdome distendido e com petéquias. Apresentou aumento progressivo da distensão abdominal, palpação de massa pétrea no hipocôndrio direito e eliminação de muco branco ao toque retal. Raios-x em 04/01/99 com imagem de extensas calcificações abdominais, distensão de alças intestinais e ausência de gás na ampola retal. Hipótese diagnóstica de peritonite meconial. Indicada laparotomia exploradora em 04/01/99, encontrando-se volumoso cisto meconial e atresia ileal, realizando-se lise de aderências e ileostomia em dupla boca. Evolução satisfatória nos primeiros dias de pós-operatório, complicada posteriormente por quadro séptico, verificando-se o óbito neonatal em 09/01/99. Conclusão: a peritonite meconial deve ser lembrada no diagnóstico diferencial das causas de ascite fetal. O diagnóstico pré-natal no presente caso poderia ter antecipado a indicação cirúrgica, com possível melhora da evolução neonatal.

Associação entre o uso de sulfoniluréias por gestantes diabéticas e malformações fetais

Objetivo: avaliar a relação entre o uso de sulfoniluréias (SF) por gestantes diabéticas seguidas na nossa clínica e as malformações (MF) fetais detectadas. Métodos: estudamos, retrospectivamente, 35 gestantes diabéticas tipo 2, seguidas no Ambulatório de Pré-Natal Patológico do Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto, USP, no período de 1993-1995, das quais 22 encontravam-se em uso inadvertido de SF no 1º trimestre da gestação (grupo SF). Avaliamos a prevalência de MF e comparamos com as gestantes diabéticas que nesse período encontravam-se em uso de insulina ou apenas dieta (grupo C). Foram também analisadas outras variáveis: tempo de doença, idade, controle metabólico e seguimento pré-natal. Resultados: não houve diferença estatisticamente significativa entre os 2 grupos quanto a faixa etária, tempo de evolução do diabetes, controle metabólico ou precocidade do início do pré-natal, sendo a freqüência de MF semelhante nos 2 grupos (8,3% no grupo C e 13,6% no grupo SF). As malformações encontradas foram: no grupo SF - agenesia renal, hipoplasia pulmonar e gônadas em fita (paciente 1); membros curtos e pododáctilos de implantação anormal (paciente 2); fenda palatina, implantação baixa de orelhas, pescoço alado, prega palmar única e nariz em sela (paciente 3), e no grupo C - micrognatia, orelha displásica, polidactilia, imperfuração anal, hipospadia, comunicação inter-atrial e comunicação interventricular (paciente 4). Conclusões: esses dados não nos permitem atribuir as malformações encontradas no grupo SF ao uso de sulfoniluréias, embora nesse grupo tenham ocorrido alterações não usualmente descritas na embriopatia diabética.

Estudo da Adesão à Quimioprofilaxia Anti-retroviral para a Infecção por HIV em Mulheres Sexualmente Vitimadas

Objetivos: embora não existam dados apropriados para estabelecer sua eficácia, alguns serviços tem utilizado, profilaticamente, a terapia anti-retroviral para o HIV nos casos de violência sexual. O objetivo deste estudo foi avaliar a aceitabilidade, tolerância e adesão a um esquema quimioprofilático para o HIV. Pacientes e método: foram avaliadas 62 mulheres vítimas de estupro e/ou atentado violento ao pudor com coito ectópico anal. Os agressores foram referidos como desconhecidos. A profilaxia foi iniciada dentro das primeiras 48 h da violência e mantida por 4 semanas, sendo administrados diariamente: zidovudina, 600 mg; indinavir, 2.400 mg e lamivudina, 300 mg. Resultados: a taxa de descontinuidade foi de 24,2%, sendo em 12 casos (80%) decorrente de intolerância gástrica. Os efeitos colaterais estiveram presentes em 43 casos (69,4%), sendo as náuseas e vômitos os mais freqüentes. A complexidade posológica e o tempo de uso foram fatores possivelmente associados ao uso inadequado das drogas, ocorrendo em 10,6% dos casos. Conclusão: a taxa de descontinuidade da quimioprofilaxia foi semelhante à observada em outras indicações.

Prevalência da colonização pelo estreptococo do grupo B em gestantes atendidas em ambulatório de pré-natal

OBJETIVO: verificar a prevalência de estreptococo do grupo B (EGB) em gestantes no terceiro trimestre da gravidez e explorar os fatores potencialmente associados à colonização. MÉTODOS: uma amostra de 273 gestantes no terceiro trimestre da gravidez, provenientes do ambulatório de pré-natal do Hospital Universitário do Sul do Brasil, foi investigada. Culturas de amostra vaginal e anorretal foram obtidas e inoculadas em meio seletivo de Todd-Hewitt suplementado com 10 µg/ml de colistina e 15 µg/ml de ácido nalidíxico e posteriormente subcultivadas em ágar sangue de carneiro desfibrinado. Todas as colônias suspeitas foram submetidas ao teste de aglutinação para detecção do antígeno específico do grupo B. O teste de Camp foi utilizado para identificação do EGB das variedades não hemolíticas. Analisaram-se também os dados demográficos, socioeconômicos, reprodutivos e clínico-obstétricos. A razão de prevalência (RP) foi utilizada como medida de risco. Considerou-se como significante o intervalo de confiança no nível de 95% (alfa=0,05). RESULTADOS: a prevalência de colonização pelo EGB foi de 21,6% (59), sendo que 9,9% (27) das gestantes tiveram positividade em ambos os sítios, 6,95% (19) foram positivas somente no sítio vaginal e 4,75% (13) da amostra tiveram positividade apenas no sítio anal. A prevalência de EGB foi ligeiramente mais alta nas gestantes com idade inferior a 20 anos, naquelas com menor escolaridade e nas gestantes primíparas, e o dobro entre aquelas que não relataram aborto espontâneo, porém sem significância estatística. Não foi encontrada diferença na prevalência de EGB de acordo com história de doenças sexualmente transmissíveis e tabagismo. Quando os dados foram analisados conjuntamente, os fatores detectados como potencialmente associados à colonização pelo EGB foram: primíparas com mais de 30 anos (RP=1,55) e mulheres com mais de um parceiro sexual e freqüência de atividade sexual aumentada (55,6 vs 20,5%; p<0,05). CONCLUSÃO: confirma-se a necessidade rotineira de cultura para EGB em ambos os sítios (vaginal e anal) de todas as gestantes no terceiro trimestre de gestação.