Targeted vs. standard treatment against Helicobacter pylori: safety assessment clinical trial

Helicobacter pylori (H. pylori) is a gram negative bacteria that represents a considerable global burden in the world and is related to many gastrointestinal diseases (peptic ulcer, gastric MALT lymphoma or gastric cancer). Currently the triple standard therapy is less used as there is an increase of the clarithromycin resistance. Therefore patients have to receive several lines of treatment with the consequence of adverse events and the possibility to interrupt the treatment. This is why the main objective is to determine if making a culture and antibiogram to do a targeted treatment cause less adverse events with the same eradication than making an empirical treatment to eradicate H. pylori. The secondary objective is to determine the prevalence of resistance to clarithromycin in the province of GironaThis is a multicentre clinical trial without blinding; patients are selected by non-probabilistic sampling, with a total sample of 868 patients randomized in two equal groups of 434 patients in each group. The study will last 2 years. The endpoints will be to evaluate the adverse events and eradication of each group of patients. Also it will be evaluated the resistance to clarithromycin

Role of ErbB2 and ErbB4 in Cancer Growth, Prognosis and as Targets for Immunotherapy

ErbB receptors (EGFR, ErbB2, ErbB3 and ErbB4) are growth factor receptors that regulate signals of cell differentiation, proliferation, migration and survival. Inappropriate activation of these receptors is associated with the development and severity of many cancers and has prognostic and predictive value in cancer therapy. Drugs, such as therapeutic antibodies, targeted against EGFR and ErbB2, are currently used in therapy of breast, colorectal and head and neck cancers. The role of ErbB4 in tumorigenesis has remained relatively poorly understood. Alternative splicing produces four different isoforms of one ErbB4 gene. These isoforms (JM-a, JM-b, CYT-1 and CYT-2) are functionally dissimilar and proposed to have different roles in carcinogenesis. The juxtamembrane form JM-a undergoes regulated intramembrane proteolysis producing a soluble receptor ectodomain and an intracellular domain that translocates into the nucleus and regulates transcription. Nuclear signaling via JM-a isoform stimulates cancer cell proliferation. This study aimed to develop antibodies targeting the proposed oncogenic ErbB4 JM-a isoform that show potential in inhibiting ErbB4 dependent tumorigenesis. Also, the clinical relevance of ErbB4 shedding in cancer was studied. The currently used monoclonal antibody trastuzumab, targeting ErbB2, has shown efficacy in breast cancer therapy. In this study novel tissues with ErbB2 amplification and trastuzumab sensitivity were analyzed. The results of this study indicated that a subpopulation of breast cancer patients demonstrate increased shedding and cleavage of ErbB4. A JM-a isoform-specific antibody that inhibited ErbB4 shedding and consequent activation of ErbB4 had anti-tumor activity both in vitro and in vivo. Thus, ErbB4 shedding associates with tumor growth and specific targeting of the cleavable JM-a isoform could be considered as a strategy for developing novel ErbB-based cancer drugs. In addition, it was demonstrated that ErbB2 amplification is common in intestinal type gastric cancers with poor clinical outcome. Trastuzumab inhibited growth of gastric and breast cancer cells with equal efficacy. Thus, ErbB2 may be a useful target in gastric cancer.

Observations on the Pharmacokinetics and Pharmacodynamics of Dexmedetomidine. Clinical Studies on Healthy Volunteers and Intensive Care Patients

Patients treated in intensive care units require sedation and analgesia. However, sedative drugs also have potential adverse effects, and there is no single ideal sedativeanalgesic drug for these patients. Dexmedetomidine is an apha2-adrenoceptor agonist licenced for sedation of intensive care patients and patients undergoing surgery and other invasive procedures. Several routes of parenteral administration (intravenous, intramuscular, subcutaneous and intranasal) have been utilized. In the present series of studies, the pharmacokinetics and pharmacodynamics of intranasally administered dexmedetomidine as well as the gastrointestinal effects of intravenous dexmedetomidine were determined in healthy volunteers. Pharmacokinetics of dexmedetomidine during long lasting, high-dose infusions were characterized in intensive care patients. The bioavailability of intranasal dexmedetomidine was relatively good (65%), but interindividual variation was large. Dexmedetomidine significantly inhibited gastric emptying and gastrointestinal transit. In intensive care patients, the elimination half-life of dexmedetomidine was somewhat longer than reported for infusions of shorter duration and in less ill patients or healthy volunteers. Dexmedetomidine appeared to have linear pharmacokinetics up to the studied dose rate of 2.5 μg/kg/h. Dexmedetomidine clearance was decreasing with age and its volume of distribution was increased in hypoalbuminaemic patients, resulting in a longer elimination half-life and context-sensitive half-time. Intranasally administered dexmedetomidine was efficacious and well tolerated, making it appropriate for clinical situations requiring light sedation. The clinical significance of the gastrointestinal inhibitory effects of dexmedetomidine should be further evaluated in intensive care patients. The possibility of potentially altered potency and effect duration should be taken into account when administering dexmedetomidine to elderly or hypoalbuminaemic patients.

Perfuração gástrica secundária a tricobezoar gigante: descrição de caso e revisão da literatura

Gastric bezoars are impactations offoreign material in lhe stomach. When they are caused by hail; they are named tricho- bezoars. The complications oftrichobezoars are very rare. In this papel; we describe a case of a 16-year-old girl that had a previous history oftricophagia, and had an acute abdominal pain with a pneumoperitoneum in the abdomen radiography. An operation was performed and a gastric perforation was founded associated with a giant trichobezoa7: The trichobezoar was removed by traction through a gastrostomy which was performed in order to remove lhe trichobezoa7: Some fragments of the ulcer were obtained to histological study. The gastrostomy was treated by a gastrorraphy confection. In lhe post- operative period a left subfrenic abscess was revealed and has been drained by laparatomy 15 days after the fisrt operation. After the second surgical procedure the patient had a good evolution, and left the hospital in good health conditions.

Perfuração gástrica por tricobezoar

Bezoars are uncommon foreign bodies found in the stomach and intestines. They are usually secundary to "strange" or "weird" alimentary habits. The contents may include hait; stones, vegetal fibers and others. Diagnosis is generally made due to complications, mainly parcial or complete obstruction of the segment affected. Bleeding and peiforation may also occur: This paper describes a case of a 14-years-old female patient, who presented herself to lhe Emergency Room and was diagnosed as having a gastric peiforation due to a trichobezoar that was 15 cm long and weighted 900g. A review of lhe literature and comments about diagnosis and management are presented.

Reconstrução total de faringe: análise de 69 casos

Os autores analisaram retrospectivamente as reconstruções após faringolaringectomias totais e faringolaringo-esofagectomias totais realizadas num período de 18 anos, com o objetivo de comparar os resultados imediatos e tardios das diversas técnicas empregadas. Foram revistos 69 casos submetidos a reconstruções totais de faringe realizadas no Hospital A.C.Camargo, de 1980 a 1997. Hipofaringe e laringe eram os locais da neoplasia em 57 pacientes (82,6%), o esôfago cervical, em sete (10,1 %), e outras localizações em cinco (7,2%). Em 62,4% dos casos, o tumor encontrava-se em estádio avançado, e em 18,8% os pacientes apresentavam recidivas de tumores previamente tratados. As cirurgias consistiram em faringolaringoesofagectomia total e transposição de tubo gástrico (gastric pull-up) em 14 pacientes (20,3%), e com interposição de cólon em cinco (7,3%); e de faringolaringectomia total com reconstrução a partir da rotação de retalho do músculo peitoral maior tubulizado em 16 pacientes (23,2%), com retalho do músculo peitoral maior suturado à fáscia pre-vertebralis em 29 (42,0%) e com outras reconstruções em cinco (7,2%). Das técnicas de reconstrução em faringolaringoesofagectomia, o gastric pull-up apresentou índices menores de complicações e mortalidade pós-operatória. Quando comparamos as reconstruções em faringolaringectomia total, os casos reconstruídos com retalho miocutâneo suturado à fáscia pre-vertebralis apresentaram índices menores de fístula e estenose. No entanto, essas diferenças não foram estatisticamente significativas. Diante destes resultados, nossa conduta em faringolaringectomias totais, quando não é possível a reconstrução da faringe com sutura primária, é realizar a rotação do retalho do músculo peitoral maior suturado à fáscia pre-vertebralis. Quando é necessária a faringolaringoesofagectomia, realizamos reconstrução com gastric pull-up.

Ingestão de corpo estranho

The great majority of the ingested foreign bodies (92,5%) enters into the gastrointestinal tract, and only a few of cases go to the respiratory tract. Eighty to 90% of those that go into the gastrointestinal tract are spontaneously eliminated but 10- 20% must be removed by endoscopy and 1% needs to be surgically removed. The authors report a case of accidental ingestion of a foreign body (toothbrush) by a 20-year-old patient.

Fistula gastrocólica

A case of gastrocolic fistula(GCF) in a patient with duodenal stenosis who had previously undergone gastroenteric anastomosis is reported. The patient went through hemigastrectomy, partial colectomy and segmental enterectomy with bloc resection. Reconstruction was carried out through Billroth II gastrojejunostomy, jejunojejunostomy and end-to-end anastomosis of the colon. The patient had good post-operative evolution and was discharged from hospital seven days after surgery. GCF should be suspected in patients presenting weight loss, diarrhea and fecal vomiting, mainly with history of peptic ulcer surgery, gastric or colonic malignancy and use of steroidal and nonsteroidal antiinflamatory drugs. Barium enema is the choice test for diagnosis, however, the benign or malignant nature of the lesion should always be evaluated through high digestive endoscopy. Clinical treatment with oral H2-antagonists and discontinuing ulcerogenic medications might be indicated in some cases; surgical treatment is indicated in cases of malignant disease and might be indicated in cases of peptic disease as it treats GCF and also the baseline disease. Some advise upwards colostomy at first. The most used technique is bloc resection, including the fistulous tract, hemigastrectomy and partial colectomy. Gastrectomy, fistulous tract excision and colon suturing may be performed in some cases. The mortality rate is related to metabolic disorders and the recurrence with the use of antiinflammatory drugs.

Peritonite por bário

We report a case of a 49 years-old man who underwent a barium meal examination for an epigastric pain. A perforated gastric ulcer with barium extravasation into peritoneal cavity was seen on X-rays. During an emergency laparotomy, a perforated pyloric ulcer was noted, along with barium contamination in the peritoneal cavity. The ulcer was closed with an omental patch and an extensive peritoneal lavage with saline was performed. During the postoperative period, the patient developed signs of peritonitis and underwent a new laparotomy was at the 9th day showing a subfrenic abscess with a large barium contamination. The patient presented septic shock and multiple organ failure. dying on the 21th day.

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.

Tricobezoares no estômago, duodeno e íleo

A 21-year-old girl presents with a 15-day history of epigastric pain and vomiting. Ten days later, constipation and abdominal distension followed. The patient reported similar epigastric pain and vomiting for 6 days last year. A painless epigastric 12-by-8-centimeter tumor was observed on abdominal palpation, and rectal examination revealed an extrinsic tumor compressing anterior rectal wall. Upper digestive endoscopy showed a trichobezoar. Upon laparotomy, one gastric and one duodenal trichobezoar were removed through an anterior gastrotomy. Another one was found 40 centimeters proximal to the ileo-cecal valve and removed through a proximal ileotomy. Trichobezoar is an unspecific disease, which diagnosis is made upon suspicion. Early recognition of bezoars is important because morbidity and mortality rise considerably once complications occur. We illustrate this case to emphasize the need for early recognition and surgical management in order to reduce morbimortality.

Ressecção videolaparoscópica de hemangiopericitoma do estômago

In the present case (77 years-old woman), the diagnosis on an extramucosal lesion by endosonography was leiomyoma or schwanoma. Radiological exam of the upper digestive tract with barium and abdominal computed tomography confirmed the site of the lesion at the level of the lesser curvature. The operative technique followed the steps of the laparoscopic partial gastric resection (wedge resection) for gastric mesenchymal tumours, described elsewhere. The Endo-GIA stapler was introduced through the 12mm port in the right upper quadrant. Proper positioning of the stapler over the lesser curvature and a satisfactory margin of tissue around the mass were attained. Nine sequential firings of the Endo-GIA 30 were needed to completely surround the mass. Histopathological diagnosis was a spindle-cell tumour measuring 3cm in diameter. Mitotic index was measured at almost null. The neoplastic cells were strongly reactive for vimentine and CD34 and negative for the immunohistochemical markers S-100 protein, muscle actin, desmin and Ag linked to VIII factor. There was a slight reaction with keratin (+/+++). The XIIIA factor reaction revealed less than 5% of dendritic elements. These data favour a vascular cell origin better than smooth muscle cell origin. In conclusion it was a gastric hemangiopericytoma. Follow-up showed no recurrence at seven years.

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.

Anastomose duodenoduodenal na pancreatoduodenectomia por pancreatite crônica

Literature has been showing a tendency of reducing the limits of Whipple's resection. The main technical advance was the pylorus preserving resection, technique proposed by Traverso and Longmire in 1978. The pancreticoduodenectomy for chronic pancreatitis, is probably the best opportunity to apply this type of procedure. In these specific patients, the author preserved the pylorus and the third portion of the duodenum. The gastrointestinal transit was reconstructed by the duodenumduodenal anastomosis and the bile duct and the pancreas were drained in a Roux-en-way loop . Follow-up showed no important complication, with no problems related to gastric emptying and without pain.

Banda gástrica ajustável laparoscópica: alternativa técnica

In these paper we are presenting a technical alternative to laparoscopic adjustable gastric banding. From January 1999 to April 2000, 60 patients with mean body mass index (BMI) of 40,7 kg/m2 underwent laparoscopic adjustable gastric banding. The new technique is performed in two steps. In the first step, an isolation instrument (laparoscopic finger) is inserted through the lesser sac, next to the junction of diaphragmatic crura, including the lesser omentum in order to pull the band catheter. The second step separates the lesser omentum from the right side of the stomach.There was no mortality and the morbidity was 11,6% (1 slippage of the band and 6 trocar port seroma). The new technique was performed in all patients with no conversion to open procedure. We didn't have respiratory complications. This technical alternative is safe and easily performed, helping to prevent transoperative perforations.