Malacoplaquia intestinal

Malacoplakia is a chronic granulomatous disease of unknown origin. However immunodeficiency states (immunossuppressive medication, old people, renal transplantation, leukaemia, diabetes mellitus, malnutrition and others) have been associated with patients with malacoplakia. An infectious cause of malakoplakia is suggested by the finding of coliform bacteria in the phagolysosomes of macrophages. The histologic study is characterized by a infiltrate of large macrophages (Hansenmann cells) with pathognomonic inclusions containing siderocalcific structures (Michaelis-Gutmann bodies). Most of the cases reported in literature, involve the genitourinary tract, but other structures can be affected (brain, bone, adrenal glands, lymph nodes, intestine, and others). A 66-year-old man whith a abdominal mass, went to our hospital with a colonic tumour diagnosis. The patient was submitted to a surgery, with resection of the rigth colon. The disease was invading a portion of the retroperitoneal tissue that was removed. The histopatologic study showed the pathognomonic sign of malakoplakia (Hansenmann cells and Michaelis-Gutmann bodies). Norfloxacin have been used to the complementar treatment with total cure of the patient.

Íleo biliar colônico

Colonic obstruction is a very rare complication of gallstone disease. We describe two cases of colonic obstruction by gallstone in old age women, in which the final diagnosis was made on surgery. In one it was found a cholecystocolic fistula and a stone impacted in the sigmoid colon which was milked until the cecum, where it was removed through a cecolithotomy. In the other there was a cholecystoduodenal fistula, the stone was impacted in the sigmoid colon and in association there was a colonic necrosis, treated by colectomy, ileostomy and mucous fistula, During colonic mobilization a colecystoduodenal fistula was exposed, making necessary to perform a cholecystectomy and fistula repair. Both patients died in sepsis.

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.

Linfomas malt do cólon: relato de dois casos

The authors report two cases of MALT (Mucosa Associated Lymphoid Tissue) lymphoma of the colon, describing their peculiarities related to diagnosis, treatment and imunopathology. Both had no signs of systemic disease and were submitted to colectomy. Follow-up was uneventful . It's emphasized about raising the possibility of a MALT neoplasm whenever investigating a colonic tumor and the value of imunocitochemistry in the correct diagnosis of these lesions. We also discuss about the pathogens of this lesion.

Marcadores tumorais no câncer colorretal

Colorectal cancer is a clinical entity of a persistent relevance in clinical practice and its early diagnosis is a determinant factor to obtain better therapeutic results. Tumor markers are helpful means for a better approach to individuals with such neoplasm. In the present review, the authors analyze the phases in which surgical-clinical treatment markers must be used: diagnosis, determination of tumor stage, establishment of prognosis and detection of recurrence. Current and future markers and the consensus on their use are discussed. Causal factors for errors in diagnosis with markers and perspectives of use are also presented.

O uso do tubo colônico bipediculado microcirúrgico na reconstrução do esôfago

In some cases of esophageal reconstruction, it is not possible to use the gastric tube. In those cases, the second option is the reconstruction with a colonic segment. In the present paper, the authors present the use of microsurgical technique to improve vascular supply in esophageal reconstructions using the colon. Therefore, the transposed segment becomes perfused by two vascular pedicles: a proximal one and a distal one. The authors describe a case of 52 years-old patient, suffering of middle third esophagus carcinoma, who underwent a primarily esophageal resection with an unsuccessful reconstruction using gastric transposition. A new reconstruction was proposed using a bipedicle microcirurgical colonic tube, four months later. The post operative was uneventful with rehabilitation of swallowing and satisfactory recovery of nutritional state.

Síndrome de Ogilvie: relato de dois casos tratados com cecostomia

Acute colonic pseudo-obstruction or Ogilvie’s Syndrome is characterized by signs and symptoms of large bowel obstruction without evidence of mechanical cause. The authors report two cases of patients with acute obstructive abdomen who were previously submitted to clinical treatment with no sucess. Later on one of them was submitted to laparoscopic cecostomy and the other to colonoscopic cecostomy The results showed that only the interventionist methods were successful.

Síndrome de Peutz-Jeghers: relato de caso

Peutz-Jeghers syndrome (PJS) is a dominant autosomal inherited disorder characterized by intestinal hamartomatous polyps in association with mucocutaneous melanocytic maculae. This syndrome is rare, and the frequency reaches from 1 in 60,000 to 1 in 300,000 people in the USA. The symptom presentations vary greatly in this disease. Some patients require minor clinical treatment while others undergo many hospitalizations and surgical treatments. In addition, patients with PJS have an increased risk for developing a variety of malignant tumors. The aim of the present study was to report one case studied of Peutz-Jeghers syndrome.

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.

Results of surgical treatment of massive localized lymphedema in severely obese patients

OBJECTIVE: to evaluate the importance of treatment of deformities caused by massive localized lymphedema (MLL) in the severely obese. METHODS: in a period of seven years, nine patients with morbid obesity and a mean age of 33 years underwent surgical resection of massive localized lymphedema with primary synthesis. This is a retrospective study on the surgical technique, complication rates and improved quality of life. RESULTS: all patients reported significant improvement after surgery, with greater range of motion, ambulation with ease and more effective hygiene. Histological analysis demonstrated the existence of a chronic inflammatory process marked by lymphomonocitary infiltrate and severe tissue edema. We observed foci of necrosis, formation of microabscesses, points of suppuration and local fibrosis organization, and pachydermia. The lymphatic vessels and some blood capillaries were increased, depicting a framework of linfangiectasias. CONCLUSION: surgical treatment of MLL proved to be important for improving patients' quality of life, functionally rehabilitating them and optimizing multidisciplinary follow-up of morbid obesity, with satisfactory surgical results and acceptable complication rates, demonstrating the importance of treatment and awareness about the disease.

Laparoscopy in uterine cervical cancer. Current state and literature review

Cervical cancer remains the most frequent gynecological tumor in Brazil and other developing countries. Minimally invasive techniques, especially laparoscopy, have been increasingly employed in such tumors. This article aims to describe the main applications of laparoscopy in the treatment and staging of cervical cancer. In the early stages, it is possible to provide a fertility-preserving surgery in the form of radical trachelectomy and, in a study protocol, the function-preserving surgery, avoiding parametrectomy and the associated morbidity. A fully laparoscopic radical hysterectomy is fairly standard in the literature and has the tendency to become the standard of care in early cases, for patients who want to bear no more children. In advanced stages, minimally invasive surgery can offer ovarian transposition, with intent to prevent actinic castration, without upsetting the time for the start of radiotherapy and chemotherapy. Staging laparoscopic surgery, including pelvic and para-aortic lymphadenectomy, has been the subject of studies, since it has the potential to modify the extension of radiotherapy depending on the extent of lymph node spread.

Total esophagogastrectomy in the neoplasms of the esophagus and esofagogastric junction: when must be indicated?

Objective: to analyse the indications and results of the total esophagogastrectomy in cancers of the distal esophagus and esophagogastric junction. Methods: twenty patients with adenocarcinomas were operated with a mean age of 55 ± 9.9 years (31-70 years), and 14 cases were male (60%). Indications were 18 tumors of the distal esophagus and esophagogastric junction (90%) and two with invasion of gastric fundus (10%) in patients with previous gastrectomy. Preoperative colonoscopy to exclude colonic diseases was performed in ten cases. Results: the surgical technique consisted of median laparotomy and left cervicotomy, followed by transhiatal esophagectomy associated with D2 lymphadenectomy. The reconstructions were performed with eight esophagocoloduodenoplasty and the others were Roux-en-Y esophagocolojejunoplasty to prevent the alkaline reflux. Three cases were stage I / II, while 15 cases (85%) were stages III / IV, reflecting late diagnosis of these tumors. The operative mortality was 5 patients (25%): a mediastinitis secondary to necrosis of the transposed colon, abdominal cellulitis secondary to wound infection, severe pneumonia, an irreversible shock and sepsis associated with colojejunal fistula. Four patients died in the first year after surgery: 3 (15%) were due to tumor recurrence and 1 (5%) secondary to bronchopneumonia. The 5-year survival was 15%. Conclusion: the total esophagogastrectomy associated with esophagocoloplasty has high morbidity and mortality, requiring precise indication, and properly selected patients benefit from the surgery, with the risk-benefit acceptable, contributing to increased survival and improved quality of life

Localization of metastasis within the sentinel lymph node biopsies: a predictor of additional axillary spread of breast cancer?

PURPOSE: To explore the relationship between morphological characteristics and histologic localization of metastasis within sentinel lymph nodes (SLN) and axillary spread in women with breast cancer. METHODS: We selected 119 patients with positive SLN submitted to complete axillary lymph node dissection from July 2002 to March 2007. We retrieved the age of patients and the primary tumor size. In the primary tumor, we evaluated histologic and nuclear grade, and peritumoral vascular invasion (PVI). In SLNs we evaluated the size of metastasis, their localization in the lymph node, number of foci, number of involved lymph nodes, and extranodal extension. RESULTS: Fifty-one (42.8%) patients had confirmed additional metastasis in non-sentinel lymph nodes (NLSN). High histologic grade, PVI, intraparenchymatous metastasis, extranodal neoplastic extension and size of metastasis were associated with positive NLSN. SLN metastasis affecting the capsule were associated to low risk incidence of additional metastasis. After multivariate analysis, PVI and metastasis size in the SLN remained as the most important risk factors for additional metastasis. CONCLUSIONS:The risk of additional involvement of NSLN is higher in patients with PVI and it increases progressively according the histologic localization in the lymph node, from capsule, where the afferent lymphatic channel arrives, to the opposite side of capsule promoting the extranodal extension. Size of metastasis greater than 6.0 mm presents higher risk of additional lymph node metastasis.

Integrins in Tumorigenesis and Cancer Cell Invasion

The integrin family of transmembrane receptors are important for cell-matrix adhesion and signal transmission to the interior of the cell. Integrins are essential for many physiological processes and defective integrin function can consequently result in a multitude of diseases, including cancer. Integrin traffic is needed for completion of cytokinesis and cell division failure has been proposed to be an early event in the formation of chromosomally aberrant and transformed cells. Impaired integrin traffic and changes in integrin expression are known to promote invasion of malignant cells. However, the direct roles of impaired integrin traffic in tumorigenesis and increased integrin expression in oncogene driven invasion have not been examined. In this study we have investigated both of these aspects. We found that cells with reduced integrin endocytosis become binucleate and subsequently aneuploid. These aneuploid cells display characteristics of transformed cells; they are anchorage-independent, resistant to apoptosis and invasive in vitro. Importantly, subcutaneous injection of the aneuploid cells into athymic nude mice produced highly malignant tumors. Through gene expression profiling and analysis of integrin-triggered signaling pathways we have identified several molecules involved in the malignancy of these cells, including Src kinase and the transcription factor Twist2. Thus, even though chromosomal aberrations are associated with reduced cell fitness, we show that aneuploidy can facilitate tumor evolution and selection of transformed cells. Invasion and metastasis are the primary reason for deaths caused by cancer and the molecular pathways responsible for invasion are therefore attractive targets in cancer therapy. In addition to integrins, another major family of adhesion receptors are the proteoglycans syndecans. Integrins and syndecans are known to signal in a synergistic manner in controlling cell adhesion on 2D matrixes. Here we explored the role of syndecans as α2β1 integrin co-receptors in 3D collagen. We show that in breast cancer cells harbouring mutant K-Ras, increased levels of integrins, their co-receptors syndecans and matrix cleaving proteases are necessary for the invasive phenotype of these cells. Together, these findings increase our knowledge of the complicated changes that occur during tumorigenesis and the pathways that control the ability of cancer cells to invade and metastasize.

Co-infection by porcine circovirus type 2 and porcine parvovirus in aborted fetuses and stillborn piglets in southern Brazil

Porcine circovirus types 1 and 2 (PCV1, PCV2) and porcine parvovirus (PPV) are widespread in pig populations around the world. Nevertheless, only PCV2 has been associated with different clinical syndromes, thus representing a major problem to the pig industry. The association of cases of swine abortions and stillborns with PCV1 and PCV2 and PPV was studied retrospectively (2005-2007). Additional pathogens were also investigated in lesioned fetuses. The studied litters included stillborn piglets and several mummified fetuses of varied sizes. Ventricular dilatation, myocardial pale areas, and mesocolic edema were the gross lesions. Escherichia coli was detected as co-infecting with PCV2 the cases in which mesocolic edema was seen. Microscopic lesions included non-suppurative myocarditis, myocardial necrosis and fibrosis, mineralization foci and intranuclear inclusion bodies in cardiomyocytes, and interstitial mononuclear pneumonia. Samples from 7 (5.78 per cent) of 121 aborted fetuses and stillborn piglets had lesions consistent with a viral cause and showed both positive anti-PCV2 immunostaining as well as PCV2-PCR. In samples from 3 (2.47 per cent) of these 7 fetuses, co-infection with PPV was confirmed by Nested-PCR. Both viruses were detected in fetuses at different stages of gestation. Viral antigens of PCV2 were detected by immunohistochemistry mainly in macrophages and myocytes. PCV1 individually was not detected in any of these affected fetuses, but it was associated with PCV2 and/or PPV in some of them. These findings indicate that PCV2 alone or in association with PPV should be kept in mind when investigating causes of infectious abortion in pigs in Brazil.